Supercharge End-to-Side Motor Transfer to a Long Nerve Graft to Enhance Motor Regeneration: An Experimental Rat Study.

BACKGROUND: Long nerve grafts are prone to chronic denervation, often resulting in unsatisfactory clinical outcomes. The authors aim to investigate whether supercharge end-to-side (SETS) motor nerve transfers to a long nerve graft can potentially enhance nerve regeneration and functional outcomes. METHODS: A reversed long nerve graft was interposed between the C6 and the musculocutaneous nerve in 48 rats. The motor nerves near the C6 proximally and the musculocutaneous nerve distally were chosen for SETS transfer to the long nerve graft. There were four groups: (A) nerve graft only, (B) proximal SETS transfer, (C) distal SETS transfer, and (D) proximal and distal double SETS transfers. A grooming test was assessed at 4, 8, 12, and 16 weeks postoperatively. Biceps weight, compound muscle action potential amplitude, tetanic contraction force, and histomorphometric analysis of the musculocutaneous nerve were evaluated at 16 weeks. RESULTS: Long nerve grafts that received SETS transfers (groups B, C, and D) showed superior results compared with the control group. Proximal SETS transfer had significantly better outcomes than distal SETS transfer in electrodiagnostic parameters, whereas double SETS transfer had the highest axonal count and biceps compound muscle action potential amplitude. CONCLUSION: SETS motor transfers to long nerve grafts can effectively improve functional outcome and optimize nerve graft regeneration to the target nerve. CLINICAL RELEVANCE STATEMENT: Long nerve grafts yield suboptimal functional results. The experimental study showed that SETS motor transfer to a long nerve graft improves muscle functional outcomes. A double motor SETS transfer provides the best results. Proximal SETS transfer might have more benefits over distal transfer.

Supercharge End-to-Side Sensory Transfer to A Long Nerve Graft to Enhance Motor Regeneration in A Brachial Plexus Model-An Experimental Rat Study.

BACKGROUND: Long nerve grafts will affect muscle recovery. Aim of this study is to investigate if supercharged end-to-side (SETS) sensory nerve transfer to long nerve graft can enhance functional outcomes in brachial plexus animal model. METHODS: A reversed long nerve graft (20-23-mm) was interposed between C6 and musculocutaneous nerve (MCN) in 48 SD rats. The sensory nerves adjacent to the proximal and distal coaptation sites of the nerve graft were used for SETS. There were four groups with 12 rats in each: (A) nerve graft alone, (B) proximal SETS sensory transfer, (C) distal SETS sensory transfer, and (D) combined proximal and distal SETS sensory transfers. Grooming test at 4, 8, 12 and 16 weeks, and compound muscle action potentials (CMAP), biceps tetanic muscle contraction force, muscle weight and MCN axon histomorphologic analysis at 16 weeks were assessed. RESULTS: Grooming test was significantly better in group C and D at 8 weeks (p = 0.02 and p = 0.04) and still superior at 16 weeks. There was no significant difference in CMAP, tetanic muscle contraction force, or muscle weight. The axon counts showed all experimental arms were significantly higher than the unoperated arms. Although the axon count was lowest in group C and highest in group D (p = 0.02), the nerve morphology tended to be better in group C overall. CONCLUSION: Distal sensory SETS transfer to a long nerve graft showed benefits of functional muscle recovery and better target nerve morphology. Proximal sensory inputs do not benefit the outcomes at all.

Intra-abdominal lymph node flaps in lymphedema therapy: An anatomical guide to donor site selection.

BACKGROUND: Secondary lymphedema is a leading sequela of cancer surgery and radiotherapy. The microsurgical transfer of lymph node flaps (LNFs) to affected limbs can improve the symptoms. The intra-abdominal cavity contains an abundant heterogenic source. The aim of this study is to aid selection among intra-abdominal LNFs. METHODS: Eight LNFs were harvested in a microsurgical fashion at five sites in 16 cadavers: gastroepiploic, jejunal, ileal, ileocolic, and appendicular. These flaps were compared regarding size, weight, arterial diameter, and lymph node (LN) count after histologic verification. RESULTS: One hundred and sixteen flaps were harvested. The exposed area correlated with the flap weight and volume (r2 = 0.86, r = 0.9). While gastroepiploic LNFs (geLNFs) showed the highest median weight of 99 ml, the jejunal LNFs (jLNFs) had the highest density with 3.8 LNs per 10 ml. The most reliable jLNF was 60 cm from the ligament of Treitz. Three or more LNs were contained in 94% of the jejunal, 88% of the ileal/ileocolic, and 63% of the omental LNs. The ileocolic LNF had the largest arterial diameter of 3 mm, yet the smallest volume. CONCLUSIONS: jLNF and ileal LNF provide a reliable, high LN density for simultaneous, smaller recipient sites. geLNFs are more suitable for larger recipient sites.

Expanding indication of free hypothenar flap transfer: Sequential pedicled ulnar palm flap transfer to a relatively large hypothenar flap donor site.

BACKGROUND: Free hypothenar flap (HTF) transfer allows sensible soft tissue reconstruction of the fingertip. However, HTF is basically indicated for a relatively small soft tissue defect, as width of an HTF is limited up to approximately 20 mm to allow primary donor site closure. Combined with sequential local flap to an HTF donor site, a larger HTF can be used without the contracture risk. The aim of this study was to evaluate feasibility of free HTF transfer and sequential ulnar palm flap (UPF) transfer (HTF-UPF) for relatively large fingertip reconstructions. METHODS: Medical charts of patients who underwent HTF-UPF for fingertip reconstruction were reviewed. An HTF was designed transversely proximal to the proximal palmar crease, and a slightly smaller hemi-spindle-shaped UPF was designed longitudinally on the mid-lateral aspect of the ulnar palm; the UPF was used to close the HTF donor site. Patient and flap characteristics, intra-operative findings, and postoperative results were evaluated. RESULTS: Twelve patients with average age of 42.7 years were included. HTF-UPF procedure was performed on 12 fingers. HTF's length/width ranged from 45/20 to 70/40 mm (average, 52.5/32.1 mm). UPF's length/width ranged from 40/20 to 55/30 mm (average, 46.7/24.2 mm). Time for sequential UPF transfer ranged from 3 to 9 min (average, 5.1 min). All HTFs and UPFs survived without flap necrosis or scar contracture. Postoperative sensation was comparable with the contralateral fingertip. CONCLUSIONS: HTF-UPF procedure allows relatively large fingertip reconstruction with a minimum risk of HTF donor site contracture.

Radical reduction and reconstruction for male genital elephantiasis: Superficial circumflex iliac artery perforator (SCIP) lymphatic flap transfer after elephantiasis tissue resection.

BACKGROUND: Treatment of elephantiasis, the most severe lymphedema, is challenging. Management of male genital elephantiasis (MGE) is even more challenging than extremity elephantiasis due to its complicated shape and high risk of lymphorrhea and cellulitis. Complete resection of fibrous tissue and lymphatic reconstruction is considered to be ideal for the treatment of MGE. The aim of this study was to evaluate the feasibility of radical reduction and reconstruction (3R) for isolated MGE. METHODS: Medical charts of patients who underwent 3R were reviewed. The 3R operation consisted of genital fibrous tissue resection and reconstruction of soft tissue and lymphatic structure using superficial circumflex iliac artery perforator (SCIP) lymphatic flap transfer (LFT). No compression was applied postoperatively. Patient and flap characteristics, intraoperative findings, and postoperative results were evaluated. RESULTS: Seven patients were included. MGE included isolated scrotal elephantiasis in 4 cases, and scrotal and penile elephantiasis in 3 cases. Resected tissue volume ranged from 609 to 2304 grams (average, 1511.0 grams). SCIP-LFT was performed in all cases; pedicled full-thickness SCIP-LFT for scrotal reconstruction in all cases, and SCIP pure-skin-perforator flap transfer for penile reconstruction in 3 cases. There was no postoperative genital complication or evidence of genital lymphedema recurrence in the mean follow-up period of 22.7 months. Genital lymphedema scores significantly improved postoperatively (6.7 ± 1.8 vs. 0.3 ± 0.5, P <0.001). CONCLUSIONS: 3R operation allowed one-stage curative treatment for MGE. LFT has the potential to play an essential role in the prevention of postoperative wound complications and lymphedema recurrence after radical resection of fibrotic tissue.

Reversal of thoracic sympathectomy through robot-assisted microsurgical sympathetic trunk reconstruction with sural nerve graft and additional end-to-side coaptation of the intercostal nerves: A case report.

Thoracic sympathectomy to treat palmar hyperhidrosis (PH) has widely been performed. Many patients regret the surgery due to compensatory hyperhidrosis (CH), gustatory hyperhidrosis, arrhythmia, hypertension, gastrointestinal disturbances, and emotional distress. Robotic applications in microsurgery are very limited. We report the technique and long-term patient-reported outcomes of bilateral robot-assisted microsurgical sympathetic trunk reconstruction with a sural nerve graft in an interdisciplinary setting. A 59-year-old female suffered from severe adverse effects after endoscopic thoracic sympathectomy (ETS) for PH 25 years ago. She reported CH over the whole trunk, gustatory hyperhidrosis, excessive dry hands, and emotional distress. An interdisciplinary surgical team performed a bilateral sympathetic trunk reversal reconstruction with an interpositional sural nerve graft per side by a da Vinci® Robot. The nerve graft was microsurgically coapted using 9-0 sutures end-to-end to the sympathetic trunk stumps and side-to-end to the intercostal nerves T2-T4. At 24, 33 and 42 months, palmar dryness and emotional distress were strongly reduced. A highly specialized interdisciplinary setting may provide a precise, safe, and efficient treatment for ETS sequelae. A clinical study is initiated to validate this new therapy.

Free tensor fascia lata true-perforator flap transfer for reconstruction of the calcaneal soft tissue defect complicated with osteomyelitis in a patient with alcohol-induced Charcot foot: A case report and literature review.

Charcot foot is can result in bone deformities and soft tissue defects. We report a case of alcohol-induced Charcot (AIC) foot with soft tissue defect including the weight-bearing zone of the heel and osteomyelitis, which was successfully reconstructed with free tensor fascia lata true-perforator flap (TFLtp). A 56-year-old male suffered from AIC foot with an 18 × 6 cm defect. Based on the preoperative ultrasound, we identified the overlying upper thigh area offering one of the thickest dermis. A TFLtp flap was raised sparing the TFL muscle based on one perforator without including the main trunk of the transverse/ascending branch of the lateral femoral circumflex vessel. The TFLtp flap was transferred to the heel and anastomosed to the posterior tibial artery in an end-to-side fashion. The patient complained no postoperative discomfort of the donor site and was able to walk on his foot after 5 weeks. This case report highlights that the TFLtp flap may offer thick dermis, faster surgery due to perforator level dissection and a concealed donor site.

Use of the superficial circumflex iliac artery perforator flap for reconstruction after sarcoma resection.

BACKGROUND: Postoperative complications after flap-coverage in sarcoma treatment can postpone postoperative adjunct treatments. Here, we present our experience with the use of the superficial circumflex iliac artery perforator (SCIP) flap after sarcoma resection. PATIENTS AND METHODS: Patients undergoing immediate reconstruction surgery with a flap after sarcoma resection at a single institution from February 2017 to April 2020 were identified. Patient demographics, tumor characteristics, surgical characteristics, and complications were examined. RESULTS: Thirty-five consecutive patients underwent reconstructions using a SCIP flap (34 free and one pedicled SCIP flaps). We also identified 47 consecutive patients who underwent reconstruction with other pedicled or free flaps over the same time period. No significant differences were found in patient age, gender, defect size, or operative time between these two groups. The incidences of overall complications (20/47 [42.6%] vs. 3/35 [8.5%], p < .001), flap dehiscence (7/47 [14.8%] vs. 0/35 [0%], p = .018), and total flap complications (15/47 [31.9%] vs. 2/35 [5.7%], p = .005) were statistically greater in the control group than in the SCIP group. CONCLUSION: With its minimal postoperative complication rate both in the reconstruction site and the donor site, the SCIP flap can be considered an optimal reconstruction option after sarcoma resection.

Nerve vascularity in free vascularized nerve flaps.

The blood supply of peripheral nerves consists of a complex internal vessels' network, feeding external vessels and the interlinking vasa nervorum. Patients with nerve damage may require nerve substitution. While the commonly performed avascular nerve grafts obtain vascularization only from random and slow inosculation into the vasa nervorum, their insufficient revascularization causes loss of the graft's potential due to central necrosis. This gets more relevant with the larger diameter of nerves injured. Examples for neurovascular flaps are the lateral femoral cutaneous nerve vascularized via the superficial circumflex iliac artery perforator (LFCN-SCIP) flap or the iliohypogastric nerve graft vascularized via the superficial inferior epigastric artery (SIEA). LFCN-SCIP shows a well concealed donor scar site with a maintained vascularization and a minor donor site morbidity. Therefore, the guaranteed axial nerve vascularity in LFCN-SCIP makes it a preferred autologous vascularized nerve therapy for peripheral nerve defects. A further option example is the anterior lateral thigh (ALT) flap with the LFCN.

Impact of Social Media on Current Medical Conferences.

BACKGROUND: Medical conferences are forums for research, continuing medical education, and networking. Social media is increasingly used for communication and networking due to its low cost and ability to overcome large distances. This study investigates the impact that social media brings to the current conference system. METHODS: There are three parts of this study: (1) comparing two similar brachial plexus injuries (BPIs) courses without (2009) and with (2017) social media support, and the participants' feedback; (2) sharing our experiences in the management of the 2018 International Course on SuperMicrosurgery (ICSM) conference; and (3) evaluating the studies from the social media platform International Microsurgery Club (IMC), for the consensus pertaining to social media and conference system. RESULTS: With the help of social media, international attendance increased during the 2017 BPI conference compared with the 2009 BPI course (25 nationalities in 2009 vs. 35 in 2017). At least 23% obtained their meeting information through social media. Live surgery was the overall main attraction (79%). The 2018 ICSM meeting revealed that video posts increased attendance; videos that were the most effective in attracting (viewership) were either short or pertained to surgical procedures. Facebook, Messenger, and WeChat smartphone applications were effective for immediate communication and troubleshooting among the participants. From the IMC polls, 78% believe that the social media and the conference complemented each other. 97% attended the conference to update their skills and knowledge. CONCLUSION: Social media is a quick and economic tool in promoting medical conferences and instant messenger systems offer immediate communication amongst associates. Despite the popularity of social media, the conference still has its irreplaceable role. The combination of the conference and the social media enhances the training and education of microsurgeons.

Vascularized Brachial Plexus Allotransplantation-An Experimental Study in Brown Norway and Lewis Rats.

BACKGROUND: Brachial plexus injuries are devastating. Current reconstructive treatments achieve limited partial functionality. Vascularized brachial plexus allotransplantation could offer the best nerve graft fulfilling the like-with-like principle. In this experimental study, we assessed the feasibility of rat brachial plexus allotransplantation and analyzed its functional outcomes. METHODS: A free vascularized brachial plexus with a chimeric compound skin paddle flap based on the subclavian vessels was transplanted from a Brown Norway rat to a Lewis rat. This study has 2 parts. Protocol I aimed to develop the vascularized brachial plexus allotransplantation (VBP-allo) model. Four groups are compared: no reconstruction, VBP-allo with and without cyclosporine A immunosuppression, VBP autotransplantation (VBP-auto). Protocol II compared the recovery of the biceps muscle and forearm flexors when using all 5, 2 (C5 + C6) or 1 (isolated C6) spinal nerve as the donor nerves. The assessment was performed on week 16 and included muscle weight, functionality (grooming tests, muscle strength), electrophysiology and histomorphology of the targeted muscles. RESULTS: Protocol I showed, the VBP-allo with cyclosporine A immunosuppression was electrophysiologically and functionally comparable to VBP-auto and significantly superior to negative controls and absent immunosuppression. In protocol II, all groups had a comparable functional recovery in the biceps muscle. Only with 5 donor nerves did the forearm show good results compared with only 1 or 2 donor nerves. CONCLUSIONS: This study demonstrated a useful vascularized complete brachial plexus allotransplantation rodent model with successful forelimb function restoration under immunosuppression. Only the allotransplantation including all 5 roots as donor nerves achieved a forearm recovery.