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(For trauma, infection, birthmarks, developmental abnormalities,
tumors, disease)
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The terms plastic, reconstructive and cosmetic surgery mean different things.
Plastic surgery refers to operations that alter anatomy to make it better, both functionally and aesthetically. Examples are reshaping a nose so that it looks and breathes better, correcting an underdeveloped breast, trimming heavy upper eyelids that obstruct vision etc.
Reconstructive surgery returns anatomy to its original form. Examples include repairing cut tendons of the hand, or rebuilding the face once damaged by cancer or trauma etc.
Cosmetic surgery aims to improve on the person's original form to make it more beautiful. Examples include facelift, breast augmentation liposuction etc.
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Only qualified specialists who have completed the required training and examinations may call themselves “Plastic Surgeons" which equates to approximately 8-10 years of additional specialist surgical training after basic medical qualifications.
However any doctor may call him or herself a cosmetic surgeon without having undergone the rigor of formal training and accreditation. This confusing situation need not cause our patients alarm as our surgeons are fully qualified specialists in plastic, reconstructive and cosmetic surgery. This is a very important point as there is often more than one treatment option for a particular need and the practitioner must be competent to select, advise, administer and follow-up the one best tailored to each case. (Courtesy of APSA)
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Breast Reconstruction |
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Cleft Lip/Palate, Craniosyostosis |
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Orbital Reconstruction Midface |
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Reconstruction Jaw Surgery |
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CF Syndrome Hemi Facial, Microsomia |
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Trea cher, Collins |
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Facial Paralysis |
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Skin Grafts |
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Tumours |
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Migrain |
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Trauma |
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Tissue Expansion |
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Flap Surgery / Microsurgery |
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Hand Surgery |
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Other Reconstructive Procedure |
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Scar Revision |
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Many Other Types of Reconstruction |
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| Craniomaxillofacial Surgery |
Craniomaxillofacial surgery is a highly specialized branch of plastic surgery, which focuses on all aspect of complicated facial and skull reconstruction. Patients who need a craniomaxillofacial surgeon include children with cleft lip/palate, craniosynostosis, or other facial malformations and adults who have undergone tumor ablative surgery involving the skull, or victims of trauma whose facial skeleton has been severely disrupted by the injury.
A craniomaxillofacial surgeon also treats complex soft tissue problems such as hemangiomas, vascular malformations, facial tumors, Bell's palsy and severe facial scarring. He or she is also uniquely qualified to treat post cosmetic surgery problems such as the secondary rhinoplasty deformity or eyelid ectropions. Even the treatment of some speech problems caused by stroke can be addressed by a well-trained craniomaxillofacial surgeon and their associated team. Lastly, craniomaxillofacial surgery includes the treatment of basic and complex jaw problems including tumors, TMJ disorders, and abnormal growth patterns requiring mandibular and maxillary reconstruction.
Any good craniofacial surgeon will belong to or lead a craniofacial team and. Dr. shar heads a team in Dubai.
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| A Craniofacial Team
Should Include: |
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craniomaxillofacial surgeon who is dedicated to this work. |
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a Neuro surgeon |
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an orthodontist |
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a dentist |
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an otolaryngologist |
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a speech therapist |
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a geneticist |
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social work and or team psychologist |
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ophthalmology |
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hand surgery- to treat patient with combined
head and hand problems |
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podiatry or some type of foot surgeon- for
combined problems |
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a nurse coordinator and feeding specialist. |
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craniofacial, interventional, and neuroradiology |
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pediatric |
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oncology |
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radiation therapy |
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prosthodontics |
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Such a team will provide the multidisciplinary care of patients with craniomaxillofacial problems in order to obtain optimal results. This type of coordinated care also allows patients to see multiple physicians during a single visit. When a patient comes to a craniofacial team, the nurse coordinator will arrange for the patient to see all doctors who need to evaluate a problem. Then, at the end of the visit, the entire team will discuss the patient's problem and generate a concise and focused treatment plan which will optimize care. This type of focused care prevents miscommunication between referring physicians and ensures the patient will have a clear idea of what each doctor involved feels is the best treatment plan.
A good craniofacial team also collects and analyzes patient data, and presents this data at national meetings. In this way, the team is able to discuss their treatment method with other leading centers around the world, making sure they are providing state of the art therapy to their patients.
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| Before |
After |
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| Benign tumours |
The majority of skin moles and growths are harmless, hence being mainly of cosmetic concern. Nevertheless, the public awareness campaign about skin cancer risk motivates people to have many such moles removed for peace of mind.
Thin or early growths may be removed by laser without causing a scar. Larger, more advanced growths may need to be surgically excised, consequently leaving a fine scar.
APSA uses the Sciton (Erbium YAG) laser for ablation of benign (and selected superficial skin cancers). The Sciton is an extremely accurate ablative laser, that produces very little collateral tissue injury, hence minimizing complications such as scarring and hyper or hypo-pigmentation.
We do not use chemical or electrical cautery, as these procedures give less control to the operator; consequently they have a higher complication risk profile.
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| Malignant Tumors
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| Skin Cancers |
Australians have one of the highest rates of skin cancer in the world. This is due to our warm climate and the fact that many of us have fair skin, which is not suited to Australian conditions. Adding to this is our love of the great outdoors, where many of our activities are based. Ultraviolet radiation causes skin cancer by not only damaging cells in the skin, but also by depressing our immune system so that it is less able to destroy cancerous cells. We accumulate damage to our cells throughout our lifetime. It is never too late to start protecting our skin with a 30+ broad spectrum sunscreen, protective clothing and hats. Most skin cancers are curable, however early detection is important.
Basal cell carcinomas (BCCs) are the most common skin cancer. They usually occur on sun-exposed areas and grow slowly over time. They almost never spread elsewhere, but left untreated they will continue to grow, potentially making treatment more difficult.
Squamous cell carcinomas (SCCs) are also very common in Australia. They can grow quickly and need to be detected early as they can occasionally spread if treated too late.
Melanomas are another form of skin cancer that arise from our pigment producing cells (melanocytes). They are not as common as BCCs or SCCs, however they are potentially fatal and early detection is crucial. They can arise from moles, but often develop on normal skin. Melanomas, unlike BCCs and SCCs, occur not infrequently in younger people. The risk factors for developing melanomas include a family history of melanoma, excessive sun exposure, sunburn (particularly when young) and having many moles. Change in a mole is an important clue as is an irregular outline or colour.
It is important for Australians to have regular skin checks to improve the chances of detecting early skin cancers. Depending on the type of skin cancer, we offer topical treatments (creams), photodynamic (cream followed by intense red light), laser therapy and surgery.
We also have treatments for other sun-induced skin problems, such as sun spots, increased pigmentation, prominent capillaries and wrinkles.
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| Photodynamic Therapy
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(A new treatment modality)
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The treatment of skin cancer and pre-malignant skin lesions has traditionally relied on surgical excision. This remains the mainstay of treatment. The benefits are that the lesion is completely excised and there is histological confirmation of that fact.
The benefits of a non-surgical solution are obvious, avoiding surgery, scarring and possible disfigurement. However one must always remember that when you are dealing with a malignancy these goals must always be secondary to the primary aim of cure.
There are many non-surgical options for the treatment of skin cancer and pre-malignant skin lesions. These include
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Cryotherapy |
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Laser ablation |
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Topical 5-fluorouracil |
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Imiqamod |
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Intralesional interferon |
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| Photodynamic therapy has a number of advantages in the treatment of skin cancer and pre-malignant skin lesions. It is a one-stage treatment with proven efficacy and may be used to treat a large area in a single setting. The process is as follows. |
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Aminolevulinic acid (an anti-neoplastic agent) is applied to the lesion.This is absorbed by the neoplastic (cancerous) cells. |
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The aminolevelinic acid cream is covered and left in contact with the lesion for 2-4 hours. |
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The lesion is then uncovered and excess cream wiped away. |
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Red light is then applied to the lesion for 20 minutes. |
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This results in cell damage that specifically targets the neoplastic cells, leaving the normal healthy cells unharmed. |
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| The treatment period when the light is applied may be uncomfortable. Following the treatment there will be redness, inflammation, and crusting of the area for 1-2 weeks.
Photodynamic therapy is only appropriate for selected skin cancer and pre-malignant skin lesions. Your doctor will advise you whether Photodynamic therapy (or any other non-surgical option) is the right choice for you.
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Head and Neck - Cancer |
Head and neck surgery has been primarily developed to treat head and neck tumours both benign and malignant. It has evolved within a number of surgical specialties including Plastic and Reconstructive surgery.
Plastic surgeons with an interest in head and neck tumours are uniquely placed as they have expertise not only in the resection of such growths but also in the reconstruction of the defects created by the ablative surgery. The confidence of resection margins for example can potentially be influenced by the ability to reliably reconstruct a defect with techniques that are aesthetically acceptable and restore function as best as can be achieved.
Treatment of benign tumours may involve the removal of small growths and cysts from the lining of the oral cavity or lumps from the salivary glands located in front of the ears (parotid), the regions beneath the jaw (submandibular and sublingual) or within the oral cavity. Surgery is usually the only treatment required for these lesions however scars and residual cosmetic deformities can be minimised with techniques familiar to most plastic surgeons.
The management of malignant tumours of the head and neck region is complex. Most larger tumours require a coordinated approach to treatment between those performing the ablative surgery, the reconstruction surgeons and other specialists such as medical and radiation oncologists, nursing staff, speech therapists, physiotherapist, dentists preferably within a multidisciplinary environment.
Smaller lesions may be adequately treated with local resection and reconstruction using techniques familiar to plastic surgeons through our routine training. The ears, nose, eyelids and lips are specific structures that require aesthetically and functionally acceptable restoration using procedures that can not be offered by other specialties involved in the management of skin cancers.
Malignancies such as malignant melanoma, squamous cell carcinoma (SCC) both of the skin and oral cavity and larynx, malignant tumours of the salivary glands and other tissues are routinely encountered in the head and neck region by those with special interest in Head and Neck Cancer.
We have surgeons with active involvement in the management of Head and Neck tumours at Flinders Medical Centre and the Royal Adelaide Hospital in multidisciplinary units and who are members of the principle Australasian academic society The Australian and New Zealand Head and Neck Society.
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| Facial Paralysis |
Facial paralysis is socially devastating and functionally disabling. Facial expression is fundamentally important in face to face relations with others. Even partial paralysis may dramatically affect one's ability to interact in a satisfactory way. Sufferers gradually learn to cope but never fully adjust to their debility.
The tragedy is compounded by neglect. Firstly these cases are often not offered surgical treatment due to a lack of appreciation of the many available surgical techniques. Secondly, facial ptosis increases with time, exaggerating the abnormal appearance and further impeding functions of the eye and mouth.
Irrespective of cause, salvage of function in cases of failed spontaneous recovery is dependent on timing of intervention. Successful treatment depends on early reinnervation (re-connecting a nerve supply) of the denervated (lacking nerve supply) facial muscle. After approximately 18 months of denervation the muscles undergo irreversible degeneration.
For effective salvage of the affected facial muscles, surgical intervention must occur within the first 12 months of facial nerve injury, as most reinnervation procedures take at least 6 months for the new nerve fibers to grow up to the muscle motor end-plates. Any delay beyond this period of time results in increased failure, due to irreversible muscle deterioration.
Once muscle degeneration has occurred then one must also import new muscle to mobilise the affected face. There are several good options; muscle selection depends on a number of factors which are discussed at consultation.
Finally there is a gamut of ancillary procedures which are used to address specific problems and to complement the main reconstruction. These help support the eyebrow, eyelids, nose and mouth. Overall appearance is concurrently improved by a face and neck lift.
The above reconstruction list is by no means exhaustive. There is a large range of options which have varying degrees of success and applicability. The key to good management is to make an individualised assessment of each case, both in terms of the paralysis and the patient in general. The former requires an accurate and comprehensive assessment of; cause, anatomical site and severity of paralysis. The second issue is equally as important and refers to the patient in terms of their wishes and suitability for the varying options.
Dr Peter Sylaidis has made facial paralysis his area of sub-specialty interest and manages these cases in a multi-disciplinary approach.
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| Breasts- Reconstruction |
For women who have asymmetric development of their breasts, abnormal development as a consequence of trauma or burns or who are about to or have experienced a mastectomy, breast reconstruction offers the opportunity to have their body image improved or restored.
This group of procedures involves recreating a breast as a consequence of surgery to treat breast cancer, congenital developmental abnormalities (e.g. Poland's Syndrome, asymmetry related to failure of breast tissue growth) and trauma or burns. It may involve more than one procedure with the initial operation designed to establish a breast shape and a second procedure to create a nipple and possibly to correct residual scars and shape.
Following mastectomy for breast malignancy, every woman should be given the option of a reconstructive procedure. This can be undertaken at the time of mastectomy (immediate reconstruction) or as a delayed procedure (at the completion of any extra treatment e.g. radiotherapy or chemotherapy). For some the need or desire to have immediate breast reconstruction may be discouraged if extra (adjuvant) treatment is planned from the outset, however good safe results are still possible.
Reconstruction can also be considered for patients who are entertaining prophylactic bilateral mastectomy either because they have developed a second lesion and do not wish to risk another breast cancer or they have a strong probability of developing a breast tumour. This risk may be based upon their family history or specific testing for genes associated with breast disease.
There are advantages and disadvantages to both immediate and delayed approaches and these are focused largely on the perception that complications may be greater in those who have immediate reconstruction depending on the choice of technique adopted and may subsequently delay adjuvant treatment. However in delayed reconstruction the aesthetic results may not be as good as with immediate reconstructive techniques.
This relates principally to effects of scarring on the tissue remaining after mastectomy. Careful consideration will be given to individual patients needs as to which approach is both the most appropriate to restore body image as well as the safest in regards to management of your breast disease.
Our surgeons with an interest in breast reconstruction are always willing to discuss immediate reconstructive options and work with your breast surgeon to co-ordinate and expedite appropriate treatment and reconstruction in a timely manner.
We have surgeons skilled in all available breast reconstructive techniques.
These include the use of tissue expanders and breast prostheses, use of sheets of tissue incorporating muscle skin and underlying fat (myocutaneous flaps) either as a pedicled flap where the flap's blood supply is retained intact (eg pedicled latissimus dorsi flap, pedicled TRAM flap) or as a free flap where the blood vessels supplying a piece of tissue are divided and then re-attached to blood vessels in the proximity of the breast/chest defect (e.g. Free TRAM flap, DIEP flap). The combination of prosthesis with a patient's own tissue can also be considered.
Important issues to consider in breast reconstruction for any woman will be whether there is a need to reconstruct both breasts, what risks or complications are acceptable to obtain the best result, whether silicone implants are an acceptable alternative to using one's own tissues alone, the expected impact upon one's lifestyle and also the amount of scarring that a person is prepared to accept.
Many of these issues are best addressed at a consultation with reconstructive surgeon.
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| Trauma - Hands |
This encompasses a wide range of conditions from a simple skin wound requiring only dressings, to severe crush / amputations of limbs requiring complex microsurgery. Amputations need immediate treatment if replantation is to be successful. The amputated part should be washed thoroughly, then wrapped in moistened gauze, placed in a sealed plastic bag then the bag immersed in ice-water slurry. Cooling the amputated limb in this fashion prolongs its survival until it is able to be replanted and its circulation re-established. Time is of the essence if replantation is to be successful and every hour counts.
Less urgent cases are placed on next available operating lists. The most common types of injuries involve the fingertips. Surgery may or not be required for simple fingertip injuries. Simple skin or pulp loss up to one cm2 is often treated conservatively with dressings. More complex skin and pulp wounds may require local flaps or skin grafts, especially if bone is exposed. Often it is more sensible to slightly shorten a fingertip rather than embark on complex reconstructions, your surgeon will asses and advise you of the options. All cut tendons and nerves needs surgical repair as do most fractures, unless they are very stable.
Post operatively the injured limb should be kept elevated and rested, so as not to become swollen and painful. Instructions are given by the surgeon. Post operative rehabilitation is crucial to attaining an optimal outcome following hand surgery. This is very dependent on the patient's motivation and correct application of his mobilisation program. Complex injuries are post-operatively referred to a hand therapist to assist with rehabilitation.
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| Elective hand surgery |
| Ganglion |
This is the most common type of benign tumour affecting hand function. It is a myxomatous (gel-like) degeneration of joints (ligamentous capsule) and tendon sheath.
They initially present as painless lumps, usually on the back of the wrist and finger joints and occasionally on the front.
Eventually, ganglions interfere with hand movement and become painful with prolonged hand use.
The treatment is surgical excision. However, there is a significant recurrence rate after such treatment. To minimise this, the hand needs to be rested post operatively and normal use reintroduced gradually.
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| Carpal Tunnel Syndrome |
Compression of the median nerve that passes through the carpal tunnel at the wrist is known as carpal tunnel syndrome. Initially it manifests as nocturnal tingling and numbness of the thumb and fingers (usually excluding the little finger). Gradually this becomes more common, occuring at any time of the day, eventually becoming permanent. The result is ongoing numbness, discomfort and loss of dexterity.
The diagnosis is usually confirmed with nerve conduction studies. Treatment consists of releasing the constrictive tunnel by a small incision at the base of the palm. Outcomes are generally very successful, but if the condition is neglected, loss of feeling may remain permanently.
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| Tenosynovitis/trigger finger |
To ensure minimal friction with tendon movement, the tendons are bathed in a lubricant called synovial fluid. This is produced by a highly vascularized tissue which surrounds the tendons, called the synovium. It is also present around the joints and lubricates them. Synovium may become inflamed, resulting in increased friction with tendon gliding. This friction may eventually result in nodules developing on the tendon and thickening of the tendon sheath. These thickenings and nodules may suddenly "catch" during tendon movement and may only release with forced manipulation of the digit. This results in a sudden release or "triggering" effect of the finger.
There are many possible causes of this type of tenosynovitis, the most common being inflammatory conditions such as rheumatoid arthritis or prolonged repetitive movements as occur in some occupations. The underlying causes need to be addressed where possible, but once established, trigger finger needs surgical release. This is performed by a small incision in the palm of the hand.
Tenosynovitis may also affect the wrist tendons (e.g. DeQuervain's syndrome), resulting in painful movement of the wrist These conditions may respond to conservative management, (e.g. rest, splints, anti-inflammaory medication and injections of steroids) but if this fails, then surgical release is indicated for this condition as well.
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| Dupuytren's disease |
This is a fibromatosis (benign scar-like growths) of the hand's palmar fascia. It may also involve the soles of feet, and penis (rarely). It presents as thickened cords under the skin which may be tender and eventually pull the finger towards the palm, restricting normal extension. It usually presents in males after the third decade of life, but may occur in both genders and at earlier stages. People of northern European or Celtic extraction have a much higher risk of this as do those who have diabetes, certain types of liver diseases, take certain long-term medications or are involved in occupations which result in repeated percussions to the hands (such as the use of pneumatic impact drill).
Treatment involves surgical resection of the cord. Surgery needs to occur as soon as restricted finger extension has set in. Excessive delay may result in permanently bent fingers which cannot be fully straightened. Delay also makes the operation technically more difficult and increases the risk of injury to local nerves and vessels which may become encased in the infiltrative fibrous tissues.
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| Arthritis |
Rheumatoid arthritis is one of the most destructive of joint pathologies of the hand. It may also involve the tendons. This complex condition often needs long term rheumatologist management. Treatment is medical in the early stages, but when the condition becomes severe and advanced, then surgical correction may be recommended. There are a host of possible operations and your hand surgeon will be able to advise you. Osteo-arthritis is the most common type of arthritis of the hand and develops with age related wear and tear of the joint.
Treatment is usually conservative, but occasionally surgery may be performed, especially if there is advanced destruction of joints resulting in ongoing pain and significant loss of function. In such cases the joint may be replaced or fused. The choice of operation is tailored to the patient's needs.
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