Regional Anesthesia for Cleft Lip Repair: A Preliminary Study

Naveen Eipe, M.D., Ashish Choudhrie, M.S., A. Dildeep Pillai, M.S., Rajiv Choudhrie, M.C.H.

Objective: To assess whether local anesthetic blockade of the infraorbital

nerve may allow for cleft lip repair to be performed under regional anesthesia.
Method: Twenty patients above 12 years of age with cleft lip (7 females and
13 males) were enrolled. Careful preoperative counseling was given. Bilateral
infraorbital block was performed (extraoral approach) with 10 mL of equal vol-
umes of 2% lidocaine with 1:200,000 adrenaline and 0.5% bupivacaine. The
point of entry was the intersection of a vertical line through the pupil of the
eye (in the neutral position) and a horizontal line through the ala of the nose.
The needle was directed medially and cephalad until the infraorbital foramina
was reached and 2 mL was injected. Through the same point of entry, but
directed medially (toward the ala), 1 mL was injected followed by a 2-mL in-
jection caudally and medially (into the lip).
Results: The block was successful in all patients without complication. The
surgery was uneventful, lasting between 45 and 60 minutes. The postoperative
duration of analgesia was between 6 and 24 hours (mean 16.5 6 5.10 SD).
Conclusions: The nerve supply of the cleft lip, our modification of the block,
and possible problems with this technique are discussed. This study confirms
the utility of this block for postoperative analgesia. Further studies are required
to apply this innovative, safe, and economical modification of anesthesia for
cleft lip surgery.

KEY WORDS: cleft lip repair, infraorbital nerve block, regional anesthesia, surgery

The infraorbital nerve provides sensory supply to the upper
lip. In selected patients, local anesthetic blockade of this nerve
may allow for cleft lip repair to be performed under regional
anesthesia.
METHODS
Patients
After institutional research and ethics committee approval,
20 patients between 12 and 40 years of age with cleft lips (7
females ages 14–22 years, 13 males ages 12–40 years) were
enrolled in this study (March 2004 to January 2005). All had
clefts of the lip; 17 were previously unoperated and the other
3 had repairs requiring revisions. The clefts were incomplete
in 17 patients and complete in the others (Table 1).
Patients with coexisting disease and those with whom com-
munication was difficult (because of language problems or
learning disabilities) were excluded. Written consent was ob-
tained from the patients. Careful preoperative counseling was
Dr. Eipe is Consultant Anesthetist in the Department of Anesthesia, Dr. A.
Choudhrie and Dr. Pillai are Consultant Surgeons in the Department of Surgery,
and Dr. R. Choudhrie is Consultant Plastic Surgeon in the Department of Plastic
Surgery, Padhar Hospital, Padhar, Betul District, Madhya Pradesh, India.
Submitted March 2005; Accepted June 2005.
Address correspondence to: Dr. Naveen Eipe, M.D., Padhar Hospital, Padhar,
Betul District, Madhya Pradesh-460005, India. E-mail neipe@yahoo.com.
given. The procedure was carried out in the regular operating
rooms (ORs) with all facilities and personnel available for pro-
viding general anesthesia.
Procedure
All patients fasted after a drink of water for 2 to 4 hours.
In the OR, intravenous access was obtained and standard mon-
itoring was instituted. The infraorbital nerve was blocked by
an extraoral approach with 10 mL of local anesthetic solution
(equal volumes of 2% lidocaine with 1:200,000 adrenaline and
0.5% bupivacaine). The point of entry was the intersection of
a vertical line through the pupil of the eye (in the neutral
position) and a horizontal line through the ala of the nose.
From this point, the 23-gauge needle was directed medially
and cephalad until the infraorbital foramina was reached. The
needle was then withdrawn slightly and 2 mL was injected.
Through the same point of skin entry, but directed medially
(toward the ala), 1 mL was injected. The last 2 mL was in-
jected caudally and medially toward the lip. The same proce-
dure was repeated on the opposite side with the remaining 5
mL. The adequacy of anesthesia was ascertained after 5 min-
utes by checking for sensation to touch over the entire lip. The
surgeon again confirmed the absence of sensation with the
marking point before the first incision. After marking the skin,
the surgeon infiltrated the edges with 5 mL of solution (1 mL
of 2% lidocaine with adrenaline 1:200,000 and 4 mL of saline)

138

TABLE 1 Distribution of Patients by Diagnosis and Surgery*
Diagnosis
Surgery Incomplete Cleft Lip Complete Cleft Lip
Primary 16 (L 5 12, R 5 4) 1 (R 5 1)
Secondary 1 (R 5 1) 2 (R 5 1, BL 5 1)
Total 17 3 20
* L 5 left; R 5 right; BL 5 bilateral.
for hemostasis. Saline-soaked gauze was placed in the ipsilat-
eral nostril to prevent the patient from breathing over the in-
cision. Extreme care was taken to prevent any blood from
trickling into the nose or mouth. In the postoperative period,
the patients were again assessed for analgesia at regular inter-
vals. They were allowed to drink water after 4 hours and there-
after received oral acetaminophen for pain.
RESULTS
The block was performed by the same anesthetist and was
successful in all patients without complication. The surgery
was uneventful, lasting between 45 and 60 minutes. The post-
operative duration of analgesia was between 6 and 24 hours
(mean 16.5 6 5.10 SD) (Fig. 1). There were no incidents of
postoperative nausea or vomiting. All patients were able to get
up and eat within 12 hours after the procedure. The overall
satisfaction with the procedure was rated as high.
DISCUSSION
In this part of the world (India), there are both teenage and
adult patients with untreated cleft lips and palates. This situ-
ation may be attributed to socioeconomic deprivation and lack
of awareness coupled with inadequate surveys and medical
facilities. As many as 30% of patients presenting for primary
surgery are over 12 years of age. Others who undergo surgery
in early childhood may require revision surgery while still in
the same age group. This technique may be useful for both
surgeries in this age group.
Nerve Supply
In a normal lip, the infraorbital nerve supplies the sensory
innervation to the skin and mucous membrane of the upper lip
and lower eyelid, the skin between them, and to the side of
the nose (Bösenberg and Kimble, 1995). In cleft lips, it sup-
plies the lateral part of the cleft lip whereas the opposite in-
fraorbital nerve supplies the medial part of the cleft lip. Bilat-
eral infraorbital nerve block has been demonstrated to be use-
ful in providing postoperative analgesia in infants and children
undergoing cleft lip repair (Nicodemus et al., 1991; Ahuja et
al., 1994; Gunawardana, 1996; Mayer et al., 1997; Prabhu et
al., 1999). In neonates and children, this technique avoids post-
operative (opioid induced) respiratory depression and allows
for the patient to wake up pain free (Bösenberg and Kimble,
1995).
Eipe et al., REGIONAL ANESTHESIA FOR CLEFT LIP REPAIR 139
Total
17
3
FIGURE 1 Duration of postoperative analgesia after infraorbital nerve
block.
Prabhu et al. (1999) have demonstrated that the infraorbital
nerve block provides better and more prolonged analgesia than
peri-incisional infiltration in cleft lip repair. Furthermore, they
conclude that although both methods of analgesia may be ad-
equate to prevent responses to skin incision, they do not sub-
stitute for adequate systemic analgesia during the operation. In
both groups, a significant rise in heart rate and blood pressure
(accompanying tracheal intubation) was observed. These re-
sponses may be prevented, avoiding intubation of the trachea
and thereby avoiding the need to administer systemic analge-
sics or opioids. Surgical infiltration of the lip with adrenaline
containing local anesthetics is useful in decreasing bleeding,
but this tends to distort the margins of the cleft and makes
esthetic repair difficult (Bösenberg and Kimble, 1995). There-
fore, cleft lip repair cannot be satisfactorily performed under
local infiltration. In this preliminary study, by blocking the
infraorbital nerve we have attempted to demonstrate its use-
fulness in providing regional anesthesia for cleft lip surgery in
teenagers and adults. Cleft lip and palate surgery under general
anesthesia has complications (Pechter and Lesavoy, 1985) and
may be avoided by this technique.
Technique
Because the infraorbital nerve is purely sensory nerve, a
peripheral nerve stimulator cannot be used to locate it. It can,
however, be easily blocked as it emerges from the infraorbital
foramina. This foramina is either palpable or can be estimated
from other palpable landmarks (Bösenberg and Kimble, 1995).
There are two well-known approaches to the infraorbital nerve:
intraoral or extraoral. The intraoral approach has been de-
scribed to be at least as effective in producing upper-lip an-
esthesia as the percutaneous approach (Lynch et al., 1994) but
has also been known to be associated with complications. Oc-
ular penetration after intraoral infraorbital nerve block has
been reported (Weinand et al., 1997) in a patient with an absent
palate (presumably caused by congenital cleft malformation or
140 Cleft Palate–Craniofacial Journal, March 2006, Vol. 43 No. 2
surgery). This allowed needle penetration through smooth tis-
sue into the globe. Many of our patients have combined clefts
of the lip and palate; therefore, we prefer the extraoral ap-
proach.
In neonates, the landmark is the midpoint of the line joining
the angle of the mouth to the midpoint of the palpebral fissure
(Bösenberg and Kimble, 1995). In adults, the landmark is the
midpoint of the line joining the supraorbital ridge and the men-
tal foramina (Wedel, 2000). Both of these locate the infraor-
bital foramina, and the direction of injection is perpendicular.
This report describes a new technique of infraorbital nerve
block for adults. Our point of entry at the level of the nasal
ala is lower. This approaches the nerve through a less bulky
part of the cheek and allows for three injections through the
same point of entry, namely, toward the nerve, through the
ala, and into the lip. This improves the block by anesthetizing
the nasal and labial branches of the infraorbital nerve that are
missed by the higher approach.
The role of preemptive analgesia in infraorbital nerve block
has been demonstrated. According to Honnma et al. (2002),
patients of the preemptive group had significantly less post-
operative pain during the whole postsurgery period. Because
of this added (theoretical) advantage, our block of the nerve
before the incision achieves superior postoperative analgesia.
Postoperative Analgesia
According to Prabhu et al. (1999), patients receiving this
block required analgesics after only 8 hours. One patient in
the current study was uncomfortable after 6 hours. Nicodemus
et al. (1991) reported a mean pain-free duration of 19.4 6
5.06 hours. Both these studies describe the duration of anal-
gesia after a general anesthetic and were therefore longer. The
mean duration (16.5 6 5.10 hours) observed in the current
study was lower because the block was the sole anesthetic.
Therefore, the utility of this block for postoperative analgesia
has been demonstrated and confirmed.
Troubleshooting
The block fails to anesthetize the nasal septum, the floor of
the nose, and the premaxilla. Therefore, wide clefts involving
or requiring the mobilization of tissue from these areas may
not be suitable for repair under this block. Bilateral complete
clefts with a prolabium may also be difficult to anesthetize
with this block.
Although satisfactory anesthesia has been provided to pa-
tients who required revision (secondary) surgery, a word of
caution is warranted. If there is extensive scarring or if the
cleft at birth was wide, this block may not be satisfactory for
revision (secondary) surgery. It is possible that, depending on
the primary repair technique, the original repair may distort
the innervation of the cleft lip. A block of the scarred tissue
is also difficult. Therefore, the application of this technique for
revisions requires further investigation.
Intraoperatively, the patient breathes directly over the inci-
sion, unlike a patient with a tracheal tube. Although not ob-
served, this may increase the incidence of wound infection.
An attempt was made to avoid this by lightly packing the
nostril. The surgeon must be careful not to allow blood or
secretions to enter the oral cavity. The anesthetist should avoid
sedatives (premedication or intraoperative) during this proce-
dure, as it is important to maintain a meaningful level of con-
sciousness and communication with the patient throughout the
procedure. It is also difficult to supplement oxygen because of
the nature of the surgery. Overall cooperation among the sur-
geon, the anesthetist, and most importantly the patient is es-
sential for the success and safety of and satisfaction from this
procedure.
CONCLUSION
Cleft lip and palate is the most common of the craniofacial
anomalies, with an incidence of approximately 1 in 800 live
births (Hatch, 1996). Many reports of series of neonatal cleft
reflect the changing approach to cleft surgery in the developed
world (Kaufman, 1991; Van Boven et al., 1993; Gunawardana,
1996; Stephens et al., 1997). This study describes an innova-
tive, safe, and economical modification of anesthesia for sur-
gery among teenagers and adults. Because such patients may
present for revision surgery even in the developed world, fur-
ther studies are required to refine teenage cleft lip repair or
revision under regional anesthesia. In conclusion, the infraor-
bital nerve block can be used for cleft lip repair as a sole
anesthetic with careful patient selection.
Acknowledgment. The SMILE TRAIN financially supported the surgery.
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