Original Article

Survey of Reconstructive Microsurgery Training in Korea Seong June Moon, MD1

Joon Pio Hong, MD, PhD, MMM2

1 Department of Plastic Surgery, Ewha Womans University Hospital,

Seoul, Korea 2 Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

So Ra Kang, MD, PhD1

Hyun Suk Suh, MD1

Address for correspondence Hyun Suk Suh, MD, Department of Plastic Surgery, Ewha Womans University Hospital, School of Medicine, Ewha Womans University, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 158710, Korea (e-mail: [email protected]).

J Reconstr Microsurg 2015;31:54–58.

Abstract

Keywords

► training programs ► reconstructive surgery ► plastic surgery

Background Microsurgical technique in reconstructive surgery is important. Despite recognizing this fact, there are no systematized microsurgery training programs in Korea. The purpose of this study was to diagnose the current training programs and discuss the direction that is needed to improve them. Methods The authors conducted a survey of graduates of a plastic surgery residency program. The questionnaire included the volume of microsurgery, training environment, area of microsurgery, department(s) performing microsurgery, and the frequency with which flaps were used. Results Many specialties other than plastic surgery involved microsurgical procedures. The volume of microsurgery cases was disproportionate between large and small hospitals, creating an imbalance of residents’ experience with microsurgical procedures. The increase in microsurgical procedures being performed has increased the number of surgeons who want to train in microsurgery. Conclusion Increasing the number of microsurgery training programs will create more microsurgeons in Korea.

Microsurgical technique is one of the most important skills in reconstructive surgery. The importance of microsurgery is increasing in reconstructive surgery, such as breast reconstruction, head and neck reconstruction, and extremity reconstruction.1–3 Clearly, microsurgical technique is an important factor in the outcome of the microsurgery. Much time and effort are needed to develop and mature microsurgical technique. It is thus necessary that surgeons are trained during a good microsurgical training program and have the opportunity to practice what they have learned.4 Although, the demand for microsurgery has been increasing, plastic surgeons who are familiar with microsurgery are limited in Korea. Most plastic surgeons were engaged in aesthetic rather than reconstructive surgery. There were fewer plastic surgeons who work in a general hospital (109, 5.5%) or a university hospital (254, 12.9%) than who were

active in local aesthetic clinics (1101, 55.9%).5 Surgeons who work in general hospitals and university hospitals are performing most of the reconstructive surgeries, and some are performing microsurgery. At present in Korea, the number of reconstructive surgeries is increasing. Immediate breast reconstruction after mastectomy has increased over the past decade because of its oncologic safety and the availability of reliable reconstruction methods. In addition, more people are aware of lower extremity salvaging procedures using microsurgical reconstructive surgery.6 It is thus essential to train more microsurgeons to perform reconstructive surgeries. Until now, too little attention has been paid to studying the volume of microsurgery in regard to the training programs in Korea. The purpose of this study was to evaluate the quality of microsurgery training programs and the amount of practical microsurgery experience during a residency and to identify

received February 4, 2014 accepted after revision May 17, 2014 published online July 31, 2014

Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI http://dx.doi.org/ 10.1055/s-0034-1383820. ISSN 0743-684X.

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training programs that can provide graduates who are prepared to perform microsurgery. We assessed the correlation between one’s proficiency in microsurgery and selecting it as a future subspecialty.

Methods A total of 87 plastic surgeons who graduated from plastic surgery programs in 2012 were included in this study. The participants were identified through the database of the Korean Society of Plastic and Reconstructive Surgeons and a survey was conducted using e-mail addresses registered in the Korean Society of Plastic and Reconstructive Surgeons.

Fig. 1 Annual number of free flap cases.

Survey Design and Administration The questionnaire had 29 categories that included many aspects of microsurgery training, including the volume of microsurgery performed, training environment, area of microsurgery, departments performing microsurgery, and frequently used flaps. The questionnaire was composed of 23 multiple choice and 6 short answer questions. If the question was not answered, that question was invalidated. We considered that the volume of cases reflected the operative experience during the surgeon’s residency. The questionnaires were sent and answered by e-mail, and the survey was then analyzed. All statistical analyses were performed using SPSS software (SPSS version 18.0; SPSS Inc., Chicago, IL). Fisher exact test and logistic regression test were used for analysis.

Results The questionnaires were sent to 87 plastic surgeons, and 71 (81.6%) were returned. Among them, 55 (63.2%) surgeons answered all the questions.

Training Environment Training hospitals have a wide range of scale. In all, 43.7% of respondents were trained in 800- to 1,200-bed hospitals, 9.9% of respondents were trained in hospitals with more than 2,000 beds, and 5.6% of respondents were trained in hospitals with fewer than 500 beds. We asked about the number of residents at each hospital. It seems that 32.4% of respondents had one resident, 33.8% had two, and 33.7% had three or more in a year. The number of surgeons who perform microsurgery was determined. In all, 33.8% of respondents stated that fewer than three microsurgery-educated surgeons were available for training the residents, and 25.4% said that there were four microsurgeons. In addition, 29.6% reported that there were generally two surgeons who actually performed microsurgery, and 4.2% of respondents replied that none performs microsurgery.

(8.5%) (►Fig. 1). The annual number of hand microsurgeries was also widely distributed: 11 to 20 cases comprised the highest number of cases, reported by 29.6% of the respondents. In all, 12.7% of respondents had not experienced hand microsurgery at all (►Fig. 2).

Head and Neck Reconstruction The majority of the specialists who performed head and neck reconstruction after head and neck cancer excision surgery provided the following information: 73.2% of surgeons answered that plastic surgeons most often performed the reconstructive surgery; 19.7% of respondents said that otolaryngologists performed cancer resection surgery and reconstructive surgery simultaneously (►Fig. 3). Regarding the annual surgical cases, the highest count was 6 to 10 cases per year (29.6%). The most frequently used flap has been the radial forearm free flap followed by the anterolateral thigh (ALT) free flap and the pectoralis major myocutaneous flap.

Breast Reconstruction The specialties that involve breast reconstruction after breast cancer excision surgery included the following: 91.1% of surgeons said that plastic surgeons most often performed breast reconstructive surgery; 4.2% said that general surgeons

Volume of Microsurgery Cases The annual number of free flap surgeries was widely distributed, ranging from 0 cases (7.0%) to more than 100 cases

Fig. 2 Annual number of hand microsurgery cases.

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Sample Selection

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Fig. 3 Majority of department of head and neck reconstruction.

performed the surgery; and 4.2% of respondents replied that their hospital does not perform breast reconstruction. In all, 76.1% of the respondents noted that plastic surgeons performed oncoplastic surgery after breast-conserving operations, whereas 11.3% said it was general surgeons who performed oncoplastic surgery. The highest number of annual immediate breast reconstructions was 1 to 5 cases (23.9%), 15.5% said that the number of cases was more than 100 cases (►Fig. 4). The most commonly used method of immediate breast reconstruction was with the pedicled transverse rectus abdominal muscle (TRAM, 21.1%) (►Fig. 5). The greatest annual count of delayed breast reconstruction was one to five cases (35.2%, ►Fig. 6). The most commonly used method was also the pedicled TRAM (22.5%, ►Fig. 7).

Fig. 5 Flap selection for immediate breast reconstruction.

Hand Microsurgery The most frequently performed hand microsurgery during residency programs was replantation of an amputated finger using vessel and nerve surgery (64.8%). Soft tissue reconstruction accounted for 21.1%. The most frequently performed operation have been with a local flap (33.8%), followed by the ALT free flap (19.7%).

Fig. 6 Annual number of delayed breast reconstruction cases.

Microsurgery Procedures Experienced During Training In all, 57% of the respondents replied that they performed a microsurgical procedure, and among them 38% (21/55) stated

Fig. 7 Flap selection for delayed breast reconstruction.

Fig. 4 Annual number of immediate breast reconstruction cases.

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that they hoped to become a microsurgeon after their residency. It was a high response rate considering the current state of the service. In all, 74.5% (41/55) of the respondents stated that they performed a microsurgical procedure during their residency. There was statistical significance between

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Table 1 Relationship between experiences of microsurgery with desired future subspecialty Desired future subspecialty With microsurgical procedure experience Without microsurgical procedure experience

Other than microsurgeon

p-Valuea

21/41 (51.2%)

20/41 (48.8%)

< 0.001

0/14 (0%)

14/14 (100%)

Fisher exact test.

experiencing microsurgical procedures and the desire of residents to become a microsurgeon (p < 0.001, Fisher exact test) (►Table 1).

Discussion The response rate of this survey was 81.6%, and the response rate for all of the questionnaires was 63.21%. The response rate was high enough that this survey can be considered to correlate well with the current status of microsurgery in Korea. In addition, the survey was credible because it targeted the most recently graduated plastic surgeons. Plastic surgery training programs consist of 4 years of training after 1 year of internship following medical school. After or before training for a specialty, however, it is mandatory for most Korean male doctors to work 3 years as a public health or military physician. Our research shows that specialties other than plastic surgery involved reconstructive microsurgery. There were overlaps of reconstructive microsurgery procedures with departments such as general surgery, orthopedic surgery, otorhinolaryngology, and oral and maxillofacial surgery. For head and neck reconstruction, 19.7% of respondents stated that otorhinolaryngologists performed reconstructive surgery in their hospitals. For breast reconstruction, 4.2% of respondents answered that general surgeons performed reconstructive surgery in their hospital. Orthopedic surgeons performed microsurgery for hand trauma and extremity reconstruction. The cause of overlap may be due to numerous newly developed subspecialty fellowship training programs in major specialties, including a breast surgery subspecialty in general surgery and a hand surgery subspecialty in orthopedic surgery. The rapid increase in aesthetic plastic clinics in Korea also contributes to the lack of plastic surgeons interested in reconstruction.7 There was a disparity in the number of microsurgery cases addressed by hospitals, with the cases being concentrated in several large hospitals located in the capital city. In addition, some hospitals do not perform free flap surgery at all, whereas several hospitals perform more than 100 cases annually. This is because of improved access to large hospitals in the capital city. This phenomenon dictates that residents in smaller hospitals do not have sufficient experience with microsurgical procedures. This fundamental problem will not easily be solved over a short period. There was a much smaller number of hand microsurgery cases than we expected. There were no cases addressed according to 12.7% of the answers, and 69% of respondents said they were doing less than 20 cases annually. Hospitals

that performed more than 100 cases were hand centers. The small number of hand microsurgery cases is consistent with the overlap of microsurgery mentioned above. Orthopedic surgeons are gradually performing more and more microsurgical procedures. Certain hospitals are in charge of most of the hand microsurgeries. Furthermore, the number of local clinics specializing in hand surgery increased recently, so cases treated in training hospitals decreased. Our study has some limitations. First, the results can be inaccurate because the replies to the questionnaire were based on the memory of the respondent regarding what they experienced during their residency rather than being based on an exact database. The National Medical Insurance Plan in the Republic of Korea covers everyone residing in the country. However, hospitals have to make a claim or demand to the Health Insurance Review & Assessment Service for some portion of the total charge after their medical service to a patient. A national database provides data regarding the service or procedure, but they have only the total numbers of the disease or procedures. According to the database of the Health Insurance Review & Assessment Service, 212 free flaps to the face and 975 free flaps to other parts of the body were performed in 2011. However, these numbers include only the flaps for reconstruction that are covered by National Medical Insurance in Korea. Operations for some other reconstructions, such as immediate or delayed breast reconstruction, are not covered by the National Medical Insurance Plan.8 The 212 and 975 flaps mentioned earlier also include only operations done in hospitals without trainees. There is no national database for plastic surgery yet that allows us to investigate what kinds of flap operations are undertaken in which hospitals. Even if we investigate the number of operations by depending on the memory of the respondent, most of the hospitals with private data record the number of surgeries monthly or yearly, and these data are mostly recorded by residents. We thus depend on them to remember those data correctly. The second limitation of our study is that there is a possibility of selection bias. Because the subject of this research was reconstructive microsurgery, surgeons who participate in reconstructive surgery replied more often than aesthetic surgeons.

Conclusion Microsurgical procedures are increasingly being performed by specialties other than plastic surgery. In the near future, most reconstructive microsurgeries may in fact be performed by these other specialties. To improve microsurgery training programs and increase the number of microsurgeons, it is Journal of Reconstructive Microsurgery

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a

Microsurgeon

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essential that we establish more training programs where more residents can gain microsurgical operative experience. Disclosure None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.

2 Heller L, Levin LS. Lower extremity microsurgical reconstruction.

Plast Reconstr Surg 2001;108(4):1029–1041, quiz 1042 3 Wong CH, Wei FC. Microsurgical free flap in head and neck

reconstruction. Head Neck 2010;32(9):1236–1245 4 Lascar I, Totir D, Cinca A, et al. Training program and learning curve

5

Conflict of Interest The authors declare that they have no conflict of interest.

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tion. Cancer J 2008;14(4):241–247

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in experimental microsurgery during the residency in plastic surgery. Microsurgery 2007;27(4):263–267 The Korean Society of Plastic and Reconstructive Surgeons. Available at: http://www.plasticsurgery.or.kr/ Malata CM, McIntosh SA, Purushotham AD. Immediate breast reconstruction after mastectomy for cancer. Br J Surg 2000; 87(11):1455–1472 Tanna N, Boyd JB, Kawamoto HK, et al. Reconstructive surgery training: increased operative volume in plastic surgery residency programs. Plast Reconstr Surg 2012;129(3):781–788 Health Insurance Review & Assessment Service. Available at: http://www.hira.or.kr/rd/dissdic/infoSickList.do?sickType=1&pg mid=HIRAA020044020100

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Survey of reconstructive microsurgery training in Korea.

Microsurgical technique in reconstructive surgery is important. Despite recognizing this fact, there are no systematized microsurgery training program...
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