Microsurgery: Replanting Life and Limb

Dr. William Aiello, Chief of Long Beach Memorial's Replantation Service, performs a microsurgery procedure, an operation that restores tiny blood vessels and microscopic nerves that have been damaged or amputated.<>

(Reprinted courtesy of: MERCURY Long Beach Memorial Medical Center - Fall 1989)

Michael Henig, 41, director of sales at Snow Summit Ski Resort in Big Bear, had a lot on his mind, not the least of which were the rainy conditions that spell gloom and doom for avid skiers. In addition, his birthday was the next day.

Barely 100 miles to the south, Wil!iam Aiello, M.D., chief of Long Beach Memorial Medical Center's Replantation Service, awoke to a cloudy morning that would soon give way to sunny skies. He went about his nor-mal Saturday routine and looked for-ward to spending a quiet evening at home.

Little did these future friends and "business acquaintances" know that they would soon meet under less than ideal circumstances. By the end of the following Sunday, the outcome would shape Michael's future and impact his life more than any other single incident.

About 10 pm, Michael, who spends half of each year split between Big Bear and Newport Beach, was driving the familiar winding roads that lead to the mountain resort. But on this night, lady luck was not with him. He hit an ice patch on the highway and lost control of his car. As his car tumbled end-over-end a half-dozen times down an embankment, he was thrown face-first through the windshield, hit his chest on the steering wheel with such impact as to bruise his heart, and his upper body was thrown onto the hood of his car and back in again.

When he looked up, he couldn't figure out why the sole his shoe was facing him. The answer soon became clear. His foot was severed at the ankle.

By the time paramedics reached him 30 minutes later, the former professional skier and ski instructor was more concerned about whether he was going to live than whether his foot would ever be functional. But when doctors at Loma Linnda University Medical Center, where he had been taken initially, said they were going to amputate his leg below me knee, he was cognizant enough to request a second opinion.

"I knew I was in trouble and that I was badly hurt. I didn't know if I was going to die," Michael recalls. "But I knew that if it was at all possible, I wanted to save my foot."

Meanwhile, back at the Aiello household, Dr. Aiello had accomplished his goals for the day and had spent a relaxing evening at home. But by early morning, the calm was shattered by the shrill ring of the telephone. It was Loma Linda -- they had a badly injured auto accident victim with an amputated foot. With one phone call Dr. Aiello mobilized the Memorial Replantation Service.

At 4 a.m., already scrubbed and wearing his surgical mask, Dr. William Aiello met Michael Henig for the first time. "I'l1 do the best job I can," Dr. Aiello said.

Frankie Vergara was a 17-year-old high school senior working as a machine operator at Durston Manufacturing in La Verne. On a Monday morning in October 1987, an employee was orienting Frankie on the punch press, a machine that cuts patterns into sheet metal.

Frankie Vergara uses a "hand helper" to strengthen his grip following reconstructive plastic surgery. Frankie's index finger now replaces a thumb that was crushed in a machinery accident.

Fortunately, Frankie's foreman retrieved the remains of the young man's digits and wrapped them up for transport to Pomona Valley Community Hospital. There, the emergency room doctors soaked Frankie's wound and contacted Dr. Aiello. By 12:30 p.m., the two men met for the first time.

"I was thinking about work and how I really had to concentrate on that new machine," Frankie recalls about that fateful morning. "I didn't even notice that my fingers were cut off at first because I thought I had gotten my hands out quickly enough."

Dr. Aiello was able to give Frankie some quick options. He determined that the thumb was far too mangled to save. One option was to take one of Frankie's toes and use it for a thumb, or to take the index finger and put it in place of the thumb.

They agreed on the latter option and went off to surgery. "I'll do the best I can," Dr. Aiello assured him.

Replantation, or microvascular surgery, is the treatment of conditions that require reconstruction using microvascular techniques that involve tiny blood vessels and microscopic nerves. It is used to provide restoration of soft tissue and/or amputated parts.

Almost all replantation is done under very precise conditions using a microscope. One technique is called "free flap" -- where one part of an individual's body is moved to restore another part that has a functional defect.

"When a body part is amputated, it is important to recover that part, wrap it in a clean, moistened cloth, place it in a plastic bag and put the bag on ice," Dr. Aleilo says. "Most hospitals are not set up or capable of doing this type of surgery. It requires a certain expertise with an integrated team approach, as well as all of the proper technology and instrumentation."

The Memorial Replantation Service, headed by Dr. Aiello, also includes such prominent surgeons as Leslie Bolton, M.D., Stewart Brown, M.D., Jed Horowitz, M.D., George Macer, M.D., and Gary Solomon, M.D.

"When another hospital contacts our service, time is of the essence," Dr. Aiello says. "We instruct them to transport the patient as soon as possible. The higher the level of injury -- the closer to the heart it is -- generally determines how much time we have before we can no longer replant a limb."

In 1980, through a generous grant from the late Grace Cassady, the Memorial Medical Center Foundation funded a microsurgery lab under the direction of William Wild, M.D. The purpose of the lab was so that Long Beach Memorial could provide a place where its surgeons would learn the skill of microsurgery from world-renowned experts in the field. While the lab was in existence, many surgeons learned the skills they possess today.

Microsurgery is an exacting science. The surgeon must look under the microscope to determine whether tendons, arteries, nerves and veins can withstand the procedure, as well as whether the amputated stump is in proper condition. The surgeon must then stabilize the bones and reduce the fracture before proceeding.

Although all of the physicians in the Memorial Replantation Service are skilled surgeons, each also has expertise in cosmetic surgery. This means they can do more than restore individuals to full functioning -- they can also correct any deformities.

"There really isn't much difference between what is cosmetic and what is reconstructive, Dr. Aiello Says.

One technique used in microsurgery is leeching, the ancient practice of using blood-sucking worms. Leeching can sometimes mean the difference between a successful replantation and a non-successful procedure.

"Leeches have been used as far back as the year 2000 B.C., Dr. Aiello says. "We use them in microvascular and replantation surgery because leeches make a 'cocktail' of the secretions that cause anticoagulation of the blood. They help release the spasms in the blood vessels and aid in the blood flow. Additionally, they also release a natural anesthetic."

When the blood does not flow properly to a replanted joint, this can cause the operation to fail. Thus the importance of proper blood flow cannot be minimized.

It took seven hours of surgery to reattach Michael's foot at the ankle and insert three pins into his tibia. However, the actual surgery was only part of the battle. Rehabilitation and proper mental outlook can be equally important to a patient's full recovery.

"Rehabilitation is extremely important. It's half the battle," Dr. Aiello says. "Most patients can re-turn to 85 percent of their former functioning."

But it is the mental aspect that often plays an even larger role in full recovery, according to Dr. Aiello.

"After surgery I was very depressed. In fact, I stayed depressed until June (four months later)," Michael says. "I didn't know whether I would recover, or, if I did recover, how fully. Also, I didn't know what my life would be like. Dealing with life day-to-day was simply devastating."

Michael Henig, a former professional skier, almost lost his foot in an auto accident. Today he walks, swims and rides his mountain bike thanks to the medical specialty known as microsurgery.

Frankie, however, was at the opposite end of the spectrum. "I never cried or was really sad," he says. "Instead, I went into deep thought about what life would be like without a finger. I felt a lot of pressure from not knowing.

"But, I also knew from the beginning that I would have to accept this. And that's what I've done. Now that this accident has happened, I've begun to plan ahead and take life as it comes."

If anything good can result from such trauma, it has for both of these patients.

Michael had a skin graft; operation in March and a nerve graft to restore sensation in the bottom of his foot in May. During his three months on crutches, he began to go to a health club and do limited activities. When he got a walking boot, he became even more active -- walking, biking and swimming. He's lost 38 pounds and feels a bright future is ahead of him.

"My attitude is to get back to my previous level," he says, although he knows that his days competing on the World Professional Ski Tour are over. "I intend to be as fully functional as I was last year. I plan to be surfing in September and skiing hard by February."

For Frankie, now 19, life goes on in the Pomona home that he shares with his mother, father, two sisters and a brother. "I haven't changed much since the accident, except I've become more focused," he says. "Now I'm more positive and have more ambition. I now know that I have to make a career for myself beyond the day-to-day."

The miracles of moderm medicine continue to abound. And through Memorial Replantation Service and Dr. William AieIlo, two success stories have been added within the past year.

Ron Yukelson