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. Dr. Bolitho 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.

Dr. Bolitho works closely with your primary care physician in designing a maximally effective treatment plan for your child. Commonly, they work in the context of a multi-disciplinary team. The family physician and pediatrician may work together with Dr. Bolitho to help parents deal rationally with treatment options.

Malformations of the Ear

Ear malformations 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.

As soon as an ear malformation is identified, Dr. Bolitho 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 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 ear reconstruction depends upon patient selection, adequate counseling of parents, surgical skill, and detailed attention in the intraoperative and postoperative periods to prevent complications.

Hemangiomas and Other Benign Vascular Lesions of the Skin

Hemangiomas and lymphangiomas, the most common benign tumors of the skin in newborns, 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. 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 Dr. Bolitho and pathologist initiates the planning for surgical removal and other treatment options.

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 is often a treatment of choice.

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. This is the congenital absence of chest wall structures in association with hand malformation.

Dr. Bolitho can correct many hand malformations definitively; in other instances, he can provide some degree of functional improvement. Consultation with the patient's parents must stress the importance of restoring function to the malformed hand, with the cosmetic appearance a secondary consideration. The unique function of the hand throughout life mandates that function be restored as fully as possible. The provision of pinch and grip function will be essential to many occupations.

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 webbing of the fingers. Treatment of breast asymmetry due to Poland's syndrome may include the use of a breast implant, or the use of the patient's own tissue to recontruct the breast or 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.

Soft-Tissue Injuries requiring 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. Dr. Bolitho emphasizes the importance 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.

Dr. Bolitho stresses that 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, Dr. Bolitho 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.

Animal Bites

Animal bites can present special problems. The majority of dog bite wounds are to the face in children and are typically contaminated, crushing type injuries. Vigorous cleaning and meticulous repair by Dr. Bolitho can frequently salvage a serious injury.

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 loss of normal tissue that requires surgical removal. Skin grafting or reconstruction with skin flap techniques may be needed after healing of the wound.

Burns

Most burns suffered by infants and young children are hot-liquid scalds. The immediate concern in scald injury is estimation of the extent of injury. The size of the 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 the temperature of the scalding liquid, and the amount of time the skin was exposed to the liquid. Good emergency management of a superficial burn should result in healing without complications. Elements of good medical 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. Dr. Bolitho is available for consultation for child with a burn on any site, but particularly for burns involving the face and hands.