Plastics

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=====Dr. Khechoyan Introduction=====

  * Idaho State University, Bachelor of Science, Biochemistry - Summa Cum Laude: August 1997 - June 2001
  * University of Washington School of Medicine, Doctor of Medicine with Honors:  August 2001 - June 2005
  * Residency - Plastic and Reconstructive Surgery - University of Washington Department of Surgery: July 2005 - June 2011\\
  * Fellowship - Pediatric Craniomaxillofacial Surgery, The Hospital for Sick Children, Toronto, ON - July 2011-June 2012

Specialty: Pediatric Craniomaxillofacial Surgery and Plastic & Reconstructive Surgery

[[https://drive.google.com/open?id=14SBh3FRsWH5NVec1e9lC_sXk09DbCHWM|Recommended Papers Link]]

[[https://drive.google.com/open?id=1O-3wa-vd3CTucqa9tHpwIhbO1ayMkGsU|Dr. Khechoyan Publications Link]]

===== Operative Reports =====

General Tips:\\
Dr. Khechoyan likes to prep the patient himself. He is methodical about muscle dissection and a believer in anatomic subunits.\\
Will place mayfield himself.\\
Has a particular way of draping the head drape. Will likely drape himself.\\
Pleasant days where he will do a lot of teaching and you will do a lot of first assist.\\

====Pediatric Plastic Surgery and Craniofacial Plastic Surgery - Post Operative Home Care Instructions====

__Primary Lip Repair__ \\

{{ :resident:document_2_.pdf |Hospital Admission and immediate Post Operative Recovery Period: What to expect.}} \\

  - Your child will day overnight in the hospital following the primary cleft lip and nose repair 
  - Your child will be admitted to the Pediatric Hospitalist team. The team and Dr.Khechoyan will follow your child while in the hospital 
  - You may start feeding your child from his/her home bottle immediately after surgery as tolerated 
  - The nurses on the ward will teach you how to care the lip incision site and the nostril splint (if present) \\   * Clean the site with t Q-tip applicators dipped in normal saline \\  * Roll the Q-tip over the upper lip incision line to remove dried blood and the accumulated antibiotic ointment.                                                       
  - There is no need for "No-No's" (arm restraints) following the primary lip and nose repair. Please avoid the use of pacifiers. 
  - Criteria for Discharge \\   * Stable patient with normal vital signs and no fevers \\   * Adequate pain control with oral pain medications \\   * Adequate oral intake with formula or breast milk \\   *  Parents comfortable with incision care and feedings 
  - Discharge Medications \\   * Tylenol \\   * Oxycodone \\   * We encourage you to transition to Tylenol and off the narcotic as soon as tolerated(usually 2-3 days after surgery) 
  - Home care Instructions \\   * Clean the lip incision site daily or more frequently as needed to removed the accumulated dried blood from the incision site and the nostril conformer (splint) \\   * Clean with clean bottled water (rather than saline); roll the Q-tip over the incision site to remove dried blood and residual antibiotic ointment or vaseline, Apply topical bacitracin to the lip incision site twice daily (minimum) for 3 days. Then  discontinue the antibiotic ointment and apply Vaseline to keep the incision site moist (apply at least twice daily). \\   *  The upper lip should be cleaned as often as needed to keep the site free of dried blood and secretions. \\   * Your child may have a bath 24 hours after surgery. The lip incision site may be washed fently with run down baby shampoo and the pad of your fingertip. Rinse with tap water.
  - Follow up: Outpatient Care (will review this at the follow up clinic visit) 
  * Your child will follow up in the clinic on day 5 or 6 for a wound check and suture removal if needed. 
  * Nostril conformers will be kept in for approximately 3 month as tolerated by your child. The nose conformers are loosely stitched in place. 
  * After the upper lip sutures are removed. The lip will be taped across the incision fir 0.5 inch 3M hypoallergenic white or tan tape. The tape will be provided to you at the clinic.
  * The tape should stay on the upper lip as much as possible for the first month (night and  day) to assist with scar maturation and to prevent thickening of the lip scar. 
  * You may start scar massage of the lip incision site once the site has adequately healed. This is usually 2-3 weeks after surgery. This is done 3-4 times a day for approximately 5 thell minutes as tolerated. Apply vaseline to the scar and grasp the upper lip gently between the thumb and index finger of your dominant hand, Rub the scar the entire length of the scar up and down and in a circular motion. Most infants are fussy the first few times the site is massage but will become more tolerant over time. You may give Tylenol prior to the massage if needed for lussiness. 
  * You should continue with scar massage as above for approximately 3-6 months. If the scar becomes thickened despite massage, Dr. Khechoyan might recommend application of a silicone sheet/dressing (Cica Care) or massage using a silicone based cream (scar fade or Biocorneum). 
  * Protect the surgical site from direct sunlight by using an infant safe sunscreen and applying a hat when outside 
  * Your follow up visit should be scheduled with Dr. Khechoyan at the time of the Sheduled scheduled surgery. If you do not have a follow up appointment, please call Kathy Vavrina at 720-777-6409. If your child has a nasal conformer, it will be removed by Dr. Khechoyan at this visit. 

If you have concerns about your child after discharge home, you may call Dr. Khechoyan's office at 720-777-6409 to schedule a clinic appointment or to speak to Dr. Khechoyan, one of the nurses, or the on call provider. 


====Endoscopic Strip Craniectomy (for bilateral coronal craniosynostosis)====
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The patient was brought to the operating room where general anesthesia was induced in the usual fashion. She was positioned prone with her head on a horseshoe. Two incisions were marked, perpendicular to the coronal suture, above the superior temporal line, where the skull angles in medially.

She was prepped and draped in the usual fashion. The left incision was opened with a skin knife and then bovie electrocautery, and the loose areolar tissue was cleared away with a bovie anteriorly and posteriorly. Then, parallel marks were marked with the bovie, 1.25 cm left and 1.25 cm right of the coronal suture, parallel to the suture. The coronal suture was clearly closed. The loose areolar tissue was cleared away down to the squamosal suture and medially to the midline. This was repeated on the right side. In this fashion, we could use the endoscope contralaterally for the dissection from lateral to medial, which allows for excellent visualization.

We started bone removal on the left. We made two burr holes, one anterior and one posterior to the fused coronal suture, and connected them with a kerrison. I then cleared away the dura medially with a #1 penfield, and using the endoscope for visualization, made two parallel cuts along the suture most of the way to the fontanelle with Tessier bone scissors. I then removed that bone with large Leksell rongeurs. Once I was satisfied with bony removal, I proceeded to repeat this procedure from the burr holes inferiorly to the skull base, visualizing the middle fossa floor and the sphenoid as well.

I then repeated the whole procedure on the right side, although I was able to remove the right medial bony strip en bloc with a combination of tessier scissors and a bovie as it dissected free more easily from the dural reflection at the fontanelle. 

Hemostasis was obtained with bone wax and surgiflo through the case.

The wound was then thoroughly irrigated with antibiotic-impregnated saline. The incision was then closed with interrupted 3-0 Vicryl in the galea and running 4-0 monocryl in the skin. The hair was washed the wound was dressed with antibiotic ointment. 
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==== Nasolabial Flap ====

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op report place holder

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====Bilateral Cleft Lip Repair====
**Pending op report**\\
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====Unilateral Cleft Lip Repair with Nose/Septum Revision====
The oral cavity was cleansed with Peridex mouthwash. The face was prepared and draped in a sterile fashion. The eyes were protected with Steri-Strips. A moistened throat pack was placed in the oropharynx. Fisher subunit approximation cleft lip repair was then marked out with limb dimensions as above; the key landmark points were tattooed with 25-gauge needle and methylene blue. 

The medial lip cuts were then made with a 6700 Beaver blade with marginal tissue discarded; the overlying skin and underlying labial mucosa was then minimally undermined for a distance of 1-2 mm. We confirmed that the Cupid's bow was level, and the medial triangle opened to the planned 1.5 mm.   Accordingly, the lateral lip upper buccal sulcus incision was then made, and the lateral lip element was mobilized in a supra-periosteal plane. The abnormal attachments of the facial musculature were released off the pyriform, as were abnormal attachments of the cleft-side lower lateral cartilage.

We then turned our attention to the septoplasty portion of the operation. The caudal septum was noted to be acutely deviated to the non-cleft side. Via the medial lip incision, we were able to carefully expose the caudal septum and developed a sub-mucoperichondrial plane on the non-cleft side. The abnormal attachments of the caudal septum were then released with a Cottle elevator. The septum was then repositioned to a midline position. 

Then, the lateral lip element incisions were made with a 6700 Beaver blade, and the marginal cleft tissue was discarded. The overlying skin and underlying labial mucosa were then undermined widely in an effort to relieve all tension on the closure.

Please note that due to the significant width of this complete cleft approximately 50% of increased procedural time and effort was required to fully mobilize the lateral lip element mucosa and skin to achieve tension-free closure, justifying the application of Modifier 22. 

The lateral nasal wall lining was released within the cleft in the coronal plane by incising intra-nasally up to the inferior turbinate, allowing for anterior transposition of the cleft-side lateral nasal vestibular lining. 

Attention was then turned to the tip rhinoplasty portion of the operation. Via the superior aspect of the lateral lip element incision, we were able to dissect carefully both superficial and deep to the cleft-side lower lateral cartilage to allow for differential re-draping of the skin envelope and the vestibular lining, respectively. Given the severity of the cleft lip nasal deformity, approximately 30% of increased procedural time and effort was required to fully mobilize the intra-nasal vestibular lining and to reposition the cleft-side lower lateral cartilage (LLC) into the proper position, justifying the application of Modifier 22. 

Once this was completed and the cleft-side lower lateral cartilage was mobilized, we placed a scroll area plication suture with 5-0 Monocryl to re-drape the cleft-side LLC into the appropriate position in relation to the upper lateral cartilage. Multiple alar transfixion sutures were then also placed in a triangular configuration to re-drape the vestibular lining with 5-0 Monocryl. Several of these alar transfixion suture were placed to define the ala-cheek crease and re-drape the vestibular lining. 

Copious irrigation with bacitracin-containing solution was then applied; hemostasis was achieved with bipolar cautery. 

The nasal floor was closed by approximation of the lateral nasal lining and the mucosa on the repositioned caudal septum with 5-0 Monocryl suture in an interrupted fashion, thereby, in effect, closing the type VII naso-labial fistula in the process and separating the nasal cavity from the labial area. Care was taken to pass at least one suture through the caudal border of the septum cartilage to secure it in the midline position. 

The labial mucosa and upper buccal sulcus incisions were closed with interrupted 5-0 Monocryl suture. The orbicularis oris muscle was then carefully approximated with a 5-0 Vicryl suture, with care taken to align the nasal, labial, and marginal components of the muscle. Finally, the dermis was approximated with 5-0 Vicryl and 5-0 Monocryl suture. The nasal sill, vermilion, cutaneous triangle, and cutaneous roll were inset and closed with interrupted 8-0 Vicryl sutures. Finally, the rest of the lip was approximated with carefully placed 7-0 Prolene sutures. 

Nasal stents (size 2) were then cut to the appropriate length, introduced to each naris, and secured with a loosely tied 3-0 Prolene suture. 

The upper lip incision was then dressed with bacitracin ointment. The throat pack was removed, and the oropharynx was suctioned.  

At the end of the operation, all sponge and needle counts were correct. The patient tolerated the operation well. The patient's care was then turned over to the Anesthesia team. The patient emerged from the anesthetic uneventfully and was transported to the recovery room in stable condition. 

Resident:\\
Marking instructions: Fisher repair. Marks alar rim stopping at the mid alar point. Next marks nasal-cheek junction and stops at subalare. These two points make a line and allow placement of the nasal sill mark. This is an intersection with a bowtie semicircular line with the columellar midline and side points. Transposes these marks to the lateral side. Draws cupid bow points. Now you can measure the total lip height (TLH usually around 8), and greater lip height (GLH usually around 6). Subtract these and rose thompson effect to get the lesser lip height (LLH). Note that this is the base of the triangle. Make the backcut perpindecular to the GLH line.\\

====Cleft Lip Instructions Patient Family====

Post Operative Home Care Instructions for Dr. David Khechoyan \\

Pediatric Plastic Surgery and Craniofacial Plastic Surgery \\

Primary lip Repair \\
__Hospital Admission and Immediate Post Operative Recovery Period: What to expect__ \\
1. Your child will day overnight in the hospital following the primary cleftlip and noscream \\
2. Your child will be admitted to the Pediatric Hospitalist team. The team and Di Khechoyan will 
Tollow your child while in the hospital \\
3. You inay start feeding your child from his/her home boltle immediately after surgery as 
tolerated. \\
4. The nurses on the ward will teach you how to care the lip incision site and the nostri splint (if 
present) \\
a. Clean the site with tQ-tip applicators dipped in normal saline b. Roll the Q-tip over the upper lip incision line to remove dried blood and the accumulated antibiotic ointment. \\

5. There is no need for "No-No's" (arm restraints) following the primary lip and nose repair. Please 
avoid the use of pacifiers. \\

6. Criteria for Discharge \\
a. Stable patient with normal vital signs and no tevers \\
b. Adequate pain control with oral pain medications \\
Ć Adequate oral intake with formula or breast milk \\
d. Parents comfortable with incision care and feedings \\

7 Discharge Medications \\
a. Tylenol \\
b. Oxycodone or Lortab \\
c. We encourage you to transition to Tylenol and off the narcoticas soon as 
tolerated(usually 2-3 days after surgery) \\

8 Home care Instructions \\
a. Clean the lip incision site daily or more frequently as needed to removed the 
accumulated dried blood from the incision site and the nostri conformer (sprint) \\
b. Clean with clean bottled water (rather than saline); roll the Q-tip over the incision site la 
remove dried blood and residual antibiotic oinuent or vaseline Apply topical bacitracin to the lip incision site twice daily (minimum) for 3 days then discontinue the antibiotic ointment and apply Vaseline to keep the incision site most (apply at least twice daily). \\
c. The upper lip should be cleaned as often as needed to keep the site free of dried blood 
and sections. Your child may have a bath 24 hours after surgery. The lip incision site may be washed 
gently with run down baby shampoo and the pad of your fingerti \\

9. Lollow up: Outpatient Care \\
l. Your child will follow up in the clinic on day 5 or 6 for a wound check and suture removal 
if needed. Nostrii conformers will be kept in for approximately 1 month as tolerated by your child. 
The rose conformers are loosely stitched in place. ( Alter the upper lip sulires are removed. The lip will be taped across the incision fir 0.5 inch 3M hypoallergenic white or tan tape. The tape will be provided to you at the clinic visil \\
d. The tape should stay on the upper lip as much as possible for the first month (night and 
day) to assist with scar maturation and to prevent thickening of the lipscal You may start scar massage of the lip incision site once the site has actequately healed This is usually 2-3 weeks after surgery. This is done 3-4 times a day for approximately 5 minutes as tolerated. Apply vaseline to the scar and grasp the upper lip gently between the bumb and index finger of your dominant hand, Ruby the scar the entire length of the seal and down and in a circular motion. Most infants are fussy the list low times the site is massage but will become more tolerant over time. You may give lylento por to the massage if needed for lussiness. You should continue will scar massage as above for approximately 3-6 months. If the Scul becomes thickened despite massage, Dr. Khechoyan might recommend application of a silicone sheet/dressing (Cico Care) or massage using a silicone based cream (scar fade or Biocomeum). Protect the surgical site from direct sunlight by using an infant sale sunscreen and 
applying a hat when outside \\
h. Your follow up visit should be scheduled with De Khechoyan at the time of the 
scheduled surgery. If you do not have a follow up appointment, please call Kathy Vavrina at 720-777-6409. \\

If your child has a nasal conformer, it will be removed lry Dr Khechoyan at the visit \\
If you have concerns about your child after discharge home, you may call De Khechoyan's office at 720-777-6409 to schedule a clinic appointment or to speak to Do Khechoyan, one of the nurses, or the on call provider. \\

====Rhinoplasty (for cleft lip revision) with Rib Graft====
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The proposed excision was marked out as a lenticular excision with a fine marking pen. Local anesthetic, 0.25% bupivacaine with 1:200,000 epinephrine was infiltrated into the proposed surgical site(s), with appropriate weight-based dosing. The surgical site was prepared and draped in a sterile fashion. The eyes were protected with eyelids taped down with Steri-Strips. 

The operation began with the rib cartilage graft harvest from the right chest. An approximately 4-cm in incision was made in the right infra-mammary fold with a 15-blade, and dissection proceeded down through the subcutaneous tissue, superficial fascia with monopolar cautery down to the deep fascia, which was in turn incised. The rectus abdominis muscle was split along its fibers, and the perichondrium of the 7th rib was incised and dissected circumferentially around the rib cartilage. The rib cartilage graft was then harvested from costochondral junction to sternochondral junction. The deep perichondrium was intact. Irrigation was instilled, and a Valsalva maneuver confirmed absence of a pleural injury, with no air leak or bubbling. The cartilage graft was stored in saline-soaked gauze. The surgical site was irrigated and closed in layers, in a standard fashion. A sterile dressing was applied.

Attention was then turned to the nose. The nasal cavity was packed with Afrin-soaked cottonoids. The nasal tip and columellar incision were infiltrated with 1% lidocaine with 1:100,000 epinephrine, with weight-based dosing. A stair-step columellar incision was made with a 6700 Beaver blade and continued bilaterally as infra-cartilaginous incisions. The nasal envelope was dissected off the underlying cartilaginous network. Please note that this was the patient's third rhinoplasty, with the most recent one performed by me with rib cartilage graft; there was excess scar tissue, which rendered the elevation of the nasal skin envelope more challenging and time consuming. The nasal envelope was successfully lifted up with no perforations of the skin and intact, preserved perfusion. The dorsum cartilaginous and bony hump was reduced with rasps and smoothed out. The lower lateral cartilages (LLCs) and upper lateral cartilages (ULCs) were split in midline and reflected off the septum. The previously placed bilateral spreader grafts, columellar, and septal extension grafts were removed. The mucosa was reflected off the septum. The caudal portion of the septum was shortened to allow repositioning to the midline, and better midline position of septum was noted. New bilateral spreader grafts were carved from the newly harvested cartilage graft and sutured in place with 5-0 PDS suture, with improved width of the mid-vault and improved straightening of the septum in this region. A new columellar graft was carved and sutured in place with 5-0 PDS suture, incorporating and equalizing the medical crura of the bilateral LLCs. Dome defining and dome equalization sutures were placed with 5-0 PDS suture. Finally, stacked transverse (rectangular) tip grafts were carved and sutured in place to improve nasal tip projection. Transfixion suture was placed with 4-0 Chromic suture to hold the caudal septum and medial crura in midline position. The skin envelope was reflected, and we noted a more straight nasal tip and mid-vault, as well as improved nasal tip projection and definition. Copious irrigation was applied; hemostasis was achieved. The columellar incision was closed with 5-0 Monocryl in the deep dermal layer, followed by interrupted 6-0 Prolene sutures. The intra-nasal portions of the incision were closed with interrupted 5-0 Chromic sutures. No nasal osteotomies were performed. No Doyle splints were placed. The nasal incisions were dressed with topical bacitracin ointment. Steri-strips and Aquaplast splint was then applied to the dorsum and tip for edema control. Please note that Modifier 22 applies to this operation given the fact that this operation is the third reconstructive operation to correct cleft lip nasal deformity for this patient. Approximately 75-100% of increased procedural time and technical effort was required to achieve a safe, reliable reconstruction. 
  
The eyes were irrigated with BSS. 
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**Setup:** 
  * Has nurses place 3x Mepilex on patient in pre-op area (sacrum and bilateral shoulders)
  * Headrest 
  * Patient shoulders to the edge of the table 
  * In females, mark the IMF on side of rib graft donor site. Then mark 1-2mm below the IMF to mark where incision will be. 
  * Place tegaderm over the ETT after it is taped in place
  * Place silk tape over eyes 
  * Throat pack goes in before prepping 
  * Preps nasal cavity with qtips and betadine 
  * Prep oral cavity with Peridex and brush teeth 
  * Prep patient face with betadine, rib graft site with CHG - prep in the ears/neck and have a continuous sterile field between face and rib graft site

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====Khechoyan’s Orthognathic Pathway==== 
(this is preliminary and may change, but at least gives you an overview)

MEDICATIONS: 
 
IV unasyn while in house; augmentin (high-dose, 875 mg) po BID for 2 weeks; substitute clindamycin if penicillin allergic. 
 
Peridex mouthwash four times a day for 6 weeks. 
 
Oxycodone for pain on discharge. 
 
DIET: 
 
Clear liquid diet for 48 hours in the hospital. 
 
Then, blenderized (full liquid diet) for 2 weeks thereafter; nutrition consult in hospital. 
 
Soft (no chew) diet after 2 weeks until 8 weeks post-op (6 weeks total). Diet restriction for a full 8 weeks. 
 
IMAGING: 
 
On discharge, patients will go from main hospital to Dental Center for Panorex, lateral cephalogram and PA cephalogram xrays. Maureen and Tracy/Alma will need to communicate close to day of discharge to coordinate/arrange this. 
 
ELASTICS: 
 
Elastics will be initiated in hospital on POD#1 based on recommendations by Dr. Lowe. 
Maureen will teach patients on elastics application/wear in hospital. 
 
DENTAL HYGIENE and ORAL/LIPS CARE: 
 
Peridex QID
Full glass of water after every meal. 
Peridex after every meal, swish and spit. 
Vaseline to upper and lower lips QID. 
Hydrocortisone 1% cream to upper and lower lip BID while in hospital. 
May brush teeth with soft pediatric tooth brush twice a day starting on POD#2. Avoid brushing close to gingiva or sutures. 
 

ACTIVITIES & RESTRICTIONS: 
 
No sports or exercise or strenuous activity for 8 weeks post-operatively. 
Sleep with head of bed elevated at 45 degrees for 2 weeks post-operatively. 
Ice packs to face for first 72 hours: 30 minutes on/30 minutes off. 
 
 
FOLLOW-UP VISITS: 
 
1 week post-op with Dr. Lowe for dental hygiene/irrigation with dental assistant and check on healing and initiation of elastics. 
Weekly or every 2 weeks follow-ups with Dr. Lowe at her discretion to continue post-operative elastics care. 
 
1 week post-op with Maureen for check on healing, oral hygiene, etc. 
2-3 week post-op visit with me AND Maureen together (or sooner if there are concerns re healing or occlusion). 
6-8 week follow-up visit with me AND Maureen together

====Cleft Physician Preference====

__**Cleft Lip	**__\\
**Antibiotics	**No (intraop)\\
**Bottle	**yes\\
**Restraints	**no\\
**Spoon Feeding	**yes\\
**Pain Medications**\\	
**Tylenol**	yes\\
**Motrin**	yes\\
**Oxycodone** yes\\
**Lortab	**yes\\
**Length of Stay	**1 day typical\\
**Incision site car**e\\	
**Glue	**no\\
**Stiches**	yes\\
**Tape	**NO\\
**Nutritional Consult	**Yes\\
**Follow up	**1-2 weeks/then 1 month\\
	
__**Cleft Palate	**__\\
**Antibiotics**	intraop\\
**Bottle**\\	
**Restraints	**yes x 3 weeks\\
**Spoon Feeding	**yes sideways\\
**Type of feeding** 	blenderized x 2 weeks and then soft x 2 weeks.\\
__Pain Medications\\	__
**Tylenol	**Yes\\
**Motrin	**NO\\
**Oxycodone**	Yes\\
**Lortab	**NO\\
**Length of Stay**	Depends on po\\
**Incision site care**\\	
**Dissolvable sutures	**yes\\
**Nutritional Consult	**yes if able\\
**Oxycodone	**yes\\
**Lortab**	no\\
**Length of Stay	**depends on po\\
**Nutritional Consult pre discharge**	yes\\
**When they can go back to ST	**4 weeks\\
**Follow up	**1 we; 1 mo\\
	
__**Ear Tubes	**__\\
**Follow up** 	per ENT\\
**Antibiotics	**\\
**Drops/Duration	**\\
**Swimming/Ear submersion	**\\
**Drainage**	\\
**Automatic renewal of Drops with Drainage	**\\
**Follow up audio	**\\
	
__**Pharyngeal Flap	**__\\
**Antibiotics	**home on po 7-10 days\\
**OTC medications**\\	
**Tylenol	**yes\\
**Motrin	**Check with him case by case\\
**Oxycodone**	yes\\
**Lortab**	no\\
**Diet Restrictions	**Blenderized x 2 and soft 2-4. \\
**Follow up	**7-10 days; then 4-6 weeks. \\
**When to resume speech	**1 month\\
**Activity Restricitons	**2 weeks for all and 1 month for contact. \\
**? Automatic referral to VPI	**No\\
**Length of stay**	1-2 nights\\
	
__**Alveolar Bone Graft	**__\\
**BMP	**No\\
**Iliac Crest	**Yes\\ 
**Pre-op Panos/Peri apical**	yes w/in 3-4 mo\\
**Post-op Panos/Peri apical	**yes at 3 mo\\
**Cone Beam	**yes if available\\
**Follow up	**7-10 days; 4-6 weeks\\
**Diet restrictions	**\\
**OTC medications**	\\
**Tylenol	**yes\\
**Motrin	care dependent**; no if raw surfaces\\
**Oxycodone	**Yes\\
**Lortab	**?\\
**Mouth rinse (peridex)	**yes qid x 4-6 weeks; also rinse with H20\\
**tooth brushing	**Not at surgical site for 4-6 weeks\\
**Activity restrictions	**No contact 4-6 weeks\\
**nutrition consult/teaching prior to d/c	**yes\\
	
	
?restraints for 2 or 3 weeks\\	
**Dr D prefers no motrin x 7 days	\\
***will discuss when has more pts in this age range	\\
	
Updated: 1/17/19  MSA	

====Cleft Palate Repair====

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Operative Report:\\
1. Cleft Palate Repair:\\
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The patient and the patient's family were met in the pre-operative area. The risks, benefits, details, and alternatives were discussed; all questions were answered. The surgical consent was acquired.  

The patient was brought into the operating room and laid supine on the operating room table. General anesthesia was induced. A pre-operative intravenous dose of antibiotics was administered. 
 
A time-out was performed during which we identified the operation and the operative site. All team members introduced themselves. All issues and concerns were discussed and resolved before proceeding with the operation. 
 
The oral cavity was cleansed with Peridex mouthwash. The nasal cavity was cleaned with q-tips and betadine. The face was prepared and draped in a sterile fashion, after the eyes were protected with Tegaderms. 
 
The Dingman mouthgag was introduced, and a tongue suture was placed through the tip of the tongue with a 2-0 Silk Suture. The cleft marginal and lateral relaxing incisions were designed, and the palate was infiltrated with weight-based dose of local anesthetic (0.25% bupivacaine with 1:200,000 epinephrine). The oral cavity and nasal cavity were then copiously irrigated with saline solution. 
 
The uvulae were further distended with tumescent sterile injectable saline solution, and incised along the medial, cleft margins with a 6700 Beaver blades. The incisions were continued anteriorly along the cleft margin on both sides, along the soft and hard palate, all the way to the alveolus anteriorly for bilateral palatal shelves. 

The lateral relaxing incisions were made with a 6700 Beaver blade down to bone bilaterally. 

LEFT-sided Veau-type mucoperiosteal unipedicled mucoperiosteal flap and RIGHT-sided bipedicled flap were then elevated with a Freer elevator (Clarke hybrid cleft palate repair). This dissection was carried posteriorly and converted to a sub-mucosal plane, where the oral mucosa and submucosa were elevated off the nasal component of the tensor veli palatini (TVP) muscle fascia laterally. This was done bilaterally, and the oral lining was elevated widely off the nasal lining and the velar musculature. The flaps were liberated widely and isolated on the greater palatine artery pedicle, which was in turn circumferentially dissected on both sides.
 
The nasal lining was then released off the medial aspect of the medial pterygoid plate and gently stretched bilaterally. 
 
The nasal lining was then elevated off the palatal shelves bilaterally and septal (vomer) lining in the midline. 
 
As part of soft tissue closure of the alveolar ridge, the nasal lining was elevated anteriorly to and past the alveolar ridge. An axial plane incision was then made at the alveolar ridge soft tissue and the nasal flaps were reflected superiorly. 
 
The nasal lining of the soft and hard palate was then closed with interrupted 4-0 Vicryl. 
 
The uvula was closed on its nasal and oral aspects with interrupted 4-0 Vicryl suture. Hemostasis was achieved with application of Surgiflo and bipolar cautery. 
 
As soft tissue closure of alveolar ridge, the nasal lining was reflected superiorly and separated from the oral lining. The nasal lining was closed at the alveolar ridge with a 4-0 Vicryl suture. 
 
The operating microscope was then brought in for dissection of levator veli palatini (LVP) muscles and intra-velar veloplasty on both sides. 

The velar musculature was treated with topical epinephrine solution (1:50,000). 
 
On the left, the plane of dissection proceeded down to the nasal lining, where the nasal component of the tensor veli palatini (TVP) was incised along the posterior hard palate edge. The nasal component of the tensor veli palatini (TVP) and palatopharyngeus muscles were sequentially released with microsurgical scissors, until access was gained to the LVP tunnel on the left. The left LVP muscle was then separated widely with dissection away from nasal lining, nasal component of TVP, and off the superior constrictor muscle all the way toward its hilum at the skull base, preserving its blood supply from the ascending palatine and ascending pharyngeal arterial systems. The left LVP muscle was dissected along 360 degrees of its complete circumference with preservation of its blood supply at hilum. 
 
On the right side, the plane of dissection proceeded down to the nasal lining, where the nasal component of the tensor veli palatini (TVP) was incised along the posterior hard palate edge. The nasal component of the tensor veli palatini (TVP) and palatopharyngeus muscles were sequentially released with microsurgical scissors, until access was gained to the LVP tunnel on the left. The left LVP muscle was then separated widely with dissection away from nasal lining, nasal component of TVP, and off the superior constrictor muscle  all the way to its hilum at the skull base, preserving its blood supply from the ascending palatine and ascending pharyngeal arterial systems. The left LVP muscle was dissected along 360 degrees of its complete circumference with preservation of its blood supply at hilum. 
 
Please note that there were no areas nasal lining perforations or attenuation at the completion of the dissection bilaterally. The nasal lining was completely intact and well vascularized as a single sheet of tissue joined in the midline. 
 
The right and left velar muscle bundles were then united in the midline with multiple 4-0 Ethibond sutures, with knots tied securely and suture ends cut short. Care was taken to pass the suture needle through the LVP muscle with each suture pass. The levator sling was thus re-created; the sling felt solid and was tensioned appropriately on digital palpation. The palatopharyngeus muscle was approximated with 4-0 Vicryl suture after appropriate overlap of the muscle. 
 
Copious bacitracin-containing irrigation was then applied. Hemostasis was achieved. 
  
To augment soft tissue closure at the LEFT relaxing incision,  a LEFT buccal fat pad flap was harvested in a standard fashion, as adjacent tissue transfer (total area: 12 square centimeters). A very small 3-mm incision was made posterior to the maxillary tuberosity with needle tip cautery. The buccinator muscle was gently spread along its fibers posterior to the maxillary tuberosity to gain access to the buccal fat pad. The fat pad was gently extracted with two smooth forceps and draped into the LEFT lateral relaxing incision and pulled anteriorly to the alveolus. The recipient site was prepared as wound preparation by mobilization and inset of the unipedicled Veau flap anteriorly and medially, which left a large, wide recipient site laterally, which was defined, irrigated and underwent hemostasis as wound preparation. The fat pad flap was then inset with a combination of 4-0 Vicryl suture to completely fill in the dead space within the relaxing incision and augment the soft tissue closure at the alveolus. 
 
To augment soft tissue closure at the soft-hard junction, in order to prevent an oro-nasal fistula at this location, a RIGHT-sided buccal fat pad flap was harvested in a standard fashion, as adjacent tissue transfer (total area: 12 square centimeters). A very small 3-mm incision was made posterior to the maxillary tuberosity with needle tip cautery. The buccinator muscle was gently spread along its fibers posterior to the right maxillary tuberosity to gain access to the buccal fat pad. The fat pad was gently extracted with two smooth forceps and draped deep to the bipedicled flap and passed from lateral to medial. The recipient site was prepared as wound preparation by further suturing and uniting the nasal submucosa, defining the defect, as well as irrigation and hemostasis as wound preparation. The fat pad flap was then inset with a combination of 4-0 Vicryl suture to completely fill in the dead space anterior to the reconstructed velar musculature. 
 
Please note that the two areas of buccal fat pad flap reconstruction were two completely distinct and separate surgical sites. 

As part of oral soft tissue closure of the maxillary alveolus, the left-sided Veau flap was advanced and its most anterior aspect was advanced and in-set with 4-0 Vicryl suture medially and anteriorly.  The LEFT-sided buccal fat pad flap was also utilized to augment the soft tissue closure of the right maxillary alveolar cleft. 
 
The oral lining was then closed with 4-0 Vicryl suture in simple interrupted fashion. The LEFT unipedicled Veau flap and bipedicled flap from the RIGHT were then united in the midline and  re-suspended to the alveolus anteriorly and laterally with 4-0 Vicryl suture. 
 
Bilateral oral lining flaps were well-perfused, pink, with normal capillary refill on both sides. The raw lateral relaxing incision areas was packed on the RIGHT with  Surgicel hemostatic material, which was secured with 4-0 Vicryl suture at two sites to prevent dislodgement. 
 
The Dingman mouthgag was removed. The oropharynx was suctioned. Lips were dressed with bacitracin ointment. The tongue stitch was taped to the cheek with Steri-Strips. 
 
A size 16 nasal trumpet was cut to size and introduced into the RIGHT (non-cleft) nostril and secured in place with a 2-0 Silk tie and taped to the cheek. 
 
Please note that Modifier 22 applies to the cleft palate portion of operation as increased procedural effort and time was required to achieve tension free cleft palate repair in this patient with complete, wide cleft palate. Also, complete, radical intra-velar veloplasty was performed bilaterally with microscope-assisted dissection utilizing microsurgical technique with preservation of the blood supply to the levator veli palati muscle bundles bilaterally. This required approximately 75-100% of increased procedural time and effort to achieve safe and complete dissection. 

At the end of the operation, all sponge and needle counts were correct. The patient tolerated the operation well. The patient's care was then turned over to the Anesthesia team. The patient emerged from the anaesthetic, was extubated and was transported to the recovery room in stable condition. 
  

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Anatomy:(Reported from Amboss)
Hard Palate: Receives blood from greater palatine artery (branch of descending palatine artery which comes from maxillary artery).
Innervated by greater palatine and nasopalatine nerves (branches of maxillary N)

Soft Palate: 
Blood supply- ascending palatine A from facial A. 
Palatine branches of ascending pharyngeal A and lesser palatine arteries.
Lesser palatine nerve does secretomotor, sensory and taste. Vagus N does motor\\

Attending Pearls: 
Cleft Lip

Failure of medial nasal process and maxillary prominence to close at 4-6 weeks of gestation
anterior to incisive foramen (IF)
problems: Can’t form fluid air seal which causes issues with speaking and eating, cosmetic and malocclusion of teeth
Van der Wounde’s syndrome
Repaired at 2-3 months, Millard Rotation-advancement

Cleft Palate

Primary: anterior to IF, failure of medial and lateral palatine processes to fuse
Secondary: posterior to IF: failure of lateral fusion at 7-12 weeks
Problems: can’t suck properly for feedings, middle ear infections, velopharyngeal insufficiency (air escapes during speech)
DiGeorge and Stickler Syndrome
Repaired at 9-15 months of hard and soft palate, then nasal and CL revisions at around 3 y/o, alveolar cleft bone grafting at around 7, around 16 orthognathic surgery to fix malocclusion of teeth and around same time can do formal rhinoplasty:\\

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====Sagittal strip craniectomy with biparietal morcellation====
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The patient and the patient's family were met in the pre-operative area. 
The surgical site was marked with the surgeon's initials. 
The risks, benefits, details, and alternatives of the operation were discussed in detail. All questions were answered. The informed consent for surgery was signed by parent/guardian. 

The patient was brought into the operating room and laid supine on the operating room table. General anesthesia was induced by the Anesthesiology provider. A pre-operative intravenous dose of antibiotics was administered. 
 
A time-out was performed during which we identified the operation and the operative site. All team members introduced themselves. All issues and concerns were discussed and resolved before proceeding with the operation. 
 
The eyes were protected with Tegaderm tapes. 
 
A bicoronal sinusoidal incision was designed from ear to ear and infiltrated with local anesthetic; local anesthetic, 0.25% bupivacaine with 1:200,000 epinephrine, was infiltrated into the proposed surgical site(s), with appropriate weight-based dosing. The hair around the incision was minimally shaved. 
 
The surgical site was prepared and draped in a sterile fashion. 
 
The incision was made with a 15-blade and monopolar cautery down through the galea; wide, bidirectional sub-galeal undermining and scalp mobilization was performed to expose the cranium from frontal to occipital bones. The sagittal suture was noted to be fused; the metopic, bilateral coronal and lamboid sutures were noted to be open. 
 
Three pairs of parasagittal burr holes were made along the planned parasagittal cuts from the anterior fontanelle to the lambda. 
  
A 3-cm strip craniectomy centered over the fused sagittal suture was then performed from anterior fontanelle to the lambda, after burr holes were made and the dissection proceeded across the midline and bone was removed across the midline with Kerrison rongeurs; there were no dural tears, and the patient remained hemodynamically stable. 
 
As bilateral frontal cranioplasty and remodeling, a caudally-based barrel stave (approximately 2 cm in width) straddling the open RIGHT coronal suture was cut with a craniotome, dissected off the dura, out-fractured as a green-stick fracture with a Tonsil clamp, and contoured into the appropriate more rounded shape with a Tessier elevator. 
 
Then, a caudally-based barrel stave (approximately 2 cm in width) straddling the open LEFT coronal suture was cut with a craniotome, dissected off the dura, out-fractured as a green-stick fracture with a Tonsil clamp, and contoured into the appropriate more rounded shape with a Tessier elevator. 
 
Then, bilateral, extensive parietal morcellation cuts were designed and then cut with a craniotome in a brick-type pattern, spanning an expanse of 6.5 to 7.0 cm from parasagittal edge of the sagittal craniectomy to the superior temporal crest, with two bone graft (flaps) caudally and three bone graft (flaps) toward the midline. These extensive bone grafts were retained with their attachment to dura and secured in placed with a Surgicel. This was done on the right side first, and then the left side. 
  
A 7-French flat Jackson-Pratt drain was placed through the RIGHT occiput. 
 
Copious irrigation was applied with at least 1 liter of normal saline; hemostasis was noted. The scalp was then closed in layers, with 3-0 Vicryl for the galea layer, followed by a running 4-0 Monocryl suture on the surface; bacitracin was applied to the incision. 
 
Please note that Modifier 22 applies to all components of this operation as significantly increased operative time and technical effort were required to safely achieve all steps of this operation. This was primarily because of thicker bone in the bilateral parietal and frontal regions, which rendered every part of the operation more challenging, including, but not limited to, making burr holes, craniotomy cuts, and reshaping of the barrel staves, among other steps. These circumstances and findings justifies the application of Modifier 22. 
 
At the end of the operation, all sponge and needle counts were confirmed to be correct. 
The patient tolerated the operation well. 
The patient's care was then turned over to the Anesthesia team. 
The patient emerged from the anesthetic uneventfully and was transported to the recovery room in stable condition. 

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