Replantation and Microsurgical Reconstruction: Why Timing Matters

Over the last two years, microsurgical success rate has been about 99%, with only two procedures not meeting expectations. For cosmetic procedures, outcomes depend heavily on patient expectations being realistic to begin with; when they are, success runs around 90-95%.

As with any surgery, there is a roughly 4-5% complication rate per case, managed through department protocols designed to minimise it. Patients prone to keloid scarring can develop keloid formation after cosmetic procedures. Patients with comorbidities like diabetes, hypertension or thyroid disease carry a higher chance of wound dehiscence, infection, haematoma or seroma formation, these are best thought of as expected side effects to plan around rather than true complications in most cases.

Yes, it varies significantly. For the arm, the golden period is 4 hours. For the forearm, 6 hours. For fingers, replantation can be attempted even at 8-10 hours. Early in his practice, proximal replantation was attempted at 10-12 hours, but the post-operative course was unpredictable enough that the lesson learned was not to attempt proximal replantation beyond 4, at most 6, hours.

Yes. For fingers, toe-to-hand transfer can restore good functional benefit even when the original finger wasn't salvaged in time. A few centres, though not this one yet, have started cadaveric hand transplant, though this is legally restricted in India to Indian citizens only, ruling it out for international patients. This centre is planning to start a hand transplant programme within about a year to a year and a half. In the meantime, options include toe transfer, cosmetic prostheses including osseointegrated ones, and myoelectric bionic hands.

Three things: clinical examination first, to map out the deformity pattern and plan; nerve conduction study and EMG, to identify how many donor nerves or muscles are available for transfer; and MRI, to map the brachial plexus itself. Both birth-related (obstetric) and adult traumatic or oncological brachial plexus injuries are managed with this same three-part workup.

Yes, significantly: roughly 4 hours for the arm, 6 hours for the forearm, and 8-10 hours for fingers, which tolerate ischaemia better due to lower muscle mass. Proximal replantation beyond 4-6 hours carries an unpredictable post-operative course.

Toe-to-hand transfer can restore meaningful function for a lost finger. Cosmetic or osseointegrated prostheses and myoelectric bionic hands are further options. Cadaveric hand transplant exists at a few centres but is restricted to Indian citizens under Indian law.