The anatomic study and clinical application of the premasseter space

To explore the regional anatomy of the rectum including the perirectal fasciae and spaces. Twenty-one cadavers (15 males and 6 females) were embalmed and their vessels were visualized by injection with color dye. From the cadavers, 30 hemipelvis and 6 three-quarter pelvis were harvested. The perirectal fasciae and spaces and the pelvic autonomic nerves were dissected and examined. Three tissue layers were dissected from the inside to the periphery including the proper rectal fascia enveloping the mesorectum, the presacral fascia, and the piriformis fascia fused with the sacral periosteum. The mesorectum comprised 2 parts with the classical posterolateral fat covered by the proper rectal fascia posteriorly and the anterior fat covered by the posterior layer of Denonvilliers fascia anteriorly. Extending anteriorly to the anterior layer of Denonvilliers fascia, the presacral fascia bisected the space between the mesorectum and the piriformis fascia into the retrorectal space and the presacral space. The retrorectal space extended cranially to the left retrocolic space, anterior to the space between the 2 layers of Denonvilliers fascia(prerectal space). From the inside to the periphery, the proper rectal fascia, the presacral fascia, and the muscular fascia are distributed in an annular pattern around the mesorectum. The presacral fascia divides the perirectal space into 2 annular parts, the central retrorectal space and the peripheral presacral space. The retrorectal space is the ideal surgical plane for total mesorectal excision.

Objective The autopsy method was used to study the adjacent layers related to right-side colon, which provided a reliable applied anatomical basis for accurate membrane anatomic right hemin-colectomy. Methods Five corpses fixed in formalin (four males and one female) were anatomically observed on the adjacent layers of right-side colon. Results The right-side colon can be divided into three fusion fascia regions according to surrounding adjacent layers: the Toldt′s fusion fascia region, the pancreaticoduodenal fusion fascia region, and the omental-transverse colon fusion fascia region. (1) The right Toldt′s fusion fascia region: It is derived from the ileocecal, ascending colon and the its dorsal mesentery fused to primary posterior peritoneum. The cranial border of the right Toldt′s fusion fascia region is the lower edge of the duodenal ring. The medial border is the right margin of the superior mesenteric vein. The right and caudal border is the rim between the ileocecal, ascending colon and posterior peritoneum. On the dorsal side of the right Toldt′s fusion fascia region, there are two layers: posterior peritoneal continuation (primary posterior peritoneum) and urogenital stratum. They form three spaces include the right Toldt′s fusion fascial space, anterior renal space and posterior renal space. (2) The pancreaticoduodenal fusion fascia region: It is derived from the fusion fascia formed by the hepatic flexure of the colon and its dorsal mesentery and propria fascia of the pancreaticoduodenal. The cranial border is the duodenal bulb which gastric omentum adhere to. The caudal border is the lower edge of the duodenal ring. The lateral border is the lateral edge of the duodenal ring. The medial border is the right edge of the greater omentum (The anatomy mark is the Right Gastroepiploic Vein). On the dorsal side of the pre-pancreaticoduodenal fusion fascia region, there are three layers: pancreaticoduodenal, posterior peritoneal continuation (primary posterior peritoneum) and urogenital stratum. They form four fusion fascial spaces include the pre-pancreaticoduodenal space, retro-pancreaticoduodenal space and anterior renal space and posterior renal space. The right Toldt′s fusion fascial space continues to the cranial and separated by the pancreaticoduodenal layer into the pre-pancreaticoduodenal space and retro-pancreaticoduodenal space. The anterior superior pancreaticoduodendal vein generates from the head of pancreas, stretch across the pre-pancreaticoduodenal space, and joins to the Henle trunk in the mesentery. (3) The omental-transverse fusion fascia region: This region from the right edge of the omentum, to the left, consisting of the right margin of the omentum and anterior layer of transverse mesenteric fascia. This region forms three spaces from the ventral side to the dorsal side, which is omental bursa, the peri-pancreatic space and the retro-pancreatic space. The third layer of omentum covers the ventral surface of the pancreas. The fourth layer of omentum surrounds the body and tail of the pancreas and the spleen from the dorsal side, There is a peripancreatic space between the third layer and the fourth layer of the omentum. The fourth layer of omentum fuse to the avascular zone of the transverse mesocolon tightly , and separates with it at the lower edge of the pancreas, the space between them is the retro-pancreatic space. Conclusion Based on the theory of embryo development, the relationship between adjacent layers of the right semicolon was studied by anatomical method. Well understanding of these layers and their interfused fascia spaces will facilitate safe, accurate, and effective right hemicolectomy. Key words: Colon; Anatomy; Right-side colon; Adjacent layer; Applied anatomy

Objective To explore the anatomy of expended facial artery perforator flaps with cervical small perforators and its clinical application for extensive facial defects with this flap. Methods Necks of fresh cadavers were dissected for studying the anatomy basis of expended facial artery perforator flaps with cervical small perforators. Based on the anatomy, two-stage operation was performed. In the first stage, expander was embedded above the platysma and the pedicle, cervical small facial artery perforator was reserved. In the second stage, the expended perforator flap was transferred as propeller flap, advanced flap or tunnel flap to reconstruct extensive facial defects. Results Cadavers dissection revealed 3 or 4 perforators were derived from facial artery when it crossed marginal mandibular and vertically penetrated platysma to the superficial fascia layer to supply cervical skin. In clinic, all flaps presented with satisfactory functional and aesthetic outcomes. Conclusions This design of expended facial artery perforator flaps with cervical small perforators provide an excellent method for reconstruction of extensive facial defects. Key words: Perforator pedicled flap; Soft tissue expansion; Cervical region; Defect

Objective To introduce an operative method of rhytidectomy with W-incision and fewer complications for facial rejuvenation. Methods A total of 84 patients were treated with rhytidectomy by multi-methods and followed up from January 2007 to December 2012. The rhytidectomy was done along the temporal hairline edge through the combined procedures, including sharp and blunt separation, liposuction and filling with autologous fat, tighting and fixing the fascial flap of superficial musculoaponeurotic system, as well as the suspension of the zygomatic cheek fiber fat pad. Results Follow-up for 3 moths to 2 years after surgery in 84 patients showed that the wound was healing with good concealment and without complications such as facial nerve injury or local uneven. All the cases achieved good results in facelift with high satisfaction rate after the combined operations. Conclusions This combined rhytidectomy is safe, effective, simple and easy. And it is a good and ideal approach of facial rejuvenation worthy of clinical application. Key words: Rhytidectomy; Lifting facial rejuvenation; Fat pad; Temporal hair line; Minimal invasive procedure

Objective To investigate the anatomical basis and clinical effects of a new surgical procedure with volar single-portal approach for minimally invasive treatment of carpal tunnel syndrome. Methods On 8 fresh adult upper limb specimens (16 sides), anatomical observation and measurement of carpal tunnel and palm structures were performed to determine the entry point, guide line and operative level of a new surgical procedure with volar single-portal approach for minimally invasive treatment of carpal tunnel syndrome. According to the anatomical findings, the new operation was performed on 68 patients with moderate to severe carpal tunnel syndrome. Postoperative recovery of the patients was followed up and compared with that of 75 patients who received conventional open carpal tunnel release at the corresponding period. Results According to the results of anatomical study, the best entry point of the surgical procedure was determined as following. A line parallel and ulnar to the metacarpophalangeal joint was drawn when the thumb was at maximum radial abduction. Another line was drawn along the long axis between the index and middle fingers. A 1-cm long vertical incision was made at 45° and 1-cm ulnar to the intersection of these two lines. The surgical projection line was the line connecting the surgical incision and the intersection point between palmaris longus tendon and distal wrist crease. The dissection plane was the space between the superficial palmar fascia and the palmar aponeurosis. The 68 minimally invasive surgery treated cases were follow-up for 6 to 12 months, the average follow-up being 9.5 months. Based on the carpal tunnel syndrome postoperative functional assessment criteria proposed by Gu, the results were satisfactory. Postoperative pain symptoms, sensory examination, muscle atrophy, thumb opposition, pinching and grip strength were all significantly improved. There was very little postoperative scar pain. Compared with the conventional surgery the minimally invasive procedure has obvious advantages. Conclusion Volar single-portal approach for minimally invasive treatment of carpal tunnel syndrome has sound anatomical basis. It can effectively reach and divide the transverse carpal ligament, decompress the median nerve. Therefore it is an effective minimally invasive approach in the treatment of carpal tunnel syndrome. Key words: Carpal tunnel syndrome; Surgical procedures, minimally invasive; Anatomy; Clinical study

Objective To provide anatomic and clinical basis for diagnosis and treatment of median nerve entrapment at the elbow.Methods Microanatomical dissection of the median nerve was done in 10 cadaver upper limb specimens to observe the anatomical factors that cause compression of the median nerve at the elbow and shape of the median nerve.Case analysis was conducted in 14 patients with median nerve entrapment at the elbow who were treated in our department.Results Anatomic studies in the 10 dissected specimens showed three types of relationship between the bicepital aponeurosis and median nerve:complete-covering (2 specimens,20％),partial-covering (1 specimen,10％) and non-covering (7 specimens,70％).Thickened fascia in the superficial layer of pronator teres ulnar head was seen in 9 specimem (90％).Intramuscular tendinous bundles in the anconeus were observed in 2 specimem (20％).The reverse fascia that traversed the median nerve was seen in 6 specimens (60％).The structures of the origins of two heads of the flexor digitorum superficialis (FDS) had three types:intramuscular tendinous bundle (1 specimen,10％),fibrous arch (1 specimen,10％),and conjoined tendinous arch (8 specimens,80％).Of the 14 patients who had median nerve entrapment at the elbow,5 were diagnosed as pronator teres syndrome while 9 were diagnosed as anterior interosseous nerve(AIN) compression.The compression points in the pronator syndrome cases were ulnar side of the thickened and taut bicepital aponeurosis (2 cases),deep tendinous arch of pronator teres (2 cases),and between two heads of pronator teres (1 case).The compression points in the AIN compression cases were deep tendinous arch of pronator teres (2 cases),ulnar head of pronator teres (1 case),between two heads of pronator teres (1 case),and thickened and taut FDS origin (5 cases).Six patients were follow-up.The average follow-up time was 2 years and 4 months.Good to excellent recovery of motor function was achieved in these patients.Condusion The shape of the median nerve,its surroanding tendinous structures and thickened and taut fascia are the anatomic basis of median nerve entrapment at the elbow. Key words: Median nerve; Entrapment; Elbow; Applied anatomy; Case report

Anatomical considerations for the spread of odontogenic infection originating from the pericoronitis of impacted mandibular third molar: computed tomographic analyses.

The injection of botulinum toxin into the masseter muscle is an important method for improving hypertrophy. However, some patients may experience adverse reactions, such as sagging of the lower jaw. Therefore, we proposed a method of injecting botulinum toxin into the masseter and platysma muscles that would reduce masseter size and enhance the jawline. The aim of this study was to reduce the masseter size while enhancing the jawline. Twenty patients received botulinum toxin injections into the masseter and platysma muscles. Pain levels were evaluated with the visual analog scale. All patients were photographed before and 6 months after treatment. Evaluations were performed based on standardized criteria. The lift index, reduction index, and symmetry index were performed to assess the degree of jawline elevation, masseter size reduction, and jawline symmetry before and after treatment. The mean visual analog scale score of the 20 patients was 2.80 (±1.24). The mean lift index score decreased from 4.93 (±0.34) to 4.53 (±0.37), P < .05. The mean reduction index score decreased from 3.13 (±0.27) to 2.74 (±0.27), P < .05. The mean symmetry index score changed from 0.0393 (±0.0296) to 0.0257 (±0.0246), P < .05. Botulinum toxin injections into the masseter and platysma muscles through nerve block reduced the masseter size, elevated the jawline, and improved symmetry.

The importance of the face for socio-ecological interaction is the cause for a high demand on any surgical intervention on the facial musculo-skeletal system. Bones and soft-tissues are of major importance for any facial surgical treatment to guarantee an optimal, functional and aesthetical result. For this reason, surgeons want to pre-operatively plan, simulate and predict the outcome of the surgery allowing for shorter operation times and improved quality. Accurate simulation requires exact segmentation knowledge of the facial tissues. Thus semi-automatic segmentation techniques are required. This thesis proposes semi-automatic methods for segmentation of the facial soft-tissues, such as muscles, skin and fat, from CT and MRI datasets, using a Markov Random Fields (MRF) framework. Due to image noise, artifacts, weak edges and multiple objects of similar appearance in close proximity, it is difficult to segment the object of interest by using image information alone. Segmentations would leak at weak edges into neighboring structures that have a similar intensity profile. To overcome this problem, additional shape knowledge is incorporated in the energy function which can then be minimized using Graph-Cuts (GC). Incremental approaches by incorporating additional prior shape knowledge are presented. The proposed approaches are not object specific and can be applied to segment any class of objects be that anatomical or non-anatomical from medical or non-medical image datasets, whenever a statistical model is present. In the first approach a 3D mean shape template is used as shape prior, which is integrated into the MRF based energy function. Here, the shape knowledge is encoded into the data and the smoothness terms of the energy function that constrains the segmented parts to a reasonable shape. In the second approach, to improve handling of shape variations naturally found in the population, the fixed shape template is replaced by a more robust 3D statistical shape model based on Probabilistic Principal Component Analysis (PPCA). The advantages of using the Probabilistic PCA are that it allows reconstructing the optimal shape and computing the remaining variance of the statistical model from partial information. By using an iterative method, the statistical shape model is then refined using image based cues to get a better fitting of the statistical model to the patient's muscle anatomy. These image cues are based on the segmented muscle, edge information and intensity likelihood of the muscle. Here, a linear shape update mechanism is used to fit the statistical model to the image based cues. In the third approach, the shape refinement step is further improved by using a non-linear shape update mechanism where vertices of the 3D mesh of the statistical model incur the non-linear penalty depending on the remaining variability of the vertex. The non-linear shape update mechanism provides a more accurate shape update and helps in a finer shape fitting of the statistical model to the image based cues in areas where the shape variability is high. Finally, a unified approach is presented to segment the relevant facial muscles and the remaining facial soft-tissues (skin and fat). One soft-tissue layer is removed at a time such as the head and non-head regions followed by the skin. In the next step, bones are removed from the dataset, followed by the separation of the brain and non-brain regions as well as the removal of air cavities. Afterwards, facial fat is segmented using the standard Graph-Cuts approach. After separating the important anatomical structures, finally, a 3D fixed shape template mesh of the facial muscles is used to segment the relevant facial muscles. The proposed methods are tested on the challenging example of segmenting the masseter muscle. The datasets were noisy with almost all possessing mild to severe imaging artifacts such as high-density artifacts caused by e.g. dental fillings and dental implants. Qualitative and quantitative experimental results show that by incorporating prior shape knowledge leaking can be effectively constrained to obtain better segmentation results.

Objective To identify the exact origin and insertion of plantar aponeurosis and the anatomic relationship of calcaneal spur to plantar aponeurosis. Methods Fourteen specimen of feet were dissected and radiographed. Three fetus feet were observed histologically. Sonographic evaluation was carried out on 20 normal adults and 52 patients with plantar fasciitis. Results (1) Anatomic observation found that plantar aponeurosis was located under the medial process of caleaneus but not attached to it, and proximally attached to the plantar aspect of calcaneal tuborosity. The insertion (origin) of plantar aponeurosis was not a point but a face. Posteriorly the plantar aponeurosis and fascia of Archlles heel were fused or transmigrated together,entirely covered and attached very coherently to the plantar and posterior aspect of calcaneal tuborosity. (2) Histological observation of heel of fetuses found plantar aponeurosis and fascia of Arehlles heel were eosinophil band-like structure. Both continued at the plantar and posterior aspect of calcaneus and attached closely to bone at this area. There were no significant demarcation between them. (3) Sonographic evaluation:normal plantar aponeurosis showed a thin band-like echo, its orgin attached to entire plantar aspect of calcaneal tuberosity and continued with fascia coming posteriorly from Archlles heel. No distinct boundary existed between these two fascias. When plantar fasciitis occurred, the orgin of plantar aponeurosis thickened significantly,this phenomenon could be detected in wholly plantar aspect of calcaneal tuberrosity. The heel spur didn't located within plantar aponeurosis. Conclusions Plantar aponeurosis orginates from entire plantar aspect of cancaneal tuberosity. Heel spur oeeures in the orgin of the intrinsic musculature, such as flexor digitorum brevis,and doesn't locate within plantar aponeurosis. Key words: Ultrasonography; Metatarsus; Fasciitis, plantar

Objective To evaluate the safety and efficacy of the anatomical retroperitoneoscopic nephrectomy(RSN)and standardize the procedure of RSN. Methods The retrospective analysis was performed on 405 consecutive patients underwent anatomical RSN in Our institute from January 2002 to June 2008.There were 232 male and 173 female patients with the average age of(57.2±14.2)years,among whom there were 228 renal cell carcinoma patients accepted RSU,96 and 49 renal pelvic carcinoma and ureteral carcinoma cases accepted retroperitoneoscopic ureteronephrectomy (RSUN) and 32 cases accepted simple RSN due to loss of renal function caused by benign renal discsses.The tadical RSN was performed by dissecting outside Gerota's fascia and in the latent cavities between this fascia and lateral conal fascia in the dorsal side and between this fascia and prerenal fusion fascia in the ventral side,whereas the simple RSN was done inside Gerota's fascia by making direct incision on it and dissecting between this fascia and perirenal adipose tissue.Kidneys and perirenal adipose tissue were completely removed by dissection along several avascular planes around the kidney under the amplified view of laparoscopy. The software SPSS 12.0 was used for the statistical analysis of all data. Results The mean operative time was (132±48)min for radical and simple RSN and (245 ± 62)min for radical RSUN, which included the time for position change and second skin preparation. The medium estimated blood loss was 100 ml(10-2500 ml) and the average drainage volume was 150 ml (0-1152 ml) postoperatively. 15 cases (3. 70%) required blood transfusion with the median volume of 400ml (400-1650 ml). Four cases (0. 99%) were converted to open surgery due to severe adhesion (2 cases), difficult exposure of renal helium (1 case) and severe bleeding (1 case).The mean drainage time was (3. 9±1.8)d, the mean time to first oral intake was (2.7±1.2)d and the mean postoperative hospital stay was (8.6±3. 8)d. Conclusion The anatomical RSN is safe and effective and should be the standard surgical procedure for laparoscopic nephrectomy. Key words: Nephrectomy; Anatomy; Laparoscopes; Retroperitoneal space

To determine the safe space for hyaluronic acid(HA) injection through anatomy study of temporal layers. 6 fresh and 8 formaldehyde-fixed cadaver heads were dissected. The skin soft-tissue layers of temporal region were incised through the cranial coronal plane and elevated layer by layer. The morphological features of layers were observed and documented, as well as the relationship of the superficial temporal artery (STA),the temporal branch of facial nerve (TFN) and the middle temporal vein(MTV) with corresponding layers. Relevant neasurements of the superficial temporal fat pad (sTFD) were recorded. With reference of cardever dissection, temporal region injection with HA was carried out clinically to confirm the safety and effect. In the temporal region, from surface to the temporal fossa, the layers are skin, subcutaneous tissue, superfiacial temporal fascia (STF),loose areolar tissue, superficial layer of deep temporal fascia(sDTF), sTFD, deep layer of deep temporal fascia (dDTF),deep temporal fat pad (dTFD) and temporalis. The temporal skin is tightly attached with the subcutaneous tissue. The STA runs within the subcutaneous tissue on the STF, whereas the TFN within the areolar tissue was just beneath the STF. The loose areolar tissue is a potential layer space. The DTF splits into two sheets of fascia at the line 1 cm above the upper orbital rim to envelope the sTFD, within which the MTV runs backward. The dTFD is the temporal extension of buccal fat pad. With reference of cadever dissection, the target space of temporal HA injection was beneath the temporalis for the area superior to the MTV, whereas within the sTFD for the area inferior to the MTV.67 cases were completed with good result and no complication. In the upper area of temporal region adjacent to the frontal border, the sub-temporalis space is the safety space for HA injection, while inferior to the middle temporal vein and near the zygoma, the superficial temporal fat pad is the target space for safe HA injection.

Retrofacial approach of cochlear implantation in inner ear malformation with aberrant facial nerve: A case report

Surgical Anatomy of the Anterior and Retrofacial Approach to the Sinus Tympani (ST)

Injury to the facial nerve during a face lift is a relatively rare but serious complication. A large body of literature has been dedicated toward bettering the understanding of the anatomical course of the facial nerve and the relative danger zones. Most of these prior reports, however, have focused on identifying the location of facial nerve branches based on their trajectory mostly in two dimensions and rarely in three dimensions. Unfortunately, the exact location of the facial nerve relative to palpable or visible facial landmarks is quite variable. Although the precise location of facial nerve branches is variable, its relationship to soft-tissue planes is relatively constant. The focus of this report is to improve understanding of facial soft-tissue anatomy so that safe planes of dissection during surgical undermining may be identified for each branch of the facial nerve. Certain anatomical locations more prone to injury and high-risk patient parameters are further emphasized to help minimize the risk of facial nerve injury during rhytidectomy.