Pork Belly: A Simulation Training Model for Intramuscular Perforator Dissection

Background: Free tissue transfer has evolved from muscle flaps to fasciocutaneous flaps. Dissection of the intramuscular course of feeding vessels is technically challenging. Simulation-based microsurgery skills acquisition is moving toward nonliving training models. Living porcine model or human cadavers are currently cost-ineffective methods for the early learning curve in teaching intramuscular dissection. The aim of this study was to validate an inexpensive ex vivo porcine model simulating harvest of the deep inferior epigastric artery perforator (DIEAP) flap, specifically including perforator intramuscular dissection. Methods: An initial needs analysis and anatomical dissections (characteristics of vascular anatomy) established the necessity and surgical design (step-by-step) of the ex vivo DIEAP flap harvesting model. A pilot study utilizing objective assessment methodology (time to complete flap raising and hand motion analysis) demonstrated the surgeons' performance. A detailed feedback questionnaire was used to assess the participants' perception of this model. Results: Fifty-seven participants completed the initial needs analysis. Fifteen pork bellies were dissected and the vascular anatomical characteristics of the inferior epigastric vessels are presented. Eight surgeons performed the step-by-step flap design demonstrating construct validity in flap raising and intramuscular dissection. All surgeons completed the ex vivo DIEAP harvesting and they recommend this model as the first step in training for intramuscular dissection. Conclusions: The pork belly simulation is a cheap, easy, ethically considerate, and high-fidelity simulation model for intramuscular dissection for the DIEAP free flap. This study guides future validation trials to explore if the absence of physiological blood flow affects skills acquisition in the intramuscular dissection learning curve. The pork belly could be the first step in perforators dissection before progressing to the in vivo porcine model. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Published online 14 February 2018. Received for publication March 20, 2017; accepted December 21, 2017. Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors. Georgios Pafitanis, MD, Academic Plastic Surgery Group, Microvascular Anastomosis Simulation Hub (MASH) Laboratory, The Blizard Institute, Queen Mary University of London 4 Newark Street Whitechapel, London, E12AT, UK E-mail: g.pafitanis@qmul.ac.uk Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.

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