The care of children with a cleft lip and palate requires a comprehensive treatment plan from the initial diagnosis through the completion of reconstruction in adolescence. A child with a complete cleft lip and palate requires several operations as he or she develops. In general, the goal of treatment is to have as few operations as possible with the best possible outcome. Naturally, there are a variety of approaches, any of which may produce the same final result. A comparison of outcomes has been difficult because of treatment differences, as well as the fact that the experience and ability of the individual surgeon may also influence the outcome.
It is important to emphasize the team approach to cleft care, which has developed gradually over the past 50 years. Although surgeons, speech therapists, and orthodontists, among others, may offer specific treatment, a dedicated cleft team offers the best possibility of coordinating the care among various specialists. This approach can both minimize the number and length of the various interventions as well as ensure that they are done at optimal times. The American Cleft Palate-Craniofacial Association has developed an outline of the standards for team care of cleft patients.
Before any surgery, it is important for the patient to have a thorough team evaluation, including genetic and pediatric examinations, which can lead to other studies to diagnose or rule out specific syndromes.
Oral intake can be compromised in children with cleft palate because of their inability to suck effectively. It is important to instruct parents in the use of a cleft nurser. There are a variety of types, all of which require less effort than a normal bottle; even a cross-cut nipple on a regular bottle may work in these cases. Most of the bottles require some squeezing to supplement flow. Adequate oral intake is assessed by weight gain.
Preoperative manipulation of the alveolar segments in complete cleft lip and palate is often used to reduce the width of a cleft, facilitating a tension-free surgical closure. Orthodontic appliances such as molding plates can be used but require frequent (weekly) modification of the plates to continue moving the segments. When extensions of the molding plate are used for stretching the nasal ala this is called nasoalveolar molding, or NAM. This is labor-intensive for the orthodontist, but can give the most accurate positioning of the segments. The use of taping across the cleft is much simpler and is still quite effective, but less predictable. This process is most important in complete bilateral clefts, in which control of the premaxilla is essential to achieving any type of repair. Once the lip is repaired, the intact orbicularis oris muscle maintains and continues to mold the position of the alveolar shelves.
Lip adhesion is a procedure in which the cleft segments are surgically united via small flaps, essentially creating an incomplete cleft lip. A successful lip adhesion molds the alveolar segment. A secondary operation is performed after an interval to convert the adhesion to a formal lip repair. Though appealing, this procedure creates scar tissue in the lip, which may impede the final lip repair.
The classic “rule of tens” is still a reasonable guideline for lip repair: 10 weeks of age, a weight of 10 pounds, and a hemoglobin of 10 have been considered prerequisites for lip repair. This is partly based on anesthetic safety, which is probably a little better with increased age. The timing of the lip repair must be individualized for the patient. A premature infant may benefit from a later repair because of the increased incidence of apnea after general anesthesia in the first 3 months or so after gestational age. Similarly, if presurgical manipulation of the alveolus or premaxilla is required, this should be completed before the lip repair is undertaken. An incomplete cleft lip has less urgency because the alveolar segments are held in place by the intact Simonart's band.
The essence of lip repair is to create a symmetrical Cupid's bow and lip fullness, without losing normal contour of the lip and the philtrum. To create length on the cleft side, some tissue from the lateral lip element must be inserted into the medial segment. Breaking up the scar also reduces scar contraction, which can create secondary shortness of the repair. This was commonly seen with the original straight-line cleft repair.
The initial efforts to break up the scar and recruit lateral tissue were so-called quadrilateral repairs, with a stair-step closure that had the disadvantage of discarding a significant amount of tissue. The triangular lip repair essentially placed a modified Z-plasty above the vermilion border. Other repairs have a Z-plasty in the central portion of the lip. The rotation advancement repair moved the Z-plasty to the area below the nasal sill.
Many fine adjustments contribute to the ideal cleft lip repair. The symmetry of the nose, including the tip, as well as the alar base and the nasal sill are critical to the final appearance. The fullness of the mucosa should be equal on the two sides. The alignment of the junction of the wet and dry vermilion (the so-called “red line”) can be a subtle but important difference between a good repair and an adequate one.
Rotation Advancement Cleft Lip Repair
The rotation advancement cleft lip repair, also referred to as a Millard repair, is probably the most commonly performed repair today. Almost no tissue is discarded; the medial lip element is rotated downward, even with a back cut, if necessary, and the lateral lip element is advanced into the defect under the nasal sill. Mucosal flaps are used to line the nose and the vestibule of the lip (Figure 20–8).
Rotation advancement (Millard) repair for unilateral cleft lip. The high point of the Cupid's bow on the central segment is brought down by the rotation; the secondary defect under the nose is filled by the lateral advancement flap.
It is important to understand that the rotation advancement repair recruits length for the lateral advancement flap by following the vermilion border. Increasing the amount of rotation (and leaving a larger secondary defect) creates length on the medial side of the repair; this length cannot be duplicated on the lateral segment unless the incision is carried along the vermilion border. This is known as a “cut-as-you-go” technique because modifications can be made during the operation to obtain better symmetry.
The Millard repair has the advantage of creating good lip projection (“pout”) by creating tension under the nasal sill rather than along the vermilion border. The most common problem is that the lip may be somewhat short after healing is complete. Placement of a tiny Z-plasty (1.0–1.5 mm) may improve this problem. Revision, if necessary, is much easier than revision after a triangular repair because of the linear nature of the lower portion of the repair.
Triangular Cleft Lip Repair
The rotation advancement repair is by far the most frequently used in the United States; the triangular lip repair makes up the majority of the remainder. The triangular lip repair may also be referred to as the Tennison–Randall cleft lip repair.
The triangular cleft lip repair evolved from earlier quadrilateral repairs; they have in common a zigzag closure, which breaks up the forces of scar contracture. In the triangular repair, a nearly horizontal incision is made in the lower half of the medial cleft segment, and a triangular piece is fashioned in the lateral flap to fit in the resulting defect. This closure is essentially a modified Z-plasty placed relatively low on the lip. In some ways, the small Z-plasty discussed with the Millard repair is a modified triangular repair appended to the rotation advancement technique (Figure 20–9).
Triangular cleft lip repair. (A) Markings for triangular repair; shaded areas will be discarded. (B) Appearance during triangular repair. (C) Completed repair.
In all Z-plasties, length is borrowed at the expense of width. The placement of the triangle low on the lip results in an excellent lip length, but it has the disadvantage of creating a flat repair when viewed from the side. In contrast, the rotation advancement repair places the tightest part of the closure beneath the nasal sill, where the lip is normally the flattest, and creates a more natural pout, but at the expense of greater difficulty in obtaining adequate length.
Bilateral Cleft Lip Repair
Several factors contribute to the greater complexity of bilateral cleft lip repair.
In complete bilateral cleft lip and palate, the premaxilla is usually quite protrusive and must be controlled preoperatively to achieve an adequate repair. Resection of the premaxilla was practiced previously, but this procedure results in severe maxillary retrusion, and an extremely complex reconstruction that can be accomplished only with prosthetics. The simplest method, taping, can be effective but requires a great deal of parental participation. As noted previously, alveolar molding with orthodontic plates is also used in a number of centers. This technique generally gives better alignment of the three segments of the maxilla before surgical intervention. Severe protrusion can be approached at the time of surgery with an osteotomy of the vomer to allow the premaxilla to be set back surgically, but this should be done only as a last resort because it is associated with maxillary hypoplasia.
The second major challenge in the bilateral cleft repair is the nasal deformity. The columella is extremely short and the nasal tip is flat, with bilateral alar base widening. Alveolar molding may be combined with nasal molding by adding small prongs anteriorly that are gradually elongated over several weeks; this can lengthen the columella nicely. Postoperative nasal stents can also be useful after lip repair.
Debate still exists over the management of the short columella. Traditionally, tissue has been obtained from the lip as forked flaps or nasal alae as V-to-Y advancement flaps. More recently, attention has been focused on obtaining length from the nose itself, since some of the loss of length is due to the separation of the nasal tip cartilages. Thus, V-to-Y incisions at the alar rim or vertical incisions over the tip have been proposed. As noted previously, preoperative orthodontic manipulation of the segments may be combined with nasal molding to lengthen the columella, which obviates any additional scars.
The third problem in the complete bilateral cleft is the maintenance of blood supply to the central cutaneous segment, the prolabium, as well as the bony premaxilla. The more extensive lengthening procedure done in a unilateral cleft cannot be applied to both sides of a bilateral cleft simultaneously without jeopardizing this blood supply, which can come only from the nasal septum. Thus, the bilateral cleft repair is often planned in stages to prevent any possible loss of tissue.
Symmetrical deformities are best approached with a symmetrical repair. It is essential to obtain complete closure of the orbicularis oris muscle at the time of the lip repair, bringing the two segments from each side together across the middle. The intact muscle contributes greatly to later growth of the lip, so the length of the lip is less critical (Figure 20–10).
(A) Markings for bilateral cleft lip repair. The forked flaps on each side of the prolabium will be placed under the nasal sills for later lengthening of the short columella. The mucosa is step-cut on the lateral segments to close in the midline under the prolabium, avoiding a whistle deformity. (B) Postoperative lateral view. The short columella is demonstrated. (C) Postoperative anteroposterior view. This child is wearing a Silastic stent in the nose to elongate the columella and round out the nostril.
Primary Cleft Nasal Repair
The cleft nasal deformity in the unilateral cleft is multifactorial. There is the cleft itself, which in a complete unilateral situation extends up through the nasal sill and floor of the nose. This creates a widening of the alar base, which is further exaggerated by the decrease in bony support in the piriform aperture on the side of the cleft. The nasal septum is generally deviated toward the side of the cleft, further tipping the nasal pyramid toward the cleft side. There is decreased projection of the dome of the alar cartilage on the side of the cleft, either as a primary deformity or secondary to the above. The final result is a nasal appearance that can be the primary stigma of the cleft deformity after a well-performed cleft lip repair.
Previously, the prevailing wisdom was that any procedure performed on a cleft nasal deformity early in life would result in irreparable scarring and the loss of growth potential of the nose. Today, abundant evidence exists that early correction of a cleft nasal deformity at the time of cleft lip repair can produce lasting improvement that grows proportionately with the child.
The common denominator in early cleft nasal correction is undermining of the nasal tip skin over the entire alar cartilage on the cleft side and over the dome of the noncleft side, extending the dissection up onto the inferior dorsum of the nose. This is done entirely through the existing incisions for the lip repair, at the base of the columella and at the alar base. No intranasal incisions are required. Suspensory sutures are then placed to elevate the nasal dome and to anchor the lateral crus of the alar cartilage on the cleft side in an advanced position; these are tied over percutaneous bolsters. Internal suturing techniques have also been described. The sutures are generally removed after only a few days. This procedure can result in excellent symmetry of the nose in simpler cases and acceptable improvement in more severe cases (Figure 20–11).
Primary nasal correction. (A) and (B) Anteroposterior views before and after surgery, respectively. (C) and (D) Views before and after lip repair, respectively, with primary nasal correction (one operation at 3 months of age).
More recently, nasal molding extensions have been added to alveolar molding plates to improve nasal contour before the lip repair. Other surgeons prefer to use postoperative nasal stents, available commercially in Silastic (ie, polymeric silicone), which can be gradually increased in size and used to help mold the nose over several weeks after the surgery for lip repair.
Cleft palate repair is primarily related to speech. Although there are obvious hygiene issues involved with the nasal regurgitation of food and fluids, most infants with cleft palates are able to gain weight appropriately and even to advance to solid food at about the same time as children without cleft palates. Intelligible speech, however, requires not only an intact palate but one with normal function.
Again, the overriding concern is speech. The trend in timing of palate repair has been toward earlier repair, and there are data supporting palate repair earlier than a year of age. Both a decrease in compensatory articulations (habits that are developed to mimic a sound that cannot be produced because of the cleft) and a decreased need for secondary surgery for speech have been demonstrated with earlier repairs, even when compared to “later” repairs at 12–18 months of age.
It is critical to think of palate repair in relation to the child's development of speech and language. The cleft does not affect speech development but, rather, the ability to produce specific sounds. In particular, sounds requiring positive intraoral pressure will be most affected. Early palate repair, then, is carried out in children who are displaying normal development in motor skills as well as in speech (babbling is the norm at about 7–9 months of age). In contrast, in children with syndromes that are associated with developmental delay, speech development may well be delayed as well and palate repair will be a little safer at a later stage, even at 18–24 months of age.
Techniques of Palate Repair
It is useful to conceptualize the different types of palate repair by separating techniques used for hard palate closure from those used for the soft palate. In both the hard and soft palates, the goal is a repair of both the nasal and oral mucosa, whereas in the soft palate, the functional repair of the levator muscle is an equally important component of the repair. Historically, the first palate repairs were of the soft palate only in patients with clefts of the secondary palate. Later, the introduction of mucoperiosteal flaps became the basis of most hard palate techniques.
Two-stage palate repairs were originally described as a means of treating wide clefts; soft palate repair was done at the same time as lip repair, with the hard palate repaired later after the cleft width had diminished. In a way, this is analogous to lip adhesion; the surgeon is committed to a second operation and has additional scar to confront at the time of the second procedure. The use of two-stage palate repair has consistently been shown to produce poorer speech results when compared with most single-stage techniques, but is still used by some surgeons.
In this technique, relaxing incisions are made on each side, just behind the alveolar ridge. The hard palate is closed with bipedicle mucoperiosteal flaps (the primary blood supply is from the greater palatine vessels). It is necessary in all of these repairs to develop corresponding flaps on the nasal side. On the noncleft side, a superiorly based mucoperiosteal flap on the vomer is elevated to allow closure of the nasal mucosa. The open areas from the relaxing incisions are left to heal by secondary intention, which generally takes about 2 weeks.
In the V-Y pushback, also referred to as the Veau–Wardill–Kilner repair, open areas are left anteriorly to attempt to improve the length of the soft palate. Since the entire anterior border of the flap is elevated, it is imperative to preserve the greater palatine vessels for blood supply. The nasal incision is made behind the posterior border of the hard palate (Figure 20–12).
V-Y pushback palate repair. (A) Markings for incisions. (B) Mucoperiosteal flaps are developed from the oral surface based on the greater palatine vessels (shown) and on the nasal surface. (C) Completed repair. Note the bare areas on the anterior surface of the palate.
Although the pushback repair is excellent for improving length and can be used to great effect in combination with a pharyngeal flap, in complete clefts there is a substantial anterior area, which depends on nasal closure only. It is not surprising that this repair has a higher incidence of anterior fistulas, which can contribute to speech problems and are difficult to repair secondarily.
This technique uses more extensive bilateral flaps, which are based on the palatine vessels, and provides both greater security in the anterior closure and a decreased incidence of fistulas. Basically, this procedure extends the von Langenbeck technique by bringing the relaxing incisions behind the alveolar ridge forward to the cleft margin (Figure 20–13).
Two-flap palatoplasty. (A) Mucoperiosteal flaps raised with intact greater palatine vessels. (B) Closure completed anteriorly up to the posterior alveolar margin.
The use of opposing Z-plasty procedures on the oral and nasal side of the soft palate produces increased length but also realigns the levator palatini muscle in an overlapping fashion. The tensor tendon can be divided to release some of the tension on the repair. This may be a difficult technique to use in wider clefts, but it is an excellent choice in narrower clefts and submucous clefts (Figure 20–14).
Furlow double-reversing Z-plasty. (A) Marking for Z-plasty. (B) Flaps transposed. Note that the nasal pattern (not seen) is the reverse pattern.
The routine repair of the levator palatini muscle has only recently become a widely accepted technique in palate repair. The dissection of the muscle from both oral and nasal mucosa can be difficult, especially on the nasal side, and some physicians have even proposed using a microscope for the procedure.
A more aggressive approach to the levator muscle is achieved by dividing the tensor palatini tendon as it curves behind the hamulus so that the conjoined portion of the levator muscle is released. The muscle can then be placed well posteriorly and even overlapped to give additional tension to the closure. Excellent speech outcomes have been reported with this technique.
Even with the best surgical technique, some patients have nasal air escape with speech after cleft palate repair. This can be due to scarring or shortening of the soft palate, inadequate movement of the levator muscle (which can be due to preexisting neurologic factors or surgical injury), or fistula formation with air loss through the hole rather than through the posterior pharynx. This is termed velopharyngeal insufficiency, or VPI.
Careful speech evaluation by a speech pathologist, usually a member of the cleft palate team, is the cornerstone of evaluation of VPI. Diagnostic methods include lateral cephalograms, nasal manometry, video fluoroscopy, or direct evaluation by nasoendoscopy. The temporary occlusion of a fistula by a piece of foil or a stoma adhesive in a cooperative patient can help to differentiate problems with the soft palate from those caused by a fistula. It is important to differentiate global VPI from “phoneme-specific” VPI, which occurs only with certain sounds, usually sibilants; the latter can be treated with speech therapy only, whereas the former generally requires surgical intervention.
Surgery for VPI can be broadly divided into procedures that lengthen a functioning palate and those that partially obstruct the area of closure in the posterior pharynx. Lengthening procedures include the V-Y pushback or the Furlow Z-plasty, both described previously. Posterior procedures include the pharyngeal flap and the pharyngoplasty.
The pharyngeal flap consists of mucosa and muscular tissue taken from the posterior pharyngeal wall, generally with a superior base near the adenoid tissue (Figure 20–15). The flap can be placed into a defect in the nasal mucosa when combined with a pushback procedure, or sutured into the soft palate with a variety of techniques. All of these methods leave the flap partially obstructing the nasopharynx with air going through “ports” on either side. If the ports are too large, VPI will persist; if they are too small, nasal obstruction and hyponasal speech may result. In most large series, the success rate in treating VPI is 80–90%. A significant rate of sleep apnea, as high as 30–40%, has been reported with pharyngeal flaps.
Pharyngeal flap. The flap is raised off the posterior pharyngeal wall and inset into the soft palate. Ports are left on each side of the flap for airflow.
The sphincter pharyngoplasty uses flaps made from the posterior tonsillar pillars, including the palatopharyngeus muscle, to create a theoretically innervated flap. These two flaps are sutured into a bare area created on the posterior pharyngeal wall just below the adenoids, creating a central port of decreased size and a larger area of prominence for contact with the velum. Success rates have been reported at approximately 90%, but with a smaller rate of sleep apnea (Figure 20–16).
Sphincter pharyngoplasty. (A) Myomucosal flaps are elevated from each posterior tonsillar pillar and a transverse incision made joining the two. (B) The overlapping flaps are sutured to each other and to the posterior pharyngeal wall, creating a central narrow port for airflow.
Nonsurgical approaches to velopharyngeal insufficiency (VPI) can be considered when patients are poor candidates for surgery either because of general health or because of specific conditions in the palate, such as scarring. Nonsurgical treatment modalities include orthodontic appliances to cover any open fistulas anteriorly or a speech bulb prosthesis (also known as a palatal lift appliance), which is a prosthetic device with a large posterior extension to lift the soft palate superiorly and posteriorly. In a palate that is not repaired, a speech bulb may itself provide a point for contact of the posterior and lateral pharyngeal walls to provide closure during speech (Figure 20–17).
(A) Speech bulb prosthesis. The large projection on the right side of the photo is gradually built up to elevate the soft palate. (B) Lateral cephalogram without the prosthesis. (C) Lateral cephalogram with prosthesis. The reduction in the posterior pharyngeal airspace can be seen clearly.
Secondary Surgical Procedures
As the child with a cleft grows, additional procedures are required. At a minimum, after lip and palate repair, bone grafting of the alveolar cleft and, later, septorhinoplasty, usually combined with any residual lip repair, are performed. It is important to reiterate the role that team care can play in this process; by having at least annual visits, the team can monitor the child's progress and recommend appropriate interventions at the optimum time.
The ultimate goal of cleft lip repair is to avoid secondary surgery, since each revision of a cleft lip scar creates new scar tissue and, of necessity, removes at least a small amount of adjacent normal tissue. Revision of the cleft repair is a common necessity, however; the most common problems are misalignment of the white roll or the junction of the wet and dry mucosa, inadequate length of the lip on the repaired side, and disparate fullness of the lip between the two sides. The last is easiest to correct because the new scar can be placed out of sight completely within the wet vermilion. Many techniques exist to correct the length of the lip repair, the most common being rerotation of an advancement-rotation repair (Figure 20–18).
Revision of unilateral cleft lip repair. (A) A 1-year-old child several months after lip repair complicated by partial separation. (B) One year after revision, with complete redo of rotation advancement repair.
The timing of revision is often coordinated with school ages, since entering a new school can be traumatic for the young child. Obvious problems are best corrected before kindergarten. A minor problem that is not causing any psychological concerns can often be addressed in conjunction with other procedures, such as bone grafting or rhinoplasty.
Bilateral cleft lip repairs are often staged, and columellar lengthening is best performed at age 4 or 5 before school starts. In some bilateral clefts with severe scarring, a cross-lip flap (also known as an Abbe flap) may be necessary; this simultaneously reduces the lower lip while adding bulk and length to the central portion of the upper lip (Figure 20–19).
A cleft lip reconstruction. The upper lip was reconstructed with an Abbe (cross-lip) flap, and a complete septorhinoplasty was completed. (A) Lateral view before surgery. (B) Lateral view after two operations. Note that the transfer of tissue from lower to upper lip has restored normal balance between the two.
Bone grafting of the alveolar cleft is generally performed during mixed dentition, before eruption of the permanent cuspid. The procedure generally follows orthodontic maxillary expansion, if it is required; it is important to coordinate this procedure with the efforts of the treating orthodontist. The bone graft serves several functions: (1) stabilization of the maxilla, (2) support for the roots of the adjacent teeth, (3) closure of any residual anterior fistula, and (4) support for the alar base on the cleft side. As noted above, the lateral incisor is usually absent; the bone graft will support a dental implant for replacement of the missing incisor and aid in support for other prosthetic devices, such as a fixed bridge.
The bone graft is placed between the bony margins of the two (or three) alveolar segments after elevating the mucoperiosteal flaps to close the nasal floor and the anterior palate; the anterior opening is then closed by advancing a gingivoperiosteal flap from the lateral segment. Although cranial bone and rib have been advocated as donor sites, iliac crest cancellous bone remains the “gold standard” for this application.
Early bone grafting has also been proposed, with placement of a small rib graft in the alveolar space at the time of lip repair. This has generally been associated with increased rates of maxillary hypoplasia, although there may be significant technical variations that have an effect on long-term results.
As discussed previously, some centers are performing gingivoperiosteoplasty, which is the closure of the alveolar gap at the time of the primary lip repair. This can be accomplished only after careful alveolar positioning with a molding plate. Early results are promising at this stage, but it is too soon to evaluate the orthodontic and maxillary growth aspects of dentofacial development in these children.
Both unilateral and bilateral clefts require rhinoplasty—usually in the early teens. If orthognathic surgery is required (see the following section), rhinoplasty is done subsequently. Every effort should be made at the time of lip repair to minimize the nasal deformity, but this has no effect on the severe septal deviation to the side of the cleft that is seen in most patients with a unilateral cleft.
The septum is corrected with septoplasty or submucous resection of the septum; the latter is useful in that the removed cartilage can be used to reconstruct the nasal tip and provide graft material for a columellar strut and for the nasal tip.
Open rhinoplasty techniques are favored for cleft nasal reconstruction since they provide greater exposure for accurate correction. In unilateral clefts, the deficient cartilage on the side of the cleft can be rotated into a symmetrical position, sometimes augmented with tip grafting. In bilateral clefts, the two alar cartilages must be sutured together to achieve better tip narrowing and projection (Figure 20–20).
Late nasal reconstruction. (A) Preoperative view. Note severe slumping of alar cartilage on the cleft (left) side, inadequate nasal dorsum. (B) Postoperative view after rib cartilage grafting to the dorsum and columellar strut to support the nasal tip.
Approximately 10–15% of patients with clefts require orthognathic surgery, usually maxillary advancement. The decision regarding jaw surgery affects the orthodontic approach as well as the timing of bone grafting (this can be done at the time of maxillary surgery in some cases, rather than as a separate procedure). A large discrepancy between the two jaws may require the simultaneous setback of the mandible. Generally, these procedures are done near skeletal maturity, since the mandible is one of the last bones to stop growing—in early teens for girls, later for boys. It is important to monitor the patient's speech after maxillary advancement because the palate may come forward enough to produce nasal air escape where none was present previously (Figure 20–21).
Le Fort I maxillary advancement. (A) Profile prior to advancement. This patient had a cleft palate only. (B) Profile after maxillary Le Fort I procedure with rigid fixation.
American Cleft Palate Association. Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. Cleft Palate Craniofac J
. (Consensus paper from the American Cleft Palate Association that summarizes their recommendations for team care of patients with cleft lip and palate.)
Millard R. Cleft Craft: The Evolution of Its Surgery. Boston, MA: Little, Brown, 1976. (Classic text on cleft repairs. Even if dated, it is encyclopedic in scope, covering both history and technical aspects of cleft lip and palate surgery.)
Losee JE, Kirschner RE, editors. Comprehensive Cleft Care. New York: McGraw-Hill Medical, 2009. (This new text is extensive, well illustrated and affordable with chapters by most of the leaders in the field.)