only rarely. spine surgeons are doing it. best regards

Yes it is helping me a lot.

I use it in hair transplant surgery to remove n put grafts.

It totally changed the result. 

Thank you Thomas and Ganesh for your contributions. In fact, spine surgery is a good indication for some surgeons used to operate with the loupes or even surgical microscope, as the magnification can improve the surgical field. Capilar transplant surgery is an indication that I didn´t knew and seems very interesting as it is a thorough and fine procedure.

I use it in hand surgery and my chairman use it in spine surgery. best regards

I'm involved in hand surgery and what you can do is quite limited unless you have microsurgical skills. Best regards.

Thank you Murat for your answer. This is very important to know that, specially to those young surgeons who want to dedicate to hand surgery. By the way, I read that Microsurgery is a technique for surgeons that are younger than 50 years old. Do you agree with that? 

I use it in hand surgery especially during nerve repair

Dear Gustavo,

I am a plastic surgeon and I use microsurgery for free flap transfer in my field such as soft tissue defect reconstruction or mandibular defect reconstruction.

I use itr for polizitation of the index finger and meybe 2 or 3 other procedures, but most of the surgery canbe done with magnifier lenses

Thank you Peter, Irfan and Luis. It is amazing to see a technique used in so many different procedures. It seems that the augmentation given by the operating microscope or the magnifying loupes enables a surgeon to carry out procedures with a precision not attainable with non-microscopic techniques. Do you think Microsurgery is a technique that could be extended to other surgical procedures, regarding, for example, the development of fluoroscopy? Could it enhance the so-called mini-invasive surgery?

For sure, it only takes time for the surgeons to try this kind of techniques and adopt them for their day to day practice.

That´s true. It takes a long time in the laboratory to dominate the microsurgery technique and being able to perform procedures such as microvascular anastomosis or microneurorraphy with good results. In your experience, how long do you think it could take to acquire those skills (in average)???

It could be part of the training of the specialty or as a tutorial, but talking about time is hard to tell.

Thank you so much Vitaliano Francesco for giving us a vision of a neurosurgeon. Certainly neurosurgery is one of those specialities where microsurgery is a primordial and indispensable tool. All the advances with the fluorescence microscope that allowed an intraoperative identification of the malignant glioma tumour and a great precise tumour resection were amazing.

https://www.youtube.com/watch?v=U8R0Zr1WbS4

No, my first step in reconstruction is local, regional or axial flap.

If there is no other way , i will use microsurgery or free flap.

only for nerve surgery microsurgery usually is needed.

Regards

Dear Gustavo. Thank you for your comments (btw, you can address me "Sinan", that's my default name). However, I disagree with that age statement. In microsurgery it's about patience, correct positioning, and teaching the brain how to operate in a disproportionate visual and actual field. As years go by, you only get better in that sense. We have microsurgeons here who have past 60 but still kick it in BP and Mutilations. If tremor is a concern, it is there and it will always be. It's physiological. Our muscles contract in micro oscillatory manner which means even our smoothest movements are the resultant vectors of uncountable tremors. What happens is, you get in sync with YOUR tremors. Also, microsurgery is about comfort. That's why, for relatively inexperienced microsurgeons I suggest to talk in advance with a colleague who can back them up when they are tired (even better if they work together). Because unlike other procedures which you can push yourself and somehow finish, you can't will your way out in microsurgery. If you're tired or stressed you secrete adrenalin and it induces tremor. It's no big deal if you're hammering a prosthesis peg in or stitching up a breast. But in microsurgery, adrenaline induced tremor is a serial killer of flaps and replants. You try to suppress it with your will and resolution and then what?.. it gets worse. So... After you dissected the flap and you're ready to harvest it, or you fixed the bones and prepared the vessels in a replantation, if you feel tired, if you realize that you don't function as you used to be, don't sweat it. Ask your colleague to keep going for a while and pull out those gloves, remove that gown, rip off that mask, and walk out of the OR. Go have a snack, grab a coffee, have a smoke if you're a smoker (not more than one. gives tremor), gossip with buddies, play a few rounds of temple run or your favorite mobile game, recline in a chair, close your eyes and/or dream of your significant other or anything that makes you happy... in other words, CHILL OUT! Do what you do when you come home after a hard day's work for 30 minutes maybe more. It's not a problem if your friend is keeping things running and even when you're alone, that break is a necessity. Giving a patient an extra 30 minutes of anesthesia is insignificant  if you'll return all calm and ready afterwards and wrap things up nice and smoothly. Otherwise, you'll struggle and in all likelihood, take a much longer time just to fail in a very disappointing manner! 

Microsurgery is cool. And you gotta be cool to nail it ;-)

keeping the patient in anesthesia for 30 minutes more ????

it is unwise and most of all illegal.

it is malpractice and every surgeon should avoid it.

I think it is a dangerous comment !!!!!

Regards

No it isn't and everyone who's involved in microsurgery on routine basis are pretty comfortable with it. A complex microsurgical procedure takes no less than 5 hours anyway. I recall reattaching a mutilated hand in 11 hours and it successfully took afterwards. I rested twice during that operation. We have a team of microsurgeons and while one is resting the other keeps things up anyway. But in a drastic incidence when you're alone and exhausted, you can either struggle with an anastomosis with shaking hands for hours, failing it repeatedly, or you refreshen up and nail it within 15 minutes. 

In microsurgery, especially reconstructive microsurgery, surgeon comfort is not a luxury. it's a necessity.

It's not dangerous, it's wise and no, there's nothing illegal about keeping a patient under anesthesia for as long as it's needed.

And I wonder.... Since when succeeding in a surgery became malpractice?...

Thank you Sinan and Hamid for both points of view and opinions.

I agree totally with Sinan in the way that you have to rest every 1-1,5 hours of surgery to stretch out and to be more productive in the following work. It is not a luxury, and is very recommended. It is very interesting, as you said, to have a good and skilled microsurgery team in which you have full confidence to proceed with the surgery, while you get some rest. This is so important as the preparation of the microscope and to have a proper posture - ergonomics, that could prevent fatigue and save final operative time.

Preferably, the microsurgeon should have his elbows at 90° (with pads under), the head in about 30° of flexion, the back straight and with a good lumbar support. In case of experimental microsurgery on the lab the table should preferably have a round opening (for the body suits surgeon and is closer to the surgical microscope).

It´s a great topic of discussion. However i would like to point out that microsurgery techniques are not just limited to free flaps or microvascular anastomosis. The techniques now allow you to increment significantly your alternatives in complex or even simple situations. Dissection techniques and anatomical knowledge will keep you safe and allways have first, second and third options even in very complex scenarios. 

In my opinion, microsurgical techniques are now standard in our practice and must be trained constantly. 

Cheers to all

I think that microsurgery is indispenssible technique in almost every reconstructive procedure - emergency or elective. Nowadays you cannot be a good hand or plastic surgeon without it and even in cosmetic procedures it is a help. It teaches you to pay attention to details, to respect anatomy and to always have a back-up plan should a technical problem arise during procedure. It also teaches you to be honest with yourself and to learn your limitations. I completely aggree that age of the surgeon has nothing to do with success - but practice and experience does...

All the best and good luck

Not necessarily. Microsurgery needs skill sets that are pointed and highly focused. Good tissue handling skills are key to being a good surgeon.  They can be overlap if you are a good microsurgeon but not necessary  as one could be technically trained for microsurgery but not very good at anything else.

Thank you Cristian, Batia and Susarla for your points of view. Very interesting the idea that microsurgery could improve and enhance your routine surgical practice, and could help to each one our limitations...I really think that learning and practice microsurgery is not an easy task at all. It is an extreme precise technique where you have to acquire the necessary physical, manual and emotional preparation for that. At the same time it is a technique that allows us to improve ourselves and our capacity of self-control...Being at peace with the world, having slept well and getting rid of phones or any stressful events could also help us to achieve our microsurgical goals.

I used it in 10% of my surgeries.

But it is my last option .

of course, because it let me more delicate and respect tissue I dissected.  

Dear Hamid. Do you mean that you use Microsurgery in 10% of you surgeries?

Thank you Chien for your contribution. Would you like to tell us a little more about your microsurgical practice in Taiwan?

Hi,

I agree with everyone here and being teaching microsurgery for many many years to many different surgical specialties and to surgeons and not only surgeons with different experiences proved to me that skills like micro significantly improve quality of technical skills everyone who has it. It not easy to obtain but in a way of learning microsurgery people also learn quite many other skills as well ( sometime without even realizing it :) like gentleness of handling and dissecting, attention to details, self-control and patience and decision making, etc I really believe that learning and using microsurgery is a very useful in many aspects and should be taught to all surgeons while they are in training even thought they are not will be using it in practice, they just will be better surgeons !!! thank you for the opening this discussion. 

I use microsurgical skill in vary area including reconstruction of ablative operation like head and neck tumor, breast cancer, replantation of digit and limb, hepatic artery anastomosis during liver transplant, tiny tissue repair like nerve or lymphatic vessel.    

Dear Yelena,

It is a huge pleasure to have you in this discussion. Your experience teaching so many different surgeons from so many different places and specialities in one of the best microsurgery labs in the World at Columbia University throughout all these years is unbelievable.

Thank you once again for all you efforts for making Microsurgery comes true!

I agree with Gustavo and Yelena. Microsurgical skills enhances the quality of your work even when it is not considered microsurgery. After I got a better grip on microsurgery (And I owe a lot to Professor Fu Chan Wei and his team in Taiwan in that sense) the way I handle the fibroosseous canal in a flexor tendon repair or the periosteum in a nonunion changed. And it reflected greatly to my results. So Gustavo, I guess it's fair to say that for all surgeons who reconstruct something, or make something look or work better, getting familiar and comfortable with microsurgical techniques is a milestone.

Thank you Gustavo for the kind words.and Im glad than many more people realize now that the microsurgery is not only the skills to put anastomosis together but much more and can significantly improve  the quality of surgical care and research..

Yes, I do. Usually when you have microsurgical skills you can get better results in your general practice. It is an important and valuable technique.

Yes, I always you microsurgical skills in clinical practice. I always use an operating microscope for nerve repair and for internal neurolysis. For all hand surgery I use a loupe. They are important to give a standard of care.