Recent conclusions regarding the reconstructive microsurgery of peripheral nerves

Abstract

The introducing of reconstructive microsurgery has meant not only the addition of microsurgical microscopes and instruments, but a change, a progress towards a new concept, the concept of the microsurgical reconstruction of tissues. The microscope and the instruments themselves are only a means of utilizing this new concept to good effect since the mere use of the microscope and of the instruments according to the old concept of tissue reconstruction cannot be considered to be reconstructive microsurgery. From December 1979 through to December 2005, more than 3000 patients with peripheral nerve lesions were operated on by the same microsurgeon, the author Doina Ionescu-Dumitrescu. The conclusions are based on the following: A huge amount of work involved in carrying out microsurgical reconstructions of over 7500 peripheral nerves in over 3000 patients, 1800 of which were nerve transplants for defects of peripheral nerves of the extremities, for posttraumatic brachial plexus paralyses (91), for replantations and/or revascularizations following partial or complete amputations of the extremities (24 out of which 23 successful) or for free transfers of functional composite tissues (53). For a more accurate picture of such an effort one should consider the operation time that these types of reconstruction involve: between 3 and 12 hours for each patient under general anaesthesia and for both the anaesthetist and the microsurgeon. Experimental microsurgery on rabbit ears The results of the histopathological examination of 500 postoperative neuromas of peripheral nerves repaired traditionally. The Moberg test. Pre, intra and postoperative monthly observations of the patients until their full recovery according to the criteria set by the International Reconstructive Microsurgery Society (postoperative intervals of 6-12-24 months). Taking pictures and recording pre, intra and postoperative stages. The patients' professional, social and familial reintegration. The patients' state of mind; level of cooperation. Comparing results with those of classic and palliative repairs. Comparing the data resulting from this experience with the information provided by the specialist literature of the world. Completing the internationally defined reconstructive procedures with the personal ones, to produce a new concept.

Fig. 1;Peripheral nerve microsurgical fascicular suture in fascicular groups In Fig. 1 see the removal of the nerve sheath, the epineurium, as well as the aligned, already sutured (coapted) fascicular groups. Fig. 2; In Fig. 2 the anastomosis of the main artery of the nerve, magnified 25 times. Fig. 3; Image exemplifies epineurial delimitation at the level of nerve graft segment extremities, its excision.

Fig. 4; Fig. 5; Fig. 6; The Volkmann Syndrome: Fig. 4. Extensive fibroses of muscles in two children. Surgery consisted in forearm fasciotomy, lengthening of deep flexor tendons, excision of m pronator teres, microsurgical reconstructions in two stages, at two and/or three months, of the median, ulnar nerves with nerve graft. Fig. 5, 6: Result at 21 months in the first child.

Fig. 7; Fig. 8; Fig. 9; Replantation case

Fig. 10; Fig. 11; Fig. 12; Fig. 13; Fig. 14 Complete Brachial Plexus Palsy

Fig. 15; Fig. 16; Progressive Facial Hemiatrophia. Reconstruction of Face Contour : the vessels of the latissimus dorsi free flap were anastomosed to the facialis vessels. One year later, the esthetic free flap modeling was performed (Fig. 15, Fig. 16)

Fig. 17; Fig. 18; Old facial nerve paralysis: The one stage surgery, free flap transfer of serratus anterior muscle inervated with sural nerve graft 12-22 days after the operation, the patient displayed obvious contractions of the affected mouth commissure and upper eyelid

Fig. 14; Fig. 15; Fig. 16; Fig. 17; Fig. 18; Fig. 19; Eye-socket reconstruction, mobile upper eyelid, lower eyelid, eyebrow