Technique

Key technical points include the following:

Loupe magnification, preferably 4.3, is employed with use of the microscope for
microneurosurgical repairs or grafts
Extremity surgery is performed using tourniquet control
Nerve coaptations are performed with 9-0 microsuture so that tension at the repair site is avoided
Bupivacaine is used at the incision site, and in some cases, it also may be used in an infusion
pump to control postoperative pain
A Jackson-Pratt drain also may be used in some cases to control postoperative drainage

Nerve repair
Reconstruction of nerve continuity can be performed with direct repair.[11] This is performed when the distal
and proximal ends of the nerve are directly coapted. The repair should be performed without tension; if it
cannot be performed without tension, other types of nerve reconstruction should be performed, such as
nerve graft or nerve transfer. If the adjacent joint must be flexed or extended to permit coaptation of the
distal and proximal ends of the nerve, a nerve graft should be used.

Nerve graft
In cases where the proximal and distal nerve segments cannot be approximated without tension or where
a gap is present between the proximal and distal end of the nerve, a nerve graft may be recommended. [2, 8,
12, 13, 14]
The use of a donor nerve results in a sensory loss in the distribution of the donor nerve. This area of
sensory loss becomes smaller over 1-3 years with collateral sprouting from the surrounding sensory
nerves.[15]
In cases where a large nerve gap is present, the sural nerve is used because of the large length of nerve
graft material that can be obtained. The sural nerve can be harvested through a single long incision or
through multiple step incisions on the posterior calf.
For shorter nerve gaps, the anterior branch of the medial antebrachial cutaneous (MABC) nerve is a good
graft donor because the donor site scar is minimal and the resultant sensory loss is on the anterior aspect
of the forearm. The MABC nerve is especially useful for upper-extremity surgical reconstructions because
all of the incisions are located in the same extremity. The lateral antebrachial cutaneous nerve provides
about 6 cm of nerve graft material, but the scar on the forearm is more noticeable than that on the inner
upper arm for the MABC.

Nerve transfer
The concept of a nerve-to-nerve transfer permits a normal neighboring noncritical nerve to be coapted to
the distal end of the injured nerve.[14] This is particularly useful in cases where a large nerve gap is
present, proximal nerve injuries are present, or both. [16, 17, 18, 19, 20, 21] Excellent results have been shown with
proximal brachial plexus injuries and distal median, radial, and ulnar nerve injuries