Fascia Tightening ??

[vdaramola]

Fascia Tightening ??

I’ve seen Hugh Gelabert (nothing to offer). I’ll try Sam Ahn. I’ve heard he is doing angiogram for diagnosing TOS, maybe he’ll be willing to go further down my arm.

Thanks again for all your help!

[drtowfigh]

Fascia Tightening ??

Try Dr. Sam Ahn in Los Angeles. He is very good at thinking outside the box and trying innovative things.
Also, can try Dr. Hugh Gelabert.
Both are vascular surgeons.

Good luck!

[vdaramola]

Fascia Tightening ??

Dr. Towfigh, thanks for putting so much time into my unusual case. I really do appreciate it.

I have been evaluated at the neck area quite extensively by different docs – positional venogram, CT angiogram, MRI/MRA/MRV, and of course numerous ultrasounds. Venous thoracic outlet syndrome (w/out a clot) was one of the first thoughts. All the testing has been normal. However, the vascular system has NOT been evaluated from shoulder to hand (other than ultrasound). Personally, I think it’s reasonable (at this very desperate place) to do a full look at my entire arm, with modality more robust than ultrasound. … CT venogram, angiogram/venogram, descending venography — but I am unable to get anyone to do this. The doctor at Kleinert Kutz was in disbelief as he reviewed my normal positional venogram. He said it had to be coming from higher up, but when I asked he if would do some sort of venography or investigation of my arm (upper arm, forearm or ideally both) — he wouldn’t do it. And, like so many others, he said – sorry, don’t know the cause of your pain. I tried to see the vascular/interventional radiologist at Stanford, and he wouldn’t take my case. I sent my records, pictures, an explanation of what’s going on — and I couldn’t even get an appointment. And of course, I’ve been too numerous vascular docs and hand docs that have all too easily been able to say — sorry, nothing to offer.

Is there someone or some particular speciality (that I’m unaware of) that would be willing to evaluate the blood flow in my arm beyond ultrasound (which is always normal) ?
Maybe I can email you again … ??

[drtowfigh]

Fascia Tightening ??

I am so sorry about your situation.

There is a hand transplant surgeon I reviewed this with as well as another vascular surgeon and two hand surgeons.

All felt that there is nothing to do in terms of fascial tightening. All agreed that you should evaluate for proximal venous obstruction at the neck and upper extremity.

Note that after fascial release, the compartment will eventually scar down. And re-tightening the fascia will only re-exacerbate your issue.

[vdaramola]

Fascia Tightening ??

Thanks for the suggestion. Already discussed. No numbness or tingling. Normal NCV/EMG tests. Pain in hands doesn’t correspond to any particular nerve distribution. Forearms are very loose and soft throughout (actually feel lovely) — no sign of potential scar tissue issue.

The original surgeon did a very thorough job and in op report mentions inspecting the nerves to make sure they were free. He even did extra release around supinator muscle to make more room in Radial tunnel area. The surgeries went smoothly and without incident. I didn’t even have temporary numbness or tingling post-op. Once the swelling went down, the relief in the forearm was tremendous and I felt “cured” by 8 weeks. I eagerly went forward with the other forearm. After the second surgery, I actually went back to work at 10 days post-op. The incisions are the entire length of each forearm from wrist to elbow, on both dorsal and volar sides. The incisions healed beautifully (couldn’t have asked for better) and people barely even notice them.

I can NOT believe this is happening. I am still in shock, awe and disbelief. I am well-aware that what is happening to me is NOT suppose to happen.

When the hand veins start to pool with blood, I would describe the pain as: warmth, fullness, deep aching pain in soft tissue, the veins that bulge as they go over the knuckle to the beginning of the fingers are very sore and particularly painful, the skin on the top of the hand gets a very surface-type “prickling” feeling. Prickling is always relieved with elevation. Even when it’s at its best (mid-day, caffeinated, air-conditioning), hands still feel congested and “sticky” inside as if the inside is soaking in Elmer’s glue. Strange analogy, just don’t know how else to describe it.

Thanks again Dr Earle for all your time and suggestions.

[Chaunce1234]

Fascia Tightening ??

Ask your hand surgeon if a re-exploration and neurolysis is appropriate.Tough situation for sure.

[vdaramola]

Fascia Tightening ??

Thank you very much for your response, Dr Towfigh, especially given it is a holiday weekend.

Yes, I have been extensively worked up for vascular obstruction and vascular thoracic outlet syndrome.
I have had a positional venography exam looking at the subclavian vein, which proved normal in all positions. I then went to another well-known TOS center, and had a CT angiogram w/ special venous TOS protocol — which also showed no vascular abnormalities. I also had an MRI/MRA done by a radiologist specializing in TOS, and again, there was no evidence of vascular TOS. I have also had another 3 MRIs looking at the brachial plexus region, and another MRI ruling out cervical spine issues.

I have also had numerous duplex ultrasound studies (both arterial and venous) and none are showing up abnormal.

The problem is bilateral. I had chronic compartment syndrome in both forearms — and very aggressive fasciotomy/partial fasciectomy surgeries in both forearms. The hand pain and blood pooling began after the forearm surgeries. Veins bulge and visibly dilate in the hand and volar forearm only. Veins are not visible any where else in the extremity, shoulder, chest, or neck.

RSD/CRPS has also been ruled out by numerous specialists and 2 separate triphasic bone scans which were normal.

I recently flew out to Kleinert Kutz, the hand transplant center previously referred to, and they were unable to provide an explanation for my symptoms.

The pain continues to be highly patterned and very severe every single evening. I am unable to sleep, I am unable to spend any time outside in summer heat, and increasingly unable to tolerate warm showers. The muscle compartments are loose and flaccid, particularly the volar compartment, and we know the pressures are very low, 1 mmHg and 3 mmHg – measured at rest midday and the pressures do not increase much after exercise.

Because of the severe pain, I am more than willing to pursue any and all possible causes. But at present, it seems like have ruled out all possibilities and it’s looking more and more like a late sequelae of the fasciectomies.

I would be grateful for any additional thoughts/suggestions ??

[drtowfigh]

Fascia Tightening ??

I have run this case by a couple of vascular surgeons. They have not seen it to this extent with even lower extremity fasciotomies, where you would expect even more problems. Their concern is perhaps there is an outflow obstruction that is causing the painful pooling of blood.

Have you been evaluated for venous flow obstruction? Perhaps a deep venous thrombosis of the upper extremity or a thoracic outlet obstruction in the shoulder or neck region cruising reduced flow of venous blood back to your heart on that side?

[Chaunce1234]

Fascia Tightening ??

Whether or not hernia repair techniques can be applied to your situation is unknown, and would best be dealt with by a hand surgeon of a variety of specialities as I mentioned. That’s really the best I can do as a hernia surgeon. Good luck. DE

[vdaramola]

Fascia Tightening ??

Thank you both for taking the time to reply.

The surgeon did a very thorough job. The fascia and each of the muscle bellies in my forearm were opened up. I just think he may have done “too good” of a job for my particular physiology. As I alluded to, there is a significant swing in my symptoms and it is highly patterned. Awake, alert, mid-day, caffeinated and in air-conditioning – symptoms are present but liveable. But every night, when my body wants to sleep, the pain is over-the-top. I am taking excessive medication to be able to pass out and get any sleep at all. I have read that during the sleep cycle, the sympathetic nervous system relaxes, causing a significant decrease in muscle tone, a drop in blood pressure, and skin vessels dilate to warm the body. To me, the layperson, this seems to support what I am experiencing.

I have tried compression garments and I get some relief but it’s no where near enough. If I wear just the forearm/arm garment without anything on the hand, the blood pooling in the hand gets worse. This makes me nervous. But I wonder if just having the arm sleeve without the hand is cutting off superficial or skin blood return, and if actual muscle belly/fascia tightening (particularly to enhance deep venous flow) would be different. This is most definitely a major concern. I bought my sleeves at a medical supply store; I was measured and then placed into one of the existing standard sizes. Perhaps I might do better with something completely custom. Worth a try, thanks for bringing it up.

I’ve also tried a lymphatic pump – I get some relief during the 50 min cycle. But once the cycle is over and I take the sleeve off, the vessels immediately pool with blood. I’ve been looking into trying to get an ongoing pneumatic pump like what they put on your shins when you are in the hospital over night, that will run all night. The pumps are easy to find, but it doesn’t seem that they have hand/forearm sleeve for these devices. I’ve considered trying a pediatric leg cuff on my forearm, but I really feel I need the hand part to force blood flow in the proper direction. Because caffeine seems so beneficial, I have been exploring medication that induces vasoconstriction. I am *very much* at last resort. (And yes, I have made an appointment in Kentucky w/ a transplant surgeon, as kindly suggested.)

So I guess I’m still wondering… how are people doing a “fasciorrhaphy”, or “fascia tightening” for tummy tucks or mesh applications for hernia repairs ?? Can these be done in the forearm muscles — to a level of tension to increase muscle tone and intramuscular pressure?? Is there a reason these special repairs and suturing techniques can’t be done in the forearm fascia?

Much thanks for the replies.

[DrBachman]

Fascia Tightening ??

It sounds like you have done a lot of research and due diligence, CGI. Have you tried being fitted for a compressive sleeve for the forearm before committing to surgery? There are centers that specialize in treating extremity lymphedema after breast cancer procedures or compression therapy for burns. You might be able to get a sleeve made that provides treatment similar to the compression stockings prescribed for patients with venous congestion of the legs. You could trial this and see if the pain from the congestion improves with an extrinsic increase to your arm’s pressure.

[Chaunce1234]

Fascia Tightening ??

You may want to ask you hand surgeon about the use of mesh. Other than that, surgery and diseases such as yours are out of my field of expertise, so I really can’t comment about the why and how of operations I have never seen, let alone done. I would also frame your questions the same way you have here, and bring up the possibility of using hernia repair techniques if on fact there is a need. The surgeon would then be able to speak with a local general/hernia surgeon to share information.

[vdaramola]

Fascia Tightening ??

Thank you for taking the time to respond! I am very grateful. This information about the expertise of a hand transplant surgeon is very valuable and I will follow up on it.

Your other comments are also interesting. My current hand surgeon comes from an orthopedics background (although he has significant expertise in compartment syndromes.) It has only recently occurred to me to see a hand specialist that also has training in plastics/reconstruction…and I have appointments scheduled in upcoming weeks/months.

Your comment regarding the possible complication of a compartment syndrome has been discussed. My hand surgeon said he would monitor the compartment pressures intra-operatively and then also monitor them very closely in the immediate post-op period. He said it’s possible to continuously monitor. I recognize this is a significant risk. In fact, I have also seen publications in the medical literature that argue against “fasciorrhaphy” in cases of a hernia in the lower leg, and instead recommend a fasciotomy – b/c of risk of compartment syndrome.

I’ll take into account your comment regarding damage to veins in skin. However, I can point to a number of things in my clinical picture that lend itself against this…I just don’t want to make this post too long.

At present, the pressure in the volar compartment is very low — below normal range. Much of venous return is based on pressure gradients. The goal of a fascia tightening surgery would be to bring pressure back into normal range, 4 to 10 mmHG at rest.

My main question is still … is it possible to tighten the fascia around the forearm muscles ?? Are there techniques regularly used in hernia repair that could also be used in the forearm? My surgeon says that anytime he has tried to stitch fascia that it just shreds apart. Yet, I seem to be reading about all these fascia repairs … it even seems like cosmetic tummy tuck procedures rely on “fascia tightening.”

Can it be done? Can someone please explain, or point me in the direction of relevant medical literature?

Obviously, I’m desperate. The pain at night is severe. There is something about “sleepiness” that puts this over-the-top for me. And during the daytime, I find caffeine to be very helpful for symptoms.

Much thanks … and hope to hear something back.

[Chaunce1234]

Fascia Tightening ??

A hand transplant surgeon deals with problems of venous congestion in the arm and forearm and hand.

[Chaunce1234]

Fascia Tightening ??

The fascia in your forearm is currently open, and the most likely explanation for the venous congestion is some sort of damage to the veins in the skin. Tightening the fascia wouldn’t help if that’s the case. Also, tightening the fascia may cause the compartment syndrome to return. There are however many factors involved that would require a more complete evaluation by a hand specialist. Hope this helps!

[vdaramola]

Fascia Tightening ??

Hi Dr Earle,

Thank you very much for your response. Can you help me understand why some fascia tightening/closure techniques wouldn’t work? For example, things like fascia plication, imbrication, figure 8 stitching, fascia lata graft ? I don’t really understand why the fascia just can’t be opened and sewn tighter together (2-0 PDS running suture) ? I am not trying to challenge you…just trying to understand why some of these things wouldn’t work….

Also, why would someone who does hand transplants be helpful? I expect you are referring to Kleinert Kutz in Kentucky??

[Chaunce1234]

Fascia Tightening ??

CDI – Unfortunately, this is in fact a very unique situation, and while I am a huge fan of “cross pollination”, nothing comes to mind that could be extrapolated to your situation. I would seek out other opinions from hand surgeons of varying specialties (general surgery, plastics, and ortho). As a last resort, you may want to get an opinion from a center that does hand transplants. I believe the biggest (and maybe only) program is in Tennessee. Hope this helps!