Most people probably associate plastic surgery with cosmetic procedures—reshaping the nose, removing the bags under the eyes, or changing the breast size. Dr. Manish Gupta reminds us, however, that plastic surgery also plays an important role in reconstructing tissues injured by trauma or burns. Often these procedures are technically complex and deal with the patient’s ability to function as well as with his appearance.
“Plastic surgeons have intensive training in hand surgery, for example,” says Dr. Gupta. “Along with orthopedic surgeons and general surgeons, we treat a wide range of hand problems from carpal tunnel to trigger finger to trauma repair.”
Dr. Gupta tells of a patient who was injured operating a drill press at work. Fortunately, modern techniques have greatly improved the surgeon’s ability to restore function and appearance, even in severe injuries.
“He ran the drill right through his hand,” says Dr. Gupta, “fracturing several fingers and cutting the tendons. The hand is a wonderfully designed instrument from an engineering perspective. The power of the hand is provided by the muscles of the forearm transferring movement via the tendons to the fingers. This allows the fingers to be smaller than they might be otherwise and capable of very delicate as well as very powerful work. The hand is extraordinarily complex and is an expression of the intellectual power of mankind. The ability to manipulate tools with great dexterity–except, perhaps, in the case of this patient—is tied to the development of the brain. You might even describe the hand as an extension of the brain. The hand is what we use to transform a concept into a reality. The hand’s dexterity and sensitivity of movement makes it possible for us to do all sorts of amazing things from assembling auto parts to playing the piano like Mozart to performing micro-surgery. Sensitivity also means, though, that when something goes wrong with your hand it tends to be more painful than if a similar injury occurred elsewhere and more difficult to repair.
“In this instance, for example, the damage to the tendons in his palm was a problem. The maximum recovery that could realistically be expected was in the 80 to 85% range. To improve his odds, I sent him, and all my hand patients, to a certified hand therapist. Effective therapy is as important as the surgery in determining the extent and quality of the recovery.”
Dr. Gupta notes that, curiously enough, though the injury was certainly gory enough, it did not require emergency surgery. “The ER docs closed his wounds and administered antibiotics but the surgery itself is better performed during regular daytime hours with the right staff and the right tools. There was no need to rush the procedure. I saw him in my office where we could examine the wound and check for other health issues, such as cardiac or pulmonary problems, that might lead to complications. I try to stack the deck in favor of my patients having a good recovery.”
In what Dr. Gupta refers to as “the old days,” the hand would have been immobilized after surgery by a plaster cast. “Now we use pins and plates and rods,” he says, “depending on the bone that needs to be fixed. Tendon repairs are somewhat more difficult. With advanced tendon repairs, we bring the severed ends together and give them a chance to heal, hoping that the scars don’t interfere with finger movement. In this case, we used a titanium plating system to provide for early mobilization. Beginning finger movemement almost immediately after the surgery increases the chances of the tendon failing to heal properly but the upside is both much better results and quicker return to function. It is a matter of balancing the risks against the benefits. Patients can get upset if there is a tendon rupture so I am always careful to discuss the pros and cons with them. It typically takes four to six weeks for adults to heal—longer if they smoke. This patient was off work for several weeks and gradually returned to full duties over six months.”
Another of Dr. Gupta’s was a six-year-old boy who caught the tip of the small finger on his left hand in the car door. It turned out that he had seen this same boy before to sew up the tip of a finger in a similar car door incident.
“Because the break in his finger was at a growth plate,” he says, “I reviewed the X-rays with the parents and explained the potential consequences. That finger might not continue to grow at the same rate as the rest of his hand.”
During the surgery, the bones were realigned and steel pins inserted through the skin to hold them in place and the hand was splinted. “The little balls on the ends of the pins left his hand looking like a Tinker Toy. He was the focus of a lot of attention at school. After three weeks, he came to my office to have the pins removed. He was surprised at how long they were. Within a few weeks he had recovered almost all function. I think the best therapy for him was his Play Station.”
Plastic surgery can often restore feeling, function, and appearance to injured hands. Recovery, though, can take weeks or months and require extensive therapy. Avoiding injury in the first place is often just a matter of common sense precautions. Workplace safety is subject to both extensive study and regulation. Conditions are dramatically improved compared to the early days of the Industrial Revolution. Even so, accidents still happen. In addition, every day life presents countless opportunities for things to go wrong. Something as common as closing a car door can get you hurt—sometimes more than once..