Dr. Geddes Interview: Blog

Last month, Med Dimensions’ Product Manager Lucas Lassinger was able to sit down with Dr. Alexander Geddes, BVetMed, PGDip (VCP), DAVDC, MRCVS for an interview. 

Dr. Geddes is currently a staff dentist at Cornell University Veterinary Specialists, as well as an Academic Liaison and Courtesy Assistant Clinical Professor of Dentistry at Cornell University College of Veterinary Medicine. He pursued his veterinary degree at the Royal Veterinary College in London, England, and completed his residency at the University of Wisconsin-Madison.

What brought you into Veterinary Dentistry and Oral Surgery originally? 

When I got to the clinical stages of my school career, it became pretty obvious to me at that point that I had a surgical interest rather than a medical interest. And I was initially interested in being a general surgeon, as in a board-certified surgeon, not a dentist or a surgeon. And so I started prepping for internship and residency. So I did a bunch of placements in Europe and the US. I took a job as a family practitioner in Southeast London for two years. And had a great time, you know, and getting my feet wet, and just learning how to be a good practitioner, and getting a bit of life experience. And then and it was during that time that I found dentistry and oral surgery, and kind of moved that way.

One, it’s very surgically biased as a specialty, you know, you spend a lot of time operating, and two, I didn’t know enough about what I was doing. So I started reading and getting textbooks. And I just you know, when you find something that you have innate motivation to learn more about. I found myself in my lunch breaks reading these textbooks and trying to learn more, and it was just very fulfilling. And I think what helps is if you’re finding a niche and nobody else in the practice wants to do it. That’s also very satisfying. So I got about 18 months in and was like, well, I don’t see why I’d wanna do a surgery residency. I think I enjoy this a lot more. And there’s so much impact that I can make by doing this underserved specialty. 

You completed your residency in Dentistry & Oral Surgery at the University of Wisconsin-Madison and then moved to Ithaca (Cornell University). Can you expand on your experience in these big moves? 

Wisconsin included oral Maxillofacial surgeons, (which) meant that our Residency was quite biased that way. And we got a lot of that advanced training just on a weekly basis. I would say that 2 of my mentors, Jason Soukup, and Graham Thatcher, who are both fellows (of Maxillofacial surgery), were also very interested in virtual planning, surgical planning, and 3D printing, and how that could augment our work. And we had some pretty basic 3D printers even within the Vet school. So we started in the first year of my residency expanding that and playing with it to help us kind of take on the kind of procedures that I do here with the help of your team.

And that’s what really kind of got me educated about how we can use those technologies to support what we’re doing and do a better job, you know, ultimately help patients in various ways. Obviously the spiel of the pros of, you know, reduced surgical time reduced morbidity reduced overall cost because of all of that stuff. 

When I was finishing my residency and looking for a place I needed, I felt like I needed somewhere that could support and facilitate both philosophically and logistically, my aspirations to keep performing those procedures and keep, pushing the envelope of what we’re all that, me, all of Maxillofacial surgery is and there are not that many centers that can do that, and not at the highest level, you know. And so CUVS checks those boxes. 

We recently printed a scale model of a canine head with an abnormality for you. Why do you think it is significant to have a model for planning surgery? 

That was actually a salivary gland tumor of the zygomatic salivary gland. And the reason that I wanted that is because we were only removing that gland. But it’s quite a narrow point of entry to remove it. And we had a lot of structures around it that were very important. So interestingly, conversely, to what I just suggested having the print of that one was because I wanted to know exactly the morphology as I worked around it, as opposed to figuring it out as I removed other structures around it. So sometimes it’s useful for knowing, for helping when I’m removing lots of structures, and sometimes it’s very helpful when I’m trying to avoid removing a lot of structures. the more complicated the area essentially, and the more complicated the surgery, the more useful these tools are.

It’s been great working with you guys. And I feel like we’re scratching the surface right now, there’s a lot more scope to utilize your expertise from my end, because, when we were doing stuff at Wisconsin, the limitations came from how much we as medical training professionals can kind of either self teach or utilize. In all honesty, you get to a level of busyness with cases and complexity, with cases where I’ve got no business trying to do a lot of the 3D planning side of things and printing right like, that’s your expertise. So, having a company where I can provide my input and you provide yours. I think that gives us the best outcomes. 

What would you say leads veterinary surgeons to utilize 3D models and guides? 

I would say that the earlier you are in your career, particularly as a resident or a trainee, the more useful these technologies are because they can assist and accelerate your experience and training. But then I think it’s also personal preference right? How much of a planner are you? In this area, all of my mentors and myself are people who like to know what we’re getting into before we walk into the OR, and I think some of that comes from being more dentistry, and oral surgery-minded. Where we have a lot more kinds of set procedures that we like to be prepared for. General surgeons are trained a little bit more fundamentally because their scope of procedures is so broad and so they’re a bit more relaxed about applying principles in real time. How much you want to preplan for the OR also influences how much you use these technologies. And I love planning. So the more I use this the better. 

Am I going to be either executing a certain (on) part of the surgery? Or am I going to be performing some kind of reconstruction where I can utilize virtual planning, or a 3D print to prepare some of the implants? So the more the more complicated that becomes, the more I need to lean on planning and 3D printing. So either, if I’m going to be, I think a big one is if we’re performing implants based on a print, and I’ll use that when the reconstruction is getting particularly complicated. So if it’s a pretty straightforward reconstruction, maybe we can do it, we can do it without the aid of performing. But as soon as we need to start bending plates or anything like that.

Significantly, I think that 3D printing and virtual planning come into their own because they save so much time, and then for me, the other one is the more complex the anatomical area of the surgery, having that 3D print that is literally a model, a to-scale model with some anatomical markers in can help aid your brain when you’re in the surgery and trying to figure out where you are, where you’ve got to go. I would say that the two big things for me are, do I have something in the surgery or multiple things in the surgery that could be made easier, faster, or safer for the patient by utilizing these models or three is the surgery is simply so complex that it’s going to having more visual and physical aids in your hand are going to just make it easier to navigate. 

What is one of the difficulties that would prevent planning surgeries with 3D models? 

Where I think I probably have the biggest frustrations, both from a resource perspective and just the logistics perspective right now is the trauma, because trauma cases are not planned. The families are coming in in a much more emergent emotional situation. They’re not financially prepared as much. Usually not always. And so we may have some more limitations as to how comprehensively we can approach things. And then the other thing is that Med Dimensions have been incredible with the turnaround time, but we still have some turnaround time. Right? A job has to be done, and then something has to be mailed. Maybe have a printer on site that we can send to you guys, do the planning, and then have it printed on-site to speed things up, and I think that would augment the trauma planning nicely. 

But I think that’s where I get a little bit more of a limitation is that with the trauma, you know, the good thing about trauma is that most patients can either be managed surgically or conservatively. They would probably return to function on normality quicker with surgery. But they’ll lead a good life conservatively. And so for those, a lot of these families, they often pick a conservative approach for various factors, and we don’t necessarily get the opportunity to execute the kind of ideal surgical plan. And so I definitely, that’s an area of my practice that I’m hoping to expand in the next few years is not just trauma in general, but surgical options for trauma, though, that most centers can’t provide by combining.

Have you found that the patient’s parents find the cost of printing 3D models to be prohibitive to performing the surgery?  

I would say no because the combination of the 3D printing is not an insignificant cost, but in the scheme of what we’re doing, it’s not a game-changing proportion of the costs, and then it is legitimately reducing anesthesia. Time, which is charged by the hour, is also not an insignificant cost. So I think that it does genuinely make it come out in the wash. And so when I have a case that is complicated, I tell the owners I need to print this one like it’s part and parcel of you taking this journey with me is we’re gonna be printing this one.

What are some of your aspirations now that you are three years out of residency and more established? 

Be one of the clinicians at the front of our profession in this sub-specialty. And I think that utilizing the technologies that Med Dimensions offers is, you can’t ignore them, right? That they are already an integral part of certain standards of care, even inventing medicine, let alone human medicine. 

My passion is these larger Maxillofacial cases. But we all have bread and butter. I still do a lot of extractions. I still do a lot of periodontal treatment. I do some root canal treatment. And that’s what I’m doing (for) at least half of my week. I think that I’m quite fortunate that at least half of my week is all maxillofacial medicine investigations and surgery. That’s quite a heavy ratio for our discipline. My aspiration is to just do oral Maxillofacial surgery, and have one or two other dental colleagues, who are more dentistry-inclined to do all of that work. And we can have two subservices.

I believe that there is some scope for implementing microvascular surgical techniques into veterinary oral Maxillofacial surgery. What I mean by that is harvesting tissue graphs from elsewhere in the body with a blood supply and plugging that blood supply into the blood supply of the face, so that that graft has, it remains with the blood supply that it came with from elsewhere in the body. 

Maybe once a month at least, I meet a patient whose facial or oral tumor is so extensive that there aren’t any good local reconstructive options, and we have to provide palliative care for that patient or send it for radiation therapy because there isn’t a surgical option to offer them in the sense that I can remove that defect. But I can’t leave them with that defect, you know. 

So I think my kind of career dream for the next 10 years is exploring the opportunity to implement those techniques into clinical practice. They have been well established in dogs and cats decades ago by our human colleagues, as they experimented on them for people. So we know that these grafts are doable, and there was a small group of colleagues on the veterinary side that did some of the pioneering work back in the eighties and nineties. 

So myself and a colleague have spent some time at the Mayo Clinic in Minnesota, doing microvascular training to start our foundation in that surgical expertise. And then our goals over the next few years will be to build on that training to become proficient and then start implementing more, we need to do more clinical training with grafting.

How do you visualize Microvascular Grafting being performed? 

I am without a doubt certain that we will need extensive virtual and 3D Printing planning for these cases. It will be you. You just wouldn’t be imagining doing them without them because they’re the kind of cases I was talking about that we would be doing that we’d print for anyway, or plan for anyway, and then having the graft come in is even more complicated. 

Virtually plan the removal of the tumor, and you can print a cutting guide as Med Dimensions does. You can evaluate that defect for replacement with a hip graft. So you cut some of the pelvis out and again you can print a cutting guide for the pelvis. You harvest the pelvis and the microvascular graph from the pelvis, and you place it in the face, and that’s all done with planning and surgical guides.

You use microvascular techniques to implant the pelvic bone and tissues into the face, and that gives you a complete reconstruction, and then the common one in the jaw for people is taking a part of your fibula and some of the blood vessels there, and putting it into the jaw. Again, it’s not uncommon that cutting guides and planning will be used so that the precision and the speed of this is increased because these procedures in people are at least 10 hours long, 10 to 15 hours in the or with a large team. So if you can cut 20, 30 min, or hours off a procedure with virtual planning. It’s a no-brainer.

I don’t know whether we are going to head in this direction in the sense that we’re talking about some pretty involved medical care. But you don’t have to look very far back in the history of that new medicine to say the same about many things that we take for granted today.

We would like to thank Dr. Alexander Geddes for sitting down with us. It is inspiring to work with him and so many other Doctors who are pushing the field of veterinary medicine forward.