10.5826/dpc.1301a49
Introduction: The coronavirus pandemic forced universities to transfer academic curricula into the digital realm and calls for the introduction of new teaching methods to adequately compensate for the limited in-patient training. Especially in the field of dermatology, the use of 3D models presents an interesting opportunity to maintain the teaching of diagnostically essential sensory and haptic characteristics of primary lesions.
Objectives: We developed a prototype silicone model and presented it to the medical service of the Department of Dermatology of the Ludwig-Maximilians University for evaluation.
Methods: Silicone models demonstrating primary skin lesions were produced by using negative 3D-printed molds and different types of silicone. An online survey obtained evaluations from a group of dermatologists regarding the quality of previously supplied silicone 3D models and their potential use in medical education. Data from 58 dermatologists were collected and analyzed.
Results: The majority of the participants rated the models overall as positive and innovative, providing constructive feedback for additional modifications, and recommended further implementation into the regular curriculum as an additional tool after the end of the pandemic.
Conclusions: Our study underlined the possible advantages of using 3D models as a supplement in educational training even after the end of the SARS-CoV-2 pandemic.
text/xml
2160-9381
2533
en
Markus  Reinholz
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
evaluation
Silicone Models for Dermatological Education: Assessment of a New Teaching Tool by Dermatologists
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-01-31
2022-04-11
2023-01-31
2023-02-27
e2023049
Dermatol Pract Concept
Introduction: The coronavirus pandemic forced universities to transfer academic curricula into the digital realm and calls for the introduction of new teaching methods to adequately compensate for the limited in-patient training. Especially in the field of dermatology, the use of 3D models presents an interesting opportunity to maintain the teaching of diagnostically essential sensory and haptic characteristics of primary lesions.
Objectives: We developed a prototype silicone model and presented it to the medical service of the Department of Dermatology of the Ludwig-Maximilians University for evaluation.
Methods: Silicone models demonstrating primary skin lesions were produced by using negative 3D-printed molds and different types of silicone. An online survey obtained evaluations from a group of dermatologists regarding the quality of previously supplied silicone 3D models and their potential use in medical education. Data from 58 dermatologists were collected and analyzed.
Results: The majority of the participants rated the models overall as positive and innovative, providing constructive feedback for additional modifications, and recommended further implementation into the regular curriculum as an additional tool after the end of the pandemic.
Conclusions: Our study underlined the possible advantages of using 3D models as a supplement in educational training even after the end of the SARS-CoV-2 pandemic.
Markus  Reinholz
2023/01/31
10.5826/dpc.1301a49
e2023049
Department of Dermatology and Allergy, University Hospital, LMU Munich, Germany
2160-9381
evaluation
en
e2023049
Schaefer I, Rustenbach S, Zimmer L, et al. Prevalence of skin diseases in a cohort of 48,665 employees in Germany. Dermatology 2008; 217: 169-172.
Silicone Models for Dermatological Education: Assessment of a New Teaching Tool by Dermatologists
https://dpcj.org/index.php/dpc/article/download/2533/1939
            Silicone Models for Dermatological
       Education: Assessment of a New Teaching Tool
                     by Dermatologists
                         Leonie Frommherz1, Pascal Hering1, Pia-Charlotte Stadler1,
                           Benjamin M. Clanner-Engelshofen1, Markus Reinholz1


1 Department of Dermatology and Allergy, University Hospital, LMU Munich, Germany



Key words: dermatological education, teaching tool, silicone models, 3D models, evaluation
Citation: Frommherz L, Hering P, Stadler PC Clanner-Engelshofen BM, Reinholz M. Silicone Models for Dermatological Education:
Assessment of a New Teaching Tool by Dermatologists. Dermatol Pract Concept. 2023;13(1):e2023049. DOI: https://doi.org/10.5826/
dpc.1301a49
Accepted: April 21, 2022; Published: January 2023
Copyright: ©2023 Frommherz et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Markus Reinholz, MD, Ph.D. Department of Dermatology and Allergy, University Hospital, LMU Munich,
Frauenlobstr. 9-11, 80337 Munich, Germany. Tel: +49 (0)89 4400-56010 Fax: +49 (0)89 4400-56389 Email: Markus.Reinholz@med.­uni-
muenchen.de




  ABSTRACT             Introduction: The coronavirus pandemic forced universities to transfer academic curricula into the
                       digital realm and calls for the introduction of new teaching methods to adequately compensate for
                       the limited in-patient training. Especially in the field of dermatology, the use of 3D models presents an
                       interesting opportunity to maintain the teaching of diagnostically essential sensory and haptic charac-
                       teristics of primary lesions.
                       Objectives: We developed a prototype silicone model and presented it to the medical service of the
                       Department of Dermatology of the Ludwig-Maximilians University for evaluation.
                       Methods: Silicone models demonstrating primary skin lesions were produced by using negative
                       3D-printed molds and different types of silicone. An online survey obtained evaluations from a group
                       of dermatologists regarding the quality of previously supplied silicone 3D models and their potential
                       use in medical education. Data from 58 dermatologists were collected and analyzed.
                       Results: The majority of the participants rated the models overall as positive and innovative, provid-
                       ing constructive feedback for additional modifications, and recommended further implementation into
                       the regular curriculum as an additional tool after the end of the pandemic.
                       Conclusions: Our study underlined the possible advantages of using 3D models as a supplement in
                       educational training even after the end of the SARS-CoV-2 pandemic.




Original Article | Dermatol Pract Concept. 2023;13(1):e2023049                                                                      1
Introduction                                                        temperature was set at 60° C with an extrusion temperature
                                                                    of 200°C. Subsequently, a cotton swab soaked in tetrahy-
At the beginning of 2020, the pandemic outbreak of the              drofuran (Sigma Aldrich, Steinheim, Germany) was repeat-
coronavirus SARS-CoV-2 necessitated a quick shutdown                edly used to smooth the molds. TinkerCAD online software
of most public life in Germany to contain dissemination.            ­(Autodesk, Inc, San Rafael, California, USA) was applied for
Accordingly, universities were confronted with new chal-
­                                                                   designing the molds. The slicing software used was Ultimaker
lenges to continue providing high-quality education.                Cura (version 4.8, Ultimaker BV, Utrecht, Netherlands).
    For most faculties, this entailed a drastic transition into        Next, after degassing for 1 minute using a vacuum
the digital realm. However, a couple of specialist fields de-       pump (diaphragm vacuum pump, Vacuubrand GmbH+Co.,
pending on physical practices could not properly substitute         Wertheim, Germany), we poured silicone rubber (equal
essential courses. Medical education in particular is heavily       amounts of part A and B) according to the lesion proper-
reliant on face-to-face contact with patients both to learn         ties (Suppl. File 1), polymerized overnight at room tempera-
clinical pictures as well as to improve important communi-          ture and applied normal skin as the last layer on the second
cation skills. Different approaches already aimed to expand         day (all materials: KauPo Plankenhorn e.K., Spaichingen,
learning and teaching strategies beyond traditional methods         ­Germany). After another overnight polymerization period,
even before the pandemic urged educators to revise their for-       the silicone model was stripped off and stuck onto a post-
merly established curriculum. Case discussions and inverted         card sized ­
                                                                               (approximately 10.5 cm × 14.8 cm) overhead
classroom courses incentivize a more active engagement of           transparency (Figure 1A). Finally, to obtain a matt surface
students, whereas websites and a range of mobile learning           finish our models were powdered with household starch.
applications, e.g. for dermatological education, encourage
auto-didactic learning[1-3]. Furthermore, patient-­orientated-      Survey
communication courses use actors to simulate true-to-life
                                                                    In February 2021, we performed a longitudinal study us-
clinical situations. However, these approaches are still not
                                                                    ing an online survey addressed to dermatologists of the
able to substitute the in-patient examination of h
                                                 ­ aptic mani-
                                                                    ­Ludwig-Maximilian-University (LMU) in Munich/Germany
festations of symptoms, the lack of which constitutes a m
                                                        ­ ajor
                                                                    to use their knowledge and dermatological expertise in the
disadvantage of currently used teaching methods[4, 5].
                                                                    assessment of silicone models in medical teaching. Questions
Therefore, other medical fields have already implemented
                                                                    were answered using a grading from strongly agree, agree,
the use of 3D models in training and education, for example
                                                                    neutral, disagree to strongly disagree. The survey was in
in anatomy, dentistry and surgical preparations[6, 7].
                                                                    German language and carried out completely anonymously
    Expanding on this idea, we created colored 3D silicone mod-
                                                                    (translated version Suppl. File 1).
els with texturized surface areas to emulate common primary
                                                                       Participants were asked about their work experience,
skin lesions. Since visual and haptic examination of the skin
                                                                    acquired knowledge about moulages and their opinion
                                                                    ­
plays a major role in dermatological differential diagnosis[8],
                                                                    about the study object, possible benefits for students and
this model should be especially useful in times of restricted pa-
                                                                    suggestions for improvement.
tient access and possibly as a general learning tool as well.
    In this study, an early version of our 3D-printed model of
                                                                    Statistics
primary skin lesions was shown to a group of dermatologists
to evaluate the quality of the model and state their opinion        Statistical calculations were done using SPSS statistics 26.0
on incorporating 3D models into dermatological education            (IBM Corp., released 2019, Armonk, NY/USA), visualiza-
in general.                                                         tions were performed using GraphPad Prism version 9.0.0
                                                                    (GraphPad Software, La Jolla, CA). Metric variables were
                                                                    indicated as mean values ± standard deviation (SD). P value
Methods                                                             was calculated by using the Mann-Whitney Test. Significance
Silicone Models                                                     level was set at P<.05. The data were evaluated descriptively.
                                                                    Ethical approval was obtained from the committee of the
Our study object was a silicone model demonstrating pri-
                                                                    LMU (project KB 20/031).
mary skin lesions. The silicone models were produced using
negative molds made from polylactide (PLA) using Martz
PLA Matt Filament (IGO3D GmbH, Hannover, Germany)                   Results
on the 3D printer Anycubic i3 Mega S printer (ShenZhen
ANYCUBIC Technology Co., Ltd, Shenzhen, Guangdong,                  Study Population
China). The layer height was adjusted to 0.1 mm without             Fifty-eight dermatologists participated in the survey.
any support structures or attachment layers. The platform           Thirty-eight participants were female (65.5%), and twenty



2                                                                       Original Article | Dermatol Pract Concept. 2023;13(1):e2023049
A
                                                                                               Macula                 Plaque      Urtica
                    Macula        Plaque           Urtica




    Papula Nodulus                Nodus    Pustula Vesicula             Papula                         Nodulus         Nodus        Pustula    Vesicula

  B                  50                                                                                      EXPERIENCE WITH MOULAGES

                                                              YEARS OF WORKING EXPERIENCE                                                          YES
                     40
                                                                                                                                                   NO
                                                                                             > 10 y
                     30
 AGE




                                                                                            5 - 10 y
                     20


                     10                                                                       <5y


                      0
                                                                                                       0         10        20     30          40         50
                              MALE    FEMALE
                                                                                                                          PARTICIPANTS

     C                100
                                                                                                                                       INNOVATIVE

                       80                                                                                                              SURFACE FEEL
% OF PARTICIPANTS




                                                                                                                                       SIZE
                       60
                                                                                                                                       QUALITY

                       40


                       20


                          0
                          STRONGLY AGREE                                                          STRONGLY DISAGREE

Figure 1. A: Study object (silicone model): Upper row illustrating patch (Macula), plaque (Plaque) and wheal (Urtica), lower row depicting
papule (Papula), nodulus (Nodulus), nudule (Nodus), pustule (Pustula) and vesicle (Vesicula) (left to right, respectively; Latinized German
terms in brackets). B: Age and gender distribution of all participants (left panel). Experience with moulages depending on working expe-
rience (right panel). C: Exemplary represented assessment (from “strongly agree” to “strongly disagree”) for different evaluation criteria.




Original Article | Dermatol Pract Concept. 2023;13(1):e2023049                                                                                            3
participants were male (34.5%). The current mean age was            However, 61.8% (34/55) of the participants strongly
34.6 years (range 25 – 64 years). Among all participants,        agreed that the models should be expanded to include sec-
thirty-eight (65.5%) were dermatological residents with less     ondary lesions or dermatological clinical pictures as well.
than five years of working experience. Nine doctors were         Over a quarter (27.3%, 15/55) answered “agree” and 10.9%
attending physicians (15.5%) and worked between five and         (6/55) answered “neutral, disagree or strongly disagree”.
ten years in the field of dermatology and eleven (mainly            To evaluate possible benefits of the 3D-printed models,
advanced attending physicians) (19.0%) worked for more           the participants were asked if they would deem the silicone
than ten years as dermatologists. Overall, fifty-one doctors     moulages advantageous over the more traditional, usually
(89.5%) stated that they have not worked or taught students      wax-based models, to which almost two-thirds (65.5%,
by using moulages while six participants (10.5%) have al-        36/55) strongly agreed, while 25.5% (14/55) answered
ready gained experience by using them. Doctors who already       “agree” and 9.1% (5/55) answered “neutral”.
used moulages provided a significantly higher working expe-         Finally, the participants were asked to rate the general
rience (P=.003) (Figure 1B).                                     idea of teaching with silicone moulages on a scale ranging
                                                                 from very good (1) to poor (5), to which 72.7% (40/55) an-
Survey                                                           swered “very good”, while 20% (11/55) answered “good”
To review the true-to-life properties of the silicone models,    and only 7.3% (4/55) answered “moderate or poor”.
the participants were asked if they would assess the moulage        Additionally, the participants had the opportunity to
as realistic in terms of sensory and haptic perception. Al-      comment on their perceived shortcomings and their general
most two-thirds (62.5%, 35/56) answered “strongly agree”,        opinion of the silicone moulages in two open-ended ques-
a quarter (25%, 14/56) answered “agree” and 12.5% (7/56)         tions. Constructive criticism involved suggestions to mod-
answered “neutral or strongly disagree”.                         ify color, haptics and size to improve resemblance to actual
    Subsequently, when asked whether the model was repre-        clinical cases. However, one comment stated that the models
sentative of the clinical picture regarding haptic properties,   are, although nice to have, rather irrelevant since students
50.9% (28/55) answered “strongly agree” 34.5% (19/55)            have always been able to correctly identify primary lesions
answered “agree” and 14.6% (8/55) answered “neutral or           without additional teaching methods.
disagree”. Furthermore, 65.5% (36/55) answered “strongly            Almost all of the participants gave positive feedback,
agree” when asked if the models are of good quality regard-      complimenting the resourcefulness and good realization, as
ing their elaboration, 29.1% (16/55) answered “agree” and        well as describing the model as a great supplement to the
5.4% (3/55) answered “neutral or disagree”.                      traditional teaching methods and long-distance teaching
    More than three-quarters (76,4%, 42/55) of the partic-       tool, especially in times of limited patient contact due to
ipants strongly agreed that the model was sufficient in size,    COVID-19 restrictions.
while 18.2% (10/55) agreed and the rest (5.4%, 3/55) an-
swered “neutral or disagree”. Additionally, when asked if the
                                                                 Discussion
model was of a handy size, 80% (44/55) answered “strongly
agree”, 18.2% (10/55) answered “agree” and only one par-         In the medical field, providing the best possible education
ticipant (1.8%, 1/55) answered “neutral”. Subsequent ques-       and preparation of students for clinical practice at any given
tions regarded the use of models as learning/teaching tools.     time is of paramount concern. Usually, this is accomplished
Therefore, participants were asked if they considered the        by connecting the knowledge obtained by lectures and text-
training with models as innovative regarding the current sit-    books with actual clinical pictures via bedside teaching.
uation. Over two-thirds (69.1%, 38/55) answered “strongly        However, times of limited patient access impose the need for
agree”, 27.3% (15/55) answered “agree” and 3.6% (2/55)           alternative substitutional methods.
answered “disagree or strongly disagree” (Figure 1C).               Physical 3D models have already found their way into
    Additionally, when asked if they would expect the mou-       various medical fields to better illustrate spatial visualization
lages to facilitate the student’s learning approach, 74.5%       of anatomical features and pathologies, rendering them a suit-
(41/55) answered “strongly agree”, 20% (11/55) answered          able candidate for a contactless teaching experience[6]. Vari-
“agree” and 5.4% (3/55) answered “neutral or disagree”.          ous studies reported improvements in students’ self-perceived
    More than two-thirds (67.3%, 37/55) of the derma-            knowledge and confidence following an auto-didactic study
tologists strongly agreed that they consider the moulages        session[9]. Furthermore, studies have shown an objective in-
a good supplement to in-patient teachings even after the         crease in knowledge acquisition[10, 11], even proving to be
end of the pandemic. Almost a quarter (23.6%, 13/55) an-         superior in direct comparison with cadaveric material[12],
swered “agree” and 9% (5/55) answered “neutral, disagree         CT scans or 3D computer simulations[13, 14]. All aforemen-
or strongly disagree”.                                           tioned studies additionally received positive feedback from



4                                                                    Original Article | Dermatol Pract Concept. 2023;13(1):e2023049
students, who expressed wishes to incorporate the 3D mod-                  chances. Journal of the european academy of dermatology and
els into the regular curriculum.                                           venereology, 2020. 34(5): p. e214-e216.
                                                                      2.   Moszkowicz, D., et al., Daily medical education for confined stu-
    Correspondingly, medical experts also reported their sat-
                                                                           dents during coronavirus disease 2019 pandemic: A simple video-
isfaction with the models and emphasized their usefulness
                                                                           conference solution. Clinical Anatomy, 2020. 33(6): p. 927-928.
in medical education[15]. These findings concur with our              3.   Brewer, A.C., et al., Mobile applications in dermatology. JAMA
own results, as the idea of 3D models generally yielded a                  dermatology, 2013. 149(11): p. 1300-1304.
very positive response, and the majority of questioned der-           4.   Dedeilia, A., et al., Medical and surgical education challenges
matologists found the silicone models to be innovative and                 and innovations in the COVID-19 era: a systematic review. in
                                                                           vivo, 2020. 34(3 suppl): p. 1603-1611.
to facilitate learning of primary lesions. Although it was
                                                                      5.   Bączek, M., et al., Students’ perception of online learning during
noted that 3D models cannot fully encapsulate the visual
                                                                           the COVID-19 pandemic: a survey study of Polish medical
and sensory representation of primary lesions and are there-               ­students. Medicine, 2021. 100(7).
fore not able to replace the clinical picture, the models pri-       6.     Dawood, A., et al., 3D printing in dentistry. British dental
marily attempt to create a basic understanding in students                  ­journal, 2015. 219(11): p. 521-529.
with little to no clinical dermatological experience. This is         7.     Coelho, G., et al., Multimaterial 3D printing preoperative plan-
                                                                             ning for frontoethmoidal meningoencephalocele surgery. Child’s
especially crucial since dermatological problems are numer-
                                                                             Nervous System, 2018. 34(4): p. 749-756.
ous and often occur as comorbidities in a variety of medical
                                                                      8.     Rosendahl, C., et al., Dermatoscopy in routine practice:’Chaos
domains[16].                                                                 and clues’. Australian family physician, 2012. 41(7): p. 482.
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picture in complete detail should not be seen as a limitation,               medical student education in congenital heart disease: across a
considering the model an auxiliary teaching tool rather than                 spectrum of disease severity. Pediatric cardiology, 2019. 40(6):
                                                                             p. 1258-1265.
a replacement for in-patient training once the pandemic sub-
                                                                     10.     Garg, A., H.-L. Haley, and D. Hatem, Modern moulage: evaluat-
sides. For this application, our study yielded almost universal
                                                                           ing the use of 3-dimensional prosthetic mimics in a dermatology
approval among participants.                                               teaching program for second-year medical students. Archives of
    Improvement suggestions stated in the open-ended ques-                 dermatology, 2010. 146(2): p. 143-146.
tions regarded slight modifications of color, size and haptic        11.   Fleming, C., et al., Effectiveness of three-dimensionally printed
characteristics. Since the nature of the silicone models allows            models in anatomy education for medical students and resident
                                                                           physicians: systematic review and meta-analysis. Journal of the
for quick and easy incorporation of feedback, our prototype
                                                                           American College of Radiology, 2020.
model can be constantly upgraded utilizing these sugges-
                                                                     12.   Lim, K.H.A., et al., Use of 3D printed models in medical
tions at a fairly low price point (approximately 50 Eurocent               education: a randomized control trial comparing 3D prints
                                                                           ­
(0.5 €) per model).                                                        ­versus cadaveric materials for learning external cardiac anatomy.
                                                                            Anatomical sciences education, 2016. 9(3): p. 213-221.
                                                                     13.    Preece, D., et al., “Let’s get physical”: advantages of a physical
Conclusions                                                                 model over 3D computer models and textbooks in learning
                                                                            ­imaging anatomy. Anatomical sciences education, 2013. 6(4):
In conclusion, experts approved the utilization of silicone                  p. 216-224.
3D-printed models as a highly promising method in derma-             14.     Knoedler, M., et al., Individualized physical 3-dimensional
tological education in times of restricted in-patient contact                ­kidney tumor models constructed from 3-dimensional printers
and further recommended the incorporation of the models                       result in improved trainee anatomic understanding. Urology,
                                                                              2015. 85(6): p. 1257-1262.
as an additional tool into the regular curriculum.
                                                                     15.      Jones, D.B., et al., Three-dimensional modeling may improve
                                                                              surgical education and clinical practice. Surgical innovation,
                                                                              ­
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Original Article | Dermatol Pract Concept. 2023;13(1):e2023049                                                                             5
