Or Binocular Loupe

practiced on thin silicone film or surgical glove material.

1 Ethicon

1 Ethicon

a End-to-end anastomosis, practiced in a thin silicone tube. The needle should enter and exit perpendicular to the vessel plane. Note the curved needle path. b The needle (not the suture itself) is grasped with the needle holder and pulled. The suture is pulled through until the short end appears in the magnified field of view.

a End-to-end anastomosis, practiced in a thin silicone tube. The needle should enter and exit perpendicular to the vessel plane. Note the curved needle path. b The needle (not the suture itself) is grasped with the needle holder and pulled. The suture is pulled through until the short end appears in the magnified field of view.

Fig. 14.6 Tying a right-handed knot.

a Held in the left forceps or micro-needle holder, the suture is passed once clockwise around the right forceps for an ordinary knot or twice for a surgical knot. b The suture is pulled through for the initial knot. A second knot can be added in the opposing direction (see Fig. 14.7).

Fig. 14.6 Tying a right-handed knot.

a Held in the left forceps or micro-needle holder, the suture is passed once clockwise around the right forceps for an ordinary knot or twice for a surgical knot. b The suture is pulled through for the initial knot. A second knot can be added in the opposing direction (see Fig. 14.7).

Plastic Surgery Loupe

Fig. 14.7 Tying a left-handed knot.

a Held in the left forceps, the suture is passed counterclockwise around the right forceps.

b The other end of the suture is grasped with the right forceps.

c The knot is pulled tight.

Fig. 14.7 Tying a left-handed knot.

a Held in the left forceps, the suture is passed counterclockwise around the right forceps.

b The other end of the suture is grasped with the right forceps.

c The knot is pulled tight.

Microvascular Anastomosis in an Experimental Animal: Vascular Dissection in the Rat

End-to-End Anastomosis of the Abdominal Aorta and Femoral Artery, Diameter 1-1.5 mm

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Fig. 14.8 Dissection in a rat with exposure of major blood vessels.

a Supine dissection exposing the abdominal aorta, vena cava, and femoral vessels. b The surrounding connective tissue is dissected off the vessels, grasping only the adven-titia.

c The scissor dissection is directed parallel to the vessel

Fig. 14.8 Dissection in a rat with exposure of major blood vessels.

a Supine dissection exposing the abdominal aorta, vena cava, and femoral vessels. b The surrounding connective tissue is dissected off the vessels, grasping only the adven-titia.

c The scissor dissection is directed parallel to the vessel

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Fig. 14.9 Preparing the skeletonized vessel for anastomosis. a With the approximator in place, the vessel is divided perpendicular to the vessel axis.

b The cut ends are flushed out with heparinized Ringer solution and/or milked with the forceps. c, d Projecting adventitia is removed along with any remaining connective tissue, completely opening up the circumference of the vessel. The tissue is pulled past the vessel end with a forceps and cut flush with the edge of the media (visible through the transparent tissue).

Fig. 14.10 The approximated vessel ends are sewn together with interrupted sutures. Placement of the key sutures. a The first two sutures are the most important and most difficult. They are placed 120° apart in the line of the anastomosis (asymmetric biangu-lation). The left forceps is inserted into the vessel lumen and opened slightly to provide counterpressure for needle insertion (the forceps does not grasp the vessel ends).

b The second key suture is placed 120° from the first. This causes the back walls of the vessel ends to retract slightly, clearing the way for placing intermediate sutures in the front wall. c Placing the intermediate sutures in the front wall.

End-to-End Anastomosis of the Inferior Vena End-to-Side Anastomosis

Plastic Surgery Loupe

Fig. 14.11 After the front wall sutures have been placed, the approximator is inverted, rotating the vessels 180°.

a The vessel ends at this stage show a typical diamond pattern. b The intermediate sutures are placed as they were in the front wall. Gentle traction on the final suture opens up the lumen slightly and reduces the danger of grasping the front wall. c The end-to-end anastomosis is also used for veins. Traction perpendicular to the vessel axis places tension on the thinner-walled veins, opening up the collapsed lumen.

Fig. 14.11 After the front wall sutures have been placed, the approximator is inverted, rotating the vessels 180°.

a The vessel ends at this stage show a typical diamond pattern. b The intermediate sutures are placed as they were in the front wall. Gentle traction on the final suture opens up the lumen slightly and reduces the danger of grasping the front wall. c The end-to-end anastomosis is also used for veins. Traction perpendicular to the vessel axis places tension on the thinner-walled veins, opening up the collapsed lumen.

Plastic Surgery Loupe

Fig. 14.12 End-to-side anastomosis.

a This technique is used to anastomose vessels of markedly different sizes, such as joining the typically small veins of a free flap to a large venous trunk at the recipient site. The suction effect provides for good venous return. b The double clamps exert tension on the recipient vessel wall, which is incised longitudinally. The opening must match the lumen of the flap vessel. The elastic fibers in the vessel wall cause the opening to assume a rounded shape.

Fig. 14.12 End-to-side anastomosis.

a This technique is used to anastomose vessels of markedly different sizes, such as joining the typically small veins of a free flap to a large venous trunk at the recipient site. The suction effect provides for good venous return. b The double clamps exert tension on the recipient vessel wall, which is incised longitudinally. The opening must match the lumen of the flap vessel. The elastic fibers in the vessel wall cause the opening to assume a rounded shape.

Fig. 14.13 Acland's technique of creating an oval opening for end-to-side anastomosis. a The vessel wall is pierced with a microneedle. The wall tissue is elevated on the needle, and the raised area is excised with a scissors. b The key sutures are inserted. The first two sutures are placed 180° apart. c The intermediate sutures are placed in the front wall. d The flap vessel is lateralized with a forceps or heavy suture, and the back wall is sutured.

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