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Overview

Title: Medial Antebrachial Cutaneous Nerve Graft Harvest.
Published: 4/22/2011, Updated: 4/26/2011.

Author(s): Susan E. Mackinnon MD, Andrew Yee BS.
Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO.

The medial antebrachial cutaneous (MABC) nerve is an available donor for nerve grafts and our institution’s preferred donor nerve graft for upper extremity nerve reconstructions. The MABC nerve is harvested from the medial aspect of the arm. Due to this location, only one extremity is required to be prepped for surgery as the MABC nerve can be harvested from the same arm as the nerve reconstruction. The MABC nerve originates from the medial cord, courses distal, and branches into an anterior and posterior branch. The anterior and/or posterior branch can be harvested depending on the length and diameter required for nerve reconstruction. An anatomical landmark used to easily identify the MABC nerve and its branches is the basilic vein, where the anterior branch is found anterior and the posterior branch is found posterior to this vein within the middle arm. Harvesting the MABC nerve will result in a sensory deficient in medial aspect of the forearm. To restore rudimentary sensation to the MABC nerve territory, the MABC nerve is end-to-side transferred to an adjacent functional sensory nerve. That is, the distal end of the transected donor sensory nerve is coaptated to the side of a sensory nerve through an epineurial window. The distal end of the donor MABC nerve can be end-to-side transferred to the sensory component of the median or ulnar nerve. If only the anterior branch is harvested, the distal end can be end-to-side transferred to the remaining posterior branch of the MABC nerve. In select cases, patients have reported full recovery of sensation with no sensory deficit in the MABC nerve territory following the end-to-side nerve transfer. The combination effects of the end-to-side nerve transfer and the spontaneous collateral sprouting from adjacent sensory territories could describe these outcomes.

Figures and Videos

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Extended Version 

Surgical Tutorial – Medial Antebrachial Cutaneous Nerve Graft Harvest. The medial antebrachial cutaneous (MABC) nerve is a viable donor for nerve grafts and our institution's preferred donor nerve graft for upper extremity nerve reconstructions. The MABC nerve is harvested from the medial aspect of the arm and is found branching distally into an anterior and posterior branch. The anterior and/or posterior branch can be harvested depending on the length and diameter required for nerve reconstruction. After harvesting the MABC nerve, the distal end of the MABC nerve is end-to-side transferred to an adjacent functional sensory nerve through an epineural window. in this case, the anterior branch of the MABC nerve is harvested for graft material and the anterior branch is end-to-side transferred to the posterior branch of the MABC nerve.

Surgical Techniques

PROCEDURE: Medial Antebrachial Cutaneous Nerve Graft Harvest.

Incision Description:
  • An longitudinal incision is marked along the bicipital groove in the medial aspect of the arm.
Sugical Steps:
Medial Antebrachial Cutaneous Nerve Graft Harvest:
1. During this surgery, a tourniquet is not utilized.
2. Subcutaneous injection of epinephrine without lidocaine is recommended. The incision is made along the bicipital groove in the medial aspect of the arm.
3. The branches of the MABC nerve are typically noted on either side of the basilic vein.
4. Depending on the size of the graft needed, the preference is to use the anterior branch of the MABC nerve to maintain sensation in the posterior aspect of the elbow and forearm innervated by the posterior branch of MABC nerve.
5. To determine the sensory territory that the MABC branches innervate, gently tug on the branches of the MABC and observe for movement of the skin.
6. Harvest the MABC nerve to the needed length depending on the case.
A-1. If necessary, harvest the entire length from the axilla to the elbow.
B-1. For shorter distances, harvest the anterior branch of the MABC nerve.
7. After transecting the proximal portion of the MABC nerve, the proximal nerve end is cauterized with micro-bipolar cautery and calmped with a hemostat as far proximal visualized with down-curve retractors. The proximal nerve end is then transposed proximally to avoid neuroma-type discomfort.
8. Whenever possible, the distal end of the MABC nerve is end-to-side transferred to an adjacent functional sensory nerve. Possible donor nerves for the end-to-side transfer include the posterior branch of MABC, sensory component of median nerve, and sensory component of ulnar nerve.
  • Intra-operative electrical stimulation can be utilized to stimulate the normal median and ulnar nerve in order to see the silent sensory areas of the nerve.
  • On the median nerve, the sensory component is found on the lateral aspect as it composes the lateral half of the median nerve.
  • When there is not enough length for the end-to-side nerve transfer, an acellurized allograft can be used, if there is no expendable nerve graft available, to bridge the transfer for a tension-free repair.
9. Regular closure with Marcaine in the incision is suggested.