A standardized approach to airway management during Abbé flap reconstruction

Abstract

Background The Abbé flap is a two‐staged procedure to address upper lip tightness, creating a surgically closed mouth during the first stage. Airway manipulation and management in the setting of a surgically closed mouth presents a challenge from an anesthetic standpoint. Aims This study aims to describe the authors' standardized approach to airway management in cleft lip patients undergoing Abbé flap reconstruction. Methods A retrospective review was performed including consecutive patients who underwent Abbe flap reconstruction at a single institution from 2019 to 2021. Five patients were included, and information regarding airway, intubation sequence, and emergence was gathered. Results During the initial surgery, the airway was secured via nasotracheal intubation to allow for adequate surgical exposure. On emergence, with a newly constructed surgically closed mouth, the anesthesiologist forfeits the ability to reintubate should the patient fail extubation without the use of nasal fiberoptic guided intubation or flap deinset. In addition, any coughing or tension on the surgical site could cause inadvertent disruption to the integrity of the new flap. Dexmedetomidine titrated to effect was used to allow for smooth emergence, with the surgeon present. During the second stage, the patient was kept spontaneously breathing while local anesthetic and intravenous anxiolytic allowed for pedicle division. The patient was then orally intubated, and the flap was inset. All five patients had successful reconstruction with no airway concerns or events. Conclusions The proposed standardized approach to airway management during Abbé flap reconstruction was safe and effective in this limited series of patients.