Plastic surgery is essentially an anatomical and structural science dealing with modification
Every activity in life is a reflex activity – a sensory stimulus processed by the brain elicits a functional response. The locomotor system comprises of the sensory end organs like the pain, pressure and temperature receptors, the peripheral nerve which transmits the impulses to and fro from the brain and the final component comprising of the muscle, tendon, bone and joint complex which executes the complex movements of the face, hands and the legs. Everybody knows neurologists and neurosurgeons take care of the conditions of the brain, orthopedic surgeons take care of the bones and the joints, the other end of the spectrum. So who takes care of the peripheral nerves, tendons and the muscles? Much has been said and discussed about this important component, but is ill understood and so nobody actually takes much responsibility of this area. Plastic surgeons have had varied interest in this area. With more and more clarity in dealing with these conditions, they have truly come to the rescue to bridge this gap and have produced some dramatic results. Clarity has also brought more and more solutions and peripheral nerves in the hand and foot and brachial plexus surgery has come to form a subspecialty of plastic surgery by itself. We in India alone have a society for peripheral nerve surgery and another for Brachial plexus surgery. Medical therapy relies on the modulation or modification of the physiologic processes to achieve relief of symptoms. Plastic surgery is essentially an anatomical and structural science dealing with modification or structural alteration that eventually will help the condition. This can often happen in a very dramatic way.
Once a diagnosis of peripheral nerve pathology is made, the medical and other treatment is greatly supportive in nature and often provides symptomatic treatment. It may be part of a larger metabolic anomaly affecting all of the peripheral nerves. A plastic surgeon looks for a definitive surgical cause, generally a focal or local cause so that the exact timing and appropriate surgical procedures can be given. This is not only to not delay treatment but to avoid the disuse atrophy of the end organs if not corrected at the right time. This is especially so in children.
Motor, Sensory and sudomotor problems, positive and negative symptoms or a combination of these may affect an individual. Face, hands and the feet form the primary areas of interest of a plastic surgeon. Lets look at some of the examples to get an idea of things dealt by a plastic surgeon. A picture says a million words and a small sample illustrated here with pictures gives examples of the broad scope of possibilities to be thought of.
Face is the “face” of expression for a human being! Facial palsy causes disabling and depressing effects on the individual.
Most may recover when the primary cause is found and treated by the neurologist, neurosurgeon and a physiotherapist. Residual and irreversible palsy with resultant permanent effects not only gives an expressionless face at rest but on animation of the face like smiling, produces a devastating and often depressing effect to the patient. Several procedures on the nerve itself, like primary nerve repair or nerve graft, using microsurgery can be performed if this is recognized at the time of injury like mastoid surgery or direct injury to the facial nerve.
Muscle transfers or tendon related procedures could be performed to get a pleasing effect at rest and a satisfactory result during animation and smiling.
Sensory symptoms masquerading as headache. Cuts and injuries to the face are common due to RTA or fights. Neuroma of the involved nerves produces extreme pain spontaneously or on touch or simply by the whiff of air from the fan. This excruciating pain is often not recognized by the regular consultations and ends up being treated for months and years on end as headache or even ends up in the lap of a psychiatrist. A trained eye and knowledge of this possibility can diagnose this condition easily. Marking the areas of pain or loss of sensation and identifying the neuroma is essential. A cross marks and localizes the neuroma, which is the point of extreme tenderness. Exploration of the neuroma and treating it effectively treats this otherwise disabling condition permanently.
Obstetrical birth palsy or Erbs palsy as it is commonly referred to, not only bring images of the brachial plexus and the complex anatomy but notion of poor results generally prevalent among the doctors and public alike. It is essentially the damage to the peripheral nerve and the resultant atrophy of the muscle -tendon -joint complex. Late and neglect of this condition produces changes to the muscles, tendons and the bone. Bony changes produce significant deformity and bony correction is necessary to restore near normal function. Understanding the condition and simplifying the surgical treatment has brought about predictable and excellent results.
Late and neglected condition seen here in a 7 year old has produced significant restriction of the movements of the shoulder, elbow and hand. The child is not able to externally rotate the left hand fully, abduct the arm and supinate the elbow. Bony correction in the form of osteotomy and repositioning of the bones alone can correct this condition. Here, the clavicle, shoulder joint and the scapula is corrected to produce good external rotation and shoulder movements. Elbow and hand movements also get better.
Remember, timing is of utmost importance when nerve injuries are being treated. Immediate surgical intervention on the nerves restores near normal function. Delay up to 2 years essentially has no scope of nerve repair to produce normal function. The regenerative capacity of the nerves becomes negligible. Muscle and tendon surgeries become the treatment of choice in neglected brachial plexus injuries seen at 2 or 3 years of age.
The best time to intervene is within the first 3-6 months of age. Careful evaluation is necessary. Damage to the nerves can be effectively treated with a combination of neurolysis, neuroma excision and primary suturing and in severe injuries with nerve grafting with the use of microscope. Good sensory and motor function can be expected.
Other condition which is the domain of the plastic surgeon /peripheral nerve surgeon is the hand. Carpal tunnel syndrome is a disabling condition. When medical treatment does not produce desired relief, surgical treatment is a viable and respectable option. Often these patients ask us why we have not been told about this procedure before.
A direct look at the damage to the nerve during the surgical procedure as shown here justifies the slogan “cry of the dying nerves”. This gives an idea as to how much insult the nerves have been subject to before being seen by a plastic surgeon. A healthy looking and pearly looking nerve in the proximal portion in the first picture is the real picture of a nerve. Dangerously swollen pathologic nerve and a pathetically looking contused and atrophic nerve in the last picture just got a lease of fresh air and well on the road to recovery. Patients can expect relief of symptoms straight away and in most cases a long lasting one too.
The feet are the one of the important organs which differentiates us from the plants. Feet means mobility and mobility means life. Nothing is more frightening to a diabetic patient, than who has the sequel of diabetic neuropathy and the fear of losing the foot.
Peripheral nerves in Diabetes get affected to various degrees. There is a subsect of pathological conditions called the compression neuropathies, which can be surgically treated successfully. Compression happens as the nerve traverses areas of narrowing in the course of the nerve – called the tunnels. Tarsal tunnel is responsible for this in the foot. It is to be reiterated again that time is of essence while dealing with neurological conditions. Diabetic peripheral compression neuropathy is no exception.
During the early stages of nerve damage, whatever the cause, the nerve responds by causing irritation of the nerve and also hypoxic damage. At this stage positive symptoms like burning, pain and similar symptoms are common. These could be equivalent to the cry of the dying nerves, a response to the ongoing damage. Damage and regeneration happens simultaneously. The regenerating nerve ends are sensitive and irritable. As the noxious damage continues without relief, damage outstrips regeneration and the nerve suffers permanent damage and the positive symptoms are replaced by loss of sensation and wasting.
Remember not to forget the sural and great saphenous nerves too in addition to the well-known posterior tibial nerve, which is commonly affected. The picture shows the importance of the clinical examination to map out the actual area of involvement. The posterior tibial nerve seen during the operation of decompression of the nerve shows the extent of damage. The inflamed and distorted nerve replaces the pearly white nerve.
Tarsal tunnel release is a commonly performed procedure which relieves pain in the foot, restores sensation to the foot and prevents and protects the formation of ulcers in the foot.
Pudendal nerve release is a much talked about subject to treat the problem of impotence in diabetic subjects. Initial results have been extremely encouraging and hope it will stand up to this reputation for long!
Article by Prof. V.B Narayana Murthy
Plastic and Reconstructive Surgeon, Kauvery Hospital