Computed Tomographic Study of Superficial Fascia of the Abdomen: Implication to Localized Fat Deposits (LFD) Areas.

Pandey AK

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OJHAS Vol. 14, Issue 3: (July-September 2015)

Original Article
Computed Tomographic Study of Superficial Fascia of the Abdomen: Implication to Localized Fat Deposits (LFD) Areas

Authors
Arvind Kumar Pandey, Assistant Professor, Department of Anatomy, Kasturba Medical College, Manipal University, Manipal,
Pramod Kumar, Consultant Plastic Surgeon, King Abdul Aziz Hospital, Sakaka, Al-Jouf, Ministry of Health, Saudi Arabia,
Radhakrishnan P, Post-graduate, Department of Anatomy, Kasturba Medical College, Manipal University, Manipal,
Sandeep Kumar, Associate Professor, Department of Radiodiagnosis, Kasturba Medical College, Manipal University, Manipal,
Sushma Rama Kotian, Lecturer, Department of Anatomy, Kasturba Medical College, Manipal University, Manipal,
Anne D Souza, Assistant Professor, Department of Anatomy, Kasturba Medical College, Manipal University, Manipal
Antony Sylvan D Souza, Associate Dean &Professor, Department of Anatomy, Kasturba Medical College, Manipal University, Manipal.

Address for Correspondence
Dr. Arvind Kumar Pandey,
Assistant Professor,
Department of Anatomy, Kasturba Medical College,
Manipal University, Manipal-576104,
Karnataka, India.
E-mail: arvind.pandey@manipal.edu

Citation
Pandey AK, Kumar P, Radhakrishnan P, Kumar S, Kotian SR, D'Souza A, D'Souza AS. Computed Tomographic Study of Superficial Fascia of the Abdomen: Implication to Localized Fat Deposits (LFD) Areas. Online J Health Allied Scs. 2015;14(3):7. Available at URL: http://www.ojhas.org/issue55/2015-3-7.html

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Submitted: Aug 25, 2015; Accepted: Sep 27, 2015; Published: Oct 15, 2015

This work is licensed under a Creative Commons Attribution-No Derivative Works 2.5 India License

This Article

Abstract: Background: Superficial fascia of the abdomen, being a supportive structure plays a vital role in abdominal localized fat deposits (LFDs) as well as in surgical treatment of obesity. Interest in the anatomy of the superficial fascia is increasing with increasing popularity of surgical procedures for abdominal obesity. The study aims at computed tomographic evaluation and classification of the superficial fascia of abdomen & comparing with the earlier published cadaveric study. Materials and methods: One hundred two 64 slice CT scans films of abdominal region of 102 subjects showing radiologically normal abdominal fat of either sex (64 males 38 females) between 25 to 70 year age were analyzed. Results: Superficial fascia of the abdomen was multilayered in the midline & gradually merged with each other laterally. Multiple layers of superficial fascia in form of multiple loculi were seen mainly over central abdomen and loin region. Conclusion: Multiple layers of superficial fascia in the form of multiple loculi may be one of the reasons for resistant nature of LFD areas like loin and central abdomen.
Key Words: Superficial fascia, Obesity, Localized fat deposit (LFD), Central abdomen, Loin area.

Introduction:

Abdominal obesity is emerging as an important driving force behind the cardiometabolic risk in the general population. Patients with evidence of cardiovascular disease often display abdominal obesity.(1,2) A strong relationship exists between the abdominal obesity, insulin resistance, and cardiometabolic risk factors. Localized fat deposits (LFD) over abdomen are more resistant to absorption and shows strong correlation with cardiovascular disease.(3,4)

The development of liposuction, abdomino-plasty & fascial flaps in reconstructive surgery has renewed interest in the superficial fascia of abdomen.(5-7)

Markman and Borton in 1987 used anatomical and CT scan studies and identified the �superficial fascia� as a discrete layer separating the superficial and deep fat on much of the trunk and lower extremities.(8)

There has been considerable controversy with respect to the number of layers/subdivision, upper attachments & terminology of superficial fascia of the abdomen.(9-24)

Recent literature explains that these controversies regarding number of the layers of the superficial fascia may be the representation of number of layers at their dissection sites.(25,26)

The deep layer of fat is hypertrophied in certain regions of body and is called Localized Fat Deposits (LFD). This is basically the unsightly reserve fat as an excessive bulge producing contour deformity of the region.(20) In the abdomen it is mainly over the lower central and in the loin regions. LFD over abdomen are more resistant to absorption and shows strong correlation with cardiovascular disease and insulin resistance.(4)

Hence, the present CT scan study was undertaken to compare with the cadaveric study of superficial fascia of abdomen published earlier (25,26) with special reference to the LFD.

Materials and Methods:

Present retrospective study was on 64 slice CT scans films of abdominal region (both in coronal and axial) of 102subjects showing radiological normal abdominal fat of either sex (64 males & 38 females) between 25 to 70 year age procured from the Department of Radiology, Kasturba Medical College, Manipal, Karnataka, India.

The abdominal superficial fascia was studied at various levels as shown in Figure 1. The details of superficial fascia were studied medial and lateral to the point of intersection with horizontal and vertical lines drawn.

Figure1: Showing different planes studied in the CT images. Two vertical lines were drawn over the radiological films: 1. anteriorly, first line joining mid clavicular point to mid inguinal point. 2. Posteriorly, second line joining the inferior angle of scapula to posterior superior iliac spine. Similarly, four horizontal lines were drawn: a) Midway between umbilicus and xiphisternum. b) At the level of umbilicus. c) Midway between umbilicus and anterior superior iliac spine (ASIS). d) At the level of ASIS.

Results

Superficial fascia of the abdomen was multilayered in the midline & gradually merged with each other laterally.

Depending upon the number of layers and its existence, the superficial fascia was divided in to following types (Table 1).

Table 1: Types of superficial fascia
Types of fascia	Features of fascia
I	One layer of superficial fascia
II	Two layers of superficial fascia
III	Multiple layers of superficial fascia
IV	No definite radiologically visible layer

Distribution of different types of superficial fascia mentioned above was different at different levels of abdomen. (Table 2 to 5).Multiple layers of superficial fascia in form of multiple loculi were seen mainly over central abdomen and loin region (Figure 2).

Table 2: Level 1; at midway between umbilicus and xiphisternum
TYPE OF FASCIA	Front of abdomen		Back of abdomen
	Lateral to midclavicular line	Medial to midclavicular line	Lateral to vertical line drawn	Medial to vertical line drawn
I	51%	31.5%	61%	67 %
II	02%	13%	08%	02%
III	05%	30.5%	02%	02%
IV	42%	25 %	29 %	29

Figure 2: Transverse Section at the level of umbilicus showing the different layers of superficial fascia: a) Line diagram, b) CT Scan

Table 3: Level 2; at the level of umbilicus
TYPE OF FASCIA	Front of abdomen		Back of abdomen
	Lateral to midclavicular line	Medial to midclavicular line	Lateral to vertical line drawn	Medial to vertical line drawn
I	94%	33%	29.5%	62%
II	0%	36%	20.5%	26%
III	02%	24%	47%	08%
IV	04%	07%	03%	04%

Table 4: Level 3; Midway between umbilicus and anterior superior iliac spine; ASIS
TYPE OF FASCIA	Front of abdomen		Back of abdomen
	Lateral to midclavicular line	Medial to midclavicular line	Lateral to vertical line drawn	Medial to vertical line drawn
I	77%	17%	12%	70%
II	02%	10%	12%	05%
III	08%	44%	75%	23%
IV	13%	29%	01%	02%

Table 5: Level 4; Two cm below the ASIS
TYPE OF FASCIA	Front of abdomen		Back of abdomen
	Lateral to midclavicular line	Medial to midclavicular line	Lateral to vertical line drawn	Medial to vertical line drawn
I	54%	31%	28%	66%
II	02%	04%	08%	0%
III	09%	20%	57%	26%
IV	35%	45%	07%	08%

Discussion

In the present computed tomography study, we observed that the superficial fascia of the abdomen was multilayered in the midline. These layers gradually merged with each other and reduced in number laterally (Figure 2). Radiologically four types of fascia were identified. Type I-III shows one to multiple radiologically distinct fascial layers. Radiological type IV fascia could be due to anatomical variation or due to technical errors.

A study of 50 computed tomography of the abdomen also supports our findings of superficial fascia.(27)

Illouz (1989) has described the resistant nature (to absorption) of the loin and central abdomen LFD. Present study reveals that distribution of superficial fascia was different at different levels of abdomen. Radiologically, multiple layers of superficial fascia with multiple loculi were seen mainly over central abdomen and loin region. These areas corresponded with the localized fat areas over central abdomen & loin areas.(21)

The radiological features of the superficial fascia of the abdomen support the results of our previously published cadaveric studies.(25,26) Fat placed in different loculi of multilayer fascia corresponded to LFD areas of the abdomen (Figure 2). This anatomical difference in fat deposition with relation to superficial fascia over abdomen may be one of the reasons for resistant nature of fat to resorption and bulge/fold of skin over abdomen. Abdominal obesity is emerging as an important driving force behind the cardiometabolic risk in the general population. The difference in anatomy of fat with fascia in abdominal area could be attributed to commonly discussed problems like increased vascular resistance, hypertension and increased cardiovascular risk associated with abdominal obesity.(1-4)

Conclusion

Difference in the numbers of layers of fascia was seen in different areas of abdomen in agreement with earlier published our cadaveric studies. Multiple layers of superficial fascia in the form of multiple loculi were seen mainly over central abdomen and loin region. This anatomical difference in fat deposition with relation to superficial fascia over the abdomen may be the one of the causes of resistant nature of fat to absorption and bulge/fold of skin over abdomen.

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