Examqo › Examqo library › Plastic surgery › Craniofacial and clefts
Cleft lip and palate
Cleft lip results from failed fusion of the medial nasal prominence with the maxillary prominence, and cleft palate from failed fusion of the palatal shelves; treatment is a timed sequence of operations by a team — lip at about 3 months, palate at 9 to 18 months, alveolar bone graft at 7 to 11 years and jaw surgery after growth ends.
Why it matters in the exam
Cleft lip with or without cleft palate occurs in about 1 in 700 to 1,000 births, more in boys and more on the left; isolated cleft palate is less common, more in girls and more often syndromic — 22q11, Stickler and Van der Woude (IRF6, lower lip pits). Most bilateral cleft lips are accompanied by cleft palate. The primary palate lies in front of the incisive foramen and the secondary palate behind it. Lip repair (Millard — rotation-advancement, or Fisher — anatomical subunits) is done around 3 months; palate repair is done before speech develops, repositioning the levator veli palatini muscle transversely (intravelar veloplasty) or using Furlow's double-opposing Z-plasty. The main aim of the alveolar bone graft is bony support for eruption of the permanent canine, arch stabilisation and fistula closure — so it is done before the canine erupts.
Velopharyngeal insufficiency (VPI) remains in about 20 to 30% after palate repair and presents with hypernasal speech and nasal air escape. Assessment is by nasendoscopy or videofluoroscopy; treatment: secondary Furlow, a pharyngeal flap when there is a central gap and good lateral wall motion, or sphincter pharyngoplasty when the gap is lateral and wall motion is weak. Submucous cleft palate is recognised by a triad: bifid uvula, a translucent midline band in the soft palate and a notch in the posterior hard palate. Pierre Robin — small jaw, tongue retraction and airway obstruction, usually with a U-shaped cleft palate — is managed with prone positioning, a nasopharyngeal airway, and in severe cases mandibular distraction; Stickler syndrome should be sought (eye examination). Middle ear infections are common and need follow-up and sometimes tubes.
Key points
- Lip — about 3 months; palate — 9 to 18 months.
- Alveolar bone graft — before canine eruption, 7 to 11 years.
- VPI in about 20 to 30%; pharyngeal flap or sphincter.
- Pierre Robin — small jaw, retracted tongue, airway obstruction.
- Isolated cleft palate — search for a syndrome.
Summary table
| Stage | Age | Aim | Note |
|---|---|---|---|
| Lip repair | About 3 months | Closure, muscle and nose reconstruction | Millard or Fisher |
| Palate repair | 9 to 18 months | Normal speech, levator reconstruction | Furlow or intravelar veloplasty |
| VPI treatment | After speech assessment | Close the velopharyngeal gap | Pharyngeal flap — central gap; sphincter — lateral gap |
| Alveolar bone graft | 7 to 11 years | Support for canine eruption, stabilisation, fistula closure | Before the canine erupts |
| Jaw surgery | After growth ends | Jaw relationship | Midface hypoplasia |
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Plastic surgery, Pediatrics, ENT and head and neck surgery, Pediatric surgery.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- American Cleft Palate-Craniofacial Association: Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial differences, 2018 revision — Team care and timing of procedures
- Plastic Surgery (Neligan), 5th edition (2023) — Cleft lip and palate repair; Velopharyngeal dysfunction
- Israeli Ministry of Health guidance on multidisciplinary cleft care, current — Team follow-up
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.