Osteocutaneous flaps for head and neck reconstruction: A focused evaluation of donor site morbidity and patient reported outcome measures in different reconstruction options

With significant improvements in success rates for free flap reconstruction of the head and neck, attention has turned to donor site morbidity associated with osteocutaneous free flaps. In this review, we address the morbidity associated with harvest of the four most commonly used osteocutaneous flaps; the free fibula flap, the scapula flap, the iliac crest flap and the radial forearm flap. A comprehensive literature search was performed to identify articles relevant to donor site morbidity for these flaps. We assessed morbidity in terms of incidence of delayed healing, chronic pain, aesthetic outcomes, site specific complications and patient satisfaction/quality of life. Weighted means were calculated when sufficient studies were available for review. The radial forearm and free fibula flaps are associated with high rates of delayed healing of approximately 20% compared to the scapular ( < 10%) and iliac flaps (5%). The radial forearm flap has higher rates of chronic pain (16.7%) and dissatisfaction with scar appearance (33%). For the majority of these patients harvest of one of these four osteocutaneous does not limit daily function at long-term follow-up. The scapular osteocutaneous flap is associated with the lowest relative morbidity and should be strongly considered when the recipient defect allows. The radial forearm is associated with higher morbidity in terms of scarring, fractures, chronic pain and wrist function and should not be considered as first choice when other flap options are available.

Development of a Five-Day Basic Microsurgery Simulation Training Course: A Cost Analysis

The widespread use of microsurgery in numerous surgical fields has increased the need for basic microsurgical training outside of the operating room. The traditional start of microsurgical training has been in undertaking a 5-day basic microsurgery course. In an era characterised by financial constraints in academic and healthcare institutions as well as increasing emphasis on patient safety, there has been a shift in microsurgery training to simulation environments. This paper reviews the stepwise framework of microsurgical skill acquisition providing a cost analysis of basic microsurgery courses in order to aid planning and dissemination of microsurgical training worldwide.

Research Priorities in Light of Current Trends in Microsurgical Training: Revalidation, Simulation, Cross-Training, and Standardisation

Plastic surgery training worldwide has seen a thorough restructuring over the past decade, with the introduction of formal training curricula and work-based assessment tools. Part of this process has been the introduction of revalidation and a greater use of simulation in training delivery. Simulation is an increasingly important tool for educators because it provides a way to reduce risks to both trainees and patients, whilst facilitating improved technical proficiency. Current microsurgery training interventions are often predicated on theories of skill acquisition and development that follow a 'practice makes perfect' model. Given the changing landscape of surgical training and advances in educational theories related to skill development, research is needed to assess the potential benefits of alternative models, particularly cross-training, a model now widely used in non-medical areas with significant benefits. Furthermore, with the proliferation of microsurgery training interventions and therefore diversity in length, cost, content and models used, appropriate standardisation will be an important factor to ensure that courses deliver consistent and effective training that achieves appropriate levels of competency. Key research requirements should be gathered and used in directing further research in these areas to achieve on-going improvement of microsurgery training.

The Rat Model in Microsurgery Education: Classical Exercises and New Horizons

Microsurgery is a precise surgical skill that requires an extensive training period and the supervision of expert instructors. The classical training schemes in microsurgery have started with multiday experimental courses on the rat model. These courses have offered a low threat supervised high fidelity laboratory setting in which students can steadily and rapidly progress. This simulated environment allows students to make and recognise mistakes in microsurgery techniques and thus shifts any related risks of the early training period from the operating room to the lab. To achieve a high level of skill acquisition before beginning clinical practice, students are trained on a comprehensive set of exercises the rat model can uniquely provide, with progressive complexity as competency improves. This paper presents the utility of the classical rat model in three of the earliest microsurgery training centres and the new prospects that this versatile and expansive training model offers.