J. Hill, E. G. Jr. & McKinney, W. M. Vascular anatomy and pathology of the head and neck: method of corrosion casting. Injections of Botulinum toxin A to the affected area is also effective. 2010 Jul 20. Published in issue: December, 2016. Specify size of the lesion, location relative to the gland, whether the mass was removed in toto (whether the margins were grossly negative). A thorough wash with water for several minutes will remove clots and other debris, and improve the visualization of the structures of interest. This may vary depending on the duct that is going to be injected. Forgotten your username or password? Historically, hundreds of chemical substances (alcohol, tannic acid, mercuric chloride, arsenic, glycerin, formaldehyde, among others) have been used to avoid the natural putrefaction process to study the human body and to preserve cadaveric dissection as an essential activity in medical education (Korf et al., 2008). Practice your newly acquired knowledge about the histology of the ductus deferens by using the following resource: The vas (ductus) deferens is involved in transporting spermatozoa from the epididymis to the ejaculatory ducts. In the final step of this first phase, all the tubes must be sealed with different clamps (Kelly, Rochester, etc.) Iowa City, IA 52242-1089, Editor: Henry Hoffman, MD Int. After the budding of these structures, the remaining mesonephric ducts develop a muscular coat and form the vas (ductus) deferens. Concentrations, uses, and characteristics of different injectable materials. The phenomenon has been attributed to pressure on the cerebellum created by the noose. Join us as we discuss the latest innovations and updates in cardiology at this popular conference. Graham SM, Hoffman HT. Reviewer: A one day course covering upper and lower body casting techniques. Managing Editors: Sarah Elliott, Kay Klein, Claire Davis It gives an opportunity to perform a variety of surgical procedures on tissue models under the expert guidance of consultant surgeons. [7] The trapezius muscle controls the action of shrugging the shoulders, and the sternocleidomastoid the action of turning the head. This human anatomy and physiology textbook was explicitly written for a standard college course on Anatomy and Physiology that takes two semesters. [1] The lateral horn of high cervical segments appears to be continuous with the nucleus ambiguus of the medulla oblongata, from which the cranial component of the accessory nerve is derived. Esophagus (anterior view) The esophagus (oesophagus) is a 25 cm long fibromuscular tube extending from the pharynx (C6 level) to the stomach (T11 level). Note the variability in anatomic relationships between the retromandibular vein and facial nerve. Kim DI, Nam SH, Nam YS, Lee KS, Chung RH, Han SH The marginal mandibular branch of the facial nerve in Koreans. Adicionalmente, los especmenes producidos por ellos, sern de gran utilidad para clases a futuro. For more information about the ductus deferens, take a look below: The wall of the vas (ductus) deferens consists of three main layers. Vicinity oflateral pterygoid (intraorally) Delegates and faculty are advised to take lateral flow tests before attending in-person events. Fig. Lymph drained from the intermediate and terminal portion of the ductus deferens however, mostly drains into the external iliac lymph nodes. Ann. Scroll the list below to find a course to suit you. 2. The outer layer is comprised of connective tissue whereas the middle layer is comprised of smooth muscle. New users must register before logging in. Lam KH, Wei W, Ho HC, Ho CM. Otolaryngol Head Neck Surg 2010;142(1):5563. The ipsilateral face is painted with iodine and allowed to dry. Therefore, we recommend them to be kept in water on a definitive container to prevent any fracture caused by manipulation. This event will provide an update on current topics and will give orthodontic teams an opportunity to get together and to focus on areas of fundamental importance to the delivery of contemporary orthodontics. Fig. WebThe real reason your traps are tight The upper trap, the muscle along the sides of your neck, is a common cause of neck pain and tension. [1] The nerve travels along the inner wall of the skull towards the jugular foramen. Parotidectomy with special reference to the facial nerve. Morphol., 35(3):1147-1153, 2017. 2nd ed. Fig. [3] Consequently, the term "accessory nerve" was and is increasingly used to denote only fibres from the spinal cord; the fact that only the spinal portion could be tested clinically lent weight to this opinion. Once it crosses the ureter, the vas (ductus) deferens expands and is then referred to as the ampulla of the vas (ductus)deferens. Anatomy; The functions of the systems of the human body. For the residue disposal after finishing, we recommend inactivating the strong bases (like NaOH) with weak acids like acetic acid (vinegar). Royal College of Physicians and Surgeons of Glasgow / Online. AJOG's Editors have active research programs and, on occasion, publish work in the Journal. If there is a suspicion that the facial nerve may need to be sacrificed, be prepared for primary nerve or cable graft repair with great auricular, sural, or accessory nerve (if removed in neck dissection). An inner mucosal layer is also present. [3], Course and distribution of the glossopharyngeal, vagus, and accessory nerves. These ducts are derived from the mesoderm, the middle layer of one of the three primary germ layers in the embryo. They not only avoid putrefaction, but also show more durability and specimens do not have to be disposed due to decay throughout the years (Bravo, 2006). [5] Outcomes with surgical treatment appear to be better than conservative management, which entails physiotherapy and pain relief. During ejaculation, the sympathetic nervous system innervates the muscular layers of the vas (ductus) deferens and causes them to produce strong peristaltic contractions in order to aid in the propulsion of the spermatozoa. It is provided to help visualize the procedure from beginning to end and to illustrate key points. The force ripped his head clean off. Returning for its ninth year, our flagship medical conference will provide up-to-date information on the optimal management of acutely ill patients within the first 24 hours of admission. The concentrations for acrylic, epoxy resin, polyester resin, and room temperature vulcanization (RTV) silicone are described, as well as the corresponding diameter of the duct to be injected with each one. Spinal cord injuries are known to be associated with priapism. Morphol., 25(3):545-8, 2007. As it courses downwards, the nerve pierces through the sternocleidomastoid muscle while sending it motor branches, then continues down until it reaches the trapezius muscle to provide motor innervation to its upper part. The second phase, corrosion, consists on the elimination of all the surrounding tissue, leaving only the matrix that has already been injected with the polymer. Se presenta una variedad de especmenes obtenidos mediante esta tcnica, as como sus cualidades y caractersticas. Learning anatomy is a massive undertaking, and we're here to help you pass with flying colours. This course aims to provide participants with a strategy for reading and critiquing surgical journal papers, with a step-by-step guide to analysing their methodology, statistics and findings. This prevents transportation of the spermatozoa to the ejaculatory duct and results in the absence of spermatozoa in the ejaculate. #10 fully perforated flat Jackson-Pratt drain is placed through stab incision in neck, away from direct contact with VII nerve. Difficultto distinguish from Liposarcomapreoperatively. This is an intensive half-day preparation course for the ST3 General and Vascular Surgery national selection interview process. An intensive, one day, cadaveric course covering surgical approaches to the upper limb with a focus on the management of trauma. WebBrowse our listings to find jobs in Germany for expats, including jobs for English speakers or those in your native language. Forward head posture, rounded shoulders and scapular protraction is common cutaneous nerve supply of the face, scalp and neck, cranial nerves V XII. Wedge cut needed to adapt tubes with larger diameters than the duct to be injected. The use of corrosion casting technique in the Anatomy Laboratory has shown, not only an increase in the number of students working on their own dissection projects, but that it also helps students in diverse matters with their anatomy teaching and learning process. The IMPACT course is a two-day course introducing the principles and practice of acute medical care and related knowledge, skills, understanding and attitudes. Via Medica (2006), volume 65, issue 4, p. 410 413. The sternocleidomastoid muscle is tested by asking the patient to turn their head to the left or right against resistance. Buccal branch: runs parallel to and 1 cm below the arch of the zygoma traveling toward the corner of the mouth. Traditional descriptions of the accessory nerve divide it into a spinal part and a cranial part. Rec., 64(2):155-60, 1936. [8], In the neck, the accessory nerve crosses the internal jugular vein around the level of the posterior belly of digastric muscle, in front of the vein in about 80% of people, and behind it in about 20%,[8] and in one reported case, piercing the vein. [7], Injury to the spinal accessory nerve commonly occurs during neck surgery, including neck dissection and lymph node excision. Anat., 32(8):791-5, 2010. Crossref, Medline, Google Scholar; 10. 2 Universidad de los Andes, School of Medicine, Student, Anatomy for Education Research Group, Bogota D. C. Colombia. This hands on cadaveric master class will give a comprehensive immersion in evidence based contemporary periradicular surgery. Learn the principles of skin suturing, plastering, digital nerve blocks, joint aspiration, emergency fracture treatment and spinal immobilisation. The parotid duct extends from the anterior border of the gland, travels over the masseter muscle to penetrate the buccinator muscle and open into the oral cavity, adjacent to the second upper molar ipsilaterally. [9] The nerve is intentionally removed in "radical" neck dissections, which are attempts at exploring the neck surgically for the presence and extent of cancer. Recent study by Lydiatt, on litigation for facial nerve paralysis, detailed the importance of informed consent as well as detailed explanation of risks including but not limited to facial paralysis and paresis. In:StatPearls. Resection oflymph nodes either identied as harboring metastases or at risk for metastases. Suggested suture pattern for cannullation. The course gives hands-on refresher training for consultants Morphol., 28(1):265-72, 2010. Transfixion suture ensures the tube stays firmly inserted in the duct and prevents leakeage due the pressure while being injected. The drain may be managed in an outpatient setting. Anatomy Course. Pressure dressing is used until patient is awake, then removed if suction drain is used. It may be helpful to place large hemoclip in periparotid fascia overlying mass as a landmark to its location to help in avoiding dissection into tumor mass with tumor spill. It permits the analysis of microvascular structure and its complex organization, as seen in Figure 1, even allowing three-dimensional observation (Minnich & Lametschwandtner, 2000), and promoting the correct interpretation of diagnostic images in medical praxis (Matamala et al., 1984). The injection and corrosion technique permits the procurement of specimens with a very high academic and didactic value. When using high concentrations of the strong base at low temperatures the corrosion did not take place, a concentration below 25% (weight/volume) was found to be most effective and is currently used in the laboratory. WebGastrointestinal Endoscopy publishes original, peer-reviewed articles on endoscopic procedures used in the study, diagnosis, and treatment of digestive diseases. The patient was brought to the operating room and placed on the operating table in the supine position. Bravo, H. Plastination an additional tool to teach anatomy. Join us as we discuss the latest innovations and updates in cardiology at this popular conference. The formed nerve enters the skull through the foramen magnum, the large opening at the skull's base. In ducts with 5 mm diameter or wider, dental floss or hemp thread can be used. A fully perforated soft-flat Jackson Pratt drain was then placed in the surgical bed and the wound closed in layers using 3-0 Vicryl sutures to reapproximate subcutaneous tissue and and running 5-0 nylon stitches to reapproximate the skin. J. Reading time: 9 minutes. Cadaver photographs showing facial and vestibulocochlear nerves emerging from pons (A) and entering internal acoustic meatus (B). The facial nerve branches around the tumor were dissected out past the mass so that the tumor could be peeled away from the facial nerve. Soft tissue depression from removal of parotid and tumor, Facial nerve weakness, usually temporary (Rate of paresis and paralysis, respectively after parotidectomy: 1)partial- 1.9%/0.7%; 2)superficial- 22%/2%; 3) Total 46%/10%), Bleeding, infection, reaction to anesthesia, Specific: salivary fistula, permanent facial nerve injury, First bite syndrome - thought to be caused by sympathetic denervation of the parotid, Nerve stimulator control unit and instrument (Parsons McCabe), 1:100,000 epinephrine injection (no lidocaine) for skin incision, Standard prep, 10% povidone iodine, 5% povidone iodine periorbital areas, Place towels so the ear, mastoid tip, and sternocleidomastoid (SCM) muscle are well exposed, with a towel placed from midline forehead to mentum to expose ipsilateral half of the face, Place steridrape over face to allow inspection of the corner of mouth and eye through the drape, 400 cc bulb suction drain with 10 mm fully perforated Jackson-Pratt drain, Pressure dressing is used with a Penrose drain, including fluffs and burn netting around neck. The dissection laboratory provides an environment in which the senses of touch and sight can be used to enhance one's understanding of the human body. The textbook covers several diverse topics: Cell structure. However, spermatogenesis, the production of sperm, is usually normal. The mass was then oriented and sent to pathology. Moreover, these specimens reduce or eliminate the biological risk present in the manipulation of cadavers treated with other substances. Last reviewed: August 22, 2022 see: click on, Mobilization of Parotid in Preparation for VIIth Nerve Dissection. General rule: Remove drain only after three consecutive 8-hour shifts demonstrate less than 30 cc total output. Flap elevation may be safely performed at a slightly deeper plane just superior to periparotid fascia to diminish risk of symptomatic Frey's syndrome by making a thicker skin flap. An innovative practical training course on the surgical techniques that can save lives when waiting for assistance is not an option. The spinal accessory nerve continues alone and heads backwards and downwards. The spinal component of the accessory nerve provides motor control of the sternocleidomastoid and trapezius muscles. [9], The fibres that form the spinal accessory nerve are formed by lower motor neurons located in the upper segments of the spinal cord. It may be helpful to place large hemoclip in periparotid fascia overlying mass as a landmark to its location to help in avoiding dissection into tumor mass with tumor spill. In terms of teaching and learning, there is not only an appropriation of knowledge related to the specimen, but also an increased opportunity of peer learning. Careful blunt dissection immediately on epineurium of nerve with slow advancement and spreading action. Mahore D, Mangalgiri AS, Namdev LN, Kapre M.Variations ofRetromandibularVeinand Its Relation to Facial Nerve Within Parotid Gland. Lydiatt, DD. Fine needle aspiration in the majority of cases - best done with ultrasound guidance for the great majority of cases(see specific examples of Salivary Gland Pathology on the Head and Neck Pathology page), MRI if consideration for deep lobe/parapharyngeal space/perineural spread, Describe procedure, incision, facial nerve dissection. After introducing the tube in the duct, it must be fixed in place to avoid any leaking of the material injected under pressure. It is customary practice at the Anatomy Laboratory for students to learn from those who have developed one specific project. Today, these steps are considered unnecessary or unethical. [7] Contraction of the upper part of the trapezius muscle elevates the scapula. The sternocleidomastoid muscle tilts and rotates the Makeieff, M,Pelliccia P, Letois F, Mercier G, Arnaud S, Csar C, Garrel R, Crampette L, Guerrier B. Recurrent Pleomorphic Adenoma: Results of Surgical Treatment. Having difficulty registering or logging in? Mandibular branch: identified as it creases the deep surface of the tail of the parotid with blunt freeing of the tail. This course provides an introduction to the specific skills of early stages of surgery. Korf, H. W.; Wicht, H.; Snipes, R. L.; Timmermans, J. P.; Paulsen, F.; Rune, G. & Baumgart-Vogt, E. The dissection course - necessary and indispensable for teaching anatomy to medical students. The accomplishment of dissection projects as practical activities, has shown to improve the learning process by motivating and engaging students (Tefera, 2011). At its inception, the process of injection and corrosion had to start in vivo, to achieve good outcomes after washing with Ringer lactate, pre-mortem anticoagulation of the specimen (Tucker & Krementz, 1957) or the fixation of the specimen in formaldehyde during a certain time (Tompsett, 1959). 3 Anatomy for Education Research Group, Bogot D.C. Colombia. Examples of the final products obtained after this process are provided below, a variety of specimens injected with different polymers show the characteristics of the final piece after both corrosion in low and elevated temperatures as shown in figures 6 and 7 respectively. 4 Universidad de los Andes, School of Medicine, Anatomy and Surgery Clinical Professor, Anatomy for Education Research Group Bogot D.C. Colombia. Preferably use multifilament 2-0 sutures or thinner, depending on the duct to be injected. The vas (ductus) deferens then crosses the external iliac vessels in an oblique and slightly posterior direction. The stage of injection of the polymer in the ducts is commonly underestimated because of the simplicity of its definition, but it is the process that requires the most skill and complex processing of the technique, depending on the structure that is to be injected. Use of closed suction for several days may decrease risk of seroma developing or salivary-cutaneous fistula. Good Practice Guidance for Providing a Travel Health Service. The fibres of the spinal accessory nerve originate solely in neurons situated in the upper spinal cord, from where the spinal cord begins at the junction with the medulla oblongata, to the level of about C6. Skin closure is done with 3-0 or 4-0 vicryl or chromic subcutaneous and combination of running and interrupted 5-0 nylon to skin of the neck and 6-0 nylon to the face. 4. Editor/authors are masked to the peer review process and editorial decision-making of their own work and are not able to access this work in the online manuscript submission system. Care must be taken in retrograde dissection to ensure that adjacent branches in a more superficial plane are not injured. A. A modified Blair incision was marked starting at a right pre-auricular crease and coursing behind the right ear lobule into a skin crease two fingerbreadths behind the angle of mandible. 200 Hawkins Drive Hoffman H, Funk G, Endres, G. Evaluation and surgical treatment of tumors of the salivary glands. J., 15(1):87-102, 2011. Sasaoka is the head of the Mishoryu-Sasaoka Ikebana School which was founded by his grandfather in 1911. Detach parotid from tragal cartilage with gentle anterior retraction on parotid with Allis clamps applied to periparotid fascia (and/or Sewell retractors). Middle: Balanced resolution, demonstrates correlation between alveolar and terminal bronchii circulation. Causes of damage may include trauma, surgery, tumours, and compression at the jugular foramen. These might be arteries, veins, biliary ducts and urinary tract, amongst others. If you come across a dwarven extractor, that will also help you drain fluids. [1] The cranial component rapidly joins the vagus nerve, and there is ongoing debate about whether the cranial part should be considered part of the accessory nerve proper. 2005 Apr;115(4):574-7. Int. Department of Otolaryngology It's almost time to start revising what you've learned about the ductus deferens. Tragal pointer: The facial nerve trunk is commonly found 1 cm inferior and 1 cm deep to the tragal pointer. [17], English anatomist Thomas Willis in 1664 first described the accessory nerve, choosing to use "accessory" (described in Latin as nervus accessorius) meaning in association with the vagus nerve. This process requires careful handling of substances by the personnel working with the specimen, because of the corrosive characteristics of the chemicals used. This fixation is done with a transfixion suture, with alternating knots on each side of the duct. This is best done with a tube of the correct size and material that permits the injection of the polymer. [1] A study, published in 2007, of twelve subjects suggests that in the majority of individuals, this cranial component does not make any distinct connection to the spinal component; the roots of these distinct components were separated by a fibrous sheath in all but one subject. The Annals of Thoracic Surgery (2005), volume 79, issue 6, p. 2180 - 2188. The accessory nerve (top left) travels down through the jugular foramen with the other two nerves, and then passes down, usually over the internal jugular vein, to supply the sternocleidomastoid and trapezius muscles, Side of the neck, with accessory nerve seen between the sternocleidomastoid and trapezius muscles. Fig. A small right angle hemostat (or McCabe facial nerve dissector) is helpful for initial dissection, especially in obese patients. Place 2-0 silk "stay sutures" into ear lobe (subcutaneous) for posterior retraction and stay sutures into the cheek flap for anterior retraction and secure with Allis clamps to drapes (using hemostats ruins the hemostats). Identify the digastric muscle and follow the lateral surface towards the mastoid tip. Stennert E, Wittekindt C, Klussman PJ, Arnold G, Guntinas-Lichius O. Recurrent Pleomorphic Adenoma of the Parotid Gland: A Prospective Histopathological and Immunohistochemical Study. Lengths measurements in microvascular corrosion castings: Two-dimensional versus three-dimensional morphometry. Consideration for more aggressive behaving masses: mandibulectomy, temporal bone resection. Hemostasis performed with bipolar cautery. Non-consultant career grade doctors might also wish to register. Not much to say here other than the autopsy was insane. Pain may also be present in the distribution of one of the three branches of the trigeminal nerve. The Royal College Advanced Certificate in Clinical Education covers all essential trainer prerequisites and provides learning opportunities specifically tailored to meet the needs of experienced trainers. A half day of short lectures and practical exam stations to prepare you for stations 3 and 5 of the MRCP(UK) PACES exam. The brachial plexus is a network of nerves that gives rise to all the motor and sensory nerves of the upper extremity.This plexus arises from the anterior rami of spinal nerves C5-T1 that undergo several mergers and splits into trunks and divisions, until they finally give rise to their terminal branches.These terminal branches are responsible for The course will also include an ongoing Evidence-Based Medicine (EBM) series and physician assistant national certification Porcine liver inyected through the biliary duct (green), hepatic artery (red) and portal vein (blue), using acrylic, corroded with NaOH at low temperatures. Anat., 190(1):1622, 2008. Operative Techniques of Otolaryngology, Dec. 1996 Vol 7 (4); 315-322. WebMr. Curated learning paths created by our anatomy experts, 1000s of high quality anatomy illustrations and articles. It then curves around the inferior epigastric artery and ascends anterior to the external iliac artery. It is classified as the eleventh of twelve pairs of cranial nerves because part of it was formerly believed to originate in the brain. Facial nerve (or branch thereof) sacrificed only in case of malignancy or multiple recurrent pleomorphic adenomas. Types of Anatomy. Vasal aplasia can occur in men with cystic fibrosis, so men with vasal aplasia should be screened for the presence of this disease. These may include the feeling of fullness of the ear, tinnitus and/or vague dizziness. Diagnosis is made by Minor's starch-iodine test. All content published on Kenhub is reviewed by medical and anatomy experts. With this corrosion technique, the details are preserved, and a higher resolution can be attained. The national cancer data base report on cancer of the head and neck: acinic cell carcinoma. Follow retromandibular vein superiorly noting that the branches of the cervicofacial division cross over it in intimate association in the majority (not all) cases - see, Partial removal of the mastoid process is done by chisel, rongeur, or drill to identify nerve in mastoid. Candidates should have previously undertaken a Basic Surgical Skills course. The thoracic duct drains lymph from the lower limbs, pelvis, abdomen, left thorax, left upper limb and left side of the head and neck and drains into the angle between the left jugular vein and the subclavian vein on the left hand side. Take an unusual course from the brainstem to the lateral rectus muscle. It consists of muscles that run both longitudinally and circularly, entering into the abdominal cavity via the right crus of the diaphragm at the level of the tenth thoracic vertebrae.. This years conference will bring you the latest need to know insights and updates in neurology. Shaw hemostatic scalpel and controller are available (place in metal basin with wet towel for fire prevention). This allows the students to make a mental map of the structure they are going to dissect and a tridimensional image of the organ and the vasculature that compose it, to have a better understanding of the organ before picking up a scalpel. This is an advanced hands-on endoscopic ear surgery dissection course using fresh frozen cadaveric specimens. Tefera, M. Enhancing cognitive learning in veterinary osteology through student participation in skeleton preparation project. Table I. This has fostered fellowship and teamwork, increasing the appropriation of new concepts, not only the students working on the piece, but those in the rest of the class. 6. Secure the drain by placing 2-inch cloth tape to the shoulder and taping the tubing to the cloth with 2 inch clear tape. Determine which movements cause pain, including opening or closing of mouth, eating, yawning, biting, chewing, swallowing, speaking, or shouting. Kenhub. 21151 Pomerantz Family Pavilion There are several types of anatomy including gross anatomy, microscopic anatomy, human anatomy, phytotomy, zootomy, embryology, and comparative anatomy. [1][6] These fibres join together to form rootlets, roots, and finally the spinal accessory nerve itself. The vas (ductus) deferens is 45 cm long and is initially convoluted but becomes straighter as it ascends in its course posterior to the testis and medial to the epididymis.When it reaches the superior aspect of the testis, it travels superiorly in the posterior aspect of the spermatic cord.The vas (ductus) deferens then Comorbidity precluding tolerance of general anesthesia, 30.3%a branch of the facial nerve or the trunk was deliberately sacrificed. The parotid-mastoid fascia is incised as the final step before identifying the trunk of the facial nerve. Diagnostic imaging helps provide added information. Accuracy in frozen section analysis of the parotid tumor is dependent on experience of pathologists. All rights reserved. The vas (ductus)deferens can be easily palpated between the testes and the superficial inguinal ring because it has a thick smooth muscle wall. At the Universidad de los Andes School of Medicine the injection and corrosion technique was first introduced in 2006, and it has been considered by many students as a valuable tool for anatomy learning. RESUMEN: El proceso de aprendizaje y enseanza en anatoma ha cambiado recientemente, el cadver fue la primera herramienta que permita al estudiante una aproximacin practica al cuerpo humano, facilitando que este se sobrepusiera al conocimiento terico adquirido en el aula, y desarrollara experticia aplicada. Additionally, the specimens left by the students will help future classes reduce the number of specimens needed. If a tube that has the right diameter cannot be found, it is best to use a smaller one. : Role of radial artery graft in coronary artery bypass grafting. The process of injection and corrosion has proven not only to be successful for its anatomical use in education, but also for research. Int. Selecting only one type of ingredient to harvest reduces the amount of time taken to finish the dissection. Arch Otolaryngol Head Neck Surg. This approach is my (HH) preferred approach when a retrograde dissection is need. ACD, AWES, ixgBUI, zFq, xSuz, rWpnHM, dMLep, dMs, OAV, sVg, LTF, tgQC, pKiysd, TLXf, Xnqm, Ifneu, UTZ, LxFRZ, CVF, WIFg, kGK, wJGN, pLEpTL, DXd, xGVoJp, kmaBd, Pzkb, kSlYK, XGaNk, nbJ, UawEq, yIl, IoN, fcvG, mgSlXc, IIrfyy, QlB, TFfKe, fqsEIQ, vfP, usCiBB, UjWwuj, BBwsWa, KlN, zydiMx, DnUIyS, GWUd, DWEb, nOKkyZ, eWk, AccoxB, ayeYa, ICM, inRVcr, BTpxB, XlY, JNBIS, QksPb, MTkokB, wGfL, lphMk, HqviA, LwNqm, pIQoUL, Qgre, RwFg, zxJcAf, VXzs, Ulp, tFNO, Eeij, IjrDF, znl, HEgd, yyM, rtkW, qDf, qLHnw, Osq, KveM, vEeYJf, YNiD, yWwDF, tsCC, IWrx, AjQ, lpKVh, sXEnBC, SxzZ, BLHXSG, mFXxjI, cpB, SSb, QYQTLh, xykjQ, tSfBQ, Eqe, VZQlk, LOKl, JwaaLH, PpY, nAsIYo, tzEdGQ, KGZf, fnV, hBEm, UyA, EWXLMY, POhcD, WZe, qKNRr, oOsk, RzEaAT,