Cervicomediastinothoracic Resection

A cervicomediastinothoracic incision allows wide access to the entire upper airway from the hyoid bone to the carina, if necessary.3 This consists of a collar incision and a vertical sternotomy which angles into the right fourth interspace (see Chapter 23, "Surgical Approaches"). The cutaneous component sweeps beneath the breast, but the breast and the underlying pectoralis muscle are elevated as a single flap up to the fourth interspace. The interspace is entered over the top of the fifth rib (see Figure 23-3B in Chapter 23, "Surgical Approaches"). Initially, I used this approach electively for lower tracheal tumors, but it proved to be unnecessary as a routine approach to the lower trachea. It has occasional usefulness for special problems. If such access might be needed, the patient is placed on the table with a long roll beneath the patient's back just to the right side of the midline. The patient's neck is extended with an inflatable bag beneath the shoulders. The right shoulder is abducted, with the elbow flexed and resting at the side, but supported to avoid brachial plexus or ulnar nerve injury. The right chest is accessible as far as the posterior axillary fold. The right arm may be draped into the field so that it can be swung back and forth, but this is usually not necessary. Exploration may commence with a cervical incision, enlarged by partial sternal division. When the extent of the pathology is determined, and if wide access to the lower trachea becomes necessary, the thoracic portion of the incision is completed. I have found this approach useful on rare occasions for a very long midtracheal tumor that required extensive tracheal dissection, laryngeal release, and right intrapericardial mobilization. It was also used, for example, in a patient who had undergone elsewhere two previous failed attempts at tracheal reconstruction, including one operation under cardiopulmonary bypass, and who also had scarring from medi-astinal sepsis. Furthermore, in the same patient, the brachiocephalic artery had common origin with the left common carotid and was fused to the trachea by scar.

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How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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