Peripheral Nerve

Peripheral Nerve Surgery

This is a quickly expanding area of cutting-edge subspecialty expertise in plastic & reconstructive surgery that focuses on the peripheral nervous system – the nervous system outside of the central nervous system (CNS). myCARE Plastic Surgery – the Center for Advanced Reconstructive & Esthetic Plastic Surgery – is privileged to offer the following cutting-edge surgeries:

Brachial Plexus Surgery

Brachial plexus injuries commonly happen in 2 scenarios—through obstetric deliveries or as a result of trauma, resulting in an outstretched arm after a vehicular accident or a fall. Around the neck on either side is a complex neural network of nerves that interweave into what we call a plexus. The brachial plexus sends nerves from the spinal cord to different parts of the shoulder, and then through the arm into the hand & fingers. Stretched injury over time can lead to:

1. Loss of function of the shoulder

2. Loss of the function of the elbow

3. Loss of function of the wrist, hand, and fingers

There is a critical short golden window of time where it may be possible to repair the brachial plexus or graft nerves from other parts of the body. This tends to be more successful on the outside aspect of the arm (the radial side) than on the inside aspect of the arm (the ulnar side) that abuts the chest. The reason for this is because on the radial side of the arm, the nerve travels a much shorter distance from the site of injury (usually at the neck level) to its end point where it connects with the end muscle that it innervates. If it takes too long to the nerve function to fully travel, and as such fully recover its stimulatory function to the muscle at the end neuromuscular junction, the muscle will have atrophied beyond the point of functional restoration.

Key functional aspects of the arm are the ability to fully use the complex design of the hand for prehensive grasp, pinch and fine motor actions. If the hand is already fully functional, its range of function in relationship to space is improved by good wrist function that extends the 360 dimensional range of motion of the hand. At a minimum, the hand should have its ability to finger flex.

If there is function to the elbow, particularly with flexion and rotation, the hand-finger function is able to extend even more in space, enhancing its usefulness. Additionally, in order for the elbow joint to be useful, the shoulder also has to be stabilized.

The most devastating injury is the total brachial plexus injury with a limp arm. There is a certain order of functional treatment that is employed, and at a minimum, we try to improve in the following order:

1. Finger flexion

2. Elbow flexion

3. Shoulder stabilization

myCARE Plastic Surgery – the Center for Advanced Reconstructive & Esthetic Plastic Surgery – is privileged to offer the above cutting-edge options as a part of the treatment spectrum for peripheral nerve problems such as brachial plexus injury, facial paralysis, chronic headaches (including migraines, cluster & tension headaches), or corneal anesthesia.

Facial Paralysis/Facial Re-Animation Treatment

Many principles of brachial plexus reconstruction and of nerve, muscle physiology are also relevant to facial paralysis. Due to tumor resection on the face, or through injury, or through Bell’s palsies, or through congenital development, or through any process where the facial nerve is injured or involved, such that it would not be able to carry out its innervative function to the muscles of facial expression, there is a critical short golden window of time to act in order to repair/graft the nerve, or to maintain the neural stimulation to the affected or potentially affected muscle. Once this time window is past, a new neural pathway has to be created (such as through a cross facial nerve graft; or the use of an alternative nerve such as the nerve to the masseter, the spinal accessory nerve, or the partial hypoglossal nerve), and a new muscle unit has to be transferred in to replace the lost muscle volume and/or vector of function.

Smile is an important function of the face, in terms of appearance, and also of interpersonal interaction. We strive to improve smile symmetry through various modalities. Other facial nerve branches may also be affected, leading to asymmetries such as brow asymmetry. The upper eyelid may not be able to close fully over time, and will need some treatment options such as eyelid weights (gold or platinum) or levator lengthening or even replacement muscle transfer for eyelid closure. The lower eyelid may also lose its tone and may need support through one of the available procedures.

Facial re-animation surgery is a fast-developing field with many new emerging techniques, and new combination modalities available to the affected patient, a testament to the commitment of those surgeons and practitioners that want to help advance the re-animation treatments for those affected with facial paralysis.

Surgical Treatment of CHRONIC Migraine, Cluster & Tension Headaches

Although the causes of headaches are many and varied, once having been formally diagnosed by a neurologist with a chronic course, these migraines, cluster or tension headaches often have a subsequent common pathway that can be successfully treated with decompression and/or neurectomy. There have been may trigger points identified to be the sites of headache. Once diagnosed with Botox or local anesthetic during an active phase, decompression of these nerve sites can bring relief to the severe, debilitating pain.

Trigger points:

1. Supra-orbital & supra trochlear – forehead

2. Zygomaticotemporal – temple

3. Zygomaticofacial

4. Occipital – back of neck and lower head

5. Nasal – a trigger site that is identified after ruling out all the other potential sites as a culprit

myCARE Plastic Surgery – the Center for Advanced Reconstructive & Esthetic Plastic Surgery – is privileged to offer the above innovative options as a part of the treatment spectrum for peripheral nerve problems such as brachial plexus injury, facial paralysis, chronic headaches (including migraines, cluster & tension headaches), or corneal anesthesia.

Corneal Re-Sensitization through Neurotization

An exciting recent plastic surgical development in collaboration with ophthalmology colleagues allows for the re-sensitization of the anesthetic cornea through the implantation of the sural nerve. This development allows for the improved protection of vision, and prevents corneal ulceration, with eventual scarring and deterioration and loss of vision. It also makes the option of subsequent corneal transplants available in the appropriate patient candidate.

Peripheral Nerve Surgery

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