Note: last updated before 2005

GENERAL CONSIDERATIONS

1. The indications 

PREOPERATIVE PREPARATIONS

1. Consent and last note should be hanging.
2. Unasyn or the equivalent should be administered pre-operatively by the anesthetist.
3. If there is going to be an EUA then make sure the microscope is in the room and ready to go.
4. The patient should be positioned supine on the bed with head hanging off of the Phillipine board and a Rae tube taped in the midline to the bottom lip and chin. A bump (a 1000 mL IV bag wrapped in a towel) should be placed under the hip and buttock to elevate the ASIS. 
5. Epinephrine 1:200,000 with 5 U of Vitrase (Hylauronidase) per mL should be drawn up in 1 cc syringes with 27 guage needles.
6. Hibiclens should be used for scrub on the face and Iodine on the hip and belly by the scrub nurse when the patient is properly positioned.# Other Considerations:

NURSING CONSIDERATIONS

1. Room Setup
2. Instrumentation and Equipment
3. Medications (specific to nursing)
4. Prep and Drape
5. Drains and Dressings
6. Special Considerations

ANESTHESIA CONSIDERATIONS 

OPERATIVE PROCEDURE

1. Intraoral Procedure
   1. The bite block is placed on the side opposite the defect. Approximately 5cc of epinephrine 1:200,000 with 5 U of Vitrase per mL should be injected into the projected incision lines along the outside of the alveolar ridge starting two teeth back from the alveolar defect / fistula on each side (both laterally and medially) as well as within the fistula and onto the hard palate.
   2. After 2-5 minutes allowing the adrenaline to take effect use a 15 blade scalpel to make an incision along the outside alveolar mucosa on the medial side of the defect, essentially peeling the mucosa off of the medial two teeth. Once the toothless defect has been reached, the incision is carried across the alveolar ridge crest and continued across the defect until the tooth on the other side is reached. The opposite alveolar mucosa is then removed off the two teeth lateral to the defect in a similar fashion.
   3. The fistula creates a cone, or crevasse that tapers to a cone, starting in the floor of nose and coursing inferiorly through the defect in the hard palate and alveolar ridge. This cone, or crevasse, shaped mucosally lined tract must be dissected off of its surrounding gingivobuccal mucosa toward the piriform aperture. BE SURE TO STAY ON BONE AS YOU DISSECT. The bone will fall away from you behind the tooth root of the upper central incisor. Dissect the mucosa and periosteum off of the underlying bone using a Freer and Cottle elevator in the region of the defect and define the maxilla, palatal cleft and head toward the pyriform aperture. 
   4. Once the cone, or crevasse, shaped mucosally lined pouch is dissected off of the overlying mucosa and the underlying bone is exposed you must ligate the inferior or fistulous portion of the sack, taking the sack up as high as you can whilst still maintaining enough tissue to close the defect internally without tension.
   5. Loosely pack bone marrow around the alveolar / palatal defect. 
   6. Close the gingivobuccal and palatal mucosa over the defect. Use 3’0 vicryl sutures on a PS2 needle or 3’0 Monocryl to reapproximate the mucosa. For verification of water tight closure, when pushing on the mucosa in the area of the sutured defect you should not be able to see bubbles extruding from the wound.
   7. Place horizontal mattress sutures through the dental commissure from the alveolar ridge mucosa on the gingivobuccal side to the palatal side to reapproximate the alveolar mucosa around the teeth.
   8. Place iodoform strip gauze packing in the affected nasal cavity which will be removed at the time of discharge.
   9. Pass an NG and suction the stomach contents.  Remove the bite block.   
2. Harvesting Hip Bone Marrow
   1. Mark a line overlying he anterior superior iliac spine approximately (ASIS), 3-4 cm in length. Stay one finger breadth above the inferior portion of the spine to avoid transecting the lateral femoral cutaneous nerve and creating paresthesia. Inject epinephrine 1:200,000 with 5 U of Vitrase per mL into the projected incision – allow 2-5 minutes for effect.
   2. Using a 15 blade scalpel make a skin and dermal incision to the subcutaneous fat. Using monopolar cautery dissect the subcutaneous fat to the periosteum of the ASIS and remove the fat leaving the periosteum intact.
   3. Mark an obliquely oriented rectangle over the ASIS and incise the periosteum with a monopolar cautery. 
   4. Using the chisel and mallet go through the bone underlying your periostial incision completely around your rectangle. Once you are through all around use the chisel to pop the cap off the ASIS. Use caution that you do not crack the cap of cortical bone during this process. The surgeon should keep in mind that in young children the bone overlying the ASIS may be cartilaginous.
   5. Using a rongeur or large curette scoop marrow from the cavity. When you think you have enough, get some more. Save the marrow in a plastic cup.
   6. Following the marrow harvest replace the ASIS cap and suture the periosteum all around the cap with 3’0 Vicryl sutures. Next place deep dermal 3’0 Vicryl sutures and then a 4’0 subcuticular Monocryl or 5’0 fast absorbing gut sutures. Place Dermabond over the wound and then Telfa, fluff and Elastoplast.

POST-OPERATIVE CARE

1. These patients should be kept overnight and given 2 doses of 0.5mg/kg of Decadron and well as three doses of Unasyn or the equivalent.
2. A mechanical soft diet should be started.
3. Use Lortab and morphine for pain.
4. Uncomplicated patients may be discharged after an evening in the hospital.

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