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Frawley G, Wilkes C, Hallett B, Chong D. Prediction of Early Postoperative Pain in Infants Undergoing Primary Cleft Palate Repair. Cleft Palate Craniofac J 2024; 61:1493-1498. [PMID: 37101364 DOI: 10.1177/10556656231172303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
OBJECTIVE Identification of at risk patients before surgery could facilitate improved clinical communication, care pathways and postoperative pain management. DESIGN A retrospective cohort study was performed in all infants who had undergone cleft palate repair. SETTING Tertiary Institutional. PARTICIPANTS Infants < 36 months of age who underwent primary repair of cleft palate between March 2016 and July 2022. INTERVENTION Requirement for analgesic intervention in the post operative care unit. MAIN OUTCOME MEASURE Adverse perioperative event defined as pain or distress. Secondary outcomes were the incidence of airway obstruction, hypoxemia or unplanned intensive care admission. RESULTS Two hundred and ninety one patients (14.6 months,10.1 kg weight) were included. Cleft distribution included submucous (5.2%), Veau I (23.4%), Veau 2 (38.1%), Veau 3 (24.4%), and Veau 4 (8.9%). Overall 35% of 291 infants undergoing cleft palate repair experienced pain or distress requiring opiate intervention in the first hour after surgery. Infants with a Veau 4 cleft palate had 1.8 times and Veau 2 cleft palate had 1.5 times the risk of postoperative pain compared to infants with Veau 1 cleft palate (relative risk 1.82, 95%CI 1.04-3.18 and 1.49, 95%CI 0.96-2.32 respectively). The use of bilateral above elbow arm splints was significantly associated with postoperative pain or distress (odds ratio 2.23, 95%CI 1.01-5.16). CONCLUSIONS Post operative pain requiring intervention in PACU is common despite adequate intraoperative multimodal analgesia, local anaesthesia infiltration and postoperative opiate infusions. Infants undergoing soft palate alone or submucous palate repair may require less perioperative opiates.
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Affiliation(s)
- Geoff Frawley
- Department of Paediatric Anaesthesia and Pain Management, Royal Children's Hospital Melbourne, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Murdoch Childrens Research Institute, Critical Care and Neurosciences Theme, Parkville, Australia
| | - Courtney Wilkes
- Department of Plastic and Maxillofacial Surgery, The Royal Children's Hospital, Melbourne, Australia
| | - Ben Hallett
- Department of Paediatric Anaesthesia and Pain Management, Royal Children's Hospital Melbourne, Parkville, Australia
| | - David Chong
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Department of Plastic and Maxillofacial Surgery, The Royal Children's Hospital, Melbourne, Australia
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Verzella AN, Laspro M, Diaz A, Cassidy MF, Park J, Schechter J, Alcon A, Shetye PR, Staffenberg DA, Flores RL. Comparison of the Effects of Postoperative Arm Restraints and Mittens on Cleft Lip Scar Quality after Primary Repair. J Clin Med 2024; 13:3619. [PMID: 38999195 PMCID: PMC11242569 DOI: 10.3390/jcm13133619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/11/2024] [Accepted: 06/17/2024] [Indexed: 07/14/2024] Open
Abstract
Introduction: Postoperative management following primary cleft lip repair varies across institutions, cleft care teams, and individual surgeons. Postoperative precautions employed after cleft lip repair include dietary restrictions, pacifier limitations, and immobilization, with arm restraints long being used. Yet, restraint distress has led to the exploration of other forms of immobilization. Thus, this study aims to assess cleft lip scar quality and complication rates after postoperative immobilization with arm restraints versus hand mittens. Methods: A retrospective review of patients with unilateral cleft who underwent primary repair with the senior surgeon was done. Data on demographics, surgical characteristics, and immobilization utilized were gathered. A survey with pictures of postoperative scars were sent to laypeople who assessed scar quality with Modified Scar-Rating Scale scores for surface appearance, height, and color of the scar tissue. Statistical analysis was carried out for significance. Results: Twenty-eight patients with a unilateral cleft underwent arm restraints after primary lip repair, and twenty-seven utilized mittens. In total, 42 medical students completed the scar assessment. Photographs were taken an average of 23.9 (±5.8) and 28.2 (±11.9) months postoperatively in the restraint and mitten groups, respectively (p = 0.239). There were no statistically significant differences in scores between scar surface, height, color, or overall scar appearance. Complication rates were also similar between groups. Conclusions: Arm restraints appear to have no additional benefit relative to scar quality, as compared to mittens. Considering the arm restraints' burden of care, mittens should be considered as a measure to protect the lip after primary repair.
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Affiliation(s)
- Alexandra N Verzella
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Matteo Laspro
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Allison Diaz
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Michael F Cassidy
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Jenn Park
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Jill Schechter
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Andre Alcon
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Pradip R Shetye
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - David A Staffenberg
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Roberto L Flores
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY 10016, USA
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Williams JL, Kotlarek KJ. Current Postoperative Feeding Practices Following Surgical Repairs for Infants With Cleft Palate. J Craniofac Surg 2023; 34:2142-2145. [PMID: 37801714 PMCID: PMC10575669 DOI: 10.1097/scs.0000000000009586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/04/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Nearly all surgeons have restrictive postoperative feeding protocols in place after primary cleft lip and cleft palate repairs. There are no standardized recommendations, potentially resulting in widely variable practices among cleft surgeons and teams. The purpose of this study was to examine current postoperative feeding practices for infants with cleft palate after lip and palate repairs. METHODS A survey of 50 questions was sent to members of the American Cleft Palate-Craniofacial Association (ACPA). Inclusion criteria included providers from North America that have either currently or previously served on a cleft palate team and reached the surgical question set within the survey. RESULTS Sixty-four respondents met inclusion criteria. The majority were in speech-language pathology (47%) or nursing (41%) disciplines, involved in feeding consultations frequently (84%), and working in an outpatient setting (69%). After lip surgery, respondents recommended cleft-adapted bottle feeding (88%), spoon feeding (9%), cup feeding (13%), and syringe/squeeze bottle feeding (23%). The majority of respondents (69%) indicated infants could return to their preoperative feeding modality immediately after lip surgery. After palate surgery, respondents recommended cleft-adapted bottle feeding (55%), typical bottle feeding (3%), spoon feeding (36%), cup feeding (64%), and syringe/squeeze bottle feeding (30%). Infants could use a feeding system that required suction at an average of 20 days postoperatively and return to an age-appropriate diet at an average of 15 days postoperatively. CONCLUSIONS The present study describes the wide variation of postoperative feeding guidelines used by cleft teams after lip and palate repairs.
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Affiliation(s)
- Jessica L. Williams
- Phoenix Children’s Center for Cleft and Craniofacial Care, Phoenix, AZ
- College of Health Solutions, Arizona State University, Tempe, AZ
| | - Katelyn J. Kotlarek
- Division of Communication Disorders, University of Wyoming, Laramie, WY, USA
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Park JJ, Colon RR, Chaya BF, Rochlin DH, Chibarro PD, Shetye PR, Staffenberg DA, Flores RL. Implementation of an Ambulatory Cleft Lip Repair Protocol: Surgical Outcomes. Cleft Palate Craniofac J 2023; 60:1220-1229. [PMID: 35469454 DOI: 10.1177/10556656221096567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Cleft lip repair has traditionally been performed as an inpatient procedure. There has been an interest toward outpatient cleft lip repair to reduce healthcare costs and avoid unnecessary hospital stay. We report surgical outcomes following implementation of an ambulatory cleft lip repair protocol and hypothesize that an ambulatory repair results in comparable safety outcomes to inpatient repair. DESIGN/SETTING This is a single-institution, retrospective study. PATIENTS/PARTICIPANTS Patients undergoing primary unilateral (UCL) and bilateral (BCL) cleft lip repair from 2012 to 2021 with a minimum 30-day follow-up. A total of 226 patients with UCL and 58 patients with BCL were included. INTERVENTION Ambulatory surgery protocol in 2016. OUTCOME MEASURES Variables include demographics and surgical data including 30-day readmission, 30-day reoperation, and postoperative complications. RESULTS There were no differences in rates of 30-day readmission, reoperation, wound complications, or postoperative complications between the pre- and post-protocol groups. Following ambulatory protocol implementation, 80% of the UCL group and 56% of the BCL group received ambulatory surgery. Average length of stay dropped from 24 h pre-protocol to 8 h post-protocol. The 20% of the UCL group and 44% of the BCL group chosen for overnight stay had a significantly higher proportion of congenital abnormalities and higher American Society of Anesthesiology (ASA) class. Reasons for overnight stay included cardiac/airway monitoring, prematurity, and monitoring of comorbidities. There were no differences in surgical outcomes between the ambulatory and overnight stay groups. CONCLUSIONS An ambulatory cleft lip repair protocol can significantly reduce average length of stay without adversely affecting surgical outcomes.
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Hughes EB, Tatum SA. Current trends in unilateral cleft lip repair. Curr Opin Otolaryngol Head Neck Surg 2023:00020840-990000000-00065. [PMID: 37144507 DOI: 10.1097/moo.0000000000000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
The purpose of this review is to provide an in-depth look at the current perioperative and intraoperative practices for unilateral cleft lip repair. The contemporary literature reveals trends towards incorporation of curvilinear and geometric hybrid lip repairs. Perioperative practices are trending in new directions as well with the use of enhanced recovery after surgery (ERAS) protocols to reduce morbidity and length of stay, continued use of nasoalveolar molding, and a tendency to favor outpatient repair with more utilization of same day surgery centers. There is much room for growth, with new and exciting technologies on the horizon to improve upon cosmesis, functionality, and the operative experience.
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Affiliation(s)
- Evan B Hughes
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, SUNY Upstate Medical University, Syracuse, New York, USA
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Piccillo EM, Farsar CJ, Holmes DM. Prophylactic Antibiotics After Cleft Lip and Palate Reconstruction: A Review From a Global Health Perspective. Cureus 2023; 15:e36371. [PMID: 37090369 PMCID: PMC10113116 DOI: 10.7759/cureus.36371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 03/20/2023] Open
Abstract
Orofacial clefts are common congenital deformities. Global initiatives have increased access to cleft care and reconstruction surgeries for cleft lip with or without cleft palate (CL/P), but there is no consensus on the use of postoperative prophylactic antibiotics. We conducted a narrative review using PubMed on the use of postoperative prophylactic antibiotics in CL/P surgery. A search of PubMed identified 30 potentially relevant articles, of which 15 were reviewed. There was no consensus among surgeons on prescribing patterns, but there was limited evidence that postoperative antibiotics reduce palatal fistulas. Notably, microbiological screening is not used to guide the choice of antimicrobial or to predict postoperative complications. Based on limited available data, we cannot make any strong evidence-based recommendations on prescribing postoperative antibiotics; however, we recommend that each cleft surgeon performing these procedures in lower-income countries without access to tertiary care centers consider the cost-benefit analysis of prescribing antimicrobials postoperatively, without antimicrobial screening, which showed no benefit.
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Pitak-Arnnop P. An evidence-based approach to antibiotic prophylaxis for oral, craniomaxillofacial plastic/head and neck surgical procedures. J Clin Pharm Ther 2022; 47:844-850. [PMID: 35132644 DOI: 10.1111/jcpt.13618] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/01/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Poramate Pitak-Arnnop
- Department of Oral and Maxillofacial Surgery, University Hospital of Giessen and Marburg, UKGM GmbH, Campus Marburg, Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
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Enhanced Recovery After Surgery for Pediatric Cleft Repair. J Craniofac Surg 2022; 33:1709-1713. [DOI: 10.1097/scs.0000000000008544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/21/2022] [Indexed: 02/07/2023] Open
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