Consultation and preoperative planning
Because CMN is such a rare condition, Bauer’s patients are not clustered in and around Chicago, but are likely to come from afar. For this reason, he and his team depend heavily on the Internet for everything from the initial consultation to the vigilant monitoring of their patients’ progress, once they go home.
Initial consultations, for example, typically start online. Bauer has a set of what he calls his Tissue Expander Bites, which are short PowerPoint presentations with many dozens of photos that he sends to parents.
One set covers the basics of tissue expansion. Another set covers cases similar to the prospective patient, demonstrating what the expanders look like and how the reconstruction is planned, along with before and after photos of children who have had this surgery.
“At this stage, there is virtually no nevus pattern that I have not seen and do not at least have some examples of,” he says.
After parents have a chance to review the presentations, he often chats with them one-on-one by phone or Skype, if they wish, to answer any final questions. If he is traveling in close proximity to potential patients, he may meet with families closer to their homes, if that is of help. He may not meet with many of these patients and their parents until the day or two before surgery, unless the complexity of the reconstruction is such that a face-to-face meeting is necessary well before the surgery date.
While each case is unique and no single technique will work in all cases, Bauer finds that there are remarkably repeatable patterns of nevus involvement among children. Because of that repetition, comes the ability to work out standardized treatment plans for removing nevi in each body region.
That said, some nevi are more complex and require more complex planning. It is here, even before surgery, that his skill, confidence, and years of experience begin to pay huge dividends.
“We can put tissue expanders almost anywhere, given the opportunity. It may not be every problem that I can explain our approach immediately, though. Sometimes I say, I think this is what we may do, but I’m going to take pictures and I’ll get back in touch with you.”
One key question Bauer needs to answer is where is the supply of blood coming from? “All over the body there are territories with different blood supplies. Any particular area of skin, where you are going to raise a flap of tissue, has to be oriented a particular way to have a blood supply and there are all kinds of ways of doing that. With some reconstructions, you can get so distant from where the main blood supply is coming in that you start running into issues. That area may take more time to heal. But that’s all part of understanding what flaps do — and understanding what you can do and cannot do.”
Other considerations include color match, skin texture, contour of the recipient site, and hair direction for scalp expansion to maximize the aesthetics and functional outcome of surgery.
“Parents want someone to take charge and say, ‘This is our plan. This is how we should approach this,’” Bauer says. “Most of the time we can do that.”