Plastic Surgery in children
Part 1

________Dr. Mohan Rangaswamy​​________

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Most people would be surprised to hear about plastic surgery for children but in fact pediatric plastic surgery forms a very important part of our work. This mainly refers to correction of birth defects and treatment of injuries or burns. Other examples may be surgery to correct babies born with a paralyzed hand or born with rare tumors. Rarely the birthing process can damage the delicate nerves in the neck leading to paralysis of the baby’s hand;early plastic surgery on the nerves can improve this significantly. All these are reconstructive surgeries;cosmetic surgery is not done in children. In this article I will cover some common birth defects and their treatments, cleft defects and vascular swellings will be covered in another article.

 

External Birth defects may be corrected by pediatric surgeons or plastic surgeons;this is an area of overlap. However, good standard of pediatric anesthesia care is needed before attempting such cases. Giving anesthesia to children demands more care and vigilance. If pediatric anesthesia cannot be assured in a given center, it is better to do it where such facilities are well developed.

Prominent Ear:

This is a common defect. There is no functional problem and in many societies, the parents do not even bother about this. However when the child goes to school, he may be teased by other kids and this can have profound psychological impact. So a “prominent”ear correction may be requested. It is best done in pre-school age when the cartilage is soft. In adult life the correction is more difficult. In this simple operation, we make a skin cut on the back of the ear and bend the ear cartilage backwards while at the same time re-creating missing folds and valleys. The ear cartilage is then fixed firmly to the tough tissues on the back of the head by permanent internal stitches. The skin is finally closed. All work is done from the back surface and there is practically no visible mark.

Ear Nodules

Some babies are born with small nodules around the ear;these can be easily corrected under local anesthesia between 1 to 3 months of age if small. If bigger then they are best left until after the first birthday or later. Parents wonder why this happened, it is not uncommon to see them remark that nobody in the family has this!! Well, it does not have to be familial. The human ear develops by a coordinated fusion and folding of 8 nodules around the ear canal. Just like in a manufacturing assembly line, defective items emerge purely by accident, so in this case some nodules persist or do not fuse. This is just a development error. But we need to look at the lower jaw carefully because in some cases there may be additional defects along this ‘second branchial arch’area of the face.

Eyelid defects:

Babies may be born with a notch on the eyelid or an extra fold or with droopy eyes. After evaluation by an eye specialist such cases are often referred to plastic surgeon. Timing of correction is decided on the basis of several factors, urgent cases risking eye exposure are done immediately;others are done before child goes to school.

Wry Neck.

Birth injury to the neck muscle can result in tightness of the muscle which in turn pulls the babies neck to one side. Such cases need early release of the tight band to prevent secondary deformities from developing.

Extra fingers:

If the extra digit is on the side of the little finger [pinky] then it can be removed in the first 3 months under local anesthesia or after one year under general anesthetic. Between 3 and 12 months, general anesthesia is more risky and local anesthesia is impractical.
But if there is an extra thumb, it needs very careful evaluation and “unification”of the two thumbs to form a single thumb rather than removing what appears to be extra. Inexperienced persons may remove one part thinking it to be extra. In fact neither thumb is extra, both elements will usually be in wrong angles and may carry parts of the whole.

Joined fingers or webbed fingers:

Babies may be born with joined fingers or toes or both. This may affect one or both sides. Usually the fingers are fully formed but rarely, they may be underdeveloped as well. In some rare forms, it is associated with anomalies of head shape as well. Usually only a skin web joins the fingers but rarely the bones may also be fused.
Correction of simple cases is done around 1-2 years of age since patterns of hand usage are established in the brain by 3 years. Also smaller children tolerate bandaging and immobilization better than older “naughtier”age groups. The operation is more tricky than it appears and must be done by well experienced plastic/pediatric surgeons only. In complex cases where bones may also be joined, timing is individualized as per the case. Almost all will require extra skin to be grafted.

Large dark birthmarks:

Called giant nevus, these large hairy patches are distressing to the parents. These require removal in stages usually with advancement of the normal surrounding skin. Removal is advised because there is a higher chance of skin cancer in later life. Smaller moles need not be removed.

Tight bands:

These may exist in any part of the body and may compromise the blood circulation. Such constriction rings need a Z plasty operation to correct it. Early surgery may be needed in some cases.

Abnormal genitalia:

With under development, abnormal location of the urinary opening [called hypospadias] or tight bands, all these abnormalities need correct evaluation, classification and planning before surgical correction. Modern methods have improved success rate in this difficult area.