harelip n : a congenital cleft in the middle of the upper lip [syn: cleft lip, cheiloschisis]

English

Noun

1. A congenital malformation of the upper lip, reminiscent of the mouth of a hare.

Synonyms

• cleft lip

Translations

Related terms

• hare
• lip

Cleft lip and cleft palate, which can also occur together as cleft lip and palate are variations of a type of clefting congenital deformity caused by abnormal facial development during gestation. This type of deformity is sometimes referred to as a cleft. A cleft is a sub-division in the body's natural structure, regularly formed before birth. A cleft lip or palate can be successfully treated with surgery soon after birth. Cleft lips or palates occur in somewhere between one in 600-800 births.

The term harelip is widely used to describe the condition, though it is considered extremely offensive. The Chinese word for cleft lip is tuchun (兔唇), literally "harelip."

Cleft lip

If only skin tissue is affected one speaks of cleft lip. Cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft) or continues into the nose (complete cleft). Lip cleft can occur as one sided (unilateral) or two sided (bilateral). It is due to the failure of fusion of the maxillary and medial nasal processes (formation of the primary palate).

image:CleftLip1.svg|Unilateral incomplete image:CleftLip3.png|Bilateral complete

A mild form of a cleft lip is a microform cleft. A microform cleft can appear as small as a little dent in the red part of the lip or look like a scar from the lip up to the nostril. In some cases muscle tissue in the lip underneath the scar is affected and might require reconstructive surgery. It is advised to have newborn infants with a microform cleft checked with a craniofacial team as soon as possible to determine the severeness of the cleft. The actor Joaquin Phoenix is an example of a person with a microform cleft that did not require surgery.

The complete restoration of this Cleft Child girl from above can be seen here. http://www.pbase.com/stella97king/cleft_lip

Cleft palate

Cleft palate is a condition in which the two plates of the skull that form the hard palate (roof of the mouth) are not completely joined. The soft palate is in these cases cleft as well. In most cases, cleft lip is also present. Cleft palate occurs in about one in 700 live births worldwide.

Palate cleft can occur as complete (soft and hard palate, possibly including a gap in the jaw) or incomplete (a 'hole' in the roof of the mouth, usually as a cleft soft palate). When cleft palate occurs, the uvula is usually split.It occurs due to the failure of fusion of the lateral palatine processes, the nasal septum, and/or the median palatine processes (formation of the secondary palate).

The hole in the roof of the mouth caused by a cleft connects the mouth directly to the nasal cavity.

Note: the next images show the roof of the mouth. The top shows the nose, the lips are colored pink. For clarity the images depict a toothless infant.

image:Cleftpalate3.png|Incomplete cleft palate image:Cleftpalate1.png|Unilateral complete lip and palate image:Cleftpalate2.png|Bilateral complete lip and palate

A direct result of an open connection between the oral cavity and nasal cavity is velopharyngeal insufficiency (VPI). Because of the gap, air leaks into the nasal cavity resulting in a hypernasal voice resonance and nasal emissions. Secondary effects of VPI include speech articulation errors (e.g., distortions, substitutions, and omissions) and compensatory misarticulations (e.g., glottal stops and posterior nasal fricatives).. Possible treatment options include speech therapy, prosthetics, augmentation of the posterior pharyngeal wall, lengthening of the palate, and surgical procedures. This process is very vulnerable to multiple toxic substances, environmental pollutants, and nutritional imbalance. The biologic mechanisms of mutual recognition of the two shelves, and the way they are glued together, are quite complex and obscure despite intensive scientific research.

The cause of cleft lip and cleft palate formation can be genetic in nature. A specific gene that increases threefold the occurrence of these deformities has been identified by Zucchero et al in 2004 as reported by the BBC.

Environmental influences may also cause, or interact with genetics to produce, orofacial clefting. Scientists have investigated seasonal causes (such as pesticide exposure); maternal diet and vitamin intake; retinoids- which are members of the vitamin A family; anticonvulsant drugs; alcohol; cigarette use; nitrate compounds; organic solvents; parental exposure to lead; and illegal drugs (cocaine, crack cocaine, heroin, etc.) as teratogens that increase the possibility of clefting.

If a person is born with a cleft, the chances of that person having a child with a cleft, given no other obvious factor, rises to 1 in 14. Research continues to investigate the extent to which Folic acid can reduce the incidence of clefting.

In some cases, cleft palate is caused by syndromes which also cause other problems. Stickler's Syndrome can cause cleft lip and palate, joint pain, and myopia. Loeys-Dietz syndrome can cause cleft palate or bifid uvula, hypertelorism, and aortic aneurysm. Cleft lip/palate may be present in Patau’s Syndrome (trisomy 13). Many clefts run in families, even though there does not seem to be any identifiable syndrome present.

Treatment

Cleft lip and palate is very treatable, however the kind of treatment depends on the type and severity of the cleft. Most children with a form of clefting are monitored by a cleft palate team or craniofacial team through young adulthood. Care can be lifelong. Treatment procedures can vary between craniofacial teams. For example, some teams wait on jaw correction until the child is aged 10 to 12 (argument: growth is less influential as deciduous teeth are replaced by permanent teeth, thus saving the child from repeated corrective surgeries), while other teams correct the jaw earlier (argument: less speech therapy is needed than at a later age when speech therapy becomes harder). Within teams, treatment can differ between individual cases depending on the type and severity of the cleft.

Cleft lip treatment

Within the first 2-3 months after birth, surgery is performed to close the cleft lip. While surgery to repair a cleft lip can be performed soon after birth, the often preferred age is at approximately 10 weeks of age, following the "rule of 10s" coined by surgeons Wilhelmmesen and Musgrave in 1969 (the child is at least 10 weeks of age; weighs at least 10 pounds, and has at least 10 g haemoglobin). If the cleft is bilateral and extensive, two surgeries may be required to close the cleft, one side first, and the second side a few weeks later. The most common procedure to repair a cleft lip is the Millard procedure pioneered by Ralph Millard. D. Ralph Millard performed the first procedure at a Mobile Army Surgical Hospital unit in Korea.

Often an incomplete cleft lip requires the same surgery as complete cleft. This is done for two reasons. Firstly the group of muscles required to purse the lips run through the upper lip. In order to restore the complete group a full incision must be made. Secondly, to create a less obvious scar the surgeon tries to line up the scar with the natural lines in the upper lip (such as the edges of the philtrum) and tuck away stitches as far up the nose as possible. Incomplete cleft gives the surgeon more tissue to work with, creating a more supple and natural-looking upper lip.

image:Millardrepair1.svg|The blue lines indicate incisions.

Cleft palate treatment

Often a cleft palate is temporarily closed using a palatal obturator. The obturator is a prosthetic device made to fit the roof of the mouth covering the gap.

Cleft palate can also be corrected by surgery, usually performed between 9 and 18 months. Approximately 20-25% only require one palatal surgery to achieve a competent velopharyngeal valve capable of producing normal, non-hypernasal speech. However, combinations of surgical methods and repeated surgeries are often necessary as the child grows. One of the new innovations of cleft lip and cleft palate repair is the Latham appliance. The Latham is surgically inserted by use of pins during the child's 4th or 5th month. After it is in place, the doctor, or parents, turn a screw daily to bring the cleft together to assist with future lip and/or palate repair.

If the cleft extends into the maxillary alveolar ridge, the gap is usually corrected by filling the gap with bone tissue. The bone tissue can be acquired from the patients own chin, rib or hip.

Speech and hearing treatments

A tympanostomy tube is often inserted into the eardrum to aerate the middle ear. This is often beneficial for the hearing ability of the child. Speech problems are usually treated by a speech-language pathologist. In some cases pharyngeal flap surgery is performed to regulate the airflow during speech and reduce nasal sounds.

Sample treatment schedule

Note that each individual patient's schedule is treated on a case-by-case basis and can vary per hospital. The table below shows a common sample treatment schedule. The colored squares indicate the average timeframe in which the indicated procedure occurs. In some cases this is usually one procedure (for example lip repair) in other cases this it is an ongoing therapy (for example speech therapy).

Craniofacial team

A craniofacial team is routinely used to treat this condition. The majority of hospitals still use craniofacial teams; yet others are making a shift towards dedicated cleft lip and palate programs. While craniofacial teams are widely knowledgeable about all aspects of craniofacial conditions, dedicated cleft lip and palate teams are able to dedicate many of their efforts to being on the cutting edge of new advances in cleft lip and palate care.

Many of the top pediatric hospitals are developing their own CLP clinics in order to provide patients with comprehensive multi-disciplinary care from birth through adolescence. Allowing an entire team to care for a child throughout their cleft lip and palate treatment (which is ongoing) allows for the best outcomes in every aspect of a child's care. While the individual approach can yield significant results, current trends indicate that team based care leads to better outcomes for CLP patients. .

A complete listing of craniofacial teams is available through the Cleft Palate Foundation

Complications

Cleft may cause problems with feeding, ear disease, speech and socialization.

Due to lack of suction, an infant with a cleft may have trouble feeding. An infant with a cleft palate will have greater success feeding in a more upright position. Gravity will help prevent milk from coming through the baby's nose if he/she has cleft palate. Gravity feeding can be accomplished by using specialized equipment, such as the Haberman Feeder, or by using a combination of nipples and bottle inserts like the one shown, is commonly used with other infants. A large hole, crosscut, or slit in the nipple, a protruding nipple and pressure applied to the bottle insert by the caregiver's hand can result in controllable flow to the infant without the stigma caused by specialized equipment.

Individuals with cleft also face many middle ear infections which can eventually lead to total hearing loss. The eustacian tubes and external ear canals may be angled or tortuous, leading to food or other contamination of a part of the body that is normally self cleaning.

Because the lips and palate are both used in pronunciation, individuals with cleft usually need the aid of a speech therapist. Bonding with the infant, socializing with family and community may be interrupted by the unexpected appearance, unusual speech and the surgical interventions necessary. Support for the parents as well as for the child can be pivotal.(see Psychosocial issues)

Psychosocial issues

Having a cleft palate does not inevitably lead to a psychosocial problem. Most children who have their cleft lips repaired early have a happy youth and a healthy social life. However, it is important to remember that adolescents with cleft palate are at an elevated risk for developing psychosocial problems especially those relating to self concept, peer relationships, and appearance. It is important for parents to be aware of the psychosocial challenges their adolescents may face and to know where to turn if problems arise.

A cleft palate may impact an individual’s self-esteem, social skills, and behavior. There is a large amount of research dedicated to the psychosocial development of individuals with cleft palate. Self-concept may be adversely affected by the presence of a cleft palate. Research has shown that during the early preschool years (ages 3-5), children with cleft palate tend to have a self-concept that is similar to their peers without a cleft. However, as they grow older and their social interactions with other children increase, children with clefts tend to report more dissatisfaction with peer relationships and higher levels of social anxiety. Experts conclude that this is probably due to the associated stigma of visible deformities and speech abnormalities, if present. Children who are judged as attractive tend to be perceived as more intelligent, exhibit more positive social behaviors, and are treated more positively than children with cleft palate. Children with clefts tend to report feelings of anger, sadness, fear, and alienation from their peers. Yet these children were similar to their peers in regard to "how well they liked themselves."

The relationship between parental attitudes and a child’s self-concept is crucial during the preschool years. It has been reported that elevated stress levels in mothers correlated with reduced social skills in their children. Strong parent support networks may help to prevent the development of negative self-concept in children with cleft palate. In the later preschool and early elementary years, the development of social skills is no longer only impacted by parental attitudes but is beginning to be shaped by their peers. A cleft palate may affect the behavior of preschoolers. Experts suggest that parents discuss with their children ways to handle negative social situations related to their cleft palate. A child who is entering school should learn the proper (and age-appropriate) terms related to the cleft. The ability to confidently explain the condition to others may limit feelings of awkwardness and embarrassment and reduce negative social experiences.

As children reach adolescence, the period of time between age 13 and 19, the dynamics of the parent-child relationship change as peer groups are now the focus of attention. An adolescent with cleft palate will deal with the typical challenges faced by most of their peers including issues related to self esteem, dating, and social acceptance. Adolescents, however, view appearance as the most important characteristic above intelligence and humor. This being the case, adolescents are susceptible to additional problems because they cannot hide their facial differences from their peers. Males typically deal with issues relating to withdrawal, attention, thought, and internalizing problems and may possibly develop anxiousness-depression and aggressive behaviors. and the BBC. Note that in the UK, an abortion could never be justified under the 1967 Abortion Act on the basis that a cleft lip and palate is not considered a serious handicap.

Famous people born with a cleft

Historical

Modern

The popular belief that Joaquin Phoenix has a repaired cleft lip is mistaken. The mark on his lip is a microform, an almost-cleft that healed itself in utero. If the tissues join up just enough to create correct bone and muscle tissues, no corrective surgery is required, as was the case with Phoenix.

Fictional

In the Thomas Harris novel Red Dragon, the future serial killer Francis Dolarhyde is born with a cleft palate to a poor St. Louis, Missouri family that can't afford proper surgical repair. As an adult, he visits Hong Kong, where a dentist constructs corrective dentures: a normal set, which allows him to eat and speak like other people; and an abnormal set, which he uses to bite his victims in gruesome ways.

One of the most important characters in Par Lagerkvist's 1951 novel, Barabbas, is the "girl with a hare-lip" who is among the book's main representatives of belief in the new Christianity which the novel ambiguously explores. The Savior is one of the only people she has ever met who was able to understand her slurred speech. She witnesses for him and may have had a sexual relationship with Barabbas. Midway through the novel, during persecutions of Christians, she is stoned to death.

In J.M. Coetzee's "Life and Times of Michael K", the titular character is born with a cleft lip. Coetzee writes that the character's "lip curled like a snail's foot, the left nostril gaped".

In the Swedish film 'The Simple-Minded Murder' the main character Sven, played by Stellan Skarsgård, has a clef palate. This makes it hard for him to speak and therefore people take him for an idiot.

In Precious Bane, the 1924 novel by Mary Webb the heroine "Prue Sarn" has a cleft lip.

In the Japanese Manga and Anime Lucky Star, the main character Konata has a cleft lip.

Cleft lip and palate in animals

Cleft lips and palates are occasionally seen in cattle and dogs, and rarely in sheep, cats, horses, pandas and ferrets. Most commonly, the defect involves the lip, rhinarium, and premaxilla. Clefts of the hard and soft palate are sometimes seen with a cleft lip. The cause is usually hereditary. Brachycephalic dogs such as Boxers and Boston Terriers are most commonly affected. An inherited disorder with incomplete penetrance has also been suggested in Shih tzus, Swiss Sheepdogs, Bulldogs, and Pointers. In horses, it is a rare condition usually involving the caudal soft palate. In Charolais cattle, clefts are seen in combination with arthrogryposis, which is inherited as an autosomal recessive trait. It is also inherited as an autosomal recessive trait in Texel sheep. Other contributing factors may include maternal nutritional deficiencies, exposure in utero to viral infections, trauma, drugs, or chemicals, or ingestion of toxins by the mother, such as certain lupines by cattle during the second or third month of gestation. The use of corticosteroids during pregnancy in dogs and the ingestion of Veratrum californicum by pregnant sheep have also been associated with cleft formation.

Difficulty with nursing is the most common problem associated with clefts, but aspiration pneumonia, regurgitation, and malnutrition are often seen with cleft palate and is a common cause of death. Providing nutrition through a feeding tube is often necessary, but corrective surgery in dogs can be done by the age of twelve weeks. Surgical techniques for cleft palate in dogs include prosthesis, mucosal flaps, and microvascular free flaps. Affected animals should not be bred due to the hereditary nature of this condition.

References

31. ^ Stella King Cleft Child; http://www.pbase.com/stella97king/cleft_lip

See also

Treatment/aids

• Oral and Maxillofacial Surgery
• Haberman Feeder
• Palatal obturator
• Vomer flap surgery
• The Latham Device http://www.pbase.com/stella97king/cleft_lip&page=2]]

Syndromes

• Hearing loss with craniofacial syndromes
• Popliteal pterygium syndrome
• Van der Woude syndrome

General Support Discussion Boards

• cleftAdvocate's Family-to-Family Connection Listserv
• aboutcleft - International Discussion Boards
• Face Forward - The UK's Number One Discussion Boards

Organizations

• List of Cleft lip & palate organizations

bowlegs, camelback, cleft palate, clubfoot, crookback, defacement, deformation, deformity, disfigurement, flatfoot, freakishness, humpback, hunchback, knock-knee, kyphosis, lordosis, malconformation, malformation, misproportion, misshape, monstrosity, mutilation, splayfoot, swayback, talipes, teratology, torticollis, truncation, valgus, wryneck