Figen Govsa

A morphometric study on the superficial palmar arch of the hand

The vascular anatomy of the hand is a complex and challenging area and has been the subject of many studies. Knowledge of the vascular patterns and diameters of the hand gained more importance with improvements in microsurgical techniques in reconstructive hand surgery. We evaluated 50 hands (26 left, 24 right) of 26 formalin preserved cadavers to determine the superficial palmar arch, its branches and contributing vessels with special attention to the diameters. The symmetry of the types was also evaluated in detail for the first time in the literature. Measurements were made with the help of a digital caliper. The diameters of the ulnar, radial and median arteries were taken at the level of the wrist while the common palmar digital arteries, hypothenar branches and the superficial palmar branch of the radial artery were measured at their origin. Two types of superficial palmar arch were found and defined as complete (43/50 hands) and incomplete arches (7/50 hands). The complete arches were divided into four subgroups and incomplete arches into three subgroups. Most cases were found at the complete AI group (17 hands). Comparison of the arterial diameters showed the ulnar artery was the dominant vessel of the palm. The diameters of the common palmar digital arteries were not different with regard to complete or incomplete arches and between both sides. It looks safe to sacrifice one of the radial or ulnar arteries in some arterial interventions including radial artery cannulation, radial forearm flap and radial or ulnar artery harvesting for bypass grafting if the arch is complete. But we still recommend the noninvasive tests like modified Allen test or Doppler ultrasonography, before performing an invasive arterial intervention. We propose the radiologists to incorporate the median artery into the Doppler dynamic test in particular the existence or the absence of anastomoses between radial and ulnar arteries.

The anatomic landmarks of ethmoidal arteries for the surgical approaches.

Knowledge of variations in the possible patterns of origins, courses, and distributions of the ethmoidal arteries are necessary for the diagnosis and important for the treatment of orbital disorders. Ethmoidal arteries are damaged in endonasal surgical interventions and in operations performed on the inner wall of the orbita. A description of the anatomic landmarks of the ethmoidal arteries and ethmoidal canals is presented, based on data from microdissection in 19 adult cadavers studied after injection of red-dyed latex into the arterial bed. In all subjects, each of ethmoidal arteries originated from ophthalmic artery. The anterior ethmoidal artery was observed in all specimens except for one case. The diameter of the artery thicker than the posterior ethmoidal artery was 0.92 ± 0.2 mm on the right and 0.88 ± 0.15 mm on the left. The branching of the anterior ethmoidal artery from the ophthalmic artery was determined in four different types. The diameter of the posterior ethmoidal artery was measured as 0.66 ± 0.21 mm on the right and 0.63 ± 0.19 mm on the left. The anterior ethmoidal canal was located between the second and third lamella in 29 of 38 cases. The mean distance between the limen nasi and anterior ethmoidal canal was 48.1 ± 3.2 mm. The article confirms the well-known variability of the ethmoidal arteries and their topographic relation to the ethmoidal canals. Advances in surgical techniques, instrumentation, and regional arterial anatomy have resulted in functional operations of endoscopic sinus and orbital surgery with fewer complications.

A study of the course of the internal carotid artery in the parapharyngeal space and its clinical importance

The differences in the course and shape of the internal carotid artery (ICA) in the parapharyngeal space were investigated to determine the possible risks for serious hemorrhage during tonsillectomy, drainage of peritonsillar abscess, soft palate injuries, adenoidectomy and velopharyngeoplasty. The course of the ICA was studied in the parapharyngeal spaces of 50 adult cadavers. From each specimen, circumferential sections were obtained and they stained with hematoxylin–eosin and Verhoeff’s elastic staining. The cervical course of the ICA showed no curvature in 70 cases; but in 25 cases it had a medial curve, and five cases showed kinking out of a total 100 dissected carotid sheaths. In two cases, kinking of the ICA was related to the pharyngeal wall. The histological examination of all kinking specimens demonstrated depletion and decreasing muscle tissue in tunica media and an increase was observed in vasa vasorum numbers in the tunica adventitia of ICA. The dissections and integrity losses were seen in tunica media and tunica adventitia. The vessel wall of histological structure change were detected in kinking specimens and lays the groundwork for the vessel wall to get easily harmed or torn either directly or indirectly by decreasing the elasticity and soundness of the wall. The transposition of the ICA artery in submucous position becomes important for otorhinolaryngologists when its aberrant course causes a widening in the retropharyngeal or parapharyngeal tissues and an impression on the pharyngeal wall. Curving and kinking of the ICA can constitue a risk factor for acute hemorrhage in routine surgical procedures, which are performed by inexperienced surgeons.

The anatomical variations of the extensor tendons to the dorsum of the hand.

To lead a quality life, tendon repair must be performed in a trauma causing damage to the extensor tendon of the hand. The aim of this study is to study the structures that can be used as donor tendons. Fifty‐four dissected adult hands were examined to study the pattern of the extensor tendons on the dorsum of the hand. The most common distribution patterns of the extensor tendons of the fingers were as follows: a single extensor indicis proprius (EIP) tendon which inserted ulnar to the extensor digitorum (ED)‐index; a single ED‐index; a single ED‐middle; a single ED‐ring; an absent ED‐little; a double extensor digiti minimi (EDM), and a single ED‐ring to the little finger. The frequency of the number of tendons is as follows: a single (87.03%) EIP, a single ED‐index (100%), a single (92.6%) ED‐middle, a single (75.9%) ED‐ring, and an absent (68.5%) or a single (24.1%) ED‐little. A double (88.9%) EDM tendons were seen. The thickest type of juncturae tendinum (JT) is found primarily between the ring and little fingers (90%). Suitable excessive tendon and the thickest JT as donor tendon were found in the fourth intermetacarpal space. The present findings, especially the fourth intermetacarpal space, may explain why incisions on the dorsum of the hand should be large and performed with particular care. It is necessary to have a thorough understanding of the arrangements of the multiple extensor muscles and their junctural connections of the hand when tenoplasty or tendon transfer is required. Clin. Anat. 21:652–659, 2008.

The anatomical features and surgical usage of the submental artery

The skin characteristics make the submental region an available flap site for facial and intraoral reconstructions. For this reason, the anatomy of the submental region and the submental artery (SA) has gained in importance recently. The SA branches out from the facial artery at the level of superior edge of the submandibular gland. The SA runs anteromedially below the mandible and superficial to the mylohyoid muscle. It gives off some perforating branches to the overlying platysma and underlying mylohyoid muscle during its course. The terminal branches continue toward the midline, crossing the anterior belly of digastric muscle either superficially or deep, and end at the mental region in general. Some perforating arteries from the terminal branches supply the anterior belly of digastric muscle. This study aimed to describe the anatomical features of the SA and its branches to help in the preparation of submental arterial flaps.

Anatomy of the supraorbital region and the evaluation of it for the reconstruction of facial defects.

Damaged supraorbital neurovascular bundle during anterior orbital approach, fronto-glabellar reconstruction flap, supraorbital injection, blepharospasm, and Graves disease surgery is an important complication reported with varying frequency. The origin, calibration, and branches of the supraorbital artery and its topographical relations were investigated by injection of the arterial bed with red-dyed latex in 38 forehead regions. The supraorbital artery with the supratrochlear artery arose from the orbit as two separate vessels in 33 out of 38 forehead sides (87%). The supraorbital artery entered the frontalis muscle between 20 and 30 mm in 20 cases (52.6%), and between 30 and 40 mm in 16 cases (42.1%). This artery was located approximately the subcutaneous tissues between 40 and 50 mm in 17 cases (44.7%), between 50 and 60 mm in 18 cases (47.4%). The transverse supraorbital vein coursed at the level of the orbital rim on 22 sides (58%) and between 6.1 and 11.2 mm (mean: 9.4 mm) above the supraorbital rim on 16 sides (42%). All branches of supraorbital nerve were located between 2.0 and 3.2 cm from the midline at the level of the orbital rim. In 23 cases (60%), the lateral branch of the supraorbital nerve exited the bone as two branches, usually one large and one much smaller, which can together run into the scalp without further branching. In the present anatomical study, special attention was paid to morphological details concerning the neurovascular relationship of the supraorbital region. A better understanding of the midline forehead neurovascularity should allow modification of reconstructive techniques, afford better localization of the supraorbital nerve during blepharoplasty and ptosis surgery, and reduce the incidence of postoperative hematomas and nerve injuries.

The superior orbital fissure and its contents

Topographic landmarks for the superior orbital fissure are useful for general orientation and approach to the middle fossa, cavernous sinus and orbit. In this study, the microsurgical anatomy and morphometry of the superior orbital fissure and its related structures were examined in 57 disarticulated sphenoid bones, 102 skull bases and 58 adult cadaveric heads. The superior orbital fissure was observed in nine different shapes based on the classification of Sharma et al. (1988), and the most frequently observed was Type VI. The distance from the superomedial to the superolateral edge was measured as 17.3 ± 3.4 mm on the right side and 16.9 ± 2.9 mm on the left side, and from the superolateral to the inferior edge as 20.8 ± 3.9 mm on the right side and 20.1 ± 3.8 mm on the left side. The distance from the superomedial to the inferior edge of the fissure was measured as 9.5 ± 2.2 mm on the right side and 9 ± 2.4 mm on the left side. No right-left differences were observed for these measurements. Measurements regarding the relationship of the oculomotor, trochlear and abducent nerves, the ophthalmic branch of the trigeminal nerve and the superior orbital vein were performed and topographic aspects of the superior orbital fissure region were described.

Variations in the origin of the medial and inferior calcaneal nerves

Introduction: Entrapment of the medial heel region nerves is often mentioned as a possible cause of heel pain. Some authors have suggested that the medial and inferior calcaneal nerves may be involved in such heel pain, including plantar fasciitis, heel pain syndrome and fat pad disorders. The aim of this study was to give a detailed description of the medial heel that would determine the variability and pattern of the medial and inferior calcaneal nerves, as well as to relate these findings to the currently used incision line for tarsal tunnel, fixations of fractures with external nailing, medial displacement osteotomy and nerve blocks in podiatric medicine. Materials and methods: The origin, relationship, distribution, variability and innervation of medial and inferior calcaneal nerves were studied with the use of a 3.5 power loupe magnification for dissection of 25 adult male feet of formalin-fixed cadavers. The medial heel was found to be innervated by just one medial calcaneal nerve in 38% of the feet, by two medial calcaneal nerves in 46%, by three medial calcaneal nerves in 12% and by four medial calcaneal nerves in 4%. An origin for a medial calcaneal nerve from the medial plantar nerve was found in 46% of the feet. This nerve most often innervates the skin of the posteromedial arch. Results: In our dissection, the rate of occurrence of the medial and inferior calcaneal nerves in medial heel region was 100%. When compared with the inferior calcaneal nerve, the medial calcaneal nerve was posterior, superior and thicker. The inferior calcaneal nerve supplies deeper structures. In the majority of the cases, inferior calcaneal nerve aroused from the lateral plantar nerve, but it may also arise from the tibial nerve, sometimes in a common origin with the medial calcaneal nerve. Conclusions: Knowledge of fine anatomy of the calcaneal nerves is necessary to ensure safe surgical intervention in the medial heel region.

Anatomical and surgical aspects of the lobes of the thyroid glands.

Variation in the descent of the thyroid gland and during fetal life and regression of the thyroglossal duct is associated with many variations in form of the mature gland. The shape and morphometric details of gland, its extension as the pyramidal lobe (PYR-L) and attachments of the levator glandulae thyroidea were studied in 40 cadavers. We categorized the shape of the thyroid into 12 types. The most frequent type was PYR-L with 22.5% which started from the left lobe and moved across by intercrossing the larynx. Horseshoe-shaped gland and the gland with separate lobes were the most frequently observed glandular shapes, with 17.5 and 20%, respectively. The incidences of the PYR-L and the levator glandulae thyroideae were 60 and 17.5%, respectively. The pyramidal lobe branched off more frequently from the left part of the isthmus (14 specimens) than from the right (5 specimens) or the midline (2 cases). Knowledge about the glandular landmarks and anatomic measurements around the thyroid will be helpful for the surgeon to constitute a simplification of the topographic anatomy, plan and decide on a safe approach to the thyroid gland, and to avoid postoperative complications.

Anatomic position of the lingual nerve in the mandibular third molar region as potential risk factors for nerve palsy.

Palsy of the lingual nerve (LN) during third molar extractions, ramus osteotomies, anesthetic injections, procedures of orthognathic, preprosthetic, and periodontal surgery are important complications reported with varying frequency. The purpose of this study is to present quantitative data describing the position and shape of the LN in the third molar area. In the course of dissection, the LN was noted, as well as the furcation pattern, position, course, and anatomic relations under 2.5X loupe magnification in 21 adult male human cadavers. The distance of the junction of the LN and the chorda tympani from the foramen ovale was measured as average 15.1 ± 5.8mm. The 4 furcation patterns of the LN and the inferior alveolar nerve (IAN) were observed based on their relative positions. Bifurcation of them above the level of the mandibular notch (type I) was observed in 66.7% of the specimens. The horizontal distance of the LN from the lingual plate of the mandible was greater in this study than in previous studies. This study provided measurable objective criteria for the relationship of LN in the third molar region. The knowledge of the relationship between the LN and third molar region is useful for the surgeon in avoiding unexpected complications.