Current status of simulation training in plastic surgery residency programs: A review <s> METHODS <s> UNLABELLED ::: The objective of this project was to develop a computer-based surgical simulation system for planning and performing cleft lip repair. This system allows the user to interact with a virtual patient to perform the traditional steps of cleft-lip repair (rotation-advancement technique). ::: ::: ::: MATERIALS AND METHODS ::: The system interfaces to force-feedback (haptic) devices to track the user's motion and provide feedback during the procedure, while performing real-time soft-tissue simulation. An 11-day-old unilateral cleft lip, alveolus and palate patient was previously CT scanned for ancillary diagnostic purposes using standard imaging protocols and 1mm slices. High-resolution 3D meshes were automatically generated from this data using the ROVE software developed in-house. The resulting 3D meshes of bone and soft tissue were instilled with physical properties of soft tissues for purposes of simulation. Once these preprocessing steps were completed, the patient's bone and soft tissue data are presented on the computer screen in stereo and the user can freely view, rotate, and otherwise interact with the patient's data in real time. The user is prompted to select anatomical landmarks on the patient's data for preoperative planning purposes, then their locations are compared against that of a 'gold standard' and a score, derived from their deviation from that standard and time required, is generated. The user can then move a haptic stylus and guide the motion of the virtual cutting tool. The soft tissues can thus be incised using this virtual cutting tool, moved using virtual forceps, and fused in order to perform any of the major procedures for cleft lip repair. Real-time soft tissue deformation of the mesh realistically simulates normal tissues and haptic-rate (>1 kHz) force-feedback is provided. The surgical result of the procedure can then be immediately visualized and the entire training process can be repeated at will. A short evaluation study was also performed. Two groups (non-medical and plastic surgery residents) of six persons each performed the anatomical marking task of the simulator four times. ::: ::: ::: RESULTS ::: Results showed that the plastic surgery residents scored consistently better than the persons without medical background. Every person's score increased with practice, and the length of time needed to complete the 11 markings decreased. The data was compiled and showed which specific markers consistently took users the longest to identify as well as which locations were hardest to accurately mark. ::: ::: ::: CONCLUSION ::: These findings suggest that the simulator is a valuable training tool, giving residents a way to practice anatomical identification for cleft lip surgery without the risks associated with training on a live patient. Educators can also use the simulator to examine which markers are consistently problematic, and modify their training to address these needs. <s> BIB001 </s> Current status of simulation training in plastic surgery residency programs: A review <s> METHODS <s> Silastic tubes are used as training material for performing microvascular anastomoses. However, silastic texture differs from that of actual blood vessels. In the present work, we evaluate the use of preserved rat arterial segments for training in microvascular anastomoses. One-centimeter-long rat arterial segments were obtained from femoral, carotid, and abdominal arteries, preserved in cold saline solution, and frozen. Trainees performed microvascular anastomoses using the aforementioned material and answered questions about texture, consistency, and wall resistence to the needle, comparing preserved arterial wall and silastic tubes. They were also asked whether the arterial pedicles had a consistency and texture similar to normal vessels, and if they were a more reliable method for practicing microsurgery techniques than synthetic materials. They preferred frozen arterial pedicles over silastic tubes. We conclude that arterial cadaveric segments are a suitable biologic material for microsurgical training. Since they can be obtained from other experiments, this is an effective way to reduce the number of animals bred and sacrificed for teaching purposes. © 2005 Wiley-Liss, Inc. Microsurgery 25:500–501, 2005. <s> BIB002 </s> Current status of simulation training in plastic surgery residency programs: A review <s> METHODS <s> BioDigital Systems, LLC in collaboration with New York University Langone Medical Center Department of Reconstructive Plastic Surgery has created an interactive, step-based latissimus musculocutaneous flap simulator. Preliminary testing of fourteen residents (PGY1-6) demonstrates that simulator training results in significant improvement in an objective assessment of surgical knowledge (p < 0.0006, pre-training score: 81.0%, post-training score 92.7%). This study is the first in the field of plastic and reconstructive surgery to demonstrate objective improvement in surgical knowledge as a result of simulator training, suggesting the potential effectiveness of simulators for a panopoly of breast reconstruction options. <s> BIB003 </s> Current status of simulation training in plastic surgery residency programs: A review <s> METHODS <s> BioDigital Systems, LLC in collaboration with New York University Langone Medical Center Department of Reconstructive Plastic Surgery has created a complex, real-time, step-based simulation platform for plastic surgery education. These simulators combine live surgical footage, interactive 3D visualization, text labels, and voiceover as well as a high-yield, expert-approved testing mode to create a comprehensive virtual educational environment for the plastic surgery resident or physician. <s> BIB004 </s> Current status of simulation training in plastic surgery residency programs: A review <s> METHODS <s> SummAry Surgery on the temporal bone is technically challenging due to its complex anatomy. Precise anatomical dissection of the human temporal bone is essential and is fundamental for middle ear surgery. We assessed the possible application of a virtual reality temporal bone surgery simulator to the education of ear surgeons. Seventeen EnT physicians with different levels of surgical training and 20 medical students performed an antrotomy with a computer-based virtual temporal bone surgery simulator. The ease, accuracy and timing of the simulated temporal bone surgery were assessed using the automatic assessment software provided by the simulator device and additionally with a modified Final Product Analysis Scale. Trained EnT surgeons, physicians without temporal bone surgical training and medical students were all able to perform the antrotomy. however, the highly trained EnT surgeons were able to complete the surgery in approximately half the time, with better handling and accuracy as assessed by the significant reduction in injury to important middle ear structures. Trained EnT surgeons achieved significantly higher scores using both dissection analysis methods. Surprisingly, there were no significant differ ences in the results between medical students and physicians without experience in ear surgery. The virtual temporal bone training system can stratify users of known levels of experience. This system can be used not only to improve the surgical skills of trained EnT surgeons for more successful and injury-free surgeries, but also to train inexperienced physicians/medical students in developing their surgical skills for the ear. <s> BIB005 </s> Current status of simulation training in plastic surgery residency programs: A review <s> METHODS <s> BACKGROUND ::: As interest in surgical simulation grows, plastic surgical educators are pressed to provide realistic surgical experience outside of the operating suite. Simulation models of plastic surgery procedures have been developed, but they are incomparable to the dissection of fresh tissue. We evolved a fresh tissue dissection (FTD) and simulation program with emphasis on surgical technique and simulation of clinical surgery. We hypothesized that resident confidence could be improved by adding FTD to our resident curriculum. ::: ::: ::: METHODS ::: Over a 5-year period, FTD was incorporated into the curriculum. Participants included clinical medical students, postgraduate year 1 to 7 residents, and attending surgeons. Participants performed dissections and procedures with structured emphasis on anatomical detail, surgical technique, and rehearsal of operative sequence. Resident confidence was evaluated using retrospective pretest and posttest analysis with a 5-point scale, ranging from 1 (least confident) to 5 (most confident). Confidence was evaluated according to postgraduate year level, anatomical region, and procedure. ::: ::: ::: RESULTS ::: A total of 103 dissection days occurred, and a total of 192 dissections were reported, representing 73 different procedures. Overall, resident predissection confidence was 1.90±1.02 and postdissection confidence was 4.20±0.94 (p<0.001). The average increase in confidence correlated with training year, such that senior residents had greater gains. When compared by anatomical region, confidence was lowest for the head and neck region. When compared by procedure, confidence was lowest for rhinoplasty and face-lift, and highest for radial forearm and latissimus flaps. ::: ::: ::: CONCLUSIONS ::: A high-volume FTD experience was successfully incorporated into the residency program over 5 years. Training with FTD improves resident confidence, and this effect increases with seniority of training. Although initial data demonstrate that resident confidence is improved with FTD, additional evaluation is needed to establish objective evidence that patient outcomes and surgical quality can be improved with FTD. <s> BIB006 </s> Current status of simulation training in plastic surgery residency programs: A review <s> METHODS <s> Summary Introduction Surgical simulation models are often limited by their lack of fidelity, which hinders their essential purpose, making a better surgeon. Fresh cadaveric tissue is a superior model of simulation owing to its approximation of live tissue. One major unresolved difference between dead and live tissue is perfusion. Here, we propose a means of enhancing the fidelity of cadaveric simulation through the development of a perfused cadaveric model whereby simulation is further able to approach life-like surgery and teach one of the more technically demanding skills of plastic surgery: microsurgery. Method Fresh tissue human cadavers were procured according to university protocol. Perfusion was performed via cannulation of large vessels, and arterial and venous pressure was maintained by centrifugal circulation. Skin perfusion was evaluated with incisions in the perfused regions and was evaluated using indocyanine green angiography. Surgical simulations were selected to broadly evaluate applicability to plastic surgical education. Result Surgical simulation of 38 procedures ranging in complexity from skin excisions to microsurgical cases was performed with high priority given to the accurate simulation of clinical procedures. Flap dissections included perforator flaps, muscle flaps, and fasciocutaneous flaps. Effective perfusion was noted with ICG angiography and notable bleeding vessels. Microsurgical flap transfer was successfully performed. Conclusion We report the establishment of a high fidelity surgical simulation using a perfused fresh tissue model in a realistic environment akin to the operating room. We anticipate utilization of this model prior to entering the operating room will enhance surgical ability and offer a valuable resource in plastic surgical education. <s> BIB007 </s> Current status of simulation training in plastic surgery residency programs: A review <s> METHODS <s> Techniques of virtual simulation have been used to teach junior surgeons how to do a cheiloplasty, but still do not meet the trainees' demands. We describe a CAD/CAM silicone simulator, which we made using several maxillofacial prosthetic techniques. An optical scanning system was used to collect the data about the cleft lip. Reverse engineering software was then used to build the virtual model, and this was processed in wax by machine. The definitive simulator was made with prosthetic silicone and extrinsic colourants. The surgical trainees practised the basic skills of cheiloplasty on the simulator, and proved its worth. <s> BIB008 </s> Current status of simulation training in plastic surgery residency programs: A review <s> METHODS <s> BACKGROUND ::: This article presents a real-time surgical simulator for teaching three- dimensional local flap concepts. Mass-spring based simulators are interactive, but they compromise accuracy and realism. Accurate finite element approaches have traditionally been too slow to permit development of a real-time simulator. ::: ::: ::: METHODS ::: A new computational formulation of the finite element method has been applied to a simulated surgical environment. The surgical operators of retraction, incision, excision, and suturing are provided for three-dimensional operation on skin sheets and scalp flaps. A history mechanism records a user's surgical sequence. Numerical simulation was accomplished by a single small-form-factor computer attached to eight inexpensive Web-based terminals at a total cost of $2100. A local flaps workshop was held for the plastic surgery residents at the University of Wisconsin hospitals. ::: ::: ::: RESULTS ::: Various flap designs of Z-plasty, rotation, rhomboid flaps, S-plasty, and related techniques were demonstrated in three dimensions. Angle and incision segment length alteration advantages were demonstrated (e.g., opening the angle of a Z-plasty in a three-dimensional web contracture). These principles were then combined in a scalp flap model demonstrating rotation flaps, dual S-plasty, and the Dufourmentel Mouly quad rhomboid flap procedure to demonstrate optimal distribution of secondary defect closure stresses. ::: ::: ::: CONCLUSIONS ::: A preliminary skin flap simulator has been demonstrated to be an effective teaching platform for the real-time elucidation of local flap principles. Future work will involve adaptation of the system to facial flaps, breast surgery, cleft lip, and other problems in plastic surgery as well as surgery in general. <s> BIB009 </s> Current status of simulation training in plastic surgery residency programs: A review <s> METHODS <s> Since the introduction of competency-based education and the restriction of residents’ working hours, simulator-aided training has obtained increasing attention for its role in teaching and assessing resident surgical skills. Within plastic surgery training, such simulators would be particularly useful for aesthetic surgery procedures such as augmentation mammoplasty where residents have fewer opportunities for hands-on experience. The aims of this study were to develop a part-task trainer that allows plastic surgery trainees to acquire skills necessary for augmentation mammoplasty and to assess its potential value as a training tool. ::: The mammoplasty part-task trainer (MPT) was designed to have a reusable and rigid thorax base and “soft” disposable layers to mimic the skin and subcutaneous tissues. A mock unilateral subglandular breast augmentation was performed by 4 board-certified plastic surgeons using standard instruments and scored using a 0 to 5 Likert scale where a score of 5 was considered the most satisfactory. ::: Four board-certified plastic surgeons participated in the survey. On a scale of 0 to 5, the MPT’s “value” as a training tool, “relevance to practice,” and “physical attributes” scored highest, with mean values of 4.5, 4.3, and 4.1, respectively. “Realism of experience,” “ability to perform tasks,” and “realism of material” scored 3.9, 3.8, and 3.7, respectively. The observed average of the “global assessment” of the MPT was 4.3. The cost of fabrication of the MPT was estimated at approximately Can $113. ::: This study describes a preliminary novel mammoplasty task trainer that was highly valued by experts as a potential training tool. <s> BIB010 </s> Current status of simulation training in plastic surgery residency programs: A review <s> METHODS <s> BACKGROUND ::: Over the last decade, simulation has become a principal training method in microsurgery. With an increasing move toward the use of nonliving models, there is a need to develop methods for assessment of microvascular anastomosis skill acquisition substituting traditional patency rate. The authors present and validate a novel method of microvascular anastomosis assessment tool for formative and summative skills competency assessment. ::: ::: ::: METHODS ::: In this study, 29 trainees with varying levels of experience in microsurgery undertook a 5-day microsurgery course. Two consecutive end-to-end microvascular anastomoses of cryopreserved rat aortas performed on day 3 and day 5 of the course were longitudinally split and photographed for randomized blinded qualitative evaluation. Four consecutive anastomoses by two experienced microsurgeons were analyzed as expert controls. Errors potentially leading to anastomotic leak or thrombosis were identified and logged. Statistical analysis using the Kruskal-Wallis analysis of variance (ANOVA) and a two-way repeated measure ANOVA was used to measure construct and concurrent validity, respectively. ::: ::: ::: RESULTS ::: A total of 128 microvascular anastomoses were analyzed for both student and control groups. Ten errors were identified and indexed. There was a statistically significant difference detected between average errors per anastomosis performed between groups (p < 0.05). Average errors per anastomosis was statistically decreased on day 5 of the course compared with day 3 (p < 0.001). ::: ::: ::: CONCLUSION ::: Evaluation of anastomosis structural patency and quality in nonliving models is possible. The proposed error list showed construct and predictive validity. The anastomosis lapse index can serve as a formative and summative assessment tool during microvascular training. <s> BIB011
An electronic literature search of the MEDLINE (PubMed) and Cochrane databases was performed using search terms simulation-based surgical training, technology for surgical education, and plastic surgery and simulation training. Studies were included if they (1) evaluated simulation-based models in improving resident competency; (2) described the application of simulation-based models in the field of plastic surgery; (3) published between January 2000 and June 2016; and (4) were available in English. Initial search yielded 8,197 articles. The search was then narrowed to include studies published from January 2000 through June 2015. Of the 5,666 articles, 292 articles were written in a language other than English and excluded from the study. The titles and abstracts of the remaining 5,374 studies were subsequently appraised to identify eligible articles. Thirteen papers met inclusion criteria (Table 1) BIB001 BIB003 BIB004 BIB005 BIB009 BIB008 BIB010 BIB002 BIB011  BIB007 BIB006 . Simulation models used in plastic surgery were evaluated for cost, effectiveness, and realism. BIB007 General reconstruction Perfused cadaver for practice of various procedures Ability to perform procedure Sheckter et al. 2013 BIB006 General reconstruction Cadaver use for procedural practice Anatomical dissection and various surgical skills based on confidence levels Platforms were categorized based on primary method of simulation. Evaluation to verify improvement through simulator use was identified in addition to the broad areas of plastic surgery which the simulators were applied in. 3D, three-dimensional; NA, not available. 