State of the Union: Cleft and Craniofacial Surgery Today

Side by side of a baby before and after cleft lip and palate surgery

Updated October 2024 to maintain the latest information in treatment and research.

An interview with Thomas Imahiyerobo, MD, Director of Cleft and Craniofacial Surgery.

What is covered under the term craniofacial surgery?

The term craniofacial surgery really refers to surgical procedures that are done within the craniofacial skeleton. Broadly speaking, this is really anything that involves the neck or upward of that area. When we think of craniofacial surgery as a specialty, it really encompasses not only the skeletal aspects of the craniofacial skeleton, so that's bone, cartilage reconstructive work, but also involves procedures and operations that are aimed at treating conditions affecting the soft tissue of the craniofacial skeleton. This includes skin malignancies, congenital birthmarks, as well as any soft tissue or bony trauma.

As a craniofacial surgeon, I find that there are two ways that we think of this field. Number one, we think of it as an anatomic specialty, so again, we highlight areas that need reconstructive or cosmetic work in the clavicle, such as the neck area and above. However, we also think of craniofacial surgery in terms of our skill set and techniques. Craniofacial specialists are really adept at doing procedures that involve bony work and structural changes to the facial skeleton. Moving around bone, skin, or soft tissue from where it is that you have it to where it is that you need it.

What are the most common procedures that you do?

The most common procedures that I'll do as a craniofacial surgeon involve reconstructive work for congenital anomalies that affect the craniofacial skeleton. Things like cleft lip and cleft palate surgery, as well as entities affecting the growth of the cranium [skull] itself, such as craniosynostosis. But this also includes more soft tissue work in the craniofacial skeleton, so treatment of congenital birthmarks or hemangiomas, and cartilaginous structures such as treatment of ear malformations or something like microtia, which is a congenital absence of the ear. 

We’re also adding new procedures focused on facial reanimation, which are procedures that help people regain movement in their face after either congenital paralysis or paralysis related to a disease process. And we have created a partnership with physicians at Cornell who have specialization in this area, so it’s a new offering with our expanding faculty.

What's new in surgical care? Have there been advancements in how you're doing these reconstructions?

There's certainly been a number of exciting and new advancements in the field over the last five to 10 years. One includes the use of minimally invasive techniques to treat craniofacial diagnoses.

When I start talking about reconstructive surgery of the facial skeleton, sometimes my patients' eyes open really wide because that sounds maximally invasive. And yet, we've really embraced the use of minimally invasive techniques to get the results that we used to do through more maximally invasive approaches. One specific example has been using minimally invasive approaches to treat craniosynostosis, the premature fusion of the cranial sutures or the cranial growth plates in the skull of a child or an infant. We know that left untreated, in some instances, it can lead to increases in intracranial pressure or issues with future neurocognitive development. It's something that we take very seriously here at Columbia.

How do you treat craniosynostosis minimally invasively? 

You know, treating craniosynostosis has always been a large part of my practice. There are many traditional standard techniques that involve open approaches to the craniofacial skeleton, and again, I would put them in the more maximally invasive category. What we've done at Columbia is embrace techniques that can be done through smaller open incisions where we do some limited work at the time of surgery and then can use our small access incisions to continue to change the craniofacial skeleton after surgery. These are techniques like distraction osteogenesis, where you can make an osteotomy [cut] in a bone that is not growing well and connect to the osteotomy a distractor, which you can think of as a device that will lengthen the bone.

Wow. So instead of one big procedure, you’re making changes slowly over time?

Exactly. You put the distractor on and do a smaller procedure, and then subsequently, you can use a distractor to slowly lengthen the bone or move the bone over time. Then, the distractors can be removed in another small outpatient procedure. We can really make big changes in the craniofacial skeleton with this combination of smaller procedural approaches.

That’s pretty amazing. 

It is! Another minimally invasive or minimal access technique that we've embraced is the use of endoscopic craniofacial surgery. An endoscope is a small device that has a light and a camera connected to it; you could think of it as a really small fiber-optic camera. So we can make small incisions somewhere in the scalp or the craniofacial area and then use the endoscope for visualization. Using smaller instruments, we go in and release points of bony fusion, remove bony tumors, and treat entities such as single-suture craniosynostosis.

After you have used the endoscope through the small access incisions, you can then, again, post-operatively, do things to continue to mold the shape of the craniofacial skeleton and overall get a treatment plan that allows you to get to the same endpoint that we used to do with much larger access procedures.

How do non-surgical management options factor into treatment for the conditions you see?

That’s a great question. There are certainly many entities in craniofacial surgery that can be adequately treated non-surgically. In the last five to 10 years, some entities that we used to treat primarily surgically have now moved over to non-surgical treatment. One is the treatment of hemangiomas. Hemangiomas are one of the most common vascular anomalies [congenital, pigmented birthmark] that we see in children. They can be big venous anomalies or capillary malformations, or they can be a collection of small arterials and capillaries that have overgrown.

The treatments for hemangiomas used to be primarily surgical. This involved us sometimes doing moderately-sized procedures on very little children and infants. What we're doing now, in partnership with some of our pediatric dermatology colleagues, is to use medical therapy to either slow the growth of the hemangioma or, in some cases, actually shrink it down to the point where it resolves. So, we’re either making surgery much smaller or obviating the need for surgical intervention altogether.

One of my colleagues, Dr. June Wu, along with Maria Garzon, MD, in pediatric dermatology, established the Vascular Anomalies Clinic at Columbia. This is a monthly clinic where they see patients from all over the tri-state area and some nationally. They come up with a treatment plan that is a combination of medical therapy and, at times, reserve surgical therapy when medical therapy has not been effective.

We’ve also expanded the clinic’s scope to include new approaches to children with micrognathia and P-band sequence-related airway obstruction. Using oral appliances, we can now intervene earlier to stimulate jaw growth, often downgrading the severity of the surgery needed or sometimes eliminating the need for surgery altogether.

Awesome. 

Another one is the treatment of congenital ear malformations. Congenital ear malformations are actually the most common congenital malformation of the craniofacial skeleton. They come in two flavors—minor ear malformations and major ear malformations. Minor ear malformations are those where all the parts of the normal ear may be present. However, they may be misaligned, folded, or projecting in a way that's not ideal. That's opposed to major ear malformations, such as microtia, where either all of or part of an ear did not develop. At Columbia, we’ve embraced non-surgical treatments for minor ear malformations by using techniques like ear molding.

What is ear molding exactly? 

Say a child has a minor ear malformation and is referred to us during the neonatal period; that means the first six weeks of life, we will use a custom or semi-custom ear orthotic to reshape the cartilage of the ear. There's been very good research that has indicated that the cartilage in the ear of a child is moldable for the first six weeks of life and maybe slightly longer than that in some children. So, we take advantage of this time to correct anomalies that used to require surgical procedures.

We've been able to get some really powerful changes from everything like prominent ear deformity to folded ears to cryptotia [ear cartilage partially buried underneath the side of the head], and a whole series of anomalies that we used to have to say to a parent, "Well, bring the child back to me when they're three years old and I'll do a small surgery."

How does the orthotic work? Is it fastened on for a period of time?

Here’s the interesting thing: if you knew how to correctly just hold the ear in place yourself and you stood there and held the ear for six weeks, the shape would change, and it would be permanent. But we don't recommend that parents do that in case they are holding it in a way that doesn't look good and then they're upset about it.

In these cases, we like to see the children as soon as possible, but certainly within the first six weeks. Through a system of adhesives, we fasten an earmold or an ear orthotic to the child's head. The orthotic is then changed out by myself in the office, and this is done on a recurring basis every one to two weeks until the treatment is done. The treatment usually lasts about four to six weeks, and again, the results are permanent. 

We’re talking 95-97 percent efficacy with this treatment. In my mind, that's a lot of children who may have been getting surgeries when they were older who are now getting successful non-surgical treatment and doing it at a relatively young age where they'll never have to be cognizant of the fact that this occurred.

Thinking along the lines of seeing the child as early as possible, have there been any developments in prenatal diagnosis?

Oh yes, this is actually a topic I’ve published on. We have a prenatal consult program in conjunction with our colleagues in Maternal Fetal Medicine where we use advanced techniques to help diagnose craniofacial abnormalities in utero. More importantly, early prenatal consultation for entities like cleft lip and palate, once diagnosed in utero, can actually have a positive effect on the postnatal course for the child and the mother.

Really, what we're doing is collaborative counseling. The patients will meet with the maternal-fetal medicine doctor, a clinical geneticist, and the craniofacial specialists, all at a minimum. We do advanced imaging to help refine the prenatal diagnosis and really give the family as much information about the pregnancy as possible, as early as possible.

But beyond giving information, this collaboration is really fruitful because the data shows that early and appropriate counseling leads to better outcomes once the child is born. We see lower rates of postpartum depression. Better rates of feeding and weight gain in children with cleft lip and palate that had prenatal diagnosis. And certainly, we can plug them in earlier with our surgical team to get them prepared for their surgeries.

Incredible. Let’s talk cleft lip and palate. How do you go about developing surgical plans to treat cleft disorders?

This is a topic I’m so very passionate about. So, research shows that children with cleft lip and palate are best-taken care of in the context of a multidisciplinary team, and as the term implies, that involves more than plastic surgery. 

Here at Columbia, I co-direct our craniofacial team along with one of my colleagues, Dr. Jeffrey Ascherman. But the team really is so much more than us. There are individuals from pretty much every specialty that a child with a cleft lip and palate could need on our team. This includes pediatrics and pediatric ENT. It includes speech therapy, oral surgery, pediatric dentistry, orthodontics, just to name a few.

Does the entire team see the child at the same time, in the same appointments?

Absolutely. It’s so much more efficient. Our kids come to one appointment, and all the providers are present. It can certainly be a long day for a little child and a family, but at the end of that day, they have a multidisciplinary treatment plan from many providers that lays out the important things for the family to do, let's say, over the next six to 12 months before they come back to the team. All instead of going to multiple appointments over multiple days in different offices. 

And I’m excited because we’re even expanding this further with the new Craniofacial Center, which will be one of only two standalone flagship centers in New York. It’s a game-changer for efficiency, with all of our specialists coming to the patient in one place.

Is cleft lip and palate generally something that requires a long-term relationship with your team?

It is. You know, generally, cleft lip and palate are entities where there can be multiple points of care as a child grows up. Our concerns for an infant may be different than our concerns for a toddler and may be different from our concerns for a school-aged child. By having the craniofacial team see the patient on a recurring basis, we not only set up an escalating treatment plan as necessary, but we also get the opportunity to really grow up with the family and make a lasting relationship that I think is mutually beneficial.

Are there any new developments within the procedure itself? Any new techniques?

Well, first, the two most common procedures that get done are repair of the external cleft lip, which is the upper lip, as well as repair of the palate which is the roof of the mouth. In our offices, these two surgeries will happen during the first year of life, during infancy. 

But neonatal cleft lip repair, which is something that I've published on, is a relatively new development in the treatment of cleft lip and palate. We used to think that the treatment of the cleft lip needed to wait until the child was a certain size or a certain age, and often, children wouldn't reach those criteria until six months or older. Now, we take advantage of the fact that we can do a lot of prescreening for children and prenatal diagnosis, which we couldn’t do when we were repairing them many years ago. Through that, we're able to find children who are good candidates for neonatal lip repair.

What are the advantages of doing the repair on newborns instead of waiting until they are older?

There really are many advantages. We feel that we get better scarring of the lip repair and better contouring of the nasal cartilage during the repair. These are things that are really important for the children and the families long term. 

We’ve also introduced new forms of pre-surgical orthopedics for cleft care. Our craniofacial orthodontist, Dr. Jill Schechter, brought a cutting-edge technique called Plana to our practice. It helps us address cleft deformities before surgery, reducing the severity of the condition by the time we reach the operating room.

What’s new in the world of research? 

There are a lot of new, exciting developments in craniofacial research, both here at Columbia and nationally. But I want to talk about some of the basic science research that's been going on that I'm really excited about. First, in the area of tissue engineering. I spend a lot of time talking about surgery on bone and cartilage and tissues of the facial skeleton. You might imagine that there are some instances where we have a challenge in finding enough bone or tissue to move around and do our procedures. Think, for instance, a patient who comes in after a traumatic accident or a patient who had a bone tumor or malignancy where that bone is now removed. These can be scenarios where it's really challenging to find enough bone elsewhere in the body to replace the bone or soft tissue that was lost.

Certainly, from a surgical perspective, there's been many advanced techniques that have been employed for these procedures over the years, but there's recently been some exciting research going on relating to tissue engineering and 3D printing of craniofacial bioconstructs. Bioconstructs are essentially cartilage scaffolds that can potentially be impregnated with the patient's own live cells, thus making a 3D fabricated replacement for an area of cartilage or bone that has been lost.

Wow, so being able to recreate part of the body with the patient’s own living cells?

Exactly. To some degree, I think of bioactive constructs as the holy grail in craniofacial research because they would allow us to refabricate part of the craniofacial skeleton in a way that is so high fidelity to natural anatomy. It would be such a major advancement. I think some of the basic science research going on here lately has been really forward-thinking, and I'm hoping that we will have bioactive 3D-printed constructs as a reality within the next decade.

In fact, our research recently made a breakthrough in collaboration with our colleagues at Weill Cornell. We discovered a novel stem cell population involved in cranial suture fusion, which could be a bioengineering target in the future. This research was published in Nature and has opened new avenues for understanding how cranial sutures function.

We’re also starting to use AI in our virtual surgery planning. This allows us to simulate surgeries using the patient’s own anatomy from CT scans. It gives us the ability to model different surgical approaches ahead of time, which makes surgeries more efficient, reduces complications, and tailors the surgery to the individual. We even published a paper on this in PRS and are presenting our latest work at the American Society of Plastic Surgeons meeting this year.

That’s amazing. What available resources should families know about? 

I think the most important thing is that families know what craniofacial specialists do because, many times, patients don't even realize that we have the skill sets they need to solve their problems. I often see patients who have seen a dermatologist or another doctor, and they don't realize that their problem is a craniofacial problem. Then, somehow, they find us. I think patients should know that if they have an issue in the craniofacial area, they should seek out someone who has specific craniofacial expertise because oftentimes, we have the appropriate skill set to treat them.

With a lot of the congenital malformations we discussed, are you mostly treating young children or babies because that is the ideal time to treat these disorders? What about older kids who may not have had access to treatment at a younger age?

Great question. You know, the treatment of craniofacial abnormalities, whether they present from a congenital aspect or an acquired aspect, is typically going to be improved by having an assessment as soon as possible. And as soon as possible can range from children to adults. We have patients from age zero all the way through adulthood.

Certainly, I would say that the majority of patients are going to be pediatric, but we see adults who have had trauma. We see adults who need cancer reconstruction after the removal of tumors or cancer procedures. We see patients who have developed facial abnormalities secondary to just aging and time. So, in all cases, I think the key is realizing that your issue is in the craniofacial area and then seeking out a craniofacial provider.

We are expanding with new specialized services, like our pediatric breast and chest disorder clinic, which offers reconstructive surgery for issues like gynecomastia, breast hypertrophy, and congenital chest deformities.

That’s one of the great things about being at Columbia; we have great expertise across all disciplines and a really collaborative working environment. With our multidisciplinary team, all of those individuals can be accessed through our craniofacial team. Or, if you don't need the entire team, the craniofacial plastic surgeon and the other provider can work together independently. We really customize your care.

What excites you most about the future of craniofacial care? 

One of the things that has really excited me recently is the recent trend towards trying to change some of the social perceptions around people with craniofacial abnormalities or craniofacial differences. A few recent things happened in the cleft lip and palate advocacy community this past year alone. Several stories caused national conversations to start around some of the stigmata that are attached to cleft lip and palate.

People need to remember that cleft lip and palate are very common and are present in one out of 700 births. You probably know someone who has had a cleft lip and palate but had surgery, so you may not be aware of it. It's a really common thing. In the cleft community and the cleft advocacy community, which I consider myself a part of, we’re pushing a lot of campaigns to try to bring social awareness around the more psychosocial challenges that children and families with cleft lip and palate go through.
 
We’re also working on building up our psychosocial support services for these children and families. We’ve integrated pediatric psychologists into our craniofacial team and are planning to hire a full-time psychologist or social worker to lead this portion of the program. We want to treat the emotional and mental health of our patients just as much as the physical aspects.

What are your goals for the next five to 10 years? 

From a programmatic standpoint at Columbia, we're really growing our team. We have one of the busiest teams in the local region, but we still feel like there is more that we have to offer the patients in the tri-state area and beyond. We have a craniofacial nurse practitioner who works in a collaborative manner with our pediatric neurosurgery colleagues at Weill Cornell in a bi-campus role. We’re expanding research and now have a full-time clinical research coordinator to really get our advances out there to the larger scientific community.

This fall, we welcomed a new faculty member, Dr. Naikhoba Munabi, who comes from California and is a brilliant surgeon. She has even been the social media liaison for the American Cleft and Craniofacial Association and worked as the Global Surgery Fellow with Operation Smile. We’re looking forward to how she can help us showcase patient stories and the incredible work we’re doing in new and exciting ways.

That’s great to hear.

You know, on a personal level, one of my goals is to really highlight some of the incredible journeys our patients have gone through. We have children and their families who have really overcome so much. I'm really proud of them. And I think their stories may serve as motivation for someone else going through or trying to overcome something similar. I think that's the really important work that we're just beginning to facilitate, and I hope to see more of that over the next five years. Our patients are incredible.

 

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