Current educational interventions and training courses in microsurgery are often predicated on theories of skill acquisition and development that follow a 'practice makes perfect' model. Given the changing landscape of surgical training and advances in educational theories related to skill development, research is needed to assess current training tools in microsurgery education and devise alternative methods that would enhance training. Simulation is an increasingly important tool for educators because, whilst facilitating improved technical proficiency, it provides a way to reduce risks to both trainees and patients. The International Microsurgery Simulation Society has been founded in 2012 in order to consolidate the global effort in promoting excellence in microsurgical training. The society's aim to achieve standarisation of microsurgical training worldwide could be realised through the development of evidence based educational interventions and sharing best practices.
Curriculum ; Humans ; Microsurgery ; Practice Guidelines as Topic

Cartilage has a limited regenerative capacity. Faced with the clinical challenge of reconstruction of cartilage defects, the field of cartilage engineering has evolved. This article reviews current concepts and strategies in cartilage engineering with an emphasis on the application of nanotechnology in the production of biomimetic cartilage regenerative scaffolds. The structural architecture and composition of the cartilage extracellular matrix and the evolution of tissue engineering concepts and scaffold technology over the last two decades are outlined. Current advances in biomimetic techniques to produce nanoscaled fibrous scaffolds, together with innovative methods to improve scaffold biofunctionality with bioactive cues are highlighted. To date, the majority of research into cartilage regeneration has been focused on articular cartilage due to the high prevalence of large joint osteoarthritis in an increasingly aging population. Nevertheless, the principles and advances are applicable to cartilage engineering for plastic and reconstructive surgery.
Aging ; Biomimetics* ; Cartilage* ; Cartilage, Articular ; Cues ; Extracellular Matrix ; Guided Tissue Regeneration ; Joints ; Nanotechnology* ; Osteoarthritis ; Prevalence ; Regeneration ; Tissue Engineering ; Tissue Scaffolds

Plastic surgery training worldwide has seen a thorough restructuring over the past decade, with the introduction of formal training curricula and work-based assessment tools. Part of this process has been the introduction of revalidation and a greater use of simulation in training delivery. Simulation is an increasingly important tool for educators because it provides a way to reduce risks to both trainees and patients, whilst facilitating improved technical proficiency. Current microsurgery training interventions are often predicated on theories of skill acquisition and development that follow a 'practice makes perfect' model. Given the changing landscape of surgical training and advances in educational theories related to skill development, research is needed to assess the potential benefits of alternative models, particularly cross-training, a model now widely used in non-medical areas with significant benefits. Furthermore, with the proliferation of microsurgery training interventions and therefore diversity in length, cost, content and models used, appropriate standardisation will be an important factor to ensure that courses deliver consistent and effective training that achieves appropriate levels of competency. Key research requirements should be gathered and used in directing further research in these areas to achieve on-going improvement of microsurgery training.
Curriculum ; Education ; Humans ; Inservice Training ; Microsurgery ; Patient Simulation ; Surgery, Plastic

BACKGROUND: Simulation training is becoming an increasingly important component of skills acquisition in surgical specialties, including Plastic Surgery. Non-living simulation models have an established place in Plastic Surgical microsurgery training, and support the principles of replacement, reduction and refinement of animal use. A more sophisticated version of the basic chicken thigh microsurgery model has been developed to include dissection of a type 1-muscle flap and is described and validated here. METHODS: A step-by-step dissection guide on how to perform the chicken thigh adductor profundus free muscle flap is demonstrated. Forty trainees performed the novel simulation muscle flap on the last day of a 5-day microsurgery course. Pre- and post-course microvascular anastomosis assessment, along with micro dissection and end product (anastomosis lapse index) assessment, demonstrated skills acquisition. RESULTS: The average time to dissect the flap by novice trainees was 82±24 minutes, by core trainees 90±24 minutes, and by higher trainees 64±21 minutes (P=0.013). There was a statistically significant difference in the time to complete the anastomosis between the three levels of training (P=0.001) and there was a significant decrease in the time taken to perform the anastomosis following course completion (P<0.001). Anastomosis lapse index scores improved for all cohorts with post-test average anastomosis lapse index score of 3±1.4 (P<0.001). CONCLUSIONS: The novel chicken thigh adductor profundus free muscle flap model demonstrates face and construct validity for the introduction of the principles of free tissue transfer. The low cost, constant, and reproducible anatomy makes this simulation model a recommended addition to any microsurgical training curriculum.
Animals ; Chickens* ; Cohort Studies ; Curriculum ; Education ; Microsurgery* ; Plastics ; Simulation Training* ; Specialties, Surgical ; Surgery, Plastic ; Thigh*

BACKGROUND: To overcome the potential drawbacks of a short half-life and dose-related adverse effects of using active transforming growth factor-beta 1 for cartilage engineering, a cell-mediated latent growth factor activation strategy was developed incorporating latent transforming growth factor-beta1 (LTGF) into an electrospun poly(L-lactide) scaffold. METHODS: The electrospun scaffold was surface modified with NH3 plasma and biofunctionalised with LTGF to produce both random and orientated biofunctionalised electrospun scaffolds. Scaffold surface chemical analysis and growth factor bioavailability assays were performed. In vitro biocompatibility and human nasal chondrocyte gene expression with these biofunctionalised electrospun scaffold templates were assessed. In vivo chondrogenic activity and chondrocyte gene expression were evaluated in athymic rats. RESULTS: Chemical analysis demonstrated that LTGF anchored to the scaffolds was available for enzymatic, chemical and cell activation. The biofunctionalised scaffolds were non-toxic. Gene expression suggested chondrocyte re-differentiation after 14 days in culture. By 6 weeks, the implanted biofunctionalised scaffolds had induced highly passaged chondrocytes to re-express Col2A1 and produce type II collagen. CONCLUSIONS: We have demonstrated a proof of concept for cell-mediated activation of anchored growth factors using a novel biofunctionalised scaffold in cartilage engineering. This presents a platform for development of protein delivery systems and for tissue engineering.
Biological Availability ; Biomimetics ; Cartilage* ; Chondrocytes ; Gene Expression ; Guided Tissue Regeneration ; Half-Life ; Humans* ; Intercellular Signaling Peptides and Proteins ; Plasma ; Polyesters ; Tissue Engineering ; Tissue Scaffolds ; Transforming Growth Factor beta1

With significant improvements in success rates for free flap reconstruction of the head and neck, attention has turned to donor site morbidity associated with osteocutaneous free flaps. In this review, we address the morbidity associated with harvest of the four most commonly used osteocutaneous flaps; the free fibula flap, the scapula flap, the iliac crest flap and the radial forearm flap. A comprehensive literature search was performed to identify articles relevant to donor site morbidity for these flaps. We assessed morbidity in terms of incidence of delayed healing, chronic pain, aesthetic outcomes, site specific complications and patient satisfaction/quality of life. Weighted means were calculated when sufficient studies were available for review. The radial forearm and free fibula flaps are associated with high rates of delayed healing of approximately 20% compared to the scapular ( < 10%) and iliac flaps (5%). The radial forearm flap has higher rates of chronic pain (16.7%) and dissatisfaction with scar appearance (33%). For the majority of these patients harvest of one of these four osteocutaneous does not limit daily function at long-term follow-up. The scapular osteocutaneous flap is associated with the lowest relative morbidity and should be strongly considered when the recipient defect allows. The radial forearm is associated with higher morbidity in terms of scarring, fractures, chronic pain and wrist function and should not be considered as first choice when other flap options are available.
Chronic Pain ; Cicatrix ; Fibula ; Follow-Up Studies ; Forearm ; Free Tissue Flaps ; Head* ; Humans ; Incidence ; Mandibular Reconstruction ; Neck* ; Outcome Assessment (Health Care)* ; Postoperative Complications ; Quality of Life ; Scapula ; Tissue Donors* ; Wrist

Inflammatory bowel disease encompasses Crohn’s disease and ulcerative colitis and is characterized by uncontrolled, relapsing, and remitting course of inflammation in the gastrointestinal tract. Artificial intelligence represents a new era within the field of gastroenterology, and the amount of research surrounding artificial intelligence in patients with inflammatory bowel disease is on the rise. As clinical trial outcomes and treatment targets evolve in inflammatory bowel disease, artificial intelligence may prove as a valuable tool for providing accurate, consistent, and reproducible evaluations of endoscopic appearance and histologic activity, thereby optimizing the diagnosis process and identifying disease severity. Furthermore, as the applications of artificial intelligence for inflammatory bowel disease continue to expand, they may present an ideal opportunity for improving disease management by predicting treatment response to biologic therapies and for refining the standard of care by setting the basis for future treatment personalization and cost reduction. The purpose of this review is to provide an overview of the unmet needs in the management of inflammatory bowel disease in clinical practice and how artificial intelligence tools can address these gaps to transform patient care.

Background: The Exoscope is a novel high-definition digital camera system. There is limited evidence signifying the use of exoscopic devices in microsurgery. This trial objectively assesses the effects of the use of the Exoscope as an alternative to the standard operating microscope (OM) on the performance of experts in a simulated microvascular anastomosis. Methods: Modus V Exoscope and OM were used by expert microsurgeons to perform standardized tasks. Hand-motion analyzer measured the total pathlength (TP), total movements (TM), total time (TT), and quality of end-product anastomosis. A clinical margin of TT was performed to prove non-inferiority. An expert performed consecutive microvascular anastomoses to provide the exoscopic learning curve until reached plateau in TT. Results: Ten micro sutures and 10 anastomoses were performed. Analysis demonstrated statistically significant differences in performing micro sutures for TP, TM, and TT. There was statistical significance in TM and TT, however, marginal non-significant difference in TP regarding microvascular anastomoses performance. The intimal suture line analysis demonstrated no statistically significant differences. Non-inferiority results based on clinical inferiority margin (Δ) of TT=10 minutes demonstrated an absolute difference of 0.07 minutes between OM and Exoscope cohorts. A 51%, 58%, and 46% improvement or reduction was achieved in TT, TM, TP, respectively, during the exoscopic microvascular anastomosis learning curve. Conclusions This study demonstrated that experts’ Exoscope anastomoses appear non-inferior to the OM anastomoses. Exoscopic microvascular anastomosis was more time consuming but end-product (patency) in not clinically inferior. Experts’ “warm-up” learning curve is steep but swift and may prove to reach clinical equality.

Over the past decade, driven by advances in educational theory and pressures for efficiency in the clinical environment, there has been a shift in surgical education and training towards enhanced simulation training. Microsurgery is a technical skill with a steep competency learning curve on which the clinical outcome greatly depends. This paper investigates the evidence for educational and training interventions of traditional microsurgical skills courses in order to establish the best evidence practice in education and training and curriculum design. A systematic review of MEDLINE, EMBASE, and PubMed databases was performed to identify randomized control trials looking at educational and training interventions that objectively improved microsurgical skill acquisition, and these were critically appraised using the BestBETs group methodology. The databases search yielded 1,148, 1,460, and 2,277 citations respectively. These were then further limited to randomized controlled trials from which abstract reviews reduced the number to 5 relevant randomised controlled clinical trials. The best evidence supported a laboratory based low fidelity model microsurgical skills curriculum. There was strong evidence that technical skills acquired on low fidelity models transfers to improved performance on higher fidelity human cadaver models and that self directed practice leads to improved technical performance. Although there is significant paucity in the literature to support current microsurgical education and training practices, simulated training on low fidelity models in microsurgery is an effective intervention that leads to acquisition of transferable skills and improved technical performance. Further research to identify educational interventions associated with accelerated skill acquisition is required.
Cadaver ; Clinical Competence ; Curriculum ; Humans ; Learning Curve ; Microsurgery

With an increasing emphasis on microsurgery skill acquisition through simulated training, the need has been identified for standardised training programmes in microsurgery. We have reviewed microsurgery training courses available across the six continents of the World. Data was collected of relevant published output from PubMed, MEDLINE (Ovid), and EMBASE (Ovid) searches, and from information available on the Internet of up to six established microsurgery course from each of the six continents of the World. Fellowships and courses that concentrate on flap harvesting rather than microsurgical techniques were excluded. We identified 27 centres offering 39 courses. Total course length ranged from 20 hours to 1,950 hours. Student-to-teacher ratios ranged from 2:1 to 8:1. Only two-thirds of courses offered in-vivo animal models. Instructions in microvascular end-to-end and end-to-side anastomoses were common, but peripheral nerve repair or free groin flap transfer were not consistently offered. Methods of assessment ranged from no formal assessment, where an instructor monitored and gave instant feedback, through immediate assessment of patency and critique on quality of repair, to delayed re-assessment of patency after a 12 to 24 hours period. Globally, training in microsurgery is heterogeneous, with variations primarily due to resource and regulation of animal experimentation. Despite some merit to diversity in curricula, there should be a global minimum standard for microsurgery training.
Animal Experimentation ; Curriculum ; Evaluation Studies as Topic ; Fellowships and Scholarships ; Groin ; Internet ; Microsurgery ; Models, Animal ; Peripheral Nerves