This one is about: Fetal Cleft Palate Repair: Could it Someday Become a Reality?

(c) 1996 Wide Smiles
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In the summer issue of Cleft Palate Reflections, editor, Dr. Robert McKinstry, reviews research done by Dr. John Canady, which was published in the Cleft Palate-Craniofacial Journal 31 (1): 37-44, 1994. The review of that research reads as follows:

Recent observations have shown that fetal skin tissue, if repaired early in gestation, heals without scarring. The authors sought to test this lack of scarring phenomenon in a fetal lamb model. Surgical clefts of the palate were created and repaired in the same operation in ten fetal lambs. The surgery was performed at different gestational ages. After repair the fetuses were returned to the uterus. One month after birth the palatal tissue was examined. The results indicated that when the clefts were repaired before 70 days gestation there was no scar formation and the tissue appeared normal in every respect. In the clefts repaired after 70 days gestation significant scar formation was observed.

This is one of the first studies to specifically focus on fetal cleft palate repair. Earlier studies have focused on fetal repair of clefts of the lip and alveolus. Further studies are needed to determine differences in fetal healing between the lip and palate. Additionally, more studies are needed in large animal models before application to human fetuses can become a possibility.

The big question in everyone's mind, of course is this: What does this mean for our children? Well, it could mean nothing, and it could mean everything. But most of all it means that the future of cleft care is full of exciting possibilities.

Of course, for children already born, fetal repair is a moot point. But for our children's siblings yet to be born, and for our children's children, and for generations to come, there may be some very welcome news indeed on the horizon.

Could it be possible to actually "undo" a cleft, simply by repairing it early enough? At this time, we don't know for sure, but the research is promising. If, however, we find that what we are learning from these early animal studies remains true for human fetuses as well, then there may very well be a time when a child with a cleft can be born perfectly normal.

However, even under the best of circumstances, that time is not exactly just around the corner. As is indicated in the review, many more studies must be done before we can even begin to apply this technology to human babies. And, while some fetal surgery is done today, it is done only rarely, and then only for life threatening conditions, and not for cleft repair. Fetal surgery is simply too risky for both the mother and child.

More realistically, this sort of research teaches us a great deal about how the body forms scar tissue and how scar tissues resulting from surgeries may be minimized in the future - even when surgery is performed after birth.

By some estimates we might see some of this technology actually affecting our children within the next few decades. When one realizes how that, at the beginning of this century a cleft was considered a "crippling" condition, and the cleft-born person was treated as an outcast, one can hardly help but believe the truism that "we've come a long way, baby!"

The possibility of prenatal surgical repair, as well as other technological surgical advancements, is one of the best arguments ever for perfecting the technology that allows for prenatal diagnosis. At present, a prenatal diagnosis allows the family to prepare for the birth of a cleft-affected child. Perhaps in the future such a diagnosis can provide parents with the opportunity of avoiding the problems that go along with a cleft-affected birth.

As promising as that may be, there will probably always be cleft-born children. A prenatal diagnosis occurs most often when possible problems with the fetus are suspected - perhaps because one or the other parent has an inheritable condition. Many clefts remain unsuspected, and therefore, many children will continue to be born with a cleft that is suspected only when it is evident by birth.

But perhaps the cleft-affected child born today can conceive with the certainty that her child need not be born with a cleft as well - even if the gene is shared. Dare we dream?

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Update 1998
 The Cleft Palate-Craniofacial Journal: Vol. 35, No. 5, pp. 425P429.

 Adverse Outcomes Following Endoscopic Repair of a Fetal Cleft Lip
     Using an Ovine Model

Eric J. Stelnicki, M.D., Karen Vanderwall, M.D., William Y. Hoffman, M.D., Zoltan Szabo, Ph.D., Michael R.  Harrison, M.D., Rob Foster, and Michael T. Longaker, M.D.

 
     Objective: The purpose of this study was to determine if endoscopic techniques could be used to repair an epithelialized lip cleft with accuracy and with an outcome comparable to fetuses treated through an open
hysterotomy.

     Interventions and Results: In contrast to previous open fetal cleft lip repairs in the same model, none of the five fetuses reported here had a good aesthetic result. Although there was no evidence of scar histologically, the edges of the lip were poorly approximated. The epithelial lining and underlying dermis of the wound margins were notably inverted. The orbicularis oris muscle, which had been reapproximated, appeared thin and hypoplastic. Most of the vermilion elements were poorly aligned, and in one animal, there was a complete dehiscence of the repair.

     Conclusions: In a more representative model of cleft lip that is not an acute lip wound, in utero endoscopic suture repair of the ovine lip gave a poor result using current technology. Only a meticulously performed, multilayered, open repair of a cleft appears to give a good cosmetic and functional outcome. Further studies to improve the endoscopic repair as our technology advances are therefore warranted.

--------Dr. Canady, the author of the research discussed above, will be attending the WIDE SMILES Symposium on Cleft care, where he will present topics on the Future of Cleft Care and on Adolescent Issues.