Saving Faces, One Child at a Time

SET ASIDE YOUR PRECONCEPTIONS about plastic surgery. A trip to a plastic surgeon is not just for Hollywood hopefuls or men and women looking to postpone aging.

When people think of plastic surgery, they usually think of cosmetic surgery, says Dr. Ned Garrigues of Scripps Clinic, Torrey Pines. Pediatric plastic surgery goes beyond aesthetics to treat serious skin, facial and skeletal trauma in children, helping them lead healthy lives.

Having a baby is a life-changing eventone filled with expectation and possibilities. When a child is born with a deformity or birth defect, the impact is often devastating. Parents may feel helpless when their child is born with a craniofacial birth defect or nasal, jaw or ear deformity. Even when children are born healthy, accidents and illnesses can leave them with scars, skin lesions and skull damage. Across San Diego, dedicated surgeons are working with children to improve these conditions, from dog bites to cleft lips and palates to protruding ears and burns.

As a society, we tend to keep such conditions behind closed doors, and with shows like Nip/Tuck glamorizing plastic surgery, many people assume deformities and imperfections are easily correctable. In reality, its not as simple as a child with a craniofacial skull deformity or cleft lip going into a clinic and emerging in perfect condition. In the case of cleft lip syndrome, for example, it can take years for correction.

Says Dr. Steven Cohen, surgical director and chief of craniofacial surgery at Childrens Hospital in San Diego, It is not the same as curing appendicitis simply by removing the appendix. It is more of a concentrated and staged effort to achieve as near to perfect as possible.

Hope on the Horizon

While no science is perfect, recent advancements have provided hope for children suffering from all kinds of conditions. What is offered to children today is so far superior to what was available even five to 10 years ago, Cohen says. These enormous advances in patient care are not possible without the daring personality of a surgeon willing to create new procedures to benefit children with severe facial differences.

One of the most important developments is understanding how the face grows and then applying that knowledge to how facial plastic surgery and reconstruction is performed. It seems logical if a child breaks his nose to simply put it back where it was, but its important to think about how the face will grow, says Garrigues. You may have noticed that when you look at children, they seem like they are all head. By the time theyre 5, most childrens heads are the normal length and width of a full-grown adult.

Absorbable sutures, screws and plates have improved post-surgery recovery for reconstructive patents. They used to be made out of metal, says Garrigues. As the child grew, problems occurred because the metal screws and plates could migrate inside the shifting skull. The new absorbables are a great solution. Now they simply go away in time, he says.

Cohen has contributed greatly to advancements in surgical devices and investigational research. Technology has rapidly progressed, and I have had the unique experience to be in the thick of it, he says. In 1994, a friend and I developed a bone- lengthening device called modular internal distraction. We implanted the device in a patient, and it was a great success. Ultimately it was developed and marketed by Stryker-Leibinger. The system can advance a patients entire face and jaw gradually without the danger associated with traditional procedures. Now these techniques are used throughout the world in patients with syndromic craniosynostosis from Crouzons, Aperts and Pfieffers syndromes.

He and his team have worked extensively with Cytori Therapeutics, formerly Macropore Biosurgery, a biotech company in San Diego. We helped them launch three successful product lines of bioresorbable plates and screws for stabilization of cranial and maxillofacial bones, says Cohen. Together with pediatric neurosurgeons Hal Meltzer and Michael Levy, we have helped pioneer endoscopic, minimally invasive surgery to correct a condition called craniosynotosis, where skull bones fuse prematurely, leading to bizarre head shapes and possibly increased intracranial pressure. We have children come from all over the United States for this surgery.

We are also working with Cytori looking for new ways to use fat-derived stem cells for regenerative medicine. It may be possible one day to use stem cells harvested from fat to make new bone and new soft tissues for reconstructive surgery.

Dr. Ralph Holmes, a surgeon specializing in ear reconstruction at Childrens Hospital, strongly believes stem cell research holds great promise for correcting deformities. Holmes and Dr. Marc Hedrick, a plastic surgeon and president of Cytori, explain that there are two types of stem cell research: the kind derived from human embryos and the kind that comes from our own tissues.

In ear reconstruction, we take cartilage from the rib, Holmes explains. There is some synthetic material available, but it doesnt tend to hold up well. Dr. Hedrick is working on a procedure using stem cells taken from a patients own abdomen fat to build the essential ear cartilage.

Hedrick is heavily involved in uncovering the biology behind adult stem cells harvested from a tissue (Cytori uses fat tissue, which has the largest amount of adult stem cells in the body). Since adult stem cells are responsible for tissue repair and regeneration in the body, they are a likely therapeutic target for wound and bone repair. Using Cytoris technology to extract and purify a patients own stem cells, combined with a bioresorbable material developed and available commercially through Cytori, Hedricks team grafted bone fragments extracted from a girls hip and combined that with stem cells to aid in bone regeneration. The successful surgery has opened the door for more research in the area, particularly for children with severe skull fractures that are unresponsive to current treatment options.

Despite recent advancements, says Garrigues, there are many procedures and much technology we take for granted, like micromacular surgery [replacing fingers], which has been around since the 1980s. It really revolutionalized our specialty.

A Team Effort

Because there are many areas involved in treating certain conditions, a multidisciplinary team is the most effective approach to treating childhood deformities. Some of these specialists include plastic/craniofacial surgeons, pediatricians, orthodontist, pediatric dentists and oral surgeons, genetic and grief counselors and speech therapists.

The emergency room doctor is a great help to us. We take over the really bad cases, says Garrigues. They are our partners in taking care of these kids. Injury patients are typically input through the emergency room. The emergency room doctor is the triage on what type of surgery is involved in some cases. We also work hand-inhand with pediatricians. Its definitely a multidisciplinary team. The plastic surgeon might work with an oral surgeon on bone grafting, and the teeth can be brought in by an orthopedic surgeon. The individual roles are important, but much greater as a whole.

In the end, every pediatric plastic surgeon has at least one case that stands out in his or her mind. Cohens most memorable case was his very first one. It involved a 27-week-old infant girl who had a massive tumor in her head behind her nose and eyes the size of my fist, pushing her palate downward, he says. The tumor had pushed her eye forward and down, contorting half of her face. After the tumor was removed and she recovered, years later she brought me a poem. It brought tears to my eyes.

Medicine has changed so much and become so much less personal that patients rarely thank you for some of the most astounding surgical techniques you could ever imagine. But once in a while, someone surprises you and expresses how much you have helped them. It means a lot. 

Do you like what you read? Subscribe to San Diego Magazine »