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Study objective We report a novel block technique aimed to provide lumbosacral, abdominal, and hip analgesia: The quadro-iliac plane (QIP) block. Design A cadaveric examination that evaluates the spread of QIP block. Setting Cadaver laboratory. Patients One unembalmed cadaver. Interventions Bilateral ultrasound-guided QIP blocks on cadavers with 40 mL of methylene blue %0.5 each side. Measurements Dye spread in cadaver. Main results There was staining in the deep interfascial plane of the erector spinae muscles. Extensive staining of the interfascial plane corresponding to the posterior aspect of the quadratus lumborum muscle (QLM) was observed. There was extensive staining on the anterior surface of the QLM. There was spread of dye traversing along the transversalis fascia and significantly infiltrating retroperitoneal fat tissue. Bilateral staining of the ilioinguinal and iliohypogastric nerves was observed. On the right, there was minimal staining over the subcostal nerve. There was dye present bilaterally within the deep regions of the transverse processes. The lumbar plexus was stained on both sides. Conclusion The local anesthetic applied from a place where the QLM reaches its largest volume and the fascial plane creates a closed gap in the caudal area may exhibit a more rounded and extensive spread. Quadro-iliac plane block, involves the administration of local anesthetic to the posterior aspect of the QLM at its origin from the iliac crest. According to our cadaver study, this technique may be a promising option for alleviating acute and chronic pain in the lumbosacral, lower abdominal, and hip regions. [ABSTRACT FROM AUTHOR]

Objective We aimed to evaluate the effectiveness of ultrasound-guided facia iliaca compartment (FIC) and erector spinae plane (ESP) blocks in managing postoperative pain after total hip arthroplasty surgery. Methods A total of 60 patients were randomized into 2 groups (n  = 30): one that received FIC blocks and one that received ESP blocks. FIC and ESP blocks were performed with 30 mL 0.25% bupivacaine at the end of the surgery. The patients received intravenous tramadol and patient-controlled postoperative analgesia. The pain scores, opioid consumption, and adverse events were recorded. Results The dynamic pain scores on movement in the postoperative first hour were significantly lower in the ESP block group than in the FIC block group (3 [2–4] vs 4 [2–5], respectively; P  = .035). Data are expressed as median (25th–75th percentiles). Postoperative opioid consumption within the first postoperative 8 hours was significantly higher in the FIC block group than in the ESP block group (80 mg [61–100] vs 100 mg [80–120], respectively; P  = .010). The adverse effects of opioids did not differ between the 2 groups. Conclusion ESP and infrainguinal FIC blocks provided similar postoperative analgesia 24 hours after total hip arthroplasty. The ESP block is more beneficial than the FIC block in terms of pain scores and opioid consumption in the early hours of the postoperative period. Trial registration www.ClinicalTrials.gov (ID: NCT05621161). [ABSTRACT FROM AUTHOR]

Objectives Idiopathic inflammatory myopathies are mainly defined by inflammatory infiltrates within the muscle (lymphocytes and macrophages). Eosinophil muscle infiltration has been described in idiopathic eosinophilic myositis (IEM) and rarely in EF. This study aimed to further delineate the nosological frame of idiopathic eosinophil muscle infiltration through the exhaustive analysis of IEM and EF patients. Methods This multicentre retrospective case series included IEM patients diagnosed between 2000 and 2022. IEM inclusion criteria were eosinophilic muscle infiltration with myositis pathological features, after the exclusion of differential diagnoses. An additional group of EF patients diagnosed between 2016 and 2022 was constituted. Inclusion criteria were an EF diagnosis and fascia thickening with inflammatory infiltrate. Results A total of 20 IEM cases and 10 EF cases were included. The median (interquartile range) age at diagnosis was 65 (49–70) years; there were 18 males. Data analysis delineated four subgroups: focal EM (FEM, n  = 3), diffuse EM (DEM, n  = 6), eosinophilic myofasciitis (EMF, n  = 11) and EF (n  = 10). FEM represented a limited and benign form of myositis. DEM cases presented objective muscle impairment with eosinophilic muscle infiltration. EMF patients presented subjective muscle impairment (myalgia, 55%), fasciitis (on histology and/or imaging), eosinophilic muscle infiltration and frequent hypereosinophilia (55%). EF patients presented myalgia (50%), muscle lesions on histology with fascia-restricted inflammatory infiltrates with (60%) or without (40%) eosinophils. Conclusions The analysis of IEM and EF patient characteristics delineates four subgroups (FEM, DEM, EMF and EF) in terms of clinical, laboratory, imaging, pathological and outcome specificities, and proposes an adapted diagnostic and care management approach. [ABSTRACT FROM AUTHOR]

The article presents the discussion on Myofascial pain being a very common disorder in the daily practice of musculoskeletal physicians. Topics include unmyelinated, nociceptive nerve fibers predominantly located within the superficial tissues usually considered to be the main histological targets for such procedures; and complex structural interactions between the deep fascia, the trapezius muscle, and the cutaneous branches of the dorsal rami (CBsDR) of spinal nerves.

Context Children with X-linked hypophosphatemic (XLH) rickets have muscle weakness that severely impairs their function. Intermuscular and intramuscular adipose tissue (IMAT and intraMAT, respectively) may contribute to this muscle weakness. Objective This work aimed to compare IMAT and intraMAT in XLH children vs typically developing (TD) children. Methods A prospective, monocentric cohort study was conducted of XLH (n = 11; aged 10.3 years [6-17]) and TD children (n = 22; aged 10.2 years [5-15.5]). All children underwent magnetic resonance imaging of the lower limbs; IMAT and intraMAT percentages were calculated after manual contouring of each muscle of the thigh and the deep fascia at mid-thigh level. Results XLH children were comparable in age but shorter and heavier than TD children (P =.001 and P =.03, respectively). They had smaller muscle length and volume than TD children (P <.001) but there was no statistically significant difference in muscle cross-sectional area between the groups (P =.833). The total percentage of IMAT was higher in XLH children (8.66% vs 3.60% in TD children; P <.0001). In addition, though the total percentage of intraMAT did not differ significantly (12.58% and 10.85% in XLH and TD children, respectively; P =.143) intraMAT was statistically significantly higher in XLH children than TD children in 4 of the 13 muscles studied. Conclusion Our results show that IMAT is higher in young children with XLH, independently of obesity and overweight. Further, these results will facilitate both the early prevention of functional and metabolic consequences of the increase in adipose tissue in XLH children. [ABSTRACT FROM AUTHOR]

Introduction Greater trochanteric pain syndrome may often mimic pain generated from other sources. However, it is most commonly caused by gluteus medius and gluteus minimus tendinopathy or tear. The purpose of this technical report was to: 1) describe the ultrasound-guided fascial plane block technique targeting the superior gluteal nerve in the plane between gluteus medius/gluteus minimus to treat moderate-to-severe, chronic, refractory greater trochanteric pain syndrome; 2) anatomically correlate the procedure with cadaveric dissections demonstrating the structures being imaged and the tissues along the needle trajectory; 3) demonstrate the feasibility of the technique with serial dissection of one cadaveric specimen following injection with color dye. Technique description The ultrasound-guided fascial plane block targeting the superior gluteal nerve to treat moderate-to-severe, chronic, refractory greater trochanteric pain syndrome has been outlined with supporting ultrasound scans and anatomical dissections. The cadaveric dissections are correlated to the ultrasound scans of a healthy volunteer and provide visualization of the tissues in the needle trajectory. The feasibility study in a cadaveric specimen showed adequate stain of the superior gluteal nerve without spread to the piriformis muscle belly, the sciatic nerve, or the inferior gluteal nerve. Conclusions This ultrasound-guided fascial plane block is a feasible option for blocking the superior gluteal nerve without inadvertent involvement of the sciatic and inferior gluteal nerves. Further randomized controlled clinical trials are necessary to assess the clinical efficacy of the gluteus medius/gluteus minimus fascial plane block to treat moderate-to-severe, chronic, refractory greater trochanteric pain syndrome. [ABSTRACT FROM AUTHOR]

Background The relative anatomical understanding of the perirectal fasciae is of paramount importance for the proper performance of total mesorectal excision (TME). This study was to demonstrate the planes of TME and validates the intraoperative findings using cadaveric observations. Methods In this combined retrospective and prospective study, bilateral attachment of the rectosacral fascia (RSF) was observed in 28 cadaveric specimens (male, n = 14; female, n = 14). From January 2018 to December 2019, surgical videos of 67 patients who underwent laparoscopic TME at the Affiliated Union Hospital of Fujian Medical University (Fuzhou, China) were reviewed and interpreted with the cadaveric findings. Results The RSF (synonym: Waldeyer's fascia) is the end of the pre-hypogastric fascia at the level of S4 and comprises two layers (upper and lower). These two layers provide double fascial protection for the venous sacral plexus. It inserts into the fascia propria of the rectum along a broad horizontal arc that merges anterolaterally in an oblique downward direction until it meets the posterolateral merge of Denonvilliers' fascia at the lateral rectal ligament (LRL). This ligament does not look like a true ligament but is more likely to be a fascial combination that cushions the rectal innervation and middle rectal vessels. Conclusions Understanding the lateral attachment of RSF and its contribution to LRL provides invaluable surgical guidance to dissect this critical area. Therefore, lateral dissection is proposed from the anterior to the posterior direction to find the correct plane that guarantees an intact mesorectal envelope to protect the important nearby nerve structures. [ABSTRACT FROM AUTHOR]

The Denonvilliers' fascia (DVF) plays an important role in rectal surgery because of its anatomic position and its relationship to the surrounding organs. It affects the surgical plane anterior to the rectum in the procedure of total mesorectal excision (TME). Anatomical and embryological studies have helped us to understand this structure to some extent, but many controversies remain. In terms of its embryonical origin, there are three mainstream hypotheses: peritoneal fusion of the embryonic cul-de-sac, condensation of embryonic mesenchyme, and mechanical pressure. Regarding its architecture, the DVF may be a single, two, or multiple layers, or a composite single-layer structure. In women, most authors deem that this structure does exist but they are willing to call it the rectovaginal septum rather than the DVF. Operating behind the DVF is supported by most surgeons. This article will review those mainstream studies and opinions on the DVF and combine them with what we have observed during surgery to discuss those controversies and consensuses mentioned above. We hope this review may help young colorectal surgeons to have a better understanding of the DVF and provide a platform from which to guide future scientific research. [ABSTRACT FROM AUTHOR]

Objective An ultrasound-guided interfascial injection, which targets the space between the epimysia, is often performed for myofascial neck and shoulder pain. However, the relationship between the injection volume and clinical effectiveness has been controversial. We conducted an anatomical study with cadavers to measure the distribution of a small amount of pigment solution injected into the interfascial space. Design An experimental cadaveric study. Setting An institutional clinical anatomy laboratory. Methods We performed 20 ultrasound-guided injections with pigment solutions of 1.0 mL each into the space between the trapezius muscle and rhomboid muscle bilaterally on 10 cadaver specimens. Cadavers were then dissected and macroscopically evaluated for pigment distribution on the fascia of the muscular surfaces. The pigment distribution area of each injection site was visually confirmed and calculated using automatic area calculation software. Results Pigment solution exclusively within the interfascial space was visually confirmed in 95% (19/20) of injection sites. The median pigmented surface area (interquartile range) was 24.50 (16.17–30.76) cm2 on the deep side of the trapezius muscle and 18.82 (13.04–24.79) cm2 on the superficial side of rhomboid muscle; these measurements were statistically significantly different (P  = 0.033). Conclusions A pigment solution comprising as little as 1.0 mL injected under ultrasound guidance separated two adjacent muscles and spread to the wide area within the interfascial space. The difference in the pigment distribution area between the two adjacent muscles can be explained by the path made by the injection needle and several layers of fascia between the epimysium. [ABSTRACT FROM AUTHOR]

Objective Pain experienced by patients with plantar heel pain has been associated with fascia thickness. It is possible that referred muscle pain may also be related to symptoms experienced by these patients. Our aim was to systematically investigate if the referred pain elicited by trigger points in the leg and foot musculature reproduces the symptoms in individuals with plantar heel pain and to determine the association of trigger points (TrPs) with pain and related disability. Methods A case–control study was conducted. Thirty-five individuals with unilateral chronic plantar heel pain and 35 matched comparable healthy controls participated. An assessor blinded to the subject's condition explored TrPs in the flexor hallucis brevis, adductor hallucis, quadratus plantae, and internal gastrocnemius. Pain and related disability were assessed with a numerical pain rating scale (0–10), the Foot Function Index, and the Foot Health Status Questionnaire. Results The number of TrPs for each patient with plantar heel pain was 4 ± 3 (2.5 ± 2 active TrPs, 1.5 ± 1.8 latent TrPs). Healthy controls only had latent TrPs (mean = 1 ± 1). Active TrPs in the quadratus plantae (N = 20, 62.5%), and flexor hallucis brevis (N = 19, 59%) were the most prevalent in patients with plantar heel pain. A greater number of active, but not latent, TrPs was associated with higher foot pain variables (0.413 < r s < 0.561, P  < 0.01), higher impact of foot pain (0.350 < r s < 0.473, P  < 0.05) and worse related disability (–0.447 < r s < –0.35456, P  < 0.05). Conclusions The referred pain elicited by active TrPs in the foot muscles reproduced the symptoms in patients with plantar heel pain. A greater number of active TrPs was associated with higher pain and related disability in patients with plantar heel pain. [ABSTRACT FROM AUTHOR]

Introduction: Precise anatomy of the PSL remains controversial. It is routinely described as having 3 components: The fundiform (FL), Suspensory (SL) and Arcuate Ligaments (AL). Proponents of penile enlargement surgery (PES) ensure that division of the "superficial" PSL (FL, SL), allows desired distraction between phallus and pubic symphysis (PS) without risking instability. Seemingly in support of this rationale, many publications imply the FL and SL provide less structural integrity as they connect only superficial fascias (Origin: Scarpa's fascia or linea alba; Insertion: Penile Dartos or Buck's fascia). AL is reported to be the primary support structure as it connects the corporal tunica albuginea (TA) directly to the bone and preserved in PES given its deeper location. Despite this, significant sexual dysfunction (SD) from PSL deficiency after PES has been reported. An improved understanding of this anatomy is paramount for quality surgical care in both pre-operative counselling and rectification of adverse functional outcomes. Objective: (1) To present initial findings of the in-situ PSL anatomy (2) To propose a new anatomical classification system Methods: Data from six male cadavers (46-87 years; mean 75) were used in present study. There was no history of genitourinary operations and cause of death were either respiratory or vascular. Following deep-freeze and 0.9mm whole-mount sectioning, specimens were impregnated with epoxy-resin mixture (E12/E1/AE10/AE30). Without specific labelling, this process allows endogenous autofluorescence of collagen/elastin/myofilaments when excited using 488nm-confocal-laser microscope. Select areas were examined using stereoscopic microscopy and scanned at high-resolution. This technique ensures preservation of anatomy in-situ and allowed enhanced examination at both macroscopic and microscopic levels (Figure 1). Results: Proposed classification divides PSL by anatomical location: Prepubic, Subpubic, Retropubic. While corresponding to the same distinct structures, it avoids the misnomers and discrepancies that are embedded in existing nomenclature. Findings are summarised in Table 1. The AL does not appear to the PSL apparatus. It fuses with the interosseus fibrocartilaginous lamina deep to it and attaches laterally to the inferior pubic rami. Inferiorly, its semicircular free edge rounds off the apex of the pubic arch but has no corporal attachment. Conclusions: Findings of the present study do not support an anatomical rationale for PES, without risking instability. Contrary to previous reports, the subpubic PSL (or suspensory ligament) is the only component that directly connects TA with PS. The purported role of AL appears unfounded. Furthermore, perpendicular fibrous orientation of the subpubic and retropubic PSL suggests a dynamic support mechanism, not dissimilar to the knee's cruciate ligaments. To the author's knowledge, this is the first description of the musculotendinous origin of the retropubic PSL, whose fibres extend anteriorly from the urogenital diaphragm. Further studies are required to better characterise the retropubic PSL insertion and may lead to new insights into the origin and architecture of deep penile fascia. Based on present findings, the TA likely consists of multiple fibrous components originating from the musculotendinous aponeuroses of superficial perineal musculature. Disclosure: No. [ABSTRACT FROM AUTHOR]

We aimed to introduce a technique by combining free fascia flaps transfer with split-thickness skin graft for the reconstruction of deep burn wounds at the ankle. Fifteen patients from 2009 to 2016 were enrolled in this study. Patients in this series suffered from a deep burn injury around the ankle, which was accompanied with exposure of tendon and medial or lateral malleolus exposure due to severe soft-tissue defects (N = 15). All the 15 wounds were repaired combining free fascia flaps with split-thickness skin graft operations, including nine anterolateral thigh fascia lata flaps (ATFL flaps) and six superficial temporal fascia flaps (STF flaps). All the fascia flaps completely survived. Two patients showed partial grafting skin necrosis due to either wound infection or subcutaneous hematoma infection, and this was eventually healed satisfactorily after conventional dressing change. All patients achieved esthetic outcome and acceptable functionality without further revisions needed. Our present study reports a useful method that involves using free fascia flaps in combination with split-thickness skin graft to repair deep burn wounds around the ankle. This method provided reliable and durable soft-tissue coverage with good outcomes. [ABSTRACT FROM AUTHOR]

Objectives: Subcutaneous involvement, including calcinosis and panniculitis, is a more common complication in juvenile dermatomyositis (JDM) than in adult dermatomyositis. Magnetic resonance imaging (MRI) is useful for evaluating disease distribution. We investigated the clinical significance of subcutaneous involvement in JDM. Methods: Thighs and hips in 18 newly diagnosed JDM patients were evaluated with fat-suppression MRI. Bilateral muscle, fascial and subcutaneous fat involvement were scored from 0 to 8 points according to the severity of distribution on MRI. Associations between clinical manifestations, serum muscle enzymes, and MRI scores were also evaluated. Results: Abnormal MRI findings in muscle, fascia and subcutaneous fat were observed in 18, 18, and 10 patients, respectively. Subcutaneous fat scores were significantly higher in early-diagnosed JDM patients (diagnosed less than 2 months from onset) than in late-diagnosed JDM patients (diagnosed later) (p¼.025). Serum aldolase was elevated in all patients, although only eight demonstrated elevated serum creatine phosphokinase. Serum aldolase was significantly correlated with MRI scores for subcutaneous fat (p<.0001, q¼.787) and fascia (p¼.013 q ¼ 0.574), but not muscle. Additionally, serum aldolase was significantly correlated with serum triglycerides (p¼.009, q¼0.629). Conclusion: Subcutaneous fat involvement is a characteristic finding in early-diagnosed JDM and correlates with elevated serum aldolase. [ABSTRACT FROM AUTHOR]

Objective Plantar fasciitis (PF) is one of the most common causes of heel pain. The affected area is often close to the attachment of plantar fascia to calcaneus bone. The purpose of this study was to compare the effects of ozone (O2-O3) injection to corticosteroid injection under ultrasound guidance for the treatment of chronic PF. Design Randomized clinical trial. Setting Academic University and Neuromusculoskeletal Research Center. Subjects Thirty patients with chronic PF. Methods The patients were randomly divided into two groups receiving methylprednisolone (15 subjects) vs ozone (O2-O3; 15 subjects). The following outcome measures were assessed before injection and then two weeks and 12 weeks after the injection in each group; morning and daily pain via visual analog scale, daily life and exercise activities via the Foot and Ankle Ability Measure, and plantar fascia thickness at insertion and 1 cm distal to its insertion into the calcaneus via ultrasound imaging. Results Intragroup changes showed significant improvement in pain, functional parameters, and sonographic findings in both groups (P  < 0.05). Pain reduction (both daily and morning) and daily activity improvement were better in the corticosteroid group two weeks after injection; however, at 12 weeks, the ozone (O2-O3) group had significantly more improvement (P  = 0.003, P  = 0.001, and P  = 0.017, respectively). Conclusions Both methods were effective in the treatment of chronic PF. Steroid injection provided a more rapid and short-term therapeutic effect. However, ozone (O2-O3) injection led to a slow and longer-lasting treatment outcome. Ozone (O2-O3) injection can be an effective treatment, with slow onset and a longer durability in the treatment of chronic PF. [ABSTRACT FROM AUTHOR]

Background We improved Inflatable Single-Incision Mediastinoscopy esophagectomy to implement the simultaneous laparoscopic esophagectomy with inflatablesingle-Incision mediastinoscope and lymphadenectomy along bilateral recurrent laryngeal nerves under mediastinoscopy through a single left-neck incision and formed the concept of modular treatment of inflatable mediastinoscopic esophagectomy based on fascial anatomy which we can achieve standardized add programmed esophageal dissociation, greatly shorten the learning curve, make it easier to popularize and promote, and help us to control the operation time and complications. Methods According to anatomy of the periesophageal fascia we summarized six surgical modules, respectively is: To make the neck incision, dissociate posterior and left esophagus, dissociate anterior and right esophagus, lymphadenectomy along left recurrent laryngeal nerves, lymphadenectomy along right recurrent laryngeal nerves, dissect the Subcarinal lymph nodes. The clinical data of patients undergoing esophagectomy with inflatable single-pore mediastinoscope from February 2020 to February 2021 in our hospital were summarized and analyzed, and compared with the data of minimally invasive thoracic esophagectomy, in order to verify the clinical application effect of this modular system. Results In the validation study of modularization in this subject, no perioperative death was found in the 44 patients and the R0 resection rate was 100% confirmed by postoperative pathology. The average operation time was 204.9 ± 45.4 minutes, mean intraoperative blood loss was 64.6 ± 45.5 mL, average number of lymph nodes removed was 19.5 ± 9.1, average length of hospital stay was 27.0 ± 18.17 days, postoperative anastomotic fistula (2.27%), anastomotic stenosis (13.64%), chylous leakage (0%), pleural effusion (4.55%), and pulmonary infection (9.09%), better than the control group. The incidence of postoperative hoarseness (18.19%) which needed to be improved. Conclusion This standardized and modular surgical procedure description based on fascia anatomy is proposed for the first time for the esophagectomy under inflatable mediastinoscope, and is an exploration of the construction of a modular system for this surgical procedure. This modular system enables us to achieve standardized, programmed and rapid esophageal dissociation, which has good clinical application value. [ABSTRACT FROM AUTHOR]

A bstract Adipocytes might arise from vascular stromal cells, pericytes and endothelia within adipose tissue or from bone marrow cells resident in nonadipose tissue. Here, we identified adipose precursor cells resident in fascia, an uninterrupted sheet of connective tissue that extends throughout the body. The cells and fragments of superficial fascia from the rat hindlimb were highly capable of spontaneous and induced adipogenic differentiation but not myogenic and osteogenic differentiation. Fascial preadipocytes expressed multiple markers of adipogenic progenitors, similar to subcutaneous adipose-derived stromal cells (ASCs) but discriminative from visceral ASCs. Such preadipocytes resided in fascial vasculature and were physiologically active in vivo. In growing rats, adipocytes dynamically arose from the adventitia to form a thin adipose layer in the fascia. Later, some adipocytes appeared to overlay on top of other adipocytes, an early sign for the formation of three-dimensional adipose tissue in fascia. The primitive adipose lobules extended invariably along blood vessels toward the distal fascia areas. At the lobule front, nascent capillaries wrapped and passed ahead of mature adipocytes to form the distal neovasculature niche, which might replenish the pool of preadipocytes and supply nutrients and hormones necessary for continuous adipogenesis. Our findings suggest a novel model for the origin of adipocytes from the fascia, which explains both neogenesis and expansion of adipose tissue. Fascial preadipocytes generate adipose cells to form primitive adipose lobules in superficial fascia, a subcutaneous nonadipose tissue. With continuous adipogenesis, these primitive adipose lobules newly formed in superficial fascia may be the rudiment of subcutaneous adipose tissue. S tem C ells 2016;34:1407-1419 [ABSTRACT FROM AUTHOR]

Nonspecific lower back pain affects a major part of the population at a certain point of their life. The intensity of pain can be debilitating and it causes a significant burden on society. Trigger point dry needling is a method of alleviating such pain by the introduction of needles into trigger points in muscles. A growing body of evidence supports its use in myofascial pain and specifically lower back pain. Submarine Medicine is a unique field due to the special characteristics and the environment of the submarine. It poses challenges that are not always seen by primary care physicians. Here, we present a case of a 40-yr-old senior submarine officer who complained of pain in his lower back and pelvis before departing on a mission. The pain persisted in spite of treatment with nonsteroidal anti-inflammatory drugs and he was then treated by the submarine's physician with trigger point dry needling. The officer showed rapid improvement following this treatment, both regarding pain and the range of motion. [ABSTRACT FROM AUTHOR]

Genetic syndromes with dermatologic findings and multisystemic involvement (e.g., visceral cancer predisposition) are underrecognized. Patients may have incomplete penetrance and variable expressivity; some patients may solely exhibit subtle skin signs, which create a diagnostic challenge for physicians. Interdisciplinary diagnostic knowledge is required for the early diagnosis and monitoring of patients with these syndromes. Cutaneous changes in the face--one of the most highly exposed areas--can be easily noticed by patients themselves, their families and friends, and physicians; these changes may serve as early indicators of genetic syndromes with malignancies. In this article, we present examples of genetic syndromes with malignancies for which a thorough faciocutaneous examination is helpful in establishing a diagnosis. These examples include lentiginosis-related syndromes (e.g., Peutz-Jeghers syndrome, Carney complex), photosensitivity-related syndromes (Bloom syndrome, Rothmund-Thomson syndrome), and hamartoma-related syndromes (Cowden syndrome, multiple endocrine neoplasia syndrome, tuberous sclerosis complex, Gardner syndrome, Muir-Torre syndrome). The characteristics of these faciocutaneous clues are summarized and discussed. Objective evaluation of these faciocutaneous clues in combination with other clinical information (e.g., family history, histopathological findings, combination with other concomitant faciocutaneous lesions) is emphasized to narrow the diagnosis. The list of genetic syndromes with faciocutaneous manifestations is still expanding. Increased awareness of faciocutaneous markers can alert physicians to underlying syndromes and malignancies, render earlier screening and detection of associated medical issues, and allow for genetic counseling of family members. [ABSTRACT FROM AUTHOR]

Introduction. Gender reassignment requires total penile reconstruction, which is commonly performed with autologous tissue. One option for reconstruction is the free fibula osteocutaneous flap, which provides a long segment of vascularized bone that is less susceptible to infection and allows for deep penetration into the vagina during sexual intercourse. One problem, however, is that their sexual partner may suffer from pain (dyspareunia) because of the long and rigid bone. Aims. Our intent is to elucidate the treatment of female dyspareunia by surgically modifying the reconstructed penis with segmental osteotomies and fascia interposition within the rigid bone stock resulting from gender reassignment with a free fibula osteocutaneous flap. Methods. In order to improve their sexual relations and alleviate dyspareunia, a semirigid penis was created by forming a pseudojoint at the junction of the proximal and distal third of the fibula bone stock with osteotomies and fascia interposition. Main Outcome Measures. Alleviation of dyspareunia by surgical modification of a previously reconstructed penis for the couple to continue to have sexual relations. Results. The created pseudojoints in the reconstructed penis allowed for pain-free vaginal intercourse between the patient and his wife because of its now semirigid structure. Conclusions. The surgical modification presented in this case report addresses the treatment of dyspareunia by creating a more malleable penile reconstruction, which will now allow for a pain-free vaginal intercourse. Salgado C, Rampazzo A, Xu E, and Chen H-C. Treatment of dyspareunia by creation of a pseudojoint in rigid bone following total penile reconstruction with fibular osteocutaneous flap. J Sex Med **; **:**–**. [ABSTRACT FROM AUTHOR]

Background and method: Techniques for autologous repair of abdominal wall defects that could not be closed primarily are reviewed. Medline and PubMed were searched for English or German publications using the following keywords: components separation technique (CST), Ramirez, da Silva, fascia lata, tensor fasciae latae, latissimus dorsi, rectus femoris, myocutaneous flap, ((auto)dermal) graft, dermoplasty, cutisplasty, hernia, abdominal wall defect, or combinations thereof. Publications were analysed for methodological quality, and data on surgical technique, mortality, morbidity and reherniation were abstracted. Results and conclusions: The CST is the best documented procedure; it is associated with a high morbidity rate of 24.0 per cent and a recurrence rate of 18.2 per cent. Although the results of the da Silva technique are good (morbidity 5-20 per cent and reherniation 0-3 per cent), the poor methodological quality of the studies precludes firm conclusions. Repair with free fascia lata or dermal grafts is an alternative if the above techniques cannot be used, but wound complications affect 42 per cent of patients and recurrent hernia up to 29 per cent. Pedicled or free vascularized flaps are reserved for complex situations. [ABSTRACT FROM AUTHOR]

Background: A comprehensive understanding of fascial structures around the rectum is important for surgeons. Multilaminar fascial structures have provided different interpretations of reliable surgical planes in rectal surgery. Methods: Pelvic visceral materials for histological assessment were obtained from 12 male cadavers. Large specimens covering wide areas around the mesorectum were embedded in paraffin, followed by preparation of semiserial horizontal sections and sagittal sections for histological examination. Results: Histological examination demonstrated a prehypogastric nerve fascia and parietal presacral fascia in the retrorectal multilaminar structure. The parietal presacral fascia seemed to divide into several lateral continuations. The prehypogastric nerve fascia appeared to join the most medial continuation of the parietal presacral fascia, which continued ventrally and communicated with Denonvilliers' fascia. Any fascial structure connecting directly between the fascia propria of the rectum and the parietal presacral fascia (that is, the rectosacral fascia) was not found in sagittal sections. Conclusion: In the retrorectal multilaminar structure, prehypogastric nerve fascia is evident between the fascia propria of the rectum and the parietal presacral fascia. Sharp dissection in front of the prehypogastric nerve fascia according to the histological configuration of the posterolateral fasciae seems reliable. [ABSTRACT FROM AUTHOR]

Dupuytren's disease (DD) is a common progressive fibrotic condition affecting the palmar and digital fascia. Although its management is undertaken by hand surgeons, it is commonly seen by other doctors as an incidental finding. In many cases it is believed to be associated with other medical conditions, although the evidence for such associations is not always clear. This review considers the evidence behind these associations and discusses the aetiology of DD. By doing so, it is hoped that this review will permit a better understanding of the relevance of DD as a clinical sign. [ABSTRACT FROM AUTHOR]

Temporomandibular joint (TMJ) ankylosis is characterized by the formation of bony or fibrous mass, which replaces the normal articulation and limitation of mouth opening. This study aims to determine the efficacy of arthroplasty and inter-positional fascia flap in the treatment of unilateral and bilateral TMJ ankylosis in three young adult men. Our operative protocol for unilateral and bilateral TMJ ankylosis entailed resection of ankylotic mass, intraoral isolate and bilateral arthroplasty. interpositional tissue transfer to the TMJ with temporalis superficial fascia flap, maxillomandibular fixation. and early mobilization and aggressive physiotherapy. Early postoperative initial exercise, physiotherapy, and strict follow-up play an important role in preventing postoperative adhesions. The temporalis superficial facia flap is an autogenous graft that has the advantages of close proximity to the TMJ minimal surgical morbidity, and successful clinical results. It was found to be a valuable option for TMJ ankylosis reconstruction. [ABSTRACT FROM AUTHOR]

Background: Various randomized studies have evaluated techniques of abdominal fascia closure but controversy remains, leaving surgeons uncertain about the optimal method of preventing incisional hernia. Method: Medline and Embase databases were searched. All trials with a follow-up of at least 1 year that randomized patients with midline laparotomies to closure of the fascia by different suture techniques and/or suture materials were subjected to meta-analysis. Primary outcome was incisional hernia; secondary outcomes were wound dehiscence, wound infection, wound pain and suture sinus formation. Results: Fifteen studies were identified with a total of 6566 patients. Closure by continuous rapidly absorbable suture was followed by significantly more incisional hernias than closure by continuous slowly absorbable suture (P < 0.009) or non-absorbable suture (P = 0.001). No difference in incisional hernia incidence was found between slowly absorbable and non-absorbable sutures (P = 0.75), but more wound pain (P < 0.005) and more suture sinuses (P = 0.02) occurred after the use of non-absorbable suture. Similar outcomes were observed with continuous and interrupted sutures, but continuous sutures took less time to insert. Conclusion: To reduce the incidence of incisional hernia without increasing wound pain or suture sinus frequency, slowly absorbable continuous sutures appear to be the optimal method of fascial closure. [ABSTRACT FROM AUTHOR]

To determine the incidence and diagnostic relevance of non-fatty 'solid appearing' components within lipomatous tumours of the trunk and extremity. Retrospective review of patients referred to a specialist musculoskeletal oncology service over a 12-month period with a lipomatous trunk or extremity soft tissue tumour. The presence and morphology (solitary/multifocal; homogeneous/heterogeneous; well-defined/poorly defined) of non-fatty components was recorded based on MRI and compared with the final histological diagnosis. 213 patients with 217 lipomatous tumours were included, 119 (55.9%) males and 94 (44.1%) females with mean age of 54.6 years (range 7–93 years). Seventy-seven (35.5%) lesions arose superficial to the fascia and 139 (64.1%) deep, while a single case involved both compartments. Mean maximal tumour dimension was 94.9 mm (range 12–288 mm). Non-fatty 'solid appearing' components were identified in 28 (12.9%) cases, of which eight were solitary and 20 were multifocal, six had homogeneous SI and 22 had heterogeneous SI, and eight had well-defined margins, while 20 had poorly defined margins. Histological diagnosis was available in 20 of the tumours containing non-fatty components, 16 of which were benign, two intermediate grade and two malignant (a dedifferentiated liposarcoma and a myxoid liposarcoma). The commonest diagnosis was spindle cell lipoma, which accounted for 10 of 20 (50%) cases with confirmed histology. Non-fatty components are identified in ~13% of trunk and extremity lipomatous tumours. The majority of such lesions are benign lipoma variants, most commonly spindle cell lipoma. Solid non-fatty components are identified in approximately 13% of lipomatous tumours referred to a specialist sarcoma service. Despite the concern that these may represent dedifferentiated liposarcomas, high-grade tumours were seen in only two cases, the commonest diagnosis being a spindle cell lipoma. [ABSTRACT FROM AUTHOR]

Sixteen patients had biopsy-proved inflammatory sclerosis of the panniculus or fascia, which usually was seen in a generalized distribution. Although the sclerosis involved the digits of five patients, it was the result of centrifugal spread of the sclerosis and was not accompanied by ulcers, calcinosis, distal phalangeal resorption or telangiectasia. Four patients may have had digital vasopasm in the extremities involved in the sclerotic process. Five patients also had cutaneous lesions of dermal morphoca or lichen sclerosus et atrophicus. Four patients had a reduced carbon monoxide diffusing capacity, and one of these had roentgenographic evidence of pulmonary fibrosis. In three patients, oesophageal motility or barium swallow studies showed evidence of scierodermatous changes. The sclerotic process was a contributory cause of the death of one patient. Five patients had peripheral eosinophilia. Six patients seemed to have responded to anti-inflammatory agents. We believe that subcutaneous morphoea is generally more inflammatory than generalized morphoea of the dermal type and may be more likely to progress to mild systemic sclerosis. We suggest that response of subcutaneous morphoea to anti-inflammatory agents is simply a reflection of the degree of inflammation present. [ABSTRACT FROM AUTHOR]

A 53-year-old woman developed swelling of her hands after strenuous sport. Soon her feet became affected and the swelling spread up the arms and legs making arm movement and walking difficult. No Raynaud's phenomenon appeared or other features of systemic sclerosis. There was eosinophilia and hypergammaglobulinaemia in the peripheral blood. Histological examination of the skin showed an increase in the collagen bundles in the dermis extending down to the adipose tissue. The fascia showed dense fibrous tissue with a perivascular infiltrate of lymphocytes, a few plasma cells and eosinophils. Immunohistology of the skin and fascia were negative for EgA, EgG, IgM, C3/, CIq and fibrin. After 4 weeks of prednisolone 40 mg daily there was a great improvement. This continued with further corticosteroid therapy. [ABSTRACT FROM AUTHOR]

The article presents a case of a 58-year-old male who was rushed to a clinic due to 2-month history of cutaneous oedema and painful subcutaneous progressive hardening of his legs, trunk and forearms. Based on histological examination, he has thickened fascia with infiltration of lymphohistiocyte and plasma cells. He was diagnosed with eosinophilis fasciitis and was treated with prednisone, corticosteroid, and methotrexate.

Eosinophilic fasciitis (EF) is a connective-tissue disease characterized by thickened fascia. Involvement of the dermis may occur during the progression of the disease, characterized clinically by morphoea-like plaques (MLPs). This more superficial feature of EF carries a poor prognosis, suggestive of refractory EF that requires intensive therapy. We report a case in which morphoea-like plaques occurred before the EF. This case and previous cases of MLPs show some differences between MLPs and classic morphoea. Clinically, MLPs present with ill-defined brown plaques, with no lilac ring or ivory colour. Histologically, there is a more marked inflammatory infiltrate and an increase in the number of eosinophils. The discovery of MLPs at an early stage should prompt examination of the fascia with magnetic resonance imaging or surgical biopsy, and aggressive treatment. [ABSTRACT FROM AUTHOR]

Chemical shift artefact (CSA) is often encountered during MRI evaluation of superficial soft tissue masses. The study aim was to determine the incidence and diagnostic relevance of CSA in a consecutive series of superficial soft tissue masses referred to a specialist musculoskeletal sarcoma service. All patients referred over a 6 month period with a non-lipomatous superficial soft tissue mass were prospectively analysed. Patients characteristics (age, gender), lesion features (anatomical location, size, relationship to the skin and deep fascia), presence of CSA and final histopathological diagnosis were collected. The presence of CSA was statistically analysed against these clinical, imaging and histopathological variables. 128 patients fulfilled the inclusion criteria [63 males, 65 females; mean age = 50.6 years (7–96 years)]. CSA was present in 50 cases (39.1%) overall, but in 39 (41.5%) of 94 cases with histological diagnosis. There was no statistically significant relationship to any assessed variable apart from relationship to the deep fascia, CSA being more frequent in lesions contacting the fascia compared to lesions contacting both skin and fascia (p-value 0.02). In particular, the presence of CSA did not allow differentiation between non-malignant and malignant lesions. The presence of CSA is a not infrequent finding in the MRI assessment of superficial soft tissue masses but does not appear to be of any significance in differentiating between non-malignant and malignant lesions. CSA is a relatively common finding in association with superficial soft tissue masses, but does not indicate a particular histological diagnosis or help in the differentiation of non-malignant from malignant lesions. [ABSTRACT FROM AUTHOR]

One of the most common causes of a failed Nissen fundoplication is disruption of the crural repair. We investigated the thickness of the subdiaphragmatic fascia overlying the right and left limb of the right crus in cadavers to determine any difference. Sub-diaphragmatic fascia specimens were obtained from three sites adjacent to the hiatus in 20 preserved cadavers. One square centimeter of fascia was excised 3 cm from the arch of the hiatus on each side and approximately 2–3 mm from the edge of the hiatal opening (labeled RL and LPL). A third sample was taken 1 cm from the arch of the hiatus on the left side (labeled LAL). The thickness of these tissues was measured. The mean tissue thickness of RL, LPL and LAL were 0.22 mm, 0.23 mm and 0.4 mm, respectively. There was no difference in tissue thickness between the lower specimens on both sides (RL vs. LPL); however, LAL was significantly thicker than both RL and LPL ( P < 0.05). The thickness of the subdiaphragmatic fascia overlying the right and left limb of the right crus does not differ significantly in the region used for crus closure during antireflux surgery; however, the fascia on the left is thicker anteriorly. [ABSTRACT FROM AUTHOR]

The article presents abstracts of research on sexual medicine. They include "Use of rectus fascia graft for corporeal reconstruction during implantation of penile prosthesis in Peyronie's disease," "Surgical treatment of Peyronie disease using ecxision of the plaque," "Nesbit straightening corporoplasty, guided by dynamic pharmacoinfusion alternated with saline solution infusion," "Congenital penile curvature" and "Penile carcinoma-organ sparing surgery."

Describes the performance of total mesocorectal excision for rectal cancer through the dissection in from of Denonvillier's fascia. Novel appreciation of the surgical and anatomical detail of the mesorectum; Preoperative visualization of the anatomy through magnetic resonance imaging; Consideration of sexual potency.

An introduction is presented in which the editor discusses articles in the issue on topics including cutaneous physical signs related to cutaneous disorders; a report of a patient with tuberous sclerosis complex (TSC); and association of TSC genes or mammalian target of rapamycin (mTOR) pathway and neoplasia.

Component separation is established for complex hernia repairs. This case presents early component separation and release of the anterior and posterior sheath to facilitate closure of the abdominal wall following emergency laparotomy, reinforcing the repair with a biological mesh. On Day 11 following an emergency laparotomy for penetrating trauma, this patient underwent component separation and release of the anterior and posterior sheath. An intra-abdominal biological mesh was secured, and the fascia and skin closed successfully. Primary abdominal closure can be achieved in patients with penetrating abdominal trauma with the use of component separation and insertion of intra-abdominal biological mesh, where standard closure is not possible. [ABSTRACT FROM AUTHOR]

Explains an experience with routine monitoring of intracompartmental pressure and selective fasciotomy in minimally invasive osteosynthesis of tibial fractures. Acute compartment syndromes; Preoperative clinical examination; Selective fasciotomy can be performed safely if intracompartmental pressure is measured during surgery.

Presents a study on the use of dynamic real-time magnetic resonance imaging in diagnosing groin pain of obscure etiology. Determination of defect in the fascia transversalis; Revelation of occult hernia in several patients; Capability of differentiating clinically apparent and occult groin hernia from musculotendinous injuries.

Discusses a detailed account of the anatomy of Denonvilliers' fascia and pelvic innervation, in a study published in the 2000 'British Journal of Surgery,' vol. 87. Differences in the anatomy of Denonvilliers' fascia between men and women; Importance of the fascia to colorectal surgeons.