Diabetic patients, presenting with both peripheral vascular disease and large soft-tissue defects, are too often treated by primary amputation. A combined revascularization and free-tissue transfer procedure can extend limb salvage in these patients. The authors report their experience over 4 years with 19 diabetic patients with peripheral vascular disease and large soft-tissue defects of the foot requiring free-tissue transfer. Although there was a 100 percent flap survival, early local wound problems occurred in three patients (16.6 percent). The recurrence rate was about 18.7 percent, but no complementary flap procedures were mandatory. With a mean follow-up of 38 months (range: 23 to 55 months), the limb salvage rate was 94.4 percent. Although there was one limb loss and one patient with ambulation difficulties, 16 patients (84.2 percent) were fully rehabilitated and were able to function independently. Despite a rather small series, this study confirms that in selected diabetic patients, a combined approach of vascular and reconstructive surgeons can reduce the limb amputation rate with acceptable complication rates. This combined approach offers major benefits to these patients, especially stable coverage and preservation of ambulation, and should always be considered before amputation.

Facial wounds are frequently associated with bone fractures and multiple trauma; however, disruption of the parotid gland or Stensen's duct is rare and is often associated with facial nerve palsy. Lesions are often undiagnosed on first assessment of the multiple trauma patient. If microsurgical repair of Stensen's duct provides good functional results, ignoring such lesions often leads to later complications such as fistulae and sialocoeles. Although simple ligation of Stensen's duct has been reported to give satisfactory results, the authors prefer a more anatomic reconstruction of this structure whenever possible. A case of Stensen's duct microsurgical repair using a vein graft are reported.

Chronic sympathetic denervation leads to the development of supersentivity to adrenergic agents. Free flap surgery results in the disruption of the autonomic nerve fibers running along the anastomosed vessels. We therefore investigated the early effect of surgical sympathectomy on the reactivity of cutaneous microcirculation challenged to adrenergic agents. Two epigastric flaps were elevated and exposed in 15 rats. On the right flap (Side A), a circular adventitiectomy of the feeder vessels was realized to provide surgical sympathectomy. On the left flap (Side N), vessels were kept intact. The following drugs were then given intravenously successively: phenylephrine (10 and 15 microg kg(-1)), norepinephrine (10 microg kg(-1)), prazocin (1 mg kg(-1)) followed by norepinephrine (10 microg kg(-1)). Cutaneous microcirculation was assessed using Laser-Doppler Flowmeters simultaneously on the two flaps after each drug administration. Mean arterial pressure was also measured. On side N, phenylephrine and norepinephrine resulted in a transient increase in cutaneous microcirculation followed by a more prolonged reduction. On side A, only the initial increase was observed, which was greater and longer as compared with side N, and paralleled the increase in mean arterial pressure. After prazocin pre-treatment, norepinephrine produced a transient increase in cutaneous microcirculation similar on both sides, and parallel to the changes in arterial pressure. No decrease in cutaneous microcirculation was observed. Immediately after surgical adventitiectomy, the vasoconstriction produced by alpha-adrenergic agents is prevented. No denervation-induced hypersentivity is observed. Surgical sympathectomy might protect cutaneous flaps from vasoconstriction induced by endogenous catecholamines release.

No abstract

The purpose of this study was to assess the relevance of the tip of the greater horn of the hyoid bone (THB) in the localization of the carotid bifurcation, the superior thyroid and lingual arteries, and the hypoglossal and superior laryngeal nerves. Measurements of these structures with respect to the THB were also made. Thirty perfusion-fixed human cadavers (60 specimens) were studied. Sharp measurements were made along two orthogonal axes crossing exactly on the THB. The vertical axis was parallel to the craniocaudal axis of the body. Taking the THB as a landmark, the five structures were identified in all the specimens. The mean value, standard deviation, and range of measurements for each structure studied are given in the text. This study shows the THB to be a useful landmark which is an aid to locating the aforementioned structures with confidence, and concludes that knowledge of this landmark would be beneficial for the surgeon dealing with the mid neck area.