The lumbar artery perforator based island flap: anatomical study and case reports
|
|
- Kevin Floyd
- 5 years ago
- Views:
Transcription
1 British Journal of Plastic Surgery (1999), 52, The British Association of Plastic Surgeons The lumbar artery perforator based island flap: anatomical study and case reports H. Kato*, M. Hasegawa, T. Takada* and S. Torii Departments of Plastic and Reconstructive Surgery, *Chubu Rosai Hospital, Nagoya; Okazaki Municipal Hospital, Okazaki; and Nagoya University School of Medicine, Nagoya, Japan SUMMARY. A lumbar artery island flap can be elevated based on a single lumbar artery. We studied the vascular anatomy using 21 specimens of lumbar arteries in 11 cadavers, and investigated the skin territory of the artery using fluorescein injection. We observed lumbar perforators emerging through the lumbar fascia at the lateral border of the erector spinae muscle, situated 5 9 cm from the midline. The diameter of the vascular bundle at the site of perforation ranged from 1 to 5 mm. Perforators of the second and fourth lumbar arteries were much more developed than others. The cutaneous territory supplied by the second lumbar artery extended from the posterior midline to the lateral border of the rectus sheath, and at least 10 cm above the anterosuperior iliac spine. We transferred four clinical flaps for coverage of ulcers on the lower back. All flaps survived and their donor site defects were closed primarily. The cadaver dissection, the injection study and our clinical success have confirmed the feasibility of lumbar artery island flaps The British Association of Plastic Surgeons Keywords: lumbar artery, perforator, island flap, pressure sore. The blood supply from lumbar arteries has been used for flaps such as the reverse latissimus dorsi musculocutaneous flaps 1 4 and the transverse lumbosacral back flaps, 5 which are generally regarded as clinically proven and reliable flaps. However, these flaps do have some disadvantages. With the reverse latissimus dorsi musculocutaneous flap the muscle is sacrificed. 1,2,4 In the transverse lumbosacral back flap, the rotational arc of the flap is limited, and the donor-site defect cannot be closed primarily. 5 These problems would be solved if a flap based on a single lumbar artery could be established as clinically reliable. There are few anatomical reports concerning the lumbar arteries. 6 Although some reports 5,7 have described the cutaneous vascular territory of lumbar arteries, the territory nourished by a single lumbar artery has not been defined in detail. The purpose of this paper is to define the vascular anatomy of lumbar arteries and the skin territory supplied by a single lumbar artery in order to establish the feasibility of lumbar artery island flap surgery. Anatomical study The lumbar arteries are similar to the intercostal arteries. Normally there are four on each side of the body, arising from the back of the aorta and travelling behind the psoas major muscle. The upper three arteries run laterally and backwards between the quadratus lumborum muscle and the erector spinae musculature, and the last set of arteries normally run in front of the quadratus lumborum muscle. From each artery, a perforating artery branches off just lateral to the erector spinae muscles sending a few branches to the skin (Fig. 1). 5,6 These perforators are of various sizes, but Figure 1 Cross-section of lumbar region. 541
2 542 British Journal of Plastic Surgery Table 1 Location of the perforator at the site of penetration through the lumbar fascia Case Distance from the midline (cm) L1 L2 L3 L4 1 L R ( ) L R L R L R L R L R L 9 8 ( ) 9 R L 8** ( ) ( ) 7 R ( ) 7* ( ) 8 9 L L 7 ( ) 7 8 R L 8 8 ( ) 8 R ( ) 7* ( ) 8 Max Min Mean ( ): Lumbar artery is present but has no perforator; ( ): Lumbar artery is absent; *: Two perforators; **: Three perforators; : Subcostal artery has a perforator at the L1 area. those of the second and fourth lumbar arteries are usually much more developed. 8 They anastomose with one another and form a vascular network in the subcutaneous layer 9,10 accompanied by veins and nerves. We investigated location as well as size of perforators at the sites of penetration through the lumbar fascia, using 21 specimens of lumbar arteries in 11 cadavers (Tables 1 and 2). The sizes of perforators were expressed by the diameter of vascular bundles including artery and veins because the dissection of the perforating artery alone was difficult in preserved cadavers. The lumbar perforators penetrated the lumbar fascia at the lateral border of the erector spinae muscles surfacing to the subcutaneous tissue at points 5 9 cm (mean: 7.22 cm) from the midline. In the cases in which the erector spinae muscles were well developed, the perforators ran on the surface of the muscle from the lateral border in a medial direction before emerging through the lumbar fascia. In the cases in which erector spinae muscles had atrophied, the perforators ran through the fascia from the lateral border of the muscle in a lateral direction before penetrating the fascia. Thus, the location of the perforator at the site of penetration through the lumbar fascia, which was recorded as the distance from the midline, did not seem to depend on the development of the erector spinae muscles. Although each lumbar artery usually had a perforating branch, some lumbar arteries had no perforator. All of the fourth lumbar arteries had perforators. Three of the first lumbar arteries (14.3%), two of the second lumbar arteries (9.3%) and five of the third lumbar arteries (23.8%) had no perforator. Although Table 2 most of the lumbar arteries were present even when they had no perforator, the first lumbar artery was absent in two sides (9.5%) and in these instances the subcostal artery gave off a perforator in the area of the first lumbar artery. In case 8, the first lumbar artery had three perforators, which compensated for the absence of perforators from the second and third lumbar arteries. In two of the four cases which had all but the perforator from the third lumbar artery, the second lumbar artery had two perforators in the area of the second and third. This sort of compensation, however, was not always present. The size of the vascular bundle was largest at the site of the fourth lumbar artery perforator, followed by the second lumbar artery. After the perforators pierced the lumbar fascia, they gave off arteries medially and laterally to supply the dorsal skin. In summary, the fourth lumbar artery was superior to other lumbar arteries in that the size of the perforator was the largest and it was the most reliably present. The next best was the second lumbar artery. Injection study Diameter of the vascular bundle (mm) Case L1 L2 L3 L4 1 L R L R L R L R L R L R L R L 3 4 R L L R L R 2 4 Max Min Mean Vascular bundle includes a perforating artery and venae comitantes. We injected fluorescein into the second lumbar artery in one clinical case. The skin territory supplied by the single lumbar artery extended from the posterior midline to the lateral border of the ipsilateral rectus sheath, and at least 10 cm above the anterosuperior iliac spine (Fig. 2). Operative techniques The sites of the lumbar artery perforators can be detected by using a Doppler ultrasound probe. The
3 Lumbar artery perforator island flap 543 Figure 2 (A) Distribution of the vascular territory of the second lumbar artery as delineated by fluorescein injection. (B) Diagram showing the vascular territory. lumbar artery perforator based island flap can be elevated based on any of these arteries. The most suitable lumbar artery perforator is selected according to the location of the ulcer. The flap is designed transversely or obliquely from the posterior midline down to the anterosuperior iliac spine to include the vascular pedicle in the flap. The distal edge of the flap can be placed as far anteriorly as the midaxillary line if required by the size and location of the ulcer (Fig. 3). Because the source lumbar artery travels obliquely and anteriorly from the lateral edge of the erector spinae muscles and then deep beneath the transverse process of a vertebra, the rotational arc cannot be widened even if further dissection were to be performed. When a wider rotational arc is needed, the pivot point can be placed in the vicinity of a transverse process by incising the erector spinae muscles. However, this manoeuvre cannot be adopted when using the fourth lumbar artery perforator because the lumbar artery runs in front of the quadratus lumborum muscle. When the rotational arc does not need to be large, the pivot point may be placed where the perforating artery emerges through the lumbar fascia. Skin incision should begin from the distal margin, and proceed proximally, including the lumbar fascia in the flap, until the pedicle is identified. The vascular pedicle is dissected only until sufficient mobility is gained to mobilise the flap adequately. The flap is passed to the defect either through a subcutaneous tunnel or by placement in an incision between the defect and donor site. The donor site defect can be closed primarily when the flap is less than 8 cm wide. Patient data We have treated four patients using the lumbar artery perforator based island flaps (Table 3). Three cases had pressure ulcers which occurred following spinal cord injuries. One had a radiation ulcer induced by surgery and radiation therapy for a malignant tumour of the soft tissue 21 years previously. The sites of ulcers were in the midline in two cases, the posterior iliac crest in one case and the paravertebral region in
4 544 British Journal of Plastic Surgery Discussion Figure 3 Design of the lumbar artery perforator based island flap. the last case. The midline ulcers were on the fifth lumbar vertebra and on the fourth to fifth lumbar vertebra. The paravertebral ulcer was just lateral to the midline, and extended vertically from the first to the third lumbar vertebra. All patients were male, and their ages ranged from 45 to 60 years. Results We used the first, second and fourth lumbar arteries. The sizes of the flaps used ranged from cm to 8 27 cm. The distal end of three flaps lay over the midaxillary line, and one reached the anterior axillary line. All flaps survived completely. Only one flap (Case 2) showed temporary congestion, but healing was uneventful. All the donor site defects were closed primarily. Case reports Case 2 (Fig. 4) A 60-year-old man who had kyphosis in his lumbar spine suffered from a pressure ulcer on the midline of his lower back after spinal cord injury. The ulcer was covered with a 6 13 cm island flap based on the second lumbar artery perforator. The distal end of the flap extended over the midaxillary line. The atrophied erector spinae was partially incised so that a long pedicle might be obtained. The flap survived completely, without complication. Case 3 (Fig. 5) A 54-year-old man with paraplegia due to spinal cord injury had a pressure ulcer on his posterior iliac crest. After debridement, the defect was covered with a cm island flap based on the fourth lumbar artery perforator. The distal end of the flap extended to the midaxillary line. Although the flap showed congestion, it survived completely. The blood supply to the skin from lumbar arteries has been used in flaps such as reverse latissimus dorsi musculocutaneous flaps 1 4 and transverse lumbosacral back flaps, 5 which have some disadvantages. The muscle is sacrificed with the reverse latissimus dorsi musculocutaneous flap. 1,2,4 In the transverse lumbosacral back flap, the rotational arc of the flap is limited, and the donor site defect cannot be closed primarily. 5 The lumbar artery perforator based island flap, on the other hand, has advantages because it is a fasciocutaneous flap based on a single artery. First of all, it does not sacrifice any muscle. Secondly, it has a large rotational arc. And finally, its donor site can be closed primarily. The perforator based flaps reported by Kroll and Rosenfield 11 were elevated from the lumbar region, but the vascular anatomy was not described in detail. The lumbar artery perforator flap differs from the flaps described by Kroll and Rosenfield in that the former has a single vascular pedicle which may be dissected up to the lumbar artery itself. Knowledge of vascular anatomy and the skin territories supplied by arteries is essential for flap surgery. Cadaver dissection showed that an artery suitable for lumbar artery island flap surgery does exist. The location of the perforator can be detected relatively easily by searching in the vicinity of the lateral border of the erector spinae, using a Doppler ultrasound probe. Although some reports 5,7 have described the skin territories of lumbar arteries, the territory supplied by a single lumbar artery has not been described in detail. Cormack and Lamberty 7 described the composite area of all the posterior cutaneous perforators, but the territory supplied by a single artery was unclear. The experimental work by Hill et al 5 described the width of the territory, but the length of the area was unclear. Kroll and Rosenfield 11 used perforator based flaps on the back and the buttocks with success because the sizes of the perforators were suited for these regions. In their clinical cases, a relatively large flap was elevated successfully, although the size of the flap was not defined. Our injection study showed that the skin territory supplied by the second lumbar artery alone was from the posterior midline to the lateral border of the rectus sheath, and at least 10 cm above the anterior superior iliac spine. This result may be helpful in determining the skin territory supplied by a single lumbar artery, although the size of the area may vary due to size variation in the lumbar arteries. Table 3 Patient summary Case Age Cause Site of ulcer Size of flap Lumbar artery (years) (cm) 1 58 Pressure ulcer Midline st 2 60 Pressure ulcer Midline nd 3 54 Pressure ulcer Posterior iliac crest th 4 45 Radiation ulcer Paravertebral st
5 Lumbar artery perforator island flap 545 Figure 4 Case 2. (A) Pressure ulcers on the midline of the lower back and on the sacrum. (B) Design of the lumbar artery perforator based island flap based on the second lumbar artery (after the sacral pressure sore was treated with a local flap). (C) Elevation of the flap. The erector spinae muscles were partially incised. The arrow shows the vascular pedicle. (D) Four months later. Figure 5 Case 3. (A) Pressure ulcer on the posterior iliac crest and the design of the lumbar artery perforator based island flap based on the fourth lumbar artery. (B) Key to Figure 5A. (C) Elevation of the flap. (D) Inset of the flap. The flap showed slight congestion.
6 546 British Journal of Plastic Surgery enables it to be used for lower back, as well as thoracic spinal region and posterior costal region reconstructions (Fig. 6). Acknowledgements We thank Yasuo Sugiura and Miya Kobayashi, Professor and Associate Professor of the Department of Anatomy at Nagoya University, for their valuable support in providing the anatomic specimens. Figure 6 Rotational arc of the lumbar artery perforator based island flap. How large a flap can be sustained by a single perforator? Our largest flap measured 8 27 cm in size, and its distal portion extended over the midaxillary line. When a larger flap is needed, the flap may be designed so that the axis of the flap runs obliquely from the midline down to the anterior superior iliac spine, because the lumbar arteries anastomose with each other and form a vascular network. 9,10 Our clinical success has proved that a relatively large flap with a distal margin extending over the midaxillary line can be safely elevated. In addition, our injection study suggests that it is possible to raise a wider flap of approximately 10 cm. Venous drainage of the flap depends on the lumbar vein. We experienced temporary venous congestion in one case (Case 2), resulting from a kink in the pedicle. There were no venous drainage problems in the other cases. Based on our study, the venous drainage through the lumbar vein appears to be reliable. We partially incised the erector spinae to obtain a greater rotational arc in two cases, including Case 1, but this procedure is applicable only to paraplegic patients whose muscles have atrophied and lost function. This procedure should not be performed on a patient who is capable of walking. Because the lumbar artery island flap has a single pedicle, it has a large arc of rotation. This mobility References 1. McCraw JB, Penix JO, Baker JW. Repair of major defects of the chest wall and spine with the latissimus dorsi myocutaneous flap. Plast Reconstr Surg 1978; 62: Bostwick J III, Scheflan M, Nahai F, Jurkiewicz MJ. The reverse latissimus dorsi muscle and musculocutaneous flap: anatomical and clinical considerations. Plast Reconstr Surg 1980; 65: Muldowney JB, Magi E, Hein K, Birdsell D. The reverse latissimus dorsi myocutaneous flap with functional preservation report of a case. Ann Plast Surg 1981; 7: Stevenson TR, Rohrich RJ, Pollock RA, Dingman RO, Bostwick J III. More experience with the reverse latissimus dorsi musculocutaneous flap: precise location of blood supply. Plast Reconstr Surg 1984; 74: Hill HL, Brown RG, Jurkiewicz MJ. The transverse lumbosacral back flap. Plast Reconstr Surg 1978; 62: Williams PL, Warwick R. The lumbar arteries. In: Gray s Anatomy, 36th ed. Edinburgh: Churchill Livingstone, 1980; Cormack GC, Lamberty BGH. The lumbar and sacral arteries. In: The Arterial Anatomy of Skin Flaps. Edinburgh: Churchill Livingstone, 1994; 156 8, Salmon M. The lumbosacral region. In: Taylor GI, Tempest MN (eds), Arteries of the Skin. London: Churchill Livingstone, 1988; Taylor GI. Foreword. In: Taylor GI, Tempest MN (eds), Arteries of the Skin. London: Churchill Livingstone, 1988; i xxxii. 10. Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993; 91: Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg 1988; 81: The Authors Hisakazu Kato MD, Tohru Takada MD, Department of Plastic and Reconstructive Surgery, Chubu Rosai Hospital, Komei, Minato-ku, Nagoya , Japan. Morimasa Hasegawa MD, Department of Plastic and Reconstructive Surgery, Okazaki Municipal Hospital, 2 2 Wakamiya-cho, Okazaki , Japan. Shuhei Torii MD, Department of Plastic and Reconstructive Surgery, Nagoya University, School of Medicine, 65 Tsurumai, Syouwa-ku, Nagoya , Japan. Correspondence to Dr H. Kato. Paper received 19 October Accepted 8 February 1999.
The gastrocnemius with soleus bi-muscle flap
The British Association of Plastic Surgeons (2004) 57, 77 82 The gastrocnemius with soleus bi-muscle flap Ikuo Hyodo a, *, Bin Nakayama b, Mitsuru Takahashi c, Kazuhiro Toriyama d, Yuzuru Kamei d, Shuhei
More informationAnatomical relationship between arteries and veins in the paraumbilical region q
The British Association of Plastic Surgeons (2003) 56, 552 556 Anatomical relationship between arteries and veins in the paraumbilical region q N. Imanishi a, *, H. Nakajima b, T. Minabe c, H. Chang d,
More informationAnatomical study. Clinical study. R. Ogawa, H. Hyakusoku, M. Murakami, R. Aoki, K. Tanuma* and D. G. Pennington?
British Journal of Plastic Surgery (2002) 55, 396-40 I 9 2002 The British Association of Plastic Surgeons doi: 10.1054/bjps.2002.3877 PLASTIC SURGERY An anatomical and clinical study of the dorsal intercostal
More informationThe gluteal perforator-based flap in repair of pressure sores
The British Association of Plastic Surgeons (2004) 57, 342 347 CASE REPORTS The gluteal perforator-based flap in repair of pressure sores Çilingir Meltem*, Çelik Esra, Fındık Hasan, Duman Ali Department
More informationJPRAS Open 3 (2015) 1e5. Contents lists available at ScienceDirect. JPRAS Open. journal homepage:
JPRAS Open 3 (2015) 1e5 Contents lists available at ScienceDirect JPRAS Open journal homepage: http://www.journals.elsevier.com/ jpras-open Case report The pedicled transverse partial latissimus dorsi
More informationThe earlier clinic experience of the reverse-flow anterolateral thigh island flap
British Journal of Plastic Surgery (2005) 58, 160 164 The earlier clinic experience of the reverse-flow anterolateral thigh island flap Gang Zhou, Qi-Xu Zhang*, Guang-Yu Chen Scar Multiple Treatment Centre,
More informationTor Chiu. Deep Inferior Epigastric Artery Perforator Flap 161
18 Deep Inferior Epigastric Artery Perforator Flap Tor Chiu Deep Inferior Epigastric Artery Perforator Flap 161 Deep Inferior Epigastric Artery Perforator Flap FLAP TERRITORY The deep inferior epigastric
More informationMedical Journal of the Volume 20 Islamic Republic of Iran Number 3 Fall 1385 November Original Articles
Medical Journal of the Volume 0 Islamic Republic of Iran Number 3 Fall 38 November 00 Original Articles ANATOMY OF THE SUPERFICIAL INFERIOR EPIGASTRIC ARTERY FLAP MAHDI FATHI, M.D., EBRAHIM HATAMIPOUR,
More informationLarge thoracolumbar meningomyelocele defects: incidence and clinical experiences with different modalities of latissimus dorsi musculocutaneus flap
The British Association of Plastic Surgeons (2004) 57, 411 417 Large thoracolumbar meningomyelocele defects: incidence and clinical experiences with different modalities of latissimus dorsi musculocutaneus
More informationAnatomical Background of the Perforator Flap Based on the Deep Branch of the Superficial Circumflex Iliac Artery (SCIP Flap): A Cadaveric Study
Anatomical Background of the Perforator Flap Based on the Deep Branch of the Superficial Circumflex Iliac Artery (SCIP Flap): A Cadaveric Study Raphael Sinna, MD, a Hassene Hajji, MD, b Quentin Qassemyar,
More informationThe posterior abdominal wall. Prof. Oluwadiya KS
The posterior abdominal wall Prof. Oluwadiya KS www.oluwadiya.sitesled.com Posterior Abdominal Wall Lumbar vertebrae and discs. Muscles opsoas, quadratus lumborum, iliacus, transverse, abdominal wall
More informationThe Thoracic wall including the diaphragm. Prof Oluwadiya KS
The Thoracic wall including the diaphragm Prof Oluwadiya KS www.oluwadiya.com Components of the thoracic wall Skin Superficial fascia Chest wall muscles (see upper limb slides) Skeletal framework Intercostal
More informationFASCIAL PLANE BLOCKS TOM BARIBEAULT MSN, CRNA
FASCIAL PLANE BLOCKS TOM BARIBEAULT MSN, CRNA TECHNIQUES Abdominal Wall TAP Rectus Sheath Quadratus Lumborum Erector Spinae Chest PECS I & II Erector Spinae TECHNIQUES Knee Ipack/LIA Hip Fascia Iliaca
More informationCase Report The Reverse Latissimus Dorsi Flap for Large Lower Lumbar Defect
Case Reports in Surgery Volume 2012, Article ID 964625, 5 pages doi:10.1155/2012/964625 Case Report The Reverse Latissimus Dorsi Flap for Large Lower Lumbar Defect Bouraoui Kotti, Olfa Jaidane, Jamel Ben
More informationScapular & Parascapular flap FLAP TERRITORY ANATOMY. is normally accompanied by two venae comitantes.
Scapular & Parascapular flap FLAP TERRITORY This is a composite flap that is situated over the scapula with various incisional arrangements. It can be harvested as a skin and subcutaneous tissue flap,
More informationBreast Reconstruction with Superficial Inferior Epigastric Artery Flaps: A Prospective Comparison with TRAM and DIEP Flaps
Breast Reconstruction with Superficial Inferior Epigastric Artery Flaps: A Prospective Comparison with TRAM and DIEP Flaps Pierre M. Chevray, M.D., Ph.D. Houston, Texas Breast reconstruction using the
More informationABSTRACT. Key words: Flaps, Adipofascial, Lower limb reconstruction. Khaldoun J. Haddadin, MD*, Samer Y. Haddad, MD. Introduction.
DISTALLY BASED ADIPOFASCIAL FLAPS: A VERSATILE FLAP FOR THE RECONSTRUCTION OF LOWER LEG AND PROXIMAL FOOT DEFECTS AT THE ROYAL JORDANIAN REHABILITATION CENTER Khaldoun J. Haddadin, MD*, Samer Y. Haddad,
More informationPedicled Fillet of Leg Flap for Extensive Pressure Sore Coverage
Pedicled Fillet of Leg Flap for Extensive Pressure Sore Coverage Shareef Jandali, MD, and David W. Low, MD Division of Plastic Surgery, University of Pennsylvania Health System, Philadelphia Correspondence:
More informationAnatomical Landmarks for Safe Elevation of the Deep Inferior Epigastric Perforator Flap: A Cadaveric Study
Anatomical Landmarks for Safe Elevation of the Deep Inferior Epigastric Perforator Flap: A Cadaveric Study Saeed Chowdhry, MD, Ron Hazani, MD, Philip Collis, BS, and Bradon J. Wilhelmi, MD University of
More informationGastrocnemius Myocutaneous Flap: A Versatile Option to Cover the Defect of Upper and Middle Third Leg
Downloaded from wjps.ir at 22:25 +0330 on Sunday November 18th 28 314 Gastrocnemius flap for coverage of leg defects Original Article Gastrocnemius Myocutaneous Flap: A Versatile Option to Cover the Defect
More informationAnatomical Study of Pectoral Nerves and its Implications in Surgery
DOI: 10.7860/JCDR/2014/8631.4545 Anatomy Section Original Article Anatomical Study of Pectoral Nerves and its Implications in Surgery Prakash KG 1, Saniya K 2 ABSTRACT Introduction: This anatomical study
More informationThoracolumbar Anatomy Eric Shamus Catherine Patla Objectives
1 2 Thoracolumbar Anatomy Eric Shamus Catherine Patla Objectives List the muscular and ligamentous attachments of the thoracic and lumbar spine Describe how the muscles affect the spine and upper extremity
More informationDistally Based Sural Artery Adipofascial Flap based on a Single Sural Nerve Branch: Anatomy and Clinical Applications
Distally Based Sural Artery Adipofascial Flap based on a Single Sural Nerve Branch: Anatomy and Clinical Applications Wan Loong James Mok 1, Yong Chen Por 1, Bien Keem Tan 2 1 Department of Plastic, Reconstructive
More informationThe Back. Anatomy RHS 241 Lecture 9 Dr. Einas Al-Eisa
The Back Anatomy RHS 241 Lecture 9 Dr. Einas Al-Eisa The spine has to meet 2 functions Strength Mobility Stability of the vertebral column is provided by: Deep intrinsic muscles of the back Ligaments
More informationMultiple Neurovascular... Pit Baran Chakraborty, Santanu Bhattacharya, Sumita Dutta.
Multiple Neurovascular... Pit Baran Chakraborty, Santanu Bhattacharya, Sumita Dutta. Fig-3: Showing high formation of Median nerve. Fig-1: Showing atypical formation of cords of Brachial plexus. 1 = Upper
More informationVersatility of Reverse Sural Artery Flap for Heel Reconstruction
ORIGINAL ARTICLE Introduction: The heel has two parts, weight bearing and non-weight bearing part. Soft tissue heel reconstruction has been a challenge due to its complex nature of anatomy, weight bearing
More informationVariation of Superficial Palmar Arch: A Case Report
Article ID: WMC003387 ISSN 2046-1690 Variation of Superficial Palmar Arch: A Case Report Corresponding Author: Dr. Liju S Mathew, Demonstrator, Anatomy, Gulf Medical University, 4184 - United Arab Emirates
More informationABDOMINAL WALL & RECTUS SHEATH
ABDOMINAL WALL & RECTUS SHEATH Learning Objectives Describe the anatomy, innervation and functions of the muscles of the anterior, lateral and posterior abdominal walls. Discuss their functional relations
More informationAn improved method of supercharged transposed latissimus dorsi flap with the skin paddle for the management of a complicated lumbosacral defect
European Review for Medical and Pharmacological Sciences An improved method of supercharged transposed latissimus dorsi flap with the skin paddle for the management of a complicated lumbosacral defect
More informationmusculoskeletal system anatomy nerves of the lower limb 1 done by: dina sawadha & mohammad abukabeer
musculoskeletal system anatomy nerves of the lower limb 1 done by: dina sawadha & mohammad abukabeer What is the importance of plexuses? plexuses provides us the advantage of a phenomenon called convergence
More informationReconstruction of the Chest Wall
HOW TO DO IT Reconstruction of the Chest Wall Reed 0. Dingman, M.D., and Louis C. Argenta, M.D. ABSTRACT Reconstruction of the chest wall can now be accomplished reliably and expeditiously. Past experience
More informationCASE REPORT An Innovative Solution to Complex Inguinal Defect: Deepithelialized SIEA Flap With Mini Abdominoplasty
CASE REPORT An Innovative Solution to Complex Inguinal Defect: Deepithelialized SIEA Flap With Mini Abdominoplasty Augustine Reid Wilson, MS, Justin Daggett, MD, Michael Harrington, MD, MPH, and Deniz
More informationThe superior gluteal artery perforator flap: an additional tool in the treatment of sacral pressure sores
ritish Journal of Plastic Surgery (1999), 52, 385 391 1999 The ritish ssociation of Plastic Surgeons The superior gluteal artery perforator flap: an additional tool in the treatment of sacral pressure
More informationA Retrospective Comparison of Perforator and Rotation Flaps for the Closure of Extensive Stage IV Sacral Pressure Ulcers
A Retrospective Comparison of Perforator and Rotation Flaps for the Closure of Extensive Stage IV Sacral Pressure Ulcers Masaki Fujioka, MD, PhD; Kenji Hayashida, MD; Sin Morooka, MD; and Hiroto Saijo,
More informationEndoscopic assisted harvest of the pedicled pectoralis major muscle flap
British Journal of Plastic Surgery (2005) 58, 170 174 Endoscopic assisted harvest of the pedicled pectoralis major muscle flap Arif Turkmen*, A. Graeme B. Perks Plastic Surgery Department, Nottingham City
More informationAbdomen: Introduction. Prof. Oluwadiya KS
Abdomen: Introduction Prof. Oluwadiya KS www.oluwadiya.com Abdominopelvic Cavity Abdominal Cavity Pelvic Cavity Extends from the inferior margin of the thorax to the superior margin of the pelvis and the
More informationSurgery Under Regional Anesthesia
Surgery Under Regional Anesthesia Jean Daniel Eloy, MD Assistant Professor Residency Program Director Rutgers-New Jersey Medical School Rutgers The State University of New Jersey Peripheral Nerve Block
More informationTHE THORACIC WALL. Boundaries Posteriorly by the thoracic part of the vertebral column. Anteriorly by the sternum and costal cartilages
THE THORACIC WALL Boundaries Posteriorly by the thoracic part of the vertebral column Anteriorly by the sternum and costal cartilages Laterally by the ribs and intercostal spaces Superiorly by the suprapleural
More informationMuscles of the Upper Limb that are dissected in the Back Region Muscle Origin Insertion Action Innervation Artery Notes
Muscles of Upper Limb that are dissected in Back Region Muscle Origin Insertion Action Innervation Artery Notes floor of thoraco thoraco inserting spines from intertubercular arm nerve (C7,8) a. tendon
More informationBreast Reconstruction Options
Breast Reconstruction Options Natural reconstruction using your ABDOMINAL tissue: TRAM Flap (Transverse Rectus Abdominis Myocutaneous) There are various forms of TRAM flap reconstruction that are commonly
More informationInferior Gluteus Maximus Island Flap for Reconstruction of Ischial Pressure Sores
Original Article Inferior Gluteus Maximus Island Flap for Reconstruction of Ischial Pressure Sores Yawar Sajjad, 1 Beenish Rahat, 2 Salman Hameed 3 Abstract Surgical management of ischial pressure sores
More informationNovel Interpositional Vein Grafting for Pedicle Extension of Island Pedicle Flaps
e50 Case Report THIEME Novel Interpositional Vein Grafting for Pedicle Extension of Island Pedicle Flaps Shuhei Yoshida, MD 1 Isao Koshima, MD 1 Shogo Nagamatsu, MD 2 Kazunori Yokota, MD 2 Shuji Yamashita,
More informationMultiple variations involving all the terminal branches of the brachial plexus and the axillary artery a case report
SHORT REPORT Eur J Anat, 10 (3): 61-66 (2006) Multiple variations involving all the terminal branches of the brachial plexus and the axillary artery a case report K. Ramachandran, I. Kanakasabapathy and
More informationORIGINAL ARTICLE DISTALLY BASED PERONEUS BREVIS MUSCLE FLAP FOR DISTAL LEG DEFECTS
DISTALLY BASED PERONEUS BREVIS MUSCLE FLAP FOR DISTAL LEG DEFECTS Peddi Manjunath 1, Ramesha K.T 2, Smitha S Segu 3, Jainath 4, Shankarappa M 5 HOW TO CITE THIS ARTICLE: Peddi Manjunath, Ramesha KT, Smitha
More informationThe free thoracodorsal artery perforator flap in head and neck reconstruction
European Annals of Otorhinolaryngology, Head and Neck diseases (2012) 129, 167 171 Available online at www.sciencedirect.com TECHNICAL NOTE The free thoracodorsal artery perforator flap in head and neck
More informationDiaphragm and intercostal muscles. Dr. Heba Kalbouneh Associate Professor of Anatomy and Histology
Diaphragm and intercostal muscles Dr. Heba Kalbouneh Associate Professor of Anatomy and Histology Skeletal System Adult Human contains 206 Bones 2 parts: Axial skeleton (axis): Skull, Vertebral column,
More informationChest wall reconstruction using a combined musculocutaneous anterolateral anteromedial thigh flap
Free full text on www.ijps.org Case Report DOI: 10.4103/0970-0358.63966 Chest wall reconstruction using a combined musculocutaneous anterolateral anteromedial thigh flap Pearlie W. W. Tan, Chin-Ho Wong,
More informationJohannesburg, South Africa
NEUROVASCULAR ISLAND FLAP IN THE TREATMENT OF TROPHIC ULCERATION OF THE HEEL By ISIDORE KAPLAN, F.R.C.S., F.R.C.S.(Ed.) Johannesburg, South Africa THE transfer of skin and subcutaneous tissue on a neurovascular
More informationAnatomy of the Thorax
Anatomy of the Thorax A) THE THORACIC WALL Boundaries Posteriorly by the thoracic part of the vertebral column Anteriorly by the sternum and costal cartilages Laterally by the ribs and intercostal spaces
More informationEssential Anatomy for oncoplastic surgery. Omar Z. Youssef M.D Professor of surgical oncology NCI- Cairo University
Essential Anatomy for oncoplastic surgery Omar Z. Youssef M.D Professor of surgical oncology NCI- Cairo University Introduction Rationale for anatomical basis for OPS Anatomical considerations: 1. Surface
More informationThe Trunk and Spinal Column Kinesiology Cuneyt Mirzanli Istanbul Gelisim University
The Trunk and Spinal Column Kinesiology Cuneyt Mirzanli Istanbul Gelisim University The Trunk and Spinal Column Vertebral column 24 articulating vertebrae 31 pairs of spinal nerves Abdominal muscles some
More informationT. Rapis, S.N. Zanakis, I.F. Letsa, A.P. Karamanos CLINICAL CASE. Summary. Introduction
Journal of BUON 8: 397-401, 2003 2003 Zerbinis Medical Publications. Printed in Greece CLINICAL CASE Basal cell carcinoma of the posterior neck, reconstructed with lower trapezius island musculocutaneous
More informationGI module Lecture: 9 د. عصام طارق. Objectives:
GI module Lecture: 9 د. عصام طارق Objectives: To list structures forming posterior abdominal wall. To follow aorta & its main branches. To describe IVC & its main tributaries. To list nerves of posterior
More informationThoracic and Lumbar Spine Anatomy.
Thoracic and Lumbar Spine Anatomy www.fisiokinesiterapia.biz Thoracic Vertebrae Bodies Pedicles Laminae Spinous Processes Transverse Processes Inferior & Superior Facets Distinguishing Feature Costal Fovea
More informationWe are IntechOpen, the world s leading publisher of Open Access books Built by scientists, for scientists. International authors and editors
We are IntechOpen, the world s leading publisher of Open Access books Built by scientists, for scientists 3,500 108,000 1.7 M Open access books available International authors and editors Downloads Our
More informationChest cavity, vertebral column and back muscles. Respiratory muscles. Sándor Katz M.D., Ph.D.
Chest cavity, vertebral column and back muscles. Respiratory muscles. Sándor Katz M.D., Ph.D. Chest cavity - bony structures Chest cavity- bony structures Sternum Ribs True ribs: first seven pairs connect
More informationOPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY
OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY BUCCINATOR MYOMUCOSAL FLAP The Buccinator Myomucosal Flap is an axial flap, based on the facial and/or buccal arteries. It is a flexible
More informationSeptic Bone and Joint Surgery
Septic Bone and Joint Surgery Bearbeitet von Reinhard Schnettler 1. Auflage 2010. Buch. 328 S. Hardcover ISBN 978 3 13 149031 5 Format (B x L): 19,5 x 27 cm Weitere Fachgebiete > Medizin > Chirurgie >
More informationSliding Perforator Island Flap For Covering A Big Lumbosacral Defect
ISPUB.COM The Internet Journal of Plastic Surgery Volume 5 Number 2 Sliding Perforator Island Flap For Covering A Big Lumbosacral Defect R Hussein, S Anis Citation R Hussein, S Anis.. The Internet Journal
More information_CH01redo.qxd 9/24/07 3:07 PM Page 1. [Half-Title to come]
10752-01_CH01redo.qxd 9/24/07 3:07 PM Page 1 [Half-Title to come] 10752-01_CH01redo.qxd 9/24/07 3:07 PM Page 2 THE BACK Lippincott Williams & Wilkins atlas of ANATOMY CHAPTER 1 Plate 1-01 Palpable Structures
More informationBorders of the Abdomen
Abdominal wall Borders of the Abdomen Abdomen is the region of the trunk that lies between the diaphragm above and the inlet of the pelvis below Borders Superior: Costal cartilages 7-12. Xiphoid process:
More information4/30/2010. Options for abdominal wall reconstruction. Scott L. Hansen, MD
Components Separation Scott L. Hansen, MD University of California, San Francisco Chief, Plastic and Reconstructive Surgery San Francisco General Hospital Overview Options for abdominal wall reconstruction
More informationExternal Obliques Abdominal muscles that attaches at the lower ribs, pelvis, and abdominal fascia.
The Core The core is where most of the body s power is derived. It provides the foundation for all movements of the arms and legs. The core must be strong, have dynamic flexibility, and function synergistically
More informationPedicled Gluteal Artery Perforator Flap for Sacral and Ischial Pressure Ulcer Reconstruction: Promising Prospects for Mauritius
UNIVERSITY OF MAURITIUS RESEARCH JOURNAL Volume 17 2011 University of Mauritius, Réduit, Mauritius Pedicled Gluteal Artery Perforator Flap for Sacral and Ischial Pressure Ulcer Reconstruction: Promising
More informationRole Of Reverse Sural Artery Flap In Ankle, Foot And Leg Defects
IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-issn: 2279-0853, p-issn: 2279-0861.Volume 15, Issue 5 Ver. VIII (May. 2016), PP 64-68 www.iosrjournals.org Role Of Reverse Sural Artery Flap In
More informationANATYOMY OF The thigh
ANATYOMY OF The thigh 1- Lateral cutaneous nerve of the thigh Ι) Skin of the thigh Anterior view 2- Femoral branch of the genitofemoral nerve 5- Intermediate cutaneous nerve of the thigh 1, 2 and 3 are
More informationThe trunk and spinal column. Functions of Spine. Bones 6/5/2017. Chapter 10. Consider the complexity of functions. 33 bones of the spine
The trunk and spinal column Chapter 10 Functions of Spine Consider the complexity of functions provides stability to a cylinder permits movement in all directions supports structures of considerable weight
More informationClosure of Myelomeningocele Defects Using a Limberg Flap or Direct Repair
Closure of Myelomeningocele Defects Using a Limberg Flap or Direct Repair Original Article Jung-Hwan Shim 1, Na-Hyun Hwang 1, Eul-Sik Yoon 1, Eun-Sang Dhong 1, Deok-Woo Kim 1, Sang-Dae Kim 2 Departments
More informationANATYOMY OF The thigh
ANATYOMY OF The thigh 1- Lateral cutaneous nerve of the thigh Ι) Skin of the thigh Anterior view 2- Femoral branch of the genitofemoral nerve 5- Intermediate cutaneous nerve of the thigh 1, 2 and 3 are
More informationThe lateral incisional hernia: anatomical considerations for a standardized retromuscular sublay repair
Hernia (2009) 13:293 297 DOI 10.1007/s10029-009-0479-0 ORIGINAL ARTICLE The lateral incisional hernia: anatomical considerations for a standardized retromuscular sublay repair M. Stumpf J. Conze A. Prescher
More informationUse of Dorsal Metacarpal Artery Flaps in Post Burn Reconstruction Two Cases Report
Macedonian Journal of Medical Sciences. 2011 Jun 15; 4(2):180-184. doi:10.3889/mjms.1857-5773.2011.0164 Case Report OPEN ACCESS Use of Dorsal Metacarpal Artery Flaps in Post Burn Reconstruction Two Cases
More informationBreast conservation surgery and sentinal node biopsy: Dr R Botha Moderator: Dr E Osman
Breast conservation surgery and sentinal node biopsy: Dr R Botha Moderator: Dr E Osman Breast anatomy: Breast conserving surgery: The aim of wide local excision is to remove all invasive and in situ
More informationNEW THREE-FLAP SCALP RECONSTRUCTION TECHNIQUE
NEW THREE-FLAP SCALP RECONSTRUCTION TECHNIQUE By MIGUEL ORTICOCHEA, M.D. Professor of Plastic Surgery, Medical School, Javeriana University, Bogotd, Colombia Former Student, Pasteur Hospital, Montevideo,
More information10/14/2018 Dr. Shatarat
2018 Objectives To discuss mediastina and its boundaries To discuss and explain the contents of the superior mediastinum To describe the great veins of the superior mediastinum To describe the Arch of
More informationThe posterolateral thoracotomy is still probably the
Posterolateral Thoracotomy Jean Deslauriers and Reza John Mehran The posterolateral thoracotomy is still probably the most commonly used incision in general thoracic surgery. It provides not only excellent
More informationHuman Anatomy Biology 351
nnnnn 1 Human Anatomy Biology 351 Exam #2 Please place your name on the back of the last page of this exam. You must answer all questions on this exam. Because statistics demonstrate that, on average,
More informationINTRODUCTION. Toshihiko Satake 1, Jun Sugawara 2, Kazunori Yasumura 1, Taro Mikami 2, Shinji Kobayashi 3, Jiro Maegawa 2. Idea and Innovation
Mini-Flow-Through Deep Inferior Epigastric Perforator Flap for Breast Reconstruction with Preservation of Both Internal Mammary and Deep Inferior Epigastric Vessels Toshihiko Satake 1, Jun Sugawara 2,
More informationDesign variations in vertical muscle-sparing thoracotomy
Surgical Technique Design variations in vertical muscle-sparing thoracotomy Noriaki Sakakura, Tetsuya Mizuno, Takaaki Arimura, Hiroaki Kuroda, Yukinori Sakao Department of Thoracic Surgery, Aichi Cancer
More informationPropeller perforator flaps for finger reconstruction
Technical Note Page 1 of 7 Propeller perforator flaps for finger reconstruction Alexandru Valentin Georgescu, Ileana Rodica Matei Department of Plastic Surgery, University of Medicine Iuliu Hatieganu Cluj
More informationA Clinical Anatomic Study of Internal Mammary Perforators as Recipient Vessels for Breast Reconstruction
A Clinical Anatomic Study of Internal Mammary Perforators as Recipient Vessels for Breast Reconstruction In-Soo Baek 1, Jae-Pil You 1, Sung-Mi Rhee 1, Gil-Su Son 2, Deok-Woo Kim 1, Eun-Sang Dhong 1, Seung-Ha
More informationSTERNUM. Lies in the midline of the anterior chest wall It is a flat bone Divides into three parts:
STERNUM Lies in the midline of the anterior chest wall It is a flat bone Divides into three parts: 1-Manubrium sterni 2-Body of the sternum 3- Xiphoid process The body of the sternum articulates above
More informationManagement of Complex Avulsion Injuries of the Dorsum of the Foot and Ankle in Pediatric Patients by Using Local Delayed Flaps and Skin Grafts
Management of Complex Avulsion Injuries of the Dorsum of the Foot and Ankle in Pediatric Patients by Using Local Delayed Flaps and Skin Grafts Ahmed Elshahat, MD Plastic Surgery Department, Ain Shams University,
More informationGross Anatomy Faculty: Gross Anatomy Faculty: Gross Anatomy Faculty: Dr. Melissa McGinn. Welcome to Gross and Developmental Anatomy
Welcome to Gross and Developmental Anatomy M1 Anatomy Gross Anatomy Faculty: Dr. Richard Krieg Dr. Milton Sholley Dr. David Simpson 1 2 Gross Anatomy Faculty: Gross Anatomy Faculty: Dr. Steve Gudas Dr.
More informationDistally based anterolateral thigh flap pedicled on the oblique branch of the lateral circumflex femoral artery
Original Article Page 1 of 8 Distally based anterolateral thigh flap pedicled on the oblique branch of the lateral circumflex femoral artery Yuanbo Liu, Mengqing Zang, Shan Zhu, Bo Chen, Shanshan Li, Bingjian
More informationBasics of Flap Design
Basics of Flap Design Reconstructive Ladder (Mathes & Nahai 1982) Consider the defect, systematically Move from simple to complex Occam s Razor Sutton s Law Ladder is simple, emphasizes closure over form
More informationThe Modified External Oblique Musculocutaneous Flap for Reconstruction of Extensive Post-Mastectomy Radio Necrosis: Clinical and Anatomical Study
Egypt, J. Plast. Reconstr. Surg., Vol. 28, No. 1, January: 1-5, 2004 The Modified External Oblique Musculocutaneous Flap for Reconstruction of Extensive Post-Mastectomy Radio Necrosis: Clinical and Anatomical
More informationClinical Study Combined V-Y Fasciocutaneous Advancement and Gluteus Maximus Muscle Rotational Flaps for Treating Sacral Sores
BioMed Research International Volume 2016, Article ID 8714713, 8 pages http://dx.doi.org/10.1155/2016/8714713 Clinical Study Combined V-Y Fasciocutaneous Advancement and Gluteus Maximus Muscle Rotational
More informationThe Forgotten Lumbocostal Ligament: Anatomical Study with Application to Thoracolumbar Surgery
Open Access Original Article DOI: 10.7759/cureus.925 The Forgotten Lumbocostal Ligament: Anatomical Study with Application to Thoracolumbar Surgery Erfanul Saker 1, Gabrielle G. Tardieu 2, Fernando Alonso
More informationThe Back OUTLINE. Vertebral Column (review) Craniovertebral Joints Dorsal Scapular Region(review) Muscles of the Back Suboccipital Region
The Back OUTLINE Vertebral Column (review) Craniovertebral Joints Dorsal Scapular Region(review) Muscles of the Back Suboccipital Region Dept. of Human Anatomy, Si Chuan University Zhou hongying eaglezhyxzy@163.com
More informationUsing the sac membrane to close the flap donor site in large meningomyeloceles
The British Association of Plastic Surgeons (2004) 57, 273 277 Using the sac membrane to close the flap donor site in large meningomyeloceles Cengiz Bozkurt a, Selçuk Akın a, *,Şeref Doğan b, Erkut Özdamar
More informationCombined tongue flap and V Y advancement flap for lower lip defects
British Journal of Plastic Surgery (2005) 58, 258 262 CASE REPORTS Combined tongue flap and V Y advancement flap for lower lip defects Kenji Yano*, Ko Hosokawa, Tateki Kubo Department of Plastic and Reconstructive
More informationSelective salvage of zones 2 and 4 in the pedicled TRAM flap: a focus on reducing fat necrosis and improving aesthetic outcomes
DOI 10.1186/s40064-016-1714-7 RESEARCH Open Access Selective salvage of zones 2 and 4 in the pedicled TRAM flap: a focus on reducing fat necrosis and improving aesthetic outcomes Chi Sun Yoon and Kyu Nam
More informationLecturer: Ms DS Pillay ROOM 2P24 25 February 2013
Lecturer: Ms DS Pillay ROOM 2P24 25 February 2013 Thoracic Wall Consists of thoracic cage Muscle Fascia Thoracic Cavity 3 Compartments of the Thorax (Great Vessels) (Heart) Superior thoracic aperture
More informationInformation within the handout. Brief Introduction Anatomy & Biomechanics Assessment & Diagnosis Treatment through Muscle Energy
Manual Medicine Diagnosis and Treatment for Somatic Dysfunction of the Pelvis Through Muscle Energy Greenman s Priciples of Manual Medicine (5 th Ed.)- Lisa DeStefano,DO Speaker disclosure I declare I
More informationREGIONAL ANAESTHESIA Determination of spread of injectate after ultrasound-guided transversus abdominis plane block: a cadaveric study
British Journal of Anaesthesia 102 (1): 123 7 (2009) doi:10.1093/bja/aen344 REGIONAL ANAESTHESIA Determination of spread of injectate after ultrasound-guided transversus abdominis plane block: a cadaveric
More informationThe anterolateral thigh perforator flap is RECONSTRUCTIVE
RECONSTRUCTIVE The Extended Approach to the Vascular Pedicle of the Anterolateral Thigh Perforator Flap: Anatomical and Clinical Study Petros K. Spyriounis, M.D., Ph.D. Athens, Greece Background: The anterolateral
More informationRadial Artery Pedicle Flap To Cover Exposed Mesh After Abdominal Wound Dehiscence-An Easy Solution To A Difficult Problem
ISPUB.COM The Internet Journal of Plastic Surgery Volume 6 Number 1 Radial Artery Pedicle Flap To Cover Exposed Mesh After Abdominal Wound Dehiscence-An Easy Solution To A Difficult Problem S Tripathy,
More informationCHARACTERISTICS OF THE ANTEROLATERAL THIGH FLAP IN A WESTERN POPULATION AND ITS APPLICATION IN HEAD AND NECK RECONSTRUCTION
CHARACTERISTICS OF THE ANTEROLATERAL THIGH FLAP IN A WESTERN POPULATION AND ITS APPLICATION IN HEAD AND NECK RECONSTRUCTION Peirong Yu, MD Department of Plastic Surgery, The University of Texas M. D. Anderson
More informationSplit Hemianterior Tibialis Turndown Muscle Flap for Coverage of Distal Leg Wounds With Preservation of Function
Split Hemianterior Tibialis Turndown Muscle Flap for Coverage of Distal Leg Wounds With Preservation of Function Vinay Gundlapalli, MD, a John W. Gillespie III, MD, b and Chris D. Tzarnas, MD, FACS c a
More informationGateway to the upper limb. An area of transition between the neck and the arm.
Gateway to the upper limb An area of transition between the neck and the arm. Pyramidal space inferior to shoulder @ junction of arm & thorax Distribution center for the neurovascular structures that serve
More information