머리에서 발까지 연결하고 있는 섬유막의 해부학적 연결

[문형철]

이 챕터는 토마스 마이어스의 해부학적 연결선을 기초로함

This chapter deals with the anatomy and physiology of fascia based on work by Myers. The anatomical description of the various types of fascia and their fascial anatomy planes throughout the body is presented. Fascial chains and trains, which are uninterrupted "tracks" of connective tissue running up and down the body, will be described.

- 인체 전체의 섬유막의 다양한 형태와 섬유막 구조면의 해부학적 묘사가 이 챕터에 있음.

- 섬유막 체인과 연결은 끊어짐없는 결합조직의 트랙..

ANATOMY AND PHYSIOLOGY OF FASCIAL PLANES

Fascia is a tough connective tissue that spreads throughout the body in a three-dimensional web from head to foot without interruption. The fascia surrounds every muscle, bone, nerve, blood vessel, and organ of the body, down to the cellular level.

- 섬유막은 질긴 결합조직으로 온몸에 걸쳐있고, 머리에서 발끝까지 끊어짐없이 삼차원 거미줄과 같음. 

Fascia can be categorized into three divisions: fascia superficialis, fascia profunda, and deepest fascia.

- 섬유막은 천층, 심층, deepest 로 구성

Fascia Superficialis

A layer of loose connective tissue located beneath the dermis of the skin, and sometimes referred to as the

subcutaneous tissue, is called the fascia superficialis.

- 성긴 결합조직은 피부의 진피층아래에 존재하고 때로는 피하조직으로 언급됨. 이를 천층 섬유막이라고 함. 

It serves as a passageway for nerves and blood vessels, and in some areas of the body it houses skeletal muscles and various quantities of adipose tissue. The superficial fascia layer is more prominent in the posterior half of the body than in the anterior half.

- 천층 섬유막은 신경과 혈관을 위한 통로이고, 인체의 어떤지역에서는 골격근과 지방조직의 다양한 모양을 둘러싸고 있음. 

- 천층 섬유막은 인체의 복부쪽보다는 후면부에 좀더 우세하게 존재함. 

The main functions of this layer are protective and supportive. It anchors the skin onto the underlying myofascia while providing (along with the skin and superficial fat) a cushion for protection. Because of the variety in the physiology of this layer, only two fasciae are identified in the fascia superficialis: Scarpa's fascia (anterior trunk) and Colles' fascia (perineum). 

- 천층 섬유막의 주요기능은 보호와 지지임. 천층섬유막은 피부에서 근막까지 연결됨. 

- 천층 섬유막의 생리기능 다양성때문에 두가지 섬유막으로 규정됨. Scarpa's fascia (anterior trunk) and Colles' fascia (perineum)

Furthermore, in the extremities (both upper and lower), it is much more difficult to separate the type of fascia superficialis.

Scarpa's fascia

The membraneous deep layer of the superficial fascia (fascia of Scarpa) is a layer of the anterior abdominal wall. It is found deep to the Camper Fascia and superficial to the External Oblique muscle.

Structure[edit]

It is thinner and more membranous in character than the superficial fascia of Camper, and contains a considerable quantity of orange elastic fibers. It is loosely connected by areolar tissue to the aponeurosis of the Obliquus externus abdominis, but in the midline it is more intimately adherent to the linea alba and to thepubic symphysis, and is prolonged on to the dorsum of the penis, forming the fundiform ligament; above, it is continuous with the superficial fascia over the rest of the trunk; below and laterally, it blends with the fascia lata of the thigh a little below the inguinal ligament; medially and below, it is continued over the penis and spermatic cord to thescrotum, where it helps to form the darts.

From the scrotum it may be traced backward into continuity with the deep layer of the superficial fascia of the perineum (superficial perineal fascia or fascia of Colles).

In the female, it is continued into the labia majora and from there to the fascia of Colles.

History[edit]

It is named for Antonio Scarpa^[1] Antonio Scarpa's description of the membranous superficial fascia is vague in his 1809 hernia monograph.^[2] Life-size illustrations included by Scarpa do not identify the layer even though some show all the other anatomical layers of the abdominal wall in the inguinal region. A probable description of the fascia is in the text which discusses femoral (called crural) hernia in the male. Scarpa describes that 'below the skin' we find 'a layer of condensed substance forming the second covering of the hernia' which adheres to 'the aponeurosis of the fascia lata'. A little later he describes this layer as being membranous and he believes it has a role in containing this particular herniation. In 1810, Abraham Colles described detailed methods of dissection to expose membranous superficial fascia in the lower abdomen and the inguino-perineal region including the penis and scrotum. Colles clearly associated the subcutaneous limitation of urine extravasation from a ruptured urethra with the attachments of membranous superficial fascia to deeper structures.^[3]

Clinical significance[edit]

Scarpa's belief that the fascia stops hernias from forming is not thought to be true today. Some anatomists suggest the membranous superficial fascia is the scaffold which attaches the skin to the deeper structures so that the skin does not sag with gravity but still stretches as the body flexes or changes shape with exercise.^[3] The attachment of the fascia to deeper layers confines fluid which may have come from inside the body in certain diseases giving rise to clinical signs such as urethral disruption noticed by Colles and bruising in Cullen's sign or Grey Turner's sign.^[3]

Fascia Profunda (Deep)

The fascia profunda is a fibrous layer of connective tissue found beneath the superficial fascia. It is also involved in passageways for nerves and blood vessels. Fascia profunda invests muscles and other internal structures.

- 심층 섬유막은 천층 섬유막 아래 섬유성 결합조직. 

- 심층 섬유막은 신경과 혈관을 위한 통로와 연관됨. 

Deepest Fascia

The deepest fascia is also known as the dural tube. This fascia surrounds and protects the brain and spinal cord.

- 가장 깊은층의 섬유막은 이중 튜브로 알려짐. 깊은층 섬유막은 뇌와 척수를 둘러싸고 보호함. 

Cellulite

Fascia superficial is consists of one to several horizontal layers containing various amounts of superficial fat deposits, which change the physiology of this layer. For example, an increased number of fat cells give rise to cellulite. This is primarily seen in women or obese individuals. 

Cellulite due to hypertrophy of adipose (fat) cells is known as primary cellulite. Its presence is noticeable when the patient is in the erect or supine position. Primary cellulite is normally seen in younger women and is not generally improved with surgery, although it can be corrected through weight loss. 

Secondary cellulite usually appears after 35 years of age and may be combined with primary cellulite. It is associated with aging, sun damage, dramatic weight loss, and liposuction. Secondary cellulite results in skin laxity compounded by gravitational forces along the vertical or oblique fibrous septum that extends from the dermis to the superficial fascial layers. Because of the damage done to this layer, weight loss is not very effective in reducing secondary cellulite. Surgical correction (plastic surgery) might be more effective in decreasing the effects of cellulite.

Variation between Sexes

The superficial fascia varies between sexes in the breast and pelvic areas. In the female breast, fascia superficialis splits into an anterior and a posterior division. The anterior division attaches to the dermis while the posterior division connects to the pectoralis

musculature. 

This allows female breasts to increase in size; but as they do, the connections become looser as a result of gravitational forces and the retromammary space is formed. A sexual difference is also noted in the pelvic region.

In females, the fascia superficial is is not as closely adhered to the pelvic musculature (gluteals, etc.), which allows for easier and larger fat deposition in this area. The fascia superficialis in males is tightly attached to the pelvic musculature a few centimeters below the iliac crest and forms the roof of the localized fat deposit that overlies the crest. This explains the differences in lateral truncal contour seen between the two sexes. The superficial fascial layer forms peaks and valleys along our bodies (zones of adherence). Areas where the superficial fascial system is most adherent to underlying muscle

fascia or periosteum are the creases of tht' skin and certain plateaus, such as those found on the bridge of the nose, whereas areas of least adherence are the bulges where the superficial fascial system forms the roof over localized deep fat deposits, as seen in the abdominal area or hips.

Variations with Adiposity

As the degree of adiposity changes, the superficial fascial system anatomy varies significantly. There is a significant amount of fat separating the layers of the superficial fascial system, even in nonobese individuals. Obesity further separates the fascial layers until they become indistinct and are not easily recognizable. The same quantity of connective tissue

remains, but it is diluted by the adipose tissue.

Variations in Different Body Regions

A confusing feature of the superficial fascial system is the inconsistent anatomy from one body region to another. In areas such as the lower anterior trunk  (Scarpa's) and the perineum (Colles'), the superficial fascial system consists of a well-defined single membranous sheet. Scarpa's and Colles' are the only named superficial fasciae in the body. To most other

areas of the trunk, there may be more than one superficial fascial system layer separating the superficial fat from the deep fat or muscle.

Interestingly, the superficial fascial system is more prominent on the posterior half of the trunk and thighs than on the anterior half. The appearance of the superficial fascial system can become diffuse in the extremities. This is seen in parts of the trunk (epigastrium) and in obese individuals, where it is difficult to separate superficial fat from the fat within the

horizontal superficial fascial system layers. Therefore, all fat superficial to the deepest superficial fascial system layer should be termed superficial fat.

Zones of Adherence

The topographic features of the human body are largely the result of superficial fascial system anatomy and its relationships to fat and muscle fascia. Varying zones of adherence of the superficial fascial system cover the trunk and extremities. Together with the fat, these zones of adherence produce creases, folds, valleys, plateaus, and bulges of

the normal body contour.

Summary

Fascia is a widespread and complex structure. It is comprised of various planes, with some notable differences of the superficial fascia, depending on body region and between sexes, Singer, through his work, has laid the foundation in describing the various components of the fascial planes according to body region. More research will be required to fully

understand the physiologic and anatomic role fascia plays in the body, so that various injuries can be diagnosed and treated more effectively.

두부의 Fascia

neck의 섬유막

흉곽의 섬유막

복부의 섬유막

골반의 섬유막

등쪽의 섬유막