PALATOPLASTY

“One patient’s journey from a nine-month old to a teenager”

Submitted by: Acuna, Francisco, Landicho, Mamolo, Margaret, Mendoza, Orfanel, Placer
Submitted to: Dr. Jocelyn Flores
I.DESCRIPTION
The patient is a nine-month old male infant who was diagnosed immediately after birth
with right unilateral cleft lip and nasal deformity. There were no unusual signs and symptoms to
detect his condition during prenatal life. According to his medical history, the patient has
undergone cheilorrhaphy when he was three months old.
The patient was subjected to the following preoperative tests: total blood count,
urinalysis, and hematocrit. All of the test results had been normal. To determine the extent of the
palatal defect, a series of facial X-rays was performed.

Unilateral cleft lip and palate

A cleft palate with a unilateral cleft lip is a common birth defect in which a baby's lip and
palate (roof of mouth) don't form properly. As a result, there is a split or opening (cleft) on one
side of the lip that can extend all the way from the nose to the back of the palate. Nine out of ten
patients (90%) with a cleft of the lip have unilateral cleft lip. Unilateral cleft lip is twice as
common on the left side as it is on the right.
Cleft lip and palate result from the incomplete closure of the upper lip and roof of the
mouth. This causes a gap or defect to occur in the affected area, involving skin, muscle and the
lining of the mouth. There is often an associated deformity of the nose on the affected side.
Symptoms:
The major symptom is the presence of the cleft at birth. A cleft lip could be as small as a
tiny notch in the upper lip. It could also be as large as a split or hole that goes up into the nose. A
cleft palate could be just a small area that isn’t formed properly. But it also could be a large
separation in the roof of the mouth.
Children who have clefts often have other health issues. They can have trouble eating and
talking. They may also have hearing problems, problems with their ears, or problems with their
teeth.
Causes:
Cleft lip and cleft palate occur when tissues in the baby's face and mouth don't fuse
properly. Normally, the tissues that make up the lip and palate fuse together in the second and
third months of pregnancy. But in babies with cleft lip and cleft palate, the fusion never takes
place or occurs only part way, leaving an opening (cleft).
Researchers believe that most cases of cleft lip and cleft palate are caused by an
interaction of genetic and environmental factors. In many babies, a definite cause isn't
discovered.
The mother or the father can pass on genes that cause clefting, either alone o r as part of a
genetic syndrome that includes a cleft lip or cleft palate as one of its signs. In some cases, babies inherit a
gene that makes them more likely to develop a cleft, and then an environmental trigger actually causes the
cleft to occur.
II. PICTURE

Picture 1. The patient as an infant Picture 2. The patient’s mouth between the
ages of 10 (at left) and almost 13 (at right)

III. TREATMENT
Cheilorraphy or lip repair surgery
- At three months old, cheilorraphy was performed wherein the cleft lip will be repaired
and closed with stitches.

Palatoplasty
- At nine months old, the patient underwent the surgical procedure to correct or reconstruct
the cleft palate.

Feeding assistance and advice

- Due to the defect in the palate, Nursing was not an option. Feeding techniques and
positioning was then advised to prevent the milk enter the nasal cavity. They end up
using a Red rubber Robinson catheter to insert drops of breastmilk to nasal cavity.

Treating hearing problems

- Children with a cleft palate are more likely to develop a condition called glue ear, where
fluid builds up in the ear. This is because the muscles in the palate are connected to the
middle ear. If the muscles are not working properly because of the cleft, sticky secretions
may build up within the middle ear and may reduce hearing. The patient is advised to use
ear tube to improve his hearing problems.

Le fort I maxillary osteotomy and a bilateral sagittal osteotomy

- A procedure used by maxillofacial surgeon to correct a wide range of dentofacial
deformity. It is a surgical operation whereby a bone is cut to shorten or lengthen it to or
to change its alignment.
Additional corrective procedures

1. Cartilage graft from the right ear to right nasal dorsum due to the considerable droop and
flattening of the lower lateral cartilage.
2. Bone graft: to close the oronasal fistula, surgeons implanted an autogenous iliac credt
bone graft in the maxilla. In 2000, oral surgeons found that his occlusal exam showed a
tendency of anterior cross bite and a unilateral posterior cross bite. Bone grafting to the
cleft alveolar ridge was also performed to correct his cross bite.
3. Dental extraction to keep the bone grafts in place.
4. Orthodontic treatment: top braces are in place and expander was inserted to widen his
narrowed dental arch. The patient underwent six years of orthodontic treatment to shape
the patient’s mouth between ages of 10 to 16years old.
5. At the completion of his orthodontic work, he will still need a septoplasty, rhinoplasty,
lip scar revision and a micrognathia repair to bring his jaw to forward position.

IV. PROCEDURE

CHEILORRHAPHY
Procedure:

1. During surgical procedures, general anesthesia and intravenous sedation was

administered in order to insure comfort and also to calm the patient during the surgery.
2. Lines are drawn to the area where incision was performed. Incisions were made on the
left or right side of the cleft to create flaps of skin and intraoral tissue that are then drawn
together. In order to make a recreation of the typical lip and, the flaps of skin were
stitched to close the cleft.
3. The two sides of the lip are then sutured together, using tissue from the area to rearrange
and close the lip as needed using removable or absorbable sutures.

PALATOPLASTY
Procedure:

1. This kind of surgery requires general anesthesia that usually takes about 2–3 hours. The
patient will remain asleep during the entire procedure.
2. The surgery itself was performed through the mouth. Two incisions (cuts) will be done
on each side of the palate behind the gums to ease tension on the palate repair.
3. Tissue on both sides of the cleft were attached together it will close the opening to the
nose and includes the muscles that lift the palate and help “pop” the ears.
4. The repair will be done in layers to create a normal palate.
(FURTHER TREATMENTS IN ADULTHOOD)
ORTHOGNATIC SURGERY/ CORRECTIVE JAW SURGERY
-to correct a wide range of minor and major skeletal and dental irregularities, including the
misalignment of jaws and teeth. Surgery can improve chewing, speaking and breathing

Procedures:
1. The Oral and Maxillofacial surgeon determine first which corrective jaw surgical
procedure is appropriate. X-rays, CT scans, and pictures of your case are needed which
will be used to plan and execute the surgery.
2. General anesthesia is employed with a breathing tube that is typically placed through the
nose.
3. Incisions are made in the mouth and sometimes additional very small incisions are made
on the cheeks. The bones will be mobilized into the planned positions and fixed with
plates and screws.
4. The results of jaw surgery are usually apparent immediately but will reveal themselves
fully as swelling and bruising subside over a period of a month or two.

RHINOPLASTY
- a facial cosmetic procedure, usually performed to enhance the appearance or reconstruct the
nose.

1. Anesthesia is administered for the patient’s comfort before the operation.

2. It can be performed either the two procedures: closed procedure where incisions are
hidden inside the nose, or an open procedure, where an incision is made across the
columella, the narrow strip of tissue that separates the nostrils.
Through these incisions, the skin that covers the nasal bones and cartilages is gently
raised, allowing access to reshape the structure of the nose.
3. Reshaping the nose structure can be done by removing bone or cartilage if you have an
overly large nose or addition of cartilage grafts which is sometimes a requirement in
surgery.
4. If the septum is deviated, it can be straightened and the projections inside the nose
reduced to improve breathing.
5. Once the underlying structure of the nose is sculpted to the desired shape, nasal skin and
tissue is redraped and incisions are closed. Additional incisions may be placed in the
natural creases of the nostrils to alter their size.

SEPTOPLASTY
-a surgical procedure to correct a deviated septum.

Procedures:
1. Anesthesia is administered for the patient’s comfort before the operation.
2. The surgeon makes an incision on one side of your nose to access the septum.
3. They next lift up the mucous membrane and move the deviated septum into right
position.
4. Any barriers, such as extra pieces of bone or cartilage, are removed.
 5. Reposition the mucous membrane and stitch it afterwards to hold the septum and
membrane in place.

LIP REVISION
-to improve the appearance and function of the lip which has been distorted with growth after a
cleft lip, cleft palate or other craniofacial surgery.

Procedures:

1. Anesthesia is administered for the patient’s comfort before the operation.

2. An incision is needed to surgically remove the old scar. The degree of improvement that
can be achieved with scar revision will depend on the severity of your scarring,
3. Scars required layered closure. Advanced techniques in scar revision include complex
flap closures and W-plasty or Z-plasty techniques. Flap closures may reposition a scar so
that it is less conspicuous or improve flexibility where contracture has restricted mobility.

SOURCES
https://www.plasticsurgery.org/reconstructive-procedures/cleft-lip-and-palate-
repair/procedure
https://pediatric-ent.com/cleft-palate-repair-palatoplasty/
https://www.news-medical.net/health/Procedure-for-Dental-Braces.aspx
https://www.plasticsurgery.org/reconstructive-procedures/orthognathic-surgery/procedure
https://www.plasticsurgery.org/cosmetic-procedures/rhinoplasty/procedure
https://www.healthline.com/health/septoplasty#procedure
https://www.plasticsurgery.org/reconstructive-procedures/scar-revision/procedure