Although operating times are long, the IGAP flap is robust, with no flap necrosis observed in this series.

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The national IR rate increased throughout the study period. Substantial regional variation remains, although considerable time has elapsed since a period of service reorganization, guideline revision and a national audit.

There has been a substantial increase in the use of immediate implant reconstruction in England. In comparison, there has been an increasing use of autologous free flap reconstruction for delayed procedures. Significant regional variation exists in the type of reconstruction performed, and these patterns need to be examined to determine if variation is related to service provision and/or capacity barriers.

With the prolific uptake of simulation-based training courses, this systematic review aims to identify the available microsurgical simulation and training models, their status of validation, associated studies, and levels of evidence (LoE) for each training model, thereby establishing a level of recommendation (LoR). MEDLINE, Embase, and the Cochrane Library databases were searched for English language articles, describing microsurgery simulators and/or validation studies. All studies were assessed for LoE, and each model was subsequently awarded a LoR using a modified Oxford Centre for Evidence-Based Medicine classification, adapted for education, with 1 being the highest and 4 the lowest score. A total of 86 studies were identified describing 64 models and simulators ranging from bench models, cadaveric animal tissue, cadaveric human tissue, live animal models, virtual reality simulators, and training curricula. Of these, 49 simulators had at least one validation study. Models were assessed for face (n = 42), content (n = 31), construct (n = 25), transfer (n = 10), and concurrent validity (n = 1) by these studies. The most commonly identified modality was bench models (n = 28) followed by cadaveric animal tissue (n = 24). The cryopreserved rat aorta model received the highest LoR followed by chicken wing, chicken thigh and practice cardboard models. Microsurgery simulation is a growing field and increasing numbers of models are being produced. However, there are still only a few validation studies with a high LoE. It is therefore imperative that training models and/or programs are evaluated for validity and efficacy in order to allow utilization in microsurgical skills acquisition.

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