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Plastic Surgery Update: Operating in 4D · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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So if the ears are prominent, then one of the surgeries we can do is an operation
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to make them less prominent,
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which although some would deem that as a cosmetic operation,
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I mean that's hugely beneficial in terms of quality of life for the child.
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In the number of children we see in clinic who have
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prominent ears and their life is made a misery by
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it you know they cover the ears with their hair they're
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bullied at school and it's something that we can
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do in plastic surgery that is a relatively
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small procedure that can have
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a huge bearing on that child's confidence you know
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sometimes i see the patients coming in afterwards you know
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after kind of six weeks or so after operation and
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they walk in hair up confident and
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you know it makes such a big difference i'm holly
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wayment and this is pediatrics now cases updates
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and discussions for the busy pediatric practitioner i'm thrilled today because
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here in the podcast studio is dr richard thompson he's an assistant professor
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for the Division of Plastic and Reconstructive Surgery at UT Health San Antonio
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and University Hospital.
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Richard, thank you so much for being here today in the podcast studio.
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Well, it's a real pleasure to be here. You recently moved here from England.
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That's right. Big move. It's going really well, actually. One of the small but.
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Funny things that I find is, you know, when I'm driving to work on the 410,
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you know, past the airport, and I think yesterday I counted,
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I think, seven roads on top of each other with all these flyovers,
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it looks like something out of kind of, I guess, a sci-fi novel or something.
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Yeah. Whereas in England, you just have probably a roundabout as opposed to seven flyovers.
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Patients are amazing. My colleagues are really friendly.
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Everybody's just so nice. Honestly, really nice and very welcoming.
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Yes. That's one of the things I love about Texas and that Southern charm.
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And then I also loved it when I lived in Oxford and was studying there.
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Such a beautiful area. Yeah. I absolutely love my time in Oxford.
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I was there for a couple of years, just did a master's there.
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I wasn't actually living in Oxford at the time, but I was kind of coming in
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and out because it was a part-time master's I was doing.
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It was a tail street college I was at. So I've got very fond memories of that time.
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I was at Brazenose College and I remember at dinnertime, we drank out of these
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silver goblets in the dining hall and going polling. Did you?
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Oh yeah, of course. Yeah. You used to live right by Stratford-upon-Avon? I did.
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So I grew up in a small kind of central part of England, a little town called
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Kenilworth, which is quite historic.
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It's got a castle, which I didn't visit until I was about 21 years old.
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And we were talking and I shamefully admitted that I'd never been to the Royal
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Shakespeare Company, even though I lived down the road from Stratford,
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which is quite shameful, actually.
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So you're building the program here for pediatric plastic surgery.
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Yeah, so it's quite a daunting task, but I'm not doing it on my own.
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There's lots of help. Actually, the hospital has been incredible.
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So I guess a lot of people probably don't really know what pediatric plastic surgeons actually do.
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And that really includes other plastic surgeons.
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In fact, including pediatric plastic surgeons, sometimes you'll catch yourself
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and think, oh my goodness, is that actually an operation we do?
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And then you work out, oh yeah, no, it is actually. One of my colleagues is doing that.
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So it can be quite a difficult area to know exactly what on earth we do.
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So broadly speaking, plastic and reconstructive surgery is about kind of trying
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to restore form and function to the patient.
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And when that's, you know, paediatric plastic surgery, that's just that, but in children.
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It's not you know children are not as we
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know as pediatricians or pediatricians know and certainly those
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of us who who spend a lot of time with in a
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pediatric practice we know that that pediatric patients aren't just little adults
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it comes with quite a lot of nuance and a lot of that is factoring in any operational
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surgery you're going to do you want that to have a positive impact with growth and development.
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So a lot of paediatric plastic surgeons say it's like operating in 4D.
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You know the 3D being the normal plastic reconstructive surgery and the 4D being time.
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So you're always factoring in how is this operation going to be affected by
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growth and how's it going to look or feel or move in 18 years time 20 years time 80 years time.
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And that's one of the challenges of a speciality, but also one of the joys.
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As children grow out of stuff. Yes, they can.
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And the thing that comes to mind would be a hemangioma. So this is the most
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common benign vascular malformation or vascular tumor, I should say.
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And this is sometimes called a strawberry nevus.
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And quite often, those will proliferate quite aggressively sometimes in the
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first year of life and then slowly involute. as the child gets older.
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So it may be that actually nothing needs to be done.
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And actually it can look quite dramatic when it's happening in a baby.
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And then actually as the child gets older, it involutes and vanishes to almost nothing.
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That's not always the case. And sometimes if it's proliferating a lot and it's
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causing problems such as ulceration or bleeding, there's a role for propanolol
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treatment, which is usually conducted in our vascular malformation and MDT.
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And sometimes when they involute, it can leave behind a little fibre fatty kind
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of scaffold, which can need corrective surgery maybe when the child's a bit older.
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But a lot of those cases, about 80 or so percent, 80 or 90 percent,
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will just involute and there'll be little to see afterwards.
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So sometimes waiting is definitely the right thing to do. But certainly factors
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change and factors that may be quite important in childhood may not be so important in an adult.
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So the right time is when the child is affected by it.
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So we've definitely moved away in paediatric plastic surgery from being led by the parents.
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And especially when it comes to operations that change the appearance of a child,
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such as prominent ear surgery, that's something that the child should really
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be wanting to do themselves.
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And there's an age at which most children will start to become a little bit
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more aware of their appearance, and that's around the age of seven.
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Before that i think it's quite difficult to gauge if they've got the maturity to actually,
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weigh up the risks and the benefits of having an operation i
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think from seven there's a
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little bit more kind of understanding of what's involved in
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in the operation and wearing a head bandage for example for
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a week afterwards and the recovery that's required so
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i'm kind of trying to be a child-led in
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that sense yeah my son has two different color eyes and i remember one day when
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he was six or seven and he was at swim practice and another boy said i can't
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i can't play with you because you're different or something to that effect and he was crushed,
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for a child whose ears look different than other kids on a day-to-day basis
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how difficult that could be? I mean, it can be really challenging.
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You know, a lot of the children, especially if they've got long hair,
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can, you know, hide the ears and often do with their long hair.
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Quite often, some of them will refuse to participate in sports and,
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you know, activities that make it more obvious that they've got prominent ears.
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And it can be, you know, can absolutely destroy a child's confidence.
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It's a really difficult kind of thing to live with, I think. It can be.
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So certainly cleft lip and palate is an area that I'm particularly interested
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in and certainly an area that a lot of my training has been in.
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And actually prior to coming to Texas, I was working as a cleft surgeon in the
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UK in a region called Bristol. It's Bristol Children's Hospital.
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The cleft services are quite centralised in the UK.
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So it's quite a high volume cleft centre. So I'd done about 80 or so primary
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clefts in that first year, which is relatively high volume.
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And here in Texas, I'm working alongside the cleft craniofacial service and
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referrals will tend to come through that service. And I sit on that in that
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multidisciplinary team.
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I suppose the thing about cleft lip and palate is that it's a team game.
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It's a multidisciplinary speciality. You know, the surgeon may be the best surgeon
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in the world at repairing a pallet, but they're probably not the best person
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to go through the speech therapy.
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So working with a speech therapist. And in the same respect,
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the expertise of a surgeon may not be so great in terms of a dental specialty.
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So working with dental specialties, same with hearing.
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A lot of the children who have a cleft
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palate in particular may run into problems with glue
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ear and have some problems with hearing in which
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case you know having an ent surgeon on the team and that's not to mention pediatricians
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who look after the global picture of the whole child then we then other specialities
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that are involved so certainly psychologists and social workers sometimes are
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involved in the service,
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as is a geneticist.
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So there are lots of different specialties and of course all of this is coordinated
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by a cleft coordinator who kind of brings everything together and makes sure
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that the patient is seeing the people they need to see at the right time.
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So a lot of the specialties that I work in, in paediatric plastic surgery,
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involve working with other people from other disciplines.
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And that's what makes the specialties so rewarding, because you get to learn
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quite a lot about different areas of medicine and surgery by working with other team members.
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And you can also correct quite complex problems by working in wide teams of expertise.
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So cleft lip and palate is certainly an area. And that's not just the primary cleft lip and palate.
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That also can be correcting speech after the palate has been...
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Maybe I should talk a little bit more about what a palate does and why we need
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a palate. Sure. Sounds great.
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So a palate serves, I guess, two main functions.
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One is kind of shutting off the nose from a mouth so you don't get food coming
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up into your nose when you're eating.
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And secondly the soft part
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of the palate the bit at the back moves up and down and
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that shuts off the nose from the mouth when you're
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speaking so things like b's
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and t's and d's they need you to generate
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pressure in your mouth in order to say those sounds and you have to have a functioning
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soft palate to do that and if you have a cleft so a line in the palate then
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air escapes through the nose and can give you kind of a nasal quality to your, to your speech.
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And that can sometimes be quite challenging to understand.
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So the aim of surgery on the palate is to correct that,
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gap in the palate and also position the muscles towards the back of the palate,
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allowing the soft palate to lift up, close off the nose from the mouth,
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so you can produce the pressure in your mouth to make the sounds that need pressure.
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And what's the window of time when a child could get a successful surgery for this?
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So for cleft palate, we know from big data sets, So in some countries,
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they have huge data sets of all children who are born with cleft lip or palate
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over the past kind of 10, 15 years.
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And we know from that data that a time before 13 months of age is really optimal for palate closure.
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And that is to allow the children with a cleft palate to develop speech patterns
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with an intact palate as opposed to a cleft palate.
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So as well as cleft lip and palate there's also
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a need for speech surgery again from these big databases
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we know about one third of children who have
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a cleft palate may end up needing another operation for
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their speech it may be that they have some air coming
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out and about half will need therapy for their speech
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so there's a need for further speech
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surgery in some of these children so that's part of the
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service the other parts of the
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service may be filling in a bony gap in the gum
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of course by the by the cleft and that's
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called an alveolar bone graft and then as the children mature into kind of young
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teenage and adults then perhaps a revision of their lip repair and or movement
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of the jaw and or a operation on the nose to make the nose look more even each side.
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And then for people, for kids who don't have insurance, there's programs like university health?
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Yes, there's certainly programs and charities that would cover the cost of cleft care.
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That's amazing. And I know you do volunteer work, surgery work. I do.
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Can you tell me about that? So yes, in the past, I've actually been on the fundraising
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committee for a UK-based cleft charity, and that's called Cleft Bridging the Gap.
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But since I've moved, I've actually started to get involved with Austin Smiles and Smile Bangladesh.
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And I'm due to be going on a trip with both of those two organizations in the
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near future. So October and November.
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That's amazing. So going to El Salvador and Dakar in Bangladesh.
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Wow. Yeah. That's incredible. But also close to home, I'm doing some work for
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a charity called Fresh Start, which is a wonderful charity based domestically
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and also has an international wing as well.
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So I'm also helping to do some cases for
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for them as well and that's the one where it's on a
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weekend at university health when is that that's right
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yeah so in fact there's one coming up on 22nd of
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february i think yeah in this podcast pediatrics now
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news feed we have a podcast on fresh start so
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if you're listening and you want to know more about that you
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can search that and i'll put i'll put a
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link to it in here surgeons volunteer their
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time university hospital staff members
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and nurses all volunteer on a weekend and there's OR
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rooms that aren't being used the surgery is
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totally free yeah yeah it's free for the patient who's
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having the surgery this is kind of trying to
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allow children who don't have access to to health care or the cost either the
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cost of health care is too high to have surgery here in san antonio right the
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charity also runs in in other locations but yes i think that the director was
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in town i think it was from Chicago.
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Yeah, Chicago and San Diego, I think, yeah.
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And they cover travel costs for the family, and it's such an amazing program.
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It's so great that you're a part of that can you tell me a little bit more about
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your background so i i went to medical school in liverpool so after school so
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it's slightly different,
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in the way that medical school runs in the
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uk compared to the us so you go usually straight out of school which is you
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know finishes at 18 you do your a levels get into medical school and then you
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start at 18 so you don't do a pre-med course or anything like that so you start
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at 18 I actually took a gap year after school and did some traveling.
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Well, I actually worked in the Philippines for two months doing some marine
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ecology. How was that? That was incredible.
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It was a coral conservation project through a company called Coral Cay.
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So I was surveying coral. The hope of lobbying the government in the Philippines
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to make marine exclusion zones to allow proliferation of marine wildlife and
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trying to prevent practices that damage the coral.
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There was a lot of dynamite fishing at the time, and it
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was working with local communities to educate in some instances as to why maybe
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putting a stick of dynamite in the sea and blowing up the coral and all of the
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marine wildlife is maybe not so great for sustainable fishing. So I did that.
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And then I went to China for, it was about nine months in China.
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And I was teaching English in a medical school in the southwest in a place called
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Shaguan, which is in Yunnan province, right in the southwest corner of China.
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And that was fascinating. And that was in 2001. on.
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So that was, you know, before kind of, I guess, the rise of China as this,
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you know, superpower that it now is.
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And it was still relatively underdeveloped part of China.
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And I had the best gig out of anybody I know. So I was paid.
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I mean, this is the best job if anybody, you know, wants to get this kind of
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job. I don't think they probably exist anymore, but I was paid.
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To for students to practice their spoken English
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so on my job and
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it was about 20 hours a week or something and all
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I would do is go and have coffee and go
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out for lunch and yeah it was such a sociable time it was it was so good and
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you know there was a group of students who came all the time and we actually
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became friends and you know their English became really good and shamefully
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my Chinese did not match their English. It was quite shameful, actually.
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Well, that sounds like it's such an interesting program and wonderful experience.
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It was so good. I don't know if it still exists, actually.
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It was through an organization called GAP, which I think has probably been taken
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over by another organization.
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So anyway, I did that before medical school and then went to medical school in 2002 in Liverpool.
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And I spent six years at medical school.
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And during those six years, you have the opportunity to take a year out and
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do another honours degree, which is again, just such a jammy thing to be able to do.
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So I joined the third year of anatomy and human biology degree.
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So I was able to get BSE and my medical degree in those six years,
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which was really fortunate.
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After medical school, I stayed in Liverpool for two years and did my internship.
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And I rotated through, it was
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quite an old school programme of six months medicine, six months surgery.
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And then the second year was four months paediatric general surgery,
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four months emergency medicine, and then four months orthopaedics.
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After internship, I then went to Birmingham, not Birmingham, Alabama,
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Birmingham in the West Midlands and did a core surgical training,
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which is, I guess there's no equivalent here, but it's I guess,
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a general surgery junior residency for two years.
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Then after that, I did my time in Oxford for a couple of years and worked in
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Glasgow Royal Infirmary in Cannesburn Plastic Surgery Unit and then also worked
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in Bristol in the southwest of England.
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And then after those two years of the masters and those kind of jobs in between,
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I gained a residency program in South Wales,
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which is the welsh center of burns and plastic surgery
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which is where i did my plastic surgery residency has
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the full spectrum of plastic surgery pediatrics and adults
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and that is when i first discovered that i really enjoyed the pediatric side
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of things certainly one of the kind of i guess one of the mentors that influenced
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me a lot there is is mr wilson jones he i should probably explain that in the UK,
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surgeons are called Mr. as opposed to doctor.
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Oh, really? Yes. And that harps back to the old barber surgeons.
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So back when surgery first started.
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The surgeons were actually barbers. They cut hair.
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Wow. And they were employed by physicians to do the dirty work of surgery.
21:12
Really? Yeah. So surgeons didn't used to go to medical school.
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Wow, I did not know that. I know. It's incredible. So as a nod to that,
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in the UK, we still take the title of Mr.
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As a surgeon. So I was Mr. Thompson in the UK.
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Now I'm obviously Dr. Thompson, now I've come here. But yeah, so Mr.
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Wilson-Jones was a strong influence on the way that the decisions I made to go into pediatrics.
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He's a pediatric plastic surgeon there and, you know, does inspiring work.
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And in England, how do you say, like we say Mr. here, though?
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What do you say instead? Like if someone's not a doctor? Oh,
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yeah, no, that's still Mr. Okay. Yeah, yeah, yeah.
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There's just no way of, yeah, knowing if you're a surgeon.
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It's yeah it's just one of those traditions that everybody carries on
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and it's when you when you get your kind of
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boards in surgery you you get
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the honor of dropping the doctor title title and going back to mister which
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is quite peculiar yeah oh well i miss england it's bringing back such great
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memories and when i moved here from when i came back after spending the time
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in oxford and then I started my journalism career in Amarillo,
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Texas, the small market.
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And I went to this group of women, banco card playing group,
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trying to make new friends.
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And we all introduced ourselves. And this woman, she stood up and said that
22:35
she and her husband just moved there from Paris to Amarillo.
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And so afterward, I came up to her like, wow, okay, I was just in the south
22:41
of France. I was living in England.
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And she looks at me, she's kind of perplexed. And she looks at me,
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she says, no, oh, I was, and she has a thick Southern accent.
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I was talking about Paris, Texas.
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I'm like, oh my gosh, I didn't know.
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But I really liked it in Amarillo. It grew on me after a time.
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So your background is really incredible and you're doing such amazing things.
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Was there one moment or one thing that inspired you to get into pediatric plastic surgery?
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As a surgeon and any surgical audience will know exactly what I'm talking about.
23:17
A lot of the time the clinics can be massively overbooked and it can be quite
23:25
difficult sometimes being in clinic.
23:29
Especially as a surgeon, you really, historically and most surgeons will absolutely
23:34
love being in the operating room and doing the operations, seeing hopefully
23:38
great results, and then seeing the patients afterwards.
23:41
So you spend your time, certainly in residency, doing clinic,
23:47
but really your love is in the operating room.
23:51
Now, I started doing the paediatric rotation, and I actually realised I loved
23:56
the clinic. I was like, what was going on?
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This is, you know, I not only love the surgery, but I also love the clinic.
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There's a lot of energy in pediatric clinics. And, you know,
24:08
I just really loved kind of seeing the same children again and again,
24:13
growing and maturing and, you know, the operations that you've done making a
24:18
huge difference to their lives.
24:20
And a lot of the time that just means minimizing the
24:23
impact of whatever anomaly they may
24:27
have been born with or acquired so yeah
24:30
that kind of inspired me and that inspired me to apply for a pediatric plastic
24:34
surgery fellowship which i did did do so and i ended up doing a pediatric plastic
24:40
surgery fellowship in vancouver in canada in brussia columbia which was so much
24:45
fun this was high volume centre,
24:48
the full spectrum of paediatric plastic surgery, cleft lip and palate,
24:52
congenital hand surgery, vascular anomalies.
24:56
Kind of the general lumps and bumps of some paediatric practice,
25:00
kind of burns, ear reconstruction.
25:03
Perineal reconstruction, abdominal wall reconstruction, I had all of it in a
25:07
big paediatric hospital in BC Children's.
25:11
And working with some amazing, amazing mentors there.
25:15
The focus, and it's very patient focused.
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It's just, it was a really inspiring place to be.
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And, you know, I just thought, okay, I really want to model my practice on the
25:26
way it's done in BC Children's.
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After that, because, I mean, one fellowship wasn't enough, clearly.
25:32
I ended up doing two more, which is some people just say, what, this is barmy.
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But actually I realised at the end of that, that you do a little bit of everything.
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And I just thought, you know what, I want more experience and more skills in
25:49
some other areas of paediatric plastic surgery, in particular craniofacial surgery and cleft surgery.
25:56
So I ended up going to Great Ormond Street Hospital in London and doing a fellowship
26:01
for a year with the craniofacial service there.
26:03
So that's Professor Dunaway and Mr. Ong and Mr. Eccles with plastic surgeons there.
26:09
And that was a big focus on cranial vault remodeling. but
26:13
you know the full spectrum of of craniofacial
26:17
surgery which is a another podcast entirely
26:20
i think and then after that focusing on
26:24
very much on cleft and that was in the evelina hospital in london a mixture
26:29
of plastic surgeons oral maxillary facial surgeons and ent surgeons all working
26:34
together in a very large cleft unit in order to try and you know get the best outcomes for patients.
26:41
So I was able to learn from multi-specialities in those years.
26:46
And you're very passionate about customer service, about the way the patient is treated.
26:53
Yeah, I strongly believe in that. I think it's really important because it's
26:59
incredibly scary for parents and children.
27:01
I mean, especially if it's an operation on a baby as well.
27:04
You know there's a lot a lot of even if it's a even if it's a quote-unquote small operation.
27:11
It's not small like small for the
27:14
surgeon yeah maybe but that's not small for the kid and certainly not small
27:18
for the parents you know that's major so and i think appreciating that and taking
27:24
the time in clinic to listen to concerns and go through in quite a lot of detail
27:30
sometimes what the operation is going to entail.
27:33
And that's all a part of building trust and building that relationship with
27:37
not only the child, but also the parents.
27:40
And that feeds into, you know, the aftercare and good communication with the
27:46
parents, you know, just directly after the operation.
27:49
So I always make sure as soon as the operation is done and, you know,
27:54
the child has kind of woken up, I come and find the parents straight away and
27:59
just go through exactly, you know, what we found in surgery.
28:02
And just a lot of the time there's
28:06
a big relief that happens when they see you and
28:09
you've got a smile on your face and you say everything went to plan and and
28:13
there's this huge emotional kind of unburdening of oh thank you so much it went
28:18
it went well and you know i think there's a huge amount of anxiety about being
28:22
away from your child and having a general anesthetic and you know recognizing that is, I think,
28:28
really important in all pediatric specialties.
28:31
And that's an area that I particularly like to focus on.
28:36
And any other pieces of advice for our listeners where it can,
28:41
so, you know, in the stress of the day and a lot of our listeners are seeing 40 patients a day,
28:47
is there one or two things that you think are the most important for customer service?
28:53
Is it the eye contact talking to the
28:55
parent and the child treating everybody as an individual i
28:59
think is is vital i think all of
29:01
those things you mentioned getting down on the all the
29:04
things that pediatricians do instinctively almost and a
29:08
lot of this i've learned from pediatricians over the years who are you know
29:11
on the on the whole incredible communicators getting down on on the level of
29:16
a child and speaking to child especially if they're slightly older and you got
29:22
to remember Remember that this is an operation on the child, not on the parents.
29:27
Although the parents are obviously helping form that decision in the best interests
29:33
of a child, ultimately the center of the care is the child.
29:38
And involving them in care as much as possible. You know, I don't lie to children.
29:45
I think that's a good thing to go by.
29:49
I mean, I think I remember early on doing paediatric rotations and,
29:55
you know, people would be doing something simple like taking blood from a child
29:59
and they'd say, oh, you know, doesn't hurt. It's just a little scratch.
30:03
It's not a scratch. It's not a scratch at all it's painful so my the way i would
30:08
always be and the way i still am is just say look this is going to be this is
30:12
going to be a bit painful or if i'm giving local anesthetic to a child,
30:16
you know try and mitigate how i do that by
30:19
giving local anesthetic beforehand
30:22
sorry localized um topical anesthetic beforehand and using a very small needle
30:28
and injecting very slowly and things like that but also just not lying and just
30:33
saying do you know what this does sting it's like a beasting and it will be
30:38
there for 10 seconds and then it will be gone and it will be numb,
30:42
and just being honest and just saying you know if you're going to be honest
30:47
about what surgery entails you know yes there is going to be some pain afterwards
30:51
yes we will try and manage it as best we can you know it's just that honesty
30:56
and children are so perceptive they are they They deserve our honesty.
31:02
They'll know. And they'll, you know, they will call you up on it.
31:07
Yeah. And all of us, you know, I'm sure a lot of the pediatricians in the audience
31:12
will know that feeling of losing trust with the child. And, you know, it's a nightmare.
31:19
Richard, anything else you would like to say about left palate surgery? Yes.
31:25
Let's hear it. But I, you know, I guess I think it's such a big area that I'm so passionate about.
31:32
I could actually talk probably all day just on this one topic.
31:37
I think the main thing I wanted to get across is it's team game,
31:41
best in a multidisciplinary team. And we've got a great team here.
31:47
And then just kind of a holistic, complete cleft care.
31:51
The way that I feel is that this should be something that's managed from before
31:59
birth, antenatally, all the way up until the child is fully grown.
32:05
Trying to minimize the number of surgeries, trying to get it right first time,
32:10
which is particularly important with palate surgery. That first time is the best time.
32:16
And just being honest, open, and caring.
32:20
There's obviously a huge amount, you know, I could say about cleft care.
32:25
And actually, you know, I'd love to maybe have another opportunity with the
32:29
rest of the cleft team to talk about.
32:33
And, you know, that would be bringing in the whole team.
32:36
It's great. Let's do it. Yeah, I think we should. Is it becoming more common, less common?
32:41
It's pretty stable. But the thing,
32:42
I suppose San Antonio has got a young population and it's a growing city.
32:49
So all of those factors mean that the rate, I mean, essentially,
32:54
if you've got high birth rates, you'll have a higher rate of congenital anomalies.
32:59
Be that cleft lip and palate, be it congenital hand concerns,
33:04
differences in the hand, other facial differences, any congenital anomaly will
33:09
be higher when the birth rate's high.
33:12
So that's why moving to somewhere like san antonio it's a big rapidly developing city,
33:19
high birth rate high levels of immigration and all
33:22
of this means young you know young population all of
33:26
this means that there's a lot of need for
33:29
a pediatric plastic surgeon hence the reason that i'm here
33:33
and the new pediatric plastic surgery program we
33:37
will put the referral information in the text because
33:39
it's not all set at this time when we're talking
33:42
but where your clinic will be that's right but you
33:45
work closely with university health that's
33:49
right here at ut health yeah so on
33:51
faculty here at ut health and i've got clinic in university hospital and that's
33:57
monday morning every monday and that's currently third floor rio the way to
34:03
refer is currently being kind of worked out because it's a new department yes
34:08
once we have yeah the referral number we'll put that in.
34:12
I know when we were talking, I was struck by how you said there's so much that
34:16
can be done with pediatric plastic surgery.
34:19
So if I'm understanding it correctly, if our pediatrician listeners are wondering,
34:24
I wonder if this could be improved, this could be helped.
34:27
It's good to, it might be able to be. So yeah, absolutely.
34:32
Yeah, it's very broad. I mean, I suppose just if I go through very briefly,
34:36
I know we talked a lot about cleft,
34:37
but I guess craniofacial anomalies kind of
34:40
overgrowth and undergrowth kind of anomalies benign
34:44
and benign tumors dermoids things
34:47
like that and sometimes you know dermoid cysts
34:51
can be can look very small and
34:54
insignificant on the surface but actually be quite significant beneath and they
34:59
can extend into cranially and and all sorts so yeah neurofibromatosis i know
35:07
there's a neurofibromatosis program here in San Antonio that I'm starting to work with as well.
35:13
We have a podcast in this feed on that program as well. There you go.
35:17
So yeah, hoping to get a bit more involved with that service.
35:20
Congential hand surgery is quite a big part of, well, hand surgery is a big
35:24
part, plastic surgery, and congenital hand is quite a big part of pediatric plastic surgery.
35:30
So children who are born with fingers fused, that's called syndactyly, or not enough fingers.
35:37
When I say not enough, less than the kind of number of fingers you or I would have.
35:45
Duplicate thumbs, duplicate kind of extra digits, hands that just don't function in the same way.
35:52
So some of the referrals we get are for extra toes as well.
35:56
Yeah, and there can be difficulty fitting shoes properly, can cause lots of problems with rubbing.
36:02
And, you know, again, relatively straightforward operation to remove those digits.
36:06
Obviously, there's a spectrum and some are more complex.
36:10
Some of these anomalies are more complex than others. But yeah,
36:13
congenital hand or foot.
36:15
Also work quite closely with vascular malformation clinic. So there's a wonderful
36:20
vascular malformation clinic here in the hospital.
36:23
And a lot of the vascular malformations are amenable to treatment with either
36:29
medicines or kind of an interventional radiology, but some will end up needing an operation.
36:35
So that is something which I would be very happy to get involved with.
36:41
Ear anomalies we mentioned briefly, things like prominent ears,
36:45
but also other differences in the ears. Some children are born without an ear.
36:50
We can make a new ear at the appropriate age, which is usually a little bit
36:54
older, but can certainly make a new ear. It's incredible.
36:58
There's a lot of stuff in plastic surgery that I pinch myself and say, this is incredible.
37:04
Making new ear is definitely one of
37:07
those things as is moving if
37:10
somebody's born without a thumb moving the index
37:13
finger into the position of a thumb that's called politicization
37:16
i think that's the best operation in plastic surgery
37:20
wow it's the best it's got it
37:23
functions incredibly well it's it
37:27
looks like a proper thumb you know if you were
37:30
to just at conversational distance you wouldn't notice that
37:33
the person had three fingers and an index
37:36
finger that's turned into a thumb and technically
37:39
it's just one of those operations that has
37:42
such finesse and it just ticks all of those boxes that make a plastic surgery
37:46
operation incredible it looks amazing it functions amazingly and the operation
37:50
is really really good and difficult to do which makes it challenging and really
37:54
great so that's an amazing operation ear reconstruction amazing clever and ballet, amazing.
38:00
Yeah, this is why anybody out there who wants to know what to do,
38:04
going to pedioplastics surgery.
38:06
Can you tell us briefly how you create the new ear?
38:10
A lot of the time, there may be a little bit of kind of remnant of where an
38:16
ear maybe should have been.
38:19
And in the first instance, when the child's, you know, very early,
38:23
it's going to be a case of checking the hearing and working with the ENT team
38:28
to see if there's actually functional hearing in that ear.
38:33
And I know the ENT team will want to get bone-anchored hearing aids in order
38:39
to allow the child to hear on that side and develop the part of the brain that
38:44
is responsible for hearing.
38:45
So that's the first thing like in any of those children.
38:50
And also some of these anomalies can come as a spectrum where you have underdevelopment
38:55
of a jaw and you can have problems with the orbit, problems with some of the
39:00
growth on that side of the face.
39:02
So it may be that it comes on top of other anomalies.
39:08
But broadly speaking, we would tend to wait until the child's a lot older.
39:13
So usually about nine, ten years old.
39:16
And then at that stage, if they were keen on having a reconstruction,
39:21
then we would take, it would be quite a long operation,
39:25
and taking some rib cartilage and then shaping it into the cartilage that you'd
39:33
normally see in an ear, placing it under a pocket in the skin,
39:37
and then some vacuum dressings.
39:40
I mean, that sounds like a crazy thing to do. Yes, it does. Wow.
39:48
Yeah, it is how we would reconstruct from nothing.
39:54
Well, Richard, this is so fascinating. I feel so lucky to be here talking to
39:58
you in the podcast studio.
40:00
Is there anything else new or important that there's so many things we could
40:05
cover, but that you want pediatric practitioners to know about?
40:08
I guess even the kind of smaller, I know we've talked about some of the big
40:12
kind of anomalies, but actually there's a lot of small things that,
40:16
you know, we can do and deal with in plastic surgery,
40:21
you know, little skin tags and moles and cysts and, you know,
40:26
congenital melanocytic nevus and things like that, that sometimes just need
40:32
a very, very quick kind of sedation, local anesthetic,
40:36
and then it's done. some of these smaller things.
40:40
And scarring is a really, really important thing as well.
40:46
Scarring from either trauma or actually from an operation.
40:49
It may be that the wound hasn't healed as expected or as hoped,
40:55
or it may be that the injury has resulted in a scar, which maybe isn't following a line of.
41:04
A line that could disguise it. And we can do things in plastic surgery where
41:09
we move the direction of the scar.
41:12
We can advance it to a position where maybe it's not as noticeable.
41:17
Maybe it's just going to be a case of if there's a big scar,
41:20
we can make it smaller, sometimes with more than one operation to serially excise it.
41:26
Or sometimes we can move tissue from the side to kind of cover it.
41:31
So there's lots of things we can do. If there's a contour
41:34
defect we can sometimes fill in that
41:37
contour with your own tissue and if there's too
41:40
much contour then we can sometimes do something simple like
41:42
liposuction and take that out so any
41:46
kind of little kind of lumps and bumps or scars
41:50
that the patient's concerned about is something
41:53
we'd be very happy to see and if there's
41:55
something we can do sometimes it can be relatively simple is there
41:59
a window when it's been too long since a surgery
42:02
for this not at all not at all i'd say there is
42:05
a window where it's too early and that's because sometimes
42:09
a scar can look quite angry red raised
42:13
quite early on and in fact
42:15
that's almost part of normal wound healing can
42:19
be it's a lot of the time
42:21
a case of letting that mature letting the scar mature because
42:25
sometimes you may look at a scar and think oh my
42:28
goodness that will definitely need another operation and
42:31
six months down the line everything's flattened the redness is gone and the
42:37
patient's no longer bothered by it in which case you just you know so we would
42:42
definitely always wait for the scar to fully mature before we would consider
42:47
doing any surgery to revise it.
42:51
Pediatric community practitioners tell me that social media is something that
42:56
comes up in almost every visit.
43:00
It's so prevalent. And as we know, there's a lot of negative effects and one
43:05
of those being body image.
43:07
Anything you want to caution about or say about cosmetic plastic surgery and
43:13
the child or preteen or teenager?
43:16
Yeah, I'd say that I wouldn't be alone in this and saying that, you know,
43:21
all of our plastic surgery colleagues, a lot of my plastic surgery colleagues
43:25
would really not be offering cosmetic surgery to a child.
43:32
It would usually wait until the child was an adult and fully grown and mature
43:38
enough to kind of understand what was involved in an operation that would change appearance.
43:44
Now there's obviously a we talked earlier about the prominent ear surgery and and various.
43:52
Anomalies that may be classed as cosmetic so there
43:55
is obviously a fine line or maybe a child who's
43:59
who's born with there's some syndromes such as
44:01
poland syndrome where the child wouldn't develop
44:04
a breast on one side for example and
44:09
it may be that that's you know that's kind of a very reconstructive
44:12
operation but things like breast augmentation may
44:15
be suitable at an earlier stage than
44:19
you would say doing breast augmentation in somebody
44:22
who has breasts that are
44:25
you know normal quote-unquote i hate
44:28
that term but i should say average right
44:32
now i know what you mean is there anything you want to say advice on
44:35
what when would be time to see the plastic surgeon on
44:38
that for breast augmentation yes for the
44:40
if the child has that poland syndrome oh
44:43
you know we could see them straight away yeah yeah because that
44:47
doesn't necessarily mean we're going to do an operation and timing's
44:51
everything in pediatric plastic surgery there are really good times to do an
44:55
operation and sometimes it just needs to you need to wait until the child's
44:59
old enough or mature enough or things have grown to a certain size and and also
45:06
sometimes just yeah like you said earlier,
45:08
waiting and seeing if it's still a problem when they're a little bit older and
45:12
have their own kind of mind about what they want.
45:17
Are there plastic surgeons who are doing breast augmentation,
45:20
cosmetic breast augmentations on high schoolers?
45:24
I'm sure there are. I'd very much caution against that.
45:27
I think it's not a good idea to do that kind of operation in somebody who's not an adult.
45:34
And I think there's good guidance on that from a lot of plastic surgery organizations,
45:40
professional organizations.
45:41
And so in that case, you'd recommend some counseling? you were saying i think
45:44
yeah and it may be that you know i'm not saying that that should be avoided
45:50
when they're an adult of course not you know it's their own right to make any decision they want,
45:56
i think it's probably worth you know speaking you can certainly speak to a plastic
46:02
surgeon speak to somebody who is who you trust and it may be a case of you know
46:08
seeing them back in a few years when they've, you know,
46:12
had a chance to think about things and they've matured.
46:16
Richard, anything else you want to talk about in terms of plastic surgery?
46:20
I'll just say that if anybody wants to, you know, thinks, oh God,
46:25
is this something which could be amenable to plastic surgery or.
46:31
You know, just pick up a phone or just send them a trial.
46:34
I'm I'm happy to see people in clinic and you know I really enjoy you know speaking to patients and,
46:40
especially if it's because there's not usually a huge amount of imaging needed for,
46:46
a lot of plastic surgery it's something
46:49
which is visual and can be
46:52
deemed gleaned by examining the
46:56
patient so it's not like something that
46:59
you need to wait for investigations for sometimes you
47:02
do but sometimes the answer you can just give
47:05
them in clinic and practitioners are getting questions from parents
47:08
when there's an injury of some sort when is it important that a plastic surgeon
47:13
sews that up as as yeah so if there's an acute injury yeah so that's another
47:20
part of service that we didn't talk about is the acute kind of trauma side of things,
47:27
and that we see a lot of injuries.
47:30
So a lot of soft tissue injuries, facial injuries, so broken bones in the face,
47:35
broken bones in the hand, soft tissue injury, dog bites, you know, lacerations.
47:39
Just, you know, I'm sure every single one of us as a child ended up in the emergency
47:45
department with some kind of stitches at some stage.
47:49
Yes, three times for me. Either that or everybody's children have,
47:52
you know, ended up being in the emergency department. Yeah.
47:54
I'd say there's no urgent rush. The right thing to do is ensure that everything's
48:00
clean before we close anything.
48:02
So if it's a contaminated wound, sometimes that can need cleaning up and sometimes
48:08
that means freshening the tissues with an operation and then before anything can be closed.
48:15
Sometimes a wound is so extensive that it needs more than just closing.
48:20
And sometimes you need to employ reconstructive techniques to close those wounds.
48:26
And that may mean moving tissue from the side of the defect,
48:30
or it may mean bringing tissue in from elsewhere in order to close those wounds.
48:37
So when you're on call, a lot of it's what you're doing is trauma?
48:42
Yeah, I'd say the vast majority, yeah.
48:46
So it's a major trauma center. The only level one trauma center that's other than BAMC in town.
48:53
Yes, that's right. This is the place to come for trauma, for sure.
48:56
I mean, this is where the expertise are. The acute trauma service here is very, very good.
49:00
And a lot of those kind of soft tissue injuries will be referred to plastic surgery.
49:06
What about for the more run-of-the-mill type of injuries?
49:11
Say, for example, my son had an impact wound from a basketball.
49:15
Yes. and so he needed stitches underneath his eye is that something you do or
49:20
after the fact he still has a little scar yeah is and it kind of bothers him
49:24
is it too late to do anything there or should it be checked out so i what i
49:30
always say to parents is you can't undo the injury that's happened.
49:33
So if you've had a laceration there's no amount of surgery or magic plastic
49:40
surgery that can undo If it's the full thickness of the skin,
49:45
then no matter what happens, there'll be a scar.
49:49
The aim of the initial surgery or the initial closure would be to ensure that
49:55
it's clean and then close it to try and minimize the scarring.
50:01
And I think in this case he had glue.
50:03
Yeah. Very common, right? So glue would be very common, especially in children.
50:07
You know, there's no stitches to come out.
50:09
Dissolving stitch is obviously an option. Glue is also a great option.
50:13
And I certainly use for my cleft lip repairs, I put stitches under the skin
50:18
and then put glue on the surface to try and avoid any of those stitch marks.
50:22
So I think you can't undo the damage, but you can minimise, hopefully,
50:28
the scar that you'll get or try and improve it.
50:30
Now, if the plastic surgery service was involved in every single closure of
50:36
a wound, I think it would be difficult to be able to provide that service.
50:41
There's lots of very able doctors in the emergency department who can do that.
50:46
Now if the scarring isn't favorable
50:49
in terms of you know that may well be from
50:52
the injury it's just resulted in a cut that
50:55
just doesn't fall in a line of the
50:57
face that is easily disguised for example then by
51:02
all means you know you can refer those cases
51:05
you know i'd certainly advise to
51:08
give it a good six months or so to just allow
51:11
things to mature i'm a big advocate of silicon ointment.
51:15
Scar massage once things are
51:17
healed you know after about two weeks once everything's healed
51:21
is that over the counter silicon ointment yeah anything you
51:24
can buy or silicon tape is even better but the keeping
51:28
silicon tape on on your face may be
51:31
a bit more of a challenge than certainly a child is it too late
51:34
if it's been about a year if it's still if the scar's still
51:36
angry if it's still red i think there's probably no harm
51:40
in doing silicon ointment and certainly scar massage now if
51:44
you know there's still you've given it a bit of time and
51:47
it's still a scar that maybe is orientated in a way that draws focus then by
51:56
all means be very happy to see them in which case you know there may be things
52:02
that we can do to either disguise that scar or maybe improve the scarring.
52:06
Change the contour things like that what about vitamin e
52:09
oil you hear about that first you know actually the
52:12
most important thing is kind of
52:15
scar massage and moisturizer essentially yeah the
52:19
other thing which i should mention is when you
52:22
have scar tissue it doesn't have melanin in it so melanin is the stuff that
52:28
on your skin causes you to your skin to turn slightly darker when it has uv
52:33
light so when it has sunlight scar tissue doesn't have melanin and that means
52:39
that it's very prone to UV exposure.
52:43
So I always advise factor 50 SPF, you know, high factor covering scar tissue.
52:49
In fact, I would advise SPF 50 on your face all the time.
52:56
I certainly wear SPF 50 every single day, even in the winter,
53:01
to just try and reduce that UV exposure.
53:03
Which is harder to do when someone's a teenager, to convince them to do that. Oh, yeah.
53:08
Yeah, I definitely certainly didn't do that as a teenager. I think I did a few
53:13
when I worked in as a resident, we did a lot of skin cancer excision.
53:18
And I just thought, you know, it was only so many skin cancers you can see be
53:22
excised from somebody's face.
53:24
And you just think, oh, my goodness, I'm going to try and try and reduce that risk.
53:28
Yeah. And it's a great reminder for all of us. And that's something I like to
53:32
focus on in the podcast as well, having a life outside of medicine.
53:37
Oh, yeah. So important. wear the sunscreen make
53:41
sure you take care of yourself and so you are very
53:44
active a triathlete you love swimming and
53:47
i do yes i do so i i used
53:50
to do a lot of triathlon i haven't done any that recently
53:53
so i haven't done any flots last couple of years but i
53:56
was doing half iron mans and kind of
53:59
olympic distance triathlons and sprint triathlon and i.
54:03
Absolutely love it it's it's being outside
54:06
and it's because you spend certainly as a surgeon vast
54:09
majority of your life is inside with no windows in
54:13
artificial light and having the opportunity
54:16
to get outside is just oh yeah that's that's
54:19
what it's all about outside swimming is
54:22
something which i discovered probably halfway through
54:25
residency and or maybe just a bit before getting
54:29
your wetsuit on and going certainly i was
54:32
living on the coast in in the uk and just getting
54:35
into the sea having that cold water and you
54:38
know swimming and yeah some scary moments from
54:41
from swimming outside and one particular moment which
54:44
i'll share so i was i was swimming across a
54:47
bay in south wales it's called langland bay and
54:51
you know it's kind of probably about maybe 600 meters
54:55
across and i used to just swim across it and
54:58
you're going kind of into i guess it's the ocean really because it's across
55:02
the bay and i used to do this you know multiple times a week and one one day
55:06
i was swimming across and i felt this tap on my foot and i just thought oh no
55:12
it's got to be a bit of it's got to be a driftwood or something so i just carried on,
55:17
And then I felt another tap on my foot. It was a bit harder.
55:21
And I thought, oh my God, what is it? I'm in the middle of the bay,
55:24
like 400 meters from land.
55:27
And then I looked below and there's a whole load of bubbles behind me.
55:31
I was like, oh my, what is this? What is this?
55:34
Starting to get quite scared. So I carried on and I was like, I can't do anything.
55:38
I'm kind of halfway between, you know, land. I've got 400 meters to go.
55:42
And then I felt a bit of a nip on my foot. and i turned around i couldn't see
55:48
anything looked below and there was this huge bull seal,
55:52
just it must have been you know six foot two
55:55
huge 400 pounds or i
55:57
don't know huge bull seal just below me and
56:01
it was playing i think i don't know if it
56:03
was playing or if it was just like this is my territory get out
56:07
that must have been so it was so terrifying because
56:10
they're so agile and fast and you're
56:13
just there so remote in this
56:16
like ocean on your own there was that was no I wasn't
56:19
swimming with anybody else I used to have a pool boy but
56:22
nothing else and oh god it was
56:25
so it was just so scary I swam into the land and it
56:28
was fine did you stay calm or just
56:30
swim as fast as you can or both or what did you Holly I'd love
56:33
to say I was really calm but I yeah I don't know how calm i was realistically
56:40
yeah i think i was i think i probably did a record 400 meter swim i'd say and
56:46
then got out and yeah and then the next week i was a bit scared to go in but i did go in.
56:51
There's there is something magical about swimming if you can get to a pool like,
56:56
last week when we had the cold snap here which is
56:59
nothing compared to what you're used to i know but some snow in
57:02
san antonio and my daughter and i still went to swim practice
57:05
and wore our swim parkas up to the edge of the pool and
57:08
it was just it's amazing i mean it's a heated pool but i love
57:11
that though but you're outside aren't you in this yeah those are
57:14
great something about being outside swimming yes yeah and and i think certainly
57:20
cold war swimming has been shown to be very good for kind of mental health and
57:23
and that side of things and you know i'm a big advocate because you feel i feel
57:28
i think you feel especially cold we feel like a bit of a hero after you've come
57:32
out yes No, when I walked into that,
57:34
there were a couple of different people who told me how brave I was just headed
57:38
to the pool. I'm like, wow, this is nice.
57:41
And it did feel great. And my son just recently, he got back from Minnesota.
57:45
He did an outward bound trip.
57:46
And his favorite part, it was dog sledding and cross-country skiing.
57:50
And his favorite part was on the last day where they did a cold plunge.
57:55
Bought my wife for christmas kind of cold exposure at
57:58
cryo fit so she's got she's got like i
58:01
think five sessions of like minus 130 whatever
58:04
it is in that in this cryo fit chambers i've seen those yeah for our listeners
58:10
do you have a quote you wanted to say i do have a quote quotes i yeah so this
58:15
is actually because it's a pediatric podcast i thought i'd you know stick to
58:20
you know on pediatric theme.
58:23
So Christopher Robin to Winnie the Pooh, so A.A. Milne, you're braver than you
58:27
believe, stronger than you seem, and smarter than you think. I love it.
58:33
Makes me tear up. I think that's such a wonderful quote, and it's important
58:36
for our pediatric patients to know that we think that of them, right? Yeah, big time.
58:42
I think this is so poignant going into surgery, and it can be quite daunting.
58:46
Like that moment you talked about in the ocean, things that happen when you're
58:50
on call or going into surgery or do it, you know, there's got to be a lot of
58:53
kind of scary things that you're facing.
58:55
I mean, you know, I suppose since the age of 18, I've been in medicine.
59:00
So it's I don't want to say it's normalized at all because it's not normal.
59:05
And there are moments that you think, oh, my goodness, this is a really big
59:08
injury or a really, you know, quite shocking thing that's happened.
59:12
But then you rely on your years of training and your team around you.
59:18
As I said before, we're not doing our own.
59:20
You know, there's lots of people helping.
59:23
And sometimes in these really difficult, challenging cases, we do them combined.
59:28
So two you know fully trained
59:31
surgeons who are who are there or sometimes more sometimes
59:34
more than that to try and speed up an operation
59:37
and also if it's very complex and needs complex decision making having two of
59:43
you or more in the room to bounce ideas off each other is really important and
59:47
so important to have that atmosphere of kindness and respect where someone who's
59:53
the This scrub tech feels comfortable.
59:56
Oh, yes. A medical assistant will speak up. I think this could be wrong.
1:00:00
Oh, this is so important.
1:00:02
So, yeah, creating an environment in the operating room where anybody can feel
1:00:07
that they can challenge what's going on.
1:00:09
And this is something that, you know, I feel passionately about and creating that environment.
1:00:14
And that's a skill to do as a surgeon. And, you know, all of us are kind of
1:00:19
learning lifelong to kind of try and create that kind of environment.
1:00:26
But yeah, you know, that's certainly what I aspire to be.
1:00:31
Creating an environment where if somebody has a suggestion, you listen and you
1:00:37
don't dismiss it and hopefully try and maybe create a bit more of a kind of
1:00:42
horizontal hierarchy in the operating room.
1:00:44
There does have to be a hierarchy and that will depend on what aspect of the case is going on.
1:00:52
So for example, when the child's being put to sleep and woken up,
1:00:58
you know, the anethicist really has to be the person leading that.
1:01:01
And when there's a part in the operation that's critical, it really does have
1:01:06
to be the surgeon that's leading that.
1:01:09
And there will be moments that are very focused, but there's also a lot of time
1:01:15
when, well, there's always time for somebody to step in and say, are you sure?
1:01:21
And that's something which I always encourage and always say that to our residents as well.
1:01:26
You know, please tell me if you think that this is not the right thing to do,
1:01:30
because i will listen and we'll just discuss it even
1:01:33
though that you know i planned i plan all
1:01:36
of my cases a lot beforehand but sometimes
1:01:39
there's not you can't plan for everything yeah and i
1:01:42
love that and the the culture of that the
1:01:45
person who's mopping the floor their job is just as
1:01:48
important as the surgeon creating the
1:01:52
ear for the child yeah it totally is yeah because you know
1:01:55
everybody's got a role in the team and you know if the
1:01:58
if the floor is full of bacteria and you
1:02:02
know every case you do that day is going to end in an infection that's really
1:02:05
not great you know that's going to be just the worst case scenario so yeah everybody
1:02:12
in the team is is important and has a role well i'll wrap it up by saying thank
1:02:18
you mr richard thompson for being here today in the podcast studio.
1:02:22
It was a pleasure to be asked onto the podcast. Thank you very much for having me.
1:02:29
What's new in pediatric neurosurgery? That's coming up next week on Pediatrics Now.
1:02:36
Pediatrics Now is brought to you by University Health's new Women's and Children's Hospital.
1:02:45
And the Department of Pediatrics at the University of Texas Health Science Center at San Antonio.
1:02:51
It's also brought to you by CPAN, no call too small.