tumour clearance has been established.

Delayed recon-
struction may be more appropriate in these cases, if Mohs
services are unavailable.
There may well continue to be limited situations where
frozen section remains justied, such as a clinical scenario
where one very small but critical area of an excision margin
requires analysis. Overall, however, it would appear dif-
cult to justify its continued widespread use.
Conict of interest/funding
None declared by any author.
References
1. Manstein ME, Manstein CH, Smith R. How accurate is frozen
section for skin cancers? Ann Plast Surg 2003;50:607e9.
2. Mohs FE. Chemosurgery: a microscopically controlled method
of cancer excision. Arch Surg 1941;42:279.
3. Nelson BR, Railan D, Cohen S. Mohs micrographic surgery for non
melanoma skin cancers. Clin Plast Surg Oct 1997;24(4):705e18.
4. Lang Jr PG, Osguthorpe JD. Indications and limitations of Mohs
micrographic surgery. Dermatol Clin Oct 1989;7(4):627e44.
5. http://www.rcpath.org/publications-media/publications/data
sets/cutaneous-basal.htm [accessed date 19.07.13].
P. Prowse
J. May
J. Morton
Dept Burns and Plastic Surgery, Whiston Hospital,
Liverpool, Merseyside L35 5DR, UK
E-mail address: phoebeprowse@gmail.com
2013 Published by Elsevier Ltd on behalf of British Association of
Plastic, Reconstructive and Aesthetic Surgeons.
http://dx.doi.org/10.1016/j.bjps.2013.10.012
Reinventing the technique
of tongueelip adhesion in
Pierre Robin sequence
*
Dear Sir,
The goal of management for children born with the Pierre
Robin sequence
1
(micro/retrognathia, glossoptosis,
breathing difculty and cleft palate) is to facilitate unob-
structed breathing and feeding and to forestall the car-
diopulmonary, metabolic, and neurologic consequences of
hypoxia. Surgical intervention is considered for patients
with prolonged use of an appliance for intubation, failure of
conservative management, and repeated problems related
to airway obstruction.
As the trigger to most episodes of respiratory obstruction
is the impaction of the tongue tip in the palatal cleft
causing a ball-valve type of obstruction, the focus of
attention in surgical treatment should be on the tongue.
2
Tongue-to-lip adhesion (TLA) is a procedure by which the
surgeon anchors the tongue anteriorly to the lower lip thus
opening up the oropharyngeal airway space as the tongue
base is pulled forward. It is a simple surgical procedure,
does not interfere with speech production, facilitates oral
intake by providing an adequate airway, and does not
require constant nursing care unlike a tracheostomy.
3
Almost all the early techniques of doing tongue-to-lip
adhesion were purely mucosal adhesions supported by
tongue-to-chin retention sutures meant to prevent dehi-
sence and kept for an average of two weeks. The reported
complications involving all techniques of TLA to date are
button and retention suture cutting through, dehisence,
injury to Whartons ducts, scarring on the lip, chin and oor
of mouth, feeding problems, epiglottis tethering leading to
aspiration, and dental abnormalities.
4,5
We have devised a new technique using internal buried
retention sutures which circumvents the problems of cut-
ting through of the retention suture on either the skin or
the tongue, care of the external sutures and an additional
procedure for their removal.
Surgical technique: Mucosal incisions were taken on the
ventral surface of the tongue, avoiding the openings of the sub-
mandibular ducts, andonthelower lip. Thelower edges of thelip
and tongue mucosal aps were sutured to each other leaving
enough space between them and the alveolus so that future
eruption of the incisors will not disrupt the mucosal adhesion.
Solid muscle-to-muscle approximation between the
tongue and lower lip was achieved with our technique as
follows (see Video, Supplemental digital content 1). A 3-
0 PDS suture was passed from the incision through the chin
muscles and periosteum emerging on the skin, then re-
entered through the same point and passed horizontally
through the muscles and periosteum again to emerge on the
skin some distance from the rst exit point. The suture then
re-enters the skin at the second point and is delivered into
the incision site (Figure 1). Using the same suture, multiple
bites were taken longitudinally and horizontally through
the intrinsic muscles of the tongue up to its base. This su-
ture was then tied under slight tension, pulling the entire
tongue base forward, thus creating an adequate oropha-
ryngeal space. Taking the multiple, deep bites through the
tongue provides better purchase and that, alongwith the
horizontal bite through the periosteum of the chin, pre-
vents the suture from cutting through the tissues and gives
added strength to the adhesion.
Supplementary data related to this article can be found
online at http://dx.doi.org/10.1016/j.bjps.2013.09.013
The following are the Supplementary data related to this
article:
Lastly the upper edges of the tongue and lip incisions
were sutured to each other, covering the muscle sutures.
Over a 15 year period from June 1997 to October 2012, a
total of 98 patients satisfying the criteria for diagnosis of
Pierre Robin sequence presented to our centre which is a
tertiary care centre specializing in pediatric and obstetric
*
Institution: Department of Plastic Surgery, B.J. Wadia Childrens
Hospital, Parel, Mumbai, India.
Correspondence and communications 415
care. In all, 26 cases had symptoms such as airway
compromise, difculty feeding, poor weight gain and fail-
ure of conservative treatment to relieve symptoms which
qualied them for surgical intervention, i.e., TLA by our
technique. The mean age at the time TLA was performed
was 9.7 days (range between 3 and 30 days). All patients
except one were successfully extubated at the end of sur-
gery. Of the extubated patients none required additional
airway instrumentation such as nasopharyngeal airway. The
patient who failed to maintain oxygen saturation following
extubation required a tracheostomy.
All patients were able to take oral/breast feeds post-
operatively. None of the 26 patients in the tongue-to-lip
adhesion group had dehisence of the adhesion, giving us a
success rate of 100%. No postoperative oral scarring or
dental abnormalities were seen.
The requirement of tracheostomy in our series of patients
was 1out of 26cases, i.e., 3.8%.Themeanfollow-upperiodin
our study was 93 months with a range of 9 monthse15 years.
Long-term clinical improvements in terms of body weight
gain, return for home care, and reduced episodes of respi-
ratory infections were also observed.
The effectiveness of a properly done TLA in relieving
airway obstruction ranges from 71% to 100% as reported by
different centers (Table 1), our own results being 96%. Our
modied technique also overcomes most of the shortcom-
ings of the earlier techniques without any major or long-
term complications.
Conict 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 in
Robin Sequence. Cleft Palate Craniofac J 1992;29:232e8.
4. Kirschner RE, Low DW, Randall P, et al. Surgical airway
management in Pierre Robin sequence: is there a role for
tongue-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 with
airway obstruction: technique and outcome. Chang Gung Med J
2005;28:90e6.
Nitin Jagannath Mokal
Mahinoor Feroze Desai
B.J. Wadia Childrens Hospital, Mumbai, India
E-mail address: dr_mahinoor@hotmail.com
Figure 1 Line diagram depicting axial (left) and saggital (right) views of the path of the 3-0 PDS suture through the tongue and
lower 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% 4
Sher 1992 24 100% None reported
Kirschner 2003 29 83.3% 5
Huang 2005 14 70% 4
Roger et al.
(GILLS study)
2011 53 89% 2
Our study 2012 26 96% None
416 Correspondence and communications
Pradnya Sawant
Department of Anaesthesiology, B.J. Wadia Childrens
Hospital, Mumbai, India
2013 British Association of Plastic, Reconstructive and Aesthetic
Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjps.2013.09.013
2-Stage free and pedicle
jejunum for esophageal
replacement after failed
colon interposition for
caustic injury in a 5 year-old
child
Dear Sir,
The common indications for esophageal replacement in
pediatric population are corrosive strictures and long-gap
esophageal atresia. The colon, the stomach and the
jejunum have been used to replace the esophagus in chil-
dren.
1,2
The choice of conduit depends on patient factors
and surgeons experience.
We recently encountered a young girl with severe
dysphagia and recurrent aspiration pneumonia one year
after colon interposition for caustic uid ingestion. The
stricture was so long that the defect had to be bridged
across with both a free and pedicle jejunum ap as a 2-
stage procedure.
A 3 year-old girl presented to the emergency depart-
ment after accidental caustic uid ingestion. Conservative
management with endoscopic dilatation failed after 1 year
and she underwent retro-sternal colonic interposition with
end-to-end esophagocolostomy and end-to-side cologas-
trostomy by a pediatric surgeon.
However, the colonic interposition was complicated with
anastomotic stricture and was put back on gastrostomy
feeding one year after the operation. She also suffered
from repeated episodes of aspiration pneumonia that
required hospitalization. Because of this recurrent life-
threatening pneumonia, the patient was referred to us for
further option of esophageal reconstruction.
A free jejunal ap was planned. Incision was made along
the old neck scar to expose the pharynx and the esoph-
agocolonic anastomosis. The scarring around the region was
extensive and there was a complete obstruction at the site
of the anastomosis with stricture formation extended
distally into the retrosternal space. A simple free jejunal
ap was unable to bridge the stricture segment. It was
decided that the proximal end of the ap was sutured to
the cervical esophagus while its distal end was opened as a
temporary jejunostomy at the mid-chest level. A piece of
jejunum based on the 3rd jejunal artery and vein was
harvested. The donor vessels were joined end-to-end with
the left thoraco-aromial artery and vein. Jejuno-jejunal
anastomosis was performed in the abdomen to restore the
continuity of the bowel and the original gastrostomy tube
was left intact [Figure 1]. Second stage operation was
planed 8 weeks later.
In the second stage, a 30 cm segment of jejunum was
mobilized based on the 4th jejunal artery. A subcutaneous
tunnel at the abdominal wall and chest was made for the
transposition of the pedicle jejunal cephalically to join up
with the previous free jejunal ap. A jejuno-jejunal
anastomosis was carried out in a Roux-en-Y fashion to
restore the bowel continuity [Figure 2]. The gastrostomy
remained in-situ and the wound was closed in layers. Post-
operative recovery was uneventful with oral feeds were
commenced 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 of
aspiration pneumonia and her quality of life has greatly
improved.
Esophageal replacement in children continues to be a
challenging operation with signicant morbidity.
1
Colon
interposition is most often used in the pediatric population,
however, the colonic interposition for esophageal replace-
ment only provides a mechanical conduit without
Figure 1 Patient before the second operation showing large
amount of saliva in the jejunostomy bag which would have
been aspirated in the lungs if without diversion.
Correspondence and communications 417