1. Vertical ramus osteotomy for improved exposure of the distal internal carotid artery: A new technique 
Peter E. Larsen, DDS, William L. Smead, MD 
Journal of Vascular Surgery 
Volume 15, Issue 1, Pages (January 1992)
DOI: / (92)70033-H
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

2. Fig. 1
Access to the internal carotid artery distal to a line from the tip of the mastoid to the angle of the mandible may be compromised. The ramus of the mandible overlies most of the artery in this region.
Journal of Vascular Surgery  , DOI: ( / (92)70033-H)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

3. Fig. 2
The broken line indicates where the osteotomy is made. It extends from the depth of the sigmoid notch to the angle of the mandible.
Journal of Vascular Surgery  , DOI: ( / (92)70033-H)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

4. Fig. 3
A, The vertical ramus osteotomy has been performed. The mandible is retracted anteriorly and rotated away from the side of the osteotomy (arrow). The proximal segment is rotated forward and laterally (arrow). This allows uncompromised access to the entire distal internal carotid artery to the level of the skull base. B, Medial view of the mandibular ramus. The vertical ramus osteotomy is performed posteriorly to the entrance of the inferior alveolar nerve. The incidence of altered sensation is minimal.
Journal of Vascular Surgery  , DOI: ( / (92)70033-H)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

5. Fig. 4
Radiograph shows plate fixation. This patient is 4 weeks after surgery. The plates have assured exact position of the segments into their presurgical position with maintenance of normal jaw opening and occlusion.
Journal of Vascular Surgery  , DOI: ( / (92)70033-H)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

6. Fig. 5
A, Lateral view of the left internal carotid arteriogram. B, PA view of the left internal carotid arteriogram.
Journal of Vascular Surgery  , DOI: ( / (92)70033-H)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

7. Fig. 6
Intraoperative view of the injury to the internal carotid artery. This through-and-through perforation of the vessel (arrows) was present 0.5 cm below the base of the skull. Note the excellent visibility and access provided by the vertical ramus osteotomy.
Journal of Vascular Surgery  , DOI: ( / (92)70033-H)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

8. Fig. 7
With anterior subluxation, the ramus of the mandible still frequently obscures visibility of a significant portion of the internal carotid artery.
Journal of Vascular Surgery  , DOI: ( / (92)70033-H)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

9. Fig. 8
Previously recommended osteotomy techniques have included (a) Horizontal ramus osteotomy, (b) Osteotomy through the mandibular angle, (c) Osteotomy through the anterior body, (d) Ostectomy of the mandibular angle.
Journal of Vascular Surgery  , DOI: ( / (92)70033-H)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

10. Fig. 9
If the osteotomy is performed horizontally through the ramus, the coronoid process and temporalis muscle remain attached to the proximal segment leading to rotation of the segment (arrow), and instability and malocclusion.
Journal of Vascular Surgery  , DOI: ( / (92)70033-H)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions