MICROSURGERY SUPPLEMENT

History of Microsurgery
Susumu Tamai, M.D., Ph.D.
Kashihara City, Nara, Japan

Summary: In the mid-1500s, the techniques of vascular ligature and vascular

suture were developed sporadically by several pioneers in this field. However,
vascular surgery became realistic experimentally as a result of the work by Carrel
and Guthrie in the early 1900s, in which they performed replantations and
transplantations of several composite tissues and organs, including amputated
limbs, kidneys, and others using experimental animals. In contrast, the development of heparin by Howell and Holt in 1918 accelerated the rate of these types
of operations being performed with increasing success in humans. Since the first
use of a monocular microscope for ear surgery by Nylen in 1921 and a binocular
microscope by Holmgren in 1923, in addition to the timely developments of the
Zeiss operating microscope, microsurgical instruments, and suture materials,
microsurgery was born in several surgical disciplines in the ensuing 50-year
period. The application of microvascular surgery and microneurosurgery in the
fields of hand, plastic, and reconstructive surgery resulted in revolutionary
advances in clinical replantation and transplantation of composite tissues and
more allotransplantations. (Plast. Reconstr. Surg. 124: 282e, 2009.)

he origins of microvascular surgery can be

traced to the introduction of fundamental
surgical techniques, anticoagulation, and intraoperative magnification in the late nineteenth
and early twentieth centuries. Innovative surgeons
performed the first successful vascular anastomoses by directly apposing or invaginating the vessels
end-to-end and suturing with fine silk.1,2 The most
significant technical breakthrough came in 1902,
when Alexis Carrel3 reported the triangulation
method of end-to-end anastomosis that is still routinely used today and for which he was later
awarded the Nobel Prize in 1912 (Figs. 1 and 2).
The following year, Hopfner4 reported the first
experimental limb replantation in dogs. Carrel
and Guthrie built on this work, performing visceral transplants as well.5 The work of these
pioneers laid the foundations for the subsequent development of microvascular surgery.
The achievements of these surgeons are especially remarkable considering they worked without the benefit of anticoagulation or intraoperative magnification.
The introduction of anticoagulation was one
of the critical developments in clinical vascular
From the Department of Orthopedic Surgery, Nara Medical
University, and the Nara Hand Surgery Institute, Nara
Seibu Hospital.
Received for publication June 14, 2007; accepted February
11, 2009.
Copyright 2009 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181bf825e

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surgery. Heparin was discovered in 1916 by Jay

McLean,6 a medical student at Johns Hopkins University, and Howell and Holt.7 The first successful
clinical trials were reported in the 1930s by
Charles and Scott.8 Heparin is one of the oldest
drugs still in wide clinical use today. The ability to
control blood clotting was an essential step forward in the development of microvascular surgery.
The final innovation that laid the foundation
for modern microvascular surgery was the introduction of the operating microscope by Nylen9 11
(Figs. 3 and 4) and Holmgren12 in the early 1920s
at the Karolinska Medical School in Stockholm,
Sweden. It was used successfully in ear and eye
surgery at various centers in Europe, and fine surgical instruments specifically designed for use under magnification were developed, such as bipolar
electrocautery by Malis1315 (Fig. 5).

DAWNING PERIOD OF MICROSURGERY

(END OF THE 1950S TO 1970)
Jacobson and Suarez16 18 are credited with the
landmark achievement of successful microvascular anastomosis using an operating microscope
in 1960 (Figs. 6 through 8). As recounted by
Comroe,19 a colleague studying pharmacology
asked Dr. Jacobson How can the periarterial

Disclosure: The author has no financial interests

to declare in relation to the content of this article.

www.PRSJournal.com

Volume 124, Number 6 History of Microsurgery

Fig. 1. Dr. Alexis Carrel. (From Guthrie CC. Blood Vessel Surgery
and Its Applications. New York: Longmans, Green & Co; 1912.)

Fig. 2. Triangulation method of vascular end-to-end anastomosis by Dr. Carrel. (From Guthrie CC. Blood Vessel Surgery and its
Applications. New York: Longmans, Green & Co; 1912.)

nerves on the carotid artery in a dog be removed?

Dr. Jacobson tried to cut the carotid artery completely to disconnect the autonomic nerves surrounding the carotid artery and subsequently repair the artery, but he encountered significant
difficulty doing this with an unaided eye. He attempted repeatedly using various forms of magnification but failed each time. Finally, he brought
in an operating microscope used for otology and
was successful. This event marked the historical
beginning of microvascular surgery.

Technological improvements in operating microscopes such as coaxial illumination,20 motorized zoom,21 and binocular viewing made microsurgery more reliable. There had been few
advances since the early work of Hopfner4 and
Carrel and Guthrie,5 but multiple teams simultaneously began to investigate experimental extremity replantation in the United States,22 Russia,23
and Japan.24,25
In 1958, Onji and I attempted to revascularize
an incompletely amputated thigh on a 12-year-old
girl at Nara Medical University Hospital. The extremity was lost 4 weeks after revascularization because of overwhelming infection and thrombosis.
In August of 1959, we successfully restored the
nerve supply in another patient with incomplete
amputation at the level of the thigh. The patient
was able to ambulate within 2 years and there
remained only a small area of hypalgesia on the
lateral aspect of her leg without foot drop after 20
years. These early experiences led to a program of
experimental surgery in limb replantation at our
clinic that continued for the next 20 years. We
investigated the physiology of ischemia-reperfusion injury and the systemic toxicity related to
replanting tissue after prolonged warm ischemia.
We concluded that the clinical replantation surgery should be limited to the hand or digits until
unsolved problems of systemic toxicity associated
with larger tissue units were resolved. For that
purpose, we needed finer instruments and techniques to accomplish microvascular anastomosis, as developed by Jacobson and Suarez.16,17 We
were, however, limited at the beginning by the lack
of operating microscopes in Japan.
In 1962, Malt and McKhann26 performed the
first replantation of a completely severed arm in a
12-year-old boy in Boston. Two years later, Kleinert
and Kasdan27 successfully revascularized an incompletely amputated thumb. In 1963, Chen and
colleagues28 successfully replanted a completely
amputated hand in Shanghai.
These successes led to new efforts to develop
reconstructive microsurgery around the world.
During the 1960s, Buncke29 31 performed numerous experiments involving replanting or transplanting tissues in laboratory animals. He developed many important principles and techniques
and has been called the founding father of microsurgery. Simultaneously, John Cobbett from
East Grinstead, England, and others were also
starting their microsurgical work.
Our program in Japan at Nara Medical University began in the spring of 1964. It has been very

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Plastic and Reconstructive Surgery December 2009

Fig. 5. Bipolar coagulator with miniature forceps developed by

Dr. Malis. (From Malis LI. Bipolar coagulator in microsurgery. In:
Donaghy RMP, Yasargil MG, eds. Micro-vascular Surgery: Report of
First Conference, October 6 7, 1966, Mary Fletcher Hospital, Burlington, Vermont. Stuttgart: Thieme; 1967:126.)
Fig. 3. Dr. Carl Olof Nylen. (From Widstrand A, ed. Svenska Laekare i ord och bild-Portraetgalleri med biografiska uppgifler oever
nu levande svenska laekare. Stockholm, Sweden: Biografiskt Galleri A-B; 1939.)

productive, making many early contributions in

digit replantation,32 functional muscle transfer,33 instrument design, and other areas of microsurgery. We bought Jacobsons microsurgical in-

struments in 1963 (Fig. 9) and used them for our

microsurgical work in the beginning of our
program.
Advances in peripheral nerve surgery occurred in parallel with progress in microvascular
surgery. In 1964, pioneers such as Smith,34 Bora,35
Hakstian,36 and Ito et al.37 reported microsurgical
nerve repair techniques and funicular nerve sutures, based on intraneural topography.

Fig. 4. A monoscope for otologic surgery used first by Dr. Nylen in 1921. (From Stahle J. Carl Olof
Nylen (18921978): Den foerste att tillaempa otomikroskopi. Sven Oenh-Tidskr. 2005;3:44.)

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Volume 124, Number 6 History of Microsurgery

Fig. 6. Dr. Julius H. Jacobson. (From Tamai S, ed. Experimental

and Clinical Reconstructive Microsurgery. New York: Springer;
2003:5.)

Fig. 8. Microvascular double clamp developed by Dr. Jacobson.

(From Jacobson JH. The development of microsurgical technique. In: Donaghy RMP, Yasargil MG, eds. Micro-vascular
Surgery: Report of First Conference, October 6 7, 1966, Mary
Fletcher Hospital, Burlington, Vermont. Stuttgart: Thieme;
1967:4 14.)

Fig. 7. A 3-mm artery anastomosis with 7-0 braided silk by Dr.

Jacobson. (From Jacobson JH. The development of microsurgical
technique. In: Donaghy RMP, Yasargil MG, eds. Micro-vascular
Surgery: Report of First Conference, October 6 7, 1966, Mary
Fletcher Hospital, Burlington, Vermont. Stuttgart: Thieme;
1967:4 14.)

The year 1965 was an eventful year in the field

of microsurgery. The first reported experimental
free skin flap transplantation of abdominal skin
based on the superficial epigastric vascular pedicle
was performed in a dog by Krizek and associates.38

On July 27, 1965, Komatsu and I32 performed the

first successful replantation of a completely severed thumb at the metacarpophalangeal joint
level in a 28-year-old man. We repaired two volar
arteries and two dorsal veins under a Zeiss diploscope using 7-0 braided silk sutures for the venous
anastomosis and 8-0 monofilament nylon sutures
for the arteries. The operating time was 4 hours,
and the ischemia time from injury to recirculation
was 3 hours. This experience and subsequent cases
of digit replantation demonstrated the need to
develop smaller vascular clips. I modified microclips originally designed for intracranial aneurysms and fashioned a metal double clamp that
became commercially available in Japan in 1980.39
Later, we developed disposable microsurgical
clamps40 (Figs. 10 and 11).
In 1966 and 1967, the first thumb reconstructions using toes transferred from the foot were
performed. Chen and associates41 in Shanghai
performed second-toe transfers in five cases in
1966. John Cobbett42 in England performed the
first great-toe transfers in April of 1967.

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Plastic and Reconstructive Surgery December 2009

Fig. 9. Photograph of Jacobsons microsurgical instruments, which we

obtained from Dr. Jacobson in 1963. We used them for the worlds first
thumb replantation in 1965.

Fig. 10. The developmental process of the Tamai microvascular double clip. (Above, left) A pair of Heifetz clips
connecting with a 23-gauge hypodermic needle. (Above, right) A home-made double clip. (Below, left) A prototype double clip manufactured by Crown Co. (Below, right) The first metal double clip, commercially available
from Crown Co.

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Volume 124, Number 6 History of Microsurgery

Fig. 11. The developmental process of the Tamai microvascular double

clip, continued. (Above) Crown metal double clips (Kono Seisakusho Co.
Ltd., Chiba, Japan). Clipping power (gram force), from left to right: L 90, M
60, and S 40. A clip applicator is also shown. (Below) Bear Medical disposable double clips (Bear Medic Co., Tokyo, Japan). Clipping power (gram
force), from left to right, TKL 120 and 60, TKM 60 and 30, TKS 40 and 20, and
TKF 30 and 15.

In November of 1967, the worlds first panel

on microsurgery was held at the Annual Meeting
of the American Society of Plastic and Reconstructive Surgeons in New York City. The panelists included Harry Buncke, John Cobbett, James Smith,
and myself, with Clifford Snyder serving as moderator. This was a landmark event in the history of
microsurgery. Buncke presented his experimental
work on rabbit ear replantation and toe transfer in
the rhesus monkey. Cobbett reported a hallux-tothumb transfer. Smith presented his method of
peripheral nerve repair. I presented the case of
thumb replantation we performed in 1965 and
created a sensation as the worlds first digit replantation. Other efforts to form organizations
dedicated to advancing the field of microsurgery
followed.
The first International Microvascular Transplantation Workshop was organized by van Bekkum and held in September of 1970, in Rijswijik,
The Netherlands, during the Biennial Interna-

tional Congress of the Transplantation Society. It

was also the occasion for the first meeting of the
International Microsurgical Society. Thereafter,
the International Microsurgical Society meetings
continued biennially until 1998 (Table 1). The
members consisted of all surgical disciplines with
a shared interest in microsurgery.

DEVELOPING PERIOD OF
MICROSURGERY (1971 TO 1980)
The decades of the 1970s witnessed numerous
important advances. Experimental tissue transfer
continued at several centers around the world,
and important strides were made in clinical microsurgery. In 1971, Strauch et al.43 first reported
pedicled vascularized rib transfer to the mandible
in dogs, demonstrating the possibility of vascularized bone transfer. In the same year, Tamai et al.39
experimented with free vascularized whole knee
joint transplantation in dogs. They showed the
possibilities of not only vascularized bone graft but

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Plastic and Reconstructive Surgery December 2009

Table 1. Chronology of the International Microsurgical Society
No.

Year

President

Chairman

Congress Site

1
2
3
4
5
6
7
8
9
10
11
12
13

1972
1973
1975
1977
1979
1981
1983
1985
1988
1991
1993
1996
1999

H. Millesi
H. Millesi
J. R. Cobbett
H. J. Buncke
M. Ferreira
B. McC. OBrien
B. Strauch
S. Tamai
Z. W. Chen
G. I. Taylor
E. Biemer
J. B. Steichen
J. Baudet

H. Millesi
H. Millesi
J. R. Cobbett
H. J. Buncke
M. Ferreira
B. McC. OBrien
B. Strauch
A. Gilbert
K. Harii
E. Biemer
H. Millesi
R. Pho
W. Shaw

Vienna, Austria
Vienna, Austria
East Grinstead, England
San Francisco, California
Guaruja, Brazil
Melbourne, Australia
New York, New York
Paris, France
Fuji, Japan
Munich, Germany
Vienna, Austria
Singapore
Los Angeles, California

also vascularized joint transfer. Experimental toe

joint transfers were reported in laboratory animals
by Daniel and colleagues.44
In 1972, Fujino and colleagues45 reported
functional mammary gland transfer in dogs.
McLean and Buncke46 reported the successful
transfer of the greater omentum for scalp reconstruction. Harii et al. performed a free-tissue transfer of temporal scalp for the purpose of hair transplantation. This procedure was performed in
September of 1972 and thus represents the worlds
first clinical free skin flap transfer,47 although the
medical literature generally cites the groin flap
transfer reported by Daniel and Taylor48 in 1973
as the first. In 1972, OBrien49 established a microsurgical teaching laboratory in Melbourne that
made numerous contributions in basic physiology,
clinical care, and education.
With improved understanding of vascular
anatomy, a variety of tissues began to be transferred using microvascular techniques. Free muscle transfer was demonstrated in 1973, with the
first clinical cases involving transfer of the pectoralis major muscle performed in China,50 followed
by a report of gracilis muscle transfer for facial
paralysis by Harii et al.51 Also in 1973, Ueba and
Fujikawa52 in Japan succeeded in free transfer of
a vascularized fibula flap for congenital ulnar
pseudarthrosis. This achievement was first published in 1983 with 9 years follow-up. The first
published case report of free fibula transfer was
from Taylor and colleagues at the Royal Melbourne Hospital in 1975.53 In that same year,
Miller and colleagues54 reported the first successful replantation of an avulsed scalp. McCraw and
Furlow55 reported the free dorsalis pedis flap. Baudet and colleagues,56 in 1976, coined the term
musculocutaneous flap and stressed the usefulness of the latissimus dorsi musculocutaneous
flap. Also in 1976, James57 reported the successful

288e

replantation of a large segment of upper lip and

nose, a prelude composite tissue allotransplantation of the face that took place 30 years later.
Replantation of an amputated penis and scrotum
was performed in Nara, Japan, by Tamai and
associates58 in June of 1976, followed a short time
later by Cohen and colleagues59 in Boston. A short
time later, reports appeared of transfers of iliac
crest60 and tensor fasciae latae.61
By the end of the 1970s, replantation surgery
was widespread throughout the world, with centers developed by Chen62 in China, Kleinert63 in
the United States, OBrien64a,64b in Australia, and
Tamai65 in Japan. Success rates were reported as
greater than 80 to 90 percent and stressed the
importance of postoperative hand therapy for
maximum functional recovery.
In parallel with advances in microvascular surgery were further developments in peripheral
nerve repair. Funicular or fascicular nerve repair
and grafting were reported experimentally and
clinically by Millesi66,67 in 1973, and thereafter by
Terzis et al.,68 Williams and Terzis,69 Samii and
Wallenberg,70 and Brunelli.71 The interfascicular nerve graft technique by Millesi et al.72
achieved useful function of the hand in 80 percent of their cases.
Consistent with steady maturation of the field,
there were further developments in professional
organizations dedicated to reconstructive microsurgery. The Japanese Society of Reconstructive
Microsurgery was founded by Fujino, Harii, Ikuta,
Ohmori, and Tamai in 1974. I had the honor of
serving as the first president during the first annual meeting in Nara, Japan. The organization
continues to thrive, with 600 to 1000 members
yearly attending the annual meeting. In 1972, the
International Society of Reconstructive Microsurgery was founded by orthopedic and plastic surgeons, and the first symposium was organized by

Volume 124, Number 6 History of Microsurgery

Millesi in Vienna. The organization met biannually until 1999 (Table 2), when it merged with the
International Microsurgery Society to become the
World Society of Reconstructive Microsurgery.
The Inaugural Meeting of the World Society of
Reconstructive Microsurgery was held in 2001 in
Taipei with Fu-Chan Wei serving as president. The
World Society of Reconstructive Microsurgery has
since met biennially in different locations around
the world (Table 3).

FULLY MATURED PERIOD OF

MICROSURGERY (1981 TO 1997)
Building on the creative efforts of early pioneers and subsequent contributors, microsurgery
matured as a specialty by the close of the twentieth
century. During this period, new tissue donor sites
and flap variations were described and research
was continued on limb/digit replantation and
free-tissue transfer worldwide.
In the hand, Urbaniak et al.,73 in 1981, reported
on the microvascular management of ring avulsion
injuries, providing guidelines for practical management. According to Furnas and Achauer74 in 1983, a
microsurgical transfer of the great toe to the radius in
partial hand avulsion injuries proved useful for reconstructing the thumb.
Also in the early 1980s, Morrison and associates75
described a method of thumb reconstruction using a soft-tissue flap harvested from the great toe
and wrapped around an iliac crest bone graft,
creating a better proportioned reconstruction and
thereby overcoming the chief disadvantage of
great-toe transfer. Wei and associates76 later reported an alternative technique using the secondtoe wraparound flap technique for digit reconstruction. The free vascularized transfer of the
proximal interphalangeal joint of the toe was reported clinically by Tsai and colleagues77 in 1982.

Developments also included advances in congenital hand malformations using transfers of the
great-toe and second-toe growth plates.78
There were descriptions of new flap designs
and refinements of previously described donor
sites, including such important ones as the scapular flap,79 the fibula osteocutaneous flap,80 and
the peroneal flap.81 The deep inferior epigastric
perforator flap was reported by Koshima and
Soeda82 in 1989, introducing a new era of flap
design based on cutaneous perforators throughout the body.
The role of reconstructive microsurgery in extremity trauma was advanced by Marko Godina83
in a landmark 1986 publication of 532 patients. He
established the principles of early debridement
and free-tissue transfer and aggressive rehabilitation to achieve salvage of extremities with optimal
functional results.
Significant advances were made in the problem of brachial plexus injuries, including phrenic
nerve transfer by Gu et al.84 and functional muscle
transfer, which was introduced by Akasaka et al.85
in 1991 and further developed by Doi and
colleagues,86 who reported double free-muscle
transfers to restore not only elbow function but
also prehension.87
In experimental microsurgery, in 1981, Nakayama and associates88 reported a study of a flap
nourished by arterial inflow through the venous
system. Ji and colleagues,89 in 1984, reported experimental venous flaps in rabbits. Honda et al.,90
in 1984, reported venous skin grafts for skin defects on replanted digits. Applying principles of
minimally invasive surgery, Lin and Levin91 reported use of balloon-assisted endoscopic harvesting of tissue for microsurgical transfer in 1991.
Buntic and Buncke92 successfully performed
replantation of an amputated tongue in a 15-year-

Table 2. Chronology of the International Society of Reconstructive Microsurgery

Meeting No.

Year

President

Chairman

Congress Site

1
2
3
4
5
6
7
8
9
10
11
12
13
14

1970
1972
1974
1976
1978
1981
1982
1984
1986
1989
1992
1994
1996
1998

D. W. van Bekkum
M. J. Orloff
G. Mazzoni
I. Hashimoto
E. Owen
F. Chavez-Peon
M. J. Orloff
J. M. Dubernard
G. Brunelli
K. Harii
J. Terzis
S. Tamai
H. B. Williams
W. Boeckx

D. W. van Bekkum
M. J. Orloff and R. Cortesini
G. Mazzoni
F. Chavez-Peon
T. S. Lie
E. Owen
J. M. Dubernard
S. Arena
G. Brunelli
T. S. Chang
P. Soucacos
S. Tamai
H. B. Williams
K. N. Malizos

Rijswijk, The Netherlands

San Diego, California
Rome, Italy
Mexico City, Mexico
Bonn, Germany
Sydney, Australia
Lyon, France
Pittsburg, Pennsylvania
Brescia, Italy
Shanghai, China (canceled)
Rhodes, Greece
Nara, Japan
Montreal, Quebec, Canada
Corfu, Greece

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Plastic and Reconstructive Surgery December 2009

Table 3. Chronology of the World Society for Reconstructive Microsurgery
Meeting No.

Year

President

Chairman

Congress Site

1
2
3
4

2001
2003
2005
2007

V. Meyer
F. C. Wei
W. Morrison
J. K. Terzis

F. C. Wei
G. Germann, H. Steinau
G. Loda
A. Beris

Taipei, Taiwan
Heidelberg, Germany
Buenos Aires, Argentina
Athens, Greece

old boy in 1997, with repair of the left lingual

artery and vein. At 2 months, the recovery of sensation started with spontaneous neurotization, although they did not perform nerve repair.
With increasing interest in microsurgery
among orthopedic and plastic surgeons in the
United States, the American Society of Reconstructive Microsurgery was founded in 1983, 11
years after the establishment of the International
Society for Reconstructive Microsurgery. The
members of the founding council included James
Steichen, Berish Strauch, Julia Terzis, James Urbaniak, and Alan Van Beek. The first meeting was
held in Las Vegas in 1985 under the presidency of
Berish Strauch, with approximately 300 orthopedic and plastic surgeons attending. Since then, the
meeting has been held once a year at several locations in the United States.

TRANSITION PERIOD FROM

AUTOGENOUS TO ALLOGENEIC
TRANSPLANTATION AND
REGENERATIVE MEDICINE
(1998 TO 2007)
The future of reconstructive microsurgery is
found in exploring composite tissue allotransplantation and regenerative medicine. Since replantation of amputated extremities has been possible,
hand allotransplantation by hand surgeons and
microsurgeons has been thought to be a technically feasible procedure. However, there has been
controversy regarding the merits and demerits of
such organ transplantation for nonlife-threatening conditions with regard to the side effects of
lifelong immunosuppressive therapy.
The era of allotransplantation of composite
tissues began with hand transplantation at the end
of the twentieth century. The first procedure was
performed on a 48-year-old man on September 23,
1998, in Lyon, France, by Dubernard and his
team.93 The second procedure was performed successfully on a 37-year-old man by Jones et al.94 in
Louisville, Kentucky, in January of 1999. The functional recovery of the transplanted left hand
proved to be quite satisfactory. According to the
International Registry on Hand and Composite
Tissue Transplantation (coordinators: Marco Lan-

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zetta and Jean M. Dubernard), as noted on their

Internet site, as of February of 2005, there had
been single hand transplantations in 16 hands on
16 patients, double hand transplantations in 14
hands on seven patients, and digit transplantation
in two digits on two patients. Conventional immunosuppressive agents have proved to be effective,
and there has been no mortality. Unfortunately,
though, two patients underwent reamputation because of the rejection phenomenon, including the
first case in Lyon.
After these successes, on November 27, 2005,
the first facial allotransplantation,95 including
nose, lips, and chin, was performed on a 38-yearold woman who had suffered a dog bite injury on
the lower face in June of 2005. The transplantation, from a brain-dead woman as the donor, was
performed by Dubernard and his group in
Amiens, France, on November 27, 2005. Bone
marrow grafting and use of immunosuppressive
agents were successful, but the final evaluation
regarding nerve regeneration will be needed at
more than 1 year.
Lutz and Wei,96 in 2002, discussed the current
operative indications and reconstructive modalities of toe-to-hand transplantations based on numerous experiences with this operation at Chang
Gung Memorial Hospital in Taipei. Rinker and
colleagues,97 in 2004, reviewed the replantation of
severed extremities as it has developed over the
past 40 years and discussed its current status and
future prospects.
There is ongoing extensive experimental investigation into flap prefabrication, flap revascularization, and tissue engineering of autogenous
tissues or biomaterials for composite grafts in combination with microsurgery.98 103 Recent applications of tissue-engineered nerve conduitsin other
words, bioartificial nerve grafts have opened a new
era in peripheral nerve surgery to overcome the
problems with nerve gaps as an alternative to autogenous nerve grafting. One of these grafts
shows promise in relieving symptoms of causalgia, which previously have never been successfully treated with conservative therapeutic measures or classic modes of surgical interventions
on the involved nerve.104 108

Volume 124, Number 6 History of Microsurgery

Table 4. Historical Achievements in Microsurgery
Reference

Achievements
1

Jassinowski, 1889
Murphy, 18972
Carrel, 19023
Hopfner, 19034
Guthrie, 19125
McLean, 19166
Nylen, 19549
Holmgren, 192312
Barraquer, 195614
Malis, 196415
Jacobson and Suarez, 196017
Littmann, 195420
Troutman, 196521
Snyder et al., 196022
Lapchinsky, 196023
Onji et al., 196324,25
Malt and McKhann, 196426
Kleinert and Kasdan, 196527
Chen et al., 196328
Buncke and Schulz, 196529
Buncke et al., 196630
Buncke and Schulz, 196631
Komatsu and Tamai, 196832
Tamai et al., 197033
Smith, 196734
Bora, 196735
Hakstian, 196836
Ito et al., 197637
Krizek et al., 196538
Chen et al., 198241
Cobbett, 196942
Strauch et al., 197143
Tamai et al., 197239
Daniel et al., 197144
Fujino et al., 197245
McLean and Buncke, 197246
Harii et al., 197447
Daniel and Taylor, 197348
Research Laboratory in
Shanghai, 197650
Harii et al., 197651
Ueba and Fujikawa, 198352
Taylor et al., 197553
Miller et al., 197654
McCraw and Furlow, 197555
Baudet et al., 197656
James, 197657
Tamai et al., 197758
Cohen et al., 197759
Taylor and Watson, 197860
Hill et al., 197861
Millesi et al., 197366,67
Urbaniak et al., 198173
Morrison et al., 198075
Wei et al., 199176
Tsai et al., 198277
Gilbert and Teot, 198279
Chen et al., 198380
Yoshimura et al., 198481
Koshima and Soeda, 198982
Gu et al., 198984
Akasaka et al., 199185
Doi et al., 199587
Nakayama et al., 198188
Honda et al., 198490
Lin and Levin, 199691
Buntic and Buncke, 199892
Dubernard et al., 199993

End-to-end vascular anastomosis

Invagination technique of vascular anastomosis
Three-stay suture technique of vascular anastomosis
Extremity replantation
Several organ transplantations in dogs
Discovery of heparin
Use of monoscope for ear surgery
Use of binocular microscope with light
Microsurgical instruments for eye surgery
Bipolar coagulator
Microvascular anastomosis
Zeiss OPMi-1 with coaxial illumination
Motorized zoom microscope
Limb replantation in dogs
Limb replantation in dogs
Limb replantation in dogs
Arm replantation
Digital artery repair
Distal forearm replantation
Digital replantation in monkeys
Hallux-to-thumb transplantation in monkeys
Ear replantation in rabbits
Thumb replantation
Free muscle transplantation in dogs
Funicular nerve repair
Funicular nerve repair
Funicular orientation by direct stimulation
Funicular nerve repair
Free skin flap transplantation in dogs
Toe-to-hand transplantation
Hallux-to-thumb transplantation
Pedicled vascularized rib transplantation in dogs
Free vascularized knee joint transplantation in dogs
Toe joint autogenous transplantation in dogs
Mammary gland transplantation in dogs
Greater omentum transplantation
Temporal skin flap transplantation
Groin flap transplantation
Pectoralis major muscle transplantation
Gracilis muscle transplantation
Vascularized fibula transplantation
Vascularized fibula transplantation
Replantation of avulsed sculp
Dorsalis pedis flap transplantation
Latissimus dorsi musculocutaneous flap transplantation
Replantation of upper lip and nose
Replantation of penis and scrotum
Replantation of penis
Iliac osteocutaneous flap transplantation
Tensor fascia lata musculocutaneous flap transplantation
Funicular nerve repair and grafting
Microsurgical salvage of ring injury
Great-toe wraparound flap transplantation
Second-toe wraparound flap transplantation
Toe proximal interphalangeal joint transplantation
Scapular flap transplantation
Fibular osteocutaneous flap transplantation
Peroneal flap transplantation
Deep inferior epigastric perforator flap transplantation
Phrenic nerve transfer to brachial plexus injury
Free-muscle transplantation to brachial plexus injury
Double muscle transplantation to total brachial plexus avulsion
Venous flap transplantation
Venous flap transplantation
Balloon-assisted endoscopic flap harvesting
Tongue replantation
Hand allotransplantation

Experimental/Clinical
First experimental
Experimental and clinical
Experimental
Experimental
Experimental
First
First clinical
Clinical
First
First experimental
Experimental
Experimental
Experimental
First clinical
First clinical
First experimental
First experimental
First experimental
First clinical
First experimental
First experimental
First experimental
First clinical
Experimental and clinical
First experimental
First clinical
First clinical
First experimental
First experimental
First experimental
First experimental
First clinical
First clinical
First clinical
First clinical
First clinical
First clinical
First
First
First
First
First

clinical
clinical
clinical
clinical
clinical

First clinical
First clinical
First
First
First
First
First
First
First
First
First
First
First
First
First
First
First

clinical
clinical
clinical
clinical
clinical
clinical
clinical
clinical
clinical
clinical
experimental
clinical
clinical
clinical
clinical
(Continued)

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Plastic and Reconstructive Surgery December 2009

Table 4. (Continued)
Reference

Achievements
94

Jones et al., 2000

Devauchelle et al., 200695
Colonna et al., 200299
Fansa et al., 2001104
Nakamura et al., 2004107
Inada et al., 2005108

Hand allotransplantation
Face allotransplantation
Flap prefabrication and tissue engineering
Peripheral nerve tissue engineering
Tissue-engineered nerve conduit
Tissue-engineered nerve conduit

In addition to the further development of allogeneic composite tissue or organ transplantations, I believe the combined use of microsurgical
composite tissue transfers with the technique of
regenerative medicine will open another new field
of microsurgery in the next decade. For the readers better understanding, historical achievements
in microsurgery, which appeared in order in this
article, are listed in Table 4.
Susumu Tamai, M.D., Ph.D.
1017 Toichi-cho
Kashihara City, Nara 634-0008, Japan
susumu@tamai.md

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