Pediatric Plastic Surgery

That's me in the back!!

That’s me in the back!!

Often in my medical training I’ve come across words that I had defined on my own prior to med school … then when I realize what they really mean, I have eureka moments. Examples: vasculature. No one tells you this word means “blood vessels (which means arteries and veins) and nerves.” But in anatomy, we were just expected to know that. Now is it so common sense that I don’t know why that word ever confused me… anyway. Plastic surgery is similar. I thought when people crushed their faces or arms or legs, or when people wanted breast implants, plastic surgeons would put hardware/plastic into the skin to reshape the surface. I was wrong.

The Greek word ‘plastikos‘ means “to mold and reshape.” Hence, plastic surgeons merely reshape the injured tissues to get a better cosmetic appearance. Sometimes they use hardware. Most of the time they don’t. Eureka moment. (Or is that a blonde moment?)

My pediatric plastic surgery rotation was nothing short of amazing. Instead of my (probably wrong/judgmental/unfair) preconceived notion of what plastic surgery typically means, it was 110% different. No one was there simply for a cosmetic boost. She actually changed the courses of kids’  lives by giving them a normal smile. She saved kids who otherwise would have had years of ridicule on the playground for having a funny lip or crooked nose or club feet. It was amazing the lasting impact my doctor had on these kids’ lives.

I saw all different forms of cleft lips and palates. I got to scrub in on tons of cases of lip and palate repair. The immediate result is a little wonky looking, but after the scar heals (and with proper scar massage and care) the kids look completely normal, as if nothing had ever been wrong! I also got to sit in on a prenatal counseling appointment where the parents had found out by ultrasound that their unborn baby had a cleft lip- and how my doctor could fix it in a few short months. It was devastating news for the parents- everyone imagines their baby being born perfect without any cosmetic or functional difficulties- and a cleft lip could mean no breastfeeding, special expensive bottles, difficulty with speech later in life, and a host of other complications. But my doctor was able to offer hope to this family with pictures of children she had repaired in the past and their good clinical outcomes with little to no lasting repercussions.

I saw tissue expanders for a patient who needed skin grafts. A tissue expander involves surgically placing a bag into a pocket of skin, then injecting a whole lot of fluid into the bag over a period of time. It stretches the skin (i.e. expands the tissue) and allows for more surface area to be covered when they need to use the skin flap. These are common for burn victims and kiddos who have had head surgery.

We took care of a lot of kids with syndactyly (webbed/connected fingers/toes) and polydactyly (extra fingers/toes). The results of these surgeries were also incredible! The scars were minimal and most of the kids had full function of their fingers afterwards (depending on the arrangement and development of the bones at birth).

I also got to see numerous dog bite repair surgeries. It was heartbreaking and infuriating, but our job was simply to fix the defect- not ask details about what happened/if the dog was still in the home/etc… those are questions for social workers and other members of the team. Still, it was difficult for me to rationalize subjecting these poor kids to unneeded surgeries simply because of a lack of parental supervision.

The syndromes and super rare congenital anomalies we saw were also striking. I’ll add a short/super abbreviated/very simplified description of what each syndrome includes… I’ll try to use layman’s terms as much as I can! We saw Beckwith Wiedemann syndrome (large tongue), Muenke syndrome (premature closure of bones of the skull during development), ablepharo macrostomia with ectodermal dysplasia (born with no eyelids, corners of the mouth go out onto the cheeks, and abnormalities of the ectoderm which includes hair, teeth, nails, sweat glands, fingers, and facial structure), campomelic dysplasia (usually lethal, malformed bones in the spine and legs, sometimes absent leg bones, cleft palate, heart and lung and brain and kidney abnormalities), hemifacial microcia (small ears) with microsomia (small face), pierre-robin sequence (underdeveloped mandible, retracted tongue, cleft palate), & teacher collins syndrome (absence of cheek bones, downward eye slant, underdeveloped eye socket/bony structure around eyes, abnormal ears and hair development).

The funniest moment that happened for me was on a pre-operative check on a 14 year old girl who was having breast reduction for her size J breasts. She was unable to attend school because she was being mocked and had intense and constant back pain. She was asking all of the usual pre-surgery questions about healing time, pain after the surgery, when she would have to stop eating before the surgery, etc…. Then she asked “What if I wake up in the middle of surgery?!” We explained to her that the job of the anesthesiologist is to make sure that doesn’t happen. I explained that the anesthesiologist is constantly monitoring her blood pressure, heart rate, breathing, and level of sedation during the entire surgery. She got a blank stare in her eye and (in the most sarcastic tone that only teenagers can pull off) said, “That sounds like a fun job.” My surgeon starting laughing and told the patient that I was interested in anesthesiology, and that she agreed with the patient that it was a super boring job! We were all laughing as I tried to explain why it’s an exciting field. It was hilarious!

The grossest thing I had to do was rebreak a kid’s nose in the operating room. She had me take a glorified butter knife (“surgical tool” is a stretch) and put it up the kid’s nose, then pull as hard as I could toward his forward. It crunched, I broke out in a cold sweat and got dizzy, and she said, “Wow, Great job!!” It was disgusting, but it was back in place!

The most incredible stories for me involved 2 families. One was a post-operative scar check up on a 15 month old with bilateral asymmetric cleft lip and palate. The mom was alone in the room with the child and was a very pleasant and peppy woman. She was so nice, asking about where I was from, what year in school I was, what my interests were, and how I like Phoenix. Her son was one of the cutest kids I’ve ever seen. Literally, he could’ve been a Gap or Gerber model. He just had one of those faces! His scars were healing well and he was able to talk normally and eat normally, which was all great news. We left the room and the doctor turned to me with tears in her eyes and said, “I just don’t know how she does it and stays so happy.” I asked what she meant, and she explained to me that the dad of this child had killed himself 2 years ago. 1 week after he killed himself, the mom found out she was pregnant. Her pregnancy was full of complications, including finding the cleft lip on ultrasound. It was an incredible story, considering how nice and full of life she was & how beautiful and perfect her son appeared. Her son was a once-in-a-lifetime precious gift.

**warning, semi-graphic story ahead, quit reading if you can’t handle!**

The other story was a baby who was born at 24 weeks (babies should ideally be born at 38-42 weeks). The baby girl was 1.5 pounds when I saw her. She was by far the tiniest baby I’ve ever seen. The mom had previously gone into labor and started to dilate, so they sewed her cervix shut (called a cerclage). When she went into labor this time, her cerclage failed, and the baby was breech. The baby’s leg went through the cervix before they could rush the mom to C section. When they did the C section, the baby was in distress so they had to get her out fast to save her- and in the process of doing so, they degloved her leg that was through the cervix (i.e. turned the skin inside out, like taking a glove off). When I saw her, she was almost 2 weeks old. Her leg was bare, down to the muscle, with little patches of skin here and there that had been spared. The grafts they had placed were taking well, and she was healing splendidly. My doctor didn’t think she’d even need surgery! Her breathing and other complications that come with being a super premature baby were also doing well. She was expected to make it out of the newborn ICU with no lasting complications. She was truly a miracle baby.

I don’t think I’ll ever understand the “why” aspect of these stories, but I’ll never forget the affect they have on me. I really enjoyed my 2 short weeks of pediatric plastic surgery. It was a little rough at times since I am now pregnant myself, and of course my mind immediately went to the worst possible scenarios (omg what if MY baby has a cleft lip? what if MY baby has some congenital syndrome?!). But I was also reassured, because so many things that happen during development are fixable/manageable and aren’t the end of the world. It definitely changed my view on the importance of cosmetic appearance in our world and how something as simple as repairing someone’s nose or dog bite scar or cleft lip can open the door to college acceptance, job interviews, and social acceptance. It was an amazing rotation!

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