Introduction

Authors: Ahmad Makki, Magnus Balslev Avnstorp MD. and Thomas Givskov Sørensen

Here you will learn the basics in microsurgery; the history of microsurgery, the setup of the operating microscope, relevant anatomy and flap types.

Definitions

Microsurgery: Surgical procedures under high magnification. A discipline used in several surgical specialties.

Microscope : The microscope has two binocular viewing fields allowing the surgeon and the assistant to perform surgical procedures under magnification from 4 to 40 times power. Magnification allows visualization of small structures, such as arteries, veins, nerves and lymphatic vessels.

Vascular pedicle: The tissue containing the blood supply for the flap.

Pedicled flap: Tissue is left partly attached to the donor site (pedicle) and simply transposed to a new location: keeping the pedicle intact as a conduit to supply the tissue with blood. This type of flap may also be a perforator flap because, if the pedicle perforates the deep fascia/muscle

Perforator flap: Flap based on an isolated vascularized pedicle arising from deep vascular system and perforating the deep fascia and/or the muscle.

Free flap: Tissue isolated on a vascular pedicle and transplanted from one part of the body to another. The tissue is completely detached from its blood supply at the origin location (donor site) and then transferred to another anatomical location (recipient site). The circulation in the tissue is then re-established by anastomosis of the artery and vein. This is also known as a microvascular transplant or free tissue transfer.

Background

In the late 19th and early 20th centuries, microsurgery evolved through refinement of fundamental surgical techniques, use of anticoagulation and intraoperative magnification. The microvascular surgery foundation was laid by pioneer Alexis Carrel (1873-1944), who reported the triangulation method of end-to-end anastomosis. Secondly, he performed visceral transplants with Guthrie and Höpfner who reported the first experimental replantation in dogs. The achievements of these surgeons are remarkable as they worked without the benefit of anticoagulation or intraoperative magnification (1).

In 1960 Jacobson and Suarez described a successful microvascular anastomosis using an operating microscope marking the historical beginning of microvascular surgery. Since then the discipline has been evolving into dissection and anastomosis of even smaller vessels such as lymphatics ranging from 0,3 mm. This technique has been named supermicrosurgery (2).

Today, microsurgical techniques have become an integrated part of the armamentarium for plastic surgeons, allowing for soft-tissue coverage and function after trauma or oncologic resections (3). It may not be the first choice in the reconstructive ladder, however it can be an important tool for achieving the optimal reconstruction by proceeding with free tissue transfer from distant sites.