Microvascular free-tissue transfers to the hand and upper extremity

Hundreds of authors world-wide are responsible for the development of the present state of microvascular free-tissue transplantation. The applied technique represents a true developmental landmark in the field of surgery, now applicable to the broad spectrum of surgical subspecialties. In hand surgery, the revolutionary use of free-tissue transplantation has saved innumerable limbs, and improved the quality of life for tens of thousands of patients. In spite of our comfort level using these techniques and incorporating them into our armamentarium of patient care, we stand only on the threshold of microsurgical clinical applicability. The field has expanded substantially during the last 15 years. First, as a substitute for more conventional solutions to wound coverage problems, substituting for often cumbersome attached random or axial pattern pedicle flaps; then, incorporating neurosurgical techniques to provide sensibility to viable but otherwise anesthetic flaps, and kinetic function to transplanted muscle; and subsequently, with the incorporation of muscle, bone, and total joints. An ever-increasing knowledge of the metabolic consequences of ischemia and hypoxia on different types of tissue has allowed us to be even more aggressive in assessing indications for composite tissue transplantation. In the future we should anticipate continued advances in optics and magnification in the surgical microscope, with particular emphasis on three-dimensional perspective and enhanced video capabilities. Technologic development of instruments and suture material should continue helping to raise the capability of what is presently the most limiting factor--the surgeon--to a higher level of potential for his or her patients. Even with improved links to video equipment, stereoscopic imaging, or even more sophisticated visual images, the lowest common denominator is the skill of the microsurgeon; more rigorous technical development will be necessary during the surgeon's training period. Besides a fundamental knowledge of vascular clotting mechanisms and the effects of anticoagulation, we have only an elementary understanding of chemically induced vasospasm, and a developing appreciation of the physiologic impact of microsurgical trauma on small blood vessels, even with the most sophisticated and delicate techniques. As the field enlarges, our ability to deal with irreversible vessel spasm, inexplicable arterial or venous clotting, or the enormity of other complications associated with microvascular free-tissue transplantation, will only grow. A richer understanding of tissue biology will not only improve our technical capabilities, but will promote consideration of a