Ganga Medical Centre & Hospitals Pvt Ltd

Coimbatore, India.

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Microsurgery

Microsurgery is the marvel of modern surgery. To put it simply, operating with microscope is called microsurgery. Surgeons of various specialties like Plastic Surgery, ENT, Ophthalmology, Neurosurgery and many more use the microscope. All of them use the microscope to do whatever they were doing a lot better. After all, you do better when you see better.

Plastic and Reconstructive surgeons took it a step further by fine tuning the skills of joining small blood vessels, as small as or even lesser than a millimeter in diameter. That helped to revolutionise reconstructive surgery. Amputated fingers and hands were joined back. When major accidents resulted in large tissue defects, they were usually amputated. With the advent of microsurgery Plastic and Reconstructive surgeons were able to transfer tissues from one part of the body to another. This led to the salvage of severely injured hands and legs.

It is just not in trauma where microsurgery is used. The same capability is also used in reconstruction of defects after removal of cancer, reconstruction of major defects left by burns and even in infectious conditions like diabetic foot. The benefits are endless. The imagination, hard work, skills and dexterity of microsurgerons has opened up endless possibilities to the benefit of patients.




Microsurgery in progress. The infrastructure of Ganga Hospital can allow 4 major microsurgical procedures to go on at the same time.


What Microsurgery can do ?

Replantation

Microsurgery has allowed us to reattach totally amputated body parts. Ganga Hospital introduced reconstructive microsurgery to the region and at present performs around 600 major microsurgical procedures every year. It also does the maximum number of replants and revascularizaions in the country.


Thumb Replant


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9 year old Kathiresan, shocked his parents when he accidentally totally cut off his right thumb while cutting fruit at home. Parents were scared if he would go to school again. Deeply worried about the future they brought him to Ganga Hospital immediately.



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By a 4 hour operation the amputated thumb was rejoined. He soon rejoined school and started writing. It is 8 years since his thumb was put back and he is now in college and no body believes that he has a reattached thumb.

We can transfer tissues from one area to another increasing function.




Toe to Hand Transfers

Vignesh was just 4 years old when the tragedy happened. He accidentally touched the cords of the electrical heater and sustained serious electrical burns. First his life was in danger, and we treated him to safety. The right thumb was the primary contact area and it was charred due to the heat. There was total loss of thumb. Few months after the injury, we reconstructed the thumb by transferring the great toe from the foot.



The right hand of Vignesh, without the thumb


The great toe harvested from the foot with the tendons, nerves and blood vessels


The reconstructed right thumb compared to the normal thumb.


He could play ball




Microsurgical Free Flaps

Microsurgery plays a great role in the salvage of major crush injuries of the limbs. When the legs or hands are crushed, the technique of covering the skin defect may prove to be the most challenging task in management. When the fracture site is open, unless the wound is covered early , infection will set in and the limb may even go for amputation.

The Plastic and Reconstructive surgery team is available 24 hours to take care of such patients. The joint efforts of the Anaesthesiology, Orthopaedic and Plastic Surgery teams helps us save many a limb which otherwise would have got amputated.


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A major crush injury of the leg with soft tissue loss and bone loss. The gap in the bone is visible. Saving these legs from amputation would need the Plastic Surgeons to transfer a big segment of tissue from one part of the body to another. Here we have taken the tissue from the opposite thigh (anterolateral thigh flap). in the bottom picture the arrow shows the blood vessels supplying the island of tissue that we have taken. The x ray shows the bone gap.



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Under the transferred soft tissue, the orthopaedic surgeons transported bone to obtain continuity. The patient is now waling comfortably. Salvage of the leg made possible through microsurgery and the combined efforts of the team.




Breast Reconstruction

Microsurgery offers great solution to woman for reconstruction of the breast after surgery for cancer. In fact this is the commonest indication for microsurgery in the western world.

Usually tissues from the lower part of the abdomen below the level of the umbilicus are taken with its supplying blood vessels and shaped like a breast over the chest. The blood vessels are attached to the blood vessels in the axilla or the chest wall. The patients are very happy because they not only their breast is reconstructed but also they get an abdominoplasty (tummy tuck) in the process.



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Functioning Free Muscle Transfer to Restore Hand Function Following Trauma

Restoration of finger flexion or extension following major trauma is a most challenging form of reconstruction. Conventional techniques cannot restore useful prehension because of significant damage to the muscles which are normally transferred.

What is FFMT ?

The gracilis muscle is used as a functioning free muscle graft. It is attached proximally to the medial aspect of lower end of humerus and distally to the long flexors (FDP) of fingers. The nerve of gracilis is attached to a branch median nerve. The muscle is kept alive by joining its nutrient artery and vein to the vessels around the elbow. In 4 to 6 months time as the muscle gets fully innervated, it starts contracting and increases in strength. In one year’s time, the patient can have good movement of his fingers.


Case Series

The patient shown here presented to us following major crush injury of his left forearm. He had lost skin and soft tissue along with the entire flexor compartment. In the first stage, he underwent thorough debridement and an abdominal flap to cover the entire raw area. The patient subsequently underwent regular physiotherapy to keep his fingers soft and supple. In the second stage he underwent FFMT to restore his finger flexion. He underwent 4 months of rigorous post operative physiotherapy and at 1 year follow-up he has got M4 outcome in his finger flexion.

Discussion

FFMT is a boon for patients who have lost ability to move their fingers and elbow following trauma. This procedure involves high end microsurgical expertise. The results following surgery are extremely gratifying and creditable. So far at Ganga Hospital, we have carried out over 125 FFMT procedure.



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Long segment bone loss


What is long segment bone loss ?

Absence of bone in of length more than 3 cm is called long segment bone loss. Loss of less than 3 cm can actually be treated by just shortening the leg and making the bone ends meet. However, for longer lengths this cannot be done and more complex reconstruction is necessary.


When does this occur?

Long segment bone loss is seen with open fractures or infection. In open fractures, bone pieces may be actually lost at site of injury or they may be removed at surgery if they are found to be without blood supply. Similarly in infections, the bone may have to be removed for control.


How can it be treated?

There are two major techniques of treating long segment bone loss – distraction osteogenesis and free fibula flap. Distraction osteogenesis is the slow stretching of bone, while the gap gradually fills with bone. The free fibular flap transfers a bone in to the gap along with its blood supply.


What role does Plastic Surgery play?

The free fibular flap requires harvesting of the thin bone from the leg with its blood vessels. This bone piece is transferred to the gap and blood vessels connected under the microscope. Such surgery is performed by Plastic surgeons trained in Microsurgery.


How long does this take?

The transferred fibula takes about 3 months to fuse the gap. Till then walking on that leg is not possible. However other leg exercises can be begun as early as one month.


What happens to the leg from which bone is taken?

The fibula is the thin bone in the leg and is not weight bearing in function. So taking it out does not cause any long term problems with walking. The ends of the bone near the knee and ankle joints are not taken to preserve joint stability.



Post traumatic massive bone loss involving lower end of femur


Allograft being measured to size of the defect


Free fibula along with contoured allograft


Free fibula along with contoured allograft


Free fibula along with contoured allograft


Allograft fibula graft in place


18 months showing good consolidation of bone









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