You'll find hundreds of files on cleft lip, cleft palate here on widesmiles.org.

This one is about: Q&A Chat with Dr. Canady, October 9, 1998

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Q&A Chat on IRC with Dr. Canady
Friday, October 9, 1998

Dr. Canady: The information presented in this forum by Dr. Canady is for informational purposes only. No attempt to practice medicine will be made because that would require a physical exam which is impossible in this setting. No specific treatment or therapy will be given for any individual. All comments are general in nature and are not meant to imply or infer the superiority of any treatment. If you wish to receive medical treatment, see your local physician or surgeon. If you cannot find a doctor who will see you, you may make an appointment in my office by calling 319-356-2168.

Dr. Canady: Sorry about that, but I think by now everyone understands the necessity of it.

Joanne: To begin tonight, Melissa has a question for you.

Melissa: Hi Dr. Canady, not sure if you remember us. Hannah is almost 3 years old, PRS, and Sticklers. (2 unsuccessful palate repairs in Dallas) She just had her palate repaired for the third time (not in Dallas this time). We are 5 weeks post op - still in arm restraints and still on full liquid diet. Her palate looks great and somewhat of a speech improvement - given all the scar tissue we are dealing with. Here is my question.

Dr. Canady:  I remember

Melissa: In 5 days she can start soft foods. I am terrified of giving her a spoon and letting her feed herself. After 6 weeks postop could a spoon do damage to the newly repaired palate?

Dr. Canady: Generally, if healing has gone without complications, most people feel that at 6 weeks the tissue has about as much strength as it is going to get. There will be some increase as the scar remodels, but the additional increase in strength is slight compared to what has happened in the first 6 weeks.

You might also consider letting Hannah feed herself from a cup with soft foods that will run out of a regular cup (ie., blenderized, or watered down a bit)

Melissa: ok, we will give that a try. Thank you VERY much for EVERYTHING!!! We are very pleased with how things have turned out!! What you told me a while back made a difference in how things turned out this time. I just wanted to tell you THANK YOU.

Dr. Canady: OK and I am REALLY glad to hear that Hannah is doing well. The key is just to never give up...you're a great mom.

Melissa: Thank you. I was able to discuss many of the ideas that you had given to me, to our new PS.

Joanne: We are ALL so excited by the good repair. Thank you, Dr. Canady. Lori has a question for you now.

Dr. Canady: Hi Lori

Lori: Hi Dr. C. My question is about Todd. The closest cleft in our families is Todd's brother, who was born with an incomplete lip only. Recently, Todd had an exam for seasonal hayfever. The doc asked him is he had ever broken his nose. He hasn't. It  seems his nasal bone is way off center. Would you assume that he could have also been "almost clefted", so to speak? He also has many sinus problems, such as constant congestion...What do you think?

Dr. Canady: Almost no one has a nasal septum that is exactly in the midline. Some people think that this may be a result of trauma in the birth canal, but I don't know that anybody really knows if that is true or not. I have seen thousands of very crooked nasal septums in folks and I don't personally believe that these are a "soft" sign of clefting, because the incidence in the general population is way way more than the incidence of clefts. Some people get better in terms of sinus complaints if their nasal septum is straightened and some don't.

Lori:  Thanks very much! Spencer says "Hi!"  :)
Dr. Canady: Hi to Spencer, I'll bet he's getting big...
Lori: Yep, VERY. Should tolerate surgery well. Thanks again.
Dr. Canady: No problem, good talking to you.

Joanne: Thank you, Dr. Canady. I do have a couple of questions for you that came from the list.

Dr. Canady: OK

Joanne: Concerning submucous clefting...how is a submucous cleft actually definitively diagnosed?? We know that speech problems, a bifid uvula and food through the nose are signs, but what do YOU look for to make the diagnosis?

Dr. Canady: There are several things. A bifid uvula like you mentioned, but often you can see a darkness in the very center of the soft palate that is actually a thinning of the muscle so that the darkness of the nasopharynx is noticeable in the midline. You can also feel the muscle separation and notch of the posterior hard palate (if the notch is present) with your finger (kids bite though, so you have to watch out!!!!! And finally, if you look with a nasopharyngoscope, you can see a groove most of the time on the nasal surface of the palate.

Joanne: I know of one child who was born with a bilateral cleft lip and - cleft soft palate, hard palate intact. As the child has grown, though, there appears to be a groove down the center of the hard palate. Would that family be concerned about a possible submucous cleft?

Dr. Canady: I have seen that type of "skip" pattern too, but is very rare and there are some folks who claim it doesn't exist...but it does. If the child had a frankly cleft soft palate that was repaired, then technically the diagnosis of "submucous cleft" would not generally apply, because it is usually applied to conditions of the soft palate. I guess almost everyone who has had palate repair would have a "submucous" (bony) cleft of the hard palate, because it is rare to find someone now who does primary bone grafting of the hard palate. There is no physiological or functional impact to not having contiguous bone in the hard palate as long as there are no fistula, ie., the nose and mouth are separate cavities. ok?

Joanne:  Yes, thanks. That answers the question very well. Next, Bonnie has a question for you.

Dr. Canady:  Hi Bonnie. What can I do for you tonight?

Bonnie: Hello Dr. Canady. I Have a 4 month old, Griffin with a unilateral cleft lip and complete palate who had his 4 mo. checkup yesterday and dropped to the 10% in height and weight. My ped and I believe it is a setback from lip repair and wants to see him at 5 mo. for a height and weight check.

She said I can start him on cereal at anytime. 1) Would you have a concern with his height and weight or is this common in cleft babies? and 2) Do I need to be aware of anything feeding him solids? Thank you

Dr. Canady: We certainly see drop off a little on the height and weight charts post operatively, but we really like to see them get right back on their individual curve as soon as possible. The differences from one percentile to another are very small so even a little change in weight can make a difference as you child gets older. The pattern over time is the thing. I recommend to moms that they pretty much feed the kids the same stuff they would regularly do if no cleft was present. I also recommend that they finish any feeding with some type of liquid to dislodge any solid food particles that may get stuck in the cleft. Kids are very adaptive and they will surprise you with their ability to eat just about anything. (except broccoli, that is !!!!--just kidding.)

Bonnie: Thank you I will keep away from the brocolli!

Joanne: Thank you, Dr. Canady. Next, Joani has a question for you.

Joani: My son (born with an incomplete unilateral cleft lip) is 2-1/2 months post-op from his lip repair. I am really concerned about the thickness and stiffness of his lip. I am massaging it as per instructions from our plastic surgeon. We were not given specific guidelines as to how much and how often to massage. I am worried that I if I don't massage it enough I will compromise his healing. Also I am concerned because the thickness and stiffness is most apparent when he smiles, it looks perfect in a relaxed state.

Dr. Canady: At 2-1/2 months, the wound is just entering the maturation phase where the collagen begins to pack down and usually the scar begins to look better with time. Bottom line -- things will in all likelihood improve a lot with just the passage of time. Things that people recommend for treating scars that are more hypertrophic than you would like to see include: 1) massage -- as much as the mom/child will tolerate and sometimes vitamin E oil makes the skin slicker and the massage easier. Aloe Vera is also used sometimes, too. I know of no prospective, double blind, randomized studies that show the benefit of either of these, but there is not much danger from Vitamin E used topically or aloe vera so a lot of people recommend it. 2) Silicone sheeting has also been shown to help reduce some scarring, through an unknown mechanism. In my hands, this seems to work better if applied early in the healing process (the gel sheet is cut and applied topically -- some of them are manufactured with an adhesive in the sheeting or you can use a piece of tape. 3) Sometimes a steroid medication such as Kenalog is injected into the scar to help soften things up.

Joani: At about what point in the healing process should we start to see it actually 'looking better'. I realize that this is better predicted on a case by case basis.  But generally speaking?

Joanne: But for the most part, if the parent feels the baby is not tolerating massage, and the scar is not red and angry, but maybe simply thick and stiff... are you saying that there is no need to be too worried?

Joani: Thanks Joanne, you took the words right out of my mouth!!

Dr. Canady: It is really individual and it is frustrating because it happens gradually. I think that is right Joanne, but if there are concerns, I would suggest talking to her surgeon about it because some of the other things that I mentioned are low risk options as well. From what you described, though, I'll bet things will turn out real nice with the passage of time. It can take up to 18 months for lip scars to really mature in these little kiddos.

Joani: Thank you so much.

Joanne:  Thanks, Dr. Canady. Next question comes from Cindy.

Cindy: Thank you for being here tonight Dr. Canady. My question is about Pharyngeal Flaps. Just a reminder - I have 3 cleft affected children. My oldest had the P-flap at 5 and since then I have learned of the problems it can cause. Now, our PS says my youngest will need one. Is there a reason why some surgeons will opt to do a flap other than another procedure? I guess what I am asking is, Is the flap the best even with the risks? Can there...

Joanne:  I think part of your question was truncated. after your question -- Is the flap the best, even with the risks?

Cindy: Yes, that was the first question.

Dr. Canady: The jury is still out on what is the best operation for VPI and probably there is no "best operation" for all kids. We do a diagnostic work up with the speech folks at our center and individualize the treatment for each patient. A lot of our choice is based on the pre-op videonasendoscopy and the position and size of the persistent closure defect. I personally believe the pharyngeal flap is still a good operation and properly done, it does not have unreasonable risks. There has been at least more one presentation at the yearly national cleft meeting (Portland, OR) that purported to show that the flap was superior to the sphincter operation. There are a lot of variable in looking at this -- ie., who is doing the surgery and how often they do it, and (real important) who is assessing the results (surgeons generally say "speech is great post-op" while speech therapists may have a different opinion after putting the patient through a more thorough speech evaluation...

Cindy: Have you ever heard of VPI being familial?

Dr. Canady: Only in terms of syndromes that run in families and have palate dysfunction as part of the syndrome or phenotypic presentation -- this may be as a result of anatomic challenges (ie., cleft or sub-mucous cleft palate) or neuromuscular disorders that affect the velar mechanism.

Speech patterns are commonly familial -- you talk like your parents and your kids talk like you -- that's the way you learned. Really done now.

Cindy: Ok wow. Yes, we do know there is some syndrome going on. We just don't have any answers yet. Thank you very much!!!!

Dr. Canady: You're welcome

Joanne: Thank you, Dr. Canady. The next question comes from Carin.

Carin: Hello Dr Canady, is there such a thing as "tissue memory" in relation to a rhinoplasty? Is it a known occurrence that on occasion, after a rhinoplasty the nose will "pull" in the wrong direction, meaning, are there studies and warnings in journal articles that support this? Would it be indicated, after such an occurrence, that during the revision, the bridge should be positioned off center to over compensate in the other direction?

Dr. Canady: There is absolutely "tissue memory" in a lot of tissues -- skin, cartilage, etc. The art of surgery is trying to effectively deal with this in a situation where all the things that affect this (scarring for one) are not totally under the control of the surgeon. It is sometimes indicated to over correct something, but this is dangerous, too, because there is no law that says the over-corrected portion has to settle in to the position you want it to.

Carin: But it is something that is done?

Dr. Canady: It depends on the individual situation and circumstances. Probably it is most commonly done for something like otoplasty (correcting of protruding ears), because they will almost always move away from the side of the head a bit as they heal. Other areas, like the nose, etc. are harder to predict.

Carin: Ok, thank you Dr Canady :)

Dr. Canady:  You're welcome

Joanne: Thanks. Now Lori has another question for you, Dr. Canady.

Lori: I thought of another question that's been bugging me. When you repair the palate, I understand you "loosen" the tissue to suture it together (I've seen the reconstruction video). What do you do with the open space between bony areas? Will that space just be "open" underneath the new palate?

Dr. Canady: The space between the bony shelves is closed in at least 2 layers and usually fills in with scar. Sometimes though, a very thin sheet of bone will actually grow there because you have actually created a periosteal pocket when you do the repair. Periosteum has the capacity to cause bone formation, but as I said before, bone is functionally not necessary in this space.

Lori: Okay, I didn't know that. Thanks very much...again.

Joanne: Thank you. Now, I have a question that was sent to me over the list. I will need to copy and paste it.

Joanne: Hello, my name is Debbie and I have asked Joanne to submit this for me, as I could not be at the chat tonight. My daughter is Jessica, age 12, bilateral cleft lip, left side complete, right side incomplete, and unilateral cleft palate, left side. On July 21, she had nasal reconstruction,
cheiloplasty, excision turbinate, and a fat graft. My question is about the fat graft. We were not informed of this part of the surgery until the morning of t

Joanne: There is more....

Dr. Canady: OK

Joanne: Later I discovered that this might not be standard cleft lip treatment. The surgery involved removing fat from her abdomen, leaving an 8 inch incision, and grafting the fat in the upper lip. I believe the fat went not only in the colored part of the lip, but the whole section between the nose and lip. I'm sorry my medical terminology is not great here. It was done to correct the flatness of this area and it has, at least for the short term, i

Joanne: Her bone structure is great, she was bone grafted 4 years ago, with no problems. Is this a newly accepted procedure in the care of clefts? Since the procedure was done, I have done some reading and found that fat grafts often absorb into the body, and therefore do not last. Is this true as you understand fat grafts? Also, if fat grafts are not the standard protocol, what other procedure could have been done to correct the flatness in her upper lip?

Dr. Canady: Fat grafts are sometimes done to provide additional tissue augmentation. Fat can be harvested either directly or with liposuctions and can be placed as a regular graft in the recipient area or injected with a syringe. Some people believe it lasts longer and more completely if it is not harvested via liposuction, but the science on this is not real solid in my opinion. Some of the graft will almost certainly resolve, but the total amount that remains is individual. I wrote a paper a few years ago to show that fat will stick around in the palate and I have used injected fat grafts successfully in people with minimal VPI.

Joanne: This graft was done on the lip itself.

Dr. Canady: I have used fat grafts there, too and they generally work well, but they may have to be augmented in the future.

Joanne: Thank you. I believe we have only one question left...and it's mine. So if anyone here has another question, please private message it to me while I am asking this one. It is a question that has come up on the list... regarding myringotomy tubes...two parts.

Dr. Canady: I'll put on my ENT hat

Joanne: First part -- many parents are advised to put tubes in prophylactically. Perhaps their child has not had infections yet; maybe there has been some fluid... but there is a surgery, and the doctor advises it... (more)...

Dr. Canady: OK

Joanne: One parent wanted to know the pros and the cons of prophylactic tubes. I'll ask the second part after this.

Dr. Canady: In kids that I care for that have cleft palate, it is almost unheard of for me to have the child in the OR and not look at the ears (I am double boarded in ENT and Plastics, though so I still have an attachment to the ears, hearing etc.) And just about every time I make a myringotomy in the eardrum of a child with a cleft palate I find fluid. This causes about a 20-30dB hearing loss (similar to putting your fingers in your ears) so I put tube in these kids (with parent's permission) because I believe that they will hear better and speak better. If they don't have a real history of acute infections, then I guess this could be considered prophylactic, but it really isn't. I honestly can't remember the last kid I saw with a cleft palate and no fluid in both ears after myringotomy at the time of palate repair.

Joanne: Ok, the second part then has to do with the types of tubes we use. Our kids need tubes for a long time, usually. Grommet type tubes make smaller holes, but they need to be replaced often. T-tubes make bigger holes, but we need fewer sets. What are your thoughts as to the types of tubes we choose for our kids? (We also are looking at more scar tissue vs. possible holes left by the tube). (One of my most famous lines on the list is... "It's always something of a trade-off", by the way). LOL

Dr. Canady: Generally, tubes that stay in longer (like T-tubes) have a higher incidence of persistent TM perforation after extrusion/removal. This may not be all bad, though, because the persistent hole usually doesn't affect hearing as much as an effusion and makes the ear safer in terms of eliminating chronic negative pressure (more)

Tubes that come out sooner (grommets) may have a lower chance of persistent perf, but that chance still is not zero. I usually put in two set of grommets or so and then go to T-tubes, but each case is individual and I vary a lot.

Joanne: ok...Thanks Dr Canady.

Dr. Canady: You are welcome. This was fun as usual. Good questions. 'Bout time for me to turn in. Hope everyone has a good evening.

Joanne: Thank you so much, Dr Canady.

Dr. Canady: Thanks everybody and goodnight. I'll talk with Joanne and we'll set this up again in the future.