Supplementing Technique Training for the Learner Microsurgeon

With rapid advancements in free tissue transfer, the teaching of microvascular anastomosis has become an essential part of plastic surgery training. However, it is one of the most difficult technical skills to acquire within the small window of opportunity to learn during residency training.[1] Several educational methods outside of the operating room have been developed to help optimize exposure to microvascular techniques such as the use of live animal models, cadavers, and surgical simulation.[2] Unfortunately, results are often not monitored and outcomes of success are unknown.[3] In addition, there are many missing elements that are present only in the operating room, including time pressures and the obvious mental adjustments that are required when operating on real patients when results matter.[2] The transfer of microsurgical skills from bench to operating table is not an easy transition, and therefore, new methods are continually being developed to supplement microsurgical training.[3]

Recently, there has been a drive to limit the number of resident work hours by the Accreditation Council for Graduate Medical Education.[4] This only adds to the challenge of achieving competency with microsurgical techniques while abiding by these policies, requiring a delicate balance between enforcing a shorter workweek for residents to prevent medical error versus emphasizing the importance of exposure and practice of microsurgical skills.[1] [5] This type of training often cannot be performed in the animal laboratory. Furthermore, simulation models do not accurately depict real tissue.

To maximize opportunities for the microsurgical training of residents, we propose using an 8–0 Polysorb Vicryl suture (Covidien, Mansfield, MD) on an SE-140 needle for simple closures on the face under loupe magnification or under the operating room microscope. The closure can be done with either microsurgical instruments or a small Webster needle holder and Castro-Viejo or Bishop Harmon forceps. The type of closure recommended is a running continuous suture approximating the edges of the epidermis, producing a cosmetically aesthetic result ([Fig. 1]). The microsurgical skills achieved include the instrument control required for using a small needle while getting a feel for real tissue under magnification in an operating room environment. More importantly, the replication of the maneuver by placing the needle just through epidermis mimics a microsurgical anastomosis and trains the resident in the appropriate techniques before he or she performs actual microvascular surgery. In addition, the small size and absorbable qualities of the 8–0 Vicryl avoids having to perform future suture removal if necessary.

Figure 1 Congenital nevi of the cheek (A) excised and closed with an 8–0 Polysorb Vicryl suture (Covidien, Mansfield, MD) on an SE-140 needle using 2.5× loupe magnification (B).

The use of an 8–0 Vicryl under loupe magnification for facial closures is a simple and yet accessible method for optimizing microsurgical skills of residents. It can be used for nearly all facial closures and so confers many opportunities for residents to practice and develop their skills before advancement to microvascular surgery.

Acknowledgment

The authors wish to acknowledge Dr. Lawrence Gottlieb for teaching all his residents and fellows this technique of facial wound closure repair.

• References

• 1 Hui KC, Zhang F, Shaw WW , et al. Learning curve of microvascular venous anastomosis: a never ending struggle?. Microsurgery 2000; 20: 22-24
• 2 Reznick RK, MacRae H. Teaching surgical skills—changes in the wind. N Engl J Med 2006; 355: 2664-2669
• 3 Balasundaram I, Aggarwal R, Darzi LA. Development of a training curriculum for microsurgery. Br J Oral Maxillofac Surg 2010; 48: 598-606
• 4 Kesselheim AS, Austad KE. Residents: workers or students in the eyes of the law?. N Engl J Med 2011; 364: 697-699
• 5 Luginbuhl AJ, Pribitkin EA, Krein H, Heffelfinger RN. Assessment of microvascular anastomosis training in otolaryngology residencies: survey of United States program directors. Otolaryngol Head Neck Surg 2010; 143: 633-636