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: [email protected] 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.
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