Plastics

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

Important phone numbers:
Maureen Andrews: 303-929-7929
Amy Circle: 970-310-7745
OR charge: 64890
OR Desk: 76492
ED: 76888
OneCall: 73999
Yellow Team: 79247
Phone stems: 720-777-XXXX. Numbers that start with 6 are all internal (usually nurse PCD). The only way to call back from outside is to call OneCall and ask them to connect you.

On call: either call OneCall or go to the Children's home page, click on Quick Links, then Amcom (must be at the hospital or remotely using the CHC Desktop).

Lounge space (ONLY Independents have access): 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. Dr. Mason is working on obtaining a PRS call room.

OR Lockers: There is a designated PRS locker in the Men's and Women's locker rooms.

Expectations: OR takes precedence over clinic. However, if you are not in cases, you are expected to attend clinic. If simultaneous cases, 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, talk to French about covering those instead. Please look ahead and coordinate coverage as needed. Some cases require extra hands (ABG, breast reduction, etc).

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 New Surgical Informed Consent (or Panel 2 or Panel 3 if it's a combo case) 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 MUST be accurate and only have one parent's name spelled correctly. They will hold the case if this is done incorrectly. You can add extra procedures and whatnot in Additional Procedure Information. Fill in your name as Provider Performing Consent. Often the procedure etc will already pre-populate. If you're consulted for a spine closure, etc, you'll have to type in all the stuff yourself.
-After the form is filled out, the parent can sign on the computer's signature pad or on the patient's iPad. To log into the iPad you put in the patient's DOB (MMDDYY). The consent must be closed (close the patient's chart) to access the consent on the iPad. Click submit after you and the patient have signed the consent. The attending can sign the consent when they're back in the OR.
Caveats:
-If the patient is over 18 and otherwise legally able to consent for themselves, THEY must sign the consent and not a parent. Parent should sign if they are the legal guardian of an otherwise >18 year old patient (delayed, etc).
-Transfusion consents are separate than the surgical sent. There is another box to click for the transfusion consent (fill out as above).

Rounding: You will see all the necessary patients yourself and update the attendings. Dr. Mason has tried to implement an attending “rounder” during the week with variable participation. Maureen will also see the Cleft/Craniofacial patients, but this should not replace your rounding.

Craniofacial patients:

• Maureen is an awesome resource. She will seeing everyone herself too, and will write her own note. She'll also check in with people postop. Text her and the attending after any craniofacial or cleft case so she knows 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 home page - Resources - Patient Handouts.
• If you put in cranial distractors, Dr. 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. Coordinate with her on who will do the AM versus PM turns.
• All of the craniofacial patients are neurosurgery primaries post-op. 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 fellows are usually slammed in the mornings, so you are responsible for the consents. All the kids need a regular procedural consent as well as a transfusion consent. The plastics attendings are typically not on the consents– Include under Additional Procedure Information: “Co-surgeon: Dr. Brooke French, MD” as appropriate.

Cleft cases:

• Maureen helps to manage these patients pre- and post-operatively as well.
• There are multiple applicable ordersets (Plastics IP Alveolar Bone Graft Admission; Plastics IP Cleft Lip Repair Admission; Plastics Cleft Palate Admission)
• These cases are now being admitted to the hospitalist service Yellow Team post-operatively. Since they are non-surgical and rotate every week, they need a lot of hand-holding. Call them after the OR to sign out the patient to them (number above). Be VERY explicit about all instructions, nursing care, diet, pain meds, antibiotics, etc.
• For Dr. Khechoyan - all primary palate repairs go to PICU postop for airway monitoring (French's patients 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. Sometimes Mo is able to remove these when she does her rounds. Coordinate with her as needed.

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. PRS patients are usually in Hallway B. There's a work room in the back hall that is shared with gyn and ID. Multi-D clinics are behind these. Sometimes you're in the clinics at one end of the hallway or the other (rooms starting with J versus rooms starting with K).
• There are several Multidisciplinary clinics that we attend: Craniofacial, cleft, brachial plexus, vascular malformations. You are mostly observing and writing notes (for some MDC clinics, Dr. Khechoyan will do his own notes).
• Plastic Surgery clinic: You are expected to see the patients yourself and then staff as usual. Notes are your responsibility.
• 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 will be called by Amy to help with the odd clinic patient (usually for tissue expander fills, steroid injections, vac changes, etc.).

Consults:

• You are first call for all consults (Face on even days, gen plastics, wound).
• For arranging outpatient follow-up, message the corresponding scheduler and the attending of record (for French/Mason– Megan Taylor. For Khechoyan/Domeshek– Melinda Bond). If you are unsure or having trouble, reach out to Amy.

ED Laceration Repairs

• Ask the ED to obtain supplies/local/baci ointment for you. They have a poor selection of sutures. I will go to the OR to select instruments I want (0.5 pick ups, small needle driver or Castros, small Iris scissors or tenotomies) and sutures. Dr. Mason has a laceration tray set up, but I have never used it and do not know what it contains.
• For ED facial lacerations, be mindful of absorbable versus non-absorbable sutures based on patient age and location of laceration. Discuss with attending if you are unsure.
• There is a note template made by Dr. Mason (.PRSEDVISIT) and discharge instructions (.PRSEDLACERATIONINSTRUCTIONS).
• See above to message scheduler for follow-up. If using nonabsorbables that need to be removed in a patient that will require sedation, coordinate this beforehand. They can be scheduled for suture removal in the Procedure Center without coming to clinic.

Admitting patients to medicine:

• Complex patients or possible non-op observation: If there's a complex medical patient coming in or if you want to have a patient stay overnight from the ED (ie lip hematomas etc that we may or may not operate on), you can have medicine admit them. Discuss with the attending. Call the One Call people and then select Admissions/Transfers and to be connected to the admitting attending and senior resident to discuss the admission.
• Yellow Team: In addition to our new collaboration with Yellow Team for Cleft patients, they admit post-op breast patients as well. There are certain other cases where you can admit post-op patients to them. Discuss with our attendings.

• 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:

• The Plastic Surgeon - 720-777-6409 - Monday through Friday 8-4:30pm
• 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 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.

• To schedule a post-op appointment in 1-2 weeks please call-Maureen at 720-777-5578.
• 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:

• Plastics Office 720-777-6409 option #1 – will plan to Follow up with Dr. French and the dept clinic in 2 months after surgery as long as 1st post op check goes ok.
• ENT Office 720-777-8501

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