OT notes · OMFS

Primary unilateral cleft lip repair

Usual anaesthesia
General, oral RAE tube
Position
Supine, head on ring
Setting
elective

Operative note template for primary repair of a unilateral cleft lip with primary nasal correction, with a filled example for a Millard rotation-advancement repair in a 5-month-old infant.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • bleeding or haematoma
  • infection
  • wound breakdown, often from the child rubbing or knocking the lip
  • visible scar and need for scar or lip revision later
  • lip or nostril asymmetry, short lip or notch in the vermilion
  • widening of the nostril base over time
  • anaesthetic risks in an infant
  • further operations for palate, alveolus and nose as part of the cleft plan

Pre-operative details for this operation

  1. Cleft typeCompleteIncompleteside (left / right); lip only, or lip and alveolus, or lip, alveolus and palate
  2. Age, weight and haemoglobinrule of 10s: over 10 weeks, over 10 lb (4.55 kg), Hb over 10 g/dL
  3. Pre-surgical mouldingNoneLip tapingNasoalveolar moulding (NAM)
  4. Feeding and general conditionfeeder used, weight gain, recent cold or chest infection
  5. Associated anomaliescardiac, syndromic features, other
  6. Pre-op photographsTakenNot taken
  7. Consentparent or guardian, relation, language used

Anaesthesia and position

  1. AnaesthesiaGA, oral RAE tubetube position and fixation
  2. EyesProtected
  3. PositionSupine, head ring
  4. Local infiltrationlocal anaesthetic with vasoconstrictor; drug, strength and volume; wait 3 to 5 minutes

Operative findings

  1. Cleft width and alar basegap in mm, alar base flattened or displaced
  2. Cupid's bow and white rollpeak on non-cleft side; where white roll is full on the cleft side
  3. Columella and septumdeviation to the non-cleft side
  4. AlveolusIntactNotchedComplete alveolar cleft

Procedure (steps)

  1. Markingsmethod (marking pen or methylene blue on 30G needle); points marked; calliper measurements in mm (e.g. point 1 to 2, planned height of Cupid's bow)
  2. TechniqueMillard rotation-advancementModified MillardOther (name it)
  3. Vermilion Z-plastyDoneNot done
  4. IncisionsNo. 11 blade; rotation incision on non-cleft side along columella base; release along alar base on cleft side
  5. Intraoral releasevestibular incision, subperiosteal release over the piriform rim
  6. Orbicularis oris dissectionhow far dissected from skin and mucosa (mm); abnormal attachments released
  7. Nasal correctionseptum freed from anterior nasal spine; cleft-side ala freed from piriform rim
  8. Alar cinchsuture and size; alar base width achieved
  9. Muscle repairorbicularis oris approximated, suture and technique
  10. Key landmarks alignedvermilion-cutaneous junction (white roll), Cupid's bow peaks, nasal sill

Closure, drains and dressing

  1. Mucosasuture and size
  2. Deep dermal layersuture and size
  3. Skinsuture and size (fast-absorbing gut or other)
  4. DressingSkin glueAdhesive stripsBoth
  5. Nostril retainer / nasal conformerPlaced, suturedNot placed
  6. Throat packNot usedPlaced and removed

Specimens and implants

  1. SpecimenNoneTrimmed tissue discarded
  2. Nostril retainertype and size

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Airway and positionobserve breathing and oxygen saturation until fully awake
  2. Feedingbottle or special feeder from when; admit until feeding normally
  3. Nothing else in the mouthno pacifier or spoon for 3 weeks
  4. Protect the lipmittens on the hands
  5. Wound careno creams or lotions on the lip
  6. Nostril retainerclean with saline nasal spray; how long to keep
  7. Analgesiadrug and dose by weight
  8. Sun protectionavoid direct sunlight on the scar for 6 months
  9. Follow-upwound check date; cleft team plan for palate

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Baby A.K., male, 5 months, weight 6.2 kg, Hb 11.4 g/dL. Left complete unilateral cleft lip and alveolus, palate intact. Lip taping done at home for 8 weeks.

Case details

Date: 14/10/2026. Elective. Paediatric OT.

In OT 08:40. Induction 08:50. Incision 09:15. Closure completed 10:35.

Surgeon: Dr A. (MDS OMFS, 3rd year). Assistant: Dr B. Consultant: Dr C., scrubbed.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: primary repair of left complete cleft lip and alveolus.

Rule of 10s met: age 5 months, weight 6.2 kg, Hb 11.4 g/dL. Feeding well with special feeder, no recent respiratory infection. Echo normal.

Pre-op photographs taken.

Consent: general, procedure-specific (scar, asymmetry, revision, further surgery) and anaesthesia consent from mother and father, explained in Telugu.

WHO checklist done. Inj cefazolin 185 mg IV (30 mg/kg) at induction.

Anaesthesia and position

GA with oral RAE tube. Eyes protected with transparent dressings. Supine on head ring.

Face and oral cavity prepared and draped.

Procedure

Findings: cleft gap 9 mm, left alar base flat and displaced outwards, columella deviated to the right, complete alveolar cleft.

Markings with methylene blue on a 30G needle. Point 1 (peak of Cupid's bow, right) and point 2 (trough) marked; distance 3.5 mm. Point 4 marked 3.5 mm from point 2 on the cleft edge of the non-cleft segment. Point 4' marked on the lateral segment where the white roll is full and the vermilion is thickest. Rotation incision along the columella base (5 to 6) curving down to point 4. Alar base release on the cleft side (5' to 6'). Vermilion Z-plasty planned (3, 3').

Technique: Millard rotation-advancement.

Local anaesthetic with vasoconstrictor infiltrated into the flaps, 5 minutes allowed.

Incisions made with No. 11 blade through skin and subcutaneous tissue. Intraoral incisions extended to the depth of the vestibule. Subperiosteal release over the left piriform rim.

Orbicularis oris dissected free for 3 mm on both sides of the cleft and detached from its abnormal upper attachments.

Anterior septum freed from the anterior nasal spine. Left ala freed from the piriform rim.

Alar cinch with 3-0 polydioxanone (PDS) through the nasalis at both alar bases, tied slightly tight.

Orbicularis oris repaired with polyglactin 910 (Vicryl) 4-0 horizontal mattress sutures.

Vermilion-cutaneous junction at points 4 and 4' aligned first, over the repaired muscle.

Closure

Mucosa closed with Vicryl 4-0 to form the labial sulcus. Deep dermal poliglecaprone (Monocryl) 5-0 to build the philtral column and nasal sill. Skin with interrupted 6-0 fast-absorbing gut.

Adhesive strips across the lip. Lubricated left nostril retainer placed and fixed with a transcolumellar silk suture.

Final result: Cupid's bow level, white roll aligned, alar bases symmetric.

Specimens and implants

Trimmed tissue discarded. No specimen for HPE.

Nostril retainer size as per sticker.

End of procedure

Estimated blood loss 15 ml. No transfusion.

Mop, needle and instrument count correct.

No intra-operative complications.

Extubated awake in OT. SpO2 99% on room air. Shifted to paediatric recovery in stable condition.

Post-op orders

Monitor breathing and SpO2 till fully awake.

Feeds with special feeder once awake. Keep admitted till feeding well.

Nothing else in the mouth for 3 weeks. No pacifier.

Mittens on both hands to stop the baby rubbing the lip.

No creams or lotions on the lip. Clean nostril retainer with saline nasal spray.

Analgesia as per paediatric anaesthesia chart by weight.

Avoid direct sunlight on the scar for 6 months.

Wound review in OPD at 1 week. Cleft team review for palate.

Signature

Dr A., MDS resident, OMFS. Reg. no. ________. 14/10/2026, 10:50.

Must document for this operation

  • Age, weight and haemoglobin on the day of surgery. Timing of repair is checked against the rule of 10s, and weight is needed for every drug dose in an infant.
  • Technique named, with the key markings and measurements. The surgeon who does a lip or nose revision years later needs to know what was done and how the lip was planned.
  • Muscle repair and nasal correction done at the primary operation. Later revisions differ depending on whether the orbicularis was repaired and the ala released first time.
  • Sutures used in each layer, and whether skin sutures need removal. Removing non-absorbable sutures in an infant may need sedation, so the ward and OPD must know in advance.
  • Nostril retainer placed, and how it is fixed. Parents need instructions for cleaning it and the team must know when to remove it.
  • Pre-op photographs taken. Photographs let the team compare the result with the starting deformity and plan any revision.

Common mistakes in these notes

  • Writing 'cleft lip repaired' without naming the technique.
  • Leaving out weight and haemoglobin, then writing drug doses without the weight.
  • No mention of whether the nasal deformity was addressed.
  • Not recording the suture type for skin, so the ward does not know whether removal is needed.
  • Consent recorded without naming which parent or guardian signed.

Indian practice and paperwork

  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the parents understand, and be taken by the person doing the procedure. (NABH 5th ed., PRE.4(c) and (e))
  • The operative note must be written before the patient leaves recovery, and post-op care must follow a written plan. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Haggerty CJ, Laughlin RM, eds. Atlas of Operative Oral and Maxillofacial Surgery. 2nd ed. Wiley; 2023, Ch 34, Cleft Lip Repair (Cheilorhinoplasty) (Zakhary G, Rehder S), pp. 525-532.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Plastic procedures, clean-contaminated: cefazolin. Table 1 paediatric dose: cefazolin 30 mg/kg, within 60 min before incision. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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