Bill Klaproth: This is OMS Voices, an AAOMS podcast. I’m Bill Klaproth and with me is Dr. Austin Gaal, who is here to discuss what to know about cleft lip and palate. Dr. Gaal, welcome.  

Dr. Austin Gaal: Hi, Bill. Thanks so much for having me. I’m excited to be here.

Bill Klaproth: Yeah, well, we’re excited to talk to you about this. Let’s start here. What are cleft lip and palate, how common are these conditions, and how severe can they be?

Dr. Austin Gaal: I’m very excited to talk about clefts. There are many things I could say, but it’s actually pretty complex to describe what a cleft is. A simple explanation, you could say it’s basically a notch, but it can really be a severe notch or a small notch because of how a face comes together. If you vaguely remember any embryology classes from school...  

Bill Klaproth: A little bit.  

Dr. Austin Gaal: ...I mean, I don’t know, I vaguely remember. I studied it a lot, and it’s hard to recall any of that. An embryo looks almost like a caterpillar. Okay, okay. If you can imagine the face coming together in utero, and it looks kind of like a caterpillar, and there are all these little bumps that have to merge. So, in the center of the face, there’s these bumps or processes, depending on how much trouble they have merging, that correlates to clefting. You can actually get even a facial cleft, but it’s most common to have a lip or a palate. So a cleft lip is the most common and that’s usually when there’s a severe notch where the middle and side don’t come together.  

Bill Klaproth: And that affects the skin and the bone behind it, is that right?  

Dr. Austin Gaal: Yes, so again, depending on the severity, it could be just soft tissue, but usually, it’s both soft and hard tissues that are affected.  

Bill Klaproth: Okay, so we hear in America it’s not as prevalent as it is in other countries, is that right?  

Dr. Austin Gaal: Yes, and so nobody knows exactly what causes this. We have lot of studies out there, but it’s all corollary. Basically, people put out surveys and say, okay, how many out of these thousand people have clefts? You know, and in America, we are lucky; we have the nutrients we need, you know, we have folic acid. So, in America, it’s fairly uncommon. Across the world, the overall incidence is about one cleft per 700 live births.  

Bill Klaproth: That seems higher than I would’ve expected.  

Dr. Austin Gaal: One for 700, yes.  

Bill Klaproth: Wow, my thought is when the baby is born, you see this right away, but is it something that gets diagnosed? How does that work?  

Dr. Austin Gaal: Well, back in the old days... a kid was born with a cleft, and I was really surprised. Oh my God, and they whisked the kid off to the corner, and that’s not the way it should be, you know? And thankfully, care has improved a lot, that it’s not a bad thing. It’s just part of who we are as humans. And historically, they’d whisk the kid off to the ICU, and they’re like, how is this kid going to survive? And then the parents and the kid don’t bond. So, to answer your question, it used to be just a big surprise to everybody. Okay, now we have ultrasound. And so in countries and places that have access to care, usually around the 14th-ish week ultrasound, you can pick up a cleft, but again, remember I said, cleft can, it depends how severe it is. So some kids, I see this in certain places where it’s very minor, where it’s just a little notch on the lip, and you can barely tell even when they’re out of the womb, sometimes they don’t even pick it up until they’re born.  

Bill Klaproth: Okay, but you can see it. So if you see it ahead of time, in utero, if you will, are you prepared then? Do you already have a plan in place? Okay, we’re going to let this baby be born, we’re going to let this child bond with their parents, and then several weeks later, we know how to address this.  

Dr. Austin Gaal: Well, exactly. Just like any part of child planning, it’s thankfully with better medical care that we have, we can do prenatal counseling. For example, one of my kids—I won’t break too much HIPAA—had a medical condition, right. And so that informed us as parents, okay, well, we, this is how we can prepare for that, and we can visit with the appropriate personnel. So, what I offer a fair bit of prenatal counseling, apparently referred to me through the cleft team because they had their 14-week ultrasound. They picked up a cleft, right? They should know about it because it helps them make informed decisions. It helps them prepare.  

Bill Klaproth: So they know. So there’s not that surprise. So they know, and they probably are comforted knowing there’s a plan in place. So, when is the initial surgery then performed generally for these conditions?  

Dr. Austin Gaal: Well, that’s a really good question. There’s actually tons of data and arguments about when to do this, they’ve even tried to do it in utero. But generally, and this is based off of historical literature from the 1960s, which I actually follow because, who doesn’t like the 1960s, right? The rule of tens, which means basically when a kid is about 10 weeks old, weighs 10 pounds, so that’s usually around three months. And the reason is, back in the day, for a 10-week-old baby, you want the kid to survive the anesthetic. You don’t really want to do this when the kid’s really small because of safety. Now what’s interesting is over the years, anesthesia is a lot better than what it used to be in the sixties, I’d argue. There are folks that try to do it early, like I said, in utero, but outcomes, long-term, it doesn’t really improve the condition.  

Bill Klaproth: Does the severity change the timing of it? If it’s really severe, do you try to repair it earlier because the child will have problems latching on for feeding?  

Dr. Austin Gaal: So one common misconception is me fixing a cleft, and it’s not just me. The surgeon’s not the only person, it’s a team, but fixing the cleft will not make a kid eat. Everybody’s like, hurry up and fix it. So, fixing the cleft is not going to make a kid eat.  

Bill Klaproth: Okay. Does it hamper the child from latching?  

Dr. Austin Gaal: So, if a kid has a cleft palate, because we didn’t talk about anatomy as much yet, but the cleft could be just the lip. But most of the time, it’s both the lip and a palate. So if a kid does not have an intact palate, they can’t suction. So they actually usually have a lot of challenges breastfeeding. But again, you can’t even fix the palate safely, usually until a patient’s at least eight months old.  

Bill Klaproth: How is that child fed then? Is it...  

Dr. Austin Gaal: That can be complex. Most of the time, most of the kids that I treat are able to tolerate a special bottle, where it’s basically a one-way valve. And it works, but some kids end up needing additional therapies to help with nutrition.  

Bill Klaproth: I would imagine. So then what happens if a cleft lip/palate is left untreated?  

Dr. Austin Gaal: That’s a great question. As long as they can tolerate oral intake, they keep growing and live their lives. And I have some adults that I’ve seen in other countries that have not been repaired yet. My oldest kid that I was able to personally treat was I think in his mid-twenties. So, fixing the cleft doesn’t ensure feeding, right. Now, it’ll help long-term. But to answer your question, if it’s not fixed, there are so many issues for the poor kid, their speech. The kid that I treated couldn’t talk, right. And that’s the main thing, his integration into society. So a cleft lip and palate, it’s not just anatomy. I think the biggest mark of success is how a kid owns who he is, or she is, or they are, and how they can feel integrated into society. If they don’t get it fixed, they have a lot of psychosocial issues and clearly problems, functional deficits.  

Bill Klaproth: It’s not just physical. At that point. So, you mentioned that team of healthcare professionals. Who is involved then? Talk about that team that’s involved in repairing and treating a cleft lip and palate. And what is the OMS’s role in all of this?  

Dr. Austin Gaal: They’re good questions. So, the American Cleft Palate Craniofacial Association, which is the accredited group that brings people together in America that help kids with cleft lip and palate. Their accreditation standards for a team caring for cleft lip and palate is you need a coordinator. You need a quarterback to get the team together. … You need an orthodontist. And I would say the orthodontist is critical. We haven’t talked about teeth, but it depends on what you want to talk to me. So, coordinator, orthodontist, you need a speech therapist. And don’t worry, I won’t recite 20 members. There are actually only four main members. It’s the coordinator, orthodontist, speech therapist, and a surgeon who’s competent with cleft care. So, those are the four main ones. But you need access to a host of people. For example, on the Yakima team that I’m a big part of, we have a geneticist, we’ve got a behavioral psychologist who’s excellent to help us with a lot of kids who are overweight. You know, we’ve got, of course, dentistry, pediatric dentists. So, you should have access to multiple specialists, plastics, ENTs. And so to answer your question, I know it’s a big question you’re asking me, what do we do as OMS? I think as oral and maxillofacial surgeons, we have such a great background with the dental field. Because as a team, you need to communicate, right? And so, as I said, the orthodontist has a very big role to help get this kid a bite because of function. And so, we can communicate very well with the orthodontist, and they need that because if you’re trying to speak English to somebody who doesn’t speak English, you have to talk the same language. We got to talk about how this canine is going to come in, or so, it’s so great to have oral surgery part of these teams. I always tell my residents, get on a cleft team, help out wherever you are.  

Bill Klaproth: Yeah. So, do you come in, there’s the coordinator, do you do the surgery? Do you come in next? And then it’s orthodontist and then speech therapist?  

Dr. Austin Gaal: It depends on the team’s capability and depends on the cleft severity. If a kid is born with just what’s called an incomplete cleft lip, what that means is basically there’s a notch in the lip, sometimes usually it’s a little deficit in the bottom part of the muscle, but it doesn’t go into the nose. Because clefting really is not just a cleft lip, it’s a cleft lip nose. As I said, sometimes a cleft could even be like here. Okay, so if it’s a small cleft, usually just the surgeon will take care of that when a kid is at least three months old, and that’s really for esthetics and so they can socially integrate. But you can wait on that small cleft. Now, if it’s a wide cleft, cause we didn’t even talk as much, if it’s a big cleft. Yeah, I like those because they’re more challenging. There are a lot of things we could talk about, but essentially, it’s better, maybe. There are some folks that argue it’s better and how to define that. But a lot of teams are able to offer pre-surgical orthodontics as well, basically. So, the orthodontist might be the first person that actually does something before we do the cleft. So, it depends on the case.  

Bill Klaproth: Right. So, then what is the outcome after cleft lip and palate surgery generally?  

Dr. Austin Gaal: And that’s a great question too because how do you define outcomes? What’s success? And the way I think about it is how does a kid feel about integration into society? Not, oh, I think that’s a perfect lip, or oh, that lip has a big notch, because that’s what we’re drawn to as surgeons, is to try to quantify something. And so that’s why there’s this 3D photography, and people are taking measurements and numbers and scales, but how does a kid accept who he is, or she is, or they are, you know. So, to answer your question, there are a lot of teams out there that try to quantify things. For example, there’s this thing called the Goslon Yardstick where orthodontists take casts and they measure how perfect is this cleft repair and the bite, and how does that compare to general norms. So, there are a lot of measurements out there.  

Bill Klaproth: I’m sure what you want is the most perfectly reformed, rebuilt mouth and look, and smile and all of that. So, what about parents? I know there is a psychological aspect to this as well, that you talked about. What advice do you give to parents who, rightfully, may be fearful learning their child has a cleft lip or cleft palate?  

Dr. Austin Gaal: Yeah, absolutely. So, Bill, I mean, knowledge is power. It can be something unexpected. Right when I had information from my kid, I was like, oh, okay, that’s one more thing we have to deal with. And so it would make a decision. So, your kid, nothing’s wrong with them, you know, it’s not that bad, there’s nothing wrong. It’s just, they just have a cleft, and so it’s just part of who they are. So, learn about it. And dive in, and the more you know about it, the more you can help them with owning that condition and giving them the best outcome and results that they can.  

Bill Klaproth: Absolutely. Well, this has been fascinating. Thank you, Dr. Gaal, anything else you want to add? As we talk about cleft lip and cleft?  

Dr. Austin Gaal: That’s a good question, Bill. I would say it’s a personal passion of mine, it’s just something that I ended up being fascinated with. I think we’re all different, and I think it’s important for kids and parents with clefting to just really own that, and it’s not a bad thing. And we as providers do our best to optimize outcomes, and we need to continue to do that. Things have gotten better over the years because we’re finally communicating better with each other. I talked to somebody in Guatemala by WhatsApp because I’m trying to help their local oral surgeon, or, because we want to make the world a better place. And so, it’s not a bad thing, it’s something that we can overcome.  

Bill Klaproth: Yes, right. And that’s important to know and important for parents to know that this can be repaired and fixed. So, for sure, Dr. Gaal, thank you so much for your time. We appreciate it. Once again, that is Dr. Austin Gaal. For more information and the full podcast library, please visit MyOMS.org. And if you found this podcast helpful, please share it on your social channels, and don’t forget to subscribe. Thanks for listening.