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Toyoda et al. Plast Aesthet Res 2022;9:17 https://dx.doi.org/10.20517/2347-9264.2021.118 Page 13 of 17

Figure 3. Reconstructive AKA with primary RPNI. A 75-year-old woman with a history of total left knee arthroplasty complicated by
chronic peri-prosthetic infection who underwent multiple surgeries with poor bone and soft tissue availability underwent removal of
hardware and left AKA. (A) The tibial and peroneal components of the sciatic nerve were dissected. (B) Small muscle grafts roughly
2 cm × 4 cm were taken from the nearby semitendinosus. (C) The tibial and peroneal components of the sciatic nerve are wrapped with
the muscle grafts for RPNI. (D) The AKA incision was closed in layers over a drain. AKA: Above-knee amputation; RPNI: regenerative
peripheral nerve interface.

[60]
patient population .

Although these techniques were developed in the realm of plastic surgery, plastic surgery has a collaborative
history in which many surgical interventions developed by plastic surgeons are adopted by other specialties.
Amputation is performed by multiple surgical disciplines, including general surgery, orthopedic surgery,
and vascular surgery, depending on the patient-specific indications as well as institution. Given the
significant morbidity that post-amputation pain can have on these patients and the optimistic results with
TMR and RPNI, collaboration with amputating surgeons is not only frontier medicine, but also owed to the
patient to provide optimal care. In cases of limb salvage, the “orthoplastic approach” is the current gold
[77]
standard . Collaboration between orthopedists and plastic surgeons has been demonstrated to decrease
time to definitive skeletal stabilization and soft tissue coverage, length of hospital stay, postoperative
complications, and need for revision procedures, ultimately resulting in improved functional outcomes .
[78]
Amputation is an important alternative treatment for many in the same patient pool. One can conjecture
that collaboration between plastic surgeons, and the primary amputating surgical specialties would result in
improved outcomes, as demonstrated in preliminary results of primary TMR and RPNI.

Increasing evidence in the medical literature, as well as anecdotal evidence on a case-by-case basis, have
made primary TMR and RPNI the gold standard at our institution and multi-surgical collaboration for
these patients commonplace. Barriers to more widespread implementation of these new surgical techniques
[68]
include awareness by the primary amputating surgeon as well as access to technical instruction . Given
how impactful these surgical interventions can be on amputees’ quality of life and function, inter-