Tiam Mana Saffari

42 CHAPTER 2 Vascularization of a long nerve segment can be achieved by using a VNG alone, placed together or enveloped with a NVNG, or a vascularized adipose f lap can be placed around a NVNG to induce angiogenesis 57 . When using a sural nerve graft, blood supply will be based on the sural artery or the saphenous vein can be arterialized 66 . In cases of a larger nerve defect, grafts up to 60 cm could be harvested from the saphenous nerve, depending on the height of the patient 67 . Other options are the superficial peroneal nerve with its vascular pedicle, to reconstruct multiple nerves ranging from 14 to 30 cm 66 , or the superficial radial nerve which could be harvested with the radial artery 68 . To use this VNG, however, it is advocated that the radial artery should be reconstructed with a vein graft, in order to minimize donor site morbidity. Although VNGs have the potential to improve nerve reconstruction after injury, the surgeries are demanding and require microvascular experience. Technical challenges in matching diameter by cabling, while preserving blood supply, and finding recipient vessels if done as a free tissue transfer may prevent widespread adoption. In addition, considerations in the clinical application include location of obtaining sufficient peripheral nervous tissue and the associated donor site morbidity. Not only is the choice of donor site of importance, the injury site limits graft options as well, especially when the injury is situated near joint creases. In these cases, the environment of the nerve graft could be optimized by using a vascularized adipose-nerve composite transfer. Foo and colleagues described a novel technique of transferring a posterior interosseous nerve graft along with vascularized synovial and adipose tissue based on a branch of the posterior interosseous artery for neuromas of digital nerves, to provide a healthy tissue bed 69 . In large nerve defects with concomitant vascular trauma, immediate revascularization of a damaged artery has priority, limiting options for VNG harvest. In these cases, vascularized allografts could be applied 70 , potentially vascularized with the use of a flap.