return to: Cleft Lip and Palate Protocols

Note: below is of historical perspective

The following guidelines apply to both unilateral and bilateral cleft lip repairs - see respective webpages for details on operative technique for unilateral vs bilateral 

PREOPERATIVE PREPARATIONS

1.  Laboratory studies

   1.  Hemoglobin and hematocrit should be obtained. Allowable blood loss may be estimated.

2. Consent

   1. Informed consent should be obtained specific to the procedure being performed

   2. Much of the time, myringotomy tubes will be placed at time of cheiloplasty, especially if the cleft lip is present in conjunction with a cleft of the palate

      1. If this is the case - consent for "Exam under anesthesia of bilateral ears with possible myringotomy and tubes" should be obtained

   3. General anesthesia

3. Calculate maximum safe dosing of lidocaine

NURSING CONSIDERATIONS

Room Setup

• Plenty of Reston© foam should be available for liberal padding of the baby - all pressure points, no lines nor anesthesia circuit should be allowed to rest directly on the skin

• Bed will be turned 90 degrees from anesthesia (anesthesia on right)

• Overhead camera will be installed upon the overhead light immediately above the patient for purposes of photography and teaching

Instrumentation and Equipment

• Microscope with 250mm lens (for tubes)

• VT grommet or Sheehy tubes

• Phillipinne board

• Monopolar Colorado tip cautery set at 8 cut, 8 coag, blend 1

• Bulldog clamps (some prefer not to use these) - for hemostasis of lip elements 

• 6-0 fast, 5-0 chromic, 4-0 vicryl, 5-0 Biosyn on P12 (similar to ethicon P2 - an 8-9mm half-round curved needle)

Medications (specific to nursing)

• Prophylactic empiric antibiotics - Unasyn would provide appropriate oral flora coverage

• Injection: 0.5% lidocaine with 1:200,000 Epinephrine 

  • Injected into the lip and nasal base for hemostasis and hydrodissection

  • Most practitioners utilize an infraorbital block 

• 3/4"x3/4" neurosurgical patties soaked in 1:200,000 Epinephrine are used for hemostasis during the case.

• Methylene blue in 1cc syringe with 25 or 27g needle - for marking critical landmarks

• Dermabond 

Prep and Drape

• Bed is turned 90 degrees to the door. The child is laid supine on the Phillippine board with the head off of the edge of the Phillippine board onto the table in maximal extension.

• Head turban drape with pillowcase (or thin towel), sterile sheet drape below head - secure with towel clamp or staple. Eyes will be covered (similar to tonsillectomy) in most cases, other cases tegaderm placed over the eyes

• Prep and drape entire face from lower lids to neck

Drains and Dressings

• Dermabond only - this is applied across the entire upper lip to prevent buckling of the skin with suck and babbling while healing takes place

ANESTHESIA CONSIDERATIONS 

• Oral Rae endotracheal tube, taped directly in midline to lower lip

• Antibiotics: Unasyn 50 mg/kg or equivalent should be ordered for administration prior to incision. 

• Steroids: Decadron 0.25 mg/kg is given at the beginning of the case.

POSTOPERATIVE CARE

• Diet

  • NORMAL bottle or pigeon/other modified bottle feeds are OK for isolated cleft lip repairs (this differs from palate repairs).

  • Breast feeding is encouraged.

  • Cup diet for older kids (uncommon).

  • No spoons, straws, utensils.

• Armboards on at all times unless directly in the arms of a parent or guardian. Supervised play. x3 weeks total

• Scheduled alternating APAP and ibuprofen, morphine for breakthrough

• Unasyn while in-house

• Antibiotics for 1 week (amoxicillin; clindamycin if penicillin allergic)

• Normally discharged POD1 if taking good PO

• Follow up in 3 weeks