click to enlarge Hannah Manocchio
Another month, another medical wonder
Alicia, a retired nurse, didn’t think twice about the nibbling of her hand by the stray cat she often fed. But a Cleveland plastic surgeon, Dr. Bahar Bassiri Gharb, who just so happens to specialize in hand reconstruction as well, ultimately rebuilt Alicia’s hand and forearm with various parts of her body like the work of a master sculptor. This is the story of a Cleveland nurse’s helping hand that she almost lost.
Like many of us during the pandemic, Alicia befriended a new furry friend in the form of a stray cat. This cat, one of an estimated 70,000 stray cats in Cleveland, would often come to her backdoor, find warmth in her basement, and get a snack. One feeding went wrong and the cat nipped the top of Alicia’s hand. We’ll never know if this was a playful nibble or an aggressive one, but Alicia was not too concerned- it didn’t seem too deep. After four days without seeking any formal medical care, she realized the area of the bite was hot, painful and red. As with many infections, they can progress very quickly. So Alicia went directly to the emergency room.
Fast Track to Destruction
Oftentimes people have trouble knowing just how deep a bite is, since the shape of cat teeth can seed bacteria deep into tissue without much of a trace. The fear is that bacteria from the person’s skin or from the cat’s or dog’s mouth gains access to a part of the body that is like a freeway for the bacteria to spread quickly — the tendons. Tendons of the hand are bathed in synovial fluid, a substance that is more slippery than motor oil. When bacteria gets in to the sheath of the tendon, it constitutes a medical emergency known as acute bacterial tenosynovitis. The infection can ravage tendons and surrounding tissues very quickly which is why a hand surgeon is usually immediately consulted when a patient has this.
Dr. Bassiri answered the call from the ER. If one requires 10,000 hours to obtain proficiency in something, Dr. Bassiri’s 30,000 hours spent in the OR gave her a special mastery of surgery. Originally from Iran, Dr. Bassiri travelled the globe training at various institutions from Italy to Taiwan, along with face transplant research in Cleveland, where she decided to stay. That night, Alicia had the perfect person walk into her ER room.
When Dr. Bassiri entered the room she thought she recognized the patient. It clicked, of course she knew this patient! Dr. Bassiri had already operated on Alicia’s other wrist after a fall a few years ago. It was a relief for Alicia to see a familiar face while the fate of her dominate hand was uncertain. Together, they would monitor the hand closely for the next 24 hours to see if the ping pong ball sized abscess would improve or not with antibiotics.
The next day, it was clear that the IV antibiotics weren’t working. The arm was inflamed and the patient was losing the ability to move her fingers without lots of pain. To the OR, said Dr. Bassiri.
Puss poured out of the hand and arm with the first cut of the scalpel. The tendons on the top of the hand were destroyed and the damage extended into the forearm. The patient, as it stood, would lose all functions of these muscles on the top of her forearm, rendering the hand significantly handicap. Alicia had some other health problems too, including obesity and uncontrolled diabetes (which can compromise healing after surgery.) But if Alicia was willing, Dr. Bassiri’s unique skill set would allow them to try and reconstruct the hand.
Pineapple Hand
Plastic surgeons, after centuries of experimentation, refined a surgical technique called free tissue transfer. This involves harvesting a piece of tissue from one part of the body, dissecting out the blood supply (imagine a hunk of skin with two vessels hanging from it, one for incoming blood the other for blood return) and re-attaching this to a completely different part of the body. With training, and specialized telescope glasses, surgeons can sew the tips of vessels 3 mm or smaller, about the size of a fork prong tip, to a new blood supply.
For Alicia, the typical sites of the body that can be used for tissue flaps were not options which created a challenge for Dr. Bassiri. Alicia’s other arm, where skin could usually be borrowed, already bore a surgical scar and would have been too fragile to use. Next, the thigh is a good place to cut out tissue and transplant it, but because of her health issues and varicose veins this tissue could not easily be dissected and repaired in that location. The same went for her abdomen, another favorite spot from which to repurpose tissue. This left just one area where a large chunk of tissue and skin could be acquired- her back.
Back tissue is notoriously tough and thick, often 4x as thick as other skin on the body. After relocating this bulky tissue with a hefty layer of fat and muscle that came with it, Dr. Bassiri re-attached tiny vessels to establish a new blood supply. The back of Alicia’s hand now looked like a pineapple, said Dr. Bassiri. This was one of the reasons multiple surgeries were needed, having to go back three times to the OR just to remove in succession the muscle that wasn’t needed.
Having gotten the back tissue to take hold of the new blood supply and morph into skin more appropriate for the hand was only part of the puzzle. Because Alicia’s tendons were obliterated by the infection, new muscles and tendons needed to be placed under the new skin and attached to her fingers.
Some From Here, Some From There
Conceptually, a muscle is simple. The red meaty part contracts and pulls on whatever the pearly white tendon is attached to. But the length, strength, and nerve connection makes moving muscles to perform a function on a different part of the body an intricate process, not to be attempted at home. Alicia knew this would be a long road and remained immensely patient and optimistic. After at least five surgeries, she still didn’t have the ability to lift her hand or fingers. Finally, the hard work of reconstructing the muscles could begin.
Silicon ropes were implanted into the new tissue, creating tunnels for future tendons to find a home. The replacement muscles would have to fire when the brain signals to extend the hand. Luckily, the grand design of the hand, which you can observe in front of you, necessitates that when you drop your hand, the fingers extend slightly. If they didn’t, every time you flexed your wrist all of your fingers would stay in the same position and curl into your palm. So, why not use one of the muscles on the bottom of your forearm which fires when you flex your wrist and extend your fingers? Move that muscle to the top of the forearm and attach it to tendons connected to the fingers. The brain will figure out the rest, with the help of therapists.
Dr. Bassiri began the delicate process of moving this muscle (flexor carpi radials) to the top of the hand. Unfortunately, the tendon is not quite long enough to attach to the fingers. Dr. Bassiri would have to harvest more tissue- tendons from Alicia’s other wrist.
The patient and doctor together were determined for many months. They trusted each other, each to take ownership of their respective roles. Alicia helped nurse her hand after each surgery, and helped avoid any complications.
Now, Alicia is enjoying retirement with a functioning hand that no one would know is made of different parts of her body- her own mosaic masterpiece.
Dr. Corey Meador is a practicing family medicine physician in Cleveland who has written for PBS NewsHour and The Washington Post. He obtained degrees from Loyola Marymount University School of Film & Television in Los Angeles and Drexel University College of Medicine.