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The Role Of Plastic Surgery In
Reducing A Patient’s Disability
Score – A Reconstructive Approach
Andrew I. Elkwood MD FACS
Director of the Center for Treatment of
Paralysis and Reconstructive Nerve
Surgery
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Peripheral Nerve Surgery
Spinal
Cord Injury
Disorders
of
Peripheral
Nerves
Stroke
Peripheral
Nerve
Surgery
Nerve Regeneration
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Peripheral Nerve Surgery
Applications
Peripheral Nerve
Disorders
Spinal Cord
Injury
• Compression
Neuropathy
• Facial Paralysis
• Phantom Limb
pain
• Nerve Trauma
• Tetraplegic hand
• Pressure sores
• Ventilator
dependency
• Bladder
dysfunction
Stroke
• Upper extremity
paralysis
• Aspiration
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Brachial Plexus Repair
Facial Reanimation
Prostate Grafting
Foot Drop Surgery
Nerve Transplantation
Reanimation After Spinal Cord Injury
Reanimation After Stroke
Resensitization of the Buttocks
Peripheral Nerve Surgery
Return of function
Decrease in pain
Decrease in disability score
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Research Initiatives
 Treatment of Spinal Cord Injury
 Treatment of Stroke
 Resensitization of Buttocks
 Diaphragm Reinnervation
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For any nerve repair
PAIN
SENSIBILITY
MOTION
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Outlet
Wire
Motor
Chain
Door
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Central Nervous System
vs.
Peripheral Nervous System
Avulsion
vs.
Rupture
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Cannot Be Fixed
Neurotization
Tendon Transfer
Joint fusion
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Can Be Fixed
 Primary Repair
 Nerve Grafting
 Neurotization
 Tendon Transfer
 Free Muscle Flap
 Joint Fusion
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 NEURAPRAXIA
 Stretching of nerve
 Results in nerve dysfunction
 Demyelination
 Function returns by 3 months
 NEUROTMESIS
 Significant nerve damage
 Nerve division
 No recovery
 Nerve repair required
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• Primary Repair
• Interposition Graft
• Neurotization
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If a cut nerve cannot find its
mate…a painful neuroma may result
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CRPS is often a misdiagnosed
occult neuroma
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 Sural Nerve
 Antebrachial Cutaneous Nerve
 Cervical Plexus
 Posterior Interosseous Nerve
 Nerve Conduit
 Allograft
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Take a functioning nerve to a less important
muscle, and attach it to a more important muscle.
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Spinal accessory branches
Buccal branches
Intercostal nerve
Nerve to subclavius m.
Contralateral Nerves
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 When nerve repair is required, recovery is
delayed
 1 - 2 Month Latency
 Nerve Growth
1 mm/day
1 inch/month
 Longer Distance, Longer Recovery Time
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Diagnosis
Work-up
Nerve Studies
Nerve Repair
Post-op Care
Rehabilitation
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PRELIMINARY WORK UP STARTS
RIGHT AWAY
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FIRST EMG AT
6 WEEK TO 3 MONTHS
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3 months nothing clinically or by EMG
Repeat EMG at 6 months if no improvement
If no improvement…operate.
If improvement…Reassess at 9 months
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Nothing by EMG or clinically at 3 months
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Minimal Progress by EMG
or clinically at 6 months
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Not completely improved by 9 months
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Brachial Plexus Repair
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NERVES
BONES
ARTERY
VEIN
LUNG
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 Often clouded by coma
 Often clouded by orthopedic injuries
 Often ignored
 Often misinformed
 May be subtle
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CXR
EMG
MRI
CT Myelogram
X-rays
MR angiogram/venogram
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Surgeons
Consultants
Nurses
Therapists
Home Care
Family
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A 22 year old 6 months after a motorcycle accident.
He has a brachial plexus injury (C5-C6)
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Status post brachial plexus repair with nerve grafting
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24 year old 5 months after motorcycle accident.
C5, C6, C7, brachial plexus injury
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After brachial plexus repair with nerve grafting
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After brachial plexus repair with nerve grafting
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Facial Paralysis
Trauma
Cancer
Stroke
Bell’s Palsy
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 C5 ROOT INTACT
 C6, C7, C8, T1 ROOTS
AVULSED
 PLAN
SHOULDER MOTION
ELBOW FLEXION
SENSATION TO HAND
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 SHOULDER
TRAPEZIUS TO SUPRASPINATUS
 ELBOW
C5 TO BICEP (SURAL NERVE)
 BACK
INTERCOSTALS TO LATISSIMUS
 SENSATION
INTERCOSTALS TO ULNAR NERVE
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 THE TEXTBOOKS ARE WRONG.
 DO NOT WAIT A YEAR.
 IF NOT IMPROVED BY 3 MONTHS, THEY WILL NOT IMPROVE.
 EMG AT 6-8 WEEKS.
 REPAIR AT ABOUT 3 MONTHS.
 ALLOWS FOR “SECOND SHOT” BEFORE ONE YEAR.
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 Immobilization
3 - 6 Weeks Post-op
 Aggressive Rehab
 Keep Joints Supple
 Maintain Strength
 Build New Strength
 Relearn Muscle Movement
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Extra capsular Spread
14 Cases
100% Potency
Multifactorial
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Peripheral Nerve Surgery
Foot Drop
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