By ACOMS Review Editor
In this article, we explore the world of cleft lip and palate care through the eyes of Austin Gaal, DDS, FACS. Learn about his experiences, from initial exposure to the field to current leadership role on a cleft care team, and hear his insights on advancements in cleft surgery and commitment to providing comprehensive care to communities worldwide.
How did you first get involved caring for kids and adults with cleft lip and palate differences? Is this a residency focus for most OMS programs?
Dr. Austin Gaal (AG): My initial exposure came during my dental school residency at Columbia University in New York. Rotations typically happen midway through the program, and I spent time with the children's department. This experience introduced me to cleft lip and palate procedures and care.
OMS is a very broad specialty. Residents get exposure to various areas like TMJ, cancer, and pathology. While most residents gain basic competencies, there's not a strong focus on primary lip repairs across the board. My deeper interest came about midway through my residency when I had good exposure to craniofacial surgeries under Dr. Mark Egbert. Later, my fellowship under Dr. Kevin Smith and Dr. Paul Tawana was entirely focused on cleft lip and palate. This fellowship perfectly aligned with my desire to see patients throughout their growth journey. Dr. Smith performed many cleft surgeries each week, and I assisted him, witnessing the outcomes firsthand.
After my fellowship, I returned to Seattle and started contributing to a cleft practice here.
Can you describe your involvement with the American Cleft Palate Craniofacial Association (ACPA)?
AG: After moving to Seattle, I realized I could contribute my background in cleft care more in eastern Washington. I joined an ACPA-approved team originally led by a pediatrician and social worker who have since retired, so I took on a leadership role. We have a well-staffed team for cleft lip and palate care, including orthodontists, speech therapists, pediatric dentists, and pediatric behavioral psychologists.
The team meets every other month. We have about 150 active kids on the team with cleft lip and/ or palate, whose ages range from 2-18 years old. Evaluations are performed in a multidisciplinary manner, with perspectives from a plastic surgeon, ENT, orthodontists, speech therapist, oral and maxillofacial surgeon, and genetics, to name a few, who all evaluate them. After individual examinations, we discuss each case as a team, creating a treatment plan and recommendations. We focus on their speech, hearing, dental development, and overall functionality. This collaboration ensures all aspects of cleft care are addressed.
Additionally, I’m a clinical professor at the University of Washington and have a busy cleft, orthognathic, and trauma practice.
Can you describe the goals of your cleft surgical outreach trips?
AG: These trips aim to provide comprehensive cleft surgery and care to communities globally. Initially, I participated with Free to Smile, conducting week-long surgical missions in places like Guatemala. Now, I participate in 2-3 trips annually with various organizations, focusing on tertiary care. The care provided includes cleft palate repair, revisions, speech therapy, and bone grafting for older children. The ultimate goal is to provide long-term, comprehensive care that improves their quality of life.
What advancements or changes are you excited for in cleft care? Are there any current innovations you're using that surprise you?
AG: Virtual surgical planning is a growing area, especially for orthognathic in cleft cases. Existing 3D technology is used for planning and research, but there's potential to take it further. For instance, 3D printing a patient's palate for training purposes has been described, though not yet implemented widely. This could improve surgical outcomes and training methods.
Traditionally, nasal endoscopy has been used to assess speech issues in cleft patients. However, MRI scans offer a radiation-free alternative with potentially valuable insights. Exploring the possibility of using MRIs instead of nasal endoscopy for diagnosis is another new area of interest.
How would you advise someone interested in cleft surgery?
AG: For aspiring cleft surgeons, I recommend:
Exploring your interest by shadowing ANY surgeons involved in cleft care, no matter if they are ENT, Plastics, or OMS trained. You have no idea what you will learn.
Building a strong foundation through an OMS residency and potentially pursuing a fellowship specifically focused on cleft surgery.
Remembering that building a cleft surgery practice within OMS requires dedication.