Fascia Glutealis As Mediator of Musculocutaneous Dynamics in the Buttocks Region

Übersichten

J Ästhet Chir M. Sandhofer1 ·P.Schauer2 ·U.Pilsl3 · F. Anderhuber3 https://doi.org/10.1007/s12631-018-0132-9 1 Zentrum für Venen, Lipödem, Laser, Haut, Praxis Dr. Matthias Sandhofer/Dr. Martin Barsch, MBA, Linz, Austria © Springer Medizin Verlag GmbH, ein Teil von 2 http://www.hautarzt-passau.com Springer Nature 2018 3 Graz, Austria Fascia glutealis as mediator of musculocutaneous dynamics in the buttocks region

The gluteal region is a pronounced body this compartment encloses the gluteal muscles, is subdivided by a connective part at the end of the torso only among muscles. Ventrally, in the area of the tissue layer, which inserts between the humans and primates. It consists of two gluteus medius, the fascia is coarse and gluteus maximus on the one hand and semi-spherical buttocks (clunes) that are tight, whereas it is thin over the gluteus the gluteus medius and minimus on the separated by the gluteal cleft. The gluteal maximus. Reinforcements that cover the other. Numerous connective tissue septa muscles surround the hips and hold the muscle like reins and reach all the way between the rough bundles of the glu- pelvis in a precarious balance. A layer of to the gluteal groove are only found at teus maximus are located in the area of fat lies on the fascia of the gluteus medius; the caudal edge of the gluteus maximus. the gluteus maximus’ surface chamber. this layer’s form is responsible for the size Here, the gluteal fascia continues to the The deep chamber runs along the glu- and shape of the gluteal region’s sides and broad fascia. Behind the gluteus max- teus medius and minimus to the greater top (. Figs. 1 and 2;[25]). imus, the fascia is connected to the sacral trochanter [24]. The buttocks are considered an inti- bone and coccyx; these connectionsclose The frontal, coarser portion of the glu- mate body part with strong attraction thechambertowardsthedorsalarea. This teusmedius’fasciaisessentiallyananchor for both sexes. Inﬂuencing its form chamber, which covers all three gluteal point for the iliotibial tract. The dynamic has become especially important in aesthetic medicine [1, 2]. The muscles, the connective tissue structures, and the subcutaneous fat in this region form a functional unit. Dermatomes and myotomes are developed from the mesoderm via the somites [23]. Here, the muscle-fascia structures form connections with the subcutaneous tissue above them and jointly form the torso fascia, so that the entire body is encased in a fascial panniculus [4]. Therefore, the border region between the free extremity and the torso requires a more detailed examination. The gluteal fascia is connected to the fasciae of its surroundings. Ventrally, it encloses the broad fascia tensor muscles before it merges into the broad fas- Fig. 2 8 Gluteal region without (left) and with cia. Cranially, it attaches to the iliac contraction of the gluteal muscles (right).Yel- low arrow contraction of the bottom third of the crest, thereby creating a compartment; gluteus maximus (GM); greenarrows retraction of the myofascially moved retinacula, red line The German version of this article can be Fig. 1 8 Gluteal region with schematic depic- lifting of the gluteal fat pad through the muscle found under https://doi.org/10.1007/s12631- tion of the bone and muscle structures of the action of the GM; thigh (blue arrow), semi-lunar 018-0127-6. gluteal and thigh region cellulite indentations

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Discussion

The fascia of the gluteus maximus is thin and has powerful connections to both the muscle and the fat pad. Strong connective tissue strands separate the muscle bundles from one another and can reach throughtheentirethicknessofthemuscle to its base. This fact can also be observed during the difficult removal of the muscle fascia. Carla Stecco [25] calls this type of fascia involving intensive muscle contacts “epimysal fascia”; the central medial and distal portion of the gluteus maximushereisaffectedparticularlyin women. The lateral part can be charac- terized as the aponeurotic fascia type, es- peciallyinmen,butalsotosomeextent Fig. 3 8 a 1 + 2 fasciaabovethegluteusmedius,3 muscleaponeurosiswithtransitiontobroadfascia, in women (. Fig. 8). The muscle–fas- 4 trochanter after lifting off the fascia and bursa, 5 attachment type of ischiatic holster, 6 iliac crest. cia power transmission can be derived b Blue gluteus maximus with fascial bands, red fascial bands of gluteus medius and aberrant fascial from the topographic anatomy of the bands from the broad fascia; green fascial bands of the broad fascia tensor; gray iliac crest, gluteal gluteal muscles (. Fig. 6). This epimus- tuberosity (femur); brown gluteal foramen cular, muscle–fascia power transmission takes effect more in the medial and distal of the fascia group (medius, maximus thigh. The bottom third of the gluteus part through the close interlacing of the top 2/3) is mediated via the trochanter maximus, with its associated fascia, starts gluteal fascia with the superficial fascia with a bursa-type sliding zone. The tran- at the gluteal tuberosity of the femur. (subcutaneous fascia). This power im- sition of the gluteus maximus’ aponeu- When standing, this part of the muscle pact is also transferred to the surface of rosis to the wide tendons of the broad covers the ischial tuberosity; when sit- the buttocks via the retinacula of skin fascia can be easily seen in the surface ting it slides up, so that the compressive (. Figs. 5, 6 and 9). The aponeurotic por- image(“trochantericfossa”).Thegreater stresses during sitting are transferred to tion is responsible more for the mus- trochanter here can be felt through the the ischial tuberosity (. Fig. 4). cle–tendon power transfer to the broad flat aponeurotic membrane and is often fascia. The gluteal muscles have a variety also visible as a slight rise [11]. Materials and methods of functions; here the extension in the Thus, the top two-thirds of the glu- hip joints is primarily important for rais- teus maximus end in an aponeurotic fas- The gluteal region was examined in four ing the body, e.g., from squatting, when cia structure, which finally ends in the femaleandthreemalecadaverspreserved standing up, climbing stairs, mountain broad fascia [25]. This is also called the according to Thiel6 [ , 7]. Firstly, fat was climbing, or hiking. These muscles are muscle’smuscle–tendonpowertransmis- aspirated. Aspiration was performed by therefore very important as flight mus- sion, which is localized in the lateral third tumescence suctioning with H2Oandap- cles. The cranial portions together with of the gluteus maximus [4]. plication of the Microair system in line the gluteus medius are also responsible The coarse, non-movable fascia of the with liposuction according to J. Klein [8, forabductionandexteriorrotationofthe gluteus medius is a fascia holster that 9]. During subsequent dissection, an at- hip joints, the caudal portion is involved radiates on the one hand from the iliac tempt was made to show the relationship inadduction[26]. Inourmodernsociety, crestwithfiberstotheiliotibialtract, from of the fasciae to both the muscles and the many of these muscle functions are no which fibers in turn radiate; these fibers subcutaneous tissue and skin (retinacula, longer adequately used and this system is thus contribute to the morphology of the neurovascularbundles; . Figs. 5, 6and7). therefore subject to a rapid degenerative ischiatic holster (. Fig. 3). Distal to this, The retinacula that originate in the process. additional fibers radiate to the fasciae of fascia were easily depicted in our dis- The fasciae are also important as the thigh flexors. The gluteal foramen sections after the fatty tissue close to the a guiding structure for the blood vessels. is formed between these two hammock- fascia had been aspirated. A compact fu- The large lymph collectors, in partic- like structures, which are attached at the sion of the connective tissue structures ular, depend on the mobility of the ischial tuberosity. with the fat lobules towards the dermis muscle fasciae and the accompanying This arrangement provides a border was found [4, 27]. Otherwise, large fat structures [13]. In addition, Paoletti for the fat pad in the gluteal region, across lobules embedded in multi-layered con- describes a spiral structure of the fasciae which the pad cannot descend to the nectivetissuewereobserved(. Fig. 6). and thus a “ wringing out” role in fluid

Journal für Ästhetische Chirurgie Abstract · Zusammenfassung transport dynamics [27]. Congestion J Ästhet Chir https://doi.org/10.1007/s12631-018-0132-9 in the lymph system causes increased © Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018 adipogenic reactions and/or hyperplasia and hypertrophy of the fatty tissues [28, M. Sandhofer · P.Schauer · U. Pilsl · F. Anderhuber 29]. Fascia glutealis as mediator of musculocutaneous dynamics in the Particularly in the case of lipedema, buttocks region impaired lymph drainage causes usually painful fat accumulation in the extrem- Abstract ities and buttocks area [30]. During Cellulite is a change of the skin and further, since almost exclusively women are subcutaneous tissue that develops mainly in affected. For this reason we have anatomically procedures and examinations we found the thighs and gluteal region of almost all examined male and female gluteal zones cellulite without exception among our women. Many concepts in the pathological and demonstrated significant genderspecific patient population of more than 400 physiology of cellulite are to some extent changes. In particular, a weakening of the lipedema patients, both during rest and contradictory and inconclusive; however, muscle-tendon and muscle-fascia dynamics of even more so during the squeezing test. some studies point to structural changes in the gluteal muscles appears to be responsible the dermis and subcutaneous tissue. A cor- for the round, superficially visible dermal On the other hand, an accumulation of relation of cellulite with focal hypertrophic changes. The entire embryonic unit of the subcutaneous fatty tissue causes a thin- subcutaneous connective tissue strands and muscle-fascia-skin structures in the buttocks ning of the dermal structures, which can lower density of connective tissue septa in and thigh area is involved in female cellulite. also be observed among patients with subcutaneous tissue also point to changes A transformation of these degenerative increased BMI [31, 32]. We found this in the related gluteal fascia and thus in the changes through regenerative measures, such closely interlaced gluteal muscles. A rapid as active movement and shock wave therapy during our examinations of lipedemous degenerative development of the muscle is, therefore, appropriate and necessary. arms [14]. The close interaction of the dynamics that were originally gained over retinacula originating from the fascia and generations unquestionably occurs in the Keywords the peripheral subcutaneous fat com- Caucasian race and its related urbanization. Thoracolumbar fascia · Gluteal groove · partments through the neurovascular The gender-specific dimorphism in the Retinacula of skin · Epimysium · Myofascial subcutaneous area must also be investigated power transmission bundles can cause significant damage to the peripheralsubcutaneousfatcompart- ments, if there is degeneration (dermal Die Fascia glutealis als Mittler der muskulokutanen Dynamik der white adipose tissue, dWAT; [33]). Here Gesäßregion the adipocyte myofibroblast transition (AMT) in terms of fibrosis takes effect Zusammenfassung [34]. This process can be reversed if Cellulite ist eine sich bevorzugt an den ausschließlich Frauen betroffen sind. Aus treated properly. Oberschenkeln und Glutealregion beinahe diesem Grund haben wir männliche und weibliche Gesäßzonen anatomisch untersucht When subjected to normal stress, the bei fast allen Frauen entwickelnde Verän- derung von Haut und Subkutangewebe. und hierbei deutliche geschlechtsspezifische greatflexibilityandelasticityofthegluteal Viele Konzepte zur Pathophysiologie der Veränderungen aufzeigen können. Vor allem fascia prevents rupture of and damage Cellulite sind teilweise widersprüchlich und eine Abschwächung der myotendinösen und to the blood vessels that run through unschlüssig. Einige Studien weisen jedoch myofaszialen Dynamik der Glutealmuskulatur it [5]. This phenomenon was already auf strukturelle Veränderungen an Dermis scheint für die runden, oberflächlich sichtba- ren dermalen Veränderungen verantwortlich described by Thiel10 [ ]. Lymph drainage und Subkutangewebe hin. Eine Korrelation von Cellulite mit fokalen hypertrophen zu sein. Die embryologische Einheit der is also easily possible in this loose mesh; subkutanen Bindegewebssträngen und muskulofasziokutanen Strukturen im Gesäß however,ifthereisfixeddamagetotissue verringerter Dichte der Bindegewebssepten und Oberschenkelbereich ist als Gesamtes bei (e.g., scars), a standstill occurs. im Subkutangewebe weist auch auf der weiblichen Cellulite involviert. Daher ist In this context, the fascia should not Veränderungen der damit verbundenen eine Transformation dieser degenerativen Veränderungen durch regenerative Maßnah- be separated from the muscle during aes- Fascia glutealis und mit der dabei eng verwobenen Glutealmuskulatur hin. Fraglos men wie aktive Bewegung und Stoßwelle thetic procedures (augmentation), since besteht bei der kaukasischen Rasse und sinnvoll und notwendig. this destroys lymph drainage, sensitive der mit ihr verbundenen Urbanisierung nerves, and blood vessels. eine rapide degenerative Entwicklung der Schlüsselwörter In the area of the gluteal region, the ursprünglich über Generationen erworbenen Fascia thoracolumbalis · Sulcus glutealis · Retinacula cutis · Epimysium · Myofasziale fasciae are formed by three layers: the Muskeldynamik. Auch ist der geschlechtsspezifische Dimorphismus im subkutanen Kraftübertragung surface layer (superficial fascia), the ac- Bereich genauer zu untersuchen, zumal fast tual gluteal fascia, and the epimysium below the fascia [12]. The surface layer includes the subcutaneous (dWAT) and deep pad-like (subcutaneous white adipose tissue, sWAT) fatty tissues, as well as various gender-specific connective tissue strandsthatrunfromthedeepglutealfas-

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Fig. 4 8 Thereisamassivethickeningoftheconnectivetissueseptainthe distal medial edge of the gluteal fascia; these show a pressure pad-like aspect,similartopalmarandplantarfatpads.Whensittingthebottommuscle edge slides towards the cranium, thus this fat structure protects the ischial tuberosity. 1 Pressure pad-like connective tissue fat pads above the ischial tuberosity ciatothesurfaceandserveasaguiding structure for the neurovascular bundles, as already described by Thiel10 [ ]. The multi-layered, centrally loosened gluteal fascia is in close contact with the gluteus 8 maximus, with perimysial and epimysal Fig. 5 Thereisacoarse,fixedglutealfasciaabovethepointofattachment forthegluteusmaximusfromtheposterioriliaccrestdownwardtothesacro- connectingtissuestructuresthatcanpen- tuberal ligament; that fascia connects to some extent with the surface tho- etrate the muscle all the way to the in- racolumbar fascia towards the cranium.Originating from these fixed fas- ner fascia sleeve. The functional three- cial structures, comparatively coarse retinacula stream through the fat pad layered structure (skin, fascia, muscle) into the dermis. Coarseness and thickness here differ substantially between found here is not as pronounced any- women and men; women’s connective tissue structures are significantly thinner and more delicate (a, b). a Female dissection, dorsomedial view: where else in the human body, except for 1 gluteal fascia, 2 retinacula of skin, 3 fascia of the coccyx.b Male dissection, the proximal portion of the upper arms dorsomedial view: 1 sacral gluteal fascia, 2 retinacula of skin, 3 intermediate [14]. Thus, the retinacula that run from fascia (Camper’s) the profound fascia cannot be viewed in isolation from the fascia. They thus also involved in the coordination of the power lulite. The fasciae of gluteus maximus transmit the pull of the muscle via the fas- transmission between spine, pelvis and and medius also form the essential fascia to the nates (clunes), which can cause legs; important neurological functions of cia holsters for the broad fascia and ili- a dimple-shaped indentation of cellulite nociception, mechanoreception, propri- otibial tract. Their radiations form both [20] when muscles are weakened; this oception, and interoception are also tied the ischiatic holster and the flexing fas- takes effect especially in women. into this area; there are specific results ciae of the thigh that are close to the Coordination between torso and legs with regard to the thoracolumbar fas- torso; at the same time, they limit expan- occurs via coordination of the muscles cia here ([4, 5, 18, 19]; . Fig. 10). The sion of the buttocks’ and thighs’ surface and their fasciae with the powerful tho- sensations of pain and lust have been de- fat layer. The hinge-like transitions be- racolumbar fascia (TL), whereby the sur- scribed by Krafft-Ebing16 [ ]inVita sexu- tween the two structures are located in face sleeve of this fascia transitions into alis. With regard to interoception, there the gluteal groove with the gluteal fossa the fascia of the gluteus maximus [15]. are alsospecific resultsinthe neighboring beneath it. The fossa. ( Fig. 12a, b)and The fasciae of the gluteus maximus and region ([17]; . Fig. 11). the gluteal groove spread out in a seated latissimus dorsi form a cross-grid pattern With regard to cellulite, not only the position; at the same time the ischiatic in the surface sleeve of this system. This subcutaneous structures, as described by holster pulls the bottom edge of the glu- fascia system of the torso and gluteal Nürnberger [21], but also the signifi- teusmaximusanditsfasciaupwards,so region with its self-contained arrange- cantly greater connective tissue supply that only the ischial tuberosity and the ment is responsible for the control of of the gluteal fascia and the associated subcutaneous pressure pads of the clunes homo erectus (servo system according retinacula in men appear to be responsi- are stressed during sitting. The distal glu- to Schleip [4]). This system is crucially ble for the gender-specific nature of cel- teus maximus, which starts at the femoral

Journal für Ästhetische Chirurgie Fig. 6 8 From the medial portion of the gluteal fascia, neurovascular bundles with retinacula run in turn from the fascia into thedermis. Theytherebysupplythesubcutaneousdermalfatdeposits.Here,too,signiﬁcantgenderdiﬀerencesareobserved. aFemaledissection,fromadorsocraniallateralaspect,retinaculacomingfromthecentralpartoftheglutealfascia:1:vascular bundle in the gluteal fascia, 2 retinaculum with blood vessel, 3 gluteal subdermal/subcutaneous fat pad, 4 gluteus maximus. b Male dissection, from a dorsocranial aspect, coarse retinacula coming from the central part of the gluteal fascia:1 gluteal fascia, 2: dermal/subcutaneous gluteal fat pad, 3 neurovascular bundle with retinaculum, 4 stretched retinaculum coming from the gluteal fascia

Fig. 7 8 a In the central area, in particular, there are latticed collagen fibers; however, these mostly run perpendicular to the direction of the muscle fibers.1 Latticed gluteal fascia fibers; 2 adhesive fat pads; 3 gluteus maximus muscle.b The fascia of the gluteus maximus muscle is thin and shows powerful connections to both the muscle and the fat pad.Strong connective tissuestrandsseparatethemusclebundlesfromoneanotherandcanreachthroughtheentirethicknessofthemuscletothe base. This fact can also be observed during the difficult removal of the muscle fascia. 1 Gluteal fascia; 2 perimysial interlacing; 3 gluteal muscle fiber gluteal tuberosity, has no uniform fas- –fascia power transmission has more of activating the gluteal and neighboring cial structure. With its interlacing to- an effect, while in men the significantly muscles through appropriate movement wards the subcutaneous tissue and mus- stronger connective tissue armoring of and sport therapy can improve the quality cle, the gluteal fascia can be considered themoreaponeuroticfasciaewiththe of the cutaneous/subcutaneous connec- a large, networked tension transfer sys- coarse retinacula, which are attached to tive tissue and fat depots. This can be tem (. Fig. 12). it to prevent atrophy of the connective supported by shock wave therapy [36]. The appearance of cellulite is not only tissue and fat compartments (. Fig. 8). The authors documented the effective- duetoasurfacedefect,butiscaused The structured fat compartments are ness of this method in a study: by pre- by a disorder of the entire unit of mus- well suited to augmentation by using treating subcutaneous fat via radial shock cles, fascia, and subcutaneous tissue. In hyaluron or autologous body fat for but- wave, they documented a noticeable in- the same way, these three structures are tock modeling (. Fig. 9). duction of mesenchymal and pericytal/ also closely linked in the face; here, too, Cellulite should be treated more by endothelial markers in the stromal vas- complex changes can be seen on the sur- subcision of the denting retinacula and cular fraction (SFV; [37]). face [35]. With cellulite in women, the reduction of subcutaneous fat [3], but weakening of the extramuscular muscle- mainlybyregenerativemethods. Forone,

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Fig. 8 8 The unity of the gluteal fascia is lost in a distal direction with the is- 8 chiaticholster(glutealgroove). Here, too, thereisasignificantgenderdiffer- Fig. 9 Female dissection. During our dissection, the retinacula originat- ence in the macroscopic fascia structure.Whileafinelatticestructuredom- ingfromthefasciacouldbeeasilyshownbyaspiratingthedeepfatpads; to- inates in women (a), a denser aponeurotic fascia structure exists in men (b). wards the dermis, a compact fusion of the connective tissue structures with Thus,there is more ofa muscle–tendondynamic inmen,andmore ofa mus- the fat lobules was found, which indicates the compactness of the subcuta- cle–fascia one in women.View from cranial lateral:distal fascia dissection neouslayers. Otherwise,largefatlobulesembeddedinseveralintermediate above the gluteal groove. a 1 delicatelatticedfasciastructure; 2 gluteal fora- fasciaewereobserved.a Distal gluteal fat pad after aspiration:1 gluteal fas- men; 3 sacral gluteal fascia.b 1 coarse, more aponeurotic gluteal fascia; 2 cia, 2 retinacula of skin (branching in several layers),3 spherical sub-dermal gluteal foramen; 3 coarse sacral gluteal fascia fat pad. b Fat pad without aspiration:1 large, pressure pad-like fat lobules with several intermediate fasciae

Practical conclusion

An understanding of the aestheti- cally functional unit of the subcutaneous gluteal fascia and gluteal muscle anatomy is a prerequisite for surgical or non-surgical approaches to successful treatment in the gluteofemoral region. This region often undergoes aesthetic body contouring by means of liposuction, buttock augmentation, as well as surgical cellulite treatment. Conserva- tive, non-surgical methods should also be oﬀered in a holistic approach, since these can only succeed if the musculo- Fig. 10 8 a The gluteus maximus acts in coordination during ﬂight movement.b The gluteus medius fascial dynamics are additionally and acts in coordination during stair climbing appropriately activated.

Journal für Ästhetische Chirurgie Fig. 11 8 Medial-distal from the attachment of the gluteus maximus and its fascia, a soft, elastic, light-colored fat pad is shown; this is the “ischioanal fat pad,”which lines thepelvic ﬂoorexternally.Afterradical aspiration of this fat pad (b), one can seeconnectivetissuestringsthatradiatefromthebottomedgeofgluteusmaximustowardsthesphinctermuscles.Voluntary contraction of the gluteal muscles thus support the sphincter function of the pelvic ﬂoor.a 1 Gluteus maximus; 2 ischioanal fat pad; 3 anus. b 1 Distal gluteal fascia; 2 retinacula radiating in the sphincter region; 3 subcutaneous fat in the anal area

Corresponding address Dr. M. Sandhofer Zentrum für Venen, Lipödem, Laser, Haut, Praxis Dr. Matthias Sandhofer/Dr. Martin Barsch, MBA Starhembergstr.12/3, 4020 Linz, Austria [email protected]

Acknowledgments. I would like to thank Dr. Martin Barsch for working on the English text version and for his scientiﬁc cooperationinthepreparationofthe article.

Compliance with ethical guidelines

Conﬂict of interest. M. Sandhofer, P.Schauer, U. Pilsl and F.Anderhuber declare that they have no compet- ing interests.

This article does not contain any studies with human participants or animals performed by any of the au- Fig. 12 8 Duringalateraldissection,the“glutealforamen”emergesastheborderregionbetweenthe thors. gluteal and thigh fat pads.The roof is formed by the collagen bundle radiating inward from the broad fascia,whichformstheischiaticholster(1sthammock).Thesefibersfinallyendattheischialtuberosity. This ischiatic holster covers the distal part of gluteus maximus and keeps the gluteal fat pad from slid- References ing off. Its structure originates from horizontal, branching collagen fibers of the broad fascia/gluteus medius and, afterfollowing an arc-like course, ends at the ischialtuberosity.In a distal direction, fibers 1. Gonzales R (2006) Buttocks reshaping. Indexa, Rio also branch from the broad fascia into the fascia of the thigh flexorand end in the “2nd hammock” (b), deJaneiro also at the ischial tuberosity.Both of these parallel branching connective tissue strucures form the ba- 2. Mandieta GG (2011) The art of gluteal sculpting. sis of a hinged joint-type foramen that opens while standing, and which, on the surface, separates the QualityMedicalPublishing,St. Louis 3. Hexsel DM et al (2009) Side-by-side comparsion gluteal fat pad from the fat pad of the thigh on the flexing side.Outwardly, this structure manifests as of areas with and without cellulite depressions the gluteal groove. When seated, this foramen closes.a 1 gluteal foramen, connective tissue strands using magnetic resonance Imaging. Dermatol coming from the broad fascia, laterally forming the anchor point of the buttocks, 2 finally continuing Surg35:1471–1477 as ischiatic holster until the ischial tuberosity, 3 connective tissue strands coming from the broad fas- 4. Schleip R et al (2014) Lehrbuch Faszien. Elsevier, cia that run into the thigh on the flexing side, 4 retinaculum in the gluteal foramen, starting from the Urban/Fischer,München,S15 muscle. b After opening the proximal connective tissue structures, the distalhammock takesthe form 5. SchleipRetal(2012)Fascia: thetensionalnetwork of an arc-like connective tissue strand in the thigh fascia.1 Distal connective tissue arc; 2 broad fascia; of the human body: the science and clinical 3 gluteal foramen applications in manual and movement therapy. Elsevier,ChurchillLivingstone

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6. Thiel W (2002) Die Konservierung ganzer Leichen 31. Ezure T, Amano S (2009) Increased subcutaneous innatürlichenFarben. AnnAnat174:185–95 adipose tissue impairs dermal function in diet- 7. Anderhuber F, Reimann (2002) „Wie von Zucker“ induced obese mice PMID:19758317. Exp Der Grazer Anatom Walter Thiel. Leykam Dermatol. https://doi.org/10.1111/j.1600-0625. Buchverlagsgesellschaft,Graz 2009.00970.x 8. Hanke CW, Sattler G (2005) Liposuction, textbook 32. Sheratt MJ (2015) Body mass index and dermal with DVD, procedures in cosmetic dermatology. remodelling. ExpDermatol24:922–923 Saunders,Philadelphia 33. Driskell RR et al (2014) Defining dermal adipose 9. Klein JA (1990) Tumescent technique for regional tissue. ExpDermatol23:629–631 anesthesia permits Lidocaine doses of 35mg/kg 34. MarangoniRGetal(2015)Myofibroblastsinmurine forliposuction. JDermatolSurg16:248–263 cutaneous fibrosis originate from adiponectin- 10. Thiel W (2003) Photographischer Atlas der positive intradermal progenitors. Arthritis präklinischenAnatomie,2.Aufl. Springer,Berlin Rheumatol67(4):1062–1073 11. Braus H (1921) Bewegungsapparat. Anatomie des 35. Sandhofer M, Anderhuber F (2007) Zur chirur- Menschen,Bd. 1. Springer,Berlin gischen Anatomie des Gesichtes. Arzt Asthet 12. Stecco L, Stecco C (2009) Facial manipulation 2:14–18 practicalpart. Piccin,Padova 36. Knobloch K, Joest B, Krämer R (2013) Vogt PM 13. Földi M et al (2005) Lehrbuch der Lymphologie. Cellulite and focused extracorporeal shockwave Urban/Fischer,München,Jena therapy for non-invasive body contouring: 14. Sandhofer M, Schauer P, Anderhuber F (2013) a randomized trial. Dermatol Ther 3(2):143–155. Der ästhetische Oberarm: Zur Anatomie und https://doi.org/10.1007/s13555-01 Klassifikation des lipodysmorphen Oberarmes. 37. Priglinger E, Sandhofer M et al (2017) Extracorpo- KosmetMed2(13):56–61 real shock wave therapy in situ – a novel approach 15. Vleeming A (2012) The thoracolumbal fascia: an toobtain an activatedfatgraft. JTissue Eng Regen integrated functional view oft he anatomy oft he Med. https://doi.org/10.1002/term.2467 TLF and coupled structures. Churchill Livingstone, London, S38–43 16. Krafft-Ebing (1886) Psychopathia sexualis. Enke, Stuttgart 17. Schleip R, Jaeger H (2012) Interoception: a new correlate for intricate connections between fascial receptors,emotion,andselfrecognition. In: Fascia: the tensional network of the human body: the science and clinical applications in manual and movementtherapy. ChurchillLivingstone,Elsevier, London, S89–94 18. HoheislUetal(2012)Nociception:thethoracolum- bar fascia as a sensory organ fascia: the tensional network of the human body. In: Fascia: the tensionalnetworkofthe humanbody: the science andclinicalapplications inmanualandmovement therapy. Churchill Livingstone, Elsevier, London, S95–101 19. Huijing PA(2012) Fascia: clinical and fundamental scientific research: considering the scientific process. In: Fascia: the tensional network of the human body: the science and clinical applications in manual and movement therapy. Churchill Livingstone,Elsevier,London,S481 20. RümmelinBetal(2012)Dermatologie. Praxis3:12 21. Nürnberger F (1978) So-called cellulite: an invented disease. J Dermatol Surg Oncol 4(3):221–229 22. Huijing PD, Langevin HM (2009) Communicating about fascia: history, pitfalls and recommenda- tions. IntJTherMassageBodywork2(4):3–8 23. RohenJ,LütjenE(2011)FunktionelleEmbryologie Bd. 4. Schattauer,Stuttgart,S48 24. Hafferl A (1969) Lehrbuch der topographischen Anatomie,3.Aufl.,S821 25. Stecco C (2015) Functional atlas of the human fascialsystem,S312 26. Anderhuber F (2012) Waldeyer Anatomie des Menschen,19.Aufl.,S342–345 27. Paoletti (2001) Faszien Anatomien Strukturen Techniken. Urban&Fischer,München,Jena,S171 28. RyanTJ(1995)Lymphaticsandadiposetissue. Clin Dermatol13:493–498 29. Harvey NL (2008) The link between lymphatic function and adipose biology. Ann N Y Acad Sci. https://doi.org/10.1196/annals.1413.007 30. Bilancini S et al (1995) Functinal lymphatic alterations in patients suffering from lipedema. Angiology46:333–339

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