key: cord-0995486-th4gau5a authors: Higgins, GC; Thomson, SE; Baker, J; Honeyman, C; Kearns, M; Roberts, J; Tay, S title: COVID-19 lockdown and beyond: home practice solutions for develop-ing microsurgical skills. date: 2020-08-20 journal: J Plast Reconstr Aesthet Surg DOI: 10.1016/j.bjps.2020.08.033 sha: ecad4f8107083fe7d63280e2269da05bdd77587a doc_id: 995486 cord_uid: th4gau5a nan COVID-19 lockdown and beyond: home practice solutions for developing microsurgical skills. Higgins GC, Thomson SE, Baker J, Honeyman C, Kearns M, Roberts J, Tay S. Dear Editor, Current COVID-19 restrictions present significant challenges to Plastic Surgery training. Numerous obstacles exist; including the necessity for social distancing, global PPE shortages, virtual clinics decreasing trainee exposure to pathology, reduced face-to-face clinical teaching, and limited time in theatre 1). Furthermore, suspension of non-urgent elective reconstruction work, including breast reconstruction, limits microsurgical training opportunities. Surgical training relies on multiple sequential practice sessions, to allow deep encoding into "muscle memory"2), this is particularly relevant for microsurgery where fine motor skills need to be developed. The authors present multiple practical and cost-effective solutions that allow trainees to practice microsurgical techniques from home and "upskill anywhere". These practice options are transferrable to other periods away from clinical practice, including research time and maternity leave, and can also be used to supplement clinical experience during unpredictable on-call rotas. In climates of economic instability, these techniques may prove particularly beneficial. A basic microsurgical instrument kit may be purchased online from multiple platforms at a relatively low cost (e.g. AliExpress™, £34). The cost of microsurgical sutures can be a limiting factor to microsurgical practice (e.g. 9.0 AliExpress™, £0.93 each) and in the context of the COVID-19 pandemic, precarious supply chains necessitate preservation of resources. Luangjarmekorn et al. describe the use of human hair and insulin needles (BD Ultra-Fine Pen Needles 4 mm x 32G, expresschemist.co.uk, £0.13 each) to make homemade microsurgical sutures (Table 1) . Feedback from trainees in their study suggested that human hair sutures ( Figure 1 ) was a "good-excellent" standard for microsurgical practice, equal to that of standard sutures 3). This is reflected in our experience; we find that a hair of dark colour, mid length, coarse texture and wavy consistency works best. There are multiple models for microsurgical practice described in the literature, including live animal models (predominantly rats), non-live animal models such as chicken wings or thighs, pig leg, placenta vessels, and cold stored vessels. Additionally, a number of non animal models exist including, rubber glove, gauze, silicone tubing and fresh leaves. All have specific advantages and disadvantages 2). Many courses, including the Canniesburn Microsurgery Masterclass (https://www.nhsggc.org.uk/about-us/professional-support-sites/canniesburn-plastic-surgeryand-burns-unit/courses-at-canniesburn/microsurgical-workshop/) feature live animal models, which may better simulate real life microsurgery and allow testing of anastomosis patency and flow. A bag of saline infused with blue food colouring, running at a rate of 10 drops per minute, described by Zeng et al. may be considered as a method of anastomosis testing in other models 4). For home practice, the authors favour non animal models, due to ease of access, cost effective-ness, infection control and compliance with the "3R principles" in accordance with the National Centre for the Replacement, Reduction and Refinement of Animals in Research. We describe the use of a novel flower petal model (Figure 1 ) as it is readily available, requires meticulous handling and poses minimal environmental impact. Simple analysis scripts on open source image analysis software such as FIJI™ (Fiji.sc) can be utilised to analyse microsurgical suture placement. Another alternative model favoured by our group is the use of silicone tubing (Pocket Suture™, £9) or a MicroTrainer strip (DigitalSurgicalSkillsAcademy™). The key benefit of the MicroTrainer™ and accompanying software/app is that it provides objective assessment of accuracy of suture spacing, orientation and progress over time. This method is currently used in the RCSEd microsurgical skills course (https://www.rcsed.ac.uk/eventscourses/event-entry?diaryId=2712). In our department, we have been running supplementary microsurgery training sessions by senior trainees and consultants, using microscopes and screens to allow for social distancing. The use of social media, such as the International Microsurgery Club (Tang et al) can also provide peer learning and communication with experts in the microsurgical community, whilst working remotely 5). Therefore; there are many innovative, low-cost options for suture material, microsurgery models, and assessment of microsurgical skill progression. These solutions may be utilised to develop microsurgical skills during periods of remote working. Covid-19 Teaching Surgical Skills: What Kind of Practice Makes Perfect? A randomized Controlled Trial Do-it-yourself Microsuture from Human Hair for Microsurgical Training Blue-Blood" -Infused Chicken Thigh Training Model for Microsurgery and Supermicrosurgery International Microsurgery Club: An Effective Online Collaboration System Acknowledgements: All of the staff, past and present, of the Canniesburn Plastic Surgery and Burns unit, who are committed to delivering excellent microsurgical care for the benefit of their patients.