P. Caix

Congenital coronary arteries anomalies: review of the literature and multidetector computed tomography (MDCT)-appearance

The prevalence of coronary arteries congenital anomalies is 1 to 2% in the general population. Although the spectrum of their clinical manifestations is very broad from total inocuity to lethal, anomalies of coronary arteries need to be recognized by clinicians in certain circumstances: they are the first cause of death in young adults under physical exercise and an abnormal course of a coronary artery can complicate a cardiac surgery. Therefore, a non-invasive test is highly suitable for detecting anomalies of coronary arteries and multidetector computed tomography (MDCT) is likely to be the best one. To understand how anomalies of coronary arteries may occur, we have reviewed the recent literature about their development. Then, the main types of anomalies are presented with their clinical context, and representative MDCT images from our personal database are used for illustration.

Septa within the sinus: effect on elevation of the sinus floor

Elevation of the sinus floor allows the correct number and length of oral implants to be placed. The sinus membrane is dissected blindly, usually by a crestal approach, but several internal configurations of the maxillary sinus or intrasinus septa can cause problems. We studied 150 sinuses from 40 male cadavers, and 35 randomised male patients by anatomical dissection and computed tomography. Forty-six subjects (61%) had no bony septa or had septa less than 4mm. Twenty-nine (39%) had bony septa of which seven were incomplete, one had a complete bony septum in each maxillary sinus, and 20 had symmetrical bony septa. We present the results of a study of bony intramaxillary sinus septa and the potential problems they can cause during elevation of the sinus floor.

The middle collateral artery: anatomic basis for the “extreme” lateral arm flap

The vascularization of the posterolateral area of the arm is supplied by the terminal branches of the deep brachial artery [middle collateral artery (MCA) and posterior radial collateral artery]. Their anatomy has been a field of confusion for a long time. An extended lateral arm flap, named the “extreme” lateral arm flap, supplied by these branches and dissected as a retrograde island flap has been proposed as an alternative for large compound defects of the distal forearm. We carried out an extensive anatomic study of the “extreme” lateral arm flap on 69 upper limbs: 54 fresh injected with colored latex, 10 embalmed and 5 radiographed after Micropaque injection. Two origin levels of the MCA were found: a proximal one (37%) above the radial groove, and a distal one (63%) at the level of the groove. The deep brachial artery always bifurcated after the origin of the MCA into a posterior radial collateral artery (PRCA) and anterior radial collateral artery (ARCA). Indeed in our dissections, after the origin of the MCA from the deep brachial artery, there was always a common trunk named the radial collateral artery (RCA) which bifurcated into the ARCA and PRCA. In all dissected arms we always found the MCA anastomosed in a transverse pattern with the inferior ulnar collateral artery (IUCA), contributing to the anastomotic circle of the elbow. This circle represents the unique vascularization source of the reverse “extreme” lateral arm flap.

Treatment of mandibular fractures with Michelet technique: manual fracture reduction without arch bars.

PURPOSE In our Bordeaux maxillofacial surgery unit, we have used the Michelet technique described for 40 years: manual fracture reduction and semi-rigid miniplate osteosynthesis fixation. No maxillomandibular fixation (MMF) with arch bars or with screws was used for reduction during osteosynthesis. The aim of this work was to evaluate results of this unknown manual reduction method. MATERIALS AND METHODS A total of 184 patients were reviewed. We recorded epidemiology of mandible fracture, clinical and radiologic evaluation before and after surgery, and treatment. Anatomic and functional manual reductions were the basic principle: manual maxillomandibular immobilization (functional) and manual fracture reduction (anatomic). In cases of condylar fractures without severe displacement, MMF with cortical bone screws was indicated (orthopedic treatment). Physiotherapy was also possible (functional treatment). RESULTS In all, 315 mandible fractures sustained by 184 patients were reviewed into the study. Of the patients, 80% were treated by osteosynthesis: 54% by osteosynthesis treatment alone, 26% by osteosynthesis and orthopedic treatments. The average time required for osteosynthesis or osteosynthesis and orthopedic treatment was 56 minutes. We observed 0.67% of disturbed occlusion, 0.67% of pseudarthrosis, and 0.67% of bilateral temporomandibular joint internal derangement. CONCLUSIONS Manual fracture reduction suppresses systematic MMF using arch bars during osteosynthesis of mandible fractures. Operating time and risk of complications are reduced. Functional results seem to be similar to that reported in the literature.

Bilateral variation of the pectoralis minor muscle discovered during practical dissection

We describe a case of an original insertion of the pectoralis minor on the coracohumeral ligament, supraspinatus tendon and the capsule of the glenohumeral joint. This variation has been described in anatomy textbooks since the nineteenth century. The peculiarity of this case is that the right shoulder presented type 2 and the left type 1 of the three varieties described by Le Double in 1897. Le Double (1843–1913) was a French anatomist who wrote a treaty on anatomical variations, in particular those of the muscle. Lately, only three publications have reported this variation in anatomic studies. Some authors have described the rotator cuff syndrome caused by this variation and an ultrasound study has demonstrated a frequency of 9.57% for the detection of this variation. It is possible to try and find this variation while investigating in order to diagnose impingement, through ultrasound, CT arthrography or MRI. We believe that this variation should be taken into consideration by surgeons during surgical procedures and arthroscopy.

Transverse cervical and great auricular nerve distribution in the mandibular area: A study in human cadavers

The angle of the jaw is innervated by the auricular branch of the superficial cervical plexus (SCP). Cervical cutaneous nerves of the CP carry the sensation from the antero‐lateral cervical skin. It is clinically relevant to identify the cervical cutaneous nerve distribution and the nerve point using superficial landmarks but published studies describing the emerging patterns and cervical cutaneous nerve branch distributions in the mandible are rare. The overlap between the cervical and trigeminal and facial nerve distributions and anastomoses is highly variable. The objective of this study was to characterize the distribution of the SCP nerves in the different parts of the mandible. Two hundred and fifty fresh and formalin‐fixed human cadaver heads were microdissected to observe the distribution of the transverse cervical (TCN) and great auricular (GAN) nerves. Two main groups (G1 and G2) based on the emergence of the TCN and GAN behind the posterior edge of the sternocleidomastoid muscle and three types (T1, T2, and T3) based on their distribution in the different mandibular parts were observed. Statistical analysis showed that parameters related to the mandibular side (P = 0.307), gender (P = 0.218), and group (P = 0.111) did not influence the facial distribution of these nerves. The only parameter influencing the distribution was the type of nerve (GAN and TCN) (P < 0.001). In the face, the SCP reached the mandible in 97% of cases, its distribution and extent were subject‐dependent. These results confirmed that the SCP could supply accessory innervation to the mandible through the TCN. Clin. Anat. 28:109–117, 2015.

Variation of the proximal insertion of the abductor digiti minimi muscle: correlation with Guyon's canal syndrome? Case report and literature review.

We describe the case of an original insertion and course of the abductor digiti minimi muscle on the medial part of the palmaris longus tendon. The anomalous muscle was only present on the left side. Various studies have reported the frequency of anomalous muscles in approximately 22 to 35% of hands and it was in majority an anomalous abductor digiti minimi muscle. The knowledge of this original insertion is important because it can sometimes be correlated with ulnar nerve compression at Guyons canal. But Guyons canal syndrome is less common than carpal tunnel syndrome, and the incidence of ulnar nerve compression in relation with anomalous muscle is approximately 2.9% of cases. It is possible to diagnose the anomalous muscle through ultrasound or MRI. This variation should be taken into consideration by surgeons during surgical procedures for ulnar nerve decompression at Guyons canal and when performing anteromedial approach to the wrist between flexors tendons and ulnar bundle.

Facial vein variation: implication for facial transplantation.

Philippe Caix, MD, PhD Mathieu Laurentjoye, MD Department of Oral and Maxillofacial Surgery Centre Hospitalio-Universitaire Bordeaux, France Department of Anatomy Université de Bordeaux Bordeaux, France Sir: T anterior facial veins ensure the venous drainage of the face and have been used as main venous pedicles for facial transplantations. The facial vein starts at the medial angle of the eye like the angular vein. Then, it runs obliquely behind the facial artery, crosses over the body of the mandible, and drains into the internal jugular vein through the thyrolinguofacial trunk. At the end of its course, the facial vein joins the retromandibular vein coming from the parotid gland establishing an anastomosis between external and internal jugular veins. We studied the course of 660 facial veins in 330 patients who underwent computed tomography angiography. There were 195 men and 135 women, with a mean age of 54.5 years, and none of them had a history of head or neck surgery. We report 2 cases with facial vein variations. The first case was a 42-year-old woman with bilateral variation of the facial vein, which drained into the jugular system through the parotid gland (Figs. 1 and 2). It could be a retromandibular ending of the facial vein. The vessels were connected with the parotid gland. The frequency of the variation was 0.3%. The second case was a 42-year-old man with unilateral variation of the right facial vein. The contralateral facial vein and facial arteries were normal. The frequency of the unilateral variation was 0.3%. To our knowledge, this is the first description of bilateral variation, whereas a unilateral facial vein variation has already been reported in 4 cases. In 2001, Peuker et al1 first described this phenomenon in an anatomically dissected cadaver. In 2004, Renshaw et al2 found one case of facial vein draining into the temporal vein in a color Doppler ultrasound study conducted in 100 patients, with a frequency of 1%. More recently, Lohn et al3 found during anatomical dissections the variation in 2 cases, with a frequency of 2%. Among the 4 previously published cases, 2 cases presented the variation on the right side of the face and 2 cases were not documented, so that no conclusion can be drawn about any predominance of one side over the other. Variations are rare with a rate ranging between 0.3% and 2%. However, anatomical variations of the facial veins and arteries are of great importance for facial transplantations because they are the main vascular pedicles that will be connected to the patient. A good arterial inflow and venous outflow are essential for the free flap survival. Several authors recommend preoperative investigations in a brain-dead donor before performing any facial transplantation.2–4 The aim is to identify any anatomical vascular variation, allowing surgeons to adapt the dissection during facial flap harvesting.

Absence du nerf musculocutané et distribution à partir du nerf médian : à propos de deux cas et revue de la littérature

Musculocutaneous nerve arises mostly from the lateral cord of brachial plexus. Nevertheless, variations have been reported and, among them: the total absence of musculocutaneous nerve (from 1.4 to 15%), the absence of its passage through the coracobrachial muscle, its variable level of penetration as measured from the tip of the coracoid process, and its communicating branches with the median nerve. We report two cases of unilateral musculocutaneous nerve absence in a 66-year-old male and a 95-year-old female cadavers, on the right and the left side, respectively. The nerve fibers normally coming from musculocutaneous nerve emerged from the median nerve. The knowledge of this anatomical variation is important specially when performing plexus bloc or Latarjets procedure.

Lambeau composite médiofacial vascularisé par l’artère faciale : étude anatomique préliminaire

INTRODUCTION Extended facial tissue defects are difficult to reconstruct because of the anatomical and functional complexity of the area. Recently, composite facial allotransplantation was used for reconstruction. This could be performed because of specific facial blood supply and its facial and maxillary anastomoses. Could a composite naso-labio-mental flap rely on the sole blood supply of a facial artery anastomosis? We performed an anatomic study of a naso-labio-mental composite flap vascularized by the facial artery. MATERIAL AND METHOD The study relied on arteriographies made on cadaveric heads and in vivo. The following data was analyzed: caliber of facial and maxillary arteries, terminal branch of facial arteries, and vascular territories. RESULTS Sixteen facial arteries and six maxillary arteries were studied. The mean facial artery caliber was 2.06 mm (1-3.2mm). The facial artery ended in the nasal area in 68.8% of the cases. The latero-nasal artery was always present; it was a branch of the facial artery in 66.7% of cases. The two facial arteries, when injected bilaterally, always allowed complete facial composite flap circulation. The nasal territory of the flap was not opacified by the homolateral facial artery in 16.7% of the cases. DISCUSSION Both facial artery anastomoses are recommended as blood supply for composite midfacial flaps. Preoperative imaging should be used systematically to assess the vascular network before harvesting.