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Page 4 of 13 Eftekari et al. Plast Aesthet Res 2022;9:43 https://dx.doi.org/10.20517/2347-9264.2022.33

Figure 2. Visualization of sural nerve symptomatic neuroma prior to resection. Photo credit to Dr. Poore SO.

rate, 20%-30% of symptomatic neuromas remain refractory to surgery, and reoperation rates for all
symptomatic neuromas have been observed to be as high as 65% . Although traditional surgical
[17]
approaches provide initial symptomatic relief, pathologic pain returns all too often.

Excision under tension with retraction into soft tissue
The most common approach for the removal of a neuroma is simple neuroma excision . In this approach,
[7]
the neuroma is visualized and dissected away from surrounding tissue before transecting the involved nerve
to resect the neuroma. As one might anticipate, this freshly transected nerve will undergo the same
regenerative sprouting and axonal elongation that caused the formation of the original neuroma. To
mitigate this, a surgeon can transect the nerve under tension to allow the nerve to recoil deep into a muscle
belly. Less commonly, a surgeon may also elect to manually redirect the transected nerve and suture it into a
neighboring muscle . Burying the end of the transected nerve into muscle through either of these methods
[7]
allows the inevitable future neuroma to relocate to a deeper and more protected space, away from any
irritating external stimuli . Moreover, any anomalous innervation and interaction with adjacent tissue are
[7]
far away from problem structures such as the skin which decreases the chances of a hypersensitive
symptomatic neuroma .
[18]
The technique of relocating the residual nerve into a muscle belly is the most common neuroma resection
approach and dates back to 1918 when it was successfully done on two patients . Today, this technique is
[16]
still commonly used and completed prophylactically during amputation procedures to reduce the risk of
[16]
future symptomatic neuroma formation . Allowing the transected nerve to be buried into the surrounding
muscles has shown positive initial results for pain relief, with a clinical study involving 60 patients with
symptomatic neuromas showing 81% of patients reporting reduced pain following surgery at 31 months
postoperatively . However, this same study showed that success rate is highly dependent on neuroma
[19]
[19]
location and presentation . Neuromas in regions of the body that have large, secluded muscle bellies to
bury the transected nerve tend to have the best results, such as the forearm or thigh. Regions of the body
that do not have deep muscle bellies, such as the palm or digits of the upper extremity, showed success rates
of 14% with this approach .
[19]