Surgical Training Simulators for Rhinoplasty: A Systematic Review.

Rhinoplasty training currently follows an apprenticeship model that is largely observational. Trainees have limited experience in performing maneuvers of this complex surgery. Rhinoplasty simulators can address this issue by providing trainees with the opportunity to gain surgical simulator experience that could improve technical competences in the operating room. This review amalgamates the collective understanding of rhinoplasty simulators described to date. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed, OVID Embase, OVID Medline, and Web of Science databases were all searched for original research on surgical simulators for rhinoplasty education and reviewed by independent reviewers. Articles underwent title and abstract screening, and then relevant articles underwent full-text review to extract simulator data. Seventeen studies, published between 1984 and 2021, were included for final analysis. Study participant numbers ranged from 4 to 24, and included staff surgeons, fellows, residents (postgraduate year 1-6), and medical students. Cadaveric surgical simulators comprised eight studies, of which three were with human cadavers, one study was a live animal simulator, two were virtual simulators, and six were three-dimensional (3D) models. Both animal and human-based simulators increased the confidence of trainees significantly. Significant improvement in various aspects of rhinoplasty knowledge occurred with implementation of a 3D-printed model in rhinoplasty education. Rhinoplasty simulators are limited by a lack of an automated method of evaluation and a large reliance on feedback from experienced rhinoplasty surgeons. Rhinoplasty simulators have the potential to provide trainees with the opportunity for hands-on training to improve skill and develop competencies without putting patients in harm's way. Current literature on rhinoplasty simulators largely focuses on simulator development, with few simulators being validated and assessed for utility. For wider implementation and acceptance, further refinement of simulators, validation, and assessment of outcomes is required.

Evidence-Based Performance Measures for Rhinoplasty: A Multidisciplinary Performance Measure Set.

SUMMARY: The American Society of Plastic Surgeons, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Academy of Facial Plastic and Reconstructive Surgery commissioned the multidisciplinary Rhinoplasty Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing both functional and aesthetic rhinoplasty. One outcome measure and three process measures were identified. The outcome looked at patient satisfaction with rhinoplasty procedures. The process measures look at motivations and expectations of the procedure, airway assessment, and nonnarcotic shared decision-making strategies for pain management. All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and Executive Committee, and the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Facial Plastic and Reconstructive Surgery, The Rhinoplasty Society, and the American Association of Oral and Maxillofacial Surgeons. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, Qualified Clinical Data Registry reporting, and national quality reporting programs.

Rhinoplasty Assisted by Endoscopic Septoplasty: Precise Job and an Educational Tool.

BACKGROUND: Septoplasty is a crucial step during rhinoplasty to correct the nose function and nasal aesthetics. The idea is not investigated regarding the educational purposes. Objective of the study is to evaluate the efficiency of endoscopic septoplasty during full job rhinoplasty and to observe its educational benefit. METHODS: Twenty-seven patients who submitted for prospective study of endoscopic septorhinoplasty operation; the analysis involves 16 female patients and 11 males. RESULTS: Endoscopic septoplasty during rhinoplasty showed an efficient illumination and visualization, which improved the precision and has an educational benefit during the reform of the posterior septum, isolated septal spurs, anterior septum, and middle turbinate attachments. CONCLUSION: The procedure allows a precise septal job with excellent visualization of the anterior and posterior septum. It also has an intraoperative educational benefit and helps to soothe the time down of patient's recovery.

Video Standards for Rhinoplasty Education: A Review and Recommended Guidelines.

Importance: Intraoperative videography is widely used to record rhinoplasty procedures, yet little is known about the optimal surgical vantage points at critical procedural steps. Objective: To assess commonly used camera angles in public and proprietary intraoperative rhinoplasty videos and discuss approaches to obtaining these viewing angles. Design: Public and propriety rhinoplasty videos were reviewed and categorized based on procedure type, specific area(s) of focus, and camera angles utilized at a series of critical operative steps. The most commonly used camera angles were recorded and assessed based on surgical field visualization and the authors' personal recording experiences. Results: Of the 114 videos that met inclusion criteria, 49 were full-length open rhinoplasty procedures, 20 full-length endonasal rhinoplasty procedures, 17 tip techniques, 8 opening techniques, 7 fashioning grafts, 7 osteotomies, and 6 cartilage harvests. With respective to footage acquisition, the upward camera angle was most frequently used for recording, and endoscopic view was least frequently used. Conclusions and Relevance: These findings demonstrate that there is extensive variability in camera angles between surgical films. Moreover, many of these camera angles are insufficient due to obstruction by surgical staff, inability to visualize deep structures, and difficulty capturing the three-dimensional nasal framework. A guide indicating the best viewing angles for different aspects of the procedure would be useful to optimize educational videos.

Reevaluating the Current Model of Rhinoplasty Training and Future Directions: A Role for Focused, Maneuver-Specific Simulation.

BACKGROUND: Rhinoplasty is known for its complexity in planning and execution. For trainees, knowledge acquisition is often adequately attained. The mastery of skills, however, occurs by means of hands-on exposure, which continues to be a challenge. This article discusses the positive progress made in rhinoplasty training, and objectively demonstrates a need for more hands-on rhinoplasty exposure for residents. METHODS: A systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Concurrently, an online survey was developed, assessing resident comfort and training in rhinoplasty, and e-mailed to Canadian and U.S. plastic surgery training programs. RESULTS: ONE HUNDRED THIRTY-EIGHT: residents completed the survey, 62 junior (first- to third-year residents) and 76 senior residents (fourth- to sixth-year residents). Seventy-two percent of senior residents (95 percent of sixth-year residents) reported adequate rhinoplasty exposure, as opposed to 13 percent of junior residents. Seventy-five percent of senior residents most often participated as observers or first assistants, 25 percent participated as co-surgeons, and 73.9 percent did not perform a key rhinoplasty step more than five times. Residents felt the three most difficult steps of rhinoplasty were nasal osteotomy (76.1 percent), caudal septum/anterior nasal spine manipulation (65.2 percent), and nasal tip sutures (55.8 percent), and 73.9 percent felt that simulator training would substantially improve confidence. CONCLUSIONS: Despite sufficient exposure to rhinoplasties, residents were least confident in performing rhinoplasties relative to other aesthetic procedures, likely because of the high proportion of rhinoplasty exposure that is observational as opposed to hands-on acquisition of surgical maneuvers in the operating room. The survey established the maneuvers residents find the most difficult, and as programs adopt competency-based training, developing rhinoplasty simulators targeting specific identified steps may help improve competence for rhinoplasty skills.

Revisión sistemática de modelos de entrenamiento en rinoplastia / Sistematic review of training models in rhinoplasty

Antecedentes y Objetivo. La rinoplastia es uno de los procedimientos más frecuentes y más complejos de la Cirugía Plástica. Residentes de todo el mundo concuerdan en que su entrenamiento en rinoplastia es deficiente y en algunas ocasiones nulo. Algunos dicen no contar con la confianza suficiente para realizarla al finalizar su formación especializada. No todos los países establecen un método de entrenamiento estandarizado para la adquisición de experiencia y habilidades en rinoplastia, y si bien existen algunos modelos, no han sido evaluados y se desconoce su efectividad. Realizamos una revisión sistemática de las publicaciones que describen modelos de entrenamiento para aprendizaje, adquisición y/o mejora de habilidades en rinoplastia. Material y método. Llevamos a cabo una revisión sistemática mediante búsqueda electrónica de la literatura en las diferentes bases de datos: MEDLINE Pubmed (1980 a junio de 2016), EMBASE Ovid (1946 a segunda semana de junio de 2016), LILACS Scielo (1982 a junio de 2016) usando como criterio de selección: estudios descriptivos sobre uso de modelos de entrenamiento en rinoplastia. Resultados. Revisamos 6 modelos de entrenamiento publicados entre 2005-2014; 3 con tejido animal, 1 en cadáveres y 2 con material sintético. Ninguno contaba con evaluación y validación de los modelos propuestos, por lo cual no es posible determinar si funcionan para mejorar las habilidades quirúrgicas durante la formación especializada en Cirugía Plástica. Conclusiones. Aunque está demostrada la eficacia de los modelos de entrenamiento quirúrgico en otras especialidades y su uso es requisito para acreditación en EE. UU., no encontramos evidencia de la existencia de modelos eficaces en rinoplastia. Es por ello que nuestra revisión abre la puerta para la búsqueda de un modelo validado en nuestra especialidad

Background and Objective. Rhinoplasty is one of the most frequent and complex surgeries performed within the Plastic Surgery field. Residents around the world agree on a general deficiency from their rhinoplasty training and, in some cases, the absence of it. Someone, by the end of their training, still feel lack of confidence when performing a rhinoplasty. Currently, not all the countries have established a standardized training method for the acquisition of expertise and skills in rhinoplasty, and although there are several models, they have not been evaluated and therefore their efficiency as a training model is unknown. Methods. We conduct a systematic review performing a systematic review of published articles about the theme. Search strategy included the following database: MEDLINE Pubmed (1980 to June 2016), EMBASE Ovid (1946 to second week of June 2016), LILACS Scielo (1982 to June 2016). Selection criteria used was: descriptive studies reporting the use of training models for rhinoplasty. Results. Six training models, during a period from 2005-2014, were evaluated. Three were based on animal tissue, 2 on synthetic materials and 1 on a cadaveric model. No one had been evaluated or validated as to whether they improve surgical skills of residents in training. Conclusions. Even do, in other medical specialties the effectiveness of surgical training models has been proven and such training is considered a requirement in the USA, within the rhinoplasty field no evidence of the effectiveness from these models was found. This revision delivers a path to continue with their effectiveness evaluation and skills improvement in Plastic Surgery

Teaching nasal analysis to otolaryngology residents.

PURPOSE: This prospective cohort study was completed to evaluate a systematic approach for teaching nasal analysis to otolaryngology-head and neck surgery residents. METHODS: Residents from each post graduate year (PGY) were randomized to the control group or study group. Residents in the study group were given a 10-slide PowerPoint (Microsoft Corp) instruction on nasal analysis using the standard sequence of photographs and anatomic elements to describe in each view. All residents were given the standard sequence of photographs of 3 patients for assessment on nasal analysis. Then 12-14 weeks later all residents were re-evaluated using photographs of 3 new patients. The results were blinded and graded using an 18 point scale modified from a previous publication [1]. RESULTS: Twenty otolaryngology-head and neck surgery residents completed the study. Analysis was performed with and without multivariate regression modeling to adjust for PGY, sex, and number of rhinoplasties performed. The study group had overall higher scores in both the initial and follow up assessment, specifically with subsite-specific dorsal deviation, tip projection, and nostril symmetry. Neither group obtained high scores in facial symmetry, skin thickness, tip shape and contour, and radix position at initial or re-assessment. CONCLUSION: Nasal analysis is a complex task. A lecture on a systemic approach to facial analysis given to a group of residents, who performed significantly better on facial analysis cases than controls. Further research in providing feedback, periods of rehearsal or testing, or focused selected elements with serial exposure can be considered.

Development and evaluation of rhinoplasty spreader graft suture simulator for novice surgeons.

OBJECTIVE: Surgical simulators aimed at mimicking elements of rhinoplasty surgery, specifically those aimed at improving cartilage suturing, are not available. Here, we present a surgical simulator for spreader graft placement that uses cartilage rather than synthetic materials and gauge improvement using objective measures for suture placement accuracy, speed, and efficiency of hand motion. METHODS: Twenty-two otolaryngologists in two groups (residents [10] and experts [12]) were instructed to secure the two spreader graft specimen into position with three mattress sutures on a nose model that used porcine septal cartilage as a proxy for the human counterpart. Hand motion was tracked using an electromagnetic position sensing device. The time required to complete the suture task, total hand displacement, cumulative number of hand motion direction changes, and accuracy of suture insertion were measured. These measurements were compared between the two cohort groups for construct validity. The subjects completed a survey to evaluate realism and value of the model. RESULTS: The expert group had a lower mean time required to complete the task (P < 0.05), total hand displacement (P < 0.01), and number of hand motion direction changes (P < 0.001). No significant difference was observed between the two groups in suture precision measurement. The subjects agreed on the face validity and usefulness of the trainer. CONCLUSIONS: Our study suggests that the simulator may be a useful tool to objectively gauge suturing efficiency. Devices such as this may be useful for developing skill with suturing cartilage tissue and potentially be used to assess resident acquisition of surgical skill. LEVEL OF EVIDENCE: NA Laryngoscope, 129:344-350, 2019.

Utility of a Systematic Approach to Teaching Photographic Nasal Analysis to Otolaryngology Residents.

IMPORTANCE: Photographic nasal analysis constitutes a critical step along the path toward accurate diagnosis and precise surgical planning in rhinoplasty. The learned process by which one assesses photographs, analyzes relevant anatomical landmarks, and generates a global view of the nasal aesthetic is less widely described. OBJECTIVES: To discern the common pitfalls in performing photographic nasal analysis and to quantify the utility of a systematic approach model in teaching photographic nasal analysis to otolaryngology residents. DESIGN, SETTING, AND PARTICIPANTS: This prospective observational study included 20 participants from a university-based otolaryngology residency program. The control and intervention groups underwent baseline graded assessment of 3 patients. The intervention group received instruction on a systematic approach model for nasal analysis, and both groups underwent postintervention testing at 10 weeks. Data were collected from October 1, 2015, through June 1, 2016. INTERVENTION: A 10-minute, 11-slide presentation provided instruction on a systematic approach to nasal analysis to the intervention group. MAIN OUTCOMES AND MEASURES: Graded photographic nasal analysis using a binary 18-point system. RESULTS: The 20 otolaryngology residents (15 men and 5 women; age range, 24-34 years) were adept at mentioning dorsal deviation and dorsal profile with focused descriptions of tip angle and contour. Areas commonly omitted by residents included verification of the Frankfort plane, position of the lower lateral crura, radix position, and ratio of the ala to tip lobule. The intervention group demonstrated immediate improvement after instruction on the teaching model, with the mean (SD) postintervention test score doubling compared with their baseline performance (7.5 [2.7] vs 10.3 [2.5]; P < .001). At 10 weeks after the intervention, the mean comparative improvement in overall graded nasal analysis was 17% (95% CI, 10%-23%; P < .001). CONCLUSIONS AND RELEVANCE: Otolaryngology residents demonstrated proficiency at incorporating nasal deviation, tip angle, and dorsal profile contour into their nasal analysis. They often omitted verification of the Frankfort plane, position of lower lateral crura, radix depth, and ala-to-tip lobule ratio. Findings with this novel 10-minute teaching model should be validated at other teaching institutions, and the instruction model should be further enhanced to teach more sophisticated analysis to residents as they proceed through training. LEVEL OF EVIDENCE: NA.

Teaching and practice patterns of lateral osteotomies for rhinoplasty.

PURPOSE: Lateral osteotomies are important during rhinoplasty and represent a challenging technique that otolaryngology and plastic surgery trainees must learn. The approaches for osteotomies are difficult to teach as they are accomplished through tactile feedback. Trends in teaching and practice patterns of lateral osteotomies are poorly described in the literature, and this study aims to fill this knowledge gap. MATERIALS AND METHODS: Members of the American Academy of Facial Plastic and Reconstructive Surgery were surveyed to characterize surgeon preferences for intranasal versus percutaneous lateral osteotomies and understand how techniques are taught. RESULTS: Among surgeons who completed the survey (n=172), 87% reported that they "always" or "mostly" use intranasal lateral osteotomies whereas only 8% "always" or "mostly" use percutaneous approaches. There is no significant trend towards changing osteotomy techniques when teaching trainees. Only 15% of respondents allow trainees to perform lateral osteotomies in more than half of operations. CONCLUSIONS: Most facial plastic surgeons prefer to use intranasal lateral osteotomies. However, many do not allow trainees to perform this critical step during rhinoplasty. This study has implications for both patient care and surgical education.

Educational Cadaveric Module for Teaching Percutaneous and Intranasal Osteotomies in Rhinoplasty.

Lateral osteotomies are essential to rhinoplasty and are performed through percutaneous or intranasal approaches. Both techniques are difficult to teach as they rely on tactile feedback. Thus, it is critical to understand trainee learning curves to minimize complications. Herein, we aim to (1) demonstrate an educational module for teaching lateral osteotomies and (2) examine potential differences in outcomes between the 2 surgical approaches when performed by trainees. After a hands-on cadaveric laboratory, trainees (n = 24) reported increased confidence in performing both types of osteotomies ( P < .0001). Completion of the bony cut was similar between intranasal and percutaneous osteotomies (96% vs 75%, P = .097), as was correct placement of the osteotomy (75% vs 67%, P = .53). Intranasal osteotomies were more likely to cause periosteal disruption ( P = .02). This pilot study demonstrates that cadaveric laboratories are an effective way to teach lateral osteotomies and that percutaneous osteotomies may be less likely to cause periosteal disruption in trainees' hands.

Analysis of a Resident Aesthetic Clinic: Process for Rhinoplasty, Resident Experience, and Patient Satisfaction.

GOALS/PURPOSE: Plastic surgery residents often desire additional training in rhinoplasty than what is provided by their residency program. The goal of this study was to define and evaluate a specific process used to structure preoperative, intraoperative, and postoperative protocols for rhinoplasty patients in the resident aesthetic clinic (RAC) to enhance qualitative and quantitative experience. Complication rates and patient/resident satisfaction scores were also examined. METHODS: Resident clinic rhinoplasty patients underwent a well-defined and established process that included patient education and informed consent, preoperative planning in a conference-based session, specific adherence to established surgical techniques, and structured postoperative management and follow-up. This process also included supervision criteria for residents in the operating room and clinical setting. Patient and resident satisfaction at the RAC was evaluated by a Web-based survey. A database of procedural complications and methods was compiled and evaluated. RESULTS: Between June 2012 and June 2015, 146 aesthetic resident cases were completed through the University of California, San Diego Residency Aesthetic Surgery Program. Of these cases, 34 (17%) were rhinoplasty procedures. Residents at our institution assisted on an average of 55 rhinoplasty procedures with the faculty and performed an average of 12 rhinoplasty procedures as primary surgeons. The residents surveyed felt that they had a good autonomous experience (P < 0.001), and 90% reported confidence with rhinoplasty. Postoperative complications were recorded and included asymmetry (n = 4, 10.5%), septal perforation (n = 1, 2.6%), and difficulty in breathing (n = 6, 15.8%). There were no patients who experienced infections, and the complication rate requiring revision in the operating room was 0%. CONCLUSIONS: Optimizing protocols in rhinoplasty in an RAC has allowed for the RAC to flourish in the breadth and complexity of rhinoplasty operations. This has enabled residents to gain a structured and autonomous exposure to rhinoplasty cases. Cases were done with an acceptable complication rate and with good patient and resident satisfaction. This is a unique report in that it provides a structured process for preoperative, intraoperative, and postoperative care in rhinoplasty operations.

Video-Assisted Septoplasty: The Future in Teaching Septal Surgery-A Technical Note.

Teaching and learning septoplasty is challenging due to the limited and intermittent visualization of the surgical site by the resident and the mentor. Our objective was to develop and test the surgical tools required to achieve optimal visualization of the surgical field during septal surgery without having to modify the way conventional septoplasty is performed. A flexible high-definition endoscope is mounted on a modified 50-mm nasal speculum. This allows real-time visualization of all steps of the surgery on the video monitor. The residents can follow all intranasal surgical steps on the monitor while the surgeon is operating. In the same way, the mentor can guide the resident through the surgery and provide more appropriate feedback. All steps of the septal surgery can be recorded for later educational use. Video-assisted septoplasty will help surgeons teach septal surgery more efficiently.

Development and testing for an operative competency assessment tool for nasal septoplasty surgery.

BACKGROUND: Assessing surgical competency in otolaryngology is challenging, and residency programs are now responsible for ensuring the surgical competency of their graduates. Therefore, more objective assessment tools are being incorporated into the evaluation process. Objective structured assessment of technical skills (OSATSs) tools have been developed for multiple otolaryngology procedures. These include tonsillectomy, endoscopic sinus surgery, thyroidectomy, mastoidectomy, direct laryngoscopy, and rigid bronchoscopy. The purpose of this study was to develop and test a new assessment tool for septoplasty surgery and ensuring its feasibility, reliability, and construct validity. This study was designed to develop and test a valid, reliable, and feasible evaluation tool designed to measure the development of trainees' surgical skills in the operating room for septoplasty surgery. METHODS: A new OSATSs-based instrument form for septoplasty was developed. During the study period of 2 years, 21 otolaryngology-head and neck surgery residents (ranging from postgraduate year 2 to 5) were evaluated intraoperatively by one faculty member obtaining a total of 175 evaluations. Surgical performance was rated using a seven-item task-specific checklist (TSC) and a global rating scale (GRS). The TSC assessed specific septoplasty technical skills, and the GRS assessed the overall surgical performance. RESULTS: Our tool showed construct validity for both components of the assessment instrument, with increasing mean scores with advancing clinical levels. Cronbach's α, a measure of internal consistency, was 0.911 for TSC and 0.898 for GRS. Strong correlation between the TSC and GRS was established (r = 0.955; p < 0.01). CONCLUSION: This study proved our educational tool to be a valid, reliable, and feasible method for assessing competency in septoplasty surgery. It can be integrated into surgical training programs to facilitate direct formative feedback. Assessing trainees' learning curves enables insight into their progression, ensuring their appropriate development.