Hierarchical structure of Five-shu points and Source-point of Triple Energizer Meridian in rabbits

The article presents anatomical features of the superficial and deep fascia, in particular on the pelvic limb of the common lynx, which are absent in the available literature. The material for the research was a sectional material - pelvic limbs (n= 6), selected from the common lynx, without external signs of pathologies of the musculoskeletal system. Methods of fine macro- and microanatomic dissection of the lynx's left pelvic limb were used. At the same time, a functional analysis of the studied structures and skeletotopic projection of muscles, fascia and fascial nodes were carried out. Based on the conducted studies, it was found that the deep fascia is separated from the superficial fascia by an interfacial space filled with loose connective (or fatty) tissue. In the pelvic limb area, it is represented by the gluteal-femoral fascia, and on the lower leg it continues as the deep fascia of the lower leg. In the process of dissecting the deep fascia, we noted that in the gluteal region, the deep gluteal fascia is fixed on the supracosteal ligament, in the area of the root of the tail, along the tail fold and up to the sciatic tubercle. We noted that the deep gluteal fascia begins from the vertebral head of the biceps femoris muscle and, in the cranial direction, covers successively the posterior, superficial gluteal and caudal part of the middle gluteus muscle. Along the way, the perimysium of the above muscles are interwoven into it, however, in the area of the iliac wing, it fuses with the perimysium of the middle gluteal muscle and then continues into the lumbar fascia. At the same time, it forms a fascial node in the maklok area. Distally, the deep gluteal fascia continues as the deep femoral fascia. The data obtained are the reference in assessing the structural and functional state of the fascial formations of the pelvic limb in the common lynx.

Fascia has traditionally been described as a passive connective tissue mainly composed of collagen types I and III. Recent research, however, has revealed its structural and functional complexity, suggesting the possible presence of additional collagen types. This study aimed to quantify the presence and distribution of collagen types I, III, VI, and XII in human superficial and deep fasciae to improve understanding of fascial extracellular matrix composition. Superficial and deep fascia samples were collected from 19 adult patients (ages 20–83 years; thigh and lumbar area). Histology, Azan Mallory staining, hydroxyproline quantification, Western blotting, and immunohistochemistry were performed. The results indicated that deep fascia contained significantly more total collagen than superficial fascia (0.55 ± 0.17 µg/mg vs. 0.36 ± 0.14 µg/mg, p < 0.01). Collagen type VI was the most abundant and widely distributed subtype in both superficial and deep fasciae (mean ratio equal to 0.24 ± 0.13 and 0.27 ± 0.10, respectively), nearly double that of collagen types I (0.12 ± 0.07 and 0.11 ± 0.08), III (0.13 ± 0.09 and 0.17 ± 0.11), and XII (0.13 ± 0.11 and 0.13 ± 0.04). Moreover, statistically significant anatomical differences were observed, despite considerable interindividual variability. Fasciae from the thigh showed higher levels of collagen types I and III (mean ratio of 0.17 and 0.27, respectively, in deep fascia; 0.14 for both types in superficial fascia), whereas fasciae of the lumbar region exhibited greater levels of collagen types VI and XII (ratio equal to 0.33 and 0.15, respectively, in deep fascia; 0.36 and 0.20 in superficial fascia). Overall, these findings highlighted the structural complexity and regional specialization of human fasciae, with potential functional implications for mechanotransduction and tissue adaptation.

Fusion zones between superficial fascia and deep fascia have been recognized by surgical anatomists since 1938. Anatomical dissection performed by the author suggested that additional superficial fascia fusion zones exist. A study was performed to evaluate and define fusion zones between the superficial and the deep fascia. Dissection of fresh and minimally preserved cadavers was performed using the accepted technique for defining anatomic spaces: dye injection combined with cross-sectional anatomical dissection. This study identified bilaminar membranes traveling from deep to superficial fascia at consistent locations in all specimens. These membranes exist as fusion zones between superficial and deep fascia, and are referred to as SMAS fusion zones. Nerves, blood vessels and lymphatics transition between the deep and superficial fascia of the face by traveling along and within these membranes, a construct that provides stability and minimizes shear. Bilaminar subfascial membranes continue into the subcutaneous tissues as unilaminar septa on their way to skin. This three-dimensional lattice of interlocking horizontal, vertical, and oblique membranes defines the anatomic boundaries of the fascial spaces as well as the deep and superficial fat compartments of the face. This information facilitates accurate volume augmentation; helps to avoid facial nerve injury; and provides the conceptual basis for understanding jowls as a manifestation of enlargement of the buccal space that occurs with age.

Key risk factors for hypertrophic scarring and surgical-site infections are high-tension wounds, fat necrosis, and dead space. All could be prevented by appropriate superficial fascia suturing. However, the as-yet poorly researched anatomy of the superficial fascia should be delineated. This study is the first to quantify the superficial fascia throughout the human body in vivo. Ultrasound was used to analyze the superficial and deep fascia of 10 volunteers at 73 points on 11 body regions, including the upper and lower trunk and limbs. Number, thickness and percentage of superficial fascia layers, and deep fascia and dermis thickness, were measured at each point. Seven hundred thirty ultrasound images were analyzed. Body regions varied markedly in terms of subcutaneous variables. Posterior chest had the thickest deep fascia and dermis and the highest average superficial fascia layer thickness [0.6 mm (95 percent CI, 0.6 to 0.7 mm)]. Anterior chest had the most superficial fascia layers [3.7 (95 percent CI, 3.5 to 3.8)]. Posterior and anterior chest had among the highest percentage of superficial fascia. Abdomen and especially gluteus had a low percentage of superficial fascia. Covariate analyses confirmed that posterior and anterior chest generally had higher superficial fascia content than gluteus and abdomen (both p < 0.001). They also showed that the dermis in the posterior and anterior chest increased proportionally to total fascia thickness. The superficial fascia, deep fascia, and dermis tend to be thick in high-tension areas such as the upper trunk. A site-specific surgical approach is recommended for subcutaneous sutures. Understanding the anatomical distribution of the superficial fascia and deep fascia will help surgeons optimize subcutaneous fasciae suturing, thereby potentially reducing the incidence of surgical-site infections and hypertrophic scars.

Purpose:Surgical Site Infections (SSIs) and Hypertrophic scars (HSs) are the most common complications of wound healing. Most SSIs are superficial infections involving the skin and subcutaneous tissue (SQ) only. Abnormal scaring is driven by ongoing dermal inflammation in high skin tension areas (e.g. anterior and posterior chest). For prevention, proper suturing techniques are required, in particular for subcutaneous adipose tissue, to reduce high skin stretching tension and prevent ischemia. While adipose lobules cannot be sutured, superficial fascia (SF) -the membranous structure of adipose stroma- must be sutured. However, the exact anatomy and characteristics such as number and thickness of SF throughout the body regions are still lacking. This is the first study to present a detailed quantitative analysis of SF anatomy. We believe such details will help in optimization of subcutaneous sutures.Methods:Superficial and deep fascia (DF) were analyzed using ultrasound imaging in predefined 73-point locations, distributed among eleven body regions of ten healthy male volunteers; Anterior chest: 9 points, abdomen: 10, posterior chest: 9, lumbar region: 6, gluteus: 2, arm: 8, elbow: 3, forearm: 8, thigh: 9, knee: 3 and leg: 6. Using ImageJ software, thickness of SF and DF layers, dermis and SQ were measured along SF percentage. Three random measurements were taken for each variable then averaged and used this average for statistical analysis. In addition, number of SF layers was counted, total thickness of SF was calculated by summing the average thickness of all SF layers and total membranous layers thickness by summing total SF and DF thicknesses.Results:Overall, 730 means were analyzed with multilevel mixed linear model for all variables except average layer thickness of SF which had 1635 means; since each point had one or more layers of SF. DF and dermis were significantly thickest in posterior chest region which had the highest layer thickness of SF measuring 0.64 ± 0.01 mm. Anterior chest and gluteus had the highest content of SF due to having the highest layers number (3.67 ± 0.08, 3.45 ± 0.143), yet significantly thickest gluteus SQ and lowest SF percentage. SF changed inconsistently within subcutaneous adipose tissue; SF, DF and dermis jointly handles stretching tension, therefore, to understand the effect of environment, analysis of the variable’s interaction was performed and showed significant accelerated increase in the thickness of SF and dermis in anterior and posterior chest as compared to lower tension regions (all p<0.001).Conclusion:Our results showed that dermis and subcutaneous membranous layers tend to be thick in the high-tension areas such as the upper trunk. It was suggested that SSIs and HSs could be prevented by realizing the tension applied on the operated area; finding then suturing the membranous layers during the operation.

Surgical Anatomy of the Mandibular Region for Reconstructive Purposes

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)

BackgroundIn last years the role of fascia in proprioception and pain has been confirmed in numerous papers, but the real structure of fasciae is not still entirely known. To date, many studies have evaluated the elastic fibres in arteries, ligaments, lungs, epidermis and dermis, but only two studies exist about the elastic fibres in the fasciae, and they did not distinguish between superficial (in the subcutaneous tissue) and deep/muscular fasciae. The aim of the study was to assess the percentage of elastic fibres between superficial and deep fascia.Materials and methodsThree full thickness specimens (proximal, middle and distal respectively) were taken from each of four regions of the thigh of three non‐embalmed cadavers: the anterior (Ant), the lateral (Lat), the posterior (Post) and the medial (Med) aspect. Thus, a total of 12 specimens were collected from each analysed thigh and histological Weigert Van Gieson stains was performed. Three sections per specimen were considered for the morphometric analysis.ResultsIn all the specimens the superficial and deep fasciae were clearly recognizable. The difference in percentage of elastic fibres between superficial and deep fasciae in same region for all four was highly significant (p < 0.001). They are abundant in the superficial fascia than deep fascia.ConclusionsIn the light of these findings is evident that the superficial (in the subcutaneous tissue) and deep fasciae have different elasticity. This difference may improve grading of fascial dysfunction in dermatological diseases as burns, scars and lymphedema to better plan treatments.

The origins and validity of the term "superficial musculoaponeurotic system" (SMAS) is reviewed. Gray stated the superficial fascia connects the skin with the deep or aponeurotic fascia and consists of fibro-areolar tissue. Hollinshead wrote superficial fascia exists throughout the body and contains a variable amount of fat. In the head and neck, it encloses voluntary muscles in its deep portion. Skoog found superficial fascia was fixed to the dense, deep fascia by fibrous adhesions in the temporal, preauricular, and parotid area. Mitz stated "There is a 'superficial muscular and aponeurotic system' (SMAS) in the parotid and cheek areas." SMAS has an intimate relationship with the entire superficial fascia of the head and neck and divides the subcutaneous fat into 2 layers. Wassef found a continuous fibromuscular layer at the deep limit of the "subcutis," which corresponded to the "superficial fascia." Nakajima reported the subcutaneous adipofascial tissue was made up of 2 adipofascial layers. Macchi found 2 different fibroadipose connective layers bounded to the laminar connective tissue layer (SMAS). In the cheek, Hwang found horizontal fibrous connective tissues (membranous layer of superficial fascia) divided the superficial fascia into the superficial fatty layer and the deep fatty layer. Recently, Mitz explained the reason for the term SMAS. The "musculo+aponeurotic" component is based on histology of muscle cells, including the risorius, in the same structure to be surgically consistent. The aponeurotic cells belong to the same surgical layer. SMAS is not sufficient to replace the old term "superficial fascia" of the cheek area.

This paper examines the main characteristics of the human fascial system, considered in its three-dimensional continuity. To better understand the anatomy of the human fascial system, a simple diagram of the subcutaneous tissue must be borne in mind. From the skin to the deepest plane, we find the superficial fascia, dividing the subcutaneous tissue into two fibroadipose layers, superficial and deep, and the deep fascia, which envelops all the muscles of the body, showing different characteristics according to region. Under the deep fascia is the epimysium, occurring in the limbs and some regions of the trunk. Skin ligaments connect the superficial fascia to the skin and to the deep fascia, forming a three-dimensional network among the fat lobules. The typical features of the superficial and deep fasciae and their relationships to nerves, vessels and muscles are reported here, highlighting the possible role of the deep fascia in proprioception and peripheral motor coordination. The main features of the fasciae with imaging techniques are also discussed. This knowledge may contribute to clinicians' understanding of the myofascial system and the role which the deep fasciae may play in musculoskeletal dysfunctions.

Ultrasound (US) imaging is increasingly the most used tool to measure the thickness of superficial and deep fasciae, but there are still some doubts about its reliability in this type of measurement. The current study sets out to assess the inter-rater and intra-rater reliability of US measurements of superficial and deep fasciae thicknesses in the arm and forearm. The study involved two raters: the first (R1) is an expert in skeletal–muscle US imaging and, in particular, the US assessment of fasciae; the second (R2) is a radiologist resident with 1 year’s experience in skeletal–muscle US imaging. R2, not having specific competence in the US imaging of fasciae, was trained by R1. R1 took US images following the protocol by Pirri et al. 2021, and the US-recorded images were analyzed separately by the two raters in different sessions. Each rater measured both types of fasciae at different regions and levels of the arm and forearm. Intra- and inter-rater reliability was excellent for the deep fascia and good and excellent for the superficial fascia according to the different regions/levels (for example for the anterior region of the arm: deep fascia: Ant 1: ICC2,2 = 0.95; 95% CI = 0.81–0.98; superficial fascia: Ant 1: ICC2,2 = 0.85, 95% CI = 0.79–0.88). These findings confirm that US imaging is a reliable and cost-effective tool for evaluating both fasciae, superficial and deep.

This paper examines the main characteristics of the human fascial system, considered in its three-dimensional continuity. To better understand the anatomy of the human fascial system, a simple diagram of the subcutaneous tissue must be borne in mind. From the skin to the deepest plane, we find the superficial fascia, dividing the subcutaneous tissue into two fibroadipose layers, superficial and deep, and the deep fascia, which envelops all the muscles of the body, showing different characteristics according to region. Under the deep fascia is the epimysium, occurring in the limbs and some regions of the trunk. Skin ligaments connect the superficial fascia to the skin and to the deep fascia, forming a three-dimensional network among the fat lobules. The typical features of the superficial and deep fasciae and their relationships to nerves, vessels and muscles are reported here, highlighting the possible role of the deep fascia in proprioception and peripheral motor coordination. The main features of the fasciae with imaging techniques are also discussed. This knowledge may contribute to clinicians’ understanding of the myofascial system and the role which the deep fasciae may play in musculoskeletal dysfunctions.

A case study of fascial manipulation method as a treatment for pain, atrophy, and skin depigmentation after pes anserine bursa corticosteroid injection

Fascia is a highly organized collagenous tissue that is intimately connected with muscles. The mechanical properties of fascia strongly affect muscular actions and development of pathologies. The objective of this paper is to determine the mechanical properties of the deep and superficial fascia by uniaxial and pure shear tests and to propose and address the feasibility of a material hyperelastic constitutive model using combined Digital Image Correlation strain measurements and Finite Element (FE) computations. Experiments on deep and superficial fascia samples from the hindlimbs of six adult sheep along or perpendicular to collagen fibres and FE simulations of each experiment were compared. An anisotropic strain energy function was proposed to reproduce the mechanical behaviour of deep and superficial fascia and the material parameters were fitted using an optimization method and included in the FE simulations.The mechanical response of the deep and superficial fascia shows typical behaviour of soft connective tissues. It is shown that the samples in longitudinal direction are stiffer than the samples in transversal direction for both kinds of tissues. When considering the deep and superficial samples, it is evident a greater stiffness of deep samples for both longitudinal and transversal directions with respect to superficial samples. Overall good predictions were obtained with the model proposed which present relatively low ε values, ε = 0.1189 and ε = 0.0722 for deep and superficial fascia respectively. The experimental and FE results were compared. The simulated curves slightly underestimated or overestimated the load for uniaxial and pure shear tests, respectively, but very accurately captured the stiffness and the overall response. These results demonstrate that the proposed model and the fitted material properties applied have a good capability of reproducing the experimental conditions.

Although the number of Ultrasound (US) imaging studies investigating the fascial layers are becoming more numerous, the majority tend to use different reference points and terminology to describe their findings. The current work set out to compare macroscopic and microscopic data of specimens of the fascial layers of the thigh with US imaging findings. Specimens of the different fascial layers of various regions of the thigh were collected for macroscopic and histological analyses from three fresh cadavers and compared with in vivo US images of the thighs of 20 healthy volunteers. The specimens showed that the subcutaneous tissue of the thigh is made up of three layers: a superficial adipose layer, a membranous layer/superficial fascia, and a deep adipose layer. The deep fascia is composed of an aponeurotic fascia, which envelops all the thigh muscles and is laterally reinforced by the iliotibial tract and an epimysial fascia, which is specific for each muscle. The morphometric measurements of the thickness of the superficial fascia were different (anterior: 153.2±39.3µm; medial: 128.4±24.7µm; lateral: 154±28.9µm; and posterior: 148.8±33.2µm) as were those of the deep fascia (anterior: 556.8±176.2µm; medial: 820.4±201µm; lateral: 1112±237.9µm; and posterior: 730.4±186.5µm). The US scans showed a clear picture of the superficial adipose tissue, the superficial fascia, and the deep adipose tissue, as well as the deep fasciae. The epimysial and aponeurotic fasciae of only some topographic areas could be independently identified. The US imaging findings confirmed that the superficial and deep fascia have different thicknesses, and they showed that the US measurements were always larger with respect to those produced by histological analysis (p<0.001) probably due to shrinkage during the processing. The posterior region (level 1) of the superficial fascia had, for example, a mean thickness of 0.56±0.12mm at US, while the histological analysis showed that it was 148.8±33.2µm. Showing a similar pattern, the thickness of the deep fascia was as follows: 1.64±0.85mm versus 730.4±186.5µm. Study results have confirmed that US can be considered a valid, non-invasive instrument to evaluate the fascial layers. In any event, there is a clear need for a set of standardised protocols since the thickness of the fascial layers of different parts of the human body varies and the data obtained using inaccurate reference points are not reproducible or comparable. Given the inconsistent terminology used to describe the fascial system, it would also be important to standardise the terminology used to define its parts. The difficulty in distinguishing between the epimysial and aponeurotic/deep fascia can also impede data interpretation.