Cleft lip and palate are birth defects that occur in 1 out of every 700 babies. These conditions happen because of an incomplete fusion of the lips and palate during pregnancy. This results in a cleft lip, where one or both sides of the lip are not fully formed, or cleft palate, where there is a gap between the roof of your baby’s mouth and his or her nose.
Cleft lip and palate can be treated in several ways. The most common treatment for cleft lip is a surgical procedure called a “lip repair.” For cleft palate, treatment options include surgery to close the gap between the nose and mouth, as well as speech therapy to help your child learn how to properly pronounce words and make sounds.
Read on to learn more about How To Treat Cleft Lip And Palate, Burn Spots After Chemical Peel Treatment
How To Treat Cleft Lip And Palate
The care of children with cleft deformities is best managed by a dedicated team of specialists committed to their care from the time of diagnosis until adulthood. This craniofacial team works together to orchestrate the complicated treatment plan. Certain patterns of management and clinical intervention emerge as a child with a cleft grows up and develops. What follows is a brief overview of the time line of care and interventions that children with clefts experience in our craniofacial center.
The management of cleft lip and palate represents a commitment to the care of the afflicted child over the course of the child’s development into adulthood. The role of a qualified surgeon in this population of patients is obvious; however, the special needs of children with clefts are best served by the participation of a craniofacial team. This team is composed of an array of specialists including nurses, dentists, orthodontists, oral surgeons, otolaryngologists, geneticists, prosthodontists, speech therapists, radiologists, psychologists, feeding specialists, and plastic surgeons. The family is integrated as an important part of this team. A road map of surgical and nonsurgical care that is needed for each patient from the initial visit is created. Often, the family is overwhelmed with trying to orient themselves. One of the initial duties of the craniofacial team is to provide emotional support and help navigate the patient and family through this road map as smoothly as possible. This article outlines our methodology of management of patients with clefts from birth to young adulthood with emphasis on long-term planning and goals, continuity of care, timing, decision making, and execution of high-quality care.
THE TEAM APPROACH
The importance of the multispecialty approach to the care of children with clefts cannot be overemphasized. The ACPA (American Cleft Palate-Craniofacial Association/Cleft Palate Foundation, 1504 East Franklin Street, Suite 102, Chapel Hill, NC 27514–2820, www.cleftline.org) and the Team Standards Committee have published the standard of care in the management of cleft children. The needs of cleft children are multifactorial, and to take them on as an independent practitioner is often to the detriment of the patient. The need for management of cleft lip and palate deformities at multiple levels is easy to appreciate when one begins to list the functional and anatomic areas affected by the deformity (Table 1).
Table 1
Critical Location of Cleft and Effect on Function
| Facial musculature arrangement and function |
| Oropharyngeal musculature arrangement and function |
| Facial bone structure and growth patterns |
| Velopharyngeal function and speech and sound production |
| Facial cavitary and sinus partitioning and function |
The craniofacial team is composed of nursing and physician specialists with particular interest and training in the care of children with cleft deformities (Table 2). One of the first consultations is with the feeding specialist, who assists families with managing the special feeding needs of cleft newborns. The geneticist serves to diagnose associated syndromes and can counsel families regarding genetic risks and future possibilities. A specialty nurse coordinator acts as a liaison between the patient and family and the craniofacial team. There may be some variability in the specific roles of the surgeons on the team, but these usually consist of a plastic surgeon, otolaryngologist, and oral surgeon. Most of the surgical needs are met with this team, including speech surgery and management of middle ear fluid. The dentist is responsible for dental restorations and encouraging good dental hygiene. The orthodontist manages tooth alignment and palatal expansion, often in preparation for orthognathic procedures. Both may be involved in presurgical molding of the cleft lip prior to surgical repair. The speech pathologist assesses language skills and performs diagnostic assessment of velopharyngeal function. A local children’s hospital is critical as a source of surgical inpatient facilities and staffing and as a resource for community education and awareness. If possible, a dedicated clinic space with examination rooms, dental examination and treatment areas, dental laboratory, radiology capabilities, photography area or studio, adequate waiting area for children, staff offices, and electronic record keeping (a craniofacial home base, if you will) is optimal. Although not an intimate part of the craniofacial team, the patient’s local pediatrician and community dentist also play a critical role in coordination and dispersal of primary care needs. If the craniofacial center, of which there are about 50 in the United States, is located far away from a patient, local physician care is even more important.
Table 2
The Craniofacial Team and Player Roles Team Approach
| Feeding specialist | Assesses and manages feeding issues related to a cleft diagnosis |
| Nurse coordinator | Coordinates the multispecialty care and management of the patient |
| Plastic surgeon/oral surgeon | Executes surgical procedures related to the cleft lip/palate, orthognathics, velopharyngeal insufficiency, and nose |
| Otolaryngologist | Assesses auditory issues, tympanic membrane management |
| Dentist | Prevents and treats tooth and gum disorders and diseases |
| Orthodontist | Corrects irregularities of tooth position |
| Prosthodontist | Replaces teeth and makes dental and alveolar molding devices |
| Geneticist | Assesses and diagnoses genetically linked diseases and disorders |
| Speech therapist | Diagnoses and treats disorders of speech |
| Social worker | Provides social services such as insurance needs |
A patient’s visit to the craniofacial clinic is attended by all members of the craniofacial team. This provides for multispecialist exposure in a single visit. In addition, with all the specialists in the same place at the same time, communication and consultation between the specialists are vastly facilitated and sometimes take place during a scheduled craniofacial conference that follows the clinic.
THE PRENATAL VISIT
In our practice, 20 to 30% of the initial family contacts are made in the prenatal period. With advances in early detection using ultrasound and the increasing frequency with which this modality is being used, partially because of an aging childbearing population, many cleft diagnoses are being made in the prenatal period. Now it is not uncommon to consult with the family regarding the cleft of their unborn child. This does afford several advantages to the surgeon and family. Time can be spent with the family discussing the plan of management in the prepartum time period before the upheaval of the postpartum time is upon them. Families also have the opportunity to meet members of the team and absorb the information. Being more prepared and informed enables more time and energy to be spent on the other aspects of care in the first few weeks of life with a cleft baby.
INITIAL POSTPARTUM VISIT
The first visit to the craniofacial clinic for a cleft child and family can be a very busy one. This is often the first opportunity for the family to meet the team and the team to meet the family. Feeding issues are often first on the list to be addressed. Most babies with a cleft lip with or without palate have some degree of difficulty nursing. The limitations of sucking, usually due to (1) an inability to create a seal or vacuum and (2) an abnormally arranged oral and velopharyngeal musculature, must be bypassed. The feeding specialist can counsel parents on the use of specially designed bottles and nipples for babies with clefts. The common denominator among these special bottles and nipples is that they ease the passage of milk from the bottle into the child’s mouth so that minimal sucking is required.
THE FEEDING EVALUATION AND MANAGEMENT
Feeding problems accompanying a diagnosis of cleft lip, cleft palate, or both have been widely documented in the literature, as well as the potential consequences of these feeding difficulties. Wilcox et al1 showed the association of feeding difficulties with death in developing countries. Pandya and Boorman2 described failure to thrive of infants with cleft palate in developed countries. Furthermore, several studies have shown slow weight gain in infants with cleft palate.3,4,5,6 The combination of a well-informed and educated parent population and better access to medical information has increased the awareness of potential feeding problems of children with clefts. Young et al7 studied the information that parents of children with cleft lip, cleft palate, or both felt was most important to them. Feeding issues were a topic that parents deemed “critical,” with an emphasis on bottle-feeding difficulties and learning about special nipples and feeders available to their children.
At Children’s Healthcare of Atlanta’s Center for Craniofacial Disorders, we have listened to the parents and developed the Craniofacial/Lactation Infant Feeding (CLIF) clinic to address the feeding concerns for this population. Infants are seen in the CLIF clinic as soon as possible after discharge from the birth hospital. This is often the first visit the family makes to the craniofacial center and is a crucial starting point for a lifetime of care. During this visit the family meets with the feeding team, which consists of a nutritionist, a feeding specialist (either occupational or speech therapy), and a lactation counselor. They also meet face to face with the clinical nurse practitioner, with whom they have already been in contact by telephone. It is at this first visit that decisions regarding the best feeding device are made, nutritional status is determined, and a treatment plan is developed. The severity of issues (e.g., weight status, severity of cleft, respiratory issues, ability to feed orally) assists with determining how quickly the infant needs to be seen by the surgeon or other specialists (e.g., gastrointestinal; ear, nose, and throat) or whether admission to the pediatric hospital is warranted.
During the first visit, the infant is weighed and measured so that the nutritionist can determine the current nutritional status, the ideal weight of the infant, and the amount of calories needed daily for proper growth. This is accomplished through the use of growth charts on which the weight, length, and head circumference for each infant are plotted and percentile ranks are determined. The nutritionist then uses the weight for length section of the growth chart to determine the ideal weight of each infant for the infant’s specific length. The actual body weight is then divided by the ideal body weight to determine the percentage of ideal body weight of each infant. This generally must be 90% or above before the infants are discharged from the CLIF clinic and cleared for surgery. The nutritionist and feeding therapist also act as a team to identify what the infant is being fed (breast milk versus formula), how many ounces the infant is receiving at each feeding, and how many ounces total the infant takes in for a full 24-hour period.
While the nutritionist is calculating the ideal body weight and the number of calories needed per day for proper growth and nutrition, the feeding specialist performs an oral evaluation to assess the cleft and the effects it might have on feeding, the infant’s feeding reflexes, and the strength and function of the oral anatomy. The type of cleft is determined and classified as bilateral, unilateral, or horseshoe shaped and complete or incomplete. The feeding therapist then checks for the presence of all oral reflexes that should be present at birth including rooting, suck initiation, and transverse tongue reflex. The feeding therapist evaluates the infant’s nonnutritive suck and swallow skills such as ability to achieve lip seal, central grooving of the tongue, suck burst, suck strength, and suck-to-swallow ratio. Respiratory status is also closely examined as breathing is the infant’s first priority. This is achieved by monitoring respiratory rate before, during, and after the feeding as well as with the use of an oxygen saturation monitor. Any and all respiratory issues have to be treated for the infant to feed safely and efficiently. Information obtained during the oral motor and nonnutritive examination as well as the respiratory evaluation assists in determining the most appropriate feeding device for each infant.
Traditionally, infants with cleft lip, cleft palate, or both have been fed using a NUK orthodontic nipple or a harder cross-cut nipple placed on a squeezable bottle. The advent of bottles with one-way valves that use compression (positive pressure) versus suction (negative pressure), such as the Haberman bottle and the Pigeon nipple, has offered new and improved ways for parents to feed their infants. There is no right or wrong nipple or feeding device, and there unfortunately is no simple equation to determine the most appropriate one. It is specific to each infant’s status and the comfort of the family with the device. There are, however, some generalities we use to determine which device to attempt first (Fig. 1).
Burn Spots After Chemical Peel Treatment
Undergoing a chemical peel can have many positive benefits, but it’s important to know what to do and what to avoid afterward. Here are the top ten things to avoid after a chemical peel.
1. Picking at the skin
The entire reason a person gets a chemical peel is to burn off the surface and get rid of damaged, dry skin cell layers. In order to do this, the skin must shed – which is what many people dislike the most about a chemical peel. Picking off the dry skin before it can lead to scarring and extra redness.
2. Skipping sunscreen
It’s critical to protect skin from the sun at any time, but especially after a peel – no matter how strong or what the type of peel was. Ideally, a person would avoid the sun for the first week or two, but if they can’t, then they should wear sunscreen. Not doing so can lead to blotchy patches and irregular skin coloring. An SPF of 30 or higher is recommended and it should be applied about a half an hour before going outdoors.
3. Letting the skin dry out
Keeping the skin clean after a peel is very important. The best option is to wash with cool water and a mild soap.
4. Not applying moisturizer
Along with regular washing, keeping the skin moisturized is also essential. A fragrance-free, dye-free, gentle moisturizer should be applied right after washing it – every time it’s washed!
5. Applying too much moisturizer
It is important to moisturize regularly, but it’s also important to avoid putting on too much moisturizer. Remember that the point of a chemical peel is to let dry surface layers peel. If they’re over moisturized, they may not flake off properly.
6. Being afraid of cold compresses
There’s a rumor out there that cold compresses work against the benefits of a chemical peel. This simply isn’t true. A cold compress can actually be very soothing and can help the skin heal faster.
7. Exfoliating
It can be tempting to exfoliate. After all, there’s skin peeling and it appears that it wants to be removed. The truth is that exfoliating can remove the skin before it is ready. This can lead to inadequate results and even scarring.
8. Expecting immediate results
There are some cosmetic treatments that have immediate results. Chemical peels are not one of them. While the results can be incredible and they’re well worth the wait, it does take a few days for the full results to be obvious.
9. Not staying hydrated
One of the best things you can do for your skin is to keep it hydrated. This is true right after a peel and it’s true every day of your life. Drink plenty of water.
10. Drinking excessive alcohol
While it is most likely fine to have a glass of wine or a cocktail, imbibing excessive alcohol can depress the immune system and should be avoided as it makes it harder for your face to heal.
Biscayne Wellness CenterDo you have questions about cosmetic treatments including chemical peels? Please contact Biscayne Wellness Center today for more information and to set up a consultation. We will be happy to answer any questions and discuss which treatments might be best for you.
How to treat hyperpigmentation after chemical peel
The application of systemic isotretinoin in the treatment of cutaneous photoaging has been well investigated. In addition, well-recognized topical antiaging therapies such as superficial chemical peeling (CP) with α-hydroxy acids have been shown to be more helpful when combined with low-dose oral isotretinoin. Even though the combination of systemic isotretinoin and medium to deep CP has been associated with serious side effects such as delayed wound healing and enlarged incidence of scarring, to date superficial CP and concomitant systemic isotretinoin have been considered safe.
Case presentation
In this report, we present the case of a patient receiving low-dose oral isotretinoin therapy who developed severe painful erythema and erosions that led to permanent hyperpigmentation and scarring of her face and neck after undergoing superficial CP with glycolic acid.