Valleix's Sign.

ABSTRACT: Some patients present with clinical symptoms of localized tenderness and pain associated with a specific peripheral nerve, such as the ulnar nerve at the elbow or the sciatic nerve, which has been called, although rarely, "Valleix point" or "Valleix phenomenon". The purpose of this article was to translate and research the 719-page book "Traité des névralgies ou affections douloureuses des nerfs" dated 1841, dedicated solely to nerve pain (neuralgia), written by the French physician François Louis Isidore Valleix (1807-1855). He may have been the first person to observe and describe this phenomenon of localized pain, but he was probably also the first to describe distal nerve radiation, which he called "élancement" or lancinating, or stabbing. He described the phenomenon of a nerve producing pain at points along its course that we now understand to be sites of compression, clearly describing cubital and fibular tunnel syndromes, which he called neuralgias. He also described some rarer sites of compression, such as supraorbital and occipital neuralgia, notalgia paresthetica, and ACNES, but he did not describe the most common site of compression today, the median nerve at the wrist. Valleix's descriptions are clear and precede the classic 1915 reports of Hoffmann's and Tinel's signs by 74 years.

Migraine/Headache "Tender Spots" Represent Referred Pain From Nerve Compression/Neuromas and Are Not "Trigger Points".

ABSTRACT: To minimize confusion in description of the clinical examination of the patient with migraine/headaches and implement peripheral nerve concepts into the surgical approach to treating the patient with migraines, the historical origin of the phrase "trigger point" is explored. The symptoms of migraine/headache are due to stimulation of the cranial/peripheral nerve being interpreted as due to stimulation of the meningeal innervation. Use of the phrase "extraction of trigger points" is discouraged in favor of either neurolysis of a compressed nerve or resection of a neuroma, depending upon the peripheral nerve pathology.

Early Penile and Donor Site Sensory Outcomes After Innervated Radial Forearm Free Flap Phalloplasty: A Pilot Prospective Study.

BACKGROUND: Radial forearm free flap phalloplasty (RFFF) is a set of complex reconstructive procedures aimed at creating an aesthetic and functional penis in transgender patients. Sensory recovery in the neophallus and donor site is crucial for optimizing outcomes, but the few prior studies that exist assess neophallus sensation at limited locations and time points. The purpose of this study was to prospectively quantify sensory outcomes in the neophallus and donor site following RFFF phalloplasty. METHODS: Sensation testing occurred prospectively over February 2019-January 2021 on Stage 1 RFFF phalloplasty patients using the Pressure Specified Sensory Device (PSSD). On the neophallus, one-point discrimination (1PS) pressure threshold and lengthwise sensory recovery were measured at six circumferential locations proximally to distally. On the donor site, 1PS was measured at three locations on the donor hand. RESULTS: Nineteen patients were included (average age 34.0 years old, range 18-53 years). Among patients that received neophallus testing (n = 13), eight had at least two follow-up appointments. Six of these patients had sensation as of their most recent measurement (75.0%), with an average of 73 days to regain sensation. There was a significantly greater proportion of patients with sensation at the right ventral (80.0% after 3 months vs. 11.1%-60.0% before 3 months, p = 0.024) and right lateral (100.0% after 3 months vs. 11.1%-60.0% before 3 months, p = 0.004) aspects of the neophallus over time. Pressure required to elicit sensation decreased by 18.0% from 1 week-1 month postoperatively to 3-7.7 months postoperatively in the right ventral neophallus (96.2 g/mm2 ± 11.3 g/mm2 to 56.6 ± 39.9 g/mm2, p = 0.037). Among patients that received donor site testing (n = 11), mixed effects regression analysis with random intercepts demonstrated significant changes in the thumb (3.4 g/mm2 ± 1.4 g/mm2, p < 0.05) and webspace (13.5 g/mm2 ± 4.9 g/mm2, p < 0.01) that returned to baseline at 3 months postoperatively (1.7 g/mm2 ± 1.0 g/mm2, p > 0.05, and 2.3 g/mm2 ± 4.0 g/mm2, p > 0.05, respectively). CONCLUSION: This pilot study demonstrates that quantitative sensory testing can be used to monitor post-phalloplasty sensory changes. Recovery was significantly associated with contralateral (i.e, right side in a left forearm RFF) aspects of the neophallus, suggesting a possible pattern of circumferential sensory innervation via RFFF sensory nerves. Future studies with a larger sample size and longer follow-ups are necessary to fully characterize sensory recovery in phalloplasty patients.

Economic Cost-Benefit Analysis of Nerve Implanted into Muscle versus Targeted Muscle Reinnervation versus Regenerative Peripheral Nerve Interface, for Treatment of the Painful Neuroma.

BACKGROUND: This study investigated the relative cost utility of three techniques for the management of symptomatic neuromas after neuroma excision: (1) implantation of nerve into muscle, (2) targeted muscle reinnervation (TMR), and (3) regenerative peripheral nerve interface (RPNI). METHODS: The costs associated with each procedure were determined using Common Procedural Terminology codes in combination with data from the Centers for Medicaid and Medicare Services Physician and Facility 2020 Fee Schedules. The relative utility of the three procedures investigated was determined using changes in Patient-Reported Outcomes Measurement Information System (PROMIS) and Numeric Rating Scale (NRS) pain scores as reported per procedure. The relative utility of each procedure was reported in terms of quality-adjusted life years (QALYs), as is standard in the literature. RESULTS: The least expensive option for the surgical treatment of painful neuromas was nerve implantation into an adjacent muscle. In contrast, for the treatment of four neuromas, as is common postamputation, TMR without a microscope was found to cost $50,061.55 per QALY gained, TMR with a microscope was found to cost $51,996.80 per QALY gained, and RPNI was found to cost $14,069.28 per QALY gained. While RPNI was more expensive than nerve implantation into muscle, it was still below the standard willingness-to-pay threshold of $50,000 per QALY, while TMR was not. CONCLUSION: Evaluation of costs and utilities associated with the various surgical options for the management of painful neuromas suggest that nerve implantation into muscle is the least expensive option with the best improvement in QALY, while demonstrating comparable outcomes to TMR and RPNI with regard to pain symptoms.

Cryoanalgesia: Review with Respect to Peripheral Nerve.

BACKGROUND: Cryoanalgesia is a tool being used by interventional radiology to treat chronic pain. Within a certain cold temperature range, peripheral nerve function is interrupted and recovers, without neuroma formation. Cryoanalgesia has most often been applied to the intercostal nerve. Cryoanalgesia has applications to peripheral nerve surgery, yet is poorly understood by reconstructive microsurgeons. METHODS: Histopathology of nerve injury was reviewed to understand cold applied to peripheral nerve. Literature review was performed utilizing the PubMed and MEDLINE databases to identify comparative studies of the efficacy of intraoperative cryoanalgesia versus thoracic epidural anesthesia following thoracotomy. Data were analyzed using Fisher's exact and analysis of variance tests. A similar approach was used for pudendal cryoanalgesia. RESULTS: Application of inclusion and exclusion criteria resulted in 16 comparative clinical studies of intercostal nerve for this review. For thoracotomy, nine studies compared cryoanalgesia with pharmaceutical analgesia, with seven demonstrating significant reduction in postoperative opioid use or postoperative acute pain scores. In these nine studies, there was no association between the number of nerves treated and the reduction in acute postoperative pain. One study compared cryoanalgesia with local anesthetic and demonstrated a significant reduction in acute pain with cryoanalgesia. Three studies compared cryoanalgesia with epidural analgesia and demonstrated no significant difference in postoperative pain or postoperative opioid use. Interventional radiology targets pudendal nerves using computed tomography imaging with positive outcomes for the patient with pain of pudendal nerve origin. CONCLUSION: Cryoanalgesia is a term used for the treatment of peripheral nerve problems that would benefit from a proverbial reset of peripheral nerve function. It does not ablate the nerve. Intraoperative cryoanalgesia to intercostal nerves is a safe and effective means of postoperative analgesia following thoracotomy. For pudendal nerve injury, where an intrapelvic surgical approach may be difficult, cryoanalgesia may provide sufficient clinical relief, thereby preserving pudendal nerve function.

Histologic evidence of brachial plexus compression sites at the thoracic inlet and variations in formation of the lower trunk in cadavers.

BACKGROUND: In thoracic "outlet" syndrome (TOS), pathologic evidence is well documented for vascular but not neurologic compression. We hypothesized that histologic evidence of compression would be identified at sites where the upper trunk was impacted by the anterior scalene muscle and the lower trunk by anatomic anomalies or the first rib. The purpose of this study was to investigate this hypothesis in human cadavers. MATERIALS AND METHODS: Twenty-five cadavers' brachial plexuses were dissected and excised. Histologic and descriptive analysis was directed at juncture 1, the upper trunk and anterior scalene muscle, and juncture 2, C8 and T1 nerve roots (lower trunk) with the posterior border of the first rib. Measurements were obtained at the juncture of the T1 nerve root with the C8 nerve root in relationship to the first rib. RESULTS: Histologic analysis demonstrated epineurial and perineurial fibrosis, myelin thinning, and Renaut bodies at junctures 1 and 2. Lower trunk formation occurred on or lateral to the first rib in 66% of specimens, with asymmetry in 32% of cadavers. A muscle of Albinus was present in 18% of cadavers. A large dorsal scapular artery coursed through 36% of plexuses with a high, arched subclavian artery. CONCLUSIONS: We report histologic changes consistent with chronic compression of the upper and lower plexus in the thoracic inlet at hypothesized sites of brachial plexus compression that may correlate with clinical neck/shoulder (upper trunk) and "ulnar nervelike" (C8-T1/lower trunk) symptoms. Anatomic anomalies identified should alert the surgeon to variations of lower trunk formation at compression sites.

Anococcygeal Nerve and Sitting Pain: Differential Diagnosis and Treatment Results.

BACKGROUND: The plastic surgeon is often asked to reconstruct the sacral area related to pilonidal cysts or a tumor, or after other surgery, such as coccygectomy. When sitting pain is not due to the pudendal or posterior femoral cutaneous nerve injury, the anococcygeal nerve (ACN) must be considered. Clinically, its anatomy is not well known. Rather than consider coccygectomy when the traditional nonoperative treatment of coccydynia fails, resection of the ACN might be considered. METHODS: A review of traditional anatomy textbooks was used to establish classical thoughts about the ACN. A retrospective cohort of patients with sitting pain related to the coccyx was examined, and those operated on, by resecting the ACN, were examined for clinicopathologic correlations. RESULTS: When the ACN is described in anatomy textbooks, it is with varying distributions of innervated skin territory and nerve root composition. Most include an origin from sacral 5 and coccygeal 1 ventral roots. Most agree that the ACN forms on the ventral side of the sacrum/coccyx, alongside the coccygeus muscle, to emerge laterally and travel dorsally to innervate skin over the coccyx and lower sacrum. A review of 13 patients with sitting pain due to the ACN, from 2015 to 2019, demonstrated a mean age of 54.6 years. Eleven were female. The etiologies of ACN injury were falls (9), exercise (3), and complication from surgery (1). Six of the 9 patients who had surgery were able to be followed up with a mean length of 36.3 months (range, 11-63 months). Overall, 3 had an excellent result, 2 had a good result, and 1 was not improved. The one with a failed result showed improvement with coccygectomy. CONCLUSIONS: The ACN must be included in the differential diagnosis of sitting pain. It is most often injured by a fall. The ACN can be evaluated with a diagnostic nerve block, can be identified at surgery, and can be resected, and its proximal end can be implanted into the coccygeus muscle. This surgery may prove an alternative to coccygectomy.

Approach to Diagnosis and Treatment of Dorsoradial Hand and Forearm Pain.

Dorsoradial forearm and hand pain was historically considered difficult to treat surgically due to a particular susceptibility of the radial sensory nerve (RSN) to injury and/or compression. A nerve block, if it were done at all, was directed at the region of the anatomic snuff box to block the RSN in an effort to provide diagnostic information as to the pain etiology. Even for patients with pain relief following a diagnostic block, resecting the RSN often proved unsuccessful in fully relieving pain. The solution to successful treatment of this refractory pain problem was the realization that the RSN is not the sole source of sensory innervation to the dorsoradial wrist. In fact, in 75% of people the lateral antebrachial cutaneous nerve (LABCN) dermatome overlaps the RSN with other nerves, such as the dorsal ulnar cutaneous nerve and even the posterior antebrachial cutaneous nerves, occasionally providing sensory innervation to the same area. With this more refined understanding of the cutaneous neuroanatomy of the wrist, the diagnostic nerve block algorithm was expanded to include selective blockage of more than just the RSN. In contemporary practice, identification of the exact nerves responsible for pain signal generation informs surgical decision-making for palliative neurolysis or neurectomy. This approach offers a systematic and repeatable method to inform the diagnosis and treatment of dorsoradial forearm and wrist pain.

A History of Anatomical Eponyms of the Ulnar Nerve.

The ulnar nerve has a long and often misunderstood history with eponym usage. We describe the history of eponym usage in the anatomy of the ulnar nerve-who, when, what, where, and how. The relevant anatomy is investigated from proximal to distal, from the Arcade of Struthers to Osborne's band, to forearm ulnar nerve to median nerve connections, to Guyon's canal. We hope to provide a historical perspective of interest, resolve any controversies in semantic definitions, and create a comprehensive library of eponymous terms related to ulnar nerve anatomy.

Complex regional pain syndrome patient treated with a below knee amputation, implanting nerves directly into muscle: A case report.

Persistent, disabling lower extremity pain, outside the distribution of a single nerve, is termed chronic regional pain syndrome (CRPS), but, in reality, this chronic pain is often due to multiple peripheral nerve injuries. It is the purpose of this report to describe the first application of the "traditional," nerve implantation into muscle, usually used in the treatment of a painful neuroma, as a pre-emptive surgical technique in doing a below knee amputation (BKA). In 2011, a 51-year-old woman developed severe, disabling CRPS, after a series of operations to treat an enchondroma of the left fifth metatarsal. When appropriate peripheral nerve surgeries failed to relieve distal pain, a BKA was elected. The approach to the BKA included implantation of each transected peripheral nerve directly into an adjacent muscle. At 5.0 years after the patient's BKA, the woman reported full use of this extremity, using the prosthesis, and was free of phantom limb and residual limb pain. This anecdotal experience gives insight that long-term relief of lower extremity CRPS can be achieved by a traditional BKA utilizing the approach of implanting each transected nerve into an adjacent muscle.

Chronic Neuropathic Pain Following Hand Burns: Etiology, Treatment, and Long-Term Outcomes.

PURPOSE: Chronic neuropathic pain (CNP) after burn injury to the hand/upper extremity is relatively common, but not well described in the literature. This study characterizes patients with CNP after hand/upper extremity burns to help guide risk stratification and treatment strategies. We hypothesize that multiple risk factors contribute to the development of CNP and refractory responses to treatment. METHODS: Patients older than 15 years admitted to the burn center after hand/upper extremity burns, from January 1, 2014, through January 1, 2019, were included. Chronic neuropathic pain was defined as self-described pain for longer than 6 months after burn injury, not including pain due to preexisting illness/medications. Two analyses were undertaken: (1) determining risk factors for developing CNP among patients with hand/upper extremity burns, and (2) determining risk factors for developing refractory pain (ie, nonresponsive to treatment) among hand/upper extremity burn patients with CNP. RESULTS: Of the 914 patients who met the inclusion criteria, 55 (6%) developed CNP after hand/upper extremity burns. Twenty-nine of these patients (53%) had refractory CNP. Significant risk factors for developing CNP after hand/upper extremity burns included history of substance abuse and tobacco use. Among CNP patients, significant risk factors for developing refractory pain included symptoms of burning sensations. In all CNP patients, gabapentin and ascorbic acid were associated with significant decreases in pain scores on follow-up. CONCLUSIONS: Substance abuse and tobacco use may contribute to the development of CNP after hand/upper extremity burns. Those who developed refractory CNP were more likely to use the pain descriptor, burning sensations. Pharmacological pain management with gabapentin or pregabalin and ascorbic acid may provide the most relief of CNP symptoms. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Effects of a Porcine Extracellular Matrix Nerve Wrap as an Adjunct to Primary Epineurial Repair.

PURPOSE: Outcomes after end-to-end epineural suture repair remain poor. Nerve wraps have been advocated to improve regeneration across repair sites by potentially reducing axonal escape and scar ingrowth; however, limited evidence currently exists to support their use. METHODS: Forty Lewis rats underwent median nerve division and immediate repair. Half were repaired with epineural suturing alone, and the others underwent epineural suture repair with the addition of a nerve wrap. Motor recovery was measured using weekly grip strength and nerve conduction testing for 15 weeks. Histomorphometric analyses were performed to assess intraneural collagen deposition, cellular infiltration, and axonal organization at the repair site, as well as axonal regeneration and neuromuscular junction reinnervation distal to the repair site. RESULTS: The wrapped group demonstrated significantly less intraneural collagen deposition at 5 weeks. Axonal histomorphometry, cellular infiltration, neuromuscular junction reinnervation, and functional recovery did not differ between groups. CONCLUSIONS: Nerve wraps reduced collagen deposition within the coaptation; however, no differences were observed in axonal regeneration, neuromuscular junction reinnervation, or functional recovery. CLINICAL RELEVANCE: These findings suggest that extracellular matrix nerve wraps can attenuate scar deposition at the repair site. Any benefits that may exist with regards to axonal regeneration and functional recovery were not detected in our model.

Neurolysis of the Dorsal Nerve to the Penis to Restore Function After Trauma.

BACKGROUND: Loss of penile sensation or development of a painful penis and erectile dysfunction can occur after injury to the dorsal branch of the pudendal nerve. Although recovery of genital sensibility has been discussed frequently in transmen, this subject has been reported rarely in cismen. The purpose of this report is to review our experience with recovery of sensation in men after decompression of the dorsal branch of the pudendal nerve after trauma. METHODS: A retrospective chart review of men who have had decompression of the dorsal branch of the pudendal nerve was carried out from 2014 to 2018. Patients were included in the cohort if they had a loss of penile sensation or the development of a painful penis after trauma. Primary outcomes measured were the change in penile symptoms, including erection, ejaculation, ejaculatory pain, erogenous sensation, numbness, and penile pain. RESULTS: For the 7 men included in this study, the mean follow-up time was 57 weeks (range, 28-85 weeks). Bilateral surgery was done in 71% (5/7). Of the 6 patients with loss of penile sensation, complete recovery of erogenous sensibility occurred in 5 (83%) patients, with partial relief in 1 (17%) patient. Of the 3 men who had erectile dysfunction, normal erections were restored in 2 (67%) patients. Of the 2 patients unable to ejaculate, 1 (50%) patient regained ejaculatory function. Of the 4 patients with ejaculatory pain, complete relief of pain occurred in 2 (50%) patients, with partial relief in 2 (50%) patients. Of the 6 patients with penile pain in the absence of ejaculation, complete relief of pain occurred in 3 (50%) patients, with partial relief in 3 (50%) patients. CONCLUSION: Neurolysis of the dorsal nerve to the penis at the inferior pubic ramus canal can be successful in relieving pain, and restoring sensation and erectile function in men who sustained an injury along the inferior pubic ramus.

Persistent genital arousal disorder: Treatment by neurolysis of dorsal branch of pudendal nerve.

BACKGROUND: Persistent genital arousal disorder (PGAD) is a woman's perception that she is in a state of sexual arousal, without the ability of arousal to be satisfied by orgasm. It is the hypothesis of this study that PGAD results from a minimal degree of nerve compression of the dorsal branch of the pudendal nerve. If this is true, PGAD could be treated by neurolysis of the dorsal branch of the pudendal nerve. METHODS: A retrospective chart review from 2010 through 2018, of those women having neurolysis of the dorsal branch of the pudendal nerve for PGAD. The main outcome measures were the pre-operative and post-operative changes in clitoral symptoms (arousal, numbness, pain). RESULTS: Eight women included in this study were followed more than 26 weeks since surgery (mean = 65, range = 26-144 weeks). Seven of these women had the surgery bilaterally, and each of these had an excellent result, meaning elimination of the arousal symptoms, and the ability to resume normal sexual intercourse. The patient with unilateral decompression of the dorsal branch of the pudendal nerve was the only patient who had some, versus complete improvement in arousal symptoms. Of the seven women that had pain, six had complete relief and one had partial relief. No major surgical complications were observed. CONCLUSION: The relief of arousal symptoms by neurolysis of the dorsal nerve to the clitoris supports the hypothesis that PGAD is due to a minimal degree of compression of the dorsal branch of the pudendal nerve.

An Algorithm for the Prevention and Treatment of Pain Complications of the Radial Forearm Free Flap Donor Site.

BACKGROUND: The radial forearm free flap (RFFF) is a staple of microsurgical reconstruction. Significant attention has been paid to donor-site morbidity, particularly vascular and aesthetic consequences. Relatively few authors have discussed peripheral nerve morbidity such as persistent hypoesthesia, hyperesthesia, or allodynia in the hand and wrist or neuroma formation in the wrist and forearm. Here, we present a diagnostic and therapeutic algorithm for painful neurologic complications of the RFFF donor site. MATERIALS AND METHODS: The peripheral nerves that can be involved with the RFFF are reviewed with respect to the manner in which they may be involved in postoperative pain manifestations. A method for prevention and for treatment of each of these possibilities is also presented. RESULTS: Nerves from the forearm that can be harvested with the RFFF will have the most likelihood for injury and these include the lateral antebrachial cutaneous nerve, the radial sensory nerve, and the medial antebrachial cutaneous nerve. A nerve that may be injured at the distal juncture of the skin graft to the forearm is the palmar cutaneous branch of the median nerve. The "prevention" portion of the algorithm suggests that each nerve divided to become a recipient nerve should have its proximal end implanted into a muscle to prevent painful neuroma. The "treatment" portion of the algorithm suggests that if a neuroma does form, it should be resected, not neurolysed, and the proximal portion should be implanted into an adjacent muscle. The diagnostic role of nerve block is emphasized. CONCLUSION: Neurological complications following RFFF can be prevented by an appropriate algorithm as described by devoting attention to the proximal end of recipient nerves. Neurological complications, once present, can be difficult to diagnose accurately. Nerve blocks are critical in this regard and are employed in the treatment algorithm presented.

Selective Thumb Carpometacarpal Joint Denervation for Painful Arthritis: Clinical Outcomes and Cadaveric Study.

PURPOSE: To determine the innervation pattern to the thumb carpometacarpal (CMC) joint and assess the safety and efficacy of selective joint denervation for the treatment of pain and impairment associated with thumb CMC arthritis. METHODS: Cadaveric dissections were performed in 10 fresh upper extremities to better define the innervation patterns to the CMC joint and guide the surgical approach for CMC joint denervation. Histologic confirmation of candidate nerves was performed with hematoxylin and eosin staining. Results from a series of 12 patients with symptomatic thumb CMC arthritis who underwent selective denervation were retrospectively evaluated to determine the safety and efficacy of this treatment approach. Differences in preoperative and postoperative measurements of grip and key-pinch strength as well as subjective reporting of symptoms were compared. RESULTS: Nerve branches to the thumb CMC joint were found to arise from the lateral antebrachial cutaneous nerve (10 of 10 specimens), the palmar cutaneous branch of the median nerve (7 of 10 specimens), and the radial sensory nerve (4 of 10 specimens). With an average follow-up time of 15 months, 11 of 12 patients (92%) reported complete or near-complete relief of pain. Average improvements in grip and lateral key-pinch strength were 4.1 ± 3.0 kg (18% ± 12% from baseline) and 1.7 ± 0.5 kg (37% ± 11% from baseline), respectively. One patient experienced the onset of new pain consistent with a neuroma that resolved with steroid injection. All patients were released to light activity at 1 week after surgery, and all activity restrictions were lifted by 6 weeks after surgery. CONCLUSIONS: Selective denervation of the CMC joint is an effective approach to treat pain and alleviate impairment associated with CMC arthritis. The procedure is well tolerated, with faster recovery as compared with trapeziectomy. Branches arising from the lateral antebrachial cutaneous nerve, palmar cutaneous branch of the median nerve, and radial sensory nerve can be identified and resected with a single-incision Wagner approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Genital Sensibility in the Neophallus: Getting a Sense of the Current Literature and Techniques.

INTRODUCTION: Phalloplasty attempts to achieve a functional and aesthetic phallus. Sensation is a key component for sexual pleasure. Sensation is also important for protection in the setting of penile implant insertion. Little data are available on genital sensibility outcomes after phalloplasty, and there are no standardized approaches for assessment of either sensibility or erogenous perception. METHODS: A literature search of PubMed, Google Scholar, and MEDLINE databases was conducted with terms related to genital sensibility after phalloplasty. Data on patient demographics, nerves used for coaptation, and measurements of genital sensibility were collected. Pooled event rates were determined for recovered glans sensibility and recovered erogenous sensation using a Freeman-Tukey arcsine transformation. RESULTS: A total of 341 articles were identified of which 26 met the inclusion criteria for final analysis. The dorsal cutaneous branch of the pudendal nerve and ilioinguinal were the most common donor nerves. The lateral and medial antebrachial cutaneous and lateral femoral cutaneous were the most common recipient nerves. Pooled event rates suggest that some recovered glans sensibility occurs in more than 70% of cismale patients and in more than 90% of transmale patients. Recovered "erogenous" sensation occurs in more than 75% of cismale patients and more than 95% of transmale patients. In cismale patients, outcomes of recovered glans sensibility and erogenous sensation may be better for upper extremity recipient nerves than lower extremity recipient nerves. CONCLUSIONS: Based on the limited data in current literature on genital sensibility after phalloplasty, it is difficult to draw evidence-based conclusions. Yet data support improved outcomes with innervation. A validated outcome measure of "erogenous sensation" and a standardized approach to measuring cutaneous sensibility are required.

Painful Complications After Cosmetic Surgery: Management of Peripheral Nerve Injury.

BACKGROUND: Aesthetic procedures are among the most common surgeries performed by plastic surgeons. The prevalence of persistent pain remains unknown and underappreciated in the plastic surgery literature. OBJECTIVES: The purpose of this article was to increase awareness of this problem while describing the diagnostic and management strategies for patients with postoperative pain after aesthetic plastic surgery. METHODS: A literature review was performed utilizing the PubMed database to identify painful complications of brachioplasty, blepharoplasty, rhytidectomy, abdominoplasty, breast augmentation, mastopexy, and breast reduction. A treatment algorithm was described to guide plastic surgeons presented with patients reporting pain after aesthetic surgery. RESULTS: Title and abstract review followed by application of inclusion and exclusion criteria resulted in 20 clinical studies for this review, including lateral femoral cutaneous nerve, iliohypogastric nerve, and intercostal nerves after abdominoplasty; median antebrachial cutaneous nerve after brachioplasty; supraorbital, supratrochlear, and infratrochlear nerves after blepharoplasty; greater auricular nerve, auriculotemporal nerve, and zygomaticofacial nerve after rhytidectomy; and intercostobrachial nerve after breast surgery. CONCLUSIONS: Neuromas can be the source of pain following aesthetic surgery. The same clinical and diagnostic approach used for upper and lower extremity neuroma pain can be employed in patients with persistent pain after aesthetic surgery.

Resection of the Posterior, Middle, and Anterior Superior Alveolar Nerves and Infraorbital Nerve Neurolysis for Refractory Maxillary Pain.

Trigeminal injury can cause intractable facial pain. However, surgical approaches to the superior alveolar nerves have not been widely described. We report resection of the anterior superior alveolar nerve (ASAN), middle superior alveolar nerve (MSAN), and posterior superior alveolar nerve (PSAN) in a patient with refractory facial pain and outline an algorithmic approach to the treatment of trigeminal nerve injury. A 56-year-old woman presented with a 3-year history of refractory facial pain in the distribution of the right superior alveolar nerves after dental trauma. As a comorbidity, central sensitization developed in the patient, manifesting in the uninjured oral areas being painful. After several temporary nerve blocks and medical management, the patient underwent resection of the ASAN, MSAN, and PSAN, as well as neurolysis of the infraorbital nerve, through a Caldwell-Luc approach. One week postoperatively, she reported substantial improvement in pain symptoms, including burning and temperature sensitivity, in the right maxilla. These findings were maintained at 7 months, without any maxillary sinus complications. Central sensitization caused continued intraoral symptoms. The ASAN, MSAN, and PSAN can be surgically resected within the maxillary sinus to treat refractory neuropathic pain. An etiology-based approach can guide successful treatment of trigeminal neuropathy. Central sensitization as a comorbidity must be addressed medically.

Defining the Anatomy of the Tendinous Intersections of the Rectus Abdominis Muscle and Their Clinical Implications in Functional Muscle Neurotization.

PURPOSE: Little is known about the definitive course of the tendinous intersections from anterior to posterior through the rectus abdominis (RA) muscle. The implications of a full thickness intersection may have effects on the ability to neurotize the RA. We hypothesized that these tendinous inscriptions would be fully adherent to the anterior rectus sheath, but there would be an incomplete penetrance into the posterior surface, thereby allowing for muscle fibers and neurovascular structures to run the entire course of the RA muscle. METHODS: Fifty-five cadaveric, hemiabdominal walls were evaluated. Measurements were taken of RA muscle thickness, depth of penetrance of the tendinous intersections, and intersection thickness. RESULTS: Of the 32 cadavers, 2 had 4 paired tendinous intersections and the remaining 30 cadavers had 3 paired tendinous intersections. Rectus abdominis muscle belly tended to be thicker at midbelly, between intersections than at the level of the corresponding intersection. A total of 168 tendinous intersections were assessed. Thirty (18%) of these inscriptions proved to be full thickness extending from anterior rectus sheath to posterior rectus sheath without any intervening muscle or neurovascular structures. Twenty-three (42%) of the 55 hemiabdomens assessed had at least one full-thickness tendinous intersection. CONCLUSIONS: The majority of RA muscles have 3 paired tendinous intersections. Most intersections are incomplete and only encompass the anterior rectus sheath. However, there may be a higher percentage of full-thickness intersections than previously appreciated and the clinical relevance behind these remains unclear.