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STAT

An MUSC blog
Keyword: plastic surgery

For three of the most common hand conditions, MUSC Health’s highly skilled surgical team offers specialized and minimally invasive solutions.

Milton B. Armstrong, M.D., professor of Surgery and Division Chief of Plastic, Reconstructive and Hand Surgery at MUSC Health, details the less invasive treatment options that exist for carpal tunnel syndrome, Dupuytren's contracture and Raynaud's disease. MUSC’s surgeons have the specialized training to consistently execute successful results.

Carpal Tunnel Syndrome: Endoscopic Treatment Approach

According to Dr. Armstrong, carpal tunnel syndrome is one of the most common conditions that bring patients into his office. This condition is caused by compression of the median nerve at the wrist, causing numbness and tingling in the fingers and weakness in the hand.

For the past century, open surgery has been the primary treatment for carpal tunnel syndrome. In this procedure, surgeons make an incision on the palm, cut the ligament that covers the nerve causing the problem and then close the skin.

Over time, surgeons have attempted this procedure using smaller and smaller incisions at the wrist. Today, Dr. Armstrong says he uses a very small incision about a centimeter in length and uses an endoscope to view the ligament from the underside. A knife attached to the endoscope then cuts the ligament and the surgeon closes the skin with one or two sutures—in a procedure that can be completed in 15 minutes or less.

For patients who are a good fit for this procedure, Dr. Armstrong says the less invasive nature can make for a quicker recovery. Often, patients can return to work 10 days to 2 weeks faster than if they had undergone the open technique.

“That helps people who have jobs that require significant use of their hands for activities as well as others, such as students, who have busy lives to return to. It's a very useful procedure,” he says.

Dupuytren's Contracture: Injection Treatment

A less common hand condition that Dr. Armstrong treats, Dupuytren's contracture is primarily seen in patients of Northern European ancestry. Patients develop contractures in the palm and the fingers, which pull the fingers down toward the palm over time. While not generally painful, the condition can cause stiffness and rigidity, making movement of the fingers difficult.

Dupuytren's contracture has traditionally been treated with an open technique. In the procedure, a hand surgeon opens the skin, then separates and takes out tissue that's fibrotic, which is otherwise normal tissue that becomes problematic in certain groups of people. This can be a lengthy procedure, lasting up to 2 hours in some cases, and requires meticulous dissection of important structures, such as digital nerves and flexor tendons.

Today, Dr. Armstrong and other MUSC Health surgeons can often bypass surgery entirely with an injection treatment. “We have an enzyme, called Xiaflex, that we can inject into the contracted cord to break it up,” he says. “In many cases, we can avoid open surgery.”

Patients receive the injection and then follow up with their doctor, anywhere from 24 hours to 7 days after the procedure. The doctor then breaks up the contracture manually—no operating room necessary.

“That's been a boon for these patients, especially people who may be older or have other medical problems that make them not ideal candidates to go under anesthesia,” explains Dr. Armstrong. “We can now treat this problem without having to put a patient under an anesthetic and open the skin with a scalpel.”

Raynaud's Disease: Botox® Offers Relief

Raynaud's disease, a type of vasospastic disorder, happens when a spasm of the arteries travels to the fingers. This can either be an isolated problem, more common in young women, or an issue related to other disease processes, such as lupus.

In severe cases, patients can develop ulcers and pain in their fingers due to lack of blood flow. “In some patients where it's very severe, to the point where the tissues have died off, we have to do amputations of some parts of the fingers,” says Dr. Armstrong.

Traditionally, doctors have performed an open operation that aims to release tissues around the arteries to allow for better blood flow.

“The smooth muscles within arterial walls are controlled by little nerves, the digital nerves, and so we separate the nerves from the arteries using magnification, sometimes with the microscope,” says Dr. Armstrong. “It’s a technically demanding operation and doesn’t guarantee success. Those patients have significant pain from the surgery, and then we have to wait for days or weeks to the results of the surgery.”

Hand surgeons treating Raynaud's disease now have another treatment option to consider: Botox®, or botulinum toxin A. Commonly used to treat a host of cosmetic problems, such as wrinkles of the face and forehead, Dr. Armstrong says Botox® can be a useful adjunct for this problem.

“What we have found is that the botulinum toxin, which relaxes smooth muscles, can be injected into some patients’ hands,” says Dr. Armstrong. “It breaks up the spasm and can have as good a result for some patients as doing the open surgery.”

Carpal Tunnel and Other Techniques Require Intensive Training

These three procedures illustrate how advanced, minimally invasive approaches can offer a multitude of benefits to patients, possibly limiting the need for surgery, often with a similar or better result. However, Dr. Armstrong emphasizes the need for specialized training in performing these hand procedures.

In the division of plastic surgery alone, MUSC Health has four physicians who are fellowship-trained hand surgeons, three of whom are also board certified in surgery of the hand. All of this additional training helps guide surgeons toward the best treatment results for patients.

“Physicians should ensure they’re referring patients to a surgeon who is trained and who understands the anatomy and pathophysiology of these problems,” says Dr. Armstrong, noting that an open procedure may be the next option if a less invasive technique doesn’t offer patients sufficient relief or isn’t recommended.

When patients discuss their treatment options with an expert in minimally invasive and open hand techniques, they can ensure they receive well-rounded recommendations and effective results.

For more information, contact Dr. Armstrong at armstrom@musc.edu.
 

A new approach to breast reconstruction offers better results for more women. According to MUSC plastic surgeon Kevin O. Delaney, M.D., pre-pectoral breast reconstruction can benefit women who:

  • Are seeking reconstruction for the first time
  • Underwent reconstruction surgery years or decades ago but aren’t happy with the results or suffer side effects

If women aren’t satisfied with how their breasts look or feel after reconstruction—or have lingering pain from the procedure—this new technique may help them.

Pre-Pectoral Breast Reconstruction: What Is It?

MUSC Health provides a range of treatment options for women seeking breast reconstruction after a mastectomy. Whether a mastectomy was performed to treat or prevent breast cancer, Dr. Delaney works closely with MUSC Health’s Hollings Cancer Center team to guide women toward the best available options.

MUSC Health offers 2 main types of breast reconstruction today. Free-flap DIEP (deep inferior epigastric perforator) breast reconstruction relies on a patient’s own skin and fat tissue to rebuild breast tissue, whereas other procedures use breast implants.

As Dr. Delaney explains, pre-pectoral breast reconstruction is a new way of performing implant-based procedures, an approach MUSC Health has been offering for close to 2 years.

“We're one of the first centers in the region to perform this pre-pectoral, or subcutaneous, breast reconstruction,” says Dr. Delaney. “In this procedure, we place a breast implant just beneath the breast skin, which means we don't need to cut a patient’s pec muscles.”

Previously, surgeons would need to cut a patient’s pec (or pectoralis major) muscles in order to set the implant underneath these muscles. That’s how implant-based breast reconstruction has traditionally been performed for the past 20 to 30 years.

Breast Reconstruction Technique Offers Many Benefits

According to Dr. Delaney, the new pre-pectoral approach offers many pros and few cons. Two significant benefits to patients: a better cosmetic outcome and less pain.

“One main benefit to this approach is that the cosmetic outcome of the reconstructed breast looks a lot better,” Dr. Delaney explains. “Pre-pectoral breast reconstruction avoids what is commonly known as an animation deformity, which happens to most women who’ve had implant reconstruction under the muscle, to varying degrees.”

This animation deformity occurs when a woman moves her arms or flexes her muscles. The implant, as well as the overlying breast skin, flattens and moves towards the armpit, which many women consider undesirable, says Dr. Delaney.

Because the pre-pectoral technique eliminates the need for cutting the pec muscle, women experience significantly less pain in the short and long term. This equates to a much faster and easier recovery following the surgery. Women also don't lose any functionality of their pec muscle, which is a possibility with the traditional approach.

Dr. Delaney says this new technique is now the preferred route of implant-based breast reconstruction at MUSC. He says it’s slowly catching on nationwide but that as of now, it’s largely offered only through academic centers.

Pre-Pectoral Breast Reconstruction: The Right Candidates

Dr. Delaney assesses the best reconstruction approach on a case-by-case basis, but he says there are only a few reasons why he would recommend against the pre-pectoral approach for implant-based reconstruction.

The main caveat is if a woman has previously undergone radiation therapy to the breast. “Since the breast skin typically doesn't heal as well after it's been exposed to radiation, it makes the pre-pectoral breast reconstruction more risky from a healing and ultimately infection standpoint,” says Dr. Delaney.

However, the majority of women seeking breast reconstruction can benefit from this approach. In addition to offering current patients a better treatment option, this procedure could also benefit a wide swath of women who received breast reconstruction previously but aren’t happy with the results.

“Many women who have undergone sub-pectoral implant-based breast reconstruction in the past, whether it was 3 years ago or 20 years ago, have significant complaints,” says Dr. Delaney. “Patients come to us with tightness in their chest or up into their arm, chronic pain in that area, as well as complaints about the animation deformity and how they don't like the look of their reconstructed breasts. Those are all real complaints that we hear every day.”

Previously, Dr. Delaney says he couldn’t offer those patients many solutions. But now, with this pre-pectoral technique, he says he can significantly improve many patients’ symptoms or complaints in a straightforward outpatient surgery that takes just a few hours.

“We can remove their old implant, put their muscle back down to where it belongs anatomically, and then put a newer, better implant in below the skin,” he says. “Their pain significantly improves. Their animation deformity goes away. And they're incredibly pleased with how much better their reconstructed breasts look and feel as opposed to when they were below the muscle.”

A Better Breast Reconstruction Option Now Available

Dr. Delaney wants to spread the message that there’s a new option available for women who may fall into this category—and that their health insurance would likely cover it because it’s a part of breast reconstruction care.

“As plastic surgeons, if patients have had breast cancer treated but they're displeased with their reconstruction, we want to help,” he says. “If they’re not local, we can often talk to patients via telehealth and let them know whether this procedure might benefit them.”

For more information, contact Dr. Delaney at delaneyk@musc.edu.
 

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