Eray Tüccar

Temporoparietal fascia : An anatomic and histologic reinvestigation with new potential clinical applications

Temporoparietal fascia constitutes a very important structural unit from both an aesthetic and a reconstructive surgical point of view. A histologically supported anatomic study was conducted for the reappraisal of the anatomic relationships and clinical application potentials of the data obtained. Anatomy of the temporoparietal fascia was investigated on 20 sides from 10 cadavers. After dissections, necropsies were obtained to demonstrate histologic features of the temporoparietal fascia. The outer part of the temporoparietal fascia is continuous with the superficial musculoaponeurotic system (SMAS) in the inferior border and with orbicularis oculi and frontalis muscles in the anterior border. Therefore, plication of the temporoparietal fascia can increase tightness of the SMAS, orbicularis oculi, and frontalis muscle in rhytidectomy. The frontal branches of facial nerve were noted to course parallel to the frontal branch of the superficial temporal artery, lying deeper to the temporoparietal fascia within the innominate fascia. In the view of these findings, conventional subfascial dissection, which is performed to protect frontal branches of the facial nerve, is not reasonable during the temporal part of rhytidectomy. Careful subcutaneous dissection just under the hair follicles is more appropriate to avoid nerve injury and also provides excellent exposure of the temporoparietal fascia for plication in rhytidectomy with protection of the auriculotemporal nerve and the superficial temporal vessels. Furthermore, two layered structures of the temporoparietal fascia are very suitable to insert a framework into the temporoparietal fascia for ear reconstruction to eliminate some of the shortcomings of Brents technique. A thin muscle layer was also noted within the outer part of the temporoparietal fascia below the temporal line; the term “temporoparietal myofascial flap” would, therefore, be more accurate than “temporoparietal fascial flap.” Finally, the innominate fascia and the deep temporal fascia can be elevated with the two layers of the temporoparietal myofascial flap to obtain a well‐vascularized, four‐layered myofascial flap based on the superficial temporal vessels. This multilayered flap can be used to reconstruct all defects when fine, pliable, thin, multilayered flaps are required. (Plast. Reconstr. Surg. 105: 40, 2000.)

Risk of Superior Gluteal Nerve and Gluteus Medius Muscle Injury During Femoral Nail Insertion

BACKGROUND Abduction weakness and limping is a well-recognized complication of closed antegrade insertion of femoral nails. Iatrogenic injuries to the superior gluteal nerve and the gluteus medius muscle are the most likely contributing factors. The purpose of this study of cadavers was to assess the risk of nerve and muscle injury with various lower-limb positions used during nail insertion. METHODS We studied thirteen hips of ten formalin-fixed adult cadavers. With the cadaver in the full lateral position, a 9-mm reamer was introduced in a retrograde fashion from the intercondylar notch and passed through the gluteus medius muscle. The distance between the point of entry of the reamer into the undersurface of this muscle and the inferior main branch of the superior gluteal nerve (the nerve-reamer distance) and the distance between the entry and exit points of the reamer in the gluteus medius muscle (the intramuscle distance) were measured in three different hip positions: 15 degrees of flexion and 15 degrees of adduction (Position 1), 30 degrees of flexion and 30 degrees of adduction (Position 2), and 60 degrees of flexion and 30 degrees of adduction (Position 3). RESULTS In Position 1, the average nerve-reamer distance was 7 mm and the average intramuscle distance was 24 mm. In three hips the reamer injured the nerve directly, and in two other hips the distance was <or=5 mm. In Position 2, the average nerve-reamer distance was 21 mm and the average intramuscle distance was 18 mm. In Position 3, the average nerve-reamer distance was 33 mm and the average intramuscle distance was 11 mm. None of the reamers in this position came closer than 20 mm to the nerve. CONCLUSIONS The risk of injury to the superior gluteal nerve and the gluteus medius muscle during closed antegrade insertion of a femoral nail is lessened by increasing the amount of hip flexion and adduction. CLINICAL RELEVANCE The risk of injury to both the superior gluteal nerve and the gluteus medius muscle is higher with limited degrees of hip flexion and adduction, such as are possible in the supine position on a fracture table, than it is with greater degrees of hip flexion and adduction, which are possible in the lateral position on a fracture table or in the so-called sloppy lateral position on an ordinary table. Therefore, insertion of a femoral nail with the hip in increased flexion and adduction might help to lower the risk of injuries to the superior gluteal nerve and the gluteus medius muscle.

Perforating Arteries of the Gluteal Region: Anatomic Study

Gluteal artery perforator flaps have gained popularity due to reliability, preservation of the muscle, versatility in flap design without restricting other flap options, and low donor-site morbidity. Today, free or local flaps based on the perforating arteries of the gluteal region are among the most commonly used procedures for the management of lumbosacral defects and autologous breast reconstruction. An anatomic study was carried out to investigate localization, dimension, and distribution of the perforator arteries in 16 gluteal regions of 8 formol-fixed cadavers. The total number of perforators in each gluteal region was 13–20 (mean 17 arteries). Mean vessel diameter and mean vessel length were 1.1 mm (range 0.7–1.7 mm) and 6.4 cm (range, 5.2–9.1), respectively. Topographic analysis of the perforators revealed that the gluteal region can be divided into 3 parts in terms of vessel density. The majority of the perforators were localized in superior zone, whereas the middle zone was documented to be the poorest region. Data derived from this analysis were also confirmed by individual analysis of each cadaver.

The jugular foramen: A comparative radioanatomic study

BACKGROUND Advances in microsurgical techniques made possible the removal of advanced jugular foramen (JF) lesions, which once had been accepted as unoperable. However, successful surgery requires detailed knowledge of the JF anatomy. METHODS Sixteen jugular foramina in eight formalin-preserved adult cadavers were scanned with axial and coronal high resolution computed tomography (HRCT) prior to dissection. After craniectomy and removal of brain tissue, the relationships of the neurovascular structures in the JF were determined by drilling the temporal bones from superior to inferior on planes parallel to the skull base. RESULTS No bony partition of the JF was observed. A dural band consistently divided the JF into two parts. Anterior to it was the glossopharyngeal nerve (IX) while the vagus (X) and accessory (XI) nerves were located posteriorly. There was a notch in which the IX nerve entered the JF. It was also identified on the CT scans and defined as the glossopharyngeal recess. The IX nerve made a genu within the JF in all specimens. Then, it ran inferiorly through a bony canal in three specimens (18.75%), and through an incomplete bony canal in two (12.5%), which were also defined on the CT images. The inferior petrosal sinus ran through a sulcus anteromedial to the glossopharyngeal recess. The posterior meningeal artery was found to be located between the X and XI nerves within the JF. CONCLUSIONS This study revealed a complex and highly variable pattern of the relationships of the neurovascular structures in the JF, and their HRCT images correlated well with the anatomic microdissections.

Comprehensive microsurgical anatomy of the jugular foramen and review of terminology

The microsurgical anatomy of the jugular foramen was studied in 12 formalin preserved cadavers (24 foramina) and 40 dry-skulls (80 foramina). The jugular foramen was exposed by microsurgical dissection with drilling from a superior to inferior direction. Observations regarding dural architecture of the jugular foramen and relationships between neurovascular structures passing through the foramen were noted in cadavers. Normal bony construction of the foramen and its variational anatomy were examined in dry-skull specimens. Using photographs and drawings, the anatomy of the jugular foramen is presented and related terminology is discussed in the light of a literature review.

Minimally invasive plating of the distal tibia: do we really sacrifice saphenous vein and nerve? A cadaver study.

Objective: To investigate the risk of saphenous nerve (SN) and great saphenous vein (GSV) injury during percutaneous screw placement of the 3.5/4.5 LCP Distal Tibial Metaphyseal Plate and the 3.5-mm LCP Medial Distal Tibia Plate with tab in distal tibias of cadaver extremities. Methods: Thirty-one unpaired (1 fresh and 30 formalin fixed) adult cadaveric lower extremity specimens were dissected. Using the principles of minimally invasive plating, a 3.5/4.5 LCP Distal Tibial Metaphyseal Plate was implanted in 16 extremities and a 3.5-mm LCP Medial Distal Tibia Plate with tab in the remaining 15 extremities. Injuries to or any evidences of direct contact with the SN or GSV were recorded. Additionally, the shortest distances of each hole to the main branches of these anatomic structures were measured. Results: The risk of injury to the SN and GSV was higher in holes 4, 5, and 6 when using the 3.5/4.5 LCP Distal Tibial Metaphyseal Plate and in holes 3, 5, and 8 when using the 3.5-mm LCP Medial Distal Tibia Plate. Conclusions: The SN and GSV are at high risk for injury during percutaneous screw placement of the 3.5/4.5 LCP Distal Tibial Metaphyseal Plate and the 3.5-mm LCP Medial Distal Tibia Plate at the distal tibia. Careful dissection in the stab incisions down the plate, atraumatic placement of the drill sleeves, and protection of the soft tissues during screw insertion might decrease the risk of injury to the SN and GSV.

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.

Maxillary artery: anatomical landmarks and relationship with the mandibular subcondyle.

Background: The maxillary artery can be injured during procedures in the subcondylar portion of the mandible. Thorough knowledge of this region is mandatory to avoid accidental puncture of the maxillary artery, which can lead to profuse bleeding that is hard to control. Methods: In 16 halves of eight embalmed cadaver heads, the maxillary artery was dissected from the branching point to the entrance point to the maxillary sinus. Its anatomical relationships with certain landmarks were recorded numerically. Results: The mean distance of the branching point of the maxillary artery to the tragal pointer was 16.2 mm (range, 14.97 to 16.80 mm) in the horizontal plane and 21.4 mm (range, 19.14 to 23.53 mm) in the vertical plane. The mean vertical distance of the branching point to the Frankfort horizontal plane was 25.7 mm (range, 24.86 to 27.47 mm). The mean distance of the branching point of the maxillary artery to the tip of the condyle was 22.4 mm (range, 21.66 to 23.99 mm). The mean distance of the artery to the medial border of the subcondylar portion of the mandible was 6.8 mm (range, 4.06 to 8.47 mm). The mean distance between the deepest point of the sigmoid notch and the junction of the maxillary artery and sigmoid notch was 5.1 mm (range, 4.97 to 5.95 mm). The mean distance of the maxillary artery–sigmoid notch junction to the tragal pointer was 22.9 mm (range, 20.95 to 25.05 mm). Conclusions: The maxillary artery can be injured during surgical procedures performed in the temporomandibular region. Its relationship with the subcondylar portion of the mandible varies.

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.

Drainage patterns of middle lobe vein of right lung: an anatomical study

OBJECTIVE The purpose of the present study was to determine the variations in the drainage patterns of middle lobe vein of the right lung. METHODS Right lungs of 30 formalin fixed cadavers, were dissected carefully to expose the variations in the venous drainage of their middle lobes. After identifying the pulmonary veins for each lobe, middle lobe vein (MLV) drainage patterns were followed to their openings. The diameters of the MLV and its lateral and medial parts were measured with a caliper. The length of the MLV trunk was also evaluated. RESULTS Five different types of venous drainage patterns were observed. Type-I: Union of medial and lateral parts to form MLV as a trunk and opening of this vein to the right superior pulmonary vein (RSPV) (53.3%). Type-II: Opening of medial and lateral parts to the RSPV separately (16.6%). Type-III: Union of medial and lateral parts to form the MLV trunk and opening of this vein into the left atrium (16.6%). Type-IV: Opening of medial and lateral parts into the left atrium separately (10%). Type-V: Union of medial and lateral parts to form MLV trunk and opening of this vein to the right inferior pulmonary vein (3.3%). CONCLUSION The venous drainage patterns of right middle lobe reveals great number of variations. Knowing the frequency of different types of drainage patterns classified in this study is extremely important for the surgeons performing pulmonary surgery, atrial fibrillation and imaging techniques.