I'm Steve Lee, you just heard me speak. I'm from Hospital Special Surgery. I'm gonna show three transfers here. One is the double fascicular transfer. The next one's gonna be the AIN to ulnar motor transfer. And then the last one's gonna be the triceps branch to axillary nerve transfer. So just to orient you here, here we have the proximal aspect of the extremity. Down on this side is the, as you can see, the hand is down here, down that way, okay? So the medial arm, and what you wanna do is you wanna have the shoulder externally rotated when you do the procedure. And a couple landmarks you're gonna go for is you're gonna feel the coronoid, or the coracoid process up here. So coracoid, and I have elbow in the mind from the other panel discussion, so here's the coracoid process right up here. And then you're gonna see the antecubital fossa right here. And the reasons that those are gonna be important is that you know that the, you should know that the branch, the motor branch that goes to the biceps is about 17 centimeters, give or take, from the coracoid process. So from my small finger to my PFP joints, five centimeters. All right, nice little internal measurement. So I'll go here, five, five, five. And if you look over here, this is right at the motor branch here, okay? Just as a, you know, just as a guide. The branch that goes to the brachialis right over here, and it goes right into the muscle. Let's have a arm navy, please. Yep, thanks. That's gonna go right into the muscle over here, okay? The branch, the brachialis, and that's gonna go about mid-arm, okay? So if you see that, that's about the mid-asp of the arm. So that's where you need to be. So when you start the incision, you have to know, generally know where they're gonna be before you make the incision. What I do is I palpate the biceps. So if this was down like this, and this was out, when this is closed over, you're gonna palpate the biceps here, and you can feel it, and there's gonna be a concavity right over here. That's where the plexus and the artery is, right in that concavity. So I'm gonna make my line in that concavity, and then know proximal distally where those other branch points are gonna be, and that's where the action has to be, all right? The incision I made is a little more generous for showing what we do here, but it is, you know, it's not a small incision, so I'm not gonna do it by any means. So then what you're gonna do is, I prospected for time's sake, but when you open it up first, you're gonna see the fascia first. The fascia's just gonna be of the medial arm. It's gonna be down like this, and you're gonna open up the fascia right where that concavity is, and so once you open that fascia, you're gonna come through here, and generally the first thing you're gonna see, and you can put your finger in here and palpate, you'll feel rope-like structures, and those are nerves and arteries, and the artery, but generally the first thing you're gonna feel is gonna be the median nerve. It's gonna be right in the middle here, and so once you feel that, then you're gonna dissect down to it, and then you're gonna see it, and you're gonna go, all right, that's the median nerve. I know where I am, generally. You're gonna, this first muscle over here is gonna be the biceps, and the nerve branch of the biceps is underneath the biceps, so you really have to evert it like this, okay? And we're gonna use self-retaining retractors and assistance here from Dr. Ennis, and so we're gonna open it up like this, and at that point, what I'm gonna do is I'm gonna lift up this biceps here, and I'm gonna start dissecting approximately to there, because I'm gonna look for the musculocutaneous nerve and its branch point, so the musculocutaneous nerve is gonna come down, and it's gonna have three portions to it. One is the motor branch to the biceps. The other is the motor branch to the brachialis, so motor branch to the biceps, and you can, you know it goes to the biceps because you dissect it all the way out to it, arborizes out, and you see it actually going into the muscle and you pull on it and the muscle pulls. Let me know if something's not clear to you when I'm doing it. Let's see, have you already split the musculocutaneous nerve? I have, yeah, I split it to about, it was like about right here before, okay? So it was about here when I got in, like this. Hopefully that's clear to everybody. I do a little intervacicular dissection so I get more length on it so that it reaches without tension, just like when we do nerve repairs, you want your nerve transfers to have no tension because when you, and I learned this from Susan when I visited her, is that when you move the arm, the muscles move back and forth, and so if you have it so the nerves at the end are just kissing like this with no wiggle room, then when you move the arm, there's gonna be potentially tension there, and so she really stressed having them like really loose. You'll see when I do it. She's gonna be laying like loose, like a nice loose noodle there so that when you move the arm, there's gonna be no way that that's gonna have any tension on it. That's a key part there, and so what I'm gonna do is once you go north of the median nerve, the first thing you're gonna see that's nerve-like is gonna be the musculocutaneous nerve itself, and that's gonna be right over here, and this is the musculocutaneous nerve after the biceps has come off, and you can imagine why because if you're going north from here, you're gonna come to this first, and then you're gonna start wanting to go more proximal until you can see that you're gonna get the nerve that's gonna go to actual biceps muscle here, so once I am at this point, I'm gonna dissect up here, see this, and then I'm gonna dissect a little farther north, and I'm gonna see this, and then I'm gonna just kind of, what you have in this area that's gonna be in your way that you're not seeing right now is just gonna be a bunch of kind of fatty, loose, roller tissue that comes off easily when you spread. The other things that don't come off easily when you spread are gonna be some passing veins over all this stuff. You'll have a couple veins that go like this, here and there, and you just simply just bipolar them or tie them off. It's no big deal. All these things can come out, all right? Anything that's a vessel that's in this way or just veins, you don't need them, so once you find the branch point, and then I dissect out so I see that it goes into the muscle. That's a key part because you always wanna make sure you actually have the actual motor branch of the muscle, so I go here and I pull on it and I go, okay, that's it. Then what I'm gonna do is I'm gonna dissect proximally, and you had brought up that good point that they were together about here, right where my scissors is. They were together here, and I want it to be a little longer so it's gonna drop down nicely to my donor nerve, so I'm gonna interfacicularly dissect. I do this under loops. I only bring the scope in when I'm gonna actually do the actual coaptation, the connection of the nerve, so what I'll do is I'll just, and when you do the dissection that way for interfacicular, all you do is you do some gentle spreading. You occasionally will do a little tiny cut of the epineurium. I'm just gonna spread like this till I get that separated here, and that's a good point right here. Once you start seeing, if you start seeing the, kind of the fascicles start crossing over, then you don't wanna cut them, and that's where you have to stop because then you start damaging branches that are gonna go farther down here to your brachialis. Okay, so you want to just kind of stay with that and not, you know, not to overdo it, so once you come to this point, I'm happy with this, and I'm gonna get ready for my transfer, so I'm gonna actually cut it here, right, and so here we go. Gonna go as far approximately as I can here, and I'm just gonna do a cut. When we do this, actually, in the OR, what we do is we take a, we have a device. I have no, you know, gain or anything in relationship with them, but it's ASSI makes a nice device. It's a nerve-cutting device that makes a nice straight cut, and the original Oberlin, as I said in the talk that I gave, was the original Oberlin was the ulnar nerve fascicle to the biceps, right, and for us and for everybody else that I've talked to, they don't necessarily always just follow that. They just follow, like, what lies nicely, and for me, generally, it's been the median nerve that lies nicer there. It's a little more, you know, it's kind of right close to the area, and what I do is I drop it down, and I just see where it's gonna lie so that it's a nice squiggly worm like that because you have more play on the recipient side than you on the donor side because the donor side, when you open the median nerve and the ulnar nerve, you can only take the fascicle out so much of a distance, and then you start getting some intertwining there, and so it only comes out maybe a centimeter or two before you get intertwining, and then you certainly don't wanna cut those. Those are going down to the hand and wrist, and you need to preserve those, so once it lies down in this one area here, I'm gonna open up the epineurium, and I did a little bit here, but generally what you do if you're gonna do this is that you just go and you just kind of, with dissectances, you just open the epineurium, and then you cut the epineurium just on the outer surface until you can get to within the nerve, and in the nerve, they're gonna be anywhere. I've seen as few as three fascicles and as many as, you know, even six or seven, and you're just gonna open up and start looking at them, and then you take a nerve stimulator. The only tie I have to this company is that they've helped some research support. I don't get paid by them in any other manner, but we like the CheckPoint device simply because it is very reliable, and that's versus the Medtronic device, which we found to be not as reliable. It also has more settings you can do. You can up the power that it put through, and what you wanna do is you wanna open up your nerve so you get a fascicle or two, and you can take up to 20% of the nerve, no more than that, and if I get one like this, for instance, here it is, and hopefully you can see that. Hopefully my head's out of the way. Is that clear to everybody? Okay. Okay, so right. Yeah, yeah, that's good. Okay, I'm able to see it there, so that's good. So I'm gonna take that, and I'm gonna stimulate that. In the operating room, I'm gonna put a loop around this, and I'm gonna take my nerve stimulator, and I'm gonna put it right on that, and you're gonna see what happens down at the hand and wrist area, and what you want is that, A, you want some motion to happen so you don't have a sensory fascicle, right? That's the biggest thing. It's very pluripotential up here, so you'll get your wrist moving and your digits moving, and what you try to get is a fascicle that's a little more wrist than hand, but for, in my experience, it's always been just like everything kind of moving, and you just try to get one that's a little more wrist, and you also try to get something that's gonna have a decent size mismatch, or a size match, that looks good here. So what I'm gonna do is I'm gonna dissect it out. In the actual case, I wouldn't be grabbing the nerve. I don't have a micro forcep, but I'd be using a micro forcep on this in the real scenario. So I'm gonna come here, and once I get to a point where I get some resistance, then I'm just gonna cut it there, and Susan also has this thing, she always says donor distal. She says, donor distal? I can hear her saying that, and you go donor down here, it's gonna cut it distal down here so you have a little more swing. All it is is just saying that you wanna have it so that it's loose. So I'm gonna cut it here, and I'm just gonna drop it up here, and this, when you do the nerve transfer, it should just lie like it's been made to be. It was meant to be. I don't know if you guys can see that, hopefully. Not guys, men and women, sorry. So it's right there. Yep, right there, that's the nerve transfer, and it should just lie in a nice bed like that, okay? So that's the first one. Then we're gonna come down. Any questions about that part? Okay, great. All right. Sometimes I'm very insecure. I need to hear, like, I like to see head nodding when I look out in the audience, but when I do these scenarios, I can't tell any of that stuff. Okay, good, good. Yeah, that's right. If there's any droopy eyelids, then we can ask them some questions. That usually wakes up, at least the residents, but not in this scenario, I suppose. So here we go, and we followed the muscutaneous nerve down after that part, and we're looking for two more sections of it. One is gonna be the nerve that goes to the brachialis, and once again, what you do is you look for the nerve that's going to arborize out like this, and it's gonna go down to the muscle. You pull on it, and it actually is attaching to muscle. And there's a lot of variation. There's variation in the biceps one, too. Sometimes you'll see two of them coming off, and so you wanna look around and make sure you get all of them. This one had one that I could see, and I've definitely more commonly seen more than one in a brachialis. I didn't see it on this one, but oftentimes I'll see it come down, and there'll be another branch going medial, and there'll be another one going lateral, but they'll coalesce together as you go more proximal, and you wanna get the whole thing if you can. So this is it, and if you look down here, this is the cutaneous portion of the muscutaneous nerve that goes down, and there's a, if you pull on it down here, you'll see the skin moving over here. I'm not sure if you do. You see the skin? Yeah, you do, in the upper corner? So that's a good sign that you're getting cutaneous down there. It's not going to the muscle there, so that's a little tug test. So you'd have the tug test for muscle. You have the tug test for motor, I mean, for cutaneous and for motor, and so once I have this, I know that I'm gonna wanna take this, just like we did for the biceps one. I'm gonna wanna take it as proximal as I can. I did some intervacicular dissection prior about to here. I'll do a little more of that on the ulnar nerve section. You'll see me do that. I left it so you could see it, but it started out about there, and I just did it to about here, and what I do then is I expose. The medial nerve's always just sitting right in front of you. It's right there. Underneath is the artery, right here. The ulnar nerve is always buried down here. Here it is, okay, and it's not like right in your face when you get in there. You have to go down there and find it. It's under this fat, and there's some veins in the way and stuff like that, so you gotta find it down here, and the reason at this point I wanna find it is I wanna see, just extrapolate in my mind, if I cut it here, where is it gonna sit, and then where do I need to be in the ulnar nerve, and oftentimes there'll be, and in this case there was, there was some veins and some fatty tissue that was right over here, and I had to move that stuff out of the way so I'd have a clear shot at it, okay, and so at this point, I can see that this is gonna drop down quite nicely over here, and once again, you're gonna dissect this back until you start getting some resistance, and then once you get a little bit of resistance, then you're gonna say, okay, that's where I'm gonna go, so I'm gonna cut it right there, and then I'm gonna take it, and I'm gonna say, how's that gonna swing down here? Okay, so it swings down here, and it looks like there's a little bit of connection here. Okay. And then, now one thing that you can, that I'm probably not appreciating is that we're really distracting the tissues this way. They're generally closer together. So then, I'm gonna look over here, and I'm gonna see my ulnar nerve, and I'm going to open it up just like I did in the other one, and you wanna go more distal, so I wanna, you know, as you imagine, I wanna swing it up here so it's loose over here too, and so I'm not gonna make my opening over here because then it's like too close to it. I'm gonna make it distal to where my recipient is. Hope that's clear to everybody. So I'm gonna come down here. I'm gonna open up the nerve, you know, past it so that when I swing it up, it's gonna come up to it nicely. So. And getting a fast glide here, I'm gonna do that whole stimulation situation again like I had talked about before, and then we're gonna cut it and then swing it up. So, I'm gonna cut it over here. And drop it up like this. Nice and loose. See how much room I have here? And it's gonna come over here. Hopefully my head's not in the way and you guys can see that. There are really small, you know, amounts here, but these motors, when you stimulate them, they are mighty. They're super powerful. Just that one fascial, you do that, and you saw the video I showed of that young woman doing the curls. This is the kind of result that you can get. You saw the literature I gave from Scott Wolf's paper. 80 some odd percent of them, four. So, it's a very, very, I mean, this is like a classic, awesome transfer. If all transfers could be like this, that'd be great. They're not always as good as this one. This is the best one you're probably gonna get. Hopefully that's clear to everybody. Steve, why don't you tee this up? If it looks like you've got more redundancy maybe than you need, will you cut some off the distal recipient? I will, yes. To move your juncture a little more distal? I will, but when it comes down to it, this is still pretty darn close. And overall, you don't want to, your transfers are generally better if they're under six months. Generally, that's the trend. We're looking at, we're kind of doing a literature analysis now. The transfers, you can probably sneak that a little later. Eight, nine months, something like that. The closer it is to the target. But before three months, depending on the scenario, if it's traction, generally, if it's definitely for plexus, we want to see what's gonna spontaneously recover first. But after three months, and then before six months, there's a golden period. That's the time to pull the trigger and do it. And I think your results are gonna be better. Hopefully that's clear to everybody. Yes? That was very clear. It's a beautiful illustration, quick question for you about the donor nerve. So when you make your epineurotomy and you're dissecting out an obstacle and stimulating it, do you dissect out three or four and stimulate all and see which one gives you the most risk functions? Or do you just dissect out one, see how it looks when you stimulate it, and if it doesn't look good, move on? We generally don't dissect them out. All you do is you spread them, and you can see them, and you can put your probe right on it. Do try to minimize the dissection because it's traumatic to it. We've had, I was telling Dr. Ennis before, we've had one or two people who had transient ulnar nerve weakness, a little bit of clawing, it wasn't totally out. They came back, and if you look at the literature, that's, other people say that too, occasional transient palsies or weakness. That wasn't full palsy, but obviously they're not fun when you see that post-op, but it's pretty infrequent. But they've come back, and I think you just have to tell the patient that's possible. It's very, very unlikely that it's gonna be something permanent. As long as you don't take, and when you open it up, like I said, you're gonna have multiple fascicles. We generally take one fascicle, maybe two if you have plenty others. You don't wanna take more than 20% of the nerve, that's the other thing. And yeah, but I will start with one, and I'll mini-dissect out a couple others maybe, but if I get a good response on the first one, I mean, you don't need to look around a lot. I'll check a couple others maybe, but. The device, again, that you use, I think many people share your frustration with their stimulators. Yeah, I presume it's disposable, who makes it? The company's called Checkpoint, and that's the company, that's them, that's all they have. And it is disposable. We exclusively use that. I use that, I even turn the trauma surgeons onto it. You know, if you're getting a radio, and I've done it myself with a humerus fracture that's been, had surgery before, and you're redoing it, and the nerve is just plastered in the scar, you can turn up the ampage on the nerve stimulator to go near a field like this, and then you sound it out almost like a Doppler. And you can know where the nerve is generally, then you can slow down your dissection when you're kind of near that. And then when you're where it doesn't do it at all, then you're like, fine, and you can dissect there. And the trauma surgeons, Dr. Halfitt, Wellman, Lorich, I mean, they're turned onto the thing when they see the value of it. And I don't, you know, they don't pay me or anything, but it's been very valuable for us. Okay, so this is, once again, bigger than it'd be. It'd be a little bit smaller, but not that much smaller in my experience. And what I do is I dissect out Guion's canal. I think everybody here are expert hand surgeons. I've dissected Guion's canal out before. You wanna find the motor branch. And the way that I always try to find it, I think most people find it, is you palpate the hook of the hamate. The motor branch is gonna go around the hook of the hamate. And so once you get into Guion's area, I'm gonna feel for the hook of the hamate. And once I know where the hook is, I know the nerve's gonna dive right around the hook. And I've opened up the fascia and the muscles around this motor branch. So you know it's quite deep. And as I tell the residents, fellas, you have to own the artery when you're doing this too. It's going around the artery. So dissect out the artery, find it safely. And then find the motor branch. It was together with the, in zone one, about here, you know, where my scissors is. So I started this and then I stopped so I can just show you this interfacicular dissection. So basically what you do is you put vessel loops around each fascicle side. And you come over here. And so you're gonna look for the pronator quadratus. And there's gonna be a nerve that goes into the pronator. So the pronator quadratus is right here. There's a nerve that's going into it right here. And that's the motor to the pronator quadratus. It's gonna come through. And it does have a sensory portion too, as you know. Much of it is motor though. So you're gonna come over here. And I dissect this out so I know where I need to get to. So this is gonna swing over to the ulnar nerve, which is over here. So I need to be working in this area here. And so if you can see, that's quite a distance. You know, this is my, Gyan's approach is down here, right? And then where my business is is here, right? So this is no, it's not like you're doing many incisions. You know, you do nerve reconstruction where many stuff is out the window, man. This is like, you gotta go for it. You just tell the patient, you know, you gotta do what you gotta do. You gotta see what you gotta see. So now we're gonna come back here. And just by, you know, putting a little bit of traction on both sides, I do a little couple snips here. I generally use a suture removal scissor like this one to do this work. So I'm glad I heard laughter. Thank you, guys. Thank you. Do you find that these groups of fascicles change their orientation at all? Or is it, can you pretty much come straight down top to bottom, like it looks like you're doing, you know? They don't change as much as you might think. And you know, Susan, I think I mentioned that before. She says she just visually does it. Yep. Like she'll look over here and just like cut it out there. And so it doesn't, I haven't found it to wind around that much. And she obviously doesn't either. I mean, if you visually do it, it can't be winding around that much. Yep. I see a question that's referrable to this sort of transverse. And probably as the other one you showed us. In the interest of maybe preserving the potential for re-nervation after the injury, would you ever consider incising? Yeah, that's a great question. The quote-unquote supercharge, right? People have heard about. I would consider doing that. And you know, the science behind that is, you know, in animals it seems like it works. I think we're all a little bit not totally sure. I don't think I would do, and I've actually heard, I visited Hanno Molesi too. And he told me he did endocides for moving the arm. He was doing, I'm trying to think what he had done. But it was, he said they all worked. And I just, I couldn't, I wasn't sure. Would you have an ulnar nerve 100% transfection at the elbow in a cubital tunnel? Is there any rule for a concomitant endocide procedure at the wrist at the time of your neuropathy? Yeah, to supercharge it there? Right. Yes, I would consider that. Because when you think about taking the motor branch from the peroneator quadratus, I mean, we cut that off all the time with radius fractures. And they have their peroneator teres, they don't lose anything. I would definitely consider doing that. I mean, I think if I had my ulnar nerve cut at the elbow, I would probably want that. I mean, you have the time, you have the ability to maybe help the person with very low morbidity. And if you, you know, if you lose that opportunity and your motor end plates die away, then you just lost that opportunity. Steve, would you want your son endocide or are you old enough that you might want an endocide? I guess that's a loaded question. It is. So we have our dorsal branch coming off here. Yeah, you know, it depends how high up, but I think if it was above the elbow, probably at or above, I'd probably be going for transfers. Okay, so here we have our ulnar, that's the motor branch. So instead of doing it with my eyes, I've done it with my scissor and I feel a lot better about doing that. I'm not sure if everybody else thinks that. Even if I might've gotten a couple of little fascicles here and there, I've got the majority of the motor over here. And I know when I plug my motor in from my PQ, that's right next door here. Hopefully everybody can see that over here. See the nerve right over here, PQ. And see how it is right there. I know that this, all that motor power is gonna go right into this guy, right? And so what I'm gonna do, just like I showed in that other Oberlin is I'm gonna cut it here. Hopefully not sawing. And I'm gonna open up my peroneator quadratus some. So it was actually closed like this a bit up to here. Let's go right up here. Yeah, right like that, okay. Hopefully everybody can see that, okay. And this was, this is the proximal edge of the muscle, the peroneator quadratus. That was closed up to here. And so, but you can see the muscle going into it right there. And so what you do is you open it up a little bit and what that gives, it just gains you some length, right? And then you'll start seeing it arborize out into the muscles. Like you pull on it and the muscles are being pulled, right? So now this is gonna have a little bit of the pain fibers, you know, the ones that you denovate in there, but I'm not gonna like take those out necessarily myself. I'm just gonna go here and if you really need length and this one we don't, but if you ever really need length, what we do is we cut all the way down to where they go into muscle and then we glue them again back together and then we swing them up. So if you're ever in a situation where for whatever reason, whatever transfer you're doing, you're like, I don't have enough length. I need length. I'm going to, what can I do? That's what you do is you dissect it all the way out to the muscle, where it goes in the muscle, cut it there, glue them. This one I can just do, you know, before they arborize, I'll just, you know, right here I can tell it's gonna swing up nicely. So go over here. Do you routinely augment your neurologies with a glue product or a nerve wrapped flesh tube? Routinely we do glue, yeah. So we do suture and glue. And so we routinely will take a, we'll kind of take a couple sutures, like for instance, like this lays nice like that. Hopefully that's clear to everybody. Once again, I'd like to stress that, see how it just lays like that. It's got to look like that when you're done. If you're like trying to get it there and it doesn't lay like that, there's something wrong. You've, you know, you don't have, you didn't dissect out distantly enough on the donor or approximately enough on the recipient. You really want it to be nice and loose like this. You can see this is like, look at how loose this nerve is here. Total laxity here. So when I bend my wrist up and down, this is not gonna have any tension on it. And so what we would do in this scenario is we bring the scope in. And oftentimes if we're doing several transfers, we just kind of lay them up like this. And then we put a background on in there. And then we just put some towels on there. And then at the end, we bring the scope in and just bang, bang, bang. And we do all the micro. And we'll just come here and put, like this one I could see maybe being just two stitches, you know, something like two ninos, 180 degrees. And then we take, what we do for the glue is we have the background like this. The nerve's gonna be here and the coaptation side's gonna be here. And we make a little square cut like this. We use the mayo stand cover. That's very kind of slippery. So not the rubber, not like a NASMARC. So slippery mayo stand cover. And then we put it in there and then we drip the glue right in there. And then we close it up like a, like a burrito or taco. And then we hold it like that for about 10 to 20 seconds. Then we let go and it should stay together. If it doesn't stay together, that's our test that the glue wasn't mixed well or there's something wrong with it. You know sometimes when you get the glue and it doesn't quite look right. That's our test for it. We let go and then we just leave it there for 20 minutes. We do something else, we take it off. You got this nice, like glued in area there. It's really an awesome way to do it. At least we feel good about it. And, you know, clinically it's worked for us. So there's that one. What I do here, and this is, once again, a little bit bigger incision, but here we take the arm, we're posterior like this, okay? And you can do this like a sloppy lateral type thing or you can do them total prone. And what I do is I feel the olecranon process. And I know that I'm gonna be aiming towards that. So you don't have to go quite this long. You could stop it about here. And then the other thing that I do is I feel the deltoid. This guy is pretty big guy, but you know, I feel the deltoid like this and I'll know where the deltoid ends and I know I need to be at least a little bit closer to the center of the arm. And I know where the deltoid ends and I know I need to be at least about this far from up from the deltoid. So I could have been a little bit shorter here. So it's just the luxury of having the cadaver. So I went big. Anyway, so here, what you do is when you first open it up, you're gonna have fascia. You're gonna open up that fascia in line with that part there. And what you're looking for is you're gonna look for the split between your long head and your lateral head of your triceps. You wanna go between that split. Sometimes it's easy to go in that split. Sometimes it's harder to go in that split. For whatever reason, there's just difference in anatomy, more fascia there. But you gotta go between those heads. Once you open up those heads, the first thing you're gonna look for and see is you're gonna actually see your radial nerve because it's gonna be a white structure coming like this with some fat on it. And these are all the branches of it. And the other thing, it's a key point. This is like the landing spot for it all is gonna be the teres major, right there. The teres major is your home base because the teres major beneath the, inferior to the teres major is where the radial nerve comes out, okay? So once you see the fibers, the fascia of the teres major, you're home. Down there is that. North of the teres major is the axillary nerve, right up here, okay? So once you got that in mind, then you start dissecting. And just quickly, the one I was gonna show is the classic somsac. And the somsac is taking the motor branch to the long head, okay? And it's gonna be the most medial branch as you come out. Yeah. Here's the teres major, and what I do also is I split this a little bit. And we can split even more than that. But we'll go like this, and you come like that. You retract it back, and you can nicely see this over here. Let's see. Here's the radial nerve, the rest of the radial nerve right there. Hopefully that's clear to everybody. Yep. And then over here is the long head branch. Does everybody see that there? Okay, long head branch. And the other thing is when I look at it this way, I see it going into muscle here, right? Going into muscle, it's going into muscle there. Long head branch. And then you stimulate it, of course, and it's a very vigorous contraction of the long head. We recently did a study. We presented it at a couple meetings, and we looked at all the other branches here, the medial head branch, lateral head branch, and then the radial nerve proper. We looked at the other branches, and you can use those other branches, too, and not have a weak triceps. Long head branch is often not quite enough, and you can take like a half of the medial head branch and augment it. Then what you do is go north here. Actually, let me just cut that one here so that we have, so we'll just swing it up. People will be able to see. This one, I have the luxury of going long, so I'm gonna go long here. I'm gonna cut it there, because I can always cut it shorter or glue it together if I need, but the longer I got, the better I feel, because my donor, you don't wanna get to the point where you're putting your nerves together, and you're like, damn, I'm not long enough, and that's just a bad feeling for multiple reasons. It won't come together. You don't wanna think about nerve grafts. That's just much worse results with nerve grafts. Once again, look at that. I just lay it up there, right? Onto the teres major. The teres major is your friend. The teres major is your table. It's your working table. My nerve's right up there, my donor. I'm gonna dissect in here, and this isn't always the easiest dissection in here. This is the most difficult part of the dissection, because the axillary nerve doesn't just pop out at you like the median nerve will in the Oberlin. It's all buried up in a bunch of fat and vessels. There's crossing veins everywhere. The main vessel that you have to look out for and not cut is the circumflex. It's down here. This is the quadrilateral space. Remember from anatomy, you have the teres minor above it, teres major below it. You have the long head, and you have the humerus here. So that's the space. You gotta dissect in there, and all it does is require is that you just dissect and you keep spreading till you see the main trunk down here and there is definite controversy how you do this transfer, which parts of the axillary nerve you go to. Susan McKinnon actually goes to the whole trunk down here. She dissects all the way down there and cuts it, excludes the cutaneous nerve portion. I'd mentioned before what the branches are. Here's the cutaneous nerve portion. You can see it coming to the skin. See the tug test? So you're gonna exclude that one if you're gonna go to the whole thing. You have the anterior head or anterior division, okay? Anterior division goes under the deltoid. It wraps around on the humerus or near the humerus under the deltoid, and it innervates the anterior two thirds of the deltoid, the anterior middle heads. You have the posterior part division that goes to the posterior head of the deltoid, as you can see here, and then you have a branch from there that goes up to the teres minor. Those are all the branches, four branches. So you dissect this out. You basically own the axillary nerve. Then I'm gonna come up here. I'm gonna just show you the classic somsac. The classic somsac is the anterior division only. You're gonna come up here. You're gonna cut it there. I'm gonna swing this down, and you can see that it just comes nicely right on your table that you've made for yourself, right over here, bang. Does everybody see that?

video

Dr. Steve Lee

nerve transfers

dissection

timing

end-to-side

reinnervation