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Impact of microsurgery skill acquisition on free flap ischaemia time and free flap outcomes



Microsurgical training is challenging in our current healthcare environment. There has been a paradigm shift in surgical training due to the reduced hands-on training opportunities. This is particularly true for highly specialised advanced skills such as microsurgery. Understandably, there is a reluctance to encourage trainees to perform micro-anastomosis due to the high stakes nature of free flap surgery. We aimed to compare flap ischaemia times and return to theatre between attending plastic surgeons and plastic surgery residents. Our secondary aim was to correlate flap outcomes to the grade of a surgeon performing the microsurgical anastomosis.


Data was collected on all free flap surgeries in a single institution over a 12-month period. Patient demographics, flap ischaemic times, return to theatre, flap outcomes and overall complications were recorded. Statistical analysis was performed using Stata 12.0. T test two group means comparison was used to compare ischemia times. Non-parametric statistics were used to evaluate flap outcome measures. A p value < 0.05 was considered statistically significant.


Fifty-four free flaps were performed in a single institution over a 12-month period. Attending group (n = 34) average flap ischaemia time was 70 min compared to 65 min for the resident group (n = 20), p = 0.4. There were no differences in return to theatre (p = 0.2), flap loss (p = 0.6), or overall complications (0.4).


This study demonstrates that resident performance of microsurgery does not adversely affect clinical outcomes in free flap surgery. The hands-on operative teaching of microsurgery should be encouraged amongst residents in plastic surgery.

Level of evidence: Level IV, risk/prognosic study

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Corresponding author

Correspondence to Paula F. Wrafter.

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Conflict of interest

Christina E. Buckley, Paula F. Wrafter, Fiachra Sheil, Niall M. McInerney and Alan J. Hussey declare that they have conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional ethics committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Galway Clinical Research Ethics Committee approved this study (approval # C.A. 2163).

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Informed consent was obtained from all participants included in this study.

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Patients signed informed consent regarding publishing their data  

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Buckley, C.E., Wrafter, P.F., Sheil, F. et al. Impact of microsurgery skill acquisition on free flap ischaemia time and free flap outcomes. Eur J Plast Surg 44, 493–496 (2021).

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  • Microsurgery
  • Surgical training
  • Ischaemia time
  • Flap outcomes