Bill Klaproth: This is OMS Voices, an AAOMS podcast. I’m Bill Klaproth and with me is Dr. Ashley Manlove who is here to discuss craniofacial surgery and the OMS. Thank you, Dr. Manlove, for being here.

Dr. Ashley Manlove: Thank you, Bill. I’m very excited to be here today.

Bill Klaproth: It’s great to talk to you. So, let’s start with this, what are craniofacial nomalies?

Dr. Ashley Manlove: So, craniofacial anomalies include conditions that patients are born with. It could include things like cleft lip and palate; it could include craniosynostosis. It could include a variety of other facial deformities that affect the patient’s ability to function properly and appear, quote unquote, normal.

Bill Klaproth: Yeah, right. You just mentioned craniosynostosis. Can you explain to us what that is, briefly?

Dr. Ashley Manlove: Sure. Craniosynostosis is premature fusion of the sutures of the skull. The sutures are basically fibrous or incomplete bone, forming a skull that allows the skull to grow as the baby grows from a baby into an infant to a child and so on.

Bill Klaproth: So obviously, that needs to be repaired or corrected. Yeah, so then what is an OMS’s role in treating a craniofacial anomaly? Where do you come in?

Dr. Ashley Manlove: As oral and maxillofacial surgeons, we specialize in taking care of the face. So, any type of facial anomaly is right in our wheelhouse. Many of us are pediatric craniofacial fellowship-trained to take care of these children. Our role can be as the craniofacial surgeon on a multidisciplinary team, or on a team that has multiple different providers, our role could be on the team but perhaps not as the primary surgeon. Our role can also be in educating the community. There are so many different roles that we can have.

Bill Klaproth: Yeah, as part of a team taking care of these craniofacial anomalies. So, you mentioned cleft lip and cleft palate. How are cleft lip and palate diagnosable, and how common are they?

Dr. Ashley Manlove: So, cleft lip, with or without cleft palate, because they can present both ways, is the most common facial anomaly. One in 650 live births approximately, around the world. It can be diagnosed pretty early, and it can be diagnosed by ultrasound. So many patients with cleft lip are diagnosed by ultrasound through their various prenatal appointments. A cleft palate, if there is just a cleft palate, that is much more difficult to identify in utero, but a lot of times, after the baby is born, it is identified.

Bill Klaproth: It’s easy to see, it’s visible.

Dr. Ashley Manlove: It’s visible if it’s a bigger cleft palate, if it’s a small cleft palate, though I’ve had babies come to me after a couple of weeks and nobody noticed because it’s so small. Whereas cleft lip is very visible, it’s right on the face. So small, or what we call microform or incomplete cleft lips, are always diagnosed in utero. But it’s very visible when the baby is born.

Bill Klaproth: So, you said cleft lip and palate are some of the most common forms of craniofacial anomalies. What are some of the less common craniofacial anomalies?

Dr. Ashley Manlove: So, there are a lot of different ones, some are associated with syndromes or other anomalies in the body. But the ones that pertain particularly to the face would include hemifacial or craniofacial microsomia where part of the face doesn’t grow at the same rate as the other side. Treacher Collins is a genetic condition, there’s an association with craniosynostosis like Apert syndrome and Crouzon syndrome. There are other syndromes that are associated with a small lower jaw, and perhaps an isolated cleft palate, like Pierre Robin or Robin sequence. And Stickler syndrome, and they can go on and on.

Bill Klaproth: Right. So, when are some of these rare anomalies diagnosed?

Dr. Ashley Manlove: Some can be passed down from the parents. If the parents have a syndrome and they’re aware of it then they have a higher likelihood or heightened awareness, perhaps, of it being passed to their child, but others a lot of times are identified at birth. Again, it’s the face, so it can be very visible. And then some of the other ones aren’t necessarily visible at birth, but as they grow over the next couple of weeks or even months, it becomes more apparent that there is a structural anomaly.

Bill Klaproth: Right. So, I would imagine for the parents, this is very difficult. What advice do you give to parents who are rightfully maybe fearful, learning their child has an anomaly?

Dr. Ashley Manlove: Right. It’s always a difficult conversation to have with somebody, either when I meet with them prenatally and they have a confirmed diagnosis of cleft lip. The parents are in disbelief. They are so excited about the baby. And then they find out news that can be a little bit devastating, especially because most parents don’t expect it. Cleft lip isn’t necessarily genetically inherited, so it was very unexpected. So, I just try to provide them with all of the information that they can use as tools to understand the timeline and what to expect. And oftentimes, I’ll share pictures of other families I’ve taken care of, so that they know one, they’re not alone. And also that it’s treatable and we’ll take care of them. And I let them know we’re there every step of the way.

Bill Klaproth: I’m sure that’s very comforting to them and helps put them at ease.

Dr. Ashley Manlove: It does. There’s so much information out there, both good and bad. There’s so much at your fingertips. I think most have a sense of relief when they meet with the medical provider or even the team. I try to meet with them in person. Oftentimes, I’ll meet with them with a feeding therapist so that they know, as soon as the baby’s born, we’ll be seeing them and they’ll be taken care of.

Bill Klaproth: Yeah. And again, I’m sure that’s very comforting to them and knowing that there is hope that, hey, this can be repaired. This can be fixed and your child will most likely lead a normal, healthy life. You’ve mentioned craniosynostosis several times now. What are the different types of craniosynostosis?

Dr. Ashley Manlove: So, at the skull, it’s super fascinating. There’s different sutures in the skull. There’s a suture that runs down the forehead, that’s called the metopic suture, so that would be one. And then there’s a soft spot, which most people know. You know, your baby has a soft spot at birth. And that is where the metopic suture kind of goes up to. And then there’s coronal sutures that come down the sides, squamosal sutures above the ears and sagittal suture that goes from the soft spot in the front to the soft spot in the back. And then there’s additional sutures in the back, the lambdoidal sutures. So, I mean, there are all sorts of growth areas for the brain to grow. And any one of those can be fused, or multiple can be fused.

Bill Klaproth: And those all fall under craniosynostosis.

Dr. Ashley Manlove: They do. It’s a very broad term.

Bill Klaproth: Got it. And then what are some complex craniofacial conditions? You don’t have to name all of them, but what are some of the most common ones that you see?

Dr. Ashley Manlove: Right. So Treacher Collins can be very, very complex.

Bill Klaproth: And what is that?

Dr. Ashley Manlove: So, Treacher Collins does not involve a premature fusion of the skull; it doesn’t involve craniosynostosis. But Treacher Collins syndrome is often genetically inherited. And the eyes are often down-slanting, they can be absent or under-formed cheekbones. They have malformed or smaller ears. They can have some hearing difficulties, they can have some issues with the eyes, they can have cleft palate occasionally. And they can also have a really small lower jaw, but there’s a big spectrum. So, somebody with Treacher Collins can be on the more severe spectrum or a very mild form.

Bill Klaproth: I could see where that would be complex.

Dr. Ashley Manlove: It’s very complex, both in taking care of the patient and taking care of the family. And just trying to make sure that their form and their function is kind of established as they get older.

Bill Klaproth: So, for things like craniosynostosis, what is the surgery or treatment like?

Dr. Ashley Manlove: For craniosynostosis, there are two options, depending on what center you’re at and what your surgeon’s preferred technique is. There is an endoscopic approach that is minimally invasive. It’s often done much earlier, in younger infants, oftentimes somewhere between that four to six, maybe eight months of age, where the suture that’s fused is essentially removed. And then the bone is released to allow the brain to grow, and then the baby wears a helmet to help mold the areas that are misshapen from that fused suture.

Bill Klaproth: And the baby will generally then heal properly or grow properly?

Dr. Ashley Manlove: They typically do, they grow properly, and that helmet helps get the head shape to be more or less normal.

Bill Klaproth: And for cleft lip and palate, how about the treatment or surgical options for those?

Dr. Ashley Manlove: Well, there’s one other type of treatment for craniosynostosis. So that was the endoscopic approach. And then there’s also an open approach where the skull is essentially reconstructed into a normal fashion, so that the brain has adequate space.

Bill Klaproth: Got it. And then for cleft lip and palate?

Dr. Ashley Manlove: So, treatment for cleft lip and palate can also be a little bit complex and every child is so different. For cleft lip and palate, I always tell the parents there are three surgeries that your child is going to have. They’re going to have a repair of the cleft lip around three to five months of age. They’re going to have a repair of the palate around a year of age, and they’re going to have a bone graft procedure to restore continuity of the upper jaw somewhere in the six to ten years of age, and those three are pretty standard. As far as additional surgeries, cleft lip and palate patients do often require additional procedures. They often require ear tubes because they’re more prone to ear infections. They may or may not need speech therapy. And with that, there’s surgery that can be done to help with speech, depending on if that’s needed. All the procedures that they have can limit the growth of the upper jaw, so some of these patients will need jaw surgery or jaw corrective surgery to try to get the skeleton and the teeth in a better alignment. And finally, these patients may benefit from a definitive rhinoplasty to correct any type of nasal asymmetry, nasal septum asymmetry, to improve breathing and function.

Bill Klaproth: And it’s interesting. The OMS is involved in all of this, really the expert in these repairs.

Dr. Ashley Manlove: Many of us are trained to take care of these patients from birth until adulthood. As our other specialties, you know, with the face being our main specialty, I do feel like we are working on the face all the time. And that is what we do. So, we are definitely well-trained to care for this population.

Bill Klaproth: Yeah. So, as we wrap up, Dr. Manlove, I want to thank you so much for your time. Anything you want to add as we talk about craniofacial surgery?

Dr. Ashley Manlove: If you have questions pertaining to your child that you feel like something might not be right, I would request to see an oral and maxillofacial surgeon who’s trained in pediatrics. If we can’t provide the adequate treatment, then obviously we can find the right person for you.

Bill Klaproth: Right. Well, it’s a good message and a great way to wrap it up. Dr. Manlove, thank you so much for your time.

Dr. Ashley Manlove: Thank you so much, Bill.

Bill Klaproth: You bet. And once again, that is Dr. Ashley Manlove. And for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast helpful, please share it on your social channels. And don’t forget to subscribe. Thanks for listening.