craniofacial surgery: a perspective on the …...craniofacial surgery: a perspective on the advances...

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Special EditorialCraniofacial Surgery: A Perspective on theAdvances Made in 40 Years of Surgery,Principles First

Mutaz B. Habal, MD, FRCSC, FACS

Tampa, Florida, USA

Welcome to the special session on cra-niofacial surgery prepared for you bythe International Confederation ofPlastic Reconstructive and Aesthetic

Surgery. My presentation concerns reconstructiveplastic surgery as it impacts craniofacial surgery. Iam from the Tampa Bay Craniofacial Center inTampa, FL. This lecture reflects my experiences overthe last 40 years, since I was introduced to the fieldby my mentor, Doctor Joseph Murray of HarvardMedical School in Boston, where I was a houseofficer in the service witnessing the first suchextensive procedure in our country. Today, incraniofacial surgery, we have a perspective thatenables us to look over the horizon to see what willbe coming our way in this special field in the future.Historical perspectives predict the future advances,and the future is today’s action. For the future, wehave skill, science, and diligence. Craniofacialsurgery is a global specialty that we would like tokeep within the wide scope of plastic surgery.Craniofacial surgery was started by plastic sur-geons, and it will stay within plastic surgeons’activities. More than 40 years ago, the first pre-sentations on craniofacial surgery were made at theinternational confederation meeting in Rome. Thatrecord emphasizes the appropriateness of ourhistorical perspective as the keynote lecture hereat a similar congress in Berlin where surgeons fromall around the world have gathered to see what isupcoming in the field. Craniofacial surgery startedon both sides of the Atlantic and flourished on bothsides of the Atlantic to spread all over the world as

a superspecialty discipline. The focus at first was onthe orbits as a technical skill of changing the anatomicboundaries and subsequently addressed all othercomponents as well as involvement of the functionalanalysis of the craniofacial skeleton.

What we had accomplished during the last 40years and what we will achieve in the future willcontinue to stress innovations, science, and newfrontiers. The skull comes in different sizes, shapes,and configurations within globally accepted param-eters demarcated by a range of norms. Not all skullsare alike. We try to make the skulls we treat as nearlynormal as possible with function as our goals (Fig 1).

Skullwars emerged during themiddle part of thecentury, as we started to disseminate the techniquesand trends of craniofacial surgery. We focused on thelocation of the cuts, or osteotomies, who would havehis name on which cut, where the osteotomies are,and related issues, to bone grafting and fixationsystems. The focus was on short-term results withapparent avoidance of concern for long-term results(Fig 2). We have passed through that particular era orstage, and now we are engaged in the mind wars, thefunctional aspect of what we do. There’s a new bookout, Mind Wars, by Doctor Jonathan D. Moreno;recommend that for those intensely involved in thefield. If you want to look at what’s going on with thefunctional structures in patients with craniofacialproblems, take a look at this book. Published recently,it deals with an emerging topic called the NewNeurometrics. If the face looks nice but does notfunction well, it is important to take the necessarysteps to get the best possible function. This is wherewe are now, moving from the techniques to functionand functional analysis to base the outcome on.

Thus far in craniofacial surgery, we havepreferred and continued to focus on principles andstay away from the skull wars. Techniques continueto change, but the principles remain the same. We aregoing to be stressing those principles and guidedgrowth processes more and more as they relate to theskull, bones, and especially bone grafts (Fig 3). Bone

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Based on a keynote speech presented at the 14th InternationalCongress of the International Confederation for Plastic, Recon-structive and Aesthetic Surgery (IPRAS 2007), Berlin, Germany byMutaz B. Habal, MD, Deputy Secretary General of IPRAS andEditor-in-Chief of the Journal of Craniofacial Surgery.

Address correspondence and reprint request to Mutaz B. Habal,MD, FRCSC, FACS, Tampa Bay Craniofacial Center andUniversityof South Florida, 801West Martin Luther King, Jr. Blvd, Tampa, FL33603 USA; E-mail: [email protected]


grafts are an essential component of craniofacialsurgery as we change the anatomic boundaries ofpatients; only autologous bone is used in craniofacialsurgery. We need precision, proper and timelydecisions, and vision. Without vision we cannotembark on craniofacial surgery. An example of thisfrom the past and how it can progress is Crouzonsyndrome (Fig 2). This is a miraculous operation.Withone operative procedure, we can change the patient’sappearance and anatomic configuration, maintainvision, and facilitate the functions of breathing,deglutition, mastication, and speech. How long thesechanges will last is going to reveal the surgeon’sappreciation of bone physiology and anatomy, themain question at present time. Apert syndrome isanother similar clinical problem. We saw this patientas a child (Fig 4), and this is how she looks 22 yearslater (Fig 5). We need to focus on multiple areas andstress their interrelationships to keep them in theappropriate alignment. Here the patient is working asa volunteer dispatch operator for the police depart-

ment (Fig 5). It is important not only to change the facebut also to enable functional changes that support andproduce a productive citizen. Another patient withSaethre-Chotzen syndrome 18 years later is a violinist(Fig 6). On the 3-dimensional imaging of her cranio-facial skeleton, you can see it is almost normal. Thispatient still has a little residual dysmorphology in thetemporal region that can be included in the main-tenance program, but today, she has elected to leavethe temporal region as is. She does not want thatchanged. She is happy with what she has. Anotherpatient with Saethre-Chotzen syndrome (Fig 7) is

Fig 2 An immediate result produces spectacular changesin the anatomic configuration of the skull. However, thelong-term results and maintenance program are what wewill be looking for.

Fig 3 Bone grafts orthotopic or heterotopic have differenthealing processes and reconfiguration that is age- and site-dependent.

Fig 1 The skull comes in different shapes and sizes, andsometimes it is very hard to determine a set of normality;variations will be the key issue in the development of theestablishment of the new anatomic boundaries.

THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 19, NUMBER 1 January 2008

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going intomedical school. She still has her hardware inand does not want it removed. This is how she lookstoday, 20 years after corrective surgery (Fig 7). She

enjoys functional and craniofacial configurations thatare within normal limits. The maintenance programindividually designed for each patient after recon-structive surgery is the most essential part of our

Fig 5 Progression over 25 years with an operativeprocedure and maintenance program that involved thedentist’s and the plastic surgeon’s coordinated efforts, thestandard for the repair of that particular deformity. Notethe 4-fingered hand.

Fig 4 Newborn with Apert syndrome as seen in thenursery right after birth.

Fig 6 Patient with deformity corrected as a child, and nowyears later, she enjoys her being and progressed functionallyas a normal child.

Fig 7 Another child with deformity corrected as a child,enjoying the progression of good function and normalappearance.

SPECIAL EDITORIAL / Habal

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cooperative efforts. Over extended time, we followclosely the patient’s functional progress, not limitingour observations to the healing of the surgical wound.The critical need for patient follow-up and main-tenance program emphasizes the lack of regard foritinerant surgery.

If we list craniofacial deformities into systemcategories for craniofacial surgery, we see that severeclefts are at the front and are the most common onesseen today. Long-term treatment for those patients isespecially important. In syndromic clinical problems,we start to understand what the bone stock is inrelation to these differences. I think the mostimportant paper we have had in the past camefrom Doctor Aduss at the University of Illinois atChicago. He published a supplement 5-year follow-up on a group of patients who were operated onwithout a close monitoring of the bony configuration.He discussed the patients’ long-term conditions aftermajor craniofacial surgery without maintenance. Hefound that the patients looked worse than they

looked immediately after the initial surgery whichwas then consideredmiraculous. Rather than lookingat the appearance, as a dentist, he focused on thefunctional occlusal relation which did not displayadequate long-term stability of the repair. He calledthe finding a relapse of initial stability.

This newborn baby has a holoprosencephalywith severe cleft area (Fig 8). You can see the outcomeof carefully timed multiple-stage repairs. This is notthe result of one miraculous operation. We needguided growth increments over a period, giving thepatient the chance after each repair to be within age-related norms in appearance and in normal function.We need functional preservation, a maintenanceprogram, a touch-up procedure, and ancillary work.The timing of treatment from birth is also essential inhow we can maintain the bone stock to hold themechano-function. Another patient with similar pro-truding severe bilateral clefts (Fig 9) 21 years later is afunctioning citizen. You can hardly see evidence thatshe had a procedure. In our center, we have seen thatthe earlier the surgeries are done, the better theimmediate result, but without maintenance, calami-tous results can occur. So, the focus is on the soft tissue

Fig 8 Patient with a severe deformity have bilateral cleftswith vestigial premaxilla and had the corrective proceduredone and a maintenance program involving the orthodon-tist and the anaplantologists.

Fig 9 A severe cleft that was corrected with multipleprocedures and a close monitoring of her craniofacialskeleton growth and development.


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first and the hard tissue next. Another patient with asevere cleft (Fig 10) who was referred to us wasexpected to die because the diagnosis by a geneticistwas holoprosencephaly. You can see her here (Fig 10)graduated from college with an interest in going intothe medical field. These are selected examples primar-ily to demonstrate points and principles and toelucidate the process that we have followed to achievea good outcome, which include normal function andconfiguration.

We have considered the different implications ofthe timing of surgery, orthodontics, distraction, andfunctional preservation, which are very important.With good training, a maintenance program, andtouch-up procedures including bone grafts and fatgrafts, which are really very essential, the patient canachieve the desired outcome. Doctor Marketa Dus-kova, the pioneer of the fat grafts is sitting in the frontrow. We have found her work is an importantapproach for it can balance the surgical result andachieve the desired outcome by enhancing thedeficient soft tissue in these patients with multiple

Fig 10 Severe deformity of the craniofacial skeletoncorrected with guided growth principles, bone grafting,facial anatomic boundaries changes, and a strict main-tenance program.

Fig 11 Guided growth is an important principle to followin a patient with severe deformities; when a gap is createdby changing the anatomic boundaries, it is essential toprevent any soft tissue fromherniating and filling the space.The guided growthwill allow the bone to continue growingwithout any interruption of the regenerative processes.

Fig 12 A youngster with Apert syndrome with severecraniofacial deformities. Note the misshaped head aswell as the beginning of midfacial collapse.


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surgeries. Doctor Marketa Duskova’s papers werepublished in the Journal of Craniofacial Surgery fewyears back.

Bone stock is another important part of theprinciples of craniofacial surgery. Its involvementnecessitates that we ensure adequate biomechanics,biomanometrics placed into a system of adaptation,and the adoption of the material into the adjacentstructures, as well as biosynthesis wherein bonegrafts are in the forefront of all these changes. As theanatomic boundaries are changed, we have to ensurethat the biomechanical properties are in goodposition to withstand the elastic recoil of the softtissue and the myofunctional considerations of thesurrounding structures. Let’s look at this guidedgrowth principle. This patient (Fig 11) had multipleprevious surgical procedures and was referred tothe center to see if we could help with his function.His face has collapsed totally after all the differenttechniques to change the anatomic boundaries. Ineach of these procedures and instances, the result ofhis surgery was unable to withstand the mechanicalforces on the new position for more than 1 year.The mother said this last collapsed position took

place about 6 months after the last surgery, althougheverybody was very happy with the immediatesurgical outcome. When you look at his scans, yousee everything contracted.Whatwe found is that therewas not enough bone stock tomaintain themechanicalstrength needed for the patient to retain the orbits andface in their appropriate positions. It took us 4 yearswith distraction using guided growth to achieve theoutcome desired and to maintain the present func-tional position. Any skeletal component we externallyadvance to change the anatomic boundaries needs tohave enough mechanical stability, resistance, andsupport to keep it in place. If we do not preserve thebone growth in a protective manner, whether you callit protected bone regeneration or guided bone regen-eration, it will collapse because of inadequatestructures to maintain the altered position of bonesegments and hold them together. As a youngsterwith Apert syndrome who has a severe craniofacialdeformity (Fig 12), this is how the patient looks now(Fig 13). He and his family are very pleased. But asyou see, it took 4 years of maintenance to stabilize hisface. He has several deformities. The main principles

Fig 13 After multiple operations of the patient with Apertsyndrome to allow for stabilization building a good bonestock, he is seen a few years later with good stability ofthe newly configured face; he has regained the importantfunctions associated with these changes.

Fig 14 Revision surgery is among the commonproceduresdone, partially because of the restricting effect of thehardware, growth, and development, and in part due tothe understanding of the operating surgeon beyond thetechnical aspect of a procedure; the procedures themselvesare dynamic in nature. This patient has Crouzon syndromeand had multiple procedures before he was referred to ourcenter; we were able to correct the condition fully followingthe designated principles, remove the hardware, move tothe functional anatomic boundaries, and replace themissing component with stable bone, either regeneratedbone or grafted ones.


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in all bone surgeries are addition, substitution,removal, reshaping, and reposition. These are theelements we proposed together in 1991 for craniofa-cial surgery published in the Advances of PlasticSurgery that year. Revision surgery is now in theforefront, the principles to remove all the hardware,replace the missing bone areas with bone grafts, and

produce a mechanically solid new craniofacial con-figuration (Fig 14).

Nowwe take a closer look at bone grafts and bonesubstitute, which is coming to the forefront along withthe new technology and anticipated technologicaladvancements (Fig 15). Bone tissue engineering is anew frontier and hasmany applications in craniofacialsurgery. Bones that are tissue engineered have toreplicate the mechanical technology, molecular tech-nology, and nanotechnology of the area to be recon-stituted. We also look at the functions of thereplacement parts using osseointegrated implantsthat require collaboration with anaplantologists andan audiologist; the ear and the Bone-AnchoringHearing Aid (BAHA) have been major contributorsto the rehabilitation of the patients with craniofacialdeformities (Fig 16). We are now working with thenanotechnology on nanofibers to help us with tissueengineering of bone graft substitute. Every plasticsurgeon should be well versed and adept at bone graftacquisitions and reconstruction. We have to under-stand that bone reconstituted areas are not dead tissueor dead bone as termed in some circles, but live tissueto be regenerated given the proper local and environ-mental factors to do so, plus the proper milieu, asnoted by some. Instead, they are living tissue replacingthe bone that is missing. We have to have adequatepenetration of blood vessels to allow for properrevascularization. We have to make sure they arewell fixated in position. Our book on bone grafts waspublished 10 years ago, the first book on the topic in 75years. However, it is now out of print. Youmay obtainused copies throughAmazon if you are interested. Thedogma that plastic surgeons are soft-tissue surgeons is,in view of today’smodern plastic surgery principles, ahistorical event to be reckoned with.

Where do today’s bone engineering stem cellscome from? They are adult versus embryonic stemcells. In the United States, we can use only adult stem

Fig 15 Bone grafts, which are an integral component ofthe growth and reconstruction in this large skull defect aftera vehicular accident seen after mainly orthotopic grafts,have totally adapted to the new positionVadaptationprinciple in action.

Fig 16 Osseointegrated implants will support the prosthetic ear as well as the hearing apparatus seen in 2 differentpatients with craniofacial deformities.


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cells. We cannot use embryotic stem cells, althoughrecently, it was found that amniotic stem cells arealso chimeras and do not retain their immunogeneticnature. In the future, these cells may also be availablefor clinical trials and perhaps regular use. But we willnot breach the embryotic area ban that we have now.The scaffold is the second element needed for tissueengineering. It is a copolymer of polylactides; theother element needed is the matrix that is the

morphogenetic cytokines that are produced by mostgenetic enzyme manufacturers, and the stimulus isthe presence of the defect itself. It has to be a critical-size defect, which means a defect that does not healor close spontaneously. The adult stem cells used,whether they come from fat or bone marrow, is a bigissue. The accepted concept on that is that the fatstem cells come from the bone marrow and basicallyget stored in the fat tissue, where they can beretrieved for further use. There are a couple ofcompanies now that produce stem cells and storethem for use from the patient’s own fat deposits asautologous tissue (Fig 17). An example of a defectin the skull in this patient is shown; the patient washit by a car (Fig 18). You can see she has a largeporencephalic cyst on the trauma site; she wasdysfunctional. The brain was nonfunctioning onthat side. She behaved and looked like a strokevictim. We reconstructed the defect. The bone graftswere obtained from different anatomic sites: ribs,hips, and skull, all heterotypic grafts. We fenestratedthe bone for rapid vascularization, and we placed theother biologic components there, and you can see thatthe patient 2 years later (Fig 19) is nearing solidificationinto the area. The function was improved tremen-dously by containing the residual brain in the vaultand not only by simple bone reconstruction. Thissecond patient is an example of a youngster with aninvasive tumor on the skull (Fig 20). The instrumentshown in Figure 19 is a depth-control power unit to cutthe bone with precision; it is the latest technologicaladvance we have in bone surgical manipulation. Youcandial the depth in the boneneeded aswell asdial theskull cut any depth you want. We removed the tumorand reconstructed the skull with a bone graft and bonemorphogenetic proteins. You can see the ground-glassappearance on the patient’s later scan showing thebone regeneration is taking place.

Fig 17 Adipose tissue aspirate and bone marrow aspirateare used to obtain the desired adult stem cells for any formof tissue-engineered units or bone regeneration.

Fig 18 A patient with posttraumatic head injury. Note thelarge porencephalic cyst in the brain, the large defect, andthe calcifications around the defect zone.

Fig 19 The same patient 2 years after reconstruction of thedefect using tissue-engineered bone for repairing themissing bone; the scaffolds are copolymers of polylactides.


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This next patient, a patient with craniopagusdeformity, is courtesy of the World CraniofacialFoundation. The separation process requires manyadvances in technology, skill of the operating surgeon,and scheduled interactive processes by a coordinatedteam who appreciates the principles of craniofacialsurgery. The important things here are skill, ethicalknowledge, potential for functional outcomes, andexpense. There are a number of instances whereinattempts to separate conjoined twins were undertakenbyworkingwith a ‘‘cookbook’’ like fashion and endedup with disastrous results. This is not for the novicewho wants to spend a day following a recipe forpublicity. I have seen this in my own backyard, andmany other incidences have been brought to myattention as editor of our journal.

Revision craniofacial surgery is another aspect ofwhat we do. Many times, patients undergo surgery,and then their results collapse. This patient presentsa system deformity seen by the combination ofhardware and configuration schema defects (Fig 14).The patient presents an example of this particularissue; it is now common to see such grown-uppatients with craniofacial deformities achieving thisfunctional disability, a new category in craniofacialdeformities, which has increased during our timesand continues to increase. The patient had asurgery, a classical approach with no vision, just acookbook fashion. Well, here he is years later; hecannot bite, eat, chew, and his lack of an occlusalrelationship interferes with swallowing and speak-ing. You can see the totally collapsed area. Thatalso needs to be adjusted and addressed appro-priately. What was done was inappropriate. The

first principle that needs to be applied here isremoval of the hardware that was placed in thewrong site, restricting the patient’s growth andproducing in him the loss of function. The hard-ware was installed in a sort of tongue-and-groovepattern to hold his face together when he was ayoungster. This restricted the growth on thetethered side, rotating the other side in. The newadvances today are replacing the nondissolvingbiomaterials with biomaterials that have the capa-bility to resorb, allowing bone regeneration to takeplace within growing bone. We have to useplatelet-rich plasma, primarily a material contain-ing a number of growth factors that allow us tocreate a site in which the patient can engineer hisown skeleton and encourage further growth. This ishow he is now (Fig 14). It takes time to reach thatstage through combinations of basic principles; it isnot an overnight procedure. Biomaterial today suchas copolymer of the polylactides is in the forefrontof craniofacial reconstruction. It does not make adifference what brand or named product you use,for they all have the same basic element withdifferent components. Actually, they all come fromthe same basic element manufacturer. The boneregenerative material, which is the bone implant, isalso in the forefront (Fig 21). There are some currently

Fig 20 A composite picture representing the dynamicnature of tumor resection and immediate reconstruction.The bone-engineered skull defect after tumor resection; thestem cells are bone marrowYoriented, the scaffold ispolylactides, and the cuts are done with the state-of-the-art depth-control instrumentation.

Fig 21 Polylactides are used in this patient for stabiliza-tion of the skull that is reconstructed using the correction ofa scaphocephalic skull. Note that the correction will nothave any restriction in the growth pattern; the standardof care for the patients younger than 6 years is the useor polylactide resorbable components.


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available materials that are bioactive. We need tomake sure they are reliable to produce stability for aperiod. Most of them resolve within a year and ahalf. So, if the bone cannot regenerate within a yearand half, there will not be enough mechanicalstrength for that tissue to hold in position. They areall mechanically active, and that is what weintended. The most common application of thebioresorbable fixation components is as seen in theorbital fracture (Fig 22), which changed the whole

understanding and technology of the components ofsuch fixation. We like the transconjunctivalapproach on the patient with orbital fracture,especially on the young ones, so no scar existsoutside. Thus, repair of the orbital fracture is done,and there is not an external scar. Those polylactidesresorb in a year, and after that, the patients have allregenerated bone without a scar and enjoy normalorbital configuration and function.

We need to look at the matrix component of thespecialty. Although there remains an arc withimpressions and beliefs, we do not want craniofacialsurgery to become a cookbook with which surgeonsenter the operating room, read a manual, note thedetails, and follow them. Ours is an applied science.It addresses a biologic system through carpentrythat involves the skill of the surgeon, tissueengineering, and a new barrier, and probably, thenext time we meet, we will hear more about this andother barriers.

Another principle I would like to bring to yourattention is that function is very important at thispoint. Two components that make a world ofdifference in the function of our patients are theimplantable ear with osteointegrated implants andthe BAHA. Besides the surgical advantage, theBAHA gives good functional improvement to thepatient with conductive hearing loss (Fig 16). Weapply them to many of the patients with craniofa-cial deformity and functional hearing loss. Our

Fig 22 Orbital floor reconstruction with polylactideresorbable plating system represents the standard ofcare for the correction and repair; the transconjunctivalapproach to the orbital floor and the orbital rim as awell as the upper maxilla is also well regarded.Technical system for it leaves no scar on the patient;the patient is seen before and after the repair withoutany residual.

Fig 23 Biologic predeterminism is the nature of thissyndrome concept that when correcting the deformity, thepatient will continue to harbor the same genes that willproduce a sibling.

Fig 24 An illustration of the structural dynamics of thecraniofacial surgery systems, based on the dynamicprinciples of adaptation and mechanics; it will culminateon the top of the pyramid with evidence-based medicine(EBM), which will allow us to do the evaluation based onfunction first and structure second, a complex system in aplain world (Previously published in the Journal ofCraniofacial Surgery).


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audiologist sees all patients with a hearing prob-lem. After testing, if the patient meets the criteriafor the fitting, we start them with the BAHA andosseointegrated implants. It is very easy. I learnedhow to apply them from our colleagues in Canada,Dr Wilkes and his associates. His original work waspublished in the journal a few years back (Fig 16).

The skull defect continues to be a majorchallenge for reconstruction. We have to understandthere are differences in what is skull, a dynamiccomponent of the craniofacial unit, and what islower facial skeleton, which is the dynamic portionwith the mandible as the fulcrum. What we apply toone does not apply to the other, primarily because ofthe dynamometry of those units and due to thediffering muscle function found in the 2 areas. Whyare skull defects on the increase? The craniofacialsurgeons are seeing more injuries from war, masscasualties, civilian injuries, and, of course, cancer,which continues to be a major causative factor. Forpeople living in Florida, skin cancer is a highcontributor for those skull defects after head traumaand mass casualties. If the bone is not involved orgrossly contaminated, the removed bone is storedwithin the biologic system, such as the abdomen,and later on retrieved for the reconstruction.

A dramatic instance of crossing barriers tookplace a year ago with a face transplant. Here is amaterial that we think will be the future of youngplastic surgeons and involve the craniofacial skele-ton. The 2 issuesVthe tissue engineering and facialcomponent transplantationVwill be a prominentpart of all the advances in plastic surgery duringthe coming 20 years. Research is indeed on thecutting edge in our field. If I were starting my careernow, I would be there, for it is most exciting. Inbrief, when a young patient had his face ripped offby a family dog, transplantation of missing compo-nents would have been ideal. We would have beenable to reconstitute his facial configuration ratherthan allow him to be crippled for life. In research,we also have ethical issues, religious issues, func-tional issues, immunologic issues, and experimentalissues. We must go to the institutional review boardto undertake extraordinary measures. That youngpatient ended up with basically a skin graft and anonfunctioning eye. Facial component transplanta-tion is not available in our area. Such proceduresshould be done by well-trained specialists in placessuch as the big clinics, of course, subsequently inother geographic sites. With crossing the barrier, wehave allografts that require having the patients onimmune suppression for the rest of their lives. Thetissues are mostly strongly antigenic. We have skin,

fat, and muscle today. Maybe in the future, a wholecomposite of tissue component will be transplantablefor the patient. Regardless, we are still a matrixspecialty with many specialists dedicating their time,effort, and passion to what we are doing. It is aprofessional group approach rather an interdepen-dent team endeavor.

We look for a common vision, pursuit of per-formance measures, quality, and safety and orientour thinking to long-term clinical outcomes. Thesedata are essential, for without them, we will beunable to continue doing what we do.

In addition, in our work, we must considerbiologic predeterminism, understanding that whatwe change anatomically with or without barriers isnot changing the totality of what is going on withthe patient. Here is an example. This patient is amusician now (Fig 23). This is how he looked whenhe was a youngster 26 years ago (Fig 23). We carriedout operative procedures and a maintenance pro-gram. He is a functioning adult citizen in all aspects.He got married and sired a baby. The baby has thesame congenital defect, Pfeiffer syndrome. Oursurgical work did not alter the genetic componentsof his fabric nor the physiology that was there for thepatient. The syndrome is biologically predeterminedto produce the differences they have, and thebiologic nature of the inherited deformity is not atall changed by surgery. The Amazon women syn-drome does not apply to what we do in craniofacialsurgery.

We need to discuss here our future directioninvolving evidence-based medicine and qualitycontrol. We have press on those topics from every-where during this congress. We have already spenta couple of weeks this year trying to work onperformance measures for the future. We cannot justsay wewould like to do this or that operation. Instead,we must recognize that our actions are predicated onevidencederived fromwhatwehavedone.Wehave toshow that there is a quality of value inwhatwewant todo for the patient and that over a period we arepermanently improving the patient’s function. Therehas to be a value, and there has to be an improvedfunction element for us to be allowed to continuedoing what we do.

A summative approach to the principles ofcraniofacial surgery falls into a pattern of structuralpillars balanced for function and skill (Fig 24). Wehave produced what we call the structural pillars oftoday. They may or may not be applicable to-morrow. The pillars are the basic components ofcraniofacial surgery: its dynamic nature, the capac-ity for molding the skeleton, the adaptation of


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differences and changes, as well as the function andthe anatomy. To produce the desired outcome forthe patient, these pillars must be balanced inconjunction with the skill of the operating surgeonand quality-based performance measures. The per-formance gives us evidence-based outcome thatreveals the quality of performance measures thatare metrically assessed by what is done. The qualitynot only is the quality for today but also mustrepresent long-term functional gain. We always haveto remember that we should minimize the mishapsand maximize the outcome. This is the foundation ofclinical judgment noted in early years in anotherjournal publication.

Our communication system is extremely impor-tant, and the Journal of Craniofacial Surgery is that

modus of communication around the world. It isnow in its 19th volume, 25 years in the works, and thebest-quality journal in the field. This has fullyenabled us to have a global forum of communication.When new procedures, innovative methods, newtechniques or instrumentation, and new skills arediscovered, created, or improved anywhere aroundthe world, we can share all of those things amongour colleagues with all in craniofacial surgery family.The horizons are wide open, limited only by theimagination of the practicing surgeon. I thank youvery much for the chance to present to you our work,our thoughts, and concerns about our future direc-tion in the field of craniofacial surgery. Alwaysremember, the principles last forever and thetechniques do not.


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