Intranasal Extramucosal Access: A New Access for Lateral Osteotomy in Open Rhinoplasty.

BACKGROUND AND OBJECTIVE: Different accesses have been used to perform lateral osteotomies in rhinoplasty. All of them have some disadvantages. The aim of this paper was to report a new access to overcome drawbacks of the other techniques in lateral osteotomy during open rhinoplasty. METHODS: An anatomical study was designed to search possibility of intranasal extramucosal access (open sky access) for the lateral osteotomy in open rhinoplasty. It was performed directly on the lateral wall of piriform aperture, and then possible advantages of this technique were investigated. Five fixed cadavers were used for this purpose. No drawbacks were observed during procedure in cadavers. Then the same procedure was performed in 23 consecutive rhinoplasty patients. Nineteen operations were primary and 4 operations were secondary. Median oblique osteotomies were added to the procedure in all patients. The mean follow-up was 17 months. RESULTS: Intranasal extramucosal access during lateral osteotomy was easily performed in all patients. Hemorrhage due to angular vessel injury was not occurred during intraoperative period. Edema and ecchymosis was minimal. Intranasal examination did not show any sign for nasal mucosal tearing in all patients. Residual bone spurs or bone irregularities were not observed in any patients. CONCLUSION: Intranasal extramucosal access that produces precise, predictable, and reproducible aesthetic and functional results could also provide better exposure during lateral osteotomy. Additionally, open sky access minimizes scars because it does not need additional incisions on the skin and mucosa. Protection of the internal periosteum of the nasal bones may be the main advantages of this technique.

Motor nerve lengths of twenty-seven muscles in upper extremity.

The purpose of this study is to determine the lengths of motor nerves in the upper extremity. Motor nerves of 27 muscles in 10 cadavers (16 extremities) were dissected from their roots at the level of intervertebral foramen to the entry point of the nerves to the corresponding muscles. Distance between acromion and the lateral epicondyle of the humerus was also measured in all cadavers. Nerve length of the coracobrachialis muscle was the shortest (18.26 ± 1.64 cm), while the longest was the nerve of the extensor indicis (59.51 ± 4.80 cm). The biceps brachii, the extensor digitorum communis, and the brachialis muscles showed highest coefficient of variation that makes these nerve lengths of muscles inconsistent about their lengths. This study also offers quotients using division of the lengths of each nerve to acromion-the lateral epicondyle distance. Knowledge of the nerve lengths in the upper extremity may provide a better understanding the reinnervation sequence and the recovery time in the multilevel injuries such as brachial plexus lesions. Quotients may be used to estimate average lengths of nerves of upper extremity in infants and children. Moreover, reliability of the biceps brachii as a determinant factor for surgery in obstetrical brachial plexus lesions should be reconsidered due to its highest variation coefficient.

Treatment of hyperdynamic nasal tip ptosis in open rhinoplasty: using the anatomic relationship between the depressor septi nasi muscle and the dermocartilaginous ligament.

BACKGROUND: Smiling causes a deformity in some rhinoplasty patients that includes drooping of the nasal tip, elevation and shortening of the upper lip, and increased maxillary gingival show. The depressor septi muscle leads this deformity. The dermocartilaginous ligament originates from the fascia of the upper third of the nose and extends down to the medial crus, merging into the depressor septi muscle. METHODS: In this study, 100 primary rhinoplasty patients were studied for hyperdynamic nasal tip ptosis. Of these patients, 36 had hyperdynamic nasal tip ptosis due to hyperactive depressor septi nasi muscle. The dermocartilaginous ligament was used as a guide to reach the depressor septi muscle in open rhinoplasty. Muscle excision was performed just below the footplates of the medial crura. A strong columellar strut graft was placed between the medial crura to avoid narrowing of the columellar width resulting from tissue excision and to withstand activation of depressor septi muscle remnants. RESULTS: No complications such as infection or hematoma occurred in the early postoperative period. The technique corrected the hyperdynamic nasal tip ptosis, increased upper lip length, and decreased gingival show when patients smiled. There was no narrowing of the columellar width. No depression in the columellar-labial junction due to distal resection of the depressor septi muscle was observed. CONCLUSION: The dermocartilaginous ligament can be used as a reliable guide to reach the depressor septi muscle in open rhinoplasty. Therefore, the hyperactive depressor septi muscle can be definitively identified and treated without an intraoral approach. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

The neurovascular relationships of the oculomotor nerve.

In this study, the arterial supply of the cisternal (initial) and the subcavernous parts of the oculomotor nerve (ON) and the relation between the nerve and adjacent vascular structures like posterior cerebral artery (PCA) and superior cerebellar artery (SCA) were investigated. A total of 140 formalin fixed hemispheres from 70 human cadaveric brains were examined. The nutrient branches reaching the cisternal and subcavernous parts of the ON were investigated, along with branches of adjacent vascular structures penetrating the nerve and passing through it. In the material examined, the ON, after arising from the midbrain, mostly continues laterally between PCA and SCA or between PCA and the rostral SCA trunk. However, in three hemispheres of our specimens, the ON run between the rostral and caudal SCA trunks. We observed that the branches of PCA-P1 segment supplied the cisternal part of the ON in all specimens. In one specimen, the cisternal part of the ON was supplied by a branch arising from the rostral SCA trunk which was also originating from PCA. Differently, in four hemispheres, branches arising from PCA or SCA perforated the cisternal part of the ON and passed through it. We also observed a tortuous caudal trunk of duplicated SCA in one of our specimens and considered it as a rare variation. The anatomy of the ON and its vascular relations is significant in terms of not only understanding the compression syndromes and its vascular dysfunctions, but the exact diagnosis and treatment as well.

Anatomy and clinical significance of the trigeminocerebellar artery.

The trigeminocerebellar artery (TCA) is a unique branch of the basilar artery supplying both the trigeminal nerve root and the cerebellar hemisphere. In this study, we describe and demonstrate the microanatomy of the TCA in 45 brainstems and discuss the neurological, neuroradiological and neurosurgical significance. This is the largest series of cadavers in the literature. The close relationship of the TCA to the trigeminal nerve root may have clinical implications including for the etiology of trigeminal neuralgia, thus the neurosurgeon must be aware of the vasculature of the trigeminal nerve root area and the anatomical variations.

Correction of hyperpigmented palmar grafts with full-thickness skin grafts from the lateral aspect of the foot.

The palmar surface of the hand possesses special features when compared with the hair-bearing parts of the body. The same quality of skin has to be used in reconstruction of the palmar skin defects to restore normal function. The lateral aspect of the foot has similar features with the palmar region histologically and can be used for palmar reconstruction. Seventeen patients who had hyperpigmentation after skin graft in the palmar region were treated. Scar contracture was combined in seven patients. The hyperpigmented grafts were excised and then the defects were full-thickness skin grafted from the lateral aspect of the foot. The mean follow-up period was 13.7 (4-22) months. Engraftment was successful in 16 patients, but one failed due to haematoma. The colour of the graft was initially reddish, and then became similar to the palmar area. The donor site healed without any problem within 3 weeks. At follow-up these grafts had good colour and texture match with adjacent palmar skin. There was no hyperpigmentation. Minimal marginal scarring and scar hypertrophy occurred in four patients (24%). The skin of the lateral aspect of the foot is a good choice for palmar skin defects, because of the similarities in their characteristics. Results are acceptable in terms of minimal recurrence of scar contracture, no hyperpigmentation, adequate colour and texture match, and minimal marginal scarring and scar hypertrophy.

Percutaneous ilioinguinal-iliohypogastric nerve block or step-by-step local infiltration anesthesia for inguinal hernia repair: what cadaveric dissection says?

PURPOSE: The repair of groin hernias with local anesthesia has gained popularity. Two main methods have been described for local anesthesia. This study was aimed at comparing percutaneous truncular ilioinguinal-iliohypogastric block and step-by-step infiltration technique by using cadaver dissections. METHODS: The study was performed on an adult male cadaver by using blue dye injection. A percutaneous nerve block simulation was done on right side and the dye was given in between the internal oblique and transversus muscles. On the left side, a skin incision was deepened and the dye was injected under the external oblique aponeurosis. Following the injections, stained areas were investigated superficially and within the deeper tissues with dissection. RESULTS: There was a complete superficial staining covering the iliohypogastric and ilioinguinal nerves in the inguinal floor at both sides. On the right side, intraabdominal observation showed a wide and intense peritoneal staining, while almost no staining was seen on the left side. Preperitoneal dissection displayed a massive staining including testicular vascular pedicule and vas deferens on the right side. The dye solution also infiltrated the area of the femoral nerve prominently. On the contrary, a very limited staining was seen on the left. CONCLUSION: It may not always be easy to keep the percutaneous block within optimum anatomical limits without causing adverse events. A step-by-step infiltration technique under direct surgical vision seems to be safer than percutaneous inguinal block for patients undergoing inguinal hernia repair.

Botulinum toxin injection of the subscapularis muscle.

Patients with hemiplegia frequently suffer from pain and have a limited range of motion (ROM) of the shoulder. The common pattern of shoulder movement in a patient with spastic hemiplegia is primarily adduction and internal rotation. Spasticity of the subscapularis muscle limits the abduction, external rotation and flexion of the shoulder. Injection of botulinum toxin or application of phenol can reduce the spasticity of the subscapularis muscle and various techniques to inject this muscle have been reported. We injected five patients with hemiplegia with botulinum toxin using our previously reported inferior approach, which is easy, safe and effective. We observed a reduction in pain and spasticity and improvement in the ROM of the shoulder for all patients.

A new technique for subscapularis muscle needle insertion.

OBJECTIVE: To investigate a new technique for needle insertion into the subscapularis muscle for botulinum toxin injection, nerve block with phenol, and electromyography. DESIGN: A new technique, which we have termed the inferior approach, was delineated by cadaver study. In the first step of the study, the thickest part of the subscapularis muscle and the route for the accurate course of the needle were determined by an anatomist on eight cadavers (16 sides). In the second step, using this technique, a physician attempted to inject India ink into the thickest part of the muscle on a separate 12 cadavers (24 sides). The anatomist then examined the accumulated ink by careful dissection of the involved muscle. RESULTS: The thickest part was determined to be at the lateral half of the muscle. With the exception of two muscles, all the cadavers were successfully injected using the defined route. If the route and injection sites are correct, there is no risk of injecting any muscle in that anatomic region other than the subscapularis. Furthermore, there were no neurovascular structures identified at risk in the area using the inferior approach. CONCLUSION: This new technique, termed the inferior approach, is both easy and anatomically safe: it did not involve any risk of damage to any major artery, vein, or nerve.

Effects of the adducted or abducted position of the arm on the course of the musculocutaneous nerve during anterior approaches to the shoulder.

Nerve injury is a common complication during anterior shoulder surgery. The purpose of the study was to evaluate the musculocutaneous nerve (MN) anatomically and to clarify the relationship of the MN to the glenoid labrum and coracoid process in different arm positions. The study was carried out on 40 shoulders of 20 adult cadavers fixed in 10% formaldehyde. The minimum distance of the MN at the entrance point of the nerve into the coracobrachialis to the anteromedial aspect of the coracoid tip and the distance between the MN and the top, middle, and inferior points of the glenoid labrum were measured. All measurements were performed with a digital caliper while the arm was in a neutral position, 45 degrees and 90 degrees of abduction, 90 degrees of abduction-internal rotation and 90 degrees of abduction-external rotation to evaluate whether arm position effects the results statistically or not. The results demonstrated that the position of the arm significantly changes the distance between the coracoid process (CP) and the MN or its cord. The change in distance between the glenoid labrum and the MN or its cord was also statistically significant. The distance between the CP and MN was greatest when the arm was abducted to 45 degrees (mean 3.4 cm) and least when the arm was positioned to 90 degrees of abduction-internal rotation (mean 2.0 cm). While the distance between the MN and the coracoid process was least at 90 degrees of abduction and internal rotation, the distance between the MN and glenoid labrum was lest with 90 degrees of abduction and external rotation. The distance between the glenoid labrum and MN was greatest with 45 degrees of abduction. The results of this study might be of use in avoiding the MN especially during Bristlow operations and certain rotator cuff procedures. Transferring the coracoid process during Bristow operations or placing arthroscopic portals when the arm is abducted to 45 degrees appears to be the safest position in terms of MN injury. Based on our results, when the arm needs to be abducted to 90 degrees during operation, externally rotating it may decrease the tension on the brachial plexus thus increasing the distance between the MN and the portals or retractors.