Plastic surgery restores form and function through reconstructive procedures, cosmetic enhancements, and body contouring.
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The patient is brought into the operating room and placed under general anesthesia. A catheter is often inserted to monitor urine output during the lengthy procedure. The arm is prepped and put on a hand table.
A brachial plexus nerve block is usually administered. This numbs the arm for 12 to 24 hours, reducing the need for heavy narcotics post-surgery. Crucially, the block causes “sympathectomy,” which relaxes the blood vessel walls and maximizes blood flow to the fingers.
The first surgical step is debridement. The surgeon examines the wound under the microscope and removes all dead, crushed, or contaminated tissue. Leaving damaged tissue behind increases the risk of infection and thrombosis.
Healthy vessel ends are identified and tagged with sutures. The nerves and tendons are also located. This preparation phase is vital; attempting to suture damaged vessels is the most common cause of failure.
The bones must be stabilized before soft tissues can be repaired. The surgeon typically shortens the bone slightly. This is a critical step: shortening the bone removes the damaged ends and, more importantly, creates slack in the nerves and vessels, allowing them to be stitched without tension.
Fixation is achieved using K-wires (metal pins) driven through the bones or with small plates and screws. K-wires are the most common as they are quick to place and minimize additional trauma.
Once the bone is fixed, the tendons are repaired. The extensor tendons (on the back of the hand) are repaired first to stabilize the finger position. Then, the flexor tendons (on the palm side) are sutured.
Restoring the tendons at this stage is easier than doing so after the delicate vessels are repaired. The repair must be strong enough to hold but smooth enough to glide through the tendon sheaths later.
This is the critical microsurgical phase. The surgeon sutures the digital arteries using a microscope and thread thinner than a hair (10 0 or 11 0 nylon). Usually, two arteries are repaired for each digit if possible.
Once the artery is connected, the tourniquet is released to check for blood flow. Seeing the finger turn pink and verifying a pulse signals the restoration of inflow. This is the moment the digit becomes “alive” again.
The digital nerves are repaired next. They run alongside the arteries. The surgeon aligns the fascicles (nerve bundles) and sutures the outer sheath (epineurium).
If there is a gap due to the injury or if bone shortening wasn’t sufficient, a nerve graft or conduit may be used. Accurate alignment is essential for the return of sensation.
After arterial flow is established, the blood must have a way to exit, or the finger will swell and die. The hand is turned over, and the veins on the back of the finger are repaired.
Vein walls are much thinner and more fragile than arteries, making this the most technically challenging part of the surgery. Surgeons aim to repair at least two veins for every artery to ensure adequate drainage.
The skin is loosely closed. The surgeon must avoid tight stitches that could constrict the swollen finger and cut off blood flow. In some cases, if the skin cannot be closed without tension, a skin graft or local flap is used.
Occasionally, the wounds are left partially open to drain or covered with a synthetic skin substitute to allow for swelling. The priority is circulation, not a watertight seal.
A bulky, non-compressive dressing is applied. Plaster splints are placed to immobilize the wrist and hand, protecting the bone and tendon repairs. The fingertips are usually left exposed so the nursing staff can monitor color and capillary refill.
The dressing acts as a cocoon, keeping the hand warm and protected from bumps or movements that could tear the delicate vessel repairs.
The patient is transferred to a specialized unit or ICU. The finger is monitored hourly for color, warmth, and capillary refill. Temperature probes may be attached to the skin to monitor temperature continuously.
Any drop in temperature or change in color (pale indicates arterial loss; purple indicates venous congestion) requires immediate evaluation and, if salvageable, a return to the operating room.
To prevent clots from forming at the repair sites, patients are placed on anticoagulation therapy. This may include Aspirin, Heparin, or Dextran.
This medication regimen balances the need to keep the blood thin for the finger with the risk of bleeding from other wounds. The protocol is tailored to the injury’s severity.
If venous congestion occurs and cannot be surgically corrected, medicinal leeches may be applied. Leeches secrete a natural anticoagulant (hirudin) and actively remove excess blood.
This allows the finger to drain while new venous channels grow, which typically takes 5 to 7 days. While it may sound archaic, it is a highly effective standard salvage technique in microsurgery.
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It varies widely. A single sharp cut finger might take 3 to 4 hours. A multi-digit crush injury or a thumb reconstruction can take 10 to 15 hours or more. It is a marathon procedure.
No, you will be under general anesthesia. You may also have a nerve block that keeps your arm numb for hours after you wake up, which helps significantly with pain control.
If the veins are too damaged to repair, blood gets stuck in the finger. Leeches act as a temporary drain. They remove the old blood and inject a thinner that keeps the blood flowing until your body grows new veins.
For clean, sharp cuts (guillotine), success rates are very high, often over 90 percent. For crush or avulsion injuries, the success rate drops significantly because the damage to the vessels is more extensive.
No. You will be in a protective splint. While early controlled motion is essential for tendons, it must be done under the strict guidance of a hand therapist. Moving too soon or too hard can break the bone fixation or tear the vessel repairs.
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