Gillette Children’s Center for Craniofacial Services — a Lifetime Impact
Pediatric craniofacial services can improve children's lives in the emotional and social spheres as well as the physical.
A child’s first day of school is a milestone. Shy hellos between kindergarteners open paths to friendship, encouragement and reaffirming experiences of success.
Although social acceptance is never guaranteed, children who have craniofacial anomalies face particularly challenging hurdles. In addition to experiencing the medical issues of some craniofacial conditions, these children can experience social devastation when their peers perceive them as looking or sounding “different.”
At Gillette Children’s Specialty Healthcare, the Center for Craniofacial Services team understands the connection between craniofacial conditions and a child’s well-being. Gillette’s comprehensive array of pediatric specialists offers the depth and breadth of expertise to address craniofacial conditions before they affect a child’s physical or emotional development. In fact, teams tailored to the needs of each patient begin coordinating and managing care from the first consultation.
Robert Wood, MD
Gillette’s team also has developed innovative treatment approaches that have advanced care and treatment outcomes.
“The sheer number of patients we have treated is what distinguishes our program,” says Robert Wood, MD, pediatric plastic and craniofacial surgeon and Medical Director of the Center for Craniofacial Services at Gillette. “During the past 15 years, we have performed 3,000 intracranial craniofacial surgeries and treated more than 20,000 children who have conditions including cleft lip and palate, craniosynostosis, deformational plagiocephaly and torticollis — as well as rarer syndromes and malformations. Statistically, we treat a significant percentage of all craniofacial pediatric patients in Minnesota, North and South Dakota, and western Wisconsin.”
A Boutique Team with Pediatric Fellowship Training
Surgeries for conditions such as cleft lip and palate address delicate structures that affect both form and function. These situations are best addressed with the skills of a pediatric plastic surgeon — but few children’s hospitals, outside of national centers, such as those at Philadelphia Children’s, UCLA and New York University, can attract pediatric plastic surgery specialists. Gillette’s team includes board-certified pediatric plastic surgeons, craniofacial surgeons and team members who have expertise in microsurgery.
Martin Lacey, MD
“Our team was not assembled from existing institution resources,” Dr. Wood explains. “When I came to Gillette in 1999, we had the opportunity to build a boutique team one specialist at a time. Each person was handpicked for his or her level of expertise in treating pediatric craniofacial patients. We had the first fellowship-trained pediatric neurosurgeons in the state, as well as craniofacial surgeons, pediatric-trained plastic surgeons and a microsurgeon. We recruited Cheryl Anderson-Cermin, DDS, one of the two foremost cleft orthodontists in the country. Speech issues are addressed by Kelly Nett Cordero, [PhD, CCC, SLP,] a bilingual speech and language pathologist. Our outcomes reflect this high caliber of excellence and focused expertise.”
“Having this high level of expertise available in one location often allows for evaluation, diagnosis and treatment recommendations in the same visit,” notes craniofacial surgeon Martin Lacey, MD. “This is particularly important for families traveling significant distances.”
Parents are often anxious about their children’s conditions and want quick access to specialists.
“With Gillette’s depth of providers and clinic services available at the main campus in St. Paul and at clinic locations in Burnsville, Maple Grove and Minnetonka, we can get children in to see us very quickly,” Dr. Lacey says.
Craniofacial Treatments at the Leading Edge of Medical Advances
Cleft Lip and Palate
Cheryl Anderson-Cermin, DDS
One in 700 infants is born with cleft lip and palate. Gillette’s experts in plastic surgery, orthodontics and speech combine their talents to maximize cosmetic and medical outcomes for each child. Early consultation is crucial.
“For these children, the best shot at getting a socially unnoticeable repair is during the first surgery,” explains plastic surgeon Paul Lim, MD.
The orthodontic phase of cleft treatment ideally begins within the first week of life.
“All of the anatomical components are there on these babies,” Dr. Anderson-Cermin explains. “They just aren’t in the right places. In the orthodontic phase of treatment, I make a plastic acrylic device, called the Gillette OrthoCleft retainer, to shape and mold the maxilla of the upper jaw prior to surgery. The infant wears this device — which is refitted every week — from the first week of life through lip surgery at three months. The retainer improves tongue posture and manipulates the maxilla so babies feed better and there’s increased psychological bonding between mother and child. Effective preoperative molding sets the child up for a more successful surgery and fewer surgeries and revisions down the road.”
Surgery to repair the lip is followed by a palate-correction surgery at nine months. Cordero consults with the surgical team to monitor the speech aspects of cleft repairs, and she attests to the importance of surgical expertise through the repair process.
“Sometimes, after the first surgery, we’ll use a secondary procedure called a pharyngeal flap surgery to correct nasality in a child’s speech,” Cordero says. “Colleagues at other institutions will ask me what I recommend in cases when my surgeon’s pharyngeal flap fails or falls apart. I don’t know what to tell them, because since I’ve been at Gillette, I can’t remember that happening. We might tweak a flap, but that’s very different from a failed surgery. Our institution’s consistency speaks to our surgical expertise.”
This congenital condition affects one in 2,000 infants, causing premature fusion of the bones in the skull. Unlike plagiocephaly, untreated craniosynostosis can result in developmental delays, permanent brain damage and death. The treatment is cranial vault remodeling surgery, which is performed at four to eight months by a neurosurgeon and craniofacial surgeon. During the surgery, the sutures are separated, and the bones are reshaped, repositioned and held in place with resorbable fixation.
Dr. Wood identifies the introduction of resorbable fixation technology — in which ultrasonic rivets and dissolving plates replace traditional plates and screws — as the most significant surgical advance in this procedure. Resorbable fixation increases the speed with which the operation can be completed, and it plays a major role in achieving the highest goal of cranial vault remodeling: transfusion-less surgery.
“Without a blood transfusion, we avoid risk of blood-borne pathogens, prions, transfusion reactions and fevers that extend hospitalization,” Dr. Wood says. “Of the past 20 cranial vault procedures we performed, 10 were done without transfusing. Going forward, we hope to perform 75 percent of these operations without transfusions.”
Dr. Lim explains that speed and efficiency are critical to achieving transfusion-less procedures.
“The need for transfusion hinges on the expertise and ability of the individual surgeon,” he notes. “The standard time for this procedure is four hours; Dr. Wood completes the entire operation in two hours.”
Plagiocephaly and Torticollis
Gillette developed the FDA-approved CranioCap to treat infants with deformational plagiocephaly.
The incidence of plagiocephaly, or flattened head, in infants is common and increasing. Dr. Wood estimates that he sees approximately 20 cases each week. Approximately half of the cases are accompanied by torticollis, a tightening of the muscles on one side of the head.
Gillette has developed the FDA-approved Gillette CranioCap orthosis, an orthotic molding helmet and treatment protocol for effective management of children who have plagiocephaly. Gillette’s certified orthotists optically scan each child’s head and fit the orthotic helmet, then reshape and revise it every two weeks. Treatment usually requires two to three months, which is often shorter than the time needed for other types of helmet therapies.
“We have treated 7,000 children with the Gillette CranioCap orthosis, and our patient satisfaction scores are outstanding,” Dr. Wood says. “Children grow rapidly during the time of treatment, and continually revising the helmets to encourage appropriate head growth is critical to success. Gillette’s commitment to superior outcomes is reflected in the fact that we have a significant number of orthotists dedicated to the CranioCap program, and each of them has handled 600 cases or more. I attribute our success to their expertise.”
Approximately 50 percent of children who have plagiocephaly also develop torticollis, which causes abnormal head posture. Gillette’s physical therapists resolve 95 percent of torticollis issues through therapy alone; the remaining 5 percent of cases are addressed through surgery.
Paul Lim, MD
Moebius syndrome is a rare birth deformity in which children are born without facial nerves. As a result, they are unable to show facial expressions. Because the condition is seldom seen, and because there are few surgeons with the pediatric microsurgical expertise needed to address the condition, many pediatricians may not be aware that treatment is available for these children.
“The facial nerves enable us to animate our faces and show expression,” Dr. Lim says. “Children with Moebius syndrome are often discounted from an intellectual standpoint, disciplined or considered insolent because they can’t emote. We are surgically able to animate their faces by taking smaller muscles from the thighs, disconnecting the blood vessels and nerves, and reconnecting them to other nerves in the face using microsurgical techniques to sew together blood vessels between 1 and 5 millimeters in diameter. This is a difficult surgery in pediatric patients because the vessels are so small, but the surgery gives these children the ability to smile when they feel happy. It’s quite astounding.”
Research Initiatives and Medical Advances
Kelly Nett Cordero, PhD, CCC, SLP
Gillette’s clinical research is informed by an extensive outcome database.
“We are able to capture data from the thousands of patients we treat on an ongoing basis, with fields for all of the different subspecialties involved in treating these patients,” Cordero explains. “The database was designed to be compatible with developing projects like Americleft, a national initiative with the goal of facilitating outcome comparisons at centers across the country. That data will help increase transparency in care.”
Cordero is also enthusiastic about new technology to inform surgical decisions and improve speech outcomes for patients.
“Developing instrumentation can measure palate deformities more accurately than was possible before,” she says. “Gillette is the only site in this area offering a precise form of aerodynamic pressure-flow testing to calculate the gap size in the velopharynx. When pediatricians have concerns related to a child’s speech, or when nasality or another speech issue seems to be related to structure — such as a bifid uvula — or to tonsils or adenoids, we have the resources to evaluate that child and the expertise to deliver treatment that will maximize speech outcome.”
As Gillette hones its resources and expertise, the craniofacial team looks forward to each patient’s first day of school.
“We want these children to go off to school and be unrecognizable to their peers as having had corrective surgery,” Dr. Wood says. “The compelling thing about craniofacial repairs such as cleft lip and palate is that laypeople can look at before and after photos and judge the quality of a repair for themselves.”
Dr. Lim’s professional experience includes three years providing cleft lip and palate repairs in Ethiopia.
“I think cleft lip repair is the most inspiring operation I do,” he says. “When this condition is not treated effectively, the results are devastating. Yet, with the right resources, a fairly brief operation can completely transform these children. It’s as though the cleft never happened. I really love that.”
Physicians and health providers can reach one of the Gillette specialists or make a patient appointment by calling Gillette’s one-call access number at 651-325-2200 or 800-325-2200. More information can be found at www.gillettechildrens.org.