Hand Surgery

Hand surgery is a big component of plastic surgery, and as a plastic surgeon Dr Aggarwal is involved in the care of both acute and chronic hand conditions.

At Mode Plastic Surgery, we look after the following hand conditions:

  • Acute hand trauma
  • Elective Hand Conditions
    • Dupuytren’s contracture
    • Carpal tunnel release
    • Ganglion removal

Acute Hand Trauma

Dr Aggarwal is often the plastic surgeon on-call for hand injuries via his appointment at Royal Prince Alfred Hospital, and Prince of Wales Hospitals.

For acute injuries it is best to present to a hospital emergency department. At the hospital, after you have been seen by the emergency doctors here the plastic surgery registrar will see and assess you before contacting Dr Aggarwal.

Your surgery may be performed at the hospital at which you presented or, if you are privately insured, or fall under Work Cover NSW, may be undertaken in a private hospital.

  • Private patients
    • Will need to ensure they are covered for the surgery under their health insurance policy by calling their insurer.
    • An exact quote for acute injuries is not always possible as unexpected findings may occur during the surgery however we will always endeavour to give you an approximate for out of pocket cost for surgical and anaesthetic fees prior to surgery.
      • In general this will be $1000-2000 out of pocket depending on the complexity of surgery, duration of surgery, if it takes place out of hours, and if it takes place in a public or private hospital.
      • This does not include anaesthetic fees, excess for your health fund, and post-operative hand therapy visits.
    • WorkCover NSW patients
      • Will need to have their employer lodge a claim with their insurer and have an active claim number
      • Sufficient approvals have to be in place by the insurance company to allow the procedure to take place in a private hospital.
      • WorkCover patients operated in a public hospital still need to have an active claim number prior to surgery.

Elective Hand Surgery

At Mode we see patients for a number of elective hand conditions including:

  • Dupuytren’s contracture
  • Carpal tunnel release
  • Ganglion removal
Procedure Snapshot

Dupuytren’s Disease

This is a disorder in which tissues of the hand thicken to form nodules, and cords, which eventually lead to a functional problem.

  • This disease is largely genetic, and most commonly occurs in men over the age of 60 with a Scandinavian, Irish or Easter European heritage.
    • Interestingly it is virtually unknown in Greece, Middle East and oriental populations.
    • Men are 7 times more commonly affected than women
    • When it occurs in women
      • It is often less severe
      • Nodules can form like men, but these can disappear as the disease progresses
  • Alcohol, smoking and HIV have also been linked to Dupuytren’s disease but probably affect disease progression rather than being the primary cause in the first instance.

  • A layer of tissue under the skin and above the tendons, nerves and vessels in the hand is the palmar aponeurosis. This layer is white in colour and has natural thickenings in certain parts of the palm and fingers (called bands).
  • In Dupuytren’s disease these natural bands thicken abnormally causing development of thick bands of tissue called cords. As cords thicken they cause the fingers to abnormally bend at certain joints, not allowing them to straighten.
  • As cords develop, they can cause severe bending of fingers, with the ring finger being most commonly affected, followed by the little, middle, index fingers and thumb.
  • As this fascial tissue thickens in certain areas it can form hard nodules.

  • Under the skin especially in the areas around the bases of the fingers, the abnormal tissue encases the nerves pulling them closer to the middle of the finger, as well as close to the skin.
  • In some patients the disease is so severe and rapidly progressing that it:
    • Occurs at an early age (in 20s-30s)
    • Affect multiple fingers on both hands
    • Causes knuckle pads (called Garrod’s pads) to develop
    • Affects the feet (Lederhosen’s disease)
    • Affects the penis in men (Peyronie’s disease)
  • Treatment for Dupuytren’s disease is not curative, and is directed at removing the cords that cause functional impairment. By definition, the disease continues to occur, and cords can reform.
  • Duputren’s disease should therefore be treated in patients who have:
    • Functional impairment with work or daily activities
    • Their finger is bent by more than 30 degrees at the first knuckle i.e. At the junction of the finger and the palm (the MCP joint)
    • Their finger is bent by any degree at the first finger joint (the PIP joint)
  • Treatment is not indicated for patients who have
    • No functional impairment
    • Involvement of the palm only
    • Involvement of the finger with only a slight bend at the first knuckle (MCP joint)
    • Isolated nodules
  • Dupuytren’s disease can be treated non surgically or through surgery

Non-surgical treatment (Collagenase – Clostridium Histolyticum, Xiaflex)

  • This is an enzyme that dissolves certain types of Collagen found in the abnormal cords
  • This medication is prepared and injected directly into the cord in an office setting
  • One vial is generally used per cord
  • The patient then returns 24048 hours later and the cord is ruptured by manual manoeuvres after a nerve block.
  • This does cause pain, bruising, swelling and requires a splint.
  • The main downsides of this treatment include
    • Cost
    • Not entirely pain free
    • Carries a 30-40 per cent risk of recurrence
    • There is a risk of tendon rupture and allergic reaction to the medication
  • Performed under General anaesthetic in a hospital setting
  • Depending on extent of disease and number of fingers the surgery can take 45-60minutes per finger.
  • Patients may stay only the day in hospital or overnight
  • Medicare/Health fund rebate: Yes which covers all the hospital costs of surgery and part of the surgical and anaesthetic fee.
  • Is performed under tourniquet control
  • Longitudinal incisions are made on the finger
  • The diseased fascia and cords are removed taking care to preserve the tendons, and especially the nerves which are often encased within the diseased tissue
  • The aim of the procedure is to get the finger as straight as possible, and sometimes certain parts of the joints may need to be released as ligaments around the joints may shorten over time due to the abnormal position
  • Closure is then performed often with Z plasties, and dressings are then applied as well as a back slab
  • You may go home the same day or stay overnight
  • You will be sent home with a sling and adequate pain relief, as well as some oral antibiotics.
  • You will be referred to a hand therapist who will change your splint to a thermoplastic splint, and begin exercises shortly after the operation. You will be required to wear the splint for a short while during the day, and then for several weeks at night, in order to maintain the straight position of the finger.
  • Generally excellent, although there is a period of wound healing, and hand therapy to achieve maximal recovery.

Every surgery carries risks, and therefore one must consider if risks outweigh the benefits for your own personal situation. If they do then the surgery may be well worth it. Dr Aggarwal will discuss the pros and cons of surgery with you during your consultation.

General Complications

  • Risks of anaesthetic – there are general risks of going under an anaesthetic such as a mild stress on the heart and lungs, risk of reaction to anaesthetic drugs and risk of clotting in the legs. These risks are generally low in patients who are otherwise fit and healthy.
  • Bleeding (1-2%) – any bleeding is controlled during surgery and really only arises from the skin incisions. Most stops with hand elevation and compression.
  • Infection (<1%) – this is very rare. However you are given antibiotics during induction (when you are going to sleep), as well as a course of oral antibiotics after your surgery to keep this risk to a minimum.
  • Poor Wound Healing (5%) – Occasionally the thin skin (created as a result of the fascia being excised directly under the skin) is slow to heal and this may require a period of dressings before complete wound closure is achieved. This can be slower if skin grafts are needed (patients with severe nodule formation or those with severe bending of the fingers), or in patients who are diabetic or actively smoking.

Specific Complications

  • Change in sensation – The nerves of the finger may be traumatised during surgery as the cords are dissected free of the nerves that they may encase. As long as the nerves are preserved intact, sensation usually returns but can take months. There is however a risk of injury to the nerve, and if this occurs the nerve is repaired but it can then take longer for the sensation to return.
  • Change in vascularity – Just as the nerves are at risk of injury in severe Dupuytren’s disease, so are the arteries located directly behind them. Furthermore in severely bent fingers the straightening of the finger itself can cause stretch and spasm of the vessels, enough that the finger can become white after surgery. If this occurs the finger is rewarmed and the vessels checked. In most cases the finger pinks up on rewarming and re-bending.
  • Hypertrophic or poor scars – How one’s body behaves to scarring is individual and largely genetic. Some types of skin are more prone to hypertrophic or keloid scarring, and some individuals and families are more prone to this. We will routinely advise you on how to improve the quality of scars over time. You should also discuss any history of abnormal scarring with Dr Aggarwal preoperatively.

Do I need a referral for Dupuytren’s disease?

  • Yes
  • This allows you to claim a Medicare rebate of approximately $73 for the initial consultation, and to be eligible for rebates for surgery.

Where can I see Dr Aggarwal?

  • You can see us at our main practice at Gordon, or at one of our other locations at Hornsby, Hunters Hill or Camperdown.
  • Please scroll to the bottom of the page to find out more information about these locations.

Where will I have my operation?

  • Any of the hospitals where Dr Aggarwal works – i.e. Sydney Adventist Hospital, SAN Day Surgery, or Hunters Hill Private hospital.

What can I do to prepare for surgery?

  • Cease fish oil, and other supplements such as Ginkgo, Ginseng.
  • Please discuss with Dr Aggarwal if you are on blood thinning medications as to when you should stop and recommence those.
  • If you are smoking you need to cease this well in advance of surgery.

After surgery, will I need to wear a special garment?

  • Yes you will be placed in a backslab immediately. This will be changed to a thermoplastic splint by a hand therapist after surgery, who will guide you as to how often you will need to wear it.

Will I be able to exercise after surgery?

  • You should not do any exercise that raises your blood pressure for at least 72 hours after surgery
  • Light exercise is generally allowable at 4 weeks
  • Heavier exercise should be avoided for 6-8 weeks

Will I need special medications after surgery?

  • Dr Aggarwal will provide you with the necessary scripts for antibiotics and pain relief.

Will I need further surgery?

  • Not usually.

Can I travel in an airplane after surgery?

  • Yes
  • However we always encourage patients not to be away overseas shortly after having a procedure, so that we can closely follow your recovery and address any concerns that may arise.

When will I be able to swim after Dupuytren’s disease surgery?

  • You may swim in a pool or beach after all the wounds have healed. In general this takes at least 2-3 weeks but it can sometimes be longer.

When will I be able to drive after Dupuytren’s disease surgery?

  • No – it is illegal to drive with a splint and as long as this is required to be worn during the day you will not be able to drive. Once the splint is no longer required during the day, your wounds have healed, and your movement in your hand and fingers is good you will be able to resume driving. Your hand therapist will guide you with this.

Are there any alternatives to surgery?

  • Non-surgical options for Dupuytren’s disease include Collagenase injection.
  • The price for Dupuytren’s disease surgery depends on the number of fingers involved and severity of the condition.
  • At Mode we follow the schedule of fees listed by the Australian Medical Association for this procedure.
  • The cost of Collagenase is approximately $1200 per vial, and this is comparable to surgery.
  • Please note that the above pricing does not include
    • Preoperative consultation fees – which are $250 for the initial consult and $125 for additional preoperative consultations

Carpal Tunnel Release

This is a disorder in which the natural tunnel in the hand, called the carpal tunnel through which tendons and the median nerve of the hand passes, narrows causing compression of the nerve in the tunnel.

This disease is quite common affecting up to 5% of the population, more commonly women in the age bracket of 40-60s.

It is also associated with diabetes and obesity.

  • In most cases the cause of carpal tunnel syndrome is unknown but in all of these cases the ligament closing the tunnel has thickened over time
  • A small percentage of CTS is related to
    • Trauma and bony injuries
    • Abnormal anatomical structures in the canal
    • Infection
    • Tumours
  • Conditions that have been associated with CTS include
    • Rheumatoid arthritis
    • Diabetes
    • Thyroid disease
    • Alcoholism
    • Pregnancy
  • Most commonly night time pins and needles or numbness
  • The fingers affected are most commonly the thumb, index, middle and half of the ring finger
  • However sometimes the whole hand can feel like it is affected
  • The symptoms improve during the day
  • As the nerve experiences further compression, the symptoms become more prolonged and the pins and needles or numbness may occur more often, with certain activities, and can eventually become constant.
  • Eventually the hand becomes weak, and can show wasting of the muscles of the hand in particular those at the base of the thumb.

Carpal tunnel syndrome should be treated in patients who have:

  • The typical symptoms associated with carpal tunnel syndrome; and
  • The symptoms are causing an interference in daily activities or work; and
  • Investigations show the median nerve is compressed in the carpal tunnel; and
  • Simpler non-surgical measures have failed to resolve the symptoms

Treatment is not indicated for patients who have:

  • Mild symptoms only
  • No functional impairment
  • Have not tried non-surgical measures
  • Have not had nerve conduction studies indicating the site of compression of the median nerve
  • Carpal tunnel syndrome can be treated non surgically or through surgery
  • This involves controlling underlying contributing causes
  • In addition night time splinting can be of benefit in reducing the compression of the median nerve that may occur overnight, with posturing during sleep.
  • Sometimes it may be beneficial to wear the splint during activities that involve flexing the wrist.
  • The main downsides of this treatment include
    • It does not definitively treat the condition, but offers symptomatic relief
    • Can be cumbersome and uncomfortable to wear the splint at night
    • Often does not improve symptoms in severe carpal tunnel syndrome
  • Performed under Sedation and local anaesthetic, or General anaesthetic in a hospital setting
  • The surgery is quick and often takes 15 minutes of surgery time.
  • Patients are in hospital for the day only.
  • Medicare/Health fund rebate: Yes which covers all the hospital costs of surgery and part of the surgical and anaesthetic fee.
  • Is performed under tourniquet control
  • A small Longitudinal incision is made in the palm
  • Dissection is carried down to the carpal tunnel and the ligament covering the contents of the tunnel (called the transverse carpal ligament) is cut under direct vision.
  • The median nerve is freed over the entire tunnel
  • The wound is then closed and dressings applied
  • You may go home the same day or stay
  • You will be sent home with a sling and adequate pain relief
  • You will be seen at the 1 week mark for a wound check, and then at 2 weeks for removal of sutures.
  • If needed you may be referred to a hand therapist for hand exercises.
  • In general the surgery offers immediate results. Most patients report immediate relief of symptoms, however the improvement depends on how severely and for how long the nerve has been compressed. The more severe the compression the longer it takes for the nerve to recover.

Every surgery carries risks, and therefore one must consider if risks outweigh the benefits for your own personal situation. If they do then the surgery may be well worth it. Dr Aggarwal will discuss the pros and cons of surgery with you during your consultation.

General Complications

  • Risks of anaesthetic – there are general risks of going under an anaesthetic such as a mild stress on the heart and lungs, risk of reaction to anaesthetic drugs and risk of clotting in the legs. These risks are generally low in patients who are otherwise fit and healthy.
  • Bleeding (1-2%) – any bleeding is controlled during surgery and really only arises from the skin incisions. Most stops with hand elevation and compression.
  • Infection (<1%) – this is very rare. However you are given antibiotics during induction (when you are going to sleep), as well as a course of oral antibiotics after your surgery to keep this risk to a minimum.

Specific Complications

  • Slow improvement in symptoms – The median nerve recovers more slowly if it has been severely compressed for a long time. In some cases where permanent damage has already occurred, especially if carpal tunnel syndrome was so severe to cause weakness and muscle wasting, the nerve may not recover fully.
  • Damage to the recurrent branch of the median nerve – there is a nerve that arises from the median nerve in the region of the carpal tunnel that supplies the muscles at the base of the thumb. These muscles assist in fine movements of the thumb. In most patients this nerve arises beyond the carpal tunnel and is not at risk during surgery. However in some patients there can be an anatomical abnormality and the nerve passes though the ligament covering the carpal tunnel and is at risk of injury. If injured this will cause weakness of the thumb movements, however the nerve is repaired and slow recovery would be expected.
  • Pillar pain – Release of the transverse carpal ligament (the ligament covering the carpal tunnel) can cause pain on either side of the palm after surgery, called pillar pain. The pain probably occurs due to lack of the stabilising function of the ligament when it was intact. The pain eventually settles.

Do I need a referral for Carpal Tunnel Syndrome?

  • Yes
  • This allows you to claim a Medicare rebate of approximately $73 for the initial consultation, and to be eligible for rebates for surgery.

Where can I see Dr Aggarwal?

  • You can see us at our main practice at Gordon, or at our other locations at Hornsby, Hunters Hill or Camperdown.
  • Please scroll to the bottom of the page to find out more information about these locations.

Where will I have my operation?

  • Any of the hospitals where Dr Aggarwal works – i.e. Sydney Adventist Hospital, SAN Day Surgery, or Hunters Hill Private hospital.

What can I do to prepare for surgery?

  • Cease fish oil, and other supplements such as Ginkgo, Ginseng.
  • Please discuss with Dr Aggarwal if you are on blood thinning medications as to when you should stop and recommence those.
  • If you are smoking you need to cease this well in advance of surgery.

After surgery, will I need to wear a special garment?

  • You will bulky dressings on your hand for 1 week. You will have to keep these dry.
  • These will be removed 1 week after surgery at which point you will be able to get your hand wet.
  • If required you may need to see a hand therapist to guide you through exercises.

Will I be able to exercise after surgery?

  • You should not do any exercise that raises your blood pressure for at least 72 hours after surgery
  • You should not do any heavy lifting or work with the operated hand until the wound is fully healed and your movement, and sensation has recovered.

Will I need special medications after surgery?

  • Dr Aggarwal will provide you with the necessary scripts for antibiotics and pain relief.

Will I need further surgery?

  • Not usually.
  • Many people have both hands affected and may choose to return for an operation on the other hand once the operated hand has healed.

Can I travel in an airplane after surgery?

  • Yes
  • However we always encourage patients not to be away overseas shortly after having a procedure, so that we can closely follow your recovery and address any concerns that may arise.

When will I be able to swim after Carpal tunnel release?

  • You may swim in a pool or beach after all the wounds have healed. In general this takes at least 2-3 weeks but it can sometimes be longer.

When will I be able to drive after Carpal tunnel release?

  • You should not do any driving for the first week.
  • Thereafter it depends on how your wound is healing and how much stiffness, pain and residual symptoms you have.
  • Your hand therapist will also guide you when you are ready for driving.

Are there any alternatives to surgery?

  • Non-surgical options for Carpal Tunnel Syndrome including splinting especially at night.
  • At Mode we follow the schedule of fees listed by the Australian Medical Association for this procedure.
    • For patients who are insured with funds that allow known gap (access gap) billing, we will usually utilise this and charge a $500 known gap. Please note that NIB does not allow known gap billing.
    • The rest of the surgical fee is claimed from Medicare and the health fund.
    • The anaesthetic fee will usually be a $250 known gap.
  • Please note that the above pricing does not include
    • Preoperative consultation fees – which are $250 for the initial consult and $125 for additional preoperative consultations if needed.

Ganglion Removal

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Meet Dr Aggarwal

Dr Aggarwal is a well regarded, respected, highly skilled and experienced Specialist Plastic Surgeon. Graduating at the top of his class throughout his training, Dr Aggarwal has completed fellowship training at some of the world’s most prestigious reconstructive and cosmetic plastic surgery institutions. He continues to publish research is prestigious plastic surgery journals, and is actively involved in the training of future plastic surgeons.

What sets Dr Aggarwal apart from others is his personal, affable and warm nature. Not only does he pay attention to detail, to producing natural, beautiful results but he ensures that the patient’s journey is just as special as their outcome. Dr Aggarwal looks after patients at two of Sydney’s most prestigious public hospital campuses (RPA and POWH/RHW), and operates privately on the North Shore.

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Why Choose Us

Highly Skilled

Highly skilled Fellowship Trained Plastic surgeon – know you are in the safest of hands with a Plastic Surgeon who is experienced, highly respected, and appointed at premier Sydney hospitals- including the SAN, RPA, POWH and RHW.

Safety

If sedation or general anaesthetic is required, it is delivered by an accredited anaesthetist

Accommodation

Have your surgery at premier, accredited Sydney private hospitals

Upfront Costs

We provide written quotes, so there are no surprises.

Patient Centered Care

We make you our top priority. Need to ask a question, worried about dressings or something else post op? We will always be at your beck and call.

Reviews

Our patients love us! Feel free to read our reviews online on independent websites, or you can speak to some of our existing patients who will gladly speak about their plastic surgery journey.

Affiliations & Associations

Latest News

New Consulting Locations

In addition to our Hornsby and Camperdown locations, in 2018 we bring you:

  • Hunters Hill (Lower North Shore) – conventiently located near one of Dr Aggarwal’s operative locations at Hunters Hill Private Hospital, Hunters Hill offers the convenience of accessing Dr Aggarwal in the lower north shore.
  • Gordon (North Shore) – set to be our primary practice, our flagship rooms will be open for trading in August 2018. Follow our blog to see an update on progress.
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Consulting Locations

Gordon (Flagship)

Suite 13, Level 3, 924 Pacific Highway, Gordon NSW 2072

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Hornsby

85 Burdett St, Hornsby NSW 2077

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Camperdown

Level 2, Clinic D, Chris O’Brien Lifehouse, Camperdown NSW 2050

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Hunters Hill

Level 1, 6 Ryde Road, Hunters Hill NSW 2110

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Phone:

1300 80 9000

info@modeplasticsurgery.com.au

Suite 13, 924 Pacific Highway
Gordon NSW 2072, Australia

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