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)     

Cytological and functional characteristics of fascia adipocytes in rats: A unique population of adipocytes

The dermal adipocytes, superficial fascia and subcutaneous adipose tissue (SAT) exist in the interspaces between the dermis and muscular fascia. They are adjacent to each other and traditionally recognized as one SAT. Recently, the dermal adipocyte was redefined as a unique population independent from the SAT. Also, we identified a novel type of adipogenic progenitors in rat superficial fascia. This study aimed to examine cytological and functional characteristics of fascial adipocytes in rats. Superficial fascia had no adipocytes in neonatal rats but gradually appeared numbers of adipocytes in growing rats. Adipogenic progenitors were found to reside in fascia and had strong ability in spontaneous and induced adipogenic differentiation in vitro. Differentiated fascial adipocytes versus subcutaneous or visceral adipocytes expressed increased adipose triglyceride lipase but decreased beta-adrenoreceptor, perilipin-1 and hormone-sensitive lipase (HSL), thus having high basal lipolysis but low lipolysis response to catecholamines. Phosphorylation of perilipin-1 and HSL and translocation of HSL to lipid droplets were attenuated in response to catecholamines rather than post-adrenoreceptoral lipolytic stimulators. The results suggested that superficial fascia was an origin of adipocytes with distinct developmental, cytological and functional characteristics. We proposed that fascial adipocytes could be considered as a unique population of adipocytes in the body. The fascia origin of adipocytes as an adipogenic model might logically explain fat neogenesis occurred at anatomical locations where originally exist no adipose tissues and thereby no adipose-derived stromal precursors. Also, the special histoanatomical relations and overlaps between the dermis, superficial fascia, SAT, and their adipocytes were discussed.     

A contribution to knowledge of the compartments and the fascial and septal formations of the popliteal fossa in the human fetus and the adult.

A contribution to knowledge of the compartments and the fascial and septal formations of the popliteal fossa in the human fetus and the adult. A study was made in human fetuses from the 3rd month onwards, newborn and the adult of the fascial and septal formations and the compartments of the popliteal fossa. Observations of serial sections of the knee of human fetuses, of macroscopic preparations of the knee of newborns and of ultrasound images of the popliteal fossa in adults showed that: the fascial formation covering the popliteal fossa consists of the popliteal fascia and the superficial fascia. The bud of the popliteal fascia is observable in the 3-month fetus as a layer of thin fibrillar connective tissue which is thicker in the tracts between the muscle buds. At birth the popliteal fascia is clearly a separate anatomical entity of continuous laminar structure which is thicker in the tracts between the muscles and thinner where it covers them. The superficial fascia becomes evident in fetuses at a later stage (6th month) in the form of a thin lamina in the frontal plane which at birth is well defined and observable as a thin continuous line deep below the subcutaneous layer. The septal formation consists of four septa: two in the sagittal plane (lateral and medial) and two in the frontal plane (lateral and medial). The bud of these septa appears in 4-month fetuses after the appearance of the popliteal fascia. They branch off from the thicker connective areas between the muscles buds as connective prolongations which later assume a laminar aspect and eventually become compact and form septa. In at-term fetuses and newborns these septal formations are clearly recognizable as antomical entities, which branch off from the deep surface of the thicker tracts of the popliteal fascia and are inserted into the femur. The relationships and connections with the muscular groups are also clearly visible. The organization and demarcation of the compartments, which is already delineated in the 6-month fetus, seems to be completed at birth, considering the presence of the superficial fascia, the popliteal fascia and the septa. It is possible to distinguish a superficial compartment between the popliteal and the superficial fascia an a deep compartment between the frontal septa, the skeletal plane and the popliteal fascia. This deep compartment is clearly subdivided by the two sagittal septa into three sectors (medial, intermediate and lateral). The medial and lateral sectors contain muscles, while the intermediate compartment contains the vasculonervous bundle and the popliteal adipose body.     

Postburn breast reconstruction: tissue expansion prior to contracture release.

Tissue expansion of the scarred chest following burns results in a poor breast mound shape with little projection or inframammary fold, since the expander, like normal developing breast tissue, is kept flat by the scarred skin envelope. We present a case that demonstrates that adequate projection of the breast and formation of an inframammary fold can be achieved by expansion if extensive release and skin grafting of contractures over the breast mound are performed after expansion. Maintained expansion will act as a stent reducing secondary contracture of the grafted-areas.     

声带组织切片方法的比较

目的:探讨犬声带冠状位切片与水平位切片各自的特点,为声带实验提供合适的切片方法。方法:家犬4只,2只取材后行冠状位石蜡切片,2只取材后行水平位石蜡切片。通过HE染色观察声带固有层的一般组织结构,Masson三色染色观察固有层中胶原的排列情况。结果:HE染色示冠状位、水平位切片均可见声带表面被覆复层鳞状上皮,固有层内有大量排列紧密的纤维组织,纤维组织中夹杂少量腺体,固有层下方为肌层。冠状位切片可观察声带某一点冠状面固有层的情况,若观察整个声带的情况需声带连续切片;水平位切片可在一张切片中观察到前联合、声带膜部及声带突部位的固有层情况,解剖标志明显,利于定位。Masson三色染色示冠状位、水平位切片均可见固有层浅层有较细的胶原纤维束,中层有较粗的纤维束与较细的纤维束交织排列,深层纤维束排列更紧密。结论:冠状位切片可观察声带某一点冠状面固有层的整体情况,水平位切片可在一张切片中观察到前联合、膜部及声带突部位的固有层情况。     

"Apron" flap and re-creation of the inframammary fold following TRAM flap breast reconstruction

To the best of our knowledge, the recreation of an inframammary fold after TRAM flap breast reconstruction has not yet been described. This article offers a technique for the creation of an inframammary fold as a secondary procedure. The technique has been performed thus far in two patients with good aesthetic outcomes and no postoperative complications. It may also be suitable for adding bulk to the TRAM flap, especially in bilateral breast reconstruction, and for other minor chest deformities.     

Correction of bilateral breast hypoplasia and pectus excavatum with single-unit customized silicone implant

The cosmetic defects of pectus excavatum and bilateral mammary hypoplasia can be corrected with a single-unit customized silicone implant. An extended pocket is made across the anterior chest wall through two inframammary incisions. It is then possible to insert and position the breast prostheses subpectorally and the sternal prosthesis subcutaneously using these incisions. A good cosmetic result can occur with minimal morbidity and scarring.     

Unilateral reduction mammaplasty: sculpturing the breast from the undersurface

Various traditional mammaplasty techniques have been suggested for unilateral breast reduction, and an inverted-T incision is still the most popular approach. However, unilaterally performed traditional techniques can rarely provide long-lasting symmetry because the operated and the unoperated breasts react differently to aging, weight changes, and pregnancy. Considerable residual scarring, interference with clinical and mammographic evaluation, and limited versatility are all major drawbacks of traditional procedures. We have performed unilateral mammaplasties on 47 patients with various types of congenital and acquired asymmetries, reducing and sculpturing the breast from the undersurface by means of minimal incisions, always avoiding horizontal scarring in the inframammary crease. Through a vertical infra-areolar incision, the breast is completely detached from the underlying pectoralis fascia and hooked up, thus completely exposing the undersurface of the mammary cone. The breast can thereafter be reshaped according to the size and shape of the contralateral breast by means of a discoid resection and/or selective sectoral removal of excessive subcutaneous tissues; modifications of the basic discoid resection can increase anterior projection of the new breast mound and can change the inclination of the anteroposterior breast axis on the anterior chest wall both on the horizontal and vertical planes. The results show that if criteria for patient selection are carefully respected, the procedure can provide long-lasting symmetry with minimal residual scarring and fully preserve the breast anatomy, function, and vascularization.     

Comparison of strategies for preventing abdominal-wall weakness after TRAM flap breast reconstruction.

To determine the best method for preserving abdominal-wall integrity after TRAM flap breast reconstruction, the records of 130 patients followed for at least 6 months (mean 18 months) were examined. Three strategies for management of the abdominal-wall repair were compared. In the first group (72 patients), the entire width of the rectus abdominis muscle was harvested with the flap, and the anterior rectus sheath was closed in one layer. In the second group (20 patients), only the medial two-thirds of the rectus abdominis muscle was removed from the abdomen. The muscle and fascial donor defects were closed in separate layers. In the third group (38 patients), only one-fifth of the muscle was preserved, and a two-layered fascial closure of the anterior rectus sheath was performed, emphasizing repair of the internal oblique fascia to the midline fascia deep to the linea alba. Reinforcing synthetic mesh was used (in 10 patients) if closure was difficult or sutures tended to pull through the fascia. The incidence of abdominal weakness and/or bulging was similar in the first two groups (33 and 40 percent, respectively), but significantly lower (8 percent) in the third group (p = 0.006).     

Longitudinal assessment of breast development in adolescent female patients with burns involving the nipple-areolar complex

Long-term follow-up of breast development in adolescent female patients with burns of the anterior chest wall is poorly documented. Between 1971 and 1976, 28 female patients with photographic documentation of burns to the anterior chest wall involving the nipple-areolar complex were reviewed. All patients were followed at least until their early teens. The mean age at the time of thermal injury was 5.9 +/- 2.5 years, with a mean follow-up time of 8.9 +/- 2.6 years. Thirteen patients (46 percent) were admitted to the Shriners Burns Institute in Galveston for acute care of their burns. Fifteen patients (54 percent) were referred for long-term follow-up or specific reconstructive procedures following care of the acute burns. In spite of significant thermal injury to the anterior chest wall with involvement of the nipple-areolar complex, no patient failed to develop breasts. Twenty patients (71 percent) required releases of the anterior chest wall to assist breast development. All anterior chest wall releases were accomplished with the use of skin grafts or local skin flaps.     

Incidence of breast and chest wall asymmetry in breast augmentation: a retrospective analysis of 100 patients

Although much is written concerning breast augmentation, few authors have addressed preoperative chest wall analysis as it pertains to postoperative outcome. In the present study, 100 patients were randomly selected, underwent bilateral augmentation, and were examined retrospectively by four independent physicians using standardized preoperative photographs. Each patient was examined for ptosis and asymmetry of the nipples, breast mound, and chest wall. Results revealed significant asymmetries in all parameters. Nipple-areola complex asymmetry was present in 24 percent (nipple/areola size) and 53 percent (nipple position) of the women. Mound asymmetry was noted in 44 percent (volume), 29 percent (base constriction), and 30 percent (inframammary fold position) of the women, and finally, 29 percent of the women had grade I to III ptosis. Chest wall asymmetry was observed in 9 percent of the women. Overall, 88 percent of the women had some degree of asymmetry, and 65 percent of the women had more than one parameter of asymmetry. These findings underscore the importance of developing a systematic preoperative breast and chest wall analysis that can be individualized for each patient. The resulting asymmetries should then be discussed with the patient, along with the potential for continued or even more pronounced asymmetry postoperatively.     

The pure posterior pedicle procedure for breast reduction

The inferior pedicle technique, which has already become classic, employs a glandular areola-bearing pedicle whose source of vascularization is primarily posterior. In fact, the inferior pedicle is a posterior pedicle with an inferior border. After systematically and progressively reducing this inferior border, I have completely eliminated it. The pure posterior pedicle that results is independent of the inframammary fold. It is vascularized by means of the pectoral muscle and fascia, as has been demonstrated by injection studies of the thoracoacromial artery in fresh cadavers. The resulting mammary reduction technique retains the advantages of the inferior pedicle technique while avoiding its major inconveniences: dependence on the inframammary fold, bulging at the inferior base of the pedicle, and the necessity of low positioning for the breast.     

Double-layered free temporal fascia flap as a two-layered tendon-gliding surface

We report the use of a two-layered free fascial flap consisting of temporoparietal and deep temporal fascia based on a single vascular pedicle, the superficial temporal artery and vein. The flap was used to reconstruct an extensive degloving injury of the dorsum of the hand, in which multiple intact extensor tendons lay fully exposed on all sides, with exposed bone beneath them. By sandwiching the tendons between the layers of vascularized fascia, gliding surfaces were provided, both superficial and deep to the exposed tendons. The single-stage reconstruction was completed with a split-thickness skin graft. The patient returned to heavy manual work within 12 weeks of injury. He obtained an excellent range of movement without the need for tenolysis.     

An improved technique for immediate retropectoral reconstruction after subcutaneous mastectomy

Subcutaneous mastectomy is becoming an operation of choice in certain cases of premalignant and other breast pathology. We describe a technique for simultaneous subcutaneous mastectomy and retropectoral implantation of a silicone prosthesis. Gentle blunt prepectoral, retromammary dissection is performed through an axillary incision as far inferiorly as the inframammary fold, where a fibrous bridge between the anterior surface of the pectoralis major muscle and the skin prevents dissection any lower. Through the same incision, the retropectoral space is dissected to about 5 cm below the inframammary fold. A second incision is made in the inframammary fold to join the retromammary plane of the first dissection. The gland is then dissected subcutaneously and removed through the inframammary incision. A silicone implant is introduced retropectorally through the axillary incision, thus avoiding splitting the pectoralis major. Satisfactory results have been obtained in 23 bilateral and 14 unilateral cases; it is important that the dissection be performed carefully in order to prevent the implant from riding up too high in its musculoaponeurotic sling.     

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.     

The sandwich temporoparietal free fascial flap for tendon gliding.

Microsurgical transfer of the superficial and deep temporal fascia based on the superficial temporal vessels has been documented. This article analyzes the functional recovery when each layer of this facial flap is placed on either side of reconstructed or repaired tendons, to recreate a gliding environment. This fascial flap also provided a thin, pliable vascular cover in selected defects of the extremities.Six patients (four male and two female) with tendon loss and skin scarring of the hand (three dorsum, one palmar, and one distal forearm) and posttraumatic scarring of the ankle with tendoachilles shortening (one patient) underwent this procedure. No flap loss was witnessed. Good overall functional recovery and tendon excursion were observed. Complication of partial graft loss was observed in two patients.     

The structure of the osteoderms in the Gekko: Tarentola mauritanica

Histological and cytological analysis reveals that the osteoderms of Tarentola mauritanica are composed of an outer part superimposed on a basal region. The structure of both parts can be related to that of the surrounding dermis. The basal part of the osteoderms, inserted in the dense dermis, is made up of abundant closely packed collagen fibrils that orient the mineral deposit. The outer part, located in the superficial loose dermis, is crossed by few bundles of mineralized collagen fibrils arising from the basal part. These bundles connect the osteoderm to the overlying loose dermis. The outer superficial part is characterized by the presence of mineralized globules surrounding the mineralized collagen bundles. In these globules, the crystals are deposited on a microfibrillar matrix rich in acidic mucosubstances and composed of radially oriented, tangled microfilaments that lie among the collagen bundles. The two different mineralizing systems in the osteoderms of Tarentola mauritanica may reflect two different organic matrices. The mineral is deposited in a preexisting dermal tissue, as a "metaplastic ossification," and is another expression of the potential retained by the reptilian dermis to form mineralized structures.     

Transaxillary subpectoral augmentation in the ptotic breast: augmentation by disruption of the extended pectoral fascia and parenchymal sweep

A new approach to transaxillary subpectoral breast augmentation based on an understanding of the anatomy of the extended pectoral fascia and the inframammary fold allows for the widespread application of this technique. Previous authors have stated that transaxillary augmentation is only applicable to a small subset of the general population and is contraindicated in mild degrees of ptosis or in large augmentations. The new approach, augmentation by disruption of the extended pectoral fascia technique and the parenchymal sweep maneuver, prevents high-riding implants and double folds. By disrupting the fascia, the lower portion of the implant is able to sit in a partially subglandular rather than subfascial plane. The anatomy and clinical implications of the extended pectoral fascia are discussed, as is the augmentation by disruption of the extended pectoral fascia technique. The parenchymal sweep maneuver is also described. Clinical cases are presented.