All right. We're going to move on, and our next speaker is Dr. Isabella Tereshevitz. She is a pediatric neurosurgeon at the University of Texas at San Antonio. She is someone who is very near and dear to my heart. She is one of my closest friends. She is just a wonderful pediatric neurosurgeon, and she's going to talk to us about craniofacial anomalies. Good morning, everyone. I have, let's see, no disclosures. I mean, I always do the same thing, other than I'm Canadian, and I now live in Texas, which is a very red state, and I'm a very feminist, liberal person, so it's very interesting, and I'm friends with... Oh, sorry. I'm friends with Mary Ann, so that's my only disclosure. So I was asked to talk about craniofacial anomalies, and the topics would be something that's very important for neurosurgery PAs or any neurosurgeons, which would be mainly craniosynostosis cases and positional plagiocephaly. So the overview of this presentation will discuss what is the definition of craniofacial anomalies, will discuss the importance of a multidisciplinary approach, and the neurosurgical cases will be, as I said, positional plagiocephaly, craniosynostosis, and we'll discuss what is the normal head growth, and I understand that most of you do not do pediatric neurosurgery, but if you have cases that you will be seeing either in clinic or in the ER, I just want you to know the basics so you don't feel like you're lost, or if you have family members that ask you questions, because they always do, at least you kind of know what to do with those. So we'll discuss craniosynostosis cases, multiple suture ones or single suture ones, and positional plagiocephaly, because it seems to be an epidemic, and people are worried, and everyone has – most of the people that we know have kids, and they're all worried about head shapes, and we see people walking around town with their kids in helmets, and you wonder why. Well, we'll be discussing that, too. Sorry. Okay, I'm not good. Okay. So craniofacial anomalies, the definition of craniofacial anomalies is a diverse group of deformities involving growth of the head and facial bones. It's most of the time congenital, so you're born with this. It's variable in severity, and sometimes it's part of a syndrome. So most of those cases have to be seen in a multi-D environment. So if you do see a case like this in your clinics, and you don't have a group of specialized people that see them, please think about referring them to a specialty group. The cause of those anomalies is genetic, environmental, and most of those, it's because of a folic acid deficiency. So the most common anomalies that we see in our clinic – and I put positional plagiocephaly at the bottom, because we do see them in clinic, and it's not a real anomaly, but it's there on that list. But the most common one is cleft lip, and it happens one in 700 live births. So you do see those kids often, and my coworkers, my colleagues in my clinic, my multi-D clinic, see them. I don't see cleft lip. I don't want to see cleft lip. I'm not specialized to see them, but we do see them in my multi-D specialty clinic. And then craniosynostosis cases, the incidence is one in 2,100 live births. And then we also see hemifacial microzomia, vascular malformations, hemangiomas, and we do see, as I said before, positional plagiocephaly. So the positional plagiocephaly clinic in my institution is run by a mid-level provider. So you do have an important role in my institution, and you do save my life, because I do not have time to see those patients. And most of the times when we see a lot of positional plagiocephaly kids, once in a blue moon or once every two, three months, we do have a real craniosynostosis that is sent by a pediatrician thinking that it's a positional plagiocephaly, but it's a true craniosynostosis. So the importance of seeing those patients in a multidisciplinary clinic is that we are all meeting once a month, and it's easy for families, because they see all those specialists at the same time. So we have a clinic coordinator that gets the referrals, gets the phone calls, triages the patients, and gets all that information ahead of time and sets the appointments. We have a pediatric neurosurgeon that would be me, a pediatric maxillofacial surgeon that's my friend Mark. And then we have a pediatric ENT group, ENT facial surgeon, a speech and a feeding specialist. We have audiology that's available, genetic testing that's available. And in my group, we have the orthotic specialists that get the helmets prepared for either positional plagiocephaly or the craniosynostosis cases that we do with the endoscopic minimally invasive procedures. They get the helmets ready for after surgery. So this is our dream team. So Mark Miller, who's also one of my really good friends, and me are the surgeons. Jim and Darren are the orthotic specialists. So they are the ones that are seeing the positional plagiocephaly kiddos with our mid-level providers. So for craniosynostosis cases, what I wanted to show you, so the definition of a craniosynostosis means that there's a premature fusion of one or multiple sutures. 20% are caused by a specific single gene mutation or a chromosomal abnormality. And then you have single suture craniosynostosis versus multiple suture craniosynostosis. The multiple ones are the syndromic ones, and you kind of see them at birth. They have weird face, facial features. But the single ones, this is the percentage of frequency. The sagittal one is the most prevalent one, followed by metopic, right coronal, left coronal, bicoronal, even if you have two coronal sutures that are involved, sometimes it's still not a syndromic case. And then lamdoid. If you look at the lamdoid one, so this is the least common craniosynostosis. And for the positional plagiocephaly frenzy, the positional plagiocephaly means that it's because of the head's positioning during sleep. You have a flatness in the head. And all the pediatricians are sending those kids to us thinking that it's a lamdoid craniosynostosis. For all the kids that we see with that flatness on the head, the incidence of lamdoid craniosynostosis is extremely low. So those are not, it doesn't happen often. But we do see those kids with the flatness on their heads really a lot. Most genetic cases are autoosomal dominant. 50% are new mutations. So it doesn't mean that the family will have another kid with that condition. Genetic cases, multiple sutures, in genetic cases, multiple sutures are involved. The genes that are involved are FGFR2, 3, TWIS1, and EFNB1. Some clinically non-syndromic cases are usually the coronal sutures are caused by single gene mutation. Those are the genes involved. So when we have cases that are syndromic ones, our goal is to protect the airway. Because they have such a small midface, they are not breathing appropriately. So when we have those kids, that we see them in clinic or in the ER, we really pay attention to airway, feeding, eye protection. Because their eyes are protruding and their orbits are so shallow. So when they're crying, they can pop their eyeballs out of their, which is very scary. And then we treat the increased ICP problems. So I wanted to show you a normal head. I do have a pointer, right? Use your mouse. Oh, okay. So this is a normal baby head. Sagittal suture is the longest suture that you have on someone's head. Lambdoid sutures are here. This is the fontanelle. Metopic suture is in the front. So this is like the diagram that we have. This is the anterior fontanelle. Metopic suture is here. Coronal sutures are here. Sagittal suture. Lambdoid sutures. So when we say that the sagittal suture is the longest suture on someone's head, when that one is closed, there's 15% of increased intracranial pressure that can happen. And it makes sense. It's the longest suture that you have on your head. Now when you think about head growth, it happens perpendicular to the suture line. So in this, if you look at the sagittal suture, your head will grow in this direction. If you just look at this suture. If you look at the coronal suture, coronal suture, when bone is deposited in that suture line, the head will grow in this direction. Metopic is in this direction, and so on and so on. So when the sagittal is closed, your head cannot grow in this direction, but all your other sutures are overcompensating. So your head becomes long and shallow, like a football. Metopic suture, if this cannot grow, your head is pointy. Coronal suture, most of the times it will be one or the other. It's rare that you have both. But the way that I remembered when I was a resident, the way that I remembered what happens with a, when a suture is closed, the suture will always attract things towards it. So let's say this, my coronal suture here is closed. My nose, the bridge of my nose will go towards my suture. My eye will go towards my suture because the suture is closed and it's attracting everything towards it. My ear will go towards it. So when you think about this, it makes sense. You don't have to remember everything. Just think about it. The suture is closed. It's not growing in this direction, and it's attracting everything towards it. Your eye goes up. Your ear goes up. Your, the bridge of the nose goes up. I think it's just common sense. Okay, head circumference curves. So this is a normal head circumference curve, and think about it. This initially is exponential growth, and at some point it plateaus. Same thing here. So what I want you to, I don't want you to memorize this, but just think about this. Head growth, skull grows a lot, face doesn't grow a lot. So 85% of skull growth happens within the first year. So if you do see a baby and you think, hmm, something's wrong, send them to a neurosurgeon early on. Because if you wait and you wait and you wait, it might be too late. I see kids that people have been thinking, oh, something's off with their head, but let's wait. And then they send it to me when they're 10 months old, wishing for an endoscopic craniosynostosis release. Well, I can't do much because if you look at the head shape or the head growth at 10, I can't bank on a lot of head growth to change the head shape. The way we do it with endoscopic craniosynostosis release, we open up the suture here. Let's say it's a sagittal one. We open up this suture and then we put them in a helmet, hoping that the head growth will change the head shape over time by squishing them in a helmet. If you are here, you have all of this head growth to change the head shape. If you're here, not so much. So the sooner they send them to us, the better the results are. So the one thing that I always remembered is when a baby's born full term, a girl on the 50th percentile at birth is 34 centimeters, a boy is 36 centimeters. And then a normal head growth is two centimeters for the first three months, one centimeter for the additional three months, and then it's 0.5 and then 0.3 centimeters. But it makes sense. When you look at the curve, initially it grows a lot and then it tapers off. Head shapes. So when you have a long and narrow head shape, it's called scaphocephaly. When you have a triangular head shape, it's called trigonocephaly because it looks like a triangular shape. If you have a flat head, it's called brachycephaly. And when you have like a flat, weird shape, skewed head shape, it's called plagiocephaly because it's flat on one side. Sorry. Okay. I don't want you to remember this. I just want you to see it once and kind of remember possibly that there are different syndromes. The most frequent ones that we talk about a lot is Apert syndrome, Crouzon syndrome and Pfeiffer syndrome. So Apert syndrome, they have big, bubbly eyes, but they have finger anomalies. Sometimes when a kid is born with Apert syndrome, Crouzon syndrome and Pfeiffer syndrome, it's hard to tell the difference between the three of them initially, so you have to send them to a genetic specialist. But Apert syndrome has syndactyly. They have fingers that are webbed together. So if a child is born with this, with finger anomalies, we know that it's not a Crouzon syndrome. Other than this, those have multiple craniosynostosis problems, so they might have ICP issues and their head won't grow a lot. So what we do initially, we see them, I send them to ophthalmology to see if they have papilledema and my orthotic specialist, they have a specific scanner that outlines the head shape and then we measure the head shape over time, over the next three, four, five months to see if the head stops growing. And then we correlate this with papilledema exams, and if we see that the head plateaus and papilledema is worse, then we know that we have to intervene. This is another table that shows you, so Apert syndrome, this is the prevalence of it, Crouzon, Pfeiffer is rarer, Monkey syndrome is bicoronal craniosynostosis that's syndromic, and I'll show you pictures of it. So Apert has limb anomaly, Crouzon doesn't, and then you have the gene mutations here. Pfeiffer syndrome, so Pfeiffer syndrome is tricky, Pfeiffer 1 has normal intellect and they can look pretty much like a Crouzon, Pfeiffer 2 and 3, they really don't do well. This is a Pfeiffer, a severe Pfeiffer, it looks like a cloverleaf because of the severity of the craniosynostosis. This is a Pfeiffer that's not as severe, type 1 is not as severe, does not have mental problems. This is the most severe ones, and when we said that the eyes can protrude and kind of pop out of the socket, this is what happens here. This is a Pfeiffer, they also have broad thumbs and toes and finger anomalies. This is a case of a Pfeiffer kiddo, so she was a year old and all her sutures were closed, so this is the same kiddo that we took to the OR to kind of do a cranial re-expansion. This is the sagittal suture that's closed, this is the front of her head, the back of her head, and what we did is we opened up the sagittal suture, we did barrel stays here, and then we created this opening to make sure that this gap here would not close. And this was the initial opening, this is the kiddo now, this is her now, her eyes, this is her now. She's super sweet. This was her before surgery, this is her now, and these are the scans that the orthotics people can do for us, so we see how their head shape changes over time. Another little diagram to show you the differences between the syndromes, so APERT is the one that we see often. These are not so often. Monkey syndrome is something that I've seen a lot when I was in New England. I don't know what was in the water that they were drinking, but they had a lot of monkey syndrome, which is bicaronal craniosynostosis, and I'll show you the head shapes. This is another one of those diagrams. It's when we study for boards, we don't find those diagrams, and when I was working for this presentation, I found 65 of them. Whatever. Okay. Crouzon syndrome. See how they look similar, the cruzon looks similar to the Pfeiffer, and if you don't know it, then the only way to figure it out is to do genetic testing, because it's not the same chromosome anomaly. So this was a cruzon kiddo. What we did initially, we did a bicoronal. So what happens sometimes with cruzon is their sutures do not close at the same time. Initially, sometimes one of those kids will have a sad show craniosynostosis close, and then over time, other sutures will close. So what we do is we follow them, we follow their head growth, their head shape, papilledema exams, and sometimes we do 3D head CTs, and we have a low radiation protocol that is not more radiation than an x-ray, so the families don't freak out that we're radiating them with x-rays or CTs. And so this kiddo had bicoronal craniosynostosis initially that we opened up with a minimally invasive endoscopic procedure, and we were following her for a couple of months. We know that cruzon down the road, before 18 months of age, might need an orbital advancement because everything closes, their midface is small, and their orbits are so shallow that before they have those googly eyes, we have to advance everything, the frontal bones and the orbits to kind of give them more space. So the bicoronal procedures happened. It was fine. We followed her for a year, and at some point, we needed to give her more room because she had papilledema and her head stopped growing, so that was the orbital advancement procedure. And we do the wavy incision just because with the hair falling, we just don't want to have like a straight line. It's more like an aesthetic incision. And so this is the initial line, craniotomy, craniotomy, and then this here, the osteotomies that we created. And this is how much we advanced it. I don't know if you see, but it's significant. We were able to advance her forehead. This is what it looks like. I mean, you still see that she has a syndrome, but at least she has more room for her orbits. That was her right after surgery. Apert syndrome, the fingers, I mean, she could look like a Crouzon, like the kid before, but this is what really gives you the diagnosis because Crouzons don't have the finger issues. So this is another apert kid. This is one of our apert kiddos. She had the endoscopic done on one side. This one was still open, but she still has asymmetry. So we were able to put her in a helmet, and we're delaying the orbital advancement because she's still open. So this is the 3D head CT that we do, and she doesn't have papilledema, but we did open up her lamdoid sutures here with the minimally invasive endoscopic procedure. So this is what the orthotics guys do for us. The red one is the initial head shape when she first came to us, and over time, her head is growing, but now it's kind of plateauing. So we know that soon enough we'll have to do the orbital advancement because her head is not growing as much. But this is over time. Her head shape has changed some, which is good, and she still doesn't have papilledema. So the types of craniosynostosis, simple, complex, primary. The other thing that I want you to remember is that sometimes you have premature closure of sutures because of thyroid issues, rickets, and some other issues that the patients have. It's not always a genetic condition, and it's not always because of some ICP issues. And then we've discussed the syndromic ones. This is another weird, very rare syndrome. I haven't seen that one in my life yet. Monkey syndrome. So this is very, I mean, I used to call it the SpongeBob because they looked like a toaster head. So this is one that we had recently. You see that the head is very, very narrow, and this is what it looks like. Before and after. It's still going to grow like this. At some point, we'll have to expand the head posteriorly with a bigger surgery. This is typical of a monkey syndrome. So bicoronal craniosynostosis is what it looks like on the skull. Bicoronal. See how the eye goes up towards where the suture is fused? That's what I was telling you. Just think about that suture being fused. It kind of attracts the eye up there. And this is a view from above. This is the affected side. It's flat. And the nose is kind of pulled towards the suture. Sorry. Wrong one. Okay. Bicoronal. Unicoronal. Bicoronal. Flatness. And this is the affected side. See how it's flat and how the nose is kind of – and then the ear goes – the ear is here. The other ear is kind of coming upwards. Nonsyndromic cases. Once again, the incidence – sagittal is the most common one, followed by metopic, coronal, coronal, bicoronal, and lambdoid. I wanted to show you the – so metopic is the second most common one. These are the cases that we've done recently. And there's a higher incidence of metopic craniosynostosis in the African-American community. So this is a metopic craniosynostosis. It's not super severe, but you see that ridge, that triangular forehead here? That triangular shape right there. So this is – the kid is asleep. This is her forehead. We marked what we want to do under the skin, how wide of a bone removal we want to create. And this is the small incision, so it's – I'm a metric kind of – you know, I'm a metric system girl, but it's less than an inch, so it's one – it's like two and a half centimeters. And so we create two little burr holes here, and then we just remove the bone from the incision all the way down to the bridge of the nose. And this is what it looks like at the end. So there's no more bone here. This is what we've created. This is how we remove it, and this is the end of the surgery. I mean, you kind of see already it's rounder, it's not as pointy. And this is another kid that came in with the same condition. We did the same here. This is no more bones. We removed all this. This is at the end of the procedure, and he came back two weeks later, and there's no more triangular forehead, like weirdness on his forehead. And I saw him two weeks ago, and he looks really good. This is sagittal, so you see there's – you can't see the suture line right here. You see how the head is really long and not round, because you can't grow the head in this direction. Head is long. So this is the kiddo we did. You can't see the incisions, but this is the endoscopic procedure. In the good old days, 20 years ago, you had to do an incision from one ear to the other. Now we just do tiny little incisions. And this is him. He came back to clinic three weeks later, and he has a small incision here and a small incision in the front of his head. This is another kiddo that we did, and this is his three-year post-op. You can't even say that he had any surgeries. I mean, his head is round. He doesn't look like he had a football head. Mom is happy. Everyone's happy. So lamdoid. This is what it looks like when you have a lamdoid craniosynostosis here. So this lamdoid is closed. This is the weird head shape. The head looks like it's caught in the wind. It's a little weird. So this is lamdoid. This is positional plagiocephaly. The way I describe positional plagiocephaly to parents, I tell them initially the kid's skull is really soft, and you can mold it by just think about pushing Play-Doh. You play with Play-Doh. You put a ball of Play-Doh on a hard surface, and if you push on it, you'll mold it to the surface that you're pushing it on. That's exactly what happens with heads. So if kids always sleep on one side, they will have a weird head shape. And the problem that happens with kiddos when they're born, 80% of kiddos with positional plagiocephaly have torticollis. That is not recognized by the pediatrician. So if you're born like this, you will sleep like this. And even if your parents are trying to put you on the other side, your head is always like this. And if it's not recognized initially, you can't fix it. So that's why we have that clinic with my mid-level provider where we have physical therapy that helps parents show parents how to stretch neck muscles and fixes the neck problem and then attacks the positional plagiocephaly. And in the literature, what it says is that if you counter position effectively early on, you really don't need a helmet. Helmets are expensive. And it's not fun to have a helmet 23 hours a day on your head. But sometimes when you don't do the right steps initially and the head is so flat, you kind of need a helmet. Because I don't know how you will be counter positioning a baby that's four months old and turns on their own. You won't be sleeping. It's just not a fun thing to do. OK. So this is an article that was published last year by a Canadian group. And so what this article says compared to all the others that were published is so all the others said that, oh, the incidence of positional plagiocephaly ranges from 3.1% to 61%. It's so rare. It's so vague. And the range is so great. But what they did in this article is that they looked at four community-based data collection groups. And they looked at kids from 7 to 12 weeks of age. And they were able to tell that the incidence of positional plagiocephaly is 46%. So if you do have kids, at some point, your kids, there's a chance that there's a 46% chance that your kids had positional plagiocephaly. My kids had a flatness on their heads. And every week I was taking pictures from above. I'm like, if my kid has a positional plagiocephaly, that would be so bad. It's just so common. It's so common. It's just look for it and know how to fix it. You just have to put the head on one side one night and on the other side. And when the kids are really tiny, you swaddle them, and it's easy. When they're 5, 6, 7 months old, good luck. It's too late. And so the recommendation to put a helmet on a baby's head is when you have moderate to severe plagiocephaly, what does that mean? So I asked my guys, what does moderate to severe mean? First of all, these are their head shape. You can still have, you know, plagiocephaly, brachycephaly, scaphocephaly due to positioning. Scaphocephaly happens in the NICU. When you have NICU babies that don't do much, they are positioned on one side, they're positioned on the other side. And because their head is so soft, it becomes a scaphocephalic head. Not because they have sagittal craniosynostosis, just because they're positioned on one side for whatever their medical needs are. And they have a funky head shape when they come out of there. So they might need a helmet because it's hard to fix that even if you are the queen and the king of counter-positioning at home. And so, and then positional plagiocephaly, the one that I see often or my mid-level provider sees often in the community is more this. Because the kid has some torticollis and is always sitting in a car seat instead of being, you know, what I tell families is do more tummy time and put them in the exosaucer or the bouncy seat so they don't have anything to rest their head on. So a normal cranial index is 78%. And please don't remember this. I just wanted to inform you so you understand how they do their measurements. So this is a normal head shape, it's 78%. If you have someone with brachycephaly, a flatness on their heads, the measurement will be 90%. If you have someone with scaphocephaly, it will be 70%. So that's how they do their measurements. And then they will send me a report saying, ooh, the kid has scaphocephaly, it's 70%. I don't do much with this because it's their specialty, they treat those. But that's how they make their measurements. Because everyone's head, when it's a normal head shape, should be around this when you have a proportional head shape. So that's pretty much it. And so how does helmets work in this way? You have a helmet 23 hours a day. And what they do, so Jim and Darren, they look at your head shape and then they create areas of pressure so that that pressure is applied 23 hours a day. And then you have some voids in your helmets where your head needs to kind of fill in and remold into a better head shape. And that's what happens over time. That's why you need to do it early on when your head is really soft, your skull is soft and easy to remold. And the younger you get those kids in the program, the shorter the treatment plan is. If you get them at 18 months, it's pretty much too late. I tell the family that's pretty much their head shape and there's nothing to do about it. It's just, I hope they have a lot of hair when they grow up. So that's pretty much it. And then duration of treatment depending on when they get in. So this is an example of positional plagiocephaly. This is how flat the head was. And at the end of the treatment, it was pretty much, you know, a nice head shape. This is a brachycephaly and this is what it was at the end of the treatment. So the importance of a multidisciplinary team for any of those conditions is, these are the people involved in my team. We meet once a month, but we text each other all the time when we have patients that we're seeing that we feel need to be seen earlier. So this is our little algorithm. And then recently, my friend Mark was at the craniofacial convention this week. And so he sent me this poster that we'll be advertising at our institution. It's pretty cool. So you have all the single suture craniosynostosis cases, the syndromic cases, and all the people involved in our multidisciplinary team. That's it. Any questions? Yes. So my daughter has a positional plagiocephaly. Yes. So she'll go back to sleep? Yes. And she'll stay in the closet? Yes. And when we have craniofacial patients in the hospital, do they have to stay in the closet? Yes, so I will tell you, depending on, I always give them the option to see Darren, and Darren will make the measurements, and it's always, I will tell you, and I don't care if you're the president of whatever, I will tell you the same thing, it depends on your level of stress. Like, if you are so anxious that you can't sleep at night. get a helmet. I mean, I have a flat head, you know. I'm not, I'm still talking to my mom. I do love her very much, you know. It's, I do think that there are, there's one condition that I kind of tell the families, listen, I'm going to send you to Darren and I really want you to consider it. It's when you have twins, because twins are, it's just hard. You don't sleep at night. You don't sleep at night, first of all, because you have twins, but then if you have to counter position them, good luck. But, you know, if you see them early on and they're two, three months old, I hope the pediatricians do their job by giving them the tips that, you know, the tricks that I give them myself. I give them mommy recipes, but I hope that people do that in the community. If it's brachycephaly and it's really bad, I, you know, I send them to Darren and he does the measurements. If it's not 78 percent, but it's like 95, you look at it and you're like, ah, well, you know, maybe. In our institution, they have a good program where even Medicaid people have a good price. So, we're trying, you know, we're trying to accommodate families so it's easy for them to do it. I never tell families, ooh, your kid won't be as smart, because it's not true. It's really an aesthetic thing. The only thing that is really a medical condition is when you have a true craniosynostosis. When you have 15 percent chances of having high ICP, I don't know which one will have the 15 percent, but when you have that 15 percent, you have 100 percent of ICP problems. I can't tell you which one it will be, you know what I mean? Yeah. Yeah. It is, because everyone wants to be perfect. Sorry, what was the first thing that you said, if they have... No, no, no, no, no, no, because I don't have no filter, so I'm thinking my resins tell me it's count to ten. Just don't say it. Let me count to ten, no, no, no, let me just rephrase this, sleep apnea, yeah, no, most of the times it's because people are fat, sometimes they have sleep apnea, no, no, no, you know, so, I have to watch, okay, positional plagiocephaly really happens, there's studies, those studies are good studies, 80% of kiddos with positional plagiocephaly have torticollis. Yes, this needs to be fixed, once it's fixed, I don't know any studies that link torticollis to sleep apnea, so, you know, that's pretty much it, I, but you know what, helmets, it's an industry that is very lucrative, so I bet you, and you can make studies say whatever you want, you know, you just change the permutation of what you're looking for and you can make them say that elephants are whatever, you know what I mean, I would just be very cautious, because I, and I work with orthotic specialists, I just don't, I would not put a helmet on every kid, because I don't think you need it. If you are a proactive person, and I sense it in families that I see, I'm like, hey, you know, every time you change a diaper, stretch the neck muscles, and go and come back and see, you know, my mid-level in like a month. If it's better, don't worry about it, I mean, it's at some point, I mean, a hundred years ago, we didn't have those things, and people lived, and they were fine, you know, there were some smart people like Einstein, and, common sense, sorry, I got a little, eh. Any other questions? That was a fantastic lecture. Thank you. Okay, so we have a beverage break, if you guys want to take a quick break.

craniofacial anomalies

craniosynostosis

positional plagiocephaly

pediatric maxillofacial surgeons

pediatric ENTs

speech and feeding specialists

genetic testing