Published in UAB Insight, Summer 2007
Restoring facial identity demands multidisciplinary care
When a congenital defect, trauma, burn, or fracture affects the face, a patient’s self-esteem may be intimately wounded. Extremity reconstruction improves range of motion and renders a realistic appearance, but when the human face is injured or deformed, the psyche is deeply affected, and the patient reminded each time someone stares. “Facial restoration, rather than reconstruction, is essential to recapturing a patient’s sense of identity, says plastic surgeon and UAB Cleft and Craniofacial Center Director John H. Grant III, MD.
“Facial restoration differs from reconstruction. Our facial identity is based on how different parts of the face fit together and achieve symmetry at rest and how each part of the face is animated during emotional expression,” he says. “The forehead, cheeks, lips, eyelids, nose, and ears all function as aesthetic subunits of the human face and must be restored in their natural place.”
Facial Identity
Grant has spent nearly two decades specializing in pediatric craniofacial differences. During his fellowship at Seattle Children’s Hospital with craniofacial pediatrician Sterling K. Clarren, MD, Clarren conducted an informal study on facial identity, showing children pictures of their hands, feet, and faces. Every child reported seeing “my hand” and “my foot”, yet when confronted with images of their faces, each child reported, “That’s me.”
“My early training revealed that our face is not just the way the world sees us, but how we see ourselves,” Grant says. “Ideally, childhood craniofacial differences should be addressed early while a sense of self is developing. When adults have complex craniofacial procedures, they may require counseling because they sense an incongruity, as if someone else is looking at them in the mirror. Some patients adapt well, but the road is difficult. Faces are the first thing people see when we interact with them, and they cannot be hidden with clothing. Restoring the eyes, nose, and lips to a normal, symmetrical location is intrinsic to facial identity.”
Grant’s own role as mentor led to the return of Peter D. Ray, MD, to UAB’s Division of Plastic Surgery. Ray completed 5 years of general surgery with 2 years of microsurgical research at UAB prior to his plastic surgery postdoctoral training and subsequent fellowship in craniofacial and pediatric plastic surgery under Grant’s direction.
During his tenure at UAB, Ray was deployed to Bosnia for 5 months, and for an entire year as part of Operation Enduring Freedom with the 325th Combat Support Hospital in Khowst, Afghanistan, where he lived in a tent near the Pakistani border caring for American and Afghani soldiers, as well as local villagers. He was awarded the Bronze Star for his service.
“We saw a significant number of acute burns, gunshot wounds, and landmine and improvised explosive device injuries. Sadly, many of the local people we treated were Afghani children. Young children sometimes picked up small anti personnel mines the Russians had left behind. The mines look like plastic toys and are designed to disable adults, so their capacity for causing injury to children is devastating,” Ray says.
When Ray returned to the United States to complete his plastic surgery residency, he decided to pursue caring for adults and children who were gravely injured and sought the opportunity to complete a fellowship with Grant. His training in both military and postdoctoral environments has led to his current focus on congenital craniofacial and secondary burn reconstruction for severe facial deformities.
Emerging Advances
Detailed advances in plastic surgery, such as the fasciocutaneous flap pioneered by Luis O. Vasconez, MD, director of UAB’s Division of Plastic Surgery, revolutionized early reconstruction by allowing deeply damaged areas to be filled, a novel approach following large tumor resection and a critical step in reconstruction.
“The flaps Vasconez developed provided a new way of reconstructing defects that were previously impossible to treat. Such techniques were ideal for reconstructing extremities, but did not always provide a realistic facial appearance,” Grant says. “With UAB’s well-deserved reputation for expertly performing free tissue transfers, we began exploring the possibilities of replacing tissues with like counterparts, such as bone with bone, to restore affected craniofacial areas.”
The unique approach to facial restoration using autologous bone distinguishes the craniofacial center from other plastic surgeons’ methods.
“Most patients undergoing craniofacial restoration are candidates for autologous bone transfer, which is typically the first option we introduce,” says Grant, who collaborates with neurosurgeons to remove a full-thickness piece of skull that provides a hard and soft layer of a patient’s own tissue.
“The full-thickness piece of bone is then split, much like separating an Oreo cookie, to yield two pieces of bone, each of half normal thickness. One piece goes back to the donor site while the other may be used for reconstruction. The challenge is in selecting the donor site and contouring the bone to reproduce the missing part. Because this requires experience and an ability to see detailed contours, many centers are now opting to use prosthetic materials.”
Plastic and synthetic implants are more popular and easier to use, but they introduce a significant risk of infection, may slip or erode over time, and in children must be replaced during revision surgeries as skull size increases.
“Three-dimensional restoration beyond stable bone placement is essential for anatomically successful results,” says Grant, who notes the UAB Cleft and Craniofacial Center’s interdisciplinary team of specialists is key to restoration and rehabilitation. Craniofacial surgeons, plastic surgeons, neurosurgeons, oral and maxillofacial surgeons, pediatricians, anesthesiologists, otolaryngologists, radiologists, orthodontists, prosthodontists, dentists, engineers, geneticists, nurses, occupational and physical therapists, audiologists, speech language pathologists, and a dedicated support staff provide compassionate care to patients and their families.
Craniofacial Trauma
Grant and Ray bring a hard-won but necessary expertise to the repair of devastating gunshot wounds and explosive devices. Firearm-related injuries are the second leading cause of injury and death in the United States (MMWR. 2001;50[SS02]:1-32), and for those who survive a blast to the face, the bony, soft tissue, nervous, and vascular anatomy make managing and restoring such facial wounds challenging. Patients who are initially stable may require early airway control and urgent care for vascular and intracranial injuries before plastic surgeons can begin to address restorative issues.
Many of the problems Grant addresses are exceedingly rare. Children with rhabdomyosarcoma or atypical frontonasal dysplasia and adults with Romberg hemifacial atrophy or calvarial defects following tumor resection represent a fraction of procedures the craniofacial surgeon performs each year, yet his approach and expertise place him and other UAB plastic surgeons in high demand. Grant is listed as one of the peer-nominated “Best Doctors in America,” a distinction less than 5% of specialists worldwide achieve.
He encourages referrals for adults with residual deformity after facial trauma or those with inadequate forehead bone healing or structure.
Grant continues to refine his approach for children with cleft palates and craniofacial disorders. “We have performed more than 300 single-procedure cleft palate repairs in 10-month-old patients. In the first 200 to 227 patients, 85% achieved normal speech and no patients experienced healing problems such as fistulas. This compares favorably with the best complication rate published to date (3%) in a sample of 119 selected patients. In the last 60 to 75 procedures, which still need long-term follow-up, our patients’ rates of normal speech are reaching 90% and above,” he says.
UAB has cultivated techniques to reconstruct lips, noses, and palates — repairs that may require minor revisions but are light-years from the former 10 to 20 operations required to achieve normal function and aesthetically pleasing results.
“A plastic surgeon’s natural goal, and the driving force behind facial restoration, is to return an area affected by illness or injury to its original appearance,” Grant says. “With cleft palates, we have achieved very reproducible results. We have not yet reached that summit in patients who have suffered facial traumas and deformities, but we can dramatically improve their self esteem and quality of life.”
For more information:
Dr. John Grant
Dr. Peter Ray
1.800.UAB.MIST
mist@uabmc.edu