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  • About Dr. Kupfer...

    After finishing undergraduate education at University of California, San Diego graduating as Summa Cum Laude and receiving the state's Regent Scholar Award, Dr. Kupfer went to one of the nation's most prestigious medical school, University of California, San Francisco. He then spent an additional 11 years of medical and surgical training before entering practice in San Diego in 1991.

    The depth of his medical training allowed him to become triple board-certified in Plastic Surgery, Hand and Microsurgery, and in General Surgery.

    He is a Fellow member of The American College of Surgeons, The American Society of Plastic Surgeons, and multiple other medical Societies.

    Since entering practice more than 20 years ago, Dr. Kupfer has served as Chief of Plastic Surgery at Sharp Hospital San Diego, served as Medical Director to multiple outpatient ambulatory surgical centers in San Diego County and has authored & published numerous research articles. He has given multiple scientific presentations in both hand and microsurgery as well as cosmetic surgery.


    Read Dr. Kupfer's CV here...
  • Dr. Kupfer

    BIRTH DATE:
    December 10, 1957

    MARITAL STATUS:
    Married with three children.

    ASSOCIATIONS & SOCIETIES:
    American Society of Ambulatory Surgeons - 1996
    American Society for Peripheral Nerve - 1996
    California Society of Plastic Surgery - 1996
    California Society of Industrial Medicine & Surgery – 1995
    American College of Surgeons: Fellow - 1994
    The American Association for Surgery of the Hand - 1993
    American College of Surgeons: San Diego Chapter - 1991
    San Diego Society of Plastic &Reconstructive Surgeons - 1991
    California Medical Association - 1990
    American Society of Plastic & Reconstructive Surgeons - 1990
    American Medical Society - 1984
    California Ambulatory Surgery Association.
    Federal Ambulatory Surgery Association.

    CERTIFICATIONS:
    American Board of Plastic Surgery: Board Certified - November 1996
    Added Certificate of Surgery of the Hand: Board Certified - August 1993
    American Board of Surgery: Board Certified - March 1990

    VOLUNTEER ORGANIZATIONS:
    American Cancer Society - Physician Speaker Bureau
    Interplast - Hand & Reconstructive Plastic Surgeon
    Outreach Surgical Program - Mercy Hospital
    Health Plus 55 - Volunteer Speaker

    HOSPITAL AFFILIATIONS:
    UCSD Medical Center
    UCSD Thornton Hospital
    Scripps Memorial Hospital – La Jolla
    Sharp Memorial Hospital

    ACADEMIC APPOINTMENTS:
    Chief of Plastic Surgery Subsection - Sharp Memorial Hospital,
    Department of Plastic Surgery - 1998

    Assistant Clinical Voluntary Professor of Surgery - UCSD Medical Center,
    Department of Surgery

    Clinical Instructor - UCSD Medical Center,
    Department of Plastic & Reconstructive Surgery

    Clinical Instructor - UCSD Medical Center,
    Department of Orthopedic Surgery

    EDUCATION:
    1989 - 1991 Fellowship, Plastic & Reconstructive Surgery
    University of Utah Medical Center
    50 North Medical Drive
    Salt Lake City, UT 84132
    Graham Lister, M.D., Chairman

    1988 - 1989 Chief Resident, General Surgery
    University of California San Diego
    225 Dickinson Street
    San Diego, CA 92103
    A.R. Moossa, M.D., Chairman

    1984 - 1988 Residency, General Surgery
    University of CA at San Diego Medical Center
    225 Dickinson Street
    San Diego, CA 92103
    A.R. Moossa, M.D., Chairman

    1980 - 1984 Medical Degree
    University of CA at San Francisco
    513 Parnassus Street
    San Francisco, CA 94143
    Class Treasurer, 1981 - 1983

    1976 - 1980 Bachelor's of Science in Biology
    University of CA at San Diego
    Revelle College
    Gilman Drive at La Jolla Village Drive
    La Jolla, CA 92037
    Chancellor's Advisory Committee, 1978 - 1990
    Provost Advisory Committee, 1977 – 1979 Graduating GPA 3.92

    HONORS:
    Clinical Instructor of the Year Award - UCSD Department of Plastic Surgery, 1998
    Clinical Instructor of the Year Award - UCSD Department of Plastic Surgery, 1994
    Plastic Surgery Residents Conference Research Award, 1990
    Award for Excellence in Teaching - UCSD Medical Center, 1989
    Regents Scholar Award - UCSF Medical School, 1980
    Summa Cum Laude - UCSD, Revelle College, 1976 - 1980
    Provost Honor Society - UCSD, Revelle College, 1976 - 1980
    Worchester Foundation Research Fellowship Award, 1976
    Valedictorian Grossmont High School (GPA 4.0), 1974

    PUBLICATIONS:
    D.M. Kupfer, G.W. Lee, W. Shoemaker, L. Dellon and J. McSweeney. Simplified Approach to Wrist Denervation for Triangulofibrocartilage Complex Disruption. Journal of Reconstructive Microsurgery, Vol. 15 (8): 621, November 1999.

    D.M. Kupfer, J. Bronson, G.W. Lee, J. Gillett, J. Beck. Differential Latency Testing: A More Sensitive Test for Radial Tunnel Syndrome. Year Book of Orthopedics 1999 – Reference No. (4)OR 15.

    D.M. Kupfer, C.L. Eaton, S. Swanson, M.K. McCarter, G.W. Lee. Ring Avulsion Injuries: A Biomechanical Study. Journal of Hand Surgery, Vol. 24A No 6, November 1999, p1249-1253.

    G.W. Lee, D.R. Massry, D.M. Kupfer, R.A. Abrams. Documentation of Brachial Plexus Compression in the Thoracic Inlet with Quantitative Sensory Testing. Journal of Reconstructive Microsurgery – Manuscript No. 98-035.

    P.E. Chasan, D.M. Kupfer. Direct K-Wire Fixation Technique During Endoscopic Brow Lift. Aesthetic Plastic Surgery Journal, Vol. 22 No 5, p338-340, September/October 1998.

    D.M. Kupfer, J. Bronson, G.W. Lee, J. Gillett, J. Beck. Differential Latency Testing: A More Sensitive Test for Radial Tunnel Syndrome. Journal of Hand Surgery, Vol. 23A No 5, September 1998, p859-864.

    G.W. Lee, E.D. Collins, D.M. Kupfer, P.M. Weeks. Healing of Specialized Tissues. Manual of Acute Hand Injuries, Mosby Publishers, Philadelphia, PA, 1997, p1-33.

    D.M. Kupfer, J. Bronson, G.W. Lee, J. Gillett, J. Beck. Differential Latency Testing: A More Sensitive Test for Radial Tunnel (Abstract). Presented by D.M. Kupfer at the American Society for Peripheral Nerve Meeting, St. Louis, MO, May 31, 1996. Journal of Reconstructive Microsurgery, Vol. 13 No 2, February 1997, p136.

    J. Bronson, G.W. Lee, J. Gillett, J. Beck, D.M. Kupfer. Provocative Nerve Testing in Carpal Tunnel Syndrome (Abstract). Presented by G.W. Lee at the American Society for Peripheral Nerve Meeting, St. Louis, MO, May 31, 1996. Journal of Reconstructive Microsurgery, Vol. 13 No 2, February 1997, p139.

    D.M. Kupfer, G.D. Lister. The Pronator Quadratus Muscle Flap - Coverage of the Osteotomized Radius Following Elevation of the Radial Forearm Flap, Journal of Plastic & Reconstructive Surgery, Vol. 90 No 6, December 1992, p1093-1095.

    D.M. Kupfer, L.M. Chick. The Gluteus Maximus Superior Split Muscle Flap for Complex Lower Back Wounds. British Journal of Plastic Surgery, November 1992.

    D.M. Kupfer, D.L. Dingman, T.R. Broadbent. Juvenile Breast Hypertrophy - A Report of a Familial Pattern & Review of the Literature. Journal of Plastic & Reconstructive Surgery, Vol. 90 No 2, August 1992, p303-309.

    J.C. Fisher, D.M. Kupfer. Indications for "Prophylactic" Mastectomy. Problems in General Surgery, A.R. Moossa, editor, Vol. 6 No 1, 1989, p143.


    SCIENTIFIC PRESENTATIONS:
    A Simplified Approach for Wrist Denervation for TFCC Disruption. D.M. Kupfer, G.W. Lee, W. Shoemaker, L. Dellon. Presented by D.M. Kupfer at the American Society for Peripheral Nerve Annual Meeting. Los Angeles, California. June 20, 1999.

    A Simplified Approach for Pull Out Suture Technique in the Hand. D.M. Kupfer, R. Bodor, G.W. Lee. Presented by R. Bodor at the California Society of Plastic Surgery Meeting. 1999.

    A Simplified Approach for Wrist Denervation for TFCC Disruption. D.M. Kupfer, G.W. Lee, W. Shoemaker, L. Dellon. Presented by D.M. Kupfer at the American Association for Hand Surgery Meeting. Kamuela, Hawaii. January 14, 1999.

    Documentation of Brachial Plexus Compression in the Thoracic Inlet with Quantitative Sensory Testing. G.W. Lee, D.R. Massry, D.M. Kupfer, R. Abrams. Presented by G.W. Lee at the American Society for Peripheral Nerve Meeting. Vancouver, BC. May 23, 1998.

    Differential Latency Testing: A More Sensitive Test for Radial Tunnel. D.M. Kupfer, J. Bronson, G.W. Lee, J. Gillett, J. Beck. Presented by D.M. Kupfer at the American Society for Peripheral Nerve Meeting. St. Louis, Missouri. May 31, 1996.

    Provocative Nerve Testing in Carpal Tunnel Syndrome. J. Bronson, G.W. Lee, J. Gillett, J. Beck, D.M. Kupfer. Presented by G.W. Lee at the American Society for Peripheral Nerve Meeting. St. Louis, Missouri. May 31, 1996.

    Cumulative Trauma Disorder in the Upper Extremity. American Academy of Disability Evaluating Physicians. San Diego, California. January 23, 1993.

    Biomechanics & Prevention of Ring Avulsion Injury. American Society for Surgery of the Hand. Phoenix, Arizona. November 11 - 14, 1992.

    The Deep Plane Rhytidectomy - A Safe Approach. Video presentation. D.M. Kupfer, D.L. Dingman. American Society of Aesthetic Plastic Surgery. Los Angeles, California. May 2-5, 1992.

    Transcoronal Blepharoplasty. The American Society of Aesthetic Plastic Surgery. Poster presentation. New York, New York. May 1991.

    The Cutaneous Radial Forearm Flap - Reducing Donor Site Morbidity. Residents Conference -American Society of Plastic & Reconstructive Surgery. Madison, Wisconsin. May 1991.

    Sandostatin - Its Use in Pancreatic Fistulas. American College of Surgeons Conference. Palm Springs, California. February 1989.

    The 8S Estrogen Receptor by Glucose Density Gradient in Breast Carcinoma. Worcester Foundation for Experimental Biology. Worcester, Massachusetts. August 1974.

  • Scientific Publications

    D.M. Kupfer, G.W. Lee, W. Shoemaker, L. Dellon and J. McSweeney.
    Simplified Approach to Wrist Denervation for Triangulofibrocartilage Complex Disruption. Journal of Reconstructive Microsurgery, Vol. 15 (8): 621, November 1999.

    D.M. Kupfer, J. Bronson, G.W. Lee, J. Gillett, J. Beck.
    Differential Latency Testing: A More Sensitive Test for Radial Tunnel Syndrome. Year Book of Orthopedics 1999 – Reference No. (4)OR 15.

    D.M. Kupfer, C.L. Eaton, S. Swanson, M.K. McCarter, G.W. Lee.
    Ring Avulsion Injuries: A Biomechanical Study. Journal of Hand Surgery, Vol. 24A No 6, November 1999, p1249-1253.

    G.W. Lee, D.R. Massry, D.M. Kupfer, R.A. Abrams.
    Documentation of Brachial Plexus Compression in the Thoracic Inlet with Quantitative Sensory Testing. Journal of Reconstructive Microsurgery – Manuscript No. 98-035.

    P.E. Chasan, D.M. Kupfer.
    Direct K-Wire Fixation Technique During Endoscopic Brow Lift. Aesthetic Plastic Surgery Journal, Vol. 22 No 5, p338-340, September/October 1998.

    D.M. Kupfer, J. Bronson, G.W. Lee, J. Gillett, J. Beck.
    Differential Latency Testing: A More Sensitive Test for Radial Tunnel Syndrome. Journal of Hand Surgery, Vol. 23A No 5, September 1998, p859-864.

    G.W. Lee, E.D. Collins, D.M. Kupfer, P.M. Weeks.
    Healing of Specialized Tissues. Manual of Acute Hand Injuries, Mosby Publishers, Philadelphia, PA, 1997, p1-33.

    D.M. Kupfer, J. Bronson, G.W. Lee, J. Gillett, J. Beck.
    Differential Latency Testing: A More Sensitive Test for Radial Tunnel (Abstract). Presented by D.M. Kupfer at the American Society for Peripheral Nerve Meeting, St. Louis, MO, May 31, 1996. Journal of Reconstructive Microsurgery, Vol. 13 No 2, February 1997, p136.

    J. Bronson, G.W. Lee, J. Gillett, J. Beck, D.M. Kupfer.
    Provocative Nerve Testing in Carpal Tunnel Syndrome (Abstract). Presented by G.W. Lee at the American Society for Peripheral Nerve Meeting, St. Louis, MO, May 31, 1996. Journal of Reconstructive Microsurgery, Vol. 13 No 2, February 1997, p139.

    D.M. Kupfer, G.D. Lister.
    The Pronator Quadratus Muscle Flap - Coverage of the Osteotomized Radius Following Elevation of the Radial Forearm Flap, Journal of Plastic & Reconstructive Surgery, Vol. 90 No 6, December 1992, p1093-1095.

    D.M. Kupfer, L.M. Chick.
    The Gluteus Maximus Superior Split Muscle Flap for Complex Lower Back Wounds. British Journal of Plastic Surgery, November 1992.

    D.M. Kupfer, D.L. Dingman, T.R.
    Broadbent. Juvenile Breast Hypertrophy - A Report of a Familial Pattern & Review of the Literature. Journal of Plastic & Reconstructive Surgery, Vol. 90 No 2, August 1992, p303-309.

    J.C. Fisher, D.M. Kupfer.
    Indications for "Prophylactic" Mastectomy. Problems in General Surgery, A.R. Moossa, editor, Vol. 6 No 1, 1989, p143.


    SCIENTIFIC PRESENTATIONS:

    A Simplified Approach for Wrist Denervation for TFCC Disruption.
    D.M. Kupfer, G.W. Lee, W. Shoemaker, L. Dellon.
    Presented by D.M. Kupfer at the American Society for Peripheral Nerve Annual Meeting.
    Los Angeles, California. June 20, 1999.

    A Simplified Approach for Pull Out Suture Technique in the Hand.
    D.M. Kupfer, R. Bodor, G.W. Lee.
    Presented by R. Bodor at the California Society of Plastic Surgery Meeting. 1999.

    A Simplified Approach for Wrist Denervation for TFCC Disruption.
    D.M. Kupfer, G.W. Lee, W. Shoemaker, L. Dellon.
    Presented by D.M. Kupfer at the American Association for Hand Surgery Meeting.
    Kamuela, Hawaii. January 14, 1999.

    Documentation of Brachial Plexus Compression in the Thoracic Inlet with Quantitative Sensory Testing.
    G.W. Lee, D.R. Massry, D.M. Kupfer, R. Abrams.
    Presented by G.W. Lee at the American Society for Peripheral Nerve Meeting.
    Vancouver, BC. May 23, 1998.

    Differential Latency Testing: A More Sensitive Test for Radial Tunnel.
    D.M. Kupfer, J. Bronson, G.W. Lee, J. Gillett, J. Beck.
    Presented by D.M. Kupfer at the American Society for Peripheral Nerve Meeting.
    St. Louis, Missouri. May 31, 1996.

    Provocative Nerve Testing in Carpal Tunnel Syndrome.
    J. Bronson, G.W. Lee, J. Gillett, J. Beck, D.M. Kupfer.
    Presented by G.W. Lee at the American Society for Peripheral Nerve Meeting.
    St. Louis, Missouri. May 31, 1996.

    Cumulative Trauma Disorder in the Upper Extremity.
    American Academy of Disability Evaluating Physicians.
    San Diego, California. January 23, 1993.

    Biomechanics & Prevention of Ring Avulsion Injury.
    American Society for Surgery of the Hand.
    Phoenix, Arizona. November 11 - 14, 1992.

    The Deep Plane Rhytidectomy - A Safe Approach.
    D.M. Kupfer, D.L. Dingman. American Society of Aesthetic Plastic Surgery.
    Los Angeles, California. May 2-5, 1992.

    Transcoronal Blepharoplasty.
    The American Society of Aesthetic Plastic Surgery. Poster presentation.
    New York, New York. May 1991.

    The Cutaneous Radial Forearm Flap - Reducing Donor Site Morbidity.
    Residents Conference - American Society of Plastic & Reconstructive Surgery.
    Madison, Wisconsin. May 1991.

    Sandostatin - Its Use in Pancreatic Fistulas.
    American College of Surgeons Conference.
    Palm Springs, California. February 1989.

    The 8S Estrogen Receptor by Glucose Density Gradient in Breast Carcinoma.
    Worcester Foundation for Experimental Biology.
    Worcester, Massachusetts. August 1974.

  • Patient Testimonials

    "Thank you all so much for the wonderful experience that I had during my surgery process. You were all so helpful in making decisions, informative, and caring with me during this process. I can't tell you how much I appreciate you making this such a pleasant experience."-Sara A

    "Dr. Kupfer, no words can truly explain the way I feel after my surgery. You did an amazing job. I am extremely happy with the results. I no longer "have to" wear the long and oversized shirts. I am wearing clothes that I never would have dared wear before. All together, I know that this has made me a better person not only physically but emotionally. I am eating healthier and have become more active. This is the best thing I have done for myself. You have been blessed with amazing hands. Thank you for being so kind."-Monica L

    "Thank you so much for your great care, and genuine concern for me. You are a wonderful doctor, and I really think you are a wonderful man. From my knees to my buttocks, I can�t thank you enough for removing all and more than you thought. I will diligently work-out so that they take great shape.� -Amanda S

    "Thank you so much for everything. I am very pleased with my results! You and your staff were wonderful.�-Lisa P

    "Where to start? Wow thank you so much! It has only been two weeks since my surgery and I�m so happy I can�t even think of what it will be like in a few more months. For the first time in my life, in my mind I�m beautiful and I wanted to thank you! You took care of me twice and there are no words to tell you how much your skill and caring meant to me and my husband, we trust you completely! Thank you again.�-Wendy H

    "It was so nice to see you again! Thank you so very much for the cosmetic consult and for giving me your honest opinion. After much thought and seeing my sisters results with all the work you performed on her, I have considered having my surgery as well. I will be sending in my payments to Katrina shortly and look forward to booking my surgery day.�-Sonia G

    "No words can express how much I appreciate what you have done for me. I love my new body. I just can�t believe how much I have changed. Thanks for being there when I needed you."-Anna F

    "Just a little note to say thank you for your patience, kindness & availability during and after my surgery. With your support things went smoothly!"-Lydia B

    "Thank you so much for your gentleness in helping my daughter through her recent surgery. I know it made a big difference to her knowing how easily she could access you. Your TLC was greatly appreciated."-Carol O

    "I have waited 2 � months to say this because I wanted full results. Once again, I want to tell you what a fantastic surgeon you truly are. My niece and I both received great results from our procedures. Your expertise is so appreciated and knowing what �Enough� is! A lot of doctors would do more than they should with problem results. I�m so thankful you take control. Because of that, I have reached more than expected, and look forward to our next adventure of surgery together."-Joni B

  • Breast, Body, Face

    "I am dedicated to providing the utmost in surgical expertise, care, and safety to all my patients. And to helping them gain confidence and appreciate their existing beauty within"

    Procedures We Offer:

    The following are some of the procedures commonly performed by Dr. Kupfer. Click on a link below to learn more:

  • Tummy Tuck - Abdominoplasty

    Tummy tuck, or abdominoplasty, is a common term for the surgical procedure to correct a protruding or loose, sagging abdomen. Areas to be treated may include the center of the abdomen or may extend to the entire area between the lower rib cage and pubic bone, as well as to the sides and back.

    Abdominal contouring can be performed using a variety of techniques. When localized fat is the cause, abdominal contour surgery may be performed using only liposuction techniques. When excess fat is combined with loose, sagging skin and tissue, a tummy tuck removes unwanted fat, tissues and skin by excision. Abdominal muscles that have weakened or separated, a condition called diastasis, can also be corrected with a tummy tuck.

    A tummy tuck is not a substitute for weight loss or an appropriate exercise program. Although the results of a tummy tuck are technically permanent, the positive outcome can be greatly diminished by significant fluctuations in weight. For this reason, individuals who are planning substantial weight loss or women who may be considering future pregnancies are advised to postpone a tummy tuck.

    Tummy tuck is best performed on adults of any age who are in good health, are close to the ideal weight for their body type and size, are moderately fit and, overall, have good muscle tone.

    In addition, previous abdominal surgery may limit the potential results of a tummy tuck. In women who have undergone cesarean section, the existing scars are usually incorporated or revised for new incisions.

    A full tummy tuck requires a horizontal incision in the area between the pubic hairline and needle. The shape and length of the incision will be determined by the degree of correction necessary. Through this incision, weakened abdominal muscles are repaired and excess fat, tissue and skin is removed.

    • tummttuck1tummttuck1

    Incision lengths are largely determined by the amount of excess skin to be removed. When the correction is isolated to the area below the naval, a limited or mini tummy with a shorter incision at the pubic bone is possible. Liposuction may be performed with a mini tummy; When excess fat is the only factor, liposuction alone may achieve the desired result.

    • tummytuck2tummytuck2

    A tummy results immediately in a flatter firmer abdominal contour that is more proportionate with your body type. The final result may be initially obscured by swelling and your ability to stand fully upright until internal healing is complete. Within a week or two, you should be standing tall and confident about your slimmer profile.

    • tummytuck3tummytuck3
  • Blepharoplasty

    Cosmetic eyelid surgery, technically called blepharoplasty, is a surgical procedure to improve the appearance of the upper eyelids, lower eyelids, or both. Specifically, eyelid surgery can treat:

    These conditions typically appear as part of the natural aging process, or due to heredity. Where they are the result of heredity, individuals in their 20s and 30s may achieve a marked improvement in the appearance of their eyes through eyelid surgery. Eyelid surgery removes excess skin, eliminates bags and restores firmness to the area surrounding the eye, making you look more rested and alert. However, it won't remove crow's feet or other wrinkles, eliminate dark circles under your eyes, or lift sagging eyebrows.

    An incision within the natural creases of the upper and lower lids allows repositioning of the fat deposits, tightening of muscles and tissue, and removal of excess skin to create a firmer eyelid contour.

    Conditions of the lower eyelid can also be corrected using a trans-conjunctival incision, one hidden within the lower eyelid. The incision lines from eyelid surgery are well concealed within the natural structures of the eyelid region. Results appear gradually as swelling and bruising subside to reveal a smooth, better define eyelid, and surrounding region.

  • Botox®- Facial Fillers

    The cosmetic form of botulinum toxin, often referred to by its product name BOTOX® Cosmetic, is a popular non-surgical injection that temporarily reduces or eliminates frown lines, forehead creases, crows feet near the eyes and thick bands in the neck. The toxin blocks the nerve impulses, temporarily paralyzing the muscles that cause wrinkles while giving the skin a smoother, more refreshed appearance. Studies have also suggested that BOTOX® Cosmetic is effective in relieving migraine headaches, excessive sweating and muscle spasms in the neck and eyes.

    Restylane® Injections

    Restylane® has been used in more than 1.5 million treatments in over 60 countries and is now approved in the U.S. for the treatment of facial wrinkles and folds. Restylane® is a safe and natural cosmetic dermal filler that restores volume and fullness to the skin to correct facial wrinkles and folds, such as nasolabial folds.

    Restylane® is injected directly into the skin in tiny amounts by an ultrafine needle, resulting in minimal discomfort. The procedure is simple and convenient and results are practically instantaneous. To optimize your comfort during the short procedure, your physician may decide to numb the treatment area.

  • Breast Augmentation

    Breast augmentation, technically known as augmentation mammoplasty, is a surgical procedure to enhance the size and shape of a woman's breast. By inserting an implant behind each breast, Dr. Kupfer is able to increase a woman's bustline by one or more bra cup sizes. For many women, the result of breast augmentation can be satisfying, even exhilarating, as they learn to appreciate their fuller appearance.

    Dr. Kupfer performs breast augmentation using implants made of medical grade, biocompatible, textured or smooth silicone shells filled with sterile saline solution or silicone gel. Implant placement, type and size will be determined based on your breast anatomy, body type and desired increase in size, as well as Dr. Kupfer's judgment. Implant manufacturers occasionally introduce new styles and types of implants; there may be additional options available to you.

    Breast implants have not been shown to impair breast health. Careful review of scientific research by independent groups such as the National Academy of Sciences Institute of Medicine (TOM) has found no proven link between breast implants and auto-immune or other systemic diseases in women. Implants can, however, create subtle or more noticeable changes in the look and feel of your breasts. Capsular contracture, a condition that causes the naturally-forming scar tissue around a breast implant to contract, occurs in a variable percentage of patients and can make the breast feel firmer than normal. While this condition can be addressed surgically, correction is not always permanent.

    You should be aware that breast implants are not guaranteed to last a lifetime and future surgery may be required to replace one or both implants. Pregnancy, weight loss and menopause may influence the appearance of augmented breasts over the course of a woman's lifetime.

    A mammogram may be recommended prior to your procedure to ensure breast health and serve as a baseline for future comparison. Following the procedure, mammography is technically more difficult. Obtaining the best possible results requires specialized techniques and additional views. You must be candid about your implants when undergoing any diagnostic breast exam.

    The best candidates for breast augmentation are women who are looking for improvement, not perfection, in the way they look. If you're physically healthy and realistic in your expectations, you may be a good candidate.

    Breast augmentation requires surgical placement of breast implants to enhance breast size. The most common incisions include an inframammary incision (near the crease under the breast), an axillary incision (in the under arm area ), or in the peri-or areolar incision placed at the end of the areola (the pigmented skin surrounding the nipple). Incision patterns very based on the type of implant, degree of doublement desired, patient's anatomy, and patient preference.

    Through the incision, a pocket is created directly behind the breast tissue (sub-mammary or sub- glandular placement) or beneath the muscle (sub-muscular). The implant is positioned within this pocket and incisions were closed with layered, sutures in the breast tissue and sutures with surgical tape to close the skin.

    The results of breast augmentation are immediately visible. However, overtime, postsurgical swelling will resolve and incisions lines we will refine. The final shape of your breasts is typically not achieved for approximately 3 months.

  • Breast Lift - Mastopexy

    Breast lift, technically called mastopexy, is surgery to uplift and improve the shape of a female breast that:

    A breast lift is appropriate for women who wish to improve breast shape and position. When an increase in breast volume is also desired, breast implants may be inserted in conjunction with a breast lift.

    While a breast lift does not generally affect breast function, women who are planning future pregnancies should discuss this with Dr. Kupfer. The changes that occur in the breasts during pregnancy can minimize or reverse the improvement 'a breast lift provides. Likewise, plans for significant weight loss should also be discussed. For these reasons, good candidates for a breast lift are generally women with stable weight whose breasts are fully developed and who have completed their family. Breast lift is appropriate in younger women as well, most commonly in cases of breast asymmetry where the position of one breast is lower than the other or where a significant discrepency in size exists.

    Incision patterns for a breast lift are determined based on the amount of excess skin, skin elasticity and the degree of lift necessary to achieve realistic goals. The incisions may include a circle around the areola, a line extending down the lower portion of the breast from the areola to the crease underneath, and possibly along the crease under the breast (infra-mammary fold).

    Not every woman will require all of these incisions. It is possible to perform a lift through an incision around the areola only, or through a combination of incisions around the areola and a vertical incision down the lower portion of the breast. The incision combinations depends on the amount of skin excess to be removed and the quality of the skin.

    Only the excess skin is removed, the breast tissue is reshaped and lifted, and the remaining skin tightened as the incisions are closed. Some incisions lines resulting from the breast with are concealed in the natural breast contour; however, others are visible on the breast surface. Incisions lines are permanent, but in most cases will fade and significantly improved in appearance over time.

  • Breast Reduction - Reduction Mammaplasty

    Breast reduction is a surgical procedure to reduce the size of large pendulous breasts that are disproportionate to a woman's body and can cause physical pain. Technically called reduction mammaplasty, breast reduction improves breast size, shape and the associated conditions of large breasts that include:

    Breast reduction can be performed unilaterally (on one breast) or bilaterally (on both breasts). It is generally considered a reconstructive procedure and may be covered by health insurance when it is performed to relieve medical symptoms. Many insurers define breast reduction surgery as reconstructive based on the amount of tissue that will be removed. However, pre-certification is often required for reimbursement or coverage.

    Breast reduction surgery can be performed at any age; however it is best performed when the breasts are fully developed. Because significant amounts of breast tissue are removed, breast reduction surgery may impair the ability to breast feed. Changes in the breasts during pregnancy can alter the outcomes of previous breast reduction surgery, as can significant weight fluctuations.

    Breast reduction reduces the size and improves the shape and position of overly large, pendulous breasts through the surgical removal of excess breast fat, tissue and skin. It may also reposition the areolas(pigmented skin surrounding the nipples), and reduced the size of a large areolas that may result from stretching of the skin over time.

    Breast reduction sometimes is performed by removal of excess fat using liposuction techniques; by surgical removal of the excess glandular tissue, fat and skin; or by a combination of these techniques. One of the common surgical techniques uses an incision pattern that begins around the areola, continues vertically down the breast, and then horizontally along the crease underneath the breast.

    Following placement of the incisions, the nipple is repositioned and the areola reduced, if necessary. The underlying breast tissue is reduced, lifted and shaped. Most incision lines are concealed in the natural breast contour; however, some are visible on the breast surface. Although permanent, incision lines are scars that usually fade and improve in appearance over time.

  • Browlift

    A brow lift is a plastic surgery procedure to improve the appearance of the facial region between the upper eyelids and the scalp, extending to the temples. The procedure improves low placement or sagging of the brows, and minimizes the appearance of lines and creases in the forehead. These conditions may be due to heredity or can be attributed to the natural aging process. In some people, repeated facial expressions that are created by contraction of underlying muscles result in visible creases and deep furrows. A brow lift can:

    Brow lift surgery can be performed through multiple limited incisions hidden within the hairline or through a single incision in the natural crease of each upper eyelid. Results of a brow lift may be enhanced through a chemical peel that can further improve skin tone and surface appearance. When there is significant excess skin in the forehead, an alternate technique using a wide incision across the top of the scalp may be recommended.

    A brow lift can be performed alone or in conjunction with other rejuvenation procedures such as eyelid surgery or a facelift. The procedure is best suited for adult men and women whose facial tissue and muscles are in good condition and who have realistic goals for rejuvenation of the upper face.

      A browlift often can be performed using an endoscope (surgical video device) and surgical instrumentation placed through small incisions made within the hairline. This allows the tissue and muscle beneath the skin to be repositioned, altered or removed, correcting the source of visible creases and furrows in the forehead.

    • Correction of a low-position or sagging brow may be made with or without the use of an endoscope through incisions at the temples and in the scalp. This technique may be done in conjunction with incisions hidden within the natural creases of the upper eyelids to correct frown lines between the brows, on or above the bridge of the nose.

    • The incision lines from a brow lift are well concealed within the hair or natural contours of the face. Results appear gradually when swelling and bruising subside to reveal smoother forehead skin and a more youthful, restful appearance.

  • Chemical Peel

    A chemical peel uses a chemical solution to improve and smooth the texture of the facial skin by removing its damaged outer layers. It is helpful for those individuals with facial blemishes, wrinkles and uneven skin pigmentation. Trichloroacetic acid (TCA) and alphahydroxy acids (AHAs) are used for this purpose. The precise formula used may be adjusted to meet each patient's needs.

    Although a chemical peel may be performed in conjunction with a facelift, it is not a substitute for such surgery, nor will it prevent or slow the aging process

    Dermabrasion

    Dermabrasion and dermaplaning help to "refinish" the skin's top layers through a method of controlled surgical scraping. The treatments soften the sharp edges of surface irregularities, giving the skin a smoother appearance.

    Dermabrasion is most often used to improve the look of facial skin left scarred by accidents or previous surgery, or to smooth out fine facial wrinkles, such as those around the mouth. It's also sometimes used to remove the pre-cancerous growths called keratoses. Dermaplaning is commonly used to treat deep acne scars.

    Both dermabrasion and dermaplaning can be performed on small areas of skin or on the entire face. They can be used alone, or in conjunction with other procedures such as facelift, scar removal or revision, or chemical peel.

    The best candidates for breast augmentation are women who are looking for improvement, not perfection, in the way they look. If you're physically healthy and realistic in your expectations, you may be a good candidate.

  • Facelift - Rhytidectomy

    A facelift, technically known as rhytidectomy, is a surgical procedure to improve visible signs of aging in the face and neck.

    Sagging in the midface can create a deep crease below the lower eyelid (called a tear trough) and between the nose and mouth (nasolabial fold) that may make you appear tired and sad. Fat that has fallen or is displaced and loss of muscle tone in the lower face may create jowls (a jaw line that sags into the neck). Loose skin and excess fatty deposits under the chin and jaw can make even a person of normal weight appear to have a "double chin."

    A facelift is designed to correct all of these aging features, restoring a more youthful, rested appearance with uplifted contours and improved tone in facial skin and underlying muscle. Where desired improvement can be isolated to the midfacial region and where excess skin is less a factor, a limited incision lift may be an alternative to a traditional facelift.

    As a restorative surgery, a facelift does not change your fundamental appearance and cannot stop the aging process. Although you will continue to age naturally, aging will progress from the more youthful version of yourself that has been restored by a facelift. Rejuvenation procedures typically performed in conjunction with a facelift are brow lift, to correct a sagging or deeply furrowed brow, and eyelid surgery to rejuvenate aging eyes. Fat injections are often added to restore youthful contours especially in the checks and under the eyes.

    A facelift is best performed on adult men and women who feel that their outward facial aging no longer reflects the youth and vigor they feel physically and emotionally. Good candidates are:

    Facelift incisions often begin in the hairline at the temples, continue around the ear and end in the lower scalp. Fat may be sculpted or redistributed from the face, jowls and neck, and underlying tissue is repositioned. Skin is redraped over the uplifted contours and excess skin is trimmed away. A second incision under the chin may be necessary to further improve an aging neck.

    An alternative to a traditional facelift uses shorter incisions at the temples, within the lower eyelids or under the upper lip. An endoscope, or surgical telescope, may help to reposition tissues and elevate midfacial muscles. Skin resurfacing techniques may be performed in conjunction with the surgery or as a separate procedure to improve skin tone and texture. Fat transplantation is often added to maximize youthful contours of the face.

    Once healed, the incision lines from a facelift are well concealed within the hairline and in the natural contours of the face and ear. The visible improvements of a facelift appear as swelling and bruising subside. Your final result should not only restore a more youthful and rested appearance, but also help you feel more confident about yourself. The critical outcome following this procedure is the result that looks entirely natural with absolutely no stigmata of surgery.

    Mimi- facelift/ Liposuction of the Neck

    Some patient may be candidates for less surgery to restore a youthful appearance of the face and neck. These patients are typically younger with less established facial aging changes. These patients often benefit from a mimi- face lift often coupled with liposuction of the neck.

  • Facial Implants (chin / cheek)

    Dr. Kupfer uses facial implants to improve and enhance facial contours. Frequently, these implants will help provide a more harmonious balance to your face and features so that you feel better about the way you look.

    There are many implants available, manufactured from a variety of materials. They may help strengthen a jawline or bring the chin or cheekbones into balance with the rest of the face.

  • Lip Augmentation

    Lip augmentation creates fuller, plumper lips and reduces fine wrinkles around the mouth. Lips may be injected with a filler material such as Juvederm, Artifill, or silicone oil. A conservative approach is used by Dr. Kupfer to avoid over-augmentation. Although a single injection is sufficient in most patients, it may take two to three injections to achieve your final result.

  • Liposuction

    Liposuction, also called lipoplasty or suction lipectomy, is the surgical removal of localized or regional excess fatty tissue. There are three common variations to the procedure:

    • The tumescent or super-wet technique that requires an infusion of saline solution, with added adrenaline and possibly anesthetic prior to removal of excess fat.
    • Ultrasound-assisted lipoplasty or UAL, where ultrasonic energy is used to liquefy excess fat prior to surgical suctioning

    These techniques may be used to reduce localized fat deposits of the:

    • Cheeks, chin and neck
    • Hips and buttocks
    • Upper arms
    • Thighs
    • Breast or chest area
    • Inner knee
    • Back
    • Calves and ankles
    • Abdomen and waist

    In some cases, liposuction is performed alone, in other cases it is used with plastic surgery procedures such as a facelift, male or female breast reduction, or a tummy tuck. Liposuction is not a treatment for obesity or a substitute for proper diet and exercise. It is also not an effective treatment for cellulite, the dimpled skin that typically appears on the thighs, hips and buttocks.

    Liposuction can, however, permanently reshape body contours where excess fat deposits create areas that are disproportionately large in an otherwise balanced figure. Ideal candidates for liposuction are adults of any age within 30% of their ideal weight and with firm, elastic skin and good muscle tone.

    Characteristics that can be addressed with liposuction include a double chin, fatty upper arms, doubled male or female breasts, love handles and excess fat in the abdomen. In addition, liposuction can recontour the lower body: hips, thighs, knees, calves, and ankles, creating a slimmer and better-proportioned figure.

    Liposuction is performed through small, inconspicuous incisions that are hidden within normal creases and contours of the body. A thin hollow tube, or cannula, is inserted through the incisions to loosen excess fat using a controlled back and forth motion. The dislodged fact is then suctioned out of the body using a surgical vacuum or syringe attached to the cannula.

    Your improved body contour will be apparent once the swelling and fluid retention routinely experienced following liposuction has subsided. With continued practice of healthy diet and fitness, loss of excess fatty tissue should be permanently maintained. However, substantial weight gain can alter an otherwise permanent result.

  • Rhinoplasty

    Cosmetic surgery of the nose, or rhinoplasty, is a procedure to improve the appearance of the nose. Specific features addressed in cosmetic surgery of the nose include:

    These features are generally caused by heredity; however, they can be caused by injury. In some cosmetic cases, the characteristics of the nose are not the only factors contributing to facial imbalance. The facial structure - especially a small chin, weak cheeks and/or lower jaw - may also contribute to imbalanced facial proportions. In these cases, surgery of the nose may be performed in conjunction with placement of facial implants or other procedures to achieve overall facial harmony.

    When nose surgery is performed to improve breathing function, the cause is most commonly an obstructed airway. This procedure, whether performed alone or in conjunction with cosmetic surgery of the nose, is considered reconstructive and may be covered by insurance. This requires a detailed examination to verify the cause of your breathing impairment and prior authorization from your insurance company.

    Whether you have a personal desire to improve your appearance or you seek to improve breathing function, surgery of the nose is best performed when facial growth is complete, beginning around age 15.

    Surgery of the nose is performed using small incisions within the nose and across the columella, the narrow strip of tissue that separates the nostrils. Through these incisions, the soft tissues that cover the nose are gently raised, allowing access to reshape the structure of the nose.

    Surgery of the nose can reduce or augment nasal structures with the use of cartilage grafting from the other areas of your body. Once the underlying structure of the nose is sculptured to the desired shape, nasal skin and tissue is redraped and incisions are closed. Additional incisions may be placed in the natural creases of the nostrils to alter their size.

    Splints and packing are often used to support the nose as it begins to heal. Although the initial swelling subsides within a few weeks, it may take up to a year for your new nasal contour to fully refine. During this time, you may notice gradual changes in the appearance of the nose as it refines to a more permanent outcome.

  • Hand&Microsurgery:

    Dr. Kupfer offers a complete range of hand and microsurgery procedures.

    Dr. Kupfer has been in practice for more than two decades performing more than 2,000 carpal tunnel release surgeries and thousands of additional nerve decompressions and reconstructions. His expertise in micro surgery allows him to offer his patients the most complex of reconstruction procedures such as Toe to Hand Transfers or Replantation Surgery.

    The following are some of the procedures commonly performed by Dr. Kupfer. Click on a link below to learn more:

  • Arthritis of the Hand

    The hand and wrist have multiple small joints that work together to produce motion. This gives the fine motion needed to thread a needle or tie a shoelace. When the joints are affected by arthritis, activities of daily living can be difficult. Arthritis can occur in multiple areas of the hand and wrist. It can have multiple causes.

    It is estimated that one out of every five people living in the United States has at least one joint with signs or symptoms of arthritis. About half of arthritis sufferers are under age 50. Arthritis is the leading cause of disability in the United States. It typically occurs from either disease or trauma. The exact number of people with arthritis in the hand and wrist is not known.

    Causes:

    Cartilage works as nature's "shock absorber." It provides a smooth gliding surface for the joint. All arthritic joints lose cartilage. When the cartilage becomes worn or damaged, or is lost due to disease or trauma, the joint no longer has a painless, mobile area of motion.

    The body attempts to make up for the lost cartilage. It produces fluid in the joint lining (synovium), which tries to act like a cushion, like water in a waterbed. But it also causes the joint to swell. This restricts motion. The swelling causes stretching of the joint covering (capsule), which causes pain.

    Over time, if the arthritis is not treated, the bones that make up the joint can lose their normal shape. This causes more pain and further limits motion.

    Cummulative Trauma

    Repetitive motion in the work place is a recognized factor that can lead to isolated arthritis of the base of the thumb due to the unique configuration of this joint.

    Disease

    When arthritis occurs due to disease, the onset of symptoms is gradual and the cartilage decreases slowly. The two most common forms of arthritis from disease are osteoarthritis and rheumatoid arthritis. Osteoarthritis is much more common and generally affects older people. It appears in a predictable pattern in certain joints. Rheumatoid arthritis has other system-wide symptoms and may be passed from parent to child (genetically).

    Trauma

    When arthritis is due to trauma, the cartilage is damaged. People of any age can be affected. Fractures, particularly those that damage the joint surface, and dislocations are the most common injuries that lead to arthritis. An injured joint is about seven times more likely to become arthritic, even if the injury is properly treated.

    Arthritis does not have to result in a painful or sedentary life. It is important to seek help early so that treatment can begin and you can return to doing what matters most to you.

    Diagnosis

    A doctor can diagnose arthritis of the hand by examining the hand and by taking X-rays. Specialized studies, such as magnetic resonance imaging (MRI), are usually not needed. Sometimes a bone scan is helpful. A bone scan may help the doctor diagnose arthritis when it is in an early stage, even if X-rays look normal.

    Arthroscopy pictures of the wrist joint. The white objects are some of the wrist bones as seen through the arthroscope. The metal rod is an arthroscopic probe with a tip measuring 2 mm. It can be seen moving between two of the wrist bones that have a ligament tear between them. Normally, the bones are close together and cannot be moved apart.

    Arthroscopy is another way to look at the joint by direct inspection. During an arthroscopic procedure, the surgeon inserts a small camera into the joint to look inside. It provides the clearest picture of the joint without having to make a large incision. However, this is an invasive procedure and should not be used as a routine diagnostic tool.

    Symptoms

    Pain

    Early symptoms of arthritis of the hand include joint pain that may feel "dull," or a "burning" sensation. The pain often occurs after periods of increased joint use, such as heavy gripping or grasping. The pain may not be present immediately, but may show up hours later or even the following day. Morning pain and stiffness are typical.

    As the cartilage wears away and there is less material to provide shock absorption, the symptoms occur even with less use. In advanced disease, the joint pain may wake you up at night.

    Pain might be made worse with use and relieved by rest. Many people with arthritis complain of increased joint pain with rainy weather. Activities that once were easy, such as opening a jar or starting the car, become difficult due to pain. To prevent pain at the arthritic joint, you might adapt the way you use your hand.

    Swelling

    Thumb extension deformity. This patient has lost mobility at the base of the thumb due to arthritis. The next joint closer to the tip of the thumb has become more mobile than normal to make up for the arthritic joint. Normally, the thumb does not come to a right angle with the rest of the hand.

    When the affected joint is subject to greater stress than it can bear, it may swell in an attempt prevent further joint use.

    Changes in Surrounding Joints

    In patients with advanced thumb base arthritis, the neighboring joints may become more mobile than normal.

    Warmth

    The arthritic joint may feel warm to touch. This is due to the body's inflammatory response.

    Crepitation and Looseness

    There may be a sensation of grating or grinding in the affected joint (crepitation). This is caused by damaged cartilage surfaces rubbing against one another. If arthritis is due to damaged ligaments, the support structures of the joint may be unstable or "loose." In advanced cases, the joint may appear larger than normal (hypertrophic). This is usually due to a combination of bone changes, loss of cartilage, and joint swelling.

    Cysts

    When arthritis affects the end joints of the fingers (DIP joints), small cysts (mucous cysts) may develop. The cysts may then cause ridging or dents in the nail plate of the affected finger.

    Treatment

    Nonsurgical Treatment

    Treatment options for arthritis of the hand and wrist include medication, splinting, injections, and surgery.

    Medications

    Medications treat symptoms but cannot restore joint cartilage or reverse joint damage. The most common medications for arthritis are anti-inflammatories, which stop the body from producing chemicals that cause joint swelling and pain. Examples of anti-inflammatory drugs include over-the-counter medications such as Tylenol™ and Advil™ and prescription drugs such as Celebrex™.

    Glucosamine and chondroitin are widely advertised dietary supplements or "neutraceuticals." Neutraceuticals are not drugs. Rather, they are compounds that are the "building blocks" of cartilage. They were originally used by veterinarians to treat arthritic hips in dogs. However, neutraceuticals have not yet been studied as a treatment of hand and wrist arthritis. (Note: The U.S. Food and Drug Administration does not test dietary supplements. These compounds may cause negative interactions with other medications. Always consult your doctor before taking dietary supplements)

    Injections

    When first-line treatment with anti-inflammatory medication is not appropriate, injections may be used. These typically contain a long-acting anesthetic, similar to novacaine but longer lasting, and a steroid that can provide pain relief for weeks to months. The injections can be repeated, but only a limited number of times, due to possible side effects, such as lightening of the skin, weakening of the tendons and ligaments and infection.

    Splinting

    Injections are usually combined with splinting of the affected joint. The splint helps support the affected joint to ease the stress placed on it by activities. Splints are typically worn during periods when the joints hurt. They should be small enough to allow functional use of the hand when they are worn. Wearing the splint for too long can lead to muscle wasting (atrophy). Muscles can assist in stabilizing injured joints, so atrophy should be prevented.

    Surgical Treatment

    If nonsurgical treatment fails to give relief, surgery is usually discussed. There are many surgical options. The option chosen should be one that has a reasonable chance of providing long-term pain relief and return to function. It should be tailored to your individual needs. It is important that the treating physician is well versed in current surgical techniques.

    If there is any way the joint can be preserved or reconstructed, this option is usually chosen.

    When the damage has progressed to a point that the surfaces will no longer work, a joint replacement or a fusion (arthrodesis) is performed.

    Joint fusions provide pain relief but stop joint motion. The fused joint no longer moves; the damaged joint surfaces are gone, so they cannot cause symptoms.

    Joint replacement attempts to provide pain relief and functional joint motion. As with hip and knee replacements, there have been significant improvements in joint replacements in the hand and wrist. The replacement joints are made of materials similar to those used in weight bearing joints, such as ceramics or long-wearing metal and plastic parts. The goal is to improve the function and longevity of the replaced joint. Most of the major joints of the hand and wrist can be replaced. A surgeon often needs additional training to perform the surgery. As with any evolving technology, the long-term results of the hand or wrist joint replacements are not yet known. Early results have been promising. Talk with your doctor to find out if these implants are right for you.

    After Surgery

    After any type of joint reconstruction surgery, there is a period of recovery. Often, you will be referred to a trained hand therapist, who can help you maximize your recovery. You may need to use a postoperative splint or cast for a while after surgery. This helps protect the hand while it heals.

    Length of recovery time varies widely and depends on the extent of the surgery performed and multiple individual factors. However, people usually can return to most if not all of their desired activities in about three months after most major joint reconstructions.

  • Carpal Tunnel Syndrome

    Carpal tunnel syndrome is pressure on the median nerve -- the nerve in the wrist that supplies feeling and movement to parts of the hand. It can lead to numbness, tingling, weakness, or muscle damage in the hand and fingers.

    Causes, incidence, and risk factors

    The median nerve provides feeling and movement to the " thumb side" of the hand (the palm, thumb, index finger, middle finger, and thumb side of the ring finger).

    The area in your wrist where the nerve enters the hand is called the carpal tunnel. This tunnel is normally narrow, so any swelling can pinch the nerve and cause pain, numbness, tingling or weakness. This is called carpal tunnel syndrome.

    Carpal tunnel syndrome is common in people who perform repetitive motions of the hand and wrist. Typing on a computer keyboard is probably the most common cause of carpal tunnel. Other causes include:

    The condition occurs most often in people 30 to 60 years old, and is more common in women than men. A number of medical problems are associated with carpal tunnel syndrome, including:

    Signs and tests

    During a physical examination, the doctor may find:

    Numbness in the palm, thumb, index finger, middle finger, and thumb side of the ring finger Weak hand grip Tapping over the median nerve at the wrist may cause pain to shoot from the wrist to the hand (this is called Tinel's sign) Bending the wrist forward all the way for 60 seconds will usually result in numbness, tingling, or weakness (this is called Phalen's test)

    Tests may include:

    Electromyography Nerve conduction velocity Wrist x-rays should be done to rule out other problems (such as wrist arthritis)

    Treatment:

    You may try wearing a splint at night for several weeks. If this does not help, you may need to try wearing the splint during the day. Avoid sleeping on your wrists. Hot and cold compresses may also be recommended.

    There are many changes you can make in the workplace to reduce the stress on your wrist:

    Special devices include keyboards, different types of mouses, cushioned mouse pads, and keyboard drawers.

    Someone should review the position you are in when performing your work activities. For example, make sure the keyboard is low enough so that your wrists aren't bent upward while typing. Your doctor may suggest an occupational therapist.

    You may also need to make changes in your work duties or recreational activities. Some of the jobs associated with carpal tunnel syndrome include those that involve typing and vibrating tools. Carpal tunnel syndrome has also been linked to professional musicians.

    Medications:

    Medications used in the treatment of carpal tunnel syndrome include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen. Corticosteroid injections, given into the carpal tunnel area, may relieve symptoms for a period of time.

    Surgery:

    Carpal tunnel release is a surgical procedure that cuts into the ligament that is pressing on the nerve. Surgery is successful most of the time, but it depends on how long the nerve compression has been occurring and its severity. The incision is made in the palm and is about a 1/2" long.

    Expectations (prognosis)

    Symptoms often improve with treatment, but more than 50% of cases eventually require surgery. Surgery is often successful, but full healing can take months.

    Complications

    If the condition is treated properly, there are usually no complications. If untreated, the nerve can be damaged, causing permanent weakness, numbness, and tingling.

  • Cubital Tunnel Syndrome

    Cubital tunnel syndrome is a condition brought on by increased pressure on the ulnar nerve at the elbow. There is a bump of bone on the inner portion of the elbow (medial epicondyle) under which the ulnar nerve passes. This site is commonly called the "funny bone" (see Figure 1). At this site, the ulnar nerve lies directly next to the bone and is susceptible to pressure. When the pressure on the nerve becomes great enough to disturb the way the nerve works, then numbness, tingling, and pain may be felt in the elbow, forearm, hand, and/or fingers.

    Causes

    Pressure on the ulnar nerve at the elbow can develop in several ways. The nerve is positioned right next to the bone and has very little padding over it, so pressure on this can put pressure on the nerve. For example, if you lean your arm against a table on the inner part of the elbow, your arm may fall asleep and be painful from sustained pressure on the ulnar nerve. If this occurs repetitively, the numbness and pain may be more persistent. In some patients, the ulnar nerve at the elbow clicks back and forth over the bony bump (medial epicondyle) as the elbow is bent and straightened. If this occurs repetitively, the nerve may be significantly irritated.

    Additionally, pressure on the ulnar nerve can occur from holding the elbow in a bent position for a long time, which stretches the nerve across the medial epicondyle. Such sustained bending of the elbow may tend to occur during sleep. Sometimes the connective tissue over the nerve becomes thicker, or there may be variations of the muscle structure over the nerve at the elbow that cause pressure on the nerve. Cubital tunnel syndrome occurs when the pressure on the nerve is significant enough, and sustained enough, to disturb the way the ulnar nerve works.

    Signs and symptoms

    Cubital tunnel syndrome symptoms usually include pain, numbness, and/or tingling. The numbness or tingling most often occurs in the ring and little fingers. The symptoms are usually felt when there is pressure on the nerve, such as sitting with the elbow on an arm rest, or with repetitive elbow bending and straightening. Often symptoms will be felt when the elbow is held in a bent position for a period of time, such as when holding the phone, or while sleeping. Some patients may notice weakness while pinching, occasional clumsiness, and/or a tendency to drop things. In severe cases, sensation may be lost and the muscles in the hand may lose bulk and strength.

    Diagnosis

    Your physician will assess the pattern and distribution of your symptoms, and examine for muscle weakness, irritability of the nerve to tapping and/or bending of the elbow, and changes in sensation. Other medical conditions may need to be evaluated such as thyroid disease or diabetes. A test called electromyography (EMG) and/or nerve conduction study (NCS) may be done to confirm the diagnosis of cubital tunnel syndrome and stage its severity. This test also checks for other possible nerve problems, such as a pinched nerve in the neck, which may cause similar symptoms.

    Treatment

    Symptoms may sometimes be relieved without surgery, particularly if the EMG/NCS testing shows that the pressure on the nerve is minimal. Changing the patterns of elbow use may significantly reduce the pressure on the nerve. Avoiding putting your elbow on hard surfaces may help, or wearing an elbow pad over the ulnar nerve and "funny bone" may help. Keeping the elbow straight at night with a splint also may help. A session with a therapist to learn ways to avoid pressure on the nerve may be needed. Injections of dexamethasone can be helpful in many patients.

    When symptoms are severe or do not improve, surgery may be needed to relieve the pressure on the nerve. A simple decompression of the nerve as noted in the photo below is often sufficient to cure the condition. Some patients with more advanced conditions of the ulnar nerve require shifting the nerve to the front of the elbow, which relieves pressure and tension on the nerve. The nerve may be placed under a layer of fat, under the muscle, or within the muscle. Some surgeons may recommend trimming the bony bump (medial epicondyle). Following surgery, the recovery will depend on the type of surgery that was performed. Restrictions on lifting and/or elbow movement may be recommended. Therapy may be necessary. The numbness and tingling may improve quickly or slowly, and it may take several months for the strength in the hand and wrist to improve. Cubital tunnel symptoms may not completely resolve after surgery, especially in severe cases.

  • De Quervain's tenosynovitis

    Causes

    De Quervain's tenosynovitis is inflammation of tendons on the side of the wrist at the base of the thumb. These tendons include the extensor pollicis brevis and the abductor pollicis longus tendons.

    De Quervain's tenosynovitis can be brought on by simple strain injury to the extensor pollicus longus tendon. Typical causes include stresses such as lifting young children into car seats, lifting heavy grocery bags by the loops, and lifting gardening pots up and into place.

    Symptoms

    De Quervain's tenosynovitis causes pain and tenderness at the side of the wrist beneath the base of the thumb. Sometimes there is slight swelling and redness in the area.

    Diagnosis

    De Quervain's tenosynovitis is diagnosed based on the typical appearance, location of pain, and tenderness of the affected wrist. De Quervain's tenosynovitis is usually associated with pain when the thumb is folded across the palm and the fingers are flexed over the thumb as the hand is pulled away from the involved wrist area. (This is referred to as the Finkelstein maneuver.)

    Treatment

    Treatment for De Quervain's tenosynovitis includes any combination of rest, splinting, ice, antiinflammation medication, and/or cortisone injection. Cortisone injection is extremely effective and is generally the optimal treatment. Normal activity may be resumed within three weeks after an injection. Surgery is reserved for persisting inflammation after failure of at least one cortisone injection.

    Prognosis

    The prognosis for complete symptom relief is excellent. The patient can generally return to full function after the inflammation quiets down with treatment. Sometimes bracing is used during future activities that involve repetitive wrist motion.

  • Distal Radius Fracture

      distalradiusfracture
    Bones of the forearm include the radius and the ulna

    The radius is the larger of the two bones of the forearm. The end toward the wrist is called the distal end. A fracture of the distal radius occurs when the area of the radius near the wrist breaks.

    Causes:

    • distalradiusfracturedistalradiusfractureDistal radius fractures

    Distal radius fractures are very common. In fact, the radius is the most commonly broken bone in the arm. The break usually happens when a fall causes someone to land on their outstretched hands. It can also happen in a car accident, a bike accident, a skiing accident, and similar situations.

    Sometimes, the other bone of the forearm (the ulna) is also broken. When this happens, it is called a distal ulna fracture.

    This fracture was first described by an Irish surgeon and anatomist, Abraham Colles, in 1814; hence the name, "Colles " fracture.

    Symptoms

    A broken wrist usually causes immediate (acute) pain, tenderness, bruising, and swelling. Frequently, the wrist hangs in an odd or bent way (deformity).

    Diagnosis

    • distalradiusfracturedistalradiusfracture X-ray of Distal radius fracture

    The doctor will take an X-ray of the wrist. This is important to understand the extent of the injury.

    The fracture almost always occurs about 1 inch from the end of the bone. The break (fracture) can occur in many different ways, however.

    A fracture that extends into the joint, it is called an intra-articular fracture.

    A fracture that does not extend into the joint is called an extra-articular fracture. (" articular" means "joint.")

    When a fractured bone breaks the skin, it is called an open fracture.

    When a bone is broken into more than two pieces, it is called a comminuted fracture.

    It is important to classify the type of fracture, because some fractures are more difficult to treat than others. Intra-articular fractures (fractures within the joints), open fractures (fractures that break through the skin), and comminuted fractures (fracture that shatter the bone into a lot of small pieces) are more difficult to treat, for example.

    Risk Factors

    Osteoporosis (decreased density of the bones) can make a relatively minor fall result in a broken wrist. Many distal radius fractures in people older than 60 years of age are caused by a fall from a standing position.

    A broken wrist can happen even in healthy bones, if the force of the trauma is severe enough. For example, a car accident or a fall off a bike may generate enough force to break a wrist.

    Good bone health remains an important prevention option. Wrist guards may help to prevent some fractures, but they will not prevent them all.

    Treatment

    Immediate Treatment

    If the injury is not very painful and the wrist is not deformed, it may be possible to wait until the next day. The wrist may be protected with a splint. An ice pack can be applied to the wrist and the wrist can be elevated until the doctor is able to examine it.

    If the injury is very painful, if the wrist is deformed or numb or the fingers are not pink, it is necessary to go to the emergency room.

    Nonsurgical Treatment

    There are many treatment choices. The choice depends on many factors, such as the nature of the fracture, age and activity level, and surgeon's personal preferences. The following is a general discussion of the possible options.

    Casting:

    If the broken bone is in a good position, a plaster cast may be applied until the bone heals.

    If the position (alignment) of your bone is not good and likely to limit the future use of the arm, it may be necessary to correct the deformity. The bone would be re-aligned (reduced).

    If the bone is straightened (reduced) without having to open the skin (incision), this is called a closed reduction.

    After the bone is properly aligned, a splint or cast may be placed on your arm. A splint is usually used for the first few days, to allow for a small amount of normal swelling. A cast is usually added a few days to a week or so later, after the swelling goes down. The cast is changed two or three weeks later as the swelling goes down more, causing the cast to loosen.

    X-rays may be taken, depending on the nature of the fracture. X-rays may be taken at weekly intervals for three weeks and then at six weeks if the fracture was reduced or thought to be unstable. X-rays may be taken less often if the fracture was not reduced and thought to be stable.

    The cast is removed about six weeks after the fracture happened. At that point, physical therapy is often started to help improve the motion and function of the injured wrist.

    Surgical Treatment

    Sometimes, the position of the bone is so much out of place that it cannot be corrected or kept corrected in a cast. This has the potential of interfering with the future functioning of your arm. In this case, surgery may be required.

    There are many ways of performing surgery. Even if the fracture is treated in the operating room, it may be possible to re-align (reduce) the fracture without making an incision (closed reduction). In other cases, it will be necessary to make an incision (open reduction) to directly access the broken bones to improve alignment.

    Depending on the fracture, there are a number of options for holding the bone in the correct position, including a cast, metal pins (usually stainless steel or titanium), a plate and screws, an external fixator (a device for which most of the hardware remains outside of the body), or any combination of these techniques.

    After Surgery

    • distalradiusfracturedistalradiusfracture X-ray of Distal radius fracture

    Prognosis

    The kinds of distal radius fractures are so varied and the treatment options are so broad that it is hard to generalize what to expect.

    Most fractures hurt moderately for a few days to a couple of weeks. Many patients find that using ice, elevation (holding their arm up above their heart), and simple, non-prescription medications for pain relief are all that are needed.

    One combination is ibuprofen plus acetaminophen ("non-aspirin pain reliever"). The combination of both ibuprofen plus acetaminophen is much more effective than either one alone. If pain is severe, patients may need to take a prescription strength medication, often a narcotic, for a few days.

    Casts and splints must be kept dry. A plastic bag over the arm while showering should help. If the cast does become wet, it will not dry very easily. A hair dryer on the cool setting may be helpful.

    Most surgical incisions must be kept clean and dry for five days or until the sutures (stitches) are removed, whichever occurs later.

    Long Term Outcome

    Most patients do return to all their former activities. The nature of the injury, the kind of treatment received, and the body's response to the treatment all have an impact, so the answer is different for each individual.

    Some generalizations can be made:

    Remember, these are general guidelines and may not apply to you and your fracture. Ask your doctor for specifics in your case. Your doctor knows that returning to activities is important to you.

    Finally, osteoporosis is a factor in as many as 250,000 wrist fractures. It has been suggested that people who suffer a wrist fracture may need to be screened for osteoporosis, especially if they have other risk factors. Ask your doctor if you need to be screened or treated for osteoporosis

  • Dupuytren's Contracture

    Dupuytren's contracture is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands. Although the exact cause is unknown, it occurs most often in middle-aged, white men and is genetic in nature, meaning it runs in families. This condition is seven times more common in men than women. It is more common in men of Scandinavian, Irish, or Eastern European ancestry. Interestingly, the spread of the disease seems to follow the same pattern as the spread of Viking culture in ancient times. The disorder may occur suddenly but more commonly progresses slowly over a period of years. The disease usually doesn't cause symptoms until after the age of 40.

    Anatomy

    What part of the hand is affected?

    The palm side of the hand contains many nerves, tendons, muscles, ligaments, and bones. This combination allows us to move the hand in many ways. The bones give our hand structure and form joints. Bones are attached to bones by ligaments. Muscles allow us to bend and straighten our joints. Muscles are attached to bones by tendons. Nerves stimulate the muscles to bend and straighten. Blood vessels carry needed oxygen, nutrients, and fuel to the muscles to allow them to work normally and heal when injured. Tendons and ligaments are connective tissue. Another type of connective tissue, called fascia, surrounds and separates the tendons and muscles of the hand.

    Lying just under the palm is the palmar fascia, a thin sheet of connective tissue shaped somewhat like a triangle. This fascia covers the tendons of the palm of the hand and holds them in place. It also prevents the fingers from bending too far backward when pressure is placed against them. The fascia separates into thin bands of tissue at the fingers. These bands continue into the fingers where they wrap around the joints and bones. Dupuytren's contracture forms when the palmar fascia tightens, causing the fingers to bend.

    The condition commonly first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytren's contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.

    Sometimes, the other bone of the forearm (the ulna) is also broken. When this happens, it is called a distal ulna fracture.

    This fracture was first described by an Irish surgeon and anatomist, Abraham Colles, in 1814; hence the name, "Colles " fracture.

    Causes

    Why do I have this problem?

    No one knows exactly what causes Dupuytren's contracture. The condition is rare in young people but becomes more common with age. When it appears at an early age, it usually progresses rapidly and is often very severe. The condition tends to progress more quickly in men than in women.

    People who smoke have a greater risk of having Dupuytren's contracture. Heavy smokers who abuse alcohol are even more at risk. Recently, scientists have found a connection with the disease among people who have diabetes. It has not been determined whether or not work tasks can put a person at risk or speed the progression of the disease.

    Symptoms

    What does Dupuytren's contracture feel like?

    Normally, we are able to control when we bend our fingers and how much. How much we flex our fingers determines how small an object we can hold and how tightly we can hold it. People lose this control as the disorder develops and the palmar fascia contracts, or tightens. This contracture is like extra scar tissue just under the skin. As the disorder progresses, the bending of the finger becomes more and more severe, which limits the motion of the finger.

    Without treatment, the contracture can become so severe that you cannot straighten your finger, and eventually you may not be able to use your hand effectively. Because our fingers are slightly bent when our hand is relaxed, many people put up with the contracture for a long time. Patients with this condition usually seek medical advice for cosmetic reasons or the loss of use of their hand. At times, the nodules can be very painful. For this reason many patients are worried that something serious is wrong with their hand.

    Diagnosis

    How do doctors identify the problem?

    Your doctor will ask you the history of your problem, such as how long you have had it, whether you've noticed it getting worse, and whether it has kept you from doing your daily activities. The doctor will then examine your hand and finger.

    Your doctor can tell if you have a Dupuytren's contracture by looking at and feeling the palm of your hand and your fingers. Usually, special tests are unnecessary. Abnormal fascia will feel thick. Cords and small nodules in the fascia may be felt as small knots or thick bands under the skin. These nodules usually form first in the palm of the hand. As the disorder progresses, nodules form along the finger. These nodules can be felt through the skin, and you may have felt them yourself. Depending on the stage of the disorder, your finger may have started to contract, or bend.

    The amount you are able to bend your finger is called flexion. The amount you are able to straighten the finger is called extension. Both are measured in degrees. Normally, the fingers will straighten out completely. This is considered zero degrees of flexion (no contracture). As the contracture causes your finger to bend more and more, you will lose the ability to completely straighten out the affected finger. How much of the ability to straighten out your finger you have lost is also measured in degrees.

    Measurements taken at later follow-up visits will tell how well treatments are working or how fast the disorder is progressing. The progression of the disorder is unpredictable. Some patients have no problems for years, and then suddenly nodules will begin to grow and their finger will begin to contract.

    The tabletop test may also done. The tabletop test will show if you can flatten your palm and fingers on a flat surface. You can follow the progression of the disorder by doing the tabletop test yourself. Your doctor will tell you what to look for and when you should return for a follow-up visit.

    Treatment

    What can be done for the condition?

    There are two types of treatment for Dupuytren's contracture: surgical and nonsurgical. The best course of treatment is determined by how far the contractures have advanced.

    Nonsurgical Treatment

    In the early stages of this disorder, your doctor may inject cortisone into the painful nodules. Cortisone can be effective at temporarily easing pain and inflammation. Heat and stretching treatments given by a physical or occupational therapist may also be prescribed to control pain and to try to slow the progression of the contracture.

    Treatment also consists of wearing a splint that keeps the finger straight. This splint is usually worn at night.

    The nodules of Dupuytren's contracture are almost always limited to the hand. Dupuytren's contracture is known to progress, so surgery may be needed at some point to release the contracture and to prevent disability in your hand.

    Surgery

    No hard and fast rule exists as to when surgery is needed. Surgery is usually recommended when the joint at the knuckle of the finger reaches 30 degrees of flexion. When patients have severe problems and require surgery at a younger age, the problem often comes back later in life. When the problem comes back or causes severe contractures, surgeons may decide to fuse the individual finger joints together. In the worst case, amputation of the finger may be needed if the contracture restricts the nerves or blood supply to the finger.

    Surgery for the main knuckle of the finger (at the base of the finger) has better long-term results than when the middle finger joint is tight. Tightness is more likely to return after surgery for the middle joint.

    Tissue Release

    The goal of tissue release surgery is to release the fibrous attachments between the palmar fascia and the tissues around it, thereby releasing the contracture. Once released, finger movement should be restored to normal. If the problem is not severe, it may be possible to free the contracture simply by cutting the cord under the skin. If the palmar fascia is more involved and more than one finger is bent, your surgeon may take out the whole sheet of fascia.

    Palmar Fascia Removal

    Removal of the entire palmar fascia will usually give a very good result. The cure is often permanent but depends a great deal on the success of doing the physical or occupational therapy as prescribed. Little ill effect is caused by removing the entire palmar fascia, although the fingers may bend backward slightly more than normal. If you decide to have this surgery, you must commit to doing the therapy needed to make your surgery as successful as possible.

    Skin Graft Method

    A skin graft may be needed if the skin surface has contracted so much that the finger cannot relax as it should and the palm cannot be stretched out flat. Surgeons graft skin from the wrist, elbow, or groin. The skin is grafted into the area near the incision to give the finger extra mobility for movement.

  • Extensor Tendon Injuries

    What is an Extensor Tendon?

    Extensor tendons, located on the back of the hand and fingers, allow you to straighten your fingers and thumb (see Figure 1). These tendons are attached to muscles in the forearm. As the tendons continue into the fingers, they become flat and thin. In the fingers, smaller tendons from small muscles in the hand join these tendons. It is these small-muscle tendons that allow delicate finger motions and coordination.

    How are Extensor Tendons Injured?

    Extensor tendons are just under the skin, directly on the bone, on the back of the hands and fingers. Because of their location, even a minor cut can easily injure them. Jamming a finger may cause these thin tendons to rip apart from their attachment to the bone. After this type of injury, you may have a hard time straightening one or more joints. Treatment is necessary to return use to the tendon and finger.

    How are Extensor Tendon Injuries Treated?

    Cuts that split the tendon may need stitches, but tears caused by jamming injuries are usually treated with splints. Splints stop the healing ends of the tendons from pulling apart and should be worn at all times until the tendon is fully healed. Your doctor will apply the splint in the correct place and give you directions on how long to wear it. Sometimes a pin is placed through the bone across the joint as an internal splint in addition to the external splint.

    What are the Common Extensor Tendon Injuries?

    Mallet finger refers to the droop of the end joint where an extensor tendon has been cut or separated from the bone (see Figure 2). Sometimes a piece of bone is pulled off with the tendon, but the result is the same: a fingertip that cannot actively straighten. Whether the tendon injury is caused by a cut or jammed finger, splinting is necessary. Often the cut tendon requires stitches. A splint is used to keep the fingertip straight until the tendon is healed. The size of the splint and length of time you will have to wear it is determined by the type and location of your injury. The splint should remain in place constantly during this time. The tendon may take four to eight weeks, or longer in some patients, to heal completely. Removing the splint early may result in drooping of the fingertip, which may then require additional splinting. Your physician will instruct you to remove the splint at the proper time. Sometimes there is a mild permanent droop, despite proper splint wear.

    Boutonniere deformity describes the bent-down (flexed) position of the middle joint of the finger from a cut or tear of the extensor tendon at the middle joint (see Figure 3). Treatment involves splinting the middle joint in a straight position until the injured tendon is fully healed. Sometimes, stitches are necessary when the tendon has been cut and even if the tendon is torn. If the injury is not treated, or if the splint is not worn properly, the finger can quickly become even more bent and finally stiffen in this position. Be sure to follow your doctor's instructions and wear your splint for a minimum of four to eight weeks. Your doctor will tell you when you may stop wearing the splint.

    Lacerations or cuts on the back of the hand that go through the extensor tendons cause difficulty in straightening the finger at the large joint where the fingers join the hand. Stitching the tendon ends together is the usual way of treating these injuries, followed by splinting to protect the repair. The splint for a tendon injury in this area may include the wrist and part of the finger. Dynamic splinting, which is a splint with slings that allows some finger motion, may be used for injuries of this kind. The dynamic splint allows early movement and protects the healing tendon.

    What Can I Expect as a Result of my Extensor Tendon Injury?

    Extensor tendon injuries may form scar that causes the tendon to adhere to nearby bone and scar tissue, limiting the movement of the tendon. The scar tissue that forms may prevent full finger bending and straightening even with the best of treatment. Many factors can affect the seriousness of the injury, including fracture, infection, medical illnesses, and individual differences. To improve motion, hand therapy may be necessary. Surgery to free scar tissue may sometimes by helpful in serious cases of motion loss. Your physician will explain the risks and benefits of the various treatments of extensor tendon injuries.

    Figure 1: Extensor tendons, located on the back of the hand and fingers, allow you to straighten your fingers and thumb.

    Figure 2: The mallet finger deformity causes a droop of the fingertip. This is caused by injury to the extensor tendon at the last finger joint.

    Figure 3: The boutonni're deformity with progressive flexion, or bending, of the middle joint may result in a stiff finger in this position if not treated. The end joint also hyperextends (bends backward) from the altered force across the finger.

  • Flexor Tendon Injuries

    A deep cut on the palm side of your fingers, hand, wrist, or forearm can damage your flexor tendons, which are the tissues that help control movement in your hand. A flexor tendon injury can make it impossible to bend your fingers or thumb.

    Anatomy

    Tendons are tissues that connect muscles to bone. When muscles contract, tendons pull on bones. This causes parts of the body (such as a finger) to move.

    The flexor tendons allow you to bend your fingers.

    The muscles that move the fingers and thumb are located in the forearm. Long tendons extend from these muscles through the wrist and attach to the small bones of the fingers and thumb.

    The tendons on the top of the hand straighten the fingers. These are known as extensor tendons. The tendons on the palm side bend the fingers. These are known as the flexor tendons.

    When you bend or straighten your finger, the flexor tendons slide through snug tunnels, called tendon sheaths, that keep the tendons in place next to the bones.

    Tendon sheaths keep the tendons in place.

    Description

    A torn or cut tendon in the forearm, at the wrist, in the palm, or along the finger will make it impossible to bend one or more joints in a finger.

    Because flexor tendons are very close to the surface of the skin, a deep cut will most likely hit a flexor tendon. In these cases, the tendon is often cut into two pieces.

    Like a rubber band, tendons are under tension as they connect the muscle to the bone. If a tendon is torn or cut, the ends of the tendon will pull far apart, making it impossible for the tendon to heal on its own.

    Because the nerves to the fingers are also very close to the tendons, a cut may damage them, as well. This will result in numbness on one or both sides of the finger. If blood vessels are also cut, the finger may have no blood supply. This requires immediate surgery.

    Occasionally, flexor tendons may be partially cut or torn. With a partial tendon tear, it may still be possible to bend your finger, but not completely. These types of tears can be difficult to diagnose.

    Causes

    In addition to cuts on the arm, hand, or fingers, certain sports activities can cause flexor tendon injuries. These injuries often occur in football, wrestling, and rugby. "Jersey finger" is one of the most common of these sports injuries. It can happen when one player grabs another's jersey and a finger (usually the ring finger) gets caught and pulled. The tendon is pulled off the bone. In sports that require a lot of arm and hand strength, such as rock climbing, tendons and/or their sheaths can also be stretched or torn.

    Certain health conditions (rheumatoid arthritis, for example) weaken the flexor tendons and make them more likely to tear. This can happen without warning or injury & a person may simply notice that his or her finger no longer bends, but cannot recall how it could have happened.

    Symptoms

    The most common signs of a flexor tendon injury include:

    Doctor Examination

    It is important to see a doctor whenever the fingers are injured. This is especially true if your finger is jammed and you cannot bend or straighten your fingertip.

    First Aid

    When you have a serious cut to your hand or fingers, apply ice immediately. Tightly wrap your hand with a clean cloth or bandage to slow down the bleeding. Elevate your hand by keeping it lifted above your heart. See a doctor as soon as possible.

    Your doctor may first clean and treat any wounds that are not deep. You may need a tetanus shot or antibiotics to prevent infection.

    Physical Examination

    These standard examination tests help your doctor determine if a tendon or nerve has been injured.

    During the examination, your doctor will ask you to bend and straighten your fingers. To test your finger strength, your doctor may have you try to bend your injured finger while he or she holds the other fingers down flat. To determine whether any nerves or blood vessels have been injured, your doctor may test your hand for sensation and blood flow to the fingers.

    Additional Tests

    Your doctor may also order an x-ray to see if there is any damage to the bone.

    Treatment

    Your hand may be placed in a splint for protection prior to surgery.

    After examining your hand, your doctor may place your hand in a splint for protection.

    Tendons cannot heal unless the ends are touching, which does not occur with a complete tear. In most cases, a cut or torn tendon must be repaired by a doctor. This requires surgery.

    Surgery is usually performed within 7 to 10 days after an injury. In general, the sooner surgery is performed, the better recovery will be.

    If your injury is restricting blood flow to your hand or finger, your doctor will schedule an immediate surgery.

    Surgical Procedure

    Because tendons tear in different ways – such as straight across, at an angle, or pulled right off of the bone – there are many different methods for your surgeon to repair them. All the methods for repair, however, involve special sutures, which are stitches.

    Surgery is usually performed on an outpatient basis (you may go home the day of surgery). Your doctor will apply a dressing and splint after the surgery. Many doctors use a plastic type of splint to protect the repair. Your fingers and wrist will be placed in a bent position to keep tension off the repair.

    After surgery, a splint is applied to limit movement and help the tendon heal.

    Recovery from Surgery

    It can take up to 2 months before the repair heals and your hand is strong enough to use without protection. It may take another month or so before your hand can be used with any force.

    Soon after surgery, you will begin physical therapy. Specific exercises will help you gradually regain motion and function. Stiffness after surgery is common, but it usually responds to therapy.

    Splint wear and proper exercise, exactly as prescribed by your therapist, are as important to recovery as the surgery itself.

    Treatment for Partial Tears

    Recent evidence suggests that partially torn tendons do not require surgery for good results. The same splinting and exercise programs that are used for surgery patients can be very effective for patients with partial tears, but with no surgery necessary.

    This nonsurgical treatment option is appropriate only after the doctor has explored the wound to accurately assess the extent of the injury.

    Long-Term Outcomes

    Over the last several decades, advanced research and experience in the treatment of flexor tendon injuries have resulted in improved patient outcomes. Flexor tendon injuries, however, can be very challenging to treat.

    Despite extensive therapy, some patients have long-term stiffness after flexor tendon injuries. Sometimes, a second surgery is required to free up scar tissue and to help the patient regain motion.

    Overall, flexor tendon surgery results in good return of function and high patient satisfaction.

  • GANGLION CYSTS OF THE WRIST & HAND

    Ganglion cysts arise from the capsule of a joint or the sheath of a tendon. They can be found at different places on the wrist. A ganglion cyst that grows on the top of the wrist is called a dorsal ganglion. Others are found on the underside of the wrist between the thumb and your pulse point, at the end joint of a finger, or at the base of a finger. Most of the time, these are harmless and will often disappear in time.

    Cause

    A ganglion cyst contains a thick, clear, mucus-like fluid similar to the fluid found in the joint. No one knows what triggers the formation of a ganglion. Women are more likely to be affected than men. Ganglia are common among gymnasts, who repeatedly apply stress to the wrist.

    Symptoms

    • Wrist ganglion.

    Because the fluid-filled sac puts pressure on the nerves that pass through the joint, some ganglion cysts may be painful. Large ganglia, even if they are not painful, are unattractive. Smaller ganglions that remain hidden under the skin (occult ganglions) may be quite painful.

    A ganglion grows out of a joint, like a balloon on a stalk. It rises out of the connective tissues between bones and muscles. Inside the balloon is a thick, slippery fluid similar to the fluid in your joints. Usually, the more active the wrist, the larger the cyst becomes. With rest, the lump generally decreases in size.

    Diagnosis

    Your doctor may ask you how long you have had the ganglion, whether it changes in size, and whether it is painful. Pressure may be applied to identify any tenderness. A penlight may be held up to the cyst to see whether light shines through. X-rays may be taken to rule out other conditions, such as arthritis or a bone tumor. Sometimes, an MRI or ultrasound is needed to find a ganglion cyst that is not visible.

    Treatment

    Initial treatment is not surgical.

    • Observation: Because the ganglion is not cancerous and may disappear in time, just waiting and watching may be enough to make sure that no unusual changes occur.
    • Immobilization: Activity often causes the ganglion to increase in size. This is because activity increases pressure on nerves, causing pain. A wrist brace or splint may relieve symptoms, letting the ganglion decrease in size. As pain decreases, your doctor may prescribe exercises to strengthen the wrist and improve range of motion.
    • Aspiration: If the ganglion causes a great deal of pain or severely limits activities, the fluid may be drained from it. This procedure is called " aspiration." The area around the ganglion cyst is numbed and the cyst is punctured with a needle so that the fluid drains away.

    Nonsurgical treatment leaves the outer shell and the stalk of the ganglion intact, so it may reform and reappear.

    The ganglion cyst can be removed through outpatient surgery, but this is no guarantee that the cyst will not grow again. Surgery may also include removing part of the involved joint capsule or tendon sheath. There may be some tenderness, discomfort, and swelling after surgery. Normal activities usually may be resumed two to six weeks after surgery.

  • Nail Bed Injuries

    What is involved with nail bed injuries?

    Injuries to the nail are often associated with damage to other structures that are in the same location. These include fractures of the bone (distal phalanx), and/or cuts of the nailbed, fingertip skin (pulp), tendons that straighten or bend the fingertip, and nerve endings.

    What causes nail bed injuries?

    Many result from crush injuries after getting the fingertip caught in a door. Any type of pinching, crushing, or sharp cut to the fingertip may result in injury to the nail bed.

    Presentation of nail bed injuries

    Simple crushes of the fingertip may result in a very painful collection of blood (hematoma) under the nail. More severe injuries can result in cracking of the nail into pieces, or tearing off of pieces of the nail and/or fingertip, and possible injuries to the adjacent structures.

    Diagnosis of nail bed injuries

    An accurate history of the cause of the injury should be obtained. X-rays are recommended to look for associated fractures that may require treatment. The full extent of the injury may not be evident until adequate anesthesia (usually local) is given and the nail is examined with magnification. Other medical conditions that may affect healing should be discussed with your physician.

    Treatment of nail bed injuries

    Restoring the normal anatomy of the nail and surrounding structures is the goal of treatment. Simple hematomas are drained by making a small hole in the nail in order to relieve the pressure and provide pain relief. Straightforward cuts are repaired to put the parts back where they belong.

    Repairing the nail bed to which the fragments of bone are attached usually restores alignment of many fractures of the fingertip. Larger fragments of bone may need to be pinned or require splinting to heal the fracture. Missing areas of nail bed can be grafted from the same finger or from other digits. Tendon injury may require splinting or pinning. Local flaps of skin may be used to replace missing skin, or the open area of skin may be allowed to just heal on its own, or covered with a skin graft.

    Prognosis

    The final appearance and function of the nail and surrounding structures depends on the ability to restore the normal anatomy. If the injury is sharp and can be repaired, a normal nail is likely. If there is more severe crushing of the nail bed, then there is a greater likelihood of nail bed scarring and subsequent deformity of the nail. If the germinal matrix (crescent-shaped zone at the base of the nail bed from which the nail grows) is injured, there will likely be a deformity of the nail as it grows. The function of the fingertip also depends on the extent of injury to structures other than the nail. It normally takes 3-6 months for the nail to grow from the cuticle to the tip of the finger.

    Surgical Reconstruction

    Loss of part or all of the nail bed can be reconstructed with grafts from other digits. Grafts may be taken from the nail bed of a toe to prevent further injury or deformity of the fingers. The most common graft is a split-thickness graft to reconstruct missing nail bed.

    • Figure 1: The anatomy of the nail bed and surrounding structures.
    Figure 2: The anatomy of the nail bed and surrounding structures from a lateral view.
  • Replantation

    Replantation aims to restore the amputated part to its anatomical site, preserving function and appearance. Outcome depends on factors intrinsic to the patient and to the nature of the injury. Young patients who have distal, cleanly amputated extremities have the best return of function; multiple levels of injury, crush, or avulsing injuries have less. Patients must be fully informed about the commitment to rehabilitation and the possibility of multiple surgeries for best results.

    With the advent of microvascular reanastomosis, digit replantation became tenable. In 1965, Shigeo Kmatsu and Susumu Tamai were the first to perform such a procedure. Since then, medicine has advanced to include the successful replantation of a child's completely amputated ear as well as replantation of multiple digits and hands.

    What is replantation?

    Replantation refers to the surgical reattachment of a finger, hand, or arm that has been completely cut from a person's body (see photos below). The goal of replantation surgery is to give the patient back as much use of the injured area as possible. In some cases, replantation is not possible because the part is too damaged. If the lost part cannot or should not be reattached, you may have the alternative of a completion amputation with or without a prosthesis, a device that substitutes for a missing part of the body. In some cases, this option will give you better and faster recovery than a replantation.

    Replantation is usually recommended when the replanted part will work at least as well as a prosthesis or completion amputation. Generally, a missing hand or finger would not be replanted knowing that it would not work, be painful, or get in the way of everyday life. Before surgery, Dr. Kupfer will explain the procedure and the substantial commitment of time and effort needed from the patient for recovery, as well as how much use is likely to return following replantation. The patient and/or family members must decide whether that amount of use justifies the long and difficult operation, time in the hospital, and months or years of rehabilitation.

    How is the procedure done?

    There are a number of steps in the replantation process. First, damaged tissue is carefully removed. Then bone ends are shortened and rejoined with pins or plates. This holds the part in place to allow the rest of the tissues to be restored to a normal position. Muscles, tendons, arteries, nerves and veins are then repaired. Sometimes grafts of bone, skin, tendons, and blood vessels may be needed, too.

    What kind of recovery can I expect?

    As the patient, you have a very important role in the recovery process. Smoking causes poor circulation and may cause loss of blood flow to the replanted part. You can improve the blood flow to the replanted part by not smoking. Allowing the replanted part to hang below heart level may also cause poor circulation. Age plays a role in recovery. Younger patients have a better chance of their nerves growing back; they may regain more feeling and movement in the replanted part. Generally, the further down the arm the injury occurs, the better the return of use of the replanted part. Patients who have not injured a joint will get more movement back than those with a joint injury. A cleanly severed part usually works better after replantation than one that has been pulled off or crushed. Recovery of use depends on re-growth of two types of nerves: sensory nerves that let you feel, and motor nerves that tell your muscles to move. Nerves grow about an inch per month. The number of inches from the injury to the tip of a finger gives the minimum number of months after which the patient may be able to feel something with that fingertip. The replanted part never regains 100% of its original use, and most doctors consider 60% to 80% of use an excellent result. Cold weather may be uncomfortable and be a cause of frequent complaints even for those with excellent recovery.

    What about therapy and rehabilitation?

    Complete healing of the injury and surgical wounds is only the beginning of a long process of rehabilitation. Therapy and temporary bracing are important to the recovery process. From the beginning, braces are used to protect the newly repaired tendons but allow the patient to move the replanted part. Therapy with limited motion helps keep joints from getting stiff, helps keep muscles mobile, and helps keep scar tissue to a minimum. Even after you have recovered, you may find that you cannot do everything you wish to do. Tailor-made devices may help many patients do special activities or hobbies. Talk to your physician or therapist to find out more about such devices. Many replant patients are able to return to the jobs they held before the injury. When this is not possible, patients can seek assistance in selecting a new type of work.

    Will additional surgery be necessary?

    After replantation surgery, some patients may need additional surgery at a later time to gain better function of the part. Some of the more common procedures are:

  • Scaphoid Fractures

    What are scaphoid fractures?

    The scaphoid bone is one of the eight small bones that make up the "carpal bones" of the wrist. There are two rows of bones, one closer to the forearm (proximal row) and the other closer to the hand (distal row). The scaphoid bone is unique in that it links the two rows together (see Figure 1). This puts it at extra risk for injury, which accounts for it being the most commonly fractured carpal bone.

    How do scaphoid fractures occur?

    Fractures of the scaphoid occur most commonly from a fall on the outstretched hand. Usually it hurts at first, but the pain may improve quickly, over the course of days or weeks. Bruising is rare, and there is usually no visible deformity and only minimal swelling. Since there is no deformity, many people with this injury mistakenly assume that they have just sprained their wrist, leading to a delay in seeking evaluation. It is common for people who have fractured this bone to not become aware of it until months or years after the event.

    Diagnosis of scaphoid fractures

    Scaphoid fractures are most commonly diagnosed by x-rays of the wrist. However, when the fracture is not displaced, x-rays taken early (first week) may appear negative. A non-displaced scaphoid fracture could thus be incorrectly diagnosed as a "sprain." Therefore a patient who has significant tenderness directly over the scaphoid bone (which is located in the hollow at the thumb side of the wrist, or "snuffbox" ) should be suspected of having a scaphoid fracture and be splinted (see Figure 2). An X-ray a couple of weeks later may then more clearly reveal the fracture. In questionable cases, MRI scan, CT scan, or bone scan may be used to help diagnose an acute scaphoid fracture. CT scan and/or MRI are also used to assess fracture displacement and configuration. Until a definitive diagnosis is made,the patient should remain splinted to prevent movement of a possible fracture.

    • ScaphoidFracturesScaphoidFracturesScaphoid Fracture

    Treatment of scaphoid fractures

    If the fracture is non-displaced, it can be treated by immobilization in a cast that usually covers the forearm, hand, and thumb, and sometimes includes the elbow for the first phase of immobilization. Healing time in a cast can range from 6- 10 weeks and even longer. This is because the blood supply to the bone is variable and can be disrupted by the fracture, impairing bony healing. Part of the bone might even die after fracture due to loss of its blood supply, particularly in the proximal third of the bone, the part closest to the forearm. If the fracture is in this zone, or if it is at all displaced, surgery is more likely to be recommended. With surgery, a screw or pins are inserted to stabilize the fracture, sometimes with a bone graft to help heal the bone (see Figure 3). Surgery to place a screw may also be recommended in non-displaced cases to avoid prolonged casting.

    • ScaphoidFracturesScaphoidFractures Scaphoid Fracture

    Complications of scaphoid fractures

    Non-union: If a scaphoid fracture goes unrecognized, it often will not heal. Sometimes, even with treatment, it may not heal because of poor blood supply. Over time, the abnormal motion and collapse of the bone fragments may lead to mal-alignment within the wrist and subsequent arthritis. If caught before arthritis has developed, surgery may be performed to try to get the scaphoid to heal.

    Avascular necrosis: A portion of the scaphoid may die because of lack of blood supply, leading to collapse of the bone and later arthritis. Fractures in the proximal one third of the bone, the part closest to the forearm, are more vulnerable to this complication. Again, if arthritis has not developed, surgery to try to stabilize the fracture and restore circulation to the bone may be attempted.

    Post-traumatic arthritis: If arthritis has already developed, salvage-type procedures may be considered, such as removal of degenerated bone or partial or complete fusion of the wrist joint.

    • ScaphoidFracturesScaphoidFractures Figure 1: The scaphoid bone is unique in that it spans the two rows of wrist bones.
    • ScaphoidFracturesScaphoidFractures Figure 2: Significant tenderness directly over the scaphoid bone (which is located in the hollow at the thumb side of the wrist).
    • ScaphoidFracturesScaphoidFractures Figure 3: A screw or pins are placed to stabilize the fracture.
  • Tennis Elbow/Lateral Epicondylitis

      tenniselbow

    What is tennis elbow/lateral epicondylitis?

    Lateral epicondylitis, commonly known as tennis elbow, is a painful condition involving the tendons that attach to the bone on the outside (lateral) part of the elbow. Tendons anchor the muscle to bone. The muscle involved in this condition, the extensor carpi radialis brevis, helps to extend and stabilize the wrist (see Figure 1). With lateral epicondylitis, there is degeneration of the tendon's attachment, weakening the anchor site and placing greater stress on the area. This can then lead to pain associated with activities in which this muscle is active, such as lifting, gripping, and/or grasping. Sports such as tennis are commonly associated with this, but the problem can occur with many different types of activities, athletic and otherwise.

    What causes tennis elbow/lateral epicondylitis?

    Overuse: The cause can be both non-work and work related. An activity that places stress on the tendon attachments, through stress on the extensor muscle-tendon unit, increases the strain on the tendon. These stresses can be from holding too large a racquet grip or from "repetitive" gripping and grasping activities, i.e. meat-cutting, plumbing, painting, weaving, etc.

    Trauma: A direct blow to the elbow may result in swelling of the tendon that can lead to degeneration. A sudden extreme action, force, or activity could also injure the tendon.

    Who gets tennis elbow/lateral epicondylitis?

    The most common age group that this condition affects is between 30 to 50 years old, but it may occur in younger and older age groups, and in both men and women.

    Signs and symptoms of tennis elbow/lateral epicondylitis.

    Pain is the primary reason for patients to seek medical evaluation. The pain is located over the outside aspect of the elbow, over the bone region known as the lateral epicondyle. This area becomes tender to touch. Pain is also produced by any activity which places stress on the tendon, such as gripping or lifting. With activity, the pain usually starts at the elbow and may travel down the forearm to the hand. Occasionally, any motion of the elbow can be painful.

    Treatment for tennis elbow/lateral epicondylitis

      tenniselbow
    Conservative (non-surgical)

    Activity modification: Initially, the activity causing the condition should be limited. Limiting the aggravating activity, not total rest, is recommended. Modifying grips or techniques, such as use of a different size racket and/or use of 2-handed backhands in tennis, may relieve the problem.

    Medication: anti-inflammatory medications may help alleviate the pain.

    Brace: a tennis elbow brace, a band worn over the muscle of the forearm, just below the elbow, can reduce the tension on the tendon and allow it to heal.

    Physical Therapy: may be helpful, providing stretching and/or strengthening exercises. Modalities such as ultrasound or heat treatments may be helpful.

    Steroid injections: A steroid is a strong anti-inflammatory medication that can be injected into the area. No more than (3) injections should be given.

    Shockwave treatment: A new type of treatment, available in the office setting, has shown some success in 50–60% of patients. This is a shock wave delivered to the affected area around the elbow, which can be used as a last resort prior to the consideration of surgery.

    Platelet Rich Plasma injection: Platelet Rich Plasma (PRP) injections represents the newest non-surgical option to treat epicondylitis. The patient's blood is centrifuged separating and concentrating the platelets and growth factors from the rest of the blood. The preparation is then injected into the epicondylar tendon. Studies suggest an 80% success rate at 6 months follow up.

    • tenniselbowtenniselbowPRP injection

    Surgery

    Surgery is only considered when the pain is incapacitating and has not responded to conservative care, and symptoms have lasted more than six months. Surgery involves removing the diseased, degenerated tendon tissue. Two surgical approaches are available; traditional open surgery (incision), and arthroscopy' a procedure performed with instruments inserted into the joint through small incisions. Both options are performed in the outpatient setting.

    Recovery

    Recovery from surgery includes physical therapy to regain motion of the arm. A strengthening program will be necessary in order to return to prior activities. Recovery can be expected to take 4–6 months.

    • tenniselbowtenniselbow
    Figure 1: The muscle involved in this condition, the extensor carpi radialis brevis, helps to extend and stabilize the wrist.
  • Trigger Finger

    What is trigger finger or stenosing tenosynovitis?

    Stenosing tenosynovitis, commonly known as "trigger finger" or "trigger thumb", involves the pulleys and tendons in the hand that bend the fingers. The tendons work like long ropes connecting the muscles of the forearm with the bones of the fingers and thumb. In the finger, the pulleys are a series of rings that form a tunnel through which the tendons must glide, much like the guides on a fishing rod through which the line (or tendon) must pass. These pulleys hold the tendons close against the bone. The tendons and the tunnel have a slick lining that allows easy gliding of the tendon through the pulleys (see Figure 1).

    Trigger finger/thumb occurs when the pulley at the base of the finger becomes too thick and constricting around the tendon, making it hard for the tendon to move freely through the pulley. Sometimes the tendon develops a nodule (knot) or swelling of its lining. Because of the increased resistance to the gliding of the tendon through the pulley, one may feel pain, popping, or a catching feeling in the finger or thumb (see Figure 2). When the tendon catches, it produces irritation and more swelling of the pulley. This causes a vicious cycle of triggering and thickening of the pulley. Sometimes the finger becomes stuck or locked, and is hard to straighten or bend.

    What causes trigger finger / stenosing tenosynovitis?

    Causes for this condition are not always clear. Some trigger fingers are associated with medical conditions such as rheumatoid arthritis, gout, and diabetes. Local trauma to the palm/base of the finger may be a factor on occasion, but in most cases there is not a clear cause.

    Signs and symptoms of trigger finger / stenosing tenosynovitis:

    Trigger finger/thumb may start with discomfort felt at the base of the finger or thumb, where they join the palm. This area is often tender to local pressure. A nodule may sometimes be found in this area. When the finger begins to trigger or lock, the patient may think the problem is at the middle knuckle of the finger or the tip knuckle of the thumb, since the tendon that is sticking is the one that moves these joints.

    Treatment of trigger finger / stenosing tenosynovitis:

    The goal of treatment in trigger finger/thumb is to eliminate the catching or locking and allow full movement of the finger or thumb without discomfort. Swelling around the flexor tendon and tendon sheath must be reduced to allow smooth gliding of the tendon. The wearing of a splint or taking an oral anti-inflammatory medication may sometimes help. Treatment may also include changing activities to reduce swelling. An injection of steroid into the area around the tendon and pulley is often effective in relieving the trigger finger/thumb.

    If non-surgical forms of treatment do not relieve the symptoms, surgery may be recommended. This surgery is performed as an outpatient, usually with simple local anesthesia. The goal of surgery is to open the pulley at the base of the finger so that the tendon can glide more freely. Active motion of the finger generally begins immediately after surgery. Normal use of the hand can usually be resumed once comfort permits. Some patients may feel tenderness, discomfort, and swelling about the area of their surgery longer than others. Occasionally, hand therapy is required after surgery to regain better use.

  • Toe to Hand Transplant

    Toe to thumb transplant for hand reconstruction

    The thumb is responsible for about 50% of the hand's function and agility. Toe-to-thumb transplantation can restore both aesthetic and functional loss to the hand with little loss of function to the foot. The human thumb is unique in that it is opposable -- it has the ability to touch each fingertip of the same hand. Simply picking up and grasping objects and fine motor skills are all made possible by the opposing thumb.

    The hand and foot have many common features; the great toe is particularly suitable to replace a missing thumb and restoring strong opposable function. Although somewhat wider than the thumb, the transplanted great toe decreases in size up to one third when transplanted to the hand.

    Microsurgery makes it possible to connect small arteries, veins and nerves that are necessary for successful digital and other free tissue transplants.

    Case example:


    • Unsuccessful replantation

    • Intra op photograph

    • Ten years post op

    • Ten years post op

    • Ten years post op

    • Ten years post op
  • Medical Provider Network – MPN

    The folling is a list of the MPN insurance carriers Dr. Kupfer is associated with.
    This list is updated on a monthly basis. Last Updated: 2/05/2013

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