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Pediatric vascular microsurgery: overview

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Microsurgery is the technique that allows transplanting vascularized tissue segments (bone, muscle, skin) or extremities (fingers, joints, etc.) between different parts of the body. We take pieces of tissue, called flaps, which are expendable to supplement losses elsewhere in the body where they are needed. For example, sacrificing the fibula bone or the latissimus dorsi muscle would not have a significant impact on the person. Thus, if a large piece of tibial bone is missing because of a fracture or a tumor resection, we may be able to replace it with a piece of vascularized fibula (Figure 1). This process is called microsurgical reconstruction.
 

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Figure 1A. 11 year old patient who suffered a car accident at 6 years of age, with loss of a fragment of tibia and subsequent infection. This is a non-union or chronic septic pseudarthrosis of the tibia with febrile episodes of drainage at knee and ankle, with chronic malnutrition. One treatment option is amputation. We opted for microsurgical reconstruction with biological methods.

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Figure 1B. Radiograph of the patient, showing a general affectation of the tibia.

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Figure 1C. Contralateral fibular vascularized flap, to be implemented in the area of the excised tibial infected fragment. The skin associated with the flap serves to supply the missing skin. Also to control the blood supply, so that the blood flow through the sutured artery and veins is correct.

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Figure 1D. Radiograph showing the replacement of the infected tibia with the vascularized fibular flap.

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Figure 1E. Radiograph 12 months after surgery, showing a thickening of the transplanted fibula. Because the fibula is vascularized, it integrates and grows physiologically, adapting to the needs of the charges that has to endure in its new location. In the following months, the transplant will continue to increase in thickness.

Since the flaps are of great size, they need irrigation / vascularization to survive. They should therefore be transplanted with blood vessels (arteries and veins) that will be connected with other blood vessels to recover the blood supply. The connection of blood vessels together or anastomosis, being typically 1 mm in diameter (Figure 2A-2B), requires the use of a microscope (Figure 2C), fine instruments (Figure 2D) and sutures of smaller diameter than a human hair. For this reason we talk about microsurgery.
 

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Figure 2A. Amplified microscope image, 15 x. Faced arterial ends to be sutured or anastomosed, and thus restore blood flow.
 

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Figure 2B. Amplified microscope image, 15 x. Anastomosed vessels.

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Figure 2C.Use of the microscope to perform the anastomosis of blood vessels.
 

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Figure 2D. Microsurgical instruments with very fine and delicate ends to allow the management of small structures.

The main advantage of vascularized tissue transfer is that their union or integration and growth is performed at a physiological rate and speed. It is also a lifelong treatment (stable and definitive). It is a fully integrated biological treatment (Figure 1E). In contrast, treatments using prosthesis or vascular structures are not (grafts from tissue banks) must be reviewed surgically along the patient's life because they degrade, loosen or not fully integrate (Figure 3).
 

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Figure 3. Patient 16 yo, operated at 8 years old of a malignant tumor in the femur. We initially placed a nonvascularized fibula to replace the 20 centimeters of femur removed and plates. We subsequently placed a cryopreserved allograft bone that was not integrated and required multiple surgeries. The use of non-biological structures determines the lack of integration, leading to a life with limitations. The structural allograft bone did not attach (non-union or pseudarthrosis). This patient has been using crutches to unload the limb for 8 years

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