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Page 12 of 16 Garbuzov et al. Plast Aesthet Res 2023;10:9 https://dx.doi.org/10.20517/2347-9264.2022.51

Figure 3. Subcutaneous adipose tissue can be harvested and treated with collagenase to produce SVF, which can be cultured for 2-3
weeks to produce undifferentiated ADCSs [37,47] . These cells can be differentiated into ADSCs, which can in turn promote nerve
regeneration [37] .

published investigating ES in PNI in the lower extremity, one recent clinical trial found improved outcomes
[39]
in patients treated with adjuvant ES during surgery for severe cubital tunnel syndrome . However, more
clinical trials are needed to evaluate the clinical applications of electrical stimulation in the lower extremity.

ES can be provided at the time of nerve repair or as part of a long-term approach with a neuroprosthesis.
For example, in a case series by Possover et al., 29 patients with spinal cord injuries had long-term low-
frequency ES of the pelvic somatic nerves with a neuroprosthesis implanted laparoscopically at the time of
surgery . While some patients were reported to have improved sensory and motor function recovery, this
[51]
study was limited by its design, and further studies are needed to confirm the benefits of ES . Notably, one
[51]
concern with implantable neuroprosthesis is an induced foreign body reaction, which can compromise
benefits by provoking an inflammatory response . However, systemic dexamethasone treatment for 2
[52]
weeks in rats was found to significantly attenuate the inflammatory response, demonstrating a potential
[52]
adjuvant therapy to improve the function of neuroprostheses .

CONCLUSION
There have been many significant advancements in peripheral nerve surgery, though advances in the lower
extremity have lagged behind the upper extremity. Nerve transfers have been successfully performed in the
upper extremity and translated to the restoration of function in the lower extremity. Meanwhile, new targets
are being evaluated for their anatomical feasibility through cadaver studies, with case reports of successful
implementation in surgery. Nerve regeneration has been researched, primarily through basic science
studies, as a critical step that can be improved through ADSCs and ES.

Given the impact of lower extremity PNI on patient well-being, there must be a concerted effort to
investigate the benefit of the discussed interventions through continued research. While there are challenges
in translating basic science research to the clinical setting, the proposed interventions can be optimized.
One key challenge in using ADSCs is finding a source of cells that is readily available and complies with
[37]
federal regulation, thereby leading to investigations into fat grafting . In ES, the current protocol relies on
an hour-long session at the time of surgery, leading to research into a possible shortened duration as a
solution . Innovative solutions like these can promote continued advancement; however, clinical trials are
[10]