Plastic surgery restores form and function through reconstructive procedures, cosmetic enhancements, and body contouring.
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The thumb is the most critical digit for hand function, facilitating pinch, grasp, and fine motor skills. Consequently, thumb reimplantation is considered an absolute indication for surgery whenever possible. Even if the injury is severe, a stiff or shortened thumb is often functionally superior to no thumb at all.
The procedure prioritizes the restoration of stability and opposition. Surgeons will often fuse the joint if necessary to provide a stable post for the other fingers to pinch against. The return of sensation is also a priority to allow for tactile feedback during manipulation tasks.
Amputations at the level of the distal phalanx, or the fingertip, are extremely common. These procedures, often termed “super-microsurgery,” involve repairing vessels that are near the limits of optical visibility, typically between 0.3mm and 0.8mm.
Successful reattachment at this level preserves the nail complex and the highly sensitive fingertip pad. While bone and tendon repair may be minimal, restoring arterial flow and venous drainage is technically demanding. In some cases, only the artery is repaired, and external bleeding is encouraged to relieve congestion.
When multiple fingers are amputated, the surgical team must make complex triage decisions. The goal is to restore the most functional hand possible. This often involves a “structure by structure” approach rather than finishing one finger before moving to the next.
For example, the surgeon may repair all bones first, then all tendons, then all arteries. This reduces the total ischemia time for the last finger. When not all parts can be saved, the most viable digits are translocated to the most valuable positions, such as the thumb or index finger.
Ring avulsion injuries occur when a ring catches on an object, stripping the soft tissue, nerves, and vessels from the underlying bone. These are classified as severe avulsion injuries and historically often resulted in amputation.
Modern microsurgery allows for the salvage of many of these digits. The procedure typically involves extensive use of vein grafts to bridge the gaps in the damaged vessels. The skin is often severely damaged and may require coverage with flaps or skin grafts.
This procedure is a form of delayed reconstruction or immediate substitution. It involves harvesting the great toe or the second toe from the foot and transplanting it to the hand to create a new thumb. The anatomy of the toe closely resembles that of the thumb, providing similar joint structure and tendon attachments.
The microsurgical connections are made to the radial artery and cephalic vein in the hand. This procedure provides excellent cosmetic and functional results, restoring pinch and grasp strength. The foot generally functions well without the second toe, and walking is minimally affected.
In devastating hand trauma where multiple digits are mangled, some parts may be unsalvageable. The “spare parts” concept involves harvesting healthy tissue—skin, bone, nerves, or vessels—from a digit being amputated to repair and save an adjacent digit with a better prognosis.
For instance, the skin from a destroyed index finger might be used as a fillet flap to cover a defect on the thumb. This resourcefulness reduces the need for distant grafts and utilizes “like with like” tissue for the best reconstructive outcome.
Often, the trauma that causes an amputation damages a segment of the artery or vein, leaving a gap that cannot be bridged by simply pulling the ends together. In these cases, a vein graft is harvested, typically from the forearm or leg.
This graft acts as a conduit to bridge the gap and restore blood flow. The surgeon must perform two microsurgical connections (anastomoses) for each graft—one at the proximal end and one at the distal end. This adds complexity and time to the procedure, but is essential for tension-free repair.
Restoring sensation is critical for the function of the reimplanted digit. Nerves that are cleanly cut are repaired directly (neurorrhaphy). However, in crush or avulsion injuries, there may be a gap in the nerve.
Surgeons use nerve grafts (harvested from a sensory nerve elsewhere in the body) or synthetic nerve conduits to bridge these gaps. The nerve fibers must grow through this graft from the hand into the finger, a process that takes months.
During reimplantation, tendons are repaired to restore movement. However, the healing process often creates scar tissue (adhesions) that binds the tendons to the surrounding tissue, limiting motion.
Tenolysis is a standard secondary procedure performed months after the initial surgery. It involves surgically releasing these adhesions to allow the tendon to glide freely again. This is crucial for maximizing the range of motion in the salvaged digit.
In some cases, the joint surfaces of the amputated digit are destroyed, or the joint is unstable. To provide a functional digit, the surgeon may perform an arthrodesis, or joint fusion.
This involves removing the cartilage and fusing the bones in a functional position (usually slightly bent). While the finger will not bend at that specific joint, it will remain stable, painless, and strong, allowing effective hand use.
Heterotopic reimplantation refers to the attachment of an amputated part to a location other than its original position. This is most commonly seen when a finger is moved to the thumb position.
If the thumb is destroyed but the index or middle finger is amputated and salvageable, the surgeon may plant the index finger onto the thumb stump. This prioritizes the restoration of the hand’s most crucial digit, the thumb, using the available “spare part.”
While technically not a reimplantation, revascularization is a standard parallel procedure. It addresses digits that are incompletely severed but have lost arterial flow. These injuries often involve fractured bones and severed tendons as well.
The procedure involves stabilizing the skeleton and repairing the damaged structures while protecting the intact skin or tendon bridges. Preserving venous drainage through the intact skin bridge can sometimes simplify the procedure compared to full reimplantation.
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If veins cannot be repaired due to damage, the finger will swell with blood. Surgeons may use medical leeches, which attach to the finger and drain excess blood, serving as a temporary venous system until the body forms new veins.
If the joint is crushed or destroyed, it will not move smoothly and will be painful. Fusing the joint (making it solid) eliminates pain and provides a stable finger that is useful for gripping, even if it doesn’t bend at that one spot.
A nerve graft is a piece of healthy nerve taken from another part of the body (often the leg or arm) to bridge a gap in a damaged nerve in the finger. It acts as a tunnel for the regenerating nerve fibers to grow through.
The priority is always the thumb, followed by the middle and ring fingers to provide a surface for the thumb to pinch against. The index finger is sometimes sacrificed or moved if it helps save the thumb or middle finger, as the middle finger can take over the index finger’s job.
Yes, specialized “super-microsurgery” techniques allow for the reattachment of fingertips near the nail base. If the vessels are too small, the surgeon might use a composite graft technique, reattaching the graft without repairing the vessel, though this is less predictable.
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