Pediatric Plastic Surgery Operating Room Block-Time Utilization: A Casualty of Illness.

BACKGROUND: Optimizing operating room (OR) utilization is a critical component of health care system efficiency. The purpose of our study was to analyze the extent of OR cancellation and its effect on raw utilization of OR block time allotted to surgeons in the pediatric plastic surgery department. METHODS: The authors retrospectively reviewed the cases of 4 plastic surgeons at a tertiary pediatric hospital between 2018 and 2019. Data collected included patient demographics, type of surgery, time of cancellation, reason for cancellation, length of surgery, and minutes of block time allotted to each surgeon per year. Percent of cases canceled, scheduled times lost, and block times lost were calculated. RESULTS: Surgeons A, B, C, and D scheduled 170, 416, 305, and 474 cases, respectively. Overall, 7% of cases were canceled, 9.1% of scheduled time was lost, and a total of 5.1% of block time was lost due to cancellation. Patients of surgeon A and D were more likely to cancel due to reasons classified as ''other,'' including causes such as failure of nil per os or a family's last-minute decision to forego elective surgery (33.3% and 37.2%, respectively), whereas patients of surgeon B and C were more likely to cancel due to illness (67.9% and 36.4%, respectively). CONCLUSIONS: Cancellations negatively impact raw utilization times; if fewer cases are performed, allotted block times are redistributed. Communication with patients in the week prior to surgery may allow for earlier identification of likely cancellations. Future directions include exploring whether particular surgeon characteristics are linked to rate of cancellations.

The Effects of Nasoalveolar Molding on Nasal Proportions at the Time of Nasal Maturity.

BACKGROUND: The aim of this study is to assess the effect of nasoalveolar molding (NAM) versus no-NAM on nasal morphology in patients with unilateral cleft lip and palate (UCLP) at the time of nasal maturity. METHODS: A retrospective, single-institution review was conducted on all non-syndromic patients with UCLP. Inclusion criteria included age 14 years or above, unilateral cleft repair at the time of infancy, and adequate photography taken at nasal maturity and prior to rhinoplasty. Exclusion criteria included age less than 14 years, syndromic diagnosis, and rhinoplasty prior to nasal maturity. Ten parameters were measured twice from standardized clinical photographs using the Dolphin Imaging Software for establishment of intrarater reliability. Subjective analysis was achieved through completion of the Asher McDade grading scale by 3 expert cleft practitioners. RESULTS: Nostril height, columellar angle, alar cant, vertical alar height, alar height angle, nasofacial angle, and nasolabial angle were found to be significantly less severe in patients who had undergone NAM in conjunction with surgical repair when compared with those who had undergone surgical repair alone. Asher McDade grading revealed significant improvement in nasal form, nasal symmetry/deviation, nasal profile, vermillion border, and overall score in patients who underwent NAM compared to no-NAM. CONCLUSION: The use of presurgical NAM during infancy can improve nasal symmetry and nasal proportions at the time of nasal maturity.

Effect on Facial Growth of the Management of Cleft Lip and Palate.

Treatment of cleft lip and palate ordinarily requires multiple interventions spanning the time of birth to adulthood. Restriction of facial growth, a common occurrence in affected children, is due to multiple factors. There are multiple surgical and therapeutic options, which may have influence on facial growth in these patients. As restriction to facial development can have significant implications to form, function, and psychological well-being, practitioners should have an appreciation for the effects of the different cleft therapies to facial growth. We have outlined and thoroughly reviewed in chronological order all of the interventions from birth to adulthood necessary in the comprehensive care of the patient with cleft lip and palate, along with the effects they may or may not have on facial growth.

Three-Dimensional Affordable Stone Models for Cleft Lip Markings: A Prospective Study of Learner Satisfaction.

INTRODUCTION: Knowledge of surgical markings for unilateral cleft lip (UCL) repair is critical for surgical competency. However, few appropriate models are accessible to residents and affordable and accurately reproduce this 3-dimensional (3D) deformity. We propose that cleft care units have the capability of creating affordable 3D stone models to teach UCL markings. METHODS: Polyvinyl siloxane and SnapStone were used to create UCL stone models. Thirteen plastic surgery residents were prospectively recruited, provided with a textbook chapter and online module for studying surgical markings for UCL repair, and then asked to perform the markings on a UCL stone model and standardized patient photograph. Learner satisfaction was evaluated using a modified survey based on the Student Evaluation of Educational Quality survey. RESULTS: The production time of each model was 10 minutes, whereas the cost was $1.84. Participants reported that the stone model was more stimulating (4.77 ± 0.44 vs 3.92 ± 0.86; U = 38.0; P = 0.008), increased their interest more (4.70 ± 0.48 vs 3.53 ± 1.20; U = 33.5; P = 0.005), allowed better learning (4.61 ± 0.51 vs 3.08 ± 0.86; U = 10.0; P < 0.001), was clearer (4.62 ± 0.51 vs 3.15 ± 0.90; U = 12.5; P < 0.001), and was more effective for learning cleft lip markings (4.77 ± 0.44 vs 3.08 ± 1.04; U = 9.0; P < 0.001). They were also more likely to recommend it (4.85 ± 0.38 vs 3.15 ± 1.07; U = 7.0; P < 0.001). CONCLUSIONS: Plastic surgery residents report that 3D cleft lip stone models are superior training tools to learn cleft lip markings compared with patient photographs. These educational tools have the potential to overcome significant financial, logistic, and time constraints in teaching cleft lip surgery markings.

Combined Primary Cleft Lip and Palate Repair: Is It Safe?

BACKGROUND: Single-stage primary cleft lip and palate (PCLP) repair is controversial in the United States, and most patients are treated with a staged approach. In this study, early postoperative complications of the single-stage approach as compared to primary cleft lip (PCL) or primary cleft palate (PCP) alone were evaluated. This study represents the largest cohort of patients undergoing combined cleft lip and palate repair. METHODS: The American College of Surgeons National Surgical Quality Improvement Program-Pediatric database was used to identify patients undergoing single-stage PCLP, PCL, or PCP repairs. Preoperative factors and postoperative outcomes were compared between the 3 groups, as well as within the PCLP group between patients with and without complications. Univariate and multivariate analyses were performed. RESULTS: A TOTAL OF:: 181 patients were included in the single-stage PCLP group, 1007 in the PCP group and 783 in the PCL group. There was no difference in the rates of early complications between the 3 groups. Within the PCLP group, cardiac risk factors (ß = 35.19; 95% confidence interval [CI] 7.88-75.21; P = 0.04) and complications (ß = 77.31; 95% CI 35.82-118.79; P < 0.001) were significant risk factors for longer operative time. CONCLUSION: Analysis of a national database showed that single-stage PCLP repair is not associated with increased risk of early postoperative complications as compared to primary lip or palate repair alone. In-depth long-term analyses of craniofacial morphology, fistulae rate, speech, and dental outcomes are essential for a comprehensive assessment of the effects of combined cleft lip and palate repair.

Nasolabial Aesthetics Following Cleft Repair: An Objective Evaluation of Subjective Assessment.

OBJECTIVE: Assess the weight and contribution of each of the parameters of the Asher-McDade Scale to overall subjective assessment of nasolabial aesthetics following cleft lip repair. DESIGN: Retrospective cohort evaluation. SETTING: Cleft and craniofacial center. PARTICIPANTS: Forty-one patients who underwent unilateral cleft lip repair. INTERVENTIONS: Unilateral cleft lip repair. MAIN OUTCOME MEASURES: Nasolabial rating using the Asher-McDade scale and overall subjective assessment of nasolabial aesthetics using a rank score following unilateral cleft lip repair. RESULTS: Strong interrater reliability was observed between the 3 raters. Significant association was determined on bivariate analysis between nasal form score (ß = 27.06; P < .001), nasal symmetry score (ß = 26.41; P < .001), nasal profile score (ß = 28.75; P < .001), vermilion border score (ß = 13.40; P = .012), and the ranking score. Adjusted ß coefficients obtained from multivariate regression analysis were used to develop a modified nasolabial appearance score (over 5), that is, weighted for each of the 4 parameters: nasal form (over 8, adjusted ß = 14.33), nasal symmetry (over 5, adjusted ß = 7.96), nasal profile (over 5, adjusted ß = 9.44), and vermilion (over 2, adjusted ß = 3.31). Regression analysis between our modified nasolabial appearance score and patient ranking score demonstrated superior goodness of fit when compared to the Asher-McDade overall nasolabial appearance score (R2 = .80; P < .001 vs R2 = .69; P < .001). CONCLUSION: The parameters evaluated in the Asher-McDade scale have different weights and contribute differently to overall subjective assessment of nasolabial aesthetic outcomes following cleft lip repair. Adjusting for their weights results in a modified score that demonstrates superior correlation with overall subjective assessment of nasolabial aesthetic outcomes.

In-House Manufacture of Sterilizable, Scaled, Patient-Specific 3D-Printed Models for Rhinoplasty.

BACKGROUND: Rhinoplasty relies on clear patient communication and precise execution of a three-dimensional (3D) plan to achieve optimal results. As 3D imaging and printing continue to grow in popularity within the medical field, rhinoplasty surgeons have begun to leverage these resources as an aid to preoperative planning, patient communication, and the technical performance of this challenging operation. OBJECTIVES: Utilizing departmentally available resources and open-access 3D imaging platforms, we have developed an affordable, reproducible protocol for rapid in-house virtual surgical planning (VSP) and subsequent manufacture of 3D-printed rhinoplasty models. METHODS: Preoperative 3D photographic images underwent virtual rhinoplasty using a freely available 3D imaging and sculpting program (BlenderTM [Version 2.78, Amsterdam, The Netherlands]). Once the ideal postoperative result was digitally achieved, scaled, sterilizable, and patient-specific 3D models of the preoperative and ideal postoperative result were manufactured in-house using a departmentally owned 3D printer. RESULTS: 3D-printed models have successfully been manufactured and employed for 12 patients undergoing rhinoplasty. The average time to prepare a set of pre- and postoperative models was 3 hours, while the printing process required 18 to 24 hours per model. Each set of surgical models can be manufactured at a total materials cost of approximately $5.00. CONCLUSIONS: We describe an affordable means to construct sterilizable, scaled, patient-specific 3D-printed models for rhinoplasty. This technique may become of increasing interest to academic and cosmetic centers as hardware costs of 3D printers continue to fall.

Haptic, Physical, and Web-Based Simulators: Are They Underused in Maxillofacial Surgery Training?

PURPOSE: Surgical residencies have increasingly incorporated both digital and mannequin simulation into their training programs. The aim of our review was to identify all digital and mannequin maxillofacial simulators available for education and training, highlight their benefit, and critically assess the evidence in support of these educational resources. MATERIALS AND METHODS: We performed a comprehensive literature review of all peer-reviewed publications of digital and mannequin simulators that met the inclusion criteria, defined as any simulator used in education or training. All simulators used in surgical planning were excluded. Before the query, it was hypothesized that most studies would be descriptive in nature and supported by low levels of evidence. Literature search strategies included the use of multiple combinations of key search terms, review of titles and abstracts, and precise identification of the use of the simulator described. All statistics were descriptive. RESULTS: The primary search yielded 259 results, from which 22 total simulators published on from 2001 to 2016 were identified using the inclusion and exclusion criteria: 10 virtual reality haptic-based simulators, 6 physical model simulators, and 6 Web-based simulators used for a variety of procedures such as dental skills, instrument handling, orthognathic surgery (Le Fort I osteotomy, vertical ramus osteotomy, bilateral sagittal split ramus osteotomy), genioplasty, bone grafting, sinus surgery, cleft lip repair, orbital floor repair, and oral biopsy. Only 9 formalized studies were completed; these were classified as low-level evidence-based cohort studies (Levels IV and V). All other simulator reports were descriptive in nature. There were no studies with high levels of evidence completed (Level I to III). CONCLUSIONS: The results of this review suggest that, although seemingly beneficial to the trainee in maxillofacial surgery, simulation in education in this field is an underused commodity because of the significant lack of scientific and validated study designs reported on in the literature thus far. The maxillofacial and simulation communities would benefit from studies on utility and efficacy with higher levels of evidence.

Single-Stage Primary Cleft Lip and Palate Repair: A Review of the Literature.

BACKGROUND: Single-stage cleft lip and palate repair is a debated surgical approach. While some studies have described favorable outcomes, concerns include the effect on craniomaxillofacial growth and increased risk of complications. To this date, there has not been a comprehensive appraisal of available data following combined cleft lip and palate repair. METHODS: An extensive literature review was performed to identify all relevant articles. The level of evidence of these articles was graded according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence Scale. RESULTS: A total of 22 relevant articles were identified, all of which were retrospective in nature. Patient age at the time of surgery ranged from 1 month to 10 years, the longest duration of follow-up was 18 years, and the largest study included 106 patients. Review of the literature shows that overall surgical outcomes following combined cleft lip and palate repair are encouraging. An increased rate of postoperative fistulas with associated speech abnormalities in some studies is noteworthy. Importantly, there is no evidence to suggest an impact on craniomaxillofacial growth, and psychosocial outcomes and parental satisfaction seem to be improved with single-stage surgery as compared with the staged approach. CONCLUSIONS: Our review shows overall favorable outcomes associated with combined cleft lip and palate repair. The limited follow-up time or nature of evaluated outcomes in some studies may underrepresent the true rate of adverse events, and highlights the need for additional long-term studies with standardized follow-up. To our knowledge, our review is the first to evaluate existing data regarding outcomes following combined cleft lip and palate repair.

Lower Eyelid Blepharoplasty: Does the Literature Support the Longevity of this Procedure?

BACKGROUND: Lower eyelid blepharoplasty has continued to evolve with ongoing debate regarding optimal techniques. Despite large case series publishing excellent results and minimal complications, the true longevity of these procedures remains unclear. OBJECTIVES: The aim of this study was to determine how thoroughly the aesthetic surgery literature assesses the longevity of lower blepharoplasty. METHODS: A 20-year comprehensive literature review from 1997 to 2017 was conducted. The titles and abstracts of 180 articles were reviewed, yielding 86 potential publications; 49 studies met inclusion criteria and were analyzed. RESULTS: A total of 10,698 patients were included for analysis. Reported follow-up ranged between 1 week and 192 months. Mean follow-up was 14.8 months for the 29 studies (59.2%) that reported these data. Pooled analysis of complication rates demonstrated 0.77% (n = 82) reoperation, 0.37% (n = 39) scleral show, 0.25% (n = 27) lid malposition, and 0.24% (n = 25) ectropion rates, among others. Forty-four studies (89.8%) published postoperative photographs with a total of 141 unique postoperative time points that were supported with photographic evidence (mean: 15.3 months; range: 1 week-192 months). In this series, for only 10 patients (0.094%) were postoperative photographs available at time points beyond 24 months. CONCLUSIONS: Lower eyelid blepharoplasty is a powerful procedure with seemingly minimal morbidity despite its technical demands. The longevity of this procedure is poorly supported with photographic evidence in the literature. Studies do not adequately report or represent their follow-up to capture long-lasting results. Standardized reporting of results is needed to ensure that anyone seeking this treatment can be adequately counseled.

Feasibility and Perception of Cross-sex Face Transplantation to Expand the Donor Pool.

BACKGROUND: A major challenge in face transplantation (FT) is the limited donor allograft pool. This study aimed to investigate the feasibility of cross-sex FT (CSFT) for donor pool expansion by: (1) comparing craniomaxillofacial metrics following CSFT versus same-sex FT (SSFT); and (2) evaluating the public and medical professionals' perception of CSFT. METHODS: Seven cadaveric FTs were performed, resulting in both CSFT and SSFT. Precision of bony and soft tissue inset was evaluated by comparing pre- versus post-operative cephalometric and anthropometric measurements. Fidelity of the FT compared to the virtual plan was assessed by imaging overlay techniques. Surveys were administered to medical professionals, medical students, and general population to evaluate opinions regarding CSFT. RESULTS: Five CSFTs and 2 SSFTs were performed. Comparison of recipients versus post-transplant outcomes showed that only the bigonial and medial intercanthal distances were statistically different between CSFT and SSFT (P = 0.012 and P = 0.010, respectively). Of the 213 survey participants, more were willing to donate for and undergo SSFT, compared with CSFT (donate: 59.6% versus 53.0%, P = 0.001; receive: 79.5% versus 52.3%, P < 0.001). If supported by research, willingness to receive a CSFT significantly increased to 65.6% (P < 0.001). On non-blinded and blinded assessments, 62.9% and 79% of responses rated the CSFT superior or equal to SSFT, respectively. CONCLUSIONS: Our study demonstrates similar anthropometric and cephalometric outcomes for CSFT and SSFT. Participants were more reticent to undergo CSFT, with increased willingness if supported by research. CSFT may represent a viable option for expansion of the donor pool in future patients prepared to undergo transplantation.

Bone Tissue Engineering in the Growing Calvaria Using Dipyridamole-Coated, Three-Dimensionally-Printed Bioceramic Scaffolds: Construct Optimization and Effects on Cranial Suture Patency.

BACKGROUND: Three-dimensionally-printed bioceramic scaffolds composed of ß-tricalcium phosphate delivering the osteogenic agent dipyridamole can heal critically sized calvarial defects in skeletally mature translational models. However, this construct has yet to be applied to growing craniofacial models. In this study, the authors implanted three-dimensionally-printed bioceramic/dipyridamole scaffolds in a growing calvaria animal model and evaluated bone growth as a function of geometric scaffold design and dipyridamole concentration. Potential adverse effects on the growing suture were also evaluated. METHODS: Bilateral calvarial defects (10 mm) were created in 5-week-old (approximately 1.1 kg) New Zealand White rabbits (n = 16 analyzed). Three-dimensionally-printed bioceramic scaffolds were constructed in quadrant form composed of varying pore dimensions (220, 330, and 500 µm). Each scaffold was coated with collagen and soaked in varying concentrations of dipyridamole (100, 1000, and 10,000 µM). Controls consisted of empty defects. Animals were killed 8 weeks postoperatively. Calvariae were analyzed using micro-computed tomography, three-dimensional reconstruction, and nondecalcified histologic sectioning. RESULTS: Scaffold-induced bone growth was statistically greater than bone growth in empty defects (p = 0.02). Large scaffold pores, 500 µm, coated in 1000 µM dipyridamole yielded the most bone growth and lowest degree of scaffold presence within the defect. Histology showed vascularized woven and lamellar bone along with initial formation of vascular canals within the scaffold lattice. Micro-computed tomographic and histologic analysis revealed patent calvarial sutures without evidence of ectopic bone formation across all dipyridamole concentrations. CONCLUSION: The authors present an effective pediatric bone tissue-engineering scaffold design and dipyridamole concentration that is effective in augmentation of calvarial bone generation while preserving cranial suture patency.

Knowledge and Skills Acquisition by Plastic Surgery Residents through Digital Simulation Training: A Prospective, Randomized, Blinded Trial.

BACKGROUND: Simulation is a standard component of residency training in many surgical subspecialties, yet its impact on knowledge and skills acquisition in plastic surgery training remains poorly defined. The authors evaluated the potential benefits of simulation-based cleft surgery learning in plastic surgery resident education through a prospective, randomized, blinded trial. METHODS: Thirteen plastic surgery residents were randomized to a digital simulator or textbook demonstrating unilateral cleft lip repair. The following parameters were evaluated before and after randomization: knowledge of surgical steps, procedural confidence, markings performance on a three-dimensional stone model, and surgical performance using a hands-on/high-fidelity three-dimensional haptic model. Participant satisfaction with either educational tool was also assessed. Two expert reviewers blindly graded markings and surgical performance. Intraclass correlation coefficients were calculated. Wilcoxon signed rank and Mann-Whitney U tests were used. RESULTS: Interrater reliability was strong for preintervention and postintervention grading of markings [preintervention intraclass correlation coefficient, 0.97 (p < 0.001); postintervention intraclass correlation coefficient, 0.96 (p < 0.001)] and surgical [preintervention intraclass correlation coefficient, 0.83 (p = 0.002); postintervention intraclass correlation coefficient, 0.81 (p = 0.004)] performance. Postintervention surgical knowledge (40.3 ± 4.4 versus 33.5 ± 3.7; p = 0.03), procedural confidence (24.0 ± 7.0 versus 14.7 ± 2.3; p = 0.03), markings performance (8.0 ± 2.5 versus 2.9 ± 3.1; p = 0.03), and surgical performance (12.3 ± 2.5 versus 8.2 ± 2.3; p = 0.04) significantly improved in the digital simulation group compared with before intervention, but not in the textbook group. All participants were more satisfied with the digital simulator as an educational tool (27.7 ± 2.5 versus 14.4 ± 4.4; p < 0.001). CONCLUSION: The authors present evidence suggesting that digital cognitive simulators lead to significant improvement in surgical knowledge, procedural confidence, markings performance, and surgical performance.

A Cost and Efficiency Analysis of the WALANT Technique for the Management of Trigger Finger in a Procedure Room of a Major City Hospital.

The "Wide Awake Local Anesthesia No Tourniquet" (WALANT) technique is gaining popularity in hand surgery owing to its benefits of reduced cost, shorter hospital stay, improved safety, and the ability to perform active intraoperative examinations. The aim of this study is to analyze the cost savings and efficiency of performing A1 pulley release for treatment of trigger finger using the WALANT technique in a major city hospital procedure room (PR) as compared with the standard tourniquet, operating room (OR) approach. METHODS: Patients who underwent trigger finger release between 2012 and 2017 were identified. Demographic and procedural information were obtained. Patients were followed for an average of 82 and 242 days in the PR and OR groups, respectively. RESULTS: Thirty-nine PR and 37 OR patients were identified. Case length and turnover time were shorter in the PR group [21.4 ± 7 versus 23.5 ± 14.3 min (P = 0.942) and 31.1 ± 11.1 and 65.3 ± 17.7 min (P < 0.001), respectively). The cost of the instrument tray utilized was calculated as $3,304.25 in the main OR and $993.79 in the PR. Cost per minute for all personal services in the OR was calculated to be $44/min, a cost that was virtually absent in the PR. Complication rates did not differ between both groups. CONCLUSION: Performing A1 pulley release for treatment of trigger finger using the WALANT technique is both cost effective and time efficient compared to performing the same procedure in the main OR of a major city public hospital.

Dipyridamole-loaded 3D-printed bioceramic scaffolds stimulate pediatric bone regeneration in vivo without disruption of craniofacial growth through facial maturity.

This study investigates a comprehensive model of bone regeneration capacity of dypiridamole-loaded 3D-printed bioceramic (DIPY-3DPBC) scaffolds composed of 100% beta-tricalcium phosphate (ß -TCP) in an immature rabbit model through the time of facial maturity. The efficacy of this construct was compared to autologous bone graft, the clinical standard of care in pediatric craniofacial reconstruction, with attention paid to volume of regenerated bone by 3D reconstruction, histologic and mechanical properties of regenerated bone, and long-term safety regarding potential craniofacial growth restriction. Additionally, long-term degradation of scaffold constructs was evaluated. At 24 weeks in vivo, DIPY-3DPBC scaffolds demonstrated volumetrically significant osteogenic regeneration of calvarial and alveolar defects comparable to autogenous bone graft with favorable biodegradation of the bioactive ceramic component in vivo. Characterization of regenerated bone reveals osteogenesis of organized, vascularized bone with histologic and mechanical characteristics comparable to native bone. Radiographic and histologic analyses were consistent with patent craniofacial sutures. Lastly, through application of 3D morphometric facial surface analysis, our results support that DIPY-3DPBC scaffolds do not cause premature closure of sutures and preserve normal craniofacial growth. Based on this novel evaluation model, this DIPY-3DPBC scaffold strategy is a promising candidate as a safe, efficacious pediatric bone tissue engineering strategy.

A Prospective, Randomized, Blinded Trial Comparing Digital Simulation to Textbook for Cleft Surgery Education.

BACKGROUND: Simulation is progressively being integrated into surgical training; however, its utility in plastic surgery has not been well described. The authors present a prospective, randomized, blinded trial comparing digital simulation to a surgical textbook for conceptualization of cleft lip repair. METHODS: Thirty-five medical students were randomized to learning cleft repair using a simulator or a textbook. Participants outlined markings for a standard cleft lip repair before (preintervention) and after (postintervention) 20 minutes of studying their respective resource. Two expert reviewers blindly graded markings according to a 10-point scale, on two separate occasions. Intrarater and interrater reliability were calculated using intraclass correlation coefficients. Paired and independent t tests were performed to compare scoring between study groups. A validated student satisfaction survey was administered to assess the two resources separately. RESULTS: Intrarater grading reliability was excellent for both raters for preintervention and postintervention grading (rater 1, intraclass correlation coefficient = 0.94 and 0.95, respectively; rater 2, intraclass correlation coefficient = 0.60 and 0.92, respectively; p < 0.001). Mean preintervention performances for both groups were comparable (0.82 ± 1.17 versus 0.64 ± 0.95; p = 0.31). Significant improvement from preintervention to postintervention performance was observed in the textbook (0.82 ± 1.17 versus 3.50 ± 1.62; p < 0.001) and simulator (0.64 ± 0.95 versus 6.44 ± 2.03; p < 0.001) groups. However, the simulator group demonstrated a significantly greater improvement (5.81 ± 2.01 versus 2.68 ± 1.49; p < 0.001). Participants reported the simulator to be more effective (p < 0.001) and a clearer tool (p < 0.001), that allowed better learning (p < 0.001) than textbooks. All participants would recommend the simulator to others. CONCLUSION: The authors present evidence from a prospective, randomized, blinded trial supporting online digital simulation as a superior educational resource for novice learners, compared with traditional textbooks.