reconstructive Surgery | Dr. Enrique Etxeberria, Plastic Surgery in Bilbao

Microsurgery

Reconstructive Surgery - Microsurgery - Microsurgery

Microsurgery

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Microsurgery is the surgical field which employs techniques for the repair of blood vessels and nerves via magnification (with magnifying glasses or microscopes). By microsurgery we mean “the branch of surgery which makes use of the magnification of the surgical field over and above normal visual acuity”. In other words, beyond where the human eye can reach, lies microsurgery and with it the constant development of new techniques and procedures for working with microscopic material. Therefore, we must not mistake microsurgery for a speciality which is charged with small operations but rather, on the contrary, it is a specialty that undertakes large interventions on a minute scale, thereby adding complexity to the work of the scientific personnel. Thanks to these techniques, it is currently possible to reconstruct or replace a patient’s damaged, amputated or absent structures by means of the transplantation of other autologous structures. MICROSURGERY is performed by Doctors Specialising in Plastic, Cosmetic and Reconstructive Surgery, duly accredited by S.E.C.P.R.E (Spanish Society of Plastic, Cosmetic and Reconstructive Surgery), who have also had specific training in Microsurgery. At the A.E.M. (Spanish Microsurgery Association) you can find information about such professionals, as well as at the W.S.R.M (World Society of Reconstructive Microsurgery).

RECONSTRUCTION WITH MICROSURGICAL FLAPS

The reconstruction of significant defects on the head and neck, breast or members, experienced a considerable advance over recent years thanks to the introduction of microsurgical techniques.  Currently, the capacity for undertaking this type of reconstruction is indispensable in any Plastic and Reconstructive Service.  These techniques involve a high degree of specialisation.  The contributions of microsurgery to the quality of life of these patients are of a functional and cosmetic nature, as it seeks to reinstate the shape and the functions of the missing tissue. Patients frequently benefiting from these procedures are those who were subjected to oncological surgery.  On other occasions, certain infectious or traumatic processes may lead to defects which require reconstructions of this complexity.
The complexity of these microsurgical reconstructions requires infrastructure and trained personnel for its performance.  Amongst them of note are:
•    Team of surgeons, anaesthetists, nurses and auxiliary personnel, whose activity is not limited solely to the surgical intervention but also to the strict monitoring that these patients require.
•    Specific microscope equipment and instrumentation.
•    Surgical team trained in the performance of these highly sophisticated surgical techniques.
•    Sufficient personnel for the two simultaneous surgical teams (resective team and reconstructive team).

These surgical techniques are based on the anastomosis under surgical microscope of the blood vessels between the receptive zone (defect) and the transplanted tissue (flap).  The viability of the flap is thereby ensured.  The use of remote tissues causes the morbidity of the flap donor site, generally very scant, maintaining motor and sensorial functionality in the majority of the territories from where these flaps are obtained.

ADVANTAGES OF MICROSURGICAL RECONSTRUCTION

1.    Facilitates more radical surgical resections and in more advanced cases.
2.    Provides functional improvement (seeks to reinstate the function of the missing tissue) in patients.
3.    Reinstates the shape of the defect to its prior condition, with satisfactory results in trained hands.
4.    Minimises post-operative complications as the provision of highly vascularised tissue reduces the risk of infection and of the dehiscence of the surgical wound.
5.    Capacity to select the most appropriate donor tissue for restoring shape and function.
6.    Facilitates earlier social and occupational reintegration of patients.

AREAS FREQUENTLY TREATED WITH MICROSURGERY

•    Breast reconstruction
•    Maxillofacial reconstruction
•    Post-traumatic defects
•    Defects due to oncological surgery
•    Burn sequelae
•    Facial paralysis

RE-IMPLANTATIONS

When a part of the body becomes separated due to an accident or trauma it is known medically as an amputation. Amputations leave definitive consequences on people’s bodies, with serious limitations which are irreparable even with the most advanced bionic and cybernetic technologies. Fortunately, since 1960 amputations have been treated using microsurgery which managed to return circulation and life to an amputated part of the body by connecting the arteries, nerves, veins... etc with the help of the surgical microscope, achieving surprising results. In theory almost any part of the body that has been amputated (accidentally separated from the body) can be once again reinstated to its original position, always providing it is technically possible to do so, the benefits outweigh the disadvantages and the end results are better than those achieved with less complex reconstruction techniques. There have been reported re-implantations of the scalp, ears, nose, lips, face, penis, legs, feet, forearms, hands and fingers. The use of re-implantation is commonplace in many medical centres around the world, particularly for hands and fingers, fields in which great advances have been made.  The success rate of re-implantations varies depending on the medical centre but in general fluctuates between 40 to 80%.

When can a re-implantation be performed?
If there are the ideal conditions in relation to time, availability and the patient is in good condition to withstand the operation, the mechanism of the injury is also important. An amputation due to crushing or avulsion, after six hours, in patients who are weakened or with multiple injuries, would not be deemed suitable for a re-implantation.


How should the patient and the amputated body part be transported?
It is important not to waste time, the patient and the amputated body part must be transported together to the Hospital. The patient’s wound must be covered with compresses or dressing and bandages and must remain elevated.  The amputated body part must be placed in a knotted plastic bag and immersed in iced water.  Ice in direct contact with the body part is harmful, and under no circumstances can you immerse the amputated body part in alcohol, formaldehyde, gasoline, or other similar substances.

RISKS OF MICROSURGICAL RECONSTRUCTION

Although any microsurgical procedure is complex, the risks tend to be acceptable if they are seen in the light of the potential benefits. In being more substantial procedures, the periods of hospitalization tend to be on average one to two weeks; they may require blood transfusions and ultimately may require admission to the intensive or special care unit. The greatest risk involved in microsurgical reconstruction is the failure of the procedure which is always an all or nothing phenomenon (when it fails, the failure is total, with no in-between), but in the event of success the results are very satisfactory. The possibility of successful microsurgery with free flaps is far higher than in many conventional surgeries and varies from some 87% in lower members to some 98% for breast reconstruction. In re-implantations the percentages are lower and vary depending on the experience of the medical team. Benefits of microsurgical reconstruction. The re-implantation or replacement of an amputated body part presents such good results that they cannot be improved upon by any other currently established technique. The use of free flaps permits the quick and effective reconstruction of the injured area through the transplantation of all the tissue necessary from another part of the body in which the damage produced (morbidity) is acceptable.

NERVOUS MICROSURGERY

The peripheral nervous system is one of the three great compartments into which the nervous system is divided, together with the brain and the spinal cord.  Its fundamental importance lies in the fact that it is the nexus that connect the site in which nervous impulses (brain and spinal cord) are generated and synchronised  with the muscles and the sensorial receptors, and therefore outside world. The surgical diseases which affect the peripheral and plexus nerves are subject to treatment by a multidisciplinary team, which includes plastic surgeons, neurosurgeons, orthopaedic doctors and physiotherapists.

The injuries that affect the nerves can be in turn divided into three large groups, depending on cause, prognosis and evolution: chronic compression caused by narrowing along their length, by passing through bone or ligament tunnels or channels, trauma caused by sharp elements, firearm projectiles, bone fragments, avulsions of the brachial plexus, lesions to the facial nerve during brain tumour surgery, etcetera and nerve tumours.

CHRONIC LESIONS

Chronic compression produced in certain sites along the length of peripheral nerves, due to the narrowing of the passageway. This does not happen anywhere on the arm or leg, but on certain areas relating to joints, bones or ligaments.  Any patient who reports a tickling sensation, pain, weakness or a combination thereof along the length of a peripheral nerve, must be suspected of suffering from the chronic compression of a nerve.

Carpal tunnel syndrome, caused by the trapping of the median nerve at the level of the carpal tunnel in the wrist, is the most common chronic compression.  It causes pain in three fingers of the hand (thumb, index and middle fingers), more significant at night, and the surgical treatment is required in the majority of cases.  Cubital tunnel syndrome, generated by the narrowing of the ulnar nerve in the elbow, presents the same symptoms but on the other two fingers of the hand (ring and little finger).  Thoracic outlet syndrome is a direct compression of the brachial plexus at neck level, and is hard to diagnose as it tends to be confused with other problems such as disc hernias or cervical arthrosis. Patients who suffer from it tend to go long periods without a specific diagnosis.  At the level of the lower limbs, the sciatic nerve in the gluteal region (pyramidal syndrome), the femoral cutaneous nerve in the crural arch, the peroneal nerve at the head of the fibula, and the posterior tibial nerve at the level of the tarsal tunnel, are all common compression sites. The treatment for chronic compressions always takes the initial shape of kinesiology, physiotherapy, analgesics, rest and change of habits.

The lack of response to these types of measures suggests the need for a surgical intervention, the objective of which would be to section ligaments or tissues which compress the nerve to definitively liberate it.

ACUTE LESIONS

Acute lesions of the peripheral nerves can have innumerable traumatic origins, amongst which we can cite lacerations through injury from sharp weapons (knife, dagger, etcetera), injuries from firearm projectiles, fractures which cause bone fragments to impact the nerves, injections and burns. 
Brachial plexus injuries deserve special mention, caused by extreme lateral traction accompanied by a drop in the shoulder, which can be seen in some accidents, particularly motorbike accidents or falling from a height on to the arm. Similarly, lesions of the facial nerve, which cause paralysis of the face, are common after trauma or resection surgeries for certain brain tumours (acoustic neuromas). Unlike chronic lesions, and in relation to the trauma they generate, these acute lesions can be found anywhere along the length of a nerve. In general and as has already been mentioned, treatment of acute lesions is rehabilitation in the first instance. In the event of the absence of clinical improvement after a variable period of between three to six months, the surgical reparation of the nerve or plexus is the treatment of choice. Subsequent to same, the patient must undergo intense rehabilitation of lengthy duration (various months and up to two years), as positive results tend to depend on the time it takes the repaired nerve to grow through to the muscle, at an estimated speed of around 1mm a day.

TUMOURS

Tumours born from peripheral nerves tend to be schwannomas or neurofibromas, the great majority of which are benign. Given that they originate in the sheath which covers the nerve, in many cases with adequate microsurgical techniques they can be extracted without altering the function of the nerve that originated them. This leads to the full recovery of the patient, without sequalae. On other occasions, luckily less common, the extraction of the tumour is not possible without causing the loss of the function of the nerve, which is why full tumoural exeresis should be indefinitely postponed. Some genetic diseases such as neurofibromatosis are linked to the presence of nerve tumours with far greater frequency than in the rest of the population. In the rare cases of malign tumours, treatment via surgery is followed by the complementary application of chemotherapy or radiotherapy, depending on the joint decision of oncologists and radiotherapists.

SURGICAL TREATMENT

The decision to surgically intervene must be made at the appropriate moment. If it is taken too early, the chances of the spontaneous recovery of the nerve are thereby limited.  On the other hand, if the decision is delayed excessively, the muscle that lacks enervation atrophies and degenerates, which make subsequent recovery more difficult.  A succinct description follows of the diverse techniques which form part of the peripheral nerve surgeon’s arsenal with which to resolve the problems of his or her patients.

Neurotization
Unlike what happens in the brain and the spinal cord, where the beneficial effect of surgery lies in the decompression of the neurological tissue affected by the injury, surgery of peripheral nerves and the plexus provides a unique opportunity to create new function where there was none, by means of neurotization, which is the process by which a muscle denervated from the disease of the nerve which usually enervates it, receives enervation from a healthy adjacent nerve. This process usually takes between 6 and 18 months to produce muscular contraction which is both evident and ultimately useful, period during which the patient is attended intensively by rehabilitation specialists.  Neurotization is used in cases where it is not possible to rebuild the axonal transmission of the nerve.

Neurorrhaphy
On the other hand, if the extremes of a nerve are sectioned, they must be joined together with a microsurgical technique, a procedure called neurorrhaphy. If said extremes are very distant one from the other, due to loss of substance, pressurised sutures must be avoided, which means the insertion of a graft between both ends.

Neurolysis
This is another of peripheral neurosurgery’s technical resources.  It consists of the decompression of a nerve which has not been completely cut, but which is simply being “squeezed” by a fibrous or ligamentary scar, caused in turn by trauma. A favourable response to this technique is usually observed earlier than with neurotization and neurorrhaphy – even occasionally in the immediate post-operative period – and lies in the fact that the indemnity of the nervous fibres, which do not function due to compression, provide quick re-enervation of the affected muscle.

The decision on whether to use neurotization, neurorrhaphy or neurolysis, in any given case, is taken by the surgeon at the time of the surgery, when he can observe and study the exposed affected nerve, thereby determining whether it is simply compressed, irreversibly damaged, and whether there is any possibility of reconstructing it. In the event of the former, neurolysis would be the procedure of choice, however if the involvement is complete neurorrhaphy would be performed either with or without graft, and if there is no possibility of reconstruction by any method, neurotization will be attempted using an adjacent nerve.

REHABILITATION

The importance of rehabilitation in a lesion of the peripheral nerve has already been highlighted.  This must be done under the supervision of appropriate personnel, on a daily basis, for the purposes of increasing the flow of the nervous impulse through the nerve and halting the potential atrophy of the denervated muscles, while safeguarding re-enervation. It is similarly important, in cases where recovery will take many months and wherever necessary, to provide the patient and his or her family with psychological support, as this will ensure a better attitude and approach to the rehabilitation.

The information contained on this page under no circumstance can or seeks to replace the information provided individually by your plastic surgeon.  In the event of any queries, your plastic surgeon will provide you with the opportune clarifications.  If you are considering undergoing a Plastic or Cosmetic Surgery procedure, visit a Specialist in Plastic, Reconstructive and Cosmetic Surgery.