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The gracilis muscle has been inset in the relative position of the biceps brachii muscle. The vascular supply comes from the axillary vessels (red arrow), and nerve supply to the gracilis nerve (open arrow) comes from intercostal donor nerves (multiple solid arrows). AAV, axillary artery and vein. C, coracoid process. G, gracilis muscle. PM, pectoralis major muscle. Pm, pectoralis minor muscle. (From Mackinnon SE, Novak CB. Nerve Transfers. Hand Clinics. 2008:24(4):357. Courtesy of Stephen H. Colbert, MD, Columbia, MO, and Elsevier.)

Surgeons at the Center for Nerve Injury and Paralysis frequently use intercostal nerves, which are located in the spaces between the ribs, for nerve transfers to restore function after total brachial plexus injury.

The brachial plexus is a complex network of nerves that lies partly within the axilla (armpit) and supplies nerves to the chest, shoulder and arm. A total injury to this network leaves a person without the use of their shoulder, arm and hand.

Nerve transfers involve taking "donor" nerves with less important roles — or branches of a nerve that perform redundant functions to other nerves — and "transferring" them to restore function in a more crucial nerve that has been severely damaged.

Intercostal nerves are used to assist the diaphragm with deep breaths and can flex the chest wall to some degree by bringing the ribs together. Nerve transfers using intercostal nerves can restore function to a number of muscles such as the deltoid (shoulder), biceps, triceps or serratus anterior. During the surgery, a large incision is made along the chest wall, and some of the intercostal nerves are cut and plugged into (transferred to) the muscles that move the shoulder, arm or hand.

Patients will, of course, be able to breathe and can still use their chest muscles after surgery. However, as they regain function from the nerve transfer, they also will be trained to flex the chest wall to activate the muscle that received the nerve transfer. The brain then learns this trick and the patient is able to move the recipient muscle simply by thinking about it.

Recovery of function after nerve transfer is a long process. Patients generally see small signs of recovery three to six months after the operation, but in most cases, return of movement usually takes more than one year.