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12
S
F. R. Garcia
4. Pyramidal Muscle of the Pelvis or Piriformis. Also in the deep muscular
plane, it is pear-shaped or attened triangular. On its way, it leaves the pelvis
through the greater sciatic notch, and originates in the upper limit an orice
through which the superior gluteal nerve and vessels enter the buttock. Its lower
border, together with the sciatic spine and the lesser sacrosciatic ligament, form
another interstitium through which the inferior gluteal nerve vascular pedicle
passes, in addition to the greater sciatic nerve, the sciatic vessels, and the internal
pudendal vessels and nerve. It receives innervation from the anterior rami of the
sacral plexus (S1, S2) (Fig.1.7).
Together with the gemellis muscles (superior and inferior), the obturators
(internal and external), and the quadratus femoris or quadratus crural, they laterally rotate the extended thigh, and abduct the exed thigh. They are pelvitrochanteric and stabilize the femoral head in the acetabulum (Fig. 1.7). The
obturator internal and the superior gemellus muscles are innervated by the obturator internal nerve; the quadratus femoris and the inferior gemellus are innervated by the quadratus femoris nerve; and the external obturator is innervated by
the nerve of the same name (L5, S1). The two gemellis are inserted through a
common tendon with that of the internal obturator muscle (Triceps Coxae), on
the inside of the greater trochanter.
GLUTEUS MEDIUS
MUSCLE
OBTURATOR INTERNUS
MUSCLE
Fig. 1.7 Medium and deep muscle plane. Gluteus medius and minimus muscle, piriformis, superior and inferior gemellis, internal obturator, and quadratus femoris muscle
PIRIFORMIS
MUSCLE
GLUTEUS MINIMUS
MUSCLE
SUPERIOR GEMELLUS
MUSCLE
INFERIOR GEMELLU
MUSCLE
QUADRATUS FEMORIS
MUSCLE
LIGAMENT
C
1 Modern and Integral Anatomy oftheGluteal Region: FROD’S Intramuscular Space
13
1.5.1 Ligaments oftheGluteal Region
The pelvic bone skeleton (Coxales, Sacrum, and Coccyx) is held together by dense
and strong ligaments. Among these we have the posterior sacroiliac ligament,
which is the postero-external continuation of the powerful brous mass of interos-
seous sacroiliac ligaments, the main structure in the transfer of weight from the
upper body to the two iliums of the pelvis. Inferiorly, it receives bers from the
posterior border of the ilium and base of the coccyx, to form the solid and powerful
sacrotuberous or greater sacrociatic ligament. In turn, this sacrotuberous ligament extends toward the ischial tuberosity, turning the sciatic notch of the hip bone
into a large sciatic foramen. Now, the sacrospinous or lesser sacrociatic ligament
of medial origin is directed laterally to the sciatic spine, dividing the great sciatic
foramen into the greater sciatic and lesser sciatic foramina. The greater sciatic foramen thus becomes the gateway for the two neurovascular bundles of the gluteal
region as well as the pyramidal muscle, coming from the pelvis. The lesser sciatic
foramen allows the entry or exit of structures toward the perineum, such as the
medial pudendal vasculonerous bundle and the internal obturator muscle [25]
(Fig.1.8).
There is also another support system that maintains rm the soft tissue structures
of the gluteal region, described by Morestin in 1894, made up of dense connective
SACROTUBEROUS
Fig. 1.8 Ligaments of the gluteal regin
ILIOLUMBAR LIGAMENT
ILIAC CREST
POSTERIOR SACROILIA
LIGAMENTS
SACROSPINOUS
LIGAMENT
14
F. R. Garcia
tissue, which makes connections between the existing osteo-ligamentous structures
and the dermis, supporting the skin and the subcutaneous fatty tissue [27]. We
observe this type of strong ligamentous connections between the deep surface of the
sacrum and the dermis at the level of the groove or intergluteal cleft [28]. A century
later, this ligament was described by González, and due to its great tensile strength
and its high content of dense connective tissue, it was called the sacrocutaneous
ligament [29, 30].
We also found that in the medial or internal zone of the gluteal sulcus or fold that
separates the thigh from the buttock, the deep face of the skin is attached to the
ischium by brous tracts that were described as Charpy’s suspensory ligament or
ischiocutaneous ligament of Luschka [24].
1.5.2 Vasculonervous Structures oftheGluteal Region
The arteries of the gluteal region originate directly or indirectly from the hypogastric or internal iliac artery, with variable origins. The veins in the area are tributaries
of the Internal Iliac vein. The lymph eventually drains into the lateral lumbar (aortic/
caval) lymph nodes, and the supercial inguinal lymph nodes. The nerves that supply innervation to this region come from the sacral plexus, other nerves cross it to
innervate the perineum and the thigh. We start with the arteries:
1. Superior Gluteal Artery. It is the thickest branch of the Internal Iliaca, and it
leaves the pelvis toward the gluteal through the greater sciatic foramen, superior
to the pyramidal muscle, immediately dividing into its two terminal branches:
Supercial branch, which supplies the gluteus maximus muscle and the skin
over its proximal insertion. Deep Branch, which supplies the gluteus medius,
lesser and tensor fascia lata muscles. Also to the iliac bone and the hip joint
(Fig.1.9).
2. Inferior Gluteal Artery. It leaves the pelvis through the greater sciatic foramen,
inferior to the pyramidal muscle. It enters deep into the gluteus maximus and
descends medial to the sciatic nerve. It irrigates the gluteus maximus, internal
obturator, quadratus femoris, and part of the hamstrings. It anastomoses with the
superior gluteal and participates frequently in the crossed anastomosis of the
thigh (Fig.1.9).
3. Internal Pudendal Artery. It does not irrigate any structure in the gluteal area.
4. Ischial Artery. It provides arterial branches for the gluteus maximus, gemini,
internal obturator, and quadratus femoris muscles (Fig.1.9).
The veins of the region, the superior gluteal and the inferior gluteal, accompany the corresponding arteries. Both are tributaries of the Internal Iliac vein,
which drains all the venous blood in the area, and transmits the negative pres-
sure of its system to the gluteal veins, important information when deep
lipoinjection surgeries are performed in this area (Fig.1.9).
NERVE OF THIGH
INFERIOR GLUTEAL
1 Modern and Integral Anatomy oftheGluteal Region: FROD’S Intramuscular Space
SUPERIOR GLUTEAL ARTERY,
VEIN AND NERVE
INTERNAL PUDENDAL
ARTERY AND PUDENDAL
NERVE
NERVE TO OBTURATOR
INTERNUS
SCIATIC NERVE
15
Fig. 1.9 Vasculonervous structures of the gluteal región
1. Superior Gluteal Nerve (L4 to S1). It leaves the pelvis toward the gluteal
ARTERY,
VEIN AND NERVE
ARTERY TO SCIATIC
NERVE
MEDIAL CIRCUMFLEX
FEMORAL ARTERY
POSTERIOR CUTANEOUS
Lymph from the supercial tissues of the gluteal region and the thigh reaches
the supercial inguinal lymph nodes, which emit efferent lymph vessels to the
external iliac lymph nodes. Lymph from deep tissues is drained to the superior
and inferior gluteal lymph nodes, from here it travels to the internal, external,
and common iliac lymph nodes, and later to the lateral lumbar lymph nodes
(aortic/caval) [25].
The gluteal region receives its innervation from the sacral plexus. Here we
nd a cutaneous or supercial innervation, and a deep innervation that we will
describe below.
Supercial Innervation. It is constituted by the so-called Cluneus or Clunial
nerves, lateral cutaneous branches of dorsal branches of nerves L1 to S3, in
charge of innervating the skin of the buttocks. They are classied as superior,
middle, and inferior, according to their origin and the area of the skin of the
innervated buttock, respectively (Fig.1.10).
Deep Innervation. With the exception of the superior gluteal nerve, all other
nerves enter the gluteal region below the pyramidal muscle (Fig.1.9).
region through the highest site of the greater sciatic foramen, above the pyramidal muscle; then it is introduced between the gluteus medius and minor muscles,
until it reaches the tensor fascia lata muscle, providing innervation to all three.
16
Fig. 1.10 Cluneal nerves:
upper, middle and lower
nerves
F. R. Garcia
2. Inferior Gluteal Nerve or Sciatic Minor (L5 to S2). It enters the gluteal region
through the greater sciatic foramen, below the pyramidal muscle, accompanied
by arterial branches and inferior gluteal venous branches. It emits branches that
supply the gluteus maximus muscle, perineum and posterior skin of the thigh.
3. Sciatic or Greater Sciatic Nerve (L4 to S3). Leave the pelvis by the lower and
lateral part of the greater sciatic foramen, below the pyramidal muscle. It is the
largest nerve in the body, the main continuation of the sacral plexus. In the buttock it passes below the gluteus maximus, and above the gemini muscles, the
internal obturator and the quadratus femoris, extending to the popliteal fossa
where it originates its terminal branches. This voluminous nerve does not innervate any structure of the gluteal region (Fig.1.9).
4. Internal Obturator Nerve and Superior Gemini (L5 to S2), Quadratus
Femoris Nerve and Inferior Gemini (L4 to S1) and Pyramidal Nerve (S1,
S2). They exit the pelvis through the greater sciatic foramen, below the pyrami-
dal muscle, and innervate the respective muscles.
5. Internal Pudendal Nerve (S2 to S4). It does not innervate any structure in the
gluteal region [24, 25].
1.6 Surgical Anatomy
Completing the comprehensive anatomical study, after general considerations, anatomical limits, surface anatomy, and descriptive anatomy, we will continue this
chapter with the study of the surgical anatomy of the gluteal region, based on the
1 Modern and Integral Anatomy oftheGluteal Region: FROD’S Intramuscular Space
17
dissection work of 20 cadavers performed by the author (Professor of
Morphology at the Universidades Libre, Norte, and Fundación Universitaria
San Martín).
We will focus mainly on the results of the study, and we will highlight the important ndings found in the physiology and morphology of the gluteus maximus muscle, some of them such as the intramuscular space of FROD, not previously
described or published in human anatomy or plastic surgery texts.
The convex silhouette of the gluteal region is highly varied, and its relief is conditioned by various factors that determine its appearance, such as age, sex, weight,
race, heredity, and lifestyle (Fig.1.11). In women, most of the volume of the gluteal
region is due to the quantity and distribution of the adipose pad; while in men the
region has little fat and is mainly muscular. The consistency and position of the
muscles in this region, over the years, tends to decline due to the loss of function and
power, which are added to the decrease in the elasticity of collagen. This great variety of silhouettes or shapes of the gluteal region has been very well conrmed,
studied, and classied by some authors as Mendieta [31].
In the anatomical work developed by the author in 20 cadavers for study, facilitated by the North Regional Legal Medicine Institute, and the Faculty of Medicine
of the Free University of the city of Barranquilla/Colombia, the average thickness
of the subcutaneous cellular tissue and the gluteus maximus muscle, the determining factors in the volume and shape of the buttock, was quantied. The length
of the muscular edges of the gluteus maximus, the types of fascia or aponeurosis present, the measurement of the submuscular area available for implants
Fig. 1.11 Aesthetically
beautiful buttocks
18
ab
F. R. Garcia
and the anatomical structures present there, important for a good surgical planning,
were also investigated. Likewise, the subfascial implant placement techniques of
Dr. De la Peña [32], and intramuscular of Dr. Vergara [33] were replicated to assess
their advantages and disadvantages.
The skin of the gluteal region is thick, exible, and compliant, with hairs and
abundant sebaceous glands.
The subcutaneous cellular tissue (SCT) presents fat of variable volume in adipose accumulations separated from each other by brous tracts and with supercial
vessels of very small caliber. An important recently published work demonstrated
the inuence of age, sex, and body mass index (BMI) on the thickness of subcutaneous fat. An increase of 1.0in BMI represented a 3mm increase in SCT for men,
and 4 mm for women. With older age, the thickness of the deep fat layer
increased, and with increasing BMI, the thickness of the supercial fat
increases [34].
1.7 Study Carried Out inCadavers
In the rst step of our study with cadavers, we determined the average thickness of
the subcutaneous fat, using most of the elements necessary for a good anatomical
dissection and some additional elements such as metal rulers, measuring tapes, needles with marking, Vernier caliper, to get fairly accurate measurements. After tabulating the thickness of the subcutaneous cellular tissue found in the 20 specimens,
we obtained an average value of this thickness: 2.72cm, which should be taken
into account for possible surgical procedures or studies that compromise this structure (Fig.1.12a, b) (Table1.1).
Taking into account the quadrilateral shape of the gluteus maximus muscle, the
four muscle borders (superior, inferior, medial, and lateral) were quantied to follow, obtaining average values that show us the superior border as the shortest
(13.43 cm), and the lateral edge as the longest (19.24 cm), also important
Fig. 1.12 (a, b) Quantication of thickness of SCT
QUNTIFICATION OF THICKNESS OF SCT
AVERAGE THICKNESS OF SCT: 2.72 (cm)
ab
1 Modern and Integral Anatomy oftheGluteal Region: FROD’S Intramuscular Space
Table 1.1 Quantication and average of SCT thickness
19
CADAVER
1
2
3
4
5
6
7
8
9
10
SCT (cm) CADAVER SCT (cm)
1,2
4,6
2,3
3,0
3,7
2,8
3,2
4,1
1,9
2,5
11
12
13
14
15
16
17
18
19
20
2,3
1,8
3,1
3,3
2,7
2,1
2,5
1,8
2,4
3,2
Fig. 1.13 (a, b) Quantication of the muscle edges of the gluteus maximus
information to relate to the length of the base of the implants to be placed in the
area, during an augmentation gluteoplasty (Fig.1.13a–c) (Table1.2).
We continue with the quantication of the thickness of the gluteus maximus
muscle in nine points of three thirds of it (superior, middle, and inferior), and from
medial to lateral, trying to verify that the gluteus maximus is not a quadrilateral
muscle of uniform thickness in all its path, if not of variable thickness according to
20
Table 1.2 Average length of the edges, of the gluteus maximus muscle
F. R. Garcia
20
18
16
14
12
10
LENGHT CM.
8
6
4
2
UPPER LOWER INTERNAL
AVERAGE LENGTH OF GLUTEUS MAXIMUS
13,43
MUSCLE EDGES
14,66
EDGES
16,55
19,24
LATERAL
The upper one is the shortest, and the lateral one, the longest
the valued area. This is an extremely important piece of information when blind
dissection or preparation of the pocket is performed in some techniques for intramuscular augmentation surgeries with prostheses (Fig.1.14a–c). Once the information was tabulated and the average value of the muscle thickness in the different
previously marked areas was obtained, the study carried out showed that the
gluteus maximus muscle on average does not exceed 3cm in thickness (2.73cm),
and that the upper third was the thinnest, while the lower third turned out to be
the thickest muscle, an unfavorable result for augmentation surgery with implants,
which uses the upper and middle thirds to make the pocket and place the implant,
treating to project the buttock in those two thirds exactly, and not in the lower third
that would give the buttock an elongated or sagging aesthetic appearance (Table1.3).
In relation to the fasciae or aponeurosis mentioned in the descriptive anatomy,
we carried out a meticulous dissection work in the cadavers of the study, nding the
ne and delicate fascia of the fatty tissue or supercial gluteal fascia, with an
appearance and consistency very similar to Scarpa’s fascia of the abdominal subcutaneous adipose tissue. Likewise, we observe a little deeper and covering the gluteus
medius muscle up to the upper edge of the gluteus maximus muscle, the deep glu-
teal fascia or regional aponeurosis, pearly, resistant, thick, which is divided at this
point, into three aponeurotic sheets called supercial sheet, middle sheet, and
deep sheet, which cover the supercial and deep aspect of the gluteus maximus,
ab
1 Modern and Integral Anatomy oftheGluteal Region: FROD’S Intramuscular Space
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c
I
II
IV
III
V
VII
VI
VIII
IX
21
Fig. 1.14 (a–c) Quantication of the thickness of the gluteus maximus muscle, in nine determined regions
and the supercial aspect of the gluteus medius, respectively. The deep or regional
gluteal fascia is considered a continuation of the lumbar fascia above and extends
down to the posterior thigh as the femoral fascia (Fig.1.15a–c).
The submuscular space was explored in detail, observing all the important anatomical structures of this plane, such as the gluteus medius muscle with its fascia,
reaching the greater trochanter. A little more inferiorly, we visualize the pyramidal
muscle of the pelvis or piriformis, with the superior and inferior gluteal vessels and
nerves, entering the area above and below said muscle, and the sciatic nerves, internal obturator, quadratus femoris, and internal pudendal artery and nerve, all emerging inferiorly to the pyramidal muscle.
Subsequently, in this plane, the vertical measurement of the safe area for implant
placement was made when using the submuscular technique recommended by Dr.
Robles [35], taking the upper border of the gluteus maximus muscle as the upper
limit, and the lower limit, the lower edge of the pyramidal muscle, which gave us
a distance of between 9 and 10cm, considered a small area, insufcient for the
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