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Medicine: "Microsurgery: Sew Small"  Uploaded: March 1, 1987
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A man came into the emergency ward at one o'clock. 
His thumb came in an hour later. 
The surgeon's job: get them back together.


The successful re-attaching of fingers to hand requires long 
hours of painstaking work in microsurgery. In the operating 
room , the surgeon doesn't stand, but sits in a chair that 
supports her body. Her arm is cradled by a pillow. Scalpels 
are present as are other standard surgical tools, but the 
suture threads are almost invisible, the needle thinner than 
a human hair. And all the surgical activity revolves around 
the most important instument, the microscope.

The surgeon will spend the next few hours looking through 
the microscope at broken blood vessels and nerves and sewing
them back together again. The needles are so thin that they 
have to be held with needlenosed jeweller's forceps and will
sew together nerves that are as wide as the thickness of a 
penny. To make such a stitch, the surgeon's hands will move
no more than the width of the folded side of a piece of
paper seen end on!

Imagine trying to sew two pieces of spaghetti together and
you'll have some idea of what microsurgery involves. 

Twenty-five years ago, this man's thumb would have been 
lost. But in the 1960s, surgeon's began using microscopes 
to sew what previously had been almost invisible  blood 
vessels and nerves in limbs. Their sewing technique had been 
developed on large blood vessels over a half century earlier
but could not be used in microsurgery until the needles and 
sutures became small enough. The surgical technique, still 
widely used today, had taken the frustrating unreliability 
out of sewing slippery, round-ended blood vessels by 
ingeniously turning them into triangles. To do this, a cut 
end of a blood vessel was stitched at three equidistant 
points and pulled slightly apart to give an anchored, 
triangular shape. This now lent itself to easier, more 
dependable stitching and paved the way for microsurgery where
as many as twenty stitches will have to be made in a blood 
vessel three millimetres thick. The needle used for this can 
be just 70 millimetres wide, only ten times the width of a 
human blood cell.

All this technology is focused on getting body parts back 
together again successfully. The more blood vessels 
reattached, the better the survival chances for a toe or a
finger. The finer the nerve resection, the better the 
feeling in a damaged part of the face, or control in a
previously useless arm. But the wounded and severed body part 
must be treated carefully. If a small part of the body, such
as a finger is cut off, instead of torn, wrapped in a clean 
covering, put on ice and then reattached within a few hours,
the chance of success is over ninety percent, as long as one
good artery and one good vein can be reattached.

Not only is micro surgery allowing body parts to be reattached,
it's also allowing them to be reshuffled. Before 1969, 
nothing could be done for you if you'd had your thumb smashed 
beyond repair. But in the past 14 years, you would have been
in luck, if your feet were intact.  Every year in North 
America, hundreds of big toes are removed from feet and 
grafted onto hands. Sometimes tendons are shifted from less 
important neighbouring fingers to allow the thumb to work 
better in its unique role of opposing the other fingers and 
allowing us to grip. 

While we in North America can live without our big toes and 
never really miss them, people in Japan can't. They need 
their big toes to keep the common footwear, the clog, on 
their feet. So their second toe is taken instead.

Farmers, labourers car accident victims and home handymen 
are the people most often helped by microsurgery replants. 
And because blood vessels are being reattached, burn victims
can now benefit. Flaps of their healthy skin are laboriously
reattached more successfully, blood vessel by blood vessel, 
to increase chances that the graft will take. Some women, 
whose diseased Fallopian tubes have become blocked, can have 
them reopened microsurgically. When a cancerous esophagus 
must be removed, it can be replaced using a section of the 
person's own bowel. These people can then lead a more normal 
life, using their mouth to eat with instead of inserting 
food though a feeding tube in their stomach.

Doctors have been able to rebuild an entire lower face by 
sculpting the lower jaw from living hip bone and covering it 
with the skin from that piece of bone. In all, over seventy 
parts of your body can be used as donor backups and recycled 
into other damaged sites. And because your body won't reject 
your own tissue - a constant hazard in transplants - in this 
case, you are your own best friend.

In everyday use, however, microsurgery is proving to be a 
miracle worker, large and small. We take for granted, for 
instance, all the complex nerve and muscle control that goes 
into a simple a gesture as smiling. But one young woman
couldn't. An accident left her with a face that was damaged 
and unable to smile.  Microsurgery reconnected severed nerves, 
giving muscle control back to her face, restoring her looks 
and giving her something to smile about.
