The history of microsurgery.

Microsurgery is a term used to describe the surgical techniques that require an operating microscope and the necessary specialized instrumentation, the three "Ms" of Microsurgery (microscope, microinstruments and microsutures). Over the years, the crucial factor that transformed the notion of microsurgery itself was the anastomosis of successively smaller blood vessels and nerves that have allowed transfer of tissue from one part of the body to another and re-attachment of severed parts. Currently, with obtained experience, microsurgical techniques are used by several surgical specialties such as general surgery, ophthalmology, orthopaedics, gynecology, otolaryngology, neurosurgery, oral and maxillofacial surgery, plastic surgery and more. This article highlights the most important innovations and milestones in the history of microsurgery through the ages that allowed the inauguration and establishment of microsurgical techniques in the field of surgery.

Hand Transplantation: Evolution of a Personal Outlook.

The field of vascularized composite allotransplantation-combining advances in reconstructive surgery, transplantation, and immunology-offers great promise for patients with heretofore unsolvable problems. In the last 30 years, hand transplantation has progressed through the phases of being a research subject, a controversial clinical procedure, a more widely accepted and expanding field, and now a promising endeavor undergoing refined indications. Although many lessons have been learned, few procedures in the author's experience have been as life-transformative in restoring the body image, motor and sensory functions, activities of daily living, and personal autonomy as successful hand transplantation.

Advances and Innovations in Microsurgery.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. summarize the evolution of perforator, chimeric, and free style flaps; 2. define and give examples of supermicrosurgery as well as understand its application in treatment of lymphedema; and 3. appreciate the development and advancements of composite tissue allotransplantation. SUMMARY: Although microsurgery may seem like a highly specialized niche within plastic surgery, it is more than just a discipline that focuses on small anastomoses. It is a tool and a way of thinking that allows us to embody the true tenets of plastic surgery, as quoted by Tagliocozzi. What began as a challenge of returning amputated tissue to the body and achieving wound closure has evolved into a refinement of technique and change in philosophy that empowers the plastic surgeon to work creatively to "restore, rebuild, and make whole."

Vascularized composite allotransplantation and tissue engineering.

For many living with the devastating aftermath of disfiguring facial injuries, extremity amputations, and other composite tissues defects, conventional reconstruction offers limited relief. Full restoration of the face or extremities with anatomic equivalents recently became possible with decades of advancements in transplantation and regenerative medicine. Vascularized composite allotransplantation (VCA) is the transfer of anatomic equivalents from immunologically and aesthetically compatible donors to recipients with severe defects. The transplanted tissues are "composite" because they include multiple types essential for function, for example, skin, muscle, nerves, and blood vessels. More than 100 patients worldwide have benefited from VCA, the majority receiving hand or face transplants. Despite its demonstrated results, the clinical practice of VCA is limited by center experience, public awareness, donor shortage, and the risks of lifelong immune suppression. Tissue engineering (TE) is the generation of customized tissues in the laboratory using cells, biomaterials and bioreactors. Tissue engineering may eventually supersede VCA in the clinic, because it bypasses donor shortage and immune suppression challenges. Billions of dollars have been invested in TE research and development, which are expected to result in a myriad of clinical products within the mid- to long-term. First, tissue engineers must address challenges such as vascularization of engineered tissues and maintenance of phenotype in culture. If these hurdles can be overcome, it is to be hoped that the lessons learned through decades of research in both VCA and TE will act synergistically to generate off-the-shelf composite tissues that can thrive after implantation and in the absence of immune suppression.

Ischemia-reperfusion injury in vascularized composite allotransplantation.

Vascularized composite allotransplantation may now be considered a viable treatment option in patients with complex craniofacial and limb defects. However, the field is still in its infancy, and challenges continue to exist. These challenges, most notably the adverse effects of lifelong immunosuppression, must be weighed against the benefits of the procedure. Improvements in this risk-benefit ratio can be achieved by achieving tolerance and preventing rejection. Five decades after Dr. Joseph E. Murray introduced the field of transplantation to the world, we now have a better understanding of the immunologic factors that may contribute to rejection and inhibit tolerance. In this article, we review emerging evidence that suggests that "danger signals" associated with ischemia-reperfusion injury contribute to innate immune activation, promoting rejection, and inhibiting tolerance. Based on this understanding, we also describe several strategies that may ameliorate the damaging effects of ischemia-reperfusion and the clinical implications of ischemia-reperfusion on the vascularized composite tissue allotransplantation outcome.