Recreating the impossible; Regenerating hopeApril 9, 2019
42-year-old Pulak Pal (name changed) was working in his hairpin manufacturing factory when he accidentally put his hands into a machine and the fingers of his right hand got crushed. Pulak’s right middle finger got a deep gash, the thumb was completely crushed and worst of all, the index finger got severed at the base. The injury was so severe that all nearby hospitals advised amputation of the fingers. However, Pulak’s family did not give up and eventually took him to Apollo Gleneagles Hospitals, Kolkata.
His case was forwarded to Dr. Srinjoy Saha, Consultant, Plastic, Aesthetic, Reconstructive & Burns Surgery. Dr. Saha methodically carried out the initial investigations to assess the extent of damage. He asked for all necessary investigations and a pre-anesthetic check to determine if Pulak could be taken up for early surgery. While the X-ray showed multiple fractures and crushed bones in the hand, advanced examinations of the fingers revealed poor blood circulation with about 80% of the tissue already dead or dying and only about 20% still healthy. Based on these findings, Dr. Saha discussed various treatment options available with the patient and his family during the initial consultation. He said Pulak could either amputate the fingers like the other doctors in previous hospitals had suggested, or he could try to save them using stem cells present inside abdominal fat. However, there would be no guarantee of saving the fingers and the process would be cumbersome for at least a 3-week period. Faced with a choice between a 3-week hardship or a lifetime of loss, Pulak and his family decided to save his fingers and give the new option of regenerative medicine a try.
Regenerative medicine is the science of replacing, engineering, or regenerating human cells, tissues, or organs to restore or establish normal form and function. It is an exciting new way of treatment, utilizing the body’s own cells to heal damaged tissues and form new ones. Stem cells have an enormous capacity to self-renew and differentiate into multiple cell types. Stems cells used to be harvested from foetal sources such as amniotic fluid or the umbilical cord. Today they can be harvested from adult tissues such as bone marrow and more recently, from adipose tissues or body fat. Adipose tissue-derived stem cells (ADSCs) are relatively easy to harvest by subcutaneous lipo-aspiration and can be induced to differentiate into different cell types as needed in the laboratory.
In this particular case involving massive bone and soft-tissue damage, however, lipo-aspirated cells would not work. More than just cells were required to regenerate the fingers, since the soft tissue of the fingers and its blood supply was also missing. Abdominal fat has been found to have a well-defined structure with a rich network of blood vessels, lymphatics, stem cells and macrophages, among others. Dr. Saha combined the principles of plastic surgery and regenerative medicine to try a novel technique using flaps made up entirely of abdominal fat. Such a flap would provide stem cells, along with the required blood supply and the necessary infection-resistance to the fractured and crushed finger bones. He made two incisions in the subcutaneous component of the abdomen, creating two tunnels through the abdominal fat in which he placed the thumb and the index finger. The patient was discharged a day after the surgery and spent time at home while his thumb and index finger regenerated within his abdomen. “Pulak was a very cooperative patient. Such placement is difficult to bear for a day, let alone for the 3 weeks that it took for complete regeneration”, remarked Dr. Saha. After 3 weeks, the fingers were separated from the abdomen. The fingers were covered with abdominal fatty tissue, which had developed new blood supply from the base of the fingers. Excess fat was trimmed away until a healthy layer of soft-tissue remained around the bones of the fingers, such that the thickness of the newly reconstructed fingers matched that of the other fingers. Dr. Saha covered these soft-tissues partially with abdominal skin taken as flaps. He performed one more surgery where he covered the remaining raw areas of the fingers with skin grafts harvested from the thigh. Reconstruction of the thumb and index finger was finally complete. During this entire period of treatment, Pulak was required to visit the hospital for a day only to perform his surgeries; and was on minimal medications including antibiotics and pain killers, that too for a limited time. Within 6 months from his injury, Pulak regained complete movement and control of all fingers of his working right hand, and easily performed all necessary hand and finger movements. Outside of work, Pulak is passionate about playing carrom. “I am even able to play and win carrom tournaments again, besides performing all my routine work,” exclaims an elated Pulak.
The regenerative procedure faced several stiff challenges. Finger bones were fractured, crushed and lost at places. Ensuring coverage and survival of the finger bones without bone death or new infection was an uphill task. Pulak’s crushed soft tissues had been found to be infected with multi-drug resistant Klebsiella during admission. Ensuring adequate control and limiting the read of infection was also a difficult challenge. Abdominal fat, with its inherent structure, vascularity, stem cell potential and infection-fighting capability, can do wonders. This case is a perfect example of how the “abdominal fat pad flap” improves vascularity, protects from infections, and allows for regeneration of lost tissue. Dr. Saha has now achieved successful regeneration of finger tissue in six patients. He credits his success to his patients, saying that “the patient is the real hero as he must be willing to spend 3 weeks with his fingers inserted in his abdomen, and then perform physiotherapy religiously to gain adequate hand function”. Dr. Saha is excited with the success of this technique and hopes that more and more plastic surgeons will get involved in successfully saving fingers instead of amputating them.