Christopher B. Gordon

Outcomes of Mandibular Distraction Osteogenesis in the Treatment of Severe Micrognathia

IMPORTANCE Patients with severe micrognathia are predisposed to airway obstruction. Mandibular distraction osteogenesis (MDO) is an alternative to tracheotomy that lengthens the mandible in order to improve the retrolingual airway. This study presents outcomes from one of the largest cohorts reported. OBJECTIVE To assess the rate and predictors of surgical success and complications among (1) patients who underwent MDO prior to other airway procedures (MDO first), and (2) patients who required an initial tracheotomy and were subsequently treated with MDO (tracheotomy first). DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study at a tertiary care pediatric medical center of patients diagnosed as having micrognathia resulting in symptomatic airway obstruction (Pierre Robin sequence) and who underwent MDO from September 1995 to December 2009. INTERVENTIONS Electronic medical records were reviewed. Multivariable regression analysis was used to assess for predictors of outcome. MAIN OUTCOMES AND MEASURES Rates of surgical success (defined as either tracheotomy avoidance or decannulation) and complications. Potential predictors included demographics, syndrome presence, follow-up time, and surgical history. RESULTS A total of 123 patients (61 in MDO-first subgroup, 62 in tracheotomy-first subgroup) underwent MDO during the study period. Median age at time of distraction was 21 months (range, 7 days-24 years). Surgical success and complication rates were 83.6% and 14.8% in the MDO-first subgroup and 67.7% and 38.7% in the tracheotomy-first subgroup. Tracheotomy-first patients were more likely to have a syndromic diagnosis (66.0% vs 43.0%; P = .009) and were older at the time of MDO (median age, 30 months vs 5.1 months; P < .001). Poorer odds of success were associated with the need for 2 or more other airway procedures (odds ratio [OR], 0.14 [95% CI, 0.02-0.82]) in the MDO-first subgroup and craniofacial microsomia or Goldenhar syndrome (OR, 0.07 [95% CI, 0.009-0.52]) in the tracheotomy-first subgroup. CONCLUSIONS AND RELEVANCE Mandibular distraction osteogenesis has a high rate of success in avoiding tracheotomy. Patients who required a tracheotomy before MDO had a lower success rate in achieving decannulation and a higher rate of complications. However, these patients also had a higher rate of syndromic diagnoses and associated comorbidities. Patients with Goldenhar syndrome have a decreased likelihood of surgical success.

Cost Analysis of Mandibular Distraction versus Tracheostomy in Neonates with Pierre Robin Sequence

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 (

Tuberculous granuloma and adenoid cystic carcinoma presenting as a single buccal space mass.

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.

Regional dermolipectomy as treatment for sequelae of massive weight loss

We report an unusual case of a 58-year-old man with a “collision lesion” of the buccal space. Initially diagnosed as tuberculoma, the patient showed only partial response to an extensive course of antibiotics, prompting more vigorous investigation. This revealed the presence of a concomitant malignancy, specifically adenoid cystic carcinoma. Definitive treatment was then achieved by surgical resection and flap reconstruction with postoperative radiation therapy.

Liposuction: Procedure for Focal Volume Reduction and Body Contour Remodeling

Abstract. Dermolipectomy is the most important procedure for treatment of the deformities engendered by massive weight loss. It remains the only treatment for excising redundant skin. Although liposuction is useful for removing fatty deposits without traditional surgical incisions, its application is limited by the ability of the skin to contract and conform to the newly sculpted figure. Thus liposuction may serve as an adjunct when treating the sequelae of weight loss but not as a primary procedure. In response to changing expectations, reconstructive surgeons have developed increasingly ingenious and specific dermolipectomy procedures to minimize or hide scars, lessen morbidity, and enhance function. Liposuction in combination with dermolipectomy has expanded the applicability of traditional procedures to a wider variety of patients. Surgical history, patient selection, surgical planning, a spectrum of regional dermolipectomy procedures, and potential complications are discussed herein.

Evolution from endoscopic to miniinvasive facelift : A logical progression?

Abstract. Liposuction is the most commonly used procedure for focal reduction of body fat deposits and remodeling the body contour. The procedure consists in aspirating fat from lamellar deposits using a vacuum source connected to a cannula that is passed bluntly through fatty tissue. Adjuncts to the procedure include infiltration of solutions to aid in fat removal or to limit blood loss and the application of ultrasonic energy to lyse fat cells before suction aspiration. Surgical history, theory, procedures, indications, potential complications, and guidelines are discussed herein.

Decision Making for Children with Obstructive Sleep Apnea without Tonsillar Hypertrophy

Abstract. Endoscopy has revolutionized the field of aesthetic surgery, permitting the advent of cosmetic surgery via minimal incisions. The procedures are modifications of subperiosteal lifting techniques which grew out of craniofacial surgery. Nonetheless, the cumbersome instrumentation and changes in operator technique have led to the development of a subperiosteal facelift through minimal incisions without the aid of endoscopy. This miniinvasive approach has yielded equivalent results to our endoscopic rhytidectomies in appropriate patients, with reduced morbidity, edema, and operating time. Further, it permits the avoidance of preauricular scars in the majority (84%) of patients; 63 cases are presented, with a follow-up of up to 4 years.

Endoscopically Assisted Le Fort I Osteotomy Using an Ultrasonic Scalpel: A Feasibility Study in Cadavers

Objective Evidence-based medicine is the gold standard practice model for patient management. Our aim was to determine whether decisions made by pediatric subspecialists regarding management of obstructive sleep apnea in children without tonsillar hypertrophy adhered to this model or were based on clinical experiences. Study Design Single-institution prospective study. Setting Multidisciplinary upper airway center in an academic pediatric hospital. Subjects and Methods Twelve pediatric subspecialists representing 8 specialties participating in upper airway clinics and management conferences. Real-time decisions made in treatment conferences and upper airway clinics were collected. Physicians were queried regarding the basis of their decisions, and these decisions were then classified into 10 categories. Results Over 13 days (10 case conferences, 3 half-day clinics), 324 decisions were made for 58 patients (mean age = 8.9 ± 7.4 years, mean body mass index percentile = 75 ± 29); 34% (n = 108) of decisions were evidence based; 59% (n = 193) were nonevidence based; and 7% (n = 23) were based on parental preference. Providers were able to cite specific studies for <20% of these decisions. There was no significant increase in the proportion of evidence-based decisions made over time. Conclusions We deemed 34% of decisions regarding the management of obstructive sleep apnea in children without tonsillar hypertrophy to be evidence based and found that sharing the basis for decisions did not improve the percentage of evidence-based decisions over time. These findings reflect significant evidence gaps and highlight the need for a systematic literature evaluation to identify best practice in managing this population. We recommend that these evidence gaps be further characterized and incorporated into an agenda for future research.

Endoscopic monobloc advancement with ultrasonic osteotomy: a feasibility study.

PURPOSE Drawbacks to conventional Le Fort I osteotomy include bleeding, infection, and relapse. The open approach predisposes itself to each of these complications through various means. We performed an endoscopically assisted Le Fort I osteotomy with an ultrasonic scalpel in cadavers to develop a new technique that minimizes such complications. MATERIALS AND METHODS Endoscopically assisted Le Fort I osteotomy was performed in 4 fresh adult human cadavers. Two 1-cm gingivobuccal sulcus incisions were used to approach the maxilla. Osteotomies were carried out with an ultrasonic scalpel from within the maxillary sinus under endoscopic visualization after a small antrostomy was made in its anterior wall. The external periosteal sleeve to the maxilla remained intact, eliminating the risk of massive hemorrhage and preserving bony vascularity. A stab incision was made with a 2-mm osteotome above the anterior nasal spine to separate the caudal septum from the Le Fort I segment. Pterygomaxillary disjunction was also performed with classic osteotomes. Disimpaction was completed with minor digital pressure inferiorly. RESULTS Each of the 4 Le Fort I osteotomies was complete, and mobility was checked by manual examination. There was a steep learning curve to the operation, but the final cadaveric dissection took 37 minutes to complete. At no time did the ultrasonic scalpel violate the maxillary periosteum as judged by postoperative direct examination. DISCUSSION This cadaveric study shows the feasibility of an endoscopically assisted Le Fort I osteotomy by use of an ultrasonic scalpel. Further experimental work combined with refinements in technique and equipment will help bring this advancement into clinical application.

Enzyme replacement therapy for congenital hypophosphatasia allows for surgical treatment of related complex craniosynostosis: a case series

Background:The monobloc procedure has been criticized owing to its tendency for cerebrospinal fluid leak, relapse, infection, and incomplete ossification. Such risks have been decreased through gradual advancement of the monobloc via distraction osteogenesis. This cadaver study was undertaken to develop an endoscopic, ultrasonic monobloc osteotomy to further minimize risks and potentially improve outcomes. Methods:Three fresh, adult human cadavers were used in this study. Endoscopic ultrasonic monobloc osteotomy was completed in all cadavers with 3 incisions hidden in the hair-bearing scalp. The incisions afforded access for small craniotomies through which the dura was dissected from the frontal bones. An ultrasonic scalpel and endoscope then traveled extradurally to osteotomize the frontal bones, temporal bones, sphenoid wings, and superior aspects of the orbits intracranially. Pterygomaxillary dysjunction was performed with conventional osteotomes intraorally. Results:The endoscopic ultrasonic monobloc osteotomy was completed as a single fragment in all 3 cadavers. No additional incisions were required. Completeness of the osteotomy and integrity of the single fragment were evaluated by manual examination and endoscopic visualization of free movement at osteotomy sites. Osteotomy completion took less than 2.5 hours. Dura and periosteum surrounding all osteotomies remained intact, eliminating concern for injury to adjacent soft tissue. Careful placement of temporal incisions and craniotomies was critical to facilitate completion of osteotomies in a clinically safe manner. Conclusions:We have demonstrated the feasibility of an endoscopic ultrasonic monobloc advancement technique in cadavers. The technique can be completed without a bicoronal incision while completely protecting all vital structures. The preservation of vascularity and periosteum afforded by this technique may provide improved outcomes and reduced complications.