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Discussion: Mandibular Distraction Osteogenesis in Pierre Robin Sequence: Application of a New Internal Single-Stage Resorbable Device

The authors are to be commended for their efforts in producing a new resorbable distraction device and reporting their experience with it. This series represents further independent confirmation of the successful application of mandibular distraction to relieve airway obstruction in micrognathic infants. This report using a different surgical approach, different technique, and new device underscores the likelihood of successful outcomes when mandibular distraction is appropriately applied to airway-obstructed infants. The authors demonstrate their knowledge and understanding of key issues in correction of the obstructed infant airway by carefully adhering to previously published guidelines for appropriate patient selection.1 This includes the development and use of an obstructed infant airway team, exclusion of patients from treatment who have airway obstruction or abnormality other than at the tongue base, and consistent use of bronchoscopy as both a diagnostic and a monitoring tool. Their adherence to these basic principles of patient selection only serves to make the success with their new device stand out more clearly.2 The mandibular infant device used in the series is well designed in size and configuration to serve the infant patient population. The authors’ observation from cranial vault applications that the LactoSorb (Arthrotek, Inc., Warsaw, Ind.) base and fixation screws would provide sufficient support for infant mandibular distraction has been proven correct. The greatest benefit of the device is allowing a single-stage procedure with resorption of the base and mounting screws. In general, the greatest risk to these very young patients with abnormal airways is the risk of anesthesia, not the surgery. The ability to avoid an additional anesthetic event is significant. As with any new technique or technology, there are associated risks and benefits. Mechanical failure of an external device requires simple bedside replacement of the device with perhaps mild sedation or analgesia. Mechanical failure of an implanted device requires a trip to the operating room, with an open surgical procedure in combination with a general anesthetic. If a mechanical failure were to occur using an implanted device, much of the intended advantage of a single-stage procedure would be lost. Much has been made of the scarring caused by the external pin-borne devices. Over a long-term follow-up, these scars do not appear to be of great significance (Figs. 1 and 2). It will be interesting to observe the long-term scarring from the modified Risdon incision used in this report. What authors Burstein and Williams have contributed is a new resorbable device. This unique device is another addition for use by interested surgeons for the correction of the obstructed infant airway by mandibular distraction. As experience continues to grow in this area, this approach may prove to be the most efficient yet in avoiding tracheostomy for these young patients. Arlen D. Denny, M.D. 9000 West Wisconsin Avenue Milwaukee, Wis. 53226 adenny@chw.org