Is There a “Learning Curve” for Muscle Perforator Flaps?

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Although soft tissue free flaps have been in the mainstream for over 40 years, muscle perforator flaps per se are a relatively recent addition to the armamentarium of the reconstructive microvascular surgeon. Even though actually only a fasciocutaneous flap subtype, a distinctively different approach is necessary for their safe and reliable use, which has deterred many from adopting this valuable asset for fear of not being able to master an implied “learning curve.” Whether this is a justifiable excuse led to our examination of our original microsurgical experience from 1982–1986, which in retrospect had its own learning curve. All 30 soft tissue flaps during that initiation period were muscle free flaps, which not only had a now unacceptable 37% major complication rate but also a complete failure rate of 26% due specifically to our technical inadequacies with the requisite microanastomoses. When compared with our first 30 muscle perforator flaps, there was a similar incidence of major complications (30%), although the eventual transferred flap success rate was 97%. This confirmed the existence of a learning curve in our preliminary experience with muscle perforator flaps that was consistent with any surgical innovation. However, our microsurgical prowess by this time had facilitated the acquisition of the skills to comfortably harvest a muscle perforator flap with a very acceptable success rate that minimized the steepness of our particular learning curve. Just what will be the configuration of the unavoidable muscle perforator flap learning curve specific for each individual will depend on their own capabilities, the relative technical difficulty of a given flap, and the level of competency expected.

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