The preoperative anesthetic evaluation provides the necessary information regarding the patient's general health, and includes the pertinent birth (if age appropriate) and medical history along with physical examination with relevant laboratory data. A baseline hemoglobin level, which is often low in very young infants (physiologic anemia of infancy reaches a nadir of 10-11 g/dL around 6-9 months), should be obtained.

A thorough airway history and exam should identify obstructive symptoms and predictors of difficult intubation. If Treacher Collins or Pierre Robin syndrome is suspected, a radiograph of the mandible can be helpful. The examination also offers a good opportunity to assess the family dynamics because parental cooperation is essential for proper postoperative care.

Periosteoplasty with cleft lip repair is a less extensive surgery than cleft palate repair, and is typically performed as soon as the segments are in alignment. The "Rule of 10s" was introduced in the 1960s, with modifications in 1976, as a set of criteria to mitigate risk in young infants regarding timing of repair. It was posited that a violation of any patient characteristics would confer an increased rate of postoperative complications from 7.6 to over 38%. Thresholds for surgical candidacy were:

• Weight—Greater than 10 lb

• Hemoglobin— Greater than 10 g/dL

• White blood cell count—Less than 10,000/µL

• Age—Greater than 10 weeks

Since the initial recommendation over 50 years ago, considerable advances have been made in the anesthetic, surgical, and perioperative care of pediatric patients. More recent studies show that of the original metrics, only weight below 10 lb (4.5 kg) at the time of surgery was identified as an independent predictor of overall complications in cleft patients, which has led to a shift toward earlier cleft lip repair. Nonetheless, preoperative screening is essential in patients with cleft lip and palate, as underlying cardiac abnormalities dramatically increase the risk of perioperative morbidity. If a cleft occurs as part of a syndrome, an echocardiogram should be performed, especially if a murmur is present. Other independent risk factors for increased complications include decreasing weight and preoperative ventilator dependence.

General health, growth, reflux, feeding difficulties, and recent infection must be considered. With an open cleft palate, it is common to have crusting and low-grade infection of the nasopharynx because of food and fluid regurgitation through the cleft. It is impossible to eliminate this completely. Unless an acute inflammatory process is present, this does not lead to further complications.

References

• Chow I, Purnell CA, Hanwright PJ, Gosain AK. Evaluating the rule of 10s in cleft lip repair: do data support dogma? Plast Reconstr Surg. 2016;138:670-679.
• Ganske IM, Rogers-Vizena CR. Cleft lip and palate: principles and treatment. In: Chung KC, ed. Grabb and Smith's Plastic Surgery. 9th ed. Wolters Kluwer; 2025:183-196.
• Schafer S, Card E, Liao EC. Cleft lip and palate: embryology and genetics. In: Chung KC, ed. Grabb and Smith's Plastic Surgery. 9th ed. Wolters Kluwer; 2025:197-208.