Overall and area-specific tactile recovery following different methods of surgical reinnervation in post-mastectomy breast reconstruction - a systematic review and meta-analysis.

Loss of breast sensation after mastectomy and breast reconstruction is associated with decreased psychosocial outcomes and quality-of-life, spurring applications of peripheral nerve repair to autologous breast reconstruction. While direct nerve coaptation is the gold standard for neurotization, the development of nerve allografts has increased candidacy for neurotization. Herein, we investigate long-term sensory and BREAST-Q outcomes in patients receiving deep inferior epigastric perforator (DIEP) flap reconstruction neurotized by direct coaptation and nerve allograft. Patients with neurotized DIEP reconstruction with direct coaptation or nerve allograft were retrospectively identified and invited to undergo breast sensation testing with a pressure-specified sensory device. Patients also completed the Reconstruction and Breast Sensation modules of the BREAST-Q questionnaire. 30 patients (53 flaps) were included in this study, with 18 flaps reconstructed with direct nerve coaptation and 35 flaps reconstructed with an allograft. The overall breast cutaneous sensitivity measurement was 64.58 g/mm2 [40.06, 78.99] in the direct coaptation group and 78.28 g/mm2 [40.60, 82.06] in the nerve allograft group, with no significant differences overall (P = 0.680) or at any specific breast area. BREAST-Q surveys were completed at an average follow-up time of 94.42 months in the direct coaptation group and 61.56 months in the allograft group. The two groups had comparable scores for all survey scales (P > 0.05). DIEP flaps neurotized by direct coaptation and nerve allograft have comparable long-term objective and patient-reported breast sensation. Nerve grafting is a viable alternative for patients who are not candidates for direct end-to-end nerve coaptation.

Management of peripheral nerve injury

Neurotization in Innervated Breast Reconstruction: A Systematic Review of Techniques and Outcomes

A Comparison of Polyglycolic Acid Versus Type 1 Collagen Bioabsorbable Nerve Conduits in a Rat Model: An Alternative to Autografting

Collagen Nerve Conduits and Processed Nerve Allografts for the Reconstruction of Digital Nerve Gaps: A Single-Institution Case Series and Review of the Literature

Purpose:Radial free forearm flap (RFFF) phalloplasty is the most commonly-used technique for gender-affirming phalloplasty procedures. Microsurgical coaptation of the free flap nerves to branches of the genital nerves aims to provide patients with a sensate neophallus. Return of sensation in the neophallus is poorly understood and has yet to be well characterized in the literature. This study serves to describe sensation in the neophallus, which will assist in setting patient expectations for recovery and improving operative technique and planning, especially in selection of nerves for coaptation.Methods:A total of 14 patients undergoing RFFF were tested for pressure sensation in the neophallus postoperatively. Testing was conducted via 1-point static (1PS) testing using the Pressure Specified Sensory Device (PSSD). A 100g monofilament was used to screen the neophallus for sensation beginning at 3 cm distal to the base and advancing distally by 1 cm until the patient reported no sensation; the PSSD was then applied at the last point the patient reported sensation for precise pressure measurements. These measurements were taken on the right and left ventral and dorsal shaft 1 cm from the ventral and dorsal midlines, respectively. The right and left urethral meatus was also measured for sensation (representing the ulnar-most skin of the RFFF). Measurements were taken at intervals beginning as early as 1 week postoperatively; the longest patient follow-up thus far has been 17 months.Results:Of the 14 patients, 13 had tactile pressure sensation at their most recent measurement (range 1-17mos). The remaining patient did not have a measurement beyond one month postoperatively. Of the 14 patients, consistent long-term follow-up measurements were currently available for 7. Among these patients, return of any sensation was measured at an average of 69 days (12-160 days) postoperatively. The earliest time point at which a patient had any sensation was two weeks postoperatively while another patient had sensation through the full length of the neophallus measured at 2.5 months postoperatively; subsequent measurements of this patient showed a decreased threshold (increased sensitivity) for pressure sensation over time.Conclusions:Preliminary data suggests that innervation of the RFFF neophallus can be accomplished via microsurgical nerve coaptation and that recovery of sensation may occur much faster in some patients than previously thought possible. Further follow-up and a larger patient cohort is necessary to fully characterize nerve recovery and regeneration in gender-affirming phalloplasty patients.

The aim of this study was to compare electrospun caprolactone (EC) and poly(lactic acid-ε-caprolactone) (PLCL) nerve conduits with nerve graft in a rat sciatic nerve defect model. A total of 32 male Wistar albino rats were divided into 4 groups, with 8 rats in each group. A nerve defect of 1 cm was constructed in the left sciatic nerve of the rats. These defects were left denuded in the sham group, and reconstructed with nerve grafts, PLCL, and EC nerve conduits in the other groups. After 3 months, nerve regenerations were evaluated macroscopically, microscopically, and electrophysiologically. The numbers of myelinated axons in the cross-sections of the nerves were compared between the groups. Macroscopically, all nerve coaptations were intact and biodegradation was detected in nerve conduits. Electromyographic assessment and count of myelinated axons in the cross-sections of the nerves displayed the best regeneration in the nerve graft group (P < 0.001) and similar results were obtained in the PLCL and EC nerve conduit groups (P = 0.79). Light and electron microscopy studies demonstrated nerve regeneration in both nerve conduit groups. EC nerve conduits and PLCL nerve conduits yielded similar results and may be alternatives to nerve grafts as they biodegrade.

Background Neuromas of the digits can be a mentally and physically disabling condition for patients in this systematic review, the authors discuss a variety of surgical techniques for digital neuroma management. Aim of the Work This systematic review aims to analyze and combine the results of relevant studies on surgical treatment for digital neuroma. It aims to determine the overall success of the surgical procedure and identify which techniques are more effective. Patients and Methods Four databases, including Embase, Scopus, PubMed, and Google Scholar, were searched for relevant studies. The search spans the years 1990 to 2022. Out of 1490 initial studies, 672 remained after removing duplicates. After screening the Abstracts, 647 were excluded for various reasons, leaving 12 eligible studies for inclusion in the systematic review, which included a total of 309 patients. Outcomes reporting included the visual analogue scale (VAS) to report pain, patient satisfaction, the Semmes-Weinstein Monofilament Test, The two-point discrimination test, a non-standard ordinal scale and the mean follow-up duration. Results The studies included neuroma excision, neuroma excision (and implantation into adjacent tissues), centro-central union, proximal relocation, interdigital direct neurorrhaphy, nerve allograft reconstruction, regenerative peripheral interface, dorsal transposition and epineural coaptation, collagen conduits, and muscle-in-vein conduits (MVCs).The results show that a majority of patients achieved pain relief after surgery, with high levels of satisfaction reported in some studies. The most successful surgical approach was not determined since there were no statistically significant differences between the various surgical techniques. However, neuroma excision followed by nerve repair/reconstruction (centro-central union, proximal relocation, direct neurorrhaphy, nerve allograft, regenerative peripheral interface, dorsal transposition and nerve conduit )show magnificent results compared to neuroma excision alone with or without implantation. Factors such as old age, smoking, and high PROMIS Depression scores were found to be independently associated with higher levels of pain interference. Conclusion The results suggest that surgical treatment is effective in reducing pain levels, with most patients reporting complete pain relief or improvement. Neuroma excision followed by nerve repair/reconstruction was found to result in better outcomes compared to neuroma excision alone with or without implantation.

PURPOSE: Radial forearm free flap (RFFF) phalloplasty is often referred to as the gold standard for gender-affirming phalloplasty procedures.1 Forearm neuropathy, a frequently listed complication of RFFF phalloplasty, has yet to be quantified in patients who undergo this procedure with a device as precise as the Pressure Specified Sensory Device (PSSD). The purpose of this study was to determine whether there is a change in tactile hand sensation following RFFF phalloplasty, and whether these changes vary by cutaneous region of the hand. The results of this study will help counsel patients who may view potential neuropathy as a barrier to pursuing this procedure. METHODS: A total of 9 patients undergoing split thickness RFFF phalloplasty were tested preoperatively and 1-week postoperatively for tactile hand sensation. Testing was conducted using a 2-point static (2 PS) test with a Disk-Criminator and PSSD. The testing sites included the cutaneous regions of the dorsal first webspace and the first phalanx of the index finger and pollex of the RFFF donor arm. The 2 PSSD prongs were set at a distance determined by initial testing with the Disk-Criminator. The PSSD measured the threshold of pressure necessary for the patient to discriminate 2 points. Two-sided paired t tests compared the pre- and postoperative pressure values on each of the 3 hand locations. The numerical differences in pre- and postoperative pressures were then compared between each of the 3 locations to determine whether or not there was a difference in postoperative sensation based on hand region. The PSSD pressure values were standardized based on the prong distance determined by the Disk-Criminator, and percent change in standardized PSSD score differences for each cutaneous region was calculated. All tests were considered significant at P < 0.05. RESULTS: There were no significant differences between pre- and postoperative PSSD pressures for all cutaneous regions tested (P > 0.05). However, on average, patients required 8.04% more pressure applied in the dorsal first webspace in order to discriminate 2 points, 8.43% more in the first phalanx of the index finger, and 16.7% more in the first phalanx of the pollex postphalloplasty (all n.s.). Furthermore, when comparing each of the three cutaneous regions to each other, there was no difference in the change in pressures between each region (P > 0.05). In other words, each of the three regions of the hand was similarly impacted by the operation. CONCLUSIONS: The results of this study suggest that while past literature reports cases of numbness and/or tingling post-RFFF phalloplasty,1 immediate postoperative sensation is not significantly different than preoperative sensation. The fear of donor arm neuropathy is a potential barrier for patients seeking this life-changing procedure, yet this study quantifies the degree of neuronal damage and may encourage patients to undergo the procedure. These results will help guide patient-physician conversations regarding RFFF phalloplasty in order to create realistic patient expectations for postoperative outcomes. REFERENCE: 1. Kovar A, Choi S, Iorio ML. Donor site morbidity in phalloplasty reconstructions: outcomes of the radial forearm free flap. Plast Reconstr Surg Glob Open. 2019;7:e2442.

Nerve capping treatment using a bioabsorbable nerve conduit with open or closed end for rat sciatic neuroma

With increasing survival rates following oncologic mastectomies, loss of breast sensation can negatively impact a patient's quality of life. PubMed, Embase, and Web of Science were searched in April 2025 for studies reporting sensory outcomes after neurotized breast reconstruction. Eligible studies included patients undergoing autologous or implant-based reconstruction with any neurotization technique. Forty studies were included, and outcomes involved objective sensory testing (e.g., Semmes-Weinstein monofilaments, pressure-specified sensory devices, and thermal thresholds) and patient-reported quality of life (e.g., BREAST-Q). Neurotization consistently accelerated and improved recovery of tactile, thermal, and protective sensation compared with non-neurotized controls, particularly in DIEP and TRAM flaps. Direct coaptation was most frequently employed, while nerve allografts, conduits, and autologous grafts offered effective alternatives when direct repair was not feasible. Implant-based reconstructions using allografts also demonstrated significant improvements in the nipple-areola complex and breast skin sensation. Across studies, earlier and more uniform sensory return was reported, with improved sensation often associated with high patient satisfaction and quality of life. The preponderance of observational evidence suggests that nerve coaptation, whether by direct suture, conduit, allograft, or autograft, represents a promising adjunct to breast reconstruction in both autologous and implant-based reconstruction. However, many studies were retrospective in design, had small sample sizes, and lacked randomization.

Ultrasound enables the accurate assessment of traumatic disorders of small peripheral nerves of extremities. Human nerve allografts and nerve conduits are increasingly used for the surgical treatment of nerve trauma but ultrasound reports on this field are scarce in the radiological literature. We present the macroscopic and in vitro ultrasound appearance of human allografts, and synthetic and biological conduits. In addition, we describe the ultrasound findings in some patients operated upon using the same devices. The in vitro ultrasound appearance correlated well with the macroscopic appearance of the devices. Awareness of their appearance in vitro can help sonologists when examining postsurgical patients.

Neurotization in breast reconstruction can be performed with the aid of nerve grafts and conduits to decrease the tedious dissection and overcome size mismatch. However, there has yet to be a formal analysis of this approach. The goal of this study was to evaluate sensory recovery after neurotized abdominally based free flaps for breast reconstruction using the authors' novel technique and analyze factors that could affect sensory recovery. A novel technique using processed nerve allograft in combination with a nerve conduit was used. Dynamic and static sensation recovery tests were performed in patients who underwent neurotized or nonneurotized abdominally based free flap reconstructions. Demographics, surgical details, and complications were analyzed. Statistical analyses were performed using chi-square and Mann-Whitney tests. Fifty patients (78 breasts) were analyzed: 60 breasts with neurotized reconstruction and 18 breasts without. For patients with more than 12 months of follow-up, the neurotized cohort demonstrated improved dynamic tests compared to the nonneurotized cohort (38 ± 21.69 versus 56.17 ± 20.8, respectively; P = 0.014). Factors associated with decreased sensory return in patients who underwent neurotized reconstruction were diabetes, higher body mass index, skin-sparing mastectomy, higher American Society of Anesthesiologists class, history of radiation therapy, or history of hormonal therapy. This is the first study to report on outcomes of neurotized autologous breast reconstruction using a nerve graft and conduit technique. The authors' approach resulted in improved sensory outcomes compared to those in patients who did not undergo sensory reconstruction. Importantly, factors that can interfere with sensory recovery were identified. Therapeutic, III.

Is Surgical Repair With Nerve Allograft More Cost-Effective Than Non-Surgical Management for Persistent Trigeminal Neuropathy? Initial Assessment With Markov Model

Entrapment of the lateral femoral cutaneous nerve has been difficult to document. The variability of the anatomic location of this nerve makes it difficult to measure with traditional electrodiagnostic studies. At the same time, anatomic variability increases the likelihood for this nerve to become entrapped within the inguinal ligament. The current study reports the ability to document the presence of this nerve entrapment in 24 patients, compared with 10 asymptomatic control subjects, by using nonpainful and noninvasive computer-assisted neurosensory testing with the Pressure-Specified Sensory Device.