Brachial Plexus Repair: Prof. Dr. Karaaltin's Microsurgical Expertise

Understanding Brachial Plexus Injuries

The brachial plexus is a complex network of five nerve roots (C5–T1) that originate from the spinal cord in the neck and converge to form the peripheral nerves controlling the shoulder, arm, forearm, and hand. Injuries to this network — whether from high-energy trauma, motorcycle accidents, birth injuries, or tumour involvement — can result in devastating loss of upper limb function, ranging from partial weakness to complete paralysis.

Why Brachial Plexus Surgery Demands Specialist Expertise

Brachial plexus reconstruction is among the most technically demanding procedures in all of surgery. It requires:

• Advanced microsurgical skills — operating under high magnification to repair or graft nerves as small as 1–2mm in diameter
• Deep anatomical knowledge of nerve root topography, fascicular anatomy, and motor/sensory organisation
• Strategic surgical planning — selecting the optimal combination of nerve repair, nerve transfer, and reconstructive techniques based on injury pattern and timing
• Multidisciplinary collaboration with neurologists, rehabilitation specialists, and pain management teams

Prof. Dr. Karaaltin's Approach

As an EBOPRAS Fellow and triple board-certified plastic surgeon with subspecialty training in microsurgery, Prof. Dr. Mehmet Veli Karaaltin brings a comprehensive skill set to brachial plexus reconstruction. His approach integrates multiple advanced techniques tailored to each patient's specific injury pattern:

Nerve Grafting

When direct repair is not possible due to a gap between nerve stumps, autologous nerve grafts (typically harvested from the sural nerve) are used to bridge the defect. Prof. Dr. Karaaltin employs meticulous fascicular matching under operative microscopy to maximise axonal regeneration across the graft.

Nerve Transfers

In cases where proximal nerve roots are avulsed from the spinal cord — making direct repair impossible — nerve transfer surgery redirects functioning but expendable donor nerves to power critical target muscles. Common transfers include:

• Oberlin transfer (ulnar nerve fascicle to biceps motor branch) for elbow flexion
• Spinal accessory to suprascapular nerve for shoulder abduction and external rotation
• Intercostal nerve transfers for elbow flexion or hand function
• Contralateral C7 transfer in select total plexus injuries

Free Functional Muscle Transfer

For late-presenting injuries where target muscles have undergone irreversible denervation atrophy, free functional muscle transfer (FFMT) — most commonly using the gracilis muscle — provides a new motor unit. This microsurgical procedure involves transplanting the muscle with its neurovascular pedicle and connecting it to available nerve sources and recipient vessels in the arm.

Timing Is Critical

Outcomes in brachial plexus surgery are highly time-dependent. Denervated muscles undergo progressive fibrosis and motor endplate degeneration, making early surgical intervention (ideally within 3–6 months of injury) essential for the best functional recovery. Prof. Dr. Karaaltin emphasises prompt referral and comprehensive electrodiagnostic evaluation to guide surgical decision-making.

Recovery and Rehabilitation

Nerve regeneration is a slow biological process, occurring at approximately 1mm per day. Full recovery after brachial plexus reconstruction may take 12–24 months, requiring dedicated physiotherapy and occupational therapy throughout. Prof. Dr. Karaaltin works closely with rehabilitation teams to optimise the recovery trajectory for each patient, setting realistic expectations while pursuing the best possible functional outcome.

A Centre of Excellence

Brachial plexus surgery requires a convergence of microsurgical virtuosity, anatomical expertise, and reconstructive innovation. Prof. Dr. Karaaltin's practice in Istanbul serves as a referral centre for complex nerve injuries, offering patients access to the full spectrum of reconstructive options — from primary nerve repair and transfers to secondary procedures including tendon transfers and free muscle flaps.