Dr. James Liau

Dr. James Liau: How I help families navigate the cleft care journey

Written by Dr. James Liau, a plastic surgeon at UK HealthCare who specializes in cleft lip and palate repair.

July is a special time of the year for me since it’s Cleft and Craniofacial Awareness Month.

Although I do all aspects of plastic surgery, pediatric cleft care is what I’m passionate about.

So, what are clefts and how are they treated? What can you expect if your child is born with a cleft? I’m here to help answer those questions and help you and your family navigate the cleft care journey – from birth through adulthood.

What is a cleft?

A facial cleft is an area where there is an absence of tissue or abnormal tissue. Although there are multiple types of clefts, cleft lips and cleft palate are the most common. Some patients may have both cleft lips and cleft palate, while others may have only cleft palate.

Unfortunately, we’re not entirely sure why clefting occurs. Although clefts are a lifelong condition, I feel very strongly that there is no reason they should limit a child’s potential in life.

Treatment in the first year of life

I like to fix cleft lips at about 4 to 6 months of age, and then fix cleft palates around 10 months to 1 year of age. Timing varies for each family. I always tell parents that the most important thing is to go home, bond with their newborn and not worry about the cleft until at least several months after birth.

As a parent myself, I understand that no one wants their child to have surgery. Unfortunately, a child with a cleft lip and palate will need two surgeries in their first year of life. Both surgeries will be overnight stays in the hospital to make sure pain is controlled and the family is comfortable with the postoperative care.

The lip repair is the most dramatic, but postoperative care is relatively easy. Cleft palate repair can make eating challenging as it requires the child to temporarily be on a diet of only thickened liquids, such as applesauce.


After the first year, cleft care is put on the back burner as we monitor speech development. As a child nears the age of 3, we have to be vigilant about their ability to communicate. Kids with cleft palates can develop hyper-nasal speech, a condition that occurs when the palate can’t close off the nose. This is called velopharyngeal insufficiency, or VPI.

If this can’t be fixed by speech therapy, another surgery may be necessary. I like to do this before the child starts preschool or kindergarten, as this is when kids really start interacting with their peers and speech becomes very important in making new friends.

At this time in a child’s life, we can also discuss whether a small touch-up to the lip or nose is necessary. I defer this decision to the child and family. Kids don’t comment negatively on physical differences until they’re at least 7 years old, so touch-ups at this age are only necessary if the cleft is bothering the child. My goal is that the first repair is perfect enough to avoid a revision!

Between the ages of 7-9, the child will start seeing an orthodontist. If there is a cleft in the gum line, we will need to put a bone graft in that area when the child’s permanent teeth come in, which usually occurs around this time.

The timing of this procedure can usually be coordinated over several months, and most families choose to do it during summer or winter break. For this operation, I use a less-invasive technique that involves harvesting bone from the hip. Postoperative care depends on the child: Some kids will stay overnight for pain control, while others will not.

Teenage years into adulthood

In the teen years, we can revisit the idea of a revision. This is when I do a lot of rhinoplasties, or nose reshaping. Naturally, we are focused on getting the nose to look more symmetrical, but we are also focused on opening the nasal airway so that breathing through the nose is normal. This is an outpatient procedure.

During the teen years, we may also do jaw surgery to improve how the face looks, and in more severe cases, to improve the airway in the nose and upper mouth.

As you can see, cleft care requires lots of coordination over many years. I tell all my families, “My role is to be your quarterback.” Raising a child is hard enough without worrying about cleft care, so my job is to make sure we don’t miss anything and to seamlessly work cleft care into what is happening in the family’s life.

I’m always honored to be able to help patients and their families navigate the process of cleft care. All children deserve a chance at a bright future, and I hope my work can help make that happen.

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