HJAR Mar/Apr 2022

HEALTHCARE JOURNAL OF ARKANSAS  I  MAR / APR 2022 49 palate, which contains the musculature integral to speech development. This al- lows patients with cleft to start learning to speak with the correct palatal anatomy. At the same time as the soft palate repair, pa- tients also undergo placement of a palatal obturator that fills the gap in their bony hard palate. This obturator helps separate the oral cavity from the nasal cavity and allows for the makeshift creation of nor- mal anatomy. Once the palatal obturator becomes loose, around 1.5 to 2 years of age, the ob- turator is removed in clinic. When this oc- curs, patients are scheduled for a hard pal- ate and alveolar cleft repair in one surgery. Traditionally, the hard palate of a cleft is not bone grafted because at the young age when patients undergo palate repair, their hips are too small to serve as good options for bone grafts. However, in standard pal- atal anatomy, anteriorly bone separates the oral from the nasal cavity. With the ad- vent of new bone allograft options, there is the opportunity to graft bone, the hard palate and alveolar ridge in one surgery rather than staging the process. There are many foreseeable benefits to this. First, the surgical correction is more anatomically accurate. In the traditional approach, no bone is placed within the hard palate, and the communication be- tween the nasal and oral cavities is only soft tissue. This ultimately leads to more collapse of the upper jaw segments be- cause there is less bone spanning between the two segments. Moreover, because the bony gap is so small at this age, there is a higher chance for successful take of the Sagar T. Mehta, MD Director of Pediatric Plastic and Reconstructive Surgery Director of Craniomaxillofacial Surgery Arkansas Children’s bone graft. The use of bone allograft re- duces the pain and paresthesia that pa- tients can have with harvest of bone graft from the hip. If you ask a patient who un- dergoes traditional alveolar bone grafting what they remember most, a majority note the significant pain in the hip. Secondly, a significant portion of the patient’s surger- ies have occurred before the patient can remember, and it allows them in their for- mative social years to relate more to their peers. Finally, this technique allows for the descent of pediatric dentition, which guides the adult dentition, improving or- thodontic adjustments in the future. The ultimate goal in cleft lip and palate surgery is to provide the best outcome that appropriately repairs all the anatomic components of the nasal and oral cavity in the most benign and tolerable way for pa- tients. Although the traditional approach to cleft care has been around for decades, these new surgical techniques help make this goal a reality and will hopefully sig- nificantly improve the process for patients with cleft lip and palate. n Sagar Mehta, MD, completed an undergraduate de- gree and a medical degree in the highly competi- tive six-year combined program at the University of Missouri at Kansas City. He subsequently went to the University of Utah for Plastic and Reconstruc- tive Surgery residency, where he spent a significant amount of time focused on bone allograft in alveolar cleft surgery and utilization of adipose-derived stem cells in reconstructive surgery.He then completed a fellowship in craniomaxillofacial surgery at the Uni- versity of Utah, honing his skills in the management of complex pediatric congenital anomalies, including cleft lip and palate,craniosynostosis,and complex jaw surgery.He worked at the University of Cincinnati and Cincinnati Children’s Hospital as a plastic and recon- structive surgeon.Mehta is the board-certified direc- tor of the craniofacial team at Arkansas Children’s. THE PARADIGM SHIFT Cleft lip and palate surgery have been performed using the traditional approach for many years; however, new products and technologies have emerged that can help augment the process. For instance, new bony substrates have been developed that can be used rather than the patient’s own bone in bone grafting procedures. With the introduction of these new prod- ucts, the question became, “Why do we need to wait in cleft surgery?” With this question in mind, cleft lip sur- gery teams have worked to tailor a new cleft lip and palate algorithm that expe- dites the cleft surgical process and allows a significant amount of the surgical pro- cess to occur when the child is too young to remember the surgeries. The initial management of the patient remains the same. Patients with clefts are seen early after birth and followed through infancy to ensure they eat well and gain weight appropriately. From there, things start to deviate. Under the care of the cleft ortho- dontist, certain patients are offered the option of nasoalveolar molding, a tech- nique used to reposition the patient’s up- per jaw segments and mold nasal cartilage to improve outcomes of their initial cleft lip repair. Individuals who do not need nasoalveolar molding are taught how to perform lip taping. Patients then undergo their cleft lip repair at approximately 3 to 4 months though this may be pushed back if more nasoalveolar molding is required. The team then addresses the cleft pal- ate at approximately 7 to 9 months of age. They first focus on repairing the soft