- Email: [email protected]
The educational hand and head: Novel teaching tools in the design and execution of local flaps
Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 981e987
CORRESPONDENCE AND COMMUNICATIONS The educational hand and head: Novel teaching tools in the design and execution of local flaps Sir, The history of surgery is the same as any skilled craft, with knowledge transferred from the master to the apprentice by exposure to cases and in the performance of the procedure. Implementation of the European Working Time Directive in times of NHS rationing and increased service commitments will inevitably reduce the exposure of trainees to plastic surgical cases. Practical teaching opportunities should be provided as an alternative to ensure maintenance of skills. Recently published articles have cited the development of unique simulators in order to improve this limited training.1,2 We describe our use of a simulated latex hand and head model in the education of plastic surgery trainees on the subject of designing, raising and the execution of a variety of local flaps for reconstructive purposes. An educational-hand (Ed-Hand) and -head (Ed-Head) were constructed utilising a plastic flectional model hand and polystyrene model head as a base. These were layered with pigmented latex to demonstrate the skin and fascial planes and coloured vascular sloops for the nerves and axial vessels essential to raising local and perforator flaps. The base hand; originally marketed for the training of manicurists is composed of soft flexible plastic and pliable fingers.3 Whereas the base head is composed of polystyrene and classically used to train artists in the technique of sculpting. The models are primarily dipped into thickened, pigmented, moulding latex (60.5% rubber solids as standard) and allowed to dry. Imitation blood vessels or nerves can then be placed in the desired anatomical location. We find red vascular “sloops” make the most realistic blood vessels whilst yellow “sloops” make good imitations of nerves. A layer of GranuFLEX was applied to sites where flaps are to be raised. The GranuFLEX layer is thin and pliable and mimics the subcutaneous soft tissue in terms of handling and allows the lifting of fascial layers such as that required for reverse cross finger flaps. The model is then re-dipped repeatedly to create the desired realistic “skin” thickness and permit easy handling. Each latex layering process takes approximately five minutes and then several hours to dry.
Differentiation of the fascial planes becomes much more appreciable when the latex is dyed contrasting shades. Once the entire process is complete the model is ready for use. Defects can be created on the models at the desired sites using a scalpel to remove layer(s) of latex. In this way partial to full thickness defects can be created. Flaps can be designed on the model as per standard practice using a marker pen. Following this, the flap can be raised and, provided the design has been correct, used to effectively cover the defect. The dissection of the simulated artery and nerve is necessary to island some of the flaps. To date we have used the “Ed-Hand” model to successfully perform a variety of reconstructive options such as cross finger/ reverse cross finger flap, 1st dorsal metacarpal artery flap, heterodigital island neurovascular flap, simple full thickness skin graft and a reverse dorsal metacarpal artery flap. (Figure 1).
Figure 1 Dorsal view of the educational hand showing 3 successfully completed flaps.
982
Correspondence and communications the restriction of the modern NHS. Surgery is a practical skill that needs tangible teaching in the “classroom” setting. Development of practical tools; such as our educational latex models, to increase trainees understanding of flaps is the way forward.
Conflicts of interest None.
Funding None.
References 1. Whallett EJ, McGregor JC. An alternative model for teaching basic principles and surgical skills in plastic surgery. J Plast Reconstr Aesthet Surg 2011;64:272e4. 2. Chipp E, Rayatt S. The stoke model for training in local flap surgery. J Plast Reconstr Aesthet Surg 2011 Jun;64(6):836e7. 3. http://www.everbella.com. 4. Menick F. Nasal reconstruciton. Mosby: Elsevier; 2009. 5. http://www.hta.gov.uk/.
Adam Gilmour Rieka Taghizadeh Caroline E. Payne Department of Plastic & Reconstructive Surgery, Royal Victoria Infirmary, Newcastle Upon-Tyne, Queen Victoria Road, NE1 4LP, UK E-mail address: [email protected]
Figure 2 “Ed-Head” showing a successfully raised forehead flap incorporating the axial vessel (seen at the base of the flap) and sutured accurately into the nasal defect.
The “Ed-Head” model is particularly useful in raising forehead flaps. The primary principles of nasal reconstruction can be simulated easily in this model as the defects often do not correspond to the nasal subunits.4 Only with this understanding can an adequate forehead flap be designed. It is possible to raise other flaps on the Ed-Head model including Z-Plasties and local random pattern flaps. We have been using the “Ed-Head” model since February 2010 to demonstrate the principles of nasal reconstruction. (Figure 2). Coupled with didactic teaching the model was highly successful at a regional registrar teaching day, being scored as “Excellent” on a 5-point Likert Scale questionnaire. Local flap teaching in plastic surgery is classically carried out on cadaveric specimens at recognised “flap” courses. Cadaveric specimens are expensive, require strict compliance with the human tissue act legislation and in modern practice are difficult to acquire, often being imported from other countries.5 In our experience it is also difficult to raise many flaps on cadaveric specimens secondary to the preservation process making them much less pliable. Our models offer distinct benefits in terms of realism and economy. Furthermore once the model has been used the base hand/head can be cleaned, re-covered in latex and the model recycled for another session. We plan to further utilise our latex layering technique to trial raising other local/regional flap options in different areas of the body including the upper and lower limb. In conclusion we believe that there may be little opportunity to visualise or perform these operations within
ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.11.044
Quick Response codes in plastic surgery Dear Sir, Recent articles have reviewed smartphone applications that are useful to plastic surgeons.1,2 We would like to highlight the use of Quick Response code readers, which were omitted by these reviews. Quick Response codes are two-dimensional matrix barcodes made from a collection of black squares on a white background (Figure 1). They can encode phone numbers, web addresses (URL), contact information and much more. Over the last year their use in advertising material has become ubiquitous. For instance, many movie advertisements use them to link to a trailer. Their major benefit is the very quick and easy transfer of information. Rather than transcribing a URL, which might be long and complicated, the scanned QR code takes the
CORRESPONDENCE AND COMMUNICATIONS The educational hand and head: Novel teaching tools in the design and execution of local flaps Sir, The history of surgery is the same as any skilled craft, with knowledge transferred from the master to the apprentice by exposure to cases and in the performance of the procedure. Implementation of the European Working Time Directive in times of NHS rationing and increased service commitments will inevitably reduce the exposure of trainees to plastic surgical cases. Practical teaching opportunities should be provided as an alternative to ensure maintenance of skills. Recently published articles have cited the development of unique simulators in order to improve this limited training.1,2 We describe our use of a simulated latex hand and head model in the education of plastic surgery trainees on the subject of designing, raising and the execution of a variety of local flaps for reconstructive purposes. An educational-hand (Ed-Hand) and -head (Ed-Head) were constructed utilising a plastic flectional model hand and polystyrene model head as a base. These were layered with pigmented latex to demonstrate the skin and fascial planes and coloured vascular sloops for the nerves and axial vessels essential to raising local and perforator flaps. The base hand; originally marketed for the training of manicurists is composed of soft flexible plastic and pliable fingers.3 Whereas the base head is composed of polystyrene and classically used to train artists in the technique of sculpting. The models are primarily dipped into thickened, pigmented, moulding latex (60.5% rubber solids as standard) and allowed to dry. Imitation blood vessels or nerves can then be placed in the desired anatomical location. We find red vascular “sloops” make the most realistic blood vessels whilst yellow “sloops” make good imitations of nerves. A layer of GranuFLEX was applied to sites where flaps are to be raised. The GranuFLEX layer is thin and pliable and mimics the subcutaneous soft tissue in terms of handling and allows the lifting of fascial layers such as that required for reverse cross finger flaps. The model is then re-dipped repeatedly to create the desired realistic “skin” thickness and permit easy handling. Each latex layering process takes approximately five minutes and then several hours to dry.
Differentiation of the fascial planes becomes much more appreciable when the latex is dyed contrasting shades. Once the entire process is complete the model is ready for use. Defects can be created on the models at the desired sites using a scalpel to remove layer(s) of latex. In this way partial to full thickness defects can be created. Flaps can be designed on the model as per standard practice using a marker pen. Following this, the flap can be raised and, provided the design has been correct, used to effectively cover the defect. The dissection of the simulated artery and nerve is necessary to island some of the flaps. To date we have used the “Ed-Hand” model to successfully perform a variety of reconstructive options such as cross finger/ reverse cross finger flap, 1st dorsal metacarpal artery flap, heterodigital island neurovascular flap, simple full thickness skin graft and a reverse dorsal metacarpal artery flap. (Figure 1).
Figure 1 Dorsal view of the educational hand showing 3 successfully completed flaps.
982
Correspondence and communications the restriction of the modern NHS. Surgery is a practical skill that needs tangible teaching in the “classroom” setting. Development of practical tools; such as our educational latex models, to increase trainees understanding of flaps is the way forward.
Conflicts of interest None.
Funding None.
References 1. Whallett EJ, McGregor JC. An alternative model for teaching basic principles and surgical skills in plastic surgery. J Plast Reconstr Aesthet Surg 2011;64:272e4. 2. Chipp E, Rayatt S. The stoke model for training in local flap surgery. J Plast Reconstr Aesthet Surg 2011 Jun;64(6):836e7. 3. http://www.everbella.com. 4. Menick F. Nasal reconstruciton. Mosby: Elsevier; 2009. 5. http://www.hta.gov.uk/.
Adam Gilmour Rieka Taghizadeh Caroline E. Payne Department of Plastic & Reconstructive Surgery, Royal Victoria Infirmary, Newcastle Upon-Tyne, Queen Victoria Road, NE1 4LP, UK E-mail address: [email protected]
Figure 2 “Ed-Head” showing a successfully raised forehead flap incorporating the axial vessel (seen at the base of the flap) and sutured accurately into the nasal defect.
The “Ed-Head” model is particularly useful in raising forehead flaps. The primary principles of nasal reconstruction can be simulated easily in this model as the defects often do not correspond to the nasal subunits.4 Only with this understanding can an adequate forehead flap be designed. It is possible to raise other flaps on the Ed-Head model including Z-Plasties and local random pattern flaps. We have been using the “Ed-Head” model since February 2010 to demonstrate the principles of nasal reconstruction. (Figure 2). Coupled with didactic teaching the model was highly successful at a regional registrar teaching day, being scored as “Excellent” on a 5-point Likert Scale questionnaire. Local flap teaching in plastic surgery is classically carried out on cadaveric specimens at recognised “flap” courses. Cadaveric specimens are expensive, require strict compliance with the human tissue act legislation and in modern practice are difficult to acquire, often being imported from other countries.5 In our experience it is also difficult to raise many flaps on cadaveric specimens secondary to the preservation process making them much less pliable. Our models offer distinct benefits in terms of realism and economy. Furthermore once the model has been used the base hand/head can be cleaned, re-covered in latex and the model recycled for another session. We plan to further utilise our latex layering technique to trial raising other local/regional flap options in different areas of the body including the upper and lower limb. In conclusion we believe that there may be little opportunity to visualise or perform these operations within
ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.11.044
Quick Response codes in plastic surgery Dear Sir, Recent articles have reviewed smartphone applications that are useful to plastic surgeons.1,2 We would like to highlight the use of Quick Response code readers, which were omitted by these reviews. Quick Response codes are two-dimensional matrix barcodes made from a collection of black squares on a white background (Figure 1). They can encode phone numbers, web addresses (URL), contact information and much more. Over the last year their use in advertising material has become ubiquitous. For instance, many movie advertisements use them to link to a trailer. Their major benefit is the very quick and easy transfer of information. Rather than transcribing a URL, which might be long and complicated, the scanned QR code takes the