Anatomy, Skin, Fascias


Article Author:
Adrianna Gatt
Sanjay Agarwal


Article Editor:
Patrick Zito


Editors In Chief:
Jasleen Jhajj
Cliff Caudill
Evan Kaufman


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
7/14/2019 8:37:31 PM

Introduction

Fascia is made up of sheets of connective tissue that are found below the skin. These tissues attach, stabilize, impart strength, maintain vessel patency, separate muscles, and enclose different organs. Traditionally, the word fascia was used primarily by surgeons to describe the dissectible tissue seen in the body encasing other organs, muscles, and bones. Recently, the definition has been broadened to include all collagenous based soft tissues in the body, including cells that create and maintain the extracellular matrix. The new definition also includes certain tendons, ligaments, bursae, endomysium, perimysium, and epimysium. [1]

Classification System 

Fascia can be classified as superficial, deep, visceral, or parietal and further classified according to anatomical location. [2]

Superficial Fascia

Superficial fascia is found directly under the skin and superficial adipose layers. It can show stratification both grossly and microscopically. Traditionally, it is described as being made up of membranous layers with loosely packed interwoven collagen and elastic fibers.

  • Superficial fascia is thicker in the trunk than in the limbs and becomes thinner peripherally.
  • Superficial fascia layers can sometimes include muscle fibers to create all types of structures in the body. A few examples include the platysma muscle in the neck, the external anal sphincter, and the dartos fascia in the scrotum.
  • A subtype of superficial fascia in the abdomen is Scarpa’s fascia.

Deep Fascia

Deep fascia surrounds bones, muscles, nerves, and blood vessels. It is commonly has a more fibrous consistency and rich in hyaluronan as compared to the other subtypes. Deep fascia tends to be highly vascularized and contain well developed lymphatic channels. In some instances, deep fascia can even contain free encapsulated nerve endings, such as Ruffini and Pacinian corpuscles.

There are 2 subtypes of deep fascia:

Aponeurotic fascia

  • It forms into sheets of pearly white fibrous tissue to attach muscles needing a wide area of attachment. Aponeurosis can thin into a tendon and become a point of origin or insertion for other muscles. Some examples of aponeurotic fascia include the fascia of limbs, thoracolumbar fascia, and rectus sheath.
  • It is the thicker of the 2 subtypes that are normally easily separated from the underlying muscle layer.
  • It is comprised of 2 to 3 parallel collagen fiber bundles.

Epimysial fascia

  • Also known as the epimysium, this is the connective tissue sheath surrounding skeletal muscle and can, in some cases, connect directly to the periosteum of bones. 
  • Some major muscle groups enveloped in epimysium include muscles of the trunk, pectoralis major, trapezium, deltoid, and gluteus maximus.
  • It is the thinner of the 2 subtypes, on average, and is more tightly connected to muscle via septa that penetrate the muscle layer.

Visceral Fascia 

Visceral fascia surrounds organs in cavities like the abdomen, lung (pleura), and heart (pericardium).

Parietal Fascia

Parietal fascia is a general term for tissues that line the wall of a body cavity just outside of the parietal layer of serosa. The most commonly known parietal fascia is found in the pelvis.

In many places in the body, superficial and deep fascial layers are connected by fibrous septa and create a connection network that weaves in between fat lobules that make up the deep adipose tissue layer. [3]

Structure and Function

Fascia may appear passive structurally but are, in fact, active. They can provide support for surrounding tissues, help reduce friction, and play a supportive role for the tissues and organs. Fascia can transmit mechanical tension generated by muscular activity or external forces. The biomechanical regulatory system of the fascia is currently being studied further.

In a healthy state, fascia is a relaxed and wavy connective tissue that can lose its malleability when damaged via local trauma or inflammation. This can then cause fascial layers to tighten and restrict movement of underlying tissues leading to pain, hindered range of motion, or decreased blood flow.

The distinct feature of fascia is that it possesses strength because it is tightly packed with bundles of collagen and wrapped tightly. The fibers are usually oriented in one direction so that the structure does not become loose or lax. Fascia is quite flexible and able to resist tension. The function of the fascia depends on its location.[4]

Embryology

The fascial system is classically understood to originate from the mesoderm layer divided during week 2 of development during the embryo's gastrulation phase. There is also some evidence that certain fascial layers, particularly in the cervical and cranial neck, derive from the ectoderm. [5]

Nerves

Sensory nerves innervate the fascial tissue. The deep fascia, specifically, is extensively innervated with multiple sensory nerve subtypes. This includes, but is not limited to, nociceptors, proprioceptors, mechanoreceptors, thermoreceptors, and chemoreceptors.

Surgical Considerations

Following a procedure, surgeons suture superficial fascia together to ensure that there is no weakness in the wound. If the suturing is not done correctly, the sutures can tear, resulting in wound dehiscence. If the patient is malnourished, suturing the fascia together can prove much more difficult, showing the importance of adequate nutrition pre-op. Wound dehiscence is a surgical emergency, and the diagnosis is usually clinical. [6]

Aponeurotic fascia (fascia lata) can be used as a surgical patch by plastic surgeons.[7]

In some cases, retaining ligaments of the face can be cut or released for aesthetic purposes.[8] 

A new technique has gained traction in recent years called myofascial release. It is a form of noninvasive manual therapy usually provided by physical therapists. The goal is to use sustained pressure along with stretching techniques to restore optimal length, decrease pain, and improve overall function of the treated area. It has also shown promise for post-operative orthopedic surgery patients.[9]

The Desarda technique is a surgical technique that sutures the aponeurosis of the external oblique to create a new posterior wall and result in a mesh-free, open, surgical treatment for inguinal hernias.

Clinical Significance

Compartment syndrome is a condition where the tissues within a fascial layer experience higher than normal pressures leading to pain, pallor, loss of pulses, and eventual paresthesias. Compartment syndrome can develop in morbidly obese patients or following crush injuries, severe burns, and impact injuries. Diagnosis can be confirmed by measuring the pressure within a fascial compartment with a pressure device, although clinical judgment is often used to determine the diagnosis. A compartment pressure of thirty mmHg or greater is pathognomonic for compartment syndrome. In patients who develop compartment syndrome, treatment regularly involves a fasciotomy. An urgent fasciotomy can be done at the bedside. A fasciotomy is a procedure where the compressing fascia is cut to relieve compartment pressure and allow the muscle to swell, decrease pressure, and restore blood flow and nerve function. [10][11][12]

Plantar fasciopathy, or plantar fasciitis, is a common health concern in the general population resulting in inferior heel pain. Patients can receive non-invasive therapies such as physical therapy, orthosis, NSAIDs, radiation therapy, or shockwave therapy to help relieve symptoms. Invasive treatments include local corticosteroid injections, botulinum injection, platelet-rich plasma injection, and surgery. [13]

Necrotizing fasciitis is a rare and sometimes fatal soft-tissue infection that is a medical and surgical emergency. It is the resulting condition of inflammation and necrosis at multiple layers including fascia, muscle, subcutaneous fat, and subsequent necrosis of overlying skin. Emergency radical debridement of the necrotic tissues is the standard mandatory procedure. [14]


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Anatomy, Skin, Fascias - Questions

Take a quiz of the questions on this article.

Take Quiz
Which of the following is a fibrous band that covers the body under the skin and invests the muscles?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which type of tissue predominates in the superficial fascia from the abdominal wall of an average 40-year-old female?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 24-year-old man complains of extreme pain in his left leg. He underwent casting for a left tibia fracture four hours ago due to a low impact collision while playing football. Physical exam reveals a cool, pale left foot and pain out of proportion to the physical exam. The posterior tibial pulse is absent in the affected leg. Motor testing is 2/5 of the left foot on dorsiflexion and 5/5 in the right foot. The affected nerve is contained within which fascial compartment?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Anatomy, Skin, Fascias - References

References

Stecco C,Tiengo C,Stecco A,Porzionato A,Macchi V,Stern R,De Caro R, Fascia redefined: anatomical features and technical relevance in fascial flap surgery. Surgical and radiologic anatomy : SRA. 2013 Jul     [PubMed]
Ajimsha MS,Al-Mudahka NR,Al-Madzhar JA, Effectiveness of myofascial release: systematic review of randomized controlled trials. Journal of bodywork and movement therapies. 2015 Jan     [PubMed]
Chen CM,Lee M,Lin CH,Chang CH,Lin CH, Comparative efficacy of corticosteroid injection and non-invasive treatments for plantar fasciitis: a systematic review and meta-analysis. Scientific reports. 2018 Mar 5     [PubMed]
Alghoul M,Codner MA, Retaining ligaments of the face: review of anatomy and clinical applications. Aesthetic surgery journal. 2013 Aug 1     [PubMed]
Stecco C,Macchi V,Porzionato A,Duparc F,De Caro R, The fascia: the forgotten structure. Italian journal of anatomy and embryology = Archivio italiano di anatomia ed embriologia. 2011     [PubMed]
Lau FH,Pomahac B, Wound healing in acutely injured fascia. Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society. 2014 May     [PubMed]
Mauser N,Gissel H,Henderson C,Hao J,Hak D,Mauffrey C, Acute lower-leg compartment syndrome. Orthopedics. 2013 Aug     [PubMed]
Björck M,Wanhainen A, Management of abdominal compartment syndrome and the open abdomen. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2014 Mar     [PubMed]
Lancerotto L,Tocco I,Salmaso R,Vindigni V,Bassetto F, Necrotizing fasciitis: classification, diagnosis, and management. The journal of trauma and acute care surgery. 2012 Mar     [PubMed]
Stecco A,Stern R,Fantoni I,De Caro R,Stecco C, Fascial Disorders: Implications for Treatment. PM     [PubMed]
Findley T,Chaudhry H,Stecco A,Roman M, Fascia research--a narrative review. Journal of bodywork and movement therapies. 2012 Jan     [PubMed]
Schleip R,Jäger H,Klingler W, What is 'fascia'? A review of different nomenclatures. Journal of bodywork and movement therapies. 2012 Oct     [PubMed]
van der Wal J, The architecture of the connective tissue in the musculoskeletal system-an often overlooked functional parameter as to proprioception in the locomotor apparatus. International journal of therapeutic massage     [PubMed]
Via AG,Oliva F,Spoliti M,Maffulli N, Acute compartment syndrome. Muscles, ligaments and tendons journal. 2015 Jan-Mar;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Optometry-Basic Science. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Optometry-Basic Science, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Optometry-Basic Science, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Optometry-Basic Science. When it is time for the Optometry-Basic Science board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Optometry-Basic Science.