In recent years, plastic surgeons have made dramatic advances in treating patients with hand injuries, degenerative disorders, and birth defects of the hand.

At the American Society of Plastic Surgeons (ASPS) Plastic Surgery 2007 conference in Baltimore in October, Donald Lalonde, MD, ASPS member surgeon and course presenter, introduced an innovative hand-reconstruction technique called the “wide-awake” approach, which requires only local anesthesia. According to Lalonde, keeping the patient awake during this procedure allows the plastic surgeon to make necessary adjustments, which may reduce the need for revisions as well as complications from general anesthesia, expense, and recovery time.

” ‘Wide-awake’ hand surgery is a technique that involves only local anesthesia lidocaine and one in 100,000 epinephrine, so that there is minimal bleeding and a tourniquet is not used,” says Neil Jones, MD, plastic surgeon and professor and chief of hand surgery at the University of California Los Angeles Medical Center in Los Angeles.

With the “wide-awake” technique, no tourniquet is used, so patients can perform a full range of motion with their fingers. The surgeon can make any necessary adjustments on reconstructed tendons and bones during the procedure and before closing the skin.

Compared with traditional hand-surgery techniques, the “wide-awake” approach has been shown to reduce costs by 25% and reduce operating times without compromising patient safety. Since the procedure is performed under local anesthesia, patients can avoid common complications of general anesthesia such as nausea and vomiting.

“The ability [of a patient] to speak and move an appendage contradicts one’s mental image of surgery,” Lalonde says. “However, having the patient awake and coherent provides better outcomes, and they are amazed that the procedure is pain-free.”

Physical therapy is often painful for patients who have undergone hand surgery, which can easily discourage them and impede their progress. With the “wide-awake” approach, physical therapists show the patients movements that help with rehabilitation before surgery, so patients can see how much movement they will regain when they are pain-free.

According to Jones, common hand surgeries that may be performed with the “wide-awake” approach include carpal tunnel release, trigger finger release, fasciectomy for Dupuytren’s contracture, tendon repairs, and tenolysis.


Modern techniques in hand surgery have greatly improved the plastic surgeons’ ability to restore function and appearance. Often, the physician will employ nonsurgical techniques before resorting to surgical options. These may include physical therapy, modification of activity, anti-inflammatory medications, corticosteroid injections, and restricted mobility measures, like splinting. However, when these treatments are exhausted and the patient has not seen any benefits, hand surgery may be the only option.

Techniques used by plastic surgeons to repair injuries to the tendons, nerves, blood vessels, and joints; fractured bones; and burns and cuts, include the following:

  • Grafting—the transfer of skin, bone, nerves, or other tissue from a healthy part of the body to repair the injured part;
  • Flap surgery—moving the skin along with its underlying fat, blood vessels, and muscle from a healthy part of the body to the injured site; and,
  • Replantation or transplantation—restoring accidentally amputated fingers or hands using microsurgery, a delicate surgery performed under magnification. Some injuries may require several operations over an extended period of time.
See also “Rejuvenate Aging Hands” by Lucy Glancey, MD, in the June 2007 issue of PSP.


Because the hand is a very sensitive part of the body, patients may experience mild to severe pain following hand-reconstruction surgery. How long the hand must remain immobilized and how quickly patients resume their normal activities depend on the type and extent of the surgery. Physicians usually prescribe injections or oral medication to make patients feel more comfortable.

Physicians will often send patients to a trained hand therapist in order to enhance the recovery process and to let patients regain full function of their hand(s). Therapy may include hand exercises, heat and massage therapy, electrical nerve stimulation, splinting, traction, and special wrappings to control the swelling.