ABSTRACT
The improvement of success rates in microsurgery can be attributed as much to better
technical skills, as to the more frequent selection of donor or recipient sites with
consistent, larger-caliber vessels. Often, these vessels may be larger than major
limb source vessels, and anastomoses using loupes can then be successful, even without
requiring an operating microscope. Thus, distinguishing our capabilities from the
domain of the general vascular surgeon, who traditionally deals only with the ravages
of disease or trauma to such large vessels, has become blurred. For some free-tissue
transfers, and especially limb replantations, perhaps it would be appropriate for
the microsurgeon sometimes to enter the realm of the macrovascular surgeon for enhancement
of the overall outcome.
A review of our 202 free flaps and pediatric limb revascularizations has validated
this opinion, as significant portions in 19 of these cases required unequivocal macrovascular
surgery. These included vein-graft bypasses (9) of major segmental arterial defects
of limbs (that incidentally improved collateral circulation, although intended primarily
to simplify arterial inflow to a free flap simultaneously needed to cover a concomitant
soft-tissue defect). Similarly, arterial grafts as part of a “flow-through” free flap
(3) were used for immediate coverage and concurrent limb revascularization. Finally,
two toddlers who sustained disruption of named leg vessels had microsurgical repair
after referral from the vascular service; they believed we were better able to deal
with such diminutive vasculature. These observations are not intended as evidence
that vascular surgery may be better performed by the microsurgeon; rather, that the
best results of microsurgery often will incorporate technical aspects usually considered
as macrovascular surgery.
