Clinical applications of the subgaleal fascia

The anatomic boundaries and vascular supply of the subgaleal fascia have been described previously. The thin and malleable subgaleal fascia was selected for difficult reconstructive problems in seven patients. This flap has been based on either the supraorbital or the superficial temporal vascular leash. The subgaleal fascia is readily dissected from superficial galea and deep periosteum, leaving behind a well-vascularized scalp and a skin-graftable calvarium. The flap conforms to a cartilage framework for ear reconstruction. It takes a skin graft well. The subgaleal fascia can patch dural defects and fill sinus dead space. It has been used to augment facial contour. Free vascularized transfer of the subgaleal fascia has included the temporoparietal fascia, which was partially split from the subgaleal fascia for bilobed flap resurfacing of the hand. The subgaleal fascial flap should be considered when ultrathin, vascularized coverage is needed.     

Anatomic basis for vascularized outer-table calvarial bone flaps

The vascularization of the scalp and calvarium was studied in cadavers to better define the design of vascularized split- or full-thickness calvarial bone flaps. Selective dye injections of the superficial temporal and internal maxillary arteries established a horizontal and vertical network of vessels within and between each layer of the scalp. The periosteum of the frontoparietal region continues over the temporal aponeurosis as a separate, distinct layer, the innominate fascia, which is irrigated by numerous proximal branches of the superficial and deep temporal arteries. The periosteum can sustain the outer table of the calvarium by means of multiple small, vertical perforators. Between the periosteum and the outer table is a thin areolar layer of subperiosteum which continues beneath the temporal muscle. We feel that vascularized outer-table calvarial flaps can safely be pedicled using only the temporal aponeurosis, innominate fascia, and periosteum without including the galea or temporal muscle.     

Surgical anatomy and blood supply of the fascial layers of the temporal region

In 15 fresh cadavers (30 sides), we studied the two layers of fascia in the temporal region, with particular regard to their blood supply and to their usefulness--together or separately--as microvascular free-tissue autografts. The superficial temporal fascia (temporoparietal fascia, epicranial aponeurosis) lies immediately deep to the hair follicles. It is part of the subcutaneous musculoaponeurotic system and is continuous in all directions with other structures belonging to that layer--including the galea above and the SMAS layer of the face below. The deep temporal fascia (temporalis fascia, investing fascia of temporalis) is separated from the superficial fascia by an avascular plane of loose areolar tissue. It completely invests the superficial aspect of the temporalis muscle down to (but not beyond) the zygomatic arch. It is firmly attached to periosteum all around the margin of the muscles. Below it is attached to the upper border of the zygomatic arch. We found the deep temporal fascia to be supplied solely by the middle temporal artery, a constant branch of the superficial temporal. The middle temporal artery arises 1 to 3 cm below the upper border of the zygomatic arch, runs always superficial to the arch, and enters the deep temporal fascia immediately above that layer's attachment to the zygomatic arch. If the middle temporal vessels are protected, the two layers of temporal fascia can be raised together as a fully vascularized tissue island. This island can be fashioned as a bilobed or a double-layered flap, depending on the manner of dissection. The potential surgical usefulness of these findings is discussed.     

The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging.

Controversy persists regarding the relationship of the superficial facial fascia (SMAS) to the mimetic muscles, deep facial fascia, and underlying facial nerve branches. Using fresh cadaver dissection, and supplemented by several hundred intraoperative dissections, we studied facial soft-tissue anatomy. The facial soft-tissue architecture can be described as being arranged in a series of concentric layers: skin, subcutaneous fat, superficial fascia, mimetic muscle, deep facial fascia (parotidomasseteric fascia), and the plane containing the facial nerve, parotid duct, and buccal fat pad. The anatomic relationships existing within the facial soft-tissue layers are (1) the superficial facial fascia invests the superficially situated mimetic muscles (platysma, orbicularis oculi, and zygomaticus major and minor); (2) the deep facial fascia represents a continuation of the deep cervical fascia cephalad into the face, the importance of which lies in the fact that the facial nerve branches within the cheek lie deep to this deep fascial layer; and (3) two types of relationships exist between the superficial and deep facial fascias: In some regions of the face, these fascial planes are separated by an areolar plane, and in other regions of the face, the superficial and deep fascia are intimately adherent to one another through a series of dense fibrous attachments. The layers of the facial soft tissue are supported in normal anatomic position by a series of retaining ligaments that run from deep, fixed facial structures to the overlying dermis. Two types of retaining ligaments are noted as defined by their origin, either from bone or from other fixed structures within the face.(ABSTRACT TRUNCATED AT 250 WORDS)     

Repair of scalp defects using a tissue expander and Marlex mesh.

A simple technique using Marlex mesh and a tissue expander to cover scalp defects is described and two patients are presented. This technique is suitable for medium-sized defects that cannot be closed primarily. Marlex mesh is sutured to the wound edges in lieu of a temporary skin graft and to prevent enlargement of the defect during tissue expansion. The tissue expander is placed under adjacent normal scalp in a subgaleal pocket developed through the scalp defect. The scalp defect is closed secondarily using the expanded scalp flap. This technique was performed in two patients with satisfactory results. Marlex mesh obviates the need for a temporary skin graft to cover the scalp defect.     

Prefabricated galeal flap based on superficial temporal and posterior auricular vessels

Scalp layers are widely used in reconstructive procedures. The authors used prefabricated galeal flaps based on the superficial temporal or postauricular vessels for ear, cheek, mandible, and cranium reconstructions in three cases. In case 1, synchronous beard and ear reconstructions were accomplished by using the temporoparietal and retroauricular flaps. In case 2, a buccomandibular defect was reconstructed by transposing the supra-auricular and retroauricular galea with prefabricated bone and skin. In case 3, an epidural hematoma in the left frontoparietal area was evacuated after a circular craniectomy. The harvested bone was not put back on the defect area but buried between the periosteal and galeal layers because of brain edema. These layers were raised as an osteogaleoperiosteal flap and transposed onto the defect area after 7 weeks. When used with a prefabrication method, scalp layers offer versatile options for repairing composite defects of the head region. A galeal flap based on the posterior auricular vessels is practical and reliable in reconstructive procedures. The authors suggest that this flap is an option in cases in which the temporoparietal fascia artery or the superficial temporal artery is not available. Prefabrication of the harvested cranial bone inside the adjacent tissues offers several advantages in that a viable bone is provided at the end of the procedure, intervention at a distant area is avoided, the graft is placed on osteogenic tissue (periosteum) that is also transposed onto the defect, and sophisticated procedures such as microsurgical techniques are not needed.     

The subcutaneous vascular system (lower extremity): studies on micro-preparations]

At the level of fascial penetration the cutaneous arteries of the lower extremity are constantly accompanied by 1 or 2 communicating veins of varying diameter. Usually, they penetrate the fascia in rows via the muscular interstitium. There they give up branches to the fascial vascular network, to pre- and subfascial areolar tissue and possibly to the muscle origins on the fascia, or to the intermuscular septa. The texture of the fascia itself determines the structure of fascial openings for the cutaneous vessels. In the subcutaneous tissue the arteries are accompanied by 1 or 2 veins (Vv. comitantes). Numerous arterio-arterial and intervenous anastomoses form a subcutaneous network of vascular bundles. Two anastomosing venous systems can be distinguished in the subcutis: The small Vv. comitantes are fed primarily by the subcutaneous adipose lobes, and end in communicating veins or flow into the subcutaneous veins (epifascial veins). These large subcutaneous veins on the other hand are responsible for the actual outflow from the venous network of the cutis. They form the saphenous system or empty into larger communicating veins. Between the subcutaneous arterioles and accompanying venules there are numerous capillary webs. In addition direct capillaries and looped as well as meandering or knotted arterio-venous shunts are found. The subcutaneous vascular bundles are fixed by a connective tissue. There are often typical capillary meshes within arterial sheat, oriented like a rope-ladder. They undergo prenatal development. The subcutaneous (epifascial) veins are surrounded by areolar tissue on the cutaneous as well as on the fascial side. Fibers from the accompanying connective tissue criss-cross into the adventitia and thereby anchor the veins in a movable fashion. Typical vascular patches with plane capillary networks characterize the areolar tissue around the subcutaneous veins, which is differentiating at the 2nd half of the fetal period. Within are also capillary loops and convoluted arterio-venous shunts.     

Blood supply of the upper craniofacial skeleton: the search for composite calvarial bone flaps

This study investigated the blood supply of the upper craniofacial skeleton by injection studies. The major supply to the calvaria is provided by the middle meningeal artery and its branches. This vessel is difficult for the plastic surgeon to exploit in composite bone-flap design. The majority of the outer surface of the craniofacial skeleton is supplied by tiny perforators from the overlying periosteum. The vascular interconnections within the periosteum are poorly developed. For this reason, the galea and the overlying vascular network (derived from the superficial temporal, occipital, supraorbital, and supratrochlear vessels) should be left broadly attached to the bone when transferring a vascularized calvarial bone flap. Dissection of the scalp away from this vascular network should be carried out just below the hair follicles. By observing these principles, vascularized calvarial bone can be transferred on the superficial temporal, deep temporal, supraorbital, supratrochlear, or occipital vessels. Details of the use of each are discussed.     

Vascularized outer-table calvarial bone flaps

Based on an anatomic study of the vascularization of the calvarium in cadavers, a technique for the transfer of vascularized outer-table calvarial bone has been developed. The outer table of the calvarium receives numerous small perforators from its overlying periosteum. The periosteum is continuous with a distinct fascial layer overlying the temporal aponeurosis which we have termed the innominate fascia. Because of a network of anastomosing vessels from proximal branches of the superficial temporal artery and perforating branches of the deep temporal artery, the outer table of the calvarium can be carried on a pedicle which contains the temporal aponeurosis, innominate fascia, and periosteum. Thirty-seven vascularized outer-table calvarial bone flaps have been performed for a variety of craniofacial reconstructive deformities. Remarkable stability and lack of resorption have led the authors to favor this method of reconstruction particularly in poorly vascularized or previously infected recipient beds.     

The structure of the canary's incubation patch

The gross morphology, histology and ultrastructure of the canary's incubation patch and the ventral apterium from which it arises are described. The apterium is vascularized by pectoral, external mammary, incubation, and prepubic arteries. It is innervated by cutaneous branches of spinal nerves. It has a surface area of 6 cm². Its epidermis is a stratified squamous epithelium with basal, intermediate, transitional and cornified layers. Cells in the stratum germinativum contain a normal array of organelles, but are characterized by tonofilaments, desmosomes and interdigitating surfaces. Cellular organelles disappear in the stratum transitivum and are replaced by large vacuoles and keratohyalin bands. Nonmyelinated nerve fibers are abundant in the stratum germinativum. The dermis consists of (1) an avascular layer of dense collagen subjacent to the epidermis and containing many nonmyelinated nerves, and (2) an underlying layer of areolar connective tissue containing blood vessels, lamellar corpuscles and nerves. A layer of coarse elastic fibers, reinforced by collagen and smooth muscle, separates the dermis from subcutaneous tissue. In contrast to the ventral apterium, the incubation patch is featherless and visibly hypervascular and edematous. Its epidermis is both hypertrophic and hyperplastic. Large spaces separate cells in the stratum germinativum. The visible hypervascularity is due to hyperemia and increased number and size of blood vessels in the dermis. Visible edema is due to the accumulation of fluid interstitially. Although no histological differences exist among various regions of the ventral apterium, such differences are present in the incubation patch.     

The new reconstruction technique in the treatment of the skin cancers located on the eyelid: Posterior temporalis fascia composite graft

BACKGROUND: Difficulty of reconstruction of the eyelids arises from the need to reconstruct different supporting and covering structures in a single operation. Defects in the anterior lamella of the eyelids can be readily repaired with skin grafts or flaps but posterior lamellar reconstruction needs more complex applications. METHODS: We performed posterior lamellar eyelid reconstruction with posterior parts of the temporalis fascia, since their anatomical and histological features are very similar to the defects. Nine patients with skin tumors located on the periorbital region were treated with local skin flaps and deep layer of the temporalis fascia. RESULTS: Grafts were harvested very easily. There was no complication related with graft or donor site. Biopsy was performed in three cases and normal conjunctival elements were seen. Functional and acceptable aesthetically results were achieved in all patients. CONCLUSION: Ideal reconstructive material for replacement of the posterior lamina is still lacking. Tarsal reconstruction can be made with deep temporalis fascia with success since the thickness of the both tissues are very similar and also since the loose areolar layer of the temporalis fascia is very thin and highly vascularized, this layer can be used in reconstruction of the conjunctiva. According to our knowledge this is the first report of using of the posterior part of temporalis fascia as a composite graft in the literature.     

An anatomic study of the septocutaneous vessels of the leg

The vascular anatomy of the skin and fascia of the leg were studied in 20 cadaver legs that were injected and dissected under magnification to identify the origin, course, and distribution of vessels from the subfascial level to the skin. In addition to the longitudinally oriented fasciocutaneous arteries and the musculocutaneous perforators, the study demonstrated a third and important system of blood supply: the septocutaneous vessels. These vessels arise directly from the posterior tibial, anterior tibial, and peroneal arteries, run along the intermuscular septum, pierce the crural fascia, and ramify radially in the subcutaneous tissue superficial to the fascia. Longitudinally oriented anastomotic arcades are formed along the leg between branches of adjacent septocutaneous vessels. Each septocutaneous vessel has one or two venae comitantes. Selected methylene blue injections of the septocutaneous vessels revealed rich staining of the superficial surface of the fascia, the subcutaneous tissue, and distinct longitudinally oriented skin territories. There was no injection of dye in the deep surface of the fascia. It is felt that the septocutaneous vessels constitute an important source of skin circulation in the leg and form the basis for various fasciocutaneous flaps that have useful clinical applications.     

Embryonic development of the axial column in the little skate,Leucoraja erinacea

The morphological patterns and molecular mechanisms of vertebral column development are well understood in bony fishes (osteichthyans). However, vertebral column morphology in elasmobranch chondrichthyans (e.g., sharks and skates) differs from that of osteichthyans, and its development has not been extensively studied. Here, we characterize vertebral development in an elasmobranch fish, the little skate, Leucoraja erinacea , using microCT, paraffin histology, and whole‐mount skeletal preparations. Vertebral development begins with the condensation of mesenchyme, first around the notochord, and subsequently around the neural tube and caudal artery and vein. Mesenchyme surrounding the notochord differentiates into a continuous sheath of spindle‐shaped cells, which forms the precursor to the mineralized areolar calcification of the centrum. Mesenchyme around the neural tube and caudal artery/vein becomes united by a population of mesenchymal cells that condenses lateral to the sheath of spindle‐shaped cells, with this mesenchymal complex eventually differentiating into the hyaline cartilage of the future neural arches, hemal arches, and outer centrum. The initially continuous layers of areolar tissue and outer hyaline cartilage eventually subdivide into discrete centra and arches, with the notochord constricted in the center of each vertebra by a late‐forming “inner layer” of hyaline cartilage, and by a ring of areolar calcification located medial to the outer vertebral cartilage. The vertebrae of elasmobranchs are distinct among vertebrates, both in terms of their composition (i.e., with centra consisting of up to three tissues layers—an inner cartilage layer, a calcified areolar ring, and an outer layer of hyaline cartilage), and their mode of development (i.e., the subdivision of arch and outer centrum cartilage from an initially continuous layer of hyaline cartilage). Given the evident variation in patterns of vertebral construction, broad taxon sampling, and comparative developmental analyses are required to understand the diversity of mechanisms at work in the developing axial skeleton of vertebrates. J. Morphol. 278:300–320, 2017. © 2017 Wiley Periodicals, Inc.     

The dynamics of morphofunctional changes in the microcirculation of the pelvic extremity after modeling the chief stages of its replantation]

Under study was the effect of autotransplantation in its "pure form" upon the morpho-functional reconstruction and structural mechanisms of adaptation of the blood and lymphatic links of the microcirculatory bed of extremities during early postoperation period up to 10 days. The pathophysiological state of the extremity sufficiently close to its autotransplantation was obtained by means of circular transection of soft tissues of the medial third of the femur together with the nerves and deep collecting lymphatic vessels. It was found that after modeling the main stages of replantation in the fascia and periosteum of the operated extremity there developed a spasm of the arteriolar link and dilatation of the venular and lymphatic links of the microcirculatory bed. The areas of leukocytic infiltration with the phenomena of diapedesis and microhemorrhages were revealed along the course of postcapillaries and venules in the paravasal connective tissue. The amount of functioning arteriole-venular anastomoses was increased. Against the background of pronounced oedema of soft tissues of the operated extremity the venous pressure increased and the rate of the capillary bloodflow in the skin and muscles decreased. The above changes tend to be reduced by the 10th day after modelling the main stages of replantation of the extremity.     

Stress and matrix‐responsive cytoskeletal remodeling in fibroblasts

In areolar “loose” connective tissue, fibroblasts remodel their cytoskeleton within minutes in response to static stretch resulting in increased cell body cross‐sectional area that relaxes the tissue to a lower state of resting tension. It remains unknown whether the loosely arranged collagen matrix, characteristic of areolar connective tissue, is required for this cytoskeletal response to occur. The purpose of this study was to evaluate cytoskeletal remodeling of fibroblasts in, and dissociated from, areolar and dense connective tissue in response to 2 h of static stretch in both native tissue and collagen gels of varying crosslinking. Rheometric testing indicated that the areolar connective tissue had a lower dynamic modulus and was more viscous than the dense connective tissue. In response to stretch, cells within the more compliant areolar connective tissue adopted a large “sheet‐like” morphology that was in contrast to the smaller dendritic morphology in the dense connective tissue. By adjusting the in vitro collagen crosslinking, and the resulting dynamic modulus, it was demonstrated that cells dissociated from dense connective tissue are capable of responding when seeded into a compliant matrix, while cells dissociated from areolar connective tissue can lose their ability to respond when their matrix becomes stiffer. This set of experiments indicated stretch‐induced fibroblast expansion was dependent on the distinct matrix material properties of areolar connective tissues as opposed to the cells' tissue of origin. These results also suggest that disease and pathological processes with increased crosslinks, such as diabetes and fibrosis, could impair fibroblast responsiveness in connective tissues. J. Cell. Physiol. 228: 50–57, 2013. © 2012 Wiley Periodicals, Inc.     

Tissue collection methods for antler research

The rapid growth of deer antlers makes them potentially excellent models for studying tissue regeneration. In order to facilitate this, we have developed and refined antler tissue sampling methods through years of antler research. In the study, antler tissues were divided into three main groups: antler stem tissue, antler blastema and antler growth centre. For sampling stem tissue, entire initial antlerogenic periosteum (around 22 mm in diameter) could be readily peeled off from the underlying bone using a pair of rat-toothed forceps after delineating the boundary. Apical and peripheral periosteum/ perichondrium of pedicle and antler could only be peeled off intact when they were cut into 4 quadrants and 0.5 cm-wide strips respectively. Antler blastema included blastema per se, and potentiated and dormant periostea. Blastema per se was sampled after it was divided into 4 quadrants using a disposable microtome blade. Potentiated and dormant periostea were collected following the same method used for sampling peripheral periosteum of pedicle and antler. The antler growth centre was divided with a scalpel into 5 layers according to distinctive morphological markers. The apical skin layer could be further separated into dermis and epidermis using enzyme digestion for the study of tissue interaction. We believe that the application of modern techniques coupled with the tissue collection methods reported here will greatly facilitate the establishment of these valuable models.     

Abdominal wall expansion in congenital defects

A method for expanding the skin, fascia, muscle, and peritoneal layers of the abdominal wall is described, and clinical application is demonstrated in two children with cloacal exstrophy and congenital absence of the lower half of the abdominal wall. This technique provides an innervated composite reconstruction of defects in excess of 50 percent of the abdominal surface and is recommended in large secondary defects where peritonealization has been achieved and in congenital defects that do not lend themselves to standard methods of closure. Cadaver dissection confirms that tissue expanders may be placed with preservation of innervation and blood supply to the abdominal wall.     

Subperiosteal brow lifts without fixation

Most surgeons today advocate an endoscopic subperiosteal brow lift for surgical correction of the upper third of the face. At the author's clinic, this operation has been performed since 1994 and the subgaleal bicoronal brow lift is no longer used. In earlier investigations, the author showed that the subperiosteal approach (n = 60) gives a better result than the subgaleal method (n = 60) when compared 1 year after surgery. In the literature, however, there are no published data regarding the long-term results of subperiosteal brow lifts. The author took material from his earlier investigations and looked at the same patients 5 years postoperatively. He compared the subperiosteal approach (n = 30) with the subgaleal brow lift (n = 15) and found that after 5 years the brows of the subgaleal patients were on the same level as they were before surgery, but in the group of subperiosteal brow lifts, almost all of the brows were higher 5 years after surgery than they were 1 year after surgery, with a mean increase in height of 2.5 mm. These findings led the author to the question whether scalp fixation was necessary at all when performing a subperiosteal brow lift. He performed 20 subperiosteal endoscopic brow lifts where scalp fixation was not used at all, relying only on changing the balance of muscle vectors around the eyebrows. Using a computerized instrument, measurements were made of the distance between the medial canthus and the top of the eyebrow, the midpupil and the top of the eyebrow, and the lateral canthus and the top of the eyebrow. All patients were measured before and 1 year after surgery. The author found an increase of the vertical height from the midpupil to the top of the brow, with an average increase of 3.9 mm. There were no differences between patients who had only a brow lift and those who had a brow lift and an upper blepharoplasty at the same time. The author concludes that for most cases where an increased vertical height of the brows of more than 4 mm is not needed, it is not necessary to use scalp fixation to achieve a natural result.     

Deepithelialized turnover flaps in burns

Acute and chronic burns leave behind a full-thickness defect that always requires a flap cover. Such defects are common in electrical burn injuries of the limbs. This paper deals with 35 patients with full-thickness defects following burns in whom deepithelialized turnover dermis flaps and deepithelialized turnover flaps with deep fascia have been used. This flap is an extension of Hynes's reversed dermis graft and Smahel's deepithelialized turnover flap where there is a larger area of blood supply on the deeper aspect of the dermis. If a good hinge is provided for safe blood supply, such a flap settles well in the defect, and cumbersome multistaged procedures can be avoided. If there is less fatty tissue in the area of flap used, then reversed dermis flaps are ideal because split-skin graft take is good. When there is a lot of fatty tissue on the undersurface of dermis, the fascia is also included to make it a reversed fasciocutaneous flap to augment the blood supply and for better split-skin graft survival. Advantages of the procedure and complications are elaborated.