Sensate Flap Research Articles

Versatility of Proximal Sural Island Sensate Fasciocutaneous Flap in Reconstruction of Soft Tissue Defects of Knee and Proximal Leg

Background: The proximal sural island sensate (PSIS) fasciocutaneous flap presents an ideal alternative in reconstruction of defects of the knee and proximal leg. It provides a thin sensate flap with good aesthetic outcomes and reduced donor site morbidity. However, only limited reports exist in the literature about this flap.Methods: This is a retrospective study done between December 2018 and December 2021 including 30 patients, among which seven cases had defects located on the knee and 23 cases in the proximal part of the leg. Mean age of the study population was 41 years. The maximum flap size was 8×12 cm, while the maximum pedicle length was 15 cm.Results: All 30 flaps survived well with only minimal complications occurring in a few patients such as epidermal loss and distal tip necrosis. No arterial or venous crisis occurred postoperatively in any case. Donor sites were managed with one-stage primary closure or split-thickness skin grafts. Functional deficits were not detected in any of the cases.Conclusion: We found the PSIS fasciocutaneous flap to be a simple and reliable technique to perform. The flap offers extensive coverage, reaching from the knee to the proximal leg, and provides thin, pliable, and sensate skin, resulting in excellent aesthetic and functional outcomes.

Osteoplastic Reconstruction of the Thumb: a case report

Background & Objectives: Thumb accounts for 50% of the hand function. Amputation of the thumb severely jeopardises the hand function. Thumb replantation, toe transfer are the ideal methods for restoring the hand function, but is not always possible owing to type of injury, time to presentation, surgical skill and set up. Osteoplastic thumb reconstruction for amputation around the metacarpophalangeal joint is a good treatment option to restore the hand in a developing setup. Presentation of Case: A 25 yrs male with amputation of thumb around metacarpophalangeal joint with delayed presentation and crushing component of distal part underwent multiple staged osteoplastic reconstruction of the thumb. The procedures consisted of bony structure fixation with bone graft followed by coverage with a thinned tubed groin flap which was divided at 2 weeks interval. The thumb was made sensate with sensate flap (first dorsal metacarpal artery flap). Discussion: Thumb replantation is ideal in acute setup in a clean traumatic amputation, while toe transfer is ideal in a delayed setup with healed wound. This requires a good operating room set up with microsurgical set up and skilled manpower, which is difficult in a developing country. Osteoplastic reconstruction requires multiple staged procedures that can be done at a primary level setup. Conclusion: Osteoplastic thumb recontruction is a good option for amputation around the metacarpophalangeal joint to restore hand function in a resource limited set up.

Utility of Sensate Pedicled Medial Thigh Perforator Flaps in Treating Recurrent Ischial Ulcers in Individuals with Cauda Equina Lesions and Spinal Dysraphism – A Retrospective Analysis

Abstract Background: Ischial pressure ulcers pose a significant challenge due to their high recurrence rates. It is imperative to provide or establish a reliable, well-vascularized soft-tissue cover over the ischial area to prevent recurrences. The objective of the study was to study the utility and complication rates associated with pedicled medial thigh perforator (P-MTP) sensate flap procedures in managing recurrent ischial ulcers and perineal lesions. Methods: A retrospective cohort study was conducted at Christian Medical College, Vellore, a tertiary care center in South India. This study involved 30 patients with ischial pressure sores. Of these, 13 patients underwent P-MTP flaps, while 17 underwent alternative surgeries for ulcer closure (January 2014–June 2020). Results: Among 13 patients who underwent P-MTP sensate flaps, 1 major complication (full-thickness flap necrosis) necessitated flap revision, while 6 minor complications occurred in the postoperative period. Three patients (23.08%) reported late recurrence of ulcers at the same postoperative site. In contrast, among the 17 patients who underwent the other (alternative) methods of surgical closure, 3 patients had wound dehiscence in the postoperative period. Four patients reported recurrence of ulcer at the postoperative site within 6 months and another four after 6 months of surgical closure. The surgical outcomes in sensate flap surgeries (P-MTP flaps) were comparable to other approaches for surgical closure. Sensation in the P-MTP flap transposed over the ischial region remained intact in all 13 patients at 6-month follow-up. Conclusion: The P-MTP sensate flap is a feasible and reliable treatment strategy for regional soft-tissue reconstruction in ischial and perineal lesions with postoperative complications comparable to other surgical methods for ischial ulcer closure. The sensate flap surgeries offer the additional benefit of maintaining intact sensation over the pressure injury vulnerable ischial region.

Outcome and Utility of First Dorsal Metacarpal Artery Flap for Finger Defects

Background: The First Dorsal Metacarpal Artery (FDMA) Flap or Foucher’s flap is an island pedicle flap proximally based on the first dorsal metacarpal artery and veins. A branch of radial sensory nerve is incorporated in the flap to make it a sensate flap. Objective: The aim of our study was to evaluate the functional and aesthetic outcomes of the seven FDMA flaps done over a period of four years for reconstruction of the distal thumb soft tissue defects and one defect over proximal phalanx of the index finger. Methods: This prospective study was performed between 2018 and 2022 at the Clinic of Reconstructive and Plastic Surgery. We present a series of six cases of distal thumb soft tissue defects and one patient with defect over the dorsal aspect of the index finger that were reconstructed with the FDMA flap. Results: In six patient donor site was grafted by full-thickness skin graft harvested from the groin and in one case was closed primary. All flaps survived and one case that was closed primary had donor site complication that was related to primary closure of the skin. All the patients had good fine touch and average two-point discrimination of 8.7 mm. Conclusion: FDMA flap is a useful and reliable flap to cover the defects of the dorsal aspect and to a certain extent the volar aspect of the thumb. We showed that can be used to cover the defects over proximal phalanx of the index finger. The flap provides adequate soft tissue coverage and good aesthetic results.

Lower-Extremity Fillet Flap for Reconstruction of Complex Stage IV Pressure Sores and Plantar Flap for Lumbosacral Padding.

The lower-extremity fillet flap is a suitable option for the repair of complex (multiple or complicated with osteomyelitis) stage IV pressure sores. If prepared from a nonfunctional extremity, it can close complex wounds and avoid the unnecessary burden of a nonfunctional organ that restricts patient movement, thereby improving quality of life. We used a lower extremity fillet flap for reconstruction in 5 patients with complex stage IV pressure sores. The flaps were prepared from the nonfunctional lower extremity with multiple lesions by using iliofemoral disarticulation. The mean age of the patients was 60 years old, and the mean follow-up period was 18 months. A plantar flap was used in 1 patient for prophylactic padding of the lumbosacral region. In another patient, the plantar flap was used as a sensate flap. No major complications, such as total or partial flap loss, occurred in these patients. In 1 patient, a hematoma developed under the flap that led to dehiscence; however, it healed uneventfully without flap loss. Patients developed minimal pelvic stability and balance loss because of iliofemoral disarticulation, but it did not affect their sitting ability and mobility. After the operation, all patients became increasingly active and mobile because of the absence of excess weight on their nonfunctional legs, allowing them to easily perform daily activities such as turning in bed, using a wheelchair, eating, and dressing. Pressure sores did not develop in any of the patients during the postoperative follow-up period. The patient who underwent lumbosacral padding with a sensate plantar flap began to perceive touch over the flap in the fifth postoperative month. These results suggest that a lower-extremity fillet flap can be a good repair option in complex stage IV pressure sores because it prevents recurrence and enables patients to perform daily activities more easily. Furthermore, plantar flaps can provide prophylactic padding in the lumbosacral region.

Primary Regenerative Peripheral Nerve Interfaces Using Devascularized Vastus Lateralis Muscle in Sensate Anterolateral Thigh Flap Donor Sites.

Sensate flaps are increasingly used in diverse areas of plastic surgery. Concurrently, modern techniques in neuroma prevention have emerged, such as regenerative peripheral nerve interface (RPNI). Despite increasing use of sensate flaps, the combined use of donor-site neuroma prevention techniques has yet to be described. We report on the use of primary donor-site RPNI at the time of sensate anterolateral thigh (ALT) reconstructions. In ALT flaps, the vastus lateralis muscle can be segmentally devascularized from perforator dissection. These segments of devascularized vastus lateralis muscle can easily be used and repurposed as the free muscle grafts needed for RPNI, providing a physiologic target for the regenerating neurons. Donor-site neuroma has not been shown to be a significant issue at standard ALT flap donor sites. Sensate ALT flaps involve harvest of the lateral femoral cutaneous nerve and/or additional femoral sensory branches at a more proximal location close to the level of the anterior superior iliac spine, where injury to the lateral femoral cutaneous nerve may be associated with pain. In this series, eight patients underwent senate ALT flaps with the use of primary RPNI at the sensate ALT donor site. At a mean follow-up of 16.3 months (range 5-25 months), there was minimal to no nerve pain and no clinical evidence of donor-site neuroma. As sensate flap reconstructions are increasingly performed in plastic surgery and data on neuroma prevention techniques continue to grow, we propose consideration of their combined use.

The Fate of Sensation in Noninnervated Perforator Free Flaps in the Lower Extremity.

The recovery of sensation for noninnervated perforator flaps is not well understood. This prospective study aims to evaluate the quality, tendency, and related factors for recovery of sensation. A total of 187 patients over a 6-year period were evaluated at intervals of 3, 6, 12, and +24 months for demographic data and sensory tests [Semmes-Weinstein (SW) monofilament test, static two-point discrimination, temperature, and pain] on peripheral and central regions of the flap. Further detailed assessment using the SW monofilament test was made according to flap thickness, size, type, and recipient sites. Factors correlated to poor recovery were evaluated. Among the flaps tested, the 5.07 SW monofilament test revealed that the peripheral flap sensory recovery was achieved in 72% at +24 months with a significantly increasing linear trend ( P < 0.001). However, the central recovery was noted in only 26% to 28%. The two-point discrimination was achieved in 21% without a significant trend, whereas temperature and pain showed significant improvement, achieving 49% and 64% on the peripheral region and 22% and 31% for the central region, respectively. The flap thickness, size, type, and recipient sites did not exert significance. Only smoking was a significant factor, with 13 times higher odds of hindering sensory recovery. The SW monofilament test, temperature, and pain sensation on the periphery of the flap showed increasing trend of recovery over the +24 months. Among the various factors, only smoking attenuated recovery. Understanding the fate of sensory recovery in noninnervated perforator flaps will allow the surgeons to further customize the reconstruction based on the defect and maximize efficiency. Risk, III.

Discussion: The Fate of Sensation in Noninnervated Perforator Free Flaps in the Lower Extremity.

Discussion: The Fate of Sensation in Noninnervated Perforator Free Flaps in the Lower Extremity.

Evaluating Sensation Recovery in Noninnervated Free Flaps Used for Oral Reconstruction

Association between time and sensation recovery in noninnervated flaps remains unclear. Our goal was to evaluate the recovery of sensation in noninnervated free flaps used for oral reconstruction. A prospective cohort study was designed and consecutive patients undergoing noninnervated free flap surgery for oral reconstruction from a tertiary medical center were enrolled. The primary outcome variable was sensory recovery of light touch, pain, hot, and cold temperature. Sensory recovery was scored as per the test on the central portion and 4 peripheral sections of every flap. The Kaplan-Meier method was used to estimate the functional recovery at different time points and the association between clinicopathologic variables and sensation recovery at 24months after surgery was analyzed using the chi-squared test and logistic regression analysis. Eighty patients were included with a median age of 50years. At 3months postoperatively, no patients exhibited sensation recovery. Positive flap sensitivity began to appear mildly at 6months postoperatively and gradually increased for at least 24months. The 24-month sensation recovery rates of light touch, pain, and temperature were 70.0% (95% confidence interval [CI]: 59.2 to 78.9%), 42.5% (95% CI: 32.3 to 53.4%), and 33.8% (95% CI: 24.45 to 44.6%), respectively. In univariate analysis, 80.5% (95% CI: 66.0 to 89.8%) of the free radial forearm flaps showed light touch sensation recovery, which was statistically higher than 59.0% (95% CI: 43.4 to 72.9%) in other flaps (P=.036). Flap size ≤ 65cm2 predicted better pain sensation recovery with 57.5% (95% CI: 42.2 to 71.5%) compared to 27.5% (95% CI: 16.1 to 42.8%) in flap size > 65cm2 groups (P=.007). Logistic regression analysis confirmed flap size ≤ 65cm2 (P=.032, odds ratio=1.957, 95% CI: 1.034 to 4.389) and not smoking (P=.015, odds ratio=2.564, 95% CI: 1.673-5.482) offered better sensation recovery of pain and hot temperature, respectively. Sensation recovery in noninnervated free flaps was common and related to not smoking and flap size.

Utility of First Dorsal Metacarpal Artery Flap for Thumb Defects.

Background Reconstruction of thumb tip, while providing a durable and sensate flap, is a challenging task. It is important as thumb accounts for 50% of hand functions. Options for coverage are: healing by secondary intention, local/regional flaps, microsurgical toe wraparound flap, etc. First dorsal metacarpal artery (FDMA) flap is one regional flap that has been used for thumb cover, usually for defects till interphalangeal joint or just distal to it. We present our case series for FDMA flap and its variations for thumb reconstruction. We also report reverse FDMA flap cover for reconstruction of defects over distal phalanx of thumb. Methods The procedure was performed in patients with partial loss of thumb soft tissue in 16 patients presenting during 2017 to 2020. The FDMA flap was performed according to the standard technique. In case after "planning in reverse," it was seen that the reach of FDMA flap was insufficient, reverse FDMA flap was done. Physiotherapy for index finger and thumb was started on day 10. Patient satisfaction, in terms of cosmesis and function was recorded (graded as poor, good, and very good). Static two-point discrimination (2-PD) was assessed at 6 months' follow-up. Patients were followed up for 6 months. Results The operative time was 1 to 2 hours. Out of total 16 cases, 8 patients underwent racquet-shaped (intact skin paddle) FDMA flap. Islanded flap was performed in five and reverse FDMA flap in three. Twelve patients had uneventful recovery and four patients (three islanded and one reverse FDMA) had partial skin loss. Static 2-PD was assessed at the 6 months postoperative period. Conclusion FDMA flap is a useful regional flap for thumb reconstruction. It provides good supple, durable, and sensate cover. The reverse FDMA flap that increases the pedicle length can be used for more distal defects, where conventional FDMA flap is doubtful.

Bilateral Pudendal Thigh Flap In The Creation of A Neovagina and Restoration of Utero-Neovaginal Continuity – A Case Report

The pudendal thigh flap is a sensate flap based on the posterior labial artery, which has shown great versatility in the reconstruction of genital anomalies as well as genital oncologic reconstruction. This report showcases the creation of a neovagina with the restoration of uterovaginal continuity in a 12-year-old girl who had vaginal atresia. She presented with concealed menstruation and cyclical abdominal pain and had a creation of a neovagina with utero-vaginal continuity using a bilateral pudendal thigh fascio-cutaneous flap. Post-operatively, she attained normal menstrual flow and a sensate neovagina with a satisfactory vaginal canal depth. Partial wound dehiscence of the flap donor site was managed with dressing and healing by secondary intention. Even in new centres, the pudendal thigh flap remains a versatile flap for managing vaginal atresia.

Trigeminal Trophic Syndrome: A Comprehensive Review of a Surgical Approach.

Trigeminal trophic syndrome (TTS) is an exceedingly rare disease that causes facial ulceration, most commonly at the nasal ala. The overall incidence of TTS is not known, with less than 150 cases published in the literature.We searched the United States National Library of Medicine National Institutes of Health (PubMed) using the terms "Trigeminal Trophic Syndrome" and "TTS" as keywords. Publications in all languages were included if an English abstract was available. We reviewed 111 cases of TTS described in 75 publications from 1979 to 2021.Fourteen cases involved surgical reconstruction. Of these, the lesions completely healed in 7 cases (50%), recurred in 5 (36%), and were unspecified in 2 (14%). Reconstruction was completed in a 2 to 3-stage approach in 6 cases; of these, healing without recurrence was observed in 5 cases (83%). When donor tissue from the affected side was used as a basis for reconstruction, healing without recurrence was observed in 2 cases (50%). This is in comparison to the use of contralateral, sensate tissue in which there was healing without recurrence in all 3 cases (100%).The surgical management of TTS remains a topic of controversy. The rates of success remain comparable despite the use of various flap types. However, the use of contralateral, sensate flaps and a staged surgical approach appears to be effective based upon the best available evidence in the literature. Further prospective orretrospective controlled studies are necessary to make more reliable recommendations, though may be challenging given the rarity of TTS.

One-stage coverage of multi-digital pulp defects with sensate flaps from the foot

BackgroundThe reconstruction of the digital pulp defects was a mix of the sensation, function, and aesthetics. As the conventional flaps became out of date, the sensate flaps were increasingly utilized in covering such defects. In this report, we present our experience with some novel flaps design, located on the foot. MethodFrom April 2015 to September 2018, nine patients received the free sensate flaps to resurface soft tissue defects in the multi-digital pulps. And all flaps were harvested from each aspect of the foot, which dimensions were tailored to the defects. The cutaneous nerve was preserved within the flap. Standardized assessment of outcome in terms of sensory, functional, and esthetic scores of the reconstructed pulps was completed. ResultsNineteen flaps survived completely without significant complications, and mild venous congestion was observed in one flap. The free sensate flaps were performed for digital pulp reconstruction in 9 patients: 6 male and 3 female patients with a mean age of 49 years (ranged, 16 to 72 years). The defects involved 3 thumbs, 6 index fingers, 5 long fingers, 3 ring fingers, and 2 little fingers. All flaps were available for a mean follow-up of 30 months (ranged, 24 to 36 months). The functional and esthetic outcomes were satisfied for all flaps, as well as the sensory restoration. ConclusionThe sensate flap from the foot is a remarkable alternative for digital pulp reconstruction with less morbidity and better outcomes. Furthermore, the foot region presents a sensitive, glabrous skin with the proper bulkiness and allows for easy dissection.

Sensory Reconstruction of a Posterior Heel Defect Using a Proximally Based Sensate Medial Plantar Flap with Retrograde Nerve Cleavage Technique.

Reconstruction of posterior heel defects is important because it requires thick and durable skin that can withstand pressure and shear from shoe and bed contact. Therefore, the sensate flap could be a better option for the defect. This paper reports on the safety of a medial plantar sensory flap for these defects as well as an objective measurement of the sensation of the medial plantar flap and the plantar surface distal to the donor site. Twelve patients had soft-tissue defects in the posterior heel and underwent reconstructive surgery using a proximally based sensate medial plantar sensory flap. Cases of plantar defects involving not posterior heel were excluded. For wider flap coverage, special neurovascular dissection was required. We evaluated levels of sensation quantitatively using Semmes-Weinstein (SW) monofilaments and a two-point discriminator at the final follow-up. All flaps survived without major complications. Postoperative follow-up was 12 to 64 months (mean 26 months). All 12 flaps healed without postoperative complications. There was no significant difference in minimal two-point discrimination and SW evaluator size between the transferred medial plantar flap area and the contralateral heel area or between the plantar area distal to the donor site and the contralateral side. Patients could walk normally and sleep without protective shoes or brace. A proximally based sensate medial plantar flap is a good option for the reconstruction of posterior heel defects. It can restore the characteristics of the posterior heel for shoe wearing and sleeping.

Reconstruction of Foot and Ankle Defects Using Free Lateral Arm Flap: A Retrospective Review of Its Versatile Application.

Background Successful reconstruction of the feet and ankles remains challenging due to limited quantities of soft tissue and laxity. The free lateral arm flap (LAF) is an alternative to conventional flaps and has been widely used due to advancements in its flap characteristics. This study is aimed at utilizing the advantages of this flap to validate its increased applications for foot and ankle defects. Methods Twenty patients with various LAF types between May 2011 and May 2020 were enrolled. Clinical data was retrospectively collected, and defect sites were classified according to the subunit principle. We utilized various LAF types, such as LAFs with sensate, extended, osteomyocutaneous, or myocutaneous flaps, as necessary. A two-point discrimination test was performed, and results were statistically compared between flaps. Results Among the diverse etiologies of skin defects, chronic inflammation was the most common cause of defects. Various LAF types, including LAFs with fasciocutaneous, extended fasciocutaneous, musculocutaneous, and osteomyocutaneous flaps, were used. The versatility of free LAF helped successfully cover various defects in all cases. Results of the two-point discrimination test were statistically significant between groups. Conclusions Free LAF is a unique soft tissue free flap that is more versatile than other flaps, allowing flaps to be continuously modified and applied to various foot and ankle defects under different clinical conditions.

Versatility of the Peroneal Perforator Propeller Sural Flap for Various Types of Injuries in the Ankle and Foot Regions.

The goals of soft tissue reconstruction in the distal lower extremities are to provide a functional limb and to help patients return to a normal life with the capability of wearing shoes or boots. A peroneal perforator propeller sural flap is a combination of a sural flap and a peroneal propeller perforator flap. This article presents the versatility of this flap in the foot and ankle regions. Eleven peroneal perforator propeller sural flaps were harvested to reconstruct the ankle and foot regions. There were 9 male and 2 female patients, with ages ranging from 9 to 64 years. The flaps were used for 7 different defect types including avulsion, gunshot, crush injury, diabetic foot, defect secondary to orthopedic surgery, tumor resection, and electrical burn. The flaps included 3 different insetting types and 2 different utilizations of the sural nerve. Eight direct propeller flaps, 2 interpolation propeller flaps, and 1 passing-through-style propeller flap were harvested as flap insetting types. In 1 patient, sural nerve coaptation was used, and in 2 patients, an additional posterior tibial artery perforator flap was used. One patient underwent surgery at the time of the injury. Only 2 patients had complications related to the type of injury. There was no need for debulking surgery for patients to wear their own shoes or boots. The peroneal perforator propeller sural flap can be harvested as a sensory flap with sural nerve coaptation, a passing-through- style, an interpolation style, an extended style, or as a component of double perforator flaps. This type of flap provides various options in the challenging field of reconstructive surgery.

Assessment of free anterolateral thigh flap for extremity reconstruction.

ABSTRACT Background: Free tissue transfer undergone substantial improvement over the past three decades, focusing on functional and aesthetic results of reconstruction for both the donor and recipient sites. The free ALT flap is a typical example of this revolution from its early description by Song el al, in 1984 and its later popularization and wide use to reconstruct defects all over the body from the head to toes yielding a very good functional and aesthetic results with relatively minimal donor site morbidity making it a workhorse free flap. For limb reconstruction it provides a good size of many tissue types including skin, subcutaneous fat, muscle and fascia with possible sensate flap and flow through flap for limb revascularization. The flap pedicle is of adequate size and length, 2 team approach is possible, and donor site morbidity is minimal especially with direct closure. Patients and Methods: From April 2016–December 2018, 11 male patients aged 5-41 years (mean 27.5 years) with extremity defects including 6 upper limbs and 5 lower limbs defects were reconstructed using free ALT flap. Defects were caused by RTA (8 cases), electrical burn (1 cases) and release of contractures (2 cases). Results: All flaps survived completely except one case suffered slowly progressive congestion ending in partial flap loss, managed by debridement and skin grafting. Except one flap harvested as musculocutaneous, all flaps were fasciocutaneous. Flaps perforator pattern were musculocutaneous in 81.9 % of cases and septocutaneous in 18.1% of cases. 9 flaps were based on single perforator, 2 and 3 perforators each vascularized one flap. Conclusion: Free ALT flap is a reliable, versatile reconstructive option for small to moderately large limb defects. Donor site morbidity is minimal with direct closure.

A Systematic review and meta-analysis of sensate versus non-sensate flaps for the prevention of pressure ulcer recurrence among individuals with spinal cord disease.

Systematic review and meta-analysis. To identify, critically appraise, and synthesize research findings on non-sensate versus sensate flaps among individuals with spinal cord disease and pelvic pressure ulcers, with pressure ulcer recurrence as primary outcome. PubMed, EMBASE, and Cochrane CENTRAL were screened for relevant studies. Data on surgical characteristics, ulcer recurrence, and sensory outcomes were retrieved and tabulated. Risk of bias was assessed with MINORS. The level of evidence was evaluated with GRADE. Meta-analysis was performed when possible. Meta-analysis of 1794 non-sensate locoregional reconstructions indicated a recurrence rate of 34% within several years (95% CI, 27-42). Twenty-one articles provided data on 75 sensate reconstructions, performed in 74 individuals. Meta-analysis of the sensate reconstructions indicated a recurrence rate of 1% (95% CI, 0-8). Sensate reconstructions were not associated with an increase of wound complications (19%; 95% CI, 7-40) compared with non-sensate ones (34%; 95% CI, 27-42). A very low level of evidence was determined with use of GRADE. Although of a very low-level, the present evidence suggests that restoration of sensory innervation may be an effective intervention for the prevention of pressure ulcer recurrence among individuals with spinal cord disease. A prospective RCT is needed to confirm or refute the results of this systematic review.

Targeted sensory reinnervation by direct neurotization of skin: An experimental study in rats

No effective methods currently exist for breast neurotization in implant-based breast reconstruction. Here, we focused on direct neurotization (DN), in which axons regenerating from nerve stumps are directed to the mastectomy flap and aimed to assess whether DN can generate a new mechano-nociceptive field using a rat model of back skin sensory denervation.Dorsal cutaneous nerves (DCNs) of rats were exposed and transected, leaving only the left medial branch of the DCN of thoracic segment 13 (mDCN-T13) intact. This procedure resulted in an isolated innervated field surrounded by a denervated field. The mDCN-T13 was transected, and the proximal nerve stump was sutured to the subdermis (DN subdermal group, n = 6) or dermis (DN dermal group, n = 5) of a different region of the denervated field. In the Crush group (n = 5), the intact mDCN-T13 was only crushed. We evaluated the generation of a new mechano-nociceptive field over time using the cutaneous trunci muscle (CTM) reflex test and histomorphometrically evaluated regenerating nerves in the reinnervated region.In the DN groups, the CTM reflex appeared in the DN area after postoperative week 4. The new mechano-nociceptive field gradually expanded afterwards, and by postoperative week 12, the area was substantially larger than the original region innervated by the mDCN-T13 in the DN dermal group, although not as large as that in the Crush group. In histomorphometric evaluations, many S100-positive myelinated fibers were observed in the dermis of the reinnervated area for all groups.In targeted sensory reinnervation, DN of the skin is revolutionary in that it allows a new innervated area to be generated at a desired location regardless of whether a distal nerve stump is available. DN may present an effective approach for breast neurotization in breast reconstruction after mastectomy, particularly for procedures that cannot use sensate flaps such as implant-based breast reconstruction.

The Feasibility of a Sensate Profunda Artery Perforator Flap in Autologous Breast Reconstruction: An Anatomic Study for Clinical Application.

The profunda artery perforator (PAP) flap has been demonstrated to be an effective method of autologous breast reconstruction, particularly when the abdominal donor site is contraindicated. However, there are no current reports regarding the use of a sensate PAP flap in this type of reconstruction. The objective of this study is to describe the feasibility and anatomic location of the sensory nerves supplying the PAP flap in relation to surface landmarks for use in autologous breast reconstruction. In this anatomic study, 10 cadaver lower limbs were microsurgically dissected. We investigated the posterior femoral cutaneous nerve (PFCN), which supplies sensation to the skin of the posterior thigh and distribution of the PAP flap. The midline of the posterior thigh and gluteal crease were used for surface landmarks. The diameter and length of the nerve branches were documented. There were between 2 and 5 PFCN branches, with an average of 3 branches, that were found within the distribution of the PAP flap. Measurements were taken from the gluteal crease and midline to the nerve branches. The average distance caudal to the gluteal crease was 2.4 cm (0 to 7 cm). The average distance medial to the midline was 4.3 cm (0.2 to 8.1 cm). The average diameter of the nerve branches was 1.8 mm (1 to 2.5 mm). The average length of nerve branches from the flap to the fascia was 2.0 cm (1.5 to 2.4 cm). The maximum length of the nerve branches from the flap to the main trunk of the PFCN was 7.8 cm when tracing the nerve branches intramuscularly. The findings from this study provide an anatomic basis for the sensate PAP flap that would potentially provide an additional dimension to the use of this perforator flap in autologous breast reconstruction. These preliminary results are promising, and further physiological studies are warranted to validate the use of this sensate flap.