Plastic surgery is the surgical discipline concerned with the restoration of normal form and function for patients with cleft and craniofacial anomalies. This is accomplished through appropriately timed operations throughout the patient's life. Some deformities can be reconstructed with one operation early in infancy and others require multiple surgical treatments as growth and development occur. There may be overlap with oral and maxillofacial surgery, and otolaryngology, head and neck surgery in the performance of these procedures. The goal is always to have normal function and appearance throughout a patient's life, realizing that this cannot always be accomplished because of anatomic or developmental considerations and how they relate to the timing of surgery.

1. Prenatal
   1. Prenatal diagnosis of cleft and craniofacial anomalies is becoming more frequent with ultrasound.
   2. Counseling regarding the implications and subsequent treatment may be carried out prior to birth.
   3. Although fetal surgery has been done in animal models for cleft repair, this is not an accepted procedure for cleft repair at present.
2. Neonatal
   1. Please see Section I for a detailed discussion of team evaluation and cleft classification.
   2. Some surgeons are advocating cleft lip and palate repair in the neonatal period. The advantages of this approach have not been proven and the risk of complications is higher.
3. Infant: This is the typical time when surgical closure of the lip and palate is accomplished.
   1. Cleft lip is usually surgically closed in the first 2 to 3 months of life when it is clear that the baby is healthy and thriving. Most surgeons still use the rule of tens to plan the timing of closure.
      1. Ten weeks.
      2. Ten pounds.
      3. Hemoglobin of ten.
   2. Some surgeons perform lip adhesion prior to definitive lip repair. This procedure is a partial lip repair that does not rearrange the structures into normal anatomic position. Its purpose is to narrow the cleft making the final lip repair easier.
   3. The goal of the lip closure is to create a lip that functions well and approximates the physical characteristics associated with a non-cleft lip. The physical characteristics of the nose will also be improved by the lip closure. Sometimes lip revision will be required to improve the result, but the first operation generally provides a dramatic and lasting improvement in the function and appearance of the baby's lip.
   4. The timing of palate closure varies from team to team but is usually carried out from 6 months to 18 months of age.
   5. In children with airway problems or extremely wide palatal clefts, closure may be delayed.
   6. The reason to close the palate is so that speech will develop normally and the patient will not regurgitate liquids and solids into the nose when eating.
   7. Every sound in the English language except M, N, and NG resonates orally.
   8. When a palate and cleft is not closed, resonance is hypernasal and multiple errors in speech development will occur.
4. Toddler
   1. Despite closure of the palatal cleft, many children with cleft palate will still require speech therapy and approximately 10 to 20 percent may require secondary surgery for persistent hypernasal speech after closure.
      1. This is called velopharyngeal insufficiency (VPI).
      2. VPI becomes evident at age 2 to 3.
      3. Rarely can occur without cleft palate.
      4. Secondary surgical procedures to correct this problem are
         1. Posterior pharyngeal flap
         2. Pharyngoplasty
         3. Augmentation of the posterior pharyngeal wall
         4. Speech prosthesis
      5. See Speech Language Pathology section for more details on evaluation.
5. Preschool
   Nasal reconstruction may be performed just prior to kindergarten, possibly combined with a lip revision. These procedures are performed to improve function of the lip and nose, and to ensure that the child will look their best at a critical time of increased peer interaction when they begin school.
6. School-Aged
   1. Dental concerns usually are primary during this time as orthodontics and alveolar cleft bone grafting are carried out.
   2. See the Orthodontics and Oral and Maxillofacial sections.
7. Adolescents
   1. Some children with clefts develop maxillary retrusion requiring jaw surgery to align their dental arches after their facial growth is complete (usually age 14 to 18).
   2. After this is accomplished a final septorhinoplasty may be performed to improve breathing and nasal aesthetics.
8. Adult
   1. Most patients have completed treatment by the time they reach adulthood.
   2. Surgical revision is usually successful in treating any residual problems.

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