by M. Shuja Shafqat, MD
As fall starts to truly settle in, I have been reflecting on my time over the past couple months. As expected, wound consults, breast reconstructions, facial fractures, 2 AM lacerations, and some particularly bad hand trauma were abundant. However, the one experience I had that was most meaningful and inspiring was the weekend my chief resident and I spent at Duke University with Dr. Michael Zenn and some of the best in reconstructive surgery.
After an 11 hour road trip from Pennsylvania, we arrived late to a welcome reception at the Durham Hilton. We signed in and received our materials, including our schedule for the weekend. Placing our name badges on ourselves, we dove into the crowd. There were residents, junior attending surgeons, and even senior faculty from every corner of the country. I quickly realized that people were here not only from the US, but from around the world. That alone spoke to the power of this course and made us truly excited to be there.
The following morning we met a large crowd in the hotel lobby. After a short shuttle ride, we arrived on Duke’s campus, well maintained and modern with old school charm. We made our way into the building and down to the Human Fresh Tissue Laboratory, an integral part of the Division of Plastic, Maxillofacial, and Oral Surgery and the residency program.
Dr. Zenn explained the course, including the fact that 18 out of 60 people had come from abroad and we were part of a long waiting list of people who wanted to come to Duke. As he continued, an overwhelming feeling came over me; I was in the same room as surgeons who had their names emblazoned on book spines that graced my shelf, or who had hundreds of publications to their credit. People I have heard of day in and day out since before I even began my training. As intimidating as this realization was, we made our way into the lab.
The basic structure of the course was 12 tables with 5 participants per table. There were 6 sessions both days, each lasting 50 minutes, with a break between every 2 sessions. Every table had their own cadaver that was freshly latex injected to highlight the vasculature (if you haven’t witnessed a latex injected cadaver before, watch any of Dr. Zenn’s “Microsurgery Made Easy” YouTube videos). Each group stayed at their respective cadaver as the faculty rotated each session and covered a different anatomic area. At the end of this review I have included a list of the faculty and the flaps covered. The course came with a 127 page dissection guide in which to take notes and follow along. We were also given free access to download iFlap, an app that breaks down many flaps by anatomic area, gives pertinent information about raising that flap, and includes many dissection videos.
No time was wasted. During each break, a different faculty member gave a series of case presentations. From facial artery perforator flaps to A-V loop grafts in free flaps, massive chest wall reconstruction to pedicled fibula flaps for tibial defects, each presenter showed their cases and gave their tips and tricks they have learned over years of experience. To make reverse sural flaps (or other flaps with a skin paddle) easier, make it into a “tear drop” shape so the proximal portion is easier to inset without tension over the pedicle. Many of the hand surgeons do not prefer cross finger flaps and instead recommend homodigital flaps so as to not create a defect in another digit. External oblique flaps are extremely versatile in reconstructing large radical mastectomy and other chest wall defects instead of sacrificing another muscle. It is safe and easy to create long deltopectoral and supraclavicular flaps using multiple delay procedures to reconstruct head and neck defects in patients that may not be candidates for microsurgical reconstruction. And they showed us how to dissect out an ALT in 5 minutes. These are just a few examples of many things I learned during the course.
I can say with confidence that by the end of those two days, I learned and saw more than I could have read in a book and watched on a DVD in a week. Every minute was full of new information or a new way to do something I have seen a dozen times. The drive back was like two kids who had just come back from their first concert. We recapped everything we learned the whole way back to Pennsylvania. Even after that, we couldn’t stop talking about it for weeks.
This course was priceless. Not only in the material that the faculty reviewed, but the discussions that came up about other topics in plastic surgery, differing opinions about certain techniques, and connections that would have been impossible to make otherwise. Dr. Zenn, Mr. Steve Wilson, the lab manager, and the rest of the Duke faculty and residents were so welcoming and accommodating, it made the learning environment that much better. I would like to thank them for a wonderful experience and I strongly recommend this course as almost a requirement for all residents in their more senior years.
Michael Zenn, MD – Duke University
Linda Cendales, MD – Duke University
Larry Colen, MD – Eastern Virginia Medical School
Peter Cordeiro, MD – Memorial Sloan Kettering Cancer Center
Detlev Erdmann, MD – Duke University
Günter Germann, MD – Heidelberg, Germany
Larry Gottlieb, MD – University of Chicago
J. P. Hong, MD – Asan Medical Center, University of Ulsan, Korea
Suhail Mithani, MD – Duke University
Scott Levin, MD – University of Pennsylvania
Peter Neligan, MD – University of Washington
Howie Levinson, MD – Duke University
Chris Pederson, MD – The Hand Center of San Antonio
Justin Sacks, MD – Johns Hopkins University
Joseph Serletti, MD – University of Pennsylvania
Randy Sherman, MD – Cedars Sinai Hospital
Milan Stevanovic, MD – University of Southern California
Back: Latissimus, Serratus, Parascapular
Posterior Leg: Gluteus, SGAP, Biceps femoris, Sural/Reverse Sural
Chest and Neck: Pectoralis, Deltopectoral, Submental, Supraclavicular
Head: Paramedian forehead, Temporoparietal fascia, FAMM
Abdomen: SIEA, DIEP, TRAM/VRAM/rectus, External oblique
Groin: Groin, Singapore, DCIA
Arm: Radial forearm, Lateral arm, Posterior interosseus
Leg: Fibula, Gastrocnemius, Soleus, Medial femoral condyle
Thigh: ALT, Gracilis, TFL, Rectus femoris
Hand and Digit: 1st DMCA, Cross finger, Moberg, Atasoy, Homodigital island, Quaba perforator
Foot Flaps and Toe Transfers: Medial plantar artery, Dorsalis pedis, Abductor digiti minimi, Flexor digitorum brevus, Abductor hallucis longus, lateral calcaneal, Great toe, 2nd toe, 3rd and 4th toe transfers