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Figure 1.
Reconstruction and Repair of Facial Fractures
Reconstruction and Repair of Facial Fractures

Three-dimensional reconstruction of midface fracture displays the coronal and sagittal views and bicoronal and gingivobuccal approaches.

Figure 2.
Resident Self-assessment Rating by Postgraduate Year and Number of Operative Cases Treated
Resident Self-assessment Rating by Postgraduate Year and Number of Operative Cases Treated

Self-assessment was performed before the course using the Otolaryngology Milestone for Facial Trauma (OMFT). Higher ratings indicate more experience. Boxes represent data points. For case log, 1 indicates 1 to 5 cases; 2, 6 to 10 cases; 3, 11 to 20 cases; and 4, 21 to 50 cases. Data points overlap and appear to represent fewer points than actually exist.

Figure 3.
Resident Self-assessment by Faculty Rank
Resident Self-assessment by Faculty Rank

Self-assessment and faculty rating were performed before the course using the Otolaryngology Milestone for Facial Trauma (OMFT). Higher ratings indicate more experience. Data points overlap and appear to represent fewer points than actually exist. The Accreditation for Graduate Medical Education Council implemented this competency-based milestone project, the OMFT.

Table.  
Otolaryngology Milestone for Facial Trauma, Modified for Self-evaluationa
Otolaryngology Milestone for Facial Trauma, Modified for Self-evaluationa
1.
Bunting  H, Wilson  BM, Malloy  KM, Malekzadeh  S.  A novel peritonsillar abscess simulator.  Simul Healthc. 2015;10(5):320-325.PubMedGoogle ScholarCrossref
2.
Tsue  TT.  Developing the otolaryngology milestones.  J Grad Med Educ. 2014;6(1)(suppl 1):162-165.PubMedGoogle ScholarCrossref
3.
Casale  GG, Fishero  BA, Park  SS, Sochor  M, Heltzel  SB, Christophel  JJ.  Classifying and standardizing panfacial trauma with a new bony facial trauma score.  JAMA Facial Plast Surg. 2017;19(1):23-28.PubMedGoogle ScholarCrossref
4.
Deutsch  ES, Wiet  GJ, Seidman  M, Hussey  HM, Malekzadeh  S, Fried  MP.  Simulation activity in otolaryngology residencies.  Otolaryngol Head Neck Surg. 2015;153(2):193-201.PubMedGoogle ScholarCrossref
5.
Varshney  R, Frenkiel  S, Nguyen  LH,  et al; National Research Council Canada.  Development of the McGill simulator for endoscopic sinus surgery: a new high-fidelity virtual reality simulator for endoscopic sinus surgery.  Am J Rhinol Allergy. 2014;28(4):330-334.PubMedGoogle ScholarCrossref
6.
Wiet  GJ, Stredney  D, Kerwin  T,  et al.  Virtual temporal bone dissection system: OSU virtual temporal bone system: development and testing.  Laryngoscope. 2012;122(suppl 1):S1-S12.PubMedGoogle ScholarCrossref
7.
Spiotta  AM, Turner  RD, Turk  AS, Chaudry  MI.  The case for a milestone-based simulation curriculum in modern neuroendovascular training.  J Neurointerv Surg. 2016;8(4):429-433.PubMedGoogle ScholarCrossref
8.
Lobel  DA, Elder  JB, Schirmer  CM, Bowyer  MW, Rezai  AR.  A novel craniotomy simulator provides a validated method to enhance education in the management of traumatic brain injury.  Neurosurgery. 2013;73(suppl 1):57-65. PubMedGoogle ScholarCrossref
Original Investigation
Nov/Dec 2017

A Facial Trauma Simulation Course for Evaluation and Treatment of Facial Fractures

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, University of Virginia School of Medicine, Charlottesville
  • 2Department of Otolaryngology–Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus
JAMA Facial Plast Surg. 2017;19(6):464-467. doi:10.1001/jamafacial.2017.0313
Key Points

Question  Does simulating the evaluation and treatment of facial fractures have a positive effect on resident training?

Findings  In this survey study of the experience of 30 resident physicians after participating in a facial trauma simulation laboratory, simulation significantly improved self-perceived comfort levels as indicated by the Otolaryngology Facial Trauma Milestone and was deemed to provide experience equivalent to 1.5 years of residency training in the management of facial fractures.

Meaning  Surgical simulation in a facial trauma course provides residents with the opportunity to practice advanced decision making and augments surgical experience.

Abstract

Importance  Traditional facial trauma laboratories are used for teaching basic concepts of fracture reduction and hardware manipulation. Facial trauma simulation laboratories allow training physicians the opportunity to develop unique treatment plans as they would in real patient encounters.

Objective  To assess the value of a novel facial trauma simulation course requiring residents to practice advanced decision making.

Design, Setting, and Participants  Data were prospectively collected July 23 and August 23 and 24, 2016, in a survey study during a resident physician trauma simulation course. Fresh frozen cadaver heads were fractured using an impactor that applied a measurable amount of force. Each head was scanned with high-resolution computed tomography. Residents were paired and tasked with evaluating their specimen’s imaging findings and developing a treatment plan.

Main Outcomes and Measures  Before the course, residents were asked their postgraduate year level, number of facial fractures treated as a resident surgeon, and their comfort level based on the Otolaryngology Milestone for Facial Trauma (OMFT; ratings range from 0-5, with 5 indicating equivalent to fellow-level experience). After the course, residents were asked to assess the course’s value relative to a theoretical number of actual operative cases, and a posttraining OMFT assessment was obtained.

Results  Thirty resident physicians completed the course at 2 institutions. Residents represented an equivalent distribution of postgraduate year levels. The residents stated that the course was worth a mean (SD) of 6.4 (2.8) operative cases of facial trauma in terms of surgical learning. The mean change in self-reported OMFT rating after the course was 0.87 (95% CI, 0.67-1.07; P < .001, paired t test). On the basis of this change in self-perceived OMFT rating, the course was deemed to be worth 1.5 years of residency training in the management of facial fractures.

Conclusion and Relevance  Conducting a facial trauma simulation course increases resident experience with advanced surgical decision making.

Level of Evidence  NA.

Introduction

As faculty oversight requirements in residency become more stringent, residents’ opportunities for developing advanced decision-making skills decrease. As the system exists currently, residents rarely have the chance to struggle in making critical decisions in the operating room until they are practicing independently, when no supervision is immediately available.

Surgical simulation has been proposed as an answer to the problem of decreasing independent resident experience. Robust simulators for interventions have been developed that use a consistent procedure, such as epistaxis and peritonsillar abscess drainage.1 The operative treatment of facial trauma requires advanced decision making. Although grounded on common principles, each case has unique fractures that must be addressed with a custom plan. Facial trauma laboratories, although used for teaching basic concepts of fracture reduction and hardware manipulation, have not advanced to the level that allows residents the opportunity to develop unique treatment plans as they would in real patient encounters. Herein we present a facial trauma course requiring residents to practice advanced decision making. A trial of this course without metrics was held in 2014 without a rigorous assessment of value. To more rigorously assess the course value, we used multiple measures, including a self-assessment with the Accreditation for Graduate Medical Education Council's implementation of the competency-based milestone project, the Otolaryngology Milestone for Facial Trauma (OMFT; ratings range from 0-5, with 5 indicating equivalent to fellow-level experience).2

Methods

The original course was developed and tested at the University of Virginia School of Medicine, Charlottesville. Because surveys were used under the rubric of course improvement, no consent was required.

Fresh frozen cadaver heads were placed in a custom holder for stabilization. To simulate blunt force trauma to the face, an impactor that applied a measurable amount of force was used to create facial fractures. At the University of Virginia, a drop tower was used to drop a 34-kg sled onto the head from heights ranging from 113 cm to 258 cm, generating varying amounts of force delivered to the face ranging from 1340 to 7160 N.3 Plain radiographic films were used to confirm the presence of fractures, and each head then underwent scanning with high-resolution computed tomography (CT) (Figure 1A and B). A similar protocol was used at The Ohio State University Wexner Medical Center; however, the impactor was hydraulically powered to deliver a similar range of force. Fractures ranged from isolated Lefort I fractures to panfacial trauma.

Residents were paired and tasked with evaluating the CT scan of their specimen and developing a treatment plan, including theoretical airway management, fracture selection and order of reduction, surgical approach, and methods of fixation. Each resident team presented their case in front of the group, and faculty provided insight or redirection if the plan was unacceptable. Each resident team then performed the planned surgical approach, including open reduction and internal fixation, on their cadaver fractures (Figure 1C and D).

Variables of postgraduate year (PGY), number of facial fractures treated as a resident surgeon, and self-perceived comfort level based on the OMFT (Table) were acquired before the course. Postcourse measures consisted of a second individual OMFT rating, as well as the question “How many operative ‘cases’ do you feel this course was worth regarding improvement in your comfort and skill?”

After the original course was subjectively believed to be successful among the residents from the departments of Otolaryngology–Head and Neck Surgery, Plastic Surgery, and Ophthalmology and the Department of Otolaryngology–Head and Neck Surgery in Virginia Commonwealth University, the decision was made to expand the course to multiple institutions and use the aforementioned metrics. The expanded course was held in Charlottesville, Virginia, and Columbus, Ohio, July 23 and August 23 and 24, 2016.

Results

Thirty residents participated in the 2016 course at the 2 institutions, and 26 completed the precourse and postcourse OMFT ratings and the question concerning the worth of the cases. Five residents were PGY-1; 6 residents, PGY-2; 7 residents, PGY-3; 6 residents, PGY-4; and 6 residents, PGY-5, resulting in equivalent distribution among PGY levels. Fractures ranged from isolated Lefort I fractures to panfacial fractures.

Data Validation

As a measure of face validity, resident self-assessment of the facial trauma milestone (OMFT precourse rating) was plotted against PGY (R2 = 0.87; 95% CI, 0.78-0.96) (Figure 2) and an ordinal measure of cases treated to date (R2 = 0.70; 95% CI, 0.53-0.87) (Figure 2). As a measure of concurrent validity, resident self-assessment on the OMFT was plotted against the most recent faculty rating of the same facial trauma milestone (R2 = 0.88; 95% CI, 0.77-0.99) (Figure 3).

Measures of Course Effectiveness

The mean change in the self-reported OMFT rating after the course was 0.87 (95% CI, 0.67-1.07; P < .001, paired t test). The effect was greater on lower PGY levels. With regard to the open-ended question of the worth of the cases, the residents stated the course was worth a mean (SD) of 6.4 (2.8) operative cases of facial trauma in terms of surgical learning.

Written feedback from the course noted the unique opportunity to independently formulate a treatment plan for facial trauma and then reap the subsequent rewards and difficulties of their decisions (eg, “I wish I had elected for a transconjunctival approach to the orbital floor as it would have given better access to the medial wall”). The mean cost of the laboratories was slightly less than $1000 per head. The mean cost of the heads was $500, with the remainder of the cost for fracture creation, CT scanning, and specimen return.

Discussion

Simulation training has been proposed to mitigate decreased resident experience with independent decision making. Most otolaryngology residency programs in the United States have already adopted some form of simulation into their curriculum.4-6 To the same end, we developed a facial trauma course designed to increase resident experience with advanced surgical decision making and immediate feedback. This course was aimed at more than developing surgical plating skills; it incorporated data gathering and interpretation, surgical planning, team work, and real-life approaches to facial fractures.

By resident subjective measures, the 1-day course was worth 6.4 facial trauma cases as an operative surgeon. If we examine change in self-perceived comfort level based on the OMFT ratings (0.87) and trust that self-perception mirrors faculty perception (Figure 3), this course is worth 1.5 years of residency training in the surgical management of facial fractures based on the graph in Figure 2 (trendline y = 0.6082x +0.7271). The magnitude of these results is comparable to those of other advanced surgical training simulators that have measured change in an objective structured clinical examination.7,8

We are using the kinetic data from this project to develop protocols that create reproducible fracture patterns. These protocols will allow for simulation that could be used in many facial trauma arenas, from testing competency at the board examination level to providing hospital privilege certification when case numbers are low. The fracture protocols also allow for creation of specific fractures of varying complexity: a simple mandibular fracture can be created for a junior resident and a complex panfacial trauma for a fellow in facial plastic surgery.

Limitations

The OMFT (Table) has components of real life that are not readily assessed or improved by this course. These components include the basic physical examination, airway status of a patient, and assessment of complications from surgery, and we must therefore assume that the improvement in the residents’ OMFT ratings applies to only the fracture classification, treatment planning, and technical components of the OMFT.

Conclusions

Since the Accreditation Council for Graduate Medical Education implemented the competency-based milestone project, simulation has moved from task-specific goals, as seen with the objective structured clinical examination–based simulations, toward milestone-oriented teaching that seeks to move residents through graduated competencies that build on each other.7 Use of the otolaryngology milestone that correlates with the clinical area being simulated helps to guide the simulation exercise. As we mentioned, junior residents can be given heads with less extensive fractures, and their treatment plan can be guided toward the lower-level competencies, and vice versa. This process helps to customize the teaching toward the level of the pupil and not just train participants on a single task-specific scenario.

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Article Information

Corresponding Author: J. Jared Christophel, MD, MPH, Department of Otolaryngology–Head and Neck Surgery, University of Virginia School of Medicine, PO Box 800713, Charlottesville, VA 22908 (jjc3y@virginia.edu).

Accepted for Publication: February 7, 2017.

Published Online: June 8, 2017. doi:10.1001/jamafacial.2017.0313

Author Contributions: Dr Christophel had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Christophel, Nogan, Essig.

Drafting of the manuscript: Christophel, Nogan, Essig.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Christophel.

Obtained funding: Nogan.

Administrative, technical, or material support: All authors.

Study supervision: Christophel, Park, Essig.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by an unrestricted educational grant from the collective Stryker Corporation, Synthes, and KLS Martin used for purchase of the cadaver heads, creation of the fractures, and computed tomographic scanner time and for provision of training plating systems and tools for the residents to use during the course.

Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: This paper was presented as a poster at the 2017 Combined Sections in Otolaryngology Meeting; April 30, 2017; San Diego, California.

References
1.
Bunting  H, Wilson  BM, Malloy  KM, Malekzadeh  S.  A novel peritonsillar abscess simulator.  Simul Healthc. 2015;10(5):320-325.PubMedGoogle ScholarCrossref
2.
Tsue  TT.  Developing the otolaryngology milestones.  J Grad Med Educ. 2014;6(1)(suppl 1):162-165.PubMedGoogle ScholarCrossref
3.
Casale  GG, Fishero  BA, Park  SS, Sochor  M, Heltzel  SB, Christophel  JJ.  Classifying and standardizing panfacial trauma with a new bony facial trauma score.  JAMA Facial Plast Surg. 2017;19(1):23-28.PubMedGoogle ScholarCrossref
4.
Deutsch  ES, Wiet  GJ, Seidman  M, Hussey  HM, Malekzadeh  S, Fried  MP.  Simulation activity in otolaryngology residencies.  Otolaryngol Head Neck Surg. 2015;153(2):193-201.PubMedGoogle ScholarCrossref
5.
Varshney  R, Frenkiel  S, Nguyen  LH,  et al; National Research Council Canada.  Development of the McGill simulator for endoscopic sinus surgery: a new high-fidelity virtual reality simulator for endoscopic sinus surgery.  Am J Rhinol Allergy. 2014;28(4):330-334.PubMedGoogle ScholarCrossref
6.
Wiet  GJ, Stredney  D, Kerwin  T,  et al.  Virtual temporal bone dissection system: OSU virtual temporal bone system: development and testing.  Laryngoscope. 2012;122(suppl 1):S1-S12.PubMedGoogle ScholarCrossref
7.
Spiotta  AM, Turner  RD, Turk  AS, Chaudry  MI.  The case for a milestone-based simulation curriculum in modern neuroendovascular training.  J Neurointerv Surg. 2016;8(4):429-433.PubMedGoogle ScholarCrossref
8.
Lobel  DA, Elder  JB, Schirmer  CM, Bowyer  MW, Rezai  AR.  A novel craniotomy simulator provides a validated method to enhance education in the management of traumatic brain injury.  Neurosurgery. 2013;73(suppl 1):57-65. PubMedGoogle ScholarCrossref
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