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A Three-Dimensional Cleft Lip Incision-Design iOS Application Using Gamification: Pilot Study Results
Nicholas Han^*, Evyn Neumeister, Philip D. Tolley, Allison Hu, Isabel Ryan, Scott Bartlett, Jesse Taylor, Jordan W. Swanson
Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, PA

Background:
Surgeon learning or refinement of cleft lip anatomical marking and incision design has traditionally relied on limited two-dimensional images, costly physical models, or practice under general anesthesia. We developed an interactive iOS app that allows users to manipulate 3D cleft lip models, mark key anatomic landmarks and incisions, and receive automated scoring based on expert-defined markings.

Methods:
The Cleft Incision Design app, built in Xcode (v.16.1) using Swift 5, features anonymized preoperative 3D photographs of patients with unilateral cleft lip. Users can rotate and move these models and mark key anatomic points and incisional lines using a stylus or their finger. Within the app, user markings are compared to expert-defined references, and the marked points are assigned a score from 0-100. Plastic surgery trainees participated in a one-hour training session covering anatomic subunit approximation technique unilateral cleft lip landmarks. Pre- and post-tests were administered through the app, and self-reported understanding and confidence 7-point Likert scale scores were analyzed.

Results:
A total of 21 surgical trainees and medical students participated. Marking accuracy scores significantly improved from pre-test (36.8±27.6) to post-test (69.5±8.3, p=0.0017). Self-reported understanding (4.62±1.35 vs. 2.98±1.89, p<0.0001) and confidence (4.28±1.47 vs. 2.61±1.72, p<0.0001) in cleft lip marking also increased significantly following the training session. Pre-test scores varied with training level, with higher scores corresponding with more advanced training (p=0.016). At one week following the teaching session, the app had been independently used by participants an additional 83 times.

Conclusion:
This novel mobile application enhances accessibility to 3D cleft lip marking education, providing an interactive platform with real-time feedback. Training with the app led to significant improvements in both accuracy and confidence, highlighting its potential as a valuable educational tool for accelerating the learning curve in cleft lip repair.