History of Microsurgery: The Legacy of Harry J. Buncke, MD

Abstract

A historical review of the history of Microsurgery including the important influence and contributions of Harry J. Buncke MD considered by many to be the “Father of Microsurgery”. An chronological list of Historic Replants and “Free Flap” and microvascular transplants is included. Those who lived through the age of the birth of this new surgical specialty were fortunate.

The history of microsurgery cannot be discussed without an in-depth understanding of the life and times of Harry J. Buncke considered by most to be the father of microsurgery.

Harry was born in 1922 and unfortunately passed away in 2008. His interest, intelligence, and tenacity helped create an entire surgical field in the 1960s. His motto “ideas are cheap and results are priceless” was the standard he set for himself and for the people he trained and inspired. When he passed away in May 2008, he was one of the few surgeons that was remembered in the “Remembrances” section in the Wall Street Journal , Sunday edition published May 24/25, 2008 by Steven Miller entitled “Harry J. Buncke – 1922-2008–Microsurgery pioneer helped to make tissue transfer and transplants possible.” ¹ Harry Buncke's intense interest in creating the early microsurgical instruments and especially the microsurgical needle, led to the development of an entirely novel surgical field that we now use on a daily basis to help patients with difficult previously nonreconstructible problems.

Harry was born in Iroquois Falls, Northern Ontario, Canada. Both parents were Americans from New York City. His father, Harry Buncke, Sr., was a paper mill engineer for the Abitibi Paper Mill in Iroquois Falls and when Harry, Jr. was about eight years old, the family moved to another Abitibi Paper Mill in Rumford, Maine where Harry spent his formative years. Harry attended Lehigh University for three years and then in 1942 enlisted into the Navy Submarine Service. He was stationed on a submarine named the Spadefish, which had several patrols throughout the pacific but two special patrols into the Sea of Japan. Admiral Lockwood, in charge of the Pacific Fleet commemorated this group of sailors as the “Mighty Mine Dodgers” and Harry was given a plaque entitled Submarine Force Pacific Fleet extends to Lieutenant J.G. Harry J. Buncke membership to the distinguished order Mighty Mine Dodgers. The plaque reads “A small band of brave men of high courage who have completed with skill and ingenuity and tenacity the task that required transit of the most dangerous of war waters through enemy mine fields and penetrating what the Emperor of Japan considered his inviolate water—The Sea of Japan. No weapons of Dai Nippon could halt these determined men. They did woefully and with due knowledge of the dangers involved, carry out their assigned task to emerge with uncontrollable proof of the success of their daring, thus becoming members of the Mighty Mine Dodgers, and entitled to all the rights and privileges thereof. Let all men who read this scroll be forever grateful and respectful of those heroic American mariners who went in and especially to those who gave their lives in this operation. The job was superlative and well done.” My father had this plaque in his office throughout his career ( Fig. 1 ).

Fig. 1.

Harry Buncke's Spadefish submarine plaque.

After the war, while he was decommissioning the Spadefish in Mare Island near Vallejo, California, he met Constance at an officer's club party at Mare Island. They married in June 1945 and with the GI Bill they both were able to matriculate and ultimately graduate New York Medical College in 1951. Constance completed her dermatology residency at Bellevue/New York University and Harry completed his plastic surgery at Cornell/New York Hospital. Harry was interested in more training in plastic surgery and applied and was accepted to the Marks Fellowship in Great Britain, 6 months being spent at the Royal Infirmary in Glasgow, Scotland, the largest burn unit in Great Britain, and then a second 6 months in East Grinsted, just outside London, working with the top reconstructive surgeons at the time.

During his time in Glasgow, Scotland at the Royal Infirmary he worked with the Chairman and Director of the Royal Infirmary, Mr. Thomas Gibson, a plastic surgeon who is well known for his pioneering work in transplantation surgery. Gibson's article, “The Fate of Skin Homographs in Man” ² published in 1943 along with his colleague Peter Medawar, was extremely important in understanding the immunological response to transplantation surgery. Medawar went on to receive the Nobel Prize in 1960 for this work. During the mid-1950s, the years of Harry Buncke's Fellowship, amputated parts could not be replanted. Reconstructive surgery was limited to pedicle flaps. While he was a fellow, he met Stewart Milton who was studying the anatomy of skin blood supply. Milton noted that including the “direct” artery and vein to a section of skin, a larger flap could be designed and be viable. ³ During a discussion with Milton, Harry Buncke had the novel idea of transplanting this tissue based on these 1-mm in diameter direct cutaneous vessels (which we now call perforator vessels) and then hooking up the blood supply at a separate location in the body, thereby avoiding the pedicle transfer process. He also postulated the ability to replant fingers that had been amputated based on repairing 1-mm vessels. Others were transplanting autologous tissue using larger vessels and vascular patches. ^{4 5 6 7} Harry Buncke, however, strongly felt that microsurgeons needed to be able to reliably repair 1-mm vessels or smaller to successfully replant body parts or transplant tissue. So began the tortuous path to successfully anastomosing 1-mm vessels.

The development of microsurgery as a field was limited by the surgical instruments and suture material available. At the time, suture material was too large to repair small blood vessels. The smallest sutures available were 6–0 in diameter and very large needles. Harry tried to design needles made from metal that he had etched with small holes going through the proximal end of the needle and then using cocoon silk as the early suturing material. Harry had mulberry trees around his home near San Francisco, California and he started making the first microsuture by unraveling a single thread of silk from silkworm cocoon.

With the help of Werner Schultz, a physicist and inventor at the Stanford Linear Accelerator, they were able metalized the end of cocoon silk and ultimately nylon creating a microsuture that was now the size of today's 11–0 ( Fig. 2 ). The design and fabrication of these early needles took place in the home laboratories of Werner and Harry ( Fig. 3 ). Surgical instruments were adapted from the jewelry making field as well as ophthalmology and were redesigned and repurposed to serve the microsurgeon ( Fig. 4 ). With the proper suture they were finally able to do the experiment, which they hoped would be the model for replantation surgeries. Specifically, replantation of a rabbit ear ⁸ ( Fig. 5 ).

Fig. 2.

Early microsuture.

Fig. 3.

Harry Buncke's microsurgery workbench.

Fig 4.

Early microsurgical instruments.

Fig. 5.

( A ) Amputated rabbit ear. ( B ) First successful rabbit ear replantation.

The rabbit ear was a reasonable model at the time for replantation. The blood vessels supplying the rabbit ear were approximately 1 mm in diameter and the entire rabbit ear could survive based on the central artery and vein. Unfortunately, much of the early problems with microvascular repair of the rabbit ear had to do with vasoconstriction as the rabbit ear is very sensitive to temperature and goes into vasoconstriction in a cold environment and vasodilatation in a warm environment. Harry Buncke had difficulty with vasoconstriction and much of his early publications had to do with trying to reverse vasospasm, ⁹ which remains a problem for microsurgeons to this day. After 56 attempts at rabbit ear replantation, he was finally successful at replanting a rabbit ear in the early 1960s. He presented his work at the Kansas City meeting of the Plastic Surgery Research Council in March 1964 entitled “Total Ear Reimplantation in the Rabbit Ear Utilizing Microminiature Vascular Anastomosis.” He liked the term “microminiature” because the word microvascular was being used to repair blood vessels that were larger than 2 mm in diameter. He felt that the 1-mm repair was extremely important in microsurgery for replanting vessels and doing tissue transplantation surgery. Several international and national hand surgeons and plastic and reconstructive surgeons became interested in the work that Harry Buncke was doing in the early 1960s. Specifically, Harold Kleinert from Louisville, Kentucky began using these techniques to repair blood vessels in patients who had devascularizing injuries to the fingers and, in fact, published the first successful anastomosis of digital vessels in the Journal of Kentucky Medical Association in February 1963 entitled, “Anastomosis of Digital Vessels” by Harold Kleinert and Morton Kasden. ^{10 11} Sasume Tamai of Nara, Japan was also quite interested in microvascular surgery and ultimately was the first to successfully replant a digit. ¹² He commemorated this in an article entitled, “Successful Replantation of a Completely Cut Off Thumb” by Komatsu and Tamai.

Neurosurgeons also became very interested in microvascular surgery. The first conference of microvascular surgery was in October 1966 ¹³ at the Mary Fletcher Hospital in Burlington, Vermont hosted by R.M. Peardon Donaghy of Burlington, Vermont and M. Gazi Yasargil of Zurich, Switzerland, both neurosurgeons and both very interested in repairing microvascular blood vessels to reperfuse the brain in stroke patient or in vascular injuries at the circle of Willis. ^{14 15}

Throughout this period of time of the development of early microsurgery, serendipitously similar surgical advances were happening in communist China. Although China was closed to any information to the outside world, especially from a medical point of view, evidence of replantation cases from China showing replantation of arms, hands, and fingers were surfacing in the western world.

Rollin Daniel, a microsurgical Fellow with Bernard O'Brien who was also an early adopter of microsurgery in Melbourne, Australia, contacted Dr. Walter R. Thach in 1972 who was the personal physician for Richard Nixon, president at the time. President Nixon was in the process of creating a mission to visit communist China in the fall of 1972. Dr. Daniel wrote a letter to Dr. Thach in February 1972 requesting that Dr. Thach meet with Dr. Zhong Wei Chen, the leading microsurgeon in China. Dr. Thach was able to meet Dr. Chen who was very interested in having microsurgeons from outside China visit him and various microsurgery groups throughout communist China.

In May 1973, 12 microsurgeons headed by Harry Buncke, the Chairman of the group, visited multiple microsurgery centers throughout China including Dr. Chen's group at the Sixth People's Hospital in Shanghai. The microsurgeons met patients and witnessed the results of microvascular by the microsurgeons in communist China including Dr. Chen. ¹⁶ The following year Chen and a group of microsurgeons from China visited the U.S.

Replantation surgery was now a viable alternative to discarding amputated parts. Microsurgery training laboratories were being created around the world. Properly trained microsurgeons could now replant any part that had vascular structures that were usable for repair including distal artery only fingers, scalps, lips, tongues, and male genitalia.

A new frontier was also developing in transplantation surgery. Plastic surgeons were at the forefront of homo- or allotransplantation and also autotransplantation. Joseph Murray, a plastic surgeon in Boston, pioneered and was the first to transplant a kidney between identical twins ¹⁷ and also in nontwin “homografts” obtaining prolonged survival with immune suppressive drug therapy. ¹⁸ Harry Buncke was always interested in preforming a toe transplant for thumb or finger reconstruction. Nicoladoni had transferred a second toe for thumb reconstruction in the early 1900s by pedicle technique. ¹⁹ Harry Buncke hoped to reconstruct the thumb with the great toe in a one-stage operation.

He was hoping to use the primate as the model for toe transplantation and luckily this prospect became less expensive because of the polio vaccine. The rhesus monkey was used as the intermediary for creation of the initial polio vaccine. Ultimately, the polio vaccine was created in a laboratory and the rhesus monkey was no longer necessary. The Southeast Asian Primate Center near the San Francisco International Airport was a large primate facility housing many rhesus monkeys that were to be used for the polio vaccine. Harry Buncke visited the primate center and discussed his plan with the primate veterinarians. On two separate occasions Dr. Buncke anesthetized the rhesus monkey at the primate center and then brought the monkey to his home laboratory operating room and did a toe to thumb transplant with his assistant, Constance Buncke, his wife and dermatologist and then recovered the monkey with the assistance of the veterinarians ( Fig. 6 ). To prove that the thumb was viable through his microvascular repair Dr. Buncke was able to get an arteriogram at a local community hospital. ²⁰ Soon after that John Cobbett, a plastic and hand surgeon from near London, England, was the first to do a toe to thumb transplant in a human. ²¹ He had spent several months with Dr. Buncke in the laboratory learning microsurgery prior to the transplant near London. Shortly after, the second transplant in the world and the first done in the United States was performed at Ralph K. Davies Hospital by Dr. Buncke and his team. ²² During that period of time, Dr. Buncke and his team also performed the first successful omentum transplant to the scalp on a patient with recurrent sarcoma requiring craniectomy, dural patch reconstruction and ultimately cover with an omentum transplant repair to the superficial artery and vein, and covered with a split-thickness skin graft. ²³ Shortly after that Rollin Daniel and Ian Taylor performed the first cutaneous microvascular transplant in Melbourne, Australia, specifically the groin flap to the ankle for an open distal tibia ankle defect. ²⁴

Fig. 6.

( A ) Rhesus monkey great toe. ( B ) First successful rhesus monkey great toe transplantation.

The bottleneck was now opened. Microvascular replantation and transplantation was now considered a viable alternative in reconstructive plastic surgery ^{25 26} ( Tables 1 and 2 ). Harry Buncke went on to train hundreds of residents and fellows throughout the rest of his career. He performed the first microvascular transplant in multiple countries and developed microsurgical laboratories throughout the world. He clearly has been and continues to be an inspiration to many reconstructive surgeons young and old ( Fig. 7 ).

Table 1. Historic replants.

Year	Replantation	Surgeon	Country	Reference
1962	Arm, mid	Malt	U.S.	27
1963	Forearm, distal	Chen	China	28
1963	Small blood vessel anastomosis	Kleinert, Kasdan	U.S.	11
1963	Revascularized thumb	Kleinert	U.S.	10
1964	Experimental digital amputation	Buncke	U.S.	8
1964	Nerve suture in upper extremity	Michon	France	29
1965	Thumb, complete	Komatsu, Tamai	Japan	12
1966	Forearm	Vogt	Germany	30
1967	Series of replants	Chen	China	31
1969	Microsurgical nerve grafting	Millesi	Austria	32
1970	Replacement of completely severed digits	Lendvay, Owen	Australia	33
1971	Hand replant	Ely	Brazil	34
1973	Digit and hand replants	O'Brien, Miller	Australia	35
1975	Hand replant	Baudet	France	36
1975	Hand replants, 8 cases	Ferreira	Brazil	37
1976	Upper extremity	Berger	Austria	38
1976	Scalp	Miller	Australia	39
1976	Thumb	Krylov	Russia	40
1976	Extremity replantation	Biemer	Germany	41
1976	Upper lip and ala	James	U.S.	42
1977	Upper extremity	Gilbert	France	43
1977	Replantation of amputated penis and scrotum	Tamai	Japan	44
1977	Thumb	Vilkki	Finland	45 46
1978	Microsurgery in hand trauma	Michon, Merle, Foucher	France	47
1980	Ear	Pennington	Australia	48
1983	Upper lip	Holtje	Germany	49
1986	Lip and chin	Schubert et al	U.S.	50
1988	Arm and Forearm	Brunelli	Italy	51
1992	Nose	Jeng et al	Taiwan	52
1992	Lower lip	Jeng et al	Taiwan	53
1997	Tongue	Buntic/Buncke	U.S.	54

Table 2. Historic “free flaps” and microvascular transplants.

Year	Replantation	Surgeon	Country	Reference
1955	Extracorporeal perfusion of flap transplants	Gibson	Scotland	Unpublished work, Glasgow, Scotland
1955	Human kidney transplant between identical twins	Murray	U.S.	17 18
1956	Neurovascular island flap	Littler	U.S.	55
1958	Middle ear microsurgery	Goodhill, House, House	U.S.	56 57
1959	Jejunal segment to neck	Seidenberg et al.	U.S.	58
1963	Abdominal flap in dog	Goldwyn et al.	U.S.	59
1964	Microsurgery of peripheral nerves	Smith	U.S.	60
1965	Microvascular flap transplants in dog	Krizek	U.S.	61
1966	Toe to thumb in the monkey	Buncke, Buncke, Schulz	U.S.	20
1966	Second toe to thumb	Young, Yang, Gu	China	62
1966	Second and third toe block	Chen	China	63
1967	Direct middle cerebral artery reconstruction	Yasargil	Switzerland	14
1969	Large toe to thumb	Cobbett	England	21
1970	Microneuromuscular transplant in dogs	Tamai et al.	Japan	64
1971	Omentum to skull	McLean, Buncke	U.S.	23
1971	Jejunal segment to neck	Peters	U.S.	65
1971	Rib to jaw on internal mammary	McKee	U.S.	66
1972	New instruments and microsutures	Acland	U.S.	67
1972	Interfascicular nerve grafting	Millesi	Austria	32
1973	Groin to foot	Daniel, Taylor	Australia	24
1973	Artery only replant	Serafin, Kutz, Kleinert	U.S.	68
1973	Groin to foot	O'Brien et al.	Australia	69
1973	Tubed pedicle to gastroepiploic	Harii, Ohmori	Japan	70
1973	Large toe to thumb	Buncke et al.	U.S.	71
1974	Scalp island	Harii, Ohmori	Japan	72
1974	Deltopectoral	Harii, Ohmori	Japan	73
1975	Dorsalis pedis arterialized flap	McCraw, Furlow	U.S.	74
1975	Superior gluteal myocutaneous flap to breast	Fujino	Japan	75
1975	Microneurovascular transplant, pectoralis major	Chen	China	76
1975	Vascularized fibular transplant	Taylor, Miller	Australia	77
1975	Neurovascular island flaps from the toe	Gilbert, Morrison, Tubiana	France	78
1975	Neurovascular island flap from the toe	Buncke	U.S.	79
1976	Iliac osteocutaneous sensory flap on SCI vessels	Tamai	Japan	80
1976	Mandibular reconstruction with rib	Ostrup, Fredrickson	Sweden	81
1976	Postauricular flap	Fujino	Japan	82
1976	Vascularized nerve graft	Taylor	Australia	83
1976	Gracilis microvascular transplant to face, seventh nerve paralysis	Harii	Japan	84
1976	Gracilis to forearm for Volkmann's contracture	Ikuta et al.	Japan	85
1976	Lateral thoracic axillary flap	Boeckx, de Coninck	France	86
1976	Thoracodorsal axillary flap	Baudet	France	87
1976	Dorsalis pedis microvascular transplant	Robinson	England	88
1976	Neurosensory flap from foot	Daniel, Terzis	Canada	89
1977	Extensor digitorum brevis	O'Brien	Australia	90
1977	Rectus femoris myocutaneous flap	Schenck	U.S.	91
1977	Double toe transplant	O'Brien	Australia	92
1977	Osteocutaneous rib on posterior intercostal	Buncke, Furnas	U.S.	93
1978	Osteocutaneous rib on anterior vascular supply	Ariyan, Finseth	U.S.	94
1978	Tensor fascia lata myocutaneous sensory free flap	Hill, Nahai, Vasconez	U.S.	95
1978	Neuromicrovascular finger flap	Buncke, Alpert	U.S.	96
1978	Latissimus dorsi myocutaneous transplant	Maxwell	U.S.	97
1978	Latissimus dorsi myocutaneous transplant	Godina	Yugoslavia	98
1979	Blood vessel to bone	Hori, Tamai	Japan	99
1979	Deep circumflex iliac artery osteocutaneous transplant	Taylor	Australia	100
1979	Dorsalis pedis osteocutaneous flap	Ohmori	Japan	101
1979	Lower abdominal flap, superficial inferior epigastric vessels	LeQuang	France	102
1979	Upper arm flap	Dolmans, Guimberteau, Baudet	France	103
1979	Omentum and stomach	Baudet	France	104
1980	Temporoparietal fascial flap	Smith	U.S.	105
1980	Rectus abdominis myocutaneous free flap	Pennington	Australia	106
1980	Partial toe transfer	Foucher, Merle, Michon	France	107
1980	Vascularized joint transplants	Mathes	U.S.	108
1980	Lateral mammary flap and inferior gluteal flap	LeQuang	France	109
1980	Free scalp flap	Ohmori	Japan	110
1980	Palm of hand free flap	May	U.S.	111
1980	Serratus-latissimus combined transplant	Buncke, Finseth	U.S.	112
1980	Serratus-latissimus combined transplant	Takayanagi	Japan	113
1980	Deltoid flap	Franklin	U.S.	114
1980	Serratus	Buncke	U.S.	115
1981	Saphenous neurovascular flap	Acland	U.S.	116
1981	Scapular crest and pedicle bone graft	Teot, Bosse	U.S.	117
1982	Scapular flap	Gilbert	France	118
1982	Serratus	Takayanagi	Japan	119
1982	Parascapular flap	Nassif, Baudet	France	120
1982	Radial forearm	Song	China	121
1982	Pectoralis minor	Terzis	U.S.	122
1982	Cervical transverse superficial	Shaw	U.S.	123
1982	Cervical transverse superficial	Baudet	France	124
1982	Scalp transplant between identical twins	Buncke	U.S.	125
1983	Peroneal flap	Yoshimura	Japan	126
1984	Free lateral thigh flap	Song	China	127
1984	Lateral Arm Flap	Katsaros	U.S.	128
1985	Fibula to femoral head	Urbaniak	U.S.	129
1987	Posterior interosseus island forearm flap	Zancolli	Argentina	130
1991	Medial condyle of femur and skin island	Baudet et al.	France	131
1993	Combined anterolateral and anteromedial thigh flap and vascularized iliac bone graft	Koshima et al.	Japan	132
1995	Lateral superior genicular vessels-based flap	Spokevicius, Jankauskas	Lithuania	133

Abbreviation: SCI, superficial circumflex iliac.

Fig. 7.

Harry J. Buncke completing a toe transplantation (Photo Courtesy of Nancy Chee OT).