Fascial Spaces Research Articles

Commentary on: SMAS Fusion Zones Determine the Subfascial and Subcutaneous Anatomy of the Human Face: Fascial Spaces, Fat Compartments, and Models of Facial Aging.

Dr Pessa's current article is a well written and beautifully illustrated cadaver study that should be of significant interest to those performing sub-SMAS facelift surgery and/or facial volume augmentation.1 He has extended the findings of Kikkawa et al2 and Mendelson et al,3 who have previously described the orbital retaining ligaments as a bilaminar membrane and roof of the prezygomatic space. Dr Pessa describes 4 additional bilaminar membranes travelling from fascia or periosteum to the SMAS. Further, he describes the deep fat compartments as bordered by a series of bilaminar vertically and horizontally oriented septae through which vessels, nerve branches, and lymphatics may be stabilized as they pass from deep to superficial. The superficial fascia is then further related to the dermis by the unilaminar reticula cutis passing from superficial fascia to skin. Understanding where these fusion points exist allows the surgeon to avoid facial nerve injury. Dr Pessa's use of dye-injection techniques correlated with cross-sectional rather than layered anatomy makes the cadaver dissections abundantly clear. This means of illustration emphasizes the all-important 3-dimensional nature of this complex anatomical area. While descent, deflation, and ligamentous attenuation have each been implicated in the etiology of facial aging, …

Commentary on: SMAS Fusion Zones Determine the Subfacial and Subcutaneous Anatomy of the Human Face: Fascial Spaces, Fat Compartments, and Models of Facial Aging

What's in a name? That which we call a rose by any other name would smell as sweet. William Shakespeare As the title suggests, this contribution by Dr Pessa1 differs from the usual focused plastic surgery articles in this journal. It is closer to a thesis, being several papers in one on related aspects of this anatomy, to which the reader will likely return. Unfortunately, as is the anatomy, the paper is not easy to understand and I regret this brief Commentary cannot do justice to many aspects worthy of comment. It is the culmination of Dr Pessa's anatomical contributions to plastic surgery over more than 20 years that have followed a continuous theme, being largely based on dye injection studies.2,3 The earlier studies focused on the superficial anatomy, whereas the recent progression into unfamiliar territory of the deeper facial anatomy has been more difficult for plastic surgeons to follow.4 The difficulty is defined in the opening paragraph “the sub-divisions of these layers, the terminology that defines them, and their boundaries have remained a source of controversy throughout medical history.”1 Some good clinical correlations and excellent dissections are included to explain the messages. Having spent considerable time studying the illustrations and their legends on several occasions. I concur with the overall message, despite some disappointing errors of detail in the text. So the focus is to understand the relationship between the superficial and deeper facial anatomy. A sound understanding of basic anatomical principles provides the framework on which to understand the detail described. The cheek is not homogenous, but consists of several functionally, and therefore structurally, different regions. In simplest terms the cheek can be considered as having a central part, the cheek proper, and a peripheral part that can be likened to a …

SMAS Fusion Zones Determine the Subfascial and Subcutaneous Anatomy of the Human Face: Fascial Spaces, Fat Compartments, and Models of Facial Aging.

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.

Aerobic microbiology and culture sensitivity of head and neck space infection of odontogenic origin.

Context:Head and neck space infections source, age, gender, tooth involved, fascial spaces involved, microbiological study of aerobic flora, and antibiotic susceptibilities.Aims:The aim of the present study is to identify causative aerobic microorganisms responsible for deep fascial spaces of head and neck infections and evaluate the resistance of antibiotics used in the treatment of such.Settings and Design:Prospective study in 100 patients.Materials and Methods:This prospective study was conducted on 100 patients who reported in the outpatient department and fulfilled the inclusion criteria to study aerobic microbiology and antibiotic sensitivity in head and neck space infection of odontogenic origin. Pus sample was obtained either by aspiration or by swab stick from the involved spaces, and culture and sensitivity tests were performed.Statistical Analysis Used:Chi-square test and level of significance.Results:Result showed aerobic Gram-positive isolates were 73% and aerobic Gram-negative isolates were 18%. Nine percent cases showed no growth. Streptococcus viridans was the highest isolate in 47% cases among Gram-positive bacteria, and in Gram-negative, Klebsiella pneumoniae was the highest isolate of total cases 11%. Amoxicillin showed resistance (48.4%) as compared to other antibiotics such as ceftriaxone, carbenicillin, amikacin, and imipenem had significantly higher sensitivity.Conclusions:Amoxicillin with clavulanic acid showed (64.8%) efficacy for all organisms isolated, whereas ceftriaxone showed (82.4%) efficacy and could be used in odontogenic infections for both Gram-positive and Gram-negative microorganisms. Substitution of third generation cephalosporin for amoxicillin in the empirical management of deep fascial space infections can also be used. Carbenicillin, amikacin, and imipenem showed (93.4%) sensitivity against all microorganisms and should be reserved for more severe infection. Newer and broad-spectrum antibiotics are more effective in vitro than older narrow spectrum antibiotics.

Pattern of Odontogenic Fascial Space Infections among a Sample of Sudanese Patients

Pattern of Odontogenic Fascial Space Infections among a Sample of Sudanese Patients

Management of Facial Space Infection in a 9-Year-Old Child - A Case Report

<i>Background: </i> Fascial space infections of the head and neck region are usually odontogenic in origin. An untreated or rapidly spreading odontogenic infections can be potentially life threatening. The present case report describes a patient with orofacial infections who required emergent incision and drainage in the oral and maxillofacial surgery OPD at our hospital. <i>Conclusion: </i> Fascial space infections of the head and neck region, though potentially life threatening, can be prevented by regular dental visits. Early recognition and treatment of the infections are necessary to prevent considerable morbidity and mortality, especially in younger patients where more care should be given for oral health. Successful results can be achieved for pediatric patients who can be treated with Incision and Drainage, removal of etiologic factor followed by a combo of three antibiotics.

Acute Fascial Space Abscess upon Dental Implantation to Patients with Diabetes Mellitus

As popularity of dental implantation is increasing, the number of cases associated with complications also increase. Evaluation on diabetes mellitus is often neglected due to the disease's irrelevance to implantability. However, patients with diabetes mellitus are susceptible to infection due to impaired bactericidal ability of neutrophils, cellular immunity and activity of complements. Due to this established connection between diabetes mellitus and infection, a couple of cases were selected to present patients with diabetes mellitus with glycemic incontrollability, suffering from post-implantation dentigerous inter-fascial space abscess.

Applied anatomy of laparoscopic-assisted right hemicolectomy for colon cancer

Laparoscopic-assisted colon surgery is an alternative to open surgery. Furthermore, complete mesocolic excision (CME) as a new concept in colon cancer surgery was first proposed by Hohenberger from Germany, which follows the oncological principle of the tumor and is based on the embryology and anatomy. Some researches about CME showed that this procedure could improve the prognosis, decrease the local recurrence of the tumor without increased complications. Although a laparoscopic approach for right colon cancer is performed frequently, identifying an adequate dissection plane is not always easy. The surgeons need to know well about local anatomy of laparoscopic-assisted radical right hemicolectomy, and to master the right surgical plane in operation process, then to reduce the incidence of conversion to laparotomy and side injury. The superior mesenteric vein (SMV) is the key landmark. The fusion fascia space is the right surgical plane, as well as a series of peripheral peritoneal attachments are important fixations in laparoscopic right hemicolectomy by medial access. Identifying the anatomical location of the SMV and performing meticulous dissection along the SMV is an essential procedure to dissect all potential lymphatic drainage during laparoscopic CME for right colon cancer.

Application of vacuum sealing drainage in the treatment of severe necrotizing fasciitis in extremities of patients

To study the application of VSD in the treatment of severe necrotizing fasciitis in extremities of patients. Eight patients, suffering from severe necrotizing fasciitis, who had been traditionally treated with iodophor-soaked gauze for 21 to 365 days in other hospitals, were transferred to our institute because of the nonhealing wounds and systemic toxic symptoms induced by infection, from January 2011 to August 2013. After admission, surgical debridement was performed timely, and the necrotic tissue was collected during the operation for pathological observation after HE staining. After the operation, VSD was started with negative pressure ranging from -100 to -80 kPa, and the furacilin solution (0.2 g/L) and oxygen (2 L/min) were continuously infused into the wound during the treatment. Surgical debridement was performed repeatedly according to the wound condition followed by change of VSD dressings to continue VSD treatment. The wounds were closed by suturing or with autologous skin grafts after being covered by fresh granulation tissue. The times of surgical debridement, times of change of VSD materials, wound healing status, and length of stay in our institute were recorded. All patients were followed up for a long time. Results HE staining showed that there were diffuse necrotic adipose and fibrous connective tissues in the necrotic tissue, and the normal tissue structure disappeared accompanied by significant infiltration of inflammatory cells. The number of surgical debridement was 2 to 10 (3.9 +/- 2.8) times. The number of VSD materials change was 2 to 10 (4.0 +/- 2.9) times. Wounds were closed by suturing and healed in two patients; wounds in the other six patients were partially sutured, their residual wounds were healed by autologous skin grafting. The length of stay in our institute was 20 to 49 (33 +/- 10) days. All patients were discharged after recovery. Patients were followed up for 2 to 24 months, and their wounds were found to be in good condition without ulceration or recurrence. VSD can effectively remove the necrotic tissues and exudates from the fascial spaces and promote proliferation of granulation tissue. Therefore it serves as an effective approach to the treatment of severe necrotizing fasciitis in extremities.

Characteristics of pyogenic odontogenic infection in patients attending Mulago Hospital, Uganda: a cross-sectional study.

BackgroundPredisposing factors of pyogenic odontogenic infection include dental caries, pericoronitis, periodontitis, trauma to the dentition and the supporting structures or complications of dental procedures. The infections are usually polymicrobial involving normal endogenous flora. We characterised pyogenic odontogenic infection in patients attending Mulago Hospital, Uganda.ResultsOf the 130 patients, 62 (47.7%) were female. The most frequently involved fascial spaces were: the buccal, 52 (25.4%); submasseteric, 46 (22.4%) and the submandibular space, 36 (17.5%). Dental caries was the most prevalent predisposing factor, particularly of the lower third molar teeth. Viridans Streptococci Group and Staphylococcus aureus were the most frequent bacterial isolates: 23.5% and 19.4%, respectively. All Viridans Streptococci isolates were resistant to penicillin G, sulfamethoxazole/trimethoprim (cotrimoxazole), ampicillin and tetracycline, but susceptible to vancomycin. All Staphylococcus aureus strains were resistant to cotrimoxazole and ampicillin while retaining susceptibility to vancomycin, cefotaxime, linezolid, moxifloxacin and amoxicillin/clavulanate. Thirty five (26.9%) patients were HIV infected and the HIV status did not significantly influence the pattern of odontogenic infection.ConclusionsDental caries was the most prevalent predisposing factor for pyogenic odontogenic infection. High prevalence of bacterial resistance to ampicillin and cotrimoxazole suggests the need for regular antibiotic susceptibility tests of isolates and rational use of antibiotics in the management of these infections. Prevention requires strengthening of oral health in the community.

Maxillofacial Infections of Odontogenic Origin: Epidemiological, Microbiological and Therapeutic Factors in an Indian Population.

Odontogenic fascial space infections are commonly encountered by the oral and maxillofacial surgeon. A retrospective study of the epidemiological characteristics, microbiological analysis and treatment response to odontogenic infections treated in the oral and maxillofacial unit of a Dental school is presented. A retrospective analysis of case records of all odontogenic infections that reported to the oral and maxillofacial surgery unit in a Dental school over a period of 2years was performed. Epidemiological data, microbiological profile and treatment responses were analysed. All data were subjected to statistical analysis using SPSS statistical package. Mann-Whitney U test, Kruskal-Wallis test and nonparametric tests were carried out. A total of 2,140 patients were included in this study. Mandibular third molars were the offending tooth in nearly 40% of cases with 107 patients becoming symptomatic following a dental extraction procedure. All patients were treated with surgical incision and drainage, antibiotics and local wound care. More than 95% cases needed intraoral incisions. Penicillin was the drug in most of the cases. The pterygomandibular space was the most commonly involved with 15% reporting with multiple fascial space involvement. Microbiological analysis showed a predominance of aerobic gram positive organisms with Streptococcus sanguis most commonly isolated. Peptostreptococci and Propionibacterium were the common anaerobes isolated. More than 80% of the strains isolated were sensitive to penicillin. The average length of stay was 6.3days. Inadequate documentation with regards to referral patterns, antibiotic history was commonly observed in case records. Penicillin continues to remain the drug of choice for a vast majority of maxillofacial infections of odontogenic origin. A delay in reporting can lead to worsening of symptoms with consequent increase in surgical morbidity and costs of treatment. Preventive dental care remains the best option available to mitigate the consequences of poor oral hygiene. Poor awareness among patient population for regular dental reviews and oral hygiene maintenance emphasises the need for sensitisation and education programs.

Analysis of glycosylated hemoglobin (HbA1c) level on maxillofacial fascial space infection in diabetic patients.

ObjectivesThis study was performed to evaluate the impact of glycosylated hemoglobin (HbA1c) level on characteristics and prognosis of maxillofacial fascial infection in diabetic patients.Materials and MethodsWe reviewed the medical records of 72 patients (35 patients with HbA1c lower than 7.0% and 37 patients with HbA1c higher than 7.0%) diagnosed with maxillofacial fascial space infection and hospitalized for treatment at the Department of Oral and Maxillofacial Surgery in Dankook University Hospital (Cheonan, Korea) from January 2005 to February 2014. We compared demographics, parameters of glucoregulation (HbA1c), laboratory parameters of inflammation (white blood cell [WBC], C-reactive protein [CRP] count), type and number of involved spaces, type and number of antibiotics, period of hospitalization, number of surgical operations, need for tracheostomy, complications, computed tomography (CT), and microorganisms between the two groups.ResultsCompared with the well-controlled diabetes mellitus (DM) group (HbA1c <7.0%), patients in the poorly-controlled (HbA1c ≥7.0%) DM group had the following characteristics: longer hospitalization periods, higher values of laboratory parameters of inflammation (WBC, CRP count) at the time of admission, higher number of antibiotics prescribed, more frequent complications, frequent deep neck space involvement, and distinctive main causative microorganisms. As the HbA1c level increases, hospitalization periods and incidence of complications increase gradually.ConclusionThis retrospective study suggests that regulation of DM significantly impacts maxillofacial fascial infection. Poorly controlled DM with high HbA1c level negatively influences the prognosis of infection.

The esthetic surgical management of a submandibular fascial space infection of odontogenic origin

Background Odontogenic infections are common complications in dental practice and can sometimes spread through the cervical fascia and cause abscesses of the deep fascial spaces. Some of these abscesses can be life threatening. Early diagnosis of these deep fascial abscesses and aggressive antimicrobial and surgical treatment with extensive drainage are of utmost importance. The aim of this presentation is to show the clinical characteristics of a submandibular fascial space abscess and its esthetic, minimally-invasive surgical management.

Species of anaerobic Gram-negative bacilli involved in abscesses localized in the fascial spaces of the head and neck

Background In general, the oro-maxillo-facial infections, including the abscesses in the head and neck spaces, are mixed infections, involving anaerobic bacteria in association with facultative anaerobic microorganisms, with the predominance of the first ones. Since most anaerobes are fastidious bacteria, their isolation and identification are not routinely performed by the clinical laboratory, being considered too time-consuming. The aim of this study was to identify at species level a collection of 44 anaerobic Gram-negative bacilli strains (isolated from pus samples collected from patients with abscesses in the spaces of the head and neck presented to the Clinical Hospital of Oro-Maxillo-Facial Surgery Bucharest, during 2011-2012), stored in ultrafreezer at the laboratory of Microbiology Chair of the Faculty of Dentistry, University of Medicine and Pharmacy “Carol Davila” Bucharest.

The effect of focused instruction on orthopaedic surgery residents' ability to objectively measure intracompartmental pressures in a compartment syndrome model.

Acute compartment syndrome is a condition characterized by an increase in intracompartmental pressure within a closed fascial space, leading to muscle ischemia and tissue death if treatment is delayed1-5. The medicolegal and economic impacts of compartment syndrome have been documented6,7. Diagnosis of compartment syndrome can be difficult in children and in obtunded or unreliable patients8,9. Use of an intracompartmental pressure measuring device, such as the Stryker Intra-Compartmental Pressure Monitor System (Stryker, Kalamazoo, Michigan), provides valuable information in such cases10-12. This system has been shown to be highly accurate in the laboratory setting10,13, but, from personal clinical experience, we hypothesized that the results might be inconsistent if residents used improper techniques. Often, resident physicians are the first clinical staff to evaluate cases of suspected compartment syndrome. Prior to this study, residents at our institution used the Stryker device to document compartment pressures, but no formal assessment of their proficiency with the device existed. Thus, we set out to determine our residents’ ability to use the device correctly (by measuring the number of technical errors they committed with the device’s use) and to document whether technical errors contributed to pressure measurement errors. Furthermore, we wanted to know whether a formal didactic presentation on the device’s proper use would decrease technical errors and would improve accuracy of pressure measurements. Our hypothesis was that, prior to formal training, residents would demonstrate more technical errors using the device at baseline than after teaching and that the number of technical errors would correlate with pressure measurement errors. As the device requires rather simple technical skills, we hypothesized that improvements would be maintained at a later, nine-month, follow-up. ### Study Design There was a sample of convenience in the group …

Factors related to the treatment outcome of maxillofacial fascia space infection

ObjectiveTo identify the predisposing factors related to maxillofacial space infection treatment outcomes. MethodsA retrospective study was performed. Our sample comprised 112 patients admitted to the hospital with fascial space infections. The study variables were classified. Descriptive statistics were computed. The chi-squared test, t test, ANOVA, multivariate linear regression, and logistic regression were used to analyze statistical differences between the groups. ResultsOne hundred and twelve patients (65 males, 47 females) with a mean age of 33.29±19.68 years were admitted to the hospital with infections, mostly due to odontogenic causes. The mean time from the first onset of symptoms to admission was 6.22±4.94 days. Patients often presented with more than one infected space (68.7%). The submandibular space was most commonly involved (46.4%), followed by the pterygomandibular space (28.6%). The white blood cell count at admission ranged from 10,000 to 15,000cell/mm3. The length of hospital stay averaged 5.93±5.39 days. The multiple linear regression showed (statistical significance p=0.002 and p=0.003, respectively) that patients aged 41–60 years or who had at least four involved spaces were positively involved with having longer hospitalizations. The logistic regression showed that patients aged more than 40 years (p=0.021) or who had at least four involved spaces (p=0.001) were more likely to develop complications. ConclusionThe factors that are related significantly to the treatment outcome of maxillofacial infection are increasing age, more than four involved fascial space infection, and immune compromised conditions. The better understanding of these factors and close monitoring of the patients will prevent serious complications.

Natale et. al.'s response to Stecco's fascial nomenclature editorial

Despite their importance in anatomy, physiology, pathology and surgery, the fasciae and the fascial spaces have been poorly described in classic textbooks. This little attention depends on the fact that these fasciae vary in thickness and composition, especially at the cervical level. Indeed, in the main literature they have been described in different forms. Furthermore, the definition itself of the fascia is not consistent in a variety of authors. As a consequence, different criteria have been used to define and classify the fascial systems. In this paper, a brief terminological history and the most common nomenclatures and classifications of the fascia have been summarized.

Descending necrotizing mediastinitis: 5 years of published data in Japan.

Descending necrotizing mediastinitis implies infection originating from the neck, most commonly an oropharyngeal or odontogenic focus, that spreads in the cervical fascial spaces and descends into the mediastinum. Early diagnosis is essential because descending necrotizing mediastinitis can rapidly progress to septic shock and organ failure. A comprehensive review of the current data of descending necrotizing mediastinitis in Japan was carried out using PubMed and ICHUSHI from the last 5 years. The symptoms, origins, comorbid conditions, treatment modalities, complications, and survival rates were analyzed. Tonsillar and pharyngeal origin was more identified compared to odontogenic origin. More than one-third of patients were diabetic and 28% of them were not identified as having any comorbidity. Streptococcus sp. and anaerobes were most isolated, reflecting the microflora of the oral cavity. Of the broad antibiotics, carbapenem was the most used as treatment, and clindamycin was the most co-given. Mediastinal drainage approach varied widely and the optimal approach is controversial. Twenty-one patients were treated with video-assisted thoracic surgical drainage and 15 cases by percutaneous catheter drainage, whereas transcervical approach was applied in 25 patients and thoracotomy was carried out in 21 patients. The overall mortality was 5.6%. Many authors advocated that the most effective management tool is a high degree of clinical suspicion followed by prompt and adequate drainage with intensive care including hemodynamic and nutritional support and repeat computer tomographic monitoring.

Use of blue dye in sentinel lymph node biopsy: Time to reevaluate

Use of blue dye in sentinel lymph node biopsy: Time to reevaluate

Closure of the axillary fascial space avoids the need for drainage in axillary dissection

Background: Axillary drainage is routinely employed after axillary lymphadenectomy to reduce the rate of seroma formation in these patients. This unit adopted a new technique for axillary dissection that allows closure without the use of an axillary drain.