Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
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This achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
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We are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
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Thank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
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Larramendy and Sonia Soloneski",publishedDate:"April 7th 2021",coverURL:"https://cdn.intechopen.com/books/images_new/9685.jpg",keywords:null,numberOfDownloads:844,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 15th 2019",dateEndSecondStepPublish:"March 5th 2020",dateEndThirdStepPublish:"May 4th 2020",dateEndFourthStepPublish:"July 23rd 2020",dateEndFifthStepPublish:"September 21st 2020",remainingDaysToSecondStep:"a year",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:"Edited by",kuFlag:!1,biosketch:null,coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"14764",title:"Dr.",name:"Marcelo L.",middleName:null,surname:"Larramendy",slug:"marcelo-l.-larramendy",fullName:"Marcelo L. 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He is an expert in genetic toxicology and is, or has been, a referee for more than 20 international scientific journals. He was a member of the International Panel of Experts at the International Agency for Research on Cancer (IARC, WHO, Lyon, France) in 2015 for the evaluation of DDT, 2,4-D and Lindane. Presently, Prof. Dr. Larramendy is Head of the Laboratory of Molecular Cytogenetics and Genotoxicology at the UNLP.",institutionString:"National University of La Plata",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"18",institution:{name:"National University of La Plata",institutionURL:null,country:{name:"Argentina"}}}],coeditorOne:{id:"14863",title:"Dr.",name:"Sonia",middleName:null,surname:"Soloneski",slug:"sonia-soloneski",fullName:"Sonia Soloneski",profilePictureURL:"https://mts.intechopen.com/storage/users/14863/images/system/14863.jpg",biography:"Sonia Soloneski has a Ph.D. in Natural Sciences and is an Assistant Professor of Molecular Cell Biology at the School of Natural Sciences and Museum of La Plata, National University of La Plata, Argentina. She is a member of the National Scientific and Technological Research Council (CONICET) of Argentina in the genetic toxicology field, the Latin American Association of Environmental Mutagenesis, Teratogenesis and Carcinogenesis (ALAMCTA), the Argentinean Society of Toxicology (ATA), the Argentinean Society of Genetics (SAG), the Argentinean Society of Biology (SAB), and the Society of Environmental Toxicology and Chemistry (SETAC). She has authored more than 380 contributions in the field, including scientific publications in peer-reviewed journals and research communications. She has served as a review member for more than 30 scientific international journals. She has been a plenary speaker in scientific conferences and a member of scientific committees. She is a specialist in issues related to genetic toxicology, mutagenesis, and ecotoxicology.",institutionString:"National University of La Plata",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"6",institution:{name:"National University of La Plata",institutionURL:null,country:{name:"Argentina"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"307",title:"Agroecology",slug:"agroecology"}],chapters:[{id:"71812",title:"Fungal Endophytes: Australian Terrestrial Orchids",slug:"fungal-endophytes-australian-terrestrial-orchids",totalDownloads:178,totalCrossrefCites:0,authors:[{id:"315183",title:"Dr.",name:"Shalika",surname:"Mehra",slug:"shalika-mehra",fullName:"Shalika Mehra"}]},{id:"72341",title:"Impact Brassinolide on Two Fig Varieties",slug:"impact-brassinolide-on-two-fig-varieties",totalDownloads:82,totalCrossrefCites:0,authors:[{id:"318963",title:"Dr.",name:"Zulias",surname:"Mardinata Zulkarnaini",slug:"zulias-mardinata-zulkarnaini",fullName:"Zulias Mardinata Zulkarnaini"},{id:"346266",title:"Dr.",name:"Mardaleni",surname:null,slug:"mardaleni",fullName:"Mardaleni null"},{id:"346267",title:"Dr.",name:"Tengku Edy",surname:"Sabli",slug:"tengku-edy-sabli",fullName:"Tengku Edy Sabli"}]},{id:"73090",title:"The Creation of Resistant Berries’ Agrobiocenosis",slug:"the-creation-of-resistant-berries-agrobiocenosis",totalDownloads:13,totalCrossrefCites:0,authors:[{id:"319385",title:"Dr.",name:"Zoya",surname:"Ozherelieva",slug:"zoya-ozherelieva",fullName:"Zoya Ozherelieva"},{id:"319387",title:"Dr.",name:"Pavel",surname:"Prudnikov",slug:"pavel-prudnikov",fullName:"Pavel Prudnikov"},{id:"319388",title:"MSc.",name:"Diana",surname:"Krivushina",slug:"diana-krivushina",fullName:"Diana Krivushina"},{id:"319389",title:"Ms.",name:"Marina",surname:"Zubkova",slug:"marina-zubkova",fullName:"Marina Zubkova"},{id:"319390",title:"MSc.",name:"Anna",surname:"Androsova",slug:"anna-androsova",fullName:"Anna Androsova"}]},{id:"72423",title:"Castor (Ricinus communis): An Underutilized Oil Crop in the South East Asia",slug:"castor-em-ricinus-communis-em-an-underutilized-oil-crop-in-the-south-east-asia",totalDownloads:90,totalCrossrefCites:0,authors:[{id:"77958",title:"Dr.",name:"Zahira",surname:"Yaakub",slug:"zahira-yaakub",fullName:"Zahira Yaakub"},{id:"191072",title:"Prof.",name:"A. 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\n
1. Introduction
\n
The actual state-of-the-art in suture-coaptation bringing together two stumps of a severed peripheral nerve requires good histologic quality of both stumps, a gap that may overcome by acceptable tension, and a good microsurgical technique when performing epineural or epi-perineural mattress sutures, leading finally to a nearly invisible congruent “anastomosis”.
\n
Few authors have dealt so far with aspects of technical improvement of nerve stump coaptation, but fascicular alignment seems to be a major factor to ensure proper regeneration [1].
\n
Peripheral nerves contain elastic fibers and after nerve transsection, even without any loss of substance, a gap between the two stumps becomes apparent. The local nerve tissue damage and ingrowing fibrosis of both stumps may increase and/or fix the gap in an irreversible manner, than the further coaptation becomes hazardous.
\n
Although “reasonable” tension may be applied to try to overcome the gap, it is generally recommended to perform nerve sutures in a tension-free environment using 9/0 and 10/0 microsurgical suture material. When these stitches break, a nerve graft is recommended.
\n
Recently, we gained reasonable experience in the reconstruction of upper and extended upper obstetric brachial plexus lesions (OBPL) in general [2] and with direct sutures [3], showing very good clinical results of motor recovery after severe obstetric traction injury with complete trunk ruptures. Optimizing the functional result after surgical reconstruction in all types of OBPL is always the prevalent aim, especially to recover an adequate hand function [4].
\n
The OBPL direct suture repair technique was introduced already over hundred years ago [5] and we know that several peripheral nerve surgeons are incline to perform a direct coaptation of two peripheral nerve stumps with a “reasonable” tension, to avoid short grafting with less dense nerve fiber interposition.
\n
There is thus a striking controversy between a clinical axioma (tensionless nerve coaptation) and surgical experience, leading us to investigate this issue further and to discuss both the existing literature and possible research protocols.
\n
\n
\n
2. Surgical technique
\n
The nerve suture should bring together two stumps of good tissue quality, that is, free of fibrosis (i.e., infiltration of collagen fibers) or neuroma (predominance of misoriented peripheral minifascicles), with good fascicular appearance and a gap overcome by slight traction and finally hold by the sutures [6, 7]. de Medinaceli introduced a microsurgical technique focusing on good fascicular alignment in both stumps [1], mainly to avoid random fascicular ingrowth of the regeneration cones.
\n
Every nerve microsurgeon knows that if there is tension, the first suture point is the most difficult to be achieved and at risk for filament rupture (Figure 1).
\n
Figure 1.
Problem of the first epineural suture knot under undue tension.
\n
As there are more points added, the tension lowers (Figure 2) and at the end, the coaptation site shows a good appearance and mechanical resistance.
\n
Figure 2.
Tension decreases with more anchor points.
\n
To prevent undue tension, either the proximal and/or the distal nerve stump may be mobilized, that is, freed from their paraneural tissue, thus giving additional length, gained at the price of decreased local blood supply (as the vasa nervorum might be interrupted by this circumferential paraneurolysis).
\n
Also may one take advantage of the existence of “reserve capacity” of each peripheral nerve at the level of major joints, which are flexed to release more tissues.
\n
In dramatic situations, like in war injuries or when considering very large nerve repairs (like the ischiatic nerve), bone shortening might be considered to reduce or overcome the gap.
\n
In very young children, like those suffering from OBPL, the structural elasticity of the longitudinally growing nerves is assumed to be enhanced, as is also the capacity of nerve regeneration and overall cortical plasticity. The young connective tissue is loose, nerve fibers and myelin sheaths are thin and the peripheral nerve structure itself is continually under a longitudinal growth stretch.
\n
Concerning nerve stump coaptation at every age, there is no way to overcome the fascicular malalignment due to the intrinsic plexual structure constitutional of most multifascicular peripheral nerves (Figure 3).
\n
Figure 3.
Intraneural plexiform fascicular structure.
\n
Moreover, we actually do not have an insight into the physiologic regeneration once the suture is completed and the wound is closed, as the diffusion tensor imaging (DTI) technology related to MRI images is actually not performed regularly after peripheral nerve surgery.
\n
When it comes to the suture material, nerve microsurgeons routinely use 8–10 or 11/0 nylon (nonabsorbable monofilament) material with fine needles proportional to the filament diameter, that is, needles for 11/0 sutures are smaller and thinner than those for 8/0 sutures.
\n
Recently, we developed in cooperation with Onatec (Pößneck Jestetten, Germany), a specific microsurgical suture material, made up of a 6/0 filament with a real microsurgical needle (Figure 4), allowing epineural nerve sutures of “bigger” nerves like the upper or middle trunk in OBPL repair or adult radial and median nerve coaptations.
\n
Figure 4.
Onalon 6/0 microsurgical filament: fine needle, 6/0 strand.
\n
As the 6/0 filament is inserted strictly epineural and thus lays outside the fascicular structures, and as nylon is supposed to be biologically inert, we continued that practice on a prospective series of OBPL repairs we actually published with a follow up of 18 months and still very promising results of sensory and motor function recovery [3].
\n
Figures 5, 6, 7 show one clinical example of a typical upper and middle trunk neuroma repair with the identification of the rupture site (Figure 5), trimming of both proximal and distal stumps (Figure 6), and the direct suture (Figure 7).
\n
Figure 5.
Clinical example of OBPL direct suture: upper and middle trunk rupture.
\n
Figure 6.
Clinical example of OBPL direct suture: after proximal and distal stump trimming.
\n
Figure 7.
Clinical example of OBPL direct suture: upper and middle trunk direct suture.
\n
The 6/0 strand together with a rather thick epineurium in larger nerves (like those mentioned above) gave us satisfactory coaptation stability already after two or three sutures, where thinner suture filaments needed more sutures to stabilize the coaptation. Nevertheless, in our OBPL trunk coaptations, we regularly used a minimum of 6–8 6/0 epineural sutures (Figure 2) before surrounding the coaptation site with a sleeve of fibrin glue.
\n
The only similar stabilizing technique using foreign material promoted polylacton (vicryl) strips applied outside the epineurium to decrease the tension onto the suture points [8].
\n
\n
\n
3. Morphologic and mechanic analysis
\n
Tension is a force applied onto a surface and might be reduced on a circumference while using more anchor points (remind Figure 2). Suture tension has so far not been quantified or measured, we probably could state that it is even unmeasurable in the in vivo situation of a surgical procedure.
\n
The question is how much of the maintained tension into the nerve stump coaptation is transmitted to the periphery, that is, the stumps, and if this affects nerve regeneration and the physiologic function afterwards.
\n
Some experiences support the concept of a negative influence of nerve stretching on the physiologic function [9]. But clinical results show the feasibility of this method without lowering the functional outcome, even providing unexpected good results.
\n
Tension could harm by decreasing the blood flow in the vasa nervorum (a stretch on a circular blood vessel-tube would flatten it and diminish the cross section, thus theoretically lower the blood flow); but one could argue that through the initial nerve lesion and the surgical paraneurolysis, those freed segments are anyhow separated from the local blood supply.
\n
Tension is also said to increase local fibrosis (the amount of collagen fibers), but we should further investigate if the tension in the epineural layer, holding the suture material, is equally transmitted to the deeper structures (the deep interfascicular epineurium and finally the perineurium and the fascicular sheets).
\n
One could imagine that the tension is hold within the thicker epineural layer of a thicker peripheral nerve and that the aligned fascicles in the nerve depth are no longer experiencing distraction stress—thus the nerve regeneration happening on the highways of the deeper fascicules would not be disturbed (that’s what our clinical cases seem to show, like a “tube-in-tube” concept).
\n
Tension is not measured easily, or even not at all, and once it comes to textbook descriptions like “reasonable tension” or “avoiding excessive tension” we should be convinced that the actually accepted dogma is weak.
\n
On the other hand, there is the real danger of “promoting” bad microsurgical technique and overindication for direct coaptation, bringing together bad quality stumps under undue tension just to avoid a graft (donor site morbidity, longer procedure, two coaptation sites, but overall less fiber density).
\n
Table 1 summarizes ideal clinical conditions for a direct suture approach; Table 2 summarizes strong arguments for a limited tension, suture approach.
\n
\n
\n\n
\n
\n
Very young patient
Acceptable nerve diameter (OBPL trunk or cord)
Limited scar and/or gap
Compliance for postoperative immobilization
\n
\n
\n\n
Table 1.
Ideal conditions for a direct suture approach.
\n
\n
\n\n
\n
\n
Good clinical result in OBPL direct sutures
Longitudinal growth in young patients
Tissue adaptation: elastic fibers, low collagen content, and postoperative immobilization
\n
\n
\n\n
Table 2.
Strong arguments for a limited tension-suture model.
\n
\n
\n
4. Literature research
\n
Between 1975 and 2017, a PubMed MEDLINE research about “nerve suture” and “tension” only prompted eight valuable articles on nerve-suture related tension [8, 10, 11, 12, 13, 14, 15, 16]; presenting animal studies in rats, cats, dogs, and monkeys; using sciatic or upper limb nerves, and studying the outcome by histology and nerve conduction studies. There are so far no conclusive data about what is better and how much tension is tolerated.
\n
\n
\n
5. Further investigations and today’s conclusions
\n
There is still enough controversy about tension tolerance in peripheral nerve surgery.
\n
Clinical outcomes oppose to the experimental background, which on deeper analysis is rather weak, as the literature on the subject is scarce.
\n
Out of our actual clinical and scientific knowledge, we believe that further investigation could be conducted in several ways:
biomechanical analysis of various suture filament strengths used in nerve coaptation
nylon suture: long term interaction with the fascicular anatomy studied by late histologic examination
a model of a tube, in tube, behavior of the peripheral nerve (epineural versus fascicular tubes)
in vivo observation of coapted nerves in a regeneration chamber.
\n
Meanwhile, we continue to use all available “tricks” and refinements to decrease the gap and the suture tension, to allow optimal nerve fiber regeneration, without any visual help to follow this biological process after reconstructive surgery.
\n
Never should our analysis allow bad techniques with insufficiently cleared stumps, undue tension on the coaptation after three or four knots, the introduction of stronger filament material (3 or 4/0), not adapted to the local anatomy, extension of the proposed technique to smaller nerves with fine epineurium, and not supporting suture material thicker than 10 or 11/0.
\n
But with further developments, we may define indications and good surgical background conditions with limited nerve damage, good mobilization capacity of stumps, good microsurgical coaptation, and rewarded after a good technique with a significant functional result.
\n
\n\n',keywords:"nerve suture, coaptation, tension, brachial plexus injury, obstetrical, peripheral nerve, microsurgery",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/62054.pdf",chapterXML:"https://mts.intechopen.com/source/xml/62054.xml",downloadPdfUrl:"/chapter/pdf-download/62054",previewPdfUrl:"/chapter/pdf-preview/62054",totalDownloads:425,totalViews:47,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,dateSubmitted:"November 19th 2017",dateReviewed:"May 15th 2018",datePrePublished:"November 5th 2018",datePublished:"July 17th 2019",dateFinished:"June 11th 2018",readingETA:"0",abstract:"Avoiding suture tension in peripheral nerve coaptation seems to be a clinical dogma since 30 years, although experimental data are weak and clinical practice shows good functional outcome after peripheral nerve repair by direct coaptation under “reasonable” tension, defined by local anatomic feasibility and the use of specific suture material. In this article, we focus on the microsurgical technique of nerve stump coaptation and the distribution of tension through epineural sutures with various suture materials; we also analyze the impact on the different nerve tissue layers, the limit of this approach and its combination with other tissue releasing techniques like paraneurolysis, adjacent joint flexion, or bone shortening.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/62054",risUrl:"/chapter/ris/62054",book:{slug:"treatment-of-brachial-plexus-injuries"},signatures:"Jörg Bahm, Tobias Esser, Bernd Sellhaus, Wissam El-kazzi and Frederic Schuind",authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Surgical technique",level:"1"},{id:"sec_3",title:"3. Morphologic and mechanic analysis",level:"1"},{id:"sec_4",title:"4. Literature research",level:"1"},{id:"sec_5",title:"5. Further investigations and today’s conclusions",level:"1"}],chapterReferences:[{id:"B1",body:'de Medinaceli L, Seaber AV. Experimental nerve reconnection: Importance of initial repair. Microsurgery. 1989;10:56-70\n'},{id:"B2",body:'Bahm J, Ocampo-Pavez C, Noaman H. Microsurgical technique in obstetric brachial plexus repair: A personal experience in 200 cases over 10 years. Journal of Brachial Plexus and Peripheral Nerve Injury. 2007;2:1\n'},{id:"B3",body:'Bahm J, Gkotsi A, Bouslama S, El-kazzi W, Schuind F. Direct nerve sutures in [extended]upper obstetric brachial plexus repair. Journal of Brachial Plexus and Peripheral Nerve Injury. 2017;12(1):e17-e20\n'},{id:"B4",body:'Kirjavainen M, Remes V, Peltonen J, Rautakorpi S, Helenius I, Nietosvaara Y. The function of the hand after operations for obstetric injuries to the brachial plexus. Journal of Bone and Joint Surgery (British). 2008;90(3):349-355\n'},{id:"B5",body:'Kennedy R. Suture of the brachial plexus in birth paralysis of the upper extremity. British Medical Journal. 1903;1(2197):298-301\n'},{id:"B6",body:'Millesi H. The nerve gap: Theory and clinical practice. Hand Clinics. 1986;2:651-663\n'},{id:"B7",body:'Trumble T. Overcoming defects in peripheral nerves. In: Gelberman RH, editor. Operative Nerve Repair and Reconstruction. Philadelphia: Lippincott; 1991\n'},{id:"B8",body:'Haas HG, Holste J. Spannungsentlastung bei Nähten peripherer Nerven. Handchirurgie, Mikrochirurgie, Plastische Chirurgie. 1990;22:156-162\n'},{id:"B9",body:'Driscoll PJ, Glasby MA, Lawson GM. An in vivo study of peripheral nerves in continuity: Biomechanical and physiological responses to elongation. Journal of Orthopaedic Research. 2002;20:370-375\n'},{id:"B10",body:'Hentz VR, Rosen JM, Xiao SJ, McGill KC, Abraham G. The nerve gap dilemma: A comparison of nerves repaired end to end under tension with nerve grafts in a primate model. Journal of Hand Surgery. 1993;18(3):417-425\n'},{id:"B11",body:'Maeda T, Hori S, Sasaki S, Maruo S. Effects of tension at the site of coaptation on recovery of sciatic nerve function after neurorrhaphy: Evaluation by walking-track measurement, electrophysiology, histomorphometry, and electron probe X-ray microanalysis. Microsurgery. 1999;19:200-207\n'},{id:"B12",body:'Miyamoto Y. Experimental study of results of nerve suture under tension vs. nerve grafting. Plastic and Reconstructive Surgery. 1979;64(4):540-549\n'},{id:"B13",body:'Okamoto H, Oka Y. Experimental study on tension and stretching to peripheral nerve. Nihon Seikeigeka Gakkai Zasshi. 1990;64(5):472-484\n'},{id:"B14",body:'Rodkey WG, Cabaud HE, McCarroll HR Jr. Neurorrhaphy after loss of a nerve segment: Comparison of epineurial suture under tension versus multiple nerve grafts. Journal of Hand Surgery. 1980;5(4):366-371\n'},{id:"B15",body:'Scherman P, Kanje M, Dahlin LB. Bridging short nerve defects by direct repair under tension, nerve grafts or longitudinal sutures. Restorative Neurology and Neuroscience. 2004;22(2):65-72\n'},{id:"B16",body:'Terzis J, Faibisoff B, Williams HB. The nerve gap: suture under tension vs. graft. Plastic and Reconstructive Surgery. 1975;56(2):166-170\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Jörg Bahm",address:"jorg.bahm@belgacom.net",affiliation:'
Euregio Reconstructive Microsurgery Unit, Franziskus hospital Aachen, Germany
Department for Orthopaedics and Traumatology, ULB Erasme University Hospital, Belgium
Department for Orthopaedics and Traumatology, ULB Erasme University Hospital, Belgium
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\n
1. Introduction
\n
The actual state-of-the-art in suture-coaptation bringing together two stumps of a severed peripheral nerve requires good histologic quality of both stumps, a gap that may overcome by acceptable tension, and a good microsurgical technique when performing epineural or epi-perineural mattress sutures, leading finally to a nearly invisible congruent “anastomosis”.
\n
Few authors have dealt so far with aspects of technical improvement of nerve stump coaptation, but fascicular alignment seems to be a major factor to ensure proper regeneration [1].
\n
Peripheral nerves contain elastic fibers and after nerve transsection, even without any loss of substance, a gap between the two stumps becomes apparent. The local nerve tissue damage and ingrowing fibrosis of both stumps may increase and/or fix the gap in an irreversible manner, than the further coaptation becomes hazardous.
\n
Although “reasonable” tension may be applied to try to overcome the gap, it is generally recommended to perform nerve sutures in a tension-free environment using 9/0 and 10/0 microsurgical suture material. When these stitches break, a nerve graft is recommended.
\n
Recently, we gained reasonable experience in the reconstruction of upper and extended upper obstetric brachial plexus lesions (OBPL) in general [2] and with direct sutures [3], showing very good clinical results of motor recovery after severe obstetric traction injury with complete trunk ruptures. Optimizing the functional result after surgical reconstruction in all types of OBPL is always the prevalent aim, especially to recover an adequate hand function [4].
\n
The OBPL direct suture repair technique was introduced already over hundred years ago [5] and we know that several peripheral nerve surgeons are incline to perform a direct coaptation of two peripheral nerve stumps with a “reasonable” tension, to avoid short grafting with less dense nerve fiber interposition.
\n
There is thus a striking controversy between a clinical axioma (tensionless nerve coaptation) and surgical experience, leading us to investigate this issue further and to discuss both the existing literature and possible research protocols.
\n
\n
\n
2. Surgical technique
\n
The nerve suture should bring together two stumps of good tissue quality, that is, free of fibrosis (i.e., infiltration of collagen fibers) or neuroma (predominance of misoriented peripheral minifascicles), with good fascicular appearance and a gap overcome by slight traction and finally hold by the sutures [6, 7]. de Medinaceli introduced a microsurgical technique focusing on good fascicular alignment in both stumps [1], mainly to avoid random fascicular ingrowth of the regeneration cones.
\n
Every nerve microsurgeon knows that if there is tension, the first suture point is the most difficult to be achieved and at risk for filament rupture (Figure 1).
\n
Figure 1.
Problem of the first epineural suture knot under undue tension.
\n
As there are more points added, the tension lowers (Figure 2) and at the end, the coaptation site shows a good appearance and mechanical resistance.
\n
Figure 2.
Tension decreases with more anchor points.
\n
To prevent undue tension, either the proximal and/or the distal nerve stump may be mobilized, that is, freed from their paraneural tissue, thus giving additional length, gained at the price of decreased local blood supply (as the vasa nervorum might be interrupted by this circumferential paraneurolysis).
\n
Also may one take advantage of the existence of “reserve capacity” of each peripheral nerve at the level of major joints, which are flexed to release more tissues.
\n
In dramatic situations, like in war injuries or when considering very large nerve repairs (like the ischiatic nerve), bone shortening might be considered to reduce or overcome the gap.
\n
In very young children, like those suffering from OBPL, the structural elasticity of the longitudinally growing nerves is assumed to be enhanced, as is also the capacity of nerve regeneration and overall cortical plasticity. The young connective tissue is loose, nerve fibers and myelin sheaths are thin and the peripheral nerve structure itself is continually under a longitudinal growth stretch.
\n
Concerning nerve stump coaptation at every age, there is no way to overcome the fascicular malalignment due to the intrinsic plexual structure constitutional of most multifascicular peripheral nerves (Figure 3).
\n
Figure 3.
Intraneural plexiform fascicular structure.
\n
Moreover, we actually do not have an insight into the physiologic regeneration once the suture is completed and the wound is closed, as the diffusion tensor imaging (DTI) technology related to MRI images is actually not performed regularly after peripheral nerve surgery.
\n
When it comes to the suture material, nerve microsurgeons routinely use 8–10 or 11/0 nylon (nonabsorbable monofilament) material with fine needles proportional to the filament diameter, that is, needles for 11/0 sutures are smaller and thinner than those for 8/0 sutures.
\n
Recently, we developed in cooperation with Onatec (Pößneck Jestetten, Germany), a specific microsurgical suture material, made up of a 6/0 filament with a real microsurgical needle (Figure 4), allowing epineural nerve sutures of “bigger” nerves like the upper or middle trunk in OBPL repair or adult radial and median nerve coaptations.
\n
Figure 4.
Onalon 6/0 microsurgical filament: fine needle, 6/0 strand.
\n
As the 6/0 filament is inserted strictly epineural and thus lays outside the fascicular structures, and as nylon is supposed to be biologically inert, we continued that practice on a prospective series of OBPL repairs we actually published with a follow up of 18 months and still very promising results of sensory and motor function recovery [3].
\n
Figures 5, 6, 7 show one clinical example of a typical upper and middle trunk neuroma repair with the identification of the rupture site (Figure 5), trimming of both proximal and distal stumps (Figure 6), and the direct suture (Figure 7).
\n
Figure 5.
Clinical example of OBPL direct suture: upper and middle trunk rupture.
\n
Figure 6.
Clinical example of OBPL direct suture: after proximal and distal stump trimming.
\n
Figure 7.
Clinical example of OBPL direct suture: upper and middle trunk direct suture.
\n
The 6/0 strand together with a rather thick epineurium in larger nerves (like those mentioned above) gave us satisfactory coaptation stability already after two or three sutures, where thinner suture filaments needed more sutures to stabilize the coaptation. Nevertheless, in our OBPL trunk coaptations, we regularly used a minimum of 6–8 6/0 epineural sutures (Figure 2) before surrounding the coaptation site with a sleeve of fibrin glue.
\n
The only similar stabilizing technique using foreign material promoted polylacton (vicryl) strips applied outside the epineurium to decrease the tension onto the suture points [8].
\n
\n
\n
3. Morphologic and mechanic analysis
\n
Tension is a force applied onto a surface and might be reduced on a circumference while using more anchor points (remind Figure 2). Suture tension has so far not been quantified or measured, we probably could state that it is even unmeasurable in the in vivo situation of a surgical procedure.
\n
The question is how much of the maintained tension into the nerve stump coaptation is transmitted to the periphery, that is, the stumps, and if this affects nerve regeneration and the physiologic function afterwards.
\n
Some experiences support the concept of a negative influence of nerve stretching on the physiologic function [9]. But clinical results show the feasibility of this method without lowering the functional outcome, even providing unexpected good results.
\n
Tension could harm by decreasing the blood flow in the vasa nervorum (a stretch on a circular blood vessel-tube would flatten it and diminish the cross section, thus theoretically lower the blood flow); but one could argue that through the initial nerve lesion and the surgical paraneurolysis, those freed segments are anyhow separated from the local blood supply.
\n
Tension is also said to increase local fibrosis (the amount of collagen fibers), but we should further investigate if the tension in the epineural layer, holding the suture material, is equally transmitted to the deeper structures (the deep interfascicular epineurium and finally the perineurium and the fascicular sheets).
\n
One could imagine that the tension is hold within the thicker epineural layer of a thicker peripheral nerve and that the aligned fascicles in the nerve depth are no longer experiencing distraction stress—thus the nerve regeneration happening on the highways of the deeper fascicules would not be disturbed (that’s what our clinical cases seem to show, like a “tube-in-tube” concept).
\n
Tension is not measured easily, or even not at all, and once it comes to textbook descriptions like “reasonable tension” or “avoiding excessive tension” we should be convinced that the actually accepted dogma is weak.
\n
On the other hand, there is the real danger of “promoting” bad microsurgical technique and overindication for direct coaptation, bringing together bad quality stumps under undue tension just to avoid a graft (donor site morbidity, longer procedure, two coaptation sites, but overall less fiber density).
\n
Table 1 summarizes ideal clinical conditions for a direct suture approach; Table 2 summarizes strong arguments for a limited tension, suture approach.
\n
\n
\n\n
\n
\n
Very young patient
Acceptable nerve diameter (OBPL trunk or cord)
Limited scar and/or gap
Compliance for postoperative immobilization
\n
\n
\n\n
Table 1.
Ideal conditions for a direct suture approach.
\n
\n
\n\n
\n
\n
Good clinical result in OBPL direct sutures
Longitudinal growth in young patients
Tissue adaptation: elastic fibers, low collagen content, and postoperative immobilization
\n
\n
\n\n
Table 2.
Strong arguments for a limited tension-suture model.
\n
\n
\n
4. Literature research
\n
Between 1975 and 2017, a PubMed MEDLINE research about “nerve suture” and “tension” only prompted eight valuable articles on nerve-suture related tension [8, 10, 11, 12, 13, 14, 15, 16]; presenting animal studies in rats, cats, dogs, and monkeys; using sciatic or upper limb nerves, and studying the outcome by histology and nerve conduction studies. There are so far no conclusive data about what is better and how much tension is tolerated.
\n
\n
\n
5. Further investigations and today’s conclusions
\n
There is still enough controversy about tension tolerance in peripheral nerve surgery.
\n
Clinical outcomes oppose to the experimental background, which on deeper analysis is rather weak, as the literature on the subject is scarce.
\n
Out of our actual clinical and scientific knowledge, we believe that further investigation could be conducted in several ways:
biomechanical analysis of various suture filament strengths used in nerve coaptation
nylon suture: long term interaction with the fascicular anatomy studied by late histologic examination
a model of a tube, in tube, behavior of the peripheral nerve (epineural versus fascicular tubes)
in vivo observation of coapted nerves in a regeneration chamber.
\n
Meanwhile, we continue to use all available “tricks” and refinements to decrease the gap and the suture tension, to allow optimal nerve fiber regeneration, without any visual help to follow this biological process after reconstructive surgery.
\n
Never should our analysis allow bad techniques with insufficiently cleared stumps, undue tension on the coaptation after three or four knots, the introduction of stronger filament material (3 or 4/0), not adapted to the local anatomy, extension of the proposed technique to smaller nerves with fine epineurium, and not supporting suture material thicker than 10 or 11/0.
\n
But with further developments, we may define indications and good surgical background conditions with limited nerve damage, good mobilization capacity of stumps, good microsurgical coaptation, and rewarded after a good technique with a significant functional result.
\n
\n\n',keywords:"nerve suture, coaptation, tension, brachial plexus injury, obstetrical, peripheral nerve, microsurgery",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/62054.pdf",chapterXML:"https://mts.intechopen.com/source/xml/62054.xml",downloadPdfUrl:"/chapter/pdf-download/62054",previewPdfUrl:"/chapter/pdf-preview/62054",totalDownloads:425,totalViews:47,totalCrossrefCites:1,dateSubmitted:"November 19th 2017",dateReviewed:"May 15th 2018",datePrePublished:"November 5th 2018",datePublished:"July 17th 2019",dateFinished:"June 11th 2018",readingETA:"0",abstract:"Avoiding suture tension in peripheral nerve coaptation seems to be a clinical dogma since 30 years, although experimental data are weak and clinical practice shows good functional outcome after peripheral nerve repair by direct coaptation under “reasonable” tension, defined by local anatomic feasibility and the use of specific suture material. In this article, we focus on the microsurgical technique of nerve stump coaptation and the distribution of tension through epineural sutures with various suture materials; we also analyze the impact on the different nerve tissue layers, the limit of this approach and its combination with other tissue releasing techniques like paraneurolysis, adjacent joint flexion, or bone shortening.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/62054",risUrl:"/chapter/ris/62054",signatures:"Jörg Bahm, Tobias Esser, Bernd Sellhaus, Wissam El-kazzi and Frederic Schuind",book:{id:"6546",title:"Treatment of Brachial Plexus Injuries",subtitle:null,fullTitle:"Treatment of Brachial Plexus Injuries",slug:"treatment-of-brachial-plexus-injuries",publishedDate:"July 17th 2019",bookSignature:"Vicente Vanaclocha and Nieves Sáiz-Sapena",coverURL:"https://cdn.intechopen.com/books/images_new/6546.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"199099",title:"Ph.D.",name:"Vicente",middleName:null,surname:"Vanachlocha",slug:"vicente-vanachlocha",fullName:"Vicente Vanachlocha"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Surgical technique",level:"1"},{id:"sec_3",title:"3. Morphologic and mechanic analysis",level:"1"},{id:"sec_4",title:"4. Literature research",level:"1"},{id:"sec_5",title:"5. Further investigations and today’s conclusions",level:"1"}],chapterReferences:[{id:"B1",body:'de Medinaceli L, Seaber AV. Experimental nerve reconnection: Importance of initial repair. Microsurgery. 1989;10:56-70\n'},{id:"B2",body:'Bahm J, Ocampo-Pavez C, Noaman H. Microsurgical technique in obstetric brachial plexus repair: A personal experience in 200 cases over 10 years. Journal of Brachial Plexus and Peripheral Nerve Injury. 2007;2:1\n'},{id:"B3",body:'Bahm J, Gkotsi A, Bouslama S, El-kazzi W, Schuind F. Direct nerve sutures in [extended]upper obstetric brachial plexus repair. Journal of Brachial Plexus and Peripheral Nerve Injury. 2017;12(1):e17-e20\n'},{id:"B4",body:'Kirjavainen M, Remes V, Peltonen J, Rautakorpi S, Helenius I, Nietosvaara Y. The function of the hand after operations for obstetric injuries to the brachial plexus. Journal of Bone and Joint Surgery (British). 2008;90(3):349-355\n'},{id:"B5",body:'Kennedy R. Suture of the brachial plexus in birth paralysis of the upper extremity. British Medical Journal. 1903;1(2197):298-301\n'},{id:"B6",body:'Millesi H. The nerve gap: Theory and clinical practice. Hand Clinics. 1986;2:651-663\n'},{id:"B7",body:'Trumble T. Overcoming defects in peripheral nerves. In: Gelberman RH, editor. Operative Nerve Repair and Reconstruction. Philadelphia: Lippincott; 1991\n'},{id:"B8",body:'Haas HG, Holste J. Spannungsentlastung bei Nähten peripherer Nerven. Handchirurgie, Mikrochirurgie, Plastische Chirurgie. 1990;22:156-162\n'},{id:"B9",body:'Driscoll PJ, Glasby MA, Lawson GM. An in vivo study of peripheral nerves in continuity: Biomechanical and physiological responses to elongation. Journal of Orthopaedic Research. 2002;20:370-375\n'},{id:"B10",body:'Hentz VR, Rosen JM, Xiao SJ, McGill KC, Abraham G. The nerve gap dilemma: A comparison of nerves repaired end to end under tension with nerve grafts in a primate model. Journal of Hand Surgery. 1993;18(3):417-425\n'},{id:"B11",body:'Maeda T, Hori S, Sasaki S, Maruo S. Effects of tension at the site of coaptation on recovery of sciatic nerve function after neurorrhaphy: Evaluation by walking-track measurement, electrophysiology, histomorphometry, and electron probe X-ray microanalysis. Microsurgery. 1999;19:200-207\n'},{id:"B12",body:'Miyamoto Y. Experimental study of results of nerve suture under tension vs. nerve grafting. Plastic and Reconstructive Surgery. 1979;64(4):540-549\n'},{id:"B13",body:'Okamoto H, Oka Y. Experimental study on tension and stretching to peripheral nerve. Nihon Seikeigeka Gakkai Zasshi. 1990;64(5):472-484\n'},{id:"B14",body:'Rodkey WG, Cabaud HE, McCarroll HR Jr. Neurorrhaphy after loss of a nerve segment: Comparison of epineurial suture under tension versus multiple nerve grafts. Journal of Hand Surgery. 1980;5(4):366-371\n'},{id:"B15",body:'Scherman P, Kanje M, Dahlin LB. Bridging short nerve defects by direct repair under tension, nerve grafts or longitudinal sutures. Restorative Neurology and Neuroscience. 2004;22(2):65-72\n'},{id:"B16",body:'Terzis J, Faibisoff B, Williams HB. The nerve gap: suture under tension vs. graft. Plastic and Reconstructive Surgery. 1975;56(2):166-170\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Jörg Bahm",address:"jorg.bahm@belgacom.net",affiliation:'
Euregio Reconstructive Microsurgery Unit, Franziskus hospital Aachen, Germany
Department for Orthopaedics and Traumatology, ULB Erasme University Hospital, Belgium
Department for Orthopaedics and Traumatology, ULB Erasme University Hospital, Belgium
'}],corrections:null},book:{id:"6546",title:"Treatment of Brachial Plexus Injuries",subtitle:null,fullTitle:"Treatment of Brachial Plexus Injuries",slug:"treatment-of-brachial-plexus-injuries",publishedDate:"July 17th 2019",bookSignature:"Vicente Vanaclocha and Nieves Sáiz-Sapena",coverURL:"https://cdn.intechopen.com/books/images_new/6546.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"199099",title:"Ph.D.",name:"Vicente",middleName:null,surname:"Vanachlocha",slug:"vicente-vanachlocha",fullName:"Vicente Vanachlocha"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}}},profile:{item:{id:"309820",title:"Ms.",name:"Anneliese",middleName:null,surname:"Gegenheimer",email:"anneliese.gegenheimer@gmail.com",fullName:"Anneliese Gegenheimer",slug:"anneliese-gegenheimer",position:null,biography:null,institutionString:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",totalCites:0,totalChapterViews:"0",outsideEditionCount:0,totalAuthoredChapters:"1",totalEditedBooks:"0",personalWebsiteURL:null,twitterURL:null,linkedinURL:null,institution:null},booksEdited:[],chaptersAuthored:[{title:"Harnessing Small Country Collaboration Opportunities to Advance Energy Innovation and Joint Investments",slug:"harnessing-small-country-collaboration-opportunities-to-advance-energy-innovation-and-joint-investme",abstract:"Greater international collaboration is required to catalyze research and development (R&D) investment flows in energy technologies. Successful deployment of such technologies requires innovative funding mechanisms, intellectual property, and data-driven analyses to make smarter, sustainable investment decisions. As small countries are increasingly dealing with effects of climate change, some are projected to lose large portions of their economy. This chapter discusses ways that smaller countries, both in the developed and developing world, can harness international cooperation to advance energy innovation and mitigate such impact. In contrast to collaboration with larger countries, smaller country collaboration can build more agile, balanced partnerships in which participating countries co-develop and co-own R&D and training, and define pilot programs that target their own needs. Leveraging each other’s strengths, small countries can become catalysts for global change. Smaller country collaboration is explored through a proposed model of collaboration in energy innovation between Singapore and Estonia, often considered gateways to Southeast Asia and the EU plus Russia, respectively. Specifically, Singapore and Estonia have the opportunity to leverage each other’s startup ecosystems, innovation systems, knowledge-based economies, and regional markets to build a niche in clean energy technologies, particularly energy storage innovation, with potential global impact on larger markets.",signatures:"Anneliese Gegenheimer and Charles Michael Gegenheimer",authors:[{id:"309820",title:"Ms.",name:"Anneliese",surname:"Gegenheimer",fullName:"Anneliese Gegenheimer",slug:"anneliese-gegenheimer",email:"anneliese.gegenheimer@gmail.com"},{id:"314737",title:"Dr.",name:"C. Michael",surname:"Gegenheimer",fullName:"C. Michael Gegenheimer",slug:"c.-michael-gegenheimer",email:"cgegenhe@columbus.rr.com"}],book:{title:"Sustainable Energy Investment",slug:"sustainable-energy-investment-technical-market-and-policy-innovations-to-address-risk",productType:{id:"1",title:"Edited Volume"}}}],collaborators:[{id:"294002",title:"Prof.",name:"Abd-alla",surname:"Gad",slug:"abd-alla-gad",fullName:"Abd-alla Gad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/294002/images/8271_n.jpg",biography:'Prof. Abd-Alla Gad Abd-Alla Gad\nSenior Professor, Environmental Studies and Land Use Division, National Authority for Remote Sensing and Space Sciences.\nSUDSOE – FP7-EU project coordinator.\nCurrent temporary position: Desertification Expert at Saudi Geologic Survey Authority, Jeddah, Saudi Arabia\n1.\tFaculty of Sciences, State University of Ghent, Belgium, Ph. D. in Soil Sciences, Using Remote Sensing Techniques, with the degree of \\"Greatest distinction\\", October 1988\n2.\tPost Doctor Studies in the Remote Sensing Technology International Center (RESTIC), Tokyo, Japan, 1994. \n3.\tPeace fellowship holder for post Doctor Studies in the State University of South Dakota, 1995.\n4.\tAwarded the “State prize of year 2001 in advanced technical Agricultural Sciences, Egypt. \n5.\tNational expert in the Egyptian Environmental Affairs Agency (EEAA), Ministry of Cabinet Affairs, 1995-2002.\n6.\tDeeply involved in environmental impact assessments in Egypt and in the Arab world.\n7.\tRegional coordinator for a number of EU funded projects (AVICENE, CAMELEO, LANDWATERMED, MEDCOASTLAND, MEDAQUA1, MEDAQWA2, MIRA, MELIA EU-INCO Project and FP4BATIW- FP7.\n8.\tCoordinator of the ERAWIDE EU-FP7 project \\"Characterization and Sustainable Use of Egyptian Degraded Soils – SUDSOE\\", January 2012-December 31, 2014.\n9.\tRegional Coordinador of the H2020 Co-funded project (EU-ASRT, Egypt) “Improvement of water and nutrient retention and use efficiency in arable farming systems from field to catchment scale in Europe and North AfricaWaterFARMING, WaterWorks2015”, start March 1, 2017 for 36 months.\n10.\tPrincipal Investigator of several National funded projects in the field of soil, water use and environmental sciences. \n11.\tProject evaluator for the Marie Curie programs. \n12.\tMember of EU-Egypt Cooperation Comity for Science and Technology since 2008. \n13.\tAttendance of a number of international scientific events around the world and has published 145 articles in different International and National Journals and bulletins. . \n14.\tTraining Program Director of \\"GIS project Management, Recent engineering techniques, Remote sensing-mapping”, Projacs International Academy. \n15.\tEditorial board member & reviewer of different international Journals, and associate editor of the Egyptian Journal of Remote Sensing and Space Sciences.',institutionString:null,institution:null},{id:"296882",title:"Dr.",name:"Mario",surname:"Jorizzo",slug:"mario-jorizzo",fullName:"Mario Jorizzo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"305163",title:"Dr.",name:"Dulce Esmeralda",surname:"Garcia Ruiz",slug:"dulce-esmeralda-garcia-ruiz",fullName:"Dulce Esmeralda Garcia Ruiz",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"305194",title:"Prof.",name:"Jorge Alberto",surname:"Navarro Serrano",slug:"jorge-alberto-navarro-serrano",fullName:"Jorge Alberto Navarro Serrano",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"306657",title:"Ph.D.",name:"Job",surname:"Taminiau",slug:"job-taminiau",fullName:"Job Taminiau",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"309663",title:"Prof.",name:"John",surname:"Byrne",slug:"john-byrne",fullName:"John Byrne",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"310457",title:"Mr.",name:"Daniel",surname:"Sanchez Carretero",slug:"daniel-sanchez-carretero",fullName:"Daniel Sanchez Carretero",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"310458",title:"Ms.",name:"Soojin",surname:"Shin",slug:"soojin-shin",fullName:"Soojin Shin",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"310459",title:"Ms.",name:"Jing",surname:"Xu",slug:"jing-xu",fullName:"Jing Xu",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"314737",title:"Dr.",name:"C. 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The Open Access model is applied to all of our publications and is designed to eliminate subscriptions and pay-per-view fees. This approach ensures free, immediate access to full text versions of your research.
As a gold Open Access publisher, an Open Access Publishing Fee is payable on acceptance following peer review of the manuscript. In return, we provide high quality publishing services and exclusive benefits for all contributors. IntechOpen is the trusted publishing partner of over 128,000 international scientists and researchers.
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The Open Access Publishing Fee (OAPF) is payable only after your full chapter, monograph or Compacts monograph is accepted for publication.
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4,000 GBP Compacts Monograph - Short Form
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Services included are:
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XML Typesetting and pagination - web (PDF, HTML) and print files preparation
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Permanent and unrestricted online access to your work
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Exceeds 20 pages (for chapters in Edited Volumes), an additional fee of 40 GBP per page will be required
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If a manuscript requires Heavy Editing or Language Polishing, this will incur additional fees.
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Your Author Service Manager will inform you of any items not covered by the OAPF and provide exact information regarding those additional costs before proceeding.
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Open Access Funding
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To explore funding opportunities and learn more about how you can finance your IntechOpen publication, go to our Open Access Funding page. IntechOpen offers expert assistance to all of its Authors. We can support you in approaching funding bodies and institutions in relation to publishing fees by providing information about compliance with the Open Access policies of your funder or institution. We can also assist with communicating the benefits of Open Access in order to support and strengthen your funding request and provide personal guidance through your application process. You can contact us at oapf@intechopen.com for further details or assistance.
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For Authors who are still unable to obtain funding from their institutions or research funding bodies for individual projects, IntechOpen does offer the possibility of applying for a Waiver to offset some or all processing feed. Details regarding our Waiver Policy can be found here.
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Indexing and listing across major repositories, see details ...
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Long-term archiving
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Live Performance Metrics to track readership and the impact of your chapter
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Dissemination and Promotion
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Proven world leader in Open Access book publishing with over 10 years experience
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Fully compliant with OA funding requirements
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Optimized processes, enabling publication between 8 and 12 months
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Personal support during every step of the publication process
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+146,150 citations in Web of Science databases
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Currently strongest OA platform with over 150 million downloads
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The Open Access Publishing Fee (OAPF) is payable only after your full chapter, monograph or Compacts monograph is accepted for publication.
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OAPF Publishing Options
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1,400 GBP Chapter - Edited Volume
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10,000 GBP Monograph - Long Form
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4,000 GBP Compacts Monograph - Short Form
\n
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*These prices do not include Value-Added Tax (VAT). Residents of European Union countries need to add VAT based on the specific rate in their country of residence. Institutions and companies registered as VAT taxable entities in their own EU member state will not pay VAT as long as provision of the VAT registration number is made during the application process. This is made possible by the EU reverse charge method.
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Services included are:
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An online manuscript tracking system to facilitate your work
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Personal contact and support throughout the publishing process from your dedicated Author Service Manager
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Assurance that your manuscript meets the highest publishing standards
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English language copyediting and proofreading, including the correction of grammatical, spelling, and other common errors
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XML Typesetting and pagination - web (PDF, HTML) and print files preparation
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Discoverability - electronic citation and linking via DOI
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Permanent and unrestricted online access to your work
What isn't covered by the Open Access Publishing Fee?
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If your manuscript:
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Exceeds 20 pages (for chapters in Edited Volumes), an additional fee of 40 GBP per page will be required
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If a manuscript requires Heavy Editing or Language Polishing, this will incur additional fees.
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Your Author Service Manager will inform you of any items not covered by the OAPF and provide exact information regarding those additional costs before proceeding.
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Open Access Funding
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To explore funding opportunities and learn more about how you can finance your IntechOpen publication, go to our Open Access Funding page. IntechOpen offers expert assistance to all of its Authors. We can support you in approaching funding bodies and institutions in relation to publishing fees by providing information about compliance with the Open Access policies of your funder or institution. We can also assist with communicating the benefits of Open Access in order to support and strengthen your funding request and provide personal guidance through your application process. You can contact us at oapf@intechopen.com for further details or assistance.
\n\n
For Authors who are still unable to obtain funding from their institutions or research funding bodies for individual projects, IntechOpen does offer the possibility of applying for a Waiver to offset some or all processing feed. Details regarding our Waiver Policy can be found here.
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Added Value of Publishing with IntechOpen
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Choosing to publish with IntechOpen ensures the following benefits:
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Indexing and listing across major repositories, see details ...
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Long-term archiving
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Visibility on the world's strongest OA platform
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Live Performance Metrics to track readership and the impact of your chapter
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Dissemination and Promotion
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Benefits of Publishing with IntechOpen
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Proven world leader in Open Access book publishing with over 10 years experience
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+5,200 OA books published
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Most competitive prices in the market
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Fully compliant with OA funding requirements
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Optimized processes, enabling publication between 8 and 12 months
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Personal support during every step of the publication process
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+146,150 citations in Web of Science databases
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Currently strongest OA platform with over 150 million downloads
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