Brachial Plexus Reconstruction
Steps Involved in IVF:
What are the Types of Brachial Plexus Injuries?
Most brachial plexus injuries result from trauma to the shoulder, often in the form of stretch injuries. They can also be caused by pressure on the brachial plexus nerves caused by tumor growth in the area, accident, or physiological problems present since birth. The nerves of the brachial plexus may also be damaged by exposure to infectious agents, chemotherapy, or radiation from radiation therapy.
What are the Methods of Brachial Plexus Reconstruction?
Depending upon its seriousness, treatments for brachial plexus injury range from physical therapy and medications that relieve inflammation, to surgical brachial plexus reconstruction to relieve pressure on the nerves or even replace the nerves. At The Institute for Advanced Reconstruction, we also perform nerve transplant surgery to help patients who have suffered massive injuries to the brachial plexus, or other types of paralysis.
Q&A With Dr. Elkwood from The Institute for Advanced Reconstruction
Q: Can you explain the various procedures you do for brachial plexus treatment?
Depending upon the seriousness of the injury, treatments for brachial plexus injury range from a “wait and see approach,” with physical therapy, to complex surgical reconstruction. At the Institute for Advanced Reconstruction, we also perform nerve transplant surgery to help patients who have suffered massive injuries to the brachial plexus, or other types of paralysis.
Q: Can you clarify the various procedures?
Technically, transplant is transferring something from one place to another. (In reality, the medical profession considers transplant taking from one person to another.) Taking something from within the body and putting it somewhere else actually is considered grafting. A transfer is taking a nerve from the general locale and using it within that locale, without completely disconnecting it. I perform all of these procedures.
A patient’s surgical treatment regimen needs to be personalized, as it is often a complex, multi-step undertaking. Some patients are not candidates for nerve surgery, and some patients have maximized the benefits from nerve surgery, but if necessary, the plan should not end there. There are many procedures that can be undertaken to help. Muscle transfers, tendon transfers, muscle flaps, and joint fusion are some of the procedures that may also benefit patients with paralysis.
Q: What advice would you give to those seeking treatment for brachial plexus injury?
As with any illness or injury, the type of treatment selected is potentially a very emotional topic. Because of the complexity of the treatment, I believe the most important aspect of a search for care is to consider a complete approach to a solution, rather than a solely compartmentalized one.
Using a true team approach to care is the hallmark of our practice. You need a team to integrate all the modalities I have described. There are very few institutions that truly use this approach. I consider myself a “soloist” in brachial plexus and peripheral nerve surgery procedure. I personally perform all of these procedures with my team’s support. By being the lead surgeon in each of these modalities, I can best integrate an overall care plan for the patient. This is very critical and counter to those who advertise the “team approach,” but merely hand the patient off from one team member to another.
Q: You call yourself a “soloist” of brachial plexus surgery. What exactly do you mean?
I know of no other surgeon that performs all aspects of this type of surgery. There are a number of steps and surgeries I explore with every patient, and I don’t quit until every treatment or surgical option has been considered and, if relevant, performed.
Q: You referred to the various surgeries you perform for brachial plexus injury. What are they necessary?
There is a hierarchy of care. Ideally, I want to get the patient as close to the way God designed him or her as possible. Sometimes, additional nerve surgeries are necessary. Often I do muscle transfers, tendon transfers, muscle flaps, and joint fusion.
In the majority of cases, I have to go beyond the first and most obvious step to ensure the best possible results. One procedure results in improvement, but to maximize results, a patient often requires a multi-faceted approach. It’s a process, not an event. There are multiple goals: One goal is to return movement; then, another goal is to restore feeling.
The most important goal, which is often overlooked, is to decrease pain. Paralysis can be very painful. Most patient complaints aren’t the paralysis, it’s the pain. You know the feeling when you hit your funny bone and that initial pain takes your breath away. Imagine hitting your funny bone and living with that initial pain 24/7. Alleviating that agony alone is huge.
Q: With so many possible procedures, how do you define success?
The way I define success is that patients are happy that they had surgery. If they don’t need to take narcotics for pain, if they gained movement—they’re happy. If there is an improvement in their quality of life—they’re happy. I am proud to say that the vast majority of my patients are glad that they had surgery and would do it again.
Q: Can you give a specific example of what sets you apart in your approach to brachial plexus surgery?
I treated a college student from North Carolina with a gunshot wound who had previously undergone a vascular reconstruction of his right arm. The fact the doctors kept his arm alive was fantastic. However, his arm was limp, basically useless. His doctors, who had, after all, saved his arm, doubted that there was anything else that could be done. Unfortunately, this is what often happens. He was referred to me through his neurologist. I did an initial surgery and about 80% of the nerve damage was improved. But I realized more could be done (he still did not have the use of his hand). I went through the hierarchy, and performed several surgeries. He got back the use of his hand. This was a young man who need not have “settled” for a partial cure, or get sent on his way because a surgeon couldn’t advise him beyond that person’s specialty.
Why did you take on the aspect of multi-level care of this injury?
I see, and treat, these procedures from “soup to nuts.” It’s just the way I see the world. That’s why, for example, in addition to my medical training, I went to Columbia University to get my MBA—to perfect my understanding of health policy issues. As remarkable as it may seem, nerve surgery can be unsophisticated in a certain sense. These days, medical professionals tend to be specialized, so often the care is not particularly integrated. Very few want to take on complex, multi-layered procedures. My interest is in system accessibility: filling the gaps.
Q: Is there a final message you want to communicate?
From the least to most complicated cases, I am dedicated to return patients to the best quality of life possible. I have devoted my career to this specialized surgery, and hope that this explanation will assist those who require brachial plexus treatment. I particularly pride myself in taking care of patients who have been told that nothing can be done, or that they have maximized their treatment, but I can take them to the next level. It’s rare that I see someone that I say there is nothing I can do. I’m going to get them better than they were—that’s my obsession.
Frequently Asked Questions
What actually happens during hyperstimulation of the ovaries?
The patient will take injectable FSH (follicle stimulating hormone) for eight to eleven days, depending on how long the follicles take to mature. This hormone is produced naturally in a woman’s body causing one egg to develop per cycle. Taking the injectable FSH causes several follicles to develop at once, at approximately the same rate. The development is monitored with vaginal ultrasounds and following the patient’s levels of estradiol and progesterone. FSH brand names include Repronex, Follistim, Menopur, Gonal-F and Bravelle. The patient injects herself daily.
What happens during egg retrieval?
When the follicles have developed enough to be harvested, the patient attends an appointment where she is anesthetized and prepared for the procedure. Next, the doctor uses an ultrasound probe to guide a needle through the vaginal wall and into the follicle of the ovary. The thin needle draws the follicle fluid, which is then examined by an embryologist to find the eggs. The whole process takes about 20 minutes.
What happens to the eggs?
In the next step, the harvested eggs are then fertilized. If the sperm from the potential father, or in some cases, anonymous donor, has normal functionality, the eggs and sperm are placed together in a dish with a nutrient fluid, then incubated overnight to fertilize normally. If the sperm functionality is suboptimal, an embryologist uses Intracytoplasmic Sperm Injection to inject a single sperm into a single egg with an extremely precise glass needle. Once fertilization is complete, the embryos are assessed and prepared to be transferred to the patient’s uterus.
How are the embryos transferred back to the uterus?
The doctor and the patient will discuss the number of embryos to be transferred. The number of successfully fertilized eggs usually determines the number of eggs to be placed in the uterus. Embryos are transferred to the uterus with transabdominal ultrasound guidance. This process does not require anesthesia, but it can cause minor cervical or uterine discomfort. Following transfer, the patient is advised to take at least one days bed rest and two or three additional days of rest, then 10 to 12 days later, two pregnancy tests are scheduled to confirm success. Once two positive tests are completed, an obstetrical ultrasound is ordered to show the sac, fetal pole, yolk sac and fetal heart rate.
Built into this technology there is a microscope with a powerful camera that allows the uninterrupted monitoring of the embryo during its first hours of life. In this way, we can keep a close eye on the embryo, from the moment when the oocyte is inseminated and begins to divide into smaller and smaller cells, until it can be transferred to the uterus.
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Stem cell therapy and PRP therapy have been shown to be most effective for: Those in the early stages of hair loss, patients who are not viable candidates for surgery and women who prefer to avoid hair surgery.
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Low Ovarian Reserve (PRP)
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Punta Mita Hospital
Punta Mita Hospital - Genesis Cell