title: Microvascular free flaps are a safe and suitable training procedure during structured plastic surgery residency: A comparative cohort study with 391 patients.
abstract: BACKGROUND
  Microvascular free flaps have become a reliable standard procedure. Due to increasing microsurgical experience in teaching hospitals, residents are getting acquainted with performing free flap surgeries earlier in their training. However, economic considerations and safety regulations contradict adequate teaching. A validation of procedures for residency training is necessary to reduce the existing concerns.
  
  
  METHODS
  This retrospective, comparative cohort study was designed to investigate whether free flaps are a safe residency training procedure. In addition, the aim was to establish standards for microsurgical training. Between 2008 and 2011, 391 patients were included who underwent reconstructive surgery with free flaps, under the supervision of either an experienced microsurgeon (cohort 1) or a resident in training (cohort 2). Patient demographics, interventional characteristics, as well as outcome parameters were attributed for comparative analysis.
  
  
  RESULTS
  The comparison of both cohorts revealed a significant difference for defect cause (p < 0.01) and defect localization (p < 0.001). Free flaps for breast reconstruction were more frequently used in cohort 1, and ALT flaps were more used in cohort 2 (p < 0.001). The length of hospital stay was significantly reduced in cohort 1 (p < 0.001). No significant differences for major postoperative complications were identified.
  
  
  CONCLUSIONS
  With respect to standardized environmental conditions and risk stratification, microvascular free flaps can be applied as a safe training procedure during residency. Adequate teaching conditions require a sufficient case load and a high level of expertise of the teacher. The resident's experience and skills as well as the institutional infrastructure and expertise require consideration.
  
  
  METHODS
  III.
authors.affiliation: Department of Hand, Plastic, and Reconstructive Surgery, Trauma Center Ludwigshafen, Ludwigshafen, Germany; Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany. Electronic address: christoph.hirche@bgu-ludwigshafen.de.
authors.forename: Christoph
authors.initials: C
authors.lastname: Hirche
authors.affiliation: Department of Hand, Plastic, and Reconstructive Surgery, Trauma Center Ludwigshafen, Ludwigshafen, Germany; Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany.
authors.forename: Ulrich
authors.initials: U
authors.lastname: Kneser
authors.affiliation: Department of Hand, Plastic, and Reconstructive Surgery, Trauma Center Ludwigshafen, Ludwigshafen, Germany; Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany; Department of Plastic and Reconstructive Surgery, Union Hospital, Huazhong Science and Technique University, Hubei, China.
authors.forename: Lingyun
authors.initials: L
authors.lastname: Xiong
authors.affiliation: Department of Hand, Plastic, and Reconstructive Surgery, Trauma Center Ludwigshafen, Ludwigshafen, Germany; Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.
authors.forename: Paul
authors.initials: P
authors.lastname: Wurzer
authors.affiliation: Department of Hand, Plastic, and Reconstructive Surgery, Trauma Center Ludwigshafen, Ludwigshafen, Germany; Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany.
authors.forename: Felicitas
authors.initials: F
authors.lastname: Ringwald
authors.affiliation: Department of Hand, Plastic, and Reconstructive Surgery, Trauma Center Ludwigshafen, Ludwigshafen, Germany; Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany.
authors.forename: Franziska
authors.initials: F
authors.lastname: Obitz
authors.affiliation: Department of Hand, Plastic, and Reconstructive Surgery, Trauma Center Ludwigshafen, Ludwigshafen, Germany; Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Fischer
authors.affiliation: Department of Hand, Plastic, and Reconstructive Surgery, Trauma Center Ludwigshafen, Ludwigshafen, Germany; Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany.
authors.forename: Leila
authors.initials: L
authors.lastname: Harhaus
authors.affiliation: Department of Hand, Plastic, and Reconstructive Surgery, Trauma Center Ludwigshafen, Ludwigshafen, Germany; Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany.
authors.forename: Emre
authors.initials: E
authors.lastname: Gazyakan
authors.affiliation: Department of Hand, Plastic, and Reconstructive Surgery, Trauma Center Ludwigshafen, Ludwigshafen, Germany; Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Kremer
mesh_terms: D015331:Cohort Studies; D058752:Free Tissue Flaps / Q000009:adverse effects; D006801:Humans; D007396:Internship and Residency; D008866:Microsurgery / Q000193:education* / Q000592:standards; D008875:Middle Aged; D012189:Retrospective Studies; D013518:Surgery, Plastic / Q000193:education* / Q000592:standards
keywords: Free flap; Microsurgery; Plastic surgery; Residency; Skills; Training procedure