Cutaneous Insertion Research Articles

Emergence and History

Emergence and History

Muscle Insertion and Strength of the Muscle Contraction as Guidelines to Enhance Duration of the Botulinum Toxin Effect in the Upper Face.

In this series of patients the cutaneous insertion and strength of voluntary contraction of the muscles in the upper third of the face were used as guidelines for botulinum toxin application named "BTA Codes." Anatomical dissection of fresh cadavers identified the shape and cutaneous insertions of the muscles in the upper third of the face. Patient voluntary contraction of the muscles in the upper third of the face created different patterns of skin lines classified by the 4-grade Facial Wrinkle Scale. For botulinum toxin application injections points followed the muscle cutaneous insertion and dose the 4-grade Facial Wrinkle Scale. Injection points ranged from 3 to 23 points per patient, average of 9.4 points. Dose per point varied from 2.5 to 7.5U, ranging from 12.5 to 72.5U per patient, average of 33.82U. Skin lines resulting from the voluntary contraction of the muscle prior to toxin application were stated as baseline 1. The absence of skin lines and muscle activity on day fifteen after toxin application defined baseline 2. Skin lines resulting from the recovered voluntary contraction of the muscle after toxin application like those of baseline 1 established baseline 3. The botulinum toxin effect was the time elapsed between baselines 2 and 3, ranging from 171 to 204days, average of 183.72days, greater than the 3 or 4 months reported in the literature. "BTA Codes" is a set of rules to apply botulinum toxin supported by muscle anatomy and degree of voluntary contraction to enhance the duration of its effect. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The existence of labial SMAS — Anatomical, imaging and histological study

Cutaneous insertion of the facial mimic muscles concerns, at different levels, the superficial fascia of that region. A superficial musculoaponeurotic system is described at face level that facilitates skin insertion of the facial expression muscles through the superficial fascia that acquires particular functional aspects in each region of the face. The existence of a musculofascial system is seen controversial among anatomists, which is why the purpose of this study is to establish its existence at the oral region. The material used in our study consists of twenty-four dissected hemifacies, wherefrom we have recorded images using an operator microscope. Tissue samples have been taken from anatomical specimens examining them by usual staining methods. In parallel, fifteen patients have been investigated with imaging methods (MRI and CT). The results prove the existence of an oral musculoaponeurotic system with a particular organization, similar in the upper and lower part. The superficial fascia disappears into the free margin of the upper and lower lips, as we are emphasizing in the images taken from this level. These findings explain the functional anatomy of this region, but they also form the background of the modern oral plastic surgery.

НАКОЖНОЕ ПРИМЕНЕНИЕ РАСТВОРА НИТРОГЛИЦЕРИНА В КОМПЛЕКСНОМ ЛЕЧЕНИИ ДЕГЕНЕРАТИВНО-ДИСТРОФИЧЕСКИХ ЗАБОЛЕВАНИЙ КРУПНЫХ СУСТАВОВ

The article presents a preliminary analysis of the application of the new non-invasive method of treatment of degenerative-dystrophic diseases of large joints. The aim of the study was to examine the results of the cutaneous insertion of a nitroglycerin solution at a concentration of 2.5 mg/ml with degenerative diseases of knee and hip joint. Materials and methods. In 9 patients studied results: physical, x-ray studies; testing scales: the Oxford Knee Score, KOOS-WOMAC, Lisholm, Leken, Harris; blood gases; pulse oximetry; capillaroscopy. Results. All patients satisfied with treatment, significant pain re-duction, increase range of motion, rejection of the use of means of additional supports, as evidenced by the data evaluation scales. Indicators of blood gas composition, the data of pulse oximetry, capillaroscopy showing improvements in tissue circulation. Conclusions. Cutaneous application of nitroglycerin in the us used concentration improves blood circulation and, as a consequence, the metabolism in the affected joint that can slow the progression of the disease. Ease of use will allow you to apply a method of treating patients not only in hospital but on an outpatient basis.

Anatomy of Forehead, Glabellar, Nasal and Orbital Muscles, and Their Correlation with Distinctive Patterns of Skin Lines on the Upper Third of the Face: Reviewing Concepts.

The purpose of this study is to establish a relationship between the skin lines on the upper third of the face in cadavers, which represent the muscle activity in life and the skin lines achieved by voluntary contraction of the forehead, glabellar, and orbital muscles in patients. Anatomical dissection of fresh cadavers was performed in 20 fresh cadavers, 11 females and 9 males, with ages ranging from 53 to 77years. Subcutaneous dissection identified the muscle shape and the continuity of the fibers of the eyebrow elevator and depress muscles. Subgaleal dissection identified the cutaneous insertions of the muscles. They were correlated with skin lines on the upper third of the face of the cadavers that represent the muscle activity in life. Voluntary contraction was performed by 20 voluntary patients, 13 females and 7 males, with ages ranging from 35 to 62years. Distinct patterns of skin lines on the forehead, glabellar and orbital areas, and eyebrow displacement were identified. The frontalis exhibited four anatomical shapes with four different patterns of horizontal parallel lines on the forehead skin. The corrugator supercilii showed three shapes of muscles creating six patterns of vertical glabellar lines, three symmetrical and three asymmetrical. The orbicularis oculi and procerus had single patterns. The skin lines exhibited in voluntary contraction of the upper third of the face in patients showed the same patterns of the skin lines achieved in cadavers. Skin lines in cadavers, which are the expression of the muscle activity in life, were similar to those achieved in the voluntary contraction of patients, allowing us to assert that the muscle patterns of patients were similar to those identified in cadavers. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Safe Planes for Injection Rhinoplasty: A Histological Analysis of Midline Longitudinal Sections of the Asian Nose.

Dorsal nasal augmentation is an essential part of injection rhinoplasty on the Asian nose. Aesthetic physicians require detailed knowledge of the nasal anatomy to accurately and safely inject filler. One hundred and thirty-five histological cross sections were examined from 45 longitudinal strips of soft tissue harvested from the midline of the nose, beginning from the glabella to the nasal tip. Muscles and nasal cartilage were used as landmarks for vascular identification. At the nasal tip, a midline longitudinal columellar artery with a diameter of 0.21 ± 0.09 mm was noted in 14 cadavers (31.1 %). At the infratip, subcutaneous tissue contained cavernous tissue similar to that of the nasal mucosa. The feeding arteries of these dilated veins formed arteriovenous shunts, into which retrograde injection of filler may be possible. All of the nasal arteries present were identified as subcutaneous arteries. They coursed mainly in the superficial layer of the subcutaneous tissues, with smaller branches forming subdermal plexuses. A substantial arterial anastomosis occurred at the supratip region, in which the artery lay in the middle of the subcutaneous tissue at the level of the major alar cartilages. These arteries had a diameter ranging between 0.4 and 0.9 mm and were found in 29 of 45 specimens (64.4 %). This was at the level midway between the rhinion above the supratip and the infratip. This anastomotic artery also crossed the midline at the rhinion superficial to the origin of the procerus on the lower end of the nasal bone. Here the arterial diameter ranged between 0.1 and 0.3 mm, which was not large enough to cause arterial emboli. Fascicular cross sections of the nasalis muscle directly covered the entire upper lateral cartilage. The subdermal tissue contained few layers of fat cells along with the occasional small artery. The procerus arose from the nasal bone and was continuous with the nasalis in 16 cadavers (35.6 %). There was fatty areolar tissue between the procerus and the periosteal layer and no significant arteries present. The procerus ascended beyond the brow to insert into the frontalis muscle with very few cutaneous insertions. The supratrochlear vessels and accompanying nerve were occasionally found on the surface of the frontalis muscle. Most nasal arteries found in the midline are subcutaneous arteries. Filler should be injected deeply to avoid vascular injury leading to compromised perfusion at the dorsum or filler emboli at the nasal tip. This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The anatomy and function of Cleland’s ligaments

The cutaneous ligaments of the digits have been recognized by anatomists for several centuries, but the best known description is that of John Cleland. Subsequent varying descriptions of their morphology have resulted in the surgical community having an imprecise view of their structure and dynamic function. We micro-dissected 24 fresh frozen fingers to analyze the individual components of Cleland's ligamentous system. Arising from the proximal interphalangeal (PIP) joint, proximal, and sometimes middle phalanx, we found strong ligaments that ran proximally (PIP-P) and distally (PIP-D). On each side of each finger there was a PIP-P ligament present, which passed obliquely from the lateral side of the proximal and sometimes middle phalanx towards its insertion into the skin at the level of the proximal phalanx. The distal (PIP-D) ligaments were found to pass obliquely distally on the radial and ulnar aspects of the digit towards cutaneous insertions around the middle phalanx. A similar arrangement exists more distally with fibres originating from the DIP joint and middle phalanx (the DIP-P pass obliquely proximally, and the DIP-D, distally). Each individual PIP ligament consisted of three different layers originating from fibres overlying the flexor tendon sheath, periosteum or joint capsule, and extensor expansion. Ligaments arising at the DIP joint had two layers equivalent to the anterior two layers of the proximal ligaments. Cleland's ligaments act as skin anchors maintaining the skin in a fixed relationship to the underlying skeleton during motion and functional tasks. They also prevent the skin from 'bagging', protect the neurovascular bundle, and create a gliding path for the lateral slips of the extensor tendon.

Surgical Softening of the Nasolabial Folds by Liposuction and Severing of the Cutaneous Insertions of the Mimetic Muscles

Surgical Softening of the Nasolabial Folds by Liposuction and Severing of the Cutaneous Insertions of the Mimetic Muscles

Surgical Softening of the Nasolabial Folds by Liposuction and Severing of the Cutaneous Insertions of the Mimetic Muscles

A surgical technique was developed to soften the nasolabial folds by liposuction and severing of the cutaneous insertions of the mimetic muscles. This procedure was used for 11 patients from September 2006 to June 2009. With the patients under local tumescent anesthesia, extraoral incisions were made in nine cases and intraoral incisions in two cases. Liposuction was performed superior and lateral to the nasolabial fold using an order-made one-hole 2.5-mm cannula. After liposuction, the fibrae septa and the cutaneous insertions of the mimetic muscles in the nasolabial region were severed by a sharp-edge eye scissors. Compressive dressings were maintained for 3days. All the patients, followed up from 3months to 3years, were satisfied with the aesthetic results. Both the depth and the length of the nasolabial folds were decreased conspicuously. The most obvious change was improvement in the lateral part of the nasolabial folds. The extraoral scars were almost imperceptible. Severe complications were not observed in this series. Surgical softening of the nasolabial folds by liposuction and severing of the cutaneous insertions of the mimetic muscles is especially suitable for 40- to 60-year-old women with aging faces who are unwilling to undergo a face-lift. The procedure is simple, and the anatomic causes for deepening of the nasolabial folds can be corrected. Patients usually are satisfied with the final postoperative results.

Pain following controlled cutaneous insertion of needles with different diameters

Background and aim. Needle injections are used daily by millions of people around the world for the administration of various drugs (e.g., insulin), venepuncture, and some neurophysiological procedures. The aim of this paper was to study the influence of the outer needle diameter on the pain evoked by controlled needle insertion.Methods. An automated needle injection system was used to perform a series of insertions where velocity, angle of insertion, and depth of injection were controlled. The frequency of pain following needle insertions (23G, 27G, 30G, 32G) was recorded together with the pain intensity (measured using the visual analogue scale—VAS) and the occurrence of bleeding.Results. The outer needle diameter was positively and significantly correlated to the frequency of the insertion pain; for example, 63% of insertions with 23G needles caused pain, 53% of insertions with 27G and 31% of insertions with the thinnest (32G) needle (p < 0.0001) caused pain. The thickest needle caused most insertions ...

Pain following controlled cutaneous insertion of needles with different diameters

Background and aim. Needle injections are used daily by millions of people around the world for the administration of various drugs (e.g., insulin), venepuncture, and some neurophysiological procedures. The aim of this paper was to study the influence of the outer needle diameter on the pain evoked by controlled needle insertion.Methods. An automated needle injection system was used to perform a series of insertions where velocity, angle of insertion, and depth of injection were controlled. The frequency of pain following needle insertions (23G, 27G, 30G, 32G) was recorded together with the pain intensity (measured using the visual analogue scale—VAS) and the occurrence of bleeding.Results. The outer needle diameter was positively and significantly correlated to the frequency of the insertion pain; for example, 63% of insertions with 23G needles caused pain, 53% of insertions with 27G and 31% of insertions with the thinnest (32G) needle (p < 0.0001) caused pain. The thickest needle caused most insertions associated with bleeding. Bleeding insertions were approximately 1.3 times more painful (as indicated by VAS scores) than insertions without concomitant bleedings (p = 0.004).Conclusion. By decreasing the outer diameter of a needle, the frequency of insertion pain can be reduced and may encourage patients to adhere to demanding injection regimens such as recurrent insulin administration.

Transpharyngeal Ultrasonography for Cannulation of the Internal Jugular Vein

Complications due to internal jugular vein (IJV) cannulation are infrequent and rarely life threatening. However, inadvertent carotid artery puncture can lead to serious problems in patients who have atheromas or bleeding disorders or who are undergoing full anticoagulation therapy, as for cardiopulmonary bypass. An external vascular ultrasound technique, using a vascular probe positioned on the neck, has previously been described as an aid for IJV cannulation.1We have found useful in our practice an alternative method, using a transesophageal probe.During the past year, we selected 50 cardiac patients for whom jugular vein cannulation could present a risk. Patients who required monitoring with a transesophageal probe and who had carotid artery disease, previous carotid artery surgery, and difficult anatomy, such as unclear landmarks or no palpable venous pulse, were selected. The mean age of the patients was 72.3 ± 8.8 yr (median, 74 yr).Transesophageal echocardiographic monitoring is performed with use of a multiplane transducer and a Sonos 5500 imaging system (Hewlett Packard, Andover, MA). Induction of anesthesia and tracheal intubation are performed before insertion of the echo probe. A small towel is placed under the patient’s shoulders. The head is then extended and turned slightly to the side opposite the cannulation, and the patient’s arms are placed by his or her sides. The patient is positioned in a 25° head-down position. The ultrasound monitor is placed in front of the operator.The transesophageal echo probe is inserted 12–20 cm from the teeth. The tip is directed along the pharyngeal lateral wall, which is why we call this method transpharyngeal . The probe is then rotated laterally 15–20° until the cervical vascular bundle is seen. The view is a mirror image of that obtained from conventional vascular ultrasonography (fig. 1).A needle covered with a plastic hood is used to search the skin surface of the neck for the best site of cutaneous insertion to find the IJV, which is not pulsating and does not compress. The ultrasound probe is kept stable on a trolley. The operating field, the operator, and the devices are then prepared as usual under sterile conditions.The skin puncture site is that nearest the IJV, and the puncturing needle is directed away from the carotid artery. The needle is inserted at a 60° angle to the neck axis and directed to the middle of the vein while it is observed on the monitor. Insertion of the needle through the vein may be seen directly, or it may be seen indirectly as movement of the vein wall (fig. 1). Aspiration of blood in the syringe confirms the proper needle position. As the probe is left in place, no adjustment is needed to maintain the correct view.The IJV puncture was successful in 100% of the patients studied. No carotid punctures or other immediate complications occurred.Conventional ultrasound-guided cannulation of the IJV significantly improves the success rate, decreases the access time, and reduces the complication rate of cannulation.2–4Meta-analyses and a systematic review of control data from literature5–7were performed and suggested an advantage of ultrasonography in complicated cases and when access problems were anticipated.1,8At our institution, the widespread use of transesophageal echocardiography, with its ability to provide a view of the vascular bundle of the neck, offers the anesthesiologist a simple way to aid in central venous cannulation, without any additive cost.Potential advantages of transpharyngeal ultrasonography in comparison with conventional ultrasonography in intubated patients undergoing transesophageal echocardiographic monitoring are as follows: Direct compression on the IJV by the external probe is not needed; other professionals do not need to be involved in the procedure; the operator’s hands are free; and the ultrasound probe, still working in the patient, can be used for other purposes.Further studies are needed to assess the reliability of this procedure for IJV cannulation, to determine its proper indications, and to compare this technique with other methods.* Azienda Ospedaliera Universitaria Careggi, Firenze, Italy. sebevi@tin.it

Biliary cutaneous stent insertion via T-tube tract by choledochoscopy

Biliary cutaneous stent insertion via T-tube tract by choledochoscopy

The anatomy of the labiomandibular fold.

The anatomy of the labiomandibular fold was evaluated in a series of 12 fresh hemifacial cadaver dissections. The techniques of methylene blue dye injection, histologic evaluation, and gross dissection all confirm that the labiomandibular fold has distinct anatomic boundaries. The superior boundary is formed by the cutaneous insertion of the depressor anguli oris muscle at the labiomandibular crease. The inferior boundary is determined by the mandibular ligament, which has been previously described. The cutaneous insertion of the depressor muscle and the mandibular ligament act as relative points of fixation. The dynamic forces of both aging and facial animation act about these two points to create the typical appearance of the labiomandibular fold. This anatomy is consistent with that seen in other areas of the face such as the nasolabial and nasojugal folds, where the dermal insertion of muscle and/or fascia defines an anatomically distinct region. Clinically, this anatomy may suggest that a subcutaneous plane of dissection during the face lift procedure may allow manipulation and reduction of the fat that was noted lateral to the dermal insertion of the depressor anguli muscle. Subcutaneous dissection also avoids lateral pull on the platysma muscle, which may tend to accentuate and distort the labiomandibular crease due to its intimate association with the overlying depressor muscle.

Anatomy of a "black eye": a newly described fascial system of the lower eyelid.

The anatomy of a black eye is examined in a series of cadaver dissections in which a previously unreported fascial system of the lower eyelid is identified. This fascia originates at the orbital rim, and is in continuity with the orbital septum and with the periosteum of the orbital floor and anterior maxillary wall. This fascia contributes to the thickened area along the orbital rim called the arcus marginale. At the level of the orbicularis oculi muscle, this fascia was noted microscopically to fuse with a fibrous septa of the superficial cheek fat. This creates one long continuous membrane from the orbital rim above to the cheek skin below. Dye injection techniques show that this membrane is impermeable and traps injected dye in the same place where a black eye forms. After periorbital injury, extravasated hemoglobin pigment is confined to the area above the cutaneous insertion of this membrane. This fascial system has been named the septum malaris: malar describes its origin along the orbital rim of the cheek, and septum further describes the partitioning nature of this ultra-thin membrane.

The Malar Septum: The Anatomic Basis of Malar Mounds and Malar Edema

The anatomy of malar mounds and malar edema is evaluated in a series of 18 fresh cadaver dissections. Dye injection, histologic evaluation, and gross anatomic dissection are used to identify a previously unrecognized fascial structure of the lower eyelid and cheek. The malar septum originates from orbital rim periosteum superiorly and inserts into cheek skin 2.5 to 3 cm inferior to the lateral canthus. This fascial structure acts as a relatively impermeable barrier that allows tissue edema and hemoglobin pigment to accumulate above its cutaneous insertion. The malar septum, which acts as both a functional and a structural barrier, defines the lower boundary of several clinical entities: malar mounds, malar edema, malar festoons, and periorbital ecchymosis. The permeability characteristics of the malar septum suggest that, at least in some persons, malar mounds may be accentuated by chronic lower eyelid edema, and these characteristics may imply a time course in the progressive development from malar edema to malar mounds and, ultimately, to malar festoons. The anatomy of the malar septum is clinically relevant because it defines the four anatomic compartments of the malar mound that should be considered during surgery: the superior compartment of suborbicularis oculi fat, orbicularis oculi muscle, and superficial cheek fat and cheek skin superior to the cutaneous insertion of the malar septum.

Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament.

The orbital and eyelid relationships of the superficial musculoaponeurotic system (SMAS) were studied in human cadavers. Using gross and microscopic techniques, the SMAS was found to be intimately related to the eyelids and orbicularis oculi muscle, and to have distinct orbital bony attachments. Sub-SMAS fat in the malar region was found to be continuous with the submuscular fat in the eyebrow region. The malar sub-SMAS fat continued superiorly into the lower eyelid above the inferior orbital rim, as a postorbicularis layer. A bony attachment emanating from the inferior orbital rim, the orbitomalar ligament, traveled through the orbicularis oculi muscle in a lamellar fashion prior to inserting into the dermis. The cutaneous insertion of this attachment corresponds to the malar and nasojugal skin folds. With aging, relaxation of the orbitomalar ligament allows inferior migration of orbital fat, in addition to the anterior migration that occurs through an attenuated orbital septum. These findings have implications not only in cosmetic surgery but also in the understanding of facial soft tissue changes that occur with aging.