Recipient Vessel Selection in Head and Neck Reconstruction.

Objective: Recipient vessel caliber may be the single most important variable for flow to free tissue transfer. We performed cadaveric dissection of the external carotid artery and its branches to analyze average diameter in order to determine an algorithm for recipient vessel selection in head and neck reconstruction. Methods: The external carotid artery and branches were exposed on 3 lightly embalmed male human cadavers, aged 82 to 85 years. Each vessel was dissected, and luminal diameters were recorded with calipers. Results: The proximal ECA had the greatest average diameter (4 ± 0.6 mm) and potential flow; followed by distal ECA (2.85 ± 0.4 mm) facial (2.0 ± 0.6 mm), lingual (1.65 ± 0.6 mm), superior thyroid (1 ± 0.3  mm), and superficial temporal (0.85 ± 0.4 mm). There was a trend towards size variation between sides of the same cadaver. Conclusion: The external carotid artery has the greatest internal diameter and potential blood flow. It should be considered, when feasible, especially for defects of the upper third of the head. For defects of the lower third, the facial artery and the lingual artery should be utilized before the smaller diameter superior thyroid artery. Vessel selection is more challenging in the setting of radiation therapy, complex trauma, and prior neck surgery. In these settings, it is useful to have knowledge of the vascular anatomy and an objective algorithm for recipient vessel selection.

Safe Tummy Tuck: Anatomy and Strategy to Avoid Injury to the Lateral Femoral Cutaneous Nerve During Abdominoplasty.

BACKGROUND: Abdominoplasty is one of the most common aesthetic procedures performed in the United States. While poor contour and unsatisfactory cosmetic result have been recognized, neuropathic pain from lateral femoral cutaneous nerve injury has been poorly described. We aim to improve outcomes by using an anatomical study to develop a strategy to avoid injury to the lateral femoral cutaneous nerve in abdominoplasty. METHODS: Twenty-three fresh cadaver abdomens were dissected to evaluate the course of the lateral femoral cutaneous nerve, using 2.5× loupe magnification. Measurements were taken from the nerve to the anterior superior iliac spine and from the pubic symphysis to the lateral femoral cutaneous nerve. Recordings of the relationship of the nerve to the inguinal ligament and depth at scarpa's fascia were also made. Statistical analysis was performed to find average distances with a standard deviation. RESULTS: On average, the distance from the lateral femoral cutaneous nerve to the anterior superior iliac spine was 3.62 (SD = 1.32) cm and 13.58 (SD = 2.41) cm from the pubic symphysis in line with the inguinal ligament. The lateral femoral cutaneous nerve was found at the inguinal ligament 80% of the time and 20% of the time superior to the ligament and always deep to scarpa's fascia. CONCLUSION: Abdominoplasty carries a high patient and surgeon satisfaction rate. The plastic surgeon is continuously challenged to identify ways to improve outcomes, efficiency, and morbidity. Minimal and careful dissection in the area around 4 cm of the anterior superior iliac spine in addition to preserving scarpa's fascia near the inguinal ligament may serve as key strategies to avoiding lateral femoral cutaneous nerve injury.

Dorsalis pedis arterial pulse: palpation using a bony landmark.

INTRODUCTION: The unreliability of the pulse examination of the foot has primarily been due to variability of technique between examiners. Whereas the groove between the medial malleolus and the Achilles tendon more readily defines the location of the posterior tibial pulse, the location of the dorsalis pedis pulse remains vague. In this paper a novel method of locating the dorsalis pedis pulse by physical examination is described. METHODS: Forty one consecutive patients admitted to a general surgery service of a tertiary medical centre within a two month period were examined. Using the dorsal most prominence of the navicular bone as a landmark, the distance to the dorsalis pedis pulse in bilateral lower extremities was measured by palpation and compared to Doppler ultrasound. Measurements were confirmed by two separate examiners blinded to each others' results. RESULTS: The dorsalis pedis artery was palpable in 78% of extremities and present by Doppler ultrasound in 95%. The location of the left dorsalis pedis artery was a mean (SD) 9.8 (1.4) mm by palpation and 11.1 (2.1) mm by Doppler ultrasound from the dorsal most prominence of the navicular bone. The right dorsalis pedis artery was 10.4 (3.4) mm by palpation and 11.5 (0.7) mm from the dorsal most prominence of the navicular bone. No significant differences in location of the dorsalis pedis artery were observed bilaterally between Doppler ultrasound and palpation; No significant differences were observed comparing contralateral dorsalis pedis arteries nor any differences between the examiners' results. CONCLUSION: The dorsal most prominence of the navicular bone provides a bony landmark to readily locate the dorsalis pedis artery. Reliability of the examination may be increased as to the patency of the dorsalis pedis artery by using this dependable anatomic landmark.

Upper blepharoplasty with bony anatomical landmarks to avoid injury to trochlea and superior oblique muscle tendon with fat resection.

The trochlea and superior oblique muscle tendon separate the medial and central fat compartments in the upper lid. The purpose of this study was to determine anatomical landmarks to predict the location of and avoid injuring the trochlea and superior oblique muscle tendon with orbital fat resection during upper blepharoplasty. The trochlea and superior oblique muscle tendon were identified in 14 cadaver heads. Bony anatomical landmarks were identified to predict the oblique vector along which the trochlea and superior oblique tendon lie. The trochlea was measured in millimeters from the palpable superior orbital foramen. The oblique course of the superior oblique muscle tendon was measured from its medial location in the lateral direction in millimeters from the frontozygomatic suture. These measurements were obtained with 4.0-power loupe magnification. The trochlea was identified 10.0 +/- 0.9 mm inferior to the palpable superior orbital foramen. The superior oblique muscle tendon coursed laterally along an oblique vector to within 1 mm of the frontozygomatic suture for all 14 dissections. The vertical vector of the superior orbital foramen was measured 15.9 +/- 1.1 mm lateral to the medial canthus. The width of the bony orbit measured 42.2 +/- 1.6 mm. In two dissections, the superior orbital foramen could not be palpated, and the latter measurements were used to predict the superior orbital foramen. This anatomical study showed that when performing orbital fat resection with upper blepharoplasty, the trochlea and superior oblique muscle tendon can be identified and avoided with the above-described bony landmarks.

Trigger finger release with hand surface landmark ratios: an anatomic and clinical study.

The purpose of this study was to identify surface landmark ratios to locate the A1 pulley and clarify the controversy of differing anatomic descriptions of the A1, C0, and A2 pulleys. Minimally invasive and percutaneous approaches to A1 pulley release may be facilitated with surface landmark ratios, which identify and predict the proximal and distal margins of the A1 pulley. Two-hundred fifty-sixty fingers were dissected in 64 preserved cadaver hands. Measurements of A1 pulley lengths and pulley margins in relation to surface landmarks were obtained. We found that the distance from the palmar digital crease to the proximal interphalangeal crease (mean, 2.42 +/- 0.03 cm) corresponds to the distance of the proximal edge of the A1 pulley from the palmar digital crease (mean, 2.45 +/- 0.03 cm). The mean absolute difference between these two measured distances in each finger was 0.13 cm, with a 95 percent confidence interval of 0.11 to 0.14 cm. Thus, the distance between the palmar digital crease and the proximal interphalangeal crease can be used to predict the distance between the palmar digital crease and the A1 pulley proximal edge with reasonable accuracy. A1 pulley length averaged 0.98 +/- 0.02 cm for the small finger and 1.17 +/- 0.02 cm for the index, middle, and ring fingers. The length of the A1 pulley was significantly shorter (p < 0.001) for the small finger than for the index, middle, and ring fingers. Additionally, a cruciate (C0) pulley was consistently located between the A1 and A2 pulleys, an average of 0.46 cm proximal to the palmar digital crease, which can serve as guide for concluding the release of the A1 pulley. Clinically, hand surface landmark ratios were used to release 32 trigger fingers with a minimally invasive technique, without a complication during 4- to 30-week follow-up. We conclude that hand surface landmark ratios can serve to locate the proximal A1 pulley edge, thus facilitating complete trigger finger release by either open or minimally invasive techniques. Additionally, our study clarifies the discrepancy of prior smaller reports of the pulley system anatomy regarding the existence of the C0 pulley between the A1 and A2 pulleys. The cruciate fibers of this C0 pulley can serve as the distal boundary for release of trigger finger.

Ruptured pseudoaneurysm complicating an infected radial artery catheter: case report and review of the literature.

The authors present the 16th case of a pseudoaneurysm forming at the site of an infected radial artery catheter and only the third case that presented with rupture and hemorrhage requiring emergent operative repair. Radial artery catheters are quite safe, and most infections can be treated effectively with line removal and intravenous antibiotics. However, two factors correlate strongly with the subsequent development of pseudoaneurysms. Infection with Staphylococcus aureus was seen in 15 of 16 cases, and persistent signs of infection lasting more than 48 hours after the institution of antibiotic therapy and line removal were seen in 16 of 16 cases. Therefore, patients with S. aureus radial artery line infections with persistence of infection more than 48 hours after the induction of treatment are at high risk and should be observed closely for signs of pseudoaneurysm formation. Once a pseudoaneurysm has formed, surgical repair is required. Most recommend ligating the artery if there is pulsatile backbleeding from the distal stump and Allen's test shows good perfusion of the hand by the ulnar artery.

Palatal fistulas: rare with the two-flap palatoplasty repair.

The purpose of this study was to examine the palatal fistula rate after repair with the two-flap palatoplasty technique. This is a retrospective review of 119 consecutive cleft-palate repairs performed over a 5-year interval by a single surgeon. The two-flap palatoplasty technique was used to provide tension-free, multilayer repairs. The age of these children at the time of repair ranged from 7 to 84 months (mode, 9 months). The initial follow-up visit occurred 2 to 12 weeks after the repair operation (mean, 4 weeks). The postoperative follow-up duration ranged from 7 to 48 months. This review of 119 cleft-palate repairs revealed a fistula rate of 3.4 percent (four fistulas in 119 repairs). This experience demonstrates the lowest reported palatal fistula complication rate with use of the two-flap palatoplasty technique.

Do not use epinephrine in digital blocks: myth or truth?

The purpose of this study was to examine the role for epinephrine augmentation of digital block anesthesia by safely prolonging its duration of action and providing a temporary hemostatic effect. After obtaining approval from the review board of the authors' institution, 60 digital block procedures were performed in a prospective randomized double-blinded study. The digital blocks were performed using the dorsal approach. All anesthetics were delivered to treat either posttraumatic injuries or elective conditions. Of the 60 digital block procedures, 31 were randomized to lidocaine with epinephrine and 29 to plain lidocaine. Of the procedures performed using lidocaine with epinephrine, one patient required an additional injection versus five of the patients who were given plain lidocaine (p = 0.098). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (p < 0.002). Two patients experienced complications after plain lidocaine blocks, while no complications occurred after lidocaine with epinephrine blocks (p = 0.23). By prolonging lidocaine's duration of action, epinephrine may prevent the need for an additional injection and prolong post-procedure pain relief. This study demonstrated that the temporary hemostatic effect of epinephrine decreased the need for, and thus the potential risk of, using a digital tourniquet (p < 0.002). As the temporary vasoconstrictor effect is reversible, the threat of complication from vasoconstrictor-induced ischemia is theoretical.

Bipedicle paraspinous muscle flaps for spinal wound closure: an anatomic and clinical study.

The purpose of this study was to evaluate the vascular anatomy of the paraspinous muscles and review their clinical use as bipedicled flaps in spinal wound closure. Anatomically, through cadaver dissections, lead oxide injections, and radiographic imaging, the blood supply to the paraspinous muscles was determined. Clinically, 29 consecutive patients treated with spinal wounds and exposed bone or hardware were reviewed retrospectively. Of these patients, 19 underwent closure in delayed primary fashion, whereas 10 were referred to plastic surgery for reconstruction because of the complex nature of their wounds. The cadaver study demonstrated the paraspinous muscles to possess a segmental arterial supply through medial and lateral perforators. Division of the medial perforators allowed for medial advancement of the muscles. Lead oxide injection of the lateral perforators demonstrated adequate medial muscle perfusion with ligation of the medial perforators. Ten of the 29 patients (six women, four men, 32 to 62 years of age) were reconstructed with paraspinous (eight), latissimus (one), and trapezius (one) muscle flaps. A higher complication rate was found in wounds closed in delayed primary fashion (13 of 19 patients, 68 percent) than those reconstructed with muscle flaps (2 of 10 patients, 20 percent) (p = 0.021). Follow-up of the muscle flap reconstructed patients averaged 12 months (range, 3 to 27 months). Cadaver muscle injections predicted and clinical cases confirmed that the paraspinous muscles can be raised on lateral perforators and advanced medially to close lumbar spine wounds reliably with fewer complications.

Langer's lines: to use or not to use.

Thirty-six differently named guidelines have developed as surgeons have searched for an ideal guide for elective incisions. Many surgeons prefer Langer's lines. These lines were developed by Karl Langer, an anatomy professor, from cadavers in rigor mortis. However, Kraissl preferred lines oriented perpendicular to the action of the underlying muscles. Later, Borges described relaxed skin tension lines, which follow furrows formed when the skin is relaxed and are produced by pinching the skin. However, these are only guidelines; there are many contributors to the camouflaging of scars, including wrinkle and contour lines. Borges's and Kraissl's lines (not Langer's) may be the best guides for elective incisions of the face and body, respectively.

A rare case of pneumosinus dilatans of the frontal sinus and review of the literature.

Pneumosinus dilatans is a rare condition of unknown etiology in which there is enlargement of the paranasal sinuses by air, with extension beyond the normal boundaries of bone. The authors present a case of pneumosinus dilatans of the frontal sinus and review the literature.

Modified Dakin's solution for cutaneous vibrio infections.

Vibrio species, specifically Vibrio vulnificus, are known to be endemic to warm saltwater environments. As a human pathogen they are capable of causing severe, progressive, necrotizing infections. The lesions are bullous in nature and often require wide surgical debridement due to the aggressiveness of this organism. The literature supports prophylactic antibiotic therapy for those with preexisting hepatic dysfunction or immunocompromise. The authors routinely implement prophylactic antibiotic coverage with doxycycline 100 mg every 12 hours for vibrio in patients with wounds exposed to or acquired in saltwater. In addition, they institute topical therapy with 0.025% sodium hypochlorite solution (modified Dakin's), based on their in vitro study of vibrio sensitivity to antimicrobials. Over the past 2 years, the authors have treated 10 patients with this protocol for cutaneous vibrio infections confirmed by quantitative cultures. None of these patients experienced progression of infection requiring operative debridement-contrary to the aggressive nature of this organism documented in other reports.

Another indication for liposuction: small facial lipomas.

The treatment of facial lipomas at times requires the use of incisions that are less than satisfactory in either size or location. In an effort to minimize scarring, the authors have been removing these lesions with liposuction. The purpose of this study was to review the authors' experience in treating small facial lipomas using liposuction. Over the last 10 years, the authors treated five patients with forehead lipomas by removal with liposuction through hair-bearing scalp incisions. All patients were evaluated after the procedure for bleeding, paresthesias, recurrence, scarring, and overall satisfaction with the procedure. All of these patients had lipomas that measured 4 cm or less at the time of surgery. No patient experienced hematoma, nerve injury, or recurrence. All patients were completely satisfied with their result and scar. The literature describes an advantage to using liposuction for the treatment of medium (4 to 10 cm) and large (>10 cm) lipomas. Because small lipomas (<4 cm) can be extracted through small incisions, the literature reports no advantage to removal with liposuction. However, favorable aesthetic results can be obtained by removing small facial lipomas with liposuction through strategically placed incisions.

A rare case of atypical eccrine acrospiroma of the scalp and a literature review.

Acrospiromas are rare cutaneous lesions of eccrine sweat gland origin that are found most commonly on the extremities. The authors present a rare case of an atypical eccrine acrospiroma arising in the scalp, and a review of the literature.

Epinephrine in digital blocks: revisited.

Digital block anesthesia with epinephrine, ring technique, and digital tourniquet have been implicated in causing finger gangrene. An extensive review of the literature provided no case of finger gangrene attributed solely to the adjunctive use of epinephrine with lidocaine for digital block. By causing vasoconstriction, epinephrine complements the local analgesic by prolonging the duration of action and providing a temporary hemostatic effect. Epinephrine augmentation of digital block anesthesia was used in the treatment of 23 finger injuries without a complication.

Creep vs. stretch: a review of the viscoelastic properties of skin.

Possessing viscous and elastic rheological properties, skin is viscoelastic. Mechanical creep, defined as the elongation of skin with a constant load over time beyond intrinsic extensibility, has been described as the vehicle harnessed for wound closure with presuturing, intraoperative tissue expansion, skin-stretching devices, and skin retraction with undermining. Resulting from the generation of new tissue due to a chronic stretching force, biological creep plays a role in conventional tissue expansion.