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Dupuytren disease is a benign fibroproliferative disease of the palmar aponeurosis, which can cause considerable functional deficiencies for the person concerned. Partial aponeurectomy is the gold standard in primary surgery. Because it is minimally invasive and has short recovery and low complication rates, the importance of needle aponeurotomy under specific indications has been increasing in the last years. Needle aponeurotomy is a cost-effective treatment with low complication rates. The revision rate compared to partial aponeurectomy is higher. Under consideration of specified indications, needle aponeurotomy is an alternative treatment option.

The exact knowledge of the anatomy of the fibrous skeleton of the hand is an absolute prerequisite for any treatment of Dupuytren's disease. The fibrous skeleton does not only include the palmar aponeurosis, but also numerous retinacula cutis, which are not found in current anatomy books. Here, eponyms facilitate the otherwise difficult and over-pronounced names of the fiber systems. Skoog, Legueu and Juvara, Gosset, Grapow, Grayson, Cleland, Thomine, and Barton are the most important. This systematic review of the fibers and strands is designed to help reduce iatrogenic complications.

Partial aponeurectomy as the state-of-the-art treatment in Dupuytren's disease is indicated when minimally invasive forms of treatment, such as needle aponeurotomy or percutaneous collagenase injection, are not possible due to the advanced stage of the disease or the morphology of the contracture. Even in earlier stages of Dupuytren disease partial aponeurectomy has advantages in comparison to minimally invasive forms of treatment. These advantages are lower recurrence rates as well as less persistent residual contractures, especially in the proximal interphalangeal joint.

Background: Secondary peritonitis causes considerable mortality and morbidity. New strategies have been introduced like relaparotomy and temporary abdominal closure in the management of such persistent intra-abdominal infections., Materials and Methods: Rats were divided into five groups each having ten animals. After induction of peritonitis, relaparotomies were done, and the abdomen was closed by different temporary abdominal closure techniques. After performing two relaparotomies during a 48-h period, all fascias closed primarily and incisional tensile strengths, hydroxyproline contents, and adhesions were measured on the following seventh day., Results: The median values of tensile strength and hydroxyproline concentrations were lowest in skin-only closure rats. Intraperitoneal adhesion scores were highest in Bogota bag closure group., Conclusion: Primary, Bogota bag, and polyprolene mesh closures seem to be safe in terms of early fascial wound healing. Although it is easy to perform, skin-only closure technique has deleterious effects on fascial wound healing probably due to fascial retraction. Interestingly, Bogota bag has caused increased intraperitoneal adhesion formation.

Little study has investigated the ischemic injury of mature adipocytes. This study researched the effects of different ischemic times on fat histology the 7th postischemic day in a rat epigastric flap model. For this study, 24 rats were randomly divided into four groups subjected, respectively, to 1, 2, 3, and 4 h of ischemia. The most severe inflammation and fat necrosis scores were seen in groups 3 and 4 (p < 0.05). According to the findings of this study, it is possible to say that fat tissue undergoes a gross necrosis after 3 or more hours of ischemia. After that ischemic time, the necrotic volume of fat tissue subjected to ischemic insult does not increase with increased ischemic time.

Background: The almost unknown stylopharyngeal fascia may be one of the reasons for unsuccessful therapy of the trigeminal neuralgia by a transoral block of the superior ganglion of the sympathetic trunk. We investigated the anatomy of the fascia to show the efficiency of the block for this therapy., Materials and Methods: 103 halves of human heads were investigated. The stylopharyngeal fascia was dissected by a lateral approach. We classified three groups. Group A was formed by fascias without perforation, group B by perforated fascias and group C by all halves without a developed fascia., Results: We found a fully developed fascia in 86 cases. 13 halves had perforated fascias; in 4 cases the fascia was not developed., Conclusion: The stylopharyngeal fascia may inhibit the distribution of opoids into the infratemporal fossa associated with a consecutive block of the mandibular nerve and lower the rate of pain relief.

The use of vacuum assisted closure (V.A.C.) therapy in postoperative infections after dorsal spinal surgery was studied retrospectively. Successful treatment was defined as a stable healed wound that showed no signs of acute or chronic infection. The treatment of the infected back wounds consisted of repeated debridement, irrigation and open wound treatment with temporary closure by V.A.C. The instrumentation was exchanged or removed if necessary. Fifteen patients with deep subfascial infections after posterior spinal surgery were treated. The implants were exchanged in seven cases, removed completely in five cases and left without changing in one case. In two cases spinal surgery consisted of laminectomy without instrumentation. In two cases only the wound defects were closed by muscle flap, the remaining ones were closed by delayed suturing. Antibiotic treatment was necessary in all cases. Follow up was possible in 14 patients. One patient showed a new infection after treatment. The study illustrates the usefulness of V.A.C. therapy as a new alternative management for wound conditioning of complex back wounds after deep subfascial infection.

Late intracapsular seroma and hematoma have been described frequently as a complication of breast augmentation surgery. However, there are few reports of late intracapsular seroma in buttock augmentation. Textured and polyurethane implants have been used for subfascial enlargement of the buttocks. In this article, the authors report a large late intracapsular bilateral seroma caused by a retrofascial polyurethane-covered implant used for buttock augmentation: 1,200 ml on one side and 300 ml on the other. This patient's intracapsular seroma was of sudden onset 2 years and 6 months after surgery, and apparently had no relation to any trauma, use of medication, or physical exercise. Local tissues, including the gluteal fascia, were distended such that the implant was replaced inside the muscle and there was no relapse of the seroma. Late intracapsular hematomas or seromas from implants for buttock and breast augmentation may have the same etiology, and textured implants seem to be involved. All the reports on the matter are associated with textured implants. Any late seroma or hematoma caused by a smooth implant is related to an additional factor that may be considered as the etiologic agent. Further studies aimed at a large-scale assessment of the cause and actual incidence of late seromas and hematomas from textured implants are required.

Purpose: We report the first case of subconjunctival mucosa-associated lymphoid tissue (MALT) lymphoma arising in Tenon's capsule (fascia bulbi)., Methods: A 75-year-old woman presented with painless swelling of the superior bulbar conjunctiva in her left eye. During the biopsy of the bulbar lymphoid lesion, it was noticed that the conjunctiva was movable and that the lesion was located in the subconjunctiva. The tissues were studied by conventional light microscopy, immunohistochemistry, flow cytometry, and gene rearrangement analysis., Results: Histopathological examination revealed that a diffuse lymphoid infiltrate consisting of small-sized lymphoid cells was present in Tenon's capsule but not in the substantia propria of the conjunctiva. Immunohistochemical and flow cytometric studies documented tumor cells of B-lymphocyte lineage. Molecular analysis demonstrated positive immunoglobulin heavy chain gene rearrangement. The final diagnosis was subconjunctival MALT lymphoma arising in Tenon's capsule., Conclusion: Ophthalmologists and pathologists need to distinguish the subconjunctival lymphoma that arises in Tenon's capsule from the conjunctival lymphoma in the substantia propria during diagnosis of epibulbar lymphoid tumors.

Recently, fat injection has gained favor among plastic surgeons for soft tissue augmentation. However, fat injections lose 50% of their volume after 1 year. The profession is in need of an injectable bulking material that gives a long-lasting improvement. Using 30 male rats, this study investigated the stability of the size and structure of the injected fascia autograft and compared it with surgically transplanted fascia. The fascia graft was harvested from the back of the rat, big, and divided into two equal pieces. The first piece was minced into a paste and injected subcutaneously on the anterior surface of the right ear. The other piece was transplanted subcutaneously on the anterior surface of the left ear. The grafts were observed for any sign of resorption over 1 to 6 months.Grossly, injection and transplantation sites were palpable at the end of the observation periods. Microscopic examination showed that injected fascia maintains its histomorphologic structure. These findings indicate that the injected fascia graft is well tolerated, and the size of the graft remained stable. According to this study, fascia injection can result in bulking material that gives a long-lasting improvement, and can be a viable alternative to other methods.

The aim of this study was to evaluate whether differences in the quantity of elastic fibres, collagen type I and collagen type III in the endopelvic fascia occur with female stress urinary incontinence (SUI). A total of 54 patients participated in the study. They were divided into two groups (continent and incontinent) that were comparable with respect to age and parity. All patients underwent gynaecologic surgical procedures and biopsies from the endopelvic fascia were obtained. Histological slides were stained with haematoxylin and eosin and Masson trichrome or Weigert's techniques and immunohistochemistry for either collagen type I or type III were performed. The elastic fibres constituted 3.81+/-0.6% and 5.93+/-0.92% of the cross-sectional area of the endopelvic fascia in incontinent and control groups of patients, respectively. Collagen type I and type III were not significantly reduced in patients with SUI. Our results suggest that the quantity of elastic and collagen fibres in the endopelvic fascia does not play a significant role in continence.

Necrotizing fasciitis is a soft tissue infection with a lethality ranging up to 80%. Infection causes the activation of interleukin, tumor necrosis factor alpha, and gamma-interferon through a triggering mechanism. This results in a capillary thrombosis with necrosis of the fascia, cutis, and subcutis. The patient's history often reveals a triggering event in the form of a recent minimal trauma or operative procedure. In a fulminant necrotizing fasciitis, the development of sepsis with consecutive multiple-organ failure mainly determines the outcome of the disease. Diagnosis is made initially upon clinical findings with a rapid progression of the disease and confirmed later by histologic and microbiologic findings. Radical surgical debridement within the first 24 h with postoperative treatment in an intensive care unit represents the cornerstone of therapy. Between January 1992 and March 2001, we treated 15 patients with necrotizing fasciitis. Lethality was 33%. There was a significant correlation between risk factors (present in 86% of the patients) and morbidity. Diagnosis and therapy should be performed by an experienced surgeon. In this contribution, we discuss the most important criteria that lead to the diagnosis and the therapeutic consequences.

The palmar fibromatosis holds the finger in the flexed position--extension inhibition rather than contraction. According to this extrinsic concept, only a passive, secondarily reactive effect can be attributed to the palmar aponeurosis. Out of 72 hands examined 5 or more years after an operation in which the aponeurosis had been left intact, 47% proved to be clear of disease.

The perivertebral space is in the midline, in the deep tissues of the neck, and can be identified from the skull base above to the mediastinum below. It is a discrete space completely enclosed by the deep layer of deep cervical fascia. The fascial attachments of the perivertebral space divide it into two areas, the anterior prevertebral and posterior paraspinal portions. We made a retrospective analysis of the radiologic and clinical records of 52 patients with lesions in the perivertebral space, to identify the imaging features that mark a lesion as originating in the perivertebral space and define the spectrum of pathology which occurs in the space. Mass lesions present in the prevertebral or paraspinal portions. In the former they usually involve the vertebral body, displacing the prevertebral muscles anteriorly. Epidural extension from lesions in the perivertebral space proper is common. Masses in the paraspinal perivertebral space usually displace the paraspinal muscles away from the spine. We found 9 inflammatory lesions, 29 malignant and 6 benign tumors, and 8 miscellaneous lesions.

In the past few years great effort has been made to reduce the morbidity after oncologic operations in the small pelvis of the male. In this respect it is essential for urologic surgeons to orient themselves with the anatomic structures that mark the course of the important vessels and nerves. For this reason an anatomic study of the connective tissue in the male pelvis was performed in which dissections and serial sections were analyzed. The results show that the connective tissue in the male pelvis does not represent a monomorphic block but consists of several portions of varying density. The looser portions are also known as the "connective tissue spaces" of the pelvis. The comparatively dense portions--the so-called "vessel-nerve guiding plate" and its three "connective tissue pillars"--envelop the vessels and nerves supplying the corresponding pelvic organs. Therefore, they provide ideal landmarks for urologic surgery.

Polyneuropathy may complicate eosinophilia-associated connective tissue disease. We report a multi-focal neuropathy in a patient with eosinophilic fasciitis proven by demonstrating an eosinophilic cellular infiltrate in a fascial biopsy specimen from the forearm. Sural nerve biopsy revealed lymphocytic cuffing of epineural arterioles. Although described in the L-tryptophan-related eosinophilia-myalgia syndrome, peripheral neuropathy with these features has not been previously noted in a patient with eosinophilic fasciitis who had not consumed L-tryptophan.

Conservative therapy of Peyronie's disease has not given very encouraging results. This means operative treatment strategies are the only effective therapy form that appears to be successful. Another treatment form, which often leads to a non-acceptable shorting of the penis, is the technique used in the Schröder-Essed and Nesbit procedures. Removal of the plaque, followed by a tissue transplant to cover the excision area, enables a correction of the deviation and maintenance of the original length of the penis. Because of the periodically described, possibly fatal results of postoperative perception disorders of the glans penis, preparation of the dorsal neurovascular bundle is performed under microsurgical conditions. Because of the certainty with which optical identification of nerves and vessels is achieved, it is possible to keep the nerves protected and to have atraumatic isolation of the plaque. After the first encouraging surgical results, we present the operative procedure under microsurgical conditions.

Two cases of the so-called fascial analogue of myositis proliferans were investigated by histological and electron microscopic methods. It was found that the structure of the fascial variant corresponds almost completely to the true myositis proliferans localized within the musculature. The electron microscopic observations show a preponderantly histiocytic differentiation of the cells and strongly activated proliferating capillaries, and exclude a myogenic origin of the characteristic ganglion-like giant cells. Ultrastructurally a traumatic genesis appears possibly, the cells of the lesion could derive from multipotent cells of the microvasculature. The relations to myositis ossificans and fascitis nodularis are discussed.

Nodular fasciitis (NF) shows a cellular proliferation which leads to widening of the fascia. Frequently unilateral or more often bilateral disruption of the fascia, with an infiltrative pattern is present. Subcutaneous fascia and surrounding fat are involved. Superficially the cellular proliferation may extend into dermal connective tissue. Deeper muscular tissue may be involved, with transitional forms or purely intramuscular changes, compatible with proliferative myositis. Proliferative myositis is considered to be a deep-seated variant of NF with muscular involvement. Intramuscular myxoma may be thought of as an intramuscular and mucoid variant of NF. A bilateral infiltrative pattern was most frequently found at all levels; in cases with muscular involvement it was always present.

The case history of a patient with subcutaneous emphysema of the abdomen from sigmoid diverticulitis is presented. The mechanisms for developing abdominal wall emphysema are reviewed. Thus when the gas originates from the gastrointestinal tract, mechanical factors are mainly responsible for this phenomenon. These inculde a direct communication through a colonocutaneous fistula. Gas may, however, also be spread into the abdominal wall by high intraintestinal pressures. Infection with gas-producing organisms may be associated with subcutaneous emphysema. This is particularly true when the emphysema develops 48 h or longer after onset of symptoms. Infection, however, is not the major cause for gas in these tissues.