What is cleft lip and palate?
Cleft lip and palate is one of the most frequent congenital malformations of the face, with an incidence of about 1 in every 700–800 live births. It occurs when, during the first weeks of gestation (between the 4th and 9th week), the structures that form the upper lip and/or the palate do not fuse completely, leaving a cleft of varying extent.
There are several clinical forms, which can occur in isolation or in combination:
- Cleft lip (cheiloschisis): a cleft limited to the upper lip, unilateral or bilateral, with different degrees of severity.
- Cleft palate (palatoschisis): a cleft of the hard and/or soft palate, without involvement of the lip.
- Complete cleft lip and palate: a cleft involving the lip, the alveolar process and the palate at the same time; this is the most complex form to treat.
The causes are multifactorial: genetic factors (a family history of the malformation), environmental factors (folic acid deficiency in pregnancy, smoking, certain medications) and associated genetic syndromes (such as Pierre Robin sequence or Van der Woude syndrome) can all contribute. In most cases, however, the malformation is isolated and not associated with other systemic anomalies.
The functional impact of an untreated cleft can be significant: difficulty with breastfeeding and feeding in the newborn, alterations in speech and language development, an increased risk of recurrent middle-ear infections due to Eustachian tube dysfunction, and orthodontic problems linked to the interrupted continuity of the alveolar arch. Early surgical treatment is therefore essential to allow the child normal physical and psychological development.
Prenatal diagnosis and preparation for treatment
Cleft lip and palate can be identified before birth by morphological ultrasound, generally between the 18th and 22nd week of pregnancy. A prenatal diagnosis allows parents to prepare psychologically and to begin consultation with the multidisciplinary team in advance. After birth, the team of specialists (plastic surgeon, paediatrician, neonatologist, orthodontist, speech therapist, ENT specialist) assesses the child comprehensively to plan the most appropriate treatment pathway, which typically begins with pre-surgical orthopaedic devices (NAM — Nasoalveolar Molding) to reduce the size of the cleft and prepare the tissues for surgery.
How the operation is performed
The treatment of cleft lip and palate involves a sequence of surgical procedures scheduled according to the child's age and the type of malformation. Each stage is carefully planned to optimise both functional and aesthetic results, while minimising the impact on normal craniofacial development.
- 1. Pre-operative assessment — before each operation the child is evaluated by the paediatrician and the anaesthetist. Complete blood tests, a basic cardiology assessment and, if necessary, further investigations are performed. The surgeon discusses the operative plan, the techniques to be used, the expected risks and benefits, and post-operative care with the parents.
- 2. Cheiloplasty (lip repair) — performed under general anaesthesia, usually between 3 and 6 months of age. Dr. Galati uses well-established techniques such as the Millard rotation-advancement technique or the Tennison-Randall technique, choosing the approach best suited to the individual morphology of the cleft. The goal is to reconstruct the three anatomical layers of the lip (mucosa, orbicularis muscle and skin) with millimetric precision, restoring muscular continuity and a symmetrical Cupid's bow. In the same session, the associated nasal deformity is often also corrected (primary cleft rhinoplasty), with reinforcement of the alar cartilage and repositioning of the nasal base.
- 3. Palatoplasty (palate repair) — generally performed between 9 and 18 months, with the aim of closing the palatal cleft before the child begins to develop speech. The most widely used techniques include the Furlow double opposing Z-plasty and the modified Von Langenbeck technique. Reconstruction of the levator veli palatini muscle is crucial to ensure correct velopharyngeal function and prevent hypernasal speech. The operation lasts on average 2–3 hours and the child remains in hospital for 2–4 days.
- 4. Secondary and refinement procedures — as the child grows, additional corrective procedures may become necessary: aesthetic touch-up of the lip at school age, closure of any residual oronasal fistulas, alveolar bone grafting (at around 8–10 years, in conjunction with the eruption of the permanent canine), and secondary rhinoplasty in late adolescence for the definitive correction of nasal asymmetries. Every secondary procedure is planned in agreement with the multidisciplinary team and the family.
Recovery and results
The post-operative course of cheiloplasty and palatoplasty is generally well tolerated by children, thanks to the high regenerative capacity typical of early childhood. The medical team provides parents with detailed instructions on how to care for the child in the weeks following surgery.
After cheiloplasty
In the first 24–48 hours the child is monitored on the ward. The operated area appears swollen and red; the swelling subsides progressively over the first two weeks. Feeding is resumed with special teats or a spoon in the hours after the operation. The sutures are generally absorbable and do not require removal. It is essential to prevent the child from touching the operated area; arm restraints (no-no splints) may be used for the first weeks. Gentle cleansing of the suture with saline solution is recommended several times a day. Scar massage, with rosehip oil or silicone cream, begins from the 4th–6th week to optimise the quality of the scar.
After palatoplasty
The hospital stay is 2–4 days. A liquid or semi-liquid diet is required for the first 2–3 weeks to protect the palatal suture. The child may be irritable due to pain, which is managed with analgesics prescribed by the physician. Intense physical activity and contact with sharp objects in the mouth must be avoided for at least 3–4 weeks. Regular check-ups with the surgeon and the speech therapist are scheduled in the following months to monitor language development and promptly identify any complications (fistulas, velopharyngeal insufficiency).
Long-term results
With timely surgical treatment and an adequate multidisciplinary pathway, children with cleft lip and palate achieve excellent functional and aesthetic results. The reconstructed lip appears symmetrical and natural; the scars fade progressively over the years. Speech develops normally or with minimal difficulties corrected by speech therapy. The quality of life of treated patients is comparable to that of the general population. Dr. Galati accompanies families along the entire treatment pathway, ensuring continuity of care from diagnosis through to adulthood.
Frequently asked questions
Cheiloplasty (lip repair) is generally performed between 3 and 6 months of age, when the child has reached a sufficient weight (at least 5 kg) and is in stable general condition. Palatoplasty (palate repair) is usually performed between 9 and 18 months, before speech development, to favour normal language acquisition. Secondary corrective procedures, if needed, are planned at school age or during adolescence.
The number of operations depends on the severity of the malformation and the individual response to treatment. In most cases, two main operations are planned: cheiloplasty in early infancy and palatoplasty in the following months. Additional procedures may later be needed for aesthetic refinement of the lip, correction of associated nasal deformities, management of palatal fistulas or orthodontic support. The treatment pathway is multidisciplinary and may extend into late adolescence.
An untreated cleft palate can cause significant speech difficulties, since the palate is essential for the correct production of many sounds. Early palatoplasty (within 12–18 months) considerably reduces these risks. Even after a successful operation, many children benefit from a speech therapy programme to refine articulation and language. With timely treatment and adequate speech therapy support, most children achieve a normal or near-normal level of speech.
Any surgical procedure leaves a scar; however, thanks to modern cheiloplasty techniques, Dr. Galati places the incisions along the natural lines of the lip, making the scar as discreet as possible. With time and appropriate care (scar massage, sun protection, laser therapy where indicated), the scar becomes almost imperceptible. The final aesthetic result is fully assessed in adulthood, when facial development is complete.
The treatment of cleft lip and palate is by nature multidisciplinary. Alongside the plastic surgeon, the team includes the paediatrician and neonatologist, the orthodontist, the speech therapist and the ENT specialist, and, where needed, a clinical geneticist and psychologist. Coordinated care from birth to adulthood is the key to achieving the best functional and aesthetic outcomes.