Basic skin surgery interactive simulation: system description and randomised educational trial

An interactive augmented reality software for facial reconstructive surgeries

BACKGROUND AND OBJECTIVE

Surgical trainees need a lot of training and practice before being able to operate independently. The current approach of surgical education mainly involves didactic teaching and psychomotor training through physical models or real tissue. Due to the unavailability of physical resources and lack of objective ways of evaluation, there is a demand for developing alternative training methods for surgeons. In this paper, we present an application that provides additional training opportunities to surgical trainees in the field of facial reconstructive surgeries.

METHODS

We built a mobile augmented reality application that helps the user to visualize important concepts and experiment with different surgical plans for facial reconstructive surgeries. The application can overlay relaxed skin tension lines on a live video input or a patient's photo, which serve as bases for aligning a skin flap. A surgical trainee can interactively compare different skin flap design choices with estimated final scars on a photo of a patient. Data collection capability is also added to the application, and we performed a Monte Carlo experiment with simulated users (five classes of 100 users each) as an example of objectively measuring user performance.

RESULTS

The application can overlay relaxed skin tension lines on a patient's face in real time on a modern mobile device. Accurate overlays were achieved in over 91% as well as 84% and 88% out of 263 generated face images, depending on the method. Visual comparisons of the three overlay methods are presented on sample faces from different population groups. From the Monte Carlo experiment, we see that user actions in each class follow a normal distribution with a distinct set of parameters.

CONCLUSIONS

This application can serve as a basis for teaching surgical trainees the fundamentals of different facial reconstructive procedures, especially concepts related to relaxed skin tension lines and skin flaps. It can objectively evaluate the performance of surgical trainees in a course. This setup focuses on illustrating the relationship between the orientation of skin flaps and relaxed skin tension lines, which is a prerequisite of minimizing scarring in patients in addition to good surgical techniques.

Advancing Surgical Education: A Comprehensive Systematic Review with Meta-Analysis and Novel Approach to Training Models for Local Skin Advancement Flaps

Performing local skin flaps is a challenging task that requires cognitive and technical skills to design flaps with proper orientation to avoid distorting normal anatomy. Junior trainees need adequate exposure to gain confidence and expertise in such procedures. This article systematically reviews the literature's different local skin advancement flap training models and describes a new, easy-to-use training model. A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Cochrane, Web of Science, and Google Scholar databases were searched from their inception until August 2022 for articles about local skin advancement flap training models. The meta-analysis results were pooled across the studies using a random-effects model and presented as a weighted mean difference with a 95% confidence interval (95% CI). Out of 773 reviewed articles, 18 were included in the systematic review, and four reported enough data to be included in the meta-analysis. Rhomboid and Z-plasty flaps were the most commonly taught flaps by training models. The most commonly used training models were synthetic-based, followed by animal-based models. The training models significantly increased the trainees' confidence and expertise regarding local skin flap procedures (p<0.00001) for both domains. Training models, per our reported data, significantly improve the trainees' confidence and expertise in performing local skin advancement flap procedures; continuous efforts in developing and establishing new, simple-to-use, and effective training models are strongly encouraged to further improvement of surgical education and enhance the trainees' surgical skills.

Randomized trial of the effect of video training on residents' surgical skills in facial skin reconstructive surgery: A SQUIRE study

OBJECTIVES

The purpose of this study was to evaluate the impact of facial skin reconstruction training videos for head and neck and maxillofacial surgery residents.

MATERIAL AND METHODS

This randomized trial, conducted in France, involved residents in head and neck and maxillofacial surgery. A website was created containing facial skin reconstruction training videos. Selected residents performed facial skin flap dissections in the Paris School of Surgery. They were randomized into two groups, one receiving a standard course before the dissection, and the other a standard course plus a video of the flap ("no-video" and "video" groups). Each resident performed 4 facial flaps and was graded (blindly) during dissection. The main study endpoint was intergroup difference in grading score (out of 15). The article was written up following the SQUIRE-EDU (Standards for QUality Improvement Reporting Excellence in EDUcation) criteria.

RESULTS

Eighteen residents were included. For the main endpoint, scores were significantly higher in the "video" than the "no-video" group (6 [IQR, 4: 9] vs. 10 [9: 12]; P<0.001). In addition, as secondary endpoint, "no-video" group residents requested more assistance (3 [2: 4] vs. 1 [1: 2] P<0.001). Power was lacking for any subgroup analysis according to year of residency or to the 4 flaps.

CONCLUSION

Videos improved surgical residents' performance during dissections. However, these results would be difficult to transpose to real clinical conditions. They need validating in a larger study evaluating performance in real-life procedures.

Teaching dermatology to medical students: a Scoping Review of published interventional studies

It is unclear how dermatology should be optimally taught to medical students. Therefore, this scoping review was conducted aiming to identify and structure all published interventional studies that investigated dermatological teaching approaches with medical students. The methodology of this scoping review followed the PRISMA Extension for Scoping Reviews. The databases Medline and Embase were searched without restriction until 30.06.2020. A categorization and a descriptive analysis of the studies published as full articles were performed. The database search yielded 36,627 hits. 114 studies met all inclusion criteria. These came from 19 countries, were mainly published since 2010 and were distributed across 64 different journals. 32 randomized controlled trials were identified. A wide variety of teaching approaches was found, including both E-learning and conventional teaching formats. The results of the studies are presented in structured tables. This scoping review documents a large number of studies published worldwide on teaching dermatology to medical students. The teaching of dermatology appears to be successful with numerous teaching approaches, whereby interventions that incorporate didactic principles were verifiably more successful. This literature review can serve as an aid for evidence-based teaching design in dermatology as well as a basis for future research approaches.

Simulation models for learning local skin flap design and execution: A systematic review of the literature

Introduction

Early exposure to practical skills in surgical training is essential in order to master technically demanding procedures such as the design and execution of local skin flaps. Changes in working patterns, increasing subspecializations, centralization of surgical services, and the publication of surgeon-specific outcomes have all made hands-on-training in a clinical environment increasingly difficult to achieve for the junior surgeon. This has been further compounded by the COVID-19 pandemic. This necessitates alternative methods of surgical skills training. To date, there are no standardized or ideal simulation models for local skin flap teaching.

Aim

This systematic review aims to summarize and evaluate local skin flap simulation and teaching models published in the literature.

Materials and Methods

A systematic review protocol was developed and undertaken in accordance with PRISMA guidelines. Key search terms encompassed both “local skin flaps” and “models” or “surgical simulation”. These were combined using Boolean logic and used to search Embase, Medline, and the Cochrane Library. Studies were collected and screened according to the inclusion criteria. The final included articles were graded for their level of evidence and recommendation based on a modified educational Oxford Center for evidence-based medicine classification system and assessed according to the CRe-DEPTH tool for articles describing training interventions in healthcare professionals.

Results

A total of 549 articles were identified, resulting in the inclusion of 16 full-text papers. Four articles used 3D simulators for local flap teaching and training, while two articles described computer simulation as an alternative method for local flap practicing. Four models were silicone based, while gelatin, Allevyn dressings, foam rubber, and ethylene-vinyl acetate-based local flap simulators were also described. Animal models such as pigs head, porcine skin, chicken leg, and rat, as well as a training model based on fresh human skin excised from body-contouring procedures, were described. Each simulation and teaching method was assessed by a group of candidates via a questionnaire or evaluation survey grading system. Most of the studies were graded as level of evidence 3 or 4.

Conclusion

Many methods of simulation for the design and execution of local skin flaps have been described. However, most of these have been assessed only in small cohort numbers, and, therefore, larger candidate sizes and a standardized method for assessment are required. Moreover, some proposed simulators, although promising, are in a very preliminary stage of development. Further development and evaluation of promising high-fidelity models is required in order to improve training in such a complex area of surgery.

Mobile applications in medical education: A systematic review and meta-analysis

Objective

This review evaluates the effectiveness of smartphone applications in improving academic performance and clinical practice among healthcare professionals and students.

Methods

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were retrieved from PubMed, Scopus, and Cochrane library through a comprehensive search strategy. Studies that included medical, dental, nursing, allied healthcare professional, undergraduates, postgraduates, and interns from the same disciplines who used mobile applications for their academic learning and/or daily clinical practice were considered.

Results

52 studies with a total of 4057 learner participants were included in this review. 33 studies (15 RCTs, 1 cluster RCT, 7 quasi-experimental studies, 9 interventional cohort studies and 1 cross-sectional study) reported that mobile applications were an effective tool that contributed to a significant improvement in the knowledge level of the participants. The pooled effect of 15 studies with 962 participants showed that the knowledge score improved significantly in the group using mobile applications when compared to the group who did not use mobile applications (SMD = 0.94, 95% CI = 0.57 to1.31, P<0.00001). 19 studies (11 RCTs, 3 quasi-experimental studies and 5 interventional cohort studies) reported that mobile applications were effective in significantly improving skills among the participants.

Conclusion

Mobile applications are effective tools in enhancing knowledge and skills. They can be considered as effective adjunct tools in medical education by considering their low expense, high versatility, reduced dependency on regional or site boundaries, online and offline, simulation, and flexible learning features of mobile apps.

A computer based facial flaps simulator using projective dynamics

BACKGROUND AND OBJECTIVES

Interactive surgical simulation using the finite element method to model human skin mechanics has been an elusive goal. Mass-spring networks, while fast, do not provide the required accuracy.

METHODS

This paper presents an interactive, cognitive, facial flaps simulator based on a projective dynamics computational framework. Projective dynamics is able to generate rapid, stable results following changes to the facial soft tissues created by the surgeon, even in the face of sudden increases in skin resistance as its stretch limit is reached or collision between tissues occurs. Our prior work with the finite element method had been hampered by these considerations. Surgical tools are provided for; skin incision, undermining, deep tissue cutting, and excision. A spring-like "skin hook" is used for retraction. Spring-based sutures can be placed individually or automatically placed as a row between cardinal sutures.

RESULTS

Examples of an Abbe/Estlander lip reconstruction, a paramedian forehead flap to the nose, a retroauricular flap reconstruction of the external ear, and a cervico-facial flap reconstruction of a cheek defect are presented.

CONCLUSIONS

Projective dynamics has significant advantages over mass-spring and finite element methods as the physics backbone for interactive soft tissue surgical simulation.

Simulation in Upper and Lower Limb Trauma Skill Acquisition: A Review

SUMMARY STATEMENT

This review aimed to explore the published evidence with regard to the types and composition of both full- and part-task trainers to teach surgeons extremity exploration procedures in limb trauma management. Studies were included if they reported the development and/or validation of synthetic or virtual task trainers. Studies were evaluated to determine their derivation, usability, and clinical utility.A total of 638 citations were identified and 63 satisfied the inclusion criteria. Twenty-five articles addressed simulator validation and 36 addressed level of learning achieved with simulator engagement. Two studies described a dedicated limb simulator. Simulators were developed to repair limb structures including skin (n = 15), tendon (n = 7), nerve (n = 1), fascia (n = 1), muscle (n = 1), vascular (n = 24), and bone (n = 11). Considerations such as material fidelity, learning outcomes, cost or reusability, validity, and effectiveness are inconsistently reported. Future studies should address design standards for the effective production of synthetic or virtual simulators for limb trauma management.

Supporting laparoscopic general surgery training with digital technology: The United Kingdom and Ireland paradigm

Surgical training in the UK and Ireland has faced challenges following the implementation of the European Working Time Directive and postgraduate training reform. The health services are undergoing a digital transformation; digital technology is remodelling the delivery of surgical care and surgical training. This review aims to critically evaluate key issues in laparoscopic general surgical training and the digital technology such as virtual and augmented reality, telementoring and automated workflow analysis and surgical skills assessment. We include pre-clinical, proof of concept research and commercial systems that are being developed to provide solutions. Digital surgical technology is evolving through interdisciplinary collaboration to provide widespread access to high-quality laparoscopic general surgery training and assessment. In the future this could lead to integrated, context-aware systems that support surgical teams in providing safer surgical care.

Computer-Aided Design, 3-D-Printed Manufacturing, and Expert Validation of a High-fidelity Facial Flap Surgical Simulator

Importance

Facial flap procedures may be difficult for surgical trainees to conceptualize and challenging for supervising surgeons to allow entrustment early in training. Simulation outside of the operating room may accelerate and enhance the surgical education experience.

Objective

To design and manufacture a 3-dimensional (3-D)-printed, multilayer, anatomically accurate facial flap model for use in surgical education.

Design, Setting, and Participants

In this multicenter validation study, a 3-D-printed facial flap simulator was designed from a computed tomographic (CT) scan and manufactured for low-cost, high-fidelity simulation. Expert otolaryngology-head and neck surgeon feedback was acquired through surgical rehearsal and performance of 8 local facial flap procedures on the facial flap simulator by 7 otolaryngologists fellowship trained in facial plastic surgery.

Main Outcomes and Measures

Likert scale surveys were made based on evaluation criteria categorized into domains of realism, experience, and applicability of the simulator. Measures of central tendency, variability, and confidence intervals were generated to evaluate the outcomes.

Results

Seven expert otolaryngology-head and neck surgeons completed a Likert scale evaluation survey containing quantitative analysis of 6 questions on physical attributes, 12 questions on realism, 8 questions on experience, and 4 questions on the applicability of the simulator. All expert surgeons were additionally fellowship trained in facial plastic surgery with their mean years in practice being 11.9. Overall evaluation demonstrated valuable ability of the simulator for medical education with suggestions for future directions. Importantly, the simulator was rated on a scale of 1 (no value) to 4 (great value) as 3.86 as a training tool, 3.57 as a competency evaluation tool, and 3.43 as a rehearsal tool.

Conclusions and Revelance

Expert experience with the local facial flap simulator was rated highly for realism, experience, performance, and usefulness. With slight refinement, the model has strong potential for broad use in training in otolaryngology-head and neck surgery and facial plastic surgery.

Level of Evidence

NA.