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There are three shortcomings of this method. First, the fascicles. Therefore, a fascicular turnover flap from
location and direction of the nerve graft are restricted the distal buccal branch was elevated to reconnect
because the nerve graft is attached to the ALT flap. the nerve gap without tension. The paralyzed major
Therefore, a sufficient length of the nerve graft is zygomatic muscle became active three months later. No
required, theoretically increasing time to reinnervation. control was provided.
Second, the number of branches of the LFCN varies When a single branch is compromised, the pedicled great
greatly among patients. In cases in which the number
of branches is fewer than that required for facial nerve auricular nerve is an option that causes no additional
reconstruction, an additional free nerve graft is needed. morbidity and which can be used with minimal additional
Finally, if the recipient nerve is larger than the lateral effort.
femoral nerve branches and the nerve has to be cable The best method for repair of multiple branches of the
grafted, vascularization will be interrupted, resulting in a facial nerve appears to be the LFCN graft without an
mixed VNG/NVNG reconstruction. ALT component that restricts motion. Should the skin
or adipose tissue component of the ALT be needed
Vascularized deep peroneal nerve graft together with the nerve to replace soft tissues, the best
Koshima et al. reported a case in which a combined solution is harvest as a chimera, based on a different
[39]
anteroposterior tibial perforator‑based flap was used perforator than that nourishing the nerve, thus avoiding
for the repair of a large facial defect involving the facial restrictions in nerve movement and allowing better
nerve (10 cm nerve gap). The deep peroneal nerve of the inset. The branching of the nerve allows repair of up
flap was interposed between the proximal stump and the to three branches with adequate length and similar
transected zygomatic and buccal branches of the facial
nerve. The authors reported the subjective judgment of a caliber. Using it with the ALT or SCIP requires an
“considerable degree of facial animation” on the affected exceedingly long graft and limits motion. An alternative
side eighteen months postoperatively. The disadvantages for the reconstruction of all five branches, which to
of this VNG are temporary postoperative edema, our knowledge has not yet been utilized, is the long
[48]
hypoesthesia of the donor foot and a poor donor site scar thoracic nerve.
where skin has been harvested. Upper limb
Injuries to the ulnar nerve are the most frequent,
Deep peroneal, sural and vastus nerves occurring either in isolation or in association with the
Kimata et al. reported 10 cases of facial nerve [49,50]
[38]
reconstruction in which several types of VNGs were used median nerve. These injuries, when compared to
for reconstruction of multiple branches of the facial radial and median nerve injuries, are believed to have
nerve. The nerves used were: (1) the free vascularized the least favorable outcome among nerve injuries in the
[51‑54]
sural nerve graft, attached to a small peroneal monitoring upper extremity. Ulnar nerve injuries are the most
flap and nourished by the peroneal vessels; (2) the free common at the wrist, forearm, or elbow, secondary to
vascularized deep peroneal nerve graft attached to a small trauma or entrapment.
dorsalis pedis monitoring flap and nourished by anterior Recovery of intrinsic muscles function is more important
tibial vessels; (3) the free vascularized motor nerve of than sensory restoration. In their meta‑analysis,
[10]
the vastus lateralis muscle nourished by the descending Ruijs et al. reported that the chance of motor recovery
[52]
branch of the lateral circumflex femoral vessels; and in ulnar nerve injuries was 71% lower than in median
(4) the free vascularized lateral femoral nerve of the thigh nerve injuries. Multivariate logistic regression analysis
combined with an ALT flap. showed that age, site (intermediate and high showed
In 4 patients, the functional recovery of the facial nerve better results than low lesions), and delay between injury
could not be assessed because of local tumor recurrence and repair were significant predictors of successful motor
soon after surgery. Results with the House‑Brackmann recovery. No significant difference was found between
system were grade II in 1 patient (vascularized sural median and ulnar nerve injuries regarding sensory
[44]
nerve), grade III in 4 patients (three vascularized deep recovery. This is supported by other large studies. [53,55] Age
peroneal nerves and one vascularized motor nerve of the and delay between injury and repair were found to be
vastus lateralis), and grade IV in 1 patient (vascularized significant predictors for sensory recovery. [52]
sural nerve). Results with the 40‑point system ranged
[45]
from 20 to 28 points (mean score, 23 points). No control Vascularized lateral femoral cutaneous nerve graft
[40]
was provided. Koshima et al. described a case of a 28‑year‑old woman
with a wide massive tumor resection of the upper arm,
Fascicular turnover method which resulted in a soft tissue defect that included 12 cm
Koshima et al. described the “fascicular turnover long segments of the brachial artery and median nerve.
[47]
method”, in which a vascularized fascicular flap was A flow‑through ALT flap and vascularized LFCN graft
used for repairing nerve gaps. A 3 cm facial nerve gap were harvested with separate vascular pedicles. Tinel’s
was repaired with this technique with preservation of sign reached the wrist joint 6 months after surgery.
the zygomatic and marginal mandibular branches. The Two and a half years postoperatively, moving 2‑point
distal portion of the main buccal branch had three discrimination (PD) on the fingers controlled by the

Plast Aesthet Res || Vol 2 || Issue 4 || Jul 15, 2015 187