Ambulatory alveolar bone grafting

Traditional practice for alveolar cleft closure requires postoperative hospital convalescence in an unfamiliar, disruptive hospital setting. An outpatient iliac crest alveolar bone grafting protocol was devised to optimize patient care. A retrospective review of the senior author's experience over 5 years (1998 to 2004) of ambulatory alveolar cleft closure was compared with the previous 5-year period (1993 to 1998) of inpatient convalescence. An iliac crest donor site and standard techniques of alveolar grafting were followed in both groups. Although local analgesia with lidocaine and epinephrine was used in both groups, the ambulatory group received preemptive local anesthesia augmented with Marcaine. Postoperative nausea also was treated preemptively in the outpatient group with the addition of dexamethasone (Decadron) and ondansetron (Zofran), whereas the control patients were treated as needed. Patient charts were reviewed for demographic information, technical aspects, length of donor-site incision, bone graft volume, and time of operation. A Fisher's exact test was used for statistical analysis. Complications including morbidity, readmission, and reoperations were recorded. Twenty consecutive patients were treated on an outpatient basis. Eight consecutive patients were convalesced as inpatients in the previous 5-year period. The ambulatory series average patient age was 12.1 years (range, 8 to 15 years). Four bilateral procedures were performed. The follow-up period averaged 3.5 years (range, 5 to 76 months). Two minor complications were identified: cellulitis at a donor site and a recipient suture line dehiscence with minor graft exposure. There were no readmissions, revision operations, hernias, wound infections, or graft losses identified. In the inpatient series, the average stay was 1.8 days (range, 1 to 3 days). One gingival suture line dehiscence requiring no further intervention was identified, for an average complication rate of 12.5 percent, which was not significant compared with the ambulatory group (10 percent) (p = 1.00). Alveolar cleft bone grafting using the iliac crest donor site can be safely performed on an outpatient basis when local pain control is followed by predictable anesthetic recovery and sufficient oral intake, and reliable motivated parents or caregivers provide a comfortable postoperative setting. Safe outpatient surgery provides patients and family the opportunity to recover in the familiar home environment.