Since we discussed the NAM appliance last week, it seemed appropriate to do this next post on cleft lip repair. It’s what comes after the NAM appliance is finished, which is around 3 months of age. 
How a cleft lip forms
A cleft lip forms during the 6th week in utero due to failure of the lip fusing properly. During this time, facial structures are coming together in utero, and if that is interrupted, a cleft lip can occur. A cleft lip can be due to many reasons, some of which are discussed HERE.
It is actually the second most common embryonic deformity. It occurs in approximately 1 in 700 births. Cleft lip occurs more commonly in males, and a unilateral (cleft on one side) cleft lip occurs more commonly than bilateral cleft lips (occurring on both sides).
The cleft can either be a small, incomplete cleft, or it can extend into the floor of the nose and involve part of the upper jaw.
The lip needs to be repaired:
To prevent future problems with hearing, breathing, eating, speaking, and it also improves the patient’s physical appearance.
Most children are able to lead a healthy, happy life after cleft repair.
How has the NAM helped us get here? 
The NAM appliance has reduced the size of the cleft, which will allow for a better esthetic outcome from the lip surgery. The surgeon doesn’t have to do as much “pulling” to connect the lip together.
Is it OK if we didn’t do the NAM, though? 
Of course it is! The outcome will still be great. I didn’t have a NAM appliance when I was young, either.
The Surgery
At 3 months old, the baby will go under general anesthesia to have the cleft lip repair, so the baby will be completely asleep. 
The baby will also receive local anesthetic after the general anesthesia has done its job in order to minimize bleeding and provide numbing to the surgical area.
The surgery usually takes between 2 and 6 hours, and the child will stay overnight for at least 1 day.
Young children usually get general anesthesia through a mask that covers the nose and mouth. 
A particular flavor can even be chosen for the scent. The good news is the baby will have no shots or needles while awake! An IV will be placed in the arm or leg to deliver medication only after the child is asleep.
The actual surgery requires an incision of one side of the cleft and then that skin is rotated to join the other part of the lip. The other part of the lip also has an incision to completely release it from underlying bone to allow the surgeon to move the lip to where he or she would like for it to go. 
The baby will have stitches on the lip and base of the nose (depending on the type of cleft).
After the surgery
The child will wake up in the recovery room with an IV still in the arm or leg. Also, there will be a set of arm restraints called “no-no’s” to make sure the baby won’t bend his or her arms at the elbow and touch the face. These will need to stay on for 2 weeks. 
Sometimes, nasal retainers will be used and placed in the nostrils to help shape the nose. These could stay in place for up to 3 months.
The baby will stay in the hospital until the baby is able to drink fluids. 
The IV will then be removed, and the baby can go home! If any sutures need to be removed because they are not dissolvable, this will be done 1 week after the surgery.
Home Care
- Only liquids until stitches are removed
- Gentle cleansing of stitches with cotton swabs & diluted hydrogen peroxide
- Gently massage area & avoid sunlight
- No-no’s stay on for at least 2 weeks
- remove them every 2-4 hours to make sure they are not too tight
- Raise baby’s head slightly while sleeping to help with swelling
- Clean the sutures after each time the baby eats
- Vaseline can be placed on the stitches after cleaning
- Most importantly: Remember that the baby crying will not harm the stitches!
What’s normal: 
- Bleeding from lip for up to 24 hours from surgery
- Swelling
- Difficulty feeding the baby
- the baby needs to get used to his or her new mouth!
- plus, there may be some soreness and swelling causing discomfort
- Redness & firmness 4-6 weeks after surgery
What’s not normal: 
- Fever
- Trouble breathing or skin color changes
- Continuous bleeding or bad smell coming from stitches
- Signs of dehydration
- Movement of the nasal stents
My story 
I didn’t have a NAM appliance when I was young because they didn’t exist yet!
I had my lip repair done when I was 3 months old. My parents kept my “no-no’s” for a really long time in the basement. I remember seeing them when I was about 10 and thinking they looked so small!! 
My mom always told me it was very difficult to feed me after my lip repair. She said only 2 people were able to successfully feed me, which were my grandmother and her. 
They would use medicine cups to drip fluids into my mouth. Imagine how tedious that must have been!
My lip repair was successful, and I went on to have many nose reconstructions, and when I was 21, I had a second lip reconstruction where my plastic surgeon was able to smooth over some of the scar tissue on the inside of my lip. It felt so amazing to not feel “bumps” on the inside of my lip.
I’ve never had any issues with my lip, and most patients don’t. After repair of the lip, patients can function normally in terms of anything to do with the lip. The challenging aspects are the palate, bone defect, and nasal defects.
Thanks so much for reading today. As always, let me know if you have a request for the next post!! 
The Cleft Dentist™
http://www.surgeryencyclopedia.com/Ce-Fi/Cleft-Lip-Repair.html
http://www.chp.edu/our-services/plastic-surgery/patient-procedures/cleft-lip-repair
https://www.aboutkidshealth.ca/Article?contentid=33&language=English
*photos courtesy of UCLA