Cleft Surgery

The Surgeon

Mr. Tomas O’Neill joined the South Wales Cleft Team in May 2019. He is a plastic surgeon who has completed additional specialist training (TIG Fellowship) in Cleft Lip and Palate with the National Cleft Surgical Service for Scotland in Glasgow. In addition to this, he has undertaken a cleft and Craniomaxillofacial fellowship with Professor David David in Adelaide, South Australia. This fellowship was combined with a Masters Degree in Advanced Surgery in the field of Craniomaxillofacial surgery awarded by Macquarie University in Sydney.

Tom is a recipient of the Rowan Nick’s Scholarship by the Royal Australasian College of Surgeons, and also the Vice-Chancellor’s International Scholarship from Macquarie University.


The type and timing of cleft care offered depends on both the type of cleft involved as well as the age of the patient. The specific plan for you or your child will be discussed in detail at a clinic appointment.

In general terms however, the timings and basics of operations are outlined below.


Cleft lip operations take place at approximately 3 months of age. We like to see children who have undergone a lip repair before they start school if there are any parental concerns over the appearance of the repaired lip, as a certain percentage of cleft lip scars are amenable to being improved with a revision procedure.

For children who have a cleft involving the lip and palate, the front part of the palate is usually repaired at the same time as the lip repair is undertaken.


Cleft palate operations take place at approximately 6 months of age unless there are other medical conditions that require more urgent attention or airway issues that need to be considered. This is for children who are born with an isolated cleft involving the palate, or in children who have a cleft involving the lip and palate and have already undergone a lip repair.

The precise nature and timing of these procedures will be discussed at the Baby Clinic.

All babies receive their anaesthetic by one of two specialist paediatric anaesthetists.

Alveolar Bone Graft:

The timing of alveolar bone grafting will vary from child to child, even if they have the same cleft type. We begin to investigate the most appropriate timing of this procedure shortly after the child’s 8th birthday. X-rays will help to guide us towards the correct time. The decision of when to undertake an alveolar bone grafting procedure is jointly undertaken by both the Consultant Orthodontist, Paediatric Dentist and Cleft Surgeon. Often an alveolar bone graft operation involves the extraction of some teeth.

Speech Surgery:

There are occasions when despite optimal timing of palate surgery, the resulting speech is not as great as it could be. Following assessment by a specialist cleft speech and language therapist, further investigation may be necessary. This usually starts with a videofluoroscopy exam. Essentially this involves taking a video x-ray from the side as the patient repeats special sentences after the speech and language therapist. This allows us to assess the structure of the palate and the throat, and also how it works. Depending on how everything looks or moves, further surgery to either the palate or throat may be recommended. This will be decided by Mr. O’Neill in conjunction with the specialist cleft speech therapists and discussed with you at the videofluoroscopy appointment. Occasionally, another test called a nasendoscopy might be warranted before a final recommendation can be reached. This involves putting a tiny camera down the nose to look at how the palate moves and touches the back wall of the throat during speech. If this is necessary, it usually takes place at another appointment on a separate day. Speech surgery is usually considered after 2 years of age.

Orthognathic Surgery:

Occasionally, some patients who have undergone surgery for clefts involving their palate can notice a facial imbalance in adolescence and adulthood. This is recognised by the front teeth of the lower jaw sitting in front of the front teeth of the upper jaw. Some patients may also complain of their upper jaw being too flat under their nose when they look at photographs of themselves in side-profile. If this is a concern, we run a specialist orthognathic clinic where patients have impressions taken of their teeth which are built into models, x-rays and photographs are taken and a digital planning session is undertaken to give the patient an idea of what result orthognathic surgery could achieve. Orthognathic surgery is best undertaken once growth has stopped. This varies between men and women, and between individuals, but the Maxillofacial surgeon and the cleft Orthodontist would help to determine the optimal timing to deliver the best possible outcome.


Patients who have a cleft that involved the lip +/- gum may get some asymmetry of the nose. This can range from barely noticeable to very obvious, however we recognise that different degrees of asymmetry might bother patients to differing degrees. The operation to improve the asymmetry is called a rhinoplasty. Some patients are also concerned by how their nose works, sometimes even more than how it looks. Often, the septum (the internal wall that separates the left and right nostril chambers) can be bent and block the passage of air through one side. A rhinoplasty can also attempt to straighten the septum and improve how air flows through the nose.

If both orthognathic and rhinoplasty surgery are being planned, the rhinoplasty is best undertaken after the orthognathic surgery has been done and fully settled. This would generally be a minimum of six months.

If orthognathic surgery is not being considered, then rhinoplasty is best undertaken at the completion of growth also. Usually this means the late teenage years or early twenties.


Sometimes, there is a very small appearance issue that can bother some patients a lot, but not enough to undergo more surgery. This can involve the nose, lips or both. Sometimes HLA (Hyaluronic Acid) filler is a suitable alternative to surgery for improving symmetry and balance. Filler can be used in both men and women and will last for 6-24 months depending on the type of filler used and the location in which it is placed. In the setting of cleft lip scars and after rhinoplasty procedures, this should be placed by an experienced and qualified practitioner who has knowledge of what is achievable and how best to achieve it.


The prospect of having an operation can be unsettling for some children or even adults and parents. Rest assured we understand that what we do as ‘every day’ or routine, might be a once in a lifetime undertaking for you or your child. We are here to help with the preparation for coming in for an operation as best we can.

For children, our psychology team and ward based play specialists are experts in giving children the tools to manage and reduce any stress they may be experiencing.

For adults, psychology input is available for anyone struggling to make a decision about whether to opt for surgery or not. It can also help with finding the tools to manage anxiety that you may experience in advance of surgery.


Further Information

The following information leaflets can explain each area in a little more detail.


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