Microsurgery in Ankara, Turkey

Microsurgical procedures are advanced surgical interventions performed under a microscope, involving the repair or transfer of vessels, nerves, and soft tissue structures. Among the most commonly used areas are free tissue transfers, nerve repairs, and replantation surgeries.

In free tissue transfers, muscle, skin, bone, or combined tissues taken from another part of the body are transplanted to the damaged area with microvascular connections. This technique is widely used in breast reconstruction, post-traumatic tissue loss, and head and neck repairs.

Nerve repair is performed by suturing severed or transected nerves end-to-end or completing them with a graft. With early interventions, recovery of sensory and motor functions may be possible. After the procedure, recovery is supported with physical therapy.

Microsurgery requires high technical equipment and experience. Surgical success is closely related to ensuring vascular and neural integrity. With these methods, both aesthetic and functional recovery is achieved; patients’ quality of life and social adaptation are improved.

What is Microsurgery?

Microsurgery is an advanced surgical technique performed on very small vessels, nerves, and tissues using an operating microscope and specialized precision surgical instruments. It is commonly used in reattachment of amputated limbs, tissue transfers, nerve repairs, and certain reconstructive surgeries. This method aims to repair tissues in the best possible functional and aesthetic manner and requires high technical expertise.

How have microsurgical technology and microscopes evolved?

In the past, surgeons worked only with magnifying loupes, whereas today our operating rooms almost resemble a space base. This evolution did not only magnify the image; it also dramatically increased surgical success rates. This journey, which began with simple lenses in the late 19th century, has now reached the peak of digitalization.

Modern surgical microscopes do not merely provide a magnified image; they also deliver depth perception. This is critical because while working on a three-dimensional organ, losing depth can cause a wrong move. New-generation devices show the finest details of tissues, vessel walls, and nerve sheaths with crystal clarity. In addition, thanks to advanced lighting systems, we can work even in the deepest and darkest points without shadow formation. Some important advantages these technologies bring to surgery are:

• Depth
• Clarity
• Safety
• Speed
• Comfort
• Recording

In particular, additional equipment such as fluorescent staining technologies allows us to see what is not visible to the naked eye during surgery. Thanks to a special dye administered through the vessel, we can see under the microscope, glowing in different colors, whether the tissue is perfused or where a tumor ends. This eliminates the question “Is the tissue alive?” and allows us to proceed with confidence.

What does free flap surgery and tissue transfer mean?

In plastic surgery, there is a repair hierarchy we call the “reconstructive ladder.” We close simple wounds with sutures, and slightly larger ones with skin grafts. However, in cases where the bone is exposed and there are very large tissue losses, these simple methods do not work. This is where “free flap” surgery, the top step of the ladder, comes into play.

A free flap is a tissue taken from a healthy region of the body, completely detached along with its vascular pedicle and transferred to another region. This tissue may be skin, muscle, bone, or fat. The key is to find the main artery supplying this piece and suture it to the vessel in the recipient area under a microscope (anastomosis). It is like unplugging from one outlet and plugging into an outlet in another room; when the electricity (blood) flow is restored, the device (tissue) continues to function. This method is often a hero in situations where there is no other chance left, preventing amputation or enabling the patient to return to social life.

How are aesthetics and function ensured in losses in the head and neck region?

The head and neck region is the most critical crossroads of human life. Eating, breathing, speaking, and facial aesthetics that allow us to appear in public are in this region. Losses that occur in this region after cancer surgery or severe trauma deeply affect the patient both physically and psychologically. When we repair these losses with microsurgery, our goal is not merely to close the hole, but to restore the lost function.

For example, think of a patient whose tongue has been removed due to tongue cancer. For this patient to be able to speak and eat again, a new tongue is needed. We can create a new tongue for the patient by using thin and flexible tissue that we usually take from the inner forearm (radial forearm flap). This tissue is thin, can be folded, and adapts very well inside the mouth.

If the jawbone has been removed, we use the leg bone (fibula). We take this thin, non-weight-bearing bone of the leg together with its vessels and, shaping it to fit the face, create a new jawbone. In fact, because this bone is alive, even dental implants can be placed on it once healing is complete. The donor sites we frequently use in head and neck reconstructions are:

• Forearm
• Thigh
• Calf
• Back
• Abdomen
• Hip

Thanks to these operations, patients can recognize themselves when they look in the mirror, eat their meals, and continue their social lives.

Is reconstruction with your own tissue possible after breast cancer?

Breast cancer is one of the most common types of cancer in women, and the mastectomy (removal of the breast) process can be as traumatic as the treatment itself. Breast reconstruction is a complementary part of this process. Although silicone implants are a practical solution, the “most natural” results always come from reconstructions performed with the patient’s own tissue (autologous).

The biggest advantage of reconstructions using your own tissue is that the tissue belongs to you. It has the same temperature as your body, is soft to the touch, and most importantly, it grows when you gain weight and shrinks when you lose it. In addition, it is free from the complication risks that implants create in skin that has undergone radiotherapy.

In this field, the method we accept as the “gold standard” is the DIEP flap. In this surgery, we use the skin and fat tissue from the lower abdomen. Just like a tummy tuck, the excess in the abdomen is removed, but instead of being discarded, this tissue is transferred with its vessels to the breast area to create a new breast shape. The best part is that we can do this without damaging the abdominal muscles at all. So the abdomen flattens and a natural breast is obtained. For patients who are not suitable for this procedure, tissue transfers from the back or thigh are also possible.

Why are limb salvage and timing critical after trauma?

Work accidents, traffic accidents, or gunshot injuries… Open wounds and bone fractures resulting from high-energy trauma are among the most common areas where microsurgery is used. In this process, which we call “extremity salvage,” microsurgery is often the fine line between amputation and saving the limb.

The most important factor here is “timing.” The first days after injury are very valuable for us. Success rates are very high and the risk of infection is minimal in tissue transfers performed within the first 7 days, which we call the “acute period.” Because the tissues have not yet become edematous, the vessels have not adhered, and surgical dissection is easier. As time passes, inflammation begins in the wound area and tissues adhere to each other, which makes it difficult to find and suture vessels.

Especially in contaminated injuries that have come into contact with soil or rusty metal, dead tissues must be removed (debridement) and immediately afterward that area must be covered with a well-perfused living tissue. This living tissue carries antibiotics to the area and prevents the infection from reaching the bone (osteomyelitis). Factors that affect success in trauma surgery are:

• Age
• Smoking
• Diabetes
• Nutrition
• Timing
• Hygiene

Can severed nerves be repaired, and does loss of sensation return?

Nerve injuries can be called the patience test of surgery. You can think of nerves as “electrical cables”; they transmit commands from the brain to the muscles or carry sensation from the skin to the brain. When these cables are cut, movement and sensation are lost. With microsurgery, we repair these severed ends under a microscope with sutures thinner than a strand of hair, matching the internal bundles called “fascicles.”

However, nerve healing is not fast like other tissues. Nerve fibers advance at an average rate of 1 mm per day. So healing of a cut at the fingertip can take months. If there is a segment loss in the nerve and the ends cannot meet, we take a segment from another part of the body (usually a non-essential sensory nerve in the leg) and place a “patch” (graft) in between.

Sometimes the injury is very high up, for example at the shoulder or the base of the neck. From there, reaching the fingertip may take years, and during this time the hand muscles may atrophy. This is where we apply a smart method called “Nerve Transfer.” We take a healthy and sacrificable nerve branch near the damaged area and connect it to the nerve of the non-functioning muscle. In other words, we draw a line from the cable in the next room that has electricity to the room where the electricity is cut. This shortens the recovery time and restores function before the muscles waste away. Then the brain is trained to learn this new connection through physical therapy. Factors that affect nerve healing are:

• Age
• Distance
• Tension
• Smoking
• Wound
• Technique

What is the process of reattaching amputated limbs (Replantation)?

Replantation, meaning reattachment of an amputated limb, is a much more complex and systematic procedure than what you see in movies. In the event of an amputation of a finger, hand, or arm, a race against time begins. The amputated part must be transported to the hospital in a cold environment without direct contact with ice.

In the operating room, things proceed in a specific order. First, the “skeleton” must be built; that is, broken bones are stabilized with plates or wires. Generally, some shortening of the bone is performed so that the vessels and nerves have enough length. After the bone is stabilized, tendons are repaired so the finger can move. The last and most delicate stage is suturing the vessels and nerves under a microscope. First, arteries are sutured to restore blood flow, then veins are sutured to ensure venous return.

Can every amputated limb be replanted? Unfortunately not. In clean cuts caused by sharp tools like a knife, which we call “guillotine” injuries, the chance of success is very high (around 90%). However, in “crush” injuries caused by a press machine, rollers, or traffic accidents, the chance of success decreases because the tissues are ruptured and the internal structure of the vessels is damaged. Still, thanks to microsurgical techniques, many limbs that were once considered impossible to save can now be salvaged. Criteria that determine replantation success are:

• Mechanism
• Duration
• Coldness
• Level
• Experience
• Equipment

Has a new era begun in lymphedema treatment with supermicrosurgery?

Lymphedema, also known to the public as “elephantiasis,” is persistent swelling that occurs in the arms or legs due to the accumulation of lymph fluid. For years, it was thought that there was no surgical treatment for this condition and that patients were doomed to lifelong massage and compression garments. However, as technology advanced, the concept of “Supermicrosurgery” emerged, allowing us to go below even 1 millimeter.

With this technique, we can work on lymph vessels with diameters ranging from 0.3 mm to 0.8 mm that are impossible to see with the naked eye. We have two main methods. The first is “Lymphaticovenous Anastomosis (LVA).” Here, we find the blocked lymph channel and connect it to a small adjacent vein. In other words, we bypass the blocked traffic and direct the flow to the highway (the blood). This is a method that can even be performed under local anesthesia and requires very small incisions.

The second method is “Lymph Node Transfer.” We transplant lymph nodes taken from healthy regions of the body such as the groin or neck, together with their vessels, to the swollen arm or leg. These lymph nodes work like a sponge, absorbing excess fluid in the area and reducing edema. Although these treatments do not eliminate the disease completely, they significantly reduce the limb circumference, relieve the feeling of heaviness, and prevent frequent infection attacks (cellulitis). The goals of lymphedema surgery are:

• Volume reduction
• Infection prevention
• Increased comfort
• Garment fit
• Psychological support
• Freedom of movement

How do robotic systems strengthen the surgeon’s hand in microsurgery?

Robotic surgical systems, the latest marvels of technology (for example, Da Vinci), have also started to take their place in microsurgery. No matter how skilled the human hand is, it has a physiological limit and a slight tremor. Robotic systems completely filter out this natural tremor in the surgeon’s hand and perfect the movement at the micron level.

The surgeon controls the robot at the patient’s side from a console. The robot’s arms can perform maneuvers that the human wrist cannot; for example, it can rotate 540 degrees around its own axis. This feature provides a major advantage in narrow areas such as the inside of the mouth, the throat, or deep pelvic regions where the surgeon’s hand has difficulty fitting. Thanks to three-dimensional cameras that provide up to 15–20x magnification, even the thinnest vessels appear like massive pipes. This minimizes the margin of error. Although robotic microsurgery has not yet become widespread in every center, it is a technology expected to become standard in the future, elevating the surgeon’s abilities to a “superhuman” level.

What are postoperative follow-up, complication management, and aesthetic revisions?

When microsurgery is finished, our work actually begins anew. Postoperative care is vital to reap the benefits of a successful surgery. The first 48–72 hours are the most stressful period for us because the risk of clot formation in the vessels we sutured and interruption of blood flow is highest during these hours.

During this process, we monitor the patient with hourly checks. We look at the color and temperature of the transferred tissue and the speed of capillary refill when we press on it. If the tissue turns purple, it indicates a venous problem; if it becomes pale and cold, it indicates an arterial problem. In this case, we take the patient back to surgery without losing any time. While the chance of salvaging the tissue is over 90% when problems are detected in the first hours, this chance rapidly decreases if delayed. That is why an experienced team and careful observation are at least as important as the surgery itself. The criteria we pay attention to in flap monitoring are:

• Color
• Temperature
• Fullness
• Bleeding
• Capillary refill

After the patient is discharged and healing is complete (usually after 3–6 months), aesthetic touches may sometimes be needed. Because the tissue we transfer may sometimes appear a bit thick or bulky compared to that region. With procedures we call “flap thinning,” we make that area more delicate, more natural, and more compatible with surrounding tissues by performing liposuction or surgically thinning the tissue. Especially in areas where shoes/gloves are worn, such as the hand and foot, these thinning procedures greatly increase the patient’s comfort.