Plastic Surgeon - Make him part of the first port of call

Plastic surgery has always had a violent history! Sushrutha is the Father of Plastic surgery who reconstructed the severed noses in ancient India, and Sir Harold Gilles, is considered Father of Modern Plastic surgery. Sir Gilles worked hard during and after the Second World War mending untold and hitherto unforeseen injuries in this war. More and more people survived thanks to the availability of penicillin which successfully controlled infection and thus people with maimed faces, hands and feet saw the light of the day. This however brought great physical and psychological deformities and physical difficulty adjusting to daily life. Rehabilitation to restore form of the face and functions of the hand and feet had to be undertaken. Innovation, Ingenuity, Challenge, Passion but above all a sense of gratitude to fulfilment to get these soldiers who fought with the surgeon's shoulder to shoulder in the battlefield to get them back to society was a call within them. A few surgeons among them became good at this and their name and fame spread.

The Neavu rich and famous, celebrities, and important people wanted their age ravaged faces mended by these war surgeons (a newly emerging field of cosmetic surgery surged ahead too.) More and more plastic surgeons wanted to cash in on this and they were moving away from acute care. Plastic surgeons were not involved during the initial injuries but were called to reverse not only the injuries but all the scarring and insults and malformed effects that had taken place from the time of injuries till seen and referred to the plastic surgeon. This was more so felt not in the distant past. Civilian injuries, war injuries and major catastrophic injuries have now become more horrendous almost comparable to each other and it was not unusual to deal with the lifesaving surgical conditions like neurosurgical, abdominal or thoracic injuries. Neglected nerve injuries of the hand meant a person was now alive after lifesaving injuries but was severely handicapped or crippled as he is left with a useless and non-functional hand. Marko Godina and Gustillo who pioneered this in the Yugoslavian war in the eighties and the nineties showed the excellent results of caring for the injured nerves in the hand and the lower extremities at the time of injury.

Closer to our times I would like to make a pitch for some of the things I consider would enormously benefit the patient if plastic surgeons are made the first port of call. I would go a step further and would like to call ourselves peripheral nerve neurosurgeons also. Not many doctors, let alone patients know the surgical procedures we offer to patients with peripheral nerve afflictions.

Plastic Surgeon - Make him part of the first port of call

The above are examples of patients who have painful conditions of the head and the face, hand and the foot. Do look for specific areas and carefully listen to the story and make a clinical assessment of the condition. There could be just a localized area of tingling, pain, or loss of sensation or any symptom and sign of either positive or negative symptoms of the nerve. The patient's experience however is more profound and debilitating. Symptoms are vague and generally dismissed during routine management of these patients. Some also have been termed psychological which these patients resent.

The above pictures show some of the common neurologic conditions we have treated successfully. Definitive localization of the symptoms and signs may delineate the affected areas innervated by the regional nerves. Specific and lasting surgical treatment can be advised. A careful history and examination is a must. A plastic surgeon is an expert in the management of the peripheral nerves surgically. Apart from the pain and other sensory symptoms there are also motor deficit and debility.

Obstetric birth palsy commonly called Erebs palsy is also the domain of a plastic surgeon. The timeline for the surgical treatment is clearly established. The best time is to be seen at birth by a plastic surgeon. The treatment is also very clearly time bound. Nerve surgery of the plexus can be undertaken between birth to up to 6 months to 9 months of age. Nerve surgery after this age of the baby is not useful. The next time bound procedure is tendon transfers for these babies. Excellent rehabilitation to restore shoulder, elbow and hand functions can be planned. This is generally performed between the ages of one year to two years.

Tendon transfers work best during these ages. When this window of opportunity is lost then the next recourse is bony correction of the scapula and the humerus. Timing is important. The purpose of including this condition is to stress the importance of not only making a plastic surgeon part of the team but to make him the first port of call as well as he can provide very valuable advice in the planning of the definitive surgical treatment in obstetric birth palsy.

Plastic Surgeon - Make him part of the first port of call

Lastly but not the least, a plastic surgeon can provide invaluable treatment in diabetic neuropathy. The fundamental reason so many people lose the limbs in DM is due to the absence of sensation of the sole of the feet. Surgical release of the compression of the nerves in the feet will restore sensation, prevent ulcer formation, prevent falls and prevent hip fractures in the elderly.

Here is a patient who has an ulcer but also pain in the area surrounding the ulcer. Note the "lightening mark" I use to depict pain in the previous pictures also and areas of the disability and mark the area of pain and discomfort. This patient had release of the Tarsal tunnel and found to have involvement of the calcaneal branch which has been released. The symptoms get better and in most cases helps heal the wounds as well.

Do make a plastic surgeon your first port of call in nerve related conditions. Spastic hand, residual hemipllegia with compromised hand function and spastic hand in cerebral palsy are other motor conditions where a functional hand can be provided to the delight of the patient, doctor and the relatives. A plastic surgeon does have several tricks up his sleeve to tackle anything, anytime but the first time and first port of call does give best outcomes.

Article by Dr. V.B Narayana Murthy, MBBS, FRCS
Plastic and Reconstructive Surgeon
Kauvery Hospital, Chennai

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