Plastics

Children's Faculty
Dr. Brooke French
Dr. David Khechoyan
Dr. Leahthan Domeshek

Important phone numbers:
Peggy Walsh: 713-320-9063
Maureen Andrews: 303-929-7929
Amy Circle: 970-310-7745
OR charge: 64890
ED: 76888
One call: 73999

How to see who's on call: either call One Call or go to children's webpage, click on quick links, then amcom.

Important rooms: There's a surgeons lounge on the 1st floor right when you walk in from the parking garage with food and drinks. There's a faculty respite room in the hallway leading up to the outpatient building on the 1st floor that has comfortable seats and 6 computers/phones and a printer.

Expectations: OR takes precedence over clinic. However, if you are not in cases, you are expected to attend clinic. If simultaneous cases, I would cover cases in order of seniority (Dr. French's cases covered first, then Khechoyan, then Domeshek). Of course, if one of the more junior attendings is doing a really cool case, I'd talk to French about covering those instead.

Consenting: Children's is all electronic consents. In order to make a consent, you click on the pre-op consult tab in Epic and then click consents. To make a consent - you click on procedure #1 (or 2 or 3 if it's a combo case) consent (or something like that) and fill in the correct information in the boxes on the right. .momsname or .dadsname in the first box and then whatever parent (or patient) is signing for the kid. This has to be accurate and only have one parent's name, they will hold a case indefinitely if this is done incorrectly. You can add extra procedures and whatnot in those boxes on the side. And then fill in your name as the person obtaining the consent. Often the procedure and stuff will already pre-populate. If you're consulted for a spine closure or something, you'll have to type in all the stuff yourself. After you did all that, you can either have the parents sign on the computer, or on the patient's ipad. To log into the ipad you put in the patient's DOB (mmddyy). Click submit after you and the patient have signed the consent. The attending can sign the consent when they're back in the OR.

Rounding: I ended up seeing everyone myself in the morning and writing everyone's notes. In the past, it sounds like the fellows have left the notes to Peggy and Maureen, but ever since that meeting we had a couple of months ago, it's clear that the attendings don't like that. - After rounding - I would text both the attending covering the patient and Peggy for general plastics kids or Maureen for the craniofacial cleft kids.

Craniofacial kids: ● Maureen is an awesome resource. She ends up seeing everyone herself too, and will write her own little note. She'll also check in with people postop. I would text her whenever we finished a craniofacial or cleft case so she would know how it went. She provides teaching to all the families while in house, and is their main point of contact after they get discharged. If she's ever not there, you can get the teaching handouts for patients on discharge on the children's webpage - resources - patient hand outs. ● If you put in distractors, French usually likes to teach the parents pretty quickly on how to turn the distractors themselves. However, for the first day or two, you and Maureen are responsible for distractions. Typically, I'd let her do the morning distraction with the parents and I did the PM distraction. ● All of the craniofacial kids are neurosurgery primaries postop. They are responsible for drains and everything. The only thing we are responsible managing are distractions. ● Consents - these cases are always booked under the neurosurgery attendings. The neuro fellows are usually slammed in the mornings, so I would be the one doing the consents there. All the kids need a regular procedural consent as well as a transfusion consent. The plastics attendings are typically not on the consents. We've established this is okay because they're co-surgeons on the same procedure. If they were doing different procedures, plastics would need their own consent.

Cleft cases: ● Maureen helps to manage these too. ● They typically stay in house only one night. If you type in “plastics” in the post op order sets, there're pre-populated ordersets for each type of cleft case. ● For Dr. Khechoyan - if they are a syndromic kid who is getting a palate repair, they go to the PICU postop (French's kids all typically go to the floor). Khechoyan will also do a tongue stitch and sometimes a nasal trumpet sutured in that you have to remove the next morning. This is super fun.

Orthognathic cases: ● Khechoyan has a big postop pathway, see separate document.

Clinic: ● The clinics are on the second floor of the outpatient side of the hospital. Hallway B tends to be where all the general plastics patients are, there's a work room in the back hall that we share with gyn and ID. Multi-D clinics are behind these. Sometimes you're in the clinics at one end of the hallway, sometimes you're in clinics on the other end of the hallway. ● There are several multidisciplinary clinics that we attend: craniofacial, cleft, brachial plexus, vascular malformations. These are kind of weird clinics where you just stand in the background and observe. I didn't pre-see patients or write notes in these clinics. They're educational, but you don't do much. side note: Khechoyan showing up to his multi-d clinics, at least for me, has been hit or miss. If he wasn't there, I wouldn't stay. ● Plastics clinic- you're expected to see the patients yourself and then staff them like we usually do. We also write the notes, like we usually do. ● Amy Circle is the go-to person for outpatient plastics stuff. She'll also help you with wound care stuff on the floor if you ask her. ● Sometimes you'll get called by Amy to help with the odd clinic patient (usually for tissue expander fills, steroid injections, vac changes, etc.)

Consults: ● We are now first call for all consults (face, gen plastics, wound). If you're slammed, Peggy is happy to help with these too. I've asked her to take care of wound care consults in the past, since she's the one who does the outpatient wound care anyway. ● Wound care consults: you'll sometimes get weird consults from wound care to establish care prior to a patient's discharge. Typically I just go see them then say continue whatever wound care recs the inpatient wound team has recommended and then set them up to see Amy and Peggy as an outpatient. It's totally reasonable to have Peggy see these too, since she'll be the one seeing them as an outpatient.

Admitting complex patients to medicine: This is a new thing for me. If there's a complex medical patient coming in (read: Maxwell Harmon) or if you want to have a patient stay overnight from the ED (I've done this for lip hematomas and stuff that we may or may not operate on), you can have medicine admit them. They usually don't put up much of a fight. You call the One Call people and then select admissions/transfers and they'll connect you to the admitting attending and senior resident to discuss the admission.

• 1 week before surgery:

1. Peridex rinses 4x per day
2. Wear splint as much as possible. Practice eating with it so it is comfortable after surgery

• First five days after surgery:

1. Continue Peridex rinses 4x per day
2. Do not remove splint for the first five days after surgery. No exceptions.
3. Lower teeth may be brushed normally

• After 5 days post-op:

1. Continue Peridex rinses 4x per day
2. Continue full time splint wear, including during meals
3. Splint may be removed for oral hygiene:

• Continue brushing lower teeth normally
• Upper back teeth may be brushed normally with caution around stitches
• Clean teeth near surgical site carefully with gauze or a wet cotton swab

Before the Surgery:

• Your child’s surgeon will talk to you about the best surgery for the bone graft.
• Please don’t give your child any ibuprofen products (Motrin®, Advil®) for 10-14 days before the surgery.
• 2-3 weeks before the surgery, we’ll schedule you with the craniofacial orthodontist for any presurgical x-rays that your child needs and to take an impression to make a bone graft splint for your child to wear after surgery. If you don’t have an appointment, please call 720-777- 3749. We will also schedule a Maxillary CBCT scan to assess alveolar bone graft take.
• The orthodontist office will call to schedule this visit. Should you not hear from their office, please call 720-777-3749 to schedule your appointment.
• One week before the surgery we’ll schedule your child to see the craniofacial orthodontist to have the bone graft splint fitted to their mouth. Please have you child wear the splint as much as possible and practice eating with the splint so it is comfortable after surgery.
• One week before the surgery we’ll prescribe a medicated mouth rinse called Chlorhexidine (Peridex) for your child. They should begin oral rinses at that time. Rinse with 10 ml (two teaspoons full) after all meals and at bedtime.
• A Surgery Scheduler will call you a few days before surgery to let you know when your child can no longer have anything to eat or drink, what time to arrive, and the scheduled time of surgery.
• If your child is sick anytime during the week before surgery, please call the nurses in the Cleft Lip and Palate Program, to make sure the surgery doesn’t need to be rescheduled. The nurses are available Monday through Friday for any concerns/questions you might have before the surgery.

After the Surgery:

• Your child will be watched closely in the Post Anesthesia Recovery Unit (PACU) for 1-2 hours after surgery. As soon as your child is awake, the PACU nurse will call you to join them.
• Your child will usually stay in the hospital for 1-2 nights. Parents/guardians can stay in the room with their child.
• Each room is a private room with its own bathroom. Parents/guardians should remember to bring their own clothes to sleep in as well as toiletries.
• We recommend that you find childcare for siblings while your child is in the hospital.

Types of Bone Graft Procedures:

• Bone Morphogenic Protein (BMP): If BMP was used to fill the cleft, the upper lip and cheek can be very swollen for the first 2-3 days after the surgery. The swelling can last up to a week after surgery. This is normal. Keeping your child’s head raised and putting an ice pack on the face may help with the swelling.
• Iliac Crest Donor Site: If bone from the hip was used to fill cleft, the upper lip and cheek can be very swollen for the first 2-3 days after surgery. The swelling can last up to a week after surgery. This is normal. Keeping your child’s head raised and putting an ice pack on the face may help with the swelling.

1. For the first 2 days after surgery, your child should only have a sponge bath to keep the donor site (hip) dressing clean and dry. After the first 2 days, the dressing on the hip can be taken off. Please leave the Steri-strips on and let them to fall off on their own.
2. It’s normal to have a bruise at the donor site. It should go away in 10 to 14 days. Your child may use an icepack to help with pain if needed.

Mouth Care:

1. Don’t let your child drink through a straw.
2. Continue using the Peridex mouth rinses as prescribed, rinsing 4 times a day.
3. Do not remove the mouth splint for the first 5 days after surgery—NO EXCEPTIONS.
4. Your child can brush their lower teeth as usual. Don’t brush the upper teeth.
5. After 5 days from surgery:

• Continue with Peridex mouth rinses 4 times a day. The mouth rinses will continue for 4 weeks after the surgery.
• Continue full time splint wear, including during meals.
• Only remove splint for oral hygiene (performed or supervised by parents, when possible).
• Continue brushing lower teeth normally.
• e. Clean teeth near the surgical site carefully with gauze or a wet cotton swab. Rinse with water after cleaning.
• Brush splint with a toothbrush and warm water to remove food and plaque before putting it back in the mouth.

Feeding after Alveolar Bone Graft Surgery: Your child will have an IV (tube in a vein) to give them fluids and medicines, while they are in the hospital.

• 1-3 days after surgery, your child should go back to drinking the same amount of liquids as they were drinking before the surgery.
• For _ weeks, your child will be on a pourable liquid or blenderized diet. A pourable liquid diet includes anything you can put in a blender and add enough liquid to make it a pourable consistency. We suggest you add liquids that are high in calories such as cream, whole milk, regular chicken/beef stock.
• After _ weeks, your child can start eating a soft diet. A soft diet includes foods that aren’t crunchy, hard or sharp and can be eaten with little biting or chewing. Examples are baby food, soft, over-cooked pasta, scrambled eggs, soft cooked veggies, and ground or finely chopped meats. Avoid spicy foods, foods with seeds, crunch or hard foods, chewy or sticky foods such as caramel, taffy or gum.

Safety: It’s very important to protect the gum line/incisions while they are healing. The stitches will dissolve on their own. It will take about six weeks for the surgical site to heal completely. Your child needs to take care not to injure the surgical area. Your child should only do quiet activity for at least 3-4 weeks. No contact sports for 4-6 weeks.

Author: Cleft Lip and Palate| Approved by Patient Education Committee | Valid through 2021 The information presented is intended for educational purposes only. It is not intended to take the place of your personal doctor’s advice and is not intended to diagnose, treat, cure or prevent any disease. The information should not be used in place of a visit, call or consultation or advice of your doctor or other health care provider. Children’s Hospital Colorado complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. • ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-720-777-1234• CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-720-777-1234.

Medicines after Surgery: Your child will usually go home on acetaminophen (Tylenol®) as well as a narcotic pain medicine like oxycodone. Depending on your child’s surgeon, your child may be able to use ibuprofen (Motrin®, Advil®). If your child is prescribed ibuprofen, you may be able to give your child both acetaminophen and ibuprofen, alternating the doses. Your child will also go home with Peridex to be used for 4 weeks after surgery and possibly an oral antibiotic for 1-2 weeks after surgery.

Call with Any Questions/Concerns, or if your child:

• Has an injury to either surgical site-mouth or hip.
• Has redness, swelling or drainage or a foul odor from the mouth.
• Is bleeding a lot from the nose or mouth.
• Has a fever above 101.5°F for more than 24 hours that Tylenol or ibuprofen (don’t take the temperature by mouth) can’t bring down.
• Shows signs of being dehydrated: low urine output, lethargy, decrease in your child’s activity level, a child who is hard to wake up, can't make tears, or a dry mouth.
• Shows signs of a reaction to the medicines: throwing up, diarrhea or a rash.

For Any Concerns/Questions, Please Call:

• The Cleft Nurse at 720-777-5364 Monday through Friday 8-4:30pm.
• Your surgeon’s office.
• To reach the ENT office after hours, please call 720-777-8501.
• To reach the plastic surgery office after hours please call 720-777-1234 and ask to speak with the plastic surgeon on call.

Follow-Up after Surgery: Your child needs to be seen for a follow-up appointment 1-2 weeks after surgery with your surgeon or Advance Practice Provider for a quick post-operative check. They will also need to be scheduled for a follow up 4-6 weeks after surgery with your surgeon. Your child needs to be seen by the Craniofacial Orthodontist in 2-4 weeks after surgery. Please call the orthodontist office at 720-777-3749 to schedule the follow up. To schedule a post-op appointment in 4-6 weeks with your child’s surgeon please call:

• Plastics Office 720-777-6409 options #1
• ENT Office 720-777-8501

For all other questions, please call the Cleft Clinic at 720-777-2572.

Before the Surgery:

• Your child's surgeon will talk with about you the best surgical approach for the repair. Depending on your surgeon's preference, your child may be scheduled for a pre-operative visit.
• You should shift your child from the bottle and to a Sippy cup before the Cleft Palate Repair. Cups should be free flowing with no valves, and should have little to no spout.

Good cups to use are:

• Avent Natural Drinking Cup
• Gerber Hard Spout
• Playtex Coolstin

1. The nurses will offer ideas as to the best cups to try. Please bring the cup with you to the hospital the day of surgery.
2. Please don't give your child any ibuprofen products (such as Motrin®, Advil®) for one week before surgery
3. A Surgery Scheduler will call you a few days before surgery to tell you when your child has to stop eating and drinking. They will also tell you what time to come to the hospital pre-op area and the time of surgery.
4. If your child is sick anytime in the week before surgery, call the nurses in the Cleft Lip and Palate Program, to make sure the surgery doesn't need to be rescheduled. The nurses are available Monday through Friday for any concerns/ questions you might have before the surgery.

After the Surgery:

• Your child will be watched closely in the Post Anesthesia Recovery Unit (PACU) for 1-2 hours after surgery. As soon as your child is awake, the PACU nurse will call you to join them.
• Your child will usually stay in the hospital for 1-2 nights. Parents/guardians are allowed to stay in the room with the child.
• You should make sure you have childcare for siblings while your child is in the hospital.

Feeding After Cleft Palate Surgery:

• Your child will have an IV (tube in a vein) to give them fluids and medicines while they are recovering in the hospital.
• Along with drinking out of a cup, your child's surgeon may suggest a special TenderCare® feeder or a syringe with a Brecht® tubing for feeding. These feeding devices will lower the chance of injury to the surgical site.
• Sometimes the surgeon will let infants go back to drinking from the bottle they were using before the surgery.
• Within 1-3 days, your child should go back to drinking the same amount of liquids as they were drinking before the surgery.
• For 2-3 weeks, your child will be on a pourable liquid or blenderized diet.

1. A pourable liquid diet includes anything you can put in a blender and add enough liquid to make it a pourable consistency.
2. We suggest you add liquids that are higher in calories such as cream, whole milk, regular chicken/beef stock.

• After a weeks, your child may start eating a soft diet.

1. A soft diet includes foods that are not crunchy, hard or sharp and can be eaten with little biting or chewing.
2. Examples are: baby food, soft, over-cooked pasta, scrambled eggs, soft cooked veggies, and ground or finely chopped meats.

• Only an adult should feed your child.

Positioning While Feeding: Hold your baby in an upright position and feed slowly to prevent choking. Burp often, holding the baby in a sitting position on your lap rather than over your shoulder. To prevent dehydration, the target volume (amount) of liquids your baby should be taking daily is about 28 ounces a day. This is 3-4 8-ounce bottles.

Safety: It is very important to protect the surgical site while it is healing. The stitches will dissolve on their own. Complete healing of the palate will take about 6 weeks. When in bed, put your baby on their back or side. Your baby should NOT be placed on their tummy with their face down towards the mattress.

Children must wear elbow restraints at all times for 2-3 weeks following surgery. These are Velcro restraints that fit over the arm and keep your child from putting their hands to their mouth. Restraints should be taken off at least every four hours while your child is awake to exercise the joints and to check the skin.

You can take the restraints off when you are holding your child or supervising them and able to keep them from putting their hands or other objects in their mouths.

• Only take one splint off at a time so you can supervise and keep your child from putting their hands in their mouth.
• Check the skin under the restraints for red areas. If red areas develop, massage the spot gently.
• The restraints can be worn over a long-sleeve shirt to keep them from irritating and make it harder for your child to take them off.
• Move your child's unrestrained arm fully; bending the elbow and wrist joints several times to keep the joints from getting stiff.
• Restraints are to be worn all night and at nap time.

Special care should be taken to avoid injury to the palate. Don't put anything in the mouth beyond the teeth. Do not let siblings or friends feed your child or take off the elbow restraints. Comfort your child when they cry by holding your child, singing to your child, and giving pain medicine as ordered.

Supervise all play activities, especially when there are other children involved.

Mouth Care:

• Give your child water after they eat to rinse the palate
• Use a moist washcloth on your finger and rub along your babies outer gum line both on the upper and lower gum. Don't put your finger past your baby's teeth/gums.
• You may also use the pink mouth swabs to clean the outer gum line of the mouth only. Don't put the swab past your baby's teeth/gums.

Medicines after Surgery: Your child will usually go home on acetaminophen (Tylenol®) as well as a narcotic pain medicine such as oxycodone. Depending on your child's surgeon, you may be able to use ibuprofen (Motrin®, Advil®). If antibiotics are ordered after surgery, please be sure to follow the directions carefully. If ear tubes were placed, give eardrops as ordered.

Call With Any Questions/Concerns, or If Your Child:

• Has an injury to the surgical site.
• Has redness, swelling or drainage that is increasing.
• Has a large amount of bleeding from the nose or mouth.
• Has a fever above 101.5°F for more than 24 hours that doesn't go down after taking Tylenol or ibuprofen (do not take the temperature by mouth)
• Has signs of dehydration: infants/babies less than 3-4 wet diapers in 24 hours, big decrease in the child's activity level, or a child who is difficult to wake up, not making tears, or has a very dry mouth.
• Has a foul odor from mouth.
• If your child has ear drainage lasting longer than 5 days please call ENT

For Any Concerns or Questions Please Call:

Plastic Star 70 777 L40G The Cleft Nurse at-720-777-5364 Monday through Friday 8-4:30pm. -Your-surgeon's office. To reach the ENT office after hours, please call 720-777-8501. -The BH To reach the plastic surgery office after hours please call 720-777-1234 and ask to speak with the plastic surgeon on call. Follow-Up after Surgery: Your child should be seen for a follow-up appointment 1-2 weeks after surgery. Then 4-6 weeks after surgery with your surgeon. If follow-up appointment is not with a Children's Hospital Colorado doctor please call your doctor's office for an appointment. 717/20 2ND Pine Plastic Surgerwin Minuten • To schedule a post-op appointment in 1-2 weeks please call-Kathy at 720-777-3880. . To schedule a post-op ear evaluation in 4 weeks please call ENT at 720-777-8501. To schedule a post-op appointment in 4-6 weeks with your child's surgeon please call: 7 P each • Plastics Office 720-777-6409 option #1 – wice plan 7 Follow us • month + The dept dinic in ENT Office 720-777-8501 lycer parger For all other questions, please call the Cleft Clinic at 720-777-2572. 1st post-op chee with me goto e please call Them To thedule. ok. a