Hey this is like an ancient write up. Why not check up the procedure link up above?
(Step by step video available at the bottom of this blog)
WWII, the Surgeon General was an orthopedic surgeon who had
experienced treating those disabled in the first world war. Many
otherwise healthy WWI veterans had been rendered incapable due to poorly treated hand wounds which
resulted in a loss of function. Prior to this, hand
surgeries required three specialists, but war doesn’t allow for such
extravagance. In many cases hand injury were being treated by the
most inexperienced of junior surgeons. The Surgeon General asked the respected Dr.
Sterling Bunnell to open hand centers around the country to assist
the injured in the hope they might regain function and return to previous occupations.
Bunnell wrote the book on hand surgeries. Literally, as in his work
was the first text specifically aimed at instruction in treatment of
hand injuries. This book remained a fixture in medical schools for over
forty years. His hobby was research in comparative anatomy.
Colleagues asked about Bunnel were just as likely to talk about the
baby rattlesnakes he’d allow to bite him in his basement, and the
Black Widows he raised in his attic as they were his many
accomplishments in orthopedics.This certainly wasn’t his only unusual attribute.
Students of Bunnell
were easily recognizable, not simply due to their skill, but
also from the many quirks they internalized from working with Bunnell. Foremost amongst these were the so-called Bunnell-isms. An entire generation of hand surgeons would dutifully recite,“Shoot the plaster to me faster, pass the
Serve your master; avoid disaster“ as they dressed
wounds and casted broken bones. Exactly as taught by
Bunnell, they’d admonish assistants holding a limb, “Steady like the
Rock of Gilbraltar.” Each step of a procedure had its own mantra.
we progress through each step performed in a magnet implantation, you
understand the value of these Bunnell-isms. Of course even the
greatest surgeons find at times injuries even they are incapable of
repairing. At the time, many such cases were the result of
inexperienced practitioners. Any surgery, especially one performed
under sub-optimal conditions by an entirely inexperienced party comes with risks. Bunnell had a special phrase
just for such a situation:
good stump is a joy forever.
blog discusses subdermal implants. The procedure discussed is a
body modification being performed by various non-medical artists
as well as some fool-hardy Do-It-Yourself-ers. Don’t misinterpret
this work as advocating for people to perform such a procedure at
home. DIY surgery of any kind can definitely have disastrous
results; furthermore, short of internal organs the hands are
likely the worst place to perform such a half-assed surgery. Before WWII
hand injuries were treated by three different specialists. Bone
injuries were treated by an orthopaedist, a plastic surgeon was
responsible for skin healing, and a neurosurgeon would care for
the nervous system aspects. I am not an orthopaedist, a plastic surgeon, or a neurosurgeon. It’s not my intent to pretend the
experience or education of one, much less all three. In fact, I’m not even
surgeon at all. The intent of this blog is as follows: If you have
already chosen that you are going to perform surgery upon yourself
and implant a magnet, then I hope this work improves your chances
of avoiding the many possible bad outcomes.
you perform any of the discussed procedures in this Blog, it’s
Selection and Marking
potentially damaging incision is a cut which runs longitudinal across
a joint. Cutting along longitudinal lines can interrupt the
joints range of motion and cause pain whenever the joint is moved.
4.Mark the Incisional Borders
and Disinfection of the Surgical Area
consider air flow in the room chosen for the procedure. It doesn’t do
much good to disinfect a room and then run the AC, effectively
re-coating every surface in the room with dust and bacteria. Choose a
room where airflow can be blocked. Close any vents and turn off
heating or air conditioning. Furthermore, the room chosen should
have a non-carpeted hard floor and minimal or no fabric furnishings
such as couches or drapes. This is to facilitate effective cleaning.
perform a preliminary cleaning of the room. This entails damp dusting
all furniture surfaces with particular attention to horizontal
surfaces. After this wet mop the floor. The liquid used for wet
dusting and mopping can be made of a Quats solution, a Chlorhexidine
solution or even diluted bleach.
the area on which the sterile field will be prepared is to be cleaned
specifically with a Quats disinfectant. Pay attention to the products
instructions; often it will give specific instructions for the amount
of time needed for the surface to be relatively sterile.
instruments used in the procedure must of course be sterile. Many of
these can be purchased as prepackaged sterile instruments; however,
reusable implements such as scalpel handles, clamps, and scissors may
require sterilization. The optimal method is steam sterilization
which can be performed using either an autoclave or a pressure
Autoclaves can be purchased for around 260 dollars, but
unless you intend to be doing this pretty often I’d go with a 50$
pressure cooker. Instruments are placed in Self Sealing Sterilization
pouch. Many of these pouches incorporate a sterilization indicator,
but if not, indicator tape can be applied to the pouch. If your using pressure cooker, keep in mind that all the implements must be above the water in order to achieve sterility. Steaming implements at the highest temperature and pressure possible (usually around 15 Psi) for twenty minutes is adequate to kill that majority of organisms.
method is chemical sterilization which must be used as Neodymium
magnets are notorious for losing strength when heated. High Alcohol
content Quats wipes such as supersanicloths kill the vast majority of
microorganisms in under 3 minutes. Some organisms such as enveloped
viruses take longer. Chemical sterilization is simple. First clean
tools and magnet of any obvious material such as hand oils, dirt,
dried blood using soap and water. When dry of water, rub the magnet
or instrument over with a quats pad and then place the item in the
fold of another quats pad. 20 minutes of wet time is sufficient to
kill just about any pathogen. Tools
and magnet can then be placed in either a sterilized metal bowl or in
the fold of sterile gauze dampened with sterile saline. The dampened
gauze must be placed on a layer of dry gauze in order to prevent the
wicking up of contaminates.
the Sterile Field
made ourselves a nice clean surface in the previous step, we can now
create our sterile field or work space. Within an operating room, this would entail
the opening of a sterile drape to cover the field. Because of the
nature of the procedure we are performing this isn’t as essential.
Your going to be using both hands when
performing the implant and
there isn’t any way you can keep the operative hand anchored to the
work system anyhow. Treat the table as dirty regardless of how well
if was cleaned and never allow a tool or open wound to contact the
still need to create a small sterile field area as a place on which
to hold our supplies. This field can created using the inside of the
packaging from one of the supplies used. Surgical gloves for example
tend to come in a big sterile container which can be everted and used
as the surface on which the tools are placed. In the video, I am using a surgical drape but as long as your working on a well cleaned non-porous surface, and you keep your equipment stored on a sterile field, you’ll be just fine.
the Surgical Site
preparation should begin three hours prior to the procedure
occurring. The hands are scrubbed and washed with a Chlorhexidine
based cleanser. Pay particular attention to the nail bed as this area
tends to harbor the most bacteria. After hands are dried using a
clean towel, don a pair of examination gloves and then go about
disinfecting the table surface and preparing the sterile field. 20
minutes prior to procedure the hands should be washed and scrubbed
again. Immediately before the operative don sterile gloves. Cut the
glove finger away from the glove and cut a slit running towards the
palm to reveal the areas of injection for a nerve block. Perform
nerve block as demonstrated in this previous blog: Magnet
jeweler does not repair a watch in an inkwell – Bunnell
adequate anesthesia has been achieved, loop the hair band tourniquet
around the finger a few times. This band will prevent excessive
bleeding while creating the incision and undermining the tissue.
incision has been made. If its not tight enough blood will flow
freely and the second hair band should be looped around the base of
the finger at a tightness that will stem blood flow. In most
surgeries, there are two primary considerations when it comes to
tourniquet use: time and pressure. We don’t have to worry about
pressure because the fingers are small and the hair bands aren’t
really capable of pressure to the point of tissue damage. In regards
to time, a tourniquet should be used for as short a time as possible.
of Surgical Technologists
recommends that a tourniquet not be used on the upper arms for more
than sixty minutes at a time. I’m going to suggest that a person go
for no more than twenty minutes. After twenty minutes, remove the
tourniquet and apply pressure and some gauze at the incision site for
a minute or so and then reapply the hair band.
one counts fingers – Bunnell
the video, note that I’m going to break one of the rules of surgery:
only use a blade when it’s attached to a handle. I thought that the
major reason for the this was to prevent the risk of blood borne
pathogen exposure. If surgeon doesn’t use a handle, they are far more
likely to cut themselves and either become infected from a pathogen
in the patients blood or infect the patient. I thought that since I’m
working on myself, that perhaps not using a handle would result in
increased dexterity. The reality? No. It doesn’t. I’ve always used a
handle before and I will always use a handle in the future.
a pair of clamps to pick up the scalpel blade and attach it to the
scalpel handle. Hold the scalpel as if you were using a writing
instrument about 4 centimeters away from where the blade meets the
handle. If possible, use the fingers on either side of the target
finger to pull the skin taught. Make your incision using the flat
edge of the knife rather than the very tip. Remember that you don’t
have to achieve full depth with the first cut and that it’s much
better to make multiple small cuts than to go too deep and hit nerve
or tendon. The final length of the incision should give at least an
extra millimeter on each side, so for a 3mm magnet, go for a 5mm long
|This image is to demonstrate the depth of skin. It certainly isn’t what your site should look like.|
incision depth warrants a paragraph of its own. I’m very leery about
giving a number because different people have different skin
thicknesses. I’ve seen elderly patients with skin at thin as perhaps
¼ of a mm that could be stripped away with a piece of tape. I’ve
seen construction working with thick callused skin all that way
around the tip of the finger that was likely 2mm thick. The depth of
the cut needed is completely dependent upon the skin of the person.
It will most likely be between ½ mm and 1mm. A person knows they’ve
achieve adequate depth because the incision can be pulled open
revealing the underlying dark red tissue beneath. If the tissue at
the base of the incision stays still when the overlying skin is
tugged, then your definitely deep enough. Remember that it’s
essential not to cut any of the underlying structure. There really
isn’t fat or muscle at this location, so you have no room for error.
If you cut too deep, your cutting tendon, vessels or nerves. Damage
to any of these can be disastrous. Not cutting deep enough simply
means that your magnet will at some point pop out, which isn’t really
all that big a deal. You can always do the process again later, and
most likely with better technique due to experience.
the wound edge
Like the Rock of Gilbraltar – Bunnell
skin edge must now be undermined in order to create the space where
the magnet will rest. Undermining is accomplished by freeing the skin
from its deep tissue attachments. A skilled surgeon would accomplish
this using a scalpel, but I feel that this is too risky for
someone without experience. I advise the use of surgical scissors.
The two sides of these scissors can be easily broken apart resulting
in a implement that is sharper and more precise than a probe, yet
dull enough that it can be used by an inept shaky hand. This tool
isn’t really used like a cutting implement, but rather more like how
a probe would be used. Slip the edge under the skin layer and push it
back and forth with pressure to tear apart the connective tissue
holding the skin to deeper tissues. It will take some pressure to
accomplish this as you are literally tearing the layers of tissue
apart. If the prospect sounds terrifying, consider practicing this on
a piece of pig skin from the local butcher with the skin intact.
is performed moving toward the anterior pulp of the finger. It should
be large enough that once the magnet is placed, it will not be
visible at the base of the incision itself.
is the most laborious and frustrating part of the procedure. The
pouch should extend at least the diameter of your magnet plus 2mm
away from the incision site. When performing this, you are creating
the final position where the magnet will be located. The magnet
should be positioned offset from the mid-line of the finger. Even
after healing, most people report that direct pressure causes pain. A
good implant shouldn’t stop you from being able to do pull-ups. If
the pouch created allows the magnet to sit 45 degrees away from the
mid-line of the finger, then pressure will simply push the magnet to
the side without resulting in pain. This step requires the most attention as the lack of a proper pouch will inevitably lead to rejection, while a poorly made pouch leads to an inconveniently place magnet.
an empty house than a poor tenant,” – Bunnell
Placement of the
magnet will likely require a person to go back to the previous step a
few times in order to enlarge the pouch. When working on yourself, it
really is difficult to get it right in one go. Once the pouch is
adequate in size, use a non-ferrous implement such as the back of a
disposable scalpel to push the magnet into place. While it’s true
that using pressure to push the magnet and get it to stay in the
pouch creates trauma to the surrounding tissue, it also helps to
position the magnet so it’s not putting pressure on the healing
incision from the inside. The magnet is placed correctly when you can
pinch the two sides of the incision site together with minimal
pressure without the magnet edge protruding.
is nature’s best dressing.” – Bunnell
advise using a 3-0 or 4-0 braided silk suture with a curved needle.
Insert the needle 1.5mm away from lateral edge of the wound to a 1mm
depth using forceps. Spin your wrist to drive the needle beneath the
incision towards where it will exit, 1.5mm away from the medial wound
edge. It’s important to pause in the middle of this process and use
pressure to push the magnet deep into its pouch. If your using a
resin coated magnet, you don’t really need to worry about scratching
it with the needle, but if your using a magnet coated in parylene C
alone, scratching the coating with the needle will inevitably lead
to rejection later. If using parylene alone, replace the
magnet prior to closing the wound. If you end up driving the needle
through and its exit point is non-optimal, it’s ok to pull it back and
the suture needle is visibly protruding from an optimal exit point,
use forceps to grasp the tip and pull it through completely. Pull a
good 8 inches or more of suture thread through the wound and then
perform a one handed surgical knot. This looks cool, but that’s not
really the point. A well tied surgical knot does not loosen under
pressure or easily become untied. The first knot determines the
quality of the stitch. It should be just tight enough that the wound
edge touch. Tying it too tightly will pull the edges of the incision
to where they overlap, which increases the likelihood of infection,
dehiscence, and scarring. Tie the knot just tightly enough that the
edges snug together like the incision never happened. Tie a second
surgical knot, and then the type of knot from there on is irrelevant.
Just make sure to make lots of them. No matter how much attention you
pay to taking care of your suture, you will at some point pick
something up or doing something without thinking that will put pressure
on the wound, so a good suture is damn near essential.
very strongly feel a suture is necessary in order to achieve a clean
well approximated site without scarring. For some strange
reason though, I read all the time about people who have no trouble
cutting themselves open and creating the pouch… but are too afraid
of needles to suture themselves. Seriously, you cut yourself wide
open so the fear of needles thing doesn’t make sense! But, I’ll
remind you that the point of this blog isn’t to advocate for people
perform this procedure, but rather to help those doing it anyhow to
do it safely and with good result.
then you can use a medical grade super-glue called Dermabond.
Dermabond does a pretty good job at preventing infection as you can
form a serious little glue cap right over the incision site. It isn’t
all that mechanically strong though, so if you use Dermabond, then
you should also be using Benzoin tincture and steri-strips. The
benzoin tincture is a sticky coating that smells good and really
helps the steri-strips stay where you want them. I advise using two
steri-strips over the incision site after application of dermabond.
Something to keep in mind is that if you cap the wound in Dermabond,
it functions not only to keep pathogens out… it also keeps them in.
A nice sutured incision naturally has a bit of seeping that acts to
clean the wound from anything that might have been introduced during
the procedure. Dermabond traps anything introduced and may increase
the likelihood of infection.
tourniquet is not off unless it is across the room.”-bunnell
a pair of scissors to snip off the hair band and observe the finger
as it re-perfuses. A little bleeding is normal although it should be
relatively scant. If the site continues to bleed, apply enough
pressure with a piece of sterile gauze to staunch the flow. Hold
pressure for a minute or two and then check to see if the bleeding
has stopped. The surgical stage is complete. Congratulations. The wound is ready to be
dressed as described below.
dress the site, begin by irrigating the incision with sterile saline.
Although large wounds are usually irrigated with pressure, such as
with a 10ml syringe, it’s unnecessary in this case. Simply pour the
sterile saline over the wound and then wipe it away with a piece of
sterile gauze. The gauze shouldn’t be used directly on the wound, but
rather around the edges and always wiped in a direction moving away
from the incision. The point of the first irrigation is primarily to
remove any blood from the surrounding area. After irrigation apply
triple antibiotic ointment directly to the site. Cover with a piece
of clean gauze and then wrap tape loosely around the circumference of
the first week it’s important to keep the site dry with the exception
of saline irrigation. The one disadvantage of a stitch is that it can
wick fluid under your skin along with bacteria leading to infection.
Put a plastic bag over the finger and wrap it in tape for showering.
Repeat the procedure of dressing the wound daily and as needed in
order to keep your finger clean. The gauze that covers the wound
should be dry so make sure the finger isn’t wet from the saline when
the gauze is applied. Carry extra triple antibiotic, gauze, and tape
with you throughout the day so that you can dress your wound again
should it get wet or become soiled.
full wound healing to take as long a month. Little healing will occur
for the first 2-3 days. By day 3, proliferation will begin.
Proliferation begins with revascularization of the tissue. All of the
capillaries that were damaged are being repaired or replaced so its
normal for the site to look very red. This isn’t necessarily
indicative of infection. Around the same time, fibroblast cells move
into the area and begin laying down the collagen matrix to bind the
incision back together.
day five, if you’ve kept your incision clean and dry and haven’t put
any pressure on your wound, you could probably get away with removing
the suture. My advice is to actually wait ten days if possible. Keep
a close eye on the site. After day 5, tug on the suture a bit after
irrigating it to make sure that the insertion sites are free of
infection. If the suture sites begin to get red or if you see any
exudate it’s better to take the suture out. To remove the suture,
clip it as close to the skin as possible on one side and then tug on
the other length to pull the suture through. After removing the
suture, it’s a good idea to apply steri-strips and benzoin tincture.
They aren’t as strong as a suture, but will help if you accidentally
use your hand. Keep the the dressed for one day after removing the
sutures, unless you notice a portion of the incision remaining open.
In this case keep it closed with steri-strips and continue to clean
and dress it. It’s good to keep the triple antibiotic on the site for
at least ten days as it will prevent the tissue from drying out which
increases the likely-hood of scarring.
day 5, there shouldn’t be an increase in redness. Any redness or
swelling, increasing sensation of warmth or pain may indicate that
you have an infection or that your body is mounting an immunological
response to the implant.
you see swelling and redness I advise you give yourself one last shot
at saving the implant: drain it. You can use a lancet and poke into
the wound after cleaning the site well. Assess the drainage closely.
If it’s just a little cream colored pus, then you have a good chance
of having the site heal nicely after draining. If its a copious
amount of drainage, or if the drainage is bloody or any other color I
advise you to remove the implant, or see your physician. Most of the
time a little infection such as this is not a major problem but there
is always the chance of something very bad such as gangrene or
necrotizing faciitis. Another very bad sign is if you see stripes of
color running down your finger or hand. Cellulitis is always a bad
thing, and because the hand is such a delicate mechanism a bad
infection can easily lead to loss of function or even amputation.
Feel free to shoot me an email if you are concerned about the healing
of your magnet, but if you have any major indication that something
isn’t right, consider going to the ER. You will most certainly get
chided and overcharged, but it’s always better to be safe then sorry.
Days to 6 Months Post Procedure
complications or too much playing with your magnet, the tissue should
have regained between 50% and 80% of its tensile strength by the end
of the first month. Picking up other magnets, particular large strong
magnets can still lead to problems as this can occlude blood flow and
cause crush injury. Ferrous objects like staples, nails, and metal
filings are just fine though. At this point, Wooly Willy is your bitch. Don’t be
disappointed however if your not getting much sensation. In fact, a
decrease in initial sensitivity is likely. You might have experienced
a bit of sensation within the first few days after the procedure, but
full sensitivity is regained generally over a 3 to 6 month period.
wound healing entails a rapid linking by collagen fibers in a rather
disorganized haphazard arrangement. As maturation of the site
progresses, the initially disorganized fibers are replaced with well
organized ones and the area surrounding the implant will contract
rather than looking visibly swollen. After the first 30 days the
tissue will begin to soften around the implant. Many of the
capillaries and small vessels formed during revascularization will be
broken down and the redness of the site will begin to resolve. Nerves
will regrow and you’ll gradually develop the ability to sense
item worth mentioning is the so-called “training” of your magnet.
I’ve read articles where those with magnets
“practice” with other magnets in order to increase their
sensitivity. Some rationalize it as “forming new connections in
brain.” I haven’t really found any support for this idea. Perhaps
the more one plays with their magnet the more sensitive they will
become to the electromagnetic fields around them. Alternatively,
perhaps they are just experiencing the subtle increase in sensitivity
that naturally occurs as the site heals, matures, and re-innervates.
Either way, you won’t be able to help yourself; it’s a very fun toy,
but if you need to justify play you can always tell yourself and
others, “I’m training.”
(Saal once accused me of hyperbole. To this I say, you aint seen nothin. )