Fascial Layers Research Articles

An anatomical and histological narrative of a subcutaneous muscle of the anterior abdominal wall in human cadavers: a case report

This report investigates a subcutaneous muscle layer found during routine dissections in four formalin embalmed human cadavers donated for medical training. The gross and microscopic morphology is described and potential implications in humans are raised. Tissue samples were taken from representative regions of the anterior abdominal wall and stained using Haematoxylin & Eosin followed by Masson’s Trichrome. The muscle tissue was seen in the deepest layers of the hypodermis of the anterior abdominal wall, with variable presentation between cadavers. Visually, it appeared as a thin greyish-pink or brown layer with variable morphology based on location, namely, sheet like, discontinuous, and enmeshed within fascial layers, with a thickness ranging from 1 to 5 mm. Tissue staining revealed muscle fibres in all samples. Our incidental findings add gross and histological evidence for the presence of a subcutaneous muscle layer found in the anterior abdominal wall of humans.

Novel muscular anomaly along the iliac crest: Innervation from the superior cluneal nerves and topographical relationship to the thoracolumbar fascia.

Aberrant muscle bundles of approximately 10cm in length, running subcutaneously from the posterior surface of sacrum to the iliac crest, were found on both sides of three males among 93 cadavers of anatomical courses for medical students. Since no precedent of this anomaly has been described in the literature, we present its morphology and discuss the significance of this muscle. This muscle originated from the tendinous fibers of the superficial-most layer of the sacral part of thoracolumbar fascia, became muscularized near the posterior superior iliac spine, passed over the origins of the gluteus maximus and medius, and inserted on the iliac crest. Some bundles crossed the iliac crest to insert between sublayers of the posterior layer of the thoracolumbar fascia. The superior cluneal nerves passed above, below, or penetrated the muscle. Branches from the segmentally lowest one or the conjoined lowest two entered the aberrant muscles. Considering its location and multi-layered structure, the muscle is likely to be a muscularized bundle of the thoracolumbar fascia. The aberrant muscle is also similar to the serratus posterior inferior in its location at the lateral end of the thoracolumbar fascia and below the latissimus dorsi. Nevertheless its innervation from the posterior rami of the spinal nerves and partial fusion at its origin implies a close relationship to the iliocostalis. This aberrant muscle may also be of clinical interest since it is potentially involved in the entrapment of the superior cluneal nerves as it runs along the caudolateral edge of the thoracolumbar fascia.

Ultrasound-guided core needle biopsy of deep fascia: A cadaveric study evaluating feasibility, accuracy and reliability.

Over the past few decades, researchers and clinicians have dedicated significant attention to fascial tissues. Current interest focuses on their anatomical and pathophysiological features. Breakthroughs in ultrasound (US) and magnetic resonance imaging (MRI) have enhanced our ability to study the dynamics and alterations of the tissue structures. However, a microscopic perspective is also essential for a comprehensive understanding of some pathologies of the fasciae. The aim of this study was to investigate, using a cadaveric study: (1) the ease of visualization of the landmarks used for the US-guided fascial core needle biopsy (CNB); (2) the consistency and accuracy of needle placement inside fascial layers using US guidance and confirmed by histological examination; (3) inter-rater reliability. We assessed the feasibility of US-guided CNB in different topographical regions of human cadavers: the thoracolumbar fascia (TLF), fascia lata (FL), and crural fascia (CF). The results, confirmed by histological examination, revealed no significant difference in needle placements between the in-plane approaches in the long and short axes for all locations and fasciae studied (long axis: 91.88%; short axis: 96.22%); p > 0.05. US-guided core needle biopsy with the in-plane approach is feasible, consistent and reliable. It could provide most or all of high-quality fascial tissue samples required for pathological examination. It could also reveal changes in fascial pathologies, capturing the exact site of pathology thanks to US guidance, in particular in patchy diseases such as eosinophilic fasciitis.

Ultrasound-guided superficial cervical plexus blocks for persistent pain after suboccipital craniotomies: a randomized trial.

The efficacy of superficial cervical plexus blocks for reducing persistent pain after craniotomies remains unclear. We therefore tested the primary hypothesis that preoperative ultrasound-guided superficial cervical plexus blocks reduce persistent pain 3 months after suboccipital craniotomies. We conducted a single-center randomized and blinded parallel-group trial. Eligible patients having suboccipital craniotomies were randomly allocated to superficial cervical plexus blocks with 10 ml of 0.5% ropivacaine or a comparable amount of normal saline. Injections were into the superficial layer of prevertebral fascia. The primary outcome was the incidence of persistent pain three months after surgery. From Nov 2021 to August 2023, 292 qualifying patients were randomly allocated to blocks with ropivacaine (n=146) or saline (n=146). The average ± SD age of participating patients was 45±12 years and the duration of surgery was 4.2±1.3 hours. Persistent pain 3 months after surgery was reported by 48 (34%) of patients randomized to ropivacaine versus 73 (51%) in those assigned to saline (relative risk 0.66; 95% CI, 0.50 to 0.88; P = 0.003) in the per-protocol population, and by 53 (36%) of patients randomized to ropivacaine versus 77 (53%) in those assigned to saline (relative risk 0.69, 95% CI, 0.53 to 0.90; P = 0.005) in the intention-to-treat population. Superficial cervical plexus blocks reduce the incidence of persistent incisional pain by about a third in patients recovering from suboccipital craniotomies.

Clinical Efficacy of Bionic Blepharoplasty Using the Flexible Suspension and Semiflexible Suspension Double-Insurance Methods.

To investigate the clinical effect of the double insurance method of flexible suspension and semiflexible suspension in bionic blepharoplasty. Between January 2020 and January 2022, a total of 115 patients (230 eyes) underwent double eyelid plastic surgery with flexible suspension and semiflexible suspension. Herein, we present a new type of double eyelid surgery that preserves the orbicular muscle of the anterior tarsus without removing the tissue. First, the loose fatty fascia layer between the anterior tarsus and the orbicularis oculi muscle was completely removed to a distance of 2mm from the base of the eyelashes, leaving the compact pretarsal levator aponeurosis. Then, the anterior tarsus orbicularis oculi muscle and the upper levator aponeurosis were sutured and fixed (flexible suspension). Finally, the skin and the upper levator aponeurosis were sutured in the flexible suspension space (semiflexible suspension). Six months after surgery, the patient's double eyelid shape had recovered well, and the satisfaction rate reached 97.3%. Among the unsatisfied patients, 1 patient had a single-focused shallow eyelid line which was associated with postoperative hematoma, and 2 patients felt that the double eyelid line was narrow. All 3 patients achieved satisfactory results after reoperation. The bionic double eyelid method with flexible suspension and semiflexible suspension can restore the natural double eyelid anatomy very well by reconstructing the connection between the orbicularis oculi muscle or skin and the upper palpebral levator aponeurosis. After the operation, the incisions healed quickly and smoothly. The eyelid depression and fleshy feeling were not obvious when the eyes were closed. Consequently, the patient's satisfaction was very high.

SP5.2 - Reducing Elective Colorectal Surgical Site Infections with Change of Gloves and Instruments Prior to Abdominal Closure; A Multicycle Audit

Abstract Aims Surgical site infections (SSI) carry a significant impact on patient morbidity, length of stay and antibiotic resistance. Our local colorectal unit has made several interventions over many years with no significant nor sustained improvement in the rate of SSI. The ChEETAh trial (Lancet, 2022) demonstrated a reduction in the rate of 30-day SSI by 13% with routine change of gloves and instruments (COGI) prior to abdominal closure. We aim to reduce our rate of SSI through implementation of COGI prior to abdominal closure; involving whole scrub team change of gloves and use of sterile instruments. Methods Adults undergoing elective colorectal surgery with an abdominal wound greater than 5cm were eligible for this study. Diagnosis of SSI was made based on at least one clinical indicator of infection or at least one symptom of SSI with data collection over 3 cycles spanning 11 months using clinical notes, imaging and microbiology results. The primary outcome was the diagnosis of a SSI involving the skin, subcutaneous, muscle or fascial layer up to 30 days post-operatively. Results The baseline SSI rate prior to intervention was audited at 29%. After implementation of COGI the rate fell to 23%. Further reinforcement of COGI and team education has demonstrated a further decrease in SSI to 15%. This has been sustained across a 6-month period post intervention. Conclusions Change of gloves and instruments is an effective, reliable and sustainable method to reduce the rate of surgical site infection in elective colorectal abdominal surgery.

Efficacy, Safety, and Longevity of Hyaluronic Acid Filler Injection in Treating Temple Hollowness by Sonographic Identifying 17 Soft Tissue Layers.

Successful aesthetic interventions in upper-face aging require a profound understanding of the intricate anatomy of temporal. This study aimed to comprehensively evaluate the effect of hyaluronic acid (HA) injection in temple areas by combining quantitative analysis with detailed anatomical insights. Twenty-five women received HA injections for temple hollowness. The injections targeted the interfacial layer between superficial and deep temporal fascia. Three-dimensional scanning, hollowness examination, and sonographic measurements were conducted 3 and 6 months postprocedure. Sonography identified 17 soft tissue layers in the temple, each with distinct characteristics. The notable layers include the epidermis, dermis, superficial and deep temporal fasciae, innominate fasciae, and superficial and deep temporal fat compartments. Three-dimensional volume was 0.86 mL at 3 months and 0.72 mL at 6 months. The average thickness of HA was 3.82 mm (immediately), 3.00 mm (3 mo), and 2.51 mm (6 mo). The depression on the temple was 4.33 mm (preprocedure), 0.71 mm (3 mo), and 1.62 mm (6 mo). The grade improved by 2.41 and 1.74 levels at 3 and 6 months. Identifying detailed superficial and deep layers of the deep temporal fascia challenged traditional descriptions, with detailed dividing of superficial and deep temporal fascia in sonography. Innominate fascia was also distinguished. This study provided a comprehensive evaluation of the effects of HA injections in temple areas. Precise anatomical insights and quantitative assessments contribute to a deeper understanding of the structural changes induced by this procedure. Sonography is valuable for delineating distinct layers and guiding aesthetic interventions in the temporal region.

African wild dog (Lycaon pictus) masticatory apparatus and oral cavity morphology.

African wild dogs (Lycaon pictus) are unique among canids in their specialized hunting strategies and social organization. Unlike other, more omnivorous canids, L. pictus is a hypercarnivore that consumes almost exclusively meat, particularly prey larger than its body size, which it hunts through cooperative, exhaustive predation tactics. Its bite force is also among the highest reported for carnivorans. Here, we dissected an adult male L. pictus specimen and conducted diffusion iodine contrast-enhanced computed tomography (diceCT) scans to evaluate and describe its masticatory and oral cavity musculature. Muscles of mastication in L. pictus are separated by deep layers of thick intermuscular fascia and deep insertions. The superficial surface of m. masseter is entirely covered by an extremely thick masseteric fascia. Deep to m. masseter pars reflexa and superficialis are additional bellies, m. masseter pars profunda and zygomaticomandibularis. Musculus temporalis in L. pictus, divides into suprazygomatic, superficial, and deep bellies separated by a deep layer of thick intermuscular fascia, and it inserts along the entire rostral margin of the mandibular ramus. Musculus digastricus appears to comprise a single, large fusiform belly which appears to receive its innervation exclusively from CN V3 (nervus mandibularis, division of nervus trigeminus). Musculus pterygoideus medialis and lateralis are each composed of a single, deep belly. However, despite its great bite force, the jaw adductor muscle mass in L. pictus is not increased for its body size over other canid taxa. This finding suggests there are other architectural adaptations to hypercarnivory beyond increased muscle volume (e.g., pennation angle, greater strength, optimization of lever arms for mechanical advantage).

How to Keep Myofibroblasts under Control: Culture of Mouse Skin Fibroblasts on Soft Substrates

During the physiological healing of skin wounds, fibroblasts recruited from the uninjured adjacent dermis and deeper subcutaneous fascia layers are transiently activated into myofibroblasts to first secrete and then contract collagen-rich extracellular matrix into a mechanically resistant scar. Scar tissue restores skin integrity after damage but comes at the expense of poor esthetics and loss of tissue function. Stiff scar matrix also mechanically activates various precursor cells into myofibroblasts in a positive feedback loop. Persistent myofibroblast activation results in pathologic accumulation of fibrous collagen and hypertrophic scarring, called fibrosis. Consequently, the mechanisms of fibroblast-to-myofibroblast activation and persistence are studied to develop antifibrotic and prohealing treatments. Mechanistic understanding often starts in a plastic cell culture dish. This can be problematic because contact of fibroblasts with tissue culture plastic or glass surfaces invariably generates myofibroblast phenotypes in standard culture. We describe a straight-forward method to produce soft cell culture surfaces for fibroblast isolation and continued culture and highlight key advantages and limitations of the approach. Adding a layer of elastic silicone polymer tunable to the softness of normal skin and the stiffness of pathologic scars allows to control mechanical fibroblast activation while preserving the simplicity of conventional 2-dimensional cell culture.

The effect of preoperative hormonal stimulation on the urethral plate; A histologic and histochemical study

Preoperative hormone stimulation (PHS) is used to increase the glans size and may improve the cosmetic appearance after hypospadias surgery. The exact effect of PHS on different penile tissues remains unclear and controversial. Previous studies showed that PHS increased vessel density in the foreskin. However, the effect of PHS on the urethral has never been studied before. In this study we examine the PHS effects on the urethral plate. Specimens of the urethral plate and the underlying tissue were excised to correct severe chordee in 16 children with proximal and perineal hypospadias with severe chordee in 2 groups. Group A consisted of 8 children received PHS prior to surgery. Group B included 8 children with proximal and perineal hypospadias with severe chordee who did not receive PHS and served as a control group. Specimens were examined blindly using hematoxylin-eosin and elastic van-Gieson stain as well as factor 8 and SMA antibodies. The median age of Group A was 13 (range 10-20) months. The median age of Group B (without prior PHS) was 17 (range 14-29) months (p=0,03). The median vessel-density in group A (82 vessels per mm2) was significantly higher than in Group B (65 per mm2), (p<0.05). The median vessel diameter was also significantly higher in Group A (13μm) than in Group B (11μm), (p<0.05). The median epithelial layer thickness in Group A was 110μm and in Group B 98μm, but showed no statistical significance (p=0,16). There was no significant change in dartos fascia layer thickness or androgen receptor expression. There was no visual change in the organization of elastic fibers. This study is the first study to document the effect of PHS on the urethral plate in hypospadias with severe chordee. PHS significantly increased the median vessel-density as well as median vessel diameter as compared to a matching control group. The findings of the study may justify PHS administration before the first operation to improve the vascularity and may reduce the severity of chordee.

Twiddle me this? Twiddled (Twiddler) Syndrome: A Case Report

Background: Twiddler syndrome is a rare but known complication after pacemaker (PM) placement. Causes of Twiddler syndrome have been described in case reports throughout the last fifty years, which has further elucidated our understanding of risk factors and mechanisms of PM dysfunction Summary: We describe a case of Twiddler syndrome caused by migrating PM due to a lack of security to the pectoral fascial layer. Conclusion: Due to the increasing number of iatrogenic causes of PM dysfunction, we propose differentiation from Pacemaker Twiddler Syndrome with known manipulation and Pacemaker Twiddled Syndrome, which includes iatrogenic causes of PM dysfunction. Additionally, the case highlights the importance of a diagnosis in the emergency department, cardiology consultation, and prompt pacemaker replacement.

Migrated tubal sterilisation clip presenting as a subcutaneous gluteal foreign body 24 years later: a case report and literature review

BackgroundThe incidence of sterilisation clip migration is reportedly 25%. However, less than 1% of those who experience clip migration will present with pain, an abscess, or spontaneous extrusion. Here we present a rare case of sterilisation clip migration through the entire pelvic floor.Case presentationA 66-year-old female was referred from community to the Surgical Emergency Unit with a possible metallic foreign body under the skin following an attempted routine gluteal cyst excision. The patient first noticed a lump under the skin 2 years ago which gradually became more apparent and tender over the previous 2 months. The patient denied recent trauma, had no co-morbidities and had a sterilisation procedure 24 years prior. Examination revealed a non-mobile solid structure just beneath the skin 5 cm laterally from the anal verge. Inflammatory markers were normal and an ultrasound confirmed a 15 × 7 mm foreign body in the subcutaneous tissues. The foreign body was excised easily under local anaesthesia, revealing a closed Filshie sterilisation clip. The wound was closed primarily, and recovery was uncomplicated.ConclusionsThis was a case of sterilisation clip migration to the subcutaneous gluteal region. A literature review revealed 34 case reports of sterilisation clip migration, mostly to the bladder. Patients with a previous sterilisation procedure and suspected subcutaneous foreign body without trauma should elicit a high index of suspicion for migrated sterilisation clips. These clips can migrate through multiple layers of muscle and fascia, including the pelvic floor.

Singular entry point technique for forehead and temple filler augmentation: Anatomical and clinical perspectives.

The depressed volume of the forehead and temple is resolved by filler injection. However, the current method has the potential to cause pain and side effects in patients, depending on the skill of the clinician. Therefore, this study proposes a new method for safer and simpler injection using only one injection entry point. Using the novel injection method, the filler was injected into the forehead and temple regions in three unembalmed cadavers and two healthy Korean volunteers. The cannula and filler locations were identified using dissection, ultrasonography, and three-dimensional (3D) scanning. Ultrasonographic images and dissection results showed that the filler injected into the cadavers was in the target layer. The cannula and filler were located on the layer as the supraperiosteal layer on the forehead and the supra deep temporal fascia layer in the temple. Finally, 3D scanning images showed that the filler was injected precisely and effectively into the forehead and temples of the volunteer who underwent the procedure. This method can reduce pain and minimize externally visible wounds caused by injections. The injected filler was naturally connected from the forehead to the temple and maintained for around 3 months. Additionally, it is possible to inject fillers into the forehead and temple at a constant and safe depth without requiring specific skills. It is expected that this method will become a universal method because it minimizes the burden on both patients and clinicians.

A Safe Methodology for Suction Drain Placement in in Head & Neck Reconstruction after Free Tissue Transfer.

Free tissue transfer is now done routinely for Head & neck reconstruction. A suction drain is needed for efficient drainage of the neck post-dissection & with it arises a new dilemma, challenge or obsession amidst the practicing surgeons about the safe and efficient placement of suction drain in an anatomical location so that it does not injure or impair the anastomosis but will still be able to carry out its role efficiently. No prior studies are available regarding the safe practice. Hence the aim of our study was to explore & establish a reliable manoeuvre where the drain could be introduced in a safe and efficient way. From April of 2017-February of 2024 a prospective study was carried out in which cases of 517 patients were taken into account who underwent head and neck reconstruction using a free tissue transfer procedure where the suction drain tube was placed in the dependent part of the neck (i.e. the posterior triangle region) & the margin of sternocleidomastoid muscle was fixed with the pre-vertebral layer of the cervical fascia. The drain was secured externally with a percutaneous non- absorbable suture. A prospective Study. April 2017- February 2024. A thorough observation was carried out & no evidence of drain induced anastomotic complications were reported. Hence it can be assumed that this particular method of drain placement is both safe & efficient and it can act as a beacon among the surgeons who suffer a from a dilemma & challenge about where to place the drain safely & efficiently.

Anatomical Insights on the Cervical Nerve for Contemporary Face and Neck Lifting: A Cadaveric Study.

Despite the significant roles it plays in the functions of the platysma and lower lip, the cervical branch of the facial nerve is often overlooked compared to other branches, but its consideration is critical for ensuring the safety of neck surgeries. The aim of this study was to clarify the anatomical discrepancies associated with the cervical branch of the facial nerve to enhance surgical safety. The study utilized 20 fresh-frozen hemiheads. A 2-stage surgical procedure was employed, beginning with an initial deep-plane facelift including extensive neck dissection, followed by a superficial parotidectomy on fresh-frozen cadavers. This approach allowed for a thorough exploration and mapping of the cervical nerve in relation to its surrounding anatomical structures. Upon exiting the parotid gland, the cervical nerve consistently traveled beneath the investing layer of the deep cervical fascia for a brief distance, traversing the deep fascia to travel within the areolar connective tissue before terminating anteriorly in the platysma muscle. A single branch was observed in 2 cases, while 2 branches were noted in 18 cases. The cervical nerve's relatively deeper position below the mandible's angle facilitates a safer subplatysmal dissection via a lateral approach for the release of the cervical retaining ligaments. Due to the absence of a protective barrier, the nerve is more susceptible to injuries from direct trauma or thermal damage caused by electrocautery, especially during median approaches.

Multilevel Analysis of the Neovascularization and Integration Process of a Nonvascularized Rectus Fascia Transplantation.

Failure to close the abdominal wall after intestinal transplantation (ITx) or multivisceral Tx remains a surgical challenge. An attractive method is the use of nonvascularized rectus fascia (NVRF) in which both layers of the donor abdominal rectus fascia are used as an inlay patch without vascular anastomosis. How this graft integrates over time remains unknown. The study aims to provide a multilevel analysis of the neovascularization and integration process of the NVRF. Three NVRF-Tx were performed after ITx. Clinical, radiological, histological, and immunological data were analyzed to get insights into the neovascularization and integration process of the NVRF. Moreover, cryogenic contrast-enhanced microfocus computed tomography (microCT) analysis was used for detailed reconstruction of the vasculature in and around the NVRF (3-dimensional histology). Two men (31- and 51-y-old) and 1 woman (49-y-old) underwent 2 multivisceral Tx and 1 combined liver-ITx, respectively. A CT scan showed contrast enhancement around the fascia graft at 5 days post-Tx. At 6 weeks, newly formed blood vessels were visualized around the graft with Doppler ultrasound. Biopsies at 2 weeks post-Tx revealed inflammation around the NVRF and early fibrosis. At 6 months, classical 2-dimensional histological analysis of a biopsy confirmed integration of the fascia graft with strong fibrotic reaction without signs of rejection. A cryogenic contrast-enhanced microCT scan of the same biopsy revealed the presence of microvasculature, enveloping and penetrating the donor fascia. We showed clinical, histological, and microCT evidence of the neovascularization and integration process of the NVRF after Tx.

Evaluating the efficacy of laparoscopic radical antegrade modular pancreatosplenectomy in selected early-stage left-sided pancreatic cancer: a propensity score matching study

BackgroundLaparoscopic radical pancreatectomy is safe and beneficial for recectable pancreatic cancer, but the extent of resection for early-stage tumors remains controversial.MethodsConsecutive patients with left-sided pancreatic cancer who underwent either laparoscopic radical antegrade modular pancreatosplenectomy (LRAMPS, n = 54) or laparoscopic distal pancreatosplecnectomy (LDP, n = 131) between October 2020 and December 2022 were reviewed. The preoperative radiological selection criteria were as follows: (1) tumor diameter ≤ 4 cm; (2) located ≥ 1 cm from the celiac trunk; (3) didn’t invade the fascial layer behind the pancreas.ResultsAfter 1:1 propensity score matching (LRAMPS, n = 54; LDP, n = 54), baseline data were well-balanced with no differences. LRAMPS resulted in longer operation time (240.5 vs. 219.0 min, P = 0.020) and higher intraoperative bleeding volume (200 vs. 150 mL, P = 0.001) compared to LDP. Although LRAMPS harvested more lymph nodes (16 vs. 13, P = 0.008), there were no statistically significant differences in lymph node positivity rate (35.2% vs. 33.3%), R0 pancreatic transection margin (94.4% vs. 96.3%), and retroperitoneal margin (83.3% vs. 87.0%) rate. Postoperative complications did not significantly differ between the two groups. However, LRAMPS was associated with increased drainage volume (85.0 vs. 40.0 mL, P = 0.001), longer time to recover semi-liquid diet compared to LDP (5 vs. 4 days, P < 0.001) and increased daily bowel movement frequency. Tumor recurrence pattern and recurrence-free survival were comparable between the two groups, but the adjuvant chemotherapy regimens varied, and the completion rate of the 6-month intravenous chemotherapy was lower in the LRAMPS group compared to the LDP group (51.9% vs. 75.9%, P = 0.016).ConclusionsLRAMPS did not provide oncological benefits over LDP for left-sided pancreatic cancer within the selection criteria, but it increased operation time, intraoperative bleeding, and postoperative bowel movement frequency. These factors impacted the regimen selection and completion of adjuvant chemotherapy, consequently compromising the potential benefits of LRAMPS in achieving better local control.Graphical

One-stage secondary debulking procedure: A unique technique to restore the differential contour of digit after groin flap reconstruction

BackgroundPedicled groin flap is a reliable reconstructive method for digits. However, problems with the contour, mobility and sensation especially while providing strict thin skin coverage still exist. Patients and MethodsA total of 17 cases with 36 digits injured by trauma were identified. One-stage secondary debulking procedure was adopted for flap revision. The skin over the flap was harvested as a full thickness graft. At the dorsal side of the reconstructed digit, the subcutaneous tissue and fat was debulked till the deep fascial layer. At the volar side, the flap was debulked till the superficial fascial layer. The skin was then re-grafted. The outcomes were reviewed after 12 months follow up. ResultsThe average timing for debulking procedure after flap reconstruction was 116 days. After removal of bolster dressing 7 days after debulking, all the grafted skin took well. A mean length of 2.5cm of digit was preserved for the non-replantatable digits. The reconstructed digits achieved comparable diameter and contour with that of the contralateral side. The two-point discrimination of the injured digits of adults was 10.4 ± 1.6mm. Using a 5-point Likert scale, post-debulking digits showed statistically significant improvement compared to pre-debulking digits. The evaluation of the patients’ satisfactory outcomes of the reconstructed digits was judged as “very satisfying” in 12 patients (75%) and “good results” in four (25%). ConclusionsOne-stage secondary debulking procedure resulted in excellent functional and aesthetic outcomes for digit according to different structure of dorsal and volar sides. Level of EvidenceIV, Retrospective

The influence of fascial manipulation on shoulder range of motion, pain, and function in individuals with chronic shoulder pain

BackgroundA prevalent musculoskeletal condition that has a substantial socioeconomic impact and causes considerable morbidity is chronic shoulder pain (CSP). CSP may result from a dysfunction of the upper quarter region's (UQR) myofascial continuum (MC), which is connected by deep fascia. Fascial Manipulation® (FM), proposed by Luigi Stecco, involves deep kneading performed at specific points on the deep fascia. FM is considered to reinstate the gliding of the fascial layers, thus may aid in the reduction of pain and improvement of shoulder function. ObjectiveThis study aims to determine the influence of FM on shoulder pain, passive range of motion (PROM), and function in participants with CSP. DesignSingle group, pretest-posttest design. MethodEighteen individuals with CSP aged 18–45 years were recruited. FM was applied to the painful and densified centre of coordination (CC) points on the MC of the UQR based on Stecco's FM method. The therapist performed the baseline, post-treatment, and numerical pain rating scale (NPRS) at rest and during activity, PROM, and pressure pain threshold (PPT). The follow-up measurements were done after seven days following the FM intervention. Also, the baseline and follow-up measurements of disability of arm, shoulder, and hand (DASH) score were performed. ResultsA considerable improvement in all shoulder PROM (p < 0.01), DASH score (p = 0.01), and pain reduction (p = 0.01) following FM were observed. However, the PPT showed no differences following FM (p > 0.05). ConclusionFM may be an effective treatment strategy in reducing pain and improving shoulder range of motion and function in patients with CSP.

The Hypoechoic Triangle: A New Sonographic Landmark for Rectus Sheath Block.

Rectus sheath blocks can provide analgesia for upper abdominal midline incisions. These blocks can be placed on patients who are anticoagulated, supine, and under general anesthesia. However, block success rates remain low, presumably because of the difficulty of placing local anesthetic between the correct fascial layers. Here we characterize a hypoechoic triangle with sonography, an anatomic space between adjacent rectus abdominis segments that can be accessed for easier needle tip and catheter placement. This approach could reduce reliance on hydrodissection to correctly identify the potential space and instead improve block efficacy by offering providers a discrete target for local anesthesia.