Caption: Kacey Marra (left) and Teun Teunis.
By Maggie Lindenberg
When a motorcycle accident left 22-year-old Elijah Kalada with a severe brachial plexus nerve injury, he lost the ability to fully use his right shoulder, arm and hand. Luckily, his team of surgeons at UPMC was ready and able to help him get it back.
“In the world of nerve injuries and trauma, brachial plexus injuries are the hardest ones to repair,” said Teun Teunis, assistant professor of plastic surgery, School of Medicine, and surgeon in the UPMC Brachial Plexus and Peripheral Nerve Disorder Center. “Thirty years ago, there was not that much we could do to restore function. Today, we’ve made a lot of progress, but it requires us to bring very complex techniques and diverse specialties together. Not many other places in the U.S. can bring all of these skillsets together like we can here.”
Surgeries like this one are what make plastic surgery the ideal specialty for Teunis. After finishing his medical training in the Netherlands and a PhD at the Harvard Medical School and Utrecht University, Teunis pursued an orthopaedics fellowship at the University of Pittsburgh in hand and upper extremity surgery. Teunis knew he wanted to do more with plastic surgery than the reconstructions for which it’s most known, so he became well-versed in microsurgery, which involves suturing together nerves and tiny blood vessels with precision. He is able to bring all of these skills together to repair complex nerve injuries today.
Complex nerve injury repair today is a difficult, long and highly collaborative procedure, involving several teams of surgeons working simultaneously for hours on end. But future repairs might be simpler and even have better outcomes, thanks to research currently underway at the School of Medicine.
While nerves can recover from minor injuries on their own, larger injuries—including severe injuries where nerves are completely pulled apart, as in Kalada’s case—require surgery to repair. Currently, that usually involves harvesting a nonessential nerve from somewhere else in the body and using it to carefully bridge the severed nerve, restoring its function. This harvested nerve is called an autograft. Kacey Marra, professor and vice chair for research in the Department of Plastic Surgery, School of Medicine, and professor of bioengineering, Swanson School of Engineering, is collaborating closely with Teunis as she develops another method.
Marra’s lab has found that by filling a slowly biodegradable polymer tube with a protein that tells nerve cells to regenerate, they can encourage nerves to regrow themselves across larger gaps, bypassing the need for an autograft.
“Imagine the regrowing nerve is going through the Fort Pitt Tunnel to reconnect itself. If the lights are all on, it can see the end and go right through,” explained Marra. “But if it’s totally dark, it might go too slowly or end up turning around. By implanting this biodegradable tube that becomes filled with cells that guide the nerve and tell it to keep going, it’s like constantly turning on the lights in the tunnel. With that, you can bridge much larger gaps.”
While it’s not available for use in humans yet, the team’s research showed that this method can help nerves span a five-centimeter gap, more than twice as long as previously thought possible, with better recovery than an autograft. Inspired by her veteran father, Marra especially hopes this method will improve outcomes for military patients whose combat experience leaves them with nerve injuries from explosions or gunshots.
The close collaboration between clinicians in the operating room and researchers in the lab, Marra said, is what makes innovations like this a reality. In addition to conducting his own research on nerve surgery outcomes, Teunis collaborates with Marra and her team to bring a clinical perspective to her lab’s work.
“Surgeons like Dr. Teunis are very motivating to work with. He has allowed me and my team to observe surgeries, and he gives us feedback and shares what works best in his experience,” said Marra. “Because I’m here, working in the Department of Plastic Surgery with surgeons who are doing these procedures in real life, we can accelerate discoveries and get them into operating rooms sooner.”