Subfascial Approach Research Articles

Safe Reduction of Intermammary Distance in Implant Breast Augmentation Without Fat Grafting.

Over the latest 15 years, breast augmentation with implant has been progressively refined technically and artistically. However, little attention is usually given to the intermammary space. The aim of this article is to report author's experience and technique in the safe reduction of the intermammary space in breast augmentation with implants without fat grafting. From July 2019 to July 2021, 62 consecutive patients undergoing cosmetic breast enhancement with implant and requesting a reduction of the intermammary space were retrospectively evaluated. Preoperatively, breast features were registered for all patients. Preoperative intermammary distance ranged from 2.3 to 7 cm (5.4 ± 0.74). The average follow-up time was 20 months (range 12 to 36 months). All implants were anatomical silicon-gel filled implants with micropolyurethane foam shell. No major early and late complications were experienced. The outcomes were graded as excellent in 45 breasts (72.6 %), very good in 15 (24.2%), good in the two cases (3.2%) with minor delayed wound healing (less than 1 cm) which solved conservatively within 1 month. Patients' satisfaction was high to very high. Postoperative intermammary distance was reduced in all cases and ranged from 1 to 4.5 (mean 2.6 ± 0.52 cm) CONCLUSION: The intermammary distance can be safely reduced with implant only in all cases who seek it, both via submuscular and via subfascial approach by a precise medial pocket dissection and implantation of micropolyurethane foam-coated implant, which guarantee device's stability during the healing process avoiding malposition. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

“Does the Exploration of the Temporomandibular Joint Using a Deep Subfascial Technique Result in a Superior Operative Outcome?”

The literature is replete with various approaches for the temporomandibular joint (TMJ), each with its own distinct advantages and disadvantages. None of these approaches, however, have been associated with superior operative outcomes. The purpose of this study was to measure the efficacy of three operative approaches to TMJ, namely superficial, subfascial, and deep subfascial approaches. The aim was to contrast selected intraoperative and postoperative outcomes among these surgical approaches. This was a prospective randomized clinical trial of subjects presenting to outpatient department. The primary predictor variables were three dissection planes of TMJ: Group-I (superficial), Group-II (subfascial), and Group-III (deep subfascial). The primary outcome variables were quality of surgical field employing fromme scale, dissection time in minutes, amount of blood loss in milliliters, and facial nerve function (FNF) using House-Brackmann scale. The secondary outcome variables were postoperative pain using visual-analog scale and swelling in millimeters measured on 1st, 3rd, and 7th postoperative days and quality of life using facial clinimetric evaluation questionnaire at 6-month follow-up. Age, gender, side, diagnosis, and type of surgery were the covariates. The data were analyzed using descriptive, comparative, and regression analysis. A P value of less than .05 was considered statistically significant. The study included thirty subjects (8 males and 22 females) with various TMJ disorders ranging in age from 8 years to 65years (mean 27.83±10.52). On evaluation of intraoperative parameters, subfascial approach had statistically significant superior quality of surgical field (Group-I: 1.90±0.57; Group-II: 1.10±0.32; Group-III: 1.40±0.52; P value=.006), statistically significant shortest dissection time (Group-I: 18.30±3.74min; Group-II: 13.240±1.96min; Group-III: 16.20±1.99min; with P value=.03), and statistically significant lower amount of blood loss compared with other groups(Group-I: 92.40±4.74ml: Group-II: 82.30±3.77ml; Group-III: 84.60±3.06ml; Pvalue<.001). On assessment of postoperative parameters, only FNF of temporal branch showed statistically significant difference from 24 hours till 3 months with better outcome in deep subfascial approach. Mean scores of FNF at 24 hours and 1-week (Group-I: 4.20±2.39; Group-II: 2.40±2.27; Group-III: 1.50±1.58 P=.02) and 1-month and 3-month (Group-I: 2.70±1.82; Group-II: 1.20±0.63; Group-III: 1.00±0.00 P=.04). The subfascial approach significantly improved intraoperative outcomes and deep subfascial approach was comparatively safe with fewer incidence of facial nerve injury.

Deep Subfascial Approach in the Management of Zygomatic Arch Fracture: A Case Report

Even for the most skilled maxillofacial surgeon, gaining access to the zygomatic arch for surgical procedures can be difficult due to the potential obstruction caused by a depressed zygomatic arch fracture, leading to restricted mouth opening. There are various treatment options available for zygomatic arch fractures. This article discusses the deep subfascial technique as a means to access the Temporomandibular Joint (TMJ) and zygomatic arch. This surgical procedure ensures a secure operative field while minimizing the risk to facial nerve branches. Here, the authors present the case of a 62-year-old male patient who sustained a right zygomatic arch fracture in a road traffic accident. The fractured segments were treated surgically through open reduction and internal fixation using the deep subfascial approach. The procedure resulted in minimal post-operative discomfort, no functional impairment, successful reduction of the fracture, and restoration of function.

Deep Subfacial Approach for Temporomandibular Joint Ankylosis Patient with Evaluating Facial Nerve Injury by “Facial Nerve Grading System

Background: Preservation of the functional integrity of the facial nerve (FN) is a critical measure of success in temporomandibular joint (TMJ) surgery. In spite of the development of a myriad of surgical approaches to the TMJ, FN remains at risk. The deep subfascial approach provides an additional layer of protection (the deep layer of the temporalis fascia and the superficial temporal fat pad) to the temporal and zygomatic branches of the FN and thus, is the safest method to avoid FN injury. Objectives: To assess FN injury following TMJ surgery using deep subfascial approach and measuring it on House and Brackman facial nerve grading system (HBFNGS). Materials and Methods: Twenty TMJs in 18 patients were operated for TMJ ankylosis, using “the deep subfascial approach.” FN function was assessed postoperatively at 24 h, 1 week, 1 month, 3 months, 6 months using HBFNGS. Statistical analysis was done using SPSS 16.0. Results: Of 20 surgical sites 3 sites showed Grade III (moderate) FN injury and 17 sites showed Grade II (mild) FN injury at 24 h. The condition improved with time with full recovery of FN at all surgical sites at 6 months. Conclusion: The deep subfascial approach has a distinct advantage over the conventional approaches when dissecting the temporal region and is the safest method to avoid injury to FN.

Cosmetic considerations for placement of deep brain stimulation pulse generator: the submammary subfascial approach.

Deep brain stimulation (DBS) is an effective treatment for a number of debilitating neurological diseases. However, the placement of an implantable pulse generator (IPG) can lead to significant cosmetic concerns for some patients. We present a subfascial technique of DBS IPG implantation under the breast using a more concealed scar location. The technique is illustrated in a female patient who favored a more aesthetic placement of the DBS to treat essential tremor. Relevant literature of this approach from both breast augmentation and cardiac pacemaker implantation was reviewed. An excellent cosmetic outcome was demonstrated, and reviewing the literature, implanting under the pectoralis major fascia has the potential benefit of reducing complication rates associated with silicone implant placement in the plastic surgery literature when compared to other planes. The subfascial implantation of IPG was described. This plane, which is used routinely in breast augmentation, has the potential to decrease complication rates compared to placement in the subglandular plane. An inframammary incision provides patients with concerns about the scar and stigmata associated with an infraclavicular location of DBS generator a better cosmetic outcome.

Subfascial versus extrafascial ultrasound-guided stellate ganglion block in patients with post-mastectomy sympathetically mediated pain: A randomized clinical trial.

Despite being a well-described intervention, the optimal anatomical approach to perform a stellate ganglion block (SGB) has been disputed. We compared the subfascial and extrafascial ultrasound-guided (USG) SGB. A randomised clinical trial was conducted, consisting of 50 patients in two groups. Group I received SGB via the subfascial approach while Group II received an SGB via the extrafascial approach. The primary endpoint was successful sympathetic blockade (as indicated by a measured temperature rise of ≥2°C). Secondary endpoints included analgesic efficiency (extent of early onset of pain relief as indicated by >50% improvement in Visual Analogue Scale (VAS) score at 300's post-procedure); occurrence of Horner's syndrome; extent of local anaesthetic distribution; and adverse events. The mean increase in sympathetic blockade was significantly higher in the subfascial group (2.6 ± 0.6°C; p = .003). Analgesic efficacy was also significantly higher in the subfascial group (p < .001). The difference in the average dermatomal spread of local anaesthetic down to T2 and up to C4 between the groups was also statistically significant (p = .021 and p = .019, respectively). The degree of temperature rise, pain relief and occurrence of Horner's syndrome were higher in the subfascial than the extrafascial group. The subfascial approach to SGB, with a limited volume of local anaesthetic agent, is a more reliable technique when compared to the extrafascial approach.

Effect of two fascial incision options for access to the temporomandibular joint on facial nerve function: objective investigation

This study was performed to compare the effects on facial nerve (FN) function of the deep supra-temporalis muscle subfascial approach (DSFA) and traditional fascial approach (TFA) for access to the temporomandibular joint (TMJ), via qualitative and quantitative evaluations. Thirty patients requiring open TMJ surgery were randomly allocated to one of two groups: group A patients underwent the DSFA approach, while group B patients underwent the TFA approach. The TMJ was accessed via modified endaural incision with temporal extension. Clinical examinations, FN conduction tests, and electromyography (EMG) of the frontalis and orbicularis oculi muscles were used to assess FN function. A FN function deficit was noted in 50% of the whole sample population immediately after surgery, with no statistically significant difference between the groups (P = 0.082). Overall, 37.5% of the total study population experienced temporary loss of frontalis muscle activity, while zygomatic nerve injury was seen only in 25% of group A. Within 2–6 months, normal function returned in both groups. Nerve conduction studies showed no statistically significant difference between the groups in terms of nerve amplitude or latency after surgery. However, EMG of orbicularis oculi activity showed a significant difference between the groups after 6 months (P = 0.010). The results suggest that the traditional dissection approach is more protective of the FN, especially the zygomatic branch, than the deeper dissection technique.

Deep Subfascial Approach as an Alternative to Explore Temporomandibular Joint: A Pilot Study

Statement of the problemThe study aimed to compare the efficacy of superficial, subfascial, and deep subfascial approaches in patients with temporomandibular joint (TMJ) disorders and to correlate its effect on facial nerve function and quality of the surgical field. Materials and methodsThe study comprised of 15 cases indicated for TMJ surgery divided randomly into 3 study groups: Groups I, II, and III based on the surgical approach used (Figure 1). In Group I patients, the superficial approach was used and dissection was limited to the superficial layer of temporalis fascia. In Group II, a subfascial approach was used where dissection was carried between the 2 layers of the fascia. In Group III, a deep subfascial approach was used where dissection was kept between the deep layer of fascia and muscle. Intraoperatively, the quality of surgical field was assessed using Fromme, et al. Scale and intraoperative blood loss were calculated for each group. The dissection time was measured as the time elapsed from the skin incision to reach the dissection plane. All patients were evaluated for pain and swelling on the first, third, and seventh postoperative day. The facial nerve function test was performed post-surgically after 24 hours, 1 week and 1, 3, and 6 months using the House-Brackman scale. Methods of data analysisStatistical analysis was performed using SPSS software (IBM Corp, Armonk, NY). Data were presented as mean and appropriate. Statistical tests were applied. ResultsThe inter-group comparison showed that the outcomes of all intraoperative parameter were superior in Group II in comparison to the other groups (Table 1), whereas postoperative pain and swelling and facial nerve function were better in Group III (Table 2). Outcomes dataThe mean time required for exposure of TMJ was least in Group I as compared to the other groups (mean score for Groups I, II, and III, respectively, 20.8 ±1.36;19.0±3.3.17; and 29.2±4 minutes). The quantity of blood loss was minimum in Group II (mean score for Groups I, II, and III, respectively, 311.8±5.15; 244.4 ±6.19; and 249.6±10.58). Similarly, the quality of the surgical field was highest in Group II (mean score for Groups I, II, and III, respectively, 2.2±0.87;1.00±0.44; and 1.04±0.33). Mean pain scores were generally better for Group III when compared to Groups I and II on all days. Highest mean score observed on the first postoperative day was 5.2±1.33; 6.2±1.17; and 4.8±1.16 for Group I, Group II and Group III, respectively. It was also observed that deep subfascial approach resulted in lesser postoperative swelling as compared to the other groups (mean score for Group I, Group II, and Group III, respectively, at seventh postoperative day was 27.2±1.13;22.1±0.86; and 20.14±2.09). At 6 months, all surgical sites in Group III had normal facial nerve function, whereas total palsy of temporal branch was seen in 1 case for Group I and mild dysfunction was noted in 1 case of Group II (Figure 1). ConclusionThe deep subfascial approach is the safest approach among the preauricular approaches to avoid injury of the facial nerve and yielded better postoperative result for pain and swelling. However, the traditional subfascial technique provided a quicker and blood-less field of dissection. Thus, either of the 2 approaches could be used depending on the surgeon's preference and training.

Assessment of facial nerve injury using Deep Subfascial approach to Temporo-mandibular joint

Background: Surgical access to the temporomandibular joint (TMJ) and zygomatic arch is a challenge even to the experienced maxillofacial surgeon. The conventional subfascial approach to these structures carries the potential risk of transient paralysis of the frontalis and orbicularis oculi muscles. The deep subfascial approach provides an additional layer of protection (the deep layer of the temporalis fascia and the superficial temporal fat pad) to the temporal and zygomatic branches of the facial nerve and thus, is the safest method to avoid facial nerve injury.&#x0D; Aims and Objective: To assess facial nerve injury (FN) following TMJ surgery using deep Subfascial approach and measuring it on House and Brackman facial nerve grading system (HBFNGS).&#x0D; Materials and Methods: A randomized study was performed from August 2013 to March 2017 on 24 patients with unilateral and bilateral TMJ ankylosis. All patients were evaluated objectively for facial nerve injury using with house and brackmann facial nerve injury grading system post-operatively and subjectively inthe various time periods, i.e. 24 hours, 1 week, 1month, 3 months and 6 months.&#x0D; Results: Brackmann facial nerve grading system at 24 hours post operatively– in the deep subfascial approach group, 91.7% of patients (23 cases) had Grade 1 injury and 8.3% (1case) had Grade 3 injury. The condition improved with time with full recovery of facial nerve injury (FN) at all surgical sites at 6 months.&#x0D; Conclusion: The deep subfascial approach has a distinct advantage over the conventional approaches when dissecting the temporal region and is thesafest method to avoid injury to facial nerve injury (FN).

Subplatysmal or subfascial approach in totally endoscopic thyroidectomy has better postoperative efficacy for voice, sensory, swallowing symptoms and cosmetic result. Cohort study

BackgroundAfter totally endoscopic thyroidectomy (TET), patients usually suffer from voice, sensory, swallowing symptoms and they are also concerned with the postoperative cosmetic result. We compared the effects of subfascial dissection method with the subplatysmal method in TET on postoperative symptoms and cervical appearance. Methods143 female patients who underwent totally endoscopic thyroid surgery were assigned to the subplatysmal approach group and subfascial approach group. The patient's voice symptoms were assessed using the Voice Handicap Index (VHI) questionnaire. Sensory function was assessed with subjective pain and light touch sensation. Swallowing symptoms were assessed using the Swallow Impairment Score (SIS) questionnaire and the 3 oz water swallow test. Neck cosmetic effect was assessed by postoperative recovery time of the suprasternal fossa and subjective satisfaction questionnaire. Each variable was measured preoperatively, at 2 weeks, 3 months and 6 months after operation. ResultsIn both groups, the subjective voice, sensory and swallowing symptoms deteriorated at 2 weeks and improved at 3 months postoperatively. Indicators of VHI, SIS and 3 oz water swallow test returned to the preoperative level at 6 months after operation. In the subfascial group, SIS was significantly better than that of the subplatysmal group (p = 0.005) at 2 weeks after operation. The recovery time of the suprasternal fossa in the subfascial group was delayed (p = 0.158), compared with the subplatysmal group. ConclusionThe subfascial approach may have certain advantages in swallowing symptoms basing on the swallowing impairment test. However, the subplatysmal approach and the subfascial approach may have the same cosmetic effect.

Is a deep subfascial approach better than the subfascial apporach to temporo-mandibular joint in terms of facial nerve injury and quality of life?

PurposeThe objective of the study was to compare the deep subfascial approach to subfascial approach in terms of facial nerve injury and quality of life. Materials and methodsA randomized study was performed from August 2013 to March 2017 on 24 patients with unilateral TMJ ankylosis. The subjects were randomly allotted to either Group I (12, Deep Subfascial) or Group II (12, Subfascial). All patients were evaluated objectively for facial nerve injury post-operatively and subjectively for quality of life in the form of a questionnaire post-operatively for 6 months. The data were analyzed using simple descriptive statistics, mean standard deviation, Wilcoxon paired t test, Friedman's test, and Mann Whitney U test. ResultsThe comparison of the difference between the groups for postoperative facial nerve function at various time intervals did not give any significant differences (p > 0.05). In terms of quality of life there was a significant difference at 1 month post-operatively (p < 0.05) amidst the two approaches, however, 6-month follow-up revealed that there is no significant difference between the two approaches (p > 0.05). ConclusionThe study reveals that both the approaches are safe in terms of facial nerve injury and quality of life long term.

Does the surgical approach for treating mandibular condylar fractures affect the rate of seventh cranial nerve injuries? A systematic review and meta-analysis based on a new classification for surgical approaches

PurposeThe purpose of this study was to determine the rate of facial nerve injury (FNI) when performing (ORIF) of mandibular condylar fractures by different surgical approaches. Materials and methodsA systematic review and meta-analysis were performed that included several databases with specific keywords, a reference search, and a manual search for suitable articles. The inclusion criteria were all clinical trials, with the aim of assessing the rate of facial nerve injuries when (ORIF) of mandibular condylar fractures was performed using different surgical approaches. The main outcome variable was transient facial nerve injury (TFNI) and permanent facial nerve injury (PFNI) according to the fracture levels, namely: condylar head fractures (CHFs), condylar neck fractures (CNFs), and condylar base fractures (CBFs). For studies where there was no delineation between CNFs and CBFs, the fractures were defined as CNFs/CBFs. The dependent variables were the surgical approaches. ResultsA total of 3873 patients enrolled in 96 studies were included in this analysis. TFNI rates reported in the literature were as follows: A) For the transoral approach: a) for strictly intraoral 0.72% (1.3 in CNFs and 0% for CBFs); b) for the transbuccal trocar instrumentation 2.7% (4.2% in CNFs and 0% for CBFs); and c) for endoscopically assisted ORIF 4.2% (5% in CNFs, and 4% in CBFs). B) For low submandibular approach 15.3% (26.1% for CNFs, 11.8% for CBFs, and 13.7% for CNFs/CBFs). C) For the high submandibular/angular subparotid approach with masseter transection 0% in CBFs. D) For the high submandibular/angular transmassetric anteroparotid approach 0% (CNFs and CBFs). E) For the transparotid retromandibular approach a) with nerve facial preparation 14.4% (23.9% in CNFs, 11.8% in CBFs and 13.7% for CNFs/CBFs); b) without facial nerve preparation 19% (24.3% for CNFs and 10.5% for CBFs). F) For retromandibular transmassetric anteroparotid approach 3.4% in CNFs/CBFs. G) For retromandibular transmassetric anteroparotid approach with preauricular extension 2.3% for CNFs/CBFs. H) For preauricular approach a) deep subfascial dissection plane 0% in CHFs b) for subfascial approach using traditional preauricular incision 10% (8.5% in CHFs and 11.5% in CNFs). I) For retroauricular approach 3% for CHFs. PFNI rates reported in the literature were as follows: A) for low submandibular approach 2.2%, B) for retromandibular transparotid approach 1.4%; C) for preauricular approach 0.33%; D) for high submandibular approach 0.3%; E) for deep retroparotid approach 1.5%. ConclusionAccording to published data for CHFs, a retroauricular approach or deep subfascial preauricular approach was the safest to protect the facial nerve. For CNFs, a transmassetric anteroparotid approach with retromandibular and preauricular extension was the safest approach to decrease risk of FNI. For CBFs, high submandibular incisions with either transmassetric anteroparotid approach with retromandibular or transmassetric subparotid approach, followed by intraoral (with or without endoscopic/transbuccal trocar) were the safest approaches with respect to decreased risk of FNI.

Assessment of facial nerve injury with "House and Brackmann facial nerve grading system" in patients of temporomandibular joint ankylosis operated using deep subfascial approach.

Background:Preservation of the functional integrity of the facial nerve (FN) is a critical measure of success in temporomandibular joint (TMJ) surgery. In spite of the development of a myriad of surgical approaches to the TMJ, FN remains at risk. The deep subfascial approach provides an additional layer of protection (the deep layer of the temporalis fascia and the superficial temporal fat pad) to the temporal and zygomatic branches of the FN and thus, is the safest method to avoid FN injury.Objectives:To assess FN injury following TMJ surgery using deep subfascial approach and measuring it on House and Brackman facial nerve grading system (HBFNGS).Materials and Methods:Twenty TMJs in 18 patients were operated for TMJ ankylosis, using “the deep subfascial approach.” FN function was assessed postoperatively at 24 h, 1 week, 1 month, 3 months, 6 months using HBFNGS. Statistical analysis was done using SPSS 16.0.Results:Of 20 surgical sites 3 sites showed Grade III (moderate) FN injury and 17 sites showed Grade II (mild) FN injury at 24 h. The condition improved with time with full recovery of FN at all surgical sites at 6 months.Conclusion:The deep subfascial approach has a distinct advantage over the conventional approaches when dissecting the temporal region and is the safest method to avoid injury to FN.

A New Subfascial Approach in Open Thyroidectomy: Efficacy for Postoperative Voice, Sensory, and Swallowing Symptoms. A Randomized Controlled Study

After open thyroidectomy, patients usually complain of voice, sensory, and swallowing symptoms. We approached the thyroid via the subfascial method to reduce these symptoms and compared postthyroidectomy symptoms with the conventional subplatysmal method. Eighty-six patients undergoing thyroidectomy were recruited and randomized into either a conventional subplatysmal approach group (subplatysmal, 42 patients) group or a subanterior fascia of strap muscle approach group (subfascial, 44 patients). Voice symptoms were assessed using the Voice Handicap Index questionnaire and acoustic voice analysis. Sensory alterations were evaluated by the light touch and pain touch methods. Swallowing symptoms were assessed using the Swallowing Impairment Score (SIS) questionnaire, barium swallowing time, and hyoid bone movement range. Each variable was measured preoperatively, and at 2 weeks and 3 months after thyroidectomy. In both groups, the subjective symptoms of voice, sensation, and swallowing were significantly worsened at 2 weeks after operation, but improved 3 months after operation. Patients in the subplatysmal group had worse SIS scores than patients in the subfascial group (p = 0.016) and delayed barium swallowing time 2 weeks after operation (p = 0.008 compared to preoperative level). In the cohort over 50 years of age, SIS score did not recover to preoperative levels in the subplatysmal group 3 months after operation (p = 0.005 compared to preoperative level). The subfascial approach may be an effective method for reducing postthyroidectomy swallowing symptoms based on swallowing impairment score, especially in patients over 50 years of age.

Deep Subfascial Approach to the Temporal Area

Surgical access to the temporomandibular joint (TMJ) and zygomatic arch is a challenge even to the experienced maxillofacial surgeon. The conventional subfascial approach to these structures carries the potential risk of transient paralysis of the frontalis and orbicularis oculi muscles. This article discusses the use of a deep subfascial approach to access the TMJ and zygomatic arch. This surgical technique provides a safe operating field without jeopardizing the branches of the facial nerve. A study was carried out on 12 patients, wherein 15 surgical exposures were made, to access the TMJ and zygomatic arch. A deep subfascial approach was used that preserved the structural and functional integrity of the temporal and zygomatic branches. Postoperatively, no functional deficit was noted in either the temporal or zygomatic branches of the facial nerve as ascertained by clinical examination. The deep subfascial approach preserves and protects the branches of the facial nerve. It relies on distinct anatomic planes that are easily identified during surgery; and hence, the technique becomes relatively simple and easy to use.

Efficacy of Deep Subfascial Approach to the Temporomandibular Joint

The aim of this study was to report the efficacy of the deep subfascial approach for the treatment of temporomandibular joint pathologies. The procedure set out below satisfies a wide-access approach for the prevention of facial nerve injury. The preauricular approach with the additional deep subfascial approach was applied to 18 patients who had various problems from ankylosis to internal derangement. All patients were assessed at the following postoperative times. Facial nerve functions were evaluated after surgery and 24 hours after surgery by the House-Brackmann facial nerve grading system. Temporary facial nerve palsy was seen in a patient who had a residual keratocyst in the condylar neck region. Other patients tolerated the procedure well, and there were no other complications. This procedure significantly decreased the risk of facial nerve injury. However, soft tissue traction at the condylar neck region or zygomatic arch where the facial nerve passes close by may increase the risk of nerve damage.

Endoscopic Transaxillary Subfascial Approach for Persistent Muscular Torticollis in Children

The endoscopic approach is a technical innovation for release of the sternocleidomastoid (SCM) fibrosis in muscular torticollis, where operation scars can be hidden at less conspicuous areas, for example, at the axilla and hair-bearing scalp. As the SCM muscle is located beneath the investing layer of deep cervical fascia which is reported to continue to the fascia of the pectoralis major, the aim of the study was to describe and evaluate the preliminary result of transaxillary subfascial approach for persistent muscular torticollis in children. A total of 4 children (2 boys and 2 girls) were included in this study from January to December 2009. Using a 2-port endoscopic technique, the division of the lower end of the fibrotic SCM muscle was performed through the subfascial working cavern. The subfascial dissection was performed under the fascia of the pectoralis major and above the muscular fibers from ipsilateral axilla with the aid of a homemade dissection balloon. The mean operating time was 67.5±11.9 minutes (range: 55 to 80 min). There was no serious operative morbidity and the mean follow-up period was 14.8±5.1 months (range: 9 to 20 mo). All patients had complete unrestricted movement of the head and no recurrence was observed during this period. The transaxillary endoscopic technique, a working cavern created under the fascia of the pectoralis major, offers a safe and straightforward way to surgically manage persistent muscular torticollis while preserving neurovascular structures, exempting extradissection of noninvolved tissues and avoiding the potential for poor cosmesis from any neck scar.

The Subfascial Approach to Perforator Dissection in DIEP Flaps

The Subfascial Approach to Perforator Dissection in DIEP Flaps

The Subfascial Approach to Perforator Dissection: A Novel Method for Identification and Harvest

The Subfascial Approach to Perforator Dissection: A Novel Method for Identification and Harvest

Subfascial breast augmentation: theme and variations

Subfascial placement of breast implants for augmentation has been advocated as an option that has some of the advantages of both the subpectoral and subglandular approaches while minimizing the disadvantages of each. The author reports on the use of the subfascial approach in athletic and thin individuals, including extension of the range of applications for this approach through the use of partial muscle flaps for upper pole coverage. A periareolar approach was preferred, particularly when segmental muscular flaps were incorporated into the augmentation. Medially-based flaps supplied by the intercostal perforators were used to achieve greater upper-pole coverage, which can be particularly beneficial when using high-profile implants. Conversion from dual-plane submuscular to subfascial placement was used for correction of a "dynamic" breast (a breast that is distorted with muscle activity) or related contour deformity. Examples of the range of applications of the subfascial approach are presented, including use of small and larger segmented muscle flaps and correction of the dynamic breast or contour deformity. Use of the subfascial approach, with selective application of segmented muscle flaps, can help reduce reoperation rates after breast augmentation.