By William Chris Pederson, MD
The area of surgery known as reconstructive microsurgery should
more appropriately be called “microneurovascular surgery,” as it
encompasses the repair of all small structures in the body using
magnification.
While not truly a specialty, the majority of practitioners
who perform reconstructive microsurgery are plastic surgeons
with some orthopaedic hand surgeons
and otolaryngologists involved in this
type of work, as well.
There are two primary divisions in
this specialty, one which involves surgery
and repair of the peripheral nervous
system, and one which involves the
repair of small blood vessels.
The repair
of peripheral nerves has actually been
around for some time, but the repair of
extremely tiny (1 mm) blood vessels is
a relatively recent development.
The aims of microvascular surgery
involve the “re-plantation” of severed
limbs and the ability to reconstruct
bodily defects by moving tissue from
one part of the body to another and
re-establishing blood supply via repair
of tiny vessels.
Much of the initial research into the
area of anastomosis of tiny blood vessels
was performed in the 1960s by
Dr. Harry Buncke of San Francisco.
He practiced on rat femoral vessels in his
home garage.
The first successful major limb replantation
was reported in 1966 by
Dr. Ronald Malt from Boston.
It involved the re-attachment of a boy’s
arm above the elbow.
The first successful digital re-plantation
(a thumb) was not reported until
1968 by Dr. Susumi Tamai from Japan.
The first successful report of a “free
flap” (a flap removed totally from the
body and re-attached elsewhere via
anastomosis of the blood vessels to the
flap) was not performed until 1973 by
Dr. Ian Taylor in Melbourne, Australia.
These cases spurred interest in the
anatomy of blood supply to various
parts of the body, and today we can
move almost any single type of tissue
and many areas of “composite” tissue
(carrying different types of tissue on
one blood supply).
Currently, reconstructive
microsurgery is utilized in
head and neck reconstruction after
cancer extirpation, in breast reconstruction
after mastectomy, and widely in
extremity reconstruction after trauma
and tumor surgery.
Perhaps the most functional reconstructive
microsurgery procedures are
represented by digital reconstruction
with toe transfer and functional muscle
transfer.
Loss of a thumb in particular
can be devastating to hand function;
however, there is a perfect substitute
in the great toe.
The great toe
can be transferred to the hand, and
with repair of bone, tendons, blood
vessels, and nerves to those of the
thumb, an excellent functional result
can be obtained. The
morbidity of loss of the great toe is
surprisingly small, and most patients
consider the trade of a toe for a
thumb an excellent choice.
The ability to transfer a muscle with
its blood supply and nerve and to reconnect
the muscle to repair muscle loss
or degeneration is another reconstructive
miracle.
This is utilized primarily in the
management of facial paralysis and
injury or paralysis to the muscles in the
forearm or lower leg.
The gracilis muscle
in the thigh works very well for both of
these applications, and with the exception
of the scar, carries no morbidity
with its harvest.
This muscle can be
trimmed and utilized to re-animate the
paralyzed face, or left as is, it can be utilized
to flex or extend the fingers.
When utilized in the paralyzed face, the transferred
muscle can give spontaneous
facial movement.
Reconstructive microsurgery represents
the pinnacle of reconstructive
surgery and has become routine in
many medical centers.
San Antonio is fortunate to have a small but very
active group of surgeons who perform
this type of surgery.
Unfortunately, many young surgeons are not interested,
as the training is long, the hours
are often difficult, and the remuneration
can be poor.
Fortunately, however,
membership in the American
Society for Reconstructive Microsurgery
is on the rise, and hopefully this
trend will continue.
Dr. William C. (Chris)
Pederson is past president
of the American
Society for Reconstructive
Microsurgery and
was formerly Chief of
the Division of Plastic
Surgery at UTHSCSA.
He has practiced hand surgery and reconstructive
surgery for 17 years as a partner
in the Hand Center of San Antonio.
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