ANATOMY OF
THORAX
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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BONES- RIB CAGE

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THE RIBCAGE
• There are 12 ribs on each side, the no may be
increased by a cervical or a lumbar rib or it
may be reduced t...
• The breadth of the ribs decreases from above
downwards. In the upper ten ribs the anterior
ends are broader than post en...
POSTERIOR VIEW

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THE STERNUM
•

The sternum is a flat bone, forming the anterior median
part of the thoracic skeleton. In shape it resemble...
THE MUSCLES
• There are two sets:
1) EXTRINSIC MUSCLES
2) INTERCOSTAL MUSCLES
• Extrinsic muscles:-pectoralis major
-traze...
INTERCOSTAL MUSCLES:- external intercostal muscle
- internal intercostal muscle
- transversus thoracis muscle( 3 parts)
1)...
MUSCLES

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INTERNAL VIEW

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POSTERIOR VIEW

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THE MEDIASTENUM

•

The mediastenum is the median septum of the thorax between
the two lungs.

•

BOUNDRIES:ant- sternum
p...
•

SUPERIOR MEDIASTENUM:BOUNDRIES: ant- manibrium sterni
post- upper 4 thoracic
vertebrae
sup- plane of the thoracic
duct
...
• ANTERIOR MEDIASTENUM :lymphnodes, lowest part of thymus
• Middle mediastenum- heart,
ascending aorta, pulmonary trunk,
2...
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www.indiandentalacademy.com
CAROTID BODY AND SINUS

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• The carotid body (glomus) contains
chemoreceptors that are activated primarily by
low oxygen levels
arterial blood and, ...
• The carotid sinus is a thin-walled, elastic
section of the internal carotid artery, the wall of
which contains stretch r...
RESPIRATION

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MUSCLES OF RESPIRATION

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PNEUMOTHORAX(OPEN/SUCKING)

www.indiandentalacademy.com
• Open pneumothorax (air in the pleural cavity)
usually results from a penetrating wound of the
chest wall, including the ...
TREATMENT

www.indiandentalacademy.com
HAEMOTHORAX
•

Hemothorax (accumulation of blood within the pleural
cavity) is common in both penetrating and
nonpenetrati...
www.indiandentalacademy.com
TREATMENT
•

A minimal amount of blood (less than 350 ml) can resorb
spontaneously, and conservative management without
th...
www.indiandentalacademy.com
HEIMLICH MANEUVER
• The Heimlich maneuver to expel an
obstructing mass in the airway is an
effective and safe rescue proce...
www.indiandentalacademy.com
POSITION OF THE RESCUER’S HANDS

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ADULT VICTIM

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INFANT VICTIM

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SELF SAVE PROCEDURE

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AUSCULTATION

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• (1) Patient sitting up, leaning forward, and,
preferably, in expiration. This position
increases the contact of the apex...
www.indiandentalacademy.com
DELTO PERCTORAL FLAP
• Indications:
- The flap may serve at almost any head
and neck level below the Ipsilateral
eyebrow o...
www.indiandentalacademy.com
• ANATOMY
- Two contiguous but separate axially
vascularised zones are present.
- Intercostal perforating branches from
in...
• OPERATIVE TECHNIQUES:
1) ROTATION TRANSFER: This open flap can
resurface the entire adjacent side or front of
the neck.
...
www.indiandentalacademy.com
www.indiandentalacademy.com
• 3) BRIDGING OVER THE NECK:
This tech is employable for intra oral defects.
With the pedicle tube and with an intervening...
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
DELTO SCAPULAR SKIN FLAP
Indications:
•

- The location of its base inferior to posterior
neck skin, which commonly receiv...
www.indiandentalacademy.com
OPERATING TECHNIQUES:
•

The inferior incision is always started as far
medial as the forth and fifth thorasic vertebral
s...
www.indiandentalacademy.com
LATTISMUS DORSI MUSCULO
CUTANEOUS FLAP
• Indication:
• - It has proved esp useful in resurfacing
defects of the cheek and ...
• ANATOMY:
• - The primary blood supply to the muscle
comes primarily from the thoracodorsal
artery,secondary contribution...
www.indiandentalacademy.com
•

OPERATING TECHNIQUES:

•

1) Muscle and mucocutaneous flap: An incision is made
just beyond the free edge of the muscle...
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
CERVICO HUMERAL FLAP
• Indications:
• - It is used to cover the anterior cervical
defects or to situations where other
alt...
www.indiandentalacademy.com
• OPERATING TECHNIQUE:
• - The standard procedure is to perform a
preliminary delay 10days prior to definitive
rotation of...
www.indiandentalacademy.com
PECTORALIS MAJOR
• Indications: Oro-Pharynx: resection of
the lateral floor of the mouth, alveolar
ridge, Post half of the...
•

Anatomy: The dominant blood supply is the Thoraco
acromial artery( a branch of sub clavian artery).

•

Operative techn...
• RECEPIENT SITE: Orbital exenteration
A PMMC flap is planned with the width
equivalent to the length sufficient to fill t...
SCAPULAR FLAP
• Indications: It is useful for repair of
a combined, composite defect of
the tongue floor of the mouth, man...
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
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www.indiandentalacademy.com
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www.indiandentalacademy.com
Leader in continuing dental education

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Anatomy of thorax onlilne dental courses /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

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Anatomy of thorax onlilne dental courses /certified fixed orthodontic courses by Indian dental academy

  1. 1. ANATOMY OF THORAX INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. BONES- RIB CAGE www.indiandentalacademy.com
  3. 3. THE RIBCAGE • There are 12 ribs on each side, the no may be increased by a cervical or a lumbar rib or it may be reduced to 11 by the absence of 12 th rib. • The gaps between the ribs are called as intercostal spaces. These spaces are deeper in front than behind, and deeper between the upper than between the lower ribs. • The ribs are placed obliquely, the upper being less oblique than the lower. • The length of the ribs increases from the first to the 7 th ribs,and then gradually decreases www.indiandentalacademy.com th th from 7 to 12 ribs.
  4. 4. • The breadth of the ribs decreases from above downwards. In the upper ten ribs the anterior ends are broader than post ends. • The first seven ribs which are connected through there cartilages to the sternum are called true ribs, or vertebrosternal ribs. • The remaining are false ribs , out of these the cartilages of 8 th ,9 th and 10 th are joined to the next higher cartilage ( vertebrochondral ribs), while the anterior ends of the 11 th and 12 th ribs are free and are called floating ribs ( vertebral ribs). • The costal cartilages represent the unossified ant parts of the ribs. They are made up of hyaline cartilage. They contribute materially to the elasticity of the thoracic wall. www.indiandentalacademy.com
  5. 5. POSTERIOR VIEW www.indiandentalacademy.com
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  7. 7. THE STERNUM • The sternum is a flat bone, forming the anterior median part of the thoracic skeleton. In shape it resembles a short sword. • Three parts:- 1) upper part- manubrium 2) middle part- body 3) lower part- xiphoid procs MANUBRIUM: the anterior border is thick, rounded and concave. It is marked by a suprasternal notch in the median part, and by the clavicular notch on each side. • The clavicular notch articulates with the medial end of the clavicle to form the sternoclavicular joint. XIPHOID PROCESS:- smallest part of the sternum, it is at first cartilagenous but in adult it becomes ossified near its upper end. • It varies greatly in shape and may be bifid or perforated. www.indiandentalacademy.com
  8. 8. THE MUSCLES • There are two sets: 1) EXTRINSIC MUSCLES 2) INTERCOSTAL MUSCLES • Extrinsic muscles:-pectoralis major -trazepius -serratus anterior -latissimus dorsi -levator scapulae -rhomboideus major - Rhomboideus minor -serratus post sup -Serratus post inf www.indiandentalacademy.com
  9. 9. INTERCOSTAL MUSCLES:- external intercostal muscle - internal intercostal muscle - transversus thoracis muscle( 3 parts) 1)subcostalis 2)intercostalis intimi 3)sternocostalis NERVE SUPPLY:• The intercostal nerves are the ant primary rami of spinal nerves t1 to t11. the primary ramus of the 12 th thorasic nerve forms the subcostal nerve. • In addition to supplying the intercostal spaces yhe upper three intercostal nerves also supply the upper limb, and the lower five intercostal nerves(t7 to t11) also supply the abdominal wall. • The remaining nerves(t4,5,6) supply only the thoracic wall and so are called typical intercostal nerves. www.indiandentalacademy.com
  10. 10. MUSCLES www.indiandentalacademy.com
  11. 11. INTERNAL VIEW www.indiandentalacademy.com
  12. 12. POSTERIOR VIEW www.indiandentalacademy.com
  13. 13. THE MEDIASTENUM • The mediastenum is the median septum of the thorax between the two lungs. • BOUNDRIES:ant- sternum post- vertebral colum sup- thoracic inlet inf- diaphragm on each side- mediastinal pluera • DIVISIONS:- superior mediastenum - inferior mediastenum(ant, middle and post mediastenum) • The inf mediastenum is subdivided into 3 parts.the area infront of the pericardium is ant mediastenum, the area behind the pericardium is post mediastenum and the pericardiuum and its contents form the middle mediastenum. www.indiandentalacademy.com
  14. 14. • SUPERIOR MEDIASTENUM:BOUNDRIES: ant- manibrium sterni post- upper 4 thoracic vertebrae sup- plane of the thoracic duct inf- an imaginary plane passing through the sternal angle in front, and the lower border of the 4 th throcic vertebrae behind. CONTENTS:muscles-sternohyoid, sternothyroid arteries- arch of aorta, bracheocephalic artery, left common carotid artery,and left subclavian artery veins- r & L bracheocephalic veins, l sup intercostal vein nerves- vagus, pherinic, cardiac nerves and l recurrent laryngeal nerve thymus thoracic duct Note: there is very little loose connective tissue between the mobile organs therefore , the space can be readily www.indiandentalacademy.com fluids and neoplasms. dilated by the inflamatory
  15. 15. • ANTERIOR MEDIASTENUM :lymphnodes, lowest part of thymus • Middle mediastenum- heart, ascending aorta, pulmonary trunk, 2 pulmonary veins, and bifurcation of trachea • Posterior mediastenum:oesophagus, vagi and splanchnic nerves. www.indiandentalacademy.com
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  18. 18. CAROTID BODY AND SINUS www.indiandentalacademy.com
  19. 19. • The carotid body (glomus) contains chemoreceptors that are activated primarily by low oxygen levels arterial blood and, to a lesser extent, by low blood pH or high levels of carbon dioxide in the blood. • consists of a mass of spongy tissue located at the bifurcation of the common carotid artery into its internal and external carotid branches. It has its own independent arterial and venous connections. • Innervation of the carotid body occurs via the carotid sinus nerve, which contains afferent fibers that join the glossopharyngeal nerve (IX) and autonomic efferent fibers derived from the vagus nerve (X). The afferent fibers from the carotid body play an important role in increasing respiration in response to a drop in blood oxygen levels. www.indiandentalacademy.com
  20. 20. • The carotid sinus is a thin-walled, elastic section of the internal carotid artery, the wall of which contains stretch receptors. These receptors are mechanoreceptive endings of afferent nerve fibers that reach the sinus via the glossopharyngeal nerve (IX) and carotid sinus nerves. • The carotid sinus receptors function as baroreceptors, informing the central nervous system about blood pressure within the artery. Strong stimulation (pressure) on these receptors results in reflex bradycardia and a marked fall in blood pressure, and may lead to loss of consciousness as well (carotid sinus syncope). • Since the more sensitive baroreceptive endings are active even at normal blood pressure levels, this reflex is constantly acting to restrict the heart rate and blood pressure. www.indiandentalacademy.com
  21. 21. RESPIRATION www.indiandentalacademy.com
  22. 22. MUSCLES OF RESPIRATION www.indiandentalacademy.com
  23. 23. PNEUMOTHORAX(OPEN/SUCKING) www.indiandentalacademy.com
  24. 24. • Open pneumothorax (air in the pleural cavity) usually results from a penetrating wound of the chest wall, including the parietal pleura, and is always a serious condition. • In an open or "sucking" wound of the chest wall (so-called because a sucking sound is often audible as air is sucked into the pleural cavitythrough the wound), the lung on the affected side is exposed to atmospheric pressure, which results in the lung's collapse and a shift of the mediastinum to the uninvolved side. Air passes into the chest more easilyon inspiration than it can leave during expiration, and this permits a progressive collapse of the lung. • As the lung on the affected side is collapsed, the increased pleural pressure there pushes the mediastinum to the uninvolved side, www.indiandentalacademy.com thereby diminishing the contralateral lung
  25. 25. TREATMENT www.indiandentalacademy.com
  26. 26. HAEMOTHORAX • Hemothorax (accumulation of blood within the pleural cavity) is common in both penetrating and nonpenetrating injuries to the chest. • If the hemorrhage is large, it may cause not only hypovolemic shock but also dangerously reduced vital capacity by compressing the lung on the involved side. • Persistant hemorrhage usually arises from an intercostal or internal thoracic artery, and less frequently from the major hilar vessels. • Blood in the pleural cavity normally does not clot because of the smooth surfaces, the defibrinating action that occurs with the motions of respiration, and the presence of an anticoagulant enzyme. www.indiandentalacademy.com
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  28. 28. TREATMENT • A minimal amount of blood (less than 350 ml) can resorb spontaneously, and conservative management without thoracentesis is sufficient. • If the hemothorax is greater than minimal, or if hemopneumothorax is found, intercostal tube thoracostomy should be performed. • A large tube is passed through the chest wall at either the 4th intercostal space laterally or the 2nd intercostal space anteriorly. • Under local anesthesia, a skin incision is made and blunt dissection is carried out with a gloved finger to prevent inadvertent lung puncture by the tube should unsuspected pleural adhesion be present. tube is then connected to underwater-seal drainage. • If the hemothorax is massive, two tubes are placed in the chest to evacuate www.indiandentalacademy.com the blood rapidly and permit the lung to expand.
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  30. 30. HEIMLICH MANEUVER • The Heimlich maneuver to expel an obstructing mass in the airway is an effective and safe rescue procedure. • The maneuver is a technique whereby subdiaphragmatic compression, or abdominal "thrust,"creates an expulsive force from the lungs to or through the upper airways. • The consequent velocity ofairflow is often sufficient to forcefully eject an www.indiandentalacademy.com obstructing object from the airway.
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  32. 32. POSITION OF THE RESCUER’S HANDS www.indiandentalacademy.com
  33. 33. ADULT VICTIM www.indiandentalacademy.com
  34. 34. INFANT VICTIM www.indiandentalacademy.com
  35. 35. SELF SAVE PROCEDURE www.indiandentalacademy.com
  36. 36. AUSCULTATION www.indiandentalacademy.com
  37. 37. • (1) Patient sitting up, leaning forward, and, preferably, in expiration. This position increases the contact of the apex of the heart with the anterior chest wall, and is preferred for auscultation of mitral and left ventricular sounds and relatively high-pitched murmurs using the stethoscope diaphragm. The sitting up, leaning forward position is preferred particularly for aortic diastolic murmurs. • (2) Patient supine. This position is best for pulmonic and tricuspid murmurs. • (3) Patient in left lateral recumbent (left decubitus) position. The low-pitched filling sounds during diastole are heard best in this position using the stethoscope bell. This position causes tachycardia and accentuates www.indiandentalacademy.com the rumbling murmur of mitral stenosis.
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  39. 39. DELTO PERCTORAL FLAP • Indications: - The flap may serve at almost any head and neck level below the Ipsilateral eyebrow or below the mid level of the Contralateral face. - The delto pectoral flap can be used for either external cover or intra oral lining or both simultaneously. - It can also be combined with pectoralis major musculo cutaneous flap. www.indiandentalacademy.com
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  41. 41. • ANATOMY - Two contiguous but separate axially vascularised zones are present. - Intercostal perforating branches from internal mammary artery. - Cutaneous vessel from thoracoacromial artery. - When the flap is elevated its survival depends entirely on the flow of blood in the branches form the internal mammary to the pectoral zone. www.indiandentalacademy.com
  42. 42. • OPERATIVE TECHNIQUES: 1) ROTATION TRANSFER: This open flap can resurface the entire adjacent side or front of the neck. This greatly simplifies the decision in RND to sacrifice cervical skin infiltrated with advanced cancer or severely damaged by prior radiation. 2) SUBCUTANEOUS TRANSFER: This transfer through the dissected neck with the flap pedicle deepithelialized, simulating an island flap, may be used for covering a high cervical and carotid area defect. This tech eliminates the need for division of the pedicle in a second stage and may bring welcome protection to the dissected neck as well as contour augmentation. www.indiandentalacademy.com
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  45. 45. • 3) BRIDGING OVER THE NECK: This tech is employable for intra oral defects. With the pedicle tube and with an intervening span of intact cervical skin form the donor area, is a more commonly employed method for transfer to locations on the head. Additionally, splitting the flap end, folding it to provide two layers, and deepithelialize the folded edge ,if necessary are auxillary maneuvers that may be used on a special circumstances. www.indiandentalacademy.com
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  49. 49. DELTO SCAPULAR SKIN FLAP Indications: • - The location of its base inferior to posterior neck skin, which commonly receives radiation in cases of head and neck cancer and which constitutes the base of the classic shoulder flap. • -Its arc of rotation,which extends to difficult to reach occipital and post neck wounds. • - Its use as an additional source of tissue when other methods are failed or not feasible. ANATOMY: • - The blood supply is from the perforating www.indiandentalacademy.com branches of the post inter costal arteries.
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  51. 51. OPERATING TECHNIQUES: • The inferior incision is always started as far medial as the forth and fifth thorasic vertebral spine and may even be back cut if necessary to improve the mobility. • The flap is gradually tappered while distally incorporating the thinner, more pliable skin of the deltoid region and upper extremities. DELAYED MULTIPLE STAGE TECH: • This is by limiting medial undermining to a vertical line at the lateral border of the neck. • IN initial stage sup and inf incisions are made,which are followed in 10- 14 days by undermining. • 10-14 days later,the distal end is incised.The flap may be transferred in 2-3 days,when vialibility is assertained www.indiandentalacademy.com
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  53. 53. LATTISMUS DORSI MUSCULO CUTANEOUS FLAP • Indication: • - It has proved esp useful in resurfacing defects of the cheek and lateral scalp. • - It is used in areas when a great deal of bulk or skin or both are needed. • - It used for reestablishing oropharyngeal continuity, the musculo cutaneous flap had been used with the skin portion placed inward and with skin graft placed in the exposed muscle surface. • - Free lattismus dorsi has been used as www.indiandentalacademy.com a muscle alone with skin graft cover.
  54. 54. • ANATOMY: • - The primary blood supply to the muscle comes primarily from the thoracodorsal artery,secondary contributions from perforating branches of the lower post intercostal arteries. • - The secondary blood supply,originating in the intercostal vessels that also nourish the ribs,is important in head and neck reconstructions and forms the basis of osteomusculo cutaneous flap that carried viable rib with muscle based only on the thoraco dorsal vessels www.indiandentalacademy.com
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  56. 56. • OPERATING TECHNIQUES: • 1) Muscle and mucocutaneous flap: An incision is made just beyond the free edge of the muscle to expose the vascular pedicle. The incision is carried post to koin the incised skin island, which is sutured to the muscle fascia early in the prodcedure to avoid shearing any musculocutaneous perforators. The muscle is dissected superficial to the serratus anterior and the scapula. If a transfer of vascularised rib is planned,the perforators to the rib are preserved,otherwise all the post vessels are divided. • • • • 2) Free flap tech: • It is similar to that of the muscle flap, except the insertion of the muscle is divided s well www.indiandentalacademy.com
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  60. 60. CERVICO HUMERAL FLAP • Indications: • - It is used to cover the anterior cervical defects or to situations where other alternatives are not available. • Anatomy: • - The dominant vascular pedicle to the trapezius is the transverse cervical artery. • The skin over the deltoid on the lateral proximal arm is supplied by the post circum flex humeral artery www.indiandentalacademy.com
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  62. 62. • OPERATING TECHNIQUE: • - The standard procedure is to perform a preliminary delay 10days prior to definitive rotation of the cervico humeral flap. • - The initial delay consists of parallel incisions of the distal 10-12 cms of the flap with the subfacial underminig of the included skin. • This delay ligates the post circum flex humeral artery. • Definitive rotation of the flap requires mobilization proximally to the acromioclavicular joint, including detachment of the trapezius muscle from the spine of the scapula. • The arm donor site has been skin grafted in every case. www.indiandentalacademy.com
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  64. 64. PECTORALIS MAJOR • Indications: Oro-Pharynx: resection of the lateral floor of the mouth, alveolar ridge, Post half of the tounge,and piriform sinus requires sufficient skin and bilk for reconstruction’s. • Orbital Exenteration: This flap is particularly useful for reconstruction in this area because it provides bulk and well vascularized tissue to fill the cavity, to seal CSF leaks, and to provide greater protection against bacterial invasion. • Temporal bone resection www.indiandentalacademy.com • Mandibular reconstruction
  65. 65. • Anatomy: The dominant blood supply is the Thoraco acromial artery( a branch of sub clavian artery). • Operative technique: -Donor site: Skin paddle- Incise along the infero lateral portion of the skin paddle first. A dermis of the skin paddle is sutured to the muscle fascia with several interrupted sutures along the entire skin paddle as a dissection proceeds around the paddle. Once the skin is incised along the Infero lateral border of the outline, the muscle fibers are split to enter the sub pectoral space. Once the muscle is dissected from the sub pectoral fascia the vascular pedicle in this fascia is separated from the muscle. CLOSURE OF THE DONOR SITE: Although some surgeons covered chest donor site with skin grafts, literature says it’s totally unnecessary www.indiandentalacademy.com
  66. 66. • RECEPIENT SITE: Orbital exenteration A PMMC flap is planned with the width equivalent to the length sufficient to fill the orbital cavity with soft tissue. The skin is removed from the distal 4-6 cms, the exposed muscle and soft tissues are used to fill the orbital cavity, and the margins of the skin of the flap are sutured to the skin edges of the orbit. MANDIBULAR RECONSTRUCTION: A PMMC flap incorporating a segment of underlying rib to reconstruct a jaw, the body and symphysis of the Mand were reconstructed with the attached rib while the floor of the mouth and chin were reconstructed with the overlying double paddle musculo cutaneous flap. www.indiandentalacademy.com
  67. 67. SCAPULAR FLAP • Indications: It is useful for repair of a combined, composite defect of the tongue floor of the mouth, mand and neck skin. • Anatomy: The sub scapular artery branches within a few mm of its origin from the axial artery into the circumflex scapular artery and thoraco dorsal artery. www.indiandentalacademy.com
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  76. 76. www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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