Invited Discussion

In this era of cost containment in resident education, the article by Rayan and Rayan represents a simple, economic method for introducing trainees to microsurgery. The logistics of maintaining independent microsurgical laboratories with microsurgical teachers, whether basic scientists or physicians, have become more difficult. In our institution, the microsurgery training laboratory has been discontinued with the retirement of Jim Urbaniak, and a decision was made by the Division of Orthopaedics not to continue microsurgery training. On the other hand, the Division of Plastic Surgery has an active microsurgical service, and our residents go to Louisville, where bench training is done in Bob Acland's lab. I'm afraid that as the future unfolds and microsurgery becomes less lucrative, there will be fewer opportunities for trainees to have a mentorship in a laboratory before they are asked to go into the clinical arena. I know that Maria Siemionow at the Cleveland Clinic teaches microsurgery in the Department of Surgery, including all the subspecialties.

We can look at microsurgical training and the future of microsurgery much in the way we look at a water glass: it is either half empty or half full. Despite decreasing economic reimbursement for reconstructive surgery, there is a certain nobility in microsurgery as a tool, a technique, or a discipline. As we await composite tissue allotransplantation becoming a reality, medicine needs microsurgery more than ever. We continue to expand our conventional armamentarium, discovering new indications for free-tissue transfer, and expanding its uses using perforator flaps, prefabricated and pre-expanded flaps, and the free style flaps popularized by Koshima. Just as the Marines say they are looking for a few good men, reconstructive microsurgery is also looking for a few good men and women to make a commitment to study, perfect technique, and execute at the highest level possible with almost 100 percent success. This mandates continued dedication to training, not only in the techniques of operating under the microscope, but in a broader responsibility to provide teaching environments, cadaveric facilities (similar to our Human Tissue Laboratory), and courses that are held around the world for trainees and even for established surgeons, to continue to improve and to get better.

If the immunological, ethical, and patient selection issues regarding composite tissue allotransplantation are solved (and I believe they will be in our lifetime), we will then need an entirely new brigade of dedicated reconstructive microsurgeons, to make their services a possibility and reality to the many deserving patients in need of these services and expertise.

Let us champion to continue training in reconstructive microsurgery, and to popularize its applications throughout the world!