Texas Celft-Craniofacial Team

Texas Cleft -
        Craniofacial Team

A multi-specialty team whose primary goal is the treatment of patients with cleft and craniofacial deformities.


Craniofacial Malformations:

Congenital facial anomalies:

Congenital deformities affect the face and the upper and lower jaws. This includes children who have craniofacial deformities such as Apert’s, Crouzon’s, and Treacher-Collins, Pierre Robin Complex, hemifacial microsomia, etc. Initial treatment of these children focuses on their ability to breathe and eat normally. Some of these infants will need a tracheotomy and possibly a feeding tube. The surgical treatment of children with these craniofacial deformities usually was delayed until adolescence and involved single or double jaw-correction (orthognathic surgery). This approach is still used in some patients with mild deformities. Recently, Distraction Osteogenesis has been used to treat these patients at an earlier age. Distraction osteogenesis has been used in the newborn with respiratory difficulties and small lower jaw to stretch the lower jaw and avoid the use of tracheotomy.

Distraction Osteogenesis:

Distraction osteogenesis (DO) has revolutionized craniofacial surgery. DO involves cutting bone and then slowly moving the cut ends of the bone. The gradual movement of the two cut pieces of bone results a new bone formation in the resulting gap. Distraction osteogenesis can be used in the lower jaw (mandible), the upper jaw (maxilla) and face (midface). There are a number of commercially available distraction devices. These devices may be placed beneath the skin or external to it. Distraction osteogenesis enables the surgeon to perform certain procedures which were not possible with conventional surgery.

Upper jaw and face Distraction Osteogenesis:

Distraction osteogenesis has enabled the surgeon to move the upper jaw and face further and safer than was possible with conventional surgery. An external rigid distraction device is the most commonly used distractor for upper jaw and face distraction. The advantage of this device is that it is easy to apply and allows for adjustments during distraction. However, the device is bulky, uncomfortable, and not well accepted by most patients.

An internal distraction device is available in several different designs. The advantages of internal device are that it is better tolerated by patients and nearly invisible. The disadvantages of the device are that adjustments during distraction are not possible, and a separate surgical procedure is needed to remove the device.

The doctors at The University of Texas Health Science Center in Houston use both internal and external distraction devices. They have developed two new internal distraction devices for use in the upper jaw and face. In addition, in order to help plan the distraction process, they have also developed a computer-assisted surgical simulation system. This involves taking a CT scan and simulating the surgery and the movement of the upper jaw and face.

Lower jaw:

Distraction osteogenesis of the lower jaw is a very complex procedure. Most surgeons utilize an external device for distraction of the lower jaw, but there are also a few surgeons who use an internal device. The Texas Cleft and Craniofacial Team at The University of Texas Health Science Center use both internal and external distraction devices. In children with congenital deformities of the lower jaw, they utilize an external multiplanar distractor. In addition, the doctors have created a surgical planning simulation system to plan distraction in the low jaw. Distraction of the lower jaw is much more complex than distraction of the upper jaw and face. Planning in the lower jaw also involves taking a CT scan, and simulating surgery and distraction.

Craniosynostosis:

Craniosynostosis is the premature closure of one or more sutures in the infant’s skull. The treatment of craniosynostosis has changed significantly over the last several decades. Initially the treatment involved removing the affected suture(s). The simple removal of affected suture(s) was replaced by more extensive reconstruction of the craniofacial skeleton. More recently a new microscopic approach to craniosynostosis has been pioneered for treatment of infants.

In older children and those who have multiple suture synostosis, extensive reconstruction of the craniofacial skeleton is utilized. This involves an incision in the scalp from ear to ear. The affected suture is removed and the surrounding bones placed in the correct position utilizing small absorbable plates and screws. Surgery usually lasts for 2-4 hours and the child is usually hospitalized from 3-5 days. Most of patients require a blood transfusion and have significant post-operative swelling. In selected patients who have craniosynostosis of the sagittal and/or coronal sutures, helmet therapy is needed after surgery.

In children who are less than 3-months of age, a new microscopic approach is employed. This involves smaller incisions in the scalp and removal of the affected suture(s) through an endoscopic approach. Surgery usually last 1-2 hours, and the child is hospitalized for only 1-2 days. Most patients do not require a blood transfusion and have minimal swelling post-operatively. All patients require helmet therapy after surgery.

Position-induced Head Shape Abnormalities:

Infants with positional deformities may present with a number of different head shapes. They may have unilateral flattening of their posterior skull, which is plagiocephaly, and/or forehead bulging along with bilateral flattening, which is brachycephaly. When they have increased skull height and/or a long, narrow skull it is scaphocephaly. Deformities result from positioning during pregnancy, sleeping position, or from neck tightness. An asymmetrical skull can result in asymmetries of the face causing various functional problems that affect chewing, speech, breathing, and vision. Some of these infants can be managed with just positioning, such as changing their sleeping position. If the deformity persists, however, treatment may be necessary.

Infant treatment of positional deformities is with a molding cap. Ideally, the treatment is begun during the first six months of life. The band is worn 23 hours a day and requires 3-4 months of wear. Severe cases in older children require longer periods of correction. The result of wearing band is typically a 70 percent rate of improvement, but the correction rate correlates with the severity of the deformity and the age that treatment commenced. Long-term follow up in these children reveals that the correction does not relapse with continued growth.

Contact Information

  • Ruth Garvey Fleshman, LMSW-ACP
    Clinical Coordinator
  • Phone: 713-500-7302
    Fax: 713-500-7296
    E-mail: Ruth.G.Fleshman@uth.tmc.edu

  • Mailing address:
    6431 Fannin St., Suite 5.252
    Houston, TX 77030

  • Office address:
    6410 Fannin St., Suite 1400
    Houston, TX 77030