Ali Firat Esmer

Retropharyngeal space and lymph nodes: an anatomical guide for surgical dissection.

Conclusions Identification of the alar fascia is the key part of surgical dissection of the retropharyngeal lymph nodes (RPLNs). In cases where mandibulotomy is not performed for the removal of the primary tumor and/or the posterior pharyngeal wall is not incised, the medial or lateral approaches described in this paper can be performed. Objective Surgical dissection of the RPLNs may improve prognosis and locoregional control in oropharyngeal, hypopharyngeal and cervical esophageal carcinomas. There have been no previous anatomical studies concerning landmarks and approaches for the surgical dissection of the RPLNs. This study was designed to illustrate the fascial anatomy of the retropharyngeal region (RPR), provide anatomical guidelines for RPLN dissection and describe and compare approaches for surgical removal of the RPLNs. Material and methods Twelve fixed cadavers were used. Slices were obtained from the necks of the first three cadavers and the RPRs of the slices were dissected under an operating microscope. The other nine cadavers were dissected in a surgical position to expose the RPLNs and the fasciae of the RPR. Results In the coronal plane, the alar fascia divides the space between the buccopharyngeal and prevertebral fasciae into two compartments and constitutes the posterior border of the retropharyngeal space, which contains the RPLNs. The alar fascia, an important landmark for reaching the RPLNs, can be identified by the cervical sympathetic trunk, superior sympathetic ganglion and superior laryngeal nerve. Two approaches can be performed to remove the RPLNs, namely medial or lateral to the internal and external carotid arteries, internal jugular vein and vagus nerve.

Callosal branches of the anterior cerebral artery: An anatomical report

Although the morphology of the corpus callosum is well defined, the arterial supply of this structure has not been comprehensively studied. To elucidate this further, 40 cerebral hemispheres from 30 adult cadaveric brains were obtained. The anterior cerebral arteries were cannulated and injected with red latex. The following were observed and documented: (1) the number, diameter, and course of the arteries supplying the corpus callosum; (2) the territories vascularized by these arteries; (3) any variations of the callosal arteries. Short callosal arteries were present in 58 hemispheres (96.6%) and supplied the superficial surface of the corpus callosum along its midline and were a primary arterial source to this structure. Long callosal arteries were found in 28 hemispheres (46.6%) and contributed to the pial plexus. The cingulocallosal arteries were present in all hemispheres and supplied the corpus callosum, cingulate gyrus, and also contributed to the pericallosal pial plexus. The recurrent cingulocallosal arteries were present in 17 hemispheres (28.3%) and also contributed to the pericallosal pial plexus. The median callosal artery, an anatomical variation, was present in 10 brains (33.3%). This vessel supplied the corpus callosum and the cingulate gyrus. The aim of the present study was to provide a detailed description of the arteries supplying the corpus callosum for those who encounter these vessels radiologically or surgically. Clin. Anat. 21:383–388, 2008.

Safe zone for the descending genicular artery in the midvastus approach to the knee

Minimally invasive total knee arthroplasty is performed using a modified version of the standard total knee arthroplasty without complete knee exposure. Traditional medial parapatellar arthrotomy has been criticized because it may disturb patellar blood flow and the extensor mechanism. Devascularization of the patella leading to osteonecrosis places the patella at risk for fracture. Alternative vastus-orientated approaches have the potential to preserve the descending genicular artery. Although this arterial supply to the patella potentially can be compromised throughout surgery, it is particularly vulnerable during deep dissection and arthrotomy. Knowledge of the anatomic course of the descending genicular artery would likely be helpful in its preservation. We investigated the course of the descending genicular artery and its entry angle to peripatellar network to determine the distance between the artery and superomedial patella during medial parapatellar arthrotomy and proximal capsular release. We dissected the descending genicular artery in 15 cadaveric knees. The average entry angle was 32.6°, and the average distance between the descending genicular artery and superomedial pole of the patella during parapatellar arthrotomy was 13.5 mm. The safest distance for splitting the vastus medialis during median parapatellar arthrotomy was 15 mm from the superior pole of the patella because of the course of the descending genicular artery.

Vascular anatomy of plantar muscles

Many reports on the plantar arteries and the deep plantar arch exist, but none of them focus on the arterial pedicles of the plantar muscles. They mainly discuss the deep plantar arch, its variations, and location. This study plans to determine the location and origin of arterial pedicles of all the plantar muscles as a preliminary study for designing new flaps. The study was carried out on 20 feet from 10 cadavers aged from 35 to 67 years. After an injection of latex via popliteal arteries, dissection of the arteries was carried out under a microscope. Abductor hallucis and flexor hallucis brevis muscles receive their main blood supply from the medial plantar artery; abductor digiti minimi and flexor digiti minimi brevis muscles receive their main blood supply from the lateral plantar artery. The flexor digitorum brevis muscle receives branches from both arteries. Adductor hallucis and plantar interosseous muscles receive branches from plantar metatarsal arteries. Quadratus plantae is directly nourished from a branch of the posterior tibial artery. No distal anastomoses between the medial and lateral plantar arteries were identified, except 1 specimen in which the medial plantar artery made anastomosis with the deep plantar arch. As a result, the arterial pedicles of all the plantar muscles were defined, and based on these findings, new flaps can be planned or existing flaps can be modified.

Arterial vascularization patterns of the splenium: An anatomical study.

The aim of this study was to provide detailed information about the arterial vascularization of the splenium of the corpus callosum (CC). The splenium is unique in that it is part of the largest commissural tract in the brain and a region in which pathologies are seen frequently. An exact description of the arterial vascularization of this part of the CC remains under debate. Thirty adult human brains (60 hemispheres) were obtained from routine autopsies. Cerebral arteries were separately cannulated and injected with colored latex. Then, the brains were fixed in formaldehyde, and dissections were performed using a surgical microscope. The diameter of the arterial branches supplying the splenium of the CC at their origin was investigated, and the vascularization patterns of these branches were observed. Vascular supply to the splenium was provided by the anterior pericallosal artery (40%) from the anterior circulation and by the posterior pericallosal artery (88%) and posterior accessory pericallosal artery (50%) from the posterior circulation. The vascularization pattern of the splenium differs in each hemisphere and is usually supplied by multiple branches. The arterial vascularization of the splenium of the CC was studied comprehensively considering the ongoing debate and the inadequacy of the studies on this issue currently available in the literature. This anatomical knowledge is essential during the treatment of pathologies in this region and especially for splenial arteriovenous malformations. Clin. Anat. 26:675–681, 2013.

Treatment of hyperdynamic nasal tip ptosis in open rhinoplasty: using the anatomic relationship between the depressor septi nasi muscle and the dermocartilaginous ligament.

BackgroundSmiling causes a deformity in some rhinoplasty patients that includes drooping of the nasal tip, elevation and shortening of the upper lip, and increased maxillary gingival show. The depressor septi muscle leads this deformity. The dermocartilaginous ligament originates from the fascia of the upper third of the nose and extends down to the medial crus, merging into the depressor septi muscle.MethodsIn this study, 100 primary rhinoplasty patients were studied for hyperdynamic nasal tip ptosis. Of these patients, 36 had hyperdynamic nasal tip ptosis due to hyperactive depressor septi nasi muscle. The dermocartilaginous ligament was used as a guide to reach the depressor septi muscle in open rhinoplasty. Muscle excision was performed just below the footplates of the medial crura. A strong columellar strut graft was placed between the medial crura to avoid narrowing of the columellar width resulting from tissue excision and to withstand activation of depressor septi muscle remnants.ResultsNo complications such as infection or hematoma occurred in the early postoperative period. The technique corrected the hyperdynamic nasal tip ptosis, increased upper lip length, and decreased gingival show when patients smiled. There was no narrowing of the columellar width. No depression in the columellar–labial junction due to distal resection of the depressor septi muscle was observed.ConclusionThe dermocartilaginous ligament can be used as a reliable guide to reach the depressor septi muscle in open rhinoplasty. Therefore, the hyperactive depressor septi muscle can be definitively identified and treated without an intraoral approach.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Percutaneous ilioinguinal-iliohypogastric nerve block or step-by-step local infiltration anesthesia for inguinal hernia repair: what cadaveric dissection says?

Purpose The repair of groin hernias with local anesthesia has gained popularity. Two main methods have been described for local anesthesia. This study was aimed at comparing percutaneous truncular ilioinguinal-iliohypogastric block and step-by-step infiltration technique by using cadaver dissections. Methods The study was performed on an adult male cadaver by using blue dye injection. A percutaneous nerve block simulation was done on right side and the dye was given in between the internal oblique and transversus muscles. On the left side, a skin incision was deepened and the dye was injected under the external oblique aponeurosis. Following the injections, stained areas were investigated superficially and within the deeper tissues with dissection. Results There was a complete superficial staining covering the iliohypogastric and ilioinguinal nerves in the inguinal floor at both sides. On the right side, intraabdominal observation showed a wide and intense peritoneal staining, while almost no staining was seen on the left side. Preperitoneal dissection displayed a massive staining including testicular vascular pedicule and vas deferens on the right side. The dye solution also infiltrated the area of the femoral nerve prominently. On the contrary, a very limited staining was seen on the left. Conclusion It may not always be easy to keep the percutaneous block within optimum anatomical limits without causing adverse events. A step-by-step infiltration technique under direct surgical vision seems to be safer than percutaneous inguinal block for patients undergoing inguinal hernia repair.

Anatomic relationship between the anterior sylvian point and the pars triangularis

The aim of this study was to show morphological sulcal variations of the pars triangularis of the inferior frontal gyrus and to provide a clearer description of the anterior sylvian point. Thirty‐six hemispheres of 18 adult cadavers were studied. The hemispheres were harvested by the classical autopsy method and fixed in 10% formalin solution for three weeks. In six hemispheres, the arteries and veins were filled with colored silicone. The proximal and distal segments of the sylvian fissure, the perpendicular distance of both the anterior sylvian point and inferior rolandic point to the insular cortex and the distances between the anterior ascending ramus and the precentral, central, and postcentral sulcus were measured. The anterior horizontal and ascending rami were exposed. The sulcus located on the pars triangularis was appraised. The relationship between the anterior sylvian point and the vascular structure around the sylvian fissure was examined. The rising of the anterior horizontal and ascending ramus from the sylvian fissure defines the shape of the pars triangularis. The pars triangularis has three shapes: V, U, and Y. In V‐ and Y‐shaped pars triangularis both rami merge but in U‐shaped pars triangularis the rami do not merge. The pars triangularis was Y‐shaped in 30.76% (4/13) of the right hemispheres and in 50% (7/14) of the left hemispheres; U‐shaped in 20.3% (3/13) of the right hemispheres and in 35.71% (5/14) of the left hemispheres; V‐shaped in 40.61% (6/13) of the right hemispheres and in 14.29% (2/14) of the left hemispheres. Minimally invasive procedures use basic anatomic landmarks intracranially to reach the targeted area; therefore, exact and detailed knowledge of the anatomy of the sylvian fissure and pars triangularis is of great importance. Clin. Anat. 25:429–436, 2012.

The neurovascular relationships of the oculomotor nerve

In this study, the arterial supply of the cisternal (initial) and the subcavernous parts of the oculomotor nerve (ON) and the relation between the nerve and adjacent vascular structures like posterior cerebral artery (PCA) and superior cerebellar artery (SCA) were investigated. A total of 140 formalin fixed hemispheres from 70 human cadaveric brains were examined. The nutrient branches reaching the cisternal and subcavernous parts of the ON were investigated, along with branches of adjacent vascular structures penetrating the nerve and passing through it. In the material examined, the ON, after arising from the midbrain, mostly continues laterally between PCA and SCA or between PCA and the rostral SCA trunk. However, in three hemispheres of our specimens, the ON run between the rostral and caudal SCA trunks. We observed that the branches of PCA‐P1 segment supplied the cisternal part of the ON in all specimens. In one specimen, the cisternal part of the ON was supplied by a branch arising from the rostral SCA trunk which was also originating from PCA. Differently, in four hemispheres, branches arising from PCA or SCA perforated the cisternal part of the ON and passed through it. We also observed a tortuous caudal trunk of duplicated SCA in one of our specimens and considered it as a rare variation. The anatomy of the ON and its vascular relations is significant in terms of not only understanding the compression syndromes and its vascular dysfunctions, but the exact diagnosis and treatment as well. Clin. Anat. 24:583–589, 2011.

Anatomy and clinical significance of the trigeminocerebellar artery

The trigeminocerebellar artery (TCA) is a unique branch of the basilar artery supplying both the trigeminal nerve root and the cerebellar hemisphere. In this study, we describe and demonstrate the microanatomy of the TCA in 45 brainstems and discuss the neurological, neuroradiological and neurosurgical significance. This is the largest series of cadavers in the literature. The close relationship of the TCA to the trigeminal nerve root may have clinical implications including for the etiology of trigeminal neuralgia, thus the neurosurgeon must be aware of the vasculature of the trigeminal nerve root area and the anatomical variations.