|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| The severed ends of the superficial dorsalis pedis and radial arteries were brought into an atraumatic small double vascular clamp (Fig. 2 G, H). Chlorpromazine 0.25 mg. per ml. in saline was applied directly to the vessels to overcome local spasm (Buncke and Blackfield, 1963). Near and far stay sutures were placed and five to seven interrupted sutures carefully inserted between them. The clamp was rotated 180 degrees and the posterior edges were approximated in a similar fashion. The same technique was used to repair the veins and nerves (Smith, 1964). The clamps were removed from the vessels to the transplant and the tourniquet released from the arm. Skin edges were closed with a continuous 4.0 nylon suture and the entire extremity wrapped in a bulky pressure dressing. A plaster cast was applied from the axilla to the fingertips exposing the distal phalanx of the transplanted hallux (Fig. 2, I).
The elbow was placed in partial flexion to prevent the cast from slipping off. The animals received 0.5 ml. of Chymar daily and 200,000 U. of penicillin and 0.25 g. of streptomycin every other day. Operative time varied from three to four and a half hours.
Results.-Three transplants have been competed to date. The first two survived completely with primary healing of all incisions (Figs. 5 to 8). An arteriogram utilising 5 ml. of Renograffin (E. R. Squibb Co.) injected into the radial artery at the elbow showed complete filling of the vascular network of the first transplant - two weeks postoperatively (Fig. 4). The last transplant was a total failure, undoubtedly brought about by immediate thrombosis of the arterial repair (Fig. 6). This was precipitated by injury to the intima of the vessel produced by a traumatic intravascular immobilising device. A good arterial flow across the anastomosis was not demonstrated at the completion of the repair.
FIG. 8. A, Animal No. 1 at two months holding a banana, utilising the transplanted hallux on his left hand. B, Animal No. 2 at two months grasping a banana in his right hand, using his transplanted hallux.
The transplantation of large blocks of composite tissue by microminiature vascular repairs is a new concept made possible by the development of the binocular operating microscope and ultrafine sutures, needles and instruments. The techniques used are borrowed directly from macrosurgery and require no unusual or unique skills on the part of the operator other than an adjustment to working under magnification (Jacobson, 1963 ; Salmon, 1964).
The viability of the two surviving transplants was quite apparent on the first post- operative day. The exposed distal phalanges were warm and unswollen. That of transplant No. 3 was cold to the touch from the first day on. On removal of the cast ten days later the entire transplant was found to be gangrenous (Fig. 6). Even so the animal could still move the distal phalanx of the hallux.
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