There have been several comments recently about how it seems strange that plastic surgeons are the leaders in peripheral nerve surgery, specifically as it relates to chronic headaches. Many have wondered why this type of procedure is not performed by neurosurgeons as would seem intuitive. As with any questions, there are often several components to the answers.
First, let me start by saying that I am not a neurosurgeon nor is anything in this post intended to disparage neurosurgeons. Their profession is a difficult and exquisitely complex one, but like many fields within medicine, typically limited to specific areas of focus. While I'm sure that there are neurosurgeons out there who do peripheral nerve work, most those with whom I have interacted and worked focus exclusively on the brain and spinal cord. Indeed, pathology within these two body parts are complex enough and could keep any practitioner busy for the rest of his/her career. Therefore, while nerves exist throughout the body, if you’ve never operated outside of the brain, spinal cord or immediate paraspinal regions repairing a nerve in the forearm would be difficult for a number of reasons. One, the anatomy is foreign and there are many structures which are unfamiliar and can be injured inadvertently resulting in worse pathology. Two, it is well-known that peripheral nerves are distinctly different than nerves within the central nervous system and therefore medical/surgical treatments which may be effective in one area, maybe ineffective in the other. Third, the operation is only a part of the overall treatment of a patient hence a surgeon must be able to manage the expectations of the patient prior to the operation and any complications/issues that might arise post-operatively. These skills require specific experience with specific procedures (see above).
Second, I should explain why plastic surgeons are uniquely qualified to perform peripheral nerve surgical procedures. Plastic surgeons are known for, among other things, being able to operate on all parts of the body. When we perform reconstructive or aesthetic procedures, we operate everywhere from the head to the feet. As part of our reconstructive training we are taught how to move and mobilize tissue from one part of the body to fill defects created either by surgery or trauma in other parts of the body. We therefore often run into peripheral nerves during these dissections and are familiar with their locations, anatomic variations and surrounding anatomy throughout the body. For example, one main sub-field of plastic surgical training is hand surgery which obviously involves many, very critical nerves. Approximately 50% of all hand surgical procedures performed in this country are performed by plastic surgeons. A few decades ago, several plastic surgeons, a little bit older and far wiser than I, began to ask themselves, ‘If nerves can be manipulated within the upper extremities and hands to relieve pain, provide sensation or restore function, why would it not be possible to perform similar types of procedures in the legs, trunk, head or neck for the same purposes?’ These pioneers adapted the surgical principals they were using in the upper extremities to these other parts of the body and for some it became the focus of their careers. It also soon became apparent that many of the principals that are applied, for example, to release of the median nerve in a patient with carpal tunnel syndrome can be applied to nerves within the foot and ankle in a patient who has tarsal tunnel syndrome. A second-generation of plastic surgeons luckily recognized the potential of these procedures, learned from the prior generation and continued their work. I’d like to also believe that we’ve been able to advance the field by applying established peripheral nerve surgical principles to yet other nerves which were once thought untouchable (e.g. I routinely see patients in my office with meralgia paresthetica who were told they would have to live with their pain forever), but have now been successfully operated upon. In addition, we have tools that didn’t exist previously such as biologic nerve allografts and utilize newer techniques such as targeted re-innervation to give amputees relief of pain as well as the potential for use of functional myoelectric prostheses. In short, peripheral nerve surgery is an exciting and burgeoning field within the larger realm of plastic surgery which will hopefully continue to grow and develop. While other surgeons may be able to perform such procedures, plastic surgeons have been and continue to be some of the pioneers in the field for the reasons noted above.
For more information on how we can help with your nerve related issues, please call us at (415) 751-0583 in San Francisco and (925) 933-5700 to set up an appointment, and visit www.peledmigrainesurgery.com today to read more about us!