22. Anesthesia for Plastic Surgery in Children
KeywordsAnesthesia 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.
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.