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Previous work concerning the efficacy of different types of nerve repair has been reviewed. We describe a model in which epineurial and perineurial suture techniques were studied by quantitative ultramicroscopy and electrophysiology. In this model, we believe suture of the perineurium was shown to have a slight advantage over suture of the epineurium. Microscopic control and fascicular alignment are advocated to increase the percentage of axons growing into the distal stump and the periphery. The model described should lend itself to the study of other traumatic peripheral neuropathies.

OBPP is a disease with deleterious medical, psychological, and socioeconomic sequelae for the patient and his or her family. The majority of patients show acceptable spontaneous recovery with nonoperative management, which includes aggressive physical rehabilitation and electrical stimulation. There are patients with guarded prognosis, however, who have no chance of recovery unless they undergo early aggressive surgical reconstruction of the injured brachial plexus. It is of great importance to diagnose the injury type as early as possible, especially if there is minimal recovery in the early weeks of follow-up. This allows timely reconstruction to take place, earlier than 3 months for global palsy cases and at 3 months in Erb's type lesions, for best functional results.

The attempts to reconstruct a transected trunk nerve with a free nerve graft of equal diameter have been hindered by the problem of delayed establishment of blood supply to the nerve graft and development eventually of central necrosis and finally failure of nerve regeneration. The transfer of a nerve graft which maintains its blood supply through its vascular pedicle that is microsurgically anastomosed to the recipient site vessels, provided the reconstructive microsurgeon with a new perspective to the clinical problem. A vascularized nerve graft diminishes endoneurial scarring by maintaining the Schwann cell population and decreasing fibroblast infiltration providing, thus, an optimal nutritional environment that results in an increased rate of axonal regeneration.

Treatment of the short nerve gap remains a challenge for the reconstructive surgeon, but it is a clinical problem that can be addressed by nerve expansion. In the present study, the effects of slow nerve expansion on the walking behavior of the rat were examined. When expansion was applied on a normal sciatic nerve or on a transected nerve at either the proximal or the distal segments, permanent 30% elongation could be achieved. The recovered function from the expanded nerve stumps was compared with such classical methods of nerve reconstruction as nerve graft, coaptation under moderate tension, and tensionless repair. The results compared favorably between the expanded groups and the time-honored methods of nerve repair. Analysis of the behavioral data indicated that any amount of expansion affected the functional capabilities of the involved nerve. However, expansion of a normal nerve and/or proximal segment of a transected nerve was better tolerated than distal segment expansion, which suggests that the presence of an axon may have a beneficial effect in minimizing the deforming mechanical insult. Slow nerve expansion appears to have a definite role in the microsurgical management of the short nerve gap.

To study partial facial palsies, to understand the mechanism of the deformity, and to design therapeutic schemes to reverse the facial imbalance.

To critically analyze microreconstructive schemes aiming at the functional substitution of the paralyzed eye sphincter.

To present the introduction and our 6-year clinical experience of a new technique for facial reanimation by which ipsilateral “strong” motor donors are used to preserve denervated targets in complete or partial facial palsies until contralateral VII nerve motor fibers take over.

This report proposes that reflex sympathetic dystrophy be defined as a pain syndrome in which the pain is accompanied by loss of function and evidence of autonomic dysfunction. In the clinical setting, this diagnosis is usually associated with other anatomic and psychological diagnoses and may be associated with a variety of systemic illnesses and medicolegal factors. All components should be assessed before a treatment plan is established. Priorities should go to emergency care, acute injuries, and systemic illness, psychiatric problems, and chronic anatomic problems, in that order. Early, accurate diagnosis improves prognosis.

The primary aim in reconstructive surgery of the upper extremity is to provide tactile gnosis to sensory depleted areas. It is essential for restoration of function and successful rehabilitation of the injured hand. Neurovascular free flaps may provide the answer to this catastrophic problem and transform a useless appendage into a functional gripping hand. Sensory mapping techniques can greatly assist the surgeon in precisely defining new donor sites for these transfers. Cutaneous sensibility, cutaneous sensation, and hand function are subjects of great complexity. Much more investigative and clinical work is needed in this challenging field to improve our evaluation of the sensory injury to the hand and to provide new avenues for restoring functional sensibility in the upper extremity.

Results with peripheral nerve injuries, which today still fall short of our goals, should intensify our efforts in this specialized field of microsurgery. We are living in an exciting era of functional reconstitution. Long gone are the times when a pink replanted digit or a successful free flap comprised the end-point of our surgical efforts. The direction from now on is toward achieving functional restoration by utilizing basic principles while armed with the unlimited potentials of reconstructive microsurgery. To this end we need the assistance and cooperation of other sciences since the enigma of the peripheral nerve can be deciphered only by a multidisciplinary approach.

The authors' experience in the management of brachial plexus injuries over three periods of evolution is presented. Developments in microsurgery have expanded the strategies in brachial plexus management, and these are discussed in full.

1. A total of 791 fibers were isolated from the ulnar nerves of five baboons. Over half of these were obtained from the right ulnar nerves subsequent to reinnervation following a nerve crush; the other fibers were obtained from the undamaged left ulnar nerves. 2. The conduction velocities in the proximal portion of the injured axons dropped below normal, and this reduction persisted until reinnervation appeared nearly complete. 3. The response properties of 65 cutaneous afferent fibers serving reinnervated glabrous skin were compared to 80 fibers from normal skin. 4. Of the afferent fibers reinnervating skin, the proportion judged to have abnormal response properties was not significantly greater than the proportion in normal skin. 5. After reinnervation, cutaneous rapidly adpating fibers displayed tuning curves characteristic of their submodality, while some cutaneous slowly adapting fibers could still be differentiated into type I and type II fibers. However, both types of slowly adapting fibers displayed an increased rate of adaptation and a lowered sensitivity to sustained displacements even at 5 mo following reinnervation. 6. In conclusion, the cutaneous mechanoreceptors in reinnervated glabrous skin regained response properties that allowed them to be assigned to the same submodalities found in normal skin. Submodality was recognizable at an early stage when the receptive field was still immature and when the threshold was elevated. With time, the receptive-field sizes and shapes returned to normal, the thresholds approached normal, and the remaining differences from normal cutaneous afferent fibers became minor.

Many large-diameter myelinated axons in spinal dorsal roots contain carbonic anhydrase activity, whereas few small-diameter ventral root axons stain for this enzyme. This differential localization of carbonic anhydrase in sensory and motor nerve fibers is indicative of the potential of carbonic anhydrase histochemistry to provide a convenient method for identifying predominantly motor or sensory fascicles in cut ends of peripheral nerves, thereby facilitating coaptation of fascicles in peripheral nerve repair.

A scheme for surgery in patients with avulsed roots is represented by a rat model whose left sciatic nerve was grafted upon the right sciatic nerve, the proximal end of the graft being introduced into the spinal cord white matter. Transcranial stimulation, EMG recording, HRP and histological studies proved that the communication between the brain and the denervated muscles may be reestablished via the motoneurons, through the graft, bypassing the motor roots. Behavioral techniques were developed and will be tested in the future. The possibility of using neurotrophic drugs will be considered.

Replanted digital survivals range between 85% to over 90% at established microsurgery centers around the world. The time has come that all surgeons engaged in this activity must utilize the basic principles of reconstructive hand surgery in order to achieve the maximum functional return of the replanted parts. The vascular repair is only one step in the road toward functional restoration of the replanted part.

Our presently inadequate knowledge of the functional anatomy of the deep branch of the ulnar nerve handicaps our management of ulnar nerve lesions. The extensive anatomical variations in the distribution of this nerve preclude adherence to a textbook pattern of innervation. Electrophysiological recordings of single sensory fibers in monkeys along with fascicular stimulation studies provided novel information about the functional organization of the deep branch of the ulnar nerve: (1) there is a wide range of sensory fibers not currently recognized by textbook descriptions; (2) the innervation pattern is far more diffuse and covers greater areas than previously suspected; (3) at the distal forearm level the motor component of the deep ulnar branch is distributed throughout the entire ulnar nerve and is not restricted to specific fascicles; (4) contrary to previous assumptions, the deep branch of the ulnar nerve is mixed, and not purely motor. In fact, it may be mostly sensory. Afferent fibers arise from muscle, joints, deep subcutaneous tissues and even skin. These findings suggest that it is unwise to look at any nerve as purely motor or having a set innervation pattern, and emphasize the pressing need for objective preoperative and/or intraoperative functional assessment in peripheral nerve surgery.

This article supplies data related to 11 operated children with obstetric brachial plexus palsy. Discussion of the obstetric background, pathology, pre- and postsurgical testing and of primary and secondary surgical reconstruction also is given. The need for rehabilitation regimen is stressed.

This study has provided baseline data of a quantitative neurophysiological appraisal of normal breast sensibility using our current understanding of cutaneous mechanoreceptive function. Test variables, including pressure, low- and high-frequency vibration, static and moving two-point discrimination, temperature, nipple erectibility, and pain, were evaluated in 11 normal volunteers using different coordinates over the nipple, areola, and body of the breast. Definite patterns were established so that the breast could be subdivided into distinct cutaneous areas with differing mechanoreceptive characteristics. The future aim is to broaden the scope of this study with preoperative evaluations in our clinical patients so that appropriate recommendations for future reconstructive breast procedures can be made.

Nerve grafting has made advances in the last 100 years. One of the most significant of these was realizing the importance of adequate blood supply for successful nerve grafting. The vascular anatomy of the six potential vascularized donor nerves we have reviewed may prove to be extremely useful in reconstructing proximal nerve lesions, large nerve defects, and compromised recipient beds.

The author introduced this muscle for the first time almost a decade ago, and this is the first extensive description of the intricate microanatomy of this complex but unique microneurovascular muscle unit. Advantages and disadvantages and indications and contraindications for its use in facial paralysis are presented in detail from an extensive clinical experience of almost 50 such microneurovascular transfers. Pitfalls that the reconstructive microsurgeon should beware and strengths in using this muscle for facial palsy are highlighted. The detailed operative approach is presented, with promise of undetectable scars and minimal functional loss. The strategies for how to inset this muscle unit in the new recipient site are given, along with the thought processes involved in selecting the actual sites of anchoring the muscle to reproduce a mirror image of the contralateral normal face. Finally, an exemplary clinical case demonstrating the use of the pectoralis minor muscle for both eye and lower face reanimation is presented in detail, demonstrating the dual nerve supply and the resulting independent eye and smile movements with total lack of mass action and/or synkinesis. Restorations of eye blink and of a symmetrical and coordinated smile are the frequent rewards of using this unique muscle for the correction of facial palsy.