^ L U I < Anatomy of the fascia 2 ANATOMY OF THE FASCIA I Superficial fascia Superficial I FASCIA THE OF ANATOMY Adipose Retinaculum Ground Ground Retinaculum Adipose el ui uef substance superf. cutis cell The aaoyo h hpdri: limbs hypodermis: of the anatomy • trunk hypodermis: of the anatomy • aaaamao superficial fascia superficial NTM O TE FASCIA THE OF ANATOMY t Aponeurotic fascia fascia Aponeurotic layer Adipose or superficial fascia superficial or eiyim, endomys. , perimysium M uscular tissue, tissue, uscular M fascia Epimysial tissue connect, Loose layer branous em M Dermis The • anatomy of the deep fascia: trunk fascia: deep ofthe anatomy • limbs fascia: deep ofthe anatomy • deep fascia deep The hypodermis lies beneath the beneath lies hypodermis The the retinaculum cutis profundus. profundus. cutis retinaculum the cutis superficial^, a membranous a superficial^, cutis The fascia. superficial the called bythree isformed it and dermis body. human the in fasciae the of deep and epimysial fasciae. epimysial and deep The Federative Committee on Committee Federative The i. 1.1. Fig. Anatomical Terminology (FCAT) Terminology Anatomical he e th layerwithloose tissueconnectiveof layeraandorsuperficialfascia true retinaculum the with layer pose adi­ an by isformed hypodermis inappropriately often are layers These tissue. connective of layers Beneath the hypodermis are the are hypodermis the Beneath complex than this definition: this than complex it image, In this tissue. connective mem­ a either as fascia the defines is evident that the fasciae are more are fasciae the that evident is of aggregation another or brane (25x, Haematoxilin-Eosin stain). Haematoxilin-Eosin (25x, i. 1.2. Fig. • muscular tissue (D). tissue muscular • (C) fascia • epimysial (B) fascia • aponeurotic (A) fascia • superficial fasciae of the thigh thigh the of fasciae Schematic arrangement arrangement Schematic irsoi mg of image Microscopic 3 ANATOMY OF THE FASCIA Superficial fascia HPE 1 CHAPTER Fig. 1.3. Superficial fascia, re­ gion of the back, being pulled while attached to a dynanometer. Before breaking, the membranous layer of the superficial fascia in the back exhibits a resistance to stretch of approximately 8 kg in a longitudinal direction and 6 kg in a transversal direction. The abdom­ L ^ inal fascia has a resistance of 2.8 kg in a longitudinal direction and 5.5 kg in a transversal direction; the fascia of the limbs exhibits a resistance ranging from 1.4 kg to 1.7 kg. o

CD Fig. 1.4. Nerve within the su­ perficial fascia (immuno-histo- Q chemical stain S100, 250x). n Many nerves pass within the su­ Q perficial fascia; in part, these nerves innervate the superficial fascia itself and, in part, they perforate it to reach the skin. The structure and function of the receptors that inner­ vate the skin differ from those that innervate the hypodermis.

Fig. 1.5. Superficial fascia of the leg, pulled upwards to highlight the underlying deep fascia. The superficial fascia has the role of: • facilitating mobility of skin with respect to the deeper planes or layers • protecting the superficial ves­ sels (venous and lymphatic) and nerves • separating exteroception, which pertains to the skin, from pro­ prioception, which pertains to the deep fascia. Anatomy of the fascia NTM O TE FASCIA THE OF ANATOMY The superficial fascia in the pos­ inthe fascia superficial The h rtncl fti ae r lying are layer this of retinacula the tissue. adipose the beneath found is fascia Scarpa's as known fascia region. trunk removal after hypodermis, the tion, however, it adheres to the to adheres it however, tion, direc­ atransverse in skin; the to adheres it processes, spinous the fibrous, a is region trunk terior the right latissimus dorsi, pulled pulled dorsi, latissimus right the almost parallel to the skin. the to parallel almost abdomen, In the superficialis. cutis retinaculum the to corresponds actually layer this fascia; superficial second a described has Camper left anterior the from skin the of quadrants for each body segment. body each for quadrants i. 1.6. Fig. membranous layer of abdominal abdominal of layer membranous Fig. 1.7. 1.7. Fig. underlying muscles to form specific specific form to muscles underlying Along region. gluteal the to neck the from manner homogeneous ain extends that lamina resistant upwards by forceps. by upwards In the abdomen, the superficial superficial the abdomen, In the h uefca aca nte neck inthe fascia superficial The irso h paym muscle. platysma the of fibres cial fascia. cial superfi­ the within comprised also are that muscles mimic the onto inserting face, the to up continues the includes and surrounds also inter­ without continues, it and muscle platysma the surrounds right side of the neck, with some some with neck, the of side right 1.8. Fig. mammary gland. The platysma platysma The gland. mammary it where thorax, the into ruption, Superficial fascia Superficial The adipose layer of layer adipose The Superficial fascia over over fascia Superficial uefca aca n the on fascia Superficial 5 ANATOMY OF THE FASCIA Superficial fascia HPE 1 CHAPTER Fig. 1.9. Mimic muscles in the face, comprised within the su­ perficial fascia. The superficial fascia in the face presents three different conforma­ tions: • it contains some mimic muscles that insert onto the skin • it contains other mimic muscles that insert onto bones • it covers the deep muscles (e.g. masseter) that originate and in­ sert onto bones.

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CD Fig. 1.10. Superficial fascia, me­ dial region of left leg, comprising Q to greater saphenous vein. n Along the limbs, the membranous Q layer of the superficial fascia com­ prises the more superficial blood and lymphatic vessels. If the three layers of the hypoder- mis become rigid, then densifica- tion can slow blood return, causing varicose vein formations, as well as the flow of lymph, causing oedema to form.

Fig. 1.11. Sole of the foot, with close-packed adipose tissue in a thick web of collagen fibres (reti­ naculum cutis superficialis). The superficial fascia adheres to the deep fascia in the palms of the hand and the soles of the feet. Therefore, the deep layer of loose connective tissue, which normally permits gliding, is absent in these areas. Here, the retinaculum cutis superficialis adheres firmly to the skin guaranteeing that the skin does not slide on the deep fascia. Anatomy of the fascia 6 NTM O TE FASCIA THE OF ANATOMY fascia fascia Aponeurotic fascia superficial fascia superficial septum septum and perimysial perimysial and mbrane em m Interosseous Interosseous with Hypodermis Epimysial Epimysial Intermuscular Intermuscular ------flexor carpi radialis and partially partially and radialis carpi flexor h oer ie rgnt many to origin gives forearm the which partially extends over the the over extends partially which scribed but never illustrated. never but scribed The deep fascia or muscular fascia fascia muscular or fascia deep The The deepThefascia isdivided into: fascia. ed n expansion. ex­ an tends tendon semitendinosus the anrfrtevrosmsls and muscles, various the for tainer fascia. Fig. 1.14. 1.14. Fig. neurotic fascia have only been de­ been only have fascia neurotic apo­ overlying the from muscles muscle. this for origin provides radialis. carpi flexor the of fibres muscle of fascia aponeurotic the how the the Istituzioni di onatomia delluomo Piccin) delluomo onatomia di Istituzioni In anatomical texts, the origins of origins the texts, anatomical In In this photograph, it can be seen be can it photograph, In this (Modified from G Chiarugi &Bucciante L Chiarugi G (Modified from and the middle third. middle the and cia is illustrated as if it were a con­ a itwere if as illustrated is cia aponeurotic fascia and epimysial epimysial and fascia aponeurotic Fig. 1.13. 1.13. Fig. right leg, between the upper third third upper the between leg, right 1.12. Fig. is found beneath the superficial superficial the beneath isfound no distinction is made between between made is distinction no illustrated in these texts. inthese illustrated been never have fascia neurotic apo­ overlying the onto muscles In anatomy texts, the muscular fas­ muscular the texts, anatomy In Furthermore, the insertions of insertions the Furthermore, • epimysial fascia, which surrounds surrounds which fascia, epimysial • • aponeurotic fascia, which sur­ which fascia, aponeurotic • h limbs the Deep fascia of of Deepfascia sial fasciae. sial extends and muscle single each trunk the also part, in and, into the perimysial and endomy- endomy- and perimysial the into stocking alike limbs the rounds limb, onto which a part of of part a which onto Antebrachial fascia, fascia, Antebrachial Aponeurotic fascia of of fascia Aponeurotic Cross section of the of section Cross

Deep fascia of ANATOMY OF THE FASCIA the limbs HPE 1 CHAPTER Fig. 1.15. Fascia lata, with its multidirectional collagen fibres. The fascia of the limbs is illustrated in anatomical texts without high­ lighting the arrangement of the collagen fibres. The presence of loose connective tissue interposed between the adjacent layers of collagen fibres allows each layer to L ^ move in an independent manner.

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CD Fig. 1.16. Fascia lata formed by the tendinous expansions of the Q gluteus maximus, gluteus medius n and tensor fascia latae. Q In the 1904 edition of his Anatomy text, Testut describes the tensor fascia lata as a derivation of the tendinous expansions of gluteus maximus, the tensor fascia lat­ ae and the internal and external obliques. The aponeurotic fascia of the upper limb is also formed by tendinous expansions from the pectoralis major and latissimus dorsi.

Fig. 1.17. Schematic illustration . Reinforcement formed Gluteus maximus by co||agen fjbres that highlights the arrangement of collagen fibres in the fascia lata. In the fascia lata there are longitu­ dinal collagen fibres (iliotibial tract) that connect the unidirectional mf units together to form mf sequenc­ es; there are also oblique collagen fibres (retinacula, but not those of the dermis) that connect the cen­ Longitudinal collagen vastus lateralis formed tres of fusion together to form mf fibres of the tensor by collagen fibres coming spirals. fascia latae from the gluteus maximus Anatomy of the fascia 8 NTM O TE FASCIA THE OF ANATOMY OF THE THE OF FASCIAE LIMBS LIMBS / ' Spr aca 1 fascia /Superf fsi | fascia \ or hypodermis ] hypodermis or or hypodermis]j loose conn.t. layer for gliding gliding for layer conn.t. loose hypodermis]j or Superf fascia 11 undulated collagen fibres collagen 11 undulated fascia Superf pmsa I Epimysial i ( l undulated collagen fibres collagen undulated l ( loecn, ise layer tissue conn, loose [ layer adipose superficial f 1 perimysium and peritenon endomysium l peritenon and 1 perimysium epitenon and > epimysium

ragd n parallel in Arranged yfsil insertions Myofascial membranous layer layer membranous h pnuoi aca inthe fasciae aponeurotic The The fasciae of the muscular tissue tissue muscular the of fasciae The fasciae either via tendinous expan­ tendinous via either fasciae ftefsie n h limbs. the in fasciae the of continue in the tendons without without tendons in the continue insertions. viaor sions arranged in parallel to the under­ the to parallel in arranged Fig. 1.20. 1.20. Fig. interruption. limbs connect to the aponeurotic aponeurotic the to connect limbs the of muscles The muscles. lying is that glove or sleeve a form limbs h rtncl o h nl r not are ankle the of retinacula The The internal surface of the fasciae fasciae the of surface internal The fibres collagen of layers three The fibres, which, in turn, tension the tension inturn, which, fibres, with the multilayered spiral-form spiral-form multilayered the with Istituzioni di anatomia delluomo Piccin) delluomo anatomia di Istituzioni so forth, give origin to muscular muscular to origin give forth, so and knee, wrist, ankle, the around retinacula the of All fibres. collagen (Modified from G Chiarugi & L Bucciante L& Chiarugi G (Modified from aponeu­ the within comprised are ankle (note differences with the illustration). the with above differences (note right ankle the of retinacula extensor rt hauoa (li F, 1995). FD, (Ellis hyaluronan crete hyal- secrete fibres these of cells retinacula. continuity in are and fascia rotic They bands. or ligaments isolated extensors. the of retinacula 1.18. Fig. has modified fibroblasts that se­ that fibroblasts modified has 1999). DM, (Klein uronan The wrist. and ankle the of nacula reti­ in the highlighted been have Fig. 1.19. 1.19. Fig. h limbs the Deep fascia of of Deepfascia Schematic summary summary Schematic Superior and inferior inferior and Superior Superior and inferior inferior and Superior

Deep fascia of ANATOMY OF THE FASCIA the trunk HPE 1 CHAPTER Fig. 1.21. Rectus abdominis sheath, formed by the aponeu­ roses of the external and internal obliques. The fasciae and muscles of the trunk carry out two functions: the first is at the service of the loco­ motor apparatus, the second is as a containment for the viscera. Much like the thoracolumbar fas­ cia, the rectus abdominis sheath is formed by tendinous expansions of the external and internal obliques and the transversus abdominis. o

CD Fig. 1.22. Schematic illustration that highlights the arrangement Q of the collagen fibres of the ex­ n ternal and internal obliques. Q The collagen fibres of the two obliques form a large retinaculum that is part of the trunk spirals, in continuity with the spirals of the limbs. More deeply there are the longitudinal fibres of rectus ab­ dominis (part of the antemotion sequence) and the horizontal fi­ bres of the transversus abdominis muscle.

Fig. 1.23. Schematic summary of the fasciae in the trunk. /Super! fascia superficial adipose layer membranous layer The aponeurotic fasciae in the or hypodermis loose connective tis. layer trunk are arranged in series with the muscular tissue. Arranged in series FASCIAE . The muscles of the trunk are ar­ OF THE ( Aponeurotic undulated collagen fibres ranged in layers: the external layer TRUNK ' fascia loose con. t. layer for gliding undulated collagen fibres corresponds to the mf spirals. The fascia forms three laminae for the Myofascial continuity large muscles and two longitudinal Epimysial superficial lamina sheaths for the erector spinae (ret- \ fascia middle lamina romotion sequence) and the rectus deep lamina abdominis (antemotion sequence).