Joseph Kerwin Williams, M.D.

Every person’s skull is composed of eight separate bones that are joined together by fibrous joints called sutures. Craniosynostosis is a congenital defect of the skull that occurs in approximately one out of every one thousand births wherein the various sutures fuse improperly or prematurely, resulting in an abnormal head shape. It is also possible to develop other abnormalities of the skull, such as a flattened head shape, after birth as a result of skull bones moving to the improper place during birth. Because of the developmental implications and need for the sutures to reform, reconstructive craniofacial surgery by a board-certified pediatric plastic surgeon is usually recommended before a child reaches one year of age. In some cases, Dr. Williams may perform the repair in conjunction with a Pediatric Neurosurgeon, depending on the amount and location of fused sutures.

Here are some of the most common deformities of the skull that are treated by board certified plastic and reconstructive surgeon Dr. Joseph Williams:

• Coronal Synostosis (Plagiocephaly): improper or untimely fusion of the suture that runs across the skull from ear to ear (Coronal Suture), exhibited by prominence of brow and/or forehead on one side of the head in which the eye is often a different shape from the one opposite.
• Brachycephaly: a congenital malformation of the skull in which premature closure of the coronal suture results in excessive lateral growth of the head, giving it a short, broad appearance.
• Trigonocephaly: a fusion of the metopic (forehead) suture evidenced by a triangular shaped/ pointed forehead in which the eyes are placed close together.
• Scaphocephaly: premature fusion of the suture that runs the length of the middle of the skull (Sagittal Suture), resulting in an elongated skull in which the length from front to back is greater than the width from side to side.
• Suture Fusion Associated with Other Congenital Defects
• Positional Head Deformities (such as Torticollis)

A cleft deformity, present during birth, occurs when the two sides of the developing palate fail to fuse properly while the fetus is still in the womb, and can potentially lead to difficulties in both speaking and feeding. A cleft deformity can affect the roof of the mouth (called a cleft palate), the upper lip, either on one side or both sides of the nose (called a unilateral or bilateral cleft lip), and it can be either complete or incomplete, depending on the presence of bridging tissue across the split. Surgery to correct a cleft lip or palate is most commonly performed on infants or young children so that the face has as much time as possible to heal and develop normally before the child reaches “school age.”

Infants who are born with a cleft lip or palate may have trouble eating and speaking properly. They may have missing teeth or a misalignment of the teeth and jaw, and they often exhibit secondary nasal deformities as well. These issues will be addressed by Dr. Williams during craniofacial surgery to restore full function and correct the appearance of the face. Patients will often require more than one surgery to close the cleft, restore full function, and improve facial appearance. Each craniofacial surgery lasts about two to three hours and typically requires a three day recovery period.

Cleft lip surgery works to correct not only the lip, but also the muscles around the lip and the nose, all of which affect the function and look of the facial area. Preparation for the surgery usually begins when the patient is between two or three weeks of age, as long as no other health problems are present. The surgeon begins by working with the skin, using special taping across the split/cleft or a small device within the patient’s mouth. The corrective surgery, which can be the first of a series of corrective surgeries depending on the severity of the deformity, is typically completed by the time the child in only three months of age.

In some cases, cleft lip patients also have a cleft or split in the alveolus, the bone which holds the teeth in place. An alveolar bone graft is a surgery to add bone to the gum ridge in a child who was born with both a cleft lip and a cleft palate.  While this is most commonly corrected when a child is about eight years old, it may also be addressed during an earlier surgery when the deformity is less severe.

Very often, cleft lip patients are also born with a gap or split in the roof of the mouth, called a cleft palate. This separation of tissue may run though all or part of the roof, and in rare cases it can also involve the lower jaw, a condition known as the Pierre Robin Sequence. Early correction of a cleft palate is especially important for infants because this defect can interfere with proper feeding by making it difficult or impossible for child to create suction. In these cases, it may be necessary to use specialized bottles and nipples or even a device placed in the child’s mouth to ensure that they are getting the nutrients they need. Even if the child can feed properly, surgery of the cleft palate is typically recommended at a very early age so that children do not form incorrect speech habits once they start to talk. Because the malformation of the palate can interfere with the Eustachian tube (which allows for fluid drainage from the middle ear) ear infections are also very common with cleft palate babies. Because of these potential issues and complications, cleft palate surgery is typically performed by a pediatric reconstructive surgeon, like Dr. Joseph Williams, when a child is six to seven months of age.

Plastic surgery designed to address the pharynx (soft tissue at the back of the mouth) when that tissue is not able to close properly. It is typically used to correct speech problems in children with cleft palate. It may also be used to correct problems from a tonsillectomy or because of degenerative diseases. After the surgery, patients have an easier time pronouncing certain sounds, such as ‘p’ and ‘t’, and the voice may have a less nasal sound.

Abnormalities of the jaw in children are usually the result of congenital defects (medical conditions present at birth), but can also be caused by disease or accidental trauma. Congenital defects of the jaw can affect the lower or upper jaw (or both) and can manifest as either a protrusion or a recession of the affected area. In severe cases, dentofacial surgery performed in conjunction with an orthodontist and/or dental specialist may be needed to correct malocclusion, or the misalignment of the jaw and teeth. Dr. Williams uses a variety of techniques, including minimally-invasive distraction osteogenesis, bone reduction and reshaping, facial implants, and repositioning of the jaw bone to correct child jaw deformities. Deformities of the jaw may include or be related to:

Upper Jaw Deformities / Abnormalities

• Upper jaw deficiency
• Short face deformity
• Long face
• Open bite
• Upper and lower jaw asymmetry
• Upper and lower jaw misalignment
• Cleft lip and palate
• Craniofacial deformities (congenital)
• Craniofacial deformities (trauma)
• Maxillofacial deformities (congenital)
• Maxillofacial deformities (trauma)

Lower Jaw Deformities / Abnormalities

• Jaw protrusion
• Jaw recession
• Chin deformities
• Sleep apnea
• Jaw fracture
• Pierre Robin Sequence

Often children with deformities of the chin are born with either a small (recessed) chin or an enlarged (protruding) chin, known as micrognathia and macrognathia, respectively. For a small chin, Dr. Williams can either surgically move the chin forward, using a procedure called Osseous Genioplasty, or enlarge the area through use of an artificial implant. Surgery of the chin may not only dramatically improve the overall aesthetics of the face and profile in children, but may also prevent excessive strain on the muscles in the neck that are attached to the chin.

For children with abnormally large chins, chin reduction surgery may be recommended. Deformities of the chin will often appear with deformities of the upper and lower jaw and/or the nose, and so can in many cases be addressed simultaneously. As with surgeries of the jaw, pediatric reconstructive surgeons and a dental specialist (like a qualified orthodontist) will typically work together to fully correct form and function.

Deformities of the ear in children can be congenital or isolated, very mild or very complex. However, unlike most other deformities in children, it is often recommended that ear surgery (also known as otoplasty) be postponed until after a child reaches the age of six, when the ears are said to reach “adult size.”

Because of the complex shape of the ear, and the ears’ unique positions on either side of the head, ear reconstruction can be a very complex surgery and should only be entrusted to a plastic surgeon with training in otoplasty and reconstructive surgery of the head and neck. Depending on the deformity or defect present, Dr. Williams can use various corrective surgical techniques, such as skin grafts, flaps, and primary linear closures, to restore the shape, size, and alignment of the ear.

Common Deformities of the Ear include:

• Absence of an Ear: A condition called microtia, in which a child is missing most of their external ear, usually due to abnormal growth of the lower jaw and upper jaw area
• Prominent Ears: A condition where the ears appear to be sticking out perpendicular to the head, making it difficult to wear glasses or hearing aids.
• Constricted Ears: A condition where the ear is abnormally short, once also known as “cup ear” or “lop ear.”

Also known as “wry neck”, torticollis is a congenital disorder induced by birth trauma or in-utero malposition that causes the involuntary contraction of the sternocleidomastoid, or neck muscles. The condition results in an inability to redirect the head straight to the front. Physical effects of torticollis include craniofacial asymmetry and very limited range of motion from the neck and head.

Dr. Williams treats torticollis using the most advanced surgical techniques to release scar tissue in the affected neck muscles. The advanced procedure carries a low risk of post-operative complications and keeps scarring to a minimum.

Girls who develop abnormally large breasts at a younger age, a condition known as breast hypertrophy, can often experience a great deal of embarrassment and discomfort. They often find that their breasts can attract unwelcome attention, make it difficult to find clothing that fits correctly, and even interfere with normal activities and exercise. A breast reduction can remove excess glandular tissue, fat and skin, giving the breasts a more proportionate appearance.

Gynecomastia, a condition which causes overdevelopment of the male breasts, does not only affect adults. In fact, it is estimated that up to 70% of adolescent boys develop physiologic gynecomastia, often as a result of hormonal changes during puberty. The majority of these cases resolve within two years of onset without treatment, but when they do not the issue can be corrected with male breast reduction surgery. By extracting excess breast tissue and removing excess skin to reshape the breast, we can give the chest a more normal appearance and alleviate a great deal of self-conscious embarrassment.