Microsurgery is a surgical technique that utilises magnification to reconnect very, very small arteries, veins, nerves and lymphatics in order to reconstruct various parts of the body.

The most common form of microsurgery performed in reconstruction involves the use of “free flaps” otherwise known as free tissue transfer. This form of reconstruction – reconstructive microsurgery – is utilised when various types of tissue need to be brought from a distant site in the body to reconstruct a defect. These defects can be the result of trauma or cancer resection. Many different types of tissue can be transferred, including skin, fat, muscle, bone and even bowel. In very complex cases combinations of these tissues may be transferred together. These reconstructions, which require complete disconnection of the tissue from its original site and then reconnection, restoring the blood supply at the reconstructive site, utilise sophisticated magnification in the form of an operating microscope. These blood vessels can be as small as 1mm in diameter or less. The restoration of blood flow in these reconstructions is crucial to the survival of the flap (free tissue transfer). This form of surgery is technically demanding and requires considerable expertise in order to be successful.

Reconstructive microsurgery is also used in various traumatic injuries in which parts, often fingers, have been detached from the body. Replanting these parts and restoring blood supply also requires precise technique, with reconnection of very small arteries and veins under the microscope. Nerve reconstruction is also a critical part of this form of surgery.

 Reconstructive microsurgery is considered a technically demanding area of reconstructive surgery and is regarded as the most technically difficult form of reconstructive surgery.

Head and neck reconstructive microsurgery is a large part of the specialty. Essentially these patients have undergone resection of cancers from the mouth, throat and upper aerodigestive system and require reconstruction in order to be able to swallow, chew, talk and have a near normal appearance. Reconstructions in this area can involve the reconstruction of soft tissues such as tongue and the lining of the mouth, jaw, hypopharynx and oesophagus. Complex skin cancer and other malignancies may require skull base surgery with reconstruction in and around the skull, eye socket and brain. Many different flaps are used in this area and can include flaps from the forearm, thigh, fibular bone, iliac crest (pelvic bone) and small intestine.

Breast reconstruction is another large area within reconstructive microsurgery. Whilst some post mastectomy patients can be reconstructed using implants, a significant percentage of patients will be better served with a free tissue transfer. Free tissue transfer has the advantage of utilising the patient’s own tissues and not requiring an implant. As such the problems that relate to silicone gel implants are avoided. Free tissue transfer at its best can give the most natural result, which will be long lasting through the patient’s life. The most common area used as a donor site for reconstructing the breast is the lower abdomen. In these procedures the patient’s lower abdominal tissue (the tissue that would be actually removed in a tummy tuck type procedure) is dissected with the relevant artery and vein, and transferred to the breast area. The new tissue is then revascularized under the microscope using microsurgical techniques. The recipient arteries and veins in the chest can be behind the ribs near the sternum or in the axilla. The most common types of flaps used in this sort of surgery are the DIEP (deep inferior epigastric perforator) flap and the muscle sparing TRAM (transverse rectum abdominus myocutaneous) flap. These flaps have the advantage of, in most people, providing adequate volume of tissue for the reconstruction or even a bilateral reconstruction and result in a tummy tuck type closure on the abdomen. Other tissue can be used to reconstruct breasts using microsurgical techniques. These alternative flaps can come from the lumbar region, inner thigh and buttock region.

Lower limb reconstruction is an area that commonly utilises reconstructive microsurgery. Particularly in areas below the knee, soft tissues are not always available to cover fractures or tumour resection. Because a significant number of motor vehicle and motor bike accidents involve compound lower limb fractures, free tissue transfer is commonly used in this area. This can mean the difference between limb preservation and amputation. As such free tissue transfer is a crucial part of lower limb trauma reconstruction and is commonly performed. These procedures involve the transfer of muscle/skin from other areas of the body such as the back, inner thigh, abdomen and outer thigh to reconstruct these wounds.

Sometimes the trauma or cancer resection requires the transfer of bone to replace the bone that has been lost, either through cancer or trauma. These transfers also require complex reconstructive microsurgical techniques.

Patients can suffer loss of function in the facial nerve from both iatrogenic (no definite cause known), trauma and from tumour resections. Patients who have lost complete function of their facial nerve on one side of the face, the face is completely paralysed on that side. These patients are unable to move their face on that side and unable to blink properly. Their face also hangs down compared to the other side.

Microsurgical techniques can be used to transfer muscle to the paralysed face and, using microsurgical techniques to revascularize the muscle and also connect the nerve to the muscle, restore function to the patient’s paralysed face. The most common area used for this surgery is the gracilis muscle in the inner thigh. However, other muscles from the chest and other areas of the body can in rare cases be used.

Microsurgery is also used to alleviate or prevent lymphoedema.  Lymphoedema occurs most commonly after surgical procedures and radiation treatment, which have required lymph node dissection. This can result in the lymphatic channels in the limb being disrupted, with resultant significant swelling and disability. Microsurgical procedures that reconnect lymphatics to other lymphatics, to other veins (LVA) and free lymph node transfers can all be used to improve limb condition and lymphatic drainage in patients who suffer lymphoedema. Lymphatic channels are usually very small in diameter and require significant magnification and the finest sutures used in microsurgery.