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1.  Female Longitudinal Anal Muscles or Conjoint Longitudinal Coats Extend into the Subcutaneous Tissue along the Vaginal Vestibule: A Histological Study Using Human Fetuses 
Yonsei Medical Journal  2013;54(3):778-784.
Purpose
It is still unclear whether the longitudinal anal muscles or conjoint longitudinal coats (CLCs) are attached to the vagina, although such an attachment, if present, would appear to make an important contribution to the integrated supportive system of the female pelvic floor.
Materials and Methods
Using immunohistochemistry for smooth muscle actin, we examined semiserial frontal sections of 1) eleven female late-stage fetuses at 28-37 weeks of gestation, 2) two female middle-stage fetus (2 specimens at 13 weeks), and, 3) six male fetuses at 12 and 37 weeks as a comparison of the morphology.
Results
In late-stage female fetuses, the CLCs consistently (11/11) extended into the subcutaneous tissue along the vaginal vestibule on the anterior side of the external anal sphincter. Lateral to the CLCs, the external anal sphincter also extended anteriorly toward the vaginal side walls. The anterior part of the CLCs originated from the perimysium of the levator ani muscle without any contribution of the rectal longitudinal muscle layer. However, in 2 female middle-stage fetuses, smooth muscles along the vestibulum extended superiorly toward the levetor ani sling. In male fetuses, the CLCs were separated from another subcutaneous smooth muscle along the scrotal raphe (posterior parts of the dartos layer) by fatty tissue.
Conclusion
In terms of topographical anatomy, the female anterior CLCs are likely to correspond to the lateral extension of the perineal body (a bulky subcutaneous smooth muscle mass present in adult women), supporting the vaginal vestibule by transmission of force from the levator ani.
doi:10.3349/ymj.2013.54.3.778
PMCID: PMC3635647  PMID: 23549829
Anal canal; levator ani muscle; longitudinal anal muscle; rectum; smooth muscle; embryology
2.  Influence of developing ligaments on the muscles in contact with them: a study of the annular ligament of the radius and the sacrospinous ligament in mid-term human fetuses 
Anatomy & Cell Biology  2013;46(2):149-156.
The supinator muscle originates from the annular ligament of the radius, and the muscle fibers and ligament take a similar winding course. Likewise, the coccygeus muscle and the sacrospinous ligament are attached together, and show a similar fiber orientation. During dissection of adult cadavers for our educational curriculum, we had the impression that these ligaments grow in combination with degeneration of parts of the muscles. In histological sections of 25 human fetuses at 10-32 weeks of gestation, we found that the proximal parts of the supinator muscle were embedded in collagenous tissue when the developing annular ligament of the radius joined the thick intermuscular connecting band extending between the extensor carpi radialis and anconeus muscles at 18-22 weeks of gestation, and the anterior parts of the coccygeus muscle were surrounded by collagenous tissue when the intramuscular tendon became the sacrospinous ligament at 28-32 weeks. Parts of these two muscles each seemed to provide a mold for the ligament, and finally became involved with it. This may be the first report to indicate that a growing ligament has potential to injure parts of the "mother muscle," and that this process may be involved in the initial development of the ligament.
doi:10.5115/acb.2013.46.2.149
PMCID: PMC3713279  PMID: 23869262
Supinator muscle; Coccygeus muscle; Sacrospinous ligament; Annular ligament of the radius; Human fetus
3.  Prominent Expression of Phosphodiesterase 5 in the Striated Muscle of Rat Urethra and Levator Ani 
The Journal of urology  2010;184(2):769-774.
Purpose
To investigate the distribution and activity of phosphodiesterase 5 (PDE5) in the urethra.
Materials and Methods
Rat tissues were examined for expression of PDE5 and alpha-smooth muscle actin (SMA). Urethral PDE5 activity was examined by tissue bath in the presence of sildenafil.
Results
Anti-SMA antibody stained all known smooth muscles in all tested tissues. It also revealed the presence of a small amount of smooth muscle fibers in the levator ani muscle. Anti-PDE5 antibody stained the smooth muscles in the penis and bladder but not the striated leg muscle. However, it stained predominantly the striated muscle in the urethra and levator ani muscle. In the urethra, the amount of PDE5 in the striated muscle was 6 times as high as in the smooth muscle. Within the urethral striated muscle, PDE5 expression was localized to the Z-band striations. Intermingling of the smooth and striated muscles were clearly visible on both the inner and outer rims of the circularly arranged striated muscle layer. Relaxation of pre-contracted urethral tissues by sodium nitroprusside (SNP) was enhanced by sildenafil, indicating the presence of PDE5 activity, which was primarily located in the striated muscle as judged by PDE5 staining.
Conclusions
PDE5, despite its presumed smooth muscle specificity, was predominantly expressed in the striated muscle of the urethra and the levator ani muscle. These results are consistent with earlier studies in which these striated muscles were found to be developmentally related to smooth muscle. They also suggest that these striated muscles are possibly regulated by PDE5.
doi:10.1016/j.juro.2010.03.110
PMCID: PMC3163603  PMID: 20639054
4.  Distribution of elastic fibers in the head and neck: a histological study using late-stage human fetuses 
Anatomy & Cell Biology  2013;46(1):39-48.
There is little or no information about the distribution of elastic fibers in the human fetal head. We examined this issue in 15 late-stage fetuses (crown-rump length, 220-320 mm) using aldehyde-fuchsin and elastica-Masson staining, and we used the arterial wall elastic laminae and external ear cartilages as positive staining controls. The posterior pharyngeal wall, as well as the ligaments connecting the laryngeal cartilages, contained abundant elastic fibers. In contrast with the sphenomandibular ligament and the temporomandibular joint disk, in which elastic fibers were partly present, the discomalleolar ligament and the fascial structures around the pterygoid muscles did not have any elastic fibers. In addition, the posterior marginal fascia of the prestyloid space did contain such fibers. Notably, in the middle ear, elastic fibers accumulated along the tendons of the tensor tympani and stapedius muscles and in the joint capsules of the ear ossicle articulations. Elastic fibers were not seen in any other muscle tendons or vertebral facet capsules in the head and neck. Despite being composed of smooth muscle, the orbitalis muscle did not contain any elastic fibers. The elastic fibers in the sphenomandibular ligament seemed to correspond to an intermediate step of development between Meckel's cartilage and the final ligament. Overall, there seemed to be a mini-version of elastic fiber distribution compared to that in adults and a different specific developmental pattern of connective tissues. The latter morphology might be a result of an adaptation to hypoxic conditions during development.
doi:10.5115/acb.2013.46.1.39
PMCID: PMC3615611  PMID: 23560235
Elastic fibers; Sphenomandibular ligament; Ear ossicles; Head; Human fetus
5.  Structure of the Perineal Membrane in Females: Gross and Microscopic Anatomy 
Obstetrics and gynecology  2008;111(3):686-693.
OBJECTIVE
To re-examine the anatomy of the perineal membrane and its anatomical relationships in whole-pelvis and histological serial section as well as gross anatomical dissection.
METHODS
Serial trichrome-stained histologic sections of 5 female pelvic specimens (0 to 37 years old) were examined. Specimens included the urethra, perineal membrane, vagina and surrounding structures. Macroscopic whole pelvis sections of 3 adults 28 to 56 years in axial, sagittal and coronal sections were also studied. Dissections of 6 female cadavers 48 to 90 years were also performed.
RESULTS
The perineal membrane is composed of 2 regions, one dorsal and one ventral. The dorsal portion consists of bilateral transverse fibrous sheets that attach the lateral wall of the vagina and perineal body to the ischiopubic ramus. This portion is devoid of striated muscle. The ventral portion is part of a solid 3-dimensional tissue mass in which several structures are embedded. It is intimately associated with the compressor urethrae and the urethrovaginal sphincter muscle of the distal urethra with the urethra and its surrounding connective. In this region the perineal membrane is continuous with the insertion of the arcus tendineus fascia pelvis. The levator ani muscles are connected with the cranial surface of the perineal membrane. The vestibular bulb and clitoral crus are fused with the membrane's caudal surface.
CONCLUSION
The structure of the perineal membrane is a complex 3-dimensional structure with two distinctly different dorsal and ventral regions; not a simple trilaminar sheet with perforating viscera.
doi:10.1097/AOG.0b013e318163a9a5
PMCID: PMC2775042  PMID: 18310372
perineal membrane; urogenital diaphragm; pelvic floor dysfunction; pelvic organ prolapse; anatomy; female
6.  New look at about nature, structure and function of Trietz ligament 
Background:
Trietz ligament connects the duodeno-jejunal flexure to the right crus of the diaphragm. There are various opinions regarding the existence of the smooth muscle fibers in the ligament. We want to resolve this complexity with microscopic study of this part in cadavers.
Materials and Methods:
This study done on three cadavers in the medical faculty of Isfahan University of Medical Sciences. Three samples of histological specimens were collected from the upper, the central, and the lower parts of Trietz ligament and were stained by H and E staining and Mallory's trichrome stain. Three samples were collected from the regions of exact connection of the main mesentery to the body wall, the intestine, and the region between these two connected regions, and these specimens were stained.
Results:
In the microscopic survey, no collagen bundles were observed in the collected samples of the Trietz ligament after the dense muscular tissues. In the samples which were collected to work on collagen tissues stretching from the Trietz ligament to the main mesentery of intestine, no collagen bundles were observed.
Conclusion:
Trietz ligament is connected to the right crus of the diaphragm from the third and the fourth parts of the duodenum. Number of researchers state that there are smooth and striated muscular tissues and some others, with regard to observations of histological phases made from the samples of Trietz muscles, conclude that it can probably be noted that muscular bundles or the dense connective tissue bundles of collagen cannot be observed in the way we imagine.
doi:10.4103/2277-9175.125853
PMCID: PMC3950839  PMID: 24627877
Collagen; duodenum; Trietz
7.  Appearance of the Levator Ani Muscle Subdivisions in Magnetic Resonance Images 
Obstetrics and gynecology  2006;107(5):1064-1069.
OBJECTIVE
Identify and describe the separate appearance of 5 levator ani muscle subdivisions seen in axial, coronal, and sagittal magnetic resonance imaging (MRI) scan planes.
METHODS
Magnetic resonance scans of 80 nulliparous women with normal pelvic support were evaluated. Characteristic features of each Terminologia Anatomica–listed levator ani component were determined for each scan plane. Muscle component visibility was based on pre-established criteria in axial, coronal, and sagittal scan planes: 1) clear and consistently visible separation or 2) different origin or insertion. Visibility of each of the levator ani subdivisions in each scan plane was assessed in 25 nulliparous women.
RESULTS
In the axial plane, the puborectal muscle can be seen lateral to the pubovisceral muscle and decussating dorsal to the rectum. The course of the puboperineal muscle near the perineal body is visualized in the axial plane. The coronal view is perpendicular to the fiber direction of the puborectal and pubovisceral muscles and shows them as “clusters” of muscle on either side of the vagina. The sagittal plane consistently demonstrates the puborectal muscle passing dorsal to the rectum to form a sling that can consistently be seen as a “bump.” This plane is also parallel to the pubovisceral muscle fiber direction and shows the puboperineal muscle.
CONCLUSION
The subdivisions of the levator ani muscle are visible in MRI scans, each with distinct morphology and characteristic features.
doi:10.1097/01.AOG.0000214952.28605.e8
PMCID: PMC1479224  PMID: 16648412
8.  A Contractile Network of Interstitial Cells of Cajal in the Supratarsal Mueller's Smooth Muscle Fibers With Sparse Sympathetic Innervation 
Eplasty  2012;12:e13.
Background: We previously reported that the supratarsal Mueller's muscle is innervated by both sympathetic efferent fibers and trigeminal proprioceptive afferent fibers, which function as mechanoreceptors-inducing reflexive contractions of both the levator and frontalis muscles. Controversy still persists regarding the role of the mechanoreceptors in Mueller's muscle; therefore, we clinically and histologically investigated Mueller's muscle. Methods: We evaluated the role of phenylephrine administration into the upper fornix in contraction of Mueller's smooth muscle fibers and how intraoperative stretching of Mueller's muscle alters the degree of eyelid retraction in 20 patients with aponeurotic blepharoptosis. In addition, we stained Mueller's muscle in 7 cadavers with antibodies against α-smooth muscle actin, S100, tyrosine hydroxylase, c-kit, and connexin 43. Results: Maximal eyelid retraction occurred approximately 3.8 minutes after administration of phenylephrine and prolonged eyelid retraction for at least 20 minutes after administration. Intraoperative stretching of Mueller's muscle increased eyelid retraction due to its reflexive contraction. The tyrosine hydroxylase antibody sparsely stained postganglionic sympathetic nerve fibers, whereas the S100 and c-kit antibodies densely stained the interstitial cells of Cajal (ICCs) among Mueller's smooth muscle fibers. A connexin 43 antibody failed to stain Mueller's muscle. Conclusions: A contractile network of ICCs may mediate neurotransmission within Mueller's multiunit smooth muscle fibers that are sparsely innervated by postganglionic sympathetic fibers. Interstitial cells of Cajal may also serve as mechanoreceptors that reflexively contract Mueller's smooth muscle fibers, forming intimate associations with intramuscular trigeminal proprioceptive fibers to induce reflexive contraction of the levator and frontalis muscles.
PMCID: PMC3281372  PMID: 22359687
9.  Functional anatomy of the levator palpebrae superioris muscle and its connective tissue system. 
AIMS/BACKGROUND: The connective tissue system of the levator palpebrae superioris muscle (LPS) consists of the septa surrounding its muscle sheath, the superior transverse ligament (STL) commonly referred to as 'Whitnall's ligament' and the common sheath which is the fascia between the LPS and the superior rectus muscle (SRM). The anterior band-like component of the common sheath is called transverse superior fascial expansion (TSFE) of the SRM and LPS. It mainly extends from the connective tissue of the trochlea to the fascia of the lacrimal gland. A detailed description of the relation between the LPS and its connective tissue is presented. Furthermore, the course of the LPS in the orbit is described. The study was conducted to provide a morphological basis for biomechanical and clinical considerations regarding ptosis surgery. METHODS: Postmortem dissections were performed in 16 orbits from eight cadavers. The microscopical anatomy was demonstrated in six formalin preserved orbits from six cadavers which had been sectioned in the frontal and sagittal plane and stained with haematoxylin and azophloxin. Surface coil magnetic resonance imaging in the sagittal and coronal plane was performed in five orbits from five normal volunteers using a T1 weighted spin echo sequence. RESULTS: The STL and the TSFE surround the LPS to form a fascial sleeve around the muscle which has attachments to the medial and lateral orbital wall. The TSFE, which is thicker than the STL, blends with Tenon's capsule. The STL and the fascial sheath of the LPS muscle are suspended from the orbital roof by a framework of radial connective tissue septa. MR images show that the TSFE is located between the anterior third of the superior rectus muscle and the segment of the LPS muscle where it changes its course from upwards to downwards. In this area, the LPS reaches its highest point in the orbit (culmination point). The culmination point is located a few millimetres posterior to the equator and superior to the globe. CONCLUSION: Whitnall's ligament can be considered to consist of two distinct parts--the TSFE inferior to the LPS and the STL superior to the LPS. Since the medial and lateral main attachments of Whitnall's ligament are situated inferior to the level of the culmination point of the LPS, the ligament itself is unlikely to suspend the levator muscle. However, a suspension of the LPS may be achieved by the radial connective tissue septa of the superior orbit. The TSFE in connection with the globe may have an additional supporting function. The elasticity of Whitnall's ligament and its connections with highly elastic structures including Tenon's capsule, may provide the morphological substrate for the previously proposed passive (that is, without orbicularis action) lowering of the lid during downward saccades.
Images
PMCID: PMC505585  PMID: 8949713
10.  Anatomy of the perineal membrane as seen in magnetic resonance images of nulliparous women 
Objective
Recent cadaver research demonstrates the perineal membrane’s ventral and dorsal portions and close relationship to the levator ani muscle. This study seeks to show these relationships in women by magnetic resonance (MR) images.
Methods
The subjects were 20 asymptomatic nulliparous women with normal pelvic examinations. MR images were acquired in multiple planes. Anatomical relationships from cadaver studies were examined in these planes.
Results
In the coronal plane the ventral perineal membrane forms an interconnected complex with the compressor urethrae, vestibular bulb and levator ani. The dorsal part connects the levator ani and vaginal side wall via a distinct band to the ischiopubic ramus. In the sagittal plane the parallel position of perineal membrane and levator ani are seen.
Conclusion
The perineal membrane’s anatomical features can be seen in women with MR. The close relationship between the perineal membrane and levator ani is evident.
doi:10.1016/j.ajog.2009.03.004
PMCID: PMC2696929  PMID: 19375575
Perineal membrane; pelvic organ support; levator ani; MR imaging; pelvic floor
11.  Posterior Compartment Anatomy as seen in MRI and 3-D Reconstruction from Asymptomatic Nulliparas 
Objective
To identify characteristic anatomical features of the posterior compartment using MR cross-sectional anatomy and 3-D modeling.
Study Design
Supine, static proton-density MR images of 20 nulliparas were analyzed. MR images were used to create models in a selected exemplar.
Results
The compartment’s upper, mid, and lower segments are best seen in the axial plane. It is bounded inferiorly by the perineal body, ventrally by the posterior vaginal wall and dorsally by the levator ani muscles and coccyx. In the upper portion, the compartment is bordered laterally by the uterosacral ligaments while in the mid portion, there is more direct contact with the lateral levator ani muscles. In the lower portion, the contact becomes obliterated as the vagina and levator ani muscles become fused to one another and to the perineal body.
Conclusion
The posterior compartment has characteristic anatomic features in MR cross-sectional anatomy that can be further elucidated and integrated with 3-D anatomy.
doi:10.1016/j.ajog.2007.11.032
PMCID: PMC2876342  PMID: 18241813
posterior compartment; cross-sectional anatomy; 3-D anatomy; levator ani; uterosacral ligaments
12.  Initial stage of fetal development of the pharyngotympanic tube cartilage with special reference to muscle attachments to the tube 
Anatomy & Cell Biology  2012;45(3):185-192.
Fetal development of the cartilage of the pharyngotympanic tube (PTT) is characterized by its late start. We examined semiserial histological sections of 20 human fetuses at 14-18 weeks of gestation. As controls, we also observed sections of 5 large fetuses at around 30 weeks. At and around 14 weeks, the tubal cartilage first appeared in the posterior side of the pharyngeal opening of the PTT. The levator veli palatini muscle used a mucosal fold containing the initial cartilage for its downward path to the palate. Moreover, the cartilage is a limited hard attachment for the muscle. Therefore, the PTT and its cartilage seemed to play a critical role in early development of levator veli muscle. In contrast, the cartilage developed so that it extended laterally, along a fascia-like structure that connected with the tensor tympani muscle. This muscle appeared to exert mechanical stress on the initial cartilage. The internal carotid artery was exposed to a loose tissue facing the tubal cartilage. In large fetuses, this loose tissue was occupied by an inferior extension of the temporal bone to cover the artery. This later-developing anterior wall of the carotid canal provided the final bony origin of the levator veli palatini muscle. The tubal cartilage seemed to determine the anterior and inferior margins of the canal. Consequently, the tubal cartilage development seemed to be accelerated by a surrounding muscle, and conversely, the cartilage was likely to determine the other muscular and bony structures.
doi:10.5115/acb.2012.45.3.185
PMCID: PMC3472145  PMID: 23094207
Pharyngotympanic tube cartilage; Levator veli palatini muscle; Internal carotid artery; Tensor tympani muscle; Human fetuses
13.  The neurofibrovascular bundle of the inferior oblique muscle as its ancillary origin. 
PURPOSE: To establish that the neurofibrovascular bundle (NFVB) of the inferior oblique muscle (IO) has ligamentous qualities that enable it to function as an ancillary origin to the muscle. Also, to show that the NFVB does function as the ancillary origin for the IO muscle, particularly when recessing and anteriorly transposing its insertion. METHODS: Fresh (no formaldehyde preservative) cadaver and patient eyes were studied anatomically, histologically, and physiologically. Eighteen orbits were dissected to isolate the IO, the inferior rectus (IR), and the NFVB to demonstrate the linear course of the NFVB and its adjacent fibrous bands. The shape of the muscle was documented. Coronal sections of the two whole, intact orbits were analyzed histologically. Light and electron microscopic sections of an autopsy specimen and a surgical specimen were used to evaluate the capsule of the NFVB and the adjacent fibrous bands near the anterior portion of the NFVB and their attachment to the IR and IO muscle capsules. The elastic modulus was measured in six in situ and six in vitro cadaver NFVB specimens and in six in vivo surgical cases at the time of denervation of the NFVB. For additional comparison, four in vitro cadaver superior oblique tendons were similarly tested. Six eyes that developed recurrent IO overaction following an anterior transposition procedure were surgically explored to determine what structure was serving as its ancillary origin. RESULTS: Gross anatomic and microscopic studies showed a linear orientation of the NFVB with adjacent fibrous bands anteriorly joining the IO and IR muscle capsules. The surgical specimens of the anterior portion of the NFVB show about 50% nerve and 50% fibrocollagenous capsule with the collagen fibers aligned parallel to the NFVB. The elastic modulus was highest (stiffest) in surgical specimens of the NFVB and in situ cadaver NFVB, followed by in vitro cadaver NFVB and, finally, in vitro cadaver superior oblique tendon. In patients who have undergone anterior transposition surgery, the NFVB served as the ancillary origin of the IO. CONCLUSIONS: The name of the neurovascular bundle should be changed to the NFVB, since it has a prominent fibrocollagenous capsule and it is encased in fibrous tissue bands anteriorly. The NFVB has a linear course in the orbit from the apex to the IO muscle and is relatively stiff. The associated fibrous band extends posteriorly from the IO muscle capsule, encasing the nerve anteriorly and attaching 3 to 7 mm posteriorly into the capsule of the IR. The NFVB binds the mid posterior portion of the IO posteriorly. Its ligamentous qualities enable the NFVB to function as an ancillary origin for the IO.
Images
PMCID: PMC1312118  PMID: 8981719
14.  Developed Lower-Positioned Transverse Ligament Restricts Eyelid Opening and Folding and Determines Japanese as Being With or Without Visible Superior Palpebral Crease 
Eplasty  2013;13:e37.
Introduction: We have reported that a developed lower-positioned transverse ligament between the superior-medial orbital rim and the lateral orbital rim on the lateral horn in the lower orbital fat space antagonizes eyelid opening and folding in certain Japanese to produce narrow eye, no visible superior palpebral crease, and full eyelid. In this study, we confirmed relationship between development of the lower-positioned transverse ligament and presence of the superior palpebral crease. Methods: We evaluated whether (1) digital immobilization of eyebrow movement during eyelid opening and (2) a developed lower-positioned transverse ligament could classify Japanese subjects as being with or without visible superior palpebral crease. Results: Digital immobilization of eyebrow movement restricted eyelid opening in all subjects without visible superior palpebral crease but did not restrict in any subject with visible superior palpebral crease. Macroscopic and microscopic evidence revealed that the lower-positioned transverse ligament behind the lower orbital septum in subjects without visible superior palpebral crease was significantly more developed than that in subjects with visible superior palpebral crease. Conclusions: Since a developed lower-positioned transverse ligament antagonizes opening and folding of the anterior lamella of the upper eyelid in subjects without visible superior palpebral crease, these individuals open their eyelids by lifting the eyebrow with the anterior lamella and the lower-positioned transverse ligament owing to increased tonic contraction of the frontalis muscle, in addition to the retractile force of the levator aponeurotic expansions. In subjects with visible superior palpebral crease, the undeveloped lower-positioned transverse ligament does not antagonize opening and folding of the anterior lamella, and so they open their eyelids by folding the anterior lamella on the superior palpebral crease via the retractile force of the levator aponeurotic expansions.
PMCID: PMC3707417  PMID: 23943676
15.  Surgical anatomy of the upper eyelid relating to upper blepharoplasty or blepharoptosis surgery 
Anatomy & Cell Biology  2013;46(2):93-100.
Eyelid anatomy, including thickness measurements, was examined in numerous age groups. The thickest part of the upper eyelid is just below the eyebrow (1.127±238 µm), and the thinnest near the ciliary margin (320±49 µm). The thickness of skin at 7 mm above the eyelashes was 860±305 µm. The results revealed no significant differences among the age groups. Fast fibers (87.8±3.7%) occupied a significantly larger portion of the orbicularis oculi muscle (OOM) than nonfast fibers (12.2±3.7%). The frontalis muscle passed through and was inserted into the bundles of the OOM on the superior border of the eyebrow at the middle and medial portions of the upper eyelid. Laterally, the frontalis muscle inserted about 0.5 cm below the superior border of the eyebrow. Fast fibers occupied a significantly larger portion of the OOM than did non-fast fibers. The oculomotor nerve ends that extend forward to the distal third of the levator muscle are exposed and vulnerable to local anesthetics and may be numbed during blepharoplasty. The orbital septum consists of 2 layers. The outer layer of loose connective tissue descends to interdigitate with the levator aponeurosis and disperses inferiorly. The inner layer follows the outer layer, then reflects and continues posteriorly with the levator sheath. Widths of the tarsal plate at its lower border, mid-height, and upper border were 21.8±1.8, 16.2±1.6, and 8.3±1.0 mm, respectively. The widths of the levator aponeurosis were 32.0±2.2, 29.2±3.5, and 27.2±3.9 mm, respectively. Below the levator, the "conjoint fascial sheath" (CFS) is attached to the conjunctival fornix. The CFS was 12.2±2.0 mm anteroposterior length and 1.1±0.1 mm thick. The shape was equilateral trapezoid with a longer base anteriorly. The superior palpebral muscle was trapezoidal. The lengths of its sides were 15.58±1.82 and 22.30±5.25 mm, and its height was 13.70±2.74 mm. The width of the levator aponeurosis was approximately 4 mm wider than the superior palpebral muscle.
doi:10.5115/acb.2013.46.2.93
PMCID: PMC3713284  PMID: 23869256
Eyelids; Anatomy and histology; Blepharoplasty; Blepharoptosis
16.  Nerves and fasciae in and around the paracolpium or paravaginal tissue: an immunohistochemical study using elderly donated cadavers 
Anatomy & Cell Biology  2014;47(1):44-54.
The paracolpium or paravaginal tissue is surrounded by the vaginal wall, the pubocervical fascia and the rectovaginal septum (Denonvilliers' fascia). To clarify the configuration of nerves and fasciae in and around the paracolpium, we examined histological sections of 10 elderly cadavers. The paracolpium contained the distal part of the pelvic autonomic nerve plexus and its branches: the cavernous nerve, the nerves to the urethra and the nerves to the internal anal sphincter (NIAS). The NIAS ran postero-inferiorly along the superior fascia of the levator ani muscle to reach the longitudinal muscle layer of the rectum. In two nulliparous and one multiparous women, the pubocervical fascia and the rectovaginal septum were distinct and connected with the superior fascia of the levator at the tendinous arch of the pelvic fasciae. In these three cadavers, the pelvic plexus and its distal branches were distributed almost evenly in the paracolpium and sandwiched by the pubocervical and Denonvilliers' fasciae. By contrast, in five multiparous women, these nerves were divided into the anterosuperior group (bladder detrusor nerves) and the postero-inferior group (NIAS, cavernous and urethral nerves) by the well-developed venous plexus in combination with the fragmented or unclear fasciae. Although the small number of specimens was a major limitation of this study, we hypothesized that, in combination with destruction of the basic fascial architecture due to vaginal delivery and aging, the pelvic plexus is likely to change from a sheet-like configuration to several bundles.
doi:10.5115/acb.2014.47.1.44
PMCID: PMC3968266  PMID: 24693482
Pelvic nerve plexus; Rectovaginal septum; Denonvilliers' fascia; Internal anal sphincter; Pubocervical fascia
17.  Orexin-A inputs onto visuomotor cell groups in the monkey brainstem 
Neuroscience  2009;164(2):629-640.
Orexin-A, synthesized by neurons of the lateral hypothalamus, helps to maintain wakefulness through excitatory projections to nuclei involved in arousal. Obvious changes in eye movements, eyelid position and pupil reactions seen in the transition to sleep led to the investigation of orexin-A projections to visuomotor cell groups to determine whether direct pathways exist that may modify visuomotor behaviors during the sleep/wake cycle. Histological markers were used to define these specific visuomotor cell groups in monkey brainstem sections and combined with orexin-A immunostaining. The dense supply by orexin-A boutons around adjacent neurons in the dorsal raphe nucleus served as a control standard for a strong orexin-A input. The quantitative analysis assessing various functional cell groups of the oculomotor system revealed that almost no input from orexin-A terminals reached motoneurons supplying the singly-innervated muscle fibers of the extraocular muscles in the oculomotor nucleus, the omnipause neurons in the nucleus raphe interpositus and the premotor neurons in the rostral interstitial nucleus of the medial longitudinal fasciculus. In contrast, the motoneurons supplying the multiply-innervated muscle fibers of the extraocular muscles, the motoneurons of the levator palpebrae muscle in the central caudal nucleus, and especially the preganglionic neurons supplying the ciliary ganglion received a strong orexin input. We interpret these results as evidence that orexin-A does modulate pupil size, lid position, and possibly convergence and eye alignment via the motoneurons of multiply-innervated muscle fibres. However orexin-A does not directly modulate premotor pathways for saccades or the SIF motoneurons.
doi:10.1016/j.neuroscience.2009.08.039
PMCID: PMC2762011  PMID: 19703526
oculomotor; eyelid; pupil; accommodation; saccade
18.  Anatomy and histology of apical support: a literature review concerning cardinal and uterosacral ligaments 
International urogynecology journal  2012;23(11):1483-1494.
The objective of this work was to collect and summarize relevant literature on the anatomy, histology, and imaging of apical support of the upper vagina and the uterus provided by the cardinal (CL) and uterosacral (USL) ligaments. A literature search in English, French, and German languages was carried out with the keywords apical support, cardinal ligament, transverse cervical ligament, Mackenrodt ligament, parametrium, paracervix, retinaculum uteri, web, uterosacral ligament, and sacrouterine ligament in the PubMed database. Other relevant journal and textbook articles were sought by retrieving references cited in previous PubMed articles. Fifty references were examined in peer-reviewed journals and textbooks. The USL extends from the S2 to the S4 vertebra region to the dorsal margin of the uterine cervix and/or to the upper third of the posterior vaginal wall. It has a superficial and deep component. Autonomous nerve fibers are a major constituent of the deep USL. CL is defined as a perivascular sheath with a proximal insertion around the origin of the internal iliac artery and a distal insertion on the cervix and/or vagina. It is divided into a cranial (vascular) and a caudal (neural) portions. Histologically, it contains mainly vessels, with no distinct band of connective tissue. Both the deep USL and the caudal CL are closely related to the inferior hypogastric plexus. USL and CL are visceral ligaments, with mesentery-like structures containing vessels, nerves, connective tissue, and adipose tissue.
doi:10.1007/s00192-012-1819-7
PMCID: PMC4258694  PMID: 22618209
Apical supports; Uterosacral ligament; Cardinal ligament; Anatomy; Histology; Imaging
19.  Regional differences within the human supraspinous and interspinous ligaments: a sheet plastination study 
European Spine Journal  2002;11(4):382-388.
Abstract.
The extent to which neighboring muscles and the fascia contribute to the formation of the supraspinous and interspinous ligaments is not clear from the literature. The purpose of this investigation is to examine the midline attachments of tendons and the posterior layer of thoracolumbar fascia in order to determine their respective contributions to the formation of these ligaments throughout the thoracolumbar spine. Study of the dense connective tissue organization in the posterior ligamentous system was carried out on two cadavers serially sectioned into thin (2.5-mm) epoxy resin plastinated slices. Additional observations were taken from a gross anatomical study of the midline anatomy in two adult cadavers. The results show that the spinal attachments of trapezius, rhomboideus major and splenius cervicis combine with the deep fascia to form the supraspinous ligament in the upper thoracic spine. The posterior layer of the thoracolumbar fascia makes a major contribution to the supraspinous and interspinous ligaments in the lower thoracic spine. In addition to the posterior layer of thoracolumbar fascia, longissimus thoracis and multifidus combine to form the lumbar supraspinous and interspinous ligaments. Their spinal attachments produce a system of dense connective tissue with marked regional variation in fiber orientation and arrangement. The findings support the description of the supraspinous and interspinous ligaments as structures formed by both muscle tendons and aponeuroses along the length of the thoracic and lumbar spine, with regional differences in their connective tissue architecture.
doi:10.1007/s00586-001-0378-2
PMCID: PMC3610481  PMID: 12194001
Connective tissue Fascia Ligaments Muscle attachments Thoracolumbar spine
20.  Upper eyelid retraction in Graves' ophthalmopathy: a new surgical technique and a study of the abnormal levator muscle. 
A new surgical procedure, the proximal levator technique, achieves recession of the retracted upper eyelid in Graves' ophthalmopathy by sectioning the levator muscle proximal to Whitnall's ligament and fixing eyelid position with sutures that permit postoperative adjustment. This technique deserves further study. Enlargement of the proximal levator muscle in Graves' eye disease is shown on orbital CT scans and is found at surgery when the proximal levator technique is employed. Histologic and morphometric studies demonstrate increased levator muscle fiber size as well as increased extracellular volume. These findings suggest that levator muscle hypertrophy is important in the pathogenesis of upper eyelid retraction in Graves' ophthalmopathy.
Images
PMCID: PMC1298826  PMID: 2979032
21.  Sphincter denervation in anorectal incontinence and rectal prolapse. 
Gut  1977;18(8):656-665.
Biopsies of the external anal sphincter, puborectalis, and levator ani muscles have been examined in 24 women and one man with long-standing anorectal incontinence, 18 of whom also had rectal prolapse, and in two men with rectal prolapse alone. In 16 of the women anorectal incontinence was of unknown cause, but in eight there was a history of difficult labour. Similar biopsies were examined in six control subjects. In all the incontinent patients there was histological evidence of denervation, which was most prominent in the external anal sphincter muscle biopsies, and least prominent in the levator ani muscles. Myopathic features, which were thought to be secondary, were present in the more abnormal biopsies. There were severe histological abnormalities in small nerves supplying the external anal sphincter muscle in the three cases in which material was available for study. We suggest that idiopathic anorectal incontinence may be the result of denervation of the muscles of the anorectal sling, and of the anal sphincter mechanism. This could result from entrapment or stretch injury of the pudendal or perineal nerves occurring as a consequence of rectal descent induced during repeated defaecation straining, or from injuries to these nerves associated with childbirth.
Images
PMCID: PMC1411705  PMID: 892613
22.  Paramyosin in invertebrate muscles. I. Identification and localization 
The Journal of Cell Biology  1976;71(1):261-272.
By sodium dodecyl sulfate-polyacrylamide gel electrophoresis and immunodiffusion, we identified paramyosin in two smooth invertebrate "catch" muscles (Mytilus anterior byssus retractor and Mercenaria opaque adductor) and five invertebrate striated muscles (Limulus telson levator, Homarus claw muscle, Balanus scutal depressor, Lethocerus air tube retractor, and Aequipecten striated adductor). We show that (a) the paramyosins in all of these muscles have the same chain weights and (b) they are immunologically similar. We stained all of these muscles with specific antibody to Limulus paramyosin using the indirect fluorescent antibody technique. Paramyosin was localized to the A bands of the glycerinated striated muscles, and diffus fluorescence was seen throughout the glycerinated fibers of the smooth catch muscles. The presence of paramyosin in Homarus claw muscle, Balanus scutal depressor, and Lethocerus air tube retractor is shown here for the first time. Of the muscles in this study, Limulus telson levator is the only one for which the antiparamyosin staining pattern has been previously reported.
PMCID: PMC2109740  PMID: 824292
23.  Modified posterior musculofascial plate reconstruction decreases the posterior vesicourethral angle and improves urinary continence recovery in patients undergoing laparoscopic radical prostatectomy 
Molecular and Clinical Oncology  2013;1(6):970-976.
The aim of this study was to evaluate the efficacy of our modified posterior musculofascial plate reconstruction (PMPR) procedure in laparoscopic radical prostatectomy (LRP). Prior to 2010, four operative procedures were used to expedite continence recovery: preserving the fascia covering the levator ani muscle, preserving the bladder neck, securing a functional urethral length by using a lateral-view dissection technique and suspending the vesicourethral anastomosis from the puboprostatic ligaments. Since February, 2010, a running suture between Denonvilliers' fascia (DF) and the median fibrous raphe (MFR, the fibrous tissue that lies immediately underneath the urethra) has also been used. In vesicourethral anastomosis, a double-armed running suture was performed. At the beginning of the anastomosis, the first stitches (at 1 and 11 o'clock positions on the bladder neck) were placed 1–2 cm dorsocephalad to the bladder neck (first through the seromuscular layer and then through the full thickness of the bladder neck). At the 5 and 7 o'clock positions of the urethra, the stitches were placed through the urethral mucosa as well as the the reconstructed musculofascial plate. The bladder shape was evaluated by postoperative cystography and the clinical results were compared between patients undergoing LRP without PMPR (group A) and those undergoing LRP with PMPR (group B). The cystograms demonstrated that the PMPR significantly shortened the vertical length of the bladder and significantly decreased the posterior vesicourethral angle. At 1, 3 and 6 months after LRP, the number of daily used pads was significantly lower in group B compared to that in group A and the time to achieve a pad-free status was significantly shorter in group B. Our modified PMPR procedure significantly improved the recovery of urinary continence following LRP and this improvement may be due in part to changes of the bladder shape.
doi:10.3892/mco.2013.182
PMCID: PMC3915695  PMID: 24649279
laparoscopic radical prostatectomy; posterior musculofascial plate reconstruction; urinary incontinence; vesicourethral angle
24.  Degenerative suspensory ligament desmitis as a systemic disorder characterized by proteoglycan accumulation 
Background
Degenerative suspensory ligament desmitis (DSLD) is a debilitating disorder thought to be limited to suspensory ligaments of Peruvian Pasos, Peruvian Paso crosses, Arabians, American Saddlebreds, American Quarter Horses, Thoroughbreds, and some European breeds. It frequently leads to persistent, incurable lameness and need to euthanize affected horses. The pathogenesis remains unclear, though the disease appears to run in families. Treatment and prevention are empirical and supportive, and not effective in halting the progression of the disease. Presently, the presumptive diagnosis of DSLD is obtained from patient signalment and history, clinical examination, and ultrasonographic examination of clinically affected horses, and is confirmed at post mortem examination. Presently, there are no reliable methods of diagnosing DSLD in asymptomatic horses. The goal of this study was to characterize and define the disorder in terms of tissue involvement at the macroscopic and microscopic levels.
Results
We examined tissues and organs from 28 affected horses (22 Peruvian Pasos, 6 horses of other breeds) and from 8 control horses. Histopathological examination revealed the presence of excessive amounts of proteoglycans in the following tissues removed from DSLD-affected horses: suspensory ligaments, superficial and deep digital flexor tendons, patellar and nuchal ligaments, cardiovascular system, and sclerae. Electron microscopy demonstrated changes in diameters of collagen fibrils in the tendon, and in smooth muscle cells of the media of the aorta compatible with increased cell permeability in DSLD-affected cells. Separation of tendon extracts by gel chromatography revealed the presence of additional proteoglycan(s) in extracts from affected, but not control extracts.
Conclusion
This study demonstrates for the first time that DSLD, a disease process previously thought to be limited to the suspensory ligaments of the distal limbs of affected horses, is in fact a systemic disorder involving tissues and organs with significant connective tissue component. Abnormal accumulation of proteoglycans between collagen and elastic fibers rather than specific collagen fibril abnormalities is the most prominent histological feature of DSLD. Because of this observation and because of the involvement of many other tendons and ligaments beside the suspensory ligament, and of non-ligamentous tissue we, therefore, propose that equine systemic proteoglycan accumulation or ESPA rather than DSLD is a more appropriate name for this condition.
doi:10.1186/1746-6148-2-12
PMCID: PMC1459153  PMID: 16611357
25.  Contraction-Induced Injury to Single Permeabilized Muscle Fibers From Normal and Congenitally-Clefted Goat Palates 
Objective
Levator veli palatini muscles from normal palates of adult humans and goats are predominantly slow oxidative (type 1) fibers. However, 85% of levator veli palatini fibers from cleft palates of adult goats are physiologically fast (type 2). This fiber composition difference between cleft and normal palates may have implications in palatal function. For limb muscles, type 2 muscle fibers are more susceptible to lengthening contraction-induced injury than are type 1 fibers. We tested the hypothesis that, compared with single permeabilized levator veli palatini muscle fibers from normal palates of adult goats, those from cleft palates are more susceptible to lengthening contraction-induced injury.
Interventions
Congenital cleft palates were the result of chemically-induced decreased movement of the fetal head and tongue causing obstruction of palatal closure. Each muscle fiber was maximally activated and lengthened.
Outcome Measures
Fiber type was determined by contractile properties and gel electrophoresis. Susceptibility to injury was assessed by measuring the decrease in maximum force following the lengthening contraction, expressed as a percentage of the initial force.
Results
Compared with fibers from normal palates that were all type 1 and had force deficits of 23 ± 1%, fibers from cleft palates were all type 2 and sustained twofold greater deficits, 40 ± 1% (p = .001).
Conclusion
Levator veli palatini muscles from cleft palates of goats contain predominantly type 2 fibers that are highly susceptible to lengthening contraction-induced injury. This finding may have implications regarding palatal function and the incidence of velopharyngeal incompetence.
doi:10.1597/06-036.1
PMCID: PMC2754850  PMID: 17328650
lengthening contractions; levator veli palatini; velopharyngeal incompetence

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