A Model To Teach Elliptical Excision and Basic Suturing Techniques

nation.
The results from this study may be used to im- describes 10 tasks broken down into smaller steps, and
prove skin cancer education in medical schools. Improved each step is marked as either “performed” or “failed to
communication between educators, both directly and perform”(Table). The global rating scale is a subjective
through literature, would allow for schools to learn from evaluation of the overall ability of trainees. It uses a
the strengths and weaknesses of other curriculums. Each sliding scale of 1 (unsatisfactory) to 5 (outstanding) to
school will need to face barriers including limited re- grade knowledge of technical details, handling of instru-
sources, time constraints, and lack of importance placed ments and “tissue,” and smoothness or awkwardness of
on dermatology education. movements (global rating scale available as an online
Medical school education needs revision to ensure that eTable [http://www.archdermatol.com]). Feedback is pro-
medical students receive adequate training and gradu- vided immediately, and residents work on areas that
ate with specific competencies for skin cancer preven- need improvement before they attempt surgery in live
tion and detection. Future studies should seek to de- patients.
velop and incorporate improved skin cancer instruction This model is more convenient than pigs’ feet, which
into the medical school curriculum and evaluate its ef- are commonly used, and more readily available and less
fectiveness. expensive than human cadavers, live animals, or virtual re-
ality models. Admittedly, the skin pad does not resemble
Heather A. Brandling-Bennett, MD real human skin (it has “low fidelity”), but this should not
Laura A. Capaldi, MD negate its educational value. Anastakis et al1 demon-
Barbara A. Gilchrest, MD strated that training on low-fidelity models was equiva-
Alan C. Geller, MPH, RN lent to training on cadavers. Also, Matsumoto et al2 showed
Correspondence: Mr Geller, Department of Dermatol- that training with a video-endoscopic–based system was
ogy, Boston University School of Medicine, 720 Harrison equivalent to the use of an expanded polystyrene cup and
Ave, Doctor’s Office Building Room 801A, Boston, MA Penrose drain models for urologic procedures.
02118 (ageller@bu.edu). In its present form, the model cannot be used as an
Financial Disclosure: None. assessment tool because it lacks validity, is not com-
Funding/Support: This project was funded by a grant from prehensive (does not evaluate consent, patient interac-
the American Skin Association, New York, NY. tion, or hemostasis), and does not discriminate
between various levels of skill. Nevertheless, future
1. Howe HL, Wingo PA, Thun MJ, et al. Annual reports to the nation on the research could focus on developing such an instru-
status of cancer (1973 though 1998), featuring cancers with recent increas- ment using our checklist and global rating scale to
ing trends. J Natl Cancer Inst. 2001;93:824-842.
2. Koh HK, Norton LA, Geller AC, et al. Evaluation of the American Academy assess performance of trainees on inanimate models or
of Dermatology’s National Skin Cancer Early Detection and Screening Program. even live patients. Also, it will be important to docu-
J Am Acad Dermatol. 1996;34:971-978.
3. Dolan NC, Martin GJ, Robinson JK, Rademaker AW. Skin cancer control prac-
ment the transfer of knowledge or skill from the inani-
tices among physicians in a university general medicine practice. J Gen Intern mate model training to the actual operative perfor-
Med. 1995;10:515-519. mance and to compare the effectiveness of inanimate
4. Moore M, Geller AC, Zhang Z, et al. Skin cancer examination teaching in US
medical education. Arch Dermatol. 2006;142:439-6. models to virtual reality simulators.3
5. FACTS—applicants, matriculants and graduates. Association of American Medi-
cal Colleges Web site. Available at: http://www.aamc.org/data/facts/2003 Carlos Garcia, MD
/2003school.htm. Accessed July 19, 2004.
Marcy Neuburg, MD
Kim Carlson-Sweet, MD
A Model to Teach Elliptical Excision and

Basic Suturing Techniques Correspondence: Dr Garcia, Department of Dermatol-
ogy, Oklahoma University Health Sciences Center, 619
T his model, which is used in our programs to teach NE 13th St, Oklahoma City, OK 73104 (carlos-garcia
elliptical excision and basic suturing tech- @ouhsc.edu).
niques to dermatology residents, consists of face Financial Disclosure: None.
diagrams, a skin substitute pad, a checklist, and a global Previous Presentation: This study was presented at the
rating scale. The face diagrams are premarked with three annual meeting of the Association of Academic Derma-
1-cm circles representing lesions on the forehead, cheek, tologic Surgeons; September 11, 2004; Chicago, Ill.
and nasolabial fold . The skin substitute pad (Limbs and Additional Resources: The online-only eTable is avail-
Things, Bristol, England) is a 3-layered model made of able at http://www.archdermatol.com.
foam and vinyl. Acknowledgment: This project was completed under the
Initially, residents undergo a 1- to 2-hour training ses- guidance and advice of Chris Candler, MD.
sion to learn the design and execution of elliptical exci-
sion, undermining, and various suturing techniques, in- 1. Anastakis DJ, Regehr G, Reznick RK, et al. Assessment of technical skills trans-
fer from the bench training model to the human model. Am J Surg. 1999;
cluding cutaneous simple interrupted and running, 177:167-170.
vertical mattress, and subcutaneous buried. Two weeks 2. Matsumoto ED, Hamstra SJ, Radomski SB, Cusimano MD. The effect of bench
later, they perform the tasks again while the attending model fidelity on endourological skills: a randomized controlled study. J Urol.
2002;167:1243-1247.
dermatologic surgeon grades their performance using 3. Haluck RS, Krummel TM. Computers and virtual reality for surgical educa-
a checklist and a global rating scale. The checklist tion in the 21st century. Arch Surg. 2000;135:786-792.
(REPRINTED) ARCH DERMATOL/ VOL 142, APR 2006 WWW.ARCHDERMATOL.COM

526
©2006 American Medical Association. All rights reserved.

Table. Excisional Biopsy Assessment Checklist
Examinee: _____________________ Examiner: ______________________ Date: _____________

Tasks Steps Performed
1. Design of the ellipse 䊐
Forehead • 3-4:1 Length-width ratio Yes___ No___
• 30° Angled tips Yes___ No___
• Design in the direction of relaxed skin tension lines Yes___ No___
Malar (cheek) • 3-4:1 Length-width ratio Yes___ No___
Nasolabial fold • 3-4:1 Length-width ratio Yes___ No___
4. Incision of the ellipse 䊐
Scalpel • Smooth movements with scalpel Yes___ No___
• Economy of movements and maximum efficiency Yes___ No___
• Cuts to subcutaneous tissue with 1 or 2 strokes avoiding “staircasing” Yes___ No___
• Avoids cross-hatching the tips of ellipse Yes___ No___
5. Excision of the ellipse 䊐
Forceps and scissors • Cuts in the same plane while removing tissue Yes___ No___
• Leaves same amount of tissue on all areas of the postoperative wound Yes___ No___
• Handles tissue delicately avoiding damage to epidermis Yes___ No___
6. Undermining 䊐
• Delicately handles tissue avoiding damage to epidermis Yes___ No___
• Undermines both edges and tips Yes___ No___
7. Simple interrupted percutaneous suture 䊐
• Needle loaded 1⁄2 to 2⁄3 from tip Yes___ No___
• Locks needle holder and takes fingers off the handle rings Yes___ No___
• Places needle holder on palm and grabs the tip of instrument with thumb and index finger Yes___ No___
• Inserts needle perpendicular to skin surface Yes___ No___
• Guides needle through skin with turn of wrist Yes___ No___
• Suture is tied with a series of square knots Yes___ No___
8. Vertical mattress suture 䊐
• The needle is inserted several millimeters outside the wound margin (4-10 mm) and exits Yes___ No___
the opposite margin at the same distance. It is then reinserted a few millimeters inside of
the previous exit point, and another, more superficial pass is made through the wound.
The needle then exits a few millimeters inside the point of initial insertion, and the suture
is tied (“far-far, near-near” needle insertion)
• Suture is tied with a series of square knots Yes___ No___
9. Running suture 䊐
• Needle loaded 1⁄2 to 2⁄3 from tip Yes___ No____
• Locks needle holder and takes fingers off the handle rings Yes___ No____
• Places needle holder on palm and grabs the tip of instrument with thumb and index finger Yes___ No____
• A simple interrupted suture is placed and tied at one of the poles of the wound. Only the Yes___ No____
distal tail of the suture is cut shorter
• The needle is inserted 3 to 4 mm distal to the initial suture in perpendicular angle to Yes___ No____
the skin
• It is then pushed through skin with turn of wrist and exits in the opposite side of the wound Yes___ No____
• The needle is reinserted 3 to 4 mm distal to the previous suture in the original side, and Yes___ No____
process is repeated until the whole length of the wound is covered
• Suture is tied with a series of square knots Yes___ No____
10. Buried interrupted dermal suture 䊐
• One side of the wound is averted using forceps Yes___ No___
• Needle is inserted at level of subcutaneous tissue and angled superiorly to pass through a Yes___ No___
small amount of subcutaneous and dermal tissue
• Needle is brought out inside the wound parallel to and just beneath epidermis Yes___ No___
• Process is then repeated in reverse on the other side of the wound beginning just beneath Yes___ No___
epidermis and ending in subcutaneous tissue
• Suture is tied with a series of square knots resulting in a “buried suture” Yes___ No___

527

WEB-ONLY CONTENT
eTable. Global Rating Scale of Operative Performance
Examinee: _____________________ Examiner: ______________________ Date: _____________

Instructions: rate the examinee’s performance by circling 1 number (1-5) for each of the 3 competencies below
(1 = unsatisfactory performance; 5 = outstanding performance)
Design of ellipse
1 2 3 4 5
Lacks knowledge of design parameters Slightly hesitant but good progression and Smooth movements until successful completion
⬍1-mm or ⬎5-mm margins completion of task of task
Angles very different than 30° Adequate 1- to 2-mm margins Adequate 1- to 2-mm margins
Length-width ratio very different than 3-4:1 Angles at ends of ellipse slightly different than 30° 30° Angles at both ends
Length-width ratio slightly different than 3-4:1 Length-width ratio 3-4:1
Incision of ellipse
1 2 3 4 5
Hesitant and inappropriate handling of Appropriate handling of instruments but somewhat Appropriate handling of instruments
instruments hesitant Careful handling of tissue; no tissue damage
Excessive damage to tissue Careful handling of tissue but occasional Smooth movements and no awkwardness
Awkward movements with instruments inadvertent damage
Competent use of instruments but occasionally
awkward
Excision of ellipse
1 2 3 4 5
Hesitant and inappropriate handling of Appropriate handling of instruments but somewhat Appropriate handling of instruments
instruments hesitant Careful handling of tissue; no tissue damage
Excessive damage to tissue Careful handling of tissue but occasional Smooth movements and no awkwardness
Awkward movements with instruments inadvertent damage
Competent use of instruments but occasionally
awkward
Simple interrupted percutaneous suture
1 2 3 4 5
Clearly hesitant and awkward movements Competent use of instruments but occasionally Smooth, confident movements with no
Inappropriate handling of needle holder awkward and hesitant awkwardness
Inappropriate loading of needle Reasonable handling of needle holder Excellent handling of needle holder
Inserts needle tangentially Needle loaded 1⁄2 to 2⁄3 from tip Needle loaded 1⁄2 to 2⁄3 from tip
Inappropriate number or type of knots Insertion of needle perpendicular to skin Insertion of needle perpendicular to skin
Ties with a series of square knots Ties with a series of square knots
Vertical mattress suture
1 2 3 4 5
Running suture
1 2 3 4 5
Buried interrupted dermal suture
1 2 3 4 5

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nation.

A Model to Teach Elliptical Excision and

(REPRINTED) ARCH DERMATOL/ VOL 142, APR 2006 WWW.ARCHDERMATOL.COM

©2006 American Medical Association. All rights reserved.

Examinee: _______ Examiner: Date: _

(REPRINTED) ARCH DERMATOL/ VOL 142, APR 2006 WWW.ARCHDERMATOL.COM

©2006 American Medical Association. All rights reserved.

eTable. Global Rating Scale of Operative Performance

Examinee: _______ Examiner: Date: _

(REPRINTED) ARCH DERMATOL/ VOL 142, APR 2006 WWW.ARCHDERMATOL.COM

©2006 American Medical Association. All rights reserved.

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