1. Procedures Intermediate Format Cleft Lip and Cleft Palate
(Cheiloschisis and Palatoschisis)
These are congenital deformities that can occur individually and are often seen in conjunction with one another.
Cleft lip and palate is a common birth defect occurring in about 1 out of every 700 births. They are more prevalent among people of Asian descent. Heredity does play a role in the occurrence of these deformities, and the incidence increases in parents older than age 30. Other contributing factors may include cigarette smoking, drug and alcohol abuse, infection,, and vitamin deficiencies. Surgical repair is required.
Historically, surgical repairs are often planned when the child is between 7 & 18 mos of age. This deformity affects the ability to suck, swallow and to form sounds properly. However, early correction aids in parent- infant bonding and feeding; there is a “rule of 10” some follow, meaning that the infant is 10 wks old, weighs 10 lbs, and has a hemoglobin of 10.

2. Objectives
Assess the related terminology and pathophysiology of the ________________.
Analyze the diagnostic interventions for a patient undergoing a cleft lip or cleft palate repair.
Plan the intraoperative course for a patient undergoing_____________.
Assemble supplies, equipment, and instrumentation needed for the procedure.

3. Objectives Choose the appropriate patient position
Identify the incision used for the procedure
Analyze the procedural steps for_____________.
Describe the care of the specimen

4. Terms and Definitions
Cleft: split or gap between two structures that are normally joined

5. Definition/Purpose of Procedure
Cleft Lip Goal: symmetry of nostril floor and nostril sil and a natural appearance of cupid’s bow
Strive for functional repair of muscles with an aesthetically pleasing approximation of the skin edges; resolve sucking difficulties
Palatoplasty: to form the absent roof of the mouth;
prevent the escape of air thr the nose during speech, keep food and fluids out of the nose, and facilitate sucking and eating

6. Pathophysiology Unilateral cleft lip Unilateral cleft palate
The cleft can be unilateral or bilateral. When there is a disruption in normal fetal development causing the 3 prominences that should fuse to form the midface to remain separated, a “cleft” occurs. It can affect just the upper lip, just the palate, or a combination of both.
A deficiency of tissue (Skin, muscle, mucosa) along one or both sides of the upper lip, or rarely, in the midline results in a cleft at this side of the deficiency. The deficiency results in distortion of Cupid’s Bow, absence of one or both philtral ridges, and distortion of the lower portion of the nose.
Cleft lip is usually associate with a notch or cleft of the underlying alveolus and a cleft of the palate.
Unilateral cleft lip
Unilateral cleft palate

7. Surgical Intervention: Special Considerations
Patient Factors
Increase room temperature or apply webril to limbs for warmth, depending on age; cap for head
Family communications hourly
Room Set-up—ESU, Suction, lights, radiant heat lamp over OR bed until pt in room; may increase room temp to 80 degrees F (26.7 C)
Surgery takes about 3 hrs—need to involve family as much as possible and keep informed during the procedure.--Calls

8. Surgical Intervention: Positioning
Position during procedure
Supine w/head at very top of bed
Bed will be turned 90 degrees after induction—be sure to turn bed around to allow “knee room” for surgeon while sitting
Supplies and equipment
Gel padding
Shoulder roll for increased palatal exposure
Special considerations: high risk areas

9. Surgical Intervention: Special Considerations/Incision
Surgeon inserts cleft palate mouth gag and infiltrates palatal structures with 5 mg/kg of 0.25% lidocaine w/epi 1:400,000 using a 3 mL syringe (resulting in hydrodissection of palatal structures, decreasing intrap bleeding)
Neonate’s face is prepped with Betadine solution x 3, to include the mouth gag and mouth, and avoiding pooling of solutions
State/Describe incision
Palatal structures are infiltrated before the prep to allow time for the hemostatic action of the epinephrine to become effective.
There are many types of cleft lip repair. If the neonate has both a cleft lip and palate, the palate is repaired first so that the lip Is not disrupted after it has been repaired.

10. Surgical Intervention: Supplies
General
Specific
Suture: 5-0 Braided absorbable; 7-0 Chromic
Blades: # 15
Medications on field (name & purpose)
0.25% lidocaine w/epi 1: 400,000
Surgical Glue
Catheters & Drains
Plastic Surgery Specialty Cart

11. Surgical Intervention: Instruments
General: Plastic surgery “local” instrument set; oral instrumentation set
Specific
Brown lip clamps, calipers, a Fomen retractor, Beaver Blades # 64 and # 65, Logan bow, Dingman mouth gag and assorted retractor blades
(Palate) Blair palate hook, palate knives, Blair palate elevators, Fomen lower lateral scissors, short & long
For a great website which is copyright protected, go to and click on the Photo Gallery, then go to the section at the bottom under “Logan Bow” and click on Emma Leigh. The family provides step-by-step stages of healing progression from surgery and one includes photo with Logan Bow in place. This kind of website is something I am not willing to risk putting on Powerpoint and sending off…..very personal pics and Copyright warnings listed everywhere.

12. Surgical Intervention: Equipment
General
Specific
Radiant warmer for bed preop

13. Surgical Intervention: Procedure Steps
Normal landmarks are identified and marked or tattooed.
Calipers & a ruler are used to make precise measurements so that corresponding points are marked along the cleft.
Surgeon places raytex sponge in back of neonate’s throat to minimize the amt of blood ingested & makes incision along hard palate.
Surgeon exposes the tensor veli palatini & levator palatini muscles, but only as much as needed to limit scarring.
* scarring increases risk for palate immobility post-op
Surgeon makes releasing incisions along the lateral aspects of the soft palate so there is no tension along the median closure line.

14. Surgical Intervention: Procedure Steps
Surgeon makes additional incisions in the nasal mucosa and the posterior edge of the soft palate musculature where it is abnormally attached to the hard palate
Surgeon elevates the oral mucosa just enough for edges to be sewn together. (Suture size depends on neonate size)
Beginning with the uvula and working anteriorly, the surgeon closes the mucosa on the nasal side using a 4-0, 5-0 or 6-0 braided absorbable suture w/small specially designed fishhook needle.
Surgeon closes the oral mucosa and muscle layers using braided absorbable suture in horizontal mattress fashion.
Surgeon places cellulose gauze over raw surfaces of the hard palate to assist with hemostasis (dissolves in 7-10 days).
Special needle allows surgeon to reach tight spaces, such as vomer area or posterior pharynx.

15. Surgical Intervention: Procedure Steps
Surgeon places a traction suture in the neonate’s tongue, which can be used if postop airway obstruction occurs
Mouth gag is carefully removed, being careful to avoid extubation.
Cleft Lip repair begins when the surgeon tattoos the desired anatomical design of the lip with MB, then injects 0.25 % lidocaine w/epi 1:
2 Techniques exist: Tennison-Randal Triangular Flap
And the Millard rotational advancement technique (more common)
In most procedures, 5-0 braided absorbable suture on a small cutting needle is used for closure of the muscle layer.
Triangular Flap: recognizes that Cupid’s Bow is high on the cleft side—a diagonal incision is made directly above the raised peak and into the philtrum. A triangular defect is created by this incision, which is filled at closure with a triangular flap from the cleft side, thus tissue is added to the lower one-third of the lip on the non-cleft side. Major disadvantage: the z-plasty crosses the philtral line (the vertical groove on the surface of the upper lip) below the nose. Advantage: the length is added to the medial lip element, rebuilding a functional nostril floor and preserving cupid’s bow.
Rotational advancement technique: Advances a triangle of tissue in the upper 1/3 of the lip. A distinct difference between this and the Tennison-Randall triangular flap is that the philtral line is not crossed. Some surgeons (King’s Daughters in Norfolk VA) combine the two , allowing them to address the differences in each neonate’s cleft lip.

16. Rotation Advancement Cheiloplasty
Defect and Closure STST p. 714

17. Two Techniques: Cheiloplasty

18. Palatoplasty Incisions are made in palate & cleft is sutured

19. Palatoplasty
A. Bilateral Defect B. Dissection C Closure

20. Surgical Intervention: Procedure Steps
Surgeon uses 7-0 chromic, followed by surgical glue, to close the skin.
No further dressing is needed—
Throat pack is removed, and the neonate is extubated.
Surgical glue allows for skin closure with a decrease in the amt of suture material needed, thus creating more pleasing cosmetic affect.

21. Counts Initial: sponges and sharps First closing Final closing Sponges

22. Specimen & Care
Identified as N/A
Handled: routine, etc.

23. Resources STST pp. 696-697; 713-715 Alexander’s pp. 1235-1237
Boegli, Rogers, & McGuinness Complete Review of ST
AORN Journal Mar 2002 “Repairing Cleft Lip and Palate Deformities” pp by Sandberg, Magee, & Denk