Journal Logo

Saturday, October 12, 2013

A Paradigm Shift in Microsurgical Fellowship Training

Revisiting the Learning Curve

Lee, Johnson C. MD; Agag, Richard MD; Lerman, Oren Z. MD; Kanchwala, Suhail MD; Sbitany, Hani MD; Au, Alexander MD; Topham, Neal S. MD; Serletti, Joseph M. MD

Plastic and Reconstructive Surgery: October 2013 - Volume 132 - Issue 4S-1 - p 38
doi: 10.1097/01.prs.0000435905.83203.7b
  • Free

INTRODUCTION: A microsurgeon’s success stems from the experience obtained during and after 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 by evaluating the outcomes of the first microsurgical cases from five microsurgery fellowship graduates.

METHODS: A review was performed of the microsurgical caseload completed by five surgeons at the University of Pennsylvania/Fox Chase Cancer Center Microsurgery Fellowship and MD Anderson Clinical Fellowship in Microvascular Reconstructive Surgery from 2008-2011. A prospectively collected, retrospective review was performed of 250 cases comprised of the first 50 microsurgical cases from each surgeon’s first year after training.

RESULTS: During fellowship, an average of 139 cases in 18 major groups were performed by each fellow: muscle-sparing transverse rectus abdominus musculocutaneous (MSTRAM) (40.4%), anterolateral thigh (ALT)(16.9%), deep inferior epigastric perforator (DIEP)(15.7%), radial forearm (RF)(6.9%), fibula (5.9%), latissimus (3.6%), transverse upper gracilis (1.7%), gracilis (1.6%), vertical rectus abdominus musculocutaneous (1.4%), scapula (1.3%), gluteal artery perforator (GAP)(0.9%), superficial inferior epigastric perforator (1.2%), jejenum (0.3%), lateral arm (0.3%), serratus (0.1%), vastus lateralis (0.1%), deep circumflex iliac artery (0.1%), and other types (1%). The first 250 microsurgical procedures after training included MSTRAM (47.6%), DIEP (26.4%), ALT (14%), fibula (3.6%), RF (3.2%), latissimus (1.6%), rectus (1.2%), GAP (1.2%), extremity replant (0.8%), and gracilis (0.4%). Overall complications occurred in 24.4% of patients: wound dehiscence (6.8%), infection (3.2%), fistula (2.4%), hematoma (1.2%), seroma (0.8%), fat necrosis (0.8%), pneumothorax (0.4%), and carotid blowout (0.4%). A second operation was required in 4.4%. Partial flap loss occurred in 1.6%. Total flap loss occurred in 2.8% for a success rate of 97.2%. 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 recent advancement in complexity, volume, and education in microsurgical training programs, we have shown that it is possible for current microsurgical fellowships to provide robust training with a sufficient amount of microsurgical exposure to produce outcomes comparable to those of experienced microsurgeons.


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
©2013American Society of Plastic Surgeons