for Plastic Surgery in Children

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© Springer Nature Switzerland AG 2020
Craig Sims, Dana Weber and Chris Johnson (eds.) A Guide to Pediatric

22. Anesthesia for Plastic Surgery in Children

Rohan Mahendran1  

Department of Anaesthesia and Pain Management, Perth Children’s Hospital, Nedlands, WA, Australia



Rohan Mahendran


Anesthesia for cleft lip palate surgeryCraniosynostosisAnesthesiaPharyngoplastyNasal intubationCleft palate surgeryAirway

Anesthesia is often required for small traumatic injuries such as lacerations, which would be treated under local anesthesia in an adult. It is also required for plastic surgery to correct congenital deformities, sometimes in children with other congenital anomalies that affect anesthesia.

22.1 Anesthesia for Cleft Lip and Palate Repair

Cleft lip and palate is the most common craniofacial disorder in children, with an overall incidence of 1 in 600 births. It occurs from the failure of fusion of the components of the nasal and maxillary prominences during early gestation. Children can have an isolated cleft clip, cleft palate only, or both cleft lip and palate. Babies with cleft lip and palate are usually otherwise well. Babies with cleft palate alone are less common (about 1 in 2000 births), but are more likely to have other congenital anomalies including cardiac disease (5–10%) or other syndromes including Trisomy 21, or Robin sequence. The cleft varies in severity and may be unilateral or bilateral. It can involve the nose, philtrum, lip vermillion, gum, hard and soft palate, uvula and Eustachian tubes.

There are many subsequent effects of the cleft. These include cosmetic and maternal attachment issues, sucking and feeding, hearing and speech development, and dental issues. Children with cleft palate are managed by a team including plastic surgeons, geneticists, ENT and speech pathology, dentistry and orthodontics, and nutritionists. An early issue for babies with cleft palate is developing an effective suck for feeding. Specialized teats or squeezy bottles are used for feeding. Orthodontic plates are used before surgical repair to align the gum margins. Infants with syndromes in association with cleft are particularly prone to gastro-esophageal reflux, which in turn inflames the upper airway and affects surgery.

22.1.1 Surgical Repair

Surgical procedures optimize function and cosmesis. The first procedure is lip repair at 3 months of age. Some centers perform this repair at ages as young as 1 week to reduce scarring, but this must be balanced against anesthesia and airway concerns. The anterior part of the gum is sometimes repaired at the same time as the lip, or otherwise later when the palate is repaired.

The cleft palate is repaired between 9 and 18 months of age. Repair at a young age improves speech development, whereas later repair allows more normal development of the midface. The age chosen for repair is a balance between these two opposing requirements. For this reason, some centers close the lip and soft palate early and leave the hard palate cleft until childhood. Repair is carried out using mucoperiosteal flaps, and intravelar veloplasty to re-orientate the muscles of the palate (Fig. 22.1). Particular attention is paid to the levator muscle of the soft palate because it is important for speech. The bony defect of the gum is corrected later with an alveolar bone graft, usually taken from the iliac crest.


Fig. 22.1

Schematic of one of the surgical techniques used to repair cleft palate. (a) Isolated cleft of hard and soft palate, showing abnormal orientation of palatal muscles in the soft palate and surgical incision lines (dotted line). (b) Surgical repair of cleft palate using mucoperiosteal flaps and intravelar veloplasty. The repair leaves anterior raw areas that may bleed postoperatively

22.1.2 Anesthesia for Cleft Lip Repair

The lip is repaired during early infancy to reduce scarring and help with maternal bonding and feeding. The airway is managed during general anesthesia with a south-facing oral RAE tube. Intubation can be awkward if the baby also has a cleft palate, and is discussed below. The surgeon will infiltrate the area with local anesthetic or perform bilateral infra-orbital blocks. Although this provides adequate analgesia, intraoperative fentanyl may help to keep the baby settled and calmer in PACU. Although the lip defect has been closed, there is no major change to the infant’s upper airway after surgery, which facilitates postoperative management.

22.1.3 Anesthesia for Cleft Palate Repair

There are several important issues for anesthetic care, mostly relating to the airway (Table 22.1). Intubation is usually straightforward, but may difficult in about 5% of cases—usually in children with a coexisting syndrome affecting the airway. Cleft palate babies are classically said to be awkward to intubate because the laryngoscope blade can fall into the cleft. However, this is not a common problem in practice, although it is more likely to occur if the cleft is left-sided. Techniques to avoid this problem include intubation using a laryngoscope with the broad Oxford cleft lip and palate blade, or using folded gauze to fill the cleft during intubation. Routine use of a videolaryngoscope would be a reasonable choice nowadays.
Nov 27, 2021 | Posted by in ANESTHESIA | Comments Off on for Plastic Surgery in Children
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