Expanding Cleft and Craniofacial Education through Virtual Simulation

Brianne Barnett Roby, MD, and Alexander P. Marston, MD, on behalf of the Otolaryngology Cleft and Craniofacial Committee

In October 2022, the Otolaryngology Cleft and Craniofacial Committee was established, highlighting the unique collaboration between pediatric otolaryngologists and facial plastic and reconstructive surgeons specializing in cleft and craniofacial care. The initial goals of the committee included creating a platform for Academy member surgeons to discuss complex cases and focus on issues related to their specific surgical needs. Further, the committee aims to educate all Academy members about the unique needs of patients with cleft and craniofacial differences that can, and are, managed by otolaryngologists in general.

The committee has undertaken this important task to educate all Academy members on standardizing care for children and adults with cleft and craniofacial differences. Education offerings thus far have included not only podcasts, webinars, panels, and videos but also a unique simulation education program for residents and fellows who may not have exposure to these types of surgical procedures.

Launch of Cleft and Craniofacial Bootcamp

In fall 2018, the first cleft and craniofacial bootcamp was held just ahead of the AAO-HNSF Annual Meeting in Atlanta, providing residents and fellows with simulation training for cleft and craniofacial surgeries. This event was the first large-scale simulation bootcamp of its kind in otolaryngology. Plans to continue the bootcamp in 2020 were disrupted by COVID-19, but as the Otolaryngology Cleft and Craniofacial Committee was then forming, they hatched the idea to continue the bootcamp virtually. In 2021, the first virtual bootcamp for pediatric otolaryngology fellows was launched, covering essential procedures such as cleft lip repair, cleft palate repair, laryngotracheal reconstruction, and microtia framework carving. Surveys of the participants indicated that the training provided was highly successful.

Expanded Virtual Simulation Training

The simulation program has continued and even expanded since! The event, now held on Zoom, has grown to include pediatric otolaryngology and facial plastic and reconstructive surgery fellows and faculty in the US and worldwide. Initially, the simulation included four stations with individual exercises with microtia, cleft lip and palate, and laryngotracheal reconstruction. Beginning in August 2024, a rhinoplasty graft carving station was added for the fellows from facial plastic and reconstructive surgery.

Delivering effective, simultaneous virtual training for participants and faculty located around the world requires collaborative planning and synchronized execution. Before the simulation event, high-fidelity cleft lip and cleft palate 3D simulator models fabricated with silicone and polylactic acid,¹ as well as 3D costal cartilage silicone material (makemedical™) are mailed to the participants. Additionally, a document is emailed to each fellow with surgical technique instructions and pre- and post-simulation surveys. Each fellow is responsible for borrowing the necessary surgical instruments from their sponsoring medical center. A basic cutting board is recommended when carving the silicone materials to create the microtia construct and rhinoplasty grafts.

Real-Time Virtual Training and Feedback

Each simulation session begins with a brief welcome from course directors before participants join breakout rooms, where at least two expert faculty from pediatric otolaryngology and facial plastic and reconstructive surgery guide fellows through the exercises, offering real-time technique instruction. With each fellow’s computer camera directed at their cleft lip/cleft palate module or graft carving surface, time is allowed to complete the simulation with periodic tips and guidance offered by the faculty members.

The sessions are executed according to a series of advancing objectives. The cleft lip simulation module handbook instructions suggest a rotation-advancement Millard-type repair technique, while the cleft palate simulation suggests a Furlow palatoplasty technique. The microtia simulation directs each fellow to practice carving the base framework, helical rim, antihelix, incisura, and tragus. Sutures are then used to assemble the microtia construct. Participants are in each virtual “room” for 45 minutes. After the simulation, the fellows complete the post-survey to assess the knowledge they acquired and to further improve the curriculum and training.

Cleft lip and palate repair, microtia reconstruction, and rhinoplasty all require a high level of expertise and experience to achieve a desirable post-operative result. As a result, this virtual simulation offers the participants unique and important opportunities to practice and conceptualize complex, multistep cleft repairs and graft carving with the virtual guidance of experts in the field. In 2024, participants included 37 pediatric fellows, 11 facial plastic and reconstructive surgery fellows, and 12 international fellows along with 16 faculty members.

A Platform for Learning and Skill Development

The committee is committed to providing a safe space to learn and practice procedures that may be less accessible in many training programs. Looking ahead, the committee believes simulation will continue to advance education for complex cleft and craniofacial procedures. For the broader Academy membership, webinars and podcasts on topics like managing nasal obstruction, eustachian tube dysfunction, and obstructive sleep apnea in cleft and craniofacial patients should help general otolaryngologists to build confidence in managing these common issues within a complex patient population. The Otolaryngology Cleft and Craniofacial Committee remains passionately dedicated to sharing valuable resources and knowledge with all otolaryngology-head and neck surgeons worldwide.

Reference

1. Reighard CL, Green K, Rooney DM, Zopf DA. Development of a Novel, Low-Cost, High-fidelity Cleft Lip Repair Surgical Simulator Using Computer-Aided Design and 3-Dimensional Printing. JAMA Facial Plast Surg. 2019;21:77-79.