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Jarnalo M, Machado P, Mendes M, Ínsua I, Costa J. Sciatic nerve reconstruction with cables of vascularized pedicled sural nerve graft. Microsurgery 2024; 44:e31150. [PMID: 38343005 DOI: 10.1002/micr.31150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/05/2023] [Accepted: 01/16/2024] [Indexed: 02/15/2024]
Affiliation(s)
- Mariana Jarnalo
- Department of Plastic, Reconstructive and Aesthetic Surgery and Burn Unit, Centro Hospitalar e Universitário de São João, Oporto, Portugal
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Oporto, Oporto, Portugal
| | - Pedro Machado
- Department of Plastic, Reconstructive and Aesthetic Surgery and Burn Unit, Centro Hospitalar e Universitário de São João, Oporto, Portugal
| | - Margarida Mendes
- Department of Plastic, Reconstructive and Aesthetic Surgery and Burn Unit, Centro Hospitalar e Universitário de São João, Oporto, Portugal
| | - Inês Ínsua
- Department of Plastic, Reconstructive and Aesthetic Surgery and Burn Unit, Centro Hospitalar e Universitário de São João, Oporto, Portugal
| | - Joana Costa
- Department of Plastic, Reconstructive and Aesthetic Surgery and Burn Unit, Centro Hospitalar e Universitário de São João, Oporto, Portugal
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Chen LWY, Zavala A, Chuang DCC, Lu JCY, Chang TNJ. Chimerization of Monitor Flap in a Vascularized Ulnar Nerve Flap Is an Efficient Way for Vascularity Monitoring and the Reinnervation Checkup after Its Transplantation. J Hand Microsurg 2021. [DOI: 10.1055/s-0041-1740436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Background Free vascularized ulnar nerve flaps (VUNF) are effective method for long nerve defects reconstruction. However, the monitorization of its microvascular circulation and the nerve regrowth can be challenging since it is usually designed as a buried flap. We designed a skin paddle based on a septocutaneous perforator from the ulnar artery that can be dissected and raised in conjunction with the vascularized ulnar nerve flap, which aims to improve postoperative monitorization to optimizing the clinical results.
Methods We retrospectively reviewed 10 cases with long nerve defects who underwent reconstruction using VUNF between June 2018 and June 2019, including eight acute brachial plexus injuries, 1 multiple nerve injury due to a rolling machine accident, and 1 sequalae of nerve injury after arm replantation. All the demographic data, surgical details, outcomes, and perioperative complications were recorded.
Results We evaluated 10 male patients, with a mean age of 34 ± 16 years. Cases included 5 antegrade, 4 retrograde, and 1 U-shaped VUNF. All chimeric skin paddles survived, and all of the underlying nerves presented with adequate circulation and functional improvement. There were no intraoperative or microvascular complications. One skin paddle had a transitory postoperative circulation compromise due to external compression (bandage) which resolved spontaneously after pressure release.
Conclusion VUNF chimerization of a septocutaneous perforator skin flap is a relatively easy and efficient method for postoperative monitorization of the nerve’s microvascular circulation as well as beneficial for postoperative Tinel’s sign checkup to confirm the success of the nerve coaptation. The outcome is potentially improved.
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Affiliation(s)
- Lisa Wen-Yu Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center and Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Abraham Zavala
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center and Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - David Chwei-Chin Chuang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center and Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Johnny Chuieng-Yi Lu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center and Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Tommy Nai-Jen Chang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center and Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
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Management of complex forearm defects: A multidisciplinary approach. ANN CHIR PLAST ESTH 2020; 65:625-634. [PMID: 32891459 DOI: 10.1016/j.anplas.2020.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 06/29/2020] [Indexed: 11/23/2022]
Abstract
Complex forearm defects with significant damage to, or loss of skin, tendon, muscle, bone and neurovascular structures represent a great challenge for surgeons. The management of such injuries, whether a result of trauma or tumor resection, is focused on preservation of the damaged limb and restoration of hand function. A multidisciplinary approach combining plastic and orthopedic surgical expertise in a coordinated team is proposed to address these challenging cases. The authors have laid emphasis on adequate debridement for wound bed preparation, bone stabilization and reconstruction for a stable bony framework, vascular repair for early revascularization, musculotendinous and nerve reconstruction as well as vascularized tissue coverage on a case-to-case basis to facilitate optimal functional recovery. They also maintain that besides expedient surgical treatment, early mobilization based on an individualized rehabilitation program as well as psychological and socio-professional supports are necessary means of achieving rapid and successful social integration.
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Saffari TM, Bedar M, Hundepool CA, Bishop AT, Shin AY. The role of vascularization in nerve regeneration of nerve graft. Neural Regen Res 2020; 15:1573-1579. [PMID: 32209756 PMCID: PMC7437604 DOI: 10.4103/1673-5374.276327] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Vascularization is an important factor in nerve graft survival and function. The specific molecular regulations and patterns of angiogenesis following peripheral nerve injury are in a broad complex of pathways. This review aims to summarize current knowledge on the role of vascularization in nerve regeneration, including the key regulation molecules, and mechanisms and patterns of revascularization after nerve injury. Angiogenesis, the maturation of pre-existing vessels into new areas, is stimulated through angiogenic factors such as vascular endothelial growth factor and precedes the repair of damaged nerves. Vascular endothelial growth factor administration to nerves has demonstrated to increase revascularization after injury in basic science research. In the clinical setting, vascularized nerve grafts could be used in the reconstruction of large segmental peripheral nerve injuries. Vascularized nerve grafts are postulated to accelerate revascularization and enhance nerve regeneration by providing an optimal nutritional environment, especially in scarred beds, and decrease fibroblast infiltration. This could improve functional recovery after nerve grafting, however, conclusive evidence of the superiority of vascularized nerve grafts is lacking in human studies. A well-designed randomized controlled trial comparing vascularized nerve grafts to non-vascularized nerve grafts involving patients with similar injuries, nerve graft repair and follow-up times is necessary to demonstrate the efficacy of vascularized nerve grafts. Due to technical challenges, composite transfer of a nerve graft along with its adipose tissue has been proposed to provide a healthy tissue bed. Basic science research has shown that a vascularized fascial flap containing adipose tissue and a vascular bundle improves revascularization through excreted angiogenic factors, provided by the stem cells in the adipose tissue as well as by the blood supply and environmental support. While it was previously believed that revascularization occurred from both nerve ends, recent studies propose that revascularization occurs primarily from the proximal nerve coaptation. Fascial flaps or vascularized nerve grafts have limited applicability and future directions could lead towards off-the-shelf alternatives to autografting, such as biodegradable nerve scaffolds which include capillary-like networks to enable vascularization and avoid graft necrosis and ischemia.
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Affiliation(s)
- Tiam M Saffari
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Meiwand Bedar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Caroline A Hundepool
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Allen T Bishop
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Tanaka K, Okazaki M, Homma T, Yano T, Mori H. Bilateral inferior alveolar nerve reconstruction with a vascularized sural nerve graft included in a free fibular osteocutaneous flap after segmental mandibulectomy. Head Neck 2015; 38:E111-4. [DOI: 10.1002/hed.24326] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2015] [Indexed: 11/08/2022] Open
Affiliation(s)
- Kentaro Tanaka
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Sciences; Tokyo Medical and Dental University; Tokyo Japan
| | - Mutsumi Okazaki
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Sciences; Tokyo Medical and Dental University; Tokyo Japan
| | - Tsutomu Homma
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Sciences; Tokyo Medical and Dental University; Tokyo Japan
| | - Tomoyuki Yano
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Sciences; Tokyo Medical and Dental University; Tokyo Japan
- Department of Plastic Surgery; Yokohama City Minato Red Cross Hospital; Yokohama Japan
| | - Hiroki Mori
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Sciences; Tokyo Medical and Dental University; Tokyo Japan
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Leclère FM, Eggli S, Mathys L, Vögelin E. Anatomic study of the superficial sural artery and its implication in the neurocutaneous vascularized sural nerve free flap. Clin Anat 2012; 26:903-10. [PMID: 22467447 DOI: 10.1002/ca.22054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 01/27/2012] [Accepted: 02/03/2012] [Indexed: 11/06/2022]
Abstract
Combined extended nerve and soft tissue defects of the upper extremity require nerve reconstruction and adequate soft tissue coverage. This study focuses on the reliability of the free vascularized sural nerve graft combined with a fasciocutaneous posterior calf flap within this indication. An anatomical study was performed on 26 cadaveric lower extremities that had been Thiel fixated and color silicone injected. Dissection of the fasciocutaneous posterior calf flap involved the medial sural nerve and superficial sural artery (SSA) with its septocutaneous perforators, extended laterally to include the lateral cutaneous branch of the sural nerve and continued to the popliteal origin of the vascular pedicle and the nerves. The vessel and nerves diameter were measured with an eyepiece reticle at 4.5× magnification. Length and diameter of the nerves and vessels were carefully assessed and reported in the dissection book. A total of 26 flaps were dissected. The SSA originated from the medial sural artery (13 cases), the popliteal artery (12 cases), or the lateral sural artery (one case). The average size of the SSA was 1.4 ± 0.4 mm. The mean pedicle length before the artery joined the sural nerve was 4.5 ± 1.9 cm. A comitant vein was present in 21 cases with an average diameter of 2.0 ± 0.8 mm, in 5 cases a separate vein needed to be dissected with an average diameter of 3.5 ± 0.4 mm. The mean medial vascularized sural nerve length was 21.2 ± 8.9 cm. Because of inclusion of the vascularized part of the lateral branch of the sural nerve (mean length of 16.7 ± 4.8 cm), a total of 35.0 ± 9.6 cm mean length of vascularized nerve could be gained from each extremity. The free vascularized sural nerve graft combined with a fasciocutaneous posterior calf flap pedicled on the SSA offers a reliable solution for complex tissue and nerve defect.
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Affiliation(s)
- Franck Marie Leclère
- Department of Hand and Plastic Surgery, Inselspital, University of Bern, Bern, Switzerland
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Terzis JK, Kostopoulos VK. Vascularized nerve grafts and vascularized fascia for upper extremity nerve reconstruction. Hand (N Y) 2010; 5:19-30. [PMID: 19381727 PMCID: PMC2820630 DOI: 10.1007/s11552-009-9189-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 03/17/2009] [Indexed: 11/26/2022]
Abstract
Since 1976, experimental and clinical studies have suggested the superiority of vascularized nerve grafts. In this study, a 27-year experience of the senior author is presented regarding vascularized nerve grafts and fascia for complex upper extremity nerve reconstruction. The factors influencing outcomes as well as a comparison with conventional nerve grafts is presented. Since 1981, 21 vascularized nerve grafts, other than vascularized ulnar nerve, were used for reconstruction of nerve injuries in the upper extremity. Indications were prolonged denervation time, failure of the previously used conventional nerve grafts, and excessive scar in the recipient site. Injury was in the hand/wrist area (n = 5), in the forearm (n = 4), in the elbow (n = 2), in the arm (n = 4), or in the plexus (n = 6). Vascularized sural (n = 9), saphenous (n = 8), superficial radial (n = 3), and peroneal (superficial and deep) nerves were used. The mean follow-up was 31.4 months. Vascularized nerve grafts for upper extremity injuries provided good to excellent sensory return in severely scarred upper extremities in patients in whom conventional nerve grafts had failed. They have also provided relief of causalgia after painful neuroma resection and motor function recovery in selective cases even for above the elbow injuries. Small diameter vascularized nerve grafts should be considered for bridging long nerve gaps in regions of excessive scar or for reconstructions where conventional nerve grafts have failed.
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Affiliation(s)
- Julia K. Terzis
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Eastern Virginia Medical School, Room 2055, Lewis Hall, 700 Olney Road, Norfolk, VA 23501 USA
| | - Vasileios K. Kostopoulos
- Microsurgical Program, Reconstructive Microsurgery, Eastern Virginia Medical School, Room 2055, Lewis Hall, 700 Olney Road, Norfolk, VA 23501 USA
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Doi K, Tamaru K, Sakai K, Kuwata N, Kurafuji Y, Kawai S. A comparison of vascularized and conventional sural nerve grafts. J Hand Surg Am 1992; 17:670-6. [PMID: 1321181 DOI: 10.1016/0363-5023(92)90315-g] [Citation(s) in RCA: 59] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Long-term results of a randomized series of 27 vascularized and 22 conventional sural nerve grafts in patients with comparable upper extremity injuries are reported. Recovery speed and outcome depended on (1) whether or not there was an overlying skin defect, (2) how the defect was closed, and (3) which nerve was injured and at what level. Generally, a vascularized nerve graft is indicated when the nerve gap is more than 6 cm and is associated with a massive skin defect or the graft is performed after reimplantation. Otherwise, results achieved with a conventional graft are equally good.
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Affiliation(s)
- K Doi
- Department of Orthopaedic Surgery, Yamaguchi University School of Medicine, Ube, Japan
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