Chapters Transcript Video Craniofacial surgery beyond childhood: Miles Pfaff, MD on cleft, microtia and ear reconstruction Learning how to carve in your, that's only one very small portion of the surgery that I realize now. Uh, in fact, I would say that's the part where people tend to focus on the part that you need to focus on as well or all the other parts like, uh, harvesting the tissue in such a way as to make it as, keep it as nice as possible and then creating that pocket. You could create the best ear reconstruction or the best framework, but if the pocket that you're gonna put it in doesn't look great. Um, you know, it's, it's, uh, it's not gonna look great in the end. Hi, I'm Lindsay Carrillo, director of Business Development at UCI Health. Hi, I'm Doctor Sunil Verma, Associate Chief Medical Officer and a laryngologist here at UCI Health. Welcome to Physician Huddle by UCI Health. So today we're joined by Doctor Miles Foff, assistant professor in the Department of Plastic Surgery. Welcome, Doctor Fuff. Thank you. Happy to be here. So tell us a little bit about yourself. I understand you're originally from California, but you've done a lot of training since then. So how did you find your way back here? So I completed my plastic surgery training at UCLA and then did my fellowship at the University of Pittsburgh at the Children's Hospital and then made my way back here. Luckily, uh, it was just by hap, you know, part of it's luck and part of it's hard work, but, uh, there was only a few jobs in the country. This was certainly the best one in my opinion, and I'm happy I made it back here. My family's happy. Uh, we're all from Southern California, so it's just good to be back home. And so tell us about your fellowship. What did you obtain advanced training in? So the fellowships in cranio maxillofacial reconstruction. So traditionally it's focused on pediatric care. So children born with congenital differences of the face, uh, and the skull. So those could be cleft lip and palate, microtia, which is a child that's born without or with a maldeveloped or underdeveloped ear. Uh, as well as children born with differences of the face that could affect the nose, uh, the shape of the skull, uh, but, uh, the definition of craniofacial surgery or cranio maxillo facial surgery is now expanded to the adult side as well, which I've incorporated now into my practice. So are you able to treat both groups here uh at UCI Health in terms of pediatric patients and adults? Yes, so I have a, an appointment here at UCI and then we also go over our department goes over to CHOC as well to provide craiofacial services amongst other services within the pediatric plastic surgery division. Now known as Brady Children's Children's Hospital, yeah, how did you find your way to reconstructive surgery? What drew you to that subspecialty? So, uh, during my third year in medical school. Uh, very, uh, uh, transformative year for me. I thought I was gonna do vascular surgery or neurosurgery, and I was just on a neuro neurology, neurosurgery rotation. Uh, I met a plastic surgeon, uh, who was doing a combination case with our neurosurgery colleagues, and I just thought what they were doing was just fascinating. It was a pediatric case, and from there I was sold on. Uh, craniofacial surgery or cranio maxillo facial surgery. Uh, I contacted that physician. I became a mentor of mine, still a mentor of mine and a friend now, and, uh, the rest was just history. Yeah, it's kind of funny how changes like that can happen. You're sort of gearing up your first, 2nd year, probably even an undergrad for 2nd year of med school, and then one random surgery that you happen to step into, and you could have been absent that day or in a totally different operating room and not met that individual, yeah. Uh, you, I was surprised to learn how much research you've done. You're very active. You've had over 100 peer-reviewed publications. How does that work for you? How does your research inform your clinical work and vice versa? What makes you excited about research? Well, close to almost 100, but yes, uh, I've been working hard. Uh, research has always been, uh, a priority for me. Uh, you know, even before medical school, I thought maybe I would go to graduate school, get a PhD, work in a lab. That was always sort of the initial goal. Uh, and then, uh, I found a mentor at, uh, UCSF and he was also a surgeon, but a scientist, and I really enjoyed what he was doing and, you know, he said if the sciences have worked out, work out, then medicine's not. You know, not a bad, like, you know, thing to fall back on. And so it worked out well, and, you know, research has always been a priority. And then when I got here to UCI, I contacted a few folks to see, you know, how I could get involved in research. The department has a Center for Tissue Engineering lab. Uh, we had the infrastructure there, um, but just seeking mentorship. I got some great recommendations. One of those was try to become an expert in maybe one or two things and really hone in on that. Uh, try to develop a niche, and that's exactly what I've been trying to do and what are, what, yeah, I do. I think that's, I, I think it goes different for different individuals. I think some people when you're fortunate enough that you can find that area of interest and you can do it early, um, other people have to, I, I've seen experiment in different areas, at least initially. But I agree at some point it's, it's just kind of easier to hone in and ask a question, answer it with your own paper, and then ask the next question. It's easier to think sequentially, um, and, and that probably leads to, frankly, more invitations to speak, better chances at funding, being known as an expert, um, it's kind of part and parcel of being in academics, yeah, but I think it's really important to be broad at first and because you gotta figure out what you wanna do. Um, and so I was brought, I said yes to everything that came towards me, and eventually I found something that I was very passionate about or a couple of things that I'm passionate about, still am, and, uh, it just kind of worked its way towards, uh, or aligned with my research and, and still trying to pursue that today. And what are those areas of passion, uh, ear reconstruction, nasal reconstruction, nasal surgery. Uh, cleft lip and palate. So there's still quite a few. It's still very broad, but you know, microtia and ear reconstruction, uh, in pediatrics and adult patients, those are er that's certainly an area of focus, uh, nasal surgery, uh, whether it's, uh, functional cosmetic or combination or reconstruction, which is actually a big passion of mine. So tell us about your reconstruction. I mean, when we were, when I was in residency, we were taking the, I think, 5th, 6th, and 7th rib or maybe 7th, 8th, 9th, I don't quite know, and cutting it up into pieces on the back table and sewing it back together in a formation of an external ear. I don't know if that's the old way or the new way or where, where are we with, uh, ear reconstruction. Please tell me things have progressed so. The, the data out there, uh, says that this is still probably the most reliable, but that's up for debate. Uh, I think really what it comes down to is what is your surgeon comfortable with, uh, what is their expertise, uh, and, um, you know, what are their outcomes look like? How long have they been doing it? Uh, it's really about training too, right? So what you're exposed to before and what your philosophy is on reconstruction. Um, but no, I, I would say autologous, which is using your own tissue, is still probably the most commonly, uh, used approach or taken approach for ear reconstruction, uh, primarily because in the end, it ends up being the easiest access for most surgeons, right? Because if you're using, uh, say a synthetic material that does cost money, um, you know, let's say if you're out in an under-resourced area. Uh, ear reconstruction using your own tissue is gonna be the easiest resource to come by, but incredibly challenging to form and carve and, uh, make believable that it's a native ear. Yeah, that's, uh, that's partly what drew me to it. Um, I'd say that, uh, in my practice, uh, I'm thankful that I'm able to offer. tissue as well as synthetic, you know, there's a porous plastic that's a skeleton to create an excuse me, but um but yeah it's There is a learning curve. It doesn't matter if you're using the pre-made or the patient's own tissue. There's a learning curve for both. Both are very challenging, but yes, learning how to carve in here. That's only one very small portion of the surgery that I realize now. Uh, in fact, I would say. That's the part where people tend to focus on the part that you need to focus on as well or all the other parts like uh harvesting the tissue in such a way as to make it as keep it as nice as possible and then creating that pocket. You could create the best ear reconstruction or the best framework, but if the pocket that you're gonna put it in doesn't look great, um, you know, it's, it's, uh, it's not gonna look great in the end. You've also done a lot of work with donor tissue, right? Yeah, so that's another area that's a little newer. I'm able to offer that as well. Externa, uh, is, uh, autologous or excuse me, allografted ear, uh, car or 4 allografted ear-based reconstruction. It's costal cartilage that's purposed specifically for total ear reconstruction. Um, so the data and the, the long-term results on that are still pretty thin. Um, the furthest that I've taken a patient out so far is about 2 years and it looks great. Um, but, uh, we're still working out some of the, the nuances of, of this, but it's really changed a lot of surgeon's practice that have embraced it, uh, rather than a, you know, 8 to 10-hour procedure where you would harvest the rib, sculpt it, put it into the pocket that you've created. Uh, you can, I can have a patient come to the pre-op. Uh, before surgery, just make sure we're all on the same page, everyone's ready to go. Uh, I can take my template or I can, uh, create the contralateral, which is the other ear template, so I know kind of what I'm looking at. And I can take that back to the OR without the patient, create the ear, and then when it's ready, I call the patient in, and I've reduced the surgery that used to be about 8 to 1012 hours to about 3.5 hours, and the patients go home the same day. Have they started a process where you can order that rib but then have them carve it for you so you take a picture of the contralateral ear and have somebody in a lab out there form it into the sounds like a great business idea, but yeah, people are, people are, uh, you know, talking about that and our research is actually involved in something very similar to that, maybe taking a different approach, um, so you know things are in development, but that would definitely be the next step. You know, carving the ear is um not so much the hard part and I think that's a, that's a great uh avenue for entrepreneurship and, you know, marketing and whatnot. How close are we to 3D printed ears? And noses and chins. Uh, we are very close and there have been some successful, uh, uh, 3D printed either constructs that are synthetic or that are not necessarily autologous, but they are of a material that's biocompatible. Uh, there was a company a little while ago that produced them, but the long-term results still we're waiting on. So what else, um, what do you enjoy about being here at UCI Health? I mean, it sounds like a pretty dynamic practice with having access to Brady children's in addition to the adult population. You're rounding it out or perhaps leading it with your research. What else do you enjoy about being here? So recently, I, uh, took over the residency training program as the program director. That's been a challenge but a real pleasant, welcome challenge. I think, you know, this is why we all do academics. It's not just about research but also about education and about innovation and clinical care and right now I feel like I get to satisfy all three of those and it's just been a great opportunity. How many residents do you train? And are they doing fellowships here at UCI Health or do they end up going elsewhere to get additional teaching? Well, by next year or the year after, we'll have a full complement, so that'll be 24 residents total. It's a 6-year training program, 4 residents per year. Um, most residents, uh, at this point now, I'd say are a little over 60% are doing a fellowship, but we want residents to go all over and it would, it's great when they stay at UCI, of course, but it's also great when they get that experience elsewhere cause they know how we like to do things. Um, and it's great when you get to see them go off and do great things at other institutions and learn new techniques and new perspectives. Always great to broaden your training. Do they, do we offer fellowships here then? Yes, we do. We have, uh, two hand fellowship positions. So that's a dual plastic surgery as well as orthopedic surgery, uh, focused hand. Uh, fellowship. Uh, we also have a craniofacial fellowship, um, so that fellow is with us both on the adult side as well as the pediatric side. Uh, we have a micro fellowship, so that's microsurgery, um, and that focuses on breasts, uh, body, lower extremity, uh, face. I work with the micro fellows as well as some of our other colleagues that are not within the micro division. Uh, in addition to that, we have a cosmetic fellowship as well, and that's, uh, the, uh. Uh, that's a fellowship that's partly based here. It's a traveling fellowship, um, and so these fellows get all the experience from a bunch of leaders in, uh, cosmetic and aesthetic surgery, uh, from all over the West Side as well as in Texas. Oh wow. What kind of questions do you get from these residents? Are there trending topics that they seem to get really into or things that they're looking ahead to that, you know, you're excited to share with them about the future of plastic surgery? Well, the focus, or at least our priority, is to just train the best possible surgeon we, we can. And so, whether that means doing a fellowship or going straight into private practice or a community-based practice is uh really up to them, you know, we want them to succeed, we want them to be happy. Uh, we also want them to be leaders in medicine as well, but, you know, you don't have to be, uh, the chair of a department to be a leader. You can always be, you know, a good representative of plastic surgery in the community. Um, so, so really the focus is that we want to train residents to be the best surgeons they possibly can be, the best academic surgeons they possibly can be, but also I want them to be happy in the future. Makes total sense. So, um, what's next for you here then? I mean, that sounds like probably the residency program is gonna keep you quite busy. Oh yeah, yeah, there's a, there's a lot going on, um, and there's always, uh, things to do, uh, with the residency, but also with the practice. The practice is building, um, it's getting busier and busier. We're hiring, uh, many new faculty, so it's been a really exciting time, a lot of opportunity for growth here at UCI. I find plastic surgery to be so interesting because unlike, say, like throat surgery, I'm probably not gonna like try to find it cheaper on the corner, you know, like someone to repair my vocal cord, but if I wanted something more cosmetic, it seems like there's a lot of that going on and so I feel like I know I've called you with questions. Questions about safety and different procedures and it's really interesting to me that the trends change in plastic surgery where it's like, yeah, no, that is not safe anymore, we don't do that anymore and we're really discouraging that, but these things can still really take on a life of their own and people might go find some way to get it done or it might be very popular and is that part of the draw for you? Do you kind of like that it's always changing like that or tell us about, you know, what it's like to sort of walk that fine line. Well, that's one of the reasons that drew me to plastic surgery. I mean, the creativity, but also just, uh, you know, it's, it's about principles, so you can always take this principle you can apply it to a new problem, right? Or you can take this principle and you develop these different perspectives on a particular problem and try to come up with a solution. Sometimes things sound good in the beginning and may not end up being that great, but, you know, procedures are changing constantly, especially as we sort of look at our, our long-term outcomes. Um, but yeah, I mean, it's, I wouldn't say it's always in flux. There's always these core principles that we like to follow. Um, occasionally we do challenge them cause that's just healthy, you know, but otherwise, I would say it's, it's a good pra or it's a good field, good specialty. Um, there's always something new and something, um, on the horizon that we can, that we can do better. So, for instance, like you work a lot with, you know, people um working on facial surgery. Is there any times that you have to counsel a patient and just be like, listen, I know that this is popular right now, but I don't think this is a good idea for you, or, you know, how do you kind of answer. Those questions, yeah, I'd just be honest with the patients, say, you know, I may not be the best surgeon for you. This is not something that's within my expertise, um, or that, you know, I, you know, I differ on my perspective on how this may sort of affect you long term. This may be just a short term solution. It just really depends, but you know, I certainly see patients that inquire or, you know, I hear patients that are inquiring clinic about certain procedures that, you know, we, that I don't offer, but maybe I know someone else that does, so I'll refer them over. Yeah, it makes sense. So I think to your point, Lindsay, it's a specialty where patients come in with a different level of understanding and appreciation and knowledge. Yeah, like, I don't know what a good vocal cord looks like, so you would have to tell me, but I generally know what, like my, what I want my nose to look like, right? Yeah, yeah. And so it's balancing that patient expectation and their knowledge base with your academic and, and intellect or academic base, if you will, and then meeting them somewhere between, not to mention, right, there's a lot of options out there, um. And so just sort of, I'd like you said, staying true probably to what you find is right is the easiest way to walk that line rather than bend for, as so many patients come with different questions. But things are changing, you know. I wanna stay open-minded, or, you know, remain open-minded because there's always new things I can learn. I mean, that's why we go to conferences, why we read our journals, and, you know, it's always always an opportunity to learn new things. So even though it's new, it doesn't necessarily, and then like somewhat of a fad may necessarily mean it's a bad thing. That, that's one of the ways actually doing vocal cord injections for spasmodic dysphonia. We use Botox. And so the, I was trained in a certain way of doing that, either passing the the needle through the mouth and, and different ways and so. Other doctors within a 200 mile radius, uh, there's not a lot of us we're doing it through a different technique, and I had enough patients moving to Orange County saying, well, why don't you do it through this technique? And I said, well, I wasn't trained in it and the data doesn't play out. Well, after you tell like 7 or 8 patients that. And they, you see the disappointment on their face. I realized I got, I have to go and learn this. And so I went and found another doctor doing it. This was like 10 years into my career, uh, sat down, watched him in clinic, and said, OK, then watched a couple of videos and said, All right, this is something I want to offer and. I remember going through that change, that transition, the first probably 10 patients we did, we kept real good track of and said, OK, in case I, this doesn't have the outcome that we want, we can always go backwards. But it was the patients that drove me to change my technique. So it's like, if I hadn't been in this geographic area, I probably would never have done it, and it was really them challenging me and really changing the assumptions I had of what was right and what the data should have shown. So it's kind of fun once you're here long enough, I think, or once you're in a place long enough where other people show up. Patients will turn your hand, I guess they'll challenge you. Well, I think that's a great environment to be in, you know. One of the things that I think you're known for is you like to be proactive about innovation. I know we had talked about some things that you're doing in like the rhinoplasty or some of the cleft, you know, issues that the kids you're seeing like you were telling me about like in a completely internal rhinoplasty. So tell us about that. Oh well, I mean that's a, that's. Potentially an older, much older way to do things. So then we talk about fads and it's now come back. Um, and it seems to be popular, but I found that, well, OK, I'll give you an example. I was trained to do rhinoplasties open, meaning it's a very small incision when we say open, it's not maximally invasive, but, you know, requires a small incision between, uh, the nostrils, the, the tissue that, uh, rides between the nostrils, and that gives you visualization of all the structures, but, um, you know, before, before all of this, people were doing these closed, meaning all internal incisions for the most part, right? Um, and then there's this other thing called the dorsal preservation, which is another sort of approach that I've incorporated into my practice. So closed dorsal preservation and closed was typically for issues of the nose that did not involve the tip and it's really just the dorsum, which is the bridge of the nose, but, you know, through innovation, development of new techniques, new approaches are able to do the whole nose through a closed incision, sometimes using cameras, sometimes using uh ultrasonic um knives essentially to cut the bones so that, you know, you minimize trauma to uh some of the other tissue. Uh, so, you know, there's lots of new different techniques that you can always do and, um, employ, but, you know, closed rhinoplasty, dorsal preservation, those are all really old, old, old techniques that have now come back but come back full force and um have been a big part of my practice now. Well, I imagine you're working with kids, so you know, the healing time and maybe even the way they feel or look after they first come out of surgery could have such a huge impact. Like, talk to us about what it's like to see the changes in these kids' lives. So the one of the main reasons why I did craniofacial surgery, other than I thought, you know, it was probably the coolest, uh, subspecialty out there, uh, was the fact that very, there's very few specialties where you get to, um, Where you get to build a relationship with a patient over, say, 25, 30 years, right? Um, so I see a baby that's just born with a cleft, a cleft lip and a cleft palate, for example, um, I will operate on the cleft lip, usually around 3 to 4 months, and then I'll operate on the palate. About 1 year of age, 9 months to 1 year of age. Uh, and then they have a series of other procedures that are just part of cleft care. So they need bone grafting to help support the jaw, to help support good tooth development and stabilization. And then they need sometimes jaw surgeries, uh, to help align the top jaw and the bottom jaw. And then they also need, uh, a rhinoplasty as well once they're done, you know, both functional and as well as cosmetic, but, or aesthetic. Um, but really, there's a, there's a really strong psychosocial drive, you know, to help. So it's not just cosmetic or aesthetic. Um, and then after that there's little things that they may need, um, so you're seeing someone over the course of their young adult life, and you know I'm fortunate enough to be able to see adults as well, so they transfer over into my clinic as adults. I haven't been here for 25, 30 years, but you know it's a theoretical possibility. So what else is on the horizon? What does the future hold? What are you excited about? Um, I would say again, uh, trying to develop the best, uh, plastic surgery training program that we can offer here at UCI. I think building our plastic surgery service, especially our presence at Radis, uh, is, um, definitely, uh, a priority of mine, uh, as well as our adult practice. So, I'm really excited about all of this, just such an opportunity here at UCI. So cool. So glad you're on board. Thank you. Thank you both so much for being with us today. This has been Physician Huddle by UCI Health. Thank you for joining us. This was an episode of the Physician Huddle podcast by UCI Health, produced by Brett Shahen, Angelica Yagubi, and Victor Ting. For more episodes, information on clinical trials at UCI Health, or to refer a patient, review the show notes or visit clinical connection. UCIhealth.org. Created by
