One hundred fascia-sparing myocutaneous rectus abdominis flaps: An update

Major efforts have been undertaken to reduce donor-site morbidity after abdominal flaps, which eventually culminated in the introduction of the deep inferior epigastric perforator (DIEP) flap. However, due to anatomical variations (absence of dominant perforators) and the risk of ischaemic complications, the selection of patients qualifying for a DIEP flap is limited. Furthermore, DIEP flaps can only be used as free flaps. We present our long-term experience with a dissection technique of rectus abdominis myocutaneous (RAM) flaps that was developed to circumvent these drawbacks. The dissection is characterised by preventing to sacrifice any perforators nourishing the flap and by fully preserving the anterior rectus sheath, but not the muscle. The study comprises a consecutive series of prospectively assessed patients, treated between February 2000 and April 2008. A total of 100 fascia-sparing RAM flaps were operated on 97 patients (age 22-84 years, median 64 years). Free flaps were mainly used for breast reconstruction (47 flaps/24 patients), and cranially (34) or caudally (19) pedicled flaps for soft-tissue coverage after sternectomy, urogenital tumour resection or rectum amputation. Eighty patients had a total of 213 risk factors, such as cardiovascular diseases, obesity, hyperlipidaemia, diabetes mellitus, smoking or steroid medication. Partial tissue loss (skin or fat necrosis) occurred in 13 flaps, out of which seven required surgical revision. The ischaemic complications were evenly distributed between the patient subsets. At a follow-up of 2-89 months (median 20 months), one patient showed a flap harvest-related abdominal bulge after bilateral-free transverse rectus abdominis myocutaneous (TRAM) flap. We conclude that the present dissection technique provides maximal perforator-related perfusion and minimal donor-site morbidity even in pedicled flaps and high-risk patients. In free flaps, it may, therefore, be recommended as an alternative to the DIEP flap.

Reconstruction of Skull Base and Fronto-orbital Defects following Tumor Resection

Reconstruction of the anterior skull base and fronto-orbital framework following extensive tumor resection is both challenging and controversial. Dural defects are covered with multiple sheets of fascia lata that provide sufficient support and avoid herniation. Plating along the skull base is contraindicated. After resection of orbital walls, grafting is necessary if the periosteum or parts of the periorbital tissue had to be removed, to avoid enophthalmus or strabism. Free bone grafts exposed to the sinonasal or pharyngeal cavity are vulnerable to infection or necrosis: therefore, covering the grafts with vascularized tissue, such as the Bichat fat-pad or pedicled temporalis flaps, should reduce these complications. Alloplastic materials are indispensable in cranial defects, whereas microsurgical free tissue transfer is indicated in cases of orbital exenteration and skin defects. The authors review their experience and follow-up of 122 skull base reconstructions following extensive subcranial tumor resection. Most significant complications were pneumocranium in 4.9%, CSF leaks in 3.2%, and partial bone resorption in 8.1%.

Reconstruction of the palatal aponeurosis with autogenous fascia lata in secondary radical intravelar veloplasty: a new method

Velopharyngeal insufficiency in cleft patients with muscular insufficiency detected by nasendoscopy is commonly treated by secondary radical intravelar veloplasty, in which the palatal muscles are reoriented and positioned backwards. The dead space between the retro-displaced musculature and the posterior borders of the palatal bone remains problematic. Postoperatively, the surgically achieved lengthening of the soft palate often diminishes due to scar tissue formation in the dead space, leading to reattachment of the reoriented muscles to the palatal bone and to decreased mobility of the soft palate. To avoid this, the dead space should be restored by a structure imitating the function of the missing palatal aponeurosis. The entire dead space was covered using a double layer of autogenous fascia lata harvested from the lateral thigh, which should allow sufficient and permanent sliding of the retro-positioned musculature. A clinical case of a 9-year-old boy who underwent the operation is reported. Postoperatively, marked functional improvements were observable in speech assessment, nasendoscopy and nasometry. The case reported here suggests that the restoration of the dead space may be beneficial for effective secondary palatal repair. Fascia lata seems to be a suitable graft for this purpose.

Excision of fascia in melanoma thicker than 2 mm: no evidence for improved clinical outcome.

BACKGROUND Lack of evidence-based data causes significant variation among surgeons concerning the depth of wide excision for primary cutaneous melanomas. OBJECTIVES To evaluate the clinical effect of excision of the deep fascia in melanomas thicker than 2 mm on patient outcome. METHODS We performed a retrospective cohort review (1996-2012) of patients with melanomas thicker than 2 mm. Included patients underwent excision with a 1-cm margin. Data collected included the patients' sex, age, tumour location, tumour type, Breslow depth and presence of ulceration. Local recurrences, locoregional and distant metastases, and disease-free and overall survival were compared between the fascia-excised and the fascia-preserved groups. RESULTS Out of 2182 patients with malignant melanomas, 213 melanomas thicker than 2 mm, with a median follow-up of 1547 days, were included. The mean age of the patients was 62·6 years and the mean Breslow depth was 4·2 mm. Analysis of data for death attributable to melanoma (P = 0·72), local recurrence (P = 0·71), and locoregional (P = 0·87) and distant metastases (P = 0·34) were not significantly different between the study groups. Furthermore, Kaplan-Meier and Cox regression analysis of both groups showed no evidence of significant difference regarding disease-free [P = 0·35; hazard ratio (HR) 1·25; 95% confidence interval (CI) 0·79-1·97] and overall survival (P = 0·63; HR 1·18; 95% CI 0·61-2·27). CONCLUSIONS We believe that excision of the deep fascia does not improve the outcome of melanomas thicker than 2 mm.

Retraction of Thyroid Gland and Exposure of Prevertebral fascia (4 of 5)

3B Carbon Dust, H and HH Carbon Pencils; Dr. Norman Thompson, University of Michigan Department of Surgery

Anatomical investigations : comprising descriptions of various fasciae of the human body : the discoveries of the manner in which the pericardium is formed from the superficial fascia : the capsular ligament of the shoulder joint from the brachial fascia : and the capsular ligament of the hip joint from the fascia lata : to which is added an account of some irregularities of structure and morbid anatomy : with a description of a new anatomical table /

Includes A treatise on the minute anatomy of the bones, by Antonio Scarpa; transl. by J.D. Godman.

Identification of Mechanical Parameters in Mathematical Model of Human Abdominal Fascia

Миглена Г. Кирилова-Донева - Едномерен експеримент на релаксация беше извършен с 14 образци от човешка пъпна фасция. Механичното поведение на фасцията по време на релаксация беше моделирано прилагайки нелинейната теория на Максвел-Гуревич-Рабинович. Параметрите на модела за изследваните образци бяха определени и стойностите им бяха сравнени в зависимост от посоката на натоварване на образците по време на експеримента. Установено бе, че стойностите на началния вискозитет ∗η0 и на параметъра ∗m, който се влияе от скоростта на деформация на материала се изменят в много широки граници не само за образци от различни донори, но и за образци от един донор. В резултат от прилагането на модела бе изчислено изменението на вискозитета и вискозната деформация на материала по време на релаксацията. Бе показано, че изменението на вискозитета и вискозната деформация зависи от посоката на натоварване на образците.

Sviluppo di una fascia addominale per angiografia con CO2

La scelta del mezzo di contrasto in angiografia è rilevante e richiede un’attenta valutazione della qualità diagnostica delle immagini e degli effetti collaterali. Essenziale è analizzare il rischio che comporta l’utilizzo dei vari mezzi di contrasto a base di iodio, come ad esempio la nefropatia. Al contrario l’anidride carbonica, riconosciuta come unico agente di contrasto sicuro, sempre più, viene utilizzata in tutti i vasi del corpo al di sotto del diaframma. L'obiettivo principale di questo lavoro, svolto in collaborazione con l’azienda bolognese Angiodroid srl, è quello di realizzare un dispositivo medico in grado migliorare la qualità delle immagini ottenute con CO2 a livello addominale. Infatti, col recente utilizzo della CO2 anche nel distretto addominale si riduce drasticamente l’utilizzo di grandi quantità di iodio, ma, in molti pazienti, il movimento della aria intestinale che ha coefficiente di assorbimento simile all’anidride carbonica, rende l’immagine inefficiente. Il progetto consiste in una fascia addominale composta da tre camere d’aria gonfiabili manualmente, che comprimendo l’addome con pressioni di 120-180 mmHg, spostano l’aria e riducono il movimento intestinale, e quindi gli artefatti. L’uso di questa semplice fascia, migliorando le immagini dei distretti addominale e viscerale, potrebbe permettere una più rapida affermazione dell’angiografia con CO2 anche in procedure come EVAR e PTA iliache. Per individuare la procedura d’utilizzo più adeguata e migliorare il dispositivo secondo le necessità cliniche, la fascia è stata provata in alcune sale angiografiche dell’Emilia Romagna, Lombardia e Campania.

Eficacia de la infiltración de Plasma Rico en Plaquetas (PRP) en pacientes diagnosticados del Síndrome de la Fascia Plantar (SFP) desde el punto de vista clínico y funcional

On the basis of the knowledge that the entheses between the plantar fascia and the calcaneus may exhibit a varied pathology, we considered the need to value the pathological factors by illustrating the anatomical changes in the Plantar Fascia Syndrome (PFS) with easy-to-obtain images which allowed us to substantiate our claims. Accordingly, we analized the anatomical (Orts Llorca, 1977; Llusá, 2007; Sobotta, 2007; Domenech Mateu, 2012; Rodriguez Baeza 2012) and biomechanical (Arandes, 1956; Viladot 1979; Caturla, 2001; Safe, 2001) literature in order to better know the location of the pathology and also to assess the functional reasons that could favor this disease. A study of the affected area by Nuclear Magnetic Resonance (NMR) revealed the presence of bone affections such as bone edema, subchondral lesions and several other bone pathologies together with fascia intrinsic injuries such as myxoid degeneration, intrasubstance fissures and perifascial edematous lesions (Larroca, 2013; Conejero, 2014). Injuries not properly treated during the acute phase can evolve into chronic processes which, month after month, become ever more difficult to resolve. In addition, as seen throughout this study, there are changes in the anatomical normality of the foot usually associated with pathological conditions of the plantar fascia. Once the pathological aspects of PFS are identified and their location is established, clinical manifestations should be registered in order to define this syndrome. Pain is the main symptom in patients with PFS and is associated, in many occasions, with tightness or stiffness of the plantar area, limited mobility of the arch of the ankle and, inevitably, a progressive functional deterioration. Thus, that sharp and stabbing pain felt when one puts the foot on the floor after a period of rest located in the front lower face of the heel and irradiating and/or projecting to the middle of the sole of the foot would be synonymous with Plantar Fascia Syndrome (PFS)...

Mathematical modelling of muscle recruitment and function in the lumbar spine

Low back pain is an increasing problem in industrialised countries and although it is a major socio-economic problem in terms of medical costs and lost productivity, relatively little is known about the processes underlying the development of the condition. This is in part due to the complex interactions between bone, muscle, nerves and other soft tissues of the spine, and the fact that direct observation and/or measurement of the human spine is not possible using non-invasive techniques. Biomechanical models have been used extensively to estimate the forces and moments experienced by the spine. These models provide a means of estimating the internal parameters which can not be measured directly. However, application of most of the models currently available is restricted to tasks resembling those for which the model was designed due to the simplified representation of the anatomy. The aim of this research was to develop a biomechanical model to investigate the changes in forces and moments which are induced by muscle injury. In order to accurately simulate muscle injuries a detailed quasi-static three dimensional model representing the anatomy of the lumbar spine was developed. This model includes the nine major force generating muscles of the region (erector spinae, comprising the longissimus thoracis and iliocostalis lumborum; multifidus; quadratus lumborum; latissimus dorsi; transverse abdominis; internal oblique and external oblique), as well as the thoracolumbar fascia through which the transverse abdominis and parts of the internal oblique and latissimus dorsi muscles attach to the spine. The muscles included in the model have been represented using 170 muscle fascicles each having their own force generating characteristics and lines of action. Particular attention has been paid to ensuring the muscle lines of action are anatomically realistic, particularly for muscles which have broad attachments (e.g. internal and external obliques), muscles which attach to the spine via the thoracolumbar fascia (e.g. transverse abdominis), and muscles whose paths are altered by bony constraints such as the rib cage (e.g. iliocostalis lumborum pars thoracis and parts of the longissimus thoracis pars thoracis). In this endeavour, a separate sub-model which accounts for the shape of the torso by modelling it as a series of ellipses has been developed to model the lines of action of the oblique muscles. Likewise, a separate sub-model of the thoracolumbar fascia has also been developed which accounts for the middle and posterior layers of the fascia, and ensures that the line of action of the posterior layer is related to the size and shape of the erector spinae muscle. Published muscle activation data are used to enable the model to predict the maximum forces and moments that may be generated by the muscles. These predictions are validated against published experimental studies reporting maximum isometric moments for a variety of exertions. The model performs well for fiexion, extension and lateral bend exertions, but underpredicts the axial twist moments that may be developed. This discrepancy is most likely the result of differences between the experimental methodology and the modelled task. The application of the model is illustrated using examples of muscle injuries created by surgical procedures. The three examples used represent a posterior surgical approach to the spine, an anterior approach to the spine and uni-lateral total hip replacement surgery. Although the three examples simulate different muscle injuries, all demonstrate the production of significant asymmetrical moments and/or reduced joint compression following surgical intervention. This result has implications for patient rehabilitation and the potential for further injury to the spine. The development and application of the model has highlighted a number of areas where current knowledge is deficient. These include muscle activation levels for tasks in postures other than upright standing, changes in spinal kinematics following surgical procedures such as spinal fusion or fixation, and a general lack of understanding of how the body adjusts to muscle injuries with respect to muscle activation patterns and levels, rate of recovery from temporary injuries and compensatory actions by other muscles. Thus the comprehensive and innovative anatomical model which has been developed not only provides a tool to predict the forces and moments experienced by the intervertebral joints of the spine, but also highlights areas where further clinical research is required.

Plantar enthesopathy : thickening of the enthesis is correlated with energy dissipation of the plantar fat pad during walking

Background: The enthesis of the plantar fascia is thought to play an important role in stress dissipation. However, the potential link between entheseal thickening characteristic of enthesopathy and the stress-dissipating properties of the intervening plantar fat pad have not been investigated. Purpose: This study was conducted to identify whether plantar fat pad mechanics explain variance in the thickness of the fascial enthesis in individuals with and without plantar enthesopathy. Study Design: Case-control study; Level of evidence, 3. Methods: The study population consisted of 9 patients with unilateral plantar enthesopathy and 9 asymptomatic, individually matched controls. The thickness of the enthesis of the symptomatic, asymptomatic, and a matched control limb was acquired using high-resolution ultrasound. The compressive strain of the plantar fat pad during walking was estimated from dynamic lateral radiographs acquired with a multifunction fluoroscopy unit. Peak compressive stress was simultaneously acquired via a pressure platform. Principal viscoelastic parameters were estimated from subsequent stress-strain curves. Results: The symptomatic fascial enthesis (6.7 ± 2.0 mm) was significantly thicker than the asymptomatic enthesis (4.2 ± 0.4 mm), which in turn was thicker than the enthesis (3.3 ± 0.4 mm) of control limbs (P < .05). There was no significant difference in the mean thickness, peak stress, peak strain, or secant modulus of the plantar fat pad between limbs. However, the energy dissipated by the fat pad during loading and unloading was significantly lower in the symptomatic limb (0.55 ± 0.17) when compared with asymptomatic (0.69 ± 0.13) and control (0.70 ± 0.09) limbs (P < .05). The sonographic thickness of the enthesis was correlated with the energy dissipation ratio of the plantar fat pad (r = .72, P < .05), but only in the symptomatic limb. Conclusion: The energy-dissipating properties of the plantar fat pad are associated with the sonograpic appearance of the enthesis in symptomatic limbs, providing a previously unidentified link between the mechanical behavior of the plantar fat pad and enthesopathy.