M. Tschabitscher

The lumbrical muscle flap: Anatomic study and clinical application†

This article describes the anatomy and clinical application of the lumbrical muscle flap. Anatomic and radiologic studies were performed in 20 fresh human cadaver hands injected with latex-lead-oxide solution. Only the 2 radial lumbrical muscles were found suitable for flap transposition. The vascular supply of the first and second lumbrical muscles is from branches originating in the superficial palmar arch and from the common palmar digital artery, respectively. The dominant branches invariably enter the muscle bellies at the junction of their proximal and middle thirds. Pedicled on these vessels, the lumbrical muscles can be transposed to reach the entire palm, up to the wrist flexion crease. The clinical use of the first and second lumbrical muscle flaps in 2 patients demonstrated the value of these flaps for coverage of the median nerve and its palmar branches.

Scarpa's Fascia Flap: Anatomic Studies and Clinical Application

Fascia and fascia-subcutaneous flaps are thin, pliable, and well-vascularized tissue with aesthetic and functional advantages, particularly for the extremities and in the head and neck region. Although various donor sites have been used for these flaps, there is an occurrence of unsatisfactory donor-site defects that are often complicated by conspicuous, widened scars or alopecia. In addition, flap elevation is sometimes prolonged because of the demanding operative procedures as well as the impossibility of a two-team approach. In this anatomic and clinical study we present a new fascial flap that results in a minimal donor-site defect and a short and easy operative procedure. Scarpas fascia, which can be used as both a free and a pedicled flap, is a well-defined single membranous sheet within the subcutaneous tissue layer at the lower abdominal wall. We studied its distribution, structure, and vascular supply in 27 fresh cadaver specimens. In addition, computed tomographic (CT) and ultrasound studies were performed in 13 healthy volunteers and in 3 cadavers before and after injection of diluted contrast material in the superficial epigastric artery. Finally, histologic examinations were done with hematoxylin and eosin or with reticulum and elastin. Our studies showed that Scarpas fascia provides a thin, pliable, and well-vascularized flap pedicled on the superficial epigastric artery. After successful application of the Scarpas fascia flap as a free flap in 3 patients and as a pedicled option in 1 patient, we can recommend this flap as a valuable tool for the reconstructive surgeon.

The vertically based deep fascia turnover flap of the leg: anatomic studies and clinical applications.

&NA; Although fasciocutaneous turnover flaps are a simple and fast method for covering soft‐tissue defects of the lower leg, many reconstructive surgeons have their doubts about them. They revolve around the lack of criteria for safely designing these random‐pattern flaps and around the risk of donor site problems. A vertically based deep fascia turnover flap with a paratibial or parafibular pedicle is presented. Anatomic studies of 36 injected lower limbs showed the deep fascia to be supplied by a mean of 61 vessels. As musculofascial, septofascial, and periosteofascial branches, these contribute to a richly anastomosing vascular network within the deep fascia. Along the deep transverse septum at the medial tibial border, the anterior and posterior peroneal septa, and between the anterior tibial and extensor muscles, the fascia is supplied by segmental vessels in a clearly defined arrangement. Pedicled on these vessels, the deep fascia is a useful candidate tissue for transversely oriented turnover flaps. These are particularly well suited for covering pretibial or prefibular soft‐tissue defects. Unlike adipofascial turnover flaps, the transversely oriented deep fascia turnover flap keeps its subcutaneous layer with its intact vascular plexus so that the overlying skin is adequately perfused even in patients with sizable flaps or an extremely thin skin. Clinical experience with the vertically based paratibial or parafibular deep fascia turnover flap in six patients confirmed its usefulness for covering small to mediumsized soft tissue defects of the lower leg. (Plast. Reconstr. Surg. 100: 1746, 1997.)

Course of the arteria vertebralis in its segment V1 from the origin to its entry into the foramen processus transversi

The segment V1 of the arteria vertebralis (pathway from its origin from the a. subclavia to the entry into the respective foramen processus transversi) has a special significance in vascular surgery. Contrary to indications in the literature, we found 47.15% of the specimens to have a contorted course in this segment. The tortuosities carried by the respective vessels were found to be horizontal in 42.5%, in a sagittal direction in 30% and in the frontal plane in 27% of the cases. However, no significant difference was found between vessels carrying a tortuosity and those without, regarding the average lengths of the arteries concerned in the segment V1.

Modifications of Temporal Approaches: Anatomical Aspects of a Microneurosurgical Approach

All subtemporal approaches have in common the risk of temporal lobe damage. To reduce the retraction of the temporal lobe we combine two synergistic modifications of temporal approaches to reach the prepontine space. The first is the temporary resection of the zygomatic arch which allows to bring the temporalis muscle more caudally and subsequently allows an anterior subtemporal approach with only minimal temporal lobe retraction. The second modification is the resection of the apex of the petrous bone after incision of the tentorium. This provides an excellent view into the posterior fossa between the trigeminal nerve medially, the internal carotid artery caudally and the internal auditory canal laterally. The anatomical aspects of a microneurosurgical approach regarding these modifications are reported and discussed.

The Persistent Trigeminal Artery and Its Topographical Relations

The topographical relation of a persistent trigeminal artery (PTA) to neighboring structures was investigated. The vessel belongs to Saltzmans type I. It originates from segment C5 of the internal carotid artery and opens into the basilar artery, 8 mm before the bifurcation into the two posterior cerebral arteries. The 6th cranial nerve winds around the first part of the PTA which is situated within Parkinsons triangle.

Die arterielle Versorgung des Musculus Biceps brachii

The bicipital arteries (Rami bicipitales) were classified according to the part of the muscle they supply, to the artery from which they originate and to their relative position to the median, musculocutaneous and ulnar nerves. The maximal density of bicipital arteries can be found in the middle of the upper arm and slightly distal to the greater tubercle.

Die Teilungsmöglichkeiten der großen Arterien in der Fossa cubiti in bezug zur Hueterschen Linie

ZusammenfassungIn der Fossa cubiti können 7 Verzweigungstypen des arteriellen Systems unterschieden werden. Neben anderen Kriterien werden sie durch das arterielle System des Oberarms bestimmt: entweder nur eine A. brachialis oder nur eine A. brachialis superficialis oder beide gleichzeitig. Die Aufteilung einer Oberarmarterie in A. radialis und A. ulnaris (Typ 1 und 3) findet sich 3 bis 4 cm distal der Hueterschen Linie. Stammt die A. interossea communis von der A. radialis (Typ 2, 4 und 7), findet sich ihr Ursprung in derselben Höhe. Ihr typischer Ursprung aus der A. ulnaris (Typ 1, 3 und 5) findet sich jedoch 6,5 bis 7,5 cm distal der Hueterschen Linie. Existiert eine A. ulnaris superficialis (Typ 2, 4, 6 und 7), variiert ihr Ursprung zwischen 5 cm proximal und 2,5 cm distal der Hueterschen Linie.Summary7 ramification types of the arterial system in the cubital fossa are distinguished. Besides other criteria they are defined by the arterial system of the upper arm: either only A. brachialis or only A. brachialis superficialis or both of them. The division of one upper arm artery in radial and ulnar arteries (types 1 and 3) takes place 3 to 4 cm distal to Hueters line. If the A. interossea communis originates from the A. radialis (types 2, 4 and 7), it branches off at that same level. Its typical branching off from the ulnar artery (types 1, 3 und 5), however, is found 6.5 to 7.5 cm distal to Hueters line. If there is an A. ulnaris superficialis (types 2, 4, 6 and 7), its origin varies from 5 cm proximal to 2.5 cm distal to Hueters line.

Endoskopische karpaltunnelspaltung@@@Endoscopic carpal tunnel release

ZusammenfassungGrundlagenObwohl die endoskopische Karpaltunnelspaltung seit mehr als 5 Jahren angewandt wird, bestehen nach wie vor kontroversielle Ansichten bezüglich der Effektivität und Sicherheit dieser Technik.MethodikAn Hand eigener Erfahrungen mit 157 endoskopischen Karpaltunnelspaltungen und nach Durchsicht der Literatur wird der aktuelle Stellenwert der endoskopischen Karpaltunnelspaltung im Vergleich zur konventionellen offenen Methode erörtet.ErgebnisseDie Vorteile der endoskopischen Karpaltunnelspaltung gegenüber der konventionellen Methode bestehen primär in der frühen postoperativen Phase und äußern sich in geringeren Wund-und Narbenschmerzen sowie einer rascheren Wiedererlangung der Funktionalität. Allerdings erfordert diese Technik ausreichende Übung und handchirurgische Erfahrung, da das Risiko einer iatrogenen Verletzung der Gefäß-und Nervenstrukturen besonders in der Karpaltunnelspaltung.SchlußfolgerungenDie endoskopische Karpaltunnelspaltung stellt bei entsprechender Indikationsstellung eine wertvolle Ergänzung zur konventionellen offenen Methode dar. Der Patient muß über das mögliche Komplikationsrisiko aufgeklärt und soll in die Wahl der Operationsmethode mit einbezogen werden.SummaryBackgroundAlthough the endoscopic carpal tunnel release has been in use since 1989 there is still considerable disagreement regarding the safety and efficacy of this procedure.MethodsBy means of our own experience with 157 endoscopic carpal tunnel procedures and guided by the literature the value of the endoscopic carpal tunnel procedure compared to the conventional open method will be discussed in detail.ResultsThe advantages of the endoscopic carpal tunnel release over the standard open technique are evident in the early post-operative period and become apparent in less scar tenderness and an earlier functional recovery. However, the endoscopic carpal tunnel release is a technical demanding procedure and the risk of inadvertent damage to the neurovascular structures always remains a possibility.ConclusionsAlthough the endoscopic carpal tunnel procedure has advantages over the standard open release this technique is not suitable for every patient and every surgeon. Early conversion to an open technique is recommendable whenever the transverse fibers of the flexor retinaculum are not clearly seen.