Epinephrine in digits is safe during hand repair

Boston - It is safe and effective to use epinephrine in the digits for hand rejuvenation and hand repair, according to Emily Fisher, M.D., chief of cosmetic dermatology and laser dermatology, Lahey Clinic, Boston.

"For many years, it was thought that epinephrine was unsafe to use in the digits, and some physicians still practice with that philosophy in mind,” says Dr. Fisher, who spoke at the 2012 American Academy of Dermatology Summer Academy Meeting. “But there have been multiple studies over the past decade or so which show that epinephrine can be used safely in the digit," unless patients have a history of digital ischemia, Raynaud's disease or peripheral vascular disease.

Epinephrine also improves results by providing a relatively bloodless field and prolonging the anesthesia's effects, both of which can ease patient recovery, Dr. Fisher says.

More than skin deep
Successful rejuvenation or repair of the hand demands careful review of the subcutaneous anatomy, Dr. Fisher says.

"As dermatologists, many of us are not operating on the hands every day, so it's very important to always review the anatomy,” she explains. “The good thing about the hand is that the important motor nerves are deep, so they're not at very high risk for injury.”

Tendons in the hand can be at higher risk, especially in elderly patients, because often they have minimal subcutaneous fat, Dr. Fisher says. To prevent complications, "Factors to consider include the joint. If you're operating over a joint on the hand, be very careful in designing a repair so that you're not putting too much tension over that joint because it can prohibit movement. This, in turn, can lead to long-term mobility problems.”

Sometimes, repairs such as grafts can contract over time. So it's important to consider the long term when designing repair procedures for the hand, she says.

If one notices a mobility issue post-surgically, “Get the patient involved in occupational physical therapy very quickly,” Dr. Fisher says. “Doing exercises to regain mobility and strength can prevent a lot of problems. Or, in the worst-case scenario, you may have to do a revision or repair of the procedure to restore the joint's mobility."

Palm pearls
Although dermatologists rarely operate on the palm, this area is at risk for tenosynovitis, a dangerous infection of the flexor tendon sheath of the hand, Dr. Fisher says. Because the thumb and small finger communicate with this sheath, operating on those digits involves risk as well. If not properly treated, tenosynovitis can threaten the entire hand.

Disclosures: Dr. Fisher reports no relevant financial interests.

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