1. Current Anaesthesia & Critical Care (2002) 13, 87^91
2002 Published by Elsevier Science Ltd.
c
doi:10.1054/cacc.2002.0384, available online at http://www.idealibrary.com on
FOCUS ON: BURNS AND PLASTICS
Anaesthesia for plastic surgery in children
S. M. Fenlon
Anaesthetic Department, QueenVictoria Hospital NHS Trust, East Grinstead, West Sussex RH19 3DZ, UK
KEYWORDS Summary Children constitute a signi¢cant and interesting part of the workload in
surgery, plastic, paediatrics, plastic surgery Many congenital and acquired problems are referred for sole or joint in-
.
anaesthesia volvement with plastic surgeons. In the same way that surgeons have narrowed their
focus to areas of special interest, so have anaesthetists. Paediatric practice has become
a 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 to maintain and improve standards, even in areas where the surgery or anaesthesia
appears mundane. As in all areas of paediatric practice, the nature of the work requires
adaptability to the often unusual, and occasionally unexpected; whilstconstantly striving
to maintain as friendly and supportive an environment as possible for apprehensive chil-
dren and their parents. Many of the children will attend for further surgery and their
outlook is easily tarnished by one bad experience.
2002 Published by Elsevier Science Ltd.
c
INTRODUCTION the UK. Cleft lip and usually cleft palate are obvious at
birth, though associated abnormalities may be more
The earliest accounts of attempted constructive and re- subtle and continuous involvement of paediatricians
constructive surgery without anaesthesia make for har- prior to and during cleft repair is essential.4 Many such
rowing reading.The early pioneers in plastic surgery not associations have now been described,5 and doubtless
only alleviated their patient’s su¡ering, they made sur- more will come to light together with further de¢nition
gery both safer and more e¡ective.1 of the genetic component. Some conditions have major
Plastic surgery caters for patients of all ages, and in its implications for the anaesthetist, particularly abnormal
paediatric branch presents patients from birth to teen- airway anatomy; others such as cardiac defects may in-
agers. Anaesthetists undertaking this work should meet £uence the optimal timing and location of surgery.6 Of
the requirements suggested by a number of bodies at- particular relevance is the Pierre Robin Sequence of mi-
tempting to limit ‘occasional practice’ in paediatric anaes- crognathia, large tongue and airway obstruction. These
thesia.2 Sta⁄ng of wards, recovery and other areas children are more likely to cause di⁄culty in airway man-
within the hospital, as well as the hospital environment agement during induction of anaesthesia and in the post-
itself, must meet certain standards.3 operative period.7 However, the condition improves
This article is divided according to the procedures with age and a scoring system may help identify those
most commonly performed at this institution. Many who should have surgery delayed to allow the airway to
areas such as burns management are dealt with else- improve.8
where in this issue, and detail is limited to avoid unneces- Occasionally, the child with CLAP also has di⁄culty in
sary repetition. feeding, and further to this may su¡er the e¡ects of re-
peated pulmonary aspiration.9 Failure to thrive may have
other aetiologies, which should be excluded. Feeding
CLEFT LIP AND PALATE SURGERY aids, a period of nasogastric tube feeding, and airway
Primary cleft lip and palate (CLAP) surgery presents support such as nasopharyngeal airway insertion may
some of the youngest patients. CLAP is one of the most be needed to help overcome some of the problems these
common congenital malformations, and may be diag- babies su¡er.10 Early communication between surgeon,
nosed in the antenatal period by ultrasound scanning. anaesthetist, and other members of the cleft team is
The incidence is between 1:300 and 1:600 live births in vital in dealing with these complicated cases.
The timing of surgery is governed by the desire for an
Correspondence to: SMF. aesthetic result and furthering development of normal
0953-7112/02/$^ see front matter

2. 88 CURRENT ANAESTHESIA & CRITICAL CARE
speech and dentition, but tempered by the practical con- analgesics postoperatively, preferring instead to use co-
siderations of operating on very young children. Primary deine. It has been shown that the pharmacokinetic and
cleft lip repair is usually undertaken at 3 months of age, analgesic properties of morphine are similar in young
and palate repair between 6 and 9 months when mouth children to adults. If required, morphine can be used
breathing is established.4 The present tendency towards safely in appropriate doses as long as there is adequate
earlier palate repair aims to improve speech develop- postoperative observation.22 Codeine phosphate may
ment. Neonatal lip repair, at one time more widely prac- be insu⁄cient, and it may be that other opioids could be
ticed, is now uncommon in this country.11 Intra-uterine more e¡ectively employed in the paediatric population.23
repair, whilst established in animal models, has not yet Surgery may be prolonged, and adequate precautions
been extended to humans.12 All babies require an estima- against hypothermia should include temperature moni-
tion of pre-operative haemoglobin as many have a phy- toring and forced air warming blankets. Accurate mea-
siological anaemia at the time of surgery for cleft lip. surement of blood loss is di⁄cult, though an attempt
There are studies supporting the use of oral atropine can be made to judge the amount collected on swabs
as a premedicant, though the observed incidence of oxy- and in suction apparatus. In palate surgery, losses are
gen desaturation was not reduced in the study by Shaw usually replaced with crystalloid infusion.24 Some
et al.13 In this hospital, we do not usually premedicate authors quote signi¢cant rates of blood transfusion fol-
these children. Our practice is to induce anaesthesia by lowing CLAP surgery, though in our own experience
inhalation with sevo£urane in 100% oxygen; intravenous the need for transfusion is rare.25 On completion of sur-
access, if not previously established, is then secured. gery, the oropharynx is inspected to remove the throat
Once a suitable depth of anaesthesia is reached, con¢r- pack and any blood clot, and to assess any continuing
mation of facemask ventilation is followed by paralysis bleeding.There is an association between slow recovery
achieved with either a depolarizing or a longer acting and postoperative airway obstruction and time should
muscle relaxant.We favour the latter. Di⁄cult face mask be allowed for adequate elimination of anaesthetic
ventilation is extremely rare, though a di⁄cult view at agents.24
laryngoscopy is a more frequent ¢nding and can to some The child is extubated when fully awake, and supple-
extent be predicted pre-operatively.14 Use of a straight mentary oxygen given by mask. At this time, particular
laryngoscope blade, the lateral or molar approach, and attention is paid for signs of airway obstruction.This may
external laryngeal manipulation can help, as may a piece occur at any part of the upper respiratory tract. If seen,
of gauze packed into the cleft lip.15,16 Techniques employ- thought should be given to possibilities such as upper air-
ing the laryngeal mask and ¢breoptic bronchoscope have way narrowing, blood clot, retained throat pack, tongue
been described.17 As mentioned above, if di⁄culty is swelling from retraction, or inadequate mouth breath-
encountered, thought should be given to postponing ing. Active management will depend on the aetiology; it
surgery to a later date. The anatomy and neuromuscular may be su⁄cient to apply continuous positive airway
co-ordination of the upper airway may improve pressure for a time. Further to this, careful insertion of
with age.7 an oro-pharyngeal airway, naso-pharyngeal airway, or
Prior to surgery, the airway is secured with an endo- even re-intubation may be needed. Close observation
tracheal tube. The preformed RAE type of tube passes continues into the recovery period, again watching for
out over the lower lip, where it is ¢xed centrally, allowing signs of airway obstruction or bleeding. Once the child
for optimal surgical access. The shared airway presents is awake, and no bleeding seen, feeding with clear £uids
opportunities for inadvertent extubation at almost any can begin and is usually comforting. Parents are encour-
stage.18 A throat pack is used for lip surgery though pa- aged to come and join their child at this time.
late surgery is usually conducted without. Anaesthesia is Later in life these children may require further sur-
maintained by controlled ventilation with volatile anaes- gery to improve speech quality, dental development and
thetic agents. There may be some advantages to using facial appearance. Awake ¢breoptic nasendoscopy allows
des£urane in this age group for its extremely rapid wash- accurate evaluation of velo-pharyngeal incompetence,
out characteristics.19 Intraoperative analgesia is provided and planning of future surgery to improve speech,12 Sur-
with fentanyl 1^2 mcg/kg intravenously, in combination gery to improve naso-pharyngeal sphincter function can
with local anaesthetic in¢ltration. For lip repair, infra- compromise the airway postoperatively so close obser-
orbital nerve blocks have been shown to be e¡ective20. vation is needed in the recovery period.
Paracetamol is commonly prescribed for postopera-
tive analgesia, and may be given as a loading dose
peri-operatively per rectum. Non-steroidal anti-in£am-
matory drugs are used by many paediatric anaesthetists
COSMETIC SURGERY
for children from 3 months of age.21 Due to fears of re- The anxiety felt by parents of children having cosmetic
spiratory depression and excessive sedation, some procedures may exceed that usually encountered. The
authors recommend avoiding the use of potent opioid surgery is often performed at their request, and may

3. ANAESTHESIA FOR PLASTIC SURGERY IN CHILDREN 89
not be considered essential by the child at the time. Cos- has not been shown on postoperative pain, this techni-
metic surgery in children is usually limited to correction que does allow for reduced anaesthetic use, and provides
of prominent ears, removal of small areas of accessory excellent postoperative analgesia.34 Digital transplants
tissue, and excision of skin lesions of varying sizes. The require continuous observation of arterial and venous
larger lesions may require serial excision in multiple sur- integrity. This may be augmented by using a pulse oxi-
gical episodes. Tissue expanders can be used to provide meter probe attached to the operated digit, and com-
a source of local autologous skin by a process of paring measurements with those from a normal digit.35
skin expansion.12 Some large skin naevii may have malig-
nant potential.26
Pinnaplasty aims to restore the antihelical fold of the TRAUMA
external ear, thus allowing the pinna to lay parallel to the
The case-load of traumatic injury to the face and hands
head. In older children, or for single ear surgery, local
of children presenting to plastic surgery units is increas-
anaesthesia may su⁄ce; but general anaesthesia is usually
ing. Though the degree of injury is usually less than that
required. Field in¢ltration or regional block with local
seen in adults, general anaesthesia is more likely to be re-
anaesthesia will both provide excellent postoperative an-
quired for the child, particularly in the younger age
algesia.27 Packing the external auditory meatus following
groups. These cases should be dealt with by appropri-
pinnaplasty causes postoperative nausea and vomiting
ately senior sta¡ at arranged times; night-time operating
and is now generally avoided. Nausea and vomiting is
is rarely justi¢ed.36 More serious pathology, particularly
further reduced by avoiding opioids with a prolonged
head injury, may occur in association with otherwise ap-
duration of action, maintaining anaesthesia by the intra-
parently trivial injury.
venous infusion of propofol,28 and the prophylactic ad-
Clear guidelines exist for fasting of elective patients
ministration of ondansetron.29
and, anaesthetists often apply similar rules to emergency
Pre-auricular skin tags are usually removed in the ¢rst
cases.37 Whilst each case should be managed on its mer-
year of life.They may contain cartilage, but are easily ex-
its, a number of individual factors may help make the de-
cised under general anaesthesia supplemented with in¢l-
cision as to how the airway should be managed.38
tration of local anaesthetic.More severe abnormalities of
As mentioned above, most trauma surgery is simple,
the external ear may occur as part of a syndrome with
but occasionally severe tissue loss will need more com-
other defects that result from abnormal development of
plex surgery with tissue transfer. Environmental tem-
the ¢rst and second branchial arches.30 In these cases,
perature control, attention to £uid balance calculations,
aesthetic correction is undertaken as part of the overall
and the use of supplementay regional anaesthetic techni-
management of the associated problems.
ques where possible are major considerations. Experi-
enced postoperative monitoring of both patient and
tissue £ap are necessary. Flap donor sites, for example la-
HAND SURGERY tissimus dorsi muscle, are not always amenable to regio-
nal anaesthesia and postoperative analgesia can be well
Congenital hand deformities range from simple acces-
managed by opioid infusion tailored to accepted local
sory digits to complete absence of digits and associated
guidelines.To this may be added a patient controlled facil-
hand structures. Thus, surgery varies from short proce-
ity according to the level of understanding of the child.22
dures to surgically complex prolonged operations such as
toe-to-hand transfer. The anaesthetic management of
such cases is usually straightforward, requiring attention
to detail in respect of positioning, temperature control
SURGERY FOR THERMAL INJURY
and e¡ective analgesia. The surgical tourniquet, occa- Management of acute burns in children is a highly specia-
sionally employed in two sites, has the potential to cause lized subject, and initial treatment has as its primary aim
permanent injury and so care should be taken with ap- restoration of skin integrity. Scarring left from the
propriate tourniquet size, padding and duration of use. healed burn and skin grafting may need further surgery
Tourniquets are a source of signi¢cant surgical stimulus, to improve the functional and aesthetic result. These
and may require potent intraoperative analgesia.31 An in- children often make several trips to the operating thea-
teresting e¡ect of tourniquet use is its potential to raise tre, and continuity of care is helpful. This permits indivi-
core temperature intraoperatively.32 dual likes and dislikes to be catered for, at times when the
Regional blocks, particularly the axillary approach to maintenance of even small degrees of control can be very
brachial plexus block, are useful for analgesia. Multiple important to the child.
site injections appear to confer no bene¢t over the single Again, the surgery ranges from minor scar revision to
injection in children.33 Insertion of a catheter into the prolonged and extensive reconstruction and anaesthesia
plexus sheath via the axillary approach allows continuous is adapted accordingly following discussion with the
blockade to be established. Whilst a pre-emptive e¡ect surgeon. Airway di⁄culties and problems in securing

4. 90 CURRENT ANAESTHESIA & CRITICAL CARE
venous access can prolong anaesthetic induction and 6. Daly H, Moscuzza F. Anaesthesia for the child with congenital
theatre timings should be adjusted appropriately. Scar- heart disease undergoing non-cardiac surgery. In: Kaufman L, Gins-
ring deformity to the upper airway may result in di⁄cult burg (eds). Anaesthesia Review 14. London: Churchill Livingstone,
1998; 57^71.
laryngoscopy and, more rarely, di⁄cult face mask venti- 7 HenrikssonT G, Skoog V T Identi¢cation of children at high anaes-
. .
lation. The former can be managed by laryngeal mask in- thetic risk at the time of primary palatoplasty. Scand J Plast Re-
sertion or ¢breoptic-assisted intubation following constr Surg Hand Surg 2001; 35: 177^182.
induction of general anaesthesia. The latter represent a 8. Caouette-Laberge L, Bayet B, Larocque Y The Pierre Robin se-
.
more complex scenario and may require an airway quence: review of 125 cases and evolution of treatment modalities.
Plast Reconstr Surg 1994; 93: 934 ^942.
to be secured prior to anaesthesia. Achieving this in
9. Tobin M, Stevenson G W, Hall S C. Anesthetic considerations for
an awake child is rarely possible and some form of the pediatric plastic surgical patient. Plast Surg Nurs 1994; 14:
light anaesthesia will usually be needed to achieve 71^78, 85.
co-operation.39 10. Marques I L, de Sousa T V, Carneiro A F, Barbieri M A, Bettiol H,
Gutierrez M R. Clinical experience with infants with Robin se-
quence: a prospective study. Cleft Palate Craniofac J 2001 Mar; 38:
171^178.
HYPOSPADIAS REPAIR 11. Asher-McDade C, Shaw W C.Current cleft lip and palate manage-
Hypospadias is a relatively common congenital condition ment in the United Kingdom. Br J Plast Surg.1990; 43: 318 ^321.
12. Sadove A M, Eppley B L. Pediatric plastic surgery. Clin Plast Surg
with an incidence quoted as high as 1:300 live male 1996 23: 139^155.
births.40 Other conditions often associated with hypos- 13. Shaw C A, Kelleher A A,Gill C P, Murdoch L J, Stables R H, Black A
padias are undescended testes and inguinal hernia. Iso- E. Comparison of the incidence of complications at induction and
lated hypospadiasis is rarely associated with upper emergence in infants receiving oral atropine vs no premedication.
urinary tract disorders, and further investigation is not Br J Anaesth 2000; 84: 174 ^178.
14. Gunawardana R H. Di⁄cult laryngoscopy in cleft lip and palate sur-
recommended in this group.41 A single- or two-stage re-
gery. Br J Anaesth 1996; 76: 757^759.
pair is usually carried out at about 3 years of age when 15. Hatch D J. Airway management in cleft lip and palate surgery. Br J
continence is established, and co-operation with cathe- Anaesth 1996; 76: 755^756.
terization is better.General anaesthesia is supplemented 16. Brown J M. Anaesthesia for cleft surgery. In: Patel H (ed.). Anaes-
with a caudal block to minimize opioid use and lead to a thesia for Burns, Maxillofacial and Plastic Surgery. London: Edward
Arnold,1993; 43^52.
smooth pain-free recovery.Various methods of prolong-
17 Andrews P J, Marchant R B. A new technique for di⁄cult intuba-
.
ing the block have been described.41,42 Children will have tion in babies.Technic 1995; 143.
an indwelling urinary catheter, usually per urethrum, for 18. Clark M X, Knights D T, Henley M. A risk associated with the
2^ 6 days postoperatively. Early mobilization reduces sur- shared airway in reconstructive palate surgery. Anaesthesia 2001;
gical complications though care must be taken to prevent 56: 1028.
pulling on or blockage of the catheter.40 19. Wolf A R, Lawson R A, Dryden C M, Davies F W. Recovery after
des£urane anaesthesia in the infant: comparison with iso£urane.
Br J Anaesth1996; 76: 362^364.
20. Bosenberg A T, Kimble F W. Infraorbital nerve block in neonates
FURTHER READING for cleft lip repair: anatomical study and clinical application. Br J
Anaesth 1995; 74: 506 ^508.
Many excellent general texts and articles exist detailing paediatric 21. de Lima J, Lloyd-Thomas A R, Howard R F, Sumner E, QuinnT M.
anaesthetic techniques for surgery, which apply as much to children Infant and neonatal pain: anaesthetists’ perceptions and prescrib-
having plastic surgery. For guidance on management of general ing patterns. BMJ1996; 313: 787 .
issues surrounding anaesthesia in children, readers may refer to es- 22. Kart T, Christrup L L, Rasmussen M. Recommended use of mor-
tablished texts.44 More speci¢c detail can be found for pre-medica- phine in neonates, infants and children based on a literature re-
tion,45 pre-operative fasting,46, peri-operative £uid balance47 and view: Part 2Fclinical use. Paediatr Anaesth 1997; 7: 93^101.
analgesia.48 23. Williams D G, Hatch D J, Howard R F. Codeine phosphate in pae-
diatric medicine. Br J Anaesth 2001; 86: 413^ 421.
24. Xue F S, An G, Tong S Y, Liao X, Liu J H, Luo LK. In£uence of
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18