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Pediatric Cleft Lip Nasal Deformity

last modified on: Fri, 05/12/2017 - 14:29

  1. GENERAL CONSIDERATIONS
    1. The indications 
  2. PREOPERATIVE PREPARATIONS
    1. Consent, office note and pre-operative photos should be hanging in the room.
    2. Turn the bed 90 degrees, place an IV bag or sand bag under the buttock of the patient on the side from which liposuction for fat injection will be performed (if fat injection is planned).
    3. Place Afrin soaked pledgets in the nose. Place Bacitracin on the nasal hairs and trim them.
    4. After the Afrin pledgets have been in place for at least 3 minutes remove them and inject lidocaine 1% 1:100,000 epinephrine into the columella on the L side in the area of a projected hemi-transfixion incision and posteriorly into the septum causing the mucosa to blanch from the nasal dorsum internally to the nasal floor. THE INJECTION IS THE MOST IMPORTANT PART OF A SEPTOPLASTY.
    5. Replace the Afrin pledgets. The nurse may prep the face with Hibiclens.
  3. Other Considerations:
    1. Anatomy
  4. 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
  5. ANESTHESIA CONSIDERATIONS 
  6. OPERATIVE PROCEDURE
    1. Perform a septoplasty in the standard fashion being sure to collect a large unblemished, un-fractured piece of septal cartilage.
    2. Following completion of the septoplasty inject lidocaine 1% 1:200,000 epinephrine with Wydase 150U/ml subcutaneously into the columella, projected vestibular incision, nasal tip, and the lateral nose at the bony cartilagenous junction superiorly.
    3. Allow 3-5 minutes for the injection to take effect.
    4. Draw out a stair-step incision at the base of the columella and extend the line to within the vestibule 2/3 of the way around the superior dome bilaterally.
    5. Using a 15 blade scalpel make an incision through the epidermis and dermis. Avoid penetrating the cartilage of the columella or the lower lateral cartilages.
    6. Using a Metzenbaum scissors dissect the superior portion of the columellar incision by advancing and spreading the scissors over the nasal tip through to the other side of the incision. Dissect widely under the skin of the nasal tip using the Metzenbaum scissors. Release the inferior cut from its attachments at the base of the columella. Lift the columellar and nasal tip skin off of the lower lateral cartilages using a 3297 scissors staying right on top of the lower lateral cartilages without violating them. Have your assistant place a nasal tip retractor and suction for you to improve visualization.
    7. At this point you are ready to fashion and place a columellar strut cartilage graft. The graft should be about 3-5 mm wide and 1 – 1.5 cm tall. Using 4’0 vicryl suture secure the columellar strut to the lower lateral cartilages in their inferior portion as they make up the natural columellar strut. This suture should pass through and through the cartilage graft and the lower lateral strut suturing one strut at with one tie and the other with another tie.
  7. POST OPERATIVE CARE
  8. SUGGESTED READING

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