Simulation in plastic surgery training and education: the path forward

Artificial Intelligence in Plastic Surgery: Insights from Plastic Surgeons, Education Integration, ChatGPT's Survey Predictions, and the Path Forward

Background

Artificial intelligence (AI) is emerging as a transformative technology with potential applications in various plastic surgery procedures and plastic surgery education. This article examines the views of plastic surgeons and residents on the role of AI in the field of plastic surgery.

Methods

A 34-question survey on AI's role in plastic surgery was distributed to 564 plastic surgeons worldwide, and we received responses from 153 (26.77%) with the majority from Latin America. The survey explored various aspects such as current AI experience, attitudes toward AI, data sources, ethical considerations, and future prospects of AI in plastic surgery and education. Predictions from AI using ChatGPT for each question were compared with the actual survey responses.

Results

The study found that most participants had little or no prior AI experience. Although some believed AI could enhance accuracy and visualization, opinions on its impact on surgical time, patient recovery, and satisfaction were mixed. Concerns included patient privacy, data security, costs, and informed consent. Valuable AI training data sources were identified, and there was agreement on the importance of standards and transparency. Respondents expected AI's increasing role in reconstructive and aesthetic surgery, suggesting its integration into residency programs, addressing administrative challenges, and patient complications. Confidence in the enduring importance of human professionals was expressed, with interest in further AI research.

Conclusion

The survey's findings underscore the need to harness AI's potential while preserving human professionals' roles through informed consent, standardization, and AI education in plastic surgery.

[Goal-setting in Plastic Surgery using the SMART principle]

INTRODUCTION

The process of continuous acquisition of surgical expertise is a key element in registrar training. The principle of active, self-directed learning, which is regularly applied in medical school, can also be used to gain surgical expertise in registrar training.

METHODS

Surgical training can be compared to acquiring expertise in music or sport, where both intellectual and manual capabilities are required. Specific training principles, including analysis, goal setting, practice and reflection on the process, are commonly encountered in these fields. Smart goal setting is preferred in order to ensure compliance and a successful strategy. This can also be used in plastic surgery training.

APPLICATION

Surgical principles as well as partial or complete surgical procedures can be practiced using the smart principle. The fragmentation of a larger task into smaller units allows rapid acquisition of surgical expertise without impeding patient safety.

DISCUSSION

Surgical training today happens in a setting caught between economic and medicolegal challenges. The reduction of case load requires simulation practice as well as self-directed learning - which has been shown to improve outcomes. The smart principle allows distinct goal setting which can improve compliance of the student and increase success. As this form of learning is not intuitive to all individuals, supervisors and mentor can support trainees in the acquisition of surgical expertise using this principle.

Competency-Based Education: Will This be the New Training Paradigm in Plastic Surgery?

The Accreditation Council for Graduate Medical Education created the "Next Accreditation System" in 2013 requiring residents to meet educational milestones based on core competencies over the course of their training. The 6 core competencies include patient care and technical skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Since the traditional time-based model requires a predetermined length of training irrespective of learning style, pace, or activity, a competency-based model is appealing because it refocuses education on deliberate and relevant skills acquisition and retention. Plastic surgery has been slowly transitioning to competency-based education (CBE), thereby permitting residents to learn at their own pace to master each competency. We performed a nonsystematic literature review of the efficacy of CBE and implementation efforts, particularly within plastic surgery. The literature revealed perceived barriers to implementation, as well as the nuts and bolts of implementation. We highlighted possible solutions and training tools with practical applications in plastic surgery. Success of CBE in plastic surgery requires instituting a transparent process that involves continuously piloting multiple assessment tools and a discussion of related costs. CBE may be particularly appealing for trainees focused on further training in craniofacial or pediatric plastic surgery after completion of an integrated or independent training program in plastic surgery to allow them to focus on their career interests once competence is achieved in the core skills required of a plastic surgeon.

Simulation in plastic and reconstructive surgery: a scoping review

Since the origins of surgery, simulation has played an important role in surgical education, particularly in plastic and reconstructive surgery. This has greater relevance in contemporary settings of reduced clinical exposure resulting in limited work-based learning opportunities. With changing surgical curricula, it is prescient to examine the role of simulation in plastic and reconstructive surgery.

A scoping review protocol was used to identify relevant studies, with an iterative process identifying, reviewing and charting the data to derive reported outcomes and themes.

Of the 554 studies identified, 52 studies were included in this review. The themes identified included simulator modalities, curriculum elements targeted and relevant surgical competencies. There was a predominance of synthetically based simulators, targeting technical skills largely associated with microsurgery, paediatric surgery and craniomaxillofacial surgery.

Existing simulators largely address high-complexity procedures. There are multiple under-represented areas, including low-complexity procedures and simulation activities addressing communication, collaboration, management and leadership. There are many opportunities for simulation in surgical education, which requires a contextual appreciation of educational theory. Simulation may be used both as a learning method and as an assessment tool.

This review describes the literature relating to simulation in plastic and reconstructive surgery and proposes opportunities for incorporating simulation in a broader sense, in the surgical curriculum.

Training on skin flap elevation in hand surgery using cadavers embalmed by the saturated salt solution method: effectiveness and usefulness

Thiel embalmed and fresh-frozen cadavers have been mainly used for hand surgery training. We held a training seminar on skin flap elevation using cadavers embalmed by the saturated salt solution method. This study aimed to evaluate the usefulness of such training and to validate the suitability of saturated salt solution-embalmed cadavers for hand surgery training. Participants were trained in elevation procedures for the oblique triangular, reverse digital artery, reverse radial forearm, and reverse dorsal metacarpal artery flaps. Forty-eight surgeons participated in three seminars (one held in 2017, 2018, and 2019 each). A self-assessment of the participants' confidence levels for their surgical skills was performed before and immediately after the seminar, and the suitability of saturated salt solution-embalmed cadavers was determined in terms of visual perception, tactility, comparison with real-world surgical settings, and usefulness. The confidence level for all skills increased immediately after the seminar. The surgeons reported that the visual perception and tactility of the saturated salt solution-embalmed cadavers were comparable to those of a living body, and the cadavers were rated higher with respect to their usefulness. Hand surgery seminars using cadavers embalmed by the saturated salt solution method are considered useful for training in skin flap techniques.

An Innovative Skin Simulation Model to Augment Competency-based Training in Facial Plastic Surgery

Introduction  Competency-based medical education (CBME) approach in the medical curriculum has been introduced globally with the goal of providing flexibility, accountability, and learner-centeredness among medical learners. Traditional surgical skill training in most places has relied on “see one, do one, teach one model,” while simulation model-based training has been shown to improve competencies in surgical trainees. We wanted to assess the usefulness of a hydrophilic barrier adhesive foam wound dressing as a novel skin simulation model for learning biomechanics and practice of cutaneous flaps among plastic surgical resident trainees at our institute.

Materials and Methods  An absorbent, soft polyurethane foam pad located centrally upon a larger polyurethane membrane, coated with a hydrocolloid adhesive, forming an island dressing, was used as a simulation model for this study. It was obtained from the hospital store either after or nearing their expiry dates of clinical use. Plastic surgery residents in different years of training were invited to participate in a simulation workshop, using this novel model, and give their feedback.

Results  Seventeen residents in different plastic surgery training levels participated in the workshop and gave their feedback on the skin flap simulation model. The simulation model received extremely high (100%) scores on two parameters, namely, utility for flap and suture practice and high scores (88%–94%) for texture, ability to mark, and improving confidence among trainees.

Conclusions  Adhesive bilayer polyurethane foam can be used as a novel cutaneous skin flap simulation model for understanding the biomechanics of skin flaps and cutaneous flap practice.

Efficacy of an Online Blended Learning Curriculum to Improve Medical Student Urologic Education

OBJECTIVE

During the COVID-19 pandemic, limitations on in-person medical school clerkships created a deficit in urologic learning opportunities. We sought to develop and evaluate a blended curriculum of interactive online modules with small-group discussion to enhance the educational experience for medical students in urology.

MATERIALS AND METHODS

We created a curriculum of four online case-based urology modules. Between July and October 2020, 14 fourth-year medical students completed the modules. Students answered questions on a discussion board and engaged in asynchronous dialogue with 16 physicians, in addition to a weekly live review session. Students and physicians completed anonymous surveys to assess satisfaction and perceived learning outcomes, with questions scored on a 5-point Likert scale.

RESULTS

Thirteen students (93% response rate) and 12 physicians (75% response rate) completed the survey. Overall, 12/13 students and 11/12 physicians "strongly agree" or "somewhat agree" that the modules improved the rotation. Students and physicians perceived that the modules were effective for learning/teaching foundational knowledge (average ratings 4.8 and 4.5, respectively) and facilitating performance assessment (4.4 and 4.0). Students reported high learning scores across multiple Accreditation Council for Graduate Medical Education core competencies, and 12/13 students found the modules fun/engaging. The majority of students (12/13) and physicians (10/12) felt that the online modules should be incorporated into future urology electives.

CONCLUSIONS

A blended learning curriculum utilizing online modules is an effective tool for enhancing urologic education, improving perceived learning outcomes and facilitating performance assessment.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-021-01427-3.

MicrosimUC: Validation of a Low-Cost, Portable, Do-It-Yourself Microsurgery Training Kit

BACKGROUND

 Microsurgery depends largely on simulated training to acquire skills. Courses offered worldwide are usually short and intensive and depend on a physical laboratory. Our objective was to develop and validate a portable, low-cost microsurgery training kit.

METHODS

 We modified a miniature microscope. Twenty general surgery residents were selected and divided into two groups: (1) home-based training with the portable microscope (MicrosimUC, n = 10) and (2) the traditional validated microsurgery course at our laboratory (MicroLab, n = 10). Before the intervention, they were assessed making an end-to-end anastomosis in a chicken wing artery. Then, each member of the MicrosimUC group took a portable kit for remote skill training and completed an eight-session curriculum. The laboratory group was trained at the laboratory. After completion of training, they were all reassessed. Pre- and posttraining procedures were recorded and rated by two blind experts using time, basic, and specific scales. Wilcoxon's and Mann-Whitney tests were used to compare scores. The model was tested by experts (n = 10) and a survey was applied to evaluate face and content validity.

RESULTS

 MicrosimUC residents significantly improved their median performance scores after completion of training (p < 0.05), with no significant differences compared with the MicroLab group. The model was rated very useful for acquiring skills with 100% of experts considering it for training. Each kit had a cost of U.S. $92, excluding shipping expenses.

CONCLUSION

 We developed a low-cost, portable microsurgical training kit and curriculum with significant acquisition of skills in a group of residents, comparable to a formal microsurgery course.

Mind the Gap: a Competency-Based Scoping Review of Aesthetic and Reconstructive Reported Simulation Training Models

BACKGROUND

Simulation training has become an integral part of plastic surgery postgraduate curricula. It facilitates the acquisition of skills in a safe environment that can be later transferred to real-life settings. A variety of models have been described covering some aspects of the specialty better than others. The aim of this study was to identify and classify all the previously reported plastic surgery simulation models and the possible gaps having the Accreditation Council for Graduate Medical Education (ACGME) list of competencies as a guide.

METHODS

Through a Delphi process, the complete list of ACGME minimum requirements for certification was analyzed to identify domains amenable for simulation training. A systematic search was conducted in Pubmed looking for all previously reported simulation models in plastic surgery. Predefined inclusion and exclusion criteria and parallel blind review were used to identify eligible models.

RESULTS

A total of 81 ACGME competencies were identified. Following a 3-round Delphi process, consensus was reached on 19 reconstructive and 15 aesthetic surgery domains suitable for simulation training. 1667 articles were initially retrieved from Pubmed, of which 66 articles were eligible for inclusion. Descriptive (65%), quasi-experimental (24%) and experimental studies (11%) were found. For the 34 identified ACGME competencies, there were simulation models described for 58.8% of these, mostly covering reconstructive surgery (84.2%) while for aesthetic surgery it was 13.3%.

CONCLUSIONS

This scoping review has identified that there are still gaps in ACGME competencies that could benefit from new simulation training models, especially in those related to aesthetic surgery.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The role of simulation in training breast surgeons: a systematic review

BACKGROUND

As surgical education has evolved, most curricula have favoured a competency-based approach over traditional apprenticeship models. Surgical simulation can be a useful aide in the training of both oncological and reconstructive breast surgery trainees. This review investigates the extent to which simulation of breast surgery procedures has been validated as a training tool.

METHODS

A comprehensive literature search for studies evaluating the objective validity of breast surgery simulators was performed, using MEDLINE, EMBASE and the Cochrane Library databases. Studies assessing construct, concurrent or predictive validity were included, as well as those demonstrating skill acquisition.

FINDINGS

The initial literature search returned 1,625 hits, with only five articles meeting the inclusion criteria. Simulators were designed to train procedures such as breast augmentation, lesion biopsy and excision. Of these, breast biopsy was the most simulated procedure (three studies). Two studies evaluated animal models, two evaluated synthetic models and one study assessed both a synthetic and animal model. Construct validity was confirmed in two studies, concurrent validity in one study and a learning curve demonstrated in another study. No association between experience and performance was seen in the remaining study. The quality of the evidence presented in each article was low due to numerous limitations. Despite the abundance of breast surgery simulators created for trainees, few have been objectively validated and they only cover a narrow range of breast procedures. Although early results are promising, further studies are required before routine use of simulators is considered in breast surgery curricula.

Virtual reality simulation in plastic surgery training. Literature review

Major changes have occurred in the medical environment leading to an evolution from the traditional residency programmes to competency-based ones. Virtual reality (VR) represents a promising simulation resource for surgical training. Several types of VR simulators can be considered, depending on the level of immersion they offer. The goal of the article is to review the progress of VR simulation in plastic surgery (PS) training. A systematic search of the literature was performed on PUBMED/MEDLINE with the following key words: (Simulation OR Virtual Reality) AND (Education OR Training) AND Plastic Surgery from January 1998 to September 2019. A total of 244 results were found, and 80 of them were selected for abstract review. Sixty-four articles were selected for complete reading. Several attempts have been made to create VR simulators and most of them are non-immersive or partially immersive. The main conclusions of them are summarized. VR simulation has been proven to have a role in PS training, offering many advantages. Furthermore, VR simulation can be used for safety training, team interaction and decision-making education. Validation is a key point for acceptance of simulators. Further efforts are required to include simulation in PS curricula.

Development of a novel mandibular distraction osteogenesis simulator using Computer Aided Design and 3D printing

INTRODUCTION

Micrognathia, a component of Robin Sequence, can cause glossoptosis, failure of palatal fusion, and critical obstruction of the airway. Mandibular distraction osteogenesis (MDO) is at times offered to anteriorly translate the mandible and tongue, relieving airway obstruction. MDO is an intricate reconstructive procedure that may be ideal for teaching using a high-fidelity educational simulator, allowing early hands-on experience in a zero-risk environment.

OBJECTIVES

To design a novel, low-cost, high-fidelity neonatal MDO simulator that can be used for trainee education and refinement of surgical technique.

METHODS

A novel MDO simulator was developed using additive manufacturing techniques. Three experts in MDO surgery completed a 20-item survey, rating the simulator's physical attributes, the realism of experience, the simulator's value, its relevance to practice and the surgeon's ability to perform tasks on a 4-point Likert scale.

RESULTS

Computer Aided Design (CAD) and 3D printing allowed for the production of a realistic surgical simulator that emulates important aspects of MDO surgery. This preliminary evaluation indicated adequate means across the five domains relevant to the simulator's fidelity and usability (M = 3.33 to 3.75) out of a maximum of 4 points. Lowest rated items were consistent with expert comments allowing future refinement on subsequent iterations. Consumable material costs per model were $9.39 USD.

CONCLUSIONS

The MDO model demonstrated adequate fidelity and holds promise as a skill-development tool for surgeons in training. Further studies are planned to determine its utility as a training and assessment tool.

A Training Model for Local Flaps Using Fresh Human Skin Excised During Body Contouring Procedures

BACKGROUND

The safe execution of local flaps tends to be challenging for surgical residents. Thus, the purpose of the study was to evaluate a training model of local flaps based on fresh human skin excised from body contouring procedures.

MATERIALS AND METHODS

A questionnaire and surgical skills evaluation-analyzing the theoretical and procedural knowledge about local flaps-were held both before and after the surgical skills training. All surgical procedures were executed on a simulation model based on fresh human skin. Skills evaluation was done according to a modified version of the Objective Structured Assessment of Technical Skills Score. Results before and after the training were compared using SPSS, version 21.

RESULTS

In pretraining evaluation, residents showed great difficulty regarding the accuracy of flap design and sufficiency of wound coverage indicating the need for surgical training outside the operating theater. After training, the procedural skills significantly improved as depicted by the modified Objective Structured Assessment of Technical Skills score with a mean cumulative pretraining score of 26.81 ± 5.41 and posttraining score of 43.59 ± 5.72 (P = 0.008). Also, theoretical knowledge significantly improved in the posttraining evaluation with exception to the indication of a Z-plasty (P = 0.257). The training model itself was generally regarded as highly useful and thus recommendable to others.

CONCLUSIONS

Surgical handling and the understanding of tissue rotation clearly improved by the presented model which mimics very realistic conditions. The simulation model based on fresh human skin shows cost-effectiveness and allows a broad range for flap procedures wherefore its use should be further promoted.

Plastic Surgery Fellowship at Nippon Medical School Hospital: An Integrative Approach to Modern Plastic Surgery Education

Plastic surgery requires extensive wide-ranging surgical knowledge, special technical dexterity, and personal skills in order to achieve improved quality of life and satisfying outcomes for patients. For decades, international plastic surgery fellowship programs have offered opportunities to enhance the subspecialty training of young plastic surgeons abroad and promote international exchange of information in the field of plastic surgery. However, concerns around enrolling in a nontraditional educational strategy at the postgraduate level have restricted young plastic surgery residents from pursuing comprehensive training opportunities overseas. Therefore, we present a personal experience of a distinct established international fellowship program in plastic, reconstructive, and aesthetic surgery at Nippon Medical School Hospital, Japan, as an example. This institution has adopted the use of highly skilled surgical techniques, providing basic research education along with the teaching of essential personal skills needed in modern plastic surgery. As a mean to promote international educational collaboration in plastic surgery, we discussed the modern plastic surgery educational strategies worldwide that participate in developing a successful plastic surgeon’s career.

Simulation-Based Comprehensive Cleft Care Workshops: A Reproducible Model for Sustainable Education

OBJECTIVE

Evaluate simulation-based comprehensive cleft care workshops as a reproducible model for education with sustained impact.

DESIGN

Cross-sectional survey-based evaluation.

SETTING

Simulation-based comprehensive cleft care workshop.

PARTICIPANTS

Total of 180 participants.

INTERVENTIONS

Three-day simulation-based comprehensive cleft care workshop.

MAIN OUTCOME MEASURES

Number of workshop participants stratified by specialty, satisfaction with the workshop, satisfaction with simulation-based workshops as educational tools, impact on cleft surgery procedural confidence, short-term impact on clinical practice, medium-term impact on clinical practice.

RESULTS

The workshop included 180 participants from 5 continents. The response rate was 54.5%, with participants reporting high satisfaction with all aspects of the workshop and with simulation-based workshops as educational tools. Participants reported a significant improvement in cleft lip (33.3 ± 5.7 vs 25.7 ± 7.6; P < .001) and palate (32.4 ± 7.1 vs 23.7 ± 6.6; P < .001) surgery procedural confidence following the simulation sessions. Participants also reported a positive short-term and medium-term impact on their clinical practices.

CONCLUSION

Simulation-based comprehensive cleft care workshops are well received by participants, lead to improved cleft surgery procedural confidence, and have a sustained positive impact on participants' clinical practices. Future efforts should focus on evaluating and quantifying this perceived positive impact, as well reproducing these efforts in other areas of need.

Plastic Surgery Lockdown Learning during Coronavirus Disease 2019: Are Adaptations in Education Here to Stay?

Summary: The novel coronavirus disease 2019 has had a major impact on human life and livelihood. The unprecedented challenges have expanded beyond just social and work life, and have grown to impact resident education. In this article, we review the structure of plastic surgery education before the pandemic, the different online learning opportunities for self-directed learning. A summary of the range of platforms and approaches of online remote access delivery of conferences and education that emerged or expanded as a result of the crisis has been reported. This article highlighted the rapid initiatives and efforts of programs and national and international societies to support continuing medical education in conjunction with the guidelines to “shelter at home” and maintain social distancing, and possible future for expanding the reach of online academic initiatives, in addition to the role of developing virtual technologies. The coronavirus disease 2019 crisis has created an opportunity to analyze and advance online learning options to overcome the associated challenges and continue as a reliable platform even following the resolution of the social distancing requirements.

Modeling and Clinical Application of Incision Space in Facial Contour Surgery

Virtual simulation surgical system is a good way to develop surgical instruments, make surgical plan, and train surgeons. At present, due to the deformation of intraoperative soft tissue after retraction and the lack of effective data collection, the surgical simulation of facial contour surgery can only be conducted according to the preoperative computed tomography data. Due to the difficulty of obtaining real operative spatial data, it is difficult for the virtual surgery trajectory planning process to yield a good effect on surgeon training. In this study, an optical tracking device was used to record the actual posture of surgical instruments, patient position, and incision space in the surgical environment, so as to construct a more accurate actual surgical space. The clinical data obtained in this study can be used for virtual simulation of surgical instrument movement and osteotomy, as well as selection, planning, and teaching purposes of surgical programs.

Use of Simulation in Plastic Surgery Training

The nationwide focus on patient safety and the health of residents has increased the demand for educational tools outside the operating room. Simulation is a valuable tool for assessing and developing surgical skills in a controlled and safe environment. The use of simulation as a formal component of training has been increasing in various surgical subspecialties. In general surgery, simulation examinations such as the Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery have become a prerequisite to board certification. Although formal simulation examinations in plastic surgery are not universal, there has been an increase in the use of simulation to increase resident competency in the operating room. For now, we will review the current state of simulation in craniofacial, hand, microvascular, and esthetic surgery and discuss applications for the future. We will also discuss the evolving role of artificial intelligence, virtual reality, and augmented reality in plastic surgery training and testing.

Graduate perception of cosmetic surgery training in plastic surgery residency and fellowship programs

BACKGROUND

As the demand for cosmetic surgery continues to rise, plastic surgery programs and the training core curriculum have evolved to reflect these changes. This study aims to evaluate the perceived quality of current cosmetic surgery training in terms of case exposure and educational methods.

METHODS

A 16-question survey was sent to graduates who completed their training at a U.S. plastic surgery training program in 2017. The survey assessed graduates' exposure to cosmetic surgery, teaching modalities employed and their overall perceived competence. Case complexity was characterized by the minimum number of cases needed by the graduate to feel confident in performing the procedure.

RESULTS

There was a 25% response rate. The majority of respondents were residents (83%, n=92) and the remaining were fellows (17%, n=18). Almost three quarters of respondents were satisfied with their cosmetic training. Respondents rated virtual training as the most effective learning modality and observing attendings' patients/cases as least effective. Perceived competence was more closely aligned with core curriculum status than case complexity, i.e. graduates feel more prepared for core cosmetic procedures despite being more technically difficult than non-core procedures.

CONCLUSIONS

Despite the variability in cosmetic exposure during training, most plastic surgery graduates are satisfied with their aesthetic training. Incorporation of teaching modalities, such as virtual training, can increase case exposure and allow trainees more autonomy. The recommended core curriculum is adequately training plastic surgery graduates for common procedures and more specialized procedures should be consigned to aesthetic fellowship training.

Concepts of Organizational Excellence in Medical Associations

Professional associations are integral to the field of medicine; every physician becomes affiliated with at least 1 association throughout his/her entire career. Obtaining membership in such groups advances career development, engages in mentorship, and contributes in legislation and advocacy. Numerous studies have reported the benefits of teamwork in health care, but few have thoroughly investigated the characteristics that lead to organizational success. This article aims to provide a conceptual model for successful high-performing organizations and discuss their fundamental qualities, including structure, trust, productive conflict, accountability, collective success, and leadership. Additionally, we shared evidence-based techniques to establish and maintain these ideals.

Simulation in Cleft Surgery

A number of digital and haptic simulators have been developed to address challenges facing cleft surgery education. However, to date, a comprehensive review of available simulators has yet to be performed. Our goal is to appraise cleft surgery simulators that have been described to date, their role within a simulation-based educational strategy, the costs associated with their use, and data supporting or refuting their utility.

Development of a high fidelity subglottic stenosis simulator for laryngotracheal reconstruction rehearsal using 3D printing

INTRODUCTION

Laryngotracheal reconstruction (LTR) with cartilage graft augmentation is an effective treatment for subglottic stenosis and a critical advanced procedure for Pediatric Otolaryngologists. Trainees almost exclusively learn this procedure intraoperatively on children due to the lack of adequate pediatric training models. An enhanced and accelerated educational experience may be possible if trainees can rehearse the key portions of the procedure on a simulation model.

OBJECTIVE

To design and manufacture a low-cost, high fidelity surgical simulation model of subglottic stenosis for LTR.

METHODS

This simulator is composed of two component models: rib cartilage and trachea. Additive manufacturing techniques, including Computer Aided Design and Three Dimensional (3D) printing, were utilized to create the simulator. Three expert Pediatric Otolaryngologists rated the functionality and realism of the simulator using Likert scale survey data.

RESULTS

The use of CAD and 3D printing techniques allowed for realistic, reproducible surgical simulation of key aspects of LTR. The validation evidence indicated good to excellent means across the five domains relevant to the simulator's fidelity and usability (M = 3.47 to 4.00) out of a maximum of 4 points. Lowest rated items were consistent with expert comments suggesting minor simulator improvements. Time of production is approximately 20 h from print to post-processing, and consumable material costs per model are $2.60 USD.

CONCLUSIONS

This subglottic stenosis airway simulator facilitated Laryngotracheal Reconstruction rehearsal and is a promising training tool for pediatric otolaryngologists. Our methods allow patient-specific, pre-surgical rehearsal for complex airway scenarios that could benefit the experienced airway surgeon and trainees alike. Future research aims to validate this device's utility for accelerating attainment of proficiency and improving surgical outcomes.

The Use of Patient-Specific Three-Dimensional Printed Surgical Models Enhances Plastic Surgery Resident Education in Craniofacial Surgery

PURPOSE

A significant challenge in surgical education is to provide a meaningful hands-on experience with the pathology the trainee will see in independent practice. Craniofacial anatomy is challenging and unfamiliar to the learner.

METHODS

Using preoperative computed tomography data, the authors produced an accurately sized, three-dimensional (3D) printed model of the congenital craniofacial anatomy of patients treated by the same attending surgeon-PGY4 resident surgeon pair over the course of a 6-month rotation. A preoperative stepwise surgical plan was written by the attending and resident, and the plan was marked on the 3D model by the attending and resident separately. The written and marked plans were measured for accuracy and time to completion. The resident surgeon's applicable milestone levels were assessed.

RESULTS

Seven congenital craniofacial anomalies met criteria for inclusion: 4 craniosynostosis cases, 2 mandibular distractions, and 1 LeFort I distraction. The number of inaccuracies of the written plan improved from 5 to 0 for sagittal synostosis and 4 to 0 for mandibular distraction. The time to complete the written plan decreased by 22% for sagittal synostosis and 45% for mandibular distraction. The number of inaccuracies of the marked plan decreased from 5 to 0 for sagittal synostosis and 2 to 0 for mandibular distraction. Time to completion of the marked plan decreased by 76% for sagittal synostosis and 50% for mandibular distraction. Milestone scores increased an average of 1.875 levels.

CONCLUSION

Three-dimensional printed craniofacial models are a positive addition to resident training and have been objectively quantified to improve the accuracy and time to completion of the surgical plan as well as progression in the plastic surgery milestones.

Maximizing Plastic Surgery Education Impact: Lessons from Resident Learning Styles and Experiential Learning Theory

Residents in many surgical disciplines express a strong preference for hands-on learning, but no studies have focused on plastic surgery. This initial study aims to ascertain the learning styles of plastic surgery residents, and identify potential trends that may better guide curriculum development.

Methods

Kolb Learning Style Index v. 3.1 was administered to plastic surgery residents across all training levels at three residency programs. The Kolb Learning Style Index is a 12-item questionnaire that characterizes an individual's learning style into 1 of 4 major categories: converging; accommodating; assimilating; and diverging.

Results

The surveyed cohort of plastic surgery residents (n = 45) demonstrated a diverse mix of learning styles: converging (38%, n = 17); accommodating (24%, n = 11); diverging (20%, n = 9); and assimilating (16%, n = 7). One resident was balanced between converging and accommodating (2%, n = 1). Despite varied learning styles, the majority (64%, n = 29) demonstrated a preference for "active experimentation," for example, hands-on learning.

Conclusions

A preliminary assessment of learning styles among plastic surgery residents suggests that they have mixed learning styles. This contrasts with the existing literature from other surgical specialties where a single learning style dominates. However, like these other specialties, active experimentation is particularly valued. As such, it behooves the plastic surgery educator to continue to strive for balance between book learning and hands-on experience for residents at all levels of training, to engage residents with all learning styles.

3-DIEPrinting: 3D-printed Models to Assist the Intramuscular Dissection in Abdominally Based Microsurgical Breast Reconstruction

Supplemental Digital Content is available in the text.

Harvest of the deep inferior epigastric vessels for microsurgical breast reconstruction can be complicated by an intricate and lengthy subfascial dissection. Although multiple preoperative imaging modalities exist to help visualize the vascular anatomy and assist in perforator selection, few can help clearly define the intramuscular course of these vessels. The authors introduce their early experience with 3D-printed anatomical modeling (to-scale) of the infraumbilical course of the deep inferior epigastric subfascial vascular tree to better assist in executing the intramuscular dissection.

A Reusable Perfused Human Cadaver Model for Surgical Training: An Initial Proof of Concept Study

OBJECTIVES

Today's surgical trainees have less exposure to open vascular and trauma procedures. Lightly embalmed cadavers may allow a reusable model that maximizes resources and allows for repeat surgical training over time.

METHODS

This was a three-phased study that was conducted over several months. Segments of soft-embalmed cadaver vessels were harvested and perfused with tap water. To test durability, vessels were clamped, then an incision was made and repaired with 5-0 polypropylene. Tolerance to suturing and clamping was graded. In a second phase, both an arterial-synthetic graft and an arterial-venous anastomosis were performed and tested at 90 mmHg perfusion. In the final phase, lower extremity regional perfusion was performed and vascular control of a simulated injury was achieved.

RESULTS

Seven arteries and six veins from four cadavers were explanted. All vessels accommodated suture repair over 6 weeks. There was minor leaking at all previous clamp sites. In the anastomotic phase, vessels tolerated grafting, clamping, and perfusion without tearing or leaking. Regional perfusion provided a life-like training scenario.

CONCLUSIONS

Explanted vessels of soft-embalmed cadavers show adequate durability over time with realistic vascular surgery handling characteristics. This shows promise as initial proof of concept for a reusable perfused cadaver model. Further study with serial regional and whole-body perfusion is warranted.

How Educational Theory Can Inform the Training and Practice of Plastic Surgeons

It is important to optimize our current learning and teaching models, particularly in a climate of decreased clinical exposure. With technical advancements and clinical care now more accountable, traditional methods of skill acquisition need to be revisited. The past decade has seen changes in plastic surgery curricula. There has also been a shift toward competency-based training programs reflecting the growing emphasis on outcomes-based surgical education. This review explores the role of educational theory in promoting effective learning in practical skills teaching. Key models of educational theory are presented and their application to plastic surgery training to an expert level are highlighted. These models include (1) learning within communities of practice (Lave and Wenger’s theory); (2) the role of the zone of proximal development and importance of the availability of expert assistance (Vygotsky’s theory); (3) skill acquisition and retention (Dreyfus’ and Dreyfus’, and Fitts’ and Posner’s theories); (4) development of expertise after repeated practice and regular reinforcement (Ericsson’s theory); and (5) the assessment of competence (Miller’s triangle). Future plastic surgeons need to possess a thorough understanding of the technical and nontechnical skills required to manage patients effectively. Surgical educators are therefore compelled to develop practical training programs that can teach each of these skills in a safe, learner-centric manner. It is hoped that new approaches to surgical skills training are designed in light of our understanding of educational theory to optimize the training of the next generation of plastic surgeons.

Current status of simulation training in plastic surgery residency programs: A review

Increased emphasis on competency-based learning modules and widespread departure from traditional models of Halstedian apprenticeship have made surgical simulation an increasingly appealing component of medical education. Surgical simulators are available in numerous modalities, including virtual, synthetic, animal, and non-living models. The ideal surgical simulator would facilitate the acquisition and refinement of surgical skills prior to clinical application, by mimicking the size, color, texture, recoil, and environment of the operating room. Simulation training has proven helpful for advancing specific surgical skills and techniques, aiding in early and late resident learning curves. In this review, the current applications and potential benefits of incorporating simulation-based surgical training into residency curriculum are explored in depth, specifically in the context of plastic surgery. Despite the prevalence of simulation-based training models, there is a paucity of research on integration into resident programs. Current curriculums emphasize the ability to identify anatomical landmarks and procedural steps through virtual simulation. Although transfer of these skills to the operating room is promising, careful attention must be paid to mastery versus memorization. In the authors’ opinions, curriculums should involve step-wise employment of diverse models in different stages of training to assess milestones. To date, the simulation of tactile experience that is reminiscent of real-time clinical scenarios remains challenging, and a sophisticated model has yet to be established.

Haptic, Physical, and Web-Based Simulators: Are They Underused in Maxillofacial Surgery Training?

PURPOSE

Surgical residencies have increasingly incorporated both digital and mannequin simulation into their training programs. The aim of our review was to identify all digital and mannequin maxillofacial simulators available for education and training, highlight their benefit, and critically assess the evidence in support of these educational resources.

MATERIALS AND METHODS

We performed a comprehensive literature review of all peer-reviewed publications of digital and mannequin simulators that met the inclusion criteria, defined as any simulator used in education or training. All simulators used in surgical planning were excluded. Before the query, it was hypothesized that most studies would be descriptive in nature and supported by low levels of evidence. Literature search strategies included the use of multiple combinations of key search terms, review of titles and abstracts, and precise identification of the use of the simulator described. All statistics were descriptive.

RESULTS

The primary search yielded 259 results, from which 22 total simulators published on from 2001 to 2016 were identified using the inclusion and exclusion criteria: 10 virtual reality haptic-based simulators, 6 physical model simulators, and 6 Web-based simulators used for a variety of procedures such as dental skills, instrument handling, orthognathic surgery (Le Fort I osteotomy, vertical ramus osteotomy, bilateral sagittal split ramus osteotomy), genioplasty, bone grafting, sinus surgery, cleft lip repair, orbital floor repair, and oral biopsy. Only 9 formalized studies were completed; these were classified as low-level evidence-based cohort studies (Levels IV and V). All other simulator reports were descriptive in nature. There were no studies with high levels of evidence completed (Level I to III).

CONCLUSIONS

The results of this review suggest that, although seemingly beneficial to the trainee in maxillofacial surgery, simulation in education in this field is an underused commodity because of the significant lack of scientific and validated study designs reported on in the literature thus far. The maxillofacial and simulation communities would benefit from studies on utility and efficacy with higher levels of evidence.

The Development of a Benchtop Breast Reconstruction Surgical Simulator

A modified Delphi technique was used to survey plastics surgeons with an expertise in breast reconstruction from 6 university centers with plastic surgery residency programs across Canada. A list of the most challenging steps in teaching alloplastic breast reconstruction was obtained. From the survey results, a benchtop post-mastectomy breast reconstruction simulator was created using various silicon materials. The simulator was designed to be completely reusable with no disposable components necessary for each use. Senior plastic surgeons (n= 6) with an expertise in breast reconstruction were recruited and asked to perform a sub-pectoral, implant-based breast reconstruction on the simulator. Following the procedure, participants were asked to complete a survey and grade the simulator on its physical attributes, realism of experience, realism of material and overall experience.Preliminary face and content validation results based on the evaluations performed by those expert plastic surgeons showed excellent results among parameters evaluated, with an overall mean score of 4.7 on 5 (94.0%). Evaluators considered the six relevant anatomical components that were successfully included in the simulator.

The Use of a Novel Local Flap Trainer in Plastic Surgery Education

With the limitations of work hour restrictions and legal liability surgical resident’s operative experience is declining. We sought to find other methods of training using tactile surgical simulations for plastic surgery. With the collaborative efforts of a local artist, a local flap trainer was designed to simulate the natural properties, layers, and interaction between layers of tissue. A session was held with Plastic Surgery faculty, residents, and students to review and practice local flaps using the trainer. Afterward, the participants filled out a survey evaluating the simulated skin and tissue model and the effectiveness of the class as a teaching model. The survey given had multiple questions asking the participant to provide a ranking from 1 to 10. The results show that the class utilizing the new suture pad was an effective teaching tool with an average score of 9.56. The suture pad was given a score of 6.77 for simulating realistic skin. Overall, the group rated increased understanding and confidence of local flaps after the class. Surgical skill simulations are becoming increasingly more important with the decline of resident operative experience. There are limited options for surgical simulations that provide a realistic experience. We designed a suture pad that is effective at simulating human tissue. The surveys show that using this suture pad in flap workshops provides a valuable teaching tool.

Undergraduate Plastic Surgery Education: A National Survey of Clerkship Directors

Background

The delivery of medical education has received increased attention in recent years due to ongoing time and financial constraints faced by medical educators. Given the recent calls to action by the Carnegie Foundation and Health Canada, an evaluation of the specialty education sector is warranted. To our knowledge, this is the first assessment of the Canadian plastic surgery undergraduate clerkship curriculum.

Method

An anonymous electronic survey was distributed to the plastic surgery clerkship directors of all Canadian medical schools (N = 17). The survey consisted of Likert scales and open-ended short answer questions. Themes included general clerkship information, exposure characteristics, teaching characteristics, resource characteristics, and challenges and barriers faced by clerkship directors.

Results

Survey response rate was 88%. All responding schools offered a clerkship rotation of varying length in time (1-4 weeks). Students had the most exposure to breast surgery (100%) and general plastic surgery (100%) and the least exposure to aesthetic surgery (40%). Sixty percent of schools indicated the use of modern educational methods. Resources available for teaching students varied. Rotations received excellent feedback from medical students (67%). More than half of respondents would like to see a universal, nationally formulated plastic surgery clerkship curriculum.

Conclusion

There is significant heterogeneity in the delivery of plastic surgery clerkship in Canada. A number of areas for improvement have been identified. We hope to establish a national plastic surgery clerkship task force to address the concerns raised here and improve the delivery of undergraduate medical education. Assessment of students based on a national curriculum may help in decision-making regarding plastic surgery program admissions by introducing an element of standardization to clerkship exposure.

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.

Surgical Education Module Improves Operative Proficiency in Endoscopic Carpal Tunnel Release: A Blinded Randomized Controlled Trial of Trainees

OBJECTIVE

The purpose of this study is to evaluate whether an interactive endoscopic carpal tunnel release (ECTR) surgical education module can improve knowledge of surgical indications and improve procedural competency.

DESIGN

An ECTR education module was developed and trainees at various level of training were enrolled and randomized to surgical module and nonmodule (control) groups. Subjects were instructed that they would be the primary surgeon performing an ECTR. A written assessment was administered before and after module completion or independent case preparation to test comprehension of the procedure. The senior author evaluated each subject's intraoperative performance using a 5-point scoring system. Statistical analysis was performed using chi-square and paired t-tests.

SETTING

This study took place at a tertiary care hospital at the University of Wisconsin.

RESULTS

In all, 30 subjects were tested (15 surgical module and 15 nonmodule). There were no differences in prepreparation test scores between groups. Postpreparation test scores following use of the module were significantly higher compared to the nonmodule group. The average operation performance scores for the surgical module group and nonmodule group were 96% and 82%, respectively. The surgical module group performed significantly better on all operative steps except for dressing application. Surgical module subjects without prior ECTR experience (n = 7) had operative scores that were significantly higher than those for nonmodule subjects without previous ECTR experience (n = 8) (95% vs. 75%). There was no difference in operative scores between surgical module subjects with no prior experience (n = 7) and nonmodule subjects who had performed at least 1 prior case (n = 7) (95% vs. 89%).

CONCLUSIONS

The use of an ECTR surgical education module demonstrates a significant benefit in ECTR-naïve subjects. When compared to subjects with previous ECTR experience, ECTR-naïve subjects trained using the surgical module demonstrate better familiarity with the equipment and equivalent performance of the procedure.

Low-Cost Training Simulator for Open Dismembered Pyeloplasty: Development and Face Validation

PURPOSE

Surgical simulation has benefited from a surge in interest over the last decade because of the increasing need for a change in the traditional apprenticeship model of teaching surgery. Open surgery for ureteropelvic junction (UPJ) poses unique training challenges owing to smaller workspaces, and finer sutures used that require increased surgical dexterity when compared with adult analogues. We describe the development and face validation of a low-cost training simulator for open dismembered pyeloplasty.

MATERIALS AND METHODS

The simulator is built with A4 Kraft envelopes, catheter tip syringe filled with 30mL of air, tape, 260 modeling balloon, and 11-in party balloon. Evaluation of the device is based on an evaluation form including 11 items on a 5-point Likert-type scale. Thirty-one departments of pediatric surgery in France were contacted and received a pack containing 4 to 10 devices, already set up and ready for use, a tutorial and an evaluation form. Candidates were stratified according to their level of expertise.

RESULTS

A total of 180 devices were sent. Procedures on the device were performed 118 times (65%) by expert surgeons (n = 44), fellows (n = 25), and residents (n = 49). Statistically significant difference was noted for 4 items (anatomy, model exposition, UPJ resection, and difficulty) for the 3 levels of expertise. The global score evaluation for realistic items, face validity, and usability was 4.2 (range: 1-5).

CONCLUSION

This low-cost model is evaluated as an efficient tool for UPJ teaching and training. It shows promise as an educational tool.

Computer Simulation and Digital Resources for Plastic Surgery Psychomotor Education

Contemporary plastic surgery residents are increasingly challenged to learn a greater number of complex surgical techniques within a limited period. Surgical simulation and digital education resources have the potential to address some limitations of the traditional training model, and have been shown to accelerate knowledge and skills acquisition. Although animal, cadaver, and bench models are widely used for skills and procedure-specific training, digital simulation has not been fully embraced within plastic surgery. Digital educational resources may play a future role in a multistage strategy for skills and procedures training. The authors present two virtual surgical simulators addressing procedural cognition for cleft repair and craniofacial surgery. Furthermore, the authors describe how partnerships among surgical educators, industry, and philanthropy can be a successful strategy for the development and maintenance of digital simulators and educational resources relevant to plastic surgery training. It is our responsibility as surgical educators not only to create these resources, but to demonstrate their utility for enhanced trainee knowledge and technical skills development. Currently available digital resources should be evaluated in partnership with plastic surgery educational societies to guide trainees and practitioners toward effective digital content.

Simulation Training for Vascular Emergencies in Endoscopic Sinus and Skull Base Surgery

Carotid artery injury during endonasal surgery is a feared and potentially catastrophic complication. Simulation training provides the opportunity for a realistic experience with management of major vascular injuries. The sheep model of carotid artery injury reproduces the challenges of dealing with vascular emergencies during endoscopic sinus and skull base surgery, which include working in narrow nasal confines, high-flow/high-pressure vascular injury, and the immediately challenging surgical field. Simulated vascular emergencies allow for research and development; training using various surgical techniques to control the field, including hemostatic products or direct vascular closure techniques; and consequently improved patient care and outcomes.

Management of arterial injury during endoscopic sinus and skull base surgery

PURPOSE OF REVIEW

The most feared complication during endonasal surgery is a carotid artery injury. The sheep model of carotid injury provides training for this event by giving a realistic endoscopic experience of major vascular injuries and tissue hemostasis.

RECENT FINDINGS

The sheep model of carotid artery injury recreates the narrow nasal confines and high-flow/high-pressure vascular injury accurately reproducing the endoscopic challenges seen in such vascular emergencies. This has led to the development of surgical techniques that quickly and effectively control the field of bleeding and achieve reliable hemostasis including the crushed muscle patch new direct vascular closure technologies. Vascular emergency simulation training is achieving better outcomes for our patients.

SUMMARY

All skull base surgeons are at risk of the unexpected carotid artery injury and recently, the sheep model not only effectively recreates this situation but has identified clinically tried and tested techniques at managing this situation and is improving patient outcomes.

Innovations in surgery simulation: a review of past, current and future techniques

As a result of recent work-hours limitations and concerns for patient safety, innovations in extraclinical surgical simulation have become a desired part of residency education. Current simulation models, including cadaveric, animal, bench-top, virtual reality (VR) and robotic simulators are increasingly used in surgical training programs. Advances in telesurgery, three-dimensional (3D) printing, and the incorporation of patient-specific anatomy are paving the way for simulators to become integral components of medical training in the future. Evidence from the literature highlights the benefits of including simulations in surgical training; skills acquired through simulations translate into improvements in operating room performance. Moreover, simulations are rapidly incorporating new medical technologies and offer increasingly high-fidelity recreations of procedures. As a result, both novice and expert surgeons are able to benefit from their use. As dedicated, structured curricula are developed that incorporate simulations into daily resident training, simulated surgeries will strengthen the surgeon's skill set, decrease hospital costs, and improve patient outcomes.

Resident simulation training in endoscopic endonasal surgery utilizing haptic feedback technology

Simulated practice may improve resident performance in endoscopic endonasal surgery. Using the NeuroTouch haptic simulation platform, we evaluated resident performance and assessed the effect of simulation training on performance in the operating room. First- (N=3) and second- (N=3) year residents were assessed using six measures of proficiency. Using a visual analog scale, the senior author scored subjects. After the first session, subjects with lower scores were provided with simulation training. A second simulation served as a task-learning control. Residents were evaluated in the operating room over six months by the senior author-who was blinded to the trained/untrained identities-using the same parameters. A nonparametric bootstrap testing method was used for the analysis (Matlab v. 2014a). Simulation training was associated with an increase in performance scores in the operating room averaged over all measures (p=0.0045). This is the first study to evaluate the training utility of an endoscopic endonasal surgical task using a virtual reality haptic simulator. The data suggest that haptic simulation training in endoscopic neurosurgery may contribute to improvements in operative performance. Limitations include a small number of subjects and adjudication bias-although the trained/untrained identity of subjects was blinded. Further study using the proposed methods may better describe the relationship between simulated training and operative performance in endoscopic Neurosurgery.