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Vascularized sural nerve graft supplied by an arterialized superior to conventional long nerve grafts (12/15 patients
[33]
saphenous vein: Townsend and Taylor presented five or 80% success rate vs. 18/27 patients or 66% success
upper extremity cases in which a composite saphenous rate). A pedicled VNG was more reliable than a free VNG
vein‑sural nerve graft was used for median (n = 3) or for the reconstruction of elbow flexion; of the 9 patients
ulnar nerve (n = 2) defect of 6‑21 cm in length. The who had a pedicled vascularized ulnar nerve graft, eight
denervation time was 5 months to 2 years. Their results achieved a muscle grade greater than M3. However, of
showed a Tinel’s advancement comparable with a primary 6 patients with free vascularized ulnar nerve graft, only
repair (1 mm/day in 2 cases). In 1 case with reconstruction four achieved a grade greater than M3.
of the median nerve with a 17 cm vascularized sural nerve Terzis and Kostopoulos reported 151 reconstructions
[65]
graft, the advancement was 3 times faster. with ulnar nerves performed in 67 patients for brachial
Gu et al. presented the same model of a sural nerve plexus injuries. Patients were divided into 4 groups:
[61]
graft based on an arterialized saphenous vein for the (1) pedicled vascularized ulnar nerve graft from
repair of median, ulnar, or radial nerves in 14 patients. As ipsilateral donors, (2) free vascularized ulnar nerve
expected, the denervation time had a profound influence graft from ipsilateral donors, (3) vascularized ulnar
on final results: 2 patients (1 radial nerve injury of 13 cm nerve graft from contralateral donors to the median
and 1 ulnar nerve injury of 10 cm) with denervation nerve, and (4) vascularized ulnar nerve graft from
time of less than 8 months had full restoration of contralateral donors to single motor targets (e.g. axillary,
motor function. In contrast, patients operated on after musculocutaneous and triceps) (n = 25, 21, 13, and 8
18 months showed no motor recovery. respectively). Postoperative muscle strength for patients
who were operated on late (denervation time > 12 months)
Vascularized nerve grafts with vascularized fascia was significantly decreased compared with the early
Terzis and Kostopoulos reported the results of twenty‑one group (< 6 months) (P = 0.049). The vascularized ulnar
[62]
VNGs used for reconstruction of nerve injuries in the nerve grafts for median nerve neurotization also yielded
upper extremity. Vascularized fascia was used to improve protective sensation in the hand in 91.6% of the patients
the blood supply of the underlying bed by enveloping the and produced better outcomes when compared to
nerve reconstruction. The authors reported satisfactory conventional nerve grafts (51% protective sensation).
[66]
results although the study lacked a control group. The authors concluded that, although VNGs can enhance
the speed of regeneration, factors such as patient
In case of a nerve injury of the upper limb associated age (better results for younger patients), denervation
with a soft tissue defect, the surgeon can use a time (poor results for late patient presentation), and graft
flow‑through ALT flap and a vascularized lateral femoral length (better results for ipsilateral grafting) do influence
nerve graft. However, inset is difficult, and the nerve the results.
should be harvested as proximally as possible in order
[67]
to obtain a larger caliber. To match the recipient nerve Birch et al. reported 42 brachial plexus lesions that
caliber, using cables from the donor as a NVNG may be were reconstructed with a vascularized ulnar nerve graft
necessary [Table 3]. (33 based on the ulnar vessel and 9 based on collateral
vessels in the arm). Of the 42 patients, 33 patients
When there is only a nerve injury for which a VNG is regained functional elbow flexion after connecting the
indicated, we advise using a vascularized sural nerve graft C5 root to the lateral cord or to the musculocutaneous
as there will be less caliber mismatch. nerve, using a free ulnar nerve graft shorter than 18 cm.

Brachial plexus injuries Significant functional recovery of the hand occurred in
Vascularized ulnar nerve graft only 1 patient. In 10 patients, recovery into the flexors
The vascularized ulnar nerve trunk graft can be used as of the wrist and/or the digits reached grade 3 power, but
function was restricted to only a hook grasp. Sensory
a free microsurgical transfer or pedicled on the superior return sufficient for recognition of harmful stimuli and
collateral ulnar artery. [63]
temperature change occurred in 10 patients. Delay from
Chuang et al. reported results of 167 patients who were injury to operation had a significant bearing on the
[64]
treated for impaired elbow flexion caused by brachial outcome: 4 patients with grafts performed more than
plexus injury. Ruptured plexus injuries recovered better 6 months following injury and 6 of 23 patients operated
than root avulsions and infraclavicular plexus injuries upon between 2 and 6 months did not achieve any
performed better than supraclavicular injuries. Functional functional recovery. These positive results match those
results revealed that nerve reconstruction produced of Oberlin et al., who also used free vascularized ulnar
[68]
results superior to muscle tendon transfers. The authors nerve grafts. The grafts had a length between 8 and
also found that vascularized ulnar nerve grafts were 25 cm (mean: 13.5 cm). In 83% of the 18 cases, there was
a functional return of elbow flexion.
Table 3: Indications for the upper limb nerve injury Bertelli and Ghizoni reported on results obtained with
[69]
Vascularized LFCN the reconstruction of elbow flexion. They used pedicled
Vascularized sural nerve ulnar nerve grafts, averaging 30 cm of length, with which
VNG with vascularized fascia they connected the C5 root to the musculocutaneous
LFCN: Lateral femoral cutaneous nerve, VNG: Vascularized nerve grafts nerve. None of the patients recovered useful function
Plast Aesthet Res || Vol 2 || Issue 4 || Jul 15, 2015 189