Pediatric Plastic Surgeons Research Articles

Shaping Plastic Surgery in British Columbia-The Courtemanche Legacy.

Dr Albert Douglas Courtemanche was born in Gravenhurst, Ontario on November 16, 1929. In 1949, he was accepted to the University of Toronto Medical School, graduating in 1955. After completing his internship at the Toronto General Hospital and at the Hospital for Sick Children, he completed his surgical training in Vancouver and in the United Kingdom. When Dr Courtemanche returned from his training in 1962, he joined Dr Cowan on the surgical staff at the Vancouver General Hospital. He was responsible for establishing a new plastic surgery ward, a dedicated operating room (OR), an integrated burn unit and also starting the UBC plastic surgery training program. Dr Courtemanche became involved in working with the Royal College, first as an examiner and then as the Chairman of the Plastic Surgery Exam Board in 1981. He eventually became the first and only plastic surgeon to ever hold the position as President of the Royal College. Dr Courtemanche emphasized throughout his career the importance of teaching and role modeling. A very proud moment in Dr Courtemanche's career was when his son Douglas became a pediatric plastic surgeon. After retiring Dr Courtemanche became a volunteer at the VanDusen Botanical Garden and completed their Master Gardeners Program.

Cost Analysis of a Multidisciplinary Vascular Anomaly Clinic.

Multidisciplinary vascular anomaly clinics (VACs) offer important value to pediatric patients with complex vascular anomalies whose care overlaps specialties. These clinics are labor intensive and costly to operate since providers see fewer patients compared to their individual specialty clinic. Our North American tertiary care institution's VAC specialists include a pediatric otolaryngologist, pediatric surgeon, pediatric plastic surgeon, pediatric dermatologist, and interventional radiologist. To assess financial feasibility, we conducted a cost analysis of our VACs comprised of 2 half-day multidisciplinary physician attended clinics (5 specialists at our main campus and 2 specialists at a satellite clinic) and a half-day nurse practitioner clinic. Assessment of net revenue based on net collections for clinic, professional, operative, hospital setting, and facility charges generated during 12 consecutive monthly VACs beginning July 1, 2015. Expense calculations included provider and staff salaries, benefits, supply costs, and clinic leasing costs. There were 469 clinic visits, of which 202 were new patient evaluations. Sixty-eight patients underwent 93 procedures under general anesthesia, including procedures performed by our interventional radiologist, most commonly sclerotherapy or embolization (n = 37), surgical interventions including endoscopy (n = 36), or laser procedures (n = 20). Three patients were admitted. Fifty-seven patients received a new diagnosis different from that for which they were referred. Gross revenue was $1 810 525, and net revenue was 42.5%, or $783 152. Expenses totaled $453 415 for a net positive revenue of $329 737. When including direct downstream revenue, particularly from operative procedures, our VAC program operates on a net positive margin, making the program financially feasible.

Tissue expansion in pediatric patients: a 10-year review

Background/PurposeTissue expansion complication rates up to 40% have been reported in the pediatric population. This study aims to review one Canadian pediatric plastic surgeon's experience with tissue expansion by examining tissue expander and flap complication rates, and discussing important aspects of the tissue expansion experience. MethodsThis is a retrospective chart review of the medical records of all tissue expansion patients treated by the senior author during a ten-year period. Data were collected on patient demographics, tissue expansion details, complications, and outcomes, and were analyzed descriptively. The relationship between tissue expander complications and flap complications was analyzed with odds ratio. ResultsNinety-three expanders were placed in 24 patients during 49 sessions. Complications occurred in 19 expanders (10 patients; 16 sessions), resulting in premature removal of nine. Only one session was unsuccessful; the expander became exposed and was removed after 1 month. The odds of having a flap complication were three times greater with preceding tissue expander complication (not statistically significant). ConclusionsOur study identifies a 20% expander complication rate in the pediatric population. Patients with tissue expander complications subsequently experienced more flap complications than those without tissue expander complications. Complications do not preclude successful reconstruction. Type of StudyPrognostic. Level of EvidenceII.

Congenital Hand Differences.

Congenital hand differences are frequently encountered by pediatric plastic surgeons. These anomalies may cause significant emotional and functional challenges for children. Pediatric plastic surgery nurses should have a basic understanding of common congenital hand differences and related treatment options to facilitate patient education and postoperative care. This article discusses clinical findings and management of 4 of the most common hand anomalies: syndactyly, polydactyly, thumb hypoplasia, and cleft hand. The goals of surgical treatment are to maximize hand function and aesthetics with minimal adverse outcomes.

30-year International Pediatric Craniofacial Surgery Partnership: Evolution from the "Third World" Forward.

Background:Craniofacial diseases constitute an important component of the surgical disease burden in low- and middle-income countries. The consideration to introduce craniofacial surgery into such settings poses different questions, risks, and challenges compared with cleft or other forms of plastic surgery. We report the evolution, innovations, and challenges of a 30-year international craniofacial surgery partnership.Methods:We retrospectively report a partnership between surgeons at the Uniwersytecki Szpital Dzieciecy in Krakow, Poland, and a North American craniofacial surgeon. We studied patient conditions, treatment patterns, and associated complications, as well as program advancements and limitations as perceived by surgeons, patient families, and hospital administrators.Results:Since partnership inception in 1986, the complexity of cases performed increased gradually, with the first intracranial case performed in 1995. In the most recent 10-year period (2006–2015), 85 patients have been evaluated, with most common diagnoses of Apert syndrome, Crouzon syndrome, and single-suture craniosynostosis. In the same period, 55 major surgical procedures have been undertaken, with LeFort III midface distraction, posterior vault distraction, and frontoorbital advancement performed most frequently. Key innovations have been the employment of craniofacial distraction osteogenesis, the use of Internet communication and digital photography, and increased understanding of how craniofacial morphology may improve in the absence of surgical intervention. Ongoing challenges include prohibitive training pathways for pediatric plastic surgeons, difficulty in coordinating care with surgeons in other institutions, and limited medical and material resources.Conclusion:Safe craniofacial surgery can be introduced and sustained in a resource-limited setting through an international partnership.

A glance at methods for cleft palate repair.

Context:Cleft palate is the second most common birth defect and is considered as a challenge for pediatric plastic surgeons. There is still a general lack of a standard protocol and patients often require multiple surgical interventions during their lifetime along with disappointing results.Evidence Acquisition:PubMed search was undertaken using search terms including 'cleft palate repair', 'palatal cleft closure', 'cleft palate + stem cells', 'cleft palate + plasma rich platelet', 'cleft palate + scaffold', 'palatal tissue engineering', and 'bone tissue engineering'. The found articles were included if they defined a therapeutic strategy and/or assessed a new technique.Results:We reported a summary of the key-points concerning cleft palate development, the genes involving this defect, current therapeutic strategies, recently novel aspects, and future advances in treatments for easy and fast understanding of the concepts, rather than a systematic review. In addition, the results were integrated with our recent experience.Conclusions:Tissue engineering may open a new window in cleft palate reconstruction. Stem cells and growth factors play key roles in this field.

Tissue Expander‐Assisted Ventral Hernia Repair for the Skin‐Grafted Damage Control Abdomen

In the article under discussion, Carr presents a series of three patients with late reconstruction of skin grafted large ventral hernias [1]. What makes his article exceptional is that he has used tissue expansion before reconstructing the hernias. Tissue expansion is more a tradition of pediatric plastic surgeons and is rarely used in the treatment of abdominal wall defects. In his work, tissue expansion was used in patients with enterostomies that were not published before. He did not encounter any infectious complications in his patients which is significant. Nevertheless, the number of patients is so small that it is not possible to draw very strong conclusions regarding this treatment method. The report can be judged more or less as an extended case study. Moreover, there are a few remarks that I would like to make. In the introduction the author claims that after damagecontrol surgery many patients are now surviving with skingraft-on-bowel ventral hernias. In the past this has been the case, but the number of skin grafted open abdomen patients has become strongly reduced lately. This is so because of the use of negative pressure devices with mesh-mediated traction in the initial phase of open abdomen treatment. With such techniques it is now rare for an open abdomen patient to end up having a skin grafted hernia [2]. Carr also states that: ‘‘operative steps do not include any mention of what to do in the patient who does not have sufficient skin to close the wound after the skin graft is removed.’’ This might be true according to the references used in this article, but for a reconstructive surgeon a large full-thickness abdominal wall defect is a straightforward indication for a flap reconstruction [3]. For fascial closure, Carr has used component separation and acellular dermal matrix (ADM) mesh with the bridging method. According to current experience, a bridged ADM is only a temporary solution for hernia repair. A bulking or recurrent hernia is to be expected in long run [4]. In this series one patient already had a recurrent hernia, and two were good at one year of follow-up and it is to be seen if this might show up after the follow-up period for these two patients. Late correction of a ventral hernia after skin expansion is not a piece of cake. The defect should be closed with a material more durable than ADM in the secondary phase. The risk of a wound complication is evident because the expanded thin skin has to be released in order to replace the ADM with a new mesh. For these reasons my choice would be a flap reconstruction is this kind of case. With a thigh flap one can get a living fascia to replace the missing fascia and skin. Under a flap one can use a mesh for temporary closure to make sure that the hernia will not recur. Tissue expansion is principally an easy operation. Creating a pocket for an expander is not difficult. Nevertheless, tissue expansion is combined with a lot of problems that are faced by surgeons who use it a lot. Placing the expanders, choosing the form and size, and determining filling intervals and the amount of filling, etc. require a lot of experience to be done safely and effectively. There are well known complications with expanders like infection, extrusion, and rupture of the implant, for which the surgeon has to be prepared. In one case reported by Carr, one of the expanders ruptured and was not replaced by another. Because of this, the author could not remove the skin graft completely, leading to an expected wound necrosis and secondary healing. Looking back, he should have completed the expansion as planned by replacing the ruptured implant with another. Carr states that ‘‘what is unique about the experience described in this article is that the tissue expanders were H. Kuokkanen (&) Tampere University Hospital, Tampere, Finland e-mail: hannu.kuokkanen@pshp.fi

Management of “Difficult” Wounds

Pressure sores (PSs) and wounds in immunocompromised children are rather rare conditions. No doubt, their management is often complex and difficult, even for experienced pediatric plastic surgeons. As there are no algorithms for standard care, the therapeutic approach is individual.Successful PS management always implies primary and secondary prevention. With a PS present, rapid relief of pressure is crucial. If local wound care fails to restore skin integrity within a short period of time, surgical defect closure is mandatory. Overall, full-thickness skin grafts and local flap surgery are the most suitable methods regarding result quality, procedure complexity, and risks. Negative pressure wound therapy (NPWT) plays an instrumental role in wound bed preparation before definitive coverage. Recurrence rate is high (the complication). It does not much depend on the surgical technique employed, but rather depends on whether the various pathogenic factors leading to PS can be eliminated or alleviated.In both temporarily and permanently immunocompromised children, wound healing is significantly impaired. At the same time, these patients have no or low host defense activity. Thus, they are at high risk not only for local wound infection but also for potentially life threatening septic complications. Rapid and definitive wound closure is therefore essential. When conservative therapy fails, simple surgical techniques granting rapid and definitive wound closure should be used.

Fellowship Review

From the Kids Plastic Surgery, St. Johns Mercy Hospital, St. Louis, MO. Received November 23, 2010, and accepted for publication, after revision, July 29, 2011. Conflicts of interest and sources of funding: none declared. Reprints: Joyce C. Chen, MD, Craniofacial and Pediatric Plastic Surgeon, Kids Plastic Surgery, St. Johns Mercy Hospital, 621 S. New Ballas Road, Suite 260A, St. Louis, MO 63141. E-mail: [email protected].

Elective Procedures and Anesthesia in Children

The Pediatric Anesthesia NeuroDevelopment Assessment research group at Columbia University Medical Center Department of Anesthesiology has conducted biannual national Symposia since 2008 to evaluate study data and invigorate continued thinking about unresolved issues of pediatric anesthesia neurotoxicities. The third Symposium extended the dialogue between pediatric anesthesiologists and surgeons in panel presentations and discussions by four surgical specialists. This paper reports the prevailing opinions expressed by a pediatric general surgeon, urologist, plastic surgeon and ophthalmologist and explores factors related to delayed operative intervention, need for multiple procedures, and parental concerns.

Acellular Dermal Matrix in Cleft Palate Repair

The repair of wide cleft palates and secondary palatal fistulas remains a challenge for pediatric plastic surgeons. To reduce the incidence of fistulization, use of acellular dermal matrix to facilitate closure has been reported in the literature. A review of the literature was performed to assess whether sufficient evidence exists to recommend the routine use of acellular dermal matrix for either primary palatoplasty or secondary palatal fistula repair. A literature search for the period between 1970 and 2011 was performed. All articles with clinical application of acellular dermal matrix in primary palatoplasty or palatal fistula repair were included. Data were analyzed using weighted averages to compare fistula rates between repairs performed with and without acellular dermal matrix (historical controls) for each repair type (primary versus secondary fistula repairs). Four studies examined the use of acellular dermal matrix in primary palatoplasty (n = 92) with a mean cleft width of 14.2 mm. The overall fistula rate was 5.4 percent compared with 10.6 percent in the non-acellular dermal matrix historical control group. Five studies used acellular dermal matrix in palatal fistula repair (n = 74). The overall recurrent fistula rate was 8.1 percent compared with 12.9 percent in the historical control group. Based on the available data, the results imply that acellular dermal matrix may have a potential benefit in reducing fistula formation/persistence in palate surgery. However, the authors did not find sufficient prospective randomized (level II or better) evidence to recommend the routine use of acellular dermal matrix for cleft palate repair.

Case Report: Odontogenic Cyst

Right facial swelling in 10-year-old boy.A10-year-old boy with no past medical or surgical history presents to the emergency department, accompanied by his mother, complaining of right-sided facial swelling for the past two months. The mother reports that he was enrolled in a beginner boxing class, and was punched in the face with a soft glove two months prior to presentation. Since he was struck, she has noticed a progressive swelling to the right side of his face. The patient denied any change in speech, pain with chewing, difficulty swallowing, or sensitivity to cold or hot foods and liquids, and he had no history of fever, chills, dental pain, or recent dental work performed. The child had been seen by his pediatrician multiple times over the few weeks prior to ED presentation, and was initially treated for a hematoma. The swelling did not improve with conservative measures, and the child was eventually referred to see a surgeon, but the mother was unable to obtain an appointment with one.Right mandibular mass in the sagittal and coronal planes.His vital signs were normal, and his physical exam demonstrated a well appearing, well developed boy in no distress. Examination of his face revealed marked swelling over the right cheek without any discernible border, erythema, warmth, or tenderness. The mouth revealed deviation of the first and second molars with increased spacing between the two teeth. No erosions, abscesses, drooling, bleeding gums, or malocclusion were present. Basic laboratory studies included a complete blood count, electrolytes, renal function, and coagulation profile, which were all within normal limits. A contrast enhanced facial bone CT scan was obtained, and revealed an expansile, septated hypo-attenuated mass measuring approximately 9.2 × 4.7 × 5.1 cm in craniocaudal, transverse, and anterior-posterior dimensions, respectively, centered around the right mandible and mildly displacing surrounding structures. Results of the CT and blood work were explained to the patient and his mother, and the patient was discharged to follow up with a pediatric plastic surgeon with subspecialty in craniofacial procedures. Odontogenic cyst is a broad term describing a variety of cysts defined as epithelial-lined structures derived from odontogenic epithelium. Odontogenic cysts can be divided into inflammatory and developmental categories. Inflammatory cysts include radicular (periapical) and paradental. Developmental cysts include dentigerous (follicular), developmental lateral periodontal, odontogenic keratocyst, and glandular odontogenic cyst. Included in the differential of the mandibular mass of this patient are traumatic bone cyst, central giant cell granuloma, and the malignant tumors that affect the area described. (Laryngoscope 1998;108[2]:280.) Most odontogenic cysts are defined more by their location than by any histologic characteristics, and the surgeon must provide the pathologist with appropriate history and radiographs when submitting such specimens for examination. The most important concept in managing odontogenic pathology is obtaining a complete history and thorough physical examination, which should include careful inspection, palpation, and percussion of the affected part of the jaw and overlying dentition. Radiologic examination is usually the first procedure of choice in evaluating jaw-related cysts and tumors. In general, well-demarcated lesions outlined by sclerotic borders suggest benign growth while aggressive lesions tend to be ill-defined lytic lesions with possible root resorption. Finally, fine-needle aspiration, open biopsy, or excisional biopsy may be necessary for definitive diagnosis, which is needed to determine appropriate medical or surgical therapy. (J Dent Child [Chic] 2009; 6[3]:217.)Dental displacement noted in bone windows.This patient's cyst is significant for the growth rate and large size at presentation to the ED. Because panorex radiography is difficult to interpret and rarely available to the emergency physician, contrast-enhanced CT scan is the most appropriate diagnostic modality for evaluation of facial masses. Patient follow-up is of utmost importance because odontogenic masses are often deforming, may be malignant, and may sometimes require extended treatment. Drs. Bair, Decena, Ruotolo, andHenesch, andMs. Millerare from the department of emergency medicine at Good Samaritan Hospital Medical Center in West Islip, NY.

Discussion: Untreated Hemangiomas: Growth Pattern and Residual Lesions

I have had a long personal and professional interest in hemangiomas. I not only had two daughters with hemangiomas, but also trained with Dr. Milton Edgerton, who published the first article on steroid treatment of hemangiomas with Dr. Harvey Zarem in 1967.1 Understanding the difficulty parents often have with waiting for hemangiomas to “go away,” my wife and I started a parent support group at Children’s Hospital Los Angeles in 1983. Interacting closely with parents attending the support group taught me three important lesions regarding hemangiomas. First, because of stares, comments, and occasional accusations of child abuse, mothers, more than fathers, bear the brunt of the psychological burden of having a child with a noticeable hemangioma. Public outings and social interactions are affected. Second, I came to realize that girls can be negatively aware of having a birthmark as early as 2 years of age. Boys generally are less aware until older. Finally, I saw that hemangiomas improve significantly with time but often leave some residual physical stigmata. This was especially true of hemangiomas with cutaneous involvement even without a history of ulceration or bleeding. “Untreated Hemangiomas: Growth Patterns and Residual Lesions” is an important and valuable outcome study. It confirms what I have personally observed over my career as a pediatric plastic surgeon. This study gives documentation that should help refute the idea, held by many pediatricians, that hemangiomas go away with time. The article found that the most common hemangiomas referred to plastic surgeons, those with cutaneous involvement, have an almost 75 percent chance of leaving a persistent deformity after involution. The percentage of a residual deformity is much higher in lesions with prior bleeding, ulceration, or infection. These patients were not included in this study. If they had been, the percentage of residual deformity would have been greater. Even in the less common subcutaneous hemangiomas without epidermal involvement, there was a 25 percent likelihood of having residual fibrofatty fullness. Persistent deformity following involution of a hemangioma is a significant issue when approximately half of all hemangiomas are known to occur in the head and neck and when girls are approximately three times as likely as boys to have hemangiomas. A similar anatomical and sex distribution was reported in this article. Although this study looked at hemangiomas that had no treatment, I suspect that similar results would be found in a study that examined residual lesions following treatment of equivalent hemangiomas with laser, steroids, or beta blockers. None of these treatment modalities can restore the normal dermal architecture that never formed in hemangiomas with skin involvement. This article is not perfect. The study is a retrospective investigation and has some small potential for selection bias. In my experience, the end of the involution stage is later than the median 4 years reported in this investigation. However, I believe that the study’s findings are compelling enough that they should be part of any hemangioma discussion so that parents can make an informed decision regarding the expected outcome when hemangiomas are allowed to involute without treatment.

Congenital Leukemia Cutis Presenting as Multiple Violaceous Lesions in a Newborn

We present a case of congenital leukemia cutis that was the presenting sign of systemic acute myeloid leukemia. The initial diagnosis was benign hemangiomatosis because ultrasound of the liver was negative for visceral involvement. However, biopsy showed monocytic cells and led to a further workup which involved a bone marrow biopsy, giving the final diagnosis of acute myeloid leukemia with leukemia cutis. Even with a thorough knowledge of the differential diagnosis of such presenting lesions, a diagnostic biopsy is often needed for a final histologic diagnosis, to proceed with the proper course of treatment. We review congenital leukemia cutis and the differential diagnosis for violaceous lesions in the newborn that may be encountered by the pediatric plastic surgeon.

Surgical repair of cleft lip and cleft palate

Patients with cleft lip and palate present the pediatric facial plastic surgeon with numerous challenges. This congenital anatomic anomaly carries with it associated cosmetic deformity, speech disorders, dental abnormalities, and deficient maxillofacial growth. This article describes proven techniques in cleft lip and palate surgical repair. The repair of unilateral cleft lip, bilateral cleft lip, and cleft palate are demonstrated. The accurate performance of these reconstructive surgical maneuvers is an important achievement in the overall care for children affected by cleft lip and palate. Patients with cleft lip and palate present the pediatric facial plastic surgeon with numerous challenges. This congenital anatomic anomaly carries with it associated cosmetic deformity, speech disorders, dental abnormalities, and deficient maxillofacial growth. This article describes proven techniques in cleft lip and palate surgical repair. The repair of unilateral cleft lip, bilateral cleft lip, and cleft palate are demonstrated. The accurate performance of these reconstructive surgical maneuvers is an important achievement in the overall care for children affected by cleft lip and palate.

Pediatric Chest Wall and Breast Deformities

Pediatric chest wall and breast deformities present as a wide spectrum of anomalies, and often occur coincidentally. Chest wall abnormalities fall into two categories, congenital (which are largely hypoplastic) and deformational (including both chest wall malignancies and postoperative abnormalities). Breast abnormalities can be categorized into three groups, including hypoplastic, hyperplastic, and deformational anomalies. Hypoplastic breast anomalies require reconstruction with augmentation techniques and are often associated with significant reoperative rates, as are deformational anomalies; hyperplastic abnormalities require reduction techniques and are less likely to require reoperation. Considerations about surgical correction of pediatric chest wall and breast deformities often require coordinated efforts between pediatric and pediatric plastic surgeons with anticipation of continued growth of the child and careful timing for treatment to maximize functional and aesthetic outcomes.

Cleft Palate

Cleft Palate

Radial dysplasia with localized cutis aplasia congenita

Consultant Pediatric Plastic and Reconstructive Surgeon, St. George's Hospital, London, SW17 OQT, UK Correspondence and requests for reprints to A.L.H. Moss, Consultant Pediatric Plastic and Reconstructive Surgeon, St. George's Hospital, London, SW17 OQT, UK E-mail: [email protected]

Pediatric Breast Deformity

Congenital breast anomalies represent a relatively common set of disorders encountered by pediatric plastic surgeons with a spectrum of severity that ranges widely from the relatively benign polythelia to the very complex disorders such as Poland's syndrome and tuberous breast deformities. While the former can be treated in a single surgical setting with minimal morbidity, the more complicated disorders often require a staged reconstructive algorithm. Some disorders also require a multidisciplinary management for both workup and management. Although rarely a source of functional morbidity, these physical deformities are often a significant source of psychological stress for the adolescent male or female who feels alienated from their peers. The purpose of this article is to review the most common congenital breast disorders including the diagnosis, workup, and management especially the timing of surgical intervention as guided by normal developmental milestones.

Extracerebral Malformations: Facial AVMs

Between 1996 and 2005 more than 400 patients suffering from vascular malformations and hemangiomas were treated by the Pretoria Vascular Malformation group, a multi disciplinary group consisting of plastic surgeons, pediatric plastic surgeons, pediatric surgeons, maxilla facial surgeons, E.N.T. specialists, interventional radiologists, dermatologists, anaesthetists, diagnostic radiologists, pathologists, psychologists and pediatricians . The direct treatment were mostly done by either plastic or pediatric surgeons or interventional radiologists, in both state hospital and in private practice. Multi disciplinary consensus meetings were held every 3 months, where all cases were discussed prior to and after treatment . A initial prospective audit was done between 1998 and 2001 (with a cohort of 95 patients), of which ±40% had hemangiomas and 60% vascular malformations. Since then more than 200 patients were treated of which 60% were head and neck lesions. The preferred mode of treatment for low flow malformations and heamangiomas was intralesional injections of 1:1 Bleomycin solution, in a sterile theatre and with all patients under general anaesthesia After obtaining a further specialized imaging full clinical history included MR, sonar and CT as well as angiography where necessary . MR was found to be the most useful modality and CT was important where bone involvement was suspected. Sonar was usedul in distinguishing between high and low flow vascular anomalies and angiography was indicated in high flow lesions. The Mulliken and Glowacki classification was used (No1 in No 1). Vascular anomalies