Biomedical subjects
Publications and source records attributed to J M Pensler.
Effective stabilization of the endotracheal tube is required for safety when performing surgery in the craniomaxillofacial region. We describe a simple technique for rigid stabilization of the airway, which has been used in over 150 patients without complication.
Twenty-three patients aged 3.3 +/- 1.6 years (mean +/- SD) presented between January of 1984 and September of 1987 with fronto-orbital trauma resulting in fractures of one (N = 20) or both (N = 3) orbital roofs. All patients had computed tomography (CT) with axial and coronal sections that revealed three fracture patterns of the orbital roof (nondisplaced, superiorly displaced, and inferiorly displaced fractures). Orbital dystopia was exhibited in 35 percent (N = 8) of the patients. Exophthalmos was noted in 61 percent (N = 14) of the patients. Only 30 percent of the patients (N = 7) sustained associated maxillofacial fractures. Eight percent of fractures exhibited orbital encephaloceles. All patients lacked frontal sinus pneumatization. The majority of children with orbital roof fractures do not exhibit concomitant facial fractures. CT utilizing both axial and coronal sections is valuable in defining the extent and pattern of the fracture as well as in identifying associated neurologic injuries. Large, displaced orbital roof fractures, which occurred in 3 of 13 patients with displaced fractures in our series, should undergo early reduction to avoid late development of encephalocele.
Airway patency following repair for choanal atresia is effectively maintained utilizing Argyle polyethylene chest tubes as stents. Retrograde placement of the tubes from the mouth into the nasal passage is accomplished so that once secured, the largest diameter of the tubes is wedged against the posterior portion of the nasal ostium. This approach limits anterior migration of the tubes, preserving the columella and nasal rims while ensuring maintenance of airway patency following treatment of choanal atresia.
A patient with a repaired upper lip cleft may acquire a deformity in the lower lip. Records of 63 cleft lip patients who exhibited lower-lip abnormalities were analyzed in order to characterize the soft-tissue and skeletal configuration. The typical deformity was a hypertrophied, superiorly displaced, and anteriorly rotated lower lip. Skeletal analysis of the mandible revealed a variable and inconsistent degree of vertical elongation with posterior displacement of the chin. Operative correction of the cleft lip lower-lip deformity required evaluation of both the soft-tissue and skeletal abnormalities. Soft-tissue procedures gave permanent correction, provided there was a normal maxillary-mandibular relationship. Skeletal correction alone did not completely rectify the abnormal lower-lip posture.
Submucous clefts of the palate may present with velopharyngeal incompetence (VPI) or a history of recurrent otitis media. Many surgeons have favored a pharyngeal flap as primary treatment of the velopharyngeal incompetence associated with this disorder. The increasing number of case reports of sleep apnea and airway compromise associated with pharyngeal flaps prompted the use of levator muscle repositioning with palatal lengthening as initial therapy in 15 patients in an attempt to correct the pathologic anatomy while avoiding the postoperative sequelae. Patients were divided into two groups: group A (N = 8) had surgery before age 2 (11.8 +/- 5.7 months), and group B (N = 7) had surgery after 2 years of age (64.3 +/- 24.2 months). No patient in group A required a secondary operative procedure for velopharyngeal incompetence. Normal speech was obtained in 75 percent (N = 6), and slight velopharyngeal incompetence not requiring secondary correction was obtained in 25 percent (N = 2). Group B obtained less dramatic speech results: normal in 14 percent (N = 1), slight velopharyngeal incompetence in 58 percent (N = 4), and no improvement or severe velopharyngeal incompetence requiring a secondary procedure in 28 percent (N = 2). Patients with preoperative otologic disorders (N = 10) obtained significant improvement in 90 percent of cases (p = 0.002). Early surgical intervention in patients with abnormal speech prior to age 2 appears to result in normal speech in the majority of instances. Late repair with levator repositioning and palatal lengthening provided improved speech in 72 percent of patients.
Thirty-two patients with nasal dermal sinuses and cysts were treated during the 10-year period from 1978 to 1987. These patients presented with midline cysts (N = 18) or sinus ostia (N = 14). Only 6 of the 32 patients manifested intracranial extension (19 percent). All the patients with intracranial extension exhibited an intracranial mass on preoperative CT scans. Ten patients with no CT evidence of intracranial mass were noted to have only a fibrous cord extending to the base of the foramen cecum. In 4 of these 10 patients, craniotomy confirmed that there was no intracranial extension of the dermoid. Four other patients presented with sinus ostia at the base of the columella. None of these 4 patients had intracranial extension. Clinical examination and preoperative CT scans provide most of the information needed to determine the nature, course, and extent of these lesions.
The long-term results of full-thickness (N = 11) and split-thickness (N = 14) skin grafts for reconstitution of the palmar surface following release of palmar burn scar contractures in pediatric patients are compared. Patients treated with full-thickness skin grafts required 1.2 +/- 0.4 operations (mean +/- SD). Patients treated with split-thickness skin grafts required 1.3 +/- 0.6 operations (mean +/- SD). No significant difference in the number of operative procedures was noted. No functional difference existed between the two groups. The use of split-thickness skin grafts provided comparable function without increased operative procedures and was less deforming. Increased use of split-thickness skin grafts following release of palmar burn scar contractures in pediatric patients should be considered.
Superomedial repositioning of the superficial musculoaponeurotic system (SMAS) in the upper lip is accomplished by means of intraoral incisions. The procedure reestablishes the convexity of the lateral vermilion border, elevates the upper lip, and restores a more youthful appearance to the upper-lip profile. Depth of the nasolabial folds are reduced. We have performed this procedure on 14 patients. Follow-up intervals range from 6 to 20 months, averaging 14 months. All patients received concomitant rhytidectomy; usual operative time was increased by 20 minutes. Results have been rated good to excellent by patients and surgeons. There have been no recurrences of nasolabial fold deepening or upper lip depression, and there have been no complications. In selected patients, this procedure, along with rhytidectomy, may provide a more youthful appearance.
Reconstructive results of 115 burned nipple-areola complexes in 84 female patients were reviewed. Results of nipple reconstruction using local quadrapod flaps (33 percent good, 45 percent fair, 22 percent poor) and composition grafts from the earlobe (20 percent good, 60 percent fair, 20 percent poor) were comparable, and both were superior to results obtained with the "double-bubble" technique (24 percent good, 35 percent fair, 41 percent poor). Differences in nipple reconstruction techniques were not appreciated until 1 year postoperatively. The early appearance of areola reconstruction with tattooing and split-thickness grafts was excellent. However, significant late hypopigmentation changes were observed with both techniques. Areola reconstruction with full-thickness skin grafts from the superomedial thigh (47 percent good, 33 percent fair, 20 percent poor) were superior to those obtained with tattooing (14 percent good, 35 percent fair, 51 percent poor) and split-thickness skin grafts from the contralateral unburned areola (21 percent good, 21 percent fair, 58 percent poor). We recommend employing local quadrapod flaps (for nipple), provided there is adequate surrounding dermis, and full-thickness skin grafts (for areola) in the reconstruction of the burned breast.
Explore the source record for details and available documents.
Ten cadavers were employed to demonstrate the presence of the SMAS in the upper lip using macroscopic and microscopic techniques. The relationships and attachments of the SMAS to the dermis of the upper lip are described. In cadavers, medial traction on the SMAS in the upper lip in conjunction with superolateral traction on the SMAS in the cheek is found to decrease the depth of the nasolabial fold. Superior traction on the SMAS in the upper lip elevates the interlabial line, reestablishes the convexity of the lateral vermilion border, and partially increases concavity of the profile.
We have reviewed our experience with reconstruction of eyebrow alopecia secondary to thermal injury in the pediatric patient. Reconstruction was performed with free composite strip grafts or vascularized island pedicle flaps. The complication rates for eyebrows reconstructed with vascularized island pedicles with respect to loss of a significant portion of the flaps (30.8 percent) and malalignment of the grafts (23.1 percent) were significantly greater (p less than 0.001) than the significant tissue loss (10.6 percent) or graft malalignment (7.9 percent) observed for free composite grafts. Hair density was more predictably restored with the free composite graft technique (p = 0.0004). The patients reconstructed with composite grafts had 89.4 percent acceptable results in contrast to 38.5 percent acceptable results obtained with the island pedicle technique. Based on these findings, we reserve the use of the vascularized island pedicle technique for male patients with unilateral alopecia and heavy hair density in the remaining eyebrow and in cases where free composite grafts have failed. The remaining patients are initially treated with free composite grafts with acceptable results in the overwhelming majority of cases.
Our experience in pollicization of the index ray for severely burned hands in children is reviewed with attention to severity of burn, functional impairment, age at pollicization, procedure used, operative time, length of hospital stay, and long-term functional results. Fifteen pollicizations were performed in 11 patients with an average follow-up of over 5 years. Indication for pollicization was lack of prehension due to total loss of the thumb with the presence of a transposable index ray. The bipedicle flap method was used in two cases and the neurovascular pedicle technique was employed in all others. Skin grafts were necessary in all cases. Results were graded according to presence or absence of tip pinch, key pinch, grasp, and opposition. Significant functional improvement was seen in 14 of 15 cases (94 percent). Four patients (27 percent) developed complications requiring secondary procedures. In our experience, pollicization provides the most rapid and effective means of restoration of thumb function in the severe pediatric hand burn with multiple digit loss.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
A burn of the oral commissure is one of the most common types of electrical injury in children. To minimize postoperative wound contracture in late reconstructive surgery, a functional reconstruction that combines excision of the burn scar with lateral advancement of the orbicularis oris muscle, re-creation of the modiolus labii, and reestablishment of vermilion continuity has been developed. Functional restoration of the labial musculature to the preinjury position with re-creation of the modiolus labii and reestablishment of vermilion continuity appears to significantly decrease the amount of postoperative wound contracture (p less than 0.025).
In major thermal burns there has been an alarming emergence of fungal sepsis as defined by involvement of three or more organs and/or repeated positive blood cultures. During an 18-month period, we treated 72 patients (aged 18 +/- 2 years; TBSA burn, 57 +/- 3%; percent of third-degree burn, 45 +/- 3) with fungal sepsis. In all patients with documented three-organ involvement, treatment was with intravenous amphotericin (0.5 mg/kg body weight/day), immediate wound debridement, and early wound closure. The mortality was 32% (23 patients); 49 (68%) survived infection. Sixty-two variables were reviewed retrospectively using multiple regression analysis to ascertain specific factors associated with fungal sepsis and their relationship to survival. In burn patients, fungal sepsis is a strong determinant of survival, and its occurrence overshadows traditional factors presently utilized to predict clinical outcome.
Malignant melanoma in prepubertal children is a rare event. Nine patients, 9.0 +/- 2.4 years (mean +/- S.D.), presented with malignant melanoma between December, 1975 and August, 1991. The thickness of the lesions ranged from 0.57 to > 4 mm. All patients (n = 6) with stage I or II disease are presently alive. Prepubertal patients with malignant melanoma tend to exhibit thick lesions when initially diagnosed. Their survival appears to be comparable or increased relative to their adult counterparts.