Surgeon-Reported Needs for Improved Training in Identifying and Managing Free Flap Compromise

This study examines the need for improved training in the identification and management of free flap compromise and assesses a potential role for simulated scenario training.

Surgeon-Reported Needs for Improved Training in
Identifying and Managing Free Flap Compromise
Catherine McMillan, BSc, MSc1 Veerle D’Hondt, MD1,2 Alexandra H. Marshall, MSc3
PaulBinhammer, MD, MSc1,2 Joan Lipa, MD, MSc1,2 Laura Snell, MD, MS1,2
1Division of Plastic and Reconstructive Surgery, Sunnybrook Health
Sciences Centre, Toronto, Ontario, Canada
2Department of Surgery, University of Toronto, Toronto, Ontario,
Canada
3MarshallMedicalCommunications, Toronto, Ontario, Canada
J Reconstr Microsurg
Address for correspondence Laura Snell, MD, MS, Division of Plastic
and Reconstructive Surgery, Department of Surgery, Sunnybrook
Health Sciences Centre, University of Toronto, 2075 Bayview Avenue,
Toronto, ON, Canada M4N 3M5 (e-mail: [e-mail]).
Free tissue transfer (free flap [FF]) procedures are the method
of choice for the reconstruction of complex defects resulting
from trauma or oncologic ablative surgery.Although the
success rates ofFF procedures are extremely high,1 failure
remains a devastating occurrence,associated with consider-
able postoperativemorbidity and increased health care
expenditures.2–5
Several authors have reported that successful FF salvage
improves significantly when vascular compromise is identi-
fied immediately and the patient is taken back to the
operating room urgently.6–11 The identification of compro-
mise and its management involve an intersection of several
disciplines, each requiring specific training, and the mastery
of technical and nontechnical skills.Due to the urgency of
Keywords
► free flap
► education
► simulation
Abstract Background This study examined the need for improved training in the identification
and managementof free flap (FF) compromise and assessed a potentialrole for
simulated scenario training.
Methods Online needs assessment surveys were completed by plastic surgeons and a
subsample with expertise in microsurgery education participated in focus groups. Data
were analyzed using descriptive statistics and mixed qualitative methods.
Results In this study, 77 surgeons completed surveys and 11 experts participated in
one of two focus groups. Forty-nine (64%) participants were educators, 65 and 45% of
which reported having an insufficient volume ofFF cases to adequately teach the
management and identification of compromise,respectively.Forty-three percent of
educators felt that graduating residents are not adequately prepared to manage FF
compromise independently. Exposure to normal and abnormal FF cases was felt to be
critical for effective training by focus group participants. Experts identified low failure
rates, communication issues, and challenging teaching conditions as current barriers
to training. Most educators (74%) felt that simulated scenario training would be “very
useful” or “extremely useful” to current residents. Focus groups highlighted the need
for a widely accepted algorithm for re-exploration and salvage on which to base the
development of a training adjunct consisting of simulated scenarios.
Conclusion Trainee exposure to FF compromise is inadequate in existing plastic
surgery programs. Early exposure, high case volume, and a standardized algorithmic
approach to management with a focus on decision making may improve training.
Simulated scenario training may be valuable in addressing current barriers.
received
October 20, 2016
accepted after revision
February 23, 2017
Copyright © by Thieme Medical
Publishers, Inc., 333 Seventh Avenue,
New York, NY 10001, USA
Tel: [phone].
DOI http://dx.doi.org/
10.1055/s-0037-1601423.
ISSN 0743-684X.
Original Article
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cases of FF compromise, adequate training of the multidisci-
plinary team responsible for its management is crucial.
Although FF procedures are commonly taught in many
surgical training programs, high success rates inevitably
translate to poor exposure of trainees and staff to cases of
live cases of compromise.As a result,the development and
maintenance ofcompetency in trainees and staffmay be
hindered by an insufficient opportunity to learn and
rehearse.Current re-exploration rates are reported to vary
between 4.4 and 12%,depending on the patient popula-
tion.6,7,12–16This range suggests that residents,microsur-
geons, and nursing staff are underexposed clinically. Another
potential barrier to adequate exposure is mandatory work
hour restrictions on trainees,which has been reported to
increase variability in operative experience.17
Inadequate or inconsistent training in the identification
and management of FF compromise could potentially lead to
the exclusion of FF procedures from future practice by
graduating residents.A need to address the challenges of
transitioning from residency to independentpractice has
been documented,especially with respect to emergency
situations.18,19 One population-based study reported a
shortage of plastic surgeons performing breast reconstruc-
tion, for which FF procedures are common. The authors
indicate that a further decline in active FF practices may
affect access to care and patient wait times.20 A recently
published quality improvement report on breast cancer care
confirms the need for focused and consistent microsurgery
training through recommendations autologous over im-
plant-based reconstruction for women having radiation.21
Existing training programs may require increased focus on
teaching the identification and management of FF compro-
mise. This mixed methods study aimed to determine surgeon-
reported needs in plastic surgery training programs specific to
the identification and management of FF compromise.The
potential for multidisciplinary simulated scenario training
was also specifically explored.The results of this study will
be combined with surveys assessing the needs of nursing staff
and surgical trainees to inform the development of specialized
simulated scenario training for the multidisciplinary team.
Methods
In this prospective needs assessment, plastic surgeons were
invited to complete a survey and a subset of experienced
microsurgeon educators were recruited for expert focus
group discussions.All study methods were approved by
the Institutional Research Ethics Board.
Needs Assessment Survey
A needs assessment survey was developed and piloted to
examine plastic surgeons’training, clinical, and teaching
experience with the identification and management of FF
compromise.Three main themes were identified through a
series of team meetings.
A pilot questionnaire was structured to include the themes:
(1) current clinical experience with FF compromise; (2) previ-
ous training in the identification and managementof FF
compromise; and (3) involvement in the education of
residents and fellows specific to FF compromise.Questions
regarding the potentialvalue of simulation in teaching the
identification and management of FF compromise were incor-
porated into each section. The pilot questionnaire was tested
by two plastic surgeon educators and two clinicalresearch
professionals for feedback on content, readability, and time to
complete. Each reviewer examined a paper copy of the ques-
tionnaire and provided written feedback.Reviewers’com-
ments and edits were discussed and incorporated prior to
translation into a web-based version and final approval.
The final questionnaire consisted of 35 questions in three
sections: (1) current practice,(2) previous training,and (3)
involvement in education.To permit both descriptive and
comparative analyses,the survey included short answer,
multiple choice, and long answer questions.
Active members of the Canadian Society of Plastic Sur-
geons (CSPS) were invited to complete the needs assessment
questionnaire (n ¼ 362) via an e-mail link. Although not all
plastic surgeons in Canada are members ofthe CSPS,the
active member roster was assumed to represent practicing
plastic surgeons in Canada (n ¼ 599).22 An electronic gift
card incentive was provided upon survey completion. A
second invitation was e-mailed to nonresponders, after
which, nonresponders were considered unreachable.
Focus Groups
A one-page focus group guide developed through a series of
team meetings was used to facilitate seven questions. Focus
groups aimed to explore expert opinion surrounding:(1)
requisites of adequate training in the identification and
managementof FF compromise, (2) current barriers to
adequate training,and (3) the potential for simulated sce-
nario training to enhance existing programs.The expected
duration of each group was 45 to 60 minutes.Focus groups
were limited to six participants and the number of groups
would depend on the number of available participants.
An international sample of 18 expert microsurgeons with at
least 3 years of experience,training residents,and fellows
were invited to participate. Potential participants were known
experts in microsurgery and were recruited via e-mail. Focus
groups were held at an international microsurgery conference
and each group was facilitated by a clinical fellow who had
received training in moderating focus groups. All focus groups
were recorded and transcribed verbatim for qualitative
analysis.
Analysis
Descriptive statistics and summaries were used to present
the demographic distribution of participants and survey
responses.Means and percentages were used for compar-
isons of continuous data.
An integrated approach combining an inductive develop-
ment of codes with a deductive organizing framework was
employed to analyze focus group transcripts. Code structure
was organized by the following predefined domains:(1)
requisites of adequate training,(2) barriers to adequate
training, and (3) the potential for simulated scenario
Journalof Reconstructive Microsurgery
Training in Free Flap CompromiseMcMillan et al.
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training. Beginning with a line-by-line analysis of tran-
scripts,initial codes were defined and themes were identi-
fied. Transcripts were coded independently by the focus
group moderator and a clinicalresearch professionalwith
previous experience conducting qualitative analysis.Codes
and categories were refined throughout the process as new
themes and subthemes emerged. Coders discussed and
reached agreementon discrepancies upon completion of
the analysis.
Results
In this study,66 active members of the CSPS responded to
the survey (response rate 18%) and 11 experts responded to
the focus group invitation (response rate 61%).Fifty-five
surgeons (71%)reported that they currently perform FF
operations,while 22 (13%) have never included FF proce-
dures in their practice. Characteristics of the survey sample
and estimated FF compromise case loads are summarized
in ►Table 1 . Twelve surgeons (16%)reported no longer
performing FF procedures after a period of including
them in practice,citing personalchoice,diminished inter-
est, and lack of hospital support as reasons. Of those with a
current FF practice,27% reported that their affiliated insti-
tution uses a standard protocol for managing a compro-
mised FF; however, 44% rated their own familiarity with an
intraoperative protocol as “extremely unfamiliar.” Details of
survey participants’own training experience willbe pub-
lished separately.
The subsample of 49 educators consisted of those actively
involved in teaching residents through clinical rotations and
included seven residency program directors (five current)
and two committee members. ►Table 2 lists the most
commonly reported teaching methods for the identification
and management of FF compromise.►Fig. 1 presents edu-
cators’ opinions about their own rotations and residents.
Requisites of Adequate Training
►Fig. 2 displays survey respondents’estimates of the mini-
mum required exposure to compromised FF cases needed for
adequate training in a 5-year program.While 65 (83%) of
respondents felt that residents should begin learning iden-
tification in junior residency (first or second year), 54 (70%)
felt that residents should begin learning managementin
senior residency (third year or higher).
►Table 2 presents the results of the focus group analysis.
Focus groups indicated that clinicalexposure is the most
crucial element in learning to identify and manage FF
compromise.Some experts felt that exposure to a high
volume of nonfailing FF cases during residency is also
particularly important. Participants felt that effective knowl-
edge transfer requires a mixed methods approach of intra-
operative exposure and interactive bedside teaching and
rounds. Patient photographs were cited as an effective aid
in education and communication.Early exposure and the
willingness of residents to be present for re-explorations
were also frequently asserted as being critical for adequate
training.
Although experts believed that successful identification of
compromise relies on a thorough understanding of physiol-
ogy, monitoring techniques,and intuition, most felt that a
framework addressing the decision-making and action steps
is essential for teaching management. The perceived clinical
value of a widely used algorithmic approach was also high
due to the need to reduce stress, increase transparency, and
improve communication.Experts also recommended that
the framework included process of care aspects and support
each type of FF.
Table 1 Characteristics of study participants
Total
sample
(n ¼ 77)
Educators
(n ¼ 49)
Focus
group
(n ¼ 11)
Current practice
Years in practice
(mean)
14 13 12
Country of practice
Canada 67 (87%) 39 (80%) 1 (9%)
United States 8 (10%) 8 (16%) 8 (73%)
Belgium 2 (3%) 2 (4%) 2 (18%)
Practice setting
Academic 42 (55%) 35 (71%) 9 (82%)
Community 25 (32%) 6 (12%) –
Mix 10 (13%) 8 (16%) 2 (18%)
FF in current practice
Yes 55 (71%) 47 (96%) 11 (100%)
No 22 (29%) 2 (4%) –
Discontinued FF 12 (16%) 2 (4%) –
FF performed
Extremity 45 (58%) 39 (80%) 8 (73%)
Breast 34 (44%) 29 (59%) 10 (91%)
Head and neck 25 (32%) 21 (43%) 8 (73%)
Other 6 (8%) 6 (12%) 2 (18%)
None 22 (29%) 2 (4%) –
FF case load (12 mo)
> 40 15 (19%) 13 (27%) 8 (73%)
11–40 23 (30%) 21 (43%) 3 (27%)
10 17 (22%) 12 (24%) –
0 22 (29%) 2 (4%) –
FF re-exploration (12 mo)
Zero cases 21 (27%) 16 (33%) 2 (18%)
One to
two cases
29 (38%) 28 (57%) 8 (73%)
Three or
more cases
5 (6%) 3 (6%) 1 (9%)
Not applicable 22 (29%) 2 (4%) –
Abbreviation: FF, free flap.
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Training in Free Flap CompromiseMcMillan et al.
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Barriers to Adequate Training
The educational value of intraoperative teaching in cases of
re-exploration and salvage was emphasized by focus groups,
although teaching in an emergent situation was acknowl-
edged as a barrier to knowledge transfer. Mindset and
motivation of the educating surgeon were feltto impact
residents heavily and experts advocated narration ofthe
thought process throughout re-exploration and salvage.
Focus groups felt that a lack of exposure to abnormal cases
is a barrier to adequate training. Contributing factors includ-
ed low revision and failure rates, work hour restrictions, and
lack of trainee motivation. Other barriers to training included
the inability to slow down or simulate on real patients,
limitations of photo- and video-based teaching,and the
lack of a universal protocol.Some experts cited exceptional
nursing staff as a barrier to learning identification and felt
that communication could improve between residents and
nursing staff during shift changes. Finally, many participants
acknowledged the high-stress circumstance of FF compro-
mise and had concerns about whether knowledge can be
conveyed effectively to residentsduring an emotionally
heightened situation.
Simulated Scenario Training
►Fig. 3 summarizes educators’opinions about including a
simulated scenario training adjunct to existing curriculum
and its potential usefulness in teaching the identification and
management of FF compromise.Experts felt that the use of
simulated scenario training could address the major current
barrier to adequate training, which is low exposure. Experts
had mixed opinions on simulated scenario training for
teaching the identification of FF compromise, generally
believing that its value would be limited in training pro-
grams.Most participants agreed that simulation could be
useful for teaching management,provided it is developed
robustly, from a stepwise algorithm, for the target audience,
Table 2 Common methods used to teach the identification and
management of FF compromise
Teaching modality Identification Management
Bedside/clinical/hands-on34 25
Intraoperative 19 27
Formalized
lecture/seminar
24 17
Informalteaching
(rounds, quiz)
14 15
Photos 3 2
Laboratory/simulation 2 0
Report/literature review 1 2
Journalclub 1 0
Abbreviation: FF, free flap.
Note: n ¼ 49.
Fig. 1 Educators’ opinions about their own rotations and residents with respect to case load and adequacy of training (n ¼ 49).
Fig. 2 Estimated minimum exposure to compromised FF cases
needed for adequate training of plastic surgery residents in a 5-year
program (n ¼ 77). FF, free flap.
Journalof Reconstructive Microsurgery
Training in Free Flap CompromiseMcMillan et al.
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and is highly sophisticated.Experts emphasized that simu-
lated scenario training would enable earlier exposure to the
concepts,thought processes,and action steps involved in
managing FF compromise regardless of whether a live case
has occurred on a rotation. Another perceived benefitof
simulated scenario training for the management of FF com-
promise was its potential to ease the pressure of educating
residents in an urgent clinical situation (►Table 3).
Discussion
This study clarifies requisites of training for residents in
identifying and managing FF compromise,in addition to
revealing severalcurrent barriers. Our findings indicate
that simulated scenario training may be able to provide
residents with early-stage structured exposure to the knowl-
edge and decision-making skills that are crucial for the
management,and to a lesser degree,the identification of
failing FFs.
Clinical exposure, early introduction, and the use of
structured content were emphasized as crucial factors nec-
essary for adequate training.Our results suggest that resi-
dents may be underexposed to live cases of compromised
FFs. The majority (65%) of surgeon educators reported having
an insufficient volume to adequately teach the management
Fig. 3 Educators’ 5-point scale ratings of the perceived usefulness of
simulated scenario training in the identification and management of
FF compromise to current residents (n ¼ 49). FF, free flap.
Table 3 Themes and subthemes emerging from focus group transcripts
Major theme Subtheme Expert opinions/quotations
Requisites of
adequate
training
Early clinicalexposure to
normal/abnormalFF
“...papers, etcetera, it’s all very interesting, but it’s nothing compared to clinicalexposition.”
“...expose [residents] to a high volume of non-failing flaps, so they just gain expertise in
identifying what a normalflap should look like so that it’s easier to identify the abnormal.”
Formalized teaching
content
“Day one-the first minute of day one [the introduction to free flap compromise] should be
formalized.”
“... [if] there’s an algorithm that they know so well that they can follow it, even if there is panic,
stress, that you can’t see, that you’re just blinded by fear, at least you’re able to say okay,...this is
what I have to do.”
Interactive knowledge
translation
“The immediate bedside exposure, I think makes a huge difference.”
“Tell them - live and aloud – why you doubt, why you say I think we have to hook on that second
vein. Do the reasoning hard – aloud – so that they understand. I think that’s very important.”
“We have a setup where every complication [is] discussed...we discuss every trap, every pitfall,
this happened to me, this happened to him, how to manage- how we could manage, how we
can prevent that.”
Teaching mindset/attitude “It’s extremely important for residents during training, to see that a surgeon goes back during
the [re-exploration] operation”
Barriers to
adequate
training
Resident training opportu-
nities are infrequent
“...fortunately the revision rate is quite low. So if [residents] don’t get exposed to a much larger
number of different reconstruction free flaps,... probably [they] finish training with [seeing FF
compromise] maybe twice, three times, by chance, if [they] are on call.”
Lack of universalframe-
work for teaching
management
“…without [an algorithm] it’s like throwing a five year old in a swimming pool and saying okay,
now sense yourself how to swim.”
“The algorithm is probably even more useful[in early residency], to kind of put something,
some framework, into their mind already, that they can then dress up as they gain experience.”
Difficult teaching settings
with little focus on non-
technicalskills
“When a flap is going down and you’re taking it back, you’re not really in ‘teaching mode’ and
yet, that is actually the time that there’s most to be learned.”
“... we don’t articulate it, we just see it and we know the patterns and we take a lot of
information in and process it and we know what the answer is. But we aren’t always as good at
going through the information”
Simulated
scenarios as a
training
adjunct
Simulated scenarios would
be usefulfor training
residents in management
“I think if you can get people in early thinking about these steps, even in a simulation the same
way, now they can convey at least some of that information.”
“[for] management, there’s stuff to do, you know; there’s cutting the LPA segment of artery
out; there’s using the Fogarty catheters for a thrombectomy. There’s different stuff that you
can do and you could probably simulate that.”
Simulation must be frame-
work-based, intended for
students, and
sophisticated
“I think what we’re allsaying is that it is pretty subtle and if it’s low fidelity, it probably isn’t
going to be that useful. If it’s very high fidelity, it’s incredibly useful because of the low event
rate, that we just don’t see it that much.”
“I think if you have the technology available to make it sophisticated enough…we should all use
it. There is not one single second a doubt about it, but it should be sophisticated enough.”
“If [simulated scenario training] is detailed, oh, then it’s a magnificent tool, then it’s a fantastic
tool.”
Abbreviation: FF, free flap.
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Training in Free Flap CompromiseMcMillan et al.
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of FF compromise and almost half reported having too few
cases to teach identification.These findings and the low
number of take backs reported by educators in this study
reiterates the need to enhance existing training curricula.
Reports showing up to an 8.2% decrease in take-back rates
over time reflect improvements in cumulative experience,
instrumentation and microscope advancements, and enhanced
technology and communication.2,4,23–26
Although longitudinal
variation in trainee exposure to FF compromise has not been
formally examined, a decline in re-exploration rates observed
over the past severaldecades2,4,26,27implies that trainee
exposure to FF compromise has also decreased.
Deliberate practice,which is defined as individualized
training to improve specific aspects of performance through
repetition and successive refinement,28 is one method that
may be able to address insufficient clinical exposure. The use of
deliberate practice has been reported to predict professional
accomplishment more strongly than experience and academic
aptitude28–31 and has been noted by severalauthors as a
critical step in the development of expertise.28–33 Evgeniou
et al determined that adequate practice improved not only
practical microsurgical skills but also cognitive skills in fellow-
ship training.34 Enabling deliberate practice in the identifica-
tion and management of FF compromise would permit
residents to develop expertise and rehearse skills in a con-
trolled and safe environment without relying on live cases.
The importance of developing the nontechnical skills in-
volved in the surgical specialties has been documented19,35–37
and the importance of communication in the postoperative
period after a FF operation has been specifically identified.38
Opinions concerning the point at which residents should begin
learning the identification and management of FF compromise
varied in our sample with all 11 experts recommending early
exposure to identification and management and only 30% of
survey respondents recommending early exposure to man-
agement.Experts felt that early exposure to formalized con-
tent creates a “mindset” that can later be complemented with
clinical training. The importance of mindset has been
highlighted in a study by Evgeniou et al,reporting that the
ability to expect the unexpected in microsurgery training is
transformative for fellows, while also challenging.34 Methods
to expedite basic competency in less-frequently performed
procedures have been endorsed in general surgery.18In plastic
surgery, authors concur that variable experience among train-
ees creates a need to reform educational curricula.32
The creation of a universal protocol for the management
of FF compromise was highly recommended by the experts in
this study. Participants felt that the pace and mindset
required for successful outcomes limits the ability to concur-
rently teach residents effectively.Despite a reported famil-
iarity with salvage protocols,the unintentional automation
of nontechnical skills during re-exploration and salvage may
hinder knowledge transfer.The automation of surgical pro-
cedures by experts has been recognized as a potential barrier
to teaching procedural knowledge to novices,28,32,39partic-
ularly for complex procedures.39,40The omission of knowl-
edge may be further exacerbated by high cognitive and
technical demands.
Groups reporting the use of a structured, stepwise approach
in FF salvage have demonstrated a positive impact on out-
comes.3,8 Additionalbenefits of an algorithmic approach to
microsurgery include facilitating a diagnosis and minimizing
unpredictablefailures.41–44 while improvementsin out-
comes45 and knowledge transfer46,47have been reported in
other specialties.
Several schematic algorithmic approaches to FF re-explo-
ration have been reported as group or institutionalstand-
ards8,41,48–50
; however, no widely accepted or implemented
protocol was described by the participants in this study, nor
are the authors aware of structured content developed for
training purposes.
A set of recommendations for supporting the transition
from training to independent practice published in 2014
strongly proposes the use of competency-based methods for
training, assessment, and advancement of residents in surgical
specialties.19 In addition to providing a means for improved
knowledge transfer, the development of a competency-based
training adjunct for FF compromise would address the lack of
formal evaluation reported in this study. Learner evaluation in
surgical training is also suggested to promote self-efficacy in
graduating residents and provides a metric for frequency and
context of exposure to a procedure.19,51
Participants in this study favored the use ofsimulated
scenarios to teach residents how to manage failing FFs.The
idea of teaching identification using simulated scenarios
yielded mixed opinions from experts and was supported
by fewer survey respondents.Further investigation will
clarify the most appropriate teaching method for identifica-
tion of FF compromise.
Knowledge translation involved in teaching the manage-
ment of a compromised FF may lend itself well to simulated
scenario training. Simulation allows learners to practice tech-
nical and nontechnicalskills such as decision making and
teamwork in a safe, reproducible, and controlled environment.
Simulation training has been associated with improved patient
outcomes and has become an essentialtool at all levels of
medical training.1,45,52–59
Flurry et al found that a simulated
scenario course in caring for microsurgery patients for nursing
staff was effective and rated highly.52 Simulation training has
also been demonstrated to effectively train teams for obstetric
cardiac arrests (codes), which are rare and complex, similar to
FF compromise.57 As an adjunct to existing plastic surgery
training programs, case-based modules with variable param-
eters could provide early exposure and introduce nontechnical
processes in the absence of clinical cases to accelerate certain
aspects of training. A subsequent needs assessment of plastic
surgery trainees will provide further evidence of the potential
for simulated scenario training for the management ofFF
compromise.
This study is limited by a possibly weighted sample and a
low response rate.The number of microsurgeons and edu-
cators in our sample is likely higher than that of the average
population of plastic surgeons identified for study inclusion.
In addition, we did not invite otolaryngologists to participate
in this study,limiting the generalizability.The implications
of study designs lacking in appropriate controls have been
Journalof Reconstructive Microsurgery
Training in Free Flap CompromiseMcMillan et al.
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discussed in the literature60; however, qualitative analysis is
supported as a crucial method for gaining insight into
multilayered and complex challenges in education re-
search.61 While a weighted sample may have skewed our
data toward the opinions and experiences of the more
enthusiastic educators,this implies that the widespread
need for improvement in training is even greater than
presented in our results.
Despite a gift card incentive, our overall survey response
rate was low (18%). We attribute a low response rate in part
to the high specificity of the topic and to the likelihood that
surgeons without a microsurgery practice may have disre-
garded the survey invitation based on the project title.
E-mails obtained from the CSPS annual program may have
also been outdated,resulting in some participants never
actually receiving the invitation.
Conclusion
This study demonstrates inadequate and inconsistent expo-
sure of plastic surgery trainees to compromised FFs, as well
as a lack of structured content and evaluation.Our results
strongly support bridging this gap by developing an evi-
dence-based algorithm to teach the managementof FF
compromise,and by subsequently creating several learner-
focused simulated scenarios to complement existing
training.
Acknowledgments
This work was supported by the Sunnybrook Education
Advisory Council (SEAC) and Education Research Unit
(ERU).
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