Dr. Mackenzie performs hand surgery in Santa Barbara. Fellowship trained in hand surgery, Dr. Mackenzie was the co-director of the Hand Surgery Fellowship while he was Assistant Professor of Plastic and Reconstructive Surgery at Oregon Health Sciences University, prior to coming to Santa Barbara in 2000. Dr. Mackenzie is also a member of the American Society for Surgery of the Hand.
Along with his private practice in aesthetic plastic surgery, Dr. Mackenzie’s activities in reconstructive surgery and hand surgery follow a direct-pay practice model. (See description of direct-pay practice here.) Therefore, the hand surgery procedures that Dr. Mackenzie currently performs are focused on certain procedures that are best suited to this type of practice.
Descriptions of some of these procedures are outlined below. Please call our office if a hand surgery procedure you need is not listed here and we will tell you if Dr. Mackenzie can perform the surgery for you. If not, we will refer you to one of the excellent hand surgeons in Santa Barbara who does.
Carpal Tunnel Syndrome
Most people are aware of carpal tunnel release, and probably know someone who has had it done. Carpal tunnel syndrome is a compression neuropathy where the median nerve gets squeezed at the wrist, causing numbness and pain typically of the index and middle fingers and sometimes ring finger and thumb. It is often worsened by certain wrist positions, even waking the patient at night. It can also affect the small muscles in the hand if left untreated. Although it is commonly thought of as being related to overuse or repetitive activities, it can occur randomly or be associated with other compression neuropathies or diseases such as diabetes.
Nonsurgical treatments, such as rest, splinting, or nonsteroidal anti-inflammatory medications, may help, but if persistent, carpal tunnel syndrome responds well to surgical release of the ligament that compresses the nerve at the wrist. There are many techniques available to do this. The surgery is very effective and safe, with a minimal recovery period and usually no need for hand therapy afterward.
Cubital Tunnel Syndrome
Like carpal tunnel syndrome, this is another common compression neuropathy. It is a compression of the ulnar nerve at the elbow, and similarly responds to decompression of the affected nerve. Common symptoms are numbness of the ring and small fingers, and weakness of grip.
Compression neuropathies are usually diagnosed by history and clinical exam, but electrophysiologic testing (EMGs and nerve conduction studies) may be done for confirmation.
Another common problem is a ganglion cyst, which is a fluid filled cyst that arises out of a joint. Although ganglion cysts can occur almost anywhere, certain spots are much more common than others. The back of the wrist (dorsal wrist ganglion) and the palm side of the wrist (volar wrist ganglion) are common sites. Ganglions of the distal finger joints are usually called mucous cysts. They can distort fingernail growth and are commonly associated with degenerative arthritis.
These cysts are most reliably treated with surgery to excise the cyst, repair the defect in the joint capsule, and remove any offending arthritic bone spurs that may be the cause of the cyst. Aspiration (removing the cyst fluid with a needle) is usually only temporarily effective at best, and not recommended for most cysts. Some cysts arising from the wrist can be associated with other pathology that may need other procedures, such as wrist arthroscopy, for diagnosis and treatment.
This is a condition in which fibrous, scar-like tissue forms under the skin in the palm. It usually affects the ring and small fingers, although any finger can be affected. It has a propensity for men of northern European descent, and may be associated with certain other conditions. As this scar tissue worsens, it pulls the affected fingers in, causing any number of functional problems due to the deformity. Many patients are also bothered by the cosmetic deformity that it causes.
Surgery for Dupuytren’s contracture involves removing the scar tissue from the palm and fingers, carefully avoiding the nerves and other delicate structures of the hand. Recovery after this surgery is significant, usually involving splinting and hand therapy for a few weeks. There is now an effective alternative to surgery for some people with Dupuytren’s, which is injection of an enzyme called Xiaflex into the Dupuytren’s scar tissue. Results are similar to surgery, although the treatment may need to be repeated or staged for multiple fingers. Recurrence of Dupuytren’s contracture after surgery or Xiaflex is always possible and seems to be somewhat higher for Xiaflex. (Use of Xiaflex requires training and certification which Dr. Mackenzie has received).
This common condition can affect any finger. It is a jerking, or “triggering,” of the tendon that flexes the finger as it passes through the tendon’s sheath. Think of a knot in a rope as it passes through a pulley. In severe cases the finger may get locked into a flexed position, a condition which requires early intervention to avoid possible permanent stiffness. Mild triggering might be relieved with rest or nonsteroidal anti-inflammatory medications. Steroid injection is usually the next step, and can relieve mild or moderate triggering in many cases. Percutaneous release of the pulley or open surgery are more definitive treatments, and can be done with minimal recovery and downtime.
Fingertip and Fingernail Injuries
One can imagine an infinite variety of fingertip and nailbed injuries. X-rays are often necessary to rule out a fracture of the distal finger bone. Soft tissue injuries of the fingerpad may need nothing more than debridement (cleaning up the injury), as the fingerpad has a remarkable ability to heal, and sometimes performing flaps or placing skin grafts on this area can do more harm than good. When a more complex reconstruction is necessary, it is often done on an elective basis after initial healing.
In fingertip injuries, the nailbed is often neglected, and untreated nailbed injuries can cause permanent deformity of the nail. Obvious or suspected nailbed injuries need removal of the nail with careful evaluation and repair of the nailbed. If the nailbed is healthy, the nail will grow back over the next few months.
Besides the face, the hands are the most sun-exposed parts of the body, and often don’t get the sunscreen protection that we are used to using on our faces. Therefore, they are susceptible to sun damage and skin cancers. Basal cell cancer and squamous cell cancer are common skin cancers of the hand. Fortunately, melanoma is a much less common cancer. Melanoma is particularly likely to be lethal if left untreated, and other types of skin cancer can also lead to permanent deformity or death when not promptly treated. Any suspicious lesion, or any coloration change of the nailbed, should be evaluated by a dermatologist or hand surgeon without delay.
Removal of basal cell and squamous cell cancers can usually be done with minimal scarring and little or no resulting deformity, although larger or neglected ones may need procedures such as flaps or skin grafts to reconstruct the defect. Melanoma will likely need a bigger excision and possible finger amputation, depending on the melanoma’s location, size, and depth.
Cosmetic Hand Procedures
As the hand ages, atrophy of the skin and subcutaneous tissues reveal more of the veins on the back of the hand and create a more aged, skeletonized appearance. The skin suffers from sun damage, with discoloration and age spots, wrinkles, and lesions such as seborrheic or actinic keratoses.
For sun damage, cosmetic improvement of the hand usually involves surface treatments including chemical peels and Intense Pulsed Light (IPL). For atrophy, filling the dorsum (back) of the hand with fat injections or Radiesse can give a more youthful contour. Sclerotherapy or vein stripping may be done in some cases.