Pediatric & Adult Congenital Defect Surgery in Beverly Hills | Dr. Daniel Golshani

Congenital defect surgery occupies a unique position within the reconstructive surgery discipline, and understanding what makes it distinct helps explain why it requires a specific depth of training and a specific approach to surgical planning.

Most reconstructive surgery addresses a structure that was once normal and has been altered by disease, trauma, or prior surgery. The surgeon knows what the correct anatomy looks like because the patient had it before. The goal is restoration toward a known baseline.

Congenital defect surgery operates from a different starting point. The structure being corrected never developed correctly in the first place. There is no prior normal anatomy to restore toward. The surgeon must understand not only what the correct anatomy looks like in the abstract but how to create it from tissue that has developed in an abnormal configuration, in a patient whose anatomy continues to grow and change, within a healing biology that differs between a six-month-old infant and a forty-year-old adult.

In children, the line between cosmetic and reconstructive surgery is often blurred, as many congenital deformities impair physical function as well as aesthetics. A cleft palate is not simply a structural difference in the roof of the mouth. It is a functional impairment of the mechanism that separates the oral and nasal cavities during swallowing and speech, producing feeding difficulties in infancy and speech development challenges in early childhood. A congenital eyelid ptosis is not simply a drooping upper lid. It is a risk of amblyopia, the suppression of visual development in the affected eye, that requires surgical correction within the developmental window when normal vision can still be established. An untreated craniosynostosis is not simply an abnormal head shape. It is a progressive increase in intracranial pressure that can produce neurological consequences if not addressed within the appropriate timeframe. Wikipedia

This is why timing, in congenital defect surgery, is as important as technique.

The Conditions Dr. Golshani Treats

The full spectrum of congenital conditions that Dr. Golshani addresses spans the face, the head, the ears, the nose, the eyelids, the hand, and the broader body. Each category has its own anatomical complexity, its own developmental timeline, and its own specific functional and aesthetic consequences that the surgical plan must address simultaneously.

Cleft Lip and Cleft Palate

Many pediatric plastic surgery procedures address abnormalities present at birth, such as cleft lip and palate, craniosynostosis, vascular malformations, ear deformities, and hand anomalies. Stanford Medicine

Cleft lip and palate are among the most common congenital conditions requiring plastic surgical intervention, occurring in approximately one in seven hundred live births. The two are anatomically and embryologically distinct, though they frequently occur together.

A cleft lip results from the failure of the medial nasal and maxillary processes to fuse completely during the fourth to seventh week of embryonic development. The resulting gap may be unilateral or bilateral, and its extent ranges from a minor notch in the lip border to a complete separation extending through the lip, the alveolar ridge, and into the nose. The associated nasal deformity, with its displaced nostril and distorted columella, is an integral component of the condition and must be addressed as part of the same surgical plan rather than as a separate concern.

Cleft palate repair addresses the separation in the roof of the mouth. The palate is the anatomical structure that separates the oral cavity from the nasal cavity during swallowing and speech. When it is open, the pressure required for normal speech production cannot be generated. Feeding in infancy requires adaptive techniques and specialized equipment. And the eustachian tube dysfunction associated with palatal clefting produces a high rate of recurrent middle ear infections and fluid accumulation that can impair hearing development.

Primary cleft lip repair is typically performed at three to six months of age. Primary palatal repair follows at nine to eighteen months, planned to support the development of normal speech mechanics before critical language acquisition milestones. Secondary procedures, including rhinoplasty for the cleft nasal deformity, lip revision, and alveolar bone grafting, follow at developmentally appropriate intervals through childhood and adolescence.

Adult patients who received cleft repairs in childhood, particularly those treated in earlier decades when techniques were less refined, frequently present for secondary correction of residual nasal asymmetry, lip irregularities, or scar deformities. These adult cleft revisions require the same anatomical precision as primary repair, operating within the context of prior surgery and its scar tissue consequences.

Craniosynostosis

Craniosynostosis is the premature fusion of one or more of the cranial sutures, the fibrous joints between the skull bones that normally remain open through early childhood to allow the growing brain to expand the skull in all directions. When a suture fuses prematurely, skull growth in the direction perpendicular to that suture is impaired, producing characteristic head shape abnormalities that reflect which suture was affected.

Sagittal synostosis, the most common form, fuses the suture running front to back along the top of the skull, producing a long, narrow head shape called scaphocephaly. Coronal synostosis, which may affect one or both sides, produces a flattened forehead on the affected side and compensatory bulging on the opposite side. Metopic synostosis fuses the frontal suture, producing a triangular forehead and a characteristic ridge from the hairline to the nose. Lambdoid synostosis, the rarest form, fuses the posterior skull suture.

Treatment typically requires surgery to relieve pressure and restore head shape for children with craniosynostosis, a type of birth defect that involves the premature fusion, or closure, of one or more seams on a baby’s skull. UChicago Medicine

The functional urgency of craniosynostosis repair comes from the progressive nature of the condition. As the brain continues to grow within a skull that cannot expand in the direction of the fused suture, intracranial pressure increases. Early surgical intervention, typically before twelve months of age, allows the skull to be reshaped and the suture to be released before the neurological consequences of sustained elevated intracranial pressure develop.

Congenital Ear Deformities

Comprehensive management for pediatric reconstructive needs includes congenital and traumatic craniofacial and hand anomalies, ear anomalies and breast deformities. Nationwide Children’s Hospital

The spectrum of congenital ear deformities is broad, ranging from the relatively common prominent ear, in which the antihelical fold is underdeveloped and the ear protrudes away from the head, to the rare and complex conditions including microtia, in which the ear is partially or completely absent, and anotia, in which no ear structure is present at all.

Prominent ear correction, or otoplasty, can be performed safely once the ear cartilage has reached its adult proportions, typically by age five or six. The same otoplasty techniques used in adult ear correction apply in the pediatric context, with the additional consideration that cartilage in younger patients is more pliable and responds more readily to the suturing techniques used to reshape the antihelical fold.

Microtia reconstruction is among the most technically demanding procedures in the congenital reconstruction discipline. The reconstruction of an absent or severely malformed ear requires either the creation of a cartilage framework from the patient’s own rib cartilage, shaped and implanted in staged procedures over several years, or the use of a prosthetic ear framework. The rib cartilage approach is the gold standard, producing a reconstructed ear that is the patient’s own living tissue, grows naturally with the patient, and produces a result that closely approximates the appearance of a normal ear. The staged nature of the reconstruction, which typically involves four or more procedures over several years, requires long-term surgical planning and a commitment to the process from both the patient and the family.

Lop ear, shell ear, cryptotia, Stahl’s ear, and other lesser deformities of ear shape and position are addressed through the same cartilage-shaping and suturing principles applied in adult otoplasty, adapted to the specific structural deficit of each condition. As covered in the Ear Surgery, Otoplasty and Earlobe Reduction page, Dr. Golshani’s approach to ear surgery applies across both the cosmetic and the congenital reconstructive spectrum.

Congenital Eyelid Anomalies

We treat congenital anomalies affecting the eyes and eyelids, such as eyelid ptosis, which is drooping of the upper eyelid caused by weakness or separation of the muscle that raises the eyelid or a problem with the nerve that sends messages to this muscle. Drooping of the eyelid usually requires corrective surgery to strengthen or tighten the muscles. Mount Sinai

Congenital ptosis, the drooping of the upper eyelid present from birth, is caused by a developmental abnormality of the levator palpebrae superioris muscle, the muscle responsible for raising the upper eyelid. The degree ranges from mild, where the lid margin is only slightly lowered, to severe, where the lid entirely covers the pupil.

The functional urgency of congenital ptosis repair is determined by the degree of visual axis obstruction. When the drooping lid covers enough of the pupil to interfere with visual input during the critical period of visual cortex development, typically the first several years of life, the brain preferentially suppresses the image from the affected eye and devotes cortical resources to the unaffected eye. This produces amblyopia, commonly called lazy eye, a permanent reduction in the visual acuity of the affected eye that cannot be recovered once the developmental window has closed. In cases of significant visual axis obstruction, ptosis repair is not an elective procedure. It is a developmental urgency.

Milder congenital ptosis that does not obstruct the visual axis can be addressed electively, typically at preschool age, to normalize the child’s appearance before the social consequences of the difference become significant.

Epicanthal folds, blepharophimosis syndrome, congenital ectropion and entropion, and dermoid cysts of the orbital rim are additional congenital eyelid and periorbital conditions that may require surgical management, each with its own anatomical approach and its own developmental timing considerations. These connect directly to the reconstructive eyelid expertise discussed on the Eyelid Lift, Blepharoplasty and Eyelid Reconstruction page.

Congenital Hand Anomalies

The hand is the most functionally complex anatomical structure in the body, and congenital differences of the hand represent one of the most technically demanding areas of pediatric reconstructive surgery.

Syndactyly, the failure of the fingers to separate during embryological development, is one of the most common congenital hand conditions, occurring in approximately one in two thousand live births. The fingers may be joined by skin alone, called simple syndactyly, or may share bone and neurovascular structures, called complex syndactyly. Surgical separation, performed typically between six months and eighteen months of age, uses a combination of local flap rearrangement and skin grafting to create individual fingers with stable, durable web spaces between them.

Polydactyly, the presence of extra digits, occurs in both radial, ulnar, and central variants, each with different anatomical characteristics and different surgical approaches. Removal of the extra digit must account for the shared tendons, joints, and neurovascular structures and be planned to leave a hand that is both functionally and aesthetically normal.

Congenital trigger finger, camptodactyly, clinodactyly, constriction band syndrome, and radial longitudinal deficiency are among the range of additional congenital hand conditions that require individualized surgical planning based on the specific anatomy of each patient’s hand.

Vascular Malformations and Birthmarks

Comprehensive management includes hemangiomas and vascular anomalies and pigmented birthmarks. Nationwide Children’s Hospital

Vascular malformations are structural anomalies of the blood vessel architecture that are present from birth and persist throughout life. They are distinct from hemangiomas, which are proliferative vascular tumors that appear after birth, grow rapidly in infancy, and in most cases involute spontaneously over the first decade of life.

Port-wine stains, capillary venous malformations, lymphatic malformations, and arteriovenous malformations each have distinct pathophysiology, clinical behavior, and treatment approach. Surgical excision, laser treatment, sclerotherapy, and embolization are among the modalities used, often in combination and often requiring multiple staged interventions over years.

Large congenital pigmented nevi, giant hairy nevi, and other significant birthmarks may require staged surgical excision or tissue expansion techniques when their size and location make single-stage removal impossible.

Adult Congenital Defects: The Patient Who Was Never Treated

A significant and often underrecognized category of congenital defect surgery addresses adults who carry the consequences of a congenital condition that was never corrected in childhood. The reasons vary: lack of access to specialized care in their country or region of origin, a condition that was not recognized as correctable at the time, a family that chose to defer treatment, or a patient who simply was not ready to pursue surgery until adulthood.

For these patients, the surgical considerations are meaningfully different from pediatric congenital repair. The anatomy has grown and adapted to its abnormal configuration over decades. Compensatory changes have developed in the surrounding structures. The tissue is adult in its healing characteristics. And in some cases, the decision to pursue correction in adulthood carries a psychological dimension, the processing of a lifetime of difference and what that has meant for the person, that is as important to the surgical relationship as the clinical assessment.

Dr. Golshani approaches adult congenital patients with the same combination of anatomical precision and patient-centered sensitivity that he brings to every consultation, understanding that the journey to this consultation is rarely a straightforward one.

Timing, Staging, and the Developmental Context

One of the most important and most frequently asked questions in congenital defect surgery is when to operate. The answer varies by condition, by the functional consequences of the defect, and by the developmental biology of the structure being corrected.

The general principles are consistent. Procedures required to prevent functional consequences, visual development in ptosis, neurological consequences in craniosynostosis, speech development in palatal clefting, are performed within the developmental window when those consequences can still be prevented. Procedures whose urgency is primarily aesthetic are timed to minimize the social and psychological impact of the difference during the child’s most impression-sensitive developmental years. And complex multi-stage reconstructions are staged in a logical sequence that builds each subsequent step on the foundation of what came before.

The relationship between surgeon and family in pediatric congenital reconstruction is therefore necessarily long-term. A child whose cleft lip was repaired at four months may return for nasal correction at adolescence, for orthodontic coordination through childhood, and for final lip refinement in adulthood. The initial repair is the beginning of a surgical relationship, not the end of one.

The Insurance Dimension of Congenital Defect Surgery

Congenital defect surgery is almost universally covered by health insurance as medically necessary reconstructive care. The distinction that insurance law recognizes, between cosmetic surgery performed to improve appearance and reconstructive surgery performed to correct a developmental anomaly or restore function, is clear in this context. Surgery to repair a cleft lip, to correct a craniosynostosis, to address a ptosis that is threatening visual development, or to separate congenitally fused fingers is not elective cosmetic surgery by any definition.

The Women’s Health and Cancer Rights Act of 1998 and the Affordable Care Act both contain specific provisions supporting coverage of reconstructive procedures. Most state insurance mandates include specific coverage requirements for congenital conditions.

Dr. Golshani’s team works directly with families and adult patients to ensure that the correct procedural documentation, letters of medical necessity, and pre-authorization submissions are prepared for every congenital defect procedure, maximizing the coverage available under the patient’s specific plan.

When Congenital Defect Surgery Is Part of a Larger Plan

Congenital defect surgery connects directly to every reconstructive and some cosmetic disciplines in Dr. Golshani’s practice:

• Ear Surgery, Otoplasty and Earlobe Reduction for congenital ear deformities including prominent ears, microtia, lop ear, shell ear, cryptotia, and Stahl’s ear addressed through the same cartilage-shaping and reconstructive techniques used across both congenital and cosmetic ear surgery
• Eyelid Lift, Blepharoplasty and Eyelid Reconstruction for congenital ptosis, epicanthal folds, blepharophimosis, and other periorbital anomalies requiring both functional and aesthetic correction
• Primary Rhinoplasty and Ethnic Rhinoplasty for congenital nasal deformities including cleft nasal deformity, nasal dermoids, and other developmental abnormalities of the nasal framework
• Microsurgery for complex congenital reconstructions requiring microvascular tissue transfer, nerve repair, or replantation at the microsurgical level
• Plastic and Reconstructive Surgery as the broader disciplinary context within which congenital defect surgery sits, reflecting the foundational reconstructive training that makes this work possible
• Revisional and Reconstructive Facial Surgery for adults presenting with the consequences of prior congenital repairs performed elsewhere that require revision or completion

The Standard Applied to Every Congenital Procedure

The goal of congenital defect surgery is the same regardless of the specific condition, the patient’s age, or the complexity of the reconstruction. The patient should leave with an anatomy that allows them to function normally in the world, to be seen by others as themselves rather than as their difference, and to move through life without the structural reminder of something that was never in their control to begin with.

For a child with a repaired cleft lip, that means a lip that smiles naturally, that closes completely, and whose scar is barely visible in a normal social context. For an adult with a congenital ear deformity corrected in adulthood, it means an ear that sits where ears are supposed to sit, that draws no attention, and whose absence from notice is the only notice it needs.

That invisibility of the correction is the standard. It is what Dr. Golshani works toward in every congenital procedure he performs, understanding that the patient who benefits from it is often someone who has waited a long time for the result.