Arterial supply of the anterior ear.

Twenty cadaver auricles were injected with a latex solution to define the arterial supply of the anteroauricular surface. Two arterial networks exist, the network of the triangular fossa-scapha and the network of the concha. Both eventually communicate on the anthelix. The triangular fossa-scapha network originates from one subbranch of the upper auricular branch of the superficial temporal artery and from branches of the posterior auricular artery that come through the earlobe and triangular fossa and over the helical margin. The conchal network is provided by two to four perforators that come from the posterior auricular artery, piercing the conchal floor. Auricular branches of the superficial temporal artery in the preauricular region and their communications with the posterior auricular artery also were confirmed. We believe that a greater understanding of the detailed arterial anatomy in this area allows one to develop safely a variety of surgical techniques for reconstruction of the ear.     

Relevance of the lesser occipital nerve in facial rejuvenation surgery

Nerve injuries are possible during facial rejuvenation surgery. The great auricular nerve has been studied; however, little is known about the lesser occipital nerve and its relevance in facial rejuvenation surgery. To understand the importance of the lesser occipital nerve in a face lift procedure, the specific anatomy of the nerve was studied in the laboratory in 19 hemifaces, with additional nerve observations in the operating room. The course of the lesser occipital nerve, its branches, and the relationship with the surrounding structures were evaluated and recorded. The great auricular nerve was also dissected to compare the two nerve territories. In the majority of the dissections, the lesser occipital nerve supplied the superior ear and the mastoid area, whereas the great auricular nerve innervated the inferior ear and a portion of the preauricular area. The nerves, however, were variable in size and distribution. Five lesser occipital nerves provided the dominant supply to the ear, compensating for a small great auricular nerve contribution. Therefore, injury to the lesser occipital nerve can result in a major sensory deficit of the ear. We also found the lesser occipital nerve to have a subcutaneous course at a proximal and variable level. These nerve branches can be superficial, and therefore postauricular flap dissection can injure the nerve if the flap is dissected at the fascial level. We therefore suggest that the dissection be at a more superficial level to avoid nerve injury. And finally, if SMAS/platysma suspension sutures are placed, we suggest these be done in a vertical-oblique direction along the course of the lesser occipital nerve, because this should minimize the possibility of trapping terminal branches.     

Reconstruction of the concha of the ear using a postauricular island flap

An effective method of reconstruction of the auricular conchal cavity using a postauricular island flap containing the postauricular blood vessels is described. In this procedure, the island flap is brought in to cover the defect of the conchal cavity through a tunnel between the defect and the retroauricle. Sound anatomic and mechanical principles are introduced in this technique. Two patients underwent the operation, and good results were obtained.     

An improved one-stage total ear reconstruction procedure

Based on anatomic studies of the postauricular cutaneous circulation, a modified single-stage total ear reconstruction procedure has been presented. The operation consists of using a large, superthin, well-vascularized, and well-innervated skin flap to cover the anterior surface of the auricular framework carved from costal cartilage, the posterior surface of which is covered by a subcutaneous tissue flap and then skin grafted. Improvements in the makeup and carving of the framework have been made and described. This method has been used to treat 15 cases of anotia, all with satisfactory results.     

A newly defined conchal floor arterial flap for auricular reconstruction

A conchal floor composite flap pedicled by skin of the helical crus has been well described in the literature. Here the flap is elevated based on the supply by an upper auricular branch of the superficial temporal artery. In this article, a newly defined conchal floor arterial flap is proposed. The flap is based on the main stem of the posterior auricular artery and its venae comitantes. Two types of conchal floor arterial flaps were elevated: a proximally based chondral arterial flap and a distally based chondrocutaneous arterial flap. The proximally based flap was used for earlobe reconstruction, whereas the distally based flap was useful in the reconstruction of the upper auricle. Nine congenital auricular malformations were successfully corrected with this newly defined conchal floor flap procedure. This type of flap is easier to elevate, more reliable, and more versatile than the one currently in use.     

Improved technique for a one-stage repair of significant defects of the ear

An improved technique for repair of severe acquired partial defects of the auricle in one stage is described. The common postauricular flap with its base on the margin of the auricular defect is usually unable to repair a severe partial auricular defect in one stage because of the limited length of the flap. The authors developed this technique by means of lengthening the flap with a piece of subcutaneous tissue of the scalp, so that the ear framework can be covered completely in one stage. All flaps in this group survived totally. Seven patients with severe acquired partial defects of the auricle underwent this procedure, and good results were obtained.     

The lobular division,bronchial tree and blood vessels of the squirrel monkey lung

The lobular division, bronchial tree, and blood vessels in lungs of seven squirrel monkeys (Saimiri sciureus) were examined from the viewpoint of comparative anatomy. The right lung of the squirrel monkey consists of the upper, middle, lower, and accessory lobes, whereas the left lung consists of the upper, middle, and lower lobes. These lobes are completely separated by interlobular fissures. In three of seven examples examined the left middle lobe was lacking. The squirrel monkey lung has four bronchiole systems, i.e. dorsal, lateral, ventral, and medial, on both sides. The upper lobes are formed by the first branches of the dorsal bronchiole systems. The middle lobes are formed by the first branches of the lateral bronchiole systems. The remaining bronchioles constitute the lower lobes. In addition to the above lobes, in the right lung, the accessory lobe is present, being formed by the first branch of the ventral bronchiole system. The right pulmonary artery runs across the ventral side of the right upper lobe bronchiole, and then across the dorsal side of the right middle lobe bronchiole. Thereafter, it runs between the dorsal bronchiole and lateral bronchiole systems along the dorso-lateral side of the right bronchus. During its course, the right pulmonary artery gives off the arterial branches which run along each bronchiole. These branches run mainly along the dorsal or lateral side of the bronchioles. In the left lung, the pulmonary artery and its branches run the same course as in the right lung. The pulmonary veins run mainly the ventral or medial side of the bronchioles, and between the bronchioles.     

The anatomic basis for the platysma skin flap

Meticulous anatomic dissection of the vasculature of the superficial anterolateral neck indicates that the platysma and overlying skin are supplied by direct cutaneous arteries measuring 0.5 mm in diameter. The small arteries are branches of the postauricular and occipital arteries in the upper lateral neck, the facial and submental arteries in the upper medial neck, the superior thyroid artery in the middle of the neck, the subclavian artery in the lower medial neck, and the transverse or superficial cervical arteries in the lateral aspect of the neck. These vessels traverse the undersurface of the platysma muscle to provide blood flow to the overlying skin. As opposed to this direct cutaneous system, the myocutaneous blood supply perforating through the sternocleidomastoid is scant. The platysma skin flap will survive if the blood supply from at least one region is preserved. In addition, it may be beneficial to include the external jugular and/or the communicating veins in the flap. By following these guidelines, the platysma flap has been successfully used for facial reconstruction in 7 of 8 consecutive patients.     

The bronchial tree,lobular division,and blood vessels of the lung of the Diana monkey (Cercopithecus diana)

The authors examined the lung of one Diana monkey (Cercopithecus diana). The right lung consists of upper, middle, lower, and accessory lobes, the upper and middle lobes being united dorsally. The accessory and lower lobes are separated from the other lobes by fissures. The left lung consists of a bi-lobed middle lobe and a lower lobe. These lobes are separated by an interlobular fissure. The Diana monkey has dorsal, lateral, ventral, and medial bronchiole systems on either side. The upper lobe is formed by the first bronchiole of the dorsal bronchiole system. The middle lobe is formed by the first bronchiole of the lateral bronchiole system and the accessory lobe is formed by the first bronchiole of the ventral bronchiole system. The remaining bronchioles of the four bronchiole systems constitute the lower lobe. The right pulmonary artery runs across the ventral side of the right upper lobe bronchiole, and then across the dorsal side of the right middle lobe bronchiole. Thereafter, it runs between the dorsal and lateral bronchiole systems, along the dorso-lateral side of the right bronchus. During its course, the right pulmonary artery gives off arterial branches running along the dorsal or lateral side of each bronchiole. The left pulmonary artery runs across the dorsal side of the left middle lobe bronchiole. Thereafter, it follows the same course as in the right lung, giving off arterial branches. The pulmonary veins run along the ventral or medial side of the bronchiole, and between the bronchioles.     

Distribution of the pulmonary artery and vein in the chimpanzee lung

Lungs of two chimpanzees (Pan troglodytes) were examined. The right pulmonary artery runs across the ventral side of the right upper lobe bronchiole and, then across the dorsal side of the right middle lobe bronchiole. Thereafter, it runs between the dorsal bronchiole system and the lateral bronchiole system, along the right bronchus. During its course, it gives off arterial branches which run along each bronchiole. The left pulmonary artery runs across the dorsal side of the left middle lobe bronchiole and then between the dorsal bronchiole system and the lateral bronchiole system. The branches of the pulmonary artery run mainly along the dorsal or lateral side of the bronchiole. The pulmonary veins run mainly along the ventral or medial side of the bronchioles, and between them. Finally, they enter the left atrium with four large veins, i.e. the common trunk of the right upper lobe vein and the right middle lobe vein, right lower lobe pulmonary venous trunk, left middle lobe vein, and left lower lobe pulmonary venous trunk.     

The tumbling concha-cartilage flap for correction of lop ear

This article presents a new surgical method that uses tumbling concha-cartilage flaps to correct lop ears. Through a posterior or anterior auricular skin incision, a rectangular or T-shaped cartilage flap is elevated from the concha and tumbled backward. After passing under the postauricular skin, the flap's tip is fixed to the lidded helix or scapha. The recoiling force of the flap's conchal side enables the lidded portion to be in a normal, erect, anatomic position. The method also increases the vertical height of the ear and creates a normally shaped scapha. Sixteen lop ears were corrected using this procedure, with most of them maintaining natural auricular features. Therefore, this method was considered effective for the correction of moderate lop ear deformity.     

Distribution of the pulmonary artery and vein in the lung of the white handed gibbon

The lungs of four white handed gibbons (Hylobates agilis) were examined. The right pulmonary artery runs across the ventral side of the right upper lobe bronchiole, and then traverses the dorsal side of the right middle lobe bronchiole. Thereafter, it runs along the dorso-lateral side of the right bronchus, between the dorsal bronchiole system and the lateral bronchiole system, and gradually follows the dorsal side of the right bronchus. During its course, it gives off arterial branches which run along each bronchiole. The left pulmonary artery runs across the dorsal side of the left middle lobe bronchiole and then along the left bronchus as in the right lung. The branches of the pulmonary artery run mainly along the dorsal or lateral side of the bronchiole, while the pulmonary veins run mainly the medial side of the bronchioles or between them. However, in a few portions, the pulmonary veins run the lateral side of the bronchioles. Finally, they enter the left atrium with four large veins i.e. the common trunk of the right upper lobe vein and right middle lobe vein, right lower lobe pulmonary venous trunk, left middle lobe vein, and left lower lobe pulmonary venous trunk.     

Distribution of the pulmonary artery and vein in the lung of the crab-eating monkey (Macaca fascicularis)

In the lung of the crab-eating monkey (Macaca fascicularis), the right pulmonary artery runs across the ventral side of the right upper lobe bronchiole and the dorsal side of the right middle lobe bronchiole. Thereafter, it courses along the dorso-lateral side of the right bronchus, between the dorsal and lateral bronchiole systems. During this course, the right pulmonary artery gives off arterial branches running mainly along the dorsal or lateral side of each bronchiole. The left pulmonary artery runs across the dorsal side of the left middle lobe bronchiole, and is then distributed as in the right lower lobe. The pulmonary veins run mainly along the ventral or medial side of the bronchiole in the upper and middle lobes whereas, in the lower lobe, they run ventrally, and between the bronchioles. Finally they enter the left atrium as four large veins.     

Modified Antia-Buch repair for full-thickness upper pole auricular defects

Various reconstructive techniques have been described for repair of full-thickness upper pole auricular defects. The wedge excision commonly used for treatment of upper pole tumors allows excision and reconstruction in a single stage. However, this technique suffers from major deficiencies. We apply the concept of crescentic scaphal excision and the Antia-Buch advancement-rotation flap principle to repair various full-thickness upper pole auricular defects resulting from excision of skin lesions in eight consecutive patients. The technique achieves a natural auricular shape in three dimensions with minimal disruption of the anatomic landmarks and avoids conspicuous scars. It has several advantages over the original Antia-Buch repair and other techniques used for reconstruction of full-thickness upper pole auricular defects.     

Subfascial expansion and expanded two-flap method for microtia reconstruction

This article presents an improved two-flap method for microtia reconstruction. In the first stage of this method, a tissue expander is inserted in the mastoid region through a subfascial pocket, after which the overlying fascia and skin are expanded simultaneously with saline infusion for about 5 months. In the second stage, the expanded fascial and skin layers are split and prepared as anteriorly based skin and fascial flaps defined by their vascularity. An erect, three-dimensional, contour-accentuated ear framework fabricated with autogenous rib cartilage is inserted between the two flaps. The anteroauricular surface of the framework is draped with the thin, expanded skin, and the postauricular surface is draped with the thin, expanded fascia and overlying grafted skin. In the third stage, remnant auricular cartilage is removed and the crus helicis, tragus, intertragic notch, conchal floor, and a hollow mimicking the external auditory meatus are shaped. In this study, 146 microtias were reconstructed consecutively using the improved two-flap method. The final results were promising--major complications were minimal and most patients showed consistently favorable aesthetic results. This method married a two-flap procedure with a gradual tissue expansion, conveniently exploiting the advantages of both methods, but without the disadvantages.     

The arterial blood supply of the skin flap of the dorsal foot

The dorsal foot skin supplied by the arteria dorsalis pedis the dorsal venous arch, the peroneal sensory nerves and the musculus extensor digitorum brevis is a very good myocutaneous flap. The material on which the study was carried out, consisted of 20 feet from standard cadavers, injected with a mixture of terebenthene and minium through the arteria tibialis anterior. The m. extensor digitorum brevis is 6.1 cm long, 1.7 cm wide, 3.9 mm thick. It is mainly supplied by the a. dorsalis pedis and its branches: the a. tarsea dorsalis (constant) and the a. metatarsea dorsalis (12 of 20 specimens). The average diameter of the a. dorsalis pedis at the upper limit of the m. extensor retinaculum was 2.14 mm and this was chosen as the most proximal limit of the dorsalis pedis flap. The a. tarsea dorsalis was present in all the specimens, with a diameter of 0.95 mm at its origin and a length of 35 mm. On average, this artery divided into four branches to the m. dorsalis pedis. The a. metatarsea dorsalis was present in 12 of 20 specimens, with an average diameter of 0.53 mm and a length of 22 mm. On average, this artery divided into three branches to the m. dorsalis pedis. We drew three lines in the proximal, middle and distal third of each flap design and calculated the sum of arterial branch sections with our lines. We think this provides a reasonable indication of the comparative richness of the cutaneous blood supply in the flap. The mean number of cutaneous branches was 10 in the proximal third, 6.7 in the middle third (13 if branches supplying the m. extensor pedis brevis are included) and 5 in the distal third. The myocutaneous dorsalis pedis arterialized flap can be safely used as an island flap to cover the ankle or heel and as a free flap for palm defects.     

Depth of the facial nerve in face lift dissections

Facial nerve depth was measured in 12 cadaver face halves after bilateral face lift dissections. The main nerve trunk emerged anterior to the midearlobe and was 20.1 +/- 3.1 mm deep. Nerve exit from the parotid edge also was deep, averaging 9.1 +/- 2.8 mm for temporal, 9.2 +/- 2.2 mm for zygomatic, 9.6 +/- 2.0 mm for buccal, and 10.6 +/- 2.7 mm for mandibular branches. Distal to the parotid gland, danger areas where nerve branches became superficial were distal temporal, lower buccal, and upper mandibular branches over the masseter muscle and marginal mandibular as it crossed the facial artery. Some protection in these danger areas was provided by fascia, especially superficial temporal and masseteric, while platysma provided some protection for the mandibular branch. Fascial and muscle protection was less in thin cadavers. Face lift dissection can be rapid in areas where facial nerve branches are deep or absent, such as postauricular, inferior to the zygomatic prominence, and near the earlobe.     

Use of the forest canopy by the agile gibbon

Brachiation was the main form of locomotion and took place along branches and boughs in the upper canopy. The posture during feeding depended on the substrate, with the gibbons sitting on branches but hanging in twigs. During foraging the gibbons hung more, even on branches, but as only short stops were made this is probably to increase mobility. Feeding on fruit took place mainly in the middle canopy on small trees; feeding on leaves and foraging occurred evenly throughout the middle and upper canopies. Gibbons are light mobile animals with a rapid and direct form of locomotion that enables them to exploit dispersed food sources and to defend a large territory.     

Lymphedema of the eyelids

Lymphedema of the eyelids is a relatively rare condition whose main effect is to obstruct vision, and it is unsightly. We present 3 cases in which the edema was treated by excision and skin grafting of the eyelid, with satisfactory functional and cosmetic results. It is suggested that a split-skin graft be used for the upper eyelid and a full-thickenss graft for the lower eyelid. The lower eyelid skin can be "de-fatted" and used as a graft, but in the more severe cases we suggest a postauricular skin graft be used.     

The influence of vessel wall elasticity and peripheral resistance on the carotid artery flow wave form: a CFD model compared to in vivo ultrasound measurements

The Doppler flow wave form and its derived measures such as the pulsatility index provide clinically important tools for the investigation of arterial disease. The typical shape of Doppler flow wave forms is physiologically known to be largely determined by both peripheral resistance and elastic properties of the arterial wall. In the present study we systematically investigate the influence of both vessel wall elasticity and peripheral resistance on the flow wave form obtained from a CFD-simulation of blood flow in the carotid bifurcation. Numerical results are compared to in vivo ultrasound measurements. The in vivo measurement provides a realistic geometry, local elasticities and an input flow wave form for the numerical experiment. Numerical and experimental results are compared at three different sites in the carotid branches. Peripheral resistance has a profoundly decreasing effect on velocities in the external carotid artery. If elasticity is taken into account, the computed peak systolic velocities are considerably lower and a more realistic smoothing of the flow wave form is found. Together, the results indicate that only if both vessel wall elasticity and positive peripheral resistance are taken into account, experimentally obtained Doppler flow wave forms can be reproduced numerically.