**2. General considerations**

Cleft lip (CL) and cleft palate (CP) are one of the most common congenital anomalies found in the United States and the most common craniofacial anomaly seen by plastic surgeons. Nearly one in five hundred live births will result in a child affected by cleft CL and/or CP. The Center for Disease Control estimates that 2650 babies are born with CP and 4440 babies are born with CL with or without a CP annually [1]. In developing countries, such as México, CL and CP is the most common congenital malformation requiring surgical treatment and its incidence is 1:800 to 1000 live births. Of these, 33% have CL. 64% CL and CP. 2% only present a CP and 1%, rare craniofacial clefts. On average, there are 9.6 new cases per day and 3521 cases per year [2].

In the United States, children with CL and CP are primarily cared for in cleft centers with multidisciplinary teams. Teams consisting of otolaryngologists, plastic surgeons, oral surgeons, speech therapists, occupational therapists, dentists and orthodontists work together to ensure optimal timing and care of these patients. Anesthesiologists also integrate into these teams when surgical procedures are required. Studies from the United Kingdom suggest that children who are cared for by these multidisciplinary teams have improved long-term outcomes with improved feeding, speech, and esthetics [3–7]. For many families, the diagnosis of a cleft occurs during the prenatal period. Prenatal counseling may be the first interaction with the cleft team, facilitating a long relationship with multiple specialists to establish expectations regarding the long-term possibilities for children with CP or CL and CP. There are approximately 139,000 Mexicans who have CL and CP. It is a very important public health problem due to the medical, psychological and social impact to the patients and their family. The causes are multifactorial and can be environmental, genetic or a combination [8].

Infants with CL and CP can have difficulty generating oral suction which can make breast feeding and bottle feeding a challenge. Many infants with CL and CP struggle with feeding and may require special bottles, nipples or education to achieve adequate weight gain. Children without access to support services may endure nutritional consequences, which if not taken care of at an early age, can deteriorate or affect growth and development [2, 9].

The goals for surgical repair of CP and CL repair are to reconstruct the affected area, leading to improved feeding, speech, and function of the nasal airway. CL repair in the United States typically occurs first within 2 to 3 months of age with CP repair occurring between 9 and 12 months [10]. The time between birth and this initial repair allows for a thorough work up of other co-morbidities and evaluation of any underlying syndromes. In the majority of children with a cleft there are no other associate syndromes or malformations. However, 20–30% of patients will have some underlying syndrome or systemic abnormalities requiring evaluation and potentially treatment prior to repair of the cleft [11]. Isolated CP has the greatest incidence of associate abnormalities while isolated CL is most likely to be an isolated feature. Thus, a thorough pre-operative evaluation by the cleft team is essential prior to surgical repair.

availability of a blood bank and an ICU in case of an adverse event. When all of these factors are well controlled and overseen by an experienced team, the risk for an adverse outcome is significantly reduced. This is why there has been an international consensus for guidelines that will lead the cleft team to successful surgical and anesthetic performances. If the team is visiting a foreign country, they must follow the same gold standards of care contained within these guidelines and work within their scope of practice. If the medical setting that they are visiting lacks the equipment, medications and supplies needed for them to perform at their best, then

Cleft lip (CL) and cleft palate (CP) are one of the most common congenital anomalies found in the United States and the most common craniofacial anomaly seen by plastic surgeons. Nearly one in five hundred live births will result in a child affected by cleft CL and/or CP. The Center for Disease Control estimates that 2650 babies are born with CP and 4440 babies are born with CL with or without a CP annually [1]. In developing countries, such as México, CL and CP is the most common congenital malformation requiring surgical treatment and its incidence is 1:800 to 1000 live births. Of these, 33% have CL. 64% CL and CP. 2% only present a CP and 1%, rare craniofacial clefts. On average, there are 9.6 new cases per day and 3521 cases per year [2]. In the United States, children with CL and CP are primarily cared for in cleft centers with multidisciplinary teams. Teams consisting of otolaryngologists, plastic surgeons, oral surgeons, speech therapists, occupational therapists, dentists and orthodontists work together to ensure optimal timing and care of these patients. Anesthesiologists also integrate into these teams when surgical procedures are required. Studies from the United Kingdom suggest that children who are cared for by these multidisciplinary teams have improved long-term outcomes with improved feeding, speech, and esthetics [3–7]. For many families, the diagnosis of a cleft occurs during the prenatal period. Prenatal counseling may be the first interaction with the cleft team, facilitating a long relationship with multiple specialists to establish expectations regarding the long-term possibilities for children with CP or CL and CP. There are approximately 139,000 Mexicans who have CL and CP. It is a very important public health problem due to the medical, psychological and social impact to the patients and their family. The

causes are multifactorial and can be environmental, genetic or a combination [8].

Infants with CL and CP can have difficulty generating oral suction which can make breast feeding and bottle feeding a challenge. Many infants with CL and CP struggle with feeding and may require special bottles, nipples or education to achieve adequate weight gain. Children without access to support services may endure nutritional consequences, which if not taken care of at an early age, can deteriorate or affect growth and development [2, 9].

The goals for surgical repair of CP and CL repair are to reconstruct the affected area, leading to improved feeding, speech, and function of the nasal airway. CL repair in the United States typically occurs first within 2 to 3 months of age with CP repair occurring between 9 and 12 months [10]. The time between birth and this initial repair allows for a thorough work up of

they should bring the equipment, medications and supplies with them.

**2. General considerations**

56 Anesthesia Topics for Plastic and Reconstructive Surgery

At least 275 different syndromes [12] have been associated with CL and CP. There are a variety of co-morbidities associated with these syndromes. However, cardiac and airway abnormalities represent the primary concerns of the anesthesia teams prior to repair of cleft abnormalities. Syndromes such as Pierre Robin Sequence, Treacher Collins, Goldenhar Syndrome and 22q deletion, are associated with mandibular hypoplasia, potentially making airway management and repair difficult. Cardiac abnormalities are the most frequent associate co-morbidity in children with clefts [13]. Tetralogy of Fallot, atrial septal defect and ventricular septal defect represent the most common congenital heart disease seen in this patient population. A thorough physical exam and imaging with cardiac echocardiogram should be performed for these children. Cardiac abnormalities should be optimized and potentially repaired prior to repair of the cleft itself. Optimization of other co-morbidities, such as airway anomalies, renal dysfunction, nutrition and additional medical issues, should also be a top priority in the months following birth. Children with CP are prone to middle ear effusions and recurrent otitis media. The dysfunction of the palate muscles impairs regulation of the Eustachian tubes, which may increase the risk of upper respiratory infections.

Patients with CP have an increased risk of gastroesophageal reflux and pulmonary aspiration which may contribute to airway reactivity. Speech impairment also occurs due to the abnormal anatomy of the CP musculature and speech development is further hindered in patients with hypoacusia [12]. In México, the multidisciplinary approach is a must in almost all 53 cleft clinics located throughout the country and the role of the anesthesiologist is vital as well as the pediatrician, cardiologist, geneticist, nutritionist, pneumologist, gastroenterologist and all other specialists that may be involved in the preoperative assessment for the patient. Once the patient has undergone the lip and/or palate surgeries, the multidisciplinary cleft team involving the surgeon, orthodontist, speech therapist, otorhinolaryngologist, audiologist and psychologist become very active in providing their services to improve the physical appearance and the functional activity regarding speech, hearing, feeding, and socialization and self-esteem of the patient [14].
