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126
Correspondence and communications
Facial reconstruction using
a skull and foam training
model
Dear Sir,
Non-melanoma skin cancer is the most common malignancy
in the Western world,1 with over 80% of lesions involving the
head and neck.2 Millard’s fifteenth principle of plastic
surgery stated ‘tissue losses should be replaced in kind’.3
After oncological clearance, reconstruction with a local
flap satisfies Millard’s principle by replacing ‘like with like’
with an aesthetically pleasing result. Appropriate flap selection, correct flap design and precise technical execution
are essential for successful reconstruction.
Local flap training models aim to replicate clinical situations and allow surgical trainees to develop and refine
their skills of flaps design, planning and execution. Current
models include clear plastic coated manikins,4 foam models
on a flat surface5 and animal products. However, these
existing models require additional material that may be
inaccessible or costly to acquire, fail to replicate threedimensional facial anatomy, and do not fully demonstrate
the subtleties of flap planning and primary closure of the
donor site. Furthermore, animal products may be expensive
to acquire, store and use, where additional gloves and
equipment may be necessary. We therefore developed a
skull and foam teaching model to enhance the teaching
experience and clinical relevance of local flap training for
facial skin cancer reconstruction.
The skull and foam model uses a human skull and foam.
A 10 10 cm section of foam (medium density; 5 mm
thickness) is positioned on the skull using velcro pads at the
four corners. The tension mimics the clinical situation of
human skin to permit laxity and rotation of the foam. The
lesion is marked, allowing the trainee to mark appropriate
surgical margins and plan the flap of choice (Figure 1). In
Figure 2 Reconstructed skull and foam model after excision
of lesion and local flap reconstruction.
this example, a rhomboid flap is demonstrated. Discussion between trainer and trainee can include the
appreciation of donor site laxity and scar positioning along
relaxed skin tension lines. The flap is marked on the foam to
replicate the clinical decision making of selecting donor tissue
that has good laxity to close directly, and to position the scar
along relaxed skin tension lines for an aesthetically pleasing
result (Figure 2). Surgical technique can be perfected using
this skull-foam model due to the ease of which the foam section could be renewed using the Velcro pads fixed to the skull.
Foam sections can subsequently be compared sequentially,
marked by an examiner objectively and anonymously, and a
permanent record kept for continuing professional
development.
This training model has been trialled at a national plastic
surgery event for undergraduates, and feedback was overwhelmingly positive from trainers and trainees alike. We
hope that the model may improve the reconstructive
armamentarium of junior plastic surgeons by allowing
practice and perfection of local flaps to the head and neck,
with an appreciation of the Principalization of Plastic
Surgery.3
Funding
None.
Conflict of interest
The authors have no financial interest to declare in relation
to the content of this article.
Acknowledgements
Figure 1 Skull and foam model demonstrating lesion (purple), planning of surgical excision and rhomboid flap reconstruction (red lines) after taking into account relaxed skin
tension lines (black lines).
The authors thank Foam for Homes in Bristol for supplying
the foam, the Centre for Comparative Anatomy at the
University of Bristol for sharing the skulls, and the individuals who donated their bodies to advancing medical
science.
Correspondence and communications
127
References
1. Cancer Research UK. Non-melanoma skin cancer incidence
data. http://info.cancerresearchuk.org/cancerstats/types/
skin/incidence/#source26 [accessed 29.07.12].
2. Franceschi S, Levi F, Randimbison L, La Vecchia C. Site distribution of different types of skin cancer: new aetiological clues.
Int J Cancer 1996;3:4e8.
3. Millard DR. Principalization of plastic surgery. Boston:
Lippincott Williams & Wilkins; 1986.
4. Nicolaou M, Yang GZ, Darzi A, Butler EM. An inexpensive 3-D
model for teaching local flap design on the face and head. Ann
R Coll Surg Engl 2006;88:320.
5. Villafane O, Southern SJ, Foo ITH. Simulated interactive local
flaps: operating room models for surgeon and patient alike. Br
J Plast Surg 1999;52(3):241.
Christopher R. Davis
Matthew Fell
Umraz Khan
Department of Plastic and Reconstructive Surgery,
Frenchay Hospital, Bristol BS16 1LE, United Kingdom
E-mail address: chrisdavis959@hotmail.com
ª 2013 British Association of Plastic, Reconstructive and Aesthetic
Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjps.2013.07.024
PIP silicone breast implants
Dear Sir,
We read the Quabas’ paper1 reporting their experience of
PIP breast implant management with great interest. The
Table 1
authors had an enviably high follow up and should be
congratulated on providing such robust data at a time of
renewed uncertainty as to the long-term safety of PIP’s
mammary devices.2,3
They kindly reference our preliminary study4 and draw
attention to the low (9.3%) explantation figure, which
initially provoked criticism of our reported rupture rate.
The authors will not have been aware of our recently
accepted update,5 but we are pleased that another large
series has drawn similar conclusions about the PIP implant.
Whilst a summary comparison (Table 1) evidences our
improved recall and confirmation, we remain an order of
magnitude in arrears. Their very high recall, perhaps
reflecting the benefits of a large company, in this case Spire
Healthcare, that both proactively sought patients and underwrote all costs.
There are several noteworthy observations: the first that
there are now three sizeable studies, with slightly different
methodologies, yielding similar rupture prevalences. The
Quabas’ explantation, our own intention-to-treat and
Maijers et al.’s MRI study.6 The second being the quantum
improvement in the accuracy of ultrasound scan (USS)
lately. Whilst we have all experienced examples of catastrophic PIP elastomer disintegration, and concur that such
ruptures are easy to spot sonographically,1 it is not our
experience that this is universal so USS appears to a
recommendable first line investigation. Thirdly, although
the trial is in progress in Marseille at the time of writing,
the alleged perpetrators have yet to assist with any
detailed information so it is reassuring that our original
finding of reducing implant durability with time has been
corroborated. As with Quaba, prostheses implanted in the
year 2000 fared no differently to their contemporaries,
however, by 2005 median time-to-rupture had almost
halved from 10.5 to 5.8 years. Finally, despite the huge
amount of negative media coverage over the past 3 years, a
Summary of three main PIP rupture studies.
Number
Study period
Study
Explanted
Rupture (patient)
Uncontactable
Treatment
elsewhere
Awaiting
Explantation alone
USS e sensitivity
USS e specificity
Temporal decline
10-yr rupture
Comments
Quaba1 (%)
Stanek 14 (%)
Maijers6 (%)
Stanek 25 (%)
429
1999e2007
Explantation
283 (66)
35.2%
55 (12.8)
12 (2.8)
453
2000e2005
ITT
42 (9.3)
15.9e33.8%
180 (39.7)
19 (4.2)
112
2000e2001
MRI
0
33%
ns
e
460
2000e2005
ITT
163 (35.4)
See below
126 (27.4)
25 (5.4)
79 (18.4)
5 (1.5)
91%
96%
Yes
ns
All funded
Higher rupture
submuscular
Some technique
heterogeneity
39 (8.6)
e
n/a
n/a
n/a
n/a
24%
No difference subglandular
vs. submuscular
32 (7)
5 (3.1)
97.3
93.1
e
19e40%
Treatment
at cost
Occult rupture
in 31.6%
e
e
Yes
e
Key: ITT Z intention to treat; MRI Z magnetic resonance imaging; ns Z not specified.