Biomedical subjects

F D Burstein

Publications and source records attributed to F D Burstein.

At least 37 records · Page 2Linked to original sources

PubMed1997

Endoscopic pediatric plastic surgery.

Although the advent of endoscopic technology is expanding the fields of reconstructive and aesthetic surgery in adults, there have been to date no reports of its use in the pediatric population. Because of its minimally invasive nature, yet wide range of exposure, endoscopic techniques have much appeal in this age group. Herein we present our initial experience with endoscopic pediatric plastic surgery. From February 1995 to December 1995, 41 patients were treated utilizing 5-mm and 10-mm endoscopes at Scottish Rite Children's Medical Center, Atlanta, GA. There were 19 males and 22 females. The mean age at surgery was 5.6 years (range, 7 months-15 years). The most common types of procedures performed were insertion of tissue expanders (N = 19), excision of facial dermoids (N = 7), torticollis release (N = 5), and excision of vascular lesions (N = 4). The remaining 6 patients underwent a variety of reconstructive procedures. The complication rate in the tissue expander group was 3 out of 39 expanders inserted (9.5%), and consisted of infection (N = 2) and rupture (N = 1). In the dermoid group, complications consisted of wound infection requiring reoperation (N = 1), and transient frontal paresis (N = 1). One patient in the hemangioma group had an incomplete resection necessitating open excision. The remaining patients all had satisfactory outcomes with no complications. The majority of the procedures were done on an outpatient basis. These results suggest that endoscopic techniques are eminently applicable in the pediatric population, providing the benefits of small and remote incisional wounds with complication rates that are comparable to those of conventional surgical treatment.

Adolescent↗

PubMed1997

Age-related outcomes of sleep apnea surgery in infants and children.

This study was designed to determine whether age at the time of surgery is an important influencing factor on outcomes following surgical correction of severe refractory obstructive sleep apnea (OSA) in infants and children. Data were collected prospectively on 55 children, all with severe OSA refractory to conservative medical and surgical measures, who underwent combinations of soft-tissue and skeletal procedures aimed at relieving their airway obstruction. The study population was subdivided for analysis into three groups based on age at the time of surgery (> 36 months, > 12 to < 36 months, and < or = 12 months). Each child was assessed for clinical outcomes, polysomnography results, and complications. Children in the > 36 months group demonstrated a significant improvement in respiratory disturbance index (RDI), apnea index, and lowest overnight oxygen saturation postoperatively. Only RDI improved significantly in the > 12 to < 36 months group. Although there was a trend toward improvement in the respiratory indices for the children < or = 12 months of age, they had a significantly longer intensive care and hospital stay, a greater mean number of extubation attempts, and the highest surgical failure rate (29%). Other complications such as infection, atelectasis, or temporary postoperative nasopharyngeal tube dependence occurred most frequently in the > 36 months group. Surgical management of severe refractory OSA in children age < or = 12 months is more difficult and less likely to succeed. The reasons for this are discussed and recommendations for management are given.

Adolescent↗

PubMed1997

Down syndrome: identification and surgical management of obstructive sleep apnea.

To date, a paucity of information is available on the optimal management of obstructive sleep apnea in Down syndrome, which may have particularly important implications in this already vulnerable patient population. The objective of this study was to evaluate prospectively the results of a new surgical approach for the treatment of obstructive sleep apnea. Patients with Down syndrome and obstructive sleep apnea underwent preoperative and postoperative polysomnography and clinical and radiologic evaluation to determine prospectively the efficacy of sleep apnea surgery. Statistical testing of apnea index, respiratory disturbance index, and lowest oxygen saturation were compared by means of paired t tests. Seven children (five boys, two girls) from 3 to 12 years of age were subjected to a management protocol that included an aggressive surgical approach to the treatment of obstructive sleep apnea. Clinical symptoms and signs of obstructive sleep apnea, apnea index, respiratory disturbance index, lowest oxygen saturation, and surgical morbidity were the main outcome measures. Surgical treatment consisted of a combination of soft-tissue and skeletal alterations including tongue reduction (n = 6), tongue hyoid advancement (n = 4), uvulopalatopharyngoplasty (n = 7), and maxillary or midface advancement (n = 2). Polysomnography was obtained preoperatively and postoperatively in six patients. One patient was intubated preoperatively. Mean preoperative apnea index and respiratory disturbance index were 34.00 and 52.46 compared with mean postoperative values of 1.62 and 6.46, respectively. Clinically, all patients were improved symptomatically in terms of snoring, noisy breathing, and oxygen requirements. The one patient who had been intubated preoperatively for respiratory failure was extubated successfully but later developed recurrent tricuspid regurgitation and was found to have fixed pulmonary hypertension with cor pulmonale. This patient represented the only treatment failure and underwent tracheostomy. An aggressive surgical approach aimed at correcting all anatomic abnormalities associated with upper airway obstruction was applied successfully to the treatment of obstructive sleep apnea in Down syndrome. We suggest periodic polysomnography in patients with Down syndrome, especially if there is unexplained deterioration in mental capacity or other signs and symptoms of obstructive sleep apnea. Surgical treatment should address both the soft-tissue abnormalities and the skeletal deformities such as midface retrusion. Preoperative cardiac ultrasonography is important to determine the presence of right-sided heart failure, which may be an indication for cardiac catheterization to determine pulmonary venous pressures.

Child↗

PubMed1997

Surgical treatment of obstructive sleep apnea in neurologically compromised patients.

Children with cerebral palsy are at risk of developing obstructive sleep apnea, which is initially managed by medical therapy but often requires tracheostomy for stabilization of the airway. We report preoperative and postoperative polysomnographic findings in a prospective series of 18 patients with cerebral palsy and obstructive sleep apnea who were refractory to medical management and underwent aggressive surgical treatment of upper airway obstruction. Fifteen of the 18 children (83 percent) in whom tracheostomy was recommended were spared the procedure. Eighteen children with cerebral palsy failed medical management of obstructive sleep apnea and were advised to have tracheostomy. There were 9 boys and 9 girls, ranging in age from 9 months to 17 years and 6 months at the time of operation. Tonsillectomy and adenoidectomy was performed in 9 patients, turbinectomy and/or septoplasty in 9, tongue-hyoid advancement in 13, uvulopalatoplasty in 13, conventional mandibular advancement in 2, distraction osteogenesis of the mandible in 2, and tongue reduction in 7. A concomitant Wilkes-Brody procedure for drooling was performed in 6 patients. Preoperative and postoperative polysomnographic data were compared by means of a paired t test. The mean preoperative apnea index, respiratory disturbance index, and lowest oxygen saturation were 3.61, 7.02, and 73.7, respectively. Mean postoperative apnea index, respiratory disturbance index, and lowest oxygen saturation were 0.67, 1.44, and 88.2, respectively. Lowest oxygen saturation and respiratory disturbance index were both improved significantly, with p values of 0.0367 and 0.0021, respectively. Fifteen patients are tracheostomy-free (83 percent) at a mean follow-up time of 30 months (range 14 to 49 months.) Two (11 percent) of the children ultimately required tracheostomy, and one (6 percent) died from respiratory failure following the parents' decision not to proceed with further treatment. Our results confirm the efficacy of an aggressive surgical approach to the treatment of obstructive sleep apnea in neurologically compromised children. Many children and their families may potentially avoid the long-term commitment and cumulative hazards of tracheostomy. Additional strategies that have been adopted include identification and aggressive management of seizures, esophageal reflux, and excessive oral secretions and the application of mandibular distraction and skeletal expansion whenever feasible. Close postoperative monitoring is necessary with reoperation for recurrent symptoms of obstructive sleep apnea if documented by sleep study and associated with evidence of recurrent or residual morphologic abnormalities.

Adenoidectomy↗

PubMed1997

Maxillary-midface distraction in children with cleft lip and palate: a preliminary report.

A miniature system of distraction devices has been employed for maxillary-midface advancement in two children with cleft lip and palate, class III malocclusion, and associated midfacial hypoplasia. The devices are made with commercially available palatal expansion screws linked to rigid fixation plates. A midfacial osteotomy is used, and distraction is begun on the third postoperative day. In the first child, a 7-year-old boy, the midface was distracted 11 mm sagittally and 4 mm inferiorly. In the second patient, a 4 1/2-year-old girl with unilateral cleft lip and palate and midfacial retrusion, an 11-mm distraction was carried out in the vertical and sagittal direction. There were no complications, and none of the devices failed. Maxillary-midfacial distraction osteogenesis to correct severe maxillary-midfacial hypoplasia in children with clefts and other craniofacial disorders permits early intervention with potentially less invasive techniques than are currently available.

Bone Lengthening↗

PubMed1997

A longitudinal, statistical study of reoperation rates in craniosynostosis.

A prospective, statistical study of reoperation rates was done in the treatment of 167 consecutive children with nonsyndromic and syndromic craniosynostosis over a 6-year period at Scottish Rite Children's Medical Center in Atlanta, Georgia. Mean length of follow-up was 2.8 years, with a range of 3 months to 6 years. Reoperation equal to or exceeding the magnitude of the original procedure occurred in 7 percent of cases. Multiple regression analysis revealed several factors associated with reoperation: Females and children with syndromic synostoses were more likely to require reoperation. Total reoperation rates for syndromic and nonsyndromic synostoses were 27.3 and 5.9 percent, respectively. Age at initial surgery, length of operation, and estimated blood loss did not predict a higher reoperation rate.

Child↗

PubMed1997

The use of porous granular hydroxyapatite in secondary orbitocranial reconstruction.

The search for the ideal bone-graft substitute has been the focus of many research and clinical studies. Hydroxyapatite is one such material that combines osseointegration with maintenance of implant volume and excellent durability. We present our experience in 29 patients ranging in age from 3 to 22 years (mean age 10.5 years) who underwent secondary orbitocranial reconstruction of large contour defects utilizing porous granular hydroxyapatite. Follow-up ranges from 6 to 72 months (mean 30 months). Indications for secondary surgery included residual bony contour defects of the frontal bone, temporal areas, and superior orbital rims that were present 12 months or more after initial surgery. There was one infection secondary to a chronic seroma necessitating removal of the porous hydroxyapatite, and one patient required revision for underfilling and another for overfilling. Excellent permanent contour improvement was obtained with a smooth skin surface in the remainder of our patients. The contour corrections have been long lasting, without evidence of porous hydroxyapatite resorption or migration.

Biocompatible Materials↗

PubMed1997

Velopharyngeal incompetence as the presenting symptom of malignant brainstem tumor.

OBJECTIVE: When a patient presents with velopharyngeal incompetence (VPI) without an obvious structural or neurologic cause, the clinician is faced with a diagnostic challenge. We present an 11-year-old male with a long history of VPI who had been referred to our institution for evaluation and treatment. RESULTS: Detailed clinical examination and work-up revealed a malignant brainstem tumor. The presenting symptoms of breathiness associated with VPI had been overlooked by several different clinicians in the past. The patient successfully underwent a sphincter pharyngoplasty. CONCLUSIONS: A careful neurologic examination with special attention to the cranial nerves is necessary to identify subtle neurologic deficits and avoid delay in diagnosis. Differential diagnosis of neurogenic VPI is discussed.

Brain Neoplasms↗

PubMed1997

Secondary management of congenital and acquired craniomaxillofacial deformities. Individualized treatment planning.

Late treatment of craniofacial disorders with concomitant abnormalities of the jaw are the most challenging cases a craniofacial surgeon faces. This article details the principles of preoperative, individualized treatment planning using anthropometric guidelines in a simple but systematic scheme for facial analysis. Seventeen skeletally mature patients without cleft lip and palate or hemifacial microsomia, aged 15 to 65 years, underwent simultaneous orthognathic and craniofacial surgery for a variety of complex craniofacial disorders. The basic clinical approaches outlined in this article permit the surgeon to develop a flexible but accurate treatment plan and proceed with confidence in the management of patients with widespread craniomaxillofacial deformities.

Adolescent↗

PubMed1995

Decision making in primary surgical repair of myelomeningoceles.

A 5-year review of 43 consecutive patients presenting to Scottish Rite Children's Medical Center with an open myelomeningocele defect was undertaken. The aim of the present study was to analyze the myelomeningocele defects, dimensions, and area to better define those factors that dictate the need for plastic surgical consultation for wound closure. Of the 43 patients identified, two were excluded because they first presented as older children; the remaining 41 all had their myelomeningoceles repaired within the first 36 hours of life. Of these, 31 underwent repair by the Neurosurgical Service, whereas for 10 patients (24.4%), the Plastic Surgery Service was asked to assist with closure. Comparison showed the mean (+/- standard deviation) area in the referred patients was 27.4 (7.6) cm2 versus 17.6 (7.9) cm2 in the patients not referred for closure (p = 0.002). A trend analysis predicting referral as a function of myelomeningocele area showed that 0 of 10 (0%) with an area of less than 15 cm2, 2 of 13 (15.4%) with an area equal to 15 to 20 cm2, 3 of 7 (42.9%) with an area of 21 to 25 cm2, and 4 of 9 (44%) with an area greater than 25 cm2 were referred (p = 0.001). Data from the interpretation of maximum myelomeningocele dimension also showed statistically significant trends in referral. Using multiple logistic regression, it was found that the odds of referral increased by a factor of 3.3 for every 1 cm increase in maximum dimension.

Decision Making↗

PubMed1995

Successful use of leeches in the treatment of purpura fulminans.

A case of purpura fulminans secondary to pneumococcal septicemia is presented in an 8-month-old girl. The purpuric lesions on the fingers of both hands, as well as on the lower extremities, were treated by the local application of medicinal leeches. There was nearly complete salvage of the threatened tissues and the baby made a complete recovery. The possible mechanisms by which the leeches may have contributed to the clinical salvage are discussed.

Animals↗

PubMed1995

Distraction osteogenesis of the human craniofacial skeleton: initial experience with new distraction system.

Application of distraction osteogenesis to the human craniofacial skeleton in properly selected cases represents a major advance in the treatment of craniofacial deformities. We report our initial clinical experience with a system of miniature distraction devices that permitted maxillary, orbital, and mandibular distraction in a 4-month-old boy with unilateral craniofacial microsomia and anophthalmia. At 6 months of age, after maxillary repositioning and orbital expansion, a costochondral rib graft was used to construct the missing left mandibular ramus and condyle.

Bone Lengthening↗

PubMed1995

Primary temporal melanoma without diffuse leptomeningeal involvement: a variant of neurocutaneous melanosis.

Plastic surgeons who treat congenital giant nevi should be aware of the neurocutaneous melanosis syndrome and its variants. When neurologic symptoms are present concurrent with MRI evidence of central nervous system involvement, treatment of the cutaneous lesion must be tempered by knowledge of a poor prognosis. In the otherwise asymptomatic patient, the plastic surgeon should consider screening with MRI imaging, realizing that the clinical significance of a positive MRI scan without neurologic symptoms is unknown.

Humans↗

PubMed1995

Surgical therapy for severe refractory sleep apnea in infants and children: application of the airway zone concept.

Obstructive sleep apnea in children may result in hypoxia, right-sided heart failure, and sudden death. Children with craniofacial deformities and/or cerebral palsy are at high risk for the development of obstructive sleep apnea. Prompted by the excellent results obtained in adults when sleep apnea was managed by an aggressive surgical approach, we undertook a similar treatment philosophy in children. Twenty-eight patients representing four diagnostic groups were evaluated and operated on for severe upper airway obstruction: Down syndrome (n = 5), cerebral palsy (n = 12), Goldenhar syndrome (n = 4), and a mixed apnea group (n = 7). Tracheostomy was avoided in 25 of 28 patients (89 percent), with a marked decrease in apnea (median 90 percent) and hypopnea (median 87 percent) episodes. Tongue hyoid suspension and skeletal expansion procedures, which were the mainstay of treatment, were applied for the first time in children and adolescents with obstructive sleep apnea.

Adolescent↗

PubMed1995

Piriform aperture stenosis: a rare cause of neonatal airway obstruction.

Because neonates are obligate nasal breathers, neonatal nasal obstruction may have serious consequences. Prompt diagnosis and appropriate treatment are essential to avoid severe hypoxia. Anterior inlet, piriform aperture stenosis is an extremely rare cause of neonatal nasal airway obstruction and can easily be confused with choanal atresia or stenosis. Computed tomography with direct coronal scans is the best means of establishing a definitive diagnosis. We present our experience with four neonates having nearly complete piriform aperture stenosis. Prompt surgical enlargement of the nasal inlet through an upper buccal sulcus approach is recommended.

Constriction, Pathologic↗

PubMed1995

Turribrachycephaly: a technical note.

We describe a technique for early correction of the so-called towering skull deformity, or turribrachycephaly. The technique makes use of the natural elasticity and plasticity of cranial bone, and it is best applied during the first year of life. Surgery consist of routine exposure of the cranial bone via a coronal incision. The frontal bone flap is elevated and removed. On either side, a bony osteotomy is then made, commencing low down in the temporal region and running posteriorly and superiorly toward the occiput. This approach leaves a superior bone flap, which may be left attached to the occipital bone via a flexible posterior hinge region, or completely detached by continuing the osteotomy across the midline. After the osteotomy, the bone flap is elevated up to the sagittal sinus on either side of the midline. The bone flap is not removed, but pushed down, compressing the brain along the craniocaudal axis. The lateral edge of the flap overlaps the temporal bone, and it can be fixed in the desired position by means of simple positional screws or Vicryl sutures. A standard fronto-orbital advancement is performed prior to lowering the skull vault, which permits the brain to be moved down and forward, filling the dead space in the anterior cranial fossa. The frontal bone flap is then shaped appropriately and fixed by means of plates and screws to the advanced fronto-orbital bar. Posteriorly, the frontal lobe is left "floating." To date, we have performed this technique on 5 patients, and we find it both faster and simpler than other techniques. Short-term results in terms of cranial shape are good. In older infants (> 2 years of age), this technique may not prove useful because of the loss of the loss of plasticity of the bone.

Cephalometry↗

PubMed1994

Tetracycline fluorescence incident photometry: a new technique to quantitate bone formation.

We describe a technique for measuring new bone formation by tetracycline fluorescence incident photometry (TFIP) based on the affinity of tetracycline for newly calcified bone. Unlike traditional fluorescent labeling techniques, which measure appositional bone growth, TFIP measures the total amount of newly labeled bone by quantitating the amount of fluorescent light emitted by tetracycline bound to new bone in response to ultraviolet light excitation. TFIP offers a technically simple and accurate technique for quantitative comparison of new bone formation. It may have broad applications in experimental as well as clinical situation.

Animals↗

PubMed1994

The effect of periosteal preservation on osteogenesis in a canine rib autograft model: tetracycline fluorescence incident photometry.

In the first portion of this study, we describe a new technique, tetracycline fluorescence incident photometry (TFIP) for quantifying new bone formation. In this portion, we use routine histology, Microfil vascular injection, and tetracycline incidence fluorescence (TFIP) to determine the effect of periosteal preservation on bone formation in canine rib autografts. We found that periosteal preservation significantly enhanced new bone formation in both cortical and trabecular bone (83-70% of control) when compared with autografts without the periosteum (76-60% of control) (p < 0.05). In addition, periosteal preservation favorably influenced graft revascularization. We found that the periosteum of the transferred rib autografts was made up of 3 distinct layers: (1) the inner (cambial) layer of osteogenic cells, (2) the middle (fibrous) layer of osteogenic reserve cells, and (3) the outer vascular network of arterioles and venules, which communicate with the trabecular vessels internally. This outer vascular network has not been previously described in transferred bone grafts and is responsible for early graft revascularization.

Animals↗