Plastic Surgery Perspectives: Hand Surgery
“Plastic Surgery Perspectives” is a recurring series of posts on the PRS Resident Chronicles blog led by Stav Brown, MD, at the Sackler School of Medicine in Tel Aviv University, and Plastic and Reconstructive Surgery Research Fellow in the Department of Surgery at Memorial Sloan Kettering Cancer Center, New York. In this installment of the series featuring leaders in hand surgery, Dr. Brown interviews The PSF past President Michael Neumeister, MD. – Rod J. Rohrich, MD, Editor Emeritus, Plastic and Reconstructive Surgery
Interview by Stav Brown, MD
Research Fellow, Memorial Sloan Kettering Cancer Center
Sackler School of Medicine in Tel Aviv University
Michael Neumeister, MD
Chair and Professor, Department of Surgery
Chief, Division of Plastic Surgery
Hand Fellowship Program Director
SIU Medicine Institute for Plastic Surgery, Springfield, Ill.
PSR: Why did you choose plastic surgery – and hand surgery in particular?
Dr. Neumeister: I've always liked the musculoskeletal system including knees, hips, hands and shoulders. As I watched patients after total hand transfers and saw how functional they were with their new digits after that very intricate surgery, I knew that was what I wanted to be doing for the rest of my life. During residency, I always enjoyed complex reconstruction all over the body, which follows the same principles as the total hand transfers – restoring form and function. I pursued a fellowship in microsurgery and then one in hand surgery.
PSR: How has hand surgery changed since you started?
Dr. Neumeister: Two things that have become popular in recent years are wide-awake surgery and the use of epinephrine. Wide-awake surgery enables the patient to actively participate in rate of motion assessment in real time, which isn't possible under general anesthetic. This enables us to achieve much better results compared to performing the same procedure under general anesthetic.
PSR: Is there a particular clinical case that influenced you?
Dr. Neumeister: Hand fractures have changed the way I practice significantly since I started. Obtaining an anatomic reduction of the metacarpal and phalangeal fractures has always been wonderful. However, in many cases, patients end up having stiffness and complications because of surgery. These cases have made me question my goals operating on them – and in cases where they already have normal range of motion, which is what I believe to be the goal of the open reduction, I will not operate on them. I examine their range of motion carefully and make a decision despite the actual fracture pattern, which can look very bad in the X-ray. I wouldn't want to operate on a patient who I think could only go backward, developing stiffness as the result of the dissection and the open reduction. Therefore, I very rarely operate on fractures in the hand unless they are intra-articular, or if gross scissoring or malrotation are apparent. I get patients moving right away, I do not splint them (except for nighttime) with these fractures and they continue to move. Since we know that micromotion aids in the healing, it helps them get back faster rather than operating on them. This philosophy really modified the way I treat these, and this is how I now teach our residents, as well. The most important thing is defining your goals and seeing what needs to be done to achieve them – not everything needs to be operated upon.
PSR: What are your clinical and research interests?
Dr. Neumeister: I like the concept of pre-fabrication, which was taught to me by Julian Pribaz, MD. You bring in new blood supply to a tissue bed and this new blood supply sprouts vessels into that new bed, so you can transfer that tissue as a flap. As a result of this innovation, we have gone on to creating new flaps – such as in an area that does not have a pedicle, cartilaginous constructs such a trachea on a thigh that we move up as a tissue transfer, ear reconstruction – and even mandible reconstruction – by taking cadaveric mandibles, prefabricating them and moving them as a free-tissue transfer. I believe that all tissues can be pre-fabricated and although not a common procedure, it's one of those procedures that I find very intriguing – which creates a lot of enthusiasm in the operating theater.
PSR: What most excites you about the future of hand surgery?
Dr. Neumeister: More residents now are interested in hand surgery, and we see a lot more applications to the fellowships in hand surgery. It's rather exciting to know that the discipline is going to grow, especially since there are many novel innovations and new concepts that have to be looked at. The idea of nerve prosthetic interface, for example, is very intriguing and more work needs to be done to optimize that. Right now, we're looking at things like targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI), but down the road there may be new ideas that will come out that change that nerve wire interface. Rather than doing something like transferring nerves into muscles which supply these muscles, we're covering them with a muscle graft such as in RPNI. We have a faster, easier way with high fidelity to create prosthetics that are like the Luke Skywalker arm.
PSR: What do you look for in a hand surgery fellow?
Dr. Neumeister: First, we want to see an honest and deep desire to do hand surgery. Enthusiasm is key, since enthusiasm generates creativity and creativity generates innovation. Sheer enthusiasm works well for the patient. It changes how we do things for the better, and that creates more enthusiasm – which creates more creativity and more innovation. I'd like to see that they would like to improve the care that we're giving today, as well as present at national meetings so the world can see what changes they are trying to make. Second, hand surgeons have to be willing to wake up in the middle of the night to put fingers and toes back on – therefore, there needs to be a willingness to practice your craft when called upon, in order to restore the function of these amputated parts.