Reconstructive Microsurgery
Background
Reconstructive microsurgery is a dedicated surgical discipline which uses precision instruments, atraumatic surgical technique and a dedicated operating microscope to repair and reconstruct tissues from head to toe. Microsurgery is one of the main pillars of plastic surgery but is now gaining traction in other surgical disciplines as well. Every plastic surgeon undergoes microsurgical training during residency, but some surgeons choose to undergo additional training in microsurgery during a dedicated fellowship
Microsurgical reconstruction is one of the most powerful tools in reconstructive surgery since it allows surgeons for the first time to truly replace “like with like” by transplanting tissues from one body part to another. This is done by dissecting out blocks of tissue (which can include skin, fat, nerve, muscle, tendon, bone, lymphatics, fascia), moving them to another body part, and individually reattaching the structures, including the artery and veins that provide blood flow to the transplanted part.
The field of kidney transplantation was pioneered by a plastic surgeon, Dr. Murray, who was awarded the Nobel Prize. Few are aware that the entire field of organ transplantation owes credit to this remarkable plastic surgeon who was applying microsurgical techniques to a then unsolved problem.
Causes
Today, microsurgery is used by many plastic surgeons to perform free tissue transfer (called “free flap” in surgical jargon) for reconstruction of:
- head and neck cancers
- congenital anomalies
- trauma reconstruction of the extremities
- nerve repair
- reattachment of body parts (replantation)
- breast reconstruction
- wound reconstruction
- toe to hand transfer
- vascularized bone transfer for bone nonunions or defects around the body.
Symptoms
Problems that require microsurgical reconstruction span from head to toe and can be associated with pain, open wounds, areas of numbness, segmental bone loss, skeletal instability, unstable scar, and lack of tissue.
Diagnosis
In preparation for a microsurgical procedure, a thorough physical examination of the diseased body part is carried out to define exactly what tissues are required, but also of potential tissue donor areas that will be used to take the tissues that are needed to complete the reconstruction.
Dr. Dowlatshahi routinely uses ultrasound technology to guide this aspect of the physical examination, especially to locate blood vessels and nerves and measure blood flow to nake the operation more expedient and predictable. Furthermore, xrays and CT scans are necessary if bony reconstruction is required. MRI can help obtain more detailed information regarding the soft tissues at the donor or recipient site. On occasion, angiograms (which are blood vessel studies) are necessary to map out the blood vessel anatomy and can be done with CT or MRI technology, but also the conventional way which is by injecting contrast dye into the blood vessels and taking pictures with xray. Dr. Dowlatshahi collaborates with radiologists, interventional radiologists and cardiologists, as well as vascular surgeons to obtain the necessary information required to complete the reconstruction successfully.
Treatment
The microsurgical procedure is completed using an operating microscope as well as surgical loupes that afford magnification to see small structures in greater detail. Dr. Dowlatshahi uses the most advanced microscope technology with 3D capability as well as modern light filter technology to perform these operations with his team. Intraoperative nerve stimulation using various devices is routine in his practice. In cases of more complex nerve reconstruction, a team of electrophysiologists will join him in the operating room.
These procedures require advanced operating room capabilities that are not available at all medical centers/facilities.
The aftercare is just as important. Dr. Dowlatshahi performs these procedures at BIDMC where a dedicated microsurgical ward is available for the safe postoperative care of these complex patients.
Dr. Dowlatshahi’s senior partner Dr. Upton is a recognized, pioneering Microsurgeon with a worldwide reputation for procedures such as toe to hand transfer, vascularized nerve grafts, pediatric free tissue transfer, pollicization, microsurgical reconstruction in vascular anomalies, and described several novel flaps such as the free temporoparietal fascia flap.
