CLINICAL PAPERS
Nerve Transfers in the Upper Extremity
A Practical User's Guide
Brian Rinker, MD, FACS
Abstract: Nerve injuries above the elbow are associated with a poor prognosis,
even with prompt repair and appropriate rehabilitation. The past 2 decades have
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seen the development of numerous nerve transfer techniques, by which a dener-
vated peripheral target is reinnervated by a healthy donor nerve. Nerve transfers
are indicated in proximal brachial plexus injuries where grafting is not possible
or in proximal injuries of peripheral nerves with long reinnervation distances.
Nerve transfers represent a revolution in peripheral nerve surgery and offer the
potential for superior functional recovery in severe nerve injuries. However, the
techniques have not been universally adopted due in part to a misconception that
nerve transfers can only be understood and performed by superspecialists. Nerve
transfer procedures are not technically difficult and require no specialized equip-
ment. Numerous transfers have been described, but there are a handful of transfers
for which there is strong clinical evidence. To restore shoulder abduction and ex-
ternal rotation in upper trunk brachial plexus injury, the key transfers are the spi-
nal accessory to suprascapular nerve and the medial triceps branch to axillary
nerve. For elbow flexion, the flexor carpi ulnaris branch of ulnar nerve to the bi-
ceps and brachialis branches of the musculocutaneous nerve is the key transfer.
For ulnar intrinsic function, the distal anterior interosseous nerve to ulnar motor
branch transfer has yielded excellent functional results. Nerve transfers form a
therapeutic triad with traditional tendon transfers and functional motor unit reha-
bilitation which, when applied appropriately, can yield excellent functional results
in complex nerve injuries. Nerve transfers are a powerful yet underused tool for
proximal nerve injuries, which offer hope for traditionally discouraging injuries.
Key Words: nerve transfers, nerve injury, nerve regeneration, brachial plexus
(Ann Plast Surg 2014;74: S222–S228)
I njuries to the brachial plexus or other proximal peripheral nerves in
the upper extremity can be functionally devastating. The second half
of the last century witnessed remarkable advances in magnification, in-
strumentation, microsurgical techniques, and a greater understanding of
nerve injury and repair. However, the expected functional recovery after
proximal nerve injuries, even when a prompt and appropriate nerve repair
was performed, remained poor. This was due to the limitations imposed
by long reinnervation distances, especially in adults. Following an injury
to a motor nerve, irreversible motor endplate damage begins immediately
after denervation, and the longer the distance from injury to the neuro-
muscular junction, the longer time is needed to allow for regeneration,
and the greater the motor endplate degredation.1 If the delay between in-
jury and endplate reinnervation exceeds a few months, functional recov-
ery will be poor. In upper extremity nerve surgery, “time is muscle.”2
An alternative to traditional nerve repair in proximal injuries
is the restoration of function through nerve transfers, whereby a dener-
vated peripheral target is reinnervated by a healthy, nonanatomic donor
Received August 24, 2014, and accepted for publication, after revision, September
25, 2014.
From the Division of Plastic Surgery, Department of Surgery, University of Kentucky
College of Medicine, Lexington, KY.
Conflicts of interest and sources of funding: none declared.
Reprints: Brian Rinker, MD, FACS, Division of Plastic Surgery, University of
Kentucky, Kentucky Clinic, K454, Lexington, KY 40536-0284. E-mail:
brink2@email.uky.edu.
Presented as a Podium Presentation at the Annual Meeting of the Southeastern Society
of Plastic and Reconstructive Surgeons, Paradise Island, Bahamas, June 2014.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/15/7404–S222
DOI: 10.1097/SAP.0000000000000373
S222 www.annalsplasticsurgery.com
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nerve. Nerve transfers have a long history, with sporadic reports in the
literature as early as the 1920s when Harris3 described a radial to me-
dian nerve transfer to treat an injury sustained in battle during World
War I. Nerve transfers experienced a revival and began to gain wide-
spread acceptance in the 1990s when Brandt and Mackinnon4 and
Oberlin et al5 described techniques for restoring elbow flexion. Over
the ensuing 2 decades, numerous transfers have been described. Nerve
transfer techniques have been nothing less than a revolution in periph-
eral nerve surgery, and functional outcomes have been achieved for bra-
chial plexus and other proximal nerve injuries far exceeding those
obtained from traditional nerve repair or tendon transfers.6–9 However,
nerve transfer techniques have not been universally adopted by sur-
geons engaged in the care of upper extremity injuries. This is due in part
to the large array of transfers described in the literature, which can be
baffling to the novice, and to the misconception that nerve transfer pro-
cedures require skills and equipment available only at specialized cen-
ters. The purpose of this review was to present the indications for nerve
transfers, the essential techniques and key transfers, to demystify the
topic for the novice, and to further clarify the topic for the experienced.
INDICATIONS
The benefits of nerve transfers are manifold. They bring live
axons close to the denervated target, essentially converting a high nerve
injury to a more distal one, thus limiting motor endplate degradation. In
addition, there is usually only one neurorrhaphy site, limiting the poten-
tial for axonal attrition due to scarring, foreign body, and fascicular mis-
alignment. Finally, nerve transfers allow the surgeon to operate in an
unscarred bed, allowing more precise anatomic identification, limiting
operative times, and reducing the potential for iatrogenic injury.
In general, a nerve transfer is indicated in cases of proximal bra-
chial plexus injuries where grafting is not possible and in proximal pe-
ripheral nerve injuries with long reinnervation distances. In the latter
case, nerve transfers may be used in place of or as an adjunct to tradi-
tional neurorrhaphy or grafting. Nerve transfers are indicated in patients
with extensive posttraumatic scarring, where exploration would risk
damage to critical structures, as is commonly seen after proximal re-
plantation or repair of severe crush or avulsion injuries. Nerve transfers
may also be indicated in patients with a delayed reconstruction, as they
can speed up reinnervation times, although it is generally understood
that target muscles must be reinnervated before they are irreversibly
atrophied, ideally before 12 to 18 months after injury, and certainly be-
fore 24 months.2,10 Nerve transfers for motor nerves are contraindicated
beyond this time point, and patients are better served with tendon or
functional muscle transfers (Table 1).
PREOPERATIVE PLANNING
The preoperative planning for upper extremity nerve transfer
procedures is similar to that for traditional tendon transfers. A thorough
examination is performed to determine priorities as to which functions
will be restored. In general, a proximal to distal approach is preferred,
restoring shoulder and elbow motion, the key “positioning” functions,
before restoring wrist and hand motion. A careful inventory must be
made of functioning and nonfunctioning musculotendinous units in
the extremity, to determine which nerves are available as donors. As
with tendon transfers, the goal is to maximize the “return on
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Annals of Plastic Surgery • Volume 74, Supplement 4, June 2015
TABLE 1. Indications for Nerve Transfers
□ Proximal brachial plexus injuries where grafting is not possible
□ Proximal peripheral nerve injuries with long reinnervation distances
□ Patients with delayed reconstruction
□ Severely scarred areas with risk of damage to critical structures
investment,” sacrificing noncritical functions to restore essential ones.
Suitable donor nerves include nerves to expendable muscles, such as
the pronator quadratus branch of the anterior interosseous nerve, or
nerves to muscles with redundant innervation.2 Examples of the latter
include the distal accessory nerve, median nerve branches to the flexor
digitorum superficialis (FDS), and ulnar nerve branches to the flexor
carpi ulnaris (FCU). It is this redundancy in proximal nerve fibers that
makes most nerve transfers possible.11
When possible, donor nerves which provide synergistic func-
tions to the target muscle should be chosen, as this will facilitate post-
operative motor unit retraining. For example, in median to radial
transfers, Ray and Mackinnon have demonstrated better outcomes
transferring the FDS branch of median nerve to the nerve to the exten-
sor carpi radialis brevis (ECRB), rather than using it to innervate the
nonsynergistic digital extensors. Likewise, the nerve to the flexor carpi
radialis (FCR) is more effectively transferred to the posterior
interosseous nerve, than it is to the nonsynergistic ECRB branch.12
KEY TECHNICAL POINTS
The performance of nerve transfer procedures is not technically
difficult. In general, the procedures are more easily performed than tra-
ditional cable grafting, as nerve dissection is carried out in a pristine,
unscarred bed. The surgical techniques are well within the abilities of
a plastic surgeon familiar with microsurgery and upper extremity nerve
repair. An inexpensive, disposable, handheld nerve stimulator is helpful
for identifying motor fascicles, but no other specialized equipment is
necessary. In addition, the stimulator can be used to verify redundancy
of motor fascicles before a donor fascicle is harvested. To preserve in-
traoperative nerve function, it is important to avoid long-acting paralytic
agents and local anesthetics. Likewise, tourniquet time during nerve
dissection should be limited to 30 minutes to avoid ischemic compro-
mise of nerve function.2
For motor transfers, the donor nerve is dissected out and stimu-
lated to verify that the appropriate fascicle has been selected, and the re-
maining fascicles are stimulated to confirm preservation of critical
functions. Donor and recipient nerves are mobilized sufficiently to pro-
vide a tension-free coaptation. The transfer should be performed as close
to the target muscle as possible, to minimize the reinnervation distance.2
KEY MOTOR TRANSFERS
Transfers to Restore Shoulder Function I—Accessory
to Suprascapular Nerve Transfer
Injury to the upper trunk of the brachial plexus commonly affects
the suprascapular nerve (SSN), which provides motor innervation to the
supraspinatus and infraspinatus muscles. These muscles are responsible
for initiating arm abduction and performing external rotation, respec-
tively. If the C5 to C6 nerve root is viable, cable grafting can restore
function, as the reinnervation distance is relatively short. However, in
an avulsion injury, there is no proximal nerve available, and the acces-
sory nerve to SSN transfer is a good alternative.13,14 For this transfer, an-
terior or posterior approaches have been described. However, a posterior
approach to the accessory nerve is generally preferred as it facilitates
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Nerve Transfers
exposure of the distal portion of the nerve as well as permitting exposure
of the radial and axillary nerves without patient repositioning (Table 2).
The accessory nerve can be located along a line parallel to the su-
perior border of the scapula at a point two-fifths of the distance from the
dorsal midline to the acromion. The SSN is also located along this line,
at the midpoint between the superior angle of the scapula and the
acromion.15 A transverse surgical incision is designed to expose both
nerves. The trapezius muscle is split, exposing the suprascapular notch.
Care is taken to avoid injury to the suprascapular artery, which passes
over the scapula immediately lateral to the notch. The nerve is released
from the notch and dissected as far proximally as possible. The distal
spinal accessory nerve is then located in the medial aspect of the wound,
deep to the trapezius muscle. Using the distal-most branch allows pres-
ervation of the proximal branches to the upper portions of the trapezius,
preserving its function.8 The distal accessory branch is dissected as far
distally as possible, divided, and transposed laterally. The SSN is di-
vided as far proximal is possible, while still allowing a tension-free co-
aptation. Nerve grafting is not necessary (Fig. 1). In a recent functional
outcomes study evaluating the results of the accessory to SSN nerve
transfer, recovery of shoulder abduction and external rotation was
achieved at an M3 or better modified Medical Research Council16 grade
level in 8 of 9 patients at 28 months mean follow-up time9 (Table 3).
Transfers to Restore Shoulder Function II—Medial
Triceps Nerve to Axillary Nerve Transfer
Upper trunk brachial plexus injuries and other proximal injuries
often cause loss of axillary nerve function and denervation of the del-
toid, the major abductor of the shoulder. In patients with preservation
of radial nerve function, abduction can be effectively restored via trans-
fer of one of the triceps branches of the radial nerve to the axillary
nerve.8,17–19 This transfer is commonly performed in conjunction with
the accessory to SSN transfer, described previously. Use of the lateral
and long triceps branches has been described, but the medial triceps
branch is preferable, due to its independence, long reach, and ease of
dissection.8 Exposure for this transfer is provided through an incision
extending from the quadrilateral space distally along the posterior arm
to the midhumerus. At the proximal end of the incision, the axillary
nerve is identified within the quadrilateral space and dissected as far
proximal as possible, to ensure inclusion of the branch to the teres mi-
nor. Often, the lateral brachial cutaneous nerve, a branch of the axillary
nerve, is encountered first, coursing around the posterior edge of the
deltoid. It can then be traced back to the main nerve trunk.
The medial triceps branch of the radial nerve is easily identified
in the posterior arm, running alongside the main radial nerve, in the in-
terval between the long and lateral heads of the triceps. As the medial
triceps branch runs independently for a long distance, it can be readily
dissected free, verified with nerve stimulation, and transposed superi-
orly, where a tension-free coaptation is made to the axillary nerve at
the level of its emergence from the quadrilateral space8 (Fig. 2). Of
course, the radial nerve is often involved in brachial plexus injuries,
and intact radial nerve function is a prerequisite for this transfer.
TABLE 2. Key Motor Nerve Transfers
Shoulder abduction/external rotation—spinal accessory to suprascapular nerve
Shoulder abduction/external rotation—medial triceps branch of radial nerve
to axillary nerve
Elbow flexion—FCU branch of ulnar nerve to biceps/brachialis branches of
musculocutaneous
Ulnar intrinsics—distal AIN to ulnar motor branch
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Rinker
FIGURE 1. A, The distal branch of the accessory nerve to SSN transfer to restore shoulder abduction and external rotation, showing
position of the nerves before transfer. B, After end-to-end transfer, preserving proximal branches to the trapezium.
Double Fascicular Transfer to Restore Elbow Flexion
The results of nerve transfers to restore elbow function can be
dramatic. Early efforts in this area involved the use of intercostal or pec-
toral nerves, with some success.4 In 1994, Oberlin described the use of
branches of the ulnar nerve as the donor, transferred to the biceps
branch of the musculocutaneous nerve at the level of the distal
brachium, thus greatly shortening the reinnervation distance. His initial
series consisted of 4 patients, 3 of whom achieved M4 level elbow
flexion.5 Humphreys and Mackinnon have subsequently demonstrated
that the classic Oberlin transfer can be augmented by transfer of a re-
dundant median nerve fascicle to the FCR or FDS to the brachialis
branch, the so-called “double-transfer.”20–22
The procedure is performed with the patient in the supine posi-
tion with the arm extended. An incision is made over the biceptal
groove in the medial arm. The brachial artery, median, and ulnar nerves
are exposed. The musculocutaneous nerve is identified lateral to these
structures, deep to the biceps muscle. It is dissected out distally, expos-
ing the branches to biceps and brachialis. The donor nerves are then
prepared. By careful nerve stimulation, a median nerve fascicle can
be identified with FCR or FDS function. There is a great deal of redun-
dancy in these functionalities; therefore, one fascicle can usually be har-
vested without yielding a donor deficit. However, once the fascicle is
identified and teased away, the remaining fascicles should be tested to
ensure preservation of function. In a likewise fashion, an FCU fascicle
of the ulnar nerve is identified, tested, and prepared for transfer. Again,
the donor fascicles should be dissected out for sufficient length so that
the nerve coaptations can be performed without tension and as close to
the recipient muscles as possible8 (Fig. 3).
Several studies have been published reporting excellent long-
term results from both the classic Oberlin transfer and the double
transfer for elbow flexion.5,7,23–25 However, by including the brachialis
muscle, the double transfer seems to confer additional functional bene-
fit, especially in terms of increased flexion strength.20,26 In 2005,
Mackinnon et al20 presented a series of 6 patients, all of whom regained
M4 or M4+ elbow flexion function after the double transfer, at a mean
follow-up of 20.5 months. As a further testament to the value of the
double transfer, Oberlin and colleagues have adopted the technique,
publishing in 2006 a series of 10 patients who had undergone the pro-
cedure. All 10 recovered elbow flexion to the M4 level and were able
to lift between 1 and 4 kg of weight, at 12 months mean follow-up.26
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Annals of Plastic Surgery • Volume 74, Supplement 4, June 2015
Anterior Interosseous Transfer to Restore Ulnar
Intrinsic Function
Recovery of ulnar intrinsic function is typically poor after a prox-
imal ulnar nerve injury, even with prompt and appropriate nerve re-
pair.27,28 Tendon transfers can be used to augment or reproduce ulnar
intrinsic function, but with variable results.29 Where median nerve func-
tion is intact, the distal anterior interosseous nerve (AIN) can be effec-
tively transferred to the ulnar deep motor branch to restore function.30,31
The transfer was initially described with an end-to-end coaptation;
however, the terminal AIN can be transferred in a reverse end-to-side
fashion to the ulnar nerve, to “supercharge” the motor fascicle of a re-
covering ulnar nerve after proximal repair.32 In our practice, we perform
this transfer regularly for any ulnar nerve repair proximal to the elbow.
A longitudinal palmar incision is used to expose the contents of
Guyon canal, and it is extended proximally in a zigzag fashion across
the wrist crease and into the distal forearm to provide exposure of the
AIN.33 The ulnar motor branch is identified as it dives deep to the origin
of the flexor digiti minimi muscle at the hamate hook. Under operative
TABLE 3. Modified British Medical Research Council Classification
Sensory function
S0: Absence of sensibility
S1: Deep cutaneous pain sensation in the autonomous zone
S2: Some degree of superficial pain sensation and tactile sensibility
S2+: Same as S2, but with overresponse to stimuli
S3: Same as S2+ without overreaction
S3+: Good localization of stimuli and some return of 2-point discrimination
S4: Complete recovery
Motor function
M0: No movement
M1: Visible or palpable contraction
M2: Muscle able to move joint when gravity eliminated
M3: Contraction against gravity
M4: Contraction against moderate resistance
M5: Normal strength
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Annals of Plastic Surgery • Volume 74, Supplement 4, June 2015 Nerve Transfers

FIGURE 2. A, The medial triceps branch to axillary nerve transfer to restore shoulder abduction, showing position of the nerves
before transfer. B, After transfer at the level of the quadrilateral space.

microscopy, the motor fascicle is readily separable from the remain- experienced recovery to the M4 level, and 1 patient, an 11-year-old
der of the nerve into the distal forearm. The AIN is identified at the boy, had M5 level function.35 Three years later, Novak and Mackinnon
proximal border of the pronator quadratus muscle. The nerve is traced reported a series of 8 patients, with a mean follow-up of 18 months. All
into the muscle a short distance and divided just before its terminal patients experienced significant improvements in lateral pinch and grip-
branches. Proximal dissection is performed to gain adequate length ping strength. Only 1 patient required subsequent tendon transfer, to re-
for a tension-free coaptation, either end-to-end or reverse end-to-side, store small finger adduction.30
as the clinical situation dictates33 (Fig. 4).
Anatomic studies have shown that there are more than 1200 mo- SENSORY TRANSFERS
tor axons in the ulnar motor branch at the wrist, compared to approxi-
Numerous sensory transfers have been described, to restore sen-
mately 900 axons in the AIN, some of which are afferent sensory
sation after ulnar, median, or radial nerve injuries, or to restore critical
fibers.34 Despite this axonal mismatch, excellent results have been
reported. In 1999, Battiston and Lanzetta reported the results of
7 cases of proximal ulnar nerve injury treated with an AIN to ulnar
motor branch transfer. At a mean follow-up of 2.5 years, 5 patients

FIGURE 3. A, The double fascicular transfer to restore elbow

flexion, showing position of the musculocutaneous, median, FIGURE 4. A, The AIN to ulnar motor branch transfer to restore
and ulnar nerves before transfer. B, After transfer of the ulnar intrinsic function, showing the position of the median
redundant FDS branch of median nerve to the biceps branch and ulnar nerves before transfer. B, After the transfer of the
and the FCU branch of ulnar nerve to the brachialis branch. distal AIN to the ulnar motor branch.

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Rinker Annals of Plastic Surgery • Volume 74, Supplement 4, June 2015

sensation after brachial plexus injuries.8,33,36–40 All of these transfers
are based on the principle of sacrificing nerves that provide noncritical
sensation to restore essential hand or digital sensation. For less critical
sensory nerves, an end-to-side nerve transfer can be performed, thus
preserving sensation in the donor dermatome. Experimental studies
have shown that in the absence of injury to the donor nerve, only sen-
sory axons will traverse such a repair.41–43 Most authors agree that the
end-to-side technique can provide protective sensibility to noncritical
areas, but higher levels of sensory recovery are not typical.33
Median nerve sensation is critical for fine manipulation and tip-
to-tip pinch. Restoring sensation to the radial aspect of the thumb and
ulnar side of the index finger are of utmost priority after median nerve
injury, and in the past neurovascular island flaps have been used to re-
store sensibility to these areas. The fourth webspace and dorsum of
the hand are less critical sensory distributions, and the nerves which
provide sensation to these areas are potential donors for nerve transfers.
Brown and Mackinnon describe a trio of nerve transfers designed to re-
store critical sensation after median nerve injury.33 In this procedure,

FIGURE 5. A, Schema of the ulnar to median sensory transfer showing the median and ulnar nerves before transfer. B, After
end-to-end transfer of the dorsal cutaneous branch of the ulnar nerve to the first and second webspace branches of the median
nerve, and end-to-side transfer of the ulnar sensory branch to the third webspace branch of median nerve. C, A 50-year-old man
18 months after stab wound to the forearm with complete median nerve transection and repair, with poor sensory recovery. Exposure of
the median nerve and its branches. D, Exposure of the dorsal sensory branch of the ulnar nerve. E, End-to-end transfer of the dorsal
cutaneous branch of the ulnar nerve to the first and second webspace branches of the median nerve. F, End-to-side transfer of the
ulnar sensory branch to the third webspace branch of median nerve.

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Annals of Plastic Surgery • Volume 74, Supplement 4, June 2015 Nerve Transfers

the dorsal cutaneous branch of the ulnar nerve is transferred end-to-end
to the branch of the median nerve to the thumb, first, and second
webspaces. The ulnar nerve branch to the fourth webspace is transferred
in an end-to-side fashion to the third webspace branch of median nerve.
The ulnar sensory branch is also transferred in an end-to-side fashion to
the distal cut end of the dorsal sensory branch of ulnar nerve, with an
autograft, to preserve protective sensation in the donor site44 (Fig. 5).
more easily achieved when a synergistic transfer is used. For sensory
transfers, early behavioral reinforcement is of proven benefit, with pa-
tients who undergo early sensory reeducation having less severe pares-
thesias and better 2-point discrimination than those who do not.46 The
process of cortical reorganization continues long after injury, so motor
unit retraining with a certified therapist may be of benefit for many
months, or even years, after injury.47

REHABILITATION
The early phase of rehabilitation after nerve transfer is similar to
any nerve injury, with a focus on range of motion and edema control. As
function improves in the recipient muscle units, a program of reeduca-
tion is initiated, with intensive practice and repetition.45 Retraining is
DISCUSSION
There is a large and rapidly growing body of literature regarding
nerve transfers in the upper extremity. Despite this fact, and possibly be-
cause of it, there has been a slow adoption of these techniques by hand
surgeons. A wide array of nerve transfers have been described, but there

FIGURE 6. A, Combining nerve and tendon transfer procedures. A 49-year-old man after a motor vehicle accident in which he
experienced a right upper trunk brachial plexus injury, with radial nerve involvement. Shoulder abduction and elbow extension are
intact, but elbow flexion, wrist extension, and digital extension are absent. B, At the first stage, an FCU branch of the ulnar nerve is
transferred to the biceps and brachialis branches, a redundant FDS branch is transferred to the ECRB branch of radial nerve, and a
pronator teres to ECRB tendon transfer is performed. Showing an FCU branch of the ulnar nerve, as well as the biceps and brachialis
branches, divided and prepared for transfer. C, After the FCU branch to biceps/brachialis transfer, performed as close to the muscles as
possible. D, A pronator teres to ECRB tendon transfer was performed to augment wrist extension. E, At a second stage, FCR to extensor
digitorum communis and palmaris longus to extensor pollicis longus tendon transfers were performed. F, Function of the elbow at
10 months postinjury. Full extension. G, Demonstrating full flexion against gravity. H, Function of the wrist and digits at 10 months
postinjury. Digital extension. I. Demonstrating wrist extension and digital flexion.

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Rinker
are a few for which the clinical evidence is very strong. These include
the accessory to SSN and medial triceps to axillary nerve for shoulder
abduction, the double fascicular transfer for elbow flexion, and the
distal AIN to ulnar motor branch transfer for ulnar intrinsic function.
These transfers are not technically challenging, require no extraordinary
equipment or expertise, and have the potential to provide dramatic
improvements in function for injuries which have been traditionally dis-
couraging to treat. For complex injury patterns, such as brachial plexus
avulsion injuries or multiple nerve injuries, nerve transfers form a ther-
apeutic triad with tendon transfers and motor unit reeducation to
achieve the fullest possible functional recovery (Fig. 6). The future will
certainly bring the development of new nerve transfer procedures, as
well as additional clarity regarding the value and indications for the
transfers already described. The possible applications of nerve transfers
are limited only by human anatomy and human imagination.
ACKNOWLEDGMENTS
The author thanks Tom Dolan, MS, and Matt Hazard, Bio-Medical
Illustrators with the University of Kentucky Academic Technology
Group, for the preparation of illustrations.
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