A Paradigm Shift in Microsurgical Fellowship Training: Revisiting the Learning Curve

Introduction

A microsurgeon’s success stems from the experience obtained during and after their training. Prior studies have shown that early success rates after training are as low as 72% and rise to 96%-97% after sufficient experience has been gained.¹  Experienced surgeons are at the peak of their learning curve with fine-tuned individual technique and minimal complications.  With the increasing popularity of microsurgery and specialized high-volume training programs, we revisit the evolution of this learning curve and evaluate the early outcomes of free flap surgery performed by two recent microsurgery fellowship graduates.

Materials and Methods

A review was performed of the microsurgical caseload completed by two surgeons at the University of Pennsylvania/Fox Chase Cancer Center Microsurgery Fellowship in 2009-2010. A prospectively collected, retrospective review was then performed of the first 100 total microsurgical cases from Albany Medical Center and Lenox Hill Hospital from each of their first years after training. 

Results 

During fellowship, an average of 165 cases comprised of 13 major groups were performed by each fellow: muscle-sparing transverse rectus abdominus musculocutaneous (MSTRAM) (41.7%), deep inferior epigastric perforator (DIEP)(15.7%), anterolateral thigh  (ALT)(12.4%), radial forearm (RF)(5.7%), latissimus (4.5%), fibula (4.5%), vertical rectus abdominus musculocutaneous (3.0%), scapula (2.7%), gracilis (2.7%), transverse upper gracilis (2.4%), superficial inferior epigastric perforator (1.5%), gluteal artery perforator  (GAP)(0.9%), and other types (2.1%). The first 100 microsurgical procedures after training included DIEP (42%), ALT (18%), MSTRAM (16%), fibula (8%) RF (5%), rectus (3%), GAP (3%), latissimus (2%), gracilis (1%), ear replant (1%), and thumb replant (1%). Overall complications occurred in 22% of patients: wound infection (6%), fistula (4%), hematoma (3%), wound dehiscence (3%), seroma (2%), fat necrosis (2%), pneumothorax (1%), and carotid blowout (1%). A second operation was required in 5%. Partial flap loss occurred in 3%. Total flap loss occurred in 3% for a success rate of 97%. There is no significant difference (p>0.05) when compared to the 96% combined success rate of 23 expert microsurgeons reported by Khouri et al.²

Conclusion

With the recent progress in complexity, volume, and education in microsurgical training programs, we have shown that it is possible for a current microsurgical fellowship to provide a robust training environment with a sufficient amount of microsurgical exposure to produce outcomes comparable to those of experienced microsurgeons.