PROCEDURES | Reconstructive
Cleft Lip/Cleft Palate
One of the most common congenital problems that occur in newborn infants are cleft deformities: cleft lip and cleft palate. They result from incomplete development of the lip or the palate during pregnancy. Though these congenital problems have been studied extensively, it is still not known exactly what causes them. It is however well understood that they are not due to something particular that the mother did during pregnancy. Proper care of an infant with a cleft deformity may involve the help of a variety of health professionals. In addition to surgery to repair the defects there may be other associated issues. Speech and hearing may be effected, requiring the care of an otolaryngologist and a speech pathologist. Dentition may be effected also, requiring the care of an orthodontist specialized in this type of care. Many University Hospitals have Orofacial Teams that work with children with cleft deformities. The team approach to management is ideal for the child and the parents.
When will the repairs take place?
Initial closure of the cleft lip takes place at 2-4 weeks of age. This surgery is done as an outpatient. The more detailed repair takes place at 4-6 months of age. This is also done as an outpatient procedure. The palate is repaired at approximately 18 months of age. This surgery requires at least one night in the hospital. It is important to be sure that your child is well hydrated and able to eat prior to discharge.
Where are the incisions placed?
With lip repair an incision is placed from the lip up toward the nose. It is visible and will fade with time.
What happens the first day or two after surgery?
Your child will be placed in "no-no" restraints. These are soft restraints that prohibit your child from bending her elbows. The surgical repair can be destroyed easily by the insertion of a fist in the mouth or by picking or rubbing the lips. The outside sutures will be removed at 4-5 days and replaced with as small tape dressing. This will fall off on its over the next few days. Internal sutures will dissolve spontaneously and do not need to be removed.
Your child may be a bit cranky the first day or two. Discomfort can be easily controlled with pain medication.
What complications are possible?
As with nearly any surgery, delayed healing or infection is a risk. In rare cases there may be poor healing of the palate, which may lead to the need for a second surgical repair.
Will my baby's feeding be affected?
Feeding a baby with a cleft lip or palate can present a large challenge to the mother. When a cleft lip is present it is hard for the baby to close tightly around the nipple. When a cleft palate is present the baby has difficulty sucking. Because of this the following things may happen:
-Feeding will take longer, resulting in a tired and irritable baby
-Excess air may be swallowed resulting in stomach discomfort, vomiting or spitting up
-Food may be lost through the nose resulting in irritation-Food may go into the trachea resulting in coughing or choking.
-Your baby may not get enough milk or formula resulting in a failure to gain weight and hunger
Your doctor should provide you with detailed information about feeding. The Orofacial Team will have a nurse specialist who can assist you.
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Skin Cancer
Skin cancer is the most common form of cancer in the United States. More than 500,000 new cases are reported each year—and the incidence is rising faster than any other type of cancer. While skin cancers can be found on any part of the body, about 80 percent appear on the face, head, or neck, where they can be disfiguring as well as dangerous.
Who gets skin cancer ...and why
The primary cause of skin cancer is ultraviolet radiation—most often from the sun, but also from artificial sources like sunlamps and tanning booths. In fact, researchers believe that our quest for the perfect tan, an increase in outdoor activities, and perhaps the thinning of the earth's protective ozone layer are behind the alarming rise we're now seeing in skin cancers.
Anyone can get skin cancer—no matter what your skin type, race or age, no matter where you live or what you do. But your risk is greater if...
- Your skin is fair and freckles easily.
- You have light-colored hair and eyes.
- You have a large number of moles, or moles of unusual size or shape.
- You have a family history of skin cancer or a personal history of blistering sunburn.
- You spend a lot of time working or playing outdoors.
- You live closer to the equator, at a higher altitude, or in any place that gets intense, year-roundsunshine.
- You received therapeutic radiation treatments for adolescent acne.
Types of skin cancer
By far the most common type of skin cancer is basal cell carcinoma. Fortunately, it's also the least dangerous kind—it tends to grow slowly and rarely spreads beyond its original site. Though basal cell carcinoma is seldom life threatening, if left untreated it can grow deep beneath the skin and into the underlying tissue and bone, causing serious damage (particularly if it's located near the eye).
Squamous cell carcinoma is the next most common kind of skin cancer, frequently appearing on the lips, face, or ears. It sometimes spreads to distant sites, including lymph nodes and internal organs. Squamous cell carcinoma can become life threatening if it's not treated.
A third form of skin cancer, malignant melanoma, is the least common, but its incidence is increasing rapidly, especially in the Sunbelt states. Malignant melanoma is also the most dangerous type of skin cancer. If discovered early enough, it can be completely cured. If it's not treated quickly, however, malignant melanoma may spread throughout the body and is often deadly.
Other skin growths you should know about
Two other common types of skin growths are moles and keratoses.
Moles are clusters of heavily pigmented skin cells, either flat or raised above the skin surface. While most pose no danger, some—particularly large moles present at birth—or those with mottled colors and poorly defined borders—may develop into malignant melanoma. Moles are frequently removed for cosmetic reasons, or because they're constantly irritated by clothing or jewelry (which can sometimes cause pre-cancerous changes).
Solar or actinic keratoses are rough, red or brown, scaly patches on the skin. They are usually found on areas exposed to the sun, and sometimes develop into squamous cell cancer.
Recognizing skin cancer
Basal and squamous cell carcinomas can vary widely in appearance. The cancer may begin as small, white or pink nodule or bumps; it can be smooth and shiny, waxy, or pitted on the surface. Or it might appear as a red spot that's rough, dry, or scaly; a firm, red lump that may form a crust; a crusted group of nodules; a sore that bleeds or doesn't heal after two to four weeks; or a white patch that looks like scar tissue.
Malignant melanoma is usually signaled by a change in the size, shape, or color of an existing mole, or as a new growth on normal skin. Watch for the "ABCD" warning signs of melanoma: Asymmetry—a growth with unmatched halves; Border irregularity—ragged or blurred edges; Color—a mottled appearance, with shades of tan, brown, and black, sometimes mixed with red, white, or blue; and Diameter—a growth more than 6 millimeters across (about the size of a pencil eraser), or any unusual increase in size.
If all these variables sound confusing, the most important thing to remember is this: Get to know your skin and examine it regularly, from the top of your head to the soles of your feet. (Don't forget your back.) If you notice any unusual changes on any part of your body, have a doctor check it out.
Diagnosis and treatment
Skin cancer is diagnosed by removing all or part of the growth and examining its cells under a microscope. It can be treated by a number of methods, depending on the type of cancer, its stage of growth, and its location on your body. Small skin cancers can often be excised quickly and easily in our office.
Most skin cancers are removed surgically, by a plastic surgeon or a dermatologist. If the cancer is small, the procedure can be done quickly and easily, in an outpatient facility or the physician's office, using local anesthesia. The procedure may be a simple excision, which usually leaves a thin, barely visible scar. Or curettage and desiccation may be performed. In this procedure the cancer is scraped out with an electric current to control bleeding and kill any remaining cancer cells. This leaves a slightly larger, white scar. In either case, the risks accompanying surgery are low.
If the cancer is large, however, or if it has spread to the lymph glands or elsewhere in the body, major surgery may be required. Other possible treatments for skin cancer include cryosurgery (freezing the cancer cells), radiation therapy (using x-rays), topical chemotherapy (anti-cancer drugs applied to the skin), and Mohs surgery, a special procedure in which the cancer is shaved off one layer at a time. (Mohs surgery is performed only by specially trained physicians and often requires a reconstructive procedure as follow-up.)
Discussing your options and concerns
All of the treatments mentioned above, when chosen carefully and appropriately, have good cure rates for most basal cell and squamous cell cancers—and even for malignant melanoma, if it's caught very early, before it's had a chance to spread.
You should discuss these choices thoroughly with your doctor before beginning treatment. Find out which options are available to you
A word about reconstruction
The different techniques used in treating skin cancers can be life saving, but they may leave a patient with less than pleasing cosmetic or functional results. Depending on the location and severity of the cancer, the consequences may range from a small but unsightly scar to permanent changes in facial structures such as your nose, ear, or lip.
In such cases, no matter who performs the initial treatment, the plastic surgeon can be an important part of the treatment team. Reconstructive techniques—ranging from a simple scar revision to a complex transfer of tissue flaps from elsewhere on the body—can often repair damaged tissue, rebuild body parts, and restore most patients to acceptable appearance and function.
Preventing a recurrence
After you've been treated for skin cancer, your doctor should schedule regular follow-up visits to make sure the cancer hasn't recurred.
Your physician, however, can't prevent a recurrence. It's up to you to reduce your risks by changing old habits and developing new ones. (These preventive measures apply to people who have not had skin cancer as well.)
- Avoid prolonged exposure to the sun, especially between 10 a.m. And 2 p.m. and during the summer months. Remember that ultraviolet rays pass right through water and clouds, and reflect off sand and snow.
- When you do go out for an extended period of time, wear protective clothing such as wide brimmed hats and long sleeves.
- On any exposed skin, use a sunscreen with SPF (sun protection factor) of at least 15. Reapply it frequently, especially after you've been swimming or sweating.
- Finally, examine your skin regularly. If you find anything suspicious, consult a plastic surgeon or a dermatologist as soon as possible.
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Tissue Expansion
The best candidates for tissue expansion
Almost anyone in need of additional skin can benefit from tissue expansion.
The procedure is used widely in breast reconstruction when there is not enough skin to accommodate a permanent implant to restore a woman's natural appearance. It is also an option for repairing or replacing areas of the scalp, where hair growth makes it difficult to replace lost tissue with skin from other areas of the body. Tissue expansion generally produces excellent results when reconstructing some areas of the face and neck, the hands, arms, and legs.
Tissue expansion is ideal for scalp repair because the stretched skin on the scalp retains normal hair growth. Most other body tissue does not grow hair to the same degree.
Following tissue expansion, the repaired scalp looks very natural. Expansion may be more difficult on the back, torso, or other areas where skin is thick. If the affected area is severely damaged or scarred, expansion is probably not an option, since healthy skin is the first requirement.
Advantages and disadvantages
Until recently, surgeons were limited to skin flaps and skin grafts to reconstruct damaged tissue. Tissue expansion, however, provides an added technique with several advantages.
First, expansion offers a near-perfect match of color, texture, and hair-bearing qualities. Second, because the skin remains connected to the donor area's blood and nerve supply, there is a smaller risk that it will die. In addition, because the skin doesn't have to be moved from one area to another, scars are often less apparent.
On the other hand, skin expansion has one significant drawback—the length of time required to grow additional skin. The process usually takes 3-4 months total, in which time there may be an visible bulge. Also, the procedure requires repeated visits to the surgeon for injection of the salt water that inflates the balloon.
Despite the drawbacks, tissue expansion can produce very pleasing results, and is a superior technique for its reconstructive purpose
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