India Ink Injection Research Articles

Anatomic feasibility study of a sartorius myocutaneous flap with a distally based pedicle and proximal skin paddle

IntroductionWe conducted an anatomic feasibility study of a sartorius myocutaneous flap with a distally based pedicle and proximal skin paddle to cover soft tissue defects of the knee region. HypothesisA recent anatomic study by Mojalla showed that the sartorius muscle had 2 distinct pedicles, making it possible to isolate this muscle on its distal pedicle and harvest it with a skin paddle. Materials and methodsThis anatomic study was conducted on 10 lower limbs. The 2 criteria assessed were (1) the viability of our proximal skin paddle and (2) the arc of rotation and coverage obtained with this myocutaneous flap. ResultsWe identified 7 proximal skin paddles after the injection of India ink into the distal pedicle of the sartorius muscle. In all cases, the arc of rotation of the flap allowed coverage of the knee region. The mean distance between the inferior edge of the skin paddle and the proximal border of the patella (DBAP) was measured at 13cm, and the mean distance between the superior edge of the flap paddle and the anterior superior iliac spine (DASIS) at 16cm. The average skin paddle size was 14 by 7cm. DiscussionOur anatomic study demonstrated the feasibility of our sartorius flap with a distally based pedicle and proximal skin paddle. This technique may be a viable alternative when using gastrocnemius flaps is not feasible, or the surgeon lacks the microsurgical skills to perform free flaps. Level of evidenceIV; descriptive anatomic study.

India Ink Tattooing of Ureteroenteric Anastomoses

While upper tract access through the insensate conduit following urinary diversion takes less time and incurs fewer costs than percutaneous kidney access does for the treatment of ureter and kidney pathology, endoscopic ureteroenteric anastomoses (UEA) identification can be difficult. We injected India Ink into the bowel mucosa near the UEA during ileal conduit diversion (IC) to determine the safety and feasibility of ink tattooing. Patients undergoing IC were prospectively randomized to receive ink or normal saline (NS) injections. The injections were placed 1 cm from UEA in a triangular configuration, and loopogram exams and looposcopy were performed to identify reflux (UR), UEA, the tattooing site and strictures in 10 and 11 patients randomized with respect to ink and NS injections, respectively. Ink patients were older (72 vs. 61 years old, p = 0.04) and had a higher Charlson Comorbidity Index (5 vs. 2, p = 0.01). Looposcopy was performed in three ink and four NS patients. Visualization of UEA was achieved in 100% of the ink and 75% of the NS patients (p = 0.26). The ink ureteroenteric anastomotic stricture (UEAS) rate was higher (N = 3 vs. N = 1) and six patients vs. one patients underwent surgery, respectively, for UEAS (p = 0.31). The study was halted early due to safety concerns. Our pilot study demonstrates that ink can be well visualized following injection near UEA during IC. However, the ink cohort had more UEAS than previously cited in the literature and our prior institutional UEAS rate of 6%. While this study sample is small, the higher incidence of UEAS after ink injection led us to question the utility and safety of ink injection following IC.

Carbon black-containing self-healing adhesive hydrogels for endoscopic tattooing

Endoscopic tattooing with India ink is a popular method for identifying colonic lesions during minimally invasive surgery because it is highly challenging to localize lesions during laparoscopy. However, there is a perceived unmet need for the injection of India ink and carbon particle suspension due to various complications and inconstant durability during the perioperative period. In this study, carbon black-containing self-healing adhesive alginate/polyvinyl alcohol composite hydrogels were synthesized as endoscopic tattooing inks. Alginate (Alg) conjugated with phenylboronic acid (PBA) groups in the backbone was crosslinked with polyvinyl alcohol (PVA) because of the dynamic bonds between the phenylboronic acid in alginate and the cis-diol groups of PVA. The carbon black-incorporated Alg-PBA/PVA hydrogels exhibited self-healing and re-shapable properties, indicating that improved intraoperative localization could be achieved. In addition, the adhesive tattooing hydrogels were stably immobilized on the target regions in the intraperitoneal spaces. These carbon black-containing self-healing adhesive hydrogels are expected to be useful in various surgical procedures, including endoscopic tattooing.

Long-Term Fluorescent Tissue Marking Using Tissue-Adhesive Porphyrin with Polycations Consisting of Quaternary Ammonium Salt Groups.

Localization of tumors during laparoscopic surgery is generally performed by locally injecting India ink into the submucosal layer of the gastrointestinal tract using endoscopy. However, the location of the tumor is obscured because of the black-stained surgical field and the blurring caused by India ink. To solve this problem, in this study, we developed a tissue-adhesive porphyrin with polycations consisting of quaternary ammonium salt groups. To evaluate the ability of tissue-adhesive porphyrin in vivo, low-molecular-weight hematoporphyrin and tissue-adhesive porphyrin were injected into the anterior wall of the exposed stomach in rats. Local injection of low-molecular-weight hematoporphyrin into the anterior wall of the stomach was not visible even after 1 day because of its rapid diffusion. In contrast, the red fluorescence of the tissue-adhesive porphyrin was visible even after 7 days due to the electrostatic interactions between the positively-charged moieties of the polycation in the tissue-adhesive porphyrin and the negatively-charged molecules in the tissue. In addition, intraperitoneal injection of tissue-adhesive porphyrin in rats did not cause adverse effects such as weight loss, hepatic or renal dysfunction, or organ adhesion in the abdominal cavity. These results indicate that tissue-adhesive porphyrin is a promising fluorescent tissue-marking agent.

Fascial Organisation and Lymphatic Systems Around the Pelvic Floor: A Literature Review.

This review summarises the anatomy and lymphatic systems around the pelvic floor. We investigated the lymphovascular network in the anorectal region, focusing on the hiatal ligament, which comprises smooth muscle fibres derived from the longitudinal muscle and connecting the anal canal and coccyx, and the endopelvic fascia, which seems to comprise collagen and elastic fibres. During rectal surgery, endopelvic fascia is recognized as a sheet of fascia covering the levator ani muscle. Endopelvic fascia is extensively attached to the smooth muscle fibres diverging from the longitudinal muscle of the rectum. Analysis of the lymphovascular network using submucosal India ink injection and indocyanine green fluorescence imaging suggests a functional lymphatic flow between rectal muscle fibres and hiatal ligament and endopelvic fascia. Precise analysis of the lymphatic systems of fascial organization around the pelvic floor may be useful in formulating therapeutic strategies for low rectal cancer.

MP53-09 INDIA INK TATTOOING OF URETEROENTERIC ANASTOMOSES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II (MP53)1 Sep 2021MP53-09 INDIA INK TATTOOING OF URETEROENTERIC ANASTOMOSES Mei Tuong, and Tracey Krupski Mei TuongMei Tuong More articles by this author , and Tracey KrupskiTracey Krupski More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002083.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Upper tract access is necessary to treat diseases in the ureter or kidney after urinary diversion. Access through the insensate conduit is more cost-effective versus percutaneous kidney access. However, endoscopic ureteroenteric anastomoses (UEA) identification can be difficult. We injected India Ink (ink) into bowel mucosa near UEA during ileal conduit diversion (IC) to determine the safety and feasibility of ink tattooing and ability to facilitate retrograde upper tract access. METHODS: After IRB approval, patients undergoing IC were prospectively randomized to receive ink or normal saline (NS) injections, a control group to assess safety of ink. Injections were placed 1 cm from UEA in a triangular configuration with a 19-gauge needle. Follow-up minimized cost and radiation exposure to assess patency and location of UEA. 1-month loopogram assessed for ureteral reflux (UR). If there was any absent UR, looposcopy was performed to assess for occult UEA stricture (UEAS). Ability to visualize UEA and/or ink tattooing was recorded at time of looposcopy. RESULTS: 42 renal units (21 patients) undergoing IC were randomized to ink (20 renal units) or NS (22 renal units). Overall median age was 65 (IQR 60, 73) years with ink patients being older (72 vs 61 years old, p=0.04). Ink patients also had a higher Charlson Comorbidity Index (5 vs 2, p=0.01). Loopogram and looposcopy protocol data are shown in Figure 1. 20 renal units had no UR on loopogram (12/16 ink vs 8/20 NS). Of patients who returned for looposcopy, 14 non-UR renal units were assessed (6/12 ink vs 8/8 NS). Visualization of UEA was achieved in 6 (100%) and 4 (50%) in ink versus NS patients, respectively (p=0.26). Follow up of the cohort revealed a higher than expected UEAS rate in the ink group (N=3, 30%) compared to NS (N=1, 9%). The ink vs NS cohorts underwent 6 vs 1 surgeries respectively for UEAS (p=0.28). 2 ink and 1 NS patients were managed with either endoscopic dilation, percutaneous nephrostomy tube, or ureteral stent. 1 ink patient required open reimplantation of UEA. CONCLUSIONS: Our pilot study demonstrates ink is well-visualized following injection near UEA during IC. However, the ink cohort had more UEAS than our prior rates of UEAS (6%) and in the literature. While this study sample is small, the higher development of UEAS after ink leads to question the utility and safety of ink injection following IC. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e942-e942 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mei Tuong More articles by this author Tracey Krupski More articles by this author Expand All Advertisement Loading ...

Widespread anorectal lymphovascular networks and tissue drainage: analyses from submucosal India ink injection and indocyanine green fluorescence imaging.

AimAbdominoperineal resection is associated with poor prognosis in patients with advanced lower rectal cancer. This study aimed to analyse the functional lymphovascular network and tissue drainage in the anorectal region.MethodsIn this descriptive study, we performed microanatomical evaluations and intra‐operative imaging analysis in a cadaver and patients with rectal cancer. Specimens with India ink injection were collected from a cadaver and from six patients who underwent abdominoperineal resection. Intra‐operative indocyanine green fluorescence imaging was performed on four patients who underwent surgery for lower rectal cancer. India ink was injected into the submucosa at the dentate line of specimens. Tissue sections were examined by immunohistochemistry for D2‐40 and CD31. Intra‐operative indocyanine green was injected into the submucosa at the dentate line. Lymph flow was traced using a near‐infrared camera system.ResultsFascia branching from the rectal longitudinal muscle layer extended to the posterior hiatal ligament and lateral endopelvic fascia connective tissue lamina on the surface of the levator ani muscle. The fascia contained veins labelled with ink in their lumina and initial lymphatics. Intra‐operative indocyanine green fluorescence imaging revealed extensive lymph flow from the muscle layer of the anal canal to the hiatal ligament and endopelvic fascia along the longitudinal muscle layer fibres.ConclusionsThe anorectal region contained widespread venous and lymphatic networks in proportion to its specific connective tissue framework around the longitudinal‐muscle‐layer‐extending muscle bundles, which provides extensive networks for tissue fluid and cells.

A new heterotropic vascularized model of total urinary bladder transplantation in a rat model

This study developed a new procedure of urinary bladder transplantation on a rat model (n = 40). Heterotopic urinary bladder transplantation (n = 10) in the right groin vessels was performed. Direct urinary bladder examination, microangiography, histological analysis, and India ink injection were performed to evaluate the proposed method's functionality. Observation time was four weeks. One week after the procedure, the graft survival rate was 80%, two urinary bladders were lost due to anastomosis failure. The rest of the grafts survived two weeks without any complications. Lack of transitional epithelium or smooth muscle layer loss and lack of inflammatory process development were observed. This study was performed in order to obtain the necessary knowledge about urinary bladder transplantation. The proposed technique offers a new approach to the existing orthotropic models.

Abstract 12540: Neural Crest Cell-derived Wnt5a Regulates Planar Cell Polarity in Cranial Second Heart Field Progenitor Cells

Introduction: Wnt5a is a known regulator of planar cell polarity (PCP) signaling in second heart field (SHF) progenitor cells. It is generally believed that Wnt5a ligands are secreted by the SHF; however, SHF-specific conditional deletion of Wnt5a does not recapitulate outflow tract (OFT) defects observed in global Wnt5a mutants. Hypothesis: Given the proximity and interaction between neural crest cells (NCC) and cranial SHF that contributes to the developing OFT, we hypothesize that NCC may serve as an additional source of Wnt5a for SHF progenitors. Methods: Wnt5a was conditionally deleted in the neural crest using transgenic Wnt1-cre mice. Embryos were harvested from control and mutant litter mates and immunofluoresence, in situ hybridization, and hematoxylin-eosin stains were performed on histologic sections using standard techniques. India ink injections were performed to evaluate pharyngeal arch artery and outflow tract morphology in whole mount embryos. Results: Wnt1-cre driven conditional deletion of Wnt5a in NCC did not impact NCC survival or migration into the developing OFT. However, SHF cells in mutant E10.5 embryos showed altered PCP signaling with reduced phalloidin and laminin expression. The resulting loss in polarized directional movement of the SHF led to reduced incorporation into and elongation of the developing OFT. The shortened OFT was mal-aligned resulting in fully penetrant double outlet right ventricle (DORV) at E14.5. In addition, maturation of pharyngeal arch arteries was also impaired such that all mutants express pharyngeal arch artery defects, including aortic arch abnormalities and aberrant right subclavian artery. In contrast, there was no observed effect on PCP in the more caudal SHF cells, and none of the mutant embryos had inflow tract or venous pole defects. Conclusions: Our results demonstrate that NCC are a novel source of Wnt5a. NCC-derived Wnt5a is critically required to regulate PCP signals in the most cranial SHF regulating the development of the OFT and pharyngeal arch arteries.

Microvascular Anatomy and Intrinsic Gene Expression of Menisci From Young Adults

Background: Meniscal vascular supply is an important determinant of its healing potential. It has been reported that only the peripheral 30% of the meniscus is vascularized in cadavers aged 53 to 94 years; however, the vascularity in young patients, in whom meniscal repair is more often performed, is unknown. Purpose: The primary objective was to analyze and measure the microvascular anatomy of the meniscus in adult cadaveric specimens <35 years old. The secondary objective was to assess angiogenic potential by quantifying regional gene expression in a meniscal allograft cohort <45 years old. Study Design: Descriptive laboratory study. Methods: In part 1 of this study, 13 fresh-frozen cadaveric knees (age range, 22-34 years; mean, 28.5 years) underwent popliteal artery India ink injection and tissue clearing using a Spalteholz technique, followed by microvascular vascular measurement. In part 2, mRNA was isolated from 13 meniscal allografts (age range, 17-43 years; mean, 27.2 years), and expression of angiogenic genes, vascular endothelial growth factor (VEGF), and vascular endothelial growth factor receptor 1 (FLT1) was quantified using real-time polymerase chain reaction. Results: The maximal depth of vascular penetration into the periphery of the medial and lateral menisci ranged from 0% to 42% and 0% to 48%, respectively. There was variation in the degree of vascular penetration within the medial meniscus, with the posterior horn having a significantly smaller depth of penetration (median, 8.7%) than that of the anterior horn (median, 17.4%; P < .0001) or midbody (median, 17.5%; P = .0003). There were no differences in angiogenesis gene expression (VEGF/FLT1) based on circumferential or radial meniscal locations. Conclusion: The vascular supply of the medial and lateral menisci in specimens from adults <35 years of age extended farther than what was reported in specimens from older individuals; however, median values remained consistent. Gene expression of the angiogenic marker VEGF was low throughout all regions of uninjured menisci from young adults, which is consistent with reports in older specimens. Clinical Relevance: Improved understanding of meniscal vascular supply in young adults is critical to informing clinical treatment decisions.

Feasibility of preoperative tattooing of percutaneously biopsied axillary lymph node: an experimental pilot study

BackgroundIn the last three decades, axillary lymph node dissection (ALND) has been replaced by sentinel lymph node biopsy (SLNB) in all clinically node-negative patients. However, when SLNB alone is performed in clinically node-positive patients who are rendered node-negative by neoadjuvant chemotherapy, the procedure has a high false-negative rate and other complementary procedures have been described to improve its reliability. Preoperative tattooing of the suspicious lymph node with India ink at the time of biopsy, in addition to sentinel lymph node biopsy, is a reasonable alternative. The objective of our study is to determine, in clinically node-positive patients, the feasibility of tattooing suspicious axillary lymph node at the time of percutaneous needle biopsy and its retrieval at the time of surgery.MethodsA prospective experimental study will be conducted divided into two phases—phases I and II. In phase I, 10 patients committed to undergo upfront surgery (without neoadjuvant chemotherapy) will have a suspicious lymph node tattooed by injecting India ink at the time of core needle biopsy. All patients will undergo a SLNB, during which the axilla will be inspected to determine if the tattooed lymph node can be visualized. Routine microscopic examination will follow, and concordance between the sentinel and tattooed node will also be established. In phase II, the process will be repeated for 30 patients who undergo surgery after neoadjuvant chemotherapy. The analysis will be performed in Stata version 12.DiscussionThere is a need to identify and test the techniques for the down-staged axilla in post-neoadjuvant chemotherapy patients, which are not only practical and limit the number of invasive procedures necessary but are representative of the new axillary status and help limit the extent of axillary surgery without negatively impacting outcomes. We propose that, for the patient undergoing neoadjuvant chemotherapy with a biopsy-proven disease in the axilla, this could be achieved by India ink which allows marking, identification, and retrieval of the biopsied lymph node. Retrieval of this previously biopsied lymph node along with sentinel nodes, if found to be representative of the status of the remainder of the axilla, could potentially eliminate the need for routine axillary lymph node dissection and thus limit morbidity.Trial RegistrationClinicalTrials.gov, NCT03939598. Retrospectively registered on 7 May 2019.

Application of a sodium alginate hydrogel for clear preoperative endoscopic marking using India ink

Preoperative marking or tattooing is a clinical procedure conducted during laparoscopic surgeries in which gastrointestinal lesions are identified by injecting India ink. However, diffusion of the carbon particles from the ink leads to its spreading in the surrounding tissues, resulting in unnecessarily extensive tissue resectioning. In this study, we determined whether this diffusion could be prevented using a sodium alginate (Alg-Na) hydrogel. We observed that the use of a 1.75% Alg-Na solution could significantly prevent the diffusion of carbon particles into the tissues of mice after subcutaneously injecting them with India ink. Similar results were observed in resected porcine large intestines. A good correlation between the concentration of Alg-Na and tattooed area was observed, in which an increase in its concentration led to an increase in its viscosity and injection pressure. To examine the effect of the molecular weight of Alg-Na on the tattooing area, a solution of 2% Alg-Na was irradiated with an electron beam at varying electron doses. Since irradiation could reduce the molecular weight, viscosity, and injection pressure of Alg-Na, a good correlation between these parameters and the tattooed area was observed. We concluded that an adequately viscous Alg-Na hydrogel could be used for clear preoperative marking. Preoperative marking or tattooing is performed in clinical situations using an India ink to identify gastrointestinal lesions. However, diffusion of the carbon particles from the ink results in unclear marking. We observed that subcutaneously injected sodium alginate solutions formed a gel and prevented the diffusion of carbon particles into the tissues of mice. Similar results were observed in resected porcine large intestines. The tattooed area was well correlated with the molecular weight and viscosity of sodium alginate, indicating that an adequately viscous sodium alginate hydrogel is useful for clear marking.

Method of Intra‐Arterial Administration in a transient MCAO Rat model to mimic the treatment of the human patient

Endovascular thrombectomy is routinely performed in patients undergoing a large vessel occlusion. This process not only allows for the removal of a blood clot but also for the selective delivery of potential therapeutics directly to the site of injury. The intra‐arterial (IA) route of drug administration in the mouse was developed to bridge the gap between animal stroke treatments and clinical stroke therapy. We have previously shown this delivery method targets the site of injury while blunting systemic effects that have proven problematic with intraperitoneal routes. Here, we adapted the IA method for use in rats, combining it with a clinically relevant large vessel occlusion stroke model (MCAO). Our goal was to characterize variances in the model in order to optimize potential therapeutic delivery methods to the ipsilaterally affected hemisphere. Male and female Sprague‐Dawley rats (4 months of age) were subjected to placement of micro‐angio tubing at the bifurcation of the common carotid artery (CCA), with delivery through the internal carotid artery (ICA). We then determined the optimal infusion rate and volume using injection of India ink and evaluation of vascular distribution within the brain and the liver. Importantly, we found the infusion rate and volume varied depending on sex and body weight. India ink was selectively delivered to the ipsilateral side of the brain in males (370–460 g) at 4 μl/min with a max volume of 25 μl and in females (250–300 g) at 2.5 μl/min with a max volume of 25 μl. Following these guidelines, no ink was observed in the liver of these animals, indicating reduced systemic circulation of administered compounds. We then performed a 5‐hour transient MCAO, on male and female Sprague‐Dawley rats (4 months of age), to mimic human stroke, since 5 hours is the average time from the clinical presentation of stroke to the thrombectomy procedure. A silicone coated monofilament was advanced till resistance was felt, occluding the MCA territory. At the 5 hour time point, we removed the monofilament and inserted the mico‐angio tubing at the same entry point on the bifurcation of the CCA. We performed variant injections using different volumes and rates, measuring delivery of dye (India Ink) and rate of induced subarachnoid hemorrhage. A rate of 4 ul/min with a max volume of 25 ul was optimal in males, and a rate of 2.5 ul/min with a max volume of 25 ul was optimal in females. The results showed that, even with a large vessel occlusion, and removal of the monofilament (recanalization), the IA injection using these sex‐specific rates and volumes resulted in appropriate limited dye delivery without ruptured subarachnoid hemorrhage. This IA method is ideally suited for combination with the MCAO stroke model and mirrors the human patient undergoing an endovascular thrombectomy. This model provides an investigative opportunity to test neuroprotective drugs and other pharmacotherapies.Support or Funding InformationUniversity of Kentucky Center for Advanced Translational Stroke Science, Surgery Core

2539 Case of a Young Man With Small Bowel Obstruction After Trauma

INTRODUCTION: In few reports, trauma has been associated with small bowel obstruction. These cases typically happen in children; however, in adults this is a rare phenomenon. We present a case in a young male with a history of MVA 5 years prior, who presented for small bowel obstruction related to his prior trauma. CASE DESCRIPTION/METHODS: A 27 yo male presented with recurrent abdominal pain for six months. He had intermittent diarrhea, abdominal bloating, and a 15 lb weight loss over that time. Physical examination was normal. Basic laboratory studies were significant for T bili of 1.4 mg/dl (normal 0.1 - 1.0). Diagnostic EGD, colonoscopy, and CT scan of the abdomen/pelvis were normal. Due to concern for a potential diagnosis of small bowel Crohn's disease, a video capsule study was performed, which showed a hold-up in the mid small bowel for over 2 hours, without any other abnormalities. Due to this, an upper double balloon enteroscopy was performed, which was revealing for a stenosis in the distal jejunum. The stenosis was marked with submucosal india ink injection. Biopsies of the stenosis were unrevealing. Previous medical history was negative with the exception of a motor vehicle accident complicated by intra-peritoneal bleeding five years ago, which was managed conservatively without surgery. Review of this patient's medications was negative for any NSAID use. He had no history of radiation exposure or abdominal surgery. He had never experienced any symptoms of abdominal pain or bloating prior to the onset of symptoms 6 months ago. Family history is negative for celiac disease or inflammatory bowel disease. Surgical resection of the stenotic segment was performed. The patient recovered from surgery without complication. Histopathology from the resected segment was consistent with benign small bowel without inflammation or other pathologic features. The conclusion of the medical providers was that this patient developed a symptomatic stricture as the result of previous MVA with hematoma. DISCUSSION: Small bowel obstruction from trauma has been highlighted in few cases in children; however, trauma-causing small bowel obstruction (SBO) in adults is more rare. Throughout the cases we reviewed, the timeline of this trauma causing SBO ranged from thirteen weeks to eight years after the initial event.2,3,4 In this case, the man presented five years after his MVA with symptoms of bowel obstruction, with a prior hematoma being the cause of this obstruction. This case highlights MVA as a cause of SBO in adults.

Anatomic study of the arterial territories of the face depending on the external carotid artery branches

Blood supply of the skin of the face is mainly provided by 3 branches of the external carotid artery: facial artery (FA), superficial temporal artery (STA) and transverse facial artery (TFA) which is a branch of the STA. The aim of the study was to describe the arterial territories of the skin of the face depending on the external carotid branches. After dissection of the first two centimeters of these arteries on one side, we performed an injection of India ink of different colors in the arteries in order to describe the arterial territories (angiosomes) of the face on 24 embalmed cadavers. The lips and the tip of the nose were vascularized in most cases by the FA. The STA vascularizes the temporal and frontal areas and a part of the auricle. The buccal area blood supply is coming from the FA with a participation of the TFA which is variable (10/24 cases), and the zygomatic area blood supply is coming from the STA with a participation of the TFA (9/24 cases). Variations in the angiosomes of the face have to be considered in reconstructive surgery, and in face transplantation.

Vascularized Olecranon Bone Graft: An Anatomical Study and Novel Technique

Autologous bone grafting is commonly used in reconstructive hand surgery. Various sources of nonvascularized autologous bone grafts have been described in the literature. However, in some situations, a vascularized bone graft may be needed. Popular vascularized bone grafts aretaken from the distal radius, iliac crest, and medial femoral condyle. The purpose of this study was to examine the feasibility of harvesting a free vascularized bone flap from the proximal ulna. Latex was injected via the brachial artery to facilitate visualization of perforators in 10 cadaveric specimens. Dissections were performed of the olecranon; all periosteal perforators were noted, and their lengths and diameters recorded. Corticocancellous bone flaps with their supplying pedicles were harvested. Three additional fresh specimens were injected with india ink via the pedicles to demonstrate perfusion of the harvested bone flap. Consistent vascular anatomy supplied the olecranon. A perforator from the posterior ulnar recurrent artery supplied the proximal ulna and olecranon, from which a vascularized bone flap can be harvested. Branches to the flexor carpi ulnaris muscle may allow chimeric flaps to be harvested. Average pedicle length was 5.8 cm and average pedicle diameter was 2.4 mm. India ink injection of the pedicles showed perfusion of the periosteum as well as intraosseous cancellous bone. A vascularized olecranon free flap can be harvested based on the posterior ulnar recurrent artery. Vascular anatomy is consistent and flap harvest is simple and straightforward in all cadaveric specimens. A vascularized olecranon free flap represents a potential new surgical option when vascular bone flap reconstruction is considered.

Transvaginal ultrasound guided trigone and bladder injection: A cadaveric feasibility study for a novel route of intradetrusor chemodenervation.

PurposeOnabotulinumtoxinA (BTX) detrusor chemodenervation is an efficacious third-line treatment for overactive bladder. Despite high clinical efficacy rates for BTX injection, many patients refuse initial or repeat treatment due to the invasiveness of the cystoscopic route of delivery. We assess the feasibility of injecting the trigone and posterior bladder wall via a transvaginal route under ultrasound guidance using a human cadaveric model.Materials and MethodsEight de-identified anonymous fresh female deceased donor cadaver pelvises were placed in supine split leg position. A transvaginal ultrasound probe guided injections of India ink into the trigone in 3 sites and the posterior wall in 2 sites. Full thickness bladder biopsies were then obtained and histologic analysis was performed to confirm presence of India ink in the detrusor layer.ResultsThe mean time from day of death was 11.0 days (range, 4.0–23.0 days). Three to five bladder biopsies were obtained per cadaver, for a total of 34 specimens (20 trigone, 14 posterior wall). Histologic analysis revealed presence of India ink within the detrusor layer in 8/8 (100.0%) of cadavers. The surgeon's perception of appropriate targeting under ultrasound guidance was confirmed in 8/8 cadavers (100.0%) involving the bladder trigone, and 7/8 (87.5%) involving the posterior wall. Of injections that were believed to have appropriately targeted the detrusor layer, 22/34 specimens (64.7%) demonstrated the presence of India ink under histologic analysis.ConclusionsIntradetrusor injection of the bladder trigone and posterior wall under transvaginal ultrasound guidance is feasible and has acceptable accuracy.

Lymphatic lacunae of the mucosal folds of human uterine tubes — A rediscovery of forgotten structures and their possible role in reproduction

The mucosa of uterine tube forms multiple and branched longitudinal mucosal folds and takes part in many reproduction events, such as oocyte pick-up, gamete transport, sperm capacitation, fertilization, and early embryonic development. In the habilitation thesis of German physician Paul Kroemer (1904) was the first to describe the lymphatic lacunae inside the tubal folds (by injection of Indian ink), which the author named the öLymphbahnen” (ölymphatic channels”). Despite the fact that this first description has existed for 110 years, there is no mention of these lacunae in most of the current literature. In this article we present a rediscovery of completely overlooked morphological structures of uterine tubes — the lymphatic lacunae in their mucosal folds. The specimens from the uterine tubes were taken from 72 women (mean age 46.25 years) who underwent transabdominal or laparoscopic salpingectomy. The tissue samples from anatomically different parts of the uterine tubes were used for hematoxylin and eosin staining and for immunohistochemistry. Primary antibodies were used to label and detect podoplanin D2-40, a selective marker of lymphatic endothelia, CD34 antigen, and von Willebrand factor (Factor VIII). In the histological slides of the uterine tubes, there were noticeable slits or gaps within the loose connective tissue of the lamina propria of the mucosal folds. They were lined with one layer of squamous endothelial cells. These öempty spaces” were most prominent in the fimbriae, but were still well recognizable in mucosal folds of the ampulla. They always run through the central part of the fold. As a results of immunohistochemistry, we confirmed that in the centre of every mucosal fold, as well as in the fimbriae of the uterine tubes, dilated lymphatic spaces were situated and were lined with a simple layer of lymphatic endothelial cells (positive for podoplanin and CD34, and negative for Factor VIII). As there is no mention on them in the current Terminologia Histologica, we proposed the term ölymphatic lacunae of tubal mucosal folds and fimbriae” in English and ölacunae lymphaticae plicae mucosae et fimbriae” in Latin. According to our hypothesis, these lymphatic lacunae may be responsible for the thickening of the fimbriae during the oocyte pick-up and the maintenance of the tubal fluid.

Forearm-Based Turnover Muscle Flaps for Elbow Soft-Tissue Reconstruction: A Comparison of Regional Coverage Based on Distal Flap Perfusion.

Elbow wounds pose a reconstructive challenge. Prior studies have described the vascular anatomy of both the brachioradialis and flexor carpi ulnaris muscle flaps. The goal of this study was to describe the distal flap perfusion of the flexor carpi radialis, with a direct comparison of the brachioradialis, flexor carpi ulnaris, and flexor carpi radialis muscle flaps for coverage around the elbow. Six fresh-frozen upper extremity specimens were dissected for brachioradialis, flexor carpi radialis, and flexor carpi ulnaris flaps. Vascular data from prior studies were combined with our anatomical measurements to determine the area of perfused coverage around the elbow for the brachioradialis and flexor carpi ulnaris. The flexor carpi radialis flap distal vascular perfusion was examined separately with transverse sections at 1-cm intervals after India ink injections to determine distal flap perfusion and elbow coverage. Perfusion data were plotted on x and y axes over the posterior elbow. The brachioradialis muscle covered an average of 56 percent of the x axis and 7.4 percent of the y axis. The flexor carpi ulnaris muscle covered an average of 90 percent of the elbow along the x axis and 23.3 percent of elbow along the y axis. The flexor carpi radialis covered an average of 34 percent of the x axis and 4.8 percent of the y axis. The flexor carpi ulnaris muscle provides the most versatile and robust coverage over the posterior elbow, followed by the brachioradialis muscle, which consistently provides coverage over the lateral epicondyle.

Arterial Vascularization of the Mandibular Condyle and Fractures of the Condyle.

Despite substantial displacements, fractures of the mandibular condyle rarely lead to necrosis. This illustrates the negligible role of the inferior alveolar artery in intraosseous supply to the condyle, and led to this systematization of its arterial vascularization. Forty-two temporomandibular joints from nonembalmed cadaveric specimens were studied following injection of latex (n = 32) or India ink (n = 10). The intraosseous branches of the inferior alveolar artery that lead to the condyle were inconstant and often rudimentary. In this study, the arteries that consistently led to the condyle were the superficial temporal artery, the deep posterior temporal artery, and arterial branches leading to the lateral pterygoid muscle emanating directly from the maxillary artery. These arteries, along with the transverse facial artery and the masseteric artery (when they participated in condoyle vascularization), formed a quadrangle around the mandibular condyle. After India ink injection, the pterygoid muscle was the most strongly colored muscle, thus indicating substantial vascularization. Although there is a lack of consensus in the literature regarding the constancy and proportions of the arteries participating in vascularization of the condyle, the superficial temporal artery, the maxillary arterial branches leading to the lateral pterygoid muscle, and the deep posterior temporal artery were constant in this study. This study shows the important role of the lateral pterygoid in the vascularization of the condyle. In case of a fracture with substantial displacement, the vascularization emanating from the superficial temporal artery and the lower alveolar artery is ruptured or compromised.