Vascularized Sural Nerve Graft with its Chimeric Skin Paddle Using Three Different Methods for Upper and Lower Extremities Reconstruction

Reconstructing nerve gaps greater than 13-15 centimeters often requires vascularized nerve grafts. However, using the sural nerve presents a technical challenge due to the lack of a consistent adjacent artery. This study introduces various free vascularized sural nerve flap designs to overcome this limitation. From 2018 to 2020, six patients at Chang Gung Memorial Hospital underwent eight free vascularized sural nerve grafts reconstruction, including brachial plexus, median, ulnar, posterior tibial, and sciatic nerve reconstructions. Three types of flap designs were performed: shunt-restricted arterialized lessor saphenous venous flap, vascularized sural nerve graft, and chimeric flap with peroneal or posterior tibial artery perforator flap. Most flaps maintained circulation successfully, with only one requiring conversion due to thrombosis. Mild congestion occurred in some venous flaps but resolved spontaneously. Tinel's sign advanced progressively in all patients, suggesting active nerve regeneration. These findings demonstrate that free vascularized sural nerve flaps are a flexible and effective option for managing long nerve defects. Tailoring the flap design to the clinical context offers reconstructive surgeons with a versatile strategy for peripheral nerve repair. Level of Evidence: Level 4/highly experienced category.