MICROSURGERY SUPPLEMENT History of Microsurgery Susumu Tamai, M.D., Ph.D. Kashihara City, Nara, Japan
Summary: In the mid-1500s, the techniques of vascular ligature and vascular suture were developed sporadically by several pioneers in this field. However, vascular surgery became realistic experimentally as a result of the work by Carrel and Guthrie in the early 1900s, in which they performed replantations and transplantations of several composite tissues and organs, including amputated limbs, limb s, kidney kidneys, s, and others using experimenta experimentall anima animals. ls. In contr contrast, ast, the devel devel-opme op ment nt of he hepa pari rin n by Ho Howe well ll andHol andHoltt in 19 1918 18 ac acce cele lera rate ted d th thee ra rate te of th thes esee ty type pess of ope operat ration ionss bei being ng per perfor formed med wit with h inc increa reasin sing g suc succes cesss in hum humans ans.. Sin Since ce the fir first st use of a monocular microscope for ear surgery by Nylen in 1921 and a binocular microscope by Holmgren in 1923, in addition to the timely developments of the Zeiss operating microscope, microsurgical instruments, and suture materials, microsurgery was born in several surgical disciplines in the ensuing 50-year period. The application of microvascular surgery and microneurosurgery in the fields fiel ds of hand, plastic, and recons reconstruct tructive ive surgery resu resulted lted in revol revolutiona utionary ry advances in clinical replantation and transplantation of composite tissues and more allot allotranspl ransplantat antations. ions. (Plast. Reconstr. Surg. 124: 282e, 2009.)
T
he origins of microvascular surgery can be traced to the introduction of fundamental surgical techniques, anticoagulation, and intraoperative magnification in the late nineteenth and ear early ly twe twenti ntieth eth cen centur turies ies.. Inn Innova ovativ tivee sur surgeo geons ns performed the first successful vascular anastomoses by directly apposing or invaginating the vessels end-to-end and suturing with fine silk. 1,2 The most significant technical breakthrough came in 1902, when Alexis Carrel3 repo reported rted the trian triangulat gulation ion method of end-to-end anastomosis that is still routine ti nely ly us used ed to toda dayy an and d fo forr wh whic ich h he wa wass la late terr awarded the Nobel Prize in 1912 (Figs. 1 and 2). The following year, Ho¨ pfner4 reported the first experimental limb replantation in dogs. Carrel and Guthrie built on this work, performing viscerall trans cera transplan plants ts as wel well. l.5 The work of these pione pi oneers ers lai laid d the fou found ndati ation onss for the su subse bse-quent que nt dev develop elopment ment of micr microvas ovascula cularr sur surgery gery.. The achievements of these surgeons are especially remarkable considering they worked without the benefit of anticoagulation or intraoperative magnification. The introduction of anticoagulation was one of the critical developments in clinical vascular From the Department of Orthopedic Surgery, Nara Medical University, and the Nara Hand Surgery Institute, Nara Seibu Hospital. Received for publication June 14, 2007; accepted February 11, 2009. Copyri Cop yright ght ©20 ©2009 09 by the Ame Americ rican an Soc Societ ietyy of Pla Plasti sticc Surg Surgeon eons s
surgery. Heparin was discovered in 1916 by Jay McLean,6 a me medi dica call st stud uden entt at Jo John hnss Ho Hopk pkin inss Un Unii7 versity, and Howell and Holt. The first successful clin cl inic ical al tr tria ials ls we were re re repo port rted ed in th thee 19 1930 30ss by 8 Charles and Scott. Heparin is one of the oldest drugs still in wide clinical use today. The ability to control blood clotting was an essential step for ward in the development of microvascular surgery. The final innovation that laid the foundation for modern microvascular surgery was the introduction of the operating microscope by Nylen9–11 (Figs. 3 and 4) and Holmgren12 in the early 1920s at the Karolinska Medical School in Stockholm, Sweden. It was used successfully in ear and eye surgery at various centers in Europe, and fine surgical instruments specifically designed for use under mag magnif nifica icatio tion n wer weree de devel velope oped, d, suc such h as bip bipola olarr 13–15 electrocautery by Malis (Fig. 5).
DAWNING PERIOD OF MICROSURGERY (END OF THE 1950S TO 1970) Jacobson and Suarez16–18 are credited with the landmark landm ark achie achievemen vementt of succ successfu essfull microvascular anastomosis using an operating microscope in 1960 (Figs. 6 through 8). As recounted by Comroe,19 a col collea league gue stu study dying ing pha pharma rmacol cology ogy asked ask ed Dr. Jac Jacobs obson on “Ho “How w can the per periar iarter terial ial
Disclosure: The author has no financial interests to declare in relation to the content of this article.
DOI: 10.1097/PRS.0b013e3181bf825e
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Fig. 1. Dr. Alexis Carrel. (From Guthrie CC. Blood Vessel Surgery and Its Applications. New York: Longmans, Green & Co; 1912.)
Fig. 2. Triangulation method of vascularend-to-endanastomosis by Dr. Carrel. (From Guthrie CC. Blood Vessel Surgery and its Applications. New York: Longmans, Green & Co; 1912.)
nerves on the carotid artery in a dog be removed?” Dr. Jacobson tried to cut the carotid artery completely to disconnect the autonomic nerves surrounding the carotid artery and subsequently repair the artery, but he encountered significant difficulty doing this with an unaided eye. He attempted repeatedly using various forms of magnification but failed each time. Finally, he brought in an operating microscope used for otology and was successful. This event marked the historical beginning of microvascular surgery.
Technological improvements in operating microscopes such as coaxial illumination,20 motorized zoom,21 and binocular viewing made microsurgery more reliable. There had been few advances since the early work of Ho¨pfner4 and Carrel and Guthrie,5 but multiple teams simultaneously began to investigate experimental extremity replantation in the United States,22 Russia,23 and Japan.24,25 In 1958, Onji and I attempted to revascularize an incompletely amputated thigh on a 12-year-old girl at Nara Medical University Hospital. The extremity was lost 4 weeks after revascularization because of overwhelming infection and thrombosis. In August of 1959, we successfully restored the nerve supply in another patient with incomplete amputation at the level of the thigh. The patient was able to ambulate within 2 years and there remained only a small area of hypalgesia on the lateral aspect of her leg without foot drop after 20 years. These early experiences led to a program of experimental surgery in limb replantation at our clinic that continued for the next 20 years. We investigated the physiology of ischemia-reperfusion injury and the systemic toxicity related to replanting tissue after prolonged warm ischemia. We concluded that the clinical replantation surgery should be limited to the hand or digits until unsolved problems of systemic toxicity associated with larger tissue units were resolved. For that purpose, we needed finer instruments and techniques to accomplish “microvascular anastomosis,” as developed by Jacobson and Suarez. 16,17 We were, however, limited at the beginning by the lack of operating microscopes in Japan. In 1962, Malt and McKhann26 performed the first replantation of a completely severed arm in a 12-year-old boy in Boston. Two years later, Kleinert and Kasdan27 successfully revascularized an incompletely amputated thumb. In 1963, Chen and colleagues28 successfully replanted a completely amputated hand in Shanghai. These successes led to new efforts to develop reconstructive microsurgery around the world. During the 1960s, Buncke29–31 performed numerous experiments involving replanting or transplanting tissues in laboratory animals. He developed many important principles and techniques and has been called the “founding father of microsurgery.” Simultaneously, John Cobbett from East Grinstead, England, and others were also starting their microsurgical work. Our program in Japan at Nara Medical Uni versity began in the spring of 1964. It has been very
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Fig. 5. Bipolar coagulator with miniature forceps developed by Dr. Malis. (From Malis LI. Bipolar coagulator in microsurgery. In: Donaghy RMP,Yasargil MG, eds.Micro-vascularSurgery:Reportof First Conference, October 6–7, 1966, Mary Fletcher Hospital, Burlington, Vermont . Stuttgart: Thieme; 1967:126.) Fig. 3. Dr. Carl Olof Nylen. (From Widstrand A, ed. Svenska Laekare i ord och bild-Portraetgalleri med biografiska uppgifler oever nu levande svenska laekare. Stockholm, Sweden: Biografiskt Galleri A-B; 1939.)
productive, making many early contributions in digit replantation,32 functional muscle transfer,33 instrument design, and other areas of microsurgery. We bought Jacobson’s microsurgical in-
struments in 1963 (Fig. 9) and used them for our microsurgical work in the beginning of our program. Advances in peripheral nerve surgery occurred in parallel with progress in microvascular surgery. In 1964, pioneers such as Smith,34 Bora,35 Hakstian,36 and Ito et al.37 reported microsurgical nerve repair techniques and funicular nerve sutures, based on intraneural topography.
Fig. 4. A monoscope for otologic surgery used first by Dr. Nylen in 1921. (From Stahle J. Carl Olof Nylen (1892–1978): Den foerste att tillaempa otomikroskopi. Sven Oenh-Tidskr. 2005;3:44.)
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Fig. 6. Dr. Julius H. Jacobson. (From Tamai S, ed. Experimental and Clinical Reconstructive Microsurgery . New York: Springer; 2003:5.)
Fig. 8. Microvascular double clamp developedby Dr. Jacobson. (From Jacobson JH. The development of microsurgical technique. In: Donaghy RMP, Yasargil MG, eds. Micro-vascular Surgery: Report of First Conference, October 6 –7, 1966, Mary Fletcher Hospital, Burlington, Vermont . Stuttgart: Thieme; 1967:4–14.)
Fig. 7. A 3-mm artery anastomosis with 7-0 braided silk by Dr. Jacobson.(FromJacobsonJH.Thedevelopmentofmicrosurgical technique. In: Donaghy RMP, Yasargil MG, eds. Micro-vascular Surgery: Report of First Conference, October 6 –7, 1966, Mary Fletcher Hospital, Burlington, Vermont . Stuttgart: Thieme; 1967:4–14.)
The year 1965 was an eventful year in the field of microsurgery. The first reported experimental free skin flap transplantation of abdominal skin based on the superficial epigastric vascular pedicle was performed in a dog by Krizek and associates. 38
On July 27, 1965, Komatsu and I32 performed the first successful replantation of a completely severed thumb at the metacarpophalangeal joint level in a 28-year-old man. We repaired two volar arteries and two dorsal veins under a Zeiss diploscope using 7-0 braided silk sutures for the venous anastomosis and 8-0 monofilament nylon sutures for the arteries. The operating time was 4½ hours, and the ischemia time from injury to recirculation was 3 hours. This experience and subsequent cases of digit replantation demonstrated the need to develop smaller vascular clips. I modified microclips originally designed for intracranial aneurysms and fashioned a metal double clamp that became commercially available in Japan in 1980.39 Later, we developed disposable microsurgical clamps40 (Figs. 10 and 11). In 1966 and 1967, the first thumb reconstructions using toes transferred from the foot were performed. Chen and associates41 in Shanghai performed second-toe transfers in five cases in 1966. John Cobbett 42 in England performed the first great-toe transfers in April of 1967.
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Fig. 9. Photograph of Jacobson’s microsurgical instruments, which we obtained from Dr. Jacobson in 1963. We used them for the world’s first thumb replantation in 1965.
Fig. 10. The developmental process of the Tamai microvascular double clip. ( Above, left ) A pair of Heifetz clips connecting with a 23-gauge hypodermic needle. ( Above, right ) A home-made double clip. (Below , left ) A prototype doubleclip manufacturedby CrownCo. (Below , right ) Thefirstmetal doubleclip,commercially available from Crown Co.
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Fig. 11. The developmental process of the Tamai microvascular double clip, continued. ( Above) Crown metal double clips (Kono Seisakusho Co. Ltd., Chiba, Japan). Clipping power (gramforce), from left to right : L90,M 60, and S 40. A clipapplicator isalsoshown. (Below ) Bear Medical disposable double clips (Bear Medic Co., Tokyo, Japan). Clipping power (gram force),fromleft to right ,TKL120and60,TKM60and30,TKS40and20,and TKF 30 and 15.
In November of 1967, the world’s first panel on microsurgery was held at the Annual Meeting of the American Society of Plastic and Reconstructive Surgeons in New York City. The panelists included Harry Buncke, John Cobbett, James Smith, and myself, with Clifford Snyder serving as moderator. This was a landmark event in the history of microsurgery. Buncke presented his experimental work on rabbit ear replantation and toe transfer in the rhesus monkey. Cobbett reported a hallux-tothumb transfer. Smith presented his method of peripheral nerve repair. I presented the case of thumb replantation we performed in 1965 and created a sensation as the world’s first digit replantation. Other efforts to form organizations dedicated to advancing the field of microsurgery followed. The first International Microvascular Transplantation Workshop was organized by van Bekkum and held in September of 1970, in Rijswijik, The Netherlands, during the Biennial Interna-
tional Congress of the Transplantation Society. It was also the occasion for the first meeting of the International Microsurgical Society. Thereafter, the International Microsurgical Society meetings continued biennially until 1998 (Table 1). The members consisted of all surgical disciplines with a shared interest in microsurgery.
DEVELOPING PERIOD OF MICROSURGERY (1971 TO 1980) The decades of the 1970s witnessed numerous important advances. Experimental tissue transfer continued at several centers around the world, and important strides were made in clinical microsurgery. In 1971, Strauch et al.43 first reported pedicled vascularized rib transfer to the mandible in dogs, demonstrating the possibility of vascularized bone transfer. In the same year, Tamai et al.39 experimented with free vascularized whole–knee joint transplantation in dogs. They showed the possibilities of not only vascularized bone graft but
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Table 1. Chronology of the International Microsurgical Society No.
Year
President
Chairman
Congress Site
1 2 3 4 5 6 7 8 9 10 11 12 13
1972 1973 1975 1977 1979 1981 1983 1985 1988 1991 1993 1996 1999
H. Millesi H. Millesi J. R. Cobbett H. J. Buncke M. Ferreira B. McC. O’Brien B. Strauch S. Tamai Z. W. Chen G. I. Taylor E. Biemer J. B. Steichen J. Baudet
H. Millesi H. Millesi J. R. Cobbett H. J. Buncke M. Ferreira B. McC. O’Brien B. Strauch A. Gilbert K. Harii E. Biemer H. Millesi R. Pho W. Shaw
Vienna, Austria Vienna, Austria East Grinstead, England San Francisco, California Guaruja, Brazil Melbourne, Australia New York, New York Paris, France Fuji, Japan Munich, Germany Vienna, Austria Singapore Los Angeles, California
also vascularized joint transfer. Experimental toe joint transfers were reported in laboratory animals by Daniel and colleagues. 44 In 1972, Fujino and colleagues45 reported functional mammary gland transfer in dogs. McLean and Buncke46 reported the successful transfer of the greater omentum for scalp reconstruction. Harii et al. performed a free-tissue transfer of temporal scalp for the purpose of hair transplantation. This procedure was performed in September of 1972 and thus represents the world’s first clinical free skin flap transfer,47 although the medical literature generally cites the groin flap transfer reported by Daniel and Taylor 48 in 1973 as the first. In 1972, O’Brien49 established a microsurgical teaching laboratory in Melbourne that made numerous contributions in basic physiology, clinical care, and education. With improved understanding of vascular anatomy, a variety of tissues began to be transferred using microvascular techniques. Free muscle transfer was demonstrated in 1973, with the first clinical cases involving transfer of the pectoralis major muscle performed in China,50 followed by a report of gracilis muscle transfer for facial paralysis by Harii et al.51 Also in 1973, Ueba and Fujikawa52 in Japan succeeded in free transfer of a vascularized fibula flap for congenital ulnar pseudarthrosis. This achievement was first published in 1983 with 9 years’ follow-up. The first published case report of free fibula transfer was from Taylor and colleagues at the Royal Melbourne Hospital in 1975.53 In that same year, Miller and colleagues 54 reported the first successful replantation of an avulsed scalp. McCraw and Furlow 55 reported the free dorsalis pedis flap. Baudet and colleagues, 56 in 1976, coined the term “musculocutaneous flap” and stressed the usefulness of the latissimus dorsi musculocutaneous flap. Also in 1976, James57 reported the successful
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replantation of a large segment of upper lip and nose, a prelude composite tissue allotransplantation of the face that took place 30 years later. Replantation of an amputated penis and scrotum was performed in Nara, Japan, by Tamai and associates58 in June of 1976, followed a short time later by Cohen and colleagues59 in Boston. A short time later, reports appeared of transfers of iliac crest 60 and tensor fasciae latae.61 By the end of the 1970s, replantation surgery was widespread throughout the world, with centers developed by Chen62 in China, Kleinert 63 in the United States, O’Brien64a,64b in Australia, and Tamai65 in Japan. Success rates were reported as greater than 80 to 90 percent and stressed the importance of postoperative hand therapy for maximum functional recovery. In parallel with advances in microvascular surgery were further developments in peripheral nerve repair. Funicular or fascicular nerve repair and grafting were reported experimentally and clinically by Millesi66,67 in 1973, and thereafter by Terzis et al.,68 Williams and Terzis, 69 Samii and Wallenberg, 70 and Brunelli.71 The interfascicular nerve graft technique by Millesi et al.72 achieved useful function of the hand in 80 percent of their cases. Consistent with steady maturation of the field, there were further developments in professional organizations dedicated to reconstructive microsurgery. The Japanese Society of Reconstructive Microsurgery was founded by Fujino, Harii, Ikuta, Ohmori, and Tamai in 1974. I had the honor of serving as the first president during the first annual meeting in Nara, Japan. The organization continues to thrive, with 600 to 1000 members yearly attending the annual meeting. In 1972, the International Society of Reconstructive Microsurgery was founded by orthopedic and plastic surgeons, and the first symposium was organized by
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Millesi in Vienna. The organization met biannually until 1999 (Table 2), when it merged with the International Microsurgery Society to become the World Society of Reconstructive Microsurgery. The Inaugural Meeting of the World Society of Reconstructive Microsurgery was held in 2001 in Taipei with Fu-Chan Wei serving as president. The World Society of Reconstructive Microsurgery has since met biennially in different locations around the world (Table 3).
FULLY MATURED PERIOD OF MICROSURGERY (1981 TO 1997) Building on the creative efforts of early pioneers and subsequent contributors, microsurgery matured as a specialty by the close of the twentieth century. During this period, new tissue donor sites and flap variations were described and research was continued on limb/digit replantation and free-tissue transfer worldwide. In the hand, Urbaniak et al.,73 in 1981, reported on the microvascular management of ring avulsion injuries, providing guidelines for practical management. According to Furnas and Achauer74 in 1983, a microsurgical transfer of the great toe to the radius in partial hand avulsion injuries proved useful for reconstructing the thumb. Also in theearly 1980s, Morrison andassociates75 described a method of thumb reconstruction using a soft-tissue flap harvested from the great toe and wrapped around an iliac crest bone graft, creating a better proportioned reconstruction and thereby overcoming the chief disadvantage of great-toe transfer. Wei and associates76 later reported an alternative technique using the secondtoe wraparound flap technique for digit reconstruction. The free vascularized transfer of the proximal interphalangeal joint of the toe was reported clinically by Tsai and colleagues 77 in 1982.
Developments also included advances in congenital hand malformations using transfers of the great-toe and second-toe growth plates.78 There were descriptions of new flap designs and refinements of previously described donor sites, including such important ones as the scapular flap,79 the fibula osteocutaneous flap,80 and the peroneal flap.81 The deep inferior epigastric perforator flap was reported by Koshima and Soeda82 in 1989, introducing a new era of flap design based on cutaneous perforators throughout the body. The role of reconstructive microsurgery in extremity trauma was advanced by Marko Godina 83 in a landmark 1986 publication of 532 patients. He established the principles of early de´bridement and free-tissue transfer and aggressive rehabilitation to achieve salvage of extremities with optimal functional results. Significant advances were made in the problem of brachial plexus injuries, including phrenic nerve transfer by Gu et al. 84 and functional muscle transfer, which was introduced by Akasaka et al. 85 in 1991 and further developed by Doi and colleagues,86 who reported double free-muscle transfers to restore not only elbow function but also prehension.87 In experimental microsurgery, in 1981, Nakayama and associates88 reported a study of a flap nourished by arterial inflow through the venous system. Ji and colleagues,89 in 1984, reported experimental venous flaps in rabbits. Honda et al., 90 in 1984, reported venous skin grafts for skin defects on replanted digits. Applying principles of minimally invasive surgery, Lin and Levin91 reported use of balloon-assisted endoscopic harvesting of tissue for microsurgical transfer in 1991. Buntic and Buncke92 successfully performed replantation of an amputated tongue in a 15-year-
Table 2. Chronology of the International Society of Reconstructive Microsurgery Meeting No.
Year
President
Chairman
Congress Site
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1970 1972 1974 1976 1978 1981 1982 1984 1986 1989 1992 1994 1996 1998
D. W. van Bekkum M. J. Orloff G. Mazzoni I. Hashimoto E. Owen F. Chavez-Peon M. J. Orloff J. M. Dubernard G. Brunelli K. Harii J. Terzis S. Tamai H. B. Williams W. Boeckx
D. W. van Bekkum M. J. Orloff and R. Cortesini G. Mazzoni F. Chavez-Peon T. S. Lie E. Owen J. M. Dubernard S. Arena G. Brunelli T. S. Chang P. Soucacos S. Tamai H. B. Williams K. N. Malizos
Rijswijk, The Netherlands San Diego, California Rome, Italy Mexico City, Mexico Bonn, Germany Sydney, Australia Lyon, France Pittsburg, Pennsylvania Brescia, Italy Shanghai, China (canceled) Rhodes, Greece Nara, Japan Montreal, Quebec, Canada Corfu, Greece
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Table 3. Chronology of the World Society for Reconstructive Microsurgery Meeting No.
Year
President
Chairman
Congress Site
1 2 3 4
2001 2003 2005 2007
V. Meyer F. C. Wei W. Morrison J. K. Terzis
F. C. Wei G. Germann, H. Steinau G. Loda A. Beris
Taipei, Taiwan Heidelberg, Germany Buenos Aires, Argentina Athens, Greece
old boy in 1997, with repair of the left lingual artery and vein. At 2 months, the recovery of sensation started with spontaneous neurotization, although they did not perform nerve repair. With increasing interest in microsurgery among orthopedic and plastic surgeons in the United States, the American Society of Reconstructive Microsurgery was founded in 1983, 11 years after the establishment of the International Society for Reconstructive Microsurgery. The members of the founding council included James Steichen, Berish Strauch, Julia Terzis, James Urbaniak, and Alan Van Beek. The first meeting was held in Las Vegas in 1985 under the presidency of Berish Strauch, with approximately 300 orthopedic and plastic surgeons attending. Since then, the meeting has been held once a year at several locations in the United States.
TRANSITION PERIOD FROM AUTOGENOUS TO ALLOGENEIC TRANSPLANTATION AND REGENERATIVE MEDICINE (1998 TO 2007) The future of reconstructive microsurgery is found in exploring composite tissue allotransplantation and regenerative medicine. Since replantation of amputated extremities has been possible, hand allotransplantation by hand surgeons and microsurgeons has been thought to be a technically feasible procedure. However, there has been controversy regarding the merits and demerits of such organ transplantation for non–life-threatening conditions with regard to the side effects of lifelong immunosuppressive therapy. The era of allotransplantation of composite tissues began with hand transplantation at the end of the twentieth century. The first procedure was performed on a 48-year-old man on September 23, 1998, in Lyon, France, by Dubernard and his team.93 The second procedure was performed successfully on a 37-year-old man by Jones et al.94 in Louisville, Kentucky, in January of 1999. The functional recovery of the transplanted left hand proved to be quite satisfactory. According to the International Registry on Hand and Composite Tissue Transplantation (coordinators: Marco Lan-
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zetta and Jean M. Dubernard), as noted on their Internet site, as of February of 2005, there had been single hand transplantations in 16 hands on 16 patients, double hand transplantations in 14 hands on seven patients, and digit transplantation in two digits on two patients. Conventional immunosuppressive agents have proved to be effective, and there has been no mortality. Unfortunately, though, two patients underwent reamputation because of the rejection phenomenon, including the first case in Lyon. After these successes, on November 27, 2005, the first facial allotransplantation,95 including nose, lips, and chin, was performed on a 38-yearold woman who had suffered a dog bite injury on the lower face in June of 2005. The transplantation, from a brain-dead woman as the donor, was performed by Dubernard and his group in Amiens, France, on November 27, 2005. Bone marrow grafting and use of immunosuppressive agents were successful, but the final evaluation regarding nerve regeneration will be needed at more than 1 year. Lutz and Wei,96 in 2002, discussed the current operative indications and reconstructive modalities of toe-to-hand transplantations based on numerous experiences with this operation at Chang Gung Memorial Hospital in Taipei. Rinker and colleagues,97 in 2004, reviewed the replantation of severed extremities as it has developed over the past 40 years and discussed its current status and future prospects. There is ongoing extensive experimental in vestigation into flap prefabrication, flap revascularization, and tissue engineering of autogenous tissues or biomaterials for composite grafts in combination with microsurgery.98–103 Recent applications of tissue-engineered nerve conduits—in other words,bioartificial nerve grafts—have openeda new era in peripheral nerve surgery to overcome the problems with nerve gaps as an alternative to autogenous nerve grafting. One of these grafts shows promise in relieving symptoms of causalgia, which previously have never been successfully treated with conservative therapeutic measures or classic modes of surgical interventions on the involved nerve.104–108
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Table 4. Historical Achievements in Microsurgery Reference
Achievements
18891
Jassinowski, Murphy, 18972 Carrel, 19023 Ho¨pfner, 19034 Guthrie, 19125 McLean, 19166 Nylen, 19549 Holmgren, 192312 Barraquer, 195614 Malis, 196415 Jacobson and Suarez, 196017 Littmann, 195420 Troutman, 196521 Snyder et al., 196022 Lapchinsky, 196023 Onji et al., 196324,25 Malt and McKhann, 196426 Kleinert and Kasdan, 196527 Chen et al., 196328 Buncke and Schulz, 196529 Buncke et al., 196630 Buncke and Schulz, 196631 Komatsu and Tamai, 196832 Tamai et al., 197033 Smith, 196734 Bora, 196735 Hakstian, 196836 Ito et al., 197637 Krizek et al., 196538 Chen et al., 198241 Cobbett, 196942 Strauch et al., 197143 Tamai et al., 197239 Daniel et al., 197144 Fujino et al., 197245 McLean and Buncke, 197246 Harii et al., 197447 Daniel and Taylor, 197348 Research Laboratory in Shanghai, 197650 Harii et al., 197651 Ueba and Fujikawa, 198352 Taylor et al., 197553 Miller et al., 197654 McCraw and Furlow, 197555 Baudet et al., 197656 James, 197657 Tamai et al., 197758 Cohen et al., 197759 Taylor and Watson, 197860 Hill et al., 197861 Millesi et al., 197366,67 Urbaniak et al., 198173 Morrison et al., 198075 Wei et al., 199176 Tsai et al., 198277 Gilbert and Teot, 198279 Chen et al., 198380 Yoshimura et al., 198481 Koshima and Soeda, 198982 Gu et al., 198984 Akasaka et al., 199185 Doi et al., 199587 Nakayama et al., 198188 Honda et al., 198490 Lin and Levin, 199691 Buntic and Buncke, 199892 Dubernard et al., 199993
Experimental/Clinical
End-to-end vascular anastomosis Invagination technique of vascular anastomosis Three-stay suture technique of vascular anastomosis Extremity replantation Several organ transplantations in dogs Discovery of heparin Use of monoscope for ear surgery Use of binocular microscope with light Microsurgical instruments for eye surgery Bipolar coagulator Microvascular anastomosis Zeiss OPMi-1 with coaxial illumination Motorized zoom microscope Limb replantation in dogs Limb replantation in dogs Limb replantation in dogs Arm replantation Digital artery repair Distal forearm replantation Digital replantation in monkeys Hallux-to-thumb transplantation in monkeys Ear replantation in rabbits Thumb replantation Free muscle transplantation in dogs Funicular nerve repair Funicular nerve repair Funicular orientation by direct stimulation Funicular nerve repair Free skin flap transplantation in dogs Toe-to-hand transplantation Hallux-to-thumb transplantation Pedicled vascularized rib transplantation in dogs Free vascularized knee joint transplantation in dogs Toe joint autogenous transplantation in dogs Mammary gland transplantation in dogs Greater omentum transplantation Temporal skin flap transplantation Groin flap transplantation
First experimental Experimental and clinical Experimental Experimental Experimental First First clinical Clinical
Pectoralis major muscle transplantation Gracilis muscle transplantation Vascularized fibula transplantation Vascularized fibula transplantation Replantation of avulsed sculp Dorsalis pedis flap transplantation Latissimus dorsi musculocutaneous flap transplantation Replantation of upper lip and nose Replantation of penis and scrotum Replantation of penis Iliac osteocutaneous flap transplantation Tensor fascia lata musculocutaneous flap transplantation Funicular nerve repair and grafting Microsurgical salvage of ring injury Great-toe wraparound flap transplantation Second-toe wraparound flap transplantation Toe proximal interphalangeal joint transplantation Scapular flap transplantation Fibular osteocutaneous flap transplantation Peroneal flap transplantation Deep inferior epigastric perforator flap transplantation Phrenic nerve transfer to brachial plexus injury Free-muscle transplantation to brachial plexus injury Double muscle transplantation to total brachial plexus avulsion Venous flap transplantation Venous flap transplantation Balloon-assisted endoscopic flap harvesting Tongue replantation Hand allotransplantation
First clinical First clinical First clinical
First First experimental Experimental Experimental Experimental First clinical First clinical First experimental First experimental First experimental First clinical First experimental First experimental First experimental First clinical Experimental and clinical First experimental First clinical First clinical First experimental First experimental First experimental First experimental First clinical First clinical First clinical
First clinical First clinical First clinical First clinical First clinical First clinical First clinical First clinical First clinical First clinical First clinical First clinical First clinical First clinical First clinical First clinical First clinical First experimental First clinical First clinical First clinical First clinical (Continued )
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Table 4. ( Continued ) Reference
Achievements
200094
Jones et al., Devauchelle et al., 200695 Colonna et al., 200299 Fansa et al., 2001104 Nakamura et al., 2004107 Inada et al., 2005108
Hand allotransplantation Face allotransplantation Flap prefabrication and tissue engineering Peripheral nerve tissue engineering Tissue-engineered nerve conduit Tissue-engineered nerve conduit
In addition to the further development of allogeneic composite tissue or organ transplantations, I believe the combined use of microsurgical composite tissue transfers with the technique of regenerative medicine will open another new field of microsurgery in the next decade. For the reader’s better understanding, historical achievements in microsurgery, which appeared in order in this article, are listed in Table 4. Susumu Tamai, M.D., Ph.D.
1017 Toichi-cho Kashihara City, Nara 634-0008, Japan
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