Lip Surgery

Cleft lip and cleft palate are among the most common birth anomalies affecting children in Pakistan and worldwide. At times there is incomplete formation of the upper lip (cleft lip) or roof of the mouth (cleft palate) alone, or both defects may occur simultaneously. The severity of the conditions can vary in both cases and may involve one or both sides of the mouth. Surgery is the mainstay of treatment to repair cleft lip and/or cleft palate to restore normal function, speech and appearance.

What is cleft lip and palate repair surgery?

Cleft lip and palate repair surgically corrects abnormal development, restores function of the lips and mouth resulting a more normal appearance as well as function.

Cause and correction

A cleft deformity of the upper lip and/or the roof of the mouth, occurs in-utero very early in the development of your unborn baby. During fetal development, few components of the upper lip and roof of the mouth fail to grow and unite together normally. In some cases, a syndrome may be responsible for the presence of the cleft along with other associated problems. For most affected children, however, the exact cause will not be known. In these cases, the cleft is attributed to result from a complex interaction of genetic and environmental factors.

Cleft lip and palate repair are types of surgery used to correct this abnormal development and are meant to restore function of the lips and mouth as well as more pleasing normal appearance. Clefts need  repair through specialized plastic surgery techniques and will help to improve your child’s ability to eat, speak, hear and breathe.

For the best treatment and best results timing of surgery is very important so is counselling of parents to understand the staged procedures with their subsequent needs and timing. Early intervention by a team of specialists is required to evaluate for management of your child’s problem and development in cases of cleft lip and/or cleft palate. The team works together to define treatment regimen, including feeding recommendations, pre surgical treatment, plan of surgical repair of the cleft, speech rehabilitation and dental restoration. The list of specialists include a:

• Plastic surgeon
• Pediatrician
• Pediatric dentist
• Orthodontist
• Otolaryngologist (ear, nose and throat specialist)
• Lactation Specialist
• Occupational therapist
• Auditory or hearing specialist
• Speech-language pathologist
• Genetic counselor
• Psychologist
• Social worker

It is of extreme importance to know that at the earliest stages feeding, growth, and development will be the most important priorities for your child’s cleft-related care. Specialized bottles with special nipples, or more rarely, feeding tubes, may be needed to help your child eat well for normal growth. Usually, when a cleft palate is there, the infant will not be able to feed at the breast milk like other infants due to difficulty with creating oral suction.

More than a cosmetic repair

Surgery to repair a cleft of the lip or palate is highly tailored. Surgery is planned to close the cleft defect, so as to help your child ability to function and grow normally. Cleft lip repair, also known as cheiloplasty, includes reconstruction of the lip to create a more normal appearance, namely:

• Closure of the cleft yields a scar present within or near the typical features of the upper lip
• Formation of a cupid’s bow
• Maintaining adequate distance between the upper lip and nose

Clefts of the upper lip usually affect the shape of the nose and additional procedures may be necessary to:

• Restore nasal symmetry and nostril shape
• create adequate length for the columella

Because the palate creates the floor of the nasal cavity and is responsible for normal speech, considerations in repairing a cleft palate include:

• Separating the oral and nasal cavities by closing the defect along its length
• Re-establishing soft palate muscle function to aid normal speech
• Recreating normal relationship of the soft palate to the auditory canal and Eustachian tube to allow normal hearing
• Promoting as much as possible the normal growth and development of the upper jaw and teeth
• Repairing, when appropriate, any defects in the gumline to allow for permanent tooth eruption

When should my child have the surgery?

The timing of the cleft repairs is criticle for best outcome and it depends on the individual circumstances of your child.  Cleft lip repairs are usually performed between 2 and 6 months of age depending on your child’s health status.

Cleft palate repairs are generally performed after cleft lip repair in a separate surgery when the child is between 9 to 18 months of age depending on health status.

Cleft lip and/or palate repair can be delayed in order to treat other, more life-threatening problems that may be present such as a heart or lung disorder.

Depending on the severity/type of the cleft, pre-operative interventions such as cleft lip taping, orthodontic molding (called NasoAlveolar Molding – NAM), or staged surgery techniques are recommended.

subsequent cleft-related surgeries may be needed over time including ear tubes to treat fluid buildup, bone grafting to repair the gumline, and dental or jaw surgery to correct the bite relationships

Congenital Anomalies  Surgical Correction of Birth Anomalies

A congenital anomaly is a medical condition present at the time of birth in a new born that significantly deviates from the common structure or function of the body.

What is a congenital anomaly?

A congenital anomaly is a medically diagnosed condition present at or from birth that is significantly different from the common structure or function of the body, whether caused by a hereditary/genetic or developmental disability or disease. These are not “rare” diseases. The Centers for Disease Control and Prevention (CDC) classifies congenital anomalies or birth defects as “common, costly and critical”.

Cleft lip and palate abnormalities are congenital anomalies commonly treated by plastic surgeons, who repair the incomplete formation of the patient’s upper lip or roof of the mouth. These conditions often prevent the patient’s routine function, specifically in the nose and mouth area, which can adversely affect an individual’s ability to speak, eat, hear and even breathe properly. If left untreated, then these conditions could undermine a patient’s health, development and ability to function. In most cases, surgery is required to repair the anomaly.

Plastic surgeons restore function and appearance for a host of other congenital anomalies, including the following. If your child has a congenital condition that could benefit from reconstructive surgery, find a plastic surgeon in your locality:

• Acrosyndactyly
• Athelia
• Amastia/Amazia
• Central ray deficiency / Cleft hand
• Cleft lip and palate
• Congenital breast anamoly(tuberous breast/Poland syndrome
• Constriction ring syndrome
• Cryptotia/microtia
• Duplicated thumbs
• Ear deformations or malformations
• Facial clefts
• Hypospadias
• Macrostomia
• Microtia
• Poland syndrome
• Polysyndactyly
• polydactyly
• Radial club hand
• Syndactyly
• Tuberous breast deformity
• Ulnar Longitudinal Deficiency

This list offers only a few of the many known diagnoses. Every day, plastic surgeons provide life-saving treatments to individuals with congenital anomalies.  Most of the times reconstructive surgery and supportive treatment is done in stages over several years as a child grows.

• Hypospadias
• GENDER CONFIRMATION

Gender Affirmation Surgeries

What surgical options are available to transgender or gender non-specific patients? Gender confirmation surgeries, also known as gender affirmation surgeries, are performed by a multispecialty team that typically involves board-certified plastic surgeons. The goal is to give transgender individuals the physical appearance and functional abilities of the gender they know themselves to be. Listed below are many of the available procedures for transwomen (MTF) and transmen (FTM) to help in their journey.

Facial Feminization Surgery

The aim of facial feminization surgery is to transform the masculine features of the face to a more feminine look or vice versa.

Transfeminine Top Surgery

The purpose of transfeminine top surgery is to enhance the size and shape of the breasts to create a more fuller appearance to the chest.

Transfeminine Bottom Surgery

The goal of transfeminine bottom surgery is to transform the ambiguous genitalia and reconstruct it into that of a female.

Transmasculine Top Surgery

The aim of transmasculine top surgery is to remove the breast tissue (mastectomy) from both breasts and create a masculine appearance to the chest.

Transmasculine Bottom Surgery

The purpose of transmasculine bottom surgery is to transform the female genitalia and reconstruct it into that of a male.

• CONGENITAL MELANOCYTIC NEVUS

Children can be born with pigmented moles called congenital nevi. The aim of giant nevi removal is to eliminate these pigmented moles and to permanently delete its hazardous effects.

What is congenital melanocytic nevi removal surgery?

Children can be born with pigmented moles called congenital nevus( or nevi, if multiple). These denote a proliferation of melanocytes, the pigment-producing cells of the skin. When they appear, congenital melanocytic nevi can be highly varied in size and shape. They may be very small, few and insignificant in appearance to very big, covering large areas of the body. Small congenital nevi are those less than 1.5cm in size. Medium nevi are the between 1.5cm to 19cm Giant nevi are the one measuring 20cm or more in size at birth. The main goal of giant nevi removal surgery is to remove the mole entirely or at least as much as is possible.

A congenital nevus or CMN occur sporadically, in a completely unpredictable fashion. These moles (also known as melanocytic nevi) are usually brown in color. That color may be uniform or irregular with darker areas mixed with lighter areas. Congenital nevi can also have raised areas, texture differences and excessive hair growth. Excessive hair growth is common, these lesions are sometimes  referred to as giant hairy nevi. While giant congenital nevi can occur at any body site, there is a predilection for them to appear on the trunk, including back, abdomen, hips and buttocks legs. The scalp and face are also frequently involved.

Rarely, some children born with giant congenital nevi are found to have deeper involvement of their tissues called neurocutaneous melanosis. The melanocytes involved in this condition proliferated in the brain and spinal cord early in fetal development and typically present with a giant scalp or trunk lesion and many smaller satellite lesions. These children can suffer from increased intracranial pressure, seizures or other neurological problems. An MRI can help to diagnose this condition if it is suspected.

Congenital nevi are believed to have an increased risk of malignant transformation over the lifetime of the child. Small- and medium-sized congenital melanocytic nevi have a risk as low as 1% or less. Large and giant melanocytic nevi have a higher risk of 5-10% over the child’s lifetime. As the child reaches puberty, congenital melanocytic nevi can develop additional changes creating a worsened appearance due to thickening, darkening or ulcerations of any part or all of the lesion.

Effective management of Giant nevi is a challenging task. Cosmetic reasons dominate for the urgency to remove the external lesion, but medical reasons are more crucial. The larger sized lesions need serial excison means they usually cannot be removed in a single go in order to allow for primary healing of the excised areas. Different techniques have been employed to provide adequate tissue for closure of created  surgical wound after removal of nevi. Most common and best options are  tissue expansion and grafting