Cleft Lip and Palate Surgery in Ankara, Turkey

Cleft lip and palate repairs are procedures performed to surgically close congenital openings in the oral and facial region. These anomalies can affect both aesthetic appearance and essential functions such as feeding, speech, and breathing.

Cleft lip repair is usually performed when the baby is 3–6 months old. With surgical intervention, the lip muscle structure and skin contours are joined to achieve a natural appearance. The type and width of the cleft determine the technique of the operation; scars are planned to align with the lip line.

Cleft palate repair is most commonly performed between 9 and 18 months. The goal is to separate the oral and nasal cavities to ensure normal speech and swallowing functions. The soft and hard palate regions are repaired and the muscular structure is reconstructed.

After surgery, a multidisciplinary approach is applied with speech therapy, orthodontic treatments, and additional operations when necessary. These repairs are of critical importance for the child’s social development, aesthetic appearance, and functional capacity.

What is Cleft Lip and Palate Surgery?

Cleft lip and palate surgery is the procedure of repairing a congenital opening in the lip and/or palate region using surgical methods. This surgery aims to correct feeding, speech, and breathing functions and improve facial aesthetics. It is usually performed in infancy with a specific timing plan. The treatment process requires a multidisciplinary approach and may include speech therapy and orthodontic treatments in addition to surgery.

Why Do Cleft Lip and Palate Occur, and What Is the Anatomical Classification?

During the baby’s development in the womb, the right and left parts of the face meet in the midline to form the lip and palate. You can think of it like a zipper closing. If this fusion process is disrupted at any point, a cleft lip or cleft palate occurs. As surgeons, we do not treat every cleft the same when planning our treatment. To determine the severity and the surgical strategy, we use a system called the Veau Classification. This system provides our roadmap.

Anatomically, we examine this condition under four main categories. The first group is the mildest; here, there is only a separation in the soft palate. From the outside, the lip is completely normal, but when the baby opens the mouth, an opening is seen in the area of the uvula. In the second group, the opening is more anterior; both the soft palate and the hard palate are affected. The third group is the scenario families most commonly encounter; it is a complete cleft that runs through the lip, gum, and palate on one side. The fourth group is the most complex; the lip and palate are cleft on both sides (right and left), and the central bony segment remains completely independent.

The most critical detail to understand here is that the problem is not just a gap in the skin. Especially in unilateral clefts, the muscles that move the lip cannot attach to their normal positions. Normally, the muscles surrounding the mouth should form a complete ring, but in cleft lip, these muscles turn upward and attach to the base of the nose. This abnormal attachment pulls the nasal ala downward and flattens it on the cleft side. The bony segments in the gum are also rotated and deformed by this unbalanced muscular pull. Therefore, our operation is not based only on suturing the skin; it is built on repositioning the muscles correctly, correcting the nasal base, and ensuring alignment of the bony segments.

What Is Surgical Timing and the Rule of Ten?

Families understandably want their babies to undergo surgery as soon as possible and be relieved of this condition. However, rushing in surgery can lead to long-term problems. The main reason surgery is not performed immediately after birth is to wait until the baby’s physiology is mature enough to tolerate surgical stress. For lip repair, there is a globally accepted rule that we also adhere to strictly: the “Rule of Ten.” This rule was established to ensure anesthesia safety and proper tissue healing.

The main criteria of this rule are:

• The baby must be at least 10 weeks old
• Body weight must exceed 10 pounds, approximately 4.5 kilograms
• Hemoglobin level must be above 10 g/dL

In addition to these parameters, we also want the white blood cell count to be below a certain threshold to rule out infection risk. Meeting these criteria both minimizes risks during anesthesia and increases the speed of postoperative healing. The lip tissue of a 10-week-old baby is more defined and more shapeable than that of a newborn, which directly affects the aesthetic outcome.

Timing for palate surgery follows a different logic. Here we must balance two opposing forces: speech development and facial bone growth. If we close the palate too early, for example in the first 3 months, speech may be excellent, but the tissue tension created by surgery can stop the growth of the upper jaw. In that case, as the child grows, the upper jaw remains too far back and the face appears flattened. Conversely, if we perform it too late, for example after age 2, the upper jaw grows comfortably, but the child learns to speak incorrectly. The brain adapts to the open palate and begins producing unusual throat-based sounds, and correcting this habit later is almost impossible. Therefore, the golden middle ground is the period just before the baby begins to form words. Generally, between 12 and 18 months is the most ideal window for palate repair.

What Are the Aesthetic Goals and Surgical Techniques in Lip Repair?

In unilateral cleft lip repair, as a plastic surgeon, our goal is not simply to close the cleft. Our goal is to create a lip that looks so natural that when you look at the child’s face, you would not think “there was a cleft here.” To achieve this, we must reconstruct three key aesthetic details: ensuring symmetry of the two column-like lines under the nose called the philtrum, creating the lip curve known as the “Cupid’s bow,” and equalizing the fullness of the red lip line.

The surgical techniques we use to achieve these goals have evolved over the years. The method we most frequently prefer and feel most in control of is the Millard Rotation-Advancement technique. The logic of this technique is as follows: we lengthen the shortened lip on the cleft side by rotating it downward. We then fill the gap created by this rotation by advancing healthy cheek tissue from the side. The greatest advantage of the Millard technique is that it allows the surgeon to adjust the incisions millimetrically during the operation according to the situation. In addition, the surgical scar formed with this technique is hidden within the natural philtral groove. Thus, when light hits, the scar appears like an anatomical shadow and does not draw attention.

Another method is the Tennison-Randall, or triangular flap technique. This method is based on a more geometric plan. The lip length is increased with a triangular piece of tissue placed in the lower part of the lip. It provides very precise results mathematically, but the zig-zag scar it creates may not fully match the natural anatomical lines. While the choice of technique depends on the surgeon’s experience and the baby’s tissue structure, what matters most in both methods is the underlying muscle repair. By releasing the orbicularis oris muscle and suturing it end-to-end, we complete the functional ring that enables the child to whistle and blow kisses.

Which Methods Are Used in Cleft Palate Surgery?

Cleft palate repair (palatoplasty) is a more technical and function-focused operation compared to lip repair. Here, physiology speaks more than aesthetics. Our goal is to separate the oral cavity from the nasal cavity and establish the mechanism called the “velopharyngeal sphincter.” This mechanism allows the soft palate to lift backward and close the nasopharynx when we speak or swallow. If this closure does not occur, food comes out through the nose and the voice becomes nasal during speech.

To provide this function, we often use the Furlow Double Opposing Z-Plasty technique. This technique is excellent for lengthening the palate and reorienting the muscles correctly. In a cleft palate, the muscles normally face the wrong direction. In the Furlow technique, we make “Z”-shaped incisions on both the oral and nasal surfaces of the palate. When we transpose these tissues, the palate both lengthens and the muscles shift from a horizontal position to a vertical position and interlock. In this way, the palate gains the ability to contract backward.

In wider clefts, that is, in cases where it is difficult for the tissues to meet, we may prefer the Bardach Two-Flap technique. In this method, tissues on the sides of the palate are elevated off the bone and brought to the midline and sutured. The gaps that form on the lateral sides of the palate then heal on their own over time. This technique is very reliable for closing large openings, but its palate-lengthening potential may be somewhat less than the Furlow technique.

What Is Done in Cases of Speech Disorder (VPI)?

No matter how successful palate surgery is, in some children the soft palate may still remain short or the muscles may not work strongly enough. In this case, when the child speaks, the soft palate cannot fully contact the back wall of the throat and air escapes into the nose. We call this “Velopharyngeal Insufficiency” (VPI). Families usually notice this when the child is 3–4 years old; the child has difficulty producing plosive sounds like “p,” “b,” and “t,” or the voice sounds very nasal.

First, intensive speech therapy is tried. However, if there is an anatomical leak despite therapy, a secondary surgical intervention may be necessary. In this case, the method we most commonly use is the Pharyngeal Flap surgery. In this procedure, a strip of tissue containing muscle and mucosa is lifted from the back wall of the throat (pharynx) and sutured to the soft palate. This strip forms a bridge behind the palate, preventing air from escaping into the nose. However, this does not mean completely blocking the nose; the child can continue to breathe through the nose through openings (ports) left on the right and left of the bridge. Fine-tuning is very important here; if the openings are too large, speech does not improve, and if they are too small, the child experiences nasal obstruction and snores.

When Is an Alveolar Graft Applied for Teeth and Bone Structure?

In most children with cleft lip and palate, there is also a cleft in the gum (alveolus), meaning a bony deficiency. This gap usually corresponds to the area where the permanent upper canine tooth will erupt. If this gap is not filled with bone, permanent teeth cannot erupt properly, adjacent teeth tip into the space, and the integrity of the upper jaw is disrupted.

We do not rush this repair. The ideal timing is during the mixed dentition period, when baby teeth begin to fall out and permanent teeth begin to erupt. Generally, between 8 and 11 years of age is the most suitable time. Why do we wait for this age? Because if we perform this procedure when half or two-thirds of the permanent canine’s root development is complete, the tooth continues to erupt while bringing the new bone alongside it, strengthening that region.

In this surgery, we usually use the child’s own bone as the “gold standard.” As the donor site, we most commonly prefer the hip bone (iliac crest). The spongy structure inside the iliac crest is very rich in stem cells, and when placed into the gum defect, it adapts there rapidly. Families may fear bone harvesting from the hip, but this procedure does not prevent the child from walking; there may only be mild pain and a slight limp for a few days.

If the cleft in the gum is very wide and seems unlikely to be closed in a single session with bone graft material, then we use the method called Distraction Osteogenesis. In this method, a screw-based device is attached to the bone segments and is turned millimeter by millimeter each day to bring the bony pieces closer together. In this way, not only the bone but also the overlying gum stretches and lengthens, allowing large gaps to be closed.

What Is the Process of Rhinoplasty and Secondary Rhinoplasty?

Although we intervene on the nasal wings during cleft lip repair, as the child grows, certain nasal deformities may become more apparent. The nasal ala on the cleft side may appear more flattened, the nasal tip may be asymmetric, or breathing problems may occur due to a deviation of the internal nasal cartilage (septum).

For definitive correction of these deformities, it is best to wait until the end of adolescence, meaning the completion of skeletal development. Around 16–17 for girls and 17–18 for boys is appropriate for “Secondary Rhinoplasty.” Nasal surgeries performed too early can damage growing cartilage centers and disrupt nasal development.

Nasal surgery related to cleft lip is much more difficult than standard cosmetic rhinoplasty. This is because the basic structure we are working with is weak and there is a significant need for “structural support.” To elevate the nasal framework and tip, we need to harvest cartilage from other parts of the body. Since the nasal cartilage is often insufficient, we use ear cartilage or, more frequently, rib cartilage. Rib cartilage, in particular, provides abundant and strong material. By carving this cartilage, we create L-shaped supports for the nose, elevate the collapsed nasal ala, and achieve a symmetric appearance. This surgery both addresses aesthetic concerns and enables the child to breathe comfortably.

What Are the Postoperative Care and Nutrition Rules?

The success of the surgery is tightly linked to the postoperative care process after leaving the operating room. Especially the first 3 weeks after lip repair are critically important. The suture lines must not be strained, must remain clean, and must be protected from trauma.

The basic nutrition rules to be observed during this period are:

• A bottle should never be used for the first 3 weeks.
• Pacifier use is strictly prohibited.
• Feeding should be done with a spoon, soft cups with a cut tip, or a syringe.
• Hard foods that require chewing and could pierce the sutures (such as crackers, bread crust, chips) should be avoided.

Foods that can be consumed include:

• Breast milk
• Infant formula
• Yogurt
• Pureed soups
• Pudding

Another important issue is physical protection. Babies instinctively bring their hands to their mouths and may want to scratch the sutures. To prevent this, we use “elbow splints.” These splints keep the arms straight so the child cannot reach the face with the hands. This may seem challenging for families, but this 2–3 week precaution determines the quality of the scar for a lifetime. For wound hygiene, regularly using the antibiotic ointments recommended by your doctor and rinsing the mouth with water after feeding minimize the risk of infection.

Who Is Involved in the Treatment Team, and How Does the Process Work?

Cleft lip and palate treatment is not a one-person show. Although the plastic surgeon may appear as the conductor, success comes only with the coordinated work of a multidisciplinary team. Different specialists become involved at different stages of the child’s growth.

The main team members involved in this process are:

• Plastic and Aesthetic Surgery Specialist
• Orthodontist
• Speech and Language Therapist
• Ear, Nose, and Throat (ENT) Specialist
• Pediatric Genetic Specialist
• Psychologist
• Pediatrician

Follow-up generally proceeds according to the following timeline:

Newborn Period: The family is trained on feeding. If the cleft is wide, tissues are prepared for surgery with plates (NAM) made by the orthodontist.

• 3–6 Months: Lip repair is performed.
• 6–18 Months: Palate repair is performed. During this period, the ENT specialist performs hearing tests and ear tubes are placed if necessary.
• 2–5 Years: Speech therapy begins. The child’s ability to produce sounds correctly is monitored. VPI surgery is planned if needed.
• 7–11 Years: Tooth alignment is corrected with orthodontic treatment and an alveolar bone graft is performed.
• 16–18 Years: After facial growth is complete, orthognathic surgery is performed if there is a jaw deformity, and final rhinoplasty is performed for the nose.