Discussion Discussion: The Surgical Correction of Pierre Robin Sequence: Mandibular Distraction Osteogenesis versus Tongue-Lip Adhesion Arlen D. Denny, M.D. Milwaukee, Wis.
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congratulate the authors for their efforts in recording and reporting objective measures of outcomes from both mandibular distraction osteogenesis and tongue-lip adhesion in the treatment of airway obstruction in Pierre Robin sequence patients. This is the first published report to include any objective measures in tongue-lip adhesion patients. My bias on this subject is well known.1–4 I have great concern that the most vocal proponents for the tongue-lip adhesion treatment offer few, if any, objective measures to report on these patients, either before or after surgery. The decision to use tongue-lip adhesion typically does not include any of the measures commonly available in neonatal intensive care units today such as bronchoscopy and polysomnography, with specific consideration of frequency, severity, duration of oxygen desaturation and apnea-hypopnea index. Proponents of this 68-year-old treatment can advance the core of the decision-making process to include these contemporary parameters in all patients and to report their results in this forum. Certainly, the tongue-lip adhesion treatment can work but, as has been shown repeatedly, the catch-up growth concept is largely a myth that continues to be perpetuated in the absence of supporting objective data. Excellent studies from respected authors and institutions have shown that growth to normal dimensions is rare in the Pierre Robin population.5–8 Tongue-lip adhesion must be recognized for the temporizing effect it produces and contrasted to mandibular distraction osteogenesis, which can produce lasting skeletal correction and, as a result, resolution of airway obstruction. Few would argue that mandibular distraction osteogenesis is the more challenging technique to use, but in my experience, it is much to the benefit of the patient. From the Center for Craniofacial Disorders. Received for publication December 9, 2013; accepted December 11, 2013. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000182
The problem of specific parameters to guide patient selection for each treatment continues and is not solved by this article, which nevertheless represents a significant first step. In his original description of the sequence that bears his name, Pierre Robin opined that only 10 percent of all patients diagnosed with Pierre Robin sequence demonstrated airway obstruction sufficiently severe to require intervention. Only through a broader experience, further reporting, and analysis of data from studies such as this will the answer for which patients to treat and how to treat them become more clear. Standardized testing and analysis before either mandibular distraction osteogenesis or tongue-lip adhesion must include upper and lower airway bronchoscopy, which in our institution is a bedside procedure. It must also include 12-channel polysomnography, with frequency, duration, and level of oxygen desaturation; apnea hypopnea index; and arterial blood gas partial pressure of carbon dioxide at the completion of the study to assess the degree of carbon dioxide retention. These are the minimum parameters for accurately assessing the severity of airway obstruction preoperatively and the outcomes of the chosen technique postoperatively. Much has been written over the past decade describing the benefits of mandibular distraction osteogenesis. I encourage the proponents of tongue-lip adhesion to collect, analyze, and report their data as has been done here by Flores et al. Only through this important dialogue will the correct approach for all Pierre Robin sequence patients with airway obstruction become evident. The significance of this article is not in its perfection as a clinical review, although that is a very important aspect. The importance derives from the fact that an established surgeon has reported on both mandibular distraction osteogenesis and
Disclosure: Dr. Denny is a consultant to Stryker, Corp.
www.PRSJournal.com
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Plastic and Reconstructive Surgery • June 2014 tongue-lip adhesion, and each technique was evaluated using the same parameters. Arlen D. Denny, M.D. Center for Craniofacial Disorders 9000 West Wisconsin Avenue, Suite C340 Milwaukee, Wis. 53226 [email protected]
REFERENCES 1. Denny AD, Talisman R, Hanson PR, Recinos RF. Mandibular distraction osteogenesis in very young patients to correct airway obstruction. Plast Reconstr Surg. 2001;108:302–311. 2. Denny A, Kalantarian B. Mandibular distraction in neonates: A strategy to avoid tracheostomy. Plast Reconstr Surg. 2002;109:896–904; discussion 905.
3. Denny AD. Distraction osteogenesis in Pierre Robin neonates with airway obstruction. Clin Plast Surg. 2004;31:221–229. 4. Denny A, Amm C. New technique for airway correction in neonates with severe Pierre Robin sequence. J Pediatr. 2005;147:97–101. 5. Bromberg BE, Pasternak R, Walden RH, Rubin LR. Evaluation of micrognathia with emphasis on late development of the mandible. Plast Reconstr Surg Transplant Bull. 1961;28:537–548. 6. Figueroa AA, Glupker TJ, Fitz MG, BeGole EA. Mandible, tongue, and airway in Pierre Robin sequence: A longitudinal cephalometric study. Cleft Palate Craniofac J. 1991;28:425–434. 7. Daskalogiannakis J, Ross RB, Tompson BD. The mandibular catch-up growth controversy in Pierre Robin sequence. Am J Orthod Dentofacial Orthop. 2001;120:280–285. 8. Eriksen J, Hermann NV, Darvann TA, Kreiborg S. Cleft Palate Craniofac J. 2006;43:160–167.
FILLER-028
PRS Policy for Non-Receipt of an Issue or for a Damaged Copy • Domestic PRS claims due to non-receipt or damage will be fulfilled by Lippincott Williams & Wilkins one time during the 3-month time period immediately following the publication of an issue. For example, a claim for the non-receipt of (or damaged) January 2010 issue will be honored by LWW one time through March 31, 2010. • International PRS claims due to non-receipt or damage will be fulfilled by Lippincott Williams & Wilkins one time during the 6-month time period immediately following the publication of an issue. For example, a claim for the non-receipt of (or damaged) January 2010 issue will be honored by LWW one time through June 30, 2010. • Claims for non-receipt or damaged journal should be made to a member of the ASPS Member Services Department. Please provide Member Services with your correct mailing address. ASPS Member services will send the publisher the claim information, and LWW will process the claim and ship the journal issue(s) to the claimant.
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I
congratulate the authors for their efforts in recording and reporting objective measures of outcomes from both mandibular distraction osteogenesis and tongue-lip adhesion in the treatment of airway obstruction in Pierre Robin sequence patients. This is the first published report to include any objective measures in tongue-lip adhesion patients. My bias on this subject is well known.1–4 I have great concern that the most vocal proponents for the tongue-lip adhesion treatment offer few, if any, objective measures to report on these patients, either before or after surgery. The decision to use tongue-lip adhesion typically does not include any of the measures commonly available in neonatal intensive care units today such as bronchoscopy and polysomnography, with specific consideration of frequency, severity, duration of oxygen desaturation and apnea-hypopnea index. Proponents of this 68-year-old treatment can advance the core of the decision-making process to include these contemporary parameters in all patients and to report their results in this forum. Certainly, the tongue-lip adhesion treatment can work but, as has been shown repeatedly, the catch-up growth concept is largely a myth that continues to be perpetuated in the absence of supporting objective data. Excellent studies from respected authors and institutions have shown that growth to normal dimensions is rare in the Pierre Robin population.5–8 Tongue-lip adhesion must be recognized for the temporizing effect it produces and contrasted to mandibular distraction osteogenesis, which can produce lasting skeletal correction and, as a result, resolution of airway obstruction. Few would argue that mandibular distraction osteogenesis is the more challenging technique to use, but in my experience, it is much to the benefit of the patient. From the Center for Craniofacial Disorders. Received for publication December 9, 2013; accepted December 11, 2013. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000182
The problem of specific parameters to guide patient selection for each treatment continues and is not solved by this article, which nevertheless represents a significant first step. In his original description of the sequence that bears his name, Pierre Robin opined that only 10 percent of all patients diagnosed with Pierre Robin sequence demonstrated airway obstruction sufficiently severe to require intervention. Only through a broader experience, further reporting, and analysis of data from studies such as this will the answer for which patients to treat and how to treat them become more clear. Standardized testing and analysis before either mandibular distraction osteogenesis or tongue-lip adhesion must include upper and lower airway bronchoscopy, which in our institution is a bedside procedure. It must also include 12-channel polysomnography, with frequency, duration, and level of oxygen desaturation; apnea hypopnea index; and arterial blood gas partial pressure of carbon dioxide at the completion of the study to assess the degree of carbon dioxide retention. These are the minimum parameters for accurately assessing the severity of airway obstruction preoperatively and the outcomes of the chosen technique postoperatively. Much has been written over the past decade describing the benefits of mandibular distraction osteogenesis. I encourage the proponents of tongue-lip adhesion to collect, analyze, and report their data as has been done here by Flores et al. Only through this important dialogue will the correct approach for all Pierre Robin sequence patients with airway obstruction become evident. The significance of this article is not in its perfection as a clinical review, although that is a very important aspect. The importance derives from the fact that an established surgeon has reported on both mandibular distraction osteogenesis and
Disclosure: Dr. Denny is a consultant to Stryker, Corp.
www.PRSJournal.com
1443
Plastic and Reconstructive Surgery • June 2014 tongue-lip adhesion, and each technique was evaluated using the same parameters. Arlen D. Denny, M.D. Center for Craniofacial Disorders 9000 West Wisconsin Avenue, Suite C340 Milwaukee, Wis. 53226 [email protected]
REFERENCES 1. Denny AD, Talisman R, Hanson PR, Recinos RF. Mandibular distraction osteogenesis in very young patients to correct airway obstruction. Plast Reconstr Surg. 2001;108:302–311. 2. Denny A, Kalantarian B. Mandibular distraction in neonates: A strategy to avoid tracheostomy. Plast Reconstr Surg. 2002;109:896–904; discussion 905.
3. Denny AD. Distraction osteogenesis in Pierre Robin neonates with airway obstruction. Clin Plast Surg. 2004;31:221–229. 4. Denny A, Amm C. New technique for airway correction in neonates with severe Pierre Robin sequence. J Pediatr. 2005;147:97–101. 5. Bromberg BE, Pasternak R, Walden RH, Rubin LR. Evaluation of micrognathia with emphasis on late development of the mandible. Plast Reconstr Surg Transplant Bull. 1961;28:537–548. 6. Figueroa AA, Glupker TJ, Fitz MG, BeGole EA. Mandible, tongue, and airway in Pierre Robin sequence: A longitudinal cephalometric study. Cleft Palate Craniofac J. 1991;28:425–434. 7. Daskalogiannakis J, Ross RB, Tompson BD. The mandibular catch-up growth controversy in Pierre Robin sequence. Am J Orthod Dentofacial Orthop. 2001;120:280–285. 8. Eriksen J, Hermann NV, Darvann TA, Kreiborg S. Cleft Palate Craniofac J. 2006;43:160–167.
FILLER-028
PRS Policy for Non-Receipt of an Issue or for a Damaged Copy • Domestic PRS claims due to non-receipt or damage will be fulfilled by Lippincott Williams & Wilkins one time during the 3-month time period immediately following the publication of an issue. For example, a claim for the non-receipt of (or damaged) January 2010 issue will be honored by LWW one time through March 31, 2010. • International PRS claims due to non-receipt or damage will be fulfilled by Lippincott Williams & Wilkins one time during the 6-month time period immediately following the publication of an issue. For example, a claim for the non-receipt of (or damaged) January 2010 issue will be honored by LWW one time through June 30, 2010. • Claims for non-receipt or damaged journal should be made to a member of the ASPS Member Services Department. Please provide Member Services with your correct mailing address. ASPS Member services will send the publisher the claim information, and LWW will process the claim and ship the journal issue(s) to the claimant.
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