State of the Union: Cleft and Craniofacial Surgery Today

An interview with Thomas Imahiyerobo, MD, Director of Cleft and Craniofacial Surgery and Section Chief of Pediatric Plastic and Reconstructive Surgery.

Dr. Imahiyerobo discusses earlier intervention in craniofacial care, advances in microtia reconstruction, virtual surgical planning, AI and robotics, the burden of cleft diagnosis, and why the future of the field depends on better operations and better systems of care.

Earlier Diagnosis, More Options

One of the major themes in our last conversation was the shift toward earlier intervention and less invasive approaches. Does anything feel meaningfully different now?

We are seeing more and more patients presenting with craniosynostosis earlier and earlier, and therefore becoming candidates for minimally invasive surgery. We think some of that is because we have done a lot of education with our referring providers and with the community, and patients know that if they are able to present a little earlier, they may have more options.

At our center, we still offer traditional open cranial vault remodeling surgery for the appropriate patients. But for patients who present at around four months or less, we are able to offer endoscopic approaches. We have even seen patients who have gotten their diagnosis prenatally seeking out our team because they know we have such a strong minimally invasive craniosynostosis program here.

What has changed technically?

We have been trying to optimize this approach beyond what we have already done. We have had an ongoing clinical project looking at the use of virtual surgical planning for endoscopic coronal suturectomy, specifically.

Together with our pediatric neurosurgery colleagues, particularly Dr. Caitlin Hoffman, we have developed a novel technique for creating a customized guide for endoscopic coronal craniosynostosis surgery. That work has been presented at national meetings and was recently published in Annals of Plastic Surgery. We are really excited and proud of that.

When is earlier not necessarily better for a family?

We had that happen about a month ago. There was a family who felt they were not going to be able to handle surgery that early, given their situation. They were also coming from pretty far away and did not feel they could have consistent access to the post-surgical helmeting process, which is part of the early intervention. If a family cannot do what is required to make the post-surgical aspects of the endoscopic approach work, we have other options.

How are you trying to make those resources more accessible?

One of the things we have tried to do is offer onsite cranial helmeting [a custom-fitted helmet used to gently correct flat head syndrome in infants] for children and families. We now have an onsite orthotic group that can take patients with all sorts of insurance types because they are here at the hospital. We try to meet every patient and family where they are and offer them different solutions.

For families choosing between endoscopic and open craniosynostosis surgery, do the results differ?

We still consider both endoscopic and open surgery as two roads to the same endpoint. We feel like we get the same results at the end of each process, so it is really about which process you would rather go through.

Minimally invasive craniosynostosis surgery has well-documented advantages: less time in the operating room, less blood loss, and easier recovery. But after the procedure, the child wears a helmeting orthotic for anywhere from six to 12 months. With traditional open surgery, the surgery and recovery are bigger upfront, but then after the surgery, they are done.

Are there cases where you move from one approach to another?

Yes. When a child has craniosynostosis, that is pretty much always treated surgically, whether it is minimally invasive or open. It is more about which course is better for your child and your family.

When we see children with syndromic craniosynostosis and multiple sutures affected, we will often start with an endoscopic suturectomy to create some initial neuroprotective environment for the brain, then do a more comprehensive open surgery later to idealize the cranial structure and cosmetic appearance.

Microtia and the Changing Possibilities of Ear Reconstruction

Can you explain what microtia is, and how treatment is changing?

Microtia is actually a really common congenital craniofacial abnormality. Ear abnormalities in general are the most common congenital facial abnormality.

Most congenital ear abnormalities are minor ear malformations, where the major parts of the ear are present but not in the right position. Those are very common, and in this day and age we try to treat them non-surgically with infant ear molding. But we still see a lot of children at Columbia with major ear malformations. When most of the external ear has not formed, we call that microtia, with severity ranging from a smaller ear to anotia, when there is no external ear, and just skin, not even an ear canal.

How is microtia treated?

There are various techniques, but they all fall under the umbrella of microtia reconstruction.

The classic way to treat microtia involves rib reconstruction. Most microtia reconstruction worldwide is done with rib cartilage, which can be fashioned into an ear and transferred under the skin envelope on the side of the head. Typically, that is not done in one operation; the major approaches involve two or three steps.

But what Dr. Naikhoba Munabi does now takes that a step further. She does not use the child’s ribs at all. With advances in medical modeling and prosthetic materials, she performs a reconstruction based on something called MEDPOR, which is a synthetic replacement for cartilage.

You can carve the MEDPOR into the shape of an ear, and there is a procedure where that ear construct can be placed under the patient’s own tissue and combined with skin grafts. With that approach, the whole ear surgery can be done in one step.

At the minimum, the benefits include a one-step surgery and no donor site, which is huge. Not having to take the child’s ribs is a major advantage. Many people would also argue that the aesthetics of the MEDPOR reconstruction look better. It is really a win-win for patients.

How does the multidisciplinary program factor into microtia care?

You can see microtia where the internal ear is totally normal, so the child does not have an external ear but still has the potential to hear. You can also have microtia where the internal ear is congenitally affected too. That is why we have formed a multidisciplinary team with plastic surgeons, led by Dr. Munabi; ENT colleagues in otology; and audiologists, who help patients optimize hearing.

There are very few places that do MEDPOR reconstruction. We have one of the only MEDPOR centers in the tri-state area. With Dr. Munabi here, we are able to give patients an option locally.

What is next in microtia reconstruction?

Dr. Munabi has either done or is about to do her first case with a new MEDPOR substrate that allows for patient customization. It is called SU-POR, and to me, that is really the culmination of a lot of cool techniques.

You are taking the MEDPOR technique, which already has benefits in terms of aesthetics, no donor site, and one-step surgery, and adding customization. With a virtual planning session based on the patient’s CT and size characteristics, they can match it more specifically to the child’s other native ear and create a customized MEDPOR construct.

To me, that is really the final evolution of reconstructive processes for the ear. That is a program she has been able to get off the ground for us here, and we are really excited about it.

Sometimes Surgery Can Be Avoided

We have talked before about the benign tumors or birthmarks, hemangiomas, and the shift toward medical management for some children. Are there other conditions where that same kind of change is happening?

The shift for hemangiomas has really happened. We try to treat everyone who is a candidate in a non-surgical fashion, and then if not, surgery is the more standard, tried-and-true approach.

Another condition where that has really occurred is minor ear malformations. It used to be that every child with an ear malformation, whether major or minor, was offered surgery between the ages of three and seven. Now we really try to treat a lot of minor ear malformations non-surgically with ear molding.

Ear molding is a process where the cartilage of the native ear can be molded into the shape we want. I tell parents you could use ear molding for good or ear molding for bad, because it can work either way.

What a lot of people do not realize is that all of the cartilage in the face, the ear, and the nose is very soft for the first six to eight weeks of life. The process takes about four to six weeks, but patients need to present early, typically by about the fourth week of life. Again, that becomes about outreach and education, so we can take advantage of that narrow window to treat things non-surgically.

Planning, Precision, and Technological Ease

You presented internationally on virtual surgical planning for craniosynostosis. How widely are those tools being used?

Virtual surgical planning tools are growing in popularity. We may use them a little bit more here in the United States, but they are growing internationally too. There was a lot of interest in how we are using that tool to advance standard techniques for craniosynostosis reconstruction.

Where do these tools matter most clinically?

So many places. That is part of what is cool and amazing about surgery at large, plastic surgery in general, and craniofacial surgery in particular. What we do still has a high level of difficulty involved in it. There are always so many layers where you are asking, “How can I make this better? How can I improve this process?”

In our multidisciplinary craniofacial clinic, we see children with conditions like hypertelorism [congenital abnormality of increased distance between the eye sockets] and midfacial hypoplasia [congenital abnormality where cheekbones, upper jaw, and eye sockets are underdeveloped]. These are relatively large surgeries, and we have been using virtual surgery to help make them easier. The question becomes: How can we use pre-surgical planning? How can we use virtual surgery imaging? How do we most effectively take all of that into the operating room to improve those procedures?

Where do virtual reality and intraoperative imaging fit in?

One of the things we have used a little bit, and I think will become more ubiquitous, is what people might refer to as virtual reality, or VR.

Using tools like Brainlab, you can make a pre-surgical plan on a patient’s CT scan, and then see the lines where you need to cut projected onto the patient in the operating room. That is a really cool thing. I think the technology is there, but the tools to institute the technology have not caught up yet. Once the tools are as good as the tech, I think these things will become more ubiquitous.

Where do AI and robotics fit into craniofacial surgery?

I think AI, and I would put robotics in there too, is the next frontier.

I do not know that robotics has been integrated into craniofacial surgery clinically yet, but I know that is going to happen. There are so many applications for it: robotic palate surgery, robotic eyelid surgery. When we are working in tight spaces and small corners, it is perfect for robotic approaches.

There are also a lot of AI diagnostic tools in the research stage right now. At Columbia, we draw patients from more rural parts of New York and other medically disadvantaged parts of the country. Could you use an AI-based app or approach to help sort out a diagnosis of craniosynostosis or plagiocephaly, so families do not have to travel so far looking for a provider? Those things are definitely in the works, and I think in the next year or two they will become clinically relevant.

Are there other uses of AI that you think could improve surgery more broadly?

This is not plastic surgery-specific, but I think it is something that will happen in all operating rooms: using AI for predictive modeling during surgery.

Can we get some sense beyond a patient’s normal vital signs? When we are doing complex surgeries, can we give the team even another five minutes of warning before a patient really crosses over into becoming unstable? The tech to do that is here. As the tools to make it happen improve, I think you are going to see more of that.

There are so many areas of surgery that can be innovated. I really like to consider myself an innovator. If I hear about a new approach or a new tool or technology, I immediately go to the space of, “How can we use this to actively improve surgery for patients and therefore patient lives?” At a place like Columbia, that is our duty.

Research Where Resources Are Harder to Find

Across pediatrics, research can be slower and harder to fund. Does that affect access to these tools and advances?

It does. Taking care of children is not necessarily the huge moneymaking entity that other aspects of surgical care might be. So there can be more resistance and fewer resources available for long-term translational research.

To me, that is why it is even more important to be involved in it. Dr. June Wu, who is one of the members of our pediatric section, has Department of Defense grants and NIH-funded grants that help fund her research on vascular anomalies and hemangioma.

Dr. Jill Schechter, who is our craniofacial orthodontist, and I have received several grants this year to study midfacial growth in children with craniosynostosis or other craniofacial diagnoses. We also have a funded project looking at growth for children with Pierre Robin sequence and microtia, comparing children who have had surgery and those who have not.

We try to go the extra mile to seek out funded research opportunities that help justify the work we are doing, because we know how important that work is. Even despite the challenges of it, we persist.

The Burden of Care, and the Burden of Diagnosis

We have talked a lot over the years about the multidisciplinary mode of bringing many different types of specialists together in a single teaml. Beyond the logistics, does that model change the emotional experience for patients and families?

We feel that it does. We have two family-centered research projects ongoing, and we are hoping to present some of that data at national and international meetings this year.

One project looks at the burden of care of getting a cleft diagnosis. In an ideal scenario, pre-surgical setup and molding can take 10 to 12 weeks, and there is a certain burden to all of that. Now that we have more than one option for families, we are studying which process is less burdensome. The classic approach is nasal alveolar molding, or NAM, which requires week-to-week appointments and works really well. We have also started our PLANA program. That is more like once-a-month visits, with families making adjustments at home week to week.

You are also studying the emotional toll of cleft diagnosis. What are you hoping to understand?

We have another project looking at the emotional toll that getting a cleft diagnosis has on caretakers and parents.

We have realized that it has a big effect on how the rest of the pregnancy is perceived if the diagnosis is made prenatally, and on how the neonatal experience is perceived if the diagnosis is made postnatally. We are studying that effect to help guide what resources we need to have available: support groups, access to therapy, and more advanced screening for postpartum depression.

What Should Become Standard

Is there any change you hope becomes standard of care in craniofacial surgery over the next few years?

I think we can improve what we are doing for setup for our cleft lip and palate patients. The PLANA program that Dr. Schechter has gotten off the ground for us deserves its own State of the Union because it is so cool, and I think it is such an advance over current standard of care.

PLANA stands for presurgical lip and nasal approximation. It is a newer way to help get children with cleft lip and palate ready for surgery. We are one of the first centers in the country, and the second center that we know of in the tri-state area, to launch this program. I hope to see something like that become more widely used, because it is a great advancement for patients.

You also mentioned social and emotional support. Is that part of what you hope becomes more standard too?

Yes. In our general society and day-to-day zeitgeist, people have recognized how important it is to pay attention to mental health and how important mental health is for overall health. Our cleft and craniofacial population is no different.

We host our annual Cleft Lip and Palate Team Day, which is our version of an advocacy day for children with cleft lip and palate. But beyond advocacy, it is really just cool to have a yearly event where our children with cleft lip and palate are having fun with a bunch of other children who have cleft lip and palate, along with all of their siblings. It helps normalize this entity for everyone there that day and lets them know they are not the only one.

Over the years, I will see children at different appointments, and at the end they ask, “Are we going to have Team Day again this year? When is the next one?” Every time I hear that, I think, “Yeah, I have to get on this. I have to keep doing it.”

I hope things like that become more ubiquitous. Every child who has a diagnosis of cleft lip and palate or any craniofacial diagnosis deserves to feel loved and recognized and to live a normal life.