Microsurgeons often track flap survival as the main sign of success, a measure Dr. Geoffroy Sisk considers necessary but incomplete.
Dr. Sisk is an assistant professor in the Division of Plastic, Oral, and Maxillofacial Surgery at Duke University School of Medicine in Durham, North Carolina. He presented ‘Flap around and find out: 5 rules for optimizing reconstruction’ at Plastic Surgery The Meeting 2026, organized and hosted by the American Society of Plastic Surgeons (ASPS). The meeting was held October 15 to 18, 2026, in Houston, Texas. His talk was part of the panel ‘Flap-off: the reconstruction bowl - what would you do when the going gets tough?’ His rules shift attention from the anastomosis to the decisions around it.
Two of the rules address failures that have little to do with operative technique. ‘Don't confuse flap survival with reconstructive success,’ he said. In microsurgery, he explained, reconstructive failures often stem from decision-making. ‘Execution is important, but ultimately, planning is what drives our success. And fortune does favor the prepared mind.’ The same logic applies after the anastomosis. For a reasonably skilled microsurgeon, ‘the case really starts after the micro,’ because a tight inset can undo a good anastomosis. He likes using troughs to place the pedicle where he wants it. ‘Your patient is going to move. The flap is going to swell. You just have to plan for that.’
Successful Flap Reconstruction Depends on More Than Defect Coverage
Two more rules widen what surgeons consider when designing a flap. The first asks them to stop thinking in 2 dimensions. A defect has length and width, but depth also matters: a bulky flap may not suit a thin defect, and a thin flap may not suit a bulky one. Time adds a fourth dimension. ‘Time tests the work that we do, and ultimately function determines whether anything that we do matters,’ he said. ‘Anybody can cover a defect.’
The second is to capitalize on vascular anatomy, which he called ‘really robust’ and ‘very redundant.’ He urged surgeons to ‘resist the desire to feel constrained by the conventional way of doing things.’ One defect need not mean one flap, and multiple flaps sometimes work best. Even so, he challenged surgeons to ask whether a single flap could do the job.
Surgical Principles Make Room for New Ideas in Microsurgery
His final rule ties the others together. ‘Don't be afraid to get a little bit weird,’ he said. ‘It's fun and it helps.’ The best solution may be one nobody has tried, which need not dissuade surgeons if the idea is rooted in principle; several of his own such ideas are moving toward publication. ‘In my professional career, there's been nothing more fulfilling than having an idea that you don't think anybody else has had before, trying it out and watching it succeed,’ he said. In a specialty built on principles, he argued, creative thinking means ‘understanding the rules well enough that you're able to imagine possibilities that nobody else has before.’