A New Substitute for Formalin: Application to Embalming Cadavers

Yoshinori Haizuka1,5, Miki Nagase1,5, Satoshi Takashino1,2, Yasushi Kobayashi3, Yoshihisa

Fujikura4, George Matsumura1*

1
Department of Anatomy, Kyorin University Faculty of Medicine, Tokyo, Japan

2
Department of Forensic Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan

3
Department of Anatomy and Neurobiology, National Defense Medical College, Saitama,

Japan

4
Department of Molecular Anatomy, Faculty of Medicine, Oita University, Oita, Japan

Abbreviated title: Dissection of Cadavers Embalmed with Pyrrolidone

5
These authors contributed equally to this work

*
Correspondence to: Prof. George Matsumura, Department of Anatomy, Kyorin University

Faculty of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo, 181-8611, Japan.

E-Mail: george@ks.kyorin-u.ac.jp

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process which may lead to
differences between this version and the Version of Record. Please cite this article as an
‘Accepted Article’, doi: 10.1002/ca.23011

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CA-17-0388 Revision

TITLE

A New Substitute for Formalin: Application to Embalming Cadavers

ABSTRACT

The development of formalin-free fixatives is an urgent issue in gross anatomy because of the

health hazard and the tissue-hardening actions of formalin. We recently identified the fixative,

antimicrobial, and preservative effects of N-vinyl-2-pyrrolidone (NVP), a precursor of the

water-soluble macromolecular polymer polyvinylpyrrolidone, in animal experiments. The aim

of the present study is to investigate whether NVP solution can be used as an alternative to

formalin in human cadaveric dissection. Twelve donated cadavers were infused with NVP via

the femoral and common carotid arteries using a peristaltic pump. Experienced teaching staff

members in our department dissected the cadavers and examined their macroanatomical

properties. The NVP-embalmed corpses showed no sign of decomposition or fungal growth.

The bodies remained soft and flexible. Notably, the shoulder, elbow, wrist, phalangeal, hip,

knee, cervical spine, and temporomandibular joints were highly mobile, almost equivalent to

those of living individuals. The range of motion of most joints was greater in the NVP-fixed
1

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than formalin-fixed cadavers. Under the dermis, the subcutaneous fat was markedly reduced

and the connective tissues were transparent, so the ligaments, cutaneous nerves, and veins were

easily discernible. The abdominal wall and the visceral organs remained pliable and elastic,

resembling those of fresh cadavers. The lungs, liver, and gastrointestinal tract were moveable in

the thoracic and abdominal cavities and were readily isolated. NVP can be used successfully as

a fixative and preservative solution for human cadavers; furthermore, NVP-embalmed bodies

could be valuable for learning clinical skills and for training, and for developing innovative

medical devices.

KEY WORDS: pyrrolidone; formalin; anatomy; joint range of motion; clinical skills

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INTRODUCTION

Formalin (formaldehyde) fixation, discovered by F. Blum in 1893 (Blum, 1893), is widely

used for cadaver fixation in gross anatomy. Formalin has excellent tissue fixative, antiseptic,

and preservative actions (Fox et al., 1985). However, concerns have recently been raised about

its deleterious effects on health, for example with respect to its carcinogenic properties (Nielsen

et al., 2017) and sick house syndrome (Miyajima et al., 2015). In 2006, the International

Agency for Research on Cancer (IARC) classified formaldehyde as a “group 1” item

(carcinogenic to humans), on the basis that it can cause cancer of the nasopharynx and leukemia

(IARC, 2006). Haffner et al. (Haffner et al., 2015) reviewed the literature and recommended

that female students who might be pregnant should avoid formaldehyde exposure; such

avoidance decreases the relative risk of low birth weight, birth malformations, and spontaneous

abortions, especially during the first trimester. Currently, every medical school in Japan is

required to place forced-air ventilation equipment for formalin in the student dissection room.

Formaldehyde can be effectively neutralized using monoethanolamine (Coskey and Gest,

2015). However, as a fundamental countermeasure, the development of alternative fixative

fluids to formalin has become urgent.

In 2012, the Japan Surgical Society and the Japanese Association of Anatomists published

“Guidelines for cadaver dissection in education and research of clinical medicine” (Japan

Surgical Society and Japanese Association of Anatomists, 2012). Since then, an increasing
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number of medical schools have used donated cadavers not only for anatomical education and

research, but also for surgical skill training for clinicians. Thus, it is desirable to develop

soft-fix embalming fluids suitable for use in surgical training.

Several methods by which the body remains pliable and flexible have been devised such as

the fresh-frozen method (Macchi et al., 2003), the use of Thiel solution (Thiel, 1992, 2002), and

saturated saline (Hayashi et al., 2014).We recently invented a novel fixation method using

N-vinyl-2-pyrrolidone (NVP). NVP is an organic compound with a five-membered lactam ring

and a vinyl group, and can be polymerized into polyvinylpyrrolidone (PVP), a water-soluble

material with multiple uses (Haaf et al., 1985). For example, povidone iodine (isodine), a

disinfectant, is a complex of PVP and iodine. PVP is also used for cosmetics, contact lenses,

artificial teeth, and absorbable surgical threads. When NVP is injected into the body it enters

the cell and replaces water, and polymerization and cross-linking reactions proceed via

intracellular radicals, leading to tissue fixation. Animal experiments demonstrated that the NVP

solution employed exerted tissue fixative and preservative actions while the organs remained

soft and flexible. The aim of the present study was to investigate whether NVP solution can be

used as a formalin substitute in human cadaveric dissection, and to examine the gross

anatomical properties of bodies embalmed with NVP.

MATERIALS AND METHODS

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Source of Cadavers

The cadavers used in the present study were donated to our institution (aged 67-98 years;

five males, 10 females). Written comprehensive consent was obtained from the donors in

advance, and from the families prior to and at donation, agreeing to body donation and its use

for anatomical education, research, and clinical skill training.

The research protocol was developed in strict accordance with the Ethical Guidelines for

Medical and Health Research Involving Human Subjects, and was approved by the Ethics

Committee of our university (approval number: 986).

NVP Embalming

“Preserve” solution, consisting of 100% NVP and <0.1% N,N’-dibutyl-phenylenediamine,

was purchased from Nippon Medical and Chemical Instruments (Osaka, Japan). The femoral

artery and contralateral common carotid artery were cannulated with a T-shaped cannula

connected to Tygon tubes (6475-25; Yamato Scientific, Tokyo, Japan). Each cadaver was

perfused with diluted “Preserve” solution via the cannula using a peristaltic pump (Masterflex

L/S; Yamato Scientific; 8 mL/min, total 12 L). “Preserve” solution was diluted so that the final

concentrations of NVP were either 4.0% to 5.5% (low dose), 10.0% to 10.5% (medium dose),

or 21.5% (high dose) of the body weight (Table …). When the infusion was complete, the

arteries were ligated and the body was immersed in 5 L of 5% “Preserve” solution in a sealed
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plastic bag and then stored at 4°C.

As a control, three cadavers were perfused with a formalin solution consisting of 5%

formalin, 5% glycerol, 5% phenol, 52% alcohol, and 33% water (8 mL/min, total 21L). The

final concentrations of formalin are shown in Table…

Cadaver Dissection

The NVP-embalmed cadavers were dissected by experienced teaching staff members in

our institution. The external appearance of the cadavers, the tissue properties (pliability,

elasticity, mobility), and the ease of dissection were recorded.

Measurement of Range of Motion (ROM) of Joints

We measured the ROM of the shoulder (flexion, abduction, external rotation and internal

rotation); elbow (flexion and extension); wrist (flexion, extension, radial deviation and ulnar

deviation); hip (flexion, abduction, adduction, external rotation and internal rotation); and knee

(flexion), according to the criteria in “Display and measurement of range of joint motion” by

the Japanese Orthopedic Association and the Japanese Association of Rehabilitation Medicine

(Yonemoto, 1995). ROM was measured as an angle with a goniometer on both the right and left

sides of three NVP- and three formalin-embalmed bodies. The values were standardized using

the reference data obtained from living individuals in the evaluation criteria list.

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Statistical Analysis

The values are expressed as means ± SEM. Student’s unpaired t-test was used to compare

the NVP- and formalin-embalmed cadavers. P values < 0.05 were considered to indicate

statistical significance.

RESULTS

Cadaver Embalming with NVP

We embalmed 12 cadavers donated to our institution using NVP. The details of the

cadavers are given in Table... The final concentrations of NVP were 4.0% to 5.5% (n = 4), 10%

to 10.5% (n = 7), and 21.5% (n = 1) of body weight. During a storage period of up to two years,

no corpse decomposed or developed fungal growth, indicating that 4.0% to 21.5% NVP had

adequate preservative and disinfectant effects.

External Appearance

Following NVP fixation, the keratinous layers of the skin were partially peeled off in all

cases (Fig. 1a). In the subsequent studies, the detached corneum was removed with a sponge

prior to analysis. The NVP-embalmed bodies remained soft and pliable, and the intercostal

spaces and the abdomen sagged downwards compared with the fresh bodies before infusion
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(Figs. 1b, c). The orbits were remarkably depressed (data not shown).

Mobility of Joints

Prior to dissection we manually examined the mobilities of major joints, specifically the

flexion-extension, abduction-adduction, and external-internal rotation movements in the

shoulder joints; flexion-extension in the elbow joints; pronation-supination of the forearms,

flexion-extension and radial-ulnar deviation in the wrist joints; flexion-extension and

abduction-adduction in the phalangeal joints; flexion-extension, abduction-adduction, and

external-internal rotation in the hip joints; flexion-extension in the knee joints;

flexion-extension, rotation and lateral bending in the cervical spine joints; and opening-closing

in the temporomandibular joints. Some of the movements are depicted in Fig. 2. Most of the

joints were highly mobile, resembling those of living individuals. We encountered no resistance

when moving them.

We measured the joint ROM as an angle according to the evaluation criteria (Yonemoto,

1995) and compared the NVP-embalmed and formalin-embalmed cadavers quantitatively. The

ROMs of most joints were significantly greater in the NVP-fixed than the formalin-fixed

cadavers (Fig. 3).

Dissection of the Superficial Structures

We dissected the superficial structures of the NVP-embalmed bodies (Fig. 4). Under the
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dermis, the subcutaneous fat was mostly absent, the connective tissue was watery and

transparent, and the underlying cutaneous nerves and veins were directly recognizable (Fig.

4a).We were also able to dissect the coracoacromial, conoid, and trapezoid ligaments around

the acromioclavicular joint without difficulty because of the disappearance of fat and the

pliability and transparency of the surrounding connective tissue (Fig. 4b).

We subsequently isolated the superficial digital flexor tendons and examined the

movement of the proximal interphalangeal (PIP) joints in response to tendon traction. When the

tendons were held without tension, the index, middle, ring and little fingers were all extended

(Fig. 4c); the PIP joint of the index finger was flexed in response to pulling on the radial side of

the tendons (Fig. 4d); the PIP joints of the ring and little fingers were flexed when tension was

applied to the ulnar half of the tendons (Fig. 4e); and all of the fingers were bent down when all

the tendons were pulled (Fig. 4f).

Dissection of the Viscera

We further performed thoracotomy and laparotomy, and dissected the intrathoracic and

intraabdominal viscera (Figs. 5a, b). The visceral organs in the chest and abdomen remained

pliable and elastic, similar to those of fresh cadavers. In the abdominal cavity, the mesentery

and ligaments were thin and flexible, with limited visceral fat accumulation. Accordingly, the

liver and gastrointestinal tract were movable and readily excised (Figs. 5c, e, f).The epiploic

foramen was also easily identifiable(Fig. 5d).

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 We next compared the macroanatomical findings of the heart and lungs removed from the

bodies infused with 4.0% to 5.5% (low), 10.0% to 10.5% (medium), or 21.5% (high) NVP

concentrations. Increasing the concentration of NVP tended to reduce pliability while

enhancing elasticity.

In the hearts of the low NVP group, the pliability was so high and the elasticity so low that

the intracardiac lumens had collapsed (Fig. 5a, arrowheads). The heart of the medium NVP

group exhibited moderate pliability and elasticity and the morphology was maintained (Fig. 5b).

In the heart with high NVP, the pliability was low and the elasticity was greater (Fig. 5c); as a

result, it was difficult to open the left ventricular wall and observe the inside (data not shown).

Few clots were found within the lumen regardless of NVP concentration.

The lung at low NVP concentration appeared to have sagged under its own weight because

the pliability was too high and the elasticity too low (Fig. 5d). At moderate NVP concentrations,

the lung retained its morphology because elasticity was higher (Fig. 5e). With the high NVP

concentration, the morphology was preserved but the tissue became stiff because of reduced

pliability and further increased elasticity (Fig. 5f).

DISCUSSION

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 In the present study, we embalmed 12 donated cadavers with NVP solution as a formalin

alternative and examined the gross anatomical findings. Infusion of NVP at final concentrations

of 4.0% to 21.5% body weight exerted adequate fixative, disinfectant and preservative effects.

Most joints were mobile to an extent close to those of living individuals. The superficial

structures such as the cutaneous nerves, veins, ligaments, and tendons were readily discernable

because of the decreased adipose tissue and the increased pliability, flexibility, and

transparency of subcutaneous tissues. The visceral organs were also soft and elastic and it was

easy to dissect, displace, and harvest them. These properties imply that NVP embalming could

be useful for clinical skill education and training, medical device development, and anatomical

research that has previously been difficult to undertake after hard tissue fixation.

NVP is a monomeric precursor of PVP, a water-soluble synthetic polymer used for

cosmetics, drug tablets, contact lenses, adhesives, inkjet printing, absorbable surgical thread,

and tissue engineering scaffolding (Haaf et al., 1985). We invented a novel tissue fixation

method using NVP (patent No. 4374435, Tissue fixation method with hydrophilic

macromolecule; patent No. 4956839, Tissue fixation method with monomer compound of

hydrophilic macromolecule; patent No. 5840193, Infusion solution for cadaveric preservation).

In experiments using rats and goats, NVP had tissue fixative and preservative effects if the

concentration per body weight was 5% or more. The hip and knee joints were highly mobile,

and the elasticity of the liver, kidney, heart, and lung was well maintained. The mesentery did

not become too hard, and the gastrointestinal tract moved well in the abdominal cavity.
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Furthermore, 2% NVP solution inactivated rabies virus, Escherichia coli, Staphylococcus

aureus, Bacillus subtilis and fungi in ex vivo assays. In the present study, we observed similar

findings in NVP-embalmed human cadavers. As for safety: NVP in the monomer form is

reported to have harmful properties, but it is converted to the nontoxic polymer PVP in the body

(Haaf et al., 1985). IARC concluded that NVP is not classifiable as carcinogenic to humans,

making it a “group 3” item, because no relevant epidemiological data were available and there

was limited evidence from experimental animals (IARC, 1999). Regarding biocidal effects,

future studies are necessary to determine whether NVP fixation can inhibit the pathogenicity of

viruses such as hepatitis B, hepatitis C, and human immunodeficiency virus in virus-positive

human cadavers.

We analyzed joint motion quantitatively, according to the evaluation criteria established

by the Japan Orthopedic Society and Japan Rehabilitation Medical Society (Yonemoto, 1995).

Hayashi et al. (Hayashi et al., 2014) analyzed ROM using the same criteria and compared the

Thiel, saturated salt solution, and formalin methods. We consider that the joint mobility in

NVP-embalmed bodies would be comparable with those of the Thiel and saturated salt solution

methods. We showed that the ROM in the shoulder, elbow, wrist, hip, and knee joints was

significantly greater in the NVP than the formalin group. The results also indicated that the

movements of many joints in the NVP-embalmed bodies were equivalent to those in living

individuals (1 or greater in Fig. 3). It should be noted that we examined ROM only after

embalming the bodies, so the data would have been affected by the condition prior to
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embalming. It is necessary to compare joint mobility before and after embalming in the same

individual in order to clarify whether NVP fixation improves the movement in joints previously

impaired by stroke or aging.

Recently, several embalming strategies have been devised to keep the body pliable and

flexible, such as the fresh-frozen method (Macchi et al., 2003), the Thiel method (Thiel, 1992,

2002), and the saturated saline method (Hayashi et al., 2014; Hayashi et al., 2016). Fresh-frozen

dissection does not use formalin but entails risks of infection and decomposition and requires

large freezers. The Thiel and saturated saline methods still involve low concentrations of

formalin (3% to 6% and 0.8%, respectively). We consider that the NVP method has several

promising characteristics: It is completely free of formalin, requires no expensive equipment,

and attains soft tissue fixation comparable with the Thiel and saturated salt solution methods.

NVP caused detachment of the keratinous layers of the skin, reduction of subcutaneous and

visceral fats, and depression of the chest, abdominal, and orbital cavities. The underlying

mechanisms are not clear, but corneal detachment has also been reported for the Thiel method

(Eisma et al., 2013).

In the current study, we used various concentrations of NVP (4.0% to 21.5% of body

weight). The optimum seemed to differ depending on the target organs and type of analysis.

Although we did not examine the effects of concentration quantitatively, and we performed

20% NVP embalming in only one case, we had impression that 10% NVP was good for

analyzing the visceral organs and surface structures, whereas bodies fixed with 5% NVP were
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too soft to maintain their morphology and fixation with 20% NVP made them too stiff.

Flexibility tended to decrease with increasing NVP concentration, whereas elasticity tended to

increase. It should be mentioned that even 20% NVP fixation was insufficient for brain

dissection (data not shown). The determination of optimum conditions is a task for the future.

The present study indicated high joint mobility and soft tissue fixation as major

advantages of NVP embalming, which indicate several practical applications. For example,

NVP embalming is expected to be useful for biomechanical cadaveric research in orthopedics,

rehabilitation, and physical therapy. It could also be applicable to surgical skill training for

laparoscopic abdominal surgery, for thoracoscopic, endoscopic and bronchoscopic procedures,

and for assessing new medical devices and procedures. Because the temporomandibular joints

were mobile, it could be valuable for training in endotracheal intubation. It has been reported

that clear ultrasonographic and X-ray images were obtained in cadavers embalmed with the

Thiel and saturated salt solution methods, in contrast to formalin fixation (Schramek et al.,

2013; Hayashi et al., 2014). If we can also obtain such imaging data from NVP-embalmed

bodies, the method could be used for training in ultrasonography-assisted and radiography-

guided clinical procedures including nerve blocks, central vein catheterization, cardiac

catheterization, and biopsy.

In conclusion, we successfully embalmed 12 donated cadavers with NVP and showed

adequate fixative, disinfectant and preservative effects with high joint mobility and soft tissue

fixation. These properties indicate that NVP embalming could be applicable to clinical skill
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education for medical students, surgical training for clinicians, and medical device

development for researchers, and for anatomical research that was previously difficult to

perform after hard tissue fixation.

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FOOTNOTES

none

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LEGENDS

Fig. 1. External appearance of the NVP-embalmed bodies. a: After embalming, the keratinous

layers of the skin were partially peeled off (case 10, 10.2% NVP). b, c: External appearance

before (b) and after (c) NVP fixation (case 11, 10.5% NVP). The detached corneum was

removed. After NVP fixation, the intercostal spaces and the abdomen were depressed. [Color

figure can be viewed at wileyonlinelibrary.com]

Fig. 2. Mobility of joints in the NVP-embalmed cadaver (case 9, 10.0% NVP). a, b: Shoulder

joint; anatomical position (a) and 90° abducted position (b). c, d: Elbow joint; anatomical

position (c) and flexed position (d). e, f: Phalangeal joints; the right open hand

(extension/abduction) (e) and clenched fist (flexion/adduction) (f). g, h: Knee joint; anatomical

position (g) and flexed position (h). i, j: Temporomandibular joints; closed (i) and open (j)

mouth. [Color figure can be viewed at wileyonlinelibrary.com]

Fig. 3. Comparison of joint movement between NVP-fixed and formalin-fixed bodies. The

ROM of each joint was measured as an angle, and the value was standardized against the

reference value for living individuals. Data are means ± SEM. The unpaired t-test was used for

statistical analysis. *P< 0.05, **P< 0.01 NVP-fixed group (black bars; n = 6) vs. formalin-fixed

group (white bars; n = 6). Abbreviations: Flex, flexion; Abd, abduction; E-Rot, external
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rotation; I-Rot, internal rotation; Rad, radial deviation; Uln, ulnar deviation; Add, adduction.

Fig. 4. Dissection of the superficial structures in the NVP-embalmed cadavers. a: Dorsal view

of the left forearm (case 1, 4.0% NVP). The subcutaneous fat was reduced, the connective

tissue was transparent, and the underlying cutaneous nerve (n: posterior antebrachial cutaneous

nerve) and vein (v: cephalic vein) were directly recognizable. b: Ligaments around the right

acromioclavicular joint (case 4, 5.5% NVP). The coracoacromial, conoid, and trapezoid

ligaments were distinguishable from the surrounding connective tissues. Abbreviations: C,

clavicle; CAL, coracoacromial ligament; CL, conoid ligament; CP, coracoid process; Hu,

humerus; TL, trapezoid ligament. c-f: Dissection of the superficial digital flexor tendons and

finger movement of the right hand (palmar view) (case 7, 10% NVP). c: When the tendons were

held without tension, the four fingers were extended. d: The index finger was flexed by pulling

the radial side of the tendons. e: The ring and little fingers were flexed by pulling the ulnar side

of the tendons. f: All of the fingers were flexed by pulling all the tendons. [Color figure can be

viewed at wileyonlinelibrary.com]

Fig. 5. Anatomical findings of the viscera in the NVP-embalmed cadaver (case 4, 5.5% NVP).

a: Intrathoracic visceral organs after thoracotomy. The pericardium was removed.

b:Intraabdominal visceral organs after laparotomy. The parietal peritoneum was removed.

c:The small intestinewas gathered to the right lower abdominal portion. The mesentery and
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intestinal wall were pliable and flexible. Abbreviation: DF, duodenojejunal flexure. d:The

epiploic foramen was easily identifiable, which was indicated by insertion of the index finger. e,

f: The liver was soft and readily rotatedup to90°. [Color figure can be viewed at

wileyonlinelibrary.com]

Fig. 5. Macroanatomical properties of the heart and lung embalmed with different

concentrations of NVP. a-c: The heart (anterior view) embalmed with low concentration (a)

(case 3, 5.4% NVP); medium concentration (b) (case 5, 10.0% NVP); and high concentration

(c) (case 12, 21.5% NVP). The lumens within the right atrium and ventricle had partially

collapsed after low NVP fixation (arrowheads), whereas their form was maintained at both the

medium and high concentrations. d-f: The right lung (medial view) embalmed with low

concentration (d) (case 4, 5.5% NVP); medium concentration (e) (case 10, 10.2% NVP); and

high concentration (f) (case 12, 21.5% NVP). The lung fixed with the low NVP concentration

had collapsed under its own weight, whereas that fixed with high NVP retained its shape and

was stiff. The lung fixed with 10% NVP was intermediate in firmness and ability to retain its

shape. [Color figure can be viewed at wileyonlinelibrary.com]

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TABLES

Table. Characteristics and fixative concentrations of cadavers

case fixative age sex height (cm) BMI BW (kg) conc. (%)
1 NVP 98 M 160 12.1 31.0 4.0
2 NVP 67 M 165 21.7 59.0 4.2
3 NVP 86 F 145 17.1 36.0 5.4
4 NVP 78 F 156 16.6 40.5 5.5
5 NVP 88 F 150 11.6 26.0 10.0
6 NVP 88 M 171 16.1 47.0 10.0
7 NVP 88 F 149 13.5 30.0 10.0
8 NVP 86 F 153 22.2 52.0 10.0
9 NVP 85 M 167 23.3 65.0 10.0
10 NVP 82 F 160 18.4 47.0 10.2
11 NVP 93 M 140 23.0 45.0 10.5
12 NVP 89 F 140 9.44 18.5 21.5
13 FA 83 F 155 28.7 69.0 1.11
14 FA 79 F 153 15.4 36.0 1.75
15 FA 87 F 147 15.3 33.0 1.85
FA: formalin, NVP: N-vinyl-2-pyrrolidone, BMI: body mass index,
BW: body weight, conc: concentration

23

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Page 25 of 29 Clinical Anatomy

Fig. 1. External appearance of the NVP-embalmed bodies. a: After embalming, the keratinous layers of the
skin were partially peeled off (case 10, 10.2% NVP). b, c: External appearance before (b) and after (c) NVP
fixation (case 11, 10.5% NVP). The detached corneum was removed. After NVP fixation, the intercostal
spaces and the abdomen were depressed. [Color figure can be viewed at wileyonlinelibrary.com]

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 Clinical Anatomy Page 26 of 29

Fig. 2. Mobility of joints in the NVP-embalmed cadaver (case 9, 10.0% NVP). a, b: Shoulder joint;
anatomical position (a) and 90° abducted position (b). c, d: Elbow joint; anatomical position (c) and flexed
position (d). e, f: Phalangeal joints; the right open hand (extension/abduction) (e) and clenched fist
(flexion/adduction) (f). g, h: Knee joint; anatomical position (g) and flexed position (h). i, j:
Temporomandibular joints; closed (i) and open (j) mouth. [Color figure can be viewed at
wileyonlinelibrary.com]

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Page 27 of 29 Clinical Anatomy

Fig. 3. Comparison of joint movement between NVP-fixed and formalin-fixed bodies. ROM of each joint was
measured as an angle, and the value was standardized with the reference one for living individuals. Data are
means ± sem. Statistical analysis was performed using unpaired t-test. *P < 0.05, **P < 0.01 NVP-fixed
group (black bars; n = 6) vs. formalin-fixed group (white bars; n = 6). Abbreviations: Flex, flexion; Abd,
abduction; E-Rot, external rotation; I-Rot, internal rotation; Rad, radial deviation; Uln, ulnar deviation; Add,
adduction.

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 Clinical Anatomy Page 28 of 29

Fig. 4. Dissection of the superficial structures in the NVP-embalmed cadavers. a: Dorsal view of the left
forearm (case 1, 4.0% NVP). The subcutaneous fat was reduced, the connective tissue was transparent, and
the underlying cutaneous nerve (n: posterior antebrachial cutaneous nerve) and vein (v: cephalic vein) were
directly recognizable. b: Ligaments around the right acromioclavicular joint (case 4, 5.5% NVP). The
coracoacromial, conoid, and trapezoid ligaments were distinguishable from the surrounding connective
tissues. Abbreviations: C, clavicle; CAL, coracoacromial ligament; CL, conoid ligament; CP, coracoid process;
Hu, humerus; TL, trapezoid ligament. c-f: Dissection of the superficial digital flexor tendons and finger
movement of the right hand (palmer view) (case 7, 10% NVP). c: When the tendons were held without
tension, the four fingers were extended. d: The index finger was flexed by pulling the radial side of the
tendons. e: The ring and little fingers were flexed by pulling the ulnar side of the tendons. f: All of the
fingers were flexed by pulling the whole of the tendons. [Color figure can be viewed at
wileyonlinelibrary.com]

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 Clinical Anatomy Page 30 of 29

Fig. 5. Macroanatomical properties of the heart and lung embalmed with different concentrations of NVP. a-
c: The heart (anterior view) embalmed with low concentration (a) (case 3, 5.4% NVP); medium
concentration (b) (case 5, 10.0% NVP); and high concentration (c) (case 12, 21.5% NVP). The lumens
within the right atrium and ventricle were partially collapsed by low NVP fixation (arrowheads), whereas the
form was maintained with both the medium and high concentrations. d-f: The right lung (medial view)
embalmed with low concentration (d) (case 4, 5.5% NVP); medium concentration (e) (case 10, 10.2%
NVP); and high concentration (f) (case 12, 21.5% NVP). The lung fixed with low NVP was collapsed because
of its own weight, whereas that fixed with high concentration NVP retained its shape and was stiff. The lung
fixed with 10% NVP was intermediate in firmness and ability to retain its shape. [Color figure can be viewed
at wileyonlinelibrary.com]

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