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Out of Options: Hand Surgery Saves Fingers and Function

11.01.2010

For several years, Melissa Warde endured disabling pain in her fingers, caused by an autoimmune system disease. She found some relief in medication, but the disease progressed, constricting blood flow to her hands so badly that amputation became a strong possibility. The surgery she had at Stanford Hospital changed all that.

On the outside, Melissa Warde just glows. Confident, quick to smile, happy. One look at her hands and a different reality is obvious.

Her left hand and fingers are purple, and swollen. Until this summer, her right hand had been the same way−worse, in fact, with unhealed ulcers on the tips of her index and ring fingers.

For more than half her life now, Warde has doggedly kept moving against scleroderma, an autoimmune system disease that can harden the skin until it feels like stone. Its scientific name means hard skin. It's not a common disease, but it can affect every organ in the body, in addition to the skin.

Its cause is unknown; a cure not in sight. The best that can be done right now is to respond to its symptoms. "It's a very, very debilitating disease," Warde said. She has developed a tremendous mental strength. "I get up every day, no matter how much pain I'm in. I always put myself together."

In part, the pain comes from blood vessels whose flow is constricted by overabundant tissue deposited around their exterior surfaces. And, Warde said, "I started to get these ulcers on my fingers that wouldn't heal." Bit by bit, Warde had to give up playing the sports she loved, and, ultimately, was unable to continue her job in a cancer research center.

This procedure is becoming a very much desired procedure for scleroderma patients, but you need a vascular surgeon who has the experience.

-Lorinda Chung, MD, Director, Stanford Hospital rheumatologist

Melissa Warde shows her Stanford plastic sugeon, James Chang, the changes in her hand since surgery.

She tried various medications, but nothing worked. Sometimes, the pain would be so bad that the necessary dose made it impossible for her to do anything. And Warde’s fingers became so damaged that amputation seemed ahead. "I was in danger of losing my fingers," she said. Finally, a scleroderma specialist at Stanford Hospital & Clinics, Lorinda Chung, MD, mentioned one last option−a surgery called a digital sympathectomy.

Delicate procedure, practiced hands

In this procedure, microvascular surgeons like Stanford's James Chang, MD, Division Chief, Plastic & Reconstructive Surgery, dissect open the wrist and palm through small incisions to isolate the blood vessels that feed the fingers. Guided by his view through an operating microscope, Chang carefully releases the scar tissue that envelops and constricts the arteries.  Freed from the scar tissue, the arteries plump open again and enough blood reaches the fingertips to nourish them. If the arteries are too damaged, then the surgeon will make a bypass around them from unaffected arteries elsewhere in the hand.

"The stakes are high, and this is a technically difficult and challenging procedure," said Chang. "But the effect can be huge. We're setting back the clock of the effects of scleroderma on hand blood vessels by 10 to 12 years."

"It's becoming a very much desired procedure, but you need to have a microvascular surgeon who has the experience," said Chung, an autoimmune system physician who has treated Warde at Stanford. She and her colleagues are part of a multidisciplinary scleroderma center there and regularly consult with physicians, like Chang, who might offer another aspect of care to her patients.

Warde said Chang explained to her that scar-like tissue had encircled her hand's blood vessels "like a piece of twine wrapping around a garden hose, and that you had to strip away the twine." Medication might be somewhat helpful, she thought, but she liked the idea of "starting with a clean slate."

I started to get these ulcers on my fingers that wouldn't heal and I was in danger of losing my fingers.

-Melissa Warde, patient, Stanford Hospital & Clinics

Stanford hand surgeon James Chang is one of a very small group of physicians with the technical expertise to successfully perform a surgery like Warde's. Called a digitial sympathectomy, the surgery includes stripping disease-caused fibers away from blood vessels. On the screen behind Chang is an angiogram of Warde's hand; the dark lines in the hand is evidence that blood is now flowing much more normally to Warde's fingers.

When Chang opened up Warde's hand, he was using microsurgical tools and technique. Microsurgery depends on optics, surgical tools and the skill of the surgeon. One early barrier now overcome: the eyes of the needles used to carry sutures to close up blood vessels were so large they tore holes in the fragile tissue. Now, the suture thread is fused to the needle, expanding what microsurgery can successfully accomplish.

More than skin deep

Within Stanford Hospital's Robert A. Chase Hand & Upper Limb Center and its Complex Reconstruction Center, surgeons treat very challenging conditions. People like Warde may come to Stanford for help with the damage caused by a chronic disorder; they may come after a traumatic accident to have a limb reattached; or they may come to talk about what might be done during or after cancer surgery.

Plastic and reconstructive surgery might mean reconstructing a face damaged in a car accident or replacing a breast removed for cancer by using abdominal skin or repairing a cleft lip. Modern microsurgery enables the reconstruction of wounds and defects anywhere from scalp to toes.

Chang and his colleagues can now, as a routine procedure, reattach a hand completely amputated across the palm or move all or just some of the big toe to make a new thumb.  The latter capability is especially critical because the thumb is responsible for 40 percent of the function of the hand.

The surgery has been the biggest lifesaver for me. I can fully function. I feel a lot more whole than I have in quite a few years because of this surgery.

-Melissa Warde, patient, Stanford Hospital & Clinics

The scale of the surgical territory in the hand is stunningly miniscule. The sutures Chang handles are no thicker than a human hair−and to secure connections he makes eight stitches around the circle of a one millimeter vessel's circumference. Just getting to where he needed to work in Warde's hand required a careful movement down through a tightly-packed group of tendons, nerves, veins and arteries, none much bigger than the ones obscured by the scleroderma. Even the most meager misstep can have major impact on how well her hand would work after surgery, or trigger chronic pain.

ABOUT PLASTIC AND RECONSTRUCTIVE SURGERY

- Plastic and reconstructive surgery techniques have broad applications, not only to limbs and the face but also to the body’s internal regions: Abdominal walls, for example, can be reconstructed, tendons transferred and even the smallest of blood vessels restored to function.

Surgeons can also retain or restore function to the tongue, palate and esophagus as one aspect of a cancer surgery.

- Specialists in plastic and reconstructive surgery are often part of a team of physicians focused on a patient’s care and their skills incorporated into a coordinated approach to treatment.

- For many millions of people who have suffered highly disfiguring injuries or health conditions, the specialty has offered the chance at a life lived without the stares of others. For others, it has meant a life returned to normal activity.

- The field had its earliest recorded beginnings in India, around 2000 BC.

- By 1794, the first published reports appeared in an English magazine.

- In 15th century Europe, the technique was used sometimes to replace a nose lost and devoured by dogs.

- In 1827, the first American plastic surgeon repaired a cleft palate. As soldiers returned from World War I, plastic and reconstructive surgeons gained, unfortunately, experience with reconstruction of explosive- and burn-injured faces.

Looking ahead

New techniques are available to take this type of surgery to an even higher level. Recently, Stanford's surgeons pioneered new techniques in wrist arthroscopy, nerve reconstruction, and release of Dupuytren's contracture, a condition that twists the hand and fingers into a nearly non-functional shape. The next steps, Chang said, will likely include the movement of more precise combinations of a patient's skin, nerve, muscle, and tendons to individually tailor a reconstruction.  Stanford's plastic surgery laboratories also are actively involved in the combination of synthetic scaffolding and human cells to repair tissue, bone and nerve.  "It's an exciting time in plastic surgery, because our toolbox is expanding," Chang said.

Since her surgery, Warde has worked hard with a hand therapist to regain mobility lost to lack of use. But she could see the effect of the surgery immediately. Her right hand and fingers lost that deep purple color and became a healthy pink again. The ulcer began to heal. "There was a drastic, drastic difference," Warde said. "It wasn't an open wound any more."

The surgery, Warde said, "has been the biggest lifesaver for me. I can fully function. I feel a lot more whole then I have in quite a few years because of this surgery."

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