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We describe a simple technique of securing surgically implanted leads for spinal cord (SCS), dorsal root ganglion (DRG) and occipital nerve stimulation (ONS), for both primary surgical implantation and correcting lead migration. This technique could also be adapted for securing percutaneously implanted leads. Thirty-nine patients underwent neurosurgical implantation of SCS, DRG, and ONS devices utilizing titanium mini-plates to obtain secure anchorage of leads to adjacent laminae close to their exit point from the epidural space, thereby minimizing the risk of further lead migration or electrode displacement. There were no cases of primary or recurrent lead migration in any patient undergoing lead placement using mini-plate anchorage. The technique appears to offer a reliable means of preventing post-operative lead migration in a variety of spinal and extra-cranial neuromodulation implants.

BACKGROUND: Posterior interosseous nerve (PIN) entrapment syndrome is a rare condition and is predisposed by anatomical factors such as narrow passages through fibrous arcades; whereas, the Arcade of Frohse (AF) is the most common entrapment point. The aim of this study was to evaluate the entrance and exit points of the PIN into the supinator in detail. MATERIALS AND METHODS: One hundred unpaired upper extremities underwent dissection. The PIN’s entrance and exit points from the supinator were depicted. The distances between the tip of the radial head (RH) and the AF and the exit point of the PIN from the supinator were measured. Further, it was checked if the borders of the AF and the exit point were muscular, tendinous or a combination of these. RESULTS: The interval between the PIN’s entry into the supinator and the tip of the RH was at a mean of 28.9 mm. Concerning the border of the AF, in 54 cases a muscular and in 46 specimens a tendinous version could be observed. The interval between the exit point of the PIN and the tip of the RH proved to be at a mean of 64.2 mm. Further, the exit’s border was muscular in 65 specimens and tendinous in 35 cases. CONCLUSION: During surgical treatment of the PIN syndrome, it needs to be kept in mind that approximately one-third of all patients might also suffer from entrapment at the exit point of the PIN.

Nerve to mylohyoid is a branch of inferior alveolar nerve. It arises in the infratemporal fossa and runs in the mylohyoid groove of mandible to reach the submandibular region, where it supplies the anterior belly of digastric and mylohyoid muscles. Though sensory distribution of this nerve have been described, it is predominantly a motor nerve. Here, a rare intra-mandibular origin of nerve to mylohyoid has been presented. This nerve arose from the inferior alveolar nerve inside the mandible and came out to the submandibular region by passing through a small foramen present on the medial surface of the body of the mandible. It ended by supplying the anterior belly of digastric and mylohyoid muscles. The knowledge of this variation could be of importance to maxillofacial surgeons and radiologists.

To develop and validate the efficacy and accuracy of a three-dimensional (3D) computed tomography (CT) reconstructive rapid prototyping drill template for cervical pedicle screw placement. CT thin-layer scans were obtained from 12 adult cadaveric cervical specimens and reconstructed. The ideal screw channels were chosen by analyzing the cross sections of the reconstructed 3D images. The navigation templates were designed and printed based on the optimal screw channels. The pedicle screws were placed on the cadaver specimens under template guidance, and the cadaver specimens were scanned and reconstructed. The pre- and post-operative models were compared. Entry point and exit point data of these two models were collected and compared using the Chi-square test. A total of 164 cervical pedicle screws were placed; among them, six punctured the cortical bone of the vertebral pedicle reaching an accuracy of 96.3%. Among the outside screws, all of the deviation distances were

Background Kirschner wire fixation remains to be the mainstream treatment modality in unstable or displaced supracondylar humerus fracture in children, with divergent lateral pins being the most preferred due to their sufficient stability and decreased risk of ulnar nerve injury. However, the entry point at which the proximal lateral pin can be inserted to achieve a more proximal exit and maximum divergence has not been reported. This study retrospectively analyzed the characteristics and factors influencing the entry and exit points of the proximal lateral pins. Methods The study was divided into two stages. In stage one, the entry and exit points of the proximal pins of lateral pinning configuration were analyzed from intra-operative radiographs of children treated for extension-type supracondylar humerus fractures. The coronal and sagittal pin angles formed by the proximal pins were also measured. Using the findings of stage one, we intentionally tried to achieve a more proximal exit with the proximal pins in stage two. Comparisons between groups of patients treated by random and intentional pinnings were done statistically. Results In the first stage, 47 (29.2%) of the 161 proximal pins exited above the metaphyseal-diaphyseal junction (MDJ) region. Of these, 85.1% entered from lateral and posterior to the ossific nucleus of the capitellum (ONC). The pin angles averaged 58.4° and 90.5° in the coronal and sagittal planes respectively. In the second stage, 47 (65.3%) proximal pins in the intended group exited above the MDJ region, while only 32 (36%) in the random group exited above the MDJ region. Conclusion While aiming at the upper border of the distal MDJ during pinning, lateral pins can easily achieve a higher, proximal exit above the MDJ if inserted from lateral and posterior to the ONC and parallel to the humeral shaft in the sagittal plane. Higher exit can also be easily achieved in younger patients and patients fixated with smaller diameter pins.

Background Many biceps tenodesis (BT) procedures are described for treating proximal biceps pathology. Axillary nerve injury has been reported during BT using bicortical drilling techniques with variable results depending on the location. In addition, there is a risk of potential articular damage during suprapectoral BT. We sought to determine the distance between the axillary nerve and the posterior passage of a bicortical pin, as well as the risk of articular damage, and to analyze whether a lateral inclination of the pin could avoid the chondral risk during suprapectoral BT with bicortical drilling. Methods Ten cadaveric shoulders were divided into 2 groups. In the first group, we determined the axillary nerve distance from the posterior exit point of 3 pins in a suprapectoral position 15 mm distal to the humeral cartilage: perpendicular, 10° caudal, and 20° caudal inclination. We measured 2 distances from the pin: to the axillary nerve and to the cartilage border. In the second group, we set one pin at the same perpendicular position and set the second pin 15° laterally tilted to determine its extra-articular passage. Results No pin injured the nerve, whereas all pins showed a transchondral direction. The 20° caudal inclination was the nearest to the nerve (18.8 mm [95% confidence interval, 5.5-32 mm]), but the perpendicular position was the safer position (38.8 mm [95% confidence interval, 28-49.6 mm]). Tilting the pin direction 15° laterally prevented cartilage damage (P = .008). Conclusions Suprapectoral BT with bicortical drilling performed 15 mm distal to the humeral cartilage is a safe procedure regarding the axillary nerve. A potential humeral chondral injury could be prevented with 15° of lateral inclination of the pin guide.

Development of xenobiotics that cross the blood-brain barrier in therapeutically-relevant quantities is an expensive and time-consuming undertaking. However, central nervous system diseases are an under-addressed cause of high mortality and morbidity, and drug development in this field is a worthwhile venture.We aim to familiarize the reader with available methodologies for studying drug transport into the brain. Current understanding of the blood-brain barrier structure has been well-described in other manuscripts, and first we briefly review the path that xenobiotics take through the brain - from bloodstream, to endothelial cells of the blood-brain barrier, to interstitial space, to brain parenchymal cells, and then to an exit point from the central nervous system. The second half of the review discusses research tools available to determine if xenobiotics are making the journey through the brain successfully and offers commentary on the translational utility of each methodology.Theoretically, non-human mammalian and human blood-brain barriers are similar in composition; however, some findings demonstrate important differences across species. Translational methodologies may provide more reliable information about how a drug may act across species. The recent finding of lymphatic vessels within the central nervous system may provide new tools and strategies for drug delivery to the brain.

Tunneled peripherally inserted central catheters (PICCs) offer several advantages such as an exit site at the green zone no matter where the puncture point is and a long subcutaneous route, which is considered a shield against infections and provides comfort to the patient. Clinicians could choose the proper exact exit site so as to avoid blood leakage from the exit point. The aim of the study was to assess the value of the tunneled PICCs versus normal PICCs with no long subcutaneous route. Sixty patients were randomly divided into two groups and underwent a PICC placement procedure between August 2014 and November 2014 and were then observed until February 2015. Thirty of them (group A) underwent a PICC placement procedure, after proper ultrasound scan and under local anesthesia, of the veins of the upper limb, internal jugular and axillary veins. The mean (±standard deviation) age of patients was 54.8 ± 9.2 years (range, 18–80 years). The primary success rate was 100% for all patients in both the groups. The procedure was not painful for the patients. In group A, after 3 months of surveillance, 7 devices were removed because the patients’ therapy came to an end, and only in one incident, the catheter was removed due to soft tissue infection. Tunneled PICCs seem to be a safe option and an easy alternative to perform in contrast to placement without a tunnel. It is an easy, cheap procedure that allows us to catheterize the vein with a larger caliber and create an exit point at any preselected point on the upper limb.

Introduction During ankle fracture fixation, iatrogenic trauma to retro fibula structures can result in morbidity and reoperation. We describe a safe zone for lag screw insertion. Materials and methods This study was completed in three sections. We identified the average entry and exit points for the lag screw using 45 Weber B ankle fractures identified from our trauma database. We then analysed 26 sequentially presented ankle magnetic resonance images, concentrating on axial sections at 4, 8, 12 and 16 mm above the ankle joint. Finally, we used 63 sequentially performed magnetic resonance scans to confirm the safe zone from these consistent structures. Results The typical lag screw exit point was 14.2 mm above the ankle joint (95% confidence Interval 11.3–17.1 mm). A safe zone trajectory occurred between 31 and 45 degrees taken from the anterior aspect of the flat fibular surface at this level. The obvious palpable landmark to direct screw trajectory and avoid ‘at risk’ structures was found to be the medial edge of the Achilles tendon. Our final dataset confirmed in 63 scans, the medial aspect of the Achilles tendon to be a consistent safe zone with a minimum distance of at risk structures of 4 mm. Conclusion This simple method of directing the fibula lag screw towards the palpable medial edge of the Achilles tendon is practical, easy to teach and directs the screw on a safe trajectory away from the most commonly injured structures around the back of the fibula.

Purpose: To determine the effect of tendon thickness on the needle penetration ability of four different designs of antegrade suture passers. Materials and Methods: Four antegrade suture passers were tested: (a) ExpresSew II (Depuy Mitek Inc., Raynham, MA), (b) Arthrex Scorpion (Arthrex, Naples, FL), (c) Concept (Linvatec Corp, Largo, FL), and (d) ElitePass (Smith and Nephew Endoscopy, Andover, MA). Bovine tendons were divided into five thickness groups: 3, 5, 7, 9 and 11 mm. At each tendon thickness, we performed 15 trials with the suture loaded and 15 unloaded per device. Successful needle penetration was recorded, and in case of success, the exit point of the needle was noted in relation to the superior arm of the grasping component. Results: All tested suture passing devices successfully penetrated tendon thicknesses of 3 and 5 mm. With the suture loaded, one device (Concept) only successfully penetrated 7 mm group tendons in 3/15 (20%) trials. Success rates at 9 mm with the suture loaded were 40% in ExpresSew II, 53% in Arthrex Scorpion, 0% in Concept and 53% in ElitePass. Among successful passages with a loaded suture in the 7 and 9 mm-groups, about 20-50% of passages were oblique, and the needle came out distal to the superior arm of grasping the component. No trial with any device succeeded with 11 mm tendons in the suture loading condition. Conclusion: Using an antegrade suture passer during arthroscopic rotator cuff repair should be carefully considered when the torn end of the tendon is thicker than about 7-9 mm due to potential failure of needle penetration and/or too oblique a suture passage. Level of Evidence: Controlled laboratory study.

The posterior interosseous nerve (PIN) is at risk during the posterior and lateral approaches to the proximal radius. We aimed to define a safe zone for these approaches to avoid injury of the PIN and to evaluate their close and changing relationship to the nerve during forearm rotation. The study collective consisted of 50 upper limbs. After performance of the lateral approach, the distance between the tip of the radial head and the PIN’s exit point from the supinator (= distance 1) and the shortest interval between the nerve’s exit to the radial margin of the ulna (= distance 2) were measured in maximum pronation and supination. Then, the dorsal approach was conducted and again distance 1 and the interval between the distal margin of the anconeus and the nerve’s exit point (distance 2) were evaluated (pronation and supination). There were significantly shorter distances during supination in comparison to pronation. Regarding the lateral approach, distance 1 changed from a mean of 60.3 mm (supination) to 62.7 mm in pronation (p

Penetrating abdomino-thoracic injuries are potentially life-threatening due to the associated haemorrhagic shock and visceral injury. The management of these injuries poses specific challenges in pre-hospital care, transport, and management strategies. We report a 35-year-old male having impalement injury of the left thorax and left upper arm with a metallic rod used for construction of the house after a fall from height. One rod penetrated thorax from left shoulder and exit point was present just above the iliac crest and second rod was seen piercing left upper arm. Patient was successfully managed without any intraoperative, post-operative surgical complications, neurological damage or permanent injuries.

Background: Hemifacial spasm (HFS) is a benign disease caused by the hyper excitement of facial nerves owing to vessel compression. The offending vessels are usually arteries, such as anterior and posterior inferior cerebellar or vertebral arteries, but there are few reports of vein involvement cases. Objective: The aim of this study was to investigate veins as offending vessels in patients with HFS confirmed by abnormal muscle response (AMR). Methods: We analyzed 5 patients with HFS caused by veins among 78 patients with HFS over the past 10 years. All patients underwent microvascular decompression (MVD) with AMR monitoring, whereas 3 of them underwent a second MVD. The mean follow-up time was 97 months. Results: Arteries were thoroughly decompressed in 3 patients with a failed first MVD surgery who received a second surgery, during which veins at the root exit point (RExP) were decompressed with the disappearance or a significant decrease in the amplitude of AMR. Two patients showed spasm resolution after the first surgery when veins were decompressed together with the disappearance of AMR. The location of veins was RExP and the cisternal portion. All patients had excellent outcomes within 3 months, and no complications were observed. Conclusions: Veins can be offending vessels in HFS patients. AMR is useful to determine the endpoint in these cases. Once arteries are decompressed thoroughly with residual AMR, surrounding veins at unusual sites, such as the RExP or the cisternal portion, must be checked to prevent persistent HFS. Complete decompression of veins leads to a good clinical outcome. Key words: Abnormal muscle response, Hemifacial spasm, Vein

We present a case of recurrent outflow tract arrhythmia despite repeated ablations. Premature ventricular contractions (PVCs) morphology suggested a right-sided focus. However, electrograms preceding PVCs were recorded from the right and left outflow tracts, distal coronary sinus, and right sinus of Valsalva. Arrhythmia was eliminated after radiofrequency (RF) applications delivered from different sites. We conclude that, in patients with recurrent outflow tract PVCs, mapping all the sites mentioned above may be necessary to find the earliest activation site and carry out successful ablation. In some patients, RF applications from multiple sites may be necessary to completely eliminate arrhythmia. (PACE 2012; 35:e6–e9)

SOLUTION The running butterfly suture is a novel approach to closing wounds under minimal tension. The technique is performed as follows: with the wound oriented parallel to the surgeon’s body, the needle is inserted through the outside of the wound, lateral to the apex, exiting in the interior of the wound. Alternately, a buried anchoring suture, such as a simple buried suture, buried vertical mattress suture, or set-back dermal suture, may first be placed. The far wound edge is then gently reflected back with the forceps, as the needle enters at the junction where the base of the incised wound edge meets the undersurface of the dermis (Fig 1). The needle then proceeds on a diagonal course, angling upward toward the surface of the skin and outward away from the wound edge, before exiting again at the base of the undermined wound edge, further along the length of the wound than its entry point (Fig 2). The needle is then reloaded, and the procedure is repeated on the contralateral wound edge. As when using the standard running subcuticular technique, the entry point on the contralateral wound edge should be slightly backtracked from the exit point on the prior side to reduce the risk of tissue bunching. Alternating bites on each side of the wound are taken until the end of the wound is reached, at which time either a final anchoring suture may be placed or the suture material can exit lateral to the apex and be secured, leaving a well-everted wound (Fig 3).

A new clinical device, the subtalar joint axis locator, was created to track the three-dimensional location of the subtalar joint axis during weightbearing movements of the foot. The assumption was that if the anterior exit point of the subtalar joint axis is stationary relative to the dorsal aspect of the talar neck, then, by performing radiographs of the feet with the subtalar joint axis locator in place on the foot, the ability of the locator to track rotations and translations of the talar neck and thus the subtalar joint axis in space could be approximated. In this preliminary study of two adults, the subtalar joint axis locator accurately tracked the talar neck position during weightbearing rotational motions of the subtalar joint. The device was also used in a series of subjects to determine its dynamic capabilities. It is possible, then, that the subtalar joint axis locator can reliably track the spatial location of the subtalar joint axis during weightbearing movements of the foot. (J Am Podiatr Med Assoc 96(3): 212–219, 2006)

BACKGROUND Various suspension suture techniques exist to elevate the mid-face, jowls, and neck. OBJECTIVE To assess safety and efficacy of a new suspension suture and inserting instrument with both standard and minimal incision (no-skin-excision) face-lifts. METHODS A new type of multianchor suspension suture assembled from commercially available 2-0 absorbable monofilament material, with 5 to 9 equally spaced knots through which are secured 7 to 9 mm bits of 0 thickness similar suture material, and an attached straightened needle, was used to elevate and suspend facial tissues to temporal or mastoid fascia. The suspension sutures are placed in the deep subcutaneous tissues, just above the superficial musculo aponeurotic system (SMAS), by use of a novel, blunt instrument, which does not require a second, distal exit point. The suspension suture distal end floats free. The proximal needle end is sutured to fascia. The suture was used on 20 patients. Fourteen of them underwent pure, "no-skin-excision," suspension lifts. Six had suspension suture elevation of the mid-face in conjunction with relatively conservative open lifts. Nine- to 12-month results were evaluated. RESULTS With open face-lifts, 9- to 12-month results are excellent with significant persistence of the correction initially achieved. Resulting scars remained fine line. There were no complications. With pure suspension lifts, initial results were impressive. By 6 months, correction started to fade. By 12 months 100% of initial correction for jowls, and 80 to 100% for mid-face, appeared lost. Recovery time was 2 to 4 days. There were no significant complications. CONCLUSION Large multianchor, absorbable monofilament sutures can safely and effectively enhance results of conservative lifts, with remarkable elevation of the mid-face not achievable with simple SMAS flaps. These suspension sutures can easily and safely achieve impressive, though relatively short-term results, with a minimal incision, "no-skin-excision" technique.

Object. The authors have attempted to define the exact borders of the root exit zone (RExZ) of the facial nerve, measure the distribution of myelin histologically, and examine the relationship between contact vessels and the RExZ. Methods. Seventy-five facial nerves were obtained from brainstems excised from 44 adult patients at autopsy. The arteries and veins associated with the facial nerve were counted and measured. The facial nerves, associated vasculature, and adjoining portions of the brainstem were then removed en bloc. These tissues were serially sectioned and stained, and a photomicrograph of each section was obtained. The distribution of myelin on each section was measured from the upper edge of the supraolivary fossette, and the relationship between contact vessels and the RExZ was examined. The lateral transitional zone of the facial nerve began 8 mm distal to the upper edge of the supraolivary fossette (root exit point [RExP]) and had a mean length of 1.9 mm. The root detachment point (RDP) of the facial nerve at the medial side was located very close to the beginning of the medial transitional zone. In more than 80% of the nerves that were examined, vascular structures compressed the central glial myelin of the nerve. Conclusions. The authors propose the use of the terms “RExP,” “RDP,” and “transitional zone,” instead of RExZ, which cannot be well defined. The RDP appears to be a good landmark for use during microvascular decompression.

SOLUTION The running percutaneous set-back dermal technique, a running percutaneous variation of the set-back dermal suture that permits placement of running buried everting sutures even in tight spaces, may be useful. It is executed as follows: the needle is inserted from inside the wound directly through the undersurface of the undermined dermis, exiting through the surface of the intact skin just lateral to the cut wound edge. The needle is then reloaded on the needle driver and reinserted, using a backhand technique if desired, just medial to the exit point of the suture material, directly through the epidermis, exiting on the undersurface of the dermis in the undermined space between the dermis and subcutaneous tissue. On the contralateral side, the needle is again inserted from the undersurface of the dermis directly through the skin. The needle is reloaded and inserted just lateral to its exit point perpendicularly through the skin, exiting the underside of the dermis in the undermined space. The suture material is then tied, allowing the knot to remain buried beneath the dermis, completing the placement of the anchoring percutaneous set-back suture. The suture throws are then sequentially repeated in parallel sets moving proximally towards the surgeon for the desired number of throws. The suture material is then tied off once the end of the wound is reached (Fig 1). Because knots are tied only at the beginning and the end of the entire line of sutures, this technique is faster than using standard interrupted percutaneous set-back dermal sutures.

We quantitatively compared relative merits of lateral approaches to the pontomesencephalic junction (PMJ): anterior petrosectomy, subtemporal transtentorial, posterior petrosectomy, and retrosigmoid transtentorial. In dissected cadaveric heads, lengths of exposure were measured anteriorly from CN V along the pontomesencephalic sulcus (PMS); posterosuperiorly along the lateral mesencephalic sulcus (LMS); and posteroinferiorly along the interpeduncular sulcus (IPS). Subtemporal transtentorial approach provided best anterior exposure along the PMS (23.8 ± 4.5 mm). Posterosuperior exposures were comparable for all approaches except anterior petrosectomy (limited). Posteroinferior exposure was most with subtemporal transtentorial approach (13.2 ± 2.8 mm). CN V entry/exit point was identified through all approaches, except for subtemporal transtentorial; shortest surgical depth with posterior petrosectomy was 43.7 ± 5.5 mm. PMS-LMS-IPS convergence point: reached through all approaches, except for anterior petrosectomy (limited); shortest surgical depth with posterior petrosectomy was 40.3 ± 4.3 mm. Anterior petrosectomy provides direct anterolateral views of the pons not afforded by subtemporal approach. Subtemporal transtentorial approach provides optimal posterolateral view to the PMJ and cerebellar peduncles. Retrosigmoid transtentorial approach offers wide exposure of the lateral surface, limited on the posteroinferior PMJ by the cerebellum. The small opening of posterior petrosectomy creates an awkward corridor to anterior PMJ targets but provides a direct and shortest route to the cerebellar peduncles.

The Radius Surgical System is a manual manipulator with two additional degrees of freedom compared with conventional laparoscopic instruments (CLIs). This study aimed to compare the performance of laparoscopic suturing tasks with the use of the Radius Surgical System and CLIs, respectively.Five experienced laparoscopic surgeons performed laparoscopic surgical tasks in a training box. The tasks consisted of knot-tying, suturing, and needle control tasks. The needle control task was performed to evaluate the precision of the needle drive by analysis of the needle exit point on a suture pad. In the knot-tying and suturing tasks, required time and accuracy value were measured. Needle control tasks were performed on three different angulations of plane. The angles between the instrument plane and the target plane (AIT) were 30 degrees, 60 degrees, and 90 degrees. The distance of the exit point to the center of the target field, the number of actions needed to fulfill a single task, and the required time were recorded and analyzed.In the knot-tying and frontal suturing tasks, there were no significant differences between the two groups. In the sagittal suturing task, the required time in the Radius group was significantly shorter than in the CLI group. In the needle control tasks on 30 degree and 60 degree AIT, the distance was significantly shorter in the Radius group than in the CLI group. There were no significant differences in the number of actions or the required time. In the frontal and sagittal needle control task on 90 degree AIT, the distance was significantly shorter in the Radius group than in the CLI group. The number of actions and the required time were significantly less in the Radius group than in the CLI group.The two additional degrees of freedom contributed to accurate and controlled needle guidance, especially in difficult spatial situations.

This is a case study of a perforating wound of the penis by a wood, which happened during the daily activity of a carpenter. The patient was referred three hours after the accident that happened at its jobsite. There were three wounds. The entry point was on the left side of the penis, the exit point on the right and the second entry point on the medial face of the right thigh. The surgical exploration revealed a wound of 1.5 by 3 centimeters that went through the corpus cavernosum. The urethra seemed to be normal and the quadriceps muscle was torn. The risk of erection disorder following the penile injury is to be considered.

Firearm injuries are common with approximately 700 daily in the United States. Missile emboli by contrast are relatively rare occurring in approximately 0.3% of penetrating wounds in the Vietnam conflict. Experience and recommendations stem from case series and reports. Management can be challenging and may confront any practitioner who deals with shrapnel or gunshot wounds. Clinical suspicion should be maintained whenever a penetrating missile entry wound is detected without a clearly defined exit point. Bullets and missiles may embolize when they possess low kinetic energy at the time of passage through the venous or arterial wall and the diameter of the projectile does not exceed that of the vessel. Remote radiologic and complete neurovascular examination should be performed in all missile wounds in which the projectile is not accounted for. Radiologic whole body surveillance imaging may be required for wounds to the chest and abdomen.

In cold steel surgery it is very important that the incision through the skin be made in a vertical fashion perpendicular to the skin surface (Fig. 13). In this was wound edges can be best aligned in a perfect match minimizing the scar. It is easier to obtain such an incision if the skin is slightly stretched during the procedure. For small lesions a gifted surgeon can stretch with one hand and guide the scalpel with the other, but usually the services of an assistant are helpful. The cut begins at the most critical point (for example, near the tear duct or at the ear canal). Ideally it is performed in a single stroke, so that the inevitable bleeding has little chance to obscure skin markings. Once the excision is completed, the skin is elevated with a skin hook, and the underlying tissues are separated with either the scalpel or Metzenbaum scissors. Bleeding must then be controlled. Vessels should be clamped and tied, or ligated with resorbable 3–0 to 5–0 sutures, or sealed with electrocautery.

Sixteen surgeons familiar with grip 1 or grip 2 were randomly selected to test the accuracy of their suture method. The accuracy was tested in two ways: suture with and suture without wavering, while searching for an expected exit point after suturing started and by the distance deviated from a point in a 2 cm suture stride. With grip 1, the first and fourth fingers were put in the rings and the second finger was put around the leg of the holder, whereas with grip 2, all the fingers were put around the holder. Without waver, the mean value was 2 +/- 1.5 mm with grip 1 and 1.4 +/- 1.1 mm with grip 2 (p less than 0.01) and with waver, 1.2 +/- 1.1 mm and 1.1 +/- 10.9 mm (p value not significant). Wavering reduced the deviation (p less than 0.01 and p less than 0.05, respectively). In conclusion, the accuracy was not as precise as the surgeon expected and grip 2 was more accurate, although equivalent accuracy was gained by more wavering with grip 1, thus, there was a greater potential for injuring the tissue.

For the basic rules of local anesthesia one should refer to the various anesthesiological texts and the corresponding volumes in the large texts on general surgery (Frey, Hugin, Killian, and others). As far as special requirements for the operations cited here are concerned, these are to be found in the respective chapters. Only local anesthesia of the nose for corrective surgery is to be presented here in more detail.