Designing a Masterclass in free flap surgery for head and neck surgeons: Our experience

Dear Editor, Free flap surgery is the gold standard in reconstruction of the Head and Neck district( Gusenoff, Vega, & Jiang, 2006). However, in Italy, the standard training in Maxillofacial and Ear, Nose & Throat surgery lacks programs focused on building the microsurgical skills needed for this highly technical surgery, to the point that many trainees do not have the chance to perform microsurgery at all. Moreover, most of the monothematic courses are focused on animal models (Komatsu et al., 2013) or cadavers, with few courses offering the possibility to experience in vivo-surgery. For these reasons, we ideated a Masterclass in Free Flap Reconstructive Surgery addressed to young surgeons, with the aim to offer a comprehensive approach to this type of reconstruction, while guaranteeing patients' safety and high standards of care. The Masterclass was conceived for a maximum of six attendants, to ensure nonchaotic interaction and group discussion (Nichols, Stadler, & Poetker, 2015). We planned three sessions of 3 days each, distributed over a period of 3 months. Each session was divided as follows: day 1 = multidisciplinary teaching; days 2 and 3 = case presentation, clinical discussion and live surgery. The multidisciplinary lessons covered surgical anatomy and surgical techniques, management of complications, as well as radiology and perioperative anesthesiological management. Two days of live surgery were provided, during which two of the most used free flaps (i.e., radial forearm, antero-lateral thigh, scapula and latissimus dorsi, gracilis muscle, fibula and iliac crest) were performed. Expert microsurgeons from Italy were invited to teach the attendants to raise and inset the flap and to perform microanastomoses. Feedback was obtained by asking the attendants to express a score ranging from 1 (worst experience) to 4 (best experience) for four items: learning targets achieved, teaching activities, teaching methods and organizational plan. Two editions of the Masterclass took place in 2018 and 2019, respectively, at IRCCS Casa Sollievo della Sofferenza, with a total of 12 participants. All the attendants were able to harvest and inset flaps and perform microvascular sutures, shadowing a teaching consultant. None of the attendants experienced any injury during the course. The free flap success rate was 92%. One patient had a flap loss 36 hr after surgery due to venous thrombosis. A second free flap was successfully performed 2 days after. No significant differences in terms of morbidity and rate of flap loss were observed in this cohort compared to patients treated in the same institute (Copelli et al., 2017). The mean score on the appreciation questionnaire for the two editions of the Masterclass was 15.6. The item that scored highest was related to the teaching methods, especially to the possibility to actively participate to surgery and confront with experts in a collaborative environment. Since clinical exposure is the most crucial element in learning indications and limits of free flaps and in identifying and managing free flap compromise (McMillan et al., 2017), we report the development of a novel surgical Masterclass that proved to be effective in providing quality education in the field of microsurgery. Our experience demonstrates that in vivo-surgical Masterclasses in microsurgery are both safe for patients and highly professionalizing for attendants.