Waldemar L. Olszewski (Editor) - Handbook of Microsurgery - Volume 1-CRC Press (1984)

CRC Handbook
of
Microsurgery
Volume I
Editor
Waldemar L. Olszewski, M.D., Ph.D.

Professor of Surgery
Department of Surgical Research
and Transplantology
Polish Academy of Sciences
Medical Research Center
Warsaw, Poland
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THE EDITOR
Waldemar L. Olszewski, M.D., Ph.D., is Professor of Surgery and Director of the

Department of Surgical Research and Transplantology Medical Research Center, Polish
Academy of Sciences in Warsaw, Poland. Dr. Olszewski graduated from the Medical Faculty,
Medical Academy in Warsaw, receiving the M.D. degree in 1954 and the Ph.D. degree in
1962. He obtained his surgical training in the Surgical Division, Warsaw City Hospital and
then the Department of Surgery, Medical Academy, Warsaw. He served as an Assistant
Professor at the Medical Academy and the Medical Research Center from 1962 to 1968 and
Associate Professor from 1968 to 1978. In 1978 he became Professor of Surgery. From
1962 to 1965 he was Deputy Director of the Department of Surgical Research, Medical
Research Center and it was in 1975 that he assumed the position of Director. Since 1974
he is associated with the laboratory of Hematology and Lymphology, Norwegian Radium
Hospital in Oslo, Norway.
Dr. Olszewski was a Research Fellow at the Royal Postgraduate Medical School in London
from 1962 to 1963 and at the Peter Bent Brigham Hospital, Harvard Medical School, Boston
in 1968 and 1969. Dr. Olszewski is a member of the European Society for Surgical Research,
International Lymphological Society, International Microsurgical Society, and the Interna-
tional Transplantation Society. He served as President of the European Society for Surgical
Research from 1977 to 1978 and as a member of its Executive Committee until 1982. He
is a member of the Executive Committee of the International Lymphological Society, National
Delegate to the International Microsurgical Society, Associate Editor of Lymphology, Zeit-
schrift fur Experimentelle Chirurgie, and the Journal of Microsurgery. He has received
awards from the Polish Society of Surgeons, Polish Academy of Sciences, International
Lymphological Society, and the Purkynje Medical Society.
Dr. Olszewski is the author of more than 150 papers and has been the author or co-author
of 5 books. His major clinical interest relate to vascular and lymphatic surgery, and research
interests to the physiology of the lymphoid organs and immunoregulation.
ADVISORY BOARD
Sven-Erik Bergentz, M.D. Erminio Cariati, Prof. Dr.

Chairman Cátedra di Chirurgia Torácica
Department of Surgery Universita di Genova
Malmõ General Hospital Ospedale S. Martino
and Genova, Italy
Professor of Surgery
University of Lund
Malmõ, Sweden
Walter Brendel, Prof. Dr. Med., Dr. S. Karacsonyi, M.D., Ph.D.
Med. h. c. Professor of Surgery
Ludwig-Maximilians-Universitát München Semmelweis Orvostudomanyi Egyetem
Klinikum Grosshardern I. SZ. Sebészeti Klinika
Institut fur Chirurgische Forschung Budapest, Hungary
München, West Germany
T. S. Lie, Prof. Dr. Dr. h. c.

Chief and Professor
Section of Transplantation
Surgical University Clinic
University of Bonn
Bonn, West Germany
CONTRIBUTORS
Sven-Erik Bergentz, M.D. Carlos O. Esquivei, M.D.

Chairman Chief Resident
Department of Surgery Department of Surgery
Malino General Hospital University of California Davis
and Medical Center
Professor of Surgery Sacramento, California
University of Lund
Malrno, Sweden Jack M. Fein, M.D.
Associate Professor
Francesco Brunelli, M.D. Department of Neurosurgery
Intern
Albert Einstein College of Medicine
Spedali Civili Brescia Bronx, New York
2A Ortopedia
Brescia, Italy
Peter Haussmann, M.D.
Giorgio Brunelli, M.D., Ph.D. Chief Surgeon
Professor Department of Handsurgery, Plastic and
Spedali Civili Brescia Reconstructive Surgery
Clinica Ortopédica Universita DRK-Hospital Baden-Baden
E.U.L.O. Baden-Baden, West Germany
2A Ortopedia
Brescia, Italy Jerzy Jablecki, M.D.
Resident of Surgery
John T. Burns, M.D., Ph.D. Department of Surgery
Assistant Professor Center of Replantation of Limbs,
Division of Orthopaedic Surgery Microsurgery and Surgery of Hand
Director, Orthopaedic Hand and Trzebnica k/Wroclaw, Poland
Microsurgery
University of Texas Medical School Janusz Kaczmarzyk, M.D.
Houston, Texas Resident of Surgery
Department of Surgery
Albert H. Capanna, M.D. Center of Replantation of Limbs,
Neurosurgeon Microsurgery and Surgery of Hand
Medical and Education Center Trzebnica k/Wroclaw, Poland
Southern Nevada Memorial Hospital
Las Vegas, Nevada
H. B. Kapila, M.B.B.S., F.R.C.S.,
Wallace H. J. Chang, M.D. F.R.A.C.S., F.I.C.S.
Clinical Associate Professor of Plastic Surgical Fellow, Microsearch Foundation
Surgery of Australia
Department of Plastic Surgery Assistant to the Microsurgeon, Hornsby
University of Washington and Ku-ring-gai Hospital
School of Medicine Assistant to the Microsurgeon, Mater
Seattle, Washington Misericordiae Hospital
Visiting Surgeon, Western Suburbs
Bernhard Endrich, Dr. Med. Hospital
Assistant Visiting Surgeon, Fairfield District
Department of Experimental Surgery Hospital
Surgical Center Clinical Assistant in Surgery, Sydney
University of Heidelberg Hospital
Heidelberg, F.R.G. Sydney, Australia
P. J. Klopper, M.D. Paul Gabriel Lendvay, M.D.
Professor and Head Consultant, Plastic Reconstructive and
Lab. Experimental Surgery Microsurgeon
University of Amsterdam Sydney, Australia
Academic Hospital Wilhelmina Gasthuis
Amsterdam, The Netherlands Konrad Messmer, Dr. Med.
Professor and Chairman
Kazimierz Kobus, M.D., Ph.D. Department of Experimental Surgery
Associate Professor of Plastic Surgery Surgical Center
Medical Center of Postgraduate Education University of Heidelberg
Warsaw, Poland Heidelberg, F.R.G.
and
Hospital of Plastic Surgery Hanno Millesi, M.D.
Polanica-Zdrój, Poland Professor and Head
Department of Plastic and Reconstructive
Ryszard Kociçba, M.D., Ph.D. Surgery
Associate Professor and Director 1st Surgical Clinic
Department of Surgery University of Vienna Medical School
Center of Replantation of Limbs, and
Microsurgery and Surgery of Hand Head
Trzebnica k/Wroc/aw, Poland Ludwig-Boltzmann-Institute for
Experimental Plastic Surgery
Vienna, Austria
Willy J. Kort, Ph.D.
Erasmus Faculty
Michael Patkin, MBBS (Melb.), FRCS
Laboratory for Experimental Surgery
Eng., FRCS Ed., FRACS
Rotterdam, The Netherlands
Surgeon
Whyalla Hospital
Henryk Kus, M.D. Whyalla, South Australia
Associate Professor of Surgery
Chief of the Chair and Clinic for Maurizio Petrolati, M.D.
Traumatological Surgery
Plastic and Hand Surgeon
Medical Academy in Wroc/aw, Poland
Department of Plastic and Hand Surgery
Ospedale-Civile Legnano (Milano)
Daniel Y. Lahr, M.D. Legnano (Milano), Italy
Medical Director
Davis & Geek Medical Research Judith J. Petry, M.D.
American Cyanamid Company Assistant Professor
Wayne, New Jersey Department of Surgery
Division of Plastic Surgery
Deodat Lapczynski, M.D. University of Massachusetts
Resident of Surgery Medical Center
Center of Replantation of Limbs, Worcester, Massachusetts
Microsurgery and Surgery of Hand
Trzebnica k/Wroc/aw, Poland Charles L. Puckett, M.D.
Professor and Chairman
Kyu Chang Lee, M.D. Division of Plastic Surgery
Professor and Chairman Department of Surgery
Department of Neurosurgery University of Missouri
Yonsei University College of Medicine Health Sciences Center
Seoul, South Korea Columbia, Missouri
Pier Luigi Raimondi, M.D. Shuhei Torii, M.D.
Plastic and Hand Surgeon Assistant Professor
Department of Plastic and Hand Surgery Plastic and Microsurgical Division
Ospedale-Civile di Legnano (Milano) Department of Orthopedic Surgery
Legnano (Milano), Italy Nagoya University School of Medicine
Nagoya, Japan
John F. Reinisch, M.D.
Assistant Professor Tsu-Min Tsai, M.D.
Department of Surgery Clinical Instructor of Surgery
Division of Plastic Surgery "Orthopaedics"
University of Missouri University of Louisville
Health Sciences Center
Louisville, Kentucky
Columbia, Missouri
Laurent Sedel, M.D. Jacques C. van der Meulen, M.D.,

Professeur Agrégé Ph.D.
Chirurgien des Hôpitaux de Paris Department of Plastic and Reconstructive
Hôpital Saint Louis Surgery
Paris, France University Hospital Rotterdam-Dijkzigt
Rotterdam, The Netherlands
Arlan R. Smith, M.D., Ph.D.
Academisch Ziekenhuis Dijkzigt D. Vickers, M.B.B.S., F.R.A.C.S.
Rotterdam, The Netherlands Consultant Orthopaedic Surgeon and
Microsurgeon
Kauko A. Solonen, M.D. Royal Brisbane Hospital
Professor and
Chief Surgeon Royal Childrens Hospital
The Orthopaedic Hospital of the Invalid Brisbane, Australia
Foundation
Helsinki, Finland Simo K. Vilkki, M.D.
Hand- and Microsurgeon, Orthopaedic
G. Jan Son ne veld, M.D. Surgeon
Department of Plastic and Reconstructive Department of Hand Surgery
Surgery The Orthopaedic Hospital of the Invalid
University Hospital Rotterdam-Dijkzigt Foundation
Rotterdam, The Netherlands Helsinki, Finland
John J. S tangei, M.D. Lídia Wilowska-Kociçba, M.D.

Section of Reproductive Endocrinology Head
and Infertility Department of Anaesthesiology
Division of Obstetrics and Gynecology Center of Replantation of Limbs,
New York Medical College Microsurgery and Surgery of Hand
Valhalla, New York Trzebnica k/Wrooiaw, Poland
TABLE OF CONTENTS
Introduction 1
GENERAL PROBLEMS IN MICROSURGERY

Microsurgery, Microinstruments, and Microsutures 5
Ergonomics and Microsurgery 13
Microsurgery Instruments — A New Philosophy 27
Microsurgery and Research 37
Microvascular Surgery: Coagulation, Fibrinolysis, and Principles
for Antithrombotic Therapy 49
Coagulation and Fibrinolytic Considerations for the Microvascular
Surgeon 65
Problems in Intravascular Coagulation in Microsurgery 73
Quantitative Analysis of the Microcirculation in the Awake Animal 79
NEUROLOGICAL MICROSURGERY
The Role of Microsurgery in the Treatment of Peripheral Nerve Injuries 109
Microsurgical Reconstruction of Peripheral Nerves — Own Experience 139
Surgical Treatment of Posttraumatic Lesions of the Brachial Plexus 157
Microsurgical Techniques of Brachial Plexus Neurotization 163
Microsurgical Treatment of Isolated Lesions of the Motor Branches
in the Hand and Forearm 173
Obstetric Plexus Palsy: Early Microsurgical Treatment 201
Microvascular Surgery for Cerebrovascular Disease 219
Microanastomosis and Total Bypass of the Cerebral Venous Sinuses
and Torcular Herophilus 241
Extracranial-Intracranial Microanastomosis Cerebral Revascularization
Operations 247
Microsurgical Treatment of Intracranial Arachnoid Cysts 251
Microlumbar Discectomy 259
Nerve Regeneration 263
Nerve Suturing and Nerve Grafting 275
Greater Omentum Transfer in X-Ray Lesions of the Brachial Plexus 289
Neurotization of Avulsed Roots of the Brachial Plexus by Means of
Anterior Nerves of the Cervical Plexus 295
REPLANTATION SURGERY
Replantation Surgery 301
Second Toe Autotransplantation to Replace Missing Fingers 317
Some Aspects of Upper Limb and Finger Replantation 341
Replantation of Amputations Involving the Upper Extremity 371
A Technique for the Replantation of Avulsed Thumbs 389
Toe-to-Hand Transfer 403
Toe-to-Hand Free Tissue Transfer 421
Dorsalis Pedis Flap 437
Postoperative Monitoring in Reconstructive Microsurgery with
Special Respect to Transcutaneous Oxygen Measurements 469
Ischemia Time Influencing Free Skin Flap Survival 479
INDEX 487
Volume I 1
INTRODUCTION
Wâldemar L. Olszewski
Microsurgery has become a technique for expanding the visual horizons of the surgeon.
It has extended the repertoire of his potentialities not only to treat the diseases but also to
improve function of organs or parts of the body, and has changed the ways of clinical
thinking by turning untreatable pathologies into treatable ones. We are witnessing a total
commitment to microsurgery by all surgeons. Microsurgical techniques have become a part
of every surgeon's training. They have become clinically applicable in every surgical spe-
ciality. This situation has created a need for teaching and training not only in basic micro-
surgical techniques but also in microsurgery in a given clinical speciality.
The progression from laboratory training into clinical surgery is a difficult one. Fast and
extensive progress has been made in microsurgical techniques and improvement of arma-
mentarium, however, the knowledge of physiology of the body microstructures, their re-
sponse to surgical trauma, healing process, and changes in blood coagulation and
microcirculation still remain far behind. The diagnostic procedures usually used for detection
of major pathologies are still not entirely suitable for detection of pathological changes of
structures the size of a 1-mm diameter artery or a small nerve branch. However, experimental
and clinical experience in these areas is accumulating rapidly and we may soon expect a
breakthrough in terms of integration of technicalities and open physiology in microsurgery.
In order to promote this trend, we have made an attempt to put together in two volumes
the experiences of clinical microsurgeons, experimentalists, and physiologists. Several recent
books on microsurgery have been presented in a synoptical form. This type of presentation
is extremely useful for newcomers into the field, however, it does not give an insight into
the nuances of microsurgical techniques and physiological events accompanying microsurg-
ical operations. The premise upon which this book was written was that only and exclusively
personal experience in microsurgical operations and their effects on tissue or organ function
could be presented. The individual chapters were written by designers of microsurgical
instruments and materials, specialists in coagulation, microcirculation, and basic micro-
surgical procedures, neurosurgeons, plastic and vascular surgeons, laryngologists, ophthal-
mologists, gynecologists, experimental surgeons, and physiologists. Each of us has described
in our own words what we have done ourselves in microsurgery and what we know best,
without referring much to the literature. This constitutes the main value of the Handbook
of Microsurgery.
General Problems in Microsurgery
Volume I S
MICROSURGERY, MICROINSTRUMENTS, AND MICROSUTURES
John J. Stangel and Daniel Y. Lahr
The function of microsurgery is the meticulous restoration of anatomy not only on a gross
or macroscopic level, but particularly on a microscopic level. With the use of magnification,
the surgeon, often for the first time, can develop an appreciation and insight for the finer
aspects of tissue anatomy. The effect of indiscriminate tissue handling can be seen in the
disruption of serosal surfaces and oozing from these raw areas. These damaged surfaces are
the later sites of scar tissue and adhesion formation. The use of magnification during surgery
can lead to a greater respect for tissue structure and handling and can result in better restoration
of anatomy and organ function.
To visualize smaller structures, the surgeon must use magnification. This can be accom-
plished with either an operating loupe or an operating microscope. The loupe is a set of
close-focusing telescopic lenses mounted on an eyeglass frame. Such instruments come with
fixed magnifications offering up to a sixfold magnification. The operating microscope is a
true microscope with an extended working distance, and it can offer variable magnification
usually up to 40-fold.
The use of magnification introduces new problems that are insignificant under normal
surgical conditions. Eye-hand coordination must be reestablished. With an operating mi-
croscope, the surgeon is often looking straight forward while the field he is seeing is below
and in front of his apparent gaze. Movements that ordinarily would be considered small
appear to be wide and sweeping under the microscope. For these reasons, a period of practice
and readjustment is necessary for the novice microsurgeon in order to learn where his hands
are and how much his muscles must contract to accomplish the hand movement he desires.
Every human has a small degree of uncontrollable peripheral hand movement identified
as a "physiologic tremor". Though this may be barely noticeable during conventional
surgery, it can become a significant problem during microsurgery. The frequency and am-
plitude of the tremor can be affected by outside factors. Anxiety, tension, and muscular
exertion can worsen tremor. Similarly, caffeine, nicotine, alcohol, and many over-the-counter
cold remedies can intensify this physiologic movement. Conditions that will slow the resting
heart rate have been associated with a decrease in tremor. Among these factors are a regular
aerobic exercise program and drugs such as Inderal.®
With this knowledge, there are certain suggestions that can be made to improve the
performance of the microsurgeon. It is probably best to diminish the use of alcohol and
tobacco. The period of time immediately before surgery should be as free from stress as
possible. The physician should have a good night's sleep prior to an operation and arrive
at the operating room relaxed, well before his scheduled surgery. He should not have to run
up several flights of stairs and rush into the operating suite. The operating-room atmosphere
should be controlled and as free from tension as possible. Some surgeons even find it helpful
to play tapes of their favorite music during surgery to create a relaxing atmosphere.
The position the surgeon uses to operate, with the use of magnification, should be as
comfortable as possible and still allow the support and stabilization of extremities. When
the unsupported hands and arms are extended forward from the body, the physiological
tremor will intensify within several minutes because the hand and arm muscles are being
stressed. As a response, the frequency and amplitude of tremor in the stressed extremities
increases, and the tremor will remain that way for several hours. It is important for the
microsurgeon not to strain the muscles of his arms or hands during surgery. Thus, the
operating surgeon should not lift or position the patient on the operating table. When an
incision is made, the surgical assistant, and not the microsurgeon, should apply traction for
proper exposure.
6 CRC Handbook of Microsurgery
FIGURE 1. The microsurgeon seated in the proper operating position.

Note that his feet are placed flat on the floor, he is sitting with his back
and neck in a line, and he is looking straight forward. His forearms and
hands are supported on the operating surface to minimize fatigue and
diminish tremor.
Attention must be given to the selection of the surgical instruments used for microsurgery.
The force that must be applied to open and close an instrument or to keep an instrument in
proper position (such as keeping the jaws of a needle holder closed on a needle), requires
exertion of the muscles of the surgeon's hand and forearm. The greater the muscular force
required to use an instrument, the greater the muscular tremor and the poorer the surgeon's
performance.
Tremor makes it more difficult to properly place a microsuture. It can result in tearing
tissue once the needle has penetrated the tissue. Tremulous movements may make it more
difficult to pick up a suture for an instrument tie. Finally, tremor may result in "springing"
(popping off) a microsurgical needle, catapulating it anywhere in or out of the surgical field.
Volume I 7
When using magnification, most commonly an operating microscope, the surgeon should
be seated at the side of the operating field. The surgeon must position himself to allow the
maximal amount of stabilization of his hands, arms, and body. Thus, he should be seated
on a stool or a chair. The seat should be adjusted so that the surgeon's feet are flat on the
floor or touching the pedals controlling the microscope. The surgeon should be seated with
his back and neck straight and his head facing forward into the oculars of the microscope.
The level of the operating surface should then be adjusted so that it will allow the surgeon
to rest his arms and extend his forearms and hands almost straight out. Thus, the operator's
forearms, hands and, ideally, fingers are resting and supported on the operating field. This
position allows minimal muscular exertion and fatigue. The result is a minimum of tremor
and a longer duration of peak surgical performance (Figure 1).
The next point of attention must be the position of the surgical instrument in the hand of
the operator. The area with the greatest proprioceptive representation on the sensory cortex
is the thumb and forefinger. The greatest combination of mechanical stabilization and ability
to perform fine movement is afforded by the position used in holding a pen or pencil in the
normal writing position. By holding a surgical instrument in this position, the surgeon will
be using a grasp that he has been using for delicately controlled movement since childhood.
Furthermore, this is the perfect synthesis of mechanical stabilization and dexterity combined
with proprioceptive sense (Figure 2).
A surgeon sutures most easily toward his own body. Thus, a right-handed operator passes
a needle most efficiently in a diagonal direction toward the left side of his body. In order
to take advantage of this movement, the surgeon should position the incision being sutured
in the opposite diagonal at 90° from the plane of the passage of the needle. A left-handed
person orients his needle and incision in exactly the mirror image of the right-handed surgeon
(Figures 3 , 4 , and 5).
Thus, the surgeon should sit at the side of the operative field with arms supported. The
microsurgical instruments are held in each hand in the usual writing position. The choice
of microsurgical instruments and microsutures is as important as knowing how to hold an
instrument and how to pass a needle.
The development of microsutures for use in microsurgical procedures has done much to
increase the success rate of the many operations in which microsurgical techniques can be
applied. With microsutures, minute and delicate tissues can be secured or anastomosed with
a minimum of damage and an improved possibility of healing with the maximal possible
preservation of function. Atraumatic, fine-gauge, swaged needles also aid in the reduction
of trauma to delicate tissues. A list of desirable qualities of sutures to be used for microsurgery
would include the following: high tensile strength for size, predictable absorbability when
that quality is needed, minimal tissue reactivity, uniformity of suture filaments, flexibility,
smoothness and ease of passage through tissues, and secure knotting.
The needles used with such microsutures must be securely attached, sharp, and extremely
fine, but resistant to bending and breaking. Although, when microsurgery was in its infancy,
surgeons had to rely on experimental and makeshift materials, microsutures of standard
diameters (Table 1) and correspondingly sized straight and curved microsurgical needles are
now routinely available. The sutures most commonly used in microsurgery are USP sizes
8/0 through 11/0, or between 10 and 50 |xm in diameter. Microneedles range between 30
and 140 (xm in diameter. Nylon is the principle suture material.
There is much discussion about whether a microsurgical instrument should be made of
stainless steel or titanium. Most instruments made of stainless steel are firm, and have a
healthy heft to them. However, after many autoclavings, the steel instruments become
magnetic and can cause the very light microsurgical needles to "dance" about. The result
is significant difficulty loading and properly positioning a needle in a needle holder. Thus,
stainless steel instruments periodically need to be "degaussed" (demagnetized) by passing
the instruments through a specially designed electrical coil.
FIGURE 2. Both long- and short-microsurgical instruments are held

and manipulated like an ordinary pen or pencil.
Volume I 9
FIGURE 3. A needle is passed most efficiently in a diagonal

which is at right angles to the incision being sutured.
FIGURE 4. A right-handed person has the greatest control of a needle when passing it in a diagonal running
from between 1 and 2 o'clock to between 7 and 8 o'clock. The incision must be placed in the opposite diagonal.
Thus, for most efficient suturing, a right-handed microsurgeon should try to position the incision to be sutured in
the diagonal extending from between 10 and 11 o'clock and 4 and 5 o'clock.
Titanium is a light, hard, nonmagnetic metal. Instruments made of this metal are lighter
in weight than an equivalent stainless steel instrument. No matter how many times the
implement is autoclaved it will not become magnetized, and unlike stainless steel, titanium
instruments will not corrode. Because the metal is harder than steel the titanium forceps and
FIGURE 5. A left-handed surgeon has the greatest control of a needle when passing it in a diagonal running
from between 10 and 11 o'clock and 4 and 5 o'clock. The incision must be placed in the opposite diagonal. Thus,
for most efficient suturing a left-handed microsurgeon should try to position the incision to be sutured in the
diagonal extending from between 1 and 2 o'clock and 7 and 8 o'clock. This is the mirror image of the right-handed
suture position. Pictured is a long titanium needle holder by Codman Instrument Company.
Table 1
STANDARD DIAMETERS OF
SUTURES USED IN
MICROSURGERY
Suture size Diameter limits (pan)
USP Metric Minimum Maximum
12-0 0.01 1 9
11-0 0.1 10 19
10-0 0.2 20 29
9-0 0.3 30 39
8-0 0.4 40 49
7-0 0.5 50 69
6-0 0.7 70 99
From The United States Pharmacopeia XX and

The National Formulary XV (Suppl. 1), U.S.
Pharmacopeial Convention, Rockville, Md.,
1980, 63.
needle holders tend to maintain their fine tips even after long, and less than ideal, use.
However, because titanium is harder than steel, it is more difficult to make a titanium needle
holder that will open and close with the same ease of movement as steel. For this reason,
in the past, titanium instruments have not had the same comfortable movement as steel. It
is only recently that the Codman Instrument Company has managed to machine the Rhoton®
titanium instruments so that they move as well as an equivalent of steel (Figure 6). Never-
theless, many operators like the feel of a stainless steel instrument. Each surgeon should
try as many different instruments as possible to find the one that feels best to him.
Volume I 11
FIGURE 6. A Rhoton® titanium needle holder. (Courtesy of Codman Instrument Company.)
Table 2
INSTRUMENTS
Needle Holder: 5 in. (13 cm)
Stangel Modified Barraquer—stainless steel

(Sklar Surgical Instrument Company)
Forceps: 7 in. (17.5 cm)
Rhoton® titanium forceps, fine 80-1701

(Codman Instrument Company)
Tying Forceps
Moria tying forceps, short and long 22-9503

(Cameron-Miller)
Scissors
Westcott scissors—produced by several manufacturers

Rhoton® titanium scissors, curved tip 80-1721
(Codman Instrument Company)
For some reason, some instrument designers have felt that a microsurgical instrument
must be small. Since a microinstrument should be held like a pen, the instrument must be
long enough to extend from the operating surface, past the fingertips, and beyond the web
space of the hand. The minimal instrument length to allow proper positioning is 5 in. Many
operators, such as neurosurgeons and gynecologic microsurgeons, who have to work in
cavities, prefer slightly longer (7 or 8 1/2 in.) instruments.
Needle holders should have a fine tip to allow ease of handling 8/0, 9/0, and 10/0 sutures
and fine 100 to 150 |xm needles. They should close with a minimal amount of pressure.
The instrument surfaces tend to reflect light back through the microscope to the surgeon,
producing squinting and eye fatigue. Thus, an ideal instrument should have a dull nonre-
flective surface.
Needle holders may have locks or catches. These are mechanical latches added to the
inside of the needle holder to hold the instrument in a closed position. Thus, a needle can
be held without the surgeon exerting pressure to keep the needle holder closed. This makes
it easier and safer for a nurse to load a needle in an instrument without loosing the needle
when passing the instrument to the surgeon. It also means that the surgeon needs to maintain
finger pressure for a shorter period during the case, thereby diminishing fatigue. However,
when the lock is released, the tip of the instrument may shake. This movement can be
transmitted to the needle's tip resulting in a small tear rather than a puncture at the point
of tissue entry. If the movement is very strong, it can catapult a needle out of the operative
field. If a surgeon decides to use an instrument with a lock, he should take care to select
one that unlocks as smoothly as possible.
A microsurgeon will also require a fine tissue forceps for tissue handling. Jeweler's forceps
can be very helpful for this use. Fine microscissors and a tying forcep are also important.
Table 2 lists instruments surgeons have found helpful in microsurgery. This list is by no
means complete or exclusive, but it may make a good point at which to begin the evaluation
of microinstruments.
Volume I 13
ERGONOMICS AND MICROSURGERY
Michael Patkin
INTRODUCTION
Microsurgery is the logical extension to small structures of ordinary methods of dissection

and repair. A special extra benefit has been the ability to transplant body parts nourished
by small blood vessels, typically 1 or 2 mm in diameter, opening up new realms of recon-
struction after wide ablative surgery.
However, the handling of fine instruments for delicate structures seen under the operating
microscope needs special preparation for small-scale hand movement; magnification by itself
does not allow fine structures to be seen clearly unless the intensity of lighting and other
factors are adequate. Because the room for error in microsurgery is so much less than in
work on larger structures, it is necessary to look in critical, detailed, and practical terms at
the whole process of work by the surgeon. The scientific study of man at work is called
"ergonomics".
Ergonomics is a term scarcely known to most surgeons. It was devised in 1965 by Murrell,1
a scientist at Cambridge, England. He had led a multidisciplinary group dealing with the
man-machine interface in the context of war — anatomists, engineers, lighting experts, and
others. The word "ergonomics" is derived from two Greek words, "ergon" ( = work) and
"nomos" ( = knowledge, foundation, or basis). The areas it deals with can be summarized
usefully as
1. Equipment design
2. Workplace layout
3. Environmental conditions, such as lighting
4. Related questions of skill acquisition, productivity, and safety
In the past 30 years, ergonomics has been applied widely to improving factory work and
product design. In the U.S., under the name of "Human Factors", it was an important part
of the aerospace program, used for space-capsule and equipment design and predicting what
human performance would achieve with a safe margin. Until this past decade, the application
of ergonomics to surgery has been slow because of the naturally conservative attitudes of
surgeons to their work and the heavy hand of tradition in equipment selection and in training.
Microsurgery is so demanding a field that its pioneers were unusually dedicated and
skillful. Even so, they had to devise many new "tricks" to help them control hand tremor
during fine hand work. As the number of surgeons working with microscopes increased
from a handful to many thousands, the demand for technical aids to allow controlled fine
movement made a systematic ergonomie approach welcome. Indeed, it is, at last, now
starting to contribute to the mainstream of general surgery at which it was orginally aimed.
Ergonomics can help the microsurgeon in all four areas listed above. The specific problems
to be tackled are
1. Visual feedback
2. Control of tremor and fine movement
3. Equipment design
4. Workplace arrangement
5. Skill acquisition
Each of these areas will be dealt with in detail.

A simplified model of the surgeon at work shows three primary components — the
operator, the instrument, and the tissue. These three components determine two interfaces.
The first of these is ergonomics, mainly dealing with the relation between hand and handle,
but including other factors such as lighting. The second interface, between instruments and
tissue, is closely related but can be separated as the study of bioengineering. This is concerned
with the physical properties of tissue and how they relate to applied physical forces. An
obvious example is the unwanted crushing effect of occluding clamps on small blood vessels.
The distinction is a useful one in sorting out a large number of interlocking factors so that
they can be analyzed and managed one at a time.
As a matter of convenience rather than logic, this chapter will refer to some aspects of
the bioengineering interface, and also mention the care of microsurgical instruments, but it
should be clear that these two areas are quite distinct from ergonomics.
VISUAL FACTORS
As the scale of fine work decreases, so the help from touch and kinesthetic feedback for
the operator decreases. Unlike other surgery, the operator using the microscope does not
often know from the feel of the tissues if his movements have been correct. He must see
tissues clearly — both for selection of the correct layer for dissection and suture, and to be
guided by the appearance of tissue displacement which tells him if his actions are correct
or not.
Magnification
The advantages of magnification need no emphasis for any surgeon with even the briefest
experience of it. Accuracy of work increases in proportion to the degree of magnification
(provided the other factors to be discussed are appropriate). It is like the difference between
seeing an ant's egg in a spider's web and a football in a goal net. The emotional impact of
using magnification can be compared to the thrill of seeing the submarine beauty of the
Great Barrier Reef using mask and snorkel. The learning experience of new perspectives of
living anatomy can be transferred back to macrosurgery with benefit, such as having a clearer
picture of the damage wrought by dissection and diathermy, and the coarseness of much
suturing.
Magnification can be provided quite usefully by loupes — binocular magnifying telescopes
— for many halfway situations in the range of 2 to 6 diopters. Beyond this, neck tremor
worsens the ability to see fine detail and is tiring, especially with longer working distances.
The quality of loupes, like their cost, varies greatly. Cheaper ones have poorer lenses, with
some chromatic aberration and slight fuzziness. They are heavier on the nose and ears, less
easy to look above or below, and less robust. The buyer has to make his own trials, starting
with half-hour practice sessions at home or in the laboratory to get used to them in order
to avoid a shambles in the operating theater, an experience which often puts off the surgeon
and his staff from further use of this aid. The best models now available are probably the
expensive binocular loupes which are cemented onto the surgeon's own prescription lenses.
A magnification of 2 or 3 diopters and a working distance of 10 in. (25 cm) are appropriate
for many neck dissections, allowing structures to be defined more clearly and safely.
While loupes of 8-diopter magnification have been marketed, they lack the crispness and
bright lighting of microscopes. However, the less powerful loupes are relatively cheap,
handy, and effective for the early stages of some microdissections, allowing much more
mobility for the operator.
The choice of microscopes is much more complex. Even the best models now available
create problems of bulk, awkwardness for the assistant, occasional mechanical failures, and
cost. Some special design problems are presented later, in the section on workplace ar-
Volume I 15
rangement. The lowest possible magnification should be used. With high magnification,
orientation from reference points is lost, needle and suture location are more difficult, and
depth of focus is small. Different phases of surgery require different magnifications, though
individual operators will vary in what they consider necessary. The microscope needs to be
well cared for and maintained. In particular, lenses should be cleaned carefully as needed,
and adjustments for perfect viewing made before scrubbing for surgery.
Visual Health and Binocularity

Surgeons whose eyesight is more than 2 or 3 diopters away from normal will need to
wear their glasses with the microscope. Of surgeons with only one eye, only a few will not
manage to use the operating microscope, according to the vast teaching experience of Acland
at Louisville. It is saddening for surgeons to learn that visual acuity falls off by about a half
between the ages of 20 and 40 years, apart from changes in accommodation.
Lighting Intensity
Within broad limits, the brighter the lighting, the more fine detail that can be seen. There
is a direct relationship between visual acuity and the logarithm of the lighting intensity. It
is impossible in a dim light to thread a needle, to read fine print, or to operate accurately.
Most modern operating theaters today have adequate intense-light sources, but at times there
are still problems when operating in shadowed cavities. The lighting of operating microscopes
has adequate intensity for lower magnifications, but has to be increased in proportion to the
degree of magnification. On most microscopes the higher-magnification level lighting is not
enough. Supplementary fiberoptics may be useful, as only a small area has to be lit.
Glare
Merely increasing the intensity of lighting may not improve acuity. Glare is the first of
several factors which further modify what detail can be seen. The closer to the line of sight
that a glare source is, the more that visual acuity suffers. Highly polished instruments, shiny
white tissues or plastic, and even a suture needle can have this effect. Today, several different
methods are used to decrease glare from instruments. These include matte finish (rough
polishing after the usual mirror-like finish), satinizing (blasting with fine sand, 1 to 2 |xm),
ebonizing, and the anodizing of titanium instruments to various soft colors.
Contrast
As in general surgery, there should not be too much contrast between the lighting of the
operation site and the theater in general, the maximum ratio being less than 5:1. This allows
the team members to look about the theater from time to time without losing their acuity,
and lets them clearly see equipment away from the brightest-lit area.
Color contrast is of special interest. Dilute methylene blue solution shows up fallopian
tube patency and leaks, and also the fine structure of cut nerves. Eye surgeons have used
fluorescent dyes such as fluorescein and bengal rose for many years without risk of toxicity
to the delicate tissues they handle. As yet, there is no established place for vital dye staining
to show up tissue layers in microsurgery, nor handy, powerful UV light sources for flu-
orescent dyes now waiting to be tested, but they may be of value in the future.
Molding Effect of Directional Lighting

The flat lighting of most microscope systems washes out some tissue detail. Use of
additional fiberoptic sources has already been mentioned and may have a place in situations
where tissue structure otherwise appears amorphous, such as the nerve. All these visual aids
help the beginner more than the veteran — experience makes up for many technical inad-
equacies — but may allow the untrained person special help, such as simpler nerve repair
in trauma.
Other Lighting Factors

The color temperature of the incident light can be altered by filters, used most often by
eye surgeons, to alter the color rendering and the contrast of tissues. Flicker of the light
source is obviously unwanted, and nonoptical factors such as heat or noise may cause
problems which are avoidable.
TREMOR AND HAND POSTURE

Everyone has tremor. In the fingers of the outstretched arm it has an amplitude of 0.5 to
3 mm and an irregular frequency of about 7 to 30 vibrations per second. The amplitude of
the tremor is altered by a number of factors which can be grouped into long-, interme-
diate-, and short-term. Knowing these factors, and their mechanism, allows for control of
tremor and also for more accurate fine hand movement.
Long-Term Tremor Factors

Individual makeup, age, and health are the important factors which will determine the
selection, or self-selection, of who is to become a microsurgeon. Aptitude tests in a similar
field, such as chalk-carving tests for would-be dental students, have not proved useful for
prediction of success. Quite likely it is motivation, or will, which determines eventual success
or not.
Intermediate-Term Tremor Factors

Training and experience are the most important factors of all. While the apprenticeship
system of training has dominated modern surgery for almost a century (with the unsatisfactory
alternative of "see one — do one — teach one"), there is no way that a microsurgeon can
prepare himself for clinical work outside of the laboratory. He may start off with an intro-
ductory workshop lasting a week, but achieving reliable basic skills will take some months
of practice, often working on an animal research project while assisting at clinical cases. It
is reasonable in these days of clinical audit to expect a vascular patency or a pregnancy rate
of 95% or more before a trainee in a large institution is considered ready to undertake clinical
cases.
The nature and length of training needed by a microsurgeon vary with the individual and
with his field of work. However, the technical factor that may be most neglected is not the
fine stitching to be carried out but the preparation for it. The small-scale work to be done
must be made easy, and made to look easy, by good exposure, mobilization, and display
of the structures to be operated on. The strategy for this, and for the organization of the
whole microsurgical team, needs careful development, rehearsal (both mental and physical),
and application. Some aspects of this will be discussed further under the headings of work-
place layout and skill acquisition, later on in this chapter.
Other intermediate-term factors are the physical and mental fitness of the operator. The
"social poisons" of smoking and alcohol vary greatly in their effect on individuals, and for
each person it becomes a matter of conscious trial and error to decide whether they apply
in his case or not. It has been said, in reply to keen questioning, that sex does not aggravate
tremor, but thinking about it does.
Short-Term Tremor Factors

These factors are the important ones in preparing and carrying out individual procedures.
Of over half a dozen, undoubtedly the most important one is point of limb support, with
its implications for providing suitable hand rests and using suitable hand postures during
microsurgery.
Point of limb support — The closer to the end of the fingertips that firm comfortable
Volume I 17
support is provided, the more that the amplitude of tremor is damped. As support was
provided successively to the upper arm, the elbow, the forearm, wrist, hand and fingers,
so did steadiness increase. It is important to have the arms hanging relaxed by the side of
the body, with no hunching of the shoulders due to too high a work surface — a condition
which induces contraction of the trapezius muscles to elevate the shoulders, and a consequent
aggravation of tremor due to big-muscle tone. The support should start at least behind the
center of gravity of the forearm, and extend to the fingertips, on a yielding surface without
sharp edges or projections to press into the skin. The details of fingertip supports are discussed
later, in the section on design of instrument handles. Support for the instruments themselves
is often supplied subconsciously, such as the case of the nondominant hand acting as a
fulcrum for long-endolaryngeal instruments, or deliberately planned, such as a billiard rest
on which to rest a billiard cue. The ultimate everyday example of an instrument guide is a
ruler for drawing a straight line. In manipulations under the microscope, the two instruments
held in the hands can be used to steady and to guide one another quite deliberately when
the angle of attack on the tissue is an awkward one, or when tremor is excessive for some
other reason and cannot be adequately controlled. As in pistol-shooting, individual tremor
varies widely. Dr. Sun Lee,7 of San Diego, is a veteran microsurgeon who can transplant
a rat heart in under an hour, single-handedly. Observations of his technique show that not
only can he manage with relatively coarse instruments that would defeat other operators,
but that he can exercise his technical virtuosity without the need for hand support. Few
others could do this.
Direction of movement — The more distal the joints moved for fine movement, the finer
the control that can be achieved, and flexors generally sçem more ' 'educated" and accurate
than extensors. Like tennis players, operators will achieve best accuracy when their strokes,
or movements, are at right angles to the body part. The easiest stroke (referred in slang
terms by experienced teachers as the ''missionary position"), is towards the opposite edge
of the body, halfway between the coronal and sagittal plane. However, the orientation of
tissues at operation is often not in this favorable lie. A good example is the suturing of the
circumference of a donor cornea, when the angle of attack must alter through 360°. One
extreme (and curious) solution to this problem has been the invention of a stool for eye
surgeons which moves on a vertical axis under the patient's head, controlled by a foot switch.
Observation of experienced microsurgeons has shown that the angle of attack can be varied
quite widely by altering the posture of the hand, through wrist flexion-extension, forearm
rotation, and by altering the grip on the instrument so that it shifts out of the thumb cleft
onto the side of the index finger.
Preceding exertion — Heavy muscular exertion aggravates hand tremor for up to 24 hr.2
This laboratory confirmation of everyday experience means that surgeons' operating lists as
well as their personal activities should fit in with their microsurgical commitments, avoiding,
for example, heavy gardening or a game of squash beforehand. Signing a motel register
after carrying heavy suitcases gives a wobbly handwriting. Morse code trainees and workers
in Swiss watch factories were given similar warnings. The effects of heavy exertion will
vary among individuals, and suggests the importance of general fitness. Dr. Harry Buncke,
a pioneer microsurgeon, happens to be a keen weight lifter, but others may not want to alter
their lifestyle to this extent.
Psychological stress — The effect of stressful emotions on tachycardia and tremor, and
their control by beta blockers, is familiar to public speakers and has also been quantified in
musicians and in general surgeons. In the latter case, this was despite apparent outer calmness,
but was missing in the case of a trainee surgical registrar. Presumably his assistant, a senior
surgeon, suffered the tachycardia instead, though there is no report of this. Outstanding
microsurgical teachers such as Owen, Acland, and Szabo, as well as many practicing
surgeons, have emphasized or confirmed the importance of a state of equanimity in ap-
proaching fine work. Few surgeons would consider the use of beta blockers, but the learning
experience from using them once may have long-term value. In factories making fine surgical
instruments and silicon chips for computers it is recognized that there are some days when
it is hardly worth the worker starting work.
Force exerted by the fingers and thumb — Forceps and needle holders which require
too much force to use will cause significant tremor. The first commercial instruments
available for microsurgery ten years ago took up to 1.2 kg (2.5 lb) pressure applied by the
fingertips to close their jaws. The best stiffness level for fine work is between 50 and 60
g, based on studying a small group of experienced microsurgeons and earlier studies on
tremor. The variation in stiffness of watchmakers' forceps can be demonstrated easily by
putting two or three pairs side by side on a flat surface. On pressing them together, they
will close at different stages. This stiffness can be measured, either by a push-pull gauge
on a motorized stand or more cheaply with an Ericson gauge used for checking the stiffness
of leaf spring contacts in telephone relays. Until 4 years ago there was no awareness by
surgeons or by instrument makers of what stiffness level was desirable. One leading man-
ufacturer had a master set of instruments kept in its safe, whose feel the senior craftsman
would compare with instruments made at extra cost for individual buyers. There was no
commercial concept of quality control in terms of a desirable level or range of stiffness until
the British firm, MICRA (following a paper presented by this writer to The World Micro-
surgery Congress II in San Francisco in 1978), adopted a value of 65 g as their standard—
somewhat suffer than the level first recommended. At the same time individual microsurgeons
were slackening off instruments by simply bending them one way and then the other, until
they felt right. Today this level of stiffness can be checked as described above. It is a simple
maneuver for an instrument maker or a competent microsurgeon to alter the setting of
instruments. It is not recommended for general use, say, by theater attendants because of
the likelihood of permanent damage to expensive instruments.
Speed of movement — Most skilled movement is controlled by one's muscle sense. Only
in the early learning phases is seeing one's movements a helpful guide. The feedback loop
for muscle sense is shorter, quicker, and less conscious than for vision-controlled movement.
However, at the scale of movement which we are concerned with here, the feedback from
muscle sense is much less, except for some maneuvers such as forming a loop of suture
around an instrument held in the other hand. (This can actually be done by sense of touch
outside the field of vision under the microscope, given a little experience and practice.)
Especially for the beginner, an irritating occurrence is the suture pulling right through tissue,
instead of leaving a tail long enough to tie. Buncke et al.3 suggested pulling the suture at
5 to 10 mm/sec to avoid this accident.
Other factors — The personal setting in which delicate work is carried out is important
for many people. The need for careful team organization crops up repeatedly in this discussion
and it is as important for avoiding annoying distraction as for the smooth flow of activities.
It has already been noted that good hand posture and handle design are vital factors for
control of tremor and fine movement, and it is convenient to discuss these now.
HAND GRIPS AND INSTRUMENT DESIGN
The two main grips of the hand are the power grip and the external precision grip. These
are typified by holding a heavy retractor and writing. There are many other grips in every-
day use that can be described, with their variations, but the only other one that need concern
us here is the "internal precision grip", which has some applications to microsurgery. In
this grip the instrument is held within the palm, parallel to the work surface rather than at
about 45° to it. It gives greater steadiness through support of the knuckles, but at the expense
of mobility.
Volume I 19
The, external precision grip is the common and important one for microsurgery. It is more
than the simple pinch grip by the tips of the index finger and thumb, often wrongly referred
to as a precision grip by anthropologists and orthopedic surgeons. It has at least three separate
components. Each is worth considering in detail because of its implications for instrument
design.
1. The tips of the semiflexed index and middle fingers, and thumb, providing grip and
also rotation, are discussed in more detail below.
2. A knowledgeable patch of skin at the apex of the thumb cleft and along the side of
the index finger. This provides antitremor support, guidance, and information by touch
and pressure about the position of the instrument and how much force it is exerting.
3. Support from the edge of the ring and little fingers, edge of the hand, wrist, and
forearm, as they rest on a stable surface providing control of tremor. This need for
support involves the whole body, whose seated posture is analyzed in detail in the
next section.
The implications of the features of this grip for instrument design are
1. A handle length of at least 12 cm to reach from the tips of the semiflexed fingers to
the apex of the thumb cleft. Many eye instruments have too short a length for secondary
support, and their advocates claim better maneuverability, without significant loss of
steadiness.
2. A handle diameter of just under a centimeter, so that the tips of the adjoining fingertips
just start to touch and support each other. The average soft fingertip indents 3 to 5
mm under forces of 50 to 100 g wt used in microsurgery, and not much more when
these forces are exceeded. This distance of 3 to 5 mm becomes the radius of the
cylindrical shape that can be held in this grip. A thinner handle, such as a large suture
needle, allows more sensitivity because the feedback of touch is not diluted Over as
large an area, but there is loss of control of position within the fingertips.
3. A cylindrical shape to allow rotatability. At the time of writing there is a debate which
has divided instrument designers into the "flat handles" and the "round handles".
Advocates of flat handles rightly emphasize the lesser cost of their design, and advocate
a series of small steps for taking the path of a suture needle through a semicircle to
avoid tearing delicate tissue. As the operator's skill increases, he can rranage flat-
handled instruments better. Advocates of the round-handled design are concerned to
provide rotatability of instruments both for positioning of instruments (for example,
for loop formation in tying knots) and for continuous movement in suturing. To achieve
these without instruments of circular cross-section requires movements of the forearm,
with consequent loss of steadiness and of fine control. Individuals can make up their
own minds based on their continuing experience.
4. A thinner butt end. If the instrument is to be twirled in the fingertips, it will roll on
the thumb cleft, and be displaced to one side. Vickers4 applied the concept of a much
thinner butt to the design of his family of instruments together with a number of other
basic innovations to be mentioned, all of great help to the microsurgeon.
5. Stiffness for closure. In discussing tremor earlier, a closing force of 50 g was rec-
ommended for microinstruments, because above this level tremor was aggravated.
This value will need further assessment in the future. If it were any lower, instruments
would slip out of the grip, which would have to be weaker for the jaws not to close.
Like the setting of trigger "pressures" (really forces) on guns, individual preference
is important. Further, this should be related to how much force has to be applied to
the needle to pass it through tissue; this can vary from 20 to 150 g and is discussed
later as a question for bioengineering rather than ergonomics.
6. The weight of the instruments should not be so great that they dilute what feel is
available to the fingers from tissue resistance. The fingertips can sense a force down
to about half a gram (an olive pip weighs about a gram), and instruments weighing
less than about 15 g (the weight of a ballpoint pen), will allow an appreciation of
tissue resistance that would be lost without heavier ones.
7. Instrument-tissue requirements for design relate both to access and to their ability to
fix or cut tissue without trauma. Shaft length from the handle depends on the depth
from the hand support to the tissue, and the angulation of the instrument. The other
factors relate not to the ergonomics interface between operator and instrument, but to
the second, bioengineering interface. Types of grip may be piercing, by sharpening
watchmakers' forceps to a point as recommended by Acland and Szabo, or by creating
encircled bulges with tiny ring ends, devised separately by Ysargil and Vickers. The
latter also come to a fine edge which can grip flimsy adventitia-like pointed jaws.
Whether scissors should be straight or serrated is a matter for debate, the latter gripping
more surely as they cut, but perhaps with more trauma. Their blades should incorporate
two curves, achieved by hollow grinding or intersecting curves, to cut cleanly without
crushing. Curved scissors achieve the same effect through the outer blade having a
slightly smaller radius. A third interface between mechanical elements in the chain
from operator to tissue is exemplified by needle holder jaws gripping needles. The
Vickers instruments achieve this in two ways, with concavo-convex jaws for needle
holders automatically positioning the needle away from the flattened tip, and by use
of the ring ends on tissue forceps, which receive the needle.
8. Metallurgical criteria for instruments are even further removed from the ergonomie
interface, but also of obvious importance. The main choice is between martensitic
stainless steel and titanium — the latter being harder, lighter, and capable of being
anodized to reduce glare, but more brittle, expensive, and difficult to machine.
9. Further practical requirements for instruments are adequate protection in custom-made
stainless steel cases in which they can be stored and autoclaved, to save handling
which may damage them.
Variations of the External Precision Grip

Earlier descriptions of hand grips used for fine work painted a rather frozen picture of an
ideal posture. The hand of an expert at work is much more fluid in its position, with alterations
in the degree of wrist flexion, pronation or supination of the hand, and the placement of
the handle butt on the base of the thumb, in the thumb cleft, or along the base of the index
finger. The internal precision grip, mentioned earlier, presents very similar design criteria
for instruments, except for the angle of the working end. The tooth extraction forceps used
by dentists illustrate such a range of angles nicely.
WORKPLACE ARRANGEMENT AND SEATED POSTURE
Perhaps the most neglected factor in considering requirements for fine work is seating.
This must be related to the height and sitting of the work surface. Apart from the trapezius
tone and tremor mentioned earlier, another effect is neck and shoulder pain which may reach
the point of disability. Studies of the ergonomie needs of computer operators working long
hours at video display terminals have indicated a number of separate requirements for seated
work:
1. Seat height and adjustment. Simple anatomical measurements indicate that a seat should
be adjustable in the range of 15 to 19 in. (38 to 48 cm) above floor level. The adjustment
should be quick and easy to make, and the best mechanism for this is a 4'gas-action
Volume I 21
piston", found on the most modern office chairs. Older-style stools, which have a
screw mechanism for altering their heights are too clumsy.
2. Castors allow the operator to shift his position from time to time, and to move into
his work easily: criticisms of lack of stability seem unreal, as it takes significant lateral
force to start them moving, but simple locking devices are also available. Leonardo
da Vinci pointed out 500 years ago that a seated person could not change his position
without stooping forward or using his arms, and the microsurgeon who needs to shift
slightly for comfort is unable to.
3. Thigh support is important for stability, and requires a seat length of 20 in. (48 cm)
which can be effectively shortened by adjusting the backrest. The front edge of the
seat must be generously rounded to avoid cutting into the under surface of the thigh
or the top of the calf.
4. Contouring to fit the shape of the buttocks is not too important in the normal seated
position (see below). Indeed a perfectly shaped seat is perfectly uncomfortable, because
of the continual need to change one's posture every few minutes, a phenomenon noted
by Sir Charles Bell addressing the Royal College of Surgeons a hundred years ago.
Today, seat designers use frequency of seated movement as an index of comfort.
Attempts made to use a mini-beanbag filled with a slurry of polystyrene beads and
water have not yet proved of value.
5. A backward tilt of the seat of 3 to 8° was recommended to stop the operator from
sliding forward, but forward tilt is probably better. Facility to alter this is best.
6. The consistency of the seat should allow it to sink about 2 or 3 cm under the weight
of an average 70- to 80-kg subject. If softer, there is no relief of high-pressure areas
by shifting, and if harder, the pressure is excessive.
7. The surface should be smooth and washable, or preferably removable and porous to
allow body moisture to evaporate, and to allow laundering and disinfection.
8. If desired, a lumbar support should be adjustable up and down and horizontally, and
swivel, to fit into the small of the back. Some operators will dispute this need.
9. Arm rests which are attached to a chair are somewhat cumbersome, and more expen-
sive. They are especially useful for eye surgery, which uses the same operator posture
each time and where support from the body and table is inadequate. For hand surgery
a better alternative is a semicircular cutout in the table on which the patient's hand is
placed.
The seated posture analyzed so far is excellent for laboratory work on small animals and
for surgery to the hand. The space between the operator's horizontal thigh and horizontal
forearm is about 15 cm. A thin body part on a thin table can be accommodated easily here.
However, microsurgery on the trunk or neck does not allow this ideal posture, especially
with the unergonomic design of most operating tables. The pedestal, and the thickness of
the operating table and the patient's trunk interfere with it. Partial solutions are to put the
patient's head on the foot end of the table, where it is less steady, or to slide the patient
down, resting his legs on an extra table.
A further possible solution, under study at the time of writing, is the use of a saddle-
shaped seat which allows the surgeon's hips to be extended so he can sit right up against
the table. Unlike present so-called saddle seats which cut into the inner side of the thigh,
the present design is molded from a best-quality dressage horse-riding saddle. The straighter
legs allow more mobility for the operator, and relief from buttock pressure which reaches
over 300 g/cm2, compared with a desirable level of 80 g/cm2. Examining a saddle of best
quality shows some body weight carried through the thighs, which are abducted at about
90°. Inevitably the user of this seat pattern will be as saddle sore as any ' 'greenhorn" on a
ranch for the first week, until his hamstring muscles have adjusted to the new posture.
Preliminary tests have suggested the value of this seat design. However, one drawback is
the need for movable foot controls, for microscope position, zoom, and focus, for diathermy,
and possibly other controls.
Foot pedal design is a specialized study all on its own. Because this is in the hands of
the manufacturer rather than the surgeon, detailed recommendations will not be made here,
and current references on general ergonomics or "Human Factors" should be consulted for
detailed advice. The features to note on choosing between one type of pedal design and
another are ease of placement, height, spacing between foot controls, force required, angle
for the foot, use by assistant, stiffness, guidance for heel and foot position, and associated
buzzers or other signals. Often it is best for the operator to operate with canvas overshoes
over his socks, so he can locate and use foot controls more accurately.
Operating Table and Microscope Design

While the height and configuration of tables is readily adjustable, it is hard to find one
with adequate leg room beneath, for the seated posture described. While controls for re-
positioning rarely need to be used during the course of a microsurgical procedure, their
placement is often awkward, and they may foul, for example, on armrests. The ergonomics
of table design are currently the subject of a separate study.
The design needs for microscopes provide a formidable and expensive challenge. Optical
quality, cost, maintenance, robustness, and ease of care and servicing all have to be con-
sidered before purchase. Bulk and ease of handling should improve with competition between
aware manufacturers. Among factors neglected so far is the need to avoid forward stooping
as a result of too short a distance from the ocular to the axis of the objective lens. This is
one of two distances which need to be checked, and adjusted, for each type of operation,
and for patients and operators of different builds.
It is interesting to note, at the same time, how few functional studies have been made in
ergonomie terms of the design of anesthetic machines,5 and of the whole operating theater
environment.
SKILL ACQUISITION AND EFFICIENT PERFORMANCE
This is the last major ergonomie area to be considered in this chapter. It is a question
bedeviled by lack of adequate basic knowledge of human skills in general, and the application
of existing knowledge to the activities of surgeons in particular. Tradiionally, those with
innate dexterity, perhaps reinforced by hobbies or research experience and the curiosity to
study surgical skills, have been the surgical masters of the recent past.
Today the requirements are more demanding. The intellectual content of surgery has
produced surgeons with lesser manual skills at the same time as anesthesia and instrumen-
tation have made procedures easier in terms of dexterity. Microsurgery is evolving in the
same way — witness the enormous technical changes of the past decade — at the same
time as the use of microsurgical skills has increased from those of the few outstanding
pioneers to those of a larger number of operators of more average talent. Surgery now uses
so many different types of human skills that there is no longer the time available for surgeons
to concentrate on purely manual virtuosity. On this basis, any help available from studies
of human skill that can improve the learning process and make it more effective are to be
sought keenly.
Stages in Skill Acquisition

Learning is an irregular process which proceeds in jumps separated by "learning plateaus".
Several stages can be defined and used to make learning briefer and more effective. Glencross6
has defined three stages, which may be interpreted freely as coding, timing, and inbuilt or
Volume I 23
subconscious. These apply usefully to the study of surgical skills, especially microsurgery,
where these are much more critical for success.
Coding
This first stage in skill acquisition is when the trainee learns to relate particular actions
to particular end results, like hearing middle C on the piano after pressing the right key, or
seeing the movement of a needle to the desired position with appropriate hand and finger
movements. This emphasizes the role of ''feedback" of information in the early stages, as
well as later.
Coding in microsurgical skills includes learning hand postures and knowing if they are
"correct" or not, learning the force-displacement characteristics of tissues, materials, and
equipment, and the general elements of the work. Coding is taught by example and super-
vision, or by the wasteful method of trial and error. A superb guide for these basic skills
is the Microsurgery Practice Manual by Acland, justly famous for his teaching courses at
Louisville.
Timing
Once coded movements are learned they have to be put in the right order and carried out
at the right rate. Timing is not as exact a term as Glencross's phrase of "temporal organ-
ization", but it is easier for the nonspecialist to use as long as the factor of organization or
sequence is remembered. This is like ordering the letters of a typed word, the notes of a
tune, or the movements in suturing. Many skills obviously depend on rhythm — those
involving balance, or teamwork — but timing is the essence of economy of movement. It
comes with repeated practice.
Inbuilding
With enough practice motor skills become subconscious. In a complicated performance
it is not possible to stop and think of each element. A subroutine, analogous to that of a
computer, becomes built into the brain. When a subroutine is called into play, values are
assigned to such variables as position, speed, and circumstances. Coded movements are not
interrupted halfway through for corrective adjustments. Once the stroke in golf or in tying
a knot is started, it is carried through as a "ballistic" movement, much as if a bullet has
been fired. If the movement is wrong it has to be started again from the beginning. There
is no substitute for the combination of innate capacity, correct basic movements, and con-
tinued practice. These, combined with equipment and workplace design, are the ergonomie
lessons for skill in surgery.
ERGONOMICS AND THE FUTURE IN MICROSURGERY
The aim of the information presented in this chapter is the further development in instru-
ments and technique. It must be recognized that this work is largely descriptive and poorly
validated as yet. The surgical habit of dogma is part of every field of practice, and there is
danger in accepting the assertions presented, like the truths of the American Constitution,
as self-evident — at least until further evidence validates them.
In the meantime a framework is presented for analyzing and quantifying the work of
microsurgeons. Apart from experience, the tools to be used vary from inexpensive measuring
devices to videotape replay of the operator's hands as well as the view through the micro-
scope, to EMG studies, and to new concepts which will simplify much of what is now
difficult and complicated. The history of surgery is one of alternating complexification and
simplification, so that new and difficult techniques may become assimilated into the everyday
work of caring for patients undergoing operation. This must apply just as much to micro-
surgery, so that its benefits may extend to patients in every field of surgical practice.
As of early 1983, the advent of ''robotics" suggests a radical change in future micro-
surgery. A bionic approach, transferring the wisdom of current ergonomics to machinery
design, will be crucial.
ASPECTS OF CARE OF MICROSURGICAL INSTRUMENTS
Stainless Steel
There is no such thing as truly stainless steel. The material used for making most surgical
instruments relies on a molecular film of chromium oxide to protect the underlying iron
atoms from oxidation. This film is achieved in manufacture by nitric acid or other treatment,
removing surface debris and iron atoms so the remaining chromium oxidizes in air. It can
be broken by mechanical scratching, stress, and weak electrolytic currents. In practice this
means care in handling, cleaning, and use.
Summary of Care
1. Tissue fluid should not be allowed to dry on instruments. Apart from this need to
avoid drying, instruments must be kept moist, and rinsed frequently in mineral-free
distilled water. Theater nursing staff have to learn these lessons thoroughly, by example
and precept from surgeons, as well as from their own professional training.
2. Mechanical damage to instruments must be avoided by ordinary careful technique,
avoiding abuse, and by storage of instruments in the special perforated stainless con-
tainers now sold by most large manufacturers.
3. Cleaning and drying of instruments must be thorough, using a soft toothbrush and
ordinary soft soap which is a little alkaline. Ultrasonic cleaners of the type used by
dentists should be used at the end of each procedure. With a sterile plastic insert, they
may in the future be used during surgery, though the need for a tissue-compatible
detergent to wet the metal surface thoroughly still awaits investigation.
4. Instruments can be demagnetized easily using inexpensive watchmakers' apparatus.
5. The adjustment, maintenance, and repair of microsurgical instruments is a specialized
field requiring many years of training and experience. The surgeon should be interested
enough, especially if involved in running a small laboratory, to consult the detailed
references in this field. The benefits of interest and study in this area inevitably rub
off to give better selection and care of surgical equipment in general.
SUMMARY
"Ergonomics", the scientific study of man at work, has been applied widely in industry.
Because the limits of microsurgery are determined by human capacity for fine work, it is
essential to study and improve this capacity if microsurgery is to advance and also become
more widely practiced.
This chapter is concerned with the practical details of seeing the minutae of tissue structure
more clearly, control of fine hand movements and of tremor, design principles for micro-
surgical equipment, and the process of skill acquisition.
Volume I 25
REFERENCES
1. Murrell, K. F. H., Ergonomics: Man in His Working Environment, Chapman & Hall, London, 1965.
2. Simon, J. R. et al., Effects of physical exercise on hand steadiness, Laryngoscope, 75, 1737, 1965.
3. Buncke, H. J., Chater, N. L., and Szabo, Z., The Complete Teaching Manual of Microvascular Surgery,
R. K. Davies Medical Center, San Francisco, 1974.
4. Vickers, D. W., A new microsurgical needleholder, Aust. N. Z. J. Surg., 47 (3), 381-384. 1977.
5. Boquet, G., Bushman, J. A., and Davenport, H. T., The anaesthetic machine — a study of function
and design, Br. J. Anaesth., 52, 61-67, 1980.
6. Glencross, D. J., The control of skilled movements. Psychol. Bull., 14-29, 1977.
7. Sun Lee, personal communication.
Volume I 27
MICROSURGERY INSTRUMENTS — A NEW PHILOSOPHY
David Vickers
INTRODUCTION
The applications of microsurgery are becoming broader in concept and more sophisticated
every day, and many factors contribute to their technical difficulty. Some of these are beyond
our control, but others, including improved instrument design, are well within our capabilities
and warrant further attention. Strangely enough some of the pioneers of a decade ago explored
very sophisticated possibilities of powered instruments, hoping to improve precision and
reduce tremor and fatigue. Salmon1 developed a pneumatic needle holder, while Buncke
and Schulz2 described a simple hydraulic attachment for standard instruments, and Parel3
experimented with electric micromotors in a range of new microsurgical equipment. None
of these inventions has found a significant place in current routine practice and, in fact,
most surgeons today are still using extremely simple jeweler-type forceps, along with needle
holders and scissors developed for ophthalmology. The needs of the ophthalmologist, who
operates upon a small relatively bloodless spherical organ on the surface of the body, are
quite different to those of the newer breed of microsurgeon operating upon blood vessels
and other tubular structures deeper in the body.
Most surgeons would agree that the generally available simple instrumentation has defi-
ciencies, and that mechanized remote-control equipment is still futuristic. More sophistication
in manually operated instruments is justified and overdue. Certainly, production and de-
velopment costs will escalate, but this factor is fairly minor when taken in perspective with
the cost of the microscopes, and more importantly the cost of professionals' time in micro-
surgery units.
The author has critically examined all functions in which the instruments may fail, as the
causes must be defined before they can be eliminated. The criteria for improved design fall
into two basic categories. The first category is ergonomically based and related to the overall
handling characteristics, while the second category relates to the functional performance of
the working ends. Ergonomie factors are most important in achieving efficiency and comfort
in the workplace and consideration of these, as outlined by Patkin,4 contributes to improved
design. The general features of length and weight, and the delicacy of the tips, will differ
according to the needs of the surgeon for a particular task. Very delicate instruments are
most suitable for laboratory work on small animals and for selected clinical cases, whereas
a more durable instrument of greater length is generally more suitable in the everyday clinical
situation.
The strength of the spring determines the closing pressure needed to just approximate the
jaws. The spring resistance must be light enough to be pleasant in operation, yet strong
enough to firstly reopen the jaws when the joint is stiff or fouled with deposits, and secondly
permit confident handling of the instrument with the jaws in the fully opened position. A
feeling of insecurity is experienced when handling a heavy instrument with a weak spring
because it is difficult to release the grip and open the jaws without fear that the instrument
will fall from the hand. Conversely, a strong spring impairs precision and produces hand
fatigue if operated repeatedly. The optimum spring resistance of an individual instrument
is fairly critical. The needle holder functions well with a closing pressure of 50 to 60 g,
measured at the center of the finger grips. Light tweezer-type instruments will function
adequately with lower pressures than this because there is no pivot joint to resist motion.
Spring scissors may have a heavier spring to provide adequate spreading via the blades for
dissection, the intermittent operation of which will not produce hand fatigue.
FIGURE 1. Speed, efficiency, and a tidy workplace result from a small set of instruments of sophisticated
design.
Instruments with a cylindrical holding zone (the finger grips and the small space between
them forming a composite cylinder) are favored. The diameter of the cylinder should be
roughly equivalent to that of familiar writing instruments. Flat-sided instruments are less
rotatable in the digits so that undesirable gross hand motion is required to achieve the same
range. Many instruments have hemicylindrical finger grips, but these do not approximate
sufficiently to form a composite cylinder. The resultant composite oval holding area is not
able to be rotated smoothly because a sudden collapsing movement occurs when the digits
roll onto the flat sides of the oval.
The production of glare is not significantly related to the surface finish of instruments
held in the hand, because the surface area is small and inclined away from the light source.
The horizontal surfaces of liquids, and less so of clamps, have the greatest glare-producing
potential.
A further consideration from an organizational point of view is to maximize the functions
of each instrument, so that the number of instruments in the basic set is kept to a minimum.
The operating area then remains tidy, instrument changeovers are reduced, and time is saved
through improved efficiency. In addition there is a purchase-cost benefit and maintenance
is less onerous. A basic working set cannot be realistically reduced to fewer than three
instruments — needle holder, tissue forceps (or pickup), and scissors (Figure 1). Attempts
have been made to combine a needle holder and scissors, but such an instrument has
limitations in dissection, and presents no advantage unless the surgeon operates without a
trained assistant.
NEEDLE HOLDER
The needle holder is probably the most crucial microinstrument, and reliable needle control
Volume I 29
FIGURE 2. Concavoconvex jaws. The holding sur-

faces of the jaws are precision ground to conform to the
curved microsurgery needle. A gentle grip on the needle
urges it to turn into the upright position and a very stable
grip is then achieved even with gentle digital pressures.
is the most demanding function. Disorientation of the needle and instability of the grip
impair performance and waste time. Rotatory motion facilitates the passage of a curved
needle, but this has physical limitations even with a composite cylindrical finger grip.
A secure grip upon the needle is most important. The grip is weakened if the length of
the jaws is too long in relation to the length of the handles by reducing the mechanical
advantage, or if the area of contact between the needle and the jaws is small and incongruous.
Curved needles are in more common usage than straight needles because they are easier to
pass through the tissues, but they have the disadvantage of incongruity and the need for
correct orientation in the needle holder before every penetration of the tissues. When a
curved needle is gripped between broad plane jaws contact is made only at three points so
that it may be deformed or it may roll on its side, both of which are unacceptable. If the
plane jaws are narrow enough this will not occur, but the needle must be gripped more
firmly to achieve security and orientation of the needle in the needle holder may be difficult.
These narrower jaws tend to make unwanted impressions in the thread during tying. The
demands of stability and correct orientation are best served by conformity between the jaws
and the needle (Figure 2). If the holding surface of one jaw is concave and the other
reciprocally convex, a curved needle always tends to rotate into the correctly orientated
attitude, then remains there.5 This helpful motion is most apparent in moist conditions where
the limiting friction on the needle is minimized, although sometimes a little assistance from
the tissue forceps is necessary. The orientated position is confidently maintained with only
gentle digital pressures thereafter, which minimizes hand fatigue. The enhanced security of
grip provided by conforming jaws allows precise wobble-free penetration of both sides of
an anastomosis in a single motion, even through scarred tissue. In addition, the tissues on
one side of the anastomosis may be manipulated and aligned on the needle point, while
those on the other side are being held with the tissue forceps. This saves time because this
bimanual manipulation is more efficient than the use of the tissue forceps alone. Finally,
the conformity between the needle and the instrument minimizes wear. The performance of
FIGURE 3. The three maneuvers during penetration with a curved needle. Rotation is essential for Stage III.
concavoconvex jaws improves with use, which is not the case when the shoulders wear
away from both sides of plane jaws, in effect producing two convex sides.
The zone of the jaws adjacent to the joint is prone to blockage with blood clot or suture
remnants, which will prevent proper closure at the tips. The adequate cleaning of this narrow
area during a procedure is difficult. The deliberate machining of a substantial clearance
between the jaws in this zone will overcome both of the above problems.
The more completely the needle point can be protruded clear of the tissues by rotation
after penetration the simpler its extraction becomes (Figure 3). Rotatability of the needle
holder is especially advantageous during the third stage of passage of the needle. As stated
before, a composite cylindrical finger grip will allow smooth rotation, but the range is limited
to about 60° because the digits will bridge the gap between the hemicylinders beyond this
point and prevent their release (Figure 4). If the grip is observed at the commencement of
Stage I it will be seen that a part of the circumference of the finger grips is being wasted.
A rotatory offset of the hemicylindrical finger grips will effectively transfer this zone to the
end of the rotatory range, hence extending the rotatability by 50%. When the common
external precision (penholding) grip is used, rotation can be even further extended if the
instrument is rolled along the radial border of the middle finger with the thumb, rather than
maintaining the grip between the thumb and the index finger. The rotatory "bias" must be
reversed for left-handed surgeons.
The ability to lock the instrument on the needle is useful as a storage facility, saving time
and reducing the loss of sutures in transit. It is not intended that the lock be used during
suturing. Ideally, the lock should engage only following a deliberate maneuver using one
hand, and release automatically again with a single-handed maneuver. The author has devised
a catch based on the torsion bar principle which achieves these objectives (Figure 5).
TISSUE FORCEPS
The tissue forceps (pickup) is used in the nondominant hand for manipulation of the
tissues, and some aspects of suturing which vary according to individual techniques. Spring
tweezer-type forceps are favored as rapid action takes precedence over the mechanical
Volume I
FIGURE 4. (Above) With a standard needle holder the grip may not be released if rotation exceeds 60° because the digits bridge the gap between
31
the handles. (Below) A rotatory offset of the finger grips will permit 90° of useful rotation.
FIGURE 5. (A) A deliberate maneuver is required to engage the locking mechanism.

(B) Single-handed automatic release of the locking mechanism follows compression
of the finger grips.
augmentation of the grip provided by a pivot joint. The closing pressure may be about 20%
lower than the figure suggested for the needle holder. Since rotatability aids maneuverability
a composite cylindrical finger grip is once again recommended, although in this case a
rotatory offset is not necessary.
Tissue control is best achieved with a toothed instrument, but teeth are traumatic to the
tissues and sutures. Fine teeth are prone to mechanical failure by bending or breaking, and
are less satisfactory than plane forceps in completing a tie. The notched variety of forceps
are no more durable and present greater difficulty when handling the suture. The frequent
interchange required from toothed forceps to plane forceps through a procedure causes loss
of time through inefficiency. Although some techniques utilize the needle holder to extract
Volume l 33
the needle after penetration, it is advantageous if the tissue forceps can be used for this
purpose. In the usual seated posture the angle subtended by the forearms is approximately
90°, and since the needle is usually grasped in the needle holder at right angles across its
shaft, its direction of travel will be directly in line with the tissue forceps. Jeweler-type
forceps will fail to achieve a secure grip on the needle unless they grasp it across its long
axis, hence, the surgeon is forced to move his hands. The problem can be avoided if the
needle is extracted with the needle holder, but this "single-handed" technique lacks control
because the original grip on the needle must be released before it can be reapplied for
extraction. During this maneuver the needle may roll over or disappear back into the tissues,
or an anastomosis may fall apart unless an approximating clamp has been applied. The
bimanual technique affords better control, but a reliable method of extraction of the needle
with the tissue forceps without having to move the hands must be found.
The Ring Forceps — Omnidirectional

A tissue forceps with tiny rings at the tips will perform all of the above functions and
provide an ever ready counterpressor function as well.6 The ring forceps are excellent needle
catchers because the needle is always grasped across its shaft (Figure 6). If extra security
of the grip is required in special situations a superior three-point hold on the needle is
achieved when its point is passed through one ring before they are opposed (Figure 7). This
is a surprisingly easy maneuver to perform and the most delicate needle locks into position
with the gentlest of closing pressures.
The rings have a relatively large surface area, hence, reducing trauma to the tissues by
compression or penetration and, in addition, crossover at the tips is less likely to occur. The
tissues may be grasped either in bulk so that they bulge into the orifice, or with the leading
edges of the rings. This instrument can take the place of both plane and toothed forceps and
combines the advantages of both without having the disadvantages of either.
A counterpressor is only occasionally required, but can be particularly useful when tissues
resist penetration. The use of a special counterpressor loop can lead to an awkward situation
when it is being exchanged again for a tissue forceps. The ring forceps is always ready as
a counterpressor, and then is immediately available to extract the needle.
Finally, "crossover" at the tips of fine forceps is an irritating phenomenon which is
difficult to overcome. A strong spring section will provide the necessary stability, but then
the closing pressure will be too great. A tapered stabilizing pin will prevent crossover, and
in conjunction with other pins will control excess pressure so that crushing of tissue during
handling is avoided. The location of each pin must be carefully planned or it may act as a
pivotal point, paradoxically causing the jaws to part again with increasing digital pressure,
which makes a secure grip evasive.
Scissors
Traditional spring scissors are not completely satisfactory because they will not cut the
full range of tissues encountered in microsurgery. Difficulties are encountered mainly at the
extremes of the range — thin elastic adventitia and thick scarred tissue. Spring scissors rely
on the "set" or curvature of the blades towards each other to provide the necessary lateral
force for the shearing of tissue. Of necessity, these blades must be sufficiently springy to
permit closure, and this is their point of weakness as the blades may then spread and jam
on the tissue. The common bow scissors may have stronger, straighter blades because the
hand provides the necessary lateral force, however, the applied direction and degree of this
force is fairly critical and presents difficulties in microsurgery. Few surgeons are sufficiently
ambidexterous to be able to use bow scissors in either hand, let alone in all degrees of
otation. The only way to ensure clean cutting following omnidirectional manipulation in
either hand is to build the necessary lateral force into the design of the scissors.
FIGURE 6. The ring forceps grasp a needle across its long axis irrespective of the angle
of approach.
Scissors — Omnidirectional
Various devices which will provide such a force along with a variable adjustment have
been tried by the author. One of these is a "variset" wheel on a threaded axle, the rotation
of which displaces the handles (Figure 8). This force is mechanically augmented via the
pivot to vary the "set" on the blades which may then be stronger, ensuring a clean cut
through all tissues. Serrations on the bevel of the blade allow a more precise cut because
the tissues are prevented from running away from the shear, but slight scalloping of the cut
edge may result if they are too coarse. As mentioned before, the spring resistance of the
scissors may be stronger than the acceptable closing resistance of the needle holder, as the
Volume I 35
FIGURE 7. The needle easily locks in position to provide a secure three-point grip.
extra force spreading the blades is useful during dissection. Cylindrical finger grips for
rotatability increase the maneuverability of the scissors as with the other instruments.
The various theoretical features described here have been incorporated into three instru-
ments which have evolved into a basic working set with fairly universal applications. Con-
servation of operating time with all its attendant advantages has been the result.
SUMMARY
Microsurgery is technically more demanding than any other branch of surgery. Neither
the tissues nor the sutures are viewed or handled directly. Instrumentation which functions
as an extension of our digits is necessary. Ideally, the functional capabilities of each in-
strument should be maximized so that fewer instruments are required, hence, avoiding the
need for frequent changeovers and, in addition, maintenance is simplified. Precision surgery
is only possible where the tissues and sutures are controlled with security, and where the
instruments are readily manipulated in an omnidirectional manner in the digits. Three novel
instruments with comprehensive functions comprise a basic microsurgery set designed by
the author who believes that instruments are currently the weakest link in the microsurgical
chain. The more sophisticated designs are certainly more expensive, however, this is quite
a small factor in the overall cost analysis of microsurgical procedures to the community.
FIGURE 8. The two arrows on the digits (right) indicate the direction of forces manually
applied to bow scissors. Similar forces are mechanically applied to spring scissors by rotation
of the "variset" wheel to allow efficient cutting in all situations.
REFERENCES
1. Salmon, P. A. and Assimacopoulos, C. A., A pneumatic needle holder suitable for microsurgical pro-
cedures, Surgery, 55, 446, 1964.
2. Buncke, H. J. and Schulz, W. P., Br. J. Plast. Surg., 19, 15, 1966.
3. Parel, J. M., Prototypal electro-microsurgical instruments, Med. J. Aust., 709, 1970.
4. Patkin, M., Ergonomics and the operating microscope, Adv. Ophthalmol., 37, 53, 1978.
5. Vickers, D. W., A new microsurgical needle holder, Aust. N.Z. J. Surg., 47, 381, 1977.
6. Vickers, D. W., Microsurgery, Int. Cong. Ser. 465, Excerpta Medica, Amsterdam, 1978, 331.
Volume I 37
MICROSURGERY AND RESEARCH
P. J. Klopper
Microsurgical techniques have, within a short period of time, developed into a valuable
tool in clinical surgical treatment. For a surgical research laboratory this means that members
of the surgical staff are learning to use this technique and in several centers courses are
organized. Transplantation surgery was stimulated by the possibility of using microsurgical
methods in transplantation of organs in small animals with all its advantages concerning
costs and standardization. This development has as a consequence that chiefly routine tech-
niques are involved, often practiced by technicians. As in pharmaceutical research, the
investigator develops the model and the scientific conclusions are based on numerous ex-
periments performed in a routine procedure.
In Amsterdam, we use microsurgery as a technical procedure to develop surgical handicraft
and we combined it as a method for surgical research. This aim also stimulates the attractive
accompanying factors of microsurgery, the careful handling of tissue, and at the same time
strengthens the self-reliance of the surgeon in training. His effort is often crowned with a
thesis at the end of his academic education. It can show him that treatment of wounds with
macromethods is often based on excessive biomechanical demands. Combining these factors
show him that minimal interference of the surgeon in handling and material can enhance
the primary healing of wounds, the main aim of surgery.
This direction in research using microsurgical techniques also prompted development in
several other disciplines of medicine. The first example is, that more knowledge is needed
about the structures present in the border-zone between macroscopic and microscopic anat-
omy, and that new parameters and methods are needed to study this field. In our department
we are using roentgenological methods as one of the means to obtain this information. The
method is based on filling the circulatory system with Micropaque® (a colloidal suspension
of barium sulfate) which is used on a large scale in roentgenological investigation of the
colon.
The animal is first perfused with saline in which (in large animals) 2.5 mg/kg of heparin
is added to prevent coagulation and to lower the viscosity of the blood. When the effluent
on the venous side becomes clear, the arterial circulation is filled at physiological pressure
with 30 to 50% of Micropaque® in Ringer's solution till adequate filling of the organs is
seen. Complete filling of an animal of about 20 kg needs up to 1500 m€. After this the
organs are fixed in buffered formalin for 24 to 48 hr. To augment intravascular fixation,
part of the Micropaque® can be given, dissolved in a solution of 8% formalin. To prevent
loss of barium, gelatin can also be added to the solution.
After fixation slices varying from 500 to 300 |xm in thickness are made; for special reasons
thinner slices can be used. The slices can be cut with a double knife, the desired thickness
is obtained by a metal plate between the blades; a plant microtome, or in special cases a
freezing microtome after freezing the specimen, can also be used. Experience with bone has
shown that slices cut with a small circular saw can lose the barium to the vacuum caused
by the movement of the saw, whereas cutting with small mechanical saws used in model
building gives more reliable results. Optimal results with bone are obtained if the small
pieces are decalcified. The sequence is to first photograph the bone to obtain microradiographs
yielding information about the structure of the bone and then to decalcify to get optimal
vascular images. X-rays of paraffin-embedded material are disappointing, whereas slices
from methylmethacrylate embedded material, cut with a microtome saw, give good results.
The roentgenological investigation to study microvascular structures can be divided in
two stages:
1. Orientation of the complete specimen by making photographs with a normal X-ray

unit on X-ray films without screens (Mammoray-Kodak® Technical Film). It is ad-
visable to use a low kilo voltage (40 to 50 kV), to install the X-ray tube at a large
distance (75 cm), and to place the specimen on a metal plate. With this method it is
also easy to obtain stereoscopic images by making two photographs at a distance of
10 cm out of the axis without moving the tube.
2. Microradiography of angiography with an X-ray diffraction tube. This type of X-ray
equipment was originally developed for geological investigations, in particular, for
crystallography. The advantage is that a small focus is present and that a low kilo voltage
can be used to increase the contrast of the radiopaque barium with the soft tissues,
the lowest range being 10 kV, but in general 30 kV is applied. With special measures
5 kV becomes possible. The amperage is dependent on the type of tube and on the
voltage chosen. A disadvantage is that exposure times can be considerable — for most
specimens 10 to 15 min are needed if reprographic film is used (Agfa-Gevaert® 081)
and up to 60 min with Kodak® high-resolution material. We prefer the contact method
where the specimen is placed directly on film or plate, separated by a thin synthetic
foil (Styrafoil®) to prevent wetting of the photographic material. Enlargements can
easily be obtained with macrophotography or microscopically. The resolution of the
reprographic material is 300 lines per millimeter, enlargements up to 30 times give
good results. Optimal images are obtained with the high-resolution plate or film (up
to 2000 lines per millimeter).
As an example of the necessity to know the anatomy in this field of research, the findings
of Bos 34 are illustrative. The aim of his investigation was to implant a revascularized
autologous graft of the canine fibula, the circulation of this part of the skeleton was hardly
described in the literature. In dogs, the popliteal artery passes the origo of the M. flexor
hallucis to the caudal border of the interosseal membrane. At this place a bifurcation is
present into the large cranial tibial artery and the small caudal tibial artery. The latter has
a diameter of 1 mm, is embedded in the long-flexor hallucis muscle, and reaches within
this muscle up to the caudal side of the fibula. At a distance of about 1.5 cm from the
bifurcation small vessels enter the periost and the muscle. At about 2.5 cm from the bifur-
cation, the nutritional fibular artery becomes visible and after a long traject at the mediocaudal
side of the fibula it enters the cortex at a sharp angle.
The anatomy shows clearly that preservation of the nutritional artery is only possible if
a muscular cuff of about 1 cm thickness remains on the periost. This finding gave rise also
to further experiments, for the eventual harmful effect of this amount of muscle on the graft
had to be compared with the transplantation of a nonvascularized autologous graft of the
bone alone.
The importance of anatomical knowledge at the macroscopical level is also illustrated by
the work of Garibyan,5 who made anastomoses between the testicular and pudendal arteries
in dogs in order to bring the intra-abdominal testis to a satisfactory intra-scrotal position.
In both man and animal, careful investigation of the vessels at macroscopic level, with their
varieties, is necessary before clinical treatment on a larger scale can be performed.
The roentgenological method is simple and has the advantage that pictures are obtained
that can be compared with clinical angiography. At the microscopic level valuable infor-
mation can be obtained on topics such as the reaction of the vascular system to implantation
materials including suturing materials. Also the behavior of polymers which are biodegrad-
able or are invaded can easily be studied (Figure 1).
As a second method in the investigation of the morphology, injection techniques were
introduced. This technique has been known for several hundred years from the work of
Leonardo da Vinci, Swammerdam, and Ruysch who produced beautiful specimens. The old
Volume I 39
FIGURE 1. Microradioangiography of a silicone rubber prosthesis in the trachea of a rabbit, a

granuloma in the borderzone is present (arrow). (Magnification x 8.)
method used wax or other materials which were often made according to a secret recipe.
Today these have been replaced by modern materials such as silicone rubber (Microfil®),
latex, PVC, or methylmethacrylates. With the latter favorable results were obtained when
this cast technique is combined with scanning electron microscopy (SEM). This technique
has the advantage that a distinct insight in the relationship between the vessels can be
obtained, while at the same time the reaction of pathological processes can be studied at
the microscopic level.
The method has been extensively described by Hodde et al.7"9 and van Gelder and Klopper.26
In rats, the injection is made into the aorta; in larger animals separate parts of the circulation
can be injected. The blood is washed out with phosphate-buffered salt solution of 300
mosmol, pH = 7.2 at 38° C to which heparin is added. This is followed by administration
of 0.5% glutaraldehyde. Then the prepolymerized methacrylate such as Mercox® or Batson®
No. 17 is injected in pure or diluted form. Minimal filling is obtained when the vessels of
the iris and of the tongue show the color of the resin. The animal is kept in a water bath
of 50 to 60°C for 15 to 30 min to complete the polymerization. Corrosion is performed with
20% NaOH or KOH at a temperature of 40 to 50°C after removal of the skin if deeper parts
are to be studied. The corroded tissue is removed by a gentle stream of water. The cutting
of the specimen (the resin cast) can be done with a razor blade from iceblocks or waxblocks,
and in a more advanced way with a laser beam.
If so desired, photographs of the whole specimen can be made. The casts are then prepared
for SEM investigation by mounting them with electron-conductive glue onto the stubs, and
subsequent gold-palladium sputtering. In most cases a limited range of magnification (up
to 1000 times) gives valuable information; the two materials mentioned also make it possible
to study the imprints of endothelial cells on the cast.
This method makes it possible to study the repair of endothelium in vascular anastomoses
with microsurgical methods. As was shown by van Gelder,27 around the anastomosis a
distinct development of capillaries is seen (Figure 2). The possibility that these vessels
FIGURE 2. Cast of a vascular anastomosis in the carotid artery of the

rat. The perivascular capillaries around the lumen are partly removed. An
imprint of an endothelial cell is visible (arrow). (Magnification x 500.)
prevent the repair of autonomous nerves around the arteries is still under study, especially
to explain the hypersensitivity to cold observed after reimplantation of digits. A second
advantage is, that after removing the vessel wall, the remaining cast of the vascular lumen
is present with the sutures embedded in the polymer. Together with the reaction of the
endothelium, the relation to the sutures and the sutures themselves can be studied (Figure
3). The damage made with instruments or by knotting can distinctly be seen. It clearly shows
that the cast technique can be of importance in the study of medical devices in the living
tissue, especially because artifacts can be avoided to a great extent.
In the first years after the introduction of microsurgical techniques in our department it
was difficult to obtain suitable instruments, and while developing this technique the need
for small instruments to facilitate the procedures became obvious. It stimulated the interest
of our mechanical engineers into developing instruments and one of the results was that also
instruments, needed for further research in this field could be developed.
For several years experiments were performed to study anastomoses in the intestinal and
urinary tracts. In anastomoses some closely related factors are present; the repair of the
superficial layer and the repair of the supporting tissue consisting of collagen and, in some
organs, muscle. These two factors are related as long as a defect of the superficial layer is
present for contamination can occur followed by a reaction of the underlying tissue.
Volume I 41
FIGURE 3. Cast of a carotid artery in the rat. The smooth suture material (polyamide) show small
cracks (arrow). (Magnification x 500.)
Until now the factors leading to excessive scar formation have been unknown, van Hattem
et al.31"33 constructed a miniature biopsy instrument to make small lesions (diameter 1.5
mm) in the bile duct of rabbits. They found that within 24 hr the defect was closed by
migration of cells. Morphologically, four types of cells could be distinguished, the common
factor in three of these types being that small protrusions were visible which made contact
with the underlying layer of connective tissue (Figure 4). This form of investigation performed
with microsurgical procedures shows that small animals can be used in the study of wound
healing, enhancing a high standardization of the model. The study of the healing of the
superficial defect was combined with that of a longitudinal incision in the common bile
duct, necessary to introduce the instrument. One of the conclusions of this investigation is
that the condition of the underlying structure has a definite influence on migration: while
most wounds healed within 24 hr some of them showed a distinct inhibition of the movement
of the migrating cells, possibly by small fibrin clots or small irregularities in the surface.
Migration is the key factor in closing of wounds, given that the underlying layer is in optimal
condition.
Mitosis cannot enhance this progress since groups of cells were seen around a small defect
in the epithelial layer, and similar observations were made in the healing of gastric mucosa.24
This observation led to the conclusion that ideal adaptation of all layers of the wound must
be a principal aim of surgical handling. This has been confirmed by a large series of
experiments carried out in our department comparing the healing of an anastomosis of the
ureter, 141617 the bile duct1534 the intestine,10 joints and tendons,20-21'25 and the trachea.1619
A microscopical study of anastomoses in hollow organs, made by experienced surgeons
taught that several anastomoses made by hand show irregular adaptation in several parts of
the wound; end-to-end adaptation, inversion, eversión, as well as pantile adaptation was
found.
To obtain ideal adaptation, two possibilities are present, anastomoses with mechanical
devices or with microsurgical techniques. It could clearly be shown in anastomoses of the
ureter and of the bile duct that mechanical stapling contributed to better wound healing.1418
FIGURE 4. Migration of cells in small defect of the common bile duct in rabbit, one of the cell
protrusions is marked. (Magnification x 700.)
The comparison of ureters anastomosed by various methods showed that the canine ureter,
anastomosed with the American vascular stapler, healed with a minimum of scar tissue.
Repeated ureterograms also showed that the function of the ureter in the first days following
intervention was hardly influenced, in contrast to the contralateral ureter treated with a
different method and other suturing material (Figure 5).
With the use of mechanical devices, foreign material still remains at the site of the
anastomosis. Our experience with mechanical devices in the anastomosis of bile duct and
ureter has shown that the amount of foreign material is of importance, all tissue between
sutures becomes less viable or necrotic in its presence and the mechanical as well as the
functional junction between both parts of the wound is dependent on a rapid connection of
living tissue between the sutures. The presence of dead tissue also has the disadvantage that
all necrotic material has to be removed by infiltrative cells, and so far the factor which plays
a role in disturbing the balance between the resorption of infiltration and the formation of
an excessive amount of scar tissue is unknown.
In the bile duct and in the ureter the importance of the amount of necrotic tissue was
clearly demonstrated with the application of Nakayama's vascular stapler using small metal
rings around both ends of the anastomosis. In both hollow organs stenosis was present within
a few weeks and this method is now performed as a standard method to evoke stenoses
(Figure 6). Nonresorbable material also shows a tendency to penetrate into the lumen of the
organ if a low pressure is present in that particular organ. This phenomenon increases the
probability of stone formation. Movement of sutures is also seen in nervous tissue and if
this process is accompanied by enhanced formation of connective tissue, the ingrowth of
axons is limited. Vuursteen,35 using small sheets around the junction of a severed nerve
which were fixed at a certain distance from the wound, showed that prevention of the
presence of suturing material within the junction gave the highest amount of regenerated
axons in the distal part of the nerve.
The study mentioned leads to the conclusion that suturing would be ideal without the use
of sutures. In a parallel series of experiments, also in small structures like the bile duct, we
Volume I 43
FIGURE 5. Microradioangiography of an anastomosis in the canine bile

duct. Normal longitudinal repair of the vascular pattern. The staple (arrow)
gives no vascular reaction. (Magnification x 10.)
studied the effect of mechanical devices developed by Murphy,23 Boerema,1-2 and Koomen
and Klopper.13 With these types of instruments only the ends of the anastomosis between
both parts of the button are compressed, the tissue in the immediate region remains viable
and well vascularized and after 1 week the compressed tissue disappears together with the
device from the wound area. The functional and morphological results are outstanding even
after years, while the amount of connective tissue is minimal. Jansen et al. ,12 using a variation
of this method could confirm the hypothesis of Halsted6 that the submucosal layer is a main
factor in healing of anastomoses of the intestine; it forms the so-called skeleton of the
intestine and if the adaptation of this structure is really end-on, vascularization between both
ends is restored within a few days and only small groups of inflammatory cells are seen.
This process is closely related to an undisturbed repair of the endothelium as mentioned
before because the chance of micro leakage in the underlying layer is limited. The study of
healing in visceral organs was closely parallel to similar studies with microsurgical proce-
dures. The advantage of these is that adaptation can be optimal, the suture has a smooth
structure, the amount can be limited, and the material employed is relatively inert. The
disadvantage remains that most experiments had to be performed with nonresorbable material,
increasing the chance of formation of stones in ureter and bile duct. Recently, resorbable
FIGURE 6. Ureteral anastomosis with Nakayama's

instrument. Distinct avascular zone (arrow). (Magnifi-
cation x 5.)
material of the poly glycolytic type of polymers has become available, which opens up the
possibility of repeating several investigations in hollow organs.
A second advantage of microsurgery in this type of research is that the vascularization of
the two anastomosed parts can be inspected carefully. A classical rule in the healing of
anastomoses of visceral organs is that not only the amount of necrotic tissue within the
anastomosis has to be minimal but also the tissue itself has to be viable. The experiments
of Lundborg22 have shown that minimal trauma of nerves can lead to vascular insufficiency;
the same is seen in ureteral surgery, the main arterial blood supply comes from the renal
side and the lower third of the ureter is only partially vascularized from the bladder. The
conclusion is that the periadventitial tissue must not be damaged and that microscopic
inspection makes an objective judgment of the vascularization possible.
Optimal vascularization of both parts of the anastomosis decreases the risk of fibrotic
activity in the wall of hollow organs, blood vessels, and lymphatic vessels. In the first place
the presence of devascularized parts in the region of the anastomosis increases the chance
of leakage, for the mechanical support of sutures in dead tissue is only minimal; in the
second place it also prevents intraluminal transport. In particular, the ureter shows a kind
of paralytic ileus when the wall cannot contribute to the formation of a bolus. This functional
Volume I 45
obstruction results in a higher pressure proximal to the anastomosis, and the vicious circle
is closed. Leakage as well as necrosis is enhanced, resulting in severe inflammatory reaction
in that region followed by stenosis.
Most publications deal with the healing of anastomoses in normal healthy structures in
animals. The anastomoses in clinical surgery are mostly done in pathologically altered tissue.
The previously mentioned experience made us decide that, in several of our projects, healing
of diseased structures was the main goal. This can be performed by changes in metabolism29
or with reintervention in hollow organs previously made stenotic by one of the procedures
mentioned. This type of experiment demonstrates that the use of stapling instruments is
limited, for the large diameter of the proximal part of the anastomosis is hard to connect
with the small diameter distal end. Microsurgical procedures prove their value here as well,
for all types of special techniques like spatulation can easily be performed. The healing of
diseased vessels take an uneventful course if special measures are taken29 in contrast to the
stated opinion that more complications can be expected.
It can be concluded that microsurgery as a procedure has taken a definite place in some
fields of surgical handicraft, extending the clinical treatment. The maintenance of the ca-
pability to perform microsurgical interventions requires that a certain part of the program
be taught in a surgical research department. The unknown factors in healing of surgical
wounds are still so large, that training of the handicraft can easily be combined with research.
This can be extended if cooperation with departments of basic sciences can be established.
Scanning electron microscopy either of casts or of tissue is not an investigation in itself,
but the value of this method in exploring changes of the surface and of vascularization
following surgical procedures gives extended possibilities as an introduction to more spec-
ialized research techniques such as electron microscopy. Recently, more synthetic resorbable
suture material has become available, making it possible to explore some fields of surgery
which are still restricted to the use of nonresorbable material such as surgery of the bile
ducts, the ureter, and in orbital surgery. It seems, however, more likely that the further
development of methods without the use of sutures can eventually contribute to better wound
healing. Biological glues like fibrin and Balane® are the first steps in this direction. Me-
chanical devices can help to facilitate microsurgical procedures, a combination of this tech-
nique with resorbable material in suitable instruments can be expected.
Parallel to the development of new suture material, the first publications on application
of small prostheses made either of natural material (processed collagen) or synthetic material
(silicone rubber, resorbable polymers made with the replaniform technique) have been pub-
lished. Research on the small vessels, via microsurgical techniques can contribute to a better
judgment of the use of prosthetic material in small vessels of patients. Processed sheep
dermal collagen30 has proved to be suitable as an implantation material in vessels. The results
of these preliminary experiments are in accordance with the behavior of this material in
clinical surgery. Collagen as a prosthetic material needs to be explored further to make
vascular reconstruction possible if natural venous segments are not available.
SUMMARY
Microsurgery has become a valuable tool in clinical surgery. The need to maintain surgical
handicraft after the initial training has given the experimental department a new task. This
task is not limited to this aspect alone, for, at the same time this new activity stimulates
research in the basic knowledge of wound healing. The process of revascularization can be
studied with microradioangiography. Bone healing of vascularized segments can be studied
by this process and also the structure can be judged with this technique, giving information
on the function of the graft at the donor site. Combining the old vascular injection techniques
with scanning electron microscopy and the use of modern polymers can contribute to the
knowledge of events after surgical interventions in the lumen of small vessels, the behavior
of suture material, and of intravascular devices. The methods in the department are shortly
described.
Further development of microsurgical technique is closely related to the knowledge of
anatomy in the area between macroscopic and microscopic structures, thus leading to a
revival of this basic science. The surgical repair of endothelial and epithelial surfaces is
essential.
The application of microtechniques, stimulated by the technological development of mi-
crosurgical instruments has accentuated the important contribution of migrating cells in the
early stages of wound healing. Experience obtained in our department with standardized
defects in the epithelial surface of bile ducts, made with microsurgical techniques, shows
that the behavior of the migrating cell is highly influenced by the condition of the underlying
tissue. Optimal surgical techniques can prevent the entry of harmful artifacts if migration
is completed soon after the intervention.
Microsurgical techniques stimulate the study of the physiological function of small struc-
tures. An early repair is essential for the undisturbed transportation of excretory fluids in
ureter and bile ducts. Even the use of a minimal quantity of suture material, with optimal
bioinertness still means that foreign material can influence wound healing. The development
of microsurgical anastomoses without foreign material remains an interesting field for further
research. This is illustrated in the healing of the intestinal submucosa after anastomoses
made with mechanical devices, leaving the wound area a few days after the intervention.
Research of this type has also stimulated a close collaboration with the histologist.
REFERENCES
1. Boerema, I., The technique of our method of transabdominal total gastrectomy in cases of gastric cancer,
Arch. Chir. NeerL, 6, 95—111, 1954.
2. Boerema, I., Klopper, P. J., and Holscher, A. A., Transabdominal ligationresection of the esophagus
in cases of bleeding esophageal varices, Surgery, 67, 409—413, 1970.
3. Bos, K. E., Bone scintigraphy of experimental composite bone grafts revascularized by microvascular
anastomoses, Plast. Reconstr. Surg., 64 (3), 353—360, 1979.
4. Bos, K. E., Transplantatie van Autoloog bot en revascularisatie Door Middel van Microvaatanastomosen,
Thesis, University of Amsterdam, 1980.
5. Garibyan, H., Experimental microvascular surgical orchidopexy, Neth. J. Surg., 33, 119—122, 1981.
6. Halsted, W. J., Circular suture of the intestine — an experimental study, Am. J. Med. Sci., 94, 436—
461, 1887.
7. Hodde, K. C , Miodonski, A., Bakker, C , and Veltman, W. A. M., Scanning Electron Microscopy
of Micro-Corrosion Casts with Special Attention on Arterio-Venous Differences and Application to the
Rat's Cochlea, SEM/1977/Part II, Research Institute of Chicago, 111., 1977, 477—484.
8. Hodde, K. C. and Nowell, J. A., SEM of Micro-Corrosion Casts, SEM/1980/Part II, SEM Inc., AMF
O'Hare, 111., 1980, 88—106.
9. Hodde, K. C , Cephalic Vascular Patterns in the Rat. A Scanning Electron Microscopic (SEM) Study of
Cast,Thesis, University of Amsterdam, 1981.
10. Jansen, A., Darmnaden met Magneten, Thesis, University of Amsterdam, 1978.
11. Jansen, A., Keeman, J. N., Davies, A. G., and Klopper, P. J., Early experiences with magnetic rings
in resection of the distal colon, Neth. J. Surg., 32, 20—27, 1980.
12. Jansen, A., Becker, A. E., Brummelkamp, W. H., Keeman, J. N., and Klopper, P. J., The importance
of the apposition of the submucosal intestinal layers for primary wound healing of intestinal anastomoses,
SGO, 152, 51—58, 1981.
Volume I 47
13. Koomen, A. R. and Klopper, P. J., Healing of the esophagus after total ligation with the Boerema button
and a similar apparatus acting with magnetic force — an experimental study, Arch. Chir. Need., 29, 217—
228, 1977.
14. Klopper, P. J., Experimental anastomoses of the ureter, Arch. Chir. Need., 19, 319—331, 1967.
15. Klopper, P. J., Kelly, K. A., and Vos, A., Experimental anastomoses of the common bile duct, Surgery,
63, 459^*63, 1968.
16. Klopper, P. J., Experimental reconstruction of the trachea, Arch. Chir. Need., 21, 293, 1969.
17. Klopper, P. J., Experimental microsurgery of the ureter, A rch. Chir. Need., 23, 233—239, 1971.
18. Klopper, P. J., Experimented ureteranastomosen, Urol. Int., 28, 282—289, 1973.
19. Klopper, P. J., Microsurgery and wound healing, in Microsurgery, Lie, T. S., Ed., Excerpta Medica,
Amsterdam, 1979, 280—282.
20. Kon, M. and de Visser, A. C , A poly (HEMA) sponge for restoration of articular cartilage defects, Plast.
Reconstr. Surg., 67, 289—290, 1981.
21. Leistikow, P. A., Healing of Tendon Autografts and Preserved Tendon Allografts in Induced Tendon
Sheats — An Experimental Investigation in Rabbits, Thesis, University of Amsterdam, 1975.
22. Lundborg, G., Structure and function of the intraneural microvessels as related to trauma, edema formation
and nerve function, J. Bone Joint Surg., 57A—2, 938—948, 1975.
23. Murphy, J. B., Cholecysto-intestinal gastrointestinal entero-intestinal anastomosis and approximation with-
out sutures, Med. Rec, 42, 665—676, 1892.
24. Schroeder, J. J. M., James, J., Muller, J. H., Everts, V., and Klopper, P. J., The epithelium in
healing experimental standard lesion in the gastric mucosa of the rat. A light microscopical and scanning
electron microscopical study, Digestion, 15, 397—410, 1977.
25. van der Meulen, J. C. and Leistikow, P. A., Tendon healing, Clin. Plast. Surg., 4, 4 3 9 ^ 5 8 , 1977.
26. van Gelder, P. A. and Klopper, P. J., Healing of microvascular arterial anastomoses, as seen on corrosion
casts by scanning electron microscopy, Plast. Reconstr. Surg., 64, 59—64, 1979.
27. van Gelder, P. A., A new method for studying the arterial microvascular anastomosis using the scanning
electron microscope and corrosion casts, in Microsurgery, Lie, T. S., Ed., Excerpta Medica, Amsterdam,
1979, 256—257.
28. van Gelder, P. A., De arteriële Anastomose. Een Experimenteel Microchirurgisch en Histopathologisch
Onderzoek, Thesis, University of Amsterdam, 1980 (Summary in English).
29. van Gelder, P. A. and Klopper, P. J., Microvascular surgery and diseased vessels, Surgery, 90 (5),
860—867, 1981.
30. van Gulik, T. M., Processed Sheep Dermal Collagen as a Biomaterial — An Experimental Study, Thesis,
University of Amsterdam, 1981.
31. van Hattem, A. H., Wondgenezing in de Galwegen, Thesis, University of Amsterdam, 1978.
32. van Hattem, A. H., James, J., Klopper, P. J., and Muller, J. H., A model for the study of epithelial
migration in wound-healing, Virchows Arch. B., 30, 221—230, 1979.
33. van Hattem, A. H. James, J., Klopper, P. J., and Muller, J. H., Healing of a superficial lesion in the
common bile duct of the rabbit, Neth. J. Surg., 33 (1), 25—31, 1981.
34. Vos, A., Damage and Repair of the Common Bile Duct — An Experimental Investigation, Thesis, University
of Amsterdam, 1971.
35. Vuursteen, P. J., Experimental neurorhaphy. Introduction of a new technique, Trans. VI Int. Congr. Plast.
Reconstr. Surg., Masson and Cie, Paris, 126—133, 1976.
Volume I 49
MICROVASCULAR SURGERY: COAGULATION, FIBRINOLYSIS, AND

PRINCIPLES FOR ANTITHROMBOTIC THERAPY
Carlos O. Esquivei and Sven-Erik Bergentz
INTRODUCTION
Any trauma induces changes in the composition and properties of the blood, i.e., plasma
proteins, coagulation factors, fibrinolysis, platelet function, and blood viscosity. Some of
these alterations may even start before surgery; for instance, an increase in fibrinolytic
activity occurs with premedication and the induction of anesthesia. The changes in blood
coagulation and fibrinolysis vary a great deal from patient to patient. They depend on the
extent of surgery, age and sex of the patients, underlying disease, intraoperative blood loss,
administration of blood or blood substitutes, intraoperative or postoperative complications,
and method applied; however, in most of the investigations, the abnormal results obtained
have been compared to the preoperative values. Thus, specific changes in the coagulation
and fibrinolysis during and after surgery have been observed.
In this chapter, we shall describe the events which take place in the circulating blood
starting at the time of surgery. We will refer to the changes occurring in the platelets,
coagulation, fibrinolysis, and arachidonic acid metabolism separately; but we should not
forget that these complex mechanisms are intimately related.
PLATELET RESPONSE TO SURGICAL TRAUMA
The adhesion of platelets to collagen exposed by injury to the vascular endothelium

constitutes the first response in hemostasis. This is followed by aggregation of platelets to
each other leading to the formation of a white hemostatic plug which is mainly composed
of platelets, a few leukocytes, and chylomicra.1 In investigations of the microcirculation, it
has been observed that fragmentation and embolism of the white thrombi frequently occurs. 12
There is a difference in the formation of the hemostatic plug in the arterioles compared to
the venules. It seems that platelets participate more effectively in the proximal arteriolar
segments than in venules and even though the explanation for this phenomenon is still
controversial, it seems that the formation of the hemostatic plug may be ADP-induced. In
the high arteriolar flow, collision and disruption of the red blood cells (RBC) might supply
a higher concentration of ADP than in the venules, hence, the difference in the formation
of the hemostatic plug.3
Platelet Count
Bergentz and Nilsson4 demonstrated that the platelet count began to decrease within 10
min after inflicting an injury in dogs, and at the end of the experiment (30 hr postinjury)
the platelet count had reached about 50% of the initial value. This thrombocytopenia remains
for 3 to 6 days and is then followed by thrombocytosis.
A thrombocytopenia during the first 3 to 4 days followed by thrombocytosis has been
demonstrated in patients after undergoing a major surgical procedure.5,6 Injured patients had
a similar response.7
The drop in the platelet count is partially related to blood loss and blood transfusions, to
the aggregation of platelets and their trapping in various organs, and to a consumption of
platelets in the traumatized area.4-8 However, other factors may also be implicated. Warren
et al.5 found that the administration of ACTH to patients was followed by a thrombocytopenia
similar to that of surgical patients; thus, they suggested that hormonal factors play an
important role in the postoperative thrombocytopenia. Moreover, the capacity of the organism
to produce new platelets in response to an increased consumption is quite limited.
Platelet Adhesion and Aggregation

Changes in the platelet activity occur after surgery and trauma. An increase in platelet
adhesion to glass bead and aggregation after addition of ADP has been demonstrated. In
dogs, this increase was seen after a hemorrhage, starting when about 20% of the blood
volume had been removed and before a change in the blood pressure had occurred.9 It was
also observed that the platelet adhesiveness and aggregation returned to the initial values 30
min after the blood loss, even if the animals were in irreversible shock.
After the induction of anesthesia, a decreased platelet adhesiveness to glass-bead column
and a decreased aggregation were shown by Kokores et al.10 In a study of patients who
underwent a surgical procedure, a significant increase in the platelet adhesiveness during
the first 3 days after surgery was reported by Bennett.11 Ham and Slack12 observed that the
platelet adhesiveness significantly augmented on the second postoperative day and in some
patients the increase was observed during the first day. These patients underwent a hernia
repair or a procedure of similar magnitude. The somewhat contradictory findings with regard
to platelet function reported by different authors may be due to differences in methodology
and in species. The timing for blood sampling is also important: an increased platelet
adhesiveness or aggregability may result in disappearance of the most active platelets and,
therefore, soon be followed by signs of impaired platelet function. It is noteworthy to add
that no correlation has been observed between the increase of platelet adhesiveness and the
development of postoperative deep venous thrombosis (DVT).13
Platelets and Vascular Wall Interaction: Role of Prostaglandins in Microsurgery

Endothelial injury, from whatever cause, results in adhesion and aggregation of platelets
to the subendothelium. This occurs between 10 to 48 hr following the injury.14 We have
found that the maximum time of platelet adherence in bypass grafts in carotid arteries of
dogs is approximately 2 hr after surgery.15
The discovery of the prostaglandins I2 (prostacyclin or PGI2) and thromboxane (TxA2)
and their effect on platelet and vessel wall interaction has contributed to the understanding
of thrombus and hemostatic plug formation. In microvascular surgery, the aggregation of
platelets to an exposed subendothelium may be severe enough to cause a technical failure.
Using phosphorus-labeled platelets, Wieslander et al.16 recently demonstrated an increase
of 300 to 600% in radioactivity after performing microvascular anastomoses. Interestingly
enough, platelet accumulation was more pronounced in the end-to-end than in end-in-end
anastomoses.
The precursor of PGI2 and TxA2 is arachidonic acid, which is present in the cellular
membrane. Any injury of the cellular membrane will activate the enzyme phospholipase A2
which releases the arachidonic acid. This product is rapidly metabolized into two different
pathways. The first pathway involves lipooxygenases and will be ignored in this context,
and the second involves the enzyme cyclooxygenase which forms the endoperoxide PGG2.17
PGG2 is then rapidly transformed into PGH2. The last reaction seems to be more efficient
in the platelets than in the endothelium and therefore the production of PGI2 by the vascular
wall is accelerated by an interaction between platelets and endothelial cells.18 These endo-
peroxides are proaggregating substances, their release occurring during the platelet
aggregation.1920
In the platelets the PGH2 is transformed into TxA2 by the enzyme thromboxane synthetase.
TxA2 is an unstable compound with a half-life of 30 sec at 37°C, and is spontaneously
decomposed into a stable metabolite designated thromboxane B2 (TxB2).21 In addition to
inducing platelet aggregation it causes vasoconstriction, properties which probably help in
the formation of the hemostatic platelet plug.
Volume I 51
FIGURE 1. Diagram depicting the pathway of arachidonic acid metabolism involved in vessel wall-platelet
interaction.
PGI2 is produced in the vessel wall by the enzyme prostacyclin synthetase.22 PGI2 induces
vasodilation and is the most powerful inhibitor of platelet aggregation. It also decreases
platelet adhesiveness, though a larger amount of PGI2 is needed to abolish platelet adhe-
siveness than platelet aggregation.23-24 PGI2 is also unstable, and at a pH of 7.5 and tem-
perature of 37°C has a half-life of 2 to 3 min. Its final metabolite is 6 OxoPGFla (Figure
1). PGI2 exerts its antiaggregating effect by stimulation of the enzyme adenylate cyclase,
which induces an increase in cAMP. Furthermore, PGI2 has the capacity for disaggregating
platelet clumps.25
Unlike the other prostaglandins, PGI2 is not metabolized in the lungs and its activity is
greater in arterial than venous blood.26 The explanation for this is that the lungs produce
PGI2 which prevents platelet aggregation in those organs. PGI2 has been considered a
circulating hormone which decreases the aggregability of the platelets.17 Trroriboxane A2
induces platelet aggregation by decreasing cAMP. Because of the antagonist effect on platelet
aggregability and vascular tone, it has been suggested that a homeostatic mechanism exists
between PGI2 and TxA2.25
Moneada et al.27 demonstrated that the intima produces more PGI2 and its production
decreases progressively in the deeper layers, whereas the proaggregatory activity increases
from the intima to the adventitia. The intima is approximately 5% of the vessel wall thickness
and contributes 45% of the PGI2 production. The rest is produced by the medial layer,
especially the smooth muscle cell.
Endothelial injury induces adhesion of platelets but not necessarily thrombosis. The ad-
hered platelets can supply the PG endoperoxides and the arterial wall will produce PGI2
which inhibits platelet aggregation. This mechanism would permit platelets to take part in
the healing process of the injured arterial wall.17 If the injury to the arterial wall is deeper,
then thrombus formation will occur; consequently, the extent of vascular injury plays an
important role in the formation of a thrombus. Thus far, we know that if there is an endothelial
injury of any kind, the platelets will adhere to the subendothelium followed by aggregation
induced by TxA2. At the same time, the arterial wall will produce PGI2 which will disag-
gregate platelets and prevent thrombosis. This is a "defensive mechanism" of the artery;
however, if the lesion is too deep the proaggregating stimulus would be greater and will
dominate over the ability of the vessel wall to form PGI2. In this situation a more stable
thrombus might occur.27
SEQUENTIAL CHANGES OF CLOTTING FACTORS AFTER

SURGICAL TRAUMA
The coagulation factors are proteins synthesized in the liver or in the reticuloendothelial
system (RES). It should be kept in mind that the alterations observed in the plasma proteins
are reflected by changes not only in their concentration but also in their turnover and
functional capacity. The effect of surgery on plasma proteins has been investigated by
Aronsen et al., 28 but in this chapter we will only discuss the changes which occur in some
of the clotting factors.
Fibrinogen (factor I) has been extensively studied because its chemical structure has been
identified allowing labeling with radioactive isotopes. It has been demonstrated that after
producing bilateral femur fractures in dogs,4 the fibrinogen decreased transiently. This could
be prevented by heparin, demonstrating that it was due to a consumption in a coagulation
process. During the first 24 to 48 hr there was a 4-fold increase in the fibrinogen concentration
compared to the initial values. A similar pattern was observed in patients during the early
postoperative period and the maximum increase occurred between 3 to 8 days after surgery.
In spite of the fact that the fibrinogen concentration is elevated, its utilization is markedly
increased; thus, after a severe trauma, this catabolic rate may surpass the anabolic rate which
leads to a fall in the fibrinogen concentration. This is secondary to consumption of fibrinogen
in disseminated intravascular coagulation (DIC) and fibrinolysis and constitutes a sign of
poor prognosis.29 In a study of the metabolism of fibrinogen in surgical operations, Hickman30
was able to show that after surgery there was a marked decrease in the half-life of this
protein from the mean preoperative value of 95 hr to the mean postoperative value of 53
hr. In the same group of patients, the concentration of fibrinogen rose to almost twice the
preoperative value. The increase in catabolic rate is at least in part due to consumption in
the coagulation process since it is impaired to some degree by heparinization.31 Fibrinogen
is synthesized in the liver and continues to be produced even in hepatic injuries or severe
shock.31 There are no extrahepatic sites of fibrinogen formation.32
Other coagulation factors have not been studied in detail. Factor V (labile factor) was
found to decrease progressively after inflicting bilateral femur fractures in dogs.4 In the same
experiments, the concentration of factor VIII (antihemophilic factor) also decreased. Con-
sumption of these factors may be the cause of the declined levels since they were prevented
by the administration of heparin. Nonetheless, in postoperative or postpartum patients, and
those with trauma or malignant diseases, an increase in factor V, factor VII, and factor VIII
has been found.33 Factor VIII is necessary for adhesion of platelets to the subendothe-
lium.34'37 A high factor VIII activity has been observed in patients after extracorporeal
circulation and in patients undergoing extensive surgical procedures.3840 It should be men-
tioned that the prothrombin time is prolonged after major surgery. Borgstrom41 observed
that this alteration occurred in patients subjected to general anesthesia and suggested that
the hypoprothrombinemia was probably secondary to a liver injury from the anesthetics.
Starvation in connection with surgery is also a contributing factor to the hypoprothrombinemia.
An elevation of the coagulation factors per se does not induce intravascular coagulation.4243
The activation of coagulation factors is necessary and this certainly can occur when several
substances such as ADP, collagen, lysozymal enzymes, and polypeptides are released into
the circulation from a traumatized tissue.
Naturally occurring inhibitors of the clotting factors have been identified. Attention has
been directed to an a2-globulin which inhibits thrombin and activates factor X. This protein,
which is called antithrombin III or Xa inhibitor, has been found to decrease during the first
Volume I 53
postoperative week.44 46 Low levels of antithrombin III may make the blood "hypercoa-
gulable" since Egeberg47 reported an increased incidence of thrombosis in families with a
deficiency of antithrombin III.
EFFECT OF SURGICAL TRAUMA ON FIBRINOLYSIS
An increase in the fibrinolytic activity after surgery was noticed for the first time by
Macfarlane48 in a patient who underwent a cholecystectomy. In the last decades several
investigators have focused on the changes of fibrinolysis postoperatively and the development
of DVT.49 54
Astrup55 suggested that an equilibrium exists between the coagulation and fibrinolytic
systems. This is controversial, nevertheless, since conditions which change this balance,
such as hemophilia A or B, should be associated with a decrease in the fibrinolytic activity,
but it has been found to be normal.56 The fibrinolytic enzyme system has a primordial
function in preventing intravascular coagulation, so much so, that the organism can handle
almost all the fibrinogen present in the blood if transformed into fibrin by a thrombin infusion
for at least 2 hr.57 Furthermore, if the fibrinolytic system in dogs is inhibited by the admin-
istration of epsiloaminocaproic acid, the infusion of thrombin is followed by death of the
animal due to intrapulmonary vascular thrombosis.58
In an experimental investigation, the fibrinolytic activity was enhanced during the first
hours after trauma, then it decreased progressively.4 Mansfield49 found an increased fibrin-
olytic activity in surgical patients which became evident before the induction of the anes-
thesia, most likely due to the premedication and possibly stress. The increased activity
persisted throughout the operation and during the first postoperative day. Subsequently, a
prolongation of the lysis time, i.e., decreased fibrinolysis, which in most of his patients
occurred on the fifth or sixth postoperative day, was observed. The type of operation did
not influence the results. Macintyre et al.51 observed a similar pattern; nonetheless, the
maximum decrease in the fibrinolysis occurred 24 hr postoperatively. It is during this time
of decreased fibrinolysis that the trauma-induced pulmonary injury usually occurs, and a
high content of fibrinolytic inhibitors has been found in postmortem examinations.59-60 The
alteration in the lysis time depends on the levels of the plasminogen activator and is inde-
pendent of the plasma fibrinogen.61
It appears that the fibrinolytic activity of the blood is induced by plasminogen activators
produced in the endothelium of small vessels. These activators are released constantly into
the blood stream and their activity can be measured in biopsy specimens of superficial hand
veins.62
Âberg and Nilsson52 found a decrease in the fibrinolytic activity of the vein wall during
the early postoperative period suggesting that the release of the plasminogen activators is
impaired.
There seems to be a correlation between a prolonged lysis time and the development of
postoperative DVT;49-52-53 others, however, have been unable to find such a correlation.5054
OTHER PATHOPHYSIOLOGIC CHANGES IN THE BLOOD
In addition to the changes in the coagulation, fibrinolytic, and prostaglandin systems,

other physiologic alterations in the blood have been demonstrated. Trauma is known to
increase the erythrocyte sedimentation rate (ESR) secondary to aggregation of RBCs.63,64
There appear to be two different mechanisms responsible for the RBC aggregation: the
release of tissue thromboplastin immediately after trauma and, hours later, the elevation of
proteins with a high molecular weight such as fibrinogen and globulin.
Bergentz et al.65-66 demonstrated that soft-tissue trauma in dogs is followed by an increase
Table 1
SUMMARY OF PATHOPHYSIOLOGIC CHANGES IN
THE BLOOD INDUCED BY SURGICAL TRAUMA
During 2nd to 7th Day

surgery First 24 hr postoperatively
Platelet count i 1 | then f•

Platelet adhesiveness i î î
Fibrinogen concentration i î î
Fibrinogen turnover (---) î î
Factor V i î î
Factor VIII i î î
Antithrombin III i 1 (—)
Fibrinolytic activity î î then | i
Plasminogen i 4 î
Plasminogen activator activ- (---) 1 1 or(—)
ity—in the vessel wall
Prothrombin time (...) î (—)
ESR (...) î î
Viscosity î or (—) î î
Note: Î = increased, j = decreased, (--) = unchanged, ( ) = not deter-
mined, and ESR = erythrocyte sedimentation rate.
a
Increased first 3 to 4 days, then decreased.
in the viscosity of whole blood. The same findings have been observed in traumatized
patients67 as well as in surgical patients.68 The increase in viscosity is probably related to
aggregation of the blood cells. Since whole blood is a pseudoplastic fluid, the viscosity is
markedly increased at low-flow rates; therefore in postcapillary venules where the blood
flow is very low, especially in shock, the viscosity may be very high, thus leading to
detrimental consequences for the organism.6566 As will be discussed later in this chapter,
low molecular weight dextran decreases the viscosity of the blood. The most consistent
findings in the blood occurring intra- and postoperatively are summarized in Table 1.
PREVENTION OF VASCULAR OCCLUSION IN MICROSURGERY
There are multiple factors involved in the success or failure of microanastomoses. The
surgeon should put into practice the basic principles of surgery such as careful handling of
tissues, the use of a fine suture, and the choice of the appropriate type of anastomoses. He
can also improve the local flow by maintaining an adequate blood pressure and by using
local vasodilators. There are, however, circumstances beyond the control of the surgeon,
for instance, the thrombogenicity of a vascular graft or the accumulation of platelets at the
anastomotic sites. It is in these situations that the use of drugs may be very helpful in
improving the results. We should now discuss a few of the drugs which have been used to
prevent occlusions of microvascular anastomoses by influencing hemostasis, coagulation,
or blood flow in clinical or experimental trials.
Drugs Which Influence Coagulation — Heparin and Heparinoids

Heparin
Heparin is a long chain composed of a sulfated polysaccharide polymer with anticoagulant
activity. Even though the mechanism of action is not well understood heparin seems to exert
its anticoagulant effect by facilitating the inhibitory action of antithrombin III.69-70 Heparin
Volume I 55
FIGURE 2. Effect of intravenous administration of ibuprofen, heparin with a molecular weight of 15,000, heparin
with a molecular weight of 5000, and sodium pentosan polysulfate (PZ-68) on platelet activity in vivo. The
cumulative number of emboli in 10 min after the laser injury is expressed as the percentage of control.
has been used in vascular surgery and microsurgery for several years; however, the results
have not been very satisfactory because it does not prevent platelet consumption, nor does
it prevent platelet adhesion to subendothelium or to artificial surfaces. In fact, heparin has
been found to induce platelet aggregation in vivo leading to thrombocytopenia.7173 There
have been several reports claiming that heparin has caused arterial embolization.74 In vitro
heparin has also been found to induce platelet aggregation,75 though others have found no
effect. The differences in results probably depend on the methodology applied but could
also be due to the fact that commercial heparin is a very heterogeneous substance because
of the different sources of origin, chemical composition, and molecular weight.76 78 More-
over, commercial heparin was found to antagonize the platelet antiaggregating effect of PGI2
in vitro probably by inhibition of the enzyme adenylate cyclase.79 In a blind study, we
recently compared the effect of a commercial heparin with a molecular weight of 15,000,
a low-molecular-weight heparin (5000), sodium pentosan polysulfate (PZ-68), and ibuprofen
on platelet activity in vivo.80 An endothelial injury of arterioles measuring between 20 and
40 |jLm was made in the ear chamber of unanesthetized rabbits, using a biolaser.81 After the
injury, the cumulative number of emboli was counted for a 10-min period. Determination
before and then at 15, 60, and 120 min after the drug administration, were obtained. The
results are shown in Figure 2. Doses of 60 U/kg (USP = 180 IE/mg activity) of commercial
heparin (mol wt = 15,000) and 60 U/kg (USP = 165 IE/mg) of low-molecular-weight
heparin did not have any effect on platelet activity. In a previous investigation82 similar
findings were reported using larger doses of heparin, in spite of the fact that the bleeding
time was markedly prolonged.
Finally, Salzman et al.75 observed that a low-molecular-weight heparin with a high affinity
for antithrombin III had a lower platelet activity. It seems that the heparin-induced aggregation
was impaired by the presence of antithrombin-heparin complexes.75 At any rate more in-
vestigations on fractionated heparins are needed, and at the present time heparin does not
seem to play a role in microsurgery.
Heparinoids
Heparinoids or heparin analogues are sulfated polysaccharides but, unlike heparin, these
drugs have specific chemical structures and their effect on the coagulation system is therefore
more predictable. One such drug is sodium pentosan poly sulfate (PZ-68), which has a
molecular weight of 4000. It is a semisynthetic heparinoid of vegetable origin and inhibits
activated factor X and to a lesser degree thrombin, thus decreasing the risk of bleeding
complications.83 PZ-68 was recently reported to be more effective in the prevention of
postoperative DVT than Dextran 70.84 Using the ear-chamber method, it was found that the
administration of 2 mg/kg i. v. of this compound80 was followed by a decrease in the number
of emboli, and compared to commercial and low-molecular-weight heparin, the difference
was statistically significant ( p = 0.05) (Figure 2). Following the administration of PZ-68
to healthy volunteers,83 the platelet function, which was determined by their adhesiveness
to glass bead and their aggregation by Born's method, was found to be unaltered. In the
same investigation, no effect on factor VHI-related antigen was observed, consequently, the
in vivo effect on the platelet activity we encountered in our experiments cannot be explained
at the present time. The discrepancy in results is probably related to the difference in species
and methods used in the investigations.
Drugs Which Increase Prostacyclin Production

In theory, it seems that by altering the balance between PGI2/TxA2 in favor of the former,
better patency rates in microsurgery should be achieved.
Prostacyclin
Conceivably, this could be done by exogenous administration of PGI2 in sufficient amount
to counteract the effect of TxA2. This type of therapy is still experimental and the problems
encountered so far are side effects such as chest pain, hypotension, and diarrhea and its
poor stability.
Dipyridamole
The other possibility is to potentiate or increase the production of endogenous PGI2.
Dipyridamole and other phosphodiesterase inhibitors potentiate the antiaggregating action
of prostacyclin in vitro and in vivo; however, these products have little or no antiaggregating
effect in vitro probably because of depletion of the cAMP. The antiaggregating effect of
phosphodiesterase inhibitors in vivo is accomplished by slowing the breakdown of cAMP;85
therefore, their action depends on the presence of circulating prostacyclin. The use of
phosphodiesterase inhibitor in conjunction with a thromboxane inhibitor should be very
effective.
Drugs Which Decrease Thromboxane A2 Production

Aspirin (ASA)
Aspirin causes acetylation of the enzyme cyclooxygenase, and a single tablet (325 mg)
inhibits the enzyme by about 90%.86 Since the platelets are unable to synthesize protein,
the inhibition is irreversible; therefore, the effect lasts as long as the platelets live. In contrast,
the endothelial cells are capable of regenerating the enzyme, and thus PGI2 production.87-88
It also appears that the cyclooxygenase of vessel walls is much less sensitive to ASA than
that of platelets.89 The final result is an inhibition of PGI2 and TxA2; the inhibition of the
former is transient as opposed to the latter which persists throughout the platelet lifetime.
The effect of ASA on the enzyme is dose-related and this explains why a small dose of
ASA prolongs the bleeding time, but a large dose does not.90 Moreover, this property might
be the most important factor implicated in the variability of results after ASA therapy in
different investigations. In addition, Jorgensen et al.91 recently reported that the response
to ASA varies according to the age of the patients.
Volume I 57
The combination of a small dose of ASA and dipyridamole has synergistic antiaggregating
effects by inhibiting TxA2 production and slowing the breakdown of cAMP, respectively,
and thus potentiating the effect of endogenous PGI2. Oblath et al.92 reported a 100% patency
rate of 4-mm Dacron® and expanded polytetrafluoroethylene (PTFE) grafts in dogs treated
with a combination of aspirin and dipyridamole. In contrast, a 35% occlusion and a 35%
stenosis rate in the control untreated group was demonstrated. This type of therapy, however,
needs further investigation to determine the optimal dose of each product as well as the
frequency of administration.
Ibuprofen
The administration of ibuprofen markedly decreased the thrombogenicity of PTFE grafts
placed in the carotid arteries of sheep.93 Ibuprofen is a nonsteroidal anti-inflammatory drug
which inhibits platelet aggregation in vivo and in vitro. This effect is probably the result of
TxA2 inhibition, even though the exact mechanism of action is not yet clear. The admin-
istration of ibuprofen (25 mg/kg) to rabbits, was followed by a marked decrease in the
number of emboli. As previously stated, regular heparin and low-molecular-weight heparin
had no effect on platelet activity (Figure 2).
The effect of ibuprofen either alone or in combination with a phosphodiesterase inhibitor
should therefore be investigated in microsurgery. At the present time several laboratories
are searching for a stable analogue of PGI2 and a selective thromboxane inhibitor.
Drug with Combined Effect — Dextran

Dextran is a polysaccharide composed of multiple units of glucose coupled into branched
chains. It is derived from sucrose by enzymatic action of the bacteria Leuconostoc mesen-
teroides.94 Its molecular weight is subsequently reduced by hydrolysis to produce dextrans
with molecular weights of 40,000 (Dextran 40) and 70,000 (Dextran 70). These are the two
types of dextran commonly used in clinical practice. Molecules of 50,000 or less are excreted
by the kidneys,95 larger ones are metabolized in the RES to C0 2 and water.9698
Most of the original studies on the effect of dextran on coagulation, hemostasis, and
thrombus formation are outdated because of the use of dextran with a high-molecular weight,
which produces intravascular coagulation with consumption of clotting factors.99100 Dextran
40 and 70 are known to prevent thrombus formation, but they are not anticoagulants. 100101
The following are some of the physiologic effects which may explain the antithrombotic
properties.
Hemodilution and reduced viscosity of blood — Dextran has been found to improve
the blood flow rate during surgery, thereby decreasing the risk of thrombus formation.102
As previously mentioned, the blood viscosity increases after trauma secondary to an elevation
of fibrinogen and globulin,65103 a condition which is prevented by dextran administration.
This effect is to a large extent due to hemodilution, but, regarding Dextran 40,104 it is also
due to changes in the viscous properties of the blood.
Reduced platelet activity — Dextran was found to decrease platelet adhesiveness to glass
bead. The maximal effect did not coincide with the highest dextran concentration immediately
after the infusion,105106 but occurred 3 to 6 hr later. Arfors et al. 82107 found a diminished
platelet activity after Dextran 40 and 70 administration, using a laser-induced injury to
arterioles in the microcirculation of ear chambers of rabbits. It was also noticed that the
effect was more sustained when Dextran 70 was used, possibly because of its delayed
excretion. In a recent report108 Dextran 40 was shown to inhibit platelet adhesion at the site
of transluminal angioplasties in coronary arteries of dogs. Dextran in doses not exceeding
1.5 g/kg is not associated with a prolonged bleeding time nor with a significant decrease in
the platelet count.109
Antiaggregating effect upon red blood cells — Dextran 40 has a disaggregating effect
on red blood cells.109
FIGURE 3. Effect of Dextran 40 and different doses of Dextran 70 on thrombus weight

(n = 5 in each group; means ± SE).
Reduced plasma levels of factor VHI-related antigen (von Willebrand factor) — This
effect might explain the defective platelet function observed after dextran administration.
The decrease in factor VIII protein is not caused by hemodilution, but probably by an
interaction between dextran and the carbohydrate component of the factor VIII.36-37
Thrombolysis — Dextran has been found to change the structure of fibrin and increase
its lysability. '10J ' ' The lysability of ex vivo thrombi incubated in plasmin is enhanced by dextran
which also decreases their weight (Figure 3). 112113 This effect of dextran is secondary to a
change in the platelet function.37
Other documented properties of dextran include: an antilipemic effect, coating the vascular
endothelium and blood corpuscles, and increasing the electronegativity of red blood cells.114
Dextran, therefore, possesses several properties which could improve patency rates in
microsurgery; nonetheless, very few reports on this subject have appeared in the literature.
Winfrey and Foster115 studied the effect of dextran on the patency of small vessels averaging
3.5 mm in diameter submitted to a surgical trauma which consisted of a longitudinal arte-
riotomy and removal of 2 cm of intima. The infusion of Dextran 40, started before surgery,
Volume I 59
was associated with a 6% patency rate after 24 hr, but a 95% patency rate was obtained
when the dextran was given postoperatively. The poor results obtained when the infusion
was started preoperatively were blamed on the increased bleeding, which required manual
compression and placement of additional stitches. Considering the weight of the dogs used
in this investigation, the dose of dextran was rather large, averaging 5 g/kg, which explains
the bleeding tendency. A patency rate of 20% after saline and 50% after plasma infusion
was observed.
Intimectomy of the femoral arteries of dogs receiving dextran with a molecular weight of
75,000 led to 85% long-term patency (1 to 5 months) as compared to a 10% patency rate
in the control group receiving no infusions.116 In this group, thrombosis of the vessels
occurred during the first 48 hr when the subendothelium was exposed to circulating blood.
Dagher et al.117 obtained similar results after the administration of dextran 40 and the
beneficial effect was significant in vessels less than 2.5 mm in diameter. Using a radium-
sodium clearance technique,118 dextran 40 was found to increase the blood flow in ischemic
flaps from 2- to 15-fold (mean = 5.9 times), compared to the initial values. In this study
no major tissue necrosis was observed.
An increase in the patency of vascular grafts has been demonstrated by other investiga-
tors. 119120 Clagget et al.121 found no improvement in the patency of autogenous vein grafts
placed in the external iliac arteries of dogs; nevertheless, the thrombus weight was reduced
when Dextran 40 was given. Thus, dextran seems to exert a beneficial effect on the patency
of small vessels after surgical trauma and of vascular grafts, and it certainly deserves a
thorough prospective clinical trial in microsurgery.
SUMMARY
Consequences on the coagulation and fibrinolytic systems following surgical trauma are
described. Some of the changes occur very early — during the induction of anesthesia —
and persist for several days after surgery. Awareness of these alterations is very important
for the proper management of the surgical patient.
The role of prostacyclin (PGI2) and thromboxane A2 (TxA2) on the platelet-vessel wall
interaction is also reviewed. Reports in the literature, and our own experience with drugs
which either influence the coagulation mechanism or have platelet antiaggregating effects,
are discussed. Some of these drugs may prove to be beneficial in improving patency in
microvascular reconstructions.
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Volume I 61
37. Âberg, M., Hedner, U., and Bergentz, S.-E., Effect of dextran on Factor VIII (antihemophilic factor)
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56. Kamel, K., Cumming, R. A., and Davies, S. H., Fibrinolytic systems in certain congenital and hereditary
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478, 1963.
57. Bergentz, S.-E., Ljungqvist, U., and Lewis, D. H., The distribution of platelets, fibrin and erythrocytes
in various organs following thrombin infusion: An experimental study in dogs with and without antifibri-
nolytic therapy, Surgery, 71, 190, 1972.
58. Gans, H., Thrombogenic properties of epsilon amino caproic acid, Ann. Surg., 163, 175, 1966.
59. Saldeen, T., The microembolism syndrome, Forensic Sci., 1, 179, 1972.
60. Rammer, L. and Saldeen, T., Inhibition of fibrinolysis in post-traumatic death, Thromb. Diath. Hae-
morrh., 25, 68, 1970.
61. O'Brien, T. E., Woodford, M., and Irving, M. H., The effect of intermittent compression of the calf
on the fibrinolytic responses in the blood during a surgical operation, Surg. Gynecol. Obstet., 149, 380,
1979.
62. Pandolfi, M., Bjernstad, A., and Nilsson, I. M., Technical remarks on the microscopical demonstration
of tissue plasminogen activator, Thromb. Diath. Haemorrh., 27, 88, 1972.
63. Gelin, L.-E., Studies in anemia of injury, Acta. Chir. Scand. Suppl., 210, 1956.
64. Borgstróm, S., Gelin, L.-E., and Zederfeldt, B., The formation of vein thrombi following tissue injury,
Acta Chir. Scand. Suppl., 247, 1959.
65. Bergentz, S.-E., Gelin, L.-E., Rudenstam, C.-M., and Zederfeldt, B., The viscosity of whole blood
in trauma, Acta Chir. Scand., 126, 289, 1963.
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rate: shear stress ratio) of whole blood in trauma, Bibl. Anat., 4, 676, 1964.
67. Bergentz, S.-E., Gelin, L.-E., Isaksson, I., Johansson, B., and Olsson, S., A report on a burn catas-
trophy, Acta Chir. Scand., 129, 257, 1965.
68. Litwin, M. S. and Relihan, M., Effect of surgical operation on human blood viscosity, Surgery, 73, 323,
1973.
69. Abildgaard, U., Highly purified antithrombin III with heparin cofactor activity prepared by disc electro-
phoresis, Scand. J. Clin. Lab. Invest., 21, 89, 1968.
70. Rosenberg, R. D. and Damus, P. S., The purification and mechanism of action of human antithrombin-
heparin cofactor, J. Biol. Chem., 248, 6490, 1973.
71. Bell, W. R., Tomasulo, P. A., Alving, B. M., and Duffy, T. P., Thrombocytopenia occurring during
the administration of heparin. A prospective study in 52 patients, Ann. Intern. Med., 85, 155, 1976.
72. Nelson, J. C , Lerner, R. G., Goldstein, R., and Cagin, N. A., Heparin-induced thrombocytopenia,
Arch. Intern. Med., 138, 548, 1978.
73. Kapsch, D. and Silver, D., Heparin-induced thrombocytopenia with thrombosis and hemorrhage, Arch.
Surg., 116, 1423, 1981.
74. Baird, R. A. and Convery, F. R., Arterial thromboembolism in patients receiving systemic heparin therapy.
A complication associated with heparin-induced thrombocytopenia, J. Bone Joint Surg. Am., 59A, 1061,
1977.
75. Salzman, E. W., Rosenberg, R. D., Smith, M. H., Lindon, J. N., and Favreau, L., Effect of heparin
and heparin fractions on platelet aggregation, J. Clin. Invest., 65, 64, 1980.
76. Blackwell, J., Schodt, K. P., and Gelman, R. A., Polysaccharide-polypeptide systems as models for
heparin interactions, Fed. Proc, Fed. Am. Soc. Exp. Biol., 36, 98, 1977.
77. Hook, M., Lindahl, U., and Iverius, P. H., Distribution of sulphate and iduronic acid residues in heparin
and heparin sulphate, Biochem. J., 137, 33, 1974.
78. Cifonelli, J. A., The relationship of molecular weight, and sulfate content and distribution to anticoagulant
activity of heparin preparations, Carbohydr. Res., 37, 145, 1974.
79. Eldor, A., and Weksler, B. B., Heparin and dextran sulfate antagonize PGI2 inhibition of platelet aggre-
gation, Thromb. Res., 16, 617, 1979.
80. Esquivei, C. O., Bergqvist, D., and Bergentz, S.-E., unpublished data, 1981.
81. Arfors, K.-E., Jonsson, J. A., and McKenzie, F. N., A titanium rabbit ear chamber: Assembly, insertion
and results, Microvasc. Res., 2, 516, 1970.
82. Arfors, K.-E., Hint, H. C., McKenzie, F. N., Matheson, N. A., and Svensjô, E., The effect of dextran
and heparin on platelet reactivity in vivo, in 6th Eur. Conf. Microcirculation, Ditzel, J. and Lewis, D. H.,
Eds., S. Karger, Basel, 1970, 348.
83. Bergqvist, D. and Nilsson, I. M., A sulphated polysaccharide — the effects in vivo and in vitro on the
haemostatic system in healthy volunteers. Brief communication, Thromb. Res., 23, 309, 1981.
84. Bergqvist, D. and Ljungnér, H., A comparative study of Dextran 70 and a sulphated polysaccharide in
the prevention of postoperative thromboembolic complications, Br. J. Surg., 68, 449, 1981.
85. Moneada, S. and Korbut, R., Dipyridamole and other phosphodiesterase inhibitors act as antithrombotic
agents by potentiating endogenous prostacyclin, Lancet, 1, 1286, 1978.
86. Burch, J. W., Stanford, N., and Majerus, P. W., Inhibition of platelet prostaglandin synthetase by oral
aspirin, J. Clin. Invest., 61, 314, 1978.
87. Roth, G. J., Stanford, N., and Majerus, P. W., Acetylation of prostaglandin synthase by aspirin, Proc.
Natl. Acad. Sci. U.S.A., 72, 3037, 1975.
88. Moneada, S., Higgs, E. A., and Vane, J. R., Human arterial and venous tissues generate prostacyclin
(Prostaglandin X) a potent inhibitor of platelet aggregation, Lancet, 1,18, 1977.
89. Baenziger, N. L., Dillender, M. J., and Majerus, P. W., Cultured human skin fibroblasts and arterial
cells produce a labile platelet-inhibitory prostaglandin, Biochem. Biophys. Res. Commun., 78, 294, 1977.
90. O'Grady, J. and Moneada, S., Aspirin, a paradoxical effect on bleeding time, Lancet, 2, 780, 1978.
91. Jorgensen, K. A., Olesen, A. S., Dyerberg, J., and Stoffersen, E., Aspirin and bleeding-time: dependency
of age (letter), Lancet, 2, 302, 1979.
92. Oblath, R. W., Buckley, F. O., Jr., Green, R. M., Schwartz, S. I., and De Weese, J. A., Prevention
of platelet aggregation and adherence to prosthetic vascular grafts by aspirin and dipyridamole, Surgery,
84, 37, 1978.
93. Carson, S., Demling, R., Esquivei, C , Talken, L., and Tillman, P., Testing and treatment of arterial
graft thrombosis, Am. J. Surg., 142, 137, 1981.
94. Grònwall, A. and Ingelman, B., Untersuchungen Über Dextran and sein Verhalten bei parenteraler Zufuhr,
Acta Physiol. Scand., 7, 97, 1944.
95. Arturson, G. and Wallenius, G., The renal clearance of dextran of different molecular sizes in normal
humans, Scand. J. Clin. Lab. Invest., 1,81, 1964.
96. Persson, B. H., Histochemical studies on the fate of parenterally administered dextran in rabbits. 2. On
the accumulation of dextran within the kidney, liver, leucocytes and reticuloendothelial system, Acta Soc.
Upsalien, 57, 421, 1952.
97. Rosenfeld, E. L. and Saienko, A. S., Metabolism in vivo of clinical dextran, Clin. Chim. Acta, 10, 223,
1964.
Volume I 63
98. Terry, R., Yuile, C. L., Golodetz, A., Phillips, C. E., and White, R. R., Metabolism of dextran — a
plasma volume expander. Studies of radioactive carbon-labeled dextran in dogs, J. Lab. Clin. Med., 42,
6, 1953.
99. Bergentz, S.-E., Eiken, O., and Nilsson, I. M., The effect of dextran of various molecular weight on
the coagulation in dogs, Thromb. Diath. Haemorrh., 6, 15, 1961.
100. Bergentz, S.-E., Dextran prophylaxis of venous thromboembolism, in Venous Problems, Bergan, J. J. and
Yao, J. S., Eds., Year Book Medical Publishers, Chicago, 1978, 529.
101. Bergqvist, D. and Esquivei, C , Dextran sulfate, dextran and platelets (letter), J. Microsurg., 2, 299,
1981.
102. Jansen, H., Postoperative thromboembolism and its prevention with 500 m€ dextran given during operation,
Acta Chir. Scand. Suppl, All, 1, 1972.
103. Bergentz, S.-E., Gelin, L.-E., Rudenstam, C.-M., and Zederfeldt, B., Experience of treatment with
low viscous dextran in surgery, Bibl. Anat., 4, 520, 1964.
104. Lim, C , Jr., Kostrzewska, E., Bergentz, S.-E., and Gelin, L.-E., Rheology of human blood following
treatment with dextran-40 and dextran-70, Bibl. Anat., 10, 9, 1969.
105. Cronberg, S., Robertson, B., Nilsson, I. M., and Niléhn, J.-E., Suppressive effect of dextran on platelet
adhesiveness, Thromb. Diath. Haemorrh., 16, 384, 1966.
106. Bygdeman, S., and Eliasson, R., Effect of dextrans in vitro on the adenosine diphosphate induced
adhesiveness of human blood platelets, Thromb. Diath. Haemorrh., 15, 436, 1966.
107. Arfors, K.-E., Hint, H. C , McKenzie, F. N., Matheson, N. A., and Svensjõ, E., Counteraction of
platelet activity using laser induced endothelial trauma, in Platelet Adhesion and Aggregation in Thrombosis:
Countermeasures, Mammen, E. F., Anderson, G. F., and Barnhart, M. I., Eds., F. K. Schattaner Verlag,
Stuttgart, 1970, 315.
108. Pasternak, R. C , Baughman, K. L., Fallon, J. T., and Block, P., Scanning electron microscopy after
coronary transluminal angioplasty of normal canine coronary arteries, Am. J. Cardiol., 45, 591, 1980.
109. Bergentz, S.-E., Gelin, L.-E., Rudenstam, C.-M., and Zederfeldt, B., Indications for the use of low
viscous dextran in surgery, Acta Chir. Scand., 122, 343, 1961.
110. Muzaffar, T. Z., Stalker, A. L., Bryce, W. A. J., and Dhall, D. P., Dextrans and fibrin morphology,
Nature (London), 238, 288, 1972.
111. Tangen, O., Wikk, O., Almqvist, J. A. M., Arfors, K.-E., and Hint, H. C , Effects of dextran on the
structure and plasmin-induced lysis of human fibrin, Thromb. Res., 1, 487, 1972.
112. Âberg, M., Bergentz, S.-E., and Hedner, U., The effect of dextran on the lysability of ex vivo thrombi,
Ann. Surg., 181, 342, 1975.
113. Esquivei, C. O., Bergqvist, D., Bjõrck, C.-G., Nilsson, B., and Bergentz, S.-E., Effect of volume
expanders on the lysability of ex vivo thrombi in the rabbit, Acta Chir. Scand., 148, 359-362, 1982.
114. Bergqvist, D. and Bergentz, S.-E., The role of dextran in severe ischemic extremity disease and arterial
reconstructive surgery. A review, Acta Chir. Scand., submitted for publication.
115. Winfrey, E. W., Ill and Foster, J. H., Low molecular weight dextran in small artery surgery, Arch.
Surg., 88, 78, 1964.
116. Papaevangelou, E. J. and Edwards, S. W., Prevention of thrombosis after small artery endarterectomy
with dextran and fibrinolytic agents, J. Cardiovasc. Surg., 16, 554, 1975.
117. Dagher, F. J., Slim, M. S., Abraham, E., and Meneshian, G., Effect of dextrans on small arterial
anastomosis, Arch. Surg., 103, 581, 1971.
118. Brown, P. B., The effect of low molecular weight dextran on the microcirculation of skin, Br. J. Plast.
Surg., 20, 272, 1967.
119. Eiken, O., Thrombotic occlusion of experimental grafts as a function of the regional blood flow, Acta
Chir. Scand., 121, 410, 1961.
120. Moncrief, J. A., Darin, J. C , Canizaro, P. C , and Sawyer, R. B., Use of dextran to prevent arterial
and venous thrombosis, Ann. Surg., 158, 553, 1963.
121. Claggett, G. P., Zelenock, G. B., Stanley, J. C , Lindenauer, S. M., and Fry, W. J., Prevention of
early vein graft thrombosis by drugs altering platelet function, Surg. Forum, 24, 253, 1973.
Volume I 65
COAGULATION AND FIBRINOLYTIC CONSIDERATIONS FOR THE

MICROVASCULAR SURGEON
Charles L. Puckett and John F. Reinisch
INTRODUCTION
Like the macro vascular surgeon, the microvascular surgeon needs some working knowl-
edge of coagulation and clot lysis. Natural trauma, surgical trauma, vascular stasis, and
ischemia adversely affect the homeostasis of this intricate and inadequately understood
phenomenon. Inevitably, there will be occasions upon which the microvascular surgeon may
wish to manipulate some aspect of this system in order to prevent vascular occlusion as a
result of intravascular thrombosis. The following is offered as a simplified overview of the
coagulation and fibrinolytic scheme along with a review of the various drug considerations
and our recommendations for procedure.
NORMAL CLOT FORMATION AND FIBRINOLYSIS
For many years, physicians felt that coagulation resulted from the cooling of blood or the
cessation of its flow. Today, we know that clotting is a complex process involving a number
of factors. This process is delicately balanced by a less well-understood system of fibrinolysis
which, together with the coagulation system, preserves intravascular hemodynamics. The
end product of coagulation (Figure 1) is a clot. The coagulation system can be divided into
three steps. The first step results in the production of thromboplastin. If injury occurs to the
vascular system, the production of thromboplastin occurs within blood vessels through the
"intrinsic pathway". In this pathway, exposed vessel collagen or foreign material results
in the activation of factor XII (Hageman factor). This combines with inactive factor XI
(plasma thromboplastin antecedent) to form an active complex. The complex combines with
inactive factor IX (plasma thromboplastin component) which results in active factor IX.
Platelet clumping at the site of injury produces platelet factors which interact with activated
factors IX, VIII, (antihemophilic globulin), and X (Stuart-Prower factor) to produce throm-
boplastinogin. The thromboplastinogin undergoes auto conversion to thromboplastin which
is accelerated by factor V (proaccelerin).
If the injury is to the tissue rather than the vascular system, thromboplastin is elaborated
through a simpler "extrinsic pathway" . In this pathway injury results in the direct formation
of inactive factor III (thromboplastin) which combines with factor VII (proconvertin) to form
a complex that then combines with factors V (proaccelerin) and X (Stuart-Prower) to form
active thromboplastin.
Phase two of the coagulation system is the production of thrombin. Active thromboplastin,
formed either from the intrinsic or extrinsic pathway, splits each prothrombin molecule into
active molecules of thrombin. This reaction is accelerated by factors V and VII.
In the final phase of blood coagulation, thrombin, a proteolytic enzyme, breaks fibrinogen
into a fibrin monomer and two small polypeptides. The fibrin polymerizes into a gel-like
mesh which traps cellular components to form the clot. Once formed, the clot retracts
liberating many of the clotting factors (especially thrombin) thus allowing them to participate
in the formation of more coagulum.
Fibrinolysis
Fibrinolysis is the breakdown of fibrin and is an important component in the scheme of
coagulation hemostasis. Theoretically, once coagulation is initiated it could proceed un-
FIGURE 2. Abbreviated scheme of the fibrinolytic system.
checked, resulting in massive intravascular thrombosis. The function of the fibrinolytic

system is removal of fibrin after it has served its useful purpose. Fibrinolysis helps to
maintain blood vessel patency by lysing the thin layer of fibrin that is constantly being laid
down in blood vessels.
In the fibrinolytic system (Figure 2), plasminogen is converted to plasmin which produces
fibrinolysis by the enzymatic breakdown of fibrin into polypeptides known as split products.
Plasminogen has a strong affinity for fibrinogen and is incorporated into the fibrin network
during clotting. Because of this affinity, the activation of plasmin allows fibrinolysis from
within the thrombus as well as externally from the circulation. Activators of fibrinolysis are
found in mesothelial and endothelial cells lining spaces, tubes, ducts, and cavities that might
be blocked by fibrin deposits. The most important activators of fibrinolysis are found in the
intima of veins, venules, capillaries, and the vasa vasorum of arteries and arterioles. The
authors have recently demonstrated that fibrinolysis is as active in the microcirculation as
it has been shown to be in the macrocirculation.1'2
Platelets
Platelets have a major, though inadequately defined, role in the coagulation and fibrinolytic
Volume I 67
processes.34 Surface adhesiveness is a characteristic property of platelets which allows them

to adhere to exposed vascular collagen, injured cells, and other platelets to form aggregates
which can occlude disruptions in the integrity of vascular channels. The precise participation
of platelets in coagulation is not well understood. Many of the coagulation factors are carried
on the surface of platelets. Platelets are involved in the production of intrinsic thromboplastin,
accelerate the clotting of fibrinogen by thrombin, and contain a fibrin-stabilizing factor.3 5
Platelets are also felt to contain an intracellular substance that can neutralize heparin and
promote local clotting. The fibrinolytic system can be accelerated or inhibited by platelets.
While plasmogen is carried on their surfaces,5 platelets also carry plasmin inhibitors. Platelets
also contain an actomyosin-like protein that appears to be responsible for clot retraction.
COMMONLY USED CLOT PREVENTION DRUGS
Heparin
Heparin is a mucopolysaccharide anticoagulant derived from domestic animals. It is made
in mast cells of liver, lung, and intestines. Its precise antithrombotic effect is uncertain but
it appears to work by inhibiting the activators of factor X (Stuart factor). Its net effect is
the prevention of prothrombin formation. It probably has activity at several points in the
coagulation scheme including interfering with platelet function.5 In pharmacologic doses,
heparin has some fibrinolytic capability as well.6
Heparin must be given parenterally as it is destroyed by hydrochloric acid and digestive
enzymes. An anticoagulating dose for the average adult is approximately 5000 units i.v.
This must be repeated in 2 to 4 hr and the most effective method of administration is a
continuous intravenous drip. For the first 24 hr an average of 1000 to 1200 units/hr are
generally required. Therapeutic effectiveness can be monitored by obtaining partial throm-
boplastin times (PTT). One selects an arbitrary PTT which constitutes an acceptable range
(usually two to three times normal). Simple clotting times can be used to follow therapeutic
effectiveness but these are cumbersome and not as accurate.
Heparin is the most effective anticoagulant available and is relatively easy to manage.
However, its use is not without sequelae. While preventing undesirable thrombosis, its use
may court inadvertent bleeding elsewhere in the body. Bleeding as a side effect may simply
be a nuisance or may be life-threatening.
Heparin is often employed in microsurgery diluted in saline or Ringer's lactate as an
irrigant solution. The routine use of heparin anticoagulation in either replantation or other
forms of microvascular surgery waxes and wanes from one institution to another and from
time to time. Currently, most centers are stridently avoiding the use of heparin except for
severe circumstances of need.
Coumarin
The coumarin preparations (the benzopyrones) are oral anticoagulants which inhibit the
synthesis of the vitamin K-dependent clotting factors (II, VII, IX, and X). This mechanism
of action requires a lag phase of 24 to 36 hr before an effective anticoagulation level is
reached. These drugs are best suited for long-term anticoagulation. Since the period of risk
of anastomotic thrombosis is probably only a few days, the coumarins are rarely indicated.
Improved patency rates of microanastomoses were noted in a series of coumarin-protected
rabbits when compared to controls, but pretreatment was necessary.7 Furthermore, reliability
is questionable as the therapeutic levels vary somewhat with diet and other factors. Effective
levels are monitored by obtaining prothrombin times.
Acetylsalicylic Acid (Aspirin)

Aspirin is probably the most widely used anticoagulant medication employed in micro-
vascular surgery today. This relatively innocuous drug has been demonstrated to be a mod-
erately effective prophylactic agent.4-8-9 Its primary potential for thrombosis prevention appears
to be through its inhibition of platelet aggregation. It can be administered orally or by rectal
suppository in the unconscious or anesthetized patient. The duration of effect is not known
but inhibition of platelet aggregation lasts for several days following a single dose; 0.5 to
1 g each day is probably adequate for prophylaxis. Generally the therapeutic level of this
drug is not monitored as it is relatively safe. Its main advantages are safety, ease of admin-
istration, and low cost.
Persantine® (Dipyridamole)
This drug also inhibits platelet aggregation and is thought to have some vasodilation
capability as well.4 It also appears to improve platelet survival. A dose of 50 mg (b.i.d.)
appears to be effective. It seems to offer no advantages over aspirin, but might be an
alternative choice in the aspirin-sensitive individual.
Dextran
Low-molecular-weight dextran is a controversial agent which also interferes with platelet
aggregation. It has other effects, predominantly on the rhéologie aspects of the blood. It is
felt that by coating erythrocytes and other hematologic moitiés, dextran can decrease blood
viscosity and prevent stickiness between the blood particles.4 Dextran is given i.v., the usual
adult dose being 500 cm3 of a 10% solution. This is given over 10 to 12 hr once each day
for 3 days. After a number of years of investigation and discussion, the real capability of
dextran in the prevention of clotting and the improvement of blood flow remains contro-
versial. However, used in the dosage range and duration quoted, it is a relatively innocuous
agent. No monitoring is indicated.
Magnesium Sulfate
This agent was introduced by Acland10 in 1972 for its ability to prevent platelet clots. A
constant drip on the surface of the vascular anastomosis was recommended. Reports of its
effectiveness have been both pro and con, but as technical expertise has improved its need
has decreased and it has received very little attention lately.
Vasoactive Drugs
Vasoactive drugs have some potential to decrease the likelihood of intravascular clot
formation by increasing flow.13 Traditionally, it has been understood that vascular stasis
predisposes the release of thromboplastin and stimulates subsequent clotting. The prevention
of vasoconstriction and, thus, the maintenance of higher flow rates would tend to counteract
the likelihood of intravascular clot formation. Local anesthetic agents such as Xylocaine®
or the other longer-acting agents are widely used to relieve vasospasm. There have also been
some indications that these agents prevent platelet aggregation.4 Their real effectiveness in
either prevention of vasoconstriction or of clot formation is uncertain and often not pre-
dictable. The use of warmth (the avoidance of cold irrigating solutions, etc.), may also
increase vascular flow and decrease the probability of clot formation. Other vasodilating
agents working either directly or indirectly may have some effectiveness.
ADDITIONAL DRUG CONSIDERATIONS
Streptokinase
The normal clot lysis process (fibrinolysis) is probably as important in the maintenance
of vascular patency as is the prevention of clotting (Figure 2). It was earlier stated that the
authors have demonstrated an intact fibrinolytic system in the microcirculation analogous
Volume I 69
FIGURE 3. Graphs comparing the effect of ischemia on fibrinolytic activity and anastomotic
patency. The incidence of patent anastomoses in rat femoral arteries decreased in direct
relationship to the duration of ischemia. A similar curve is noted for the fibrinolytic activity
of the intima of these femoral artery segments. By 9 to 12 hr of ischemia, a zero incidence
of patency and no detectable fibrinolytic activity was present.
to that apparent in the macrocirculation.1 This fibrinolytic activity is adversely affected by

ischemia, particularly when prolonged — a situation frequently encountered in microvascular
surgery.214 With prolonged periods of ischemia this system may be rendered incompetent
and incapable of dealing effectively with any intravascular clot formation. Streptokinase has
been shown to be an effective agent catalyzing the conversion of plasminogen to plasmin,
which stimulates active fibrinolysis.1516 Studies in our laboratory have demonstrated im-
proved anastomotic patency rates, and improved tissue survival, when streptokinase was
used to augment the fibrinolytic activity in situations of prolonged ischemia (Figure 3).
Streptokinase can be given by direct intra-arterial infusion, peripheral systemic administra-
tion, and irrigation of vessels during anastomosis. It appears to be most effective by direct
intra-arterial infusion. The use of an indwelling catheter for infusion over a several-day
period has received some clinical use. 17J8 Our clinical trials of streptokinase in microvascular
surgery have been, as yet, too few to indicate effectiveness. However, our laboratory studies
in rats have shown a moderate potential for tissue salvage when faced with prolonged
ischemia.14
Pentoxifylline
Pentoxifylline is an interesting drug which has several potentially attractive actions. It
may cause some degree of vasodilation and may inhibit platelet aggregation. It appears to
definitely decrease blood viscosity and to improve the desirable rhéologie characteristics of
whole blood (increasing red cell deformability).19 These effects would seem to compliment
our need to prevent thrombosis in microvascular surgery. We have designed studies looking
at the potential of pentoxifylline to salvage tissue survival in microvascular surgery and have
also compared it to streptokinase under the circumstances of prolonged ischemia. Some
studies utilizing the drug alone have appeared promising. However, there has been no strong
statistical confirmation of its effectiveness and, indeed, its combination with streptokinase
has resulted in a lesser effectiveness than when either drug was used alone.20
Prostaglandins
Several of the prostaglandins have significant effects upon coagulation. Prostacyclin is
currently being evaluated and some synthesized analogues are being developed. Prostacyclin
interferes with platelet adherence to the vessel wall and is a potent inhibitor of the aggregation
process.4-9 PGEj and PGE2 have shown some potential in clinical trials and may improve
platelet survival as well as inhibiting aggregation.
PROTOCOL FOR OUR USUAL THERAPEUTIC APPROACH

Currently, our regimen for anticoagulant therapy in microvascular surgery has followed
a rather nihilistic approach. All patients are treated with prophylactic rectal aspirin which
is initiated preoperatively (or intraoperatively in the case of emergency replantations, etc.).
Generally, low molecular-weight dextran has also been used at a dosage of 500 cm3 of a
10% solution. This is given over a 12-hr infusion, once each 24 hr for 3 days. We have
used Persantine® only in those patients who could not take aspirin.
This constitutes the extent of our routine use of medications. Only if difficulties are
encountered are other drugs utilized. Our approach to vasospasm has generally been to utilize
warm 2% Xylocaine® topically applied. We also warm the area to prevent vasoconstriction.
If we are faced with an anastomotic thrombosis, an excessively low-flow situation, or other
hypercoagulable circumstances, we have initiated heparin therapy at this point: 5000 units
is given i.v. and an i.v. infusion is initiated at 1000 units/hr. If this regimen is adopted it
is continued for 8 to 10 days with a gradual tapering over 2 to 3 days. No subsequent
anticoagulant therapy is used other than aspirin. In the case of the extremely delayed re-
plantation effort (with an excessive warm ischemia time) we would further recommend the
consideration of an intra-arterial administration of 50,000 units of streptokinase under direct
vision. This could be repeated postoperatively at several-hour intervals by proximal arterial
injection with a tiny needle and direct infusion. The possible bleeding complications of
either heparin or fibrinolytic therapy must be weighed against the potential immediate mi-
crovascular benefit.
SUMMARY
This chapter has attempted to offer a summary of the normal physiology in the formation
of clot and its lysis. This is followed by a summary of the pharmacologic manipulations
available to the microvascular surgeon which may influence clot formation and fibrinolysis
to his advantage. It seems probable that focus for the future will include a better understanding
of prostaglandins, their role, and their manipulation in the control of undesirable clot for
the microsurgeon.
Volume I 71
REFERENCES
1. Jacobs, G. R., Reinisch, J. F., and Puckett, C. L., Quantitative analysis of small artery plasminogen
activator by modified fibrin plates, J. Microsurg., 3, 147-150, 1982.
2. Jacobs, G. R., Reinisch, J. F., Puckett, C. L., Microvascular fibrinolysis after ischemia: its relation to
vascular patency and tissue survival, Plast. Reconstr. Surg., 68, 737-741, 1981.
3. Spaet, T. H., The platelet in hemostasis, Ann. N.Y. Acad. Sci., 115, 31-42, 1964.
4. Mustard, J. F. and Packham, M. A., Factors influencing platelet function: adhesion, release, and ag-
gregation, Pharmacol. Rev., 22, 97-187, 1970.
5. Silver, D. and McGregor, F. H., Nonmechanical causes of surgical bleeding, in Current Problems in
Surgery, Ravitch, M. M., Ed., Year Book Medical Publishers, Chicago, 1980, 1-51.
6. Markwardt, F., and Kloecking, H. P., Heparin induced release of plasminogen activator, Hemostasis,
6, 370-374, 1977.
7. Kolar, L. , Wieberdink, J., and Reneman, R. S., Anticoagulation in microvascular surgery, Eur. Surg.
Res., 5, 52-57, 1973.
8. Zucker, M. B. and Peterson, J., Inhibition of ADP-induced secondary aggregation and other platelet
functions by acetylsalicylic acid, Proc. Soc. Exp. Biol. Med., 127, 547, 1967.
9. Chang, W. H. J. and Perry, J. J., Platelets, prostaglandins and patency in microvascular surgery, J.
Microsurg., 2, 27-35, 1980.
10. Acland, R., Prevention of thrombosis in microvascular surgery by the use of magnesium sulphate, Br. J.
Plast. Surg., 25, 292-299, 1972.
11. Nomoto, H., Buncke, H. J., and Chater, N. L., Improved patency rates in microvascular surgery when
using magnesium sulfate and a silicone rubber vascular cuff, Plast. Reconstr. Surg., 54, 157, 1974.
12. Engrav, L. H., Benjamin, C. I., Crandall, H., and Perry, J. F., Experimental effects of heparin or
magnesium sulfate on the patency of microvascular anastomosis, Plast. Reconstr. Surg., 55, 618-619, 1975.
13. Swartz, W. M., Brink, R. R., and Buncke, H. J., Prevention of thrombosis in arterial and venous
microanastomoses by using topical agents, Plast. Reconstr. Surg., 58, 478-481, 1976.
14. Puckett, C. L., Misholy, H., and Reinisch, J. F., The effects of streptokinase on ischemic flaps, J. Hand
Surg., 8, 101-104, 1983.
15. Alkjaersig, N., Fletcher, A. P.; and Sherry, S., The activation of human plasminogen. II. A kinetic
study of activation with trypsin urokinase and streptokinase, J. Biol. Chem., 233, 86, 1958.
16. Wohl, R. C , Summaria, L., Aryadon, L., and Robbins, K. C , Steady state kinetics of activation of
human and bovine plasminogens by streptokinase and its equimolar complexes with various activated forms
of human plasminogen, J. Biol. Chem., 253 (5) 1402-1407, 1978.
17. Wilcox, W. C. and Jarkowski, T. L., Thrombolysin therapy in acute main pulmonary thromboemboli,
Thromb. Diath. Haemorrh. Suppl., 47, 283-299, 1971.
18. Serafín, D., Puckett, C. L., and McCarty, G., Successful treatment of acute vascular insufficiency in
a hand by intra-arterial fibrinolysin, heparin and reserpine, Plast. Reconstr. Surg., 58, 506-509, 1976.
19. Takayanagi, S. and Ogawa, Y., Effects of pentoxifylline on flap survival, Plast. Reconstr. Surg., 65,
763-767, 1980.
20. Misholy, H., Reinisch, J. F., and Puckett, C. L., unpublished data.
Volume I 73
PROBLEMS IN INTRAVASCULAR COAGULATION IN MICROSURGERY
Judith J. Petry and Wallace H. J. Chang
INTRODUCTION
The initiating event in the failure of a vascular anastomosis at the microscopic level is
not the intrinsic or extrinsic clotting cascade but instead the production of a platelet plug.
This is initiated by platelet adherence to the damaged endothelium, resulting in the platelet
release reaction and the aggregation of more platelets to ultimately occlude the tiny lumen.
In order to prevent early failures in microvascular surgery, we need to modify this platelet-
vessel wall interaction to prevent the initiation of formation of the platelet plug. To accom-
plish this it is essential to understand the vessel wall-platelet interactions. This involves an
understanding of the biochemical pathways of arachidonic acid metabolism in the platelet
and the endothelial cell (Figure 1). Although the pathways are similar, the end products at
these two sites are compounds with opposing actions on platelet aggregation. The integrity
of the vessel wall depends on a balance between the proaggregatory and antiaggregatory
effects of the biochemical products of arachidonic acid metabolism. In both the platelet and
endothelial cell, arachidonic acid is first converted to the cyclic endoperoxides — PGG2 and
PGH2 — in the presence of cyclooxygenase. From these precursors the pathways differ
drastically. In the platelet the enzyme thromboxane synthetase converts PGG2 and PGH2 to
thromboxane A2 (TxA2), a vascoconstrictor and potent stimulus to platelet aggregation, and
to thromboxane B2 which is a less potent stimulus to aggregation but is chemically more
stable than thromboxane A2. In the endothelial cell a different enzyme, prostacyclin syn-
thetase, converts the same precursors (PGG2 and PGH2) to prostacyclin (PGI2), which is a
vasodilator and powerful inhibitor of platelet aggregation. When a circulating platelet en-
counters a surface of exposed collagen or subendothelial structure, platelet-collagen adhesion
occurs, the arachidonic acid metabolic pathway is initiated, and platelet aggregation occurs
as a result of the production of thromboxane A2. Aggregation of platelets is, on the other
hand, inhibited by the production of prostacyclin by the endothelial cells. The appropriate
balance results in repair of the site of damage to the endothelial cell layer without production
of a platelet plug.
Our use of anticoagulant agents which have been reliable in macrovascular surgery are
no longer appropriate in the microvascular situation. The agents used, for instance heparin,
Coumadin®, aspirin, and associated compounds are used for their effect on the intrinsic
clotting pathway to prevent thrombosis in large vessels. Since we know that the platelet
plug is the problem in microvascular surgical repairs we are more interested in preventing
platelet aggregation than in preventing the intrinsic clotting cascade. Some of the agents
used in macrovascular surgery have been shown to have a deleterious effect on the platelet-
endothelial cell interaction. For instance, heparin and dextran have been shown to allow
platelet aggregation by arachidonic acid, ADP, and epinephrine at subthreshold levels of
these agents. ' The effect is caused by the inhibition of adenyl cyclase by heparin and dextran.
The antiaggregatory effect of prostacyclin results from an increase in intracellular cyclic
AMP caused by stimulation of platelet adenyl cyclase. It has been shown by investigators
that heparin neutralizes the antiaggregatory effect of prostacyclin by inhibiting prostacyclin-
induced enhancement of platelet cyclic AMP. We no longer use heparin in microvascular
surgery because of this inhibitory effect on prostacyclin.
Aspirin has, likewise, been used in macro- and microvascular surgery. It has been shown
to interfere with cyclooxygenase which converts arachidonic acid to endoperoxides, the
precursors of both prostacyclin and thromboxane.2 The effect of aspirin is dose-related and
FIGURE 1. Pathways of arachidonic acid metabolism in the platelet and endothelial cell.
it acts differently on platelets than it does on the vessel wall. Aspirin inhibits cyclooxygenase
in the platelet at a much lower dose than the dose required to inhibit cyclooxygenase in the
vessel wall. A very low dose of aspirin is sufficient to block thromboxane synthesis and for
this reason we have begun using doses of a single aspirin per day for microvascular surgery.
We are currently measuring the effect of aspirin on prostacyclin production at varying levels
in the rat experimental model.
It would seem that treatment of the microvascular surgical patient with prostacyclin would
be the answer to our problems of platelet plug occlusion of small vessels, however, pros-
tacyclin is an extremely unstable compound. At pH 7.48 and 25°C its half-life is 3 1/2 to
10 min, at pH 9.37 and at 0°C its half-life increases to 48 hr. Its effect is very transient
because of this short half-life and it would be very difficult to give clinically. There are a
number of analogues of prostacyclin which are more stable that are currently being evaluated
for clinical use. It may be an important benefit in microvascular surgery if a prostacyclin
analogue which is clinically usable can be developed. Another choice may be to block the
production of thromboxane A2 by the platelets to avoid platelet plug formation (see Figure
1). This may be accomplished by low doses of aspirin or by the use of other thromboxane
inhibitors. Sulfinpyrazone strongly inhibits the production of platelet precursors of throm-
boxane A2 accounting for its ability to decrease the incidence of recurrent coronary throm-
bosis.3 Imidazole has also been demonstrated to act as an inhibitor of thromboxane synthetase.4
It is evident from studies with aspirin and other agents that we must not only look at the
biochemical effect of the particular agent but on the dose curve of the agent. A small dose
may result in an increase in antiaggregatory compounds whereas a larger dose may reverse
this effect. Since it is impossible to perform microvascular repairs or vein grafting without
injuring endothelial cells and exposing collagen, our research efforts must be directed toward
determining the effect of our pharmacologic agents on the local production of prostacyclin
by vessel wall in order to allow appropriate pharmacologic intervention to prevent platelet
aggregation.
EXPERIMENTAL WORK
The culprit in failures in technically correct microvascular surgery is the platelet plug.
How to prevent the platelet plug from sticking to the anastomotic site or the traumatized
vessel or vein graft in the microvascular reconstruction and then to attract its fellows into
a platelet plug that mechanically occludes the tiny lumen is an unsolved problem. Now that
we are technically able to replant fingers successfully, how do wc prevent the patient's own
Volume I 75
homeostatic hemostatic mechanism from plugging our reconstructive conduits? Research

aimed at answering this question has been directed chiefly at controlling the platelet either
by heparin, aspirin, dextran, or more recently by thromboxane inhibitors. We have been
interested in the vessel wall contribution, via prostacyclin, to the inhibition of platelet
adherence to itself. Levels of prostacyclin production by arteries have been shown to be
consistently different from those produced by veins. Some authors have reported higher
levels in arteries, and others have reported higher levels in veins, depending on species and
assay techniques. Our current research endeavors are directed at answering the following
questions:
1. Do arteries in the experimental rat produce more or less prostacyclin than veins?
2. Do vein grafts in the arterial circulation produce prostacyclin at venous levels, arterial
levels, or other levels?
3. Is there a recovery time after vein grafting when prostacyclin production is low? If
there is a recovery time after vein grafting before this segment of vessel can begin
producing locally effective levels of prostacyclin there may be a similar critical time
when pharmacologic intervention may be of benefit to prevent platelet adherence to
the vein graft segment.
EXPERIMENTAL MODEL
Wistar male albino rats, weighing 250 to 350 g, were anesthesized with ether induction
followed by intraperitoneal Nembutal®. Through a groin incision a segment of epigastric
vein approximately 1 cm in length was removed, reversed, irrigated with heparinized lactated
Ringer's solution, and interposed in a gap in the ipsilateral femoral artery. After varying
intervals of 24 hr, and 1, 2, 3, and 6 weeks the vein graft was harvested, irrigated with
lactated Ringer's solution, and the prostacyclin production determined. The vessels were
cut into 1-mm rings, then incubated in 0.5 m€ of 0.05 M potassium phosphate buffer (pH
8.0) contained in 5-m€ glass vials. Incubations were carried out at 37° in an atmosphere of
95% 0 2 /5% C0 2 with gentle shaking for 1 hr. The tissues and media were then separated
and the latter stored in polypropylene tubes at — 15° until assayed. The assay was a standard
radioimmunoassay for 6-keto-PGFla, a stable breakdown product of prostacyclin. A 1-cm
segment of contralateral femoral artery, femoral vein, and epigastric vein was harvested for
similar assay. Control assays were performed on sham dissected rat femoral artery, femoral
vein, and epigastric vein, harvested 1 day and 2 weeks postop and on epigastric vein grafts
placed in the femoral vein and harvested at 2 weeks postop. Of the 43 rats grafted there
was one failure, for a patency rate of 97.7%. There were 17 rats used in the present study.
RESULTS
The femoral artery produced significantly higher levels (p<0.0005) of prostacyclin than
did the femoral vein or epigastric vein, a finding consistent with that of other investigators
(Table 1). Sham dissected vessels showed no significant difference (p<0.05) from normal
values at day 1 and 2 weeks postgraft. Vein segments grafted into the venous circulation
produced low levels of prostacyclin at 2 weeks postgrafting (Table 2).
Vein grafts in the arterial circulation produced prostacyclin in increasing levels measurable
throughout the length of the experiment. At 3 weeks the levels were 73.2% of arterial levels
and by 6 weeks the levels were higher than arterial levels (Figure 2).
Table 1
PROSTACYCLIN PRODUCTION —
RAT VESSELS
[CONTROL VALUES (MEANS)]
Femoral artery 6.41 ng/m€ SD ± 1.70

(n=17)
Femoral vein 0.41 ng/m€ SD ± 0.25
(n = 7)
Epigastric vein 0.41 ng/m€ SD ± 0.20
(n=17)
Table 2
PROSTACYCLIN PRODUCTION —
RAT VESSELS
[VEIN-VEIN GRAFT (MEANS)]
Vein-vein graft 1.51 ng/m€ SD ± 0.76

(n = 3)
Femoral vein 0.63 ng/m€ SD ± 0.12
Epigastric vein 0.70 ng/m€ SD ± 0.23
DISCUSSION
Our experiment confirms the results of others that in the rat, arteries produce significantly
higher levels of prostacyclin than femoral veins. 58 We have also shown that vein grafts in
the arterial circulation produce increasing levels of prostacyclin with time in their new
location, surpassing venous levels early and surpassing arterial levels at 6 weeks postgrafting.
There is a delay period of sorts before the vein grafts produce arterial levels of prostacyclin.
This may be related to recovery of endothelial cells and/or reendothelialization of the vein
grafts. It has been shown in other species that harvesting a vein for grafting results in loss
of all or most of the endothelial cell lining.9 At 1 week postgrafting our vein grafts had
widely varying levels of prostacyclin. This may be related to varying degrees of endothelial
cell loss along with varying degrees of reendothelialization. By 2 weeks postgrafting the
differences had resolved.
Although our patency rate was 97.7% this is not the case in clinical cases where early
failure rates may be quite high (10 to 15% in CABGs). If the human vein graft behaves in
a fashion similar to the rat, that is, there is a recovery period before effective levels of
prostacyclin are produced, it may be possible to prevent some early failures by treating the
patient with an appropriate agent during this interval. Prostacyclin or an analogue, or throm-
boxane inhibitors may be effective choices.
Much work needs to be done before we can extrapolate our animal data to the human,
but it is certainly intriguing that a vein placed in the arterial circulation can behave bio-
chemically like an artery with respect to prostacyclin production.
SUMMARY
A summary of the actions of prostacyclin and thromboxane is related to the problems of

formation of platelet plug and microsurgical vascular anastomosis. The use of various agents
in modifying the effects of thromboxane and prostacyclin are reviewed. This is followed by
a report of experimental work on rats, measuring the production of prostacyclin by vein
grafts in the arterial circulation at varying intervals after grafting.
Volume I 77
FIGURE 2. Prostacyclin production by rat femoral artery, epigastric vein, and vein graft.
ACKNOWLEDGMENTS
Biochemical support provided by Sumner Burstein, Ph.D. and Sheila Hunter, M.S.,
Department of Biochemistry, University of Massachusetts Medical Center, Worcester. Tech-
nical support provided by Kathleen A. Wortham, B. A., Director, Plastic Surgery Micro-
surgery Research Laboratory, University of Massachusetts Medical Center, Worcester.
REFERENCES
1. Eldor, A. and Weksler, B., Heparin and dextran sulfate antagonize PGI2 inhibition of platelet aggregation,
Thromb.Res., 16, 617, 1979.
2. Masotti, G., Galanti, G., Poggesi, L., Abbate, R., and Neri Serineri, G. G., Differential inhibition of
prostacyclin production and platelet aggregation by aspirin, Lancet, 2, 1213, 1979.
3. Anturane Reinfarction Trial Research Group, Sulfinpyrazone in the prevention of cardiac death after
myocardial infarction, N. Engl. J. Med., 298, 289, 1978.
4. Needleman, P., Raz, A., Ferrendelli, J. A. and Minkes, M., Application of Imidazole as a selective
inhibitor of thromboxane synthetase in human platelets, Proc. Natl. Acad. Sci. U.S.A., 74, 1716, 1977.
5. Villa, S. and de Gaetano, G., Prostacyclin-like activity in rat vascular tissues. Fast, long-lasting inhibition
by treatment with lysine acetylsalicylate, Prostaglandins, 14, 1117, 1977.
6. Villa, S., Mysliwiec, M., and de Gaetano, G., Prostacyclin and atherosclerosis in rats, Lancet, 1, 1216,
1977.
7. Skidgel, R. and Printz, M., PGI2 production by rat blood vessels: diminished prostacyclin formation in
veins compared to arteries, Prostaglandins, 16, 1, 1978.
8. Wyatt, A. and Taylor, G.,Vein grafts: changes in the endothelium of autogenous free vein grafts used as
arterial replacements, Br. J. Surg., 53, 943, 1966.
9. Ramos, J. R., Borger, K., Mansfield, P. B., and Savage, L. R., Histologic fate and endothelial changes
of distended and nondistended vein grafts, Ann. Surg., 183, 205, 1976.
Volume I 79
QUANTITATIVE ANALYSIS OF THE MICROCIRCULATION IN THE

AWAKE ANIMAL*
Bernhard Endrich and Konrad Messmer
INTRODUCTION
Current microsurgical and optical techniques permit the transposition of entire tissue units
whose vascular supply is derived from very minute vessels. The anastomosis of vessels
smaller than 1 mm in diameter can be performed successfully with very predictable reliability.
Replantation of digits and extremities are, nowadays, reported with increasing frequency.
Any microsurgical procedure, however, even in a bloodless field, will affect the delicate
adjustment of flow within the microvascular network, hence, disturbing the equilibrium
between oxygen and nutritional supply and the drainage of waste products, respectively. In
all tissues, postcapillaries and collecting venules represent "weak" segments at which any
injury reaction is most prominent (for review see References 52, 93, and 117). Localized
prestasis and stasis in these segments will result in blockage of outflow and, hence, in
inhomogeneous capillary perfusion. Increased shunt flow will possibly cause and aggravate
localized tissue hypoxia. Due to a temporarily enhanced venular resistance, the balance of
osmotic gradients and transcapillary fluid exchange is disturbed, favoring and enforcing
tissue edema. The tissue edema per se will compromise already existing low flow conditions
in the microcirculation and increase the vascular resistance, thus even further deteriorating
the flow conditions of the blood, particularly within the network of nutritional capillaries.78
Any attempt to explain and evaluate this pathological disorder of the microcirculation in
greater detail will inevitably require the accurate analysis of vascular dimension and func-
tional geometry of the terminal vascular network. With regard to microsurgery and the very
often significant postoperative tissue swelling and edema, it needs to be emphasized that
volumetric exchange flow rates through single capillaries are of the magnitude of picoliters
per second, and, consequently are below the range of volume determinations based upon
collection of fluid samples.57
The fluid transudation across the wall of a single or several capillaries can, however, be
quantitatively analyzed at the level of the light microscope through changes that occur in
the intracapillary lumen. Consequently, the direct microscopic quantitative determination of
the exchange of fluid between blood and tissue has been almost exclusively evaluated in
terms of intracapillary effects associated with motion of organic elements occurring in vivo,
such as red blood cells or particles, and through changes in concentration of dyes that can
be injected and observed in the microcirculation.57 Experimental models allowing such
quantitative studies of the microvascular network have been reviewed by Greenblatt et al.43
and more recently by Wiedeman.109 The validity of data utilizing these models, however,
is directly related to the skill of the person conducting the experiment and, hence, to the
given experimental conditions which are assumed to be representative of those really existing
in vivo and in situ.
Effects of exposure, surgical microtrauma, and the composition of the fluids in micro-
surgical preparations, even under so-called optimal conditions, very likely cause a varying
degree of inflammatory reaction and vasodilation. These artifacts produce higher permea-
bilities and augment the rates of fluid exchange through a concomitant increase in perme-
ability and local precapillary and capillary pressures. Therefore, values on exchange rates
deduced from microvascular data have probably overestimated those values which really do
exist.57
* Supported by a grant from the Abbott Foundation, Chicago, 111.

Moreover, intravital microvascular research ultimately depends on "observability" of

vessels.91 This is not only crucial in the study of a single capillary but should be extended
to the whole network under observation so that vessels can be analyzed in terms of their
hierarchical order within the microvascular bed. 56116118
Vessels 25 to 40 |xm below the surface of the given tissue or organ, however, will be
obscured by their surroundings to the extent that they are almost invisible when observed
by epi- or transillumination. Furthermore, techniques of intravital microscopy are limited
by the amount of light the tissue tolerates. It should further be noted that most cells possess
some level of photosensitivity, which might significantly be increased by the fact that these
cells are normally in a "dark" environment; they become exposed to light only during the
experimental procedure.56 Up to the present, these effects have been considered to be
negligible when compared to the effects of microsurgical trauma and exposure; however,
as the "physiological" state of microcirculatory preparations continues to improve, it also
becomes increasingly desirable to maintain light and temperature at a physiological level.56
In view of the fact that microcirculatory disturbances should preferably be prevented in
microsurgery, experimental studies on microsurgical trauma should be focused on improving
the flow properties and tissue perfusion at the level of single capillaries. This is of importance
because the term capillary perfusion is a resultant of capillary diameter, capillary blood cell
velocity, and capillary length and density. They can be simultaneously assessed only by
direct intravital microscopy and quantitative analysis of TV images.
Furthermore, it seems inevitable to study tissue trauma, microvascular damage, and vas-
cular repair in a "chronic" microcirculatory model, i.e., observing the terminal vascular
bed over a period of several weeks. Such chronic models are summarized in Table 1, each
model bearing its advantages and disadvantages. Microcirculatory observation and meas-
urements in the human forearm as well as in rabbit ear and mouse and rat skin can be carried
out without anesthesia, but the chambers contain subcutaneous tissue only. To obtain clear
visibility and excellent contrast, the preparations of the human forearm (besides the ethical
considerations necessary) as well as of the rat skin fold require great microsurgical skill.
As a result the preparation of the rat skin flap is frequently not suitable for a quantitative
microvascular analysis due to tissue edema which will obscure the microvascular bed.
On the other hand, the study of the microcirculation in the hamster cheek pouch chamber
requires anesthesia. Moreover, this preparation does not contain muscle fibers. Therefore,
one would conclude that studying muscle tissue with intact vascular system in the awake
animal is closer to the "physiological state" of a microcirculatory network. It should,
therefore, be more useful than a chamber containing s.c. tissue exclusively. The skin fold
chamber (double frame) is very easy to implant in the hamster; the microcirculation can be
observed for 4 weeks. In our opinion, for a microcirculatory model suitable for the study
of tissue trauma, we would require:
1. The presence of a normal microcirculation characterized by the absence of wall-

adherent leukocytes, petechial bleeding, and vascular stasis, but with arteriolar va-
somotion (i.e., spontaneous rhythmic changes in diameter to regulate blood flow)
present.
2. Possibility of sequential observation of the normal microcirculation in the same animal
for several days.
3. The possibility of conducting measurements of macrohemodynamic and microcircu-
latory parameters in the conscious animal during the period of observation. This
preparation maintains the anatomically given tissue type (i.e., skeletal muscle) in which
microcirculatory blood vessels are embedded. They are not affected by the development
of scar or granulation tissue, which in turn will also affect growth and reactivity of
vessels (for a review see Reference 31) (Figure 1).
Table 1
TRANSPARENT CHAMBER MODELS FOR MICROCIRCULATORY STUDIES
Estimated size of
feeding vessels Tissue thickness Period of
Species Chamber position Tissue (fun) (jxm) observation First author/year Ref.
Human Forearm s.c. 5 0 — 100 50 — 70 At least 8 months Asano (1972) 8

Rabbit Ear s.c. scar 30 — 80 30 — 50 Up to 6 months Arfors (1970) 6
Brânemark (1963) 17
Clark (1939, 1954) 20,21
Eriksson (1977) 31
Leaf(1970) 68
Rand (1970) 86
Williams (1967) 110
Woods (1966) 111
Mouse Skin flap s.c. -100 Not defined At least 4 weeks Algire (1943, 1955) 1, 2
Rat Skin flap s.c. scar 100 — 250 100— 150 At least 4 weeks Papenfuss (1979) 83
Yamaura (1974) 112
Hamster Cheek pouch Mucoareolar 80 — 120 <50 Approx. 3 — 6 Goodall (1965) 39
membrane weeks Greenblatt (1969) 43
Sanders (1964) 90
Sewell (1966) 94
Warren (1970) 105
Hamster Skin fold s.c. muscle 50 — 150 400 — 450 4 weeks Asaishi (1981) 7
Endrich (1980, 1981) 28,29
Volume I
81
FIGURE 1. Slightly oblique section of a true capillary running between the cross-striated fibers of the cutaneous
muscle layer from a Syrian golden hamster (from a 7-day-old preparation). The capillary wall consists of a continuous
endothelium whose individual cells meet at two junctions (—>). The capillary basal lamina (^) is barely visible,
but delicate collagen fibrils (*) are found, directly adjacent to the abluminal endothelial cell membrane. The
cytoplasm displays only a few of its organelles (mitochondria, cisternae of the rough endoplasmic reticulum)
together with a moderate number of micropinocytic vesicles. (Magnification x 8,550.) (This electronmicrography
is a result of our microcirculatory studies in collaboration with Professor F. Hammersen, Department of Anatomy,
Technical University of Munich, FRG.)
In the following section we will discuss a chronic microcirculatory model where tissue
trauma inflicted by microsurgery has been reduced to the extent that all criteria previously
defined for a normal microcirculation118 are met; furthermore, conventional microcirculatory
models are reviewed.
CHRONIC MICROCIRCULATORY MODEL IN THE HAMSTER
The microcirculatory model as established in the hamster skin fold has been described in
detail previously.28 Syrian gold hamsters (Cricetus auratus) weighing between 85 and 110
g are anesthetized by an i.p. injection of pentobarbital (60 to 70 mg/kg body weight).
Animals of up to 90 g are preferred because of less adipose tissue in the subcutis. Upon
surgical anesthesia, the entire back of the hamster is shaven and a depilatory subsequently
used to remove any hair remaining. Two catheters are passed s.c. along the back of the
animal almost to the base of the skull, then pushed through the tissue along the midclavicular
line and brought exterior at the anterior neck near the right jugular vein.
The technique of implanting an aluminum access chamber83 was modified and adapted
to meet carefully established criteria for stability of the thin, translucent skin in hamsters.
Therefore, spacers made of stainless steel are used, yielding a frame-to-frame distance of
Volume I 83
FIGURE 2. Frame of the transparent aluminum cham-

ber used for microcirculatory studies in the hamster.
400 to 450 fxm while the chamber is fixed on the animal's back. The thickness of the
preparation, and thus the distance between both frames, is chosen on the basis of the optical
translucency needed for proper visualization of microscopic blood channels without com-
pressing larger feeding and draining blood vessels. To smooth the edges and the coarse
surface of the aluminum, the frames are covered with a thin layer (20 to 30 (xm) of Teflon®
S at a temperature of 400°C. This measure also serves to reduce thermal conductivity and
to ensure biological inertness. This chamber is very well tolerated by the animals.7,28
The surgical procedure is done by placing the animal on a specially designed surgical
stage. A midpoint is drawn along the back and a dorsal skin fold is affixed to the surgical
stage by means of silk sutures (5/0) to stabilize the preparation. One part of the chamber
frame (Figure 2) consisting of the frame, two lower bolts, and spacers is pushed slightly
under the skin fold. Two small holes are carefully cut through the skin; this part of the
chamber is introduced through the holes and temporarily fixed using two baby mosquito
hemostats.
A template, equivalent to the outer diameter of the chamber collar, serves to mark a circle
outlining the subsequent incision. A crisscross cut is made, resulting in four small skin flaps.
Each flap is removed with a fine, curved scissor, precisely tracing the perimeter of the
outline with an effort to follow the hypodermis. The overlaying fascia is reimvxi carefully;
this procedure is facilitated by using an operating microscope and leaving one layer of s.c.
tissue at the opposite side of the epidermis intact. During the entire microsurgical procedure
the exposed area is always kept moist by allowing drops of warmed normal saline to irrigate
the preparation that is limited to one side of the skin fold only. After trimming the area
under observation, the matching side of the chamber is inserted. Mechanical connection of
the two chamber frames is finally accomplished by using metal nuts for the upper and lower
bolts and 5/0 sutures are fixed at several points around the chamber to support the position
of the skin flap.
After completing the implantation of the chamber, the animal is placed in a supine position
and the right carotid artery and right jugular vein are surgically isolated. A fine catheter
(PE 10) filled with heparinized saline solution (50 USP in 1 mi) is introduced into each
vessel and advanced toward the left or right ventricle, respectively. The correct position of
the catheter is evaluated from pressure recordings and pulsatile movements of the catheter.
The positions of both catheters are later checked during autopsy. Both catheters are affixed
to the entry points of the vessel cannulated (with silk suture 5/0), to the tissue hole proximally
and distally, as well as to adjacent muscle and s.c. tissue. The anterior incision is then
closed with a 5/0 suture and both catheters are positioned between the frames of the chamber
(Figure 3).
FIGURE 3. One typical animal after implantation of the chamber and indwelling
catheters.
FIGURE 4. Simplified schematic drawing of the animal stage for microvascular measurements. T = trans-
parent plastic tube in which the conscious animal is immobilized, with the skin fold chamber (Ch) protruding
through a small slit within the tube. The tube guarantees rigid support for fixing the chamber frame on the
microscope stage. O = area of observation (approximately 0.78 cm2) and M = microscope.
For the purpose of direct observation, as well as video and photographic recordings, the
hamster is later taught to crawl into a transparent plastic tube of approximately the same
diameter as the animal in its crouched position. The tube has a narrow slot running lengthwise
which allows the skin fold to be outside the tube, while providing rigid support sufficient
for placement of the microscope stage (Figure 4). Special care is taken to avoid any artificial
constraint on the preparation.28 With some experience this preparation can be performed
successfully in approximately 90% of the animals.
Volume I 85
After 24 to 48 hr are allowed for recovery, measurements of systemic arterial and venous
pressure are taken with the animal unanesthetized. The catheters are subsequently flushed
with diluted heparin and closed by a knot through the catheter. These catheters can be kept
open for about 14 to 18 days. It should further be noted that the cover glass of the chamber
can be removed allowing access to the tissue for implantation of cells,29 microvascular
pressure measurements, and measurements of local P0 2 (platinum multiwire electrode).6374
ANALYSIS OF THE MICROCIRCULATION IN THE HAMSTER SKIN FOLD
Description of the Microvascular Bed

The entire region of observation consists of preformed vessels from which, on occasion,
new minute vessels proceed into the center of the preparation. The exposed area is usually
supplied by two small arteries (50 to 150 |mm) and drained by two or three small veins (80
to 280 fxm). Arterioles and venules are the most prominent structures when transillumination
is used, with venules outnumbering arterioles by a factor of three.
Arterioles (20 to 40 |xm) show spontaneous changes of diameter and flow in quasiperiodic
intervals (vasomotion) (Figures 5a, b, and c). Using FITC-dextran (molecular weight 150,000
daltons), fluorescent microscopy, and an appropriate magnification, capillary structures can
be seen. Depending on the depth of focus, two characteristic patterns of vessel alignment
can be distinguished. Superficial layers reveal long, parallel-coursing capillaries resembling
the capillary anatomy of the skeletal muscle (Figure 6). Electron microscopy confirmed this
notion (Figure 1). Continuous-type capillaries are embedded in skeletal muscle fibers. At a
depth of 30 to 40 \xm, the typical pattern of s.c. vessels, short capillary loops, and anas-
tomoses is seen gradually extending from the periphery toward the center of the preparation.
Sometimes new vessels are evident at the periphery.
Technique of Microscopy and Quantitative Hemodynamic Analysis

The basic technique of intravital microscopy and hemodynamic analysis used within the
microcirculation are essentially those originally described by Zweifach114>U6>U* and Intaglietta
and co-workers54,55 (for a graphical illustration see Figure 7). In general, these techniques
are followed up with minor modifications of the optical and audiovisual system. Great care,
however, should be taken to minimize bias of microcirculatory observation and measurement.
Any selection of microvascular modules is performed in our laboratory 48 hr after implan-
tation of the aluminum chamber and is based on tissue transparency and the visibility of
arterioles and collecting, nonmuscular venules (20 to 40 |xm). When transillumination is
used, capillaries are barely visible in this chamber model, and consequently, any measure-
ment at the capillary level actually refers to a blind selection of this type of micro vessel.
Thereafter, microvascular networks are better visualized utilizing fluorescent microscopy
and a SIT low-light-level videocamera after i.v. injection of 0.2 m€ of 5% fluorescein
isothiocyanate (FITC)-Dextran 150 (Pharmacia AB, Uppsala, Sweden). These measures
improve the poor contrast between the wall of large vessels and capillaries, the surrounding
tissue, and the blood cells in vivo. Blood cells are delineated as dark structures vs. the
bright background of fluorescent plasma within the capillaries (Figures 5 and 8).
Videotape recordings needed for measurements of blood cell velocities and vascular
diameters are performed in restrained but conscious animals without the use of anesthesia
or sedatives. At the conclusion of each experiment, the tape recordings are played back and
the raster-line signals produced by the movement of blood cells are passed through a video
Photometric Analyzer® (IPM Inc., San Diego, Calif.). The Photometric Analyzer® is an
instrument that generates two optical windows which can be positioned manually along the
centerline of any given blood vessel within the television scene. Another instrument, the
Photodiode® (IPM Inc., San Diego, Calif.), is utilized when the linear flow velocity exceeds
FIGURE 5. Spontaneous alterations of arteriolar diameter in the dorsal skin fold preparation of the hamster. The
frequency of this periodic event (vasomotion) is approximately 2 to 3 cycles/min. The flow velocity in the daughter
vessels is diminished when the constriction is almost complete (5c). (Magnification ~ x 800.)
Volume I 87
FIGURE 5c
2.5 mm/sec. In this device, optical sensors are placed at the known distance for measuring
the blood cell velocity directly in the image at the eyepiece.55
The use of videotape recordings provides a number of advantages that are specific to this
kind of investigation, namely:
1. It shortens the time needed to restrain the awake animal for observation and videotape
recordings.
2. It provides sufficient time for analysis since a very dense capillary network (mean
intercapillary spacing approximately 40 |xm) is consistently seen, resulting in a re-
dundancy of information.
3. It permits a double check of any measurement in the microvascular network by the
principal investigator when the information is ultimately stored on video cassette.
Quantitative Morphology
Morphologic studies of the vascularization pattern can also be performed by constructing
photomontages from black and white prints taken either from the microscopic image at low
power92118 (Figures 9 and 10), or from the TV monitor at a magnification of 500 x , resulting
in a magnification of approximately 250 x on printed paper (Figure 6). Moreover, an
electronic video image-shearing technique can be employed to determine luminal vascular
diameters for all vessels in which velocity measurements are possible. This can be performed
at an effective magnification of 600 x , as observed on a TV monitor.54
For morphometric measurements of capillary density, the total length of vessels per unit
area can also be calculated utilizing stereological techniques.92 The procedure is graphically
illustrated in Figure 11. A rectangular grid is superimposed on the vessel overlay. At the
present time the total number of intersections between vessels and grid within a given
microvascular module is still counted manually. Assuming a random orientation of vessels,
88
CRC Handbook of Microsurgery
FIGURE 6. Typical microvascular bed in our model after injection of 0.2 m€ FITC-dextran (molecular weight 150,000 daltons). The long,
parallel-coursing capillaries, indicative of microcirculatory structures of a skeletal muscle, should be noted. Photographed from the TV screen to
obtain a photomontage. The white rectangular spots are "windows" for measurements of blood cell velocity. (Magnification x 210.)
Volume I 89
FIGURE 7. Optical and electronic design for quantitative microcirculatory studies. (From Endrich, B., Zweifach,
B. W., Reinhold, H. S., and Intaglietta, M., Int. J. Radiât. Oncol. Biol. Phys., 5, 2021-2030, 1979. With
permission.)
FIGURE 8. A selected microvascular region in the hamster skin-fold preparation before (A) and after (B) injection
of FITC-Dextran 150. Note that capillaries are visible only when fluorescent microscopy is employed. (Magnification
x 85.)
FIGURE 9. Capillary and postcapillary network in the rat omentum. This picture was obtained
using a Wild Photomacroscope® M 400 (Leitz GmbH, Wetzlar, FRG) which is particularly suitable
for microscopic photography up to an original magnification of 110 x . (Magnification here x 190
because of additional photographic enlargement.)
Volume I 91
FIGURE 10. Microvascular network of the rat omentum. Note the clear visibility of blood vessels as obtained
by transillumination. A = arteriole, V = collecting venule, C = capillary network, and F = fat cells. (Magnifica-
tion x 60.)
FIGURE 11. Determination of capillary density; diagram of the procedure. The microvascular bed is photographed
from the TV monitor; after obtaining the vessels overlay, a rectangular grid is superimposed and the number of
intersections is counted manually (for further details see text).
capillary density (LA) is obtained from the probability of these intersections according to
the following equation
LA = T T - N - X ^ L o t c m - 1 )
where N equals the number of intersections between vessels and grid, X equals the total
magnification, and LG equals the total length of grid lines enclosed in the designated area.
In our laboratory, however, efforts are being made to determine capillary density by a
computerized image analyzing procedure.
Measurements of Local P 0 2 and Summary of Data

Measurements of local tissue P0 2 can be used as one criterion of a normal microcircu-
lation.6374 Measurements of local P0 2 on the surface of the preparation have been performed
on different days using a platinum multiwire electrode.63-74 This P0 2 electrode is a design
consisting of eight platinum wires, 15 |mm in diameter, sealed in glass and covered by a
Teflon® membrane. The electrode registers 0 2 tension simultaneously on any accessible
tissue surface at eight different positions in a hemispherical area of 30 to 50 |Jim. The
electrode is placed upon the preparation by means of a micromanipulator after lifting and
removing the cover glass from the tissue surface. By controlled movement of the electrode
on the tissue surface a statistical distribution of P0 2 values can be obtained. The data is
shown as P0 2 histograms. During the P0 2 measurements the local temperature should be
measured in the subcutis, even though it was found that this parameter remains constant in
conscious animals (30.1 ± 0.1°C, mean value ± SEM).
Table 5 summarizes the data derived from this model during an observation period of 12
days. It should be noted that the changes of local P0 2 (Figure 12) correspond very well to
the data of capillary density.29 Furthermore, it is worth mentioning that the hemodynamic
results are in good agreement with data from the literature,1519'27'30'32'55'92118 particularly
with data from the human nail-fold. Blood flow measurements within the "forearm-cham-
ber" in humans have, to our knowledge, not yet been performed.
DISCUSSION
Advantages/Disadvantages of Methods for Microvascular Analysis

One considerable disadvantage of most methods that allows for the microscopic obser-
vation of blood vessels is the necessity of using microsurgery to expose the tissue to be
studied. This ultimately requires the use of an anesthetic, many of which will modify the
responses and activity of the cardiovascular system.3 5-72 One further disadvantage is the
exposure of tissue to an external environment, even though careful handling of tissues and
organs during surgery and artificial substitutes for the natural environment might overcome
these disadvantages to some extent.
Human Studies
To study the microcirculation without anesthesia and surgical exposure, vessels of the
conjunctiva1214,69'79 and capillaries in nail-fold tissue 1519 ' 32 ' 5077 have been looked at in hu-
mans (Table 2). Although the studies are done in humans, both models bear some disad-
vantages. The human conjunctiva has not been accessible as yet for a quantitative
microhemodynamic analysis because the almost consistent movement of the eye does not
permit motion pictures in the unanesthetized patient for a period sufficient for measurement
of blood cell velocity. On the other hand, in the human nail-fold, only the capillaries are
visible and not the entire microvascular network. Thus, any conclusion on the regulation of
Volume I 93
FIGURE 12. Frequency distribution of local P0 2 in the preparation on different days after chamber
implantation in the hamster (n = number of determinations, Pa0 2 ~ 75 mmHg, pH ~ 7.4, pC0 2 ~ 40
mmHg, animals breathe room air spontaneously.) (Data obtained in collaboration with Cand. Med. Christine
Laprell-Moschner, Institute for Surgical Research, Klinikum Grosshadern, University of Munich, FRG.)
blood flow will be limited, even though quantitative microhemodynamic data are
available.1519'32-50
Experimental Animals — Tissue Studies

Therefore, for microcirculatory physiology and pathology, it seems important that appro-
priate animal models are being used. Studies have been performed in the past on the bat's
wing, 6281108 hamster cheek pouch; 243773 cremaster muscle,10'41'51'53-75 spinotrapezius mus-
cle,42 mesentery,9,40116 cecal mesentery of the rat,113115 mesentery of the frog,40 omentum
and mesentery of rabbits and cats, 55 ' 92113114116 and on the tenuissimus muscle of rabbits and
cats.30 Most of these "acute" preparations can be used for just 2 or 3 hr one given day and
will inevitably lead to the sacrifice of the animal thereafter.
Utilizing models of an almost two-dimensional preparation, such as the omentum or
Table 2
MICROCIRCULATORY STUDIES IN HUMANS
(INTRAVITAL MICROSCOPY)
AS REPORTED IN THE LITERATURE
Tissue A/D First author/year Ref
Nail-fold finger A: no anesthesia, Bollinger (1974, 1981) 15, 16

toe easy access Butti (1975) 19
Fagrell (1977) 32
D: only capillaries Hollinger(1975) 50
are visible Isenring (1982) 61
Mariq (1970) 77
Conjunctiva A: no anesthesia Bloch (1954, 1956) 12, 14
required Ditzel (1975) 23
12, 14
23
Fenton (1979) 33
D: difficult to visualize, Fink (1965) 34
no hemodynamic measure- Heisig (1965) 47
ments are possible Lee (1955) 69
Monro (1971) 79
Retina D: very difficult to Tsacopolos (1975) 103
access
Inner ear D: observation possible Naumann (1965) 80
during surgery only Passe (1951) 85
Seymour (1954, 1960) 95, 96
Tongue A: easy access Harders (1964) 46
D: thick tissue,
poor contrast
between vessels and
surroundings
Note: Specific advantages (A) and disadvantages (D) other than those listed in the discussion.
skeletal muscle, the capillary filtration coefficient was established in different mammalian
tissues employing the so-called microocclusion technique (for a review see Reference 57),
and methods were designed for direct accurate measurements of intravascular pressures,
even in the capillary network. Moreover, it was possible to measure blood cell velocity and
vascular diameters electronically. The availability of these techniques opened the way to a
systematic exploration of flow properties, flow distribution, and segmental resistance in
these tissues. Furthermore, it became a widely accepted fact that capillaries are smaller in
diameter than the erythrocytes and leukocytes which have to pass through them, and also
that the arterial end of the capillary is the narrowest part of the circulatory system — the
capillaries increasing in diameter along their length (Figures 9 and 10). (For a concise review
on experimental models see Table 3).
Organ Studies
A particularly difficult situation arises when the microcirculation of single organs is to
be studied because those structures are very difficult to transilluminate. One technique
commonly employed is the so-called fused quartz rod technique. At the present, however,
thick portions of organs still cannot be transilluminated, but it is possible to transmit sufficient
amounts of light at the edges. Thus, it remains an open question whether areas selected at
the boundaries of any organ are representative of the microvascular pattern. Moreover,
coupled with this is the exposure of the organ to an external environment which tends to
Volume I 95
Table 3
DIRECT QUANTITATIVE MICROCIRCULATORY STUDIES AS REPORTED IN
THE LITERATURE
Animal Studies — Acute Models
Species Tissue A/D First author/year F

Ref.
Bat Wing A: no anesthesia Jones (1852) 62

D: Chronic studies impossible Nicoll (1946) 81
unless the animal remains in Wiedemann (1973) 108
a state of hibernation
Hamster Cheek pouch A: clear visibility of blood ves- Duling (1973) 24

sels, thin tissue section Fulton (1946) 37
Lutz(1954) 73
D: anesthesia required, extensive
dissection, no lymphatic ves-
sels, diffuse nervous supply
Hamster Retractor muscle A: simple geometric property, Sullivan (1982) 99
muscle fibers and capillaries
are parallel, thin tissue
(20 — 30 |xm)
D: anesthesia required
Rat Cremaster muscle D: only low magnification possi- Baez (1973) 10
ble because of the high-light Grant(1964) 41
intensity needed for Hutchins (1973) 51
transillumination Hyman (1962) 53
Majno (1967) 75
Spinotrapezius muscle A: clear visibility of vessels, thin Baez (1959) 9
Mesentery tissue section Gore (1973) 40
Cecal mesentery D: anesthesia required Zweifach (1948, 1955) 113 115
Frog Mesentery D: no systemic pressure measure- Gore (1973) 40

ments possible, amphibia
Rabbit Mesentery See rat mesentery Intaglietta (1975) 55
and
Cat Omentum Schmid-Schonbein 92
(1977)
Zweifach (1948, 1954) 113, 114
Rabbit Tenuissimus muscle A: suitable to study vasomotion Eriksson (1972) 30
Cat
D: difficult preparation for inex-
perienced persons
Note: Studies on isolated organs and vessels are not included in this survey; advantages (A) and disadvantages
(D) according to the authors.
lower the temperature below the normal values, and where anesthesia and surgery might
have already affected the microvascular network (Table 4).
Chronic Models in Experimental Animals

One great advantage of the chronic transparent chamber preparation is that the tissue
under observation can build up its ''natural environment". The tissue can be spread and
held in place to present a thin undistorted surface for microscopic observation. Precautions
against tissue trauma (fine instruments, operating microscope) and the postoperative appli-
cation of antibiotics might provide better results in some preparations which will allow for
an even longer observation period.
Table 4
SUMMARY OF ORGAN STUDIES OF THE MICROCIRCULATION
IN ANIMALS
Type of
Organ Animal Experiment First author/year Ref.
Lung Rabbit Chronic Flach (1965) 35

Guinea pig Acute Heuck (1965) 49
Irwin (1954) 59
Krahl (1964, 1964) 66, 67
Liver Rat Acute Bloch (1955) 13
Guinea pig Irwin (1953) 58
Rappaport (1975) 87
Spleen Mouse Acute Knisely (1936) 64
Rat Parpart (1955) 84
Cat
Pancreas/pan- Mouse Acute Bunnag (1964) 18
creatic duct
Kidney Rat Acute Steinhausen (1965, 1970) 97, 98
Hamster
Cat
Heart Dog Acute Bassingthwaighte (1974) 11
Rat Henquell (1976) 48
Cat Tillmanns (1974, 1980) 101, 102
Turtle Wearn (1928) 106
Stomach Rat Acute Guth (1972, 1982) 44, 45
Cat Acute S vanes (1975) 100
Dog Chronic (gastric Rudick (1967) 89
pouch)
Brain Cat Acute Koo (1975) 65
Wahl (1979) 104
Rat Acute Leniger-Follert (1975, 1976) 70, 71
Mouse Acute Rosenblum (1982) 88
Inner ear Guinea pig Acute Costa (1970) 22
Irwin (1965) 60
Choroidea Rabbit Acute Friedman (1965) 36
Rat
Clark20-21 gave precise details on the development of suitable chambers; for instance, one
with a removable cover glass so that undesirable debris can be removed, and one designed
for implantation of cells. Clark2021 and Wiedeman109 have listed the advantages with regard
to the various medical fields. A pathologist could possibly study the inflammatory reaction
from the early onset, hemorrhage, fibrin formation, movement and migration of leukocytes,
as well as differentiation of new tissue structures. A pharmacologist could study the reactions
of substances introduced systemically or topically, the bacteriologist could observe reactions
of tissue cells to bacteria, and tumor researchers could benefit from observation of growth
of tumors in such chronic models.109
The disadvantages include the possibility of infection, as already discussed, the need of
a high intensity of light due to a tissue thickness above 100 |xm, overgrowth by epithelium,
and endothelial irritation from compression associated with compromised blood flow. In
view of the obvious advantage of repeated observation over a prolonged period, efforts were
made in our laboratory in recent years to design a model in which the apparent disadvantages
are significantly reduced or even eliminated. Even though a great number of microcirculatory
models have been described, so that any investigator in this field is confronted with an
overwhelming number of data gathered from different structures, different species, and
Volume I 97
different techniques and procedures, it was found that a chronic animal model is particularly
needed to study the postoperative treatment modalities in the event of microsurgery.
Structure and Behavior of the Microcirculation as an Organic Unit in the Transparent

Chamber Model of the Hamster Skin Fold
Direct observation of the microcirculation in the hamster dorsal skin fold allows one to
utilize previously developed measuring techniques and analytical models. Alterations in flow
rate, distribution of flow down to the capillary level, and total volume of flow to a vascular
module can be readily quantitated by television techniques. These direct microvascular
studies are justified because this segment of the circulation is able to function independently
in the hamster as well, with an extreme sensitivity of small arteries, arterioles, and
precapillaries.
As a functional test for a normal microcirculation, Wiedeman107 has suggested the ap-
plication of epinephrine and isoproterenol. We have intravenously injected 2 and 20 |xg/kg
epinephrine as a bolus in hamsters bearing the chamber; 2 |xg/kg caused the mean arterial
pressure to rise by 10 to 20% with vasoconstriction persisting in small arteries, arterioles,
and precapillaries for about 5 to 10 min; 20 |xg/kg increased the mean arterial pressure by
approximately 50% — a total constriction was consistently observed during a period of 20
min. By contrast, the continuous infusion of 0.1 |xg/kg/min of isoproterenol did not have
an effect on vascular diameter and density of erythrocyte perfused capillaries.119
Spontaneous alterations of vascular diameters (vasomotion) were observed at arterial and
arteriolar branches resulting in fluctuations of flow in daughter vessels. Moreover, Figure
1 demonstrates the existence of continuous-type capillaries embedded in fine fibers of skeletal
muscle in a transparent chamber preparation 7 days after surgical implantation. As a result,
leakage of FITC-Dextran 150 was not observed in such preparations within the first 2 hr
after i.v. injection, indicating the existence of a normal microcirculation within the skeletal
muscle and subcutaneous tissue. It should be noted that these tissues were subjected to very
low light intensity due to the use of fluorescent microscopy and low-light-level video cameras.
Tissue trauma (Figure 13) can be induced purposely, but more frequently it is inadvertently
induced; in any event, the changes occurring in the microcirculation can be listed in ap-
proximate temporary sequence as follows:
1. Temporary vasoconstriction of arterioles resulting in occasional partial ischemia.

2. Arteriolar dilation accompanied by increased flow through arterioles 2 to 5 days after
tissue trauma.
3. Increased flow through capillaries and venules, as well as opening of previously
"inactive" capillary beds.
4. Increased permeability of the venular micro vasculature as indicated by leakage of
FITC-dextran and extrusion of erythrocytes in some preparations (petechial bleeding).
5. Local slowing of blood flow in capillaries and venules, sometimes to the point of
complete stagnation. In the healing wound, as given in such preparations, this was
accompained by other inflammatory components, such as white blood cell adherence
and venular dilation (Figures 14A and B).
These observations are in good agreement with findings reported in the litera-
ture 2o,3i,38,39,76,82,93,94,io5,ii2 S u c h c h a n g e s u s u a n v o c c u r m transparent chamber preparations
in the rat where postcapillary and venular dilation is a consistent phenomenon after im-
plantation of the chamber. As a result, the blood cell velocities measured 25 27 are lower
when compared to data at identical location within the microvascular network in the hamster
(Table 5).
FIGURE 13. A typical example of a traumatized preparation. Such a preparation is characterized

by petechial bleeding, absence of vasomotion, and progressive vasodilation. The blood cell velocity
in collecting venules reaches values of less than 0.5 mm/sec. (Magnification x 10.)
As a consequence, we consider such preparations not suitable for studies of a normal

microcirculation. They might, however, be very useful to evaluate treatment modalities after
inflicting microsurgical injuries. It should be emphasized that in both models any response
to treatment can be quantitatively analyzed, not only with regard to its initial reaction but
over a prolonged period of time. It is self-evident that the exact mechanism of microvascular
response and reactivity can be precisely established only when data gathered at the micro-
circulatory level are correlated to measurements of (at least) systemic pressures and heart
rate. In the conscious hamster measurements of mean arterial pressure, central venous
pressure, and heart rate as well as microhemodynamic measurements can be combined with
daily intravital, microscopic observation.
In "chronic" microcirculatory models, however, the existence of a normal microcircu-
lation is documented both by morphological evaluation and quantitive, microhemodynamic
data29 only in transparent skin-fold preparations of the hamster. As a result, the data gathered
from a normal microvasculature in this experimental model might serve as a reference and
comparison of what should be achieved when treatment measures are evaluated in patho-
logical microcirculatory disorders such as increased permeability, vascular dilation, hyper-
coagulopathy, and low flow state. The "hamster model" provides data on the normal
microcirculation over a prolonged time; therefore, this model should be of great use in studies
aimed at understanding all of those procedures which have a direct effect on microvascular
function.
Volume I 99
FIGURE 14. (a) Typical overview photography of a microcirculatory preparation of the hamster skin fold (4
days after implantation of the chamber), (b) The same preparation 6 days later. Note the dilation and tortuosity,
particularly of venules and small veins, as a result of inflammation.
SUMMARY
A chronic microcirculatory model is described which permits quantitative studies in the

event of microsurgical injuries. It consists of implanting a transparent chamber in the dorsal
skin fold of the hamster and permanent indwelling catheters in the carotid artery and jugular
vein. All segments of the microcirculation of skeletal muscle and s.c. tissue can be quan-
titatively evaluated in the conscious animal. Measurements of vascular diameter, length,
density, and blood cell velocity are possible at any given day over a period of at least 4
weeks. It is concluded that this model may provide useful data not only on the pathology
of a microsurgical injury but also on treatment modalities to improve microcirculatory flow.
FIGURE 14b
ACKNOWLEDGMENT
The authors would like to thank Professor M. Intaglietta, Department of AMES-Bioen-

gineering, University of California, San Diego, for his generous advice and review of this
manuscript.
Volume I 101
Table 5
MEAN ARTERIAL PRESSURE (MAP), CENTRAL VENOUS PRESSURE
(CVP), HEART RATE (HR), BLOOD CELL VELOCITY AND VESSEL
DIAMETER RANGE ALONG DIFFERENT MICROVASCULAR
SEGMENTS, CAPILLARY LENGTH, CAPILLARY DENSITY, AND
MEAN LOCAL P0 2 IN THE DORSAL SKIN FOLD CHAMBER
PREPARATION OF THE HAMSTER ON DIFFERENT DAYS OF
OBSERVATION
Days of observation
0 4 8 12
MAP (mmHg) 93.2 ± 5.2 107.6 ± 7.2 117.2 ± 5.4 115.3 ± 6.7
CVP (mmHg) - 1 . 7 ± 1.1 0 ± 1.5 - 0 . 4 ± 1.2 - 0 . 6 ± 0.8
HRfcniir 1 ) 380 ± 10 350 ± 46 392 ± 15 382 ± 7
Blood cell
velocity (mm/sec)
Arterioles 1.20 ± 0.34 0.94 ± 0.13 1.38 ± 0.22 1.61 ± 0.46
Range (jim) 15.6 — 30.0 15.0 — 51.6 18.7 — 50.6 16.1—39.9
n = 6 n = 5 n = 7 n = 6
Precapillaries 1.21 ± 0.20 1.70 ± 0.16 1.88 ± 0.12 1.94 ± 0.17
Range (|xm) 8.1 — 11.9 7 . 3 — 11.3 6.4— 16.0 6 . 5 — 13.8
n = 12 n = 29 n = 48 n = 31
Capillaries 0.48 ± 0.04 0.79 ± 0.05 0.70 ± 0.03 0.73 ± 0.06
Range (|Jim) 4 . 4 — 13.1 4.1 — 7 . 9 4.5— 11.0 3.5 — 7.9
n = 82 n = 139 n = 181 n = 78
Postcapillaries 0.34 ± 0.05 0.70 ± 0.06 0.64 ± 0.04 0.53 ± 0.05
Range (|xm) 11.3 — 21.3 7.4— 13.0 7.0— 19.4 8.1 — 14.6
n = 23 n = 71 n = 81 n = 52
Collecting venules 0.47 ± 0.04 0.75 ± 0.04 0.90± 0.05 0.65 ± 0.05
Range (|xm) 14.1 —36.3 14.6 — 38.5 14.3 — 43.5 14.2 — 34.2
n = 22 n = 92 n = 102 n = 67
Capillary length 491.2 ± 21.9 414.4 ± 30.9 412.9 ± 24.0 418.5 ± 21.8
(N n = 174 n = 121 n = 156 n = 168
Capillary density 165.9 ± 8.4 178.6 ± 11.1 231.8 ± 10.7 241.9 ± 14.6
(cm/cm2) n = 8 n = 15 n = 17 n = 23
Mean local P0 2 26.8 27.5 36.0 35.0
(mmHg)
Note: Local temperature 30.1°C, mean values ± SEM, n = number of single determinations.
From Endrich, B. and Messmer, K., Drug Res., 31, 2007, 1981. With permission.
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Neurological Microsurgery
Volume I 109
THE ROLE OF MICROSURGERY IN THE TREATMENT OF PERIPHERAL

NERVE INJURIES
H. B. Kapila
INTRODUCTION AND HISTORY
The treatment of injuries to the peripheral nerves has been a great challenge to surgeons
for many centuries. Only in the last few years has it become possible, by means of electron
microscope, to describe the detailed structure of nerve fiber. The operating microscope helps
to approximate the two ends of a damaged nerve close to their anatomical structure, preserving
their blood supply. Any surgeon contemplating operating on the nerve must understand the
anatomy and physiology of normal nerve, and the series of changes (degeneration and
regeneration) occurring in the proximal and distal end of a severed (or damaged) nerve. No
nerve should be sutured without magnification; and only microsurgical instruments and fine
nonreactive microsutures must be used. If the facilities are not available, the patient should
be transferred to a unit where a proper nerve repair can be performed, because the results
of delayed primary repair are much better than secondary repair of the nerve. (Care must
be taken so that the patient has no other life-threatening injury before being transferred.)
The most commonly injured peripheral nerves in the body are those of the upper limbs
(median and ulnar nerve) and their branches.
The microscope was first used in 1921 for otosclerosis surgery by Holmgrum. In 1946
both the ENT and ophthalmic surgeons started using the microscope. It was only in the
1960s when the plastic, orthopedic, and neurosurgeons began to use microsurgery in the
treatment of peripheral nerve injuries. In the 1970s microsurgery was extensively used and
by 1980 there was hardly any surgeon who would treat peripheral nerve injuries without the
use of a microscope or some kind of magnification and microsutures. It has been proven
beyond a doubt that the end results of nerve repair, performed under the operating microscope,
are much superior to those of conventional neurorrhaphy.
ANATOMY AND PHYSIOLOGY OF NERVES
The peripheral nerves lie outside the brain and spinal cord.1 They are made up of many
nerve fibers and their connective tissue coverings. The innermost covering, which surrounds
each nerve fiber, is called the endoneurium. The nerve fibers are grouped together to form
fasciculi. Each fasciculus is covered by perineurium. The whole nerve trunk, made up of
many fasciculi, is surrounded by epineurium. The loosely packed arrangement of these
connective tissue sheaths is important for the blood supply of the nerve. The epineurium
form the mesoneurium, like the mesentery of the bowel, through which the nerve gets its
blood supply (see Figure 1).
The size, number, and pattern of the fasciculi vary greatly in different nerves and at
different points along the length of nerve. The number of fibers increases and their size
decreases, just before the nerve trunk gives branches.
The neurone (basic unit of the peripheral nerve) consists of a nerve cell and its processes
— dendrites and axon. The nerve cell has almost the same structure as the other cells in
the body. It contains a nucleus, cytoplasm, mitochondria, and a golgi apparatus. The Nissl
bodies are present only in the cell body and dendrite, but not in the axon. The dendrites
extend from the cell body and arborize extensively. The axon, which is a long process of
the cell body, varies in length, acquires, a sheath of myelin, a protein lipoid complex in
myelinated nerve fibers. The myelin sheath envelopes the axon except at its ending and at
FIGURE 1. Transverse section of a nerve trunk with mesoneurium carrying its blood supply.
periodic constrictions about 1 mm apart called the nodes of Ranvier. The axon ends in a
number of synaptic knobs. These knobs contain granules in which the synaptic transmitter
secreted by the nerve is stored.
The peripheral nerve trunk can be compared with an electric cable. The only difference
is that in an electric cable each small wire is well insulated and not communicating with
the next wire. On the other hand, in the nerve trunk fasciculi divide repeatedly and their
branches unite with those of other fasciculi to form a plexus along the whole length of the
nerve. This will result in changes in the fascicular pattern and variation in the size and
contents of the fasciculi at different levels. This fascicular pattern is subject to a wide range
of variation.
BLOOD SUPPLY OF NERVE
Arteriae nervorum arise from the surrounding artery, enter the mesoneurium and terminate
at the nerve. The nutrient artery divides into anastomotic vascular plexuses just before the
nerve trunk. This vascular plexus further divides to form an intraneural vascular network
which runs along the whole length of the nerve, so it is important to ligate the blood vessels
as far away from the nerve trunk as possible in order to preserve their anastomosis. The
branching and subbranching of the nutrient artery form four vascular systems of blood vessels:
(1) surface chain, (2) interfunicular chain, (3) perineurial channels, and (4) intrafunicular
capillary network (see Figure 2).
The veins follow the same pattern as the corresponding arteries. The lymphatics are only
present in the epineurium.
Volume I 111
FIGURE 2. Nerve trunk and its mesoneurium magnified x 20 to show the blood vessels to the nerve.
Table 1
TYPES OF NERVE FIBERS
Based on histological appearance

Myelinated
Nonmyelinated
On the basis of diameter of the nerve fiber

and the rate of impulse conduction
A
B
C
On the functional grounds

Efferent
Afferent
TYPES OF NERVE FIBERS
Various types of nerve fibers, classified according to their histological appearance, func-
tion, and rate of impulse conduction, are shown in Table 1.
Most of the peripheral nerves are of mixed variety, which means they are composed of
motor, sensory, and sympathetic fibers. This classification has clinical as well as physio-
logical significance. For example, pressure on the nerve can cause the loss of conduction
in motor, touch, and pressure fibers, while the pain sensation remains relatively intact. Rate
of impulse conduction is faster in large A fibers than in C fibers. Local anesthetics depress
transmission in the group C fibers before they affect the touch fibers in the A group.
EFFECTS OF INJURY TO THE NERVE
The effect of injury to the nerve depends upon the severity of the trauma. Histologically,
it can be one of the following three types:
Neurapraxia — The nerve fibers are in continuity and there is no degeneration of the
distal axon. The recovery is fast and prognosis is good.
Axonotmesis — The nerve fibers are still in continuity, but there is degeneration in the
distal axon. Recovery follows the rate of nerve regeneration and the prognosis is satisfactory.
Neurotmesis — The nerve is completely divided into two. There is degeneration in the
distal axon. Recovery and prognosis depend on the type of repair and many other factors
to be discussed later.
There could be a mixed type of effect in the partially divided nerve trunk.
Series of Changes that Occurs in a Nerve When Completely Divided

Degeneration
These changes can be seen in the cell body and proximal and distal axon. 23
Cell body — The cell body swells 1 to 3 weeks after the nerve is damaged, stays swollen
till the degeneration and regeneration is complete, and then returns to normal size. The
nucleus becomes eccentric and also bigger in size. Chromatolysis occurs and these changes
indicate nerve regeneration.
Proximal axon — After complete nerve division, the two ends of the nerve retract due
to the action of elastic fibers in the mesoneurium and also within the nerve itself. The
Schwann cells rapidly fill this section preventing collapse of the epineurium which become
swollen due to edema, depending upon the severity of the injury.
Distal end — The series of changes that occur in the distal end are called Wallerian
degeneration. There is swelling of the distal end. Within a day or two of the trauma the
neurofibrils disappear, cytoplasm in the axon clumps and forms optically dense lamellar
bodies. Schwann cells digest fragmented myelin and empty spaces within the myelin sheath
appear as the myelin degeneration progresses. The Schwann cells also form cords of cells
along the dengerated axis cylinder and later on the empty neurolemmal sheath of the distal
axon shrinks and may be reduced to 1 % of its normal cross-sectional area over a period of
2 to 3 years.
Nerve Regeneration
Cell body — If the nerve is injured near the cell body, more stress is placed on the cell
body to regenerate the larger segment of the peripheral nerve. According to Ducker et al., 3
the nerve cell during successful regeneration replaced 50 to 100% of the organic material
contained in the cell body. So during regeneration the cell metabolism is increased to produce
more protein and other material required for the cell regeneration.
Proximal axon — In the first 2 to 3 days after trauma there is a marked proliferation of
Schwann cells with varying amount of retrograde destruction of the nerve fasciculi and
myelin. As the nonviable tissue is demarcated and phagocytosed, newly formed axoplasm
flows down the axis cylinder and may, within 3 to 6 weeks, cross the nerve gap at the site
of damage.
Distal axon — There is active phagocytosis of degenerated axoplasm and myelin which
continues for about a month. As new axons grow down the distal fragment they are myelinated
and the edema subsides. With complete nerve regeneration there is a new endplate formation
and the normal muscle activity results.
TYPES OF NERVE INJURIES
The type of nerve injury plays an important role in the ultimate prognosis of nerve repair.
Volunte I 113
Table 2
TYPES OF NERVE INJURIES
Closed injuries
Blunt trauma
Traction injuries
Open injuries
Clean cut
Without loss of nerve segment
With loss of nerve segment
Contaminated wound
Without loss of nerve segment
With loss of nerve segment
Strangulated by scar
Near old fracture or soft tissue injuries
Compression
In carpal tunnel
By ganglion or other soft tissue tumors
By bony spur
By fragment of fracture or bony tumor
For example, if the nerve is only divided in a clean cut without any loss of nerve segment,
the prognosis is good as compared to the nerve repair when there is a contaminated wound
and the loss of nerve segment. Various types of nerve injuries are shown in Table 2.
SYMPTOMS AND SIGNS OF NERVE INJURY
The symptoms and signs of nerve damage depend upon the type and severity of injury.
If a sensory nerve is damaged there will be loss of tactile sensation, stereognosis, and joint
position in the area supplied by that particular nerve. The area with lost sensation can be
easily mapped out using a light touch and pin prick. Take a cotton wisp and, starting in an
anesthetic area, move the cotton wisp outwards until the patient, with his eyes closed, can
feel it. This is repeated with a sharp pin and recorded as shown in Figure 3. It is important
to compare the loss of sensation after the nerve repair is performed. In a good nerve repair,
the area of loss of sensation will be reduced as time passes.
If a motor nerve is severed the muscle supplied by that nerve is paralyzed. Atrophy of
the muscle begins after a few months and eventually the muscle undergoes fibrous degen-
eration, which takes about a couple of years. After 2 years the fibrosis is so bad that even
complete nerve regeneration will not bring back the function of that muscle. The opposing
active muscle will contract and produce different kinds of deformities. Some muscles are
supplied by more than one nerve. A partially paralyzed muscle may be unable to move the
part normally, but careful testing by isolating tfye muscle function and especially by palpating
the muscle as it contracts, will aid in the final diagnosis. A standard system of recording
muscle activity is shown in Table 3.
Neuroma Formation
A traumatic neuroma is an inevitable result when a lacerated nerve fiber cannot reestablish
continuity with its distal counterpart. There are three morphological types of neuroma de-
pending upon the etiology (see Figures 4, 5, and 6): (1) terminal neuroma follows complete
transection of nerve, (2) neuroma in continuity, follows repeated blunt trauma, and (3)
eccentric neuroma is a result of partial laceration of the nerve.
FIGURE 3. (A) Desensitized area (shaded) after completely severed ulnar nerve. (B) Same
hand 16 months after the nerve repair.
Table 3
STANDARD SYSTEM FOR RECORDING
MUSCLE POWER
Complete paresis
Trace of contraction
Visible and palpable contraction with gravity eliminated
Active movement against gravity
Active contraction against gravity and resistance
Normal power
Electromyography (EMG)5
The interpretation of the results of electrical studies on the nerve and muscle is becoming
quite a simple process. The conduction time of sensory and motor nerves can help in the
differential diagnosis of different nervous and muscular disorders. This can also help in
studying the prognosis of nerve repair. The EMG should preferably be performed in the
same unit and read by the same examiner who has studied the previous EMG.
INSTRUMENTS REQUIRED FOR MICROSURGERY
The following instruments are required for microsurgery.
1. The ideal microscope is a triploscope, hanging from the ceiling so that it doesn't
interfere with the movements of theater staff. A smaller version of a similar microscope
is quite adequate.
2. Microinstruments.
3. Microsutures.
Volunte I 115
FIGURE 4. Longitudinal section of terminal neuroma.
FIGURE 5. Terminal neuroma on the proximal end of the nerve.
4. Nerve stimulator.
5. Bipolar coagulator diathermy.
6. Colored background which helps in suturing the nerve.
7. General surgical set for plastic surgery.
8. Vesseloops to retract nerves.
FIGURE 6. (A) Neuroma in continuity; (B)

eccentric neuroma.
Details of these instruments and their use have already been discussed in a previous chapter
in this book.
Type of Anesthetic
Most of the patients who come for treatment have injury to the nerves of the upper limb.
Brachial block with a long-acting anesthetic is used, and every patient gets premedication
an hour before the operation. A small percentage of patients not suitable for brachial block
require general anesthetic. The advantage of brachial block is that the patient has no pain
for about 6 to 8 hr after the operation and his arm can be elevated without any discomfort.
Elevation is very essential in the early postoperative period as it will reduce swelling and
hematoma and promotes good venous drainage.
Tourniquet
Since most of the nerves are repaired in the limbs, an avascular field helps in better repair
of the nerve. A pneumatic tourniquet is applied in almost all cases unless there is some
specific contraindication for its use. If the tourniquet is used more than 1V2 to 2 hr, the
tourniquet can be released and after a few minutes can be reapplied, so that the ischemic
time is shortened. The use of an Esmark® bandage is avoided because it will prevent the
identification of vessels in the mesentery of the nerve and the vessels running on the nerve,
which help in the orientation of the nerve ends. The limb should be elevated for about 5
min; that will drain enough venous blood for the pneumatic tourniquet to be effective.
TIMING OF NERVE REPAIR
When a nerve should be repaired is as controversial as how the nerve should be repaired.
Volume I 117
It depends on whether it is an open or a closed injury. In an open injury, depending upon

the facilities available, it could be either primary repair, delayed primary repair, or secondary
repair.
Primary repair — This means that the nerve is repaired within a few hours after the
injury. If it is performed properly and in optimal circumstances, the results are very good.
Delayed primary repair — This means that the nerve is repaired 1 to 3 weeks after the
injury and at this time the nerve regeneration activity is quite good. If the nerve is repaired
properly, using microsurgical techniques, in a clean wound, prognosis is again, quite good.
Secondary repair — This type of repair is mostly performed when there is a very untidy
wound or in cases where the nerve injuries are missed and recognized later. This mostly
happens with patients with multiple injuries. Most of the patients develop neuroma at the
proximal end and a lot of scarring around the nerve. The neuroma is normally excised and
the two ends of the nerves are sutured. If the gap is big, a nerve graft is required, otherwise
the two ends of the nerve are sutured without any tension. Under no circumstances should
the nerve be stitched with tension at the site of nerve repair. If the suturing is performed
accurately, the prognosis is quite satisfactory. One must keep in mind that an accurately
performed secondary repair in a clean wound, by a surgeon using microsurgical techniques,
has better prognosis than primary suturing under questionable circumstances.
In cases of closed injury the patient should be observed for the recovery of nerve function.
Only after the given period of time has elapsed, based on the anticipated rate of return of
1 mm/day and also with the help of EMG studies, should exploration of the nerve be
performed. In most of the cases, neurolysis is all that is required. Occasionally the nerve
is partially or completely divided by the blunt trauma, and in these cases the nerve must be
repaired — fortunately this type of injury happens very rarely. Most of the nerve injuries
as a result of blunt trauma and nerve stretching are caused by dislocations or fractures and
recover satisfactorily. Seddon22 has reported that spontaneous recovery occurs in 82% of
the cases of nerve injuries caused by fractures of the humerus.
FACTORS INFLUENCING THE RESULT OF NERVE REPAIR 6
The rate and degree of recovery of nerves does not only depend upon the accurate
opposition of fasciculi of nerves using microsurgical techniques, but also upon a number of
other factors (see Table 4).
Severity of injury — As mentioned at the beginning of this chapter, the prognosis is
better if the trauma is not severe enough to divide the nerve completely. In minor trauma
when the nerve is not completely divided, recovery is fast and almost complete.
Type of wound — The prognosis is better if the injury is at the periphery of the nerve
because the nerve is mostly sensory or motor as compared to the more proximal trunk, where
there is mixed nerve made up of motor, sensory, and sympathetic fibers. Also, if the recovery
(which is at the rate of approximately 1 mm/day) takes more than 2 years to reach the
affected muscle, the muscle would have undergone atrophic changes and no return of function
of that muscle is possible.
Age of patient — The recovery rate and final result is better in younger children than in
adults. Nobody really knows why that is true: most probably children have better power of
regeneration.
Time lapse between the injury and the repair — The shorter the time between the
injury and the repair the better is the prognosis. Some protective sensation can still be
achieved after many years of injury, but the motor function may not return 2 years after the
injury.
State of local blood supply — The regeneration of nerve activity depends on the presence
of an adequate blood supply passing through the mesoneurium of the nerve. Recovery is
slow when there is injury to the local blood vessels.
Table 4
FACTORS INFLUENCING THE RESULTS
OF NERVE REPAIR
Severity of injury
The type of wound
Site of lesion
Age of the patient
Time lapse between the injury and the repair
State of local blood supply
Amount of fibrosis near the nerve
Tension at the suture line
Gap between the two ends of the nerve
Motivation of the patient
Type of repair
Table 5
VARIOUS METHODS USED FOR PROPER
ORIENTATION OF NERVE ENDS
Attachment of mesoneurium to the nerve

Presence of blood vessel on the surface of the nerve
Use of dental mirror for matching the fasiculi
Looking at the end of the nerve for shape and size of the fasciculi
Looking at the side of the nerve from where the branches are arising
Use of nerve stimulator
Understanding various mapping studies done by several authors
Amount of fibrosis near the nerve — Again, if there is a lot of scarring at the site of
the nerve damage or around the nerve, the blood supply of that area is markedly reduced,
which interferes with the regeneration of fiber.
Tension at the suture line — If the nerve is sutured under tension, there is a lot of
fibrosis at the junction and the prognosis is bad.
Gap between the two ends of the severed nerve — If there is a big gap between the
two ends of the severed nerve, a graft is required and the prognosis is not very good because
there are two junctions as compared to end-to-end suturing of the nerve.
Motivation of the patient — Motivation of the patient plays an important role in the
ultimate result of nerve repair. The patient must religiously follow postoperative physio-
therapy, sensory retraining, and occupational therapy to have good functional result after
nerve repair.
VARIOUS METHODS FOR PROPER ORIENTATION OF NERVE ENDS

BEFORE SUTURING7
Nerve sutured by epineural opposition does not allow a good opposition of various fas-
ciculi. Motor fasciculi can be sutured to sensory ones, which would result in loss of function.
Various methods used for the orientation of nerve ends are shown in Table 5 and Figures
7 to 11. These will help in recognizing and orientating the fasciculi so that the nerve repair
will be superior to just approximating the nerve by epineural sutures.
Volume I 119
FIGURE 7. Compare the shape and size of the two ends of the severed nerve and fasciculi. (Mag-
nification x 20.)
FIGURE 8. Looking at the attachment of the mesoneurium to the nerve trunk.

FIGURE 9. Using dental mirror to orientate the nerve ends.
FIGURE 10. Applying nerve stimulator to recognize motor and sensory fasciculi.
Volume I 121
FIGURE 11. Artery on the surface of the nerve trunk helps in proper orientation of the nerve ends.
Table 6
SURGICAL PROCEDURES
WHERE MICROSURGERY CAN
BE USED IN THE TREATMENT
OF PERIPHERAL NERVE
INJURIES
Removal of tumors in or adjacent to a nerve

Neurolysis of the nerve
External
Internal
Nerve repair
Primary repair
Delayed repair
Secondary repair
Free nerve graft
Pedicle nerve graft
Vascularized nerve graft
Direct neurotization of degenerated muscle
SURGICAL PROCEDURES WHERE MICROSURGERY CAN BE USED IN

THE TREATMENT OF PERIPHERAL NERVE INJURIES
No surgeon should operate on any nerve without some kind of magnification. The various
procedures where microsurgery can be used are shown in Table 6.
General Principles of Microsurgery

When the diagnosis is reached after proper history and examination of the patient, then
one proceeds to operate on the nerve. The following principles should be observed to avoid
unnecessary inconvenience during the operation.
1. Positioning of the patient — The patient should be comfortably positioned and the
limb should be abducted on a table away from the body, so that the microscope can
be properly placed away from the anesthetist.
2. Position of the surgeon — The surgeon should be sitting comfortably with his arms
and wrists resting on the table. Special chairs and arm rests have been designed but
they are not absolutely necessary.
3. Setting the microscope — The microscope should be set according to one's height
and position of the table and properly focused to make sure it is in good working
condition.
4. Checking the instruments — All the microsurgical instruments should be checked
before the operation. If they are not in good working order, then the second set of
instruments should be used. After the operation the instruments should be cleaned
properly to avoid any damage to the delicate ends of the instruments.
5. Preparation of donor area — If you anticipate taking a nerve graft, the donor area
should be prepared and draped properly at the same time as the operative field is
prepared.
6. Keep tissues wet with normal saline at all times.
Use of Microsurgery in Removing Tumors in or Around the Nerve

The use of the operating microscope during the removal of tumors in or around the
peripheral nerve avoids unnecessary damage to the nerve which could be crippling to the
patient. Injury to the peripheral nerve is quite frequently seen after surgery for removing
small ganglions of the hand.
Steps of Operation (See Figures 12 and 13)
1. After the tourniquet is applied to the limb, the tumor is dissected in an avascular field.
2. When the tumor or ganglion is reached the microscope is then used to dissect out the
nerve from the tumor.
3. The nerve should be very gently retracted to avoid damage. If the nerve is damaged,
the patient not only loses the functions of the nerve but can develop a very painful
neuroma at the site of injury, which could be very distressing.
4. After the tumor is removed the nerve should be inspected to see that no damage has
been done.
5. Then the wound is closed in the usual way after hemostasis is achieved.
Neurolysis8
Freeing of the nerve from the surrounding scar tissue is essential for good blood supply
to the nerve. If the scarring is very extensive, transposition of the nerve should be performed.
Neurolysis can be either external or internal.
External Neurolysis — Steps of Operation (See Figure 14)
1. After applying the tourniquet to the limb, the nerve in question is exposed.
2. The nerve is observed carefully; then starting from the normal-looking nerve and
working towards the scar tissue, the whole nerve trunk is carefully freed from the
scar. In this way there will be less risk of damage to the nerve itself.
3. Try to avoid unnecessary mobilization of the nerve, because if the nerve is mobilized
more than 10 or 12 cm it is converted into a nerve graft and there is risk of necrosis
in the central part of the nerve.
4. Hemostasis is achieved and the wound is closed in the normal manner.
Volume I
FIGURE 12. Digital nerve wrapped around the tumor in the finger. FIGURE 13. Tumor removed using microscope; the nerve is preserved with-
out any trauma.
123
FIGURE 14. External neurolysis has been carried out preserving the branches of the nerve.
Internal Neurolysis — Steps of Operation (See Figure 15)
1. If the nerve seems to be constricted, the epineurium is opened, starting from the
normal-looking nerve and working towards the scarred nerve. Using the microscope
and microinstruments, the epineurium is slit in a longitudinal fashion.
2. If the fasciculi appear scarred, each fasciculus is separated, again with microscissors
and fine scalpel, using the microscope.
3. Hemostasis is achieved using bipolar diathermy and the wound is closed.
NERVE REPAIR 9 1 7
The nerve may be damaged completely or incompletely. Even though the nerve may be
incompletely divided, there is always some damage to the nerve, which is in continuity; so
very carefully handle the nerve to avoid further damage to the undivided part.
Steps of Nerve Repair When the Nerve is Completely Divided in a Clean Wound Without
Loss of Nerve Segment
1. After an avascular field is achieved, the nerve in question is exposed, by extending

the existing wound. Irregular edges of the skin are excised. All the blood clots and
dead tissues are removed.
2. The severed ends of the nerve are identified and the damaged part excised.
3. The axoplasm, which flows out of the fasciculi, is removed using fine microforceps
and microscissors. Freshening of the nerve ends is very important and should be done
very carefully. Irregular cutting of the nerve ends leads to more fibrosis and bad results.
Volume I US
FIGURE 15. Internal neurolysis has been done by splitting the epineurium longitudinally and each
fasciculus has been freed of scar tissue.
4. The epineurium is excised away from the end of the nerve for a short distance till the
fasciculi protrude out (see Figure 16).
5. Suturing the nerve ends — using microforceps, the interfascicular tissue is picked up
and 10/0 nylon suture is used. The fasciculus is pierced, double the thickness of the
needle away from the edge of the fasciculus, on one side and then taken out and
reintroduced into the corresponding fasciculus on the distal nerve end, the same distance
away from the margin of the fasciculus (see Figures 17 and 18).
6. Tying of the suture — the sutures should be loosely tightened using proper surgical
knots with the help of microforceps and needle holder (see Figure 19).
7. In the same way, the other fasciculi are sutured, using 10/0 nylon sutures. The number
of sutures depend upon the size of the fasciculi. Each fasciculus will require one or
two sutures. If 10/0 nylon suture is too fine, 8/0 sutures will do the job quite well.
Some surgeons use metal sutures as a marker to check breakdown of the junction
postoperatively, with the help of an X-ray. The author does not think that they are
essential if the junction is checked for tension after the nerve repair. If the junction
is under great tension, use a nerve graft.
8. Hemostasis is achieved using bipolar coagulation and the wound is closed in the usual
manner.
Secondary Suturing of the Nerve

When the patient has developed a neuroma at the end of the proximal segment, the
neuroma is excised repeatedly until the fasciculi are seen clearly, as shown in Figure 20. It
must be cut in a straight line. Irregular cutting at the end of the nerve will produce more
fibrosis. Different techniques have been used to cut the end of the nerve. Special types of
knives have also been designed, but the ordinary Number 11 blade and a little tension on
FIGURE 16. Fasciculi are clearly visible after the epineurium has been excised on one end of the
nerve on the right side. The other end still needs excision of epineurium. (Magnification x 40.)
FIGURE 17. The fasciculus has been pierced with a microneedle near the end of the nerve. (Mag-
nification x 40.)
Volume I 127
FIGURE 18. This fasciculus will require another stitch. (Magnification x 40.)
FIGURE 19. Proper surgical knot has been tied to reduce fibrosis.
FIGURE 20. Transverse sections through the terminal neuroma. (A) Only fibrous tissue, no fasciculi; (B) very
few fasciculi; and (C) good fasciculi for suturing.
Table 7
VARIOUS METHODS USED TO
OVERCOME THE GAP
BETWEEN THE TWO ENDS OF
THE NERVE
Flexion at the adjacent joint

Nerve mobilization
Nerve transposition
Rerouting of the nerve
Bone shortenings
Stretching of the nerve
Combination of above
Nerve graft
Autograft
Homograft
Heterograft
the end of the nerve with microforceps by the assistant, using a spatula on the back of the
nerve, will do the job quite well. For smaller nerves serrated microscissors are adequate.
After the fasciculi are clearly seen, assessment is made as to whether the two ends of the
nerve can be brought together without any tension by slightly flexing the joint or using other
methods for reducing the gap between the two nerve ends as shown in Table 7. If it is not
possible, then a nerve graft should be used to bridge the gap. Otherwise, primary repair of
the nerve is carried out as described above.
Volume I 129
FIGURE 21. (A) Severed nerve fibers have been dissected away from
the intact nerve fibers and suture without any graft. (B) The gap between
the two ends of the severed nerve fibers are bridged with an inlay graft.
If the Nerve is Incompletely Divided

In an incompletely divided nerve there is always some damage to the intact nerve, so
very carefully handle the whole nerve. If there is no gap between the ends of the divided
nerve, then fascicular suturing as described before is carried out. If there is a gap between
the two ends of the incompletely divided nerve, then one of the following procedures can
be carried out (see Figures 21A and B): (1) intact nerve fibers can be separated by micro-
dissection away from the divided part of the nerve and the nerve ends brought together by
suturing the fasciculi, or (2) the gap between the two ends can be bridged using an inlay
nerve graft.
Badly Contaminated Wound with Loss of Nerve Substance

If the wound is badly contaminated and there is a lot of crushing and bruising of the
muscles it is better to do a primary debridement and cleaning of the wound; then after a
few days or weeks, suture the nerve with or without the nerve graft, depending upon the
size of the gap between the two ends of the nerve.
Pedicle Nerve Graft with Intact Blood Supply

Unfortunately this is only possible in a small percentage of cases where there is injury to
FIGURE 22. Pedicle graft with intact blood supply has been used to bridge the gap between the two ends
of adjacent nerve trunk.
tissues supplied by one particular nerve and the adjacent nerve is lost in the same injury,
for example, injury to the hand where median and ulnar nerves are lying near to each other.
Otherwise, it means that one nerve has to be sacrificed to retain the function of the other
nerve.
Steps of Operation
1. After achieving an avascular field, both the nerves are dissected out.
2. Then the nerve used for pedicle graft is mobilized from one end to the other, preserving
the blood supply in the mesoneurium.
3. The required length of the nerve is cut and the graft is put between the two ends of
the recipient nerve and the nerve is sutured by fascicular sutures as described above.
4. Make sure that the blood supply of the donor nerve is not kinked. Hemostasis is
achieved and the wound is closed in the usual manner (see Figure 22). Sometimes a
part of the side of the nerve is used to bridge a gap between the two ends of the other
nerve.
Rarely, one end of the nerve is joined to the other end of the nerve and a few months
later the donor nerve is excised and then that nerve is used as a graft to bridge the gap
between the two ends of the recipient nerve.
Free Nerve Graft1821

Free nerve graft is most often used when the two ends of the nerve cannot be brought
Volume I 131
Table 8
CHARACTERISTICS OF THE
NERVE GRAFT
It should be easily available and removed
It should have minimum fat and a large fasciculus
It should not produce any serious damage to the area supplied
by the nerve
It should have sufficient length
Nearly same diameter as the recipient nerve
The whole thickness of the nerve should not be too big otherwise
it will produce necrosis in the center of the nerve
FIGURE 23. Cable graft has been used to bridge the gap between the two ends of the severed nerve trunk.
together without tension due to loss of nerve substance or a gap is created by excising the
neuroma at the end of the proximal end of the nerve. The free nerve graft may be autograft,
homograft, or heterograft. The most commonly used graft is the cable interfunicular graft.
No nerve is ideal for nerve graft and cutaneous nerves are mostly used. The most commonly
used nerves are sural nerve, lateral cutaneous nerve of the forearm, or lateral cutaneous
nerve of the thigh. The donor nerve should have the characteristics which are shown in
Table 8. The nerve graft should not be taken near the area which is already denervated and
make sure that the scar produced as a result of removal of nerve is not near the pressure
bearing area.
Steps of Operation
1. The two ends of the nerves in question are exposed after an avascular field is achieved.
The ends of the nerves are cleaned till the fasciculi are protruding.
2. The required length of the nerve is measured without putting any joint in flexion.
3. The donor nerve is also dissected from its bed and the required length is removed. It
is better to take a couple of millimeters more than required.
4. The two ends of the nerve graft are sutured with the recipient nerve using fascicular
suturing as described before (see Figure 23). Make sure that there is no extensive
scarring in the bed of the nerve graft. If required, reroute the nerve into a healthy
area.
FIGURE 24. Incisions used for removal of the sural nerve.
5. Hemostasis is achieved and the wound is closed in the usual manner.
Steps of Operation for the Removal of Sural Nerve

The author's practice is to use a tourniquet; few surgeons prefer to remove the nerve
without any tourniquet. About a couple of inches of incision is made a finger-width behind
the ankle. The short saphenous vein is seen and is retracted. The sural nerve is easily
identified, lying just deeper than the vein. The distal end of the nerve is cut and a 6/0 nylon
stitch is put in as a marker for the distal end. When fixing the nerve graft, the distal end
should be stitched to the distal end of the nerve if sensory feeling is required and to the
proximal end of the recipient nerve if motor function is required.
Depending on the length of nerve required, multiple cuts are made about a couple of
inches apart on the postolateral aspect of the leg and the sural nerve is pulled after undermining
subcutaneously, from distal to proximal end. Some surgeons use a long vertical incision
extending from behind the ankle up to the point of length of nerve required (see Figure 24).
Up to 20 to 40 cm of the sural nerve can be removed, if required.
Hemostasis is achieved and the wound is closed with 5/0 nylon and the patient's leg is
elevated for about 24 hr to prevent postoperative swelling and edema.
If it is anticipated before the operation that a nerve graft is required the patient should be
informed that he will have some loss of sensation in the area of the donor nerve which will
gradually become small and unnoticeable.
Vascularized Nerve Graft19

This is a major procedure and the surgeon must be well trained in neurovascular anas-
Volume I 133
FIGURE 25. Vascularized nerve graft has been used to bridge the gap between
the two ends of the severed nerve trunk. Artery is anastomosed to the artery of
recipient area.
tomosis. The result of this type of surgery is good because the nerve has an adequate blood
supply. As in the pedicle graft, its use is limited because sometimes the donor nerve has to
be sacrificed. It is a very laborious and a time-consuming operation and should not be taken
lightly.
The patient should have preoperative angiogram to outline the blood supply of the donor
as well as the recipient nerve and the limb.
Steps of Operation
1. After an avascular field is achieved, the ends of the recipient nerve and its blood
supply are dissected out.
2. The donor nerve, with its intact blood supply, is dissected out and removed.
3. The artery of the donor nerve is anastomosed to an artery carrying the blood supply
to the recipient nerve.
4. The ends of the nerve are sutured using fascicular stitches.
5. Hemostasis is achieved and the wound is closed in the usual manner (see Figure 25).
Direct Neurotization of Denervated Muscle20

When the terminal part of the motor nerves of a muscle are damaged, the muscle is
denervated and atrophies. Direct neurotization of the denervated muscles can be performed
with satisfactory results, in a few cases. It has been demonstrated with the light and electron
microscope that the terminal nerve has the capacity to form new motor end plates in a
muscle.
FIGURE 26. The nerve trunk has been divided into various fasciculi and stitched
into the slits made in the muscle to increase the number of neurotized muscle
fibers.
Steps of Operation
1. Under an avascular field the muscle and the nerve grafts are exposed.
2. The terminal end of the nerve is cleaned until the various fasciculi are visible.
3. Small slits are made in the muscle.
4. The nerve fasciculi are inserted in the muscle slits and stitched with 8/0 microsutures,
taking the perineurium and the muscle sheath (see Figure 26).
5. Hemostasis is achieved and the wound is closed.
POSTOPERATIVE INSTRUCTIONS
The battle of the nerve repair is not fought in the operating theater, but in the postoperative
period. It is important to strictly carry out postoperative instructions, as the result not only
depends upon the operation but also on proper care in the postoperative period. Postoperative
care should start immediately after the operation. The patient should have a posterior plaster
slab installed after the bandage is applied and the hand immediately elevated in a sling. The
tourniquet should be removed and the circulation checked. The patient is sent out of the
operating theater with the following postoperative instructions.
Postoperative Orders in the Immediate Postoperative Period
1. Elevate the hand on a stand, in a sling, or on two or three pillows.

2. Watch for the circulation of the fingers.
Volume I 135
3. Use antibiotics i.v. if there is any risk of infection.

4. Postoperative analgesia — no strong analgesic should be used. If the patient needs
strong analgesics, the dressing should be changed to exclude any tightness of the
bandage or hematoma formation.
Delayed Postoperative Instructions
1. Every patient is advised to protect the denervated area from heat, cold, or other traumas.
2. The dressing is changed within 24 to 48 hr after the operation.
3. The patient is discharged after 3 to 5 days, depending upon the operation performed.
The patient keeps the hand in a sling and splint.
4. A week later the patient is seen and the stitches are removed.
5. Patient is again seen 3 to 4 weeks after the operation and the plaster splint is removed.
Patient is sent for physiotherapy and occupational therapy.
Postoperative Desensitization
In the postoperative period during the recovery phase, after nerve repair, there is always
hypersensitivity in the area supplied by that particular nerve. Patients are scared to touch
that area, so the process of desensitization is explained to them.
1. Patient is informed that avoiding contact with that sensitive area will result in an
increase in sensitivity.
2. Patient is taught to massage the area with lanolin, starting with a very gentle massage
and increasing pressure gradually till the touch improves. This should be carried out
four to six times a day.
3. Gently tap the sensitive area with the fingers of the normal hand. Again, the pressure
is increased as the tolerance improves.
4. The sensitive area is stimulated with different kinds of textures, beginning with a very
soft and least irritating one, for example, cotton wool, velvet etc. then gradually using
coarser material.
5. Patient is encouraged to use his hand in everyday activities, which helps in desensitizing
the area.
Postoperative Sensory Retraining

The aim is to stimulate the peripheral receptors of touch, pain etc. which sends impulses
to the brain to improve the impression of the area stimulated. This helps to improve ster-
eognosis in the hand. It is started as soon as the patient begins to feel. Objects of different
shape, size, and texture are used for retraining. The normal areas are covered so that sensory
retraining is carried out in desensitized area. The patient exercises this for about 10 to 15
min 3 to 4 times a day. The patient is encouraged to use everyday objects, which helps in
early recovery of sensation.
Make sure that the patient understands that the desensitized area should not come in
contact with very hot, cold, or shaq} objects.
ASSESSMENT OF RESULTS
Various time-consuming and sophisticated tests and methods have been designed to assess
the ultimate results of nerve repair. Seddon's classification for the return of nerve function,
shown in Tables 9 and 10, is used in our unit.22
Most commonly used tests for assessing the return of sensory function are
Table 9
CLASSIFICATION OF MOTOR RECOVERY
MO No contraction
Ml Perceptible contractions in the proximal muscles
M2 Perceptible contraction both in the proximal and distal muscles
M3 Return of function of such a degree that all important muscles
are sufficiently powerful to act against resistance
M4 Return of function as in M3 with addition that all synergic and
independent movements are possible
M5 Complete recovery
Table 10
CLASSIFICATION OF SENSORY RECOVERY
50 Absence of sensibility
51 Recovery of deep cutaneous pain
52 Return of some degree of superficial cutaneous pain and tactile
sensibility
53 Further recovery of superficial cutaneous pain and tactile sensibility
with no dysesthesia
53 + Same as Stage 3, with addition of some two-point discrimination
54 Complete recovery
1. Light touch sensation, using a wisp of cotton.

2. Pain sensation, using a sharp pin.
3. Hot and cold sensation.
4. Two-point discrimination — using the points of a compass is quite an accurate method
for evaluating return of sensory function. The normal value is 2 to 6 mm.
5. Coin test — the patient tries to identify various coins, based on their size and surface
characteristics.
6. Tinel's sign — in this test, gentle tapping is carried out beginning at the level of the
nerve repair. This will produce a tingling sensation radiating into the area supplied by
the particular nerve. The most distal point at which this tingling appears is recorded.
Tinel's sign is a promising but by no means an absolute indicator of satisfactory
functional return. If the Tinel's sign is stationary for many months after the postop-
erative period, little or no return of nerve function is expected. Normally, the Tinel's
sign advances about 1 mm/day. When the expected time of functional return has
passed, the form shown in Table 11 is filled out and a final decision regarding per-
centage return of function is made.
The presence of work stain on fingers and absence of any pain and tenderness are very
good signs of satisfactory functional return.
CONCLUSION
The author's experience suggests that perineural nerve repair using microsurgical tech-
niques and suturing the nerve without any tension, in a good healthy bed, followed by
postoperative physiotherapy, sensory retraining, and occupational therapy give good results
in any nerve injury. It is possible to have S3 and S3 + return of sensory function in about
70% of the patients and M3 in about 60% of the cases. One must keep in mind that the
results depend upon the site of lesion. If the nerve is divided near or below the wrist the
results are much better compared to when the nerve is divided in the forearm or above.
Volume I 137
Table 11
ASSESSMENT FORM FOR RESULTS
OF NERVE REPAIR
Surname:
First Name:
Age:
Sex:
Occupation:
Date of Injury:
Type of Injury:
Date of First Treatment:
Type of First Treatment:
Date Seen by our Unit:
Type of Surgery:
Last Date of Follow-Up:
Postoperative Physiotherapy:
How do you Feel?
Do you Think your Operation was Worth Doing?
Examination:
Work Staining
Size of Digit
Color of Digit
Sweating or Dry
Movements of Fingers
Tenderness
Pin Prick
Light Touch
Two-Point Discrimination
Stereognosis
Tinel's Sign
SUMMARY
The treatment of injuries to the peripheral nerves has been a great challenge to surgeons
for many centuries. Any surgeon contemplating operating on a nerve must necessarily
understand the anatomy and physiology of the normal nerve and the series of changes
(degeneration and regeneration) occurring in the proximal and distal ends of a severed nerve.
It has been shown conclusively that the end results of nerve repair performed under the
operating microscope are clearly superior to those of conventional neurorrhaphy. Since the
late 1960s the end result of surgical treatment of peripheral nerve injuries has improved
immensely with the advent of microsurgery. Microsurgery is extensively used, not only for
the primary and secondary repair of nerves, but also for nerve grafting and neurotization of
denervated muscle. The nerve grafting can be either the cable type or vascularized nerve
graft, neither of which would achieve a satisfactory result without the use of microsurgery.
The best results can be obtained only by following microsurgical techniques and suturing
the nerve without tension using fine sutures (8/0 to 10/0). The nerve bed should be healthy
and free of excessive scarring and every patient should have postoperative physiotherapy,
sensory retraining, and occupational therapy. Using such techniques it is possible to have
grade S3 and S3 + return of sensory function in 70% of the patients and grade M3 motor
function in 60% of the cases.
Fundamentals of Peripheral Nerve Repair
N — Never suture a nerve under tension

E — Epineurium suturing is not recommended because it produces excessive fibrosis
R — Repair the nerve using microsurgical techniques, operating microscopes, and microinstruments
V — Vital structures, like the blood supply of the nerve, should be preserved carefully
E — Elevate the arm or leg postoperatively to prevent swelling, edema, and intraneural hematoma
R — Reroute the nerve if the bed is scarred and unhealthy

E — Every patient should have postoperative sensory retraining, physiotherapy, and occupational therapy
P — Perineural suturing recommended for nerve repair
A — Apply tourniquet to achieve avascular field
I — Investigate the patient thoroughly before the operation
R — Repair the nerve using fine suture (8/0 to 10/0)
REFERENCES
1. Kuczynski, K., Histology of peripheral nerve trunks, Int. Surg., 65, 495, 1980.
2. Kleinert, H. E. and Griffing, J. M., Techniques of nerve anastomosis, Orthop. Clin. North Am., 4, 907,
1973.
3. Ducker, T. B., Kempe, L. G., and Hayes, G. J., Metabolic background for peripheral nerve surgery,
J. Neurosurg., 30, 270, 1969.
4. Sunderland, S., Nerve and Nerve Injuries, E. & S. Livingstone, Edinborough, 1968.
5. Yacubovich, E., Electromyographic follow up study of fascicular nerve graft in the upper extremity, J.
Hand Surg., 2, 162, 1977.
6. Smith, J. W., Factors influencing nerve repair, Arch. Surg., 93, 433, 1966.
7. Brunelli, G., Nerve suture, Int. Surg., 65, 499, 1980.
8. Palazzi, S., Neurolysis in compression neuropathies, Int. Surg., 65, 509, 1980.
9. Millesi, H., Microsurgery of peripheral nerves, The Hand, 5, 157, 1973.
10. Hakstian, R. W., Perineural neurorrhaphy, Orthop. Clin. North Am., 4, 945, 1973.
11. Grabb, W. C , Bernent, S. L., Koepke, G. H., and Green, R. A., Comparison of methods of peripheral
nerve suturing in monkeys, Plast. Reconstr. Surg., 46, 31, 1970.
12. Terzis, J., Faibisoff, B., and Williams, B., The nerve gap. Suture under tension vs. graft, Plast. Reconstr.
Surg., 56, 166, 1975.
13. Salvi, V., Problems connected with the repair of nerve sections, The Hand, 5, 25, 1973.
14. Wise, A. J., Topuzlu, C , Davis, P., and Kaye, I. S., A comparative analysis of macro- and microsurgical
neurorrhaphy techniques, Am. J. Surg., 117, 566, 1969.
15. Orgel, M. G. and Terzis, J. K., Epineural vs. perineural repair, Plast. Reconstr. Surg., 60, 80, 1977.
16. Levinthal, R., Brown, J., and Rand, R. W., Comparison of fascicular, interfascicular and epineural
suture techniques in the repair of simple nerve lacerations, J. Neurosurg., 47, 744, 1977.
17. Gabaud, H. E., Epineural and perineural fascicular nerve repairs, a critical comparison, J. Hand Surg.,
1, 131, 1976.
18. Walton, R. and Finseth, F., Nerve grafting in the repair of complicated peripheral nerve trauma, J.
Trauma, 17, 793, 1977.
19. Taylor, G. I. and Ham, F. J., The free vascularized nerve graft under tension vs. graft, Plast. Reconstr.
Surg., 57,413, 1976.
20. Brunelli, G. and Brunelli, L. M., Direct neurotization of severely damaged denervated muscles, Int.
Surg., 65, 529, 1980.
21. Brunelli, G. and Brunelli, L. M., Long term results of nerve sutures and graft, Int. J. Microsurg., 1, 27,
1979.
22. Seddon, H., Surgical Disorders of the Peripheral Nerves, Williams & Wilkins, Baltimore, 1972.
Volume I 139
MICROSURGICAL RECONSTRUCTION OF PERIPHERAL NERVES —

OWN EXPERIENCE
Henryk Kus
INTRODUCTION
The reconstruction of peripheral nerves is a procedure of great importance, not only in

traumatology but also in replantation and in the surgical treatment of tumors. The purpose
of repairing severed nerves is to restore their sensibility and motor function.
For more than 80 years severed peripheral nerves have been treated surgically, but the
actual surgery of the peripheral nerves advanced greatly in the last decade due to the
improvement of diagnostics, new materials, and tools. 14
The application of magnifying glasses, handglasses, and microscopes allowed penetration
into the topography of damaged peripheral nerves which had been impossible with the unaided
eye. Studies of the complex regeneration processes of the damaged and cut peripheral nerves
as well as the anatomic evaluation of the nerve structure have also been of great importance.35
The progress in reconstruction has been stimulated by increasing number of defects in
peripheral nerves — the result of massive war traumas and progressing mechanization of
everyday life and work. The consequence has been specialization of surgical centers and
groups of surgeons in reconstruction of peripheral nerves, equipped with the modern di-
agnostics, surgical materials, and tools.
In practice, however, the development of reconstructive surgery of peripheral nerves is
still in progress and requires further technical improvement based upon the scientific
data. 258
The results of peripheral nerve surgery have improved considerably during the last 12
years, but despite many experimental and clinical investigations the methods of nerve re-
construction vary from center to center and even from surgeon to surgeon.
MACROSCOPIC AND MICROSCOPIC RECONSTRUCTION OF

PERIPHERAL NERVES
The reconstructive operations of peripheral nerves may be divided into conventional

macroscopic and microscopic procedures.916 Both were modified according to the basic or
clinical experience to improve the technical procedure and to achieve better clinical results.
Generally, the microscopic methods allow much better insight into the intraneural topography
of the severed and sutured nerves and a much better alignment of the nerve fascicles.2'7
The microscopic procedure is based not only upon the use of magnification, delicate
instruments, and the finest suture materials, but also requires a new way of thinking17 based
upon the objective evaluation of clinical results.
Experimental and clinical results reveal that the apposition of fascicles of peripheral nerves
by the microsurgical technique is superior to the usually applied epineurial suture method.5'67
Magnification allows easier and more precise determination of the nerve fascicles and
better adaptation of their cross-sections.1'25-8 Another advantage of microsurgery is the better
late results of regeneration after reconstruction of peripheral nerves, as well as better ap-
position of the sensory and motor fascicles, with higher probability of their territorial at-
tachment than that offered by the classical macroscopic technique.
Microsurgical technique, contrary to the classic macroscopic epineurial suture, is much
more time consuming and requires greater experience. Moreover, almost as a rule, the
application of nerve grafts is necessary to assure the reconstruction of a nerve since the
fascicular microsurgical suture cannot be under any tension.
Reduction of the tension in the microsurgical nerve suture, achieved either by the im-
mobilization of the neighboring joints by flexion or displacement of nerves, is not advised
because it requires a prolongated period of immobilization of the limb and may lead to
secondary injuries or even to the damage of the nerve suture during rehabilitation.2,6
OWN EXPERIENCE
We have applied the methods of macroscopic and microscopic nerve reconstruction with
various modifications in peripheral neurorrhaphy in over 700 patients on more than 1000
nerves in the years 1968 to 1981.
The purpose of our presentation is the microsurgical technique elaborated and applied by
our surgical team in the reconstruction of peripheral nerves and is based upon the clinical
examination of patients treated since 1968.
The results of the surgical treatment of peripheral nerves depend upon the:
1. Kind of trauma and accompanying damage

2. Age of the patient
3. Level of the damage and the length of nerve defect
4. Time factor
5. Surgical technique18 20
The surgeon is capable of improving the results of treatment by the most proper choice
of the time for reconstruction after the trauma and by means of the best surgical technique.
The principles generally accepted in reconstruction of nerves are refreshment of the stumps
to the healthy areas, good adaptation of nerve fascicle sections, and prevention of the
formation of scars by traumatic surgery.57-20 Tension in a nerve suture should be avoided.
Sutures should be as thin as possible so that the reaction around them would not make nerve
regeneration difficult.
From the technical point of view, the neurorrhaphy is different in the emergency and the
secondary operations. It has been proved that the most successful operation is the early
reconstruction performed immediately after the injury or within a few weeks. It makes the
operation easier and ensures better regeneration conditions than in chronic cases.
Some observations revealed that better results were achieved when the treatment was
performed a couple of weeks after the trauma, than in an emergency. This is most important
in mixed traumas and might be due to the yet unknown features of damaged nerves, in
which the dynamics of biological regeneration processes could increase in a couple of days
or weeks after the trauma. The fact that the secondary operation is usually better prepared
for and performed by a team of specialists could also be of importance.
Therefore, for many years we have advised that the primary treatment for unclean surgical
wounds combined with nerve damage either be by the simple alignment of the nerve stumps
or the overlapping of the stumps in a length of about 5 mm.20 Such a two-step procedure
allows, in a great number of patients, the direct microsurgical suture of fascicles during the
secondary operation, without nerve grafts.
In all patients who came to see us because of the lack of regeneration of sutured nerves
after an emergency operation in a nonspecialized hospital we have ordered the revision of
the nerve lesion, independent of the time after the lesion.
MICROSURGICAL TECHNIQUE IN EMERGENCY FOR LARGE

NERVE STUMPS
A nerve transected in a clean incise wound can be repaired by direct suturing of the
Volume I 141
stumps. The nerve stumps are dissected from the neighboring and adventitional tissues and
are carefully refreshed. Great care must be exercised so that the stumps are in correct vascular
topography and the fascicular pattern of the cut nerves match each other. The dissection
should be done in ischemia by tourniquet of the extremity, but the nerve suture itself is done
without a tourniquet, which facilitates the local hemostatis and the location of the fascicles
and their groups. Two or three traction mattress sutures are placed in the epineurium using
6/0 to 8/0 nylon, to either effectuate or facilitate the apposition of the main fascicles. The
sutures are left untied until the fascicle surfaces are aligned. Then 2-6 additional finer sutures
are placed on the epineurium close to the distinguished fascicle groups. A satisfactory external
appearance is not a guarantee of an exact apposition of the surfaces of the nerve ends.
Magnification enables the identification of the fine structure of the nerve components and
a proper fascicle alignment during the nerve suture.
In some peripheral nerves, especially in young patients, the fascicle groups may be visible
by transparence which helps to align them correctly. Sutures that cause misalignment should
be removed and replaced correctly.
In our experience the best results in freshly cut peripheral nerves were achieved by the
following procedure. On the cross-section the fascicle topography is not precise, therefore,
we incise the epineurium longitudinally about 1 cm (Figure 1A), mobilize the fascicles
(Figure IB), and perform the epineurial suture and the finest fascicular suture (Figure 1C).
If there is also damage to the tendons or other tissues they should be repaired prior to the
nerve suture. The extremity should be put in a neutral position and the nerve suture carefully
observed.
The incision should be performed so that the skin sutures would not cover the underlying
nerve. A splint of plaster of Paris is applied for about 3 weeks, but some movement of
fingers should be allowed.
In cases of tension in the nerve union after the placement of two-traction sutures, nerve
grafts or the two-step procedure should be considered. A nerve graft is used only in clean
and fresh wounds. Using grafts (sural nerve) one should prepare the nerve stump in different
lengths of the fascicular groups, since the union of fascicular groups with the autologous
nerve graft has better stability due to the plasmatic conglutination of the grafts.3
Sometimes the final reconstruction may be performed a few days after the injury according
to the method described by Iselin (''traitement immediate avec l'opération différée").29 The
reconstruction may be done as in clean wounds with the classic or modified epineural sutures
or with nerve graft.
SURGICAL TECHNIQUE IN EMERGENCY FOR SMALL NERVES
Small nerves, such as the proper digital nerve or the sensitive branch of the radial nerve
at the wrist, which have been freshly and cleanly transected, can be repaired by direct suture
under microsurgical procedure.
The first suture of 8/0 or 10/0 is passed through the epineural and perineural tissue around
the largest fascicle. The knot is tied with good apposition of the nerve surfaces. Usually the
first knot does not allow a good alignment. Therefore, a second suture is usually placed
between 100 to 120° with respect to the first (Figure 2). Sometimes a third suture is needed
depending upon the number of greater fascicles. Fibrinous adhesion is rapid and helps the
fixation and an adequate alignment of the nerve fascicles.
SECONDARY RECONSTRUCTION OF PERIPHERAL NERVES
In secondary neurorrhaphy the epineurium is thickened and also the connective tissue
inside the nerve is firmer than in fresh cases. The fascicles do not correspond often to each
FIGURE 1. (A) Clean-cut peripheral nerve stumps. The intraneural topography of the refreshed cross-sections
of the nerve is not clearly visible. The nerve fascicles often protrude from the connective tissue. Therefore, a small
longitudinal incision of the epineural sheet helps not only the proper refreshment of the fascicles within unchanged
limits, but also in a better adaptation of the nerve fascicles. (B) Dissected groups of fascicles. (C) To reconstruct
the nerve, first the epineurium behind the nerve fascicles is sutured and then the nerve fascicles are joined by a
microsurgical technique. This procedure is possible only in fresh wounds without a marked defect of the nerve.
other, especially if it is necessary to excise some part of the damaged nerve stumps or if a
primary nerve defect exists. Quite often the distal fascicles are also atrophied, so that their
diameter is smaller than in the proximal nerve stump. Therefore, an ideal alignment of the
nerve stumps is, in practice, impossible, as can be seen more precisely under magnifica-
tion.2 4-6-8 For the mentioned reason, in secondary neurorrhaphy a proper and more precise
Volume I 143
FIGURE 2. One of the best methods for direct small nerve

suture in emergency with the location of three sutures where
the smallest distance between the epineurium and perineu-
rium of main fascicles exists.
nerve suture is more important, and the epineural suture less effective, than in emergency
cases.19-20
Usually, the adventitial tissues and the epinerium are excised along the whole periphery
of the nerve for a distance of V2 to 1V2 cm and the fascicle groups are isolated. In most
cases, or as a rule, the nerve reconstruction is performed with autologous skin nerve
grafts.2"619
SECONDARY NERVE RECONSTRUCTION

For the secondary reconstruction of peripheral nerves (from 2 months until several years
after the trauma) we have elaborated a method which allows, in a large number of cases,
the direct and easy alignment and suture of fascicle groups without the use of interposition
of nerve grafts.
This method is based upon the advantage of the epineurium as a strong membrane for
splinting and relaxation for the delicate perineural sutures. This technique, in use since 1980,
is one of our standard methods of nerve reconstruction in patients with isolated or mixed
nerve injuries of the upper and lower extremities.19
In the patients treated surgically because of previous incorrect nerve suture or simple
nerve adaptation in an emergency operation, a small or medium nerve defect were found.
In the follow-up clinical examinations there were no signs of neuroma at the anastomosis,
and good or very good results were obtained. In three cases of mixed injuries at the wrist
we have performed reoperations for tenolysis and have found excellent nerve anastomoses.
TECHNIQUE OF OWN METHOD FOR THE SECONDARY

NERVE RECONSTRUCTION
The first step after the isolation of the neuroma or nerve stumps is identical to the method
described by Millesi et al.2-3 and is based on the longitudinal incision of the epineural sheet
along the epineural nerve vessels (Figures 3A, B, and C). This makes it possible to distinguish
the intraneural topography (Figures 4A to F). The grouped fascicles are split longitudinally
for a distance of 1/2 to 1 cm in order to assure the subsequent adequate apposition. During
FIGURE 3. (A) Neuroma after emergency suturing of the transected median nerve at the wrist; (B) preparation
of nerve fascicles after longitudinal incision of the epineurium; and (C) the intraneural topography near the
posttraumatic neuroma.
this part of the microsurgical operation damage to the intranerval connections and lesion of
the nerve vessels should be avoided. Then the nerve sheet is examined and its excess excised
(Figure 5A). The edges of the perineural sheet are joined by everting mattress or continuous
suture 5/0, so that the cross-sections of the isolated fascicle groups touch each other without
tension in a neutral position of the extremity (Figures 5B and C). The sutures must not
protrude inside the nerve tissues (Figures 5D and E). It is the most difficult part of the
operation.
PLATE 1. Intraneural neuroma with thickening and induration of the median nerve.
PLATE 2. Typical dissection of the nerve fascicles with the excision of the epineurium. The
reconstructions are (in the rule) performed with skin nerve grafts.
PLATE 3. Vein graft (arrow) ready for anastomosis to superior sagittal sinus (arrowheads).
PLATE 4. Functioning, completed bypass of torcular herophilus. Superior sagittal sinus (arrow);
graft (arrowheads). Clips occluding original torcular apparent.
Volume I 145
FIGURE 3C
The subsequent stage is based upon the alignment of the separated groups of fascicles
using 8/0, 9/0, or 10/0 microsurgical sutures as in the routine apposition of the interfascicular
nerve suture (Figure 5F). The needles should be sharp to avoid damage to the nerve. Usually,
unresorbable nylon sutures were applied, but now we give preference to absorbable micro-
surgical Dexon® sutures 9/0 or 10/0.22 The nerve fascicles may also be united without suture
by using fibrin adhesives.19
The described neurorrhaphy might prove to be, in a large number of cases, physiologically
comparable with other methods of microscopic fascicular nerve reconstruction, but it is less
work and less time-consuming and allows early rehabilitation of the patients.
The same principle may also be used in reconstruction after partial nerve lesion (Figures
6A and B; and Plate 1*). In most cases, the popularized excision of the epineurium on the
whole periphery of the partially damaged nerve 25,6 (Plate 2) is, in our experience, not
necessary and does not potentiate the invasion of scar tissues into the fascicular sutures.
The scar tissue has its origin not only in all surrounding tissues but also in the epineurium
if it has a tubular shape.
We incise the epineurium longitudinally and excise the damaged parts of the fascicles
with the scar tissue (Figure 6C). Only very small defects may be reconstructed by a direct
suture. In most cases it is necessary to use skin nerve grafts which are shorter than after the
total excision of the epineurium (Figure 6D). The sutures and the fascicle groups are also
better protected against traction and extension.
* Plates 1 and 2 will follow page 144.

FIGURE 4. Various anatomic arrangements of nerve fascicles near the posttraumatic neuromas. (A) Large neuroma
of the transected median nerve; (B) topography of the nerve fascicles after longitudinal incision of the epineurium;
(C) transected median nerve at the wrist and four fascicles of different lengths are visible; (D) the intraneural
topography near the proximal median nerve stump connected with forearm muscles; (E) preparation of the proximal
median nerve stump for reconstruction; and (F) distal ulnar nerve stump after longitudinal incision of the epineurium.
SOME REMARKS ON SUTURE MATERIALS FOR NERVE RECONSTRUCTION
Very often the question arises as to what suture materials should be used in peripheral
nerve reconstruction.12227 Generally, the kind of materials and needles used for nerve suture
depends upon the operator's preference, his habits, or his practical experience.
This question was part of our experimental study project, i.e., to prove the value and
quality of unresorbable and resorbable microsurgical sutures implanted into sciatic nerves
in rabbits and pigs.
Local tissue reaction with foreign body cells was observed around all types of the mono-
filamentous suture materials (nylon, polyester, Dexon® 9/0, 10/0), but the resorbable Dexon®
sutures seemed to be superior since the granulomas around them decreased with progressing
absorption, which lasted usually for 30 to 90 days. That may be essential in the formation
of scar tissues and in the late results of neurorrhaphy. Similar results were obtained in the
application of Vicryl® microsurgical sutures.28
Among different types of tissue adhesives, the immuno human fibrin adhesive was found
to be the best, and better than autologous fibrin. It gives minimal tissue reaction and is
absorbed much faster than the Dexon®.22'2526
Originally, the plasma clot nerve suture was elaborated in order to avoid the use of suture
material for the nerve suture. 2324 In practice, however, the anastomosis proved to be so
weak that the plasma clot method had to be combined with the suture technique.
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FIGURE 4B
FIGURE 4C
FIGURE 4D
FIGURE 4E
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FIGURE 4F
In our opinion, the immuno human adhesive may be used as an adjunct to the "one stitch
fascicle nerve suture" or as a sealant for faster adaptation of fascicle groups, if there is no
tension in the suture line. The ideal situation has been in cases using the epineural relaxation
suture for the direct fascicles alignment.19 The fibrin may interponate the joined fascicles
but should be placed after the proper alignment of them. If more than six anastomoses are
to be performed then gluing is a time-saving method.
Obviously, the proper choice of suture material for nerve repair is important, but certain
principles should be emphasized:
1. There should be minimal trauma connected with the suture insertion; therefore, only
sutures with smooth and regular surfaces and the proper atraumatic needle should be
used.
2. The surface area of sutures in contact with neural tissue should be reduced to a
minimum.
3. The nerve ends should be approximated with great accuracy, without either torsion or
tension.
4. Resorbable microsurgical sutures seem to be superior to the commonly used unre-
sorbable ones.
5. Fibrin adhesives may play a role as an adjunct in fixation of some fascicle nerve
sutures or nerve grafts.
SUMMARY
The results of peripheral neurorrhaphy have been improved during the last 14 years, but
FIGURE 5. (A) The longitudinally incised epineurium and dissected fascicle groups of the proximal and distal
nerve stumps of the median nerve prepared by reconstruction. (B) The nerve stumps prepared for direct fascicle
anastomosis. The strong epineural sheet may be sutured in all cases where the nerve defect is of moderate length,
serving as a secure relaxation for the delicate perineural sutures. (C) Schema to Figure 5B. (D) The epineural
relaxation suturing is performed; the first attempt for the correct alignment of the dissected nerve fascicles. (E)
Schema to Figure 5D. (F) The final results of direct fascicular anastomosis.
despite many experimental and clinical investigations the methods of nerve reconstruction
vary from center to center and even from surgeon to surgeon.
We have applied the methods of macroscopic and microscopic nerve reconstruction of
peripheral nerves in over 700 patients on more than 1000 nerves.
A nerve transected in a clean wound can be repaired by direct suturing of the stumps.
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FIGURE 5C
FIGURE 5D
On the cross-section the fascicle topography is not precise and, therefore, we prefer the
longitudinal incision of the epineurium with the one-side epineural retension suture and the
finest alignment of the fascicle groups.
In cases of tension in the nerve union, nerve grafts or the two-step procedure should be
considered.
For many years we have advised that the primary treatment of uncleaned wounds combined
with damage of peripheral nerves be performed by using the simple alignment of the nerve
stumps. A two-step procedure allows, in a great number of patients, the direct microsurgical
suture of nerve fascicles without nerve grafts.
FIGURE 5E
FIGURE 5F
In secondary neurorrhaphies, a proper and more precise nerve suture is more important,
and the epineural suture less effective, than in emergency cases. In a number of cases the
direct and easy alignment and the suture of fascicle groups without the use of interposition
of nerve grafts is possible. This method is based upon the advantage of the epineurium as
a strong membrane for one-side splinting and relaxation for the delicate direct perineural
sutures of fascicles or their groups. This technical procedure is described and illustrated in
Figures 5B to F. The same principle without the excision of the epineurium on the whole
periphery may be used in the reconstruction of a partial nerve lesion.
This paper, also, presented some remarks on suture materials for nerve reconstruction
based on our own experience with attention given to resorbable microsurgical sutures (Dexon®)
and some usefulness of the immuno fibrin adhesive (Tissucoll®).
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FIGURE 6. Secondary reconstruction of a partial lesion of the nerve trunk. (A) Lesion of the median nerve by
a small stab wound at the wrist; (B) schema to Plate 1; (C) after the lengthwise incision of the epineurium two-
damaged fascicles with the formation of neuroma and scar tissues are visible; and (D) reconstruction of the defect
with adequate nerve grafts.
FIGURE 6D
REFERENCES
1. Edshage, S., Peripheral nerve suture. A technique for improved intraneural topography. Evaluation of some
suture materials, Acta Chir. Scand. Suppl., 331, 1, 1964.
2. Millesi, H., Ganglberger, J., and Berger, A., Erfahrungen mit der Mikrochirurgie peripherer Nerven,
Langenbecks Arch. Klin. Chir., 316, 723, 1966.
3. Millesi, H., Meissl, G., and Berger, A., The interfascicular nerve grafting of the median and ulnar nerves,
J. BoneJt. Surg., 54A, 737, 1972.
4. Brunelli, G., Les sutures fasciculaires sous microscope, in Les Lésions Traumatiques des Nerfs Périphé-
riques, Collana, G. E. M., Ed., L'Expansion Editeur, Paris, 1972, 48.
5. Brunelli, G., Microchirurgia, Vol. Editor a Cura, Fondazione Pelizza, Brescia, 1978.
6. Meyer, V., Microsurgical reconstruction of peripheral nerves, Sei. Rep., Microsurgery, Société Steril
Catgut (SSC), 1, 18, 1981.
7. Miction, J. and Moberg, E., Traumatic Nerve Lesions of the Upper Limb, No. 4, Churchill Livingstone,
London, 1976.
8. Narakas, A., Microsurgical neurorrhaphy technique, Sci. Rep., Microsurgery, Société Steril Catgut (SSC),
1, 21, 1981.
9. Gabrielson, G. J. and Stenstron, S. J., A contribution to nerve suture technique, Plast. Reconstr. Surg.,
38, 68, 1966.
10. Kline, D. G. and Nulsen, F. E., The neuroma in continuity: its preparative and operative management,
Surg. Clin. North Am., 52, 1189, 1970.
11. Smith, J. W., Microsurgery of peripheral nerves, Plast. Reconstr. Surg., 33, 317, 1964.
12. Geldmacher, J., Die Wiederherstellung verletzter Nerven, Muench. Med. Wochenschr., 52, 2675, 1969.
13. Sunderland, S., Nerves and Nerves Injuries, Churchill Livingstone, Edinburgh, 1972.
14. Buck-Gramcko, D., Wiederherstellung peripheren Nerven, Chir. Praxis, 15, 55, 1971.
15. Tsuge, K., Ikuta, Y., and Sakane, M., A new technique for nerve suture, Plast. Reconstr, Surg., 56,
497, 1975.
16. Tubiana, R., Les dates et les indications des réparations secondaires après lésion des nerfs périphériques
du membre supérieur, in Les Lésions Traumatiques des Nerfs Périphériques, Collana, G. E. M., Ed.,
L'Expansion Editeur, Paris, 1972.
17. Millesi, H., Reconstructive microsurgery, 50th Jubilee Congr. Polish Surgeons, Kraków, in press.
18. Brown, P. W., Factors influencing the success of the surgical repair of nerves, Surg. Clin. North Am.,
52, 1137, 1972.
19. Kus, H., Mikrochirurgische direkte faszikulare Nervennacht. Eigene Méthode. 29. Jahrestagung der
Deutschsprachigen Gemeinschaft für Handchirurgie, Travemünde-Lübeck 1981, Kongressbericht, in Hand-
chirurgie, Mikrochirurgie, Plastische Chirurgie, in press.
20. Kuá, H. and Kordecki, J., Zabiegi rekonstrukcyjne w urazowych uszkodzeniach nerwów obwodowych
koñczyn górnych i dolnych (Reconstructive operations in traumatic lesion of peripheral nerves of the upper
and lower extremity), 46 Zjazd Chir. Pol. (46th Congr. Polish Surgeons), 2, 727, 1974.
21. Kuá, H., Kedra, H., and Kordecki, J., Odroczone zabiegi operacyjne w ranach miazdzonych reki
(Deferred surgical procedures in crush injuries of the hand), Chir. Narzadow Ruchu Ortop. Pol., 36, 413,
1971.
Volume I 155
22. Kus, H., Resorbable and unresorbable microsurgical sutures. Experimental investigations, Simp. Primav-
erilleSoc. ltd. Microchir., Brescia, June 1981.
23. Young, J. Z. and Medawar, P. B., Fibrin suture of peripheral nerves; measurement of rate of regeneration,
Lancet, 2, 126, 1940.
24. Tarlow, I. M., Plasma clot suture of nerves — illustrated technique, Surgery, 15, 257, 1944.
25. Kuderna, H. and Matras, H., Die Klinische Anwendung ker Klebung von Nervenanastomosen mit
Gerinnungssubstanzen bei der Rekonstruktion verletzter peripherer Nerven, Wien. Klin. Wochenschr., 87,
495, 1975.
26. Matras, H. and Kuderna, H., Gluing nerve anastomosis with clotting substances, Trans. 6th Int. Congr.
Plast. Reconstr. Surg., 135, 1975.
27. Ippisch, A., Wriedt-Lübbe, I., Duspiva, W., and Blümel, G., Mikrochirurgische Nerven — und Ge-
fàssnáhte mit resorbiebarem Material, Z. Plast. Chir., 4, 1, 1980.
28. Thümler, P., Reinhard, V., and Elbing, H., Faszikulare Nervennahte mit synthetischen resorbiebaren
Nahtmaterial (Polyglactin 910), Orthopad. Praxis, 2, 154, 1979.
29. Iselin, M. and Iselin, F., Chirurgie de la Main, Masson, Paris, 1955.
Volume I 157
SURGICAL TREATMENT OF POSTTRAUMATIC LESIONS OF THE

BRACHIAL PLEXUS
H. Millesi
INTRODUCTION
Posttraumatic lesions of the brachial plexus are most commonly a consequence of a traffic
accident, especially of motorcycle accidents. Usually young people are involved. A loss of
function of one arm means a severe functional loss for a boy or the young man. The flail
arm is not only useless, but very often an obstacle. It is, therefore, understandable that in
the past surgeons have attempted to improve the situation of these patients by operations at
the level of the brachial plexus. Some 20 years ago these attempts were not very successful.
At the 10th Congress of the Société Internationale de Chirurgie Orthopédique et Trauma-
tologique in Paris in 1966, a round table assembling all important capacities in this field
was held, which included Sir Herbert Seddon, R. M. Merle d'Aubigne, and so on. During
this round table it was concluded that surgery has nothing to offer in the case of root lesions,
except clarifying the diagnosis, and establishing the fact that a loss of continuity is present
in order to avoid further loss of time while waiting for spontaneous recovery. In these cases,
amputation at an upper arm level with arthrodesis of the shoulder joint was regarded as the
treatment of choice, with subsequent application of a prosthesis. Further studies revealed
that many patients were not very happy with the shoulder joint arthrodesis and did not use
the prosthesis.
In 1962, the author started to operate on posttraumatic brachial plexus lesions, and since
1963 has applied microsurgical techniques. Thus, when confronted with the conclusions of
the above-mentioned round table, the author already had some promising results and con-
tinued his research. In 1967 the author was visited by A. Narakas, who attended some
brachial plexus operations. Prior to this he was skeptical that surgery could be of value in
brachial plexus cases. In 1969, on the invitation of Professor Claude Verdan, the author
presented his research results at the Clinique Longeraie, where A. Narakas had already done
brachial plexus surgery but still could not present results.
The negative attitude against direct brachial plexus surgery can be explained by two
arguments:
1. In cases of a loss of continuity at the brachial plexus level there usually were long
nerve defects which could not be managed by end-to-end coaptation. Nerve grafting
would have been necessary. In those days confidence in nerve grafting was rather low
and, therefore, this solution was seldom considered in spite of the fact that some
important successes had been reported. Sir Herbert Seddon, in 1943, reported on
functional recovery of the biceps in two of five cases with upper brachial plexus lesions
treated by nerve grafts. But he gave up this operation when Clark presented his
technique of major pectoralis muscle transfer to replace biceps function.
2. In cases of preserved continuity, surgical activity was limited by the possibility of
damaging portions of the brachial plexus and thus the prospect of spontaneous recovery.
Microsurgery offered the opportunity to solve these two problems. Confidence in the
results of nerve grafts was markedly increased by new techniques.5 Using optical magni-
fication and atraumatic microsurgical techniques, it was now possible to use intraneural
neurolysis with a sufficiently high safety range to avoid damage and thus enhance chances
of spontaneous recovery.
For several years even microsurgery of peripheral nerves was not well accepted. The
arguments against microsurgery were that these operations consumed more time and needed
more sophisticated equipment and were not worthwhile to perform. It was not until the 12th
SICOT Meeting in 1972, in Tel Aviv, that this technique became generally accepted.
Arguments against direct surgery of posttraumatic brachial plexus lesions, in particular,
are that the relatively limited functional results do not justify this complicated and time-
consuming type of surgery, and that in many cases spontaneous recovery occurs without
surgery. In the following pages the author presents his personal experience with brachial
plexus surgery and the results achieved.
INDICATIONS FOR SURGERY AND SELECTION OF PATIENTS
Posttraumatic brachial plexus lesions can be differentiated according to the level of the
injury, and the amount of damage.
Level of Injury
It is evident that in cases of avulsion restoration of continuity is impossible. For this
reason, in the past, attention was focused on the establishment of a valid differential di-
agnosis, recognizing cases of avulsion. If an avulsion was proved, e.g., by myelography,
some surgeons3'89 immediately performed intercostal nerve transfer after Sir Herbert Seddon
(1963) had published a successful case. According to our experience an avulsion of all five
roots occurs only exceptionally. Narakas6 observed an avulsion of all five roots in only 5%
of his cases. Even this number might be too high, because the author, personally, has seen
cases operated by distinguished surgeons who established the diagnosis of root avulsion but
which finally proved not to be an avulsion of all five roots. Therefore, the indication to
perform an intercostal nerve transfer should be established only after the surgeon has con-
vinced himself by careful exploration that all roots are really avulsed. If there is an avulsion
of three or four roots only, nerve transfers can be combined with restoration of continuity
between the stumps of the ruptured roots and distal stumps.
If proximal stumps with neuromas are available, continuity is restored by nerve grafts
after resecting the neuroma and restoring continuity. Regardless, whether this happens at
root, trunk, or cord levels. Bilevel injuries have to be considered and it is, therefore, necessary
to explore the whole brachial plexus.
Amount of Damage
The amount of damage of a peripheral nerve can be classified according to Sunderland7
in five degrees:
1. In a lesion of the first degree (conduction block without axonolysis) function returns
rapidly. These cases can be recognized by electrophysiologic studies (conductivity of
motor fibers is preserved several weeks after the accident). No surgery is indicated.
2. In a second degree lesion (axonotmesis) axonolysis occurs, but due to the fact that
the other structures remain intact full spontaneous recovery can be expected. These
cases can be recognized by observation of the course, detecting early signs of recovery
after 3 or 4 months. No surgery is indicated.
3. In a third degree lesion the fascicular pattern and the perineurium remain intact. These
cases also have chances of spontaneous recovery, but due to the fact that the epifas-
cicular and interfascicular epineural tissue may develop a severe fibrosis in consequence
of a traction lesion, constriction prevents spontaneous recovery within a reasonable
time. These are the cases in which decompression by intraneural neurolysis enhances
recovery and shortens the time of recovery considerably. In sequence epifascicular
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epineurotomy, epifascicular epineurectomy and partial interfascicular epineurectomy

are performed until the constriction of the fascicles is released. The operation is
immediately stopped at any point when decompression is achieved. It is not the aim
of intraneural neurolysis to isolate each individual fascicle.
4. In a fourth degree lesion the fascicular pattern has been lost but continuity is preserved
by fibrotic epineural tissue. In these cases spontaneous recovery within reasonable
time cannot be expected. Segments showing a fourth degree lesion are attacked by
intraneural neurolysis. During intraneural neurolysis it becomes evident that the whole
segment or part of it has lost the fascicular pattern and the diagnosis of a fourth degree
lesion is established. In this case the involved part is resected and by restoration of
continuity, using nerve grafts, the fourth degree lesion is converted into a third degree
lesion without constriction.
5. In a lesion of the fifth degree, the two stumps have to be resected until normal tissue
is met in the cross-section and continuity is restored by nerve grafts. It is evident that
this also means converting the fifth degree lesion into a third degree lesion without
constriction.
It has to be mentioned that lesions of degrees 1 to 4 can be accompanied by external

pressure on the brachial plexus. This external pressure can prevent spontaneous recovery of
first and second degree lesions. Consequently, if in a lesion of first and second degree
recovery does not occur within the expected period of time, this possibility has to be
considered and an external neurolysis is indicated.
In summary: direct surgery on the brachial plexus is indicated in cases in which spontaneous
recovery cannot be expected or did not occur, or spontaneous recovery came to an unexpected
standstill. It is our experience that the chances of recovery decrease significantly 6 months
and later after the accident. Therefore, we have to establish the indication for operation
within this period of time by repeated examinations and observation of the course and, if
an operation is indicated, it should be performed between months 4 and 6 after the accident,
or earlier.
THE TECHNIQUE OF OPERATION

Since 1963 we have used the following technique: the patient is supine, with the shoulder
of the involved side slightly elevated. The arm is abducted. The incision follows the dorsal
order of the sternocleidomastoideus muscle, turns at the level of the insertion of this muscle
into the clavicle bone and follows the clavicle to a level near the coracoid processus and
turns again, reaching the ventral axillary fold in a zigzag form. It can be easily extended to
the inner side of the upper arm. The technique is based on the principle of saving as many
structures as possible. We do not transect the omohyodeus muscle or the subclavius muscle
and, with a few exceptions, do not perform an osteotomy of the clavicle bone. The external
jugular vein is usually transected and ligated, and the major pectoralis muscle is partially
desinserted from the clavicle to provide sufficient space. The minor pectoralis muscle, the
subclavius muscle, and the omohyodeus muscle are isolated and, using a firm rubber sling,
they can be drawn in either direction to provide sufficient access. The clavicle bone is also
isolated and can be easily drawn into a cranial or caudal direction. From a supraclavicular
approach the roots C4, C5, C6, and C7 are defined. Entering between the deltoideus and
the major pectoralis muscle, the axillary artery and the cords are defined distal to the lesion
and then followed in proximal direction. Isolating the medial cord from the subclavian artery,
the inferior trunk, and roots C8 and Tl can be defined from an infraclavicular approach. If
roots or trunks are ruptured, neuromata has formed at the proximal stumps, and the situation
can be clarified quite easily. If there is an avulsion with extrusion of certain roots, the
intervertebral channel is empty and the root with the ganglion and the filaments can be
isolated on the distal stump. If continuity is preserved, an external neurolysis is performed
to remove any structure which might constrict or compress the involved portion. If there is
a fibrosis of the epineurium, an epifascicular epineurotomy is performed. If this step provides
sufficient decompression and the fascicular pattern in the involved segment is intact, no
further activity is necessary. If the fibrosis extends partially into the interfascicular epineu-
rium, an epifascicular epineurectomy has to be carried out. In many cases this is sufficient.
If there is still interfascicular fibrosis, but the fascicular pattern intact, a partial interfascicular
epineurectomy is performed.
All these situations refer to a third degree lesion. If the perineurium is also fibrotic and
the fascicular pattern is lost, we resect this particular part and restore continuity by nerve
grafts. This situation would be referred to as a fourth degree lesion. Very often the different
types are present simultaneously in the brachial plexus. The most difficult problem is pre-
sented by cases in which continuity is apparently preserved, but, in fact, an avulsion has
occurred and the root still sticks in the intervertebral canal. Since the sensory fibers are still
in contact with the ganglion, there is no Wallerian degeneration. Conductivity for the sensory
fibers in distal direction is preserved. But stimuli cannot proceed in proximal direction to
the spinal cord and to the cerebrum. In the early years some of the failures were due to the
fact that this situation had not been recognized correctly. By the use of evoked potentials,
the conductivity in central direction can be proved or excluded.
If there is a loss of continuity, nerve grafts are used to fill the gaps between the proximal
and distal stumps. Sural nerves, the medial cutaneous nerve of the forearm, and the ulnar
nerve, are used as donor grafts if all five roots are involved. The epifascicular epineurium
of the ulnar nerve is resected and the ulnar nerve is split longitudinally into several fascicle
groups which are dealt with as individual grafts. The use of the ulnar nerve as a vascularized
nerve graft can be regarded as a progress in this situation. If four or five roots are ruptured,
continuity is restored as well as possible between the proximal stumps and the distal stumps,
except the part going to the ulnar nerve. Sufficient resection is mandatory. It is better to
accept a longer defect than to have fibrous tissue in the stumps. If there are neuromas on
C5, C6, and C7 with C8 and Tl avulsed, nerve grafts are placed between C5 and part of
C7, and the dorsal cord, one graft from C5 going to the suprascapular nerve. Other grafts
are placed between C6 and part of C7, and the lateral cord. If only C5 and C7 are available,
C5 is united with the dorsal cord and the suprascapular nerve, and C6 is connected with the
lateral cord.
If only one root — C5 or C6 — is available, this root is connected with the dorsal cord
and nerve transfers are used to achieve neurotization of other distal territories. At least three
intercostal nerves are connected via nerve grafts with the musculocutaneous nerve and two
or three intercostal nerves are connected with the distal stump of the median nerve. In the
early years we tried to distribute the intercostal nerve on too many peripheral stumps, but
these cases did not achieve more than academic function. Neurotization of avulsed trunks
by intercostal nerves have poor chances for return to useful function. Instead of isolating
the whole length of the intercostal nerves, we prefer to expose the intercostal nerve in the
midaxillary line, transect it, and connect the proximal stump to the distal stump by a nerve
graft. The advantage of this procedure is that the nerve has more motor fibers at this level
than further distally, and the innervation of the intercostal muscles proximal to the transection
remains intact.
We did not follow the suggestion of Kotani et al.3,4 to use the accessory nerve for a nerve
transfer, because we regarded the function of the trapezius muscle as too important. But we
agree with the suggestion to use branches of the accessorius nerve and if so, we connect
these branches by a nerve graft with the suprascapular nerve. We have limited experience
yet with the use of parts of the cervical plexus for neurotization of the brachial plexus, as
Volume I 161
suggested by Brunelli1 and Celli et al.2 In the cases we are reporting in this paper, these
techniques have not yet been used.
COMBINED TREATMENT
It is evident that direct surgery on the brachial plexus alone represents only a small part
of the combined treatment. It is extremely important that the patient having suffered a
brachial plexus lesion is guided along the different phases of treatment. Preoperatively an
exact diagnosis has to be established and physiotherapy performed to avoid stiffness of the
joint and to stimulate the denervated muscles. Immediately after the operation physiotherapy
is restarted. During this period the patient especially needs psychological encouragement.
It takes a long time until early signs of recovery occur. Some of the patients may lose their
confidence in the treatment because nothing happens over several months. Also, during this
period social care for the patient is important to provide a profession which the patient can
perform using one arm only and integrate him again into professional life. Splints for the
wrist joint and the elbow joint, and suspensions are helpful. The psychological situation
improves dramatically as soon as the patient realizes that some reinnervation is going on.
Any returning muscle function should be improved by physiotherapy.
After about 12 to 18 months a careful examination is performed to evaluate what has
been gained and what further improvement could be achieved. In many cases arthrodesis of
the wrist joint is performed. There is the possibility of simultaneous innervation of antag-
onists, which can be handled by a tendon transfer. In ten cases, it happened that biceps and
triceps muscles were innervated simultaneously, preventing useful function. In these cases
the triceps tendon was transected, the triceps muscle mobilized and transferred to the volar
side, and inserted into the biceps tendon. Now both act as flexors and extension is provided
by gravity. If a less important function has returned, it can be sacrificed and an important
function reconstituted by a tendon transfer. For instance if only the triceps returned, a similar
transfer, as mentioned above, of the triceps muscle can provide elbow flexion.
If two or more muscles at the forearm have regained independent function, a key grip
can be reconstituted by arthrodesis of the wrist joint and multiple arthrodesis and tenodesis
of finger joints.
There is no alternative between direct surgery in a brachial plexus and palliative surgery.
Both possibilities should be combined and applied in an optimal way for each individual
patient.
EVALUATION OF RESULTS
The evaluation of results of brachial plexus surgery is extremely difficult. This is due to
the variety and the severity of the lesions. In some of the patients with preserved continuity,
in whom neurolysis had been performed, nearly full function returned. But in all cases in
which there was a loss of continuity with avulsion of some roots, the functional return is
limited. This limited functional return, from an objective point of view, serves as an argument
against brachial plexus surgery. For the patient who had lost the complete function of the
whole arm, a partial return means an enormous advantage, and, from the patient's point of
view, even if he regained a small amount of function, this is of important value.
WHAT CAN BE EXPECTED?
Only a few patients do not show any sign of regeneration. The vast majority develop
improvement of trophicity and partial return of protective sensibility. The vast majority of
patients also shows some motor recovery, but not always sufficient for useful function. We
regard it as a useful return of function if the patient (1) regains full control of elbow flexion
and (2) has the possibility of stabilization of the shoulder joint, avoiding subluxation, and
achieving some active motion, even if it is very little. If, in addition, a key grip can be
restored, we would regard this as a good result.
In cases of partial brachial plexus lesions it would be considered a useful recovery if the
patient regains the lost function to a level of M3 or better.
From 1963 to 1978, 151 cases with complete or partial brachial plexus lesions have been
operated on. In 47 patients the treatment is not yet completed. Of the 104 patients who
could be evaluated there were 64 complete palsies and 40 peripheral palsies of the brachial
plexus. In 46 of the 64 complete brachial plexus lesions a useful recovery could be obtained
according to the above-mentioned evaluation scheme. Of 40 patients with a partial brachial
plexus palsy 33 achieved a useful recovery, and 5 of 16 intercostal nerve transfers achieved
useful recovery.
SUMMARY
From 1963 to 1978, 151 patients with brachial plexus lesions had direct surgery on the
brachial plexus. The selection of the cases and the different surgical techniques which had
been applied are described. The results of 104 patients with a sufficiently long follow-up
are presented; 79 of them achieved a useful recovery.
REFERENCES
1. Brunelli, G., Neurotisation of avulsed roots of the brachial plexus by means of anterior nerves of the
cervical plexus. Preliminary report, Int. J. Microsurg., 2(1), 55—58, 1980.
2. Celli, L., Montorsi, A., de Luise, G., and Rovesta, C , Utilizzazione dell'XI nervo cranico e dei nervi
del plesso cervicale nelle lesione radicolari del plesso brachiale, Chir. Organi Mov., 64(4), 365—371,
1978.
3. Kotani, P. T., Toyoshima, Y., Matsuda, H., Suzuki, T., Ishikazi, Y., Iwani, H., Yamano, K., Inoue,
H., Moriguchi, T., Ri, S., and Asada, K., Postoperative results of nerve transfer for the brachial plexus
injury with root avulsion, in Proc. 14th Ann. Meet. Jpn. Soc. Surg. Hand, Osaka, 1971, 34—55.
4. Kotani, P. T., Matsuda, H., and Suzuki, T., Trial surgical procedures of nerve transfer to avulsion
injuries of plexus brachialis, in Int. 12th Congr. SICOT, Ser. 291, Excerpta Medica, Amsterdam, 1972,
345—350.
5. Millesi, H., Ganglberger, J., and Berger, A., Erfahrungen mit der Mikrochirurgie peripherer Nerven,
paper held at the 83rd Congr. Dtsch. Ges. Chir., April 14, 1966, Chir. Plast. Reconstr., 3, 47—55, 1967.
6. Narakas, A., Brachial plexus surgery, Orthop. Clin. North Am., 12(2), 303—323, 1981.
7. Sunderland, H., A classification of peripheral nerve injuries producing loss of function, Brain, 74, 491,
1951.
8. Tsuyama, N. and Hara, T., Intercostal nerve transfer in the treatment of brachial plexus injury of root
avulsion type, in Int. 12th Congress SICOT, Ser. 291, Excerpta Medica, Amsterdam, 1972, 351—353.
9. Tsuyama, N., Further studies on nerve crossing in irrepairably damaged peripheral nerve, 1st Congr. Int.
Fed. Soc. Surg. Hand, Rotterdam, 1980.
Volume I 163
MICROSURGICAL TECHNIQUES OF BRACHIAL PLEXUS NEUROTIZATION
L. Sedel
INTRODUCTION
In 158 cases of brachial plexus operated on since 1972, 28 neurotizations were per-
formed.56 This procedure, first described by Seddon4 and Tsuyama and Hara,7 consists in
branching a healthy nerve to a ruptured distal one. Millesi3 has underlined the superior
results obtained by taking the intercostal nerves at their proximal part. Kotani et al.2 described
the use of the accessory nerve, with which Allieu et al.1 reported obtaining positive results.
It is this technique, therefore, that we have used since 1977, alone or in conjunction with
intercostal nerves.
Above all, it is in very severe brachial plexus lesions with root avulsion that these
procedures are indicated. It is important to assure the existence of nerve root avulsion by
using myelography and electromyelography before surgery, since it may not be possible to
determine avulsion during the operation.
We shall first describe the techniques of intercostal and accessory nerve transfer to the
distal part of the plexus. This will be followed by a discussion of the results obtained by
using these methods in 18 cases with more than 3 years follow-up.
INTERCOSTAL NERVE TRANSFER (SEE FIGURES 1, 2, 3A, AND B)
The patient is placed on the operating table in a supine position with the arm in abduction.
The incision follows a downward course along the posterior axillary line. It joins the incision
made for the axillary approach posterior to the dorsalis major tendon. An axillary flap is
thus created which is then retracted backwards. By a carefully performed blunt dissection,
the gap between the anterior serratus and the dorsalis is identified. Dissection must avoid
the pedicles of the latter muscle. By retracting the anterior serratus foreward and the dorsalis
major backward, the costal grid is exposed. Dissection of the nerves requires a precise
technique: the rib periosteum is incised at the center of the rib, the incision follows a course
parallel to that of the rib. A pair of forceps is used to clamp the inferior part of the periosteum
which is then gently retracted from the inferior and medial part of the rib. Then a blunt
hook is used to try to catch the nerve at the medial part of the inferior aspect of the rib.
Careful attention must be paid to the intercostal artery which accompanies the nerve, and
to the pleura which lie very close medially. It usually requires 2 or 3 min to find the nerve,
which is generally thin and may sometimes be double. It is then followed laterally and
posteriorly where it is sectioned at the level of the posterior axillary line.
This procedure is repeated for three to four other intercostal nerves from T3 to T6 or T7.
T2 usually lies too deep to be dissected easily and suturing afterwards may be very difficult.
The nerve which has been chosen to be neurotized is then dissected and passed behind the
axillary vessels. If it is the musculocutaneous, it has to be dissected all the way up to the
lateral cord in order to gain some length. The radial nerve, however, is usually long enough.
Grafts are then taken from either the sural or brachial cutaneous nerves. They are generally
short in length (i.e., 3 to 7 cm). Each suture is made under the microscope at 6 x mag-
nification. One or two stitches of 10/0 nylon suture achieves the necessary cohesion of the
nerves ends for each cable graft. Following the procedure, no tension should be present at
the suture site. The cutaneous flap is sutured in such a manner that the graft is covered by
the posterior angle of the flap. Suction drainage is employed for 2 days. If the pleura has
been damaged, the anesthesiologist is asked to inflate the lungs before the wound is closed.
This occurred in 2 of the 20 times this technique was used.
FIGURE 1. Case no. 18 — intercostal nerve transfer on the lateral cord (T3T4T6 + 3 grafts).
ACCESSORY NERVE TRANSFER (FIGURE 4)
This procedure was first described by Kotani et al.2 It consists in branching the lateral
branch of the accessory nerve to a distal motor branch of the plexus, the musculocutaneous
generally being the one which is chosen.
Exposing the Accessory Nerve

Generally, the supraclavicular approach to the brachial plexus permits dissection of the
accessory nerve. It should be looked for just underneath and very close to the anterior aspect
of the trapezius muscle. It is deep and small, but it is easy to identify by using an electric
nerve finder. Many nerves cross the supraclavicular area, however. They are, for the most
part, sensory branches of the superficialis cervical plexus. Sometimes, if the nerve is difficult
to isolate, one should look for it at the anterior aspect of the sternocleidomastoid muscle.
It resets on its medial aspect and crosses the medial, cleidomastoid part of this muscle. It
should not be cut at this level, however, for a muscular paralysis may occur, so sectioning
is performed more distally. It is then joined by a graft to the musculocutaneous. Because
of the thinness of the lateral branch of the accessory nerve, one cable graft is generally
sufficient.
The graft must be connected to the anterior part of the musculocutaneous which contains
the motor fibers.
RESULTS
In over 28 brachial plexus neurotizations, results are known for 18 patients having follow-
up of more than 3 years.
These 18 cases are presented below and in Table 1.
Volume I 165
FIGURE 2. Case no. 11 — results of T3T4T5T6 transferred on the musculocutaneous; a 5-year

follow-up.
Age: 12 to 46; mean: 19 years

Sex: 4 females and 14 males
Initial trauma: motorcycle accidents, 13; car accidents, 3
Direct trauma: 1, by traction: 1
Delay between the accident and the procedure: 2 to 14 months; mean: 6 months
All but two had a complete palsy — one had a C5C6C7 palsy with roots avulsion and one
had a C5C6C7C8 avulsion with 1\ intact.
The types of neurotization were rather different:
6 had intercostal neurotization alone

3 had intercostal and accessory nerve neurotization
2 were mixed
8 had a graft from C5 and a neurotization via the intercostal nerves
1 had a graft from C5 and a neurotization via the accessory nerve
The receiving sites of the neurotization were the musculocutaneous — 10 cases, the lateral
cord — 3 cases, and radial nerve — 6 cases, the median nerve — 5 cases, and the posterior
cord — 1 case.
All patients were examined more than 3 years after the procedure. A useful function was
obtained by neurotization eight times for biceps graded 3 or 3 + and one time for triceps
graded 4.
FIGURE 3. (A) Case no. 2 — a 4-year follow-up after grafting C5 with the posterior cord and
T3 and T4 with the musculocutaneous. (B) Case no. 2 — dorsal view.
Some improvement, i.e., protective sensitivity or some muscle contraction, was obtained
five times.
Failures occurred in four instances and for one case it was impossible to conclude: he
regained a rather strong elbow flexion (1500 g) and had a graft on the musculocutaneous
coming from C4 and from the accessory nerve. We must emphasize that the best results are
obtained when numerous intercostal nerves are used to neurotize one distal nerve. If the
neurotization goes to the lateral or the posterior cord, the results are even less satisfying.
Volume I 167
FIGURE 3B
In any case, the results are always rather disappointing. The best one can do is to create
an esthetically improved arm capable of some movement but devoid of any functional
capacities.
CONCLUSION
Neurotization by the intercostal nerves or by the accessory nerve can provide some
improvement in complete brachial plexus avulsion from the cord. Best results are obtained
with a precise microsurgical technique, when many nerves are used to regain one function.
Hardly more than an esthetic animated arm is usually achieved, in our experience. We hope
that by improving the technique and the numbers of nerves used, function can be improved.
FIGURE 4. Scheme of case no. 5 — repairs.

Table 1
THE 18 BRACHIAL PLEXUS NEUROTIZATION CASES OF MORE THAN 3 YEARS FOLLOW-UP
Results
Delay Receiving Follow-up
Age Sex Accident (months) Palsy Myelogram site Donor site Graft (years) Motor Sensory
17 F Motorcycle 4 Complete Avulsion L. C. Accessory nerve + 3 Biceps: 3 + SO

C5C 6 C 7 C 8 T! R. T3T4T5 +++ Flex. D: 3
23 M Car 5 Complete Avulsion P. C. ++++ 4 Deltoid: 4
CôCyLg 1 i M.C. T3T4 + Triceps: 4
Ext. carpi: 2
Elbow flexion: 3
27 F Car 12 Complete Avulsion L. C. c5 Ulnar 4 Biceps: 4 (2 kg) SI
C6C7C8T, R. T2T3T4 + Triceps: 2
12 M Traction 4 Complete Avulsion M.C. c5 Ulnar 4 Biceps: 4 +
injury C7C8T, M. c6 Ulnar Longus palmaris: 1
+ Q? R. T2T3T4 + 0
18 M Motorcycle 9 Complete Avulsion R. Accessory nerve + 3 Biceps: 3 + SI
M. T2 + T5 -+ +
M.C. T3 + T4 ++
19 M Motorcycle 6 Complete Avulsion M.C. T3T4T5 +++ 3 Biceps: 3 + SI
CsC6C7C811
17 M Motorcycle 2 Complete Avulsion P.C. Q ++ 3 Triceps: 2 SI
C6C 7 C 8 T, M.C. + Ext. carpi: 3
M. T4T5 Brachio radial: 3
22 M Motorcycle 5 Complete Avulsion L.C. T2T3T4T5 ++ 4 Biceps: 2 + SI
CôCyCgT,
18 F Motorcycle 3 Complete Avulsion L.C. c5 ++ 3 Biceps: 3 SI
CÓC 7 C 8 11 Radial T3T4 ++ Flex. D: 3
19 M Motorcycle 6 Complete Avulsion M.C. c5 Ulnar 3 0 SI (Hand)
c&c7c81 ! M. T2T3T4 +++
44 F Car 14 Complete Complete M.C. 5 Biceps: 3 + SI
Volume I
T2T3T4T5 ++++
avulsion
17 M Motorcycle 10 Complete Avulsion P.C. c5 Ulnar + + 4 Triceps: 2 SI (Hand)
C6C 7 C 8 1 1 M. T2T3 + Biceps: 2
169
M.C. T4T5 + +
Table 1 (continued)
170
THE 18 BRACHIAL PLEXUS NEUROTIZATION CASES OF MORE THAN 3 YEARS FOLLOW-UP

Results
Delay Receiving Follow-up
Age Sex Accident (months) Palsy Myelogram site Donor site Graft (years) Motor Sensory
19 M Motorcycle 3 Complete Avulsion P.C. Accessory nerve + + 3 Deltoid: 3 + SO

^5^6^7^-8 1 1 M. T2 +
M.C. T3T4 ++ Biceps: 3 + SI
36 M Direct 10 Partial None done M.C. T3 + 4 Triceps: 3 +
trauma (^5^6^7^8) R. T4T5 ++
46 M Motorcycle 9 Partial Avulsion M.C. T2T3T4 +++ 5 0 (Wrist arthrodesis)
(QC 6 C 7 ) c7
20 M Motorcycle 3 Complete Avulsion M.C. C4 + accessory ++ 3 Biceps (1.5 kg) SI (Hand)
R. nerve Brachio radial: 3
++
M. Q +
41 M Motorcycle 13 Complete Avulsion L.C. T3T4T5 +++ 3 Triceps: 3

CsC6C7C81 ! Biceps: 1
16 M Motorcycle 4 Complete Avulsion L.C. ++++ 4 Biceps (2.5 kg)
QACgT, R. T3T4T5 +++ Triceps: 4 SI (Hand)
Note: L . C , lateral cord; R., radial nerve; P.C., posterior cord; M . C , musculocutaneous; and M., median nerve. Each cross means one sural graft.
Volume I 171
REFERENCES
1. Alnot, Y. et al., Symposium sur la paralysie traumatique du plexus brachial de l'adulte, Rev. Chir. Orthop.,
63, 17, 1977.
2. Kotani, T., Matsuda, H., and Suzuki, T., Trial surgical procedures of nerve transfer to avulsion injuries
of brachial plexus, in Proc. 12th Cong. Int. Soc. Orthop. Surg. Trauma, Excerpta Medica, Amsterdam,
1972, 348.
3. MiUesi, H., Indications et résultats des interventions directes. Symposium paralysie traumatique du plexus
brachial chez l'adulte,/tev. Chir. Orthop., 63, 82, 1977.
4. Seddon, H. J., Surgical Disorders of the Peripheral Nerves, 2nd éd., Churchill Livingstone, London,
1972.
5. Sedel, L., Brachial plexus injury repair using microsurgical techniques, in Microsurgery, Lie, T. S., Ed.,
Excerpta Medica, Amsterdam, 1979, 85.
6. Sedel, L., Results of direct surgical repairs of posttraumatic brachial plexus lesions, J. Bone Jt. Surg.,
64B, 54—66, 1982.
7. Tsuyama, N. and Hara, T., Intercostal nerve crossing as a treatment of brachial plexus injury of root
avulsion type, in Orthopaedic Surgery and Traumatology, Delchef, J., de Marneffe, R., and Vander Elst,
E., Eds., Excerpta Medica, Amsterdam, 1972, 512.
Volume I 173
MICROSURGICAL TREATMENT OF ISOLATED LESIONS OF THE MOTOR

BRANCHES IN THE HAND AND FOREARM
Peter Haussmann
INTRODUCTION
Traumatic and nontraumatic lesions of the peripheral nerves of the upper extremities
impair hand function considerably. Lesions of the nerve trunks in the upper arm mostly
produce combined sensory and motor disorders, because sensory and motor nerve fibers are
spread equally over the cross-section of the nerve. In the hand and forearm, however, isolated
lesions of sensory as well as motor nerve branches are possible. In this region sensory and
motor fascicles are well defined either within the nerve trunk or in separate branches.
Lesions of the sensory branches are common and present no difficulties in diagnosis
because loss or impairment of sensibility and pain in the site of the lesion is promptly
recognized by the patient. Isolated lesions of the motor branches are rare and diagnosis is
often not made before myatrophy has established itself. ' Lack of pain and slow development
of weakness hide the lesion for a long time. Early treatment is desired in order to prevent
impairment of hand function caused by weakness and muscular imbalance. In late cases,
when marked myatrophy or muscular fibrosis and contractures have established themselves,
recovery of hand function after surgical repair of the damaged motor branches is very poor.
In such cases tendon transfer is preferable.
ANATOMY
Motor branches of clinical significance in the hand and forearm are
1. The thenar motor branch of the median nerve (Ramus Thenaris Nervi Mediani), which
arises from the main trunk in the distal part of the carpal tunnel and supplies the
following muscles: Abductor Pollicis Brevis, Opponens Pollicis, and Flexor Pollicis
Brevis (superficial head).
2. The deep motor branch of the ulnar nerve (Ramus Palmaris Profundus Nervi Ulnaris),
which arises from the division of the ulnar nerve in the distal part of the Loge de
Guy on and supplies the following muscles: Hypothenar muscles, Lumbricalis III and
IV, all the interossei, Adductor Pollicis, and Flexor Pollicis Brevis (deep head).
3. The posterior interosseous nerve (Ramus Profundus Nervi Radialis), which arises from
the division of the radial nerve distally from the elbow and supplies Extensor Carpi
Radialis Brevis, Supinator, Extensor Digitorum Communis, Extensor Digiti Minimi,
Extensor Carpi Ulnaris, Abductor Pollicis Longus, Extensor Pollicis Brevis, Extensor
Pollicis Longus, and Extensor Indicis Proprius.
4. The anterior interosseous nerve (Nervus Interosseus Anterior), which arises from the
median nerve distally from the Pronator Teres and supplies the Flexor Pollicis Longus,
Flexor Digitorum Profundus II and III, and Pronator Quadratus.
CAUSES OF NERVE LESIONS
The commonest cause of lesion is trauma. Stab or cut injuries, especially by splinters of
glass, are capable of damaging the motor branches in the thenar and hypothenar regions as
well as their fascicles in the distal part of nerve trunks on the wrist level. Total, subtotal,
and partial severance is possible, so various degrees of paralysis may result. Skeletal injury
174 CRC Handbook óf Microsurgery
sometimes involves the motor branches, especially the anterior and posterior interosseous
nerve in fractures of the shaft or the head of the radius. Not to be forgotten are iatrogenic
injuries in the course of operations on carpal tunnel syndrome (thenar motor branch), or
Dupuytren's disease (thenar motor branch and therminal motor branch of the ulnar nerve),
and on fractures of the proximal part of the radius (posterior and anterior interosseous nerve).
Compression lesions may appear due to some anatomic anomalies, occupational diseases,
tumors, and scar formations following soft tissue injuries adjacent to the nerve. Very un-
common is an intraneural compression by torsion and fibrosis of the perineurium (see the
section on Lesions of the Anterior Interosseous Nerve).
DIAGNOSIS
Clinical examination using meticulous muscle testing reveals weakness or paralysis of the
characterizing muscles. EMG is an additional measure to confirm diagnosis and is very
helpful in obtaining objective data for follow-up. In some cases X-ray examination reveals
bony anomalies, malunited fractures, or foreign bodies which accompany or cause the nerve
lesion.
TREATMENT
Modern surgery of the peripheral nerves means microsurgery. There is no doubt that
results after microsurgical treatment of nerve lesions are, in general, superior to those after
surgery without optical magnification. Apart from the general advantages of microsurgery
for surgery of the peripheral nerves (e.g., concerning atraumatic technique, identification
of fascicles, discrimination between epineurium and perineurium, as well as between intact
and damaged parts of the nerve), microsurgery is especially necessary in hand surgery because
most of the nerve branches in the hand and forearm, in particular the motor branches, are
so small that magnification is needed to identify and to handle them correctly.
Three microsurgical procedures are available:
1. Neurolysis (epineural or internal)

2. Nerve suture (primary or secondary)
3. Nerve grafting (primary or secondary)
Epineural Neurolysis
Epineural neurolysis is performed in compression lesions caused by anatomical anomalies
such as fibrous bands crossing the nerve branch, accessory muscles, and tumors (ganglia or
other synovial cysts, fibromata, lipomata, osteomata) adjacent to the nerve. In such cases
treatment consists in separation of the nerve branch and in resection of the compressing
structure. If epineural fibrosis or proximal pseudoneuroma has developed due to longstanding
compression the epineurium must be incised longitudinally and resected partially in the
involved area to facilitate nerve regeneration. Total resection of the epineurium and internal
neurolysis is not only unnecessary, since the internal structure of the nerve is intact, it is
also detrimental because it impairs the epineural and internal blood supply of the nerve.
Conditions like those mentioned above occur mostly in the forearm and involve the anterior
and posterior interosseous nerve. In the hand, lesions of the motor branches demanding only
epineural neurolysis are very rare.
Internal Neurolysis
Internal neurolysis is indicated when the interfascicular tissue or the fasciculi themselves
are affected. The interfascicular tissue may be scarred after partial severance of a nerve or
Volume I 175
a crush injury or an iatrogenic injection trauma. The fasciculi themselves may be affected
by mono- or oligofascicular neurofibromata or by fibrosis of the perineurium, conditions
which will be discussed later. Internal neurolysis may be equally necessary in all the motor
branches of the hand and forearm.
Primary Nerve Suture

Primary nerve suture is indicated in all clean-cut wounds. It should be performed whenever
possible. Stab injuries by splinters of glass or by any other sharp and acute instrument are
capable of dividing the nerve branches in the hand and forearm, sometimes without any
other lesion of a nerve, vessel, or tendon. Especially in the thenar and hypothenar region,
even small stab wounds may cover the division of the thenar motor branch or the deep
branch of the ulnar nerve. If there is any doubt as to whether or not the motor branch is
intact the wound should be explored.
Primary suture is a relatively simple procedure because it is much easier to identify the
small nerve stumps in the fresh wound than in the scarred and sclerotic tissue during a
secondary exploration. Because there is no gap in the nerve primary suture using 10/0 or
11/0 absorbable sutures (for example polyglactin) may be performed without tension. Di-
vision of the motor fasciculi within the nerve trunk, seen in the median or ulnar nerve on
the wrist level, are especially suited for primary suture.
Secondary Nerve Suture

Secondary nerve suturing is feasible only in cases where, after resection of the proximal
neuroma and distal glioma, the resulting defect in the nerve can be overcome by mobilizing
the nerve stumps or stretching a curved course of the nerve in order to avoid suture tension.
This may be in the thenar motor branch or the deep branch of the ulnar nerve, as will be
discussed later. In all other cases where suturing cannot be done without tension nerve
grafting should be performed.
Primary Nerve Grafting

Primary nerve grafting in the treatment of traumatic lesions of the motor branches in the
hand and the forearm is an exceptional procedure.2 It is practicable in situations when
laceration of a motor branch is accompanied by soft tissue or vascular damage (Figures 1
and 2). In such cases later scar formation either complicates secondary exploration of the
stumps or the motor branch or hinders it totally. If vascular grafting in the neighborhood of
the nerve lesion was necessary initially to restore circulation the vascular graft may be
endangered during secondary exploration. To overcome such difficulties a primary nerve
graft may be used, taken either from the remnants of another nerve or from a cutaneous
nerve branch, preferably the Nervus Cutaneus Antebrachii Medialis. Primary nerve grafting
should not essentially extend the primary management of the wound. Primary nerve grafting
in order to bridge a gap in a nerve resulting from a resection of neurofibroma is obvious
and is no different from secondary nerve grafting.
Secondary Nerve Grafting

Secondary nerve grafting is the method of choice in all cases where the methods mentioned
above are not practical. Grafting of the motor branches in their isolated courses presents no
difficulties in identification of the corresponding parts of the nerve and is no different from
nerve grafting in other small nerve branches. For grafting in the thenar motor branch and
the terminal motor branch of the ulnar nerve, one graft is sufficient. For bridging a gap in
the anterior and posterior interosseous nerve, two to four grafts are necessary.
Lesions of the fascicles forming the motor branches within the main trunk of the nerve
are much more difficult to identify and to define either from intact or sensory fascicles. In
FIGURE 1. (A) Transection of the thenar, carpal tunnel, and hypothenar by a circular saw.
(B) The thenar muscles, the median and ulnar nerve, the ulnar artery and the hypothenar muscles
are lacerated.
a partial severance of a nerve trunk the motor fascicles may be cut off together with some
sensory fascicles. The sensory lesion often evinces no essential impairment and would not
be an indication for operation by itself, therefore, correct identification of the motor fascicles
Volume I 111
FIGURE 2. (A and B) Primary nerve grafting. Intraoperative findings to Figure 1. The

thenar motor branch (black) is torn off (white arrows). The gap between the stumps is being
bridged by a graft (black arrows) taken from the remnants of the median nerve (NM). The
median and ulnar nerve will be reconstructed in a second stage by secondary nerve grafting.
FIGURE 3. (A and B) Secondary nerve grafting I. A large neuroma has developed after
partial severance of the median nerve at the wrist. (FDS = superficial flexors, and dotted
line = fascicle of thenar motor branch within the nerve trunk.)
is the crucial point. In most cases a large neuroma covers the damaged fascicles (Figure 3)
so preparation must be started away from them. First, the motor branch must be identified
in its isolated course and traced back into the main trunk until the neuroma is reached. Here
Volume I 179
FIGURE 4. (A and B) Secondary nerve grafting II. The neuroma is isolated. It has involved
the fascicle of the thenar motor branch (black) and one sensory fascicle. Note the intact
fascicles.
the shape of the adjacent fascicles and their arrangement to the motor fascicles is to be
recorded. Adjacent to the neuroma the corresponding arrangement must be found by dis-
secting from the intact nerve towards the neuroma. The intact fascicles may be used as
guidelines in both directions (Figure 4). Considerable torsion of the damaged fascicles is
FIGURE 5. (A and B) Secondary nerve grafting III. The neuroma is resected. The proximal
and distal cross-sections of the fascicles (arrows) are compared precisely for fascicular ori-
entation (motor fascicle is black).
not to be expected because they are held in place by the intact fascicles. The most important
fascicles are favorably marked by some microsurgical sutures. After this the neuroma is
resected together with the stumps of the damaged fascicles (Figure 5). The pattern of the
Volume I 181
FIGURE 6. (A and B) Secondary nerve grafting IV. The defect in the fascicles resulting
from resection of the neuroma is bridged by nerve grafts (Nervus Cutaneus Antebrachii
Medialis). Arrows indicate the suture line.
cross-section of the fascicles is used as a further aid for orientation. Then nerve grafting is
performed (Figure 6).
Intraoperative electrical stimulation to obtain evoked somatosensory potentials using com-
puterized EEG will probably facilitate fascicular orientation in the future.
FIGURE 7. Marked myatrophy of the Musculus Abductor Pollicis Brevis and Musculus
Opponens Pollicis without any disturbance of sensitivity.
ISOLATED LESIONS OF THE MOTOR BRANCHES IN THE HAND

AND FOREARM
Lesions of the Thenar Motor Branch

In all cases of lesions of the thenar motor branch the carpal tunnel must be totally opened.
In rare cases the thenar motor branch may be compressed on the site of its origin by anomalous
bundles of the palmar fascia, by fibrotic epineurium (Figures 7 and 8), or by a neurofibroma
in the distal part of the carpal tunnel (Figure 9). 3 In these cases treatment consists of excision
of the compressing structures and epineural or perineural neurolysis. Stab or cut injuries in
the thenar region may sever the thenar motor branch at different levels either within the
thenar muscles or in the retinacular region or in the carpal tunnel. If detected in time, primary
suturing is possible and advisable. In delayed cases secondary suturing is often practicable
(Figures 10 and 11).
Primary nerve grafting is an exceptional procedure (see Figures 1 and 2). Secondary nerve
grafting often becomes necessary in delayed cases of partial severance of the median nerve
at the wrist level (Figures 3 to 6) if primary suturing was omitted or has failed. A special
case will be described:
The sensory recovery of a 10-year-old girl after total severance of the median nerve at the wrist level and primary
suturing was excellent despite a large neuroma at the suture site (Figure 12), but no motor function returned. In
order to restore motor regeneration, and yet not disturb sensitivity, the motor fascicle was identified proximal and
distal to the neuroma according to the procedure mentioned above. Additionally, intraoperative neurography was
used to confirm or to exclude nerve conduction. The neuroma was bypassed by using a nerve graft (Figure 13).
Motor function improved and sensitivity remained excellent.
Lesions of the Deep Motor Branch of the Ulnar Nerve

Epineural neurolysis becomes necessary when the motor branch is compressed by a
ganglion protruding from a carpometacarpal joint or by another benign tumor in the deep
layer of the palm.
Primary suturing should be performed whenever possible in all clean-cut or stab wounds.
Volume I 183
FIGURE 8. Intraoperative findings of the case shown in Figure 7. The thenar motor branch was
constricted (arrows) by thickened epineurium which is removed. Note intact longitudinal vessels of the
median nerve. There is no compression of the median nerve trunk.
Falling into splinters of glass with the hands extended is a common cause of cut wounds of
the hypothenar region and is sometimes accompanied by an injury to the deep motor branch
of the ulnar nerve.
Secondary suturing is possible if there are some fibers of the epineural sheath left intact
which hold the nerve stumps together (Figures 14 and 15). In other cases nerve grafting is
to be performed. To expose the distal stump of the nerve sufficiently, the aponeurotic origin
of the radial hypothenar muscles must be excised (Figure 16).
Lesions of the Posterior Interosseous Nerve

The posterior interosseous nerve may be compressed by the hypertrophic supinator muscle
or its fibrotic aponeurosis (Figures 17 and 18).4 The resulting paralysis is known as supinator
syndrome. Any swelling between the proximal part of the radius and the aponeurotic covering
of the supinator muscle may produce a compression neuropathy of the posterior interosseous
nerve. Ganglia or rheumatoid synovial cysts protruding from the elbow joint, as well as
lipomata arising from the intermuscular fatty tissue, or anomalies or malunited fractures of
the proximal part of the radius may impair the nerve.
Exploration of the posterior interosseous nerve in its total course in the supinator region,
superficial or total division of the supinator aponeurosis or muscle belly, removal of path-
ological structures, and microsurgical epineural neurolysis is the treatment of choice.
Primary suturing should be done according to the general principles of primary nerve
suturing. Secondary suturing is almost impossible because the peripheral stump of the nerve
has slipped away under the supinator muscle and posttraumatic fibrosis of the surrounding
soft tissue is often so extensive that length which is gained by mobilization is very limited.
In such cases secondary nerve grafting solves the problem. Unrealized lesions of the nerve
in the course of operations on fractures of the proximal part of the radius is the commonest
occasion for secondary nerve grafting (Figure 19). Generally, the grafts must be passed
FIGURE 9. (A and B) Monofascicular neurofibroma (arrow) which compresses the

thenar motor branch in the distal part of the carpal tunnel. The hook is under the thenar
motor branch. Resected neurofibroma in Figure B.
through a tunnel under the superficial layer of the extensor muscles to reach the distal nerve
stumps (Figure 20).
Lesions of the Anterior Interosseous Nerve

The anterior interosseous nerve may be compressed by fibrous bands running across the
nerve in the region of the pronator teres muscle. The resulting paralysis is known as anterior
interosseous nerve syndrome.5,6 Anomalous bellies of the superficial flexor muscle or its
sharp-edged aponeurotic covering may compress the nerve during its course between the
Volume I 185
FIGURE 10. (A and B) Secondary nerve suture in the thenar motor branch I. A former
cut injury has severed the thenar motor branch in the carpal tunnel. Neuroma at the end of
proximal stump (arrow on the left).
superficial and deep flexor muscles. Treatment is similar to that of the posterior interosseous
nerve.
Internal neurolysis is required if the motor fascicles are compressed within the nerve trunk
of the median nerve. Two cases have been observed:78
FIGURE 11. (A and B) Secondary nerve suture in the thenar motor Branch II. The neuroma
is resected. Secondary nerve suturing without tension was possible by smoothing the curved
course of the thenar motor branch. Arrow indicates the suture line.
A 37-year-old male suffering from an anterior interosseous nerve syndrome was sent for operation. On exploration
the anterior interosseous nerve was normal. Further exploration of the median nerve proximal to the origin of the
anterior interosseous nerve revealed an outstanding compression of the three fascicles which more distally form
Volume I 187
FIGURE 12. (A and B) Neuroma of the median nerve after conventional epineural suture
(see text). (Dotted line = motor fascicle, and white arrows = Palmaris Longus tendon.)
the motor branch. Thickened fibers of the perineurium constricted the fascicles so heavily that they were thought
to be interrupted, so they were resected and primary nerve grafting was performed. Later on, motor function
recovered very well. Histological examination of the specimen showed severe axonotmesis (Figure 25).
FIGURE 13. (A and B) The neuroma is left intact. The motor fascicle is isolated proximal
and distal to the neuroma which is bypassed by using a nerve graft (see text). Arrows indicate
suture line.
In another case of a 51 -year-old female with the same history one large fascicle forming the anterior interosseous
nerve was found constricted within the median nerve trunk (Figure 21). Internal neurolysis was performed (Figures
22 to 24). Recovery of motor function was excellent.
Volume I 189
FIGURE 14. (A and B) Secondary nerve suture in the terminal motor branch of the ulnar
nerve I. A splinter of glass (arrows) subtotally transected the motor branch 3 months ago.
Some fibers of the epineurium remained intact so the nerve stumps could not slip away.
Curved arrow indicates the proximal stump.
Indication and technique of primary and secondary suturing as well as grafting of the
anterior interosseous nerve correspond with those of the posterior interosseous nerve.
FIGURE 15. (A and B) Secondary nerve suture in the terminal motor branch of the ulnar
nerve II. The splinter of glass is removed and both stumps of the motor branch (arrows) are
exposed. There is no gap between the stumps.
SUMMARY
Traumatic and nontraumatic isolated lesions of the motor nerve branches in the hand and
forearm are rare. They impair hand function considerably, but diagnosis is often not made
Volume I 191
FIGURE 16. (A and B) Secondary nerve grafting in the terminal motor branch of the ulnar
nerve. Both stumps of the motor branch are exposed (arrows). A nerve graft is necessary to
overcome the gap between the stumps.
before myatrophy has established itself. Lack of pain or sensory disturbances, as well as
the slow development of weakness, hides the lesion for a long time. The lesion is diagnosed
by thorough clinical examinations including meticulous muscle testing and supplementary
FIGURE 17. (A and B) Supinator syndrome I. The posterior interosseous nerve was com-
pressed (thick arrows) by the sharp-edged aponeurosis of the supinator muscle with is split
upon the nerve (small arrows). The extensor muscles are retracted distally.
Volume I 193
FIGURE 18. (A and B) Supinator syndrome II. Epineural neurolysis is performed. Note
intact longitudinal vessels. The arrows indicate the site of compression. The extensor muscles
are retracted proximally.
electromyography and X-ray examination. Early treatment is desirable to prevent impairment

of hand function caused by weakness and muscular imbalance. After delayed treatment the
functional prognosis is poor due to the limited reversibility of the myatrophy and the sec-
FIGURE 19. (A and B) Neuroma of the posterior interosseous nerve. The curved arrows
show the entrance of the supinator tunnel. RPNR = Ramus Profundus Nervi Radialis (pos-
terior interosseous nerve); RM = Ramus Muscularis (motor branch to Extensores Carpi
Radiales); and RSNR = Ramus Superficialis Nervi Radialis (superficial sensory branch of
the radial nerve).
Volume I 195
FIGURE 20. (A and B) Secondary nerve grafting in the posterior interosseous nerve. The
neuroma (Figure 19) is resected. Nerve grafts are passed through the supinator tunnel (curved
arrows). Straight arrow indicates suture line.
ondary contractures of the joints. The involved motor branches are the thenar motor branch
of the median nerve, the deep motor branch of the ulnar nerve, the posterior interosseous
nerve, and the anterior interosseous nerve. These nerve branches may be damaged, isolated
FIGURE 21. (A and B) Internal neurolysis I. The epineurium of the median nerve at the
elbow is incised and held laterally. The fascicles are exposed. The motor fascicle (black)
which, more distally, forms the anterior interosseous nerve is constricted by the contorted
perineurium.
Volume I 197
FIGURE 22. (A and B) Internal neurolysis II. The thickened fascicle is mobilized.
by open injuries or compression either in their separate course or within the nerve trunk.
Treatment consists in epineural or internal neurolysis, primary or secondary suturing, and
nerve grafting. Microsurgical technique is very helpful in epineural neurolysis and is not to
be abandoned in internal neurolysis as well as in nerve suturing and nerve grafting. The
procedures are described in detail.
FIGURE 23. (A and B) Internal neurolysis III. The constricted fascicle is freed from the
adjacent intact fascicles. The torsion of the perineurium is clearly seen.
Volume I 199
FIGURE 24. Internal neurolysis IV. The thickened fibers of the perineurium are removed (arrows).
Decompression of the fascicle is obtained.
FIGURE 25. Histological findings in another case similar to Figures 21 to 24 in which the compressed section
of the fascicle was resected and nerve grafting was performed. Arrows indicate the site of compression with
severe axonotmesis. The proximal part of the fascicle is dilated (see text).
REFERENCES
1. Haussmann, P., Microsurgical repair of severed motor branches of the median and ulnar nerve in the hand,
in Proc. 5th Int. Congr. Int. Microsurg. Soc, Excerpta Medica, Amsterdam, 1979, 93.
2. Haussmann, P., Die interfaszikulare Nerventransplantation als Notoperation, in Kongressbericht 19. Ta-
gung Òsterreichischen Ges. Chir., Kremsmiinster, Wayand, E. and Briicke, P., Eds., Egermann, Vienna,
1979, 414.
3. Kreuzer, K. B. and Haussmann, P., Ungewõhnliche Ursachen des Karpaltunnelsyndromes, Handchi-
rurgie, 11, 173, 1979.
4. Spinner, M., The arcade of Frohse and its relationship to posterior interosseous nerve paralysis, J. Bone
Jt. Surg. Am., 50B, 809, 1968.
5. Kiloh, L. G. and Nevin, S., Isolated neuritis of the anterior interosseous nerve, Br. Med. J., 1, 850, 1952.
6. Spinner, M., The anterior interosseous-nerve-syndrome, J. Bone Jt. Surg., 52A, 84, 1970.
7. Haussmann, P. and Kendel, K., Oligofaszikuláres Medianus-Kompressionssyndrom, Handchirurgie, 13,
268, 1981.
8. Haussmann, P., Intratrunkulare, faszikulare Kompression des Nervus interosseus anterior, Handchirurgie,
14, 183, 1982.
Volume I 201
OBSTETRIC PLEXUS PALSY: EARLY MICROSURGICAL TREATMENT
M. Petrolati and P. L. Raimondi
INTRODUCTION
Obstetric paralysis is an unfortunate event whose solution remains a problem even today,
partly because its spontaneous resolution does not always lead to a positive end, sometimes
resulting in deficits and deformities which cannot be repaired even through palliative surgery,
and partly because primary treatment of a lesion itself is fraught with intrinsic difficulties.
Even though recent and reliable statistics1-2 show a notable decrease in its frequency the
phenomenon is still diffuse, with 20% of cases revealing slow and incomplete recovery as
opposed to 80% of cases in which spontaneous resolution progresses favorably.3 The slowness
of recovery has a negative effect on the recovery itself, as has been shown by Gilbert4 in
his review of 300 cases treated with traditional conservative methods, as well as by other
authors.3-56 On the basis of these results our department critically reviewed 45 analogous
cases treated with our palliative surgery and the resulting conclusions were similar to those
quoted above.
On the other hand, we must bear in mind that the manifestation of obstetric palsy is
none other than the consequence of a lesion in the brachial plexus, as is commonly ac-
cepted,3-57 and this explains all the spontaneous resolutions consequent to the etiopatho-
genetic mechanism. In the brachial plexus of the newborn this phenomenon causes lesions
completely analogous to those found in adult accident victims; we can therefore, find simple
lesions of 2° according to Sunderland's classification with the various evolutions typical of
this type of injury: postganglionic radicular lesions; preganglionic lesions, or mixed post-
and preganglionic lesions.
Neuroapraxial lesions are caused by moderate traction and generally show spontaneous
recovery, the course of which is more or less rapid relative to the intensity of the trauma.
With regard to tear lesions (total or partial) in the postganglionic area two things must be
considered: the gap created between the two nerve stumps is in the order of 1 to 1.5 cm
but, on the other hand, the nerve fibers of the newborn possess an elevated power of
regeneration (Figure 1). This explains the regeneration consistently observed in these forms,
but also the disorderly organization observed in the joining of the altered nerve stumps6
(Figure 2). The consequence of this wrongly directed regeneration is the appearance of co-
contractions (synkinesis) in antagonistic muscles or groups of muscles so that their simul-
taneous actions annul or significantly reduce the limb's functionality.3-910 In paralysis of
the upper limb, such as the Erb-Duchenne type, the lack of recovery of extrarotation of the
shoulder is caused by the impossibility of a confrontation between the two suprascapular
nerve stumps, whose caliber is normally reduced and whose distal head easily retracts, thus
precluding the possibility of neurotization (Figure 3).
The result of this disordered spontaneous reconstruction during the course of regrowth is
a serious imbalance in articulation, particularly felt in both proximal and distal radio-ulnar
joints. These alterations in the mechanics of articulation are frequently the cause of disap-
pointing results from secondary palliative surgery.
We must admit that, except for a small minority of partial lesions, results for this type
of treatment of obstetric palsy have not been very satisfying for at least two reasons: first,
(and this happens especially in cases of serious palsies) the child tends to exclude the injured
limb from his cerebromotor calculations as early as the first few days after birth; second,
the co-contractions (synkinesis) of antagonist muscular groups reinnervated through spon-
taneous neurotization cause ever-increasing disorder in the dynamic effects of these muscles.
FIGURE 1. The gap that can arise between nerve stumps. Given the high regenerative power of the newborn we
can't exclude the possibility of peripheral regrowth of the nerve fiber.
FIGURE 2. Example of spontaneous neurotization. The C6 root can simultaneously regrow along the anterolateral
trunk (musculocutaneous nerve) and the posterior cord (radial nerve). This is the origin of the co-contractions
(synkinesis).
Volume I 203
FIGURE 3. (A) Case 1 — S. Chiara, 5 months, abnormal delivery, 4600 g Erb-

Duchenne paralysis of the right brachial plexus. Myelograph was negative. (B) Scheme
of the lesion and the roots repair. We effected one graft from C5 to the suprascapular
nerve; two grafts from C5 to the posterior branch of the upper trunk (axillary nerve);
and two grafts from C6 to the lateral cord. (C) View of the brachial plexus after
removal of the median cervical fascia: the upper trunk appears to be enveloped in a
large amount of scar tissue. (D) View of the nerve grafts as described in Figure 3B.
(E) Morphological and functional result 10 months after surgery. Note good extra-
rotation of the shoulder.
These considerations, together with the experience amassed by Gilbert, who was the first
to initiate early systematic treatment of the lesions to the brachial plexus in the newborn via
reconstruction, convinced us to follow this path as far back as 1978. We were also spurred
on by our vast experience in treatment of traumatic forms in the adult. At this point it is
necessary to say a word about symptoms indicative of surgery before describing our
experiences.
INDICATIONS FOR SURGERY
Deciding which are the indications for early surgery in cases of obstetric palsy is a delicate
problem and we feel that the following points are of the greatest importance:
FIGURE 3B
FIGURE 3C
Volume I 205
FIGURE 3D
FIGURE 3E
1. Early examination of the child; if possible, the newborn should be seen a few hours
after birth in order to evaluate muscular activity and initiate therapy, if necessary.
2. Check up after 2 months; this time lapse represents the interval for a more or less
complete and spontaneous recovery from neuropraxia lesion. We feel that instrumental
tests, such as electromyography, should be undertaken only if there are no physical
signs of recovery.
3. Repeat examination at 3 months of age. This should include clinical and instrumental
tests, especially myelography and chest X-rays (to visualize the mobility of the dia-
phragm). Such a comprehensive evolution of all available data leads to a qualitative
and quantitative diagnosis regarding the degree of recovery so that a decision can be
made whether to continue conservative rehabilitative therapy until complete functional
recovery is attained or proceed to surgery.
Again we wish to stress the necessity of evaluating the sum of all the tests performed, since
clinical examinations or electromyography alone can lead to erroneous conclusions.
All these considerations can be well applied in an ideal case, but unfortunately reality is
not so simple. In our experience we have operated on a child as late as 1 year after birth
because of a tardy observation.
There are serious difficulties in completing a clinical examination of a newborn; various
expedients must be adapted to overcome the lack of cooperation from the infant patient,
and if necessary the mother can be of great help by being the first to notice even the smallest
sign of recovery of motion. Another technique which is very useful in evoking muscular
contraction is to rub the skin over the area of muscles in question with an appropriate
instrument, such as a toothbrush;3 for example, contraction of biceps can be evoked by
stimulating the skin of the anterior surface of the arm.
The contractive force of a muscle under examination is expressed on a scale according
to Gilberg with values ranging from MO to M3, whereas in adults the range is MO to M5,
because in this case collaboration from the patient is lacking. To be more exact, the scale
signifies the following:
MO = absence of contraction
Ml = palpable contraction
M2 = contraction against gravity
M3 = contraction against resistance
As we shall see, the same scale is used for the evaluation of results.
It has been said that one must be very cautious in the interpretation of electromyographic
data; in cases of obstetric palsy it is possible to see unit motor potentials, but these indicate
a certain kind of nerve regeneration which may never lead to complete recovery. An ex-
cessively optimistic interpretation of such results can carry physician and patient towards
disappointing clinical results. Electromyographic data, therefore, must always be backed up
by clinical data.
Another very useful examination (considered together with all others of course) is mye-
lography, and our department has been using it routinely for 2 years. Recent critical revi-
sions, 612 however, have shown as much as 10% disparity between myélographie images
and anatomical and pathological intraoperative findings (false-positives and false-negatives);
once again, it is obvious that results from all examinations, particularly the clinical one,
must be integrated to achieve a better prognostic evaluation with a diagnosis of pre- or
postganglionic lesions. An evaluation of the mobility of the diaphragm, together with the
condition of the frenic nerve, can reveal a concomitant, usually preganglionic, lesion of the
C5 root. In the same way, the presence of CL Bernard-Horner sign can lead to a diagnosis
of the tear lesions of the T t root, frequently injured along with C8. A myelography should
confirm the presence of a pseudomeningocele on the corresponding root.
SURGICAL TECHNIQUE
The surgical technique used in the repair of the plexus in obstetric palsy is substantially
Volume I 207
the same as that used in adults. The cutaneous incision follows the posterior margin of the
sternocleidomastoideus muscle, the clavicle, and the deltopectoral sulcus. Obviously, in
superior lesions of the plexus (Erb-Duchenne type) we will limit ourselves to the upper
incision: in fact, the roots involved in this type of lesion can be found in the interscalenic
space. In cases of complete palsyor of paralysis of the lower roots or secondary trunks it
will be necessary to explore the intraclavicular space as well. The exposure of the plexus
will reveal one of the following circumstances;
1. Postganglionic lesions (extraforaminal) of the roots or primary trunks — There

is usually a continuity of scar tissue which may explain the beginnings of spontaneous
neurotization. These lesions should be classified as axonotmesis or neurotmesis.
2. Preganglionic lesions with radicular avulsion — These avulsions may involve all
the roots or can be associated with postganglionic lesions (mixedforms).
In postganglionic forms the next step is to restore the continuity of the nerve trunk by grafting
segments obtained from the sural nerve (it is often necessary to utilize both surals); the
exposure and removal of this nerve are effected by means of a complete longitudinal incision
in order to avoid stretching the fragile nerve itself.
In preganglionic lesions the problem is more difficult to solve; in mixed forms it is possible
to obtain neurotization of roots injured in the intraforaminal area by means of grafts on the
distal stumps of the injured roots in the extraforaminal area. In two cases we used the spinal
nerve and in another the motor branches of the cervical plexus (Figures 4C to D).13 In
newborns there are no indications for the use of intercostal nerves, as there are in adults.
In those rare cases of complete preganglionic lesions of the entire plexus, the only possibility
for repair lies in the neurotization of the musculocutaneous nerve with the spinal nerve,
hoping to at least restore elbow flexion.
Postoperative immobilization of the head, which we consider to be of the maximum
importance, is obtained with application of a preconstructed cast; this cast is made in the
form of a valve around the trunk, neck, and head of the child, the head being tilted towards
the side of the lesion in order to avoid any possible tension on the grafts.
The valve cast is kept on the child for 3 weeks and includes the affected limb with the
elbow maintained in flexion. Very rarely is it necessary to resort to osteotomy and successive
osteosynthesis of the clavicle.
Removal of the cast is immediately followed by continued electrotherapy and physical
therapy. At this time we add routine medical treatment with gangliosides (Cronassial) ad-
ministered in cyclic intervals. Recently reported experimental results15 have shown that
exogenously administered gangliosides have a pharmacological action on reinnervation proc-
esses, leading to early functional recovery.
CASES AND RESULTS
From June 1978 to June 1981 our department has treated 25 cases of brachial plexus
lesions due to delivery trauma (Table 1). Our evaluation of the results considered 14 cases
that were followed for over 1 year — not enough time to draw definitive conclusions but
enough to judge the usefulness of the treatment. Evaluations were carried out together with
a physical therapist and electromyographist to achieve maximum objectivity and were ex-
pressed according to the method suggested by Gilbert. Given the difficulty of testing all the
muscles of the small patient, we examined various groups of muscular function (see Table
1). The average age of the patients being operated on is quite variable, as the table shows,
and this can also be "ascribed to the fact that there is no clear programing in our country for
the treatment of these forms of health problems.
208
FIGURE 4. (A) Case 2 — C. Vanessa, 5 months, abnormal delivery, 4200 g. Total palsy of the right brachial plexus. Myelograph showed pseudomeningoceles
involving C5C6C7 roots. (B) Scheme of the lesion and the repair. We effected a graft from the spinal nerve to the lateral cord; a direct suture between C3 (motor
branches) and suprascapular nerve. Neurolysis of the lower trunk. (C) Intraoperative view: motor branches of C3 and distal stump of suprascapular nerve. (D) View
of the effected reparation: s = spinal nerve, g = graft, lc = lateral cord, C3 = motor branches of the third cervical root, and ss = suprascapular nerve. (E)
Functional result 12 months after surgery: moderate abduction of the limb. (F) Good elbow flexion obtained with spinal neurotization and good wrist flexion obtained
with neurolysis of the lower trunk.
Volume I
FIGURE 4C FIGURE 4D
209
FIGURE 4F
FIGURE 4E
FIGURE 5. (A) Case 3 — S. Angelo, 6 months, abnormal delivery, 4800 g. Total palsy of the right brachial plexus. (B) Myelography: evident is a preganglionic
lesion of C6. (C) Scheme of the lesions and repair. (D) View of the brachial plexus with the large neuroma and the great amount of scar tissue. (E) Operative view
Volume I
of the distal stump of the upper trunk (ut) and of the posterior cord (pc). (F) View of the reconstruction of the brachial plexus as described in the scheme C5; the C8
is not visible. (G) Functional result after 15 months. Besides a recovery of abduction of the shoulder and flexion of the elbow we can see the beginnings of finger
flexion.
211
FIGURE 5C
FIGURE 5D
Volume I 213
FIGURE 5E
FIGURE 5F
Even though we have obtained reasonable results after operating on children at 1 year of
age, we are in agreement with Gilbert in stating that it is better not to wait more than 3 or
4 months after birth for surgery.
Classifying according to the types of lesions, we have treated three cases of Erb-Duchenne
FIGURE 5G
palsy, four cases of C5C6C7 root lesions, and the remaining seven cases were complete
lesions. In 7 of the 14 cases there were one or more (up to three) avulsed roots at a
preganglionic level. In two cases of avulsion of the superior roots of the plexus we neurotized
with the accessory spinal nerve and with the motor branches of the cervical plexus, obtaining
partial results in one case.
In ten cases nerve grafts were performed, sometimes associated with neurolysis of parts
of the plexus which appeared to be continuous, but were constricted by fibrous tissue.
Contrary to our predictions, in those two cases where only neurolysis was performed we
did not obtain a positive result; we believe that, since they were cases in which myelographs
were not taken, what seemed " a normal plexus" was in reality a plexus avulsed in pre-
ganglionic level whose roots had remained in their places, held there by ligament-like
structures which fixed them to the transverse apophysis.14 Another hypothesis which may
explain this failure is that the outward appearance of normality of the nerve structure, which
seems to be continuous, actually corresponds to an axonotmesis or fourth grade lesion
according to Sunderland's classification.
In general, we consider the results obtained to be positive as far as treatment of superior
and postganglionic lesions are concerned; we cannot say the same for the inferior lesions,
particularly with regard to hand function. Perhaps this can be explained by the brevity of
the follow-up. Even though one could have thought that recovery times for nerve regeneration
would be shorter for newborns than for adults, in fact it would seem that regeneration is
equally slow for both; this implies that restoration of finger flexion or intrinsic muscular
function of the hand can be seen about 3 years after surgery.
Table 1
OUTLINE OF LESIONS TREATED, AND RESULTS
Age Type of Shoulder Elbow Wrist Finger Intrinsic
Name (months) injury8 Follow-up Operation abduction flexion extension flexion function
Sc.C. 7 c5c6 1 year Grafts 3 3 _ _ _

• •
Pe.S. 8 1 year 9 months Neurotization 0 1 0 — —
c5c6
Lo.G. 14 QC6< 1 year 4 months Grafts 0 1 1 — —
Ci.V. 5 ^5^6^-7 1 year 5 months Neurotization 1 2 0 — —
Ma.R. 4 ^-5^-6^-7 1 year 10 months Neurolysis 0 0 0 — —
Ri.F. 5 ^5^-6^7 1 year 7 months Grafts 2 2 2 — —
Do.D. 5 CsC6C7 1 year 9 months Grafts 3 3 3 — —
Sc.A. 5 2 years 3 months Grafts 3 3 1 2 0
Complete
Pi.A. 10 Complete 2 years 2 months Grafts 3 3 1 2 0
Sa.P. 6 Complete 1 year 4 months Grafts 3 3 2 1 0
Neurolysis
Pr.E. 13 Complete 2 years 1 month Grafts 0 1 0 0 0
Ti.G. 7 Complete 2 years 10 months Neurolysis 0 0 0 1 0
Si.M. 5 Complete 1 year 5 months Grafts 2 2 1 1 0
Neurolysis
Po.A. 6 Complete 1 year 1 month Grafts 3 2 1 2 0
Note: The frequency of preganglionic lesions can be noted. Also evident is the high percentage of good results in lesions of the upper roots, while
poor results have been achieved in hand function.
a
• = avulsion.
Volume I
215
CONCLUSIONS
What we have shown above is only a report of our experience in this field, since we can't
claim to have reached definitive conclusions. We can affirm, however, that the goal of early
surgical treatment of obstetric palsy must be to avoid spontaneous and disordered neuroti-
zation, guiding nerve regeneration along physiological channels in order to restore those
morphological and functional conditions which can lead to regained utilization of a limb
which would otherwise have been lost.
SUMMARY
The authors, following their wide experience in the microsurgical treatment of traumatic
plexus injuries in adults, refer their approach to the problem related to brachial birth palsy.
They review the anatomopathological findings and the phenomenon of the spontaneous
neurotization in birth palsies and underline the importance of a correct indication for an
early surgical treatment of the plexus lesions in the newborn.
They expose the preoperative investigations and the surgical techniques, which do not
substantially differ from those followed by other authors concerned with the pathology.
Discussing their own results they state, in conclusion, that undoubtedly the surgery of
the brachial plexus in birth palsies has to be performed very early after birth in order to
restore as correct as possible an anatomical pattern of the injured plexus by means of nerve
grafts; this will avoid those spontaneous "anarchic" neurotizations which finally cause the
nonutilization of the upper limb by the affected children.
REFERENCES
1. Adler, J. B. and Patterson, R. L., Erb's palsy: long term result of treatment in 88 cases, J. Bone Jt.
Surg., 49A, 1052—1064, 1967.
2. Bennet, G. C. and Harrold, A. J., Prognosis and early management of birth injuries to the brachial
plexus, Br. Med. J., 1520—1521, 1976.
3. Mallet, J. et al., Symposium sur la paralysie obstétricale du plexus brachial, Rev. Chir. Orthop. Suppl.,
2, 117—202, 1972.
4. Gilbert, A., personal communication, 3rd Symp. lesions of the brachial plexus, Lausanne, September 27-
30, \91%Jnt.J. Microsurg., 1(2), 103—106, 1979.
5. Taylor, A. S., Brachial birth palsy and injuries of similar type in adults, Surg. Gynecol. Obstet., 30, 494—
502, 1920.
6. Gilbert, A., Khouri, W., and Carlioz, N., Exploration chirurgicale du plexus brachial dans la paralysie
obstétricale. Constatations anatomiques chez 21 malades opérés, Re v. Chir. Orthop., 66, 33—42, 1980.
7. Gordon, M., Rich, H., Deutschberger, J., and Green, M., The immediate and long term outcome of
obstetric birth trauma. I. Brachial plexus paralysis, Am. J. Obstet. Gynecol., 117, 51—56, 1973.
8. Bonnel, F., Allieu, Y., Bruner, P., Gilbert, A., and Rabischong, P., Anatomical and surgical principles
of the brachial plexus in newborn children, Int. J. Microsurg., 2(1), 12—15, 1980.
9. De Grandis, D., Fiaschi, A., Michieli, G., and Mezzina, C , Anomalous reinnervation as a sequel to
obstetric brachial plexus palsy, J. Neurol. Sci., 127—132, 1979.
10. Esslen, E., Electromyographic findings on two types of misdirections of regenerating axons, Electroen-
cephalogr. Clin. Neurophysiol, 12, 738—741, 1960.
11. Raimondi, P. L., Petrolati, M.,.and Morelli, A., Surgical management of traumatic plexus injuries:
considerations and results, Trans. 7th Int. Congr. Plast. Reconstr. Surg., Rio de Janeiro, 95—98, May
1979.
12. Ayala, H., Myélographie et Constatations Opératoires Pathologiques, personal communication, 7th Int.
Meet. Microsurg., Group pour 1'Advancement de la Microchirurgie, Lausanne, November 9, 1981.
Volunte I 217
13. Brunelli, G., Neurotization of avulsed roots of the brachial plexus by means of anterior nerves of the
cervical plexus (preliminary report), Int. J. Microsurg., 2(1), 55—58, 1980.
14. Mansat, M., Lebarbier, P., and Mansat, A., Mécanismes lésionnels dans les traumatismes fermés du
plexus brachial, in Les Lésions Traumatiques des Nerfs Périphériques, Monogr. GEM-No. 10, Expansion
Scientifique Française, Paris, 1979, 157—164.
15. Gorio, A., Carmignoto, G., Facci, L., and Finesso, M., Motor nerve sprouting induced by ganglioside
treatment. Possible implications for gangliosides on neuronal growth, Brain Res., 197, 236—241, 1980.
Volume I 219
MICROVASCULAR SURGERY FOR CEREBROVASCULAR DISEASE
Jack M. Fein
INTRODUCTION
Microsurgical techniques play an important part in the contemporary management of

patients with cerebrovascular disease. Innovative procedures as well as refinements in con-
ventional procedures have been developed. These microtechniques have made it possible to
treat patients with lesions of the carotid and vertebral circulation who were previously
considered to be inoperable. Furthermore, the results of more conventional procedures such
as carotid and vertebral endarterectomy have been improved by the application of micro-
surgical instrumentation, microsuture techniques, and the operating microscope. In this
chapter emphasis will be placed on those areas which have been of particular interest to this
author.
SURGERY IN THE CAROTID ARTERY TERRITORY

(EXTRACRANIAL-INTRACRANIAL BYPASS)
Historical
Superficial temporal-middle cerebral bypass graft was introduced by Yasargil1 to treat
patients with cerebrovascular insufficiency caused by otherwise inoperable or inaccessible
occlusive lesions. Fein and Molinari2 demonstrated that such procedures increase regional
cerebral blood flow (CBF) after experimental middle cerebral artery occlusion. Alternatives
to the use of the superficial temporal artery (STA) have been suggested. These include the
use of radial artery, saphenous vein, and synthetic material such as Gortex® (expanded
polytetrafluorethylene vascular graft). Each of these is more difficult to handle and is as-
sociated with a lower patency rate. Recipient arteries deep within the sylvian fissure as well
as the intracranial internal carotid artery have also been used in order to increase the flow
capacity of the anastomosis.
These procedures are designed to reduce the risk of stroke in patients with transient
ischemic attacks or minor strokes who have an appropriate angiographic lesion. This includes
internal carotid occlusion, high internal carotid stenosis not amenable to carotid endarter-
ectomy, middle cerebral artery stenosis, and middle cerebral artery occlusion. Bypass pro-
cedures, as well as the other revascularization procedures to be discussed, are contraindicated
after a major infarction has occurred. In the presence of active coronary ischemia the risks
of bypass surgery may be considerable. In some cases with combined coronary and cere-
brovascular insufficiency, however, cerebral bypass may be a requisite first step prior to
coronary artery bypass grafts.
Technique
The patient is placed in the supine position with the ipsilateral shoulder elevated and the
head is turned to the opposite side (see Figure 1). The pin head-holder is used and an arterial
line and Foley® catheter are placed. The temporal region is prepared and the Doppler
stethoscope is used to locate and outline the course of the STA. Yasargil1 utilized a formal
craniotomy flap; however, we have found it more expeditious to incise the skin over the
scalp artery directly (Figure 2), using the operating microscope. After incising the skin with
a #15 scalpel blade anterior to the tragus, the STA is followed to its bifurcation into frontal
and parietal branches. It is preferable to mobilize the parietal branch, since the frontal branch
may contribute to the internal carotid collateral circulation through the orbit. Approximately
FIGURE 1. Patient positioned for left STA-MCA anastomosis. The pin head-holder secures the temporal region
in a perfectly lateral position.
5 cm of the artery is mobilized and left in continuity. The skin incision is then extended
posteriorly to allow elevation of scalp flaps in the supraauricular region. A T-shaped muscle
incision is made and a small bone flap is raised from the region underlying the scalp artery
(Figure 3). After securing the dura to the periphery of the bone flap, it is opened and a
suitable cortical artery is selected with the operating microscope. This is mobilized from
the cortex by sharp incision of the overlying arachnoidal trabeculae. Two to three small
perforating branches of the cortical artery are coagulated and cut. A small rubber dam is
placed under the artery to protect the cortex and to provide a surface which can be suctioned
free of accumulating fluid and blood. A temporary Biemer® clip is placed proximally on
the STA following which the distal end is mobilized, cut obliquely, and transposed intra-
cranially. Temporary Biemer® clips are placed across a 1-cm segment of the cortical artery.
An oval arteriotomy flap 5- to 8-mm long is removed from the cortical artery (Figure 4).
A long fish-mouth incision is made on one side of the STA to approximate the length of
the cortical arteriotomy. It is, therefore, possible to obtain an oval-shaped anastomosis which
is 5 to 8 mm in length. Since flow is related to the fourth power of the radius, a relatively
small increase in the size of the lumen at the anastomosis has a significant effect on flow
through the bypass. The anastomosis is carried out under 16 x and 25 x magnifications
by placing 10/0 sutures at 180° and then using either a continuous or interrupted suturing
technique on either side of the graft (Figure 5). Clips are removed, hemostasis is obtained,
and patency of the bypass is verified.
Results
The prophylactic value of bypass and aspirin has been evaluated in relation to a similar
group of patients managed by aspirin alone. A total of 180 patients with thromboembolic
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FIGURE 2. View through the operating microscope of partially dissected superficial temporal artery (STA).
(Magnification x 6.)
diseases who were maintained on ASA 5 g, b.i.d., have now undergone STA-MCA (middle
cerebral artery) anastomosis. Of these, 162 patients were followed for 6 months and 85
patients have been followed for 3 years. Another group of 70 patients suitable for surgery
who were maintained on aspirin alone were also followed: 68 patients were followed for 6
months and 43 were followed for 3 years. The rate of new ischemic events after periods of
6 months and 3 years is indicated in Table 1. There is a significantly (p <0.01) decreased
rate of both transient ischemic attack(s) (TIAs) and recurrent stroke in the patients undergoing
bypass.
Complications
Transient scalp flap necrosis was seen in four patients in areas of the scalp most distant
from their blood supply. One of these patients required a split thickness skin graft, while
in the other three spontaneous healing by secondary scar occurred. Two patients had subgaleal
abscess due to Staphylococcus aureus and improved after drainage and irrigation. One patient
developed a chronic subdural hematoma two weeks postoperatively, which required drainage.
One death occurred in a woman with crescendo TIAs and bilateral carotid occlusions who
developed hyperemic cerebral swelling after emergency revascularization.
FIGURE 3. The STA is mobilized, but flow is maintained. The craniectomy defect underlying it is seen, the
dura is still intact.
SPECIAL APPLICATIONS OF BYPASS SURGERY
STA-MCA anastomosis may be a useful adjunct in the treatment of giant saccular aneu-
rysms of the internal carotid and middle cerebral arteries by carotid ligation. Internal carotid
ligation is normally associated with a risk of ischemic symptoms estimated at between 30
to 50%. 3 Fein and Flamm4 have shown that carotid ligation can be undertaken safely if
preceded by a bypass procedure. Drake5 has shown that middle cerebral artery aneurysms
may be trapped safely if a bypass is first used to augment the distal collateral circulation.
There were 11 patients with saccular aneurysms who were untreatable by direct intracranial
clipping. Cortical artery and internal carotid stump pressure was measured intraoperatively
in each case. A precipitous drop in cortical artery and internal carotid stump pressure and
the electroencephalogram (EEG) changes accompanied test internal carotid ligation. These
patients were, therefore, considered to be at increased risk of ischemia from internal carotid
ligation. Measurements were repeated and the pressure drops were less significant after the
bypass was completed. Prior to completing the bypass, the gradient of pressure between the
STA and the MCA was increased by deliberate partial occlusion of the internal carotid artery
to reduce its stump pressure by 50%. 6 Final occlusion of the internal carotid artery was
carried out over 2 to 6 days preoperatively.
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FIGURE 4. Intraoperative view of cross-clipped cortical artery. An oval arteriotomy has been
made and the beveled end of the STA has been transposed intracranially and lies in apposition to
the cortical artery.
Results
The bypass was patent and the aneurysm was no longer visible in all 11 cases. In one
patient with a carotid cavernous aneurysm and fistula there was no refilling of the aneurysm
or the fistula after ligation and bypass. This patient developed transient worsening of her
right hemiparesis postoperatively but recovered completely.
CAROTID MICROENDARTERECTOMY
Historical
The results of the Joint Study on Extracranial Occlusive Disease7 indicate that patients
with recurrent transient ischemic attacks who have a hemodynamically significant lesion at
the carotid bifurcation may benefit from carotid endarterectomy. The first reported carotid
endarterectomy was performed at Montefiore Hospital in New York on January 28, 1953.
Since then various technical improvements, as well as better techniques for monitoring
cerebral hemodynamics during anesthesia, have developed. Intraoperative monitoring which
includes EEG and stump pressure measurements permits safe interruption of carotid flow
and serves as a guideline for reinstitution of flow with an internal shunt if necessary.
Endarterectomy can now be performed with a morbidity and mortality of less than 1.5%.
FIGURE 5. The partially completed anastomosis is seen. In this case individual interrupted sutures of 10/0 nylon
were used. Each suture is placed separately and then all the sutures are tied on each side. A continuous suture is
performed more rapidly but requires significantly greater skill in maintaining perfect intimai apposition.
Table 1
ISCHEMIC EVENTS
6 Months 3 Years
ASA 11/68 18/43

BYP/ASA 3/162 6/85
p 0.01 0.01
Microtechniques were introduced in 1977 to further reduce the chances of technical errors
and perioperative thromboembolism.
Technique
The operating microscope is positioned at the head of the table opposite the surgeon and
first assistant. The carotid bifurcation is exposed by an incision anterior to the sternomastoid
muscle which curves medially at the C5 level (Figure 6). The platysma is incised medial to
the sternomastoid muscle. Sharp dissection is performed between the sternomastoid muscle
and the midline trachea and esophagus. When the carotid bifurcation is higher than C3-C4
level, the digastric muscle may be divided and the hypoglossal nerve gently mobilized. The
common, internal, and external carotid arteries are exposed and tourniquets are placed around
each (see Figure 7). Care is taken to avoid injury to the vagus, recurrent laryngeal, and
hypoglossal nerves. The external, common, and internal carotid arteries are temporarily
clamped. The EEG is monitored and the internal carotid artery stump pressure is measured.
Unilateral or bilateral flattening of the EEG or a drop in stump pressure by more than 50%
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FIGURE 6. The incision planned for carotid microendarterectomy is somewhat smaller than that for conventional
endarterectomy, and is carried over the anterior border of the sternomastoid muscle.
FIGURE 7. Operative exposure of the cervical common carotid bifurcation taken through conventional photog-
raphy and approximates the view that the surgeon sees without magnification. Ligatures have been placed on the
common carotid, internal carotid, the external carotid, and the superior thyroid artery.
FIGURE 8. Intraoperative electroencephalogram (EEG) in a patient with a right internal carotid stenosis and a
left internal carotid occlusion. With temporary clamping there is significant slowing and flattening of the EEG
bilaterally. Simultaneous measurement of internal carotid artery stump pressure indicated a drop of the mean
pressure from 87 to 30 mmHg. When an internal shunt was placed there was rapid return of normal EEG activity.
are indications for placing an internal shunt (Figure 8). After a stab wound is made in the
common carotid artery, a linear arteriotomy from the common through the internal carotid
artery is made using a Potts scissor. If an internal shunt is required it may be placed at this
time (Figure 9). The binocular head of the microscope is then positioned and focused.
Endarterectomy is carred out at 10 to 16 x magnification. Modified DeBakey forceps are
used to grasp the arteriotomy edges and the cut surface is inspected under 16 x magnification
to select the best plane between plaque and the outer media to start the dissection. A small
dissector is then introduced with its cutting edge directed toward the lumen (Figure 10).
The plaque is separated from the media in a plane which is maintained from the common
carotid artery through the bifurcation (Figure 11). The plaque is cut sharply with microscissors
approximately 2 cm below the bifurcation. The plaque is delivered from the orifice of the
external carotid artery with a micronerve hook and is then separated from the wall of the
internal carotid artery. If the plaque extends beyond the occluding tourniquet in the internal
carotid artery, its distal segment is secured to the wall by several 8/0 Prolene® vertical
sutures. After the plaque is removed, the arterial wall is inspected under 16 x magnification
to identify and remove any residual shards which may protrude into the lumen. Each shard
is firmly grasped and either stripped out to the arteriotomy opening or cut with a curved
microscissor flush with the arterial wall. The arteriotomy is then closed using continuous
6/0 Prolene® sutures. The precision of the closure allows smaller amounts of tissues to be
included in the suture and has completely eliminated the need for vein patch grafts.
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FIGURE 9. Demonstrates insertion of a shunt which can be seen through the arteriotomy incision.
Results
The last 86 of 427 endarterectomies have been carried out using microsurgical techniques.
Improved results in this group of patients may be related to other factors, but the author
feels that the more precise techniques afforded by the microscope have played an important
role. Of greater significance is that there have been no postoperative ischemic events over
a mean follow-up of 2.5 years. This reflects the presence of an intact residual lumen which
is free of thrombus formation, suture line stenosis, residual shards of plaque, or dissection
under a distal fragment of plaque.
Complications
Two patients had transient recurrent laryngeal nerve palsy. One patient developed a wound
hematoma which resolved spontaneously.
SURGERY FOR VERTEBROBASILAR ISCHEMIA
Microsurgical procedures may now be employed to correct occlusive lesions of the ver-
tebral or basilar arteries or of their major tributaries. This requires the highest quality
angiography to delineate the lesion as well as to assess the hemodynamic patterns of the
available collateral circulation.
Vertebrobasilar Insufficiency
Revascularization procedures for vertebrobasilar insufficiency are indicated for patients
who experience transient ischemic attacks, progressive stroke, or minor completed strokes
involving the brain stem or cerebellum. Transient ischemic attacks involving the vertebral
circulation are less characteristic than those involving the carotid circulation, but may consist
FIGURE 10. View through the operating microscope of the distal end of a calcific atherosclerotic plaque which
has been separated with a microdissector from the wall artery.
of episodes of stance ataxia, limb dysmetria, vertigo, transient dysarthria, or diplopia.

Dizziness, nausea, and syncope are not consistently related to ischemic insufficiency. The
syndrome of progressive stroke is seen in patients when symptoms of ischemic insufficiency
evolve over hours or days. These patients require a period of stabilization prior to surgery
and should be managed medically with intravascular volume expanders and heparin infusion
if there is no hemorrhagic component. Patients with extensive infarction are unsuitable
candidates since the goal of revascularization surgery is the prevention of stroke. In a small
number of patients who have recovered from the acute effects of infarction and are func-
tionally independent in activities of daily living, revascularization may be appropriate for
future stroke prophylaxis.
VERTEBRAL CAROTID TRANSPOSITION (VCT)
Indications
This procedure is employed in patients with ischemic insufficiency secondary to stenosis
of the vertebral artery origin. The advantage of transposition over vertebral endarterectomy
is that it is completely extrathoracic and there is a decreased incidence of postoperative
stenosis with VCT.8 VCT is also suitable for symptomatic patients with the subclavian steal
syndrome who have reversal of flow in the vertebral artery. The anastomosis between the
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FIGURE 11. Further progress in the dissection of the plaque using microtechnique. The residual wall behind the
shunt is seen.
proximal portion of the vertebral artery and the side of the common carotid artery results
in antegrade flow from the carotid to the vertebral artery.
Technique
An incision is made along the anterior border of the sternomastoid and extended laterally
along the supraclavicular region to the lateral border of the sternomastoid muscle. The
jugular vein is retracted more gently on the left side to avoid injury to the thoracic duct.
The superior surface of the subclavian artery is exposed (Figure 12) uncovering the origin
of the costocervical trunk and the vertebral artery more medially. The proximal segment of
the vertebral artery is mobilized from its origin to its entrance into the transverse foramen
at C6. The origin of the vertebral artery is then ligated and divided. The common carotid
artery is temporarily occluded between two tourniquets and a stab wound is made on its
posterolateral surface. An aortic punch is then used to produce an arteriotomy. A partially
occluding clamp is then placed behind the arteriotomy on the common carotid artery to allow
continued blood flow during anastomosis. The vertebral artery origin is ligated and transected
at its origin and is transposed for anastomosis with the side of the common carotid artery
(Figure 13). An end-to-side anastomosis is performed using continuous 7/0 Prolene® suture
with the microscope at 10 to 16 x magnification.
In cases of subclavian steal, ligation of the vertebral artery may be contraindicated, if
FIGURE 12. Sketch of the intraoperative view of the dissection during left vertebral
carotid transposition procedure. The retractor is on the internal jugular vein separating it
from the carotid artery more medially. Between these two great vessels can be seen the
dorsal surface of the subclavian artery with its first branch of the vertebral artery and
more laterally the costocervical trunk.
this is a major source of blood supply for the brachial artery. It is worthwhile to perform
test occlusion of the vertebral artery while blood pressure is monitored in both arms. It is
safe to ligate the artery if the mean brachial blood pressure falls by less than 15 mmHg.
Anastomosis is difficult if there is significant atherosclerotic disease of the common carotid
artery. If this is demonstrable on the angiogram, VCT should not be attempted. Other more
conventional procedures such as axillary-axillary bypass for subclavian steal syndrome or
vertebral endarterectomy for vertebral origin stenosis should then be utilized. When atheroma
are confined to the region of the carotid bifurcation, VCT may be combined with endarter-
ectomy (Figure 14).
Results
A total of 11 patients with stenosis of the vertebral artery origin underwent VCT. Pre-
operatively five patients had transient ischemic symptoms, four had minor completed strokes,
and two had progressive posterior fossa ischemic insufficiency. After 1 to 5 years of follow-
up one patient had a recurrent posterior fossa TIA and one patient with diplopia preoperatively
is still debilitated by the same complaint. Seven patients with recurring transient symptoms
related to subclavian steal have undergone VCT; six of the seven patients have been free of
symptoms since. One patient had a single transient ischemic event 2 days after surgery, but
this has not recurred. There have been no significant complications to date.
DECOMPRESSION OF THE VERTEBRAL ARTERY IN THE

VERTEBRAL CANAL
Indications
Cervical osteoarthritis occasionally produces compression of one or both vertebral arteries
within the vertebral canal. Patients have symptoms of vertebrobasilar insufficiency exac-
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FIGURE 13. Operative sketch of the proximally ligated vertebral

artery origin. The vertebral artery has been dissected up to its entrance
into the transverse foramen at C6 and temporarily cross-clipped. An
end-to-side anastomosis using the operating microscope and 7/0 Pro-
lene® suture is seen. The partially occluding clamp allows continuous
flow in the common carotid artery.
erbated by turning the head away from the side of the lesion. The combination of cerebro-
vascular symptoms and cervical radiculopathy should alert one to this possibility. Plain
cervical spine films show overgrowth of the uncovertebral joint. Vertebral angiography often
shows a medial defect most frequently at C4.5 or C5.6. This defect is often exacerbated by
head turning.
Hardin et al.9 first described the surgical treatment of spondylitic vertebral artery insuf-
ficiency. They described a lateral approach to the transverse processes. Bakay and Leslie10
described the beneficial effects of cervical fusion alone in two patients with vertebral in-
sufficiency. Verbiest11 described the removal of the anterior segments of the transverse
processes in two patients with compression of the vertebral artery by overgrowth of the
uncovertebral joints. Our approach to decompression of the vertebral canal utilizes the same
techniques and instrumentation as developed by Cloward12 for anterior diskectomy and
fusion.
Technique
The patients are placed in the supine position with the head resting on a ring support. An
oblique incision is used and dissection is carried down to the prevertebral fascia between
the sternomastoid muscle and the trachea. After X-ray confirmation of the appropriate level
FIGURE 14. Intraoperative sketch; simultaneously performed inter-

nal carotid endarterectomy and vertebral carotid transposition. The
vertebral carotid transposition precedes the endarterectomy so that there
is no compromise of the fresh endarterectomy sight by a period of
interrupted flow.
the longus colli muscle on the involved side is stripped from the transverse process and
excised over the segments involved. The transverse process is removed using small rongeurs
(Figure 15). Using the operating microscope the osteophyte is found between the transverse
processes and is removed with the air drill. Tributaries of the perivertebral venous plexus
and the associated fibrous scars are coagulated and cut with microscissors (Figure 16). It is
essential to remove the associated fibrous bands which are often seen to produce kinking
and traction on the artery.
Results
The procedure has been performed in seven patients. Preoperatively these patients all had
vertebrobasilar insufficiency manifested by vertigo in seven, diplopia in three, and a small
Wallenburg-type stroke in two. Three patients had local cervical pain and tenderness, two
had an ipsilateral cervical radiculopathy, and one had both a cervical radiculopathy and
myelopathy. All had plain cervical spine films indicative of localized osteophytes and an-
giographic demonstration of various degrees of compression of the vertebral artery. There
was relief of all vertebrobasilar symptoms in five patients. In one patient an increase in C5
radiculopathy postoperatively was remedied with a cervical collar. One patient had a further
transient ischemic attack with extreme neck rotation. This has not recurred.
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FIGURE 15. Intraoperative sketch showing re-

moval of anterior aspect of transverse foramen to
expose left vertebral artery.
FIGURE 16. The vertebral artery is normally en-

meshed in a plexus of veins and fascia which may
significantly constrict and compromise flow. These
adhesive bands should be thoroughly lysed.
FIGURE 17. AP vertebral arteriogram demonstrating multiple stenotic and ectatic portions of the left vertebral
artery in a young patient with posterior fossa transient ischemic attacks. This patient underwent occipital PICA
bypass.
POSTERIOR FOSSA BYPASS
Hemodynamically significant lesions of the intradural portions of the vertebral artery or

of the basilar artery may be responsible for cerebellar hemispheric, midline, or brainstem
dysfunction.13 Arterial lesions which are suitable for posterior fossa bypass operations are
located in the intradural portions of the vertebral or basilar arteries or at the proximal portions
of the posterior inferior cerebellar (PICA), anterior inferior cerebellar (AICA), or superior
cerebellar (SCA) arteries (Figure 17).
Contraindications
Posterior fossa bypass procedures are technically more difficult and associated with a
higher surgical risk than superficial temporal-middle cerebral artery bypass. The most com-
mon risk factors in this population are cardiac. For these reasons surgery is contraindicated
in the presence of active coronary artery disease manifested by either anginal complaints,
ischemic changes on the electrocardiogram, or a history of recent (<6 months) myocardial
infarction.
Technique
Patients should be well hydrated and the blood volume should be determined and corrected
if necessary prior to surgery. On the morning of surgery the lower extremities are wrapped
with elastic stockings and a urinary catheter is inserted. In the operating room, systemic
arterial pressure is monitored through a percutaneously inserted catheter into the radial artery
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FIGURE 18. Sketch of the relationship of the external occipital

branch of the external carotid artery to the mastoid and muscular
structures of the suboccipital region. The artery can be palpated
just inferior to the mastoid process.
and a Doppler stethoscope is affixed to the precordium to ascertain the presence of air
embolism. Patients with cerebrovascular disease are at significant risk of further ischemic
insult when placed in the sitting position. The "park-bench" position is ideal for this group
of patients and also mitigates against air embolism. This allows for gravity drainage of blood
and cerebrospinal fluid from the surgical bed, but avoids the complications of the sitting
position. This has been utilized for the last eight patients and none of these complications
has occurred.
The patient's head is fixed in the pin head-holder anteriorly. A set of instruments designed
for these procedures allows precise handling of the donor and recipient arteries at the depths
required. This has simplified the posterior fossa bypass operation significantly. The occipital
branch of the external carotid artery enters the suboccipital region after penetrating the
mastoid groove and the retromastoid region. The course of the occipital artery is estimated
from the anteroposterior angiogram, but is localized precisely with the Doppler stethoscope
and traced on the skin. A hockey stick incision provides exposure of the suboccipital region
and allows dissection of the external occipital artery from the suboccipital musculature (Figure
18). The scalp and muscle flap is then mobilized downward and laterally. It is important to
leave an adequate cuff of fascia on the occipital bone so that the muscle layer may be closed
completely. Once the semispinalis muscle flap is turned down the occipital artery is usually
palpable on its underside. It enters the suboccipital region between the longissimus capitus
and the superior oblique muscle. It then lies between the semispinalis capitus muscle layer
and the layer composed of the superior and inferior oblique and the teres major and teres
minor muscles.
For the PICA bypass the craniectomy should include the posterior lip of the foramen
magnum (Figure 19). The lamina of C, should also be removed to obtain adequate exposure
FIGURE 19. The external occipital artery has been dissected,

clipped proximally. The proposed stellate durai incision is shown.
The arch of C, has also been removed.
of the cisterna magna and the PICA. The intradural portion of the procedure is carried out
with the microscope fitted with a straight binocular 20 x eyepiece and a 250 mm objective.
The medullary portion of PICA is a more satisfactory recipient artery than the hemispheric
portion and is found medial and anterior to the tonsil (Figure 20). Each branch is temporarily
occluded with a Kleinart-Kutz® clip before ligation to ascertain whether this results in a
change of cardiac or respiratory rhythm. One to three small branches (<200 |xm diameter)
of the PICA are ligated and divided, the artery is mobilized off the brainstem and a small
rubber dam is placed underneath. The occipital artery is then mobilized completely from its
fascial bed and the fascia from its distal 1.5 cm is stripped from the adventitia. Two miniature
Biemer® clips are used to occlude a 1-cm segment of the PICA. Under 25 x magnification
an eliptical arteriotomy flap approximately 6 mm in length is excised. The segment to be
removed is grasped with a bayonet Dumont® jeweler forceps. The interior of the remaining
arterial wall should not be grasped or injured by instruments. The beveled end of the occipital
artery is then brought into opposition with the PICA artery. A final adjustment in the length
of the occipital artery lumen can still be made at this point by lengthening the fish-mouth
opening. A second microsuture is placed 180° to the first and both are left long so that a
continuous suture technique can be used. After completing the anastomosis the intraluminal
pressure against the anastomosis is increased gradually. The clip on the distal segment of
PICA is removed first, followed by the proximal clip, and finally the clip on the occipital
artery is removed. The stellate durai incision is closed with interrupted #4/0 Neurolon®
suture to avoid troublesome cerebrospinal fluid (CSF) leaks. A separate opening is left in
the dura for the donor artery.
Volume I 237
FIGURE 20. Exposure of the medial tonsillar area is performed.

The first portion of the PICA as it courses around the brain stem
is seen and a segment which is relatively free of branches is selected.
The craniectomy for the AICA bypass is centered over the posterolateral portion of the
cerebellar hemispheres similar to the opening for an acoustic neuroma (Figure 21). The dura
is opened more laterally and a large hemispheric branch of the AICA is traced anteriorly
toward its origin from the main AICA artery. One of the hemispheric cortical branches larger
than 1-mm diameter can be found in the arachnoid of the larger sulci. The arachnoidal
covering is opened sharply and three or four branches of the cerebellar cortical artery over
a 1.5-cm length are coagulated, ligated, and cut. The recipient artery is then isolated between
small Biemer® clips and the arteriotomy and anastomosis are carried out as previously
described for the PICA bypass.
Complications
Some of the complications of posterior fossa bypass are related to the sitting position
(i.e., air emboli, convexity subdural air and hematoma collection over relatively atrophic
brains), and to decreased ability of the cerebral circulation to respond to transient alterations
in perfusion pressure. Many of these problems are avoidable by using the "park-bench"
position. In one patient an epidural hematoma developed from a bleeding point on the donor
graft. In another patient graft occlusion was associated with a new neurologic deficit. In
our own patients the only significant complication was a pseudomeningocele in the suboc-
cipital region which resolved after 3 days of lumbar drainage.
CONCLUSIONS
The treatment of patients with cerebrovascular disease was previously limited by the
surgeon's visual acuity and inability to manipulate 1-mm diameter arteries. Since the ap-
plication of the operating microscope, endarterectomy and decompression of the vertebral
canal may be carried out with greater degrees of precision. Newer procedures such as
FIGURE 21. Craniectomy for occipital-AICA bypass is shown.

The durai incision and opening is over the more lateral portion
of the hemisphere and a suitable cerebellar cortical artery has
been utilized for this anastomosis.
extracranial-intracranial bypass and vertebral carotid transposition have been introduced to

treat arterial lesions which are inoperable by more conventional techniques. It is apparent
that these procedures will play an increasingly significant role in the future management of
patients with cerebrovascular disease.
SUMMARY
Microsurgical techniques have improved our ability to treat many patients with cerebro-
vascular disease. New procedures as well as refinements in more conventional techniques
have increased the number of patients who may be treated before the onset of severe
neurologic disability. New procedures in the anterior circulation include the extracranial-
intracranial bypasses. In addition to the STA, various other graft materials have been used
to increase the collateral blood supply to the cerebral hemispheres in patients with TIA.
After an average follow-up of 3 years, the stroke rate in 85 patients undergoing surgery was
significantly less than in 43 patients with similar lesions and risk factors who were not
treated surgically. In addition to cerebrovascular disease this procedure may be useful when
surgical ligation of the internal carotid or middle cerebral artery for aneurysm or tumor is
anticipated. Although carotid endarterectomy is performed using conventional techniques
the rate of postoperative stroke in most series still averages 2 to 4%. In an effort to obtain
Volume I 239
more precise endarterectomy and arteriotomy repair, the operating microscope has been
utilized in 86 patients. In this group there were no postoperative ischemic events after a
mean follow-up of 2.5 years. This reflects the presence of an intact residual lumen which
is free of thrombus, suture line stenosis, and residual shards of plaque. Revascularization
procedures for vertebrobasilar insufficiency are indicated for patients with transient ischemic
attacks who have stenotic or occlusive lesions on the proximal or distal portions of the
vertebral arteries. The more proximal stenotic lesions of the vertebral artery have classically
been treated with endarterectomy, however, vertebral carotid transposition has specific ad-
vantages. It is a completely extrathoracic approach and there are fewer instances of post-
operative stenosis. In this procedure the proximal portion of the vertebral artery is joined
to the side of the carotid artery in an end-to-side anastomosis which provides an opportunity
to enlarge the lumen of the vertebral artery. This procedure is useful both for vertebral origin
stenosis as well as for the subclavian steal syndrome. Severe spondylosis may produce
compression of the vertebral artery in the vertebral canal and this may be treated by an
anterior cervical approach and decompression of the vertebral canal. Lesions of the vertebral
and basilar artery intradurally may be treated by extracranial-intracranial bypass procedures.
These procedures are technically more demanding than the anterior circulation bypass pro-
cedures but are effective in patients with recurrent vertebrobasilar ischemia.
REFERENCES
1. Yasargil, M. G., Anastomosis between the superficial temporal artery and a branch of the middle cerebral
artery, in Microsurgery Applied to Neurosurgery, Academic Press, New York, 1969, 105—155.
2. Fein, J. M. and Molinari, G., Experimental augmentation of regional cerebral blood flow by microvascular
anastomosis,/. Neurosurg., 41, 421—426, 1974.
3. Miller, J. D., Jawad, K., and Jennett, B., Safety of carotid ligation and its role in the management of
intracranial aneurysms, J. Neurol. Neurosurg. Psychiatry, 40, 64—72, 1977.
4. Fein, J. M. and Flamm, E., Planned revascularization prior to proximal ligation for traumatic aneurysm,
Neurosurgery, 5, 254—258, 1979.
5. Drake, C. G., Giant intracranial aneurysms: experience with surgical treatment in 174 patients, Clin.
Neurosurg., 26, 12—95, 1978.
6. Fein, J. M., Lipow, K., and Marmarou, A., Cortical artery pressure in normotensive and hypertensive
aneurysm patients, J. Neurosurg., 59, 51-66, 1983.
7. Fields, W. S., Maslenikov, V., Meyer, J. S., Hass, W. K., Remington, R. D., and MacDonald, M.,
Joint study of extracranial arterial occlusion. V. Progress report of prognosis following surgery or nonsurgical
treatment for transient cerebral ischemic attacks and cervical carotid artery lesions, JAMA, 211, 1993—
2003, 1970.
8. Fein, J. M., Vertebral artery transposition for vertebrobasilar insufficiency, paper presented at Annu. Meet.
Am. Assoc. Neurological Surgeons, Boston, April 1981.
9. Hardin, C. A., Williamson, W. P., and Streegman, A. T., Vertebral artery insufficiency produced by
cervical osteoarthritic spurs, Neurology, 10, 855—858, 1960.
10. Bakay, L. and Leslie, E. V., Surgical treatment of vertebral artery insufficiency caused by cervical
spondylosis, J. Neurosurg., 23, 596—602, 1965.
11. Verbiest, H., A lateral approach to the cervical spine: technique and indications, J. Neurosurg., 28, 191—
203, 1968.
12. Cloward, R. B., Treatment of lesions of the cervical spine by anterior surgical approach, in The Spinal
Cord, Hurton, G., Ed., Charles C Thomas, Springfield, 111., 1972.
13. Fein, J. M., Posterior fossa bypass surgery for vertebrobasilar insufficiency, Contemp. Neurosurg., 4,
Lesson 7, 1982.
Volume I 241
MICROANASTOMOSIS AND TOTAL BYPASS OF THE CEREBRAL

VENOUS SINUSES AND TORCULAR HEROPHILUS*
Albert H. Capanna
INTRODUCTION
Surgery on the durai sinuses has, until recently, been considered fraught with danger.
The risk of air embolism or thrombosis with subsequent edema is real. Operations on the
superior sagittal sinus, particularly in the anterior and middle thirds, have been reported.16
The torcular herophilus has, heretofore, been considered "no man's land". In an attempt
to dispel this myth, a canine model to totally bypass the torcular herophilus was developed
and successfully performed on eight dogs (five acute and three chronic).7
Operations to bypass the superior sagittal sinus, including anastomosis of cerebral veins
to the sinus, were successfully performed.
METHODS AND MATERIALS
Mongrel canines were utilized without sex predilection. Larger dogs were preferred for
superior sagittal sinus bypass operations. Smaller dogs were deliberately chosen for the
torcular bypasses after it was learned that the bone drilling time was shorter. All procedures
were carried out under endotracheal general anesthesia using fluothane or nitrous oxide-
oxygen. Intravenous diazepam was occasionally administered.
The dogs were placed in the lateral position and the medial aspect of the left posterior
extremity prepped. A longitudinal incision was used, and a portion of the saphenous vein
removed. Skin was closed with 2/0 silk interrupted vertical mattress sutures and covered
with celloidin.
The saphenous veins were then prepared using a Zeiss®** OPMI 1 or OPMI 6 operating
microscope with 20 x oculars, objective lens off = 275 mm, and control settings at medium
to maximum magnification. The veins were stripped of adhesions and checked for valves
by injecting normal saline. In sinus bypasses with cortical cerebral veins also anastomosed
as collateral branches, if an adequate bifurcation was not present in the vein autograft (the
usual case), then a bifurcation was created. This was accomplished by using a segment of
the vein, and an end-to-side anastomosis was performed using interrupted 10/0 or 11/0 nylon
microvascular suture, thus creating a Y-shaped or branch graft. This was also done to create
the new torculae.
The dog is repositioned prone and the head is positioned with slight flexion of the head
and neck. A special frame was devised to hold the snout in place and mounted to the table,
leaving the mandible and endotracheal tube free. A midline skin incision is made in the
cranium over the area to be bypassed, and in the torculae operations from the posterior
parietal-occipital area to approximately the C2 cervical level. Bovie and bipolar coagulation
are used as needed. All muscle is stripped laterally. A burr hole is placed on each side of
the midline. The burr holes were connected superiorly across the midline thus localizing the
superior sagittal sinus. This and the remainder of the bony exposure is accomplished with
power drills. Multiple sizes of drill tips were used, and the larger bits were preferred. The
canine torcular herophilus is entirely interosseous and starts at the superior sagittal sinus at
the foramen impar. The drilling procedure is extensive. After the sinus, or sinuses, to be
bypassed are completely exposed, the prepared saphenous vein graft is positioned and tailored
* At the time the chapter(s) were written, Dr. Capanna was employed as a Neurosurgeon, Renaissance Neuro-
surgery, East Detroit, Michigan.
** Carl Zeiss, D-7082 Oberkocher, W. Germany.
to the desired length and angles. Temporary angled Yasargil microclips were used to partially
occlude the segments for anastomosis and small Week clips were used to obliterate the
original sinus, or torculae, after the anastomoses were completed.
The sinuses were opened with microscissors and end-to-side anastomosis performed with
10/0 or 11/0 nylon microvascular suture in interrupted, vertical manner (Plates 3 and 4*).
Methylene blue was injected i.v. and into the proximal superior sagittal sinus to visualize
patency in some of the acute animals. In acute experiments, all animals are sacrificed
immediately on the same day of surgery.
Chronic dogs were operated on in exactly the same manner except a sterile technique was
employed and i.v. cephalothin was given intraoperatively and for 1 day postop, as a pro-
phylactic measure. The chronic dogs were closed in four layers with 2/0 interrupted silk
suture, and celloidin placed over the skin sutures. The second operations were performed
on an average of 70.3 days after the first operations. Reexploration was in the same manner
as the initial operation and extensive drilling was again needed as ossification had occurred
around the new torculae. Carotid angiography resulted in poor phlebography8 and, therefore,
direct sinography in the proximal portion of the superior sagittal sinus was used. The first
sinograms were less than satisfactory, and multiple techniques were tried. The best technique
was using a #20 gauge needle to open the superior sagittal sinus, then replace it with a
#17 gauge catheter (30.4 cm Bard I-cath®**), a small amount of cyanoacrylate around the
entrance of the catheter into the sinus stopped leakage. Iodinated contrast was used for
injection, and radiographs made (Figures 1 to 4). Then either methylene blue or indigo
carmine 0.4% was injected and visualized.
All grafted areas were completely excised after sacrifice of the animals, and submitted
to histological study.
RESULTS
Bypass of the cerebral venous sinuses was achieved at all levels. The superior sagittal
sinus was bypassed and tributary cerebral cortical veins were successfully microanastomosed
to the bypasses.
Total bypass of the torcular herophilus was performed in eight dogs (five acute and three
chronic). The chronic dogs were all approximately 3 months postop at the time of phle-
bography, sinography, reexploration, and sacrifice. Patency was achieved in all cases, and
no neurological deficits resulted in any of the dogs. Similar techniques have been used to
bypass the torculae in rats.
DISCUSSION
Total bypass of the cerebral venous sinuses and the torcular herophilus has been performed.
All cases were patent. The techniques presented were utilized in dogs. These techniques are
difficult to apply even with a team highly specialized in microsurgical techniques with
extensive experience in animal experimentation. The canine model is an excellent technical
exercise, involving extensive drilling as well as microanastomoses.
The canine torculae, however, are venous segments without durai covering and, therefore,
very difficult to work with. The human torcular herophilus being extraosseous, possessing
an interior venous portion and a durai covering, and grossly larger than the dog's torcular
should be technically a less difficult operation. The experimental results demonstrate, for
* Plates 3 and 4 will follow page 248.

** C.R. Bard International Ltd., Sunderland, England.
Volume I 243
FIGURE 1. Lateral-view sinogram at 3 months post bypass, showing superior sagittal sinus, new torcular, clips
occluding original torcular, and both lateral sinuses.
the first time, that it is possible to bypass the torcular herophilus without disastrous con-
sequences, and indeed with a normal life expectancy. This knowledge will hopefully allow
bypass of human sinuses and torculae and offer a cure for patients with tumors, such as
meningiomas invading the torculae, and for traumatic lesions involving the sinuses.
SUMMARY
Total bypass of the cerebral venous sinuses and the torcular herophilus is presented.
Details of the methods and materials used to avoid air embolism and thrombosis are explained.
A canine model was utilized.
Operations to bypass the superior sagittal sinus, including anastomosis of cerebral veins
to the sinuses, were successfully performed. Total bypass of the torcular herophilus was
achieved. Patency was present in all cases, and no neurological deficits resulted in the
chronic dogs.
These techniques should be applicable to patients with tumors, such as meningiomas, and
for traumatic lesions of the sinuses.
FIGURE 2. Submental-vertex view. Sinogram showing new torcular, sinuses, and jugular veins.
FIGURE 3. Lateral, subtraction view of chronic dog demonstrating the patent graft bypassing the original torcular
(arrow points to torcular).
Volume I 245
FIGURE 4. Subtraction, submental-vertex view of chronic dog, showing all sinuses and successful total bypass.
REFERENCES
1. Bonnal, J. and Brotchi, J., Surgery of the superior sagittal sinus in parasagittal meningiomas, J. Neu-
rosurg., 48, 935, 1978.
2. Capanna, A., Ho, R., and Saadi, J., Microanastomosis and shunting of the superior sagittal sinus,
presented as exhibits at Congr. Neurological Surgeons 28th Annu. Meet., Washington, D.C., September
24 to 29, 1978; Am. Assoc. Neurological Surgeons 47th Annu. Meet., Los Angeles, April 22 to 26, 1978;
Congr. Neurological Surgeons 29th Annu. Meet., Las Vegas, October 7 to 12, 1979; Mich. Neurosurgical
Soc. Meet., Detroit, June 12 to 14, 1979.
3. Hatmann, K. et al., Recurrent and possible surgery procedure in meningiomas of the middle and posterior
parts of the superior sagittal sinus, Acta Neurochir. (Wien), 31(3,4), 283, 1975.
4. Sindau, M., Mazoyer, J. F., Fischer, G., and Pialat, J., Experimental bypass for sagittal sinus repairs,
J. Neurosurg., 44, 325, 1976.
5. Kapp, J., Gilechinsky, I., and Petty, C , An internal shunt for use in the reconstruction of durai venous
sinuses,/. Neurosurg., 35, 351, 1971.
6. Donaghy, R., Wall man, L., and Flanagan, M., Sagittal sinus repairs, J. Neurosurg., 38, 244, 1973.
7. Capanna, A., Saadi, J., Yasagil, M., and Zumstein, M., Torcular Herophilus Total By-Pass, presented
as exhibits at Cong. Neurological Surgeons 30th Annu. Meet., Houston, October 5 to 10, 1980; Am. Assoc.
Neurological Surgeons 50th Anniversary Meet., Boston, April 5 to 9, 1981; Am. Assoc. Neurological
Surgeons, 51st Annu. Meet., Honolulu, April 25 to 29, 1982.
8. Mazoze, J. F., Sindou, M., and Fizile, G., Experimental surgery of the sagittal sinus in dogs, Lyon Med.,
233, 123, 1975.
Volume I 247
EXTRACRANIAL-INTRACRANIAL MICROANASTOMOSIS CEREBRAL

REVASCULARIZATION OPERATIONS
Albert H. Capanna
INTRODUCTION
The advent of the operating microscope allowed vascular suture technique to be applied
to minute extracranial and intracranial vessels. Experimental models were developed in the
late 1960s, and the first extra-intracranial anastomosis between the superficial temporal
artery (STA) and the middle cerebral artery (MCA) were performed by Yasargil (in Zurich)
and Donaghy (in Vermont) on June 7, 1967. While this new technique is slowly finding
wide application, and as its benefits are becoming recognized and the number of trained
microsurgeons is increasing, bypass operations are performed with increased frequency.
Numerous combinations between extracranial and intracranial vessels have now been suc-
cessfully performed. The use of vein grafts to allow diversion of blood from greater vessels
to the intracranial cerebral vessels is also now feasible.
OPERATIVE TECHNIQUE
The experimental surgical training for end-to-end and end-to-side anastomosis of vessels
with a diameter of 1 mm or less is an extremely difficult technique14 and will not be
superficially discussed here. It is sufficient to say that adequate laboratory training is a
prerequisite before/one is presented to the operating theater as a microsurgeon.
The principle of the operation is to establish an artificial collateral circulation between
branches of the external carotid artery and the intracranial cerebral circulation. The STA
and the occipital artery (OA) are very suitable as the afferent branch of the anastomosis.
The use of prosthetic grafts, veins, or arteries is not suitable (although recent interest and
use of vein grafts may prove useful).
In cases with correct indication and surgical technique, a patency of 80 to 90% can be
expected. The duration of the operation is of some importance. The STA-MCA bypass has
taken some as long as 17 hr to perform, but most microsurgeons take about 6 hr. The author
has performed the operation in 2V2 hr and averages 3V2 hr skin-to-skin. The occipital artery
to posterior inferior cerebellar artery (OA-PICA) bypass takes considerably longer because
the occipital artery is smaller and embedded in more muscle, thus making the dissection
more difficult.
STA Exposure
This may be accomplished using a flap situated with the STA more or less in its center.
It is also possible to dissect the STA with an incision directly above the vessel, which has
been traced by palpation and echography. The direct cutdown technique allows a better
blood supply to the scalp.
Technical note 1 — By placing the incision to one side of the STA (rather than directly
above the vessel) one can dissect directly to the fascia of the superficial temporal muscle.
It then becomes easier to dissect around the STA with less chance of injury to the vessel.
In order to prevent postoperative complications, a large fibrous mantle should be left
around the vessel. This protects the vessel while being handled and also improves nutrition
to the vessel.
Technical note 2 — The use of blunt Metzenbaum scissors greatly facilitates the speed
of dissecting the STA with an adequate mantle and decreases the risks of injury to the vessel
posed with sharp microscissor dissection.
The use of both main branches of the STA (frontal and parietal) to improve perfusion of
the anastomosed region is considered advantageous by some authors. The risk of scalp
necrosis is particularly great when both branches are used, and must be considered in each
case.
OA Exposure
Exposure of this vessel is much more difficult because of the overlying occipital muscle.
If the O A is to be anastomosed to the middle cerebral artery, it is necessary to dissect free
a long segment of the OA. For anastomosis with the PICA, a shorter segment will suffice.
Exposure of the Cortical Vessel

The MCA is best exposed by a 3- to 4-cm diameter bony opening, 6 cm above the external
auditory meatus. This will allow finding a vessel 0.8 mm or greater in size.
Cortical vessels are surrounded by a thickened arachnoid in patients with a stroke. Mi-
crodissection will often reveal an adequate vessel in the sulci.
The Anastomosis
After preparing the donor and recipient vessels adequately, one must decide whether to
simply end-to-side anastomose the vessels, or use an alternate preparation of the STA. Some
authors prefer the "patch" or "fish-mouth" technique of making an incision from the end
of the STA a short distance on one side, thus allowing a bigger area to cover the MCA
during anastomosis. Suturing is done in a simple vertical manner with 10/0 or 11/0 nylon.
Technical note 1 — Take bigger bites with the suture in the STA than the MCA. This
gives a better seal between the vessels, with less stenosis of the MCA occurring.
Performing the back wall of the anastomosis first will usually be easier than trying to
suture the front wall and then rotate the vessels. Remember that the microscope and surgeon
can move in many directions to facilitate the ease of doing the anastomosis.
Technical note 2 — Often during the anastomosis cerebrospinal fluid runs into the field
and makes the anastomosis more difficult. By placing a cottonoid at the periphery of the
field with a suction on low power, held by a self-retaining retractor, this problem can be
eliminated.
Technical note 3 — The use of a running suture can decrease the time of anastomosis,
but may also decrease the amount of subsequent dilation of the anastomotic site. To increase
speed and yet maintain simple vertical sutures, one may use a running suture with large
loops. After all are placed on one side of the anastomosis, each loop in succession is cut
and tied, resulting in simple vertical sutures.
INDICATIONS FOR EXTRA-INTRACRANIAL BYPASS PROCEDURES
The current indications for the bypass procedure are
1. Occlusion of the internal carotid artery

2. Stenosis of the internal carotid artery which cannot be directly approached
3. Occlusion of the MCA
4. Stenosis of the MCA
5. Occlusions and stenosis in the vertebrobasilar region
6. Multiple vascular lesions
7. Moya-Moya syndrome
8. Large aneurysms
9. Angiomas
10. Carotid cavernous fistulas
11. Large benign tumors (where large vessels may be compromised during resection)
PLATE 5. Tendon repair with Kessler suture. PLATE 6. All volar structures repaired in replanted
finger,
PLATE 7. Dorsal vein repair in progress. PLATE 8. Replant congestion relieved by midlateral'
pulp incisions.
PLATE 9. Shows scarring at 8 weeks after PLATE 10. Gap to be bridged with nerve grafts when
reimplantation. primary repair could not be carried out.
PLATE 11. Showing nerve grafts and stage 1 of two- PLATE 12. Three months after stage 2 tendon grafts,
stage tendon grafting procedures.
PLATE 13. Printing press injury resulting in amputation PLATE 14. Distal tendon sutures commenced while pa-
through the distal carpal row. tient is being resuscitated.
PLATE 15. Postoperative splinting in intrinsic-plus PLATE 16. Showing edema of replanted hand at 3
position. weeks.
Volume I 249
CONCLUSIONS
The extra-intracranial bypass operations may be helpful in preventing cerebral vascular

accidents and decreasing or eliminating transient ischemic attacks (TIAs). Patients with
motor paresis seem to make the most rapid recovery with speech and (often) higher functions
being slower to improve after revascularization operations.
The morbidity and mortality from the operations are very acceptable. While each patient
presents a different problem and solution, the extracranial-intracranial bypass procedures
have added further options to the patient-care armamentarium.
SUMMARY
An overview of the extracranial-intracranial microanastomsis operations is presented. The

operative techniques are presented in general terms with specific emphasis on "technical
notes' ', which explain methods of avoiding intraoperative complications and greatly facilitate
the ease of the procedure.
Extracranial-intracranial bypass operations may be helpful in preventing cerebral vascular
accidents and decreasing or eliminating transient ischemic attacks (TIAs). Many partial
neurological deficits can be reversed. Patient selection is as important as operative technique
if good results are to be anticipated with these operations.
REFERENCES
1. Jacobson, J. and Suarez, E., Microsurgery in anastomosis of small vessels, Surg. Forum, 11, 243, 1960.
2. Jacobson, J., Wallman, L., Schumaker, G., Flanagan, M., Suarez, E., and Donaghy, R., Microsurgery
as an aid to middle cerebral artery endarterectomy, J. Neurosurg., 19, 108, 1962.
3. Yasagil, M., Experimental small vessel surgery in dog including patching and grafting of cerebral vessels
and the formation of functional extra-intracranial shunts, in Micro-Vascular Surgery, Donaghy, R. and
Yasagil, M., Eds., C. V. Mosby, St. Louis, 1967, 87.
4. Piza-Katzer, H., Mikrochirurgische Technik bei Gefássen mit einem Duchmesser unter 1.2 mm, Vasa, 3,
293, 1974.
Volume I 251
MICROSURGICAL TREATMENT OF INTRACRANIAL ARACHNOID CYSTS
Kyu Chang Lee
INTRODUCTION
Intracranial arachnoid cysts are benign, thin-walled cysts characteristically lying in the
arachnoid, filled with clear fluid, located in general near primary fissure of the cerebral
cortex and cerebellum, and associated with varying degrees of cerebral tissue loss by compres-
sion. The most common location is in the Sylvian fissure, where there is compression of
the underlying frontal and temporal operculum, with the island of Reil and the middle
cerebral artery being brought into view. Starkman et al. believe that the cysts arise from a
developmental abnormality of the passage of cerebrospinal fluid into the perimedullary
mesenchyme.1
Since the advent of the CT scan numerous case reports have been presented, and many
authors are in agreement that these lesions are probably much more common than previously
realized. This lesion not only presented as a space occupying mass, but was demonstrated
by CT to enlarge.2 In some cases of the middle fossa cysts are complicated by the chronic
subdural hematoma formation.3 Some cases of the midline cysts and most of the posterior
fossa cysts are complicated by the obstructive hydrocephalus resulting in increased intra-
cranial pressure.4
Although cystoperitoneal shunt surgery is indicated in some cases with the midline or the
posterior fossa cysts, the rest of the arachnoid cysts are best managed by the radical micro-
surgical technique of establishing an adequate communicating channel between the cyst and
the basal cisterns.
Since 1970 we have observed 20 supratentorial arachnoid cysts, 18 of which were located
in the middle cranial fossa, and 9 cases of infratentorial cysts, 1 of which was located in
the retroclival region. Our methods for the radical microsurgical treatment of the middle
cranial fossa cysts and the clival cyst are described.
MICROSURGICAL APPROACH OF THE MIDDLE CRANIAL FOSSA CYSTS
Diagnosis of the middle fossa arachnoid cyst was established mostly by the CT scan. The
involved middle fossa is enlarged. Anterior and medial to the agenetic temporal pole,
occupied by a hypodense cystic lesion (Figure 1). Enhanced CT study visualizes the main
trunk of the middle cerebral artery exposed in the medial wall of the cyst (Figure 2). Among
18 cases of middle cranial fossa cysts, 5 cases had combined chronic subdural hematoma.
For middle cranial fossa cysts, the frontotemporal pterional approach was applied. For a
right-side lesion, the head is held in the three-point skull fixation apparatus and turned about
30° to the left, tilted 20° to the left, and dropped about 20°. This brings the pterional point
into the center and to the highest point of the operative field. The skin incision extends from
the lateral frontal region near the hairline, upwards, backwards, and then downwards to
terminate in front of the ear at the level of the zygoma. This curved skin flap is turned down
exposing the anterior half of the temporal muscle.
The temporal fascia, muscle, and periosteum are incised with an electrocautery. The
thinned-out and outward-bulging temporal bone is exposed, and making burr holes through
it requires extreme caution to avoid inadvertent injury to the underlying brain tissue, because
this part of the temporal bone is paper thin. Four burr holes are drilled, one at the junction
of the temporal line and the zygomatic process, one posterior to the first, one in the parietal
bone, and one in the temporal bone just in front of the ear. The thin bone flap, attached to
FIGURE 1. CT scan of a middle cranial fossa ar- FIGURE 2. Enhanced CT study visualizes main
achnoid cyst. The involved middle fossa is enlarged. trunk of the middle cerebral artery (arrow) exposed
Anterior and medial to the agenetic temporal lobe, in the medial wall of the cyst,
occupied by a hypodense cystic lesion (c).
the incised temporalis muscle, is turned over the zygomatic arch. The sphenoid wing is
rongeured down to the base of the anterior clinoid process. The dura is opened in half-circle
fashion with the base directed orbitobasally. The portion of the dura over the sphenoidal
cover is pulled down and anteriorly to cover the frontoorbital base. The remaining dura is
incised radially to form four flaps, each reflected and held by sutures. A distended cystic
wall containing plenty of venous channels is exposed.
At this point the surgeon brings in the microscope. Through the transparent arachnoid-
like membrane, the clear cystic fluid with the appearance of cerebrospinal fluid is seen
(Figure 3). Clear cystic fluid is evacuated. Outer and inner walls of the cyst are removed
by microdissection, disconnecting the bridging venous channels between the cystic wall and
the cortex and/or the inner surface of the dura mater. Now the space which was occupied
by the cyst is fully exposed showing an enlarged Sylvian fissure and the partially or totally
absent temporal pole as well as the main trunk of the middle cerebral artery with its branches
exposed on the Sylvian fissure (Figure 4). The spatula is advanced under the frontal lobe
and the thickened arachnoid membrane in the mesial Sylvian fissure and over the chiasmatic-
carotid complex is exposed (Figure 5). The thickened arachnoid membrane is incised and
dissected from the optic nerve, the internal carotid artery, and the Sylvian fissure (Figure
6). Liliequist's membrane is opened between the optic nerve and the internal carotid artery
and also posterior to the internal carotid artery, to create a communicating channel for the
cerebrospinal fluid between the chiasmatic cistern and the interpeduncular cistern (Figure
7).
Completing microdissection, papaverine is applied topically onto the internal carotid artery
to relieve the spasm caused by surgical manipulation. Within 15 min the caliber of the
spastic artery is markedly increased (Figure 8). The dura is closed watertightly and the bone
flap is fixed in place. The temporalis muscle, the fascia, and the scalp are sutured leaving
a low-pressure suction drain in the subgaleal space. For cases with chronic subdural he-
matoma, the hematoma and its capsules were removed before dealing with the arachnoid
cysts.
Volume I 253
FIGURE 3. Microphotograph of a middle cranial fossa arachnoid

cyst. A distended cystic wall (c) which contains plenty of venous
channels is exposed, (d) Dura and (f) frontal lobe.

cyst. Clear cystic fluid is evacuated. Outer and inner walls of the
cyst are removed. The main trunk of the middle cerebral artery (a)
with its branches is exposed on the wide Sylvian fissure.
The postoperative course was uneventful in all but one patient in whom seizure developed
following surgery. This patient required heavy doses of anticonvulsant medication under
artificial ventilation to combat status epilepticus. The five patients who had experienced
seizure before surgery remained on antiepileptic drugs and were free of further attacks
postoperatively. At the last follow-up examination 1 to 6 years after intervention, all patients
were free of symptoms and the CT scans showed no signs of recurrent cysts.
TRANSORAL-TRANSCLIVAL APPROACH FOR REMOVAL OF A CLIVAL

ARACHNOID CYST
Although arachnoid cysts in the posterior fossa are less frequent than those supratentorially,

cyst. The spatula (s) is under the frontal lobe and the thickened
arachnoid membrane (m) in the mesial Sylvian fissure and over the
chiasmatic-carotid complex is exposed.

cyst. The thickened arachnoid membrane (m) is incised and dis-
sected from the optic nerve (o) and the internal carotid artery (arrow)
and the Sylvian fissure.
clival cysts are extremely rare.5 A 25-year-old male patient was presented with headache
and vomiting. CT scan demonstrated a huge clival cyst and a supratentorial hydrocephalus.
The supratentorial pressure was relieved by a ventriculoperitoneal shunt operation but the
clival cyst remained unchanged (Figure 9). Transoral-transclival approach was applied to
reach the prepontine lesion. The patient was intubated through elective tracheostomy. With
the patient in supine position, the head was extended about 20°. The face and the mouth
were prepped, and the Mclvor retractor was applied to keep the mouth open throughout the
procedure (Figure 10). The soft palate was incised in the midline beginning on the right
side of the uvula and was retracted with sutures. The oropharyngeal mucosa and the preclival
Volume I 255

cyst. Liliequist's membrane (1) is opened between the optic nerve
and the internal carotid artery, and the posterior to the internal
carotid artery to create a communicating channel for the cerebro-
spinal fluid between the chiasmatic cistern and the interpeduncular
cistern.

cyst. Compared to Figure 7, the caliber of the spastic internal carotid
artery (arrow) is markedly increased after topical application of
papaverine solution.
soft tissues were also divided with an electrocautery. All the transclivai procedures were
monitored by a C-arm X-ray image intensifier. Under the surgical microscope a clivectomy
of 1 x 1 cm2 was performed with a pneumatic drill. The dura was opened in cruciate
fashion. The bulging, thin arachnoid-like membrane was torn open resulting in the evacuation
of a cerebrospinal-like clear fluid. Then a bulging, whitish posterior cystic wall appeared
through the dura opening (Figure 11). Light microscopic examination of the partially removed
cyst wall disclosed an arachnoid membrane.
After removal of the cyst, pons and basilar artery were visualized. The clival opening
FIGURE 10. Transoral-transclival approach for a

removal of a clival arachnoid cyst, (u) Uvula.
FIGURE 9. CT scan of a clival arachnoid cyst (c).
FIGURE 11. Microphotograph of a transclivai approach. The

bulging cystic wall (c) is seen through the dura opening.
was sealed off with a muscle piece and ethyl-2-cyanoacrylate. Divided oropharyngeal mucosa
and soft palate were approximated. The tracheostomy remained for 3 weeks postoperatively.
Nasogastric feeding was performed during the wound healing period. At the last follow-up
check 2 years after intervention, the patient was asymptomatic.
SUMMARY
Microsurgical procedure for the radical treatment of intracranial arachnoid cysts was
described on the basis of the author's own experience. For the middle cranial fossa cysts,
careful dissection of the outer and inner arachnoid cyst walls and opening of the Liliequist's
membrane to establish the cerebrospinal fluid circulation were emphasized. For an unusual
case with clival cyst, a transoral-transclival approach was applied with success.
Volume I 257
REFERENCES
1. Starkman, S. P., Brown, T. C , and Linell, E. A., Cerebral arachnoid cyst, J. Neuropathol. Exp. Neurol.,
17, 484, 1958.
2. Geissinger, J. D., Kohler, W. C , Robinson, B. W., and Davis, F. M., Arachnoid cysts of the middle
cranial fossa: surgical considerations, Surg. Neurol., 10, 27, 1978.
3. La Cour, F., Trevor, R., and Carey, M., Arachnoid cyst and associated subdural hematoma. Observation
on conventional roentgenographic and computerized tomographic diagnosis, Arch. Neurol., 35, 84, 1978.
4. Vaquero, J., Carrillo, R., Cabezudo, J. M., Nombella, L., and Bravo, G., Arachnoid cysts of the
posterior fossa, Surg. Neurol., 16, 117, 1980.
5. Little, J. R., Gomez, M. R., and MacCarty, C. S., Infratentorial arachnoid cysts, J. Neurosurg., 39,
380, 1973.
Volume I 259
MICROLUMBAR DISCECTOMY
Albert H. Capanna
INTRODUCTION
Microlumbar discectomy is a new operation1 4 for the surgical treatment of herniated

nucleus pulposus, with distinct advantages. The surgical microscope with its high magni-
fication and illumination, and special instruments, make it possible to remove a herniated
nucleus pulposus through a 1- to 2-cm skin incision without laminectomy. Blood loss is less
than 30 m€ and patients are discharged home postoperatively in 1 to 3 days.
THE OPERATION
The patient is positioned prone on rolls which will allow the stomach to move freely with
respirations, or preferably on an Olympic Vac-Pac®* support with an inflated rubber bladder
or sandbags below the abdomen. The Vac-Pac® is then molded tightly under the patient
during full inspiration and hardened by suction. The bladder is deflated, or sandbags removed,
leaving a vacant space under the abdomen thus decreasing intraspinal pressure and extradural
vascular engorgement. Also greatly decreased are lumbar respiratory movements, which
disturb the depth of field during high-magnification surgery.
The operation is entirely microsurgical, and an assistant surgeon is not necessary. Special
instruments developed for the operation are now commercially available.** A 1- or 2-cm
skin incision is placed by palpation from the lumbosacral notch over the interspace to be
explored. A lateral lumbar spine roentgenogram is taken if necessary for localization. A
direct vertical approach to the interlaminar space is made.
The surgical microscope with a 350 to 400 mm objective lens is utilized. Magnification
is progressively increased to the maximal level as the herniated disc is approached. Following
skin incision, the fascia and muscle are subperiosteal^ reflected on the side of the herniated
disc and a self-retaining retractor placed. The ligamentum flavum is incised and then pierced
with a Penfield # 4 dissector. The lateral one third of the ligament is removed with a 1-mm
cup rongeur. The nerve root is identified and retracted medially with a suction retractor.
The annulus is bluntly pierced, and the disc material removed with a 1-mm pituitary cup
forceps. Foraminotomy may be performed if indicated.
The fascia, subcutaneous tissue, and skin are closed in layers. Operating time averages
approximately 45 min.
RESULTS
Postoperative hospital stay is from 1 to 3 days. Minimal analgesic medications are required.
The surgical cure rate has been greater than 92% in all reported series. 58 Patients resume
normal activities in 2 to 4 weeks.
The apparent advantages of this new operation are the minimal alteration of anatomy and
the lack of any complications such as wound infection, cerebrospinal fluid leaks, increased
neurological deficit, or blood transfusions. By parting the fibers of the annulus, instead of
cutting them, the retaining wall effect of the annulus is maintained. The extradural fat
surrounding the root is preserved, thus minimizing the chances of adhesions postoperatively.
* Olympic Medical Corporation, Seattle, Wash.

** Codman and Shurtleff, Inc., Randolph, Mass.
FIGURE 1. Lumbar skin incision (less than 1-cm long), sutures just removed 1 week postop,
to the left of U.S. penny (less than 2 cm in diameter).
FIGURE 2. Skin incision 3 weeks postop (approximately 1.5-cm long) beside U.S. dime.
Should any future symptoms necessitating myelography arise, the myelogram will appear
normal unless a new problem is present.
The operation allows the same amount of disc material to be removed as with conventional
laminectomy,910 but with greatly reduced morbidity (Figures 1, 2, and 3).
SUMMARY
The surgical microscope makes it possible to remove a herniated lumbar nucleus pulposus
Volume I 261
FIGURE 3. Scar from prior lumbar laminectomy at L3-4 (ar-

rows), scar 1 week postop from microdiscectomy L3-4 for re-
current disc (arrowheads) beside U.S. dime.
through a 1- to 2-cm skin incision without laminectomy. The detailed methods and materials
of the operation are presented.
There are numerous advantages to the operation. There is very little destruction of normal
anatomy. Blood loss is minimal. Little postoperative pain is encountered. Patients are dis-
charged home in 1 to 3 days after surgery. There is little future scarring of the nerve roots.
The overall cure rate is higher than with chemonucleolysis or laminectomy.
REFERENCES
1. Williams, R. W., Surgical Techniques: Microlumbar Discectomy, Codman and Shurtleff, Inc., Randolph,
Mass., 1977.
2. Williams, R. W., Microlumbar discectomy, a conservative surgical approach to the virgin herniated lumbar
disc, Spine, 3, 175, 1978.
3. Loew, F. and Caspar, W., Surgical approach to lumbar disc herniations, in Advances and Technical
Standards in Neurosurgery, Vol. 5, Krayenbiihl, H., Ed., Springer-Verlag, Berlin, 1978, 163.
4. Capanna, A. H., Microlumbar discectomy in rats, J. Microsurg., 1, 351, 1980.
5. Williams, R. W., Microlumbar discectomy, a surgical technique with three year follow-up, presented at
the 25th Annu. Meet. Congr. Neurological Surgeons, Ponte Vedra Beach, Fla., October 26, 1976.
6. Goald, H. J., Microlumbar discectomy, Va. Med. Monitor, 568, 1976.
7. Goald, H. J., More on microsurgery, Va. Med. Monitor, 104, 519, 1977.
8. Capanna, A. M., Microlumbar discectomy, presented at Operative Surg. Spine Conf., Jefferson ville, Vt.,
August 26, 1981.
9. Capanna, A. H., Williams, R. W., Austin, D. C , Darmody, W. R., and Thomas, L. M., Radiographic
calculation of the percentage of disc removal during lumbar discectomy, presented at the 47th Annu. Meet.
Am. Assoc. Neurological Surgeons, Los Angeles, August 24, 1979.
10. Capanna, A. H., Williams, R. W., Austin, D. C , Darmody, W. R., and Thomas, L. M., Radiographic
calculation of the percentage of disc removal during lumbar discectomy and detection of anterior annulus
perforation, Spine, 6, 6, 1981.
Volume I 263
NERVE REGENERATION
G. Brunelli and F. Brunelli
INTRODUCTION
The recovery of peripheral nerve lesions is not yet a well-known topic. There are, of
course, different appearances and regenerating features according to the differences of the
lesions:
Neuroapraxia — This is a temporary interruption of nerve conduction due to a molecular
disorder, does not show any evident change under light and electron microscopy and will
repair spontaneously and quickly without Wallerian degeneration.
Axonotmesis — On the contrary, will produce complete Wallerian degeneration distal to
the lesion as well as repairing reaction in neurons and Schwann cells, but since the endoneural
tube (i.e., basal lamina) is not interrupted regenerating axons will progress normally within
the basal lamina tubes with complete recovery.
Neurotmesis — Eventually, this is a more severe lesion with interruption of nerve con-
tinuity. Besides Wallerian degeneration and neuronal reaction, it will produce a neuroma
with macrophage and fibroblast proliferation at the site of severance with a good possibility
of mistaken axon connections (exclusion of a great part of them from their function) and
great difficulty for the axons to bridge the scar and to reach their distal basal lamina tube.
REVIEW OF CLASSICAL KNOWLEDGE
The majority of recent research brings data that differ from classical knowledge on Wal-
lerian degeneration and regeneration. The following is a brief review of classical knowledge
based on contributions of Waller (1862),9 Ranvier (1875),8 Nageotte (1922),6 and Ramon
y Cay al (1928).7 When a nerve is severed there are phenomena distal to the severance, at
the lesion site and proximal to it. The distal part of the axon undergoes classical Wallerian
degeneration which consists of a very quick disappearance of axolemma and, immediately
following fragmentation and cancellation of axoplasm, with breaking and disappearance of
neurofilaments, neurotubuli, and mitochondria. Within 24 to 36 hr the myelin sheath begin
to show alterations which, at the beginning, are represented by widening of Ranvier's nodes
and dilation of Schmidt Lanterman's incisures immediately followed by disorganization of
characteristic lamellar structure of myelin sheath. Then the myelin undergoes fragmentation.
At the end of the first day it separates into ovoids or ellipsoids, varying in shape and number,
then is phagocytized by Schwann cell cytoplasm. This degeneration progresses distalward
at a varying speed, according to fiber size. The proximal stump of a severed nerve undergoes
two different kinds of "degeneration". The first one is called either "Ramon y Cay al" or
"traumatic degeneration" and affects the axon for a very limited distance proximal to the
lesion. It is related to trauma, crush, and local ischemia. The other one, the so called
"retrograde Wallerian degeneration", affects all the proximal stump and the neuron (we
will see that this part of classical knowledge, especially, has changed very much). At the
site of the lesion, macrophages and fibroblasts produce a scar of various sizes according to
the kind of lesion, nerve, and individual.
NEW KNOWLEDGES
The majority of recent research has yielded data which differ from classical knowledge
of Wallerian degeneration and regeneration, particularly, on the increase in axon population
at the site of the lesion and distal to it in axonotmesis and their smaller size and poorer
myelination, as well as Schwann-cell proliferations (and their smaller size) and the complex
sprouting phenomenon. In fact, at the site of the lesion and distal to it there are early sprouts
that are small and strongly myelinated and late sprouts that are less myelinated, bigger, and
more vital as well as "regenerating bundles" which are constituted by multiple axons inside
one original basal membrane; on the other side cell modifications are no longer to be
considered degenerating changes but, to a great extent, regenerating reactions.2
CELL CHANGES
As far as we know today, after a peripheral nerve lesion changes in cells and axons start
immediately. The starter of the cell regenerating reaction can be one or some of the following
messages sent to the mother-cell body from the periphery:
1. The interruption of normal retrograde axon flow (which normally leads molecules
released by innervated targets and may be a maintenance substance) to the nerve cell
body.
2. The short circuit of anterograde axon flow with the retrograde one with early turnaround
of ortograde transported materials.
3. The retrograde diffusion, up to cell body, of enzymes produced by trauma at the distal
end of the proximal stump.
4. The entry into the proximal stump of exogenous substances which reach the cells.
In normal axons, as is well known, there is both a fast and slow anterograde flow as well
as a retrograde flow. The slow orthograde axon flow transports soluble proteins and the
major components of the axonal cytoskeleton, i.e., tubulins, neurofilament proteins, actin,
and myosin-like proteins (1 to 4 mm/day). Also, mitochondria, besides having a swift back
and forth movement, migrate at a slow velocity. The fast orthograde axon flow conveys (at
a speed of 200 to 400 mm/day) membrane constituents such as phospholipids, glycolipids,
cell surface glycoproteins, and membrane associated enzymes which go distal to form
synaptic vesicles;* this fast transport is due to the smooth endoplastic reticulum which forms
a dynamic system of intraaxonal conduits. The retrograde axonal transport conveys spheroid
or tubular bodies, and their luminal content, back from nerve endings to nerve cell bodies
at a speed of 150 to 300 mm/day. Axonal flow is an ATP-dependent process using ATP
formed in axonal mitochondria.
The transduction of free energy into vectorial convection is due to repetitive molecular
interaction between actin (anchored to axolemma) and myosin (associated with neurofila-
ments) triggered by C a + + with generation of forces longitudinally propelling the axonal
components. In the course of many years of research on rabbit and rat nerve regeneration
after nerve lesion (axonotmesis and neurotmesis) we have observed that anterior horn cells,
whose motor axons have been damaged, modify their normal appearance very early.
1. At 2 days neurons are slightly altered, there is a widening of the pericellular space
probably due to lipid and amino acid assumption. Ribosomes and rough endoplasmic
reticulum are still condensed (Nissl clumps).
2. At 5 days their condensation is less evident because of rough (Figure 1) endoplasmic
reticulum cistern dilation and ribosome scattering. Nuclei shift peripherally, nucleoli
* Not all the cells will react in a regenerating way. Proximal lesions with severely crushed or elongated cells
undergo degeneration up to cell death, especially if the connection with the distal appropriate organ is not
reached.
Volume I 265
FIGURE 1. Cell body at 5 days after nerve severance. Nucleus has been shifted to periphery; Nissl clumps are
less evident. Rough endoplasmic reticule cisterns have enlarged (large black arrow), ribosomes have scattered
(small black arrows). Mitochondria are enlarged (white arrows).
become prominent and the number of satellite cells increases; mitochondria start to
increase.
3. At 10 days these processes are more evident and nuclear membrane is irregularly folded
with dilation of membrane pores. Mitochondria tend to be megamitochondria, the
number of astrocites around the cell improves up to four times the normal, with a
nutritional meaning (satellitosis) (Figure 2).
4. At 15 days Nissl clumps tend to be restored to their former shape; that means that the
rough endoplasmic reticulum has already accomplished its work, and its cisterns nar-
row. Pores of the nuclear membrane are wide with activation of exchanges between
nucleus and cytoplasm. Smooth endoplasmic reticulum as well as Golgi apparatus are
widened and activated (Figure 3).
5. The same phenomena can be seen at 20 days.
6. At 30 days satellite cells begin to diminish, but rough endoplasmic reticulum, mito-
chondria and Golgi apparatus are still activated. This appearance, which is the expres-
sion of a cell in full function and repairing activity, will persist unchanging for at least
30 more days. Responding in an equal and similar fashion are cells of the dorsal
ganglion whose dendrites coming from the sensory end organs have also been dam-
aged.3 (Sensory dendrites will be named axons because they and their parent-cells
react in an identical way).
All these features are related to peripheral (extrinsic) neurons whereas central (intrinsic)
FIGURE 2. Part of cell body at 10 days. Astrocites grouping around the cell (arrows): satellitosis.
neurons react in a worse way showing progressive, severe atrophy of cell nuclei and nucleoli
which may culminate in cell death.1 In regenerating peripheral nerves, structural membrane
proteins are conveyed with fast axonal transport at a normal velocity in an amount that can
be larger or smaller according to the molecular species while transmitter metabolizing en-
zymes, which are not needed during the outgrowth, show a decreased axonal transport.4
Axoplasmic proteins, on the contrary, such as tubulins and neurofilament proteins would
be transported at a normal rate by means of slow axon flow in a reduced amount, whereas
other axoplasmic proteins would be conveyed in a larger amount and, perhaps, at a higher
velocity.
In conclusion, in regenerating peripheral nerves the supply of the growing segment does
not dramatically change the normal axonal flow which is a distinctly different process from
axonal growth in fetuses or babies.
CHANGES AT THE LESION LEVEL
When an axon is severed there is no loss of axoplasm, as it was thought in the past.
Axoplasm coagulates immediately, as we were able to see by means of the light microscopy.
At the site of severance there is a proliferation of true macrophages and fibroblasts as well
as of Schwann cells in a macrophagic attitude. Fibroblasts can form a transverse barrier of
scar between the proximal and distal stump that will not allow regenerating axons to reach
their distal organs, despite the real possibility of a chemotaxis that (in absence of scar) would
lead motor axons to match motor distal neurotubes and sensitive axons (dendrites) to enter
distal sensitive neural tubes.
Volume I 267
FIGURE 3. Cell body 15 days after axon severance (n = nucleus) nuclear membrane pores are still enlarged
(black arrows). Rough endoplasmic reticule still activated, as well as smooth reticule. Golgi apparatus (white
arrows) are very active.
This chemotactic mechanism had been suspected for many years and has recently been
demonstrated by means of experimental research.5
AXON CHANGES DISTAL TO THE LESION
Distal to the lesion, the light and electron microscope confirm the appearance of Wallerian
degeneration (Figure 4) and regeneration, as is classically known. To a certain extent we
can also see a number of smaller axons more or less myelinated inside only one endoneural
tube (the basal lamina of a Schwann cell in the former axons): "fascieau de regeneration"
or ''regenerating bundles". Their appearance is frequent, but up to now the interpretation
of their utility has been controversial (Figure 5). Maybe several small axons reach different
muscle fibers and constitute small motor units, but it is also possible that many of these
axons do not get in contact with a muscle fiber, so becoming only a kind of parasite of the
functional axon.
Furthermore, there are observations that lead us to formulate the hypothesis that the earlier
sprouts (generated immediately after severance when the neuron is still in a rest condition
and not yet able to send new proteins distally to reconstruct axolemma and cytoskeleton and
while Schwann cells, not yet proliferated, are still big) are small and strongly myelinated.
They are probably not able to reach target organs undergoing early degeneration, while the
sprouts produced some days later (when the neurons have been activated) are bigger and
more vital even if less myelinated (because of the small size of proliferated Schwann cells)
(Figures 6 and 7). The Schwann cell proliferation is also the cause of a shorter internodal
268
FIGURE 4. Classical appearance of Wallerian degeneration 8 days after severance.

Volume I 269
FIGURE 5. "Regenerating bundles": in the same Schwann cell are a vital axon (A), four remnants of myelin
(ellipsoids) (M), three early sprouts precociously myelinated and in phase of degeneration (E), and many myelinated
sprouts (1 to 17) around the Schwann cells.
distance with diminution of the conduction velocity. When the axons reach their distal organ
there is probably some kind of maturation of the regenerate axons, but due to the narrowing
of the basal lamina tube during the Wallerian degeneration and to collagen formation among
endoneural tubes, regenerated axon will never reach the former size.
Motor end-plates (which are a functional adaptation of the distal end of axons when in
contact with the muscle fiber) disappear due to Wallerian degeneration while sensitive
corpuscles (which are organized with particular cells) only become empty. When the re-
generating axons, following the path of the endoneural tubes arrive at their targets, they
will reform motor end-plates and reinhabit former sensitive corpuscles. However, the mere
contact of an axon with an appropriate end organ is not sufficient to allow functional
restoration, as anatomical and functional readjustments are required in order to have a
functional effector or receptor end organ and to correct the trophic modifications resulting
from denervation and inactivity. This will take different periods of time according to different
situations.
A very important necessity, in order to have a good repair, is the perfect matching of
proximal and distal axons, which is absolutely impossible. One should consider that every
time a regenerating motor axon enters a distal sensitive tube two axons will be without
function; the motor one and the sensitive one. As in nerve trunks there are thousands of
fibers, the possibilities for a mismatch are really very numerous.
FIGURE 6. Features at 20 days after severance distal to suture. In the right hand top corner are remnants of an
axon (R). Note the size (black arrows) and the number of myelinic bodies. On the left: remnants of another former
axon. Note the size (black arrows). Many myelin remnants (R); one early sprout heavily myelinated in phase of
degeneration; one small, vital axon scarcely myelinated. In the middle: at the place of another former axon and
its endoneural tube, many proliferated small Schwann cells (1 to 6) containing axons (A) (at varying stages of
myelination), and small sprouts (S). Each of these small Schwann cells will later produce a basal lamina which
will constitute a new, narrow endoneural tube.
FIGURE 7. Another small proliferated Schwann (S) cell at higher magnification containing a degenerating, small
early sprout (E) and a small but vital axon (A) containing neurofilaments, with its mesoaxon (M). A new basal
lamina is already visible (arrows, the outer line).
Volume I 271
FIGURE 8. At 9 days after severance: tightened axon (A) which is vital (see neurofilaments, neurotubules, and
mitochondria): myelin sheet has split and its inner part has leaned to the axon.
If a motor axon enters a motor distal endoneural tube that is not the original one, motor
function can be obtained but it can be useless if the patient is not able to change his cortical
representation of motor pattern (as happens in adults) (see further in chapter on "Nerve
Suturing and Nerve Grafting). A very helpful phenomenon in achieving clinically acceptable
functioning even though only a very small number of axons pass into the distal stump, match
their appropriate distal tube, and reach the target, is the phenomenon of "adoption". By
means of this one axon after having reformed its distal motor end-plates can produce another
sprout that branches before the motor end-plate and goes further to find paralyzed muscle
fibers that it can "adopt", neurotizing them because of the spread sensitivity to acetylcholine
of paralyzed muscle fibers. This way giant motor units are formed which can be easily
demonstrated by means of EMG. These giant motor units can be reduced if and when original
axons reach their muscle fibers. Otherwise, the function of many muscle fibers will depend
on one axon forever. Later on the former basal lamina tube can be reabsorbed and new
basal lamina tubes form around proliferated Schwann cells (including single newly formed
axons) thus dividing regenerating bundles.
In later experiments, after suturing as perfectly as possible, under irrigation, and imme-
diately after experimental, neat, ideal nerve severances we have seen evidence which seems
to demonstrate that in these conditions Wallerian degeneration can be avoided. In fact, at
time intervals that would absolutely not allow regeneration (5 to 7 to 9 days) we have found
preserved axons with very limited alterations of myelin sheath that was split only at its
middle part as if the axons were only tightened and the inner part of the myelin sheath had
leaned toward it (Figures 8 and 9).
FIGURE 9. At 9 days after severance: one axon is in complete Wallerian degeneration (2), while two (3 and
4) show complete preservation — which is not acceptable according to the classical theory of Wallerian degeneration
9 days after complete transaction; 1 cm distal to severance.
We think that there are several conditions producing Wallerian degeneration, like trauma,
drying, and lack of immediate juxtaposing with enzyme liberation, but we are inclined to
think that in very rare, ideal conditions such as when a neat section of distal peripheral nerve
is sutured very quickly without drying (under saline irrigation), a large number of fibers
may not undergo Wallerian degeneration and this will condition the choice of treatment of
neat recent lesions in favor of immediate suturing.
In fact, in all the other conditions, the time needed for the repairing activation of parent-
cells and the appearance of sprouts of adequate size together with the fact that in the interim
a barrier of scar tissue has formed at the place of severance, led us for many years to perform
our operation on human beings in the following way:
1. Immediate suturing in cases of neat severance without stump contusion or in distal

small nerves in the hand where two operations will give a more severe scar than one,
and where less repairing substances are required.
2. Delayed suturing (or grafts) 18 to 20 days later (in order to operate when neuron
repairing mechanisms have been activated and to remove the scar that has formed at
the lesion site) in all other cases where there is contusion, drying, and added lesions.
In this case the waiting time can be prolonged up to 40, 60, or more days according
to the recovery time of added lesions (tendons, bones, and so on) which have to be
allowed to recover in advance.
Volume I 273
REFERENCES
1. Barron, K. D., Dentinger, M. P., and Rodichok, L. D., The axon reaction of central and peripheral
manmalian neurons: a comparison, in Post-Traumatic Peripheral Nerve Regeneration, Gorio, Millesi, and
Mingrino, Eds., Raven Press, New York, 1981.
2. Brunelli, G., Optimal time for nerve repair, in Post-Traumatic Peripheral Nerve Regeneration, Gorio,
Millesi, and Mingrino, Eds., Raven Press, New York, 1981.
3. Ducker, T. B., The central cell body and axonal regeneration, in Post-Traumatic Peripheral Nerve Re-
generation, Gorio, Millesi, and Mingrino, Eds., Raven Press, New York, 1981.
4. Frizell, M. and Sjostraud, J., Changes in axonal transport in relation to the nerve cell body response,
during peripheral nerve regeneration, in Post-Traumatic Peripheral Nerve Regeneration, Gorio, Millesi,
and Mingrino, Eds., Raven Press, New York, 1981.
5. Lundborg, G. and Hausson, H. A., Nerve lesions with interruption of continuity: studies on the growth
pattern of regenerating axons in the gap between the proximal and distal nerve ends, in Post-Traumatic
Peripheral Nerve Regeneration, Gorio, Millesi, and Mingrino, Eds., Raven Press, New York, 1981.
6. Nageotte, J., Sheaths of the peripheral nerves. Nerve regeneration and degeneration, in Cytology and
Cellular Pathology in the Nervous System, Vol. 2, Penfield, New York, 1922, chap. 5.
7. Ramon, Y. Cayal, S., Degeneration and Regeneration of the Nervous System, Vols. 1 and 2, May, R.
M., Ed., Oxford University Press, London, 1928.
8. Ranvier, C., Traité Technique d'Histologie, Savy, Paris, 1875.
9. Waller, A., On the sensory, motor and vasomotor symptoms resulting from refrigeration and compression
of the ulnar and other nerves in man, Proc. R. Soc. London, 12, 89, 1862.
Volume I 275
NERVE SUTURING AND NERVE GRAFTING
G. Brunelli and F. Brunelli
INTRODUCTION
The problems a surgeon has to solve when dealing with a nerve lesion are numerous.
There are biological problems related to nerve regeneration, the age of the patient and his
health, the condition of surrounding tissues and blood supply, and fibroblast proliferation.
There are also technical problems related to fascicle recognition and their correct alignment,
the necessity to know if and to what extent a lesion in continuity can conduct nerve impulses,
the necessity of avoiding tension and subsequent scar formation, the necessity of magnifi-
cation to see the intraneural anatomy and the quality of fascicles, the quality of threads and
needles, as well as the ergonomie qualities of instruments, Eventually there are social
problems related to the length of the treatment, its cost, patient age, job, and psychology.
As regards to the biological problem, Wallerian degeneration, cell reaction, and sprouting
the reader is requested to review the chapter on Nerve Regeneration.
TIMING OF SURGERY
According to the results of research the timing of nerve repair can be as follows:
Primary nerve stuture — This should be done in cases of neat severance without added
lesions* and in cases of distal severances as at the hand or fingers (no matter if in this case
there are added lesions). In all the other cases few epineural stitches have to be given in
order to prevent retraction and secondary surgery shall follow.
Early secondary suture — Done at the 20th day, in order to take advantage of nerve
regeneration in cases of lesion proximal to the hand and when the severance is not neat,
but there are not additional lesions.
Delayed secondary surgery — Done from the 20th to 90th day, when there are additional
lesions (tendons, bones, skin, etc.) which have to be repaired earlier. In these cases surgery
will be mainly grafts.
Tardy surgery — Done when the patient returns after 3 months or more, often having
undergone previous surgery elsewhere.
Other diseases of the patient should be treated and diabetes should be compensated for
after a primary suture or before secondary surgery; alcohol, smoking, and drugs should be
prohibited.
TECHNICAL PROBLEMS
The problems of the surrounding tissues will influence the choice of sutures or grafts and
can be solved in cases of severe fibrosis either by removing scar tissue and using different
types of flaps or by using grafts which bypass the damaged area. The problem of fibroblast
proliferation is not yet solved. According to certain authors the epineurium should be removed
at an extent of 3 to 5 mm at both the stumps because it contains some fibroblasts which
will proliferate and produce scar tissue with subsequent concentric retraction, axonosthenosis,
and possibly axonochachexy. On the other hand, removing the epineurium offers no pro-
tection against the scar tissue coming from the surrounding tissues. We will further see that
systemic steroid administration and local Roentgen therapy can help to avoid or diminish
scar formation.
Vessel lesions should not be considered an obstacle to primary repair.

FIGURE 1. Criteria of correct matching, (a) External shape of the nerve,

(b) mesoneurium, (c) dorsal vessel, (d) mirror-like internal map, and (e)
quadrantal location according to the destiny.
MATCHING FASCICLES
Recognizing fascicles is another difficult problem not yet solved: if we are dealing with
a fresh severance we can recognize fascicles by means of electrical stimulation (3 mA, 1
to 5 V) under local anesthesia of surrounding tissues. All fascicles producing muscle con-
traction, when stimulating the distal stump, are motor fascicles and are stained by means
of diluted methylene blue. Sensory fascicles which will not produce any contraction are left
unstained.
In the proximal stump the stimulation will produce a paraesthetic sensation or pain in
sensory fascicles which will become stained, while motor fascicles will not respond (at least
at low intensity, because at higher intensity there can be diffusion of the stimulus to neigh-
boring sensory fascicles) and will be left unstained. This way we have stained sensory
fascicles in the proximal stump and motor fascicles in the distal stump. Connecting stained
with unstained fascicles will avoid misconnection of motor and sensory fibers which would
result in complete palsy of either the motor or the sensory fibers involved. Avoiding this
mistake, however, will not guarantee that each motor or sensory fascile matches its corre-
spondent one in the other stump even if connections between nonmatching motor fascicles
cannot result in severe impairment. A correct matching will be achieved when keeping in
mind (Figure 1):
1. The internal anatomy of all the nerves at different places as drafted in maps by several
authors.1-31016'23
2. The internal quadrantal location of fascicles as related to the branching and the density
Volume I 277
of terminal branches (possibly recognizing the division distally and going back to the
lesions).
3. The location of the dorsal blood vessel.
4. The location of the mesoneurium.
5. The external shape of the nerve.
6. The internal shape of fascicles, especially in neat severances in which a mirror-like
map can be seen in the two stumps.
Studies are in progress with the aim of recognizing motor and sensory fascicles by means
of differential staining; but until now this has only been possible by means of removing a
small part of both the stumps with marks to recognize the section, closing the wound,
examining the specimens by light microscopy, and going back to surgery 2 days later.8 This
has not been practical and cannot even assure absolute precision.
Another problem arises in the ' ' in-continuity ' ' lesions in order to distinguish those fascicles
able to conduct nerve impulses and those that are not. Recognition is possible by means of
careful fascicular neurolysis and electrical stimulation, recording (on the other side of the
lesion) the evoked action potentials. Conducting fascicles will be kept while nonconducting
ones have to be resected and grafted.
AVOIDING TENSION
Another very important problem is tension. Experimental studies as well as clinical ob-
servations demonstrate that suturing performed under tension produces scar tissue to a greater
extent than suturing done without tension. This knowledge is accepted by everybody but
the methods used by various authors are different. Some of them would suture a nerve whose
gap between stumps is large — up to 4.5 cm. Others reduce the length of the gap to not
more than 1.5 cm. The authors believe that it is not possible to speak in terms of centimeters.
A gap of 0.5 cm may be too big in order to avoid tension when suturing a collateral nerve,
while 4 cm of gap can allow suturing without tension to a nerve in the axillary region where
the mobility of the nerve (because of its mesoneurium) is large. So the best criterion is to
try the first stitch by means of a 10/0 nylon suture. If the stitch can be done without breaking
the thread it means that the tension is not too important and it will not produce pathological
scarring. If the thread breaks it means that there is too much tension and that it will be better
to graft.*
So, no matter if this criterion is met the delayed operation will result in grafts. In fact in
these conditions grafts give better results than sutures performed under tension. One must
not compare classical grafts (formerly performed only in very severe cases) with sutures.
Comparison should be made between sutures and grafts done under the same conditions.
INSTRUMENTS
Considering the necessity to see and distinguish the epineurium, groups of fascicles and
fascicles, if freshly and neatly severed, can be sutured with only the aid of a loupe. In
delayed surgery, on the contrary, the operating microscope is absolutely necessary and it
should be used at medium magnification during the fascicle dissection, and at a low mag-
nification when suturing. Needles and thread must be of the best quality. The caliber of the
needle should not be too much greater than the caliber of the thread; the point of the needle
must be sharp and easily cut the perineurium, and the thread must be thin, resistant, and
* Joint positioning reduces tension but is only a temporary measure; tension and fibrosis will onset at the time
of mobilization.
FIGURE 2. Scheme of what happens when suturing by means of epineural suture: (a)
external correct suture with hypothetical good matching of fascicles; and (b) real condition
under epineurium — anarchy of fascicle positioning.
have a sufficient elasticity. Today, 9/0 and 10/0 nylon sutures of several makes have these
prerequisites.
Finally, ergonomie instruments give very important help to the surgeon that can be
appreciated, especially in tedious operations like brachial plexus repair. Ergonomie forceps,
needle holders, operating seats, and microscopes have been developed in recent years.
TYPE OF SUTURES
The epineural suture which has been used for years has proven to be inadequate because,
underneath a very good epineural suture, fascicles are not well oriented and the appearance
at a histological examination is completely anarchic (Figure 2). There are several techniques
of nerve suturing which attempt to preserve the orientation of the fascicles (Figure 3).
The first technique was proposed by Hakstian9 in 1967, using threads passed inside
corresponding fascicles and through the skin as temporary guides; eventually the epineurium
was sutured (periepineural suture). On becoming aware of the danger of scar tissue if suturing
the epineurium, the authors used lost guide threads removing the epineurium (perineural
suture). Michon13 proposed a suture passing among correspondent fascicles and suturing the
epineurium above (epiperineural suture). The most diffuse technique is that proposed by
Millesi14 which consists in freeing groups of fascicles from the epineurium and suturing
them by means of perineural stitches (one to each fascicle) passing into the proper perineural
sheet of fascicles without taking axons. The authors are currently following this technique
but use two and even three stitches (10/0 or 11/0) for each fascicle or group of fascicles in
order to have a better and steady matching.
With regards to the epineurium, we proceed as follows. If the epineurium is normal (as
in fresh severances) and there is absolutely no tension, an epineural suture is made, but as
soon as there is scar tissue the epineurium is removed and an attempt is made to have the
Volume I 279
FIGURE 3. Techniques of nerve suturing, (a) Hackstian fasci-

cular suture by means of intrafascicular guide threads; (b) Michon
interfascicular guide threads + epineural suture; and (c) Millesi
method: removal of epineurium, perineural suturing of fascicles.
best surrounding tissues (in order to avoid, the scar), even doing flaps if it seems to be
helpful. Michon suggests, and we agree, that any surgeon who is dealing with nerve repair
must be trained in all types of repair so as to be able to use any of them according to the
particular anatomical conditions in each particular case, frequently combining some of them
during one single operation.
EXPOSURE
The exposure and the recognition of both stumps in primary surgery or of the neuroma
(proximal) and the Schwannoma (distal) in secondary surgery has to be done by means of
regular surgery, according to the region and to the type of scar and other tissues involved.
Both neuroma and Schwannoma stumps have to be removed in secondary nerve repair.
There is general agreement that in lacerated wounds it is very difficult to judge to what
extent the stumps have been damaged and have to be resected in order to avoid fibrosis of
the damaged tissue; this is one of the weak points of primary nerve repair. On the other
hand, if we make delayed repair (according to the biological research) after 18 to 20 days,
the scar tissue can be easily recognized and removed and the sprouting of the axons at that
time is so strong that the sprouts pass in to the distal (entering endoneural tubes filled by
proliferated Schwann cells) before a new scar is formed.
At this time if we completely remove the neuroma and the Schwannoma the gap will be
so large that suturing will not be allowed. So resection should only be done in those cases
in which neuroma and Schwannoma are small or the loose tissues allow suturing without
tension or, on the other hand, when the gap is so great at the beginning that we can be sure
in advance that a graft shall be needed. Otherwise, we have to try to preserve the length of
the fascicles by performing a fascicular neurolysis to remove the hypertrophic epineurium
and perineurium and cutting only the extreme part of damaged fascicles.
By means of interfascicular dissection, each large fascicle or group of small fascicles are
located in a healthy part of the nerve and followed toward the severance. When the microscope
shows us that a fascicle loses its normal appearance the damaged part is resected. This way
one also gets rid of a large amount of epineural nonfascicular tissue. In proximal nerves
where the fascicular pattern is not well defined it is obviously impossible to perform that
type of fascicular preparation and the transverse resection can be used.
APPROXIMATION AND COADAPTATION
The approximation and matching of the stumps can be done in several ways (even using
approximators as described by some authors). As was discussed above, tension must be
avoided; so we have to test if a stitch is able to sustain the moderate tension that is given
to a 10/0 thread without breaking. Then each large fascicle or group of small fascicles, as
previously prepared, has to be sutured with the aim of providing the best areal contact of
fascicles. Two or three stitches are often required to adapt as much as possible the severance
areas of both proximal and distal fascicles. Of course if the nerve has a monofascicular
pattern the surgery will not demand intraneural dissection.
The same is true for nerves containing two or three fascicles but if there are several
fascicles then fascicular suturing has to be done. On the contrary, the fascicular dissection
may be useless or even dangerous in polyfascicular nerves, proximally, where there is still
a great mixing of functionally different axons. In fact when the nerve consists of many small
fascicles the isolation of individual fascicles would be a tremendous job and it would be
very difficult to define the function of each of them and the corresponding ones in the other
stump, besides the real danger of a severe intrafascicular scar.
As the fascicular and intrafascicular pattern at cross-sections changes very quickly in short
distances, if there is even a minimal nerve defect the shape and the number of fascicles in
proximal and distal stumps would not correspond. This is especially true in proximal lesions
because proximally the axons, arising from several anterior and posterior roots, have to set
themselves in order to reach their distal density. In this type of nerve there is no practical
possibility to make a good suture and coadaptation of fascicles and a trunk juxtaposition
has to be done, possibly by means of intrafascicular threads as suggested by Michon, unless
one can make a subjective statement on the function of groups of fascicles — especially in
case of nerves with a large amount of nonfascicular tissue (which can go up to 70% of the
whole cross-section) and suture these groups of fascicles.
Summarizing, we may have to face four different types of nerves: monofascicular, oli-
gofascicular, multifascicular with arrangement in groups of fascicles, and multifascicular
without any arrangement in groups (Figure 4). The first type (monofascicular) should be
treated by means of trunk-to-trunk coadaptation. The second and third should be treated by
means of fascicular or fascicular-group suturing. The fourth type should be sutured by means
of a trunk-to-trunk suture, trying to obtain the best orientation by means of interfascicular
stitches.
Volume I 281
FIGURE 4. Fascicular matching according to the type of fascicular pattern;

(a) monofascicular, (b) oligofascicular, (c) polyfascicular (with group arrange-
ment), and (d) polyfascicular (without group arrangement).
While suturing, especially in the polyfascicular type, it is easy to force the contents of
the fascicle (whose internal pressure is elevated) to protrude out of the perineural tissue, so
that it is difficult to achieve a good alignment. Of course biological tropism will aid out-
growing axons to find their way distally, but we have to help this process as much as
possible.
We give the first stitch to the fascicle, then we cut the protruding fascicle by means of
microsurgical scissors and place one or two more stitches in order to have the best possible
coadaptation. To maintain the coadaptation stitches can take perineurium around the fascicles,
among the fascicles, and if necessary, the epineurium too. Suturing should be done by means
of nylon thread which does not produce macrophagic reaction. The newer types of reab-
sorbable threads seem to be able to behave the same way.
The allogenic fibrogen solutions12 have not yet demonstrated any improvement as related
to stitches and, on the contrary, are very difficult to use on polyfascicular nerves besides
the danger of disruption on the second day because of normal fibrinolytic activity.
NERVE GRAFTS
As stated above, there is a large percentage of cases where the gap between the severed
stumps doesn't allow coadaptation without tension and a nerve graft has to be done. Nerve
grafts have been done since the last century. Auto-, homo-, and even allografts have been
used but results were very poor because of technical deficiencies. Even the biological basis
of grafting was misunderstood until very recent times. In fact the only advantage that a
nerve graft can offer to the axons regenerating from the proximal stump is to put at their
disposal the endoneural tubes, filled by proliferated Schwann cells, that will lead the re-
growing axons to the distal stump and to the peripheral organs, i.e., the same type of tube
that an axon can find distal to a neat, recent severance. That is because a nerve graft will
undergo the same typical Wallerian degeneration as every severed nerve, even in the very
recent types of vascularized nerve grafts (pedicled or free).22
Homo- and allografts will not give results because of the fibrosis due to biological reaction
against foreign proteins. Even autografts can undergo fibrosis if the graft is a thick nerve
trunk whose larger internal part will undergo ischemia and necrosis and subsequent fibrosis
with loss of a larger part of endoneural tubes (only the peripheral fascicles can survive), or
if it is put in a sclerotic area with scarring surrounding tissues.
Only thin nerve grafts are useful because organic fluids can make them survive as the
ratio between the surface and the mass is favorable. As motor branches are generally short
and motor nerve removal will result in palsy, only sensory cutaneous nerves can be used,
choosing those whose removal will not bother the patient. Long cutaneous nerves will enable
one to use several segments of them, cut in the required length, to fit the whole cross-
section of the stumps.
The best donor nerve is the sural nerve that can supply up to 38 to 40 cm of graft from
each leg, and even much more if necessary (as in case of brachial plexus grafting) by
performing an intraneural dissection of the sciatic nerve in the thigh.
Other useful nerves can be the cutaneous medialis of the forearm and the cutaneous
medialis of the arm, as well as other nerves that one can find in the operating field, such
as the supraacromialis and supraclavearis nerves in brachial plexus surgery. With the pedicled
trunk grafts and also microvascular free grafts, thick nerves can be used, but this can only
be in the case of amputations when a nerve trunk removal doesn't worsen motor function,
or of avulsion of C8T1 in brachial plexus lesions.
The so-called cable grafts have been used for some time some years ago and consist of
gluing or suturing together several thin grafts, but besides being a more difficult technique,
the survival of the internal grafts is less sure than using separate grafts.
The cutaneous nerve grafts, even if composed of two or more fascicles and of nonfascicular
tissue, is generally the size of the largest fascicles. Therefore, the connection has to be made
between proximal and distal corresponding fascicles previously prepared by means of a
careful atraumatic dissection from the sound nerve towards the stumps, removing the dam-
aged terminal part as has been explained for the nerve preparation for the suture. In the
same way, when the nerve has a poly fascicular pattern, groups of fascicles reaching the
cross area of the graft should be sutured to it at both its extremities. In proximal lesions,
fascicles can be too large for only one graft so it is possible either to use two grafts for each
fascicle or one segment of the graft can be split and one or two of its fascicles used to
improve the cross area of the graft (Figure 5).
When grafting, the knowledge of the internal maps of nerves at different levels is much
more important than when suturing. In fact, in principle, grafts are used when there is a
gap that cannot be overcome by suturing without tension, which means that there has been
loss of substance and that there will not be correspondence of fascicular maps in the stumps.
All the criteria mentioned above for suturing should be reviewed in the decision to graft.
The surgeon should draw maps of the fascicular pattern of both stumps, with vessels and
mesoneurium, and according to his knowledge decide how to connect the fascicles. Even
with long practice and much knowledge this decision is often insecure and the surgeon
remains with the doubt of having made some mistakes. This doubt has the savor of remorse
that only disappears when the results start to comfort him. Grafts have to be cut a little
longer than the gap (5 to 8%) keeping in mind their retraction. Of course, no tension should
result after grafting.
Volume I 283
FIGURE 5. (a) Scheme of intraoperatory map for grafting; and (b) scheme of
grafts connecting fascicles either of the same size as the graft or smaller and
grouped.
DIRECT MUSCULAR NEUROTIZATION
When the distal part of the nerve and the proximal part of the muscle are missing, then
classically there is no possibility of making repairs. Recently, however, the authors dem-
onstrated in experimental animals and in clinical cases the ability to graft directly from the
proximal stump into the distal part of the muscle by means of splitting the grafts into many
small units which are then introduced into thin slits made in the muscle. New motor end-
plates, easily visible under light and electron microscopy, are formed in ectopic places and
they become useful with a good practical function by means of the adoption phenomenon
that allows an axon to branch and send the new branches to surrounding paralytic muscular
fibers with the formation of giant motor units.
Recovery will be different in suturing and in grafts. Formerly, surgeons were afraid that
at the distal suture growing axons would find a transverse scar impossible to pass through.
So a secondary suture of the graft at the distal stump or the resection of the second suture
(after the different times according to the distance to go), and immediate new suture had
been suggested. In fact, operations done in the past in order to remove the second suture,
and their histological examination, demonstrated that the scar tissue at the second suture
was very moderate, probably due to the absence of tension. This second operation is no
longer done unless the recovery process stops and the Tinel sign halts at the very point of
the second suture. In these cases (very rare) the removal of the scar has to be done in time
(15 to 30 days from the cessation of Tinel sign progression). The same procedure has to be
done if there is no progression at the site of a suture or at the first suture of grafts.
POSTOP TREATMENT
Several contrivances have to be used after surgery:

Table 1
MICHON EVALUATION (MODIFIED)
Two-point
discrimination Other
Muscles (cm) criteria
Very good M5—M4 <1 No pain

Good M4 ssl.5 No pain
Fair M3 <2 No pain
Bad M2 or less >2 Pain, distrophy
causalgia
1. Muscle have to be maintained in good trophicity in order not to be fibrotic when the
regenerating axon reaches the muscle fibers. This can be done by means of massages
and electrical stimulation. With regard to the electrical stimulation it should be placed
on the muscle and not on the nerve because studies have shown that nerves react by
means of internal production of collagen. The stimulation should only be exponential
since it is the only one able to selectively stimulate the paralyzed muscles because of
the accommodation capacity of normal muscles to the increase of electric power.
2. Joints have to be kept functioning by means of daily passive mobilization in order to
avoid stiffness when muscles start to function again.
3. Edema should be treated by means of massages, elevation, and elastic or pneumatic
bandages in order to avoid secondary diffuse fibrosis.
4. Muscles starting to function again have to be helped by diminishing the distance
between their heads in order to avoid fatigue and fibrillation (splints).
5. Skin should be protected in order to avoid traumatic lesion, burns, and infections due
to insensitivity.
6. The scar tissue has to be limited in order to present less difficulty for the axons to
pass the severance site and to avoid tardy axonotmesis. This can be done by means
of systemic steroid administration and of local Roentgen therapy at antifibroblastic
doses.
7. Gangliosides can be administered throughout the regeneration time whereas the ex-
periments seem to indicate that this improves nerve growth and myelination.
EVALUATION RESULTS
The evaluation of results must be done carefully. Muscle recovery has to be tested by
means of electromyography and clinical examination according to the Seddon Table. Dif-
ferent types of dynamometers can be used in particular cases. Sensory recovery can be tested
by means of the Highet-Zechery Table which covers gross sensation up to two-point dis-
crimination. The ninhidrine or sweat drop counting test can be added, as well as the gnostic
rings test. In particular cases, skin conduction and temperature sensitivity tests can be added.
The picking-up test, which combines the motor and sensory functions with passive joint
motion, is useful for a general assessment but is not able to give a comparative quantification.
The evaluation of several muscles and of different areas of skin cannot be exactly quantified.
There is not yet a satisfying scoring table. We use the evaluation of Michon, which is
practical and gives an overall, even if incomplete, evaluation (Table 1). Results depend
upon many factors, some of which are related to the trauma, others to the surgeon, the
patient, or the postop treatment (see Tables 2 to 6):
Volume I
Table 2
MICROSURGICAL OPERATIONS PERFORMED
IN THE MICROSURGICAL SECTION,
DEPARTMENT OF ORTHOPEDICS, EULO
UNIVERSITY, BRESCIA, UP TO APRIL 1981
No. of nerves No. of cases
Neurolysis 91 91
Nerve sutures 230 159
Nerve grafts 548 376
Treatment of neuromes 46 40
Brachial plexus 170 170
Total 1085 836
Table 3
NERVE SUTURES: RESULTS ACCORDING TO AGE,
47 REVIEWED CASES WITH MORE THAN 3 YEARS
FOLLOW-UP*
Age (years) 10 10—20 20—30 30-^K) 40—50 50—60 60 +
Very good 4 7 3 4 2
Good
Fair 3
Bad
Note: Sutures have only been made when local conditions were good. All other cases
were postponed and treated by means of grafts (mainly).
a
As of April 1981.
Table 4
NERVE GRAFTS: RESULTS ACCORDING TO AGE,
127 NERVES, 98 CASES8
Age <10 10—20 20—30 30—40 40—50 50—60 60—70
No. 12 34 31 19 18 6 7
Very good 6 15 8 6 5 3
Good 5 18 22 7 6 1 2
Fair 1 1 1 6 5 2 4
Bad 2 1
a
As of April 1981.
1. Type of lesion
2. Site of the lesion
3. Surrounding tissues
4. Type of surgery
5. Time of surgery
6. Health of the patient
7. Use of alcohol, tobacco, or drugs
8. Age
9. Post operative treatment
Table 5
NERVE GRAFTS: RESULTS ACCORDING TO THE TIME
ELAPSED FROM THE LESION, 127 NERVES, 98 CASES"
Time from lesion 20-60 60—20 120—180 180—365 1—2 >2

to surgery days days days days years years
No. 35 22 28 18 16 8
Very good 16 14 8 2 2
Good 16 4 8 12 9 4
Fair 3 4 2 3 3 2
Bad 1 2 2
Note: To be noted that generally a long elapsed time is coupled with poor local conditions.
a
As of April 1981.
Table 6
NERVE GRAFTS: RESULTS ACCORDING TO
THE GRAFT LENGTH, 127 NERVES»
Centimeters 5 5—10 10—15 15—20 >20
No. 51 42 20 11 3
Very good 35 2 1
Good 15 34 12 3 1
Fair 1 6 5 6 1
Bad 2 2 1
a
As of April 1981.
Type of lesion — Will influence recovery depending on if it is a neat or a dilacerated

lesion, if there is diffuse trauma on the trunk, if there is contamination, if there are additional
lesions of vessels, tendons, bones, muscle, and skin.
Site of the lesion — This is also important; proximal lesions have to be considered more
severe because the neuron loses a large part of its axon and axoplasm (which can even
produce cell death) and because of the difficulties of correctly matching the fascicles.
Surrounding tissues — If these are fibrotic, with blood supply impairment, they will
not allow sutures and grafts to recover well and even can result in failures.
Type of surgery — When performed under the operating microscope, by means of careful,
delicate surgery by a trained surgeon the operation improves the result very much. In the
case of grafts, their length will affect the result as short grafts recover better than long ones
even though we have obtained good results with very long grafts (longer than 20 cm).
Time of surgery — This is also an important factor. Suturing at the 20th to 40th day
has proved to give the best results; tardy surgery will give less satisfactory results even if
very good and good results have been obtained after 2 years and good results after 5 to 7
and 9 years (Table 7).
Health of the patient — This is important too. General diseases can worsen the results
and have to be treated, particularly diabetes, which is very dangerous for nerves.
Alcohol, smoking and drugs — These should be prohibited because they affect the result
to a very large extent.
Age of the patient — This also play a role. Very young babies have worse recovery than
young adults, perhaps because of lack of collaboration. Young people recover much better,
while adults and the elderly recover with more difficulty, even if we have achieved good
results in people older than 60.
Volume I 287
Table 7
RESULTS OF NERVE SUTURES ACCORDING TO SURGERY TIME,
41 NERVES, NEAT SEVERANCES"
Elapsed time from injury to suturing (days)
8 Sutured
immediately 33 Afterb
1 — 20 21 22 23 24 25 26 27 28 29 30 31 32 33
Very good 2 3 1 3 2 1 2 1 2 1 3
Good 3 3 2 2 2 1 1 1 1 1
Fair 3 1 1 1
Bad
a
Knife cuts or similar conditions.
b
After 20 to 33 days.
Postoperative treatment — Can improve or worsen the results depending on whether

the care has been correctly used or not. All these factors will interact, so it is their global
combination that will determine the quality of the result. In any event, the age, time elapsed,
length of the gap, etc. should not cause the surgeon to renounce the operation, as fairly
good results have been obtained in worse conditions, thanks to the improvement of surgery.
SUMMARY
Biological and technical problems are taken into consideration as well as the timing of
surgery. The problem of properly matching fascicles of proximal and distal stumps is dis-
cussed. Various types of sutures are presented as well as the technique of suturing according
to the different pattern of the nerve. Nerve grafts are presented and pros and cons are
considered, eventually concluding that it is better to have a good graft without tension than
a bad suture under tension. Direct muscle neurotization is suggested in cases where the distal
stump of the nerve cannot be found. Postoperative treatment is emphasized, as regards
steroids and Roentgen therapy in order to block fibroblast proliferation and secondary ax-
onosthenosis or axonochachexy. Results of a large series of surgical cases are presented in
seven tables.
REFERENCES
1. Alnot, J. Y. and Huten, B., La sistematisation du plexus brachial, Rev. Chir. Orthop., 63, 27, 1977.
2. Bishoff, A., Anatomie chirurgicale des nerfs périphériques. Ultrastructure-vascularisation-reparation fas-
ciculaire, in Les Lesions Traumatiques des Nerfs Périphériques, Collana, G. E. M., Ed., L'Expansion,
Paris, 1972.
3. Brunelli, G., Long term result of nerve sutures and grafts, Microsurgery, 1, 27, 31, 1979.
4. Brunelli, G. and Fontana, G., Studio sulla rigenerazione nervosa, Riv. Chir. Mano, 17 (Fase. 1), 1980.
5. Cayal, R. Degeneration and regeneration, in Les Lesions Traumatiques des Nerfs Périphériques, Collana,
G. E. M., Ed., L'Expansion, Paris, 1972.
6. Daniel, R. K. and Terzis, J. K., Reconstructive Microsurgery, Little, Brown, Boston, 1972.
7. Edshage, S., Peripheral nerve suture, Acta Chir. Scand. Suppl., 331, 1—104, 1964.
8. Freilinger, G., Gruber, H., Holle, J., and Mandl, W., Zur methodik "sensomotorisch" differenzierter
faszielnaht peripherer nerven, Handchirurgie, 7, 133, 1975.
9. Hakstian, R. W., "Funicular orientation by direct stimulation", J. Bone Jt. Surg., 50A, 6, 1978.
10. Ito, T. and Ishikawa, F., Experimental study of funicular suture for peripheral nerve repair, Orthopaedics,
15, 10, 1964.
11. Lundborg, G. and Hansonn, H. A., Nerve lesion with interruption of continuity: studies on the growth
pattern of regenerating axons in the gap between the proximal and distal nerve ends, in Post-Traumatic
Peripheral Nerve Regeneration, Raven Press, New York, 1981, 229—241.
12. Matras, H. et al., Non-sutured nerve transplantation, J. Max. Fac. Surg., 1, 1973.
13. Michon, J. and Moberg, E., Les Lesions Traumatiques des Nerfs Périphériques, Collana, G. E. M., Ed.,
L'Expansion, Paris, 1972.
14. Millesi, H., Traitment des lesions nerveuses par greffes libres fasciculaires, in Les Lesions Traumatiques
des Nerfs Périphériques, L'Expansion, Paris, 1972.
15. Millesi, H., Meissl, G., and Berger, A., Further experience with interfascicular grafting of the median,
ulnar and radial nerves, J. Bone Jt. Surg., 58, 209, 1976.
16. Narakas, A., Les lesions dans les elongations du plexus brachial, Rev. Chir. Orthop., 63, 44, 1977.
17. O'Brien, B.M., Microvascular Reconstructive Surgery, Churchill Livingstone, London, 1972.
18. Samii, M., Aspects Modernes de la Chirurgie des Nerfs Périphériques, Fabre, Paris, 1977.
19. Seddon, H. J., Surgical Disorders of the Peripheral Nerves, Churchill Livingstone, London, 1972.
20. Serafín, D. and Buncke, H. J., Microsurgical Composite Tissue Transplantation, C. Mosby, St. Louis,
1979.
21. Spinner, M., Injuries to Major Branches of Peripheral Nerves of the Forearm, W. B. Saunders, Philadel-
phia, 1972.
22. Strange, F. G., An operation for nerve pedicle grafting. Preliminary communications, Br. J. Surg., 34,
423, 1947.
23. Sunderland, S., Nerves and Nerve Injuries, Churchill Livingstone, London, 1972.
Volume I 289
GREATER OMENTUM TRANSFER IN X-RAY LESIONS OF THE

BRACHIAL PLEXUS
G. Brunelli
INTRODUCTION
Treatment with ionizing radiation after mastectomies for mammary carcinomas probably
lengthens the life expectancy of the patient and in some cases saves the life of the patient,
but produces in many of the treated cases serious lesions involving skin, subcutaneous layers,
blood and lymphatic vessels, brachial plexus, and ribs. Cellular reaction to radiation is
ionization. Water molecules, the principal component of cells, are broken up into hydrogen
and oxygen ions. Normal cellular oxidation processes stop, essential enzymes and the genetic
nuclear apparatus are damaged, with coagulation of chromatin, nuclear disintegration, vac-
uolization, and necrosis.
The sensitivity of various tissues is different. The most sensitive are the endothelial and
epithelial cells while the least sensitive are the nervous and muscular tissues. The fibrocytes
show signs of deformation and gigantism and produce a dense and hyaline collagen without
elastic fibers.
In patients who underwent a routine mastectomy, the irradiated area is the armpit and the
supraclavicular region.
NERVE LESIONS
After variable periods following radiation, the skin presents symptoms (at varying stages)
of radiodermatitis. The blood vessels present signs of obliterating vascularitis and of hyaliñóse
or hyaline degeneration concerning arteries, veins, and lymphatic vessels. Tissues become
sclerotic and hard with areas of white necrosis.
Even though nervous tissue is not very sensitive to ionizing radiation, brachial plexus
trunks and cords are damaged because of an indirect mechanism: mechanical constriction
due to shrinking, and ischemia due to radiovasculitis. The anatomic and functional lesions
can be compression-irritation, compression-neuroapraxia, axonostenosis, axonocachexia,
and necrosis. The clinical syndrome appears at varying times depending on the differences
of tissues, individual reactivity, total dosage of ionizing treatment, single doses, their division
in time, type of irradiation, and the time elapsed. The syndrome consists of a motor and
sensory palsy that develops at varying rates into a total paralysis, and of paresthesia and
pain often so intense as to push patients to commit suicide.
Surgical Techniques
Until a few years ago there were no surgical techniques that referred to radiation lesions
of the plexus. Even in important recent texts on plastic surgery such as Barsky, Kahn and
Simon, Dufourmentel and Monly (1959 and additions), Grabb and Smith (1973), Aston and
Pikrell in Converse (1977), there are descriptions of plastic surgery techniques for recon-
struction of the skin and the thoracic wall, but little or nothing regarding neural lesion
restoration.
In 1963, Kirikuta proposed a plastic operation by means of a greater omentum pedicled
flap in order to reconstruct the thoracic wall and obtain good lymphatic drainage. He
mentioned the possibility that the omentum could prevent secondary scars from constricting
the plexus. He took a segment of greater omentum, with a vascular pedicle based on the
right gastroepiploic artery, passing the whole subcutaneously to the area where there was a
loss of skin. A dermal-epidermal graft guaranteed the covering of the omentum flap.
Operations intended to surgically repair actinic lesions of the plexus have been performed
since the early 70s, consisting of neurolysis, and (later in the 1970s) the addition of rotational
skin flaps to give a softer covering with better vascularization; but usually the surrounding
skin is also damaged and cannot supply very large flaps and the result is esthetically bad.
Free Microvascular Omentum Flap

The utilization of free microvascular omentum grafts is a very recent technique proposed
by Clodius et al.3 in 1974, with the goal of improving the lymphatic edematous condition.
The author has adopted a similar technique with a different goal: to release plexus sthenosis.
Neurolysis is the essential part of the operation, but if it is performed in isolation it does
not prevent a new scar, new stenosis and a relapse or a worsening of the preoperating
symptoms. Miocutaneous or pedicled muscle flap (great dorsal, Tubiana) have been put
forward as a suggestion but as far as the author is aware of, it has not been experimented
with. In addition, miocutaneous flap would only cover part of the plexus, as would a free
microvascular miocutaneous flap with limited efficiency in preventing the scar. The pedicle
greater omentum flap cannot cover all of the plexus after neurolysis, arriving, at most, to
the axilla whereas the lesions are not only axillary but also retroclavicular and even supra-
clavicular; furthermore its subcutaneous passage can twist the pedicle or press it because of
the poor quality of the skin, with necrosis and subsequent scar. In addition, placing the
omentum around the plexus is rendered very difficult because of the connection to the
stomach by the gastroepiploic artery.
Out of 61 cases of actinic lesions of brachial plexus that the author has had the opportunity
to see, only 36 have been operated on, in 31 of which free microvascular omentum flap
was used. After operating during the first years on three cases by means of neurolysis and
on two other cases by means of rotational cutaneous skin flap, since 1977 the author has
performed a wide neurolysis in all the areas suffering from sclerosis (axillary, retroclavicular,
and supraclavicular), afterwards covering the liberated plexus by means of a free omentum
graft removed in varying sizes depending on the needs of the particular case, and placing
this around all the plexus in need of covering, thus enveloping the plexus as completely as
possible in order to pad, defend, and vascularize it without stretching.
This omental graft is revascularized by microvascular anastomosis, a completely safe
technique for anyone practicing microsurgery since we are dealing with vessels with a
diameter greater than 1 mm. If necessary, necrotic parts of trunks or terminal branches are
removed and substituted with sural nerve grafts. The shape and the length of the cutaneous
incision depends on the extent of the lesion.
As soon as the skin is retracted, the subcutaneous layer is seen to be sclerotic and
insufficiently vascularized but, nevertheless, there is bleeding because of the rigidity of the
small blood vessels. The great pectoral muscle is often completely absent because of surgical
removal and the small pectoral muscle has often been transformed into a very hard fibrous,
whitish tissue: the remains of these muscles are sectioned and removed. At this stage terminal
branches of the plexus are identified distal to the cicatrical area, then nerves are followed
in a proximal direction, performing a precise external neurolysis and a careful dissection of
the axillary artery up to the subclavian artery.
Then liberation of the subclavian vein is performed. This is often the one with the scar
and is easily ruptured (requiring a suture of the laceration which is generally longitudinal).
Prudent external neurolysis by itself is usually enough to liberate the nerves or trunks, which
(except in the worst cases) dilate as soon as they are freed and assume normal appearance.
Sometimes an internal neurolysis, usually limited both in extent and depth, is required.
Severe sclerosis obliges extensive liberation (external neurolysis) of the terminal nerves of
the plexus which are more severely hit than the secondary trunks. When the supraclavicular
fossa has also been exposed to radiation neurolysis should be performed even on primary
trunks (cords).
Volume I 291
In only two cases was it necessary to continue and perform external neurolysis of the
roots. In 12 cases it was necessary to perform internal neurolysis on short tracts of one or
more trunks. In three cases there were such severe lesions that the nerve trunks were yellowish
and fibrous. These had to be removed and replaced with nerve grafts which were then
covered by the omentum. The most recent cases were operated on with a double team. This
is necessary so as not to inordinately lengthen the duration of the operation. The second
team removes the omentum and begins its work 1V2 hr after the first team has started. In
this way about 2V2 or 3 hr from the beginning of the whole operation the first team has
finished the neurolysis, while the second team can furnish the omentum. The size of the
omentum graft is determined each time, depending on the extent of the lesion and the
thickness of the omentum. It is possible to find thick omenta and thin omenta, some rich
in quite solid fat, others extremely loose, and still others extremely thin and transparent.
After splitting the omental layers and deciding on the size of the graft, the blood vessels
at the end of the graft to be removed are tied, and so are, finally, the gastroepiploic artery
and vein both left and right, only on the side of the stump which remains attached to the
stomach.
One has to immediately color the mouths of the small blood vessels with methylene blue
applied by means of a sterile toothpick. Otherwise these retract into the fatty tissue and are
extremely difficult to find and, hence, make one lose a lot of time. After various techniques
in the earlier operations, today the standard technique is to remove a long, thin segment of
omentum with two or three radial vascular axes.
Depending on whether the recipient vessels (artery and vein) are near or far from each
other the donor vessels will be either the right gastroepiploic artery and vein or the right
artery and left vein.
If nerve grafts are needed during the operation a third team shall take the sural nerve from
the patient's leg by means of a long undulated incision to permit its atraumatic removal and
not to provoke internal lesions (partial neurotmesis) and lesions of the collateral branches
as in stripping. One must not repair a damaged machine with damaged parts!
Donor and Receiving Vessels

Usually, the local blood vessels in the lesioned area are reduced in number, small and
hard, and display signs of severe sclerosis and separation of the intima so that they do not
appear reliable enough for patency of the anastomosis to be performed. This means that the
recipient blood vessels are to be found far from the lesioned area. If there has been no
irradiation of the supraclavicular fossa, the transversa scapulae artery, or cervicalis transversa
artery are suitable, otherwise it is more convenient to search for the facial artery and veins
under the mandible or to perform an end-to-side anastomosis of the gastroepiploic vein on
the jugular vein. The usefulness (or harmfulness) of perfusion of the omentum flap is a
controversial subject.
Microsurgical suturing is not always easy to perform, often having to be executed at depth
and usually not permitting the use of approximator clamps. The suture is easier to apply
when one uses the facial blood vessels. Suturing is performed under the surgical microscope,
at every stitch exploiting the zoom pedal in such a way as to have high magnification (30 x )
when the needle passes through the wall of the blood vessel and a low magnification (6 to
8 x ) when the stitch is being knotted. This way one saves a lot of time. Suturing is performed
first on the vein and then on the artery. First the clamp on the vein is removed, then the
clamp below the arterial suture, and then that above it. The omentum immediately reinflates,
reddens, and begins to pulsate. The omentum is now distended on the front of the liberated
plexus, placed lateral to the plexus, and is made to run under it. The omentum is then
anchored to fibrous tissue underneath with a few stitches which have to scrupulously respect
the omental vessels.
Great care must be taken not to damage the omentum vessels, especially where the
circumflex nerve separates from the plexus and where the radial nerve is directed posteriorly.
Despite these difficulties it is possible to envelop the omentum around the base of these
branches of the plexus. Sclerotic and lardaceous skin is sutured by means of extroverting
stitches. Only in two cases was it necessary to recur to additional flaps because of skin
necrosis.
Indications
1. Pain (of no importance is the extent and duration of paralysis, because pain is the
most important symptom in these patients, two of whom had tried to commit suicide
before the operation)
2. Paralysis still in progression
3. Paralysis recently stabilized (4 to 6 months)
4. Radiodermatitis
Contraindications
1. Slightly stabilized paralysis without pain

2. Total, old, stabilized paralysis without pain completed by more than 6 months
3. Slow progressive paralysis having lasted more than 5 years without pain
POSTOP TREATMENT
Postoperative treatment consists of a 12-day course of treatment of calciparine, 330 mg

of aspirin (orally) every 3 days, platelet antiaggregants (Persantine® or ageroplas) and, for
the first 5 days, reomacrodex. Locally a large fat medication is put on the surgical wound
in order to not "take" and the arm and forearm are immobilized by means of sticking plaster
in moderate abduction on a large cotton-wool pack is recommended.
MISTAKES
It is not simple in a survey of such limited size to find many mistakes. In the light of the
gained surgical experience we consider as mistakes: a too-limited neurolysis, the use of too
large a segment of omentum, the removal of a part of the clavicle (which the author did in
some cases in order to free the shoulder to a large extent, but which resulted in a cicatrical
narrowed shoulder), and performing anastomosis where the recipient blood vessels have
been damaged by radiation.
COMPLICATIONS
The cases operated on have had complications only three times ( ± 10%) because of
dehiscence of the skin due to radiodermatitis. In these cases a rotational cutaneous flap
resolved the problem of closing the lesion but obviously creating an esthetical problem,
lengthening recovery, and reducing the mobility of the shoulder.
RESULTS
Obviously, the results of the operation are different depending on numerous factors:
1. The severity of the lesion

Volume I 293
2. The time of onset of paralysis

3. Individual response to radiation and to treatment
4. The thoroughness and extent of the operation
The results of this survey cannot be considered complete because it is well known that
the repair of proximal lesions of the nerves requires a long time in relation to the distance
the regenerating axon must cover. The distance from the supraclavicular fossa to the fingers
is about lm in some cases, and this means about 3 years repair (at the growth rate of 1 mm
a day).
The maximum time elapsed in the first operations is now 4V2 years while in most of the
cases the follow-up is shorter. Anyway, we can state that pain, which is the most important
indication for this operation, always disappears completely from the day of the operation
and has never reappeared, so the results in this sense are excellent. In a more detailed analysis
of the 31 cases operated on with microvascular graft of omentum in order to see the results
according to the type of operation, we found that pain in all cases has disappeared, that the
improvement of motor palsy is more marked in cases where only external neurolysis was
performed without internal neurolysis (this is probably due to the better state of the nerve
at the moment of the operation). Even in cases of severely damaged nerves with need of
nerve grafting there was improvement.
The same can be said for tactile sensitivity. Passive movement worsened in cases where
a rotational flap was used and in three out of five cases in which the clavicle was removed.
The improvement of the paralytic syndrome is still in progress in all the cases which have
been operated on except two, one of which after having reached a fair level of improvement
remains unchanged whereas the other one, after a fair improvement, went back to the
preoperative motor conditions. Nevertheless, the pain did not reappear.
The recovery of the motor and sensory function is better and can reach a good function
in those cases that can be operated on before the onset of too severe a palsy and before a
long period of time elapses from the palsy onset; in the other cases the motor function
improvement can be an academic observation without a functional result whereas the really
good result is the disappearance of the pain.
SUMMARY
The damages provoked by X-ray radiations are reviewed and the lesions of the brachial
plexus taken into consideration. Careful neurolysis of damaged plexus and its padding, and
revascularization by means of a micro vascular-free omentum flap is presented. Indications
depend upon the degree of the lesions, the time of onset, and overall, on the presence of
pain, as this is the most excruciating symptom (enough to push patients to suicide) and
disappears from the very moment of the operation. The recovery of motor or sensory function
is inversely proportional to the severity of the palsy, the dose of the radiation, and the time
elapsed from the onset. The operation is a major surgical procedure and may require added
procedures such as clavicle section and osteosynthesis or removal of necrotic nerves and
their substitution by means of nerve autografts. There have been 36 cases operated on, 31
of them by means of free greater omentum flap. In all of them pain disappeared while motor
and sensory recovery were variable according to the various factors which are discussed in
the text.
REFERENCES
1. Brunelli, G., Lesioni del plesso brachiale, in Microchirurgia, Pelizza, Brescia, 1978, 78—97.
2. Clodius, L., Symposium on Microsurgery, New York, 1974.
3. Clodius, O., Uhlschmid, G., and Madridtsch, W., Chirurgische Mõglichkeiten der Lymphodembehan-
dlung, Folio AngioL, 11, 304, 1973.
Volume I 295
NEUROTIZATION OF AVULSED ROOTS OF THE BRACHIAL PLEXUS BY

MEANS OF ANTERIOR NERVES OF THE CERVICAL PLEXUS
G. Brunelli
INTRODUCTION
In the various possible conditions found in brachial plexus surgery there are situations
that do not allow sutures or grafts because the proximal stump is missed, as in root avulsion
which can involve one, some, or all the roots of the brachial plexus.
INTERCOSTAL NERVE TRANSFER (CRITICISM)
The avulsion lesions of brachial plexus roots that cannot be repaired by means of sutures
or grafts are commonly neurotized by means of intercostal nerves. They can be taken at the
middle axillary line or posteriorly and then connected, either directly (when it is possible)
or by means of grafts, with the distal stump of the roots, or better, with selected nerves;
either way, the results of this technique are always poor. This is better than nothing, but,
however, it is very little.
In fact, the intercostal nerves are constituted by a small number of fibers. The first
intercostal nerves have very few fibers, the deeper ones have more fibers but they are more
difficult to take and the operation becomes very bloody. If the intercostal nerves are taken
posteriorly the operation is equally long and bloody with no evident improvement of results
because of the length of grafts needed. Taking the nerves at the axillary line the number of
fibers is even less because at this point the nerves have already lost a part of their fibers.
Moreover, it is very difficult, if not impossible, to recognize sensory from motor fibers so
that we must consider that, on average, 50% of the fibers will be functionally lost after
surgery because of mistakes of axon connection.
In the author's experience, four intercostal nerves can supply a total of about 3000 fibers,
one third of which are lost at the axillary line and a lot of the remaining two thirds lose
their function because of connection mistakes from motor to sensory fibers and vice-versa.
So we can only roughly count on a maximum of 1000 fibers for a brachial plexus that
generally is constituted by 120,000 to 160,000 fibers. This very poor contingent of fibers
can only give a very weak movement even on the condition that all these fibers are con-
centrated on only one nerve (such as the musculocutaneous nerve for biceps movement). If
they are distributed on more than one nerve (as was done 3 or 4 years ago) the movement
is absolutely useless because of its weakness and cocontractions with antagonist muscles.
Moreover, the cerebral scheme of intercostal nerves is semi-automatic and a great job of
cerebral reassessment is required. Often the movement of the arm requires a contemporary
movement of voluntary inspiration and it is not useful because of antagonistic muscles
cocontraction. What's more, the operation is very serious, with a large loss of blood, and
it lasts a long time.
ANATOMIC RESEARCH FOR CERVICAL DONOR NERVES
For these reasons the author looked at the possibility of using other nerves and studied
the nerves of the cervical plexus in order to use them to neurotize the brachial plexus (Figure
1). The cervical plexus has, classically, eight superficial nerves (besides the others), four
of which are motor and four are sensory. They are the nerves for the sternocleidomastoideus,
trapezius, levator scapulae, and rhomboideus muscles, and the auricularis, cervicalis trans-
versus, supraclavicularis, and supraacromialis sensory nerves.
FIGURE 1. Scheme of the recent method of neurotization of avulsed brachial plexus

by means of cervical nerves: 1 = St. cleid. mast, n., 2 = trapezius n., 3 = levator
scap., and 4 = rhomboid n. Suprascapularis n. is connected by means of a graft to
rhomboid n.; axillary n. receives two grafts from st. cl. mast, and trapezius nn.;
musculocut. n. receives two grafts from XI cranial n.; and all other sensory nerves
and, if left, motor nerves (as in this scheme levât, scap. n.) are led to median nerve.
In order to obtain complete information about this possibility, nine cervical plexuses in
cadavers have been dissected in order to confirm the presence of those superficial nerves
and to count their fibers, with the following results.
Sensory nerves Av. no. of fibers
Supraacromialis 450
Supraclavicularis 580
Auricularis 740
Cervicalis transversus 730
Possible other sensory nerves 600
Motor nerves
Sternocleidomastoideus 800
Rhomboid 840
Levator scapulae 900
Trapezius 780
Other possible motor nerves 750
Av. total 7170
Volume I 297
Many clinical cases have also been studied and recorded: sensory nerves were almost
constant while motor nerves presented some variations. In some cases all the nerves of the
cervical plexus were very large, in other cases very small. The superior nerve for the
sternocleidomastoideus muscle often was absent. The nerve for the rhomboid muscle was
absent in one case, very large in three cases, and was constituted by many small nerves in
several cases. Also, the nerve for the levator scapulae was often absent.
In many cases it was possible to find and electrically stimulate some other motor nerves
for posterior muscles which were large enough to be used for neurotization. It is easy to
recognize, by means of their anatomical position and electrical stimulation, the motor nerves
for the sternocleidomastoideus, the trapezius, the levator scapulae, and the rhomboid mus-
cles, and the sensory nerves: auricularis, cervicalis trans versus, supraclavicularis, and
supraacromialis.
Severance of all these sensory nerves produces a narrow irregular area of anesthesia that
goes from the ear to the acromion, the borders of which are partly replaced distally by Tl
and medially by controlateral C3. Severance of the four motor nerves produces a partial
palsy of the cucullaris and sternocleidomastoideus muscles (which are also innervated by
the accessorius spinalis nerve), and of rhomboid and levator scapulae which are innervated
by the brachial plexus, too.
Advantages
The advantages we have by using these eight nerves are
1. To put at our disposal a greater quantity of fibers

2. To give us the possibility to anastomose well-defined pure motor and sensory nerves
3. That motor nerves are voluntary motor nerves with autonomous function
4. The possibility in some cases of direct anastomoses without grafts (especially for
sensory nerves)
We can roughly count on some 4000 motor and 3100 sensory fibers that we can recognize
well and correctly distribute on those nerves we want to neurotize. In the early cases the
author tried to neurotize C5 and C6 roots by leading and suturing the sensory nerves on the
posterior part of the avulsed roots distally to ganglions and the motor nerves on the anterior
part. But it was a mistake because the roots are constituted of a very large number of assorted
fibers, so their neurotization is not worthwhile because many fibers are functionally lost.
Now, the motor nerves are distributed on well-chosen branches of brachial plexus as, for
instance, the nerve for the trapezius muscle on the suprascapularis nerve, the nerve for the
rhomboid muscle on the axillary nerve, and the nerve of the sternocleidomastoideus and
levator scapulae muscles on the musculocutaneous nerve; while all the sensory nerves are
sutured on the median nerve. If the cervical nerve to the trapezius muscle is small or missing
one can use the XI cranial nerve.
The material used for the neurotization of brachial plexus by means of cervical plexus
superficial nerves is much richer than that used when neurotizing by means of intercostal
nerves. Concentrating the motor fibers on two motor nerves and the sensory fibers on the
median nerve produces better results.
Clinical Cases
A total of 26 clinical cases have been operated on since 1977. As we need at least 3 years
in order to get complete results in brachial plexus injuries and as the first cases were operated
on by means of an incorrect technique (distributing and losing the greater part of the fibers
on many roots), the results only start to become significant.
It is easily comprehensible that limited avulsion of one or two roots repair better. In these
cases the same number of axons only have to neurotize the suprascapularis and musculo-
cutaneous nerve while distal muscles and skin are normal. If we have only one root avulsed*
we can neurotize the root and not the peripheral nerves and in this case we can hope to have
a better result. In total avulsion (or large avulsion) we have to carefully study what we can
hope to obtain and limit the neurotization to the chosen muscles in order to obtain what we
want. Otherwise, if we try for too much we will not have good results.
Of course the results we consider good are good as related to the single muscles and to
their former condition, while the limb function is in any event, very poor. That is, never-
theless, a useful result as compared to total palsy.
Summarizing: with this technique we have at our disposal a great quantity of well-
distinguished sensory and voluntary motor fibers that can be distributed on well-chosen
branches of the brachial plexus with the possibility of a useful neurotization of one or two
muscles and of the sensory part of the median nerve.
SUMMARY
In brachial plexus root avulsion neurotization by means of intercostal nerves gives very
poor results because of the scarcity of fibers, the impossibility to recognize which are motor
and sensory fibers, and the semiautomatic pattern, besides the cocontractions of reinnervated
muscles. An anatomic study has been carried out to search for donor nerves in the cervical
plexus and we were able to find eight (or more) donor nerves (four sensory and four motor
nerves) which can supply a higher number of fibers, well-characterized as to sensory and
motor functions, that are voluntary fibers. Concentrating these more than 7000 fibers (on
an average) on two nerves that should be suprascapular and musculocutaneous nerves in
proximal or total avulsion (or other nerves in distal avulsion) one can get better results.
REFERENCES
1. Alnot, J. Y., Etude clinique et paraclinique plus evolution spontanée des paralysies du plexus brachial,
Rev. Chir. Orthop., 63, 58, 1977.
2. Alnot, J. Y., Mansat, M., Huten, B., Bonnel, F., Narakas, A., Cadre, N., Sedei, L., Millesi, H.,
and Allieu, Y., Symposium sur la paralysie traumatique du plexus brachial chez l'adulte, Rev. Chir. Orthop.,
63(1), 19—126, 1977.
3. Brunelli, G. Neurotisation of avulsed roots of the brachial plexus by means of anterior nerves of the cervical
plexus, Int. J. Microsurg., 2(1), 55—58, 1980.
4. Gilbert, A., Khouri, N., and Carlioz, H., Exploration chirurgicale du plexus branchial dans la paralysie
obstétricale, Rev. Chir. Orthop, 66(1), 33—43, 1980.
5. Jaeger, R. and Whiteley, W. H., Avulsion of the brachial plexus, J. Am. Med. Assoc, 153, 633, 1953.
6. Mendelsohn, R. A., Weiner, J. H., and Keegan, J. M., Myélographie demonstration of brachial plexus
root avulsion, Arch. Surg. Chicago, 75, 102, 1957.
7. Millesi, H., Surgical management of brachial plexus injuries, J. Hand Surg., 2, 367, 1977.
8. Narakas, A., Plexo Brachial. Terapéutica quirúrgica directa. Técnica. Indication operatoria. Resultados,
Rev. Orthop. Traumat., 16, 855—921, 1972.
9. Sedel, L., Traitment palliatif d'une serie de 103 paralysies par elongation du plexus brachial, Rev. Chir.
Orthop., 63(7), 651—677, 1977.
10. Sunderlad, S., Brachial plexus lesions due to compression, stretch and penetrating injuries, in Nerves and
Nerve Lesions, Churchill Livingston, London, 1972.
* To be sure if the material found at the location of the roots is nervous tissue and supports conduction, it is
very important to have evoked potential detection during the operation, besides the preoperative EMG and
myelography.
Replantation Surgery
Volume I 301
REPLANTATION SURGERY
Tsu-Min Tsai and John T. Burns
INTRODUCTION
Since Malt and McKhann reported the first successful replantation of an amputated ex-
tremity in 1962, numerous centers throughout the world have developed microsurgical
capabilities permitting replantation surgery.l Viability (or success) rates have steadily climbed
and are now as high as 91% in digital replants and 88% in major limb replants, with better
patient selectivity and improved microsurgical techniques accounting for such a high per-
centage of successful surgery. 23 Only recently, however, has function in viable replants as
determined by sensory return, restored joint motion, freedom from cold intolerance and
dysesthetic pain, recovery of strength, etc. been appropriately scrutinized to determine if
most of these long and tedious surgical procedures are subsequently beneficial to the patient.
PATIENT SELECTION
It is imperative that surgeons engaged in replantation surgery exercise studied selectivity

of patients. Familiarity with absolute and relative contraindications as well as appropriate
indications will enhance surgical success and temper undue optimism of the injured, of
family members, and perhaps of the referring physician. Although the following guidelines
are widely accepted at the present time, the constant dynamism of medicine, particularly in
refinement of microsurgical technique and in sophisticated improvements in microsurgical
instrumentation, encourages the microsurgeon to remain current in his field of expertise and
to alter such guidelines in concert with medical advancements.
Absolute Contraindications (Table 1)

Significant associated trauma — A candidate for replant surgery frequently has been
involved in a traumatic event potentially affecting other major organ systems. This is par-
ticularly true when a limb amputation has occurred. Severe and possibly life-threatening
injuries must receive immediate medical attention and preoccupation with the more obvious
injury (amputation) avoided. Replantation may be considered if the patient's general con-
dition improves within a reasonable period of time.
Extensive crush, multiple level injuries, or severe degloving of the amputated part
— Obvious damage to a part is exceeded by less visible damage at the microscopic level.
Severely crushed parts with X-ray evidence of multilevel fractures are generally doomed to
failure if replantation is nonetheless attempted. Red discoloration along digital neurovascular
bundles ("red ribbon sign") is indicative of avulsion of the digital vascular tree, a serious
injury that makes attempts at vascular repair almost futile.4 Amputated parts (particularly
digits) that are largely degloved, if salvaged, present a formidable reconstructive problem
to obtain sensation and are often functionally compromised, thus becoming a liability to the
patient.5
Poor general health — A chronically ill patient whose life is threatened by a prolonged
surgical procedure or the anesthesia required to endure such a procedure should not be
encouraged to undergo replantation.
Relative Contraindications (Table 1)

Patients over 60 years of age — The chronological age of the patient does not necessarily
correspond to his or her physiologic age. Degenerative joint changes as determined by
radiographs and the degree of arteriosclerotic changes in the vascular tree as judged by the
Table 1
ABSOLUTE AND RELATIVE CONTRAINDICATIONS FOR REPLANTATION
Absolute contraindications Relative contraindications
Significant associated trauma Age of patient greater than 60 years

Extensive crush, multilevel injury, or severe degloving Amputation of single digit
of the amputated part Hypertension, generalized vascular disease, long-
Poor general health of patient standing diabetes mellitus
Avulsion injuries
Previous injury or surgery to the amputated part
Prolonged warm ischemia time
Extreme contamination
Mental instability
physical examination and appropriate X-rays must be critically evaluated by the responsible
surgeon. A decision whether or not to proceed with surgery is reached by weighing these
factors against the predictable functional deficit that will ensue if replantation is not attempted.
Amputation of a single digit — Justifiable arguments may be presented against replan-
tation of a single digit with exception of the thumb.5 The compromised index finger is
frequently bypassed in deference to the middle finger, a situation commonly resulting in ray
amputation of the bothersome replanted index.6 A common origin of the profundus tendons
of the ulnar three digits results in all being affected by a single, poorly functioning digit.
If, however, the amputation is sharp and distal to the flexor digitorium superficialis insertion,
replantation may be advisable since the distal interphalangeal joint can be arthrodesed and
sensory recovery is often acceptable.7
Hypertension, generalized vascular disease, severe or long-standing diabetes mellitus
— These are all contraindications for replantation surgery.
Avulsion injuries — The history and close inspection of the amputated part frequently
underscore the mechanism of injury. Structures (usually tendons and nerves) dangling from
the specimen vividly indicate the absence of a sharp injury. Vascular damage is extensive
necessitating generous use of vein grafts to restore circulation in those cases where replan-
tation is undertaken. Even in successfully replanted parts neural recovery may be less than
satisfactory.8
Previous injury or surgery to the amputated part — Unanticipated surgical difficulties
may obviously be encountered under these circumstances. If information accumulated pre-
operatively indicates that these preceding events are not likely to adversely affect the im-
mediate surgery or the functional outcome, then replantation may be appropriately considered.
Prolonged warm ischemia time — Irreversible deterioration occurs in muscle continu-
ously deprived of its blood supply for 6 hours and maintained at room temperature.9 Other
tissues such as nerve, tendon, bone, and skin deteriorate more slowly.10 If the amputated
part is immediately cooled to approximately 0 to 4°C, deterioration of tissues is greatly
retarded thus permitting successful replantation, both experimentally and clinically, long
after the time of injury (up to 36 hr at our institution).1113 Digits, having no muscle tissue,
undergo anoxic deterioration more slowly.
Extreme contamination — Extensive surgical debridement is seldom a problem in replant
cases but on occasion the surgeon may encounter such profuse and penetrating tissue con-
tamination that adequate excision of foreign material would functionally compromise the
amputated part. One must then detemine if secondary procedures may reverse these deficits
and, with the patient's cooperation, decide if the mental anguish to the patient, the financial
burden to the patient or insurer, the numerous disruptive hospitalizations, and the possibility
of total failure allow pursuit of replantation. A favorable functional outcome should then be
Volume I 303
Table 2
INDICATIONS FOR
REPLANTATION
Thumb amputation
Amputation of multiple digits
Amputations in children
expected to exceed what could be gained from mere closure or revision of the amputation
stump and perhaps employment of a prosthetic appliance.
Mental instability — There are rare instances where self-mutilation has resulted in
amputation of parts.14 If loss of the part is not life-threatening the surgeon must decide,
after consultation with a psychiatrist, whether or not to pursue replantation.
There are instances where the above contraindications should be viewed less stringently
and every effort made to salvage the amputated part. These are considered in the following
section.
Indications for Replantation (Table 2)

Thumb amputation — As mentioned before, arguments against single digit replantation
are not universally applicable to the thumb. Its importance in prehension and its ability to
function with only the basilar joint intact if sensation is restored or provided encourage every
reasonable effort to salvage this digit.
Amputation of multiple digits — Unless failure is inevitable an attempt at replantation
should be made when more than two digits are dismembered, including loss of a hand or
arm. In such cases survivability is obviously unpredictable; therefore, all digits should ideally
be replanted. A rigid anatomical surgical approach is not essential as digits should be
distributed in a manner offering the best opportunity for functional recovery.15
Amputations in children — The potential for nerve regeneration in children supercedes
that in adults, a fact that frequently results in exceptional functional return following re-
plantation of even a single digit.16 Additionally, whereas adults usually have an established
vocation and thus a predictable need for specific anatomic parts, children have undetermined
interests and may be excluded from certain vocational pursuits if left permanently handi-
capped by loss of an amputated part.
Aside from factors discussed earlier, other possibly influential considerations must be
recognized before one firmly concludes whether or not to proceed with replantation. The
patient's opinion must be respected but should be sought only after the surgeon has carefully
acquainted him or her with all aspects, both immediate and long-term, of his injury. Preceding
handicaps such as previous amputation, paraplegia, blindness, etc. may encourage salvage
surgery that in an otherwise healthy individual would not be attempted.17
PREPARATION OF THE AMPUTATED PART FOR TRANSFER

(TABLE 3)
Adequate but not lengthy attention must be directed toward the completely severed part.
Gross contaminants may be gently washed away with lactated Ringer's solution but prolonged
irrigation and tissue manipulation is unnecessary. If a major limb is involved and inspection
of the part reveals an unstable fracture, gentle splinting may be of benefit to prevent additional
tissue injury during transfer. The part is then placed in a dry plastic bag which is then sealed
and placed on ice in a closed container of appropriate size (Figure 1). The ambient temperature
is thus maintained at approximately 0 to 4°C, significantly slowing the unavoidable ischemic
catabolic process initiated at the time of injury. The part must remain in this environment
until its arrival at the replantation center.18
Table 3
RESPONSIBILITIES OF REFERRING PHYSICIAN
Preparation of amputated part Preparation of patient
Gentle irrigation with lactated Thorough physical exam

Ringer's solution
Splinting of unstable fractures Treatment of severe injuries or serious illnesses
Sealed in dry plastic bag and placed Compressive hemostatic dressing to stump
on ice in closed container
Fluid replacement including blood if required
Broad-spectrum parenteral antibiotic coverage
Tetanus prophylaxis
Qualified personnel to accompany patient
FIGURE 1. Amputated part sealed in dry plastic bag and placed on ice.
(From Kleinert, H. E., Jupiter, J. B., and Tsai, T. M., Clinical Trends in
Orthopedics, Thieme-Stratton, New York, 1981. With permission.)
PREPARATION OF THE PATIENT FOR TRANSFER

(TABLE 3)
If the referring and consulting physicians agree that replantation may be advisable, the
consulting physician must assure himself that appropriate emergency medical measures have
been performed prior to the patient's transport to another medical facility.
Identification and treatment of severe injuries or serious illnesses are mandatory.
Volume I 305
FIGURE 2. Patient being administered axillary block with long-acting anesthetic agent.
Hemostasis, best obtained by application of a pressure bandage and elevation of the affected
part, preferably with ice bags surrounding it, must be assured. Ligatures and clamps, when
possible, are to be avoided but major amputations frequently require their use.
Intravenous fluid replacement must be maintained and, if required, pretransport transfusion
administered.
Analgesia should be afforded the patient and broad-spectrum antibiotic coverage instituted.
Accompaniment of the patient by medically qualified personnel is essential if the injured
is receiving intravenous fluids. This is reassuring to both the patient and the involved
physicians.
On arrival at the replantation center the patient must again be thoroughly reexamined, the
history reviewed, appropriate laboratory and X-ray studies (including those of the amputated
part) obtained, tetanus prophylaxis assured, and anesthesia preparations immediately
undertaken.
ANESTHESIA
Regional anesthesia in the form of an axillary block utilizing a long-acting agent (Már-
came®) is commonly employed (Figure 2). The anesthetic lasts 12 to 16 hr and simultaneously
induces a sympathetic block that aids distal circulation.19 Moderate sedation is also advisable.
General anesthesia is seldom necessary.
Throughout the operative procedure the patient is appropriately monitored (urinary catheter
for output measurement, electrocardiography, pulse and blood pressure monitors, central
venous pressure catheter, rectal thermometer, and intravenous fluid catheter). Broad-spec-
trum parenteral antibiotic coverage is continued.
SURGICAL TECHNIQUE
When the decision to undertake replantation has been made, the primary surgeon should
immediately proceed to the operating suite with the amputated part. Debridement of nonviable
and heavily contaminated areas must not be timid. Perfusion of major limb parts with chilled
heparinized lactated Ringer's solution assists in muscle debridement (nonperfused areas
should be sacrificed) and seems to contribute to the success rate20 (Figure 3). Skin incisions
should be thoughtfully made to permit access to essential anatomic structures (bone, tendons
or muscles, nerves, arteries, and veins) and to allow loose skin closure at completion of the
procedure (Figure 4). Microscopically dissected structures should be readily identifiable,
some authors suggest separately tagging them for later recognition.21 Bone stabilization may
be initiated on the amputated parts. All of these measures are ideally accomplished prior to
the arrival of the patient in the operating theater. Similar steps are then performed on the
amputation stump.
Digits
The order of repair should usually be as follows:
1. Bone fixation
2. Tendon repair
3. Vessel and nerve repair (in most instances the artery should be repaired first)
4. Skin closure
Bone shortening (avoid additional injury to adjacent soft tissue) of 5 to 10 mm is advisable

with reflected periosteum repaired over congruously coapted bone. Fixation by either crossed
K-wires, interosseous wiring, or a combination of both is recommended.15-22 Intramedullary
screws are also used23 (Figure 5).
Amputation through a joint may be stabilized by utilizing a silastic implant (proximal
interphalangeal or metacarpophalangeal joints) or by arthrodesing the joint in a functional
position. An intramedullary bone peg may complement stability and promote solid bone
union24 (Figure 5).
Tendons should be precisely repaired on both extensor and flexor surfaces with tendon
sheath and pulleys preserved where possible25,26 (Figure 6).
The previously identified vascular structures (note that arteries are more easily visualized
prior to tourniquet elevation) are mobilized and attention then directed to arterial repair.
Damaged areas are resected proximally and distally to a level where healthy-appearing
intima is seen. Strong proximal flow must be assured by observing flow following tourniquet
deflation. If distal flow is sluggish, surgical release of Guyon's canal usually immediately
reverses this problem. Vessel reapproximation and repair then ensue if tissue resection has
not resulted in undue vessel tension. Reversed vein grafts best acquired from the distal one
half of the volar forearm are employed for arterial repair if tension is judged to be excessive.
Both digital arteries should be repaired. Venous repairs (bleeding veins are readily identifiable
after arterial flow has been established) ideally outnumber arterial repairs two to one although
all veins amenable to repair should be repaired.27 Again, veins must be free of tension and
nonreversed vein grafts are generally assured in those instances where skeletal shortening
is not desirable.
Nerves may usually be coapted, thus obviating the need for primary interpositional grafts
that, if required, may best be obtained from the lateral antebrachial cutaneous nerve. Epi-
neurial repair is recommended.2831
Thumb
Thumb replantation should usually be attempted unless the extent of damage negates any
Volume I 307
FIGURE 3. Major limb amputated part perfused with chilled lactated Ringer's solution.
FIGURE 4. Examples of digital skin incisions permitting good surgical exposure and Z-plasty (loose) closure.
FIGURE 5. Methods of digital bone stabilization.
reasonable hope of success.32 Since thumb amputations are frequently attributable to severe
avulsion injuries, arterial repair is often best accomplished by circumventing unsuspected
tissue damage by utilizing a generous reversed vein graft anastomosed proximally (end-to-
Volume I 309
FIGURE 6. Preferred method of flexor tendon repair.
side) to the radial artery in the snuffbox area, tunneled distally and subcutaneously, and
anastomosed distally (end-to-side or end-to-end) either to one or two (preferred) digital
arteries33 (Figure 7). One should recall that the ulnar digital artery is dominant and, therefore,
preferably repaired if only one vessel can be utilized. In rare instances a severely degloved
and replanted thumb may be afforded soft tissue coverage and ulnar pulp sensation by
primary transfer of a neurovascular island (usually obtained from the ulnar aspect of the
long finger).
Transmetacarpal
Several critical surgical points about this region must be underscored. Bone fixation may
prove difficult but many methods have worked satisfactorily. The surgeon, however, using
the method most reliable in his hands, must tediously realign the metacarpals and particularly
avoid rotational deformity, an embarrassing and functionally incapacitating error in what
may otherwise be a flawless replantation. Additionally, caution must be exercised in ap-
proaching vascular repairs. Metacarpal arteries originating from the deep palmar arch are
not essential to the replantation and may easily be overlooked, yet persistent deep bleeding
from these vessels in the postoperative period has been directly responsible for loss of the
replant due to formation of a deep, compressive hematoma.34 It is wise either to coagulate
the cut ends of the metacarpal arteries or to occlude the deep communicating branch between
common digital and palmar metacarpal arteries.
Wrist
Amputations at this level not uncommonly present challenging problems in bone fixation.
Arthrodesis with a wide range of bone stabilization methods is often desirable but some
cases offer alternatives such as proximal row carpectomy or radius shortening combined
with distal ulna resection.
FIGURE 7. Long reversed vein graft employed to salvage amputated thumb. (From
Kleinert, H. E., Jupiter, J. B., and Tsai, T. M., Clinical Trends in Orthopedics,
Thieme-Stratton, New York, 1981. With permission.)
Forearm or Arm (Major Limb Replant)

Since a large muscle mass is necessarily involved in amputations at this level, ischemia
time becomes critical as irreversible muscle changes are known to occur if warm ischemia
exceeds 6 hr.35 Therefore, the previously outlined order of structural repair must be altered
and arterial repair affected immediately following bone fixation. If possible, the amputated
part remains in ice packs until arterial flow has been reestablished.
One must remember that fasciotomies, closure with split thickness skin grafts, adequate
drainage, and nonconstricting dressings are critical in preventing postoperative compression
that might lead to vascular compromise and extensive deep tissue necrosis or complete loss
of the replant. Loose skin closure is imperative (Table 4).
POSTOPERATIVE CARE
A noncompressive bulky dressing without circumferential bandages should be applied and

Volume I 311
Table 4
CRITICAL SURGICAL CONSIDERATIONS IN MAJOR
LIMB REPLANTATIONS
Fasciotomies where indicated
Loose skin closure (skin graft where necessary)
Adequate drainage
Nonconstricting dressings
FIGURE 8. Routine postoperative replant dressing in place, digits exposed for observation,
and limb appropriately elevated.
appropriately splinted to effectively immobilize the part yet permit adequate visualization
of the distal extremity for viability examination36 (Figure 8).
Digital color, capillary refill, and skin temperature (recorded by an externally applied
FIGURE 9. Externally applied thermocouple as utilized to record digital temperatures.
thermocouple) are carefully monitored and charted — hourly the first day, every 2 hr the
second day, then every 4 hr19-3739 (Figure 9). Skin temperature may rise slowly in the
immediate postsurgical period, but persistent readings below 30°C 2 hr after leaving the
operating room or any time thereafter connotes vascular compromise and a need for surgical
reexploration if loosening of the dressing is not beneficial. Likewise persistent signs of
venous occlusion (rapid capillary refill, throbbing sign, deep pink color of nailbed) or arterial
occlusion (slow capillary refill, palor of nailbed, digital coolness) necessitate reexploration
if not reversed by dressing alteration.19-31'32'40'41
There is unequivocal evidence substantiating the adverse small vessel vasoactive effect
of nicotine.42 Smoking of any tobacco product must therefore be prohibited for a reasonable
period of time (at least 3 weeks and preferably permanently) postoperatively.
Although a debated issue is the efficacy of various medications used in the postoperative
period to assist in maintaining circulation in the replanted part, there is certainly a movement
away from the routine use of anticoagulants and vasoactive drugs, a movement that we view
favorably.
Untidy wounds are the rule in replantation surgery and, in spite of extensive and apparently
adequate surgical debridement, contaminants often persist. For this reason routine broad
spectrum parenteral antibiotic coverage is initiated preoperatively and maintained through
the 3rd postoperative day when coverage is changed to oral medication for at least an
additional 7 days.
Dressings are customarily changed on about the 3rd postoperative day and the patient is
allowed to return home 5 to 7 days (minor limb replant) or 10 to 14 days (major limb replant)
Volume I 313
Table 5
OVERALL SURVIVAL
IN ATTEMPTED
REPLANTATIONS
Louisville, 1975—1980
Survival
Total (%)
Minor 260 85.6

Major 26 62.0
Table 6
FUNCTIONAL
RESULTS IN MINOR
LIMB REPLANTATION
Louisville, 1975—1980
Category Percentage
Excellent 38.1
Good 45.2
Fair 12.9
Poor 3.8
following surgery if convalescence is progressing uneventfully. Rehabilitation measures,

informally begun in the immediate postoperative period, are instituted on an individual basis
with mechanism and extent of injury, quality of postoperative wound healing, psychological
composition of the patient, etc. determining the type and intensity of therapy.
RESULTS OF REPLANTATION
Survival of minor replantations (those distal to the wrist) now approaches 95% in most
centers whereas major replantations (those proximal to the wrist or in the lower extremity)
are less successful. Salvage procedures, or those attempted under very adverse conditions,
culminate in a viable replanted part approximately 50% of the time. Table 5 presents survival
figures at one institution for the period 1975 through 1980.
Survival rates in replant surgery have vastly improved in recent years and are continuing
to improve. Functional recovery is therefore rightfully receiving increasing attention and is
an area where much progress remains to be made. Sensory return and joint mobility are the
major objective considerations related to the patient's functional ability, with subjective
symptomology such as cold intolerance or chronic pain being of equal functional significance
in some cases. Tabulations of functional results of our recent (1975 to 1980) experiences
in minor replantation surgery are presented in Table 6 and are based on the patient's ability
to return to work with a two-point discrimination of 12 mm or better.
The surgeon plays a major role in determining the degree of functional recovery expe-
rienced by the patient. Nerve regeneration and the speed thereof is not only dependent upon
the patient's age and the extent of neural damage but also upon the accuracy of neurorrhaphy.
Functional repair of muscles and tendons, prevention of excessive compartmental pressures
that result in myofibrosis by appropriate use of fasciotomies and drains, avoidance of con-
stricting dressings, postoperative limb elevation to avoid excessive edema, and employment
of an early, progressive rehabilitation program are all under the surgeon's command and
greatly influence the overall outcome in replantation surgery.
SUMMARY
Replantation of severed parts has proliferated since first reported in 1962. As success
rates have increased, the surgeon's responsibility has shifted from achieving reattachment
to attaining functional return.
The surgeon considering replantation must be aware of the contraindications to such
surgery. Absolute contraindications include significant associated trauma, extensive crush,
multiple levels of injury, extensive degloving of the part and poor general health. Relative
contraindications include the elderly, single-digit amputations excluding the thumb, serious
systemic illness, and avulsion. Other relative contraindications are prior injury to the am-
putated part, prolonged warm ischemia time, extreme contamination, and psychiatric disease.
Once a decision has been made that replantation may be possible, the part should be
cooled to 0 to 4°C. The patient must be stabilized, associated injuries managed, intravascular
volume replenished, antibiotics administered, and tetanus prophylaxis assured.
Replantation is best done under regional anesthesia which offers the advantage of local
sympathetic blockade. As any wound, debridement of nonviable structures is essential.
Surgical exposure should be generous.
In digital replantation, bone fixation is usually done first. The method should be solid
and allow early motion. Periostium should be repaired. Tendon repair follows. Only then
are arteries, nerves, and veins anastomosed. Finally, skin closure by direct approximation,
graft, or flap is done.
Only healthy intima lends itself to successful microvascular anastomosis. Avulsion in-
juries, especially common in thumb amputations, produce extensive intimai injury. Vein
grafts should be used liberally when intimai injury is suspected.
Transmetacarpal amputations require special care. Rotational deformity in particular must
be avoided at this level and demands tedious reduction and fixation. Hematoma is common
at this level and can be avoided by ligating the cut end of the metacarpal artery or by ligating
the communicating branch between common digital and palmar metacarpal arteries.
Amputation at the wrist requires special care in bone fixation. Options include fusion,
proximal row carpectomy, and shortening of the radius.
Forearm and lower-extremity amputations are major limb replants. These involve large
muscle masses and warm ischemia times tolerable are much decreased, rarely exceeding 6
hours. Fasciectomies should always be considered in such patients.
Postoperatively, compressive dressings are to be avoided. Skin temperature measurement
is the primary means of replant monitoring. Antibiotics are administered but anticoagulants
and vasoactive drugs are rarely employed.
At present, replants distal to the wrist exceed 90% success rates in most centers. Those
done proximally fare less well.
As the rates of success have climbed, attention has shifted from the attainment of a viable
reattached part to the achievement of useful functional return. It is here, in improving sensory
return, joint mobility, and cold intolerance that the greatest gains will be made.
ACKNOWLEDGMENT
We wish to thank Doctors Harold Kleinert, Joseph Kutz, Erdogan Atasoy, Graham Lister,
and Thomas Wolff for permitting reviews of their patients in preparing this manuscript; also
Grace Ascher for creation of the excellent illustrations; and Doris Petty for typing the
manuscripts.
Volume I 315
REFERENCES
1. Malt, R. A. and McKhann, C. F., Replantation of severed arms, JAMA, 189, 716, 1964.
2. Jupiter, J. B. and Kleinert, H. E., Major limb replantation, unpublished data, 1980.
3. Tamai, S., Hori, Y., Tatsumi, Y., Okuda, H., Nakamura, Y., Sakamoto, H., and Takita, J., Major
limb, hand, and digital replantation, World J. Surg., 3, 17, 1979.
4. Ch'ien, Y. C , Ch'en, C. W., and Lin, C. T., Some problems concerning small vessel anastomosis in
the reattachment of traumatic amputation, Chin. Med. J., 85, 79, 1966.
5. Lister, G. D. and Kleinert, H. E., Replantation, in Plastic Surgery, 3rd éd., Little, Brown, Boston, 1979,
679.
6. Kleinert, H. E. and Jupiter, J. B., Replantation — an overview, unpublished data, 1980.
7. Kleinert, H. E., Present indication and contraindications for replantation as reflected by long-term functional
results (Louisville experience), in press.
8. Gelberman, R. H., Urbaniak, J. R., and Bright, D. S., Digital sensibility following replantation, J.
Hand Surg., 3, 313, 1979.
9. Usui, M., Ishii, S., Muramatsu, I., and Takahata, N., An experimental study on "replantation toxemia".
The effect of hypothermia on an amputated limb, J. Hand Surg., 3, 589, 1978.
10. O'Brien, B. M., Replantation surgery of limbs, in Microvascular Reconstructive Surgery, Churchill Liv-
ingstone, Edinburgh, 1977, 124.
11. Pho, R.W.H., Chacha, P. B., Yeo, K. Q., and Daruwalla, J. S., Replantation of digits using micro-
vascular technique, Ann. Acad. Med., 8, 398, 1979.
12. Leung, P. C , Prolonged refrigeration in toe-to-hand transfer — case report, J. Hand Surg., 6, 152, 1981.
13. Tsai, T. M. and Tomita, Y., Delayed transfer of latissimus dorsi free flap — an experimental study,
unpublished data, 1980.
14. May, J. W. and Gordon, L., Palm of hand free flap for forearm length preservation in nonreplantable
forearm amputation: a case report, J. Hand Surg., 5, 377, 1980.
15. Biemer, E., Experience in replantation surgery in the upper extremity, Ann. Acad. Med., 8, 393, 1979.
16. Jaeger, S. H., Tsai, T. M., and Kleinert, H. E., Upper extremity replantation in children, unpublished
data, 1980.
17. Godfrey, A. and Kleinert, H. E., Replantation of the digits and hand, unpublished data, 1980.
18. Kutz, J. E., Preparation for replantation, in Symposium on Microsurgery, C. V. Mosby, St. Louis, 1976,
14.
19. Weiland, A. J., Villarreal-Rios, A., Kleinert, H. E., Kutz, J. E., Atasoy, E., and Lister, G. D.,
Replantation of digits and hands: analysis of surgical techniques and functional results in 71 patients with
86 replantations, J. Hand Surg., 2, 1, 1979.
20. Ferreira, M. C , Marques, E. F., and Azza, E. J., Limb replantation, Clin. Plast. Surg., 5, 211, 1978.
21. Lister, G. D., Techniques in replantation, nerve grafting and microsurgery, in A Practice of Hand Surgery,
Blackwell Scientific, Edinburgh, 1977.
22. Lister, G. D., Interosseous wiring of the digital skeleton, J. Hand Surg., 3, 427, 1978.
23. Tamai, S., Digit replantation, Clin. Plast. Surg., 5, 195, 1978.
24. Leung, P. C. and Kok, L. C , Use of an intramedullary bone peg in digital replantations, revascularizations,
and toe-transfers, J. Hand Surg. ,6, 281, 1981.
25. Lister, G. D., Kleinert, H. E., Kutz, J. E., and Atasoy, E., Primary flexor tendon repair followed by
immediate controlled mobilization, J. Hand Surg., 2, 441, 1977.
26. Lundborg, G., Hansson, H. A., Rank, F., and Rydevik, B., Superficial repair of severed flexor tendons
in synovial environment, J. Hand Surg., 5, 451, 1980.
27. Wang, S. H., Young, K. F., and Wei, J. N., Replantation of severed limbs — clinical analysis of 91
cases, J. HandSurg., 6, 311, 1981.
28. Cabaud, H. E., Rodkey, W. G., McCarroll, H. R., Jr., Mutz, S. B., and Niebauer, J. J., Epineural
and perineurial fascicular nerve repairs: a critical comparison, J. HandSurg., 1, 131, 1976.
29. Rodkey, W. G., Cabaud, H. E., and McCarroll, H. R., Neurorrhaphy after loss of a nerve segment:
comparison of epineurial suture under tension versus multiple nerve grafts, J. HandSurg., 5, 366, 1980.
30. Poppen, N. K., McCarroll, H. R., Doyle, J. R., and Niebauer, J. J., Recovery of sensibility after
suture of digital nerves, J. HandSurg., 4, 212, 1979.
31. McFarlane, R. M. and Mayer, J. R., Digital nerve grafts with the lateral antebrachial cutaneous nerve,
J. HandSurg., 1, 169, 1976.
32. Kleinman, W. B., Replantation and revascularization, in Practical Hand Surgery, Yearbook Medical
Publishing, Chicago, 1980, 101.
33. Schlenker, J. D., Kleinert, H. E., and Tsai, T. M., Methods and results of replantation following
traumatic amputations of the thumb in 64 patients, J. HandSurg., 5, 63, 1980.
34. Lister, G. D., personal communication, 1980.
35. McNeil, I. F. and Wilson, J. S. P., The problems of limb replacement, Br. J. Surg., 57, 365, 1970.
36. Jupiter, J. B. and Tsai, T. M., Replantation: an overview (the Louisville experience), unpublished data,
1980.
37. O'Brien, B. M. and Miller, G. D. H., Digital reattachment and revascularization, J. Bone JT. Surg.,
55(A), 714, 1973.
38. Stirret, C. R., Seaber, A. V., Urbaniak, J. R., and Bright, D. J., Temperature monitoring in digital
replantation, J. Hand Surg., 3, 342, 1978.
39. Kleinert, H. E., Juhala, C. A., Tsai, T. M., and Van Beek, A., Digital replantation — selection,
techniques, and results, Orthop. Clin. North Am., 8, 309, 1977.
40. Tsai, T. M., A complex reimplantation of digits: a case report, J. Hand Surg., 4, 145, 1979.
41. Leung, P. C , The "throbbing sign" — an indication of early venous congestion in replantation surgery,
J. Hand Surg., 4,409, 1979.
42. Saran, C. L., et al., Effect of smoking on digital blood-flow velocity, JAMA, 229, 1329, 1974.
Volume I 317
SECOND TOE AUTOTRANSPLANTATION TO REPLACE MISSING FINGERS
Ryszard Kociçba, Deodatâpczyñski, Janusz Kaczmarzyk,

Lidia Wilowska-Kociçba, and Jerzy Jar>técki
INTRODUCTION
The thumb is the most important finger on the human hand. It is the possession of a
functional and properly formed thumb which distinguishes our hand from that of anthropoid
apes except for the chimpanzees. The loss of a thumb is tantamount to the loss of about
35% of the functional value of the hand!314 This type of mutilation constitutes one of the
biggest and most important problems in reconstructive surgery of the hand. Man deprived
of his first finger, despite having the rest of his fingers undamaged, cannot perform any
precise movement.1-2'6
There is a long history of reconstructive operations on the thumb. They have all been
able to restore only a partial fitness of the hand or improve its cosmetic look without affecting
its functional value. 23 It was the development of microsurgery that established the full
possibility of reconstructing the amputated thumb. 5 ' 7911 The development in the clinical
practice of the second toe-to-hand transplant is the most successful solution of the problem
and revolutionizes all other methods of treatment of this mutilation.4
The literature on toe-to-hand transplants is becoming richer every day and because of this
we regard it as repetitous to once again mention everything available in various publications.
Therefore, one should not treat our paper as a complete presentation of the problem but
rather as a discussion of specific problems selected by us.
The development in our center of some new techniques in these operations has widened
the indications for carrying out autotransplants.
Other new possibilities for toe-to-hand autotransplants are, for example, the transplantation
of the second toe for reconstruction of congenital defects of a hand with adactylia as well
as the reconstruction of a hand with traumatic loss of all the fingers and the metacarpals,
save for the wrist bones. 1517
Toe-to-hand transplants, and particularly those of a second toe, represent many advantages:
1. A highly functional thumb permitting pinch and grasp

2. Excellent innervation of a reconstructed thumb
3. Rapid and satisfactory restoration of wounded parts
4. Any length of transplant depending on the size of postamputated stump or the length
of other fingers, can be obtained
5. No static disorders of the foot resulting from the loss of the toe can be found
6. The excellent cosmetic effect1314
No essential contraindications for this surgical procedure can be found. The authors here
have stressed that the operation is rather long and exhausting for the surgical team as we
oppose having each stage of the operation performed by different specialists such as or-
thopedic surgeons,9 vascular surgeons, and neurosurgeons. The team should bear in mind
the whole effect of the operation otherwise a satisfactory result cannot be achieved.14
The indications for the second toe-to-hand transplants are as follows:
1. Traumatic amputation of a thumb (Figure 1)

2. Amputation of the second to fifth fingers with a left thumb (the transplant of the second
toe in place of the second finger, permitting a pinch) (Figures 2, 3, and 4)
FIGURE 1. Traumatic amputation of a thumb.
3. Amputation of all fingers at different levels (Figure 5) as far as to the first row of the
wrist bones with the unaffected radiocarpal joint (Figure 6)
4. Congenital defects of the hand in which the carporadial joint and part of the wrist are
unaffected (Figure 7)
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FIGURE 2. Traumatic amputation of fingers two to five with an impaired movement ability
of the fourth and fifth fingers.
SURGICAL T E C H N I Q U E OF THE SECOND T O E - T O - H A N D

TRANSPLANTATION
The operation can be performed by one team working separately on each stage of the
operation or by two or more teams working simultaneously provided they are in constant
communication and are interchangeable and interdisciplined.16 In each case, the preoperative
checkup and marking of the vessels on the wrist level as well as on the foot is necessary.
For anastomosis, patent arteries and veins are required. The radial artery and radial web of
veins on the hand and dorsal artery with a large saphena vein are preferable.416
Our material indicates that the transplantation of the second toe cannot be performed in
all patients previously qualified for the transplantation. In some cases we have met, while
FIGURE 3. Traumatic amputation of fingers three to five with an im-

paired movement ability of the second finger.
operating, anatomical defects of the dorsal artery in the form of a poorly developed arcuate
branch of the anterior tibial artery. These anatomical defects are usually present on both
feet and make such transplants unfeasible. As an alternative procedure we can resort to the
great toe transplantation. Foucher and Merle10 and Gilbert11 have described the variations
of the dorsalis pedis artery. In this context, the operation should be started with identification
of the vessels supplying the area of the toe which ensures the possibility of the transplant.
Removal of the Second Toe

The incision from the dorsal aspect is recommended to be started a little above the point
of a well-palpable pulse of the dorsal pedis artery where it curves down to the first metatarsal
bone. From the plantar aspect a straight-line incision as far as the Chopartsche line is
preferable. Such an incision provides good access to the toe enabling its dissection, reduces
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FIGURE 4. Traumatic amputation of fingers from two to five with an

unaffected thumb.
the pain after the operation, and prevents calluses from appearing (Figures 8 and 9). It is
necessary to isolate from the dorsal aspect the following anatomical elements of the toe:
1. One vein tributary of the great saphenous vein

2. The dorsal cutaneous nerve branches of the superficial perineal nerve, which becomes
the dorsal digital nerve for the first to third toes
3. The extensor longus and brevis tendons of the second toe
4 The dorsal pedis artery which forms the arcuate artery and the branches of this artery
(metatarsal arteries)
FIGURE 5. Traumatic amputation of all fingers at different levels.
FIGURE 6. Amputation of the metacarpum extending to the first row of the wrist bones.
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FIGURE 7. Congenital defects of a hand.
Special difficulties may be encountered while operating on the level of the metatarsal
bones and at the ligation of the branch of the plantar profundai artery and numerous branches
of the dorsal metatarsal arteries. There is a real danger of causing lesions of some branches
resulting in the failure of the operation at its very beginning or in the postoperative course
in the form of various complications.
Meticulous identification of particular branches and proper ligation of both veins and
arteries on this level is necessary. From the plantar aspect, after the incision of plantar
aponeurosis, the medial plantar nerve and its branches to the second toe and both flexors
should be identified. All these elements should be harvested as long as possible in order to
avoid possible problems in the further stages of the operation. Interosseous muscles are
exfoliated from the metatarsal bones. For the time period of preparation of the recipient area
on the hand, the isolated second toe has an unbroken blood supply maintained by the isolated
arteries and veins. In this way the efficiency of circulation in this new condition is maintained.
At the moment of taking the graft, the blood supply is broken, the arteries and veins are
peripherally ligated, and a metatarsal bone is cut with a surgical saw at the required level.
Preparation of Recipient Area on the Hand

The incisions are done over the planned anastomoses of the anatomical elements of the
hand with those of the graft (Figures 10 to 13). The anatomical elements of the hand which
should be isolated and then anastomosed with those of the toe are as follows:
FIGURE 8. Recommended incision on a foot for harvesting the second toe for a transplant: (1) the dorsal
pedis artery and (2) the large saphena vein.
1. One artery
2. One vein
3. One branch of the medial and radial nerve or both digital nerves when present at the
level of the planned bone fixation
4. The extensor and flexor tendons of the amputated thumb
5. The peripheral part of the metatarsal or carpal bone
The Proper Procedure of Transplantation

At the moment of breaking the blood supply to the toe and bringing it to the field, the
proper transplantation starts. In the toe, ready for grafting, a perfusion is done with low-
molecular-weight dextran/heparin at the temperature of about 10°C. We believe that hy-
pothermy protects the transplant from acute ischemia. The other essential element of the
procedure is the contouring of the proximal end of the metatarsal bone to the slope of about
65° in order to prevent graft rotation and to achieve its most physiological position. The
stable bone fixation is accomplished by creating in both bone ends a thread channel for a
screw which is then located in the bone of the hand. The toe is then screwed in and in this
way attached to the first or second metacarpal bone or to the trapezium bone (Figures 14
to 17). The authors consider this method to be very advantageous for the following reasons:
1. We achieve very strong and stable fixation of the bones.

2. The possibility of local infection is decreased by elimination of contact of the metal
junction piece with the skin.
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FIGURE 9. The right foot after the toe has been harvested for a transplant.
3. Rehabilitation is possible as early as the 2nd or 3rd day after the operation.
4. The time required for performing the fixation is shorter as compared to that where
other methods are applied.
5. The articular surfaces are left untouched, unlike with the K-wire operations.
The only disadvantage considered is the difficulty of removing this junction piece in case
of bone infection. Following this technique, we haven't observed any complications. The
fixation locus is covered by previously exfoliated periostium of the metatarsal bone. The
long extensor and flexor tendons of the toe are then anastomosed to their counterparts in
the hand. The extensor anastomosis should be done under slight tension, positioning the
graft in an extensor position. In this way, the flexor predominance is counteracted. The
flexor and extensor policis brevis are excised. The anastomosis on a wrist level is recom-
mended, if possible. Such a technique seems to ensure a better mobility of the grafted toe.
A good tactile sense makes its value even greater. We have made it a rule to anastomose
as many neural bundles as possible. In cases when the recipient area lacks neural bundles,
we derive them from the nearest sensitive neural trunk, but only the required number. After
having introduced this method, excellent innervation is observed in both the graft and donor
nerve area. In performing the neural anastomoses an exact adaption of neural bundles should
be done to avoid neuromas (Figure 18).
FIGURE 10. The incision lines on a hand for second toe-to-hand transplants to replace the amputated thumb: (1)
and (3) — incisions for anastomosing nerves and bones, (2) — incision for anastomosing the extensor vein and
the nerve; and (4) — incision for anastomosing the artery and flexors.
FIGURE 11. The incision lines for second toe-to-hand transplant to replace the missing index finger: (1) and (3)
— incision for anastomosing nerves and bones; (2) and (5) — incisions for anastomosing the extensor, the vein,
and the nerve; and (4) and (6) — incisions for anastomosing the artery, the nerve, and the flexor tendon.
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FIGURE 12. The incision lines for second toe-to-hand transplant to replace the missing fifth finger: (1) and (4)
— incision for anastomosing nerves and bones; (2) and (3) — incisions for anastomosing the artery and the flexor;
and (5) and (6) — incisions for anastomosing the vein, the nerve, and the extensor.
FIGURE 13. The incision lines for second toe-to-hand transplant in the case of amputation on a wrist level: (1)
and (3) — incision for fixation of bones; (2) — incision for anastomosing the nerve, the vein, and the extensor;
and (4) — incision for anastomosing the artery, the nerve, and the flexor extensor.
The crucial point of the grafting are the vascular anastomoses. We always anastomose
the veins first. The largest possible veins available are preferable. The locus of anastomosis
depends largely on the length of the grafted vein pedicle. The anastomosed vein-artery ratio
is 1:1. We believe that methods different from end-to-end anastomosis lead to complications,
such as thrombi. With a successful anastomosis of the dorsal artery to the radial one per-
formed, with the same techniques, the fundamental part of the operation is completed.
Wound margins are closed loosely but not before the blood circulation in the graft has been
stabilized, equalizing its temperature to the one on the hand. The skin defect on the hand
is covered with a medium-thickness skin graft taken from the thigh. A molded plaster splint,
which must not evoke any circular disorders in the graft, immobilizes the wrist in a com-
fortable position (Figure 19).
FIGURE 14. The recommended method of fixation of the graft bones with the first metacarpal
bone performed by the internally located screw.
POSTOPERATIVE TREATMENT AND SURVIVAL CRITERIA
Postoperatively the patient receives antibiotics, vasodilators, and analgesics. We do not

use anticoagulants because of their side effects, such as serious local bleeding and hematomas
which result in blood circulation disorders in the graft. The most important element of the
postoperative treatment seems to be a constant monitoring of the color, temperature, and
capillary filling. Any change in these must be brought to the attention of the staff as only
the immediate reexploration of the vascular repairs may be lifesaving for the digit. The
transplanted digit has usually the same or a bit higher temperature than the original thumb.
It is slightly edemic when compared with its analogue in the foot. A pulse of the digital
artery is easily palpable. Discoloration in the form of lividity and increasing swelling indicate
a venal insufficiency, whereas paleness and tissue flaccidity (wrinkled skin) point to an
arterial insufficiency, even in the form of occluding the arterial circulation.
An uncomplicated postoperative course makes rehabilitation of the digit possible 2 to 3
days after the operation. The extent of movement is subsequently broadened. The immo-
bilizing plaster cast is removed 3 to 4 days later depending on the local condition. The stable
fixation of bones with a screw makes such an early rehabilitation feasible.
Volume I 329
FIGURE 15. The condition 5 months after the successful second toe-
to-thumb transplantation.
FIGURE 16. The second toe-to-hand transplant in a con-

genital defect of a hand.
COMPLICATIONS
The following are early and late postoperative complications. The early complications are
1. Blood circulation disorders resulting from improper positioning of the transplant in

the plaster cast
2. A clot in the veins
3. A clot in the arteries
4. An inflammatory reaction in the location of anastomosis
5. Necrosis of the transplant as a result of the complications mentioned above
The late complications are
1. An inflammatory reaction in the wound and bones

Volume I 331
FIGURE 17. The second toe-to-hand transplant in the amputation of all fingers.
The graft is removed without a metatarsal bone.
2. Necrosis of the transplant

3. Failure in repair of tendons
4. Failure in innervation
RESULTS
The results of the second toe-to-hand transplants are excellent, as was already stressed.
The operation helps the hand with a missing thumb to regain its function, enabling the
performance of precise movements. The return of a patient to his previous profession is not
uncommon.1314 In patients who sustained the loss of all their fingers, as in one of our cases
(together with metacarpal bones), or in patients with congenital defects of the hand, self-
help is again enabled. Returning to a professional job requires, in these cases, a broad self-
adjustment (Figures 20 to 26).
FIGURE 18. The authors' method of anastomosing the sensory nerve of the toe (2) with the cutaneous branch
of the radial nerve (1).
SUMMARY
The authors present the autotransplantation of the second toe to replace the missing thumb
as an optimal solution for this serious hand mutilation.
The qualifications, indications, technical problems of the operation and, as far as its
complications and methods of treatment are discussed.
The authors' own method of bone fixation in this type of operation and postoperative
management are discussed. The results achieved are evaluated as very good.
Volume I 333
FIGURE 19. A molded plaster cast stabilizing the hand after the autotransplantation.
FIGURE 20. The traumatic amputation of a thumb.

Volume I 335
FIGURE 21. The view of the same hand 5 weeks postoperatively.

FIGURE 22. Amputation of all fingers with part of the fifth finger left.
FIGURE 23. Late postoperative photograph of the hand in Figure 22 after successful transplant of the second
toe-to-the-hand. Demonstration of a pinch.
Volume I 337
FIGURE 24. Amputation of both hands at the wrist level, late view after the trauma.
FIGURE 25. The authors' method of pinning the grafted toes with the wrist bones. The proper thumb length is
taken into consideration (see Figure 24).
FIGURE 26. The final result of the surgery on the patient in Figure 24. The missing parts of the hand are
successfully replaced by a modeled prosthesis.
REFERENCES
1. Biemer, E. and Duspiva, W., Replantationen an der oberen Extremitat durch microvasculare anastomosen,
Chirurgische Praxis, 22, 281, 1977.
2. Biemer, E., Klassifizierung von totalen und subtotalen Amputationen, Hand Chirurgie, 9, 21, 1977.
3. Biemer, E., Replantationen von Fingern und Extremitatenteilen — Technik und Ergebnisse, Chirurg, 48,
353, 1977.
4. Buncke, H. J., Free toe-to-hand transfers, Plast. Reconstr. Surg., 14, 14—18, 1974.
5. Buncke, H. J., Free toe-to-hand transfers, in Symposium on Microsurgery, Daniller, A. and Strauch, B.,
Eds., C. V. Mosby, St. Louis, 1976 .
6. Bunnel, S., Intrinsic muscles of the hand; loss of the thumb; and methods of repairing, in Surgery of the
Hand, Vol. 10, Lippincott, Philadelphia, 1944, 371—397.
7. Chien, C. W., CH'en, Y. C , Pao, Y. S., and Lin, C. T., Further experience in the restoration of
amputated limbs, Clin. Med. J., 3, 225, 1965.
8. Cobbett, J. R., Free digital transfer; Report of a case of transfer of a great toe to replace an amputated
thumb, J. BoneJt. Surg., 51B, 677,1969.
9. Cobbett, J. R., Two free transfers, in Trans. 5th Int. Cong. Plastic Surgeons, Hueston, J. T., Ed., London,
1971.
10. Foucher, G. and Merle, M., Transfert articulaire au niveau d'un doigt en microchirurgia, Groupe d'A-
vancement Microchirurgie, Plast. Reconstr. Surg., 616—626, May 1980.
11. Gilbert, A., Composite tissue transfers from the foot; anatomic basis and surgical technique, in Symposium
on Microsurgery, Damiller, A. and Strauch, B., Eds., C. V. Mosby, St. Louis, 1976, 230—242.
12. Harii, K. and Ohmori, S., Successful clinical transfer of ten free flaps by microvascular anastomosis,
Plast. Reconstr. Surg., 53, 259, 1974.
13. Kociçba, R^^^pczynski, D., Kaczmarzyk, J., Wilowska-Kociçba, L., Mozalewski, P., Çlbwacki,
P., Kuniewska, B., Józefczyk, H., and Olipra, A., Transfer of toe to replace amputated thumb — optimal
solution for restitution of hand function (original in Polish), paper presented at the 16th Symp. Hand Surgery,
Warszawa, 1979.
Volume I 339
14. Kociçba, R., âpczynski, D., Kaczmarzyk, J., Wilowska-Kociçba, L., Kuniewska, B., Mozalewski,
P., Çfbwacki, P., Józefczyk, H., Olipra, A., Qlbwacka, E., Jablecki, J., and Kaczmarzyk, L., Transfer
of toe to replace amputated thumb-optimal solution for restitution of hand function, paper presented at the
50th Congr. Polish Surgeons, Krakow, 1980.
15. Kociçba, R., Lapczynski, D., Kaczmarzyk, J., Wilowska-Kociçba, L., Olipra, A., Kuniewska, B.,
Mozalewski,,P., Glowacki, P., Józefczyk, H., Jablecki, J., and Glowacka, £., New possibilities of
treatment of missing thumb, paper presented at the 15th Conf. Sect. Plast. Surg. Soc. Polish Surgeons,
Lodz, 1980.
16. Kutz, J. E., Preparation for replantation , in Symposium on Microsurgery, Damiller, A. and Strauch, B.,
Eds., C. V. Mosby, St. Louis, 1976.
17. O'Brien, B. M., McLeod, A. M., and Hayhurst, J. W., Clinical replantation of digits, Plast. Reconstr.
Surg., 52,490, 1973.
Volume I 341
SOME ASPECTS OF UPPER LIMB AND FINGER REPLANTATION
Ryszard Kociçba, Janusz Kaczmarzyk, Deodat tâpczynski,

Lidia Wilowska-Kociçba, and Jerzy Jah/ecki
INTRODUCTION
The hand makes life, work, and pleasure possible for man. It is the conveyer of artistic
emotions and feelings, and for a blind person it is his eye and guide. On many occasions
we realize this even when a small injury to one finger renders our hand unfunctional.
Therefore, what happens when a part or all of it is lost? Amputation of the hand represents
not only the physical loss which makes a man an invalid but also a psychological problem
often causing loss of self-esteem to a degree which is not met even in such drastic forms
such as amputation of the lower extremities. These findings were extrapolated in the very
numerous letters we received from people, who during their lifetime lost an upper extremity,
asking us to perform a transplant from a corpse.
Since 1970 problems on the replantation of extremities and their procedures have been
considered, such that several years of working experience in this field has permitted us to
give our own personal views on general and specific problems such as the qualification of
patients for this procedure, the operation itself, and the postoperative procedure.27
The literature on replantation becomes richer every day and because of this we regard it
as repetitious to once again mention everything available in various publications. The fol-
lowing paper therefore deals with problems which are rarely presented by authors, and those
which on the basis of our experience may become a trap for the surgeon preparing to perform
such a procedure. One should not treat our paper as a complete presentation of the problems,
but rather as a discussion of specific problems selected by us.
QUALIFICATIONS FOR REPLANTATION OF EXTREMITIES OR FINGERS
In qualifying an extremity or finger for replantation we must take into consideration above
all the value it will serve after the operation. We must ask ourselves if it will be able to
fulfill its function even to a minimal degree. For this reason, the most important evaluation
is on the state of the nervous system after trauma. One should not qualify for replantation
of those extremities in which the peripheral nerves were ripped from the central or peripheral
systems 4713 (Figures 1 and 2). In such nervous system trauma the extremity does not return
to its specific function even if we perform anastomosis as quickly as possible.8 However,
in trauma due to segmental compression and laceration of nerves, one should maintain great
care in disqualification as to not take away the patient's last chance. A very difficult problem
is qualification of crushed extremities. We are of the opinion that the above mentioned
transversal compression of the extremity is a destruction of one of its parts or multilacerations
at various sites (Figures 3 and 4). The evaluation depends upon which part of the extremity
the trauma occurs at. One should understand that this means that the decision to remove the
laceration and to replant implies that the extremity will continue to fulfill its function after
replantation.10*17 We will try to treat this problem beginning with the fingers. In qualifying
the fingers one should take into consideration the thumb. It has separate requirements for
qualifications than fingers two to five due to its special functions. A common requirement
in qualifying fingers is that their movable parts and nerves are maintained in a state in which,
after the replantation, one can assure normal functional movements and innervation.7 All
necessary shortenings of the fingers also including injury to the joints have a rather poor
prognosis and one should take great care for qualifying them for replantation.
FIGURE 1. Amputation of an extremity with the peripheral avulsion of nerves.
FIGURE 2. Amputation of an extremity with the central avulsion of nerves (from plexus).
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FIGURE 3. Transversal crush of an extremity with a tissue loss.
FIGURE 4. Amputation of an extremity with its multifocal crush.

FIGURE 5. The left hand 5 weeks after second toe-to-hand transplant replacing the am-
putated thumb. Compare with the unaffected right hand.
Replantation of the thumb with regard to its opposition function in relation to the rest of
the fingers should be more compassionately decided than replantation of the remaining fingers
and should take into account at least two alternatives.6 One should decide whether replantation
of the thumb will, for certain, fulfill its function or will it be better for the patient to perform
the other possible procedure — autotransplantation of a toe from a foot. The decision whether
to perform the operation or to disqualify the patient is exceptionally difficult (Figure 5). It
is for certain that the requirements for replantation become less for fingers two to five due
to the possibility of replacing the function of the amputated finger by the rest of the fingers.
However, one should keep in mind cosmetic results and all eventual wishes of the patient.
This refers only to the amputation of one finger.
A different problem is the amputation of all the fingers from two to five. In such a situation
every possibility of joining the fingers back to their positions or their transposition should
be very carefully decided. Here one should also not forget the possibility of transplanting
a functional toe from the lower extremity.
A transamputation across the hand gives us a greater possibility of achieving a good final
result due to the fact that after the replantation the possibility exists for a variety of procedures,
and unfortunately difficult corrective operations in the case of posttraumatic defects of the
tendons or nerves. It is necessary to remember that we are dealing here with the entire hand,
lack of which gives greater mutilation than the loss of fingers, and the possibility of the
reconstructoplasty are incomparably less.11 The most important problem in this type of
amputation is the evaluation of the vascular state of the arteries as well as the veins in the
amputated part. It is not permissible to overlook additional injures which may prohibit the
normal circulation in the amputated part. These additional traumas often cause large doubts
during qualification because they are the cause of serious complications and even postop-
erative failures. In such cases we always perform artériographie studies with the venous
phase of the amputated part. 811 Such artériographie studies clear up those doubts (Figures
6 and 7). Unfortunately, in opposition to more proximal amputations, we do not have here
many possibilities in performing shortenings of the arm if the amputation is accompanied
Volume I 345
FIGURE 6. Amputation with the multifocal vessels' lesions.
by a wide band of destruction. The higher the amputation, the greater the chance of shortening
of the extremity, if necessary.12 The wrist region (the carpeoradial joint) if it was destroyed
by trauma permits us to quite comfortably remove one or two rows of the carpal bones and
even, at times, both rows and to join the metacarpals in a proper replantation position with
the forearm bones (Figures 8 to 13). One should in the meantime evaluate whether it will
be possible to perform anastomoses after they have been shortened.112
In the forearm, especially in the medial and proximal parts, it is possible to perform at
a comfortable degree, the shortening of the extremity by cutting part of it. In our experience
FIGURE 7. Amputation with the monofocal vessels ' lesions — the indication for a replantation.
performing the shortening of the extremity at a point greater than 10 cm gave very good
function with a small cosmetic defect (Figures 14 and 15). One should very carefully maintain
at qualification the extremity in which the trauma took 1/3 of the proximal part of the forearm
and also the elbow joint. In these cases there exists great difficulty in proper reconstruction
of the injured elements, which has a decided negative influence on the final results1212
(Figure 16).
If the level of the amputation is far below the medial arm one can also perform quite a
large shortening of the extremity as there remains in the medial parts enough muscle fibers
Volume I 347
FIGURE 8. Guillotine-type amputation across the wrist.
FIGURE 9. Amputation with a wide band of crush across the wrist.

FIGURE 10. Amputation with a partial loss of wrist bones.
for normal flexion or extension of the elbow joint (Figures 17 to 19). However, if amputation
with compression occurs in the upper third of the arm the case becomes quite serious because
the majority of the muscle ventricles may lose their contractibility and succumb to multiple
adhesions. This pertains above all to the biceps and brachial muscles. The triceps muscle
Volume I 349
FIGURE 11. The same extremity 6 months after the replantation.

FIGURE 12. Amputation with an almost total wrist destruction.

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FIGURE 13. The same extremity 8 months after the replantation.

FIGURE 14. Amputation performed by a tranversal crush of the extremity.
usually is less susceptible to a complete destruction (Figures 20 to 22). Even if the replanted
extremity shows a large deficit in the range of movements there still exists the possibility
of correcting its state through additional procedures (Figures 23 and 24). For us, the problem
of the age of the patient qualified for replantation is quite controversial. We agree with the
statement that the younger the patient the quicker and better is the achieved result. However,
we did operate with good results on a patient above 50 years of age and we are of the
opinion that the decision should be based on the type of amputation and the possibility of
later cooperation with the patient.
FIXATION OF THE BONES
We are adamant supporters of implanting a piece of wire or metal in all sites with the
exception of the wrist region and metacarpals in youngsters.112 In these cases we perform
a strong suturing of the separated parts with slow-absorbing sutures (e.g., Dexon®) which
goes through the ossium and periossium. 81217 Using these procedures in a large number of
cases we achieved very good results with complete healing5 (Figures 25 to 29). Introduction
to the fixation, if necessary, of K wires can be the focus of infection if the wires are brought
through to the external environment,1-314 which is usually the case, and in addition, they
injure the metacarpophalangeal joints.
TENDONS AND MUSCLES
Proper anastomosis of the tendons decides the possibility of introducing very early re-
habilitation, which in a fundamental way prevents adhesions and also muscle atrophy.
Muscles and tendons which do not have a significant role in the function of the extremity
may be removed.8-9, n
Volume I 353
FIGURE 15. The same extremity 6 months after the replantation accom-
panied by a 10-cm shortening of the extremity.
At muscle anastomosis we pay close attention to the role of suturing anatomically similarly
cut ventricles in such a way as not to hinder their blood supply as much as possible. Naturally,
after muscle anastomosis it is required to fix the extremity in an immovable position, but
for the shortest period possible.
PERIPHERAL NERVES
In amputations we basically meet four types of nerve trauma:7,815
1. Diffuse contusion with hyperextended nerves

2. Disruption in the nerve continuity
3. Contusion with disrupted nerve continuity
4. Avulsion of a nerve or nerves peripherally or centrally (from plexus)
FIGURE 16. The crush destruction of the proximal part of the forearm and the elbow joint disqualifying the
extremity for replantation.
FIGURE 17. Amputation on the peripheral one-third part of the arm.

Volume I 355
FIGURE 18. Radiogram for Figure 17.
Our procedure in contused nerves of various lengths limits us to controlling the contused
area for the self-assurance of maintained nerve continuity, and we perform dissection of the
epineural sheath for the purpose of releasing accumulated blood and perineural liquid there.
With this type of procedure we achieved, in all our cases, a satisfying final effect. Disrupted
nerves are always anastomosed in the course of the replantation procedure.116 This procedure
also in a large majority of patients gives very good results. If in the course of rehabilitation
of the extremity we find a lack of innervation in a previously anastomosed nerve, we perform
the procedure of excising the scar and again anastomosing the nerve.713
A separate problem is the procedure for ripped single nerves.15 If we are dealing with its
peripheral rupture we limit ourselves to taking care of its stump, however, if we are dealing
with a central rupture of the nerve accompanied by laceration of remaining nerves we perform
the cutting of all the stumps and fitting all the proper nerve bundles and anastomosing them
in such a way that we join for every single raustral nerve segment, depending on the degree
of possibility, two peripheral nerves (Figure 30). In this way we achieve the satisfying return
of motor and sensory function.
VASCULAR SYSTEM
Despite opposite opinions, we are supporters of perfusing the vascular system at a tern-
FIGURE 19. The result achieved 4 months after the replantation of the extremity (see Figure
17). Wide extent movements in the elbow joint.
perature of 5 to 8°C.2'8,11'17 We do this at every type of amputation of the extremities,

remembering the rules governing this procedure. Beside cleansing of the vascular bed, we
also lower the temperature of the extremity to the level of the perfusing fluid. In order to
maintain the achieved temperature of the amputated part up the moment we join it to the
blood supply, we perform the procedure on a table with a cooled surface.
In diffused traumas, on various levels of the vascular system, we advise the already
mentioned performance of an angiographic study of the arterial-venous network for its
evaluation.67-914 In performing the replantation of the extremity, independent of its height
we try to anastomose as many veins and arteries as possible.811 We admit, however, that
in numerous cases concerning amputation at various heights peripherally from the forearm,
we are forced through necessity to stop at one vein to one artery anastomoses.6-7 Despite
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FIGURE 20. Amputation on the upper part of the arm.
this, the postoperative course is smooth without venous system insufficiency. However, an
amputation in the proximal part of the forearm or an amputation of the arm, for the sake
of keeping the extremity ''alive", it is necessary to anastomose several veins for the purpose
of assuring proper venous drainage for the muscle mass in the replanted part. At times we
must be prepared for the necessity of performing a vein transplant at the site of the destroyed
vein.17
The danger of a sudden appearance in the circulation of accumulated metabolic products
in the blood circulation must be taken into account in the replantation of highly amputated
extremities where we are dealing with large muscle masses. In order to prevent this, before
joining the amputated part of the extremity to the general circulation, we for a moment
perfuse it with the patient's own blood which is evacuated externally through a partly
anastomosed vein.2-3 Using this method we never observed any of the mentioned compli-
cations (Figure 31).
FIGURE 21. The result achieved by the shortening of the arm. Extent of movements. Flexation
of joints.
Ending the procedure, we always implant a drainage tube to the region of performed
anastomoses and always suture the skin only. If we are dealing with a trauma affecting a
large part of the extremity we perform numerous incisions of the fascia and skin.2
FINAL REMARKS
In the postoperative procedure, despite monitoring the circulation in the vicinity of the
replanted extremity and the general state of the patient, physical evaluation of the circulatory
sufficiency in the extremity still remains actual. The extremity should be observed closely
in order to diagnose any complication as early as possible, lest we become disappointed and
upset with the failure of the operation. We believe that in the case of complications, only
a very rapid reoperation is able to remove the complication in a radical manner.
Volume I 359
FIGURE 22. The same patient — the extension of joints.
Passive and active rehabilitation should be initiated between the 2nd and 4th day post-
operatively if the condition permits.
The last problem we want to mention are the corrective procedures which at times are
necessary with the replanted extremity. We are of the opinion that they should be performed
in regard to the specific system and anatomical relations which exist after replantation of
the extremity by the same surgical team which performed the initial procedure. Results of
the replanted extremities, at proper qualification for the procedure, proper operational pro-
cedure, and with a greatly experienced surgeon, are very good and the amount of failure is
realistically minimal.5,910
SUMMARY
The authors present some problems of hand replantation which they encountered in the
course of 12 years of their experience. The authors' own solutions for dealing with these
problems are discussed.
Qualification for replantation is done taking into account prospective function of the
extremity. Technical problems of the anastomosis of particular anatomical systems, especially
vessels, are discussed.
The authors present the method of perfusion of the replanted extremity with the patients'
own blood, recommended in crushing type of the amputation. The problem of finger re-
plantation, thumb especially, is raised as well as the postoperative management.
FIGURE 23. Amputation on the distal one-third part of the arm.

Volume I 361
FIGURE 24. The result achieved after the additional repairing procedures of bones and a skin transplant on the
whole extremity except the hand (27 months after the replantation).
FIGURE 25. The condition after the total amputation across the wrist. The replantation was
performed by applying long absorbing sutures for repairing of the wrist bones.
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/ /
FIGURE 26. Amputation across the metacarpum.

FIGURE 27. The metacarpal bones are stabilized by an internally inserted metal piece; the
current method in use by the authors.
Volume I 365
FIGURE 28. The achieved result 6 months after the replantation — the
extension.
FIGURE 29. The achieved result 6 months after the replantation — the
flexation.
Volume I 367
FIGURE 30. Method of neural anastomosis when one of the nerves is avulsed and
the others are cut off (the authors' method); (1) and (2), the median nerve is cut off;
and (3), the distal part of ulnar nerve is suitable for anastomosis.
FIGURE 31. Perfusion of the replanted part of the extremity with

the patient's own blood.
REFERENCES
1. Ikuta, Y., Method of bone fixation in reattachment of amputations in the upper extremities, Clin. Orthop.
Relat.Res., 133, 169—178, 1978.
2. Kociçba, R., Mozalewskí, P., Wílowska-Kocíçba, L., âpczyñski, D., Jacaszek, M., Kaczmarzyk,
J., and Dajczer-Kaczmarzyk, S., The problems of limb replantation based on own experience, paper
presented at Congr. Polish Surgeons (in Polish), in Rep. 46th Congr. Polish Surgeons, Vol. 2, Lublin,
1972, 728.
3. Kociçba, R., Mozalewskí, P., Wílowska-Kocíçba, L.,âpczynski, D., Jacaszek, M., Kaczmarzyk,
J., and Dajczer-Kaczmarzyk, S., The results of upper limb replantations in the Reimplantation Center in
Trzebnica, paper presented at the 11th Symp. Hand Surgery (Polish), Bull. No. 10, in Rep. on Surgery of
the Hand, Medical Academy in Poznan, 1974, 115—118.
Volume I 369
4. Kociçba, R., Wilowska-Kociçba, L., Mozalewski, P., jZapczyñski, D., Jacaszek, M., Kaczmarzyk,
J., and Dajczer-Kaczmarzyk, S., The principles of qualification for replantation, paper presented at the
12th Symp. Hand Surgery, Warszawa, in Rep. Surgery of the Hand, 1975, Polish Scientific Publishers,
Warszawa-Poznan, 1979, 103—106.
5. Kociçba, R., Mozalewski, P., Wilowska-Kociçba, L., âpczynski, D., Kaczmarzyk, J., Dajczer-
Kaczmarzyk, S., Arendarska, W., Kuniewska, B., and Olipra, A., Late results of upper limb replantation
(in Polish), Proc. 48th Cong. Polish Surgeons, Warsaw, 1976.
6. Kociçba, R., Kaczmarzyk, J., Mozalewski, P., âpczynski, D., Wilowska-Kociçba, L., Dajczer-
Kaczmarzyk, S., Olipra, A., Kuniewska, B., and Glowacki, P., Microsurgery in replantation of upper
limbs and fingers (in Polish), paper presented at the 14th Conf. Plast. Reconstr. Surg., Warsaw, 1978.
7. Kociçba, R., âpczyñski, D., Kaczmarzyk, J., Mozalewski, P., Kuniewska, B., Olipra, A., and
Glowacki, P., Microsurgical techniques in reconstruction of vessels and nerves, paper presented at the
16th Symp. Hand. Surgery, Warsaw, 1979.
8. Malt, R. A., and McKhann, Ch. F., Replantation of severed arms. Classic microvascular surgery and
limb replantation, Clin. Orthop. Relat. Res., 133, 3, 1978.
9. Malt, R. A., Remensnyder, J. P., and Harris, W. H., Long-term utility of replanted arms, Ann. Surg.,
176, 334, 1972.
10. Malt, R. A. and Harris, W. H., Long-term results in replanted arms, Br. J. Surg., 56, 705, 1969.
11. McNeill, I. F. and Wilson, J. S. P., The problems of limb replacement, Br. J. Surg., 5, 57, 1970.
12. Meuli, H. Ch., Meyer, V., and Segmuller, G., Stabilization of bone in replantation surgery of the upper
limb, Clin. Orthop. Relat. Res., 133, 179, 1978.
13. MiUesi, H. and Berger, A., Nerve grafting, microvascular surgery and limb replantation, Clin. Orthop.
Relat. Res., 133,49, 1978.
14. Tamai, S., Hori, Y., Tasumi, Y., Okuda, H., Nakamura, Y., Sakamoto, H., Takita, T., and Fukui,
A., Microvascular anastomosis and its applications on the replantation of amputated digits and hands, Clin.
Orthop. Relat. Res., 133, 106, 1978.
15. Tsai, T., Experimental and clinical application of microvascular surgery, Ann. Surg., 181, 169, 1975.
16. Tsuge, K., Ikuta, Y., and Sakane, M., A new technique for nerve suture, Plast. Reconstr. Surg., 56(5),
497, 1975.
17. Wilson, J. S. et al., Some observations on the autografting of digits and upper limb replantation, Hand,
2, 145, 1970.
Volume I 371
REPLANTATION OF AMPUTATIONS INVOLVING THE UPPER EXTREMITY
Paul G. Lendvay
INTRODUCTION
The Goal of Replantation is Restoration of Function
Carrell and Guthrie's pioneering work in 1908 on replantation and homograft transplan-
tation of dogs' limbs,3 followed by Lapchinsky's successful reattachment of canine extremity
amputations in I960,18 paved the way to the first human clinical success in 1962 reported
by Malt and McKhann.13
With continued improvement in the quality of instrumentation and suture materials, thanks
to Buncke and Schulz2 and Cobbett,4 success in digital reimplantation was inevitable and
Komatsu and Tamai's initial successful replantation of an amputated thumb9 in 1965 was
soon followed by reports of several successful digital replantations.
The late 1960s saw the evolution of surgical techniques striving at improving functional
results in the replanted parts and establishing guidelines of indications for replanting the
amputated parts, and by 1973 several large series of successful digital replants had been
documented.1114
Between 1981 and 1983 an average of 37 patients per annum have been treated in our
unit by replantation surgery following amputations involving the upper limb.
The ensuing chapter is a result of experience gleaned from these cases.
DEFINITIONS
Complete amputation is one in which a composite part is totally severed from the body.
Incomplete amputation is one in which a body part is totally depleted of its vascular
supply with severance of all major vessels and where less than one eighth of its normal skin
attachment remains intact.
Incomplete amputations are further subdivided according to the structures remaining in
continuity.
Type I: Bone attachment only

Type II: Extensor tendon intact
Type III: Flexor tendon continuity
Type IV: Nerve connection
Type V: Skin or soft tissue attachment
Digits involved are the thumb 30%, index 23%, middle 20%, ring 17%, and little 10%;
where 55% of all digital amputations occurred through the proximal phalanx.
Level of amputation has its main importance in analysis of results of replantation surgery.
Zone I — Extends distally from the base of the nail (Figure 1). Venous drainage is diffuse
and anastomosis of volar veins is virtually impossible. Successes have been reported fol-
lowing both revascularization and artery repair only (Figure 2) as well as replacement of
the finger tip as a composite graft.
Zone II — Extends from the distal interphalangeal joint to base of the nail. In cases
where venous anastomosis could not be carried out, Isaacs (in our unit) achieved 28% salvage
with a combination of heparinization and midlateral pulp incision.7
Zone III — Extends from the point of division of the common digital artery at the
metacarpophalangeal joint as far as the distal interphalangeal joint. The anatomical com-
FIGURE 1. Zone I amputation of the right index finger of a 19-year-old girl. Nondominant hand; result of a
meat cleaver injury.
FIGURE 2. Survival after repair of the radial digital artery and both digital nerves. No bony fixation was performed.
Volume I 373
plexity of the flexor-extensor mechanism in this zone is responsible for the generally poor
range of movement in the joint just distal to the replantation site.
Zone IV — Extends from midpalm to metacarpophalangeal joint level, and is the zone
of the common palmar digital arteries. One arterial anastomosis is often sufficient to re-
vascularize up to three fingers and dorsal veins are often found on either side of each extensor
tendon. Proximally based vein:containing skin flaps are easily raised.
Zone V — Extends from the radiocarpal articulation to the midpalm region.
Zone VI — Refers to amputation proximal to the radiocarpal articulation, and as such is
referred to as extremity amputation.
SUITABILITY EVALUATION
Only a surgeon with wide experience in reconstructive hand surgery should assess suit-
ability. Because of simple hypothermic preservation of the part, transfer of the patient to a
replantation center is possible anywhere in the world.
The only absolute contraindications for replantation are the presence of associated injuries
which prevent surgical replantation, absolute refusal for the surgery by an "informed pa-
tient", and warm ischemia time exceeding 8 hr in proximal amputations.
Among relative contraindications we include single-digit amputations in the elderly and
manual laborers, or those with chronic psychiatric conditions. However, it must be stressed
that after careful evaluation of employment, leisure activities, requirements in the home
environment, and motivation, we have carried out several single digit replantations, with
almost uniform patient satisfaction. Of the single digit replantations, 78% were carried out
on females, as the cosmetic, social, and psychological rejection of amputation stumps by
women is a phenomenon well recognized by hand surgeons. Children have a unique capacity
to regain function, and for this reason replantation should be attempted even in single-digit
amputations, especially if the amputation is at the level of or distal to the sublimis insertion.
Finally, among relative indications for replantation, one must consider the prophylaxis
against painful stump neuromata by replantation and digital nerve repair.
Factors to Consider
1. Suitability of the part and its importance to hand function.
2. Suitability of the patient; this point includes both medical and psychiatric status.
3. Economic considerations, including cost to the patient and to the community.
4. Total duration of warm ischemia time.
Absolute Indication to Replant

Amputations involving the thumb, multiple digits, or amputations including and proximal
to Zone IV are indications for replantation.
First Aid
Usually administered at the site of the accident or on arrival at the Casualty Section of a
peripheral hospital. Resuscitation of the patient is carried out. Bleeding is arrested by local
pressure to achieve hemostasis. Major contaminants are removed from the amputated part,
which is then placed in a clean cloth or gauze moistened with saline, sealed in a plastic
bag, and placed in a container full of crushed ice.
Normovolemia is restored using Hartman's solution and/or cross-matched blood, and
analgesia is attended to.
Transfer of the patient and the amputated part to the replantation center is arranged as a
matter of urgency after resuscitation has been completed.
SURGICAL TECHNIQUES FOR DIGITAL REIMPLANTATION
Preoperative Preparation
On arrival at the replantation center, full medical examination is carried out, taking a
detailed history. X-ray examination of the stump and the amputated part is ordered routinely,
together with hemoglobin, hematocrit, group and cross-match of anticipated volume of blood
required.
One member of the replantation team once again discusses the proposed operation with
the patient so that a truly informed consent is obtained.
While the above admission procedures are being carried out the amputated part is examined
under sterile conditions. Using the operating microscope gross contaminants are carefully
removed. Bone and tendon ends are debrided. Midlateral incisions facilitate exposure of the
neurovascular bundles. Under magnification nerves, arteries, and veins are identified, dam-
aged segments are excised, and ends are tagged with 8/0 nylon. Some surgeons apply Heifetz®
clamps as markers. It is important that the clamped segments are excised prior to anastomosis.
At this time phalanges may be drilled with a dental burr if interosseous wiring is contem-
plated, K wires may be passed and flexor tendon repair may be initiated by commencing
the distal repair with a Kessler® or Bunnell® suture. Dealing with multiple digital ampu-
tations, storage at 4°C in a refrigerator allows a more methodical approach to the replantation,
dealing with one digit at a time in order of priority as related to future hand function.
Operative Procedures
In our unit the majority of replantations have been carried out under light general anesthesia
augmented by axillary or brachial plexus block with 0.25% Marcaine® in 1:200,000 Ad-
renalin® to abolish tourniquet pain, increase limb perfusion, and abolish postoperative pain
with resultant restlessness. The patients are placed on ripple mattresses and have intermittent
positive-pressure pneumatic stockings on their lower limbs.
Where general anesthesia is contraindicated because of a concomitant medical condition,
regional field block augmented with neuralept analgesia or intravenous diazepam may be
acceptable.
All patients are catheterized and fluid loss meticulously monitored.
Preparation of the Stump

Midlateral incision, with elevation and suturing of the triangular skin flaps, provides better
access to the neurovascular bundles.
A pneumatic cuff is applied and the limb exsanguinated. Tourniquet time not exceeding
2 hr is aimed at. Debridement and structure identification in the proximal stump is now
proceeded with. The parts are continuously moistened with repeated irrigation of heparinized
saline, 5000 units/100 m€. Skeletal shortening is usually carried out to permit adequate
debridement and minimize the occurrence of tension during soft tissue repair, or to tidy a
grossly comminuted fracture.
Order of Reimplantation
Bone fixation — Common methods for skeletal fixation include:
1. Single-axial K wire
2. Direct interosseous wiring
3. Intramedullary bone peg
4. Intramedullary screw
5. Step cut osteotomy and oblique screw fixation
6. Plate and screw fixation
7. Two cross-K wires
Volume I 375
Of these techniques, intramedullary bone peg fixation, direct interosseous wiring, and
single-axial K wire fixation are all associated with diminished incidence of nonunion and/
or avascular necrosis.
Where amputation passes through joints, primary arthrodesis in a position of function
may be carried out or primary insertion of a Swanson® or Niebauer-Cutter® prosthesis may
be considered. When primary joint prostheses are inserted adequate skeletal shortening to
provide good skin cover is essential.
Extensor tendon repair is carried out next, with meticulous attention to the repair of the
lateral banks, which alone are responsible for return of interphalangeal joint extension.12
Extensor tendon repair will also minimize axial rotation.
Flexor tendon repair is now completed using a Kessler® suture with 4/0 Mersilene®, and
a continuous suture of the epitenon with 5/0 or 6/0 monofilament nylon (Plate 5*). In adults,
resection of the sublimis and repair of the profundus tendon only is carried out. In children
both tendons are sutured. Wherever possible repair of the synovial sheath should be carried
out to facilitate tendon gliding.
Digital artery repair — Damaged segment,of artery is resected until the intima appears
normal. Less than 0.5 mm of the adventitia is removed with sharp dissection to facilitate
suturing and prevent adventitial tags being dragged within the lumen. We attempt to suture
both arteries to ensure optimal sensory rjeturn in both digital nerve territories.5 Vessel end
approximation is achieved by assistant traction, or the use of Acland® or Kleinert-Kutz®
clamp approximators. When microclamps are used (Acland® or Week®) they are calibrated
to have a closing pressure not exceeding 25 g. End-to-end anastomosis of a digital artery
with an external diameter of 0.8 to 1 mm usually needs 9 to 10 interrupted sutures with 9/
0 to 11/0 nylon. Where vessel size is less than 0.6 mm, an oblique anastomosis is often
performed.
If the arteries cannot be approximated without tension, isodiametric interposition vein
graft is obtained from the volar forearm or the dorsum of the foot. Alternatively, a digital
artery may be dissected out and transposed from an adjoining finger.
Digital nerves — It is usually convenient to repair each digital nerve at the same time
as the ipsilateral artery. We carry out a combined repair picking up perineurium and fascicular
epineurium with each suture to ensure satisfactory funicular apposition. Where extensive
gaps exist as a result of avulsion injuries, secondary nerve grafting is carried out at 6 weeks.
We carry out perineural grouped fascicular bundle repair on major nerve trunks in amputations
proximal to Zone V. The patient is now given 60 mg/kg heparin i.v. and 5 min later the
tourniquet is released (Plate 6).
Dorsal Vein Anastomosis

Initial artery repair not only allows earlier oxygenation of the amputated part, but also
allows easier identification of the digital veins.10 The tourniquet may be reapplied after 10
min, and a minimum of three veins per digit are repaired. If tension or a deficiency exists,
a vein graft, or a vein-containing transposition flap from an adjoining finger may be utilized.
The importance of providing adequate venous drainage cannot be overemphasized. Raised
venous pressure leads to congestion, edema, secondary artery spasm, and thrombosis due
to the diminished perfusion.
All unsatisfied veins are now ligated and the skin loosely approximated. Occasionally it
may be necessary to apply thin split-thickness skin grafts as dressings to avoid tension.
When dealing with multiple digital amputations, intraoperative cooling with the use of cryogel
packs ;» routinely carried out.
* Plates 5 to 22 will follow page 376.

Dressings
Longitudinal strips of vaseline gauze, or nonadherent strips of Telfa® covered with fluffed
gauze and velband, are held in place by a bandage. The fingers are supported in the intrinsic
plus position by plaster slabs, and the extremity is elevated so that the amputated part rests
20 cm above the manubriosternal angle, with the palm supinated to improve venous drainage.
Postoperative Management
Drugs —
1000 Units heparin per hour for 12 days in replantations distal to Zone V
Chlorpromazine 25 mg three times daily (t.d.s.)
Analgesia when required (p.r.n.)
Ampicillin® ± Cloxacillin® 1 g every 6 hr
Smoking is absolutely prohibited
Aspirin 300 to 500 mg/day
Acetylsalicylic acid slows the formation of prostacyclin secreted by cells in the blood vessel
walls and thromboxane secreted by the platelets. Prostacyclin prevents platelet aggregation,
inhibiting clotting as well as expanding blood vessels so that they are less likely to be blocked
by a clot. Thromboxane causes platelet aggregation and constricts blood vessels. The effect
on the blood vessel cell is temporary, but the effect on the platelets lasts for its week-long
life. Thromboxane blocking requires one aspirin tablet per day, or less (i.e., daily dose
should not exceed 500 mg). Aspirin in larger doses loses its effectiveness as a clot inhibitor!
Replant — Half-hourly condition assessment including speed of capillary return, color,
presence or absence of cyanosis, temperature monitoring with a thermocouple, and tissue
turgor.
Dressing change — Usually at 48 hr if blood soaked. If dressings are clean and dry leave
intact for 1 week.
Physiotherapy — Gentle active movement allowed 1 week after replantation. Gentle
passive movement commenced on discharge from hospital after 14th day. Vigorous active
and passive movement is commenced after 4 weeks. Occasionally a Jobst® glove is required
to minimize swelling and stiffness.
Intraoperative Complications
The commonest problem is apparent anastomotic failure manifested by the "nonflow
phenomenon". Prolonged cooling and capillary bed spasm is the likely cause and can be
overcome by "hydrostatic dilatation" using heparinized blood or saline.
Arterial spasm is relieved by topical application of 1% Xylocaine® or longitudinal slitting
of the adventitia. A two-part patency test will confirm perfusion. Intraoperative thrombosis
is caused by inadequate resection of damaged vessel, or faulty suturing technique. To correct,
resection and usually interposition vein graft is necessary.
Too much time is often wasted removing a suture and irrigating out the thrombus only
to find that the vessel ends are too damaged for satisfactory repair.
Intraoperative venous thrombosis is rare if vein repairs are left to last, but in centers where
arterial repair is performed after venous repair this complication can occur. Treatment is
resection of anastomosis; suture if this can be accomplished without tension. Frequent
irrigation is required and reapplication of tourniquet not recommended.
Postoperative Complications
Vascular
Assessment of circulation in the replant is facilitated by plethysmography, which is very
PLATE 17. Amputated right arm following a circular PLATE 18. Decompression of forearm also provides
saw injury. better access to neurovascular bundles.
PLATE 19. Skeletal stabilization with Rush® pin and PLATE 20. Arterial suture with 8/0 nylon.
interosseous wiring.
PLATE 21. Fascicular alignment at beginning of nerve PLATE 22. Using lively extension splint 4 months after
repair. reimplantation.
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Volume I 377
sensitive to impending arterial failure, the use of a miniature Doppler probe, relatively
insensitive to problems on the venous side of the circulation, and the thermocouple. Of all
objective aids we have found the latter to be the most sensitive to changes in the circulatory
status of the replant.
Subjective assessment of turgor, color, and capillary refill are still the most helpful
indicators of circulatory status.
Sudden onset of pallor is suggestive of spasm or arterial thrombosis. A small stab wound
with a #11 scalpel blade or an 18-gauge hypodermic needle rapidly confirms one's fears.
Increased turgidity with bright plum red color and very rapid refilling is an early sign of
insufficient venous drainage and suggests the need for urgent change of dressings. Progression
to cyanosis, relieved by "bleeding the replant" (as above, also see Plate 8) is a sure sign
of venous thrombosis.
If anastomatic failure is suspected, whether venous or arterial, it should be explored and
treated in the operating theater as a matter of urgency. Bleeding is an uncommon complication
in spite of heparinization, and is a sign of inadequate venous drainage. If present, every
attempt should be made to "satisfy" the distal veins using grafts where necessary.
Skin loss — Most commonly seen in replants following crush injury. May require sec-
ondary skin grafting procedures, or even flap coverage of exposed bone, tendon, or neu-
rovascular bundles.
Infection — In digital replants this is extremely rare. Occasionally it is seen around entry
wound caused by K wire and resolves rapidly after removal of the pin. In humid climates
fungal infection has been a noticeable complication of antibiotic therapy.17
Skeletal complication — Nonunion or malunion are the commonest of the skeletal com-
plications of replantation surgery. Some nonunions form a painless pseudarthrosis and require
no treatment. When fusion is indicated, sclerosed ends are resected, and a cancellous bone
peg is inserted into the medullary cavity, immobilization being achieved with crossed Kir-
schner wires. Treatment of malunion is usually deferred until maximum function is restored.
Results of Digital Replants

Factors Influencing Survival
Mechanism of injury
Crush and avulsion 47%

Generalized crush 58%
Localized crush 79%
Clear-cut amputation 93%
Red line sign on the amputated digit indicates shearing stress on the vessel, resulting in
extravasation of blood along the neurovascular bundle caused by tearing of branches from
the digital artery.
Ribbon sign shows as marked tortuosity at the site of amputation, often coupled with
intimai tears and separation from the media.16 Extensive resection is indicated.
Time Survival
Author (years) Cases rate (%)
Lendvay, Sydney (1973) 4 63 45

No. VI People's Hospital, Shanghai (until 1973) 10 200 56.3
No. VI People's Hospital, Shanghai (1976) (these cases were done during 1 1 31 93.5
year (1973) after the introduction of the operating microscope together with a
very strong indication)
O'Brien, Melbourne (1977) 5 103 69.9
Mandei et al., Vienna (1976) 2 31 74.2
Tamaii, Nara, Japan (1974) 10 135 88
Berger et al., Vienna (1977) 2 30 67

Ikuta, Hiroshima, Japan (1977) 5 110 79.1
Biemer, Munich (1977) 3 465 89
Analysis of the author's reimplantation figures over a 3-year period, 1980, 1981, and
1982 shows an overall survival rate of 78%.
Main factors responsible for the increase in survival rate are improved suture materials
and the more frequent use of vein grafts. If one excluded "salvage" replantations, i.e.,
severe crush or avulsion injuries, survival approximating 100% could probably be achieved!
Function
When assessing functional recovery one must first analyze basic hand function. Precision
pinch is dependent on pulp-to-pulp opposition of the thumb, index, and middle fingers and
can be achieved with only minimal interphalangeal joint movement.
Power grasp is an expression of function of the ulnar half of the hand acting synchronously
with the thumb.
Key pinch can be achieved by a thumb possessing sensation on the ulnar side and any
replanted digit possessing radial sensation.
The following criteria are used for evaluation of function:
1. Pinch grip between replanted finger and thumb.

2. Span grasp — measuring force of compression on an object 8 cm wide.
3. Range of movement if exceeding 150° — excellent, 110 to 115° — good. The average
total active movement (TAM) in a series of 65 replants has been reported as 120°,
with avulsion injuries resulting in the poorest TAM. Proximal phalanx amputations
resulted in the poorest range of TAM.15
4. Recovery of sensation. In assessment, the ridge test, two-point discrimination, ability
to recognize hot and cold, and pick up tests have been used. Quality of sensibility has
been found to continue to improve for up to 3 years after reimplantation.
5. Subjective symptoms, such as pain, cold intolerance, paresthesiae, and numbness.
6. Return to preinjury employment and integration into normal lifestyle.
7. Patient satisfaction.
8. Cosmesis, including atrophy, color changes, and deformities.
A total of 49 patients were treated with reimplantations following amputation in Zones

IV, V, and VI. Only one patient considered reamputation because of persistent pain and
severe restriction in function. In this patient warm ischemia time exceeded 5 hr and post-
operative Volkmann's changes were noted both in the flexor and the extensor groups.
Secondary Procedures
In our series of 481 patients, 21% required later reconstructive procedures.
The commonest procedures performed were tenolysis or two-stage tendon grafts, with
excision of neuroma and nerve grafting running a close second (Plates 9 to 12).
In 17% of the amputations proximal to Zone IV, elective reexploration of the major nerve
repairs was carried out 6 to 12 weeks after replantation. The majority of these cases were
avulsion injuries or diffuse crush injuries, and in all but two cases required resection of the
repair site and restoration of continuity using sural cable grafts.
Only three silastic arthroplasties were carried out and one instance of bone graft for painful
nonunion was required. Reconstructive procedures, such as digital shifts or toe-to-hand
transfers, are dealt with in another chapter.
Transmetacarpal or Zone IV amputations warrant a separate mention. Recovery of function
Volume I 379
is usually a reflection on the damage sustained by the intrinsic muscles. Meticulous attention
should be given to repairing the intrinsics immediately following skeletal stabilization because
of their inaccessibility following nerve or vessel repair.
Both Zone IV and V amputations are best stabilized by interosseous wiring. This allows
early and unrestricted mobilization.
Replantation of Zone V amputations tends to give the surgeon his best functional results.
Careful identification and repair of the motor branches of ulnar and median nerves is stressed.
Total decompression of the carpal tunnel is necessary when treating Zone V amputations,
not just to facilitate primary repair, but also to prevent median nerve fibrosis caused by the
inevitable postoperative swelling.
Zone VI or Extremity Amputations

The total uncooled ischemia time assumes critical importance.6 Muscle metabolism fol-
lowing loss of circulation becomes anaerobic, with glycogen breakdown and accumulation
of lactic and pyruvric acids. After 6 hr, muscle cells break down and release of large amounts
of potassium ions commences. With cooling to 4°C, muscle breakdown and metabolic
acidosis is delayed, as well as reducing bacterial multiplication. Successful extremity replants
have been reported after 30 hr of cooled ischemia time.
If immediate replantation is not possible attachment to a pump oxygenator, combined
with cooling, will enable the surgery to take place when the patient's medical condition is
stabilized.
Operative Technique
For segmental loss of tissue, skeletal shortening is the preferred method of approach.
Thorough wound debridement is stressed, as clostridial infection is a direct result of insuf-
ficient wound debridement and is the commonest cause of replant failure.
Skeletal fixation is by intramedullary Rush nail, compression plates, or direct interosseous
wiring.
Early restoration of circulation is aimed at, but deep muscles must be repaired first,
because of danger of traumatizing the vascular anastomosis if completed last.
We attempt to carry out primary neurorrhaphy on all replants, but where segmental loss
results from avulsion injuries, secondary nerve grafts are performed 6 to 8 weeks after
replantation.
When dealing with extremity replantation, muscle compartment decompression (both
flexor and extensor) is advocated, combined with skin release and temporary partial thickness
skin graft cover. Careful subcutaneous fasciotomy is sufficient if warm ischemia time has
been short. Because of the thicker medial muscle layer and larger diameter of the vessels
involved in Zone VI amputations, 8/0 nylon is used for repair.
Primary repair of major nerves, using perineural fascicular or fascicular bundle suturing
with 10/0 nylon and epineural repair with 8/0 nylon to eliminate tension at the repair site,
is the method most likely to result in return of intrinsic function in extremity replantation,
and is the key to final function. Following "good nerve" repair in replant patients one can
often elicit sensory localization 2 to 3 days postoperatively. This has been shown to correlate
with good to excellent final results.
After restoration of circulation gradual release of clamps or tourniquet is recommended
to minimize the hypotensive effect caused by the accumulated tissue breakdown products.
Gentle active movement is initiated after 1 week, and massage with lanolin is commenced
after 2 weeks to minimize edema. If swelling is persistent, a Jobst® garment is fitted and
gentle passive movement commenced between 2 to 3 weeks after replantation. Work against
elastic traction is started at 4 to 5 weeks, and in high amputations (above-elbow level) a
portable muscle stimulator is provided for the patient to carry out 2-hr percutaneous muscle
FIGURE 3. Showing good intrinsic recovery 2 V2 years after above-elbow reimplantation on a 46-
year-old woman.
FIGURE 4. Zone IV amputation sustained in a meat slicing machine.
stimulation with special emphasis on the intrinsic group. As sensory recovery proceeds
distally, stimulation is discontinued in the more proximal group of muscles. Good intrinsic
recovery has been observed in 48% of our above-elbow reimplantations, with observed
clinical and electromyographically substantiated return of function as late as 18 months after
initial injury (Figure 3).
Illustrative Examples
Example 1 — M. B., age 21, sustained amputation of her dominant left hand in a meat
slicer (Figure 4). The thumb was processed through the machinery and could not be re-
covered. Replantation and primary pollicization of the little finger was carried out. The
patient was able to return to her preinjury employment after 6 months (Figures 5 and 6).
Volume I 381
FIGURE 5. Reimplantation with primary pollicization of little finger.
FIGURE 6. Function 12 months after reimplantation.
Example 2 — E. H., a 46-year-old farmer, sustained crushing amputation of his dominant

right hand when caught in a hay baler (Figure 7). Skeletal fixation was via interosseous
wires (Figure 8). For vascular anastomoses interposition vein grafts were used to minimize
FIGURE 7. Transmetacarpal amputation as a result of a hay baler injury; shows method of intraoperative cooling.
FIGURE 8. X-ray showing interosseous wires in situ.
the need for bone shortening. Excessive edema necessitated the use of a Jobst glove and a
night splint in the intrinsic plus position for a period of 8 weeks after reimplantation (Figures
9 to 11).
Volume I 383
FIGURE 9. Night splint to prevent thumb web space contracture, worn from 2nd until 8th week after
replantation.
FIGURE 10. Jobst® glove and night splint in use at 3 months.
Example 3 — R. M., a 53-year-old printer, sustained amputation of his dominant right

hand in a printing machine (Figure 12 and Plate 13). Excision of the distal row of carpal
bones, careful repair of the joint capsule, and two oblique Kirschner wires were used for
FIGURE 11. Median nerve motor function in intrinsic thenar muscles at

8 weeks.
FIGURE 12. Printing press injury resulting in amputation through the distal carpal row. X-ray of amputated
part.
Volume I 385
FIGURE 13. Showing edema of replanted hand at 3 weeks.
skeletal fixation. Primary repair of all vital structures was performed, the carpal tunnel
decompression was dressed with a temporary split skin graft (Figures 13 and 14 and Plates
14 to 16). Motor intrinsic recovery was first noted at 4 months, when full range of movement
at the wrist was documented (Figure 15).
Example 4 — M. B., Age 28, sustained amputation of the dominant right arm in an
electric saw injury (Plate 17). After 7 1/2 hr of cooled ischemia time revascularization was
completed. Both the radial and ulnar arteries were repaired, and the brachial and cephalic
veins, as well as two venae commitantes, and two unnamed subcutaneous veins were sutured.
Skeletal fixation was achieved using an intramedullary Rush® pin for the ulna and compres-
sion interosseous wiring for the radius (Plates 18 through 20). Definitive repair of muscles
and tendons was carried out and microsuture of median and ulnar nerves performed as
described (Plate 21).
Because of segmental loss of radial nerve just at its terminal branching, nerve grafting
was deferred. Fasciotomy of both flexor and extensor compartments, skin decompression,
and split thickness skin grafting was carried out at the completion of the surgical procedure.
This patient was noted to have accurate sensory localization in all fingers for a period of
3 days after replantation. The patient was readmitted for sural cable graft to the radial nerve,
and excision of the split thickness skin graft from the arm 8 weeks after replantation.
FIGURE 14. X-ray of reimplanted hand at 6 months.
FIGURE 15. Range of wrist movement at 6 months is the same as the uninjured hand.
Extensor reinnervation was noted 4 months after nerve grafting, intrinsic motor median
activity commenced at 12 months, but signs of ulnar intrinsic activity was delayed until 18
months after reimplantation (Plate 22 and Figures 16 and 17).
Volume I 387
FIGURE 16. Showing active metacarpophalangeal joint extension and palmaris brevis reinnervation at 12 months.
FIGURE 17. Showing strong thenar and hypothenar func-

tion after 2 V2 years.
REFERENCES
1. Acland, R. D., Instrumentation and technique, in Symposium on Microsurgery, Daniller A. and Strauch,
B., Eds., C. V. Mosby, St. Louis, 1976, 8—20.
2. Buncke, H. J. and Schulz, W. P., Experimental digital amputation and reimplantation, Plast. Reconstr.
Surg., 36, 62, 1965.
3. Carrel, A. and Guthrie, C. C , Complete amputation of the thigh with replantation, Bull., John Hopkins
Hosp., 18, 18, 1907.
4. Cobbett, J. R., Microvascular surgery, Surg. Clin. North Am., 47, 521, 1967.
5. Gelberman, R. H., Urbniak, J. R., Bright, D. S. et al., Digital sensibility following replantation, J.
Hand Surg., 3, 313, 1978.
6. Hamel, A. L. and Moe, S. H., Affect of total ischaemia on hind limbs of dogs subjected to hypothermia,
Surgery, 55, 274, 1964.
7. Isaacs, I., Vascular complications of digital replantation, Aust. N.Z. J. Surg., 47(3), 292—299, 1977.
8. Kleinert, H. E. and Tsai, T. M., Microvascular repair in replantation, Clin. Orthop. Relat. Res., 133,
205—211, 1978.
9. Komatsu, S. and Tamai, S., Successful replantation of a completely cut off thumb, Plast. Reconstr. Surg.,
42, 347—351, 1968.
10. Lendvay, P. G., Replacement of amputated digits and extremities, Symposium on Reconstructive Hand
Surgery, Vol. 9, C. V. Mosby, St. Louis, 1974, 300—305.
11. Lendvay, P. G., Replacement of the amputated digit, Br. J. Plast. Surg., 26, 398, 1973.
12. Lendvay, P. G., Pursuit of Function in Digital Replantation, Reconstructive Microsurgery, Daniel, R. K.
and Terzis, J. K., Eds., Little, Brown, Boston, 1977, 168—171.
13. Malt, R. A. and McKhann, C. F., Replantation of severed arms, JAMA, 198, 716, 1964.
14. O'Brien, B., Macleod, A. M., Miller, G. D. H., Newing, R. K., Hayhurst, J. W., and Morrison,
W. A., Clinical replantation of digits, Plast. Reconstr. Surg., 52, 490, 1973.
15. Scott, F. A., Howar, J. W., and Bos wick, J. A . , / . Trauma, 21(3), 204—213, 1981.
16. Van Beek, A. C , Kutz, J. E., and Zook, E. G., Importance of the ribbon sign indicating unsuitability
of the vessel in replanting a finger, Plast. Reconstr. Surg., 61, 32—35, 1978.
17. Vickers, D., personal communication, 1978.
18. Lapchinsky, A. G., Recent results of experimental transplantation of preserved limbs and kidneys and
possible use of this technique in clinical practice, JAMA, 198, 716, 1964.
Volume I 389
A TECHNIQUE FOR THE REPLANTATION OF AVULSED THUMBS
Simo K. Vilkki
INTRODUCTION
An avulsed-type amputation of the thumb occurs frequently when the glove of a worker
gets caught in the rotating axle of an agricultural machine, or in the machinery of the wood
processing industry, or in drilling machines. The chances for a successful replantation have
been clearly lower with such avulsion injuries than after other amputation injuries.12
There are more uncertain factors compared with local crush or clear-cut injuries. An
avulsion of the thumb can be associated with a forearm fracture or fracture-luxation through
the wrist joint because of the typical mechanism of these injuries.
PATHOLOGY
Stretching injury causes extensive trauma to the tissues and it is difficult to define the
margin of healthy tissue. Avulsions most often sever the thumb through the metacarpo-
phalangeal (MP) joint or through the epiphyseal plate of the proximal phalanx in younger
patients. This can sometimes also occur through the interphalangeal (IP) joint. Usually there
is no rupture of the tendons, but rather whole tendons are avulsed with a piece of muscle
belly. The extensor tendons may be pulled out with the muscle or they may rupture out of
the bone distally. The volar digital nerves are stretched and disruption occurs so that a length
of 5 to 20 cm of the more or less injured nerve tissue comes out with the thumb. At the
same time the proximal ends can be long but thin, including fewer and fewer funicles at
the distal end. The nerves to the dorsal skin are severed more sharply on a level with the
skin edge. The blood vessels — the most important tissue for the success of the replantation,
are severed so that distally with the thumb can be found the tails of the arteries, usually 0
to 6 cm in length, which are clearly stretched and tortuous with small ruptures of the intima
at the junction of the arterial branches.
The veins rupture more sharply along the skin edge.3 The skin at the base of thumb is
normally severed circularly, but sometimes large skin flaps from the dorsum of the hand
can be hanging with the thumb (Figures 1 to 4).
THE DETAILED TECHNIQUE
Preparation of the Patient and the Avulsed Thumb

As soon as possible after the avulsion, the free part is cooled in an ice water box. In the
hospital radiographs are taken of both the free part and the stump. Dextran infusion with
addition of Na-penicillin is started. Tetanus prophylaxis is mandatory. Normally, plexus
anesthesia is preferred because of the good sympathetic blocking effect. The supraclavicular
plexus is favored in young patients, while the transaxillary route is safer for elderly patients.
A combination of 0.5% Marcaine® + 0.5% Lidocaine® is used for the anesthesia at a dose
of 30 to 60 m€. This anesthesia can last up to 12 to 15 hr.
The preparation of the avulsed thumb is done during the time the patient is made ready
for the operation. The severed thumb with the tendons is rinsed and cleansed in a cold
Ringer's solution. The skin of the thumb is prepared by normal scrubbing. Betadine® can
be used for a short period before revision. After gross washing, all the foreign material on
the raw surface is taken away meticulously. The debridement of the skin margin is done by
cutting off a circular layer of skin with a width of 2 to 3 mm of healthy tissue and also
FIGURE 1
FIGURE 2
Before
FIGURES 1 to 4. An avulsion injury pre- and postoperatively.
cutting off some tissue from raw surface with the skin margin. Copious irrigation with
Ringer's solution is used. All the muscle tissue is cut away from the flexor tendon and the
dirty synovial sheet of the tendon is peeled away. The extensor tendons are prepared in a
similar manner. There is no need for very long pieces of extensors any more, but only
enough for reconstruction by primary transposition. It is also necessary to take away the
dirty-epineural surface of the nerves meticulously.
Success in replantation depends on an accurate evaluation of the arterial ends and a
knowledge of the vessel condition inside the thumb. The following steps help in preventing
Volume I 391
FIGURE 3
FIGURE 4
After
complications. On both sides of the thumb the neurovascular bundle must be examined. The
ulnar one is normally larger and more important than the radial one. The bundle is explored
through longitudinal incisions on both sides, with the skin flaps attached by stay sutures.4
A Bruner-type volar incision is an alternative, but then there is a need for an incision in
the midline dorsally to get a good approach to the veins and extensor apparatus. The skin
flaps are pulled aside and temporarily sutured in the same manner to get a good and free
approach during microreconstruction. It is necessary to follow the arteries to the first healthy
branch. Anastomosis proximal to any partially ruptured branch is followed by arterial throm-
bosis (Figure 5), so all damaged parts of the artery have to be resected and the use of vein
grafts is almost always necessary. The best dorsal vein is freed about 1 cm, irrigations are
FIGURE 5. The level of anastomoses (a) is selected just proximal to

the first healthy branch.
repeated, and the prepared thumb is put back into the ice water box in a sterile glove while
doing the preparation of the stump, if it is to be done by the same team.
Preparative Steps at the Stumpside

Washing and preparation is done as with a normal acute hand surgical patient. A bloodless
field is important. The debridement of the skin margin must be adequate (2 to 3 mm in
width). The raw surface is meticulously debrided down to the healthy tissue. All the foreign
material and devitalized tissue is taken away. Many irrigations and a change of instruments
and gloves after gross preparation are essential. The bony stump must be exposed enough
to expose all the important structures. Sometimes some shortening is needed — preferably
on the thumb side. The thenar is opened and an incision is made dorsally to expose the
extensor tendons and the dorsal nerves (Figures 6 and 7). The skin in the first interdigital
Volume I 393
FIGURES 6 and 7. Routine incisions used by the author for identification of different structures.(From
Vilkki, S. K., Handchir. Microchir. Plastichechir.,14, 156—160, 1982. With permission.)
webspace is left intact. A zigzag type incision on the thenar is placed over the normal site
of the flexor tendon and the branches of the median nerves to the thumb. Again we have
to use stay sutures to hold the skin edges to prevent unnecessary handling during microwork.
The rupture site in the branches of the median nerve is identified. If it is very high up we
can use a nerve branch to the volar skin flap, which almost constantly is seen during the
exposure of the thenar. This small nerve is enough for only one of the digital nerves. The
superficial branches of the nervus radialis to the dorsal skin are exposed. At the same time
we must be very careful with the dorsal veins to get a useful vein long enough for anastomosis.
If there is none it is possible to search for a vein on the dorsum of the index finger and
prepare it free for transposition.
A longitudinal incision is placed between the radial artery and the flexor carpi radialis
(F.C.R.) tendon to expose the flexor pollicis longus (F.P.L.) muscle in the distal antebran-
chium. When the antebranchial fascia is opened the hematoma pouring out is the landmark
for that muscle. The proximal part of the F.P.L. muscle is normally good enough for function
in the future. All the hematoma is irrigated out. A smooth, long instrument is passed through
the carpal tunnel, accurately following the original route. It is easier to do this from distal
to proximal. A strong nylon suture (2/0) is pulled through for tendon replacement.
The artery is exposed dorsally from the first interdigital space near the adductor muscle
or volarly from the thenar. Sometimes we have to use long vein grafts to bridge the gap
directly from the radial artery in the fossa Tabatière or possibly a transposition of an intact
neurovascular bundle is needed. If all the important structures are tagged during preparation
there no longer is a need for a bloodless field. A good strong proximal spurt of blood is the
FIGURE 8. Types of bone fixation used in replantation of fingers (types 2 and 3 preferred by the author).
best recommendation for a useful artery. However, if there is plenty of tourniquet time left
the reconstructive procedure is begun and done as far as possible under the bloodless field.
Reconstruction of the Thumb (Bone, Joint, and Tendons)

Skeleton — The uncertain prognosis of an avulsion injury is an indication for the ar-
throdesis of the MP joint in total amputation cases. The arthrodesis seems to be better for
the possibility of spontaneous vascularization, which occurs through the bone during the
first week and also helps the bone live if necrosis takes place in soft tissues. If the injury
is only a partial type and there is some skin bridge left, an MP joint reconstruction in younger
patients is preferred.
Technique of arthrodesis — The joint surfaces are removed and some shortening on the
distal side may be necessary for a good adaptation of the soft tissues. Two crossed K-wires
or the Lister intraosseous wiring method is used for stabilization5 (Figure 8). Positioning to
a 20 to 30° flexion is usually recommended. The periosteum is left intact as long as possible
and then some adaptive sutures with 5/0 Dexon® are applied.
Technique of joint reconstruction — The torn ligaments are usually on the distal side.
Then we have to repair them using 3/0 Dexon® sutures which are pulled through the proximal
bone (Figure 9). Thereafter the synovial membrane in the joint is sutured with 5/0 Dexon®
as well as the articular capsule being sutured with an atraumatic technique. Before putting
the thumb back the cleaned flexor tendon (F.P.L.) on the volar side must be pulled through
the original route as a first step in both techniques. A 2/0 nylon suture is used for that
purpose. The annular ligament is preserved and adapted to the joint capsule and the volar
plate is sutured if necessary. The tendinous parts of the avulsed adductor and thenar muscles
are also sutured to their original muscles for further stabilization.
Tendon repair — Tendon repair is usually begun with the extensor apparatus, and
depending on the type of injury the possibilities for its reconstruction are
1. If the extensor longus has ruptured distally a reinsertion with a 4/0 pull-out suture is
possible. (The rupture site is the basis of the distal phalanx.)
Volume I 395
FIGURE 9. The repair of collateral ligaments.
2. The extensor indicis proprius can be primarily transposed to the extensor longus.
3. The extensor brevis can be used as an extensor longus if still available on the proximal
side (MP-joint fused).
4. The abductor brevis muscle in the thenar can be sutured to the extensor longus (MP-
joint fused).
5. An avulsed extensor longus tendon can be used again and pulled back to its own
muscle subcutaneously.
Proximal repair in the flexor tendon is either completed in this phase or else it is done as a
last procedure after microreconstruction. The tendon is pulled through the original muscle
remnants, which are kept stretched during the adjustment of the tendon tension. Atraumatic
handling of the muscle is important while the tendon is brought through it several times and
then the tail of the tendon is sutured to itself, making a loop (Figure 10).
Microreconstruction
Nerves — Different possibilities are available for nerve reconstruction:
1. Direct suturing is very seldom possible. Good nerve tissue is lacking on both sides.
2. Primary nerve grafts may be used if the proximal nerve end can be identified without
extensive dissection of the injured median nerve.
3. Selection of a pair of longer tails, one from the proximal and one from the distal. One
of the two nerves can be repaired by a transposition of the distal nerve end to a branch
of the volar skin nerve in the thenar or dorsally to the nervus radialis.
4. Both volar digitalnerves transposed to the sensory branches of the radial nerve to the
thumb6 (author's choice).
5. Primary transposition of the ulnar neurovascular bundle from the middle or ring finger
for thumb nerve and arterial repair.7
FIGURE 10.. The tendon repair using the avulsed tendon and original F.P.L. muscle.(From Vilkki, S. K..
Handchir. Microchir. Plastichechir., 14. 156—160, 1982. With permission.)
Artery reconstruction — In most cases there is need for vein grafts to bridge the defects
in vessels. The minimum aim is to get one functional artery and vein. The ulnar digital
artery of the thumb is usually the larger one. Clear tagging in the preparatory phase helps
the finding of artery ends. The vein graft is taken from the antebrachial vein; the diameter
must be the same as the distal artery if end-to-end anastomosis is done. Sometimes a Y-
shaped vein graft can be used for two arteries and then only one proximal anastomosis is
needed. First, the most difficult anastomosis is completed and thereafter the easier one when
the other end of the graft is already fixed. The proximal vessel is normally arteria princeps
pollicis, but sometimes the revascularization must be done using a vein graft with an end-
to-side anastomosis from the arcus superficialis volarly, or directly from the arteria radialis
dorsally at the fossa Tabatière.68 The good proximal vessel is the one which gives a good
run-off when opened temporarily. The vessel wall must be healthy on both sides of the
anastomosis. If a bloodless field is used the anastomosis can be done without clips; if needed
they should be used only on the artery side. Some cases are suitable for the Lauritzens
telescope anastomosis technique9 (Figure 11) at the proximal anastomosis, but with a normal
technique at the distal anastomosis. Too large a diameter in the vein graft is very bad
hemodynamically, and it is often the cause for thrombosis if the distal run-in is very poor,
as it is sometimes in avulsion injuries. One good artery is enough but, however, another
artery should be repaired as well if it is possible.
Venous anastomosis — It depends on the special situation if the anastomosis can be done
directly end-to-end. A gentle microclip can be used on both sides. In some cases there is a
dorsal skin defect at the base of the thumb, and then the vein must be repaired with a vein
graft or by transposing the dorsal vein from the index finger with or without the skin flap
(Figure 12). A 11/0 suture is helpful with very tiny vessels. If there is a skin defect and the
vein graft or a transposed vein could remain exposed, a better alternative is to turn the whole
skin flap with a vein and to put free-split skin to the secondary defect.
Postanastomotic management — After completing the anastomoses, and before the
circulation is opened to the thumb, a dose of heparin i.v. is recommended (5000 IU); 1 to
2% Lidocaine® may also be used topically. The circulation often begins very slowly. De-
pending on the grade of stretching injury to the tissues the vasospasm is more obvious. The
circulation and vessels are very sensitive to all manipulation and after the first promising
Volume I 397
FIGURE 11. The telescope anastomosis with four stitches used by the author preferably only at the proximal
anastomosis of the vein graft. Observe! No stitch penetrates the intimai layer of the arterial wall.
FIGURE 12. A vein repair with transposition from intact index finger.
minute of new life in the thumb the flow often seems to stop almost completely. Lidocaine®
1 to 2% may be repeated topically against the spasm after some minutes. However, it is
best to leave the vessels, thumb, and the hand alone and only adapt the skin edges loosely
and apply thereafter voluminous and dry dressing on the hand. If the hand is continuously
wet and cold and open the spasm may go on and on. If the circulation does not begin after
waiting for 15 to 20 min it may be better to check the anastomoses. If the distal anastomosis
in the artery is thrombosed it must be exposed more distally to find a more healthy distal
vessel and sometimes a new longer vein graft is needed. That is why it is important to do
the extensive preparation of the avulsed part meticulously to prevent these troublesome
complications during the surgery. However, after all attempts, the circulatory function may
be very poor, in many cases after hours of hard work. The surgeon may be tired and it is
better to leave the hand alone; if there are no marks of beginning function after 6- to 8-hr
wait, another exploration of the vessels is indicated.
Aftercare
It may be useful to infuse Dextran during the operation and in the early postoperative
period. Also, single-dose heparinization (5000 IU) before the opening of the anastomoses
is recommended, but systemic heparin should not be continued afterwards. Only in some
crush injuries may there be indications for anticoagulant therapy if damaged tissue may
persist in the replanted part. Aspirin at a dose of 250 mg x 2 can be used for the 1st week.
However, there is a lot of controversy about the use of different anticoagulant agents.
Voluminous dressing, elevation of the hand, and absolute bed rest are essential during
the first 1 or 2 postoperative days. The first dressing change is routinely done after 10 days,
or earlier if blood clots make the dressings hard and compressing. The monitoring of skin
temperature has a definite place in the after control done by nurses in critical cases. 1011 A
normal (34 to 36°C) or slowly rising skin temperature is a very good sign of recovery during
the 1st postoperative day. If the temperature stays between 28 to 30°C it is a sign of venous
insufficiency or thrombosis, and if the temperature stays constantly under 27°C it may be
readily expected that the artery has failed.11 In the latter instance a reoperation is indicated
during the first 8 hr and almost always the cause of trouble is in the distal vein graft
anastomosis in the artery. If there are signs of venous complication (bleeding, cyanosis, and
temperature steadily between 28 to 30°C) the reoperation may be carried out during the 1st
or 2nd postoperative days. If a delay cannot be excluded, systemic heparinization while
waiting is indicated to prevent artery thrombosis and to keep the thumb bleeding outwards.
The patient may need blood transfusions.
After 1 week there is still a risk of losing the thumb if circulatory difficulties arise. It is
advisable to reoperate several times for a vascular failure as long as the tissue in the replanted
part has normal appearance without hemolysis. After 10 days of good circulation it is already
almost certain that the replanted part will be living without the function of the main artery.
However, a late thrombosis is easily followed by complications like partial skin necrosis,
infection, or pseudarthrosis.
If nothing helps to establish the circulation during the 1st week it is recommended to
deglove the necrotic soft tissue from the thumb, and leave only the proximal phalanx. A
tubed groin flap can be applied on the skeleted thumb thereafter. That gives the possibility
of maintaining the length of the thumb at least to the IP joint, if not all of it. A secondary
neurovascular island flap and plastic trimming of the thumb is needed to give a useful thumb
to the patient in the near future. Every patient is more eager to undergo the complicated
reconstructive procedures during the acute phase than later on, when an alternative may be
replacing the lost thumb with a toe.
Individual solutions are, however, needed in many cases and a replantation after avulsion
injury always carries less favorable prognosis than replantations after other types of injuries.
That is why the opinions of the respected authors about the technique, and even indications,
differ in the literature. Various results have been reported in the treatment of these difficult
injuries. The primary success rates ranging from 18 to 100%.!-2'12-13 But all the series have
Volume I 399
Table 1
SERIES OF 44 AMPUTATION INJURIES OF
THE THUMB, WITH 25 AVULSION
INJURIES (1977—1983)
Avulsion Local crush

injury or sharp cut Total
Complete amputation 20 11 31
Incomplete severance 5 8 13
25 19 44
Table 2
SURVIVAL RATES IN THE SERIES OF 44
THUMB REPLANTATIONS
Avulsion Others All

(25) (19) (44)
Survival 23 (92.0%) 18 (94.7%) 41 (93.2%)

Reamputated 2 (8.0%) 1 (5.3%) 3 (6.8%)
Table 3
RETURNING TO ORIGINAL OCCUPATION
AFTER REPLANTATION OF THE THUMB
Successful cases
Returned to Avulsions Others All

original work (13) (14) (27)
1—3 months 6 6 12
4—6 months 6 4a 10
7—12 months 1 3a 4
Not working for 1 1
other reasons
a
Two patients returned to light work.
From Vilkki, S. K., Handchir. Microchir. Plastichechir., 14,

156—160, 1982. With permission.
been relatively small in number, not least of all because of the fact that some authors think
avulsion injury is a contraindication to replantation surgery.
Functionally, sensibility recovery constantly remains somewhat worse than after more
benign types of amputation injury.12
The author's results in a series of 44 thumb replantations are summarized in Tables 1 and
2. The functional aspects of recovery are compared in an earlier series of 27 successful
thumb amputations in Tables 3, 4, and 5.
SUMMARY
The thumb is to be considered so important functionally that the indication for an attempt
Table 4
IP-JOINT MOBILITY AFTER
REPLANTATION
Complete amputations
IP-Joint active Avulsions Others

mobility (10) (10)
Extension
Flexion range 10—65° 10—70°
Mean 40° 40°
Extension
Lag 5—35° 5^5°
(5 patients) (4 patients)
Mean 25° 25°
From Vilkki, S. K., Handchir. Microchir. Plasti-

chechir., 14, 156—160, 1982. With permission.
Table 5
SENSIBILITY RECOVERY IN
THE SERIES OF THUMB
REPLANTATIONS
Complete amputations
Avulsions Others
Sensibility (10) (10)
Good protective but no 5 2

2PD a
2 PD < 20 mm 5 8
Range (mm) 10—18 8—15
Mean (mm) 15 f3812
Pulp atrophy % of 10% 9%
circumference
a
2 PD = 2 point discrimination (used in meas-
uring sensibility.)
From Vilkki, S. K., Handchir. Microchir. Plas-

tichechir. 14, 156—160, 1982. With permission.
at replantation is present even after an avulsion-type amputation injury. Difficulties of

reconstruction have been obvious as many authors consider a totally avulsed thumb as a
contraindication to replantation surgery. This concept may be altered by a detailed description
of a technique which has given a primary success rate of 92% among 25 avulsion-type
amputations of the thumb so far.
Typical mechanisms and posttraumatic pathology of the avulsion injury is explained. The
grave avulsion injury causes remarkable changes to the different anatomical structures and
their understanding is the basis for correctly directed treatment. The detailed technique is
presented step by step. Important preparative dissections of the free part as well as the stump
are described. Different possibilities in the reconstruction of separate tissues are presented
in detail. Incisions used, bone fixation or ligament repair, rerouting of flexor tendon, as
Volume I 401
well as microsurgical procedures are discussed. Aftercare and monitoring with special ref-
erence to skin temperature dynamics and complication management is considered an im-
portant part of the total management for achievement of successful results.14 A comparison
of the functional results is made in tabular form from the author's personal material of 15
avulsions and 15 other amputations of the thumb.
REFERENCES
1. Kleinert, H. E. and Tsai, T.-M., Microvascular repair in replantation, Clin. Orthop., 133, 205, 1978.
2. Morrison, W. A., O'Brien, B., and McLeod, A., A long term review of digital replantation, Aust. N.Z.
J.Surg., 47,767, 1977.
3. Biemer, E. and Duspiva, W., Eds., Ausrissamputationen, in Rekonstruktive Mikrogefasschirurgie, Sprin-
ger-Verlag, Berlin, 1980.
4. Nissenbaum, M., A surgical approach for replantation of complete digital amputations, J. Hand Surg., 5,
58, 1980.
5. Lister, G., Intraosseous wiring of the digital skeleton, J. Hand Surg., 3, 427, 1978.
6. Pho, R. W. H., Chacha, P. B., and Yeo, K. Q., Rerouting vessels and nerves from other digits in
replanting an avulsed and degloved thumb, Plast. Reconstr. Surg., 64, 330, 1979.
7. Doi, K., Replantation of an avulsed thumb, with application of a neurovascular pedicle, Hand, 8, 258,
1976.
8. Schlenker, J. D., Kleinert, H. E., and Tsai, T.-M., Methods and results of replantation following traumatic
amputation of the thumb in 64 patients, J. Hand Surg., 5, 63, 1980.
9. Lauritzen, C , A new and easier way to anastomose microvessels, Scand. J. Plast. Reconstr. Surg., 12,
291, 1978.
10. Bright, D. S. and Wright, S., Postoperative management in replantation, in AAOS: Symposium on Mi-
crosurgery, American Association for Orthopaedic Surgery, Eds., C. V. Mosby, St. Louis, 1979, 83.
11. Vilkki, S. K., Postoperative skin temperature dynamics and the nature of vascular complications after
replantation, Scand. J. Plast. Reconstr. Surg., 16, 151—155, 1982.
12. Vilkki, S. K., Daumenreplantationen: Ergebnisse bei Ausrissverletzungen und anderen traumatischen Am-
putationen — Ein Vergleich, Handchir. Microchir. Plastiche-chirur., 14, 156—160, 1982.
13. Stock, W., Biemer, E., and Wolfensberger, Ch., Results of 72 replanted thumbs, Int. J. Microsurg., 1,
68, 1979.
14. Vilkki, S. K., Replantation, Studies on Clinical Replantation Surgery (Thesis), Ser. A, Vol. 156, Acta
Universitatis Tamperensis, Finland, 1983.
Volume I 403
TOE-TO-HAND TRANSFER
Kauko A. Solonen
INTRODUCTION
Reconstruction of an amputated thumb has constituted a challenge for surgeons for more
than a century.8 Nicoladoni1011 pioneered the staged toe-to-hand transplantation of the second
toe to replace an amputated thumb. In 1954, Clarkson4 published a series of 15 transfers
that he performed by means of his dorsal-flap method. The first free experimental big-toe-
to-hand transplantation was carried out by Buncke et al.1 on rhesus monkeys in 1966. The
first clinical report of a successful transfer of a big toe in one stage to replace the thumb
was published by Cobbett5 in 1969. Since then the transfer of one or two toes to replace an
amputated thumb and fingers has been made safe by recent advances in microvascular
surgery.
CLINICAL SERIES
Clinical cases undertaken by us in the 3-year period from 1978 to 1980 at the Orthopaedic
Hospital of the Invalid Foundation, Helsinki, include ten free toe-to-hand transfers. Six of
these procedures were performed for thumb reconstruction and four for index finger length-
ening. In five cases the big toe and in one case the second toe was transferred to the thumb.
The index finger was always replaced by the second toe. Of the patients, six were males
and four females, their ages varying from 11 to 39 years, the average being 24. Nine transfers
were performed for traumatic amputations and one due to a congenital anomaly. The time
interval between the injury and the transplantation varied from 5 months to 15 years, the
average being 2.5 years. The patient with congenital absence of the thumb was an 11-year-
old girl.
PREOPERATIVE CONSIDERATIONS
Thumb or finger reconstruction utilizing the big toe or the second toe transfer is indicated,
in carefully selected cases, for a healthy individual who is able to undergo a prolonged
general anesthesia (or epidural anesthesia and brachial block) and a lengthy operation.
Consideration must be given to the patient's age, occupation, and motivation. He must be
fully informed of what is involved and cooperative. The vascular system of the extremities
in question must be in good condition. The location of the cut ends of the nerves and tendons
have to be ascertained. Preoperative arteriograms on both the hand and the donor foot as
well as Doppler mapping of the arterial supply are made in order to plan the dissection and
the siting of the vascular anastomoses. We share the opinion of O'Brien et al.14 that the
dorsalis pedis artery and saphenous vein are usually capable of supporting the circulation
of the hallux and the second toe. We prefer whenever possible to use the proximal vessels
for anastomoses rather than the more or less damaged stump vessels. Occasionally the foot
has an anomalous vascular pattern not suitable for the customary dorsal approach. The
possible disadvantages to the foot should always be taken into consideration: these include
large scarring, possible infection, walking limitations, difficulty with shoes, etc.
The big toe will give a better cosmetic and functional result for thumb reconstruction than
the second toe, but for the other fingers the second toe, which is generally the longest one
and has the best PIP motion is preferred. The second-toe-to-hand transfer is technically more
difficult than that of the big toe because of the smaller size of the digital vessels. In societies
FIGURE 1. The MP joint of the big toe can be included in the graft. The sesamoids are left in place. Due to
the original hyperextension of the MP joint of the big toe, the transplanted part of the MT head is fixed in flexion
to the recipient I MC bone (A). The same applies to the transfer of the second toe (B). (C) Postoperative
roentgenogram of a hand (case 5) where the MP joint of the big toe was included in the transplant.
where stable shoes with uppers are in general use, loss of the big toe is of minor importance,
whereas in communities where open-toe sandals are the traditional footwear the second toe
may be more readily transferred — for both functional and cosmetic reasons. It is possible
to transfer simultaneously two or more toes from a foot. The big toe is usually slightly
longer than the thumb, and correct measurement of the part to be transplanted is important.
Estimation of the length of the new thumb may induce the surgeon to shorten the thumb
metacarpal.
The ipsilateral big toe is the preferred donor because of its slight lateral angulation, which
in the new position will help in the pinch function with the fingers.9 The MP joint of the
big toe may be included in the transplant in cases where the MP joint of the thumb has been
lost (Figure 1). A sparing resection of the metatarsal head does not seem to impair the gait.
The sesamoid bones are left in place because of their importance in weight bearing. The
resection of the first metatarsal head, however, demands careful weighing of the pros and
cons. In children, the growth centers of the recipient ray and the transplant have to be given
proper consideration. The epiphyseal plates are preserved for future growth.
In cases where there is much scarring in the recipient area in the hand, a preliminary skin
and subcutaneous tissue replacement is advisable. Alternatively, a portion of the dorsal foot
skin should be transplanted in connection with the toe. This again means increased difficulty
in the treatment of the donor foot.
Operative Treatment
Big Toe
The patient is given 500 m€ (10 m€/kg body weight) low-molecular-weight dextran during
the operation. On the operating table the patient is kept warm and well padded. A
Volume I 405
FIGURE 2. Outline of incision for the big toe disarticulation (a). More
dorsal and plantar foot skin can be taken with the graft (b).
catheter is passed into the bladder. Two surgical teams are employed. The foot dissection
takes more time than the preparation of the recipient site and is begun first. We prefer to
use pneumatic tourniquets on both the upper arm and the thigh.
Dissection is carried out with magnifying loupes ( x 2.5 to 4.0). The carefully planned
skin incisions in the hand and foot are outlined with a marking pencil. When the big toe is
to be transferred the incision is made around the base of the toe leaving the plantar skin to
cover the metatarsal head. A triangular flap of skin is incised on the dorsal-medial aspect
and the incision on the dorsal surface is extended longitudinally for exposure of vessels,
nerves, and tendons (Figure 2). The vascular anatomy of the first intermetatarsal space
demands great care in the dissection. A thorough study of the arteriogram provides important
guidance. Usually a long vascular pedicle can be dissected containing the dorsalis pedis
artery and the first dorsal metatarsal artery arising from it, together with one to three dorsal
drainage veins continuing to the great saphenous vein. Occasionally the first plantar meta-
tarsal artery is dominant and is used for anastomosis in the hand. This artery is better
approached from the plantar incision. The artery gives a short pedicle and may involve the
use of a lengthening venous graft. It may, however, be preferable to use a short arterial
pedicle of the first dorsal metatarsal artery to spare as much as possible of the circulation
of the dorsum of the foot. The first plantar metatarsal artery should be prepared for use in
case another recipient artery of the transplant is needed (Figure 3).
The flexor hallucis longus and the extensor hallucis longus tendons are divided through
separate incisions at the ankle level and pulled out distally. In some cases shorter tendons
are adequate. The extensor hallucis brevis tendon is divided, and will usually not be attached
to the thumb motors (compare with Figure 7). The deep peroneal nerve is found beneath
this tendon (Figure 4). The nerve to the hallux is separated interfascicular^ from the medial
FIGURE 3. The most common distribution of the arteries for the big and second toe. ATA =
a. tibialis anterior, ATP = a. tibialis posterior, ADP = a. dorsalis pedis, AA = a. arcuata,
AMP = a. metatarsea perforans, AP = arcus plantaris, AMD = a. metatarsea dorsalis I, and
AMPL = aa. metatarseae plantares.
digital nerve to the second toe by interfascicular dissection, so as not to denervate the skin
of the second toe, and divided so proximally that it can be anastomosed with the superficial
branch of the radial nerve. The two plantar digital nerves are divided at the level of the base
of the first metatarsal bone and marked with ligatures placed close to the ends. When selecting
the level of where to divide the nerves, the prevention of painful neuromata should be borne
in mind. Before the vessels are ligated and cut, the tourniquet is released and the flow
through the planned vascular system of the graft is ascertained.
In the meantime the hand dissection is begun. It is important not to start this part of work
too early, otherwise undue swelling may develop in the hand. A radial flap based volarly
is elevated and the incision is extended over the stump volarly and dorsally (Figure 5). The
flexor and extensor tendons of the thumb as well as the volar digital nerves and the dorsal
superficial branch of the radial nerve, the dorsal branch of the radial artery in the anatomic
snuffbox, and tributaries of the cephalic vein are sought and identified. An incision in the
volar wrist is usually needed to identify the flexor pollicis longus tendon. The metacarpal
(or phalangeal) bone is cut across with an oscillating saw after determination of the length
requirements. When the vessels and nerves are carefully identified and the hallux has had
a 20-min perfusion, the vessels to be anatomosed with the recipient vessels of the hand are
doubly ligated and divided between the ligatures. The hallux is exarticulated or the proximal
phalanx is osteotomized proximally according to the length needed. The defect on the dorsum
of the foot should then be closed with a rotation flap and free skin grafts.
Volume I
FIGURE 4. Isolation and division of the nerves to the big toe. Similar technique is adopted in transplantation of the second
toe. NC = nervi cutanei dorsi pedis, NFP = n. fibularis (peroneus) profundus, MEB = m. extensor hallucis brevis, and
407
NP = n. plantaris tibialis (medialis).

FIGURE 5. Development of radial dorsal and radial volar skin flaps for toe-to-thumb transfer.
The articular cartilage is removed from the surfaces to be connected. The toe is connected
to the thumb metacarpal or the first phalanx with one or two Kirschner wires or with a bone
peg from removed parts of bone. A sleeve of periosteum of the recipient bone is used, if
possible, to enclose the bone juncture (Figure 6). We use a tourniquet for the hand even in
this phase of the operation and we employ the microclamps minimally, if at all.
The operating microscope is used to anastomose the main artery of the transplant with
the distal branch of the radial artery, preferably end-to-side, with 10/0 monofilament nylon
sutures. Occasionally anastomosis of the plantar metatarsal artery with an artery of the thumb
is done instead. One to three veins from the toe are anastomosed with the cephalic vein or
its tributaries. After vascular repair the plantar nerves of the graft are anastomosed with the
volar nerves of the thumb and the deep peroneal nerve of the transplant is sutured to the
peripheral branch of the radial nerve with epineurially placed interrupted 10/0 monofilament
nylon sutures using the operating microscope. The flexor hallucis longus tendon is sutured
to the flexor pollicis longus tendon and the extensor hallucis longus tendon to the extensor
pollicis longus (Figure 7). If the thenar muscles are well preserved, they are fixed to the
new thumb ray according to the original thenar pattern. The eventual arterial spasm is relieved
by measures commonly adopted in microvascular surgery (warmth, 2% Lidocaine®, Papav-
erine®, or adventitectomy). Systemic administration of heparin is not used, but the blood
and fibrin clots are washed off with a heparinized saline solution (100 U/m€). When the
blood flow through the new thumb is judged satisfactory, the wounds are closed.
Volume I 409
FIGURE 6. Different ways of osteosynthesis adopted in toe-to-hand transfer.

(A) Bony fixation accomplished through two crossing Kirschner wires. (B) Bone
peg + a K wire. (C) The shaped end of the first thumb phalanx pegged into the
cavity of the proximal phalanx of the hallux, two crossing K wires are used for
greater stability. (D) MP joint of the big toe included in the transplant, and the
end of the MC bone is pegged into the base of the transplant. K wires are used
for initial stability. (E) The bony juncture is enclosed with a periosteal cuff from
the MC bone, two K wires.
Second Toe
The second toe transfer is preferred by many reconstructive surgeons for the thumb, but
is particularly suitable for missing fingers or short finger stumps of an inferior quality in
patients for whom a long finger is indispensable. The functional impairment in the donor
foot is minimal after loss of the second ray. The dissection and transplantation of the second
toe is generally more difficult than that of the big toe.
Skin incision is made taking triangular distally based skin flaps with the toe (Figure 8).
The plantar flap has to be taken sparingly since a good plantar skin is essential for trouble-
free use of the foot. In selected cases it may be important to transfer more dorsal foot skin
and a portion from the sides of the adjacent toes with the toe to be transferred. The anomalies
of the vascular anatomy should be kept in mind. The dorsalis pedis artery is isolated,
beginning proximally. The second metatarsal bone is preferably osteotomized proximally
and lifted so that the plantar arch can be seen. The arterial branches from the first dorsal
metatarsal artery, dorsalis pedis artery, or a part of the arcus plantaris with the branch
extending to the second toe can readily be taken with the toe, provided the circulation of
the remaining toes is not at risk. In this phase, if the arterial supply seems to be very limited
it is better to discontinue the direction and leave the toe in place.7 The dorsal one to three
veins from the toe are isolated and followed up to the great saphenous vein.
FIGURE 7. Big toe-to-hand transfer. Approximation of the nerves, vessels, and tendons. EHB = extensor
hallucis brevis tendon, VH = venae hallucis, EHL = extensor hallucis longus tendon, ADP = a. dorsalis pedis,
AR = a. radialis, NFP = n. fibularis (peroneus) profundus, NR = ramus superficialis n. radialis, VC = v.
cephalica, EPL = extensor pollicis longus tendon, NPH = nervi plantares hallucis, NDP = nervi digitales volares
pollicis, APB = m. abductor pollicis brevis, FHL = flexor hallucis longus tendon, and FPL = flexor pollicis
longus tendon.
The long extensor tendon and the dorsal nerve are dissected and divided with adequate
lengths. The plantar nerves and the long flexor tendon are dissected from the longitudinal
plantar incision. The interosseal muscles are freed from the bones to be removed. The
tourniquet is deflated and the isolated toe with its vascular pedicle is observed to discover
whether there is sufficient circulation.
When the hand is prepared for the transplant and the toe has had a 20-min perfusion the
toe is removed from the foot. If additional length is needed, the distal part of the metatarsal
bone is included in the transplant.
The recipient bone and the graft bone are connected with two crossing Kirschner wires,
Volume I 411
FIGURE 8. Outline of incision for the second toe transfer (a). Dorsal foot skin and
flaps from the sides of the adjacent toes may be taken depending on the size of the
recipient defect to be covered (b and c).
or a bone peg from the removed metatarsal bone is used for fixation. If the MP joint is
included in the transplant, the distal part of the metatarsal bone must be fixed in slight
flexion due to the normal hyperextension position of the toe MP joint (Figures IB, 6, and
9).
If the dorsalis pedis artery is included in the vascular pedicle it is connected end-to-side
to the dorsal branch of the radial artery in the anatomic snuffbox. If the main artery of the
toe is very short, it must be connected to the digital artery or proximally via a vein graft.
The resected saphenous vein or the dorsal veins of the transplant must be anastomosed with
the cephalic vein or its chosen tributaries.
After excising the neuromata of the disrupted nerves of the hand, the digital nerves of
the toe are anastomosed with the recipient nerves using 10/0 monofilament nylon sutures
epineurially. Interposition of free nerve grafts may be needed.
The respective tendons are connected in due tension and the wounds are closed, possibly
using free skin grafts.
Postoperative Care
A bulky dressing with elastic bandage and a volar splint is applied to the forearm and
hand. The tip of the transplanted toe should be left uncovered. The hand is kept elevated
slightly above the heart level. The leg elevation is advantageous for the healing of the foot.
Low-molecular-weight dextran is given at the rate of 500 m€/day (10 m€/kg body weight)
over a 3-day period. The circulation through the new thumb or finger is monitored hourly
in the first 3 days and then every 2 to 3 hr for 5 to 7 days. The laser Doppler flowmeter
will probably be useful in this observation. Signs of arterial failure or venous congestion
must be watched for. When thrombosis is diagnosed, immediate reexploration is mandatory
in order to reestablish circulation. Usually resection and vascular reconstruction is required.
Postoperative heparin was not used in our series, but after a repeat vascular reconstruction
anticoagulant treatment is important.
FIGURE 9. Transfer of a toe to a hand with congenital absence of the thumb or fingers follows the principles
described in the text. The details of reconstruction have to be individually planned. Shown is the right hand of a
11-year-old girl with congenital defect of all four fingers, only the anomalous thumb being present (A). The result
of second toe-to-hand transfer 2 years after the reconstruction (B and C). The motions of the transplanted second
toe are little, but the pinch is useful. There is reliable identification sensibility. The outline of the reconstructive
operation (D): 1 — volar skin incision, 2 — bone fixation with two K wires, BMC = the united proximal parts
of the second and third metacarpal bones, and MT2 = the distal end of the second metatarsal bone; 3 and 4 —
EL = extensor longus tendon of the second toe, EC = extensor communis tendons for the second and third finger,
V = dorsal veins of the toe, VC = v. cephalica, ND = digital nerves of the second toe, NU = n. ulnaris, FL
= flexor longus tendon of the second toe, FP = flexor profundus tendons for the second and third finger, ADP
= a. dorsalis pedis, and AIO = a. interossea volaris.
Volume I 413
FIGURE 9D
Slight active movements of the transplanted toe are permitted during the first days after
the operation. After 4 weeks the splint is removed and vigorous active exercises are started.
Non weight-bearing ambulation is usually begun at 10 to 14 days and full-weight bearing is
permitted at 3 weeks.
Results
We experienced one postoperative failure leading to loss of the transplanted big toe 14
days after surgery owing to thrombosis and delayed surgical intervention. Six of the eight
adult patients returned to their jobs and one to vocational training.
The ranges of active movements of the reconstructed fingers and thumbs were somewhat
diminished although functionally quite satisfactory (Figures 10 to 14). Stability was good
in every case.
The grasp and pinch of the hand functioned well in all cases, the strength varying from
44 to 55%, respectively, of that of the other hand. All but one had regained identification
ability and good thermal sensibility. The two-point discrimination was in five cases between
10 and 18 mm. Six of the nine patients with successful results regarded the dexterity of the
hand good or satisfactory even when handling small objects. Cosmetically, the result was
estimated as satisfactory or good in all cases of the big toe transplantations, whereas trans-
plantation of the second toe-to-thumb or index finger was invariably regarded as unsatis-
factory (Figures 9, 11, and 13). No patient complained of restricted walking ability. The
two children were reported to have experienced some trouble when running barefoot. Many
of the patients suffered minor, insignificant inconvenience in the donor foot.
CONCLUSION
Toe-to-hand transfer seems to significantly improve the function of a hand with missing
thumb or fingers. The surgery is demanding and the patients have to be selected carefully.
The patients seem to appreciate the functional and cosmetic improvement to their hands.
FIGURE 10. Case 1 — A 28-year-old male. (A) Preoperative status 9

months after injury; (B, C, and D) 5 months after transfer of big toe-to-
thumb.
Volume I 415
FIGURE 11. Case 2 — A 13-year-old girl. (A) Preoperative status 20 months after partial am-
putation of the right hand; (B, C, D, and E) motions 14 months after transplantation of the second
toe to the short stump of the first MC bone.
FIGURE 12. Case 3 — A 30-year-old woman. Twelve months before admission she accidentally lost her right
hand through the carpal level, and the thumb and index finger of the left hand. (A) Preoperative status; (B, C, D,
and E) function of the left hand 7 months after big toe-to-hand transfer.
Volume I 417
FIGURE 13.. Case 4 — A 27-year-old architect had traumatic amputation of three fingers of the right hand
5 months before admission (A and B); (C, D, E, and F) 32 months after second toe-to-index finger transfer.
FIGURE 14. Case 5 — An 18-year-old man. Traumatic amputation of all fingers of therighthand 2V2 months
before admission. (A); (B, C, and D) functional documentation 3V2 months after big toe-to-hand transfer.
Volume I 419
REFERENCES
1. Buncke, H. J., Jr., Buncke, C , and Schulz, W. P., Immediate Nicoladoni procedure in the Rhesus
monkey, or hallux-to-hand transplantation, utilizing microminiature vascular anastomosis, Br. J. Plast.
Surg., 19, 332, 1966.
2. Buncke, H. J., Jr., McLean, D. H., George, P. T., Greech, B. J., Chater, N. L., and Commons,
G. W., Thumb replacement: great toe transplantation by microvascular anastomosis, Br. J. Plast. Surg.,
26, 194, 1973.
3. Buncke, H. J., Jr. and Shah, K. G., Toe-digital transfers, in Microsurgical Composite Tissue Trans-
plantation, Serafín, D. and Buncke, H. J., Jr., Eds., C. V. Mosby, St. Louis, 1979.
4. Clarkson, P., Reconstruction of hand digits by toe transfers, J. Bone Jt. Surg., 37A, 270, 1955.
5. Cobbett, J. R., Free digital transfer. Report of a case of transfer of a great toe to replace an amputated
thumb, J. BoneJt. Surg., 51B, 677, 1969.
6. Leung, P. C , Second toe-to-hand transplantation: a clinical experience of 25 cases, Aust. N.Z. J. Surg.,
50, 254, 1980.
7. Leung, P. C , Transplantation of the second toe-to-hand — a preliminary report of sixteen cases, J. Bone
Jt.Surg., 62A, 990, 1980.
8. Littler, J. W., On making a thumb: one hundred years of surgical effort, J. Hand Surg., 1, 35, 1976.
9. May, J. W. and Daniel, R. K., Great toe-to-hand free tissue transfer, Clin. Orthop., 133, 140, 1978.
10. Nicoladoni, C , Daumenplastik, Wien. Klin. Wochenschr., 10(28), 663, 1897.
11. Nicoladoni, C , Daumenplastik und organischer Ersatz der Fingerspitze (Anticheiroplastik und Daktylo-
plastik), Arch. Klin. Chir., 61, 606, 1900.
12. O'Brien, B. M., MacLeod, A. M., Sykes, P. J., and Donahoe, S., Hallux-to-hand transfer, Hand, 7,
128, 1975.
13. O'Brien, B. M., Microvascular Reconstructive Surgery, Churchill Livingstone, Edinburgh, 1977.
14. O'Brien, B. M., MacLeod, A. M., Sykes, P. J., Browning, F. S. C., and Threlfall, G. N., Microvascular
second toe transfer for digital reconstruction, J. Hand Surg., 3, 123, 1978.
15. O'Brien, B. M., Black, M. J. M., Morrison, W. A., and MacLeod, A. M., Microvascular great toe
transfer for congenital absence of the thumb, Hand, 10, 113, 1978.
16. O'Brien, B. M., Brennen, M. D., and MacLeod, A. M., Microvascular free toe transfer, Clin. Plast.
Surg., 5, 223, 1978.
17. Ohmori, K. and Harii, K., Transplantation of a toe to an amputated finger, Hand, 7, 134, 1975.
18. Solonen, K. A., Brummer, H., and Telaranta, T., Toe-to-thumb transfer by microneurovascular anas-
tomosis, Acta Orthop. Scand., 50, 604, 1979.
19. Tamai, S., Hori, Y., Tatsumi, Y., and Okuda, H., Hallux-to-thumb transfer with microsurgical technique:
a case report in a 45-year-old woman, J. Hand Surg., 2(2), 152, 1977.
20. Tsai, T. M., Experimental and clinical application of microvascular surgery, Ann. Surg., 181, 169, 1975.
21. Yoshimura, M., Nomura, S., Yamauchi, S., Ueno, T., and Iwai, Y., Toe-to-hand transfer: experience
with thirty-eight digits, Aust. N. Z. J. Surg., 50, 248, 1980 .
Volume I All
TOE-TO-HAND FREE TISSUE TRANSFER
John T. Burns and Tsu-Min Tsai
INTRODUCTION
Single-staged composite toe-to-hand tissue transfer has become an accepted surgical pro-
cedure utilized to restore prehensile function to the hand defective either due to injury or to
a congenital abnormality.11 In 1898 Nicoladoni1 ingeniously developed a method of suc-
cessfully transferring a toe to the hand by means of a pedicle graft, but the technique was
not widely recognized until 1955 when Clarkson2 popularized the staged transfer. Buncke
et al.3 in 1964 performed the first experimental free toe-to-hand transfer in monkeys and in
1968 Cobbett4 reported the first successful clinical microneurovascular free toe-to-hand
transfer in the Western world when he used a great toe to reconstruct a thumb. The American
replantation mission to Red China in 1973 reported that Yang had successfully transferred
a second toe for an absent thumb in 1965.5 In 1972 Buncke et al.6 reported a great toe-to-
thumb transfer utilizing the dorsalis pedis and first dorsal metatarsal arteries as donor vessels,
Cobbett4 having used plantar digital arteries. Tsai7 transferred two toes for an ulnar hand
deficiency in 1973, a technique later successfully employed and reported by O'Brien et al.7,8
Numerous reports of toe-to-hand free tissue transfers followed,914 including Morrison et al.
report15 of an innervated toe wrap including the nail for osteoplastic thumb reconstruction
and May et al.16 report of a sensory first web-free composite graft. Vascularized joint toe-
to-hand transfers, though not discussed here, are currently under experimental and clinical
investigation.1719
Prior to performing such a transfer, one must consider alternative and, perhaps, safer
methods of obtaining or improving hand function even though staged procedures may be
required. For the thumb one may consider, in appropriate cases, deepening of the first web
or phalangization of the first metacarpal with or without metacarpal lengthening, osteoplastic
thumb reconstruction, digital transposition (pollicization), or merely conservative treatment
without surgical intervention.2025 For the digits, "on-top-plasty" as proposed by Kelleher
et al.26 or phalangization are possibilities, again either with or without metacarpal length-
ening. In some cases, however, the most judicious method of reconstruction is by toe-to-
hand free tissue transfer.
INDICATIONS
Traumatic loss of thumb — Reid in 1960 established a classification of thumb loss based
on the anatomic level of amputation.27 Group I is comprised of individuals with thumb loss
distal to the metacarpophalangeal joint (MPJ) but with a residual stump adequate for thumb
function either with or without phalangization. Group II consists of amputation at or distal
to the MPJ with an insufficient stump for active use. Group III individuals have an intact
carpometacarpal joint (CMCJ) and some remaining thenar musculature with loss of the MPJ.
Group IV amputation is at or near the CMC J with loss of all thenar musculature. It is in
groups II and III that free microneurovascular toe-to-thumb free tissue transfer is primarily
indicated. The great toe is frequently transferred in adults whereas the second toe is generally
transferred in children (Figures 1A and B). However, when "zori slippers" are commonly
worn, a second toe transfer is also recommended for adults.28
Congenital absence of thumb — In most instances pollicization is a valid consideration
but absence of multiple digits negates this surgical possibility.2930 To repeat, in children
second toe transfer is preferred, whereas in adults the great toe is more commonly transferred.
FIGURE 1. (A) Great toe-to-thumb transfer in a 26-year-old man performed 7 months following failed
thumb replant. (B) Second toe-to-thumb transfer in a 4-year-old child performed 11 months following
traumatic amputation of thumb, index and long digits. (C) Second and third toe transfer in a 55-year-old
man 1 year following traumatic amputations of index through small digits.
Loss of ulnar digits at metacarpal level (metacarpal hand) — Although congenital

absence of multiple digits may occur, digital loss at the metacarpal level is often attributable
to a traumatic injury. If a more conservative surgical approach is judged inadequate, transfer
Volume I 423
FIGURE 1C
of two toes to the hand is recommended either by transferring the second and third toes
from one foot as a single-composite graft or by transferring the second toes from each foot
as a single or staged procedure7-28'3136 (Figure 1C). Phalangization may also be incorporated
to gain additional digital length.
CONTRAINDICATIONS
Toe-to-hand transfer as an emergency procedure — Although a successful great toe-

to-hand transfer performed as an emergency procedure has been reported, elective surgery
under more predictable circumstances affords the least risk to the patient.37-38 Immediately
following such a devastating injury the extent of tissue damage is difficult to evaluate even
on a microscopic level, thus compromising one's ability to establish and maintain distal
vascularity. Eventual skin loss may occur that may be appropriately remedied by incorpo-
rating an innervated cutaneous flap as part of a toe transfer, an excellent reconstructive
alternative sacrificed if the original estimation of soft tissue damage was erroneous.
Congenital absence of thumb with three or four normal digits — It is generally agreed
that toe-to-thumb transfer is contraindicated in a child with otherwise normal digits. Polli-
cization is the procedure of choice.
Advanced vascular disease — Generalized, advanced vascular disorders such as arte-
riosclerotic cardiovascular disease, diabetes mellitus, collagen disorders, etc. mitigate against
such surgery. Caution should be exercised in cases of digital loss secondary to electrical
burns or those where trauma has destroyed the thumb basilar joint.
ESSENTIALS PRIOR TO TOE-TO-HAND TRANSFER
A complete history and physical examination, although prerequisites for any surgical
FIGURE 2. Free composite groin flap in a 19-year-old man 18 months following severe punch press
injury for soft tissue coverage preliminary to great toe-to-thumb transfer and fifth metacarpal rotational
osteotomy.
procedure, must be recorded and carefully scrutinized. Any type of advanced vascular disease
as mentioned above jeopardizes the contemplated surgery. Previous injury or abnormality
of the donor site must be evaluated. It is also essential that the recipient site either has
existing supple soft tissue coverage or the potential for scar excision and flap coverage as
part of the planned free tissue transfer3940 (Figures 2 and 3).
The detrimental effect of nicotine on the circulatory system has been firmly established.41
Therefore, surgical candidates should preferably cease using tobacco products for at least 1
week preoperatively and remain abstinent for an additional 3 weeks postoperatively.
Joint mobility of toes is less than in fingers or thumbs. It may be helpful to have the
patient passively exercise the donor digit several times a day in hopes of influencing its
eventual total active range of motion following transfer.
As a rule, it is advisable to obtain preoperative arteriograms of both the recipient and
donor limbs, some suggesting these be done at least 3 weeks prior to the definitive surgery
in order to avoid troublesome vascular spasm that may persist for a variable period following
introduction of the contrast media.42 Others feel 1 to 2 days is sufficient time for vessel
recovery. The normal variations that one may encounter in the arterial supply of the toes
has been aptly studied by Gilbert,43 May et al., 16 and Ti-Sheng et al.39 and must be familiar
to the surgeon. To best evaluate the vascular anatomy in this area, anterior-posterior and
lateral radiographs of the foot should be a routine part of the preoperative arteriogram.
Relying solely on palpation of pulses or Doppler examination may be misleading as the
dorsalis pedis may appear to be absent in 8.9% of the cases so examined.16 It has also been
recommended that selective arteriograms be performed with the benefit of regional anesthesia
to obviate vasospasm and encourage vasodilatation, thus aiding evaluation of the distal
arterial tree.44 Recently, the senior author (Tsu-Min Tsai) has performed fewer preoperative
arteriograms and has begun to rely on careful surgical dissection for definition of the essential
vascular anatomy.
Volume I 425
FIGURE 3. Great toe-to-thumb transfer in a 24-year-old man incorporating generous dorsal foot
flap performed 2 years after mutilating punch press injury.
OPERATIVE TECHNIQUES
Under general anesthesia (simultaneous axillary and epidural regional blocks have been
employed) two surgical teams are utilized to simultaneously prepare the recipient and donor
sites.28 Foot dissection is comparable regardless of whether the great, second, and third toes,
or any of these in combination with a sensory flap is utilized.
Dissection of the Foot

Flaps designed to afford good soft tissue coverage at the recipient (hand) site are outlined
dorsally and plantarly, venous channels observed and marked, the dorsalis pedis pulse
palpated and marked, and the tourniquet then inflated to 350 to 450 mmHg after elevating
the limb for 2 min (exsanguination is avoided as it obscures the vascular tree during dis-
section). With 4.5 x loupe magnification the skin incisions on the dorsum of the foot are
carefully made and extended proximally to the midtarsal area (or beyond) in the form of a
lazy S. The dorsal venous system is identified, freed proximally, and retracted medially.
The superficial peroneal nerve is preserved distally and mobilized proximally where it is
transected at an appropriate length. Next the extensor hallucis brevis tendon is visualized
and sectioned proximally, thus exposing the interval between the extensor hallucis longus
and extensor digitorium communis tendons where one then identifies and protects the dorsalis
pedis artery and its accompanying vena comitantes in addition to the deep peroneal nerve,
which consistently supplies cutaneous innervation to the first web space.16 The terminal
branches of the first dorsal metatarsal artery (FDMA) are carefully visualized in the first
web and the FDMA dissected proximally to its origin from the dorsalis pedis artery at the
base of the first and second metatarsals. It is at this level that the dorsalis pedis artery gives
off a deep communicating branch that dives plantarly between the two heads of the first
dorsal interosseous muscle to join the plantar arterial arch. This communicating branch must
be carefully ligated and transected. The long extensor tendons are then cut proximally at
appropriate lengths.
Attention is then turned to the plantar aspect of the foot where, following incisions as
previously outlined, the plantar arteries, nerves, and flexor tendons are identified. Prior to
transection digital nerves are intraneurally and proximally separated to obtain the predeter-
mined necessary length for reanastomosis at the recipient site. It has been suggested that
the first plantar metatarsal artery (FPMA) then be dissected, the tourniquet deflated, and
the FDMA and the FPMA alternately occluded to determine the dominant blood supply to
the donor digit while observing the vascularity of the adjacent digits.28 The transfer should
be based on the arterial supply that is dominant to the donor digit. Once this evaluation is
completed, the flexor tendons are divided at an acceptable length, proper digital arteries to
remaining adjacent toes ligated and divided, a metatarsal osteotomy (if required) performed,
the superficial and deep transverse metatarsal ligaments and interosseous muscle divided,
and the composite transfer permitted to perfuse for at least 20 min prior to division of its
vascular pedicle (dorsalis pedis and saphenous vessels) and transfer to the hand.
The dissection as described is for a ''long" transfer, that is a composite transfer based
on the dorsalis pedis or metatarsal arteries and saphenous vein, whereas a "short" transfer
is one based on the plantar digital vessels.8,28 (Figure 4). Dissection of the short transfer is
much less tedious.
Dissection of the Hand

Following exsanguination of the limb, tourniquet ischemia is initiated. Palmar and dorsal
incisions are planned to permit access to essential deep structures and to allow good soft
tissue coverage. Dorsally, sensory branches of either the radial or ulnar nerve are identified,
veins carefully protected, the appropriate extensor tendons mobilized, and the involved
metacarpal or metacarpals exposed. Palmarly, digital nerves, arteries, and flexor tendons
are dissected free. If a short transfer is to be done, the dissection is complete. If, however,
a long transfer is to be performed, exposure of the cephalic vein and radial artery in the
snuffbox area is required. If the superficial palmar arch or ulnar artery is to be the recipient
arterial vessel, it is then recommended that Guy on's canal be surgically released to avoid
postoperative compromise of proximal in-flow.
Transfer of the Toe to the Hand

After adequate perfusion of the composite transfer at the donor site (foot), the vascular
pedicle is divided at an appropriate length and the specimen transported to the recipient site
(hand).
The metatarsal is shaped for intramedullary impaction into the recipient metacarpal and
bone fixation obtained by use of longitudinal and oblique K-wires. Shorter transfers may
be stabilized by utilizing an intramedullary bone peg and K-wire or by use of an interosseous
wiring technique.45-46 One should, if possible, avoid bone fixation methods in children that
may produce epiphyseal damage.
Flexor tenorrhaphies are optimally located at or proximal to the wrist to discourage
diminished tendon excursion secondary to adhesions. Extensor tendon repairs are generally
placed distal to the extensor retinaculum. An opponensplasty may be performed if needed.28
A Pulvertaft weave is the most secure method of tendon repair.47
Arterial reconstruction then follows. In a long transfer, the dorsalis pedis is anastomosed
end-to-side into the radial artery in the snuffbox area and its vena comitantes and the
saphenous vein anastomosed either end-to-end or end-to-side into the cephalic vein and its
tributaries. In short transfers, the plantar digital donor arteries may be anastomosed end-to-
end into the recipient palmar digital arteries with or without elongation by reversed vein
grafts. Where the superficial palmar arch or ulnar artery are the recipient vessels, however,
Volume I
427
FIGURE 4. Illustration depicting difference between long (left) and short (right) second toe-to-hand transfer. (A) Plantar view; (B) dorsal view.
FIGURE 5. Second toe-to-thumb transfer in a 25-year-old woman with generous use of split thickness
skin graft for recipient site closure performed 5 years after severe punch press injury.
elongation of the plantar digital vessels by reversed vein grafts is mandatory and end-to-
side anastomoses usually required. Good proximal flow must always be assured and vessel
kinking carefully avoided. Vessel repair is with 10/0 nylon suture. Digital perfusion is begun
immediately after completion of the vascular anastomoses.
Palmar and plantar digital nerves are correctly coapted and dorsally the deep and superficial
peroneal nerves approximated to branches of the dorsal radial or dorsal ulnar sensory branches
— 10/0 nylon epineural sutures are used. 4849
It is critical that skin closure is tension free to avoid vascular compromise of the transfer.
Split thickness skin grafts may be needed and one should not hesitate to place them directly
over vascular channels where the vascularized adventitia promotes excellent graft incorpo-
ration (Figure 5). Drains are routinely used to prevent fluid accumulation and subsequent
compression.
Dressings must also be nonconstricting and bulky with the transferred part adequately
exposed for periodic postoperative viability evaluations (Figure 6).
It is important that throughout the procedure, in addition to the usual precautionary
observations, the patient's core temperature is monitored and appropriately maintained and
excellent hydration ensured.
Foot Reconstruction
A second surgical team simultaneously closes the donor site as the transfer is being
completed. Time spent on meticulous hemostasis following tourniquet deflation is worthwhile
since hematoma formation in the foot is a common postoperative complication. Closure in
layers over a deep drain is carried out by reapproximating the remaining superficial and
deep transverse metatarsal ligaments and interosseous muscles with heavy nonabsorbable
sutures if a second or combined second and third toe transfer has been performed. A split
Volume I 429
FIGURE 6. Postoperative dressing in place permitting constant limb elevation and ready access
to transferred digits for viability monitoring (thermocouple for skin temperature determination
illustrated).
thickness skin graft is at times required, particularly in cases where a dorsal foot or fibular
side great toe sensory flap has been dissected. Plantar skin closure is seldom a problem and
occasionally skin excision is needed to prevent bothersome fissure formation. However,
before excising skin, first attempt to close as much of the deficit as possible with the thick,
resilient plantar skin. An effort should likewise be made to preserve the maximum amount
of the first (great toe) metatarsal head permissible and to carefully round it off to avoid
subsequent weight-bearing problems (Figure 7).
A bulky compressive dressing incorporating a short leg posterior plaster splint supporting
the ankle in neutral position is then applied.
FIGURE 7. Healed donor site defects shown in full weight-bearing stance demonstrating
great toe (A), second toe (B), and second and third toe (C) transfers. Minimal discomfort
was experienced and none were functionally handicapped (including A who jogs 2 mi a
day).
POSTOPERATIVE MANAGEMENT
Both the foot and upper limb are maintained in an elevated position. The vascularity of
the transfer is carefully monitored hourly for 24 hr, every 2 hr the 2nd day, every 3 hr the
3rd day, then every 6 hr until discharge. Digital color, capillary refill and, most importantly,
skin temperature as determined by an externally applied thermocouple are observed and
recorded at these intervals.50 One should be aware that the transfer temperature is initially
about 28°C in the operating theater with good capillary refill and color and thereafter gradually
attains a temperature of 31 to 32°C over next 3 to 4 hr. If the temperature fails to rise or
later drops one must loosen the dressing, check systemic factors (blood pressure, hemoglobin,
and hemacrit), and perhaps employ vasoactive (Vasodilan®) or anticoagulant (LMD or
heparin) medications. Reexploration is mandatory if improvement is not observed within 2
hr. Most instances of vascular compromise occur within 12 hr of surgery. The patient remains
fasting (NPO) but well hydrated (parenteral fluids at 100 to 150 m€/hr in adults) for 24 hr
postoperatively in anticipation of such an event.
Aspirin, grains 10 every 12 hr and parenteral broad spectrum antibiotics for 3 days followed
by oral coverage for a variable period are routinely used. 5153 Dressings are normally changed
on the third postoperative day. Barring complications the patient is returned home on the
4th to 10th postoperative day.
Volume I 431
FIGURE 7B
FIGURE 1C
RESULTS IN LOUISVILLE 1974 TO 1980
During this period of time there were 53 toe-to-hand transfers involving 34 patients and
38 surgical transfers. A total of 31 patients experienced traumatic injuries and 3 had congenital
abnormalities; 24 cases were for thumb reconstruction — 13 undergoing great toe transfer
and 11 second toe transfer. For digital reconstruction 14 cases of combined second and third
toe composite transfers were performed and second toe transfer alone undertaken in 2 cases.
The patients ranged in age from 4 to 60 years, with an average of 28.8 years. Groin flaps
were required in 27 cases (80%) for adequate skin coverage of the recipient site prior to
toe-to-hand transfer. Significantly, 25 cases involved the long transfer (dorsalis pedis-first
dorsal metatarsal arteries), whereas 13 cases utilized the short transfer (plantar arteries).
There were 13 postoperative explorations, 7 involving the short transfer (46%) and 6 the
long transfer (24%). The large-caliber vessels and general use of end-to-side anastomoses
with the long transfer are significant factors that make it more advantageous.
Two-point discrimination was less than 10 mm in 15 cases, 11 to 15 mm in 4 cases, 16
to 20 mm in 4 cases, and absent with only protective sensation in 13 cases. Sensation in
the transfer never exceeded that measured in the normal contralateral toe. All patients
experienced cold intolerance in both the recipient hand and donor foot. The average range
of motion was
1. Metacarpophalangeal joint 5/40°

2. Proximal interphalangeal joint 20/47°
3. Distal interphalangeal joint 4/5°
Power grip averaged 28.5% of the contralateral (normal) hand and pinch 26.6%.
There were 2 cases requiring femoral arterial thrombectomies following arteriography and
26 cases requiring secondary surgical procedures (tenolysis, bone graft, and deepening of
web space). Five toes in four patients failed to survive, for an overall survival rate of 92%.
All individuals with successful transfer resumed the majority of their preinjury activities and
most returned to gainful employment (Figure 8).
CONCLUSION
Composite toe-to-hand free tissue transfer represents a complex surgical procedure that
should only be attempted by highly skilled individuals thoroughly familiar with the involved
anatomy and who are convinced that other reconstructive alternatives are not equally ad-
vantageous to the patient. It is evident from this report that successful toe transfers frequently
require additional surgery and that functional gain always falls short of the normal state.
Yet the ability to restore prehensile function to a maimed or congenitally deformed hand in
a single-staged procedure has gained wide acceptance in the past 5 years and with continued
refinement of surgical techniques, appreciation of appropriate surgical indications, and per-
haps more aggressive postoperative rehabilitation functional results should continue to improve.
SUMMARY
Toe-to-hand free tissue transfer is an accepted technique for restoration of function to the
injured or congenitally deficient hand: 53 toe-to-hand transfers in 34 patients and 38 pro-
cedures done in Louisville, 1974 to 1980, are reviewed.
The indications considered for toe-to-hand transfer in this series included: traumatic loss
of thumb, congenital absence of thumb, and the metacarpal hand. Contraindications to free
toe transfer were congenital absence of the thumb with three or four normal digits, advanced
Volume I 433
FIGURE 8. (A) Same patient as shown in Figure 2 demonstrating

pincher motion and cosmetic appearance 7 months following great toe
transfer. (B) Same patient as shown in Figure IB demonstrating ap-
pearance and functional gain 19 months after second toe-to-thumb
transfer. (C) Remarkable active flexion and independent function in
second and third toe transfer to left hand in a 37-year-old man 4 years
following surgery.
vascular disease, and the emergency setting. Alternative reconstructive techniques are dis-
cussed. Preoperative evaluation, operative techniques, pertinent anatomy, and postoperative
management are presented.
Both long transfers (25 cases), based on dorsalis pedis-first dorsal metatarsal arteries, and
short transfers (13 cases), based on plantar arteries are evaluated.
Thirty-one patients were victims of trauma, 3 had congenital defects, and 27 (80%) required
groin flap coverage prior to toe transfer. There were postoperative explorations in 7 of 13
short transfers and in 6 of 25 long transfers. This reflects the greater reliability of the larger
vessels.
Five toes in four patients failed giving an overall survival rate of 92%. A total of 26
patients required secondary procedures. Power grip and pinch averaged greater than 25%
that of the contralateral hand. Most of these individuals returned to gainful employment.
FIGURE 8B
FIGURE 8C
Volume I 435
ACKNOWLEDGMENTS
We wish to thank Doctors Harold Kleinert, Joseph Kutz, Erdogan Atasoy, Graham Lister,
and Thomas Wolff for permitting review of their patients in preparing this manuscript; Grace
Ascher for creation of excellent illustrations; and Doris Petty for typing manuscripts.
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Surg., 1, 131, 1976.
49. Rodkey, W. G., Cabaud, H. E., and McCarroll, H. R., Neurorrhaphy after loss of a nerve segment:
comparison of epineurial suture under tension versus multiple nerve grafts, J. Hand Surg., 5, 366, 1980.
50. Stirret, C. R., Seaber, A. V., Urbaniak, J. R., and Bright, C. R., Temperature monitoring in digital
replantation,/. Hand Surg., 3, 342, 1978.
51. Weiss, H. J., Antiplatelet drugs — a new pharmacologic approach to the prevention of thrombosis, Am.
Heart J., 92, 86, 1976.
52. Clagett, P. G., Schneider, P., Rosoft, C. B., and Salzman, E. W., The influence of aspirin on post-
operative platelet kinetics and venous thrombosis, Surgery, 11, 62, 1975.
53. Gertz, D. S., Kurgen, A., Wajnberg, R. S., and Nelson, E., Endothelial cell damage and thrombus
formation following temporary arterial occlusion — effects of pretreatment with aspirin or heparin, J.
Neurosurg., 50, 578, 1979.
Volume I 437
DORSALIS PEDIS FLAP
Kazimierz Kobus
INTRODUCTION
Of the free skin flaps described thus far, the most popular and useful group in clinical
practice includes the groin and dorsalis pedis flaps. The latter was suggested first and set
up as a so-called island flap1214 and later on, beginning from 1975 — transferred directly
with the use of microvascular anastomoses.18
At first the interest in the use of dorsalis pedis flaps was connected almost exclusively
with their long pedicles and large caliber of vessels (2 to 3 mm), which made vascular
anastomosis quite safe and relatively easy. In the course of time, however, attention was
paid to other advantageous flap properties providing facilities for composed tissue transfer
with nerves, second metatarsal bone, and extensor tendons.2"5'8'10'13151619'22 To crown it,
the method of partial finger reconstruction with use of adjacent parts of the first and second
toe has been elaborated by Foucher et al.4
Considering the above described qualities as well as the known excellent mechanical
properties and thin subcutaneous tissue which conditions the malleability and resistance to
infection, the increasing popularity of the flaps may be understood, the more so as there is
an almost unanimous positive opinion among surgeons and a very high success rate (about
95%), compared to the groin flap transfer.1021 In distinction to the other flaps, the dorsalis
pedis flap is willingly used not only in highly specialized centers, but — and this seems to
be even more important — in numerous moderately equipped departments with deprived
facilities for fully specialized and permanent microsurgical training.
ANATOMY
In adults the dorsal surface of the foot is about 200 cm2 and the potential size of the flap
is 13 x 15 cm. The skin is rather thick, and to the most characteristic features belong
important development of the corneal layer, relatively poor innervation (two-point discrim-
ination test is about 1.5 to 3 cm), with moderate vascularization which is fed by multiple
musculocutaneous perforating vessels from the anterior tibial-dorsalis pedis system.
Arterial System
At the junction of the middle and lower third of the leg the anterior tibial artery lies
superficial to the tibia between the tibialis anterior muscle and the extensor digitorum tendon.
In the lower third of the leg it is crossed from the lateral to the medial side by the extensor
hallucis longus tendon (Figure 1). At the ankle joint, passing under the extensor retinaculum
the artery is usually between the tendon of the above-mentioned muscle medially and the
tendon of the extensor digitorum longus muscle laterally (Figure la). The level of crossing
is sometimes at a distal point to the extensor retinaculum. This is very important from the
surgical point of view, as in such cases the extensor hallucis longus tendon interferes with
flap elevation (Figure lb).
The artery, called at this level the dorsalis pedis artery, lies in an intimate relationship to
the tarsal bones, giving off its first branches — the tarsal arteries. As it trans verses the
retinaculum it is usually covered by the belly of the extensor hallucis brevis muscle and as
it travels distally, the tendon, which is at first lateral, crosses to the medial side. This is
another important anatomical detail, as during dissection this tendon must be severed to
allow for flap elevation (Figure 2).
FIGURE 1. The relationship between the dorsalis pedis artery and the extensor
hallucis longus tendon, (a) High level crossing, the artery is located lateral to the
tendon; (b) distal level crossing, proximal part of the artery lies under the tendon.
FIGURE 2. Arterial system and the relationship between the dorsalis

pedis artery and the extensor hallucis brevis tendon.
At the tarso-metatarsal level, before leaving the dorsum of the foot by passing through
the gap between the two heads of the first interosseous muscle at the proximal end of the
first intermetatarsal space, the artery gives off the arcuate artery which travels to the lateral
side of the foot, and the small cutaneous terminal branch. The latter should be preserved,
especially in cases of distal crossing, in order to secure an arterial flow for the flap. Before
the dorsalis pedis artery disappears into the sole of the foot, it branches off into the first
dorsal metatarsal artery, which travels along the dorsal side of the first dorsal interosseous
muscle. In the majority of cases the dorsal metatarsal artery travels above the muscle level
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FIGURE 3. Eventual wrong interpretation of the vessel course by the

palpation method. To avoid severance of both vessels (discoid area), an
clear identification and tracing of the artery to the takeoff point is mandatory
(see dissection).
or superficially enough in it and distally after bifurcation secure the blood supply to the
medial part of the big and second toes. In 22% of the cases, however, it runs under the
muscle belly, making dissection more tiresome and complicated. In 12% of the cases only
a slender vessel is encountered.6
The takeoff of the first dorsal metatarsal artery from the dorsalis pedis artery is rather a
Y- than a T-shaped pattern.19 Great care should be exercised during dissection to avoid
eventual division of the artery proximal to the takeoff point of the cutaneous branch. The
real danger for beginners who operate without tourniquet is uncritical dependence on the
palpation method. Ascertainment of pulsation between two close points may lead to the
wrong impression of vessel continuity and result in accidental severance of both arteries
(Figure 3).
Preservation of the first dorsal metatarsal artery is extremely important and essential for
flap vascularity. The subdermal plexus of the vessels is fed by multiple musculocutaneous
perforating vessels from the dorsalis pedis artery and its major branches. Proximally these
perforating vessels appear to be more sparse, and since they travel deep to the tendons most
of them are divided as the flap is raised, like perforating branches between the arcuate and
second, third, and fourth dorsal metatarsal arteries.
Therefore, the vessels arising directly from the dorsalis pedis artery distally to the extensor
retinaculum and the dorsal metatarsal artery are of the highest importance, being the con-
clusive factor in flap vascularization. When this is understood, it is simple to deduce that
the medially distal part is the safest area of the flap.
Venous Drainage
Like most other flaps, there is a choice of two sets of veins which drain the dorsalis pedis
flap: superficial veins and venae comitantes.
There are three superficial veins which are of anastomosable size: lateral and medial veins
that become the short and long saphenous veins and a median superficial vein (Figure 4).
Each of them, as well as venae comitantes (usually paired), are of significant caliber (from
2 to 3 mm) and have already been successfully transferred.
Nerves
The skin of the dorsum of the foot is innervated by the superficial peroneal nerve which
is a branch of the common peroneal nerve. It pierces the deep fascia at about the junction
FIGURE 4. Veins and nerves of the foot.
FIGURE 5. The sensory pattern on the dorsalis surface of the

foot.
of the middle and lower third of the leg. Just proximal to the ankle joint the superficial
peroneal nerve divides into several branches superficial to the paratenon of the extensor
tendons. They terminate on the dorsum of the toes. The skin of the dorsum of the foot has
rather poor sensitivity. Its better properties are found in the skin of the adjacent surfaces of
the first and second toes, adjoining web included, which are innervated by the deep peroneal
nerve (Figure 5).
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FIGURE 6. Basic design of the dorsalis pedis flap. Heavy line in-
dicates start of incision.
SURGERY
Preoperative Assessment
Good patency of the posterior tibial and dorsalis pedis arteries is an essential condition
for the flap elevation. Absence or disease of the posterior tibial artery is an absolute con-
traindication to surgery as it may result in severe compromise of the circulation to the foot,
especially in adults and aged patients.
In most cases the state of the vascularization of the foot can be ascertained quite easily
by clinical examination and with a Doppler flowmeter. As an assessment of the arterial
input to the foot is very important, both palpation and Doppler probe should be done with
great care and overall length of the arteries must be determined to avoid any possible pitfalls
and disasters. If there are any doubts concerning the vessel patency, more sophisticated
investigations such as arteriography are indicated. The assessment of suitable drainage of
the foot usually does not present any significant problems. Special attention should be paid,
however, to patients revealing thrombophlebitis, prolonged drips, or blunt trauma to the
foot in anamnesis.
Preoperative Design
Preoperative design includes the flap contours, the course of the dorsalis pedis artery,
and a map of the superficial venous drainage. Required size of the flap is marked on the
dorsum of the foot as symmetrically as possible in relation to the course of the artery (Figure
6). In most cases the flaps are extended to the toe web. Occasionally, if a flap shorter than
FIGURE 7. Diagrammatic representation of the problems connected

with the small flap elevation. To maintain the connections between the
flap and the large vein, the subcutaneous tissue has to be included.
8 cm is needed it can be ended distally 2 cm short of the first toe web. To be sure, such
approach makes grafting of the secondary defect quite simple indeed, but the most vascu-
larized and safest part of the dorsal skin is not put to good use.
If microsurgical transfer is planned, any of the four venous outflow systems can be used
and the choice depends mainly on the size of the recipient veins. Because microsurgery
should not be regarded as competition with small vessel anastomosis, it is quite clear that
the largest veins should be taken into consideration first of all. However, using either the
long or the short saphenous vein for drainage of the narrow skin flaps, the subcuaneous
tissue has to be included to maintain the vascular connections. So, it is sometimes better to
choose the smaller median vein or venae comitantes to avoid bulkiness of the flap (Figure
7). If only neurovascular island flap transposition is intended, the vein selection is rather
limited because, as a rule, the short saphenous vein is the vessel of choice.
Anesthesia
As a free flap transfer, on the whole, takes many hours, general or extradural anesthesia
is preferred, the more so as it provides facilities for operation with a tourniquet. Nevertheless,
in very special cases or conditions local anesthesia can be used with good results, too. It is
of special interest if, e.g., for some reason the whole surgical procedure is planned to be
divided into two stages. To be sure, the above-discussed flaps do not demand any delaying
procedure but such conditions as the time limit in the operational theater, unavailability of
a second team, expected tiresome dissection at the recipient site, or insufficient experience
of the surgeon can justify such an attitude.
Despite the fact that the use of vasoconstrictors is not advised as a rule in flap plasties,
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FIGURE 8. Diagrammatic representation of the posttraumatic dorsalis pedis

artery occlusion (X) revealed intraoperatively. Without arteriography, the pre-
operative diagnosis of the retrograde inflow to the first metatarsal and arcuate
artery from the plantar arterial system was very difficult and perhaps impossible.
no adverse effects with 1:200,000 Adrenalin® solution have been observed. Unavoidable
spasm of the vessels can be relieved quickly if warm compresses or papaverine® solution
are applied.
Tourniquet
The necessity for visualization of the fine anatomical structures lean many surgeons toward
operating with a tourniquet. Dissection of the exsanguinated limb is relatively easy and in
experienced hands the time needed for the flap elevation is about 2 hr. Some surgeons,
however, are rather adherent to the raise of the flap without using a tourniquet, as this gives
the possibility of permanent control of the artery pulsation. As a matter of fact this technique
is more tiresome and time consuming, but it secures better late bleeding control and can
reveal any unexpected damage or anomalies of the vessels. For example, thanks to such an
attitude the unavoidable failure could be prevented in one particular case ( presented sche-
matically in Figure 8).
Despite the dorsalis pedis artery posttraumatic segmental unpatency, the first metatarsal
and arcuate artery pulsation was diagnosed preoperatively as normal because of the retrograde
input from the plantaris artery system. As distal clamping of the dividing dorsalis pedis
artery resulted in pulsation interruption of the above vessel, further dissection was stopped
just in time to avoid necrosis of the detached part of the dorsalis pedis flap.
Surgical Dissection
The dissection is started by incising the skin down to the subcutaneous tissue distally and
to the level of the deep fascia on the medial side. The skin edge is elevated with hooks or
heavy sutures and the dissection continues superficially into the deep fascia and extensor
hallucis longus tendon. On the lateral side of this tendon both layers of the deep fascia are
incised and the periosteum of the first metatarsal and cuneiform bones is encountered. The
distal insertion of the extensor hallucis brevis muscle is divided (Figure 9). Careful dissection
at the level of the cuneiform bone allows for the dorsalis pedis artery, venae comitantes,
and deep peroneal nerve identification. Next, the dissection is carried deep enough to elevate
the fatty tissue of the intermetatarsal space, tracing the artery distally to the point at which
it disappears between the two heads of the first interosseous muscle. From here extreme
FIGURE 9. Elevation of the medial part of the flap. Clearly visible is the tendon of
the extensor hallucis brevis.
caution has to be exercised until the Y-shaped pattern of the disappearing dorsalis pedis
artery and the dorsal metatarsal branch becomes clearly visible (Figures 10A and B).
Next, the incision in the first web is deepened and both the deep peroneal nerve and the
first dorsal metatarsal vessels are divided (Figure 11). The described maneuver allows for
rough orientation of the course of the artery in relation to the interosseous muscle. Both
proximal and retrograde dissection done carefully down to the level of the metatarsal artery
results in separation of the intervening section of the flap from the interosseous muscle. If
the above-described artery runs through the muscle belly all the fibers above this level have
to be included in the flap as intermetatarsal fatty tissue. If the operation is performed with
a tourniquet, the division of the venae comitantes and dorsalis pedis artery distally to its
bifurcation is done without clamping the vessels, which are secured later when the flap is
released.
Dissection without a tourniquet demands precise prior ligation of the vessels, which is
rather difficult because of the narrow space between the metatarsals. Unquestionably, profit
from such an attitude consists in the possibility of immediate control of the metatarsal artery
patency as an increased input results in its clearly visible pulsation. Improper dissection and
damage to the vessels are rather irreparable in this region. As only a slight part of the flap
is elevated it can be sutured back and no essential damage to the foot occurs.
If dissection of the first metatarsal space is successful no further important obstacles are
expected, so the remaining incision around the whole flap can be finished. Attention is now
turned to the lateral side of the flap which is dissected just superficially to the paratenon of
the extensor tendons. Above the dorsal veins and perforating vessels, the divided branches
of the superficial peroneal nerve are included if a sensory flap is required (Figure 12).
After dissection of the flap from the dorsal aspect of the second metatarsal and cuneiform
bones the proximal end of the extensor hallucis brevis tendon has to be identified. The
tendon is divided at its origin and the muscle belly is pulled back laterally giving access to
the underlying dorsalis pedis artery. The artery is cleared of small adhesions to the periosteum
Volume I 445
FIGURE 10. (A) Diagrammatic representation of the T- and V-shaped pattern of bi-
furcation of the dorsalis pedis artery; (B) dissected bifurcation.
and all the neurovascular bundle is traced proximally (Figure 13). Further dissection depends
on the recipient vessel diameter and on their distance from the recipient bed. If a long pedicle
is needed the extensor retinaculum is exposed and divided over the course of the artery. In
this region, separation of the skin from the dorsalis pedis artery is unavoidable. That is why
the arterial pedicle comes into contact with the long flap several centimeters distally to the
proximal end of the skin (Figures 13 A and B). Dissection above the level of the ankle joint
is rather uncommon and demands that not only the tarsal but also the malleolar branches be
ligated. Usually, very long pedicles are not required so much for the free flap transfer, but
rather when an island flap transposition to the heel or to the upper leg is planned (Figure
14).
To diminish the period of ischemia as much as possible division of the vessels is done at
the very last moment, when the recipient site is fully prepared for immediate anastomosis.
Despite precise manufacturers' tests, the conventional vessel clips probably exert some
FIGURE 11. Dissected first dorsal metatarsal artery and the deep
peroneal nerve.
FIGURE 12. Three fourths of the flap is elevated. Divided tendon of the extensor
hallucis brevis is held in the pean.
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FIGURE 13. (A and B) Totally detached flap, ready for transfer.
unnecessary trauma to the vascular walls, so the donor site vessels are not closed at all at
the end of dissection and during the anastomosis procedure, or sometimes clips of our own
production, made from metallic plates and rubber ribbons, are gently applied (Figure 15).
FIGURE 14. Island flap on very long pedicle.
FIGURE 15. Author's clips made from metallic plates and

rubber ribbons.
Cut ends of the vessels are not prepared in the conventional manner either. The adventitia
is not removed but rolled back according to the unpublished Strzyzewski method in order
to produce some kind of a muff when vessel anastomosis is accomplished (Figure 16).
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FIGURE 16. Diagrammatic representation of the adventitial muff.
Donor Site
As the skin of the foot is rather inextensible all secondary defects, even if produced by
small flap elevation, always demand skin grafting. As for take of the grafts the vascularized
bed is a fully evident and essential condition, all paratenon ruptures have to be repaired in
a careful manner and eventual defects covered with the belly of the extensor brevis muscle.
To achieve good quality of the donor site cover, as a rule, very thick skin grafts (three
fourths of the whole skin) are preferred exclusively. On the graft covered with oiled gauze
the paraffin-soaked cotton dressing is used and plaster immobilization applied. On the next
day the dressing is removed and the eventual small seroma and hematoma are incised and
emptied by gentle rolling pressure. The second — dry, as a rule — dressing remains intact
for a period of 5 to 7 days when the stitches are removed and daily greasing is started and
continued for a period of many weeks. Moderate limb elevation is maintained for at least
two postoperative weeks, and when ambulation is allowed (1 to 2 weeks later) compressive
bandage or elastic stockings are mandatory for a 2- to 3-month period.
Delaying grafting — although advised by some authors19 — seems to be rather unnecessary
and even risky, as there is a danger of paratenon desiccation and necrosis. So, if the temporal
wound cover with biological dressing cannot be secured, the author is rather adherent to
immediate grafting. In spite of the irregular surface (first intermetatarsal space) and very
thin vascularized layer of tissue (paratenon), the grafts take quite well as a rule. Most
frequently, small graft losses occur over the first intermetatarsal surface, but they heal rapidly
and demand secondary grafting procedure only exceptionally.
Late results are good as a rule, too, and during the 5-year period in over 20 patients no
significant problems concerning the donor site cover were noted, with one exception of a
small papillomatous reaction in the first metatarsal space (Figure 17). Protective sensitivity
of the grafted surface returns quite well, too, and significant denervation is noted exclusively
over the extensor of the hallucis longus tendon.
MODIFICATIONS
Neurovascular Flap
As it was mentioned before, to convert the standard flap into a neurovascular one simply
involves keeping the superficial branches of the common peroneal nerve as they are, su-
perficial to the paratenon proximally and tracing them to a common trunk. Despite rather
poor sensitivity they are distinctly superior to ordinary flaps,20 and achievement of adequate
sensation to the weight-bearing areas and to the hands has already been proven several times
(see later). Donor site disability does not present any essential problems as only dorsal,
nonweight-bearing areas of the foot are insensitive. So, the consequences of the neurovascular
flap excision are not harmful to the patients, the more so since after several months quite
adequate return of the protective sensation is noted.
FIGURE 17. Donor site appearance 3 years after

surgery.
Osteocutaneous Flap
Among the many bones underlying the skin of the dorsalis pedis flap the second metatarsal
is both the longest and the most readily available. Its periosteum receives the blood supply
from the first dorsal interosseous muscle which, in turn, receives a small branch from the
region of bifurcation between the dorsalis pedis and arcuate artery. So, to achieve a vas-
cularized segment of bone, both the muscle and periosteum should be elevated together.
The segment of bone 6 to 7 cm in length can be obtained with preservation of the cunei-
formmetatarsal and metatarsophalangeal joints. Division of the bone graft in 1-cm distances
from the above joints allows one to maintain the integrity of the proximal and distal transverse
arches of the foot. The secondary defect is covered with a split graft in the usual manner.
Quite marked depression in the dorsum of the foot shallows with the passage of time.
Extended Flap
In addition to typical flaps, the possibility of the use of the first web dissection together
with adjacent parts of the big and second toe is well-known today and very useful in clinical
practice.1'4'5-6'717
Apart from the small branches to the muscle and dorsal skin the first dorsal metatarsal
artery, the diameter of which is from 1 to 1.5 mm, gives off two articular branches to
metatarsophalangeal joints and the dorsal branches for the second and big toe, essential for
extended flap nutrition.3,6 Next, the artery takes a plantar direction where it is joined by the
first plantar metatarsal artery and branches off to give plantar collateral arteries to the first
and second toe (Figure 18). If a sensory flap is planned, the terminal cutaneous branch of
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FIGURE 18. Arterial system of the first metatarsal space.
the deep peroneal nerve is dissected (it lies close to the artery). If, however, hemipulps are
to be included, the common digital nerve of the first web space is dissected as the pulps of
the first and second toes are innervated by the terminal branches of the medial plantar nerve.
The plantar approach is necessary for isolation of the plantar common digital nerve. Free
partial toe dissection for finger reconstruction according to the Foucher et al.4 method is,
as a matter of fact, quite similar, and the only difference consists of bone which is included
in the flap.
CLINICAL APPLICATION
Although theoretically the dorsalis pedis flaps are suitable for coverage anywhere a defect
of appropriate size is to be filled there are some limitations to their use, such as a need for
a deep contour or a hairy defect replacement. Table 1 illustrates the use of the dorsalis pedis
flaps in several regions of the body.
Head and Neck

Such characteristics as suitable texture, good color match, and relative thinness belong
to the main decisive factors in the use of dorsalis pedis flap to resurface the defects in the
head and neck region. 11617 Usually, in the majority of cases ordinary flaps are applied (Figure
19), but occasionally the use of composed flaps suitable, e.g., for nose reconstruction, may
be taken into consideration too. The latter flaps, including the second metatarsal bone, are
especially suitable for filling intraoral defects of the mucosa and mandible. They are distinctly
less bulky than groin or osteocutaneous rib grafts and, what is also very important, their
long pedicles make possible quite distant anastomoses which prevent eventual contamination
and allow for a choice of relatively large recipient vessels.911 Late results of intraoral
Table 1
THE CLINICAL APPLICATIONS OF VARIOUS FLAPS
TO DIFFERENT REGIONS OF THE BODY
I S L A N D ' F R E E
O R D 1 NARY SENSITIVE ORDINARY SENSITIVE COMPOSED 1
ORAL CAVITY X X
FACE AND
NECK X X
HAND X X X I
LEG
X X
FOOT X X
resurfacing with dorsalis pedis flaps seem to be encouraging as well, since they remain soft,
pliable, and resistant to eventual disadvantageous changes for many years (Figure 20).
Hand
Increasing management of the dorsalis pedis free flaps with extensive and deep contractures
of the hand is connected mainly with sensory nerve potential. Insofar as conventional flaps
could offer no more than cover deprived of sensitivity, some deterioration of the hand
function is regarded as unavoidable, because eventual use of small neurovascular flaps (e.g.,
Littler's) only have limited application anyway. Dorsalis pedis free flap transfer to the hand
lends itself to quite easy and very efficient procedures. In the author's experience excellent
return of sensitivity was noted, and once the two-point discrimination test was even better
than at the donor site, probably due to the larger cortical representation (Figure 21).
In the majority of cases both vessels and nerves are dissected in the snuffbox region where
the superficially lying radial artery, the subcutaneous vein, and the sensitive branch of the
radial nerve are of convenient size for anastomosis. A subcutaneous tunnel from the recipient
bed to the snuffbox region should be large enough and, in addition to the neurovascular
pedicle, the convenient space for eventual suction drain application should not be neglected.
If only small flaps are required for finger reconstruction (Figures 22 and 23), the extensive
tunnel dissection is of no use and the so-called short pedicle anastomosis is more reasonable.
To avoid the vessel size discrepancy the digital vessels are avoided and larger ones at the
metatarsal level are considered to be more suitable. The same attitude is advised if extended,
composed flaps for thumb reconstruction according to the method of Foucher et al.4 is
planned (Figure 24). Above it, in such cases, the rotation of the neurovascular pedicle from
the dorsal to the volar surface is to be borne in mind.
Leg
At the very beginning of the microsurgical era the indications for free dorsalis pedis flap
transfer seemed to be more evident and also perhaps excessive (Figure 25). With the passage
of time, however, the island flaps have become increasingly more popular as a relatively
simple method of treatment. Provided that both major arteries are patent, such flaps are
especially suitable for management with open fractures of the tibia (Figures 26 and 27). In
our own material they are used mostly in chronic cases, and in spite of a case of osteomyelitis
no failures have been noted so far.
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FIGURE 19. (A) Postburn contracture of the neck; (B) result of

surgery 4 years later; quite acceptable color match and texture of the
dorsalis pedis flap.
FIGURE 20. Intraoral appearance of the dorsalis pedis flap 19 months after surgery.
Foot
Efficient and durable covering of the weight-bearing areas presents a real challenge to
orthopedic and plastic surgeons. Sensory dorsalis pedis island or free flap introduction have
brought new possibilities which, in the author's opinion, merit wider application and po-
pularization (Figures 28 and 29).
Transposition of the island flaps with preservation of the peroneal nerve branches to the
heel region is sometimes difficult, however, as the extensor hallucis longus tendon stands
out in dorsalis pedis artery mobilization. If it is crossing at a high level, the dorsalis pedis
artery transposition under the extensor hallucis longus tendon is quite possible, but in the
exact opposite situation perhaps the temporary division of the tendon is the worthy solution.
As the sensitivity is not disturbed the island flaps are an ideal material for covering the
weight-bearing areas. Hypersensitive reactions seem to be uncommon and transient as a
rule.
Although more complicated, dorsalis pedis free flap transfer allows for greater malleability
and can be used in all regions of the foot. As such relatively small flaps are insufficient to
cover extensive scalpation injuries or other large defects of the foot, they are used exclusively
in the weight-bearing areas as one can see in Figure 30. Another solution consists of using
the so-called extended flaps, covering the skin of the first web space (Figure 31).
The sensitivity returns after a period of 2 to 3 months and even if it is not ideal (two-
point discrimination test from 20 to 30 mm) it is always superior to the questionable protective
sensitivity of the conventional flaps.20 Anyway, during 16 years of practice the author has
not seen any patient with a really stable ordinary flap to the weight-bearing areas. Thanks
to the introduction of sensory dorsalis pedis flaps one can, at last, present normal living and
walking patients (Figure 32).
Critical Evaluation
Apart from the undeniable reconstructive advantages, the dorsalis pedis flap transfer, like
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FIGURE 21. (A) Severe postburn deformity of the hand. (B) The neurovascular
free dorsalis pedis flap revealed a two-point discrimination test between 8 and 10
mm 6 months after the operation. During the 3-year observation the sensitivity
even improved and actually is better than on the donor site.
many other surgical methods, is connected with s o m e unavoidable and eventual pitfalls and
shortcomings. The list of the shortcomings is related to the flap itself, which includes their
limited size and difficult dissection. The main objections concern the donor site, however
such as unavoidable grafting, prolonged morbidity, unpleasant appearance, and foot insta-
bility due to the removal of the second metatarsal bone. Last but not least, the most important
objection is related to the sacrifice of the big artery which may result in later impairment
of the blood supply to the foot due to eventual arteriosclerosis development.
So far, both weakening of the transverse arches and blood supply problems to the foot
are, to be sure, rather theoretical objections, but it is still too early to give conclusive
opinions on this subject. Further observations and collection of more material will be nec-
essary and of great value.
FIGURE 22. (A and B) Posttraumatic severe contracture of the fin-

gers; (C) small flap applied to both fingers; and (D and E) late result
of treatment.
SUMMARY
In the armamentarium of plastic and reconstructive surgery, the dorsalis pedis flap transfer
is indeed a very useful and worthy method. Its management should be evaluated with regard
to the surgical goals and in relationships to various regions of the body. If planned exclusively
as ordinary covering of skin defects, despite their known qualities one should regard them
as one of the many choices available, although not always the optimal solution. The need
of composed reconstruction (e.g., after partial resection of the mandible) does increase the
value of the discussed flap significantly as there are only two other alternative free flap
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FIGURE 22C
choices and both of them are of rather poor quality. The same and even higher estimation
is produced if a large sensitive area repair is demanded. Apart from some pedicled flaps
(e.g., flexor digitorum brevis musculocutaneous flap in the plantar region) and in addition
to the tensor fascia lata free flap, the dorsalis pedis flaps represent perhaps the best and
sometimes the only possibility of successful reconstruction.
FIGURE 22D
FIGURE 22E
FIGURE 23. Small flap appliance in treatment of a deep electric burn to the
hand.
Volume I 459
FIGURE 24. Partial thumb reconstruction according to Foucher et al.4

method. (A) Preoperative drawing; (B) reconstructed part of the finger
ready for transfer; (C) preoperative condition and (D) early result of surgery.
FIGURE 24C
FIGURE 24D
Volume I 461
FIGURE 25. Free dorsalis pedis flap in repair of the postelectric burn of the
foot. (A) Before surgery; (B) late result of treatment.
FIGURE 26. Late result of the island dorsalis pedis

flap appliance in treatment of the chronic osteomyelitis.
FIGURE 27. Management of island dorsalis pedis flap on very

long pedicle in treatment of the open fracture of the tibia.
Volume I 463
FIGURE 28. Transposition of the island flap to the calcanear

region. (A) Before surgery; (B) result of treatment 3 years later.
FIGURE 29. Management of free dorsalis pedis sen-

sory flap in covering of the calcanear region. (A) Before
surgery; (B) result of treatment. Normal sensitivity was
attained 2 years after operation.
FIGURE 30. (A) Severe scalpation injury of the foot before treatment; (B) unsuccessful result of reconstruction with tubular flap (chronic ulceration); and (C)
sensory dorsalis pedis flap in situ.
Volume I
465
466
FIGURE 31. The use of the extended dorsalis pedis flap for covering of the plantar surface. (A) Elevation of the extended flap; (B) chronic ulceration as a result
of a crushing injury; and (C) postoperative appearance (operation by Dr. J. Stepniewski).
FIGURE 32. (A) Posttraumatic chronic ulceration of the foot before treatment; (B) unsuccessful repair with cross-leg flap, and (C) sensory dorsalis pedis free flap
2.5 years after transplantation. Good protective sensitivity. Two-point discrimination test is between 8 and 20 mm. The patient works as a farmer.
Volume I
467
REFERENCES
1. Chait, L. A., Cort, A., and Braun, S., Upper and lower eyelid reconstruction with a neurovascular free
flap from the first web space of the foot, Br. J. Plast. Surg., 33, 132, 1980.
2. Daniel, R. K., Terzis, J., and Midgley, R. D., Restoration of sensation of an anaesthetic hand by a free
neurovascular flap from the foot, Plast. Reconstr. Surg., 57, 275, 1976.
3. Daniel, R. K., Terzis, J. K., and May, J. W., Jr., Neurovascular free flaps, in Microvascular Composite
Tissue Transplantation, Serafín, D. and Buncke, H. J., Eds., C. V. Mosby, St. Louis, 1975, 285.
4. Foucher, G., Merle, M., Maneaud, M., and Michon, J., Microsurgical free partial toe transfer in hand
reconstruction: a report of 12 cases, Plast. Reconstr. Surg., 65, 616, 1980.
5. Gilbert, A., Morrison, W. A., Tubiana, R., Lisfranc, R., and Firmin, F., Transfert sur la main d'un
lambeau libre sensible, Chirurgie, 101, 691, 1975.
6. Gilbert, A., Composite tissue transfers from the foot: anatomic basis and surgical technique, in Symposium
on Microsurgery, Daniller, A. I. and Strauch, B., Eds., C. V. Mosby, St. Louis, 1976, 230.
7. Hamilton, R. B. and Morrison, W. A., Microvascular segmental thumb reconstruction: a case report,
Br. J. Plast. Surg., 33, 64, 1980.
8. Kobus, K., Licznerski, A., Stepniewski, J., and Charko, W., Management of island and free dorsalis
pedis flaps in surgery of lower extremities, Acta Chir. Plast., 22, 132, 1980.
9. Kobus, K., Licznerski, A., Stepniewski, J., Wiertel, L., and Charko, W., The surgical treatment of
vascular tumors of the face, J. Max - Fac. Surg., 10, 99, 1982.
10. Kobus, K., Stepniewski, J., and Charko, W., History and remarks on clinical use of groin, dorsalis,
pedis and musculocutaneous latissimus dorsi free flaps, Acta Chir. Plast., 24, 66, 1982.
11. Leeb, D. C , Ben-Hur, N., and Mazzarella, L., Reconstruction of the floor of the mouth with a free
dorsalis pedis flap, Plast. Reconstr. Surg., 59, 379, 1975.
12. McCraw, J. B. and Furlow, L. T., The dorsalis pedis arterialized flap: a clinical study, Plast. Reconstr.
Surg., 55, 177, 1975.
13. Morrison, W. A., O'Brien, B. Mc. C , Macleod, A. M., and Gilbert, A., Neurovascular free flaps
from the foot for innervation of the hand, J. Hand Surg., 3, 235, 1978.
14. O'Brien, B. Mc. C. and Shanmugan, N., Experimental transfer of composite free flaps with microvascular
anastomoses, Aust. N. Z. J. Surg., 43, 285, 1973.
15. Ohmori, K. and Harii, K., Free dorsalis pedis sensory flap to the hand, with microneurovascular anas-
tomoses, Plast. Reconstr. Surg., 58, 546, 1976.
16. Ohmori, K., Sekiguchi, J., and Ohmori, S., Total rhinoplasty with a free osteocutaneous flap, Plast.
Reconstr. Surg., 63, 387, 1979.
17. Ohtsuka, H., Torigai, K., and Shioya, N., Toe-tip-to-nose transplant with long vascular pedicle, Kitasato
Med., 8, 113, 1978.
18. Robinson, D. W., Microsurgical transfer of the dorsalis pedis neurovascular island flap, Br. J. Plast.
Surg., 29, 209, 1976.
19. Robinson, D. W., Dorsalis pedis flap, in Microsurgical Composite Tissue Transplantation, Serafín, D.
and Buncke, H. J., Jr., Eds., C. V. Mosby, St. Louis, 1979, 257.
20. Roffe, J. L., Magalon, G., and Bureau, H., La resensibilisation des lambeaux à distance, Ann. Chir.
Plast., 26, 205, 1981.
21. Serafín, D., Sabatier, R. E., Morris, R. L., and Georgiade, N. G., Reconstruction of the lower extremity
with vascularized composite tissue: improved tissue survival and specific indications, Plast. Reconstr. Surg.,
66, 230, 1980.
22. Tropet, Y., Merle, M., Vichard, P. H., and Michon, J., Reconstruction des teguments du talon par
lambeau libre et lambeau en ilôt, Ann. Chir. Plast., 26, 213, 1981.
Volume I 469
POSTOPERATIVE MONITORING IN RECONSTRUCTIVE

MICROSURGERY, WITH SPECIAL RESPECT TO TRANSCUTANEOUS
OXYGEN MEASUREMENTS
Arlan R. Smith, Wil J. Kort, G. Jan Sonneveld, and Jacques C. van der Meulen
INTRODUCTION
The experience of a failing replantation or a failing free tissue transfer after a long operation
is common knowledge for each reconstructive microsurgeon. The frustration that one ex-
periences is enhanced by the fact that no objective monitoring system which is more accurate
than the clinical picture is present. At present, survival of a replanted digit or a free flap is
judged by such clinical signs as color, warmth, and capillary refill, or by Doppler exami-
nation,1 plethysmography,2-3 and temperature recordings.4
Most monitoring devices cannot be used continuously. Consequently occlusion of arterial
and venous anastomoses may be of long duration and perhaps complete at the time that
reexploration, based on the present monitoring systems, is performed. There may be irre-
versible damage due to the period of undetected ischemia and this is probably the reason
why intervention is only successful in about 50% of the cases.
Since we are experienced with transcutaneous oxygen measurements in our department,
this paper will deal mainly with this type of postoperative monitoring in replantation surgery
and in free tissue transfer.
CLINICAL SIGNS
A disadvantage of the clinical signs such as color, warmth, and capillary refill is the fact
that all symptoms occur several hours after the actual thrombosis. Although some experienced
reconstructive surgeons claim that in their opinion the clinical picture is the most important
parameter, the subjective approach of each individual is quite different. It is well known
that sudden disappearance of capillary refill and decrease in warmth is suspect for arterial
occlusion, while on the other hand increase in warmth and capillary refill velocity will
indicate venous obstructions. In these obvious situations there is no doubt about the cause
and nature of the obstructed microcirculation. However, in less obvious cases the clinical
signs are not accurate enough and become fully manifest several hours after the actual
thrombus formation so that irreversible tissue damage might have occurred.
Temperature
Temperature recordings were one of the first postoperative monitoring systems in micro-
surgery. One of the most important disadvantages is that with this method it is almost
impossible to differentiate between arterial or venous occlusion. Moreover, external factors
like room temperature influence the temperature readings. Besides the above-mentioned
factors, the temperature does not react immediately when arterial or venous thrombosis
occur. This means that by the time the temperature drops, a long period of undetected
ischemia has already past. Therefore irreversible tissue damage might have occurred and
revisions of arterial or venous anastomoses are often not successful anymore (too late).
Doppler
For measurements within elective free flap transfer this instrument has proved disappoint-
ing. It cannot measure dermal blood flow; and indeed measurement of blood flow within a
vessel requires a frame to maintain the position of the probe relatively accurate to the skin
surface. Clinically, if the supplying blood vessel to a flap is being tracked, the point of
sudden cessation of sound may signify a point of obstruction or an increase in depth of the
blood vessel relative to the surface. Moreover, a positive Doppler sign does not provide any
information about blood flow through the vessel.
Photoplethysmography
It was recently demonstrated by Harrison et al., 5 in a series of 40 free flap transfers that
photoplethysmography can be successful in assessing vascular problems. The authors claim
that by using this method a clear differentiation can be obtained between arterial and venous
obstruction.
A disadvantage of the method is that the probe is still not commercially available. More-
over, with this technique only the blood flow in the superficial layers of the skin can be
detected, and therefore it is ineffective in patients with de-epithelialized free flaps placed
subcutaneously.
Clearance Studies
A number of radioactive isotopes have been employed for assessing blood flow in several
tissues. The disadvantages of this method are (1) only small areas (1 cm2) can be scanned;
(2) it is an invasive technique and cannot be performed continuously; and (3) too frequent
exposure to radioactivity is probably undesirable.
Oxygen Measurements
In a replanted finger or free tissue transfer (like a free musculocutaneous flap or a toe-
to-hand transfer) wound repair is completely dependent on sufficient blood flow and patency
of the nutrient vessels. The most reliable parameters for wound repair are glucose and oxygen
(Table 1). Therefore alterations of oxygen and glucose levels during the postoperative period
could indicate changes in the vascular status on the replant or transplant. Moreover, it is of
vital importance that by using these parameters a distinction between arterial or venous
occlusion can be established. In our department we are experienced with the use of trans-
cutaneous oxygen measurements in replantation surgery and in free tissue transfers. Since
it was shown in 1979 that in a replanted rabbit ear7 (Figure 1) it was possible to differentiate
between normal flow status and arterial or venous obstructions we started to monitor our
patients postoperatively using Tcp0 2 after replantations and elective microsurgery.
Technique
Several types of transcutaneous oxygen sensors are commercially available at the moment.
Using a Radiometer Copenhagen® TCM-1 unit we could obtain good results (Figure 2).
Like most of the available Tcp0 2 measuring systems, this unit measures oxygen by means
of a Clark-type electrode. An oxygen-selective membrane covers the electrode, trapping a
small amount of electrolyte solution. Conforming to the polarographic principle, the available
oxygen becomes reduced at the cathode, while the needed amount of electrons is therefore
delivered by the anode. In this way a shift in current is generated in the bipolar system,
whereas the basic potential remains constant at approximately —0.6 mV.
The electrode is attached to the skin with double-sided adhesive tape. A built-in heating
element heats the skin below the electrode to a preestablished temperature, causing complete
vasodilation of the dermal capillary plexus. This, together with a changed diffusion char-
acteristic of the epidermis, enables the available oxygen to diffuse through the skin toward
the electrode.
In intermittent monitoring an electrode temperature of 45°C can be chosen, but in con-
tinuous monitoring the temperature has to be limited to 42 or 42.5°C. Higher temperatures
Volume I 471
Table 1
MAIN ENERGY SOURCES
FOR WOUND REPAIR
Skin: Glucose
Connective tissue: Glucose
Bone: o2
Tendon: o2
Muscle: o2
Nerve: Glucose + 0 2
Endothelium: o2
P 0 2 REPLANTED EAR/CONTROL EAR
FIGURE 1. Oxygen levels measured within 72 hr after replantation

of a rabbit ear. Values are expressed in percent of the control ear
(contralateral). As is shown in this graph, in arterial occlusion p0 2 is
decreasing, while in venous occlusion p0 2 is increasing after 24 hr.
A ~ A success; O-O venous occlusion; and A-A arterial occlusion.
will result in superficial burns on free tissue transfers or replants when monitoring exceeds
1V2 hr. Burns were never seen on nonamputated tissue at 45°C even in prolonged monitoring
up to 4 hr.
FIGURE 2. Detailed picture of the transcutaneous oxygen

electrode.
The electrode must be calibrated between every two measurements to prevent false results.
Two-point calibration is performed using a special tonometer for calibration to room air and
by immersion of the electrode in a sodium sulfite solution to obtain zero adjustment. The
latter is needed only once a week. For oxygen measurements in replanted extremities and
free flap transfers, we have adapted the fixation rings by which the electrode is mounted to
the skin to a wide range of exact radii of digits and flaps. This enables proper adhesion to
the skin without influencing the measuring conditions. In fingers or toes the probe is attached
to the dorsum of one of the phalanges and in flaps the site for electrode attachment is
alternated each hour between base, center, and apex of the flap.
In replantation or free tissue transfer operations we measured pre-, per-, and postopera-
tively for 5 to 7 days, 24 hr/day. In addition, the Oxygen Response Test (ORT) was performed
routinely to obtain information about the metabolism of the tissue and the patency of the
anastomosis (Figure 3). For this purpose, oxygen (4 €/min) is inhaled by a Ventimask or
nasal tube while the probe is on the replanted or transferred part.
For measurements during operations, sterilization of probes and accessories is required,
which can be done quite easily. Halothane is known to interfere with transcutaneoeus oxygen
measurements.
Volume I 473
FIGURE 3. The shape of a normal Oxygen Response Test (ORT).

Horizontal axis: time in minutes and vertical axis: oxygen value expressed
in mmHg.
CLINICAL EXPERIENCE
Correlation Between p 0 2 Levels Using Micro-Astrup® or TCM

Previous studies have shown that capillary p0 2 level can be used as an objective parameter
for postoperative monitoring of the circulation in replanted fingers or hands. In humans it
has been demonstrated that capillary p0 2 levels show a characteristic pattern after successful
replantation.7 In animals p0 2 levels alter immediately after deliberately produced arterial or
venous occlusion.79 The former method of measuring capillary p0 2 had the disadvantage
of being one that cannot be used continuously and also requires invasive techniques. Both
of these factors render its clinical use far from easy.
In contrast, the TCM method enables continuous monitoring and is not invasive. In order
to compare the reliability of the TCM method with the capillary oxygen measurements both
methods were compared on a series of 130 patients. The patients, with an average age of
±35.6 years, were admitted to our department for routine plastic surgical operations (breast
reduction or reconstruction, abdominoplasty, bat ears, etc.) and p0 2 levels were measured
FIGURE 4. Oxygen values in successfully replanted fingers (n = 75). This diagram is used as a baseline and
if a significant change in p0 2 occurs (increase or decrease) reintervention is considered.
using the Micro-Astrup® and the TCM method. p0 2 was first measured by the TCM method
and then the Micro-Astrup® technique was employed in the same area. p0 2 levels were
measured using the TCM as well as the Micro-Astrup® method in those areas of the body
corresponding with the most frequently used axial pattern flaps, and on the fingers. There
appeared to be no significant difference between the Micro-Astrup® and the TCM method.
Replantation
p0 2 was measured using TCM on 65 replanted fingers in 45 patients. Monitoring was
continued for 7 days postoperatively and the neighboring digit used as a control. In the
beginning we were not experienced enough with the readings of our Tcp0 2 and waited until
the clinical signs indicated venous or arterial obstruction. After the third reexploration,
however, the p0 2 seemed to be a reliable parameter for monitoring microcirculation and we
started to rely completely on these measurements only. In one case only there was a negative
observation but no arterial thrombosis could be detected, probably arterial spasm contributed
to this false positive observation. The results are shown in Figure 4.
Free Tissue Transfer

In 12 free latissimus dorsi flaps and in 6 toe-to-thumb transfers p0 2 levels were determined
using TCM. Oxygen levels were measured with the flap still in situ after raising the flap
before the vascular pedicle was divided, and after microvascular transfer. Monitoring was
continued for 7 days after the operation.
Temperature recordings and clinical observations on the condition of the flaps were made
simultaneously (see Figures 5 and 6).
GENERAL COMMENTS
1. Our experience indicates that oxygen measurements are much more accurate than the
temperatures or the clinical picture in monitoring microcirculation (see an example of
a toe-to-thumb transfer in Figure 7.)
Volume I 475
FIGURE 5. Oxygen values in successfully transferred free latissimus dorsi flaps (n= 12).
FIGURE 6. Oxygen values in successfully transferred toe-to-thumb operations (n = 6).
In using oxygen levels as postoperative monitoring our success rate after reexploration
has increased (Table 2).
SUMMARY
The postoperative monitoring of the microcirculation with the use of transcutaneous oxygen
FIGURE 7. Graphicrepresentationof a toe-to-thumb transfer in which successful reexploration was performed.

At the top is the clinical picture, at the bottom are the temperature and oxygen levels at the same moment.
Table 2
SUCCESS RATE OF REEXPLORATION BEFORE AND AFTER
Tcp02 MEASUREMENTS
No. of No. of No. of Total success

replantations failures successful reexploration rate (%)
Before TcpOz 62 13 42 82
After Tcp0 2 65 14 102 90
Statistically significant (p = 0.05).
measurements has been described in 75 replantations and 12 free tissue transfers. Using this
method, it is possible to recognize arterial or venous occlusion earlier than with temperature
measurements or the clinical picture.
Volume I 477
REFERENCES
1. Freed, D., Hartley, C. J., Christman, K. D., and Lyman, H. C , High frequency pulsed doppler
ultrasound; a new tool for microvascular surgery, J. Microsurg., 1, 148, 1979.
2. Denck, H., Kobinia, G., and Weidinger, P., Surgical therapy and results in arterial occlusive disease of
the upper extremities, in Pain in Shoulder and Arm: An Integrated View, Greep, J. M., Urshel, H., and
Lemmens, J. A. M., Eds., Martinus Nijhoff, Gravenhage, 1979.
3. Creech, B. J. and Thorn, F. L., The pocket plethysmography, Plast. Reconstr. Surg., 49, 380, 1972.
4. Smith, A. R., Sonneveld, G. J., Kort, W. J., and van der Meulen, J. C , Clinical application of
transcutaneous oxygen measurements in replantation surgery and free tissue transfer, J. Hand Surg., 8(2),
186, 1983.
5. Harrison, D. H., Girling, M., and Mott, G., Experience in monitoring the circulation in free flap transfers,
Plast. Reconstr. Surg., 68(4), 543, 1981.
6. Webster, M. H. C. and Patterson, J., The photoelectric plethysmograph as a monitor of microvascular
anastomosis, Br. J. Plast. Surg., 29, 182, 1976.
7. Smith, A. R., Sonneveld, G. J., Kort, W. J., and van der Meulen, J. C , Clinical application of
transcutaneous oxygen measurements in replantation surgery and free tissue transfer, J. Hand. Surg., 8(2),
190, 1983.
8. Achauer, B. M., Black, K. S., and Litke, D. K., Transcutaneous p0 2 in flaps. A new method of survival
prediction, Plast. Reconstr. Surg., 65(6), 738, 1980.
9. Matsen, F. A., Ill, Bach, A. W., Wyss, C. R., and Simmons, C. W., Transcutaneous p0 2 ; a potential
monitor of the status of replanted limb parts, Plast. Reconstr. Surg., 65(6), 732, 1980.
Volume I 479
ISCHEMIA TIME INFLUENCING FREE SKIN FLAP SURVIVAL
Shuhei Torii
INTRODUCTION
Recent advances in microvascular surgery have introduced new techniques in tissue trans-
plantation and replantation. The clinical advantages of free skin flap transfers by microvas-
cular anastomoses have been clearly demonstrated since Daniel and Taylor1 first described
them in one of their early reports. Free skin flaps can be transferred to any site on the body,
but serious consideration must be given to the ischemia time of the flap from when it is
lifted from the donor site to when revascularization occurs at the recipient site. Ischemia
time varies with the surgeon's techniques and procedures. Postsurgical thrombus formations
may occur at the anastomosis site resulting in ischemia. It is essential for the surgeon to
know the isolated flap tolerance relating to the duration of ischemia, and how to safely
prolong the flap ischemia time.
In this chapter the author describes studies made on ischemia and its relation to flap
survival, and discusses some of the reasons for their failure to survive along with ways that
ischemia time may be safely prolonged.
ISCHEMIA TIME AND FLAP SURVIVAL
Experiments were carried out to further our understanding on the influence of ischemia
time upon the survival of free skin flaps.
Torii etal.2 demonstrated the relationship between the ischemia time of isolated rat skin
flaps and their survival after being transferred. The rat's abdominal flaps were lifted and
then nourished by the superficial epigastric artery and vein (Figures 1 and 2). The isolated
flaps were then divided into two groups; one group being wrapped in saline gauze and stored
at a room temperature of 20 to 25°C (their actual skin temperature being 15 to 20°C), and
the other group being refrigerated at a temperature of 4 to 6°C. All the flaps were revas-
cularized by microvascular anastomoses after storage, and none of the rats were given
postsurgical systemic anticoagulants. The results of these procedures are shown in Figure
3. The transferred flaps tended to be edematous when the ischemia time was prolonged, but
edema development was delayed in those flaps that were refrigerated (Figure 4). As the
periods of ischemia time increased, reestablishment of the flap pedicle, venous return was
not seen and eventually resulted in the flap becoming necrotic. Necrosis developed in those
flaps that were cooled for 72 hr even though dermal bleeding was seen at their edges. This
is believed to be the result of the venous circulation of the flap becoming impaired. Based
on histological findings, degeneration of vessels and fatty tissue was the most important
ischemic change in the skin flaps. This study showed that ischemia of 9 hr or less at room
temperature will not adversely affect survival of transferred rat skin flaps, and that survival
of ischemic flaps of 24 hr duration is possible. Adverse effects in ischemic flaps cooled for
48 hr were negligible.
Milton3 demonstrated that the average island flap in pigs can tolerate about 13 hr ischemia,
and that signs of the blood initial inflow were seen in flaps averaging 18 hr of ischemia.
This is 5 hr longer than prior survival rates.
May et al.4 studied the no-reflow phenomenon in ischemic free rabbit epigastric flaps.
The isolated flaps rested in a site at the surface of the skin, and their temperatures were
slightly less than normal. All the flaps survived in the 1- and 4-hr ischemia groups, 12 out
of 15 (80%) survived in the 8-hr ischemia group, and 15 flaps expired in the 12-hr ischemia
FIGURE 1. The rat donor and recipient site.
FIGURE 2. The free flap is nourished by the superficial epigastric artery and
vein which were dissected with a cuff formed from their femoral vessels.
group. Venous aggregates in the flap vessels developed before anastomosis when ischemia
periods were increased. Delay of venous filling of the pedicle, sludge, and thrombi were
seen in the microcirculation after revasculavization when periods of flap ischemia were
Volume I 481
FIGURE 3. Survival rates of the flaps related to ischemia time rats (10 rats in each group).
prolonged. They concluded that free epigastric rabbit flaps can be reliably transferred with
100% flap survival within a 4-hr ischemia time.
The different results of flap survival described by May et al.4 and Torii et al.2 seem to
be the result of the ischemia temperature of the flaps and the selection of the animals that
were experimented on. The flap temperatures reported by May et al.4 were higher than those
of Torii et al.2 This indicates that temperature is a very important factor concerning the
survival of ischemia flaps. There is a difference between experimental animals, and Willms-
Kretschmer and Majno5 showed that while there was no gross damage to rabbit skins, rat
skins necrosed after 8 hr of ischemia.
Donski et al.6 demonstrated that 97% of rabbit flaps survived after being cooled for 24
and 48 hr and that 14 out of 20 flaps survived when cooled for 72 hr. They concluded that
6 to 7°C cooling for 48 and/or 72 hr can significantly increase ischemia flap survival, and
that the 72-hr cooling factor was shown to be about 70% effective. Edema and inflammation
increased proportionately with the duration of ischemia and revascularization, and were
especially noticeable in the fatty tissue. The most significant changes were noticed in the
muscle tissue, while fatty tissue was second in histological degeneration. The epidermis and
small vessels showed little histological changes.
Anderl7 reported the successful clinical transfer of a free groin flap after storing it for 30
hr at a temperature of 4°C. Lower molecular dextrans and anticoagulants were given after
the operation. The flap survived without complications.
Ischemia flaps were clinically classified into three categories:
1. Ischemia flaps isolated during the operation

2. Ischemia flaps problems caused by faulty vascular anastomoses
3. Ischemia flaps that were refrigerated
Temperature was the only variation in the above categories, resulting in the maximum
toleration time for ischemia, being different in each category.
482
FIGURE 4. Transferred flaps 2 days postop: (A) 24-hr cooling ischemic flap shows slight swelling; (B) 48-hr cooling ischemic flap shows
severe swelling. (From Torii, S., Harii, K., and Ohmori, K., Chir. Plast., 4, 225, 1979. With permission.)
Volume I 483
Although application of experimental animal data to humans is seldom without hazard,

several of the observations made in these studies may have some clinical application. Skin
flap toleration time for ischemia in humans, in the author's opinion, is generally less than
in animals due to man's greater volume of fatty tissue.
The author's clinical experience has shown that an ischemia time of around 4 hr during
an operation does not influence the survival of a transferred free skin flap. This study also
indicated that ischemia in clinical free skin flap transfers could safely be prolonged for more
than 4 hr. The author further concluded that greater concern should be directed toward the
accuracy of vascular anastomosis techniques or vein grafts even if the ischemia time may
exceed 4 hr.
Ischemia flap problems caused by faulty vascular anastomoses require early diagnosis and
treatment. An onset of complications should always be anticipated because the flap toleration
time ranges under 4 to 6 hr.4-8 Therefore, the flap blood circulation should be continuously
monitored.
CAUSES OF FLAP SURVIVAL FAILURE
Successful transfer of free skin flaps depends on:
1. The patency of anastomoses

2. The viability of the flap
3. The circulation system of the flap
It should be noted that ischemia can adversely influence all of the above factors, and that
when ischemic vessels dilate they become fragile, and that manipulation of anastomosed
ischemic vessels may result in thrombus formation.
Donski et al.6 however, demonstrated that the dead flaps showed marked edema and
scattered thrombi in their peripheral vessels, but the large microvascular anastomed vessels
supplying the flaps were generally patent and had no thrombosis.
Each tissue composing the flap varied in its sensitivity to ischemia. Significant histological
changes were initially observed in the flap's fat and blood vessels. 2 ' 5911 The viability of
the skin was preserved for about 3 weeks in a moist environment at 4°C.12 Skin seems to
tolerate ischemia more than other tissues do.
Takata14 studied energy metabolism of ischemia flaps on wounds in rats in order to clarify
the critical time for ischemic flap survival. Adenosine triphosphate (ATP), adenosine di-
phosphate (ADP), energy charges, and glucose levels were examined. Ischemia markedly
reduced the ATP levels of the flaps 5 hr after they were ligated (30.4% of the nonischemic
control). Reflow of arterial blood into the island flaps in the 3-, 5-, and 7-hr ischemic groups
resulted in complete recovery of their ATP levels within 24 hr. The 12-hr ischemic group,
however, gained only partial restoration of their ATP levels.
Ischemic flaps seem to become necrotic before they lose their tissue viability. Failure of
flap survival may directly result from cessation of circulation in the flap rather than loss of
viability of the flap.
The no-reflow phenomenon is also very significant in the ischemic flap. There are two
basic explanations for the no-reflow phenomenon. One is edema and swelling, and the other
is sludge and thrombus formation.
Chait et al.15 demonstrated that an ischemia-related obstruction in the peripheral blood
flow occurred in the absence of stagnant ischemic blood. They emphasized the importance
of cellular swelling and of interstitial edema in the pathogenesis of the no-reflow phenom-
enon. The author's research agrees, and is supported by the following:
1. Washout of the blood by whole flap perfusion before storage does not prolong ischemia
from developing.
2. Nonelastic tissue, such as finger skin, has less tolerance for ischemia than does free
skin flap.
In other words, edema seems to be followed by thrombosis.
PROLONGATION OF ISCHEMIA TIME
Cooling of Tissue
Cooling of tissue can generally prolong the time before ischemia develops. It can prolong
the duration of ischemia thereby permitting successful revascularization of free skin flaps
and amputated fingers, and cooling at a temperature of 4°C is a simple and practical method.
Perfusion
Perfusion techniques are applied in tissue transplantations, but it is generally accepted
that perfusions are not necessary for isolated skin flap transfers.
Chait et al.15 studied the effects of solution perfusion in free skin flaps of rabbits before
and after normothermic ischemic periods. Flaps perfused before ischemia had survival rates
below those flaps perfused after ischemia. All fluids used for perfusion after ischemia
developed were not beneficial in promoting flap survival. However, mannitol solutions did
have protective effects on fatty tissue survival.
Harashina and Buncke16 demonstrated that no perfusion was better than perfusing groups
of rats undergoing leg replantations.
The purposes of perfusion are to wash out blood, cool the flap, and maintain flap me-
tabolism. No microsurgical anastomosis may be necessary when perfusion is successful in
maintaining the metabolism of free skin flaps until neovascularization between the flap and
recipient site has begun.
Improvement in methods of perfusion and storage of flaps may permit extension of
ischemia time. This may be an important factor in future transplanted human skin flaps.
Further research is needed in coagulation and fibrinolysis of ischemic skin flaps.
SUMMARY
Ischemia time and flap survival, causes of flap survival failure, and prolongation of
ischemia time were described in this chapter.
Our study indicated that ischemia of 9 hr or less at room temperature does not adversely
affect the survival of transferred rat skin flaps, and that any adverse effects in ischemic flaps
cooled for 48 hr were negligible.
The author emphasized the importance of cellular swelling and interstitial edema as
causative factors when ischemic flaps fail to survive.
Volume I 485
REFERENCES
1. Daniel, R. K. and Taylor, G. I., Distant transfer of an island flap by microvascular anastomoses, Plast.
Reconstr. Surg., 52, 111, 1973.
2. Torii, S., Harii, K., and Ohmori, K., Experimental study of ischemia time influencing free skin flap
survival, Chir. Plast., 4, 225, 1979.
3. Milton, S. H., Experimental studies on island flaps. II. Ischemia and delay, Plast. Reconstr. Surg., 49,
444, 1972.
4. May, J. W., Chait, L. A., O'Brien, B. M., and Hurley, J. V., The no-reflow phenomenon in experimental
free flaps, Plast. Reconstr. Surg., 61, 256, 1978.
5. Willms-Kretschmer, K. and Majno, G., Ischemia of the skin. Electron microscopic study of vascular
injury, Am. J. Pathol., 54, 327, 1969.
6. Donski, P. K., Franklin, J. D., Hurley, J. V., and O'Brien, B. M., The effects of cooling on experimental
free flap survival, Br. J. Plast. Surg., 33, 353, 1980.
7. Anderl, H., Storage of a free groin flap, Chir. Plast., 4, 41, 1977.
8. Harashina, T., Sawada, Y., and Watanabe, S., The relationship between venous occlusion time in island
flaps and flap survivals, Plast. Reconstr. Surg., 60, 92, 1977.
9. Hayhurst, J. W., O'Brien, B. M., Ishida, H., and Baxter, T. J., Experimental digital replantation after
prolonged cooling, Hand, 6, 134, 1974.
10. Morrison, A. D., Berwick, L., Orci, L., and Winegard, A. I., Morphology and metabolism of an aortic
intima-media preparation in which an intact endothelium is preserved, J. Clin. Invest., 57, 650, 1976.
11. Morrison, A. D., Orci, L., Berwick, L., and Winegard, A. I., A new look at the metabolism of the
arterial wall, Trans. Assoc. Am. Physicians, 89, 237, 1976.
12. Skoog, T., An experimental and clinical investigation of the effect of low temperature on the viability of
excised skin, Plast. Reconstr. Surg., 14, 403, 1954.
13. Jobsis, F. F., Boyd, J. B., and Barwick, W. J., Metabolic consequences of ischemia and hypoxia, in
Microsurgical Composite Tissue Transplantation, Serafin, D. and Buncke, H. J., Jr., Eds., C. V. Mosby,
St. Louis, 1979, chap. 4.
14. Takata, H., Biochemical studies on functional preservation on skin flaps: energy metabolism of ischemic
island flaps and effect of the reflow (in Japanese), Med. J. Hiroshima Univ., 27, 1077, 1979.
15. Chait, L. A., May, J. W., O'Brien, B. M., and Hurley, J. V., The effects of the perfusion of various
solutions on the no-reflow phenomenon in experimental free flaps, Plast. Reconstr. Surg., 61, 421, 1978.
16. Harashina, T. and Buncke, H. J., Jr., Study of washout solutions for microvascular replantation and
transplantation, Plast. Reconstr. Surg., 56, 542, 1975.
ALAM: “2894_c000” — 2005/9/26 — 22:24 — page ii — #2
Index
Volume I 489
INDEX
A peripheral nerve injuries, 116

replantation surgery, 305
Anesthetics, 68, 92
Absorbable sutures, 175
Aneurysms, 222—223, 248
Accessory nerve transfer, 163—164, 168
Angiomas, 248
Accumulated metabolic products, 357
Annulus, 259
Acetylsalicylic acid, see Aspirin
Anterior interosseous nerve, 173—174
Acoustic neuroma, 237—238
lesions of, 184—190, 195—199
ACTH administration, 49
Anterior interosseous nerve syndrome, 184—188
Activators of fibrinolysis, 66
Anterograde axon flow, 264
Acute ischemia, 324
Antiaggregating effect on red blood cells, 51
Adenylate cyclase, 55
Antibiotics, 328, 430
Adenyl cyclase, 73
Antibiotic therapy, 377
Adhesion of platelets to collagen, 49
Anticoagulant agents, 67—68, 73, 328, 398, 430
Adhesions, 348
Anticoagulant therapy, 67—70
Adhesiveness of platelets, 67
Antihemophilic globulin (factor VIII), 52, 65
Adoption phenomenon, 271, 283
Antilipemic effect, 58
ADP, 73
Antithrombin III, 52—55
Advanced vascular disease, 423, 432—433
Approximation, 280—281
Adventitectomy, 408
Aptitude tests, 16
Adventitial muff, 449
Arachidonic acid, 50
Age, of patient, 117—118, 286
Arachidonic acid metabolism, 51, 73—74
qualification for replantation surgery, 352
Arachnoid, 248
reconstruction of peripheral nerves, 140
Arachnoid cysts, 251—257
Agenetic temporal pole, 251
Arachnoid membrane, 255
Ageroplas, 292
Arm replantation surgery, 310
Aggregation of platelets, 49—50, 55, 67, 73
Arterial embolization, 55
Air embolism, 241
Arterial insufficiency, 328
Alcohol, use of, 5, 16, 275, 286
Arterial reconstruction, 396—397, 426
Allogenic fibrogen solutions, 281
Arterial spasm, 376
Allografts, 281—282
Arterial system
Aluminum access chamber, 82
Ampicillin, 376 dorsalis pedis flap, 437—439
Amputated extremity, replantation surgery for, see first metatarsal space, 451
also Replantation surgery, 301—316 relationship between dorsalis pedis artery and ex-
Amputated thumb, see Toe-to-hand transfer tensor hallucis brevis tendon, 438
Amputation with compression, 348 Arteries, 75, 110
Analgesia, 376 Artériographie studies with venous phase, 344—346
Analgesics, 328 Arteriography, 441
Anamnesis, 441 Arteriolar dilation, 97
Anastomoses, 219—221, 228—230, 239, 247— Arteriolar vasomotion, 80
248, 290, 329, 428, 479 Arteriosclerotic cardiovascular disease, 423
adaptation, 41 Arteriotomy, 226, 239
blood flow during, 229 Arthrodesis, 394
cerebral veins, 241 Aspirin, 56—57, 67—68, 73—75, 220—221, 292,
disrupted nerves, 355 376, 430
experiments to study, 39—45 Assessment form for results of nerve repair, 137
level of, 325 Assessment of results of nerve repair, 135—136
platelet accumulation, 50 Ataxia, 228
upper limb replantation, 352—353 Atheroma, 230
vascularization, 44—45 Atherosclerotic disease, 230
Anastomotic failure, 376—377 Autografts, 281—282
Anastomotic thrombosis, 67 Avulsed thumbs, see Replantation of avulsed
Anatomic anomalies, 174 thumbs
Anatomy Avulsion, 158—160, 214, 295—298, 342, 375
dorsalis pedis flap, 437—440 Avulsion injuries, 378
motor branches in hand and forearm, 173 Axon, 109
nerves, 109—110 changes distal to lesion, 267—272
Anesthesia, 50, 53, 95, 4 4 2 - ^ 4 3 flow, 264
matching, 269 Brain stem, 227

population, 263—264 Bypass procedures, 219—222, 241—245, 247—249
Axonocachexia, 289 complications, 221
Axonochachexy, 275, 287 special applications of, 222—223
Axonolysis, 158
Axonosthenosis, 275, 287, 289
Axonotmesis, 112, 158, 263—264, 284 c
Axoplasmic proteins, 266
Cable graft, 131, 282
Calcanear region, covering of, 464
B Calciparine, 292
cAMP, 51, 56—57, 73
Basilar arteries, 227 Canine model, see Dogs
Bat's wing, 93, 95 Capillaries, 79, 85, 92, 97
Benzopyrones, 67 Capillary density, 87, 91—92
Beta blockers, use of, 17—18 Capillary filtration coefficient, 94
Big toe-to-hand transfers, see Toe-to-hand transfer Capillary network, 94
Bilateral carotid occlusions, 221 Capillary pressures, 79
Bile duct, 41—43, 46 Capillary refill, 469
Binocularity, 15 Carotid artery, 239
Bioengineering, 14, 19—20 Carotid artery territory, 219—222
Biological dressing, 449 Carotid bifurcation, 223—225, 230
Biological problems, see also Nerve regeneration, Carotid cavernous aneurysm, 223
275, 287 Carotid carvernous fistula 5, 248
Bionic approach, 24 Carotid lesions, see also Cerebrovascular disease,
Bipolar coagulator diathermy, 115 219
Bipolar diathermy, 124 Carotid microendarterectomy, 223—227
Blood Carotid stenosis, 219
flow conditions, 79 Carpal bones, removal of, 345
state of local supply, 117—118 Carpal tunnel, 182, 184, 379
Blood cell velocities, 97, 99 Carpal tunnel syndrome, 174
Blood loss, 49 Castors on seat, 21
Blood supply of nerve, 110—111, 174 Cecal mesentery, 93, 95
Blood transfusions, 49 Cell body, 112
Blood viscosity, 54, 57, 69 Cell changes, 264—266
Blunt trauma, 117, 441 Cell death, 266
Bone fixation, 324, 328—331, 352, 362—366, Cerebellar cortical artery, 237
374—375, 394 Cerebellum, 227
Bone graft, 378 Cerebral blood flow (CBF), 219
Bone healing, 45 Cerebral revascularization operations, 247—249
Border zone between macroscopic and microscopic Cerebral vascular accidents, 249
anatomy, sutures present in, 37 Cerebral veins, anastomosis of, 241
Brachial block, 116 Cerebral venous sinuses, 241—245
Brachial plexus Cerebrospinal fluid, 248
avulsion lesions of roots, neutralization of, 295— Cerebrovascular disease
298 carotid artery territory, 219—222
greater omentum transfer in X-ray lesions of, carotid microendarterectomy, 223—227
289—293 decompression of vertebral artery in vertebral
neurotization, 163—171 canal, 230—233
accessory nerve transfer, 163—164, 168 extracranial-intracranial bypass, 219—222
follow-up results, 169—170 microsurgical techniques, 219—239
intercostal nerve transfer, 163—167 posterior fossa bypass, 234—237
musculocutaneous nerve, 163 special applications of bypass surgery, 222—223
results, 164—168 vertebral carotid transposition, 228—230
newborn, 201, 203 vertebrobasilar ischemia, 227—228
obstetric plexus palsy, 201—217 Cerebrovascular insufficiency, 219
posttraumatic lesions, surgical treatment of, Cerebrovascular symptoms, 231
157—162 Cervical osteoarthritis, 230
X-ray lesions of, greater omentum transfer in, Cervical plexus anterior nerves, 295—298
289—293 Cervical radiculopathy, 231—232
Brain, 96, 109 Checking instruments, 122
Volume I 491
Chemonucleolysis, 261 Cosmesis, 378

Chemotaxis, 266—267 Coumadin, 73
Chest pain, 56 Coumarin, 67
Chest X-rays, 206 Craniectomy, 235—238
Children, 373, 375,421,423 Cremaster muscle, 93, 95
Chlorpromazine, 376 Crushed extremities, qualification for replantation,
Choroidea, 96 341—361
Chromatolysis, 112 Crush injury, 175, 377
Chronic osteomyeltis, treatment of, 462 Cutaneous medialis, 282
Chronic subdural hematoma, 221, 251—252 Cutaneous nerve grafts, 282
Circulation system of skin flap, 483—484 Cut injuries, 173
Clavicle section, 293 Cyclic endoperoxides, 73
Clearance studies, 470 Cyclooxygenase, 50, 56, 73
Clival arachnoid cyst, removal of, 253—256 Cystoperitoneal shunt surgery, 251
Closed nerve injuries, 113, 117 Cytoplasm, 109
Clostridial infection, 379
Clot formation, 65—67
Clot lysis, see also Fibrinolysis, 65 D
Clot prevention drugs, see Anticoagulant agents
Clotting cascade, 73 Dacron, 57
Clotting factors after surgical trauma, 52—53 Death, 221
Clotting of blood, see Coagulation Decompression of vertebral artery in vertebral canal,
Cloxacillin, 376 230—233
Coadaptation, 280—281 Decompression of vertebral canal, 237
Coagulation, 57, 65—71 Deep motor branch of ulnar nerve, 173
drugs which influence, 54—56 lesions of, 182—183, 189—191, 195
intravascular, 73—78 Deep peroneal nerve, 440
Coagulation factors after surgical trauma, 52—53 Deficit in range of movements, 352
Coding, 22—23 Definitions, see specific terms
Coin test, 136 Degeneration of nerve, 112
Collagen, adhesion of platelets to, see Adhesion of Delayed grafting, 449
platelets to collagen Delayed secondary surgery, 275
Collagen disorders, 423 Demagnetizing of instruments, 7, 24
Color, 469 Dendrites, 109
Color contrast, 15 Denervated muscles, direct neurotization of, 133—
Colored background, 115 134
Complete amputation, 371 Dental mirror, 120
Complications, 330 Dermal-epidermal graft, 289
Components of surgeon at work, 14 Desensitization, 135
Composed tissue transfer, 437 Design of instruments, 13, 18—20
Compression-irritation, 289 sophistication in, 27—28
Compression lesions, 174 Design of microscope, 22
Compression nerve injury, 113 Dexon suture material, 146, 152, 352
Compression-neuroapraxia, 289 Dexterity, 7
Compression of vertebral artery in vertebral canal, Dextran, 57—59, 68, 73, 75
239 Dextran 40, 57—58
Concavoconvex jaws, 29—30 Dextran 70, 56—57
Concentric retraction, 275 Diabetes, 275
Conduction block without axonolysis, 158 Diabetes mellitus, 423
Congenital anomaly, 403 Diarrhea, 56
Congenital defects of hand, 317—318, 323 Differentiation of new tissue structures, 96
Conjunctiva, 94 Diffuse crush injuries, 378
Conjunctiva vessels, 92 Diffuse traumas, 356—357
Continuous-type capillaries, 97 Digital artery repair, 375
Contraindications for surgery, see specific type of Digital nerve repair, 375
surgery Digital perfusion, 428
Control values, 76 Digital reimplantation, see also Upper limb replanta-
Cooling of tissue, 484 tion, 374—387
Corrective procedures, 359 digital artery repair, 375
Cortical artery, 222 digital nerves, 375
Cortical vessel, 248 dorsal vein anastomosis, 375
dressings, 376 variations, 320

drugs, 376 Dorsalis pedis flap, 437—468
evaluation of function, 378 anatomy, 437—440
extremity amputations, 379 anesthesia, 442—443
factors influencing survival, 377—378 arterial sytem, 437—439
functional recovery, 378 basic design of, 441
illustrative examples, 380—387 biological dressing, 449
infection, 377 clinical application, 451—467
intraoperative complications, 376 covering of weight-bearing areas, 454
operative procedures, 374 critical evaluation, 454—455
order of, 374—375 delayed grafting, 449
physiotherapy, 376 donor site, 449—450
postoperative complications, 376—377 essential condition for elevation, 441
postoperative management, 376 extended flap, 450—451, 454
preoperative preparation, 374 first web dissection, 450—451
preparation of stump, 374 foot, 454, 463-^67
results of, 377—378 hand, 452, 4 5 5 ^ 6 0
secondary procedures, 378—380 head and neck region, 451—452, 454
skeletal complications, 377 intraoral resurfacing, 451—452
skin loss, 377 ischemia, period of, 445
vascular complications, 376—377 leg, 452, 4 6 1 ^ 6 2
Digital replantation surgery, 306—309 modifications, 449—451
Digital shifts, 378 nerves, 439—440
Digital transposition, 421 neurovascular flap, 449
Diplopia, 228, 230, 232 osteocutaneous flap, 450
Dipyridamole, 56—57, 68 pitfalls and shortcomings, 455
Direct cutdown technique, 247 preoperative assessment, 441
Direct interosseous wiring, 374, 379 preoperative design, 441—442
Directional lighting, molding effect of, 15 return of sensitivity, 452, 454
Direction of movement, 17 skin grafting, 449
Direct muscular neurotization, 121, 133—134, 283, surgery, 441—450
287 surgical dissection, 443—449
Disectomy, 259—262 tourniquet, 443
Disc material, 259 venous drainage, 439
Dislocations, 117 Drainage, 358
Dissection of the foot, 425—426 Dressings, 376, 4 2 8 ^ 2 9
Dissection of the hand, 425 Drugs
Disseminated intravascular coagulation (DIC), 52 combined effect, 57—59
Distal arterial tree, 424 digital reimplantation, 376
Distal axon, nerve regeneration, 112 prohibition of, 275, 286
Distal end, nerve degeneration, 112 Dupuytren's disease, 174
Dizziness, 228 Durai sinuses, 241
Dogs, microanastomosis and total bypass of cerebral Dysarthria, 228
venous sinuses and torcular herophilus, Dysmetria, 228
241—245
Donor area, preparation of, 122
Doppler examination, 269—270, 424 E
Doppler flowmeter, 441
Doppler mapping, 403 Ear-chamber method, 56
Doppler probe, 441 Early secondary nerve suture, 275
Dorsal metatarsal artery, 438—439 Eccentric neuroma, 113, 116
Dorsal vein anastomosis, 375 Echography, 247
Dorsalis pedis artery, see also Dorsalis pedis flap, Edema, 241, 284, 4 8 3 ^ 8 4
437, 439 Electrical burns, 423
anatomical defects, 320 Electrical stimulation, 284, 297
diagrammatic representation of T- and V-shaped Electroencephalogram (EEG), 222—224, 226
pattern of bifurcation of, 445 Electromyography (EMG), 114, 117, 193, 205—
relationship to extensor hallucis brevis tendon, 206, 284
438 Emergency procedure reconstruction of peripheral
relationship to extensor hallucis longus tendon, nerves, 140—141
438 toe-to-hand transfer as, 423, 433
Volume I 493
Endarterectomy, 219, 223, 226—227, 230, 237— Extracranial-intracranial bypass, 219—222, 238—
239 239, 249
Endoneurium, 109—110 indications for, 248
Endoperoxides, 73 Extracranial-intracranial microanastomos is cerebral
Endoplasmic reticulum, 264—265 revascularization operations, 247—249
Endothelial cell, 73—74 Extracranial vessels, 247
Endothelial injury, 50—51 Extremities' blood perfusion, 357
Energy metabolism, 483 Extrinsic pathway, 65
Environmental conditions, 13 Eye-hand coordination problems, 5
Epidural hematoma, 237
Epifascicular epineurectomy, 159—160
F
Epifascicular epineurium resection, 160
Epifascicular epineurotomy, 158—160
Epigastric vein, 75—77 Facial artery and veins, 291
Epinephrine, 73, 97 Factor I, 52
Epineural fibrosis, 174 Factor III, 65
Epineural neurolysis, 174, 182, 197 Factor V, 52, 65
Epineural sheath, 355 Factor VII, 65
Epineural suture, 278 Factor VIII, 52, 65
Epineurium, 109—110, 275 Factor VHI-related antigen, 58
Epiperineural suture, 278 Factor IX, 65
Epsiloaminocaproic acid, 53 Factor X, 52, 65, 67
Equipment design, 13, 18—20 Factor XI, 65
Erb-Duchenne paralysis, 201, 203, 207, 213—214 Factor XII, 65
Ergonomie instruments for nerve suturing, 278 Fasciculi, 109—110, 118—119
Ergonomics, 13—25 Femoral artery, 75—77
applications to microsurgery, 13—23 Femoral vein, 75—76
components of surgeon at work, 14 Fibrin, 65—66
definition, 13 Fibrin formation, 96
Fibrinogen (factor I), 52—53, 57, 65, 67
environmental conditions, 13
Fibrinolysis, 65—71
equipment design, 13, 18—24
Fibrinolytic activity, effect of surgical trauma on,
fine movement, 13, 16—18
53
future in microsurgery, 23—24
Fibroblasts, 266, 275
microsurgical instruments, 27
Fibromata, 174
performance, 22—23
Fibrosis, 124, 127, 158, 160, 175, 275, 282, 284
productivity, 13
amount near nerve, 118
safety, 13
Fibrous scars, 232
seated posture, 20—22 Fine movement see also Tremor factors and control,
skill acquisition, 13, 22—23 13, 16—18
tremor factors , 1 3 , 1 6 — 18 Finger reconstruction, free partial toe dissection for,
visual feedback, 13—16 451
workplace arrangement, 27 Finger replantation, see Upper limb replantation
workplace layout, 13, 20—22 Fingers missing, see Toe-to-hand transplants
Erythrocyte sedimentation rate (ESR), 53 First metatarsal space, arterial system of, 451
Esmark bandage, 116 First web dissection, 450—451
Evaluation of arterial-venous network, 356 First web space, extended flap covering skin of,
Evaluation of vascular state, 344 454, 466
Evoked somatosensory potentials, 181 Fish-mouth technique, 248
Exchange of fluid, 79 FITC-dextran, 85
Exertion, 17 Fitness, mental and physical, 16
Experience, 16 Fixation, see specific type
Experimental free toe-to-hand transfer, 421 Flail arm, 157
Extended flap, 450—451, 454 Flaps, 275, 279
Extensor hallucis brevis tendon, 438 Flap survival, 479—485
Extensor hallucis longus tendon, 438 failure causes, 483—484
Extensor tendon repair, 375, 394—395, 426 Flap vascularity, 439
External carotid artery, 247 Flexor digitorum brevis musculocutaneous flap, 457
External neurolysis, 121—122, 124, 159—160, Flexor tendon repair, 375, 393, 395
290—291 Flicker of light source, 16
External precision grips, 18—20 Flow conditions of blood, 79
Flow distribution, 94 Great toe-to-thumb transfer, 421

Flow properties, 94 Grips
Fluorescent dyes, 15 external precision, 18—20
Fluorescent microscopy, 85, 97 hand, 18—20
Foot internal precision, 18, 20
covering of weight-bearing areas, 454 needle holders, 29—30, 32
dissection, 425—426 power, 18, 433
dorsalis pedis flap, 454, 463—467 Groin flap, 437
nerves, 440 Guillotine-type amputation across wrist, 347
postelectric burn, repair of, 461
posttraumatic chronic ulceration, 467
H
return of sensitivity, 454
scalpation injury of, 465
sensory pattern on dorsalis surface of, 440 Hageman factor (Factor XII), 65
veins of, 440 Hamster, 80
Foot pedal design, 22 Hamster cheek pouch, 93, 95
Foot reconstruction, 438—430 Hamster skin fold, 80, 82—99
Foraminotomy, 259 transparent chamber model, 97—100
Force exerted by fingers and thumb, 18 Hand
Forceps, 11—12 dissection of, 426
Forearm, isolated lesions of motor branches in, see dorsalis pedis flap, 452, 455—460
Motor branches in hand and forearm isolated lesions of motor branches in, see Motor
Forearm-chamber, 92 branches in hand and forearm
Forearm replantation surgery, 310 return of sensitivity, 452
Fractures, 117 Handgrips, 18—20
Free composite groin flap, 424 Handle design for instruments, 19
Free microvascular omentum flap, 290—291 Hand posture of operator, 16—18
Free nerve graft, 121, 130—132 Headache, 254
Free partial toe dissection for finger reconstruction, Head and neck region, dorsalis pedis flap, 451—
451 452, 454
Free skin flaps, 437 Head turning difficulty, 230—231
storage, 479, 484 Heart, 96
Free skin flap transfers, 479—485 Heat, 16
Free tissue transfer, postoperative monitoring in, see Hemodilution, 57
Postoperative monitoring in reconstructive Hemorrhage, 96
microsurgery Hemostasis, 49, 57, 122, 124, 132, 305, 428
Functional recovery, 378 Hemostatic plug formation, 49—50
Functional value of hand, 317 Heparin, 54—55, 57, 73, 75, 85, 228, 376, 396,
Fungal infection, 377 408, 411
Future in microsurgery, 23—24 low-molecular weight, 55, 57
Heparin analogues, 56
Heparinoids, 56
G Herniated disc, 259—262
Herniated nucleus pulposus, 259—262
Ganglia, 174, 183 Highet-Zechery Table, 284
Gangliosides, 284 Holding zone of instruments, 28
Homeostasis, 51, 65
Gap between two ends of nerve, 118, 128
Homografts, 281—282
Gastroepiploic artery and vein, 291
Hormonal factors, 49—50
General anesthesia, 116, 425
Hot and cold sensation, 136
General surgical set for plastic surgery, 115
Human nail-fold, 92
Giant motor units, 271
Hydrostatic dilatation, 376
Glare while operating, 15, 28
Hypercoagulopathy, 98
Glass splinter injuries, 173, 175, 183
Hyperemic cerebral swelling, 221
Globulin, 53, 57
Hypoprothrombinemia, 52
Golgi apparatus, 109
Hypotension, 56
Gortex, 219
Hypothermy, 324
Graft occlusion, 237
Grafts, see specific types
Greater omentum transfer in X-ray lesions of bra- I
chial plexus, see also Brachial plexus, 289—
293 Iatrogenic injection trauma, 175
Volume I 495
Iatrogenic injuries, 174 period of, 445

[buprofen, 55, 57 temperature, 481
Imidazole, 74 time, 4 7 9 ^ 8 5
[mmobilization of extremity, 353 Ischemic flaps, 59
[mmuno fibrin adhesive, 149, 152 Ischemic symptoms, 222
Implantation of cells, 85 Island flap, 437, 452
[nbuilding, 22—23 Isolated lesions of motor branches in hand and
Incisions of fascia and skin, 358 forearm, see Motor branches in hand and
Incomplete amputation, 371 forearm
[n-continuity lesions, 277 Isoproterenol, 97
Increased permeability, 98
[ndications for surgery, see specific type of surgery
Infection, 377 j
Inflammatory reaction, 79, 96
Injection techniques, 38—40 Jeweler-type forceps, 33
Inner ear, 94, 96 Jobst glove, 382
Innervated cutaneous flap, 423 Joint reconstruction, 394
Innervation, lack of, 355
Instrument design, 18—20
Instruments, see Surgical instruments K
Instrument-tissue requirements, 20
Intercostal nerve transfer, 158, 163—167, 295—298 6-Keto-PGF,la, 75
Interfascicular dissection, 280 Key pinch, 378
Interfascicular epineurectomy, 159—160 K wires, 352, 374, 377, 426
Interfascicular vascular system, 109—110
Intermediate-term tremor factors, 16
Internal carotid artery, 248 . L
Internal carotid occlusion, 219
Internal maps of nerves, 282 Labile factor (factor V), 52
Internal neurolysis, 124—125, 291 Laminectomy, 259—261
isolated lesions of motor branches in hand and Laryngeal nerve palsy, 227
forearm, 174—175, 185—188, 196—199 Learning, see Skill acquisition
Internal precision grips, 18, 20 Leg, dorsalis pedis flap, 452, 461—462
Interosseous wiring, 379 Lidocaine, 396—397, 408
Intima, 51 Lighting, directional, 15
Intimectomy, 59 Lighting contrast, 15
Intracellular cyclic AMP, 73 Lighting factors, 15—16
Intracranial arachnoid cysts, 251—257 Lighting intensity, 15
Intracranial clipping, 222 Light touch sensation, 136
Intracranial internal carotid artery, 219 Light tweezer-type instruments, 27
Intracranial vessels, 247 Liliequist's membrane, 252
Intramedullary bone peg, 374, 426 Limb support, 16—17
Intramedullary screw, 374 Lipomata, 174, 183
Intraneural compression, 174 Liver, 96
Intraneural neurolysis, 157—159 Local P0 2 , 85, 92
Intraoperative complications in digital reimplanta- Long-term tremor factors, 16
tion, 376 Loupe, 5, 14
Intraoperative monitoring, 223, 226 Low flow state, 98
Intraoperative neurography, 182 Low-light-level video cameras, 97
Intraoperative thrombosis, 376 Lumbar respiratory movements, 259
Intraoperative venous thrombosis, 376 Lung, 96
Intraoral resurfacing with dorsalis pedis flaps, 451— Lysis time, 53
452
Intravascular coagulation, 73—78
Intravascular pressures, 94 M
Intravascular volume expanders, 228
Intravital microscopy, 85 Macrohemodynamic parameters, 80
Intrinsic muscles, 379—380 Macrophages, 266
Intrinsic pathway, 65, 73 Magnesium sulfate, 68
Ionizing radiation, lesions from, 289—293 Magnification, 14—15, 85, 259
Ischemia, 69, 282 reconstruction of peripheral nerves, 139, 141
use of, 5—12 Microsuture, see Suture

Magnifying telescopes, 15 Microvascular analysis, 92—97
Main energy sources for wound repair, 471 chronic models in experimental animals, 95—97
Major pectoralis muscle transfer, 157 experimental animals, 93—95
Malunion, 377 human studies, 92—94
Marking of vessels, 319 organ studies, 94—96
Massive intravascular thrombosis, 66 tissue studies, 93—95
Mastectomies for mammary carcinomas, 289—293 Microvascular anastomosis, 290, 437, 479
Matching fascicles, 276—277 Microvascular bed, 85—88
Median nerve fibrosis, 379 Microvascular modules, 85
Membrane proteins, 266 Microvascular network, 91, 97
Meningiomas, 243 quantitative analysis of, 79—105
Mental fitness, 16 Microvascular pressure, 85
Mental rehearsal, 16 Microvascular response, 98
Mesentery, 93, 95 Microvascular structures, roentgenological investiga-
Mesoneurium, 109—110, 119 tion to study, 37—38
Metacarpal hand, 4 2 2 ^ 2 3 , 432 Microvascular surgery, 49—63
Metal junction pieces, 352 cerebrovascular disease, 219—239
Metallurgical criteria for instruments, 20 coagulation factors, 52—53
Microanastomosis erythrocyte sedimentation rate, 53
cerebral revascularization operations, 247—249 fibrinolysis, 53
cerebral venous sinuses, 241—245 platelet response to, see also Platelet response to
torcular herophilus, 241—245 surgical trauma, 49—52
venous sinuses, 241—245 prevention of vascular occlusion, 54—59
Micro-Astrup method, 473—474 viscosity of whole blood, 54
Microcirculation, see also Normal circulation Microvascular suture, 241—242
organic unit, 97—100 Middle cerebral artery (MCA) 247—248
quantitative analysis in awake animal, 79—105 Middle cerebral artery anastomosis, 221
single organs, 94 Middle cerebral artery occlusion, 219
Microcirculatory models, 81—82 Middle cerebral artery stenosis, 219
hamster, 82—99 Middle cranial fossa cysts, 251—253
Microcirculatory network, 80 Migration of cells, 41—42
Microcirculatory parameters, 80 Migration of leukocytes, 96
Microinstruments, see Surgical instruments Minor completed strokes, 227
Microlumbar discectomy, 259—262 Minor pectoralis muscle, 159
Microneedles, see Needles Minor strokes, 219
Microneurovascular free toe-to-hand transfer, 421 Miocutaneous flap, 290
Microocclusion technique, 94 Mistakes, 292
Microradioangiography, 39, 43 Mitochondria, 109
Microradiography of angiography with X-ray dif- Mitosis, 41
fraction tube, 38 Molded plaster splint, 329, 333
Microreconstruction, 395—398 Molding effect of directional lighting, 15
Microscope, see also Operating microscope; Sur- Monitoring
gical microscope, 14—15, 227, 248 replantation of avulsed thumb, 398
design, 22 toe-to-hand transplants, 328
setting before surgery, 122 Monofascicular neurofibroma, 184
Microscope stage, 84 Monofascicular neurofibromata, 175
Microsurgery, see also specific topics, 1, 5—12 Monofascicular pattern, 280—281
amputated thumb reconstruction, 317 Morphologic studies, 87, 90—92
branchial plexus surgery, 157—158 Morphometric measurements, 87
cerebrovascular disease, 219—239 Motivation of patient, 118
function, 5 Motor branches in hand and forearm
future in, 23—24 anatomic anomalies, 174
general principles of, 121—122 anatomy, 173
intravascular coagulation in, 73—78 anterior interosseous nerve, 173—174
peripheral nerve injuries, 109—138 lesions of, 184—190, 195—199
research in field of, 37—47 causes of nerve lesions, 173—174
role of prostaglandins in, 50—52 compression lesions, 174
Microsurgical instruments, see Surgical instruments cut injuries, 173
Microsurgical procedures, see Surgical procedures deep motor branch of ulnar nerve, 173
Microsurgical vascular anastomosis, 74—76 lesions of, 182—183, 189—191, 195
Volume I 497
diagnosis, 174 Needle holder, 11—12, 28—31

evoked somatosensory potentials, 181 concavoconvex jaws, 29—30
iatrogenic injuries, 174 locking mechanism, 30, 32
identification of motor fascicles, 176, 178 orientated position, 29
intraneural compression, 174 rotatability, 30
isolated lesions, microsurgical treatment of, Needles
173—200 characteristics of, 7
nerve grafting, 174—183, 197, 199 nerve suturing, 277
primary, 174—175, 182 passing of, 9—10
secondary, 174—183 passing position, 7
nerve suture, 174—175, 182—183, 185—186, requirements for, 7
189—190, 197 Nerve cell, 109
neurolysis, 174—175, 182, 185—188, 196—199 Nerve ends, proper orientation before suturing of,
occupational diseases, 174 118—121
posterior interosseous nerve, 173—174 Nerve fibers, 111
lesions of, 183—184, 192—195 Nerve grafts, see also Nerve suturing, 117, 139,
scar formation, 174—175 141, 151, 281—283, 378
skeletal injuries, 173—174 brachial plexus surgery, 157—160
soft tissue injuries, 174 characteristics of, 131
stab injuries, 173, 175, 182 direct muscular neurotization, 283, 287
tendon transfer, 173 evaluation of results, 284—287
thenar motor branch of median nerve, 173—174 isolated lesions of motor branches in hand and
lesions of, 182—186, 195 forearm, 174—183, 197, 199
treatment, 174—181 obstetric plexus palsy, 212—215
tumors, 174 postop treatment, 283—284, 287
Motor end-plates, 269, 271 primary, 174—175, 182
Motor fasciculi, 118, 120 secondary, 174—183
Motor nerve injury, 113—114 second suture, 283
Motor palsy, 289 technical problems, 275, 287
Motor recovery, 136, 293 tension avoidance, 277
Moya-Moya syndrome, 248 Nerve reconstruction, see Reconstruction of periph-
Multifascicular nerves, 280 eral nerves
Muscle compartment decompression, 379 Nerve regeneration, 112, 117, 263—273
Muscle metabolism, 379 axon changes distal to lesion, 267—272
Muscle power, standard system for recording, cell changes, 264—266
113—114 changes at lesion level, 266—267
Muscle strain, 5 classical knowledge, 263
Muscles, see also Skeletal muscles recent research, 263—264
anastomosis, 353 Nerve repair, see also Nerve grafts; Nerve suturing;
contractibility loss, 348 Peripheral nerve injuries
reconstruction, 352—353 assessment of results, 135—136
removal, 352 assessment form for results of, 137
Muscular control, 6 delayed primary, 117, 121
Muscular exertion, 17 direct neurotization of denervated muscle, 121,
Muscular fibrosis, 173 133—134
Musculocutaneous nerve neurotization, 163 factors influencing result of, 117—118
Myatrophy, 173, 191, 193 free nerve graft, 121, 130—132
Myelin sheath, 109 fundamentals of, 138
Myelogram, 260 pedicle nerve graft, 121, 129—130
Myelography, 158, 206, 260 peripheral nerve injuries, 124—134
Myelopathy, 232 primary, 117, 121, 128
secondary, 117, 121
secondary suturing of nerve, 125, 128
N steps of, 124—127
timing of, see also Peripheral nerve injuries,
Nail-fold, 94 116—117, 121
Nakayama's vascular stapler, 42, 44 vascularized nerve graft, 121, 132—133
Nausea, 228 Nerve root, 259, 261
Neck and shoulder pain, 20 Nerve stimulator, 115, 120
Necrosis, 282, 289 Nerve stretching, 117
Necrotic tissue, 42 Nerve suturing, 275—288
approximation, 280—281 direct muscular, 283, 287

coadaptation, 280—281 obstetric plexus palsy, 208—211, 215
delayed secondary surgery, 275 Neurotmesis, 112, 263—264
early secondary, 275 Neurovascular flap, 449
epineural suture, 278 Nicotine, 424
epiperineural suture, 278 Night splint, 382—383
ergonomie instruments, 278 Nissl bodies, 109
evaluation of results, 284—287 Nissl clumps, 264—265
exposure, 279—280 Nodes of Ranvier, 110
instruments, 277—278 Noise, 16
interfascicular dissection, 280 Nonabsorbable sutures, 428
isolated lesions of motor branches in hand and Nonflow phenomenon, 376
forearm, 174—175, 182—183, 185—186, No-reflow phenomenon, 483
189—190, 197 Nonunion, 377
matching fascicles, 276—277 Normal microcirculation, 80, 82, 92, 97—98
needles, 277 Nucleus, 109
periepineural suture, 278 Nylon sutures, 278, 281, 428
perineural stitches, 278
postop treatment, 284—284
primary, 174—175, 182—193, 197, 275
O
resection, 280
secondary, 174—175, 182—183, 185—186, Oblique screw fixation, 374
189—190, 197 Obstetric plexus palsy, 201—217
tardy surgery, 275 cases and results, 207—215
technical problems, 275, 287 indications for surgery, 203—206
tension avoidance, 277 nerve grafts, 212—215
threat, 277—278 neurolysis, 215
timing of surgery, 275, 286 neurotization, 208—211, 215
types of sutures, 278—279 surgical technique, 206—207
Nerve trunk, 110—111, 121 Obstructive hydrocephalus, 251
Nerves Occipital artery (OA), 247—248
dorsalis pedis flap, 439—440 Occipital artery to posterior inferior cerebellar artery
foot, 440 (OA-PICA) bypass, 247
Nervous system evaluation, 341 Occlusive lesions, 219
Nervus cutaneous antebrachii medialis, 175 Occupational diseases, 174
Neural anastomoses, 325, 332 Oligofascicular nerves, 280—281
Neuroapraxia, 112, 263 Oligofascicular neurofibromata, 175
Neuroapraxial lesions, 201 Omentum, 93, 95
Neurofibroma, 182 Omnidirectional ring foreceps, 33—35
Neurological deficits, 249 Omnidirectional scissors, 33—36
Neurolysis, 117, 121—122, 124—125, 290, 293 Omohyodeus muscle, 159
epineural, 174, 182, 197 On-top-plasty, 421
external, 121—122, 124, 159—160, 290—291 Open fracture of tibia, treatment of, 462
internal, 121, 124—125, 174—175, 185—188, Open nerve injuries, 113
196—199, 290 Operating microscope, see also Microscope; Sur-
intraneural, 157—159 gical microscope, 5, 15, 95, 109, 219, 224,
isolated lesions of motor branches in hand and 228, 232, 237, 277, 408
forearm, 174—175, 182, 185—188, 196— Operating table 22
199 Operative techniques, see specific types
obstetric plexus palsy, 215 Orientation of nerve ends, 118—121
Neuroma, 117, 143—144, 146, 158, 178—180, Original F. P. L. muscle, 396
182, 185—188, 263, 279—280, 325, 378 Orthograde axon flow, 264
Neuroma formation, 113, 115—116 Osteocutaneous flap, 450
Neuroma in continuity, 113, 116 Osteomata, 174
Neurone, 109 Osteomyelitis, 452
Neurorrhaphy, see Reconstruction of peripheral Osteophyte, 232
nerves Osteoplastic thumb reconstruction, 421
Neurotization, 160 Osteosynthesis, 293
avulsed roots of brachial plexus, by means of an- Oxygen measurements, 470—471
terior nerves of cervical plexus, 295—298 Oxygen Response Test (ORT), 472—473
brachial plexus, see Brachial plexus
Volume I 499
P primary repair, 117, 121, 128

reconstruction, see also Reconstruction of periph-
eral nerves, 139—155
Pain, 136, 289
regeneration, see Nerve regeneration
disappearance of, 293
role of microsurgery in treatment of, 109—138
Pancreas, 96
secondary repair, 117, 121
Pancreatic duct, 96
severity of, 117—118
Papaverine, 408, 443
site of lesion, 118
Paralysis, 289
social problems, 275
Paresthesia, 289
spontaneous recovery, 117
Park-bench position, 237
state of local blood supply, 117—118
Partial finger reconstruction, 437
strangulated by scar, 113
Partial thromboplastin times (PTT), 67
surgical procedures, see also Surgical procedures,
Partial thumb reconstruction, 459—460
121—125
Passing of needle, 7, 9—10
symptoms and signs, 113—114
Passive mobilization, 284
technical problems, 275, 287
Patch technique, 248
tension at suture line, 118
Patency of anastomoses, 483
time lapse between repair and, 117—118
Patency of small vessels, 58—59
timing of nerve repair, 116—117
Patency rate, 76
tourniquet, 116
Patient, see also Age of patient; Selection of patient
tumors, removal of, 121—123
position, 121—122
types, 112—113, 263
Pedicle graft, 421
Peripheral nerves
Pedicle nerve graft, 121, 129—130
finger replantation, 353, 355, 367
Pentoxifylline, 69—70
lack of innervation, 355
Performance, efficiency in, 22—23
reanastomosing of, 355
Performance of microsurgeon, improvement in, 5
ripped, 341, 355
Perfusion of omentum flap, 291
upper limb replantation, 353, 355, 367
Perfusion techniques, 484
Permeability, 79
Periepineural suture, 278
Persantine, 68, 292
Perineural liquid, 355
Petechial bleeding, 97
Perineural stitches, 278
Phagocytosis, 112
Perineurium, 109—110
Phalangization of first metacarpal, 421
fibrosis, 175
Phlebography, 242
Peripheral nerve injuries
Phosphodiesterase inhibitors, 56—57
age of patient, 117—118 Phospholipase, A2, 50
amount of fibrosis near nerve, 118 Photodiode, 85, 87
anatomy of nerves, 109—110 Photometric Analyzer, 85
anesthetic, 116 Photoplethysmography, 469—470
biological problems, 275, 287 Physical fitness, 16
blood supply of nerve, 110—111 Physiologic tremor, 5—6,
closed, 113, 117 factors affecting, 5
compression, 113 factors slowing, 5
degeneration, 112 Physiology of nerves, 109—110
delayed primary repair, 117, 121 Physiotherapy
effects of, 112 digital reimplantation, 376
factors influencing result of nerve repair, 117— posttraumatic brachial plexus lesions, surgical
118 treatment of, 161
gap between two ends of severed nerve, 118, 128 Picking-up test, 284
instruments required for microsurgery, 114—116 Pinch grip, 378
motivation of patient, 118 Plantar surface, covering of, 466
motor branches in hand and forearm, 173—200 Plaque, 226—227, 239
nerve regeneration, 112 Plasma thromboplastin antecedent (factor XI), 65
nerve repair, see also Nerve repair, 121, 124— Plasma thromboplastin component (factor IX), 65
134 Plasmin, 66
neurolysis, 121—122, 124—125 Plasminogen, 66
open, 113 Plasminogen activators, 53
orientation of nerve ends before suturing, 118— Plate and screw fixation, 374
121 Platelet aggregation, 73
physiology of nerves, 109—110 Platelet antiaggregants, 292
postoperative instructions, 134—135 Platelet count, 49—50
Platelet plug, 74, 76 Posttraumatic fibrosis, 183

Platelet response to surgical trauma, 49—52 Potts scissor, 226
Platelets, 66—67, 73—74 Power grasp, 378
Platinum multiwire electrode, 85, 92 Power grips, 18, 433
Plethysmography, 376 Precise movements, ability to perform, 331
Plexus anasthesia, 389 Precision pinch, 378
Pneumatic tourniquet, 116 Preganglionic lesions, 201, 207
P0 2 histograms, 92 Preoperative angiogram, 133
Pollicization, 421, 423 Preoperative arteriograms, 403, 424
Polyfascicular nerves, 280—281 Preparation for microsurgery, 5
Polyglactin, 175 Primary arthrodesis, 375
Polypeptides, 65—66 Primary nerve grafts, 174—175, 182
Polysaccharide, 57 Primary nerve suture, 174—175, 182—183, 189,
Polytetrafluoroethylen (PTFE) grafts, 57 197, 275
thrombogenicity of, 57 Proaccelerin (factor V), 65
Position Proaggregating substances, 50
graft in toe-to-hand transplants, 325 Proconvertin (factor VII), 65
patient, 121—122 Productivity, 13
surgeon, 6—7, 122 Progressive stroke, 227—228
surgical instruments, 7—8 Prolonged drips, 441
Position used to operate, 5 Pronator teres muscle, 184
Postanastomotic management, 396—398 Proprioceptive sense, 7
Postelectric burn of foot, 461 Prostacyclin, 50, 70, 73, 75—77, 376
Posterior fossa bypass, 234—237 drugs which increase production, 56
Posterior fossa cysts, 251 levels of, 75
Posterior fossa TIA, 230 Prostacyclin synthetase, 73
Posterior inferior cerebellar artery (PICA), 247— Prostaglandin E,, 70
248 Prostaglandin E2, 70
Posterior interosseous nerve, 173—174 Prostaglandins, 50—52, 70
lesions of, 183—184, 192—195 Prostaglandins I2 (PGI2), 50—51, 55
Postganglionic lesions, 207 Prosthetic materials, 45
Postganglionic radicular lesions, 201 Prothrombin, 65
Postoperative care, 283—284, 287, 292, 310—313 Prothrombin time, 52
digital reimplantation, 376 Proximal axon, 112
replantation of avulsed thumb, 398—399 Pseudarthrosis, 377
toe-to-hand free tissue transfer, 430 Pseudomeningocele, 237
toe-to-hand transfer, 411—413 Pseudoneuroma, 174
toe-to-hand transplants, 328
upper limb replantation, 358—359
Postoperative complications, digital reimplantation, Q
376—377
Postoperative instructions, 134—135 Quantitative analysis of microcirculation in awake
Postoperative monitoring in reconstructive microsur- animal, 79—105
gery, 469^177 Quantitative hemodynamic analysis, 85—90
clearance studies, 470
clinical experience, 473—474
clinical signs, 469—472 R
correlation between p0 2 levels using Micro-As-
trup or TCM, 4 7 3 - ^ 7 4 Radial artery, 219
Doppler examination, 469—470 Radial hypothenar muscles, 183, 191
free tissue transfer, 469, 474 Radiation, lesions from, 289—293
oxygen measurements, 470—471 Radiodermatitis, 289, 292
photoplethysmography, 469—470 Radiographs of foot, 424
replantation, 469, 474 Radiovasculitis, 289
technique, 470—472 Range of movement, 378, 413
temperature recordings, 469 Rat skin fold, 80
Postoperative stenosis, 239 Rat's abdominal flaps, 479—480
Postoperative Volkmann's changes, 378 Reabsorbable threads, 281
Posttraumatic branchial plexus lesions, see Brachial Reactivity of vessels, 80, 82, 98
plexus Reconstruction of foot, 428—430
Posttraumatic chronic ulceration of foot, 467 Reconstruction of peripheral nerves, 139—155, 395
Volume I 501
age of patient, 140 survival rates, 399

emergency surgery, 140—141 telescope anastomosis, 396—397
importance of procedure, 139 tendon repair, 394—396
kind of trauma and accompanying damage, 140 transposing dorsal vein, 396
length of nerve defects, 140 vein repair, 397
level of damage, 140 Replantation surgery, see also specific type, 301—
macroscopic procedures, 139 316
magnification, 139, 141 absolute contraindications, 301—303
microscopic procedures, 139—140 anesthesia, 305
nerve grafts, 139, 141, 151 avulsed thumbs, 389—401
principles generally accepted, 140 finger, 341—369
secondary operation, 140—143 indications for, 303
technique for, 143—154 patient selection, 301—303
surgical technique, 140 postoperative care, 310—313
suture materials, 146, 149 postoperative monitoring in, see Postoperative
tension, 140—141, 151 monitoring in reconstructive microsurgery
time factor, 140 preparation of amputated part for transfer, 303—
Reconstruction of tendons and muscles, 352—353 304
Reconstruction of thumb, bone, joint and tendons, preparation of patient for transfer, 304—305
394—395 relative contraindications, 301—303
Reconstructoplasty, 344 results of, 313—314
Recovery of sensation, 378 survival rates, 313
Recovery time, 75 techniques, 306—310
Recurrent vertebrobasilar ischemia, 239 upper limb, 341—369
Red line sign, 377 Research, microsurgical techniques in, 37—47
Reendothelialization, 76 Resection, 280
Regenerating bundles, 264, 267, 269, 271 Results of surgeries, see specific types of surgeries
Regenerating reactions, 264 Retina, 94
Regneration of peripheral nerves, see Nerve Retrograde axon flow, 264
regeneration Retrograde input from plantaris artery system, 443
Rehabilitation, 325 Revascularization, 219, 221, 227—228, 239, 247—
toe-to-hand transplants, 328 249
upper limb replantation, 352, 359 Rheumatoid synovial cysts, 183
Rehearsal, mental, 16 Ribbon sign,377
Removal of second toe, 320—324 Ring forceps, 33—35
Reomacrodex, 292 Ripped single nerves, 341, 355
Reoperations, avulsed thumb replantation, 398 Robotics, 24
Replantation, 79, 479-^185 Roentgen therapy, 275, 284, 287
avulsed thumbs, 389—401 Root avulsion, see Avulsion
aftercare, 398—399 Rotatability of instruments, 19, 32
anticoagulant agents, 398 Rotatability of needle holder, 30
arthrodesis, 394 Rotational cutaneous flap, 292
associated injuries, 389 Rotational skin flaps, 290
bone fixation, 394 Running suture, 248
detailed technique, 389—399
microreconstruction, 395—398
monitoring skin temperature and complications, s
398
pathology, 389 Safety, 13
preparation of patient and avulsed thumb, Saphenous vein, 219, 241
389—392 Saphenous vein graft, 241
preparative steps at stumpside, 392—394 Satellitosis, 264—265
reconstruction of thumb (bone, joint and ten- Scalp necrosis, 248
dons), 394—395 Scalpation injury of foot, 465
reoperation, 398 Scanning electron microscopy (SEM), 39, 45
repair of collateral ligaments, 395 Scar formation, see Scar tissue formation
results, 3 9 9 ^ 0 0 Scar tissue formation, 5, 41—42, 117, 174—175
routine incisions used, 393 avoidance, 275
sensibility recovery, 400 limitation of, 275, 284
skeleton, 394 removal, 275
steps to help prevent complications, 390—391 Schwann-cell proliferations, see Schwann cells
Schwann cells, 112, 264, 266—267, 269—271, 282 Snuffbox area, 426, 452
Schwannoma, 279—280 Social problems, 275
Scissors, 11—12, 28, 33—35 Sodium pentosan polysulfate (PZ-68), 55—56
omnidirectional, 33—36 Soft tissue injuries, 174
spring, 27, 33 Span grasp, 378
variset wheel, 34, 36 Speed of hand movement, 18
Sclerosis, 290 Spinal cord, 109
Seat castors, 20—22 Spinotrapezius muscle, 93, 95
Seated position, 6—7, 20—22 Spleen, 96
Secondary nerve grafts, 174—183 Splints, 284
Secondary nerve suture, 174—175, 182—183, Split products, 66
185—186, 189—190, 197 Spondylitic vertebral artery insufficiency, 231
Secondary reconstruction of peripheral nerves, see Spondylosis, 239
Reconstruction of peripheral nerves Spontaneous neurotization, 201—202
Second toe autotransplantation to replace missing Spring scissors, 33
fingers, see also Toe-to-hand transplants, Spring tweezer-type forceps, 30, 32
317—339 Sprouting phenomenon, 264
Second toe-to-hand transfers, see Toe-to-hand Stabilization of hands, arms and body, 7
transfer Stab injuries, 173, 175, 182, 226, 377
Seddon Table, 284 Stainless steel instruments, care of, 24
Segmental resistance, 94 STA-MCA bypass, 247
Seizure, 253 Step cut osteotomy, 374
Selection of patients, 158—159, 301—303 Stereological techniques, 87
Selection of person to become microsurgeon factors Steroid administration, 275, 284, 287
in, 16 Stiffness of microsurgical instruments, 18—19
Self-help, 331 Stomach, 96
Sensory dorsalis pedis island or free flap, 454 Storage of flaps, 479, 484
Sensory fasciculi, 118, 120 Strangulation of nerve by scar, 113
Sensory flap, 444, 446, 450 Streptokinase, 68—70
Sensory nerve damage, 113—114 Stress, 5, 17—18
Sensory palsy, 289 Stroke, 219, 248
Sensory recovery, 136, 293 Strzyzewski method, 448
Sensory retraining, 135 Stuart-Prower factor (Factor X), 65, 67
Severity of injury, 117—118 Stump pressure, 222—224
Sex, 16 Subclavian steal syndrome, 228—230, 239
Shortening of upper extremity, 344—346 Subclavius muscle, 159
Short-term tremor factors, 16—18 Subcutaneous tissue, 97
Silastic arthroplasties, 378 Subgaleal abscess, 221
Single-axial K wire, 374 Subjective symptoms, 378
Single capillaries, 80 Sulfated polysaccharide polymer, 54
Single-digit replantations, 373 Sulfated polysaccharides, 56
Single-staged composite toe-to-hand tissue transfer, Sulfinpyrazone, 74
see also Toe-to-hand free tissue transfer, 421 Superficial peroneal nerve, 439
Sinograms, 243—245 Superficial temporal artery (STA), 219, 247—248
Sinography, 242 Superficial temporal-middle cerebral bypass graft,
Site of lesion, 118 219
SIT low-light-level videocamera, 85 Superior saggital sinus, 241—243
Sekeltal complications, 377 bypass operations, 241—245
Skeletal fixation, 379, 385 Supinator muscle, 183, 192—193
Skeletal injury, 173—174 Supinator region, 183
Skeletal muscle, see also Muscles, 84—88, 94, 97, Supinator syndrome, 183, 192—193
99 Supraacromialis nerve, 282
Skeletal shortening, 379 Supraclavearis nerve, 282
Skill acquisition, 13, 22—23 Supratentorial hydrocephalus, 254
Skin flaps, 83 Sural nerve, 282
Skin fold chamber, 80 Sural nerve removal, 132
Skin graft, 329, 375, 428^429, 449 Surgical instruments, 5—12, 27—36, 114
Skin loss, 377 care of, 14, 24
Slow-absorbing sutures, 352 checking before surgery, 122
Sludge, 483 choice of, 7
Smoking, 16, 275, 286, 312, 376 demagnetizing of, 7, 24
Volume I 503
ergonomie factors, 27 Synaptic vesicles, 264

fine, 95 Syncope, 228
functional performance, 27—28 Synkinesis, 201
glare, 28 Synovial cysts, 174
holding zone, 28 Synthetic material, 219
length, 11 Syrian gold hamsters, 82—99
light tweezer-type, 27
list, 11
metallurgical criteria, 20 T
needle holder, 28—31
nerve suturing, 277 Tactics and strategy, 16
peripheral nerve injury, 114—116 Tactile sense, 325
position of, 7—8 Tardy surgery, 275
powered, 27 TCM method, 473-^74
rotatability, 19 Tear lesions, 201
scissors, 28, 33—35 Technical problems, 275, 287
sophistication in design, 27—28 Telescope anastomosis, 396—397
spring strength, 27 Television techniques, 97
stainless steel, 24 Temperature of transplant, 328
stiffness, 18—19 Temperature recordings, 469
tissue forceps, 28—30, 32—33 Tendon repair, 375, 394—396
tissue requirements, 20 Tendons, 352—353
titanium, 9—11 Tendon transfer, 173
ultrasonic cleaners, 24 Tenolysis, 378
weight, 20 Tension at suture line, 118
Surgical microscope, see also Microscope; Operat- Tension avoidance, 277
ing Microscope, 259—260 Tensor fascia lata free flap, 457
Surgical procedures, see also specific types Tenuissimus muscle, 93, 95
checking instruments, 122 Terminal neuroma, 113, 115, 128
general principles, 121—122 Thenar motor branch of median nerve, 173—174
neurolysis 121—122, 124—125 lesions of, 182—186, 195
peripheral nerve injuries, treatment of, 121—125 Thread for nerve suturing, 277—278
position of surgeon, 122 Thrombin, 53, 65, 67
positioning patient, 121—122 Thrombocytopenia, 49, 55
preparation of donor area, 122 Thrombocytosis, 49
removal of tumors in or around nerve, 121—123 Thromboembolism, 224
replantation surgery, 306—310 Thrombolysis, 58—59
setting microscope, 122 Thrombophlebitis, 441
Surgical team, 317, 319, 425 Thromboplastin (factor III), 65, 67
Surgical trauma, see Microvascular surgery Thromboplastinogin, 65
Survival criteria in toe-to-hand transplants, 328 Thrombosis, 241, 398, 484
Survival rates, see specific types of surgeries Thromboxane, 376
Suture line stenosis, 227, 239 Thromboxane (TxA2), 50
Suture material, 45 Thromboxane A2, 51, 73—74
absorbable, 175 drugs which decrease production, 56—57
reconstruction of peripheral nerves, 146, 149 Thromboxane inhibitors, 75—76
Suture tension, 175 Thromboxane synthetase, 73
Sutures, see also Microvascular suture; Nerve sutur- Thrombus formation, 51, 57, 227, 239, 483
ing, 5—12, 114, 219 congenital absence of, 421, 423, 432
desirable qualities of, 7 thumb amputated, see Toe-to-hand transfer
diameters of, 7, 10 amputation of, 334—335
nonabsorbable, 428 avulsed, see Replantation of avulsed thumbs
nylon, 278, 281, 428 destruction of basilar joint, 423
reabsorbable threads, 281 importance of, 317
running, 248 reconstruction, 452
slow-absorbing, 352 reconstruction after amputation, see also Toe-to-
Suturing, 42—43 hand transplants, 317
nerve repair, 117 replantation surgery, 306, 309—310, 344
orientation of nerve ends before, 118—121 traumatic loss of, 421, 432
Sylvian fissure, 219, 251—252 Tilt of seat, 21
Synaptic knobs, 110 Time lapse between injury and repair, 117—118
Timing, 22—23 molded plaster splint, 329, 333

Timing of surgery, 275, 286 neural anastomoses, 325, 332
Tinel's sign, 136, 283 positioning the graft, 325
Tissucoll, 152 postoperative treatment, 328
Tissue forceps, 28—30, 32—33 precise movements, ability to perform, 331
jeweler-type, 33 preparation of recipient area on hand, 323—324,
omnidirectional, 33—35 326—327
ring, 33—35 proper procedure of transplantation, 324—328
rotatability, 32 rehabilitation, 325, 328
single-handed technique of extracting needle, 33 removal of second toe, 320—324
spring tweezer-type, 30, 32 results, 331—338
toothed instrument, 32 self-help, 331
Tissue hypoxia, 79 skin graft, 329
Tissue trauma, 97—98 surgical team, 317, 319
Tobacco, use of, 5, 424 survival criteria, 328
Toe-to-hand free tissue transfer, 421—436 tactile sense, 325
advanced vascular disease, 423, 432—433 temperature of transplant, 328
congenital absence of thumb, 421, 423, 432 vascular anastomoses, 329
contraindications, 423, 432 vein anastomoses, 329
dissection of the foot, 425—426 Tongue, 94
dissection of the hand, 426 Torculae, 241
dressings, 428—429 Torcular herophilus, 241—245
emergency procedures, 423, 433 Total active movement (TAM), 378
essentials prior to, 423—424 Total bypass, 241—245
foot reconstruction, 428—430 Tourniquet, 116, 443
indications, 4 2 1 ^ 2 3 , 432 Tourniquet deflation, 428
loss of ulnar digits at metacarpal level, 422—423, Tourniquet ischemia, 426
432 Training, 16
operative techniques, 425—430 Transcapillary fluid exchange, 79
postoperative management, 430 Transcutaneous oxygen electrode, 470, 472
results, 432 Transcutaneous oxygen measurements, see also
transfer of toe to hand, 426—429 Postoperative monitoring in reconstructive
traumatic loss of thumb, 421, 432 microsurgery, 469—477
Toe-to-hand transfer, see also Toe-to-hand trans- Transfer of toe-to-hand, 426—429
plants, 378, 4 0 3 ^ 1 9 Transient ischemic attack (TIA), 219, 221, 227,
big toe, 403—408 232, 239, 249
clinical series, 403 crescendo, 221
congenital anomaly, 403 recurrent, 223
operative treatment, 404—411 Transient scalp flap necrosis, 221
big toe, 404—409 Transillumination, 80, 85
second toe, 409—411 Transmetacarpal amputations, 378—379
postoperative care, 411—413 Transmetacarpal replantation surgery, 307
preoperative considerations, 403—404 Transoral-transclival approach, 253—256
results, 413 Transparent chamber model, 97—100
second toe, 4 0 3 ^ 0 4 , 409--111 Transplantation surgery, 37
traumatic amputations, 403 Transplantation techniques, 479—485
Toe-to-hand transplants, 317—339, 344 Transposition of fingers, 344
advantages, 317 Traumatic amputations, 403
anastomoses of anatomical elements of hand, Traumatic lesions of sinuses, 243
323, 326—327 Tremor factors and control, 13, 16—18
bone fixation, 324, 328—331 Tremor of operator, see Tremor factors and control
complications, 330—331 Tremulous movements, 5—6
congenital defects of hand, 317—318, 323 Triceps muscle, 161
contraindications, 317 Triceps tendon, 161
dorsalis pedis artery, 320 Triploscope, 114
functional value of hand, 317 Trunk-to-trunk coadaptation, 280
identification of anatomical elements, 323 Trunk-to-trunk suture, 280
indications for, 317—318 Tumors, 174, 243, 248
level of anastomoses, 325 Tumors in or around nerve, removal with microsur-
marking of vessels, 319 gery, 121—123
microsurgery, 317 Two cross-K. wires, 374
Volume I 505
Two-point discrimination, 136 zone II, 371

Two-stage tendon grafts, 378 zone III, 371, 373
Tying forceps, 11—12 zone IV, 373, 378—379
Type of repair, 118 zone V, 373, 375, 378—379
Type of wound, 117—118 zone VI, 373, 378—379
Ureter, 42, 44, 46
u
V
Ultrasonic cleaners of instruments, 24
Unanesthetized animal, 85 Vascular anastomoses, 329
Uncovertebral joints, 231 Vascular complications, 376—377
Upper extremity repllantation, see Upper limb Vascular dilation, 98
replantation Vascular grafts, 59
Upper limb replantation, see also Replantation sur- Vascularization, 44—45
gery, 341—369, 371—388 Vascularized joint toe-to-hand transfers, 421
absolute contraindications, 373 Vascularized nerve graft, 121, 132—133, 160, 282
absolute indication to replant, 373 Vascular lesions, 248
accumulated metabolic products, 357 Vascular module, 97
age of patient qualified for, 352 Vascular network, 110
amputation with compression, 348 Vascular occlusion, prevention of, 54—59
artériographie studies with venous phase, 344— Vascular plexus, 110
346 Vascular spasm, 424
bone fixation, 352, 362—366 Vascular suture technique, 247
complete amputation, 371 Vascular system, 355—358, 368
complications, 358 blood vessels, 110
corrective procedures, 359 perfusing, 355—356
deficit in range of movements, 352 Vascular wall interaction with platelets, 50—52
diffuse traumas, 356—357 Vasoactive drugs, 68, 430
drainage, 358 Vasoconstriction of arterioles, 97
evaluation of arterial-venous network, 356 Vasoconstrictors, use of, 442
evaluation of vascular state, 344 Vasodilation, 51, 79, 424
factors to consider, 373 Vasodilators, 328
first aid, 373 Vasomotion, 85—87, 97
immobilization of extremity, 353 Vasospasm, 396, 424
incisions of fascia and skin, 358 Vein anastomoses, 329
incomplete amputation, 371 Vein-artery ratio, 329, 356
lack of innervation, 355 Vein-containing transposition flap, 375
metal junction pieces, 352 Vein grafts, 75—77, 249, 375, 428
muscle contractibility loss, 348 Vein patch grafts, 226
muscles, 352—353 Vein repair, 397
nervous system evaluation, 341 Veins, 75
peripheral nerves, 353, 355, 367 foot, 440
postoperative procedure, 358—359 Vein-vein graft, 76
qualifications for, 341—361 Vein insufficiency, 328
reanastomosing of nerves, 355 Venous anastomosis, 396—397
rehabilitation, 352, 359 Venous drainage dorsalis pedis flap, 439
relative contraindications, 373 Venous system insufficiency, 357, 398
removal of carpal bones, 345 Venous sinuses, 241—245
restoration of function as goal, 371 Ventriculoperitoneal shunt operation, 254
return to function, 341 Vertebral arteries, 227, 229, 239
ripped single nerves, 341, 355 compression in vertebral canal, 239
shortening of extremity, 344—346 decompression in vertebral canal, 230—233
slow-absorbing sutures, 352 Vertebral carotid transposition, (VCT), 228—230,
suitability evaluation, 373 238
surgical techniques for digital reimplantation, see Vertebral lesions, see also Cerebrovascular disease,
Digital reimplantation 219
tendons, 352—353 Vertebral origin stenosis, 230, 239
vascular systems, 355—358, 368 Vertebrobasilar insufficiency, 227, 239
venous system insufficiency, 357 Vertebrobasilar ischemia, 227—228
zone I, 371—372 Vertebrobasilar region, 248
Vertigo, 228, 232 Whole blood viscosity, see Blood viscosity

Vesseloops to retract nerves, 115 Workplace arrangement, 27
Vessels, 248 Workplace layout, 13, 20—22
Viability of skin flap, 483 Wound debridement, 379
Vicryl microsurgical sutures, 146 Wound healing, 5, 41, 45—46
Video image-shearing technique, 87 Wound hematoma, 227
Visceral organs, 44 Wrist replantation surgery, 309
Viscosity of blood, 54, 57, 69
Visual acuity, changes in, 15
Visual factors, 13—16
X
Visual health, 15
Vital dye staining, 15 Xa inhibitor, 52
Vomiting, 254 X-ray examination, 193
von Willebrand factor, 58 X-ray lesions of brachial plexus, greater omentum
transfer of, see also Brachial plexus, 289—
293
w X-ray photographs, 38
Xylocaine, 68, 276
Wallenburg-type stroke, ¿32
Wallerian degeneration, Í60, 263, 268—269, 272,
282
z
avoidance of, 271
Warm ischemia time, 3^8—379 Zori slippers, 421
Warmth, 469

Waldemar L. Olszewski (Editor) - Handbook of Microsurgery - Volume 1-CRC Press (1984)

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CRC Handbook

Waldemar L. Olszewski, M.D., Ph.D.

Boca Raton London New York

CRC Press is an imprint of the

Reissued 2019 by CRC Press

© 1984 by Taylor & Francis Group, LLC

No claim to original U.S. Government works

A Library of Congress record exists under LC control number:

ISBN 13: 978-0-367-21167-7 (hbk)

Waldemar L. Olszewski, M.D., Ph.D., is Professor of Surgery and Director of the

Sven-Erik Bergentz, M.D. Erminio Cariati, Prof. Dr.

T. S. Lie, Prof. Dr. Dr. h. c.

Sven-Erik Bergentz, M.D. Carlos O. Esquivei, M.D.

Laurent Sedel, M.D. Jacques C. van der Meulen, M.D.,

John J. S tangei, M.D. Lídia Wilowska-Kociçba, M.D.

GENERAL PROBLEMS IN MICROSURGERY

MICROSURGERY, MICROINSTRUMENTS, AND MICROSUTURES

John J. Stangel and Daniel Y. Lahr

FIGURE 1. The microsurgeon seated in the proper operating position.

FIGURE 2. Both long- and short-microsurgical instruments are held

FIGURE 3. A needle is passed most efficiently in a diagonal

Suture size Diameter limits (pan)

USP Metric Minimum Maximum

From The United States Pharmacopeia XX and

FIGURE 6. A Rhoton® titanium needle holder. (Courtesy of Codman Instrument Company.)

Needle Holder: 5 in. (13 cm)

Stangel Modified Barraquer—stainless steel

Forceps: 7 in. (17.5 cm)

Rhoton® titanium forceps, fine 80-1701

Moria tying forceps, short and long 22-9503

Westcott scissors—produced by several manufacturers

ERGONOMICS AND MICROSURGERY

Microsurgery is the logical extension to small structures of ordinary methods of dissection

Each of these areas will be dealt with in detail.

Visual Health and Binocularity

Molding Effect of Directional Lighting

Other Lighting Factors

TREMOR AND HAND POSTURE

Long-Term Tremor Factors

Intermediate-Term Tremor Factors

Short-Term Tremor Factors

HAND GRIPS AND INSTRUMENT DESIGN

Variations of the External Precision Grip

WORKPLACE ARRANGEMENT AND SEATED POSTURE

Operating Table and Microscope Design

SKILL ACQUISITION AND EFFICIENT PERFORMANCE

Stages in Skill Acquisition

ERGONOMICS AND THE FUTURE IN MICROSURGERY

ASPECTS OF CARE OF MICROSURGICAL INSTRUMENTS

MICROSURGERY INSTRUMENTS — A NEW PHILOSOPHY

FIGURE 2. Concavoconvex jaws. The holding sur-

FIGURE 5. (A) A deliberate maneuver is required to engage the locking mechanism.

The Ring Forceps — Omnidirectional

MICROSURGERY AND RESEARCH

1. Orientation of the complete specimen by making photographs with a normal X-ray

FIGURE 1. Microradioangiography of a silicone rubber prosthesis in the trachea of a rabbit, a

FIGURE 2. Cast of a vascular anastomosis in the carotid artery of the

FIGURE 5. Microradioangiography of an anastomosis in the canine bile

FIGURE 6. Ureteral anastomosis with Nakayama's

MICROVASCULAR SURGERY: COAGULATION, FIBRINOLYSIS, AND

Carlos O. Esquivei and Sven-Erik Bergentz

PLATELET RESPONSE TO SURGICAL TRAUMA

The adhesion of platelets to collagen exposed by injury to the vascular endothelium