Clinical Insights

Developing Skills in Rhinoplasty

Through Cadaver Training

The author advocates cadaver training for plastic osteotomy by performing

surgery residents seeking to develop an understanding specific surgical maneuvers

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of anatomy and surgical technique for rhinoplasty. twice in “open nose” fresh
Here, he describes a study that applied objective mea- cadavers (Figure); and (3)
sures to assess the value of a 40-hour program of performing live patient
cadaver training in rhinoplasty. (Aesthetic Surg J rhinoplasty for the first time,
2005;25:643-645.) assisted by a staff surgeon
and recorded on video,
using the same surgical Patricio F. Jacovella, MD, PhD,
Buenos Aires, Argentina, is a

I
n performing aesthetic surgery of the nose, when per-
forming rhinoplasty, the stakes are high and the margin
for errors is narrow. Because surgeons operate in a
reduced surgical field, rhinoplasty can be considered a
“surgery of sensations.” In all surgery, but especially in
nasal surgery, surgeons are very concerned about the deli-
cate and appropriate handling of tissues.1 Therefore, move-
ments must be efficient and gentle enough to avoid dam-
age. To achieve rhinoplasty-specific skills, residents require
long training programs. Here, I present a study assessing a
simple cadaver-based training program based on step-by-
step development of rhinoplasty surgical skills. The train-
ing took place in 40 hours spread over a 2-week period.
Material and Methods
The study and training, conducted at the University of
Buenos Aires (Argentina) School of Medicine, Plastic
Surgery Training Program, included 25 plastic surgery
residents who had no previous experience performing
rhinoplasty before entering the cadaver-based training
program. After the training, residents performed rhino-
plasty on live patients. Surgical procedures were video-
taped, and evaluators used the tape to assess surgical
skills. Evaluators did not know the identity of the resi-
dents. The study group was compared with a control
group of 25 plastic surgery residents who did not partici-
pate in the cadaver-based training program but learned
rhinoplasty techniques through academic training.
The teaching/learning method was divided into 3 main
steps: (1) becoming familiar with different nasal struc-
tures by performing anatomic dissection of the nose in
fresh cadavers; (2) becoming familiar with hand sensa-
tions in nasal approach, dorsum resection, and lateral
maneuvers that had been plastic surgeon.
rehearsed on cadavers. To
evaluate how residents per-
formed these maneuvers, parameters of knowledge, atti-
tudes, and specific skills were assessed.
In terms of testing, Strasser2,3 has developed an objec-
tive grading system for the evaluation of cosmetic surgi-
cal results. It allows the observer to objectively grade the
surgeon's mastery of shape and form by breaking it down
to its component parts, eliminating bias. Similar criteria,
simplifying the system, have been adopted for this study.
Residents were evaluated on accuracy and number of
attempts, using the following rating scale:
• Very good (VG) - performed without suggestions
from the staff surgeon; 2 or less attempts
• Good (G) - performed without suggestions; up to 3
attempts
• Acceptable (A) - suggestions needed; more than 3
attempts
• Not acceptable (NA) - suggestions needed; assistance
needed.
Results
In the study group, 76% scored “very good,” 16%
scored “good,” and 8% scored “acceptable.” In the con-
trol group, 4% scored “very good,” 32% scored “good,”
48% scored “acceptable,” and 16% scored “not accept-
able.” Statistical analysis4 demonstrates the differences
between the 2 groups (Table).
Discussion
Surgeons use their eyes for visualization and their
hands for sensation and manipulation of tissues. Even

AESTHETIC SURGERY JOURNAL ~ NOVEMBER/DECEMBER 2005 643

 C
ClLiIn
N iI c
CaAl
L In
NSs Ii G
Table. Comparison of study and control groups
Very good Good
N % N %
Study group 19 76 4 16
Control group 1 4 8 32
χ2 = 28.68; P < 0.001.
Figure. Dorsum resection in an open nose fresh cadaver allows resi-
dents to become familiar with hand sensations.
though touch provides only about 5% of overall sensory
input,5 this sense plays a crucial role in developing specif-
ic skills in rhinoplasty. According to Stava et al,6 the per-
formance of a surgical procedure is 75% cognitive and
25% technical skill. Cognitive skills can be assessed by
using a multiple choice test, but maneuvers must be mas-
tered by direct practice. Therefore, a resident training in
plastic surgery needs an integrated program,7,8 and this
simple cadaver training can be easily incorporated.1,9
The scientific basis for this study has its origins in
behavioral psychology, which establishes the importance
of 3 elements in developing technical skills: visual, per-
ceptual, and psychomotor.10 The correct execution of
surgical maneuvers requires an integration of cognitive
analysis, manual dexterity, and sense of touch. Therefore,
to develop optimal surgical skill, with the ability to han-
dle tissues gently and efficiently, residents should learn
using a real 3-dimensional model.1,9
Realistic computer-based surgical simulation offers the
opportunity to touch and manipulate virtual objects in
real time. In 1987, Constantian et al11 presented a
method for learning rhinoplasty using interactive com-
644 Aesthetic Surgery Journal ~ November/December
gHh TtSs
Acceptable Not acceptable
N % N %
2 8 0 0
12 48 4 16
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puter graphics. Some computer-assisted plastic surgery
simulation programs use a 3-dimensional graphic model
of a human face, incorporating a mathematical model of
the physical properties of tissue.12,13 Although simulators
like DataGlove,5 which incorporate the touching and
receiving of sensations through a 3-dimensional comput-
er-aided program, are available for surgery, such technol-
ogy has not been widely adopted into the educational
curriculum. Explanations for the lack of widespread use
include prohibitive costs, necessity for frequent upgrades,
and inadequate validation of effectiveness.14
The benefit of the cadaver-based training program
tested in this study is that it enables residents to identify
anatomic structures and perform rhinoplasty using the
correct sequence of steps.15 It allows the learner to prac-
tice in a controlled and familiar environment and the
instructors to define teaching objectives.16 Errors can be
made without detrimental consequences to patients. The
training experience provides the development of hand
sensation and skills. It is a highly efficient training
method, with a relatively low cost in the context of plas-
tic surgical education. ■
References
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4. Dawson BK, Trapp R. Basic and Clinical Biostatistics. New York:
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5. Meier AH, Rawn CI, Krummel TM. Virtual reality: surgical application-
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2005 Volume 25, Number 6
 CLINICAL INSIGHTS

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Reprint requests: Patricio F. Jacovella, MD, PhD, Plastic Surgery Training

Program, Hospital de Clinicas, University of Buenos Aires School of
Medicine, Guido St. 1754 PB 01016, Buenos Aires, Argentina.
Copyright © 2005 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/$30.00
doi:10.1016/j.asj.2005.09.007

Developing Skills in Rhinoplasty Through AESTHETIC SURGERY JOURNAL ~ November/December 2005 645
Cadaver Training