Figure 109-26. Open tip rhinoplasty with dorsal hump reduction including cartilage and bone, cephalic scroll resection of lower

lateral cartilage, nasal septal cartilage spreader grafts, and nasal osteotomies. A, B: Preoperative appearance. C, D: Postoperative

appearance. Note the nice reduction in the dorsal hump, supratip break, and improved dorsal aesthetic lines. The midvault

collapse has been dramatically improved.

Postoperatively, the patient is instructed to keep their head elevated and apply ice packs. An external

splint is used to maintain the position of the nasal bones and cartilage for 10 to 14 days. Patients should

expect nasal swelling, pain, and bruising for 2 to 3 weeks; if osteotomies are performed, the patient

may also experience periorbital ecchymosis. A full year is required for complete resolution of nasal tip

swelling, particularly following an open-tip rhinoplasty. Approximately 10% of primary rhinoplasty

patients will require an operative revision due to dissatisfaction with the cosmetic or functional

outcome; the revision rhinoplasty should not be performed for at least 1 year following the original

procedure to ensure that all postoperative swelling and tissue remodeling has stabilized.

Genioplasty

Genioplasties are common plastic surgical procedures to manipulate the position of the chin and thereby

improve facial appearance. Based on the design of the mandibular symphysis osteotomy, the vertical

height and anterior projection of the chin can be adjusted.85 Patients with a “weak” chin may undergo

an advancement genioplasty to enhance chin projection and improve the cervicomental angle. Chin

augmentation may also be accomplished with an alloplastic implant, eliminating the need for an

osteotomy. Patients with a very prominent chin can undergo a reduction genioplasty where the vertical

height and anterior projection can be reduced. The dental occlusion is not affected by these procedures,

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but the lip position and neck appearance may be altered.86

A complete physical examination, photographic analysis, and radiographic evaluation are performed

to evaluate facial harmony and determine the extent of the advancement or reduction. Dental occlusion

is carefully examined to ensure that orthognathic surgery is not required to correct chin position.

Operations are typically performed under general anesthesia, but can also be performed under local

anesthesia if desired. Local anesthesia containing epinephrine is injected intraorally for hemostasis and

postoperative pain control. Access to the mandibular symphysis is achieved through an inferior buccal

sulcus incision. The osteotomy is measured and marked based on the preoperative photographs and

lateral radiographs; the mental foramen is avoided. The bony segment is mobilized and secured in its

new position with plates and screws. If an alloplastic chin augmentation is to be performed, incisions

can be performed in the submental region or intraorally for placement of the implant. Postoperatively,

swelling and pain persist for approximately 4 to 6 weeks. During this time, the patient should perform

meticulous oral hygiene and avoid foods that may traumatize the inferior buccal sulcus incision.

Cosmetic Procedures of the Trunk and Extremities (Body Sculpting)

Abdominoplasty

Abdominoplasties encompass a wide array of surgical procedures used to correct abdominal deformities

resulting from excess abdominal skin, fatty tissue, and abdominal wall laxity. Abnormalities in any of

these tissue planes may produce an aesthetically unappealing abdomen. Surgical procedures are

designed to correct the underlying pathology and include dermatolipectomy, liposuction, and abdominal

wall plication. These procedures are often combined and tailored to fit the surgical needs and desires of

the patient. It is critical to define the physical anomaly responsible for the abdominal deformity so that

the appropriate operative procedure or combination of procedures can be performed.87,88

A standard abdominoplasty combines a dermatolipectomy, liposuction, and abdominal wall plication

to correct deformity in each of the three previously mentioned abdominal wall layers. The operation is

performed under general anesthesia through a bikini-line incision extending from the cephalad margin

of the pubic escutcheon to the iliac crests bilaterally. The skin incisions are made and the abdominal flap

is elevated off the underlying abdominal wall fascia. A circumferential incision is made around the

umbilicus to allow complete elevation of the abdominal flap up to the costal margin. The patient is then

placed in a flexed position, the abdominal flap is redraped caudally, and the redundant skin is resected.

If any abdominal wall laxity is identified along with the skin redundancy, then a vertical, midline

abdominal wall plication is also performed. Occasionally, suction-assisted lipectomy (SAL) is performed

at the time of abdominoplasty to help recontour the abdomen and flanks. However, aggressive SAL of

the abdominal flap may critically compromise flap vascularity and contribute to flap necrosis.

Occasionally it is helpful to perform SAL along the lateral and posterior iliac crests bilaterally to reduce

the prominence which may have developed following the anterior dermatolipectomy and caudal

repositioning of the skin flap. A small incision is then made in the midline of the abdomen at the level

of the iliac crests for delivery of the umbilicus into its new position. Closed-suction drains are placed

prior to wound closure (Fig. 109-27).

A “mini-abdominoplasty” is used to treat mild abdominal skin redundancy and abdominal wall laxity.

The same approach is used as previously described for a standard abdominoplasty except the skin

incision is limited to the central portion of the abdomen. A limited skin resection can be performed

through this approach along with an abdominal wall plication. SAL can be used in combination with this

procedure if necessary.

Endoscopic abdominoplasty can be used to treat abdominal wall laxity (i.e., postpartum rectus

diastasis) and localized collections of fatty tissue. Patients who are candidates for this operation must

have good skin quality and only mild to moderate lipodystrophy. The endoscopic abdominoplasty is

performed through two incisions, a 3- to 5-cm transverse incision within the pubic hair and a

circumferential incision around the umbilicus. These incisions function as the two access ports through

which the endoscopic instruments are passed. The entire abdominal wall is then elevated off of the

abdominal wall fascia under endoscopic visualization with electrocautery. The midline of the abdominal

wall is plicated from pubis to xiphoid. The abdominal wall is then recontoured with SAL, which is

performed through the two access ports.65

Liposuction

Liposuction is a surgical procedure designed to resect collections of fat from isolated anatomic regions.

It is not a form of weight loss and is not indicated in obese patients. Liposuction is ideally suited to

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patients who are within 20% to 30% of their ideal body weight and have localized collections of fat that

are refractory to dietary modifications and exercise. A complete evaluation of skin elasticity is very

important in patients considering liposuction because once fat is surgically removed, the skin must be

able to contract down to the contour of the remaining subcutaneous tissue. If the skin quality is poor,

then wrinkling, dimpling, or skin ptosis may severely compromise the aesthetic result.87–90

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Figure 109-27. Mastopexy, abdominoplasty, and rectus abdominis plication. A, B: Preoperative appearance of breasts. C–E:

Preoperative appearance of abdomen. F–H: Postoperative appearance. Note the dramatic improvement in the appearance of the

breasts and abdomen. The abdomen is flat with a narrowed waistline.

Two forms of liposuction are currently used: SAL and ultrasonic assisted liposuction (UAL). SAL is

used in all areas of the body but may not be as effective as UAL in more fibrous anatomic regions such

as the flank, upper abdomen, or male breast. Treatment of lipodystrophy in these regions is more

effective with UAL alone or UAL in combination with SAL.87,91 A number of technologic advances have

led to new techniques for performance of liposuction or liposculpting (i.e., lipodissolve, endermologie,

and Smart-lipo). However, none of these newer devices or techniques has proven to be clinically

efficacious in rigorous clinical trials, nor have they been shown to be as effective as Standard SAL or

UAL.

As with all aesthetic procedures, careful patient selection is of paramount importance. All patients

must undergo a complete evaluation preoperatively to ensure that their goals can be achieved by

performance of liposuction. Preoperative photographic documentation is performed on all patients.

Markings are then made with the patient in the upright position. Access ports (6 to 8 mm), through

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which the SAL or UAL is performed, are marked in concealable areas. Patients can undergo these

procedures under local or general anesthesia. Tumescent fluid (1,000 mL of LR, 50 mL of 1% lidocaine,

and 1 mg of epinephrine) is then infiltrated for pain control and hemostasis.

SAL is performed with metal cannulas connected to an aspirating device that generates a negative

pressure of 1 atmosphere. Various cannula configurations are used to perform the resection. Fatty tissue

is aspirated into the holes of the cannula and then resected by movement of the cannula tip. The

operation is performed through multiple access ports, starting with large (6- to 8-mm diameter)

cannulas and progressing to smaller (3- to 4-mm diameter) cannulas with fewer holes to allow more

precise body contouring. Overlapping patterns of resection are used to avoid contour irregularities.

UAL is a surgical technique that allows body contouring through the liquefaction and aspiration of

fatty tissue. When employed alone or in combination with traditional SAL, UAL is effective for treating

lipodystrophy in fibrous anatomic regions such as the flank, upper abdomen, and male breast. The UAL

probe tip produces sound waves at an ultrasonic frequency of 20 to 30 kHz. The sound waves cause

cavitation which disrupts lipocytes. Low-power suction is then employed to remove the resultant fluid.

If UAL is used inappropriately, patients may experience severe complications, including full-thickness

skin loss from thermal injury.91

All patients are placed in a compressive garment 24 hours per day for 6 weeks postoperatively. Early

postoperative compression reduces the chances of hematoma formation. Prolonged compression reduces

swelling and the potential for skin wrinkling. All patients experience some degree of ecchymosis,

swelling, and decreased sensibility. The end result will not be realized for approximately 2 to 3 months

following the procedure.

PEDIATRIC PLASTIC SURGERY

The specialized area of pediatric plastic surgery focuses on the reconstruction of abnormalities in

children with congenital malformations and acquired deformities. Utilizing a sound knowledge of

embryology as well as the changes inherent during growth and development, pediatric plastic surgeons

employ a combination of innovation and technical expertise to restore both form and function to their

patients. Although the manifestations of congenital malformations may be diverse, the approach to

reconstruction is always based on solid fundamental surgical principles. Similarly, the management of

traumatic or other acquired maladies in the pediatric population is founded on essential surgical tenets

influenced by the special considerations of maturation and growth. This section concentrates on the

most salient aspects of pediatric plastic surgery to give the clinician an accurate grasp of the

subspecialty.

Cleft Lip and Palate

Perhaps the area of expertise that best exemplifies the specialty of pediatric plastic surgery is the

management of children with cleft lip and palate deformity. The cleft lip and palate pose a variety of

structural and functional deficits that must be addressed with respect to growth and development as

well as psychosocial concerns of the individual patient and family. The care of these children requires

exacting surgical technique in combination with the efforts of a team of allied health professionals to

effect a comprehensive level of rehabilitation.

The overall incidence of cleft lip and palate deformity is approximately 1 in 750 children. This

incidence is significantly higher in the Asian population, 1 in 300, and significantly lower in the black

population, 1 in 2,000.92–95 The distribution of cleft types is approximately 46% combined cleft lip and

palate, 21% isolated cleft lip, and 33% isolated cleft palate.95 Almost 30% of children with cleft lip and

palate deformity have associated birth defects that vary in scope and extent and therefore require

vigilance in the physical examination.96 The chance of having a second child with cleft lip and palate to

unaffected parents is approximately 4% as is the chance of one affected parent producing an offspring

with a cleft.97,98 Genetic counseling is usually helpful in both educating the parents and screening for

other associated congenital anomalies.

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Figure 109-28. Left unilateral complete cleft lip.

7 A cleft lip deformity can be bilateral or unilateral and is considered complete if it extends into the

nose and incomplete if it does not (Fig. 109-28). The cleft lip can extend into the gum partially or

completely through the alveolus, creating a bony defect. The cleft lip deformity affects the nose as well

as the lip, and therefore both of these structures must be addressed in the reconstruction of the

deformity. Although the timing of cleft lip repair is controversial, the repair of the cleft lip is most often

addressed in about the third month of life, after the child shows sufficient weight gain. This timing

permits a potentially safer anesthetic administration.

There are multitudes of cleft lip repairs, but the goals of the repairs remain the same: an anatomic

reconstruction with minimal scarring and normal function. In general, the skin around the cleft is cut

into flaps that are brought together in a way that will give adequate length to the lip and restore the

continuity of the orbicularis musculature (Fig. 109-29).99 Long-term symmetry is the goal of

reconstructive procedures to the cleft lip–nasal deformity, and taking into account how the face changes

with growth is necessary to execute the appropriate operation in infancy.96

The cleft palate can affect the soft palate alone or include the hard palate. Victor Veau classified the

degree of clefting I to IV from the least severe (soft palate only) to most severe (through the soft

palate, hard palate, and alveolus bilaterally) (Fig. 109-30).100 In some cases, a cleft palate may have no

mucosal separation at all and display only a separation or clefting of the underlying musculature. This

special situation is referred to as a submucous cleft palate and may also have functional consequences

for the patient. Functionally, the hard palate acts as a structural barrier between the oropharynx and the

nose. The soft palate moves superiorly and articulates with the posterior and lateral pharyngeal walls to

create a seal between the oropharynx and the nasopharynx during speech and swallowing. The

coordinated activity of the soft palate prevents regurgitation of solids and liquids into the nose while

eating and prevents hypernasal speech while producing strictly oral sounds. As with cleft lip, there are a

multitude of cleft palate repairs but the goals of the repairs remain the same: repositioning the

abnormal anatomy and creating normal function. Reconstructive procedures are based on reconstituting

the oral and nasal lining of the palate and reapproximating and realigning the palatal musculature. A

purely soft palatal cleft may require only the separation of the layers of the palate, reorientation of the

muscles, and simple closure. The wider clefts and many of the hard palatal clefts, however, require

relaxing incisions and release of the mucosa from the underlying bone. The lateral mucosa from both

sides is transposed over the midline cleft and sewn closed. The addition of double-opposing Z-plasties in

the velum adds further length to the palate (Fig. 109-31).100 Flaps derived from the vomer may be

required to achieve closure without tension, a chief precept for any repair of the palate. Many children

with this deformity exhibit growth restriction of the midface and bony palate, which is thought to be

due to the dissection of mucosal tissue off the bone.101 Delaying palate closure until the maxilla has

finished growing allows better facial growth, but leads to poor speech outcomes, whereas early

intervention is thought to improve speech. For this reason, the timing of the repair of the cleft palate is

controversial; however, the cleft palate repair is most often addressed by the age of 1 year.

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Figure 109-29. A: Markings. B: Dissection of the orbicularis muscle and rotation of the central (greater segment) and advancement

of the lateral (lesser segment). C: Appearance of the closure.

Figure 109-30. Veau classification of cleft palate. A: Veau I involves the soft palate only. B: Veau II involves the soft palate and

hard palate up to the incisive foramen. C: Veau III involves the soft and hard palate and is through the alveolar ridge. D: Veau IV,

the most severe, involves the soft and hard palate and the premaxilla is discontinuous with the alveolar arch.

Speech therapy is almost always required for children with a cleft palate and is instituted as soon as

the child develops the necessary language skills. Early intervention programs have arisen for

preschoolers, and speech programs are often available through local school systems. Unfortunately, the

palate repair alone is successful in normalizing speech in only about 80% of patients.102 The remainder

of patients will require a supplemental operation to decrease residual hypernasality and improve

speech. The operations directed at salvaging speech are performed early enough to have the most

beneficial effect on speech development, while giving adequate time to ensure that the patient has been

given ample opportunity for speech therapy to maximize the potential of the palate repair. The decision

to operate is based on a perceptual analysis of speech and is aided by visualization of palatal function

with nasoendoscopy and objective measures of function using nasometry techniques. Techniques vary,

but the operative procedures are based on placement of either dynamic or static tissue near the

velopharyngeal port to better regulate and impede the abnormal flow of air into the nasopharynx.

Orthodontics is a key portion of the comprehensive restoration of the cleft patient and requires close

interaction between the pediatric plastic surgeon and the orthodontist. One of the early interactions

involves the repair of any residual clefting of the alveolus. Bone grafting is required for reconstruction

of the alveolar cleft to restore the continuity of the upper maxillary dental arch, allow the normal

emergence of the canine tooth, close the persistent oral nasal fistula, and provide structural support for

the recessed nasal alar base. The orthodontist will monitor tooth eruption and may institute early-phase

therapy to align the teeth in preparation for bone grafting. The timing of alveolar bone grafting is also

controversial but is mandatory for normal tooth emergence. Bone grafting is often performed at about 7

to 8 years of age and entails the surgical isolation and repair of the oral nasal fistula, the reconstruction

of the adjacent nasal floor and palatal roof, the placement of bone graft in the alveolar defect, and

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coverage anteriorly with gingival flaps. Cancellous bone grafts harvested from the iliac crest is used

most commonly. To eliminate the donor site, other bone substitutes have been trialed, with studies

using recombinant human bone morphogenic protein (rhBMP2) showing promise103; however, iliac

bone graft currently remains the standard of care.

Many patients respond favorably to the skilled implementation of a long-term orthodontic plan, but

some patients display bony hypoplasia as mentioned earlier and require orthognathic surgery of the

maxilla, and possibly the mandible, to assist in establishing normal occlusion. Operations to restore a

normal occlusion should await the cessation of growth so that the surgical registration of occlusion will

be permanent and not require additional procedures. The most common operation to address midfacial

hypoplasia and restore occlusion in the cleft patient is the Le Fort I osteotomy. The orthodontist helps

the pediatric plastic surgeon to determine the best postoperative occlusion for the patient based on the

orthodontic plan, and an oral surgical splint is fashioned to allow easy registration intraoperatively. The

patient undergoes a horizontal osteotomy above the level of the tooth roots and across the

nasomaxillary and zygomaticomaxillary buttresses below the level of the zygomatic body (Fig. 109-32).

The bones of the midface are separated from the cranial base by performing a pterygomaxillary

disjunction, and the floating maxilla is then repositioned into the planned occlusion by registering the

teeth in the splint. The bones of the maxilla are then fixed using plates and screws. In severe

malocclusion cases, the mandible may also need to be cut and moved into a position that results in an

anatomic orthognathic bite.

Figure 109-31. Furlow double-reversing Z-plasty cleft palate repair. A: Lines of incision. B: Dissection of palatopharyngeus muscles

and Z-plasty incisions. C: Transposition of the musculomucosal flaps. D: Final closure.

Figure 109-32. Le Fort I osteotomy in an advanced position. One side has been plated into position.

The last operation to be performed on the patient with a cleft lip and nasal deformity is often the

formal rhinoplasty. There is almost always septal deviation that must be addressed in these patients and

is an important part of the procedure. Each rhinoplasty is necessarily individualized, but the procedure

usually entails repositioning and trimming of the nasal tip cartilages, added support to the nasal tip and

slumping lower lateral cartilages to achieve projection, straightening of the septum, and finally

infracturing of the widened nasal bones.

Although the care of the cleft patient requires interaction with the pediatric plastic surgeon and the

cleft team throughout the patient’s childhood, it should remain a small and unobtrusive part of life. The

number of operations is kept to the minimum needed to attain an adequate reconstruction as deemed

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necessary by both the patient and the surgeon. Revisional surgery is usually an important part of cleft

care but should be guided by the principle that the intervention is done for the child and not to the child,

with an attempt to empower the patient as often as possible.

Craniosynostosis

8 Craniosynostosis is defined as the premature fusion of one or more of the cranial sutures. The child

afflicted with craniosynostosis displays abnormalities in the size and shape of the cranial vault. Virchow

law states that the growth of the skull will be restricted in the direction perpendicular to a synostosed

suture while compensatory growth occurs in a parallel direction.103 The ensuing skull shape of the

patient provides the nomenclature of the deformity and is primarily empiric in nature (Fig. 109-33).

Synostosis of the metopic suture most often results in a triangular forehead and is referred to as

trigonocephaly. Unilateral coronal suture involvement often results in a recessed or slanted supraorbital

bar and forehead and is referred to as plagiocephaly, whereas bilateral coronal synostosis often results in

a shortened and flattened forehead referred to as brachycephaly. The sagittal suture is the most

commonly fused suture and results in a boat- or keel-shaped head referred to as scaphocephaly.

Figure 109-33. A: Turribrachycephaly (short, flat head). B: Plagiocephaly (slanted head). C: Trigonocephaly (triangular head). D:

Scaphocephaly (keel-shaped head).

Figure 109-34. A: Plagiocephalic head viewed from above. B: The surgeon removes the bone of the forehead and advances the

forehead to allow the brain to grow and the skull to resume a normal shape.

The abnormal shape of a synostotic cranium can often be severe and progressively worsens as the

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brain continues to grow and expand in the wrong dimensions. In addition, a small percentage of patients

with a single-suture synostosis, and a much larger percentage of children with multiple-suture

synostosis, are at risk for the development of increased intracranial pressure.105,106 The care of these

patients, therefore, requires close interaction between a pediatric neurosurgeon and a pediatric

craniofacial plastic surgeon. A thorough clinical evaluation is mandatory and an ophthalmologic

evaluation to check for papilledema can be beneficial. A CT scan is also useful in these patients to

confirm the diagnosis and assess the ventricular system as well as the neuroanatomy for possible

associated developmental anomalies of the brain.

Once the functional aspects of craniosynostosis are evaluated and addressed, the operative strategy is

then aimed at restoring normal morphology. The operation is tailored to the individual diagnosis and

malformation, but the underlying surgical principles remain the same. A sinusoidal coronal incision in

the scalp is used to afford access to the cranium and to hide the scar. The pediatric neurosurgeon

performs a craniotomy to provide access to the cranial vault. In the case of plagiocephaly and

trigonocephaly, the craniofacial pediatric plastic surgeon removes the frontal bar by performing a

bilateral osteotomy at the lateral orbital rim, and along the orbital roof meeting in the midline with a

cut across the region just above the glabella. The frontal bar is removed, reshaped, and replaced in an

advanced position with bone grafts placed to support the reconstruction. The bones of the forehead are

similarly cut, bent and reshaped, and placed into a normal anatomic position. The bones are fixed with

resorbable plates and screws (Fig. 109-34). A gap is left in the area of the coronal suture to allow

growth and expansion of the brain. During infancy the dura is osteogenic and fills the gap in slowly

with newly formed bone. In the case of a sagittal synostosis, the frontal bar often need not be removed;

the operation entails removing and remodeling the majority of the calvaria, increasing the biparietal

distance and decreasing the anteroposterior distance, leaving areas posteriorly open to encourage

growth in that direction. This arrangement encourages subsequent growth to fill out the parietal region

and create a more anatomic shape. Another common approach to treating sagittal craniosynostosis is the

endoscopic strip craniectomy whereby the synostosed suture and a few centimeter margin of bone on

either side are removed. This is followed by approximately 8 to 12 months of helmeting to coax the

head into the correct shape. In syndromic craniosynostosis patients, such as those with Apert, Crouzon,

or Pfeiffer syndrome, similar reconstructions are required for the cranial vault. Additional operations

are often needed to address deformities of the orbits and midface. In contrast to the midfacial

hypoplasia exhibited by the cleft patient, the patient with syndromic craniosynostosis has a much more

severe and extensive deformity and therefore requires more involved operations. Le Fort III and

monobloc advancements move the entire upper and midfacial region forward and can be used to vastly

improve the appearance of the patient while establishing a more normal functional anatomy (Fig. 109-

35). These operations address the bulging eyes, malar hypoplasia, and recessed and diminutive

nasopharyngeal airway of these patients, restoring normal eye position and opening up the breathing

passages to relieve obstructions of the airway and symptoms of sleep apnea.107

Figure 109-35. A: Outline of the osteotomies required. B: Appearance after frontofacial advancement and bone grafting.

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Figure 109-36. Infantile hemangioma. A: Appearance a few weeks after birth. B: Proliferative phase. C: Involutional phase.

Hemangiomas and Vascular Malformation

The pediatric plastic surgeon is often the primary care giver for children afflicted with cutaneous

hemangiomas and vascular malformations. These lesions may present at birth or in the neonatal period

and require careful diagnosis and management. Hemangiomas are benign tumors that most often arise

just after birth and undergo a spontaneous rapid growth phase followed by a slow involutional stage.108

In general, acute management of hemangiomas is nonoperative. After the involutional phase is complete

some patients will require excision of the fibrofatty residuum, usually before school age (Fig. 109-36).

Ulceration or interference with function may prompt intervention. The use of local or systemic steroids

can arrest the proliferative phase. Propranolol has recently been shown to effectively halt the growth of

these vascular tumors and is replacing steroids in popularity.109 Rarely hemangiomas require early

excision and in such cases operative strategies should strive to conserve tissue and function, avoiding

the creation of significant deformities that would necessitate extensive and delayed reconstruction.

Vascular malformations are comprised of arteries, veins, capillaries, lymphatic vessels, or a

combination of each. The malformations are present at birth and grow in proportion to the patient. As

opposed to vascular tumors (e.g., hemangiomas) vascular malformations do not grow rapidly nor

spontaneously involute. Superficial capillary malformations (“port-wine stains”) respond well to pulseddye laser therapy. Venous malformations, lymphatic malformations and lymphaticovenous

malformations can often be managed with sclerotherapy or intralesional laser treatment. Larger lesions

are often infiltrative, and staged partial excisions can be performed if there are functional indications

for intervention. Arteriovenous malformations can be the most vexing to treat as no options that ensure

eradication exist.

Nevi

Congenital nevi are the most common benign tumor seen by the pediatric plastic surgeon. The small- to

moderate-sized nevi are usually of little consequence but need to be monitored closely for any

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