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The Scar Solution Natural Scar Removal

Scar Solution Book By Sean Lowry

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Chronic nerve compression is one of the most common clinical phenomena in the peripheral nervous system. Surgical decompression of entrapped peripheral nerves is generally efficacious. However, a significant number of patients do not experience good long-term results with this treatment, and the socioeconomic impact is enormous.

Multiple attempts of surgical releases can create more scar tissue which develops and further compresses the nerve. The epineural surface of the nerve is surrounded by scar tissue and stressed by strenuous work or a new injury. The result is a chronic neuropathy, called a "traction neuropathy" and the optimal treatment may be a combination of procedures. Mobilization of the nerve followed by internal neuroly-sis cannot alleviate these problems, due to recurrent scar. Most authors agree that soft tissue coverage is necessary to prevent this phenomenon, and several options have been suggested for this purpose. For recurrent carpal tunnel syndrome the hypothenar fat pad flap can produce good results and is uncomplicated in most cases. Pedicle or free flaps, including the groin flap, lateral arm flap, posterior interosseous flap, provide excellent protection of the nerve, but the technique is complex and the results not always satisfying. Small local flaps such as the abductor digiti minimi, the palmaris brevis, the pronator quadratus and lumbricalis also have been used. However the dissection of these flaps is not always easy, and skin closing problems may occur. Also the coverage provided by these local flaps is often inadequate. Use of implanted peripheral nerve stimulators has been suggested to relieve pain resulting from compressed of injured peripheral nerves, but failures have been reported in many cases because of complications such as nerve injuries, skin problems, and early formation of scar tissue due to silicone.

Masear et al1 were the first to report the successful use of a vein graft for treatment of recurrent compressive neuropathy. Gould2 and Koman et al3 have also shown that the vein graft wrapping technique can improve the recovery of nerve function,

Saphenous Nerve Splitting

Fig. 3.1. A and 1B. Artist's drawing showing the technique used for vein wrapping of scarred nerves. a: The saphenous vein is harvested from the ipsilateral or contralateral leg, b: is split longitudinally, and c: opened to form a rectangular. d: The saphenous vein is wrapped around the scarred portion of the nerve in a spiral pattern with its intima on the surface of the nerve. Each ring of the nerve is tacked to the adjacent rings with a 7-0 or 8-0 nylon stitch. e: The entire scarred portion of the nerve is covered with the saphenous vein.

Fig. 3.1. A and 1B. Artist's drawing showing the technique used for vein wrapping of scarred nerves. a: The saphenous vein is harvested from the ipsilateral or contralateral leg, b: is split longitudinally, and c: opened to form a rectangular. d: The saphenous vein is wrapped around the scarred portion of the nerve in a spiral pattern with its intima on the surface of the nerve. Each ring of the nerve is tacked to the adjacent rings with a 7-0 or 8-0 nylon stitch. e: The entire scarred portion of the nerve is covered with the saphenous vein.

in patients with recurrent nerve compression. Malizos et al7 used vein conduits to bridge small defects in sensory nerves and in covering the stump of sensory nerves after neuroma excision with satisfactory results in pain relief.

Our experimental studies, as well as other studies, have shown that wrapping a compressed nerve with an autologous graft is an excellent option for treatment of recurrent neuropathy. However, the mechanism of its effect is still uncertain. Based

Saphenous Nerve Neuroma
Fig. 3.3. The wrapping of the nerve with the saphenous vein proceeds circumferentially according to the technique described by Masear et al (1990).
Internal Neurolysis
Fig. 3.4. The saphenous vein covers the entire portion of the nerve where internal neurolysis has been performed.
Neuroma Saphenous Nerve

Fig. 3.5. This patient underwent an exploration for a neuroma of the medial antebrachial cutaneous nerve two years after vein wrapping of the ulnar nerve at the cubital tunnel. There was no scar tissue between the intima of the vein and the surface of the ulnar nerve. A forceps could easily enter the space between the wrapping vein and the wrapped nerve.

Fig. 3.5. This patient underwent an exploration for a neuroma of the medial antebrachial cutaneous nerve two years after vein wrapping of the ulnar nerve at the cubital tunnel. There was no scar tissue between the intima of the vein and the surface of the ulnar nerve. A forceps could easily enter the space between the wrapping vein and the wrapped nerve.

on etiology, and the pathophysiology of recurrent nerve compression, we believe that the procedure works by protecting the peripheral nerve from surrounding scar tissue, thereby preventing adhesion between the nerve epineurium and the surrounding tissue. In addition, the formation of scar tissue within the peripheral nerve trunk is minimized after vein wrapping, possibly, due to properties of endothelial cells of the intimal layer of the vein.

Endothelial cells prevent the adhesion of tissue or blood cells to the inner surface of the vessel in vivo. Perhaps the vein graft also functions in a similar fashion, preventing adhesion and scar tissue formation between the periphery and the nerve. In addition, the autogenous vein graft with this smooth inner surface should improve the gliding function of the nerve trunk during motion of the relevant joint, avoiding the possible damage induced by gliding friction of the trunk and/or "spot welding" of the nerve to scar tissue with subsequent traction neuropathy.

Pain, which is often associated with recurrent compressive neuropathies, subsides significantly after vein wrapping. Sensation and two-point discrimination in the median nerve distribution in the hand are also improved in most cases. Follow-up electromyographic studies in most patients revealed improved nerve conduction velocity and amplitude.

The use of autogenous vein graft wrapping as a supplementary technique to treat chronic nerve compression has many advantages. It is a simple technique that causes minimal complications in the donor area. In addition, the donor is readily available, with easy harvesting. Based on the results that we observed, we believe that vein wrapping as a treatment option for refractory chronic neuropathy is an excellent adjuvant procedure.

References

1. Masaer JR, Tullos JR, Mary ET et al. Venous wrapping of nerve to prevent scarring. J Hand Surg, 1990; 15A:817-818.

2. Gould JS. Treatment of the painful injured nerve in continuity. In: Gelberman RH, ed. Philadelphia: JB Lippincott 1991:1541-1549.

3. Koman LA, Neal B, Santigen J. Management of the postoperative painful median nerve at the wrist. Orthop Trans 1995; 18:765.

4. Sotereanos DG, Giannakopoulos PN, Mitsionis GI et al. Vein graft wrapping for the treatment of recurrent compression of the median nerve. Microsurgery 1995; 16:752-756.

5. Xu J, Varitimidis SE, Fisher KJ et al. The effect of wrapping scarred nerves with autogenous vein graft to treat recurrent chronic nerve compression. J Hand Surg 2000; 25A:93-103.

6. Masear VR, Colgin S. The treatment of epineural scarring with allograft vein wrapping. Hand Clinics 1996; 12:773-779.

7. Malizos KN, Dailiana ZH, Anastasiou EA et al. Neuromas and gaps of sensory nerves of the hand: management with vein conduits. Am J Orthop 1997; 26:481-485.

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