Neurotization and free muscle transfer for brachial plexus avulsion injury

Reconstructive strategies for avulsion injuries of the brachial plexus have evolved from the irreparable and hopeless limb to the reparable and functional limb as a result of development of neurotization and free muscle transplantation. With more detailed knowledge of macro- and micro-nerve anatomy, the surgeon can be more confident in refining neurotization without causing a deficit in the donor nerve. Microsurgical anastomoses and nerve coaptation continue to be challenges in free muscle transplantation. End-to-side anastomoses or vein grafts are often required to facilitate access to the donor nerve for direct nerve coaptation. For functioning free muscle transplantation, every effort should be made to achieve direct nerve repair rather than direct end-to-end vessel repair.