Eight free flaps in 24 hours: a training concept for postgraduate teaching of how to raise microvascular free flaps

Development of a porcine training model for microvascular fasciocutaneous free flap reconstruction

BACKGROUND

In reconstructive surgery, improvements are needed in the effective teaching of free flap surgery. There is a need for easily accessible and widely available training without high financial costs or ethical concerns while still providing a realistic experience. Our aim was to develop an appropriate training model for microvascular flaps.

METHODS

We identified pig head halves as most appropriate regarding availability, cost, and realism. These accrue largely by the food industry, so no animals need to be sacrificed, making it more ethical from an animal welfare perspective. We evaluated the suitability as flap donor site and analyzed the vascular anatomy of 51 specimens.

RESULTS

Anatomical evaluation revealed a reliable and constant vascular anatomy, allowing the design of a flap model that can effectively illustrate the entire process of microvascular flap surgery. The process was divided into 6 key steps. The flap can be harvested after marking the vascular pedicle 5.3 cm from the lateral corner of the mouth. Skin island design and subsequent tissue dissection follow until a fasciocutaneous flap is raised, similar to a radial flap. Upon completion of flap harvesting, it can be freely transferred for defect reconstruction. Microvascular anastomosis can be performed on recipient vessels in the cervical region, and the difficulty can be individually adjusted.

CONCLUSIONS

The developed training model is a reasonable compromise in terms of surgical realism, availability, didactic value, and cost/time effectiveness. We believe it is a powerful and effective tool with high potential for improving surgical education and training.

Merits of simulation-based education: A systematic review and meta-analysis

BACKGROUND

The drive to improve surgical proficiency through advanced simulation-based training has gained momentum. This meta-analysis systematically evaluated evidence regarding the impact of plastic surgery-related simulation on the performance of residents.

METHODS

A systematic search of PubMed, Web of Science, and Cochrane Library and review of articles was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol. An inverse-variance random-effects model was used to combine study estimates to account for between-study variability. Objective structured assessment of technical skills (OSATS) scores and subjective confidence scores were used to assess the impact of the simulation with positive changes from the baseline indicating better outcomes.

RESULTS

Eighteen studies pooling 367 trainees who participated in various simulations were included. Completion of simulation training was associated with significant improvement in subjective confidence scores with a mean increase of 1.44 units (95% CI: 0.93 to 1.94, P < 0.001), and in OSATS scores, with a mean increase of 1.24 units (95% CI: 0.87 to 1.62, P < 0.001), both on a 1-5 scale. Participants reported high satisfaction scores (mean = 4.76 units, 95% CI = 4.61 to 4.91, P = 0.006), also on a 1-5 scale.

CONCLUSIONS

Participation in surgical simulation markedly improved objective and subjective scoring metrics for surgical trainees. Several simulation devices are available for honing surgical skills, with the potential for advancements. The evidence demonstrates the effectiveness of simulations; thus, incorporating simulation into training curricula should be a priority in the field of plastic surgery.

A novel simulation module for segmental mandibulectomy and mandible reconstruction using 3D models

INTRODUCTION

Mandibular resection and reconstruction are common but complex procedures in head and neck surgery. Resection with adequate margins is critical to the success of the procedure but technical training is restricted to real case experience. Here we describe our experience in the development and evaluation of a mandibular resection and reconstruction simulation module.

METHODS

3D printed (3DP) models of a mandible with a pathologic lesion were developed from imaging data from a patient with an ameloblastoma. During an educational conference, otolaryngology trainees participated in a simulation in which they reviewed a CT scan of the pathologic mandible and then planned their osteotomies before and after handling a 3DP model demonstrating the lesion. The adequacy of the osteotomy margins was assessed and components of the simulation were rated by participants with pre- and post-training surveys.

RESULTS

52 participants met criteria. After reviewing the CT scan, 34 participants (65.3 %) proposed osteotomies clear of the lesion. This proportion improved to 48 (92.3 %, p = 0.001) after handling the 3D model. Among those with initially adequate margins (n = 33), 45.5 % decreased their margins closer to the ideal, 27.2 % made no revision, 21.2 % widened their margins. 92 % of participants found the simulation beneficial for surgical planning and technical training. After the exercise, the majority of participants had increased confidence in conceptualizing the boundaries of the lesion (69.2 %) and their abilities to ablate (76.5 %).

CONCLUSIONS

The structured mandibulectomy simulation using 3DP models was useful in the development of trainee experience in segmental mandible resection.

LAY SUMMARY

This study presents the first mandibulectomy simulation module for trainees with the use of 3DP models. The use of a 3DP model was also shown to improve the quality of surgical training.

Simulation of Reconstructive Microsurgery in Soft Embalmed Cadavers: A Teaching Module for Plastic Surgery Residents

Background  Cadaveric dissection courses—comprising flap harvesting techniques, vessel dissections, flap transfers to the defect, and microvascular anastomosis—would help residents gain confidence and master these difficult major reconstructive microsurgery procedures. Formalin embalmed bodies lack natural softness and many other features of a live body. Many soft embalming techniques have evolved to mimic live tissue and Theil technique is the most popular one among them. We explored alternate soft embalming options and started using Genelyn.

Materials and Methods  Over a span of 2 years (2019–2021), we have conducted three flap dissection workshops using soft-embalmed cadavers. Six soft-embalmed and two formalin-embalmed cadavers were used. Total number of participants was 80.

Results  Feedback of experience from the third course participants in the form of grades (1–5) for different criteria was obtained and evaluated. Confidence in the dissection of the various flaps and microsurgery is noticeable in all the participants.

Conclusion  Based on our experience, we propose that flap dissection and microsurgery training on soft-embalmed cadavers be included as a teaching module in the plastic surgery postgraduate curriculum.

Porcine As a Training Module for Head and Neck Microvascular Reconstruction

Live models that resemble surgical conditions of humans are needed for training free-flap harvesting and anastomosis. Animal models for training purposes have been available for years in many surgical fields. We used the female (because they are easy to handle for the procedure) Yorkshire pigs for the head and neck reconstruction by harvesting the deep inferior epigastric artery perforator or the superior epigastric artery perforator flap. The anastomosis site (neck skin defect or tracheal wall defect) was prepared via the dissection of the common carotid artery and the internal jugular vein, in which 3.5× loupe magnification was used for anastomosis as we use on human cases in real life. This procedure demonstrates a new training method using a reliable learning model and provides a detailed anatomy in a live scenario. We focused on the ischemia time, harvesting, vessel anastomosis, and designing the flap to fit the defect site. This model improves tissue handling and with the use of proper instruments can be repeated many times so that the surgeon is fully confident before starting the surgery on humans.

An enhanced fresh cadaveric model for reconstructive microsurgery training

BACKGROUND

Performing microsurgery requires a breadth and depth of experience that has arguably been reduced as result of diminishing operating exposure. Fresh frozen cadavers provide similar tissue handling to real-time operating; however, the bloodless condition restricts the realism of the simulation. We describe a model to enhance flap surgery simulation, in conjunction with qualitative assessment.

METHODS

The fresh frozen cadaveric limbs used in this study were acquired by the University. A perfused fresh cadaveric model was created using a gelatin and dye mixture in a specific injection protocol in order to increase the visibility and realism of perforating vessels, as well as major vessels. A questionnaire was distributed amongst 50 trainees in order to assess benefit of the model. Specifically, confidence, operative skills, and transferable procedural-based learning were assessed.

RESULTS

Training with this cadaveric model resulted in a statistically significant improvement in self-reported confidence (p < 0.005) and prepared trainees for unsupervised bench work (p < 0.005). Respondents felt that the injected model allowed easier identification of vessels and ultimately increased the similarity to real-time operating. Our analysis showed it cost £10.78 and took 30 min.

CONCLUSIONS

Perfusion of cadaveric limbs is both cost- and time-effective, with significant improvement in training potential. The model is easily reproducible and could be a valuable resource in surgical training for several disciplines.Level of Evidence: Not ratable.

[Application of free anterolateral thigh Kiss flap in repair of large scalp defect after malignant tumor resection]

Objective

To investigate the effectiveness of free anterolateral thigh Kiss flap in repair of large scalp defect after malignant tumor resection.

Methods

Between December 2012 and December 2016，18 patients with large scalp defect after malignant tumor resection were treated. There were 16 males and 2 females with an average age of 52.6 years (range, 43-62 years). There were 17 cases of squamous carcinoma and 1 case of dermatofibrilsarcoma protuberan. The size of scalp defect ranged from 15 cm×10 cm to 17 cm×12 cm after resection of tumors. The scalp defects were repaired with the free anterolateral thigh Kiss flap. And the size of flap ranged from 15 cm×6 cm to 20 cm×8 cm. The skull was completely resected in 2 cases, and repaired with Titanium mesh. The sizes of skull defects were 12 cm×10 cm and 10 cm×8 cm. The donor site was sutured directly.

Results

Eighteen flaps survived with primary healing of wounds; and healing by first intention was obtained at the donor sites. One patient died because of intracranial metastasis at 5 months after operation, and no local recurrence occurred in the other 17 patients. The follow-up time ranged from 6 months to 4 years (mean, 26.6 months). The results of both appearance and function were satisfactory, without ulceration during follow-up. No obvious scar was found at donor sites and no obvious impairment was observed after harvesting free anterolateral thigh flap.

Conclusion

Large scalp defects after malignant tumor resection can be effectively repaired by free anterolateral thigh Kiss flap. The donor site can be sutured directly, without skin grafting, thus avoiding the secondary donor site.