[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!

[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 … ??

[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.

[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 ??

[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.

[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.

[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??