Correspondence and communications 415

tumour clearance has been established. Delayed recon-struction may be more appropriate in these cases, if Mohsservices are unavailable.

There may well continue to be limited situations wherefrozen section remains justified, such as a clinical scenariowhere one very small but critical area of an excision marginrequires analysis. Overall, however, it would appear diffi-cult to justify its continued widespread use.

Conflict of interest/funding

None declared by any author.

References

1. Manstein ME, Manstein CH, Smith R. How accurate is frozensection for skin cancers? Ann Plast Surg 2003;50:607e9.

2. Mohs FE. Chemosurgery: a microscopically controlled methodof cancer excision. Arch Surg 1941;42:279.

3. Nelson BR, Railan D, Cohen S. Mohsmicrographic surgery for nonmelanoma skin cancers. Clin Plast Surg Oct 1997;24(4):705e18.

4. Lang Jr PG, Osguthorpe JD. Indications and limitations of Mohsmicrographic surgery. Dermatol Clin Oct 1989;7(4):627e44.

5. http://www.rcpath.org/publications-media/publications/datasets/cutaneous-basal.htm [accessed date 19.07.13].

P. ProwseJ. May

J. MortonDept Burns and Plastic Surgery, Whiston Hospital,

Liverpool, Merseyside L35 5DR, UK

E-mail address: phoebeprowse@gmail.com

ª 2013 Published by Elsevier Ltd on behalf of British Association ofPlastic, Reconstructive and Aesthetic Surgeons.

http://dx.doi.org/10.1016/j.bjps.2013.10.012

Reinventing the techniqueof tongueelip adhesion inPierre Robin sequence*

Dear Sir,

The goal of management for children born with the PierreRobin sequence1 (micro/retrognathia, glossoptosis,breathing difficulty and cleft palate) is to facilitate unob-structed breathing and feeding and to forestall the car-diopulmonary, metabolic, and neurologic consequences ofhypoxia. Surgical intervention is considered for patientswith prolonged use of an appliance for intubation, failure ofconservative management, and repeated problems relatedto airway obstruction.

* Institution: Department of Plastic Surgery, B.J. Wadia Children’sHospital, Parel, Mumbai, India.

As the trigger to most episodes of respiratory obstructionis the impaction of the tongue tip in the palatal cleftcausing a ball-valve type of obstruction, the focus ofattention in surgical treatment should be on the tongue.2

Tongue-to-lip adhesion (TLA) is a procedure by which thesurgeon anchors the tongue anteriorly to the lower lip thusopening up the oropharyngeal airway space as the tonguebase is pulled forward. It is a simple surgical procedure,does not interfere with speech production, facilitates oralintake by providing an adequate airway, and does notrequire constant nursing care unlike a tracheostomy.3

Almost all the early techniques of doing tongue-to-lipadhesion were purely mucosal adhesions supported bytongue-to-chin retention sutures meant to prevent dehi-sence and kept for an average of two weeks. The reportedcomplications involving all techniques of TLA to date arebutton and retention suture cutting through, dehisence,injury to Wharton’s ducts, scarring on the lip, chin and floorof mouth, feeding problems, epiglottis tethering leading toaspiration, and dental abnormalities.4,5

We have devised a new technique using internal buriedretention sutures which circumvents the problems of cut-ting through of the retention suture on either the skin orthe tongue, care of the external sutures and an additionalprocedure for their removal.

Surgical technique: Mucosal incisions were taken on theventral surface of the tongue, avoiding the openings of the sub-mandibularducts,andonthe lower lip.The loweredgesof the lipand tongue mucosal flaps were sutured to each other leavingenough space between them and the alveolus so that futureeruption of the incisors will not disrupt the mucosal adhesion.

Solid muscle-to-muscle approximation between thetongue and lower lip was achieved with our technique asfollows (see Video, Supplemental digital content 1). A 3-0 PDS suture was passed from the incision through the chinmuscles and periosteum emerging on the skin, then re-entered through the same point and passed horizontallythrough the muscles and periosteum again to emerge on theskin some distance from the first exit point. The suture thenre-enters the skin at the second point and is delivered intothe incision site (Figure 1). Using the same suture, multiplebites were taken longitudinally and horizontally throughthe intrinsic muscles of the tongue up to its base. This su-ture was then tied under slight tension, pulling the entiretongue base forward, thus creating an adequate oropha-ryngeal space. Taking the multiple, deep bites through thetongue provides better purchase and that, alongwith thehorizontal bite through the periosteum of the chin, pre-vents the suture from cutting through the tissues and givesadded strength to the adhesion.

Supplementary data related to this article can be foundonline at http://dx.doi.org/10.1016/j.bjps.2013.09.013

The following are the Supplementary data related to thisarticle:

Lastly the upper edges of the tongue and lip incisionswere sutured to each other, covering the muscle sutures.

Over a 15 year period from June 1997 to October 2012, atotal of 98 patients satisfying the criteria for diagnosis ofPierre Robin sequence presented to our centre which is atertiary care centre specializing in pediatric and obstetric

Figure 1 Line diagram depicting axial (left) and saggital (right) views of the path of the 3-0 PDS suture through the tongue andlower lip/chin.

Table 1 Comparison of various studies in which tongue-to-lip adhesion was done.

Author Year No. of cases Relief of airway obstruction Wound dehisence (no. of cases)

Aragamaso 1992 24 100% 4Sher 1992 24 100% None reportedKirschner 2003 29 83.3% 5Huang 2005 14 70% 4Roger et al.

(GILLS study)2011 53 89% 2

Our study 2012 26 96% None

416 Correspondence and communications

care. In all, 26 cases had symptoms such as airwaycompromise, difficulty feeding, poor weight gain and fail-ure of conservative treatment to relieve symptoms whichqualified them for surgical intervention, i.e., TLA by ourtechnique. The mean age at the time TLA was performedwas 9.7 days (range between 3 and 30 days). All patientsexcept one were successfully extubated at the end of sur-gery. Of the extubated patients none required additionalairway instrumentation such as nasopharyngeal airway. Thepatient who failed to maintain oxygen saturation followingextubation required a tracheostomy.

All patients were able to take oral/breast feeds post-operatively. None of the 26 patients in the tongue-to-lipadhesion group had dehisence of the adhesion, giving us asuccess rate of 100%. No postoperative oral scarring ordental abnormalities were seen.

The requirement of tracheostomy in our series of patientswas1out of 26cases, i.e., 3.8% .Themean follow-upperiod inour study was 93 months with a range of 9 monthse15 years.Long-term clinical improvements in terms of body weightgain, return for home care, and reduced episodes of respi-ratory infections were also observed.

The effectiveness of a properly done TLA in relievingairway obstruction ranges from 71% to 100% as reported bydifferent centers (Table 1), our own results being 96%. Ourmodified technique also overcomes most of the shortcom-ings of the earlier techniques without any major or long-term complications.

Conflict of interest/funding

None.

Acknowledgments

Mr. Manish Mistry for his artistic input.

References

1. Randall P, Krugman WM, Jahina S. Pierre Robin and the syn-drome that bears his name. Cleft Palate J 1965;2:237e46.

2. Sher AE. Mechanisms of airway obstruction in Robin sequence:implications for treatment. Cleft Palate Craniofac J 1992;29:224e31.

3. Aragamaso RV. Glossopexy for upper airway obstruction inRobin Sequence. Cleft Palate Craniofac J 1992;29:232e8.

4. Kirschner RE, Low DW, Randall P, et al. Surgical airwaymanagement in Pierre Robin sequence: is there a role fortongue-lip adhesion. Cleft Palate Craniofac J 2003;40:13e8.

5. Huang F, Lo LJ, Chen YR, Yang JC, Niu CK, Chung MY. Tongue-lip adhesion in the management of Pierre Robin sequence withairway obstruction: technique and outcome. Chang Gung Med J2005;28:90e6.

Nitin Jagannath MokalMahinoor Feroze Desai

B.J. Wadia Children’s Hospital, Mumbai, India

E-mail address: dr_mahinoor@hotmail.com

Correspondence and communications 417

Pradnya SawantDepartment of Anaesthesiology, B.J. Wadia Children’s

Hospital, Mumbai, India

ª 2013 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.bjps.2013.09.013

2-Stage free and pediclejejunum for esophagealreplacement after failedcolon interposition forcaustic injury in a 5 year-oldchild

Figure 1 Patient before the second operation showing largeamount of saliva in the jejunostomy bag which would havebeen aspirated in the lungs if without diversion.

Dear Sir,

The common indications for esophageal replacement inpediatric population are corrosive strictures and long-gapesophageal atresia. The colon, the stomach and thejejunum have been used to replace the esophagus in chil-dren.1,2 The choice of conduit depends on patient factorsand surgeon’s experience.

We recently encountered a young girl with severedysphagia and recurrent aspiration pneumonia one yearafter colon interposition for caustic fluid ingestion. Thestricture was so long that the defect had to be bridgedacross with both a free and pedicle jejunum flap as a 2-stage procedure.

A 3 year-old girl presented to the emergency depart-ment after accidental caustic fluid ingestion. Conservativemanagement with endoscopic dilatation failed after 1 yearand she underwent retro-sternal colonic interposition withend-to-end esophagocolostomy and end-to-side cologas-trostomy by a pediatric surgeon.

However, the colonic interposition was complicated withanastomotic stricture and was put back on gastrostomyfeeding one year after the operation. She also sufferedfrom repeated episodes of aspiration pneumonia thatrequired hospitalization. Because of this recurrent life-threatening pneumonia, the patient was referred to us forfurther option of esophageal reconstruction.

A free jejunal flap was planned. Incision was made alongthe old neck scar to expose the pharynx and the esoph-agocolonic anastomosis. The scarring around the region wasextensive and there was a complete obstruction at the siteof the anastomosis with stricture formation extendeddistally into the retrosternal space. A simple free jejunalflap was unable to bridge the stricture segment. It wasdecided that the proximal end of the flap was sutured tothe cervical esophagus while its distal end was opened as atemporary jejunostomy at the mid-chest level. A piece ofjejunum based on the 3rd jejunal artery and vein washarvested. The donor vessels were joined end-to-end withthe left thoraco-aromial artery and vein. Jejuno-jejunal

anastomosis was performed in the abdomen to restore thecontinuity of the bowel and the original gastrostomy tubewas left intact [Figure 1]. Second stage operation wasplaned 8 weeks later.

In the second stage, a 30 cm segment of jejunum wasmobilized based on the 4th jejunal artery. A subcutaneoustunnel at the abdominal wall and chest was made for thetransposition of the pedicle jejunal cephalically to join upwith the previous free jejunal flap. A jejuno-jejunalanastomosis was carried out in a Roux-en-Y fashion torestore the bowel continuity [Figure 2]. The gastrostomyremained in-situ and the wound was closed in layers. Post-operative recovery was uneventful with oral feeds werecommenced on the seventh post-operative day. The gas-trostomy was removed at second post-operative month.Currently 8 months later, she is eating orally, no episode ofaspiration pneumonia and her quality of life has greatlyimproved.

Esophageal replacement in children continues to be achallenging operation with significant morbidity.1 Coloninterposition is most often used in the pediatric population,however, the colonic interposition for esophageal replace-ment only provides a mechanical conduit without