A head-on collision on a wintry highway all but tears the arm off a teenage boy. The surgical removal of skin cancer leaves a gaping hole in a man’s scalp and skull, leaving the brain exposed.
These things happen. We don’t want to even think about them.
Dr. Frederic Deleyiannis lives them, day in and day out at UCHealth Memorial Hospital Central in Colorado Springs. On a recent Friday afternoon, a sleep-deprived but still-sharp Deleyiannis described his week so far.
“I saved somebody’s leg on Monday, doing two free flaps on a knee, on a knee joint that was exposed,” he said. “On Tuesday, we took out somebody’s jaw for cancer and reconstructed their jaw with a fibula. Last night, when a young girl had a maxillary carcinoma, we took out her maxilla and her palate, and I used her leg to make her a maxilla.”
The maxilla is the upper jaw; the fibula is the thinner of the bones between the knee and ankle. The free flaps? We’ll get to those in a moment.
Microsurgery, the key enabler of reconstructive plastic surgery
Deleyiannis is a board-certified plastic surgeon and head and neck surgeon. The title of his recent book captures his key expertise and his life’s work: “Reflections of a Microvascular Plastic Surgeon: Reconstructing Shattered Lives.”
The key term there is “microvascular.” Because without it, there’s no reconstructing shattered lives.
Microvascular surgery, often shortened to “microsurgery,” involves using six to eight sutures to connect blood vessels just 1 millimeter to 3 mm in diameter or smaller. A No. 2 pencil lead is 2 mm across; a USB-C connector is 2.56 mm thick. It takes a microscope.
Dr. Julius Jacobsen pioneered microsurgery at the University of Vermont in the early 1960s. Jacobsen had come upon the idea because he knew microscopes from working in a lab studying pondwater one-celled organisms after initially having been rejected from 23 medical schools, Deleyiannis says. (In addition to extensive medical training and a master’s in public health, Deleyiannis has a master’s degree in the history of medicine from the University of Cambridge in the United Kingdom.)
Prior to Jacobsen’s innovation, connecting blood vessels less than 7 mm in diameter – about a quarter inch, or just under the full diameter of a No. 2 pencil – was fraught. Jacobsen’s insight was that “the eye could not see to tell the hand what to do.” So, he reasoned, if surgeons could see a tiny blood vessel clearly and had the right microsurgical tools, their hands could manage the challenge of dexterity. After all, people can create art on grains of rice.
With the advent of microsurgery, there could be free flaps.
A free flap needs a blood supply
A free flap is an area of skin and, sometimes, a layer of muscle and even sections of bone to be moved from one part of the body to another. It needs a dedicated blood supply. Without that blood flow, you’re trying to resod a bare patch of lawn with grass clippings.
Unlike sod’s carpet of roots, Blood reaches the skin through the occasional blood vessels (technically, cutaneous perforators) that push through layers of muscle and then branch out to provide sustenance for the tissues above. Research dating back to the 19th century has identified their approximate locations, and, with time, demarcated the patches of tissue (called angiosomes) that particular perforators feed. But it wasn’t until 1972, Deleyiannis says, that surgeons managed the first free-flap transplantation. It involved the reconstruction of a cancer patient’s scalp using tissue from inside the abdomen.
Microsurgery involving perforators opened a door that Deleyiannis and colleagues around the world have since exploited to reconstruct every diseased or damaged body part imaginable from free flaps harvested from about every soft surface below the neck and above the feet. They use those free flaps to reconstruct breasts, tongues and jaws lost to cancer; limbs damaged in accidents; wounds from gunshots or animal attacks, and other trauma that leaves bodies in want of tissue.
A typical free flap includes a patch of tissue fed by a single 1-to-3-mm artery and one or two similarly svelte veins. With the placement of the free flap at the destination site, the microsurgeon then connects those blood vessels to blood vessels at or close to the destination site.
Microvascular surgery is only part of it
Getting a free flap reconstruction right involves much more than just suturing with the aid of a microscope.
“The actual sewing of the blood vessels together is sort of a minor part of the procedure, to be frank,” Deleyiannis says.
The much harder part of the microvascular plastic surgeon’s job is the art and science of determining the shape and nature of the destination site, figuring out which of the many possible free flaps may be needed for the patient at hand, and where and how the flap’s perforators will connect to arteries and veins at the destination site. That complexity is why Deleyiannis’s procedures range from 6-8 hours to 14 hours or longer, and some reconstructions require multiple surgeries. The stakes are often life-or-death.
“You know that, when you take off somebody’s skull and you’re looking at their brain, if you don’t put something on that works, he’s dead,” Deleyiannis said.
An emotionally difficult, demanding, but rewarding job
Deleyiannis’s work has informed his worldview, particularly around guns.
“I don’t think anyone can contribute to a conversation on gun violence unless they actually experience it firsthand,” he said. “You have to understand how destructive it is, how devastating it is, and how difficult reconstruction can be.”
Given the trauma so explicit in the work, microsurgical careers tend to be short. Deleyiannis cites numbers showing American Society of Reconstructive Microsurgery (ASRM) membership skewing young and shrinking as careers progress and the pull of less-stressful plastic surgery work grows stronger.
“Everybody knows that microsurgery provides the greatest good to patients, but it is hard, and there’s a compromise in terms of quality of life from our own standpoint,” Deleyiannis said. “This surgery reimburses the surgeon with the quiet awareness that you have just helped someone recover from a life-altering event.”
Deleyiannis, now two decades along as a microsurgeon, shows no signs of dialing back from some of the most challenging surgeries operating rooms host. He’s motivated by the medical challenges, the positive outcomes, and the grit and fortitude of so many of his patients as they pick up the pieces of shattered lives reconstructed and, more often than not, move forwar