Cleft surgery is a set of reconstructive procedures that close gaps in a baby’s lip, gum, or roof of the mouth (palate) that formed during early pregnancy. Most children born with a cleft will have their first surgery before their first birthday, but the full course of treatment often spans years and involves several different operations timed to a child’s growth.
What a Cleft Is and Why Surgery Is Needed
A cleft forms when tissues in the face don’t fuse completely during fetal development, leaving an opening in the upper lip, the palate, or both. A cleft lip is a split in the skin and muscle of the upper lip, sometimes extending up toward the nose. A cleft palate is an opening in the roof of the mouth that connects the oral and nasal cavities. Some children have one or the other; some have both.
Without repair, these gaps make feeding difficult from birth, because a baby can’t create the suction needed to nurse or bottle-feed effectively. As the child grows, an unrepaired cleft palate prevents normal speech development and increases the risk of chronic ear infections and hearing problems. Surgery restores the structure so the lip, palate, and underlying muscles can function as they should.
Timing of Each Surgery
The CDC recommends cleft lip repair within the first 12 months of life, and most surgical teams schedule it around 3 to 6 months of age. Cleft palate repair is recommended within the first 18 months, or earlier if possible. Surgeons generally wait until the baby is old enough to tolerate anesthesia safely but operate early enough to support normal feeding and the beginning stages of speech development.
Before lip surgery, some teams use a presurgical device called a nasoalveolar molding appliance. This is a small custom-fitted plate, similar to a retainer, placed in the baby’s mouth along with a nasal stent. Over roughly four to five months, it gradually reshapes the gum segments and nasal cartilage, narrowing the cleft gap so the surgeon has less distance to bridge. Not every center uses this approach, but when it’s part of the plan, families attend regular appointments to have the device adjusted.
How Lip Repair Works
Cleft lip repair (cheiloplasty) rebuilds the upper lip so it looks and functions as close to normal as possible. The most widely used approach for the past half-century is a rotation-advancement technique. The surgeon makes precise markings on the lip to identify key landmarks: the center of Cupid’s bow, the philtrum columns, and the base of the nostril. The tissue on the cleft side of the lip is then advanced inward while the tissue on the middle portion is rotated downward into its natural position.
The goal is to restore the natural curve of Cupid’s bow, align the red border of the lip, and create symmetry between the nostrils. A guiding principle of this technique is minimal tissue discard, because every bit of the baby’s tissue matters for the final result. In more severe clefts, a small flap of tissue tucked near the base of the nose also helps correct nostril asymmetry during the same operation. Minor revisions to fine-tune lip symmetry are common about six months later.
How Palate Repair Works
Palate repair (palatoplasty) closes the roof of the mouth in two functional layers: the hard palate toward the front and the soft palate toward the back of the throat. The soft palate is especially critical because it contains muscles that lift and close off the nasal passage during speech and swallowing.
In children born with a cleft, these muscles attach in the wrong place, inserting along the bony edge of the hard palate instead of spanning across the midline. A key step in palate repair is detaching those muscles from the bone and repositioning them horizontally so they form a working sling across the back of the throat. This muscle sling is what allows the soft palate to seal against the back of the throat when a child speaks, preventing air from escaping through the nose.
Several techniques accomplish this. Some use tissue flaps raised from the roof of the mouth and shifted toward the center. Others use a Z-shaped rearrangement of the soft palate tissue, which both lengthens the palate and overlaps the muscles for a stronger sling. The choice of technique depends on the width and location of the cleft and the surgeon’s assessment of what will give the best speech outcome with the fewest complications.
Bone Grafting in Later Childhood
Children whose cleft extends through the gum line (the alveolar ridge) typically need a bone graft between ages 7 and 11. Surgeons take a small amount of bone, usually from the hip, and pack it into the gap in the gum. This procedure is timed to the development of the adult canine tooth so it can erupt into solid bone rather than empty space.
The graft serves several purposes: it creates a continuous dental arch, stabilizes the upper jaw segments after orthodontic alignment, closes any remaining opening between the mouth and nose, and provides support for the base of the nostril. In cases where a permanent tooth is missing in the cleft area, the grafted bone can later support a dental implant.
What Recovery Looks Like
After lip surgery, most babies can return to their usual bottle or breast within a day or two, though many teams recommend using a cleft-adapted bottle or syringe feeding for a short period. Common restrictions include keeping hard objects away from the mouth, avoiding pacifiers, and sometimes using soft arm restraints to prevent the baby from touching the surgical site. These restrictions typically last up to a few weeks.
Recovery from palate surgery requires more caution because the repair is inside the mouth and constantly exposed to food and saliva. Most surgical teams recommend cup feeding or syringe feeding for roughly two to three weeks before allowing anything that requires suction, like a standard bottle or sippy cup. A soft or liquid diet is typical for about two weeks. The same precautions about keeping objects out of the mouth and using arm restraints apply, often for a longer stretch than after lip repair.
Possible Complications
The most closely tracked complication of palate repair is a fistula, a small hole that reopens in the repaired palate. In a 25-year review of over 600 patients, the overall fistula rate was about 3%, though rates varied by surgical technique, ranging from 2% to 12%. A fistula can cause food or liquid to leak into the nasal cavity and may require a second operation to close.
Other possible complications include wound separation, bleeding, and long-term effects on midface growth. Extensive surgery on the hard palate can sometimes restrict how the upper jaw grows, which is one reason surgeons try to minimize the amount of tissue they strip from the bone during repair.
Speech Outcomes and Secondary Surgery
One of the primary measures of a successful palate repair is whether the child develops normal speech. The soft palate needs to close firmly against the back of the throat to produce sounds like “p,” “b,” and “k.” When it can’t close completely, air escapes through the nose, creating a condition called velopharyngeal insufficiency. This makes speech sound hypernasal and can be difficult for listeners to understand.
About 11% of children who undergo palate repair will need a secondary surgery specifically to improve this seal. Of those who do, roughly three-quarters need only one additional procedure. Speech therapy is a standard part of cleft care regardless, beginning in toddlerhood and continuing as long as needed.
The Cleft Care Team
Cleft treatment is not a single surgeon working alone. Comprehensive cleft programs bring together plastic surgeons, ear-nose-and-throat specialists, orthodontists, pediatric dentists, speech therapists, audiologists, geneticists, psychologists, and social workers. A child born with a cleft will see many of these specialists at regular intervals from infancy through adolescence, with treatment milestones coordinated across the team. Orthodontic work, hearing monitoring, speech therapy, and dental care all run alongside the surgical timeline, each timed to the child’s developmental stage.