Dhruv Singhal, U.S.A.

BY Dhruv Singhal

I recently completed a one year Craniofacial Fellowship at Chang Gung Memorial Hospital. In brief, prior to the fellowship, I had completed my training in both general surgery and plastic surgery. I came to Taiwan seeking a Craniofacial Fellowship that would allow me to experience and learn about the care of the adult and pediatric patients with craniofacial deformities. In retrospect, it was an incredible year and my above goals were absolutely met.

Soon after my arrival in Taiwan, I met with Dr. Yu-Ray Chen to discuss my goals for the year. We then set up a rotation schedule for my time at Chang Gung Memorial Hospital. I began the year on Dr. YR Chen's service (Orthognathic) and worked closely with him and Dr. EJ Chen in learning about all aspects of orthognathic surgery including pre-operative, intra-operative, and post-operative care. The majority of patients present with class 3 malocclusion, however, given the high volume at CGMH, a fair number of class 2 patients are also treated. Having essentially no prior experience in orthognathic surgery, the operative experience was incredible and included performing bilateral sagittal split osteotomies, lefort osteotomies, and more often than not an osseous genioplasty. During my time on service, I scrubbed in over 65 index bimaxillary cases with or without genioplasty. During my time on service, I also spent 2 months with Dr.
Clement Lin who performs orthognathic cases with a focus on sleep apnea patients.
 
Attending clinic in the Sleep Center and participating in these cases, different
techniques and approaches are taught specifically for patients with airway issues. An adjunctive portion of this rotation is spending time with the world class orthodontic team that works side by side with the Craniofacial surgeons. Led by Dr. Huang, the team is academically oriented and always working on innovative methods of correcting the dento-skeletal deformity. Specifically, I worked with Dr. Sheng-Ping Hsu on the use of CASS (specifically the Simplant program) for 3D simulation of orthognathic movements.
 
Following my time on the orthognathic service, I proceeded to my cleft/pediatric rotation with Dr. Philip KT Chen. On this service, the focus was primary cleft lip and palate procedures and revisional cases. Given the relatively low incidence of craniosynostosis in Asia, you do not perform many cranial vault remodeling procedures though in my time I did assist on two such cases (one monobloc advancement and one cranioplasty). Dr. Chen also performs procedures on other congenital conditions afflicting the head and neck region such as craniofacial neurofibromatosis cases.
 
I rotated onward to the trauma service led by Dr. CT Chen. On the trauma service, I got a vast exposure to both primary and secondary procedures. On the acute cases, utilization of the endoscope was one of the unique aspects of training at CGMH. Utilizing the endoscope for medial approaches to the orbital apex for decompression, lateral approaches for superior orbital fissure syndrome, and subcondylar fractures were particular highlights. Learning how to safely approach condylar fractures from a preauricular incision was another critical aspect of my training over this time period. As Dr. CT Chen is well-known both nationally and internationally for his experience in facial trauma, secondary cases are often referred to him. Specifically, management of secondary enophthalmos is a common case that he performs.
Finally, for my final 2 months, I chose to rotate back onto the orthognathic service to solidify my experience in approaches to the lower mid face and mandible and care for the sleep apnea patient. Over the course of the year, the opportunities to perform research are endless. The first project I took on upon arrival was a review of the 30 year experience of Craniofacial Neurofibromatosis at CGMH. This project was a longitudinal project that generated many separate manuscripts that took me the entire year. Along the way, I worked on various other projects including orthognathic papers related to CASS and sleep apnea.
 
On the trauma service, I wrote about condylar process fractures and retrobulbar
hematomas. Overall, the Craniofacial Center at CGMH is a world class institution offering singular training in craniofacial surgery. One of the most unique aspects of the program is the breadth and depth of opportunities. From teams ranging from ear reconstruction, cleft care, orthognathic, sleep apnea, and trauma - it is truly up to the fellow to tailor an experience that will augment their future practice. The focus on clinical excellence while approaching patients in an evidence based medicine approach is readily apparent.
 
Every Monday, fellows participate in a comprehensive research conference for 3 hours in the morning which is attended by all the orthodontists, surgeons, and researchers alike. Tuesday mornings fellows attend a one hour didactic session dedicated to Craniofacial Surgery. Impromptu teaching sessions occur as well - during a period of 2 months during my time at CGMH, Dr. Philip Chen, the program director, met with all the fellows weekly to provide didactic sessions on cleft care.
 
As I depart Taiwan today, I can not thank everyone enough for an incredible
international craniofacial surgery experience. I want to particular extend my gratitude to the NCF. Specifically, Rebecca and Debbie have been central figures of the organization since I first became involved often checking in on me and the other fellows to assure that our experience was meaningful. The NCF continues to look for novel methods and opportunities to aid others in learning the art of craniofacial surgery as Dr. Sam Noordhoff emphasized during his tenure in Taiwan.
 
Thank you to the NCF and the Craniofacial Center for an absolutely incredible year!
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