Faculty Bibliography

BACKGROUND: We present an outcomes analysis of the surgical treatment of Robin sequence including all infants and comorbid conditions treated by tongue-lip adhesion (TLA) or mandibular distraction osteogenesis (MDO). METHODS: A 19-year single-institution, multisurgeon retrospective review of all syndromic and nonsyndromic neonates with Robin sequence treated with TLA (1994-2004) or MDO (2004-2013) was performed. Comorbid conditions were recorded in all patients. Outcomes include incidence of tracheostomy, improvement in obstructive breathing, and surgical complications. Need for repeat distraction and conversion from TLA to MDO were included as secondary end-points. Polysomnography data were recorded preoperatively at 1 month and 1 year as a measure of airway improvement. RESULTS: Seventy-four MDO patients and 15 TLA patients during the study period met inclusion criteria. There was no significant difference in mean age at intervention (32.1 +/- 29.0 vs 35.5 +/- 32.1 days), birth weight (2.9 +/- 0.7 vs 3.2 +/- 0.6 kg), prematurity (23.0 vs 35.7%), or intrauterine growth restriction (31.1 vs 15.4%). Central nervous system anomalies (24.3% vs 0.0%; P < 0.04) and gastrostomy tubes (66.2% vs 33.3%; P < 0.03) were present more frequently in MDO patients versus TLA patients. Rates of other organ system anomalies were similar between the groups. The success rate was significantly higher in the MDO group (90.5% vs 60.0%; P < 0.008). Postoperative tracheostomies occurred in 8.1% of the MDO group and 33.3% of the TLA group (P < 0.02). Preoperative apnea-hyponea index was similar between the two groups (38.3 vs 38.1). The apnea-hyponea index was significantly improved in the MDO group at 1 month (4.0 vs 21.7; P < 0.002) and 1 year (5.7 vs 20.5; P < 0.005). Surgical complications were statistically less in the MDO group (20.3 vs 53.3%; P < 0.02). CONCLUSIONS: In the heterogeneous population of Robin sequence, MDO demonstrates superior outcomes measures at 1 month and 1 year compared to TLA. Fewer complications occurred in the MDO group compared to the TLA.

Background & Purpose: We have produced a freely available, web-based, multimedia surgical simulator in partnership with Smile Train which demonstrates the cardinal procedures in primary cleft surgery. This tool is intended to help surgeons in developing countries care for their local cleft populations. Limitations of Internet access and local technology may hinder use in the developing world. We report on the international utilization of the world's first internet-based cleft simulator. Methods & Description: The Smile Train Virtual Surgery Simulator contains an internal tracking system which records the unique Internet Protocol (IP) addresses all users. Using these IP addresses, each country accessing the Simulator was identified over a one year period. All users accessing the Simulator for less than 5 minutes were eliminated. The countries were analyzed based upon economic factors such as Gross Domestic Product (GDP) and per capita income (PCI) as well as health metrics such as health expenditures and underweight children. Results: There were 849 novel users of the Simulator from 78 countries were recorded over the one-year study period. Those countries represent 6.28 billion persons or 88.5% of the global population. Of the countries utilizing the simulator 54 were classified as developing economies, representing 5.3 billion people. The developing countries average GDP was $467.4 +/- 147 billion and PCI was $8,281 +/- 815. The poorest developing countries accessing the Simulator in terms of PCI were Congo ($400), Ethiopia ($1,200), and Nepal ($1,300). In terms of percent population living below the poverty line, the poorest countries accessing the simulator were Haiti (80%) Congo (71%) and Nigeria (70%). In developing countries, the health expenditures as a percentage of GDP averaged 6.1%. The nations with the lowest healthcare expenditures as a percentage of GDP were Myanmar 2%, Pakistan 2.2%, and Indonesia 2.6%. Penetration into advanced economies was also extensive including 24 countries representing 979 million people and an aggregate GDP of $40.98 Trillion. In the United States the simulator was used in 40 states from both academic and community Internet service providers. Surprisingly, the simulator was used in 21 countries with active armed conflicts and 28 where the US State Department advises against travel including Ukraine, Egypt, Yemen, Iraq and Nigeria. Conclusions: The presented internet-based surgical simulator is accessible globally and has quickly gained use in 78 countries representing 88% of the global population including 5.3 billion of the worlds developing population. Over 2/3rds of the countries accessing the simulator are developing nations and include regions experiencing severe poverty. Projects directed towards international education of cleft care in the developing world should strongly consider the use of web-based digital technology as a means to immediately access and educate caregivers, particularly in countries with significant economic and political constraints. Disclosure: Receipt of Intellectual Property Rights/Patent Holder-Aaron Oilker holds the intellectual property rights for the biodigital surgery simulator

Background: Comparison of long-term survival of patients with clinical Stage I non-smallcell lung cancer (NSCLC) with and without mediastinal lymph node resection (MLNR) in the International Early Lung Cancer Action Program, a large prospective cohort in a lowdose CT screening program. Methods: All instances of thoracic surgery for first solitary primary non-small-cell lung cancer prompted by low-dose CT screening, performed under an IRB approved common protocol at each of the participating institutions since 1992 to 2014, are included. Follow-up time was calculated from diagnosis to death from lung cancer, last contact, or December 31, 2014, whichever came first. Univariate logistic regression analysis of the demographic, CT, and surgical findings for those with and without MLNR was performed. Kaplan-Meier (K-M) survival rates and Cox regression analysis was performed using all significant univariate variables. Results: The 10-year Kaplan-Meier (K-M) NSCLC-specific survival rate for the 225 patients manifesting as a subsolid nodule was 100%, regardless of whether they had MLNR (N = 169) or not (N = 56). For the 373 NSCLC patients manifesting as a solid nodule, for those who had MLNR (N = 285) and those who did not (N = 88), the K-M NSCLC-survival rate was not significantly different (86 % vs. 93%, P = 0.23). The rate was 95% vs. 96% (P = 0.86) for those whose pathologic tumor diameter was <= 10 mm; 83% vs. 94% (P = 0.19) for 11-20 mm, and 79% vs. 86% (P = 0.67) for 21-20 mm. Cox regression analysis comparing MLNR with no MLNR showed that survival rates were not significantly different (P = 0.33), but significantly survival decreased when the tumor diameter was above 20 mm (HR= 5.1, 95% CI: 1.6-15.7). Conclusion: Lymph node evaluation is not necessary for resection of subsolid nodules in patients with screen-detected lung cancer

PURPOSE: Facial fractures in the pediatric population have a significant impact on public health. Although some demographic data exists regarding the overall epidemiology of facial fractures, little attention has been paid to the patterns of facial fractures based on the etiology of the trauma. MATERIAL AND METHODS: The Kids' Inpatient Database 2000-2009 was utilized to analyze pediatric facial fractures. A total of 21,533 patients were identified. Associations of patient characteristics with outcomes of interest were assessed. RESULTS: The top three etiologies were motor vehicle accident (MVA), intentional trauma (IT), and falls. There was a decrease in the incidence of facial fractures due to MVAs and an increase in injuries due to IT and falls. Concomitant injuries were present in 58.8% and the mortality rate was 2%. The rate of concomitant injuries increased during study period. Age was significantly associated with concomitant injury, mortality, and LOS. CONCLUSION: The increasing rate of IT and falls with concomitant injury warrants special consideration to reduce undiagnosed accompanying injuries. Further programs should be put in place to protect children younger than 5 years of age, who have increased risk of concomitant injury and mortality following intentional trauma.

Agnathia-otocephaly complex (AOC) is characterized by mandibular hypo- or aplasia, ear abnormalities, microstomia, and microglossia. Though rare and often fatal, this is the first report detailing various reconstructive strategies beyond infancy as well as longitudinal follow-up into adulthood.All patients with AOC treated at our institution over a 30 year period were reviewed. Four patients were identified, one with agnathia, one with micrognathia. Two males with nanognathia (defined as a symphyseal remnant without body nor ramus) were also included. The mean follow-up was 17 years. All four underwent perinatal tracheostomy and gastrostomy-tube placement. Commissuroplasties were typically performed before 3 years of age and repeated as necessary to allow for oral hygiene. Mandibular reconstruction was most successful with rib between ages 3 and 8, after which time, free fibula transfer was utilized. Due to some resoprtion or extrusion, all patients underwent repeated bone grafting procedures. Tissue expansion of the neck was used to restore the lower third of the face, but was most successful in the teenage years. At last follow-up of the eldest patients, one was in college while another was pursuing graduate education.AOC need not be a fatal nor untreatable condition; a reasonable quality of life can be achieved. Although the lower-facial contour may be improved, and a stoma created, the lack of musculature make deglutition virtually impossible with current therapies. Just as transplantation has emerged as a modality for facial restoration following severe trauma, so too may it be a future option for congenital deformities.

BACKGROUND: The aim of this study is to evaluate the efficacy, safety profile and the complications associated with mandibular distraction osteogenesis (MDO) performed in infants < 4kg with Robin sequence (RS). METHODS: A 11-year retrospective review of all infants (< 6 months) with MDO treated RS was performed. Patients < 4 kg (experimental) and >/= 4 kg (control) who underwent MDO were compared. Demographics, medical comorbidities, improvement in apnea/hypopnea index (AHI), need for tracheostomy, repeat distraction, and complications were evaluated. RESULTS: One hundred twenty-one patients underwent MDO. 81 patients were < 4 kg while 40 were >/= 4 kg. The mean follow up was 2.8 years in patients < 4 kg and 3.0 years in the control group. Mean age and weight at time of distraction were 23 days old / 3.1 kg and 2.7 years / 11 kg; respectively. There was no significant difference in success of MDO to treat airway obstruction in the < 4 kg group versus the control group (92.6% vs. 88.9%; p = 0.49). The most common complication in each group was surgical site infection (9.9% and 20.0%; p = 0.15). Overall complication rates were similar between the two groups (17.3% vs. 25.0%; p = 0.34). The rates of repeat distraction were similar between the two groups (6.3% and 13.5%; p = 0.28). CONCLUSION: MDO is a safe and effective treatment modality for infants < 4 kg with severe airway obstruction. The efficacy, safety, and complication profiles are not significantly different from larger patients.