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 one 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 worked in conjunction to develop one 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. The ability to make 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 to 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 to demonstrate tears, dirt, etc. for trauma scenarios. 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 made to investigate those products before application. The simulation community is growing, and tips and tricks are abundantly published on the internet and within listservs. Lastly, always inquire whether an SP has allergies before applying products, especially those with adhesives and latex.

Issues of Concern

There are various instructional videos and documents available online showcasing techniques for making a variety of injuries and physiologic patterns. At least one study examined the effectiveness of moulage applied by nonprofessionals (i.e., introductory training versus makeup artists) with learners reporting added realism to their immersive experience no matter who applied the moulage.[3] Simulation conferences also offer workshops and courses. Typical materials include wax, latex, petroleum jelly, tissue paper, stage blood, charcoal powder, and eyeshadow, along with 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 as an 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, which 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 as to what the real diagnosis of their simulated patient is, leading to a disintegration of the simulation scenario.[10][11] As with any technique incorporating increasing levels of fidelity, simulation educators should always keep in mind the learning goals and objectives. The safety and comfort of the individual wearing the moulage is also a consideration; 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

As technology advances, one particular method can supplement and perhaps replace moulage 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, such as 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 actual 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

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.