Pediatric Plastic Surgery
Falls, traffic accidents, animal bites, hot liquids, electrical equipment
and physical abuse all produce injuries to the soft tissues of children.
Treatment in an emergency department is often adequate, but failure to provide
appropriate or definitive treatment in the emergency setting may produce
permanent injury or disfigurement. It is important for the primary care
physician to recognize when consultation with a plastic surgeon is indicated
for definitive treatment.
Soft Tissue injuries of the face
Facial injuries require special attention because of their potential for
permanent disfigurement. Contusions, lacerations, puncture wounds, tattoos
with debris and especially avulsive injuries all have the capacity to permanently
disfigure the patient. Inadequate suturing of even small lacerations on
the face can result in poor healing and scarring. Definitive repair of facial
soft-tissue injuries is best carried out in an operating room rather than
an emergency room, and preferably by a plastic surgeon. Should the injuries
be complex or severe, the surgeon can perform procedures that will be definitive
or will lay the foundation for later revision surgery. Injuries to particularly
vulnerable facial features require special attention. Injuries to the forehead
and eyebrow, eyelids, ears, nose, cheeks and chin have the most potential
to result in disfigurement. In the case of injuries to cheek and chin, injuries
also may result in loss of function if facial nerves or muscles are injured.
Repair to facial nerves and muscles should be placed in the hands of a plastic
surgeon experienced in this type of surgery.
Animal Bites
Animal bites can present special problems--e.g., most dog bite wounds are
to the face in children and are typically tearing-type soft-tissue wounds.
Aggressive cleaning and meticulous repair by a plastic surgeon can frequently
salvage a serious injury cosmetically and functionally. Snakebite presents
the possibility of envenomation in addition to bite injury. If the type
of snake is unknown, emergency treatment proceeds with observation and suspicion
of envenomation. Bites inflicted by rattlesnakes may result in tissue necrosis--often
severe--that requires wide dissection and debridement. Skin grafting or
reconstruction with skin flap technique may be needed after primary healing
of the wound site.
Superficial Burns
Most burns suffered by infants and young children are hot-liquid scalds,
and as many as 15 percent of scald burns may be due to child abuse. Scald
burns on the buttocks are especially likely to have resulted from abuse--e.g.,
sitting the child in very hot water as punishment. The immediate concern
in scald injury is estimation of the extent of injury. The ratio of head-to-total
body burn must be calculated differently in infants and children than in
adults, due to inherent differences in relative size of head to body. Estimation
of the severity of the burn is dependent upon (1) temperature of the scalding
liquid, and (2) amount of time the skin was exposed to the liquid. Good
emergency management of a superficial burn--i.e., limited extent, less than
full-thickness--should result in healing without complications. Elements
of good management include (1) evaluation, (2) rinsing with saline solution
and light cleaning with mild soap-and-water solution, (3) debridement of
any blisters that interfere with function, such as blisters on the eyelids,
(4) instruction to the child's family in how to care for the burn after
the patient is released from the hospital, and (5) examination of the patient
by the treating physician within 2 days after the first dressing change,
to rule out the possibility of wound-site infection. Burns of the ears and
hands require special attention. Even superficially burned ears may later
develop scarring or deformation. Burned hands can potentially develop scarring
and contracture that limit function. A plastic surgeon should be called
into consultation for burns on vulnerable sites such as ears and hands.
Congenital anomalies
A deforming birth defect has a devastating psychological impact upon the
child's parents, and has the potential for life-long impact upon the physical,
psychological and socioeconomic well-being of the child. Plastic surgery
can improve or correct many of these birth defects. Because timing of surgery
is often an important factor in improving the prospect for successful outcome,
early consultation should be sought with a plastic surgeon. The primary
care physician and the plastic surgeon work closely together in designing
a maximally effective treatment plan for the affected child. Commonly, they
work in the context of a multi-disciplinary team. The family physician and
pediatrician may work together with the surgeon to help the parents deal
rationally with treatment options. The physicians also may counsel the parents
regarding the emotional, psychological and financial resources that may
be strained by treatment that sometimes requires many months or years to
complete.
Cleft Lip
Anomalies of the heart and other organs are found in a substantial percentage
of cleft lip/cleft palate patients, especially in conjunction with bilateral
clefts. Every neonate with facial clefting should have a complete pediatric
examination for indications of additional anomalies. Cleft lip may occur
alone or in conjunction with cleft palate. Its forms range from mildly disfiguring
to bilateral complete cleft with nasal deformity and involvement of the
hard palate and teeth.
Cleft Lip Treatment
Treatment begins soon after birth with pediatric evaluation of the patient
for any coexistent anomalies, evaluation of the defect by a plastic surgeon,
and consultation with the family regarding treatment options. Nonsurgical
treatment may be used early--elastic headcap traction, a nose retainer and
preoperative orthodontics if indicated. Lip repair can be performed any
time after birth. In general, most repairs are timed according to the "Rule
of 10s"--10 weeks old, weight of 10 pounds and 10 grams of hemoglobin. Secondary
surgery may be necessary later for repair of a nasal deformity, revision
of an earlier repair as the patient grows and develops, or repair of postoperative
abnormalities in the scar. Severe bilateral cleft lip requires treatment
and on-going coun- seling throughout the patient's childhood and adolescence.
Cleft Palate Treatment
Repair of the palate is directed at producing normal speech, restoring eustachian
tube function, attaining closure of oronasal fistulas and minimizing alterations
in maxillary growth. Depending on the patient, repairs may start as early
as 10 months or as late as 24 months. Planning for primary surgical repair
begins in the hospital shortly after the child is born, or soon after discharge.
A small or moderate degree of clefting may be repaired by simple closure;
a larger defect may require a pharyngeal flap, alveolar arch alignment,
orthodontic and dental work, and bone grafting. Dental, orthodontic or prosthodontic
consultation is sought when teeth are malformed or missing. Bilateral clefts
are the most complex to repair, requiring a spectrum of medical and surgical
specialists. In some cases, secondary soft palate (velopharyngeal) surgery
may be necessary some months or years after primary palate repair, to correct
hypernasal speech. Speech-language pathologists may assist in identifying
the specific defect to be repaired. Velopharyngeal repair procedures include
(1) palatal pushback plus pharyngeal flap lining, (2) posterior pharyngeal
wall implant with Teflon injection, (3) pharyngeal flap, (4) palatopharyngeal
flap, and (5) tissue expansion to create a flap. Long-Term Treatment:
Some patients require months or years of speech-language training to acquire
normal speech. The family members of a cleft palate patient may need long-term
guidance and counseling to support them through the years of treatment.
Hemangiomas and other vascular lesions of the skin
Hemangiomas and lymphangiomas, the most common benign tumors of the skin
in neonates, may be present at birth or appear in the first months after
birth. Some lesions regress and disappear in the first few months of life--e.g.,
the strawberry hemangioma. Large vascular lesions in critical locations
can be life-threatening as well as disfiguring--e.g., multiple hemangiomas
of the newborn involving skin, liver and intestinal tract. Consultations
with a plastic surgeon may include consults with other specialists such
as a hematologist when a lesion is very large or life-threatening. Laser
treatment is often a treatment of choice for vascular lesions, including
port-wine stain and unregressed strawberry hemangioma. Careful evaluation
is required before laser treatment is undertaken.
Pigmented lesions of the skin
Pigmented lesions in the newborn are frequently difficult to interpret regarding
their present or potential malignancy. Early consultation with a plastic
surgeon and pathologist initiates (1) planning for surgical removal or other
appropriate treatment, and (2) providing treatment options and counseling
to the parents. Large congenital nevi pose a significant risk of early malignancy
or later malignant transformation. Large and sometimes hairy nevi also are
physically uncomfortable and psychologically damaging for child and parents.
Surgical excision with skin grafting is often a treatment of choice.
Malformations of the ear
Ear malformations such as microtia can severely affect a child's self-image,
especially if the condition is allowed to go uncorrected until school age.
The importance of well formed ears in overall facial esthetics is reflected
in the severe teasing inflicted by schoolmates on a child with malformed
ears. Microtia is usually apparent at birth or soon after, seen as a "remnant"
ear lobule, concha, acoustic meatus, tragus and incisura intertragica. Microtia
is usually unilateral. Bilateral microtia may be associated with severe
hearing defects that require consultation with an otologist. As soon as
microtia is identified, the plastic surgeon should become a partner with
the primary care physician in planning an approach to reconstruction. Consultation
with the child's parents will help to plan the age at which reconstruction
should begin; usually, reconstruction should be completed before the child
enters school. Because autologous rib cartilage is commonly required to
form a new ear framework, definitive reconstruction may take place at about
age 5 or 6 years when rib growth has been adequate. Parents should be informed
regarding potential complications of harvesting rib cartilage. Skin flap
techniques are commonly used to mobilize the skin used to cover the new
ear framework. The ultimate success of microtic reconstruction depends upon
patient selection, adequate counseling of parents, selection of the proper
material for an ear framework, surgical skill, and detailed attention in
the intraoperative and postoperative periods to prevent complications such
as infection, skin flap necrosis, and undue pressure on the operated ear.
Malformations of the hand
Hand malformations include syndactyly (webbed fingers), polydactyly (extra
fingers), trigger fingers, crooked fingers, absent thumb, short fingers
and missing fingers. All congenital hand malformations should raise suspicion
of associated deformities of other organs or tissues. Syndactyly, for example,
is frequently a readily visible manifestation of Poland's syndrome--congenital
absence of thoracic structures in association with hand malformation. Plastic
surgery can correct many hand malformations definitively; in other instances,
plastic surgery can provide some degree of functional capacity. An example
of functional restoration is microvascular toe-to-hand tissue transfer,
which offers potential for surgical correction of hypoplastic or aplastic
fingers. Consultation with the patient's parents must stress the importance
of restoring function to the malformed hand, even if cosmetic appearance
must be a secondary consideration. The unique function of the hand throughout
life mandates that function be restored as fully as possible--e.g., providing
pinch and grip function will be essential to many occupations. The primary
care physician has an essential role in working with the patient and family
to assure that exercise and rehabilitation regimens are followed, in order
to maximize the advantages of surgical reconstruction and prevent debilitating
complications such as contracture.
Anomalies of the breast
Congenital breast asymmetry may be a manifestation of underlying congenital
anomalies. Poland's syndrome, the most frequent congenital cause of breast
asymmetry, is a syndrome of thoracic structure deformities, breast asymmetry,
and ipsilateral syndactyly. Computed tomography and magnetic resonance imaging
are definitive in identifying the thoracic deformities. Treatment of breast
asymmetry due to Poland's syndrome may include prosthetic augmentation,
use of a musculocutaneous flap to fill hollow space on the exterior of the
chest, or augmentation with tissue from the opposite breast. Definitive
treatment includes surgical repair of the chest wall. As in the case of
other congenital deformities, Poland's syndrome may be seen in association
with anomalies of other tissues and organs.
