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J Reconstr Microsurg
DOI: 10.1055/a-2564-6762
Letter to the Editor

Twelve Commandments of Reconstructive Microsurgery

Dominik A. Walczak 
1   1st Department of Oncological Surgery with Subunit of Reconstructive and Plastic Surgery, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice, Gliwice, Poland
,
Daniel Bula 
1   1st Department of Oncological Surgery with Subunit of Reconstructive and Plastic Surgery, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice, Gliwice, Poland
,
Tommy Nai-Jen Chang
2   Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
,
Jakub Opyrchał
1   1st Department of Oncological Surgery with Subunit of Reconstructive and Plastic Surgery, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice, Gliwice, Poland
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Dear Editor,

A commandment, or a principle established by the highest authority, is traditionally associated with the Decalogue – the Ten Commandments that, according to Judeo–Christian faiths, were dictated by God to Moses on Mount Sinai. Today, we frequently create similar collections of aphorisms or rules aimed at conveying technical guidance, ways of thinking, or approaches to work/tasks. Every profession has its own “commandments.” For instance, electricians say, “Before you do anything, turn off the power.” Chefs remind us that “A little salt goes a long way.” Plastic surgeons often draw inspiration from the principles laid out by Ralph Millard.[1] These rules are highly universal, and many can be applied to microsurgery.

However, Millard's principles were developed in the 1950s—long before Jacobson and Suarez[2] performed the first microsurgical anastomosis. This is why we decided to create a collection of our own, specifically tailored to the unique demands and philosophy of reconstructive microsurgery.

To achieve this, we asked a Facebook group—the International Microsurgery Club (IMC),[3] [4] currently over 21,300 members—to contribute statements or aphorisms that could form part of such a “collection of commandments.” We received 48 submissions. In the next stage, these aphorisms were presented in a poll, also posted on the IMC forum. A total of 501 votes were cast.

We chose the most popular 12 ([Table 1]), as this number avoids an obvious reference to the original Decalogue and symbolizes completeness, perfection, and divine order in many cultures. Besides 12's use in the Bible (apostles, tribes of Israel, etc.), it is common in Ancient Greek, Hindu, and Islamic texts. What's more, 12/0 is the finest commercially available suture.

Table 1

Twelve commandments of reconstructive microsurgery

Commandment

Number of votes

Practice makes perfect. Patience makes progress.

56

Preparation is key. Stitch crafts only play a small part in the whole thing.

53

If the anastomosis does not look right, redo it.

40

When in doubt, take it back and re-explore.

31

If you are ever in doubt if something is working or not, the answer is: that it is not.

24

Pulsation must be seen before you leave. Don't leave the patient with a dead flap.

21

Do not prioritize arterial supply over venous drainage.

19

Never give up.

18

Plan and contingency plans. Don't burn the bridge early.

17

Passion keeps things going on and further. Life goes on after a flap dies. Party, play, and pray.

12

Posture and position mean steadiness. Have good hand support.

11

If you're not sure about flap viability, it's probably dead long ago!

11

We recognize that this is neither a definitive list nor the most brilliant ever created. However, it is likely the first of its kind, emerging as the result of voting by microsurgeons gathered in the largest online community of its type. This collection can serve as a foundation for the development of a more refined and sophisticated set of principles.

Sentences, aphorisms, and golden thoughts are how people organize knowledge, share experiences, and inspire both themselves and others. Their simplicity and universality make them tools that help us better understand the world, reflect on life, and sometimes even approach it with a smile.

In the case of microsurgery, these “commandments” combine practical wisdom, a philosophy of work, and a touch of humor—exactly what's needed in challenging professional situations.



Publication History

Received: 29 December 2024

Accepted: 12 March 2025

Accepted Manuscript online:
24 March 2025

Article published online:
22 April 2025

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