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Anatomy and Embryology of the Mouth and Dentition
Published in John C Watkinson, Raymond W Clarke, Terry M Jones, Vinidh Paleri, Nicholas White, Tim Woolford, Head & Neck Surgery Plastic Surgery, 2018
There are two sets of veins draining the tongue. The deep lingual vein begins near the apex of the tongue and runs back on its ventral surface (see Figure 41.3). It joins a sublingual vein from the sublingual salivary gland, to form the vena comitans nervi hypoglossi. This then passes backwards with the hypoglossal nerve and joins the lingual, facial or internal jugular vein. Dorsal lingual veins drain the dorsum and sides of the tongue and join the lingual veins accompanying the lingual artery. They drain into the internal jugular in the region of the hyoid bone.
Rectus abdominis
Published in John Dudley Langdon, Mohan Francis Patel, Robert Andrew Ord, Peter Brennan, Operative Oral and Maxillofacial Surgery, 2017
The deep inferior epigastric artery is a large caliber vessel (3–4 mm diameter) that travels on the deep surface of the rectus abdominis muscle. The vessel splits into two main branches as it courses the undersurface of the muscle greater than 50% of the time. From the point that the artery exits the muscle at the level of the arcuate line travelling inferiorly for approximately 8–10 cm, it inserts into the medial aspect of the external iliac artery. Paired vena comitans accompanying the artery will commonly form into a single larger caliber vein (greater than 60%) and enter into the external iliac vein.
Vascular access
Published in Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg, Operative Pediatric Surgery, 2020
Marcus D. Jarboe, Ronald B. Hirschl
For peripheral access, the arm is stabilized on a support board. Standard, sterile skin preparation is carried out and a local anesthetic injected after selection of an appropriate entry site to the basilic or cephalic vein, usually above the elbow (Figure 1.5a and b). The vein is punctured with a 21-gauge needle or 22-gauge cannula. Aspiration of blood confirms successful puncture. A 0.018-inch (0.5 mm) guidewire is then advanced into the vein. If resistance is felt at this point, the needle or cannula should be repositioned (it is usually too far in). An appropriately sized PICC is selected. The needle or cannula is removed and a peel-away sheath of diameter just sufficient to accept the PICC is advanced over the guidewire. The guidewire should be fixed relative to the patient, and pressure applied over the puncture site as this is done. The guidewire and the dilator of the peel-away sheath are then removed, and the PICC inserted into the sheath. It is usually easier to advance the PICC to a central position if its stiffening wire is left in. In certain places, especially near the termination of the cephalic vein in the deltopectoral groove, it may be easier to fix the stiffening wire and advance the PICC over it, unsupported. When the tip lies in the low SVC or upper right atrium, the peel-away sheath is split and removed, aspiration of blood is confirmed, and the catheter is flushed with normal saline. It is then sutured to the skin, and a transparent occlusive dressing applied. When no suitable superficial vein is available, ultrasound-guided puncture of a brachial vein (vena comitans of the brachial artery) is usually successful.
Pharmacological thrombolysis: the last choice for salvaging free flaps
Published in Journal of Plastic Surgery and Hand Surgery, 2018
Sik Namgoong, Jong-Phil Yang, Seong Ho Jeong, Seung Kyu Han, Woo Kyung Kim, Eun Sang Dhong
A 54-year-old woman underwent ALT free flap transfer for chronic osteomyelitis in the left anterior tibial area. The descending branch of the lateral circumflex femoral artery was anastomosed to the left anterior tibial artery. A single venorrhaphy was performed with the anterior tibial veins and vena comitans. Within 24 h, the flap became hyperemic with accelerated capillary refilling, warm temperature, and positive Doppler sound. At 36 h, the distal flap margin appeared purple and congested overall. Surgical exploration of the anastomotic site showed intact arterial and venous blood flow without discernable thrombosis. Intact circulatory flow at the venorrhaphy site was confirmed by milking test; however, venous flow was sluggish. Based on our salvaging algorithm, we could attribute the sluggish venous outflow to internal causes such as arterial spasm, perforasome selection issues (i.e. extremely large flap territory for the area perfused by the perforator) [12,13], and intra-flap microthrombosis. At this point, we attempted to apply topical papaverine and lidocaine to the anastomotic site to rule out the abovementioned internal causes; however, venous return did not recover.
Reconstruction of a malignant soft tissue tumor around the elbow joint using a frozen autograft treated with liquid nitrogen, in combination with a free anterolateral thigh flap: A report of two cases
Published in Case Reports in Plastic Surgery and Hand Surgery, 2018
Akihiro Hirakawa, Akihito Nagano, Shingo Komura, Daichi Ishimaru, Kenji Kawashima, Haruhiko Akiyama
A 76-year-old woman visited her previous doctor with a six-month history of two tumors in her elbow. An excision biopsy was performed, with a diagnosis of fibrosarcoma confirmed through pathological examination. The patient was referred to our hospital for further assessment and treatment. On physical examination, two masses (2 × 2 cm in size) were identified on the lateral aspect of the right elbow (Figure 5), with the scar of a previous surgery between the two masses. The ROM of the elbow was within normal limits. No abnormal findings were identified on plain radiographs. On Gd-DTPA-enhanced T1WI, contrast enhancement was observed in the tumors and the fascia and subcutaneous tissue surrounding the lesions, which was considered as residual tumor tissue (Figure 6). The location of the skin incision and the level of resection were defined in the same manner as in Case 1. The tumor was excised en bloc (Figure 7a). Briefly, the wrist and finger extensor, supinator, anconeus, and triceps brachii were resected. One third of the lateral portion of the distal humerus and radial head were also resected using a bone saw. With the exception of the radial articular capsule attached to the humerus, the fascia of the wrist and finger extensor with its insertion and the tendon of the triceps brachii with its insertion, all other soft tissues and the tumor were dissected from the bone sections. The excised bone portion was frozen in liquid nitrogen in the same manner as in Case 1 (Figure 7b) and then reconstructed in situ using a locking plate (LCP Distal Humerus Plate: DePuy Synthes) and headless compression screw (3.5 mm HCS: DePuy Synthes). The triceps brachii, augmented with the Leeds-Keio ligament, was reattached to the olecranon and the radial articular capsule was reattached to the radial notch using a suture anchor (Corkscrew, Mini Corkscrew: Arthrex, Naples, FL). The wrist and finger extensor were repaired by using a polyethylene terephthalate suture (ETHIBOND®: Ethicon Inc.) (Figure 7c). The soft tissue defect was reconstructed with a free, 27 × 18 cm, ALT flap (Figure 7d). Arterial revascularization was performed end-to-end to the deep brachial artery. Venous anastomosis was done end-to-end to the vena comitans of the deep brachial artery and the basilic vein. The affected limb was elevated postoperatively and the elbow was immobilized for 14 days. Subsequently, ROM exercise was initiated in the same manner as in Case 1. Filling of the host-graft junction gap was observed 7 months after the operation. At the 1-year follow-up, elbow ROM was −35° extension and 130° flexion. Bone union was achieved (Figure 8a,b), and a complete and stable coverage of the defect was obtained (Figure 8c,d). Local recurrence of the tumor was not detected.