J Reconstr Microsurg
DOI: 10.1055/s-0039-1700558
Special Topic Issue: Reconstruction of the Lower Extremity
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The First Thousand Free Flaps are the Hardest

Geoffrey G. Hallock
1  Division of Plastic Surgery, St. Luke's Hospital, Sacred Heart Campus, Allentown, Pennsylvania
› Author Affiliations
Further Information

Publication History

19 August 2019

12 September 2019

Publication Date:
13 November 2019 (online)

All this will not be finished in the first hundred days. Nor will it be finished in the first thousand days … nor even perhaps in our lifetime … But let us begin.”[1] JFK, Inaugural Address, January 20, 1961.

In times gone by, the successful development of a private practice by a young plastic surgeon depended on their possession of “ability, affability, and availability” to which I cynically later added “appearance” as the fourth required “A”[2] in this era of social media. And “ability,” even long ago, seemed to be the least important attribute! Yet, as I previously stated in this journal,[3] to become a true microsurgeon demanded even more and perhaps the innate possession of the four P's—to be persistent, a perfectionist, always the pragmatist—while always having a touch of paranoia. Perfection we all know too well requires that every suture be placed with precision or risk a microanastomic catastrophe. The resultant seemingly tortuous trail that consequently always follows is reminiscent of the loneliness of the long-distance runner who only with perseverance will then insure that the finish line is crossed. And all this must be achieved using good judgment to sustain pragmatism by the realization that sometimes there is an unpredictable outcome that we cannot control no matter how hard we try. The pervasive cloud of insecurity from the fear of take-backs or worse if failure is a universal phenomenon, and may or may not be a unique personality disorder of us all; but if such paranoia is not an essential character trait of the microsurgeon, perhaps it should be.

Maybe it is again paranoia now on my part to question why would the editors want to know what are the challenges of lower extremity reconstruction for the solo private practitioner? Therefore, I will begin by recognizing that the latter term itself is rapidly becoming an anachronism as the overall number of solo private practice plastic surgeons in the United States has recently plummeted below 25%,[4] with most of those remaining probably just cosmetic surgeons. Increased medical liability, rising administrative costs, lack of institutional support, nonavailability of appropriate operating room time, and dwindling reimbursements[5] have irrefutably resulted in the rise of the hospitalist plastic surgeon who instead has become a captured employee.[6] Gone are the days when a “private practice” could be built from the ground up by starting in the emergency room, as the course of patient flow instead is now dictated by the insurance company or workman's compensation panels or diverted by hospital administrators as the “businessification” of medicine has overtaken us.[7]

So how could microsurgery have ever begun in a private practice setting? The answer partially can be found by perusing the advertising in the journals from that bygone era, which actually then advertised courses on “How to Start a Solo Plastic Surgical Practice.”[8] The compelling attraction was that all subject matter was fair game including explaining the “disadvantage of joining a clinic,”[8] much less a hospital. Also, at that time, microsurgery was in its infancy or almost stillborn. Just as a developing country today must encounter extreme impediments in starting a microsurgical program, even though the need for complex reconstructions may be omnipresent,[9] that fact alone often remains unrecognized or misunderstood by patient and provider alike. To overcome these roadblocks, teaching must be a prerequisite to spread the gospel, with ourselves included by “repetition, repetition, and then repetition” in our animal laboratory, which fortuitously for me had existed for other reasons. The advantage of youth, or some may say neophyte, in my trauma center brought the only valid interest or perhaps stamina for attempting these time consuming and difficult microsurgical cases. It was well recognized by all that the otherwise lack of interest included the anesthesiologists and nursing staff needed for both intra- and postoperative management, another challenge! We provided our own instruments, even including a microscope, finding all difficult to keep in working order due to the inattentiveness or even damage by personnel unfamiliar with reasonable protocols. Many of these detriments, unfortunately, have persisted even to this day in our financially strapped innercity hospital and remain a constant struggle.

Continuing medical education was then, as still now, another imperative requirement, demanding constant vicarious learning gained from the experiences of others written in our journals, so that our techniques and flap selections would evolve in concert as they did in the general plastic surgery community ([Fig. 1]). Vividly I remember well as a plastic surgery fellow that our usual solution for lower extremity soft tissue coverage was a cross-leg flap. Microsurgery, even by the novice proponent that I was, justified our becoming the obvious saviors for the otherwise suffering we had previously caused these individuals. By the 1980s, free muscle flaps such as the latissimus dorsi and gracilis flaps were our predominant choices[10] and admittedly still have a role.[11] Pontén's[12] fasciocutaneous flaps and Song et al's[13] anterolateral thigh (ALT) flap soon followed, and we grew with them. Wei et al[14] proselytized the ALT to be the “ideal soft tissue flap,” which was soon adopted by many including ourselves. We strongly believe that Koshima and Soeda[15] deserves the accolades for establishing perforator flaps as “mainstream”[16] and perhaps a better way to replace “like with like.” Now serving as both local and free cutaneous flaps, these have provided yet another alternative for solving the many and continued challenges of the lower extremity while better preserving muscle function and simultaneously obtaining a better aesthetic result even at the donor site.[17]

Zoom Image
Fig. 1 An historical overview of the evolution of the flap selection process for each traditional zone of the lower extremity, from the archaic random flap of the past to the local perforator flap today. (Reproduced with permission of Koh, K, Goh, TLH, Song, CT, et al. Free versus pedicled perforator flaps for lower extremity reconstruction: a multicenter comparison of institutional practices and outcomes. J Reconstr Microsurg 2018;34:572–580.)

With this experience recapitulated, I cannot avoid answering the pertinent question as to whether lower extremity reconstruction should be in the realm of the solo private practitioner today. Without hesitation, in general, except for the simplest challenges, that would be a mistake—and I am not being paranoid! We did not achieve our numbers in a few days, or a thousand days, nor have we stopped. We gave and still give our blood, sweat, and tears. But our numbers are paltry in comparison to international meccas like Chung Gung where a thousand can be a normal year's work[14] and not a lifetime, or a regional center like the University of Pennsylvania that performed 5,000 free flap procedures just in the last decade.[18] A superior approach to establish a microsurgical unit as outlined by the University of Pennsylvania is absolutely the right way. A culture to be successful necessitates a multifactorial approach, requiring the recruitment of an accomplished and diverse faculty, nurturing constant research including not just outcome studies, and fundamental support by their institution.[18] All are essential attributes if the incredibly low take-back rates of 1.53% and flap loss of 0.55% are to be expected, as the University of Pennsylvania has shown possible![18] In contrast, in our almost “country” private practice, I could never expect those outcomes as I am alone far from perfect, as our center admittedly lacks the necessary support system the University of Pennsylvania has proven necessary. My only consolation may be that once upon a time, our trauma center was the only available reliable option for microvascular tissue transfer present for three decades in Northeastern Pennsylvania! So we did serve a valuable purpose; but must be the first to recognize that as microsurgery continues to become ever more challenging, and resources are shrinking beyond our grasp, can I appropriately without change meet my goals first as a physician and then as a microsurgeon? Whether or not the solo individual has all the 4“A” and 4“P” attributes today is not as important as having the capability to work within a team whose system is what together assures the desired outcome for our patients, which always has been and should always be our ultimate objective.