Fascial Layers Research Articles

Ultrasound-guided superficial cervical plexus block reduces opioid consumption in patients undergoing craniotomy via suboccipital retrosigmoid approach: a randomized controlled trial

IntroductionThe effectiveness of superficial cervical plexus block (SCPB) at decreasing opioid use and improving hemodynamic stability during suboccipital retrosigmoid craniotomy has not been established. The aim of this study is...

Single midline incision approach for decompression of greater, lesser and third occipital nerves in migraine surgery

BackgroundThe traditional approach for occipital migraine surgery encompasses three separate surgical incisions in the posterior neck to decompress the greater occipital nerves (GON), lesser occipital nerves (LON), and third occipital nerves (TON). Other incisions have been investigated, including singular transverse incisions. We sought to evaluate a single, vertical midline incision approach for decompression of all six occipital nerves.MethodsUsing 10 cadaveric hemi-sides (5 fresh cadaver head and necks). Anatomic landmarks and the location of the bilateral GON, LON, and TON were marked according to previous anatomic studies. A single, midline 9-cm incision was made, and lateral skin flaps were raised to decompress or avulse all six nerves.ResultsThrough the midline incision, the GON and TON were identified at 3.5 and 6.2 cm, respectively, inferior to a line bisecting the external auditory canal (EAC) and 1.5 cm lateral to the midline. The LON was identified as 6-cm inferior and 6.5-cm medial to a line bisecting the EAC in the plane just above the investing layer of the deep cervical fascia until the posterior border of the sternocleidomastoid was encountered. The LON had the greatest amount of variation but was identified lateral to the posterior border of the SCM.ConclusionsA single midline incision approach allows for successful identification and decompression of all six occipital nerves in migraine surgery.

Hem-o-lok-free and Retzius-sparing robot-assisted laparoscopic radical prostatectomy with retrograde release of the neurovascular bundle

Abstract Background: Robot-assisted laparoscopic radical prostatectomy (RARP) has gradually become the standard surgical procedure for prostate cancer. This video, http://links.lww.com/CURRUROL/A10 aimed to demonstrate a new and improved surgical approach for prostate cancer that passes through the pouch of Douglas and allows retrograde release of the neurovascular bundle (NVB). The technique is Hem-o-lok-free and Retzius-sparing and is performed without opening the pelvic floor fascia during RARP. Methods: A 69-year-old man was diagnosed with prostate cancer (clinical stage T2bN0M0). We followed the process of Retzius-sparing RARP [published by Galfano et al. in 2013] and did some modification. The critical technical points associated with this technique included locating the fascial layer at the prostatic apex and performing complete retrograde release of the NVB along the anatomical structure. We used diathermy to perform precision hemostasis on large vessels, especially those around the basal part of prostate, with relatively less damage. In addition, Hem-o-lok was not used in this procedure. Results: Negative surgical margin and stage T2bN0M0 were confirmed. Continence was achieved immediately after cathter removal. One month after surgery, prostate specific antigen was undetectable. Erectile function was preserved 3 months postoperatively. Conclusions: Hem-o-lok-free and Retzius-sparing RARP is a feasible surgical approach that combines the benefits of complete retrograde release of the NVB, preserving the nerves and vascular structures around the prostate, protecting the pelvic floor structure, and ensuring rapid recovery of micturition control.

Anchoring the Temporalis Muscle with an Intact Fascial Layer Along the Superior Temporal Line in Pterional Craniotomy: A Technical Note

Manipulation of the temporalis muscle during pterional and frontotemporal approaches poses major cosmetic and functional issues postoperatively. The temporalis muscle has usually been secured in its normal position using implants or by leaving a thin rim of muscle and fascia attached along the superior temporal line. In the present report, we have described a pure tissue-based method of anchoring the intact temporalis muscle precisely along the superior temporal line. A total of 30 consecutive cases of pterional or frontotemporal craniotomy were performed by single surgeon (SKR). A subfascial dissection technique was used to expose the transition zone of the frontal pericranium with the temporalis fascia. These were then separated by sharp dissection along the superior temporal line at which the muscle is attached. The temporalis muscle and fascia were repositioned during closure, precisely at their original anatomical location by passing multiple anchoring sutures along the free edge of the muscle and fascia lying along the superior temporal line. Temporalis muscle reattachment was achieved in all 30 cases with good cosmesis and functional outcome without temporalis muscle-related complications at 6 months of follow-up. The approximation of sutures running through the free edge of the temporalis muscle with intact fascia along the superior temporal line from anteriorly to posteriorly restored the muscle and fascial layer to its original position. Avoidance of the formation of any potential dead space during surgical exposure will prevent periorbital edema and/or subgaleal collection postoperatively. The described inexpensive technique avoids implant-related complications, with good functional and aesthetic outcomes. A comparative study is needed to establish the superiority of this procedure over other techniques.

Inferior oblique muscle of the eye: its foetal development with special reference to understanding of the frequent variants in adults.

To provide better understanding of frequent variations of the inferior oblique (IO) of adult extraocular muscles, we observed sagittal and horizontal histological sections of the eye and orbits from 32 foetuses (7-34 weeks of gestational age; 24-295 mm of crown-rump length). In early foetuses (7-8 weeks), the IO was restricted at an antero-infero-medial angle of the future orbit. In contrast to extraocular recti, the IO appeared to extend along the mediolateral axis and had no definite tendon. At midterm, the IO tendon became evident. Sometimes, the IO muscle belly attached to the inferior rectus or, the IO tendon divided into two laminae to enclose the lateral rectus. At late-term, a multilayered sheath was evident around the sclera and, via one or some of the fascial layers, the IO was communicated with a fascia enclosing the inferior rectus. At midterm and late-term, the IO originated not only from the maxilla near the orbicularis oculi origin but also from a vein-rich fibrous tissue around the lacrimal sac. Both origins were muscular without intermittent tendon or ligament. Therefore, the fascial connection as well as a direct contact between the IO and the inferior or lateral rectus seemed to provide variant muscular bridges as reported in adults. Moreover, the two attachment sites at the origin seemed to provide double muscle bellies of the adult IO. Consequently, the present specimens contained seeds of any types of adult variations. The muscle fibres from the lacrimal sac might play a role for the lacrimal drainage.

An Extremely Rare Case Report of a Retroperitoneal Hernia Following Spinal Surgery

Introduction: Retroperitoneal hernias are extremely rare lumbar wall defects. Secondary hernias can occur after previous flank surgeries, infection or trauma. There is a paucity of literature regarding lumbar incisional hernias, most of them related to lateral approaches to the spine. Research Question: The objective of this article is to report a rare case of a retroperitoneal hernia following spinal surgery. Material and Methods: We review a rare presentation of a symptomatic acquired retroperitoneal hernia following several posterior lumbar spine approaches. An extensive literature review regarding retroperitoneal hernia and its relation to spinal surgery was performed. Results: A successful hernia repair suturing the transversalis fascia to the middle layer of the thoracolumbar fascia using a biological mesh was performed, with resolution of the hernia symptoms. Discussion and Conclusion: Although retroperitoneal hernias are extremely rare, we must emphasize the importance of an adequate surgical exposure in order to preserve the retroperitoneal and thoracolumbar fasciae as biological barriers during surgical approaches to the spine.

An Updated Review on Layered Closure Techniques for Total Hip Arthroplasty.

One of the main concerns with total hip arthroplasty is the development of periprosthetic joint infections (PJIs). Appropriate wound closure can contribute to the prevention of PJIs with a watertight closure effectively sealing the implant from the outside. It is important to continuously investigate which materials as well as techniques are potentially the most efficacious and cost effective for wound closure. Therefore, the purpose of this review article was to critically appraise the current total hip arthroplasty wound closure materials and techniques as reported in the literature. Specifically, we evaluated: 1) fascial approximations; 2) subdermal closures; 3) subcuticular and skin closures; 4) wound dressings; as well as 5) capsular and short external rotator repairs. A literature search was performed using the PubMed database from inception to February 2022. The query consisted of terms including "hip, arthroplasty, wound, closure, capsular closure, fascial closure, subcutaneous closure, and skin closure." References from selected texts were also reviewed for inclusion. Only manuscripts written in the English language were included for final analysis. A systematic review was performed for the five topics: 1) fascial approximations; 2) subdermal closures; 3) subcuticular and skin closures; 4) wound dressings; as well as 5) capsular and short external rotator repairs. Additionally, a meta-analysis was performed on the closing time of fascial approximations. The current literature supports performing a layered closure of the wound by approximating the fascial layers, which can help close any empty spaces. The techniques for closure at this layer seem to be equal regarding wound complications between running knotless barbed sutures versus interrupted throws; however, knotless sutures have the potential of a quicker closure time. A total of three out of four reports and the meta-analyses demonstrated that wound closure time can be reduced with barbed sutures, along with decreased number of sutures required as also shown by three out of four reports. The most superficial layers, subcuticular and skin, can be closed with either sutures, staples, or skin adhesives, all of which appear to have adequate outcomes. A report found that patients who had skin closure with barbed suture had faster time to a dry postoperative wound and lower rates of delayed discharge. For the overlying dressing, an occlusive and absorbent dressing can both protect the wound as well as collect any residual wound drainage. Two reports found increased dryness, decreased wound drainage, and decreased rates of delayed wound healing with use of 2-octyl cyanoacrylate topical adhesive with flexible self-adhesive polyester mesh dressings. If the capsule and short external rotators are taken down during the approach, repairing these can potentially help increase postoperative hip stability as well as decrease dislocation rates. The variety of materials and techniques available to close a THA wound allows surgeons to tailor closure to be patient specific. In general, the authors recommend performing layered closures from the capsule and short external rotators (if taken down during the approach), fascial layer closure with either a running knotless suture, subcutaneous closure either with the same knotless suture as the fascial layer brought more superficially, or with simple interrupted sutures to tack down any empty space, as well as finally subcuticular and skin sutures with a skin adhesive glue overtop. The skin adhesive can help provide an extra layer, particularly in active patients.

Outcomes of Deep Wound Management Methods During Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

Wound closure for total knee arthroplasty (TKA) typically focuses on promoting the most optimal healing, while preventing infection, allowing for functionality and immediate ambulation, as well as providing for excellent cosmesis. We have previously described four aspects of closure for TKA including the: (1) deep fascial layer; (2) subdermal layer; (3) intradermal layer, including the subcuticular region; and (4) a specific dressing. In this systematic review and meta-analysis of the literature, we will focus on closure of the deep fascial layer. Specifically, we assessed: (1) wound complication risks of different techniques; (2) closing times of different sutures; and (3) postoperative ranges of motion depending on varying levels of knee flexion or extension. There were 12 reports on wound complication risks, closing times, and positionings. The meta-analysis demonstrated overall lower wound complication risks with the use of barbed sutures (6 versus 13%, p<0.05). It also demonstrated overall significant closing time reductions with the use of barbed sutures (p<0.05). Additionally, three out of four reports showed the positive effects of closure in flexion for TKAs, while one report was inconclusive. In conclusion, this systematic review and meta-analysis demonstrated lower wound complications, decreased closing times for barbed sutures, as well as superior outcomes for closures in a semi-flexed knee position.

African Wild Dogs (Lycaon pictus) Show Adaptations to Sociality and Hypercarnivory in Their Cranial Musculature

African wild dogs (Lycaon pictus) are highly social canids that live in large, hierarchical packs and engage in coordinated hunts. Recent research has suggested that enlarged muscles associated with expressive movement of the eyes and eyebrows may have evolved in domestic dogs (Canis familiaris) to facilitate interspecies communication with their human owners. In L. pictus, communication is reported to occur predominantly through vocalization with reduced reliance on facial expressions; however, the mimic muscles in L. pictus have never been described and evaluated. L. pictus is also hypercarnivorous with the highest documented bite force quotient of any mammalian carnivore. It has large, mobile ears, which enhance its auditory capabilities while hunting and assist with thermoregulation.We performed detailed dissections of the muscles of facial expression, mastication, and auricular movement in an adult male L. pictus,and conducted diffusible iodine‐based contrast‐enhanced computed tomographic (diceCT) scans of the head. Musculus levator anguli oculi medialis (LAOM) and retractor anguli oculi lateralis (RAOL), muscles of hypothesized importance in domestic dog‐human non‐verbal communication, are enlarged in L. pictus, suggesting that ocular expressions represent a significant component of communication. LAOM exhibits an intricate relationship with adjacent orbital musculature including partial fusion along its borders with mm. orbicularis oculi and frontalis. Muscles that draw the angles of the mouth caudally (e.g., m. zygomaticus major) are expanded. Numerous ramifying branches of CN VII and CN V2 course across the face to provide extensive sensory and motor innervation. These findings indicate that facial expression musculature of African wild dogs is well‐equipped for non‐verbal communication and that the same adaptations argued to facilitate communication between domestic dogs and humans may also facilitate intraspecific communication in L. pictus.Muscles of mastication are especially enlarged in L. pictus, with multiple bellies of mm. masseter and temporalis separated by deep layers of thick intermuscular fascia and with expanded insertions onto the mandible. Musculus digastricus is composed of a single, large belly without intervening tendon, and it receives its innervation exclusively from CN V3. These enlargements reflect increased masticatory capabilities in L. pictus, which enable its powerful bite force and hypercarnivorous diet. Auricular muscles are also well‐developed, supporting greater leverage and fine manipulation of its large, mobile ears. Musculus frontoscutularis is well‐developed and distinctly separable from m. frontalis, suggesting greater leverage of the auricle via attachments to the scutiform cartilage. The intrinsic ear muscles differ in pattern and orientation from all other published canids, demonstrating unique muscular control over rotation and fine manipulation of the auricle. Taken together, these morphological patterns illustrate that specific adaptations in the cranial musculature of L. pictus facilitate its ecological habits.

MP46-14 INGUINAL LYMPHADENECTOMY FOR PENILE CANCER USING A FASCIAL SPARING TECHNIQUE - OUTCOMES FROM A SINGLE CENTRE

You have accessJournal of UrologyCME1 May 2022MP46-14 INGUINAL LYMPHADENECTOMY FOR PENILE CANCER USING A FASCIAL SPARING TECHNIQUE - OUTCOMES FROM A SINGLE CENTRE Nicolo' Schifano, Castiglione Fabio, Matthew Rewhorn, Paul Hadway, Rees Rowland, Raj Nigam, Hussain M. Alnajjar, and Asif Muneer Nicolo' SchifanoNicolo' Schifano More articles by this author , Castiglione FabioCastiglione Fabio More articles by this author , Matthew RewhornMatthew Rewhorn More articles by this author , Paul HadwayPaul Hadway More articles by this author , Rees RowlandRees Rowland More articles by this author , Raj NigamRaj Nigam More articles by this author , Hussain M. AlnajjarHussain M. Alnajjar More articles by this author , and Asif MuneerAsif Muneer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002612.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical inguinal lymphadenectomy is performed for penile cancer patients who have pN+ disease in the inguinal lymph nodes. In order to reduce the morbidity, modified approaches have been described to reduce the size of the incision or reduce the number of lymph nodes removed. We describe the technique and report the oncological outcomes and complication rates of a fascial sparing inguinal lymphadenectomy technique. METHODS: Over a 10 year period, 294 fascial sparing inguinal lymphadenectomy procedures were performed in 173 patients. The technique uses a subinguinal incision with an ellipse of skin excised if there are any palpable nodes. Identification and preservation of the Scarpa’s and Camper’s fascia is the first layer preserved. All the superficial inguinal nodes were removed en bloc in the femoral triangle under this fascial layer whilst preserving the subcutaneous veins and fascia lata. The saphenous vein was spared where possible as part of the technique. Kaplan-Meier curves estimated the survival functions after the procedure. Postoperative morbidity was also retrospectively analysed. RESULTS: Median (interquartile range, IQR) follow-up was 28 (14-90) months. A median (IQR) number of 9 (6-12) nodes were removed per groin. The 3-year cancer-specific survival rate was 84% for pN1, and 56% for pN2-3 disease (p<0.001) compared to 91% for pN0 cases (Figure 1). A total of 105 postoperative complications (35.7%) occurred, including 46 conservatively-managed wound infections (15.6%), 13 cases of deep wound dehiscence (4.4%), 41 cases of lymphoedema (13.9%), 3 cases of deep vein thrombosis (1.0%), 1 case of pulmonary embolism (0.3%), and 1 case of postoperative sepsis (0.3%). There were no patients requiring blood transfusion. CONCLUSIONS: Fascial sparing inguinal dissection offers excellent oncological outcomes whilst decreasing the morbidity rates. Preservation of the fascia lata does not affect oncological outcomes. Patients with more advanced nodal-involvement had poorer survival rates which is in keeping with contemporary data. The technique reduces the risk of wound breakdown and bleeding from the structures deep to the fascia lata. Source of Funding: No source of founding to be acknowledged © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e778 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicolo' Schifano More articles by this author Castiglione Fabio More articles by this author Matthew Rewhorn More articles by this author Paul Hadway More articles by this author Rees Rowland More articles by this author Raj Nigam More articles by this author Hussain M. Alnajjar More articles by this author Asif Muneer More articles by this author Expand All Advertisement PDF DownloadLoading ...

Retropharyngeal, Parapharyngeal and Peritonsillar Abscesses.

Deep neck infections (DNIs) include all the infections sited in the potential spaces and fascial planes of the neck within the limits of the deep layer of the cervical fascia. Parapharyngeal and retropharyngeal infections leading to parapharyngeal abscess (PPA) and retropharyngeal abscess (RPA) are the most common. DNIs remain an important health problem, especially in children. The aim of this narrative review is to describe the management of peritonsillar, retropharyngeal and parapharyngeal abscesses in pediatric age. Despite relatively uncommon, pediatric DNIs deserve particular attention as they can have a very severe course and lead to hospitalization, admission to the intensive care unit and, although very rarely, death. They generally follow a mild upper respiratory infection and can initially present with signs and symptoms that could be underestimated. A definite diagnosis can be made using imaging techniques. Pus collection from the site of infection, when possible, is strongly recommended for definition of diseases etiology. Blood tests that measure the inflammatory response of the patient may contribute to monitor disease evolution. The therapeutic approach should be targeted toward the individual patient. Regardless of the surgical treatment, antibiotics are critical for pediatric DNI prognosis. The diagnostic-therapeutic procedure to be followed in the individual patient is not universally shared because it has not been established which is the most valid radiological approach and which are the criteria to be followed for the differentiation of cases to be treated only with antibiotics and those in which surgery is mandatory. Further studies are needed to ensure the best possible care for all children with DNIs, especially in this era of increased antimicrobial resistance.

Development of Tribological Model of Human Fascia: The Influence of Material Hardness and Motion Speed

Low back pain is one of the most prevalent health disabilities worldwide. It is suggested that thoracolumbar fascia is possible causality of low back pain due to nerve innervation and pathological changes. A tribological model of fascia layers sliding across each other was developed in the present study. The influence of motion speed was investigated. The experiments were carried out in a pin-on-plate configuration using a normal load of 1 N and a range of speed from 1 to 5 Hz. Additionally, since fascia changes its structure depending on health conditions and physical activity, the influence of material hardness was studied. Therefore, different hardness of PDMS is considered to mimic different densities of the tissues. High-viscosity hyaluronic acid and low-viscosity oil were used as the lubricants. It was revealed that there is an apparent influence of lubricant viscosity with increasing material hardness. The friction increased with increasing movement speed for most of the PDMS hardness investigated. It seems the combination of high viscosity of hyaluronic acid, compliant material, and low speed can lead to low friction behaviour. Therefore, future studies will focus on finding even more compliant material for further development of the model towards mimicking the contact of human soft tissues.

Anatomy of the vesicovaginal fascia and its relation to branches of the inferior hypogastric plexus.

The inferior hypogastric plexus (IHP) lies in the extraperitoneal pelvis, and supplies branches to pelvic and perineal viscera. In men, the rectoprostatic fascia (Denonvillier's fascia) forms a distinct double fascial layer between the seminal glands and the rectum. The hypogastric nerve projections to the prostate and seminal glands run anterior to this. An analagous fascial layer in women between the vagina and cervix posteriorly and the urinary bladder anteriorly has recently been described. The purpose of this study was to examine the anatomy of the vesicovaginal fascia (VVF) and to determine its relationship to the anterior branches of the IHP. This dissection study examined the fascial layers between the posterior urinary bladder and anterior vagina/cervix (VVF) in 15 female embalmed cadavers and three fresh specimens. Anterior branches of the IHP were identified and followed distally. The relationship between these nerve projections and the VVF was examined. In 16 dissection, the VVF was identified as a complete fascial plane extending beneath the vesicouterine pouch to the neck of the bladder inferiorly and to the endopelvic fascia laterally. Anterior projections from the hypogastric nerves and IHP maintained an extraperitoneal course passing anteriorly to the VVF towards the urinary bladder The VVF is a distinct fascial structure and projections of the hypogastric nerves pass anterior to this. This may have implications for nerve sparing hysterectomy.

The Key of Pocket Dissection in Transaxillary Dual-plane Breast Augmentation: How to Control Inferior Malposition of Smooth Implants

Inferior implant malposition after breast augmentation is the second most common reason for revision surgery. This article introduces the new concept of dual-plane pocket formation in transaxillary breast augmentation to prevent inferior implant malposition by preserving the continuity of the superficial layer of the deep pectoralis fascia. Patients who underwent transaxillary endoscopic breast augmentation performed from January 2017 to December 2019 were retrospectively reviewed. With the aid of the endoscope, dissection proceeded. During pectoralis muscle origin detachment, the superficial layer of deep pectoralis fascia was preserved. After making the pocket, silicone gel implants were inserted. A retrospective chart review was done to collect data on postoperative complications. A total of 251 patients were performed, and the mean follow-up time was 20.6 months. In a total of 28 cases of complications (9.6%), there were 2 cases of reoperations. In a total of three patients (1.2%) of implant malposition, one patient (0.4%) developed mild bilateral bottoming-out deformity. Meticulous dissection by endoscopy could avoid the destruction of the superficial layer of the deep pectoralis fascia during pocket dissection and produce an intact fascial system with its own continuity at the inframammary fold (IMF). A well-controlled envelope over the implant and a supporting structure underneath it are important in breast augmentation to prevent inferior implant malposition.

Laparoscopic total mesorectal excision with urogenital fascia preservation for mid-low rectal cancer: Anatomical basis and clinical effect - Experimental research

BackgroundTotal mesorectal excision (TME) is conventionally performed according to Heald's principles through the so-called 'holy plane', between the visceral and parietal fasciae. However, urinary and sexual dysfunctions remain frequent postoperative complications. We proposed to preserve urogenital fascia (UGF) in TME, and this study aimed to clarify the anatomical basis of this technique and evaluate its efficacy and safety. Materials and methodsCadaveric dissection was performed on 26 pelvises, and laparoscopic TME with UGF preservation was performed in 212 patients with mid-low rectal cancer. The fasciae and spaces related to TME were observed and described, and the clinical effect of UGF-preserving TME was analyzed. ResultsIn the 26 cadavers, fascia propria of the rectum (FPR) presents as a fibrous capsule enveloping the mesorectum. UGF extends postero-laterally to the rectum, enveloping the hypogastric nerves and ureters. We demonstrated that the visceral fascia is actually the UGF, and FPR and visceral fascia (i.e. UGF) are two independent layers of fascia. Thus, FPR, UGF and parietal fascia form two avascular spaces behind the rectum. The plane ventral to the UGF is the real 'holy plane' for TME, rather than that dorsal to the UGF as is traditionally thought. Laparoscopic TME with UGF preservation was successfully performed in all 212 patients, with low perioperative complications (10.8%) and a low 3-year local recurrence rate (4.2%). Furthermore, the incidences of urinary and sexual dysfunctions at postoperative 6 months were only 6.1% and 10.8%, respectively. ConclusionThe avascular plane between the FPR and UGF (i.e. visceral fascia) is the real 'holy plane'. Laparoscopic TME with UGF preservation is a feasible radical surgery for mid-low rectal cancer, with better protection of urinary and sexual functions.

Comparison of deep neck infections in children and adults from diagnosis to treatment: A cross-sectional retrospective study

Background: Although deep neck infections (DNI) are less common today with antibiotics and oral care, they carry a serious risk of morbidity and mortality, especially when complications develop. These infections spread in potential cavities created by the layers of the deep neck fascia. Since the process of DNI in children and adults may differ, it was aimed to examine the patients in two groups, children and adults. Demographic characteristics, clinical findings, diagnosis and treatment processes of children and adults with DNI were presented and compared. In addition, another aim of the study was to examine the differences between the most common deep neck infections in the study. Methods: The medical files of 166 patients aged 1-78 years diagnosed with DNI were scanned retrospectively. In our study, when the differences between adults and children were taken into account about DNI, the 9 most common diagnoses were compared in terms of age, complaints, examination findings, radiological imaging reports, complete blood count, C-Reactive Protein, erythrocyte sedimentation rate, surgical procedures, medical treatment, hospitalization time and mortality rates. Results: The three most common causes of DNI were dental problems, lymphadenitis and tonsillitis. When the imaging methods requested for diagnosis were examined, it was seen that 52.4%(n=87) of those performed were computed tomography and 43.4%(n=72) ultrasonography. During treatment, all patients received prophylactic antibiotherapy. Tracheostomy was performed in 9 of 15 patients who developed respiratory distress during follow-up. Conclusions: Although the decreasing frequency of DNI, technological developments and increasing awareness, it still carries a serious risk of mortality and morbidity due to its potential and important complications. Due to inadequate dental and oral care, dental problems are still the most important factor in the aetiology of DNI. Reducing morbidity and mortality depends on rapid diagnosis and appropriate treatment selection.

A comparative study of ultrasound-guided serratus anterior plane block with pectoral nerve block type II in breast surgeries

Background: The use of ultrasonography (USG) to identify fascial layers has led to the development of several newer interfascial techniques for analgesia of the chest and abdominal wall. Two such modalities are the Pectoral nerve block (PEC) and Serratus Anterior Plane (SAP) block. Objective: To compare the duration and quality of analgesia provided by ultrasound-guided SAP block with PEC block II in patients undergoing breast surgeries after induction of general anesthesia. Design: Randomized, double-blinded, prospective study. Methods: Sixty female patients were divided into two groups of 30 each. Patients in Group P received USG guided PEC II block, whereas patients in Group S received USG-guided SAP block after induction. Outcome Measure: The primary objective was to compare the duration of pain relief, whereas the secondary objectives were to compare the degree of pain relief, postoperative analgesic requirement within 24 h after the completion of the surgery, patient satisfaction score and complications if any. Results: The mean time of the first dose of analgesic given was 826 ± 405.24 min. in Group P and 1280 ± 264.29 min. in Group S (P < 0.001). The mean numeric rating scale score at rest at 6 h, on movement at 2 h and 6 h and satisfaction scores in Group P were significantly more than Group S. Conclusion: Ultrasound-guided SAP block provides better postoperative analgesia both in quality and duration over PEC II block.

Anatomy of the Breast Fascial System: A Systematic Review of the Literature.

Understanding the anatomy of the fascial and ligamentous structures of the breast is important in both aesthetic and reconstructive breast surgery. Several structures have been identified that play a significant role in the aesthetic qualities and support of the breast warranting consideration in the context of breast reconstruction. The authors performed a systematic review of anatomical, clinical, histologic, and radiologic studies that have described, characterized, and named these structures. The authors have summarized and critically appraised prior research to clarify and define the key fascial structures of the breast, their anatomical function, and their clinical significance in aesthetic and reconstructive breast surgery. Through their review, six distinct breast fascial structures were encountered consistently in the literature. The authors have organized them into intraglandular and extraglandular structures and have reviewed their significance in the context of reconstructive breast surgery. The primary fascial structures of the breast are important anatomical landmarks with numerous clinical applications. Cooper ligaments divide the breast parenchyma. The superficial and deep layers of the superficial fascia encase the breast in a "pocket," condensing into one thickened layer of fascia along the peripheral breast footprint. The inframammary fold supports and defines the inferior pole. The horizontal septum is a reliable neurovascular landmark. The vertical septum is a newly discovered fascial structure. There are certainly clinical implications that have yet to be described because of the relatively limited and disputed information on the fascia of the female breast and, ultimately, more research is warranted.

Clinicopathological features of verrucous hemangioma

Objective: To investigate the clinicopathological features, and differential diagnosis of verrucous hemangioma (VH). Methods: Twenty-eight VH cases diagnosed from 2005 to 2020 in Henan Provincial People's Hospital, Zhengzhou, China were analyzed retrospectively. Immunohistochemical studies were used to detect diagnostic markers. The mutation status of PIK3CA (exons 9 and 20) was detected using fluorescence PCR. Results: There were 13 males and 15 females in 28 cases, with the male to female ratio of 1.0∶1.2. There were 25 patients under the age of 18 years. The age range was from 10 months to 56 years (mean, 9.7 years; median, 4.5 years). There were 17 cases occurred in the lower extremities, 7 in the upper extremities and 4 in the trunk. All 28 cases were irregular red patches on the skin, which grew slowly. Some of them were thickened with uneven surface, which was light pink or red-white. Skin lesions of the 7 cases ranged from dark red and reddish brown, with a rough and hard surface. Satellite foci were present. Microscopically, 28 cases had a wide range of pathological features. Dilated, malformed vessels were observed from dermal papilla to deep soft tissue. Among them, the dermal papillary layer was mainly composed of many proliferating and expanding thin-walled capillaries and cavernous blood vessels. Thin-walled small vessels were found in the dermal reticular layer and subcutaneous fascia layer, with no obvious endothelial cell proliferation, occasional papillary hyperplasia, and lobular distribution of the malformed vessels in the fascia layer mixed with the fibroadipose tissue. There was epidermal papillary hyperplasia with hyperkeratosis and parakeratosis, lengthening and mutual fusion of epithelial horns. Immunohistochemistry showed that CD31, CD34, ERG and WT-1 were diffusely and strongly positive. The expression of GLUT-1 was present in superficial dermal vascular endothelial cells, but undetectable in the deep layer. The PIK3CA tests of 13 cases showed that no somatic mutations were found in exons 9 and 20. Twenty-five patients were followed up for 5 months to 10 years. Seven patients underwent multiple surgical resections and plastic surgeries due to the large size, and 8 patients had recurrence. Conclusions: VH is a rare congenital vascular malformation and more commonly occurs in infants and children. It tends to appear in limbs, especially lower limbs and distal limbs. Its morphology and immunophenotype are characteristic and should be distinguished from other vascular malformations and the resolution phase of infant hemangiomas. In about one third of the cases, postoperative recurrence may occur and long-term follow-up is often required.

Unilateral absence of external oblique musculo-aponeurotic complex during routine inguinal hernia repair.

IntroductionThe isolated absence of the external oblique musculo-aponeurotic complex in adults is an extremely rare anomaly. This complex is an important contributor to the strength of the inguinal canal. The present case report describes the unilateral absence of the external oblique muscle in a patient.Case presentationA 40-year-old male patient presented with a history of intermittent lower abdominal pain for 5 years which had increased over the past 6 months. Abdominal examination revealed unilateral reducible, incomplete, left sided direct inguinal hernia.Clinical discussionElective unilateral Lichtenstein's mesh hernioplasty was planned for the patient. Intraoperatively, there was no evidence of the external oblique aponeurosis and the spermatic cord was noted deep to the thickened membranous fascial layer. The inguinal ligament was thin and atrophic and was attached to the pubic tubercle medially and anterior superior iliac spine laterally. There was no evidence of any superior aponeurotic connection to the inguinal ligament. A postoperative ultrasound examination of the abdomen confirmed the unilateral absence of the external oblique musculo-aponeurotic complex.ConclusionThe possibility of such an anomaly should be considered in patients without other risk factors for hernia.