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PubMed1999

Thoracoscopic resection of posterior neurogenic tumors.

Video-assisted thoracic surgery (VATS) may be used for resection of posterior mediastinal tumors to avoid thoracotomy and shorten hospital stay. Between October 1990 and June 1998, 23 patients had VATS resection of posterior neurogenic tumors. The 14 females and 9 males ranged in age from 14 months to 70 years, with a median of 35 years. Operation time ranged from 30 to 120 minutes (median, 83), and intraoperative complications were limited to minor problems as well as conversion to thoracotomy to enhance complete tumor resection in four cases. Tumor pathology included nerve sheath origin (20) and autonomic ganglia (3). There was only one malignant schwannoma. Tumor size ranged from 0.7 to 13 cm in diameter. Median chest tube days was 1 day (range, 1-4), and hospital stay was 2 days (range, 1-9). Postoperative complications included transient paresthesia (three cases), ileus (two cases), pleural effusion (one case), and transient intercostal pain (one case). Posterior neurogenic tumors may be resected safely using video-assisted techniques. Conversion to thoracotomy to enhance complete resection is both possible and encouraged. The use of VATS seems to decrease hospital stay and minimize postoperative complications. In posterior neurogenic tumors without tumor extension to the spinal canal, VATS has become our preferred method for resection.

Adolescent↗
PubMed2001

Nerve-preserving aortoiliac reconstruction surgery: anatomical study and surgical approach.

OBJECTIVE: Dysfunctional ejaculation and, to a lesser extent, dysfunctional erection caused by disruption of efferent sympathetic pathways is a common complication after aortoiliac reconstruction surgery. The aim was to give an anatomic motivation for a nerve-preserving approach on the basis of right-sided unilateral disruption of lumbar splanchnic nerves. METHODS: Anatomic and microscopic analysis of preaortic and para-aortic retroperitoneal regions in human cadavers was performed. Anatomic analysis was conducted of two aortoiliac reconstruction operations performed on human cadavers; one was performed according to a single-blind procedure, the second with a modified procedure. RESULTS: The lumbar splanchnic nerves supplying the superior hypogastric plexus from the right side were found to be less voluminous than the left-sided ones. The superior hypogastric plexus was found slightly shifted to the left of the midsagittal plane across the abdominal aorta and its bifurcation. Microscopic analysis revealed a thin fascia between the aorta and the subperitoneal tissue compartment. This fascia was used as a plain of dissection to mobilize the preaortic nerve-plexuses without damage from the aortic wall. Analysis of the specimens operated on showed a significant difference in nerve disruption. The standard procedure caused total disruption of the superior hypogastric plexus and extensive disruption of the inferior mesenteric plexus. The modified procedure only caused right-sided unilateral disruption of lumbar splanchnic nerves. CONCLUSION: The autonomic nerves supplying the bladder neck, the vas deferens, and the prostate are closely related to the abdominal aorta and its bifurcation. Right-sided unilateral disruption of lumbar splanchnic nerves without further damage to nervous structures would ensure at least one functional sympathetic pathway remaining after aortoiliac reconstruction surgery.

Aorta, Abdominal↗
PubMed1999

Anatomical studies of the autonomic nervous system in the human pelvis by the whole-mount staining method: left-right communicating nerves between bilateral pelvic plexuses.

PURPOSE: Some recent neurophysiological studies have suggested cross-innervation of pelvic genitourinary organs by extrinsic left-right communicating nerves. However, no definite course for these nerves has been clearly determined macroanatomically in humans. In the present study we extensively investigated the adult human pelvis to elucidate their courses by the whole-mount staining method. MATERIALS AND METHODS: A total of 6 male human specimens that had been subjected to pathological dissection were examined by means of an acetylcholinesterase whole-mount staining method. A map of nerve pathways was made by composite photomicrography. Histologically, nerves dissected accurately under a dissecting microscope were stained with both Klüver-Barrera stain and the Bodian method. RESULTS: The communicating nerves between bilateral pelvic plexuses were observed at the back of the rectum and in the rectoprostatic space. The former were composed of nothing but myelinated fibers in the same way as the pelvic splanchnic nerve. By contrast, the latter were composed of unmyelinated fibers with a few myelinated fibers. The pelvic plexus could be divided into three portions, anterosuperior, anteroposterior and inferior areas, by ganglion type. Morphologically, fiber components differed among those three portions. CONCLUSION: The communicating nerves at the back of the rectum seemed to be predominantly parasympathetic communicantes between bilateral pelvic splanchnic nerves rather than pelvic plexuses. These nerves may be involved in postoperative voiding function in the case of pelvic surgery with hemilateral nerve preservation. The function of the pelvic plexus seemed to be heterogeneous in each portion according to our morphological results.

Aged↗
PubMed2004

Role of penile electrodermal activity in the evaluation of autonomic innervation of corpus cavernosum.

Electrodiagnostic tests measuring the activities of cavernous smooth muscle and sudomotor structures of penile skin are used in order to evaluate autonomic innervation of the penis. Owing to closeness of these tissues, the interference of sympathetic activity during recording is a possibility. In this study, we investigated this possibility in 10 patients whose cavernosal tissues were destroyed during penile prosthesis implantation by comparing the pre- and postoperative penile skin electrodermal activities. Penile electrodermal activities were recorded with surface electrodes before and after the operation. All of the patients had spontaneous and evoked penile electrodermal activity (EDA). The mean amplitude of evoked EDA decreased from 2159+/-700 to 1413+/-515 microV following penile prosthesis surgery (P=0.017). The decrease in the amplitude of penile-evoked EDA following penile prosthesis implantation suggests the contribution of cavernous smooth muscle activity to the sudomotor responses prior to operation. Although corpus cavernosum sympathetic activity contributes to the penile skin recordings, these recordings are mostly the result of penile skin sudomotor sympathetic activity. Therefore, surface potentials recorded from penile skin should not be used for the evaluation of autonomic innervation of corpus cavernosum.

Adult↗
PubMed2001

[The neurovegetative system in heart failure and heart transplantation].

Increased sympathetic activity and plasma levels of norepinephrine, parasympathetic withdrawal and impaired baroreflex gain have been reported in patients with chronic heart failure (CHF). Since excessive neurohormonal activation is implicated in the progression of heart failure, it is crucial to measure and quantify it in clinical practice. Some techniques that may be suitable for this purpose such as catecholamine plasma level assessment or direct recording of the neural efferent activity to the peripheral muscles, require expertise and are very unattractive in terms of cost-effectiveness. On the contrary, the measures that test the reflex or tonic responses of the sinus node activity have been extensively used in both experimental and clinical studies. However, consensus regarding their true relevance in the clinical scenario has not yet been reached. Heart rate variability is one of the easiest techniques available for physicians but the identification of the RR intervals in CHF is often very difficult owing to the presence of rhythm disorders or of sino-atrial or atrioventricular blocks and the analytical softwares included in the commercially available Holter systems are not reliable enough. Similarly, for all methods currently employed in clinical practice, the assessment of baroreflex sensitivity in CHF has some limitations or is not applicable for all patients. In this article, the main clinical methods used to assess the autonomic nervous system in CHF are reviewed focusing on the clinical applicability of the obtained parameters. It is underlined that, using these techniques, many investigators have obtained important results in the pathophysiological comprehension of the disease, but to date their use in the clinical setting is very modest. Indeed, before the measurement of the autonomic nervous system can be applied to clinical practice and used to guide therapy, more precise insights into the link between the autonomic indexes and sympathetic or parasympathetic activity and between them and mortality are needed. Moreover, no standardization has been established for the various commercial systems and the development of their software has not been guided by any research committee. For many other techniques there are no commercially available devices and the software has been developed in the physiological laboratories as prototypes. These limitations will be overcome if the researchers succeed in convincing the companies about the importance and the clinical applicability of the evaluation of the autonomic nervous system. With regard to cardiac transplantation, as the donor heart is completely denervated, it constitutes an important physiological model for the study of autonomic activity. The more interesting research field has been the assessment of a possible post-transplant reinnervation both at the experimental and clinical levels. It has been shown that in animal models reinnervation occurs within the first year of heart transplantation. Several authors have demonstrated a time-dependent restoration of myocardial norepinephrine content as well as an increase in the heart rate and myocardial contractility in response to neural sympathetic stimulation. Parasympathetic efferent reinnervation has also been demonstrated in a canine transplanted model within 12 months of surgery. Despite evidence in favor of both sympathetic and parasympathetic reinnervation in animals, the problem of whether such reinnervation also occurs in humans is still debated, especially as far as parasympathetic reinnervation is concerned. The presence, in humans, of sympathetic reinnervation has been documented by different methods. However, there are significant differences regarding the degree of regeneration and the frequency of occurrence. It has also been assumed that the regeneration of sympathetic fibers takes place slowly over time. In contrast, regrowth of parasympathetic nerve fibers in patients after heart transplantation has not been unequivocally confirmed. Although various investigators have used the same method, their results differ and are indeed often contradictory. Recently it has been suggested that the type of surgery may have a major influence on neural and particularly parasympathetic regeneration. If the patients undergo heart transplantation by bicaval techniques the nerves are resected and they are more prone to regenerate towards the donor heart. This is not true if the traditional technique is employed.

Autonomic Nervous System↗
PubMed1990

Giant inflammatory polyps associated with idiopathic inflammatory bowel disease. An ultrastructural study of five cases.

Five cases of giant inflammatory polyps associated with idiopathic inflammatory bowel disease are reported. Polyps produced intestinal obstruction in three cases; consequently, surgery was performed. In a further two cases, intestinal bleeding was improved by endoscopic polypectomy. Electron microscopy showed fibroblasts, myofibroblasts, mast cells, lymphocytes, collagen fibers, capillaries, and venules. Remnants of the original mucosal epithelial cells, smooth muscle cells, and hypertrophic autonomous nerve plexuses were noted. Nerve fibers were interwoven with the matrix of the polyps. Mast cells were closely linked with vessels, nerves, and collagen fibers. They may have an important role in the excessive granulation, angiogenesis, and fibrotic process in giant inflammatory polyps.

Adult↗
PubMed1996

[Monitoring intraoperative awareness. Vegetative signs, isolated forearm technique, electroencephalogram, and acute evoked potentials].

Several methods have been developed to quantify central anaesthetic effects and monitor awareness during general anaesthesia. The most important of these are the PRST score, calculated from changes in blood pressure, heart rate, sweating, and tear production, the isolated forearm technique, where the patient is allowed to move during surgery, the processed electroencephalogram (EEG) and the derived parameters median frequency (MF) and spectral-edge frequency (SEF), and mid-latency auditory evoked potentials (MLAEP). In clinical practice, the application of individual doses of anaesthetics is generally guided by autonomic vegetative clinical signs such as changes in blood pressure, heart rate, sweating, and tear production, quantified as the PRST score. Unfortunately, these parameters are not very reliable with regard to predicting the suppression of consciousness and awareness, especially when high-dose opioids are used in patients with cardiovascular medications and a variety of accompanying diseases. The PRST score probably indicates mainly the autonomic responses to painful stimuli, and seems to be useful in guiding the individual use of analgesics. The isolated forearm technique is a useful test of the patient's responsiveness during general anaesthesia, and thus an instrument for investigating the incidence of awareness during different anaesthetic regimens and when muscle relaxants are employed. A disadvantage is that it can only be used for 20 to 30 min because of pressure-induced nerve blocks or lesions. It can not be employed when long-term relaxation is necessary and consciousness and awareness are to be monitored continuously. The processed EEG and the derived parameters MF and SEF are important scientific tools to quantify central effects of many anaesthetics and opioid analgesics that allow the development of pharmacodynamic-pharmacokinetic models of anaesthetic action. MF has proven to be useful in monitoring closed-loop feedback of intravenous drug administration. Unfortunately, until now there have been no clinical studies that document the usefulness of MF or SEF with regard to predicting intraoperative arousal or awareness. To the contrary, some experimental data failed to predict imminent arousal and response to surgical incision or verbal commands by MF or SEF. Therefore, the EEG seems to be of limited value for monitoring awareness, consciousness, or memory formation during anaesthesia. MLAEP are suppressed in a dose-dependent fashion by many general anaesthetics and correlate with wakefulness, awareness, and explicit and implicit memory during anaesthesia and seem to be a promising method of monitoring awareness during anaesthesia. Nevertheless, future studies will have to determine threshold values for the different MLAEP parameters for intraoperative awareness and explicit and implicit recall of intraoperatively presented information for the different commonly used anaesthetics. Only then will it be possible to determine the usefulness of the method in clinical practice.

Anesthesia, General↗
PubMed2005

[Evaluation of residual urine volume by ultrasound for detection of urinary bladder dysfunction after surgical therapy of rectal cancer].

INTRODUCTION: Despite total mesorectal excision and protection of the pelvic autonomous nerve system, dysfunctions of the urinary bladder are often observed after surgical therapy for rectal cancer. In this prospective study, the frequency of urinary bladder malfunctions was assessed by measuring residual urine volume using transcutaneous ultrasound before and after surgery. PATIENTS AND METHODS: Seventy-five patients with rectal cancer were analyzed for urine volume retained before and after surgical therapy. The tumors were localized in the lower third of the rectum for 31 patients, in the middle for 30, and in the upper third for 14. RESULTS: An increase in retained urine of more than 100 ml was found in 12 patients (15%), and neurogenic bladder was diagnosed in two (3%). In female patients, urinary bladder malfunctions were significantly less frequent and severe. CONCLUSIONS: The percutaneous assessment of urine volume retained in the bladder is suited for determining urinary bladder malfunctions after surgery. This method can serve to assess the quality of surgical treatment for rectal cancer. A standardized definition of relevant urinary bladder malfunctions is required.

Adult↗
PubMed2005

The body mass index and level of resection: predictive factors for compensatory sweating after sympathectomy.

OBJECTIVE: Compensatory sweating (CS) is the most common adverse event and the main cause of dissatisfaction among patients undergoing a VATS sympathectomy for the treatment of primary hyperhidrosis. It has been described that obese individuals experience more sweating than thinner ones. The aim of this study is to identify the Body Mass Index (BMI) and the level of resection as predictive factors for CS and its relation to levels of patient satisfaction following the procedure. METHODS: From October 1998 to June 2003, 102 patients undergoing VATS sympathectomies (51 for palmar hyperhidrosis, PH, and 51 for axillary hyperhidrosis, AH) were prospectively surveyed. They were divided into three groups according to their BMI: Group I was composed of 19 patients with BMI<20 (9 patients with PH and 10 with AH); Group II was composed of 52 patients with 20 < or =BMI<25 (25 with PH and 27 with AH); and Group III was composed of 31 patients with BMI > or =25 (17 with PH and 14 with AH). Each procedure was simultaneously and bilaterally performed under general anesthesia using two 5.5 mm trocars and a 30 degrees optic system. RESULTS: Patients treated for PH (resection of T2-T3) had more severe CS than those with AH (resection of T3-T4) (p=0.007) and the greater the BMI, the greater the severity of the CS (p<0.001). No statistically significant difference was found between the BMI bands in relation to the degree of satisfaction (p=0.644), nor when we compared the degree of satisfaction to the degree of CS (p=0.316). CONCLUSIONS: The greater the BMI, the more severe the CS, but this did not correlate with the patients' level of satisfaction. Avoiding the resection of T2 sympathetic ganglia is also important in reducing the intensity of CS.

Adolescent↗
PubMed1990

The subserosal ganglia of the human taenia.

Specimens of the taenia from the sigmoid colon of female patients undergoing surgery for carcinoma of the rectum were studied histochemically and immunohistochemically for acetylcholinesterase (AChE) and for vasoactive intestinal polypeptide (VIP)-, substance P (SP)-, somatostatin (SOM)-, neuropeptide Y (NPY)-, calcitonin gene-related peptide (CGRP)- and Met-enkephalin (mENK)-immunoreactivity. Autonomic ganglia were observed on the serosal surface of the longitudinal muscle of the taenia. The subserosal ganglia contained SP-, mENK-, NPY-, SOM-, but not CGRP- or VIP-immunoreactive nerve fibres. In addition, they contained SP-, mENK- and NPY-, but not CGRP-, SOM- and VIP-immunoreactive nerve cell bodies (although CGRP- and VIP-immunoreactive nerve fibres were observed in the longitudinal muscle of the taenia). AChE-activity was found both in nerve fibres and nerve cell bodies in these ganglia. The greatest numbers of nerve cell bodies contained AChE, followed in decreasing order by SP, mENK and NPY. The possible function of the subserosal ganglia of the human taenia is discussed.

Acetylcholinesterase↗
PubMed2004

Bolus application of remifentanil with propofol for dilatation and curettage.

BACKGROUND AND OBJECTIVE: This study was designed to determine which single bolus dose of remifentanil in combination with propofol and nitrous oxide is best to control the haemodynamic, autonomous and somatic responses in patients scheduled for dilatation and curettage of the uterine cervix. We evaluated the adequacy of different bolus doses of remifentanil, associated with propofol and nitrous oxide, for dilatation and curettage in a prospective double-blind study. METHODS: After institutional approval and informed consent, 34 healthy females undergoing curettage to remove material from the uterus after spontaneous abortion were randomized to receive remifentanil 0.5 microg kg(-1) intravenously (i.v.) (Group A; n = 4), 1 microg kg(-1) i.v. (Group B; n = 15) or 1.5 microg kg(-1) i.v. (Group C; n = 15), with propofol 2 mg kg (-1) i.v. in all groups. Anaesthesia was maintained with 60% nitrous oxide in oxygen. Haemodynamic, somatic and autonomic signs of light anaesthesia were registered to assess the response to surgical stress. Recovery times and Aldrete score were recorded at the end of the procedure. RESULTS: The groups were similar with regard to biometric data and duration of surgery. The poor results using the lowest dose of remifentanil obliged us to abandon this dose. The total dose of remifentanil was larger in Group C (100 +/- 5.7 microg vs. 65 +/- 4.1 microg in Group B; P < 0.05), but more patients required extra bolus injections in Group B (69% vs. 38% in Group C; P < 0.01). Recovery times were significantly shorter in Group C. Aldrete scores when leaving the operation room was similar. CONCLUSIONS: Remifentanil 1.5 microg kg(-1) i.v. with propofol 2 mg kg(-1) i.v. and 60% nitrous oxide in oxygen provided the best anaesthetic control with the fastest recovery times.

Adult↗
PubMed1993

[Long-term results of surgical treatment of bronchial asthma based on adaptive response].

The authors discuss the late-term results of operative treatment of 115 patients with severe forms of bronchial asthma in 6 months to 5 years after surgery with due regard for the adaptation reactions of the immune, sympathoadrenal, and hypophyseal-adrenal systems. The high efficacy of surgical treatment of bronchial asthma was confirmed, particularly of one-stage combined operations on various links of the autonomic nervous system which were introduced into practice for the first time. It is shown that operative treatment allows the adaptation status of the patients to be raised, which ensures a positive clinical effect. The role of immunocorrection in increasing the efficacy of surgical treatment is shown. The causes of the poor results of treatment were studied.

Adaptation, Physiological↗
PubMed2002

Changes in heart rate variability in sevoflurane and nitrous oxide anesthesia: effects of respiration and depth of anesthesia.

STUDY OBJECTIVE: To quantify the effects of sevoflurane on autonomic nerve function by analyzing changes in heart rate (HR) variability in sevoflurane anesthesia; and to investigate the effects of anesthetic depth and apnea on HR variability. DESIGN: Prospective study. SETTING: Operating room (OR) of a university medical center. PATIENTS: 7 ASA physical status I and II patients scheduled for elective surgery. INTERVENTIONS: Patients were premedicated with ranitidine 150 mg. Anesthesia was induced with thiopental sodium 4 mg/kg intravenously (IV) and succinylcholine 1 mg/kg IV, and maintained with nitrous oxide (N(2)O) 67% and sevoflurane in oxygen. Patients were ventilated mechanically at a rate of 15 breaths/min. MEASUREMENTS: R-R interval of electrocardiography (ECG), electroencephalogram (EEG), noninvasive arterial blood pressure (BP), and end-tidal sevoflurane concentration were recorded. Measurements were performed 1) after patients arrived at the OR and were placed in the supine position, 2) a stable period after inhalation of 2% sevoflurane, and 3) following the appearance of an isoelectric EEG at a higher concentration of sevoflurane. At times 2) and 3), data were recorded during mechanical ventilation and during apnea. MAIN RESULTS: There were decreases in both the low-frequency (LF; 0.04 to 0.15 Hz) and high-frequency (HF; 0.15 to 0.4 Hz) components of HR variability during anesthesia compared with the awake state. HF decreased during apnea at 2% sevoflurane, but LF did not change. Neither LF nor HF changed in response to the absence or presence of respiration during isoelectric EEG. CONCLUSIONS: Autonomic nerve activity was attenuated by sevoflurane. Parasympathetic input to the heart by respiration was markedly suppressed following the appearance of isoelectric EEG.

Adult↗
PubMed1990

[Coincidence of chronic inflammatory paranasal sinus disorders and cochleo-vestibular disorders].

In the course of initial examination the authors frequently observed a coincidence of labyrinthine symptoms with radiologic signs of chronic sinusitis. Of 72 patients who were hospitalized for acute labyrinthine symptoms, 72% presented with these signs. On the other hand, 49% of the patients admitted to sinus surgery manifested labyrinthine symptoms. A well-pneumatized mastoid was found in both groups. In the control group, consisting of patients whose consultation was unconnected to ear or nose complaints, chronic sinusitis was found in 28% and labyrinthine symptoms in 24%, but the two together were only found in 11%. It was shown by means of the chi2 test that the two symptom complexes are interdependent (p less than 0.01). Histologic examination of the mucosa of paranasal sinuses and peri-labyrinthine cells does not at the moment provide a satisfactory explanation. Pathologic autonomic nerve connections between the two systems may lead to higher vulnerability of the labyrinths of patients with chronic sinusitis. Other possible explanations, i.e., relating to certain neuropeptides and a well-pneumatized mastoid, are discussed. The authors wish to emphasize that their study is based on clinical data. At the moment a satisfactory pathophysiological explanation is lacking. In addition to antiphlogistic and rheologic medication, long-term planning of sinus surgery should be recommended for all patients in whom the two symptoms occur simultaneously. Whether this can help prevent recurrences, or put an end to progressive processes, can only be determined after a longer observation period.

Chronic Disease↗
PubMed1984

Vesicourethral dysfunction following pelvic visceral ablative surgery.

Management of vesicourethral dysfunction after a major extirpative pelvic visceral operation could be complex and difficult owing to the variety of partial and complete functional and anatomical derangements produced by the primary operation. We report our experience with 22 patients who suffered various types of vesicourethral dysfunctions after extirpative pelvic visceral surgery, 5 of whom had preoperative studies. The surgical procedures were abdominoperineal resection in 9 patients, proctocolectomy in 3, anterior resection of the rectum in 2 and radical hysterectomy in 8. All 22 patients underwent urodynamic evaluations. The abnormalities noted on the preoperative urodynamic evaluations in patients about to undergo extirpative pelvic visceral surgery suggest the need for routine preoperative assessment of the lower urinary tract for an accurate understanding of the postoperative changes.

Autonomic Nervous System↗
PubMed1992

Mitral valve prolapse: etiology, clinical presentation and neuroendocrine function.

Based on our experience and the experience of others, the following classification of patients with mitral valve prolapse has been proposed. Mitral valve prolapse - Anatomic includes patients with a wide spectrum of mitral valve abnormalities from mild to severe. Symptoms, physical findings and laboratory abnormalities in these patients are directly related to mitral valve dysfunction and progressive mitral regurgitation. Complications related to abnormal mitral valve include infective endocarditis, thromboembolic events, cardiac arrhythmias, progressive mitral regurgitation, rupture of chordae tendineae and congestive heart failure. Individuals with thick mitral leaflets and mitral systolic murmur are at higher risk of developing complications. The term mitral valve prolapse syndrome refers to the occurrence of symptoms such as palpitation, chest pain, fatigue, poor exercise tolerance, dyspnea, orthostatic phenomena and syncope or presyncope in patients with mitral valve prolapse which cannot be explained on the basis of mitral valve abnormality alone. The pathogenesis of these symptoms in patients with mitral valve prolapse syndrome appears to be related to metabolic neuroendocrine abnormalities. Preventing infective endocarditis is a major consideration in patients with mitral valve prolapse. Significant mitral regurgitation with the development of congestive heart failure often requires mitral valve surgery. The most important therapeutic approach in patients with mitral valve prolapse syndrome is to explain the mechanisms of symptoms and to reassure the patient.

Autonomic Nervous System↗
PubMed1983

[Biologic bases of musculo-cutaneous flaps most frequently used in cervico-maxillo-facial surgery].

An anatomical investigation on the vascular supply to "Pectoralis major", "Trapezius lateralis" and "Latissimus dorsi" muscolo-cutaneous flaps is presented. The AA. call particular attention to the vascular supply of the cutis going beyond the muscular borders. In this way we can determine the maximal width of the flap it is possible to achieve, without previous autonomization and without trophic problems.

Head and Neck Neoplasms↗