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Introduction Female genital mutilation (FGM) includes all procedures that involve partial or total removal of the female external genitalia or any other injury of the female genitalia that is performed for nonmedical reasons. FGM is classified into 4 types. Surgical clitoral reconstruction was first described by Thabet and Thabet in Egypt and subsequently by Foldes in France. The technique was then modified by different authors. Aim This article aims to provide a detailed description of clitoral surgical reconstruction and the modifications which have been made over time to improve the procedure while recalling current knowledge in the anatomy of the clitoris. Methods We performed a broad systematic search in PubMed/Medline and EMBASE bibliographic databases for studies that report the surgical technique of clitoral reconstruction. From the anatomical point of view, we examined available evidence (from 1950 until 2020) related to clitoral anatomy, the clitoral role in sexual functioning, female genital mutilation/cutting, and surgical implications for the clitoris. Main Outcomes A review of the surgical techniques for clitoral reconstruction after female genital mutilation/cutting Results We described the current anatomical knowledge about the clitoris, and the procedures based on the surgical technique by Pierre Foldes, We included the technical modifications and contributions described in articles published subsequently. Conclusion Surgical repair of the clitoris for FGM offers anatomical and functional results although they still have to be evaluated. However, it should not be the only therapeutic solution offered to women with FGM. Botter C, Sawan D, SidAhmed-Mezi M, et al. Clitoral Reconstructive Surgery After Female Genital Mutilation/Cutting: Anatomy, Technical Innovations and Updates of the Initial Technique. J Sex Med 2021;18:996–1008.

Although direct exposure to procedures in the operating theater environment, together with practice on laboratory animals, is still seen as the gold standard of teaching in microsurgery, practice on nonliving simulators is currently being validated as an important educational tool. We reviewed the widely used nonliving training models, together with currently accepted innovations, which are parts of curricula of training courses in microsurgery. Using the experience accumulated in training programs at the Centre for Simulation and Training in Surgery, we identified which particular skills can be reliably targeted by each nonliving tissue exercise. We were able to find five groups of nonliving training models: basic manipulation, knot-tying principles, completing the anastomosis, the real tissue experience, and training in virtual reality. The more abstract models might seem quite far from the real life experience, but they each closely address specific skills. It thus becomes convenient for the instructor to train these skills separately. This generates series of consistently favorable results once the skills are integrated into a more complex procedure. Focused exercises, once assembled in continuity, reconstruct the real life scenario. The training program can comprise a series of increasingly difficult exercises, which mirror the real life situations. Performance on nonliving models in each progressively more challenging exercise can be assessed via direct observation, assisted by clear and objective criteria. Finally, focused training will help both the transition to human surgery and replication of the favorable results to large series of subjects.

Thirty-five years after Brescia et al. (N Engl J Med 275:1089-1092, 1966) realized the first peripheral autogenous arteriovenous fistula, the "Achilles' heel" of chronic dialysis is still the absence of a good-quality permanent vascular access. The number of patients depending on hemodialysis is increasing. Until 10 years ago, in Romania, there was a need to treat isolated critical cases. Nowadays, every dialysis center needs algorithms for a standardized approach, adaptable for each case. We reviewed 171 consecutive arteriovenous fistulas (132 patients) performed in adults in identical standard conditions: use of an inflatable tourniquet during the vascular dissection, microsurgical techniques, and use of only autogenous tissues. We analyzed our results, the technical difficulties encountered, and their management in long-term follow-up. The aim of this study was to set up the basic principles of our algorithms. Our approach, based on our education as plastic surgeons involved in hand surgery and microsurgery, might present the advantage of sparing renal patients vascular capital.

Standard magnification in microsurgery is accomplished with the operating microscope. Loupes are perceived by the microsurgical community as technically less safe. However, after several years of microscope-only microsurgery, most of our microvascular procedures are performed under loupes 3.5-4x. Considering our results using loupes-only microsurgery, which are comparable with those obtained when using the microscope, we suggest that loupe-aided microsurgery might represent a natural progression for the experienced microsurgeon. Microsurgical skills and experience outweigh the importance of the magnification factor. While the microscope is mandatory for replantations distal to the palmary arch, microneurosurgery, and supramicrosurgery, loupes should be used in so-called "macro-microsurgery." One may include in this category replantations down to the palmar arch and free flaps with vessels more than 1.5 mm, such as the latissimus, serratus, (para)scapular, fibula, radial forearm, rectus abdominis, dorsalis pedis, omentum, and jejunum. Before starting loupes-only microsurgery, intensive training under the microscope is crucial. Less magnification does not mean less quality.