Search for tag: "pediatric plastic surgery"

Interviewer: Three types of surgery can be used to treat craniosynostosis, which one depends on a few different factors. If the synostosis is caught early enough, the newer endoscopic procedure can be used.

Pediatric plastic surgeon Dr. Faizi Siddiqi and pediatric neurosurgeon Dr. John Kestle are here to discuss the three different types of surgery for a synostosis and why they would consider one over the other. So, first of all, how early does a child need to see you for the less invasive endoscopic procedure to be an option?

Dr. Kestle: So the endoscopic method we've been doing since '07, and we've found that the best time to do it is usually between two and three months of age. So we have to see the patient before that and the earlier the better. The surgery is done under a general anesthetic, and the surgery typically lasts about two hours, and most of them spend one night and can go home the next day. Occasionally, they need two nights. It's done with, for example, sagittal synostosis with two incisions -- one just behind the soft spot and one toward the back of the head. And then we work under the skin to remove the fused bone.

Removing the fused bone doesn't really change the shape much at all immediately. It just releases the bone. And then about two weeks after the surgery, they start wearing a special helmet that's designed for surgical patients, that is a little snug front to back and a little loose on the sides, and it just guides the growth so that as the baby's head growing, it's taking on a more normal shape. They wear the helmet for about six months, some shorter, some longer, and we just monitor the growth pattern and make that decision. And they'll go through several custom-made helmets over the course of the treatment as they grow.

Interviewer: Generally, I'd imagine a less invasive procedure is always better. Why is this procedure better than say the traditional treatments?

Dr. Kestle: Well, it's got a shorter hospital stay, a much lower rate of blood transfusion. It's a lot less swelling associated with the surgery. It's easier on the babies, and the results are at least as good.

Interviewer: Is there a reason, other than age, why a child would not be eligible for the endoscopic surgery?

Dr. Kestle: We don't often do it in children that have syndromes where they might have multiple malformations in other parts of the body, such as Crouzon syndrome or Apert syndrome. And in addition to those other malformations, they have synostosis. Those children usually need the more traditional, bigger surgery. But any child that has one suture fused is a great candidate for the smaller surgery.

Interviewer: Dr. Kestle, you're a neurosurgeon. So you handle that part of the procedure?

Dr. Kestle: Yes.

Interviewer: Okay. And then Dr. Siddiqi, you're a pediatric plastic surgeon. With the endoscopic procedure, both of you are in the operating room at the same time. Just kind of walk me through how the surgery goes. Dr. Siddiqi, you start the surgery.

Dr. Siddiqi: So we're in the OR together. It's a team approach. So once the anesthesia team have completed their part, which is getting the baby asleep and making sure the IVs are put in and everything is safe to proceed, that's when we position the baby for surgery. I would make the initial incisions. For example, for sagittal synostosis, we make two incisions on the top of the scalp. Again, that's one of the advantages of doing it this way versus the bigger procedure because you have two small incisions. Through those incisions, we expose the area that we want to operate on, which is that fused sagittal suture. And once everything's exposed and visible, then Dr. Kestle would take over.

Dr. Kestle: What we do is remove a little bit of bone under each incision. And that allows us to get underneath the bone. Underneath the bone is a layer called the dura, which is a covering layer over the brain. It's kind of like leather, like a thin leather. And we use the endoscope to separate that layer from the bone, and that allows us to safely cut the bone and remove it. Once the bone is removed, we look at the dura and make sure it's okay. We stop any little bits of bleeding, but there usually isn't much. And we check the bone edges, which sometimes ooze, and make sure that any bleeding is stopped. And then at that point, Dr. Siddiqi and his team continue working.

Dr. Siddiqi: Yeah. So we take out or remove additional segments of bone. There are these little triangles we take out, about four them. Again, afterwards, we make sure that the bone edges are, you know, clean. They're not bleeding. Again, that's one of the other advantages to doing it this way. The blood loss is quite small, minimal compared to the traditional way. Most of the time, it's maybe 10 or 15 milliliters of blood. So once those triangles are removed, then we close the incisions. Then the anesthesia team takes over, and the baby's, you know, woken up and then taken to the recovery room.

Interviewer: What does the recovery look like then for a child? And, you know, what kind of outcomes can parents expect?

Dr. Kestle: With the small surgery, they don't need to go to the intensive care unit. They stay in the hospital in a regular room, and the parents can stay with them. The vast majority of those children are here for one night. Occasionally, they need two nights. The criteria for going home are pain control and feeding. They get some swelling toward the back of the head, that gradually goes down over the first week at home. Stitches dissolve on their own. And within a day or two, they're back to their usual self as far as feeding and behavior goes.

Interviewer: And Dr. Siddiqi, how long does it take for the head then to regain more of what would be considered a normal shape?

Dr. Siddiqi: Yeah. So as Dr. Kestle mentioned earlier on, the shape doesn't change after the surgery, right after. It's once they're in the helmet. The helmet is critical for reshaping the head. And typically, they're in the helmet usually two to three weeks after the surgery. It's a custom helmet. You know, it just guides the growth of the head, and over the ensuing, you know, three to six months, we have a more normal head shape. And hopefully, after six months of helmeting, that's all they need.

Interviewer: And the incisions that were talked about out in the endoscopic surgery, are those visible or are those in the hairline?

Dr. Siddiqi: You know, they're in the hairline. And again, another advantage to doing it this way is the incisions are on the top of the scalp, the head, and those scars heal very nicely. They're quite thin and they're barely perceptible. You only notice them when the hair gets wet. Again, with the bigger procedure, you have a much bigger incision from ear to ear, which is much more noticeable.

Interviewer: Let's talk about the more traditional procedures in the event that a parent is in a situation where their child is older than six months old or there's other reasons why they might have to have that. What are the two procedures, and can you explain those a little bit?

Dr. Siddiqi: Yeah. So sometimes, you know, we do see kids who are, you know, two, three months old and they're eligible for the smaller procedure, but for various reasons, let's say they live out of state or they don't want to do the helmeting, they would like to do the traditional, what's called cranial vault reconstruction with orbital advancement. So then we would wait until they're 10 to 12 months of age to do that procedure. Essentially, that's a much more involved procedure, but it's a procedure that's, you know, well described. People have been doing it for, you know, 30, 40 years. You know, the results that you get are comparable to the endoscopic procedure, but, again, it's how you get there.

So with this procedure, you have to expose the entire skull. So that means an ear-to-ear incision through the top of the scalp. I would expose that, mark out where I want Dr. Kestle to make the cuts and remove the segments of bone that we want to reconstruct and reshape. Then Dr. Kestle would remove those pieces of bone, make sure that the lining of the brain is okay, make sure everything is okay. Then I would reshape all those bones and reconstruct the skull in a more normal configuration, and everything is stabilized with plates and screws. And these are resorbable plates and screws. They dissolve in about a years' time. So we put everything back together and close the scalp. That's a four or five-hour process. Much more blood loss than with the endoscopic procedure.

They typically would go to the intensive care unit for one night, and they typically would be in the hospital three or four nights. Oftentimes there's quite a bit of swelling. The eyes can get swollen shut, and it would take maybe 10 days to 2 weeks for that swelling to go down.

Again, the advantage is you don't need a helmet. It's all done in one stage. You know, the compromise is that it's a much bigger operation.

Interviewer: If parents are evaluating a center or physicians to do this procedure, what advice would you give to them to, you know, pick out the best place for them?

Dr. Kestle: I think it's a procedure that is usually done very safely, and children do very well and go home quickly. We are exposing the layer over the brain, and there is a potential for bleeding. And so I think that experience matters. And I think that you do want to be treated by people who do this a lot and people who can handle problems, which are rare, but if they arise, they need to be dealt with appropriately. So I think it's a big advantage to being treated by people who have experience with this, who are in a children's hospital with pediatric-trained specialists, including anesthesia and a pediatric intensive care unit if they need that.

Interviewer: And you mentioned a third procedure, a cranial vault distraction, when might that be used?

Dr. Kestle: So there are some children where their brain is in trouble or potentially in trouble because they have presented very late or they have multiple sutures that are closed. And in that situation, we want to make the skull bigger to give the brain room to grow. Probably the best way to do that these days is a procedure called distraction, where some implants are inserted and then the skull is gradually expanded over time.

Dr. Siddiqi: You know, with cranial vault distraction, again, the idea is to give the brain as much room as we can because of the fact that more than one suture is fused. And the way that's done is I would ask Dr. Kestle to make some cuts on the bones. And then I would put these little devices, they're called distractors, on either side of the cuts. And then three days after surgery, we would have the family start turning those distractor devices. Typically, it would be total of one millimeter a day. So over the ensuing three to four or five or six weeks, the bones are slowly being separated. And what happens is that, as they're separated, there's new bone being formed in the gap. And over time, that new bone will solidify. So we're not only expanding the volume for the brain, we're also creating new bone. This is really the only way we can expand the brain to this degree using these devices. We couldn't do it as a single-stage procedure.

Interviewer: Between the two procedures, the endoscopic procedure, the less invasive, and the cranial vault reconstruction, are there any tangible differences and outcomes or how the head is going to look or anything like that?

Dr. Siddiqi: I would say like the overall head shape is probably going to be comparable, just the head shape itself. But again, as I said, it's how do you get there? You know, how long does it take? What are the risks involved? In terms of the shape itself, with the endoscopic procedure, overall the head feels and looks quite smooth at the end of the day when everything is healed. Whereas with the bigger procedure, you know, we're taking all the bones out or in multiple pieces, putting it back together. So when everything is healed in a year, two, three years' time, you do feel some irregularities over where the bones are joined together. But overall, the head shape is probably comparable. But, you know, I think you get an overall smoother head shape. And I think it probably looks a little bit better as well.

Dr. Kestle: And obviously, the scar is different as well. In the endoscopic, there's two scars on the top of the head that hide really well. And the bigger surgery has an ear-to-ear incision, which also usually heals really well. But as people age and start to lose hair, it's a lot more obvious.

Interviewer: You notice that your child is starting to develop a flat or misshapen head. Is that something to really worry about? And what should you do? We'll discuss that with Dr. Barbu Gociman next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Barbu Gociman is a plastic surgeon who specializes in pediatric plastic surgery at the Craniofacial Program at the University of Utah Health Care. If your child is showing signs of a flat or misshapen head, could be a couple of things going on. We're going to find out more about that right now. Is that always something to worry about?

Dr. Gociman: We see two different patterns. One would be the parents are really worried, the other one, the pediatrician is very worried. In either instance, there are two different causes. The more common deformity that you see is actually acquired after birth, is due to positioning in the uterus. As babies, we have a position of comfort. That is whatever the position of the uterus is. So once the baby is born, they tend to reproduce that position and preferentially just lay on one side.

As the brain pushes the bones and the head keeps growing, because the baby preferentially lays only on one spot, that becomes flatter and flatter. The rest of the cranium grows, and suddenly at three, four, five months of age, your baby has a flat head. Usually, it's on the back of the head one side. Obviously, there's a different degree of severity. We say usually about 1 in 300 babies has a very severe deformity that will need some time of aggressive management. That is the least severe problem because it's just an easy fix. Basically, you have the baby not lay on that spot. We will have to have the parents aggressively trying to rotate the baby from that spot. The challenge is the baby will always want to turn back into the same position.

Interviewer: How do you prevent that? What are some strategies you have to prevent that?

Dr. Gociman: Unfortunately, there's no one perfect strategy. All the pillows and things that try to make it through the FDA were to kind of reposition the baby in the crib did not make it because of safety hazards. They can act as chokers, basically. So there's no good device that will keep the baby from rotating so it's just the diligence of the parents. Some parents will be more diligent than others.

Interviewer: And you just have to go back in there and just . . .

Dr. Gociman: Keep rotating. Obviously, once the baby is growing a little bit more, more tummy time, more sitting position and that will alleviate the problem.

Interviewer: Gotcha.

Dr. Gociman: If the deformity is really severe, then we recommend a helmet, which the helmet is worn for 24 hours a day, basically. That will take off all those problems where the parents will have to go repeatedly and change the position.

Interviewer: The harm is not only a misshapen head, but it could actually affect the brain?

Dr. Gociman: There's absolutely no influence of the developing brain. It's just an aesthetic problem.

Interviewer: Oh, really? Okay. Well, I guess that's a relief on some level.

Dr. Gociman: This is the more common problem of a flat head. Unfortunately, there is a much more severe problem that could lead to a flat head or misshaped head. The technical name is craniosynostosis, in which one of the sutures, which normally separates the different bones into the cranium, fuses prematurely. The sutures usually fuse when we are in our 20s or 30s. If a suture fuses prematurely, either in utero or as a very, very young baby, the head will be forced to compensatorily grow and you will deal with a really misshapen head.

One suture can be fused, or multiple sutures can be fused. The more sutures that are fused, the more severe the deformity, and the higher the chance that misshapen head will put pressure on the growing brain and lead to developmental problems. That is a condition that will require surgical intervention. We do some surgical intervention, minimally invasive, in which the operation is done in conjunction with your surgery that is much quicker and the patients recover much easier.

We also, for more severe forms or for delayed presentation, the patient will require really very, very significant operations and the patient will require prolonged hospitalization, intensive care unit care after the operation. So, definitely, the way to tell the difference between the two, although we highly have a suspicion on physical exam, is to do a CT scan. The CT scan will tell us exactly if a suture is fused or not. We'll know 100%. We usually, on clinical exam, we can have a 90% to 99% suspicion of if we deal with one or another. Usually, for positional plagiocephaly, it's very easy to make the diagnosis just on physical exam.

Interviewer: That's the one where sleeping in the same position too much . . .

Dr. Gociman: And which is the more common one.

Interviewer: Gotcha.

Dr. Gociman: In order to make the exact diagnosis, we'll be happy to see you to our Craniofacial Program at the University of Utah, to see you and discuss what the problem is and what the next steps will be.

Announcer: TheScopeRadio.com is University of Utah Health Sciences radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You are listening to The Scope.

Interviewer: You found out your ultrasound that your child possibly might have a cleft lip. What should you do after that? What's going to be coming up and what are some things you need to know? Dr. Barbu Gociman is a plastic surgeon and a specialist in pediatric plastic surgery at the Cranial Facial Program at University of Utah. First of all, what is a cleft lip exactly? What's going on?

Dr. Gociman: Yes, it's not an extremely easy question to answer. It's anomalous and biologic developmental problem in which the forming face and particularly the lips, do not come together. It can be associated with a clefting of the palate. There are different degrees of clefting present. What a cleft means is basically an opening where, instead of the tissues coming together, they do not, and the bigger the defect, obviously the wider the gap between the elements that should come together.

Interviewer: So in the ultrasound meeting, they may indicate the there is a cleft lip possible. It could be very minor to very major. And what's that extreme?

Dr. Gociman: Yes, exactly. There is a whole spectrum. It can start with just a furrow that you can see on the lip which is not going to be present on the ultrasound. To mind comes, Joaquin Phoenix as an actor that has that deformity, as a personality that you can always look up. From that point you can have different degrees of deformities, just small degrees of notching in the lip. It can go all the way to the nose and extending to the alveolus, which is the bony part carrying the teeth, and all the way into back of the palate, which is the roof of the mouth, can be completely clefted.

Interviewer: And do the ultrasounds, do you have a pretty good indication of how bad it's going to be at that point? Or you could a parent be even surprised even more after the birth?

Dr. Gociman: Yeah, the ultrasound, obviously is a good modality to diagnose, but as any diagnostic modality, it's not 100%. So you'll not completely know the degree or exactly what structures are affected until you actually see the baby and you can examine him.

Interviewer: And that degree can mean the difference between maybe a single operation or many operations through the child's childhood, up until 18, 19 years old.

Dr. Gociman: Yeah, exactly. So there is a stepwise process that has been validated over the last 50 years or so, and obviously it continues to undergo refinements in how we treat these patients. So if only the lip is involved, usually one operation is enough to correct the deformity. The sequence of treatment for the more severe deformities involving the lip and the palate would be we start taping or do what we call a nasal alveolar molding, which would be reshaping of the structures and bringing them in a more anatomic position to facilitate the surgical repair. That is done by our orthodontist, Dr. Duane Yamashiro, and requires multiple adjustment. That will last for approximately for the first three months of life.
We usually do the lip repair around three months of life. At the same time we examine the palate, if the palate defect is really wide, we insert a palatal prosthesis, which is an obdurator that will facilitate feeding.
The second operation is done at around 10 months to one year of age, which is the soft palate repair. That is done right before the speech develops. We exchange usually the palatal prosthesis at the time if a large hard palate cleft is present. We repair the hard palate at around four years. At six years of age we do a repair of the clefted alveolus with bone grafting, if the baby has that problem. And finally we will do a formal rhinoplasty operation at the late teenage years if the nasal deformity is still persistent.

Interviewer: I would imagine one of the major concerns parents have is physical appearance. It sounds like there's also a lot of functional things that aren't going to be right if these surgeries don't happen. But as far as physical appearance, can you bring somebody back to the point where you couldn't tell they ever had a cleft lip?

Dr. Gociman: Unfortunately to completely, scarlessly repair somebody, it's not possible. We as humans we heal by scarring, so you'll always see a scar. The quality of the scar can be from a very, very thin line, which it's imperceptible to a person that is not very attune to what he's looking at, to a fairly thick scar that will require revisions or steroid injections or scar treatments. That is at the level of the lip.
As I said, because the nose is mis-shaped by the deformity, usually the eyes are going to be really drawn to that deformity. That's why we put a lot of effort in reconstructing the nose in a very anatomical fashion to try to avoid that from happening. We do the cleft lip repair at three months of age, just because we want the parents and everybody that comes in contact with the baby to see a normal baby. We do not want them to get used to the clefted baby.
All the other functional portions, the palate actually, functionally, the palate repair is much more important because the palate is involved in speech, is involved in swallowing. So functionally that is more important. But what we see, and it's human, we judge, where most of the people, the lip repair is the most important step and that is why we do it first, and that's why we pay a lot of attention to it.

Interviewer: I'm sitting here, hearing this and in a way my heart is breaking for parents that find out that this might be something that their child will have to face. How do you even address that? What do you say? How can people find comfort?

Dr. Gociman: It's definitely not an easy process. Fortunately, especially nowadays there are all the support groups. We can always put you in contact with the families that went through with our group. That brings a lot of comfort. It's very difficult, especially the first moment when you feel like you are all alone confronting with such a big, challenging problem. But our Cranial Facial Program at the University of Utah has the answers and we are very happy to address all of them multiple times. Our phone number that you can reach us is 801-581-7719. The Cranial Facial Center is the way to go.

Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.