Keywords
high fidelity simulation training - medical education - plastic surgery procedures
- plastic surgery - training courses
Introduction
Educational methods involving high-fidelity simulations provide medical students with
early experience in complex clinical topics, allowing them to develop skills essential
to real-world work environments. Simulation allows practicing medical skills in a
controlled environment, promoting meaningful learning that encourages reflection on
one's practice. The use of simulators has been driven by trends in healthcare and
education, such as increasing medical literacy, the significance of patient safety
and quality of life for healthcare professionals, limitations on work hours, and the
movement toward competency-based education.[1]
A particularly notable aspect is using simulation to teach surgical skills, a crucial
area for new physicians. In 2014, the Association of American Medical Colleges (AAMC)
introduced 13 professionally entrustable activities (EPAs) essential for all medical
graduates entering residency. The measure answered the concerns of residency program
directors, especially in Surgery, about the lack of preparation of recent graduates
for the duties of a first-year resident.[2] The Brazilian National Curricular Guidelines also emphasize this aspect since surgical
skills are paramount to train a generalist physician.[3]
Meaningful learning through simulation has been established in other high-risk professions,
increasing safety and reducing risks. For a long time, simulation incorporation in
medical education was underestimated for several reasons, including high costs, lack
of rigorous evidence of its effectiveness, and resistance to change. Despite the undeniable
value of training in real situations, its limitations include safety-related concerns.
In addition, it is preferable to perform training in invasive surgical procedures
in simulators, reducing the risk of medical errors and complications in actual procedures.[4]
[5]
During academic training, healthcare professionals often perform outpatient or surgical
procedures with no prior training. The lack of economic resources and the high cost
of medical practice training products resulted in the development of viable alternatives
as low-cost teaching resources.[6]
[7]
Objective
This study aimed to evaluate the effectiveness of low-cost synthetic models in simulating
surgical procedures and teaching surgical skills to medical students.
Methods
This prospective intervention study occurred at the University of Fortaleza (Unifor)
with undergraduate medical students over 18 years old, of both genders, enrolled from
the first to the last period of the course, from September 2023 to August 2024, participating
in a surgical skill training course promoted by the institution's Academic League
of Plastic Surgery (LICIP).
We recruited the participants through a public call with broad virtual dissemination
of the research via e-mail, as a hidden list, and publication on social networks and
electronic messages, containing the invitation, the electronic address with information
about the study, an informed consent form, and an opinion questionnaire. Students
under 18 years old, with suspended course enrollment, who did not agree to participate
in the study or dropped out at some stage, and questionnaires with filling errors
were excluded. We used a self-administered virtual questionnaire from the Google Forms
online platform with 26 objective questions about the theoretical and practical surgical
training classes using simulators and the content retention by the students. The students
evaluated their content retention after a single theoretical class and after the class
plus a simulated practice on a scale of 1 to 5 (1 = very poor; 2 = poor; 3 = indifferent;
4 = good; 5 = very good).
The training and the manufacturing of low-cost simulators occurred at the Experimental
Biology Center (NUBEX) of Unifor. The course lasted 40 hours, including 20 hours of
distance learning and 20 hours in person, divided into seven meetings lasting 2 hours
each and 3 in-person meetings lasting 4 hours each. Remotely, students watched theoretical
video classes recorded via the Google Scholar platform, and, in person, they practiced
the surgical techniques discussed in the video classes using synthetic models with
the help of monitors and professors. The release of each video class occurred 3 days
before the corresponding practical class. The topics included basic Anesthesiology,
fundamentals in surgery, Aesthetic Plastic Surgery - basics in rhinoplasty and labiaplasty,
Reconstructive Plastic Surgery - basics in flap and reconstruction of the nipple-areola
complex (NAC), liposuction and otoplasty, and basics in videolaparoscopy.
The low-cost simulators manufactured for practical training were the following:
Otoplasty Model
The base structure used a mannequin head covered with a uniform layer of foam 1 cm
thick, fixed with hot glue, providing the shape and consistency necessary to simulate
the anatomical characteristics of the ear region. Next, we applied a fabric mesh to
the foam surface to represent the skin, giving the model a more realistic aesthetic
appearance. In the ear region, we made two bilateral and symmetrical openings in the
mesh, each measuring 6 cm in diameter, for the insertion and removal of the synthetic
ears as this model was designed to be reusable, allowing the replacement of the synthetic
ears after each suture practice using the Furnas and Mustardé surgical techniques.
We produced two models and 80 pairs of interchangeable ears for training, allowing
their replacement after each participant had performed the procedure. The total production
cost of a model was approximately R$ 100.00 ([Figure 1]).
Fig. 1 Model for otoplasty training. Source: the authors.
Rhinoplasty Model
We used a plastic mask with hot glue applications as a bony framework for the face,
including the nasal septum and the nasal bones. We did the cartilages with acetic
silicone, using a handcrafted epoxy mold to reproduce the shape of the upper and lower
lateral cartilages. We fixated the cartilages to the bony framework using suture threads,
providing stability and realistic anatomy to the model. Acetic silicone allows repeated
training without significant wear, facilitating the cartilage replacement with new
molded parts as needed. We prepared three models, each with a total cost of approximately
R$ 150.00 ([Figure 2]).
Fig. 2 Model for rhinoplasty training. Source: the authors.
NAC Reconstruction Model
We used a mannequin of the upper limb as a base and applied a 0.5 cm-thick foam layer.
Additionally, we superimposed several layers of foam on the flanks and thorax, fixated
with hot glue, to anatomically shape the body and simulate female characteristics.
Next, we covered the model with mesh, providing a more aesthetic surface. In the breast
region, on both sides, we left strategic spaces for foam disc insertion and removal
with sutures. These discs had the same thickness and mesh coverage as the mannequin.
We inserted the discs in the designated spaces on the model to allow repeated reconstruction
performance after replacing the removed discs with new ones after each practice. We
made two models, each costing approximately R$ 170.00 ([Figure 3]).
Fig. 3 (A). Model for nipple-areola complex (NAC) reconstruction. (B). Removable piece for performing the technique, reproducing a post-mastectomy breast.
Piece replacement allows reusing the model. (C). Reproduction of the C-V flap technique for NAC reconstruction. Source: the authors.
Labiaplasty Model
The labiaplasty model consisted of a fabric mannequin filled with foam representing
a female pelvis in the lithotomy position. We made the labia majora individually from
thicker fabric and molded them by sewing to fit snugly into the model's pelvis. The
model allowed students to practice the labia majora reduction from the labiaplasty
procedure and sutures. After suturing, it is easy to replace the labia majora alone,
made from thicker, dark pink fabric. As such, it is possible to reuse the model, saving
resources and allowing multiple students to practice the labiaplasty technique efficiently
and realistically. We made two models, each costing approximately R$ 100.00 ([Figure 4]).
Fig. 4 (A). Model for labiaplasty with the possibility of replacing and reusing the labia minora
after training. (B). Labia minora before (right) and after (left) training in the star resection technique.
Source: the authors.
Liposuction Model
The liposuction model consisted of a mannequin body, a 0.5 cm wide sponge, 1.5 m of
beige mesh fabric, 0.5 m of light pink fabric, a zipper, and micro-pearl Styrofoam.
We used a mannequin thorax wrapped in a layer of a 0.5 cm sponge, covered with fabrics
sewn together to form the shape of a bust, simulating a human body. We sew another
fabric layer on top of it, in the abdominal region, delimiting a virtual cavity. We
filled this cavity with micro-pearl Styrofoam and closed it at the bottom with a zipper.
The purpose of this double layer is to absorb the Styrofoam with a cannula attached
to a homemade vacuum cleaner, simulating the removal of body fat. We sew the tissue
in the umbilical region separately to allow reuse after the suprapubic incision and
put a small layer of replaceable foam. Other plastic surgeons and league members tested
the model, proving its effectiveness as an innovative alternative for the surgical
practice of liposuction. We manufactured one model at a total cost of approximately
R$ 200.00 ([Figure 5]).
Fig. 5 Model for liposuction training. Source: the authors.
For questionnaire response analysis, we expressed categorical data as absolute counts
and percentages. First, we assessed continuous data for normality using the Shapiro-Wilk
test. We expressed parametric data as mean ± standard deviation (SD), and nonparametric
data as median and interquartile range (IQR). Comparisons between two independent
groups used the Student's t-test for parametric data and the Wilcoxon test for nonparametric data. The hypothesis
was that retention was higher after simulated training compared with theoretical training
alone. Statistical significance was set at p < 0.05. We performed the analyses using
Jamovi software.[8]
The Unifor Ethics Committee approved the project considering the ethical and legal
precepts guiding research involving human beings per Resolution 466/12 from December
2012 of the Brazilian National Health Council (CAEE 73903623.6.0000.5052).
Results
Fifty students participated in the study, including 23 (46%) males and 27 (54%) females.
The median age of the participants was 19.5 years (minimum, 17, and maximum, 39; IQR,
2). All participants were enrolled in the Medicine course, including four (8%) in
the 1st semester, 17 (34%) in the 2nd semester, 17 (34%) in the 3rd semester, nine (18%) in the 4th semester, one (2%) in the 5th semester, one (2%) in the 6th semester, and one (2%) in the 8th semester.
Most participants (n = 29, 58%) responded that their main study method was attending theoretical classes
and performing actual practices simulating the reality of the theoretical content.
A minority answered that they only had theoretical classes or had classes and imagined
actual situations.
Most participants (n = 34, 68%) had never had contact with a surgical simulator before participating in
the LICIP course. Among those who responded that they had had contact before, the
main simulators mentioned were a skin or arm model for suture training, a thoracic
drainage simulator, and a paracentesis simulator. No student had previously contact
with synthetic models for training in otoplasty, rhinoplasty, and liposuction. A single
student knew of a model for NAC reconstruction surgery, and four were aware of a model
for labiaplasty.
Approximately 76% (n = 38) of the students evaluated their knowledge of plastic surgery techniques as
zero, 1, or 2 (on a scale where zero is equivalent to no knowledge and 5 is maximum
knowledge) before the course.
After attending a single theoretical class on otoplasty, labiaplasty, rhinoplasty,
NAC reconstruction, and liposuction, most students answered that they had good retention
of the content learned, respectively 64% (n = 32), 62% (n = 31), 56% (n = 28), 68% (n = 34), 64% (n = 32). After performing practical training of each surgical technique on low-cost
synthetic models, most students responded that learning retention was very good: 80%
(n = 40) for otoplasty, 80% (n = 40) for labiaplasty, 76% (n = 38) for rhinoplasty, 78% (n = 39) for NAC reconstruction, and 70% (n = 35) for liposuction. After the practical sessions, 88% (n = 44) of the participants evaluated their knowledge as 4 or 5.
The frequencies of responses regarding content retention after theoretical class alone
and after class plus simulated practice for all surgeries followed a non-normal distribution
(Shapiro-Wilk test, p < 0.01). The median values of the responses after classes and practices were significantly
higher (Wilcoxon test, p < 0.001) when compared with theoretical classes alone ([Table 1]). Although mean values do not represent the behavior of the variables well, we decided
to present them for potential comparisons with other studies. All respondents reported
that the practice with synthetic models helped to awaken some interest in surgery
and that they consider the use of low-cost surgical models to be relevant in the development
of medical skills.
Table 1
|
After attending the theoretical class on the surgical technique alone
|
After attending the theoretical class and practicing with a synthetic model
|
|
|
|
Mean (SD)
|
95% CI
|
Median (IQR)
|
Mean (SD)
|
95% CI
|
Median (IQR)
|
W
|
p
|
|
Otoplasty
|
3.80 (0.67)
|
3.61 - 3.99
|
4 (0.75)
|
4.70 (0.64)
|
4.52 - 4.88
|
5 (0.0)
|
95[a]
|
<.001
|
|
Labiaplasty
|
3.80 (0.80)
|
3.57 - 4.03
|
4 (0.0)
|
4.74 (0.56)
|
4.58 - 4.90
|
5 (0.0)
|
78[b]
|
<.001
|
|
Rhinoplasty
|
3.80 (0.80)
|
3.57 - 4.03
|
4 (1.0)
|
4.62 (0.75)
|
4.41 - 4.83
|
5 (0.0)
|
78[d]
|
<.001
|
|
NAC reconstruction
|
3.86 (0.60)
|
3.69 - 4.03
|
4 (0.0)
|
4.74 (0.52)
|
4.59 - 4.89
|
5 (0.0)
|
64.5[b]
|
<.001
|
|
Liposuction
|
3.92 (0.69)
|
3.72 - 4.12
|
4 (0.0)
|
4.56 (0.73)
|
4.35 - 4.77
|
5 (1.0)
|
134[e]
|
<.001
|
Discussion
This study evaluates the effectiveness of low-cost synthetic models in simulating
surgical procedures and teaching surgical skills to medical students. The study involved
50 students using low-cost synthetic models to train in otoplasty, rhinoplasty, and
liposuction. After the course, most participants rated their knowledge as high, and
all reported that hands-on experience with synthetic models helped spark their interest
in surgery.
In recent years, medical school has undergone significant changes, requiring adaptations
in surgical skill teaching. The traditional teaching scenario also changed due to
financial costs, cultural and social alterations, and new teaching-learning technologies.[5]
Over the years, it was realized that medical school graduates trained in surgical
skills using the Halstedian model (“see one, do one, teach one”) had no proper preparation
for medical residency. An efficient and accessible method of teaching and assessing
knowledge and skills that could be widely applied was needed. The solution was simulated
training, which provides a safe environment for students to practice and learn before
dealing with actual patients and scenarios.[9]
[10]
Simulation includes physical models, such as synthetic “dry lab” benches, cadaver
and animal models, and virtual and augmented reality simulators. New simulator-based
technologies are increasingly in use, with varying levels of realism. The American
College of Surgeons, for instance, does not require animal training, using simulators
for specialist accreditation.[7]
Low-fidelity simulators consist of static mannequins to train basic skills and do
not interact with the trainee. In contrast, high-fidelity simulators are computer-controlled
and adjust parameters according to the participant's performance; they are often expensive.
Low-cost simulators are made with accessible materials and replicate the anatomy required
for specific training.[11] Despite the differences between simulator types, the literature shows that training
surgical skills on low-fidelity models is as effective as training on high-fidelity
models.[9]
[12] These data corroborate the findings of our study.
The evaluation of the effectiveness of the simulators manufactured and used in our
study was based on several well-established aspects, such as expert opinion on how
well the simulator content reflects the required skills and knowledge, user opinion,
and cost-effectiveness.[13]
In health education, the local manufacture of simulators for training in clinical
procedures enables and encourages students and professors to actively engage and develop
new ways to assess performance in using these resources. Corroborating our findings,
research shows that simulation is more enjoyable, engaging, effective, and safe than
traditional lecture-based teaching.[14] Some commercially available simulators are costly to acquire and maintain limiting
access by educational institutions. These barriers drive the development of affordable
models that are easy to manufacture and replace.[15]
Similar to ours, another study with 91 fourth-year medical students from an institution
in western Paraná, Brazil, used simulators for male urogenital training. Forty-five
students received guidance and training with simulators, and 46 had only information
from theoretical classes. Those trained on simulators had higher scores and greater
confidence. In addition, they were twice as likely to get higher scores. Those who
only followed the theoretical classes had more difficulty, stress, and anxiety when
performing the tasks on the mannequins.[16]
The 2015 Lancet Commission on Global Surgery highlighted the shortage of healthcare
professionals providing surgical services, especially in low and middle-income countries,
leaving 5 billion people without access to surgical care. In some countries, postgraduate
training is not required for surgery, increasing the need to train surgically competent
generalists. This is challenging due to the lack of faculty, the large number of students,
the priority of residents in healthcare settings, and the workload of supervisors.
Simulation-based surgical training may help address these challenges.[17]
[18]
This study has limitations. First, the number of participants is relatively small,
which may compromise the representativeness of the results. In addition, the limited
variety of synthetic models simulating surgical procedures restricts the comprehensiveness
of the conclusions, potentially diminishing the impact of the study.
Despite these limitations, we achieved our main objective, i.e., to develop and evaluate
low-cost synthetic models as practical, accessible, and scalable tools for early surgical
training focusing on plastic surgery. These models were designed to enable procedures
such as resections, mobilizations, and rotations with a degree of realism appropriate
for basic training.
Some biological materials traditionally used for this type of training, such as bovine
tongues, may offer specific advantages. Synthetic models have additional benefits,
such as practicality and safety, eliminating the handling and disposal of organic
materials, which require care, reproducibility and standardization, as anatomical
characteristics are consistent, ensuring uniformity in training, and sustainability
and accessibility, as the materials are easy to acquire, allowing modular component
replacement and reducing operating costs.
Recent studies corroborate the effectiveness of synthetic models in surgical education.
A recent systematic review with 57 articles highlights that non-biological simulators
are effective in acquiring motor skills and increasing learners' confidence in the
initial training stages of microsurgical techniques in plastic surgery. In addition,
they are widely accepted as viable and economical alternatives.[19] Awad et al (2023) demonstrated that foam-based models for skin suture training are
a high-fidelity non-biological alternative and not inferior to other high-cost materials.[20] Another systematic review on microsurgical training reinforces that synthetic simulators
are viable for initial teaching, reducing the need for biological and animal models.[21] These findings support our results as 88% of participants reported significant improvement
in learning and confidence after training with synthetic models compared with theoretical
classes.
It is worth noting that our models do not intend to replace more advanced approaches,
but rather complement practical teaching, providing an accessible and efficient alternative
for introducing technical skills. Their simplicity and cost-effectiveness allow for
greater scalability and democratization of access to surgical training.
It is essential to increase the number of participants and diversify the synthetic
models to improve the validity and reliability of the results. These actions would
not only strengthen the reliability of the conclusions but also increase the impact
of the study, providing a more robust basis for the practical application of the findings.
For future studies, we also recommend expanding the evaluation of different synthetic
materials to improve the realism of the models, conducting direct comparisons between
the effectiveness of biological and synthetic models in advanced training, and expanding
both the number of participants and the techniques evaluated. Despite the limitations,
the data show that low-cost simulators allow training in surgical skills.
Conclusion
Practical simulation using low-cost models for training in different plastic surgery
techniques has proven to be an effective teaching method. In addition, it offers a
safe learning environment, reducing insecurity and improving students' preparedness
and confidence to interact with actual patients in the future. Thus, students face
challenging situations, see the consequences of their actions, and receive immediate
feedback. This interactive learning develops clinical judgment, error recognition,
and management, reducing risks and increasing patient safety.
It is noteworthy that the early introduction of simulation into the medical curriculum
provides significant learning linking theory and practice. Other institutions can
replicate the models described and used in this study to disseminate medical-surgical
education.
Bibliographical Record
Artur Diógenes Vasques Farias, Ivens Rafael Resplande de Sá, Leticia Libório Santos,
Lucas Evangelista de Andrade, Lourrany Borges Costa. Simuladores sintéticos de baixo
custo no ensino de Cirurgia Plástica para estudantes de Medicina. Revista Brasileira
de Cirurgia Plástica (RBCP) – Brazilian Journal of Plastic Surgery 2025; 40: s00451809396.
DOI: 10.1055/s-0045-1809396
