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Faculty Focus

Mitchell Stotland, M.D.: Making faces

like this: "You know, the mommy and daddy bring the baby to me and they just say, 'Help.'"

That was it—there were no consent forms to sign back then. The parents simply trusted Tessier. Several months later, Kawamoto told Stotland that Tessier considered that question the most meaningful one he'd been asked during his visit to UCLA. "It made [Tessier] think back about how there was a time when you trusted yourself or your family to a physician," says Stotland, "and how things have changed."

But countless families have trusted Stotland, and he hasn't let them down. He's documented his cases with before and after photos, which he shows to families contemplating reconstructive surgery for their children. His files include photos taken during surgery, too. As he scrolls through the images on his computer, he provides a running commentary. "This is after we take the skull off," he says. "The eye socket has been taken off and put back on in a new shape."

One set of images is of his first midface advancement procedure. In the before photo, the little girl's eyes bulge, she has a severe underbite, and her face is very flat. Stotland did a procedure called distraction osteogenesis to lengthen her facial bones. The surgery involves cutting the bones and slowly moving the cut ends apart—via tiny screws attached to cables that run under the scalp—so new bone tissue grows in the gap. The screws are turned twice a day.

"It's infinitesimal movement forward, but over the course of a few weeks you actually end up moving the face," he says, the same way orthodontic braces move teeth. "So this is her postop, and you can see a little cable coming out here." The girl looks like a different person. "Her upper jaw now is in front of her lower jaw but you can see her eyes are further in, her nose is actually a little more prominent, and you can see the relationship of the upper and lower jaw. She has a better bite. She probably has a better nasal airway."

Children with severe facial deformities

Grew up: Montreal, Canada
Education: McGill University '85 (B.S. in physiology); McGill Faculty of Medicine '89 (M.D.); Dartmouth Medical School '07 (M.S. in the evaluative clinical sciences)
Training: General surgery resident, experimental surgery fellow, and plastic surgery resident, McGill University; craniofacial surgery fellow, University of California at Los Angeles
First paying job: Counselor at Camp Dunmore, near Middlebury, Vt.
What he's fanatic about: Sports—as is his wife, Sheryl. Their first date was at batting cages in Montreal. "The day after I proposed, in LA," says Mitch Stotland, "we . . . stopped at a batting cage. I have pictures of her with her brand new diamond ring on and high heels [as] she's hitting."
Other favorite activities: Writing, reading, skiing, making granola

Stotland "had a soft spot for
kids who were shunned for
no good reason other than
their appearance."

may be perfectly normal intellectually, but because of the way they look and speak they are often assumed to be, and treated as if they are, developmentally delayed. There are plenty of problems—breathing, eating, talking, hearing, and so on—associated with craniofacial deformities, but learning is rarely one of them.

Social interaction is, however, a problem for such children. Stotland and his Dartmouth colleagues are doing research on the subject. In one study, Stotland administered an implicit association test—designed to reveal subconscious prejudices—to 163 Dartmouth students.He determined that, to them, faces with repaired cleft palates were more aversive than normal faces.

By exposing such hidden perceptions, might we better tailor our reconstruction?" Stotland wonders. "Maybe there are certain things that are perceived more negatively than others, such as a twisted nose or no ear. Or maybe left-sided cleft lips are

considered worse than right, because of left-brain differences or maybe the way the tooth is exposed." His hope is that if surgeons better understand hidden biases, they can tailor their surgery to produce better outcomes for their patients. "Other than saying, 'She looks good,' maybe the measurement won't be what I say, but what people perceive."

In another study, Stotland is testing a hypothesis called facial feedback—the idea that one's expression can regulate emotion. For instance, he says, if "someone stomps in . . . with an angry face, you begin to process it in a subliminal way. You fire some of your anger muscles because there's a feedback . . . that tells your brain, 'Anger's coming in—you need to process how to deal with anger.'"

As part of this study, Stotland is testing what happens to people who have had facial Botox injections, which prevent their face muscles from responding to external emotional cues. Study participants—some who've had Botox and some who have not—are shown pictures of angry faces while they're lying in a functionalMRI scanner (fMRI measures changes in blood oxygen during brain activity). "We're going to look at how their brain is firing," he says, and then compare the pattern of activity in those who've had Botox treatments to those who haven't. His pilot results suggest that those treated with Botox do not process the images the same as non-Botox participants; his hypothesis is that because their facial response is different, their emotions are different.

Stotland hopes his contribution to craniofacial surgery will be in the socialization realm, but he thinks it's also important to celebrate the accomplishments of those who've advanced the field's surgical techniques. In fact, he started a biannual symposium in 1995 to honor DMS's Rad Tanzer; considered the "Father of Ear Surgery," Tanzer died in 2003. "Rad was a big inspiration in terms of his ear work and his work with kids," says Stotland. Last year, Stotland invited someone else who was a big inspiration to him to be the keynote speaker for the Tanzer Symposium—Henry Kawamoto.

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Laura Carter is Dartmouth Medicine magazine's associate editor.

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