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PubMed2006

Transversalis, endoabdominal, endothoracic fascia: who's who?

In Terminologia Anatomica of 1998, the fasciae of the trunk are listed as parietal, extraserosal, and visceral. Parietal fascia is defined as the fascia located outside the parietal layer of a serosa (e.g., pleura, peritoneum) lining a body wall cavity. The parietal fascia of the thorax is endothoracic fascia, and that of the abdomen is endoabdominal fascia. According to Terminologia Anatomica, endoabdominal fascia comprises: 1) transversalis fascia and 2) investing abdominal fascia: deep, intermediate and superficial. Thus, transversalis fascia is the innermost layer of endoabdominal fascia and, consequently, not synonymous with it. We assert that transversalis fascia is the inner epimysium of transversus abdominis muscle; no separate deep investing fascia exists. Embryologically, deep, intermediate and superficial layers of investing fascia are produced as muscular primordia--originating from somites invading somatopleura--penetrate somatic wall connective tissue, and thus obtain epimysium on either side, which give layers of investing fascia. In the thoracic wall, muscle layers are not separated and no distinct investing fasciae are found on them. Furthermore, in the thorax extraserosal fascia does not exist. Therefore, only endothoracic fascia is found on the inner side of the innermost intercostal muscle, which is deprived of investing fascia, to separate this muscle from pleura.

Abdomen↗
PubMed2006

Anatomy and clinical significance of pectoral fascia.

BACKGROUND: The submuscular or subglandular plane for breast augmentation is widely used. Recently, the subfascial plane for breast augmentation was reported by some authors who achieved satisfactory results. The anatomy of the pectoral fascia in Chinese female corpses was investigated to explore the possibility for a location of augmentation mammaplasty under the pectoral fascia. METHODS: The anatomy of 30 side pectoral fascias on 15 corpses was studied. The thicknesses of the pectoral fascias were measured. RESULT: The pectoral fascia is attached to the clavicle and sternum and covers the pectoralis major muscle. It is continuous inferiorly with the fascia of the abdominal wall. Furthermore, the pectoral fascia extends laterally to be continuous with the fascia of the back. The pectoral fascia, which can be successfully dissected bluntly along the subfascial plane, varies in thickness from 0.2 to 1.14 mm. Perforating branches of vessels and nerves emerging from the pectoral fascia are located mainly at the medial lateral and lower fascias. CONCLUSIONS: The pectoral fascias can be dissected bluntly along a subfascial plane with the pectoral fascia intact. The potential pocket between the pectoralis major muscle and the pectoral fascia can be used as a place for breast augmentation. The pectoral fascia may provide the breast implant with more soft-tissue coverage.

Adult↗
PubMed2000

Temporoparietal fascia: an anatomic and histologic reinvestigation with new potential clinical applications.

Temporoparietal fascia constitutes a very important structural unit from both an aesthetic and a reconstructive surgical point of view. A histologically supported anatomic study was conducted for the reappraisal of the anatomic relationships and clinical application potentials of the data obtained. Anatomy of the temporoparietal fascia was investigated on 20 sides from 10 cadavers. After dissections, necropsies were obtained to demonstrate histologic features of the temporoparietal fascia. The outer part of the temporoparietal fascia is continuous with the superficial musculoaponeurotic system (SMAS) in the inferior border and with orbicularis oculi and frontalis muscles in the anterior border. Therefore, plication of the temporoparietal fascia can increase tightness of the SMAS, orbicularis oculi, and frontalis muscle in rhytidectomy. The frontal branches of facial nerve were noted to course parallel to the frontal branch of the superficial temporal artery, lying deeper to the temporoparietal fascia within the innominate fascia. In the view of these findings, conventional subfascial dissection, which is performed to protect frontal branches of the facial nerve, is not reasonable during the temporal part of rhytidectomy. Careful subcutaneous dissection just under the hair follicles is more appropriate to avoid nerve injury and also provides excellent exposure of the temporoparietal fascia for plication in rhytidectomy with protection of the auriculotemporal nerve and the superficial temporal vessels. Furthermore, two layered structures of the temporoparietal fascia are very suitable to insert a framework into the temporoparietal fascia for ear reconstruction to eliminate some of the shortcomings of Brent's technique. A thin muscle layer was also noted within the outer part of the temporoparietal fascia below the temporal line; the term "temporoparietal myofascial flap" would, therefore, be more accurate than "temporoparietal fascial flap." Finally, the innominate fascia and the deep temporal fascia can be elevated with the two layers of the temporoparietal myofascial flap to obtain a well-vascularized, four-layered myofascial flap based on the superficial temporal vessels. This multilayered flap can be used to reconstruct all defects when fine, pliable, thin, multilayered flaps are required.

Adult↗
PubMedDate not supplied

The deep fascia in response to leg lengthening with particular reference to the tension-stress principle.

OBJECTIVE: To investigate the morphological changes of deep fascia subjected to distraction in a rabbit model of leg lengthening. METHODS: The animal model of leg lengthening was established in 20 New Zealand white rabbits using a unilateral external fixator with 4 half pins medially fixed to the tibia, and osteotomy was performed between the second and the third pins. The distraction was initiated 7 days after the osteotomy procedure, with the rate of 1 and 2 mm/d in 2 steps, and proceeded until 10% and 20% increases in the initial length of the tibia had been achieved. The deep fascia samples were studied by the hematoxylin-eosin stain, the Masson-trichome staining, and the JEM2000EX electron microscopy. RESULTS: Under light, the cross section of normal deep fascia without distraction consisted of 3 layers. Whereas in the longitudinal sections, the deep fascia consisted of wavy collagen fibers. The normal deep fascia consisted of fibrocyte and collagenous fibrils under electron microscopy. After leg lengthening, the morphology of the fascia distracted at each rate changed. Under light, the fascia distracted at each rate kept the normal 3 layers in the cross sections. The fascia subjected to distraction at a rate of 2 mm/d showed injuries of collagen fibers. Under electron microscopy, the fascia distracted at a rate of 2 mm/d showed active metabolism to repair the necrotic collagenous fibrils. Whereas the fascia subjected to distraction at a rate of 1 mm/d showed regenerative changes. The endotheliocyte of capillaries within the deep fascia subjected to distraction at a rate of 1mm/d with 20% lengthening of tibia was metabolically active. CONCLUSIONS: The tension stress, which is applied in leg lengthening and deformity correction as described by Ilizarov, has a great effect upon the fascia, which is always related to the function of the involved limb. The appropriate regimen of distraction at the rate of 1 mm/d with 20% lengthening of tibia leads to the regenerative changes in deep fascia, ultimately close to the morphological structure of normal under the condition of this investigation.

Animals↗
PubMed2005

A novel technique for approaching the endopelvic fascia in retropubic radical prostatectomy, based on an anatomical study of fixed and fresh cadavers.

OBJECTIVE: To present the anatomical basis and details of a technique for an approach to the endopelvic fascia devised to preserve urinary continence. PATIENTS, MATERIALS AND METHODS: For cross-sectional macroscopic observation, seven formalin-fixed specimens of the male pelvic contents including the pelvic wall were serially sectioned at a 5-mm thickness. Semi-serial sections from eight other specimens were examined histologically. Eight fresh cadavers were dissected to mimic the various steps in a retropubic radical prostatectomy. After approaching the endopelvic fascia in an anatomically determined manner to reach the paraprostatic space, the pubic bone was removed and nerves near the rhabdosphincter dissected. To assess the clinical implication of this approach, we examined the time to achieve continence in 23 consecutive patients who had a radical retropubic prostatectomy using the new technique. RESULTS: Sectional macroscopic observation depicted the fascia of the levator ani as a definite structure adherent to but not fused with the lateral pelvic fascia. The thin fascia overlying the levator ani fascia and lateral pelvic fascia represented the true endopelvic fascia. Microscopically, the lower part of the fascia of the levator ani was rich in smooth muscle, which interdigitated with the framework of the rhabdosphincter. In fresh cadavers, the levator ani muscle was removed laterally still covered by its fascia, without visualizing the muscle fibres. Small branches from the pudendal nerve entered the rhabdosphincter. The mean (sd, range) distance from the lowest point of the endopelvic fascia to the point where the sphincteric branch entered the rhabdosphincter was 5.5 (1.8, 3-8) mm. The continence rate at 1, 3, 6 and 9 months after surgery using the new technique was 44%, 83%, 96% and 100%, respectively. CONCLUSIONS: Preserving the fascia of the levator ani helps to protect the levator ani muscle, rhabdosphincter and pudendal nerve branches to the rhabdosphincter. In retropubic radical prostatectomy, this anatomical approach to the endopelvic fascia should preserve or allow the earlier recovery of urinary continence.

Aged↗
PubMed1998

Grading of subcutaneous soft tissue tumors by means of their relationship with the superficial fascia on MR imaging.

OBJECTIVE: To assess the diagnostic value of the relationship between subcutaneous tumors and the superficial fascia in the characterization of soft-tissue masses. DESIGN: MR studies of 64 soft tissue masses located in the subcutaneous space were reviewed. We established five grades of relationship between tumors and superficial fascia and analyzed the probability of the lesions in each group being malignant. Group 1 tumors did not contact the fascia; group 2 lesions contacted it slightly, with acute angles between the tumor and the fascia; group 3 lesions had wider contact with larger acute or right angles; group 4 tumors had even wider contact with obtuse angles with the fascia; and group 5 was composed of lesions that crossed the superficial fascia. RESULTS: The probability of a subcutaneous lesion that crosses the superficial fascia being malignant was 6.88 times greater than for lesions that did not cross the fascia. For lesions forming obtuse angles with the fascia the probability of malignancy was 6.3 times greater than that of tumors that did not present this sign. All histologically verified fascial infiltrations occurred in malignant lesions of groups 4 and 5. CONCLUSIONS: Malignant tumors of the subcutaneous compartment have a higher tendency to develop a close relationship with the fascia than benign lesions. Obtuse angles between superficial fascia and a subcutaneous mass or a lesion crossing the fascia strongly suggest malignancy.

Carcinoma, Squamous Cell↗
PubMed2007

A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department.

STUDY OBJECTIVE: We determine whether a fascia iliaca compartment nerve block can provide superior pain management compared with intravenous morphine sulfate for the initial pain management of femur fracture patients presenting to a pediatric emergency department. The primary outcome measured is pain scores; a difference of 15% in scores assessed at 30 minutes from the study's baseline pain management is considered clinically meaningful. Secondary outcomes include the duration of analgesia, the need for additional medications, adverse events, nerve block complications, and satisfaction scores. METHODS: This was a prospective, randomized, unblinded, controlled trial conducted on children aged 15 months to 18 years with acute femur fractures, presenting to a free-standing, tertiary care children's hospital. Patients were randomized to receive intravenous morphine sulfate or a fascia iliaca compartment nerve block using ropivacaine (Naropin). Pain scores (Children's Hospital of Eastern Ontario Pain Scale [CHEOPS]; Face, Legs, Activity, Cry and Consolability Pain Scale; Faces Pain Scale) were recorded at initial analgesic administration (baseline), at 5, 10, 15, 30, and 60 minutes, and then hourly up to 6 hours from baseline by trained nursing observers and research assistants. RESULTS: Fifty-five patients, 26 in the fascia iliaca compartment nerve block group and 29 in the morphine sulfate group, ranged in age from 16 months to 15 years (median 5.7 years). Baseline mean CHEOPS scores were similar: 9.4 fascia iliaca compartment nerve block and 9.5 morphine sulfate. Mean CHEOPS scores at 30 minutes after initial treatment were 5.87 for fascia iliaca compartment nerve block and 7.54 for morphine sulfate, with a difference of 1.67, which corresponds to an 18% (95% confidence interval [CI] 8% to 27%) difference in pain reduction between the 2 groups, according to the average baseline score of 9.45. Similar lower pain scores were observed in the fascia iliaca compartment nerve block group as early as 10 minutes from baseline and throughout the 6-hour duration of the study. In comparing the entire 6-hour CHEOPS pain scores, patients who received a fascia iliaca compartment nerve block showed lower scores by approximately 15% (95% CI 6% to 24%) compared to patients who received morphine sulfate. Median duration of analgesia was longer in the fascia iliaca compartment nerve block group compared with that in the morphine sulfate group (313 minutes [95% CI 154 to 360 minutes] versus 60 minutes [95% CI 10 to 255 minutes]). Fewer additional medications were given to patients who received the fascia iliaca compartment nerve block. No complications from the nerve block occurred. Satisfaction scores were higher with the fascia iliaca compartment nerve block among the medical staff. CONCLUSION: Fascia iliaca compartment nerve block provided clinically superior pain management compared with intravenous morphine sulfate at 30 minutes from baseline and throughout the initial 6 hours of medical treatment of children 16 months to 15 years who had isolated acute femur fractures. The results of this study, however, may be inflated by the nonblinding of the pain observers. Despite this potential bias, the fascia iliaca compartment nerve block should be considered as a valuable procedure in managing the pain commonly observed in these injured children.

Adolescent↗
PubMed2005

The surgical anatomy of the parotid fascia.

UNLABELLED: Currently, there are no reports in the literature of the parotid fascia suggesting that this structure is crucial to the identification of the facial nerve trunk (FNT). Traditional surgical and anatomical descriptions of this fascia report it as a collection of connective tissue large enough to be described by the unaided eye. This study was performed to investigate the composition and limit of the fascia surrounding the parotid gland. An appreciation of these on safe and effective parotid surgery was also considered. HISTO-ANATOMICAL STUDY: Microsurgical step-by-step dissection was performed on 18 adult cadavers (n=36) to define the composition, arrangement, and attachment of the parotid fascia. Samples were subjected to the Masson Trichrome Technique (1990). CLINICAL STUDY: A total of 18 patients presented for parotidectomy. Eight patients had a pleomorphic adenoma and ten had lympho-epithelial disease of the parotid gland. Boundaries of parotid fascia were posteriorly-mastoid process, anteriorly--ramus of mandible, superiorly--cartilage of external acoustic meatus, and inferiorly-imaginary line joining tip of mastoid process to ramus of mandible. These landmarks formed a quadrangular space. HISTO-ANATOMICAL STUDY (N=36): Parotid fascia formed a fibrous meshwork over the gland. In the upper two-thirds, fascia was thick and strong; in the lower one-third, fascia was thin. Soft tissue arrangement (from superficial to deep): dermis, subcutaneous fat, superficial cervical fascia, deep cervical fascia. CLINICAL STUDY (N=18): The technique described was applied consistently in all patients. Mean time for localization of FNT was 11 min (range 7-18 min). In two patients (both with an underlying inflammatory disorder of the parotid gland), a transient facial nerve palsy developed postoperatively. In both patients, this settled within 7 weeks of operation. The true surgical potential of the parotid fascia during parotidectomy has been reported.

Adenoma, Pleomorphic↗
PubMed2004

Effects of fascia lata on HIFU lesioning in vitro.

The effects of fascia lata on high intensity focused ultrasound (US), or HIFU,-induced lesions were demonstrated through comparison with and without fascia lata in bovine thigh muscle tissue. Experiments were conducted in an arrangement with a three-way multiscan ultrasonic inspection system and imaging done by B-mode US. Bovine thigh muscle (8-cm thick) was treated with 1.5 MHz for 8 s. Spatial peak intensity (ISP) was 3000 W/cm2. B-mode US imaging detected appearance at the HIFU treatment site. At a free-field intensity of 4000 W/cm2, the observed lesion length (along the axis) with fascia lata was 12 +/- 1.82 mm, compared with 4 +/- 1.54 mm for samples without fascia lata. At 3000 W/cm2, the values for samples with fascia lata and samples without fascia lata, respectively, were 13 +/- 1.50 mm and 2 +/- 1.42 mm. During a 30-s exposure, at ISP of 2000 W/cm2, the peak temperature reached 41 degrees C in samples without fascia lata and 70 degrees C in samples with fascia lata. At ISP of 3000 and 4000 W/cm2, the peak temperature reached, respectively, 73 degrees C and 84 degrees C in samples without fascia lata, compared with 102 degrees C and 104 degrees C, respectively, for samples with fascia lata. The results confirm that fascia lata contributes to increasing tissue necrosis, temperature elevation and echogenicity in US images.

Animals↗
PubMed1993

Invasion of Denonvilliers' fascia in radical prostatectomy specimens.

Denonvilliers' fascia consists of a single fibromuscular structure covering the posterior aspect of the prostate and surrounding the seminal vesicles. This structure has multiple layers that are fused together, and to the stroma of the prostate and seminal vesicles. A separate posterior layer of Denonvilliers' fascia was not seen during radical prostatectomy. The cleavable interprostatorectal plane extends posteriorly throughout the thickness of Denonvilliers' fascia and anteriorly to the muscular wall of the rectum. Medially this fascia is fused with the prostatic capsule into a single sheath and contains thick smooth muscle bundles in continuity with the prostatic stroma. In a series of 243 radical prostatectomy specimens for prostate cancer, we studied the morphological relationship of Denonvilliers' fascia with the prostatic capsule and stroma, and traced the progression of prostatic cancer in relation to the anatomical landmarks. In 19% of the cases tumor was found progressing within Denonvilliers' fascia, in the medial posterior area of the prostate, unrelated to perineural space invasion. For specimens with an intracapsular cancer volume of less than 12 cc, which may be cured by radical prostatectomy alone, the frequency of invasion of Denonvilliers' fascia was 13%. In these cases cephalad progression of cancer was seen almost exclusively in Denonvilliers' fascia overlying the central zone at the prostate base and surrounding the seminal vesicles. Invasion of Denonvilliers' fascia can lead to positive surgical margins if complete excision of this fascia is not performed during radical prostatectomy. Even among large tumors in our series there were no cases of tumor invasion completely through the full thickness of Denonvilliers' fascia at the posterior medial area and, therefore, rectal wall invasion was never suspected at this level.

Adenocarcinoma↗