xRead - Treatment of Cleft Lip and Cleft Palate (May 2025)

Plastic and Reconstructive Surgery • February 2024

between 10 and 14 months of age ( P < 0.001) and 29% less likely if initial repair occurred at more than 14 months of age ( p = 0.002) (level of evi dence: III). 32 Another recent retrospective cohort study identified that patients with more extensive fea tures (ie, Veau IV cleft palate) had significantly fewer adverse events when surgery was performed after 250 days of age, whereas infants with Veau I or II cleft palate had fewer events after 125 days of age (level of evidence: IV). 24 Coexisting Disease There is a wide variation of the incidence and prevalence of coexisting disease among neonates with cleft palate, and all presentations should be fully evaluated in the 9 to 12 months preceding typical cleft palate repair, and appro priately planned for from an anesthetic stand point. American Society of Anesthesiologists Physical Status Classification class III and IV (severe systemic disease limiting day-to-day activ ity), bronchopulmonary dysplasia/chronic lung disease, and cerebral palsy are some of the great est predictors of poor outcomes after cleft pal ate repair (level of evidence: IV). 33 In addition, if the patient has a history of prematurity, it is our institutional preference to postpone primary palatoplasty until after 1 year of age to account for both, corrected postnatal age and for the increased risk of postanesthetic apnea that can be observed up to 60 weeks postnatal in prema ture infants. Airway Anomalies Patients with cleft palate often present with concurrent airway and respiratory anomalies that must be assessed for and managed appropri ately. These are more often observed in patients with syndromic clefting and include anatomical and neuromuscular abnormality. Most patients are referred for evaluation because of the clini cal observation of snoring. Several studies have sought to characterize the incidence of sleep- disordered breathing and sleep apnea in patients with cleft palate, and have found that sleep disordered breathing is evident in 37% to 75% of patients. 34 Compared with children without clefting who also have sleep apnea, children with cleft palate were more likely to demonstrate cen tral apnea episodes, suggestive of variable mech anisms for control of breathing during sleep. 34,35 These findings have prompted clinicians to rec ommend polysomnographic evaluation for all

children with cleft palate. Other options for eval uation include nasal endoscopy and bronchos copy to assess for anatomical obstructions in the airway. Perioperatively, flexible nasal endoscopy may be considered to assist with intubation. 36 Subspecialty Anesthesia Considerations The senior author (A.K.G.) suggests that it is incumbent on the surgeon to ascertain that the anesthesia team is equipped and trained to man age the difficult pediatric airway. In resource rich environments, cleft surgery should involve an anesthesiologist with subspecialty training in pediatric anesthesia. On medical mission trips abroad, it may be more critical to use an anesthe siologist with pediatric experience than a surgeon with pediatric training. 36 Patients at high risk for respiratory collapse may benefit from opiate min imization strategies and nonopiate multimodal analgesics, such as nerve blocks and local anes thetic administration, which have been shown to provide excellent analgesia and decrease postop erative opiate use. 37 Perioperative Steroids Perioperative steroids have been used suc cessfully to mitigate airway risks such as postop erative edema and subsequent respiratory distress and have also demonstrated benefits in prevent ing postoperative fever. The standard protocol used by the senior author (A.K.G.) is 0.5 mg/kg of dexamethasone initiated preoperatively and continued for up to 24 hours. A retrospective cohort study of 118 patients undergoing Furlow palatoplasty with and without steroid use demon strated no airway distress in patients with steroid administration and comparable rates of fistulas in both groups, despite prior concerns from sur geons regarding adverse impacts of steroids on wound-healing. 38 Objectives of Repair The main objectives of cleft palate correction are to reposition velar muscles to recreate anatom ical sling and maximize palatal length to achieve functional speech and restore anatomical separa tion of oral and nasal cavities for normal feeding. Repair techniques must aim to also mitigate the risks of palatoplasty, such as avoidance of oronasal fistula formation by means of tension-free closure, avoidance of maxillary growth restriction by limit ing the presence of denuded bone, and avoiding SURGICAL TECHNIQUES

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