Current Anaesthesia & Critical Care (2002) 13, 87̂ 91�c 2002 Publishedby Elsevier Science Ltd.doi:10.1054/cacc.2002.0384, available online at http://www.idealibrary.com on

FOCUSON:BURNSANDPLASTICS

Anaesthesia for plastic surgery in childrenS.M.Fenlon

Anaesthetic Department,QueenVictoria Hospital NHS Trust, East Grinstead,West Sussex RH19 3DZ,UK

KEYWORDSsurgery, plastic, paediatrics,anaesthesia

Summary Children constitute a signi¢cant and interesting part of the workload inplastic surgery.Manycongenital and acquiredproblems are referred for sole or joint in-volvement with plastic surgeons. In the same way that surgeons have narrowed theirfocus to areas of special interest, so have anaesthetists.Paediatric practice has becomea sub-specialty within anaesthesia, and the ¢eld of plastic surgery in the paediatric po-pulation is a further branch to this specialization.The onus is on those currently practi-cing tomaintain andimprove standards, evenin areaswherethe surgeryor anaesthesiaappearsmundane.Asin all areas of paediatric practice, the nature oftheworkrequiresadaptability totheoftenunusual, andoccasionallyunexpected; whilstconstantly strivingtomaintain as friendly and supportive an environment aspossible for apprehensivechil-dren and their parents. Many of the children will attend for further surgery and theiroutlook is easily tarnished byone bad experience.�c 2002 Publishedby Elsevier Science Ltd.

INTRODUCTIONThe earliest accounts of attempted constructive and re-constructive surgery without anaesthesia make for har-rowing reading.The early pioneers in plastic surgery notonly alleviated their patient’s su¡ering, they made sur-gery both safer andmore e¡ective.1

Plastic surgery caters for patients of all ages, and in itspaediatric branch presents patients from birth to teen-agers. Anaesthetists undertaking this work shouldmeetthe requirements suggested by a number of bodies at-tempting to limit ‘occasionalpractice’ inpaediatric anaes-thesia.2 Sta⁄ng of wards, recovery and other areaswithin the hospital, as well as the hospital environmentitself, mustmeet certain standards.3

This article is divided according to the proceduresmost commonly performed at this institution. Manyareas such as burns management are dealt with else-where in this issue, and detail is limited to avoidunneces-sary repetition.

CLEFTLIPANDPALATESURGERYPrimary cleft lip and palate (CLAP) surgery presentssome of the youngest patients.CLAP is one of the mostcommon congenital malformations, and may be diag-nosed in the antenatal period by ultrasound scanning.The incidence is between 1:300 and 1:600 live births in

0953-7112/02/$^ see frontmatter

Correspondence to: SMF.

the UK. Cleft lip and usually cleft palate are obvious atbirth, though associated abnormalities may be moresubtle and continuous involvement of paediatriciansprior to and during cleft repair is essential.4 Many suchassociations have now been described,5 and doubtlessmore will come to light together with further de¢nitionof the genetic component. Some conditions have majorimplications for the anaesthetist, particularly abnormalairway anatomy; others such as cardiac defects may in-£uence the optimal timing and location of surgery.6 Ofparticular relevance is the Pierre Robin Sequence of mi-crognathia, large tongue and airway obstruction. Thesechildren aremore likely to cause di⁄culty in airwayman-agement during induction of anaesthesia and in the post-operative period.7 However, the condition improveswith age and a scoring system may help identify thosewho should have surgery delayed to allow the airway toimprove.8

Occasionally, the childwith CLAP also has di⁄culty infeeding, and further to this may su¡er the e¡ects of re-peatedpulmonary aspiration.9 Failure to thrivemay haveother aetiologies, which should be excluded. Feedingaids, a period of nasogastric tube feeding, and airwaysupport such as nasopharyngeal airway insertion maybeneeded to help overcome some of theproblems thesebabies su¡er.10 Early communication between surgeon,anaesthetist, and other members of the cleft team isvital in dealing with these complicated cases.The timing of surgery is governed by the desire for an

aesthetic result and furthering development of normal

88 CURRENT ANAESTHESIA & CRITICALCARE

speech anddentition, but temperedby thepractical con-siderations of operating on very young children. Primarycleft lip repair is usually undertaken at 3 months of age,and palate repair between 6 and 9 months when mouthbreathing is established.4 The present tendency towardsearlier palate repair aims to improve speech develop-ment.Neonatal lip repair, at one timemorewidely prac-ticed, is now uncommon in this country.11 Intra-uterinerepair, whilst established in animal models, has not yetbeen extended to humans.12 All babies require an estima-tion of pre-operative haemoglobin as many have a phy-siological anaemia at the time of surgery for cleft lip.There are studies supporting the use of oral atropine

as a premedicant, though the observed incidence of oxy-gen desaturation was not reduced in the study by Shawet al.13 In this hospital, we do not usually premedicatethese children.Our practice is to induce anaesthesia byinhalation with sevo£urane in 100% oxygen; intravenousaccess, if not previously established, is then secured.Once a suitable depth of anaesthesia is reached, con¢r-mation of facemask ventilation is followed by paralysisachieved with either a depolarizing or a longer actingmuscle relaxant.We favour the latter.Di⁄cult facemaskventilation is extremely rare, though a di⁄cult view atlaryngoscopy is a more frequent ¢nding and can to someextent be predicted pre-operatively.14 Use of a straightlaryngoscope blade, the lateral or molar approach, andexternal laryngeal manipulation can help, as may a pieceof gauze packed into the cleft lip.15,16 Techniques employ-ing the laryngealmask and ¢breoptic bronchoscopehavebeen described.17 As mentioned above, if di⁄culty isencountered, thought should be given to postponingsurgery to a later date.The anatomy and neuromuscularco-ordination of the upper airway may improvewith age.7

Prior to surgery, the airway is secured with an endo-tracheal tube. The preformed RAE type of tube passesoutover the lower lip,where it is ¢xedcentrally, allowingfor optimal surgical access. The shared airway presentsopportunities for inadvertent extubation at almost anystage.18 A throat pack is used for lip surgery though pa-late surgery is usually conductedwithout. Anaesthesia ismaintained by controlled ventilation with volatile anaes-thetic agents. There may be some advantages to usingdes£urane in this age group for its extremelyrapidwash-outcharacteristics.19 Intraoperative analgesia is providedwith fentanyl 1^2mcg/kg intravenously, in combinationwith local anaesthetic in¢ltration. For lip repair, infra-orbital nerve blocks have been shown to be e¡ective20.Paracetamol is commonly prescribed for postopera-

tive analgesia, and may be given as a loading doseperi-operatively per rectum. Non-steroidal anti-in£am-matory drugs are used bymany paediatric anaesthetistsfor children from 3 months of age.21Due to fears of re-spiratory depression and excessive sedation, someauthors recommend avoiding the use of potent opioid

analgesics postoperatively, preferring instead to use co-deine. It has been shown that the pharmacokinetic andanalgesic properties of morphine are similar in youngchildren to adults. If required, morphine can be usedsafely in appropriate doses as long as there is adequatepostoperative observation.22 Codeine phosphate maybe insu⁄cient, and itmay be that other opioids could bemore e¡ectivelyemployedin thepaediatric population.23

Surgery may be prolonged, and adequate precautionsagainst hypothermia should include temperature moni-toring and forced air warming blankets. Accurate mea-surement of blood loss is di⁄cult, though an attemptcan be made to judge the amount collected on swabsand in suction apparatus. In palate surgery, losses areusually replaced with crystalloid infusion.24 Someauthors quote signi¢cant rates of blood transfusion fol-lowing CLAP surgery, though in our own experiencethe need for transfusion is rare.25 On completion of sur-gery, the oropharynx is inspected to remove the throatpack and any blood clot, and to assess any continuingbleeding.There is an association between slow recoveryand postoperative airway obstruction and time shouldbe allowed for adequate elimination of anaestheticagents.24

The child is extubated when fully awake, and supple-mentary oxygen given by mask. At this time, particularattention is paid for signs of airwayobstruction.Thismayoccur at any part of the upper respiratory tract. If seen,thought shouldbe given to possibilities such as upper air-way narrowing, blood clot, retained throat pack, tongueswelling from retraction, or inadequate mouth breath-ing. Active management will depend on the aetiology; itmay be su⁄cient to apply continuous positive airwaypressure for a time. Further to this, careful insertion ofan oro-pharyngeal airway, naso-pharyngeal airway, oreven re-intubation may be needed. Close observationcontinues into the recovery period, again watching forsigns of airway obstruction or bleeding. Once the childis awake, and no bleeding seen, feeding with clear £uidscan begin and is usually comforting. Parents are encour-aged to come and join their child at this time.Later in life these children may require further sur-

gery to improve speech quality, dental development andfacial appearance. Awake¢breoptic nasendoscopy allowsaccurate evaluation of velo-pharyngeal incompetence,and planning of future surgery to improve speech,12 Sur-gery to improve naso-pharyngeal sphincter function cancompromise the airway postoperatively so close obser-vation is needed in the recovery period.

COSMETICSURGERYThe anxiety felt by parents of children having cosmeticprocedures may exceed that usually encountered. Thesurgery is often performed at their request, and may

ANAESTHESIAFORPLASTIC SURGERYINCHILDREN 89

notbe considered essential by the child at the time. Cos-metic surgery in children is usually limited to correctionof prominent ears, removal of small areas of accessorytissue, and excision of skin lesions of varying sizes. Thelarger lesions may require serial excision in multiple sur-gical episodes. Tissue expanders can be used to providea source of local autologous skin by a process ofskin expansion.12 Some large skin naevii may have malig-nant potential.26

Pinnaplasty aims to restore the antihelical fold of theexternal ear, thus allowing the pinna to lay parallel to thehead. In older children, or for single ear surgery, localanaesthesiamay su⁄ce; butgeneral anaesthesia isusuallyrequired. Field in¢ltration or regional block with localanaesthesiawillbothprovide excellentpostoperative an-algesia.27 Packing the external auditorymeatus followingpinnaplasty causes postoperative nausea and vomitingand is now generally avoided. Nausea and vomiting isfurther reduced by avoiding opioids with a prolongedduration of action, maintaining anaesthesia by the intra-venous infusion of propofol,28 and the prophylactic ad-ministration of ondansetron.29

Pre-auricular skin tags are usually removed in the ¢rstyear of life.Theymay contain cartilage, but are easily ex-cised under general anaesthesia supplementedwith in¢l-tration of local anaesthetic.More severe abnormalities ofthe external ear may occur as part of a syndrome withother defects that result from abnormal development ofthe ¢rst and second branchial arches.30 In these cases,aesthetic correction is undertaken as part of the overallmanagement of the associated problems.

HANDSURGERYCongenital hand deformities range from simple acces-sory digits to complete absence of digits and associatedhand structures.Thus, surgery varies from short proce-dures to surgically complexprolongedoperations such astoe-to-hand transfer. The anaesthetic management ofsuch cases is usually straightforward, requiring attentionto detail in respect of positioning, temperature controland e¡ective analgesia. The surgical tourniquet, occa-sionally employed in two sites, has the potential to causepermanent injury and so care should be taken with ap-propriate tourniquet size, padding and duration of use.Tourniquets are a source of signi¢cant surgical stimulus,andmay require potent intraoperative analgesia.31An in-teresting e¡ect of tourniquet use is its potential to raisecore temperature intraoperatively.32

Regional blocks, particularly the axillary approach tobrachial plexus block, are useful for analgesia. Multiplesite injections appear to confer no bene¢tover the singleinjection in children.33 Insertion of a catheter into theplexus sheathvia the axillary approach allows continuousblockade to be established.Whilst a pre-emptive e¡ect

has not been shown on postoperative pain, this techni-que does allow for reduced anaesthetic use, andprovidesexcellent postoperative analgesia.34 Digital transplantsrequire continuous observation of arterial and venousintegrity. This may be augmented by using a pulse oxi-meter probe attached to the operated digit, and com-paringmeasurements with those from a normal digit.35

TRAUMAThe case-load of traumatic injury to the face and handsof children presenting to plastic surgery units is increas-ing.Though the degree of injury is usually less than thatseen in adults, general anaesthesia ismore likely to be re-quired for the child, particularly in the younger agegroups. These cases should be dealt with by appropri-ately senior sta¡ at arranged times; night-time operatingis rarely justi¢ed.36 More serious pathology, particularlyhead injury, may occur in associationwith otherwise ap-parently trivial injury.Clear guidelines exist for fasting of elective patients

and, anaesthetists often apply similar rules to emergencycases.37 Whilst each case should bemanaged on itsmer-its, a number of individual factorsmay helpmake the de-cision as to how the airway should bemanaged.38

As mentioned above, most trauma surgery is simple,but occasionally severe tissue loss will need more com-plex surgery with tissue transfer. Environmental tem-perature control, attention to £uid balance calculations,and the use of supplementay regional anaesthetic techni-ques where possible are major considerations. Experi-enced postoperative monitoring of both patient andtissue £ap are necessary.Flap donor sites, for example la-tissimus dorsi muscle, are not always amenable to regio-nal anaesthesia and postoperative analgesia can be wellmanaged by opioid infusion tailored to accepted localguidelines.To thismaybe added a patientcontrolled facil-ity according to the level of understanding of the child.22

SURGERYFORTHERMALINJURYManagement of acute burns in children is a highly specia-lized subject, and initial treatment has as its primary aimrestoration of skin integrity. Scarring left from thehealed burn and skin grafting may need further surgeryto improve the functional and aesthetic result. Thesechildren often make several trips to the operating thea-tre, and continuity of care is helpful.This permits indivi-dual likes anddislikes to be catered for, at timeswhen themaintenance of even small degrees of control canbeveryimportant to the child.Again, the surgery ranges fromminor scar revision to

prolonged and extensive reconstruction and anaesthesiais adapted accordingly following discussion with thesurgeon. Airway di⁄culties and problems in securing

90 CURRENT ANAESTHESIA & CRITICALCARE

venous access can prolong anaesthetic induction andtheatre timings should be adjusted appropriately. Scar-ring deformity to the upper airwaymay result in di⁄cultlaryngoscopy and, more rarely, di⁄cult face mask venti-lation.The former can bemanaged by laryngealmask in-sertion or ¢breoptic-assisted intubation followinginduction of general anaesthesia. The latter represent amore complex scenario and may require an airwayto be secured prior to anaesthesia. Achieving this inan awake child is rarely possible and some form oflight anaesthesia will usually be needed to achieveco-operation.39

HYPOSPADIASREPAIRHypospadias is a relatively common congenital conditionwith an incidence quoted as high as 1:300 live malebirths.40 Other conditions often associated with hypos-padias are undescended testes and inguinal hernia. Iso-lated hypospadiasis is rarely associated with upperurinary tract disorders, and further investigation is notrecommended in this group.41A single- or two-stage re-pair is usually carried out at about 3 years of age whencontinence is established, and co-operation with cathe-terization is better.General anaesthesia is supplementedwith a caudal block to minimize opioid use and lead to asmooth pain-free recovery.Various methods of prolong-ing the block have been described.41,42 Childrenwill havean indwelling urinary catheter, usually per urethrum, for2^6 days postoperatively.Earlymobilization reduces sur-gical complications though caremustbe taken topreventpulling on or blockage of the catheter.40

FURTHERREADING

Many excellent general texts and articles exist detailing paediatricanaesthetic techniques for surgery, which apply asmuch to childrenhaving plastic surgery. For guidance on management of generalissues surrounding anaesthesia in children, readersmay refer to es-tablished texts.44 More speci¢c detail can be found for pre-medica-tion,45 pre-operative fasting,46, peri-operative £uid balance47 andanalgesia.48

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