The Impact of Training Pathway on Breast Surgery Cases Performed during Plastic Surgery Residency

BACKGROUND

Operative volume is a critical component of surgical resident education. This study compares reported breast surgery case volume between resident training pathways in plastic surgery.

METHODS

This retrospective cohort study reviewed case logs of plastic surgery residents in the independent/combined and integrated training pathways. Breast surgery case volume was compared via t tests across two major categories: reconstructive and aesthetic. Differences in intra-pathway variability were compared with F tests. Five consecutive cohorts of plastic surgery residents (n = 818): independent/combined (n = 526, 64%) and integrated (n = 292, 36%) at Accreditation Council for Graduate Medical Education (ACGME) accredited residency programs, were included (2011-2015).

RESULTS

Independent/combined residents reported significantly more aesthetic cases than integrated residents, but similar reconstructive cases. Independent/combined residents reported more breast augmentations, mastopexy, cosmetic breast fat grafting, and other cosmetic breast cases. Within the reconstructive category, independent residents reported more breast reconstruction fat grafting cases while integrated residents reported more breast reconstruction with pedicle flap, other breast reconstruction, and breast reduction cases. Independent residents had greater intra-pathway variability in five case subcategories, while integrated residents had greater variability in one case subcategory.

CONCLUSIONS

Disparities in breast surgery case volume exist by plastic surgery residency training pathway. Given the importance of case volume to residents and faculty, these disparities may warrant greater attention.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Identification of New Tools to Predict Surgical Performance of Novices using a Plastic Surgery Simulator

OBJECTIVE

To identify new tools capable of predicting surgical performance of novices on an augmentation mammoplasty simulator. The pace of technical skills acquisition varies between residents and may necessitate more time than that allotted by residency training before reaching competence. Identifying applicants with superior innate technical abilities might shorten learning curves and the time to reach competence. The objective of this study is to identify new tools that could predict surgical performance of novices on a mammoplasty simulator.

METHOD

We recruited 14 medical students and recorded their performance in 2 skill-games: Mikado and Perplexus Epic, and in 2 video games: Star War Racer (Sony Playstation 3) and Super Monkey Ball 2 (Nintendo Wii). Then, each participant performed an augmentation mammoplasty procedure on a Mammoplasty Part-task Trainer, which allows the simulation of the essential steps of the procedure.

RESULTS

The average age of participants was 25.4 years. Correlation studies showed significant association between Perplexus Epic, Star Wars Racer, Super Monkey Ball scores and the modified OSATS score with r_s = 0.8491 (p < 0.001), r_s = -0.6941 (p = 0.005), and r_s = 0.7309 (p < 0.003), but not with the Mikado score r_s = -0.0255 (p = 0.9). Linear regressions were strongest for Perplexus Epic and Super Monkey Ball scores with coefficients of determination of 0.59 and 0.55, respectively. A combined score (Perplexus/Super-Monkey-Ball) was computed and showed a significant correlation with the modified OSATS score having an r_s = 0.8107 (p < 0.001) and R² = 0.75, respectively.

CONCLUSIONS

This study identified a combination of skill games that correlated to better performance of novices on a surgical simulator. With refinement, such tools could serve to help screen plastic surgery applicants and identify those with higher surgical performance predictors.

The Development of a Benchtop Breast Reconstruction Surgical Simulator

A modified Delphi technique was used to survey plastics surgeons with an expertise in breast reconstruction from 6 university centers with plastic surgery residency programs across Canada. A list of the most challenging steps in teaching alloplastic breast reconstruction was obtained. From the survey results, a benchtop post-mastectomy breast reconstruction simulator was created using various silicon materials. The simulator was designed to be completely reusable with no disposable components necessary for each use. Senior plastic surgeons (n= 6) with an expertise in breast reconstruction were recruited and asked to perform a sub-pectoral, implant-based breast reconstruction on the simulator. Following the procedure, participants were asked to complete a survey and grade the simulator on its physical attributes, realism of experience, realism of material and overall experience.Preliminary face and content validation results based on the evaluations performed by those expert plastic surgeons showed excellent results among parameters evaluated, with an overall mean score of 4.7 on 5 (94.0%). Evaluators considered the six relevant anatomical components that were successfully included in the simulator.

Relevancy of an In-Service Examination for Core Knowledge Training in a Surgical Subspecialty

OBJECTIVE

To facilitate knowledge acquisition during plastic surgery residency, we analyzed the breast curriculum on the Plastic Surgery In-Service Training Exam (PSITE).

DESIGN

Breast-related questions on 6 consecutive PSITEs were analyzed (2008-2013). Topics were categorized by the content outline for the American Board of Plastic Surgery written board examination. Question vignettes were classified by taxonomy and clinical setting. References for correct answer choices were categorized by source and publication lag.

RESULTS

A total of 136 breast-related questions were analyzed (136/1174, 12%). Questions tended to appear more in the Breast and Cosmetic (75%) section than the Comprehensive (25%) section (p < 0.001). Most question vignettes were written in a clinical setting (64%, p < 0.001). Question taxonomy was evenly distributed among recall (34%), interpretation (28%), and decision-making (37%, p > 0.05). Only 6% of questions required photographic evaluation. Breast-related topics focused on esthetic problems (35%), traumatic deformities (22%), and tumors (21%). Answer references comprised 293 citations to 63 unique journals published a median of 6 years before PSITE administration. Plastic and Reconstructive Surgery (57%) was the most cited journal (p < 0.001) and Surgery of the Breast: Principles and Art by Spear was the most referenced textbook (22%).

CONCLUSIONS

The PSITE affords a curriculum that reflects breast-related topics on the American Board of Plastic Surgery written board examination. These data may optimize knowledge acquisition in esthetic and reconstructive breast surgery.

The Development of Assessment Tools for Plastic Surgery Competencies

BACKGROUND

Objective tools to assess procedural skills in plastic surgery residency training are currently lacking. There is an increasing need to address this deficit in order to meet today's training standards in North America.

OBJECTIVES

The purpose of this pilot study was to establish a methodology for determining the essential procedural steps for two plastic surgery procedures to assist resident training and assessment.

METHODS

Following a literature review and needs assessment of resident training, the authors purposefully selected two procedures lacking robust assessment metrics (breast augmentation and facelift) and used a consensus process to complete a list of procedural steps for each. Using an online survey, plastic surgery Program Directors, Division Chiefs, and the Royal College Specialty Training Committee members in Canada were asked to indicate whether each step was considered essential or non-essential when assessing competence among graduating plastic surgery trainees. The Delphi methodology was used to obtain consensus among the panel. Panelist reliability was measured using Cronbach's alpha.

RESULTS

A total of 17 steps for breast augmentation and 24 steps for facelift were deemed essential by consensus (Cronbach's alpha 0.87 and 0.85, respectively).

CONCLUSION

Using the aforementioned technique, the essential procedural steps for two plastic surgery procedures were determined. Further work is required to develop assessment instruments based on these steps and to gather validity evidence in support of their use in surgical education.

Time to be BRAVE: is educating surgeons the key to unlocking the potential of randomised clinical trials in surgery? A qualitative study

BACKGROUND

Well-designed randomised clinical trials (RCTs) provide the best evidence to inform decision-making and should be the default option for evaluating surgical procedures. Such trials can be challenging, and surgeons' preferences may influence whether trials are initiated and successfully conducted and their results accepted. Preferences are particularly problematic when surgeons' views play a key role in procedure selection and patient eligibility. The bases of such preferences have rarely been explored. Our aim in this qualitative study was to investigate surgeons' preferences regarding the feasibility of surgical RCTs and their understanding of study design issues using breast reconstruction surgery as a case study.

METHODS

Semistructured qualitative interviews were undertaken with a purposive sample of 35 professionals practicing at 15 centres across the United Kingdom. Interviews were transcribed verbatim and analysed thematically using constant comparative techniques. Sampling, data collection and analysis were conducted concurrently and iteratively until data saturation was achieved.

RESULTS

Surgeons often struggle with the concept of equipoise. We found that if surgeons did not feel 'in equipoise', they did not accept randomisation as a method of treatment allocation. The underlying reasons for limited equipoise were limited appreciation of the methodological weaknesses of data derived from nonrandomised studies and little understanding of pragmatic trial design. Their belief in the value of RCTs for generating high-quality data to change or inform practice was not widely held.

CONCLUSION

There is a need to help surgeons understand evidence, equipoise and bias. Current National Institute of Health Research/Medical Research Council investment into education and infrastructure for RCTs, combined with strong leadership, may begin to address these issues or more specific interventions may be required.

Implications of rationing and the European Working Time Directive on aesthetic breast surgery: a study of trainee exposure in 2005 and 2011

BACKGROUND

There are concerns that current trainees may be lacking operative experience in aesthetic and functional breast surgeries. Reduced exposure to such cases during training may stem from rationing, EWTD compliance, and an increasingly consultant-led service. These issues are examined in a single NHS hospital, with analysis of trends over time, and are contrasted with the changes that have occurred in a related private hospital.

METHODS

A single NHS hospital trusts database was retrospectively analysed for all aesthetic breast surgeries from 2005 to 2011, noting the total number of cases and the grade of the principal surgeon. The analysis was repeated in a related private sector hospital in the same catchment area.

RESULTS

A statistically significant drop of 55% of NHS aesthetic breast surgeries performed in 2011 compared to 2005 was demonstrated with an increasing trend for consultant led procedures. The NHS caseload decline was matched by a corresponding increase of 57% within the private sector.

CONCLUSIONS

Current trainees in plastic surgery face a significant reduction in operative exposure to aesthetic breast surgeries compared to their predecessors due to the EWTD working hours, surgical rationing policies, and an increasingly consultant led service. Approaches to maintaining training standards are discussed.

The supero-medial dermal-glandular pedicle mastoplasty with Wise pattern: an easy technique with a shorten learning curve. is it the gold standard for severe gigantomastia?

The Authors present their experience using the supero-medial dermal-glandular pedicle technique with a "Wise pattern" for severe gigantomastia, which they found easy to perform and to explain when teaching and they recommend its use especially for junior who are at the beginning of their experience with breast reduction. Although the preferred technique in our practice is the vertical scar mammaplasty with the superomedial pedicle according to Hall-Findlay, we believe the extension of the "Wise pattern" is necessary for severe gigantomastia (> 1200 g). From January 2005 to April 2008 50 breast reductions were carried out by the Authors using the supero-medial pedicle technique with a Wise pattern skin resection. The mean age was 40 years (range 20 to 65), mean body mass index was 28 (range 25 to 32) and mean weight of breast tissue removed was 1450 g per side (range 1120 to 2200). A maximum follow-up of 3 years was carried out. The complications were minor and self-limiting. The revision rate was very low (2%) compared to the other techniques. The supero-medial pedicle technique is a safe and reliable procedure in patients with severe gigantomastia and its versatility allows to be performed on all types of breasts regardless of size or degree of ptosis.

Institutional Review of Free TRAM Flap Breast Reconstruction

INTRODUCTION

A 10-year experience with breast reconstruction in a university hospital was recently reviewed. The purpose of this study was to determine the subtypes of breast reconstructive procedures and to evaluate the frequency and change in technique over time of free TRAM (transverse rectus abdominis muscle) flap breast reconstruction performed at one institution. Trends in the development of the procedure over this period were also reviewed.

MATERIALS & METHODS

Between November 1994 and September 2004, a 10-year retrospective chart review was conducted. The indications for mastectomy and reconstruction were determined. The median age was 48 (range 31-66). The range of follow-up was 2 to 71 months, with a median of 19.5 months. The mean follow-up was 23.5 months. Outcome data were grouped into 2 consecutive 5-year periods (period 1: 1994-1998; period 2: 1999-2004) and evaluated for changes over time in techniques and outcome. Statistical analysis (Decision Analyst, Inc., STATS Statistics software, version 1.1, 1998) was performed using the difference between 2 proportions module to assess the probability of a significant difference in the data for period 1 and period 2 parameters.

RESULTS

Over a 10-year period, 117 patients underwent breast reconstruction. This consisted of 12 pedicle procedures (11.3%), including 1 bipedicle flap (0.9%) and 2 bilateral pedicle procedures (1.8%). There were 3 latissimus dorsi pedicle flaps (2.8%). Sixteen patients (15.1%) received tissue expander or implant reconstructions. Of the 117 patients, 79 underwent free flap breast reconstruction. Of the 79 free-flap patients, 22 (27.8%) had bilateral procedures, for a total of 101 free flaps performed in these 79 patients. Fifty-two patients underwent immediate reconstruction (65.8%) and 25 were delayed (31.6%) reconstructions using either deep inferior epigastric artery perforator (DIEP) flaps (4 = 3.9%) or free TRAM flaps (97 = 96.0%). A muscle-sparing technique was used in 43 of the 97 free TRAM flaps (44.3%). The preferred vascular inflow was the internal mammary artery, which was used in 66 out of 101 flaps (65.3%). The rate of anastomotic revision (arterial and venous) was 4.9%. The majority of cases used a 2.5-mm venous coupler (65.3%). In 2 of the free TRAM cases, there was insufficient volume to establish the patients preexisting volume. Therefore, at the patient's request, immediate implants were used to augment the reconstruction. The average hospital stay was 8.13 days, and the average intensive care stay was 4.59 days. When assessed for trends over time, we noted a reduction in our hospital length of stay and our ICU length of stay.

CONCLUSION

The experience with free tissue breast reconstruction reveals predominant use of the TRAM flap. This is justified by the reliability of this flap and the advances in achieving esthetic breast reconstruction. Additionally, we have begun performing DIEP free-flap reconstructions. Our clinical practice has evolved concurrent with standards of care, as noted by the increase in use of muscle-sparing techniques and the reduction in the use of dextran. We do not routinely use therapeutic anticoagulation in our cases. Our hospital length of stay and average intensive care length of stay have also decreased over time, consistent with a system-wide effort to increase the efficiency of healthcare delivery.