Supermicrosurgery: History, Applications, Training and the Future

Ido Badash, Daniel J Gould, Ketan M Patel, Ido Badash, Daniel J Gould, Ketan M Patel

Abstract

Supermicrosurgery, a technique of dissection and anastomosis of small vessels ranging from 0.3 to 0.8 mm, has revolutionized the fields of lymphedema treatment and soft tissue reconstruction. The technique offers several distinct benefits to microsurgeons, including the ability to manipulate small vessels that were previously inaccessible, and to minimize donor-site morbidity by dissecting short pedicles in a suprafascial plane. Thus, supermicrosurgery has become increasingly popular in recent years, and its applications have greatly expanded since it was first introduced 20 years ago. While supermicrosurgery was originally developed for procedures involving salvage of the digit tip, the technique is now routinely used in a wide variety of microsurgical cases, including lymphovenous anastomoses, vascularized lymph node transfers and perforator-to-perforator anastomoses. With continued experimentation, standardization of supermicrosurgical training, and high quality studies focusing on the outcomes of these novel procedures, supermicrosurgery can become a routine and valuable component of every microsurgeon's practice.

Keywords: free flap; lymph node transfer; lymphedema; microsurgery; perforator; plastic surgery; soft tissue reconstruction; supermicrosurgery.

Figures

Figure 1
Figure 1
Lymphovenous anastomosis by end-to-side technique. The lymphatic vessel and vein are shown clamped (A). After anastomosis, the outflow vein and lymphatic vessel are unclamped to demonstrate flow (B). Many lymphovenous anastomoses are performed on each limb in sequence in order to improve lymphatic outflow (C).
Figure 2
Figure 2
Supraclavicular flap. Skin markings for the supraclavicular donor site of the vascularized lymph node transfer to the upper extremity (A). Nodes were confirmed with lymphoscintigraphy and ICG. (B) shows the flap in place after harvest. (C) shows the recipient edematous upper extremity. (D) shows the dissected recipient artery and vein. (E) shows the dissected flap, and (F) shows the flap after inset and de-epithelialization.
Figure 3
Figure 3
Skin markings for the groin-based lymphatic flap with nodes identified by lymphoscintigraphy and ICG (A). The dissected flap is shown with arrows indicating lymph nodes (B).
Figure 4
Figure 4
(A) shows markings for the SCIP flap, and (B) shows the thin dissected flap. (C) demonstrates the recipient wound bed, and (D) demonstrates the recipient site with the flap in place. (E) shows the same foot 3 months postoperatively.
Figure 5
Figure 5
Salvage of a diabetic wound. The patient presented with an infected great toe amputation, and underwent 3 staged debridements with osteotomy. (A) shows the defect before soft tissue reconstruction, (B) demonstrates the markings for SCIP flap, (C) shows the dissected flap and vessels, and (D) shows the flap after inset. (E) demonstrates the flap 6 months postoperatively.

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Source: PubMed

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