Keywords
microsurgery - training - attributes
Pride is one of the biblical sins, which one should avoid at all costs.[1] For a microsurgeon, this temptation is the hardest to resist whenever he looks at
a patient with a replanted hand, writing his name on that crumbled piece of paper
or whenever he notices a lymphedema patient, wearing her favorite polka-dot skirt
from her disease-free years, once more. In today's world of rapid surgical advancement
where technologies and procedures may become obsolete overnight[2]
[3] microsurgery has perched on top of the reconstructive ladder for quite some time
now, which in itself is a remarkable feat. Calling it the pinnacle of reconstructive
prowess achieved by human seems like a fair statement, until something substantive
surpasses it in the foreseeable future.
The fascination of our ancestors with reassortment of conventional anatomy and permutating
it into novel forms has often manifested through replete religious symbolism or mythical
imagination over the ages.[4] Only, that these ideas remained embedded in beautifully lyricized folklore and despite
the various transcendental powers at their disposal, none of the gods and goddesses
could transform this fascination into reality. Microsurgery as we see it today is
instead a by-product of the sweat and blood of numerous real-life heroes who climbed
every unsurmountable mountain without the aid of fire-breathing dragons or magic carpets.
Every reported success was a culmination of an untold saga of a million preceding
failures.[5]
From its humble beginnings as an experimental endeavor that mostly had nonhumans as
its first patients to its present, highly evolved state, microsurgery has been a worthy
example of human determination to mimic nature's artistry and sophistication. An art
that was previously ascribed to miracles and was synonymous with supernaturality is
now being performed with impunity by microsurgeons the world over. Be it a fibula
molded into a new jaw, redundant abdominal tissue crafted into a near normal breast
or a whole new face being given to a faceless man; these are the very examples that
make every reconstructive surgeon indulge in that sin of pride, even if for a moment.[6]
[7] One is tempted to think, if microsurgeons, with their miraculous ordeals of reattaching
limbs and henceforth, would have been the obvious saints of yesteryears.
While these astounding marvels are flashed the world over as articles of success and
garner unprecedented attention, much remains unsaid about the hidden ordeals that
all microsurgeons undertake to prepare themselves before they reach the zenith of
their careers. This journey is full of challenges and hardships and before embarking
on this arduous trail, it is imperative that a young aspirant is cognizant of these
challenges as well as the various desirable attributes that will make his journey
easier.[7] This essay, mostly deduced from personal experience, is a humble attempt on part
of the authors to sum up the attributes that would be considered beneficial for all
novices contemplating to enter this exciting field. The six basic attributes that
are quintessential from a microsurgical point of view are Clarity, Curiosity, Perseverance,
Passion, An Open Mindset, and Action.[8]
Fig. 1 First attribute-Clarity of thoughts.
Eminent economist Theodore Levitt was a great proponent of creativity and innovation
but at the same time he also stressed upon the need of being in the right field so
as to maximally harvest one's potential and thus, be of maximum service to the society.[9] While this mercantile and rather cold approach may be viewed with a bit of skepticism
by some in the medical fraternity but nevertheless, it is an important tool before
choosing any profession, including microsurgery. Before stepping into the world of
microsurgery, one of the most important answers to be sought is, “What is it that
draws you to this discipline?” Mundane as it may seem, but a clear answer to this
question is a stepping stone toward a successful career as a microsurgeon. Prospective
candidates may have a myriad of reasons to join this field, consistent with their
own desires and ambitions.
The answer spectrum can vary from patient care, enthusiasm for the subject, achieving
a name, emulating a mentor, monetary reasons to many more. While enthusiasm and patient
care have been traditionally viewed as the ideal qualities,[10] it is perfectly fine to pursue a profession if the reasons are “unconventional.”
Some of the greatest visionaries over the years have been people who were influenced
by a role model and would have not excelled if it wasn't for this influence. Legendary
surgeon, Emil Theodor Kocher, by his own admission, was significantly influenced by
the work of Theodor Billroth and as well as von Langenbeck, both of whom made an indelible
mark on his future professional life.[11] A strong desire to achieve fame should also not be seen through the tinted glasses
of bias, as it is a basic human trait which can do wonders to a person's motivation.
Fame and mercantilism (rather than pure scientific temper) have been postulated by
many as the reason for Thomas Elva Edison's countess inventions. Regardless of his
intentions, all his contributions are still a boon to humanity.[12]
Armed with an answer, the next logical step is to do a cost–benefit analysis of one's
capabilities versus one's desires. A person is one's own best judge and does not lie
to oneself. It is highly unlikely that you will have all the desired qualities that
are required to be a good microsurgeon, at the very onset of your journey. Also, many
of these qualities can be acquired by means of sheer hard work and dedication later
on, so this should not be a cause of worry. At the very least, you should pay attention
to any red flags that might prove as an impediment toward your chosen path. Do you
have enough respect and passion for this field and will it last? Are you temperamentally
prone to being easily influenced and later abandoning your new path, midway? Are your
expectations realistic? Do you suffer from any physical condition that may not be
compatible with long hours under the microscope or will potentially aggravate it?
Have you discussed your decision with immediate family members or persons who may
be affected by lack of your presence in their lives on a regular basis? If the answer
to any of these questions is in the affirmative, then perhaps you should get back
to the drawing board, reassess your priorities and then make a valid decision thereof.
This clarity of vision serves as guide for a prospective microsurgeon and has the
benefit of forewarning him/her about the many undulations that lie ahead, and in some
cases, it can outrightly make him/her realize that there is a stark difference between
his/her attributes and the stipulations. A discipline that is more appropriate can
thus be chosen accordingly. If attention is not paid to these preliminary questions,
there is a possibility of disillusionment and loss of interest in the subsequent phase
of one's career that is relatively a lot harder situation to deal with.
The journey of Robert Acland, illustrious microsurgeon cum educator whose world-famous
videos have succored all of us in our nascency, is a specimen of clarity and lesson
for every budding microsurgeon. While discharging minor surgical duties as a medical
intern in Africa, he developed a keen interest in surgery and was convinced that this
is how he was going to contribute toward the welfare of his fellow human beings.[13] Accoutered with this clear objective, every subsequent step of his journey was laden
with immense coherence that eventually propelled him toward microsurgical pre-eminence,
while concurrently nurturing the careers of numerous other microsurgeons by means
of his innovations and revolutionary ideas.
Upon his return to the United Kingdom, he was fascinated by the punctilious craft
of microsurgery and more importantly, he was correctly able to predict the plethora
of possibilities that microsurgery could offer for many reconstructive dilemmas. He
immersed himself in further training in this unknown field, not letting the fear of
failure dampen his spirits. Despite the absence of any clear-cut guidelines, it was
his clarity that kept him going on and he soon realized that the biggest impediment
to microsurgery in those early times was the lack of customized microscopic instruments
and fine suture materials.[14] He also realized that the problem at hand required a dedicated approach which warranted
that he temporarily halts his clinical career, and instead dwell into the world of
research and innovation.[13]
[14]
Subsequently, he applied for a grant with the Medical Research Council and despite
being a novice trainee, his grant was approved on account of his clear-cut ideas,
the gist of which he was effectively able to communicate to the council. During this
research stint, he came up with many marvels like refined microvascular threads/needles,
the “Acland clamp” and much more.[13] His hard work started to bear fruits as many of the earlier technical hurdles plaguing
microsurgery ceased to exist. He continued his crusade of refinement, and popularized
the usage of microvascular techniques, while working as a registrar in Plastic Surgery
at the Canniesburn Hospital at Glasgow.[15]
As these meticulous microsurgical procedures were time consuming and meant that Acland
would occupy the operating room for as much as 12 hours or more at a stretch, many
in the National Health Service started questioning the logic of dedicating so much
time and disproportionate resources toward a newly created discipline, which was still
in its infancy and conjured ambiguous outcomes. Taking note of this indifference toward
his work, Acland soon realized that his current work environment was not really the
appropriate one, as his nascent ideas needed a lot of nurturing and unflinching commitment.
This realization made him undertake a crucial decision—that of leaving the comfort
of his home along with everything that he had built over the years and migrate across
The Atlantic too far away Kentucky, where he would establish a new microsurgery teaching
laboratory from scratch.[16] To his credit, it was here in Kentucky, where over many decades, he contributed
immensely toward the development and popularization of microsurgery. Toward the latter
part of his career, he metamorphosized from a clinician to a world-class educator,
with his widely popular video tutorials bearing a testimony to his credentials and
lucid foresight.[17]
Curiosity ([Fig. 2])
Fig. 2 Second attribute-Curiosity.
A few words that have profoundly altered the discourse of human history are why, how, when, who, and where. Most groundbreaking ideas have taken flight upon the utterance of these innocuously
sounding words, by a curious observer at various points of time. As best depicted
in the book “The Little Prince” by author Exupery, one has to question his surroundings
like an innocent child, trying to seek as much clarity as he can, about everything
that mystifies us. The famous quote from this book, “Only the children know what they
are looking for,” symbolizes this attitude in body and spirit.[18]
“Why” was it not possible to repair, assassinated French president Sadi Carnot's severed
portal vein, ushered Alexis Carrel toward his journey of seeking a stabler approach
for vascular anastomosis and the subsequent development of his now famous “triangulation
technique” that eventually fetched him the Nobel Prize.[19] “How to increase the resolution of the of the microscope?” was the question that
made Ernst Abbe dedicate his life toward optical physics and conjure marvels like
the Abbes condenser, refractometer, and Abbes number, without which microsurgery would
have been impossible to perform.[20] “Where, would he, be able to transform his nascent but brilliant microsurgical ideas
into reality?,” led Robert Acland (previously discussed) to leave a life of comfort
in his native England and set up a new institute from near scratch in faraway Kentucky.[21]
Curiosity is the basic ingredient that makes one seek the unknown and realize how
he/she is better off, with this newly acquired knowledge.[22] Lack of curiosity is the biggest obstacle for the development of a microsurgeon
as it curtails the zeal of venturing out of one's comfort zone and embracing newer
ideas. It is the driving force that makes a microsurgeon want to know how his techniques
or abilities fare in comparison to his peers and obtain feedback, so that he can constantly
improve himself. Curiosity makes him brave enough to let his work be scrutinized without
the fear of being ridiculed, say if a possible lacuna was to be found in somewhere.[23] It also makes him question things eternally, even when he reaches the pinnacle of
his trade, and he never lets the degree of his seniority turn him complacent. He is
willing to exchange ideas with one and all, knowing fully that every discussion will
polish his knowledge further and may also help him identify any shortcomings, which
could have escaped his notice, till date.
Thus, a microsurgeon should always be analytical and should never shy away from questioning
the logic, working, merits, and demerits behind a particular procedure or a protocol.
The important thing though is to maintain a fine balance between genuine curiosity
versus questioning for the sake of self-glorification or for the mere purpose of impressing
one's peers. Also, one should extensively explore a given topic with all sincerity
before proceeding for help. Self-exploration may obviate the need to seek answers
to many questions, while enriching one's comprehension at the same time.[18] Seeking answers without self-analysis is akin to glorified spoon feeding that may
provide fleeting advantages, at the cost of impairing the overall growth of a budding
microsurgeon and thus should be discouraged.
Perseverance ([Fig. 3])
Fig. 3 Third attribute-Perseverance
“In the early days of my fellowship, I failed three consecutive flaps and I thought
I was not talented to work in the field of microsurgery. It was only then my mentor
Yoon Kyu Chung told me that you will not be a true microsurgeon till you fail 1oo
flaps. It was from this encouragement that I learned from the failures and avoid making
the same mistake. Today over +20 years of experience and +3000 microsurgery cases,
according to his definition, I am still not a true microsurgeon.”
-Prof. J. P. Hong
As Edison famously said about his light bulb, he counted all his previous one thousand
failed attempts as rewarding experiences, which were instrumental for his eventual
success. This Edisonian spirit is what symbolizes the importance of being persistent
in life.[24] All of us must have seen stalwart microsurgeons, either live or in videos, weaving
their magic with such elegance that it leaves one spellbound. Meticulous hand movements,
precise dissection, crafty anastomotic techniques; it just seems like an opera being
conducted under the microscope. But did they reach this crescendo overnight? Were
they innately blessed with such surgical exquisiteness? Surely, most of these stalwarts,
if asked, would narrate their bespoke tales of grit and endurance that have been written
over entire lifetimes. In short, it just boils down to one word, “perseverance.”
Rapid advancement has turned microsurgery into the acme of reconstruction and as a
corollary, the competition has also increased manifold. Right from the moment when
one decides to plunge in this exhausting but rewarding discipline, perseverance is
the key factor that will propel you from one difficult stage to the other. In his
bestselling book titled “Outliers: The Story of Success,” Malcolm Gladwell has very
succinctly postulated his “10000 Hour Rule” as a general guideline on the amount of
practice any individual requires to become an expert.[25] A typical 40 hours/week schedule usually amounts to 20 hours/week of real practice
(after deduction of time which is spent on ancillary activities). These 20 hours can
be considered unadulterated practice hours and may involve practicing the skill, striving
for improvements, monitoring for improvements, evaluating success, and concentrating
on weaker areas. At this rate, it generally takes about a decade for any individual
to accomplish these 10,000 hours of practice and attain expertise of any craft. There
can always be exceptions where one can take more or less time in achieving proficiency,
but in our experience this “10000 Hour Rule” is a good tool for a microsurgeon to
quantify the amount of time he needs to have under his belt before he can consider
himself accomplished.
The story of success is the ability to move on from one failure to the other. Similarly,
a microsurgeons path is bound to be punctuated by many setbacks, as he meanders through
his journey. Even after working with absolute dedication and honesty, success is never
a guarantee. Perseverance is the key factor that enables a microsurgeon to take these
failures into his stride and be ready for the next challenge. A microsurgeon should
always be ready to accept failures as the best method of learning how not to repeat
mistakes and how to take corrective measure for the future. Each failure and nullification
of the accompanying hard work should not demoralize a budding microsurgeon but should
instead galvanize his resolve to overcome failure. He should be ready to imbibe the
positives from his failed efforts and quickly move forward with doubled resolve to
tame the problem at hand.
Microsurgical history is inundated with examples where stalwarts, who came to be known
for their exemplary work later on, were initially met by heartbreaking disasters and
nonfulfilment. If it was not for their persistence and never-say-die attitude, they
would have otherwise succumbed to despair, and we would have been deprived of all
their marvelous work. The life story of Harry Buncke fondly called the “Father of
Microsurgery” in mainland America is a befitting tale of perseverance and a perfect
template to emulate for upcoming microsurgeons, for years to come.[26] A Canadian by birth, he trained initially at Cornell University and at Glasgow,
Scotland, before finally settling in California. Like all great minds who are triggered
by an event that may seem ordinary to the lesser mortals, the numerous digital amputations
that he encountered in his daily practice and his inability to offer a satisfactory
solution to this menace turned out to be his beckoning. Determined to improve the
outcome of such amputations, he famously started his revolution from his garage. His
efforts were also directed toward one of the most common problems encountered by microsurgeons
of that era—the unavailability of proper microsurgical instruments that were in turn
hampering the execution of many microsurgical procedures. Over a period, he developed
many microsurgical instruments that greatly eased the sufferings of microsurgeons.
Very famously, his first successful transplantation of a rabbit ear was possible after
exactly 50 unsuccessful attempts, which is a measure of the man's perseverance and
patience. He never stopped and continued his mission of microsurgical refinement and
ended up doing the first successful case of toe to thumb transfer in the United States.[26]
Fig. 4 Fourth attribute-Passion for the subject.
“Choose a job that you love, and you will never have to work a day in your life,”
said the Chinese philosopher Confucius.[27] Among the various attributes that an ideal microsurgeon should possess, passion
is that one quality that already endears an aspiring candidate to us, and at times,
even makes us turn a blind eye to his other possible shortcomings. Passion is not
a quantifiable attribute but instead it signifies that abstract zeal that someone
possesses for a given discipline.[28] Unless somebody is not passionate about microsurgery, he can rarely cultivate the
other attributes (perseverance, hard work, etc.) that are required to excel in this
field.
A microsurgeon's passion should be multidimensional and not confined to the technical
aspects of the subject alone. Primarily, a microsurgeon should be passionate about
the well-being of his patients. Empathy for fellow human beings is probably the biggest
motivational factor that makes all of us embrace this noble profession and microsurgeons
are no different.[29] Whatever we plan, strive, or execute as microsurgeons should be guided by a solitary
principle—genuine passion for patient care. Will it benefit my patient? How can I
ameliorate his sufferings? How can I restore his functions with minimal morbidity?
Our every effort should be directed toward achieving these goals and everything else
should be secondary. It should be our aim, first and always, that our reconstructive
strategies are dictated by a genuine need and not by our personal ambition or stature.
It is paramount to explain to the patient the various options available to him as
well as the advantages and limitations of each option. A patient should be an equal
participant and a didactic conversation should always be the norm in such scenarios.
Second, a microsurgeon should be passionate about his work.[30] From an early stage a budding microsurgeon should function like a sponge, trying
to absorb as much information as he can either from mentors, seniors, or peers. He
should especially cherish the time he spends in the emergency section as well as in
the operating room, whether he is actively involved in a procedure or not. A single
glimpse at a live procedure can many a times fetch more information than an entire
textbook. Additionally, the feeling of acclimatization with the microsurgical environment
often boosts the morale of younger recruits and also helps them plan for the various
tasks that lay ahead. With the advent of internet and easy availability of videos
and books, a young microsurgeon can greatly enhance his surgical as well as clinical
skills, even before he gets to execute a certain procedure in future.
Third, a microsurgeon should be passionate about ideas. Once he has acquired academic
and practical knowledge, he should use his imagination and approach a problem from
multiple directions which will multiply his learning avenues and invigorate his enthusiasm.
If possible, he should assemble a team of like-minded individuals who can collectively
enhance each other's aptitude. From an early stage, adequate time should be set apart
for academic activities like conduction of studies, presentations, and experimentation.[31] Additionally, a microsurgeon should be well versed with various formats of epidemiological
studies (case control studies, cohort studies, randomized control trials) and should
have at least a working knowledge of various statistical modalities commonly applied
in such studies.
The evolution of the perforator flaps, serves as a lucid example demonstrating how
this “passion” for a better method of reconstruction, eventually ended up revolutionizing
the world of reconstructive surgery.[32] A divergent group of people built on each other's work and like runners in a relay
race passed on the baton forward to the next person, without actually meeting in real
life.[33] The idea of a customized flap with no excess baggage but just the pure blood supply
needed for survival had been envisioned for a long time by many. This, yet to be named
flap, was the likely holy grail that could be an answer to many reconstructive dilemmas.
The evolution and subsequent refinement of skin flaps (perforator flaps included)
were possible because a group of determined individuals decided that a fellow human
being with a partially gangrenous body part or a limb with chronically exposed bones
deserved something better than an outright amputation. The obsession of these people,
who may have lived during different periods of time, but with a common passion of
finding ways to salvage a human body part staring at amputation, was the reason skin
flaps took birth and evolved. This continuum of passion that has manifested over the
ages either through a Sushruta[34](ancient times), a Tagliacozi[4] (Middle Ages), a Koshima (initial phase),[35] or a Hong[36] (more recent times) aptly describes this journey of constant passion owing to which
a flap was transformed from a bulky mass of flesh to a customized unit of tissue based
on a tiny, microscopic perforator.
In specific pertinence to perforator flaps, Taylor[37] and his colleagues, feeling confident after their industrious work on vascular territories,
were the first ones who separated mud from water and suggested a practical way of
harvesting such flaps by chasing these perforators through fascia, soft tissue, or
even muscles, correctly hypothesizing that it was the “ends” (eventual perforators
supplying the flap) and not the “means” (whether harvested as direct/septal/muscular
fashion) that were important for flap survival. Due to their deep inquisitiveness,
numerous investigators from around the world decided to test Taylor's brilliant but
untested suggestion and find out how feasible it would be to isolate these tiny perforators
through dense jungles of connective tissue/muscle fibers. They started working on
the challenge from multiple dimensions and while some, like Kroll, targeted the septal
perforators on account of their relatively easier anatomy,[38] others like Hallock trapped the more elusive muscular perforators as a vascular
basis of their newly harvested perforator flaps.[39] The credit for one of the earliest documented perforator flaps though, goes to Koshima,
who used the inferior epigastric artery skin flaps without the rectus muscle to demonstrate
his concept.[40] His constant pursuit for refinement made him challenge the limits further which subsequently led to his next
milestone, in the form of a paraumbilical perforator flap from the deep inferior epigastric
artery, arguably one of the original perforator flaps in true sense that cemented
his name as a pioneer in perforator flap history.[41]
Soon plastic surgeons the world over realized the potential of perforator flaps and
started to weave their own threads of magic from the template provided by Koshima
and other pioneers. Alan and Treece[42] started using it for breast reconstruction, Angrigiani customized his own version
in the form of the thoracodorsal artery peforator flap,[43] Martin gave us the superficial musculoaponeurotic system flap,[44] while Hong has extensively used it for lower leg reconstruction and hence made its
use really popular for lower limbs.[45]
[46]
[47] From scratch, we suddenly find ourselves at a stage where more than 400 cutaneous
perforators have already been described[48] and the situation has ironically become such that we are starting to find ways to
deal with the problem of plenty![49]
Open Mindset ([Fig. 5])
Fig. 5 Fifth attribute-An open mindset.
Human education starts from the day of birth and continues until our last breath,
with every new dawn enriching our minds with knowledge that was concealed to us, a
day before. Whenever a person decides that he knows everything is the exact moment
when his intellectual decline commences.[50] Microsurgery, being a discipline that owes its existence to experimentation and
generous exchange of ideas, is a glaring case in point, highlighting the importance
of an open mindset. Thereby, it remains one of the quintessential qualities that a
microsurgeon should possess.
He should be open to people as well as ideas. Instead of rigidly adhering to his own
thoughts or conclusions and considering them infallible, he should always have the
sagacity to accommodate a varying viewpoint, validate it for its possible authenticity,
and only discount it after a rigorous scrutiny.[51] This “varying viewpoint” can come from a senior or a junior peer, an ancillary staff
member or even from a patient. Such viewpoints should be judged strictly on the basis
of merit and not on stature. We personally bear testimony to instances where eagle-eyed
nurses or para medical staff have been the first ones to recognize atypical features
of a flap in the recovery room and whose vigil thereby led to timely intervention
and subsequent salvage of such flaps.
Similarly, benign suggestions from junior colleagues can many times lead to substantial
improvements in the end result and thus should be treated with due respect instead
of contempt. A microsurgeon should welcome all such suggestions and incorporate them
even if it means deviating from the originally formulated plan. This “mentorship reversal”
is an essential feature by means of which growth becomes a two-way exchange between
various members of the team rather than flowing from top to bottom always.[52]
[53] It also strengthens the bonds between members, as younger colleagues view themselves
as equally appreciated and valued components of a team.
Also, a microsurgeon must have the ability to take criticism in a positive way.[54] Criticism is usually synonymous with outright rejection of one's work and hence
is different from the “varying viewpoint” as described above. Critics come in all
forms and shapes and can include well-meaning mentors, purely analytical observers,
or a subset of “jealous peers” whose job is, only and only, to belittle us! Regardless
of the source of this criticism, a microsurgeon should view every commentary on his
work as an opportunity to introspect whether the aspects of his work being questioned
are really in need of some overhauling. As a corollary of the same principle, a microsurgeon
should always be truthful about his assessment of others work and personal relationships
should never obfuscate his sense of judgement. Favorably assessing a friendly colleague's
“not so brilliant” work or unnecessarily downgrading meritorious work from some other
colleague, whom we may be not very fond of, are both equally condemnable endeavors.
A closed mindset on the contrary is everything that a microsurgeon should stay away
from.[55] Self-obsession, poor communication skills, inability to deal with criticism, no
zeal for self-correction as well as being surrounded by “yes men” are all attributes
that are detrimental in the overall growth of a good microsurgeon.
The Fifth International Course on Perforator flaps held in Belgium, 2001(“The Gent
Consensus”) is a fine example that illustrates the benefits of this open mindset in
its most pristine form.[56] On account of the rapidity with which progress was being made in the field of perforator
flaps, a lot of confusion had prevailed regarding the nomenclature and terminology
of this newly evolved mode of reconstruction, which seemed full of promise otherwise.
To cut this clutter, wise men from all parts of the globe got together, set their
individualities aside and simplified the whole issue for the common good of their
colleagues. The end result was a “duck soup” version of perforator flap nomenclature,
devoid of all redundancies and easy for plastic surgeons the world over to use and
compare their results, an exercise that has further proliferated and helped in the
usage of perforator flaps universally.[57]
Action and Innovation ([Fig. 6])
Action and Innovation ([Fig. 6])
Fig. 6 Sixth attribute-Action.
The final but the most important attribute that makes it possible for a microsurgeon
to transform all his lofty ideas into palpable reality is by simply acting on them.
There is no substitute for hard work and in fact, sheer hard work can compensate for
many other attributes that many of us may lack initially.[58] One stark similarity between people who have shone in their respective fields is
that after dreaming big, they dedicated time to achieve those dreams by virtue of
their toil and grit.
First of all, it is imperative that microsurgeon sets up a graduated target list for
himself wherein he allocates a specific period of time to achieve a stipulated target
and then moves on to the next level. During this time, his entire focus should be
toward attainment of the said goal with all the dedication at his disposal. Mastering
a certain technique or a procedure is the glorified end result of numerous background
exercises that one has to achieve proficiency at beforehand. The list may include
dusting off those old anatomy books, cadaveric dissections, practicing on animal models,
seeking help from mentors, attending workshops, apprenticeship, and years of relentless
practice. Each and every step demands action and discipline of the highest order possibly
at the cost of leisure time and involves odd hours.
An honest appraisal of one's capabilities as well as limitations should always be
taken into consideration while formulating a list of targets.[59] As such, the list should be as ambitious as possible but should always be within
the ambit of achievability. Setting up impossible targets for oneself with mismatched
expectations only leads to disappointment as well as wasting of precious time and
energy.
Innovation is yet another characteristic that fuels the growth of an individual and
is a natural by-product of being proactive. A microsurgeon should always have a good
sense of anticipation and an ability to stay ahead of competition and this can be
only achieved by constant innovation. In his bestselling book titled “Zero to One,”
Peter Thiel explains the importance of being innovative in a marvelous way and the
concept has universal applications, including in the field of microsurgery.[60] The biggest threat to any discipline comes from stagnation and complacency and microsurgery
is no different. To stay relevant, innovation serves as the tool that prunes the microsurgical
tree at regular intervals, helps it get rid of concepts that have turned redundant,
which in turn paves a new way for proliferation of concepts that are pertinent and
contemporary.[61]
[62] A good microsurgeon is never content and should always be on the lookout for opportunities
wherein he can simplify things for others. He should be on a relentless pursuit to
identify problems and be the first one to try to seek innovative approaches to tackle
these problems. These innovative approaches can relate to microsurgical techniques,
decision making, patient care, as well as the society in general. His tendency should
always be to turn good into better and better into best. While it may all seem too
radical at the beginning, but over a period of time one can realize the benefits of
such an approach as his labor starts to bear fruits. If we analyze some of the most
important microsurgical innovations in hindsight, they all seemed either unconventional
or a bit too radical at the beginning. It was only due to the self-belief of the persons
involved that such radical ideas eventually gained approval as well as appreciation
from one and all.
Surgical treatment of lymphedema was something that traditionally generated more scoff
and barely any enthusiasm, for the better part of history. It was usually considered
as a last resort for patients who otherwise seemed refractory to all other forms of
conservative treatment.[61]
[63] To be fair, the unpredictability of the surgical results did not do improve its
bleak reputation either. All these procedures (Charles's procedure,[64] Homan's procedure,[65] etc.) were essentially gross debulking measures with scant regard for any physiological
principles and thus yielded unsatisfactory results, especially with regard to recurrence
and cosmesis.[66]
Fast forward to the present times, where surgical treatment in its various avatars
(LVA, VLNT, VLVT, SCIP flap, and the list seems to be growing!) has become our primary
tool to deal with lymphedema of all forms while producing results that are far superior
to yesteryears.[67] It is to the credit of pioneers like Koshima, Hong, and others, who refused to surrender
to the status quo and stuck to their beliefs that surgical treatment for lymphedema
had the potential to offer much more than the crude procedures being offered at that
time.[68]
[69] Their zeal for innovation and their desire to act outside their comfort zones fueled
the revolution that changed the management of lymphedema for good and thus lessened
the sufferings of countless lymphedema patients the world over.[70]
Conclusion
Plastic surgery (including microsurgery) is probably the most dynamic among all surgical
branches, wherein techniques that were considered infallible and worshipped once were
consigned to the bin of history overnight, as better ones started displacing them.
A random glance at the trends of publications or at the most frequently searched plastic
surgical terms bears testimony to this fact, wherein words like VLVT, VLNT, and SCIP
flap, which would have seemed like alien words a decade ago, are currently the flavor
of the season.[71] To stay relevant, it becomes paramount that a young microsurgeon imbibes into his
training, all the attributes that will help him achieve proficiency in his field and
that he can do justice to his chosen profession as well as to himself.
The making of an accomplished microsurgeon is not a static point in time that arrives
after obtainment of a specific diploma or a fellowship. It is instead, a lifelong
process[35] and the only mantra that makes it possible, is by working toward his goal with utmost
honesty and self-discipline. The above essay with its six basic ingredients of “Clarity,
Curiosity, Perseverance, Passion, An Open Mindset and Action,” is meant to be a modest
attempt on part of the authors to share their microsurgical insights, procured through
their own respective journeys, with budding aspirants, hoping to sensitize as well
as prepare them for a challenging, but beautiful and promising future, that lies ahead.[72]
An equally compelling reason that prompted the authors of this manuscript to pen this
rather philosophical chronicle is to reiterate the rich and proud history of reconstructive
surgery and to reinvigorate us all as plastic surgeons. Inadvertently or not, this
history seems to be lost in oblivion and is probably not discussed as frequently as
it should be. While it may be spoken in hushed up tones, but the thought regarding
a disproportionate number of young plastic surgeons opting for the more glamorous
and financially overwhelming sub-discipline of cosmetic surgery, is a thought that
must have crossed the mind of every plastic surgeon, who holds reconstructive surgery
close to his heart. There is no denying of the fact that cosmetic surgery is the most
famous member of our family and is in no way any less important. It brings a smile
to millions of faces worldwide and has given us, plastic surgeons, fame and recognition
among general masses. While joining this glamorous branch of plastic surgery needs
very little motivation on account of the self-propelled and ever-increasing beauty
conscious environment we live in, this article is an attempt on part of the authors
(all self-confessed reconstructive surgery radicals!) to make budding plastic surgeons
aware of the rich past that we come from as well help them choose a path ahead.
