Thoracodorsal Nerve Research Articles

Reinnervation of segmented latissimus dorsi muscle with the distal stump of the thoracodorsal nerve: A preliminary experimental study in rats

To date, nerve stumps have been dissected at the proximal side of the donor muscle for reinnervation of the muscle in free neurovascular muscle transfer. Herein, we examined the use of the distal thoracodorsal nerve, dissected from the muscle belly at the distal side of the latissimus dorsi muscle, for the reinnervation of muscle. The rat right latissimus dorsi muscle was employed as the model for our study. Twenty Wistar rats were used in this study. A rectangular muscle segment was dissected with the distal stump of dominant thoracodorsal nerve. After rotation of muscle, the distal nerve stump was sutured to a severed proximal recipient thoracodorsal nerve (n = 5). The degree of reinnervation through the distal nerve stump was compared with control groups that received proximal-to-proximal nerve sutures (n = 5), nerves that were not severed (n = 5), and severed nerves that were not sutured (n = 5) using electrophysiological, histological, and muscular volume assessments. Reinnervation of the distal nerve stump was confirmed by the contraction of the muscle following electrical stimulation and electromyography. Crossing of axons into motor endplates was confirmed by histology. Results of these assays were similar to that of the proximal nerve suture group. The volume of muscle in the distal nerve suture group was not significant different from that of the proximal nerve suture group (P = 0.63). It was demonstrated that the distal stump of the thoracodorsal nerve can be used to innervate segmented latissimus dorsi muscle. This novel procedure for the reinnervation of transplanted muscle deserves further investigations.

Characterisation of antibody responses to Gal-positive and Gal-free biological heart valves

Characterisation of antibody responses to Gal-positive and Gal-free biological heart valves

End-to-side neurorrhaphy in brachial plexus reconstruction

Although a number of theoretical and experimental studies dealing with end-to-side neurorrhaphy (ETSN) have been published to date, there is still a considerable lack of clinical trials investigating this technique. Here, the authors describe their experience with ETSN in axillary and musculocutaneous nerve reconstruction in patients with brachial plexus palsy. From 1999 to 2007, out of 791 reconstructed nerves in 441 patients treated for brachial plexus injury, the authors performed 21 axillary and 2 musculocutaneous nerve sutures onto the median, ulnar, or radial nerves. This technique was only performed in patients whose donor nerves, such as the thoracodorsal and medial pectoral nerves, which the authors generally use for repair of axillary and musculocutaneous nerves, respectively, were not available. In all patients, a perineurial suture was carried out after the creation of a perineurial window. The overall success rate of the ETSN was 43.5%. Reinnervation of the deltoid muscle with axillary nerve suture was successful in 47.6% of the patients, but reinnervation of the biceps muscle was unsuccessful in the 2 patients undergoing musculocutaneous nerve repair. The authors conclude that ETSN should be performed in axillary nerve reconstruction but only when commonly used donor nerves are not available.

Medial pectoral pedicle is a reliable landmark for axillary lymph node dissection

The anatomical orientation of structures in the axilla has not been well studied, although it is essential for a neat and safe dissection. The objective of this study was to determine the relations between neurovascular structures in the axilla as they were encountered during axillary lymph node dissection (ALND) for breast cancer. This was a prospective study of 29 consecutive ALNDs accompanying either mastectomy or wide local excision. The dissections were conducted in a stepwise manner and the orientation of the structures was determined as the dissections advanced from superficial to deeper planes. The medial pectoral pedicle was the most superficial neurovascular structure encountered during the dissections and was curled around the lateral border of the pectoralis minor muscle in most cases. The intercostobrachial nerve lay 1-2cm behind and below, and the axillary vein was located 2-3cm behind and above the pedicle. The long thoracic nerve was constantly found 2-3cm behind the intercostobrachial nerve. The thoracodorsal nerve was always accompanied by a posterior tributary of the axillary vein. Relations between neurovascular structures in the axilla are predictable. The medial pectoral pedicle, which is consistently found and superficially located, could be used as a landmark for ALND.

Anatomical Research of the Three-dimensional Route of the Thoracodorsal Nerve, Artery, and Veins in Latissimus Dorsi Muscle.

Background:The latissimus dorsi (LD) muscle flap has been widely used in facial reanimation surgery. However, there are no standards to what degree the muscle flap may be safely thinned because the three-dimensional positional relationship of thoracodorsal artery, vein, and nerve inside the LD muscle is poorly understood.Methods:From 18 formalin-fixed cadavers, we made 36 transparent specimens of LD muscles using a newly developed decoloration technique. In 26 specimens, nerve staining (Sihler’s staining method) and silicone rubber (Microfil) injection to the thoracodorsal artery were performed, and the relationship of the artery and the vein was examined in 10 specimens.Results:The thoracodorsal artery and vein always ran parallel in a deeper layer compared to the nerve. The thoracodorsal nerve constantly existed in a deeper layer than half (50%) of the muscle in the range of use of the muscle flap in facial reanimation surgery.Conclusions:The thoracodorsal nerves ran in a shallower layer, and the depth to the nerve in the muscle flap in actual facial reanimation surgery is safe enough to avoid damage to the nerves. The LD muscle may be thinned to half its original thickness safely.

The clinic application of thoracodorsal artery perforator flap: a report of 16 cases

To investigate the effects of free and pedicled thoracodorsal artery perforator (TDAP) flaps for repairing skin and soft tissue defects in limbs, neck, axillary and shoulder. From October 2009 to Auguest 2011, 16 TDAP flaps were used to repair skin and tissue defects. Among them, five ipsilateral pedicled flaps were used to repair wounds in neck, axillary and shoulder. 11 free TDAP flaps were used to repair the wounds with bone or tendon exposure. In 12 cases, the flaps were pedicled with thoracodorsal artery and vein-lateral branches-perforators, in 4 cases, pedicled with thoracodorsal artery and vein-serratus anterior muscular branches-perforators. The deep fascia, the latissimus dorsi and thoracodorsal nerve were not included in all flaps. The flaps size ranged from 10 cm x 5 cm to 26 cm x 10 cm. All 16 flaps survived completely with primary healing both at donor site and recipent area. After a follow-up of 3 to 24 months, all flaps gained good texture and appearance. Only linear scar was left at donor area. The shoulder could move freely. TDAP flap has good texture, long vascular pedicle,and reliable blood supply, leaving less morbidity at donor site. The latissimus dorsi and thoracodorsal nerve are also preserved. The pedicled TDAP flap is an ideal flap for repairing the ipsilateral skin and soft tissue defects of the neck, shoulder, axillary. The free TDAP flap is suited for repairing skin and soft tissue defects of the extremities.

Thoracodorsal nerve graft for reconstruction of facial nerve branching

ObjectSurgical treatment of parotid malignancies may frequently involve facial nerve amputation to achieve oncological radical resection. The entire facial nerve branching from its exit from the stylomastoid foramen to the periphery of the gland is often sacrificed. The first reconstructive strategy is the immediate reconstruction of the facial nerve by directly anastomosing the trunk of the facial nerve to its distal branches by interpositional nerve grafting.The present study was performed to determine the adequacy of thoracodorsal nerve grafting for immediate repair of the facial nerve. The anatomical features of the thoracodorsal nerve make it particularly appropriate to match its trunk to the stump of the facial nerve at its exit from the stylomastoid foramen. Up to seven branches of the thoracodorsal nerve may be distally anastomosed to the severed distal branches of the facial nerve. More complex reconstruction may be addressed simultaneously by contemporary harvesting a de-epithelialized free flap from the same site based on thoracodorsal vessel perforators and preparing a rib graft from the same donor site. MethodsBetween October 2003 and August 2010, seven patients affected by parotid tumors (6 with parotid malignancies and 1 with multiple recurrences of pleomorphic adenoma) underwent radical parotidectomy with intentional sacrifice of the facial nerve to obtain oncological radical resection. In all patients, the facial nerve was reconstructed with an interpositional thoracodorsal nerve graft. In four patients, a de-epithelialized free flap based on the latissimus dorsi was transposed to cover soft tissue defects. Moreover, two of these patients also required a rib graft to reconstruct both the condyle and ramus of the mandible. With the exception of one patient affected by recurrent pleomorphic adenoma, all patients underwent radiotherapy after surgical treatment. ResultsAll patients in our study recovered mimetic facial function. Facial muscles showed clinical signs of recovery within 5–14 (mean: 7.8) months, with varying degrees of mimetic restoration, and almost complete facial symmetry at rest in all patients. The House–Brackmann final score was I in two patients, II in two patients, and III in three patients. ConclusionsA thoracodorsal nerve graft to replace extratemporal facial nerve branching is a valid alternative technique to multiple classical nerve grafts, with good matching at both the proximal and distal anastomoses.

A Variation of the Cords of the Brachial Plexus on the Right and a Communication between the Musculocutaneous and Median Nerves on the Left Upper Limb: A Unique Case

During routine anatomical dissection of the upper extremity of a 64-year-old cadaver for educational purposes, we observed variations in the brachial plexus on each side. On the right an anomaly of cord formation was present and on the left there was a communication between the musculocutaneous nerve (MCN) and median nerve (MN). On the right side the brachial plexus showed two trunks, superior (C5 and C6) and inferior (C7, C8, and T1); the middle trunk was absent. The superior trunk bifurcated into anterior and posterior divisions, the anterior division continued as the lateral cord forming the MCN. The posterior division gave off the subscapular branch. The inferior trunk trifurcated into radial, median, and ulnar nerves. The radial nerve gave off the axillary and thoracodorsal nerves. The ulnar nerve gave off the median cutaneous nerves of the arm and forearm. The median nerve received a small ascending branch from the MCN. On the right side, there was a communicating branch from the MCN to the MN in the lower third of the arm region. This communicating branch also gave rise to a muscular branch to the brachialis muscle and the lateral cutaneous nerve of forearm. No additional heads of the biceps brachii muscle were observed in either upper limb. Knowledge of the variations of the brachial plexus in humans can be valuable for operations of the shoulder joint and its repair for providing an effective block or treatment for anesthetists and also for explaining otherwise incomprehensible clinical signs for neurologists.

Breast reconstruction with the denervated latissimus dorsi musculocutaneous flap

ObjectiveTo analyze clinical implications of the thoracodorsal nerve division in the latissimus dorsi musculocutaneous flap breast reconstruction. Patients and methodsProspective cohort study was conducted on 29 patients. Breast reconstruction with latissimus dorsi musculocutaneous flap was performed unilaterally in 20 patients or bilaterally in 9 women (38 breasts). Thoracodorsal nerve was divided during reconstruction of 20 breasts (group 1) and was preserved for 18 breasts (group 2). Height, width, projection, area of the covering skin and volume of the reconstructed and healthy breasts were measured on the 3D images of the anterior chest wall, taken 6 weeks and 6 months postoperatively with the Di3D 3D camera. Data regarding tissue consistency, painfulness and animation of the reconstructed breast, symmetry of both breasts and overall satisfaction after the surgery were collected at 6 months. ResultsThe reconstructed and healthy breasts decreased in volume in group 1 (−45.85 cm3 ± 48.41 cm3, p = 0.0004; −29.13 cm3 ± 14.98 cm3, p = 0.0009) and in group 2 (−31.5 cm3 ± 25.35 cm3, p = 0.0001; −15.4 cm3 ± 21.96 cm3, p = 0.0537). There were no differences in decrease in volume between groups 1 and 2 (p > 0.05).Respondents in group 1 in comparison to group 2 showed similar satisfaction of the tissue consistency of the reconstructed breast (p > 0.05) and the level of symmetry between both breasts (p > 0.05), gave lower scores for painfulness (p < 0.0001), animation (p < 0.0001) and higher scores for the overall satisfaction about the reconstructed breast (p = 0.0001). ConclusionWe suggest that division of the thoracodorsal nerve during latissimus dorsi musculocutaneous flap breast reconstruction is a useful undertaking to minimize unnatural animation of the reconstructed breast.

The axillary arch muscle (Langer′s muscle): Clinical importance

This was a cadaveric study aimed at studying the incidence of axillary arch muscle and the extent of its different attachments, and discussing its clinical importance. Totally, 30 upper limbs were meticulously dissected to locate the axillary arch. Wherever found, the arch was dissected from its origin to insertion and its nerve supply and blood supply was noted. The dimensions of the arch were measured. Its relations to the structures in axilla were studied in detail. Any additional related variations were investigated. The axillary arch was present in one right upper limb i.e., an incidence of 3.33%. The muscle extended from the lateral border of latissimus dorsi muscle across the axillary vessels and nerves lying superficial to the coracobrachialis, short and long heads of biceps brachii muscles, finally dividing into multiple slips of insertions into fascia covering the deep surface of pectoralis major muscle, fascia covering the biceps brachii muscle, and some slips extending into the capsule of shoulder joint. Across the middle of the axillary arch, a tendinous intersection was observed. The muscle was supplied by a branch of the thoraco-dorsal nerve. The presence of the axillary arch must always be kept in mind due to the possibility of such a muscular arch causing axillary vein entrapment, lymphatic compression, and shoulder instability by neurovascular compression, impeding the access to axillary lymph nodes during breast cancer surgeries and in latissimus dorsi transplants. It may also restrict abduction at shoulder joint.

Reconstruction of complex defects of the parotid region using a lateral thoracic wall donor site

Radical treatment of parotid neoplasms may lead to complex parotid defects that present functional and aesthetic reconstructive challenges. We report our experience using the lateral thoracic wall as a single donor site.Between 2003 and 2009, four patients with malignant tumours in the parotid gland underwent radical parotidectomy and simultaneous reconstruction using a perforator latissimus dorsi cutaneous free flap (de-epithelialized and entire skin paddle in two cases each). A thoracodorsal nerve graft was used in all cases to replace the intraglandular branches of the facial nerve. Costal grafts were used for mandibular reconstruction in two patients. All patients underwent postoperative physiotherapy. No donor-site complication occurred and all treatments achieved good aesthetic results. All patients recovered nearly complete symmetry at rest and partial facial mimetic function.The lateral thoracic wall is a good donor site for the reconstruction of complex parotid defects.

Otfrid Foerster (1873–1941)—Self-Taught Neurosurgeon and Innovator of Reconstructive Peripheral Nerve Surgery

Otfrid Foerster (1873-1941) became a self-taught neurosurgeon during and after WW I, playing a critical role in the development of peripheral nerve reconstruction. Although best known for describing dermatomes, he published over 300 articles on the nervous system. Confronted by thousands of nerve injuries during WW I, as well as poor results and disinterest from his surgical colleagues, Foerster began performing neurolysis and tension-free nerve repairs himself under emergency conditions. He pioneered grafting motor nerve defects by expendable cutaneous nerves (e.g., sural) and performed intraplexal neurotizations and various nerve transfers, such as the pectoral, subscapular, long thoracic, and thoracodorsal nerves in brachial plexus injuries. Foerster championed rehabilitation, recognizing the potential of electrostimulation and physiotherapy to influence cortical reorganization (brain plasticity) and improve recovery after nerve injury. Foerster died from tuberculosis in 1941, leaving a rich reconstructive peripheral nerve legacy; his innovative and visionary spirit serves as a role model.

A rare variation of posterior cord brachial plexus branching coexisting with the intercalated ectopic muscle

During a dissection of the brachial plexus we found a rare variation of left posterior cord branching coexisting with an unusual intercalated ectopic muscle. This muscle originated from the shoulder joint capsule at the lesser tubercle on insertion of the subscapularis then pierced between the brachial plexus, enclosed by two roots of the radial nerve, and inserted into the upper part of the latissimus dorsi muscle. The variant posterior cord divided into two roots; a thin lateral and thick medial root. The lateral root gave off the thoracodorsal nerve that penetrated and also innervated the ectopic muscle. The medial root gave off five nerve branches; two upper subscapular, one lower subscapular, one axillary and one terminal branch. A terminal branch fused with the lateral root to form a loop enclosing the ectopic muscle then continued as the radial nerve. This type of variation may be useful to interpret unexplained clinical signs and symptoms and provided additional knowledge to surgeons who perform brachial plexus surgery.

To Sever or Not the Thoracodorsal Nerve in Latissimus Dorsi Flap Breast Reconstruction

Sir:FigureWe read with pleasure the extremely interesting article by Kääriäinen et al.1 on surgical denervation of the musculocutaneous latissimus dorsi flap for breast reconstruction, and we congratulate the authors on their study. Use of the latissimus dorsi muscle for breast reconstruction has maintained a strong popularity because of the relative simplicity with which it can be harvested coupled with reliable and consistent flap vascularity; the ability to provide additional prosthetic coverage; the lack of requirement for microsurgical skills; the lack of intensive, sophisticated, costly postoperative flap monitoring; and the lack of the requirement for preoperative imaging to investigate the vascular anatomy. The latissimus dorsi flap can be an alternative technique for both immediate and delayed reconstructions, even without implants, as purely autogenous tissue,2 and several variations of this flap have been described over the years with a wide range of skin paddle designs and orientations.3–5 Whether or not to cut the thoracodorsal nerve is often a dilemma, and we would like to share our approach in denervation of the myocutaneous latissimus dorsi flap. In our unit, we are accustomed to performing three different types of latissimus dorsi flap surgery for breast reconstruction: standard latissimus dorsi combined with implant, descending branch muscle-sparing latissimus dorsi flap with implant, and autologous latissimus dorsi flap. In these three different settings, we cut the nerve in the standard latissimus dorsi flap procedure (Fig. 1) and do not in muscle-sparing and autologous latissimus dorsi procedures because we want to preserve the greatest volume of the flap (Fig. 2). In extended autologous latissimus dorsi flaps, where only the patient's own tissue of the back is used to reconstruct the breast, it is particularly important to have a healthy and trophic muscle flap, which maintains its volume as much as possible. Even in muscle-sparing latissimus dorsi flap surgery, where only a vertical strip of muscle is harvested, based on the descending branch of the thoracodorsal vessels, keeping the nerve intact may preserve the muscle volume to guarantee adequate implant coverage, avoiding any shrinkage of the flap.Fig. 1: A 54-year-old patient underwent breast reconstruction with a standard latissimus dorsi flap, with an implant on the right and expander replacement with implant on the left. The thoracodorsal nerve was cut. With muscle contraction, no distortion is the reconstructed breast is present. Mild atrophy of the flap is present.Fig. 2: Muscle-sparing and autologous latissimus dorsi flap breast reconstruction patients. The thoracodorsal nerve was not divided in either patient. Note the trophism of the two flaps.We agree with the authors that thoracodorsal nerve severing should be performed safely without jeopardizing flap vascularity, and in delayed breast reconstruction with previous axillary dissection and radiotherapy there could be some scar tissue that may render the procedure more difficult and dangerous. Regarding the irksome contractions, we surmise that these are not real problems because they tend to fade over time. The important point is to warn patients about it; if they persist, the nerve can always be severed during a secondary procedure, such as during prosthesis replacement or nipple reconstruction. The authors reported that they completely transect the muscle at both the origin and the insertion, and we believe that in case of nerve sparing, the muscle contractions may hamper the vascular pedicle, causing pedicle avulsion. For that reason, we keep the humeral insertion intact. Furthermore, we wonder whether the authors noted any difference in muscle atrophy in the implant latissimus dorsi flap group compared with the autologous latissimus dorsi flap group. Finally, with fat graft injection, some of the minor deformities can be corrected, and flap volume flap can be improved if necessary. Stefano Bonomi, M.D. Andrè Salval, M.D. Flavia Sorbi, M.D. Fernanda Settembrini, M.D. Department of Plastic Reconstructive Surgery and Burn Unit Center, Ospedale Niguarda Ca' Granda, Milano, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.

Reply

Sir:FigureWe read with great interest the comments of Drs. Bonomi, Salval, Sorbi, and Settembrini about our article.1 The notes made are well justified. However, there are some comments that we would like to make. In their practice, the thoracodorsal nerve is saved in autologous total or partial latissimus dorsi flaps. This is done to preserve the volume of the flap in the long run. According to the results of our study, the volume remained practically the same in patients with a cut nerve and an intact nerve. The atrophy of the muscular fibers was more severe in the denervated muscles, but the volume was replaced by fatty tissue. Thus, saving the nerve is not necessary to preserve the volume of the flap. The conclusion not to cut the nerve in our practice is based on the result that the muscle activity diminished significantly in the intact nerve group in most patients within 1 year. In addition, we found muscle activity in some of the patients in the denervated group. This is probably because of aberrant nerve connections or reinnervation of the muscle. The clinical results are presented more precisely in another article that we have not yet published. In conclusion, cutting or saving the nerve does not have an effect on the flap volume or muscle activity in the long run. Thus, both practices seem to be justified. Contrary to the opinion of the discussants, we prefer to cut the tendon of the muscle from its humeral insertion completely. This is because we want to avoid bulging of the axillary fold by completely fixing the proximal part of the muscle/tendon to the edge of the pectoralis major muscle. We feel that releasing both ends of the muscle avoids uncomfortable superolateral twitching of the muscle. We suppose that an intact insertion of the muscle may maintain the muscle activity more probably than a completely isolated muscle. This is based on basic research on development of muscle atrophy in experimental models.2,3 We did not notice any difference of muscle atrophy between patients with or without an implant. However, the study groups were too small for us to draw a reliable conclusion about this. We agree completely that fat graft injection is a useful tool for filling possible late defects or minor contour deformities in the reconstructed breast. Minna Kääriäinen, M.D., Ph.D. Hannu Kuokkanen, M.D., Ph.D. Department of Plastic and Reconstructive Surgery, Tampere University Hospital, Tampere, Finland DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.

The Significance of Latissimus Dorsi Flap Innervation in Delayed Breast Reconstruction

Background It is controversial whether surgical denervation of the thoracodorsal nerve should be performed in breast reconstruction with a myocutaneous latissimus dorsi flap. Denervation may prevent discomforting symptoms caused by muscle contraction, but the flap may also lose significant volume. The authors prospectively evaluated the influence of latissimus dorsi flap innervation on the latissimus dorsi muscle structure in delayed breast reconstruction. Methods Between 2007 and 2008, 28 breast reconstructions were performed and divided randomly into the denervation group (surgical denervation by excision of 1 cm of thoracodorsal nerve, n = 14) and the intact group (thoracodorsal nerve saved intact, n = 14). Muscle biopsy specimens were taken during the operation and 6 months after reconstruction. Histologic (hematoxylin and eosin), immunohistochemical (human developmental, neonatal, slow, and fast myosin heavy chains), and morphometric analyses were performed. Magnetic resonance imaging of the breasts was performed 1 and 12 months after surgery. Results There was a significant decrease in type I and type II myofiber diameters from 0 to 6 months in both groups. Denervation caused more significant atrophy than disuse alone. However, there was no significant difference in flap thickness between groups that can be explained by more pronounced fatty tissue infiltration in the denervation group. Conclusions The authors' data suggest that the volume and consistency of the flap remain more or less the same, regardless of whether the thoracodorsal nerve is cut or not. Thus, in their practice, the authors do not cut the nerve to save surgical time. Clinical question/level of evidence Therapeutic, II.

Axillary nerve repair by fascicle transfer from the ulnar or median nerve in upper brachial plexus palsy

Nerve repair using motor fascicles of a different nerve was first described for the repair of elbow flexion (Oberlin technique). In this paper, the authors describe their experience with a similar method for axillary nerve reconstruction in cases of upper brachial plexus palsy. Of 791 nerve reconstructions performed by the senior author (P.H.) between 1993 and 2011 in 441 patients with brachial plexus injury, 14 involved axillary nerve repair by fascicle transfer from the ulnar or median nerve. All 14 of these procedures were performed between 2007 and 2010. This technique was used only when there was a deficit of the thoracodorsal or long thoracic nerve, which are normally used as donors. Nine patients were followed up for 24 months or longer. Good recovery of deltoid muscle strength was seen in 7 (77.8%) of these 9 patients, and in 4 patients with less follow-up (14-23 months), for an overall success rate of 78.6%. The procedure was unsuccessful in 2 of the 9 patients with at least 24 months of follow-up. The first showed no signs of reinnervation of the axillary nerve by either clinical or electromyographic evaluation in 26 months of follow-up, and the second had Medical Research Council (MRC) Grade 2 strength in the deltoid muscle 36 months after the operation. The last of the group of 14 patients has had 12 months of follow-up and is showing progressive improvement of deltoid muscle function (MRC Grade 2). The authors conclude that fascicle transfer from the ulnar or median nerve onto the axillary nerve is a safe and effective method for reconstruction of the axillary nerve in patients with upper brachial plexus injury.

Continued twitching of the latissimus dorsi miniflap after breast conservation therapy: a case report

We report a case of continued twitching of the latissimus dorsi muscle following breast conservation therapy, along with immediate reconstruction with a latissimus dorsi miniflap, which continued despite several attempts at control including BTX-A percutaneous local injection, and was finally cured by delayed division of the thoracodorsal nerve via a small well-tolerated axillary incision.

The End-to-Side Neurorrhaphy in Axillary Nerve Reconstruction in Patients with Brachial Plexus Palsy

Sir:FigureAlthough a number of theoretical and experimental studies dealing with end-to-side neurorrhaphy have been published to date, there is still a considerable lack of clinical trials. In this communication, we describe our experience with end-to-side neurorrhaphy in axillary nerve reconstruction in patients with upper brachial plexus palsy. Of 791 reconstructed nerves in 441 patients operated on from 1993 to 2011, we performed 21 axillary nerve sutures onto median, ulnar, and radial nerves from 1999 to 2007. This technique was performed only in patients whose “classic donors” such as the thoracodorsal or long thoracic nerve that we generally use for repair of the axillary nerve were not available. The average age of the patients was 32 years. The average time between the trauma and surgery was 4.8 months (Table 1).Table 1: Data for Patients with End-to-Side Neurorrhaphy of the Axillary Nerve onto the DonorIn all patients, a perineurial suture was carried out after the creation of a perineurial window (Fig. 1). It is our standard technique because it has been shown in experimental models that the success rate of such sutures is much higher.1 The precise site on the donor nerve where end-to-side neurorrhaphy was to be performed was chosen by direct bipolar electrical stimulation and registration in the corresponding muscle. There were no signs of denervation of the donor nerve after the perineurial window was created in experimental models.1,2 Similarly, none of our patients had any sensory or motor loss in the innervation zone of the donor nerve, contrary to the Oberlin technique, which carries a risk of sensory loss and, rarely, weakness of hand movements.5Fig. 1: End-to-side neurorrhaphy of the axillary nerve (A) onto the ulnar nerve (UN).The axillary nerve reinnervated successfully in 10 of 21 patients (average follow-up, 30.7 months; Medical Research Council grade 3 to 4 during shoulder abduction over 30 degrees). In four patients, no electrophysiologic signs of reinnervation were observed. In contrast, seven patients whose electromyograms showed reinnervation potentials exhibited insufficient deltoid function (Medical Research Council grade 1, and in one case, grade 2). The success rate was 47.6 percent. The use of different donor nerves (ulnar or median) did not affect the success rate. In the study with the largest series of patients published to date, the author reported good results with reconstructions of various nerves in the upper extremities. These results, however, are not comparable to our study because of a large variety of both donors and recipients.4 We previously reported successful reinnervation using end-to-side neurorrhaphy in 64 percent of patients. These results were based on 14 patients who completed a sufficient follow-up period.3 In the present study, the success rate was 47.6 percent, suggesting that the chance of successful reinnervation using end-to-side neurorrhaphy is lower than we previously thought. The results of end-to-side neurorrhaphy in brachial plexus reconstruction are similar to neurotization using the extraplexus nerves as donors of motor nerve fibers in end-to-end neurotization. Generally, a limited amount of motoneurons have the capacity to send off collateral sprouts from intact axons.2 We conclude that end-to-side neurorrhaphy should be used in adult brachial plexus reconstructive surgery only if “classic donor nerves” are not available. One advantage of end-to-side neurorrhaphy over “classic” neurotization is that there is no need to sacrifice the surrounding nerves or fascicles of the ulnar nerve (Oberlin technique). Pavel Haninec, M.D., Ph.D. Radek Kaiser, M.D. Third Faculty of Medicine, Charles University, Department of Neurosurgery, Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic DISCLOSURE The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this article. ACKNOWLEDGMENT This study was supported by grants IGA NS 10496-3/2009 and MSM 0021620816.

One-Stage Transfer of 2 Paddles of Thoracodorsal Artery Perforator Flap With 1 Pair of Vascular Anastomoses for Barraquer-Simons Syndrome

We report a novel technique: a 1-stage transfer of 2 paddles of thoracodorsal artery perforator (TAP) flap with 1 pair of vascular anastomoses for simultaneous restoration of bilateral facial atrophy. A 47-year-old woman with a severe bilateral lipodystrophy of the face (Barraquer-Simons syndrome) was surgically treated using this procedure. Sufficient blood supply to each of the 2 flaps was confirmed with fluorescent angiography using the red-excited indocyanine green method. A good appearance was obtained, and the patient was satisfied with the result. Our procedure has advantages over conventional methods in that bilateral facial atrophy can be augmented simultaneously with only 1 donor site. Furthermore, our procedure requires only 1 pair of vascular anastomoses and the horizontal branch of the thoracodorsal nerve can be spared. To our knowledge, this procedure has not been reported to date. We consider that 2 paddles of TAP flap are safely elevated if the distal flap is designed on the descending branch, and this technique is useful for the reconstruction of bilateral facial atrophy or deformity.