Julia K. Terzis

The nerve gap: suture under tension vs. graft.

Conduction velocities and amplitudes of evoked responses were used in experimental models to compare reinnervation through nerve gaps sutured under tension or bridged with nerve grafts. The best results were obtained when end-to-end suture was done without tension. Regeneration through mildly stretched nerve repairs was equivalent to applying a properly tailored graft. Minimal axonal activity was exhibited by severely stretched repair sites.

The surgical treatment of brachial plexus injuries in adults.

Learning Objectives: After studying this article, the participant should be able to: 1. Evaluate clinically a patient with brachial plexus paralysis and define the appropriate electrophysiologic and radiographic studies. 2. Differentiate between preganglionic (root) avulsion and postganglionic lesions and identify appropriate motor donors and nerve grafts. 3. Describe various nerve reconstructive strategies and make appropriate selection of secondary procedures for shoulder stability, elbow flexion, and hand reanimation. 4. Anticipate the possible functional outcome.

Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis.

Thus far, devastating injuries of the adult brachial plexus have had a poor prognosis. This article presents the possible outcomes of aggressive microsurgical reconstruction in the largest series of patients in North America to date. It should change the pessimistic outlook that has surrounded these lesions. In this study, the outcomes of surgery were analyzed in relation to the type and level of injury, the age of the patient, and the denervation time; stronger donors for neurotization in relation to the various targets were delineated. The results were analyzed in 204 patients with adequate follow-up from a total of 263 patients who were operated on between 1978 and 1996. The mean age of the patients was 25.9 years, and the injuries were caused by high-velocity motor accidents involving avulsion in 55 percent of the patients. Nerve reconstruction included 577 nerve repairs (140 direct neurotizations and 437 cases of nerve grafting). Microneurolysis was performed in 89 cases. Vascularized nerve grafts were used in 120 repairs. Muscle transfers (29 pedicled and 78 free) were used to enhance function. The results were good or excellent in 75 percent of suprascapular nerve reconstructions, 40 percent of deltoid reconstructions, 48 percent of biceps reconstructions, 30 percent of triceps reconstructions, 35 percent of finger-flexion reconstructions, and 15 percent of finger-extension reconstructions. The majority of the patients had protective sensation and pain relief postoperatively.

Analysis of 100 cases of free-muscle transplantation for facial paralysis

&NA; Free‐muscle transplantation is the treatment of choice for long‐standing facial paralysis. It enables the reconstructive surgeon to restore facial movement and some emotional animation. Despite all technical innovations and 20 years of experience with free‐muscle transplantation, the aesthetic and functional outcomes of the surgery are still unpredictable. The present report reviews 100 free‐muscle transplantations to the face by a single surgeon and analyzes various preoperative, intraoperative, and postoperative factors in relation to the functional recovery of the muscle transplants. These factors were demographic variables such as age, gender, and etiology as well as intraoperative variables such as choice of muscles, number of nerve coaptations, and ischemia time of the muscle. Additionally, four independent raters not involved in the care of these patients rated standardized preoperative and postoperative videos and judged the functional and aesthetic outcomes. From 1981 to 1993, 93 patients with facial paralysis underwent free‐muscle transplantation. A total of 100 muscles were transplanted, since 7 patients received two muscle transplants. There were 33 male and 60 female patients ranging in age from 3 to 57 years, with an average of 22.2 ± 14.9 years. The gracilis muscle was used in 63 cases of free‐muscle transplantation, while the pectoralis minor was used in 34 cases. In 2 patients a segment of the rectus abdominis was transferred, and in 1 patient a small segment of the latissimus dorsi was transferred. In 89 patients the onset of muscle function was reported. The range was from 6 to 48 weeks postoperatively. The average was 21.6 ± 9.14 weeks after muscle transplantation. The correlations showed a trend to earlier onset of function and higher aesthetic rating in young female patients. The intraoperative ischemia of the free muscle did not correlate with the onset of muscle function. Using a five‐step scale of judgments, a higher postoperative rating was seen in 94 percent of the patients, and 80 percent of all patients achieved a moderate or better result. (Plast. Reconstr. Surg. 99: 1905, 1997.)

Pectoralis minor: a unique muscle for correction of facial palsy.

The author introduced this muscle for the first time almost a decade ago, and this is the first extensive description of the intricate microanatomy of this complex but unique microneurovascular muscle unit. Advantages and disadvantages and indications and contraindications for its use in facial paralysis are presented in detail from an extensive clinical experience of almost 50 such microneurovascular transfers. Pitfalls that the reconstructive microsurgeon should beware and strengths in using this muscle for facial palsy are highlighted. The detailed operative approach is presented, with promise of undetectable scars and minimal functional loss. The strategies for how to inset this muscle unit in the new recipient site are given, along with the thought processes involved in selecting the actual sites of anchoring the muscle to reproduce a mirror image of the contralateral normal face. Finally, an exemplary clinical case demonstrating the use of the pectoralis minor muscle for both eye and lower face reanimation is presented in detail, demonstrating the dual nerve supply and the resulting independent eye and smile movements with total lack of mass action and/or synkinesis. Restorations of eye blink and of a symmetrical and coordinated smile are the frequent rewards of using this unique muscle for the correction of facial palsy.

The "babysitter" procedure: minihypoglossal to facial nerve transfer and cross-facial nerve grafting.

Background: In 1984, Terzis introduced the “babysitter” procedure, a new concept in facial reanimation. It involves two stages, with coaptation of ipsilateral 40 percent hypoglossal to facial nerve on the affected side, performed concomitantly with cross-facial nerve grafting and secondary microcoaptations 8 to 15 months later. This article presents the senior author’s (J.K.T.) experience with the original procedure. Methods: Of 75 patients who had minihypoglossal nerve transfer, 20 fulfilled the selection criteria for the original babysitter procedure. All patients’ records, photographs, videotapes, and needle electromyography studies were reviewed. The clinical results were scored using Terzis’ Grading Scale. Eye closure, smile, and lower lip depression were each assessed separately. Functional and aesthetic outcomes and preoperative and postoperative electromyography results were analyzed. Results: Seventy-five percent of patients achieved excellent and good results, 15 percent had moderate results, and 10 percent had fair results. The difference between preoperative and postoperative eye closure was statistically significant (t test, p < 0.001). Symmetrical smile and full contraction (excellent result) was achieved in two patients (10 percent), 13 patients (65 percent) had nearly symmetrical smile (good result), and five patients (25 percent) had a moderate result. Two patients (10 percent) had full lower lip depression (excellent result) and 15 (75 percent) had good results. In three patients (15 percent), subsequent digastric or platysma muscle transfer was performed because of inadequate depression and symmetry (moderate result). A statistically significant difference was observed between preoperative and postoperative electromyography results, in eye closure, smile, and lower lip depression. Conclusions: The original babysitter procedure offers significant improvement in selected patients with facial paralysis. Symmetry and coordinated movements can be restored, with satisfying aesthetic and functional outcomes.

Suprascapular nerve reconstruction in 118 cases of adult posttraumatic brachial plexus.

Background: Shoulder stabilization is of utmost importance in upper extremity reanimation following paralysis from devastating brachial plexus injuries. The purpose of this report is to present the authors’ experience with suprascapular nerve reconstruction in 118 cases of adult brachial plexus lesions. Outcomes were analyzed in relation to various factors, including patient age, denervation time, donor nerve used, and functional restoration achieved in the supraspinatus versus the infraspinatus muscles. Methods: The medical records of 118 adult patients operated on by a single surgeon between 1978 and 2002 who had suprascapular nerve reconstruction were reviewed; 102 patients had adequate follow-up. Direct neurotization of the suprascapular nerve was carried out in 78 patients, while in 40 patients, interposition nerve grafts were used. In 80 patients, the distal spinal accessory was used as the motor donor nerve for suprascapular nerve neurotization, while in 10 patients, other extraplexus motor donors were used. In 28 patients, intraplexus motor donors were used to reinnervate the suprascapular nerve. Results: Results were good or excellent in 79 percent of the patients for the supraspinatus muscle and in 55 percent for the infraspinatus. There was a statistically significant difference between direct spinal accessory to suprascapular nerve neurotization and accessory to suprascapular via a nerve graft. Early surgery and less than 6 months of denervation time yielded significantly better results than late surgery and more than 6 months of delay in the treatment. Conclusions: Suprascapular nerve neurotization is a high priority in upper limb reanimation for restoration of glenohumeral joint stability, shoulder abduction, and external rotation. Concomitant neurotization of the axillary nerve yields improved outcomes in shoulder abduction function. The best results are seen when direct neurotization of the suprascapular nerve is performed within 6 months from the injury.

New concepts in phallic reconstruction.

Over the past four years we have performed total phallic reconstructions in 12 patients. Six patients underwent reconstruction following trauma, 3 were female-to-male transsexuals, and 3 had micropenis deformities. These reconstructions were one-stage microsurgical tissue transfers that included urethral reconstruction and coaptation of erogenous nerves. The surgical indications, techniques, and results are discussed.

Nerve transfers in facial palsy.

The facial paralysis patient suffers serious functional, cosmetic, and psychological problems with impaired ability to communicate. Despite the advances of recent years and the number of new techniques proposed in the literature, facial reanimation remains a challenge for the reconstructive surgeon. With the advent of microsurgery, reanimation of the paralyzed face took a major leap forward with the use of cross facial nerve grafts, nerve transfers, and free muscle transplantation. Today, nerve transfers represent the backbone of facial reanimation, especially in cases where reconstruction of the affected facial nerve is not feasible. The suitability of each nerve transfer is related to the type of facial palsy, time elapsed since injury, and the age and general health of the patient. The selected motor nerve must provide strong muscle contraction and allow the patient to control the facial movements. The purpose of this chapter is to present the senior authors (J.K.T.) experience in the selection of motor nerves that can function as possible donor nerves for dynamic facial reanimation. Indications and surgical technique for each procedure is also presented.

Selective contralateral c7 transfer in posttraumatic brachial plexus injuries: a report of 56 cases.

Background: Large experience in Asia has shown that the contralateral C7 nerve transfer has proved one of the major treatments for brachial plexus root avulsions. The authors report their experience in North America using the selective contralateral C7 transfer for neurotization of multiple targets. Methods: A retrospective review of 56 patients with posttraumatic root avulsion brachial plexus injuries who underwent contralateral C7 transfer using selective technique was conducted. The targets included the axillary, musculocutaneous, radial, and median nerves. Additionally, neurotization of future free muscle transplantation was performed. The mean follow-up period was 6.1 years (range, 2.5 to 14 years). Results: Motor recovery reached a level of M3+ or greater in 20 percent (two of 10) of patients for the deltoid, 52 percent (12 of 23) for the biceps, 24 percent (five of 21) for the triceps, 34 percent (10 of 29) for the wrist and finger flexors, and 20 percent (two of 10) for the wrist and finger extensors. In addition, sensory recovery of S2 or greater was achieved in 76 percent (22 of 29) of patients with median nerve neurotization. As far as the postoperative morbidity of the donor limb, by 6 months, there was no discernible motor or sensory deficit. Patients with a surgical delay of 9 months or less and patients aged 18 years or younger achieved significantly better results. Conclusions: Brachial plexus root avulsions, long considered to be irreparable, are by no means unreconstructable. The selective contralateral C7 transfer appears to be a safe procedure, and it can be successfully applied for simultaneous reconstruction of several different nerves and/or for neurotization of future free muscle transfers.