Diabetic neuropathies.

Diabetic neuropathy is a common complication of diabetes that may be associated both with considerable morbidity (painful polyneuropathy, neuropathic ulceration) and mortality (autonomic neuropathy). The epidemiology and natural history of diabetic neuropathy is clouded with uncertainty, largely caused by confusion in the definition and measurement of this disorder. We have reviewed various clinical manifestations associated with somatic and autonomic neuropathy, and we herein discuss current views related to the management of the various abnormalities. Although unproven, the best evidence suggests that near-normal control of blood glucose in the early years after diabetes onset may help delay the development of clinically significant nerve impairment. Intensive therapy to achieve normalization of blood glucose also may lead to reversibility of early diabetic neuropathy, but again, this is unproven. Our ability to manage successfully the many different manifestations of diabetic neuropathy depends ultimately on our success in uncovering the pathogenic processes underlying this disorder. The recent resurgence of interest in the vascular hypothesis, for example, has opened up new avenues of investigation for therapeutic intervention. Paralleling our increased understanding of the pathogenesis of diabetic neuropathy, refinements must be made in our ability to measure quantitatively the different types of defects that occur in this disorder. These tests must be validated and standardized to allow comparability between studies and more meaningful interpretation of study results.

Correction of congenital auricular deformities by splinting in the neonatal period.

Many congenital ear deformities involve abnormal plical folding. This appears to be a result of deficient intrinsic and extrinsic auricular muscle activity as well as intrauterine pressure effects. These deformities can usually be corrected by appropriate splinting in the neonatal period, a time when estrogen activity is increased and the ear is very malleable. The methods used and the results of treatment are presented.

Limb salvage despite extensive tissue loss. Free tissue transfer combined with distal revascularization.

Extensive lower-extremity tissue loss may preclude limb salvage despite successful arterial reconstruction. We attempted to avoid limb loss in such patients by combining arterial bypass with microvascular free tissue transfer. Fourteen patient (12 diabetic), 33 to 74 years of age, presented with extensive tissue loss in 15 lower extremities, exposing bone or tendon on the heel, ankle, lower part of the leg, or hindfoot. Mean ulcer size was 5 X 8 cm. Four patients had had previous contralateral below-knee amputations. Femorodistal (seven), popliteal-distal (three), or femoropopliteal (four) bypass, or tibial angioplasty (one), was performed to provide sufficient inflow for free tissue transfer. Serratus anterior, scapular, latissimus dorsi, rectus abdominis, gracilis, ulnar, or temporalis free flaps were used. One free flap failed due to venous thrombosis and was corrected with a second flap. Limb salvage was achieved in 14 (93%) of 15 limbs during a mean follow-up of 24 months. The single amputation occurred due to severe foot ischemia in a patient whose femorodistal bypass remained patent only to the viable free flap. The remaining 13 patients (14 limbs) became ambulatory, including those with free flaps to weight-bearing regions.

Wound healing in diabetes mellitus.

Diabetes mellitus is a complex metabolic disorder whose components have several direct and indirect effects on the healing of wounds. This article examines how diabetes affects wound healing from the standpoint of alterations in the microvasculature, nerve function, and the immune system.

Foot reconstruction in diabetes mellitus and peripheral vascular insufficiency.

The great majority of diabetic patients have diabetic foot symptoms. Significant recent advances in reconstructive surgery, as well as improvements in the management of both diabetes mellitus and peripheral vascular disease, make these patients eligible for plastic and reconstructive surgery. Many diabetic patients who would previously have had below-the-knee amputations are now having their complex foot wounds reconstructed. In addition to the metabolic consequences of the disease and the increased susceptibility to infection and wound healing complications, infrapopliteal arterial occlusive disease, peripheral neuropathy, and hemorrheologic changes are addressed in this article.

Limb salvage in the patient with severe peripheral vascular disease: the role of microsurgical free-tissue transfer.

Severe peripheral vascular disease has traditionally precluded the use of free-tissue transfer for lower extremity salvage. In the present series, 10 microvascular transfers performed over a 2-year period are critically evaluated. Vascular surgical consultation was obtained if the preoperative assessment revealed reconstructible vascular disease proximal to the offending wound. Flaps were performed for osteomyelitis in two cases and neurotrophic ulcers in eight cases. Seven of the 10 extremities had prior distal revascularization procedures before the tissue-transfer procedure. There were no anastomotic flap failures; however, one lower extremity underwent below-knee amputation due to sepsis and its cardiovascular sequelae. In properly selected peripheral vascular disease patients, limb salvage can be effected with microsurgical free-tissue transfer. The technique appears invaluable in those patients who have undergone prior contralateral amputation.

Soft tissue reconstruction. Coverage of lower leg. Rotational flap.

The combined orthopedic and plastic surgical approach to the injured lower extremity has permitted successful salvage of otherwise severely injured limbs. Although numerous muscle and fascial flaps have been described for all regions of the leg between the knee and foot, specific treatment regimens have become popular based on the location of the wound. Refinements in flap surgery have permitted the approach discussed in this article to become standard in the care of patients with either chronic osteomyelitis or acutely injured limbs. This article delineates the muscle and fascial flaps that are used to reconstruct these defects.

The V-Y plantar flap for reconstruction of the forefoot.

Stable reconstruction of the forefoot remains a formidable challenge. The present study reviews our experience with a flap of plantar skin and fascia advanced in a V-Y manner to cover metatarsal head ulcers. Although this technique was used in a variety of clinical situations, 71 percent of the 38 patients were diabetic with neurotrophic wounds. The anatomic basis for flap design is reported based on 10 fresh cadaver dissections. Flap survival was 100 percent. Ulcer recurrence was related to the problems inherent in the hypesthetic foot. We feel that judicious manipulation of the bony architecture along with weight-dispersion shoe inserts assists in preventing recurrent ulceration.

The integrated approach to suppurative mediastinitis: rewiring the sternum over transposed omentum.

Acute mediastinitis after cardiopulmonary procedures remains a devastating complication and a challenge to the reconstructive surgeon. A review of the literature and our own experience confirm the need for early aggressive drainage followed by timely reconstruction. In carefully selected patients, the sternum may be reclosed, provided that omental tissue has been transposed into the defect between the myocardium and the posterior cortex of the sternum. The technique is outlined and the results are analyzed and compared with three additional patient subgroups: (1) sternal wounds rewired over drains, (2) sternal wounds rewired with drains and irrigation catheters, and (3) wounds closed by sternal excision and muscle-flap transposition. To date, nine omental transfers have been performed with complete success. Mediastinal drainage routinely ceases after 3 to 5 days, and hospitalization has averaged 10 to 14 days. Early open debridement allows establishment of drainage and permits close evaluation of the character of the bony sternum. Muscle flaps may then be used in those patients with multiply fractured or frankly necrotic sternal tissue, while sternal closure over omental flaps may be used in all other patients. Adherence to this protocol has allowed for bacteriologic control of the wound, minimal morbidity, and no mortality.

The effect of pentoxifylline on random-pattern skin-flap necrosis induced by nicotine treatment in the rat.

Cigarette smoke, and specifically nicotine, has been shown to reduce skin-flap survival. The purpose of this study was to determine if the preoperative administration of pentoxifylline can counteract the deleterious effects of nicotine on skin-flap survival in the rat. Sixty rats were distributed into four groups (n = 15). The survival of modified McFarlane skin flaps was assessed on postoperative day 7. The administration of nicotine (0.6 mg/kg) for 24 weeks preoperatively produced an average skin-flap survival of 59 percent; this was significantly decreased compared with controls (p < 0.05). When similarly treated animals were given pentoxifylline (20 mg/kg) for 30 days preoperatively, the mean skin-flap survival improved significantly to 80 percent (p < 0.05). Withholding nicotine for 2 weeks preoperatively also was found to significantly improve skin-flap survival to 73 percent (p < 0.05). Blood filterability was measured as an indicator of viscosity. The blood filterability in rats that received nicotine for 24 weeks was significantly decreased compared with controls (p < 0.05). Both the addition of pentoxifylline preoperatively and the withholding of nicotine for 2 weeks preoperatively were found to significantly improve blood filterability compared with rats that received nicotine alone for 24 weeks postoperatively (p < 0.05).

The relationship between the number of sutures and the strength of microvascular anastomoses.

The relative strengths of microvascular anastomoses in rat femoral arteries were measured, comparing controls (no anastomosis) to those with 4, 6, 8, 10, 12, and 14 stitches. The ones in which 8 sutures were used most closely paralleled the control state, whereas those with 4 or 6 sutures were clearly inferior. With a greater number of sutures the vessel behaves as a "shorter" vessel, with the anastomosis becoming the weakest part of the vessel.

Effect of parenteral steroids on edema in replanted rat legs.

The experiments described demonstrate that parenteral steroid therapy will decrease the amount of postoperative edema in the replanted leg of a rat.

Tobacco smoking and complications in elective microsurgery.

This study assesses the risk for complications in patients who chronically smoke but who have quit in the perioperative period of an elective free-tissue transfer as compared with patients who do not smoke. A retrospective review identified 104 free-tissue transfers in 93 smokers and 58 transfers in 51 nonsmokers. The demographics, wound etiology, and recipient sites were similar in the two populations. With the exception of a higher incidence of chronic obstructive pulmonary disease (COPD) among smokers, preexisting comorbid factors also were similar. Postoperative medical complications were comparable between populations. When comparing smokers with nonsmokers, we found that anastomotic patency and flap survival were not different (95 versus 94 percent, respectively), that delayed wound healing at the recipient site was different (35 versus 24 percent), and that smokers require an additional procedure to achieve final wound closure more frequently (27 versus 12 percent, p = 0.03). These findings suggest that cigarette smokers are at increased risk for complications, not at the site of the anastomosis in free-tissue transfer, but rather at the flap's interface with the wound or overlying skin graft.

The segmental pectoralis major muscle flap: a function-preserving procedure.

A function-sparing pectoralis major muscle flap is presented. The flap is a medially based segmental transfer of a single intercostal portion of the pectoralis major muscle supplied by a single perforating branch of the internal thoracic artery. The segmental terminal nerve distribution of the medial and lateral pectoral nerves permits preservation of the remainder of the muscle in situ. Six cases of this procedure are presented with five successful outcomes. The single exception was in the loss of the distal tip when used to cover an irradiated carotid sheath to the base of the skull.

Reconstruction of the extremity with the dorsal thoracic fascia free flap.

The dorsal thoracic fascia is the anatomic layer that contains the blood supply to the scapular and parascapular fasciocutaneous flaps. The cutaneous vascular territory of the circumflex scapular artery and its parascapular branches is well known. During the past 8 years, the authors have employed the dorsal thoracic fascia free flap for extremity reconstruction in 17 patients (upper extremity, n = 9; lower extremity, n = 8). The indications for using this free flap included primary coverage after trauma (n = 10), resurfacing of "unstable" scar (n = 3), coverage of plantar foot ulceration (n = 3), and coverage of an exposed lower extremity distal arterial bypass graft (n = 1). The large anatomic boundaries of this flap, the consistent vascular anatomy, and the thin yet durable quality of the tissue make this flap an excellent choice for the reconstruction of upper and lower extremity defects.

The accuracy of duplex ultrasonography in the planning of skin flaps in the lower extremity.

The septocutaneous perforators represent one of the major sources of the blood supply to the skin of the lower extremity. Despite several well-described anatomic accounts, the location of lower leg septocutaneous perforators, as they originate from each of the three main infrapopliteal vessels in the leg, remains inconsistent as a result of individual anatomic variations. With the aid of duplex ultrasonography (color Doppler imaging), preoperative, mapping and size determination of these perforators can be provided. The skin paddle can then be designed to lie exactly over these perforators, ensuring blood supply to the skin paddle. The location and distribution of medial septocutaneous perforators in the leg, which originate from the posterior tibial artery, were mapped using anatomic dissections (29 lower extremities). These findings were then compared with duplex ultrasonographic data in 9 living volunteers (18 lower extremities). The medial septocutaneous perforators were chosen for this study because they course directly over the posterior tibial artery, making their location difficult to assess with standard Doppler techniques. The hand-held Doppler is incapable of distinguishing flow originating from the perforators versus the posterior tibial artery. No significant difference existed between cadaver and duplex distributions. "Large" perforator vessels (> 1 mm outer diameter) were evenly distributed with a central tendency at 140 to 150 mm from the medial malleolus. The distribution of "small" perforator vessels (< 1 mm outer diameter) was skewed. Fifty percent were found within 80 mm of the medial malleolus and the remainder spread proximally in the leg.(ABSTRACT TRUNCATED AT 250 WORDS)

The gastrocnemius muscle as a free-flap donor site.

Despite the fact that the pedicled gastrocnemius flap has been used clinically for almost two decades, precise data on its neurovascular anatomy are lacking. A detailed knowledge of the neurovascular anatomy of this flap may encourage its more extensive use as a donor site by the means of microvascular free-tissue transfer. The femoral or popliteal artery in 27 fresh cadavers was injected with radiopaque contrast material to study the gross vascular supply of 54 medical and 50 lateral gastrocnemius muscles. The intramuscular vascular anatomy also was analyzed in 29 medial and 24 lateral gastrocnemius muscles using x-ray technique. Depending on the number of the sural arteries that supply the gastrocnemius muscle, flaps were classified as type 1 or type 2. Type 1 muscle bellies (lateral or medial gastrocnemius muscle belly) are supplied by one sural artery, while in type 2 muscles two arteries supply one muscle belly. Eighty-five percent of medial and 84 percent of lateral gastrocnemius muscle bellies had single vascular pedicles (type 1). The point of origin of the sural artery(s) permitted us to further classify the blood supply to the muscle bellies as subtypes A, B, and C. Intramuscular vascular anatomy is characterized as either a single vessel (dominant type) or two vessels (nondominant type). A single motor nerve, from the tibial nerve, accompanied the primary vascular pedicle into each muscle belly. When there were two vascular pedicles supplying one muscle belly, only one motor nerve accompanied the major pedicle.(ABSTRACT TRUNCATED AT 250 WORDS)

Reconstruction of breast asymmetry in Poland's chest-wall deformity using microvascular free flaps.

Poland's syndrome comprises a spectrum of chest-wall deformities affecting, to various degrees, the rib cage, the chest-wall muscles, the neurovascular structures of the ipsilateral arm, and the overlying breast. This study details our experience with nine female Poland's syndrome patients who had chest-wall and breast asymmetry corrected by microvascular free-tissue transfer. Nine female patients with Poland's chest deformity underwent 12 microvascular free flaps between 1989 and 1994. Donor sites for free-tissue transfer included eight transverse rectus abdominis flaps, two superior gluteal flaps, one inferior gluteal flap, and one contralateral latissimus dorsi flap. Recipient vessels were branches of the subscapular vascular axis in all patients. Patients' ages ranged from 18 to 47 years at the time of reconstruction. Chest-wall and breast asymmetry varied from accompanying severe pectus and rib cage deformities to isolated breast involvement. Complications were limited to a superior gluteal flap loss due to anomalous subscapular venous drainage. This patient underwent a successful second superior gluteal flap reconstruction utilizing the cephalic venous outflow system. Chest-wall and breast symmetry was restored in all patients. This study demonstrates that microsurgical reconstruction of chest-wall and breast asymmetry in Poland's syndrome yields excellent results with a high degree of patient satisfaction. Careful intraoperative assessment of the recipient vessels prior to flap transfer is mandatory. Because Poland's chest-wall deformity may include anomalies of the vascular system, preoperative vascular assessment with duplex ultrasonography should be considered in all patients, and use of preoperative angiography or venography in selected patients also appears justified.

Microvascular anastomotic thrombosis in experimental diabetes mellitus.

An experimental model was developed to investigate the effects of glycemic control and pentoxifylline administration on microvascular anastomotic patency rates in streptozotocin-induced diabetic rats. Diabetes was confirmed by blood glucose levels of more than 300 mg/dl prior to administering insulin and/or pentoxifylline. Microvascular anastomoses of the femoral artery and vein were performed 4 weeks after induction of diabetes. Subsequently, the comparative rates of anastomotic thrombosis in diabetic and nondiabetic groups with or without insulin or pentoxifylline administration were assessed by direct visualization of the anastomotic sites after 4 days. The results suggest that hyperglycemia impairs the post-operative patency of microvascular venous anastomoses. The diabetic animals maintained under insulin regimens that tightly controlled their serum glucose levels (100 to 200 mg/dl) experienced patency rates similar to those of nondiabetic controls (p < 0.05). Pentoxifylline improved microvenous patency at all levels of hyperglycemia studied, suggesting a possible hemorrheologic mechanism for microvascular venous anastomotic thrombus formation in diabetic animals.

The role of microsurgical free flaps in foot and ankle surgery.

Microsurgery is clearly an extremely useful adjunct in foot and ankle reconstruction. It requires careful planning between the microsurgeon and vascular, podiatric, and orthopedic surgeons. Ideally, each member of the team should have a special focus on limb salvage. The more experienced the microsurgeon and the better the planning the higher the chance of success. Current success rates in large microsurgical centers exceed 95% free flap survival. Skill in choosing the appropriate flap and optimizing how it is inset ensure an optimal aesthetic and functional result while minimizing the need for later revisions. Adding microsurgical free flaps to the armamentarium of limb salvage surgeons ensures a much higher salvage rate in limbs that heretofore posed too large of a reconstructive challenge and, therefore, were amputated. Current efforts should be directed toward the salvage of only those feet that will be functional, while avoiding limb salvage surgery in other cases. Microsurgical salvage should not be undertaken simply because it is technically feasible. The patient who undergoes 10 to 15 procedures over a 2 to 3 year interval and has a viable, but minimally functional, limb has not been helped. One, therefore, must be sure that the functional salvage can be performed within a defined number of operations in a given time. If not, a below-knee amputation should be considered strongly.