Bilateral Branch Research Articles

Important CT Findings for Prediction of Incomplete (R1 or R2) Resection and Poor Survival of Perihilar Cholangiocarcinoma after Curative-Intent Surgery

Purpose: To evaluate CT findings to predict incomplete (R1 or R2) resection and poor survival in patients with perihilar cholangiocarcinoma using pre-operative CT.Materials and Methods: From 2006 to 2012, a total of 139 patients with perihilar cholangiocarcinoma who underwent pre-operative multiphase CT and subsequent curative-intent surgery were included. After two radiologists independently reviewed CT findings including the likelihood of bile duct (BD) involvement from intrapancreatic common bile duct (CBD) to bilateral second-order branches and peritumoral fat stranding using a 5-point scale, vessel involvement (no, abutment, encasement), and LN involvement, imaging findings were finalized by a consensus of two radiologists. When the likelihood scale of 4 or more on preoperative CT was regarded as BD involvement, the diagnostic ability of CT was analyzed by the receiver operating curve using histopathologic results as a reference standard. Residual tumor categorized into no residual tumor (R0) and residual tumor (R+; R1 or R2). Predictive factors of R+ resection on pre-operative CT were analyzed by logistic regression. Cox proportional hazard model was used to determine the prognostic factor for overall survival by using pre-operative CT findings and laboratory results.Results: Seventy-one patients were R0 and sixty-eight patients were R+ resection. For resectability evaluation, mid-CBD involvement (score ≥ 4) in pre-operative CT was significant factor for R+ resection in multivariable analysis (<i>P</i> < 0.01) with substantial interobserver agreement. In multivariable Cox regression, intrapancreatic CBD involvement (score ≥ 4, hazard ratio [HR] = 1.81, <i>P</i> < 0.01) as well as elevated total bilirubin (HR = 1.53, <i>P</i> = 0.04) and CA 19-9 level (HR = 1.75, <i>P</i> < 0.01) were significant predictors for poor survival. Diagnostic ability to predict mid-CBD and intrapancreatic CBD involvement on pre-operative CT were 0.71 and 0.72 (AUC values).Conclusions: Distal longitudinal extent of perihilar cancer on pre-operative CT is a significant factor for margin positive resection and poor survival on curative-intent surgery.

Mathematical Model of the Effect the Energy on (Y-W-D) Types of Fungi , with Exponential function

The phenomenon of dysplasia describes the mathematical model. The model that shows the behaviour of the growth of bilateral branching, lateral branching, filament tip anastomosis, limb anastomosis, and limb death due to overcrowd- ing with thread death. The study shows energy consumption; in general that the growth of fungi needs to be resolved until its goal becomes a correction. More- over the study reduced the cost, effort by predicting the best class of plants for cultivation according to the results. Herein we suggest mathematical solution using the solution of Partial Differential Equations (PDEs). Furthermore, Matlab software codes were utilized numerical analysis because of some of the difficulties we face in the direct mathematical solution. Finally, the study mod- els shows the success or failure of the growth of the studied fungi

The Technique of Bilateral Pulmonary Artery Banding in High-Risk Patients With Hypoplastic Left Heart Syndrome

The management of high-risk neonates with hypoplastic left heart syndrome or its variants remains a tremendous surgical and medical challenge for our specialty. The hybrid strategy has been shown to improve outcomes in high-risk patients. This article illustrates the specific technical details of bilateral branch pulmonary artery banding for such high-risk patients.

Surgical Strategy for Ethmoidal Dural Arteriovenous Fistula

Ethmoidal dural arteriovenous fistula (DAVF) is a rare type of intracranial DAVF. The aim of this study was to report our experience with a unilateral approach and discuss its effectiveness for ethmoidal DAVF treatment. The study included 19 patients who underwent surgical treatment for ethmoidal DAVF between January 1999 and May2021. Median age of patients was 59.7 years; 16 (84%) patients were male. Three patients had a ruptured ethmoidal DAVF. Preoperative digital subtraction angiography showed that all ethmoidal DAVFs were supplied by the bilateral external carotid artery branches. In 18 (95%) patients, cortical draining veins were located on the unilateral side. Bilateral lesions were identified in only 1 (5%) patient. The frontobasal approach was performed in 5 patients (26%), the pterional approach was performed in 5 (26%) patients, and the lateral supraorbital approach was performed in 9 (47%) patients; median procedural times were 198 minutes, 172 minutes, and 111 minutes, respectively. Cortical draining vein was successfully disconnected in all 19 patients with 20 ethmoidal DAVFs. Complete obliteration of ethmoidal DAVF was confirmed in all patients, with no postoperative complications. No recurrence or related clinical events were reported in 13 (68%) patients over 12 months of clinical and radiological follow-up. We reconfirmed excellent outcomes of surgical treatment for ethmoidal DAVFs. Three different surgical strategies were attempted, and each had pros and cons. The lateral supraorbital approach is an efficient surgical option for unilateral ethmoidal DAVFs. Careful preoperative examination for the presence of bilateral drainage is essential.

Anomalous Origin of the Left Coronary Artery From the Right Pulmonary Artery of an Infant.

A female presented 2 weeks after birth with an unbalanced atrioventricular canal, double outlet right ventricle, mild pulmonary stenosis, and patent ductus arteriosus that eventually caused pulmonary over circulation. After pulmonary artery banding, she experienced myocardial ischemia, suggesting interference with coronary blood flow by the band that had been placed on the main pulmonary trunk. The band was removed and revised to bilateral branch pulmonary artery banding, and cardiac function improved. An anomalous left coronary artery from the underside of the right pulmonary artery was identified. Eight weeks later, the patient underwent coronary transfer and reimplantation of the left coronary artery into the aorta followed by main pulmonary artery banding. She subsequently underwent bidirectional Glenn.

An Atypical Origin of the Saphenous Nerve and a Variation of the Right Iliacus Muscle: A Case Report

During a routine cadaveric dissection of the posterior abdominal wall, variations of the bilateral lumbar plexus and a variant saphenous nerve, originating in the lower abdomen was noted and documented. Further study revealed variations at the root of the lumbar plexus and bilateral branching patterns. A variant iliacus muscle entrapping the superior portion of the femoral nerve was also observed on the right side within the abdominal cavity. To the best of our knowledge, the saphenous nerve arising from L1‐L3 above the inguinal ligament has not been reported in literature as of yet, which raises the question of how rare this variation may be. Anatomical variations should always be kept in mind in clinical and surgical settings, not only to prevent iatrogenic effects but also to determine proper diagnosis and care for the patient. Nerves in particular, are important to consider when a patient is experiencing pain or paresthesia, or when performing invasive procedures.

Involuntary crying episodes with Susac\u2019s syndrome\u2014a rare presentation of a rare disease: a case report

BackgroundIn this case, we reported the pseudobulbar affect (PBA) in a patient with Susac’s syndrome—a rare condition that was caused by a rare syndrome. Previous case reports of Susac syndrome described psychiatric symptoms such as emotional disturbances or personality changes. Only a few case reports have reported psychiatric disorders in patients with Susac’s syndrome. There were no reported cases of Susac syndrome with PBA as an initial presentation.Case presentationOur patient was 56 years old and presented with involuntary crying, left-sided headache, left-sided hearing loss, and tinnitus. Brain MRI showed numerous areas of restricted diffusion and enhancement involving the corpus callosum, bilateral hemispheres, and brainstem. Ophthalmological evaluation showed bilateral branch retinal artery occlusion. She was diagnosed with Susac’s syndrome and PBA. She was treated with cyclophosphamide and dextromethorphan hydrobromide/quinidine sulfate with excellent recovery. This is a 2-year clinical course.Discussion and conclusionsRecognition of the clinical presentation of Susac’s syndrome and PBA with early diagnosis and treatment are the keys to preventing further disability and impact on patients and their families.

GUIDED IMPLANT PLACEMENT ON EDENTULOUS MAXILLA TO AVOID DAMAGE TO ACCESSORY BRANCHES OF THE CANALIS SINUOSUS: A CASE REPORT

​Introduction The canalis sinuosus (CS) is an anatomical structure arising from the infraorbital nerve. It is a neuromuscular canal, carrying the anterior superior alveolar nerve and vessels. Rarely, accessory bilateral branches of CS are observed on cone beam computed tomography(CBCT) images, during implant planning, in the anterior maxilla region. It is an important anatomical structure often overlooked by surgeons and not visible by conventional radiographs. Case report A case of anatomical variation in the CS with accessory branches was detected after a CBCT was performed on an edentulous 72 years old male patient pre operatively for implant placement. On the examination of the axial slices of the CBCT, additional foramina lateral and anterior to the nasopalatine foramen were observed. By tracing into the bone from these foramina, it was observed that these accessory canals communicate with the CS. Implant planning was performed, respecting these canals and a surgical guide was fabricated, using the dual scan protocol from the patient’s denture. A post-op CBCT was performed to determine the accuracy of our guide and the position of the implants. No post-op complications were observed. Conclusion Several cases of intractable pain following implant placement in the anterior maxilla have been reported. Damage to the CS and its accessory canals may be the cause. Knowledge of these anatomical variations is of great importance and the use of guided implant placement is a useful tool to avoid iatrogenic surgical trauma and post-op surgical distress to the patient.

Staged left ventricular recruitment facilitated by Sano conduit upsizing

Staged left ventricular recruitment facilitated by Sano conduit upsizing

Analytical model for the activation of off-axis secondary faulting between two dissimilar rock layers

Bimaterial faults can be found in nonhomogeneous rock media between dissimilar rock layers. An analytical model was extended for the right lateral strike-slip fault between two dissimilar rock layers to predict the activated tensile, right and left lateral shear zones around the fault tip. The effect of elastic modulus contrast (E2/E1, the ratio of the Young's moduli of the lower to the upper layer), rupture velocity (c), precompression stress ratio (-ϭxxo/-ϭyyo), residual to peak strength ratio (τr/rp) and fracture energy (G) were considered. Results show that under an intermediate rupture speed of (0.5 of the Rayleigh wave speed): the extension of activated tensile and shear zones depends strongly on the ratio of E2/E1 and it increases with increasing this ratio. The preferred direction of the new branches is little affected by the elastic modulus contrast. Increasing precompression stress ratio encourages right and left lateral shear branching on the compressional side of the fault and decreases the size of activated tensile and shear zones. Under an extreme rupture speed of (0.98 of the Rayleigh wave speed): the mechanism of branching differs, for E2/E1 < 1, the three activated zones are located in the lower layer and there is only a possibility for unilateral branching on the extensional side of the fault. For E2/E1 ≥ 1, right and left lateral shear zones extend to the upper layer (compressional side), which means the possibility of bilateral shear branching on the two sides of the fault. For all values of E2/E1, c, -ϭxxo/-ϭyyo, tensile branches can only be formed in the lower layer on the extensional side of the fault.

A retrospective cohort study of major adverse cardiac events in children affected by Kawasaki disease with coronary artery aneurysms in Thailand

Kawasaki disease (KD) is a common form of vasculitis in children that can be complicated by coronary artery aneurysms (CAAs). Data of long-term outcomes and major adverse cardiac events (MACE) in children with CAAs following KD in developing country are limited. Our aims were to determine the rates of MACE and identify risk factors associated with MACE in children with KD and CAAs in Thailand. We performed a retrospective analysis of data from 170 children diagnosed with KD and CAAs in two tertiary hospitals between 1994 and 2019. During a median (range) follow-up of 5.4 years (22 days to 23 years), 19 patients (11.2%) experienced MACE, that included 12 coronary artery bypass grafting, 2 percutaneous coronary intervention and 5 children with evidence of myocardial ischemia and coronary occlusion. Coronary interventions were performed at a median time of 4 years (0.01 to 9.5 years) after KD diagnosis. Forty-nine patients (28.8%) had giant CAAs. No MACE was reported in children with small CAAs. Independent risks of MACE were from the absence of intravenous immunoglobulin treatment (HR 7.22; 95% CI 2.21 to 23.59; p = 0.001), the presence of giant aneurysms (HR 13.59; 95% CI 2.43 to 76.09; p = 0.003), and CAAs that involved bilateral branches of coronary arteries (HR 6.19; 95% CI 1.24 to 30.92; p = 0.026). Among children with giant CAAs, the intervention-free rate was 93.8%, 78.7% and 52.2%, at 1, 5 and 10 years, respectively. Of note, 81% of the small CAAs regressed to a normal size, and for medium CAAs, 50% regressed to normal size. Overall, ~10% of children with CAAs following KD experienced MACE in this cohort. Timely IVIG treatment in children with KD following symptom onset will reduce the risk of MACE. Cautious surveillance to identify cardiac complications should be recommended for children once medium or giant CAAs develop. Trial registration: TCTR20190125004.

Middle cerebral arterial bifurcation aneurysms are associated with bifurcation angle and high tortuosity

PurposeTo investigate the association of middle cerebral artery (MCA) bifurcation aneurysms with bifurcation morphology. Materials and methods205 patients were enrolled, including 61 patients with MCA bifurcation aneurysms and 144 non-aneurysmal subjects. Aneurysmal cases were divided into types C (aneurysm neck on extension of the parent artery centerline) and D (deviating neck). The radius of the parent artery M1 (RP) and bilateral branches (RS and RL, respectively), smaller (φS) and larger (φL) lateral angles, bifurcation angle, and arterial tortuosity from parent vessel to bilateral branches (TS and TL, respectively) were analyzed. Logistic regression and receiver operator characteristic (ROC) curve analysis were performed to identify risk factors and predictive values for MCA aneurysm presence and types. ResultsIn aneurysmal MCA bifurcations, bifurcating angle, TS, TL and RL were significantly larger (P<0.01), while φS was significantly smaller (P<0.001) than those in controls. The bifurcation angle, TS and LogitP were better morphological parameters for predicting MCA aneurysm presence with the AUC of 0.795, 0.932 and 0.951, respectively. Significant (P<0.05) differences were observed in the bifurcation angle, φL, RP, RL and TL between types C and D aneurysmal bifurcations. TL was an independent factor in discriminating types C from D aneurysms with an AUC of 0.802. ConclusionsBifurcation angle and arterial tortuosity from the parent artery to the branch forming a smaller angle with the parent artery have a higher value in distinguishing MCA aneurysmal from non-aneurysmal ones, and the tortuosity from the parent artery to the contralateral branch is the best indicator for distinguishing types C from D aneurysmal bifurcations.

Effect and Mechanism of Lidocaine Pretreatment Combined with Dexmedetomidine on Oxidative Stress in Patients with Intracranial Aneurysm Clipping.

This study aimed to explore the effect and mechanism of lidocaine pretreatment combined with dexmedetomidine on oxidative stress in patients with intracranial aneurysm clipping. Many studies have used various drugs such as lidocaine to explore the effect and mechanism of lidocaine pretreatment. A total of 80 patients with intracranial aneurysm clipping surgery were randomly divided into 4 groups: the single lidocaine group, single dexmedetomidine group, lidocaine combined with dexmedetomidine group, and control group. The thread embolism method was used to establish a stable intracranial aneurysm model of Hashimoto rats. Fifty adult rats were randomly divided into a sham operation group, ligation of the left common carotid artery and bilateral posterior branch of renal artery, lidocaine group, dexmedetomidine group, and lidocaine combined with dexmedetomidine group. The colorimetric method was used to determine the oxidative stress indicators in brain tissue: MDA content, SOD activity, and T-AOC content. The western blot method characterized the protein levels related to oxidative stress: nNOS, iNOS, and NADPH oxidase subunits p22phox, gp91phox, and p47phox. The differences in each index between the groups were statistically significant (P < 0.05). Animal experiment results revealed that the content of MDA in the brain tissue of rats in the LD group was significantly lower than that in the single-drug group and sham group. The T-AOC and SOD concentrations in the LD group were significantly higher than those in the single-drug group and sham group, and the differences between the groups were statistically significant (P < 0.05). The protein expression of the LD group was significantly lower than that of the drug-alone group and model group, and the difference between groups was statistically significant (P < 0.05). To sum up, lidocaine pretreatment combined with dexmedetomidine can effectively maintain the hemodynamic stability of patients with intracranial aneurysm clipping and reduce postoperative oxidative stress response. Its mechanism of action may be related to the inhibition of oxidative stress damage mediated by nNOS, iNOS, and p22phox, gp91phox, and p47phox in the hippocampus. Our study has significant and applicable medical aspects in lidocaine pretreatment combined with dexmedetomidine on oxidative stress in patients.

P35 Dermatomyositis with retinal involvement: a case series

P35 Dermatomyositis with retinal involvement: a case series

Comparison between ultrasound-guided and anatomical landmark-guided block of internal branch of the superior laryngeal nerve for awake fiber-optic intubation in suspected difficult intubation: a randomized controlled study

BackgroundAirway anesthesia is pivotal for successful awake intubation provided either topically or by nerve blocks. The widespread use of ultrasonography allows anesthesiologists to evaluate complex and varied anatomy before needle insertion. This study aims to evaluate the effect of ultrasound-guided technique for the block of the internal branch of the superior laryngeal nerve in difficult airway patients in comparison to blind anatomical technique. Sixty patients aged 18–60 years, of either sex, with the American Society of Anesthesiologists’ physical status (ASA) I–II were divided into two groups 30 patients of each. Group (L): using anatomical landmark technique to bilateral block internal branch of the superior laryngeal nerve (ibSLN) with 1 mL 2% Lidocaine and group (U): using ultrasound technique to bilateral block the ibSLN with 1 mL 2% Lidocaine. Assessment of the excellence of airway anesthesia during intubation by using the 5 points grading scale, time for intubation, effects on hemodynamic variables, and evaluation of patient awareness of pain and discomfort during fiber-optic intubation using numerical rating scale were compared.ResultsThe duration of tracheal intubation was shorter in the ultrasound group as compared to the anatomical group; also, patient comfort was significantly better in the ultrasound group besides the effect of tracheal intubation on hemodynamics which was significant with a higher peak value during intubation and post-intubation in the anatomical group compared to the ultrasound group.ConclusionsThis study concludes that an ultrasound-guided block of ibSLN used as a part of the preparation of the airway for awake fiber-optic intubation enhances the quality of airway anesthesia and patient tolerance during the procedure.

Three Cases of Hepatocellular Carcinoma With Massive Macrovascular Invasion Successfully Treated With Radiotherapy

In clinical practice, the treatment approach for hepatocellular carcinoma (HCC) with macrovascular invasion (MVI) is determined on a case-by-case basis. The common management options include systemic and local therapies, although the former is the more widely accepted approach. We present three cases of HCC with MVI successfully treated with radiotherapy. The first patient was a 62-year-old man with Child-Pugh A cirrhosis who had a 5.7-cm treatment-naïve HCC invading the bilateral branches of the portal vein. Stereotactic body radiotherapy (SBRT) was administered, with no evidence of recurrence observed at the 24-month follow-up. The second patient was an 81-year-old man with Child-Pugh A cirrhosis who had a 3.8-cm HCC invading the inferior vena cava (IVC). Transcatheter chemoembolization performed one month earlier had been ineffective, and the tumor had grown rapidly. SBRT was administered, and no evidence of recurrence was observed up to his death from pneumonia 24 months after the treatment initiation. The third patient was a 72-year-old man with Child-Pugh A cirrhosis who had a 6.7-cm treatment-naïve HCC with portal vein tumor thrombosis (PVTT) from the main trunk to the secondary branches of both lobes. PVTT was treated with hypofractionated radiotherapy, while the primary HCC and intrahepatic recurrent lesions were subsequently treated with hepatic arterial infusion chemotherapy (HAIC) and five rounds of ablation. Six months after the last ablation (48 months after initial therapy), no evidence of recurrence was observed. Our cases illustrate that radiotherapy leads to the successful treatment of HCC with MVI.

VP22.23: Fetal complex rare cardiac malformation

A 27-year-old gravida 1 para 0 attended for anomaly scan with a singleton pregnancy. There were no significant events of interest nor consanguinity between both parents. Second-trimester ultrasound scan at 22+3 weeks showed a single live fetus in changing lie. Fetal Echo revealed: Situs solitus. The 4- chamber view showed univentricular heart, left handed ventricular topology, right sided main ventricle of left ventricular morphology, hypoplastic left sided (morphological right) ventricle, left sided AV valve (likely tricuspid valve) atresia, VSD (subaortic), AV & VA discordance - congenitally corrected transposition. Foramen ovale was largely restrictive with significant a-wave reversal. Aorta was located to right and anterior to pulmonary artery - D malposition. Aortic arch hypoplasia, mild preductal aortic coarctation, main pulmonary arterial dilatation, bilateral branch pulmonary artery origin stenosis was noted. No arrhythmias, no disturbances in the heart rate. Fetal cardiac function was normal. Amniocentesis and microarray offered but refused by patient. At 39+3 weeks of gestation a 3.05 kg male infant was born by spontaneous vaginal delivery, required PPV and CPAP at birth, due to poor respiratory effort then recovered. Postnatal echocardiography confirmed the diagnosis and on second day after birth the newborn underwent Norwood surgery with right modified Blalock-Taussig shunt and recovered uneventfully. The second stage surgery (Glenn superior cavo pulmonary shunt) and PA plasty was performed at 6 months of age and the patient recovered uneventfully. The patient will be followed in multidisciplinary fashion along with pediatric cardiac critical care and pediatric cardiology teams. He will proceed along the univentricular pathway, with a Fontan procedure (at a weight of 15 kg or greater) at 3 to 4 years of age, preceded by cardiac catheterisation. He should remain on aspirin (5 mg/kg once daily) until his Fontan (if feasible).

Clinical Characteristics and Long-Term Outcomes of Endovascular Treatment of Renal Artery Fibromuscular Dysplasia With Branch Lesions

Renal artery fibromuscular dysplasia (FMD) can cause arterial stenosis, dissection, and aneurysm of renal arteries. This study aimed to analyze the clinical characteristics and evaluate the long-term outcomes of renal branch artery FMD in children and adults. Sixty-one patients with renal artery FMD underwent endovascular treatment, including 23 children and 38 adults. They were divided into two groups, the main artery FMD group (n = 40, with severe stenosis located in the main renal artery) and the branch artery FMD group (n = 21, with only the branch lesions in unilateral or bilateral branch artery). The clinical characteristics and long-term outcomes of these pediatric and adult patients were evaluated. The incidence of branch FMD was higher in children than in adults (P = 0.005). Thirteen children showed one or more branch artery involvements. Hypertension and headache were the most common symptoms. The branch aneurysm with coexisting stenosis was more common in patients with branch artery FMD. During the follow-up, blood pressure was normal in 8 patients and lowered in 11 patients in the branch FMD group. The patient’s glomerular filtration was increased in 61 patients (P < 0.001). Four-year freedom from reintervention in 21 branch artery FMD patients was lower than that in 40 main artery FMD patients (P < 0.05). A higher incidence of renal branch artery FMD was observed in children than in adults. Endovascular treatment with balloon angioplasty can be used for treating renal branch artery FMD.

Cerebral Arterial Bifurcations Harboring D Type Aneurysm are more Asymmetrical than those with C Type Aneurysm

ObjectivesThis study was designed to determine aneurysm deviation and to compare anatomical differences of bifurcations harboring C and D-type aneurysms. Materials and methodsA total of 198 arterial bifurcations harboring aneurysms were enrolled in this study, including 58 anterior cerebral arteries (ACAs), 64 middle cerebral arteries (MCAs), 19 basilar arteries (BAs), and 57 internal carotid artery-posterior communicating arteries (ICA-PComAs). Aneurysms were defined as C type if the neck was located on the extension of the parent artery midline and D type if it was not, then, aneurysm deviation was examined. The angles forming between bilateral branching arteries and the main artery were lateral angles, and smaller one named φ2, larger one termed φ3, respectively, D2, S2, C2 and T2 representing the diameter, cross-sectional area, circumference, and tortuosity of the branch forming angle φ2 with the parent vessel, respectively, and D3, S3, C3 and T3 representing the corresponding values of the contralateral branch. The lateral angle ratio (LA ratio; larger lateral angle/smaller lateral angle), daughter artery ratio (DA ratio; the diameter of branch forming larger lateral angle with parent artery/ the diameter of contralateral branch), SA (S3/S2), CA (C3/C2) and TA (T3/T2) ratios were used to describe bifurcation symmetry. ResultsThe angle φ2 of the main cerebral bifurcations was significantly smaller than the angle φ3, whereas T2 was significantly larger than T3. Most of the C-type and 100% of the D-type aneurysms deviated toward the angle φ2. The LA, DA, SA and CA ratios of ACA, MCA bifurcations and ICA-PComAs harboring D-type aneurysms were all significantly larger than those harboring C-type aneurysms; moreover, the LA, DA and SA ratios demonstrated significant differences between the bifurcations with C and D-type aneurysms, as determined by ROC analysis. ConclusionsThe majority of C-type and all of the D-type aneurysms deviated toward the smaller lateral angle, and bifurcations harboring D-type aneurysms were more asymmetrical than those harboring C-type aneurysms.

Reconstruction of a large nasal–facial defect using an augmented temporal myocutaneous tube flap in a dog

The muzzle region of dogs contains various composite tissues, which are challenging to recreate during reconstruction. Small or moderate facial/nasal defects can be closed primarily or left for second‐intention healing. However, larger defects require the application of composite tissue or labial advancement flaps. Axial pattern flaps based on the caudal auricular artery, superficial temporal artery (STA), angularis oris artery, and other cutaneous arteries have been reported. In our case, we aim to report the reconstruction of a large composite defect of the rostral and dorsal nasal regions in a dog using an augmented, axial myocutaneous flap based on bilateral STAs. This is a clinical report on a spayed female mixed‐breed dog (age, 7 years; weight, 15 kg), in which a large‐scale nasal–facial composite tissue defect was surgically reconstructed using an axial myocutaneous flap based on bilateral STA branches. A delay technique was applied to prefabricate the flap to enrich the blood supply. New nostrils were created on a folded, rostral hard palate. As a result, the axial tube rotational flap was successfully transferred. The use of delay technique for prefabricating the tube flap optimized its size and survival. In addition to the folded rostral hard palate, the flap fully closed the defects on the face and nose. Functional and cosmetic outcomes were satisfactory, with minimal donor‐site morbidity. In, conclusion, a large‐scale nasal–facial defect in a dog was successfully reconstructed using an augmented tube pedicle flap based on the bilateral STAs, which may, thus, be used to repair very large facial‐nasal defects in dogs.