Plastic Surgery Perspectives: Craniofacial Surgery

by Stav Brown, BS1, and Paymon Sanati-Mehrizy, MD2

Sackler School of Medicine at Tel Aviv University, Tel Aviv, Israel

2 Department of Surgery, Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY

Through interviews with leaders in the field, we present here the first piece in the series “Plastic Surgery Perspectives”, dedicated to providing residents and medical students an insight into future career options and possible fellowships within the field.

This piece includes contributions from Dr. Peter J. Taub, Dr. Jesse A. Taylor, Dr. Eduardo D. Rodriquez, and Dr. Joseph E. Losee.

Why craniofacial surgery?

Dr. Taub: Of all the amazing disciplines in Plastic Surgery, I believe craniofacial surgery enjoys the most history, possesses the most passion, and requires the most skill.  I still do breast surgery and I still do hand surgery as these are areas that still interest me, but craniofacial surgery will always thrill me. Many of the founding giants in Plastic Surgery, such as Harold Gillies and Archibald McIndoe, were craniofacial or maxillofacial surgeons. They developed techniques for head and neck reconstruction during World War I and created units to manage such problems thereafter. And it is this history that has been passed down from Paul Tessier and Fernando Ortiz Monasterio and Hugo Obwegeser (and others) to Henry Kawamoto and Linton Whitaker and Joseph Gruss and Anthony Wolfe and John Persing (and others) to their fellows today. Unlike other specialties, craniofacial surgery requires management of the osseous framework as well as the overlying soft tissue envelope.  Precise bony reconstruction is needed for the former; subtle nuance for the latter.

Dr. Taylor: During my training, I fell in love with craniofacial pathological processes and their treatment. I also had strong mentors in craniofacial surgery whose passion for the field was imbued in me.  

Dr. Rodriguez: It is the field of Plastic Surgery that was best suited for me as a previously trained Oral & Maxillofacial surgeon. I found it to be a very artistic field that offered me the ability to create, shape, and mold the hard and soft tissue of the face and skull in children and adults. Finally, it is the one area of our body that we cannot conceal and must therefore always aim to achieve the most optimal functional and aesthetic results.

Dr. Losee: I knew that I wanted to do something with kids all along. I taught in an elementary school before going to medical school, and enjoyed my pediatrics time a lot. As a second-year medical student I shadowed with Joseph Serletti and when we were doing a cranial vault procedure, a light bulb went off and I knew that’s what I wanted to do. 

How has craniofacial surgery changed since you were a resident?

Dr. Taub: Craniofacial surgery has been revolutionized by technology. While autogenous bone remains a gold standard, alloplastic materials have proven valuable in many instances without the need for donor site harvest. And perhaps more revolutionary is the development of imaging techniques that can be directly utilized and applied to solve reconstructive problems.

Dr. Taylor: The vast majority of craniofacial surgery has not changed drastically from when I was a resident. That said, we have seen stepwise improvements in diagnostic testing (genetic screening, whole genome analysis, higher resolution 3D CT imaging, black bone MRI imaging, fetal ultrasound and MRI, intra-operative CT navigation, and OCT for imaging the optic nerve), implants (3D-printed plates and screws, patient-specific implants for cranial reconstruction, improved bio-resorbable fixation for infant craniofacial surgery), and anesthetic techniques. I also feel like craniofacial surgery has benefitted from some global trends in surgery such as enhanced recovery techniques, the “quality improvement” movement, and improved ICU medicine. 

Dr. Rodriguez: Refinement in techniques, imaging, computerized planning, and 3-D printing have become more sophisticated, allowing for more predictable surgeries. Face transplantation is a part of our current surgical practice and will ultimately become a more routine procedure.

Dr. Losee: That’s an interesting question. I am not sure anything has made any dramatic changes in what I practice since I limit myself to mostly cleft and craniofacial surgery. Some of the main improvements include: fat grafting, the way we treat Romberg’s disease and the way we treat hemifacial atrophy. New distraction techniques, some of the minimally invasive craniosynostosis treatments: springs, strips and helmets and face transplantations have made significant changes in the field. 

What are your main interest areas within the field/specific elements that you are particularly interested in, either from a clinical perspective or research perspective?

Dr. Taub: My main interest is calvarial reconstruction both in infants and adults. I enjoy working with my neurosurgical colleagues, which is both stimulating and rewarding. 

Dr. Taylor: My focus is mainly on pediatric craniofacial problems such as craniosynostosis, hemifacial microsomia, craniofacial clefts, cleft lip and palate, and orthognathic pathologies. I do, however, enjoy a challenging adult secondary craniofacial reconstruction.  

Dr. Rodriguez: Hard and soft tissue facial reconstruction with local tissue flaps and distant microvascular flaps. Primary and secondary facial trauma reconstruction. Facial skeleton osteotomies and orthognathic surgery. The combination of these main interest areas has played an important role in the success of our face transplantation program.

Dr. Losee: The thing that I find most interesting and challenging is primary rhinoplasty at the time of cleft lip repair. When I started out we did barely anything for the nose, we fixed the cleft lip and saved the nose for later. We currently do a semi-open septorhinoplasty. I separate the quadrangular cartilage and the caudal septum from the anterior nasal spine, reposition the anterior nasal spine and fix it in place. Then, I make rim incisions bilaterally, dissect out the lower lateral cartilages and sew them together. We then use three months of postoperative nasal stenting to try to keep everything in place. We are currently collecting data and I do think it makes a difference. 

Tell us about a special case or aspect that has influenced you or shaped your vision of the field.

Dr. Taub: The care of a child with any one of a number of craniofacial syndromes can be exceptionally rewarding. At the time of birth, the parents need comfort and knowledge about what to expect and the infant needs the care of a multi-disciplinary team, led by a craniofacial surgeon. As the child grows and develops, surgical hurdles need to be solved that often require significant risk but also tremendous reward. The pathology is not limited to the skull but often involves the midface and mandible. Care extends throughout childhood and into adulthood, creating a special bond between the patient and the surgeon.

Dr. Taylor: Like many of my colleagues, I am vexed by the challenging nature of the Apert phenotype. It is difficult to “de-Apertize” the Apert’s face, but I feel that work by Richard Hopper with the Lefort II + zygomatic repositioning and by David Dunaway with facial bipartition are pointing us in the right direction. I am not wedded to a single operation to “de-Apertize” the Apert face, but I have recently been performing a monobloc + Lefort II distraction in which I differentially advance and rotate the nose and maxilla (Lefort II segment) from the monobloc segment. Like the other operations I mentioned, the monobloc + Lefort II corrects many of the phenotypic differences of the Apert phenotype.

Dr. Rodriguez: In January 2018, we performed our most recent face transplant at NYU Langone, where we replaced much of the upper, mid, and lower face and jaws of a 26-year-old man from California who suffered a self-inflicted facial gunshot wound. The surgery took approximately 25 hours and the result confirms that this is the appropriate surgical solution for this very difficult central face deformity. It was the shortest period of time from injury to transplantation, the longest distance to travel for a face transplant, one of the shortest wait times to identify a donor, and the most technologically advanced face transplant resulting in significant reductions in surgical times and hospital length of stay.

Dr. Losee: I remember doing a fronto-orbital advancement with Dr. Serletti early in my second year and pretty much realizing that this is what I wanted to do. I have done research with bone, skull reconstruction and all kinds of facial fracture research but I guess the one thing that really picks my interest is fixing the primary cleft lip nasal deformity, as previously mentioned. 

What role does technology (ie.e, virtual surgical planning, 3D modeling and printing) play in craniofacial surgery?

Dr. Taub: Virtual surgical is beginning to scratch the surface of its role in craniofacial surgery. Today we are able to completely visualize complex bony architecture and virtually design operative treatment strategies to manage them.

Dr. Taylor: I am increasingly utilizing virtual surgical planning (VSP) in various aspects of pediatric craniofacial surgery. In reviewing our recent series of over 100 VSP cases at CHOP, we found that we are utilizing it most commonly for orthognathic surgery, complex facial osteotomies (such as the previously mentioned monobloc + lefort II), bony free tissue transfer for head and neck reconstruction, and teenage cranioplasty. We have NOT found it to be particularly useful in infant cranial surgery as others have published, but perhaps there is an occasional role in a rare, complex case. While I am a big fan of VSP technology, I am careful to tell my trainees that we have to “keep our thinking caps on” both during planning sessions and VSP surgical cases—poorly planned VSP operations will turn out poorly, and unrealistic plans can be disastrous. Remember—VSP engineers can move bone on a screen any way you ask them, but that is not true in the operating room.  

Dr. Rodriguez: Computerized surgical planning (CSP) allows for dedicated time to visualize a procedure, without any distraction, prior to performing the actual operation. The combination of three-dimensional CSP, three-dimensional printed patient-specific cutting guides, intraoperative navigation, and intraoperative CAT scan ensure that facial bones are aligned perfectly and that implantable plates and screws are in an ideal position. Intraoperative navigation and intraoperative CT’s have also increased our ability to tackle the most complex cases more precisely in real time with maximal aesthetic and functional results, minimizing the need for additional follow-up surgeries. This technology has the added bonus of providing a unique setting for educating trainees and ultimately provides operative time savings.  

Dr. Losee: Technology has made it possible to visualize and plan the procedure prior to performing it and new technologies such as the computer-aided process planning (CAPP) cam has made a huge difference in orthognathic surgery. 

What most excites you as you anticipate the future of craniofacial surgery?

Dr. Taub:  I think I most look forward to the creativity and passion of the next generation of craniofacial surgeons. I know they will utilize evolving technology in ways not yet considered to develop safer and more precise treatment options.

Dr. Taylor: Craniofacial surgery has so much interplay with the most interesting areas of medicine today—neuroscience, bone biology, genetics, the study of appearance—that it’s future will undoubtedly be fascinating. I don’t pretend to know where we are going, but I know it will be a great ride.

Dr. Rodriguez: Advances in technology, improvement in tissue regeneration, and sophisticated surgical practices will continue to ultimately improve patient care. In addition, most face transplant cases in the U.S. have been performed under research grants, mostly from the U.S. Department of Defense. However, for our most recent case, financial reimbursement support was provided by the patient’s commercial insurance.  

Dr. Losee: I think the future will help us figure out what patients need cranial vault surgery and determine whether or not kids need really big releasing kind of surgeries when they’re small and prone to subsequent growth problems. Figuring out who needs to have these operations, when they need to be done and non-devascularizing ways of doing them is imperative. The spring is a great example of that because we can do minimal surgery and do not devascularize all the bony flaps, so we shouldn’t have the growth restriction that we see in a classic fronto-orbital advancement.  

For a resident interested in pursuing a craniofacial surgery fellowship, what advice do you have?

Dr. Taub: Embrace the history of craniofacial surgery. Seek out those whose careers may be ending but who have been monumental in the advancement of our specialty. Learn from them as well as from those whom they have taught about all of the amazing things our specialty can do for people burdened by craniofacial anomalies.

Dr. Taylor: Read. Ask questions. Develop a passion for a niche of craniofacial surgery, learn everything there is to know about that area, and then become the world’s expert. Take advantage of opportunities to publish your mentor’s results, especially in any area in which he or she is an “expert.” Above all, try to have fun on your academic journey so that you want to be a lifelong learner.

Dr. Rodriguez: Remember that the field continues to evolve and has expanded beyond the routine treatment of congenital malformation.

Dr. Losee: Recognizing upfront that the job market is limited. 
If that is what you want to do and you really love it, then you should do it, but you need to recognize upfront that it is going to be tough. Doing a fellowship and spending time in training is never a bad thing, sharpening your sword is never time wasted. It will make you a better surgeon and a better doctor. 

Residents should look for well-rounded pediatric plastic surgery fellowships that include cleft, craniofacial, vascular anomalies, brachial plexus and transgender procedures. Choose a really broad training program since you never know what you end up doing. 

Be a good doctor, take care of your patients, be ethical and work hard. Be a good technician, a mature surgeon, a dedicated physician. We look for a someone who is a good person, a technically good surgeon and somebody who has the fire to be academic later on.

Craniofacial surgeons at the 2018 Alpine workshop in Telluride.
Pictured (left to right): Yamada, Taylor, Bartlett, Hopper, Whitaker, Taub, Losee, Baker, and Gilardino.

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