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By: A. Roy, M.A., M.D.

Clinical Director, Icahn School of Medicine at Mount Sinai

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The unique advantage of the flap is its colour match with facial skin and the relative inconspicuous nature of the donor site scar erectile dysfunction treatment homeopathy generic caverta 100 mg free shipping. There have been reports of problems with venous congestion erectile dysfunction treatment viagra buy caverta overnight, particularly when tunnelled through the submandibular space but the flap does violate a clinically significant oncological site. Facial artery myomucosal flap Submental island flap this flap, first described by Martin in 1983,3 has great utility as an axial pattern flap or a free flap for reconstruction of the facial skin or intraoral lining. The flap is supplied by a branch or branches of the facial artery which either pass over or through the submandibular gland traversing medially on the mylohyoid muscle and then deep to the anterior belly of the digastric muscle to provide a perforator-based arterial supply and venous drainage to the submental skin. There can be occasional problems with venous congestion particularly in the reverse flow design because of valves in the facial vein. The anatomy of this flap is based on the buccinator muscle and its relationship to the facial artery. The buccinator is covered medially by the submucosa and mucosa and laterally by the external lamina of the muscles of facial expression, the masseter, the buccal fat pad, and the facial artery and vein. The facial artery, a branch of the external carotid artery, enters the face by curving around the lower border of the mandible at the anterior edge of the masseter muscle. At this point, it lies deep to the risorius, zygomaticus major muscle and the superficial lamina of the orbicularis oris muscle. It lies superficial to the buccinator muscle and the lateral edge of the deep lamina of the orbicularis oris muscle. At this point in its course, it gives off multiple perforating vessels to the cheek and the superior labial artery. The flap may be harvested as an inferiorly based flap based on antegrade flow or a superiorly based flap with retrograde flow. The basic harvest technique is to Doppler out the facial artery through the buccal mucosa and map the course of the vessel. For the inferiorly based flap, dissection begins anterosuperiorly to identify the arterial supply to the upper lip with division of the facial artery at this point and then retrograde dissection which includes the mucosa, buccinator, facial artery and the tissue and venous plexus that lies between the artery and the muscle. In the superiorly based flap, the dissection begins inferiorly with visualization and ligation of the facial artery and then a retrograde dissection of the tissues including the buccinator muscle. The flap can also be rotated across the alveolus to close small defects of the floor of mouth or tongue, as well as the palate. Temporoparietal fascial flap the temporoparietal flap is a versatile local rotation or free fascial flap for reconstruction of the head and neck or extremities. More recently, it has been popularized by Brent and Byrd,7 and others for microtia repair and auricular reconstruction. Its unique characteristics are a remarkably robust vascular supply with a very thin and pliable flap with minimal donor site morbidity. The arterial supply of the temporoparietal flap is the superficial temporal artery, a terminal branch of the external carotid artery. The vessel classically has a number of branches above the zygoma with most patients having a prominent frontal branch and dominant branch which ascends towards the vertex of the skull. There is some variation in venous anatomy with a small percentage of patients having venous drainage through the post-auricular vein or occipital veins. The fascia has an inner and an outer layer with the artery and vein entering between the inner and outer layers and then coursing vertically in the outer layer of the fascia. A thin muscular layer (the superficial auricular muscle) separates two parts of the outer layer of the fascia below the temporal line. For flap harvest, the patient is usually positioned in the supine position, with the drape line along the vertex of the scalp leaving the post-auricular area exposed. The important landmarks for this flap are the arch of the zygoma, the pinna and the usual landmarks of the facial nerve. The flap is harvested as an elliptical or teardrop shape, above the level of the zygoma.

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Patient positioning is quite important in order to allow visualization of the medial aspect of the crest erectile dysfunction injection medication trusted 100 mg caverta. In most iliac crest bone graft harvests a bag is placed under the hip to rotate it away from the surgeon psychological erectile dysfunction drugs buy 50 mg caverta. One approach is to place a soft roll under the sacrum to elevate the pelvis and then rotate the operating table towards the surgical side to maximize visualization. As mentioned, most experienced microsurgeons try to avoid the osseocutaneous version of the flap because of the unreliability of the flap. Probably the most commonly harvested version of the flap incorporates the internal oblique as a myosseous flap. One option to reduce donor site complications is to harvest only the inner table splitting the crest by making an oblique cut through the top of the crest extending just below the transversalis reflection. This technique provides adequate bone for mandibular reconstruction and preserves the lateral crest and anterior iliac spine. If the internal oblique is harvested, most surgeons routinely repair the defect with a surgical mesh to avoid abdominal wall laxity. In the midportion of the lateral thigh, the descending branch provides a number of perforators to the skin of the lateral thigh. These perforators can either run between the rectus femoris and vastus lateralis muscle then traverse the fascia lata as septocutaneous perforators to supply the skin of the lateral thigh or they can traverse the vastus lateralis muscle and the deep fascia as musculocutaneous perforators to supply the skin. The donor site has limited morbidity and in most patients can be closed primary, in a vertical line. Provided the nerve to vastus lateralis is preserved, little functional disability is associated with this flap. The flap may be harvested as a perforator flap with or without the fascia lata and can incorporate the vastus lateralis if a muscle component is required. In patients with the appropriate body habitus this flap is thin and pliable and provides an excellent reconstruction for the oral tongue and floor of mouth. The skin colour match to facial and neck skin is poor, especially in Caucasian patients. The anatomy of the flap is variable and somewhat unpredictable, thus the surgeon contemplating the use of this flap needs to understand the basic anatomic variations and be prepared for them. Since the cutaneous version of this flap is usually supplied by a single perforating vessel, proximal venous occlusions are usually difficult to salvage because of the small calibre of Chapter 207 Free flaps in head and neck reconstruction] 2881 the perforating vessels. In addition, because of the small size of the perforating vessels, the flap pedicle may be easily compromised by external compression. This makes it a poor choice for reconstructions requiring tunnelling of the pedicle. In some ethnic populations the thickness of fat in the lateral thigh makes this a poor donor site as the volume and bulk of the flap will produce an unreliable flap and a poor functional result. If a suprafascial technique is to be used for a thin flap, the dissection is carried laterally until the major perforators to the skin are identified. If a fasciocutaneous harvest is planned, the incision is carried through the deep fascia with the flap site mobilized laterally until the perforating vessels are visualized traversing the deep fascia. The pedicle is dissected in a retrograde fashion either to the descending branch for septocutaneous flaps or through the vastus lateralis in patients with myocutaneous perforators. In myocutaneous perforators, a small cuff of muscle is left around the pedicle to protect the small perforating branches. Great care should be used to maintain hemostasis in this portion of the elevation because the vessels frequently will go into spasm and the muscle may bleed excessively after revascularization. The artery passes distally with paired venae comitantes lying on the medial aspect of the fibular between the tibial posterior and the flexor hillocks longus. The peroneal artery provides perforating branches to the surrounding musculature and nutrient artery and periosteal supply to the fibula. The skin island is of an appropriate thickness for most oral cavity and oropharyngeal reconstructions.

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In many patients erectile dysfunction onset generic caverta 50mg line, a warning or herald bleed occurs and when there is any significant bleeding the wound should be explored and the bleeding point located impotence causes and cures discount caverta 100mg with mastercard. In the situation where a carotid bleed seems likely, blood is cross-matched and the patient should have a cuffed tracheostomy tube to protect the airway. When rupture occurs and emergency ligation of the artery is performed the complication rate is very high (mortality of 38 percent and a hemiplegia rate of 50 percent). Local pressure is applied to the bleeding vessel until volume replacement can be instituted. More usually, a leak of fluid occurs when the lower end of the jugular vein is being dissected and the duct must then be found and ligated. At the end of a neck dissection, this area should be inspected for any fluid leak. The loss at this stage is not severe because the patient is starved but once postoperative feeding is instituted, milky fluid pours out of the drain. However, if the leak is major, most surgeons will re-explore the wound, attempt to identify the source of the leak and oversew it. This is far from easy but probably an attempt should be made if the fistula is producing large volumes of chyle. If conservative measures and exploration of the neck do not control the leak, a lateral thoracotomy and a suture placed between the oesophagus and descending aorta in the inferior and posterior mediastinum will usually succeed. This will usually be obvious because there will be an air leak at the time if the patient is being ventilated and the tear should then be repaired. These are the lesser occipital, greater auricular, transverse cutaneous nerve of the neck, supraclavicular nerves and probably some motor branches to the trapezius (see below); the descendens hypoglossi. They include: the facial nerve or its mandibular or cervical division; the hypoglossal and lingual nerves; the vagus, symphathetic trunk, phrenic nerve or brachial plexus. The effect of damage to these nerves is obvious, but some discussion of division of the accessory nerve and its effects is worthwhile. Division of the accessory nerve during radical neck dissection gives rise to the shoulder syndrome: pain in the joint, limitation of abduction and drooping of the affected shoulder. It has been reported that this complication occurs (in varying degrees) in approximately 60 percent of patients following a standard radical neck dissection. The main effects of this syndrome are long-standing pain in the shoulder and the inability to perform certain manoeuvres, such as putting on a jacket. Two important movements at the shoulder joint must be considered: abduction and flexion. Denervation of the trapezius muscle allows the shoulder girdle to rotate through 301 anteriorly. Abduction in these patients then becomes the equivalent of extension in the normal subject. The normal subject is unable to extend the arm beyond 451 because of locking of the glenohumeral joint. Abduction of the shoulder beyond 451 is therefore physically impossible in the patient with a denervated trapezius muscle. Flexion at the shoulder joint in the patient with a denervated trapezius is the equivalent of abduction in the normal subject. Abduction of the arm is a combination of two movements: firstly, elevation and rotation of the scapula on the trunk achieved by the trapezius muscle, and secondly, abduction of the humerus on the scapula mainly achieved by the deltoid muscle, assisted by the supraspinatus muscle, which helps to prevent displacement of the head of the humerus during strong deltoid action. The first 901 of the movement takes place at the shoulder joint under the control of the deltoid muscle and remains possible in the patient with a denervated trapezius. However, this 901 of movement only brings the arm to approximately 751 from the trunk because the shoulder girdle is tilted downwards. Furthermore, the remaining 901 of movement due to movement of the shoulder girdle on the trunk by the trapezius muscle is no longer possible. In summary, a patient with a denervated trapezius muscle can only abduct the arm from the trunk to an angle of 751, and abduction beyond that point is prevented by locking of the glenohumeral joint. The patient can flex the arm from the trunk to an angle of approximately 451 by the action of the deltoid muscle, but further flexion is prevented by a downward tilt of the shoulder girdle and the loss of the rotation of the shoulder girdle on the trunk by trapezius. The best way to prevent this syndrome is to preserve both the accessory nerve and the separate branches from the cervical plexus (C3 and C4) to the trapezius muscle.

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Phase-locking is seen only at low frequencies erectile dysfunction guidelines effective caverta 50mg, however erectile dysfunction vacuum therapy purchase caverta from india, where the cyclic changes in inner hair cell intracellular potential are large. The degree to which action potentials are phase locked, therefore, declines above this frequency. For stimulus frequencies below some 5 kHz, therefore, the timing of the action potentials in the nerve is able to signal details of the temporal properties of the sound waveform. A second important way that auditory nerve fibres code information is by means of their frequency selectivity. Auditory nerve fibres, therefore, share the tuning characteristics of single points on the membrane and of the inner hair cells. Each fibre has a frequency of stimulation for which it is most sensitive, that is for which the sound pressure level was lowest for the criterion response. As expected from the tonotopic organization of the mechanical travelling wave in the cochlea, fibres innervating the base have the highest best frequencies, and those innervating the apex the lowest. Coding based on frequency selectivity is called place coding, for the reason that the fibres responding best to different frequencies arise from different places in the cochlea. It would therefore be possible to determine the frequency of a stimulus by telling which fibres were activated. It should be noted that the temporal code and the place code are not mutually exclusive. A low frequency stimulus will be frequency filtered, according to the place principle, before the fibre is stimulated. In this record, the action potentials always occur just before the peak of the sound waveform. The relative extent to which these two principles are actually used by the nervous system under different circumstances has been a matter of debate for many years. It is indeed a general finding that the most sensitive fibres have their lowest thresholds in an intensity range close to the behavioural absolute threshold. In fact, some 75 percent of fibres have their best thresholds within a 15 dB range of this. It is likely that the low thresholds arise because the fibres have very sensitive synapses on the hair cells. A second minor population of fibres have much higher thresholds, in some cases 70 dB or more above the behavioural threshold. One way is to measure the bandwidth of the tuning curve at a set distance above the tip; bandwidths are often measured 10 dB above the tip. In that case, the bandwidth of cat auditory nerve fibres, in the range in which they are most frequency selective (around 10 kHz) is one-eighth of their characteristic frequency. This derives from the nonlinear mechanical response of the basilar membrane vibration, where the application of one stimulus can reduce the response to a second stimulus. It can, therefore, be distinguished from inhibition mediated by inhibitory synapses because spontaneous activity cannot be inhibited. This reduces the extent to which the hair cells can increase their response to a second superimposed stimulus, and so contribute to the active mechanical amplification of the travelling wave to the second stimulus. In the firing of the auditory nerve fibre array, it aids in keeping separate the representation of the different elements of a complex stimulus. A second major way in which nonlinearity is revealed is by the formation of distortion products by the inner ear. The slopes of the rate intensity functions, like the basilar membrane functions, are steeper for stimuli below the characteristic frequency than for those above it. Moreover, stimuli below the characteristic frequency can drive a fibre to greater firing rates than can stimuli above the characteristic frequency. Therefore, it would seem that the intensity of an acoustic stimulus can be coded in the firing rates of the auditory nerve fibres at least up to this intensity. A minority of fibres with high thresholds do not reach their maximum firing rates until much higher intensities.