What is Reconstructive Surgery?
We bring back, refashion and restore to wholeness the features that nature gave but chance destroyed, not that they may be an advantage to the living soul, not as a mean artifice but as an alleviation of illness, not as becomes charlatans but as becomes good physicians and followers of the great Hippocrates. For though the original beauty is indeed restored . . . the end for which the physician is working is that the features should fulfill their offices according to nature's decree.
Gaspare Tagliacozzi, 1597
What is reconstructive surgery?
It's estimated that more that one million reconstructive procedures are performed by plastic surgeons every year. Reconstructive surgery helps patients of all ages and types - whether it's a child with a birth defect, a young adult injured in an accident, or an older adult with a problem caused by aging.
The goals of reconstructive surgery differ from those of cosmetic surgery. Reconstructive surgery is performed on abnormal structures of the body, caused by birth defects, developmental abnormalities, trauma or injury, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.
Cosmetic surgery is performed to reshape normal structures of the body to improve the patient's appearance and self-esteem.
Although no amount of surgery can achieve "perfection," modern treatment options allow plastic surgeons to achieve improvements in form and function thought to be impossible 10 years ago.
This will give you a basic understanding of some commonly-used techniques in reconstructive surgery. It won't answer all of your questions, since each problem is unique and a great deal depends on your individual circumstances. Please be sure to ask your doctor to explain anything you don't understand. Also, ask for information that specifically details the procedure you are considering for yourself or your child.
WHO HAS RECONSTRUCTIVE SURGERY?
There are two basic categories of patients: those who have congenital deformities, otherwise known as birth defects, and those with developmental deformities, acquired as a result of accident, infection, disease, or in some cases, aging.
Some common examples of congenital abnormalities are birthmarks; cleft-lip and palate deformities; hand deformities such as syndactyly (webbed fingers), or extra or absent fingers; and abnormal breast development.
Burn wounds, lacerations, growths, and aging problems are considered acquired deformities. In some cases, patients may find that a procedure commonly thought to be aesthetic in nature may be performed to achieve a reconstructive goal. For example, some older adults with redundant or drooping eyelid skin blocking their field of vision might have eyelid surgery. Or an adult whose face has an asymmetrical look because of paralysis might have a balancing facelift. Although appearance is enhanced, the main goal of the surgery is to restore function.
Large, sagging breasts are one example of a deformity that develops as a result of genetics, hormonal changes, or disease. Breast reduction, or reduction mammaplasty, is the reconstructive procedure designed to give a woman smaller, more comfortable breasts in proportion with the rest of her body.
In another case, a young child might have reconstructive otoplasty (outer-ear surgery) to correct overly-large or deformed ears. Usually, health insurance policies will consider the cost of reconstructive surgery a covered expense. Check with your carrier to make sure you're covered and to see if there are any limitations on the type of surgery you're planning. Work with your doctor to get pre-authorization from the insurer for the procedure.
ALL SURGERY CARRIES SOME UNCERTAINTY AND RISK
When reconstructive surgery is performed by a qualified plastic surgeon, complications are infrequent and usually minor. However, individuals vary greatly in their anatomy and healing ability and the outcome is never completely predictable.
As with any surgery, complications can occur. These may include infection; excessive bleeding, such as hematomas (pooling of blood beneath the skin); significant bruising and wound-healing difficulties; and problems related to anesthesia and surgery.
There are a number of factors that may increase the risk of complications in healing. In general, a patient is considered to be a higher risk if he or she is a smoker; has a connective-tissue disease; has areas of damaged skin from radiation therapy; has decreased circulation to the surgical area; has HIV or an impaired immune system; or has poor nutrition. If you regularly take aspirin or some other medication that affects blood clotting, it's likely that you'll be asked to stop a week or two before surgery.
PLANNING YOUR SURGERY
In evaluating your condition, a plastic surgeon will be guided by a se t of rules known as the reconstructive ladder. The least-complex types of treatments-such as simple wound closure-are at the lower part of the ladder. Any highly complex procedure-like micro-surgery to reattach severed limbs-would occupy one of the ladder's highest rungs. A plastic surgeon will almost always begin at the bottom of the reconstructive ladder in deciding how to approach a patient's treatment, favoring the most direct, least-complex way of achieving the desired result.
The size, nature and extent of the injury or deformity will determine what treatment option is chosen and how quickly the surgery will be performed. Reconstructive surgery frequently demands complex planning and may require a number of procedures done in stages.
Because it's not always possible to predict how growth will affect outcome, a growing child may have to plan for regular follow-up visits on a long-term basis to allow additional surgery as the child matures.
Everyone heals at a different rate-and plastic surgeons cannot pinpoint an exact "back-to-normal" date following surgery. They can, however, give you a general idea of when you can expect to notice improvement.
OPTIONS IN WOUND TREATMENT
In deciding how to treat a wound, a plastic surgeon must carefully assess its size, severity, and features: Is skin missing? Have nerves or muscles been damaged? Has skeletal support been affected?
As you and your plastic surgeon form your surgical plan, it's important to have a clear understanding of what will happen during the procedure. Asking questions is key to making an informed decision.
Direct closure is usually performed on skin-surface wounds that have straight edges, such as a simple cut. Maximum attention is given to the aesthetic result, taking extra care to minimize noticeable stitch marks.
SKIN GRAFTS
A wound that is wide and difficult or impossible to close directly may be treated with a skin graft. A skin graft is basically a patch of healthy skin that is taken from one area of the body, called the "donor site," and used to cover another area where skin is missing or damaged. There are three basic types of skin grafts.
A split-thickness skin graft, commonly used to treat burn wounds, uses only the layers of skin closest to the surface. When possible, your plastic surgeon will choose a less conspicuous donor site. Location will be determined in part by the size and color of the skin patch needed. The skin will grow back at the donor site, however, it may be a bit lighter in color.
A full-thickness skin graft might be used to treat a burn wound that is deep and large, or to cover jointed areas where maximum skin elasticity and movement are needed. As its name implies, the surgeon lifts a full-thickness (all layers) section of skin from the donor site. A thin line scar usually results from a direct wound closure at the donor site.
A composite graft is used when the wound to be covered needs more underlying support, as with skin cancer on the nose. A composite graft requires lifting all the layers of skin, fat, and sometimes the underlying cartilage from the donor site. A straight-line scar will remain at the site where the graft was taken. It will fade with time.
TISSUE EXPANSION
Tissue expansion is a procedure that enables the body to "grow" extra skin by stretching adjacent tissue. A balloon-like device called an expander is inserted under the skin near the area to be repaired and then gradually filled with salt water over time, causing the skin to stretch and grow. The time involved in tissue expansion depends on the individual case and the size of the area to be repaired.
The advantages of tissue expansion are many-it offers a near-perfect match of skin color, sensation, and texture; the risk of tissue loss is decreased because the skin remains connected to its original blood and nerve supply; and scars are less apparent than those in flaps or grafts. The expander temporarily creates what can be an unsightly bulge, making this option undesirable for some patients.
ADVANCED WOUND CARE: FLAP SURGERY/MICROSURGERY
Though success will largely depend on the extent of a patient's injury, flap surgery and microsurgery have vastly improved a plastic surgeon's ability to help a severely injured or disfigured patient. Using advanced techniques that often take many hours and may require the use of an operating microscope, plastic surgeons can now replant amputated fingers or transplant large sections of tissue, muscle or bone from one area of the body to another with the original blood supply in tact.
A flap is a section of living tissue that carries its own blood supply and is moved from one area of the body to another. Flap surgery can restore form and function to areas of the body that have lost skin, fat, muscle movement, and/or skeletal support.
A local flap uses a piece of skin and underlying tissue that lie adjacent to the wound. The flap remains attached at one end so that it continues to be nourished by its original blood supply, and is repositioned over the wounded area.
A regional flap uses a section of tissue that is attached by a specific blood vessel. When the flap is lifted, it needs only a very narrow attachment to the original site to receive its nourishing blood supply from the tethered artery and vein.
A musculocutaneous flap, also called a muscle and skin flap, is used when the area to be covered needs more bulk and a more robust blood supply. Musculocutaneous flaps are often used in breast reconstruction to rebuild a breast after mastectomy. This type of flap remains "tethered" to its original blood supply.
In a bone/soft tissue flap, bone, along with the overlying skin, is transferred to the wounded area, carrying its own blood supply.
A microvascular free flap is a section of tissue and skin that is completely detached from its original site and reattached to its new site by hooking up all the tiny blood vessels.
OTHER RECONSTRUCTIVE PROCEDURES
In addition to correcting cuts and other surface wounds, plastic surgeons also regularly treat both cancerous and non-cancerous growths and problems with the supporting structures beneath the skin.
Tumors, both cancerous and benign, vary widely in type, severity and recurrence. The removal method chosen will depend largely on the type of growth, what stage it's in, and its location on the body.
Skin cancers and growths are usually removed by excision and closure, in which the growth is simply removed completely with a scalpel, leaving a small thin scar. If the cancer is large or spreading, major surgery may be necessary, using flaps to reconstruct the affected area.
HAND SURGERY
Whether the defect is congenital or acquired, plastic surgeons can usually restore comfort, mobility, and normal appearance to patients with hand problems. Acquired defects include carpal tunnel and other painful conditions caused by pressure on the nerves (usually at the wrist or elbow); trigger fingers, a condition caused by swelling of a flexor tendon in the hand; ganglion cysts, a benign cystic growth and scar contracture which occurs when a wound or burn on the hand heals poorly and forms scar tissue that curls the fingers or restricts mobility. Dupuytren's disease causes a similar problem of hand contracture.
Children born with syndactyly (webbed fingers) can benefit from finger separation, where a zig-zag-type incision separates the fingers and rearranges the tissue between them, preventing growth deformities. If a child had polydactyly (extra fingers), correction is often more than simply removing the extra digits. The surgeon may also need to balance the tendons of the hand and stabilize the remaining finger joints so that the hand functions as normally as possible. Plastic surgeons also reconstruct missing digits, including the thumb, which supplies half of the hand's function.
IF YOU'RE CONSIDERING LASER SURGERY...
In the past decade, laser technology has revolutionized many areas of plastic surgery. The laser's allure comes from its ability to "blast" away or diminish imperfections or growths with a minimum of bleeding, bruising, and scarring.
Currently, there are many types of lasers available, with many more under development. Therefore, it's important to understand that not all lasers are alike.
If you're planning to have laser surgery, it's best to find a doctor who is well experienced with, and has access to, a variety of lasers.
The yellow pulsed-dye laser uses a type of dye as its active medium. It has a pulsing beam that is heavily absorbed by hemoglobin, which gives blood its red color. This laser is often used for performing surgery on children who have pinkish birthmarks called port-wine stains. The laser destroys the abnormal blood vessels, lightening the birthmark to the point of being barely noticeable. Scarring, which was a problem with earlier laser models, is minimal with the yellow pulsed-dye laser.
The "pigment-blasting" laser family-the Q-switch ruby, the Q-switch YAG, and the alexandrite is a new group of lasers effective in eliminating the black and blue pigments of tattoos, pigmented lesions and the brown patches and spots that often occur with aging. Though the removal of decorative tattoos is considered a cosmetic procedure, the removal of "traumatic tattoos" is a reconstructive process. Traumatic tattoos occur when material particles are forced under the skin through an accident-as in an explosion or a collision.
The carbon dioxide laser, sometimes called the "workhorse" of lasers, is an invisible light absorbed by water, the primary component of human skin. When the beam is focused, it can cut tissue and seal blood vessels simultaneously. When defocused, it vaporizes. These characteristics make it the treatment of choice for removing warts and many types of skin growths.
The YAG laser has been shown to be effective in the surgery of various types of hemangiomas, which are skin growths with heavy concentrations of blood vessels. It delivers highly-focused energy and-unlike other lasers-its tip can be placed directly on the skin, mimicking a scalpel.
The argon laser is similar to the yellow pulsed-dye laser. The argon laser emits a blue-green light that is absorbed heavily by the color red. It is particularly effective in treating abnormalities that have a proliferation of blood vessels, such as blood blisters, "spider" blood vessels on the face, "strawberry" birthmarks, hemangiomas, and bulky vascular tumors.
The copper vapor laser is a newer type of laser that emits a yellowish light. Its uses include treating brown or red pigmented areas.
The number of laser treatments you'll need depends largely upon the size and severity of the defect. A child with a large birthmark may need six to ten laser treatments to achieve satisfactory results. Only one treatment may be needed to remove some small spider veins on the face.
Lasers have a number of valuable uses, but a laser should not be viewed as a "magic wand" that improves the results of any type of surgery. For traditional kinds of surgery and most plastic surgery, the scalpel is still the proven instrument of choice.
Gaspare Tagliacozzi, 1597
What is reconstructive surgery?
It's estimated that more that one million reconstructive procedures are performed by plastic surgeons every year. Reconstructive surgery helps patients of all ages and types - whether it's a child with a birth defect, a young adult injured in an accident, or an older adult with a problem caused by aging.
The goals of reconstructive surgery differ from those of cosmetic surgery. Reconstructive surgery is performed on abnormal structures of the body, caused by birth defects, developmental abnormalities, trauma or injury, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.
Cosmetic surgery is performed to reshape normal structures of the body to improve the patient's appearance and self-esteem.
Although no amount of surgery can achieve "perfection," modern treatment options allow plastic surgeons to achieve improvements in form and function thought to be impossible 10 years ago.
This will give you a basic understanding of some commonly-used techniques in reconstructive surgery. It won't answer all of your questions, since each problem is unique and a great deal depends on your individual circumstances. Please be sure to ask your doctor to explain anything you don't understand. Also, ask for information that specifically details the procedure you are considering for yourself or your child.
WHO HAS RECONSTRUCTIVE SURGERY?
There are two basic categories of patients: those who have congenital deformities, otherwise known as birth defects, and those with developmental deformities, acquired as a result of accident, infection, disease, or in some cases, aging.
Some common examples of congenital abnormalities are birthmarks; cleft-lip and palate deformities; hand deformities such as syndactyly (webbed fingers), or extra or absent fingers; and abnormal breast development.
Burn wounds, lacerations, growths, and aging problems are considered acquired deformities. In some cases, patients may find that a procedure commonly thought to be aesthetic in nature may be performed to achieve a reconstructive goal. For example, some older adults with redundant or drooping eyelid skin blocking their field of vision might have eyelid surgery. Or an adult whose face has an asymmetrical look because of paralysis might have a balancing facelift. Although appearance is enhanced, the main goal of the surgery is to restore function.
Large, sagging breasts are one example of a deformity that develops as a result of genetics, hormonal changes, or disease. Breast reduction, or reduction mammaplasty, is the reconstructive procedure designed to give a woman smaller, more comfortable breasts in proportion with the rest of her body.
In another case, a young child might have reconstructive otoplasty (outer-ear surgery) to correct overly-large or deformed ears. Usually, health insurance policies will consider the cost of reconstructive surgery a covered expense. Check with your carrier to make sure you're covered and to see if there are any limitations on the type of surgery you're planning. Work with your doctor to get pre-authorization from the insurer for the procedure.
ALL SURGERY CARRIES SOME UNCERTAINTY AND RISK
When reconstructive surgery is performed by a qualified plastic surgeon, complications are infrequent and usually minor. However, individuals vary greatly in their anatomy and healing ability and the outcome is never completely predictable.
As with any surgery, complications can occur. These may include infection; excessive bleeding, such as hematomas (pooling of blood beneath the skin); significant bruising and wound-healing difficulties; and problems related to anesthesia and surgery.
There are a number of factors that may increase the risk of complications in healing. In general, a patient is considered to be a higher risk if he or she is a smoker; has a connective-tissue disease; has areas of damaged skin from radiation therapy; has decreased circulation to the surgical area; has HIV or an impaired immune system; or has poor nutrition. If you regularly take aspirin or some other medication that affects blood clotting, it's likely that you'll be asked to stop a week or two before surgery.
PLANNING YOUR SURGERY
In evaluating your condition, a plastic surgeon will be guided by a se t of rules known as the reconstructive ladder. The least-complex types of treatments-such as simple wound closure-are at the lower part of the ladder. Any highly complex procedure-like micro-surgery to reattach severed limbs-would occupy one of the ladder's highest rungs. A plastic surgeon will almost always begin at the bottom of the reconstructive ladder in deciding how to approach a patient's treatment, favoring the most direct, least-complex way of achieving the desired result.
The size, nature and extent of the injury or deformity will determine what treatment option is chosen and how quickly the surgery will be performed. Reconstructive surgery frequently demands complex planning and may require a number of procedures done in stages.
Because it's not always possible to predict how growth will affect outcome, a growing child may have to plan for regular follow-up visits on a long-term basis to allow additional surgery as the child matures.
Everyone heals at a different rate-and plastic surgeons cannot pinpoint an exact "back-to-normal" date following surgery. They can, however, give you a general idea of when you can expect to notice improvement.
OPTIONS IN WOUND TREATMENT
In deciding how to treat a wound, a plastic surgeon must carefully assess its size, severity, and features: Is skin missing? Have nerves or muscles been damaged? Has skeletal support been affected?
As you and your plastic surgeon form your surgical plan, it's important to have a clear understanding of what will happen during the procedure. Asking questions is key to making an informed decision.
Direct closure is usually performed on skin-surface wounds that have straight edges, such as a simple cut. Maximum attention is given to the aesthetic result, taking extra care to minimize noticeable stitch marks.
SKIN GRAFTS
A wound that is wide and difficult or impossible to close directly may be treated with a skin graft. A skin graft is basically a patch of healthy skin that is taken from one area of the body, called the "donor site," and used to cover another area where skin is missing or damaged. There are three basic types of skin grafts.
A split-thickness skin graft, commonly used to treat burn wounds, uses only the layers of skin closest to the surface. When possible, your plastic surgeon will choose a less conspicuous donor site. Location will be determined in part by the size and color of the skin patch needed. The skin will grow back at the donor site, however, it may be a bit lighter in color.
A full-thickness skin graft might be used to treat a burn wound that is deep and large, or to cover jointed areas where maximum skin elasticity and movement are needed. As its name implies, the surgeon lifts a full-thickness (all layers) section of skin from the donor site. A thin line scar usually results from a direct wound closure at the donor site.
A composite graft is used when the wound to be covered needs more underlying support, as with skin cancer on the nose. A composite graft requires lifting all the layers of skin, fat, and sometimes the underlying cartilage from the donor site. A straight-line scar will remain at the site where the graft was taken. It will fade with time.
TISSUE EXPANSION
Tissue expansion is a procedure that enables the body to "grow" extra skin by stretching adjacent tissue. A balloon-like device called an expander is inserted under the skin near the area to be repaired and then gradually filled with salt water over time, causing the skin to stretch and grow. The time involved in tissue expansion depends on the individual case and the size of the area to be repaired.
The advantages of tissue expansion are many-it offers a near-perfect match of skin color, sensation, and texture; the risk of tissue loss is decreased because the skin remains connected to its original blood and nerve supply; and scars are less apparent than those in flaps or grafts. The expander temporarily creates what can be an unsightly bulge, making this option undesirable for some patients.
ADVANCED WOUND CARE: FLAP SURGERY/MICROSURGERY
Though success will largely depend on the extent of a patient's injury, flap surgery and microsurgery have vastly improved a plastic surgeon's ability to help a severely injured or disfigured patient. Using advanced techniques that often take many hours and may require the use of an operating microscope, plastic surgeons can now replant amputated fingers or transplant large sections of tissue, muscle or bone from one area of the body to another with the original blood supply in tact.
A flap is a section of living tissue that carries its own blood supply and is moved from one area of the body to another. Flap surgery can restore form and function to areas of the body that have lost skin, fat, muscle movement, and/or skeletal support.
A local flap uses a piece of skin and underlying tissue that lie adjacent to the wound. The flap remains attached at one end so that it continues to be nourished by its original blood supply, and is repositioned over the wounded area.
A regional flap uses a section of tissue that is attached by a specific blood vessel. When the flap is lifted, it needs only a very narrow attachment to the original site to receive its nourishing blood supply from the tethered artery and vein.
A musculocutaneous flap, also called a muscle and skin flap, is used when the area to be covered needs more bulk and a more robust blood supply. Musculocutaneous flaps are often used in breast reconstruction to rebuild a breast after mastectomy. This type of flap remains "tethered" to its original blood supply.
In a bone/soft tissue flap, bone, along with the overlying skin, is transferred to the wounded area, carrying its own blood supply.
A microvascular free flap is a section of tissue and skin that is completely detached from its original site and reattached to its new site by hooking up all the tiny blood vessels.
OTHER RECONSTRUCTIVE PROCEDURES
In addition to correcting cuts and other surface wounds, plastic surgeons also regularly treat both cancerous and non-cancerous growths and problems with the supporting structures beneath the skin.
Tumors, both cancerous and benign, vary widely in type, severity and recurrence. The removal method chosen will depend largely on the type of growth, what stage it's in, and its location on the body.
Skin cancers and growths are usually removed by excision and closure, in which the growth is simply removed completely with a scalpel, leaving a small thin scar. If the cancer is large or spreading, major surgery may be necessary, using flaps to reconstruct the affected area.
HAND SURGERY
Whether the defect is congenital or acquired, plastic surgeons can usually restore comfort, mobility, and normal appearance to patients with hand problems. Acquired defects include carpal tunnel and other painful conditions caused by pressure on the nerves (usually at the wrist or elbow); trigger fingers, a condition caused by swelling of a flexor tendon in the hand; ganglion cysts, a benign cystic growth and scar contracture which occurs when a wound or burn on the hand heals poorly and forms scar tissue that curls the fingers or restricts mobility. Dupuytren's disease causes a similar problem of hand contracture.
Children born with syndactyly (webbed fingers) can benefit from finger separation, where a zig-zag-type incision separates the fingers and rearranges the tissue between them, preventing growth deformities. If a child had polydactyly (extra fingers), correction is often more than simply removing the extra digits. The surgeon may also need to balance the tendons of the hand and stabilize the remaining finger joints so that the hand functions as normally as possible. Plastic surgeons also reconstruct missing digits, including the thumb, which supplies half of the hand's function.
IF YOU'RE CONSIDERING LASER SURGERY...
In the past decade, laser technology has revolutionized many areas of plastic surgery. The laser's allure comes from its ability to "blast" away or diminish imperfections or growths with a minimum of bleeding, bruising, and scarring.
Currently, there are many types of lasers available, with many more under development. Therefore, it's important to understand that not all lasers are alike.
If you're planning to have laser surgery, it's best to find a doctor who is well experienced with, and has access to, a variety of lasers.
The yellow pulsed-dye laser uses a type of dye as its active medium. It has a pulsing beam that is heavily absorbed by hemoglobin, which gives blood its red color. This laser is often used for performing surgery on children who have pinkish birthmarks called port-wine stains. The laser destroys the abnormal blood vessels, lightening the birthmark to the point of being barely noticeable. Scarring, which was a problem with earlier laser models, is minimal with the yellow pulsed-dye laser.
The "pigment-blasting" laser family-the Q-switch ruby, the Q-switch YAG, and the alexandrite is a new group of lasers effective in eliminating the black and blue pigments of tattoos, pigmented lesions and the brown patches and spots that often occur with aging. Though the removal of decorative tattoos is considered a cosmetic procedure, the removal of "traumatic tattoos" is a reconstructive process. Traumatic tattoos occur when material particles are forced under the skin through an accident-as in an explosion or a collision.
The carbon dioxide laser, sometimes called the "workhorse" of lasers, is an invisible light absorbed by water, the primary component of human skin. When the beam is focused, it can cut tissue and seal blood vessels simultaneously. When defocused, it vaporizes. These characteristics make it the treatment of choice for removing warts and many types of skin growths.
The YAG laser has been shown to be effective in the surgery of various types of hemangiomas, which are skin growths with heavy concentrations of blood vessels. It delivers highly-focused energy and-unlike other lasers-its tip can be placed directly on the skin, mimicking a scalpel.
The argon laser is similar to the yellow pulsed-dye laser. The argon laser emits a blue-green light that is absorbed heavily by the color red. It is particularly effective in treating abnormalities that have a proliferation of blood vessels, such as blood blisters, "spider" blood vessels on the face, "strawberry" birthmarks, hemangiomas, and bulky vascular tumors.
The copper vapor laser is a newer type of laser that emits a yellowish light. Its uses include treating brown or red pigmented areas.
The number of laser treatments you'll need depends largely upon the size and severity of the defect. A child with a large birthmark may need six to ten laser treatments to achieve satisfactory results. Only one treatment may be needed to remove some small spider veins on the face.
Lasers have a number of valuable uses, but a laser should not be viewed as a "magic wand" that improves the results of any type of surgery. For traditional kinds of surgery and most plastic surgery, the scalpel is still the proven instrument of choice.
posted by Enigma Valdez at 7:35 PM
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