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.
The growing expectations of proficiency and service delivery, combined with diminished surgical exposure due to restricted working hours and fewer opportunities for clinical teaching, result in reduced opportunities for work-based learning [
Plastic and reconstructive surgery is the oldest documented surgical specialty, tracing its origins to Susruta’s description of nasal reconstruction [
Simulation enables the learner to participate in experiential activities with varying degrees of realism and affording opportunities for reflection, feedback and debriefing [
Encompassing such a broad range of subspecialties, plastic surgery has the opportunity for many simulation modalities to support trainees’ learning. Indeed, this field has been the subject of a number of studies, including recent reviews on simulation in reconstructive and aesthetic surgery [
As described in a previous article (2), the methodological framework articulated by Arksey and O′Malley was used as the basis for our scoping review, adhering to five phases: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarizing and reporting the results [
In this review, we sought to identify simulation modalities used in plastic and reconstructive surgical training, with particular reference to both plastic and reconstructive surgery competencies and essential surgical competencies. Accordingly, the research question posed was ‘what types of simulation modalities are used in plastic and reconstructive surgery training?’. A further sub-question was ‘how does simulation-based training address achievement of both plastic and reconstructive surgery-specific competencies and essential surgical competencies?’
In accordance with the Population, Context, Concept (PCC) framework [
Search strategy defined along with PCC guidelines, including complete strategy incorporating Boolean operators and medical subject headings terminology
Population terminology | Plastic |
---|---|
Concept terminology | Simulat*, education, training, learning |
Context terminology | Plastic, reconstructive, skin, soft tissue, aesthetic, esthetic, cosmetic, burn, craniofacial, craniomaxillofacial, head and neck, hand, breast, chest, trunk, perineum, lower limb, paediatric plastic, pediatric plastic, microsurgery, competenc*, communication, teamwork, collaboration, management, leadership, health advocacy, scholarship, teaching, professionalism, ethics |
Search strategy | (Simulation Training/ or simulat*) AND (plastic) AND (education or training or learning) AND ((plastic or reconstructive or skin or soft tissue or aesthetic or esthetic or cosmetic or burn or craniofacial or craniomaxillofacial or (head and neck) or hand or breast or chest or trunk or perineum or lower limb or paediatric plastic or pediatric plastic or microsurgery) OR (competenc* or communication or teamwork or collaboration or management or leadership or health advocacy or scholarship or teaching or professionalism or ethics)) |
Medical subject heading terms | Simulation Training/ |
A search strategy was developed with the intention of capturing maximal results initially, subject to subsequent refinement. Search terms included ‘simulation’ with truncation to maximize search results, ‘plastic’, ‘education’, ‘training’ and ‘learning’. Further terms were added from Curriculum 2019, the most recent revision of the Plastic and Reconstructive Surgery Curriculum, which defines both Plastic and Reconstructive Surgery Competencies and Essential Surgical Competencies [
The first author (MAS) conducted the search on 28 May 2021, initially identifying sources in three Ovid MEDLINE databases (MEDLINE, In-Process & Other Non-Indexed Citations and Epub Ahead of Print). A subsequent search of the ERIC (Education Resources Information Centre) database was conducted with an identical search strategy. English language was used as a filter at the conclusion of the search. There were no qualifications on date or publication type employed. A search of the grey literature was not conducted given the volume of sources identified from existing databases.
As a result of the extensive breadth of subject matter and constraints on our resources, exclusion criteria were determined. The iterative nature of this process ensured that these criteria were modified in the development of a sound search strategy. A requirement of only English-language literature circumvented the need for translation of material which would have proved both time and resource consuming. Additional exclusion criteria were imposed throughout the process (
Exclusion criteria determined via an iterative process undertaken during the collation of studies identified using the search strategy
Exclusion criteria | Non-English language source |
---|---|
Sources discussing simulator development without reference to educational impact | |
Sources discussing courses incorporating simulation but without specific discussion of the simulators | |
Sources discussing the use of simulation without reference to education | |
Sources discussing simulation in education of undergraduate medical students | |
Sources relating to specialties other than plastic and reconstructive surgery | |
Duplicate source |
Titles were screened independently by two authors (MAS and ABY). Sources proceeded to abstract review where authors agreed on inclusion or where there was disagreement. A predetermined strategy for addressing disagreement involved an independent review of source inclusion by each author. If disagreement remained, referral to a third author (DN) was used to resolve disagreement. Sources where authors agreed that titles be excluded led to exclusion. A similar process was undertaken in the abstract review phase. Additionally, any source without an abstract automatically progressed to full-text review where the same consultative process was repeated.
The data charting phase involved the synthesis and interpretation of data by sorting the material thematically [
The final stage of the scoping review framework relates to the presentation and analysis of the results as outlined below.
The initial database searches yielded 554 sources, which was reduced to 538 when results were limited to English-language sources. Title and abstract screens resulted in the exclusion of 391 and 46 results, respectively, following which a full-text review occurred. Further restriction of sources proceeded according to exclusion criteria determined via the iterative process inherent in a scoping review. One paper was excluded as it was reporting the evaluation of a simulator already included in the search results, and another was identified as a duplicate despite a reversal of author order. Thus, 52 sources were included in the scoping review (
PRISMA flow diagram (adapted from Moher et al [
The characteristics of included studies are presented in
General characteristics of included sources on simulation in plastic surgery
Year | ≤2000 [ |
2001–2005 [ |
2006–2010 [ |
2011–2015 [ |
2016–2020 [ |
2021 [ |
Number of authors | 1–2 [ |
3–4 [ |
5–6 [ |
7–8 [ |
9–10 [ |
|
Continent of origin | North America [ |
Europe [ |
Asia [ |
South America [ |
||
Publication type | Surgical [ |
Education [ |
Medical [ |
|||
Article type | Original article [ |
Review article [ |
Letter to editor/ editor’s choice [ |
Innovation/ technical/ experimental section [ |
Despite some overlap with either simulator material or targeted skill-set, 42 different simulators were reported in individual articles. Further modalities were reported in the review articles (each considered a single source in this review). The most widely reported form of simulator was a prosthetic/synthetic simulator (30, 55.6%), followed by cadaveric models – human (15, 27.8%) and animal (13, 24.1%). Three sources (5.6%) described the use of fruit for skin graft harvesting [
Simulator characteristics identified in included sources, represented graphically.
When considering the curriculum areas of the plastic and reconstructive surgery curriculum [
Curriculum areas addressed by sources included in this scoping review, represented graphically.
The surgical competencies, as defined by the Royal Australasian College of Surgeons (RACS) [
Royal Australasian College of Surgeons competencies [
Competency | Number | Percentage |
---|---|---|
General | 7 | 13.0 |
Technical expertise | 45 | 83.3 |
Medical expertise | 17 | 31.5 |
Judgement/clinical decision-making | 15 | 27.8 |
Communication | 3 | 5.6 |
Collaboration/teamwork | – | – |
Management/leadership | – | – |
Health advocacy | – | – |
Scholarship/teaching | – | – |
Professionalism/ethics | 1 | 1.9 |
Cultural competence and cultural safety | – | – |
This review of 52 sources details the presence of simulation in plastic surgical education, providing insight into opportunities for simulation in this context. Below, we describe simulators and their applications, gaps in simulations and identify opportunities.
The simulators, as identified by this review, consist largely of prosthetic or synthetic materials, followed by cadaveric models. The curriculum areas addressed by the literature are heavily weighted towards microsurgery, skin and soft tissue, as well as craniomaxillofacial and paediatric procedures. When viewed in conjunction, these findings paint a picture of simulators largely addressing higher-complexity procedures. This may be an optimal scenario for simulation as an educational modality, wherein the margin of error may be too narrow to allow for ‘practice’ in a live scenario without the accrual of a pre-requisite skill level. In microsurgical procedures, the difference in sub-millimetre accuracy may prove the difference between success and failure. Similarly, the risk of long-term disfigurement of paediatric craniofacial patients possesses significant psychological and social impact for patients and potential medicolegal ramifications for treating surgeons. The proportionally greater presence of simulation in these areas is likely to borne out of the above considerations.
However, simulation need not be limited to these types of high-complexity procedures. There is a benefit to simulation being employed in lower-complexity procedures, to provide feedback and the improvement of practice [
A simplistic appreciation of simulation restricts its application to the technical aspects of surgery. However, surgeons need to achieve a range of competencies. Accordingly, this review seeks to examine simulation in plastic surgery through the framework of the surgical competencies as detailed by RACS [
Recreating the complexity of holistic surgical practice in simulation can be challenging, and reducing this complexity risks losing key features. Certain competencies including professionalism are difficult to define and, therefore, to demonstrate in isolation. This may explain the focus on competencies that can be simulated with reduced complexity, such as
The advantage of this scoping review lies not in its description of deficiencies but rather in the opportunities for simulation to complement existing educational practices. For this to occur, there must be an appreciation of simulation in a broader sense, beyond technical exercises on synthetic devices. Procedural simulation is largely supported by the educational theories on the development of expertise. Mastery learning [
The incorporation of multiple elements in a simulation, increasing the realism of the simulation scenario and widening the scope to include multiple competencies, holds great potential for plastic and reconstructive surgical education. Examples of such might include clinical situations in which the challenges associated with diversity might allow for practice of
With the gradual transition from the Halstedian model of time-based apprenticeship to competency-based medical education [
Simulation might also be used for summative assessment, with structured simulation incorporated into the formal curriculum. The Objective Structured Clinical Examination (OSCE) in undergraduate education is certainly applicable to postgraduate study. The opportunity to present the learner with a simulated patient who can enable the demonstration of
The scoping review reveals the potential of simulation for formative and summative assessment and for procedural and holistic surgical practice.
The iterative nature of this review provides a holistic view of simulation in plastic surgery, allowing for an appreciation of sources free of the constraints imposed by otherwise restrictive predetermined inclusion and exclusion criteria. The limitations of the study largely relate to excluded sources. A strength of the scoping review approach is the inclusion of sources from grey literature. While we sought to adhere to the scoping review method, the large number of sources balanced against our own resources led us to focus only on conventional databases. We acknowledge this limitation in our review. Furthermore, the title screen may have led to some relevant studies having been excluded, which may not have occurred had all studies undergone abstract review. The decision to screen titles and abstracts separately, as well as the exclusion of non-English literature sources, was also pragmatic and considered available resources. Accordingly, a potential limitation was having not employed librarian services to conduct the search, though we did consider the search to be a significant component of the study and thus undertook this process ourselves rather than outsourcing this process. Both grey literature and non-English sources may have added to the findings and are an important area for future research.
Simulation has been used as an educational modality in plastic and reconstructive surgery for millennia. Simulators have focused on the technical expertise of surgery and have been designed, largely, for high-complexity procedures. With the progression towards competency-based medical education, opportunities to use simulation to address a wider range of competencies is an exciting prospect. Examination of the competencies addressed by existing simulation modalities has revealed certain strengths and avenues of opportunity for the greater implementation of simulation in plastic and reconstructive surgery. This review may provide the impetus for the incorporation of simulation into formal curricula, to better complement existing educational strategies.
All authors contributed equally to this study.
There are no sources of funding for this study.
None.
None declared.
None declared.
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2019 | Nonbiological microsurgery simulators in plastic surgery training: a systematic review | |
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