Original Article 233

Anastomosis Lapse Index (ALI): A Validated End

Product Assessment Tool for Simulation
Microsurgery Training
Ali M. Ghanem, MRCS, MD, PhD1 Yasser Al Omran, BSc (Hons)1 Bashar Shatta, MD, MRCS1
Eunsol Kim, BSc (Hons), MBBS1 Simon Myers, MBBS, FRCS (Plast), PhD1

1 Academic Plastic Surgery Group, Barts and The London School of Address for correspondence Ali M. Ghanem, MRCS, MD, PHD,
Medicine and Dentistry, London, United Kingdom Academic Plastic Surgery Group, Centre for Cutaneous Research,
Blizard Institute, Barts and The London School of Medicine and
J Reconstr Microsurg 2016;32:233–241. Dentistry, London, United Kingdom (e-mail: a.ghanem@qmul.ac.uk).

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Abstract Background Over the last decade, simulation has become a principal training method
in microsurgery. With an increasing move toward the use of nonliving models, there is a
need to develop methods for assessment of microvascular anastomosis skill acquisition
substituting traditional patency rate. The authors present and validate a novel method
of microvascular anastomosis assessment tool for formative and summative skills
competency assessment.
Methods In this study, 29 trainees with varying levels of experience in microsurgery
undertook a 5-day microsurgery course. Two consecutive end-to-end microvascular
anastomoses of cryopreserved rat aortas performed on day 3 and day 5 of the course
were longitudinally split and photographed for randomized blinded qualitative evalua-
tion. Four consecutive anastomoses by two experienced microsurgeons were analyzed
as expert controls. Errors potentially leading to anastomotic leak or thrombosis were
identified and logged. Statistical analysis using the Kruskal–Wallis analysis of variance
(ANOVA) and a two-way repeated measure ANOVA was used to measure construct and
concurrent validity, respectively.
Results A total of 128 microvascular anastomoses were analyzed for both student and
control groups. Ten errors were identified and indexed. There was a statistically
significant difference detected between average errors per anastomosis performed
Keywords between groups (p < 0.05). Average errors per anastomosis was statistically decreased
► microsurgery on day 5 of the course compared with day 3 (p < 0.001).
► education Conclusion Evaluation of anastomosis structural patency and quality in nonliving
► educational models is possible. The proposed error list showed construct and predictive validity. The
intervention anastomosis lapse index can serve as a formative and summative assessment tool during
► technique microvascular training.

“See one, do one, teach one!” For years, this has been the
axiom of the “Halstedian” apprenticeship model; a model
that has been used widely in postgraduate surgical train-
ing.1 It involves giving trainees “increased responsibility,”
until they can perform the operation unassisted; it forms
the way in which many of today’s surgeons have acquired
their technical skill and flourished into competent
surgeons. With surgical training programs witnessing
increasing pressures to reduce clinical training hours, the
Halstedian model is becoming less feasible and is being

received Copyright © 2016 by Thieme Medical DOI http://dx.doi.org/

March 31, 2015 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0035-1568157.
accepted after revision New York, NY 10001, USA. ISSN 0743-684X.
October 1, 2015 Tel: +1(212) 584-4662.
published online
December 8, 2015
234 Anastomosis Lapse Index Ghanem et al.

superseded by competency-based surgical teaching with

variable reliance on nonclinical simulation environments
worldwide.2 Microvascular anastomosis involves surgery of
small vessels down to less than 1 mm in diameter. This
technique is now widely employed by many surgical
specialties, including those relating to plastic and recon-
structive surgery.3,4 The refined movements, precision, and
stamina microsurgery require make it technically
challenging, and as a result, it is associated with a very
steep learning curve. 5,6 The development of competency-
based curriculum in microsurgical simulation training
would facilitate optimum training and patient safety.
Many courses have been developed with both didactic
and practical components to equip surgical trainees with

principles of microsurgical techniques.7 At the end of these
courses, participants are awarded a “certificate of comple-
tion” as oppose to a “certificate of competence.”3,6 In high-
fidelity live animal model courses, assessment of microvas-
cular anastomosis success is easily quantifiable by means of
patency rate.8 These courses are both expensive and may be
ethically questionable when used for early training in
microsurgery.1 For beginner trainees, simulated low-
fidelity microvascular models can be as effective as higher
fidelity ones.9 Nonetheless, nonliving low-fidelity models
courses, although more distributed globally, lack the value
of feedback on skill levels when compared with live high-
fidelity models courses.7 To address this gap, a
feedback system for nonliving low-fidelity models courses
is required.
The aim of this study was to develop a simple valid
objective and low cost assessment method that can
serve as formative and summative evaluation index of
microvascular anastomosis skill level in both living and
nonliving simulation training environments.
Methods
Following Institution Review Board approval, informed
consent from students and postgraduate trainees who
registered to take part in the 5-day basic microsurgical
training course at Queen Mary, University of London was
obtained to participate in this study. Two microsurgery
educators who organize and instruct on established micro-
surgery courses with extensive experience in experimental
microsurgery were recruited to form a positive expert control
(EC) group. All participants completed a questionnaire
detailing previous microsurgical experience and their current
level of training, and were placed into distinct cohorts.
A low-fidelity, cryopreserved rat aorta model was used for
the purpose of this study.7 With the exception of the ECs, each
participant performed four end-to-end microvascular anasto-
moses using standard microsurgery set and 9/0 nylon suture;
two anastomoses were performed on each assessment day (day
3 and day 5 of the course) using both biangulation and triangu-
lation techniques (►Fig. 1). Each EC performed six end-to-end
anastomoses on the same cryopreserved rat aorta model using
their preferred technique. Three of the six anastomoses per-
formed by the ECs were undertaken at one time point, followed
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Fig. 1 Schematic diagrams showing (A) biangulation and (B) trian-
gulation techniques.
by a 2-day delay before completing the other set of three
(to match the assessment environment of the other candidates).
Upon completion of each anastomosis, the cryopreserved
rat aorta was cut longitudinally to view the intimal side and
was photographed at
25 magnification. Anastomosis photo-
graphs were randomized using MS Excel random number
generator. Two expert reviewers, blinded to the participant’s
identity and sequence of the anastomosis, analyzed the
photographs and identified all anastomosis errors. Identified
errors were further reviewed and indexed, and their
association with the participant’s level of training (pretest)
and course progress (posttest) was assessed.
Validity Assessment
In broad terms, validity refers to the extent of which an
assessment tool can measure what it aims to evaluate.10 In the
context of microsurgery skills’ evaluation, the assessment
tool is required to measure not only skill level but
also changes occurring in these levels as a result of training
(skill acquisition) and/or pattern of practice and continuous
development (skills’ maintenance and loss).
Two types of validity were assessed, predictive validity and
construct validity. Predictive validity evaluates the extent to
which an assessment tool can detect future performance. In
the context of this study, this parameter was used to evaluate
the change in the levels of competence as a result of training.
Construct validity evaluates whether an assessment tool can
consistently identify with theoretical concepts. In this case,

Journal of Reconstructive Microsurgery Vol. 32 No. 3/2016

 Anastomosis Lapse Index Ghanem et al. 235

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Fig. 2 (A) Images demonstrating an error free anastomosis, (B) an anastomosis with multiple errors, and (C–L) anastomoses highlighting the 10
identified errors: (C) Error 1: Disruption of the anastomosis line (dotted line) created by the opposed vessel ends. (D) Error 2: Inadvertently
catching the back- or sidewall when taking suture bites (white arrows) causing occlusion of the lumen. (E) Error 3: Placing of an oblique stitch
(white arrow) causing tissue distortion. (F) Error 4: Taking too wide a bite (white arrow) that causes tissue infoldment. (G) Error 5: Placing of a
stitch that does not go through the full thickness of the vessel (partial thickness stitch: white arrow), allowing some of the intimal layer to conceal a
part of the stitch. (H) Error 6: Unequal distancing of sutures (between parallel lines) that is more than twice what is expected. (I) Error 7: Causing a
visible tear in the vessel wall (white arrow. (J) Error 8: Excessively tight suture (white arrow) that strangulates the tissue. (K) Error 9: Threads left in
the lumen (white arrow). (L) Error 10: Allowing for a large edge overlap (white arrow).

Journal of Reconstructive Microsurgery Vol. 32 No. 3/2016

236 Anastomosis Lapse Index Ghanem et al.
whether it can distinguish the participant with more micro-
surgical experience from that with less experience.
To determine predictive validity, the average errors per
anastomosis identified on day 3 and day 5 of each participant
were compared using a two-way analysis of variance (ANOVA)
with repeated measures, followed by the post hoc Bonferroni
test for multiple comparisons. Average errors per anastomo-
sis of experts’ first two anastomosis were compared with the
following set performed 2 days later. To explore construct
validity, a Kruskal–Wallis ANOVA was used to evaluate the
average errors per anastomosis of the different cohorts
followed by the Dunn multiple comparison test. The use of
each of these statistical tests was validated with a Shapiro–
Wilk test for normality, and with Levene test for homogeneity
of variance. Results are presented as the mean  standard
deviation, and statistical significance was assumed when
differences were at p < 0.05.
Results
In all, 31 participants were recruited into the study: 11 were
medical students (MS), 9 were basic surgical trainees (BSTs), 9
were higher surgical trainees (HSTs), and 2 were ECs.
Anastomosis Lapse Index Errors Identification
A total of 128 anastomoses were analyzed. Ten anastomosis
errors were identified and these were indexed in the anasto-
mosis lapse index (ALI) error list (►Fig. 2). These errors were
disruptions of the anastomosis line; back wall catches; obli-
que stitches that cause distortion; wide bites causing tissue
Fig. 3 Frequency of errors from all anastomoses examined. Black, high frequency; gray, medium frequency; white, low frequency.
Journal of Reconstructive Microsurgery Vol. 32 No. 3/2016
enfoldment; partial thickness stitches; vessel tears or cheese
wiring; a large (more than twice the average distance)
interstitch gap, tight stitches causing tissue strangulation;
suture thread protrusion in lumen; and finally, large edge
overlaps. The frequency of these errors varied with distortion
of the anastomosis line being the most commonly identified
error and catching the back-wall being the least
identified. ►Fig. 3 presents a summary of error distribution
within the study sample.
Validity Assessment
Construct validity was significantly demonstrated by com-
paring the average total errors per anastomosis between
the study cohorts on two time points (day 3 and day 5 of the
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course for the trainees) of the 5-day training course
(►Fig. 4). On day 3 of the course and using the first
time point of the expert group, the average error per
anastomosis made by the various cohorts varied signifi-
cantly. This ranged from 7.4  1.0 and 7.1  1.3 errors per
anastomosis for the MSs and BSTs down to 5.4  1.2 and
2.0  2.5 for the HSTs and ECs cohorts. This variability in
average error per anastomosis continued until the end of
the course (day 5 for the trainees compared with the later
time point of the expert group) with the EC cohort making
less errors compared with the trainees group (2.5  1.6
error per anastomosis for experts vs. 3.8  1.0, 3.9  0.7,
3.5  1.0 error per anastomosis for MS, BSTs, and HSTs,
respectively). The variability in errors per anastomosis
made by different cohorts at their respective later time
point was not statistically significant.

Fig. 4 The average total errors per anastomosis on day 3 and day 5
between the groups were evaluated individually. (A) On day 3, a
statistical significance was seen between medical students and higher
surgical trainees (p ¼ 0.031), medical students and expert controls
(p ¼ 0.019), and basic surgical trainees and expert controls ( p
¼ 0.047). (B) On day 5, there was no statistically significant difference
between the groups.
By exploring this significant variability through post hoc
tests, the average error per anastomosis was found to depend
on the level of expertise with the EC cohort making signifi-
cantly less number of errors compared with the MSs and BSTs
(p ¼ 0.019 and 0.047, respectively). Similarly, the senior
trainees cohort (HSTs) made significantly less number of
errors per anastomosis compared with the MS cohort
(p ¼ 0.031; ►Fig. 4).
Predicative validity was assessed by comparing the aver-
age errors per anastomosis made by each cohort on different
time points (day 3 and day 5 of the 5-day training course for
the trainees and two different time points for the EC cohort).
The MSs’ average number of errors per anastomosis fell from
Anastomosis Lapse Index Ghanem et al. 237
7.4  1.0 on day 3 to 3.8  1.0 on day 5. A similar significant
reduction in errors made was also observed in the other
trainee cohorts of basic and HSTs with average numbers of
errors per anastomosis reducing from 7.1  1.3 to 3.9  0.7
for BSTs and from 5.4  1.2 to 3.5  1.0 for HSTs. The reduc-
tion in average error per anastomosis between day 3 and
day 5 within the trainee groups was statistically significant
(p < 0.0001; ►Fig. 5).
For the EC cohort, the average number of errors per
anastomosis for the earlier set of four consecutive anastomo-
ses performed in the first time point was 2.0  2.5. In the later
set of four consecutive anastomoses performed, the average
number of errors per anastomosis was 2.5  1.6. There was
no statistically significant difference between the two sets
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(►Fig. 5).
Discussion
From replantation of amputated parts,11 microsurgery has
evolved to facilitate free tissue transfer for wound and defect
reconstruction, and recently, total composite tissue allotrans-
plantation of hand and face.12,13 As evidenced in this study,
and in others,5,6,14 success in microsurgery requires extensive
range of technical skills that are associated with a steep
learning curve.3
In modern times, many microsurgical simulation models
and educational interventions have been developed to facili-
tate assessment and development of proficiency in the bundle
of technical skills contained in microsurgery.3,9,15 The aim is
to place trainees in an environment that replicates, as much as
possible, experiences to be encountered in the operating
room. Therefore, microsurgery training and assessment mod-
els can be categorized into higher or lower fidelity according
to how close to reality they are able to recreate the training
environment.
At the beginning of trainees learning curve, low-fidelity
models are usually used to practice the basic skills of micro-
surgery including instruments handling and suturing of latex
gloves, simple polyurethane cards,16 and silicone tubing.17 As
trainees skills advance and the trainee has conceptualized,
the general principles of microsurgery higher fidelity models
are then introduced in advanced courses that allow in vivo
live practice on live animal models such as anesthetized rats
or other larger mammals.9 High-fidelity models not only have
the advantage of recreating a realistic training environment
simulating all aspects of in vivo microvascular anastomosis
but also present an excellent feedback and assessment system
in which both the trainees and their trainers can evaluate
the outcome of skills acquisition when the end product—the
anastomosis—flows or fails.
However, higher fidelity models present significant chal-
lenges to microsurgery education because of the ethical and
logistical issues they raise, lack of evidence supporting their
use,9 or even justification as a valid educational interven-
tions.18 Therefore, low-fidelity ex vivo models, such as
chicken legs, porcine coronary arteries, and cryoprotected
rat aortas remain the most common training model used
in basic microsurgery courses worldwide.7 However,
Journal of Reconstructive Microsurgery Vol. 32 No. 3/2016
238 Anastomosis Lapse Index Ghanem et al.
Fig. 5 The average errors per anastomosis of each group on day 3 were compared with those in day 5, except in the expert control whereby the
average errors for the first three anastomoses were compared with the second three anastomoses. Asterisks indicate significance within groups,
between the two time points. All apart from the expert controls show statistical significance between the time points (p < 0.0001).
other models have been developed and may be soon
introduced.19–21
The aim of this study was to devise and validate a nonliving
microsurgery tool that can be used to evaluate and quantify
skill levels in the early stages of microsurgery training for the
purpose of formative and summative assessment. For this
purpose, we used a cryoprotected rat aorta model as it
represents an example of popular nonliving vessels models
commonly used in basic microsurgery courses.7 By opening
the vessel at the end of the procedure and examining the
regularity and structural architecture of the end product, we
were able to assess microsurgical skill through the identifi-
cation of 10 anastomotic errors. The rationale behind the
identification of these particular errors was based from one
end on the current end product assessment components
present in most of microsurgery global rating scales.3,4
From the other, it was based on the stipulation that such
an error may lead to anastomotic failure such as leaking or
thrombosis. Whether or not these identified errors have face
validity to be considered a true measure of in vivo anasto-
motic patency rate and/or microsurgery skill requires further
investigation as “the actual training device, system, simulator,
or curriculum requires an assessment of its own value for
effectiveness.”2
Nevertheless, to evaluate the validity of this identified
10-error list, the average errors per anastomosis of the
participants were compared among a group of operators at
various stages of their surgical training to see if the findings
exhibits construct validity. The distribution of errors
committed between the various cohorts of these operators
varied significantly on the third day of a 5-day microsur-
gery training course where novice MSs and BSTs were at a
relatively early stage of their skills learning curves.
Operators with greater microsurgery experience made
Journal of Reconstructive Microsurgery Vol. 32 No. 3/2016
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less numbers of errors and performed better than those
with less experience (construct validity).
Furthermore, following the level of skill as evaluated by
this 10-error list from the third day of a basic microsurgery
course to the fifth day, we observe significant
improvement in the performance of trainee operators. In
contrast, the cohort of expert did not demonstrate any
significant change of such level compared at two different
time points.
The system continued to show a relationship between
the level of experience of the operator and average number
of errors per anastomosis made with the MS making the
largest number of errors per anastomosis on the final day of
the course and the experts maintaining their position as the
ones with least number of errors. However, the statistically
significant variance in performance was not demonstrated
at the end of the 5-day basic surgical course indicating both
the advantage of this system in demonstrating skill acqui-
sition as far as anastomosis architecture as well as its
limitation to this context only (anastomosis architecture)
as we know already that the level of novice operators would
not have reached that of their more senior counterparts at
the end of 5-day course.
Another advantage of this method in the assessment of
basic microsurgery skills lies in its simplicity and availability.
A common problem with microsurgical training courses is
that competency is not formerly assessed. Although trainees
receive guidance and feedback throughout the course, their
level of microsurgical competency is not usually formally
assessed and the student receive a certificate of attendance or
completion of the course rather than a measure of their
skill at the end of the course.3 Criteria-based observations
and global rating scales (GRSs) can provide a valid means
of assessing microsurgical competency Grober et al22

Fig. 6 The anastomosis lapse index (ALI) assessment tool.
(modified later by Atkins et al23) and was the first GRSs
adapted for the assessment of microsurgical skills. GRSs
incorporate several important outcome measures such as
tissue and instrument handling, time and hand motions,
and are graded on a Likert scale.
The principal disadvantage of GRSs use in this regard is
their time consuming and relatively complex requirements of
special equipment (e.g., video recording for blinded assess-
ment, monitor display) as well as the presence of a trained
reviewer provide feedback on the trainees’ performance.
Anastomosis Lapse Index Ghanem et al. 239
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Thus, GRSs represent a labor-intensive method that may
not be simply and readily available to enhance learning and
feedback in conventional 5-day courses.
Hand motion analysis presents a solution to some of the
challenges associated with GRSs. However, despite excellent
construct, concurrent, and predictive validity, hand motion
analysis was not popularized globally due to its own set of
disadvantages not to mention its prohibiting costs.3 Another
simpler alternatives to assess microsurgical skill are still to be
found.
Journal of Reconstructive Microsurgery Vol. 32 No. 3/2016
240 Anastomosis Lapse Index Ghanem et al.
Based on the principles of cognitive psychology,
Kaufman et al24 noted that mastery of a technical skill is
achieved in three critical stages: cognitive, associative, and
autonomous. The cognitive stage refers to the understanding
and development of skill, the association stage relates to
repetition and practice to the point where the autonomous
stage is reached, whereby performance of the skill no longer
requires external cognitive intervention. The error list used in
this study addresses the cognitive stage of the three-step
process to proficiency. By supplementing the guidance and
feedback with this error index measure, course tutors may
provide participants with a more conceptualized under-
standing of the errors they performed, and more importantly
how they may improve. This will, in theory, prime partic-
ipants for the associative stage of skill development and
reduce the steepness of their learning curve.
Therefore, the 10-error list is a simple, readily available
tool that demonstrated very good construct and concurrent
validity when used to evaluate the skill required to produce a
structurally sound anastomoses at early stages of microsur-
gery training. On this basis, the use of this index at this stage
for the purpose of feedback tool to aid learning and/or
facilitate assessment can be justified. To facilitate this, a
specific assessment tool was generated by combining the
10-error identified in a card named the ALI.
ALI provides a pictorial representation of each error and
a simple index to refer to the level of competency achieved
(►Fig. 6). We have demonstrated earlier that deliberate
practice is one of the most important tenets of a compe-
tency-based curriculum in microsurgery.9 By using ALI
during basic microsurgery training in either ex vivo or
live animal models, participants can easily identify and
learn from their errors upon evaluation of the lumen of
their anastomosis with or without the aid of a more senior
trainer. This may lead to a focused error-centered
deliberate practice that may lead to avoiding errors made
earlier in a competency-based accelerated learning.
Despite the potential benefit that this study may pro-
vide, it is not without some limitations. First, this study did
not evaluate whether this index does indeed facilitate
reduced anastomotic errors, and although in theory it
should it is an important criteria that needs to be investi-
gated. Second, concurrent validity, that is, the extent to
which an assessment tool correlates with the “gold stan-
dard” was only determined by means of level of pre-
existing microsurgery skill. It will be important to correlate
ALI to other “gold standards” of microsurgery skill indica-
tors such as vessel patency, flap survival, or even hand
motion analysis.3 Furthermore, although predictive validi-
ty was assessed by assuming increased skill at day 5 versus
day 3 of a 5-day microsurgery course, this assumption is a
semiquantitative tool that cannot replace trainer judgment
or objective assessment.
Finally, ALI’s assessment deals with one set of param-
eters (errors performed and identified in the finished
product of an end-to-end microvascular anastomosis)
and does not take into account other parameters of micro-
surgery skills such as tissue handling, pedicle dissection,
Journal of Reconstructive Microsurgery Vol. 32 No. 3/2016
hand movements, and time to complete the anastomosis.
These parameters are very important indicators of micro-
surgery skills at an advanced level that cannot be
ignored.3,25,26 ALI is an end product assessment tool of
early microsurgery skill and it should not be generalized or
assumed to extend beyond this limited use. Thus, for a
comprehensive trainees’ formative and summative
feedback, it is important to couple the ALI tool with other
validated methods such as skills GRS and hand motion
analysis. Further educational research will be necessary
to address these limitations.
Conclusion
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ALI is a simple low-fidelity training model feedback system
developed and validated for the teaching and assessment of
early microsurgery skills. This system has good construct
and predictive validity and has the potential to provide
semiquantitative immediate feedback on microsurgery
skill’s level and its development. Its simplicity
and availability may facilitate early microsurgery
training and positively contribute to trainees’ learning
experience.
Funding
This study was funded by STeLI London Deanery.
Note
This article was presented in the XII Congress of the
European Federation of Societies for Microsurgery Barce-
lona, Spain, April 3–5, 2014.
References
1 Reznick RK, MacRae H. Teaching surgical skills—changes in the
wind. N Engl J Med 2006;355(25):2664–2669
2 Tsuda S, Scott D, Doyle J, Jones DB. Surgical skills training and
simulation. Curr Probl Surg 2009;46(4):271–370
3 Ramachandran S, Ghanem AM, Myers SR. Assessment of micro-
surgery competency-where are we now? Microsurgery 2013;
33(5):406–415
4 Temple CL, Ross DC. A new, validated instrument to evaluate
competency in microsurgery: the University of Western
Ontario Microsurgical Skills Acquisition/Assessment instru-
ment [outcomes article]. Plast Reconstr Surg 2011;127(1):
215–222
5 Chan WY, Srinivasan JR, Ramakrishnan VV. Microsurgery training
today and future. J Plast Reconstr Aesthet Surg 2010;63(6):
1061–1063
6 Lascar I, Totir D, Cinca A, et al. Training program and learning curve
in experimental microsurgery during the residency in plastic
surgery. Microsurgery 2007;27(4):263–267
7 Leung CC, Ghanem AM, Tos P, Ionac M, Froschauer S, Myers SR.
Towards a global understanding and standardisation of educa-
tion and training in microsurgery. Arch Plast Surg 2013;40(4):
304–311
8 Starkes JL, Payk I, Hodges NJ. Developing a standardized test for the
assessment of suturing skill in novice microsurgeons. Microsur-
gery 1998;18(1):19–22

9 Ghanem AM, Hachach-Haram N, Leung CC, Myers SR. A systematic
review of evidence for education and training interventions in
microsurgery. Arch Plast Surg 2013;40(4):312–319
10 McDougall EM. Validation of surgical simulators. J Endourol 2007;
21(3):244–247
11 Kleinert HE, Tsai TM. Microvascular repair in replantation. Clin
Orthop Relat Res 1978;(133):205–211
12 Dorafshar AH, Bojovic B, Christy MR, et al. Total face, double jaw,
and tongue transplantation: an evolutionary concept. Plast Re-
constr Surg 2013;131(2):241–251
13 Holmes WJ, Williams A, Everitt KJ, Kay SP, Bourke G. Cross-over
limb replantation: a case report. J Plast Reconstr Aesthet Surg
2013;66(10):1428–1431
14 Hui KC, Zhang F, Shaw WW, et al. Learning curve of microvascular
venous anastomosis: a never ending struggle? Microsurgery 2000;
20(1):22–24
15 Singh M, Ziolkowski N, Ramachandran S, Myers SR, Ghanem AM.
Development of a five-day basic microsurgery simulation training
course: a cost analysis. Arch Plast Surg 2014;41(3):213–217
16 Usón J, Calles MC. Design of a new suture practice card for
microsurgical training. Microsurgery 2002;22(8):324–328
17 Weber D, Moser N, Rösslein R. A synthetic model for microsurgical
training: a surgical contribution to reduce the number of animal
experiments. Eur J Pediatr Surg 1997;7(4):204–206
18 Grober ED, Hamstra SJ, Wanzel KR, et al. The educational impact of
bench model fidelity on the acquisition of technical skill: the use of
Anastomosis Lapse Index Ghanem et al. 241
clinically relevant outcome measures. Ann Surg 2004;240(2):
374–381
19 Bates BJ, Wimalawansa SM, Monson B, Rymer MC, Shapiro R,
Johnson RM. A simple cost-effective method of microsurgical
simulation training: the turkey wing model. J Reconstr Microsurg
2013;29(9):615–618
20 Sener S, Menovsky T, Maas AI. Use of bubble wrap for microsurgi-
cal training. J Reconstr Microsurg 2013;29(9):635–636
21 Nam SM, Shin HS, Kim YB, Park ES, Choi CY. Microsurgical training
with porcine thigh infusion model. J Reconstr Microsurg 2013;
29(5):303–306
22 Grober ED, Hamstra SJ, Wanzel KR, et al. Validation of novel and
objective measures of microsurgical skill: Hand-motion analysis
and stereoscopic visual acuity. Microsurgery 2003;23(4):317–322
23 Atkins JL, Kalu PU, Lannon DA, Green CJ, Butler PE. Training in
microsurgical skills: Does course-based learning deliver? Micro-
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
surgery 2005;25(6):481–485
24 Kaufman HH, Wiegand RL, Tunick RH. Teaching surgeons to
operate—principles of psychomotor skills training. Acta Neurochir
(Wien) 1987;87(1–2):1–7
25 Moulton CA, Dubrowski A, Macrae H, Graham B, Grober E, Reznick
R. Teaching surgical skills: what kind of practice makes perfect?: a
randomized, controlled trial Ann Surg 2006;244(3):400–409
26 Ilie V, Ilie V, Ghetu N, Popescu S, Grosu O, Pieptu D. Assessment of
the microsurgical skills: 30 minutes versus 2 weeks patency.
Microsurgery 2007;27(5):451–454
Journal of Reconstructive Microsurgery Vol. 32 No. 3/2016