A surgeon, who can correct deformity, scars and disfigurement caused by accidents, birth defects and treat diseases like skin cancer (melanoma), is called a plastic surgeon. A plastic surgeon also performs surgeries purely based on cosmetic purposes, e.g. rhinoplasty. The first plastic surgeon of the U.S. was Dr. John Peter Mettauer who performed his first surgery of cleft palate in the year 1827. Plastic surgeons perform various levels of surgeries on human body to beautify and restructure it. The main surgeries performed by plastic surgeons:
Reconstructive surgeries: The most common surgeries in the reconstructive section are breast reconstruction, palate surgery, cleft lip, surgery for patients suffering from burns called contracture surgery. Another technique called microsurgery is performed where tissue is transferred from one place to another where tissue is damaged and needs replacement.
Cosmetic surgery: The most famous and common surgery in the area of plastic surgery is cosmetic surgery and is performed purely from beautification point of view. Cosmetic surgery also known as aesthetic surgery is done just to enhance the beauty of any part and may possibly be a reconstructive surgery. The surgery improves the beauty or looks of any part of the body and is usually referred with the name of that particular part of the body. For e.g. Abdominoplasty (tummy tuck - reconstruction of the abdomen), Blepharoplasty (eyelid surgery) - application of permanent eyeliner or reshaping the eyelids.
Cosmesis: Another common procedure called as cosmesis is a blend of reconstructive plastic surgery and cosmetic plastic surgery. In the process of reconstructive surgery, cosmetic surgery techniques are utilized thus improving cosmesis.
In addition to these branches of plastic surgery, there are also surgeries such as craniofacial surgery - mainly dealing with pediatric deformities, maxillofacial surgery - improvement of the jaw and the face.
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Fetal surgery refers to the surgical treatment of the developing baby in the womb to rectify congenital defects. Surgery of the fetus is performed to fix the prenatally diagnosed anomalies. However fetal surgery is a complicated procedure and comes with lot of risks to both mother and the baby. Yet, doctors recommend fetal surgery, if the risks associated with continuing the pregnancy, without surgical intervention, outweighs the risks that come with fetal surgery. Certain abnormalities, if left to progress in the womb, may turn fatal and infant may die soon after the birth. However fetal intervention is initiated only after taking the safety of the mother into consideration. The common risks that are associated with fetal surgery are premature delivery, infection of the uterus, leaking of amniotic fluid through the membrane, potential infertility and the risk of anesthesia.
There are various techniques followed to diagnose fetal anomalies. The diagnostic method can be non invasive such as ultrasound, fetal echocardiography, MRI, Radiography, Measuring MSAFP (maternal serum alpha-fetoprotein) and Measuring maternal serum beta-human chorionic gonadotropin (HCG) or invasive procedure such as amniocentesis, Chorionic villus sampling and Percutaneous umbilical blood sampling (PUBS) are used to detect the birth defects.
Types of Fetal Surgery
Depending on the incision level, fetal surgery is classified into three types.
Open Fetal Surgery
Open fetal surgery is almost similar to cesarean section and involves a total opening of the uterus. In this type of surgery, a long incision is made in the mother's abdomen and then on the uterus to reach the fetes. Once the surgical correction is performed on the fetus to treat the birth defect, the uterus and abdominal is closed back leaving the fetus intact. Open fetal surgery is performed under general anesthesia. Surgery is performed using special instruments containing staples to prevent bleeding from uterus. During the operation, warm saline water is infused to maintain the position of placenta and umbilical cord and surgeon will keep a vigil on the pulse and heart rate of the baby with the help of the oximeter. After the surgery, the mother is hospitalized for close to a week to facilitate close monitoring. One should remember that, with open fetal surgery, mother will forgo the option of vaginal delivery for the present and future deliveries. She can deliver the baby only through C-section. She may be given some medication to avoid pre term labor. Open fetal surgery is followed for the conditions like chest mass, neck mass, spinbifida, myelomeningocele and Sacrococcygeal teratoma (SCT) (a tumor at the base of the child's tail bone).
There is one more variation to the open fetal surgery called the EXIT (Ex Utero Intrapartum Treatment) Procedure. EXIT surgery is performed at the end of the full term and just before the delivery. In this method the baby is partially delivered by bringing out only a part of the fetes from uterus and keeping rest of the fetes attached to placenta and umbilical cord to allow blood circulation. Once the defect is rectified, the baby is delivered fully. Exit procedure is essentially followed to correct the airway blockage in the baby.
Fetoscopic surgery is minimally invasive and unlike open fetal surgery, fetes remains inside the uterus while operating. Surgeon uses special instruments such as laser and makes a small incision with the help of the fetoscope to correct the birth defects. Fetoscopic surgery has shown high success rate in conditions such as Twin-Twin Transfusion Syndrome (TTTS), Twin Reversed Arterial Perfusion (TRAP), Amniotic band syndrome, and Tracheal occlusion for CDH. Fetoscopic surgery does not pose a risk of pre term labor and also eliminates most of the risks associated with open fetal surgery. This is essentially why fetoscopic surgery is the preferred choice, yet one should note that few complicated birth defects can be corrected only through open fetal surgery.
Fetal image guided surgery
Fetal image guided surgery is the least invasive of all wherein surgery is performed with the guidance of images of fetus produced on the external screen by ultrasound. Very thin instruments are inserted through a small opening in the abdomen and the correction is made without any endoscopic view and the whole procedure is guided by the sonogram images.
Various congenital conditions treated through fetal intervention
Congenital diaphragmatic hernia (CDH): Congenital diaphragmatic hernia (CDH) refers to the opening in the diaphragm through which the contents of the abdomen enter the chest cavity leaving no space for the lungs to develop properly. This is a serious condition and may lead to respiratory failure after birth. This condition, depending upon its severity, is treated through fetal intervention.
Spina bifida: Spina bifida refers to a condition wherein spinal column of the baby does not close properly around the spinal cord and the nerves start to protrude through the opening. Spina bifida can range from mild to severe form, and the severe cases lead to serious neurological problems after the birth. Only the severe form of spina bifida like Meningocele and Myelomeningocele call for fetal intervention through open fetal surgery.
Neck masses: Neck masses are the tumors of the neck that may obstruct the airway and esophagus of the child and also increase the level of amniotic fluid surrounding the baby. Typically, tumors of any kind are treated after birth. In rare cases they grow very large and may even cause heart failure. In such cases fetal intervention becomes necessary to remove the tumors.
Lung lesions: Lung lesions refer to the abnormal growth of lung tissue and these lesions can be cystic (fluid filled) or solid. There are various types of lung lesions and treatment depends upon their size and location. During pregnancy, continuous monitoring is necessary to keep vigil on the size of the lesion. Most often lung lesions shrink and make way for normal development. Lesions of smaller and moderate size are best treated after delivery. But if the size of the lung tumor is abnormally huge and poses a risk of hydrops (excess accumulation of fluid in the fetus) fetal intervention is initiated. Cystic lesions are normally removed through needle aspiration under the constant guidance of ultrasound images, but solid lesions require more elaborate procedure such as EXIT.
Congenital heart diseases: Not all congenital heart defects call for fetal intervention. Sometimes the septum (wall separating the right and left side of the heart) of the heart develops a hole while in the womb. However septum defects are typically treated after the birth of the child and rarely require fetal surgery. But if the heart develops severe obstructive cardiac disorders such as aortic stenosis, pulmonary stenosis and coarctation of the aorta,a fetal image-guided procedure may be necessary to open or enlarge the narrowed valve. This procedure involves placing a balloon catheter by inserting it through the uterus and into the fetal’s heart.
Amniotic Band Syndrome: This is a condition where fetus is entrapped in fibrous amniotic bands in the womb, restricting blood flow to the affected portion of the fetes. It normally affects legs, arms, toes and fingers. In utero surgery may be performed to rectify the condition if there is risk of amputation of the limb after the birth.
Twin-to-twin transfusion syndrome (TTTS): TTTS is a condition that occurs in identical twins wherein unbalanced exchange of blood takes place between the twins. One receives higher amount of blood whereas the other receives less amount. The fetus with less blood supply may become anemic and the one with excess blood supply may suffer heart failure due to excess fluid. Fetal surgery through laser fetal intervention is the preferred option to correct the condition. This procedure involves inserting a laser along with small telescope into the uterus and separating the blood vessels on the placenta that are connected to both twins.
Congenital high airway obstruction syndrome (CHAOS): Congenital high airway obstruction syndrome (CHAOS) refers to the blocking of fetal airway resulting in enlarged lungs, windpipe and bronchial tube. A complete or near to complete blockage may lead to a heart failure. Though congenital high airway obstruction syndrome (CHAOS) is treated after birth, in severe cases where fetes is at high risk such as hydrops, fetal surgery is performed.
Certain skin conditions like Multiple Myeloma (a type of Cancer due to abnormal plasma cells), Hansen's disease (Leprosy) can be treated or the symptoms mitigated using thalidomide. It reduces redness and inflammation in Hansen's disease. It reduces the formation of blood vessels that feed tumors and thus is used extensively in cancer treatment. Thalidomide is an immunomodulatory agent. It works on the immune system to decrease certain substances that cause skin inflammation. Thalidomide is also prescribed for treatment of Sarcoidosis, HIV and Crohn's disease.
Thalidomide as a drug was primarily developed and used as a sedative to treat insomnia, anxiety and tension. The drug is also known as Asmaval, Valgis, Tensival, Distaval Forte and Valgraine. The drug that was popular as a wonder drug was banned in the early 1960s as it was found to cause deformity in children born to mothers who consumed this drug. Thalidomide caused severe to life threatening birth defects when either the father or mother consumed it during the time of fetal conception. Studies prove that this drug did cause birth defects in body parts like the eyes, face, heart, legs, bones and ears. Thalidomide blocked the formation of blood vessels thereby limiting blood flow and creating limbless babies.
In the 1970s thalidomide was used to treat leprosy. Later it was used as an anti-angiogenic - to stop the formation of new blood vessels. The same property of the drug which caused birth defects actually played a vital role in shrinking tumors. Thalidomide is used to treat cancer as it:
This medication should be taken orally. It is usually taken at bedtime, an hour after taking a meal. Handle the capsules with care; do not take them out of the blister pack if not being used immediately. Do not break the capsule. In case of skin contact with the powder, wash the area with soap and water. Hands should be washed thoroughly after handling the drug.
Pregnant women should not consume this drug. Doctors provide dosage based on the prevailing conditions, dosage should not be increased or decreased by the patient. Increase in dosage can cause serious side effects. Do not donate blood or sperm while on this drug. Avoid sexual contact while on this drug as the semen carries the drug in it. To get the maximum benefit of this drug, it has to be used regularly and should not be stopped suddenly. Stopping intake of the drug suddenly may worsen the condition.
While on this drug, make sure that your blood does not come in contact with any other person's blood. Thalidomide can make a person feel sleepy; hence alcohol should not be consumed while on this drug.
Thalidomide side effects
Side effects may vary from person to person. Common side effects include dizziness, chest pain, risk of blood clots, general weakness, racing heartbeat, dry skin, seizures and muscle cramps. Nerve damage may cause permanent damage in a few cases. Rare side effects include blood in urine, low blood pressure, reduced urination and fever without rash.
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Bibliography / Reference
Collection of Pages - Last revised Date: February 21, 2020