The External Oblique Intercostal Block: Anatomic Evaluation and Case Series.

STUDY OBJECTIVE: We report a modified block technique aimed at obtaining upper midline and lateral abdominal wall analgesia: the external oblique intercostal (EOI) block. DESIGN: A cadaveric study and retrospective cohort study assessing the potential analgesic effect of the EOI block. SETTING: Cadaver lab and operating room. PATIENTS: Two unembalmed cadavers and 22 patients. INTERVENTIONS: Bilateral ultrasound-guided EOI blocks on cadavers with 29 mL of bupivacaine 0.25% with 1 mL of India ink; single-injection or continuous EOI blocks in patients. MEASUREMENTS: Dye spread in cadavers and loss of cutaneous sensation in patients. MAIN RESULTS: In the cadaveric specimens, we identified consistent staining of both lateral and anterior branches of intercostal nerves from T7 to T10. We also found consistent dermatomal sensory blockade of T6-T10 at the anterior axillary line and T6-T9 at the midline in patients receiving the EOI block. CONCLUSIONS: We demonstrate the potential mechanism of this technique with a cadaveric study that shows consistent staining of both lateral and anterior branches of intercostal nerves T7-T10. Patients who received this block exhibited consistent dermatomal sensory blockade of T6-T10 at the anterior axillary line and T6-T9 at the midline. This block can be used in multiple clinical settings for upper abdominal wall analgesia.

External Approach to Buccal Fat Excision in Facelift: Anatomy and Technique.

BACKGROUND: Masculinization of the face is a common finding in facelift patients. It is attributed to deflation and decent of the midface-jowls coupled with skin laxity. Fullness is evident lateral to the jowl in a small percentage due to prominent buccal fat pad (BFP). OBJECTIVES: The authors sought to examine the anatomy of the BFP, triangulate the prominent BFP with surgical landmarks, and describe an external approach to excise the BFP during facelift surgery. METHODS: Eighteen cadaveric dissections were performed. Facelift flap was elevated and the prominent buccal extension of the BFP protruding through the superficial-musculo-aponeurotic-system was identified. Measurements were taken from the BFP to surgical landmarks: zygomatic arch, tragus, and gonial angle. The locations of the facial nerve, parotid duct, and vascular pedicle relative to the BFP were calculated. RESULTS: BFP was 4.1 cm inferior to the zygomatic arch, 7.5 cm anterior the tragus, and 4.5 cm medial the gonial angle. The middle facial artery supplied the BFP on the inferior-lateral quadrant in 61% and inferior-medial quadrant in 39% of specimens . In all specimens, the parotid duct traversed the BFP superiorly, and the buccal branches of the facial nerve traversed the capsule superficially. CONCLUSIONS: The buccal extension of the BFP can pseudoherniate in the aging face. Excision may improve lower facial contour. Measurements from facial landmarks may help surgeons identify the buccal extension of the BFP intraoperatively. The surgeon must be careful of the vascular pedicle, parotid duct, and the facial nerve. The external approach safely excises buccal fat during facelift dissection while avoiding intraoral incisions and unnecessary contamination.

Full Facial Allotransplantation Including the Temporomandibular Joints: A Radiologic and Anatomical Cadaveric Study.

BACKGROUND: Facial allotransplantation including the temporomandibular joints may improve the functional outcomes in face transplant candidates who have lost or damaged this joint. METHODS: Linear and angular measurements were taken in 100 dry skulls and mandibles and in 100 three-dimensionally-reconstructed facial computed tomographic scans to determine the variability of the temporomandibular joint, glenoid fossa, and mandible. A vascular study was performed in six fresh cadaveric heads, followed by harvest of the face allograft in three heads. Next, four heads were used for mock transplantation (two donors and two recipients). The full facial allograft included four different segments: a Le Fort III, a mandibular tooth-bearing, and two condyle and temporomandibular joint-bearing segments. Statistical analysis was performed using SAS software. RESULTS: In only one-third of the skulls, the condylar shape was symmetric between right and left sides. There was a wide variability in the condylar coronal (range, 14.3 to 23.62 mm) and sagittal dimensions (range, 5.64 to 10.96 mm), medial intercondylar distance (range, 66.55 to 89.91 mm), and intercondylar angles (range, 85.27 to 166.94 degrees). This high variability persisted after stratification by sex, ethnicity, and age. The temporomandibular joint was harvested based on the branches of the superficial temporal and maxillary arteries. The design of the allograft allowed fixation of the two condyle and temporomandibular joint-bearing segments to the recipient skull base, preserving the articular disk-condyle-fossa relationship, and differences were adjusted at the bilateral sagittal split osteotomy sites. CONCLUSION: Procurement and transplantation of a temporomandibular joint-containing total face allograft is technically feasible in a cadaveric model.

Rhomboid Intercostal and Subserratus Plane Block: A Cadaveric and Clinical Evaluation.

BACKGROUND AND OBJECTIVES: Fascial plane blocks are rapidly emerging to provide safe, feasible alternatives to epidural analgesia for thoracic and abdominal pain. We define a new option for chest wall and upper abdominal analgesia, termed the rhomboid intercostal and subserratus plane (RISS) block. The RISS tissue plane extends deep to the erector spinae muscle medially and deep to the serratus anterior muscle laterally. We describe a 2-part proof-of-concept study to validate the RISS block, including a cadaveric study to evaluate injectate spread and a retrospective case series to assess dermatomal coverage and analgesic efficacy. METHODS: For the cadaveric portion of the study, bilateral ultrasound-guided RISS blocks were performed on 6 fresh cadavers with 30 mL of 0.5% methylcellulose with india ink. For the retrospective case series, we present 15 patients who underwent RISS block or RISS catheter insertion for heterogeneous indications including abdominal surgery, rib fractures, chest tube-associated pain, or postoperative incisional chest wall pain. RESULTS: In the cadaveric specimens, we identified staining of the lateral branches of the intercostal nerves from T3 to T9 reaching the posterior primary rami deep to the erector spinae muscle medially. In the clinical case series, dermatomal coverage was observed in the anterior hemithorax with visual analog pain scores less than 5 in patients who underwent both single-shot and continuous catheter infusions. CONCLUSIONS: Our preliminary cadaveric and clinical data suggest that RISS block anesthetizes the lateral cutaneous branches of the thoracic intercostal nerves and can be used in multiple clinical settings for chest wall and upper abdominal analgesia.

Procurement of Extended Vascularized Skin Flaps from the Donor Enables Hand Transplantation in Severe Upper Extremity Burns: An Anatomical Study.

BACKGROUND: Hand transplantation in patients with severe upper extremity burns can be associated with an increased risk of exposure of vessels, tendons, and nerves because of extensive skin and soft-tissue deficit. This study evaluated how to reliably transfer additional extended skin flaps with a standard hand allograft. METHODS: Twenty-five upper extremities were used. Sixteen were injected with latex to map the perforating branches of the brachial, superior ulnar collateral, radial, ulnar, and posterior interosseous arteries. Nine hand allografts were procured, injected with blue ink through the brachial artery to assess the perfusion of the skin flaps, and then mock transplanted. RESULTS: Sizable perforators from the brachial, superior ulnar collateral, radial, ulnar, and posterior interosseous arteries were used to augment the vascularization of the skin flaps. The average stained area of the medial arm flap was between 85.7 and 93.9 percent. The stained area of the volar forearm flap was the smallest when based on perforators within 6 cm from the wrist crease (51.22 percent). The dorsal forearm flap showed the least amount of staining (34.7 to 46.1 percent). The average time to repair tendons, nerves, and vessels was longer when a single volar forearm-arm flap was harvested (171.6 minutes). Harvest of the allograft associated with a distally based forearm flap and islanded arm flap was the fastest (181.6 ± 17.55 minutes). CONCLUSION: Extended skin flaps, based on perforators of the main axial vessels, can be reliably transplanted with a standard hand allograft based on the brachial or axillary vascular pedicle.

Continuous Positive Airway Pressure Thresholds for Nasolacrimal Air Regurgitation in a Cadaveric Model.

PURPOSE: To elucidate the mechanisms underlying nasolacrimal air regurgitation (AR) in the setting of continuous positive airway pressure therapy. METHODS: Twelve nasolacrimal systems of 6 fresh female human cadavers were evaluated individually for AR using continuous positive airway pressure therapy before any nasolacrimal procedure. Cadavers were then randomly assigned to undergo nasolacrimal duct probing or endoscopic dacryocystorhinostomy and then each hemisystem was again evaluated for AR. The pressure where AR was first observed (discovery pressure) or maximum possible pressure in systems without AR was recorded. In systems that demonstrated AR, the pressure was then gradually decreased to the lowest pressure where regurgitation persisted. This pressure was recorded as the secondary threshold pressure. RESULTS: None of the 12 unoperated nasolacrimal systems or the 6 systems that underwent nasolacrimal duct probing demonstrated AR through the maximum continuous positive airway pressure therapy (30 cm H2O). After endoscopic dacryocystorhinostomy, all 6 nasolacrimal systems demonstrated AR. The mean discovery pressure was 16.0 cm H2O (range, 14.0-18.0 cm H2O) and mean secondary threshold pressure was 7.25 cm H2O (range, 6.5-8.0 cm H2O). CONCLUSIONS: Air regurgitation during continuous positive airway pressure therapy in the setting of prior endoscopic dacryocystorhinostomy can be replicated in a cadaver model. The secondary threshold pressures required for AR in this model were similar to AR pressures reported clinically. Prior to dacryocystorhinostomy, patients using continuous positive airway pressure therapy should be counseled on AR, and physicians should consider this phenomenon when evaluating ophthalmic complaints in postoperative patients on positive airway pressure therapy.

Evidence-Based Medicine: A Graded Approach to Lower Lid Blepharoplasty.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Define the anatomy of the lower eyelid tarsoligamentous framework and the related periorbital retaining ligaments, and cite their surgical relevance. 2. Perform a systematic functional and aesthetic evaluation of the lower eyelid focusing on the lid-cheek junction, and clinical tests that predict the need for lateral canthal tightening. 3. Enumerate the different approaches to lower eyelid rejuvenation and discuss their merits/limitations. 4. Describe surgical strategies to blend the lid-cheek junction and tighten the lateral canthal retinaculum. SUMMARY: Modern lower lid blepharoplasty requires a thorough understanding of periorbital anatomy, age-related changes of the lid-cheek junction, and the variables controlling lower lid tone and position. The surgical strategies are best used in a graded fashion. The patient with isolated lower lid bags may be treated by transconjunctival fat resection alone. Additional mild skin laxity can be improved with skin pinch or skin-only undermining. Skin resurfacing using chemical peeling or laser can further address fine lines. In these patients with an abnormality of the lid-cheek junction, release of the medial orbicularis oculi muscle and variable amounts of the orbicularis retaining ligament is essential. This is combined with orbital fat resection or repositioning through a transconjunctival or transcutaneous skin-muscle flap. The transcutaneous approach most often necessitates lateral canthal tightening to optimize lid margin control. Generally, the degree of laxity dictates whether a canthopexy or a canthoplasty is most appropriate. Lateral canthal procedures can be applied to patients displaying clinical signs predictive of lid malposition and to those presenting with varying degrees of established lid descent.

The Simultaneous Use of Breast Reduction and Internal Mammary Artery Perforator Flap in Sternal Wound Reconstruction.

Internal mammary artery perforator (IMAP)-based fasciocutaneous flaps have recently gained popularity in sternal wound reconstruction due to their decreased donor site morbidity. However, patients with significant macromastia or who are obese present a challenge when using these flaps due to their anatomy and associated comorbid conditions. Despite the prevalence of this population, there is a relative paucity of data on the use of local fasciocutaneous flaps and techniques to close sternotomy wounds in the obese population with hypertrophic or ptotic breasts. The authors describe a novel technique using simultaneous unilateral breast reduction with a fifth intercostal IMAP-based flap for closure of a median sternotomy wound through a case presentation, an anatomical injection study, and review of the literature. Five fresh female cadavers were used to conduct 8 trials of injection of the IMAP arteries, isolation of the fifth IMAP branch, and elevation of a local flap. The literature was comprehensively reviewed with a total of 33 cases of IMAP flaps for sternal reconstruction being described. The most commonly used perforators with the second and sixth IMAPs. Overall complication rate was reported to be 9.1% (3/33), with 2 cases reporting dehiscence and 1 with flap tip necrosis. No cases reported use of the fifth IMAP or formal breast reduction procedures, which was successfully performed in a 40-year-old diabetic female patient history of multiple left-sided thoracic surgeries and radiation with a chronic sternal wound.

International association for the study of lung cancer (IASLC) lymph node map: radiologic review with CT illustration.

Accurate clinical or pretreatment stage classification of lung cancer leads to optimal treatment outcomes and improved prognostication. Such classification requires an accurate assessment of the clinical extent of regional lymph node metastasis. Consistent and reproducible regional lymph node designations facilitate reliable assessment of the clinical extent of regional lymph node metastasis. Regional lymph node maps, such as the Naruke lymph node map and the Mountain-Dresler modification of the American Thoracic Society lymph node map, were proposed for this purpose in the past. The most recent regional lymph node map to be published is the International Association for the Study of Lung Cancer (IASLC) lymph node map. The IASLC lymph node map supersedes all previous maps and should be used in tandem with the current seventh edition of the tumor, node, metastasis stage classification for lung cancer.

A failsafe method to avoid injury to the great auricular nerve.

BACKGROUND: The great auricular nerve (GAN) is the most commonly injured nerve during facelift surgery. Although rare, injury can result in long-term sequelae. OBJECTIVES: Previous reports have described the nerve's location at the midbelly of the sternocleidomastoid muscle (SCM) or at its emergence from underneath the SCM. The purpose of our study was to identify the superior course of the great auricular nerve as it applies to facelift. METHODS: Thirteen fresh cadavers were dissected. A vertical line through the midlobule was drawn perpendicular to the Frankfort's horizontal, acting as a reference to the course of the GAN. Transparent paper overlay tracings were then done to record each nerve's location. The distance from the bony external auditory canal (EAC) to the nerve was measured at the anterior muscle border, at the midbelly of the SCM, and as the nerve emerged from under the SCM. Branching patterns of the nerve and its relation to the external jugular vein were identified. RESULTS: In 100% of the dissections, the superior course of the GAN fell within a 30-degree angle constructed using the vertical limb perpendicular to the Frankfurt horizontal and a second limb drawn posteriorly from the midlobule. The distance from the EAC to the nerve was 4.9 ± 1.1 cm at the anterior muscle border, 7.3 ± 1.0 cm at the midbelly of the SCM, and 9.8 ± 1.2 cm at the GAN's emergence from under the SCM. Four types of branching patterns were identified. CONCLUSIONS: The 30-degree angle described above rapidly and accurately identifies the nerve's location.

Nonuniform pressure generation in the optic chiasm may explain bitemporal hemianopsia.

PURPOSE: To measure the pressure in the temporal and central aspects of the chiasm simultaneously during compression of the optic chiasm from below with an expanding simulated tumor. DESIGN: Experimental study. METHODS: Craniotomies were performed on 5 unfixed cadaveric specimens ranging in age from 49 to 89 years, and the optic chiasm was exposed. After a pediatric gauge Foley catheter was inserted into the sellar region, the temporal side of the chiasm (temporal aspect uncrossed fibers) was impaled with a 30-gauge needle connected to a pressure transducer. In like fashion, the central portion of the chiasm (crossed fibers) was impaled with another 30-gauge needle connected to a pressure transducer on a separate channel. The Foley catheter was inflated for a period of 30 seconds to 1 minute and the pressure in each channel continuously monitored. Multiple trials were performed on each of the 5 specimens. MAIN OUTCOME MEASURE: Pressure change between the temporal and nasal aspects of the optic chiasm. RESULTS: In all cases in which intrachiasmal pressure could be measured, higher pressures were always generated in the central aspect of the chiasm than in the temporal aspect of the chiasm. In cadaver 1, the mean central pressure was 19.75 mmHg, whereas the mean temporal pressure was 6 mmHg. In cadaver 5, the mean central pressure was 4 mmHg, whereas the mean temporal pressure was zero. Donors 70 and older demonstrated abnormally thin and frail chiasms that were unable to support a sustained pressure increase during simulated tumor expansion. CONCLUSIONS: During deformation of the optic chiasm from below by a radially expanding mass analogous to a pituitary tumor, the central aspect of the optic chiasm consistently manifests a higher pressure than the temporal aspect. It is hypothesized that the peculiar geometry of the optic chiasm renders the crossing nasal fibers more prone to a deformation stress exerted from below. Nonuniform pressure generation between the central and temporal aspects of the chiasm results in a greater effective stress on the crossing fibers of the chiasm and may be responsible for the clinical phenomenon of bitemporal hemianopsia.

A unique, innovative, and clinically oriented approach to anatomy education.

The establishment of The Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, whose first class entered in 2004, provided a unique opportunity to design an anatomy program that, from all indications, is effective, time efficient, and clinically relevant in the context of a nonlecture, problem-based, organ-systems-oriented curriculum. Through consultation with surgery colleagues, the case-directed anatomy program was developed. This approach, meeting one day a week for 1 hour 50 minutes for 30 weeks, uses clinical cases to introduce anatomical information that is reinforced using prosected cadavers and imaging. The format of the approach involves three steps: (1) students preview a clinical case with clinical questions and learning objectives, (2) students acquire basic knowledge using textbooks and self-directed learning modules, and (3) students reinforce their basic knowledge in weekly case-directed anatomy sessions, which involve an interactive discussion of the clinical case followed by a laboratory. In the laboratory, students rotate around stations viewing prosected cadavers and imaging. Learning anatomy does not stop after the first year, because the program is longitudinal. During the second year, students review anatomy in each organ-system course using the first-year format. Also, second-year students can assist the fellows or residents prepare the prosections for first-year students and for their review of anatomy in the second year. This provides students with a dissection experience. During third-year clinical rotations, anatomy knowledge is reinforced, and several surgery anatomy electives are available during the final year. In this way, anatomy is learned and reinforced throughout the medical school curriculum.