Nerve Coaptation Research Articles

Robotic microsurgery for pediatric peripheral nerve surgery

The technology of microsurgical robotic systems has shown potential benefit during the last decade for a variety of microsurgical procedures, such as vascular anastomoses, lymphatic anastomoses or nerve coaptation. At the same time, peripheral nerve surgery has produced ever more sophisticated nerve transfers in which the smallest nerve structures are connected to each other. Following obstetric brachial plexus injuries, nerve reconstruction surgery is often required in the first few years of life in order to improve the function of the affected arm, including nerve transfers to denervated muscles, which enable reinnervation of target muscles. In pediatric patients, these donor-nerve structures are even smaller than in adults, which further increases the demands to the microsurgeon. In this publication, we show the possible applications, capabilities and limitations of a dedicated microsurgical robotic system for nerve transfers in pediatric patients.

Anatomical mapping of the 4th intercostal nerve's lateral cutaneous branch in both sexes: implications for advanced breast Reconstruction.

This study aims to map the point of emergence of the lateral cutaneous branch of the fourth intercostal nerve in both sexes, addressing gaps in the current literature. The findings are intended to support surgeons in restoring breast function by providing precise anatomical data, regardless of the specific surgical technique employed. An anatomical study was conducted using 50 sides from 25 formalin-preserved full-body donors, with equal representation of male and female subjects. Measurements were taken to determine the fascial point of emergence of the lateral cutaneous branch of the fourth intercostal nerve relative to the anterior axillary line and the transverse line. Multiple linear regression models were applied to evaluate the influence of variables such as sex, height, and side. Our findings indicate that the fascial point of emergence of the lateral cutaneous branch of the fourth intercostal nerve is consistently located within 20 to 24mm relative to the transverse line in 37 (74%) cases, and within 4 to 10mm relative to the anterior axillary line in 39 (78%) cases, regardless of sex, height, or side. The multiple linear regression analysis showed no significant correlation between these variables and the position of the point of emergence (p > 0.05). These results provide surgeons with a practical tool for nerve coaptation during breast reconstruction, showing that sex and height do not affect the anatomical localization of the point of emergence. Precise knowledge of this point can improve surgical accuracy and enhance sensory recovery, leading to better patient outcomes.

Technical Strategies and Learning Curve in Robotic-assisted Peripheral Nerve Surgery.

Robotic-assisted peripheral nerve surgery (RASPN) has emerged as a promising advancement in microsurgery, offering enhanced precision and tremor reduction for nerve coaptations. This study investigated the largest published patient collective in RASPN and provided specific technical aspects, operative setups, and a learning curve. Data collection involved creating a prospective database that recorded surgical details such as surgery type, duration, nerve coaptation time, and number of stitches. The experienced surgeon first underwent a 12-hour training program utilizing the Symani robot system in combination with optical magnification tools before using the system clinically. The study included 19 patients who underwent robot-assisted peripheral nerve reconstruction. The cohort included six men (31.6%) and 13 women (68.4%), with an average age of 53.8 ± 18.4 years. The procedures included nerve transfers, targeted muscle reinnervation, neurotized free flaps, and autologous nerve grafts. Learning curve analysis revealed no significant reduction in time per stitch over the initial nine coaptations (4.9 ± 0.5 min) compared with the last 10 coaptations (5.5 ± 1.5 min). The learning curve for RASPN was compared with early experiences with other surgical robots, emphasizing the importance of surgical proficiency and assistant training. Obstacles such as instrument grip strength and blood clot formation were highlighted, and suggestions for future advancements were proposed. RASPN presents an exciting opportunity to enhance precision; however, ongoing research and optimization are necessary to fully harness its benefits.

Course Review: National Microsurgery Course at the Newcastle Surgical Training Centre March 2024.

Microsurgery is a unique and specific surgical skill, known to have a steep learning curve. Surgical trainees may wish to undertake a microsurgical skills course to learn the rudiments of microsurgery and to direct future practice and skill acquisition. The National Microsurgery Course in Newcastle, United Kingdom, aims to equip early-year surgical trainees with basic microsurgical skills including tissue handling, vessel anastomosis, and nerve coaptation. The course in 2024 gave delegates an excellent opportunity to learn and practice these skills in a well-resourced environment with a high delegate-to-faculty ratio. Overall, the course was an extremely high-quality educational experience with most of the course time allocated to practicing surgical skills. This course is recommended to surgical trainees wishing to learn the basics of microsurgery.

Combined Whole Eye and Face Transplant: Microsurgical Strategy and 1-Year Clinical Course.

Catastrophic facial injury with globe loss remains a formidable clinical problem with no previous reports of reconstruction by whole eye or combined whole eye and facial transplant. To develop a microsurgical strategy for combined whole eye and facial transplant and describe the clinical findings during the first year following transplant. A 46-year-old man who sustained a high-voltage electrical injury with catastrophic tissue loss to his face and left globe underwent combined whole eye and face transplant using personalized surgical devices and a novel microsurgical strategy at a specialized center for vascularized composite allotransplantation. Reperfusion and viability of the whole eye and facial allografts, retinal function, and incidence of acute rejection. The patient underwent a combined whole eye and face transplant from an immunologically compatible donor with primary optic nerve coaptation and conventional postoperative immunosuppression. Globe and retinal perfusion were maintained throughout the immediate postoperative period, evidenced by fluorescein angiography. Optical coherence tomography demonstrated atrophy of inner retinal layers and attenuation and disruption of the ellipsoid zone. Serial electroretinography confirmed retinal responses to light in the transplanted eye. Using structural and functional magnetic resonance imaging, the integrity of the transplanted visual pathways and potential occipital cortical response to light stimulation of the transplanted eye was demonstrated. At 1 year post transplant (postoperative day 366), there was no perception of light in the transplanted eye. This is the first report of whole eye transplant combined with facial transplant, demonstrating allograft survival including rejection-free graft survival and electroretinographic measurements indicating retinal response to light stimuli. These data highlight the potential for clinical allotransplantation for globe loss.

Learning Curve for Performing Targeted Nipple Areola Complex Reinnervation (TNR) for Gender Mastectomy- Moving from Nerve Graft Reconstruction to Direct Nerve Coaptation

Learning Curve for Performing Targeted Nipple Areola Complex Reinnervation (TNR) for Gender Mastectomy- Moving from Nerve Graft Reconstruction to Direct Nerve Coaptation

Robotic-Assisted Obturator Nerve Repair: A Technical Report.

Untreated obturator nerve injury may result in weakness in thigh adduction, decreased medial thigh sensation, and groin pain. A neurosurgeon may be consulted intraoperatively for repair. Although there are reports of obturator nerve injury and repair in the gynecologic surgery literature, there are few reports detailing the specific steps of nerve repair after partial transection and the underlying principles of nerve coaptation, especially in the robotic-assisted setting. A partial transection of the right obturator nerve was noted in a patient undergoing total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection using the da Vinci robot. Sutures were placed in the epineurium of the cut nerves to realign the fascicles. A porcine wrap was placed around the coaptation site and covered with fibrin glue. The right lower extremity was passively ranged to ensure no tension was present across the repair site. The patient had loss of right leg adduction after surgery, but she recovered full motor function 5 months after surgery with no numbness or pain. The current report describes a repair strategy for partial-thickness obturator nerve injury in the setting of a laparoscopic surgery. Working in a multidisciplinary fashion, the tenets of nerve repair may be applied to robotic-assisted cases of obturator nerve injury, resulting in neurologic recovery.

MRI and Ultrasound Visualization of a Nerve Repair Implant Containing Nitinol.

Nerve Tape is a novel nerve repair device containing nitinol microhooks that provide sutureless attachment for nerve coaptation. This study evaluated visualization of Nerve Tape on magnetic resonance imaging (MRI) and ultrasound, with the objective of exploring its potential as an imaging marker for localizing nerve repair sites. Phantom imaging experiments were first conducted to assess the visibility of Nerve Tape on MRI and ultrasound. A cadaveric limb investigation was then performed to further characterize the magnetic susceptibility patterns of Nerve Tape and to confirm its localization at the repair site. Phantom imaging experiments demonstrated clear visualization of Nerve Tape on both MRI and ultrasound, with Nerve Tape microhooks appearing as signal voids on MRI and hyperechoic foci on ultrasound. Subsequent cadaveric limb investigation further characterized Nerve Tape's magnetic susceptibility patterns and confirmed localization of the device at the repair site. The physical dimensions of Nerve Tape and locations observed on both MRI and ultrasound matched design and measurements made during surgery. Measurement discrepancies could be attributed to magnetic susceptibility artifacts in MRI, and to comet tail and shadowing effects in ultrasound. Repairs performed with Nerve Tape can be reliably localized for imaging, potentially facilitating assessment of repair site integrity and further advancement toward image-based monitoring of nerve regeneration. Further research, including in vivo human studies, is warranted to confirm these preliminary findings.

Targeted Muscle Reinnervation for a Symptomatic Neuroma in a Traumatic Transmetatarsal Amputee: A Case Report.

An overall healthy 48-year-old man suffered a left foot mangled crush injury resulting in a post-transmetatarsal amputation and subsequently developing a painful neuroma on the plantar surface of the foot. To avoid the zone of injury, targeted muscle reinnervation was used to treat the neuroma by coapting the tibial nerve to the motor point of the flexor hallucis longus (FHL) muscle. At 1-year follow-up, the patient reported no pain at rest, returned to work, and could ambulate with an orthosis for 30 minutes. Rare tibial nerve coaptations to the FHL could serve as a treatment option for patients with neuromas in traumatic postmetatarsal amputation.

A Scoping Review of Innervated Breast Reconstruction.

After breast surgery, patients experience significant alterations to breast sensation, which can diminish quality of life. Nerve coaptation technique, introduced in the 1990s, has gained traction in recent years. We performed a scoping review of the literature to determine the available outcomes in sensate breast reconstruction. The review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews statement guidelines. EMBASE and PubMed databases were queried using standardized terminology. Studies were included if they reported original sensory outcomes following innervation techniques during breast reconstruction and were published from January 1, 1990, to April 18, 2022. Data extraction and analyses were performed on Microsoft Excel. From 602 screened articles, 27 studies met the inclusion criteria. Innervated autologous reconstructive procedures were described in 24, whereas the remaining 3 (all published after 2019) described direct reinnervation of the nipple-areola complex. Most (88.9%) of the studies comparing innervated versus noninnervated reconstruction reported improved sensory outcomes in at least 1 modality. Two studies investigated patient-reported outcomes using validated questionnaires, both of which reported improvement with innervated reconstruction. Sensate breast reconstruction has the potential to improve outcomes for patients. There is a recent progressive increase in studies involving direct nipple-areolar reinnervation. Larger, prospective studies are needed to better characterize the quality-of-life outcome using validated scales, as well as evaluate sensory and patient-reported outcomes with implant and autologous reconstruction.

455 Distal Nerve Transfers in Treatment of Peripheral Nerve Lesions

INTRODUCTION: Distal nerve transfers can be used in treating patients with irreparable high nerve lesions, aiming to regain hand function. The indications for these transfers include upper (C5-C6) and lower (C8-T1) brachial plexus palsy, isolated proximal extensive radial, median, or ulnar nerve lesion, or isolated axillary or musculocutaneous nerve lesion. METHODS: The selected cases (n = 5) included lower brachial plexus injury (n = 2), and isolated radial (n = 1), ulnar (n = 1), and median (n = 1) nerve injuries. The MRC grading was used to examine postoperative muscle strength. The DASH and PNSQoL questionnaires were used to assess the postoperative quality of life. RESULTS: The useful functional recovery (MRC = 4-5) was achieved in all presented cases. The DASH and PNSQoL scores indicated a satisfying quality of life in terms of the absence of postoperative disability. CONCLUSIONS: Distal nerve transfers are a valuable technique for treatment of the patients with irreparable proximal nerve lesions. This technique reduces the path necessary for the regenerative nerve fibers to pass, provides direct nerve coaptation without additional suture line, and facilitates faster and better recovery, with the final outcome as an increase in the patients’ quality of life.

Management of Superficial and Deep Peroneal Nerve Neuromas with Targeted Muscle Reinnervation in Nonamputees: Operative Technique and Early Outcomes.

Targeted muscle reinnervation (TMR), a surgical technique developed by the senior authors that coapts proximal ends of nerves to distal motor nerves of adjacent muscles, has demonstrated efficacy in the treatment and prevention of neuroma pain. The objective of this study is to describe the surgical technique for TMR of the superficial peroneal nerve (SPN) and deep peroneal nerve (DPN) in nonamputee patients and provide data on postoperative functional outcomes. A single-institution retrospective chart review was performed between March 2018 and April 2021. Patients were de-identified and included if they were nonamputees receiving TMR for pain in the peroneal nerve distribution. Data extracted included demographic information, symptoms before operation, relevant nerve coaptation, peri-, and postoperative complications, and long-term functional outcomes. Of the 19 patients reviewed, 11 patients underwent TMR of the SPN alone: eight had complete resolution of their symptoms; two indicated partial improvement in pain; and one patient had no improvement. Four patients underwent TMR of the DPN alone: two patients had complete resolution of their pain, and two patients had partial improvement with pain. Four patients underwent TMR of both the SPN/DPN: two patients had complete resolution of their symptoms, and two patients were noted to have significant improvement but had persistent pain from prior foot operations. Average follow-up time was 260 days. TMR is a successful technique in the management of SPN and DPN neuroma pain. Our technique revealed excellent clinical outcomes, no procedure-specific complications, and improved subjective pain reports.

Revealing digital nerve lesions–A comprehensive analysis of 2084 cases of a specialized center

BackgroundFinger nerve injuries have a significant impact on hand function and can result in reduced sensation, pain and impaired coordination. The socioeconomic implications of these injuries include decreased workplace productivity, reduced earning potential, and financial burdens associated with long-term medical treatment and rehabilitation. However, there is a lack of comprehensive literature regarding the incidence, mechanisms, and associated injuries of finger nerve lesions. MethodsA retrospective analysis was conducted on patients treated at our institution from January 2012 to July 2020. Cases of peripheral finger nerve lesions were identified using the digital hospital information system and ICD-10 Classification. Exclusion criteria included injuries to the median nerve at the carpal tunnel level or superficial branch of the radial nerve. Data were collected using a pseudonymized approach, and statistical analyses were performed using SPSS Statistics (Version 27). ResultsA total of 2089 finger nerve lesions were analyzed, with a majority of cases occurring in men. Most injuries97.4 % were caused by trauma, predominantly cut/tear injuries. Isolated finger nerve injuries were more common than multiple nerve injuries, with the index finger being the most frequently affected. Concomitant tendon and vascular injuries were observed in a significant proportion51.7 % of cases. Surgical management included direct nerve coaptation, interposition grafting and neurolysis. DiscussionFinger nerve injuries are the most prevalent type of nerve injury, often resulting from small lacerations. These injuries have substantial societal costs and can lead to prolonged sick leave. Understanding the epidemiology and etiology of finger nerve injuries is crucial for implementing effective preventive measures. Accompanying tendon injuries and the anatomical location of the nerve lesions can impact sensory recovery and treatment outcomes. Proper management of peripheral finger nerve lesions is essential for optimizing functional outcomes and minimizing the impact on daily activities. Treatment options should be tailored to the severity and underlying cause of the nerve injury.

Bionic Surgery Meets Bionic Reconstruction - First In-human use of Robotic Microsurgery in Targeted Muscle Reinnervation

Robotic microsurgery is an emerging field in reconstructive surgery, which provides benefits such as improved precision, optimal ergonomics, and reduced tremors. However, only a few robotic platforms are available for performing microsurgical procedures, and successful nerve coaptation is still a challenge. Targeted muscle reinnervation (TMR) is an innovative reconstructive procedure that rewires multiple nerves to remnant stump muscles, thereby reducing neuroma and phantom limb pain and improving the control of bionic prostheses. The precision of surgical techniques is critical in reducing axonal sprouting around the coaptation site to minimise the potential for neuroma formation. This study reports the first use of a microsurgical robotic platform for multiple nerve transfers in a patient undergoing TMR for bionic extremity reconstruction. The Symani robotic platform, combined with external microscope magnification, was successfully used, and precise handling of nerve tissue and coaptation was easily feasible even in anatomically challenging environments. While the precision and stability offered by robotic assistance may be especially useful for nerve surgery, the high economic costs of robotic microsurgery remain a major challenge for current healthcare systems. In conclusion, this study demonstrated the feasibility of using a robotic microsurgical platform for nerve surgery and transfers, where precise handling of tissue is crucial and limited space is available. Future studies will explore the full potential of robotic microsurgery in the future.

Robot-assisted Microsurgery: Lessons Learned from 50 Consecutive Cases.

The potential of robot-assisted surgery in plastic and reconstructive surgery remains to be established, especially in free tissue transfer. This prospective study aimed to present our experience and findings from the first 50 consecutive cases of robot-assisted microsurgery using the Symani surgical system. A prospective database was maintained, recording patient demographics and surgical details for all cases of robot-assisted microsurgery in a large academic institution. All surgeons underwent an intensive training program with the Symani surgical system. A total of 50 patients who underwent robot-assisted microsurgical reconstruction were identified. Free microsurgical tissue transfer was performed in 45 cases, targeted muscle reinnervation in four cases, and lymphovenous anastomoses in a single case. A total of 94 robot-assisted anastomoses and coaptations were performed, (46 venous and 30 arterial anastomoses, 16 nerve coaptations, two lymphovenous anastomoses). Six cases involved perforator-to-perforator anastomoses. Ninety-eight percent of attempted anastomoses were completed using the robot. Size-mismatch anastomoses, seen in 37.8% of cases, took significantly longer. Minor complications occurred in three cases and major in six cases. There were three cases of microvascular compromise requiring revision. One partial flap loss and no complete flap loss occurred. Our study highlights the immense potential of robot-assisted microsurgery, and a feasible and effective modality for various microsurgical procedures, with outcomes comparable to those of conventional microsurgery. Despite challenges, such as increased operating times and higher costs, the technology offers significant advantages, such as enhanced precision and motion scaling. We identify a slow learning curve and a necessity for higher caseloads.

The efficacy of sensory nerve coaptation in DIEP flap breast reconstruction – Preliminary results of a double-blind randomized controlled trial

BackgroundSensory nerve coaptation has great potential to restore sensation after autologous breast reconstruction. However, blinded and randomized studies are lacking. We therefore present the preliminary results of our ongoing double-blinded randomized controlled trial that compares sensory recovery of innervated versus non-innervated DIEP flaps. MethodsPatients who underwent DIEP flap breast reconstruction between July 2019 and February 2022 were included and randomized. The anterior cutaneous branch of the second or third intercostal nerve was coapted. Pre- and postoperative sensory testing was performed with Semmes-Weinstein Monofilaments, Pressure Specified Sensory Device, and a thermostimulator, for tactile and temperature thresholds. ResultsThis interim analysis comprised 41 patients contributing 29 innervated and 38 non-innervated breasts. At 24 months of follow-up, the mean monofilament value of the flap skin was lower in innervated than in non-innervated flaps (4.48 vs. 5.20, p = 0.003). Touch thresholds were lower the center of the innervated flaps (47.8 vs. 71.2 g/mm2, p = 0.036), and heat pain was more often imperceptible in non-innervated flaps (42.1% vs. 10.3%, p = 0.004). No adverse events were associated with sensory nerve coaptation. ConclusionsThese preliminary results indicate superior sensibility and recovery of protective sensation in innervated compared with non-innervated DIEP flaps. Although the results of the completed trial must be awaited to establish the full clinical impact, including highly anticipated quality of life outcomes, we encourage continuation of scientific and clinical efforts in this promising technique.

Usability of Nerve Tape: A Novel Sutureless Nerve Coaptation Device

Microsuture neurorrhaphy is technically challenging and has inherent drawbacks. This study evaluated the potential of a novel, sutureless nerve coaptation device to improve efficiency and precision. Twelve surgeons participated in this study-six attending hand/microsurgeons and six trainees (orthopedic and plastic surgery residents or hand surgery fellows). Twenty-four cadaver arm specimens were used, and nerve repairs were performed at six sites in each specimen-the median and ulnar nerves in the proximal forearm, the median and ulnar nerves in the distal forearm, and the common digital nerves to the second and third web spaces. Each study participant performed nerve repairs at all six injury locations in two different cadaver arms (n= 12 total repairs for each participating surgeon). The nerve repairs were timed, tested for tensile strength, and graded for alignment and technical repair quality. A substantial reduction in time was required to perform repairs with the novel coaptation device (1.6 ± 0.8 minutes) compared with microsuture (7.2 ± 3.6 minutes). Device repairs were judged clinically acceptable (scoring "Excellent" or "Good" by most of the expert panel) in 97% of the repairs; the percentage of suture repairs receiving Excellent/Good scores by most of the expert panel was 69.4% for attending surgeons and 36.1% for trainees. The device repairs exhibited a higher average peak tensile force (7.0 ± 3.6 N) compared with suture repairs (2.6 ± 1.6 N). Nerve repairs performed with a novel repair device were performed faster and with higher technical precision than those performed using microsutures. Device repairs had substantially greater tensile strength than microsuture repairs. The evaluated novel nerve repair device may improve surgical efficiency and nerve repair quality.

A Relative Value Unit–Based Model for Targeted Nipple–Areola Complex Neurotization in Gender-Affirming Mastectomy

Background: For transmasculine individuals, double-incision mastectomy with free nipple grafts is the most common procedure for gender-affirming chest masculinization. However, patients report decreased sensation postoperatively. Direct coaptation of intercostal nerves to the nipple–areolar complex (NAC) is an experimental technique that may preserve postoperative sensation, yet whether reimbursements and billing codes incentivize hospital systems and surgeons to offer this procedure lacks clarity. Methods: A retrospective cross-sectional analysis of fiscal year 2023 Medicare physician fee schedule values was performed for neurotization procedures employing Current Procedural Terminology codes specified by prior studies for neurotization of the NAC. Additionally, operative times for gender-affirming mastectomy at a single center were examined to compare efficiency between procedures with and without neurotization included. Results: A total of 29 encounters were included in the study, with 11 (37.9%) receiving neurotization. The mean operating time was 100.3 minutes (95% CI, 89.2–111.5) without neurotization and 154.2 minutes (95% CI, 139.9–168.4) with neurotization. In 2023, the average work relative value units (wRVUs) for neurotization procedures was 13.38. Efficiency for gender-affirming mastectomy was 0.23 wRVUs per minute without neurotization and 0.24 wRVUs per minute with neurotization, yielding a difference of 0.01 wRVUs per minute. Conclusions: Neurotization of the NAC during double-incision mastectomy with free nipple grafts is an experimental technique that may improve patient sensation after surgery. Current reimbursement policy appropriately values the additional operative time associated with neurotization relative to gender-affirming mastectomy alone.

Distal nerve transfers for peripheral nerve injuries: indications and outcomes.

Distal nerve transfer is a refined surgical technique involving the redirection of healthy sacrificable nerves from one part of the body to reinstate function in another area afflicted by paralysis or injury. This approach is particularly valuable when the original nerves are extensively damaged and standard repair methods, such as direct suturing or grafting, may be insufficient. As the nerve coaptation is close to the recipient muscles or skin, distal nerve transfers reduce the time to reinnervation. The harvesting of nerves for transfer should usually result in minimal or no donor morbidity, as any anticipated loss of function is compensated for by adjacent muscles or overlapping cutaneous territory. Recent years have witnessed notable progress in nerve transfer procedures, markedly enhancing the outcomes of upper limb reconstruction for conditions encompassing peripheral nerve, brachial plexus and spinal cord injuries.

The surgical management of frontal branch of the facial nerve injuries

Aim: The frontal branch of the facial nerve is particularly vulnerable to traumatic injury or during surgery. While the larger branches of the facial nerve, such as the buccal branch, are more easily identifiable and amenable to repair, the repair of the frontal branch is not common due to its complex branching pattern and smaller size. The description of the surgical approach to repair the frontal branch of the facial nerve is limited in the literature. In this study, we aim to explore the outcomes of patients who underwent frontal branch facial nerve repair in our centre. Method: In a retrospective case review at a single, tertiary Plastic Surgery centre, we performed frontal branch repair for eight patients (n = 8) who sustained complete or partial division of the frontal branch of the facial nerves. These patients were followed up postoperatively and assessed with the Sunnybrook Facial Grading System. Results: Using super microsurgical techniques, primary nerve coaptations, fascicular nerve flaps, and direct neurotisations were performed. All eight patients (100%) demonstrated improvements in terms of resting brow symmetry. There was a significant improvement in brow and frontalis function following surgical repair of the frontal branch, with 87.5% (seven patients) demonstrating improvement in forehead movement. Conclusion: In this case series, we demonstrated that the repair of the frontal branch of the facial nerve is relevant, with reasonably good functional outcomes. Repair of the frontal branch of the facial nerve should ideally be done as early as possible following the injury. Nevertheless, delayed repair may still be beneficial within 18 months after the injury.