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Mace EL, Krishnapura SG, Golinko M, Phillips JD, Belcher RH. Pre-Operative Characteristics Helping to Avoid Gastrostomy Tube After Mandibular Distraction in Neonates With Pierre-Robin Sequence: A Institutional Case-Series and Review of the Literature. Ann Otol Rhinol Laryngol 2024:34894241249547. [PMID: 38712740 DOI: 10.1177/00034894241249547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
OBJECTIVE to investigate the ability of mandibular distraction osteogenesis (MDO) to avoid gastrostomy tube (G-tube). DATA SOURCES PubMed, EBSCOhost, Cochrane, and Embase. REVIEW METHODS We retrospectively reviewed the number of MDO cases performed at our institution for patients with Robin Sequence (RS) over the past 10 years. In our institutional review, patients were excluded if they had a G-tube already placed at the time of surgery. We also performed a systematic review of the literature. Articles were excluded if they did not detail feeding outcomes after MDO, or if MDO was performed on patients that did not have RS. RESULTS In our systematic review, 12 articles were included that comprised a total of 209 neonates with RS that underwent MDO. A total of 174 (83.3%) patients avoided a G-tube once MDO was performed. A total of 14 patients met the inclusion criteria at our institution. Of the 14 RS patients, 9 (64%) avoided having a G-tube placed and all (14/14) avoided tracheostomy. The average birth weight of patients avoiding a G-tube was 3.11 kg compared to 2.25 kg (P = .045) in the group requiring a G-tube. In the group avoiding a G-tube, the average weight at time of operation was 3.46 kg compared to 2.83 kg (P = .037) in the group requiring a G-tube. CONCLUSION MDO may be considered as a surgical option to prevent G-tube placement for neonates with non-syndromic RS who have difficulty with PO feeding but whose airway obstruction is not severe enough to require respiratory support. Based on our institutional experience, a minimum weight of 3.00 kg correlated with higher success rates of PO intake and avoiding a G-tube.
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Affiliation(s)
- Emily L Mace
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Michael Golinko
- Vanderbilt Department of Plastic Surgery, Nashville, TN, USA
| | - James D Phillips
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Cleft and Craniofacial Program, Nashville, TN, USA
| | - Ryan H Belcher
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Cleft and Craniofacial Program, Nashville, TN, USA
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McGhee H, Gehle D, Shope C, Wen CC, Marston AP, Discolo C, Pecha PP. Feeding Performance and Outcomes in Infants With Robin Sequence Undergoing Mandibular Distraction Osteogenesis. Cleft Palate Craniofac J 2024; 61:295-301. [PMID: 36128745 PMCID: PMC10074639 DOI: 10.1177/10556656221127542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
To describe perioperative feeding performance in infants with Robin sequence (RS) who underwent mandibular distraction osteogenesis (MDO). A retrospective study of infants that underwent MDO from May 2010 to December 2019. Tertiary pediatric hospital. A total of 40 patients underwent MDO and 20 met inclusion criteria. Of the included infants, 6 had an associated syndrome and 80% were male. Time to full oral feeds, rate of G-tube placement, and change in weight percentile following MDO. Average oral intake prior to MDO was 22.1% of individual goal feeds. Among the 15 (75%) children that did not require G-tube placement, mean time to full oral feeds after MDO was 11 days ± 5.7 days, with 80% of infants reaching full oral feeds within 2 weeks after extubation. The proportion of G-tube placement in patients with a syndrome was higher than in isolated RS (-0.6; 95% CI: -1.0, -0.2). Mean percentages of weight-for-age percentile decreased during the first 3 months after the procedure. This was followed by a mean upturn in weight starting after the third month after MDO with a recovery to preoperative mean weight-for-age percentiles by 6 months after surgery. This study suggests that infants with RS may achieve full oral feeds despite poor feeding performance before MDO. Infants with syndromic RS are more likely to require G-tube. These findings may be used to inform G-tube discussion and offer a timeline to work toward goal oral feeds for infants with RS after MDO.
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Affiliation(s)
- Heather McGhee
- Department of Otolaryngology – Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Daniel Gehle
- Department of Otolaryngology – Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Chelsea Shope
- Department of Otolaryngology – Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Chun-Che Wen
- Department of Otolaryngology – Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Alexander P Marston
- Department of Otolaryngology – Head and Neck Surgery, Tufts University School of Medicine, Boston, MA, USA
| | - Christopher Discolo
- Department of Otolaryngology – Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Phayvanh P Pecha
- Department of Otolaryngology – Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
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Padula MA, Naing K, Wenger TL, Ahmad I, Coghill CH, Wild KT, Rottgers SA, Resnick CM, Goldstein J, Ehsan Z, Watkins D, Deptula N, Lai KC, Lioy J, Gogcu S, Cielo CM. Spectrum of Disease in Hospitalized Newborns with Congenital Micrognathia: A Cohort of 3,236 Infants at North American Tertiary-Care Intensive Care Units. J Pediatr 2024; 265:113799. [PMID: 37879601 PMCID: PMC10872910 DOI: 10.1016/j.jpeds.2023.113799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/15/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To describe the spectrum of disease and burden of care in infants with congenital micrognathia from a multicenter cohort hospitalized at tertiary care centers. STUDY DESIGN The Children's Hospitals Neonatal Database was queried from 2010 through 2020 for infants diagnosed with micrognathia. Demographics, presence of genetic syndromes, and cleft status were summarized. Outcomes included death, length of hospitalization, neonatal surgery, and feeding and respiratory support at discharge. RESULTS Analysis included 3,236 infants with congenital micrognathia. Cleft palate was identified in 1266 (39.1%). A genetic syndrome associated with micrognathia was diagnosed during the neonatal hospitalization in 256 (7.9%). Median (IQR) length of hospitalization was 35 (16, 63) days. Death during the hospitalization (n = 228, 6.8%) was associated with absence of cleft palate (4.4%, P < .001) and maternal Black race (11.6%, P < .001). During the neonatal hospitalization, 1289 (39.7%) underwent surgery to correct airway obstruction and 1059 (32.7%) underwent gastrostomy tube placement. At the time of discharge, 1035 (40.3%) were exclusively feeding orally. There was significant variability between centers related to length of stay and presence of a feeding tube at discharge (P < .001 for both). CONCLUSIONS Infants hospitalized with congenital micrognathia have a significant burden of disease, commonly receive surgical intervention, and most often require tube feedings at hospital discharge. We identified disparities based on race and among centers. Development of evidence-based guidelines could improve neonatal care.
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Affiliation(s)
- Michael A Padula
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Khatija Naing
- School of Public Health, University of Illinois Chicago, Chicago, IL
| | - Tara L Wenger
- Division of Genetic Medicine, University of Washington, Seattle, WA
| | - Irfan Ahmad
- Division of Neonatology, Children's Hospital of Orange County, Orange, CA
| | - Carl H Coghill
- Division of Neonatology, Children's of Alabama, Birmingham, AL
| | - K Taylor Wild
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - S Alex Rottgers
- Division of Plastic & Reconstructive Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Cory M Resnick
- Department of Plastic & Oral Surgery, Boston Children's Hospital, Boston, MA
| | - Jeffrey Goldstein
- Department of Plastic & Reconstructive Surgery, Children's Mercy Hospital, Kansas City, MO
| | - Zarmina Ehsan
- Section of Pulmonary and Sleep Medicine, Children's Mercy Hospital, Kansas City, MO
| | - Donna Watkins
- Division of Neonatology, Riley Hospital for Children IU Health Physicians, Indianapolis, IN
| | - Nicole Deptula
- Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO
| | - Kuan-Chi Lai
- Division of Neonatology, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Janet Lioy
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Semsa Gogcu
- Division of Neonatology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Christopher M Cielo
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
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汪 景, 徐 梦, 金 蕾, 顾 美, 李 晓. [The airway management and treatment of newborns with micrognathia and laryngomalacia]. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2023; 37:622-625;631. [PMID: 37551568 PMCID: PMC10645534 DOI: 10.13201/j.issn.2096-7993.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Indexed: 08/09/2023]
Abstract
Objective:To explore the perioperative airway management and treatment of newborns with micrognathia and laryngomalacia. Methods:From January to December 2022, a total of 6 newborns with micrognathia and laryngomalacia were included. Preoperative laryngoscopy revealed concomitant laryngomalacia. These micrognathia were diagnosed as Pierre Robin sequences. All patients had grade Ⅱ or higher symptoms of laryngeal obstruction and required oxygen therapy or non-invasive ventilatory support. All patients underwent simultaneous laryngomalacia surgery and mandibular distraction osteogenesis. The shortened aryepiglottic folds were ablated using a low-temperature plasma radiofrequency during the operation. Tracheal intubation was maintained for 3-5 days postoperatively. Polysomnography(PSG) and airway CT examination were performed before and 3 months after the surgery. Results:Among the 6 patients, 4 required oxygen therapy preoperatively and 2 required non-invasiveventilatory support. The mean age of patients was 40 days at surgery. The inferior alveolar nerve bundle was not damaged during the operation, and there were no signs of mandibular branch injury such as facial asymmetry after the surgery. Laryngomalacia presented as mixed type: type Ⅱ+ type Ⅲ. The maximum mandibular distraction distance was 20 mm, the minimum was 12 mm, and the mean was 16 mm. The posterior airway space increased from a preoperative average of 3.5 mm to a postoperative average of 9.5 mm. The AHI decreased from a mean of 5.65 to 0.85, and the lowest oxygen saturation increased from a mean of 78% to 95%. All patients were successfully extubated after the surgery, and symptoms of laryngeal obstruction such as hypoxia and feeding difficulties disappeared. Conclusion:Newborns with micrognathia and laryngomalacia have multi-planar airway obstruction. Simultaneous laryngomalacia surgery and mandibular distraction osteogenesis are safe and feasible, and can effectively alleviate symptoms of laryngeal obstruction such as hypoxia and feeding difficulties, while significantly improving the appearance of micrognathia.
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Affiliation(s)
- 景 汪
- 上海市儿童医院 上海交通大学医学院附属儿童医院耳鼻咽喉头颈外科(上海,200062)Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062, China
| | - 梦柔 徐
- 上海市儿童医院 上海交通大学医学院附属儿童医院耳鼻咽喉头颈外科(上海,200062)Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062, China
| | - 蕾 金
- 上海市儿童医院 上海交通大学医学院附属儿童医院耳鼻咽喉头颈外科(上海,200062)Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062, China
| | - 美珍 顾
- 上海市儿童医院 上海交通大学医学院附属儿童医院耳鼻咽喉头颈外科(上海,200062)Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062, China
| | - 晓艳 李
- 上海市儿童医院 上海交通大学医学院附属儿童医院耳鼻咽喉头颈外科(上海,200062)Department of Otorhinolaryngology Head and Neck Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200062, China
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Wang X, Kim BS, Zhang Z, Wang HC, Zhang Y, Chai G. Piezosurgery in hemifacial microsomia: a promising exemption from conventional peri-osteotomy suffering. Front Pediatr 2023; 11:1149710. [PMID: 37456572 PMCID: PMC10348876 DOI: 10.3389/fped.2023.1149710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction Mandibular distraction osteogenesis, a recommended therapy for hemifacial microsomia, has brought much agony because of its traumatic procedures and peri-osteotomy complications. Our study aims to retrospectively compare piezoelectric osteotome with conventional reciprocal bone saw for hemifacial microsomia patients and validate its meliority in operability, surgical risks and patient outcomes. Methods All patients included underwent osteotomies conducted by either piezosurgery or bone saw. Information of intraoperative blood loss, operation duration, postoperative pain and complications was collected from patient files, ward round inspections and follow-ups. Results Among all 40 patients, 13 underwent piezo-osteotomy. Piezosurgery performed better than conventional reciprocal bone saw in decreasing intraoperative blood loss (p < 0.001) and operation duration (p = 0.030). No significant difference was found in hospitalization duration, total expenses or complication rates between two groups. There were positive relations between operation duration and intraoperative blood loss (p = 0.042), and between hospitalization duration and total expenses (p = 0.0096). Postoperative pain scores of both groups declined over time while the piezosurgery group had a statistically significant tendency (p = 0.006) to suffer less than the conventional group. Discussion Piezosurgery diminishes intraoperative blood loss, operative duration, and postoperative pain, making an alternative to conventional osteotomes to mitigate patients' and families' peri-osteotomy sufferings, and a more humane solution to HFM.
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Kosyk MS, Carlson AR, Zapatero ZD, Kalmar CL, Swanson JW, Bartlett SP, Taylor JA. Cleft Palate Repair in Robin Sequence following Mandibular Distraction Osteogenesis Compared to Tongue-Lip Adhesion. Cleft Palate Craniofac J 2023; 60:151-158. [PMID: 34730034 DOI: 10.1177/10556656211055019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To evaluate the timing and safety of cleft palate (CP) repair in patients with Robin sequence (RS) treated with mandibular distraction osteogenesis (MDO) or tongue-lip adhesion (TLA) for airway obstruction. DESIGN Retrospective cohort study. SETTING Tertiary Pediatric Hospital during 2004-2020. PATIENTS 148 patients with RS underwent MDO, 66 met inclusion by having MDO and followed by palatoplasty. 26 patients with RS underwent TLA, 14 met inclusion by having TLA and followed by palatoplasty. MAIN OUTCOME MEASURES Patient characteristics, hospital/operative details, postoperative complications, and polysomnographic (PSG) data were compared. RESULTS Groups were well-matched except more patients with syndromes underwent MDO (N = 27, 41%, P ≤ .002). In the MDO and TLA cohorts, mean CP repair age was 12.8 ± 1.9 months and 14.6 ± 1.6 months, respectively (P ≤ .002). Despite the earlier CP repair in the MDO group, there were no differences in peri-operative complication rates after palatoplasty in either group. All sleep respiratory parameters improved after MDO/TLA prior to palatoplasty P ≤ .050. All PSG parameters remained significantly improved after palatoplasty compared to preoperative values, P ≤ .043. Obstructive apnea hypopnea index and Oxygen saturation nadir further improved after palatoplasty within the MDO group, P ≤ .050, while no changes in the TLA group, P ≥ .500. CONCLUSIONS MDO was associated with earlier age at palatoplasty than TLA with a similar perioperative risk profile. In those patients with pre- and post-palatoplasty PSG data, palatoplasty was not associated with a deterioration in PSG parameters, and in fact in the MDO group, PSG data improved.
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Affiliation(s)
- Mychajlo S Kosyk
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anna R Carlson
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zachary D Zapatero
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher L Kalmar
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jordan W Swanson
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott P Bartlett
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Singhal M, Goyal M, Mittal N. Evaluation of effect of single vector mandibular distraction for correction of postankylotic mandibular hypoplasia requiring multiplanar correction: A prospective case series. Natl J Maxillofac Surg 2023; 14:101-108. [PMID: 37273432 PMCID: PMC10235742 DOI: 10.4103/njms.njms_447_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/28/2021] [Accepted: 01/02/2022] [Indexed: 06/06/2023] Open
Abstract
Introduction Uniplanar devices have been criticized for being insufficient to correct complex mandibular deformities and associated problems of open bite and cross bite. The use of oblique vector to correct complex multiplanar deformities using uniplanar mandibular distraction devices is the uniqueness of the present case series. Aim and Objective The aim of the present case series is to describe the successful use of uniplanar mandibular distraction devices for the correction of complex multiplanar deformities. Material and Method The technique of callous molding was employed to overcome any open bite. A total of 40 mandibular distractors in 20 patients (mean age 13 ± 2.67 years) were placed on the mandible for correction of the facial deformity associated with the lower jaw(mandible) in vertical, horizontal and/or sagittal plane, secondary to temporomandibular joint ankylosis. The distraction was done before and after the gap arthroplasty in 15 and 5 patients, respectively. A latency period of 3-5 days was applied, and distraction was performed at a rate of 1 mm/day with the rhythm of 0.5 mm twice daily. Results The significant lengthening was observed in both mandibular height (Ar Go) (50.40 ± 1.52 mm from 38.80 ± 4.38mm, P = 0.006) as well as in mandibular corpus length (Go Pg) (79.40 ± 2.28 from 58.80 ± 4.09, P = 0.001). Statistically significant changes in mandibular dimensions, facial proportions, and soft tissue profile were seen, which was assessed with the help of COGS analysis done on lateral cephalogram taken preoperatively and postoperatively. Conclusion With intelligent vector planning and callus molding multiplanar complex deformities can be corrected by using semiburieduniplanar devices.
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Affiliation(s)
- Mayank Singhal
- Department of Oral and Maxillofacial Surgery, Santosh Dental College and Hospitals, Santosh Deemed to be University, Ghaziabad, Uttar Pradesh, India
| | - Manoj Goyal
- Department of Oral and Maxillofacial Surgery, Santosh Dental College and Hospitals, Santosh Deemed to be University, Ghaziabad, Uttar Pradesh, India
| | - Neeti Mittal
- Department of Oral and Maxillofacial Surgery, Santosh Dental College and Hospitals, Santosh Deemed to be University, Ghaziabad, Uttar Pradesh, India
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Kosyk MS, Carlson AR, Zapatero ZD, Kalmar CL, Liaquat S, Bartlett SP, Taylor JA, Cielo CM, Swanson JW. Multimodal Treatment of Robin Sequence Utilizing Mandibular Distraction Osteogenesis and Continuous Positive Airway Pressure. Cleft Palate Craniofac J 2022:10556656221088173. [PMID: 35352571 DOI: 10.1177/10556656221088173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Mandibular distraction osteogenesis (MDO) and continuous positive airway pressure (CPAP) may each have a role in effectively treating tongue-based airway obstruction (TBAO) in Robin sequence (RS). This study describes longitudinal outcomes after treatment of TBAO with CPAP and/or MDO. Retrospective cohort study. Tertiary Pediatric Hospital. A total of 129 patients with RS treated with CPAP and/or MDO from 2009 to 2019 were reviewed. Subjects receiving baseline and at least one follow-up polysomnogram were included. 55 who underwent MDO ± CPAP and 9 who received CPAP-only treatment were included. Patient characteristics, feeding, and polysomnographic data were compared and generalized linear mixed modeling performed. Baseline obstructive apnea-hypopnea index (OAHI) was greater in the MDO-treated group (median x˜ = 33.7 [interquartile range: 26.5-54.5] than the CPAP-treated group (x˜ = 20.3[13.3-36.7], P ≤ .033). There was significant reduction in OAHI following treatment with CPAP and MDO modalities, P ≤ .001. SpO2 nadir after MDO was lower in syndromic (x˜ = 85.0[81.0-87.9] compared to nonsyndromic patients (x˜ = 88.4[86.8-90.5], P ≤ .005.) CPAP was utilized following MDO in 2/24 (8.3%) of nonsyndromic and 16/31 (51.6%) of syndromic subjects (P ≤ .001,) for a median duration of 414 days. Three patients (5%) underwent tracheostomy, all had MDO. Nasogastric tube feeding at hospital discharge was more common following MDO (44, 80%) than CPAP-only (4, 44.4%, P ≤ .036), but did not differ at 6-month follow-up (P ≥ .376). CPAP appears to effectively reduce obstructive apnea in patients with RS and moderate TBAO and be a useful adjunct in syndromic patients following MDO with improved but persistent obstruction.
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Affiliation(s)
- Mychajlo S Kosyk
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anna R Carlson
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zachary D Zapatero
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher L Kalmar
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sidra Liaquat
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott P Bartlett
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher M Cielo
- Division of Pulmonary & Sleep Medicine, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jordan W Swanson
- Division of Plastic and Reconstructive Surgery, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Kochhar R, Modi V, Silva ND, Gueye-Ndiaye S, Neugarten JM, Ward MJ, Gerber LM, An A, Mauer E, Veler H. Polysomnography-guided mandibular distraction osteogenesis in Pierre Robin sequence patients. J Clin Sleep Med 2022; 18:1749-1755. [PMID: 35332870 DOI: 10.5664/jcsm.9960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Craniofacial malformations with micrognathia cause high grades of obstructive sleep apnea (OSA) measured by polysomnography (PSG). Mandibular Distraction Osteogenesis (MDO) is a novel procedure for upper airway obstruction (UAO) relief. Our primary objective was to describe the utilization of PSGs to improve obstruction in patients undergoing mandibular distraction. METHODS This is a retrospective study. Patients with micrognathia and severe UAO, presenting with severe OSA diagnosed by PSG, were included from a single tertiary care center between 2015-2019. PSGs were done: (1) prior to surgery, (2) once cosmetic goal was achieved (Post-Op 1) (3) if residual moderate-to-severe OSA was seen, every 2 nights until mild or no OSA was achieved (Post-Op 2). RESULTS Thirteen patients were included. The median age at surgery was 1.1months (10 days-3 months). All thirteen patients had baseline severe OSA, with a median obstructive apnea-hypopnea index (OAHI) of 33 events/h and a median O2 nadir of 73%. Post-Op 1 PSG was done at a median of 6 days after surgery. Median first post-operative OAHI in all 13 patients was 6.8 events/h, with a median O2 nadir of 87%. A median additional distraction of 3 mm was needed beyond the traditionally recommended advancement. Long term follow-up studies at or after 1year were done in 5 patients, all showing persistent non-severe OSA. CONCLUSIONS This is the first case-series utilizing PSGs as a guide for MDO in patients with micrognathia showing the need for jaw over-correction to achieve resolution of OSA.
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Affiliation(s)
- Rashi Kochhar
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, CT
| | - Vikash Modi
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, NY
| | - Neranjan de Silva
- Department of Pediatrics, Division of Pulmonology, Allergy & Immunology, Weill Cornell Medicine, NY
| | | | - Jay M Neugarten
- The New York Center for Orthognathic and Maxillofacial Surgery, Weill Cornell Medicine, NY
| | - Mary J Ward
- Department of Pediatrics, Division of Pulmonology, Allergy & Immunology, Weill Cornell Medicine, NY
| | - Linda M Gerber
- Department of Population Health Sciences, Weill Cornell Medicine, NY
| | - Anjile An
- Department of Population Health Sciences, Weill Cornell Medicine, NY
| | - Elizabeth Mauer
- Department of Population Health Sciences, Weill Cornell Medicine, NY
| | - Haviva Veler
- Department of Pediatrics, Division of Pulmonology, Allergy & Immunology, Weill Cornell Medicine, NY
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Mao Z, Battaglino R, Zhou J, Cui Y, Shrivastava M, Tian G, Sahebdel F, Ye L. The Effect of Timing of Mandibular Distraction Osteogenesis on Weight Velocity in Infants Affected by Severe Robin Sequence. Children (Basel) 2022; 9:children9030319. [PMID: 35327691 PMCID: PMC8947281 DOI: 10.3390/children9030319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 11/23/2022]
Abstract
Background: Impaired weight gain is prevalent in Robin Sequence (RS) newborns. Although mandibular distraction osteogenesis (MDO) has been proven to improve oral feeding, its impact on postoperative weight gain remains unclear. The purpose of this study is to explore whether MDO can help RS babies reach a normal weight, as well as the effect of MDO timing on weight velocity. Methods: One hundred infants with severe RS and one hundred with normal controls met the inclusion criteria for the study. Included patients underwent MDO. Weights at different timing points were recorded and analyzed and compared to normal controls. Results: After the distractor removal weights of patients undergoing MDO at <1 month and 1−2 months were close to the normal control (6.81 ± 0.93 kg versus 7.18 ± 0.61 kg, p = 0.012, and 6.82 ± 0.98 kg versus 7.37 ± 0.75 kg, p = 0.033, respectively), the weights of patients undergoing MDO at 2−3 months and 3−4 months still lagged behind (7.56 ± 1.29 kg versus 8.20 ± 0.61 kg, p = 0.000206 and 7.36 ± 1.05 kg versus 8.25 ± 0.77 kg, p = 0.004, respectively). The weights of all RS infants undergoing MDO showed no significant difference compared to the controls when they aged to 1 year (9.34 ± 0.99 kg versus 9.55 ± 0.45 kg, p = 0.254 for MDO at <1 month; 9.12 ± 0.91 kg versus 9.33 ± 0.46 kg, p = 0.100 for MDO at 1 to 2 months; 9.38 ± 0.29 kg versus 9.83 ± 0.53 kg, p = 0.098 for MDO at 2 to 3 months; and 9.38 ± 0.29 kg versus 9.83 ± 0.53 kg, p = 0.098 for MDO at 3 to 4 months). Conclusion: The MDO procedure helped patients with severe RS to reach a normal weight; and MDO intervention was recommended at an early stage for early weight gain.
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Affiliation(s)
- Zhe Mao
- Department of Oral and Maxillofacial Surgery, Guangzhou Women and Children’s Medical Center, Guangzhou 510623, China; (Z.M.); (J.Z.); (Y.C.); (G.T.)
| | - Ricardo Battaglino
- Department of Rehabilitation Medicine, Medical School, University of Minnesota, Minneapolis, MN 55455, USA; (R.B.); (F.S.)
| | - Jiawei Zhou
- Department of Oral and Maxillofacial Surgery, Guangzhou Women and Children’s Medical Center, Guangzhou 510623, China; (Z.M.); (J.Z.); (Y.C.); (G.T.)
| | - Yingqiu Cui
- Department of Oral and Maxillofacial Surgery, Guangzhou Women and Children’s Medical Center, Guangzhou 510623, China; (Z.M.); (J.Z.); (Y.C.); (G.T.)
| | - Mayank Shrivastava
- Department of Diagnostic and Biological Sciences, School of Dentistry, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Gabriel Tian
- Department of Oral and Maxillofacial Surgery, Guangzhou Women and Children’s Medical Center, Guangzhou 510623, China; (Z.M.); (J.Z.); (Y.C.); (G.T.)
| | - Faezeh Sahebdel
- Department of Rehabilitation Medicine, Medical School, University of Minnesota, Minneapolis, MN 55455, USA; (R.B.); (F.S.)
| | - Liang Ye
- Department of Rehabilitation Medicine, Medical School, University of Minnesota, Minneapolis, MN 55455, USA; (R.B.); (F.S.)
- Correspondence:
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11
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Khansa I, Aldabbeh S, Pearson GD, Baylis A, Madhoun LL, Schoenbrunner A, Splaingard M, Kirschner RE. Airway and Feeding Outcomes in Pierre Robin Sequence: A Comparison of Three Management Strategies. Cleft Palate Craniofac J 2022; 60:689-694. [PMID: 35098759 DOI: 10.1177/10556656221076345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Controversy remains regarding optimal management of Pierre Robin sequence (PRS). The goal of this study was to compare airway and feeding outcomes in infants with PRS who underwent surgical intervention, specifically mandibular distraction osteogenesis (MDO) or tongue-lip adhesion (TLA), or who had conservative management (CM) without surgery. METHODS All consecutive patients treated for PRS at a pediatric academic medical center, with at least one year follow-up, were included. Patients who underwent tracheostomy as an index procedure were excluded. Patients were divided into those who underwent MDO, TLA or CM. Feeding status and data from initial and follow-up polysomnograms were collected. Comparisons between groups were made using the Kruskal-Wallis test, followed by Mann-Whitney pairwise comparison with a Bonferroni correction, when appropriate. RESULTS 67 neonates were included. 19 underwent TLA, 29 underwent MDO and 19 underwent CM. The proportions of syndromic patients were similar between groups. Patients undergoing CM had the lowest baseline AHI (9.1), but there were no significant differences between TLA (20.1) and MDO (25.4). At follow-up, the three groups had similar mean AHI (MDO 1.3, TLA 4.2, CM 4.5). A similar proportion of patients achieved AHI 5 or less (TLA 89.5%, MDO 96.6%, CM 84.2%). At one year, there were no significant differences in weight percentiles or in risk of failure-to-thrive between groups. One patient from the TLA group required a tracheostomy. CONCLUSION The three treatment modalities achieved high airway and feeding success rates. All three modalities should have a place in the armamentarium of the craniofacial surgeon.
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Affiliation(s)
- Ibrahim Khansa
- Department of Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Plastic and Reconstructive Surgery, 12305The Ohio State University College of Medicine, Columbus, OH, USA
| | - Summer Aldabbeh
- 2647The Ohio State University College of Medicine, Columbus, OH, USA
| | - Gregory D Pearson
- Department of Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Plastic and Reconstructive Surgery, 12305The Ohio State University College of Medicine, Columbus, OH, USA
| | - Adriane Baylis
- Department of Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Plastic and Reconstructive Surgery, 12305The Ohio State University College of Medicine, Columbus, OH, USA
| | - Lauren L Madhoun
- Department of Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Plastic and Reconstructive Surgery, 12305The Ohio State University College of Medicine, Columbus, OH, USA
| | - Anna Schoenbrunner
- Department of Plastic and Reconstructive Surgery, 12305The Ohio State University College of Medicine, Columbus, OH, USA
| | - Mark Splaingard
- Sleep Disorder Center, Division of Pulmonary Medicine, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Richard E Kirschner
- Department of Plastic and Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Plastic and Reconstructive Surgery, 12305The Ohio State University College of Medicine, Columbus, OH, USA
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12
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Han T, Ji Y, Cui J, Kong L, Shi L, Chen J, Shen W. Treated Pierre Robin Sequence Using Placed Allogenic Acellular Bone Matrix and Mandibular Distraction Osteogenesis in the Neonate. Front Pediatr 2022; 10:890156. [PMID: 35676894 PMCID: PMC9168749 DOI: 10.3389/fped.2022.890156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The aim of the study was to report our experience with placed allogenic acellular bone matrix and mandibular distraction osteogenesis in Pierre Robin sequence (PRS), and explore the role of distraction in the osteogenesis of acellular bone. MATERIALS AND METHODS A total of 428 neonates with severe PRS managed with placing allogenic acellular bone and bilateral mandibular distraction osteogenesis were included in the study. The procedure included using oblique-shaped osteotomy, fixing bilateral mandibular distractor, instantly extending a 4-6 mm gap, and placing allogenic acellular bone into the gap. The length of allogenic acellular bone was 4-5 mm. Although the surgical techniques, distraction, and consolidation periods were similar, the allogenic acellular bone matrix we placed was quite different from the traditional distraction. With the technology we used, tracheal intubation could be immediately removed, thus quickly improving breathing conditions compared to traditional methods after the surgery. The jaw extending and oral feeding could begin on the 5th day. The jaw was extended 0.6 mm twice a day until the mandible was overcorrected by 20%. RESULTS All 428 cases included in this study were successfully extubated after the operation, and the difficulty in breathing was instantly relieved. Total mandibular distraction was 15-20 mm. Oral feeding was started at 6 h to 6 days postoperatively, while hospital stay ranged from 18 to 20 days postoperatively. No major complications were reported. Medium to long-term results was good. Mandibular distractors were removed after 3 months. CONCLUSIONS Bilateral mandibular distraction osteogenesis combined with placing allogenic acellular bone in the neonate are safe and accurate procedures, which are the primary treatment options for cases of severe PRS. It can be considered that the tension of distraction can promote osteogenesis in acellular bone and thus improve distractive effect of the mandible.
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Affiliation(s)
- Tao Han
- Department of Burns and Plastic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yi Ji
- Department of Burns and Plastic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jie Cui
- Department of Burns and Plastic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Liangliang Kong
- Department of Burns and Plastic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lijun Shi
- Department of Burns and Plastic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jianbin Chen
- Department of Burns and Plastic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Weimin Shen
- Department of Burns and Plastic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
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13
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Taufique Z, Ebert B, Smith EC, Zavala H, Scott AR, Roby BB. The Safety and Efficacy of Mandibular Distraction Osteogenesis Among Infants Less Than 3 kg. Laryngoscope 2021; 132:1295-1299. [PMID: 34636425 DOI: 10.1002/lary.29877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/16/2021] [Accepted: 09/09/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS Mandibular distraction osteogenesis (MDO) is a safe and effective surgery to address respiratory and feeding issues due to micrognathia in patients with Robin Sequence (RS). Previous studies examining postoperative complications in neonates receiving MDO have considered 4 kg as the cut-off for low weight; however, an increasing number of MDO interventions are performed in infants <4 kg. To determine if a weight <3 kg at time of MDO is a risk factor for postoperative complications or need for subsequent tracheostomy or gastrostomy tube (G-tube). STUDY DESIGN Retrospective chart review. METHODS A retrospective review of all infants <6 months of age undergoing MDO at two tertiary pediatric hospitals from 2008 to 2018. Demographic data, syndromic status, weight, and age at time of surgery, length of postoperative hospital stay, and postoperative outcomes were recorded including tracheostomy placement, G-tube placement, hardware infection, reintubation, facial/marginal mandibular nerve damage, and need for revision MDO. RESULTS Sixty-nine patients with RS were included. The mean age at MDO was 25 ± 20 days and mean weight was 3.32 ± 0.44 kg. There was no statistically significant correlation between weight (P = .699) or age (P = .422) and unfavorable postoperative outcomes. No patients (0%) underwent tracheostomy pre-MDO. Two patients (2.9%) required tracheostomy postsurgery; neither was <3 kg. Eight patients (11.6%) required a G-tube postoperatively. CONCLUSION Newborns <3 kg who undergo MDO experience the same rates of success and complication as larger infants, suggesting that MDO is a safe and efficacious procedure in infants less than 3 kg. Laryngoscope, 2021.
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Affiliation(s)
- Zahrah Taufique
- Department of ENT and Facial Plastic Surgery, Children's Minnesota, Minneapolis, Minnesota, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, U.S.A
| | - Bridget Ebert
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, U.S.A
| | - Emily C Smith
- Department of Pediatric Otolaryngology, Tufts Children's Hospital, Tufts Medical Center, Boston, Massachusetts, U.S.A
| | - Hanan Zavala
- Department of ENT and Facial Plastic Surgery, Children's Minnesota, Minneapolis, Minnesota, U.S.A
| | - Andrew R Scott
- Department of Pediatric Otolaryngology, Tufts Children's Hospital, Tufts Medical Center, Boston, Massachusetts, U.S.A
| | - Brianne B Roby
- Department of ENT and Facial Plastic Surgery, Children's Minnesota, Minneapolis, Minnesota, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A
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14
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Marston AP, Patel T, Pecha PP, Nguyen SA, Discolo CM. Impact of Hospital Characteristics on Mandibular Distraction Osteogenesis Outcomes Among Patients With Pierre Robin Sequence Utilizing a National Inpatient Database. Cleft Palate Craniofac J 2021; 59:622-628. [PMID: 33977781 DOI: 10.1177/10556656211015007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This study collected national inpatient data to investigate the impact of hospital specialty and size on patient outcomes following mandibular distraction osteogenesis (MDO). DESIGN Kids' Inpatient Database was used to identify patients less than 12 months of age with Pierre Robin sequence (PRS) who underwent MDO in one of the following years: 2006, 2009, and 2012. SETTING Inpatient database from the United States. PARTICIPANTS Two hundred seventy-six patients with PRS underwent MDO with 134 (48.6%) identified as nonsyndromic and 142 (51.4%) as syndromic. INTERVENTIONS Mandibular distraction osteogenesis. MAIN OUTCOME MEASURES Length of hospital stay, adjunct airway and nutritional interventions and disposition. RESULTS The average length of stay was 24 and 30 days for patients with nonsyndromic and syndromic PRS, respectively (P = .066). Patients with a syndromic as compared to nonsyndromic diagnosis had a higher incidence of gastrostomy tube placement (21.8 vs 12.7%, P = .045). Univariate analysis showed that a lower proportion of patients at children's hospitals as compared to non-children's hospitals necessitated 1 or more airway or nutrition-related intervention (19/148 [12.8%] vs 31/127 [24.4%]; P = .012) and had a lower incidence of a nonroutine discharge (transfer or patient death; 7.4% vs 40.0% nonroutine; P < .001). Multivariable analysis additionally revealed that patients at children's hospitals were less likely to discharge nonroutine (OR = 0.07, 95% CI: 0.02-0.32). CONCLUSIONS Results from this national cohort demonstrated that at children-specific hospitals patients with PRS were less likely to require additional airway and nutritional procedures and more likely to discharge to home.
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Affiliation(s)
- Alexander P Marston
- Department of Otolaryngology-Head and Neck Surgery, Tufts University School of Medicine, Boston, MA, USA
| | - Terral Patel
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Phayvanh P Pecha
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Christopher M Discolo
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
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15
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Kwan JT, Ebert BE, Roby BB, Scott AR. Detection of Chronic Hypoventilation Among Infants With Robin Sequence Using Capillary Blood Gas Sampling. Laryngoscope 2021; 131:2789-2794. [PMID: 33914349 DOI: 10.1002/lary.29594] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 04/03/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS To describe the use of capillary blood gas (CBG) sampling to detect and quantify hypoventilation in infants with Robin sequence (RS). METHODS Case series with chart review at two institutions. Infants with RS presenting over a 10-year period were identified using departmental databases. CBG values obtained during infancy or until airway intervention (AI) were reviewed. RESULTS From 2008 to 2018, 111 infants with RS were identified as having had been assessed and managed from birth or transfer until discharge home and having CBG data available. In most cases, CBG sampling was obtained every other day until intervention or discharge. A total of 81 (73%) infants required AI: 72 (89%) underwent mandibular distraction osteogenesis, five (6%) underwent tracheotomy, and four (5%) were discharged home with a nasopharyngeal airway. The mean PCO2 at day of life (DOL) 7-30 for the AI group was 52.7 mmHg (95% confidence interval: 51.7-53.7) and for the no AI group was 45.9 mmHg (44.8-47.0; P < .0001). The mean HCO3 at DOL 7-30 for the AI group was 29.8 mEq/L (29.4-30.1) and for the no AI group was 27.0 mEq/L (26.5-27.4; P < .0001). Receiver operating characteristic curves were created for maximum PCO2 and HCO3 values and cutoffs were established by optimizing a balance of sensitivity and specificity. Infants requiring AI surpassed the PCO2 and HCO3 cutoff at a median of DOL 9. CONCLUSIONS Among infants with RS and hypoventilation, objective measures of respiratory acidosis may be apparent by DOL 9. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- James T Kwan
- Department of Otolaryngology - Head & Neck Surgery, Tufts University School of Medicine, Boston, Massachusetts, U.S.A
| | - Bridget E Ebert
- Department of Otolaryngology - Head & Neck Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, U.S.A
| | - Brianne B Roby
- Department of Otolaryngology - Head & Neck Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, U.S.A.,Department of Otolaryngology and Facial Plastic Surgery, Children's of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Andrew R Scott
- Department of Otolaryngology - Head & Neck Surgery, Tufts University School of Medicine, Boston, Massachusetts, U.S.A.,Divisions of Pediatric Otolaryngology and Facial Plastic Surgery, Department of Otolaryngology-Head and Neck Surgery, Tufts Children's Hospital - Tufts Medical Center, Boston, Massachusetts, U.S.A
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16
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Zhang N, Mao Z, Cui Y, Xu Y, Tan Y. Risk Factors of Prolonged Mechanical Ventilation in Infants With Pierre Robin Sequence After Mandibular Distraction Osteogenesis: A Retrospective Cohort Study. Front Pediatr 2021; 9:587147. [PMID: 33912517 PMCID: PMC8072210 DOI: 10.3389/fped.2021.587147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 03/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background: After mandibular distraction osteogenesis (MDO), most infants with Pierre Robin sequence (PRS) require mechanical ventilation to assist their breathing. However, the optimal duration of intubation during early mandibular distraction osteogenesis activation is poorly understood. This retrospective study was carried out to identify perioperative risk factors of prolonged mechanical ventilation in infants undergoing MDO. Methods: A total of 95 infants with PRS underwent MDO at Guangzhou Women and Children's Medical Center between 2016 and 2018, and the clinical records of 74 infants who met the selection criteria were analyzed. Of the 74 infants, 26 (35.1%) underwent prolonged mechanical ventilation, 48 (64.9%) did not. t-test, Wilcoxon Sum Rank test or chi-squared test were performed to compare variables that might associate with prolonged mechanical ventilation between the two groups, and then, significant variables identified were included in the multivariate logistic regression model to identify independent variables. Results: Univariate logistic regression analysis revealed that age, preoperative gonial angle, and postoperative pulmonary infection were associated with prolonged mechanical ventilation (all P < 0.05). Multivariate logistic regression analysis confirmed that the preoperative gonial angle and postoperative pulmonary infection were independent risk factors of prolonged mechanical ventilation (both P < 0.05). Conclusions: Infants with PRS and smaller preoperative gonial angle or postoperative pulmonary infection may be more likely to undergo prolonged mechanical ventilation after MDO. For others, extubation may be attempted within 6 days after MDO.
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Affiliation(s)
- Na Zhang
- Department of Anesthesia and Preoperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Zhe Mao
- Department of Stomatology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Yingqiu Cui
- Department of Stomatology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Yingyi Xu
- Department of Anesthesia and Preoperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Yonghong Tan
- Department of Anesthesia and Preoperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou, China
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17
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Şensoy AT, Kaymaz I, Ertaş Ü. Biomechanical evaluation of a novel mandibular distraction osteogenesis protocol: an in-vitro validation and the practical use of the method. Comput Methods Biomech Biomed Engin 2020; 24:1-12. [PMID: 33241695 DOI: 10.1080/10255842.2020.1850704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/28/2020] [Accepted: 11/10/2020] [Indexed: 10/22/2022]
Abstract
The aim of this study was to optimize and experimentally validate the certain parameters affecting the operation success of Mandibular Distraction Osteogenesis (MDO). According to FEA results, the displacement of the samples showed 28.5% reduction as only the osteotomy line was separately optimized, and 64.2% less displacement was determined when the osteotomy line and the screw configuration were optimized together. In consistent with the FEA results, the samples showed 62% and 84.5% fewer displacement values, respectively. As a result, the MDO protocol suggested, which is validated by both numerical and experimental studies, offers promising outcomes for operation success.
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Affiliation(s)
- A T Şensoy
- Engineering Faculty, Samsun University, Samsun, Turkey
| | - I Kaymaz
- Mechanical Engineering Department, Erzurum Technical University, Erzurum, Turkey
| | - Ü Ertaş
- Oral & Maxillofacial Surgery Department, Atatürk University, Erzurum, Turkey
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18
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Siegel N, Lopez J, Shi AC, Neimanis S, Jodeh D, Khavanin N, Redett RJ, Sterni LM, Walsh JM, Dalesio NM, Rottgers SA, Morrison CS, Steinberg JP. Laryngoscopy Grade Improvement and Difficult Airway Resolution in Infants With Robin Sequence Undergoing Mandibular Distraction Osteogenesis: A Multi-Institutional Study. Cleft Palate Craniofac J 2020; 58:805-814. [PMID: 33030045 DOI: 10.1177/1055665620964052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Mandibular distraction osteogenesis (MDO) aims to relieve tongue-based airway obstruction in Robin Sequence (RS). We investigated direct laryngoscopy grade (DLG) improvement and difficult airway (DA) resolution following MDO. DESIGN Retrospective cohort analysis. SETTING Three tertiary care institutions. PATIENTS Sixty-four infants with RS who underwent a single MDO procedure in their first year of life were identified from January 2010 to January 2019. MAIN OUTCOME MEASURES The primary outcome was DLG pre- and post-MDO. Secondary outcomes included DA designation, pre- and post-MDO polysomnographic assessment for obstructive sleep apnea (OSA), length of stay, need for gastrostomy, and major/minor adverse events. RESULTS Median DLG improved from II pre-MDO to I at the time of distractor removal (n = 43, P < .001). No significant change was seen in patients with a third recorded time point (eg, palatoplasty; n = 78, P = .52). Twenty-six (47%) of 55 patients were designated as DA pre-MDO, and 10 (18%) of 55 patients retained the label post-MDO (P < .01). Five (50%) of these 10 patients appeared to be inappropriately retained. Median obstructive apnea-hypopnea index improved from 38.6 (range 31.2-62.8) pre-MDO to 2.9 (range 1-3.9) post-MDO (n = 12; P = .002). CONCLUSION Mandibular distraction osteogenesis allowed for DLG improvement that was stably maintained as well as functional improvement in OSA, with minimal morbidity. Difficult airway designation persisted in the electronic record of some infants despite clinical resolution.
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Affiliation(s)
- Nicholas Siegel
- Department of Plastic and Reconstructive Surgery, 1500The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Joseph Lopez
- Department of Plastic and Reconstructive Surgery, 1500The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Aria C Shi
- Department of Plastic and Reconstructive Surgery, 1500The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sara Neimanis
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 6923University of Rochester Medical Center, Rochester, NY, USA
| | - Diana Jodeh
- Department of Plastic and Reconstructive Surgery, 7582Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Nima Khavanin
- Department of Plastic and Reconstructive Surgery, 1500The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Richard J Redett
- Department of Plastic and Reconstructive Surgery, 1500The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Laura M Sterni
- Division of Pulmonology, Department of Pediatrics, 1500The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jonathan M Walsh
- Department of Otolaryngology-Head and Neck Surgery, 1500The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Nicholas M Dalesio
- Department of Anesthesiology, 1500The Johns Hopkins Hospital, Baltimore, MD, USA
| | - S Alex Rottgers
- Department of Plastic and Reconstructive Surgery, 7582Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Clinton S Morrison
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 6923University of Rochester Medical Center, Rochester, NY, USA
| | - Jordan P Steinberg
- Department of Plastic and Reconstructive Surgery, 1500The Johns Hopkins Hospital, Baltimore, MD, USA
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19
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Susarla SM, Mercan E, Evans K, Egbert MA, Hopper RA. Short-term condylar and glenoid fossa changes in infants with Pierre Robin sequence undergoing mandibular distraction osteogenesis. Int J Oral Maxillofac Surg 2020; 50:171-178. [PMID: 32814654 DOI: 10.1016/j.ijom.2020.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/05/2020] [Accepted: 07/07/2020] [Indexed: 11/16/2022]
Abstract
The purpose was to evaluate short-term changes in condylar and glenoid fossa morphology in infants with Pierre Robin sequence (PRS) undergoing early (age <4 months) mandibular distraction osteogenesis (MDO) for the management of severe airway obstruction. Computed tomography data from infants with PRS who had MDO were compared to those of age-matched control infants without facial skeletal dysmorphology. Surface/volume, linear, and angular measurements of the condyle and glenoid fossa were obtained and compared between infants with PRS and controls. Eleven infants with PRS met the inclusion criteria. There were five female and six male subjects with a mean age at the time of MDO of 41±32 days. Prior to MDO, PRS mandibles had a smaller condylar articulating surface area and volume than age-matched control mandibles, with a more laterally positioned condylar axis (P≤0.05). Following MDO, there were significant increases in condylar articulating surface area and volume, approaching those of normal controls, with further lateral translation of the condylar axis (P≤0.05). Condyle and glenoid fossa morphology is largely normalized following early MDO in infants with PRS. The condylar axis translates laterally as a result of MDO; this change is not observed with mandibular growth in infants without PRS.
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Affiliation(s)
- S M Susarla
- Division of Plastic and Craniofacial Surgery, Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA; Division of Oral and Maxillofacial Surgery, Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA.
| | - E Mercan
- Division of Plastic and Craniofacial Surgery, Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - K Evans
- Division of Craniofacial Medicine, Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - M A Egbert
- Division of Plastic and Craniofacial Surgery, Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA; Division of Oral and Maxillofacial Surgery, Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - R A Hopper
- Division of Plastic and Craniofacial Surgery, Craniofacial Center, Seattle Children's Hospital, Seattle, Washington, USA
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Jones Oguh S, Elden L, Swanson J, Tapia I, Subramanyam R. New treatments for obstructive sleep apnea in children. Paediatr Anaesth 2020; 30:232-240. [PMID: 31788899 DOI: 10.1111/pan.13775] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 11/26/2019] [Indexed: 11/26/2022]
Abstract
Obstructive sleep apnea (OSA) has a prevalence of up to 5% in children and 50% in obese children. OSA is associated with various comorbidities in the general population and in the perioperative period. In this review, we will provide background of OSA and insights into the available treatment options both surgically and medically. Unlike adults, most pediatric OSA is treated with adenotonsillectomy. Continuous positive airway pressure therapy is the commonly used medical treatment. Management of pediatric OSA is multidisciplinary. We will discuss the surgical options and medical options of managing pediatric OSA.
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Affiliation(s)
- Sheri Jones Oguh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lisa Elden
- Division of Otolaryngology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jordan Swanson
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ignacio Tapia
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rajeev Subramanyam
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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21
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Yu X, Wang J, Hou S, Zeng R. Mandibular distraction osteogenesis in the treatment of pediatric temporomandibular joint ankylosis with micrognathia and obstructive sleep apnea syndrome: A case report with 4-year follow-up. Exp Ther Med 2019; 18:4888-4892. [PMID: 31798712 PMCID: PMC6880390 DOI: 10.3892/etm.2019.8119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 10/02/2019] [Indexed: 11/15/2022] Open
Abstract
Temporomandibular joint (TMJ) ankylosis in pediatric patients is rare and may cause severe micrognathia and obstructive sleep apnea syndrome. The present study reports on the treatment and 4-year follow-up of a pediatric patient with early-onset bilateral TMJ ankylosis and severe secondary micrognathia, as well as obstructive sleep apnea syndrome. A typical ‘bird face’ appearance was noted with severe mandible retrognathism and a significant convex facial profile. The treatment of this patient involved TMJ ankylosis release with condylectomy and simultaneous bilateral mandibular distraction osteogenesis, which enabled the surgeons to simultaneously reconstruct the neocondyle and correct facial malformations. Following treatment, the micrognathia was corrected and the oropharyngeal airway was significantly expanded. However, the maximal incisal opening was limited. During the 4-year follow-up, no signs of mandible retraction were noted and mouth opening increased to 17 mm (passive) compared with the inability to open that was noted immediately following surgery. A certain degree of MIO shrinkage was identified in the patient. In such cases of TMJ ankylosis, early post-operative exercise, active post-operative physiotherapy and stringent follow-up are essential to prevent post-operative shrinkage and adhesions.
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Affiliation(s)
- Xingna Yu
- Department of Oral and Maxillofacial Surgery, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong 510055, P.R. China
| | - Jianning Wang
- Department of Oral and Maxillofacial Surgery, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong 510055, P.R. China
| | - Shida Hou
- Department of Oral and Maxillofacial Surgery, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong 510055, P.R. China
| | - Rongsheng Zeng
- Department of Oral and Maxillofacial Surgery, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong 510055, P.R. China
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22
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Zhang N, Mao Z, Cui Y, Tan Y, Zhang H, Ye X, Xu Y. Optimal duration of mechanical ventilation and influencing factors following mandibular distraction osteogenesis in infants with Pierre Robin sequence. Medicine (Baltimore) 2019; 98:e18339. [PMID: 31860988 PMCID: PMC6940173 DOI: 10.1097/md.0000000000018339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Mandibular distraction osteogenesis (MDO) is an effective treatment for tongue-based airway obstruction in infants with severe Pierre Robin sequence (PRS). Most infants receiving MDO require postoperative mechanical ventilation (MV) to assist breathing. Optimal MV time for each individual patient and factors influencing the time must be identified to guide clinical decision-making.A retrospective analysis was performed on 75 infants with PRS receiving MDO from November 2016 to August 2018. Twenty-six were females and 47 were males. Data extracted from the hospital information system included sex, age, weight, history of preterm labor, preoperative pulmonary infection, laryngomalacia/tracheomalacia, laryngoscope exposure classification, anesthesia duration, operation duration, postoperative treatment site, situation of distraction, postoperative complications and MV duration. Statistical analyses were conducted to investigate the potential associations of these factors with MV time.Seventy-three PRS syndrome patients received anesthesia for MDO device procedures were considered eligible for study. Patient sex, history of preterm labor, preoperative pulmonary infection, laryngomalacia/tracheomalacia, laryngoscopy exposure difficulty, postoperative treatment site (neonatal or pediatric intensive care unit), ventilator-associated pneumonia, age, weight, anesthesia duration, and operation duration had no significant influence on postsurgical MV time (P > .05). Amount of distraction at the time of extubation had statistically significant influence on postoperative MV time (P < .05). In addition, scatter plots revealed linear relationships between postoperative MV time and amount of distraction at extubation.According to this analysis, amount of distraction was associated with MV time following MDO for severe PRS and roughly 6 days post-surgery is a generally safe extubation time.
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Affiliation(s)
- Na Zhang
- Department of Anaesthesia and Prioperative Medicine, Guangzhou Women and Children Medical Center
| | - Zhe Mao
- Department of Stomatology, Guangzhou Women and Children Medical Center, Guangzhou, Guangdong, PR China
| | - Yingqiu Cui
- Department of Stomatology, Guangzhou Women and Children Medical Center, Guangzhou, Guangdong, PR China
| | - Yonghong Tan
- Department of Anaesthesia and Prioperative Medicine, Guangzhou Women and Children Medical Center
| | - Huanhuan Zhang
- Department of Anaesthesia and Prioperative Medicine, Guangzhou Women and Children Medical Center
| | - Xiaoxin Ye
- University of New South Wales, Sydney, NSW, Australia
| | - Yingyi Xu
- Department of Anaesthesia and Prioperative Medicine, Guangzhou Women and Children Medical Center
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Abstract
OBJECTIVES To assess for differences in postoperative care following mandibular distraction osteogenesis (MDO) in infants before and after implementation of a standardized protocol. STUDY DESIGN Retrospective chart review. SETTING Urban tertiary pediatric hospital. SUBJECTS AND METHODS The inpatient charts of infants who underwent MDO before 90 days of age were assessed for metrics such as postoperative length of stay (LOS), duration of mechanical ventilation, and the choice and duration of sedating medications. RESULTS Over a 6-year period, 16 patients met inclusion criteria. The first 4 consecutive patients were managed at the discretion of the critical care staff. The remaining 12 infants were managed with a planned 4- to 6-day period of postoperative intubation, during which a standard protocol determined the choice, dosage, and duration of sedating medications. The mean age was similar between groups (preprotocol: mean, 26.5 days; protocol: mean, 20.3 days; P = .51). The mean postoperative LOS was 13.3 days less among infants managed with the protocol (P = .06), and the mean number of midazolam boluses was fewer among protocol patients (P < .01). A more consistent postoperative LOS, duration of mechanical ventilation, and exposure to sedating medications was observed among protocol subjects (P < .01). The LOS for 2 patients in the preprotocol group was extended due to iatrogenic withdrawal syndrome. There were no instances of accidental extubation or anoxia in either group. CONCLUSIONS Among infants undergoing MDO, standardizing postoperative airway and sedation practices may offer a more predictable postoperative course as compared with a case-by-case management philosophy.
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Affiliation(s)
- Grace R Leu
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Andrew R Scott
- Tufts University School of Medicine, Boston, Massachusetts, USA.,Divisions of Pediatric Otolaryngology and Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, USA.,Department of Pediatrics, Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts, USA
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24
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Tomáz FMDAF, Borges AH, Borba AM, Volpato LER. Recovering Breathing and Feeding of a Newborn with Pierre Robin Sequence. Ann Maxillofac Surg 2017; 7:104-107. [PMID: 28713745 PMCID: PMC5502493 DOI: 10.4103/ams.ams_20_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Pierre Robin sequence (PRS) is characterized by the triad micrognathia, glossoptosis, and airway obstruction, commonly associated with cleft palate. This study reports the case of a patient with characteristics consistent with the diagnosis of PRS in the 1st week of life. To stabilize the airway, oro-tracheal intubation was performed without success, followed by tracheostomy and glossopexy and after a small improvement in symptoms, it was decided to perform the mandibular distraction osteogenesis (MDO). At the age of 6, her maxillofacial development was within expectations, with patent airway, the presence of deciduous teeth, and without neurological impairment. The MDO described in this case allowed patient's respiratory and feeding improvement, thus avoiding episodes of cyanosis, allowing timely removal of the tracheostomy and glossopexy, and execution of palatoplasty at the right time. While it is uncertain whether MDO will replace the possible need for future orthognathic surgery, treatment greatly improved the quality of life of the patient.
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25
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Li WY, Poon A, Courtemanche D, Verchere C, Robertson S, Bucevska M, Malic C, Arneja JS. Airway Management in Pierre Robin Sequence: The Vancouver Classification. Plast Surg (Oakv) 2017; 25:14-20. [PMID: 29026807 DOI: 10.1177/2292550317693814] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pierre Robin sequence (PRS) is a triad of micrognathia, glossoptosis, and respiratory distress. There is no standard clinical classification used in the management of neonatal airway in patients with PRS. The goal of our study was to review the presentation and management of patients with PRS and formulate a clinical grading system and treatment algorithm. METHODS A 10-year retrospective review of all neonates diagnosed with PRS was performed after obtaining institutional ethics approval. Patients were identified using our cleft lip and palate program database. Inclusion criteria were 2 of the following 3 clinical features-glossoptosis, retrognathia, or airway obstruction. We collected demographic data, clinical information (coexisting airway morbidity, maxillary-mandibular discrepancy, type of intervention used, complications, and outcomes (feeding, length of stay, and airway status) during the first year of life. RESULTS Sixty-three patients met our inclusion criteria. Of these, 55 (87%) had cleft palate and 17 (27%) were syndromic. Forty-eight (76%) patients were managed by prone positioning. Of the 15 surgically managed patients, the initial procedure was floor of mouth release in 7, mandibular distraction osteogenesis (MDO) in 4, and tongue-lip adhesion in 4. Five patients with coexisting airway morbidity needed a second surgery; 2 had MDO and 3 tracheostomies (one patient was later decannulated). Seven (47%) of the surgically managed patients required a gastrostomy tube. CONCLUSION At present, there is no consensus on neonatal airway management in infants with PRS. From our review of 63 patients with PRS, we hereby propose a simple 4-point classification system and treatment algorithm, based on clinical features.
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Affiliation(s)
- Wai-Yee Li
- Division of Plastic Surgery, University of British Columbia, Vancouver, Canada.,British Columbia Children's Hospital, Vancouver, Canada
| | - Alana Poon
- Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Douglas Courtemanche
- Division of Plastic Surgery, University of British Columbia, Vancouver, Canada.,British Columbia Children's Hospital, Vancouver, Canada
| | - Cynthia Verchere
- Division of Plastic Surgery, University of British Columbia, Vancouver, Canada.,British Columbia Children's Hospital, Vancouver, Canada
| | | | - Marija Bucevska
- Division of Plastic Surgery, University of British Columbia, Vancouver, Canada
| | - Claudia Malic
- Division of Plastic Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | - Jugpal S Arneja
- Division of Plastic Surgery, University of British Columbia, Vancouver, Canada.,British Columbia Children's Hospital, Vancouver, Canada
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26
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Tee BC, Sun Z. Mandibular distraction osteogenesis assisted by cell-based tissue engineering: a systematic review. Orthod Craniofac Res 2016; 18 Suppl 1:39-49. [PMID: 25865532 DOI: 10.1111/ocr.12087] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To review the advances and limitations of recent investigations on mandibular distraction osteogenesis (MDO) assisted by mesenchymal stem cell (MSC) transplantation. MATERIALS AND METHODS Following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines, the PubMed, Scopus, and Cochrane electronic databases were systematically searched and screened from their inception through August 2014. Searching terms included the following: 'distraction osteogenesis', 'mandible OR mandibular OR jaw', and 'cells', without any other limitations. RESULTS Nineteen studies meeting the eligibility criteria were selected from 227 published articles and used for qualitative synthesis. Fifteen of the studies used small animal models (rats or rabbits), while the other four used large animal models (dogs, pigs or sheep). Among these studies, large variations exist in MDO protocol, cell transplantation time, route and quantity, as well as methodology of outcome assessment. Additionally, all studies had certain biases. Nevertheless, the majority of studies found that MSC transplantation enhanced MDO bone regeneration. CONCLUSION Evidence from animal studies indicates that MDO may be enhanced by mesenchymal stem cell transplantation, but many questions related to animal models, MDO protocols, and cell transplantation remain to be investigated.
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Affiliation(s)
- B C Tee
- Division of Orthodontics, College of Dentistry, The Ohio State University, Columbus, OH, USA
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27
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Goudy S, Jiramongkolchai P, Chinnadurai S. Logistic regression analysis of Pierre Robin sequence patients requiring surgical intervention. Laryngoscope 2016; 127:945-949. [PMID: 27378721 DOI: 10.1002/lary.26143] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 06/02/2016] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Determine predictive patient characteristics that guide the decision to proceed with surgical management of tongue-based airway obstruction (TBAO) in Pierre Robin sequence (PRS) patients. STUDY DESIGN Retrospective review of PRS patients between 2005 and 2014 requiring observation in the neonatal intensive care unit (NICU). METHODS Patient charts were reviewed for prenatal diagnoses, clinical course, and need for surgical intervention (tracheotomy or mandibular distraction osteogenesis), and the nonsurgical and surgical group were compared with a logistic regression model. RESULTS Thirty-eight PRS patients who were identified with TBAO and required NICU observation had an average follow-up of 5.4 years. Associated anomalies identified in the PRS patients included neurologic disease (n = 6), renal abnormalities (n = 5), limb abnormalities (n = 4), and cardiac abnormalities (n = 12). Nonsurgical management of PRS TBAO included side (n = 12)/stomach positioning (n = 15), oral airway (n = 6), nasopharyngeal airway (NPA) (n = 14), and intubation (n = 12). Surgical intervention occurred in 13 patients, with tracheotomy in eight due to unstable airway, and mandible distraction in five due to NPA dependence. Factors with significant uncontrolled correlations with the need for surgical airways included presence of cardiac disease (P = .03), cardiac disease severity (P = .03), neurologic disease (P = .01), and continuous positive airway pressure (CPAP)/bilevel positive airway pressure (BiPAP) use (P = .006). Further, stepwise regression showed strong predictive value for CPAP/BiPAP use (odds ratio [OR]: 10.43) and presence of neurological disease (OR: 9.16). PRS TBAO patients required multiple modalities of noninvasive surgical intervention to stabilize their airway. CONCLUSIONS This study identified patient characteristics predictive of progression to a surgical airway to address TBAO, which may decrease healthcare utilization and improve quality of life for these families. LEVEL OF EVIDENCE 4 Laryngoscope, 127:945-949, 2017.
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Affiliation(s)
- Steven Goudy
- Department of Otolaryngology, Emory University, Atlanta, Georgia, U.S.A
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28
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Newbury PA, Adams NS, Girotto JA. Mandibular Distraction Osteogenesis: Upper Airway Management in Pierre Robin Sequence. Eplasty 2015; 15:ic50. [PMID: 26396662 PMCID: PMC4564975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Patrick A. Newbury
- aMichigan State University College of Human Medicine, Grand Rapids, Mich
| | - Nicholas S. Adams
- aMichigan State University College of Human Medicine, Grand Rapids, Mich,bGrand Rapids Medical Education Partners Plastic and Reconstructive Surgery Residency, Grand Rapids, Mich,Correspondence:
| | - John A. Girotto
- aMichigan State University College of Human Medicine, Grand Rapids, Mich,bGrand Rapids Medical Education Partners Plastic and Reconstructive Surgery Residency, Grand Rapids, Mich,cHelen DeVos Children's Hospital Pediatric Plastic and Craniofacial Surgery, Grand Rapids, Mich
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29
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Fauman KR, Durgham R, Duran CI, Vecchiotti MA, Scott AR. Sedation after airway reconstruction in children: A protocol to reduce withdrawal and length of stay. Laryngoscope 2015; 125:2216-9. [PMID: 26152806 DOI: 10.1002/lary.25176] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/19/2014] [Accepted: 01/05/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Karen R Fauman
- Department of Pediatrics-Critical Care Medicine, Floating Hospital for Children, Boston, Massachusetts, U.S.A
| | - Rashed Durgham
- Department of Pediatrics-Critical Care Medicine, Floating Hospital for Children, Boston, Massachusetts, U.S.A
| | - Carlos I Duran
- Department of Pediatrics-Critical Care Medicine, Floating Hospital for Children, Boston, Massachusetts, U.S.A
| | - Mark A Vecchiotti
- Department of Pediatric Otolaryngology and Facial Plastic Surgery, Floating Hospital for Children, Boston, Massachusetts, U.S.A
| | - Andrew R Scott
- Department of Pediatric Otolaryngology and Facial Plastic Surgery, Floating Hospital for Children, Boston, Massachusetts, U.S.A
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30
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Abstract
Mandibular distraction has revolutionized the treatment of Robin sequence associated with severe airway obstruction. The distraction technique remains the only intervention that directly corrects mandibular hypoplasia and the retropositioned tongue, providing efficient relief of airway stenosis. Multiple studies have demonstrated the efficacy of distraction in avoiding tracheostomy and decreasing the severity airway obstruction in this patient population. The benefit to avoiding tracheostomy and relieving airway obstruction is superior to that of tongue-lip adhesion. It is, therefore, not surprising that mandibular distraction has become the first-line intervention at many centers for the surgical treatment of Robin sequence. The complication profile associated with mandibular distraction appears low; the most common complication is infection, which can be treated by antibiotics alone. The severity of airway obstruction can be quantified by polysomnogram: This tool has become one of the most widely used objective metrics in the Robin sequence population. Therefore indications for surgery, timing of palatoplasty and long-term assessment of airway function should be performed in conjunction with sleep study analysis. The effects of mandibular lengthening on feeding difficulty in Robin sequence patient remains a topic of controversy. Studies have demonstrated conflicting results: This can be an area of future study. Agreed-upon indications for surgery and definitive protocols of care have yet to be formulized; future research should focus on achieving these goals. Such studies would require agreed-upon terminology for Robin sequence, an increase in comparative and prospective analysis, and the use of quantifiable metrics of clinical results.
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Affiliation(s)
- Roberto L Flores
- Department of Plastic Surgery, NYU Langone Medical Center, New York, New York
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Runyan CM, Uribe-Rivera A, Karlea A, Meinzen-Derr J, Rothchild D, Saal H, Hopkin RJ, Gordon CB. Cost analysis of mandibular distraction versus tracheostomy in neonates with Pierre Robin sequence. Otolaryngol Head Neck Surg 2014; 151:811-8. [PMID: 25052512 DOI: 10.1177/0194599814542759] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To evaluate costs associated with surgical treatment for neonates with Pierre Robin sequence (PRS). STUDY DESIGN Retrospective cohort study. SETTING Cincinnati Children's Hospital Medical Center. SUBJECTS AND METHODS With Institutional Review Board approval, we retrospectively studied neonates with PRS treated from 2001 to 2009 with either tracheostomy (Trach), mandibular distraction (MD), or Trach with subsequent MD (Trach+MD). Actual charges over a 3-year period associated with operative costs, hospital stay, imaging and sleep studies, clinic visits, and related emergency room visits were collected. Home tracheostomy care charges were estimated individually for each patient. Charges were compared using regression and appropriate statistical analyses. RESULTS Forty-seven neonates were included in the study (MD, n = 26; Trach, n = 12; Trach+MD, n = 9). Trach group patients had 2.6-fold higher charges than the MD group despite no difference in length of hospital stay. This difference increased to 7.3-fold when including home trach care-related costs. Trach+MD group patients had longer hospital lengths of stay and higher operation room (OR) fees, but no increased total charges compared with the Trach only group. CONCLUSIONS For patients with severe PRS, mandibular distraction provides significant cost savings over tracheostomy ($300,000 per patient over 3 years). Increased costs with tracheostomy come from greater hospital-related charges, more frequent airway procedures, a higher incidence of gastrostomy tube feeds, and home trach care costs. A careful examination of long-term outcomes will be critical as mandibular distraction continues to gain acceptance for treatment of PRS.
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Affiliation(s)
- Christopher M Runyan
- Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA These authors contributed equally to this article
| | - Armando Uribe-Rivera
- Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA These authors contributed equally to this article
| | - Audrey Karlea
- Kaiser Permanente Clinical Genetics Department, Oakland, California, USA
| | - Jareen Meinzen-Derr
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Dawn Rothchild
- Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Howard Saal
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Robert J Hopkin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA These authors contributed equally to this project
| | - Christopher B Gordon
- Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA These authors contributed equally to this project
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Donneys A, Deshpande SS, Tchanque-Fossuo CN, Johnson KL, Blough JT, Perosky JE, Kozloff KM, Felice PA, Nelson NS, Farberg AS, Levi B, Buchman SR. Deferoxamine expedites consolidation during mandibular distraction osteogenesis. Bone 2013; 55:384-90. [PMID: 23598047 PMCID: PMC4162399 DOI: 10.1016/j.bone.2013.04.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 03/29/2013] [Accepted: 04/07/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND A limitation of mandibular distraction osteogenesis (DO) is the length of time required for consolidation. This drawback subjects patients to possible pin-site infections, as well as a prolonged return to activities of normal daily living. Developing innovative techniques to abridge consolidation periods could be immensely effective in preventing these problematic morbidities. Deferoxamine (DFO) is an angiogenic activator that triggers the HIF-1α pathway through localized iron depletion. We previously established the effectiveness of DFO in enhancing regenerate vascularity at a full consolidation period (28 days) in a murine mandibular DO model. To investigate whether this augmentation in vascularity would function to accelerate consolidation, we progressively shortened consolidation periods prior to μCT imaging and biomechanical testing (BMT). MATERIALS AND METHODS Three time points (14d, 21d and 28d) were selected and six groups of Sprague-Dawley rats (n = 60) were equally divided into control (C) and experimental (E) groups for each time period. Each group underwent external fixator placement, mandibular osteotomy, and a 5.1 mm distraction. During distraction, the experimental groups were treated with DFO injections into the regenerate gap. After consolidation, mandibles were imaged and tension tested to failure. ANOVA was conducted between groups, and p < 0.05 was considered statistically significant. RESULTS At 14 days of consolidation the experimental group demonstrated significant increases in bone volume fraction (BVF), bone mineral density (BMD) and ultimate load (UL) in comparison to non-treated controls. The benefit of treatment was further substantiated by a striking 100% increase in the number of bony unions at this early time-period (C:4/10 vs. E:8/10). Furthermore, metrics of BVF, BMD, Yield and UL at 14 days with treatment demonstrated comparable metrics to those of the fully consolidated 28d control group. CONCLUSION Based on these findings, we contend that augmentation of vascular density through localized DFO injection delivers an efficient means for accelerating bone regeneration without significantly impacting bone quality or strength.
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Affiliation(s)
- Alexis Donneys
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Sagar S. Deshpande
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Kelsey L. Johnson
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Jordan T. Blough
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph E. Perosky
- Orthopedic Research Laboratory, Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Kenneth M. Kozloff
- Orthopedic Research Laboratory, Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Peter A. Felice
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Noah S. Nelson
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron S. Farberg
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Benjamin Levi
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
| | - Steven R. Buchman
- Craniofacial Research Laboratory, Plastic Surgery Section, University of Michigan, Ann Arbor, Michigan, USA
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