Objective: Health services in Latin America have witnessed continuous expansion, improving access for patients requiring treatment for trauma and cancer. However, while demand for complex reconstruction is on the rise, the number of trained microsurgeons remains limited. The aim of this study is to investigate current experiences of plastic surgery residents with regard to microsurgery. It also aims to find out ways through which the number of trained microsurgeons in the region can be increased for better medical care.
Methods: A cross-sectional survey was designed to obtain information regarding the exposure and training that plastic surgery residents receive during residency in Latin American countries. We ensured that our procedure followed the data protection rules laid down in the General Data Protection Regulation (GDPR).
Results: We requested 129 microsurgeons in Latin American countries to respond to our survey questions. A total of 93 survey responses were received, corresponding to a response rate of 72.1%. An analysis of the survey data showed that in terms of hands-on microsurgical training, 79.6% of the respondents had previous experience of being involved in performing a microsurgical procedure. However, 59.1% of the respondents mentioned that this was part of their formal training program. The majority of respondents (74%) reported that they would not be confident in performing a microsurgical procedure unsupervised. About half, or 48.4% of the respondents said that they would consider applying for a microsurgery fellowship. However, only 63.4% reported that they had access to a fellowship program in their home country.
Conclusion: Few resident plastic surgeons in Latin America are able to attain the required level of experience so as to feel comfortable acting as independent microsurgeons. Both time and effort are required to address this problem. A powerful tool to change this situation is to gain access to international microsurgical fellowships. An influx of returning trained microsurgeons can provide two benefits: (a) increasing the caseload in the short run, and (b) improving the training of plastic surgeons for future generations of doctors.
Microsurgery is a powerful tool in the reconstructive field, allowing free transfer of vascularized tissues to restore form and function. Strategies to train the next generation of microsurgeons have been studied in detail in literature [1,2]. However, to become competent, plastic surgery residents require exposure to microsurgical procedures, either simulated or in clinical settings. Microsurgery courses play a major role in the first steps of the learning curve for trainees to acquire skills. These skills can then be applied in the operating room under supervision. Previous studies have shown that the free flap success rate is directly correlated with surgical training and experience [3,4].
Over the last half century, health services in Latin America have sustained continuous expansion, improving access for patients requiring treatment for trauma and cancer. While demand for complex reconstruction is increasing in Latin America, the number of trained microsurgeons remains limited [5]. Despite reports that the area has a sufficient number of certified plastic surgeons, there are not many trained microsurgeons, and microsurgery procedures cannot be performed in all regions. A literature search shows that no previous study has looked into the training opportunities for microsurgery in Latin America. This study analyzes the present status and aims to find strategies to improve microsurgery training in the region.
A GDPR (General Data Protection Regulation) compliant, cross-sectional survey was designed to obtain information regarding the exposure and training that plastic surgery residents experience during residency in Latin American countries. This survey consisted of 15 questions including demographic information (Table 1). Senior residents and plastic surgeons who had completed their training within two years of the survey were approached to participate. The survey was voluntary and anonymous, and was distributed using the online survey platform, Jisc, United Kingdom. The respondents were from five countries: Argentina, Brazil, Chile, Mexico, and Uruguay. No compensation was offered to participants.
Data was extracted from the platform and collated in a Microsoft Excel spreadsheet. Descriptive and inferential statistics was performed using SPSS software 26.0. Fisher’s exact test was used to compare percentages obtained and results were significant at a P-value less than 0.05.
Surveys were distributed to eligible participants in five training centers in Argentina, five centers in Brazil, two in Chile, three in Mexico and two in Uruguay. A total of 93 survey responses were received, corresponding to a response rate of 72.1%. Forty-four percent of the survey responses were answered by residents and 56% by recently graduated plastic surgeons (Table 2). We organized the survey in three major sections: laboratory training, clinic training and post-residency training (Table 1).
In terms of microsurgical training during residency, 79.6% of the respondents said that they had been involved in performing part of a microsurgical procedure either in a clinical or simulated setting. However, for 59.1% of respondents, this was part of their formal training program. Of all participants, 51.6% had experience in microsurgical training with simulated non-living models and 49.5% with living models. In terms of clinical experience, 46.2% of the respondents had collaborated with a primary surgeon in at least one microsurgical procedure as a trainee. However, only 12.9% of them had performed more than 10 procedures.
From the questionnaires, it was evident that 96.8% of the respondents had observed at least one microsurgery procedure, while 90.3% had assisted in at least one operation. Of the surveyed trainees, 25.8% had scrubbed in more than 20 procedures (Figure 1).
Figure 1. The distribution of procedures with eligible participants observing (A), assisting (B), or performing them themselves (C). The results of the questionnaire reveal that 96.8% of the respondents have observed at least one microsurgery procedure. In addition, 90.3% have assisted in at least one microsurgery procedure based on their responses to the questionnaire. Of the surveyed trainees, 25.8% have scrubbed in more than 20 procedures.
The majority of respondents (74%) reported that they would not be confident in performing a microsurgical procedure unsupervised. Trainees who had some degree of training were more confident about this technique than the group that did not (P = 0.01).
When asked about the main limitations in microsurgical training, residents responded that there were not enough cases (22%), lack of experienced trainers (19%) and that cases in their unit were usually resolved without microsurgery (16%). Some 47.4% of the respondents reported being trained in units where there were no requirements of minimal logbooks for microsurgery.
The survey also showed that 48.4% of the respondents would consider applying to a microsurgery fellowship, but only 63.4% had access to a fellowship program in their home country. Among the trainees who expressed an interest in pursuing a career in microsurgery, a multiple-response question revealed that the main areas of interest were breast reconstruction (65%), limb reconstruction (58%), head and neck reconstruction (27%) and lymphedema surgery (14%).
Although there are many board-certified plastic surgeons in Latin America, microsurgery is not a commonly used procedure. We theorized that this was a result of lack of training opportunities during residency. This study sought to identify strategies to enhance microsurgery training by assessing its current status. Our study showed that only 46.2% of the surveyed Latin American plastic surgery residents had actually performed at least one microsurgical procedure as part of their residency. This figure is in stark contrast to the exposure gained by surgeons in other countries, most notably the USA, where microsurgery is an incorporated part of the curriculum. Mueller et al. evaluated different aspects of microsurgery training and found that 94% of the programs in the US had access to training microscopes for residents [6].
Our survey further showed that while 96.8% of respondents had observed at least one microsurgery throughout their training, just 25.8% had been involved in more than 20 procedures. While 90.3% of the respondents were able to scrub and assist, only 25.8% had done so in more than 20 operations.
An increased exposure of residents to microsurgeries would certainly be beneficial for such countries. Studies show that performing these complicated operations by residents under supervision has no significant impact on the percentage of complications that occur. They also demonstrate that basic lab microsurgery training can enable residents to work independently in the operating room with a low risk of complications [7,8].
Learning how to use a surgical microscope using non-living models is a useful method to practice and handle equipment, and to gain experience in micro suture procedures. It also gives students more confidence to practice on living models [9-11]. However, rat models are still essential for learning advanced techniques such as continuous stitching sutures, organ transplants, and working with vessels with a size discrepancy [12-17]. It is significant to mention that more than half of the respondents did not have access to simulated microsurgery during their residence, despite empirical evidence suggesting that surgeons with prior training perform better than those without [18,19]. For example, the United Kingdom stipulates that in order to qualify as a certified plastic surgeon, a trainee has to perform a minimum of 27 free tissue transfers as primary operator.
According to Maldonado and Song, microsurgery requires a high level of precision and development of exact skills. Hence it is essential that trainees should be gradually introduced to these procedures with the ultimate goal of gaining the ability of doing them independently and with repeatable results [20]. Numerous studies have shown that fellowships speed up the learning process, as they provide training in microsurgical reconstruction rather than focusing solely on the microsurgery technique [21].
A study by Ezra et al. showed that, regardless of their baseline ability level, all fellows improved over the course of the year, the overall skill gap closed dramatically, and almost all fellows were able to master microsurgery to a high level. Furthermore, fellows with lower initial assessments improved their technical abilities faster, whereas those with higher initial assessments improved their speed and efficiency the most [22]. According to studies, completing a fellowship not only enhances technical skills but also contributes to clinical decision-making, research, and dealing with experimental questions in microsurgery [23-25].
We believe that before performing microsurgical procedures on real patients, trainees should practice their abilities in the lab until they are proficient. Even though international opportunities and fellowships could benefit the field of microsurgery in Latin American countries, it is crucial to improve fundamental training to build a strong base. Without fundamental training, it is likely that residents would find it challenging to perform procedures in an international fellowship.
Further, fifty-four responders (58.1%) believed that one needs at least 25 flaps experience to become a skilled microsurgeon. This corresponds with Chan’s recommendation of an exposure of 10 to 25 microsurgery cases per year to maintain technical skills, with 25 to 50 cases per year rated "optimal" exposure [26]. Scholz showed that early-career microsurgery training, especially for medical students, helps in not only improving technical skills but also increases the number of microsurgeons in the field [27].
The field of microsurgery is constantly improving and expanding, with increased demand not only in specialized institutions but also in general hospitals [28]. The study presented here reveals the status of microsurgical training opportunities in Latin America. Few residents were able to gain the level of experience required to act as independent microsurgeons. We have identified three main reasons for this based on the following findings. To begin with, there is a lack of lab training that is available to residents. There is also the issue that there are not enough instructors to allow students to practice in operating rooms. The third issue is that there are not enough fellowship positions available in the field of microsurgery.
This study has several limitations as it is limited in its coverage. It does not cover all the residency programs or all of the countries in Latin America. Therefore, it is not representative of the entire area, despite the high response rate and getting responses from countries with the largest departments in the region.
There is ample room for improvement in microsurgical training in the region. It will take time and effort to address this problem. Increased opportunities in the operating room must be combined with mandatory microsurgery training as part of residency programs. Additionally, in our opinion, having access to foreign microsurgical fellows can be a potent weapon for reversing the current regional shortage. Fellowships allow local plastic surgeons to gain high-volume experience in a limited period of time. An influx of returning trained microsurgeons would allow increasing the caseload while improving the training of future generations of microsurgeons.
Received date: June 17, 2022
Accepted date: August 18, 2022
Published date: October 31, 2022
The manuscript has not been presented at any meetings on the topic.
The study is in accordance with the ethical standards of the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was exempted from review by the Institutional Review Board.
This research has received no specific grant from any funding agency either in the public, commercial, or not-for-profit sectors.
There are no conflicts of interest declared by either the authors or the contributors of this article, which is their intellectual property.
It should be noted that the opinions and statements expressed in this article are those of the respective author(s) and are not to be regarded as factual statements. These opinions and statements may not represent the views of their affiliated organizations, the publishing house, the editors, or any other reviewers since these are the sole opinion and statement of the author(s). The publisher does not guarantee or endorse any of the statements that are made by the manufacturer of any product discussed in this article, or any statements that are made by the author(s) in relation to the mentioned product.
© 2022 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY). In accordance with accepted academic practice, anyone may use, distribute, or reproduce this material, so long as the original author(s), the copyright holder(s), and the original publication of this journal are credited, and this publication is cited as the original. To the extent permitted by these terms and conditions of license, this material may not be compiled, distributed, or reproduced in any manner that is inconsistent with those terms and conditions.
The communication among international microsurgeons have switched from one direction (from paper, textbook) to multiway interactions through the internet. The authors believe the online platform will play an immensely important role in the learning and development in the field of microsurgery.
Traditionally, suturing techniques have been the mainstay for microvascular anastomoses, but owing to its technical difficulty and labour intensity, considerable work has gone into the development of sutureless microvascular anastomoses. In this review, the authors take a brief look at the developments of this technology through the years, with a focus on the more recent developments of laser-assisted vascular anastomoses, the unilink system, vascular closure staples, tissue adhesives, and magnets. Their working principles, with what has been found concerning their advantages and disadvantages are discussed.
Prof. Koushima, president of World Society for Reconstructive Microsurgery, proposes an innovative concept and technique of the multi-stage ‘Orochi’ combined flaps (sequential flaps in parallel). The technique opens a new vista in reconstructive microsurgery.
The video presents a useful technique for microvascular anastomosis in reconstructive surgery of the head and neck. It is advantageous to use this series of sutures when working with limited space, weak vessels (vessels irradiated, or with atheroclastic plaques), suturing in tension, or suturing smaller vessels (less than 0.8 cm in diameter).
Authors discuss a silicone tube that provides structural support to vessels throughout the entire precarious suturing process. This modification of the conventional microvascular anastomosis technique may facilitate initial skill acquisition using the rat model.
PEDs can be used as alternative means of magnification in microsurgery training considering that they are superior to surgical loupes in magnification, FOV and WD ranges, allowing greater operational versatility in microsurgical maneuvers, its behavior being closer to that of surgical microscopes in some optical characteristics. These devices have a lower cost than microscopes and some brands of surgical loupes, greater accessibility in the market and innovation plasticity through technological and physical applications and accessories with respect to classical magnification devices. Although PEDs own advanced technological features such as high-quality cameras and electronic loupes applications to improve the visualizations, it is important to continue the development of better technological applications and accessories for microsurgical practice, and additionally, it is important to produce evidence of its application at surgery room.
Avulsion injuries and replantation of the upper arm are particularly challenging in the field of traumatic microsurgery. At present, the functional recovery of the avulsion injuries upper arm after the replantation is generally not ideal enough, and there is no guideline for the surgeries. The aim of this study was to analyze the causes of failure of the upper arm replantation for avulsion injuries, summarize the upper arm replantation’s indications, and improve the replantation methods.
The supraclavicular flap has gained popularity in recent years as a reliable and easily harvested flap with occasional anatomical variations in the course of the pedicle. The study shows how the determination of the dominant pedicle may be aided with indocyanine green angiography. Additionally, the authors demonstrate how they convert a supraclavicular flap to a free flap if the dominant pedicle is unfavorable to a pedicled flap design.
The implications of rebound heparin hypercoagulability following cessation of therapy in microsurgery is unreported. In this article the authors report two cases of late digit circulatory compromise shortly after withdrawal of heparin therapy. The authors also propose potential consideration for changes in perioperative anticoagulation practice to reduce this risk.
In a cost-effective and portable way, a novel method was developed to assist trainees in spinal surgery to gain and develop microsurgery skills, which will increase self-confidence. Residents at a spine surgery center were assessed before and after training on the effectiveness of a simulation training model. The participants who used the training model completed the exercise in less than 22 minutes, but none could do it in less than 30 minutes previously. The research team created a comprehensive model to train junior surgeons advanced spine microsurgery skills. The article contains valuable information for readers.
The loupe plays a critical role in the microsurgeon's arsenal, helping to provide intricate details. In the absence of adequate subcutaneous fat, the prismatic lens of the spectacle model may exert enormous pressure on the delicate skin of the nasal bone. By developing a soft nasal support, the author has incorporated the principle of offloading into an elegant, simple yet brilliant innovation. A simple procedure such as this could prove invaluable for microsurgeons who suffer from nasal discoloration or pain as a result of prolonged use of prismatic loupes. With this technique, 42% of the pressure applied to the nose is reduced.
This retrospective study on the keystone design perforator island flap (KDPIF) reconstruction offers valuable insights and compelling reasons for readers to engage with the article. By sharing clinical experience and reporting outcomes, the study provides evidence of the efficacy and safety profile of KDPIF as a reconstructive technique for soft tissue defects. The findings highlight the versatility, simplicity, and favorable outcomes associated with KDPIF, making it an essential read for plastic surgeons and researchers in the field. Surgeons worldwide have shown substantial interest in KDPIF, and this study contributes to the expanding knowledge base, reinforcing its clinical significance. Moreover, the study's comprehensive analysis of various parameters, including flap survival rate, complications, donor site morbidity, and scar assessment, enhances the understanding of the procedure's outcomes and potential benefits. The insights garnered from this research not only validate the widespread adoption of KDPIF but also provide valuable guidance for optimizing soft tissue reconstruction in diverse clinical scenarios. For readers seeking to explore innovative reconstructive techniques and improve patient outcomes, this article offers valuable knowledge and practical insights.
This comprehensive review article presents a profound exploration of critical facets within the realm of microsurgery, challenging existing paradigms. Through meticulous examination, the authors illuminate the intricate world of microangiosomes, dissection planes, and the clinical relevance of anatomical structures. Central to this discourse is an exhaustive comparative analysis of dermal plexus flaps, meticulously dissecting the viability and potential grafting applications of subdermal versus deep-dermal plexi. Augmenting this intellectual voyage are detailed illustrations, guiding readers through the intricate microanatomy underlying skin and adjacent tissues. This synthesis of knowledge not only redefines existing microsurgical principles but also opens new frontiers. By unearthing novel perspectives on microangiosomes and dissection planes and by offering a comparative insight into dermal plexus flaps, this work reshapes the landscape of microsurgery. These elucidations, coupled with visual aids, equip practitioners with invaluable insights for practical integration, promising to propel the field of microsurgery to unprecedented heights.
This article presents a groundbreaking surgical approach for treating facial paralysis, focusing on the combination of the pronator quadratus muscle (PQM) and the radial forearm flap (RFF). It addresses the challenges in restoring facial functions and skin closure in paralysis cases. The study's novelty lies in its detailed examination of the PQM's vascular anatomy when combined with the RFF, a topic previously unexplored. Through meticulous dissections, it provides crucial anatomical insights essential for enhancing facial reanimation surgeries, offering significant benefits in medical practices related to facial reconstruction and nerve transfer techniques.
This article exemplifies a significant advancement in microsurgical techniques, highlighting the integration of robotic-assisted surgery into the deep inferior epigastric perforator (DIEP) flap procedure for breast reconstruction. It demonstrates how innovative robotic technology refines traditional methods, reducing the invasiveness of surgeries and potentially lessening postoperative complications like pain and herniation by minimizing the length of the fascial incision. This manuscript is pivotal for professionals in the medical field, especially those specializing in plastic surgery, as it provides a comprehensive overview of the operative techniques, benefits, and critical insights into successful implementation. Moreover, it underscores the importance of ongoing research and adaptation in surgical practices to enhance patient outcomes. The article serves as a must-read, not only for its immediate clinical implications but also for its role in setting the stage for future innovations in robotic-assisted microsurgery.
The groundbreaking study illuminates the complex mechanisms of nerve regeneration within fasciocutaneous flaps through meticulous neurohistological evaluation, setting a new benchmark in experimental microsurgery. It challenges existing paradigms by demonstrating the transformative potential of sensory neurorrhaphy in animal models, suggesting possible clinical applications. The data reveal a dynamic interplay of nerve recovery and degeneration, offering critical insights that could revolutionize trauma management and reconstructive techniques. By bridging experimental findings with hypothetical clinical scenarios, this article inspires continued innovation and research, aimed at enhancing the efficacy of flap surgeries in restoring function and sensation, thus profoundly impacting future therapeutic strategies.
The authors present a novel synthetic vascular model for microanastomosis training. This model is suitable for trainees with intermediate level of microsurgical skills, and useful as a bridging model between simple suturing exercise and in vivo rat vessel anastomosis during pre-clinical training.
Using a safe and controlled simulation environment, authors develop an effective and realistic oropharyngeal bleeding mass scenario that was well received by participants in preparing them for real life scenarios.
The review article presents an expansive list of otolaryngology-specific surgical simulation training models as described in Otolaryngology literature as well as evaluates recent advances in simulation training in Otolaryngology.
Authors discuss a silicone tube that provides structural support to vessels throughout the entire precarious suturing process. This modification of the conventional microvascular anastomosis technique may facilitate initial skill acquisition using the rat model.
PEDs can be used as alternative means of magnification in microsurgery training considering that they are superior to surgical loupes in magnification, FOV and WD ranges, allowing greater operational versatility in microsurgical maneuvers, its behavior being closer to that of surgical microscopes in some optical characteristics. These devices have a lower cost than microscopes and some brands of surgical loupes, greater accessibility in the market and innovation plasticity through technological and physical applications and accessories with respect to classical magnification devices. Although PEDs own advanced technological features such as high-quality cameras and electronic loupes applications to improve the visualizations, it is important to continue the development of better technological applications and accessories for microsurgical practice, and additionally, it is important to produce evidence of its application at surgery room.
In a cost-effective and portable way, a novel method was developed to assist trainees in spinal surgery to gain and develop microsurgery skills, which will increase self-confidence. Residents at a spine surgery center were assessed before and after training on the effectiveness of a simulation training model. The participants who used the training model completed the exercise in less than 22 minutes, but none could do it in less than 30 minutes previously. The research team created a comprehensive model to train junior surgeons advanced spine microsurgery skills. The article contains valuable information for readers.
Vizcay M, Troisi L, Navia A, Lopez A, Nicolas G, Miranda E, Pafitanis G, Berner JE. Microsurgery training in Latin America: A survey of residents’ experiences. Int Microsurg J. 2022;6(2):1. https://doi.org/10.24983/scitemed.imj.2022.00166
PDF