Masseteric-Facial Anastomosis: A Report of Three Cases

Intoduction The pathways of the facial nerve are variable, and knowledge of that is essential. The worst impact caused by facial paralysis is related to quality of life, especially regarding the self-esteem and social acceptance on the part of the patients, leading to social isolation and disruption on their mental health. Case Report A 33-year-old female patient, with a stage-T3 acoustic neurinoma, presented with a moderate dysfunction (grades II to III) according to the House- Brackmann (HB) Facial Nerve Grading System. A 43-year-old male patient, with a stage- T4B trigeminal schwannoma, underwent a resective surgery and presented grade-VI dysfunction according to the HB scale. And a female patient with a stage-T4A acoustic neurinoma presented grade-IV dysfunction according to the HB scale. Discussion We performed a literature review of papers related to surgeries for masseteric-facial nerve anastomosis and compiled the results in table; then, we compared these data with those obtained from our cases. Conclusion The masseteric nerve is the one that shows the best prognosis among all the cranial nerves that could be used, but it is also necessary to perform well the surgical technique to access the facial branch and consequently achieve a better masseteric-facial nerve anastomosis.

Per-oral cross-facial sural nerve graft for facial reanimation / 대한악안면성형재건외과학회지

BACKGROUND: Cross-facial nerve graft is considered the treatment of choice for facial reanimation in patients with unilateral facial palsy caused by central facial nerve damage. In most cases, a traditional parotidectomy skin incision is used to locate the buccal and zygomatic branches of the facial nerve. METHODS: In this study, cross-facial nerve graft with the sural nerve was planned for three patients with facial palsy through an intraoral approach. RESULTS: An incision was made on the buccal cheek mucosa, and the dissection was performed to locate the buccal branch of the facial nerve. The parotid papillae and parotid duct were used as anatomic landmarks to locate the buccal branch. CONCLUSIONS: The intraoral approach is more advantageous than the conventional extraoral approach because of clear anatomic marker (parotid papilla), invisible postoperative scar, reduced tissue damage from dissection, and reduced operating time.

Nerve Repair and Nerve Grafting in Brachial Plexus Injuries

Brachial plexus injuries (BPI) can have devastating effects on upper extremity function, however, treatment in this injuries remains a difficult problem. Several kinds of surgical methods have been used to treat BPI, and nerve repair and nerve grafting have been traditionally used in postganglionic injury of brachial plexus. Because the several studies reported that nerve transfer to restore shoulder and elbow function has yielded superior results to historical reports for nerve grafting in partial BPI, the indication of nerve repair and nerve grafting has been decreased. Nonetheless, nerve repair and nerve grafting is still useful in focal damage in brachial plexus, such as laceration or gunshot wound and postganglionic neuroma in continuity without conduction of nerve action potential. In this paper, we described the basic concept, detailed indication and outcomes of nerve repair or nerve grafting in BPI.

Prevention and treatment of erectile dysfunction after prostatectomy: An update / 中华男科学杂志

Prostate cancer has the highest incidence among malignant tumors of the urinary system in China. Radical prostatectomy (RP) is the most effective treatment for localized prostate cancer with a good long-term prognosis. Erectile dysfunction (ED) is a common complication after RP, which seriously affects the patient's quality of life. With the rising incidence and early diagnosis of prostate cancer, the proportion of young cases of RP is increasing, and so is the importance of the treatment of post-RP ED. The restoration of erectile function after RP is closely related to the timing of penile rehabilitation as well as to pre- and intra-operative measures such as surgical strategies and methods. Common options for the treatment of post-RP ED include oral medication of phosphodiesterase type 5 inhibitors, application of vasoactive substances in the urethra or corpus cavernosum, use of vacuum erection devices, and implantation of penile prosthesis. Stem cell therapy, nerve transplantation, low-intensity extracorporeal shockwave therapy, and erythropoietin have shown great potential in penile rehabilitation after RP. At present, the stress is placed on the remission of symptoms in the treatment of ED. Stem cell therapy may reverse the cause of disease or cure ED by reversing its pathophysiological changes. A series of clinical trials of stem cell therapy are underway and have preliminarily confirmed the safety of stem cell therapy and proved that it can improve erectile function in patients with post-RP ED. This review focuses on the progress in the prevention and treatment of ED after RP.

Evaluation on effectiveness of neurolysis and nerve grafts surgery in treatment of early spontaneous posterior interosseous nerve entrapment / 吉林大学学报(医学版)

Objective To investigate the surgery method for early spontaneous posterior interosseous nerve entrapment,to observe the postoperative efficacy in treatment,to evaluate the surgical outcomes,and to provide a foundation for clinical choice of reasonable operation scheme.Methods 21 cases of early spontaneous posterior interosseous nerve entrapment received operation. 1 3 cases (1 8 arms) were treated by neurolysis, and 8 cases (8 arms )were treated by nerve grafts with small vessels wrapping operation;all the patients were followed up for 10 to 20 months;the finger extensor muscle strength and metacarpophalangeal joint activity were evaluated. Results The lesion extensor muscles were part of the denervation changes.Neurolysis muscle strength:14 arms were excellent(82.35%),2 arms were good,1 arm was fair,1 case was lost;extensor function:15 arms were excellent(88.24%),1 arm was good,1 arm was fair,1 case was lost.Nerve graft muscle strength:6 arms were excellent(75.00%),1 arm was good,1 arm was fair;extensor function:7 arms were excellent(87.50%),0 arm was good,1 arm was fair.Conclusion Neurolysis can have a good efficacy in treatment of early spontaneous posterior interosseous nerve entrapment without obvious degeneration.When the severe degeneration of entrapment nerve happens,a nerve graft surgical treatment is needed.

Surgical Anatomy of Sural Nerve for the Peripheral Nerve Regeneration in the Oral and Maxillofacial Field

The comparative study of different nerve reconstruction for curing the brachial plexus root injury with wrist and finger drop / 中华显微外科杂志

ObjectiveTo evaluate the influence of different surgical technique on the pup and　adult rats after the rupture of upper trunk and middle trunk so as to find the best way of surgical therapy.MethodsFrom January 2010 to June of 2010, forty-eight Sprague-Dawley male rats were divided into two　groups of 24 each, i.e., pup groups at the age of 7 days postnatal (P7)and one adult (3 months old)group.After C5-7 injured,each group was subdivided into three equally:group A (repair C5-7),B(repair C5,6),and C (no reinnervation performed).In the 3rd month postoperatively,the following tests were performed to estimate the recovery of each group:(1)Compared the rate of carpoptosis of each group.(2)Compared the regenerated nerve traversing rate of the radial nerve in each group.(3)HE stain to compared the cross-sectional area recovery rate.(4)The MyoD1 and Myogenin of the affected extensor of forearm were measured by Western blot.Results(1) The ethology test:there were no carpoptosis in group of adult A and pup A; the carpoptosis rate of pup B and pup C were higher than that of adult A(P ＜ 0.05) ;the carpoptosis rate of pup A was lower than that of B and C(P ＜ 0.05); there was no difference between carpoptosis rate of adult A and B,but they were both lower than C(P ＜ 0.05).(2) Histological test of radial nerves:The percentage of myelinated both higher than C (P ＜ 0.05).(3) Western blot:The protein level of MyoD1 and Myogenin in radial nerve fiber in experimental side of pup A,B and C descended progressively (P ＜ 0.05).There was no difference between adult A and B,but they were both higher than C (P ＜ 0.05).(4) Histological test of the extensor digitorium:There was no difference between cross-sectional area recovery rate of adult A and B,but they were pup A,B and C increased progressively (P ＜ 0.05).There was no difference between protein level of MyoD1 and Myogenin in adult A and B,but they were both lower than C (P ＜ 0.05),ConclusionIn adult rats, there is no difference between the recovery of wrist extensor of the two surgical procedure after the C5-7 injured. The restoration of C5-7 but not C5,6 can do more good to the recovery of wrist extensor in pup rats.It's important to repaire the C7 by nerve graft after injury of C5-7 in newborn.

Anatomic Study of the Vessels of the Digital Nerves in the Fingers

PURPOSE: The vessels of peripheral nerves have been extensively studied since Breidenbach used vascularizd nerve grafts. Tayor and Pinel studied the course and distribution of the vessels of peripheral nerves. However, the vessels of digital nerves are still not well known. The objective of this study was to prove vessels of digital nerves and to investigate the pathway of that. MATERIALS AND METHODS: 36 patients and 2 fresh human cadavers were studied under the microscope and histologic sections under the light microscope. RESULTS: We found that digital nerves had own arterioles and venules as well as peripheral nerves. This small vessels of digital nerves paralleled the digital nerves or run in a spiral. Digital nerves were abundantly vascularized throught their length by a succession of vessels and by their repeated divisions and anastomoses. CONCLUSIONS: The clinical implications of this results can be discussed in relation to the dissection of nerves, the possibility of vasculized nerve grafts.

Donor Site Morbidity after Sural Nerve Harvesting for Peripheral Nerve Reconstruction

PURPOSE: Although the sural nerve is the most commonly used donor for autologous nerve graft, its morbidity after harvesting is sparsely investigated. The sural nerve being a sensory nerve, complications such as sensory changes in its area and neuroma can be expected. This study was designed to evaluate the donor site morbidity after sural nerve harvesting. METHODS: Among the 13 cases, who underwent sural nerve harvesting between January 2004 and August 2009, 11 patients with proper follow up were included in the study. The collected data included harvested graft length, actual length of the grafted nerve, anesthetic and paresthetic area, presence of Tinel sign and symptomatic neuroma, and scar quality. RESULTS: In 7 patients, no anesthetic area could be detected. Of the patients with a follow up period of more than 2 years, all the patients showed no anesthetic area except two cases who had a very small area of sensory deficit (225 mm2) on the lateral heel area, and large deficit (4,500 mm2) on the lateral foot aspect. The patients with a short follow up period (1~2 m) demonstrated a large anesthetic skin area (6.760 mm2, 12,500 mm2). Only one patient had a Tinel sign. This patient also showed a subcutaneous neuroma, which was visible, but did not complain of discomfort during daily activities. One patient had a hypertrophic scar in the retromalleolar area, whereas the two other scars on the calf were invisible. CONCLUSION: After a period of 2 years the size of anesthetic skin in the lateral retromalleolar area is nearly zero. It is hypothesized that the size of sensory skin deficit may be large immediately after the operation. This area decreases over time so that after 2 years the patient does not feel any discomfort from nerve harvesting.

The Treatment of Neuroma-in-Continuity with Interpositional Nerve Graft and Vein Wrapping: A Case Report

We report a case of 44 years old male patient with neuroma-in-continuity of ulna nerve. In the patient's past history, he had received operative treatment for the open supracondylar fracture of right distal humerus and ulnar nerve injury at 10 years ago, and neurolysis was tried 2 times due to severe neuropathic pain. Despite of these operations, the symptom was not improved. In operative field, we noticed neuroma-in-continuity and decided to resect the neuroma until normal nerve fascicle was noted. The nerve cable graft was done with auto sural nerve on the defect site and the nerve was wrapped with small saphenous vein. At post operative 7 months, pain was markedly decreased and sensory recovery was slightly improved and patient was satisfied with the result.

Unsuspected Plasticity of Single Neurons after Connection of the Corticospinal Tract with Peripheral Nerves in Spinal Cord Lesions

OBJECTIVE: To report an unsuspected adaptive plasticity of single upper motor neurons and of primary motor cortex found after microsurgical connection of the spinal cord with peripheral nerve via grafts in paraplegics and focussed discussion of the reviewed literature. METHODS: The research aimed at making paraplegics walk again, after 20 years of experimental surgery in animals. Amongst other things, animal experiments demonstrated the alteration of the motor endplates receptors from cholinergic to glutamatergic induced by connection with upper motor neurons. The same paradigm was successfully performed in paraplegic humans. The nerve grafts were put into the ventral-lateral spinal tract randomly, without possibility of choosing the axons coming from different areas of the motor cortex. RESULTS: The patient became able to selectively activate the re-innervated muscles she wanted without concurrent activities of other muscles connected with the same cortical areas. CONCLUSION: Authors believe that unlike in nerve or tendon transfers, where the whole cortical area corresponding to the transfer changes its function a phenomenon that we call "brain plasticity by areas", in our paradigm due to the direct connection of upper motor neurons with different peripheral nerves and muscles via nerve grafts motor learning occurs based on adaptive neuronal plasticity so that simultaneous contractions of other muscles are prevented. We propose to call it adaptive functional "plasticity by single neurons". We speculate that this phenomenon is due to the simultaneous activation of neurons spread in different cortical areas for a given specific movement, whilst the other neurons of the same areas connected with peripheral nerves of different muscles are not activated at the same time. Why different neurons of the same area fire at different times according to different voluntary demands remains to be discovered. We are committed to solve this enigma hereafter.

Study on repair of sciatic nerve lesions using acellular nerves implanted with adipose tissue-derived stromal cells / 中华显微外科杂志

Objective To evaluate the effectiveness of using adipose-derived stromal cells (ADSCs)into a tissue-engineered peripheral nerve on bridging sciatic nerve gaps.Methods Forty-eight F344 female rats weighing 200 - 220 g were randomly divided into 6 groups of nerve grafting to repair 15 mm long asiatic nerve lesions,with 8 mrs in each group.Group A:ADSCs-laden acellular nerves;group B:differentiated ADSCs-laden acellular nerves;group C:Schwann cells-laden acellular nerves;group D:acellular nerves without cells;group E:autografts;group F:nonimplanted grafts.The effects were evaluated in terms of electrophysiulogy,Fluorogold retrograde tracing,histology and tracking studies.Results At 12 weeks after surgery,there was no graft bridging nerve gap in nonimplanted grafts.All the examinations of group A and B were better than group D,respectively (P＜0.05 or P＜0.01).But there were no statistically significant differences among group A,B,C,and D (P＞0.05).Conclusion ADSCs and differentiated ADSCs could promote nerve regeneration when used as seed cells to build tissue-engineered peripheral nerves with acellular nerve scaffolds.

T lymphocyte subsets and intracellular cytokines after transfer of chemical acellular nerve allograft / 中华创伤骨科杂志

Objective To provide immunological evidence for clinical transfer of chemical extracted acellular nerve allografL Methods One hundred and twenty-eight BALB/C mice were randomly divided into 4 groups of equal size according to their different treatments:negative contrast group(NC),fresh autograft group(AG),fresh allogeneic nerve group(FN)and chemical extracted aceflular allogeneic nerve group(CEN).Then we implanted various kinds of nerve grafts into the thigh muscle of BALB/C mice in corresponding groups.At 3,7,14,28 days postoperatively,8 mice from each group were killed each time to harvest their spleens,from which T lymphocytes were collected.Theu monoclonal antibodies(CD3,CD4 CD8 CD25,IL-2,IFN-γ, TNF-α)were added into the suspension.Then fluorescence.activated cell sorting(FACS)was used to determine the positive rates of cells combined with the above monoclonal antibodies. Results There were no statistically significant differences between CEN group,NC group,and AG group,but indexes of FN group were significantly higher than those of the other 3 groups at corresponding time points. Conclusion There is no obvious immune reiection of chemical extracted acellular nerve allograft when compared with fresh nerve autograft.

Precise Anatomical Location of the Autonomous Nerve from the Pelvic Plexus to the Corpus Cavernosum / 대한비뇨기과학회지

PURPOSE: We wanted to study the precise anatomical location of the branches of the pelvic plexus from the sacral root to the cavernous nerve. MATERIALS AND METHODS: We performed microdissection on the pelvises from 4 male formalin fixed cadavers under a Zeiss surgical microscope and we traced the location of the branches of the pelvic plexus at a magnification of 6x. RESULTS: The configuration of the pelvic plexus was an irregular diamond shape rather than rectangular. It was located retroperitoneally on the lateral wall of the rectum 8.2 to 11.5cm from the anal verge. Its midpoint was located 2.0 to 2.5cm from the seminal vesicle posterosuperiorly. A prominent neurovascular bundle (NVB) was located on the posterolateral portion of the apex and the mid portion of the prostate. The pelvic splanchnic nerve (PSN) joined the NVB at a point distal and inferior to the bladder-prostate (BP) junction. The PSN components joined the NVB in a spray-like distribution at multiple levels distal to the BP junction. The distance from the membranous urethra to the NVB was 0.5 to 1.2cm. We also found multiple tiny branches on the anterolateral aspect of the prostate apex. CONCLUSIONS: In contrast to the usual concept, the NVB was much wider above the mid portion of the prostrate and it supplied multiple tiny branches on the anterolateral aspect of the prostate. The PSN branches arose from the more posteroinferior area of the pelvic plexus. Therefore, we recommend a more anterior dissection of the lateral pelvic fascia for nerve sparing radical prostatectomy. If surgeons plan a nerve graft after radical prostatectomy, they should consider this neuroanatomy for obtaining a successful outcome.

Post-operative rehabilitative nursing of patients repaired with acellular nerve allograft / 中国矫形外科杂志

[Objective]To evaluate the effect of post-operative rehabilitative nursing of patients repaired with acellular nerve allograft.[Method]From April 2003 to April 2006,39 inpatients with peripheral nerve defect were subjected to receive acellular nerve allograft in order to repair nerve defect.The patients were rehabilitated with special nursing after being operated and discharged.Among of them,21 patients were followed up over 6 months,the effect of treatment was analyzed.[Result]Among 21 patients,16 people had excellent and good effect of treatment and the efficient rate was 71.4%.[Conclusion]Post-operative rehabili tative nursing is important and effective for rehabilitation patients of peripheral nerve injuries repaired with acellular nerve allograft.

Sural Nerve Graftafter Resection of a Schwannoma in the Sciatic Nerve : A Case Report / 대한정형외과학회잡지

A schwannoma is one of the most common neoplasms in the central and peripheral nervous systems, but schwannomas of the sciatic nerve are rare. Treatment is a surgical excision and the overall prognosis is good. But functional loss occurs when a neurectomy is performed with inevitable cause. We report one case of a successful sural nerve graft after resection of a schwannoma in a sciatic nerve and we present a brief review of the literature.

The Availability of Gore-Tex(R) Tube as Nerve Conduit at the Peripheral Nerve Defect

When a large peripheral nerve defect occurs, an autologous nerve graft is the most ideal method of recinstruction. But an autologous nerve graft has many limitations due to donor site morbidities. Many previous focused on finding the ideal nerve conduit. Among them, Gore-Tex(R) has several advantages over other conduits. It can be manipulated to a suitable size, does not collapse easily, and it is a semi- permeable material that contain pores. A round shaped nerve can be newly formed because of its smooth inner surface. The purpose of this study was to evaluate the availability of Gore-Tex(R) tube as a nerve conduit at the peripheral nerve defect in the rat sciatic nerve. The 10 mm nerve gap was made in each group. A Gore-Tex(R) tube filled with skeletal muscle was inserted and autologous nerve graft was harvested, respectively. In the experimental group, we placed a 0.5mm thickness, 30micrometer pored, 1.8mm in diameter and 14mm length tube with skeletal muscle inserted inside. In the control group, the nerve gap was inserted with a rat sciatic nerve. We estimated the results electrophysiologically and histologically to 16 weeks postoperatively. Results in the nerve conduction velocity, total myelinated axon count, myelin sheath thickness and mean nerve fiber diameter, the experimental group was substantially lower than that of the control group, but the statistic difference was not significant (p<0.05). The morphology was very similar in both groups, microscopically. From the above results, We conclude that Gore-Tex(R) qualifies as an ideal nerve conduit. It is suggested that Gore-Tex(R) tube filled with skeletal muscle may, substitute for an autologous nerve graft.

Early nerve regeneration on the crushing injury model and the autogenous nerve graft model of rat sciatic nerve

Various Vein Conduit Modalities for Nerve Regeneration in Rats

Over the years, many surgeons have used various natural and synthetic materials to bridge the nerve defect. However, none of these materials has surpassed the effectiveness of the nerve autograft. Among natural materials, a vein graft has been used as conduit for nerve regeneration in both research protocols and clinical situations. Unfortunately, the comparison of various research reports is difficult, for each research has employed a different experimental model and method of evaluation for the study of the nerve regeneration. This study introduced various modifications of the vein graft technique, and investigated several vein graft models in an attempt to find the most effective formulation . Four vein graft models were employed: 1) the empty vein graft, 2) the inside-out pattern vein graft, 3) the vein graft filled with skeletal muscle strips, 4) the inside-out pattern vein graft filled with skeletal muscle strips. Regeneration was assessed with gross appearance, histologic examination and electromyography(EMG). In the vein graft filled with muscle strips, there was the increased axonal diameter, myelin sheath thickness, ratio of myelinated axon to unmyelinated axon, and conduction velocities. The result showed that any vein graft filled with muscle strips is superior to the empty vein graft and the inside-out pattern vein graft model which are not filled with muscle strips. It is concluded that the nerve repair using a vein graft filled with skeletal muscle strips can be effectively employed in the clinical field. Further study should be aimed at the regeneration of a longer distance nerve gap and its clinical application.

Outcome Study of Sural Nerve Autografts for High Radial Nerve Injury with a Large Gap / 대한정형외과학회잡지

PURPOSE: There have been few reports on the outcome of nerve grafts for radial nerve injury with a large gap. Furthermore, the results of reports are variable. It was the purpose of this study to report our results of nerve grafting for high radial nerve injury with a defect of more than 9 cm. MATERIALS AND METHODS: Five patients with high radial nerve injury were treated by sural nerve autograft. The gap of radial nerve, measured in the operative field, was 9 cm in one patient, 10 cm in three, and 11 cm in one. There were four men and one woman of average age was 35 years. The causes of the injuries were, fracture of the humerus in three patients and surgery-related complications in two. Average delay from injury to operation was 8 months, and average duration of follow up after surgery was 49 months. RESULTS: Overall motor recovery was M5 in two patients, M4 in two, and M2 in one. CONCLUSION: Good motor recovery can be expected in patients with a large gap radial nerve gap, when sural nerve autografts are sutured to areas which have motor fascicles dominantly.