Complete avulsion of the nose is a devastating injury that may result in permanent disfigurement. Microvascular reattachment is technically difficult due to small size of the injured vessels, associated avulsion or crush injury, and relative inability to achieve venous anastomosis. This report describes a successful case of microsurgical replantation of the distal third of the nose in a 47-year-old patient after a dog bite injury with the use of a superficial temporal vein graft for arterial repair and leeching for venous outflow. The recovery was uneventful with total survival of the replant noted except for marginal skin necrosis, which healed by secondary intention. There was no need for any transfusion. The authors found that use of the superficial temporal vein for arterial revascularization was efficient and convenient as it was in the same surgical field, offering a favorable donor site scar in the preauricular sulcus. Microsurgical replantation should be attempted whenever feasible in cases of complete nose amputation.

Sir: As surgical education evolves toward more outcome-based measures, methods for objective and accurate evaluation of residents will be increasingly necessary.1 In microsurgical education, there is currently no standardized method of training and evaluation; however, global rating scale assessment instruments have been validated.2 These require senior microsurgeons to grade live or video-recorded operations performed by residents in simulation laboratories. Recent Plastic and Reconstructive Surgery Viewpoints have discussed software tools that facilitate assessment by simultaneously displaying recorded video and the evaluation form to be completed.3 Smartphone coupling to microscopes or other optical instruments has been used in pathology, ophthalmology, dermatology, and hematology, and for global health and teleconsultation. Although photography is commonplace is plastic surgery, the literature includes few applications of smartphone cameras, such as an app for postoperative free flap perfusion monitoring.4 The senior author (M.A.) has previously experimented with consumer digital cameras in microstructural photography.5 We present a simplified and cost-effective method for video recording of microsurgical operations using a smartphone's high definition camera coupled to an operating microscope. During the annual microsurgery training course at our institution, we experimented with coupling smartphones to an operating microscope with an additional monocular viewing eyepiece (Fig. 1). After developing prototype adapters, which were functional albeit cumbersome, we discovered the many commercially available adapters for this purpose. We selected the Snapzoom (HI Resolution Enterprises, Honolulu, Hawaii) adapter because it is low cost, universally adjusts to different phone models with or without a protective case, and is designed to attach to either binocular or monocular eyepieces in the widescreen mode. Once positioned properly, the smartphone camera recorded high-quality video while displaying video on the screen (Fig. 2). (SeeVideo, Video Supplemental Digital Content 1, which demonstrates a rat femoral artery anastomosis recorded using a smartphone coupled to an operating microscope. The quality has been reduced to ease online access; however, the original quality is high-definition 1080p video, https://links.lww.com/PRS/B287.) It was possible to broadcast live video to a computer using video-sharing programs such as Skype (a division of Microsoft Corp., Redmond, Wash.). Typically, a black rim was visible, even when properly positioned, which could be easily removed by digital zoom on a camera app.Fig. 1: Smartphone (iPhone; Apple, Inc., Cupertino, Calif.) attached to Snapzoom adapter, coupled to a monocular third viewing eyepiece, displaying and recording residents performing a rat femoral vessel anastomosis.Fig. 2: A single frame from video captured using a smartphone (iPhone) during a rat end-to-end femoral artery anastomosis demonstrates the high quality and clarity of video output possible using this technique.Video: Supplemental Digital Content 1 demonstrates a rat femoral artery anastomosis recorded using a smartphone coupled to an operating microscope. The quality has been reduced to ease online access; however, the original quality is high-definition 1080p video, https://links.lww.com/PRS/B287.As smartphones with high-definition cameras are ubiquitous among plastic surgery trainees and faculty, this method presents an affordable alternative to expensive clinical-grade video solutions for the recording of microsurgical simulations. Multiple adapters can be used for recording multiple residents simultaneously. Disadvantages of this method include limited storage space on many consumer smartphones and that, unless a third eyepiece is available (Fig. 1), the second microscope eyepiece must be used for the camera instead of by an assistant. Future developments should focus on directly recording video to a networked location where it can easily be stored, accessed, and evaluated by attending surgeons. In conclusion, a simple and affordable smartphone method for capturing high-definition video recordings of microsurgery training operations is presented. Access to recorded video is essential for microsurgical education, allowing later review and evaluation with previously described assessment tools.2,3 Methods that are simple, cost-effective, and validated will enable surgical training programs to easily implement competency-based curricula designed to objectively evaluate resident aptitude in performing simulation exercises. DISCLOSURE This work was funded by the University of Massachusetts Division of Plastic Surgery as part of the annual microsurgery course. The authors have no financial disclosures or commercial associations that might create a conflict of interest related to this communication, including the following products mentioned: Snapzoom smartphone-microscope adapter, Apple iPhone, and the Skype program. Dylan Perry, B.A. Mark Albert, M.D. Mustafa Akyurek, M.D., Ph.D. Division of Plastic Surgery Department of Surgery University of Massachusetts Medical School Worcester, Mass.