Enrico Vigato

Histotopographic study of the fibroadipose connective cheek system.

The purpose of this study was to investigate the morphology of the superficial musculoaponeurotic system (SMAS). Eight embalmed cadavers were analyzed: one side of the face was macroscopically dissected; on the other side, full-thickness samples of the parotid, zygomatic, nasolabial fold and buccal regions were taken. In all specimens, a laminar connective tissue layer (SMAS) bounding two different fibroadipose connective layers was identified. The superficial fibroadipose layer presented vertically oriented fibrous septa, connecting the dermis with the superficial aspect of the SMAS. In the deep fibroadipose connective layer, the fibrous septa were obliquely oriented, connecting the deep aspect of the SMAS to the parotid-masseteric fascia. This basic arrangement shows progressive thinning of the SMAS from the preauricular district to the nasolabial fold (p < 0.05). In the parotid region, the mean thicknesses of the superficial and deep fibroadipose connective tissues were 1.63 and 0.8 mm, respectively, whereas in the region of the nasolabial fold the superficial layer is not recognizable and the mean thickness of the deep fibroadipose connective layer was 2.9 mm. The connective subcutaneous tissue of the face forms a three-dimensional network connecting the SMAS to the dermis and deep muscles. These connective laminae connect adipose lobules of various sizes within the superficial and deep fibroadipose tissues, creating a three-dimensional network which modulates transmission of muscle contractions to the skin. Changes in the quantitative and qualitative characteristics of the fibroadipose connective system, reducing its viscoelastic properties, may contribute to ptosis of facial soft tissues during aging.

Histo-topographic study of the longitudinal anal muscle

The longitudinal anal muscle (LAM) has been described as a vertical layer of muscular tissue interposed between the circular layers of the internal (IAS) and external (EAS) anal sphincters. There is, however, no general agreement in the literature on its composition and attachments. The aim of this study was to investigate the histological structure, attachments, and topography of the LAM in order to evaluate its role in continence and defecation, thus enhancing knowledge of the surgical anatomy of this region. After in situ formalin fixation, the pelvic viscera were removed from eight male and eight female cadavers (age range: 52–72 years). Serial macrosections of the bladder base, lower rectum and anal canal, cervix and pelvic floor complex, cut in the transverse (six specimens) and coronal (six specimens) planes, underwent histological and immunohistochemical studies. Four specimens were studied using the E12 sheet plastination technique. The LAM was identified in 10/12 specimens (83%). Transverse and coronal sections made clear that it is a longitudinal layer of muscular tissue, marking the boundary between the internal and external anal sphincters. From the anorectal junction it extends along the anal canal, receives fibers from the innermost part of the puborectalis and the puboanalis muscles, and terminates with seven to nine fibro‐elastic septa, which traverse the subcutaneous part of the external anal sphincter, reaching the perianal dermis. In the transverse plane, the mean thickness of the LAM was 1.68 ± 0.27 mm. Immunohistochemical staining showed that the LAM consists of predominantly outer striated muscle fibers and smaller numbers of inner smooth muscle fibers, respectively coming from the levator ani muscle and from the longitudinal muscular layer of the rectum. The oblique fibers suggest that the LAM may represent the intermediate longitudinal course of small bridging muscle bundles going reciprocally from the striated EAS to the smooth IAS and vice versa. The spatial result is the helical course of striated and smooth muscle fibers between the EAS and IAS, which contribute not only to the narrowing but also to some shortening of the anal canal during sphincter contraction. Thus, rather than being a boundary, the LAM gives anatomical evidence of a functional connection between two muscle systems with different structures and topography. Clin. Anat. 21:447–452, 2008.

The gracilis muscle and its use in clinical reconstruction: an anatomical, embryological, and radiological study.

The gracilis muscle is used widely in reconstructive surgery, as a pedicled or as a free microsurgical flap, for soft tissue coverage or as a functioning muscle transfer. Many studies, based on cadaver dissections, have focused on the vascular anatomy of the gracilis muscle and provided different data about the number, origin, and caliber of its vascular pedicles. Computed tomographic (CT) angiography of both thighs of 40 patients (35 males and 5 females, mean age: 63 years) have been analyzed to provide a detailed anatomical description of the arterial supply of the gracilis muscle. The gracilis muscle had a mean length of 41 ± 2.1 cm. The principal pedicle enters the gracilis muscle at a mean distance (±SD) of 10 ± 1 cm from the ischiopubic attachment of the muscle. Its caliber shows a mean value of 2.5 ± 0.5 mm, and it is statistically larger when originating directly from the deep femoral artery (45%) than from its muscular branch supplying the adductors, i.e., the “artery to the adductors” (46%) (P < 0.01). A significant correlation between the caliber of the artery of the main pedicle and the volume of the gracilis muscle was found (P < 0.01). The mean number of distal accessory pedicles is 1.8 (range, 1–4,) and the artery of the first of these pedicles shows a mean caliber of 2.0 mm. There is no correlation between either the number or the caliber of the artery of the accessory pedicles and the volume of the gracilis muscle. CT angiography, providing detailed images of the muscular and vascular structures of the thigh of each patient, could be a useful preoperative study for the reconstructive surgeon. It would allow a personalized planning of a gracilis flap, reducing the risk of iatrogenic damage. Clin. Anat. 21:696–704, 2008.

The Expansions of the Pectoral Girdle Muscles onto the Brachial Fascia: Morphological Aspects and Spatial Disposition

Background/Aims: The aim of this study was to analyse the relationships between the expansions of the pectoral girdle muscles, i.e. pectoralis major, latissimus dorsi and deltoid, and the brachial fascia. Methods: Thirty shoulder specimens from 15 unembalmed adult cadavers were studied by dissection and in vivo radiological studies were performed in 20 patients using magnetic resonance (MR) imaging. Results: The clavicular part of the pectoralis major muscle sent a fibrous expansion onto the anterior portion of the brachial fascia, its costal part onto the medial portion and medial intermuscular septum. The latissimus dorsi muscle showed a triangular fibrous expansion onto the posterior portion of the brachial fascia. The posterior part of the deltoid muscle inserted muscular fibres directly onto the posterior portion of the brachial fascia, its lateral part onto the lateral portion and the lateral intermuscular septum. In MR images, the brachial fascia appeared as a low-signal-intensity sinuous line of connective tissue, sharply delineated in T1-weighted sequences. Conclusion: The expansions of the pectoral girdle muscles onto the brachial fascia were present in all the subjects and showed a quite constant course with a specific spatial organization. During the various movements of the arm, these expansions stretch selective portions of the brachial fascia, with possible activation of specific patterns of fascial proprioceptors.

Reversed gracilis pedicle flap for coverage of a total knee prosthesis.

BACKGROUND Poor wound-healing and skin necrosis are potentially devastating complications after total knee arthroplasty. Primary soft-tissue coverage with a medial or lateral gastrocnemius transposition flap is typically the first choice for reconstruction. The aim of this study was to evaluate the use of a distally based secondary-pedicle flap of the gracilis muscle for reconstruction of a soft-tissue defect. METHODS The characteristics of the distally based (secondary) pedicles of the gracilis muscle were studied with use of dissection (ten cadavers) and computed tomographic angiograms (fifty patients). On the basis of the anatomical features, an extended reversed gracilis flap based on the secondary pedicles was used in three patients with severe soft-tissue complications of total knee arthroplasty. RESULTS The mean number of secondary pedicles was 1.8 (range, one to four). The pedicles originated from the superficial femoral or popliteal artery. The most proximal pedicle was often the largest (mean caliber, 2.0 mm), and its point of entry into the gracilis muscle was an average (and standard deviation) of 21 +/- 3.6 cm (range, 16 to 28 cm) from the ischiopubic branch. A significant positive association (p = 0.001; r(2) = 0.49) was found between the caliber of the proximal secondary pedicle and the number of other secondary pedicles. In all three patients, the adequate caliber of the secondary pedicles (as shown on preoperative computed tomographic angiograms) and good muscle vascularization confirmed the utility of the gracilis as a distally based pedicle flap. CONCLUSIONS For the treatment of large soft-tissue defects of the patella or the proximal part of the knee, or for soft-tissue reconstruction over an exposed total knee prosthesis, the reversed gracilis pedicle flap may be an alternative to, or may be integrated with, a lateral or medial gastrocnemius flap.

Surgical anatomy of the radial nerve at the elbow.

An anatomical study of the brachial portion of the radial nerve with surgical implications is proposed. Thirty specimens of arm from 20 fresh cadavers (11 male, 9 female) were used to examine the topographical relations of the radial nerve with reference to the following anatomical landmarks: acromion angle, medial and lateral epicondyles, point of division between the lateral and long heads of the triceps brachii, lateral intermuscular septum, site of division of the radial nerve into its superficial and posterior interosseous branches and entry and exit point of the posterior interosseous branch into the supinator muscle. The mean distances between the acromion angle and the medial and lateral levels of crossing the posterior aspect of the humerus were 109 (±11) and 157 (±11) mm, respectively. The mean length and calibre of the nerve in the groove were 59 (±4) and 6 (±1) mm, respectively. The division of the lateral and long heads of the triceps was found at a mean distance of 126 (±13) mm from the acromion angle. The mean distances between the lateral point of crossing the posterior aspect of the humerus and the medial and lateral epicondyles were 125 (±13) and 121 (±13) mm, respectively. The mean distance between the lateral point of crossing the posterior aspect of the humerus and the entry point in the lateral intermuscular septum (LIS) was 29 (±6) mm. The mean distances between the entry point of the nerve in the LIS and the medial and lateral epicondyles were 133 (±14) and 110 (±23) mm, respectively. Our study provides reliable and objective data of surgical anatomy of the radial nerve which should be always kept in mind by surgeons approaching to the surgery of the arm, in order to avoid iatrogenic injuries.

Radiological anatomy of the perforators of the gluteal region: The “radiosome” based anatomy

The superior (SGA) and the inferior gluteal artery (IGA) perforator flaps are widely used in pressure‐sore repair and in breast reconstruction. The aim was to exhaustively depict the topographical anatomy of the whole system of perforators in the buttock.

Knee Region Coverage with Reversed Gracilis Pedicle Flap (GReSP Flap)

[Introduction][1] To treat severe soft-tissue complications of total knee arthroplasty, we used an extended reversed gracilis flap based on secondary pedicles (the GReSP flap). ![Figure][2] ![Figure][2] [Step 1: Prepare Wound Bed][3] Locate the gracilis and pedicles, then debride the wound bed. ![Figure][2] [Step 2: Expose Gracilis Muscle][4] Expose the superficial aspect of the muscle, while protecting the saphenous vein and nerve. ![Figure][2] [Step 3: Check Muscle Perfusion][5] Temporarily clamp the main vascular pedicle to ensure blood supply when perfused only by the secondary pedicles. ![Figure][2] [Step 4: Mobilize Muscle Flap][6] Transect the proximal tendon of the gracilis muscle to provide maximal length for the muscle flap and ligate the main vascular and nerve pedicles. ![Figure][2] [Step 5: Cover with Skin Graft][7] Suture the flap in place and cover with skin graft. ![Figure][2] [Step 6: Postoperative Care][8] Immobilize the knee for two weeks; follow with rehabilitation to restore range of motion. [Results & Preop./Postop. Images][9] We treated three patients who had an infection at the site of a total knee arthroplasty and exposure of the implant. [What to Watch For][10] [Indications][11] [Contraindications][12] [Pitfalls & Challenges][13] [Introduction][1] To treat severe soft-tissue complications of total knee arthroplasty, we used an extended reversed gracilis flap based on secondary pedicles (the GReSP flap). ![Figure][2] ![Figure][2] [Step 1: Prepare Wound Bed][3] Locate the gracilis and pedicles, then debride the wound bed. ![Figure][2] [Step 2: Expose Gracilis Muscle][4] Expose the superficial aspect of the muscle, while protecting the saphenous vein and nerve. ![Figure][2] [Step 3: Check Muscle Perfusion][5] Temporarily clamp the main vascular pedicle to ensure blood supply when perfused only by the secondary pedicles. ![Figure][2] [Step 4: Mobilize Muscle Flap][6] Transect the proximal tendon of the gracilis muscle to provide maximal length for the muscle flap and ligate the main vascular and nerve pedicles. ![Figure][2] [Step 5: Cover with Skin Graft][7] Suture the flap in place and cover with skin graft. ![Figure][2] [Step 6: Postoperative Care][8] Immobilize the knee for two weeks; follow with rehabilitation to restore range of motion. [Results & Preop./Postop. Images][9] We treated three patients who had an infection at the site of a total knee arthroplasty and exposure of the implant. [What to Watch For][10] [Indications][11] [Contraindications][12] [Pitfalls & Challenges][13] [1]: #sec-11 [2]: pending:yes [3]: #sec-12 [4]: #sec-13 [5]: #sec-14 [6]: #sec-15 [7]: #sec-16 [8]: #sec-17 [9]: #sec-18 [10]: #sec-19 [11]: #sec-20 [12]: #sec-21 [13]: #sec-22