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Introduction of an Individualized Palatal Splint for Wound Protection after Cleft Palate Repair

Jacobsen, Christine M.D., D.M.D.; Zemann, Wolfgang M.D., D.M.D.; Metzler, Philipp M.D., D.M.D.; Obwegeser, Joachim M.D., D.M.D.

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Plastic and Reconstructive Surgery: April 2012 - Volume 129 - Issue 4 - p 745e-746e
doi: 10.1097/PRS.0b013e318245e878
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Sir:

Figure
Figure

Since the early 1800s, palatal repair in children with cleft lip has become a routine procedure, although different surgical techniques and postoperative regimens are used. Not much has been published about the influence of the early postoperative regimen.

Different risk factors for early postoperative wound breakdown have been described. One factor is premature hard food intake, and another factor is the direct manipulation by the child himself or herself in the wound area.1 Another important factor for an early postoperative healing problem is the formation of hematoma, which may lead to failure of adequate wound healing, with subsequent oronasal fistula. In addition, surgical intervention with areas of secondary healing and intraoral stitches puts extraordinary stress on a small child.

Although contrary reports have been published,2 most surgeons still use different methods to prevent early wound breakdown. One possibility is a strict postoperative food regimen.1 Another important measure is the prevention of direct manipulation by the child in the operated region, mostly with some form of arm restraints. A survey by Katzel et al. in 2009 showed that 85 percent of 306 cleft surgeons used some form of arm restraints, usually for 2 weeks.3,4 Another possibility of wound protection would be packing the wound surface with iodine gauze pack or using tongue depressors.5 Most of these postoperative methods are associated with a lot of discomfort for both the child and the parents. In this article, a simple and inexpensive method of protecting the wound surface postoperatively is presented.

Wound protection with simultaneous administration of moderate pressure onto the different layers is achieved by using a thermoplastic tailorable splint (X-Lite; Allenspach Medical, Balsthal, Switzerland), made of a lightweight, low-temperature thermoplastic cotton mesh, impregnated with a copolymer. The material is nontoxic and biodegradable, and can easily be fixed in the oral cavity with three nonresorbable sutures (Ethilon; Johnson & Johnson Medical GmbH, Norderstedt, Germany).

After cutting an adequate size piece of the splint material and warming it in water at the end of the surgical intervention, the splint is fabricated directly in the oral cavity for perfect fit (Fig. 1). If required, a hemostatic interface can be put in between the splint and the wound surface. The splint is removed on postoperative day 4 on the ward or in the outpatient setting by cutting the three sutures.

Fig. 1
Fig. 1:
(Above) Intraoperative view of the situation after cleft palate repair, before fixation of the splint. Note the areas of secondary wound healing. (Below) The situation after fixation of the tailorable splint with sutures.

There are several advantages to using this tailorable splint:

  • There is no need for arm restraint in children undergoing surgery. The operated area is covered.
  • The splint is thin and easy to clean, in contrast to a bulky gauze pack. Discomfort for the patient therefore is decreased.
  • The wound with its areas of secondary healing is protected; therefore, the postoperative food regimen can be released and postoperative pain is reduced.
  • The reversible, thermoplastic material makes the splint fit perfectly in the individual palate geometry.
  • Moderate pressure is put on the wound; therefore, hematoma formation is prevented.
  • The splint is easy, quick to use, and cost- effective.

Christine Jacobsen, M.D., D.M.D.

Wolfgang Zemann, M.D., D.M.D.

Philipp Metzler, M.D., D.M.D.

Joachim Obwegeser, M.D., D.M.D.

Department of Craniomaxillofacial Surgery, University Hospital of Zurich, Zurich, Switzerland

REFERENCES

1. Kent R, Martin V. Nasogastric feeding for infants who have undergone palatoplasty for a cleft palate. Paediatr Nurs. 2009;21:24–29.
2. Sommerlad BC, Kangesu T. Arm restraint in children with cleft lip/palate. Plast Reconstr Surg. 2003;112:331–332; author reply 332.
3. Katzel EB, Basile P, Koltz PF, Marcus JR, Girotto JA. Current surgical practices in cleft care: Cleft palate repair techniques and postoperative care. Plast Reconstr Surg. 2009;124:899–906.
4. Babuccu O, Hoşnuter M, Kargi E, Babucçu B, Işikdemir A. Another practical method for arm restraint in children with cleft lip/palate. Plast Reconstr Surg. 2002;110:1185–1186.
5. Serel S, Can Z, Yormuk E. Arm restraint in children with cleft lip and palate. Plast Reconstr Surg. 2003;112:712; author reply 712.

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