Turkof E, Jurecka W, Sikos G, Piza-Katzer H
Division of Plastic and Reconstructive Surgery, First Surgical University Clinic of Vienna, Austria.
Plast Reconstr Surg. 1993 Aug;92(2):238-47. doi: 10.1097/00006534-199308000-00007.
The aim of this study was to clarify the following questions: (1) Do newly sprouting axons use the empty neurilemmal sheaths of a flap as conduits? (2) To what extent can sensibility recover? (3) Does sensory recovery occur at the margins of the flap or at its center? (4) Does chemotaxis influence the regeneration process? In 16 free myocutaneous flaps (12 latissimus dorsi, 4 rectus abdominis) we investigated pain (pinprick), constant touch, temperature, 30- and 256-Hz vibration, and static and moving two-point discrimination between 1 1/2 and 8 years after surgery. Four flaps were anesthetic, eight recovered partly, and four had six or more modalities present all over the flap; six of ten flaps with poor recovery showed better sensitivity close to the anastomosis. Nine patients agreed to have two punch biopsies (6 mm) taken from their flaps (seven from areas with different degrees of sensory recovery and two from the center and the periphery when recovery was homogeneous). Biopsies from the areas with better sensory recovery showed slightly more nerves than the other punches in five instances, showed no difference between the two biopsies in one instance, and seemed to have more nerves in the biopsy from the area with less recovery in the last instance. The two pairs of biopsies from the homogeneously recovered flaps showed similar amounts of nerves. S-100 protein-positive neural structures (Schwann cells) were found in 13 biopsies, and neuron-specific enolase-positive nerve fibers (nerve axons) were found in 10 biopsies. Electron microscopy showed mainly unmyelinated fibers, always adjacent to vessels and sometimes with regenerative phenomena. We believe that sprouting axons probably grow into a flap attracted by chemotaxis from hair follicles, the basement membrane, and the laminin contained in the sheath. We recommend maximum scar excision at the recipient site to enhance sensory recovery in flaps. We conclude that (1) the sprouting axons primarily use the empty neurilemal sheaths as conduits, (2) sensory recovery can reach two-point discrimination equal to the donor site of the flap, and (3) sensory recovery occurs mainly from the margin of the flap but also from the bed.
（1）新萌出的轴突是否利用皮瓣的空神经鞘作为管道？（2）感觉能恢复到何种程度？（3）感觉恢复是发生在皮瓣边缘还是中央？（4）趋化作用是否影响再生过程？在16块游离肌皮瓣（12块背阔肌皮瓣，4块腹直肌皮瓣）中，我们在术后1.5至8年调查了疼痛（针刺）、持续触觉、温度、30赫兹和256赫兹振动以及静态和动态两点辨别觉。4块皮瓣无感觉，8块部分恢复，4块皮瓣各处存在六种或更多感觉模式；恢复较差的10块皮瓣中有6块在吻合口附近感觉较好。9名患者同意从其皮瓣取两块6毫米的穿刺活检组织（7块取自感觉恢复程度不同的区域，2块在恢复均匀时取自中央和周边）。在5例中，感觉恢复较好区域的活检组织显示神经略多于其他穿刺组织；1例中两块活检组织无差异；最后1例中感觉恢复较差区域的活检组织似乎神经更多。来自恢复均匀的皮瓣的两对活检组织显示神经数量相似。在13块活检组织中发现S - 100蛋白阳性神经结构（施万细胞），在10块活检组织中发现神经元特异性烯醇化酶阳性神经纤维（神经轴突）。电子显微镜显示主要为无髓纤维，总是与血管相邻，有时伴有再生现象。我们认为，萌出的轴突可能在毛囊、基底膜和鞘中所含层粘连蛋白的趋化作用吸引下长入皮瓣。我们建议在受区最大限度切除瘢痕以促进皮瓣感觉恢复。我们得出结论：（1）萌出的轴突主要利用空神经鞘作为管道；（2）感觉恢复可达到与皮瓣供区相等的两点辨别觉；（3）感觉恢复主要发生在皮瓣边缘，但也发生在皮瓣床。
