Hand Surgery

• Toe to Hand
• Obstetrical Brachial Palsy

Cosmetic Surgery

• Prominent Ears
• Brest Augmentation Surgery

Cleft Lip and Palate

• Cleft Lip
• Cleft Palate
• Frequently Asked Questions

Hand Surgery

Toe to Hand Transfer

Toe to thumb surgery is designed to reconstruct missing digits in the hand (thumb or fingers). The digits may have been lost due to trauma or may have been absent since birth. A toe or parts of a toe are removed from the foot and the vessels, tendons, and nerves re-attached to the hand. The surgery is not for all defects and there are several variations depending on the problem. Success depends on the patients efforts, good hand therapy, and an experienced surgical team. Rehabilitation takes months and as such is better managed near where the patient can stay for the prolonged therapy.

Choice of toe to be transferred: most commonly it is the first or the second toe which is transferred. Both have their advantages and disadvantages. The first toe is a little bigger than the thumb, but there are surgical techniques to make it smaller to match the thumb closely in size. These include:Trimmed great toe transfer and great toe wrap around technique.
The second toe is smaller than the thumb in thickness, but functions equally well. The great advantage of the second over the first toe is that it leaves very little cosmetic or functional deficit in the foot. If done properly, the foot looks and functions almost like normal, except it has only 4 toes. In Indian patients, who like to wear chappals, and some time even go barefoot, the second toe transfer is almost always chosen over the great toe.

The operation: the operation of toe to hand transfer is a fairly complex operation. Usually two teams work together. One team harvests the toe, and the other surgical team prepares the hand. The vital structures like arteries and veins(providing blood circulation to the transferred toe), the nerves(providing sensations), the tendons( causing the movements) are all detached in the foot, and re-attached in the hand using an operating microscope.

After the operation: both the hand and the foot will be in a plaster for about a month during which time movements will be restricted. The patient needs to spend about a week in the hospital. After the plaster is removed, unrestricted walking can be started. The hand plaster usually stays for about 6 weeks. Even after the hand plaster  is removed, the transferred toe will need to be protected for a few months, as it takes 3 to 6 months for the toe to regain sensations. Once the sensations have returned, and with appropriate help from  physiotherapy the hand can be expected to return to near normal function.

Patient Story

Miss M. B.
This 8 year old child had an accident 2 years back, when her right thumb was caught in the spokes of a cycle and was amputated. The local hospital where the parents of M B sought reatment did not have the facilities for re-attachment ( replantation ) of amputated digits. Even after the wound healed, she was able to do very little useful work with her right hand. But being a bright child, she quickly learn to eat and write with her left hand.
The parents of M B kept looking around and making enquiries, as to what could be done to help their daughter to overcome her disability. Eventually they were referred to Sparsh Hospital for a toe- to-thumb transplant. In Sparsh hospital, in an operation lasting 7 hours, her right second toe was transferred to replace her missing thumb, She was discharged from the hospital after 9 days. The plaster from her foot was removed after 4 weeks and she was allowed to walk. The hand plaster was removed after 6 weeks. She regularly attended a physiotherapy centre near her home. The sensations in the transferred toe returned in about 5 months time. Within 9 months of the operation, she was able to comfortably write, and eat with her right hand. The sensations and movements in the hand have continued to improve over the next few months. Now she has completed one and a half years after the surgery, and she feels she can sue her hand as well as a normal hand. She is due for another minor operation to get rid of the unsightly scars on her hand. 

Photographs:
Fig.1 & 2 Showing front and back views of right hand which had lost it's thumb
Fig.3 xray of the hand with the missing thumb
Fig.4 is acollage of photographs showing the function of thereconstructed thumb
Fig.5 shows the appearance of the foot after removal of the toe
A video clip showing the child writing with her new "toe thumb"

Obstetrical Brachial Palsy (Erb's palsy)

What is Erb's Palsy?
Obstetrical brachial palsy (also known in its various forms as Erb's palsy, Klumpke's paralysis, Erb-Duchenne palsy) complicates a very small proportion of births. Furthermore it seems likely that many cases recover with little in the way of remaining deficit but it is equally certain that some cases will not recover. There is increasingly good evidence that microsurgical help at an early stage can improve the prognosis in some cases. We believe that specialist surgical advice, specialist physiotherapy and where appropriate, either early nerve surgery or secondary reconstructive procedures at a later date can improve the condition of many of these children.

Incidence: The incidence of obstetrical brachial palsy has been reported to be between 0.2 to 0.7 per 1000 live births. Better medical care during delivery has definitely decreased the incidence over the years.

Causes and risk factors: The most common cause is injury to the nerves supplying the upper limb during delivery. When the baby is large the shoulder tends to get stuck during delivery. This is called shoulder dystocea. Trying to pullout the baby by mechanical traction (like the use of foreceps are vaccum) can increase the chances of nerve injury. High risk patients include diabetic mothers, older mothers (over 35), patients with previous history of giving birth to large babies (more than 3.5 kilos), breech presentation. The best method of avoiding the injury is identifying the high risk patient before child birth and having the delivery conducted in a well equipped centre. Specific maneouvers have been described to avoid and treat shoulder dystocea. Other wise caesarean section is another alternative. There are some theories which propose that the injury or insult to the nerves occurs in-utero because of toxic / infective are ischemic reasons. However the majority of cases appear to be related to injury during child birth.

Diagnosis
The diagnosis of brachial plexus injury is easily made in a new born infant when the one upper extremity is not moved actively and the passive range of motion is equal on both sides. If the active and passive motion is equally restricted a fracture of the humerus should be suspected. X-rays will help to exclude this lesion as well as a fractured clavicle. Accurate documentation of level of function in each joint is valuable for later comparison.
Other limbs should be examined as well, in order to rule out neonatal tetraplegia (paralysis of all four limbs which has a poor prognosis) and hemiparesis (weakness of the arm and leg on one side). In addition x-rays should be taken to check for associated arm fractures or for paralysis of the hemidiaphragm (which indicates injury to the phrenic nerve).
Forty-eight hours after birth, a more detailed neurological examination should be carried out. This will reveal further information about the nature and extent of the lesion. An MRI may reveal the nature of the nerve injury but is difficult to interpret.

Classification: the upper limb is supplied by 5 main nerves coming out of the spinal cord in the neck. These are labelled as C5 (cervical – 5), C6, C7, C8 and T1 (thoracic 1). The presentation as well as the prognosis differ according to the extent of involvement of various nerves. 

It is widely accepted that there are generally three main types of lesion:

* C5-6 the arm is held against the chest, the elbow is straight, the forearm is turned inward, and the wrist (and sometimes fingers) flexed. This is the classical 'waiters tip' posture.
* C5-7 as above, although the elbow may be slightly flexed.
* C5-T1 the arm is totally flail with a claw hand. The arm has a marbled appearance due to circulatory disturbances.


Prognostic Factors and Natural History: The following groups of patients generally have a poor prognosis.

1. Complete palsy (involvement of all 5 nerves).
2. Involvement of lower nerves (C8 - T1).
3. persistence of Horner's syndrome (characterised by pin point pupil, ptosis of the eye lid, and absence of sweating on the face on the same side of the body).

Early Management
Affected infants should be followed up at clinic over a period of a couple of months, at regular intervals, in order to assess the extent of recovery, if any. Physiotherapy should be instigated on the affected limb to help prevent joint contractures. Some upper lesions may recover spontaneously within a few days or weeks.
In deciding the care of patients with OBP it is generally accepted that direct nerve surgery is less successful the later it is performed. Although the upper age limits and nerve repair has never been satisfactorily evaluated and some authors have anecdotally reported good results with repair as late as a year of even 24 months. However it is also accepted that the majority of cases recover spontaneously to a greater or lesser degree (19, 31, 42). It is for this reason that great attention has been devoted to prognostication at an early stage and studies of the natural history have assumed great importance

Indications for Surgery:
Unfortunately, the treatment of obstetrical brachial plexus injuries and the timing of surgical intervention has proved to be a very controversial field over the last century. It is difficult to predict which children will improve over time and which will not.
About 15 to 20% of all these children do require early nerve surgery. We usually follow the guidelines of Gilbert. These are

1. complete paralysis with horner's syndrome
2. upper plexus paralysis with no recovery of elbow flexion by 3 months of age

We believe that early surgery on the injured nerves gives these children a better chance of recovery.
Children who continue to show progressive recovery need to be followed closely and given regular therapy and appropriate splinting. Many of these children do have incomplete recovery and residual deformities of the shoulder, arm and hand. A lot of improvement is possible by late surgery on muscles, tendons and bones.
Children who present late can not be considered for nerve surgery. These children can also benefit enormously from secondary surgery. This surgery consists of a releasing contractures, and transferring muscles to rebalance the shoulder and other joints of the upper limb.

COSMETIC SURGERY

Prominent Ears

Introduction
Setting back prominent ears (otoplasty)
It is difficult to give a figure, as to how prevalent this problem is, because the degree of prominence is very variable, and while most people may ignore milder forms of the deformity, others may want correction for even the most deformity. Approximately about 1 to 2% of the population in west consider their ears to be too prominent. In many cases the shape and lie of the ears is inherited, and a family trend can be seen. The most prominent ears often lack a normal fold, and sometimes one ear is more prominent than the other. People with prominent ears are sometimes teased, particularly during their school years, and this can lead to a loss of self-confidence.

What can be done?
When an ear is noted to be prominent within the first few weeks of life, it may be possible to reshape it by applying a small splint to the rim. The cartilage of a new borns's ear is very floppy and easily remoulded and after several weeks of splintage a permanent correction can be achieved. The older the child, the more stiff is the cartilage and the longer the period of splintage must be. By the age of six months the cartilage is too hard to be remoulded and a surgical solution is required.
Otoplasty is an operation, which adjusts the shape of the cartilage within the ear to create the missing folds and to allow the ear to lie closer to the side of the head. Because the operation is carried out from behind the ears, a small scar is left close to the groove between the ear and the side of the head. The procedure can be carried out under local anaesthetic, but in young children a general anaesthetic is usually required. Where the lobe of the ear is especially large, a small procedure to reduce its size may also be required.

After the operation?
A head bandage is usually worn after the surgery until the stitches are removed at between 10 - 14 days after surgery. Once the dressing has been discharged, it is wise to wear a protective headband or bandage when sleeping to avoid the ears being bent forward against the pillow.
The ears are often sore and tender for several weeks and painkilling medication such as Paracetamol and Ibuprofen are usually advised. The scar behind the ear usually settles well, but on rare occasions it can become red and lumpy. A small number of patients, particularly those who are very sensitive about the precise shape of their ears, may require a minor adjustment procedure. The vast majority of patients, however, are pleased by the result, and the procedure has a high satisfaction rate.

What care is required after the operation?
The hair can be washed after the dressing and the stitches have been removed. It is important to keep the grooves behind the ears clean.

What is the ideal time for surgery?
The operation is most often done during childhood, but it is best to operate when the patient is 5 years old or more, as until then the cartilage is very floppy and does not hold the stitches very well. It is recommended that although parents may feel that their child's ears should be corrected to avoid teasing and stigmatisation it is best to wait until the child recognises the problem and wants the ears corrected. Children are generally more co-operative and happy with the outcome when they fully understand why the surgery is taking place. Otoplasty can also be performed during adult life, when either a local or general anaesthetic can be used.

Are there any risks?
In children the operation is carried out under general anaesthetic, and this carries with it a very small risk. In a small number of patients, the scars can become thick and prominent, and may require further treatment. Infection is not common, but should this occur it would require treatment with antibiotics and regular dressing changes. The ears are often a little numb after the procedure, and this usually takes several months to settle

Patient Story

Miss S K, 19, was born in a middle class family in a small town. As long as she can remember, she has had this embarrassing feeling of her ears being too prominent. Luckily though, being a girl, she could wear her hair long, and use it camouflage her ears to some extent. But all the time she could feel the stares and jibes of her friends and playmates. Only when she reached college, did her parents realise that this problem could be tackled surgically. After an operation under local anaesthesia, and requiring only half a day's stay in the hospital. Now her ears are set back nicely and one can see a faint smile of satisfaction on her lips.

Photographs:

1. The two prominent ears, seen from the front.
2. Close-up of the deformed left ear.
3. Frontal view, 3 months after the set-back operation.
4. Close-up of the left ear after the operation.

Brest Augmentation Surgery

Am I a Good Candidate for a breast implant?
Almost any relatively healthy patient who wants to enhance the size and shape of her breasts would be a good candidate for breast augmentation surgery. However, the best candidates are healthy, women who are at or near their ideal weight, with enough of their own breast tissue to cover and support an implant adequately.

What are the Risks & Complications of a breast implant?
Although complication rates are low, the most common risks include infection, excessive bleeding, bruising, tissue death, loss or increase of sensation, asymmetry, implant rupture, and capsular contracture (a hardening of the breasts due to the formation of scar tissue around the implant). In surgeries where tear-drop shaped implants are used, another risk is malrotation of the implant, which can cause the breast to appear misshapen. It is also worth noting that the presence of breast implants can make breast tissue abnormalities harder to detect. Your surgeon will explain any additional risks specific to your case.

How much rest do I need after the surgery?
Because there are several options regarding incision and implant placement, recovery time can vary widely. In general, though, you will need at least 2 days of rest following the procedure, followed by a period of several days of reduced activity. Most patients can return to work after several days to one week. However, swelling and soreness may be present for 3-4 weeks.

What is a breast implant made of?
All breast implants are made of a bag of tough silicone polymer, which is filled with either a thick viscous jelly again made of silicone (gel-filled implants) or saline (saline-filled implants)

• Implant Texture - Implants may be smooth or have a rougher, textured surface, which many surgeons believe may reduce the risk of capsular contracture. On the other hand, the textured implants are harder to remove if needed.
• Implant Shape - Implants can be round or anatomical (tear-drop) shaped. Some people prefer the shape provided by the anatomical implants. The anatomical shaped implants give a little more natural look to the breast. However there is a chance that the implant may rotate in its place, and look distorted.
• Implant Composition - Silicone implants feel more natural. However, though no adverse effect on health has ever been proven, some women opt for saline because they are still concerned about the safety of silicone implants.

Will the surgery leave any scars?
All surgery leaves some scars. The scar depends upon the incision. Breast implant surgery is performed through small well-hidden incisions, which are almost unnoticabel. The incision may be placed in one of the following places:

• Periareolar Incision - an incision made on the lower border of the areola (the darker colored area surrounding the nipple)
• Inframammary Crease Incision - an incision made in the natural fold or crease underneath the breast
• Transaxillary Incision - an incision made in the armpit

There are advantages and disadvantages to each of these options, and they are all useful for meeting different needs in different situations. Except in case of a small minority of patients who have a tendency for hypertrophic scarring or keloid formation, the scar following a breast implant is almost inconspicuous. Be sure to find out what your surgeon recommends as the best option for your particular case.

• Over the Muscle - Implants are placed on top of the pectoral muscle, under the fatty tissue of the natural breast. This option usually provides more projection, and is suitable for women who have a sufficient amount of natural breast tissue to cover the edges of the implant.
• Under the Muscle (Sub-Pectoral) - Implants are placed underneath the pectoral muscle. This option is better for women who do not have very much natural breast tissue to cover the edges of the implant. Sub-muscular placement also can help decrease the risk of capsular contracture.

What kind of anaesthesia is used?
Breast Augmentation surgery is usually performed either under general anaesthesia or intravenous sedation (aka "twilight sleep") combined with local anaesthetic.

Other Things to Consider:
Most breast implants will need to be replaced at some point in the patient's life, especially saline implants. Also, you should keep in mind that extreme weight fluctuations (including those associated with pregnancy) can affect the appearance of the breasts over time.

• The patient is marked for surgery. Your surgeon will make markings on your breasts and the surrounding areas. These marks include incision marks, as well as general measurements that will to be used by your surgeon as a visual guide during surgery.
• Anaesthesia is administered and patient is prepped for surgery. You will be given general anaesthesia, or in some cases, "twilight" sedation via IV. The surgery site will be prepared by a through cleansing and disinfecting of the area, followed by the application of a topical antibiotic solution.
• Incisions are made. An incision will be made either in the crease underneath the breast mound (called the inframammary fold), around the bottom half of the areola (the colored area of skin surrounding the nipple), under the arm, or through the navel. Usually, electric cautery is used to minimize bleeding at the incision sites.
• A pocket is created and shaped to receive the implant. The surgeon dissects tissue to create a space for the implant to occupy. Proper placement and shaping of the pocket is crucial to the quality of the end result. The pocket may be created underneath or on top of the pectoral muscle.
• The implants are placed into the pockets which have been created. If the implants are to be filled with saline, they are rolled up before being placed, and filled with saline once in place, up to the desired fill amount. The surgeon may decide to fill one implant more or less than the other, in order to achieve the most symmetrical result. (If silicone implants are being used, the implant shell comes to the surgeon pre-filled. If this is the case, all size decisions must have been made prior to surgery.)
• The surgeon checks the result for symmetry and proper placement. The patient is positioned in an upright posture on the operating table, so that the surgeon can better judge implant placement before closing the incisions. If needed, adjustments to the pocket placement or fill amount can be made at this point.
• Incisions are closed. Once the surgeon is happy with the placement and symmetry of the breasts, he or she will suture the incisions closed. In some cases, drains are put in place at the incision site before the last suture is put in. These drains are used to prevent fluid build-up, and are usually removed at the

Cleft Lip and Palate

Cleft Lip operation:
A cleft lip can range in severity from a slight notch in the red part of the upper lip to a complete separation of the lip extending into the nose. Clefts can occur on one or both sides of the upper lip. Surgery is generally done when the child is about 10 weeks old.
To repair a cleft lip, the surgeon will make an incision on either side of the cleft from the mouth into the nostril. He or she will then turn the dark pink outer portion of the cleft down and pull the muscle and the skin of the lip together to close the separation. Muscle function and the normal "cupid's bow" shape of the mouth are restored. The nostril deformity often associated with cleft lip may also be improved at the time of lip repair or in a later surgery.

After Cleft Lip Surgery
Your child may be restless for awhile after surgery, but your we can prescribe medication to relieve any discomfort. If dressings have been used, they'll be removed within a day or two, and the stitches will either dissolve or be removed within five days. We will advise you on how to feed your child during the first few weeks after surgery.
It's normal for the surgical scar to appear to get bigger and redder for a few weeks after surgery. This will gradually fade, although the scar will never totally disappear. In many children, however, it's barely noticeable because of the shadows formed by the nose and upper lip.

Cleft Palate operation
In some children, a cleft palate may involve only a tiny portion at the back of the roof of the mouth; for others, it can mean a complete separation that extends from front to back. Just as in cleft lip, cleft palate may appear on one or both sides of the upper mouth. However, repairing a cleft palate involves more extensive surgery and is usually done when the child is nine to 12 months old, so the baby is bigger and better able to tolerate surgery.
To repair a cleft palate, the surgeon will make an incision on both sides of the separation, moving tissue from each side of the cleft to the center or midline of the roof of the mouth. This rebuilds the palate, joining muscle together and providing enough length in the palate so the child can eat and learn to speak properly.

Recovering From Cleft Palate Surgery
For a day or two, your child will probably feel some soreness and pain, which is easily controlled by medication. During this period, your child will not eat or drink as much as usual -- so an intravenous line will be used to maintain fluid levels. Elbow restraints may be used to prevent your baby from rubbing the repaired area. Your doctor will advise you on how to feed your child during the first few weeks after surgery. It's crucial that you follow your doctor's advice on feeding to allow the palate to heal properly.

Patient Story

Master  M.  was born with a partial cleft of the lip on the right side. At the age of 3 months his cleft lip was repaired.

1. The photograph shows him just before the start of cleft lip operation. The plastic tube in his mouth for administering the anesthetic.
2. This photograph was taken 1 week after the operation, immediately after the stitches were removed. Nowadays we almost always use absorbable sutures, which do not need to be removed.
3. This photograph was taken when he was 8 months old. Note that the scar has almost disappeared, the red margin of the lip is symmetrical, and the height of the upper lip is equal on both sides.

Master P was born with a complete cleft of his upper lip on the left side.

1. Master P just before the operation of cleft lip repair (age: 3 months)
2. At age 7 months (4 months after repair). Please note that while the scar is quite fine, the vertical height of the repaired lip is slightly less than on the normal side. This is quite common in major complete clefts. It is due to the phenomena called scar contraction. The scar tends to become a little tight in the first few months after surgery. This problem usually corrects itself in 9 to 12 months.

Q. What caused my baby's cleft?
cleft is formed by the 4th - 8th weeks of pregnancy. Many women do not even know they are pregnant before the cleft has been formed. A cleft happens when the tissues of the face fail to fuse during gestation. It is a repairable birth defect.
cleft happens in about one in every 700 births. It happens all over the world. It is the fourth most common birth defect. You will want to see a geneticist who will try to gain a clearer understanding of just what factors contributed to your baby's cleft, but very often the final answer is "We don't really know."
cleft is most commonly caused by a combination of several factors. In most cases, genetics plays a role, although sometimes not the only role. There may be a number of environmental factors as well. The most important thing to recognize is that there is nothing that the parents could have done (or not done) which would have prevented the cleft.

Q. How to feed the baby?
If the cleft is limited to the lip, and the palate is normal, there is usually no difficulty in breast-feeding the baby. In children with cleft palate, breast feeding is usually not possible, but there are other effective ways of feeding, so the child has no reason to suffer malnourishment. You may have some difficulty in finding the best way to feed your child at first, but with patience and perseverance, these babies do get fed quite alright.
Because of the cleft palate, the baby is unable to suck effectively, so what is required is a mechanism which eliminates the need to suck. Broadly, there are two methods of achieving this. One is feeding with a small spoon, or a cup with a spout. This method involves a little extra effort, but has the advantage of being very simple. It is much easier to maintain hygiene for a cup and spoon than a feeding bottle.
The other technique is to use a feeding bottle with a larger hole or slit, so that milk drips from it drop by drop. Specially designed feeding bottles are also available for use for cleft palate kids.
The child should be held inclined with the head at a higher level (semi recumbent) to facilitate swallowing.
It is a good idea for the new mother to extract her breast milk with a breast pump and feed it to the baby with a bottle or a spoon.
You will want to experiment until you find the method that works best for you and your baby. If you have problems feeding your child, please do not hesitate to contact us for advice regarding feeding.
These babies also have a tendency to swallow a lot of air during feeding. This makes them have a feeling of full ness in the stomach quickly. For this reason these babies need to be fed smaller but more frequent feeds. They also need to be burped regularly during feeding.

Q. How and when will the problem be corrected?
A team of professionals works together to manage the problem of cleft. The team consists of the paediatrician, the plastic surgeon, anaesthetist, dental specialist, speech therapist, ENT specialist and a social worker. These children require regular follow up and periodic medical and surgical interventions to achieve optimal appearance and function.
The timing for repair varies with the doctor and with the child. However, most of the time a cleft lip is repaired at around 3 months of age. The baby should ideally weigh at least 4½ kg. The cleft in the palate is repaired at about age 9 - 10 months. There will likely be a bone graft at around age 9. There is no guarantee that those will be the only surgeries your child will have to repair the cleft. Many cleft-affected children have revision work done as they grow. Rhinoplasty is also common. There may or may not be some speech-related surgeries or palate-lengthening surgery. At the time of your first consultation with the plastic surgeon, you will be given a detailed description, as to what you might expect for your child. Just remember that it IS repairable, and that each surgery will only improve upon what is already there.

Q. Will my baby be retarded?
No.  Unless your baby has an underlying syndrome that includes both cleft and retardation (this is quite rare), or unless your baby has a cleft and an unrelated condition that results in retardation, you can expect your child to grow up to be a normal, healthy individual. The majority of clefts are what is called, "isolated clefts". That is, they are clefts that are unrelated to any other syndrome or condition. There is no reason to suspect retardation.

Q. Will my baby have other health concerns?
For the most part, your baby is just as healthy and normal as any other baby. It is just that for some reason or another his/her lip failed to fuse when it was supposed to. A cleft baby is more prone to ear infections because the Eustachian Tubes are usually affected by the cleft and do not drain the fluid from the middle ear properly. This can be prevented or treated by appropriate medical attention

Q. How often is cleft palate associated with mental retardation and how would this be detected in an infant?
Cleft affects the tissues of the lip, palate, throat and nose. Those tissues do not, in any way, affect developmental function (brain). There are occasions, and they are somewhat rare, when the cleft is a part of a larger condition - a syndrome - that also includes, as a part of the syndrome, mental retardation (not all syndromes include mental retardation, by the way). When that happens - about 5% of all cleft conditions are syndrome-related, (and most of those syndromes do not include mental retardation) - the syndrome is usually apparent or suspected at birth.
In the past, with very late palate closure (ie, after the 3rd birthday) children with cleft were very difficult to understand, and deemed "retarded" by the schools. Also, before wide spread use of myringotomy tubes, recurring ear infections could compromise hearing to the extent that the child would fall behind in school. However, tubes, early surgeries, and speech therapy have changed all that. These kids do quite well in keeping up with (and often surpassing) their peers.
Mental retardation, in the absence of an identifiable syndrome, is NOT a real concern when it comes to children with clefts.

Would you like to learn more about this topic?
There are tens of thousands of pages of cleft-related content from the world's most respected medical journals, leading magazines and newspapers, and cleft-related web sites. all of it is available free when you visit www.SmileTrain.org.