Single-incision endoscopic sural nerve harvest for cross face nerve grafting

Cross face nerve grafting followed by free muscle transfer has become a standard of care in rehabilitation of the paralyzed face. In an effort to address the surgical morbidity of sural nerve harvest, multiple groups have attempted to minimize lower extremity trauma from sural nerve harvest. In very preliminary studies, investigators have adapted the use of vein harvesting equipment for harvest of the sural nerve. In this article we describe the use of endoscopic vein harvesting equipment for sural nerve harvest in a series of eight patients undergoing facial reanimation, in which a single distal incision is made posterior to the lateral malleolus. Eight patients presented for first-stage cross face nerve grafting for facial reanimation over a 6-month period. Each patient was operated on using a two-team approach. One team exposed the donor branches of the facial nerve on the healthy side while the endoscopic harvest was simultaneously executed in the lower limb by the second team. In each case, the sural nerve graft > 20 cm in length was removed through a single 1.5-cm incision. There were no complications. Operative times decreased steadily throughout the period examined and were < 20 minutes for the last two patients. For the final two cases, a modified sural nerve stripper was introduced through the instrument portal of the VasoView device (Guidant Co., Natick, MA), which contained a small notch through which the nerve could be threaded, greatly facilitating dissection. This contributed to decreasing operative times. Thus we combined the technological advances of a sophisticated endoscopic system with our minimally invasive nerve stripper technique to improve sural nerve harvest. We found no increased morbidity from the endoscopic approach, and in all cases we were able to remove the nerve through a single incision. The endoscopic sural nerve harvest is an excellent addition to the armamentarium of the facial reanimation surgeon.