This surgery has been taught for decades using Styrofoam cups. 3-D technology is changing that

One of the world’s most common surgeries in children has been taught for decades using a Styrofoam cup.

Cleft lip and palate repair is a delicate procedure, and the outcome is sometimes hard to predict. One wrong move inside the tiny mouth of a 1-year-old could mean a child with speech defects, problems eating, or lifelong problems breathing. Training for the surgery takes years of practice — surgeons are still improving 10 years after they graduate, said Dr. Christopher Forrest, chair of plastic surgery and reconstructive surgery at the University of Toronto.

“It’s where I get the biggest level of coronary spasm,” said Forrest, of watching apprentice surgeons take the lead. “It requires measurement in millimeters, familiarity with the nuances of anatomy, and the tissues are particularly fragile.”

For years, no other model existed. But in Toronto, a plastic surgery resident at SickKids Hospital has fused his engineering and medical skills to build 3-D printed models that resemble children’s mouths. They’ve been a welcome innovation.

“It makes absolute sense,” said Forrest, to invest in a surgical model that allows trainees to practice the repair in a low-stakes environment. “The cost of something going wrong on a patient is undoable.”

During a training session a few weeks ago at SickKids, Dr. Natalia Ziolkowski, a plastic surgery resident at the University of Toronto, focused hard as she moved a scalpel inside the tiny model mouth. Basic sutures are challenging in such a small space, she said, and the model allows her to focus not only on what she’s doing in a given moment, but plan her next steps and guide herself away from “danger zones” containing critical arteries.

After more than a dozen mock surgeries, she feels more confident in performing the surgery on a patient.

“I know the sequence, I know the danger zones,” she said, referring to tiny nerves and arteries she has to avoid to prevent complications. “YouTube gives you a sense of how things may look, and a book can give you the steps, but its a completely different experience to be working with your tools in the 3-D space.”

Dr. Dale Podolsky invented the model. Reducing trainee stress was part of his motivation, along with improving patient outcomes. Since he started the project in 2014, he has worked with a biomedical incubator in Toronto to spin off a company called Simulare Medical.

“Commercialization is essential — it allows you to conduct research and build the infrastructure to manufacture [the model],” he said.

One of the first buyers was New York-headquartered Smile Train, an international children’s charity dedicated to teaching surgeons around the world how to repair cleft palates.

Poldosky’s model will be deployed to “Africa and Latin America to accelerate learning and elevate the level of cleft care worldwide,” said Erin Stieber, vice president of strategic partnerships at Smile Train.  The simulator, she said, is a game-changer that will be integrated into the current education model of virtual, classroom, and operating room training. “This could be massive.”

Currently, a model costs about $500, and includes training tools, a video camera, and instructional materials. Video recording capability, said Podolsky, is particularly valuable as performance can be assessed remotely. “I could be halfway around the world and give feedback to a training surgeon.” Charities, hospitals, and universities in more than 10 countries have purchased the model, but Podolsky wouldn’t release sales figures.

Another global charity that provides free cleft surgeries has raised a concern. Dr. Ruben Ayala, senior vice president of medical affairs for Operation Smile, said the barrier of cost needs to be addressed to “democratize” education, bringing better training to places where the surgery could be “life-changing for enormous amounts of people.” The global need is great: “There is a plethora of patients who need [cleft palate] care,” he said.

Ayala said Podolsky’s model has great potential to influence training but it “needs to be manufactured at higher quantities and much lower costs.” Until then, surgeons will continue to be trained as they have for centuries, via textbook and practice.