LETTER TO THE EDITOR
MICROSURGERY 34:419–420 (2014)
A SURVEY OF MICROSURGERY TRAINING AMONG UK PLASTIC SURGERY AND MAXILLOFACIAL SURGERY TRAINEES Dear Editor,
Microsurgery
continues to be a fundamental technique in many surgical subspecialties. It is an integral part of several specialty programs, such as plastic surgery, vascular surgery, maxillofacial, and ENT surgery. The ultimate goal of every surgical training program is to produce competent professionals capable of meeting the healthcare needs of society.1 Our aim in this survey was to compare microsurgical experience among the two surgical subspecialty programs deemed to have the highest microvascular workloads; plastic and maxillofacial surgery. An online survey was developed, compromising 13 questions on microsurgery training, experience, and satisfaction. The survey was disseminated online through national trainee organizations and at trainee days. All trainees of all levels in all the deaneries (training regions) of the UK and Ireland were asked to complete the survey. Trainees not in a training program and junior trainees, such as core surgical trainees, were excluded. In this study, where the answers were for the number of procedures, the choices given were in categories; 1–3, 4–7, 8–10, 11–13, 14–17, 18–20, and more than 20 (Table 1). Seventy-seven responses were received. One trainee in a nontraining program and two others in the core surgery training program where excluded. Of the included 74 trainees, 34 (46%) were plastic surgery trainees and *Correspondence to: Ammar Allouni, MB.Bch, M.Sc., MRCS, Department of Plastic Surgery, University Hospital of North Durham, North Road, Durham DH1 5TW, UK. E-mail: [email protected] Received 13 February 2014; Revision accepted 9 March 2014; Accepted 11 March 2014 Published online 24 March 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22251 Ó 2014 Wiley Periodicals, Inc.
40 (54%) were maxillofacial trainees. Forty-seven percentage of the plastic trainees and 50% of the maxillofacial trainees were in the first 3 years of their training (ST 3–5). All the trainees have attended at least one microsurgical training course before or during their training period. Nine plastic surgery and six maxillofacial surgery trainees did not answer the question regarding happiness with their training program. Of the trainees who answered this question 15 of the plastic surgery group (60%) and nine (26%) of maxillofacial group were unhappy with the microsurgery training they are receiving. Overall 79% of the plastic surgery trainees and 75% of the maxillofacial surgery trainees said that they have assisted in more than 20 free flaps procedures (Table 1). The results also show that 59% of the plastic surgery trainees and 50% of the maxillofacial surgery trainees have assisted in microsurgery anastomosis. However, only 20% of the plastic surgery group and 27% of the maxillofacial group has actually performed microsurgical anastomosis. The commonest free flaps encountered during the period of plastic microsurgery training program are deep inferior epigastric perforator flap and transverse rectus abdominus myocutaneous flaps. Following this are the free radial forearm flap (RFF), anterolateral thigh (ALT) flap, and the free Latissimus Dorsi flap. These differ to maxillofacial training experience in this cohort who most commonly were exposed to RFF, fibular flap and the ALT Flap. Both plastic and maxillofacial surgery trainees felt they were competent raising the RFF (Table 2). Only 13 (38%) of the 34 plastic surgery trainees and 16 (40%) of the 40 maxillofacial surgery trainees feel
420
Letter to the Editor Table 1. Illustrating some results in the survey Number of surgical procedures divided into groups
How many free flaps assisted in No of free flaps you raised No of microvascular anastomosis assisted in No of microvascular anastomosis performed
P M P M P M P M
None
1–3
4–7
8–10
11–13
14–17
18–20
>20
– – 7 (20.6%) 6 (15%) – 2 (5%) 9 (22.5%) 8 (20%)
– – 10 (29.4%) 3 (7.5%) 4 (11.8%) 6 (15%) 5 (14.7%) 7 (17.5%)
3 (8.9%) 2 (5%) 7 (20.6%) 6 (15%) 1 (2.9%) 5 (12.5%) 9 (22.5%) 4 (10%)
1 (2.9%) 5 (12.5%) 4 (11.8%) 2 (5%) 1 (2.9%) 1 (2.5%) 2 (5.9%) 3 (7.5%)
1 (2.9%) 1 (2.5%) 2 (5.9%) 4 (10%) 4 (11.8%) 2 (5%) 0 5 (12.5%)
– 2 (5%) 1 (2.9%) 4 (10%) 1 (2.9%) 2 (5%) 1 (2.9%) 2 (5%)
2 (5.9%) – – 1 (2.5%) 3 (8.9%) 2 (5%) 1(2.9%) 0
27 (79.4%) 30 (75%) 3 (8.8%) 14 (35%) 20 (58.8%) 20 (50%) 7 (20.6%) 11 (27.5%)
These percentages calculated based on that total P (plastic surgery training trainees 5 34 and total M (Maxillofacial surgery training trainees 5 40.
Table 2. Illustrating types of free flaps raised and free flaps trainees are competent raising without supervision Type of flap Types of raised free flap by respondents No of respondents competent raising alone without supervision
P M P M
TRAM/DIEP
Free Radial Forearm Flap
Free Latissimus Dorsi flap
Deep circumflex iliac artery flap
Anterolateral thigh flap
Free fibula
22 3 14 2
17 37 17 32
17 8 14 6
4 18 2 6
17 20 10 10
2 30 0 16
P: Plastic surgery training trainees, M: Maxillofacial surgery Training trainees.
comfortable to perform microvascular anastomosis without supervision. No free text reasons were provided. Of all the 74 respondents, only seven (9%) said that there are microsurgery fellows in the department, who compete with them to perform microsurgical procedures, which they felt limited opportunities. This survey demonstrates that plastic and maxillofacial trainees have a similar exposure to microsurgery. There are fewer maxillofacial trainees and there has been a perception this may increase exposure to microsurgery. Although a small proportion of trainees completed this survey, this perception is not supported. With the introduction of the new intercollegiate curriculum it may be useful to concentrate microsurgical training in high volume units to ensure competence is developed and maintained. Changes to training in recent years may mean that dedicated microsurgery fellowships will provide a platform to build on microsurgery experience in the earlier years of training.
Microsurgery DOI 10.1002/micr
AMMAR ALLOUNI, MB.Bch, M.Sc., MRCS* Department of Plastic Surgery University Hospital of North Durham, Durham DH1 5TW, UK JONATHAN DUNNE, MB.Bch, MRCS Department of Plastic Surgery St George’s Hospital, London THOMAS COLLIN, M.B.B.S., FRCS (Plast) Department of Plastic Surgery University Hospital of North Durham, Durham DH1 5TW, UK DANIEL SALEH, MB ChB, FRCS (Plast) Department of Plastic Surgery Castle Hill Hospital, UK
REFERENCE 1. Chan WY, Srinivasan JR, Ramakrishnan VV. Microsurgery training today and future. J Plast Reconstr Aesthetic Surg 2010;63:1061–1063.
MICROSURGERY 34:419–420 (2014)
A SURVEY OF MICROSURGERY TRAINING AMONG UK PLASTIC SURGERY AND MAXILLOFACIAL SURGERY TRAINEES Dear Editor,
Microsurgery
continues to be a fundamental technique in many surgical subspecialties. It is an integral part of several specialty programs, such as plastic surgery, vascular surgery, maxillofacial, and ENT surgery. The ultimate goal of every surgical training program is to produce competent professionals capable of meeting the healthcare needs of society.1 Our aim in this survey was to compare microsurgical experience among the two surgical subspecialty programs deemed to have the highest microvascular workloads; plastic and maxillofacial surgery. An online survey was developed, compromising 13 questions on microsurgery training, experience, and satisfaction. The survey was disseminated online through national trainee organizations and at trainee days. All trainees of all levels in all the deaneries (training regions) of the UK and Ireland were asked to complete the survey. Trainees not in a training program and junior trainees, such as core surgical trainees, were excluded. In this study, where the answers were for the number of procedures, the choices given were in categories; 1–3, 4–7, 8–10, 11–13, 14–17, 18–20, and more than 20 (Table 1). Seventy-seven responses were received. One trainee in a nontraining program and two others in the core surgery training program where excluded. Of the included 74 trainees, 34 (46%) were plastic surgery trainees and *Correspondence to: Ammar Allouni, MB.Bch, M.Sc., MRCS, Department of Plastic Surgery, University Hospital of North Durham, North Road, Durham DH1 5TW, UK. E-mail: [email protected] Received 13 February 2014; Revision accepted 9 March 2014; Accepted 11 March 2014 Published online 24 March 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22251 Ó 2014 Wiley Periodicals, Inc.
40 (54%) were maxillofacial trainees. Forty-seven percentage of the plastic trainees and 50% of the maxillofacial trainees were in the first 3 years of their training (ST 3–5). All the trainees have attended at least one microsurgical training course before or during their training period. Nine plastic surgery and six maxillofacial surgery trainees did not answer the question regarding happiness with their training program. Of the trainees who answered this question 15 of the plastic surgery group (60%) and nine (26%) of maxillofacial group were unhappy with the microsurgery training they are receiving. Overall 79% of the plastic surgery trainees and 75% of the maxillofacial surgery trainees said that they have assisted in more than 20 free flaps procedures (Table 1). The results also show that 59% of the plastic surgery trainees and 50% of the maxillofacial surgery trainees have assisted in microsurgery anastomosis. However, only 20% of the plastic surgery group and 27% of the maxillofacial group has actually performed microsurgical anastomosis. The commonest free flaps encountered during the period of plastic microsurgery training program are deep inferior epigastric perforator flap and transverse rectus abdominus myocutaneous flaps. Following this are the free radial forearm flap (RFF), anterolateral thigh (ALT) flap, and the free Latissimus Dorsi flap. These differ to maxillofacial training experience in this cohort who most commonly were exposed to RFF, fibular flap and the ALT Flap. Both plastic and maxillofacial surgery trainees felt they were competent raising the RFF (Table 2). Only 13 (38%) of the 34 plastic surgery trainees and 16 (40%) of the 40 maxillofacial surgery trainees feel
420
Letter to the Editor Table 1. Illustrating some results in the survey Number of surgical procedures divided into groups
How many free flaps assisted in No of free flaps you raised No of microvascular anastomosis assisted in No of microvascular anastomosis performed
P M P M P M P M
None
1–3
4–7
8–10
11–13
14–17
18–20
>20
– – 7 (20.6%) 6 (15%) – 2 (5%) 9 (22.5%) 8 (20%)
– – 10 (29.4%) 3 (7.5%) 4 (11.8%) 6 (15%) 5 (14.7%) 7 (17.5%)
3 (8.9%) 2 (5%) 7 (20.6%) 6 (15%) 1 (2.9%) 5 (12.5%) 9 (22.5%) 4 (10%)
1 (2.9%) 5 (12.5%) 4 (11.8%) 2 (5%) 1 (2.9%) 1 (2.5%) 2 (5.9%) 3 (7.5%)
1 (2.9%) 1 (2.5%) 2 (5.9%) 4 (10%) 4 (11.8%) 2 (5%) 0 5 (12.5%)
– 2 (5%) 1 (2.9%) 4 (10%) 1 (2.9%) 2 (5%) 1 (2.9%) 2 (5%)
2 (5.9%) – – 1 (2.5%) 3 (8.9%) 2 (5%) 1(2.9%) 0
27 (79.4%) 30 (75%) 3 (8.8%) 14 (35%) 20 (58.8%) 20 (50%) 7 (20.6%) 11 (27.5%)
These percentages calculated based on that total P (plastic surgery training trainees 5 34 and total M (Maxillofacial surgery training trainees 5 40.
Table 2. Illustrating types of free flaps raised and free flaps trainees are competent raising without supervision Type of flap Types of raised free flap by respondents No of respondents competent raising alone without supervision
P M P M
TRAM/DIEP
Free Radial Forearm Flap
Free Latissimus Dorsi flap
Deep circumflex iliac artery flap
Anterolateral thigh flap
Free fibula
22 3 14 2
17 37 17 32
17 8 14 6
4 18 2 6
17 20 10 10
2 30 0 16
P: Plastic surgery training trainees, M: Maxillofacial surgery Training trainees.
comfortable to perform microvascular anastomosis without supervision. No free text reasons were provided. Of all the 74 respondents, only seven (9%) said that there are microsurgery fellows in the department, who compete with them to perform microsurgical procedures, which they felt limited opportunities. This survey demonstrates that plastic and maxillofacial trainees have a similar exposure to microsurgery. There are fewer maxillofacial trainees and there has been a perception this may increase exposure to microsurgery. Although a small proportion of trainees completed this survey, this perception is not supported. With the introduction of the new intercollegiate curriculum it may be useful to concentrate microsurgical training in high volume units to ensure competence is developed and maintained. Changes to training in recent years may mean that dedicated microsurgery fellowships will provide a platform to build on microsurgery experience in the earlier years of training.
Microsurgery DOI 10.1002/micr
AMMAR ALLOUNI, MB.Bch, M.Sc., MRCS* Department of Plastic Surgery University Hospital of North Durham, Durham DH1 5TW, UK JONATHAN DUNNE, MB.Bch, MRCS Department of Plastic Surgery St George’s Hospital, London THOMAS COLLIN, M.B.B.S., FRCS (Plast) Department of Plastic Surgery University Hospital of North Durham, Durham DH1 5TW, UK DANIEL SALEH, MB ChB, FRCS (Plast) Department of Plastic Surgery Castle Hill Hospital, UK
REFERENCE 1. Chan WY, Srinivasan JR, Ramakrishnan VV. Microsurgery training today and future. J Plast Reconstr Aesthetic Surg 2010;63:1061–1063.
