PubMed · 12576905
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Rick Nelson, Herand Abcarian. 2003. Randomizing the dead.. https://doi.org/10.1097/01.dcr.0000049443.94835.49
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The purpose of this study was to investigate the nerve supply to the clavicular part of the pectoralis major muscle so that the innervation to this part can be maintained in the muscle-preserving pectoralis major island-flap transfer. Although methods have been described that include a limited portion of the muscle while leaving the upper parts undisturbed with an intact motor innervation, reports on anatomical studies of this nerve supply are brief. The distal distribution of the nerves, the spatial relationship to the main vascular pedicle, and the ways to preserve them during surgical procedures remain unclear. Surgically relevant features of the clavicular part of the pectoralis major muscle were studied by dissection. The nerve supply to this part was examined on 11 sides of eight formalin-fixed cadavers. Two fresh cadavers were used for dissection, intraarterial polymer injection, and application of a nerve-preserving surgical technique. In all subjects, a separate nerve innervated the clavicular and upper medial sternocostal portions of the pectoralis major muscle. This nerve arises craniomedial to the main vascular pedicle of the flap and divides into several branches. These branches run in a fascia on the deep surface of the pectoralis major muscle, superficial to the origin and distal course of the vascular pedicle. Most branches to the clavicular part end medial to the coracoid process. The course of the branches to the upper sternocostal part is more medial. Based on their anatomical findings, the authors propose a surgical technique for transfer of the pectoralis major island flap to the head and neck area through a tunnel in the deltopectoral groove, lateral to the origin of the vascular pedicle. Head and neck reconstruction was performed using this technique. The presented method is a muscle-preserving procedure that maintains maximal donor-site function and morphology.
Transverse landmarks have recently been determined to predict the proximal and distal edges of the A1 pulley for trigger finger release. Percutaneous A1 pulley release has been discouraged for the border digits because of the risk of injury to the neurovascular structures of the index and small fingers. The purpose of the study was to identify longitudinal surface landmarks to prevent injury to the neurovascular bundles during percutaneous A1 pulley release of the ulnar and radial border digits. Longitudinal surface landmarks were identified and marked on 29 cadaver hands. Proximal and distal landmarks for the longitudinal vector through which the A1 pulley of the small finger was released include the midline of the proximal digital crease and the scaphoid tubercle. Proximal and distal landmarks for the longitudinal line through which the index finger A1 pulley was released include the midline of proximal digital crease and radial edge of the pisiform. Longitudinal incisions were performed between these landmarks, straight through the skin and deep enough to score the A1 pulley. The distance of the medial edge of the neurovascular structures from the longitudinal incision in the A1 pulley was measured for each small finger and index finger. Using these longitudinal landmarks for the index and small fingers, none of the neurovascular structures was injured while performing these longitudinal incisions through the skin, scoring the A1 pulley. In fact, the average distance for the neurovascular structures from the longitudinal vector of the small finger was 5.4 +/- 1.4 mm radially and 6.7 +/- 1.9 mm ulnarly. The average distance for the neurovascular structures from the longitudinal line of the index finger was 8.5 +/- 1.8 mm radially and 6.2 +/- 1.7 mm ulnarly. Based on the findings of this anatomical study, these longitudinal landmarks can be used to avoid injury to neurovascular structures in the management of trigger finger involving the border digits with steroid-injection, open, or percutaneous A1 pulley release.
Submandibular gland resection for aesthetic reasons has been hotly debated. Detractors maintain that the procedure is dangerous because it puts too many important structures at risk, notably motor nerves. The present study was undertaken to elucidate the neurovascular and soft-tissue anatomy of the digastric triangle via cadaver dissections so that a surgical approach to achieve safe aesthetic submandibular resection could be performed. Fifteen digastric triangles dissections were performed in fixed and fresh cadaver specimens. The dissection focus was to understand the submandibular neurovascular relationships, capsule as well as fascial layers, and measurements to known structures. The marginal mandibular nerve is located external to the submandibular capsule, approximately 3.7 cm cephalad to the inferior margin of the gland. The hypoglossal nerve is posterior to the digastric sling in a position that is protected deep within the visceral layer of the neck. The lingual nerve is located underneath the mandibular border, crossing anterior to the submandibular duct. The vascular supply is variant, but with an average of one and a half vessels entering medially to the superficial lobe of the gland, one intermediate vessel entering medially to supply the superficial and deep lobes, and one deep perforator that runs from the central portion of the deep lobe to the superficial lobe. Appreciation of this anatomy is critical in the submental approach for partial resection. Although it can be technically challenging, the anatomy is straightforward and partial submandibular gland resection can be executed via a consistent, safe approach to optimize facial rejuvenation in certain patients.