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Reconstructive microsurgery is a surgical field where specialized operating microscopes and precision instrumentation are utilized to perform intricate operations on tiny structures.
Utilizing magnification up to fifty times that produced by the naked eye and stitches finer than a hair, surgeons are able to repair transected blood vessels and nerves less than 1mm in diameter.
The ability to reestablish continuity and blood flow to small, severed nerves and vessels has made a major impact on the potential to restore form and function to individuals impaired by trauma, cancer and congenital differences. Advances in technology and surgical technique in the early 1960s for the first time allowed surgeons to successfully replant severed digits and limbs.
This innovation was rapidly followed by the development of vascularized toe transfers that allowed relocation of toes to replace missing fingers. The thumb accounts for approximately fifty percent of the hand’s function and the ability to utilize the great toe to replace a missing thumb was a major advancement in the surgical rehabilitation of the injured hand.
The dawning of the 1970s ushered in the development of the free flap where by surgeons could borrow tissues from regions of relative excess including skin, muscle, bone and intestine and transplant them, utilizing microvascular techniques, to cover wounds and restore missing structures. Free flaps, also know as free tissue transfers have provided a powerful tool for reconstructive surgeons in the treatment of cancers of the head and neck, breast and extremities. They have also proved invaluable in the salvage of complex extremity injuries and open fractures. Major strides have also been made in the microsurgical treatment of the injured nerve. Many peripheral nerve injuries once deemed hopeless can now be successfully managed allowing for the return of lost motion and sensation. The architecture of divided nerves can be precisely restored with the aid of the operating microscope. Damaged or missing nerve segments can be replaced by grafting pieces of expendable sensory nerve branches (nerve grafts) providing new hope for individuals with facial paralysis and injury to the brachial plexus.
Smaller nerve gaps can be bridged with nerve guidance tubes fashioned from various absorbable materials. Decellularized cadaveric nerve grafts provide an additional option for spanning nerve gaps. Technical advances in nerve repair have provided the opportunity to transplant functioning muscles to restore motion to paralyzed faces and extremities. Nerve transfers have also proved to be an effective new tool. Nerves that are expendable or have branches with duplicated function can be connected to injured nerves to restore motion and sensation.
Reconstructive microsurgery has witnessed major advancements in the last decade including the emergence of hand and face transplantation. These techniques are providing a new lease on life for severely injured patients whose problems cannot be solved by more traditional techniques. Advanced computing and robotics continue to foster the expansion of more precise and minimally invasive surgeries while the potential to biologically engineer missing tissues and structures (tissue engineering) offer an exciting gateway to the future.
Case Study 1: Traumatic Injury to the Ankle with Open Fracture
A fun outing turned serious when this young passenger was dragged and crushed by an overturned golf cart. She sustained a limb threatening injury with a significant loss of foot skin, fracture of the ankle bones and joint contamination. She was urgently taken to the operating room where grass, dirt and foreign material were removed and the wound was spray-washed with gallons of antibiotic solution. Small beads saturated with antibiotics were left in the wound in an effort to fight infection. This surgical treatment was repeated until the foot and ankle wounds were clean and infection free. The permanent reconstruction was then undertaken. A long, thin muscle (gracilis) was borrowed from the inner thigh and utilized to cover the exposed bones, joints and tendons in the foot and ankle. With the aid of the operating microscope, tiny stitches and fine instruments were used to connect the muscle’s artery and vein into the sides of vessels in the ankle restoring circulation and allowing the muscle to survive in the new location. The transferred muscle (free muscle flap) was now resurfaced with a thin shaving of skin (split thickness skin graft). After a period of healing and rehabilitation she is able to walk in regular shoes without the need for a cane or walker.
Case Study 2: Jaw Reconstruction
This young woman sought medical advice regarding a slowly enlarging, painless mass involving the lower jaw. Imaging studies and a biopsy were consistent with a benign locally destructive tumor (ameloblastoma). The tumor incorporated the central part of the jaw and was removed through an incision inside the mouth. A segment of pelvic bone and its accompanying blood vessels were removed and shaped to create a new jaw with the aid of a computer-generated model. The reconstructed jaw was anchored into position with titanium plates and screws and the associated artery and vein were connected to vessels in the cheek with fine instruments and tiny stitches under the operating microscope. After the initial healing period the new jaw can be fitted with dental implants to complete the restoration.
Case Study 3: DIEP Flap Breast Reconstruction
With a young family, advancing career and active life style a suspicious result on a routine mammogram was an unwelcome finding. A needle biopsy confirmed breast cancer, a diagnosis faced by one in nine women in the United States. After thoughtful consultation with her cancer doctors and plastic surgeon she decided to proceed with bilateral mastectomies and immediate reconstruction. Past pregnancies had left her with excess tissue in the lower abdomen. This redundant skin and fat was removed along with its nutrient blood vessels (deep inferior epigastric artery and vein) that were freed from their connections to the abdominal muscles. The abdominal muscles were preserved in an effort to maximize postoperative function. This composite of skin, fat and blood vessels (Deep Inferior Epigastric Perforator Flap) was now transferred to the anterior chest and shaped to create new breasts. Utilizing an operating microscope, fine sutures and precision instruments the blood vessels previously residing in the abdomen were connected to chest vessels in the new location restoring circulation to reconstructed breast. After a period of initial healing, a subsequent nipple reconstruction was performed completing the breast restoration.
Case Study 5: Total Face Transplantation
Dallas Wiens, then a 23 year old man, had no way of knowing that his day as a volunteer church painter would forever change his life. When his cherry picker came in close contact with high voltage power lines, he sustained a severe electrical injury to the face. After a lengthy stay in intensive care and almost two dozen surgeries, it was clear that Dallas would survive but was left blind and essentially face-less. No traditional reconstructive surgery techniques could fully restore his loss, and he was referred to Harvard University’s Brigham and Women’s Hospital to be considered for facial transplantation. In March of 2011, a team of 30 health care professionals worked for 15 hours to make Dallas Wiens the first person in the United States to receive a total face transplant. The new face included a nose, lips, skin, hair and the nerves and muscles needed to provide motion and sensation. Despite the extent of the transplant, the features do not clearly resemble the donor or Wiens’. The characteristics of both merge together, producing an entirely new, distinct face. To date, he has regained his sense of smell and touch. The transplanted face continues to demonstrate improving tone and motion. Wiens can again now enjoy some of the simple yet sweet things in life, the feel of his daughter’s kiss, the smell of a good meal and the ability to go unnoticed in a crowd.