Alex Viezel-Mathieu

The Effectiveness of Mandibular Distraction in Improving Airway Obstruction in the Pediatric Population

Background: Distraction osteogenesis is an effective technique for elongating the deficient mandible. The authors specifically evaluated its effectiveness in the treatment of airway obstruction in pediatric patients with mandibular hypoplasia. Method: A comprehensive literature review of the National Library of Medicine (PubMed) database was performed. English-language studies involving isolated distraction of the pediatric mandible (younger than 18 years) with descriptive reporting of airway changes were included. Extracted data included demographics, initial diagnosis, distractor type, distraction protocol, predistraction and postdistraction airway status, and complications. Results: Seventy-four articles met the inclusion criteria, resulting in 711 patients with craniofacial abnormalities who underwent mandibular distraction osteogenesis. Mean age at the time of distraction was 18.1 months. The most common diagnoses were isolated Pierre Robin sequence (52.9 percent), syndromic Pierre Robin sequence (7 percent), and Treacher Collins syndrome (6.8 percent). Mandibular distraction osteogenesis successfully treated airway obstruction in 89.3 percent of cases. Success was defined as either decannulation of tracheostomy, avoidance of tracheostomy or continuous positive airway pressure, or alleviation or significant improvement of obstructive sleep apnea symptoms. One hundred seventy-one (84.2 percent) of the 203 tracheostomy-dependent patients were successfully decannulated. Among the 181 patients with obstructive sleep apnea, mandibular distraction osteogenesis successfully allowed for either complete resolution or significant improvement of symptoms in 95.6 percent. A 23.8 percent overall complication rate was noted. The mean follow-up time was 28.7 months. Conclusion: In addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients.

Outcome Following Surgical Interventions for Micrognathia in Infants with Pierre Robin Sequence: A Systematic Review of the Literature.

Background Tongue-lip adhesion (TLA), mandibular distraction osteogenesis (MDO), and subperiosteal release of the floor of the mouth (SPRFM) are the most commonly performed surgical procedures to treat severe airway obstruction in infants born with Pierre Robin sequence (PRS). Objectives To determine the rate of failure of each type of procedure, in terms of mortality and the need for tracheostomy, and to determine what proportion of infants have significant airway obstruction postoperatively as determined by polysomnography (PSG) and compare the data by procedure type. Method A comprehensive literature search (1981 through June 2015) was done of the National Library of Medicine database using PubMed. Extracted data included diagnosis, type of surgery, and outcome including mortality, need for postoperative tracheostomy and details of PSG. Persistence of significant airway obstruction was defined as an apnea-hypopnea index > 15 events/h on PSG. Results Both mortality rate and need for tracheostomy were low for all procedures. Many studies lacked sufficient detail to identify significant airway obstruction postoperatively. In studies with sufficient data, MDO was associated with the lowest percentage of significant airway obstruction postprocedure (3.6%) compared to 50% for infants who underwent TLA. Insufficient PSG data was available for patients who were treated with SPRFM. Conclusions There is a paucity of objective PSG data to definitively assess postoperative airway outcomes for PRS. MDO appears to be the most effective technique based on the available PSG data. Standardized use of PSG may lead to better identification and treatment of patients at risk for suboptimal airway outcomes postoperatively.

A Systematic Review of the Effectiveness of Tongue Lip Adhesion in Improving Airway Obstruction in Children With Pierre Robin Sequence.

Background:Tongue–lip adhesion (TLA) involves surgically tethering the tongue forward to the lower lip and is a technique to relieve airway obstruction caused by glossoptosis and retrognathia. The purpose of the present study was to evaluate the effectiveness of TLA for the treatment of airway compromise in patients with Pierre Robin sequence (PRS). Methods:A comprehensive literature review was performed. Inclusion criteria consisted of patients having undergone isolated tongue lip adhesion and results that included airway outcome. Selected manuscripts were analyzed with regards to patient demographics, principle diagnosis, pre and postintervention airway status, and complications. Results:Thirteen manuscripts met inclusion criteria, yielding 268 patients with PRS who underwent TLA. The mean age at the time of procedure was 30.5 days. Tongue lip adhesion proved to be successful in relieving airway obstruction caused by PRS in 81.3% (n = 218) of patients. Nonsyndromic patients benefited from a higher success rate as compared with the syndromic cohort (91.5% and 79.8% respectively, P = 0.0361). Eight patients who were initially successfully managed with TLA required a repeat procedure due to dehiscence. Conclusions:Tongue–lip adhesion is a safe and effective technique and is associated with lower morbidity and mortality as compared with mandibular distraction osteogenesis and tracheostomy and should be considered in patients with PRS who fail conservative management. The greater success and lower complication rates in nonsyndromic patients reinforce the importance of proper patient selection and consideration of other techniques such as mandibular distraction osteogenesis should be given in patients with associated syndromic diagnoses.

Dupuytren Contracture in the Pediatric Population: A Systematic Review

Dupuytren contracture of the palm is a relatively common benign fibroproliferative disease of the palmar fascia typically affecting the adult population. There have however been several reported cases of Dupuytren contracture in children. We sought to review the literature for Dupuytren contracture and highlight the main clinical features and management of the disease in children.

Identification of New Tools to Predict Surgical Performance of Novices using a Plastic Surgery Simulator

OBJECTIVE To identify new tools capable of predicting surgical performance of novices on an augmentation mammoplasty simulator. The pace of technical skills acquisition varies between residents and may necessitate more time than that allotted by residency training before reaching competence. Identifying applicants with superior innate technical abilities might shorten learning curves and the time to reach competence. The objective of this study is to identify new tools that could predict surgical performance of novices on a mammoplasty simulator. METHOD We recruited 14 medical students and recorded their performance in 2 skill-games: Mikado and Perplexus Epic, and in 2 video games: Star War Racer (Sony Playstation 3) and Super Monkey Ball 2 (Nintendo Wii). Then, each participant performed an augmentation mammoplasty procedure on a Mammoplasty Part-task Trainer, which allows the simulation of the essential steps of the procedure. RESULTS The average age of participants was 25.4 years. Correlation studies showed significant association between Perplexus Epic, Star Wars Racer, Super Monkey Ball scores and the modified OSATS score with rs = 0.8491 (p < 0.001), rs = -0.6941 (p = 0.005), and rs = 0.7309 (p < 0.003), but not with the Mikado score rs = -0.0255 (p = 0.9). Linear regressions were strongest for Perplexus Epic and Super Monkey Ball scores with coefficients of determination of 0.59 and 0.55, respectively. A combined score (Perplexus/Super-Monkey-Ball) was computed and showed a significant correlation with the modified OSATS score having an rs = 0.8107 (p < 0.001) and R2 = 0.75, respectively. CONCLUSIONS This study identified a combination of skill games that correlated to better performance of novices on a surgical simulator. With refinement, such tools could serve to help screen plastic surgery applicants and identify those with higher surgical performance predictors.

A Novel Mohs Precision Tool

BACKGROUND Effective treatment by Mohs micrographic surgery requires preparation of high-quality slides. OBJECTIVE To examine a novel tissue alignment device designed to address variability in tissue processing because of excessive sample trimming. MATERIALS AND METHODS A device was designed to account for angular errors and unparalleled tissue embedding. A retrospective chart review was performed both with and without the use of the device over the course of a 4-year period (2012–2015). RESULTS Between January 1, 2012, and June 10, 2014, before device implementation, mean number of stages per case was 1.65 (n = 3,680) and mean number of surgeries per day was 6.34 (n = 640). Between June 11, 2014, and October 02, 2015, with device implemented, the average number of stages per case between decreased to 1.58 (n = 2,562) and the number of daily surgeries increased to 7.05 (n = 358). This represents a significant decrease in number of stages per case by 0.07 stages (95% CI: −0.01 to −0.13, p = .02), as well as an increase in the number of cases per day by 0.71 cases (95% CI: 0.12–1.3, p < .01). CONCLUSION Slide preparation using the novel alignment device may result in less tissue waste and more cases being performed daily.

Recurrent infantile digital fibromatosis

We present a case of an 8-year-old-boy with recurrent infantile digital fibromatosis (IDF) who presented with new fibrotic lesions. IDF is a benign fibrous growth of childhood. Typically affecting the fingers and toes of children, the condition is nonmalignant and has a high recurrent potential following surgical excision. Although ∼200 cases of IDF have been described to date, a generalized consensus does not seem to exist on an approach to treatment. The current treatment modalities for IDF are reviewed.

Catheter-induced brachial artery thrombosis in the neonate

Acute arterial thrombosis is a rare complication of brachial artery cannulation that can threaten the viability of the affected limb. We present a case of a premature male neonate who suffered complete thrombosis of the brachial artery following multiple failed attempts at cannulation. He subsequently underwent emergent thrombectomy, resection of the involved vessel segment, and primary microanastomosis with good recovery.