British Journal of Oral and Maxillofacial Surgery (2000) 38, 138–141

© 2000 The British Association of Oral and Maxillofacial Surgeons

DOI: 10.1054/bjom.1999.0334

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Vascularized transplantation of the long thoracic nerve for sensory

reinnervation of the lower lip

G. Schultes, A. Gaggl, H. Kärcher*

Surgeons; *Head, Clinical Department of Oral and Maxillofacial Surgery, University Hospital Graz, Graz,
Austria

SUMMARY. Microsurgical techniques have improved functional and morphological reconstruction of the face in
recent years. An important factor is the re-establishment of neuronal function. The aim of this study was a follow-up
of the regeneration of sensation in the inferior alveolar nerve after partial resection of a tumour and reconstruction
with a vascularized long thoracic nerve graft. Five patients were examined in monthly intervals to assess the degree
of re-establishment of sensation. Pressure and pain responses were elicited as early as three months postoperatively,
sense of touch and vibration were found after five months, and sensitivity to temperature after seven months
postoperatively. In four patients nine months postoperatively, sensory qualities in the region of the mental nerve were
identical on both sides. The vascularized long thoracic nerve is therefore an adequate nerve graft for covering defects
as a result of resection of the inferior alveolar nerve patients with tumours.

INTRODUCTION for implementation of the complex vascularized nerve

transplant such as poorly vascularized transplant
Since the introduction of microsurgical techniques, sites, unsuccessful conventional nerve transplants,
methods of reconstruction in oral and maxillofacial wide transplants, and the need for microvascular
surgery have greatly improved. Adequate morpho- reconstruction of the defect during the operation. The
logical reconstruction has been paralleled by func- vascularized nerve transplant does, however, offer
tional improvement. An important advance was the numerous advantages over the non-vascularized
opportunity to cover neuronal defects and re-establish transplant. Terzis et al.17 found a reduction in the
sensory and motor function. The re-establishment of amount of endoneural scar formation through an
neuronal ability after loss of neuronal function after increase in the number of Schwann’s cells, a reduction
injury or resection of a tumour is of the utmost in fibroblast infiltration into the nerve tissue, and an
importance in reconstructive surgery. In the case of increased rate of axonal regeneration. Ozcan et al.18
extensive resection in tumour surgery, vital parts of also found larger axon diameters and broader myelin
peripheral nerves responsible for function and aes- sheets as did Koshima and Harii.19 In general, there
thetics must be resected. This may involve the is better and quicker histomorphological regeneration
hypoglossus nerve, the facial nerve, the accessory in vascularized nerve transplants, as described by
nerve, branches of the trigeminal nerve, the mandibu- Kärcher and Kleinert.14 This could be the result of
lar and maxillary nerve and their terminal branches, an improved long-term intraneural perfusion.20 The
and the mental and infraorbital nerves. Since nerve microsurgical anastomosis of vascularized nerve
transplants were first described by Phillipeaux and transplants increases the possibility of neuronal
Vulpian1 and Albert,2 attention has been mainly regeneration and functional rehabilitation. We have
focused on different techniques of neurolysis3,4 and used vascularized long thoracic nerve transplant to
exact adaptation of nerve endings by perineural and cover nerve defects combined with microvascular free
epineural suture techniques. If there was an adequate pedicled transplants from the shoulder region for the
cut surface of nerve, the suture technique with broad treatment of extensive resection defects in oral and
surface adaptation was of only secondary impor- maxillofacial surgery in five patients.
tance.5–7 For extensive nerve defects, autologous auric-
ularis magnus, transversus colli, or suralis nerve were
interposed. These nerve interpositions were mainly PATIENTS AND METHODS
used in reconstruction of the facial nerve and were
independent non-vascularized transplants until vascu- Five patients (three men and two women) had recon-
larized transplants were described by Taylor8 and struction of the inferior alveolar nerve through a vas-
Taylor and Ham.9 These independent transplants cularized long thoracic nerve transplant after
required rapid capillarization, were initially sustained resection of carcinomas of the oral cavity. They were
by diffusion, and necessitated a good vascularized followed up and the sensation in the area that was
transplant site.10 Vascularized nerve transplants11–13 supplied by the mental nerve was assessed. Their
were used in areas with poor circulation after radia- mean age was 66 years (range 63–75). The primary
tion.14–16 Frey et al.15 established certain requirements tumour in all cases was a T4 N2 M0 carcinoma of the
138
 Vascularized transplantation of the long thoracic nerve 139

Fig. 1 – Neuro-myocutaneous latissimus dorsi transplant:

*myocutaneous latissimus dorsi transplant; ** long thoracic nerve;
and *** thoracodorsal artery and vein.

mandibular alveolar ridge. All patients were treated

by partial mandibular resection, radical neck dissec-
tion on the side of the tumour, and suprahyoidal
lymph node resection on the other side. Fig. 2 – Proximal stump of the alveolar inferior nerve.
The primary defect was reconstructed with a
microvascular pedicled osseomyocutaneous scapula-
latissimus dorsi transplant. Microvascular anasto-
moses were made between the dorsal thoracic artery
and the superior thyroid artery, and between the dor-
sal thoracic vein and the external jugular vein. The
part of the inferior alveolar nerve being resected with
the tumour was reconstructed by the vascularized
long thoracic nerve transplant together with the
mandible. The long thoracic nerve was removed with
the scapula latissimus dorsi transplant (Fig. 1). After
the operation site had been prepared in the posterior
axillary line, the anterior edge of the latissimus dorsi
muscle was exposed and the inherent dorsal thoracic
artery and vein entering the back of the muscle were
prepared. The course of the vessels up to the branch-
ing or joining into the subclavian vein and artery was
prepared. After the latissimus dorsi muscle had been
turned to one side, the long thoracic nerve could be
seen on the anterior surface of the anterior serratus
muscle. Its course runs along the mid-axillary line
downwards over this muscle. From its insertion into
the anterior serratus muscle, the nerve can be followed
Fig. 3 – Vascularized long thoracic nerve transplant *** after
along the mid-axillary line to its origin, the supraclav- anastomosis of the alveolar inferior nerve ** and mental nerve *.
icular part of the brachial plexus, and can be severed
in the axilla together with the dorsal thoracic vein and
artery that sustain it. neuronal regeneration was followed up monthly for
After preparation and osteotomy of the scapula, a each patient according to a specific regimen. Clinical
neuro-osseomyocutaneous scapula-latissimus dorsi evaluation of sensitivity in the area originally supplied
transplant was removed. This was used to establish by the mental nerve was carried out in numerous
morphological continuity of the mandible and soft- steps. Pain sensation and differentiation (classified as
tissue defect. We prepared the proximal nerve rem- sharp or blunt) were tested by prodding a dental
nant of the inferior alveolar nerve (Fig. 2) and the probe into the lower lip and chin. Temperature sensa-
distal remnant of the mental nerve for insertion of the tion was tested by asking the patient to differentiate
vascularized long thoracic nerve (Fig. 3). The nerve cold (carbon dioxin snow) and heat (a spatula heated
was anastomosed under the microscope (SM Zeiss®, to 60°C). Pressure and touch were tested by dental
Oberkochen Germany) with three 9/0 perineural probes. Rough and slight pressure were exerted with
sutures. The mean length of the defect was 5 cm range the blunt end of the dental probe, rough indicating
4–6. After straightforward primary healing, all strong pressure to the transplant and slight merely
patients were given radiotherapy with a total dose of resting of the dental probe on the transplant. Two-
60 Gy to the area of the cervical lymph nodes about point discrimination was verified in the mental nerve
10 weeks (range 9–14) postoperatively. The extend of region of the same side. To compare physiological
140 British Journal of Oral and Maxillofacial Surgery

differentiation the region of the opposite mental nerve on the morphological aspects of reconstruction, but
was tested with a two-point compass; simultaneous microvascular transplants have enabled satisfactory
stimuli were applied. The shortest distance identifying coverage of extensive defects from an aesthetic point
two separate points was measured in millimeters and of view. Without neuronal reconstruction, however,
identified as the discrimination point. The sense of this was only a substitution of functionless morpho-
vibration in the transplant was tested by applying a logical structures. The removal of the inferior alveolar
60-Hz tuning fork. nerve (which is often necessary when tumours of the
mandible are excised) leads to loss of sensitivity in the
chin and lower lip. This sensory deficit results in
RESULTS inability to chew or to feel liquid or solid food running
out of the mouth. These symptoms are even more
The examinations were made monthly, and showed apparent in patients with chewing difficulties after
initial return of pressure sensation for three patients transplant reconstruction. After the neuronal interpo-
during the third month and for two during the fourth sition and anastomosis of the vascularized long tho-
month postoperatively. When pressure was applied racic nerve distally to the severed alveolar nerve, our
sensations of pain were elicited. Pain sensation patients were able to differentiate several sensation in
increased over the following two months, when pro- the area originally supplied by the mental nerve. The
nounced hyperaesthesia on exertion of pressure was long thoracic nerve turned out to be ideally suited for
described as painful. This hypersensitivity lessened nerve interposition in the case of large defects after
after the fifth and sixth months to reach a normal removal of the inferior alveolar nerve. Gailliot and
level within a further month. The next sensation to Core21 reported an excellent potential for regeneration
return was that of slight touch with sharp and blunt of the ulnar nerve. We found the same for the long
discrimination for four patients five months postoper- thoracic nerve with the sense of pressure returning as
atively; only one patient had to wait seven months. At early as three months postoperatively, followed by
this point, all patients were able to differentiate two continuous re-establishment of sensory qualities the
points in the original area of the mental nerve with region supplied by the reconstructed nerve.
the distance initially being significantly greater than The vascularized nerve is more useful than the non-
on the opposite side. Within two months, the distance vascularized nerve, as Kanya et al.22 described more
between discriminated points balanced out and ended accurate discrimination and better regeneration. The
up identical on both sides. Senses of vibration and excellent result of full bilateral differentiation between
touch returned at about the same time. Thermal stim- sensation was achieved by four of our patients nine
uli were sensed by two patients six months postopera- months after nerve transplantation. Shibata et al.23
tively, by one patient after seven months, and by one found that vascularized nerves were able to produce
patient after eight months. Nine months after the more axons and neuronal endorgans, which may be
primary neuronal reconstruction of the mental nerve one of the main reasons for the good result. For re-
four patients had similar sensitivity bilaterally. Only establishment and persistence of sensitive function,
one patient had a permanent deficit in thermal sensa- long-term axonal bridging in the form of myelin
tion. The individual values for re-establishment of sheets is the mainstay of nerve regeneration. Long-
sensory ability are shown in Table 1. term persistence of myelin sheets seems to be particu-
Four patients judged the sensitivity of the lower lip larly important for poorly perfused tissues as well as
as normal compared with the other side and only one those treated by radiotherapy, as found by Frey et
felt all sensations in the lower lip, but not as much as al.,15 particularly in the case of nerve defects larger
on the other side. than 6 cm. The vascularized nerve transplant seems to
be better able to regenerate, according to Doi et al.24
The regenerative potential of the vascularized long
DISCUSSION thoracic nerve does not seem to be affected by radia-
tion.
In oral and maxillofacial surgery, extensive recon- According to Koshima et al.25 the ideal nerve trans-
structive measures are required for extensive facial plant for routine use should have a constant anatomy,
defects. In previous years, most attention was focused minimal functional loss after removal, and sufficient

Table 1 – Results of resensitization of the mental nerve region

Date of Age Postoperative month

operation (years)

1 2 3 4 5 6 7 8 9

Oct.1997 65 – – – Pain Touch Touch Touch Temperature

Oct.1997 67 – – – Pain Pain Pain Touch Touch
Nov.1997 72 – – Pain Pain Touch Touch Temperature Temperature
Nov.1997 63 – – Pain Pain Touch Temperature Temperature Temperature
Nov.1997 65 – – Pain Touch Touch Temperature Temperature Temperature
 Vascularized transplantation of the long thoracic nerve 141

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to Frey et al.,21 it is important for a transplant to Vaskularisiertes Nerventransplantat: theoretische Vorteil und
Nachteile. Handchir Mikrochir Plast Chir 1988;
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site. As the long thoracic nerve has these qualities, it 16. Hausamen J-E. Mikronervenchirurgie im Mund-, Kiefer- und
seems to be ideally suited for coverage of neuronal Gesichtsbereich. In: Horch HH, ed. Mund-, Kiefer- und
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235–243.
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