Introduction

Simulation-based education is a widely utilized tool for experiential learning. Simulation techniques can employ a range of fidelity to incorporate realism; moulage is 1 such technique. Moulage was once the art of wax model making to depict certain conditions for medical education. As medical training has evolved, moulage has transformed into the art of special effects makeup to replicate various disease processes and injuries. Some simulation centers have the advantage of having an experienced moulage artist on staff; however, with some brief training, other individuals can learn this technique.

Function

Moulage was once the art of wax model making to depict certain conditions for medical education. In the early 1800s, Franz Martens and Joseph Towne were some of the earliest moulage artists. Years later, Charles Lailler and Jules Pierre Francois Baretta collaborated to develop 1 of the largest collections of wax models for Hospital Saint Louis in Paris. Johann Nepomuk Hoffmayr is yet another moulage artist who was particularly adept at creating a wide range of ophthalmic conditions for educational purposes.[1] The practice of moulage spread throughout Europe, serving as a teaching modality for dermatologic and venereal disease recognition.[2] Moulage has since transformed into the practice of special effects makeup in simulation to illustrate and corroborate a patient’s history and physical exam by providing visual and tactile cues. Making a standardized patient (SP) look pale with makeup to simulate internal blood loss can provide valuable visual information to a learner, just as ecchymoses and abrasions applied to a lower extremity following a story of a vehicular crash can. 

Moulage can be as simple as a bruise or abrasion or something as complicated as replicating mass casualty injuries such as impalements and burns. Moulage can also include staging an environment to provide even more immersion into a clinical setting. For example, blood pooling on a floor or bed can represent hypovolemia. Personal articles such as photographs in a simulated clinical room can add emotion to a breaking bad news scenario. Clothing can also be modified for trauma scenarios to demonstrate tears, dirt, etc. Moulage can be effective on both SPs and mannequins. There are some products, such as grease makeup, that stain the silicone-based skin on mannequins. Therefore, due diligence should be done to investigate those products before application. The simulation community is growing, and tips and tricks are abundantly published online and within listservs. Lastly, always inquire whether an SP has allergies before applying products, especially those with adhesives and latex.

Issues of Concern

Various instructional videos and documents are available online showcasing techniques for making a variety of injuries and physiologic patterns. At least 1 study examined the effectiveness of moulage applied by nonprofessionals (ie, introductory training versus makeup artists), with learners reporting added realism to their immersive experience no matter who applied it.[3] Simulation conferences also offer workshops and courses. Typical materials include wax, latex, petroleum jelly, tissue paper, stage blood, charcoal powder, eyeshadow, and common household cooking ingredients such as corn syrup, cocoa powder, and food coloring. For example, a burn can be made with tissue paper and petroleum jelly, while corn syrup and food coloring can be applied near the mouth of an SP to simulate blood. Cocoa powder and charcoal powder can be a stand-in for dirt.[4] Moulage can also incorporate constructing prosthetics and attaching them to an individual instead of using makeup directly on the skin. While moulage can be time-intensive with the added cost of materials, this is an invaluable option to incorporate into simulation scenarios.

Clinical Significance

The use of moulage consistently appears in the literature to aid in evaluating, diagnosing, and treating burns and dermatologic conditions.[3][4][5][6][7][8] As a result, moulage has been shown to assist in content and face validity, along with the transfer of clinical skills and knowledge retention.[3] Comparative studies of moulage versus no moulage demonstrated improved learner performance and immersion in their clinical scenario.[9] When conducting scenarios without moulage, verbal descriptions and stickers with written descriptions of injury patterns are the cues that render the fidelity to a low level. Learners who have participated in simulation with realistic moulage comment that the scenario becomes more urgent, allowing them to engage their critical thinking skills earlier in the interaction.[9]

Moulage application should work in a manner that contributes to realism. Thus, accuracy and authenticity are important facets to consider when using this technique; if used incorrectly, learners can become confused about the real diagnosis of their simulated patient, leading to a disintegration of the simulation scenario.[10][11] As with any technique incorporating increasing levels of fidelity, simulation educators should always keep the learning goals and objectives in mind. The safety and comfort of the individual wearing the moulage are also considered; an injury pattern may look intriguing but may not add any value to the objectives and may be uncomfortable for the SP; this may also hamper their performance.

The Future

One method can supplement and perhaps replace moulage as technology advances over time. Three-dimensional (3D) printing has become increasingly prevalent in simulation. Models, once composed of wax, are now composed of various polymers and resin. Moulage items like skin lesions have successfully been printed for teaching purposes. Not only does the printed lesion look realistic, but it also feels realistic.[12] Moreover, 3D models can be fabricated based on patient radiologic images to serve as visual surgical guides to facilitate pre-planning for operative approaches. Complex anatomical pathology resulting from congenital disease, cancer, or trauma, especially vascular and orthopedic, can be studied in a way that it has not been afforded in years past.[13][14] A recent study demonstrated that implementing this resource can save valuable time in the operating room.[15]

Pearls and Other Issues

Key facts to keep in mind about moulage in medical simulation are as follows:

1. Moulage should be used carefully to ensure it enhances the educational experience and does not become distracting or confusing.
2. Used effectively, moulage can greatly enhance fidelity in medical simulation.

Enhancing Healthcare Team Outcomes

Moulage is commonly used in military medicine simulation to demonstrate combat injuries, along with civilian mass casualty exercises. In doing so, interprofessional teams with and across multiple organizations can perform and collaborate to triage patients appropriately.

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References

1.

Zampieri F, Comacchio F, Zanatta A. Ophthalmologic wax models as an educational tool for 18th-century vision scientists. Acta Ophthalmol. 2017 Dec;95(8):852-857. [PubMed: 28205422]

2.

Bray FN, Simmons BJ, Falto-Aizpurua LA, Griffith RD, Nouri K. Moulage: the decaying art of dermatology. JAMA Dermatol. 2015 May;151(5):480. [PubMed: 25693165]

3.

Pywell MJ, Evgeniou E, Highway K, Pitt E, Estela CM. High fidelity, low cost moulage as a valid simulation tool to improve burns education. Burns. 2016 Jun;42(4):844-52. [PubMed: 26810642]

4.

Swan NA. Burn moulage made easy (and cheap). J Burn Care Res. 2013 Jul-Aug;34(4):e215-20. [PubMed: 23702856]

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Hernandez C, Mermelstein R, Robinson JK, Yudkowsky R. Assessing students' ability to detect melanomas using standardized patients and moulage. J Am Acad Dermatol. 2013 Mar;68(3):e83-8. [PubMed: 22196980]

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Shiner N, Howard ML. The use of simulation and moulage in undergraduate diagnostic radiography education: A burns scenario. Radiography (Lond). 2019 Aug;25(3):194-201. [PubMed: 31301775]

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Zorn J, Snyder J, Guthrie J. Use of Moulage to Evaluate Student Assessment of Skin in an Objective Structured Clinical Examination. J Physician Assist Educ. 2018 Jun;29(2):99-103. [PubMed: 29787509]

8.

Rabionet A, Patel N. Much More Than Movie Magic-Dermatologic Applications of Medical Moulage. JAMA Dermatol. 2017 Mar 01;153(3):318. [PubMed: 28273309]

9.

Mills BW, Miles AK, Phan T, Dykstra PMC, Hansen SS, Walsh AS, Reid DN, Langdon C. Investigating the Extent Realistic Moulage Impacts on Immersion and Performance Among Undergraduate Paramedicine Students in a Simulation-based Trauma Scenario: A Pilot Study. Simul Healthc. 2018 Oct;13(5):331-340. [PubMed: 29672468]

10.

Stokes-Parish J, Duvivier R, Jolly B. Expert opinions on the authenticity of moulage in simulation: a Delphi study. Adv Simul (Lond). 2019;4:16. [PMC free article: PMC6615296] [PubMed: 31333880]

11.

Stokes-Parish JB, Duvivier R, Jolly B. Does Appearance Matter? Current Issues and Formulation of a Research Agenda for Moulage in Simulation. Simul Healthc. 2017 Feb;12(1):47-50. [PubMed: 28009654]

12.

Vazquez T, Forouzandeh M, Sisk M, Florez-White M, Nouri K. The modern-day moulage: incorporating three-dimensional scanning and printing to enhance dermatology education and teledermatology. J Eur Acad Dermatol Venereol. 2019 Oct;33(10):e383-e384. [PubMed: 31081191]

13.

Kadam D, Pillai V, Bhandary S, Hukkeri RY, Kadam M. Facial contour deformity correction with microvascular flaps based on the 3-dimentional template and facial moulage. Indian J Plast Surg. 2013 Sep;46(3):521-8. [PMC free article: PMC3897098] [PubMed: 24459343]

14.

Tack P, Victor J, Gemmel P, Annemans L. 3D-printing techniques in a medical setting: a systematic literature review. Biomed Eng Online. 2016 Oct 21;15(1):115. [PMC free article: PMC5073919] [PubMed: 27769304]

15.

Ballard DH, Mills P, Duszak R, Weisman JA, Rybicki FJ, Woodard PK. Medical 3D Printing Cost-Savings in Orthopedic and Maxillofacial Surgery: Cost Analysis of Operating Room Time Saved with 3D Printed Anatomic Models and Surgical Guides. Acad Radiol. 2020 Aug;27(8):1103-1113. [PMC free article: PMC7078060] [PubMed: 31542197]

Disclosure: Heidi Felix declares no relevant financial relationships with ineligible companies.

Disclosure: Leslie Simon declares no relevant financial relationships with ineligible companies.