Topography of the pelvic autonomic nerves - an anatomical study to facilitate nerve-preserving total mesorectal excision.

INTRODUCTION: Urogenital dysfunction caused by iatrogenic injury to the autonomic nerves persists as a common complication of rectal cancer surgery. This study aims to investigate the relationship between autonomic nerves and the 'holy plane' with the intention of identifying hazardous sites at which urogenital dysfunction may occur. PATIENTS AND METHODS: Dissection of the 'holy plane' and preparation of the autonomic nerves were performed on Thiel-embalmed bodies. The morphology of the inferior hypogastric plexus and its distance to nearby reference points was recorded. RESULTS: In all 28 bodies (13 females, 15 males), we observed that the autonomic nerves were enveloped in parietal pelvic fascia and thereby absent from the 'holy plane' of total mesorectal excision. The midpoint of the inferior hypogastric plexus resided 85 mm from the sacral promontory, and 47 mm from the coccygeal apex. Both distances were significantly longer in men than in women (p < 0.01, p < 0.01). The ureter coursed 11 mm superiorly to the inferior hypogastric plexus. Distal to the ischial spine, it ran 13 mm laterally to the mesorectal fascia. Differences between females and males were not statistically significant (p = 0.32, p = 0.85). CONCLUSIONS: Pursuit of the 'holy plane' spares the autonomic nerves. Restricted visibility may complicate the identification and sparing of the autonomic nerves, and, thus, requires the meticulous planning and execution of surgery. Contextual, the ureter may act as another landmark for the localisation of the inferior hypogastric plexus, additionally to the already established lateral ligaments of the rectum.

Prevention of Progression of Lipedema With Liposuction Using Tumescent Local Anesthesia: Results of an International Consensus Conference.

BACKGROUND: Lipedema is a chronic, progressive disorder of subcutaneous adipose tissue that usually affects the lower extremities of women. Also known as "two-body syndrome," the fat accumulations in lipedema are unsightly and painful. The disorder is well-known in Europe but is largely unrecognized and underdiagnosed in the United States. OBJECTIVE: To hold the First International Consensus Conference on Lipedema with the purpose of reviewing current European guidelines and the literature regarding the long-term benefits that have been reported to occur after lymph-sparing liposuction for lipedema using tumescent local anesthesia. METHODS: International experts on liposuction for lipedema were convened as part of the First International Congress on Lipedema in Vienna, Austria, June 9 to 10, 2017. RESULTS: Multiple studies from Germany have reported long-term benefits for as long as 8 years after liposuction for lipedema using tumescent local anesthesia. CONCLUSION: Lymph-sparing liposuction using tumescent local anesthesia is currently the only effective treatment for lipedema.

The fascial suspension of the prostate: A cadaveric study.

AIMS: Analysis and description of the supporting fascial structure around the prostate and urethra, which needs to be preserved or restored during radical prostatectomy (RP). METHODS: Anatomical dissection of 10 male cadavers was performed and the supporting fascial structures of bladder neck, prostate, and proximal urethra were investigated. The cadavers were embalmed according to Thiel's method, which preserves a natural texture and color of tissues. RESULTS: Anteriorly, the puboprostatic ligament (PL), the dorsal vein complex, and the urethropelvic ligament form an integral structure that suspends and stabilizes the prostatic apex. Laterally, the fascia originates from the fascial tendinous arch of the pelvis and stabilizes the prostate in the central position. In the posterolateral aspect, we could demonstrate a tendineous dorsal raphe, which represents an important stabilization structure of the urethra. CONCLUSIONS: The anterior and posterior pelvic fascial structure seems to be important stabilizer for the prostate and proximal urethra. Their preservation or reconstruction during RP is mandatory to restore the anatomic and functional continuity of the bladder neck and urethra. Neurourol. Urodynam. 36:1131-1135, 2017. © 2016 Wiley Periodicals, Inc.

Detailed vascular anatomy of the medial femoral condyle and the significance of its use as a free flap.

OBJECTIVE: The aim of this study is to provide detailed information on the arterial variations of the descending geniculate artery (DGA) for the harvest of a cortico-periostal flap from the medial femoral condyle and a fascio-cutaneous perforator flap with its respective pedicles. MATERIAL AND METHODS: A total of 50 lower limbs from embalmed cadavers were dissected. The distribution pattern, length, and diameter of the DGA, saphenous artery (SA), muscular, periostal, and articular branches, and their concomitant veins were measured and evaluated. RESULTS: The DGA was present in 98% of the cases. In 80%, a Y-shaped distribution was identified where the SA branched from the DGA. Here, the mean lengths of DGA, SA, and the articular branch of the DGA were 3.2 ± 1.1, 7.18 ± 3.2, and 6.72 ± 2.07 cm, respectively. In 18%, an H-shaped distribution was noted, where the SA emerged directly from the femoral artery with a length of 10.2 ± 1.9 cm, whereas the length of the DGA (and its terminal articular branch) was 7.5 ± 1.5 cm. The mean length of the arterial pedicle for a cortico-periostal flap from the medial condyle was 9.92 cm, whereas for the fascio-cutaneous perforator flap, it was 9.46 cm in Y-shaped distribution and 10.2 cm for the H-shaped distribution. CONCLUSION: Different arterial distribution patterns increase the need for routine preoperative vascular imaging when planning to harvest a cortico-periostal flap and a fascio-cutaneous perforator flap from the medial femoral condyle, especially when a double-chimeric flap is targeted. LEVEL OF EVIDENCE: Level 4, case series.

The External Nose: The Nasal Arteries and Their Course in Relation to the Nasolabial Fold and Groove.

BACKGROUND: The blood supply to the external nose is poorly described. The aim of this study was to identify the different types of blood supply to the external nose and the course of the arteries in relation to the nasolabial fold and groove and to the facial muscles. METHODS: With 96 facial halves of 48 adult specimens, the arteries of the outer nose were dissected, and three-dimensional computed tomographic reconstructions and horizontal sections were made. RESULTS: Three main types of blood supply to the external nose were identified, associated with the different types of facial arteries. Moreover, a deep course of the nasal arteries in relation to the nasolabial fold and a very superficial course in relation to the nasolabial groove were found. CONCLUSION: Knowledge regarding the nasal arteries is clinically relevant for filler injection for aesthetic improvements of the nose and nasolabial fold and for planning local flaps in facial reconstructions and also for rhinoplasty.

The Facial Artery-The Main Blood Vessel for the Anterior Face?

BACKGROUND: The facial artery is said to be the main vessel for the blood supply of the anterior face. However, its course is quite often not as described in the textbooks. OBJECTIVE: The purpose of this study was to find out the different courses of the facial artery, its anastomoses, and its position in relation to the fat compartments of the face. MATERIALS AND METHODS: With 60 hemifaces three-dimensional reconstructions with computed tomography, cross dissections and horizontal sections were performed. RESULTS: Of note, 4 types of facial arteries were identified. Not even half of the specimens showed a textbook course of the facial artery and only a quarter of the specimens had a textbook course of the artery on both sides. CONCLUSION: To know the different appearances of the facial artery can be helpful for filler injection in aesthetic medicine but also for planning flaps in reconstructive surgery.

Chondrocyte cultures from human proximal interphalangeal finger joints.

Osteoarthritis (OA) of the hand is a common disease resulting in pain and impaired function. The pathogenesis of hand OA (HOA) is elusive and models to study it have not been described. Chondrocyte culture has been essential to understand cartilage degeneration, which is a hallmark of OA. We investigated the feasibility of human chondrocyte culture derived from proximal interphalangeal (PIP) finger joints. Hyaline cartilage of the PIP and knee joints was obtained from human cadavers. Chondrocytes harvested up to 236 h after death of the donors were viable and expressed chondrocyte-specific genes. Gene expression comparing chondrocytes from PIP and knee joints using Affymetrix GeneChip arrays resulted in a unique PIP-specific gene expression pattern. Genes involved in developmental processes including the WNT pathway were differentially expressed between the joints. These findings suggest that our knowledge on chondrocyte biology derived mainly from knee and hip joints may not apply to chondrocytes of the PIP joints and some of the distinctive features of HOA may be caused by the specific properties of PIP chondrocytes. Chondrocyte culture of PIP cartilage is a novel tool to study cartilage degeneration in HOA. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1569-1575, 2016.

Subcutaneous fat patterning in athletes: selection of appropriate sites and standardisation of a novel ultrasound measurement technique: ad hoc working group on body composition, health and performance, under the auspices of the IOC Medical Commission.

BACKGROUND: Precise and accurate field methods for body composition analyses in athletes are needed urgently. AIM: Standardisation of a novel ultrasound (US) technique for accurate and reliable measurement of subcutaneous adipose tissue (SAT). METHODS: Three observers captured US images of uncompressed SAT in 12 athletes and applied a semiautomatic evaluation algorithm for multiple SAT measurements. RESULTS: Eight new sites are recommended: upper abdomen, lower abdomen, erector spinae, distal triceps, brachioradialis, lateral thigh, front thigh, medial calf. Obtainable accuracy was 0.2 mm (18 MHz probe; speed of sound: 1450 m/s). Reliability of SAT thickness sums (N=36): R(2)=0.998, SEE=0.55 mm, ICC (95% CI) 0.998 (0.994 to 0.999); observer differences from their mean: 95% of the SAT thickness sums were within ± 1 mm (sums of SAT thicknesses ranged from 10 to 50 mm). Embedded fibrous tissues were also measured. CONCLUSIONS: A minimum of eight sites is suggested to accommodate inter-individual differences in SAT patterning. All sites overlie muscle with a clearly visible fascia, which eases the acquisition of clear images and the marking of these sites takes only a few minutes. This US method reaches the fundamental accuracy and precision limits for SAT measurements given by tissue plasticity and furrowed borders, provided the measurers are trained appropriately.

The premaxillary space: a location for filler injection?

BACKGROUND: A four-layer fat structure is found in the anterior cheek region. The deepest of these fat layers is the premaxillary fat. OBJECTIVE: To determine whether the premaxillary fat is located in a closed compartment and whether injection of substances affects the appearance of the face. METHODS & MATERIALS: Filler or arterial mass (0.5-0.8 mL) after Thiel were injected, and gross dissections, horizontal and sagittal sections, and three-dimensional reconstructions with computed tomography were performed. RESULTS: The premaxillary fat is located in a semiopen space, the premaxillary space, with mainly bony and muscular borders. The injected substances spread in lateral and superficial located tissues. CONCLUSION: Injection of substances into this space leads to discrete improvements in the appearance of the nasolabial groove.

Complete mapping of lateral and medial sural artery perforators: anatomical study with Duplex-Doppler ultrasound correlation.

INTRODUCTION: The precise vascular anatomy of posterior lower leg skin is not well understood. Despite being a potential donor site for sural artery perforator flaps, this region is rarely used and underestimated. The aim of this study was to provide exact preoperative planning for medial and lateral sural artery perforator flap harvest. METHODS: An anatomical study on 16 cadaveric lower legs was performed to determine the number and location of all medial and lateral sural artery perforators in relation to five fixed points (medial and lateral maleolus, calcaneus, medial and lateral condyle). A Duplex study on 32 lower legs determined the number and location of dominant medial and lateral sural artery perforators in relation to same anatomical points. Results of the two studies were correlated. RESULTS: A total of 234 perforators were found in the anatomical (134) and Duplex studies (100). A dominant lateral sural artery perforator was found in 9.4% of all lateral perforators in 31% of dissected legs. A dominant medial sural artery perforator was found in 37% of all medial perforators in 94% of legs. The difference in the number of dominant medial and lateral perforators was significant (p < 0.001) in the anatomical study, while no significant difference was found in the Duplex study (p = 0.920). CONCLUSION: The anatomical study showed relative unreliability of sural region regarding number of dominant perforators. Therefore, harvest of medial and particularly lateral sural artery perforator flap is unsafe without preoperative perforator mapping. No significant difference in location of dominant perforators was found between Duplex and anatomical studies. Duplex proved reliable for planning of sural artery perforator flaps due to high precision in detecting location of dominant perforators.

Corrugator supercilii muscle terminal nerve ablation using a novel thread technique for the treatment of hyperdynamic vertical glabellar furrows.

BACKGROUND: A novel percutaneous corrugator supercilii muscle terminal nerve CSMTN ablation technique is proposed for the treatment of hyperdynamic vertical glabellar furrows (HVGF). TECHNIQUE: Two surgical marks are placed on each eyebrow. One is placed at the level of the lateral canthus and the second at the outer border of the limbus. At each of the four marks, the following steps are carried out: (1) a guiding needle is used to punch the frontal skin at 3 mm above the eyebrow (orifice A) and will then travel deeply at the level of the supraperiostium and emerge outside the skin 3 mm below the eyebrow (orifice B) at the palpebral skin; (2) the needle is then reentered exactly at orifice B and will travel underneath the skin at a more superficial level in the subcutaneous layer and then emerge outside exactly at orifice A. Both ends of the thread are gently pulled in a sawing motion with counter tension until no more resistance is felt from the anatomical structures involved, and then the loops of thread are withdrawn from orifice A. RESULTS: Forty-seven subjects underwent bilateral CSMTN ablation. In the first 10 cases, the authors performed only one neurotomy per eye and observed a 50 percent HVGF recurrence rate. Then, the authors chose to perform two neurotomies per side and had a three percent recurrence rate (1/37) with a high degree of patient satisfaction. Major complications such as deforming hematomas, eyelid ptosis, abscess, scar formation or adhesions were not observed during follow up. CONCLUSION: This novel technique may represent a simple and permanent solution for HVGF.

Flexibility of Thiel's embalmed cadavers: the explanation is probably in the muscles.

INTRODUCTION: The flexibility of cadavers conserved using Thiel's embalming method remains unexplained. We aimed to perform microscopic comparison of muscle and tendon fibres from fresh cadavers (FC), formaldehyde-preserved cadavers (FPC) and cadavers conserved by Thiel's method (TC). METHODS: Muscle and tendon biopsies performed on FC, FPC and TC were conditioned and stained by Masson's trichrome, Sirius red and Ramon y Cajal, then studied under optical microscope. Alignment and integrity of the muscle and tendon fibres were studied. RESULTS: We observed a modification of the muscle fibres in all specimens from TC, regardless of the type of staining used. The muscle fibres taken from FC and FPC were relatively well conserved, both in terms of alignment and integrity. We did not observe any modification of collagen in either muscle or tendon fibres. CONCLUSIONS: The considerable fragmentation of the muscle proteins, probably caused by certain corrosive chemicals, (e.g. boric acid) present in Thiel's embalming solution, could explain the suppleness of the TC. However, we cannot exclude the possibility of alterations in tendon or muscle collagen, since the experimental methods we used, did not allow for the study of collagen ultrastructure.

Is Thiel's embalming method widely known? A world survey about its use.

INTRODUCTION: Thiel's embalming technique, first described by Thiel in 1992, conserves texture and colour in cadavers close to that observed in the living. It would appear that few anatomy laboratories use this method, and literature describing its use worldwide is sparse. The aim of our study was to conduct a worldwide survey on the use of this method. METHODS: A questionnaire was sent out by mail to 311 anatomy laboratories or institutes across the five continents. There were six multiple choice questions to assess the level of awareness of Thiel's method, the frequency of its use among respondent institutions, the most frequently used solutions for conservation of cadavers and perceived obstacles to the use of Thiel's technique. RESULTS: 109/311 (35%) centres replied to the questionnaire; 56% of centres had previously heard of Thiel's technique, but only 11 centres (10% of respondents) used it regularly, and all of these were in Europe. Formalin remains the most widely used conservation solution around the world. CONCLUSIONS: Thiel's embalming technique is not widely known, and therefore, little used. The main obstacle to its wider use is likely the language barrier, since most of the publications describing Thiel's method are in German, which is not widely spoken outside of a few European countries.

The septum subcutaneum parotideomassetericum.

BACKGROUND: The fatty tissue of the face is divided into compartments. The structures delimiting these compartments help shape the face, are involved in aging, and are encountered during surgical procedures. OBJECTIVE: To study the border between the lateral-temporal and the middle cheek fat compartments of the face. METHODS & MATERIALS: We studied 40 human cadaver heads with gross dissections and macroscopic and histological sections. Gelatin was injected into the subcutaneous tissues of 35 heads. RESULTS: A sheet of connective tissue, comparable to a septum, was consistently found between the lateral-temporal and the middle compartments. We call this structure the septum subcutaneum parotideomassetericum. CONCLUSION: There is a distinct septum between the lateral-temporal and the middle fat compartments of the face.

The functional anatomy of the cricothyroid joint.

Postoperative long-term treatment problems of male-to-female transsexuals can be caused by the underestimated mobility of the cricothyroid joint. One hundred cadaveric larynges were analysed to reveal the morphological and functional anatomy of the CTJ focusing on possible horizontal and vertical gliding movements. Furthermore, the distance of the cricothyroid space for rotational movements was measured. The articular surface of the cricothyroid joint showed three different possibilities: a well-defined facet (Type 1 61%), no definable facet (Type 2 22%) or a flat surface with or without a tiny protuberance (Type 3 17%). Side different statements and intraindividual differences between male and female specimens were included. These different types affect horizontal and vertical gliding movements, besides rotational movements. The mobility between Type 1 and the others was highly significant (P < 0.001). Regarding different motions in the cricothyroid joint, rotational movements caused significant elongation of the vocal folds, which should be taken into consideration for phonosurgical methods.

The cricothyroid joint--functional aspects with regard to different types of its structure.

The cricothyroid joint (CTJ) plays a key role in pitch adjustment of the human voice. It allows an external elongation of the vocal fold performed by the cricothyroid muscle with a consecutive stretching and increasing of tension. Phonosurgical methods such as cricothyroid approximation need sophisticated investigations on anatomical and functional principles because of the low satisfaction rates. Fifty cadaveric specimens were analyzed to reveal the morphological and functional anatomy of the CTJ focusing on possible gliding movements in a horizontal and vertical direction. The cartilaginous surfaces of the CTJ were categorized according to Maue and Dickson into three different types (type A: well-defined facet; type B: no definable facet; type C: flat cartilage surface or protuberance) and functional correlations examined. Side different statements and intraindividual differences between male and female specimens were included. Besides from rotational movements, the CTJ allowed horizontal and vertical gliding movements depending on the different types of the cartilaginous surfaces. Especially the difference concerning mobility between type A and the others was highly significant (P<0.001). Two thirds of our specimens showed a similar type in both CTJs, whereas in one third it was asymmetric. In comparison to the possible change of distances between horizontal gliding movements and rotation, rotation caused significant elongation of the vocal folds, which should be proposed in phonosurgical methods for cricothyroid approximation.

The chin and adjacent fat compartments.

BACKGROUND: The human face contains numerous subcutaneous compartments of fatty tissue, but neither a chin compartment nor a submental compartment have been described. Definitions of the jowl compartment vary considerably. OBJECTIVES: To investigate the borders between the subcutaneous fat compartments of the chin, submental region, and jowls. METHODS AND MATERIALS: Colored gelatin was injected into the subcutaneous tissues directly under the skin of 30 human cadaver heads. Macroscopic dissection was performed. RESULTS: Distinct chin and submental compartments were identified in all cases. The chin compartment is demarcated by the mentolabial groove superiorly, the submental ligaments inferiorly, and the labiomandibular grooves laterally. The submental compartment is demarcated from the chin by the submental ligaments, laterally by the paramedian platysma-retaining ligaments, and inferiorly by the hyoid ligament. The upper border of the jowl compartment is formed by the mandibular ligaments and the platysma-mandibular ligaments, the anterior border by the paramedian platysma-retaining ligaments, and the dorsal boundary by the submandibular platysma retaining ligaments. CONCLUSION: The chin compartment is well demarcated from adjacent compartments. The limits of the submental compartment vary. The jowl compartment is clearly demarcated from adjacent compartments.