PARIS To obtain the best cosmetic results, you must intervene early in pediatric dermatologic tumors, Patrick A. Diner, M.D., said at the Fourth International Academy of Cosmetic Dermatology World Congress.
A common misconception is that surgery should be delayed in children because of the potential risks associated with general anesthesia. But research shows that the risk is not relevant after 1 year of age, and that waiting does not guarantee that local anesthesia can be used, especially when a lesion is located on the face, he said.
Dr. Diner recommended early surgical intervention because of the loss of skin elasticity, the potential for a lesion to grow, and the risk of infection, deformity, and loss of function associated with some lesions.
Larger excisions can be performed with better results because younger skin is more elastic and has a significantly thick layer of fat, and there is decreased muscular activity in younger patients, he said.
Early intervention should also be considered to reduce the psychological impact of dermatologic tumors on children, said Dr. Diner, a plastic and reconstructive surgeon with the Armand Trousseau Children's Hospital, University of Paris.
"How can we refuse this early surgery, which can change their quality of life … when later on we will not obtain the same results?" he said.
Waiting to excise dermoid cysts, midline nasal fistulas, and preauricular fistulas can increase the risk of local infection and also lead to a more complex surgery.
In severe cases of preauricular fistula, waiting can put the facial nerve at risk because the resection has to be extended, he said.
Dr. Diner also advocates early surgery with periorbital and orbital hemangiomas because of the risk of amblyopia, astigmatism, and intraorbital infiltration resulting in displacement of the eyeball.
Emergency prophylactic surgery should be considereddespite a normal first ophthalmic examinationwith a hemangioma with partial closure of more than one-third of the eye, or with a bulky localized hemangioma.
In his study of 62 patients, average age at surgery was 8 months for orbital hemangiomas. However, he contends that the surgery should happen as soon as possible if there is any risk of visual impairment.
Among 450 patients aged 5 days to 20 years who were treated for calvarial tumors and alopecia at the Armand Trousseau Children's Hospital, 72% were operated on before they were 2 years old, and 15% before they were 3 years old, fellow plastic surgeon Gérald Franchi, M.D., said during the same session at the meeting.
Dr. Franchi said a combination of techniquessuch as simple excision, tissue expansion, and skin graftingis best when dealing with calvarial tumors and alopecia in children. Large skin resection can be performed before the age of 3 months, when skin laxity is greatest. Wound care and skin grafts are the most reasonable approach for aplasia cutis congenita. Simple excision and tissue expansion are suggested for congenital pigmentary nevi, he said, especially if they involve two-thirds of the scalp. The approach doesn't result in growth-related problems later on, although the density of the hair will be affected.
Scalp hemangiomas in children should not be operated on unless ulcerated because of a risk of bleeding, he said.
A large palpebral hemangioma put the development of good vision at risk.
Prophylactic emergency surgery was performed to correct the occlusion. Photos courtesy Dr. Patrick A. Diner