Intramuscular Layer Research Articles

Clinical Implications of Fat Grafting in the Posterior Calf: A Dynamic Cadaver-based Study.

Intramuscular fat grafting in extremity muscles, especially the gastrocnemius, has become increasingly popular. However, while safety in truncal muscle fat grafting has been well-studied, research on extremity muscles is lacking. In this study, we aimed to explore the anatomy of the gastrocnemius muscle and adjacent structures as intramuscular and subcutaneous recipient sites. Additionally, we sought to analyze pressure-volume relationships and fat migration patterns during posterior calf grafting. Eight cadaveric lower extremities were examined. A prosection was performed to better understand the vascular complex around the gastrocnemius. Ultrasound-guided fat injections were then performed into both the subcutaneous and intramuscular layers; dynamic pressures were measured with a manometer. Last, dyed-injectant was injected subcutaneously to better elucidate subcutaneous anatomy. Anatomic prosection demonstrated the proximity of the gastrocnemius muscle to the popliteal venous system that arborized (>1 mm) intramuscularly. In the 3 specimens that underwent intramuscular fat grafting, the peak intramuscular pressures plateaued at 21 mmHg (19.5-23 mmHg); there was no observed extrafascial migration of the injectant. With subcutaneous injectant in 1 specimen, pressures in the subcutaneous space increased (125 mmHg) with additional injectant (240 mL) while pressures in the intramuscular space remained relatively constant (4 mmHg). Intramuscular gastrocnemius fat grafting should be done with caution: its proximity to critical veins and sustained increased intramuscular pressures following grafting increases risks of embolus and thrombosis, respectively. Subcutaneous injection may be safer in that increased pressures are not communicated to deep structures. Last, we present a novel description of posterior calf subcutaneous compartments that may better allow surgeons to direct and predict subcutaneous injectant.

S3687 Unusual Cause of Bleeding From an Underlying Glomus Tumor

Introduction: Glomus tumors (GTs) are rare, mostly benign mesenchymal neoplasm accounting for nearly 1% of all gastrointestinal soft tissue tumors. Commonly seen in distal extremities, they do rarely occur in the gastrointestinal tract where it most commonly involves the stomach, especially the antrum. These tumors lack specific symptoms and endoscopic findings making it hard to differentiate from other gastrointestinal submucosal tumors without resection. We present a rare case of gastric glomus tumor (GGT) in the antrum diagnosed in a patient presenting with melena. Case Description/Methods: 47-year- old male patient presented with melena. Upper endoscopy revealed a non-bleeding gastric ulcer with a visible vessel. Almost 3 cm submucosal lesion was seen at the site of the ulcer concerning for possible hematoma. Given the size of the lesion a follow up CT scan was performed 2 months later which showed persistent 3 cm submucosal circumscribed hyper enhancing lesion at the pylorus. The patient was then scheduled for endoscopic ultrasound which showed a hypoechoic lesion with discrete borders arising from the muscularis propria measuring 22 × 24 mm in maximal dimension. Fine needle biopsy of the lesion was performed using 22-gauge needle. Pathology revealed uniform round cells intimately associated with gaping vessels. The cells were reactive for vimentin and smooth muscle actin consistent with the diagnosis of glomus tumor. The patient was referred to surgery for excision (Figure 1). Discussion: Glomus tumor of the stomach arise from the intramuscular layer and often present as a solitary submucosal lesion. GGTs usually present with epigastric discomfort, hematemesis, melena, nausea or vomiting or rarely as an incidental finding. Endoscopic ultrasound typically shows hypoechoic circumscribed lesions mostly arising from the fourth layer of the stomach. However biopsies are rarely conclusive thus making preoperative diagnosis challenging. Given its rare malignant potential, wide local surgical excision is the treatment of choice.Figure 1.: Endoscopic ultrasound of a glomus tumor in the gastric antrum. Figure 2: Upper endoscopy of a glomus tumor with a central ulcer and visible vessel.

The Study of Relationship between Anatomical Sites and Depth of the Lipoma.

BackgroundLipomas are the most common benign tumors and surgical removal is the treatment of choice. However, some deep-seated lipomas are technically challenging to surgically excise from a dermatologist’s perspective. This study was planned to help predict the depth of lipomas depending on their anatomical site of occurrence.ObjectiveTo determine whether there is a relationship between the anatomical site and the depth of lipomas.MethodsWe retrospectively reviewed the medical records of 459 patients with 459 lesions diagnosed as lipoma, surgically treated between June 2006 and June 2019. Histopathologic evaluation was performed to determine the relationship between the depth and the specific subtype of the lipoma.ResultsThe most common site of occurrence was the trunk (177; 38.6%). Most of the lipomas (388; 84.5%) were located in the subcutaneous fat layer. Some lipomas (71; 15.5%) were found in deeper tissues, such as the intramuscular, intermuscular, and submuscular layers. The forehead and flank had a higher incidence of deep-seated lipomas than other areas.ConclusionOur results revealed that lipomas in the forehead and flank are more likely to occur in deeper layers. In clinical practice, physicians often skip radiologic evaluation before surgery. However, we recommend preoperative radiologic evaluation before surgical excision of lipomas of the forehead and flank.

Colonic electrical stimulation promotes colonic motility through regeneration of myenteric plexus neurons in slow transit constipation beagles.

Slow transit constipation (STC) is a common disease characterized by markedly delayed colonic transit time as a result of colonic motility dysfunction. It is well established that STC is mostly caused by disorders of relevant nerves, especially the enteric nervous system (ENS). Colonic electrical stimulation (CES) has been regarded as a valuable alternative for the treatment of STC. However, little report focuses on the underlying nervous mechanism to normalize the delayed colonic emptying and relieve symptoms. In the present study, the therapeutic effect and the influence on ENS triggered by CES were investigated in STC beagles. The STC beagle model was established by oral administration of diphenoxylate/atropine and alosetron. Histopathology, electron microscopy, immunohistochemistry, Western blot analysis and immunofluorescence were used to evaluate the influence of pulse train CES on myenteric plexus neurons. After 5 weeks of treatment, CES could enhance the colonic electromyogram (EMG) signal to promote colonic motility, thereby improving the colonic content emptying of STC beagles. HE staining and transmission electron microscopy confirmed that CES could regenerate ganglia and synaptic vesicles in the myenteric plexus. Immunohistochemical staining showed that synaptophysin (SYP), protein gene product 9.5 (PGP9.5), cathepsin D (CAD) and S-100B in the colonic intramuscular layer were up-regulated by CES. Western blot analysis and immunofluorescence further proved that CES induced the protein expression of SYP and PGP9.5. Taken together, pulse train CES could induce the regeneration of myenteric plexus neurons, thereby promoting the colonic motility in STC beagles.

COLON ATRESIA IN COMBINATION WITH HIRSCHSPRUNG’S DISEASE: A RARE CLINICAL CASE

Introduction. Hirschsprung’s disease is a congenital anomaly characterized by the absence of ganglion cells in submucosal and intramuscular layers of intestinal wall that leads to the intestinal obstruction. 70–80 % of cases are isolated malformation but it can be combined with chromosomal abnormalities and other malformations. Coexistence of Hirschsprung’s disease with intestinal atresia is extremely rare. It can cause significant difficulties in diagnostics and treatment.Material and methods.Patient A, a boy, was transferred to the surgical department at the age of two days with a history of intestinal obstruction. He had abdominal X-ray studies: intestinal obstruction. The contrast enema showed microcolon that was coiled in the pelvis. Patient was prepared to the surgical treatment. Intraoperatively colonic atresia was identified at 10 sm from the ileocecal valve. A double colostomy was performed to the child and biopsy on the level of mucous fistula was taken. Histological study showed the aganglionosis of the distal colon. At the age of 4 months, the patient underwent Soave-Swenson endorectal pullthrough procedure with intraoperative extended express-biopsy that confirmed the absence of ganglion cells in whole distal bowel. The aganglionic part was resected, the ileocecal valve with the part of the colon of 10 cm long was mobilized and the endorectal bringing the colon down to the perineum was performed by Soave – Swenson. Postoperative recovery was uneventful.Results.A high index of suspicion is required to promptly diagnose Hirschsprung’s disease in a child with colonic atresia despite the rare combination of these two anomalies. In this case the histological study allowed to recognize association of colonic atresia with Hirschsprung’s disease and helped to avoid complications after further surgery.Conclusions. Early detection of coexisting of these two anomalies helps to prevent the development of serious postoperative complications.

Positional relationship of superior and inferior labial artery by ultrasonography image analysis for safe lip augmentation procedures.

The aim of this study was to use ultrasonography to determine the locations and distributions of the superior labial artery (SLA) and the inferior labial artery (ILA) relative to the vermilion border (VB). Sixty healthy Korean volunteers (35 males, 25 females; age, 21-36 years) were investigated using ultrasonography. The participants had not received any noninvasive treatment or surgical procedure in the facial regions during the previous 6 months. Based on the VB, the overall thicknesses of the upper and lower lips were 9.4 ± 0.4 mm (mean ± SD) and 10.9 ± 0.7 mm, respectively. In most cases, the labial arteries were located in the wet mucosal layer on both the upper (35-57%) and lower lips (28-55%), respectively. In the upper lip, the SLA was in the intramuscular layer in 20-45% of cases, making it the second most common type. At some of the measuring points, the SLA was observed more often in the intramuscular layer than in the wet mucosal layer. In the lower lip, the ILA was also located in the dry mucosa (5-27%). The dry-wet mucosal junction is unclear in the lip area, and the ILA was commonly observed at the dry-wet mucosal junction. The arterial depth was 5.3 ± 0.3 mm in the upper lip and 4.2 ± 0.4 mm in the lower lip. The SLA and ILA are evenly distributed over all parts of the oral mucosa. Injection procedures for lip augmentation should therefore use very superficial approaches. Clin. Anat. 33:158-164, 2020. © 2019 Wiley Periodicals, Inc.

Gastrointestinal Occurrence of a Glomus Tumor

Glomus tumors are benign subepithelial mesenchymal neoplasms generally found in the fingers. It is rare to find a glomus tumor in the gastrointestinal tract. This is a case of a gastric glomus tumor (GGT). It is important to understand the difference betwen a glomus tumor and a gastrointestinal stromal tumor (GIST), which is far more common. The patient is a 26 year old Caucasian female who, for the past one year, had been visiting the gastroenterology clinic with complaints of epigastric abdominal pain, constipation, diarrhea, and heartburn. She was a moderately built individual with no abnormal vitals or notable findings on physical examination. We decided to do an EGD, and a mass in the body of the stomach was discovered. CT abdomen revealed a high density nodular lesion. EUS showed a 2.5cm x 2.2cm submucosal mass with mixed echogenicity and cystic spaces, arising from the muscularis propria of the stomach wall. The biopsy was consistent with a neuroendocrine lesion. Neuroendocrine markers were negative. However, smooth muscle actin and vimentin were strongly immunoreactive. Serotonin levels were normal, and octreotide scan revealed a faint glow in the tumor. Surgery was consulted and laparoscopic partial gastrectomy was performed. Pathology of the wedge resection revealed a gastric glomus tumor 1.8cm in diameter with well-defined margins and no evidence of malignancy. Subepithelial tumors of the gastrointestinal tract include carcinoid tumors, lymphomas, glomus tumors, and GIST. GIST, being the most common, are thought to arise from the interstitial cells of Cajal of the autonomic nervous system of the intestine. Glomus tumors arise from the glomus body in the intramuscular layer, typically in the antrum of the stomach. Both appear on CT as well-circumscribed homogenous masses, and on EUS as hypoechoic masses. However, GGT can be distinguished from GIST based on immunohistochemisty. GIST is typically positive for c-kit (CD117), whereas GGT may test positive for smooth muscle actin, laminin, collagen type IV, desmin, and vimentin.2680_A Figure 1. MR Abdomen, showing a 2.2cm homogenously-enhancing subepithelial gastric antral wall mass.2680_B Figure 2. Microscopic examination, showing multiple blood vessels surrounded by round glomus cells.Even though EUS-FNA differentiates GTs from more aggressive gastric tumors with a 95.6% accuracy, surgery is still preferred. According to the National Comprehensive Cancer Network, if the GIST is >2cm it should be surgically resected. Even if there were any doubt between a GT or GIST, wedge resection is the therapeutic management of choice. This rare case taught us how to diagnose and treat a gastrointestinal glomus tumor.

Identification and Distribution of the Interstitial Cells of Cajal in the Abomasum of Goats

The interstitial cells of Cajal (ICCs) are regarded as pacemakers and are involved in neurotransmission in the gastrointestinal tract (GIT) of animals. However, limited information is available about the existence of ICCs within the GIT of ruminants. In this study, we investigated the ultrastructural characteristics and distribution of ICCs in goat abomasum using transmission electron microscopy and c-kit immunohistochemistry. Two different kinds of c-kit immunoreactive cells were observed in the abomasum. The first was identified as ICCs, which appeared to be multipolar or bipolar in shape, with some processes. These c-kit immunoreactive cells were deposited in the submucosal layer, myenteric plexus between the circular and longitudinal muscle layers, and within the longitudinal and circular muscle layers of the abomasum. The second type of cell was round in shape and was identified as mast cells, which were located in the submucosal layer as well as in the lamina propria. Ultrastructurally, ICCs were also observed as stellate or spindle-shaped cells, which were consistent in shape with our c-kit immunoreactive cells. In the cytoplasm of ICCs, numerous mitochondria, rough endoplasmic reticulum, and caveolae were detected. ICCs were located in the myenteric plexus between the longitudinal and circular muscle layers (ICC-MY), with the longitudinal and circular muscle layer was replaced as “intramuscular layers” (ICC-IM), and in the submucosal layer (ICC-SM). In addition, we found ICCs surrounding nerve fibers and smooth muscle cells, where they formed heterocellular junctions in the form of close membrane associations or gap junctions and homocellular junctions among the processes of the ICCs. In the current study, we provide the first complete characterization of ICCs within the goat abomasum and propose that ICCs might have a key role in producing contractions in the ruminant stomach for proper absorption of nutrients.

Ácidos grasos de lípidos intramusculares y grasa de cobertura en búfalos suplementados con aceite de pescado

El objetivo fue investigar la influencia de la suplementación dietaria de búfalos con aceite de pescado sobre el ácido linoleico conjugado (ALC) y los ácidos grasos Ω6 y Ω3 en lípidos intramusculares (IM) y grasa de cobertura (GC). Se emplearon veinte animales divididos en dos grupos alimentados sobre <i>Brachiaria brizantha</i> y suplementados con 3 kg de afrecho de arroz, 500 g de maíz y 500 g de pellet de girasol, durante 60 días. El grupo I se mantuvo con esta dieta, el II recibió adicionalmente 100 ml/día de aceite de pescado por animal. Los resultados (expresados en mg/g grasa) indicaron una disminución de ácido palmítico en IM y GC del grupo II (189,05) vs grupo I (206,97) y en II (259,72) vs I (280,84) respectivamente. El ALC se incrementó levemente en IM y GC del grupo II (17,09) vs I (11,56) y en el II (16,80) vs I (11,75) respectivamente. El ácido linoleico (18:2 n6) en IM del grupo II (23,45) disminuyó en relación con el I (38,19) y en GC del grupo II (13,21) se incrementó levemente con relación al I (12,71). El ácido alfa linolénico (18:3 n3) en IM de grupos I y II fue similar (8,37 y 8,69), en cambio el contenido de dicho ácido en GC fue menor en el grupo I (4,70) comparado con el grupo II (6,05). La relación Ω6/Ω3 en IM y GC fue más estrecha en el grupo II (2,69:1) y (2,18:1) con relación al grupo I (4,55:1) y (2,70:1) respectivamente. La suplementación con aceite de pescado produjo disminución del ácido linoleico, mejorando la relación entre Ω6/Ω3. Además causó una leve disminución de los valores de ácido palmítico y un pequeño aumento de ALC.

The Fate of Fat Grafts in Different Recipient Areas: Subcutaneous Plane, Fat Pad, and Muscle.

Although fat is transplanted into several layers, including subcutaneous, fat, and muscle layers, there is little (clinical) scientific basis for these procedures. To determine the optimal recipient layer for fat transplantation. Fat harvested from inguinal fat pads of green fluorescent protein (GFP) mice was grafted into the subcutaneous and intramuscular planes and the fat pads of C57 mice. Specimens collected after 1, 4, 8, 12, and 16 weeks were stained with hematoxylin and eosin to determine angiogenesis and fibrosis in the grafts. The survival rate of donor adipose tissue was determined by measuring GFP expression. Fat was retained longer in fat pads than in subcutaneous layers of recipient mice and longer in subcutaneous than in intramuscular layers. Angiogenesis and vascularized connective tissue were greater in intramuscular than in subcutaneous or fat grafts. Neovascularization, however, was similar in fat pads and subcutaneous grafts. Survival rate was higher for intramuscularly injected fat than subcutaneously and fat pad injected fat. Fat pad injection showed the highest graft retention rate, indicating that fat pads maybe the optimal area for fat transplantation. The increased blood supply to muscle suggests that intramuscular injection maybe optimal when there is little movement.

Endoscopic Management of Recurrent Food Impactions and Dysphagia in a Patient With Allgroveʼs Syndrome

Clinical Vignette: A 23-year-old male with Allgrove's syndrome complicated by multiple esophageal strictures with esophageal diverticula, and recurrent food impactions presented with dysphagia. He was diagnosed with achalasia in infancy and was previously treated by Heller myotomy and fundoplication. Endosopcy was performed and a gastroscope could not pass an esophageal stricture, just below the upper esophageal sphincter. Instead, an ultraslim nasal scope was successfully used and a jagwire was passed under fluoroscopic guidance into the stomach. The jagwire then assisted scope navigation through the esophagus. A long stricture was identified from 30 cm to 40 cm with a food bolus located proximally and removed by Roth net. The stricture was serially dilated using a TTS CRE balloon from 4 to 6 mm (Image 1). The nasal scope was then advanced distally to 40 cm where another food bolus was fragmented using biopsy forceps and deposited into the stomach. The patient tolerated the procedure well and his diet was advanced. He was discharged with outpatient follow-up for stricture dilation. Discussion: Allgrove's syndrome is a rare autosomal recessive disorder characterized by a triad of adrenal insufficiency, achalasia, and alacrima often associated autonomic dysfunction. Esophageal abnormalities are similar to idiopathic achalasia caused by a thickening of the intramuscular layer, loss of the myenteric ganglia and decreased nitric oxide signaling. Traditional treatments include Heller myotomy and endoscopic dilation. The most frequently used dilators for achalasia are the wire-guided polyvinyl dilators (Savary-Gilliard) and the TTS CRE balloon dilators. The Savary-Gilliard dilator exerts a radial force as it gradually passes distally, though the dilating force is transmitted longitudinally secondary to shearing effects. In contrast, the balloon dilators lack longitudinal force and deliver the radial force instantly. Longitudinal force and lack of visualization pose a significant risk for perforation and are contraindicated in multiple, long, or complex strictures, or when diverticula are present. Our patient has a complex esophageal stricture due to asymmetry, diameter < 12mm, and inability to pass the endoscope. While no clear advantage has been demonstrated among dilator types, this case highlights the benefit of endoscopic visualization with the CRE balloon dilator to accurately position the balloon across the stricture.Figure 1

A compound ampoule for large-volume controllable jet injection.

We present a new design for a needle-free injector ampoule, using two concentric pistons to pressurize the fluid during the injection. The smaller, inner piston is used to provide an initial high-velocity piercing jet; it then engages the outer piston to deliver the remaining drug via a low-velocity jet. The goal of this design is to enable needle-free delivery of relatively large volumes to controlled depths in tissue, a task impractical with conventional ampoules and actuators. We demonstrate this concept by constructing a 1.2mL ampoule, measuring the jet velocity it produces in free air, and performing a set of injections into post-mortem porcine tissue. The ampoule smoothly produces the two desired phases of an injection, with a smooth transition of jet velocity as the two pistons engage. The injection is able to penetrate porcine skin to a controlled depth and deliver fluid to the subcutaneous and/or intramuscular layers, though further investigation is required to ensure that all of the fluid delivered can be retained at the desired depth.

Anaplastic lymphoma kinase-negative anaplastic large cell lymphoma with extranodal involvement of the thigh muscle: a case report

IntroductionAnaplastic large cell lymphoma is a rare type of non-Hodgkin lymphoma. The most common extranodal sites of anaplastic large cell lymphoma are skin, subcutaneous tissue, bone, lung, and gastrointestinal organs. The involvement of the skeletal muscle has been described rarely in extranodal anaplastic large cell lymphoma.Case presentationAn 89-year-old Japanese man visited our hospital with a three-month history of swelling of his left thigh and slight fever. The swelling had rapidly enlarged and become painful within the previous three days. Magnetic resonance imaging scans revealed two soft-tissue tumors in the intramuscular layer between the vastus medialis muscle and the adductor muscle. Extensive peritumoral inflammatory edema was obvious. As the results of physical and radiological examinations were highly suggestive of abscess formation, we prescribed antibiotics for two weeks. However, our patient’s symptoms did not improve. Therefore, we suspected a soft-tissue sarcoma, and our patient underwent an incision biopsy. Histological analysis revealed that the atypical cells were positive for CD3 and CD30 but negative for anaplastic lymphoma kinase. A computed tomography scan of the thorax revealed mediastinal lymphadenopathy and bilateral pleural effusions, suggestive of extranodal involvement of skeletal muscle in anaplastic lymphoma kinase-negative anaplastic large cell lymphoma. We planned to give our patient systemic chemotherapy. However, rapid systemic dissemination occurred and our patient died of multiple organ failure five weeks after his first visit to our hospital.ConclusionsHere, we present a case of anaplastic lymphoma kinase-negative anaplastic large cell lymphoma with extranodal involvement in the thigh muscle. The involvement of such a rare organ may lead to initial misdiagnosis and a delay in the onset of treatment.

Intravascular Glomus Tumor of the Forearm Causing Chronic Pain and Focal Tenderness

Introduction. A glomus tumor is a benign vascular tumor derived from glomus cells and occurs mainly in the subcutaneous layer of the subungual or digital pulp. Extradigital glomus tumors have been reported within the palm, wrist, forearm, foot, bone, stomach, colon, cervix, and mesentery. Glomus tumors can originate from the intraosseous, intramuscular, periosteal, intravascular, and intraneural layers. However, a glomus tumor originating from the intravascular layer of the forearm is a rare condition. Case Report. A 44-year-old woman had a 7-year history of chronic pain and focal tenderness of the forearm. No hypersensitivity or sensory alterations were observed. Contrast magnetic resonance imaging (MRI) showed a mass measuring 5 × 3 × 2 mm leading to a vein. Surgical excision was performed, and the tumor was completely resected. Finding of gross examination revealed a dark-red, well-defined soft tissue tumor, and histologic examination confirmed that the mass was a glomus tumor. The patient's symptoms were completely resolved postoperatively. Conclusion. Intravascular glomus tumors rarely occur in the forearm; therefore, a thorough physical exam, comprehensive medical history, in-depth imaging, and early surgical excision upon clinical suspicion may be helpful to prevent a delayed or incorrect diagnosis.

Sparganosis of Upper Extremity in Subcutaneous and Intramuscular Layers

Sparganosis of Upper Extremity in Subcutaneous and Intramuscular Layers

Diffuse-Type Giant Cell Tumor in Deltoid Muscle

Diffuse-type giant cell tumor is relatively rare than localized giant cell tumor. Moreover, diffuse type giant cell tumor is common in intraarticular area, rarely occurs at intramuscular or subcutaneous layer. We experienced 1 case of giant cell tumor within the deltoid muscle. So we report this case with review of the literatures.

Diagnostic value of Power Doppler flow imaging through vagina in malignant gestational trophoblastic tumors

Objective To evaluate the diagnostic value of power Doppler ultrasonography through vagina in malignant trophoblastic tumor(MTT).Methods The features of power Doppler flow imaging of 43 cases with MTT were studied retrospectively.The imaging differences in normal group,benign gestational trophoblastic tumors and malignant gestational tropho-blastic tumors were compared,and the relationship between imaging character and benign or malignant gestational trophoblastic tumors was analyzed.At the same time,the change of blood flow in uterine intramuscular layer was obeserved before and after chemotherapy combined with β-hCG.Results The blood folw character of uterine intramuscular layer in normal group was punctate and scattered blood flow signal,flow shape was regular;The blood folw character of uterine intramuscular layer in benign gestational trophoblastic tumors group was short pole blood flow signal,flow shape was less regular;The blood folw character of uterine intramuscular layer in malignant gestational trophoblastic tumors group was very rich blood flow signal,flow shape was anomalistic; After chemotherapy,the extent and diameter of the blood folw of uterine intramuscular layer was decreased seriously,while the β-hCG reduced.Conclusion PDI had diagnostic value in MTT and could be seemed as a guide for observing the chemotherapeutic effect and prognosis of MTT. Key words: Malignant gestation trophoblastic tumor; Power doppler image; Blood flow

Cavernous hemangioma occurred between the trapezius and splenius capitis muscle.

Hemangiomas are the most common benign tumor of soft tissue. They are frequently seen on the trunk and extremities. In addition, most of them exist at the skin and subcutaneous layer, but fewer than 1% does in the intramuscular layer. For the diagnostic images of the intramuscular cavernous hemangioma, ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) are used currently. Multiple therapeutic methods are used, but surgical excision is considered as the most ideal treatment. We describe the recurred cavernous hemangioma occurred between the trapezius and splenius capitis muscle. The mass was well demarcated but scattered and infiltrated into the adjacent muscle layer, therefore, extensive resection was unavoidable. When determining a treatment regime for the hemangioma, it is essential to consider the size of the mass, cosmetic and functional aspects of the patient.

Case Report: Successful Endovascular Treatment of Saccular Thoracic Aneurysm with “Shaggy Aorta”

A 68 year old man was admitted to our hospital with dysphagia and back pain. Contrasted computed tomography showed "Shaggy aorta" forming a saccular descending aortic aneurysm with edematous esophagus. Low density area in the intramuscular layer of the esophagus suggested the possibility of connection between the esophagus and the aneurysm. The patient underwent endovascular treatment of the aneurysm. The postoperative course was uneventful, and the patient was discharged from the hospital with improvement in his symptoms. Although there are reports suggesting endovascular treatment as a contraindication for shaggy aorta due to risk of embolization, it may be considered as an option for a patient who is in need of surgical treatment.

Anterolateral Thigh Perforator Flap

The anterolateral thigh (ALT) perforator flap is based on the septocutaneous or musculocutaneous perforators from the lateral circumflex femoral vessels. Each perforator artery should be accompanied by 2 veins. Anomalies of the perforator anatomy in the subfascia and intramuscular layer are rarely reported. This study analyzed 6 anatomic perforator variations from subfascial to intramuscular level out of 1043 ALT perforator flaps performed from 2005 to 2007 in China Medical University Hospital in Taichung, Taiwan and from 2004 to 2007 in E-Da Hospital in Kaohsiung, Taiwan. The perforator flaps included (1) 1 perforator artery and 4 accompanying veins, (2) 1 perforator artery and 1 accompanying vein, (3) 1 tortuous perforator artery and 1 accompanying vein, (4) 1 perforator artery with no accompanying vein, (5) 2 veins with no accompanying perforator artery, and (6) 1 vein only. These variations in perforator anatomy were believed to be the causes of total or partial flap failure after excluding all the other possibilities such as vessel kinking or perforator injury during intramuscular dissection. Further, the nearby anteromedial thigh or tensor fasciae lata flaps were considered alternative flaps in cases of unusual perforator anatomy. The contralateral ALT flap was also necessary in some cases. However, anatomic variations in perforators from subfascial to intramuscular layer must be considered if the flap is to be used safely and reliably.