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the whole of man without leaving the least portion of his spirit free for other distractions.” Though a dedicated surgeon, he was able to achieve a deep quality of respect from his children and developed a closely knit family that persists to this day. He passed on to his family his interest in books, surgery, andsport. In the wordsof hissonHarry,”Hewasour first University”. He was a man of great surgical fortitude. In the early days, in one regular operating list in the Mater Hospital, his first two patients died under general anaesthesia. One can only admire the immense courage of this man as he faced his third operation that day. Happily, the patient survived. In his unhurried manner, he never came away from the bedside without the patient feeling better, for he gave hope to all. He had a natural recognition that total surgical care commenced at the first consultation and only finished when the greatest good had been done. His judgements were based on clinical experience, for there were few X-ray or pathology facilities available. He demanded the highest standards of himself. He was tough, yet gentle, a perfectionist, and critical. He did not suffer fools gladly, yet he was a generous and charitable man. In 1956 Henry Windsor became a Papal Knight of St Gregory. Queen Elizabeth II created him a Commander of the British Empire in 1965. In 1957
Henry Windsor was elected a Fellow of the Royal College of Surgeons of England and received his Diploma of Fellowship from the President, Sir James Patterson Ross, after an introduction by the VicePresident and famous plastic surgeon, Sir Archibald Mclndoe (Figure 3a). I n 1963 Henry Windsor was elected a Fellow of our own College and achieved the unique distinction of being a father with three sons, Harry, Morgan and Clem, all Fellows of both the English and Australasian Colleges, the first and only time in the long history of both Colleges (Figure 3b). At the age of 70 he ceased major surgery, but continued as a surgical consultant and general practitioner until his death. It is interesting to speculate how Henry Windsor would have practised if he was commencing today. Perhaps with his gentle touch and patience he may have. been attracted to microsurgery. ACKNOWLEDGEMENTS The author expresses his appreciation to the members of the Windsor family in Brisbane and Sydney who provided much material regarding Henry Joseph Windsor.
AHERN, E. D.
REFERENCE (1931-1932).AUST N Z J SURG. 1: 52
THE HENRY WINDSOR LECTURE: PART II, THE CONTRIBUTIONS OF MICROVASCULAR SURGERY TO MEDICINE BERNARD MCC. O’BRIEN
Microsurgery Research Unit and Plastic Surgery Unit, St Vincent’s Hospitai, Metbourne MICROSURGERY commenced in 1921, when CarlOlof Nylen, a noted otolaryngologist from Uppsala, Sweden, used a monocular microscope for a middle ear infection, followed by his chief, Holmgren, in 1922, using a binocular microscope. Perritt (1950) commenced micro-ophthalmology in the United States, in 1946 and this was also followed by experimental microvascular surgery (Jacobson and Saurez, 1960) and microneural surgery (Smith, 1964) in the United States. Microneural surgery commenced at St Vincent’s Hospital, Melbourne, in 1964, followed in 1966 by AUST. N.Z. J. SURG.VOL. 49-No.
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m i c r o i a s c u l a r surgery. O u r experiences i n approximately 400 clinical microvascular cases, more than 1,000 cadaver dissections, and some 40,000 experimental microvascular anastomoses are outlined. During the last 20 years microscopes have become increasingly sophisticated. Microsurgery is not a separate speciality, but a technical surgical advancement applicable to all the surgical specialties. A microsurgery programme integrates clinical and laboratory experience and must possess adequate human cadaver access with a clinical workload that can support a viable 403
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programme. In microsurgical training, the surgeon initially requires his surgical specialty training on which is superimposed microsurgical laboratory and clinical experience. The fusion of these components leads to proper case selection, proper technique, and proper case management. Microinstrumentation is maintained at a simple level with fine instruments and sutures. The microbipolar coagulator has become invaluable in securing haemostasis in a microsurgical procedure. Meticulous microsurgical technique is all-important in the repair of arteries, veins, lymphatics, and nerves. Vascular anastomoses may be end-to-end or end-to-side, and microvascular grafts may be venous (usually) or arterial. Histological and scanning electron microscopic studies of smallvessel surgery have given an understanding of the trauma of surgery and the reparative processes in a patent repair. Endothelialization commences at three days and is complete in two to three weeks. High patency rates have been achieved in large series of experimental microvascular techniques without the need for anticoagulants (Table 1).
reconstructive surgery of all divided parts, and demands the appropriate background in reconstructive and hand surgery. All amputated tissiJes should be preserved, because even if not replanted they may be valuable donors of arteries, veins, nerves and skin. Tissues that can be replaced by microsurgical techniques include digits, extremities, scalp, penis, and areasof the face difficult of reconstruction such as the ear, nose and lips. Early cooling by insertion of the severed part into a clean plastic bag surrounded by ice, together with rapid transportation, is essential in the early management of the severed part. Extremity Replantation Guillotine and localized crush injuries give the best results, especially below the junction of the upper two-thirds and lower third of the forearm (Figure 1 ) . Avulsion injuries, particularly above the
TABLE1 Microvascular Surgery Patency Rates, Second Postoperative Week Vessel Diameter Artery Vein Artery Vein Microvenous w a f t to artery Lymphaticovenous
I m m
lmm 05mm 04mm lmm
% Patency
__
9R
92 a5 925 96
80
Atraumatic handling, meticulous suture placement, and fine sutures and needles are essential. The following principles of microvascular surgery have emerged. (1) Suture only NORMAL vessels with NORMAL flow as seen through the microscope. (2) Suture vessels of similar diameter preferably end-to-end, but end-to-side anastomosis may be useful. (3) Normal vessel tension must be maintained. (4) There must be no kinking or torsion of vessels. ( 5 ) Use the largest small vessel available. (6) Obtain the longest leash of vessels possible in tissue transfer to provide maximum flexibility. CLINICAL APPLICATIONS OF MICROVASCULAR SURGERY REPLANTATION SURGERY
There are two main aims in replantation surgery: (1 ) Survival, and (2) Adequate function. This surgery is not only microvascular surgery, but total 404
FIGURE1: (a) A guillotine amputation of the left hand in a young woman through the left wrist joint from a flying axe; (b) complete survival with extension of wrist and fingers after two years; (c) flexion of the fingers at two years. The middle finger flexion is impaired, but was improved by subsequent tenolysis. AUST. N.Z. J. SURG. VOL. 49-No.
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elbow, give poor results. The presence of muscle, which withstands prolonged ischaemia poorly, stresses the need f o r early c o o l i n g and reattachment. Total primary reconstruction is recommended, including tendons and nerves, and it is essential to achieve primary skin healing. Eighty-two per cent survival was achieved, the losses being in the avulsion group above the elbow. All incomplete or complete hand amputations survived (Table 2). TABLE2 Limb Replacement. Results Degree Hemi-hand Hands
4 11
Mechanism
Survival
Complete
4
Guillotine Local crush
2 2
4
Complete Incomplete
7 4
Guillotine Local crush Avulsion
2 6 3
11
Forearms
6
Complete
1
Diffuse crush or Avulsion
6
5
Above elbow
6
Complete
3
Avulsion
4
0
Incomplete
1
Feet
1
Complete
1
Local crush
1
1
Lower leg
1
Complete Incomplete
1 1
Diffuse crush Local crush
1 1
2
Total
28
23 (82%)
Results.- Nerve repairs have been rewarding, with an average two-point discrimination of 17mm and no paraesthesia. Most cases have required tendon surgery, including transfers. Extensor tendon adherence and intrinsic paralysis have been common, and tenolysis is often indicated. In replanted hands the joints have achieved useful, painless, and stable movements (Figure 1). The patients have been pleased with their aesthetic result and function has been superior to that of a prosthesis. There has been a high incidence of cold symptoms in the winter. Digital Replantation Guillotine and localized crush amputations are routinely replanted, but avulsion amputations of the thumb only are reattached. Contraindications to replantation include digits with gross crush, extensive tissue loss, extensive vessel damage, multiple fractures, long ischaemia time, and other serious injuries. Amputations of the thumb are most important because of the dominant function of this digit. M u l t i p l e d i g i t a l i n j u r i e s present the commonest situation, although not all of these digits can be replanted or revascularized. Single digits are not replanted as a routine except in special circumstances, such as in children or in women for cosmetic reasons. Digits may be transposed, e.g., the index finger on the middle finger stump when the AUST. N.Z.J. SURG. VOL. 49-No.
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TABLE3 Results: Survival, Digital Replantation and Revascularization Nature of Injury
Number
Degree
Survival
Guillotined and localized crush
111
Complete 58 Incomplete 53
Complete Incomplete
46(79%) 48(90%)
Avulsion and diffuse crush
49
Complete 25 Incomplete 24
Complete Incomplete
17(71%)
Total
160
Total
8(32%) 119(75%)
proximal vessels and nerves are more satisfactory and where the middle finger is unsuitable for replantation. Every patient should be treated as an individual problem, remembering their age, occupation, and wishes. One hundred and twenty cases involving 160 digits have been treated (Table3). Ofthese,83 (52%) were complete amputations and 77 (48%) were incomplete amputations. The incomplete amputations are analysed w i t h completely amputated digits as they present similar problems and may be more difficult to treat. The age of the patients ranged from 13 months to 70 years, average 27.5 years, 23 under the age of 15 years. The ischaemic time varied from 5 to24 hours. Most of the replantations occurred on the more dominant radial aspect of the hand, the thumb being thecommonest site. The commonest level of replantation in all digits was the proximal phalanx (Morrison et alii, 1977, 1978a). There is a substantial drop in survival in the avulsion and/or diffuse crush injuries, and these failures have been unrelated to the age of the patient, the digit, and the ischaemia time. The cause of failure (Table 4) has been mainly arterial thrombosis following damage to arteries, TABLE4 Causes of Failure in Digital Replantation and Revascularization Arterial thrombosis Venous thrombosis Failure to revascularize Infection Total
23 9 7 2 41
(56%) (22%) (17%) (5%)
even though all apparently damaged segments have been resected with the aid of the operating microscope. Residual damage has been confirmed by experimental scanning electron and light microscopy studies. Despite the contaminated sources, the incidence of infection has been e x t r e m e l y l o w . O c c a s i o n a l l y b l e e d i n g is encountered postoperatively, but this is corrected by cessation of heparin administration for a short period. About 80% of the failures occur in the first three days, and most result from avulsion injuries. 405
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Subjective assessment.- All the patients had experienced cold symptoms, but hand function,had improved significantly. Only four late amputations (4%) were performed for poor function of the digit. Objective assessment.- Bony problems have been uncommon, with only one non-union and a small incidence of malrotation without interference with function. Two-point discrimination averaged nine millimetres. The amplitude of movement has been limited in all cases except when the flexor tendons were intact. I f replantation occurred through a joint, arthrodesis or fibrous ankylosis nearly always occurred. Aesthetically, the appearance of the digits was pleasing, though a mild degree of atrophy was evident. If there was no interference with the epiphysis, growth remained
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little disturbed. Thumbs developed good function despite limited movement. The main problems in digital replantation have been flexor tendon adherence and joint stiffness. In summary, careful selection of patients is required with the institution of early cooling, the availability of an organized replantation service, and good rehabilitation. MICROVASCULAR FREE FLAP TRANSFER The one-stage transference of skin and fat from one part of the body to another without a pedicle, suturing the vessels of the flap to the appropriate vessels in the recipient site, has been one of the most revolutionary reconstructive procedures to develop in this century. The flaps may be combined with
FIGURE3. (a) severe compound injury of the left lower leg four months previously. The leg has been grafted with split thick-nessskin graft; (b) skiagram X-ray of same patient illustrating large tibia1 defect; (c) a microvascular free osteocutaneous right groin flap incorporating 10 crn of the iliac'crest: (d) skiagram of the left tibia showing hypertrophied iliac crest bone graft with solid union; (e) same patient two years later following single procedure, transferring osteocutaneous groin flap to the left lower leg.
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other tissues, and the breadth of application is steadily increasing. The groin has been the commonest donor site (Figure 3), but other areas have been the dorsum of the foot, deltopectoral, lateral thoracic, first web space of the foot, and more recently, the tensor fascia lata. Bone. muscle. nerve and tendon can all be transferred as a composite unit in the free flap. These flaps allow simultaneous nerve, telldon, or bone repair. They eliminate awkward posture in multiple injuries or in old Patients. The flap circulation IS greatly improved and Joints Can be mobilized earlier. Free flaps may be applied to extensive skin losses and cover vital underlying structures. They have become established in cancer surgery, especially in the head and neck, and for the treatment of irradiation necrosis. They have been used too in the correction of congenital and acquired deformities of the hand, for congenital disfigurement, and aesthetically for the correction of burn scars, especially in the face and neck. RESULTS From March 1973 to September 1978 there were 73 microvascular free flap transfers performed with a total flap survival in 57 (78%), partial flap necrosis in 5 (7%), and complete flap necrosis in 11 (15%). In approximately 5O0h of the complete flap failures survival of the deepest layers occurred, allowing the application of split thickness skin grafts, previously impossible. The cause of the failures was arterial thrombosis, which was avoidable except where atherosclerosis was present and for which no solution was evident, unless a non-diseased segment was available. Postoperative vascular complications need urgent treatment, as these flaps do not withstand secondary ischaemia well. Early recognition of these complications is essential, and reoperation has salvaged a number of these flaps. There have been no tai\ures as a result of venous thrombosis. The commonest recipient site has been the upper limb, especially the hand, with the lower limb next frequent. followed by head and neck and thorax. In the lower limb the use of the external Wagner fixateur on the side opposite to the miCrOVaSCUlar surgery has greatly simplified the use of free flaps and the overall management of these Serious b w e r limb injuries. The free flap can resurface below knee FIGURE 2 (a) Congenital absence of the left breast and pectoralis maloi in a 12-year-old girl ( b ) freedermollpomatous groin flap cut to a pattern of the chest defect with the nipple circumscribed on the pattern (c) same patlent one year latet after wsertion of the microvascular free dermolipomatous groin flap through a small axillary incision The flap was vascularlzed from branches of the axillary artery Good contour correction is seen
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amputation stumps, where minimal stiortening of bone would otherwise result in an above knee amputation. The free flap for lower limb injuries has proved to be a reasonably safe, one-stage procedure, which can be carried out as a primary or secondary operation. The use of the deep circumflex iliac vessels with their long leash and large diameter has improved the safety of the free groin flap when transferred with, or without, an iliac bone segment. The free dermolipomatous transfer, removing the epidermis and superficial dermis from the groin flap, has proved of use in the correction of facial atrophy and for congenital absence or hypoplasia of the pectoralis major muscle with, or without, absence of the breast (Figure 2). In the face the patterned transfer is inserted through a preauricular incision and the vessels are anastomosed to the superficial temporal vessels. I n the chest the approach is via a relatively inconspicuous axillary wound, and the patterned dermolipomatous graft is fixed into position. Where the breast is absent, an implant will be inserted under the transfer in subsequent years.
COMPOSITEFREEFLAPS Free flaps may be combined with other structures listed in Table 5. TABLE5 Composite Free Flaps Groin and iliac bone
3
Dorsum of the foot and second metalarsai
2
Dorsum of the foot and extensor tendon
2
Neurovascular (foot to hand)
11
Total
20
Osteocutanous Free Flap The osteocutaneous flap from the groin includes the crest of the ilium up to 10 cm long with the maximum soft tissue connection of the crest to the flap. The feeding vessels of the groin flap nourish the iliac crest via periosteal vessels, enabling a vascularized bone graft to be transferred. This has been of special use in difficult lower limb problems (Figure 3). The immobilization of the limb should be continued for approximately 18 months, as otherwise fracture of the bone graft may occur. An additional use of the osteocutaneous flap has been the combination of the dorsum of the foot and the underlying second metatarsal vascularized via the dorsalis pedis artery and drained via the saphenous system or the venae comitanies surrounding the dorsalis pedis artery. This composite flap has proved useful in resurfacing the floor of the mouth, where loss of lining and part of the mandible have occurred following cancer surgery or trauma. 408
Anastomosis of the flap vessels to the facial vessels revascularizes the transfer. A lower posterior rib and the overlying skin may be transferred also, but this appears rather unreliable, requiring delayed procedures. Neurovascular Free Flap This has become a valuable procedure in the reconstruction of the severely mutilated hand. The neurovascular free flap from the first web space to the foot has special qualities of texture with the glabrous nature of its innervation and with vessels suitable for transference to the hand (Morrison et alii, 1978b). The flap can be enlarged by incorporating the dorsum of the foot. The vasculature of the flap has been well described (Gilbert, 1976 May; et alii, 1977). The thumb can be reconstructed in the adult who possesses a mobile carpometacarpal joint by inserting an iliac crest bone graft into the proximal phalanx or first metacarpal, wrapping around it a neurovascular first web free flap incorporating the nail and its bed and some terminal (Morrison et alii, 1978a). The flapsize corresponds to the circumference of the opposite normal thumb, and the flap is revascularized from the snuff-box area, the most important key area for microvascular surgery of the hand. Innervation is achieved by joining the plantar digital nerves to the palmar digital nerves of the thumb. All cases have survived except for the first case five years ago. This method of thumb reconstruction is not applicableto children, as the transfer does not contain any joint with epiphyses for growth. These neurovascular free flaps have an absolute indication where an island flap is not available. There is no cerebral m i s i d e n t i f i c a t i o n possible as exists i n the conventional neurovascular island flaps from the ring finger. There is minimal or no secondary morbidity in the big toe, whoseskeleton is preserved by free grafts and cross toe flaps to provide essential soft tissue cover. More area is available than an island flap and aesthetically the result is superior. The two-point discrimination is approximately 15-20 mm, but this is not a disadvantage because there is no other functional alternative to the thumb. No pain nor paraesthesia has been associated with any of these cases. Vascularized Tendon Graft More recently tendon grafts have been elevated with the dorsal free flap from the foot vascularized by the same system. These tendon grafts have less likelihood of adherence to underlying bones as they carry their own vascularized surrounding soft tissue. The more conventional methods would incorporate a two-stage groin flap which may require thinning and subsequently passing tendon grafts through the AUST.N.Z. J. SURG.VOL. 49-No. 4 AUGUST
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fat of the flap. The most appropriate donor site is the dorsum of the foot, incorporating the extensor hallucis brevis and extensor digitorum longus tendons. Primary reconstruction of severe injuries of the dorsum of the hand could be undertaken using this free flap and vascularized tendons. Microvascular Free Toe Transfers Free toe transfer is becoming increasingly important in hand reconstruction. Wherever possible the toe is transferred, based on thedorsalis pedis artery from which the first dorsal metatarsal artery usually arises, supplying the big toe. Arterial communications exist at the base of the big toe with the plantar digital system. The long extensor and flexor tendons are divided at ankle level. The dissection is kept to a minimum on the sole of the foot, dividing the plantar digital nerves at the appropriate level. If the thenar web needs reconstruction, some of the dorsum of the foot and the medial aspect of the second toe are included. Results.- Nineteen toes have been transferred in 17 cases. Two of these have been for congenital absence of the thumb (O'Brien et alii, 1978) and the remaining 17 for acquired conditions (Table6). Ten metatarsophalangeal joints have been included in the transfer. There has been a 100% survival following the failure of the first transfer. Minimal postoperative
TABLE 6 Number of Toes Transferred Single toe transfer Hallux Second toe
15 9 6
Double toe transfer
9
Hallux second Toe
1
(Same feet)
Second toe Third toe
1
(Same foot)
Total
19
vascular complications have been encountered with only one arterial thrombosis, and this was corrected. There has been significant upgrading of hand function, and the two-point discrimination has averaged 21 millimetres compared with the control of 15 millimetres on the opposite foot. This twopoint discrimination, though much greater than that of the normal thumb, has not been of significance where there has been no other functional alternative. The movements of the transferred toes have been adequate and useful. Independent study of t h e , feet b y orthopaedic surgeons has demonstrated little or no disability, despite transference of a metatarsophalangeal joint. It is recognized, however, that long term follow-up of these donor feet is required. A toe transplant provides joints and all other structures common to a digit, including nail and nail
FIGURE4 (a) metacarpal amputation of the left hand of a25-year-od male Groin flap has been used for primarycover (b) appearance eighteen months postoperatively of the same patient following a simultaneous transfer of the hallux for thumb reconstruction and cross hand ring finger transfer to the second metacarpal Both the metatarsophalangeal joint and the metacarpophalangeal joint were included in the transfer of these two digits A wide span is noted (c) same patient 18 months postoperatively demonstrating a strong pinch between the transplanted hallux and ring finger
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bed. Its transfer preserves other digits such as the index finger. In the big toe transfer i o r congenital absence of the thumb, the entire metatarsal including its basal epiphysis is transferred to provide future growth. Tendon transfers have beer carried out at four weeks subsequent t o this transfer. but it is recommended that in tuture these be performed at the original surgery. Where digits are congenitally absent, haliux transfer becomes important in thumb reconstruction in order to preserve the diminished number of digits. The double toe transfers may be from one foot or both feet. Where the second and third toe are taken as a combined unit, the two toes provide a greatel area of pinch and grip than a single second toe transfer. Cross Hand Ring Finger Transfer An alternative method to toe transfer is the use of the ring finger from the normal opposite hand. Two patients have been operated upon who have had virtually metacarpal hands. Reconstruction in one case has been achieved by a simultaneous big ioe transfer for the thumb in a cross hand ring finger transfer (Figure 4 ) and, in the second case, by a neurovascular free flap to the remains of thefirst ray and by a ring finger transfer from the opposite hand. The ring finger is appropriately placed. revascularized and innervated Good pinch and span has been achieved and a good range of flexion and extension. Tendon transfers or grafts are needed for the extension of the interphalangeal joints. Strong pinch is achieved, and the normal hand, though minus a ring finger, does not haveany detectable alteration in strength or performance. Microvascular Free Bone Grafts Experiments in our laboratory with the canine tibia have revealed the superiority of the transfer of large masses of bone with microvascular surgery (10 dogs) over similar bony masses transferred without microvascular surgery (13 dogs) (Haw etalii. 1978). There was a 94.5% union of osteotomies at 12 weeks in the microvascular group compared with only20% in the control group. In addition, there was less infection in the microvascular group. The early experimental and clinical work in the late sixties and seventies by McKee (1978) involved the use of ribs for mandibular reconstruction. Other bones capable of transfer include fibula, second metatarsal, the iliac crest combined with the groin flap (Figure 4 ) , the second metatarsal with the dorsum of the foot, and the lateral thoracic flap with underlying ribs. The rib has been used for replacement of the hemimandible or smaller mandibular segments and for the tibia, though it is 410
less suitable for this weight-bearing area It has also been used tor bony defects of theskull The fibulaor the iliac crest with the groin flap are superior alternatives for the lower limb The fibula has beep used for the tibia. temur, humerus and w i n e In weight-bearing areas, long immobilization is required to allow the graauai hypertrophy of the bone transplant There has been only one bone graft failure five years previously, and this was due to infection in the anterior end of a rib bone graft for mandibular substitution All other bone grafts united in thearea5 describe;: Microvascuiar Free Muscle Transfe: There are two areas of special application. (1' Facial palsy, congenital or acquired (long established); and (2) partial paralysis or muscle destruction of the upper limb Facial pa/sy.- The aims in tne treatment of the long-established facial palsy are first. to provide movement symmetrical with that of the opposite side of tne face, and second, to develop acontrolled mass action movement that concentrates on tne upper and lower lips. nose and eyelids. This reconstruction is carried out in two stages (Figure 5). A sural nerve graft joins the fascicular periphera! plexus of the normal facial nerveabout 1.5cm laterai to the nasolabial line. This nerve graft is passed across the chin to the opposite preauricular area, where it is left unsatisfied for approximately six months. After four to six months percussion of the unsatisfied nerve ending elicits a pins and needles sensation at the site of the union of the nerve graft to the normal facial nerve. This is the result of fifth nerve sensory fibres normally present in the peripheral facial nerve growing along thesural nerve graft. This positive sign is an indication that axonal regeneration is well advanced and that the second stage of a microvascular free muscle transfer can proceed. More recently a supraorbital nerve graft has been d d e d connecting thezygomatic branch of the normal facial nerve and tunnelled to the opposite preauricular area. Initially. the extensor digitorum brevis was transferred and the tendons of the muscle were led into the upper and lower lips (O'Brien, 1977). The muscle was revascularized by joining the dorsalis pedis artery to the facial artery and a vena comitans to the facial vein. The previously inserted nerve graft was then joined to the nerve of the muscle and any unsatisfied ends of the nerve were plunged into,the various bellies of the muscle. This muscle was not sufficiently consistent in its power. The gracilis muscle has a nerve supply similar in fascicular pattern to that of the sural nerve, and this AUST.N.Z. J. SURG.VOL. 49-No.
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FIGURE 5 fa) sural nerve graft connecting fascicles of the right normal facial nerve just lateral to the right nasolabial line The free end of tbe nerve graft lies i n the left preaurictilararea (b) second stage of the facial nerve reconstruction six months later the gracilis muscle is inserted with segments attached to the upper and lower I ~ Dand C the side of the nose The muscle is revasculdrized by anastomosing tne gracilis vessels and innervated by joining he nerve to tne previously inserted cross facial sural nerve graft
muscle has proved more consistent and stronger. The muscle is turned upside down and maximum tension is placed on it. The gracilis muscle has several areas of blood supply, but its proximal region is the largest with the nerve adjacent to it. More recently the gracilis muscle has been inserted not only into tne lips and angle but also into the base of the nose. eyelidsand forehead.The nerve union is made as close to the muscle as possible to allow the earliest reinnervation and less likelihood of atrophy. Tne supraorbital nerve graft is joined to the upper branch of the nerve to the gracilis and the lower nerve graft to the lower segment of the nerve to the gracilis. The ischaemic time is usually about two hours More bulk than appears necessary is inserted to allow for any muscle atrophy. Clinical movement commences at four to five months (Figure 6). It has been shown with one electrode in the transplanted muscle and the other in the opposite normal facial nerve that stimulation of the latter provides activity in the muscle transplant. In the upper limb the gracilis has again been the main muscle used, and Manktelow and McKee (1978) have achieved an excellent result in the substitution of forearm flexors. The extensor digitorum longus has been used similarly on one occasion in our Unit. It possesses four tendons which are vascularized and can be joined to the appropriate long flexors in the wrist or palm. AUST. N.Z. J. SURG. VOL. 49-No.
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Microvascular Testicular Transfer The high undescended testis, especially if bilateral, may lead to malignancy, torsion, and sterility. Conventional methods of delivering the testis into the scrotum often fail because of the shortness of the vascular leash and the tension placed upon it. Division of the testicularvessels with mobilization of the vas has been carried out (Fowler and Stephens, 1963), but long-term follow-up of these cases has demonstrated a significant degree of atrophy. It seems logical, therefore, that the abdominal testis when mobilized should have the testicular vessels divided high in the abdomen and anastomosed by microvascular surgery in the inguinal area, so that the testis resumes a normal blood supply. High mobilization of the testicular vessels via a transperitoneal approach is performed and the vas deferens mobilized, bringing the testicle into the medial inguinal area and finally into the scrotum. The small testicular vessels are joined to branches of the deep inferior epigastric vessels. This work has been carried out with the Paediatric Department of the Monash University at Queen Victoria Hospital, Melbourne. It has been based on experimental work (MacMahon et alii, 1976), removing, the canine testis and replanting with microvascular surgery. Histological examination one month later showed, in most cases, a normal testicular pattern. 41 1
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FIGURE^ (a) middle-aged lady witha rightfacial nervepalsy of eightyearsduration. (b) twoyearsaftercompletionofthetwostage cross facial nerve graft and gracilis muscle facial reconstruction The previously paralysed right sideof the face has now only a slight droop of the right upper lip
A series of six cases involving eight testicles has now been carried out. Following revascularization, a biopsy shows a bleeding testis and the histological findings, whilst not normal, show revascularization. Apart from the first two transfers, growth has been observed in the remainder. It is a logical approach for the bilateral abdominal testis, and there is a relative indication for unilateral high undescended testis. The method enables a one-stage transfer to be carried out with reasonable certainty, but a longterm follow-up is required to asses testicular growth and spermatogenesis. Microvascular Free Small Joint Transfer The value of this procedure in hand surgery lies in small joint reconstruction in young adults and children where epiphyses are needed. Artificial joints in the young are not considered suitable as their life span is relatively short. Experimental work in our laboratory (O'Brien, 1977; Hurwitz, 1978) has clearly shown that vascularized small joints are macroscopically, histologically and radiographically similar to normal joints, whereas a small 412
joint transferred without microvascular surgery experimentally and in previous clinical reports has little hope of maintaining its normal architecture or function. Two clinical cases have been completed. In the first patient a proximal interphalangeal joint of the second toe was transferred to reconstruct a proximal interphalangeal joint of a middle finger in a 10-year-old child. This finger was short and flail as a result of old trauma. The epiphysis was included in the joint transfer and is radiologically normal at nine months. Bone union has been achieved and 50" of stable active flexion has been achieved. A segment of second toe extensor tendon was included as part of the toe transfer. A second case has involved the use of a proximal interphalangeal joint of an otherwise useless little finger to reconstruct the metacarpophalangeal joint of the middle finger in a digital replantation case. Microvascular Jejunal Transfer Reconstruction following resection of carcinoma of the cervical oesophagus has always created AUST. N.Z. J. SURG.VOL. 49-No.
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problems. Sometimes the entire oesophagus is resected and the stomach pulled up through the mediastinum into the neck, suturing the stomach to the pharynx. This is not always possibleasthechest may not be capable of entry. Also, there are some cases in which the vasculature of the distal end of the mobilized stomach is inadeauate and in these circumstances it is desirable thaithe arteries of this gastric segment should be sutured to arteries in the neck. An alternative method is the use of a segment of jejunum, revascularizing the jejunum by microvascular surgery in the neck (McKee and Peters, 1978). An abdominal surgeon and a head and neck surgeon working concurrently are responsible for the resection of the head and neck cancer and the removal of the jejunal segment. This jejunal segment has its vessels anastomosed to the transverse cervical artery and the external jugular vein. Peristalsis returns to this jejunal segment immediately, and the postoperative recovery can be dramatic with its ease of management In uncomplicated cases, patients leave hospital in two or three weeks with a normal barium swallow. MICROLYMPHATIC SURGERY
The lymphatics are small, fragile vessels approximately 0.25 mm in diameter. The purpose of this branch of surgery is to join obstructed lymphatics in end-to-end fashion to neighbouring veins in secondary obstructive lymphoedema, bypassing the site of obstruction in the axilla or the groin (O'Brien et alii, 1977).These obstructions have resulted from surgical and irradiation treatment for malignancy, commonly carcinoma of the breast. The technique follows the pattern of microvascular surgery with end-to-end anastomoses using the finest commercial needles of approximately 70 microns in diameter and monofilament nylon 18 microns in diameter. The needle is passed through the lymphatic wall first, which is being dilated carefully and gently with a pair of No. 5 jewellers' forceps. About four to eight sutures are required for each anastomosis. Experimental work in the nonlymphoedematous canine model has shown patency rates in the three groups explored at varying times of 78% at one week, 73% at one and half to three months, and 83% at six months (Gilbert, etalii, 1976). Patients with obstructive lymphoedema are admitted to hospital three days before operation, and intensive conservative treatment of elevation, daily pumping and bandaging is commenced, in order tht the volume of the limb can be reduced toas low a level as possible. The circumferential limb measurements are recorded daily in the upper limb AUST. N.Z J. SURG.VOL. 49-No.
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15 cm above the elbow, 15 cm below the elbow, and at the wrist and the hand. This, combined with the volume displacement in a water tank, gives a reasonable assessment of the dimensions of the limb. However, it does not indicate the skin tension of the limb, and this is one aspect which is requiring further investiaation. Approximately 100 lyrnphangiograms were c a r r i e d out b e f o r e i t was r e a l i z e d t h a t lymphangiograms can cause irreparable damage to the obstructed lymphatics. Lymphangiograms and venograms are therefore no longer performed in the preoperative investigation. In one patient a group of lymphatics was demonstrated on a lymphangiogram on the medial aspect of the humerus. These lymphatics were located three months later and all w e r e o b l i t e r a t e d , w h i c h was c o n f i r m e d histologically. From August 1974 to June 1978, 136 cases of lymphoedema have been seen of which 14 have been p r i m a r y . Of the 124 obstructive lymphoedemas, 102 have been present in the upper limb and 22 in the lower limb. The lymphangiograms revealed that any obstructed lymphatics will be present in the medial aspect of the upper arm, at the elbow, or just below the medial aspect of the elbow. Incisions made in these areas may demonstrate the presence of lymphatics following the injection of 0.25ml of Patent Blue dye into an interdigital web. In the lower limb a transverse incision of 2-3 inches is made at the mid-medial aspect of the thigh several inches above the knee and on the medial aspect of the lower leg, just below the knee. If the obstructed lymphatics are at least two or more in numberandof reasonable size, then they are anastomosed end-to-end to neighbouring veins of similar size. In addition, a longitudinal elliptical segmental reduction is made on the outer aspect of the upper arm or on the outer aspect of the thigh. If lymphatics of inadequate number or size are found, then a one-stage reduction procedure is carried out, reducing onehalf to two-thirds of the circumference with removal of much fat and deep fascia via a mid-medial excision along the length of the limb. I t has become evident that microlymphatic surgery is applicable to the moderate obstructive lymphoedema, whereas a one-stage reduction procedure applies to the gross oedema where the destruction of lymphatics is too advanced for microlymphatic surgery. The anastomoses have averaged approximately four, and the follow-up has ranged from one month to 43 months, with an average of t8.6 months. 413
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Forty microlymphatic operations have been performed, and 35 of these are available for followup. The average decrease in the excess volume has been 12.2%. In 21 cases there has been significant improvement, and the average decrease of excess volume in this group is 32.3%. the aecrease in the excess volume ranging from 2.2% to 66.7%. Fourteen cases have remained unchanged or have had increased oedema, sometirnes caused by lymphangiography. The average time of healing has been one weeh, Subjectively the patients have been more comfortable, with less weight in the arm, which has been distinctively softer. Clothes fit better, and swelling has subsided fast with conservative measures and there has been less embarrassment. Even though the volume of the limb may have changed little, the patient feels considerably improved 111 these circumstances the limb is distinctly softer. and so skin tension is assuming greater importance.
Microlymphaticovenous surgery provides a better contoui with more rapid healing There is minimal scarring and the limb is softer Draining of the hand and the lower forearm is more complete than with other methods (Figure 7) There I S more raprc drainage with conservative measures and there has been a significant reduction in cellulitts from 42% preoperatively t o 17% postoperatively No correlation of results has been found with axillat-) vein thrombosis the duration of the oedema, and brachial neuritis I t seems logical, however that in the individual case the sooner the patient is seen with obstructive lymphoedema the better the chances of a satisfactory result without the need foi postoperative conservative measures I t 1 5 recognized that lymphoedema has a fluctuhting life cycle and that long-term follow-up is essential MICROVASCULAR HOMOTRANSPLANTATION This is an area fraught with many difficulties Only one such operation has been carried out in our Unit
FIGURE 7 (a) obstructive lymphoedema of the right uppei limb following right radical mastectomy and irradiation of t h e axilla and neck seven years previously (b) same patient 18 months after four microlymphaticovenous anastomoses on the medial aspect of the right upper limb There has been a significant reduction in thesizeofthe right upper limb
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in association with the Monash University Department of Obstetrics and Gynaecology, and the Melbourne University Department of Medicine, Austin Hospital, involving the micovascular homotransplantation of the Fallopian tube (Wood, et ah;, 1978). A lady in her late thirties with a 10-yearold child had both Fallopian tubes destroyed by ectopic pregnancies. Her sister, with reasonable histocompatibility, had five children and donated to her sister a Fallopian tube and a core of uterus based on the ovarian vessels. This complex was transferred, revascularized by anastomosing the deep inferior epigastric artery to the ovarian artery, and draining the ovarian vein into the saphenous vein turned up from the thigh through the femoral canal. The transplant was revascularized outside the peritoneal cavity, appeared quite normal, and was placed in its correct abdominal position without kinking of the vessels. Immunosuppressive therapy was continued for some months. She had no apparent complicationsand remained in hospital for only ten days. A laparoscopy at six weeks did not achieve an adequate view of the Fallopian tube because of the presence of omentum, but methylene blue dye injected into the cervix was seen to emerge through the distal end of the Fallopian tube. At laparotomy six months later, the transplant was necrotic and was removed. The specimen was examined, and histologically there was evidence of chronic rejection, similar to that seen following a renal transplant. It would seem that this operation cannot succeed without improved histocompatibility. and this path will be persued. CONCLUSIONS Microvascular surgery has had a short history, for it is the surgery of the present as it speeds rapidly towards the eighties and nineties of this century. Fortunately, Henry Windsor lived to see it flourish. The first Henry Windsor Lecture, given by Henry Windsor, was entitled "How Far that Little Candle Throws his Beam", but Henry Windsor was no candle. He was a beacon whose light shone across several generations, and his name is perpetuated by the Royal Australasian College of Surgeons with this lectureship. The Royal College of Surgeons of England now grants a Windsor Prize annually to a worthy young Australian in Great Britain. and the English College made its first award in 1977. On Henry Windsor's ninetieth birthday his family and friends produced a work entitled "Henry Windsor - A Remarkable Man". The Australian
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surgical comrnunitycan join with the Windsor family and truly say that Henry Windsor was a great and remarkable man.
ACKNOWLEDGEMENTS The author is greatly indebted to his immediate colleagues, Mr Allan MacLeod and Mr Wayne Morrison, who have been closely associated with this work and many of whosecases are incorporated in this Lecture. Gratitude is expressed to Mr R . K . Newing for his continued encouragement and referral of many patients. The assistance of the members of the staff of the Mater Misericordiae Hospital, Brisbane. is gratefully acknowledged. The Microsurgery Research Unit at St Vincent's Hospital, Melbourne, is supported by a grant from the National Health and Medical Research Council.
REFERENCES FOWLER, R , jr and STEPHENS, F. D. (1963) Congenital Malformations o f Rectum. Anus and Genito-Urinary Tracts, Livingstone. Edinburgh, Chap. 19. GILBERT,A. (1976) in Symposium of Microsurgery, C. V. Mosby and Co, St Louis. J. W. and SYKES.P J. GILBERT,A,, O'BRIEN. B. McC., VORRATH, (1976), Brit. J. Plast. Surg , 29, 355. T. (19781, J. Bone Jt. HAW,C., O'BRIEN,B. McC. and KURATA, Surg.. 606: 266. HURWITZ,P. (1978). Experimental small joint transplantation with microvascular anastomosis, J. Plast, Reconstr. Surg. in press JACOBSON,J. H. and SAUREZ,E L (1960). Surg. forum, 11: 243. MACMAHON, R. A,, O'BRIEN,B McC. and CUSSEN, L. J. (1976). J. pediat. Surg., 11: 4. MCKEE,D M (1978). Clin. plast. Surg., 5: 283. MCKEE, D. M and PETERS,C R . (1978) Clin. Plast Surg., 5. 305 MANKTELOW, R T. and MCKEE.Nancy H (1978) J. handSurg., 3: 427. MAY,J. W., jr CHAIT, L. A,, COHEN,8. E and O'BRIEN,0. McC. (1977). J. hand Surg., 5: 387. MORRISON, W A,, O'BRIEN.B. McC. and MACLEOD, A M. (1977). AUST. N Z.J SURG..47: 767. MORRISON, W. A , O'BRIEN,B. McC. and HAMILTON, R (1978), Clin. plast. Surg.. 5: 265. MORRISON,W. A,, O'BRIEN, B. McC.. MACLEOD,A . . M and GILBERT.A. (1978b). J..handSurg.. 3: 235 O'BRIEN, B. McC. (1977), Microvascular Reconstructive Surgery, Church111 Livingston, London and Edinburgh. O'BRIEN, B. McC. (1977) AUST.N.Z.J. SURG..47: 284. O'BRIEN. 8 . MCC., BRENNEN, M. D. and MAcLEOD. A. M. (1978). Hand, 10: 232. O'ERIEN,B. McC., SYKES.P. J , THRELFALL, G. N and BROWNING, F. S. C. (1977). Plast. reconstr. Surg.. 60: 197. PERRITT,R. A . (1950), American Academy of Opthalmologyand Otolaryncology, Course N o 280. SMITH.J W. (1964), Plast. reconstr. Surg., 33: 317 P., MCKENZIE,I.,O'BRIEN. B. McC. and WOOD, C., PATERSON. B. (1978). Fertil. Steril. 29: 604 DOWNING,
41 5
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the whole of man without leaving the least portion of his spirit free for other distractions.” Though a dedicated surgeon, he was able to achieve a deep quality of respect from his children and developed a closely knit family that persists to this day. He passed on to his family his interest in books, surgery, andsport. In the wordsof hissonHarry,”Hewasour first University”. He was a man of great surgical fortitude. In the early days, in one regular operating list in the Mater Hospital, his first two patients died under general anaesthesia. One can only admire the immense courage of this man as he faced his third operation that day. Happily, the patient survived. In his unhurried manner, he never came away from the bedside without the patient feeling better, for he gave hope to all. He had a natural recognition that total surgical care commenced at the first consultation and only finished when the greatest good had been done. His judgements were based on clinical experience, for there were few X-ray or pathology facilities available. He demanded the highest standards of himself. He was tough, yet gentle, a perfectionist, and critical. He did not suffer fools gladly, yet he was a generous and charitable man. In 1956 Henry Windsor became a Papal Knight of St Gregory. Queen Elizabeth II created him a Commander of the British Empire in 1965. In 1957
Henry Windsor was elected a Fellow of the Royal College of Surgeons of England and received his Diploma of Fellowship from the President, Sir James Patterson Ross, after an introduction by the VicePresident and famous plastic surgeon, Sir Archibald Mclndoe (Figure 3a). I n 1963 Henry Windsor was elected a Fellow of our own College and achieved the unique distinction of being a father with three sons, Harry, Morgan and Clem, all Fellows of both the English and Australasian Colleges, the first and only time in the long history of both Colleges (Figure 3b). At the age of 70 he ceased major surgery, but continued as a surgical consultant and general practitioner until his death. It is interesting to speculate how Henry Windsor would have practised if he was commencing today. Perhaps with his gentle touch and patience he may have. been attracted to microsurgery. ACKNOWLEDGEMENTS The author expresses his appreciation to the members of the Windsor family in Brisbane and Sydney who provided much material regarding Henry Joseph Windsor.
AHERN, E. D.
REFERENCE (1931-1932).AUST N Z J SURG. 1: 52
THE HENRY WINDSOR LECTURE: PART II, THE CONTRIBUTIONS OF MICROVASCULAR SURGERY TO MEDICINE BERNARD MCC. O’BRIEN
Microsurgery Research Unit and Plastic Surgery Unit, St Vincent’s Hospitai, Metbourne MICROSURGERY commenced in 1921, when CarlOlof Nylen, a noted otolaryngologist from Uppsala, Sweden, used a monocular microscope for a middle ear infection, followed by his chief, Holmgren, in 1922, using a binocular microscope. Perritt (1950) commenced micro-ophthalmology in the United States, in 1946 and this was also followed by experimental microvascular surgery (Jacobson and Saurez, 1960) and microneural surgery (Smith, 1964) in the United States. Microneural surgery commenced at St Vincent’s Hospital, Melbourne, in 1964, followed in 1966 by AUST. N.Z. J. SURG.VOL. 49-No.
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m i c r o i a s c u l a r surgery. O u r experiences i n approximately 400 clinical microvascular cases, more than 1,000 cadaver dissections, and some 40,000 experimental microvascular anastomoses are outlined. During the last 20 years microscopes have become increasingly sophisticated. Microsurgery is not a separate speciality, but a technical surgical advancement applicable to all the surgical specialties. A microsurgery programme integrates clinical and laboratory experience and must possess adequate human cadaver access with a clinical workload that can support a viable 403
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programme. In microsurgical training, the surgeon initially requires his surgical specialty training on which is superimposed microsurgical laboratory and clinical experience. The fusion of these components leads to proper case selection, proper technique, and proper case management. Microinstrumentation is maintained at a simple level with fine instruments and sutures. The microbipolar coagulator has become invaluable in securing haemostasis in a microsurgical procedure. Meticulous microsurgical technique is all-important in the repair of arteries, veins, lymphatics, and nerves. Vascular anastomoses may be end-to-end or end-to-side, and microvascular grafts may be venous (usually) or arterial. Histological and scanning electron microscopic studies of smallvessel surgery have given an understanding of the trauma of surgery and the reparative processes in a patent repair. Endothelialization commences at three days and is complete in two to three weeks. High patency rates have been achieved in large series of experimental microvascular techniques without the need for anticoagulants (Table 1).
reconstructive surgery of all divided parts, and demands the appropriate background in reconstructive and hand surgery. All amputated tissiJes should be preserved, because even if not replanted they may be valuable donors of arteries, veins, nerves and skin. Tissues that can be replaced by microsurgical techniques include digits, extremities, scalp, penis, and areasof the face difficult of reconstruction such as the ear, nose and lips. Early cooling by insertion of the severed part into a clean plastic bag surrounded by ice, together with rapid transportation, is essential in the early management of the severed part. Extremity Replantation Guillotine and localized crush injuries give the best results, especially below the junction of the upper two-thirds and lower third of the forearm (Figure 1 ) . Avulsion injuries, particularly above the
TABLE1 Microvascular Surgery Patency Rates, Second Postoperative Week Vessel Diameter Artery Vein Artery Vein Microvenous w a f t to artery Lymphaticovenous
I m m
lmm 05mm 04mm lmm
% Patency
__
9R
92 a5 925 96
80
Atraumatic handling, meticulous suture placement, and fine sutures and needles are essential. The following principles of microvascular surgery have emerged. (1) Suture only NORMAL vessels with NORMAL flow as seen through the microscope. (2) Suture vessels of similar diameter preferably end-to-end, but end-to-side anastomosis may be useful. (3) Normal vessel tension must be maintained. (4) There must be no kinking or torsion of vessels. ( 5 ) Use the largest small vessel available. (6) Obtain the longest leash of vessels possible in tissue transfer to provide maximum flexibility. CLINICAL APPLICATIONS OF MICROVASCULAR SURGERY REPLANTATION SURGERY
There are two main aims in replantation surgery: (1 ) Survival, and (2) Adequate function. This surgery is not only microvascular surgery, but total 404
FIGURE1: (a) A guillotine amputation of the left hand in a young woman through the left wrist joint from a flying axe; (b) complete survival with extension of wrist and fingers after two years; (c) flexion of the fingers at two years. The middle finger flexion is impaired, but was improved by subsequent tenolysis. AUST. N.Z. J. SURG. VOL. 49-No.
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elbow, give poor results. The presence of muscle, which withstands prolonged ischaemia poorly, stresses the need f o r early c o o l i n g and reattachment. Total primary reconstruction is recommended, including tendons and nerves, and it is essential to achieve primary skin healing. Eighty-two per cent survival was achieved, the losses being in the avulsion group above the elbow. All incomplete or complete hand amputations survived (Table 2). TABLE2 Limb Replacement. Results Degree Hemi-hand Hands
4 11
Mechanism
Survival
Complete
4
Guillotine Local crush
2 2
4
Complete Incomplete
7 4
Guillotine Local crush Avulsion
2 6 3
11
Forearms
6
Complete
1
Diffuse crush or Avulsion
6
5
Above elbow
6
Complete
3
Avulsion
4
0
Incomplete
1
Feet
1
Complete
1
Local crush
1
1
Lower leg
1
Complete Incomplete
1 1
Diffuse crush Local crush
1 1
2
Total
28
23 (82%)
Results.- Nerve repairs have been rewarding, with an average two-point discrimination of 17mm and no paraesthesia. Most cases have required tendon surgery, including transfers. Extensor tendon adherence and intrinsic paralysis have been common, and tenolysis is often indicated. In replanted hands the joints have achieved useful, painless, and stable movements (Figure 1). The patients have been pleased with their aesthetic result and function has been superior to that of a prosthesis. There has been a high incidence of cold symptoms in the winter. Digital Replantation Guillotine and localized crush amputations are routinely replanted, but avulsion amputations of the thumb only are reattached. Contraindications to replantation include digits with gross crush, extensive tissue loss, extensive vessel damage, multiple fractures, long ischaemia time, and other serious injuries. Amputations of the thumb are most important because of the dominant function of this digit. M u l t i p l e d i g i t a l i n j u r i e s present the commonest situation, although not all of these digits can be replanted or revascularized. Single digits are not replanted as a routine except in special circumstances, such as in children or in women for cosmetic reasons. Digits may be transposed, e.g., the index finger on the middle finger stump when the AUST. N.Z.J. SURG. VOL. 49-No.
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TABLE3 Results: Survival, Digital Replantation and Revascularization Nature of Injury
Number
Degree
Survival
Guillotined and localized crush
111
Complete 58 Incomplete 53
Complete Incomplete
46(79%) 48(90%)
Avulsion and diffuse crush
49
Complete 25 Incomplete 24
Complete Incomplete
17(71%)
Total
160
Total
8(32%) 119(75%)
proximal vessels and nerves are more satisfactory and where the middle finger is unsuitable for replantation. Every patient should be treated as an individual problem, remembering their age, occupation, and wishes. One hundred and twenty cases involving 160 digits have been treated (Table3). Ofthese,83 (52%) were complete amputations and 77 (48%) were incomplete amputations. The incomplete amputations are analysed w i t h completely amputated digits as they present similar problems and may be more difficult to treat. The age of the patients ranged from 13 months to 70 years, average 27.5 years, 23 under the age of 15 years. The ischaemic time varied from 5 to24 hours. Most of the replantations occurred on the more dominant radial aspect of the hand, the thumb being thecommonest site. The commonest level of replantation in all digits was the proximal phalanx (Morrison et alii, 1977, 1978a). There is a substantial drop in survival in the avulsion and/or diffuse crush injuries, and these failures have been unrelated to the age of the patient, the digit, and the ischaemia time. The cause of failure (Table 4) has been mainly arterial thrombosis following damage to arteries, TABLE4 Causes of Failure in Digital Replantation and Revascularization Arterial thrombosis Venous thrombosis Failure to revascularize Infection Total
23 9 7 2 41
(56%) (22%) (17%) (5%)
even though all apparently damaged segments have been resected with the aid of the operating microscope. Residual damage has been confirmed by experimental scanning electron and light microscopy studies. Despite the contaminated sources, the incidence of infection has been e x t r e m e l y l o w . O c c a s i o n a l l y b l e e d i n g is encountered postoperatively, but this is corrected by cessation of heparin administration for a short period. About 80% of the failures occur in the first three days, and most result from avulsion injuries. 405
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Subjective assessment.- All the patients had experienced cold symptoms, but hand function,had improved significantly. Only four late amputations (4%) were performed for poor function of the digit. Objective assessment.- Bony problems have been uncommon, with only one non-union and a small incidence of malrotation without interference with function. Two-point discrimination averaged nine millimetres. The amplitude of movement has been limited in all cases except when the flexor tendons were intact. I f replantation occurred through a joint, arthrodesis or fibrous ankylosis nearly always occurred. Aesthetically, the appearance of the digits was pleasing, though a mild degree of atrophy was evident. If there was no interference with the epiphysis, growth remained
O'BRIEN
little disturbed. Thumbs developed good function despite limited movement. The main problems in digital replantation have been flexor tendon adherence and joint stiffness. In summary, careful selection of patients is required with the institution of early cooling, the availability of an organized replantation service, and good rehabilitation. MICROVASCULAR FREE FLAP TRANSFER The one-stage transference of skin and fat from one part of the body to another without a pedicle, suturing the vessels of the flap to the appropriate vessels in the recipient site, has been one of the most revolutionary reconstructive procedures to develop in this century. The flaps may be combined with
FIGURE3. (a) severe compound injury of the left lower leg four months previously. The leg has been grafted with split thick-nessskin graft; (b) skiagram X-ray of same patient illustrating large tibia1 defect; (c) a microvascular free osteocutaneous right groin flap incorporating 10 crn of the iliac'crest: (d) skiagram of the left tibia showing hypertrophied iliac crest bone graft with solid union; (e) same patient two years later following single procedure, transferring osteocutaneous groin flap to the left lower leg.
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other tissues, and the breadth of application is steadily increasing. The groin has been the commonest donor site (Figure 3), but other areas have been the dorsum of the foot, deltopectoral, lateral thoracic, first web space of the foot, and more recently, the tensor fascia lata. Bone. muscle. nerve and tendon can all be transferred as a composite unit in the free flap. These flaps allow simultaneous nerve, telldon, or bone repair. They eliminate awkward posture in multiple injuries or in old Patients. The flap circulation IS greatly improved and Joints Can be mobilized earlier. Free flaps may be applied to extensive skin losses and cover vital underlying structures. They have become established in cancer surgery, especially in the head and neck, and for the treatment of irradiation necrosis. They have been used too in the correction of congenital and acquired deformities of the hand, for congenital disfigurement, and aesthetically for the correction of burn scars, especially in the face and neck. RESULTS From March 1973 to September 1978 there were 73 microvascular free flap transfers performed with a total flap survival in 57 (78%), partial flap necrosis in 5 (7%), and complete flap necrosis in 11 (15%). In approximately 5O0h of the complete flap failures survival of the deepest layers occurred, allowing the application of split thickness skin grafts, previously impossible. The cause of the failures was arterial thrombosis, which was avoidable except where atherosclerosis was present and for which no solution was evident, unless a non-diseased segment was available. Postoperative vascular complications need urgent treatment, as these flaps do not withstand secondary ischaemia well. Early recognition of these complications is essential, and reoperation has salvaged a number of these flaps. There have been no tai\ures as a result of venous thrombosis. The commonest recipient site has been the upper limb, especially the hand, with the lower limb next frequent. followed by head and neck and thorax. In the lower limb the use of the external Wagner fixateur on the side opposite to the miCrOVaSCUlar surgery has greatly simplified the use of free flaps and the overall management of these Serious b w e r limb injuries. The free flap can resurface below knee FIGURE 2 (a) Congenital absence of the left breast and pectoralis maloi in a 12-year-old girl ( b ) freedermollpomatous groin flap cut to a pattern of the chest defect with the nipple circumscribed on the pattern (c) same patlent one year latet after wsertion of the microvascular free dermolipomatous groin flap through a small axillary incision The flap was vascularlzed from branches of the axillary artery Good contour correction is seen
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amputation stumps, where minimal stiortening of bone would otherwise result in an above knee amputation. The free flap for lower limb injuries has proved to be a reasonably safe, one-stage procedure, which can be carried out as a primary or secondary operation. The use of the deep circumflex iliac vessels with their long leash and large diameter has improved the safety of the free groin flap when transferred with, or without, an iliac bone segment. The free dermolipomatous transfer, removing the epidermis and superficial dermis from the groin flap, has proved of use in the correction of facial atrophy and for congenital absence or hypoplasia of the pectoralis major muscle with, or without, absence of the breast (Figure 2). In the face the patterned transfer is inserted through a preauricular incision and the vessels are anastomosed to the superficial temporal vessels. I n the chest the approach is via a relatively inconspicuous axillary wound, and the patterned dermolipomatous graft is fixed into position. Where the breast is absent, an implant will be inserted under the transfer in subsequent years.
COMPOSITEFREEFLAPS Free flaps may be combined with other structures listed in Table 5. TABLE5 Composite Free Flaps Groin and iliac bone
3
Dorsum of the foot and second metalarsai
2
Dorsum of the foot and extensor tendon
2
Neurovascular (foot to hand)
11
Total
20
Osteocutanous Free Flap The osteocutaneous flap from the groin includes the crest of the ilium up to 10 cm long with the maximum soft tissue connection of the crest to the flap. The feeding vessels of the groin flap nourish the iliac crest via periosteal vessels, enabling a vascularized bone graft to be transferred. This has been of special use in difficult lower limb problems (Figure 3). The immobilization of the limb should be continued for approximately 18 months, as otherwise fracture of the bone graft may occur. An additional use of the osteocutaneous flap has been the combination of the dorsum of the foot and the underlying second metatarsal vascularized via the dorsalis pedis artery and drained via the saphenous system or the venae comitanies surrounding the dorsalis pedis artery. This composite flap has proved useful in resurfacing the floor of the mouth, where loss of lining and part of the mandible have occurred following cancer surgery or trauma. 408
Anastomosis of the flap vessels to the facial vessels revascularizes the transfer. A lower posterior rib and the overlying skin may be transferred also, but this appears rather unreliable, requiring delayed procedures. Neurovascular Free Flap This has become a valuable procedure in the reconstruction of the severely mutilated hand. The neurovascular free flap from the first web space to the foot has special qualities of texture with the glabrous nature of its innervation and with vessels suitable for transference to the hand (Morrison et alii, 1978b). The flap can be enlarged by incorporating the dorsum of the foot. The vasculature of the flap has been well described (Gilbert, 1976 May; et alii, 1977). The thumb can be reconstructed in the adult who possesses a mobile carpometacarpal joint by inserting an iliac crest bone graft into the proximal phalanx or first metacarpal, wrapping around it a neurovascular first web free flap incorporating the nail and its bed and some terminal (Morrison et alii, 1978a). The flapsize corresponds to the circumference of the opposite normal thumb, and the flap is revascularized from the snuff-box area, the most important key area for microvascular surgery of the hand. Innervation is achieved by joining the plantar digital nerves to the palmar digital nerves of the thumb. All cases have survived except for the first case five years ago. This method of thumb reconstruction is not applicableto children, as the transfer does not contain any joint with epiphyses for growth. These neurovascular free flaps have an absolute indication where an island flap is not available. There is no cerebral m i s i d e n t i f i c a t i o n possible as exists i n the conventional neurovascular island flaps from the ring finger. There is minimal or no secondary morbidity in the big toe, whoseskeleton is preserved by free grafts and cross toe flaps to provide essential soft tissue cover. More area is available than an island flap and aesthetically the result is superior. The two-point discrimination is approximately 15-20 mm, but this is not a disadvantage because there is no other functional alternative to the thumb. No pain nor paraesthesia has been associated with any of these cases. Vascularized Tendon Graft More recently tendon grafts have been elevated with the dorsal free flap from the foot vascularized by the same system. These tendon grafts have less likelihood of adherence to underlying bones as they carry their own vascularized surrounding soft tissue. The more conventional methods would incorporate a two-stage groin flap which may require thinning and subsequently passing tendon grafts through the AUST.N.Z. J. SURG.VOL. 49-No. 4 AUGUST
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fat of the flap. The most appropriate donor site is the dorsum of the foot, incorporating the extensor hallucis brevis and extensor digitorum longus tendons. Primary reconstruction of severe injuries of the dorsum of the hand could be undertaken using this free flap and vascularized tendons. Microvascular Free Toe Transfers Free toe transfer is becoming increasingly important in hand reconstruction. Wherever possible the toe is transferred, based on thedorsalis pedis artery from which the first dorsal metatarsal artery usually arises, supplying the big toe. Arterial communications exist at the base of the big toe with the plantar digital system. The long extensor and flexor tendons are divided at ankle level. The dissection is kept to a minimum on the sole of the foot, dividing the plantar digital nerves at the appropriate level. If the thenar web needs reconstruction, some of the dorsum of the foot and the medial aspect of the second toe are included. Results.- Nineteen toes have been transferred in 17 cases. Two of these have been for congenital absence of the thumb (O'Brien et alii, 1978) and the remaining 17 for acquired conditions (Table6). Ten metatarsophalangeal joints have been included in the transfer. There has been a 100% survival following the failure of the first transfer. Minimal postoperative
TABLE 6 Number of Toes Transferred Single toe transfer Hallux Second toe
15 9 6
Double toe transfer
9
Hallux second Toe
1
(Same feet)
Second toe Third toe
1
(Same foot)
Total
19
vascular complications have been encountered with only one arterial thrombosis, and this was corrected. There has been significant upgrading of hand function, and the two-point discrimination has averaged 21 millimetres compared with the control of 15 millimetres on the opposite foot. This twopoint discrimination, though much greater than that of the normal thumb, has not been of significance where there has been no other functional alternative. The movements of the transferred toes have been adequate and useful. Independent study of t h e , feet b y orthopaedic surgeons has demonstrated little or no disability, despite transference of a metatarsophalangeal joint. It is recognized, however, that long term follow-up of these donor feet is required. A toe transplant provides joints and all other structures common to a digit, including nail and nail
FIGURE4 (a) metacarpal amputation of the left hand of a25-year-od male Groin flap has been used for primarycover (b) appearance eighteen months postoperatively of the same patient following a simultaneous transfer of the hallux for thumb reconstruction and cross hand ring finger transfer to the second metacarpal Both the metatarsophalangeal joint and the metacarpophalangeal joint were included in the transfer of these two digits A wide span is noted (c) same patient 18 months postoperatively demonstrating a strong pinch between the transplanted hallux and ring finger
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bed. Its transfer preserves other digits such as the index finger. In the big toe transfer i o r congenital absence of the thumb, the entire metatarsal including its basal epiphysis is transferred to provide future growth. Tendon transfers have beer carried out at four weeks subsequent t o this transfer. but it is recommended that in tuture these be performed at the original surgery. Where digits are congenitally absent, haliux transfer becomes important in thumb reconstruction in order to preserve the diminished number of digits. The double toe transfers may be from one foot or both feet. Where the second and third toe are taken as a combined unit, the two toes provide a greatel area of pinch and grip than a single second toe transfer. Cross Hand Ring Finger Transfer An alternative method to toe transfer is the use of the ring finger from the normal opposite hand. Two patients have been operated upon who have had virtually metacarpal hands. Reconstruction in one case has been achieved by a simultaneous big ioe transfer for the thumb in a cross hand ring finger transfer (Figure 4 ) and, in the second case, by a neurovascular free flap to the remains of thefirst ray and by a ring finger transfer from the opposite hand. The ring finger is appropriately placed. revascularized and innervated Good pinch and span has been achieved and a good range of flexion and extension. Tendon transfers or grafts are needed for the extension of the interphalangeal joints. Strong pinch is achieved, and the normal hand, though minus a ring finger, does not haveany detectable alteration in strength or performance. Microvascular Free Bone Grafts Experiments in our laboratory with the canine tibia have revealed the superiority of the transfer of large masses of bone with microvascular surgery (10 dogs) over similar bony masses transferred without microvascular surgery (13 dogs) (Haw etalii. 1978). There was a 94.5% union of osteotomies at 12 weeks in the microvascular group compared with only20% in the control group. In addition, there was less infection in the microvascular group. The early experimental and clinical work in the late sixties and seventies by McKee (1978) involved the use of ribs for mandibular reconstruction. Other bones capable of transfer include fibula, second metatarsal, the iliac crest combined with the groin flap (Figure 4 ) , the second metatarsal with the dorsum of the foot, and the lateral thoracic flap with underlying ribs. The rib has been used for replacement of the hemimandible or smaller mandibular segments and for the tibia, though it is 410
less suitable for this weight-bearing area It has also been used tor bony defects of theskull The fibulaor the iliac crest with the groin flap are superior alternatives for the lower limb The fibula has beep used for the tibia. temur, humerus and w i n e In weight-bearing areas, long immobilization is required to allow the graauai hypertrophy of the bone transplant There has been only one bone graft failure five years previously, and this was due to infection in the anterior end of a rib bone graft for mandibular substitution All other bone grafts united in thearea5 describe;: Microvascuiar Free Muscle Transfe: There are two areas of special application. (1' Facial palsy, congenital or acquired (long established); and (2) partial paralysis or muscle destruction of the upper limb Facial pa/sy.- The aims in tne treatment of the long-established facial palsy are first. to provide movement symmetrical with that of the opposite side of tne face, and second, to develop acontrolled mass action movement that concentrates on tne upper and lower lips. nose and eyelids. This reconstruction is carried out in two stages (Figure 5). A sural nerve graft joins the fascicular periphera! plexus of the normal facial nerveabout 1.5cm laterai to the nasolabial line. This nerve graft is passed across the chin to the opposite preauricular area, where it is left unsatisfied for approximately six months. After four to six months percussion of the unsatisfied nerve ending elicits a pins and needles sensation at the site of the union of the nerve graft to the normal facial nerve. This is the result of fifth nerve sensory fibres normally present in the peripheral facial nerve growing along thesural nerve graft. This positive sign is an indication that axonal regeneration is well advanced and that the second stage of a microvascular free muscle transfer can proceed. More recently a supraorbital nerve graft has been d d e d connecting thezygomatic branch of the normal facial nerve and tunnelled to the opposite preauricular area. Initially. the extensor digitorum brevis was transferred and the tendons of the muscle were led into the upper and lower lips (O'Brien, 1977). The muscle was revascularized by joining the dorsalis pedis artery to the facial artery and a vena comitans to the facial vein. The previously inserted nerve graft was then joined to the nerve of the muscle and any unsatisfied ends of the nerve were plunged into,the various bellies of the muscle. This muscle was not sufficiently consistent in its power. The gracilis muscle has a nerve supply similar in fascicular pattern to that of the sural nerve, and this AUST.N.Z. J. SURG.VOL. 49-No.
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FIGURE 5 fa) sural nerve graft connecting fascicles of the right normal facial nerve just lateral to the right nasolabial line The free end of tbe nerve graft lies i n the left preaurictilararea (b) second stage of the facial nerve reconstruction six months later the gracilis muscle is inserted with segments attached to the upper and lower I ~ Dand C the side of the nose The muscle is revasculdrized by anastomosing tne gracilis vessels and innervated by joining he nerve to tne previously inserted cross facial sural nerve graft
muscle has proved more consistent and stronger. The muscle is turned upside down and maximum tension is placed on it. The gracilis muscle has several areas of blood supply, but its proximal region is the largest with the nerve adjacent to it. More recently the gracilis muscle has been inserted not only into tne lips and angle but also into the base of the nose. eyelidsand forehead.The nerve union is made as close to the muscle as possible to allow the earliest reinnervation and less likelihood of atrophy. Tne supraorbital nerve graft is joined to the upper branch of the nerve to the gracilis and the lower nerve graft to the lower segment of the nerve to the gracilis. The ischaemic time is usually about two hours More bulk than appears necessary is inserted to allow for any muscle atrophy. Clinical movement commences at four to five months (Figure 6). It has been shown with one electrode in the transplanted muscle and the other in the opposite normal facial nerve that stimulation of the latter provides activity in the muscle transplant. In the upper limb the gracilis has again been the main muscle used, and Manktelow and McKee (1978) have achieved an excellent result in the substitution of forearm flexors. The extensor digitorum longus has been used similarly on one occasion in our Unit. It possesses four tendons which are vascularized and can be joined to the appropriate long flexors in the wrist or palm. AUST. N.Z. J. SURG. VOL. 49-No.
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Microvascular Testicular Transfer The high undescended testis, especially if bilateral, may lead to malignancy, torsion, and sterility. Conventional methods of delivering the testis into the scrotum often fail because of the shortness of the vascular leash and the tension placed upon it. Division of the testicularvessels with mobilization of the vas has been carried out (Fowler and Stephens, 1963), but long-term follow-up of these cases has demonstrated a significant degree of atrophy. It seems logical, therefore, that the abdominal testis when mobilized should have the testicular vessels divided high in the abdomen and anastomosed by microvascular surgery in the inguinal area, so that the testis resumes a normal blood supply. High mobilization of the testicular vessels via a transperitoneal approach is performed and the vas deferens mobilized, bringing the testicle into the medial inguinal area and finally into the scrotum. The small testicular vessels are joined to branches of the deep inferior epigastric vessels. This work has been carried out with the Paediatric Department of the Monash University at Queen Victoria Hospital, Melbourne. It has been based on experimental work (MacMahon et alii, 1976), removing, the canine testis and replanting with microvascular surgery. Histological examination one month later showed, in most cases, a normal testicular pattern. 41 1
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FIGURE^ (a) middle-aged lady witha rightfacial nervepalsy of eightyearsduration. (b) twoyearsaftercompletionofthetwostage cross facial nerve graft and gracilis muscle facial reconstruction The previously paralysed right sideof the face has now only a slight droop of the right upper lip
A series of six cases involving eight testicles has now been carried out. Following revascularization, a biopsy shows a bleeding testis and the histological findings, whilst not normal, show revascularization. Apart from the first two transfers, growth has been observed in the remainder. It is a logical approach for the bilateral abdominal testis, and there is a relative indication for unilateral high undescended testis. The method enables a one-stage transfer to be carried out with reasonable certainty, but a longterm follow-up is required to asses testicular growth and spermatogenesis. Microvascular Free Small Joint Transfer The value of this procedure in hand surgery lies in small joint reconstruction in young adults and children where epiphyses are needed. Artificial joints in the young are not considered suitable as their life span is relatively short. Experimental work in our laboratory (O'Brien, 1977; Hurwitz, 1978) has clearly shown that vascularized small joints are macroscopically, histologically and radiographically similar to normal joints, whereas a small 412
joint transferred without microvascular surgery experimentally and in previous clinical reports has little hope of maintaining its normal architecture or function. Two clinical cases have been completed. In the first patient a proximal interphalangeal joint of the second toe was transferred to reconstruct a proximal interphalangeal joint of a middle finger in a 10-year-old child. This finger was short and flail as a result of old trauma. The epiphysis was included in the joint transfer and is radiologically normal at nine months. Bone union has been achieved and 50" of stable active flexion has been achieved. A segment of second toe extensor tendon was included as part of the toe transfer. A second case has involved the use of a proximal interphalangeal joint of an otherwise useless little finger to reconstruct the metacarpophalangeal joint of the middle finger in a digital replantation case. Microvascular Jejunal Transfer Reconstruction following resection of carcinoma of the cervical oesophagus has always created AUST. N.Z. J. SURG.VOL. 49-No.
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problems. Sometimes the entire oesophagus is resected and the stomach pulled up through the mediastinum into the neck, suturing the stomach to the pharynx. This is not always possibleasthechest may not be capable of entry. Also, there are some cases in which the vasculature of the distal end of the mobilized stomach is inadeauate and in these circumstances it is desirable thaithe arteries of this gastric segment should be sutured to arteries in the neck. An alternative method is the use of a segment of jejunum, revascularizing the jejunum by microvascular surgery in the neck (McKee and Peters, 1978). An abdominal surgeon and a head and neck surgeon working concurrently are responsible for the resection of the head and neck cancer and the removal of the jejunal segment. This jejunal segment has its vessels anastomosed to the transverse cervical artery and the external jugular vein. Peristalsis returns to this jejunal segment immediately, and the postoperative recovery can be dramatic with its ease of management In uncomplicated cases, patients leave hospital in two or three weeks with a normal barium swallow. MICROLYMPHATIC SURGERY
The lymphatics are small, fragile vessels approximately 0.25 mm in diameter. The purpose of this branch of surgery is to join obstructed lymphatics in end-to-end fashion to neighbouring veins in secondary obstructive lymphoedema, bypassing the site of obstruction in the axilla or the groin (O'Brien et alii, 1977).These obstructions have resulted from surgical and irradiation treatment for malignancy, commonly carcinoma of the breast. The technique follows the pattern of microvascular surgery with end-to-end anastomoses using the finest commercial needles of approximately 70 microns in diameter and monofilament nylon 18 microns in diameter. The needle is passed through the lymphatic wall first, which is being dilated carefully and gently with a pair of No. 5 jewellers' forceps. About four to eight sutures are required for each anastomosis. Experimental work in the nonlymphoedematous canine model has shown patency rates in the three groups explored at varying times of 78% at one week, 73% at one and half to three months, and 83% at six months (Gilbert, etalii, 1976). Patients with obstructive lymphoedema are admitted to hospital three days before operation, and intensive conservative treatment of elevation, daily pumping and bandaging is commenced, in order tht the volume of the limb can be reduced toas low a level as possible. The circumferential limb measurements are recorded daily in the upper limb AUST. N.Z J. SURG.VOL. 49-No.
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15 cm above the elbow, 15 cm below the elbow, and at the wrist and the hand. This, combined with the volume displacement in a water tank, gives a reasonable assessment of the dimensions of the limb. However, it does not indicate the skin tension of the limb, and this is one aspect which is requiring further investiaation. Approximately 100 lyrnphangiograms were c a r r i e d out b e f o r e i t was r e a l i z e d t h a t lymphangiograms can cause irreparable damage to the obstructed lymphatics. Lymphangiograms and venograms are therefore no longer performed in the preoperative investigation. In one patient a group of lymphatics was demonstrated on a lymphangiogram on the medial aspect of the humerus. These lymphatics were located three months later and all w e r e o b l i t e r a t e d , w h i c h was c o n f i r m e d histologically. From August 1974 to June 1978, 136 cases of lymphoedema have been seen of which 14 have been p r i m a r y . Of the 124 obstructive lymphoedemas, 102 have been present in the upper limb and 22 in the lower limb. The lymphangiograms revealed that any obstructed lymphatics will be present in the medial aspect of the upper arm, at the elbow, or just below the medial aspect of the elbow. Incisions made in these areas may demonstrate the presence of lymphatics following the injection of 0.25ml of Patent Blue dye into an interdigital web. In the lower limb a transverse incision of 2-3 inches is made at the mid-medial aspect of the thigh several inches above the knee and on the medial aspect of the lower leg, just below the knee. If the obstructed lymphatics are at least two or more in numberandof reasonable size, then they are anastomosed end-to-end to neighbouring veins of similar size. In addition, a longitudinal elliptical segmental reduction is made on the outer aspect of the upper arm or on the outer aspect of the thigh. If lymphatics of inadequate number or size are found, then a one-stage reduction procedure is carried out, reducing onehalf to two-thirds of the circumference with removal of much fat and deep fascia via a mid-medial excision along the length of the limb. I t has become evident that microlymphatic surgery is applicable to the moderate obstructive lymphoedema, whereas a one-stage reduction procedure applies to the gross oedema where the destruction of lymphatics is too advanced for microlymphatic surgery. The anastomoses have averaged approximately four, and the follow-up has ranged from one month to 43 months, with an average of t8.6 months. 413
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Forty microlymphatic operations have been performed, and 35 of these are available for followup. The average decrease in the excess volume has been 12.2%. In 21 cases there has been significant improvement, and the average decrease of excess volume in this group is 32.3%. the aecrease in the excess volume ranging from 2.2% to 66.7%. Fourteen cases have remained unchanged or have had increased oedema, sometirnes caused by lymphangiography. The average time of healing has been one weeh, Subjectively the patients have been more comfortable, with less weight in the arm, which has been distinctively softer. Clothes fit better, and swelling has subsided fast with conservative measures and there has been less embarrassment. Even though the volume of the limb may have changed little, the patient feels considerably improved 111 these circumstances the limb is distinctly softer. and so skin tension is assuming greater importance.
Microlymphaticovenous surgery provides a better contoui with more rapid healing There is minimal scarring and the limb is softer Draining of the hand and the lower forearm is more complete than with other methods (Figure 7) There I S more raprc drainage with conservative measures and there has been a significant reduction in cellulitts from 42% preoperatively t o 17% postoperatively No correlation of results has been found with axillat-) vein thrombosis the duration of the oedema, and brachial neuritis I t seems logical, however that in the individual case the sooner the patient is seen with obstructive lymphoedema the better the chances of a satisfactory result without the need foi postoperative conservative measures I t 1 5 recognized that lymphoedema has a fluctuhting life cycle and that long-term follow-up is essential MICROVASCULAR HOMOTRANSPLANTATION This is an area fraught with many difficulties Only one such operation has been carried out in our Unit
FIGURE 7 (a) obstructive lymphoedema of the right uppei limb following right radical mastectomy and irradiation of t h e axilla and neck seven years previously (b) same patient 18 months after four microlymphaticovenous anastomoses on the medial aspect of the right upper limb There has been a significant reduction in thesizeofthe right upper limb
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in association with the Monash University Department of Obstetrics and Gynaecology, and the Melbourne University Department of Medicine, Austin Hospital, involving the micovascular homotransplantation of the Fallopian tube (Wood, et ah;, 1978). A lady in her late thirties with a 10-yearold child had both Fallopian tubes destroyed by ectopic pregnancies. Her sister, with reasonable histocompatibility, had five children and donated to her sister a Fallopian tube and a core of uterus based on the ovarian vessels. This complex was transferred, revascularized by anastomosing the deep inferior epigastric artery to the ovarian artery, and draining the ovarian vein into the saphenous vein turned up from the thigh through the femoral canal. The transplant was revascularized outside the peritoneal cavity, appeared quite normal, and was placed in its correct abdominal position without kinking of the vessels. Immunosuppressive therapy was continued for some months. She had no apparent complicationsand remained in hospital for only ten days. A laparoscopy at six weeks did not achieve an adequate view of the Fallopian tube because of the presence of omentum, but methylene blue dye injected into the cervix was seen to emerge through the distal end of the Fallopian tube. At laparotomy six months later, the transplant was necrotic and was removed. The specimen was examined, and histologically there was evidence of chronic rejection, similar to that seen following a renal transplant. It would seem that this operation cannot succeed without improved histocompatibility. and this path will be persued. CONCLUSIONS Microvascular surgery has had a short history, for it is the surgery of the present as it speeds rapidly towards the eighties and nineties of this century. Fortunately, Henry Windsor lived to see it flourish. The first Henry Windsor Lecture, given by Henry Windsor, was entitled "How Far that Little Candle Throws his Beam", but Henry Windsor was no candle. He was a beacon whose light shone across several generations, and his name is perpetuated by the Royal Australasian College of Surgeons with this lectureship. The Royal College of Surgeons of England now grants a Windsor Prize annually to a worthy young Australian in Great Britain. and the English College made its first award in 1977. On Henry Windsor's ninetieth birthday his family and friends produced a work entitled "Henry Windsor - A Remarkable Man". The Australian
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surgical comrnunitycan join with the Windsor family and truly say that Henry Windsor was a great and remarkable man.
ACKNOWLEDGEMENTS The author is greatly indebted to his immediate colleagues, Mr Allan MacLeod and Mr Wayne Morrison, who have been closely associated with this work and many of whosecases are incorporated in this Lecture. Gratitude is expressed to Mr R . K . Newing for his continued encouragement and referral of many patients. The assistance of the members of the staff of the Mater Misericordiae Hospital, Brisbane. is gratefully acknowledged. The Microsurgery Research Unit at St Vincent's Hospital, Melbourne, is supported by a grant from the National Health and Medical Research Council.
REFERENCES FOWLER, R , jr and STEPHENS, F. D. (1963) Congenital Malformations o f Rectum. Anus and Genito-Urinary Tracts, Livingstone. Edinburgh, Chap. 19. GILBERT,A. (1976) in Symposium of Microsurgery, C. V. Mosby and Co, St Louis. J. W. and SYKES.P J. GILBERT,A,, O'BRIEN. B. McC., VORRATH, (1976), Brit. J. Plast. Surg , 29, 355. T. (19781, J. Bone Jt. HAW,C., O'BRIEN,B. McC. and KURATA, Surg.. 606: 266. HURWITZ,P. (1978). Experimental small joint transplantation with microvascular anastomosis, J. Plast, Reconstr. Surg. in press JACOBSON,J. H. and SAUREZ,E L (1960). Surg. forum, 11: 243. MACMAHON, R. A,, O'BRIEN,B McC. and CUSSEN, L. J. (1976). J. pediat. Surg., 11: 4. MCKEE,D M (1978). Clin. plast. Surg., 5: 283. MCKEE, D. M and PETERS,C R . (1978) Clin. Plast Surg., 5. 305 MANKTELOW, R T. and MCKEE.Nancy H (1978) J. handSurg., 3: 427. MAY,J. W., jr CHAIT, L. A,, COHEN,8. E and O'BRIEN,0. McC. (1977). J. hand Surg., 5: 387. MORRISON, W A,, O'BRIEN.B. McC. and MACLEOD, A M. (1977). AUST. N Z.J SURG..47: 767. MORRISON, W. A , O'BRIEN,B. McC. and HAMILTON, R (1978), Clin. plast. Surg.. 5: 265. MORRISON,W. A,, O'BRIEN, B. McC.. MACLEOD,A . . M and GILBERT.A. (1978b). J..handSurg.. 3: 235 O'BRIEN, B. McC. (1977), Microvascular Reconstructive Surgery, Church111 Livingston, London and Edinburgh. O'BRIEN, B. McC. (1977) AUST.N.Z.J. SURG..47: 284. O'BRIEN. 8 . MCC., BRENNEN, M. D. and MAcLEOD. A. M. (1978). Hand, 10: 232. O'ERIEN,B. McC., SYKES.P. J , THRELFALL, G. N and BROWNING, F. S. C. (1977). Plast. reconstr. Surg.. 60: 197. PERRITT,R. A . (1950), American Academy of Opthalmologyand Otolaryncology, Course N o 280. SMITH.J W. (1964), Plast. reconstr. Surg., 33: 317 P., MCKENZIE,I.,O'BRIEN. B. McC. and WOOD, C., PATERSON. B. (1978). Fertil. Steril. 29: 604 DOWNING,
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