"Dr. Grayson's presurgical work makes my job easier and allows me to accomplish more," says Dr. Cutting. "After the molding, the gum pads are lined up instead of wide apart, so I can usually repair the gums without a bone graft. In children with bilateral clefts, the nose can be repaired at the same time. The net result is that in one operation, I can repair the lip, gum, and nose.

"We're also getting improved results in closing the palate," Dr. Cutting adds, "using a technique of dissecting out missplaced muscles in the soft palate that would otherwise interfere with complete closure. The usual success rate in achieving a fully closed palate is about 80%; ours is 96%. A more complete closure has dramatically improved the ability of children with cleft lip to speak more clearly."

Orthodontics and Surgery: Melding Two Traditions

The success of Drs. Cutting and Grayson's approach requires close collaboration between surgeon and orthodontist. "Orthodontists are very patient," explains Dr. Cutting. "It is interesting that Dr. Grayson's hobby is bonsai. He'll take a very young tree and hang a small weight on one branch and it will slowly bend; or he may use a wire to gently change the direction of growth of a branch. Little by little, with small forces, you can completely shape a miniature tree.

"Orthodontists routinely do something very similar in correcting the teeth with braces. With a little bit of force applied over a long period of time, the braces manage to move a child's teeth through bone into a new pattern," says Dr. Cutting. "Surgeons, in contrast, like to get in there and 'fix it now'. We're bringing the best of these two different traditions together and getting wonderful results."