- 100 Riverside Boulevard
22D
New York
NY10069 - 2124344050
- Pediatric facial plastic surgeon who specializes in the treatment of congenital vascular anomaliesedit
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Research Interests: Medicine and hemangioma
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Both infantile hemangiomas and vascular malformations can involve the upper airway. Each of these lesions has a characteristic anatomical distribution pattern and clinical presentation and any one of them may lead to airway obstruction.... more
Both infantile hemangiomas and vascular malformations can involve the upper airway. Each of these lesions has a characteristic anatomical distribution pattern and clinical presentation and any one of them may lead to airway obstruction. Airway infantile hemangiomas, the most common, may be focal or segmental in their distribution. Focal infantile hemangiomas are almost always subglottic, whereas segmental lesions are more diffuse and involve all levels of the upper airway. Up to 60 % of children with mandibular segmental infantile hemangioma will have airway disease, while over 50 % of patients with facial or head and neck vascular malformation will also have airway involvement. This is important to recognize since many patients may remain asymptomatic until their disease progresses and upper airway obstruction develops. We advocate a staged approach to treatment. Treatment of infantile hemangiomas may be medical, laser, or surgical. There is no medical treatment for airway vascular malformations; however, laser, sclerotherapy, and surgical excision are the mainstay of treatment.
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Imaging of subcutaneous veins is important in many applications, such as gaining venous access and vascular surgery. Despite a long history of medical infrared (IR) photography and imaging, this technique is not widely used for this... more
Imaging of subcutaneous veins is important in many applications, such as gaining venous access and vascular surgery. Despite a long history of medical infrared (IR) photography and imaging, this technique is not widely used for this purpose. Here we revisited and explored the capability of near-IR imaging to visualize subcutaneous structures, with a focus on diagnostics of superficial veins. An IR device comprising a head-mounted IR LED array (880 nm), a small conventional CCD camera (Toshiba Ik-mui, Tokyo, Japan), virtual-reality optics, polarizers, filters, and diffusers was used in vivo to obtain images of different subcutaneous structures. The same device was used to estimate the IR image quality as a function of wavelength produced by a tunable xenon lamp-based monochrometer in the range of 500-1,000 nm and continuous-wave Nd:YAG (1.06 microm) and diode (805 nm) lasers. The various modes of optical illumination were compared in vivo. Contrast of the IR images in the reflectance mode was measured in the near-IR spectral range of 650-1,060 nm. Using the LED array, various IR images were obtained in vivo, including images of vein structure in a pigmented, fatty forearm, varicose leg veins, and vascular lesions of the tongue. Imaging in the near-IR range (880-930 nm) provides relatively good contrast of subcutaneous veins, underscoring its value for diagnosis. This technique has the potential for the diagnosis of varicose veins with a diameter of 0.5-2 mm at a depth of 1-3 mm, guidance of venous access, podiatry, phlebotomy, injection sclerotherapy, and control of laser interstitial therapy.
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Research Interests: Endocrinology, Biology, Medicine, Multidisciplinary, Transgenic Mice, and 15 moreBiological Sciences, Cell Differentiation, Humans, Internal Medicine, Hyperglycemia, Blood Glucose, Insulin, Diabetes mellitus, Mice, Animals, PNAS, Cell Transplantation, Fluorescent Antibody Technique, Induced Pluripotent Stem Cells, and Type 2 Diabetes Mellitus
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Objectives/HypothesisTo characterize the anatomic distribution of lymphatic malformations of the upper airway.Study DesignCase series with chart review.SettingTertiary care referral center specializing in the diagnosis and treatment of... more
Objectives/HypothesisTo characterize the anatomic distribution of lymphatic malformations of the upper airway.Study DesignCase series with chart review.SettingTertiary care referral center specializing in the diagnosis and treatment of vascular anomalies.MethodsA 7‐year (2004‐2011) retrospective chart review of patients with lymphatic malformations was performed at a tertiary care referral center. Patients with airway lymphatic malformations were identified. The anatomic distribution of lymphatic malformations within the airway was reviewed.ResultsA total of 141 patients with lymphatic malformations of the upper aerodigestive tract (UADT) were studied. Of these, 15 (11%) had laryngeal (supraglottic) involvement. In all of these patients, the disease was above the true vocal folds. Seventy‐four (52%) patients had involvement of 1 anatomic zone (most common was the oral cavity), and 67 (48%) had involvement of multiple zones. With regard to each zone, 105 (75%) patients had involvement of the oral cavity, 50 (36%) the oropharynx, 8 (6%) the hypopharynx, 42 (30%) the parapharynx, and 12 (9%) had retropharygeal disease (some patients had multiple zones involved). No patients were identified with glottic, subglottic, or tracheal involvement.ConclusionsBased on our large series, airway involvement in head and neck lymphatic malformations may occur at multiple sites above the glottis. A high percentage of these patients have involvement of the oral cavity (75%) and oropharynx (35%). None involve the glottis, subglottis, or trachea.
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When considering the treatment of infantile hemangiomas, several questions must be answered. Whether or not to treat, when to treat, and how to treat. During the past decade, the paradigm for the treatment of hemangiomas has changed.... more
When considering the treatment of infantile hemangiomas, several questions must be answered. Whether or not to treat, when to treat, and how to treat. During the past decade, the paradigm for the treatment of hemangiomas has changed. Propranolol has become the first line of therapy. However, there are instances where surgery and or laser treatment is indicated. Lesions that fail to respond or inadequately respond to propranolol, or where propranolol is contraindicated, should be considered. We have selected various anatomical sites to demonstrate the various problems and surgical techniques.
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Background: Soft-tissue loss is expected after resection of large vascular lesions. Autologous fat transfer improves asymmetries; however, systematic outcomes are not previously described for vascular anomaly reconstruction. Methods:... more
Background: Soft-tissue loss is expected after resection of large vascular lesions. Autologous fat transfer improves asymmetries; however, systematic outcomes are not previously described for vascular anomaly reconstruction. Methods: Retrospective chart review from 2012 to 2015 included patients receiving autologous fat transfers for soft-tissue defects during or following vascular anomaly surgery at a tertiary care center. Patients received dermal en bloc fat grafts, lipoaspirates, or both. Pre- and postoperative photographs were blindly reviewed by 3 facial plastic surgeons using a 5-point scale. Dermal abdominal en bloc fat grafts were placed immediately after excision of a vascular anomaly. Lipoaspirate fat grafting was performed using liposuction (modified Coleman technique) and centrifugation. The effectiveness of fat transfers was assessed using patients’ photographs. Final follow-up was 6 months to 5 years. Results: There were 35 autologous fat transfer surgeries in 27 patie...
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BackgroundIn the last few decades there has been development of innovative therapies for the treatment of craniofacial lymphatic malformations. Percutaneous sclerotherapy has demonstrated efficacy in the management of macrocystic... more
BackgroundIn the last few decades there has been development of innovative therapies for the treatment of craniofacial lymphatic malformations. Percutaneous sclerotherapy has demonstrated efficacy in the management of macrocystic lymphatic lesions, but it is less suitable for microcystic lesions given their size. The gravity-dependent technique is a novel augmentation of standard percutaneous sclerotherapy: the technique enables a sclerosing agent to permeate the small microchannels seen in microcystic lesions that would otherwise be difficult to treat.MethodsBetween 2005 and 2021, 124 patients with microcystic or mixed lymphatic malformations were treated using a novel gravity-dependent sclerotherapy technique. Bleomycin at a maximum dose of 15 IU per session was used as the main sclerosing agent. Fluoroscopy and ultrasound were used to ensure proper positioning of the catheter prior to injecting the sclerosing agent. The response to treatment was assessed clinically and with cross-sectional imaging.ResultsNearly all cases showed significant improvement after the gravity-dependent technique. There have been no permanent complications from sclerotherapy treatment. There was a mild transient adverse effect from bleomycin in one case of erythema and tenderness that lasted several weeks then ameliorated.ConclusionsThe gravity-dependent sclerotherapy technique is a suitable treatment option for microcystic lymphatic malformations.
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To describe a multidisciplinary approach to the treatment of airway vascular malformations (venous or lymphatic) with direct suspension rigid laryngoscopy and direct puncture transmucosal bleomycin sclerotherapy injected under... more
To describe a multidisciplinary approach to the treatment of airway vascular malformations (venous or lymphatic) with direct suspension rigid laryngoscopy and direct puncture transmucosal bleomycin sclerotherapy injected under road-mapping fluoroscopic monitoring, supplemented by Dyna-computed tomography utilization. Case series. We performed a retrospective medical record and imaging review of four patients with venous malformations or lymphatic malformations located in the airway. Patients were treated with a combination of direct suspension laryngoscopy or rigid nasopharyngoscopy and image-guided direct puncture bleomycin sclerotherapy. Two patients presented to our institution with extensive lymphatic malformation of the neck, parapharyngeal, and retropharyngeal spaces, and two presented with venous malformation of the nasopharynx and oropharynx. All patients were treated with multiple sclerotherapy and debulking procedures before undergoing combined direct transmucosal puncture bleomycin sclerotherapy guided by direct laryngoscopy or nasopharyngoscopy. All patients had complete resolution of disease while maintaining a safe airway. A multidisciplinary approach to airway vascular malformations with a combination of endoscopy and direct puncture bleomycin sclerotherapy was demonstrated to be a safe and effective treatment in our patient cohort. Direct laryngoscopy and nasopharyngoscopy provide easy access to the nasopharynx, oropharynx, retro- and/or parapharyngeal spaces and larynx. Unlike traditional agents, bleomycin induces minimal edema and therefore is an ideal substance to treat airway lesions. 4. Laryngoscope, 2015.
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Infantile hemangioma (IH) clearance may be slow or incomplete in response to pulsed dye laser (PDL) or propranolol alone. To evaluate whether IH treated with PDL and propranolol displayed more rapid and complete clearance than IH treated... more
Infantile hemangioma (IH) clearance may be slow or incomplete in response to pulsed dye laser (PDL) or propranolol alone. To evaluate whether IH treated with PDL and propranolol displayed more rapid and complete clearance than IH treated with propranolol alone. Retrospective review of facial-segmental IH treated with propranolol and PDL and controls treated with propranolol was conducted. Blinded physicians used patient photographs to select clearance level and the earliest date of near-complete clearance. Days of propranolol, PDL sessions, and propranolol dose, each until date of near-complete clearance; total days of propranolol; and total propranolol dose were recorded. Infantile hemangiomas treated concurrently with propranolol and PDL achieved complete clearance (6/12) more often than IH treated with propranolol followed by PDL (2/5) or IH treated with propranolol alone (1/8; difference in clearance scores p = .01) and achieved near-complete clearance after fewer days of propranolol (mean 92 days for concurrent propranolol and PDL vs 288 days for propranolol; p < .001). Cumulative propranolol dose until near-complete clearance was lowest in the concurrent propranolol and PDL group (149.16 vs. 401.25 mg/kg for propranolol; p < .001). Facial-segmental IH treated with propranolol and PDL displayed morerapid and complete clearance and required a lower cumulative propranolol dose to achieve near-complete clearance.
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Vascular tumors of infancy and childhood represent a number of clinicopathologically distinct entities for which precise histopathological diagnosis is often essential in determining effective therapeutic approach. Unfortunately,... more
Vascular tumors of infancy and childhood represent a number of clinicopathologically distinct entities for which precise histopathological diagnosis is often essential in determining effective therapeutic approach. Unfortunately, pathologists and clinicians alike have traditionally tended to lump these tumors, in addition to small vessel vascular malformations, under overly generic terms like capillary hemangioma that do little, if anything, to guide proper clinical management. In the last decade this nosologic oversimplification has begun to wane as important new diagnostic tools and better understanding of etiology have evolved, facilitated by international recognition of the need for a multidisciplinary approach in dealing with these perplexing and often clinically devastating lesions. This article provides a brief historical perspective on this progress, and then focuses on the current clinical, histological, and immunophenotypical features that distinguish the major types of vascular tumors of infancy and childhood, also reviewing new evidence regarding their mechanisms of pathogenesis.
Research Interests: Pathology, Cardiovascular, Medicine, Humans, Child, and 13 moreInfant, Etiology, Newborn Infant, Blood Vessels, Cardiovascular Pathology, Multidisciplinary Approach, Capillary Hemangioma, Skin Neoplasms, Child preschool, vascular tumors, Diagnostic Tool, hemangioma, and Cardiovascular medicine and haematology
To analyze the operative benefit of preoperative sclerotherapy of facial venous malformations and assess long-term patient outcome. Preoperative sclerotherapy was performed in 24 consecutive patients referred before resection of facial... more
To analyze the operative benefit of preoperative sclerotherapy of facial venous malformations and assess long-term patient outcome. Preoperative sclerotherapy was performed in 24 consecutive patients referred before resection of facial venous malformation. Pretreatment imaging was reviewed for malformation dimensions (length, width, and height), and volumes were estimated. Sclerotherapy was performed with 3% sodium tetradecyl in the first 15 patients and 98% dehydrated alcohol in the remaining 9 patients. Operative blood loss, operative time, transfusion requirement, and hospital stay were recorded. Operative time per lesion volume and operative blood loss per lesion volume were calculated. Results were compared with 15 historical control patients who underwent resection of facial venous malformations without preoperative sclerotherapy. Long-term follow-up of study and control patients was performed. Compared with controls, patients undergoing preoperative venous sclerotherapy were significantly older (P = .0206) and had larger lesions in all three dimensions (height, P = .0002; length, P = .0010; width, P = .0004). Patients receiving sclerotherapy had shorter operative time per lesion volume (P < .0001) and reduced blood loss per lesion volume (P < .0001). Neither hospital stay nor the need for blood transfusion differed from the control patients (P = .2449 and P = .6857). Mild periprocedural complications were encountered in 12.5% of cases, and nerve paresis occurred in 8.3% of cases. Long-term follow-up revealed retreatment was required in 2 of 24 patients (8.3%). Preoperative sclerotherapy of venous malformations was associated with less operative time per lesion volume and less operative blood loss per lesion volume. Long-term follow-up revealed a low need for retreatment.
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L'invention concerne un appareil permettant de placer un catheter intraluminal (10) a demeure utilisant un signal infrarouge (IR) code dans ledit catheter (10), de surveiller sa position et de detecter ledit signal IR a l'aide... more
L'invention concerne un appareil permettant de placer un catheter intraluminal (10) a demeure utilisant un signal infrarouge (IR) code dans ledit catheter (10), de surveiller sa position et de detecter ledit signal IR a l'aide d'un detecteur optique (50) IR. Le signal IR peut etre code de deux manieres differentes dans le catheter (10) a l'aide d'un IR emis depuis ledit catheter ou d'un IR reflechi depuis ce meme catheter. Selon la premiere maniere, le catheter (10) est eclaire par un rayonnement IR emis depuis l'extremite distale dudit catheter soit a l'aide de dispositifs optiques (31) a fibre optique soit a l'aide d'une micro-diode (80). Selon la seconde maniere, le catheter (10) est marque a l'aide de regions dont les proprietes optiques varient afin de former un motif (60) facilement visualise et distinct des structures anatomiques proches. Selon un mode de realisation, les regions dont les proprietes optiques varient possedent un mot...
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Lymphatic malformations (LMs) occur in 2.8 to 5 per 100,000 live births. Most involve the head and neck and they are equally common in men and women. They are developmental anomalies of unknown cause, although recent evidence suggests... more
Lymphatic malformations (LMs) occur in 2.8 to 5 per 100,000 live births. Most involve the head and neck and they are equally common in men and women. They are developmental anomalies of unknown cause, although recent evidence suggests that an upregulation of the mammalian target of rapamycin (mTOR) pathway may be a causal factor leading to the overproduction of abnormal lymph vessels. These vessels are likely dilated lymphatic sacs sequestered from the lymphatic and venous systems. This overproduction results in the accumulation of lymph in dilated cystic spaces, which in turn results in the clinical features of an LM.
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The molecular pathophysiology of venous malformations (VMs), which are a type of vascular malformation, is poorly understood. Until now, it is known that VM lesions are related to the process of angiogenesis. Because angiogenesis is... more
The molecular pathophysiology of venous malformations (VMs), which are a type of vascular malformation, is poorly understood. Until now, it is known that VM lesions are related to the process of angiogenesis. Because angiogenesis is induced under hypoxic conditions, hypoxia is thought to be important in VM lesion formation. Therefore, we examined the implications of hypoxia on the biological behavior of VM vascular smooth muscle cells (VSMCs). In doing so, we investigated the expression patterns of hypoxia-inducible factor-1α (HIF-1α), which plays a key role in hypoxia-induced angiogenesis, to provide a further understanding of the molecular mechanisms involved in VM. Vascular smooth muscle cells from 5 normal veins and 5 VM lesions were cultured under moderate hypoxic conditions (3% O2, 5% CO2). The effects of hypoxia on HIF-1α expression were measured by immunocytochemical staining, reverse transcription-polymerase chain reaction, and real-time reverse transcription-polymerase chain reaction. Overall, the expression of HIF-1α in cells was high after exposure to hypoxia for 6 or 12 hours, but decreased after 24 hours of hypoxia. HIF-1α expression in VM VSMCs was 2 times higher than that in normal VSMCs. Immunocytochemically, HIF-1α was mainly located in the nucleus and the intensity in VM VSMCs was stronger after 6 and 12 hours of hypoxia when compared to the expression pattern of HIF-1α in VSMCs from normal tissue. This suggested that VM tissue is more susceptible to the effects of hypoxia than normal tissue. These results indicate that the high expression of HIF-1α in VM VSMCs under hypoxic conditions could be an important factor for stimulating downstream angiogenesis in VM. Furthermore, the results of this investigation could provide the basis for future studies of VM pathophysiology, and ultimately lead to the development of new therapeutic approaches.
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propagation of infantile hemangioma stem cells and an in vivo mouse model
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When considering the treatment of infantile hemangiomas, several questions must be answered. Whether or not to treat, when to treat, and how to treat. During the past decade, the paradigm for the treatment of hemangiomas has changed.... more
When considering the treatment of infantile hemangiomas, several questions must be answered. Whether or not to treat, when to treat, and how to treat. During the past decade, the paradigm for the treatment of hemangiomas has changed. Propranolol has become the first line of therapy. However, there are instances where surgery and or laser treatment is indicated. Lesions that fail to respond or inadequately respond to propranolol, or where propranolol is contraindicated, should be considered. We have selected various anatomical sites to demonstrate the various problems and surgical techniques.
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Both infantile hemangiomas and vascular malformations can involve the upper airway. Each of these lesions has a characteristic anatomical distribution pattern and clinical presentation and any one of them may lead to airway obstruction.... more
Both infantile hemangiomas and vascular malformations can involve the upper airway. Each of these lesions has a characteristic anatomical distribution pattern and clinical presentation and any one of them may lead to airway obstruction. Airway infantile hemangiomas, the most common, may be focal or segmental in their distribution. Focal infantile hemangiomas are almost always subglottic, whereas segmental lesions are more diffuse and involve all levels of the upper airway. Up to 60 % of children with mandibular segmental infantile hemangioma will have airway disease, while over 50 % of patients with facial or head and neck vascular malformation will also have airway involvement. This is important to recognize since many patients may remain asymptomatic until their disease progresses and upper airway obstruction develops. We advocate a staged approach to treatment. Treatment of infantile hemangiomas may be medical, laser, or surgical. There is no medical treatment for airway vascular malformations; however, laser, sclerotherapy, and surgical excision are the mainstay of treatment.
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Infantile hemangiomas (IHs) are the most common tumors of infancy. To describe the patterns of occurrence of lip IHs and correlate these findings with patterns of anatomical distortion and predictable clinical outcomes and to describe the... more
Infantile hemangiomas (IHs) are the most common tumors of infancy. To describe the patterns of occurrence of lip IHs and correlate these findings with patterns of anatomical distortion and predictable clinical outcomes and to describe the surgical management of these lesions. A retrospective medical record review of patients diagnosed as having facial IH of the upper or lower lips during an 8-year period (January 1, 2004, through December 31, 2011). Using clinical photographs and patient records, we mapped the 360 IHs of 342 patients on a lip schematic. Each lesion was encoded with a number reflective of its location, and this number was shared by other lesions found at the same site. Frequencies of lesion characteristics, complicating functional and aesthetic factors, and airway obstruction were documented. The treatment course was noted. Tertiary care hospital and practice specializing in the care of congenital pediatric vascular anomalies of the head and neck. Three hundred forty...
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Problem Infantile hemangiomas have a well-known distinct proliferative phase characterized by rapid proliferation of capillaries, followed by an involuting phase characterized by spontaneous and steady regression of the tumor.... more
Problem Infantile hemangiomas have a well-known distinct proliferative phase characterized by rapid proliferation of capillaries, followed by an involuting phase characterized by spontaneous and steady regression of the tumor. Histologically, proliferating hemangiomas are composed of masses of compact capillaries lined by plump endothelial cells with high mitotic rates. As the lesions involute, mitosis gradually decreases with increased apoptosis of endothelial cells, and vascular tissue is gradually replaced with fibrofatty tissue. Vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF) are among several markers that have been qualitatively found in proliferating and involuting phases of infantile hemangiomas, respectively. The purpose of this study is to quantitatively measure growth factors in proliferating and involuting hemangiomas. Methods A high-throughput xMAP multiplex immunobead assay technology (Luminex Corp., Austin, TX) was used to test VEGF, FGF, e...
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Educational objective: To easily identify cutaneous pigmented and vascular lesions in the head and neck and to use new laser technology to successfully remove cutaneous vascular and pigmented lesions with minimal risks of scarring.