Development of a Haptic Model for Teaching in Reconstructive Surgery—The Radial Forearm Flap

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.

Toward Competency-Based Training: To What Extent Are We Competency-Based?

BACKGROUND

Time-based training models in plastic surgery vary in exposure, resulting in low confidence levels among graduates. The evolution of postgraduate medical education into a competency-based model to address these issues requires an understanding of interventions described in the plastic surgery literature to identify gaps and guide creation of assessments to demonstrate competence.

METHODS

A systematic search of the MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, PubMed, and Cochrane databases from inception until December of 2017 was conducted using search terms and synonyms of educational interventions reported in plastic surgery. Full texts were retrieved following filtering and data extracted were related to intervention design and execution, involvement of competency assessment, and educational objectives and alignment to Accreditation Council for Graduate Medical Education competencies and Royal College of Physicians and Surgeons of Canada Canadian Medical Education Directives for Specialists roles. Study quality was assessed using Kirkpatrick's levels of learning evaluation, validity evidence, and the Medical Education Research Study Quality Instrument score.

RESULTS

Of the initial 4307 results, only 36 interventions met the inclusion criteria. Almost all interventions aligned to medical knowledge and patient care Accreditation Council for Graduate Medical Education competencies. One-fifth of the interventions involved no assessment of competency, whereas most displayed assessment at the level of design as opposed to outcomes. Quality assessment revealed low levels of learning evaluation and evidence of validity; the average Medical Education Research Study Quality Instrument score was 10.9 of 18.

CONCLUSION

A systematic review of educational literature in plastic surgery was conducted to assess the quality of reported educational interventions, and to help guide creating tools that ensure competency acquirement among trainees.

Advances in Surgical Training Using Simulation

Simulation involves the re-creation of real-life situations, processes, or structures for the purpose of improving safety, effectiveness, and efficiency of health care services: simulation provides a controlled and safe environment for training and assessment. In an age in which regulatory burdens, fiscal challenges, and renewed focus on patient safety increasingly constrain surgical residency programs, innovation in teaching is vital for the future of oral and maxillofacial surgery (OMS) training. Of the simulation technologies in modern day health care education, many have found their way into OMS training. This article reviews these technologies, and some examples of their uses in OMS.

Design of a haptic model for the training of cleft treatment procedures

INTRODUCTION

Cleft lip and palate (CLP) defects are considered to be the most common facial birth defect. Despite the relevance of this global health issue, the knowledge level on CLP is alarmingly low. Therefore, it was our aim to construct a realistic haptic anatomic CLP model that can be used for 3-dimensional visualizing CLP and practicing the first steps of CLP treatment.

METHODS

Models of newborns with CLP are not commercially available so far. Therefore, construction was based on a purchased baby doll of a healthy newborn. After fabrication of the model, we used it in a hands-on course for medical students. A total of 138 students were asked to perform practical tasks such as like taking intraoral impressions and fixating drinking and nasoalveolar plates on the CLP model. To evaluate the didactic benefit, preteaching and postteaching multiple-choice tests were performed.

RESULTS

A suitable patient's plaster model from our archive served as a template for shaping a unilateral CLP in the face of a baby doll by means of a scalpel and a handheld rotating milling machine. Hard and soft palate were milled out and replaced by a hard stone cast of a patient with cleft palate. When analyzing the preteaching and postteaching scores of the students' multiple-choice tests, an improvement was achieved in 69.6%, which proved to be statistically significant (P < 0.001).

CONCLUSIONS

In our opinion, the CLP model is a useful teaching tool with a high potential to improve the level of knowledge and practical expertise in the field of CLP.

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

Microvascular free flaps are complex but important tools in oral and maxillofacial surgery (OMFS), and though techniques to raise flaps are challenging surgeons often have little structured training. In this study we have evaluated a structured, three-day, hands-on, practical training course on raising flaps. Five human, Thiel-embalmed cadavers were used for training in how to raise the following flaps: radial forearm, anterolateral thigh, lateral arm, fibular, latissimus dorsi, scapular, iliac crest, and rectus abdominis. The total duration of the course was 24 hours over three days. All participants were asked to evaluate the design and conduct of the course, their own learning curve, and general questions about their knowledge of how to raise flaps and microsurgery. There was a significant increase in participants' assessments of how they raised all free flaps, except the lateral arm flap (4.74 (0.68) compared with 2.42 (0.81); p=0.052) before and after the course. The radial forearm flap was thought to be the most relevant in clinical practice (n=40; 75%), followed by the anterolateral thigh (n=5; 9%) and fibular (n=4; 8%) flaps. Comparisons between residents and consultants showed unsurprising differences in experience with microsurgery and self-assessment in raising particular free flaps before the course. We have shown that a structured, hands-on course using a well-established simulation model can significantly improve postgraduate surgeons' skills in raising free flaps.

Special training in maxillofacial surgery for medical students--economic burden or investment in the future?

We measured the motivation and interest of medical students in oral and maxillofacial surgery at a German university. After a detailed cost-benefit analysis of a course that used an ex-vivo animal model and active participation in the operating theatre, we measured changes in the students' interest in taking up a surgical specialty in the future. We found that practical experience could lower the expenses of the course by almost 70%. Twenty per cent of students chose oral and maxillofacial surgery as an elective in their final year. These students could be residents one day.

Reconstruction of facial defects with local flaps--a training model for medical students?

Introduction

The lack of surgeons will be a future major problem in patient care for multifaceted reasons. Niche specialties such as OMFS face an additional drawback because of the need for dual qualification. Special surgical training that gives students the opportunity to gain experience in the techniques of plastic-reconstructive surgery (PRS) has therefore been established to promote interest in OMFS.

Methods

Two hands-on courses with 8 modules of 2 h for 10 students were established. Course modules included surgical techniques of PRS, such as local flaps in a complex facial defect on pig heads, and were supervised by two OMFS surgeons. The identical initial and final tests examined theoretical knowledge and practical skills. Questionnaires concerning basic demographic data, future career goals, and perception of surgical disciplines before and after the completion of the course were handed out.

Results

The 19 participating students (12 female, 7 male; median age 24 ± 2.24) were in their 8.31 ± 1.20 semester. Results of the tests showed improvement in knowledge following the courses (before 52.68 ± 12.64 vs. after 77.89 ± 11.37; p < 0.05). Based on the Likert scale, an increase in interest in a career in OFMS was observed (3.90 ± 1.18 vs. 2.72 ± 1.33; p < 0.05), but this was not so marked with regard to a career in a surgical discipline in general (1.93 ± 1.30 vs. 1.62 ± 1.19; p > 0.05). Perception of OMFS as a surgical discipline changed (3.68 ± 1.09 vs. 1.80 ± 0.64; p < 0.05). The following values also changed: students´ perception of PRS in OMFS (14 (74.68 %) vs. 5 (25.32 %); 19 (100 %) vs. 0 (0 %)), evaluation of PRS as a study subject for medical students (7 (36.84 %) vs. 12 (63.16 %); 19 (100 %) vs. 0 (0 %)), and the interest in an OMFS elective subject (6 (31.58 %) vs. 13 (68.42 %); 18 (94.74 %) vs. 1 (5.26 %)) and as a final clinical year subject (4 (21.05 %) vs. 15 (78.95 %); 14 (73.68 %) vs. 5 (26.32 %)).

Conclusions

Hands-on courses with complex facial defects can be used to gain new professionals, even in niche specialties such as OMFS. Moreover, a hands-on course design, including innovative teaching methods and structured objective tests combined with a close student-teacher relationship and motivated instructors, is able to promote complex surgical skills in PRS.