Resident Education in Autologous Rib Microtia Repair: A Structured Framework for Global Surgery Missions

Humanitarian surgical efforts have long played a role in expanding access to medical care in low-resource settings. Within facial plastics, microtia reconstruction is a frequent focus, while also offering a powerful opportunity to enhance global surgical training for residents and fellows. Autologous rib reconstruction is a complex, multistage procedure requiring significant technical proficiency. Mastery is a prolonged process that demands continued repetition, practice, and mentorship—far beyond the exposure of a single mission trip. Nevertheless, defining clear, objective learning goals strengthens the experience. This report describes a competency-based training framework for otolaryngology residents and facial plastic surgery fellows participating in autologous rib microtia reconstruction missions. The framework is intended for use by FPRS-trained attending surgeons leading international surgical missions with trainees at varying levels of experience—from those with no prior microtia exposure to those approaching independent practice. Developed iteratively over multiple missions across several countries, the model addresses premission preparation, stepwise intraoperative involvement, postoperative education, faculty feedback, and ethical obligations to host communities. Adequate preparation is the foundation for intraoperative success. Didactic sessions reviewing anatomy, auricular framework design, and rib harvest are essential. In our experience, framework design and cartilage harvest represent the greatest barriers to proficiency. Resources like Auricular Reconstruction by Firmin contain detailed color photographs, drawings, and lecture videos on framework carving [1]. Numerous materials, ranging from vegetables and animal tissue to 3D silicone constructs, can serve as effective cartilage carving models [2-12]. A 2023 review of 354 articles demonstrated that cost-effective synthetic materials, such as foam, are most appropriate for junior surgeons in the early stages of skill acquisition, followed by a transition to animal cartilage or 3D printed silicone as proficiency increases [13]. Computer-aided design and 3D printing capabilities have continued to evolve, and we have found success with the silicone: starch composite negative model proposed by Berens et al. [9] This model is low cost, readily reproducible, and based on CT imaging, allowing for patient-specific rehearsal. Dedicated practice has been shown to build confidence and technical skill, particularly in carving fundamentals and framework assembly [14]. Cadaveric training is also invaluable, offering experience in preharvest planning and dissection. Beyond technical skills, preparation should include relevant cultural and logistical information. Understanding patient demographics, hospital limitations, and trainee-specific roles helps streamline workflow and promotes cultural sensitivity. Autologous rib microtia reconstruction is typically limited to high-volume tertiary centers, and trainee exposure can be limited. A 2022 study of a single center's experience highlighted only 229 patients over a 20-year period [15]. Even when microtia cases are present, autologous rib reconstruction may not be the preferred technique. Therefore, meeting the trainee at their individual level ensures a safe and effective learning environment. Graduated autonomy bridges the gap between limited exposure and technical complexity. Early tasks include marking incision lines, designing templates, and performing basic dissection. As comfort increases, trainees can advance to supervised dissection of the auricular pocket or rib cartilage harvest. Framework carving begins with lower-stakes regions, such as helical rim contouring, before progressing to more sensitive components like the antihelix, conchal bowl, tragus-antitragus complex, and baseplate definition. Surgical assignments should align with each trainee's skill level to optimize learning while ensuring surgical quality. Trainee advancement through operative roles is guided by demonstration of the competencies expected at each stage, including anatomic knowledge, technical execution, and situational awareness. These competencies are consistent with standards applied in traditional academic training environments. Progression is not defined by case count alone, but by qualitative assessment of readiness as determined by the supervising attending. The attending surgeon leading the mission serves as the sole arbiter of role assignment and advancement, with final authority over all intraoperative decisions. Formal assessment tools can provide a reproducible framework for evaluating technical skills across missions and over time, supporting longitudinal tracking of trainee development. Education should extend into the postoperative phase. Our senior author recommends twice-daily rounding to assess healing and monitor for potential complications. A 2013 systematic review of over 9000 autologous cartilage microtia reconstructions reported a 16.2% complication rate, underscoring the importance of structured postoperative monitoring [16]. During rounds, trainees should be able to distinguish expected postoperative swelling from early hematoma, assess drain output and character, evaluate skin flap perfusion, and identify signs of potential framework exposure. Developing sound clinical judgment around these endpoints is particularly valuable in mission settings, where access to advanced imaging and other diagnostic tests may be limited. Standardized pre- and postoperative photography is an additional responsibility well-suited for trainees and should be performed at consistent intervals throughout the postoperative course. Systematic photo documentation serves multiple purposes: it provides a visual record for continuity of care across annual missions, facilitates remote consultation with local providers between visits, and establishes a foundation for future outcomes research. Trainees involved in documentation gain familiarity with aesthetic outcome assessment and develop an appreciation for the longitudinal arc of microtia reconstruction. Global surgical missions carry an ethical obligation to avoid extractive models of care in which visiting teams operate independently of local infrastructure and provide no lasting benefit to host communities. Our group's missions to Latin America and Southeast Asia are designed with longitudinal engagement as a foundational principle. Microtia patients are identified and referred by local providers throughout the year, ensuring that community partners remain central to the care pathway rather than passive recipients of visiting expertise. At the start of each annual mission, the team conducts new patient screening alongside local providers, previously operated patients are seen for follow-up, and prior first stage microtia reconstruction patients are seen for planning of their second stage operation, creating a continuity of care model that extends beyond the mission itself. Local providers participate in all clinical sessions and receive direct instruction in wound care and complication recognition. Relationships with local hospital leadership are maintained year-round, and certified interpreters facilitate communication across all clinical interactions, reflecting evidence that sustained continuity of care is essential to maintaining patient safety and surgical standards in global surgery settings [17]. This model of reciprocal, longitudinal engagement represents a verifiable standard for ethical mission conduct that we propose as a benchmark for similar global surgery programs. Structured feedback and postmission reflection are key for evaluating performance and encouraging growth. The Objective Structured Assessment of Technical Skills (OSATS) is a validated, reproducible tool for evaluating technical ability [18]. It is particularly well suited for global missions, where time-limited exposure requires efficient, standardized feedback across learners of variable experience levels. While we have not yet implemented OSATS in a formalized manner, we see significant potential for its future use in documenting trainee growth across sequential missions and in comparing pre- versus postmission technical ability. Our group is exploring how to integrate streamlined, procedure-specific evaluations—such as helical rim carving, rib cartilage harvest, and skin pocket creation—into future trips. This would provide actionable feedback while also creating a foundation for longitudinal performance tracking. Outside of formal assessment, frequent verbal feedback should address both technical and nontechnical competencies, such as communication, professionalism, and situational awareness. Short debriefs allow focused discussion on strengths and growth areas, and trainees should be encouraged to reflect and document their experiences to internalize key takeaways. These opportunities for feedback play a vital role in shaping surgical development, as surgical missions offer a unique opportunity to gain technical experience in a new clinical and cultural environment. Autologous rib cartilage microtia reconstruction demands a level of technical proficiency that cannot be acquired through passive observation alone, yet formal training frameworks for this procedure remain largely absent from the global surgery literature. We present a novel competency-based resident education model (summarized in Table 1) specifically designed for autologous rib microtia repair in the context of international humanitarian missions. This framework defines learner roles, progression criteria, implementation requirements, and ethical obligations to host communities. It offers a structured, reproducible model for programs seeking to integrate meaningful surgical education into global surgery efforts. As demand for microtia reconstruction in low-resource settings continues to grow, frameworks such as this are essential to ensure that mission-based training is both educationally rigorous and ethically accountable. Future studies should focus on validating this model with prospective trainee data. The authors have nothing to report. The authors have nothing to report. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.