the history of microsurgery

Microsurgery was developed in the twentieth century by combining techniques of vascular surgery with an operating microscope, fine instruments, micro-suture and new operative strategies and techniques.  

The Father of Microsurgery - Harry J. Buncke 1922-2008

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In 1964 Harry Buncke reported the first successful rabbit ear replantation to the Plastic Surgery Research Council Meeting in Kansas City, Kansas.  This was a milestone in the development of the field of microsurgery because it was the first report of an amputated part successfully reattached using blood vessels 1 millimeter in size.  This size was considered critical because it approximated the size of vessels in fingers and major vessels supplying muscles and skin.  Dr Buncke made his own microsurgical instruments and developed the fine nylon sutures with hand-made needles bonded directly to the end of the suture.  His work was originally begun in his garage and the laboratory at Stanford University and was later continued at Davies Medical Center, the location of the Harry J. Buncke Microsurgical Research Laboratory.  In 1966 he reported in a second landmark paper, the transplantation of a monkey great toe to hand using microsurgery.  These two studies opened the door to replantation of amputated body parts and to  microsurgical tissue transplantation. Then in 1969 with Dr. Donald McLean, Dr. Buncke performed the first successful microvascular transplant using omentum to fill a large scalp defect.  

Clinical microsurgery would experience rapid growth following this.  Indeed, the year after Buncke and McLean performed their omentum transplant, Daniel and Taylor reported the use of a vascularized groin flap to the lower extremity.   Multiple donor tissues have now been successfully used to reconstruct complex composite tissue defects of the head and neck, limbs, abdomen, chest and breast.  

Microsurgery is a culmination of achievement in vascular surgery.  The first vascular anastomosis was performed by J.B. Murphy in 1897, but Alexis Carrel originated the method for triangulation of blood vessels to perform arterial and venous repairs in 1902.  He performed an end-to-end anastomosis.  In 1908, he had devised methods for the transplantation of whole organs.  Together with C.C. Guthrie, Carrel was able to amputate and reattach an entire lower limb at the level of the thigh in an animal.  Born in France, but residing in the United States and Working at the Rockefeller Institute in New York City, Carrel was awarded the Nobel Prize in Medicine and Physiology in 1912, " in recognition of his work on vascular suture and the transplantation of blood-vessels and organs".  

The Second World War provided momentum for further advancement in vascular surgery. With the establishment of antibiotics in clinical surgery and the prevention of infection, results improved and vascular surgeons developed more sophisticated suture and instrumentation. Small vessels on the order of two to three millimeters were still beyond the scope of routine practice.

It was in 1960 that Jules Jacobson, a vascular surgeon, described microsurgical anastomoses in vessels as small as 1.4 millimeters using a microscope.  Working at the University of Vermont, Jacobson found that a microscope used by ear, nose and throat surgeons for surgery on the middle ear could aid in small vessel repair.  Not surprisingly, he was the first to use the term "microvascular surgery".  

Jewelers instruments were then adapted for use in plastic surgery and in addition were modified into needle drivers.  The indications for microsurgery were about to expand and tremendous interest in clinical and laboratory research began.

A traumatic arm amputation was reattached surgically for the first time in 1962 when Malt and McKhann described their experience with a ten year old boy.  Microsurgical techniques were not used since the amputation was at the level of the upper arm where blood vessels were large enough to repair by conventional methods.  

In 1963 Goldwyn, Laub and White attempted to use macrovascular techniques to transplant large island flaps in animals.  Without fine suture and microsurgery they were unsuccessful, however  Kleinert and Kasdan reported the successful revascularization of a incompletely amputated thumb in 1963.

To successfully and consistently repair very small arteries and nerves it was necessary to develop finer suture and needles.  Needles and suture that would not damage fragile small blood vessels. That was where Harry Buncke came in, and the field, and reconstructive plastic surgery would never be the same.