significant changes in size, shape, color, bleeding, or ulceration. The potential for degenerative

malignancy into a melanoma for small- to moderate-sized congenital nevi is controversial.110 Serial

examination and even photographs can be helpful to document changes over time, and the gold

standard for any doubtful skin lesion is still excisional biopsy.

Figure 109-37. Fully expanded tissue expanders in preparation for excision of a congenital melanocytic nevus.

Giant congenital melanocytic nevi are larger and less common, but they can be devastating to a child

and the family. These lesions can affect the entire body or vast areas, including vital structures such as

the eyelids, anus, and genitalia. Although the risk of malignancy is higher in these patients, operations

have not shown to decrease that risk, hence a reasoned and conservative approach to such difficult cases

is mandatory.111,112

It is often helpful to enlist the aid of a dermatologist and the patient’s pediatrician to assist in

monitoring these lesions. Again, photographic documentation is helpful in serially assessing these

lesions. Areas that show significant change warrant incisional biopsy and pathologic evaluation. The

aesthetic consequences of these lesions often can be severe, and parents often want them to be excised.

The surgical approaches to benign giant congenital melanocytic nevi are varied and range from excision

and grafting to serial excision as well as the use of tissue expansion.

The use of extensive skin grafting as a reconstructive option for the reconstruction of giant hairy

congenital nevi is usually reserved for malignant or dysplastic lesions. Skin grafts are not a particularly

durable long-term cover, and they are often aesthetically displeasing and require subsequent resection

and reconstruction. Serial excision can be useful in limited giant hairy congenital nevi, especially in

locations near tissues that stretch well. The tissues adjacent to the lesion are undermined and advanced

over the nevus to determine the amount that can be resected, and then a portion of the nevus is excised

and the tissues are then reapproximated and allowed to heal. After 4 to 6 months the same procedure is

performed until the nevus is fully excised. Tissue expansion requires the placement of a tissue expander

adjacent to the lesion with slow instillation of saline into the expander over time, allowing stretching

and recruitment of new tissue near the nevus to assist in excision and closure (Fig. 109-37). The quality

and thickness of the skin, the possibility of exposure and infection, and the cooperation of the young

patient at times limit the usefulness of this technique.

Prominent Ears

3256

Prominent ears are a deformity that is mainly in the domain of the pediatric plastic surgeon. Children

with prominent ears are prone to ridicule by classmates in school, teasing by siblings, and thoughtless

comments by insensitive adults. The deformity does not usually present with an enlarged ear but rather

with a lack of an antihelical fold, either with or without conchal hypertrophy. An incision is made on

the posterior portion of the ear exposing the cartilage, and sutures are placed in a mattress fashion to

reconstruct an antihelical fold. The stiff conchal cartilage can be weakened, and the concha is then

secured to the mastoid fascia using permanent suture. A strict postoperative headbanding protocol may

be used to avoid trauma to the ear and allow undisturbed healing. Successful otoplasty is one of the

most rewarding procedures performed by a pediatric plastic surgeon because the child usually wants the

surgery and is rewarded with immense satisfaction.

Myelomeningocele

The interaction between the pediatric neurosurgeon and the pediatric plastic surgeon often extends

beyond the realm of craniofacial surgery. A prime example of the symbiotic interaction between the

two specialties is in the repair and reconstruction of the myelomeningocele which is a form of spina

bifida. The neurosurgeon is often presented with an exposed dural sac and a wide-open skin defect. The

neurosurgeon may be faced with a tenuous dural closure and may need to resort to the use of a

homograft to achieve an adequate dural repair. The pediatric plastic surgeon can assist by closing the

defect over the dural reconstruction with stable, reliable coverage using well-vascularized tissue,

protecting the neurosurgeon’s repair. The soft tissue coverage may require local paraspinous muscle

flaps or various fasciocutaneous flaps, but the goal of a durable reconstruction with a normal contour is

paramount so as to avoid persistent long-term complications both at the level of the skin and at the

level of the dural repair (Fig. 109-38).

SUMMARY

Although there are a multitude of additional procedures and topics in the specialized domain of the

pediatric plastic surgeon, such as pediatric facial trauma, facial reanimation surgery, and various

deformities resulting from congenital hypoplasia and hyperplasia, this chapter has focused on some of

the major and more common areas of patient management. In fact, the pediatric plastic surgeon is often

a chief collaborator with many of the pediatric surgical services when presented with a case of

challenging wound care or any case which poses a reconstructive dilemma. Continuing innovation and

technical advances combined with an appreciation for sound fundamental surgical principles allow the

specialty to continue meeting that challenge.

3257

Figure 109-38. A: Myelomeningocele defect. B: Cross section of local flap coverage of myelomeningocele defect. C: Durable

closure over defect of muscle, fascia, and skin. This can be mobilized to complete repair.

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Index

Note: Page number followed by f and t indicates figure and table respectively.

A

A77 1726 (metabolite of leflunomide), 550

Abbreviated injury scale (AIS), 323, 403

AbbVie, 948

Abciximab (ReoPro), 1527

Abdomen. See also Abdominal aortic aneurysms (AAAs); Abdominal trauma; Abdominal wall; specific

organs

full-thickness graft from, 224, 225f

pain

abruptio placentae and, 485

acute pancreatitis and, 862, 864

after gastric bypass, 748

bowel obstruction and, 785, 786

colorectal cancer and, 1130

duodenal ulceration and, 728

intra-abdominal infection and, 129

small bowel NETs and, 831

pediatric, 1870–1929

stab wounds to, 241

x-ray films

ileus, 800, 800f

pancreatitis, 856–857

for trauma to spleen, 1270, 1270f

ulcerative colitis, 1084, 1085f

Abdominal aorta, 1563f, 1648, 1661f, 1682

Abdominal aortic aneurysms (AAAs)

aortoenteric fistula and, 1759

classifications, 1732, 1733f

clinical presentation, 1735–1738

definitions, 1732

diagnosis, 1735–1738, 1736f, 1737f, 1738f

dissecting, 1733–1734

evaluation for, 1605, 1605f

incidence of, 1732–1733

infected, 1758–1759

inflammatory, 1756–1761

intra-abdominal disease and, 1761

isolated iliac artery aneurysms and, 1755–1756

juxtarenal, 1757–1758

management, principles of, 1734–1735

mortality rate, 1735

open/endovascular repair, choice of, 1739–1744

operative repair

endovascular repair, 1749–1754, 1750f–1751f

indications, 1738–1739

open repair, 1744–1749, 1745f

preoperative evaluation, 1744

pathogenesis of, 1733–1734

problem, 1732–1733

renal anomalies and, 1760

3263