Millesi, Meissl, and Berger describe a microsurgical interfascicular nerve grafting technique developed from experimental and clinical work between 1964 and 1970. The core question: can tension-free grafting across two suture lines outperform direct end-to-end repair under tension? Results from 33 median and 32 ulnar nerve repairs are reported in detail.
Before this paper, nerve grafting was widely considered inferior to primary end-to-end repair. Prior series reported useful recovery in only up to 50% of patients, and the prevailing belief was that two suture lines meant two barriers to regeneration.
Millesi proved the opposite: tension is the dominant variable. When you see a nerve gap in the OR, the decision rule is straightforward — if you cannot coapt nerve ends without tension with joints in full extension, graft it. Do not stretch the repair to avoid a graft.
For median nerve defects, graft if the gap exceeds 2 cm. For ulnar nerve injuries at the elbow, anterior transposition buys up to 4 cm before grafting is needed. Use the sural nerve as your first-choice donor (approximately 35 cm available). One 10-0 nylon suture per graft end is sufficient. More suture means more endoneurial scar.
This paper directly enabled Mackinnon's 1989 refinements of nerve reconstruction and remains the conceptual foundation for every tension-free peripheral nerve repair performed today.
Millesi, Meissl, and Berger describe a microsurgical interfascicular nerve grafting technique developed from experimental and clinical work between 1964 and 1970. The core question: can tension-free grafting across two suture lines outperform direct end-to-end repair under tension? Results from 33 median and 32 ulnar nerve repairs are reported in detail.
Before this paper, nerve grafting was widely considered inferior to primary end-to-end repair. Prior series reported useful recovery in only up to 50% of patients, and the prevailing belief was that two suture lines meant two barriers to regeneration.
Millesi proved the opposite: tension is the dominant variable. When you see a nerve gap in the OR, the decision rule is straightforward — if you cannot coapt nerve ends without tension with joints in full extension, graft it. Do not stretch the repair to avoid a graft.
For median nerve defects, graft if the gap exceeds 2 cm. For ulnar nerve injuries at the elbow, anterior transposition buys up to 4 cm before grafting is needed. Use the sural nerve as your first-choice donor (approximately 35 cm available). One 10-0 nylon suture per graft end is sufficient. More suture means more endoneurial scar.
This paper directly enabled Mackinnon's 1989 refinements of nerve reconstruction and remains the conceptual foundation for every tension-free peripheral nerve repair performed today.