We have broken our Q&A into specific areas of interest. From the list below, click on a specific subject matter to read questions and answers:
| Cleft Lip and Cleft Palate Surgery | Craniofacial Surgery |
| Nevi and Pigemented Birthmarks | Hemangiomas and Vascular Birthmarks |
Cleft Lip and Cleft Palate Surgery:
Question: What causes clefting?
Cleft deformities occur in 1:700 live births worldwide. The cause of facial clefting is multifactorial. Approximately one third of children with a cleft lip or cleft palate have a relative with a cleft, whereas the remaining two thirds of children have a primary cause that is environmental in nature. Cigarette smoking during pregnancy has been shown in numerous studies to be associated with an increased risk for cleft lip and cleft palate malformations.
Question: Can a cleft lip or palate be detected on my prenatal ultrasound?
Prenatal ultrasound diagnosis of cleft malformations was first reported in the early 1980's, and is commonplace in our practice. Consultation with a plastic surgeon before delivery is always preferable and allows time for education and preparation of the expecting parents. Ultrasound diagnosis greatly aids parents towards understanding the necessary steps to repair the cleft lip or palate and the anticipated needs of their child. We have also found that early prenatal diagnosis helps facilitate surgical repair of a cleft lip or palate during infancy.
Question: At what age do children have surgery to repair their cleft lip and cleft palate?
We routinely repair cleft lips and cleft palates in the first few days or weeks of life. In our experience, repairing clefts during infancy leads to improved overall results, more normal feeding and improved early childhood development. Furthermore, our patients are cared for at the Children's Hospital of the King's Daughters in Norfolk, Virginia, where skilled pediatric anesthesiologists allow us to provide the safest of care. Excellent anesthesia support as well as experienced post-operative nursing care allows us to routinely care for children as young as two to three days of age.
Question: Can my child breast feed?
Breast feeding is always a feeding option and should never be dismissed in an infant with a cleft lip or cleft palate. Many of our patients breast feed immediately after their surgery. Surgical repair during infancy greatly improves the chances for successful breast feeding. Feeding at the breast promotes better muscle development of the infant's face, mouth, and tongue, resulting in improved speech and dentition. Breast feeding also enhances maternal bonding. We work very closely with lactation consultants and speech therapists to provide support in feeding education to each and every family.
Question: What is a cleft team?
Children with cleft malformations need comprehensive care at institutions staffed by experts in pediatric medical, surgical, and dental specialties. Virtually all cases need continuous follow up throughout childhood, adolescence and into adulthood. The benefits of a team approach go beyond surgery. The Institute for Craniofacial and Plastic Surgery has over 10 years experience in this specialized field and is made up of a multi-disciplinary team of experts including plastic surgeons, medical geneticists, speech pathologists, neurosurgeons, otolaryngologists, dentists, orthodontists, social workers and psychologists. All of our team is routinely available in one office where we see between 20-25 patients each Tuesday. If you wish to get in touch with the coordinator of our team, Karen Via, M.S.N., R.N., her phone number is (757) 668-7031.
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Craniofacial Surgery:
Question: What is craniosynostosis?
Craniosynostosis is a condition that results from premature or early fusion of one or more sutures in an infant's skull, and leads the child to have an abnormal skull shape. Physicians have seen a significant increase in the number of misshapen heads since the early 1990's when pediatricians began the Back-to-Sleep Campaign. An infant's head can be misshapen during a normal delivery, but it routinely corrects itself within the first four to six weeks of life. Any abnormality in head shape beyond that age requires a correct diagnosis. Treatment of a child with a misshapen head depends entirely on an accurate assessment and the exact cause of the problem. Our diagnosis is based on expert assessment of the child's head, as well as radiographic evidence of suture fusion on CT scan. Plastic surgeons and neurosurgeons at the Institute for Craniofacial and Plastic Surgery focus their attention on differentiating positional molding or positional plagiocephaly from true craniosynostosis. This distinction is significant, because children with true craniosynostosis routinely require surgery early in life, while children with positional plagiocephaly can be treated without surgery.
Question: What types of treatment are required for children with craniosynostosis or children with positional plagiocephaly?
Positional plagiocephaly can be caused by premature birth, restrictive in uterine positioning, neck abnormalities, birth trauma, torticollis, persistent sleeping positions or car seat use. Non-surgical treatment of positional plagiocephaly depends on accurate diagnosis and includes: physical therapy, parental education, and cranial remodeling helmets. Early recognition of positional plagiocephaly is essential and treatment is focused on taking advantage of the rapid growth period children's skulls go through during their first year of life.
Children with true craniosynostosis require craniofacial surgery. Corrective skull surgery is routinely done cooperatively with a plastic surgeon and a neurosurgeon. The aim of the surgery is to physically remove the restrictive suture and reposition the remaining skull bones in a more normal shape.
Question: How many operations will my child need to correct his skull shape?
Children with craniosynostosis can undergo corrective surgery as early as 3 months of age. Due to advances in surgical techniques, many children can have correction of their skull abnormality with one operation. Our experience has been that children routinely require a 2-3 night hospital stay and can return to normal activities soon afterwards. Early detection and surgical correction of craniosynostosis ultimately leads to fewer surgeries and improved results.
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Nevi and Pigmented Birthmarks:
Question: What is a congenital nevus?
A congenital nevus is a birthmark which contains melanocytic cells. Most pigmented skin lesions, or melanocytic nevi, are acquired as we age; however, roughly two percent of children will have melanocytic nevi which are present at birth or soon thereafter. Congenital nevi may be as small as 1.0 to 2.0 mm in size, or cover a child's entire back and buttocks. Small nevi are defined as being less than 1.5 cm in diameter and large, or giant, nevi greater than 20 cm in size.
Question: When should a congenital nevus be treated?
Congenital nevi have an increased risk for degeneration into skin cancer, namely malignant melanoma. Malignant melanoma is the most deadly form of skin cancer and is increasing in frequency. At one time, malignant degeneration was thought to happen only after puberty, but recently has been documented to take place as young as two to three years of age. The risk of malignant degeneration is near zero for small nevi, but as high as 15-20 percent for giant nevi.
Assessment of suspicious pigmented lesions requires observation of five characteristics:
A) Asymmetry of the lesion
B) Border of a lesion -- irregular
C) Color of a lesion -- varied or multiple
D) Diameter -- more than 6.0 mm
E) Elevation within a flat lesion
Any lesion, small, medium, or large, which has two or more of the above characteristics should be removed. Both the aesthetic appearance and functional result of children undergoing removal of congenital nevi in our practice is excellent. Children should not live with worrisome pigmented lesions over the fact that pediatricians or parents are worried about scarring. A range of plastic surgical techniques is present to obtain the most satisfying result. Direct excision and closure, local advancement flaps, tissue expansion, skin grafts, and utilizing skin glue are a few of the plastic surgical techniques which bring about improved results for young children. Furthermore, surgery in the preschool years gives the maximum amount of time for scar maturation or scar revision surgery prior to the development of peer pressure issues during the school years and early teenage years.
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Hemangiomas and Vascular Birthmarks:
Birthmarks are extremely common in children and may have many different forms. Children may be born with hemangiomas, strawberry birthmarks, a stork bite, darkly pigmented birthmarks, or skin colored birth marks. Vascular birthmarks, which include hemangiomas and vascular malformations are by far the most common of all birthmarks. The vast majority of vascular birthmarks quickly fade or remain small and inconsequential. However, as many as one child in every 100 will have a vascular birthmark that requires a referral to a doctor or an opinion of a medical specialist. This simply means that roughly 40,000 children in the United States each year will have a vascular birthmark which needs the attention of a knowledgeable and well-informed health care provider.
Fortunately, disfiguring and grossly large vascular birthmarks are rare. However, afflicted children and their families experience a great deal of anxiety searching for someone in the medical profession who truly understands their problems. It is not uncommon for parents to go from doctor to doctor in search of answers to their questions and solutions to their problems. Early and accurate diagnosis of a hemangioma or a vascular birthmark is essential and most helpful to such families.
Our experience is that at the very earliest opportunity, parents should be given a good indication of what the future may hold for their child, including what types of treatments are possible or preferred.
Question: What is a vascular birthmark?
A vascular birthmark is an abnormal collection of blood vessels. Two types of vascular birthmarks exist: hemangiomas and vascular malformations. Hemangiomas, the most common benign mass or tumor affecting newborns, are typically bluish or red, flat or raised areas apparent at birth or soon thereafter. Vascular malformations are benign collections of blood vessels which typically grow steadily as the child grows.
Question: What causes vascular birthmarks?
The exact cause is unknown. Most vascular birthmarks are not due to difficulties or problems that happen to the mother during pregnancy, nor are they inherited. Research is presently underway to identify the exact etiology of vascular birthmarks. Teams of medical s pecialists, including plastic surgeons, hematologists, dermatologists and radiologists are cooperating in efforts to better understand and treat all types of vascular birthmarks.
Question: How frequently do vascular birthmarks occur?
One out of every 5-10 children born in the United States may have a vascular birthmark. One third of these birthmarks are present at the day of birth while most others appear within the first 2-3 weeks of life. Although the exact cause of hemangiomas is poorly understood, the natural course these lesions take is well documented.
Question: What is the natural course that hemangiomas follow?
Traditionally, medicine has held the view that most hemangiomas will disappear in time. Many parents have been frustrated by physicians telling them that their child's vascular birthmark will go away if they simply wait. Clinical studies and medical research have shown that this is not true. Hemangiomas do progress through two stages. First -- a growth stage. Second -- an involution stage. The growth phase occurs over the first 6-12 months of age when a hemangioma may grow quite rapidly. The involution, or shrinking stage, varies from child to child. Hemangiomas typically start to involute during the 10th month of life. However, the rate and completeness of involution is different for all children.
Traditional medical theories have claimed that 90 percent of hemangiomas are completely gone by nine years of age. This has been shown distinctly to not be true. Upwards of 60-70 percent of children with a hemangioma will need some type of corrective surgery for a hemangioma which did not completely involute. Remember: Involution does not mean to disappear.
Question: How are vascular birthmarks and hemangiomas being treated?
The most important thing for the parents of a child with vascular birthmark is the correct diagnosis. An unclear or uncertain diagnosis can lead to months and years of confusion and even inappropriate treatment. Once the correct diagnosis has been made, a vascular birthmark can be treated in a number of ways including: C ompression garments, oral corticosteroids, topical cryotherapy, surgical excision, radiographic embolization, interferon, and lasers. Parents must be confident in the physicians caring for their children and should fully expect doctors to completely explain which of the above options is best for their child. Remember: Your questions should be fully answered to the point that you are very comfortable with the options presented for the care of your child.
Question: Does plastic surgery have a place in the care of a child with a hemangioma or vascular birthmark?
The plastic surgeons at Magee-Rosenblum Plastic Surgery have much experience in the care of children with vascular birthmarks. Our philosophy of care has evolved over the past 20 years. During our first five years of practice, we routinely told patients that their hemangioma would go away. This information we learned from our education and the classic textbooks about hemangiomas. During our second five years in practice, we witnessed that many hemangiomas we were following were not going completely away. Although we continued to tell patients that they would go away, our minds were quickly being changed. During our third five year time period in practice we started to operate on hemangiomas early in a child's life. We readily realized that patients and their families were much happier, and so were we.
Our criteria for early operation includes:
Question: What are some popular myths concerning the care of hemangiomas?
MYTH:Hemangiomas bleed a lot. FACT:This is wrong in that most hemangiomas usually have well defined margins surrounding them and at the time of surgery can be "shelled out" with minimal blood loss. If the vascular birthmark is a vascular malformation, it is an entirely different problem and blood loss is certainly a distinct possibility at the time of surgery. In this case, angiographic and radiographic techniques can be used prior to surgery to improve the safety and minimize the blood loss during the subsequent operation.
MYTH:Hemangiomas will go away.
FACT:Certainly hemangiomas will involute or shrink, but, remember, involution does not mean to disappear. Hemangiomas certainly stretch the skin and the overlying soft tissue leaving behind irregular skin and oftentimes excessive fibro-fatty tissue which ultimately must be operated on in order to improve the appearance. If that is the case, why not operate on children earlier rather than later? The advantages of early plastic surgical intervention include: There is no need for the child to live with a deformity for years if he/she eventually will need to be operated on anyway. A young child will not remember the hemangioma or subsequent surgery if operated on early in their life. Parental anxiety can be greatly diminished with early surgical intervention. Early surgical intervention gives more time for scars to mature and improve in appearance before the peer group pressure stage begins at the start of school.
Question: Who else besides plastic surgeons help care for children with hemangiomas or vascular malformations?
Many children require a team of medical experts for the most comprehensive and complete care. Drs. Magee, and Rosenblum are part of a vascular birthmark team which includes: Anesthesiologists from the Children's Hospital of the King's Daughters, hematologists, and pediatricians including Dr. William Owens, a hematologist at Children's Hospital of the King's Daughters. Also, radiologists trained in invasive techniques including angiography and embolization are most helpful. Dr. Jon Agola is an expert in interventional radiology and has been very helpful in helping us treat complex hemangiomas or vascular malformations.
Furthermore, our patients are cared for at the Children's Hospital of the King's Daughters in Norfolk, Virginia where skilled pediatric anesthesiologists allow the safest of care. Would you rather your child be put to sleep by an anesthesiologist who cares for children 100 percent of the time, or just 10 percent of the time? We find that this question is easy to answer and we certainly feel extremely secure with the anesthesiologists and operating rooms at Children's Hospital.
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