V A
C L
P
S
Derek J. Rogers
Christopher J. Hartnick
Usama S. Hamdan
Video Atlas of Cleft Lip and Palate Surgery
(Trang không có chữ)
Video Atlas of Cleft Lip and Palate Surgery
Derek J. Rogers, MD
Christopher J. Hartnick, MD, MS Epi
Usama S. Hamdan, MD, FICS
5521 Ruffin Road
San Diego, CA 92123
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NOTICE TO THE READER
Care has been taken to confirm the accuracy of the indications, procedures, drug dosages, and diagnosis and remedia-
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Library of Congress Cataloging-in-Publication Data
Video atlas of cleft lip and palate surgery / editors, Derek J. Rogers, Christopher J. Hartnick, Usama S. Hamdan.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-59756-483-0 (alk. paper)
ISBN-10: 1-59756-483-4 (alk. paper)
I. Rogers, Derek J. II. Hartnick, Christopher J. III. Hamdan, Usama S.
[DNLM: 1. Cleft Lip — surgery — Atlases. 2. Cleft Palate — surgery — Atlases. 3. Otorhinolaryngologic
Surgical Procedures — methods — Atlases. WV 17]
RD525
617.5'225 — dc23
2013013000
v
Contents
List of Videos
vii
Preface
ix
Acknowledgments
x
Contributors
xi
Section I General
1
Chapter 1
Anatomy and Embryology of Cleft Lip and Palate
3
Kyle R. Eberlin, Raj M. Vyas, Kamlesh B. Patel, and Usama S. Hamdan
Chapter 2
General Anesthetic Considerations in Cleft Lip and Palate Surgery
9
Dima G. Daaboul and Navil F. Sethna
Chapter 3
International Surgical Outreach Initiatives: Planning, Execution, and Safety
17
Raj M. Vyas, Kyle R. Eberlin, Kamlesh B. Patel, and Usama S. Hamdan
Section II Presurgical Treatment of the Cleft Lip and Palate Child
39
Chapter 4
The Role of Pediatric Dentists and Orthodontists in the Presurgical Treatment
41
of Infants Born with Cleft Lip and Palate
Barry H. Grayson, Mohammad Mansoor Ahmed, and Serena N. Kassam
Section III Primary Cleft Lip Repair with Rhinoplasty
51
Chapter 5
Anthropometry: Evaluation and Planning
53
Kamlesh B. Patel, Kyle R. Eberlin, and Raj M. Vyas
Chapter 6
Repair of the Unilateral Cleft Lip Deformity
57
Dunia Abdul-Aziz and Usama S. Hamdan
Chapter 7
Repair of the Bilateral Cleft Lip Deformity
81
Dunia Abdul-Aziz and Usama S. Hamdan
Section IV Primary Repair of Clefts of the Hard and Soft Palate and Alveolus
103
Introduction
104
Lawrence T. Herman and Sara H. Runnels
Chapter 8
Repair of Incomplete Cleft Palate
105
Lawrence T. Herman, Sara H. Runnels, Kyle J. Chambers, and Thomas Q. Gallagher
Chapter 9
Repair of Unilateral Complete Cleft Palate
113
Lawrence T. Herman, Sara H. Runnels, and Kyle J. Chambers
Chapter 10
Repair of Bilateral Complete Cleft Palate
123
Lawrence T. Herman, Sara H. Runnels, and Kyle J. Chambers
Chapter 11
Repair of Soft Palate Cleft and Submucous Cleft Palate
131
Lawrence T. Herman, Sara H. Runnels, Derek J. Rogers, Kyle J. Chambers, and
Christopher J. Hartnick
Chapter 12
Repair of Nasoalveolar Clefts
143
Lawrence T. Herman, Sara H. Runnels, Kyle J. Chambers, and Steven M. Roser
vi
Video Atlas of Cleft Lip and Palate Surgery
Section V Secondary Cleft Lip Rhinoplasty
160
Chapter 13
Secondary Cleft Lip Rhinoplasty
163
Krishna G. Patel and Jonathan M. Sykes
Section VI Surgical Management of Cleft-Related Midface Deformity
181
Chapter 14
Orthognathic Surgery in the Cleft Patient
183
Shahid R. Aziz, Derek J. Rogers, and Steven M. Roser
Section VII Revision Cleft Lip and Palate Surgery
195
Chapter 15
Revision Cleft Lip Repair
197
Usama S. Hamdan, Blake C. Alkire, Sami U. Hamdan, and Kenneth R. Pellegrino
Chapter 16
Revision Cleft Palate Repair
229
Lawrence T. Herman, Sara H. Runnels, and Kyle J. Chambers
Section VIII Velopharyngeal Insufficiency
245
Chapter 17
Evaluation and Management of Speech and Resonance Disorders
247
Jean E. Ashland and Marie J. Rozeboom
Chapter 18
Prosthetic Rehabilitation for Velopharyngeal Insufficiency
255
Matthew J. Jackson
Chapter 19
Surgical Management of Velopharyngeal Insufficiency
263
Derek J. Rogers and Christopher J. Hartnick
Chapter 20
Superior Pharyngeal Flap
269
J. Paul Willging
Chapter 21
Sphincter Pharyngoplasty
277
Scott E. Bevans and Kathleen C.Y. Sie
Chapter 22
Furlow Palatoplasty for the Treatment of Velopharyngeal Insufficiency
285
Mark E. Boseley
Chapter 23
Posterior Pharyngeal Wall Augmentation
291
Colleen F. Perez and Matthew T. Brigger
Chapter 24
Revision Velopharyngeal Surgery
295
J. Paul Willging
Index
303
vii
List of Videos
Section II Presurgical Treatment of the Cleft Lip and Palate Child
Chapter 4
The Role of Pediatric Dentists and Orthodontists in the Presurgical Treatment of
Infants Born with Cleft Lip and Palate
Video 4–1. Nasoalveolar Molding
Section III Primary Cleft Lip Repair with Rhinoplasty
Chapter 6
Repair of the Unilateral Cleft Lip Deformity
Video 6–1. Repair of Unilateral Complete Cleft Lip Deformity
Video 6–2. Repair of Unilateral Incomplete Cleft Lip Deformity
Chapter 7
Repair of the Bilateral Cleft Lip Deformity
Video 7–1. Repair of Bilateral Cleft Lip Deformity
Section IV Primary Repair of Clefts of the Hard and Soft Palate and Alveolus
Chapter 8
Repair of Incomplete Cleft Palate
Video 8–1. Repair of Incomplete Cleft Palate
Chapter 9
Repair of Unilateral Complete Cleft Palate
Video 9–1. Repair of Unilateral Complete Cleft Palate and Alveolar Cleft
Chapter 10 Repair of Bilateral Complete Cleft Palate
Video 10–1. Repair of Bilateral Complete Cleft Palate
Chapter 11 Repair of Soft Palate Cleft and Submucous Cleft Palate
Video 11–1. Repair of Soft Palate Cleft with Midline Technique
Video 11–2. Repair of Soft Palate Cleft with Furlow Technique
Chapter 12 Repair of Nasoalveolar Clefts
Video 12–1. Repair of Nasoalveolar Cleft
Section V Secondary Cleft Lip Rhinoplasty
Chapter 13 Secondary Cleft Lip Rhinoplasty
Video 13–1. Secondary Cleft Lip Rhinoplasty
Section VI Surgical Management of Cleft-Related Midface Deformity
Chapter 14 Orthognathic Surgery in the Cleft Patient
Video 14–1. Alveolar Cleft Repair with Tibial Bone Graft
Section VII Revision Cleft Lip and Palate Surgery
Chapter 15 Revision Cleft Lip Repair
Video 15–1. Type I Revision Cleft Lip Repair
Video 15–2. Type II Revision Cleft Lip Repair
Video 15–3. Type III Revision Unilateral Cleft Lip Repair
Video 15–4. Type III Revision Bilateral Cleft Lip Repair
Video 15–5. Type IV Revision Unilateral Cleft Lip Repair
Video 15–6. Type IV Revision Bilateral Cleft Lip Repair
viii
Video Atlas of Cleft Lip and Palate Surgery
Chapter 16 Revision Cleft Palate Repair
Video 16–1. Revision Repair of Anterior Palatal Defect with Advanced Island Flap
Video 16–2. Revision Repair of Cleft Palate with Island Flap
Video 16–3. Revision Repair of Soft Palate Fistula
Section VIII Velopharyngeal Insufficiency
Chapter 17 Evaluation and Management of Speech and Resonance Disorders
Video 17–1. Videofluoroscopy
Video 17–2. Cine MRI
Chapter 20 Superior Pharyngeal Flap
Video 20–1. Superior Pharyngeal Flap
Chapter 21 Sphincter Pharyngoplasty
Video 21–1. Sphincter Pharyngoplasty
Chapter 22 Furlow Palatoplasty for the Treatment of Velopharyngeal Insufficiency
Video 22–1. Furlow Palatoplasty for Velopharyngeal Insufficiency
Chapter 23 Posterior Pharyngeal Wall Augmentation
Video 23–1. Injection Pharyngoplasty
Chapter 24 Revision Velopharyngeal Surgery
Video 24–1. Injection Pharyngoplasty for Velopharyngeal Port Augmentation
Video 24–2. Velopharyngeal Port Reduction
Video 24–3. Velopharyngeal Port Enlargement
ix
Preface
The quest for optimal outcomes in patient care is a
driving force for health care professionals. This is espe-
cially true for those caring for patients born with clefts.
The significant advances in medicine coupled with the
exponential expansion of information dissemination
have facilitated sharing of knowledge throughout the
globe. This book presents, both in print and videogra-
phy, the knowledge, understanding, philosophy, and
skills of various multispecialty cleft experts. It serves to
unravel many of the questions regarding cleft manage-
ment, particularly, surgical techniques.
Having been involved in cleft outreach programs
for the past 26 years and being the founder of Global
Smile Foundation (), I have
been fortunate to interact with patients and families
from various cultures and backgrounds and see first-
hand the scope of cleft care in both major capitals and
in more remote, impoverished areas. The disparity in
surgical outcomes as well as lack of comprehensive care
and concept of cleft team methodology are quite strik-
ing, yet, understandable, considering the deficiency of
resources in many parts of the world. However, even in
regions or capitals where resources are available, com-
prehensive cleft care can be scarce or absent. A multi-
disciplinary team approach is essential for rendering
the best possible cleft care.
This book shares with readers the vast practical
experience of authors from various specialties, enhanc-
ing the dissemination of training at a global level and,
one hopes, serving as a catalyst for the development of
comprehensive cleft programs worldwide. The video
documentation accompanying this book also enhances
the reader’s ability to capture the step-by-step surgi-
cal techniques used by the authors with successful
outcomes.
I am grateful to all the patients who were the
inspiration for undertaking this project and for all the
lessons they taught me in perseverance and humility.
I am also grateful to my coauthors, Christopher Hart-
nick and Derek Rogers, for their initiative, dedication,
and determination that transformed an idea of a book
into actuality. I am thankful to our colleague authors,
volunteers, and supporters whose tireless energy and
focus on providing safe and comprehensive cleft care
throughout the world have been instrumental in this
undertaking.
Usama S. Hamdan, MD, FICS
Assistant Clinical Professor of Otolaryngology
Tufts University School of Medicine
Clinical Instructor in Otology and Laryngology
Harvard Medical School
Clinical Instructor of Otolaryngology
Boston University School of Medicine
x
Acknowledgements
We would like to formally acknowledge our artist, Stephen P. Comstock, for his
outstanding illustrations. Without his tireless work, this book would not have been
possible. We wish him the best with his career in dentistry.
xi
Contributors
Dunia Abdul-Aziz, MD
Resident in Otolaryngology
Massachusetts Eye and Ear Infirmary
Boston, MA
Chapters 6 and 7
Blake C. Alkire, MD
Resident in Otolaryngology
Massachusetts Eye and Ear Infirmary
Boston, MA
Chapter 15
Jean E. Ashland, PhD, CCC-SLP
Department of Speech Language and Swallowing
Disorders
Massachusetts General Hospital
Boston, MA
Chapter 17
Shahid R. Aziz, DMD, MD, FACS
Associate Professor
Department of Oral and Maxillofacial Surgery
University of Medicine and Dentistry, New Jersey
Newark, NJ
Chapter 14
Scott E. Bevans, MD
CPT, MC, USA
Otolaryngology — Head and Neck Surgery
Madigan Healthcare System
Tacoma, WA
Chapter 21
Mark E. Boseley, MD, MS Epi
LTC(P), MC, USA
Chief of Otolaryngology
Pediatric Otolaryngology
Madigan Healthcare System
Tacoma, WA
Chapter 22
Matthew T. Brigger, MD, MPH
CDR, MC, USN
Naval Medical Center San Diego
Department of Otolaryngology — Head and Neck
Surgery
San Diego, CA
Chapter 23
Kyle J. Chambers, MD
Resident in Otolaryngology
Massachusetts Eye and Ear Infirmary
Boston, MA
Chapters 8, 9, 10, 11, 12, and 16
Dima G. Daaboul, MD
Assistant in Cardiac Anesthesia
Children’s Hospital, Boston
USA Instructor in Anesthesia
Havard Medical School
Boston, MA
Chapter 2
Kyle R. Eberlin, MD
Harvard Plastic Surgery Training Program
Division of Plastic Surgery
Massachusetts General Hospital
Boston, MA
Chapters 1, 3, and 5
Thomas Q. Gallagher, DO
LCDR, MC, USN
Pediatric Otolaryngology
Naval Medical Center Portsmouth
Portsmouth, VA
Chapter 8
Barry H. Grayson, DDS
Craniofacial Orthodontist
Associate Professor Plastic Surgery
NYU Langone Medical Center
New York, NY
Chapter 4
Sami U. Hamdan
Boston University, School of Public Health
Boston, MA
Chapter 15
Usama S. Hamdan, MD, FICS
Assistant Clinical Professor of Otolaryngology
Tufts University School of Medicine
Clinical Instructor in Otology and Laryngology
Harvard Medical School
Clinical Instructor of Otolaryngology
Boston University School of Medicine
xii
Video Atlas of Cleft Lip and Palate Surgery
Boston, MA
Chapters 1, 3, 6, 7, and 15
Christopher J. Hartnick, MD, MS Epi
Professor
Department of Otology and Laryngology
Harvard Medical School
Division Director
Pediatric Otolaryngology
Massachusetts Eye and Ear Infirmary
Boston, MA
Chapters 11 and 19
Lawrence T. Herman, DMD, MD
Assistant Clinical Professor
Department of Oral and Maxillofacial Surgery
Boston University School of Dental Medicine
Boston, MA
Private practice
Oral and Maxillofacial Surgery
Walpole, MA
Section IV Introduction, Chapters 8, 9, 10, 11, 12,
and 16
Matthew J. Jackson, DMD, MSD
Consultant in Maxillofacial Prosthodontia
Massachusetts Eye and Ear Infirmary
Brigham and Women’s Hospital
Massachusetts General Hospital
Dana Farber Cancer Institute
Boston, MA
Chapter 18
Serena N. Kassam, DMD
Craniofacial Pediatric Dentist
Assistant Clinical Professor
Tufts University School of Dental Medicine
Boston, MA
Chapter 4
Mohammad Mansoor Ahmed, DDS, MS
Craniofacial Pediatric Dentist
Dubai Health Authority
Dubai, UAE
Tufts University School of Dental Medicine
Boston, MA
Institute of Reconstructive Plastic Surgery
New York University–Langone Medical Center
New York, NY
Chapter 4
Kamlesh B. Patel, MD
Assistant Professor
Division of Plastic and Reconstructive Surgery
Washington University
St. Louis, MO
Chapters 1, 3, and 5
Krishna G. Patel, MD, PhD
Director
Facial Plastic and Reconstructive Surgery
Department of Otolaryngology — Head and Neck
Surgery
Medical University of South Carolina
Charleston, SC
Chapter 13
Kenneth R. Pellegrino, CBET
Clinical Engineering Manager
Massachusetts Eye and Ear Infirmary
Boston, MA
Chapter 15
Colleen F. Perez, MD
LT, MC, USN
Naval Medical Center San Diego
Department of Otolaryngology — Head and Neck
Surgery
San Diego, CA
Chapter 23
Derek J. Rogers, MD
MAJ, MC, USA
Pediatric Otolaryngology
Massachusetts Eye and Ear Infirmary
Boston, MA
Chapters 11, 14, and 19
Steven M. Roser, DMD, MD, FACS
DeLos Hill Professor
Division Chief
Oral and Maxillofacial Surgery
Emory University School of Medicine
Atlanta, GA
Chapters 12 and 14
Marie J. Rozeboom, MS, CCC-SLP
Department of Speech Language and Swallowing
Disorders
Massachusetts General Hospital
Boston, MA
Chapter 17
Contributors
xiii
Sara H. Runnels, DMD, MD
Private practice
Oral and Maxillofacial Surgery
Walpole, MA
Section IV Introduction, Chapters 8, 9, 10, 11, 12, and 16
Navil F. Sethna, MD
Clinical Director
Pediatric Pain Rehabilitation Center
Senior Associate
Perioperative Anesthesia
Senior Associate
Pain Medicine
Children’s Hospital, Boston
Boston, MA
Chapter 2
Kathleen C.Y. Sie, MD
Professor
Department of Otolaryngology — Head and Neck
Surgery
University of Washington
Childhood Communication Center
Seattle Children’s Hospital
Seattle, WA
Chapter 21
Jonathan M. Sykes, MD
Director
Facial Plastic and Reconstructive Surgery
Department of Otolaryngology — Head and Neck
Surgery
University of California Davis Medical Center
Sacramento, CA
Chapter 13
J. Paul Willging, MD
Professor
Otolaryngology — Head and Neck Surgery
University of Cincinnati College of Medicine
Cincinnati Children’s Hospital Medical Center
Cincinnati, OH
Chapters 20 and 24
Raj M. Vyas, MD
Harvard Plastic Surgery Training Program
Division of Plastic Surgery
Massachusetts General Hospital
Boston, MA
Chapters 1, 3, and 5
(Trang không có chữ)
For my wife Melanie and our daughters Sophia, Natalie, and Christina. Thank
you for all your sacrifice so that we may help those less fortunate!
— Derek J. Rogers, MD
This book is for all the surgeons, doctors, speech pathologists, and health care professionals all
over the world who take care of children with cleft lip and palate disorders. It is a wonderful
and awe-inspiring job! We hope this book helps you in some significant way. This book is
also dedicated to the parents of these children who work tirelessly day after day to improve
the lives of their children. Finally, to the children themselves, this book is for you.
— Christopher J. Hartnick, MD
This book is dedicated to the cleft patients and colleagues who have enriched my life
with their stamina, perseverance, and hard work; and to my loving family, Aida,
Amoula, and Sami, for their understanding, support, and contributions.
— Usama S. Hamdan, MD, FICS
(Trang không có chữ)
Section I
General
(Trang không có chữ)
3
Chapter 1
Anatomy and Embryology of
Cleft Lip and Palate
Kyle R. Eberlin, Raj M. Vyas, Kamlesh B. Patel, and Usama S. Hamdan
Abstract
Cleft lip and palate deformities have been observed for
thousands of years, and yet the surgical correction of these
anomalies remains a challenge to the reconstructive surgeon.
This chapter describes the embryologic basis and associated
anatomy of cleft lip and palate and provides a basic classifi-
cation system for these malformations. The functional impli-
cations are also described, arming the cleft surgeon with a
fundamental understanding of the anatomy required for
surgical repair.
The pathologic entities of cleft lip and palate have been
observed for thousands of years. The first reported
cleft lip repair was performed in China in 390 bc;
however, the first successful cleft palate repair was
not performed until 1816.1 Scientific understanding of
the anatomy, genetics, and environmental contribu-
tions has become increasingly sophisticated over the
past 2 centuries. In order to master the surgical correc-
tion of these anomalies, a thorough grasp of pertinent
anatomy and embryology is essential, and this chapter
endeavors to present basic information germane to the
cleft surgeon.
Embryology of Cleft Lip and Palate
Formation of the lip and palate represents a compli-
cated set of events that begins in the early stages of fetal
growth, with lip development occurring between the
4th to 7th weeks of gestation and palatal development
occurring in weeks 6 to 10.2,3 The incidence of cleft lip
with or without cleft palate is approximately 1 out of
1,000 live births. If a family has one affected child with
a cleft lip, the risk in the next pregnancy is 4%; for cleft
palate, following one affected child the risk in the sec-
ond pregnancy is approximately 2%.4
Embryologically, the face develops from five
prominences: (1) the frontonasal prominence, (2) a left
and (3) right maxillary prominence, and (4) a left and
(5) right mandibular prominence (Figures 1–1A and B).
These prominences surround the stomodeum, or prim-
itive mouth, and coalesce during development to form
the structures of the central face. The frontonasal prom-
inence is formed from mesenchymal tissue ventral to
the forebrain and is further subdivided into the medial
nasal and lateral nasal prominences.5 The paired max-
illary and mandibular prominences are formed from
neural crest cells migrating from the first pharyngeal
arch.6 To achieve normal development of the lip and
palate, fusion of these prominences must occur in nor-
mal sequence and without aberration.
The normal lip is formed from the fusion of the
advancing maxillary prominences with the merged
medial nasal prominences. A unilateral cleft lip occurs
when there is failure of complete fusion between the
advancing maxillary prominence and the medial nasal
prominence on one side, whereas a bilateral cleft lip
occurs when there is failure of fusion between these
prominences on both sides (Figure 1–1C).
Normal palatal development requires fusion of
the medial nasal/palatine prominence and nasal sep-
tum (derived from the frontonasal prominence) and
the lateral palatine shelves (derived from the maxillary
prominences). The medial palatine prominence and
nasal septum comprise the primary palate, whereas the
lateral palatine shelves comprise the secondary palate.
4
Video Atlas of Cleft Lip and Palate Surgery
The division between these two embryologic units is
the incisive foramen (Figure 1–2). A cleft palate occurs
when there is incomplete fusion of the lateral palatine
processes with the medial palatine process and/or
nasal septum.
Classification of Cleft Lip and Palate
There have been numerous classification systems pro-
posed for cleft lip and palate; however, we believe that
a simple system with objective and clearly defined ana-
tomic features is most useful for practitioners. Differ-
ent anatomic combinations of cleft lip and palate are
possible from a developmental standpoint; it is most
common to have cleft lip and palate together (46%), fol-
lowed by isolated cleft palate (33%), and then isolated
cleft lip (21%).4
A cleft lip can be classified by two main charac-
teristics: (1) unilateral versus bilateral deformity and
(2) complete versus incomplete deformity (Figure 1–3).
A unilateral cleft lip occurs when the defect is iso-
lated to one side of the midline, and a bilateral cleft
is observed when the defect is found on both sides.
A complete cleft lip is characterized by through-and-
through involvement of the lip, alveolus, and nasal
sill, whereas incomplete clefts have partial penetrance
through these layers. Incomplete cleft lips may be fur-
ther characterized as minor form (defect extending
3 mm or more above the normal Cupid’s bow peak),
microform (notch less than 3 mm above the nor-
mal peak), or minimicroform (disrupted vermilion–
cutaneous junction without elevation of the bow peak),
and the optimal treatment varies by subtype.7
Similarly, a cleft palate may be defined as: (1)
unilateral or bilateral (depending on laterality of
involvement of the primary palate) and (2) complete
or incomplete (Figure 1–4). A complete cleft pal-
ate extends from the alveolar ridge to the uvula and
involves the primary and secondary palates. An incom-
plete cleft palate involves the secondary palate only,
and can be characterized as a submucous cleft palate
(no apparent soft tissue defect, but failure of muscular
fusion) or, in its most slight form, a bifid uvula. The
primary palate, containing the premaxilla, alveolus,
and lip, is anterior to the incisive foramen, whereas the
secondary palate, containing the uvula, palatal muscu-
Figure 1–1. Embryology of lip formation.
Figure 1–2. Embryology of palate formation.
Anatomy and Embryology of Cleft Lip and Palate
5
lature, maxilla, palatine bones, and pterygoid plates, is
posterior. The incisive foramen is important because it
forms this boundary and also because it contains the
nasopalatine vessels and nerve. Six muscles attach to
the palate: the levator veli palatini, tensor veli pala-
tini, musculus uvulae, palatopharyngeus, palatoglos-
sus, and superior pharyngeal constrictor, and these
must be anatomically realigned for optimal functional
outcomes following cleft palate repair. It is important
for the cleft surgeon to note the precise anatomic loca-
tion of the cleft, as palatal defects can involve different
components of the hard palate, soft palate, and palatal
musculature and the surgical treatment varies based on
anatomic location.
A
C
B
Figure 1–3. Cleft lip variations: A. Unilateral incomplete cleft
lip, B. unilateral complete cleft lip, and C. bilateral complete
cleft lip.
6
Video Atlas of Cleft Lip and Palate Surgery
Functional Anatomy of
Cleft Lip and Palate
Patients with cleft lip and palate have developmen-
tal anomalies that extend beyond the strict borders
of the lip or palate itself; the nose, septum, alveolus,
and other structures of the midface can be affected as
well. The abnormal anatomy seen in patients with cleft
lip or palate must be understood in three dimensions,
and the cleft surgeon must also recognize the changes
that occur over time for optimal surgical repair (the
so-called fourth dimension). Patients with orofacial
clefts have a spectrum of deformity ranging from
minor to severe, with a range of subsequent functional
abnormalities.
The functional anatomy of a unilateral cleft lip
includes a defect in the upper lip and vermilion border,
discontinuity and abnormal insertion of the orbicularis
oris muscle into the dermis and nasal sill,8,9 outward
splaying of the lower lateral cartilage on the cleft side
as well as the septum,10 and a shortened columella.11
A
C
B
Figure 1–4. Cleft palate variations: A. Incomplete cleft palate,
B. complete unilateral cleft palate, and C. complete bilateral
cleft palate.
Anatomy and Embryology of Cleft Lip and Palate
7
These deformities are typically more severe in patients
with a complete cleft lip and less severe in patients with
an incomplete cleft lip. The cleft lip nasal deformity is
variable and is usually related to the degree of severity
of the cleft lip.12,13 Patients with bilateral cleft lip defor-
mity have the aforementioned anatomic abnormalities
but also have a characteristic protrusion of the premax-
illary alveolar segment and a paucity of upper lip skin
near the Cupid’s bow.14
Patients with cleft palate have abnormal palatal
musculature, with hypoplasia and aberrant insertion of
the levator veli palatini15 as well as abnormalities of the
bony midface, which can include the pterygoid plates.16
Additionally, there is often a disruption in nasal mucosa,
which may require vomerine flaps for closure.17
Restoration of normal surface and muscular
anatomy is paramount to achieving optimal surgical
outcomes in patients with cleft lip and palate. Cleft lip
repair demands technical precision and careful cepha-
lometric analysis to restore the continuity of the lip and
produce nasal symmetry. Effective cleft palate repair
demands meticulous closure of the nasal mucosa and
anatomic reorientation of the palatal musculature,
including the levator and tensor veli palatini, with par-
ticular attention to speech development and the move-
ment of pharyngeal structures. The cleft surgeon must
be familiar with normal anatomy and its variants when
preparing to care for these patients.
References
1. Perko M. The history of treatment of cleft lip and palate.
Prog Pediatr Surg.1986;20:238–251.
2. Mossey PA, Little J, Munger RG, Dixon MJ, Shaw WC.
Cleft lip and palate. Lancet. 2009;374(9703):1773–1785.
3. Diewert VM. Development of human craniofacial mor-
phology during the late embryonic and early fetal peri-
ods. Am J Orthod. 1985;88(1):64–76.
4. Grabb WC. Grabb and Smith’s plastic surgery, 6th edition.
Lippincott Williams & Wilkins. 2006:201–224.
5. Kirschner RE, LaRossa D. Cleft lip and palate. Otolaryngol
Clin of North Am. 2000;33(6):1191–1215.
6. Tapadia MD, Cordero DR, Helms JA. It’s all in your head:
New insights into craniofacial development and defor-
mation. J Anat. 2005;207(5):461–477.
7. Yuzuriha S, Mulliken JB. Minor-form, microform, and
mini-microform cleft lip: anatomical features, opera-
tive techniques, and revisions. Plast Reconstr Surg. 2008;
122(5):1485–1493.
8. Dado DV, Kernahan DA. Anatomy of the orbicularis oris
muscle in incomplete unilateral cleft lip based on histo-
logical examination. Ann Plast Surg. 1985;15(2):90–98.
9. De Mey A, Van Hoof I, De Roy G, Lejour M. Anatomy
of the orbicularis oris muscle in cleft lip. Br J Plast Surg.
1989;42(6):710–714.
10. Li AQ, Sun YG, Wang GH, Zhong ZK, Cutting C. Anat-
omy of the nasal cartilages of the unilateral complete cleft
lip nose. Plast Reconstr Surg. 2002;109:1835.
11. Pai BC, Ko EW, Huang CS, Liou JW. Symmetry of the
nose after presurgical nasoalveolar molding in infants
with unilateral cleft lip and palate: a preliminary study.
Cleft Palate Craniofac J. 2005;42(6):658–663.
12. Stenstrom SJ, Oberg TR, Stemstrom SJ. The nasal defor-
mity in unilateral cleft lip: some notes on its anatomic
bases and secondary operative treatment. Plast Reconstr
Surg. 1961;28(3):295–305.
13. McComb H. Primary correction of unilateral cleft lip
nasal deformity: a 10-year review. Plast Reconstr Surg.
1985;75(6):791–797.
14. Mulliken JB. Bilateral complete cleft lip and nasal defor-
mity: an anthropometric analysis of staged to synchro-
nous repair. Plast Reconstr Surg. 1995;96(1):9–23.
15. Cohen SR, Chen LL, Burdi AR, Trotman CA. Patterns of
abnormal myogenesis in human cleft palates. Cleft Palate-
Craniofac J. 1994;31(5):345–350.
16. Trotman CA, Hou D, Burdi AR, Cohen SR, Carlson DS.
Histomorphologic analysis of the soft palate musculature
in prenatal cleft and noncleft A/Jax mice. Cleft Palate-
Craniofac J. 1995;32(6):455–462.
17. Agrawal K, Panda KN. Use of vomer flap in palatoplasty:
Revisited. Cleft Palate-Craniofac J. 2006;43(1):30–37.
(Trang không có chữ)
9
Chapter 2
General Anesthetic Considerations in
Cleft Lip and Palate Surgery
Dima G. Daaboul and Navil F. Sethna
Abstract
Cleft lip and palate are the most common congenital defects,
estimated at 6 to 10 in 10,000 live births. Primary repair
is recommended in early infancy. A thorough preoperative
evaluation allows detection of associated congenital anoma-
lies (craniofacial, cardiovascular, central nervous system,
and skeletal systems anomalies). Children with cleft lip and
palate have a higher incidence of difficult laryngoscopy or
difficult endotracheal intubation. The association of other
craniofacial abnormalities, notably the presence of micro-
gnathia as well as a history of early airway and feeding dif-
ficulty, is a good predictor of difficult airway and should be
detected during preoperative evaluation. Nonetheless, the
anesthesiologist should always be prepared for the possibil-
ity of a difficult airway and should have alternate plans,
such as the use of a laryngeal mask airway, bougies, and a
fiberoptic scope. It is recommended that muscle relaxants not
be administered before ensuring adequate mask ventilation.
Multimodal pain management is recommended to avoid opi-
oid overdose and the risk of postoperative airway obstruction.
Local anesthetic infiltration and nerve blocks are effective in
decreasing postoperative pain scores in children and the need
for rescue analgesia postoperatively. At the conclusion of the
surgery, careful suctioning is performed, and the trachea is
extubated when the patient is fully awake and has regained
complete airway reflexes. These children should be observed
and fully monitored in the post anesthesia care unit (PACU)
until they are fully awake and stable, then observed closely
on the ward for 12 to 48 hours with continuous monitoring
of their airway status and for bleeding. Patients with known
airway difficulties are usually transferred to an intensive
care unit for continuous monitoring.
Cleft lip and palate (CLP) are among the most common
craniofacial abnormalities, and even the most common
congenital defects. They occur in isolation, or in associ-
ation with other congenital and craniofacial abnormali-
ties. It is estimated that 6 in 10,000 live births are born
with an isolated cleft palate, and around 10 in 10,000
are born with a cleft lip, either isolated or associated
with a cleft palate. Ideally, the primary surgical repair
is done before the age of 1 year for cleft lip and before
the age of 18 months for cleft palate to promote healthy
growth and development of these children. Nonethe-
less, the age of repair varies in developing countries,
where many patients have limited access to specialized
health care. With the increasing number of medical
missions conducted to developing countries facilitat-
ing medical care access to many patients, more patients
are undergoing surgical repair at a later age. In addi-
tion to the primary repair recommended in infancy,
many patients require one or more additional surgeries
depending on the type of procedure performed, each
presenting its own surgical and anesthetic challenges.
These procedures are usually staged over several years
and include revision of the primary lip or palatal repair,
rhinoplasty, pharyngoplasty, alveolar cleft bone graft,
palatal fistula closure, and orthodontic procedures.1–6
Preoperative Evaluation
A thorough preoperative evaluation of patients with
CLP is of prime importance, with a special focus on
detecting associated congenital or medical disorders
specific to this patient population. The incidence
10
Video Atlas of Cleft Lip and Palate Surgery
and type of associated congenital malformation vary
between studies, but can affect 14% to 66% of patients
with CLP. The most common association remains addi-
tional craniofacial abnormalities, such as Pierre Robin
sequence, velocardiofacial syndrome, Treacher Collins
syndrome, and Goldenhar syndrome, implicating more
difficult airway management in these patients. Other
systems can also be affected, such as the cardiovascu-
lar, central nervous, and skeletal systems. It is there-
fore recommended that children with orofacial clefts be
thoroughly evaluated by a pediatrician preoperatively
for better recognition and categorization of potential
congenital malformations.3,7–9
Nutrition and Hydration
It is important to recognize the increased incidence of
feeding problems in some children with cleft lip or pal-
ate, leading to an increased number of children with
failure to thrive, malnutrition, and anemia.
Respiratory Infection
In addition to upper respiratory infection common in
children, patients with orofacial clefts are at increased
risk of recurrent infections of the nasal cavity and respi-
ratory tract due to constant irritation from saliva and
food to the mucosa. In addition, their swallowing skills
might be impaired leading to impaired airway protec-
tion and increased risk of aspiration, recurrent respira-
tory infection, and lung disease. Children with CLP are
at increased risk for respiratory complications in the
perioperative period, and this risk increases in the pres-
ence of respiratory infection and in patients with large
clefts of the lip and palate as compared to a simple uni-
lateral cleft lip. Postponing elective cleft surgeries in
infants with respiratory tract infection decreases peri-
operative airway complications. Many of these chil-
dren have chronic rhinorrhea without overt infection,
and a thorough preoperative screening to distinguish
them from sick children is important. 10–13
Airway Assessment
In comparison to patients without CLP, children with
CLP have a higher incidence of difficult laryngoscopy
or difficult intubation. Patients with isolated cleft lip
usually do not pose airway difficulties. Patients with
cleft palate can present different scenarios. In the
absence of any other craniofacial abnormality, especially
in the absence of micrognathia, patients with isolated
cleft palate do not pose many problems with airway
management. During mask ventilation, the tongue can
fall into the cleft and obstruct the nasal airway, but this
is easily overcome by placement of an oropharyngeal
airway. The difficulty of laryngoscopy correlates with
several factors, including age, with the degree of diffi-
culty decreasing dramatically after the age of 6 months.
Another factor that affects the degree of difficulty
of laryngoscopy is whether the cleft is one sided or
bilateral, as well as the size of the defect. In left-sided
cleft lip associated with left-sided cleft alveolus and
more so in children with severe bilateral cleft lip and
alveolus where the premaxilla is angled anteriorly
with high-vaulted arch deformity, the laryngoscope
blade tends to fall into the defect during laryngoscopy
and alters the line of vision. Larger clefts of the hard
palate level are associated with increased difficulty of
intubation.
It is important to detect the presence of other cra-
niofacial anomalies and to be vigilant of the possible
increased risk of difficult intubation in these patients,
especially patients with retrognathia, micrognathia,
or any discrepancy in the size of the tongue relative
to the mandible or the oral cavity. One frequent asso-
ciation with orofacial clefts is Pierre Robin sequence
characterized by micrognathia, glossoptosis, and respi-
ratory obstruction. These patients have a higher risk
of difficult intubation. The presence of a hypoplastic
mandible may worsen the situation. The detection of
airway obstruction as well as the presence of feeding
difficulties is a useful predictor for difficult airway
management. Despite a higher incidence of difficult
laryngoscopy (average 5%, with 3% for unilateral cleft
lip and 45% in the subgroup of patients with bilateral
cleft lip from the study by Gunawardana14), the inci-
dence of difficult intubation is low, averaging from
0.1% to 1% in different studies. Of note, the definition
of difficulty was not constant among the different stud-
ies, and most of these patients were intubated by expe-
rienced pediatric anesthesiologists with good airway
skills and experience.
It is important to conduct a full reevaluation of the
patients at each subsequent anesthetic because of the
dynamic nature of their airways depending on their
age and associated syndrome. Children usually become
easier to intubate with age. The same applies to many
patients with the Pierre Robin sequence who have a
General Anesthetic Considerations in Cleft Lip and Palate Surgery
11
“catch-up” growth of the mandible with age, and the
difficulty of intubation decreases. On the other hand,
patients with Goldenhar syndrome pose increased air-
way difficulty with age.12,15–20
General Anesthesia
Induction
Both inhalation and intravenous induction of general
anesthesia have been described for cleft lip and pal-
ate surgery, depending on the presence of intravenous
access, the age of the patient, and the anesthesiologist’s
preference. Nonetheless, many authors emphasize
the importance of keeping the patient spontaneously
breathing and recommend establishing mask venti-
lation before the administration of muscle relaxant.
Intubation of the trachea can be performed without
muscle relaxation once a certain depth of anesthesia is
reached, but some authors suggest that the administra-
tion of muscle relaxants facilitates laryngoscopy and
decreases the incidence of difficult airways.12,16,21
A variety of techniques has been described to
overcome some of the difficulties that can be encoun-
tered during laryngoscopy and intubation. It has been
shown that external laryngeal manipulation decreases
the difficulty of laryngoscopy significantly and should
be the first maneuver used. A laryngeal mask airway
(LMA) can be life-saving in cases of difficult intubation
or mask ventilation and should be readily available on
induction. In infants with large left or bilateral cleft
alveolus, wet gauze padding of the cleft alveolus can
prevent the laryngoscope blade from falling into the
cleft. The anesthesiologist should have alternate plans
and be prepared for the use of bougies or a fiberoptic
scope, either through an LMA or through the orophar-
ynx. Fiberoptic intubation is more often required in
patients with severe micrognathia, as in patients with
Pierre Robin sequence. Rarely, an emergent surgical air-
way may be required, or the patient must be woken up
and surgery canceled. In the case of an isolated cleft lip,
general anesthesia can be conducted without endotra-
cheal intubation but requires extra vigilance and coop-
eration between the anesthesiologist and the surgeon.
The most popular endotracheal tube (ETT) used in
cleft lip and cleft palate surgery is the oral preformed
RAE®, which can be fixed in the center of the lower lip
giving good exposure to the surgeon. As with any sur-
gery where the surgeon and the anesthesiologist share
the airway, extra care should be directed toward early
detection of any ETT problems, such as disconnection
or compression, especially with the use of a mouth gag.
Therefore, monitoring airway pressure and capnogra-
phy is essential.
In addition, head and neck manipulation and the
use of a mouth gag with a tongue depressor can dis-
place the ETT and cause either accidental extubation or
endobronchial intubation. Based on previous studies,
placing the tip of the tube 1.5 cm above the carina at the
neutral head position minimizes the risk of displace-
ment by giving enough room for movement during
neck extension of flexion. Kohjitani et al demonstrated
that although the growth of children with orofacial
clefts is usually impaired, it is still reasonable to apply
the current standards for choosing the size and depth
of insertion of an ETT. Attention should be paid to the
site of taping a preformed ETT. Taping the tube at the
curvature does not always ensure an ideal tube posi-
tioning in the trachea, especially in cuffed ETT, and
the curvature site varies depending on the manufac-
turer. The ETT placement must always be checked
when changing the head position or after insertion of
the mouth gag to detect any possible dislodgement
or kink.17,20,22–26
Maintenance
General anesthesia is usually maintained with intrave-
nous or inhalation anesthetics and supplemented with
small doses of opioids for pain management. Care
should be taken to limit the dose of narcotics admin-
istered to avoid postoperative airway complications
and airway obstruction. The usual recommended dose
is 1 to 2 mcg/kg of fentanyl for cleft lip repair, and one
should consider adding a longer acting opioid, such as
0.05 to 0.1 mg/kg of morphine in cleft palate cases. This
is usually combined with local anesthetic infiltration or
nerve block to ensure adequate analgesia and to limit
the need for intraoperative and postoperative opioid
use. Care should be taken especially when traveling on
medical missions to different countries, where studies
have shown geographic differences in perioperative
opioid requirements. A careful preoperative screening
should be able to identify children with a history of
obstructive sleep apnea as well, because children with
recurrent hypoxia are known to be more sensitive to
the effects of exogenous opioids.27–29
The benefit of the administration of an intrave-
nous dose of dexamethasone 0.25 to 0.5 mg/ kg in the
12
Video Atlas of Cleft Lip and Palate Surgery
perioperative period is equivocal but remains a com-
mon practice in orofacial cleft surgeries. It is believed
that steroids reduce upper airway edema, decrease the
risk of problems at extubation, and shorten the time
to first oral intake in children undergoing cleft palate
surgery.30–32
Intravenous fluids maintain a good fluid status
and compensate for blood loss, especially in the case
of cleft palate. The need for preoperative laboratory
values or a transfusion card is controversial. The rate
of transfusion in these surgeries is usually very low,
although it reached 10% in one reported series of
patients. Many physicians do not order routine preop-
erative screening tests anymore and find it more cost
effective and less stressful to the patients when decided
on a case-by-case basis. Nonetheless, the availability
and feasibility of cross matching should be checked for
all patients undergoing cleft palate repair.33–35
Local Anesthetics
Wound infiltration with local anesthetics has been
proven to be effective in decreasing postoperative pain
scores in children and the need for rescue analgesia
postoperatively. One popular local anesthetic mixture
is equal volume of lidocaine and bupivacaine with epi-
nephrine prior to incision. Other authors recommend
the use of ropivacaine to decrease the side effects of
local anesthetics.36–38 Some authors are reluctant to
inject local anesthesia prior to incision because they
fear the anatomy will be distorted. Nevertheless, this
technique remains popular among other surgeons
because the vasoconstrictive effects of epinephrine
ensure a dry operative field.
Nerve Block
Several studies showed that infraorbital nerve block is
an effective means of achieving analgesia after surgery
for cleft lip in infants lasting 6 to 24 hours, and it is even
superior to simple local anesthetic infiltration. Several
adjuncts have been used with local anesthetic solutions
to increase the duration of the block, such as clonidine
or opioids. The infraorbital nerve is a branch of the
maxillary nerve. It exits the skull via the infraorbital
foramen and provides sensation to the lower eyelid,
cheek, side of the nose, and mucous membrane lining
the nasal vestibule. It can be blocked with a small dose
of local anesthetic (1 cc of 0.25% bupivacaine on each
side). Combined with an external nasal nerve block, it
can be used as the sole anesthetic for cleft lip repair in
adolescents and adults. The infraorbital block has no
efficacy in cleft palate surgeries. Mesnil et al described
a suprazygomatic approach to bilateral maxillary nerve
block and demonstrated its efficacy in cleft palate sur-
geries by decreasing the need for postoperative analge-
sics and time to oral intake.39–48
Emergence and Extubation
It is well established that children undergoing cleft
lip or palate surgery are at increased risk of airway
complications due to their age, anatomy, associated
syndromes, surgical manipulation, airway and tongue
edema exaggerated by the use of a mouth gag, potential
bleeding or increased secretions, and possibility of opi-
oid sensitivity. Therefore, the trachea should be extu-
bated after ensuring the patient is fully awake and has
regained complete airway reflexes. Careful suctioning,
preferably done by the surgeon while the mouth gag is
still in place, is recommended. The placement of an oral
airway is contraindicated because this may disrupt the
suture lines. Some authors recommend placement of a
nasopharyngeal airway before extubation to facilitate
further suctioning and to maintain airway patency. It
is usually placed in patients with a higher risk of post-
operative airway obstruction, such as patients with
micrognathia, in patients with preoperative airway
obstruction as evidenced by a history of snoring and
feeding difficulty, and patients who require the place-
ment of an oro- or nasopharyngeal airway on induc-
tion of general anesthesia to ensure the patency of the
airways.20,49,50
Postoperative Care
Orofacial cleft surgeries, especially cleft palate repair,
are usually painful procedures. Adequate pain con-
trol is important to minimize vigorous crying and the
risk of disruption of the sutures, as well as to ensure
early return to feeds and to avoid dehydration. Pain
control is usually multimodal, comprising a combina-
tion of acetaminophen, nonsteroidal antiinflammatory
drugs (NSAIDS), and small incremental doses of long-
acting opioids if needed. The use of local anesthetics
intraoperatively, either by direct wound infiltration or
nerve blocks, significantly decreases the need for opi-
oid analgesia in the post anesthesia care unit (PACU)
and reduces the risk of airway obstruction. These chil-
dren should be observed and fully monitored in the
PACU until they are completely awake. They should
have good pain control and hemostasis without signs
General Anesthetic Considerations in Cleft Lip and Palate Surgery
13
of significant airway obstruction before they are trans-
ferred. Some reports of delayed tongue edema have
been described. Vigilant observation should be main-
tained on the ward for 12 to 48 hours with continu-
ous monitoring of their airway status and for bleeding.
Patients with known airway difficulties are usually
transferred to specialized units or intensive care units
for a continuous monitoring. On rare occasions, some
patients may require reintubation or a tracheostomy to
maintain airway patency.49–51
Pearls and Pitfalls
• Increased incidence of additional craniofacial
and congenital abnormalities.
• Increased incidence of respiratory
infections and increased risk of respiratory
complications in the perioperative period.
• High index of suspicion of difficult
endotracheal intubation, especially in the
presence of micrognathia.
• Difficulty of laryngoscopy and/or
endotracheal intubation correlates with
younger age, presence of large left cleft lip
with left-sided cleft alveolus, severe bilateral
cleft lip and alveolus, larger width of the
cleft in the hard palate, early age airway
obstruction, and feeding difficulty.
• Administration of muscle relaxants only after
establishing mask ventilation.
• Importance of alternate plans for airway
management, including external laryngeal
manipulation, the use of laryngeal mask
airway, bougie, or fiberoptic scope.
• Popularity of preformed oral endotracheal
RAE® tube. The ETT placement must always
be checked when changing the head position
or after insertion of the mouth gag to detect
any possible dislodgement or kink.
• Multimodal pain control and combined
local anesthetic infiltration and nerve
blocks to limit the dose of narcotics to avoid
postoperative airway complications and
airway obstruction. Children with a history of
obstructive sleep apnea are more sensitive to
the effects of exogenous opioids.
• Infraorbital nerve block for postoperative
analgesia after cleft lip surgery in infants lasts
6 to 24 hours and is superior to simple local
anesthetic infiltration.
• Infraorbital nerve block, combined with
external nasal nerve block, can be used
as the sole anesthetic for cleft lip repair in
adolescents and adults.
• Suprazygomatic approach to bilateral
maxillary nerve block in cleft palate surgeries
decreases the need for postoperative
analgesics.
• The use of steroids is controversial but
remains common practice (intravenous
dose of dexamethasone 0.25 to 0.5 mg/kg
intraoperatively).
• Postoperative complications include increased
risk of airway obstruction, airway and tongue
edema exaggerated sometimes by the use
of a mouth gag, bleeding, and increased
secretions.
• Extubation of the trachea when the patient
is fully awake and has regained complete
airway reflexes and after careful suctioning of
the oropharyngeal cavity.
• The placement of an oral airway is
contraindicated. Some recommend placement
of a nasopharyngeal airway before extubation,
especially in patients with a higher risk of
postoperative airway obstruction or patients
who required the placement of an oro- or
nasopharyngeal airway on induction of
general anesthesia to ensure patent airway.
• Continuous monitoring of airway status and
bleeding in PACU and on the ward. Transfer
patients with known airway difficulty to
specialized units or intensive care units for
continuous monitoring.
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35. Eley KA, Goodacre TE. Are routine pre-operative blood
tests required in children undergoing primary cleft lip
and/or palate repair? J Plast Reconstr Aesthet Surg. 2010;
63(6):926–929.
36. Fell D, Derrington MC, Taylor E, Wandless JG. Paediatric
postoperative analgesia. A comparison between caudal
block and wound infiltration of local anaesthetic. Anaes-
thesia. 1988;43(2):107–110.
37. Coban YK, Senoglu N, Oksuz H. Effects of preoperative
local ropivacaine infiltration on postoperative pain scores
in infants and small children undergoing elective cleft
palate repair. J Craniofac Surg. 2008;19(5):1221–1224.
General Anesthetic Considerations in Cleft Lip and Palate Surgery
15
38. Bateman MC, Conejero JA, Mooney EK, Rothkopf DM.
Short-stay cleft palate surgery with intraoperative dexa-
methasone and marcaine. Ann Plast Surg. 2006;57(3):
245–247.
39. Ahuja S, Datta A, Krishna A, Bhattacharya A. Infra-orbital
nerve block for relief of postoperative pain following cleft
lip surgery in infants. Anaesthesia. 1994;49(5):441–444.
40. Nicodemus HF, Ferrer MJ, Cristobal VC, de Castro L.
Bilateral infraorbital block with 0.5% bupivacaine as post-
operative analgesia following cheiloplasty in children.
Scand J Plast Reconstr Surg Hand Surg. 1991;25(3):253–257.
41. Prabhu KP, Wig J, Grewal S. Bilateral infraorbital nerve
block is superior to peri-incisional infiltration for analge-
sia after repair of cleft lip. Scand J Plast Reconstr Surg Hand
Surg. 1999;33(1):83–87.
42. Eipe N, Choudhrie A, Pillai AD, Choudhrie R. Regional
anesthesia for cleft lip repair: a preliminary study. Cleft
Palate Craniofac J. 2006;43(2):138–141.
43. Rajamani A, Kamat V, Rajavel VP, Murthy J, Hussain SA.
A comparison of bilateral infraorbital nerve block with
intravenous fentanyl for analgesia following cleft lip
repair in children. Paediatr Anaesth. 2007;17(2):133–139.
44. Simion C, Corcoran J, Iyer A, Suresh S. Postoperative pain
control for primary cleft lip repair in infants: is there an
advantage in performing peripheral nerve blocks? Paedi-
atr Anaesth. 2008;18(11):1060–1065.
45. Jindal P, Khurana G, Dvivedi S, Sharma JP. Intra and post-
operative outcome of adding clonidine to bupivacaine in
infraorbital nerve block for young children undergoing
cleft lip surgery. Saudi J Anaesth. 2011;5(3):289–294.
46. Salloum ML, Eberlin KR, Sethna N, Hamdan US. Com-
bined use of infraorbital and external nasal nerve blocks
for effective perioperative pain control during and after
cleft lip repair. Cleft Palate Craniofac J. 2009;46(6):629–635.
47. Mesnil M, Dadure C, Captier G, Raux O, Rochette A,
Canaud N, et al. A new approach for peri-operative anal-
gesia of cleft palate repair in infants: the bilateral supra-
zygomatic maxillary nerve block. Paediatr Anaesth. 2010;
20(4):343–349.
48. Sola C, Raux O, Savath L, Macq C, Capdevila X, Dadure
C. Ultrasound guidance characteristics and efficiency
of suprazygomatic maxillary nerve blocks in infants: a
descriptive prospective study. Paediatr Anaesth. 2012;
22(9):841–846.
49. Antony AK, Sloan GM. Airway obstruction following
palatoplasty: analysis of 247 consecutive operations. Cleft
Palate Craniofac J. 2002;39(2):145–148.
50. Chan MT, Chan MS, Mui KS, Ho BP. Massive lingual
swelling following palatoplasty. An unusual cause of
upper airway obstruction. Anaesthesia. 1995;50(1):30–34.
51. Junghaenel S, Keller T, Mischkowski R, Hinkelbein J,
Beutner D, Koerber F, et al. Massive macroglossia after
palatoplasty: case report and review of the literature. Eur
J Pediatr. 2012;171(3):433–437.
(Trang không có chữ)
17
Chapter 3
International Surgical Outreach Initiatives:
Planning, Execution, and Safety
Raj M. Vyas, Kyle R. Eberlin, Kamlesh B. Patel, and Usama S. Hamdan
Abstract
Many surgical outreach organizations reconstruct con-
genital facial deformities, such as cleft lip, cleft palate, and
microtia. Others perform orthopedic, ophthalmologic, gen-
eral surgical, and medical operations.1–5 Each has a unique
governing philosophy, organizational structure, and method
of assessing safety and quality.
Since the 1980s, Global Smile Foundation (GSF) vol-
unteers have donated time and expertise in over 100 medical
missions in 11 countries. GSF provides high quality surgical
and dental services to underprivileged patients. As a founda-
tion, GSF seeks the highest standards of preoperative plan-
ning, patient education/counseling, patient/team safety, and
long-term follow-up. Over the past 5 years, GSF’s commit-
ment and partnerships have resulted in the first cleft center
in Latin America capable of providing presurgical ortho-
pedic nasoalveolar molding therapy (Guayaquil, Ecuador).
Additionally, GSF has established the first global fellowship
in craniofacial pediatric dentistry and has encouraged the
development of a comprehensive cleft team approach at its
other sites. GSF is a leader in developing quality assurance
guidelines and protocols optimizing emergency prepared-
ness.6–7 These standards reflect the foundation’s strong
philosophy that outreach initiatives must attain the high-
est quality of operative results, patient safety, and long-term
continuity of care congruent with ethical, legal, and medical
standards found at home.
In this chapter, we first present a logical, stage-by-stage
outline of the various components of a well-organized over-
seas surgical outreach initiative. Clear goals are enumerated,
and the strategies used to achieve these standards are dis-
cussed. We then share our (now formally instituted) quality
assurance guidelines and emergency preparedness protocols
that minimize adverse outcomes and optimize team and
patient safety.
International Outreach
Planning and Considerations
When planning a medical mission, a useful approach
is to divide the major organizational components into
pre-, peri-, and postoperative stages. A typical mission
breakdown is presented in Table 3–1.
Table 3–1. Various Stages of a Typical Global Smile
Foundation (GSF) Mission to Be Conducted at a Previously
Unvisited Site*
Preoperative Stage
1. Site selection
2. Site visit
3. Trip Preparation
Perioperative Stage
4. Preoperative screening
5. Case selection
6. Operative care
Postoperative Stage
7. Screening/follow-up
*Missions to established sites conform to the same model, but with omission of
steps 1 and 2 in the trip preparation stage.
18
Video Atlas of Cleft Lip and Palate Surgery
Preoperative Stage
Site Selection
Goal #1: Develop a rigorous protocol to be used in
the selection and evaluation of potential mission sites.
The success of a medical mission is highly dependent
upon careful and appropriate site selection. New sites
should be considered only after an invitation by a local
government official, hospital administrator, plastic
surgeon, or other interested party, although this is not
always possible for newer organizations. This invi-
tation is regarded as an important initial step in the
development of a cordial relationship with the local
health care and sociopolitical networks by minimizing
a local perception of an intrusive presence. Such a rela-
tionship not only improves the continuity of care by
promoting better integration with the local networks,
but also provides for a more positive experience for
patients, team members, and all others involved with
the mission. Longitudinal care is paramount to the
development of strong relationships with all involved
individuals.
Following invitation, further consideration should
be contingent on the fulfillment of predetermined crite-
ria, including but not limited to: (1) there exists a true
need for a surgical mission (not merely a perceived
need), (2) a local hospital is available for use by a vis-
iting team, (3) a local plastic surgeon (mission-focus
specific) and medical network are present, willing, and
able to help with preoperative screening and postop-
erative care, and (4) a local coordinator is available to
assist with trip planning and logistics. The importance
of the local plastic surgeon’s contribution to the suc-
cess of the mission and overall quality of care cannot be
overemphasized because he or she will be responsible
for a sizable amount of the preoperative screening as
well as overseeing all of the postoperative care follow-
ing the departure of the visiting team members.
Site Visit
Goal #2: Use a standardized form to assess and
document available facilities and equipment.
Goal #3: Network with the local medical community;
identify a local coordinator.
A visit to the potential mission site should be under-
taken 3 to 12 months before the expected mission date.
A preliminary survey can often be filled out by the host
hospital and emailed to the designated team leader. If
local resources allow, photographic documentation of
available equipment should also be obtained and com-
municated electronically, as this is an important and
recognized component of medical and surgical mis-
sions.8 Table 3–2 illustrates the content of a proposed
site survey.
Our organization’s typical site visit lasts 3 to 4 days
and involves a small team consisting of one surgeon,
one anesthesiologist, one operating room (OR) nurse,
and one pediatric postanesthesia care unit (PACU)
nurse. All of the departments to be included on the
eventual mission should be represented. It is during
this time that visiting team members network with the
local medical and nursing staff at all levels, assessing
the feasibility of a surgical mission, determining the
credentialing process, and identifying any foreseeable
obstacles or pitfalls within the hospital facilities as well
as the local health care delivery system.
By the end of the site visit, a liaison should be iden-
tified through which communication will occur prior to
the full team mission. The liaison will be responsible
for orchestrating the dissemination of trip information
to the general public via television, radio, and news-
paper advertisements as well as through the locally
active nongovernmental organizations (NGOs) and
other local social institutions. Because effective sharing
of information is necessary for the continuing stages of
trip planning (and ultimately the success of the mis-
sion), it is imperative that an appropriate person be
chosen on the basis of willingness to donate time, com-
puter literacy, and knowledge of the local advertising
and social networks.
Trip Preparation
Goal #4: Develop and implement a comprehensive
staffing algorithm.
Goal #5: Appoint a team leader to review the site
survey and determine the necessary resources to be
acquired and shipped prior to the mission.
Once the need for a mission has been established and
the capacity to support such a mission has been fully
assessed and documented, the process of trip prepa-
ration can begin. Proper preparation is a vital compo-
nent of the overall success of any given mission and is
therefore a lengthy process undertaken with great care.
The mission team must be carefully selected. We rec-
ommend that at least 75% to 80% of the proposed team
be composed of members with prior experience of the
International Surgical Outreach Initiatives: Planning, Execution, and Safety
19
organization’s missions. We have found that build-
ing teams in this way helps to not only ensure team
cohesiveness on each mission, but furthermore helps to
ensure a consistently high level of care across all mis-
sions independent of time or location. The number of
team members on a single trip should vary with the
Table 3–2. GSF Site Survey*
Facilities (general)
Staff Support (numbers/time available)
OP (number/times available for GSF)
ICU (adult v. pediatric)
Pediatric unit
PACU
Lab
Radiology
CSR
Pharmacy
Storage room (available for GSF use)
Location of nearest critical care unit/hospital
WiFi/Internet access
Surgeons
Anesthesiologists
OR nurses
PACU nurses
Biomedical engineers
Translators
Host/guides
General support
OR (per room)
Anesthesia (per room)
Room size
Electric voltage (voltage, number/location of 120v, 220v)
Back-up power source
Lighting (surgical lights, head lights, ceiling lights)
Medical air/O2 Outlets
Sterilizer (brand, type, quantity, cycle duration)
ESU/Bi-Polar coagulation, Electrocautery
Defibrillators
Suction (wall-mounted, portable)
Head scope/Microscope
Gases (number, location, outlet type [DISS, DIAMOND])
Backup tanks and flow meters
Gas scavenger system
Anesthesia machines (make, model)
Vaporizers (agent, brand, including sevoflurane)
Monitoring systems (O2, agent, ECG, SPO2, NIBP, Direct
Pressure, Temperature, ETCO2)
Ventilators (number, brand, pediatric?)
IV administration sets — pediatric
Medicines available for purchase (IV fluids, narcotics, ancillary
anesthesia medicines)
Transfusion capabilities (Availability of blood)
Dantrolene
PACU
Miscellaneous:
Beds (available for GSF use)
Bedside monitors, O2, suction
Utilities available (gas outlets, power)
Crash cart
Additional GSF equipment needed
Additional supplies needed
Administrative Duties:
Hotel accommodations
Security arrangement while on mission
Airline & airport customs/ land transportation/Ministry of Health licensing
Coordinating meals/food
*The GSF site survey is a standardized form that is completed during the site visit at each potential mission site. The table illustrates the components
of the survey, which should be updated with each mission, and photodocumented when possible.
20
Video Atlas of Cleft Lip and Palate Surgery
anticipated medical and surgical need, the number of
operating rooms and clinics available for use, the avail-
ability of local nursing staff, and the need for ancillary
staff such as volunteers, coordinators, residents, and
medical students. Newer missions may require as few
as 10 to 15 members, whereas more established mis-
sions often require more than 30 team members.
Each mission should be led by a designated team
leader, most often a surgeon who has participated
in five or more missions within the last 5 years. It is
imperative that the leader has both a broad under-
standing of the goals of the mission as well as a work-
ing knowledge of the local network. Prior to the trip,
the team leader and accompanying heads of anesthesia
and nursing divisions must become familiar with the
equipment and facilities available at the host hospital.
Although the team leader often partakes in the site
visit, verification of what is available on site and what
must be brought down with the team is confirmed
using the photographic documentation taken during
the site visit. Table 3–2 lists important considerations
in this process.
Given the diverse nature of surgical missions,
there are many possible staffing algorithms. It is our
recommendation that each operating room be staffed
with two surgeons, the senior of whom has at least
10 years of specialized surgical experience, a pediatric
anesthesiologist, and one OR nurse. It is further rec-
ommended that an additional anesthesiologist and OR
nurse be available to “float” among rooms, helping to
begin cases and providing other assistance as needed.
It is our policy to have two anesthesiologists present at
the beginning of every case. The recovery room should
be similarly staffed with one PACU nurse (pediatric
advanced life support [PALS] certified) per OR (eg,
three PACU nurses for three running ORs). A pediatric
intensivist should also be part of every mission team
that plans on working with children; he or she provides
perioperative management and assists in the handling
of any significant recovery room and inpatient issues
throughout the duration of the mission. The composi-
tion of a typical team, with required member numbers,
where applicable, is listed in Table 3–3.
Administrative coordinators play an indispens-
able role in trip preparation and the handling of day-
to-day concerns during the mission, allowing the
medical personal to more fully concentrate on patient
care. They are responsible for the mission logistics and
must arrange travel itineraries, hotel stays, security
arrangements, travel within the mission country, and
the shipment of any necessary medical equipment
and supplies.
Perioperative Stage
One team member should plan to arrive in the host
country 1 to 2 days prior to the start of the mission to
facilitate the arrival of the team, meet with the local
medical community, and go over the prescreening pro-
cess with the plastic surgeon. The local heads of anes-
thesia and OR at the host facility can be recruited to
resolve any remaining logistical issues at this time.
Patient Screening
Goal #6: Institute a rigorous screening process with
evidence-based inclusion criteria.
Appropriate site selection allows the screening process
to take place in two distinct phases: (1) selection and
screening by the local plastic surgeon prior to the mis-
sion, and (2) screening by team members upon arrival
at the mission. Screening by local physicians and sur-
geons typically occurs over a period of 4 to 8 weeks
prior to the mission. This provides the first direct mea-
sure of patient safety because the local medical staff
speaks the native language and is intimately familiar
with regional customs and belief systems. Prior to
screening, local physicians are provided with a set
of strict selection guidelines as well as the necessary
equipment needed to undertake the case selection pro-
cess. Specific criteria are used to determine operative
eligibility:
• Cleft lip patients must be at least 10 weeks
of age, at least 10 pounds, and with a
hemoglobin of at least 10 g/dL.9
• Cleft palate patients should be around 10 to
18 months old, although variability exists due
to time of presentation.10
• Microtia patients should be at least 5 to 8
years old.11
• No patients with congenital syndromes or
extensive comorbidities; we only operate on
American Society of Anesthesiologists (ASA)
Class I patients for safety purposes.12
• Other normal screening guidelines
apply — that is, no concurrent respiratory
illnesses, no contraindications to anesthesia,
and so forth.
Electronic medical records formatted by the out-
reach organization are completed by local physicians
during the prescreening process. Photographs are
taken and sent electronically to the team of surgeons
International Surgical Outreach Initiatives: Planning, Execution, and Safety
21
in the United States. Standardization of photographic
documentation is important, as surgeons utilize these
during the prescreening process and begin to formu-
late an operative schedule. Screening by the visiting
team of physicians should take place on the first full
day of the mission. Although the vast majority of these
patients have been prescreened by local surgeons, as
described previously, there are inevitably several addi-
tional patients who present for the first time on this
day. Given the sheer number of patients and the com-
plexity of the screening process, organization of patient
flow and transfer of patient information is essential.
Each patient must be evaluated independently by
three groups during the screening process; the screen-
ing area should be set up to allow each group to main-
tain a distinct station (Figure 3–1). The first group is
Table 3–3. Staffing Requirements For a Typical GSF Team, with Numerical Requirements Where Applicable*
Surgeons
Facial Plastic Surgeons
General Plastic Surgeons
Otolaryngologists—Head & Neck Surgeons
Pediatric Otolaryngologists
Oral and Maxillofacial Surgeons
• 1 team/mission leader
• 2 GSP surgeons per OR
• 1 senior GSF surgeon per OR
Anesthesiologists
Pediatric
General
• 1 GSF pediatric anesthesiologist/OR
• 1GSF “floating” anesthesiologist
Other Physicians
Pediatric Intensivist
• 1 per team
Nurses
OR
PACU
Post-Op Nurse
• 2 GSF OR nurses per OR
• 1 GSF PACU nurse per OR
• 1 postoperative GSF nurse
Other Surgical Team Members
Nutritionist
Biomedical Engineers
Administrative Staff
Volunteers
• Variable
• Includes medical students and residents
Dental Team
Dentists—Pediatric, General
Dental Assistants
Dental Hygienists
Dental Students
• Variable
In-Country Team
On-Site Coordinator
Plastic Surgeon
Health care Facility Staff
Lecture Coordinator
Local Host Organizations
• Local plastic surgeon is responsible for screening before
and after mission
• Includes translators
*Residents and students are not to be included in these numbers.
22
Video Atlas of Cleft Lip and Palate Surgery
comprised of a team of surgeons, who determine the
surgical priority and estimated surgical duration of
each proposed procedure. If there are any surgical
contraindications to operation, they are determined at
this time, and the patient is not scheduled for surgery.
The second group is comprised of pediatric anesthe-
siologists and a pediatric intensivist, who together
determine the ASA patient classification and pro-
vide a second, independent screening opinion on the
patient’s suitability for surgery. Importantly, the car-
diac and respiratory status of the patient is carefully
evaluated at this time, as additional congenital defects
are not uncommon in patients with cleft syndromes.
Cleft patients have approximately a 21% chance of hav-
ing significant associated malformations, up to one-
quarter of which are cardiac in nature.13–14 The third
group is composed of administrative personnel, where
surgical/photographic consent and additional stan-
dard photographs are obtained from patients under
consideration for surgery. If prior photographs taken
by the local surgeons are sufficient for a given patient,
no more are needed. In addition to coordinating the
preoperative screening process, other team members
should be simultaneously involved in the preparation
of the operating rooms and PACU. OR nurses should
unpack and inspect all transported supplies and equip-
ment while the biomedical engineer helps ensure the
quality of the operating rooms and the compatibility of
equipment for the week’s work.
Case Selection
Goal #7: Develop an operative schedule based on
capacity, level of deformity, and urgency of care.
Goal #8: Schedule younger patients earlier in the
day; do not schedule cases involving the airway
within 48 hours of team departure.
Figure 3–1. Global Smile Foundation (GSF) screening algorithm illustrating the flow of a
normal GSF screening day from patient check-in to checkout. The surgical and anesthesia
screenings are conducted independently of one another, in separate rooms if possible. At the
administrative/photographic station, the administrative and surgical team members draw up
the OR schedule for the week and prepare the necessary consent and preoperative instructions
for explanation and distribution during patient checkout.
International Surgical Outreach Initiatives: Planning, Execution, and Safety
23
The case selection process should be a collaborative
process involving the surgeons and anesthesiologists
with input from the pediatric intensivist and OR and
PACU staff. A number of factors are involved in the
selection process: Patient age and degree of deformity
are taken into account, as well as distance traveled and
the need for future operations. Cases are evenly dis-
tributed among the provided operating rooms, such
that the total duration of cases will be similar in each
of the rooms for a given day. Younger patients are typi-
cally scheduled earlier in the day, with the exception of
Monday, in which a slightly older patient is selected for
the first case of the week (in case of equipment failure
and its associated risks). Such a policy has been pre-
viously described for international missions.15 Finally,
no cases involving the airway (ie, cleft palate repair or
pharyngeal flap) are performed within 48 hours of the
team’s departure in order to allow for adequate airway
monitoring. This is an important safety measure due
to the higher incidence of airway obstruction that has
been noted on similar missions.12
Following case selection, patients chosen for sur-
gery are brought back into screening rooms, notified
about the date and time of surgery, and given compre-
hensive verbal and written preoperative instructions
including feeding and dietary directives in their native
language. The patients and their families must also be
made aware of any foreseeable operative complications
and fully consent for care; attention should be paid to
ensure that verbal and written explanations are clearly
understandable to the population being served. Infor-
mational DVDs, pamphlets, volunteer translators, and
child life specialists play an important role in these
assignments.
Operative Care
Goal #9: Verify again the functionality of all
equipment and facilities prior to the first case.
Goal #10: Incorporate local physicians and surgeons
into the operative and teaching process, with
graduated involvement throughout the week.
Goal #11: Plan for emergencies — maintain an
on-call schedule, provide the on-call team with cell
phones known to the local hospital staff, and outfit an
OR prior to departure each night.
Both surgeons and anesthesiologists must be famil-
iar with the hospital facilities and equipment prior to
performing any operative procedure. Appropriate trip
planning allows much of this to be accomplished before
the team departs for the mission site so that the neces-
sary surgical instruments, equipment, and supplies
(including sutures, IV medications, etc.) can be brought
down by team members, particularly if there are spe-
cialized items not readily available locally. Once on site,
these items should be labeled and stored with extreme
care to minimize the risk of loss or damage. The ster-
ilization of surgical instruments can be problematic in
older or rural hospitals, and it is recommended that
such facilities be examined carefully upon arrival to
ensure adequate sterilization for required procedures.
If there is any doubt regarding availability, a portable
sterilizer should be part of any team’s transportable
equipment.
Monitoring equipment must likewise be outfitted
with the entire complement of safety devices available
in the United States. The site visit and the trip prepara-
tion stages (described previously) should allow for this
provision; if such safety devices are not locally avail-
able, these machines must be transported from the
United States. Without comparable equipment with
which physician operators are familiar, patient safety is
compromised and potential problems could ensue.12,15
At the end of each mission, GSF donates many of its
supplies and equipment to local hospitals and health
care providers and arranges for additional donations
from benefactors in the United States depending on the
hospital’s needs. In this way, local providers are able
to incorporate the technological advances after team
departure, and supplies are available for returning
teams the following year.
The authors specifically recommend end-tidal CO2
(ETCO2) monitors, defibrillators, and pediatric intuba-
tion devices. Four-in-one monitors, such as Propaq™
monitors, are well suited for this task. They contain an
EKG, pulse oximeter, blood pressure, and ETCO2 sen-
sors, and are portable and lightweight, thus facilitat-
ing easy transport.15 These monitors are transported
in special protective casing, reducing the potential for
damage. The inclusion of a biomedical engineer on
the mission team ensures that equipment will be fully
functional when needed. It is also imperative to deter-
mine the availability of intensive care unit (ICU) beds
and transfusion capabilities, in the rare circumstance
that these are needed.
Lectures about operative technique, anesthesia
monitoring, and various other medical topics are given
throughout the week. Specific attention is given to sub-
jects germane to the particular mission; cleft and micro-
tia care is perpetually evolving and is a topic ripe for
24
Video Atlas of Cleft Lip and Palate Surgery
instruction and discussion. Following these lectures,
local providers are better able to assimilate their skills
with those of visiting teams and are given graduated
responsibility in the operating room. By the end of the
week, local providers should become increasingly pro-
ficient and independent with cleft care, reflecting the
benefit of teaching throughout the mission.
When confronted with the overwhelming local
need for care, it is natural to want to schedule and
perform as many cases as possible. Operative teams
should institute a procedural policy addressing work
hour restrictions, limiting their members to a maxi-
mum of 10 to 11 hours per day to prevent the pitfalls
that have been associated with severe fatigue.16,17 This
ensures optimal patient care and allows for full func-
tionality throughout the week. At no point during the
mission should the local staff be left solely responsi-
ble for the team’s postoperative patients. The mobile
phone numbers of all on-call staff are provided to the
hospital as well as members of the local team at the
beginning of the mission.
It should be every operative mission’s policy to
outfit an entire OR before leaving at night in case of
a surgical emergency. It has been our experience that
some hospitals visited by our teams shut down com-
pletely at the end of the day and lock the doors to
the ORs. It is therefore important to have guaranteed
access to an OR at night. This issue must be addressed
prior to the start of the operative week.
Postoperative Stage
Screening and Follow-Up
Goal #12: Provide clear discharge instructions,
verbal and written, to patients and their families in
their native language.
Goal #13: Screen all operative patients on the
penultimate day of the mission to evaluate for
potential complications and plan for future
procedures.
Clinical rounds should be carried out every morning
before the start of the OR as well as every evening for
the entire week, with a minimum of two senior sur-
geons present for evaluation. Prior to discharge, fami-
lies must be given strict instructions for the remainder
of their home care. This includes both oral and writ-
ten instructions disseminated in the native language
regarding dietary and functional restrictions, follow-up
with local surgeons, and the use of elbow restraints in
an attempt to prevent manual disruption of the surgi-
cal site in cleft lip and palate patients. It is important to
involve local surgeons, dentists, orthodontists, speech
therapists, and social workers in this process, as these
health care professionals will be involved in the major-
ity of follow-up care. Using only absorbable sutures,
such as 5-0 or 6-0 Ethicon™ fast-absorbing plain gut
(Johnson and Johnson, LLC, Branchburg, NJ), for skin
closure obviates the unequivocal need for removal. The
authors recommend screening every surgical patient
on the penultimate day of the trip. It is important that
the team’s surgeons and anesthesiologists examine
each patient to ensure operative success, to monitor
for adequate pain control, to ensure that no complica-
tions have arisen, and to answer any questions for the
patients and their families. Postoperative photographs
should be taken at this time and patients given infor-
mation regarding the following year’s mission.
Patient Safety: Quality Assurance
Guidelines and Emergency
Response Protocol
Medical and surgical missions to the developing world
can provide an extremely positive experience for both
patients and health care providers. Providing medical
care in such locales is not without its challenges, how-
ever, and the transient nature of many medical missions
coupled with the lack of long-term postoperative care
by visiting teams has drawn the criticism of some.12
Despite the best efforts of the most experienced teams,
adverse outcomes do occur. Morbidity and mortality
rates encountered on these missions due to complica-
tions such as bronchospasm, laryngospasm, nosoco-
mial infections, and fatal cardiac problems are higher
than those encountered when the same procedures are
conducted in the developed world.18 This increased
incidence has been documented by even the most expe-
rienced surgical outreach groups.6,12,15,19 It has also been
suggested that the rates of complications may actually
be higher than previously reported due to the unavail-
ability of more sophisticated intraoperative monitoring
and the paucity of long-term follow-up data.19
To meet these challenges, GSF has recently for-
malized and implemented a set of standardized qual-
ity assurance guidelines that encompass all aspects of
medical mission planning and execution.6 GSF has also
described a standardized emergency response proto-
International Surgical Outreach Initiatives: Planning, Execution, and Safety
25
col to improve our team’s emergency preparedness
and optimize responses to various unexpected emer-
gent scenarios in unfamiliar settings.7 These important
safety advances are outlined here and are important for
any humanitarian organization planning and executing
an overseas medical mission.
Quality Assurance Guidelines
Prior to GSF’s publication of its “Quality Assurance
Guidelines for Surgical Outreach Programs,”6 there
existed no definitive set of quality assurance guidelines
for the medical outreach community.20 The guidelines
proposed were developed as the result of critical obser-
vation and gradual policy change over many years.
The goal of such guidelines is to ensure patient safety
congruent with domestic standards without imposing
excessive bureaucracy or disruption of team work-
flow and morale. All strategies advocated here should
be easily understood, readily adoptable, and easily
modifiable to each group’s unique mission structure
and setting.
Table 3–4 details our formalized quality assurance
guidelines based upon the various stages of mission
preparation described previously and the accompa-
nying enumerated mission goals and policies. We
recommend absolute perioperative monitoring uti-
lizing equipment with which the visiting medical
team is familiar, coupled with diligent case selection
and appropriate scheduling to ensure the high stan-
dards maintained by the visiting team members at
their home institutions. A standardized staffing algo-
rithm with a goal of 75% to 80% repeat members is an
equally important consideration. Not only does such
a requirement make certain that all of the patients can
be adequately cared for by physicians and nurses with
sufficient experience, but it also allows the same volun-
teers to interact with the same patient population and
local volunteer staff over a course of years rather than
days. Continued, repeated contact between the visiting
and local medical teams helps to further integrate the
two, allowing for a higher degree of ownership on the
part of the local team during the postoperative stages.
By fostering a sense of ownership, continuity of care
can be greatly increased, and this is especially impor-
tant following the departure of the visiting team.
International missions provide educational oppor-
tunities for local medical personnel from various
departments: surgery, anesthesia, pediatrics, nursing,
dental, and biomedical engineering. An important
component of quality assurance is for traveling teams
to work closely with these local specialists to facili-
tate the transfer of education, knowledge, and recent
innovations through a series of specialty lectures and
conferences that parallel hands-on training in the
above-mentioned doctrines. Local surgeons, anesthesi-
ologists, and OR staff actively participate in cases with
the senior visiting surgeons in a graduated fashion
throughout the week. Equipment donations (ie, com-
puters, monitors) are also part of our missions; these
allow the local team to provide the same level of care
in the absence of the visiting team while also allowing
for an increased ability to support more extensive mis-
sions in the future.
GSF’s quality assurance guidelines are intuitive
but require ongoing quantitative validation, which is
currently under way. The organization has recently
developed a Web-based medical record system that
enables local and visiting physicians to load patient
information onto standardized forms both preopera-
tively and postoperatively in order to allow for bet-
ter patient selection and follow-up, respectively. Such
a system will allow the ability to quantitatively and
qualitatively assess the effectiveness of our described
quality assurance guidelines.
GSF views its quality assurance mechanisms as a
perpetual work in progress that is subject to constant
refinement. Improvements are continually made based
on feedback solicited from team members during the
evaluation sessions held on the final day of each mission.
We do not advocate that these current guidelines
are authoritative or wholly comprehensive, but we do
believe they are a necessary facilitator for ongoing dis-
cussions regarding the reduction of unnecessary mor-
tality and improvement of the quality and continuity
of care provided.
Emergency Response Protocol
Few data have been reported on the frequency of emer-
gency scenarios, near-miss events, or adverse outcomes
encountered by the multitude of surgical humanitarian
outreach providers. In 1999, Operation Smile reported
18 deaths while treating 50,000 patients (0.04% mortal-
ity).21 In 2002, the International Task Force collectively
evaluated 10 large overseas cleft surgery organizations
having treated 3,500 total patients and reported that
7 groups experienced notable morbidities (unspecified)
whereas 2 reported a combined 4 mortalities (0.11%
mortality).22
26
Table 3–4. Proposed Quality Assurance Guidelines
Preoperative Stage
Site selection
1. Consider a potential site after invitation only
2. Evaluate potential site according to
• the need, real or perceived, for a surgical mission
• the local hospital is available for use by mission team
• the presence of a local plastic surgeon and medical network willing and able to help with
preoperative screening and postoperative care
• the availability of a local coordinator to assist with trip planning and logistics
Site Visit
1. Assess the real need for a medical mission, as well as potential obstacles
2. Complete a site survey
3. Evaluate and photodocument the available facilities and equipment
4. Identify and network with the local coordinators and physicians
5. Identify an appropriate liaison to orchestrate patient recruitment, and to facilitate pre-trip
communications and logistics
Trip preparation
1. Team selection
• 75% to 80% of team must have prior experience with organization and its missions; team
leader must have been on 5+ missions in past 5 years
• All ORs must be fully staffed by staffed by fully-trained physicians and nurses (2
surgeons, 1 pediatric anesthesiologist, and 2 OR nurses per room) with an additional
anesthesiologist floating between rooms
• A fully-trained pediatrician and PACU nurses (one for every OR and one specialized floor
nurse) must be staffed to handle postoperative care and must be PALS certified
2. Team leader must review all site visit documentation and determine what equipment and
supplies must be shipped or transported by the visiting team, with input from nursing,
anesthesia, and biomedical engineering division heads
Perioperative Stage
Patient screening
1. A senior team member or mission coordinator will travel to the site 1 to 2 days prior to arrival
of the team to facilitate all logistical issues with local facility and staff
2. Screening must involve two steps, both with photographic documentation:
• Pre-screening by the local plastic surgeon, occurring 4 to 8 weeks prior to mission with
identification of potential cases according to organizational guidelines
• Screening by mission team upon arrival, including independent assessment by both
surgeons and anesthesiologists
3. Operative selection criteria should be evidence-based and consistent with standard of care in
the developed world
4. Only ASA Class I patients should be considered for elective reconstructive surgery
Case selection
1. Determine operative capability based upon team size/experience and prospectively establish
number of cases for the week by category
2. Schedule younger patients early in the day (with exception of first day, where an older patent
undergoes first operation)
3. Do not perform operations involving the airway on the last operative day (or within 48 hours
of team departure)
4. After patient selection, give patient and family full preoperative instructions translated into
native language
5. OR load: 5 cleft lips/OR, 4 cleft palates/OR, and 2 microtias or 4 or 5 cleft rhinoplasties, scar
revision, or similar cases/OR
continues
International Surgical Outreach Initiatives: Planning, Execution, and Safety
27
Operative Care
1. Entire team, including surgeons, anesthesiologists, and nurses, must be familiar with hospital
facilities and equipment prior to beginning cases for the week
• Verify again that monitors, sterilization equipment, resuscitation devices, and an ICU are
in good repair and available, if necessary
• Verify that anesthesia machines, servoflurane vaporizers, oxygen sources, scavenging
systems, and all monitoring equipment are compatible and fully functional
2. Use only absorbable sutures for skin closure, to obviate the need for future suture removal
3. On call team: One senior surgeon and one senior anesthesiologist on call per night supported
by 1 OR and 1 PACU nurse, and outfitted with cell phones, with phone numbers given to
hospital night staff
4. Outfit an operating room with full complement of supplies before leaving for the day, in case
of emergent return to the OR
Postoperative Stage
Screening/Follow-up
1. Postoperative screening/clinical rounds should take place twice daily, at a minimum, to
evaluate all inpatients postoperatively
2. Prior to discharge, give patients strict instructions (in native language) for postoperative care
and instructions for follow-up with local plastic surgeon—both written and verbal instructions
3. Screen all patients on day prior to departure to evaluate the surgical result and look for
potential complications
4. Inform patients about need for future procedures/return of team in the following year
Table 3–4. continued
In response to these concerns, GSF recently for-
malized and published the first standardized protocol
to prevent and manage unforeseen emergencies during
overseas surgical outreach initiatives.7 In most devel-
oped countries, credentialed hospitals have instituted
established protocols to ensure that physicians, nurses,
and hospital staff are prepared to optimally manage
patient and hospital emergencies.23–24 Designated emer-
gency response teams are comprised of several members
with clearly defined roles and necessary built-in redun-
dancy.25 Familiarity and facility with such emergency
response protocols are considered a prerequisite for all
hospital staff, and mandatory training modules are often
instituted to ensure compliance for all credentialed
personnel. The goal of the GSF emergency response
protocol is to ensure that all members of our overseas
surgical outreach initiative have the requisite resources
and training needed to emulate the high emergency
responsiveness mandated by developed nations.
The challenge is clear: to effectively educate and
train a group of surgeons, anesthesiologists, nurses,
and administrators — coming together for only a brief
overseas humanitarian initiative — in order to optimize
their collective emergency responsiveness. Further-
more, this education and training must be portable,
standardized, reproducible, efficient, and adaptive to
each unique setting. Most morbidity and mortality on
overseas surgical outreach initiatives result from unfa-
miliarity with both the host hospital setting and other
team members during an operative (airway, bleeding,
circulatory, anesthetic) or location/resource-based
(power outage, fire, oxygen shortage, etc) emergency.
Clearly, the need to formally train health care person-
nel to coordinate and manage emergency scenarios is
nowhere more important than on an overseas surgi-
cal outreach initiative. Team members are unfamiliar
with the layout of operating rooms, recovery rooms,
and intensive care units. Furthermore, the location
and availability of blood banks, fire extinguishers, and
backup power generators can be variable. Valuable
medications and operating room resources are often
sparse, and language and cultural barriers can impede
a coordinated emergency response amid even highly
talented host and visiting medical/nursing personnel.
Here we outline the main features of our emergency
response protocol to demonstrate the fundamental
components necessary to ensure optimal patient safety
during overseas surgical outreach initiatives.
28
Video Atlas of Cleft Lip and Palate Surgery
Equipment Portability
Depending on the locale, surgical outreach teams
typically travel with a large amount of equipment.
Therefore, a practical emergency response kit must be
organized logically with maximal ergonomic atten-
tion that minimizes confusion and baggage. We now
travel with a comprehensive GSF Emergency “Crash”
Cart (ECC) (Figure 3–2, left). This is a single, clearly
marked piece of heavy-duty, trauma-resistant luggage
with wheels allowing a compact, portable means of
handling emergency situations in various locations
(PACU, OR, or hospital floor). The bag is unlocked
upon arrival to the host nation and then left unlocked
for the duration of the trip. The cart’s contents are
clearly enumerated on the inside cover (Table 3–5)
and include all instruments and equipment needed to:
(a) establish and protect an emergent airway, (b) resus-
citate a patient according to pediatric advanced life
support (PALS) protocols (including PALS medications
and laminated PALS algorithms), and (c) counteract
Figure 3–2. Left: Global Smile Foundation (GSF) emergency “crash” cart (ECC) and contents.
Right: GSF emergency crash cart shoe holder and contents.
Table 3–5. List of Global Smile Foundation (GSF) Emergency
“Crash” Cart Contents
Crash Cart Contents
1. AMBU BAGS X3
2. PALS shoe holder
3. PALS MED BOX x2
4. AED
5. IV TUBING2
6. IV FLUIDS (ON SITE)
7. INTRALIPID
8. TRACH TUBES: SIZES 3.0, 4.0, 5.0
9. TRACH INSTRUMENTS
10. Malignant hyperthermia box
11. Pulse oximeter
12. Suction, Surgicel, Flashlight
13. Broselow, PALS, and other charts
International Surgical Outreach Initiatives: Planning, Execution, and Safety
29
adverse anesthetic complications (ie, malignant hyper-
thermia with dantrolene and local anesthetic toxic-
ity with intralipid). Prior to departure, all crash cart
contents are inspected for adequate supply and expi-
ration status and restocked as necessary. In the ECC,
we pack a GSF ECC Shoe Holder that organizes criti-
cal emergency equipment (Figure 3–2, right). A large
laminated spreadsheet lists the equipment stored
within the shoe holder and is structured to be spatially
congruent with all equipment within the shoe holder
(Appendix 3–1). Any used equipment is recorded on
this spreadsheet at the end of an emergency situation,
facilitating replenishment. All members of the team are
formally introduced to the GSF ECC after unpacking
team equipment and after becoming familiar with the
layout of the hospital/operating suite (morning of first
full day) but before patient selection (morning of sec-
ond full day). Subsequently, the ECC is kept clearly vis-
ible in the PACU during the entire operative day before
being transferred to the possession of the on-call anes-
thesiologist each evening.
Location-Specific Adaptability
An effective emergency response protocol must be
adaptive to each hospital setting’s unique structural
and resource limitations. We now utilize a multiphase
approach in order to maximize the flexibility of the
team’s emergency responsiveness. One month prior to
departure, a slideshow presentation is sent to all team
members providing a virtual location-specific hospital
tour. The focus of this presentation is to familiarize the
team with the layout of ORs, PACUs, ICUs, and hos-
pital floors, as well as the location of backup power
generators, blood banks, oxygen supplies, and fire
extinguishers. An accompanying Checklist for Site-
Specific Emergency Preparedness is also distributed to
all team members (Appendix 3–2). These materials are
reviewed during a routine mandatory videoconference
held with all team members 2 weeks prior to departure.
Upon arrival at the host hospital, all team members
participate in an on-site walk-through of the hospital
facilities featured before and the team leader manages
the completion of the Checklist for Site-Specific Emer-
gency Preparedness. This ensures location-specific
familiarity and coordination among all team members
in case of an emergency.
Workflow and Communication
To guarantee maximal emergency preparedness, a
safe, reliable, and clear infrastructure that guides daily
workflow and team communication must be estab-
lished and maintained daily. Establishing an on-call
schedule is important to ensure sufficient and account-
able staff is present to properly initiate and complete
the emergency response protocols. This also reassures
local medical personnel of the team’s complete avail-
ability. Call schedules should include multiple spe-
cialists so that each night the following persons are
available: administrator (who can contact local admin-
istrators and additional team members as needed), sur-
geon, anesthesiologist, pediatrician, PACU nurse, and
OR nurse. Once the call team is established, the mode
of communication should be clarified. Depending on
how remote the location is, pagers, personal phones,
rented phones, or walkie-talkies are made available to
each on-call member. A call tree is designed so that all
on-call personnel are efficiently notified of any emer-
gency situation. Each evening, the on-call team con-
firms that the mode of communication among team
members and those providing overnight patient care is
functioning properly. If the location of lodging for the
team is at a distance from the site of patient care, then
there must also be a plan for transportation to and from
the hospital after working hours. If team members are
not fluent in the local language, it is imperative to
always have a translator available to assist with routine
and emergent scenarios. This is especially important
when active issues arise at night and local nurses must
speak with on-call doctors and nurses. Each workday
should begin with a daily briefing by the team leader
to the entire team. The daily workflow is discussed,
any concerns are addressed, and all team questions
are answered. A subset of surgeons, anesthesiologists,
pediatricians, and nurses participates in daily morning
ward round to identify any active patient concerns and
facilitate proper postoperative care. All overnight cel-
lular phones, pagers, and walkie-talkies are recharged.
At the end of each working day, daily evening ward
rounds are performed and one OR is set up to prevent
any delay if a patient requires an emergent overnight
return to the OR. Taking these additional safety steps
not only reduces the risk of adverse outcomes and
maximizes emergency preparedness, it also builds
trust and confidence among host medical personnel
and confirms the team’s collective dedication to safe
and excellent patient care.
Standardization of Team Roles
Each overseas surgical outreach initiative is comprised
of a unique combination of physicians, nurses, and
administrators. Therefore, any sustainable emergency
30
Video Atlas of Cleft Lip and Palate Surgery
response protocol must rely upon standardized roles
and easily reproducible training techniques. No matter
how talented the team, it is crucial to clearly delineate
each team member’s role in any emergency. We offer
our GSF Emergency Response Protocol Team Roles
and Responsibilities as a starting point for each team
to adopt and/or modify as needed (Appendix 3–3).
These roles are distributed 1 month in advance of the
outreach initiative and discussed at length during the
mandatory videoconference 2 weeks prior to depar-
ture. Upon arrival to the host country, mock simula-
tions are held after all supplies are unpacked and
before patient selection begins (usually the evening of
the first full day). Simulations are performed for each
of the following emergency situations: power outage,
fire, oxygen failure, need for emergent transfusion, and
all medical/surgical adverse events in the OR, PACU,
and floor (airway, respiratory, cardiac, and anesthetic-
related). Successful emergency responsiveness relies
on all team members participating in the mock sim-
ulations and executing their standardized roles in a
reproducible manner. With prior review by all team
members, completion of the mock simulations usu-
ally requires only a few hours. The team leader, ideally
most familiar with the emergency response protocol, is
able to observe the simulations to identify and resolve
any potential issues that might obstruct delivery of
efficient and rapid care. The GSF Emergency Response
Protocol Team Roles and Responsibilities placard is not
only distributed to all team members, it is also clearly
posted within each operating room, PACU, and patient
floor. Additionally, standardized protocols for manag-
ing malignant hyperthermia and local anesthetic tox-
icity, including step-by-step administration/dosing
guidelines, are posted in each operating room for facile
review if needed (Figure 3–3).
Most morbidity and mortality on surgical out-
reach initiatives result from emergencies involving loss
of airway, bleeding, anesthetic toxicity, and unfamil-
iar settings/resources. Despite seemingly formidable
odds, these complications are largely preventable and
can be overcome with aggressive team education and
training protocols. Optimal emergency preparedness
requires more than just talented personnel and good
intentions; it demands proper equipment, individual
responsibility, group preparation, team coordination,
and a collective dedication to patient safety.
Regardless of the exact details, an effective emer-
gency response protocol must be portable, adaptive,
efficient, standardized, and reproducible. Our pro-
tocol has been structured to function with the limita-
tions and uncertainties inherent in providing medical
care in resource-limited settings and reflects a wealth
of experience accumulated over the past 25 years. It is
our hope that other groups participating in overseas
surgical outreach initiatives will utilize the basic tenets
and principles of our safety checklists and protocols
and customize them to fit the unique dynamic of their
teams and host locations. Certainly, this protocol con-
tinues to be modified and will require more experience
to refine and validate. Still, we believe that implement-
ing such an initiative has intangible positive externali-
ties that go far beyond the primary goal of improving
patient outcomes. The dedication to patient care
inherent in optimal emergency preparedness deliv-
ers a strong message of compassion to host nations
that builds trust and provides additional credibility to
surgical outreach teams. As an increasing number of
humanitarian groups reach out to additional under-
resourced regions, these measures create a new para-
digm that strengthens new partnerships and bolsters
existing international relationships.
31
Figure 3–3. Protocols for management of malignant hyperthermia and local anesthetic toxicity are posted in each OR (Guayaquil, Ecuador). All needed equipment is found
in the Global Smile Foundation (GSF) emergency “crash” cart.
32
Video Atlas of Cleft Lip and Palate Surgery
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International Surgical Outreach Initiatives: Planning, Execution, and Safety
33
Appendix 3–1
Global Smile Foundation (GSF) Emergency “Crash” Cart Shoe Holder Contents
The structure of the spreadsheet visually imitates the
structure of the GSF emergency “crash” cart shoe
holder to allow for quick identification of needed sup-
plies. This spreadsheet is printed and laminated for
easy dry/erase marking and therefore allows for quick
replenishment of any used supplies.
PLEASE RECORD ANYTHING USED
EKG PADS 5
IV START KIT 1
1" CLEAR TAPE 1, 1”
T STRIPS 2
T PIECES 1
1" CLOTH TAPE 1
PINK TAPE 1
GAS SAMPLING LINE & FILTER 1
XTENSION TUBING 1
TEGADERM 3
EKG PADS 5
18G IV 1 22G IV 2
TOURNIQUET 1
CPR HANDBOOK
20G IV 2 24G IV 2
BENZOIN 1
GAUZE 2X2
GLOVES M
ALC PADS 10
BUTTERFLY NEEDLE 2
STOPCOCKS 1
BURETTROL 1
TONGUE DEPRESSORS 1
NEEDLES
60 DROP SET
YANKAUER
18G 2 20G 3
15 DROP SET
SURGILUBE 1
22G 2 25G 2
AFRIN
SYRINGES
20 CC 1
10 CC 5 5 CC 2
3 CC 2 1 CC 2
ORAL AIRWAYS
SUCTION CATH
NG TUBES
#4 1 #7 1
#8 2 #14 2
#10 1 #16 1
#5 1 #8 1
#10 2 #18 2
#12 1 #18 1
#6 1 #9 1
#12 2
#14 1
TODDLER MASK 1
INFANT MASK 1
LARYNGOSCOPE HANDLE 1
WIRE GUIDE
STETHOSCOPE 1
MILLER #1 1
ESCHMANN STYLET
ADULT MAGILL
MILLER #2 1
ADULT STYLET 1
PEDI MAGILL
WIS #1 1/2 1
PEDI STYLET 1
BANDAGE SCISSORS
MAC #1 1
TUBE EXCHANGERS S, M, L
MAC #2 1
16G CATHETER
MAC #3 1
continues