Nerve Suture Research Articles

Termino-lateral nerve suture in lesions of the digital nerves: clinical experience and literature review

Documented experience of treatment of digital nerve lesions with the termino-lateral (end-to-side) nerve suture is limited. Our clinical experience of this technique is detailed here alongside a systematic review of the previous literature. We performed, from 2002 to 2008, seven termino-lateral sutures with epineural window opening for digital nerve lesions. Functional outcome was analysed using the two-point discrimination test and the Semmes-Weinstein monofilament test. The results showed a sensory recovery of S3+ in six cases and S3 in one case. The mean distance found in the two-point discrimination test was 12.7 mm (range 8-18 mm). After a review of the literature, we were able to obtain homogeneous data from 17 additional patients operated by termino-lateral coaptation. The overall number of cases included in our review was 24. A sensory recovery was observed in 23 out of 24 patients. The functional results were S0 in one case, S3 in one case, S3+ in twenty cases and S4 in two cases. Excluding the one unfavourable case, the mean distance in the two-point discrimination test was 9.7 mm (range 3-18 mm). It can thus be concluded that the treatment of digital nerve lesions with termino-lateral suture showed encouraging results. Based on the results obtained in this current study we believe that in case of loss of substance, end-to-side nerve coaptation may be an alternative to biological and synthetic tubulisation when a digital nerve reconstruction by means of nerve autograft is declined by the patient.

End-to-side nerve suture in traumatic injuries of brachial plexus: review of the literature and personal case series

We used end-to-side nerve coaptation combined with standard end-to-end neurotisations to treat 11 patients who presented with complete (six cases) or incomplete (five cases) traumatic brachial plexus injuries. All patients were available for functional evaluation at a minimum of 2 years postoperatively. In three patients with shoulder abduction recovery, electromyographical studies (EMG) showed a contribution from the end-to-side neurotisation. In the remaining cases end-to-side neurotisations were unsuccessful. Our study did not demonstrate a reliable role for end-to-side nerve suture in brachial plexus surgery. We believe that at present end-to-side suture must not be a substitute for standard reconstructive techniques in brachial plexus surgery. Occasionally termino-lateral nerve sutures may represent a support to standard reconstructive procedures especially in case of severe injuries when few undamaged donor nerves are available.

Electrical stimulation combined with exercise increase axonal regeneration after peripheral nerve injury

Although injured peripheral axons are able to regenerate, functional recovery is usually poor after nerve transection. In this study we aim to elucidate the role of neuronal activity, induced by nerve electrical stimulation and by exercise, in promoting axonal regeneration and modulating plasticity in the spinal cord after nerve injury. Four groups of adult rats were subjected to sciatic nerve transection and suture repair. Two groups received electrical stimulation (3 V, 0.1 ms at 20 Hz) for 1 h, immediately after injury (ESa) or during 4 weeks (1 h daily; ESc). A third group (ES+TR) received 1 h electrical stimulation and was submitted to treadmill running during 4 weeks (5 m/min, 2 h daily). A fourth group performed only exercise (TR), whereas an untreated group served as control (C). Nerve conduction, H reflex and algesimetry tests were performed at 1, 3, 5, 7 and 9 weeks after surgery, to assess muscle reinnervation and changes in excitability of spinal cord circuitry. Histological analysis was made at the end of the follow-up. Groups that received acute ES and/or were forced to exercise in the treadmill showed higher levels of muscle reinnervation and increased numbers of regenerated myelinated axons when compared to control animals or animals that received chronic ES. Combining ESa with treadmill training significantly improved muscle reinnervation during the initial phase. The facilitation of the monosynaptic H reflex in the injured limb was reduced in all treated groups, suggesting that the maintenance of activity helps to prevent the development of hyperreflexia.

Restoration of Active Fingers Flexion With Tensor Fascia Lata Transfer in Total Brachial Plexus Palsy

In total brachial plexus palsy, fingers flexion restoration is a real challenge. Nerve surgery can generally restore shoulder abduction and elbow flexion. However, results of nerve grafts or nerve transfers are generally poor for hand function. As a matter of fact, the long distance between nerve sutures and terminal nerve branches in muscles decreases the rate of reinnervation. When finger flexion occurs, strength is generally weak and function remains fair. Therefore, we proposed a new technique to restore fingers flexion. The tensor fascia lata tendon is harvested and sutured between the biceps and flexor digitorum profundus (FDP) tendons. When elbow is flexed, the biceps muscle contraction pulls FDP tendons resulting in a partial but strong hand occlusion. This technique is an alternative to free muscle transfers or nerve surgery with reliable results.

Inhibition of nitric oxide synthase promotes facial axonal regeneration following neurorrhaphy

Reconnection of interrupted peripheral nerve by microsurgical suture is a common clinical practice. However, the extent to which peripheral neurorrhaphy improves nerve regeneration and functional recovery remains unsatisfactory. Here, we used anatomical and electrophysiological techniques to investigate the temporal correlation between the expressions of oxidative stress-related biomarkers such as neuronal nitric oxide synthase (nNOS) and the facial axonal regeneration after an immediate facial nerve repair in adult rats since peripheral nerve lesion is well known to induce a dramatic increase of NOS expression in the affected neuronal cell bodies. We found that compared to nerve cut without suture, facial nerve repair not only caused the facial axonal regeneration but also consistently prevented the fluctuations of expressions of oxidative stress-related biomarkers in 10 weeks postlesion. To further elucidate the role of nitric oxide (NO) in the axonal degeneration/regeneration, four different NOS inhibitors were applied to additional rats after facial nerve cut or repair. Both of facial nerve cut + NOS inhibition and facial nerve repair + NOS inhibition were seen to prevent the alterations of expressions of the biomarkers, no matter which NOS inhibitor was used. Moreover, we found that facial nerve repair + NOS inhibition promoted earlier and better axonal regeneration than facial nerve repair, demonstrated by labeling of neuromuscular junctions, retrograde tracing, and electromyography. These results provide direct evidence that peripheral nerve suture and/or treatment of NOS inhibitors can maintain the homeostasis of oxidative stress-related biomarkers, especially nNOS in neuronal cell bodies. These actions may thus facilitate the axonal regeneration.

Analysis of patients with bone injury in Wenchuan earthquake

To evaluate the patients with bone injury in Wenchuan earthquake. From May 12th to June 15th 2008 the data of 1410 patients with bone injury in Wenchuan earthquake were analyzed to evaluate clinical intervention and remedy-managing experience. The 1410 patients average age was from 4 to 103 years old. And 744 cases (52.7%) suffered from blunt injuries, 379 cases (26.9%) from buried injuries, 287 cases (20.4%) from falling injuries; And 1317 cases were with fracture, 93 with limbs soft tissue injuries; 261 patients combined with other parts of injuries including 45 cases with paralysis; 66 cases were with crush syndrome, 25 with gas gangrene, 76 with acute kidney failure, 26 with multiple organ failure. And 912 operations were performed including 402 fracture fixation, 224 debridement, 152 debridement and suture, 85 amputation, 29 implant skin, 8 fixation of joint dislocation, 5 surgical flaps transplantation, 4 nerve and tendon suture, 2 arthroscopes, 1 joint replacement. Among the 66 crush syndrome patients, 49 accepted continuous renal replacement therapy, in which 9 cases were bleeding from named arteries and 20 blood vessels were getting embolism. Among the 1410 cases, 1 died from multiple organ failure. Among the patients with bone injury in Wenchuan earthquake, the elderly patients are more than the youth; The injuries are always combined with other complications; Opened injuries are polluted severely; It is difficult to deal with the crush syndrome; Paraplegia cases are less, but the amputees are more.

Clinical evaluation of a resorbable wrap-around implant as an alternative to nerve repair: A prospective, assessor-blinded, randomised clinical study of sensory, motor and functional recovery after peripheral nerve repair

Peripheral nerve injures are common and often result in impaired functional recovery. The majority of injuries involve the arm and/or the hand. The traditional treatment for peripheral nerve injuries is repair by using microsurgical techniques, either by primary nerve suture or nerve graft, but research to find more successful methods that could improve recovery is ongoing. Tubulisation has been investigated by several authors and is suggested as an alternative to microsurgical techniques. The resorbable poly[(R)-3-hydroxybutyrate] (PHB) is one of the materials that has been previously tested experimentally. In this prospective, randomised, assessor-blinded clinical study, PHB was investigated as an alternative to epineural suturing in the treatment of peripheral nerve injuries at the wrist/forearm level of the arm. Twelve patients, with a complete, common, sharp injury of the median and/or ulnar nerve at the wrist/forearm level, were treated by either using PHB or microsurgical epineural end-to-end suturing. All patients were assessed using a battery of tests, including evaluation of functional, sensory and motor recovery by means of clinical, neurophysiological, morphological and physiological evaluations at 2 weeks and 3, 6, 9, 12 and 18 months after surgery. No adverse events or complications considered as product related were reported, and thus PHB can be regarded as a safe alternative for microsurgical epineural suturing. The majority of the methods in the test battery showed no significant differences between the treatment groups, but one should consider that the study involved a limited number of patients and a high variability was reported for the evaluating techniques. However, sensory recovery, according to the British Medical Research Council score and parts of the manual muscle test, suggested that treating with PHB may be advantageous as compared to epineural suturing. This, however, should be confirmed by large-scale efficacy studies.

P.134 The effect of immediate and delayed facial nerve suture after nerve transection

P.134 The effect of immediate and delayed facial nerve suture after nerve transection

Iatrogene Nervenläsionen der oberen Extremität – Häufigkeit und Ergebnisse der mikrochirurgischen Therapie

BACKGROUND The purpose of this study was to investigate the number, types and the outcome of iatrogenic peripheral nerve injuries of the upper extremity including the spinal accessory nerve out of a group of 112 surgically treated patients in our hospital during a 15-year period. PATIENTS AND METHODS The retrospective study presents the data of 28 operated patients with iatrogenic nerve lesions of the upper extremity. Surgical management included nerve suture in 4, neurolysis in 10 and nerve transplantation in 14 patients. RESULTS The highest incidence was found in radial nerves (12) and accessory nerves (7). Patients with a good outcome had been operated in a time span of 6 months after injury. The younger the patient the better was the functional outcome. A good functional reinnervation was achieved in 83 % of the patients. CONCLUSION Early microsurgical repair of an iatrogenic nerve lesion does predict the best outcome.

Klinische Ergebnisse von End-zu-Seit-Nervennähten

In end-to-side-neurorrhaphy the collateral sprouting of axons has been proven in many animal studies. It has not yet been determined if a satisfactory sensory recovery occurs. Unfortunately, there is still a lack of well documented clinical studies. We have used end-to-side nerve sutures in five patients. Four of them showed gaps in digital nerves, the fifth patient had a partial transsection of the superficial branch of the radial nerve. At the time of follow-up examination, surgery had been performed an average of 21 months previously (11 - 39 months). We examined sensibility, temperature perception, patient satisfaction and the presence of pain and neuroma. Two of the patients with injured digital nerves reached an almost normal two-point discrimination of 6 mm, the other two patients only achieved a value > 10 mm. With monofilaments one patient was able to recognise the 3.61 filament, which constitutes a standard value. The other three recognised the 4.31 filament, which is only one degree less. All measurements concerning the superficial branch of the radial nerve turned out to be less satisfactory, however, one must consider that the sensation qualitiy in this area is less to begin with. No neuromas occurred, except in the case of the radial nerve. None of the patients showed full recovery of temperature perception. Two were able to recognise a warm and three a cold probe head. Our results confirm the findings made in other studies which also found a clinical correlate to collateral axonal sprouting. Unfortunately results are still inconsistent.

Comparative Analysis of Biomechanical Performance of Available “Nerve Glues”

To compare a variety of potentially useful artificial and biological sealants applied to sutured nerve repairs to decrease gapping at the repaired site. Fifty-seven fresh-frozen cadaveric nerve specimens were transected and repaired with two 8-0 nylon epineural sutures placed 180 degrees apart. The specimens were divided into 5 groups. Four groups received augmentation of the repair with application of either autologous fibrin glue, Tisseel fibrin glue, Evicel fibrin glue, or DuraSeal polyethylene glycol-based hydrogel sealant, and the fifth group had no glue. Each nerve construct was mounted in a servohydraulic materials testing machine and stretched at a constant 5 mm/min displacement rate until failure. A noncontact video analysis permitted normalization of stretch within the repair region. Statistical analysis was performed via analysis of variance followed by Tukey-Kramer post hoc pairwise comparison when indicated. Resistance to gapping as measured through normalized stiffness (N/mm/mm) was greater for the Tisseel group, Evicel group, and DuraSeal group versus the no-glue group only. The stiffness of the autologous group approached significance versus the no-glue group. There were no significant differences in stiffness between any of the nerve glue groups. There was no statistical difference for the peak load at failure between any of the groups. Avoidance of gapping at the nerve repair site is crucial in achieving successful nerve regeneration. Commercially available tissue sealants (Tisseel, Evicel, and DuraSeal), when used to augment 2-suture nerve repairs, as in our protocol, help prevent this initial gapping. None of the tissue sealants tested, however, increased the ultimate load to complete failure of the repair.

Nervale und muskuläre Ersatzoperationen zur Wiederherstellung der gelähmten Ellenbogenfunktion

Paralysis of elbow flexion or extension leads to major impairment of upper extremity function. Surgical reconstruction can be achieved using several procedures. If the time interval since the nerve injury is short, anatomic reconstruction by means of nerve suture or nerve transplantation should be attempted. Alternatively, nerve transposition is possible. If more than 12-18 months have elapsed, reinnervation of arm muscles can no longer be expected. In this case, muscle transposition is helpful. Restoring flexion is predominantly required following brachial plexus injury, when the function of the biceps, brachioradialis and brachialis muscles are lost. As donor muscles the latissimus dorsi, pectoralis major and triceps brachii can be used, alternatively a transfer of the flexor-pronator muscles of the forearm is possible. Latissimus dorsi transfer to reconstruct elbow flexion is also indicated in defects of the anterior upper arm muscle compartiment due to trauma, ischemia, or tumor. Patients with proximal radial nerve lesions may benefit from latissimus transfer to reachieve elbow flexion extension. In tetraplegic patients, elbow extension is restored mainly by transfer of the posterior deltoid muscle extended with a tendon graft, or by means of a biceps-to-triceps transfer.

Transplantation of adult myoblasts or adipose tissue precursor cells by high‐density injection failed to improve reinnervated skeletal muscles

We previously showed that transfer of adult myoblasts (MB) into cardiotoxin-damaged muscle improved the properties of reinnervated tibialis anterior muscle of rabbits. However, this cell therapy protocol cannot be applied to humans because of the hazardous effects of the myotoxin. To circumvent this approach, we used the recently developed high-density injection technique to autotransplant cultured cells 1 mm from each other into the tibialis anterior muscle without previous cardiotoxin-induced damage. Two months after transection and immediate suture of the common peroneal nerve, we transferred by this technique two types of precursor cells, MB or cells isolated from the adipose tissue stromal vascular fraction. In contrast to our previous results, muscles studied at 4 months showed no benefits in terms of function or morphology, whatever the transferred cells. These results, together with the results of earlier studies, emphasize the importance of delivery methods and the muscle environment in supporting cell integration into host tissues.

Long-term Results After Microsurgical Repair of Traumatic Nerve Lesions of the Upper Extremities

Peripheral nerve injuries are still underestimated. This study examines the outcomes after surgical treatment of traumatic nerve lesions of the upper extremities. The different surgical techniques are analyzed with regard to the long-term outcome. This retrospective study presents the data of 93 patients (female: 24; male: 69) who were operated on for peripheral nerve injuries of the upper extremities in our department between 1991 and 2003. Mean age was 31 years (range, 5-67 years). Altogether 100 traumatic nerve lesions (ulnar nerve: 20; radial nerve: 22; median nerve: 25; axillary nerve: 6; accessory nerve: 7; musculocutaneous nerve: 2; long thoracic nerve: 1; digital nerve: 3; combined nerves: 7) were surgically treated. Surgical management included primary nerve suture in 16, neurolysis in 25, and nerve grafting in 59 patients. 74 patients (80%) were available for follow-up examination. The mean follow-up period was 35 months (range, 18-132 months). All patients up to the age of 20 years demonstrated good or excellent sensorimotor recovery. A good functional outcome was observed in 79% of the patients older than 20 years. Overall, good to excellent improvements of motor function were achieved for lesions of the musculocutaneous, radial, accessory and axillary nerves (100%, 89%, 100%, 100% functional useful muscle innervation, muscle recovery grade 3 and more). The length of grafts, in cases of secondary nerve reconstruction, did not influence functional outcome. Generally, early surgical repair of a nerve lesion predicted a better outcome. A good functional motor recovery was dependent on the age of the patient. Traumatic nerve lesions, without signs of reinnervation, should be treated surgically within a period of three months after injury.

Lingual nerve injury: II. Observations on sensory recovery after micro-neurosurgical reconstruction

The aim of this study was to report on neurosensory recovery after micro-surgical lingual nerve repair, and to evaluate the effect on recovery of age, delay in repair and gender of the patient. Seventy-four patients entered the study. The micro-surgical repair performed was direct nerve suture ( n = 71), external neurolysis ( n = 2) and excision of neuroma without nerve coaptation ( n = 1). A standardized neurosensory examination was employed in all patients before surgery and during follow up. Recovery was significant for perception of all tested stimuli: feather light touch, pin prick, pointed/dull discrimination, warm, cold, location of touch, and brush stroke direction, pain perception and two-point discrimination. The rate of recovery was highest during the first 6 months. Females were more often affected than males, but recovery was not influenced by gender. The distribution of neurogenic discomfort (paraesthesia, etc.) remained essentially unchanged. Disregarding cases with poor recovery, delay of surgery had a small but significant influence on the regain of neurosensory function of the lingual nerve whereas age had no such effect. None of the patients recovered to normal. Lingual nerve injury seriously affects the quality of life of patients, and micro-surgical repair is beneficial in the absence of spontaneous recovery.

Suture of Transected Nerve Suppresses Expression of BH3-Only Protein Noxa in Nerve-Transected Motor Neurons of C57BL/6J Mouse

Disrupted peripheral nerves are typically sutured as spontaneous recovery does not always occur. However, the molecular mechanisms involved in nerve regeneration following end-to-end nerve suture are obscure. Here, we investigated effects of end-to-end nerve suture after peripheral nerve transection on motor neurons, using the C57BL/6J mouse hypoglossal nerve injury model. In this animal model, 60-80% of injured motor neurons gradually progress to neuronal death, while the remaining injured neurons survive and regenerate. Mice were divided into the Cut and Suture groups. In the Cut group, the right hypoglossal nerve was transected. In the Suture group, the right hypoglossal nerve was transected and then was repaired using end-to-end nerve suture. We assessed differences between the Cut and Suture groups by analyzing the neuronal survival rate by thionine staining and the nerve terminal regeneration rate by vesicular acetylcholine transporter (VAChT) immunohistochemistry, which is a marker for cholinergic presynaptic terminal. We found that 82.9% of motor neurons survived in the Suture group, whereas only 39.2% of motor neurons did in the Cut group 56 days after surgery. At that time point, 86% of presynaptic terminals compared to controls were regenerated in the Suture group, and 21% were regenerated in the Cut group. These results demonstrate that peripheral nerve suture prevented death of nerve-transected motor neurons and promoted nerve regeneration. We also examined expression profiles of major survival and death signal-associated genes in hypoglossal nuclei using in situ hybridization and real-time polymerase chain reaction (PCR). Although most of the survival- and death-associated genes were regulated in a similar manner in both groups, expression of BH3-only protein Noxa mRNA was significantly lower in the Suture than in the Cut group. A significant suppression of Noxa expression by the Suture may be a major reason why nerve suture induces survival and regeneration of nerve-injured motor neurons.

Promotion of Regenerative Processes in Injured Peripheral Nerve Induced by Low-Level Laser Therapy

This study aimed to assess in vitro the influence of low-level laser therapy (LLLT) on the regenerative processes of a peripheral nerve after trauma. In peripheral nerve injury initiated after severing due to accident or by a surgeon during operation, photomodulation by light in the red to near-infrared range (530-1000 nm) using low-energy lasers has been shown to accelerate nerve regeneration. Twenty-four New Zealand adult male rabbits were randomly assigned to two equal groups (control and laser-treated). General anesthesia was administered intramuscularly, and exploration of the peroneal nerve was done in the lateral aspect of the left leg. Complete section of the nerve was performed, which was followed by suturing of the neural sheath (epineurium). Irradiation was carried out directly after the operation and for 10 consecutive days. The laser used was diode with wavelength of 901 nm (impulsive) and power of 10 mW; it was a square-shaped window type (16 cm(2)), and its energy was applied by direct contact of the instrument's window to the site of the operation. Three rabbits from each group were sacrificed at the end of weeks 2, 4, 6, and 8, and specimens were collected from the site of nerve suturing and sent for histopathological examination. Two important factors were examined via histopathology: diameter of the nerve fibers and individual internodal length. Compared to the control group, significant variations in regeneration were observed, including thicker nerve fibers, more regular myelin layers, clearer nodes of Ranvier with absence of short nodes in the treated group. Variations between the two groups for diameter were significant for the 2(nd) week (p < 0.05), highly significant for the 4(th) and 6(th) weeks, respectively (p < 0.01), and very highly significant for the 8(th) week (p < 0.001). Variations between the two groups for internodal length were highly significant for the 2(nd) and 4(th) weeks (p < 0.01), and very highly significant for the 6(th) and 8(th) weeks (p < 0.001). This experiment affirms the beneficial effect of LLLT on nerve regeneration, since LLLT produced a significant amount of structural and cellular change. The results of the present study suggest that laser therapy may be a viable approach for nerve regeneration, which may be of clinical relevance in scheduled surgery or microsurgery.

Primary Transection of the Superficial Peroneal Nerve Resulting From a Distal Fibula Fracture

Although a superficial peroneal nerve injury following an ankle fracture occurs frequently, primary transection of the nerve represents a rare injury. This report documents a case of primary lesion of the superficial peroneal nerve sustained following a Weber B bimalleolar ankle fracture. The nerve injury was diagnosed at the initial examination when the patient was found to have hypoesthesia in the area of her third to fifth toes. Subsequently an open reduction and internal fixation of the ankle fracture was done along with primary suture of the superficial peroneal nerve. At the patient's last follow-up at 8 months, the nerve had completely recovered and there was normal ankle range of motion. This report emphasizes the importance of a detailed neurologic examination including testing for sensation in patients with ankle fractures.

PLGA 90/10 and caprolactone biodegradable nerve guides for the reconstruction of the rat sciatic nerve

The purpose of this study was to test in vivo two different nerve guides for promoting nerve regeneration across a 10-mm gap of the rat sciatic nerve: 1) one made of PLGA in a novel proportion (90:10) of the two polymers poly(L-lactide):poly(glycolide); 2) another made of (DL-lactide-epsilon-caprolactone) copolyester (Neurolac) tube, by comparing its healing efficacy with that of the more traditional methods of end-to-end nerve suture and autologous graft. Motor and sensory functional recovery were assessed throughout the healing period of 20 weeks, and the repaired nerves were processed for morphological and histomorphometrical analysis. Both motor and sensory functions improved significantly in all experimental nerve repaired groups. At the end of the 20-week follow-up, the end-to-end group showed better recovery of motor function when compared with the groups treated with guiding tubes. However, at this time point, the level of motor function in the Neurolac(R) and PLGA groups was similar to the one of the graft group. Nociception function also recovered faster in the end-to-end group compared with the Neurolac(R) and PLGA groups, and in this case, recovery was also delayed in the graft group. At the end of follow-up, nociception was similar in all experimental groups. Morphological and histomorphometrical analysis showed that axon regeneration occurred in both PLGA and Neurolac(R) experimental groups, with no significant differences in the total number of regenerated fibers, but disclosed a different pattern of degradation of the two types of tubes with larger biodegradation of PLGA material by the end of 20 weeks. These results suggest that both types of biomaterials are a good substrate for preparing tubular nerve guides, and their different pattern of degradation does not seem to influence the degree of nerve regeneration.

Microsurgical treatment of injury to peripheral nerves in upper and lower limbs: A critical review of the last 8 years

Nerve injuries to the upper and inferior limbs represent a common event due both to home and working accidents. Minor traumas can lead to severe disabilities if a wrong treatment is carried out. From 1997 to 2005, 920 patients were observed with a total of 1,200 major or minor nerves injuries operated. In 852 cases acute lesions treated. In 68 patients we reviewed old injuries. In 707 patients direct nerve suture and in 145 patients nerve grafts were carried out. One to 8 years follow up observed. Different protocols were adopted according to the injury: simple cut, complex lesion or surgical revision. Results were evaluated during the follow up period with different models: motor evaluation in six levels (BMRC), sensitive evaluation in five levels (HIGHET), and global evaluation with four grades (from the worst to the best result). Nerve healing is a complex biological phenomenon influenced by many parameters related both to the patient characteristics and nerve lesion. Functional and esthetical outcomes vary also according to: age, cultural and economic condition, health status, and smoking. Post operative rehabilitation is mandatory to obtain an acceptable functional result. Nerve injuries to the upper and inferior limbs represent a challenge for the microsurgeon. Ultimate success in nerve surgery is judged by functional as well as cosmetic parameters. Only patients with the appropriate indication should be operated and always by a skilled surgeon.