Good morning everyone.
It is my pleasure to introduce our next keynote speaker,
uh, Kunrat van. He is an associate professor at the University
of Ghent in Belgium and now based in the University of Rios in Tarragona in Spain.
He has a vast experience in reconstructive microsurgery in the breast,
lower limb, and paediatrics.
It would be a pleasure to introduce you and let you take the stage for your keynote lecture.
I, I would like to thank the organising committee for inviting me,
and, uh, first of all, I would like to apologise also for the status of my voice,
uh, which I attribute completely to our organising committee also because of throwing
this fantastic party last night.
So obviously it's a great honour to be invited, uh, on this stage to give a keynote lecture.
On, on the other hand, once they start inviting you, uh,
to talk about your personal journey, you realise that it's done,
you know, it's a time to give over to the younger people.
So in this lecture, uh, I hope to present you some things about what happened in my life
during my microsurgical career and especially I would like to address the,
the young people. In the sense that there's not gonna be that
much uh groundbreaking new things in here, but I hope that you can catch some points
of how it could go in life.
So, uh, after medical school, I trained as a general surgeon,
and I think this is also one of the points which we lack a little bit nowadays,
is that the training for a plastic surgeon, uh, doesn't involve that much general surgery
anymore. I trained for 5 years as a general surgeon and
I was finally lured into.
Plastic surgery by this other guy. You, you see,
uh, my younger version and you see also the younger version of a guy that you might know is
Patrick Tonar who gone completely to the bad side.
He is completely into aesthetic surgery, but he lured me into plastic surgery.
I couldn't find immediately a place, so I spent some time in the Netherlands and I spent some
time. In, uh, uh, Germany before I started my,
uh, plastic surgery training in uh Kent University Hospital at that time led by
Professor Hido Matton.
The nice thing was that immediately after I finished my,
my, uh, training, uh Gudo Matton left and, uh, uh, stan Mostra,
you see here, started up and give a new, uh, uh, starts kickoff to the Department of Plastic
Surgery and together with, uh, Philip Blomdale and I,
we, uh, Start this plastic surgery unit in Ghent.
So from the beginning, we were thinking we have to do it differently.
Up to these days, you know, most of the services were organised in a top down hierarchy.
The chief uh was the decision maker, and especially in Germany,
where I saw it, and also a little bit in Rotterdam.
You know, it was the chief who decided and the rest had to obey.
So we thought we're gonna do it differently and I would like to quote Sir,
uh, Krebs to argue without quarrelling, quarrel without suspecting,
suspect without abusing, criticise without vilifying or ridiculing and praise without
flattering. That was the aim, and I think we managed quite
well, although it didn't work out like that every time,
obviously. So in those days microsurgery was still in the
beginning in Belgium. And here you can see one of my previous results,
and I was extremely proud of this.
Obviously it's a, it's a huge disaster and you can see why because in those days,
oops sorry, in those days, we're still thinking that in order to raise the skin flap,
you know, you have to really secure it on the, on the underlying muscle because we didn't know
anything about the vasculature of the skin and we thought the muscle is really needed.
So afterwards, I had to take down the this complete uh uh free flap and put the skin graft
on it. I immediately started with some diabetic feed
and why? Because the guy at those days, most of these
patients with atherosclerosis were treated in kind of a salami technique.
You had an affected toe.
They cut off the toe, it didn't heal, they cut off a piece of the foot and eventually it ended
up with a 4 ft amputation.
But the guy, uh, uh, here used to be my former, uh, senior,
and he became the chief of plastic surgery. I convinced him to grade up a little bit
instead of doing all the surgery without loops. He will put on the loops and I would use the
microscope and we had a two team, uh, simultaneous intervention to limit the level of
amputation, good arterial inflow of the flap and outflow for the bypass and venous
annostomosis out of a scar zone.
In this way, this is the technique we did reversed or in situ
softenness bypass, and even if there was only a stump of the artery left,
we always did the revascularization and put the free flap on top of it,
and we had results like this.
We did minimal debridement, and we could achieve kind of results like this.
And we saw also that the free flap attributed to the revascularization of the foot.
Everything changed though completely and this only by a three minute lecture.
We went to the American Society in '94 and Philip Blomdale went listening to a guy called
Bob Allen talking about the deep flap, and I went uh listening to another guy talking about
the latissimus d'Orsa without the muscle, Claudia and Gregiani,
3 minute talk each.
And this completely changed our department.
So this was the time that suddenly perforator flaps showed up.
Now everybody knows what the perfor.
Everybody pretends to know what a perforator flap is,
and everybody uses the word perforator.
I, I don't know how many times, but we thought at that moment that it could revolutionise.
What is a perforator, a cutaneous perforator, the definition is any vessel that perforates
the outer layer of the deep fascia to supply the overlying subcutaneous fat and skin,
and the perforators are supplied by underlying source vessels.
So in the beginning, uh, everybody thought it was an interesting concept,
but nobody really believed in it.
We were able to organise already in '97, the first international course of perforated flats,
and in this course, and again you see some younger version of me and Philip here,
uh, we, we were able to get the big shots at those days uh coming to Ghent.
Uh there was, uh, Isa Koshima, Fu Chang Wei, uh, Martin Webster,
Bob Allen, and a couple of other guys.
So we realised that perforated flaps were not just an extra choice of flap,
but a huge paragram shift.
And you could compare it with minimal and invasive open surgery.
I trained in surgery and I left surgery, you won't realise how old I am,
but I left surgery just before endoscopic surgery made his entrance.
Nowadays you can't think about open surgery anymore.
So the skin flap used to be a down up dissection.
You take a piece, a chunk of muscle or fascia or whatever,
and then you hope that the skin will survive.
And then the new concept was completely different.
You go for the perforator, you follow it down, and you only take the amount of vessel that you
really need, and you leave all the rest behind.
In the beginning, nobody believed it, you know, there was a huge struggle because there were
issues about is this reliable? Will a piece of tissue that size,
will it survive on this stupid little perforator?
Is it really technically feasible, and is it safe?
So I think it is not it was also a paradigm shift in the way of dissection.
It is not that it is tedious or difficult. You have to do a meticulous dissection and
especially a prudent different dissection with adequate instruments,
carefully splitting the muscle, taking care of the motor nerves.
There's no use of doing a perforator flap if you kill off all the motor nerves around.
You need a bloodless field. It is like an endoscopic surgery.
Why was there an advancement in surgery by doing it endoscopically?
Not as much because they used the endoscope, but because by using the endoscope they
couldn't afford any bleeding anymore.
So it's the same. You have to see what you're doing frequent
rinsing. Clipping of side branches, burning of of side
branches. Don't touch the vessels, no vessel loops,
no traction, prevents internal damage. There's there's a couple of tricks in there
which are essential to the whole thing, and you have to conserve the motor nerves.
So it is different. It is not tedious or difficult is just
different. And it is a huge shift.
And in the beginning, it was difficult also to realise it was a paradigm shift.
This is a classical textbook illustration of an ALT in the beginning,
and tie flap, and most people will address it from the media side.
Because they first go and look for the vessels, oops sorry,
first go and look for the vessels. That was what we were told,
you know, you go for the autismus dorsal, you first look at the horaca dorsal vessels,
and then everything on top of it is all right. So there was the,
it was not really a paradigm shift. We approached the the teeth from the lateral
side. We first go for the perforator, and the vessels
will follow. in here is obviously planning, and there's a
lot of means where you can plan your perforator flaps, but,
uh, this is a tribute to John Marcia, who came up with this idea of doing CT scans for
planning of your perforator flaps, and this is a massive advantage on an invention.
So we started doing a perforator flaps. I did a lot of perforator flaps in lower limb
reconstruction. Blondele immediately started doing breast
reconstruction, only breast reconstruction.
So, and I think this is one of the nice cases, just one case,
and I know you're all breast surgeons, but you have to endure this.
This is a guy who in '88 had a working injury with the glove of the heel,
so they debrided it, put the skin graft.
The next thing it didn't heal, it break down. They did a facial turnover flap.
Again, broke down.
I did a free cellus anterior flap. Me, myself,
put an STG on it. I had to do a red excision.
We had to do the belting, flap lighting, excision of sin calan,
tightening of the flap once over, excision of a chronic ulcer,
skin graft.
And in October '99, he presented again with a, a chronic ulcer.
And this guy all the time was unfit to work, and he had the,
all the time uh wound breakdowns, and he was up to the point and he said,
we have to you have to amputate it.
So I, I asked him for the last trial, so I, I did an angiography.
I could see that the free flap, the vessels of the free flap were still there.
So we took off everything.
We had the remaining pedicle left.
And then we decided to do a, a kind of a, uh, a combined reconstruction of the Achilles tendon
with a free vascular right fasciallata flap, and, uh,
and an ELT skin cover and heel pad reconstruction with a free medial planter flap.
And this is the immediate post-op result, and this is the result 2 years after surgery,
and the guy is functionally complete in order, and is,
uh, very grateful for this that we, at least, we did not amputate his foot.
So I think it is a question about choosing the best matching tissue needed and limited donorsy
morbidity, and I think that free flaps don't do extra damage to traumatise them.
They're frequently faster and more reliable, and you have multiple choices.
I do know that some people in the audience are extremely keen on on the propeller flaps,
and I, I don't believe in them that much because you see,
this is essentially a functionally working propeller flap,
but you see the damage that we did to this leg. I think you could solve this better with a
little free flap. So did we do the breast, did I do breast
reconstruction? I did a fair amount of breast reconstruction.
Did we started immediately with a deep flap, and I would call this the deep flap 1.0.
We worked towards an aesthetic, uh, breast deconstruction.
I think that we could achieve the goal.
We had a fairly reasonable results with our deep flaps.
But then at some points, some deep flaps, you know, if your only instrument is a hammer,
everything becomes a nail.
So we started doing all kinds of little tricks to augment the volume of deep flaps.
You could supercharge them. You could do bipedicle,
deep flaps. You could anastomo one pedicle to the other.
You could do all kinds of tricky anastomosis in the on the memories.
Uh, but in the end, or you could do a vascularized matrix,
secondary lipofilling, secondary breast augmentation, how however,
frequently you end up with a bad abdominnoplasty result because essentially,
the patient was not meant for an aesthetic abdominnoplasty.
So, uh, we, we started doing uh what I call the flab version 2 towards
minimising the donor site morbidity and the technique that we started to use.
This is one of my own previous patients. You see,
it was an ugly result.
The scar was too high. The, you know, the umbilicus was not,
not nice. There was no correction of the waistline.
And what we do now is kind of a modified modified uh South American technique which is
called Tullua abdominoplasty with liberal liposuction, horizontallication,
and limited undermining, and then vertical raffi and horizontal raffi and tightening of
the external oblique muscles, and you get a much more pleasing pleasing result.
We do a neo umbilical plasty, so there is no circumferential scar,
and we can lower the abdominnoplasty scar.
There are a lot of flaps out there because if you can't do a deep flap,
there, there are plenty of opportunities out there.
So I just want to present you one of them. We like to do what we call lap flap,
this lumbar, uh, artery perforator flaps. This is a 30 year old female.
Uh, she got a previous mastectomy, bilateral, and some,
uh, attempts at prosthetic reconstruction.
She doesn't have, you could do a deep flap, you know, she has abdomen,
but she doesn't have sufficient abdomen to do a decent uh breast reconstruction.
So, uh, this is first, the first stage one of, uh, because lap flaps we do always in two
stages. This is after the first stage of the lap flap
before any corrections.
And you can see that she already has an improvement of the waistline.
This car obviously is quite visible at that moment, and this is just the lining of the
second flap. And this uh uh is the result after the
reconstruction and one session of secondary corrections.
As you can see, it's a fairly result compared with what she had previously and the donors
side scar, although it is always visible, uh can be reasonably good.
And we started to promote this and everybody thinks that I'm the big promoter of,
of, of lumber flats. Uh, lumber flaps is one of the options out
there, but we started to promote this elsewhere, and this was the first flap down in Portugal.
And I think we thought now we're there. We have all these opportunities.
We have all these flaps. We do a reasonable ophologists reconstruction,
but then came up Aldona Spiegel and she issued, why is the restoration of sensation not a
reconstructive goal.
And so we went on to breast reconstruction 3.0.
If you carefully look at your patients, and especially those patients who had a prosthesis,
you will see that frequently they present a painful point in the axilla.
It's always on the same spot. You can pinpoint it with one finger.
Most of the patients won't complain about it because they think it's normal,
but obviously it's not normal. It's a painful neuroma.
So, and it's not that difficult to find this neuroma.
This neuroma is always there. It's hidden in the scar,
but because of the inflammation, the nerve is engorged and you can easily find this neuroma
on the lateral border of the pectoral muscle, and.
And you can do something about it because if you raise your D flap,
you can raise a nerve and if you take the nerves which are down there,
they're reasonably lengthy. You can see you can take nerves of up to 8
centimetres and you can take them as kind of a vascularized nerve even because there's always
a perforated supply in this nerve and I always try to keep this vascularization intact.
And with this nerve you can solve not only the problem of the neuroma,
the patient the next day is solved of the neuromas.
They're extremely happy because the next day the pain is gone and it doesn't come back.
But on top of that there is a reasonable uh uh idea that you will gain some extra sensation in
the breast. And you can even do it in primary
reconstruction if you do like we were addressing the point of doing a decent
lymphadenectomy, you can also do a decent mastectomy and you can find these nerves at the
lateral border of the pectoralis major. You can find these stumps of the nerves so you
could do a primary nerve reconstruction too.
So there is a vast amount of possible perforated flaps out there,
and they have been described by different authors, most of them not knowing of each other.
Nobody reads the German or French literature, but you see all these flaps were there even
before Ian Taylor started describing them.
So there is nothing new under the sun.
just addressed this, we did also a lot of local perforated flaps for the breast.
I'm not going to go dive deep into this because I'm not a real in favour of oncoplastic surgery,
but you could do T aps, a superficial epigastric artery,
perforator flap, uh, eye caps, uh, and uh like caps, uh,
according to which zone of the breast you have to address.
And all these flaps have been invented before, and I think this is a highly recommendable book.
It doesn't talk about perforator flaps, it only shows you where you can raise perforator flaps.
So what about supra microsurgery? Supra microsurgery was a term which was
invented by Isaokoshima or was brought up by Isa Koshima and it was the team of Jame who did
kind of a, a consensus on what is, uh, super microsurgery.
Super microsurgery is a technique of micro neurovascular anastomosis of vessels of 0.3 to
0.8 millimetres and single nerve vasicles.
So we were thinking, what are we doing already?
Super microsurgery, these are my.
Youngsters, I have the deafortunate uh uh success that I have 4 daughters,
so I'm completely, uh, in a hormonal crisis. I have a wife,
4 daughters, female patients, nurses.
I know when it's full moon, uh, so we already did, uh.
Perforator flaps in children in 2005, and everybody was scared of the size of the of the
of the perforators. Obviously the perforators were smaller,
but in a strange way they are.
Bigger than you would expect in children.
So I would show you one of these cases, which one I'm obviously quite proud of it.
This is the smallest FIFA I ever did. It was in a minus 10 weeks old premature baby
who had an iatrogenic lesion on the foot because of an oxygen tension metre and they
wanted me something to do about it.
And they said, and I said, leave the crust, it will fall off.
I said, no, can't you do because iatrogenic can't you do anything?
I said, if I want to do something, I have to take off the crust.
And if I take off the crust and there is something viable underneath,
then I have to do something because leaving it again it will be a new crust,
and it was no there was no way to do imaging on this baby.
So we hope for an exploration.
You can see the little kit over here, all the hands around.
Then I debride it unfortunate for the kids, but unfortunate for me,
there was some living tissue underneath.
So we did a, a TA flap.
And it was a kind of a chimerati flap with a piece of skin and a piece of muscle.
We did everything under the microscope, and this is the flap,
the size of the flap.
And this is the anastomosis.
And by doing everything under the microscope, we were able to perform this in about 3 hours,
which was reasonable because this was also an issue in such a small child,
and this is the kid afterwards, a couple of years later.
So with perforator flaps also in kids, you have decent scars,
and that's one of the main advantages also.
So is this supra microsurgery? I think it is.
It's not a finger, but there was a a dog bite. Uh, the,
the child lost piece of the lip. We were able to reinsert it to do some
anastomosis, and this is the child a couple of years later.
But the real supra microsurgery, I think, is in lymphatic surgery and so not only for breast,
but also for sarcoma resection, we started thinking.
Uh, about the donor side morbidity, you know, uh, you do a resection and what happens is the
patient will develop lymphedema in some cases. So, there's a couple of techniques out there.
The latest one is, uh, first of all, you, you look for the lymphatics,
sometimes you can save some lymphatics.
And then there's this lymph interpositional flap, it's a new idea.
But there's also this lymphovenous anastomosis. We did in this case,
we did extra lymphovenous anastomosis and, uh, obviously you only do lymphovenous anashemosis
in healthy vessels, and this is this supra microsurgery technique where you do end to end
anastomosis, uh, with using uh special sutures 100, 110,
12 volt sutures, which are not always easily available.
And this was the original lympha technique. And obviously,
if you see the lympha technique for a decent microsurgeon, this is kind of revolting,
you know, you're just propping all these lymphatics together with the vessel,
together with the fats, just stomping them into a vein.
You start thinking, is it able to work? So I'm,
I'm not judging if it works or it doesn't work. I'm just saying that it's quite revolting for a
microsurgeon. So this is a technique that is proposed,
the supra microsurgery, but unfortunately, supra microsurgery is not for everybody,
uh, on the other hand, because it's kind of a difficult technique and especially in
preventing lymphedema, you don't want to elongate the time of the surgery that much and,
uh, so I'm, I'm definitely in favour, as was said of doing a preventive uh lymphatic surgery
because there is no risk, uh, you only, uh.
Uh, connect the collectors which are already severed, so you don't do any extra damage to
the axilla. So we developed kind of a technique which is
not the real technique, but it's something in between.
It's kind of a microsurgical technique which was based on a technique which was already
described the peripheral venous angioplasty.
So what's in essence the technique is that we clip, we let the because it's also the breast
surgeons who do the lymphadenectomy in our place, so we clip,
we ask them to clip everything blue that they find.
Uh, and then they do the lymphadenectomy, and while they're clipped,
it's, it starts engorging. So it's easier to find your lymphatic.
And we keep, we replace this clip, we replace this clip with the suture afterwards,
and then we keep this engorged lymphatic. We clean it completely as much as possible.
We clean it as much as possible. We just introduce it into a vein.
We do some very advantageous, uh, sutures over there which you can do with the 100.
And then we just cut the loose end and we clip the end of the vein.
And this is a, a, a kind of a, I think it's a nice technique.
It's something in between. It's not intima to intima,
but it's kind of a nice technique, and you, you can do it if you have a decent understanding of
about doing a little bit of microsurgery, you can do it in half an hour,
3/4 of an hour.
Obviously you need extra instruments, very fine tip things.
This is all things that happened during my lifetime.
All these kind of instruments were not available in the beginning,
good microscopes, and now we have these robots, these robots coming up.
And what about these robots? If you look at the timeline,
and this is just the timeline of my generation, you know,
the first laparoscopic cholecystectomy in 1986, and then now the first human use of Simani
system. The idea is the technology is there,
but how about the clinical relevance?
But you know this was a question that we were posing ourselves already but uh at the first
endoscopic cholecystectomy was the the the same question that we were posing when the first
perforator flap came up so they already start.
Reporting. Although I'm still doubting a little bit what
is the use of doing an endoscopic, uh, uh, deep flap harvesting if you take any weight,
the, the whole skin over there, but obviously the endoscopic mastectomy or robotic mastectomy,
there is a future in there, and you should realise that there is there's gonna be a par
shift nowadays in Belgium, it is hard to find a guy who can still do an open
laparotomy. You can't imagine, you know, if they do robotic
surgery, there's always an old fart from my age who is standing by in case there's something
going wrong, because they're not able to open up the abdomen anymore.
So things are changing, obviously.
So, but microsurgery is not all about this, uh, kind of,
uh, uh, highly innovative techniques. I did a lot of,
uh, a lot. I did some humanitarian work in Myanmar,
and, uh, this was our theme. Most of the time we did,
uh, it's a team of, uh, um, uh, ophthalmic surgeons and plastic surgeons.
So most of the time we did kind of clefts and and this kind of thing,
burn woods. Occasionally, we did a free flap.
So this is one of the first free flaps I did over there.
It's a secondary NOMA case. You can see obvious deformity of the face.
And we, with limited means, you know, uh, I had to do the tracheostomy,
uh, without, uh, with uh local anaesthesia.
And then, uh, we did the whole debridement. You can see I put in uh a rib graft.
I had to open it up because I didn't have a jiggly so I did it with the breaking cable of a
bike, uh, uh, and we found, uh, we took a rib graft.
Rip graft in there to reconstruct the orbital floor.
We took a chimaera ALT flap with a piece of muscle, two perforators.
We split the, the, the ALT flap in 21 piece was used to,
uh, reconstruct the floor of the mouth and the floor of the of the of the mouth and the and
the floor of the of the nose.
And then another piece, the muscle piece was to fill up the,
the whole structure of the face, and then we had the skin island on top of it.
And we had a fair results after the surgery. So you can do microsurgery in our days.
It's not kind of a, uh, a special thing, you know?
It's just a piece of our armamentarium. You should train to do it and you can do it
everywhere. Microsurgery is an easy technique.
So we're almost all way around because microsurgery started with in 75,
or not in 75, but it started with all these kind of uh uh exotic strange tree flaps because
in the, in the early days they were looking for immediately arterized skin flaps and so you had
popleal flaps, you had anticubital flaps, axillary flaps.
And then we went for the, the workforce the slab door side radial forearm tram flaps.
Why we wanted longer vessel vessels and bigger vessels came the paradigm shift of perforated
flaps and now we're back to microsurgery and supra microsurgery,
you see, this is classical orobburo.
I thank you For your attention and I hope
And I hope that you know that if new technology is coming up you should embrace it.
Thank you.