Fresh Adult Cadavers Research Articles

The anatomy and clinical application of sural blood vessel combined with free skin flap

Objective To study the anatomical characteristics of sural blood vessel, and to explore the clinical effect of sural blood vessel combined with free skin flap in repairing large tissue defect of calf. Methods 10 fresh adult cadavers were col-lected for experimental studies. Chose 8 cadavers randomly and ligate the sural medial vessel （4 cases） or sural lateral vessel （4 cases） of one limb, leaving the contralateral limb un-ligated as control. Angiography was performed to observe the blood supply of the gastrocnemius muscle after the ligation of the sural medial vessel or sural lateral vessel. For the remaining 2 cadavers, the ori-gin, diameter, and location of the communicating branch of the gastrocnemius muscle were observed by macroscopic anatomy and vascular cast. The data of 19 patients with large tissue defect of calf from October 2006 to September 2013 were analyzed retro-spectively for clinical research. There were 11 males and 8 females aged from 10-40 years （mean, 32 years）. 12 patients took sural medial blood vessels as recipient vessels, and 7 patients took sural lateral blood vessels. 6 patients were grafted with free chest na-vel flaps, 8 with anterolateral thigh flap, 2 with lateral thoracic flap, and 3 with latissimus dorsi flap. The areas of wound surface were ranging from 5 cm×10 cm-8 cm×37 cm. The areas of the flap dissected were ranging from 7 cm×10 cm-10 cm×30 cm. Re-sults The study found that the blood supply of gastrocnemius muscle of the calf was multifocal, and was mainly by sural artery. When the blood supply of sural artery was cut off from one side, the gastrocnemius muscle could be supplied by the communicat-ing branches between medial and lateral head of gastrocnemius muscle and the communicating branches of soleus muscle. The communicating branches were at constant anatomical locations, with larger diameter and rich branches. All the 19 cases of free skin flip transplantation were survived. Healing time of wound was ranging from 13-29 d, among which 11 cases were primary healing, and 8 were secondary healing. The follow-up duration was ranging from 12-24 months. The flaps could endure friction of certain degree. No sensory dysfunction was reported. For the cases that split thick skin graft or split-thickness thin skin flap taken from abdomen or huckle were autografted to cover the donor site, primary healing was all gained. Conclusion The sural blood vessels are deeply located in the gastrocnemius muscle at constant anatomical locations, with a long pedicle and a large diameter, and are easy to be dissected, thus they are suited for anastomosis. Sural vessel combined with free skin flip provides a new treat-ment option for the repair of large tissue defect of calf. Key words: Blood vessels Surgical flaps Transplantation; autologous Leg

The microvascular anatomy of superior and inferior gluteal artery perforator (SGAP and IGAP) flaps: a fresh cadaveric study and clinical implications.

Our study aimed to highlight anatomical similarities, differences, and variations in the microvascular anatomy between superior and inferior gluteal artery perforator (SGAP and IGAP) flaps. Thirty gluteal flaps (15 SGAP and 15 IGAP) were studied on 22 adult fresh cadavers. We recorded the number and location of perforators, the characteristics of the main perforator (course, length, and diameter at the level of division at the greater sciatic foramen), and the anatomical variations of the submuscular venous plexus. The mean number of perforators was similar in both flaps (n = 7). We found a statistically significant difference in the total length of the vascular pedicle between SGAP (mean = 9.80 cm) and IGAP (mean = 13.36 cm) flaps, which correlated strongly with the difference in the intramuscular length (mean difference = 3.40 cm) of the perforator. There was no statistically significant difference in the diameter of the superior and inferior gluteal vessels at the point of pedicle division. The complex submuscular venous plexus, which is typically found on SGAP flaps deep to the sacral fascia, was never encountered on IGAP flaps. Perforators originating from the inferior gluteal artery were found on the lower half of five superior gluteal flaps. These were dominant perforators in two cases. We also report a rare anatomical communication between superior and inferior gluteal vessels deep to the piriformis muscle and a case of atheromatous disease of the inferior gluteal artery. Our findings are highly relevant to clinical practice and contribute to the understanding of the vascular anatomy of SGAP and IGAP flaps and the successful use of these challenging flaps. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Biomechanical study of the funnel technique applied in thoracic pedicle screw replacement.

Funnel technique is a method used for the insertion of screw into thoracic pedicle. To evaluate the biomechanical characteristics of thoracic pedicle screw placement using the Funnel technique, trying to provide biomechanical basis for clinical application of this technology. 14 functional spinal units (T6 to T10) were selected from thoracic spine specimens of 14 fresh adult cadavers, and randomly divided into two groups, including Funnel technique group (n = 7) and Magerl technique group (n = 7). The displacement-stiffness and pull-out strength in all kinds of position were tested and compared. Two fixed groups were significantly higher than that of the intact state (P < 0.05) in the spinal central axial direction, compression, anterior flexion, posterior bending, lateral bending, axial torsion, but there were no significant differences between two fixed groups (P > 0.05). The mean pull-out strength in Funnel technique group (789.09 ± 27.33) was lower than that in Magerl technique group (P < 0.05). The Funnel technique for the insertion point of posterior bone is a safe and accurate technique for pedicle screw placement. It exhibited no effects on the stiffness of spinal column, but decreased the pull-out strength of pedicle screw. Therefore, the funnel technique in the thoracic spine affords an alternative for the standard screw placement.

Comparative Morphometric Analysis of 5 Interpositional Arterial Autograft Options for Adult Living Donor Liver Transplantation

In living donor liver transplantation, the right-sided graft presents thin and short vessels, bringing forward a more difficult anastomosis. In these cases, an interpositional arterial autograft can be used to favor the performance of the arterial anastomosis, making the procedure easier and avoiding surgical complications. ObjectiveWe compared the inferior mesenteric artery (IMA), the splenic artery (SA), the inferior epigastric artery (IEA), the descending branch of the lateral circumflex femoral artery (LCFA), and the proper hepatic artery (PHA) as options for interpositional autograft in living donor liver transplantation. MethodSegments of at least 3 cm of all 5 arteries were harvested from 16 fresh adult cadavers from both genders through standardized dissection. The analyzed measures were proximal and distal diameter and length. The proximal diameter of the RHA and the distal diameter of the SA, IMA, IEA and the LCFA were compared to the distal diameter of the RHA. The proximal and distal diameters of the SA, IEA and LCFA were compared to study caliber gain of each artery. ResultsAll arteries except the IMA showed statistical significant difference in relation to the RHA in terms of diameter. Regarding caliber gain, the arteries demonstrated statistical significant difference. All the harvested arteries except PHA were 3 cm in length. ConclusionThe IMA demonstrated the best compatibility with the RHA in terms of diameter and showed sufficient length to be employed as interpositional graft. The PHA, the SA, the IEA and the LCFA presented statistically significant different diameters when compared to the RHA. Among these vessels, only the PHA did not show sufficient mean length.

The selective odontoidectomy: endoscopic endonasal approach to the craniocervical junction.

The resection of the odontoid process via an extended endoscopic endonasal approach has been recently proposed as an alternative to the microscopic transoral method. We aimed to delineate a minimally invasive endoscopic transnasal odontoidectomy and to describe the endoscopic anatomy of the anterior craniovertebral junction (CVJ). The anterior CVJ of 14 fresh adult cadavers were selectively accessed via a binostril endoscopic endonasal approach using 0- and 30-degree endoscopes. The nasopharynx was widely exposed without removing any of the turbinates and without performing a sphenoidotomy. Occipital condyles and lateral masses of the C1 vertebra have been exposed inferiorly at lateral margins of the exposure, in addition to the foramen lacerum, which came into view at the superolateral corner of the operative field. The anterior arch of C1 and the upper 1.5 cm of the odontoid process of C2 have been removed via a minimally invasive endoscopic transnasal approach in all dissections. We propose the selective odontoidectomy as a minimally invasive method for the endoscopic endonasal removal of the odontoid process. By using this approach, turbinates and the sphenoid sinus remain unharmed. In addition, this approach may be used in exposing pathologies situated laterally at the anterior CVJ, such as the lateral masses of atlas and occipital condyles.

Superficial Femoral Artery Perforator Flap

The medial thigh has been infrequently studied as a donor site for pedicled or free flaps. In their previous studies, the authors observed a direct cutaneous branch from the superficial femoral artery. This study aimed to investigate the anatomy and potential possibility for flap elevation (the midmedial thigh flap) on this direct branch of the superficial femoral vessels. Circumferential adipocutaneous thigh flaps were harvested from 14 fresh adult cadaver legs. The direct cutaneous branch from the superficial femoral vessels was located between the sartorius and gracilis muscles. Pedicle location, diameter, and length and position of the great saphenous vein and saphenous nerve were recorded. A flap based on this vessel was designed. Height, width, and surface of the skin paddle were recorded. Three-dimensional computed tomographic angiography was used to analyze the area of cutaneous territory supplied by the studied perforator. The pedicle was located at an average distance of 22.79 ± 1.55 cm below the pubic tubercle on the medial axis of the thigh, and it was found in 100 percent of dissections. It was always located between the sartorius and gracilis muscles, with a mean diameter of 2.82 ± 0.69 mm and mean length of 4.79 ± 0.52 cm. The average area of skin perfused was 182.24 cm, located preferentially distal and posterior to the perforator pedicle. Two clinical cases illustrate the feasibility of the midmedial thigh perforator flap. The superficial femoral artery perforator flap appears to be reliable and has a constant vascular anatomy. Donor-site morbidity is low, resulting in only a vertical scar on the medial thigh. Therapeutic, V.

Collagen fibers in the rectus abdominis muscle of cadavers of different age

To assess collagen content and types in the rectus abdominis muscle of cadavers of different ages. Forty fresh adult male cadavers within 24 h of death were obtained from an Institute of Legal Medicine and divided by age at death into Group 1 (mean age, 23.3 years; range, 18-30 years; n = 20) and Group 2 (mean age, 46.2 years; range, 31-60 years; n = 20). From each cadaver, samples of the rectus abdominis muscle measuring 1 cm(2) were collected 3 cm superiorly and 2 cm inferiorly to the umbilicus. Histological sections were prepared and stained with picrosirius red and Masson's trichrome stain for visualization of total collagen fibers, and immunohistochemical analysis was performed to distinguish types I, II, III, IV and V collagen. No significant differences in total collagen were found between groups by Masson's trichrome staining. However, picrosirius red staining revealed a significantly greater amount and higher concentration of total collagen and types I and III collagen in Group 1 than in Group 2 (P < 0.05). All but type II collagen were detected by immunohistochemistry in both groups. No significant difference in type IV collagen was found between groups. Type V collagen was detected by immunohistochemistry in both groups, but quantification was not possible due to background staining. The amounts of types I and III collagen in the rectus abdominis muscle were significantly smaller in older subjects.

Effect of machined interfacet allograft spacers on cervical foraminal height and area

Iatrogenic foraminal stenosis is a well-known complication in cervical spine surgery. Machined interfacet allograft spacers can provide a large surface area, which ensures solid support, and could potentially increase foraminal space. The authors tested the hypothesis that machined interfacet allograft spacers increase cervical foraminal height and area. The C4-5, C5-6, and C6-7 facets of 4 fresh adult cadavers were exposed, and the cartilage was removed from each facet using customized rasps. Machined allograft spacers were tamped into the joints. The spines were scanned with the O-arm surgical imaging system before and after placement of the spacers. Two individuals independently measured foraminal height and area on obliquely angled sagittal images. Foraminal height and area were significantly greater following placement of the machined interfacet spacers at all levels. The Pearson correlation between the 2 radiographic reviewers was very strong (r = 0.971, p = 0.0001), as was the intraclass correlation coefficient (ICC = 0.907, p = 0.0001). The average increase in foraminal height was 1.38 mm. The average increase in foraminal area was 18.4% (0.097 cm(2)) [corrected]. Modest distraction of the facets using machined interfacet allograft spacers can increase foraminal height and area and therefore indirectly decompress the exiting nerve roots. This technique can be useful in treating primary foraminal stenosis and also for preventing iatrogenic foraminal stenosis that may occur when the initially nonlordotic spine is placed into lordosis either with repositioning after central canal decompression or with correction using instrumentation. These grafts may be a useful adjunct to the surgical treatment of cervical spine disease.

Cadaveric study of the endoscopic endonasal transtubercular approach to the anterior communicating artery complex

The endoscopic transnasal approach to the anterior communicating artery (ACoA) complex is not widely performed. This cadaveric study investigated the surgical relevance of the anterior endoscopic approach to the treatment of ACoA aneurysms. Bi-nasal endoscopic transtubercular surgery was carried out on fresh adult cadavers. Primary outcomes measures incorporated dimensions of the endonasal corridor (operative field depth, lateral limits, size of the transplanum craniotomy and dural opening); vascular exposure (proximal and distal anterior cerebral arteries [ACA], ACoA, clinoidal internal carotid artery [ICA] segment); and operative manoeuvrability defined by clip placements (ipsilateral and contralateral). Eight cadaver heads were used (mean age 84±7years, range 76–94years, 75% female). Mean operative depth was 97±4mm. The lateral corridors were limited proximally by the alar rim openings (31±2mm), and distally by the optic nerves (22±6mm). The endonasal craniotomy dimensions were 21±5mm anteroposteriorly, and 22±4mm laterally. Vascular exposure was achieved in 100% of subjects for the ACoA segment and the ACA segments proximal to the ACoA (A1). The ACA segments distal to the ACoA (A2) were accessible only in 40% of subjects. Endonasal clip placement across the ACoA segment, clinoidal ICA, A1 and A2 were 100%, 90%, 90%, and 30%, respectively. The ventral endoscopic endonasal approach to the ACoA complex provides excellent vascular visualisation without brain retraction or gyrus rectus resection. However, the limitation in access to the A2 for temporary clip placement may prove to be a significant limitation of this approach.

Impact and Role of Subdermal Plexus in DIEP Flap Perfusion

INTRODUCTION: Single stage procedures in breast reconstruction following skin sparing or nipple sparing mastectomy with free DIEP flap usually do not require a large skin paddle. The majority of the flap is thus de-epithelialized and placed under the native conserved skin. We hypothesized that the conservation of an intact dermis and it subdermal plexus plays a critical role in the overall flap perfusion, through the recruitment of indirect linking vessels. The goal of the study was to investigate and compare the vascularity of DIEP flaps harvested with intact dermis versus de-epithelialized DIEP flaps. METHODS: Twelve hemi-DIEP flaps were harvested on six fresh adult cadavers acquired through the Department of Anatomy at Mayo Clinic, Rochester MN. After flap dissection, the perforator was canulated using a 24-gauge butterfly catheter (0.7-mm diameter) (BD Insyte; Becton Dickinson S.A., Madrid, Spain). The flaps were de-epithelialized using face-lift scissors (ASSI Face Lift Supercut scissors; New York, NY). 10 flaps were flushed with warm heparinized saline. The flaps were then scanned through a 64-slices CT-Scanner (Siemens) after injection of 5cc of contrast agent (Omnipaque 180). The contrast agent was flushed out with heparinized saline and the dermis was removed from the flap with the same face-lift scissors. The flaps were then rescanned after injection of 5cc of contrast agent (Omnipaque 180). The second phase consisted in scanning the flaps through a micro-CT scanner, with a resolution allowing the visualization of subdermal plexus. 1 flap was injected with 15cc of Microfil ((Flow Tech Inc., Carver, MA), stored at 4°C during 48 hours and subsequently scanned with a micro computed tomography (micro-CT) scanner, which generates three-dimensional (3-D) images. 1 flap was processed in the same way after the dermis was removed. The three-dimensional reconstructions were then compared. RESULTS: CT-Scanner injections studies showed a significant decrease in flap perfusion after removal of the dermis. Micro-CT Scanner images showed the importance of the subdermal plexuses CONCLUSION: The dermis plays a significant role in enhancing the overall DIEP flap perfusion through the preservation of indirect linking vessels. Preservation of the DIEP flap dermis and its subdermal plexus should be considered after skin sparing mastectomy and nipple sparing mastectomy in order to potentially decrease the partial flap necrosis and flap ischemia.

Improving tension decrease in components separation technique

The purpose of this study is to evaluate the tension at the aponeurotic edges after the undermining of the anterior rectus sheath associated with the classic components separation in cadavers. Twenty fresh adult cadavers were placed supine and an incision in the anterior rectus sheath was done, thus exposing the posterior sheath. The two levels to be studied were marked 3 cm above and 2 cm below the umbilicus. An analogical dynamometer was used to measure the traction values, consecutively during four stages as follows: initial stage, no aponeurotic undermining; Stage 1, separation of the anterior rectus sheaths; Stage 2, after Stage 1 the external oblique aponeurosis were incised along the semilunaris and the external oblique muscles were undermined; Stage 3, after Stage 2 rectus muscles were completely separated from their posterior sheaths. Statistical analysis was done by Friedman's analysis of variance (p < 0.05). There was a progressive and significant decrease in tension along the stages (Friedman's analysis of variance, p < 0.001). Traction indexes were higher in the initial stage and became gradually lower along the other stages. The undermining of the anterior rectus sheaths helps to decrease tension during the components separation technique. Level V, experimental study.

Anatomy of the depressor septi nasi muscle: The basis for correction of deformities of the nose/lip junction

The purpose of this study was to analyse the macroscopic aspect of the depressor septi nasi muscle in cadavers according to its relations with the nasolabial region, and to describe a surgical technique developed out of the knowledge gained from its study to take care of nasal tip drooping and gummy smile. Twenty fresh adult cadavers were studied. All of them were men. A transverse incision was done at the gingivo-labial sulcus, through the frenulum, to expose the orbicularis oris and the depressor nasi muscles. These muscles were isolated and their anatomical aspect, localisation, origin, and insertion were registered. Sixteen of the cadavers presented the muscle. From these, 14 were bilateral and two were unilateral. Four cadavers did not present the muscle. Muscular fibres were vertically disposed and presented oblique direction towards the midline, in a quadrangular shape. From the 16 cadavers of the subgroup in whom the muscle was present, 14 originated in the orbicularis oris and its insertion was in the maxilla. Two of the cadavers presented the origin and insertion at the maxilla. According to these findings, a surgical approach of the muscles was proposed to treat the gummy smile deformity during rhinoplasty and two clinical cases are presented. The depressor nasi muscles presented an anatomical variation. In most cases it is intimately related with the orbicularis oris and the maxilla, being a relatively thick structure. We suggest its treatment simultaneously during rhinoplasty for a better result of the nasal tip and it benefits the “tense nose” aspect and the smiling deformity.

Perforating Frontal Branch of the Superficial Temporal Artery as Related to Subcutaneous Forehead Lift

The aim of this study was to elucidate the precise anatomy of the perforating branch of the superficial temporal artery in relation to subcutaneous forehead lift (SFL).Ten hemifaces of 6 fresh adult Korean cadavers were used in this study. In 4 hemifaces, following injection of red latex, dissection was performed. In 2 hemifaces, following injection of methylene blue solution into the perforator, the area of discoloration was observed. An artery perforating the frontalis muscle into skin of the forehead was identified in 18 foreheads of 9 patients who underwent SFL. Measurements were taken of the external diameter and the location of the perforator.Perforating branches originating from the frontal branch of the superficial temporal artery, perforating the frontalis muscle into skin of the forehead, were observed in all 10 of the dissected hemifaces. Thereafter, it was referred to as the perforating frontal artery (PFA). Skin of the ipsilateral mid-forehead was discolored by methylene blue solution. Most of the PFA (83%) was included in a circle having a radius of 8.9 mm. The center of the circle was located 40.5 mm from the midline on the x axis and 53.6 mm from the supraorbital rim (on the y axis). The center of the circle was located at 89.8% of the length of the midline to the lateral canthus (x axis) and 79.1% of the length of the supraorbital rim to the hairline (y axis).Plastic surgeons can use the PFA in order to achieve sufficient circulation of the skin flap. When surgeons are required to sacrifice the PFA in order to achieve flap mobilization, they can safely cauterize the PFA after isolation without causing accidental burn injury to the skin flap. In addition, the PFA might be useful in creation of local or distant flaps for reconstruction of the forehead or scalp.

Do Upper and Lower Orbital Fat Have a Connection?

This study, using cadavers, was conducted to determine whether there is a true connection between upper and lower orbital fat. A total of 39 orbits of 20 fresh Korean adult cadavers were used. Colored gelatin was injected into the upper or lower peripheral fat (preaponeurotic fat) of each orbit. One week after injection, dissection was continued and connection of the upper and lower orbital fat was examined. No migration of gelatin injected into the upper or to the central fat (intermuscular cone fat) was observed. However, migration of gelatin injected into the upper or lower preaponeurotic fat into the entire episcleral space through the adipose orifice (AO) was observed. The 3 sides of the upper AO consisted of the superior oblique muscle before the trochlea, superior oblique tendon after the trochlea, and sclera. The 3 sides of the lower AO consisted of the inferior oblique muscle, lateral rectus muscle, and fascia between the inferior rectus muscle and lateral rectus muscle. The upper AO was located at the medial one third of the orbital width and superior one fifth of the orbital height. The lower AO was located at the lateral one third of the orbital width and inferior one fifth of the orbital height. The shape of the upper AO was a triangle with a base of 4.3 ± 2.0 mm and a height of 2.3 ± 1.2 mm. The shape of the lower AO was a triangle with a base of 4.5 ± 1.8 mm and a height of 2.7 ± 1.1 mm. We think that surgical obliteration of the AO might prevent migration of preaponeurotic fats. Prevention of migration of preaponeurotic fats will aid in avoidance of baggy lower eyelid or deepening of the supratarsal fold.

Stress and strain analysis on the anastomosis site sutured with either epineurial or perineurial sutures after simulation of sciatic nerve injury.

The magnitude of tensile stress and tensile strain at an anastomosis site under physiological stress is an important factor for the success of anastomosis following suturing in peripheral nerve injury treatment. Sciatic nerves from fresh adult cadavers were used to create models of sciatic nerve injury. The denervated specimens underwent epineurial and perineurial suturing. The elastic modulus (40.96 ± 2.59 MPa) and Poisson ratio (0.37 ± 0.02) of the normal sciatic nerve were measured by strain electrical measurement. A resistance strain gauge was pasted on the front, back, left, and right of the edge of the anastomosis site after suturing. Strain electrical measurement results showed that the stress and strain values of the sciatic nerve following perineurial suturing were lower than those following epineurial suturing. Scanning electron microscopy revealed that the sciatic nerve fibers were disordered following epineurial compared with perineurial suturing. These results indicate that the effect of perineurial suturing in sciatic nerve injury repair is better than that of epineurial suturing.

Biomechanical analysis of the impact of fibular osteotomies at tibiotalar joint: A cadaveric study

Background:Osteotomy of the fibula is a common orthopedic procedure performed for various indications, including harvesting fibula for grafting purposes. The effect of fibular osteotomy and need for tibiofibular syndesmotic fixation fusion at different levels on tibiotalar joint is matter of debate. We performed a biomechanical analysis of the impact of fibular osteotomies at different levels and whether the fixation of distal tibiofibular joint mitigates instability caused by the osteotomy.Materials and Methods:Six lower limb specimens from fresh adult cadavers were used to prepare leg-foot models. The specimens were assigned to six status according to the level of osteotomy and whether fixation of distal tibiofibular joint was performed or not. Each specimen was then loaded axially to 700 N by the material testing machine, and the tibiotalar joint contact area and peak pressure were measured using an electronic pressure sensor.Results:The contact area and the pressure of tibiotalar joint showed significant changes when compared to the normal specimen. All osteotomy specimens had a decreased tibiotalar contact area and an increased peak pressure. This positively correlated with proximity of level of osteotomy to the lateral malleolus.Conclusions:Through this study, we found that fibular osteotomy had an adverse effect in terms of decreasing the contact surface of tibiotalar joint that led to increased peak pressure in the joint. However, bone fusion and screw fixation of the distal tibiofibular joint reduced these adverse effects.

Anatomy of the petrous apex as related to the endoscopic endonasal approach

The endoscopic endonasal approach (EEA) has been reported to be an efficient approach for treating lesions of the petrous apex. However, there have been only limited anatomic studies for the EEA. Furthermore, most of the relevant distances for EEA cannot be measured easily on a cadaveric skull. Two fresh adult cadaver heads and five formalin-fixed adult cadaver heads were dissected using the EEA to identify groups of landmarks for safe guidance during this approach. The distances between these landmarks were then measured by CT angiography by using three-dimensional software. The EEA to the petrous apex can be divided into five phases. In each phase, a group of landmarks, rather than a single landmark, can be identified easily for guiding the next phase of the approach. There was no significant difference between males and females in any of the distances reported in the present study. The EEA can be performed to manage a petrous apex lesion more safely by referring to multiple landmarks and the distances between them.

Perforator arteries of the medial upper arm: anatomical basis of a new flap donor site

The development of perforator flaps' concept based on knowledge on vascular anatomy of the skin represents a major improvement in reconstructive surgery. Succeeding description about vascular territories and anatomical basics of the main donor sites, the study of hidden donor sites, such as medial upper arm, constitutes a new step and an additional refinement. 20 upper limbs of 10 fresh adult cadavers were studied with colored latex injections. The origin and distribution of the perforator arteries of the superior ulnar collateral artery and the brachial artery were investigated. We have noted constant perforator arteries and described the limits of vascular territories of the medial upper arm.

Anatomy of the lateral perforator flap supplied by posterior intercostal artery and its clinical application

Objective To provide the applied anatomy of the posterior intercostal artery perforator flap and the clinical results of repairing the soft tissue defects with lateral perforator flap. Methods Six fresh adult cadavers were injected with a lead oxide-gelatin mixture for three-dimensional visualization reconstruction using a 64-slice spiral computed tomography scanner and specialized software (Materiaise's interactive medical image control system,MIMICS).The origin,course,diameter,and distribution of the the 6-10th posterior intercostal artery perforators in the thoroax region were observed and measured.Clinically,nine cases were treated with the lateral perforator flap supplied by 7-10th posterior intercostal artery transplantation for repairing wounds in upper limbs.The flap size was 9 cm × 7 cm-16 cm × 12 cm. Results The 6-10th posterior intercostal artery perforator (outer diameter 1.70 ± 0.14 mm) were from the artery in the chest region, which pierce in deep fascia near midaxillary line. The average pedicle length from the deep fascia was (87.56 ± 6.48) mm.All of 9 cases were repaired successfully,the clinical results were satisfactory.Conclusion The posterior intercostal artery perforator flap can be used to form many kinds of axial skin flaps,it is a good option for repairing soft-tissue defect. Key words: Posterior intercostal artery; Perforator; Perfora flap; Applied anatomy; Microsurgery

The body as a living bioreactor: a feasibility study of pedicle flaps for tracheal transplantation

Reconstruction of long-segment tracheal stenosis remains problematic. Ex vivo transplantation of stem cell-derived tracheas has been established in humans using external tissue bioreactors. These bioreactors, however, are not widely accessible. Thus, we are developing a rotational flap-based "internal bioreactor" to allow in vivo stem cell engraftment in a pre-vascularized recipient bed. This muscle will also then serve as a carrier for the transplanted trachea during rotation into position for airway reconstruction. Herein, we present a study investigating the feasibility of two pedicle muscle flaps for implantation and subsequent tracheal transplantation. Trapezius and latissimus flaps were raised using established surgical techniques. The length and width of each flap, along with the distance from the pedicle takeoff to the trachea, were measured. The overall ability of the flaps to reach the trachea was assessed. Twelve flaps were raised in 5 fresh adult human cadavers. For the trapezius flap, averages were: flap length of 16.4 cm, flap width of 5.95 cm at the tip, and distance from the pedicle takeoff to the trachea of 11.1 cm. For the latissimus dorsi flap, averages were: flap length of 35.4 cm, flap width of 7.25 cm at the tip, and distance from the pedicle takeoff to the trachea of 27.3 cm. All flaps showed sufficient durability and rotational ability. Our results show that both trapezius and latissimus dorsi flaps can be transposed into the neck to allow tension-free closure of tracheal defects. For cervical tracheal transplantation, both flaps are equally adequate. We believe that trapezius and latissimus dorsi muscle flaps are potential tracheal implantation beds in terms of vascular supply, durability, and rotational ability.