Getting Powerful Shapely Glutes
On CT, definite involvement of muscular structures (levator ani, internal obturator, coccygeal, piri-form and greatest gluteal muscles) is defined based on the detection of enlargement of the involved muscle. It should be noted that because of the normal lack of adipose planes between the levator ani, the most caudal portion of the rectum and the anal sphincter, in this site the assessment of the extramural infiltration is frequently impossible 18 .
Trochanter major. Large prominence on the superolateral aspect of the femur shaft for attachment of the gluteus medius, gluteus minimus, and piriformis muscles. A B 9 Trochanter tertius . Process occasionally present posteriorly at the lateral end of the linea aspera at the level of the lesser trochanter for attachment of a part ofthe gluteus maximus. B
6 M. gluteus maximus. o Posterior, external surface of ilium, sacrum, coccyx, sacrotuberous ligament. i Iliotibial tract, gluteal tuberosity, lateral intermuscular septum, linea aspera. A Extension, lateral rotation, abduction and adduction of thigh at the hip joint. I Inferior gluteal nerve. A D E 7 M. gluteus medius. o External surface of ilium. i Greater trochanter. A Abduction, medial and lateral rotation, flexion and extension of thigh at the hip joint. I Superior gluteal nerve. A D E 8 M. gluteus minimus. o External surface of ilium between anterior and inferior gluteal lines. i Greater trochanter. A Abduction, medial and lateral rotation, flexion and extension of the thigh at the hip joint. I Superior gluteal nerve. A D E Deep, sheet-like tendon of origin of the gluteus maximus lying on the gluteus medius.
Many disorders do not have a chromosomal abnormality or an enzyme defect expressed in chorion, fetal blood or cultured amniocytes or alternatively a DNA test may not be available. Prenatal diagnosis is then achieved by direct fetal tissue sampling. In inherited skin disorders, histology, immunofluorescent and ultrastructural studies on fetal skin provide the diagnosis. Fetal skin is biopsied in the second trimester when the majority of fetal skin tissues are differentiated. Under ultrasound guidance a biopsy of the preferred fetal location is made. For example, buttock or leg biopsies are used for the prenatal diagnosis of epidermolysis bullosa lethalis (Rodeck et al., 1980), and the scalp for albinism in harlequin ichthyosis hyperkeratosis around the hair follicles and sweat glands of scalp and axilla confirms the diagnosis. In a few rare and lethal inborn errors of metabolism where protein expression is localized to hepatocytes, prenatal diagnosis is made by fetal liver biopsy. The...
Bursa subcutanea trochanterica. Synovial bursa on the tendon of the gluteus maximus between the skin and greater trochanter. B 6 Trochanteric bursa of gluteus maximus. B. trochanterica m. glutei maximi. Synovial bursa between the tendon of the gluteus maximus and the greater trochanter. B
Auricular and postauricular full-thickness skin (good color and texture match). The auricular defect is grafted with split-thickness skin from the buttock or groin. auricular and postauricular full-thickness skin (good color and texture match). The auricular defect is grafted with split-thickness skin from the buttock or groin.
Larger corticocancellous grafts (Figs. 15.3 and 15.4). The desired graft size will determine whether it is necessary to strip the medial periosteum with the iliac muscles, the lateral periosteum with the attached gluteal muscles, or the periosteum on both sides. The inner table is easier to expose, and larger corticocancellous grafts should be taken from the inner table whenever possible (Fig. 15.4b). This leaves the outer table with the gluteal muscle attachments intact. The anterior superior iliac spine with the tensor fasciae latae attachment should also be preserved. The grafts can be harvested with straight and curved osteotomes or with a motorized saw. 4 Gluteus minimus muscle 5 Gluteus medius muscle 6 Gluteus maximus muscle Wound closure The wound should be closed in layers. When large bone grafts have been obtained, the iliac muscles can be sutured to the gluteal muscles over the iliac wing, and the medial and lateral periosteum are sewn together with heavy sutures.
If the primary reconstruction flap can be raised in the preauricular area (Fig. 8.18a), the secondary defect can be closed with an inferiorly based retroauricular flap. The tertiary defect can then be covered by mobilization (Fig. 8.18) or with a thick split skin graft (e.g., from the buttock).
Split-thickness skin is then used to cover the fascia. The preferred donor site for this skin is the posterior surface of the opposite auricle, as this will provide the best color and texture match. The entire postauricular surface and mastoid area can be utilized while leaving the perichondrium on the auricle. A large split-thickness skin graft from the groin or buttock is then used to cover the postauricular surface and mastoid area on the normal side, and if necessary it can be used for the reconstructed postauricular surface as well. Split skin from the nearby scalp can also be used in a thickness of approximately 0.3 mm. If an ipsilateral parietotemporal fascial flap (Fig. 10.32) cannot be used due to an inadequate blood supply (evaluate by Doppler) or a severe burn, the surgeon may try to obtain a fan flap from the opposite side. This would require a free transfer and thus a surgical team trained and equipped to perform microvascular anastomosis. Another option is...
Gluteus maximus muscle 11. Gluteus minimus muscle 15. Insertion of gluteus minimus and medius muscle (greater trochanter) 9. Gluteus medius muscle 10. Gluteus maximus muscle 3. Gluteus medius muscle 6. Gluteus maximus muscle 24. Gluteus maximus muscle
Generally the eighth rib is used to reconstruct the helix it should be at least 8-10 cm long (see Fig. 11.3). Rib cartilage remnants are reimplanted subcu-taneously in the thoracic wound for the second stage of the operation. The cartilage framework is inserted into the pocket (Fig. 10.30), and one or two continuous suction drains and bolster sutures coapt the skin to the frame. The bolster sutures are left in place for about 8 days (Fig. 10.30c). The suction drains are not removed before the sixth or seventh day. Second stage (Brent 1992, Weerda 1996, Weerda et al. 1996 Fig. 10.31) About 8-12 weeks latera curved incision is made about 1-1.5 cm above and behind the rim of the implanted framework, and a thick split skin flap is sharply dissected to the rim on a shallow plane using a No. 15 blade (Fig. 10.31a, see Fig. 10.19 and pp. 33). The framework itself is not exposed, and care is taken to leave ample connective tissue on the back of the framework to ensure cartilage nutrition...
Ramus superficialis. It lies between the gluteus maximus and medius and anastomoses with the inferior gluteal artery. A 21 Deep branch. Ramus profundus. It lies between the gluteus medius and minimus. A 22 Superior branch. Ramus superior. It runs along the upper margin of the gluteus minimus as far as the tensor fasciae latae. A 23 Inferior branch. Ramus inferior. It courses in the gluteus medius as far as the greater trochanter. A 24 Inferior gluteal artery. A. glutealis inferior. Emerges through the greater sciatic foramen below the piriformis muscle infrapiriform foramen its branches are distributed beneath the gluteus maximus. They anastomose with the superior gluteal, obturator and circumflex femoral arteries. A C
Adductor magnus, gluteus maximus, hamstrings, lateral rotators Adductor magnus, gluteus maximus, hamstrings, lateral rotators The foot is in dorsiflexion with eversion. The hip and knee are in full flexion with the heel close to the lateral border of the buttock. The knee and heel are aligned with each other and lined up approximately with the lateral border of the left shoulder. The hip has the same amount of rotation as it did in the straight leg pattern. Straighten the knee to check the rotation. Apply the stretch to the hip, knee, and foot simultaneously. With your proximal (right) hand combine traction of the hip through the line of the femur with a rotary motion to stretch the external rotation. Your distal (left) hand stretches the foot farther into dorsiflexion and eversion and stretches the knee extension by bringing the patient's heel closer to his buttock. Your distal hand resists the foot and ankle motion with a rotary push. The rotary resistance at the foot also resists...
B Step 2 An incision is made 1-1.5 cm behind the cartilage margin, and a thick split skin flap is dissected close to the helical rim with a No. 15 blade. c The new posterior auricular surface is carefully dissected, preserving the connective-tissue layer on the cartilage framework. The split-thickness skin flap is folded over. The mastoid defect is reduced in size, and the residual defect is grafted with split-thickness skin from the scalp, groin, buttock, or old thoracic wound (see Fig. 10.31).
Gluteus medius, gluteus maximus (upper), hamstrings Gluteus medius, gluteus maximus (upper), hamstrings The foot is in dorsiflexion with inversion. The hip and knee are in full flexion with the heel close to the right buttock. The knee and heel are aligned with each other and lined up approximately with the right shoulder. Apply the stretch to the hip, knee, and foot simultaneously. With your proximal hand combine traction of the hip through the line of the femur with a rotary motion to stretch the internal rotation. Your distal hand stretches the foot farther into dorsiflex-ion and inversion as you stretch the knee extension by bringing the patient's heel closer to the buttock. Your distal hand resists the foot and ankle motion with a rotary push. Using the foot as a handle, resist the knee extension by pushing the patient's heel back toward the buttock. The angle of this resistance will change as the knee moves further into extension. The rotary resistance at the foot resists the...
Tensor fascia lata, rectus femoris, gluteus medius (anterior), gluteus minimus Tensor fascia lata, rectus femoris, gluteus medius (anterior), gluteus minimus lateral border of the buttock. The knee and heel are aligned with each other and lined up approximately with the lateral border of the left shoulder. Tensor fascia lata, rectus femoris, gluteus medius (anterior), gluteus minimus
Intramuscular and subcutaneous injection. With the exception of oral vaccines and BCG, all vaccines available currently should be given by intramuscular injection or by deep subcutaneous injection. The site of injection is important the upper arm (the deltoid region) or the anterolateral aspect of the thigh are strongly recommended, and not the buttock. The injection of vaccine into deep fat in the buttocks is likely, particularly with needles shorter than 5 mm, and there is a lack of phagocytic or antigen-presenting cells in layers of fat. Another factor may involve the rapidity with which antigen becomes available to antigen-processing cells from deposition in fat, leading to delay in presentation to T and B cells. An additional factor may be denaturation of antigen by enzymes as a result of deposition in fat for many hours or days. This is well illustrated in the case of hepatitis B vaccines. There are over 100 reports of low antibody seroconversion rates after hepatitis B...
Rough double line on the posterior aspect of the femur for attachment of two vasti muscles and the short head of the biceps. Insertion of the adductors, gluteus maximus, and pectineus muscles. B 17 Gluteal tuberosity. Tuberositas glutaealis. Rough, oblong field continuous with the linea aspera superolaterally. Insertion of the gluteus maximus. B
The patient is placed in an appropriate position, depending on the localisation of the tumour. We made a parasacral incision caudally. The peripheral aspect of the incision is deepened to identify the lower fibres of gluteus maximus. Then the somatic and visceral musculature around the anorectum is subsequently divided longitudinally, marking the internal anal sphincter and mucosa separately for subsequent reconstruction. The rectal lesion should then be displayed. Essentially the same technique is used, as described previously for tumour excision, ensuring that a full-thickness disc of rectal wall is removed with the lesion. The rectal wall is then closed transversely in two layers. The anorectum is reconstructed by closure of the mucosa, then the internal anal sphincter and finally the external anal sphincter. Skin closure completes the operation.
Linea glutealis anterior. A flat ridge situated somewhat in the middle of the ala of the ilium between the fields of origin of the gluteus medius and minimus muscles. A 27 Posterior gluteal line. Linea glutealis posterior. Bony ridge between the fields of origin of the gluteus medius and maximus muscles. A 28 Inferior gluteal line. Linea glutealis inferior. Bony ridge above the acetabulum between the fields of origin of the gluteus minimus and rec-tus femoris muscles. A
Dermis-fat grafts can be obtained from the periumbilical and groin regions of the abdomen or from the buttock. The graft is marked and xylocaine adrenaline injected to obtain a peau d'orange effect. The epidermis is raised and excised using a blade in a manner similar to raising a split-skin graft, then discarded. The dermis-fat graft is excised and placed in sterile, saline-soaked gauze while the donor site is closed. The dermal element can be sutured into the scarred tissues such that it supports the fat element which comes to lie subcutaneously.
The first attempt at perineal colostomy was made in 1930 by Chittenden using a flap of the gluteus maximus as a neo-sphincter 4 . In 1950, Margottini reported a series of 90 patients with a perineal colostomy following resection of the rectum 5 . In 1952 Pickrell reported the results of graciloplasty to treat anal incontinence in children 6 . In 1986 Cav-ina 7 presented his initial experience of anorectal reconstruction following Miles resection adding elec-trostimulation (EMS) of the transposed muscle in order to prevent atrophy and improve its performance. In 1989, Williams 8 published the results of his experience with perineal colostomy and gracilo-plasty following rectal resection, associated with an implantable system. Other experiences of this subject were subsequently reported by Cavina 9-11 , Beaten 12 and Williams 13,14 .
The levator ani muscle is oblique to reach the steepest point of the floor, thus transverse CT scans section it almost perpendicularly. Only coronal MR scans visualise the muscle completely 6 . Posteriorly, the pelvic floor is composed of the ilio-coccygeus muscle continuous with the levator ani. Outside the 'pelvic cone', posteriorly, the posterior group muscles (greatest, middle and least gluteal muscle) trans-versally located between the sacrum, the wing of ilium and the femur, attach the lower limb to the pelvis together with the muscles of the anterolateral group of the leg extending longitudinally between the iliac spine and proximal femur. Outside the pelvic cone there are the pectinate and external obturator muscles transversally located between the pubis and the posterior aspect of femur.
C The auricle is lifted from its bed 6-8 weeks later, and the split-thickness skin previously obtained from the buttock or thorax scar is stitched and glued to the raw surfaces on the back of the ear and the mastoid (skin grafts should be 0.350.40 mm thick). Second stage The auricular skin is incised 6-8 weeks later and the framework is elevated from the mastoid (see Fig. 10.31a, b), taking care to preserve a good connective-tissue layer on the cartilage. The resulting defects are covered with thick split or full-thickness skin obtained from the thoracic donor site, groin, or buttock (Fig. 10.15c). Reconstruction with an anteriorly based flap employs a similar technique (Fig. 10.16).
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