Plastics

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.

op report place holder

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.

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

Operative Report:
1. Cleft Palate Repair:

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.

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: