This article presents a comparison of microsurgical training of groups with different background. A protocol based on the rat femoral arterial anastomoses was used to provide an objective representation of the microsurgical skills progress. The performance is assessed by consistent (x4) patency of a standardized anastomosis. Three groups of beginner residents with progressive microsurgical experience and one group of experienced surgeons were observed. The patency curve of the beginner-groups was as an abrupt learning curve, and then a plateau was reached. There was no statistically significant difference in the patency rate between the beginner-groups after their first 32 anastomoses. No statistically significant difference was noted when the patency of the advanced group was compared with beginner-groups after different numbers of anastomoses (inverse proportional with their training experience). A slight or a plateau learning curve was found among the experienced group. The learning curve is a useful adjunct in the assessment of training.

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Glomus tumors are frequently associated with pain, tenderness and cold sensitivity. We report the diagnosis and successful surgical management of a case of a classic glomus tumor in a young woman. The clinical diagnosis was made on the basis of medical history and MRI findings. The lesion was excised via a dorsolateral subungual approach, leading to the complete resolution of symptoms. Histology confirmed the lesion to be a glomus tumor. Glomus tumors are painful subungual lesions. They produce a throbbing or lancinating local discomfort, cold-sensitivity, and severe pain following minor trauma. The diagnosis is confirmed by histology, but the clinical diagnosis is highly suggestive. Complete excision will usually relieve pain. Recurrence is common following incomplete resection.

Introduction: Despite hundreds of training models for microsurgery being available in the literature, very few of them are scientifically validated. We chose to validate our low-fidelity training model on flower petals by comparing it headto-head with a moderate fidelity training model, the anastomosis on chicken leg femoral artery. Materials and methods: A total of 16 participants of different levels of expertise were randomized into 2 groups, 1 training on flower petals and 1 on chicken leg femoral arteries. The groups were evaluated on performing a rat femoral artery anastomosis using the validated Stanford Microsurgical Assessment (SMaRT) Scale. The Mann-Whitney U test was used to check for statistically significant differences between the groups. The flower petal sutures were also evaluated and Pearson correlation was used to check for associations between better petal anastomosis scores and better final SMaRT results. Results: After 6 weeks of flower petal training, microsurgical trainees had significantly better overall SMaRT scores than trainees using chicken leg training, better fine tissue feeling, and better scores in knot tying. The anastomosis times for the rat femoral arteries did not differ between the 2 groups. Good scores for flower petals strongly correlated with a better SMaRT score for the anastomosis. The number of rats used in training reduced after the implementation of this model in continuous training. Conclusions: The flower petal technique, despite being a low-fidelity model, shows superiority in developing fine tissue feeling and improved knot tying in microsurgery beginners and intermediate level practitioners adding this training model to their program. Further research needs to establish if the improvements also apply to already seasoned microsurgeons and whether the petal score has predictive value for future clinical application.

A wealth of modifications of the original end-to-side technique 1 are described in the literature, but so far no human randomized study has shown the superiority of one technique over another. 2 To answer the needs of reduced time and increased efficiency, we devised the "double stitch everting technique." Leaving the needle in situ in the vessel wall in order to help with the tying of the final two knots, also known as the "modified Harashina procedure" has already been described. 3 For this technique, the two corner sutures are placed first. The needle is then inserted in order to perform the third knot and instead of deploying it on a surgical patty in the area of the anastomosis, as common in our practice, the needle is then reinserted parallel to the third knot, which is not yet tied and left in place (Fig. 1A).The knot is then tied in usual microsurgical fashion keeping in mind the eversion of the edges and intima-tointima contact. Care should be taken not to entangle the needle in the knot. The needle can be picked up and reinserted without difficulty in an optimal position inside the needle holder (Fig. 1B). We find that performing the sutures from left to right for right-handed people poses an advantage (Fig. 1C). The technique works just as well for fish-mouthed and nonfish-mouthed donor vessels.The double stitch everting seeks to accomplish several other objectives: shortening the time spent manipulating the needle, while ensuring wall eversion especially in venous anatomoses and improving symmetrical spacing and proper bite size.Further studies and validation in the rat femoral model are underway and are the subject of a large validation project. The double stitch everting technique Figure 1. The needle is inserted parallel to the previous stitch, for at least two-thirds of its length in order to reinforce the eversion of the vessel wall and aid in intima-to-intima contact (A). The anterior wall can be easily sutured (B) with regard to bite size and symmetrical placing of knots (C). Euromex StereoBlue Trino ZoomV C microscope at 15x magnification; 9-0 suture Ethilon, Ethicon, Johnson and JohnsonV C ; Muaranaka Medical Instruments Co., Ltd., Tokyo, Japan V C silicone elastic vessel 1.5 mm.