David A. Billmire

Tissue Expanders in the Lower Face and Anterior Neck in Pediatric Burn Patients: Limitations and Pitfalls

Radovans 1982 landmark work on the clinical use of tissue expanders was felt to be a panacea for multiple reconstructive problems. We have used and probably overused tissue expanders for reconstruction of many complicated pediatric facial burn problems. This has enlightened us to some of the limitations of their use, and we have, therefore, reassessed our indications for their use. From 1984 through 1990, 52 tissue expanders were used in 37 pediatric patients for face and anterior neck burn scar resurfacing. This experience, combined with the unique problems encountered with face and neck tissue expansion, provided the groundwork for operative guidelines. The long-term effects of gravity, growth, and scarring on facial features adjacent to expanded skin led to the following principles. (1) Caution should be used in advancing expanded neck skin beyond the border of the mandible. The risk of scar widening or possible lip or eyelid ectropion needs to be considered when planning these flaps. Extreme overexpansion is necessary to advance unburned neck flaps over the mandibular border to avoid these problems. (2) After advancement or rotational flaps neck flaps to the face, vertically directed suture lines in the neck may need redirection to prevent linear contracture. This correction may be performed during the primary operation or during revisions. (3) Expanded cheek or neck skin should preferably replace burned areas, but at the same time, not violate unburned facial aesthetic units. (4) To counteract the affects of gravity, expanded cheek skin in conjunction with expanded neck skin, if unburned, may be the best choice for face or mandibular border scar replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

Complications of Controlled Tissue Expansion in the Pediatric Burn Patient

All patients at the Burn Institute reconstructed with tissue expanders between June of 1984 and June of 1987 were included in this review. There were 122 expanders used in 77 patients. Complications were defined as “absolute” (23 of 122 expanders, 20 percent) if they resulted in loss of expanders or additional surgery or none of preoperative plan was satisfied or “relative” (14 of 122 expanders, 11 percent) if they included spotty alopecia or alopecia greater than 50 percent or the operative plan only partially satisfied, reflecting poor judgment. The most common absolute complication was prosthetic exposure secondary to wound dehiscence occurring in the scalp area. Complications relative to specific anatomic areas were neck and face, 2 of 20 (10 percent); lower extremity, 1 of 4 (25 percent); trunk, 0 of 6 (0 percent); and scalp, 20 of 92 (22 percent). We feel that this high complication rate in the use of tissue expanders may be unique to the pediatric burn patient. Knowledge of indications for use and potential complications is essential to add this entity to the armamentarium of the burn reconstructive surgeon.

Current Practice in Assessing and Reporting Speech Outcomes of Cleft Palate and Velopharyngeal Surgery: A Survey of Cleft Palate/Craniofacial Professionals

Objective To determine methods by which professionals serving cleft palate/craniofacial teams are evaluating velopharyngeal function and to ascertain what they consider as a successful speech outcome of surgery. Design A 12-question survey was developed for professionals involved in management of velopharyngeal dysfunction. Participants The survey was distributed through E-mail lists for the American Cleft Palate–Craniofacial Association and Division 5 of the American Speech-Language-Hearing Association. Only speech-language pathologists and surgeons were asked to complete the survey. A total of 126 questionnaires were completed online. Results Standard speech evaluations include perceptual evaluation (99.2%), intraoral examination (96.8%), nasopharyngoscopy (59.3%), nasometry (28.9%), videofluoroscopy (19.2%), and aerodynamic measures (4.3%). Significant variation existed in the types and levels of perceptual rating scales. Pharyngeal flap (52.9%) is the most commonly performed procedure for velopharyngeal insufficiency, followed by sphincter pharyngoplasty (27.5%). Criteria for surgical success included normal speech (50.8%), acceptable speech (27.9%), and “improved” speech (8%). However, most respondents felt that success should be defined as normal speech (71.2%). Most respondents believed that surgical success should be determined by the team speech-language pathologist (81.5%); although, some felt success should be determined by the patient/family (17.7%). Conclusion This survey shows considerable variability in the methods for evaluating and reporting speech outcomes following surgery. There is inconsistency in what is considered a successful surgical outcome, making comparison studies impossible. Most respondents thought that success should be defined as normal speech, but this is not happening in current practice.

Hypertrophic tonsils : the effect on resonance and velopharyngeal closure

This paper presents a case of altered resonance secondary to hypertrophic tonsils. Through nasopharyngoscopy, the tonsils were found to be in the nasopharynx and interposed between the velum and posterior pharyngeal wall. This resulted in incomplete velopharyngeal closure and evidence of hypernasality. This large mass was also felt to obstruct sound transmission into both the oral and nasal cavities, causing a mixture of hyponasality and cul-de-sac resonance. Tonsillectomy resulted in an elimination of all of these characteristics. Resonance was judged to be normal on the postoperative assessment.

Management of pediatric burns.

It is estimated that in the United States there are 2.0 million burn injuries every year. There are 30,000 inpatient admissions and between 1,000 and 5,000 deaths per year related to burns in children. Along with the elderly, children suffer the highest rates of morbidity and mortality from thermal injuries. Achieving good clinical outcomes requires early, accurate diagnosis and aggressive treatment. Once acute burn injuries have evolved into fixed deformities they can be next to impossible to treat, leading to life-long limitations in form and function. Rehabilitation is a critical factor in achieving an acceptable functional and cosmetic outcome for both adult and pediatric burn patients. Without a rigorous and well-orchestrated rehabilitation program, the treatment of a burn is not complete. The management of burn injuries also frequently involves reconstructive surgical intervention. Acute or sub-acute reconstruction is aimed at restoring lost anatomic structures such as the eyelids and nose. In general, scars lead to surgical evaluation because of either functional loss or cosmesis. This paper discusses our experience and procedures for managing burns in the paediatric population. As a general rule, if wounds have failed to heal within 5 to 7 days, the patient should be referred to a surgeon familiar with paediatric burn injuries.

Testicular Autotransplantation: A 17-Year Review of an Effective Approach to the Management of the Intra-Abdominal Testis

PURPOSE Patients with intra-abdominal testes represent a small but challenging group who require innovative therapy. We report our 17-year experience with testicular autotransplantation. MATERIALS AND METHODS Testicular autotransplantation was performed in 23 patients with 27 intra-abdominal testes. RESULTS The success rate was 96% and average operative time was 4.25 hours with 40 to 90 minutes for vascular anastomoses. A contralateral Fowler-Stephens procedure had previously failed in 3 cases. CONCLUSIONS Since the variability of collateral blood supply in patients with high undescended testes may potentially compromise the Fowler-Stephens procedure, we believe that testicular autotransplantation should be strongly considered in such patients, particularly those with bilateral undescended testicles.

Total eyelid reconstruction with free dorsalis pedis flap after deep facial burn.

A case of severe facial and corneal burns with complete loss of upper and lower eyelids is reported together with the acute management and surgical options for total eyelid defects secondary to thermal injury. An acutely burned man with 78 percent total burn surface area presented with complete exposure of the left cornea. Because of the severe thermal injury, no facial tissues were available as donor sources for reconstructing the eyelid. A free dorsalis pedis flap was used to cover the exposed cornea after bilateral conjunctival advancement flaps, with septal cartilage graft for structural support. A conjunctivodacryocystorhinostomy was performed at the time of the coverage. The patient was unable to perform an exact visual acuity test; however, his gross vision was intact.

Neonatal kyphectomy in the patient with myelomeningocele.

Study Design. A retrospective cohort study was used to investigate a group of neonates with myelomeningocele who had a kyphectomy performed in conjunction with dural sac closure during the first few days of life. Objectives. To assess the effectiveness of operative intervention in the neonatal period to correct the kyphotic deformity in the patient with myelomeningocele and to monitor its long-term results. Summary of Background Data. Orthopedic management originally focused on the immediate treatment of the kyphotic deformity in the infant with myelomeningocele. However, there has been a movement toward postponing surgical treatment of the kyphos until a later age. This study included the longest follow-up of the largest group of neonates that a single surgeon has managed surgically since the treatment of this condition was originally described. Methods. The radiographic and clinical results for all neonates treated with a kyphectomy at the time of myelomeningocele closure between 1980 and 2000 were analyzed. Results. Neonatal kyphectomy was performed on nine males and two females. The average preoperative kyphotic angle measured 67°. The average initial correction was 77°, and the average loss of correction at follow-up assessment was 55°. There were no serious complications, and wound closure was successful in all patients. One patient required a repeat kyphectomy and posterior spinal fusion at the age of 9 years and 2 months. The average follow-up period was 7 years and 4 months (range 44–174 months). Conclusions. Kyphectomy performed at the time of dural sac closure in the neonate is a safe procedure with excellent initial correction. Eventual recurrence is expected despite the procedure. However, it occurs in the form of a longer, more rounded deformity that is less technically demanding.

Outcomes of Mandibular Distraction Osteogenesis in the Treatment of Severe Micrognathia

IMPORTANCE Patients with severe micrognathia are predisposed to airway obstruction. Mandibular distraction osteogenesis (MDO) is an alternative to tracheotomy that lengthens the mandible in order to improve the retrolingual airway. This study presents outcomes from one of the largest cohorts reported. OBJECTIVE To assess the rate and predictors of surgical success and complications among (1) patients who underwent MDO prior to other airway procedures (MDO first), and (2) patients who required an initial tracheotomy and were subsequently treated with MDO (tracheotomy first). DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study at a tertiary care pediatric medical center of patients diagnosed as having micrognathia resulting in symptomatic airway obstruction (Pierre Robin sequence) and who underwent MDO from September 1995 to December 2009. INTERVENTIONS Electronic medical records were reviewed. Multivariable regression analysis was used to assess for predictors of outcome. MAIN OUTCOMES AND MEASURES Rates of surgical success (defined as either tracheotomy avoidance or decannulation) and complications. Potential predictors included demographics, syndrome presence, follow-up time, and surgical history. RESULTS A total of 123 patients (61 in MDO-first subgroup, 62 in tracheotomy-first subgroup) underwent MDO during the study period. Median age at time of distraction was 21 months (range, 7 days-24 years). Surgical success and complication rates were 83.6% and 14.8% in the MDO-first subgroup and 67.7% and 38.7% in the tracheotomy-first subgroup. Tracheotomy-first patients were more likely to have a syndromic diagnosis (66.0% vs 43.0%; P = .009) and were older at the time of MDO (median age, 30 months vs 5.1 months; P < .001). Poorer odds of success were associated with the need for 2 or more other airway procedures (odds ratio [OR], 0.14 [95% CI, 0.02-0.82]) in the MDO-first subgroup and craniofacial microsomia or Goldenhar syndrome (OR, 0.07 [95% CI, 0.009-0.52]) in the tracheotomy-first subgroup. CONCLUSIONS AND RELEVANCE Mandibular distraction osteogenesis has a high rate of success in avoiding tracheotomy. Patients who required a tracheotomy before MDO had a lower success rate in achieving decannulation and a higher rate of complications. However, these patients also had a higher rate of syndromic diagnoses and associated comorbidities. Patients with Goldenhar syndrome have a decreased likelihood of surgical success.

SKIN RESURFACING FOR THE BURNED PATIENT

It has been estimated that 2 million people per year have burns requiring medical attention in the United States. The available and expert clinicians in dedicated burn centers around the country have cared successfully for these patients and given them a second chance at a functional life. It still behooves current-day plastic surgeons to be knowledgeable and adept in their care, not only because they may be called upon at times to manage some of the smaller acute burns, but also because many of the general principles of burn reconstruction and wound management are relevant to other areas of general plastic surgery. Acute burns should be dealt with like any other major trauma with the ABCs of aggressive resuscitation and airway management. Like any other wound, debridement and nutrition are important (i.e., early escharectomy of the burn wound and enteral nutrition during the hypermetabolic state). Early coverage of the open wound is essential to limit bacterial colonization and prevent infection and to reduce fluid and electrolyte and heat loss. If autografts are not available immediately, temporary coverage with one of the above-mentioned barrier materials should be used. Still, autografts, when available, should be the burn surgeons first choice. Donor sites may be reharvested to provide more autograft than was anticipated with large-percentage TBSA burns. Physicians should keep in mind the advantages (and disadvantages) of using the scalp and back. As far as research and technological advances in the area of plastic surgery, burn surgery may be the most progressive, with the evolution of biologic tissue-engineered skin substitutes and the research of growth factors in healing. Further improvements in tissue engineering and technology should result in even more effective skin substitutes and hence better functional and aesthetic outcomes with economic efficiency in large burns.