Humanity first pondered limb reattachment and organ transplantation centuries ago; however, the introduction of the monocular microscope into the operating room only recently led these contemplations to reality. A series of refinements to the primitive microscope throughout the 1900s has led to today’s advanced operative microscope—an apparatus that is instrumental in numerous surgical fields. In particular, plastic surgeons make frequent use of microsurgical techniques in traumatic and oncologic reconstruction, gender affirmation, lymphedema, extremity conservation, and congenital repair. Microsurgical principles are recognized as critical to the training of plastic surgeons; therefore, residency programs now universally incorporate significant microsurgical experience into core curricula. Furthermore, surgeons interested in advanced training can select from 58 formal microsurgery fellowship programs sponsored by the American Society for Reconstructive Microsurgery.2
Although hand fellowship continues to receive the most applications,1 the popularity of microsurgery has been increasing in recent years (Fig. 1). However, unlike hand and craniofacial fellowships, microsurgery is not formally accredited by the Accreditation Council for Graduate Medical Education (ACGME) (Table 1). This may relate to the relatively recent prominence of microsurgery as a specific subspecialty unto itself. Notwithstanding this and other factors, it is time that microsurgery fellowships receive formal recognition by the ACGME.
FIG. 1.
Trend of microsurgery applicants who submitted rank lists through the San Francisco (SF) Match during the years 2014 to 2021.2
TABLE 1.
Characteristics of Common Plastic Surgery Fellowships*
| Fellowship | Prerequisite Residency Training | Length, mo | Total Number of Programs in the United States | No. Accredited Programs in the United States |
|---|---|---|---|---|
| Microsurgery | Plastic surgery | 12 | 58 | 0 |
| Hand | Plastic surgery, orthopedic surgery, general surgery | 12 | 91 | 84 |
| Aesthetics | Plastic surgery | 6–12 | 24 | 0 |
| Burn | Plastic surgery, general surgery | 12 | 26 | 0 |
| Craniofacial | Plastic surgery | 12 | 30 | 8 |
*Information gathered from the American Burn Association, San Francisco (SF) Match and National Resident Matching Program (NRMP) data.
Though this is not the first call for support for microsurgery accreditation, lack of forward progress warrants revisitation. Advantages of formal recognition include standardized training criteria and guidelines, improved identification of experts within the field, and the potential for increased research funding.3,4 Additionally, hospitals are more likely to recognize fields with formal accreditation as distinct subspecialities. Prior criticisms of ACGME accreditation include the risk of fragmenting plastic surgery and minimizing the role of microsurgical techniques in all areas of plastic surgery.3,4 However, we believe there is no empirical basis for these assertions. Furthermore, there is a distinction between basic microsurgical techniques taught in residency programs to complex microsurgical reconstruction practices by fellowship-trained microsurgeons. Additional potential benefits of accreditation include institutional financial support for trainees for accredited fellowships as well as increased compensation for surgeons with ACGME-recognized fellowship experience. Indeed, this may have implications for trainees deciding whether to pursue a fellowship.
Importantly, the need for fellowship-trained microsurgeons is likely to grow as the complexity of reconstructive surgery amplifies. Outcome data increasingly suggest the superiority of microsurgical reconstructive options; thus, hospital systems may insist on specialized training for reconstructive surgeons. In addition to improved outcomes, microsurgical reconstruction generates substantial revenue, which may further bolster hospitals’ preference for fellowship-trained surgeons.5
Like microsurgical fellowships today, early discussions of the utility of ACGME subspecialty recognition for hand surgery were characterized by uncertainty. However, formal accreditation has served the field well by formalizing training (ie, required case log and official examination), by improving visibility of experts within the field, and by increasing research.4 To that end, formal recognition of microsurgery is important, timely, and would serve to benefit key stakeholders including surgeons, patients, and hospital systems.
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
Footnotes
Published online 8 October 2021.
REFERENCES
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