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NextGenFace Craniofacial Conference 2021

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James P. Bradley, MD gives an educational lecture on Craniofacial surgery and shares patient cases.

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to introduce Jim Bradley who's relatively recent addition to our staff at gym I had is an internationally known a craniofacial surgeon was at UCLA as a dresser for 15 years and joined us a few years ago and we're privileged to have him and I'm delighted to introduce him for the adoption doctor Thorne my honor to be here for this educational lectures Spa buy next-gen face Michael to share with you some of our stories from our craniofacial patients I want to give you an understanding of our surgical techniques and the proper timing of this procedure I also want you to understand the strength and courage of a creamy facial children one or go major procedures that are often staged it is their desire to overcome these facial differences have the ability to go out to the world to accomplish anything good morning I'm happy to be here for this next gen faces Zoom meeting I'm going to be talking about craniofacial reconstruction own energy to shoe to a few next-gen face page the first one is SEMO who was born with a rare Tessier cleft nine year old boy born in Portugal lives in the area with his mom and older sister you can see he's has facial asymmetry you can see his Orbitz are misaligned so that one sits below the other and he has exotropia which is means his eyes going different directions he worth prism glasses in order to see straight without probation he has a nose deformity wide Highbridge breathing sleep apnea problems and you can see hear from the CT scan he has an abnormally we call a number 212 rare Tessier cleft what we're aiming to fix we use something called a facial by partition you can see the bone cuts on the left including the section we removed between the eyes and we had to bring the face together after the buy partition so that we could and secure it in a normal position for incorrect is orbits you can see him on the table with his interop view correction of his nose deformity and again intraoperatively then afterwards after the facial by partition correction after his first surgery you can see the Improvement of his eye with and laterally is nose and this is SEMO again with his action figure he drew and was made into a doll for him is that subsequently under one another surgery to start first next-gen page patients on the talk to you about craniofacial reconstruction there's certain diagnosis is called craniofacial dysostosis there's about 20 of them actually is about 90 of them and we're going to focus on the so the treatment protocol as I've been taught marches from north to south or from the top of the head down to the bottom of the face so cranial Vault procedure mid-face correction lefort 1 advancements this patient has April you're one of the crayfish with this tossed osis now this treatment protocols Outline by my mentors doctor kimoto does the cow mode of fella book and Doctor commode on the left Doctor MacArthur in the middle or some of my mentors that taught me clinical protocols but these are based on science based on basic science my mentor Bernard sore knots and I publish his book which goes over this and this is the reason we have these protocols is dr. Sarno was kind enough to Jen Tennessee donate a chair so these clinical Protocols are based on science these craniofacial dysostosis as a spectrum of phenotypes you can see all the different diagnosis basically turricephaly tall head brachiocephalic broad forehead and mid-face hypoplasia so to look at all these they have similar spectrum of phenotypes and common features two were able to use protocols this is the same patient from birth to adulthood you can see we started stop with the cranial Vault remodeling at Age 3 to 6 months then the mid face later on in Mid childhood to advances made face and then finally down at the lower face orthognathic or jaw correction and you can see the correction as we go depending on his growth so the skull was done in the newborn the mid-face mid childhood and then the orthographic sore jaw surgery so is an infant they can have different craniosynostosis you can see the Triangular trigona cefaly the boat shapes k + f oblique plagiocephaly so if you have that try trigonic trigona cefaly the correction has to do with them Age 3 to 6 months and you correct forehead to allow the brain to expand so it's not constricted and get a result like this now if you have coronal synostosis that's that's one side you can see the flattening with the red arrow and our virtual plant expansion so you have these colored ideas of how you going to do the Reconstruction the yellow goes to the yellow pre on the Left Post on the right and you can see the advancement so when you have piranhas in Austin this isn't one side you have to plan in advance and Ticking Symmetry and release the brain that's constricted most of the patients had break is cefaly which is bilateral coronal synostosis you can see the diagnosis and the percentage that have that so to correct that it's a little different these are the osteotomy lines the frontal meatotomy the supraorbital bar all that get Advanced to correct the flat in forehead weed Advance it almost to centimeters we flipped the side that's bulging out and then we reduce the fight all those things are done in the operating room and then see a large advancement to decrease the Dead Space week we lower the height and that's necessary to overcorrect so that later on we don't have to do as much of a forehead correction so with admit childhood then we have to focus on the face often we have to fix hyperchiller baptism and midface retrusion so we devised a procedure at his facial by petition combined with Mana boklok distraction we called the Roman Arch procedure the facial by partition we had seen before was SEMO and you can see how the orbits can be corrected in this case the immediate post-op you you can see not only reflecting the orbits but that Bunch skin we call the K Stitch after Cal Moto it's goes away with time to create our correction so monoblock distraction is combined with this in this case this patient with antley Bixler syndrome is trait dependent having breathing problems ocular problems but after the advancement after the mid faces for the trait can be removed so we're combining the facial by petition and monoblock distraction in the Roman Arch so it's called that because based on the Roman art stability in the center were pushing forward the arch of the face as you can see here we curved the face to correct the flatness we provide a keystone for fixation in the middle and then our devices laterally push the face forward so we need that stability we had to study this so we patients that had the procedure the insurable distance was studied and you can see it preoperatively 38 down to 20 and follow up and we looked at the inter-campus distance between the eyes and the correction from 48 ml 235 and finally be a brow distance to all these measurements were done and we can see the improvements of the brow distance interocular distance now lightolier also advancing the face do we need to study this and we found it an average advancement about 16 mm with a mild relapse of 2 mm you can see this at the far head at the top you can see this at the mid face in the middle and down below at the maxilla so we realized that this was effective now we talkin about patients with chronic facial dysostosis we treat them from birth to adulthood at 3 years of age frontal orbital advancement is done 7 monoblock advancements 10 years before lefort 3 that's the mid-face 12 and after lefort 3:15 before lefort 1 that's the Jog and 18 after the fourth one so you can see following the patient I'm beginning to end is necessary because of the growth here's the lateral view of the same patient again with a primer surgery in infancy mid-face surgery and then orthognathic surgery as an adult you can meet rocas Resort our next inflation with craniofacial microsomia and a cleft when he was brought to us some people compare them to Auggie from the Wonder although he has a different diagnosis is diagnosis is craniofacial microsomia but also has cleft so he was missing his bone on the right side we call the super sanski 3 mandible it was too small to be able to stretch that phone so we had to replace it with the rib here in tropically rib graft and we also did Fat grafting is right cheek you can see the rib graft Replacements in the CT scan and that how advanced him and then the fact I think so that was not just for cosmetic or aesthetic reasons but it actually helped his Airway you can see on the left business is tongue base collapse to his throat and then afterwards his openness that's an open Airway and that's what we wanted to achieve in him so this is his correction and then Rocca's just sent us at holiday card she is with the sister overseas and he comes back to visit our team and he will again have another procedure but he's he's doing quite well craniofacial microsomia roquetaillade often require mandibular distraction and sometimes fat grafting you can see before this happened to the asymmetry after the distraction the chin Point moves over and then after fat grafting then we can get more symmetry often ear reconstruction is needed and Thorn will get in to help totally reconstruction can be done mandible distraction is something where we can grow bone it's this was pioneered by doctor Thorne is on our team McCarthy and carp and you can see the vertical vector we can have or the horizontal Vector with craniofacial microsomia a vertical Vector is preferred this this patient is older but still with crayfish in my car so MIA she had a double job procedure to correct or asymmetry you can see your midline traitor but still her orbits are off so we had to do an orbital box osteotomy to bring that orbit down to correct her I bet you could still she was flat and her face so we had to fill that with a free slot car in IMAX flap because it's too much just fat grafting craniofacial microsomia should be differentiated from Treacher Collins which is bilateral and symmetric and you can see this patient from pre-op to post-op we had to correct the cheekbone is the eyelid areas and the mandible those are all involved with Treacher Collins In addition they can require ear reconstruction so there's different severities to this this Mallory construction or cheek bone reconstruction does require bone graft it also requires what week on island switch flap listen involve procedure or barring Bones from the head reconstructing the cheekbone to correct the Staten eye appearance of the Treacher Collins patient this is Jana 100 Russia patient host by the largest frontal naissance apples to I've dealt with the interorbital distance was 81 mm she can see by the cats can you actually enviable brain herniating between the eyes and we had to bring those iced tea Heather and and bring up the brain so we used a ventricular ostomy drain we did something unique called the contraction of the orbits so we use a distraction device in Reverse to correct that we did halfway on the table you can see the left on the right we finished that afterwards to bring him from 81 mm all the way down to a normal orbital distance after that was done we did soft tissue correction of his cleft lip his nose his palate with a friend joke and it's a child who came in and basically in a stroller not talkin drooling and was looking from one side to the other until his correction and was basically playing like a normal child afterwards this is a smaller but still nasal a frontal nasal aphmau do insect Lucille smaller lesion but you can see this is not normal bring her needing but aglio landmass that has to be taken care of when we correct this we need to correct everything in around the medial canthus the media orbit the nasal maxillary process the procedure we used to cut a fuller procedure we do a limited craniotomy we split the phone we do crack the orbit crack the nose move the bouncer this is the bones that moved in place for translocating the orbits back into normal position translocating the nose is doing a bone graft to the nose to do the correction when the skin is damaged like this we have to do it externally an inch how to remove this so you can see here the correction of the encephalocele the Bony reconstruction and a similar patient all these are slightly different but we have to correct both the medial canthus the nose for the Reconstruction and pair the herniation when we do our procedures with when we see them as a team we're looking at patients from infancy to adulthood this patient came as an infant with a critical Airway patient was diagnosed with and Ruby can see the small lower jaw we can see imagine the tongue base sticking to the back of the throat so we had to do was called neonatal mandibular distraction to bring out the lower jaw to correct the tongue base in the save a child from trachea often we have patients come in and then these are could be more life-threatening emergencies in this case this child had an expanding cystic mass that at 2 weeks was growing day by day so we had to urgently decompress this mess in the operating room you could see Imaging showed that the cyst was filled with CSF fluid you can see the Distortion of the bones and you can see afterwards we does decompression then you could really see the deformity the face that had to be addressed we did a fusion surgery which can be similar to lip adhesion followed by a formal cleft lip repair and then required secondary reconstruction after this so listen infant that required compare just to get to the place where we can then provide definitive care of this patient mid childhood this is actually not a child from third world country child that's here locally at functional problems tracheostomy since birth G-tube dependent speech problems we did one procedure to correct a lot of these this Tessier cleft so she was born with what we call a 410 cleft and a 678 Club show it all on the left side so to do this we did and eyelids switch flap medially translate is a wiring we did a cheek advancement and correct the nose and the patient was reconstructed after the second reconstruction trach was removed Cooper's remove and she's ready for next round of surgeries I'm finished with a patient that you're going to be introduced by our director Barbara so this is Diana who's born with cruise on like and cleft lip and palate I'm going to focus on the medical aspects she underwent hyperchiller baptism correction and correction of mid-face hypoplasia you can see with the planning we had to remove the red phone and bring her orbits together we had to then correct the I'm on both sides against she's at skeletal maturity so she's been followed until this time that you can see in addition to correcting with the with the hyperchiller because we want to do a mad face and Van that's done with an internal distraction device and you can see how much the face is brought forward to give that correction of her Orbitz nose and her upper jaw this is our next-gen face team so all patients that come in get a full evaluation including the images we see them as a teen misses preco bed but we're we're seeing patients safely now and we can basically have experts from each of the subspecialties weigh-in so that nothing is missed so that all the details are addressed at each time point that they're seeing again infant to adulthood you can see how each next-gen face team member evaluates the patient each team member has their own expertise each team member has their own different specialty in each team member give their input then together we will formulate a plan and it will be shared with the patient's the fan primary care physician in the referral Ed Sheeran story of our next-gen page patients today I hope to gain an understanding of the timing and techniques of craniofacial care all of the members of next-gen face putting myself are passionate. Comprehensive care for a patient thank you so much for your attention today

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NextGenFace Craniofacial Conference 2021

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