Guy H. Haskell
Not all plastic surgery is elective. More commonly, you’ll encounter pediatric lacerations in a busy ER. Photo iStockhoto.com
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Before my four-year stint at a children's hospital, I held the same misconceptions about plastic surgery that most people probably hold, conflating the specialty of cosmetic surgery with the larger field of plastic surgery. I was further prejudiced by the negative stereotypes surrounding elective cosmetic surgery -- overpaid celebrity docs reconstructing aging starlets, or hacks disfiguring patients with botched nose jobs. Those misconceptions disappeared when I was exposed to what most plastic surgeons actually do; try to piece back together bits of torn or diseased human flesh as best they can.
One of my very favorite assignments in the pediatric ER was assisting the plastics docs. As you can imagine, repairing various and sundry lacerations makes up a significant portion of the pediatric ER business, and each doctor had their own method of preparing a child for laceration repair; different topical concoctions and different sedation cocktails.* The older the child, the smaller the laceration, and the farther from the face, the less the preparation that was necessary. A 13-year-old with a one-inch laceration to the knee? Local anesthetic. A 3-year-old with a one-inch laceration to the cheek? Conscious sedation, local anesthetic and sedation for the parents.
Another consideration was perception of cosmetic significance, and here everybody -- docs, patients, and parents -- were bald-faced sexists. A little girl with a facial laceration? Call in the plastic surgeon, especially if the cut crossed the sacred vermillion border (great title for a book, by the way -- Across the Vermillion Border, or something). A little boy with a face laceration? I used to joke to the parents that ″we should just rub in a little ash and hope for a really macho scar!" The horrified looks I sometimes got indicated that some of the parents didn't share my sense of humor; "Just kidding mom, just kidding, honest."
Human tissue is incredibly difficult to put back together the way it was. Every region of the body has a different combination of skin type, tension, moisture, underlying fat and structures, and each layer comes apart -- and back together -- in a different way. That is why a plastics residency is so long; lots and lots of practice.
One day a little boy, about 4 years old, I think, came in with a nasty dog bite. The dog got his left cheek, including part of his nose and lips. The skin was torn through in places and just hanging, and it was hard to tell if all of it was still there. The parents were terrified, both by the pain their son was in now, and by the prospect that they had failed to protect their child from what would now be a lifetime of disfigurement.
The charge nurse asked me if I could assist Dr. Jones with the sedation and repair. That meant I would be out of circulation for an hour or two, and get to watch the whole process. I got all of the equipment together, including the entire cart of suture materials, since I knew the doc was going to need a wide variety of sutures given the number of different tissue types and depths involved. I got the meds from the Pyxis dispensary, started the IV, hooked up the monitors and administered the sedation. Dr. Jones came in and went to work.
Dr. Jones was from South Africa, and he enjoyed chatting and explaining as he worked. He was completing his residency at Emory University but hoped to return home as soon as possible. I asked him about the health care system in South Africa and what he would be doing as a plastic surgeon there. Basically, he would be giving up the opportunity to have a practice that made several hundred thousand dollars a year in the U.S. for making a government salary well below $50,000 there.
I watched as he first brought together the various underlying structures of the child's face with different types of suture material, using a variety of stitches and angles. I couldn’t imagine how all the hanging pieces of flesh could possibly be brought back together in any semblance of humanity. Like an elastic jigsaw puzzle, Dr. Jones worked on different sections. But it wasn't until near the very end that the picture of the magic act he was performing emerged. He talked about blood flow, infection, tension, healing drainage, scarring and everted edges, and I watched in fascination and awe. By the time he was finished putting in the last tiny stitches in the lip with the tiniest of needles and the most delicate of threads, one could see that the outcome was going to be very, very good.
The smiles and tears of relief on the parents' faces when they saw their little boy back together again brought some tear-welling in our own. I occasionally wonder how Dr. Jones is doing back in his beloved South Africa, performing daily miracles, largely for their own sake.
*Trivia of the day
Question: What's the most common part of the body repaired in the pediatric ER?
Answer: The head
Question: What's the most common cause of the pediatric head laceration?
Answer: The coffee table!
