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Letters to the Editor - Year2014 - Volume29 - Issue 1

Dear Editor:

Ricardo Baroudi - Editor-in-Chief of the Brazilian Journal of Plastic Surgery

Concerning the article entitled "Practical model for microvascular anastomosis training"1 by Fraga et al., published in edition 27(2) of the Brazilian Journal of Plastic Surgery, we would like to add some information concerning the objective assessment of simulation-based microvascular surgical training.

Over the last few years, the Halstedian model of surgical training ("See one, do one, teach one") has been replaced with a methodology of simulation-based surgical skill development ("Do one, teach one")2. In this context, besides the remarkable commitment of several institutions toward the improvement of different bench models (or simulators) that enable the refinement of surgical skills, such as the model prepared with surgical pieces discarded from abdominoplasties, which is reported by the authors1, it is important to highlight the significance of assessing the simulated acquisition of surgical skills3.

In the Halstedian model, residents learn and train their skills with patients, under the supervision of a tutor, who subjectively determines the point when they had achieved technical proficiency3. Meanwhile, in surgical skill simulated teaching, tutor observation must follow fixed criteria (objective assessment)3. Therefore, surgical training programs must objectively assess the acquisition of technical skills of all those (e.g., resident physicians) in training3. Several tools have been described for this purpose3, and specific rating scales have been used for measuring microsurgical skills4-6, such as the Structured Assessment of Microsurgery Skills (SAMS)4, the University of Western Ontario Microsurgical Acquisition/Assessment (UWOMSA)5, and the Objective Structured Assessment of Technical Skills (OSATS), which have been adapted for the assessment of microvascular anastomosis6.

With such tools4-6, skill level can be assessed and shortcomings can be identified in order to provide feedback, with the aim of improving microsurgical training, both of individual skills (e.g., handling of surgical instruments, knots, and sutures) and complex procedures such as the preparation of microvascular anastomoses, which is described by the authors1. Toward this purpose and by using the aforementioned rating scales4-6, tutors may provide an objective assessment, during and at the end of the whole training process, for each specific microsurgical skill in order to measure the level of acquisition of the competencies taught and to monitor, during the subsequent sessions, the skill gain of resident physicians, always identifying the specific points that deserve greater attention among those assessed (variable according to the rating scale used4-6). This assessment may be performed in real time, or performances may be recorded for later assessment so that constructive feedback may be given without affecting results4,5.

We thank the authors for their contribution toward simulation-based microsurgical skill training.


1. Fraga MFP, Perin LF, Green AC, Zacarias R, Faes JC, Tenório T, et al.Modelo prático para treinamento de anastomose microvascular. Rev Bras Cir Plást. 2012;27(2):325-7.

2. Picarella EA, Simmons JD, Borman KR, Replogle WH, Mitchell ME. "Do one, teach one" the new paradigm in general surgery residency training. J Surg Educ. 2011;68(2):126-9.

3. Memon MA, Brigden D, Subramanya MS, Memon B. Assessing the surgeons technical skills: analysis of the available tools. Acad Med. 2010;85(5):869-80.

4. Chan W, Niranjan N, Ramakrishnan V. Structured assessment of microsurgery skills in the clinical setting. J Plast Reconstr Aesthet Surg. 2010;63(8):1329-34.

5. Temple CL, Ross DC. A new, validated instrument to evaluate competency in microsurgery: the University of Western Ontario Microsurgical Skills Acquisition/Assessment instrument. Plast Reconstr Surg. 2011;127(1):215-22.

6. Nimmons GL, Chang KE, Funk GF, Shonka DC, Pagedar NA. Validation of a task-specific scoring system for a microvascular surgery simulation model. Laryngoscope. 2012;122(10):2164-8.

1- MD - Aspiring Member in Training of the Brazilian Society of Plastic Surgery (SBCP), Resident Physician in Plastic Surgery of the Plastic Surgery Department "Prof. Dr. Cassio M. Raposo do Amaral," Craniofacial Plastic Surgery Institute, SOBRAPAR Hospital, Campinas, SP, Brazil
2- MD, PhD - Full Member of the Brazilian Society of Plastic Surgery (SBCP); Associate Professor at the Plastic Surgery Division, Department of Surgery, Faculty of Medicine, University of Marília (UNIMAR); and Lecturer of the Plastic Surgery Course, Faculty of Medicine of Marília (FAMEMA), Marília, São Paulo, Brazil

Institution: Plastic Surgery Division, Department of Surgery, Faculty of Medicine, University of Marília (UNIMAR), Marília, SP, Brazil.

Corresponding Author:
Rafael Denadai, M.D.
Paula Fabiana Tudela, 161 - Esmeralda
17516-707 Marília - São Paulo - Brazil
Phone / Fax +55 14 3453-5456

Article received: October 29, 2012
Article accepted: November 20, 2012


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