Cleft and Craniofacial Surgery in Adolescence and Adulthood: Addressing Needs That Don't End in Childhood

November 15th, 2026

Cleft lip and palate care is often described as a journey that begins in infancy. The first repair happens early, follow-up visits continue through childhood, and families are told that the major work is behind them. Then adolescence arrives, the face grows, and a new set of problems appears: the upper jaw falls behind the lower jaw, the bite shifts, the nose looks more asymmetric, or speech that was once clear becomes nasal again.

These changes are not a sign that earlier treatment failed. They are the predictable result of a craniofacial skeleton that keeps growing after the first operations, and of scar tissue that does not grow at the same rate as the bone around it. Roughly one in 700 babies is born with a cleft lip or cleft palate, and a meaningful number of those patients need additional surgery in their teens or adult years.

Some adults are seeking care for the first time. They may have had limited access to specialized treatment earlier in life, or they may have reached a point where they are ready to address a difference they have lived with for decades. Cleft and craniofacial surgery in adolescence and adulthood is a distinct field, and it is the focus of our program at Scripps Prebys Cancer Center.

Why the Need Does Not End in Childhood

A child's face is not a smaller version of an adult's face. The jaws, midface, and nasal skeleton continue to grow through the teenage years, and the position of the upper jaw relative to the lower jaw can change substantially during that growth. In a child born with a cleft, the upper jaw often grows forward more slowly than the lower jaw. The result is maxillary retrusion, a recessed midface that becomes more obvious as the lower jaw catches up.

Scar tissue from early palate repair can also restrict the forward growth of the upper jaw. This is one of the central tensions in cleft care: the same operation that closes the palate and enables speech can influence how the midface grows afterward. Modern surgical timing has reduced that effect, but it has not eliminated it.

The consequences show up across several areas at once:

• Bite and jaw position: A Class III malocclusion, an open bite, a crossbite, or a jaw that shifts to one side.
• Speech: Velopharyngeal insufficiency, in which the soft palate does not close completely against the back of the throat, producing hypernasal speech and nasal air escape.
• Breathing: A narrow or recessed upper jaw can crowd the nasal airway and contribute to mouth breathing, snoring, or obstructive sleep apnea.
• Dental health: Missing, malformed, or malpositioned teeth near the cleft, along with bone defects in the alveolar ridge that complicate implants or orthodontics.
• Appearance: Residual lip and nasal asymmetry, scarring, a flattened midface, or a profile that does not match the person's sense of self.
• Social and emotional health: The cumulative effect of years of medical visits, teasing, or simply feeling different during the years when identity is forming.

Functional Problems That Deserve Attention

The word cosmetic is sometimes used to dismiss cleft-related concerns. That framing misses the point. Most of what cleft and craniofacial surgery addresses in adolescents and adults is functional, and the aesthetic changes are usually inseparable from the functional ones.

Speech and velopharyngeal insufficiency

Velopharyngeal insufficiency (VPI) is one of the most consequential problems that can persist or reappear in adolescence. The soft palate and the side walls of the throat are supposed to close off the nose during speech, except for the nasal sounds. When that closure is incomplete, air leaks through the nose, speech sounds hypernasal, and certain consonants become hard to produce clearly. VPI can affect intelligibility, confidence in conversation, and performance at school or work.

Assessment begins with a speech-language pathologist and often includes nasal endoscopy or videofluoroscopy to see how the palate moves. Treatment may involve speech therapy, a palatal revision, autologous fat transfer, a pharyngeal flap, or sphincter pharyngoplasty. The right choice depends on how the palate moves and where the closure fails, which is why the evaluation is as important as the operation.

Chewing and the bite

A recessed upper jaw and a Class III relationship make biting and chewing inefficient. Patients may avoid tough foods, chew on one side, or notice that their front teeth do not meet. Over time, the uneven load can wear the teeth and strain the jaw joints. Orthodontics alone cannot correct a skeletal discrepancy of this kind. When the problem is the position of the bone, orthognathic surgery is often the definitive answer, and it is frequently planned together with braces.

Breathing and sleep

Maxillary retrusion narrows the nasal passage and the space behind the palate. Patients may breathe through the mouth, snore, wake unrefreshed, or carry a diagnosis of obstructive sleep apnea. Moving the upper jaw forward can enlarge the airway as well as improve the bite and the profile. A sleep study and an airway evaluation are reasonable parts of the workup when these symptoms are present.

Oronasal fistulas and alveolar defects

An oronasal fistula is a persistent opening between the mouth and the nose. It can let liquids escape through the nose, interfere with speech, and cause chronic nasal irritation or infection. An alveolar cleft is a bone defect in the ridge that supports the teeth. Secondary alveolar bone grafting stabilizes the dental arch and creates bone for tooth eruption or a future implant. Some adults who never had grafting are candidates for it later in life, often coordinated with orthodontics and restorative dentistry.

Ear disease and hearing

Children with cleft palate have a higher rate of middle ear problems, and the effects can continue into adulthood. Hearing should be part of the overall assessment, particularly when speech or school performance is a concern. Coordination with otolaryngology and audiology is standard in comprehensive cleft care.

Aesthetic Concerns Are Part of the Picture

The lip and nose are the most visible parts of a cleft difference. Primary repair often leaves asymmetry of the nostril, a flattened nasal tip, deviation of the septum, or scarring that becomes more noticeable as the face matures. The upper jaw may sit too far back, the midface may look flat, and the chin may appear prominent by comparison.

These features affect more than appearance. They influence how a person speaks, breathes, and feels in photographs and social situations. Secondary cleft lip revision and cleft rhinoplasty address the soft tissue and cartilage of the lip and nose, while orthognathic surgery addresses the underlying skeletal base. Doing one without the other can leave the result unbalanced, which is why the plan should consider the face as a whole.

Our before and after gallery shows the kind of change that coordinated cleft and craniofacial surgery can produce. The goal is not a generic face. It is a face that looks like the person, with a bite, airway, and speech that work.

What Treatment Can Include

Cleft and craniofacial care is not a single operation. It is a set of procedures selected for the individual patient, often staged over time.

Secondary cleft lip and nasal surgery

Secondary cleft lip revision refines the contour of the lip, corrects asymmetries, and addresses scars that have thickened or shortened. Cleft rhinoplasty rebuilds the nasal tip, straightens the septum when the airway is blocked, and repositions the lower lateral cartilages. Functional breathing correction and aesthetic refinement are planned together.

Palatal and speech surgery

Palatal revision, pharyngeal flap, sphincter pharyngoplasty, and fat transfer are used for VPI when speech therapy alone is not enough. Each changes the geometry of the velopharyngeal closure in a different way, so the choice follows a careful speech and imaging evaluation.

Alveolar bone grafting and fistula repair

Bone grafting of the alveolar cleft restores the dental arch and supports future teeth or implants. Oronasal fistula repair uses multilayer soft tissue closure, and sometimes a local or regional flap, to separate the mouth from the nose reliably. These procedures are often coordinated with orthodontics and prosthodontics so that the dental rehabilitation is timed correctly.

Orthognathic surgery for cleft patients

When the upper jaw is retruded, a Le Fort I osteotomy can move it forward and restore the relationship with the lower jaw. Some patients also need a bilateral sagittal split osteotomy of the mandible, a genioplasty, or a combination of procedures. Cleft patients often have a narrower upper arch and scar tissue that make the surgery more demanding than a routine orthognathic case, which is why experience with cleft anatomy matters. Our orthognathic jaw surgery program and guide to jaw misalignment explain the underlying principles.

Craniofacial reconstruction

Conditions such as craniosynostosis, hemifacial microsomia, Treacher Collins syndrome, and Crouzon syndrome can require reconstruction in adolescence or adulthood. The operations may involve a Le Fort 3 osteotomy, distraction osteogenesis, bone grafting, or microvascular free tissue transfer when the soft tissue or bone defect is large. Our microvascular reconstruction team rebuilds defects that cannot be closed with local tissue alone.

Secondary procedures

Patients who had multiple operations as children sometimes benefit from revision of a prior reconstruction, bone augmentation, hardware removal, or soft tissue refinement. These are not failures. They are the natural later chapters of a treatment plan that began before the face finished growing.

How Computer-Aided Planning Helps

Cleft and craniofacial anatomy is asymmetric, scarred, and often has been operated on before. Planning in three dimensions has made a real difference in these cases.

A high-resolution CT scan is converted into a digital model of the patient's skull. The surgeon can simulate the jaw movement, the bone grafts, and the reconstruction on screen, compare several options, and choose the one that best restores the bite, the airway, and facial symmetry. Patient-specific cutting guides, splints, and fixation plates are designed from that plan and manufactured before surgery, so the planned movement is transferred to the operating room with millimeter-level control.

The benefits are practical: fewer surprises during surgery, shorter operating time, more consistent symmetry, and a clearer conversation with the patient about what the operation will change. The technology does not make a difficult case simple, but it makes the execution of a thoughtful plan more reliable. Our overview of jaw surgery procedures describes the main osteotomies in more detail.

The Team Around the Patient

Cleft and craniofacial care has never been a one-surgeon endeavor. Adolescents and adults are best served by a group that can address the surgical, dental, speech, hearing, and emotional dimensions of the condition together.

• Orthodontists prepare the teeth before jaw surgery and refine the bite afterward.
• Speech-language pathologists assess velopharyngeal function, guide therapy, and help determine when surgery is appropriate.
• Prosthodontists and restorative dentists plan implants, bridges, and other dental rehabilitation around the surgical timeline.
• Otolaryngologists and audiologists manage ear disease and hearing concerns.
• Psychologists and counselors support the emotional and social side of living with a facial difference, especially in adolescence.
• Anesthesiologists and perioperative teams plan for airway management in patients whose anatomy has been operated on before.

This coordination is not a formality. The timing of orthodontics, bone grafting, speech surgery, and jaw surgery changes the outcome, and the best plans are made with all of those specialists in the room, or at least in the same conversation.

Adolescence Versus Adulthood

The timing of surgery depends on growth. Orthognathic procedures are generally performed after the facial skeleton has finished growing, which is usually in the late teens or early twenties. Some soft tissue procedures, such as lip revision or rhinoplasty, can be done earlier, but the plan has to account for the growth that remains.

Adults bring a different set of considerations. Treatment often has to fit around work, caregiving, and financial responsibilities. Some adults have never had a complete cleft evaluation and are learning for the first time what is available. Others had surgery decades ago and were told that nothing more could be done. That is rarely true today. Imaging, virtual planning, and modern reconstructive techniques have expanded what is possible well into adult life.

Age itself is not the deciding factor. General health, the condition of the teeth and gums, the quality of the soft tissue, and the patient's goals matter more than the number of birthdays.

Recovery and Realistic Expectations

Recovery depends on the procedures performed. Lip and nasal surgery typically involves swelling and bruising for a week or two, with gradual refinement of the result over months. Palatal surgery requires a soft diet and careful attention to speech therapy afterward. Jaw surgery brings several weeks of swelling, a soft or no-chew diet, and numbness that may take months to improve.

Cleft and craniofacial treatment is often staged, so the full result may not be visible after a single operation. Scars mature over a year or more. Speech improvement after VPI surgery depends on the cause of the problem and on ongoing therapy. The most useful conversation before surgery is an honest one about what is likely to change, what may not, and how many stages the plan involves.

Insurance and Access

Cleft and craniofacial procedures are generally considered medically necessary and are covered by most insurance plans when they address function: speech, breathing, chewing, dental rehabilitation, or reconstruction of a congenital defect. Coverage for purely aesthetic refinements can be more limited, and the distinction is usually documented in the preoperative assessment.

Our team has experience with prior authorization and with explaining the functional rationale for surgery in the terms insurers require. Patients are encouraged to start the insurance conversation early, before scheduling, so that the clinical plan and the coverage plan develop together.

Questions Worth Asking

• Which of my concerns are functional, and which are aesthetic, and how does the plan address each?
• Do I need orthodontics before surgery, and for how long?
• Is my facial growth complete, and how does that affect timing?
• Would speech therapy help, or is surgery the next step for my VPI?
• Which procedures can be combined, and which should be staged?
• What will recovery involve, and how much time will I need away from school or work?
• How many cleft and craniofacial cases does the team perform each year?
• What does insurance cover, and what documentation will you provide?

Care That Continues

A cleft or craniofacial difference is not a childhood problem that gets left behind. It is a condition that changes with growth, with age, and with the person's own goals. The good news is that the surgical options available to adolescents and adults today are far more precise and more comprehensive than they were a generation ago.

Dr. Ravi Garg and the team at the Advanced Head and Neck, Cranial / Orbital / Maxillofacial Surgery Program at Scripps Prebys Cancer Center provide cleft and craniofacial surgery in San Diego for adolescents and adults, with virtual surgical planning, coordinated orthodontic and speech care, and reconstruction capability under one program. Whether you are a teenager who has grown into a new bite, a parent wondering what comes next, or an adult who has never had a complete evaluation, a consultation is the place to start.

Contact our team to request a consultation, or call us directly at 619-452-7332. We are located at 4044 Fifth Ave, San Diego, CA 92103, and we respond within one business day.

Posted in: Cleft and Craniofacial Surgery