A Structured Facial Feminization Fresh Tissue Surgical Simulation Laboratory Improves Trainee Confidence and Knowledge.

Abstract

Plastic surgery has seen a dramatic rise in gender-affirming surgery over the past decade, in part because of an increase in social acceptance of transgender and gender-nonconforming identities.1 Between 2016 and 2017 alone, the American Society of Plastic Surgeons reported a 155 percent increase in gender-affirming–related operations.2 A key element of gender-affirming surgery includes facial feminization, which necessitates a detailed understanding of the anatomical features that differ between female and male bony and soft tissues.3 In this communication, we describe our experience with a structured facial feminization cadaver laboratory and evaluate its educational value in plastic surgery training. Eleven plastic and reconstructive surgery residents (postgraduate years 1 through 7) and five medical students (n = 16) participated in a structured facial feminization educational curriculum that included a lecture and facial feminization surgical cadaver laboratory. The lecture was approximately 1 hour in length and covered various topics in facial feminization surgery, including indications and surgical steps. The cadaver laboratory consisted of multiple donor heads with four participants per group. All necessary surgical instruments were provided. An anonymous, volunteer-based self-assessment and knowledge-based test was administered before and after the cadaver laboratory to all participants. (See Document, Supplemental Digital Content 1, which shows the survey and test distributed to participants before and after the cadaver laboratory, https://links.lww.com/PRS/E69.) The self-assessment component of the test included evaluation of the participant’s ability to describe the surgical options, indications, surgical steps, and overall confidence with facial feminization surgery on a five-point Likert scale (1 = strongly agree, 2 = agree, 3 = neither agree nor disagree, 4 = disagree, and 5 = strongly disagree). The knowledge-based component consisted of a series of objective-based questions testing centered on facial feminization surgical management and decision-making. The survey was piloted to a sample participant before administration. Facial feminization procedures covered in the laboratory included frontal setback, scalp advancement, brow lift, mandibular body reduction, and genioplasty. Pretest and posttest results were tabulated and statistically analyzed using a paired t test. The results are presented in Figure 1. Sixteen of 16 participants completed the pretest and posttest (100 percent response rate). A statistically significant improvement between pretest and posttest scores was observed within each self-assessment category of the test. Similarly, there was an observed increase within the knowledge-based section of the test between pretest and posttest scores (67.1 ± 22.4 percent versus 84.4 ± 11.7 percent; p = 0.011).Fig. 1.: Pretest and posttest results following a structured facial feminization cadaveric laboratory. A significant improvement was observed between pretest and posttest results in all categories. Results presented are obtained from a five-point Likert scale (1 = strongly agree, 2 = agree, 3 = neither agree nor disagree, 4 = disagree, and 5 = strongly disagree). Results presented as the mean ± standard deviation. *p < 0.05; **p < 0.01.The presented results demonstrate that a structured facial feminization curriculum can significantly improve surgical trainee understanding and knowledge. These findings are especially relevant given the imposed duty-hour restrictions for medical trainees implemented by the Accreditation Council for Graduate Medical Education. Such restrictions have pushed training programs to use alternative means of augmenting resident education, including surgical simulation models and cadaveric surgical simulation exercises. Simulation models are also valuable for less common procedures or where exposure of surgical trainees to such specialized cases may be limited but desired, as in gender-affirming surgery.5 Efforts to build on this curriculum and improve resident understanding within this relatively new and rapidly evolving field within the specialty are ongoing. DISCLOSURE None of the authors has any commercial associations or financial disclosures that would create a conflict of interest with the information in this article.