Biceps femoris long head muscle and aponeurosis geometry in males with and without a history of hamstring strain injury.

OBJECTIVES: Hamstring strain injuries (HSIs) commonly affect the proximal biceps femoris long head (BFlh) musculotendinous junction. Biomechanical modeling suggests narrow proximal BFlh aponeuroses and large muscle-to-aponeurosis width ratios increase localized tissue strains and presumably risk of HSI. This study aimed to determine if BFlh muscle and proximal aponeurosis geometry differed between limbs with and without a history of HSI. METHODS: Twenty-six recreationally active males with (n = 13) and without (n = 13) a history of unilateral HSI in the last 24 months underwent magnetic resonance imaging of both thighs. BFlh muscle and proximal aponeurosis cross-sectional areas, length, volume, and interface area between muscle and aponeurosis were extracted. Previously injured limbs were compared to uninjured contralateral and control limbs for discrete variables and ratios, and along the relative length of tissues using statistical parametric mapping. RESULTS: Previously injured limbs displayed significantly smaller muscle-to-aponeurosis volume ratios (p = 0.029, Wilcoxon effect size (ES) = 0.43) and larger proximal BFlh aponeurosis volumes (p = 0.019, ES = 0.46) than control limbs with no history of HSI. No significant differences were found between previously injured and uninjured contralateral limbs for any outcome measure (p = 0.216-1.000, ES = 0.01-0.36). CONCLUSIONS: Aponeurosis geometry differed between limbs with and without a history of HSI. The significantly larger BFlh proximal aponeuroses and smaller muscle-to-aponeurosis volume ratios in previously injured limbs could alter the strain experienced in muscle adjacent to the musculotendinous junction during active lengthening. Future research is required to determine if geometric differences influence the risk of re-injury and whether they can be altered via targeted training.

Tarsal Buckling and Entropion after Levator Aponeurosis Advancement in Patients with Floppy Eyelid Syndrome.

Two patients with floppy eyelid syndrome presented with severe eye pain and foreign body sensation after recent levator aponeurosis advancement. The examination in both patients was notable for entropion of the upper eyelid, and upper lid eversion revealed deformity of the tarsus in both patients. Surgical revision with full-thickness horizontal tarsotomy and limited excision of the abnormal tarsus corrected the deformity. The authors propose a mechanism for this phenomenon and a modification of surgical technique that may prevent this complication.

Transconjunctival Levator Aponeurosis-Müller Muscle Complex Plication to Correct the Acquired Ptosis Following Double-Eyelid Surgery.

One of the most common adverse outcomes of an upper blepharoplasty involving double-eyelid surgery is asymmetric upper eyelids due to unbalanced supratarsal folds or a difference in the palpebral fissure height. This study aimed to evaluate the efficacy and safety of transconjunctival levator aponeurosis-Müller muscle complex plication for correcting acquired ptosis following double-eyelid surgery. This retrospective study evaluated 18 patients who underwent transconjunctival levator aponeurosis-Müller muscle complex plication between June 2016 and June 2019 to correct acquired ptosis. On the basis of the main area of eyelid drooping, ptosis was categorized as central (mid-pupillary), medial (medial limbus), or lateral (lateral limbus). Preoperative and postoperative palpebral fissure heights were measured and compared. Three months postsurgery, the mean difference in palpebral fissure height between bilateral eyes decreased from 0.96 to 0.04 mm in the medial ( P <0.001), from 0.93 to 0.00 mm in central ( P =0.003), and from 1.30 to -0.03 mm in lateral ptosis ( P =0.079). In 13 patients who underwent unilateral correction, the amount of plication was significantly associated with increased palpebral fissure height at the medial limbus ( P =0.043) and mid-pupillary line ( P =0.035). All patients reported a significant improvement in satisfaction. Five patients experienced acute postoperative complications, including chemosis, conjunctival injection, and foreign body sensation, all of which were resolved after a month of observation. No asymmetries or recurrences were observed. Transconjunctival levator aponeurosis-Müller muscle complex plication is a minimally invasive, safe, and effective technique for correcting acquired ptosis following upper eyelid surgery.

Mechanical Ptosis by Medial Upper Eyelid Fat Prolapse.

Common symptoms of medial fat pad prolapse may include a noticeable bulge in the inner corner of the upper eyelid, puffiness, and a tired or aged appearance. In some cases, this condition may contribute to mechanical ptosis. However, mechanical ptosis caused by medial upper eyelid fat prolapse has not been reported previously. The purpose of the current study is to report the author's experience of successful treatment of ptosis caused by medial upper eyelid fat prolapse in a 67-year-old woman. The patient complained of slowly aggravating asymmetric upper eyelids starting from 5 years ago. At the time of her visit, she had to use her left forehead to open her eyes, making her left eyebrow upwardly positioned. This condition might be related to medial upper eyelid fat prolapse-related mechanical ptosis. The author explored her left upper eyelid with a 9 mm height incision. The author found a substantial amount of medial fat herniation and levator aponeurosis tear. After fat pad removal, the author fixed the levator aponeurosis tear with nylon 6-0, and transdermal sutures were done. The patient was happy with esthetically pleasing results 2 months after the initial surgery. The author successfully treated this rare condition with basic principles, such as fat removal, levator aponeurosis repair, and transdermal sutures.

Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach in Double-Eyelid Blepharoplasty Revision.

BACKGROUND: Incisional double-eyelid blepharoplasty is the main surgical technique to obtain an artificial crease. Postoperative complications decrease patients' satisfaction, and patients with prominent depressed groove and persistent pretarsal swelling (sausage phenomenon) usually need revision surgery. To resolve the sausage phenomenon after blepharoplasty, we adopt Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach to create natural double eyelids. METHODS: We included 68 patients in the study. The inclusion criteria for revision surgery were as follows: (1) pretarsal OOM remained after primary surgery, (2) prominent depressed surgical scar/groove and persistent pretarsal bulge (sausage phenomenon), (3) postsurgical abnormally wide crease. The surgical procedure involved releasing the pretarsal OOM, forming OFOOM-OOM flap, and OFOOM-OOM flap fixed with aponeurosis. Outcome observations were assessed using the FACE-Q questionnaire, and the follow-up period ranged from 6 to 36 months (mean=18 months). RESULTS: The depressed groove and pretarsal bulge showed significant improvements, and FACE-Q scores of the 68 patients before surgery (mean scores=66) compared with those after surgery (mean scores=90) were significantly different (P<0.01). Four patients with palpebral fold asymmetry and two patients with shallow eyelids received revision surgery, and patients were satisfied with the secondary surgery effects. Six patients presented with unnatural curves of folds and revision surgery alleviated these situations. CONCLUSIONS: Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach is an effective way to resolve the sausage phenomenon. The OFOOM-OOM flap is a reliable and flexible structure to create natural double eyelids. LEVEL OF EVIDENCE IV: 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 .

A Modified Algorithm-Based Levator Aponeurectomy in Mild to Moderate Congenital Blepharoptosis.

BACKGROUND: Levator aponeurectomy is a common operation for mild to moderate blepharoptosis. The accuracy of ptosis correction relied on intraoperative judgement when patients were under local anesthesia. For patients who must receive the operation under general anesthesia, it would be an issue to determine how much length of levator aponeurosis to shorten. To solve this issue, we collected data from patients who underwent the operation under local anesthesia and concluded an algorithm. METHODS: This single-center, prospective bivariate regression study allocated patients of mild to moderate congenital blepharoptosis who received levator aponeurectomy under local anesthesia. Preoperative MRD1 and levator function, intraoperative amount of levator aponeurotic shortening, and postoperative MRD1 were measured. The follow-up period was right after the operation. RESULTS: Twenty-nine patients were included in this trial. Two subjects exited because of not receiving allocated operation and data of the other 27 subjects (including 34 eyelids) were analyzed. A scatter diagram was drawn where x axis referred to levator function and y axis referred to the ratio of the amount of shortening of levator aponeurosis over the height of MRD1 correction. Linear regression showed y = - 0.2717*x + 5.026, R2 = 0.8553. CONCLUSION: A modified algorithm to predict the amount of shortening of levator aponeurosis based on levator function and height of ptosis correction was concluded with better accuracy and clinical feasibility. LEVEL OF EVIDENCE IV: 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 .

Comparisons of the Fusion Point of Orbital Septum and Levator Aponeurosis in Patients with and Without Mild Ptosis.

OBJECTIVE: By comparing the position of the fusion point between the oriental orbital septum and the levator aponeurosis of the upper eyelid in Asian without and with mild ptosis, this study explores the relationship between the fusion point and mild ptosis, providing scientific basis for better utilizing the orbital septum to correct mild ptosis. METHODS: In this study, the outpatients who underwent double eyelid blepharoplasty with incision method in the plastic laser cosmetology department of Hunan Provincial People's Hospital from October 2018 to April 2019 were divided into the normal group and the mild ptosis group. The position of the fusion part of the orbital septum and the aponeurosis of the levator palpebrae superioris was observed in the two groups. There are three types of this position: the height of the fusion part is greater than the width of the tarsal plate, the height of the fusion part is equal to the width of the tarsal plate, and the height of the fusion part is less than the width of the tarsal plate. After the fusion part was exposed during the operation, the width of tarsal plate and the height of fusion part were measured with a scale. The difference of the location of fusion part between the two groups was analyzed. RESULTS: The tarsal plate width was 11.061 ± 0.635 mm in the normal group and 11.062 ± 0.675 mm in the mild ptosis group. There was no significant difference in tarsal plate width between normal group and mild ptosis group (t = 0.645, p = 0.16). The height of the fusion part was 11.032 ± 0.646 mm in the normal group and 11.645 ± 0.429 mm in the mild ptosis group. The fusion position of mild ptosis group was higher than that of normal group (t = 3.769, P < 0.05). There was significant difference in the distribution of fusion site between the two groups (x2 =38.00, P < 0.0001). CONCLUSION: The height of aponeurosis fusion of orbital septum and levator palpebrae superioris in mild ptosis group was higher than that in normal group, which may be the cause of mild ptosis. It is suggested that the appropriate treatment of orbital septum in clinical operation may be effective in the treatment of mild blepharoptosis. LEVEL OF EVIDENCE III: 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 https://www.springer.com/00266 .

Biochemical and Histological Differences between Longitudinal and Vertical Fibres of Dupuytren's Palmar Aponeurosis and Innovative Clinical Implications.

Dupuytren's disease, a chronic and progressive fibroproliferative lesion of the hand, which affects the palmar fascia, has a recurrence rate after selective aponeurotomy of 20-40% at 5 years. This study focused, for the first time, on the microanatomical and histopathological characteristics of the longitudinal and vertical fibres (usually spared during surgery) in the aponeurosis with Dupuytren's disease, in different stages of the Tubiana's classification. Twelve human samples were collected and analysed by immunostaining, Total Collagen Assay, ELISA Immunoassay, and immunoblotting for the Von Willebrand factor, α-Sma, D2-40, CD-68, Total Collagen, Collagen-I and III, IL1ß, TNF-α to analyse the blood and lymphatic vascularization, the amount and distribution of collagen, and the inflammation. The results show a progressive increase in the arterial vascularization in the vertical fibres (from 8.8/mm2 in the early stage to 21.4/mm2 in stage 3/4), and a parallel progressive decrease in the lymphatic drainage (from 6.2/mm2 to 2.8/mm2), correlated with a local inflammatory context (increase in IL-1ß and TNF-α until the stage 2) in both the longitudinal and vertical fibres. The acute inflammation after stage 2 decreased, in favour of a fibrotic action, with the clear synthesis of new collagen (up to ~83 µg/mg), especially Collagen-I. These results clearly demonstrate the involvement of the septa of Legueu and Juvara in the disease pathology and the modifications with the disease's progression. A greater understanding of the pathology becomes fundamental for staging and the adequate therapeutic timing, to obtain the best morpho-functional result and the lowest risk of complications.

Congenital ptosis with aponeurotic maldevelopment: clinical and surgical perspectives : Aponeurotic maldevelopment in congenital ptosis.

PURPOSE: Levator muscle dystrophy has been commonly accused being the main pathology of congenital ptosis, nevertheless, few reports drew attention to the existence of congenital aponeurotic defects. This study aims at highlighting the detailed clinical and surgical features of aponeurotic maldevelopment together with the efficacy of simple aponeurosis repair. METHODS: This is a retrospective nonrandomised study including patients with congenital ptosis who underwent levator muscle surgery throughout 4 years. Patients' records were reviewed for the preoperative clinical assessment and photographs, intraoperative recorded data, and videos as well as postoperative data and photographs. RESULTS: Twenty-seven eyes of 22 patients (9.4%) out of 287 eyes were recorded to have absent levator muscle at its typical anatomical insertion site intraoperatively. The mean preoperative MRD1 was (0.44 ± 1.17 mm). The mean levator function was 8.56 ± 3.89 mm, with higher-than-normal crease position (mean value 10.07 ± 1.62 mm). 25 eyes of included cases (92.6%) showed total absence of the levator aponeurosis edge which only was revealed after cutting through the orbital septal covering of the preaponeurotic fat. CONCLUSION: Congenital aponeurotic defect is an established yet under reported entity of congenital ptosis with reproducible characteristic intraoperative findings. Simple aponeurosis repair could achieve ptosis correction in such cases.

Orbital septum attachment site on the levator aponeurosis sling for mild congenital blepharoptosis.

PURPOSE: This study aimed to investigate the value of the orbital septum attachment site on the levator aponeurosis (OSASLA) sling in correcting mild congenital blepharoptosis. METHODS: A total of 60 patients (92 eyes) with mild congenital blepharoptosis (levator function ≥ 8 mm) were treated in our hospital from January to October 2021, and relevant data of these patients were collected. All patients underwent OSASLA sling for ptosis correction. The distances from the superior tarsal border to the OSASLA were measured. The primary outcome was the number of postoperative changes in the marginal reflex distance 1 (MRD1). Pearson's correlation coefficient between the distance from the superior tarsal border to the OSASLA and the height of the upper eyelid elevated was analyzed. RESULTS: Fifty-eight patients (89 eyes) successfully underwent OSASLA sling surgery. The preoperative MRD1 was 1.4-3.6 mm (mean 2.1 ± 0.5 mm), and the postoperative MRD1 was 3.4-5.0 mm (mean 3.7 ± 0.6 mm). The distance from the superior tarsal border to the OSASLA sling was significantly and positively correlated with the height of the upper eyelid elevation (r = 0.7328, P < 0.0001). The eyelid margin positions of the patients did not regress substantially during 6-18 months of follow-up. CONCLUSIONS: Compared with the shortening of levator palpebrae superioris (LPS) and pleating of LPS, the OSASLA sling is a less invasive, more effective, and easy-operating surgery for mild congenital blepharoptosis.

Intramuscular aponeuroses and fiber bundle morphology of the five bellies of flexor digitorum superficialis: A three-dimensional modeling study.

Restoring balanced function of the five bellies of flexor digitorum superficialis (FDS) following injury requires knowledge of the muscle architecture and the arrangement of the contractile and connective tissue elements. No three-dimensional (3D) studies of FDS architecture were found in the literature. The purpose was to (1) digitize/model in 3D the contractile/connective tissue elements of FDS, (2) quantify/compare architectural parameters of the bellies and (3) assess functional implications. The fiber bundles (FBs)/aponeuroses of the bellies of FDS were dissected and digitized (MicroScribe® Digitizer) in 10 embalmed specimens. Data were used to construct 3D models of FDS to determine/compare the morphology of each digital belly and quantify architectural parameters to assess functional implications. FDS consists of five morphologically and architecturally distinct bellies, a proximal belly, and four digital bellies. FBs of each belly have unique attachment sites to one or more of the three aponeuroses (proximal/distal/median). The proximal belly is connected through the median aponeurosis to the bellies of the second and fifth digits. The third belly exhibited the longest mean FB length (72.84 ± 16.26 mm) and the proximal belly the shortest (30.49 ± 6.45 mm). The third belly also had the greatest mean physiological cross-sectional area, followed by proximal/second/fourth/fifth. Each belly was found to have distinct excursion and force-generating capabilities based on their 3D morphology and architectural parameters. Results of this study provide the basis for the development of in vivo ultrasound protocols to study activation patterns of FDS during functional activities in normal and pathologic states.

Aponeurotic expansion of the supraspinatus tendon and concomitant shoulder pathologies.

OBJECTIVES: We investigated the correlation of aponeurotic expansion of the supraspinatus tendon (AESST) with shoulder pathologies such as long head of biceps tendon (LHB), supraspinatus tendon (SST), and subscapularis tendon (SSc). METHODS: We retrospectively evaluated 47 healthy patients and 163 patients with shoulder symptoms from August 2014 to March 2021. First, the presence of AESST was evaluated based on Moser et al.'s classification. Second, the presence of abnormal findings of including LHB tendinitis, LHB subluxation, SST tendinitis, SST tear, SSc tendinitis, and SSc tendon tear was evaluated. We analyzed the prevalence and type of AESST between the two study groups and the relationship between abnormal findings and the presence of AESST. RESULTS: The prevalence of AESST for readers 1 and 2 was 26.1% and 30.4% in the asymptomatic group, respectively, and 22.8% and 31.3% in the symptomatic group. Type 1 was most common (17.3-23.9%) followed by types 2a and 2b. There were no significant differences in the distribution of aponeurosis type between the two groups. In the AESST-positive groups, 45.9% and 47.1% had SST tears on examination by readers 1 and 2, respectively, whereas only 26.4% and 27.9% had SST tears in the AESST-negative group suggesting AESST is associated with SST tear. The odds ratio for SST tear in the presence of AESST was 2.370 and 2.294 (readers 1 and 2). CONCLUSIONS: There is an association between SST tears and the presence of AESST. KEY POINTS: • We evaluated the prevalence of aponeurotic expansion of the supraspinatus tendon (AESST) on MR imaging by type in both symptomatic and asymptomatic groups. • We investigated the correlation of AESST with shoulder pathologies such as biceps tendon and supraspinatus tendon tears. • There is an association between SST tears and the presence of AESST. • Radiologists should be aware of the risk of rotator cuff pathology if AESST is detected.

Chronic changes in muscle architecture and aponeurosis structure following calf muscle strain injuries.

BACKGROUND: Muscle strain injuries in the human calf muscles are frequent sports injuries with high recurrence. Potential structural and functional changes in the medial head of the musculus gastrocnemius (GM) and the associated aponeurosis are not well documented. PURPOSE: To test whether a GM muscle strain injury affects muscle fascicle length, pennation angle, and the morphology of the deep aponeurosis at rest and during muscle contraction long time after the injury. Additionally, electromyography (EMG) of the GM and the soleus muscle during a unilateral heel rise was measured in the injured and uninjured calf. METHODS: GM fascicle length, pennation angle, and aponeurosis thickness was analyzed on dynamic ultrasonography (US) recordings in 10 participants with a chronic calf strain. In addition, US images taken across the distal portion and mid-belly of the GM were analyzed at three different ankle positions. EMG recordings were obtained during a unilateral heel rise. RESULTS: The pennation angle of the injured distal GM was significantly larger compared to the uninjured GM in the contracted, but not the relaxed state. Pennation angle increased more in the injured compared to the uninjured GM during contraction. Fascicle length was shorter in the most distal portion of the injured GM. Fascicles at the distal portion of the injured GM showed a pronounced curvilinear shape as the muscle contracted and the aponeurosis was enlarged in the injured compared to the uninjured GM. The ratio between GM and soleus EMG activity showed a significantly higher relative soleus activity in the injured compared to the healthy calf. CONCLUSION: The greater change in pennation angle and curvilinear fascicle shape during contraction suggest that a long-term consequence after a muscle strain injury is that some muscle fibers at the distal GM are not actively engaged. The significantly enlarged aponeurosis indicates a substantial and long-lasting connective tissue involvement following strain injuries.

Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts are effective in the treatment of chronic Achilles tendon ruptures - a systematic review.

INTRODUCTION: A chronic Achilles tendon rupture (ATR) is defined as an ATR that has been left untreated for more than four weeks following rupture. This systematic review aims to summarize the outcomes of chronic ATR treated using either a gastrocnemius aponeurosis flap or semitendinosus tendon graft. METHODS: A systematic search was conducted in three databases (PubMed, Scopus and Cochrane), for studies describing outcomes after surgical treatment of chronic ATR using gastrocnemius aponeurosis flaps or semitendinosus tendon grafts with more than 10 patients included. The studies were assessed for quality and risk of bias using the Methodological Items used to assess risk of bias in Non-Randomized Studies (MINORS). RESULTS: Out of the 818 studies identified with the initial search, a total of 36 studies with 763 individual patients were included in this systematic review. Gastrocnemius aponeurosis flap was used in 21 and semitendinosus tendon graft was used in 13 of the studies. The mean (SD) postoperative Achilles tendon Total Rupture Score (ATRS) for patients treated with a gastrocnemius aponeurosis flap was 83 (14) points and the mean (SD) American Orthopaedic Foot and Ankle Score (AOFAS) was 96 (1.7) points compared with ATRS 88 (6.9) points and AOFAS 92 (5.6) points for patients treated with a semitendinosus tendon graft. The included studies generally had low-quality according to MINORS, with a median of 8 (range 2-13) for all studies. CONCLUSION: Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts give acceptable results with minimal complications and are valid methods for treating chronic ATR. The main difference is more wound healing complications in patients treated with a gastrocnemius aponeurosis flap and more sural nerve injuries in patients treated with a semitendinosus grafts. The current literature on the subject is of mainly low quality and the absence of a patient-related outcome measure validated for chronic ATR makes comparisons between studies difficult. LEVEL OF EVIDENCE: Level IV.

Anatomical considerations and clinical implications of bicipital aponeurosis: A magnetic resonance imaging study.

The bicipital aponeurosis (BA) is the distal aponeurosis of the biceps brachii which usually covers the median nerve (MN), and the brachial artery (BrA) and sometimes causes compression of these structures. Since these situations are rarely reported in the literature, BA frequently does not come to mind as a cause of such compression. Therefore, the diagnosis may be delayed. In this study, we aimed to investigate the morphometry of BA and its relationship with the surrounding neurovascular structures and to draw attention to BA as a structure that can cause entrapment of the MN and rarely, the BrA. We examined the MRIs of the elbow of 279 patients (107 women, 172 men) aged between 18 and 72 years. We measured the thickness, length and width of BA, and investigated the anatomical relationship between BA, BrA, and MN. The respective median thickness, width, and length of BA were 0.7 (0.4-1.8 mm), 18.0 (6.0-34.0 mm), and 32.0 (18.0-50.0 mm), respectively. In all sections examined, the BA covered the BrA and MN, and was located immediately anterior to the BrA. In 225 (80.6%) of 279 MRIs, the BrA was located anterior to the MN and posterior to the BA. In the remaining 54 (19.4%) MRIs, the MN was located anterior to the BrA and posterior to the BA. The respective median thickness, width, and length of the BA were 0.7 mm, 18.0 mm, and 32.0 mm, respectively. It covered the BrA and MN and was located immediately anterior to the BrA. The BA sometimes causes compression syndromes of these structures, therefore, for physicians, it is important to understand the anatomy of the BA.

Cadaveric Study and Micro-Computed Tomography of the Anatomy of Palatine Aponeurosis and its Link to the Soft Palate Muscles and Pharyngeal Muscles.

OBJECTIVE: There have been few studies on the anatomy of palatine aponeurosis (PA). Herein, we elucidated the relationship between the PA and soft palate muscles and pharyngeal muscles. DESIGN: Two cadaveric specimens were dissected to observe the gross anatomy of the PA. Six cadaveric specimens were processed and scanned by micro-computed tomography to determine the elaborate anatomy. Images were exported to Mimics software to reconstruct a three-dimensional model. RESULTS: The PA covered the anterior (32.1%-38.8%) of the soft palate, extending from the tensor veli palatini (TVP) and connecting to 3 muscles: palatopharyngeus (PP), uvula muscle, and superior pharyngeal constrictor (SC). The SC and PP are attached to the PA on the medial side of the pterygoid hamulus. SC muscle fibers were attached to the hamulus, forming a distinct gap between the hamulus. Some muscle fibers of the PP and uvula originated from the PA. The PA extended from the TVP to the midline and the posterior edge of the hard palate. The PA was not uniformly distributed, which was complementary to the attached muscles in thickness. CONCLUSIONS: PA, as a flexible fibrous membrane, maintains the shape of the soft palate. It extends from the TVP and covers anteriorly about one-third of the soft palate. The PA provides a platform for the soft palate muscles and pharyngeal muscles, connecting to the PP, uvula muscle, and SC. These muscles are important for palatopharyngeal closure and middle-ear function. It is necessary to minimize the damage to the PA during surgical interventions.

Auricular Cartilage Graft for Lengthening Levator Muscle Aponeurosis With Ectropion Correction for Paralytic Lagophthalmos.

BACKGROUND: Paralytic lagophthalmos can have devastating consequences for vision if left untreated. Several surgical techniques have been described, including the utilization of alloplastic and autologous materials. OBJECTIVES: The authors sought to evaluate the effectiveness of the surgical treatment of paralytic lagophthalmos with combined techniques employing autologous material and involving the upper and lower eyelids. METHODS: Patients with paralytic lagophthalmos underwent stretching of the levator aponeurosis with interposition of conchal cartilage in the upper eyelid associated with sectioning of the orbitomalar ligament and lateral canthoplasty in the lower eyelid. The effectiveness of the technique was evaluated employing subjective (symptomatology) and objective parameters (ophthalmologic evaluation and measurements of lagophthalmos and marginal reflex distances 1 and 2). RESULTS: Eight patients with paralytic lagophthalmos were subjected to the proposed technique. In the postoperative period, 85.7% reported complete improvement of symptoms and 62.5% presented a normal eye examination. The mean lagophthalmos measurement was reduced by 5.93 mm, the mean marginal reflex distance 2 was reduced by 2.61 mm, and the mean marginal reflex distance 1 was reduced by 0.69 mm. CONCLUSIONS: The technique presented herein, employing autologous material associated with sectioning of the orbitomalar ligament and lateral canthoplasty, was effective in the treatment of paralytic lagophthalmos and did not present significant complications, such as extrusion.

Sensory innervation of the human palmar aponeurosis in healthy individuals and patients with palmar fibromatosis.

The human palmar aponeurosis is involved in hand proprioception, and it contains different sensory corpuscle morphotypes that serve this role. In palmar fibromatosis (classically referred to as Dupuytren's disease), the palmar aponeurosis undergoes fibrous structural changes that, presumably, also affect the nervous system, causing altered perception. We analysed the various sensory nerve formation morphotypes in the palmar aponeuroses of healthy subjects and patients with palmar fibromatosis. To do this, we used immunohistochemistry for corpuscular constituents and the putative mechanoproteins PIEZO2 and acid-sensing ion channel 2. Free nerve endings and Golgi-Mazzoni, Ruffini, paciniform and Pacinian corpuscles were identified in both the healthy and the pathological conditions. The densities of the free nerve endings and Golgi-Mazzoni corpuscles were slightly increased in the pathological tissues. Furthermore, the Pacinian corpuscles were enlarged and displayed an altered shape. Finally, there was also morphological and immunohistochemical evidence of occasional denervation of the Pacinian corpuscles, although no increase in their number was observed. Both PIEZO2 and acid-sensing ion channel 2 were absent from the altered corpuscles. These results indicate that the human palmar aponeurosis is richly innervated, and the free nerve endings and sensory corpuscles within the palmar aponeurosis undergo quantitative and qualitative changes in patients with palmar fibromatosis, which may explain the sensory alterations occasionally reported for this pathology.

Aponeurosis linguae-Myocutaneous or myotendinous junctions of skeletal muscle fibres in the human tongue?

The morphology of the more superficial tissue of the human tongue was investigated and discussed with the clinical appearance of fissures. Three regions could be distinguished according to the presence and shape of the aponeurosis linguae: the central region showed a thick aponeurotic plate with myotendinous muscle fibre insertions. The lateral region showed still an aponeurosis linguae but of reduced thickness and without muscle insertions. The edge-wise and lower region showed no aponeurosis linguae but a fatty subcutis and myocutaneous muscle fibre insertions lacking specific molecules of myotendinous junctions. This system of partially developed exoskeleton seems to underlie but not to be involved in tongue fissures, which are more superficial within the epidermis and dermis.

Tendon length estimates are influenced by tracking location.

PURPOSE: Measurement of medial gastrocnemius (MG) tendon length using ultrasonography (US) requires the muscle-tendon junction (MTJ) to be located. Previously, the MG MTJ has been tracked from different proximo-distal locations near the MTJ, which could influence estimates of tendon length change due to the different characteristics of the aponeurosis and tendon. We used US to evaluate the effect of tracking point location on MG MTJ displacement during maximal and submaximal (10, 20 and 30% of the non-injured maximal) isometric plantar flexion contractions. METHODS: Displacement behaviour of MTJ was tracked from (1) the exact MTJ; and (2) from an insertion point of a muscle fascicle on the aponeurosis 1.3 ± 0.6 cm proximal to the MTJ, in both limbs of patients with unilateral Achilles tendon rupture (ATR) (n = 22, 4 females, 42 ± 9 years, 177 ± 9 cm, 79 ± 10 kg). RESULTS: In the non-injured limb, displacement (1.3 ± 0.5 cm vs. 1.1 ± 0.6 cm) and strain (6.7 ± 2.8% vs. 5.8 ± 3.3%) during maximal voluntary contraction were larger when tracking a point on the aponeurosis than when tracking the MTJ (both p < 0.001). The same was true for all contraction levels, and both limbs. CONCLUSION: Tracking a point on the aponeurosis consistently exaggerates estimates of tendon displacement, and the magnitude of this effect is contraction intensity-dependent. When quantifying displacement and strain of the Achilles tendon, the MTJ should be tracked directly, rather than tracking a surrogate point proximal to the MTJ. The latter method includes part of the aponeurosis, which due to its relative compliance, artificially increases estimates of MTJ displacement and strain.