Head First into the Future: Exploring innovation in craniofacial surgery with Dr. Christopher R. Forrest

Head First into the Future: Exploring innovation in craniofacial surgery with Dr. Christopher R. Forrest

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Dr. Christopher R. Forrest
M.D., M.Sc., FRCS(C), FACS
Chair of Division of Plastic and Reconstructive Surgery; Medical Director of SickKids Centre for Craniofacial Care and Research
Professor in Department of Surgery, Full member of IMS


By: Yousef Manialawy
Photo provided by Dr. Forrest 


Many an artist has dedicated themselves to the pursuit of capturing the sheer complexity of the human body–from the subtle veins snaking through the hands to the quivering tendons underlying every contraction of muscle–nature has crafted a work that defies simple imitation. Of the body’s many facets, the face undeniably poses one of its greatest challenges. Integral to human identity, its every twitch and twinge guides communication and subconscious perception. To capture its intricacies in a brushstroke is impressive, and even more so in marble and stone; but the stakes are much higher when the face you’re designing is that of a living, breathing person. As a pediatric craniofacial plastic surgeon at SickKids Hospital, Dr. Christopher R. Forrest is challenged with head and facial reconstruction of children on a daily basis. He offers insight into how technological innovation, such as 3D-printing, is pushing the limits of craniofacial surgery.

After receiving his medical degree at UofT, Dr. Forrest pursued a residency in Plastic and Reconstructive Surgery in 1983. Having also developed a strong interest in research, he concurrently investigated the effects of nicotine in microcirculation on post-surgical wound healing with IMS, ultimately receiving both an M.Sc. from IMS and completing his residency in 1990. Following multiple fellowships in both Toronto and the United States, he was recruited to Sunnybrook Hospital in 1993 with a part-time appointment at SickKids. By 1999 he was appointed Medical Director of the SickKids Centre for Craniofacial Care and Research and has been the Chair of the Division of Plastic and Reconstructive Surgery at UofT since 2003.  As of 2009, he manages the largest division of full-time surgeons dedicated to paediatric plastic and reconstructive surgery in North America.

With such a wealth of experience, Dr. Forrest has emerged as a leader at the cutting edge of his field. He has long maintained an interest in pushing the boundaries of surgical technology. “There’s a saying that biology beats surgery every day,” he says. “But as surgeons doing this kind of work, we always want to beat that idea”. In a profession already riddled with complexity, operating on children adds yet another factor to the equation: “The world of pediatric craniofacial surgery is very, very challenging…but it’s also very rewarding,” explains Dr. Forrest. “And to me, the fact is that we’re not just treating the child but we’re treating the family.” Offering some further insight, he explains how he measures the success of his operations. “I have this thing I call the supermarket test” he begins. “If you’re in the supermarket and you see this child run by, would you look twice and think to yourself ‘there’s something wrong with that child’…or would you not pay attention?”

Outside of the operating room, Dr. Forrest and his team are also busy developing new technologies for surgical applications, most notably through the application of 3D-printing. “We use it in creating scale models [of the skull]” he explains. “These are really essential for planning out complex surgeries–the advantage is that we don’t have overlying soft tissue sitting on the bones, so we can see the anatomy”. This has become standard practice for Dr. Forrest, who has used the information garnered from these 3D models to better operate on his young patients, such as in the case of 6-year old Mumtaz who was born with a cleft skull, facial disfigurement, and missing her upper right eyelid. After a CT scan was taken of her head, a model of her skull was 3D-printed and used to develop and implement a successful operation. 3D-printing has even gone a step further for direct application within the surgery. “So, I have a child who for example may be missing bone from an accident” explains Dr. Forrest. “And using CAD-CAM technology [i.e. computer-aided design and manufacturing] we can actually use 3D printing to make implants to fit the patient very specifically”.

Dr. Forrest has also employed 3D-printing for the purpose of training aspiring surgeons. As with most professions, proficiency is gained through hands-on experience, but the room for error is significantly smaller for surgeons in training. “In my world, teaching somebody how to repair a cleft lip or even nasal surgery is technically very demanding” explains Dr. Forrest. “And as a surgeon, allowing somebody to train and learn on a patient is always a little anxiety-provoking.”  To address this, he teamed up with surgery resident and biomedical engineer Dr. Dale Podolsky to develop a life-sized, 3D-printed simulator model of a cleft palate (i.e. when a baby’s lip/mouth does not properly form during pregnancy). This is a major advancement for the field, considering that cleft lip repair is a notoriously difficult and delicate procedure, not least of all because it is typically carried out in young infants.

The simulator consists of a composite silicone plastic frame with a disposable cartridge that slides in. It was designed to simulate a high-fidelity, anatomically accurate representation of the various muscles that require surgical reconstruction during the operation. Notably, the model has offered a more accurate and objective metric by which to evaluate surgical proficiency in trainees. “We’re moving away from an apprentice model which is what I went through, where I would basically stand and watch… and when the professor felt that I was good enough to do the operation he would allow me to do it” he explains. “Now what we’ve done is break down every single technical aspect of that operation into competencies… and we have objective data that you’re able to demonstrate.”

For operations that involve reshaping the bones of the skull, Dr. Forrest and his team have also developed steel templates based on normal skull contours to help guide surgeons during reconstruction. The difference between the reconstruction and the template is measured as the mathematical area under the curve, which serves as a proxy of how close the surgery was to achieving a healthy shape.  “Based on CT scans collected from healthy patients, we’ve created standard norms for certain shapes—for example, the forehead,” explains Dr. Forrest. “The results are better, and what we’ve also found is that the time for surgery is decreased… also, we can actually rate according to where the skull fits on the scale and get objective data to show ‘that’s a five or seven out of ten’ as opposed to how funky it looks.”

In light of his many pursuits, Dr. Forrest is well on his way to making a lasting impact in his field. When asked what’s next, he shares his exciting vision for the future: “An area of interest of mine is developing a robotic approach to surgery… but we realized that we couldn’t take a robot and use it on a baby because it’s never really been done before.” To address this, Dr. Forrest is looking to use his cleft lip simulator to train the robot, which he describes as “the next huge advancement in terms of the specialty.”

With his efforts fuelling so many avenues of innovation, one could not be faulted for wondering where exactly Dr. Forrest finds his drive. To this, he offers some powerful insight: “It sounds cliché, but if you’re passionate about something, that passion will take you to whole new worlds and take you down roads that you never expected to go on. I always think when a door opens you should take advantage and walk through it because that door may close and you may never have that opportunity again.”