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A Paradigm Shift in Microsurgical Fellowship Training: Revisiting the Learning Curve
Johnson C. Lee, M.D.1, Stephanie Lopez, M.D.1, Richard Agag, MD1, Oren Z. Lerman, MD2, Suhail Kanchwala, MD3, Neal S. Topham, MD4, Joseph M. Serletti, MD3.
1Albany Medical College, Albany, NY, USA, 2Lenox Hill Hospital, New York, NY, USA, 3University of Pennsylvania, Philadelphia, PA, USA, 4Fox Chase Cancer Center, Philadelphia, PA, USA.

Background:
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 three recent microsurgery fellowship graduates.
Methods:
A review was performed of the microsurgical caseload completed by two surgeons in microsurgery fellowships at the University of Pennsylvania/Fox Chase Cancer Center in 2009-2010 and one surgeon at the MD Anderson Cancer Center in 2008-2009. A prospectively collected, retrospective review was then performed of the first 50 total microsurgical cases from each surgeon in their first year after training.
Results:
During fellowship, an average of 141 cases comprised of 14 major groups were performed by each fellow: muscle-sparing transverse rectus abdominus musculocutaneous (MSTRAM) (30.7%), anterolateral thigh (ALT)(24.1%), deep inferior epigastric perforator (DIEP)(12.8%), radial forearm (RF)(8.2%), latissimus (4.3%), fibula (7%), vertical rectus abdominus musculocutaneous (2.3%), gluteal artery perforator (GAP)(2.3%), scapula (1.9%), gracilis (1.9%), transverse upper gracilis (1.6%), superficial inferior epigastric perforator (0.8%), jejunum (0.8%) and other types (1.2%). The first 150 microsurgical procedures after training included MSTRAM (36.7%), DIEP (30.7%), ALT (16.7%), fibula (5.3%) RF (3.3%), rectus (2%), GAP (2%), latissimus (2.7%), gracilis (0.7%), ear replant (0.7%), and thumb replant (0.7%). Overall complications occurred in 20% of patients: seroma (4.7%), wound infection (4%), hematoma (3.3%), fistula (2.7%), wound dehiscence (2.7%), fat necrosis (1.3%), pneumothorax (0.7%), and carotid blowout (0.7%). A second operation was required in 4.7%. Partial flap loss occurred in 3.3%. Total flap loss occurred in 2% for a success rate of 98%. 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.
Reference Citations:
1. Khouri RK. Avoiding free flap failure . Clin Plast Surg . 1992;;19:773-781.
2. Khouri RK, Cooley BC, Kunselman AR, Landis JR, Yeramian P, Ingram D, Natarajan N, Benes CO, Wallemark C. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg. 1998 Sep;102(3):711-21.


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