A Journey to Japan: Travel Fellow Observes Cutting-Edge Microsurgery

At Toffeln, our vision of enabling better healthcare extends beyond providing world-class footwear and innovative surgical products. As a long-term supplier to healthcare (45 years and counting), we are passionate about giving back and are proud to have partnered with the Royal College of Surgeons of Edinburgh (RCSEd) with their Travelling Fellowship Programme. This initiative sponsors a budding trainee surgeon to gain international experience by learning advanced surgical techniques that they can bring back to the UK.
In June 2024, our sponsored Travel Fellow travelled to Tokyo to learn from Professor Takumi Yamamoto, a globally recognised expert in microsurgical reconstruction. Hosted by the National Center for Global Health and Medicine (NCGM), this observership focused on the intricate technique of harvesting thin, soft tissue free flaps for advanced reconstructive surgery.

UK practice traditionally involves harvesting fasciocutaneous flaps, this observership programme enabled our Fellow to explore the Pure Skin Perforator (PSP) technique, which achieves greater precision by raising flaps at the dermis level and minimises the need for secondary thinning and expanding – Clever stuff!

Our Fellow's Experience: Learning from a Master Surgeon

Read his full story below:

Observership in the National Center for Global Health and Medicine NCGM

RCSEd Toffeln Travelling Fellowship
Tokyo, Japan
17th-30th June 2024

I travelled to Tokyo to learn how to harvest thin, soft tissue free flaps. The common practice in the UK is to harvest fasciocutaneous flaps when reconstructing head and neck defects. The thickness of the flap depends on how much fat is between the dermis and the deep fascia. The decision of which soft tissue flap to harvest is often driven by this. Tokyo is home to one of the microsurgical masters in raising thin flaps. Professor Takumi Yamamoto raises free flaps at the dissection plane required for the defect, rarely having to perform secondary flap thinning. He has published the technique of raising flaps at the level of the dermis, the Pure Skin Perforator flap. This is effectively a vascularised skin graft and is the limit of how thin a free flap can be. I was hopeful to see this technique during my visit.

I met Professor Yamamoto in his outpatient department. He is a plastic surgeon with a large part of his work devoted to lymphoedema and lower limb reconstruction. He took the time to explain some of his concepts which he has put into practice and popularised. The first was the Lymph-Interposition-Flap-Transfer reconstruction (LIFT). Lymphatic vessels are transferred from a donor site to an area with poor lymphatic drainage, in the correct orientation.  He uses indocyanine green and Ultrasound to plan his reconstructions in the outpatient setting. The latter I have already incorporated into my practice and the former appears to be a valuable tool to make reconstruction more reliable. 

The first case was a Superficial Circumflex Iliac Artery Perforator (SCIP) flap with a LIFT chimeric component. The SCIP flap is a useful addition to a reconstructive surgeon’s armamentarium. Two lymphaticovenous anastomosis were also being carried out by his team. With considered planning, four microsurgeons with three microscopes were all working simultaneously. This economy of space is something I wish to employ in my practice.

I observed another SCIP flap, yet this time it was a PSP for an ankle defect. The dissection technique was wonderful. Only the Colorado Needle and Addison Forceps were used for the entirety of the harvest. An intralobular pedicle dissection technique was executed masterfully and the whole procedure was bloodless. These skills are required if flaps are to be raised in planes more superficial to the deep fascia.

In addition to observing a master of his craft I was also lucky to have many conversations about reconstruction with Professor Yamamoto and his team. The ideas and concepts will undoubtedly influence my practice upon my return home.
Tokyo is the largest city in the world. I only saw a fraction of it. To escape the crowds, I took a 2-hour bullet train 600km to climb Mount Iwate, a volcano on the North of the island.

I thoroughly enjoyed my trip to Japan. I feel like I have observed the limits of what can be achieved when harvesting thin free flaps. Incorporating some of these skills into my practice will allow the refinement of reconstructions and offer other potential donor sites for free tissue transfer.

I am grateful to the RCSEd, Toffeln and Professor Yamamoto for their support during this observership.

Fig. 1 - NCGM, Tokyo

Fig. 2 - Professor Yamamoto  (3rd from left) presenting me with an observership certificate

Celebrating Our Fellow's Achievements and Impact on UK Healthcare

It's clear that the time spent observing Professor Yamamoto and his team has been transformative for our Fellow. We are incredibly proud to have supported him through his journey to Japan, knowing that the skills and knowledge he has gained will not only enhance his career but will also promote better patient outcomes by bringing his new knowledge of the pioneering PSP technique back to the UK.

Beyond the operating theatre, it's good to see our Fellow fully embraced the diverse culture of Japan, with his journey ending in a triumphant climb up Mount Iwate, still an active volcano that takes an average of 8 hours to climb—a perfect symbol of the determination and ambition demonstrated throughout this experience.