Intraoperative Microvascular Complications in Autologous Breast Reconstruction: The Effects of Resident Training on Microsurgical Outcomes
Background Academic medical centers with large volumes of autologous breast reconstruction afford residents hand-on educational experience in microsurgical techniques. We present our experience with autologous reconstruction (deep inferior epigastric perforators, profunda artery perforator, lumbar artery perforator, bipedicled, and stacked) where a supervised trainee completed the microvascular anastomosis.
Methods Retrospective chart review was performed on 413 flaps (190 patients) with microvascular anastomoses performed by postgraduate year (PGY)-4, PGY-5, PGY-6, PGY-7 (microsurgery fellow), or attending physician (AP). Comorbidities, intra-operative complications, revisions, operative time, ischemia time, return to operating room (OR), and flap losses were compared between training levels.
Results Age and all comorbidities were equivalent between groups. Total operative time was highest for the AP group. Flap ischemia time, return to OR, and intraoperative complication were equivalent between groups. Percentage of flaps requiring at least one revision of the original anastomosis was significantly higher in PGY-4 and AP than in microsurgical fellows: PGY-4 (16%), PGY-5 (12%), PGY-6 (7%), PGY-7 (2.1%), and AP (16%), p = 0.041. Rates of flap loss were equivalent between groups, with overall flap loss between all groups 2/413 (<1%).
Conclusion With regard to flap loss and microsurgical vessel compromise, lower PGYs did not significantly worsen surgical outcomes for patients. AP had the longest total operative time, likely due to flap selection bias. PGY-4 and AP groups had higher rates of revision of original anastomosis compared with PGY-7, though ultimately these differences did not impact overall operative time, complication rate, or flap losses. Hands-on supervised microsurgical education appears to be both safe for patients, and also an effective way of building technical proficiency in plastic surgery residents.
* These authors should be considered as first authors.
Received: 20 April 2020
Accepted: 26 July 2020
06 September 2020 (online)
Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.
- 1 Operative minimums effective review committee for plastic surgery. Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramResources/Operative_Minimums_effective_07012014.pdf?ver=2017-07-10-102733-190 (PMID: . Accessed August 17, 2020)
- 2 Johnson SP, Chung KC, Waljee JF. Evidence-based education in plastic surgery. Plast Reconstr Surg 2015; 136 (02) 258e-266e
- 3 Javid P, Aydın A, Mohanna PN, Dasgupta P, Ahmed K. Current status of simulation and training models in microsurgery: a systematic review. Microsurgery 2019; 39 (07) 655-668
- 4 Al-Bustani S, Halvorson EG. Status of microsurgical simulation training in plastic surgery: a survey of united states program directors. Ann Plast Surg 2016; 76 (06) 713-716
- 5 Evgeniou E, Walker H, Gujral S. The role of simulation in microsurgical training. J Surg Educ 2018; 75 (01) 171-181
- 6 Mueller MA, Pourtaheri N, Evans GRD. Microsurgery training resource variation among US integrated plastic surgery residency programs. J Reconstr Microsurg 2019; 35 (03) 176-181
- 7 Hashmi A, Khan FA, Herman F. , et al. A survey of current state of training of plastic surgery residents. BMC Res Notes 2017; 10 (01) 234
- 8 Jubbal KT, Chang D, Izaddoost SA, Pederson W, Zavlin D, Echo A. Resident involvement in microsurgery: an american college of surgeons national surgical quality improvement program analysis. J Surg Educ 2017; 74 (06) 1124-1132
- 9 Cho M-J, Halani SH, Davis J, Zhang AY. Achieving balance between resident autonomy and patient safety: Analysis of resident-led microvascular reconstruction outcomes at a microsurgical training center with an established microsurgical training pathway. J Plast Reconstr Aesthet Surg 2020; 73 (01) 118-125
- 10 Brady JS, Crippen MM, Filimonov A. , et al. The effect of training level on complications after free flap surgery of the head and neck. Am J Otolaryngol 2017; 38 (05) 560-564
- 11 Wu WW, Medin C, Bucknor A, Kamali P, Lee BT, Lin SJ. Evaluating the impact of resident participation and the july effect on outcomes in autologous breast reconstruction. Ann Plast Surg 2018; 81 (02) 156-162
- 12 Sebai ME, Bello RJ, Lifchez SD, Cooney DS, Rosson GD, Cooney CM. The effect of resident involvement on postoperative short-term surgical outcomes in immediate breast reconstruction: a national surgical quality improvement program study of 24,005 patients. Plast Reconstr Surg 2017; 139 (06) 1325-1334
- 13 Jubbal KT, Echo A, Spiegel AJ, Izaddoost SA. The impact of resident involvement in breast reconstruction surgery outcomes by modality: an analysis of 4,500 cases. Microsurgery 2017; 37 (07) 800-807
- 14 Haddock NT, Teotia SS. Deconstructing the reconstruction: evaluation of process and efficiency in deep inferior epigastric perforator flaps. Plast Reconstr Surg 2020; 145 (04) 717e-724e
- 15 Malyar M, Peymani A, Johnson AR, Chen AD, Van Der Hulst RRWJ, Lin SJ. The impact of resident postgraduate year involvement in body-contouring and breast reduction procedures: a comprehensive analysis of 9638 patients. Ann Plast Surg 2019; 82 (03) 310-315
- 16 Kaplan J, Volk AS, Ashley JR, Izaddoost S, Reece E, Winocour S. A systematic review of resident aesthetic clinic outcomes. Aesthet Surg J 2019; 39 (09) NP387-NP395
- 17 Walker NJ, Crantford JC, Rudolph MA, David LR. Outcomes analysis of chief cosmetic clinic over 13 years. Ann Plast Surg 2018; 80 (06) 600-606
- 18 Stotland MA, Boonipat T, Lundgren CM, Gonzalo EG. Universal applicability of the furlow palatoplasty: resident as primary surgeon in a consecutive, nonselective series. Ann Plast Surg 2018; 80 (04) 406-411
- 19 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42 (02) 377-381
- 20 Cho MJ, Haddock NT, Teotia SS. Clinical decision making using CTA in conjoined, bipedicled DIEP and SIEA for unilateral breast reconstruction. J Reconstr Microsurg 2020; 36 (04) 241-246
- 21 Opsomer D, Stillaert F, Blondeel P, Van Landuyt K. The lumbar artery perforator flap in autologous breast reconstruction: initial experience with 100 cases. Plast Reconstr Surg 2018; 142 (01) 1e-8e
- 22 Chao AH, Coriddi M. The impact of intraoperative microvascular compromise on outcomes in microsurgical breast reconstruction. J Reconstr Microsurg 2015; 31 (07) 493-499
- 23 Huffman EM, Martin JR, Stefanidis D. Teaching technical surgery. Surgery 2020; 167 (05) 782-786
- 24 Rao A, Tait I, Alijani A. Systematic review and meta-analysis of the role of mental training in the acquisition of technical skills in surgery. Am J Surg 2015; 210 (03) 545-553
- 25 Flinn JT, Miller A, Pyatka N, Brewer J, Schneider T, Cao CG. The effect of stress on learning in surgical skill acquisition. Med Teach 2016; 38 (09) 897-903
- 26 Dietrich A. Neurocognitive mechanisms underlying the experience of flow. Conscious Cogn 2004; 13 (04) 746-761
- 27 Chan W, Niranjan N, Ramakrishnan V. Structured assessment of microsurgery skills in the clinical setting. J Plast Reconstr Aesthet Surg 2010; 63 (08) 1329-1334
- 28 Selber JC, Chang EI, Liu J. , et al. Tracking the learning curve in microsurgical skill acquisition. Plast Reconstr Surg 2012; 130 (04) 550e-557e
- 29 Temple CLF, Ross DCA. A new, validated instrument to evaluate competency in microsurgery: the University of Western Ontario Microsurgical Skills Acquisition/Assessment instrument [outcomes article]. Plast Reconstr Surg 2011; 127 (01) 215-222
- 30 Schaverien MV, Liu J, Butler CE, Selber JC. Factors correlating with microsurgical performance: a clinical and experimental study. J Surg Educ 2018; 75 (04) 1045-1051
- 31 Cho MJ, Teotia SS, Haddock NT. Classification and management of donor-site wound complications in the profunda artery perforator flap for breast reconstruction. J Reconstr Microsurg 2020; 36 (02) 110-115
- 32 Cho MJ, Teotia SS, Haddock NT. Predictors, classification, and management of umbilical complications in DIEP flap breast reconstruction. Plast Reconstr Surg 2017; 140 (01) 11-18
- 33 Lindenblatt N, Gruenherz L, Farhadi J. A systematic review of donor site aesthetic and complications after deep inferior epigastric perforator flap breast reconstruction. Gland Surg 2019; 8 (04) 389-398