Perioperative complications in infant cleft repair.

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ssBioMed CentHead & Face Medicine
Open AcceResearch
Perioperative complications in infant cleft repair
Thomas Fillies*1, Christoph Homann†1, Ulrich Meyer†2, Alexander Reich†3,
Ulrich Joos†1 and Richard Werkmeister†4
Address: 1Department of Cranio-Maxillofacial Surgery, University Münster, Waldeyerstr. 30, D-48149 Münster, Germany, 2Department of
Maxillofacial and Facial Plastic Surgery, University of Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany, 3Department of Anaesthesiology,
University Münster, Albert-Schweizerstr. 33, 48161 Münster, Germany and 4Department of Oral and Maxillofacial Surgery, Central German Armed
Forces Hospital, Rübenacher Str. 170, 56072 Koblenz, Germany
Email: Thomas Fillies* - fillies@uni-muenster.de; Christoph Homann - Christophhomann@aol.com; Ulrich Meyer - ulrich.meyer@med.uni-
duesseldorf.de; Alexander Reich - reich@anit.uni-muenster.de; Ulrich Joos - Ulrich.Joos@ukmuenster.de;
Richard Werkmeister - Rwerkmeis@aol.com
* Corresponding author †Equal contributors
Abstract
Background: Cleft surgery in infants includes special risks due to the kind of the malformation.
These risks can be attributed in part to the age and the weight of the patient. Whereas a lot of
studies investigated the long-term facial outcome of cleft surgery depending on the age at
operation, less is known about the complications arising during a cleft surgery in early infancy.
Methods: We investigated the incidence and severity of perioperative complications in 174 infants
undergoing primary cleft surgery. The severity and the complications were recorded during the
intraoperative and the early postoperative period according to the classification by Cohen.
Results: Our study revealed that minor complications occurred in 50 patients. Severe
complications were observed during 13 operations. There was no fatal complication in the
perioperative period. The risk of complications was found to be directly correlated to the body
weight at the time of the surgery. Most of the problems appeared intraoperatively, but they were
also followed by complications immediately after the extubation.
Conclusion: In conclusion, cleft surgery in infancy is accompanied by frequent and sometimes
severe perioperative complications that may be attributed to this special surgical field.
Background
Surgical treatment of clefts during the infancy is not only
a particular challenge for the maxillo-facial surgeon but
also for the anaesthesiologist. Studies by Tiret et al. [1,2]
showed that the risk of complications during the general
anaesthesia is three times higher in children than in
adults. From the physiological point of view, an infant dif-
anatomical particularities which can cause problems dur-
ing the cleft treatment. The enhanced incidence of anaes-
thesiological complications in children with cleft lip and
palate (CLP) can be attributed to various factors such as a
higher viscid airway resistance, a higher incidence of res-
piratory infections, nutritional deficiencies, developmen-
tal anomalies and anatomical features like micrognathia,
Published: 5 February 2007
Head & Face Medicine 2007, 3:9 doi:10.1186/1746-160X-3-9
Received: 2 November 2006
Accepted: 5 February 2007
This article is available from: http://www.head-face-med.com/content/3/1/9
© 2007 Fillies et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5
(page number not for citation purposes)
fers from an older child in that most organs are still imma-
ture [3,4]. Young infants possess
macroglossia and jaw-bone hyoplasia. Furthermore, in
cleft lip and/or palate patients the anomaly requiring sur-

Head & Face Medicine 2007, 3:9 http://www.head-face-med.com/content/3/1/9
gery can be associated with one of 150 different syn-
dromes or nonsyndromical abnormalities [3,5].
The factors influencing the overall outcome of cleft repair
are multiple and complex. Timing of cleft lip and palate
closure remains controversial in the literature [6]. A com-
promise must be made on the age at surgery and the sur-
gical outcome concerning facial growth, scarring, speech,
language development, and psychological factors [7].
Until the last decade, primary cleft operations were usu-
ally carried out in the first three years of age [6]. Today,
CLP repair is done within the first 12 months of life. At
this age the body weight varies between 5 and 10 kg, the
whole blood volume between 400 and 700 ml. Thus,
blood loss is of major concern in infant surgery.
Aspects on the time schedule for cleft surgery discussed in
the literature are focused mainly on local surgical
demands and outcomes, whereas only a few studies con-
sider the occurrence of perioperative complications [8,9].
The aim of our investigation was to analyse the peri- and
postoperative complications of primary cleft repair in the
early stages of infancy.
Methods
The anaesthesia protocols for 174 patients with cleft lip/
palate undergoing surgery at our centre in the course of
three years were reviewed. Only children younger than
three years at the time of surgery were included in the
study. Primary closure of the cleft lip and alveolus was
usually performed at the age of three months, closure of
the palate at the age of nine months. No single step sur-
gery was performed.
The perioperative supervision included pulse oximetry,
ECG, measurement of the end expiratory carbonic diox-
ide, blood pressure, rectal measurement of temperature
and auscultation using precordial stethoscopes. Face mask
ventilation was performed until the child was in deep
sleep. Atropine dosed at 0.01 mg kg-1 body weight and
Trapanal dosed at 3–5 mg kg-1 were given before orotra-
cheal intubation was done without relaxation. Special
designed tubes were used with steel strengthening inside
the tube. After tube fixation and monitor complementa-
tion all children got paracetamol suppositories. The body
temperature was stabilized by using warm blankets. The
monitoring was continued in the recovery room. The chil-
dren returned to the children's ward after their conditions
were stabilized.
All surgical and anaesthesiological complications were
evaluated on the basis of medical records. The complica-
recorded as minor when the heart rate exceeded 20% or
dropped below 50% at the beginning or if the loss of
intraoperative body temperature was about 1°C above or
2.5°C below starting level. Decreased oxygen saturation
lower than 85% and disconnection of the endotracheal
tube were also considered as minor complications.
Anaesthesiological difficulties like a tube dislocation, oxy-
gen saturation below 85% exceeding one minute, an
increasing heart rate above 50% of the baseline level or
lower than 80 beats per minute were recorded as severe
complications. Increased body temperature by more than
2.5°C was considered as hyperpyrexia. Other severe com-
plications were laryngospasm, bronchospasm and cardi-
opulmonary resuscitation. The perioperative blood loss
was directly determined in 68 cases by an evaluation of
the weight of compresses, instruments, sucker and suction
tubes and indirectly by a measurement of the haemo-
globin and hematocrit concentration one day before and
12 hours after surgery.
Results
Cleft lip closure was performed in 73 patients, cleft palate
closure in 101 patients. Additional surgery, such as myrin-
gotomy in 44% (76/174) of the patients, was performed
by otorhinolaryngologists when indicated. We had minor
complications in 50 out of 174 operations (28.7%). Tem-
perature variation was found to be the most frequent com-
plication (n = 48). Other complications such as tube
disconnection (n = 1), increasing blood pressure (n = 1),
reintubation (n = 1) or low oxygen saturation (n = 1)
occurred rarely. Tube dislocation and hyperthermia
occurred in two patients, hypothermia in one patient. Dif-
ficulties during intubation led to fiberoptic intubation in
one infant, and reintubation in another. Laryngospasm
and bronchospasm each occurred once. During the 174
operations 25 (14.4%) severe complications occurred in
13 patients (Table 1). Two of these 25 severe complica-
tions appeared in the group of syndromic cleft patients (2/
5, Down's syndrome (two patients), De-Georgie's Syn-
drom, Marfan's syndrome, Pierre Robin's).
We found a direct correlation between the occurrence of
complications and the body weight at the time of opera-
tion. Complications were found in 54 % of patients
weighing between 4 and 6 kg. The incidence of complica-
tions in patients with a bodyweight of more than 8 kg was
found to be 26% (Table 2). Regarding the occurrence of
all severe and minor complications we found no signifi-
cant differences between the groups of lip closures and
palate closures. Correlating with the complication rates
regarding the body weight, we found 8 operations with
severe complications and 5 operations with minor com-Page 2 of 5
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tions were classified in minor or severe cases based on the
classification of Cohen et al. [10] Complications were
plications in the group of lip closures (Table 3).

Head & Face Medicine 2007, 3:9 http://www.head-face-med.com/content/3/1/9
Both minor and severe complications occurred mostly
intra-operatively (45 minor complications, severe 9 com-
plications). A increased number of complications were
also found after the extubation. Complications in the
recovery room occurred in 7 patients after the extubation.
The directly measured blood loss during the primary cleft
repair closure of the lips was amounted to (mean (S.D.))
15,5 ml (12,1 ml) during closure of the lips and to 28,0
ml (19.1 ml) during closure of the palate (Figure 1). In the
patient group undergoing operations of the lip (28 opera-
tions) we measured a decrease in haemoglobin concentra-
tion of 1.3 g dl-1 on average in 4 patients (14.2 %) and of
1.4 g dl-1 in 9 (22.5 %) patients of the group with correc-
tion of the palate (40 operations). Decreased haemo-
globin concentration was found in 8 patients (21.4%)
after lip closure and in 16 patients (40 %) after closure of
the palate. The average decrease in haemoglobin concen-
tration was 4.4 % below the baseline level in the patients
undergoing lip repair and about 5.5% below the baseline
level in patients undergoing palate repair.
Discussion
Many concepts of cleft repair have been discussed in liter-
ature focussing mainly on the timing of cleft surgery and
its long-term surgical outcome. The potential benefits of
cleft closure in infants regarding developmental and
social-emotional factors must be weighed against the sur-
gical risks because the risk of early cleft repair is basically
the risk of surgery in early infancy [6,10]. Our study
revealed frequent complications during cleft surgery. A
high number of complications were associated with the
emergence and maintenance of stable upper airway dur-
ing intubation, ventilation and extubation. The data of
this study confirm the findings of other authors evaluat-
ing airway complications during cleft surgery [11]. Guna-
wardana [12] prospectively studied 800 pedriatric
patients undergoing a repair of a cleft lip and palate in
order to determine the factors that are predictive of diffi-
cult laryngoscopy. The occurence of a difficult laryngos-
copy (Cormback and Lehane grade III and IV [13]) was
found to be 3.0% in patients with a unilateral cleft lip,
45.8% in patients with a bilateral cleft lip and 34.6% in
patients with retrognathia. It was demonstrated by Guna-
wardana [12] that in general, laryngoscopy becomes eas-
ier with increasing age (66.1% of the patients with a
difficult laryngoscopy were younger than 6 months of
age). As extensive clefts, retrognathia and an age of less
than 6 months are associated with difficult laryngoscopy,
these conditions have to be kept in mind when the anaes-
thetic technique is planned [12]. Van Boven thus con-
cluded that it would be necessary to have an experienced
anaesthesiologist with expertise in children's anaesthesia
being supported by appropriate intra- and postoperative
monitoring [4]. This is of particular importance consider-
ing the possible association of nonsyndromatic abnor-
malities with clefts of the lip and palate and resulting
anaesthesiological complications. In 40% of the cases of
Table 2: Coherence between body weight and anaesthesiological complication
weight (kg) quantity (n = 174) No complications minor complications severe complications
4–6 42 22/42 (52.4%) 15/42 (35.7%) 5/42 (11.9%)
6–8 52 31/52 (59.6%) 18/52 (34.6%) 3/52 (5.8%)
>8 80 58/80 (72.5%) 17/80 (21.3%) 5/80 (6.3%)
Table 1: Occurences of minor and severe complications (scp: syndromic cleft patient)
minor complications quantity (n = 174) severe complications quantity (n = 174)
Hypothermia 15 hypothermia 1
Hyperthermia 30 Hyperthermia 2
tube disconnection 1 CPR 2
increasing blood pressure 1 tube dislocation 2
Reintubation 1 Bradycardia 5
low oxygenation 2 Iow oxygenation 5
difficult intubation (scp) 1
reintubation 1
laryngospasm (scp) 1
bronchospasm 1
50 operations 50 13 operations 25Page 3 of 5
(page number not for citation purposes)
174 111/174 (63.8%) 50/174 (28.7%) 13/174 (7.5%)

Head & Face Medicine 2007, 3:9 http://www.head-face-med.com/content/3/1/9
the group of cleft patients with syndromic abnormalities
we observed severe complications such as difficult intuba-
tion and bradycardia.
Moreover, our investigations revealed a significant
number of minor and severe complications in the recov-
ery room. For this reason we agree with Denk and Magee
that specialised postoperative care with experienced med-
ical and nursing staff is of equal importance as careful pre-
operative evaluation and safe intraoperative care [6].
Our investigations revealed frequent complications that
may be attributed directly or partially to intra-operative
blood loss. Whereas the alteration of the heart beat fre-
quency is a direct consequence of blood loss, the lowering
of the body temperature is an indirect consequence. The
shortening of the duration of a cleft surgery is an impor-
tant step to reduce the total loss of blood [11]. The reduc-
tion of the intra-operative blood loss is one approach to
decreasing the probability and the severity of intra- and
post-operative complications. A blood loss of about 50 ml
during infant surgery with total patient blood volume of
400 to 700 ml can disturb the circulation, requiring a
transfusion of blanked blood or plasma substitutes. A pre-
cise assessment of the blood loss is therefore vital in order
to find the balance between over-transfusing and unnec-
essary transfusion [15,16].
An exact determination of quantity of intra-operatively
lost blood is important, though methodologically diffi-
cult. Several methods to monitor perioperative blood loss
have been described in literature – weighing swabs [17],
colorimetry [18], osmolality dilution technique [19] and
methods specifically for cleft surgery [15].
Clinical studies showed that the amount of blood loss
depends on the operation technique, the surgeon's expe-
rience and the timing of cleft closure [6,16]. Scheune-
mann and Stellmach, for example, described an average
blood loos of 32–50 ml in their patient group during an
unilateral cheiloplasty. Cheiloplasty in combination with
the repair of the nasal floor was associated with an average
blood loss of 49–60 ml and confirmed on palatoplasty
with a blood loss of about 87–129 ml [20]. Another inves-
tigation by Reinisch described an average blood loss of 30
ml during cheiloplasty [21].
In infant surgery, special consideration should be given to
the fact that 50–59% of the haemoglobin is fetal haemo-
globin with impaired oxygen emission despite generally
high haemoglobin concentrations in the infant period. A
newborn infant is therefore dependent on higher haema-
tocrit [22]. It has to be kept in mind that in the first 3
months of life the normal haemoglobin concentration
decreases to low values (trimenon anaemia) because fetal
haemoglobin decreases and is only slowly replaced by
adult haemoglobin [16].
In this study, the blood loss was first directly quantified.
Additionally the haemoglobin and haematocrit concen-
tration were measured before and 12 hours after surgery.
In our patient group blood loss was higher after the repair
Directly measured blood loss during primary lip(n = 28) and palate repair (n = 40)Figure 1
Directly measured blood loss during primary lip(n = 28) and
lip surgery palate surgery
0,00
10,00
20,00
30,00
40,00
50,00
60,00
70,00
bl
oo
d
lo
ss
in
m
l
Table 3: Coherence between lip/palate closure and anaesthesiological complications
operation quantity no complications minor complications severe complications
lip closure 73 40/73 (54.8%) 25/73 (34.2%) 8/73 (11.0%)
palate closure 101 71/101 (70.3%) 25/101 (24.8%) 5/101 (5.0%)Page 4 of 5
(page number not for citation purposes)
of the palate than after closure of the lip. No blood trans-
fusion was necessary. We found an increased incidence of
palate repair (n = 40).

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Head & Face Medicine 2007, 3:9 http://www.head-face-med.com/content/3/1/9
complications in dependence on the body weight at the
time of operation. In accordance to our findings Wilhelm-
sen and Musgrave found that a body weight of more than
5 kg, haemoglobin of more than 10 g dl-1 and additionally
a white blood count of less than 10000 µl-1 was associated
with less risk of complications to the factor of 5 [23].
Our study revealed that the risk of perioperative complica-
tions was found to be correlated to the body weight at the
time of the surgery. Substantially, the perioperative com-
plication concern anaesthesiological complications in
cleft repair. No severe surgical complication as fulminant
blood loss was found.
Conclusion
In view of today's multitude of time-related concepts of
cleft surgery investigations are required searching for the
optimal moment for a cleft repair – with low severe peri-
operative complication rates but favourable functional
and aesthetic results.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
TF: Project planning, data analysis and writing of the man-
uscript
CH: Project planning, data analysis and writing of the
manuscript
UM: Writing of the manuscript, critical appraisal of the
manuscript
AR: Project planning, critical appraisal of the manuscript
UJ: Critical appraisal of the manuscript
RW: Project planning, critical appraisal of the manuscript
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