27/09/2025
Musings and Memoirs of An Accidental Plastic Surgeon -2
Late Prof C Balakrishnan Nair(CBKL), who was the teacher of my Professor K Ramakrishnan Nair (KRK), visited The plastic Surgery department at Government Medical college Thiruvananthapuram, in 1995, while I was undergoing My MCh plastic surgery Training. In reply to a Professor KRK's request for a message for us Postgraduate students, He said "read a good book". Being advanced in age with its frailties , he was not able to carry a long discussion. But we were blessed to have an occasion to meet face to face, a Legend who brought organized and systematic Plastic surgery training to India. He Set up the first civilian unit of plastic surgery at Nagpur Medical College in the immediate post-independence decades.
I was also blessed with having as my co PG Dr. P Kishore (Now professor at AIMS, Kochi). It was his idea to regularly spent at least 2 hours every day to read the Test Book of Plastic Surgery by Mathes and Nahai, (and later other textbooks), the whole 8 volumes of it totaling nearly 6000 pages, from beginning to end not skipping a single page, by the time we completed our MCh training. Without his initiative and persistence, I wonder if I would have completed MCh with such a wide reading and understanding of the basic as well as specialized areas of plastic surgery.
Since we were always available in the department library, emergency calls were directed to us. Thus, we slowly built up the theoretical as well as practical knowledge, guided by our professors.
Plastic surgery and its application need such a wide based knowledge, as the solutions to be applied to each situation will be subtly different.
One day, my orthopedic Colleague, Dr Saji P O Thomas, Referred a young man to me. This man sustained what is called a hydraulic injection injury in a workplace accident nearly 3 years ago. The nozzle of a hydraulic pressure injector accidentally caused the left index finger to be injected with grease. The pulp had necrosed and the finger healed with an exquisitely painful scar over the terminal digit of the index finger. Due to this severe pain, he was not able to do any work. He was referred to my orthopedic colleague for an opinion, before being considered for Permanent disablement certification, under the ESI Scheme. Permanent disablement certification allows the ESI Scheme beneficiary to receive lifelong disablement pension.
When I saw the young man in his late 30's, his right index fingertip was scarred with a whitish scar, with the nail crookedly bent toward the pup side, due to the forces of the scar. In addition he had few small sinuses on this middle and proximal phalanges of index finger. The scar of the terminal phalanx was exquisitely tender, so much so that he will withdraw his finger as soon as I try to touch the finger to feel the scar.
I explained to him that there is a possible solution to his problem, which can allow him to go back to work. His skeptical face showed that he did not believe this. However, he agreed to go ahead with the surgery
In the upper portion of first webspace of the foot, a size of skin , which is approximately the width of the finger pulp, is supplied by the terminal branch (First dorsal Metatarsal artery) of the Dorsal artery (Dorsalis Pedis Artery) of the foot and is provided sensation by a single strand of nerve coming from the Anterior Tibial nerve ( the nerve in front of leg supplying signals to the muscles of the front part of leg. After removing this we can close the skin directly without producing any difficulty in using the foot once it is healed. This tissue can be brought to the finger and connected to the vessels supplying the finger as well as the nerve connected to the end of the nerve supplying the index finger, near the base of the finger in the hand. Once the Nerve axons grow in and establish the connection to the "sensors" in the skin tissue being transplanted from the foot, the finger will regain its completely natural normal sensation, which is expected for the index finger.
I shall not dwell too much here, on the complex neural physiology involved, for fear of boring or confusing the readers.
The patient agreed and the surgery proceeded without a hitch. The whole of the scar is removed, the sinuses in the skin opened and the grease, which was harboring beneath the skin, producing the sinuses. were removed. The composite of tissue from the foot transferred to the finger. This microvascular surgery takes a long time, as each step has to be absolutely precise and accurate. The artery and the vein are connected and finally the nerve is connected. After nearly 10 days of observation for any occlusion of the repaired artery or veins, once we were sure that the wounds are healing uneventfully, the patient is sent home. His finger sensation had fully returned by 6 months.
He was afraid to go back to the work, fearing for the pain he felt. When the ESI doctor phoned me to ask regarding extending the leave, I said " please don’t give him any more leave. Sak him to go back to work" Then patiently sitting with him to encourage him to overcome his fear (of the severe pain he felt) over the next month, made him courageous enough to go back to work.
Months later he would come back for a review when he says, "doctor you are like a god to me".
While disablement pension is a relief, for a working person, a fully functioning hand and ability to work and get a better income is always important.
Offering the complex reconstructive choices like a well-planned functioning composite tissue transfers, though apparently costly in the short term, is the best, cost-effective reconstruction solution in the long term. Often, once the choices are explained and offered to choose, many a time without hesitation patients choose the Sensate/ Functioning Microvascular tissue transfers.
The Next person landed with me was a Toddy tapper, who sliced off a half of the tip of the index finger, nail, slice of bone and skin of the Radial (thumb side) border. We as plastic surgeons were routinely offering a distant flap of skin (in this situation, flap form the abdominal skin) to be attached to the finger and the finger kept taped to abdomen for three weeks, before dividing the connecting bridge of the skin and then suture the skin back. This skin is softer and of a different quality to the specialized skin of the finger pulp. This young man could not accept the idea of taping the hand to abdomen for three weeks. So, I again offered the microvascular 'foot first webspace sensate skin flap' to him. (after calculating the possible total cost of treatment alone, I realized that the total cost is only 30% for this microvascular flap, compared to the traditional pedicled flap with its nearly 4-5 weeks of not using the hand and two staged of operation). Even after hearing the cost apparently being (what I thought was) very high, after a brief consideration he opted for the microvascular flap. The surgery was competed the same night.
Though the flap initially looked bulky (possibly due to the immediate swelling) after nearly 6 months the finger shape was almost like that of a normal finger, barring a darker color shade. And he was back to work actively climbing coconut trees as a toddy tapper.
Microvascular surgery gives us ability to engineer complex tissues to give back near normal function, with well-planned and chosen surgical plans. As I said at the beginning, reading a good "book" which is encyclopedic in its knowledge content is important to empower us to offer real qualitatively superior choices to the patient.
(And for pretty much other avenues of Knowledge).A good book provide (along with a brief history of the development) background information, context and choices possible in a given situation. Once we assimilate, assess and apply this knowledge, we can provide technically sound and innovative solutions.
Here in lies the importance of The Assertion of Prof C B K " read a good Book" that I referenced to in the first part of this chapter.
