Autologous Fascia Lata Research Articles

Intraventricular Tension Pneumocephalus after Endoscopic Skull Base Surgery

Postoperative pneumocephalus is commonly observed after neurosurgical intracranial procedures and is usually of little consequence. Intraventricular tension pneumocephalus, however, is a rare complication and a neurosurgical emergency that requires immediate intervention. We describe the first case of intraventricular tension pneumocephalus that developed 1 week following an expanded endoscopic endonasal approach for resection of a suprasellar mass. A patient who underwent an endoscopic transplanum transtuberculum approach for resection of a suprasellar epidermoid tumor developed a sudden change in mental status, with imaging consistent with intraventricular tension pneumocephalus. Immediate endotracheal intubation and placement of an external ventricular drain prevented further deterioration. Endoscopic exploration of the skull base reconstruction revealed a one-way ball valve mechanism as the source of pneumocephalus. The skull base reconstruction was revised with autologous fascia lata and repositioning of the pedicled nasoseptal flap. Intraventricular tension pneumocephalus is a rare neurosurgical emergency that may develop after endoscopic skull base surgery. Initial management includes endotracheal intubation and placement of an external ventricular drain to decompress the ventricles. Endoscopic exploration and revision of the skull base repair is imperative to obliterate the ball-valve fistula to prevent further entrapment of air.

Triple‐layer reconstruction technique for large cribriform defects after endoscopic endonasal resection of anterior skull base tumors

Endoscopic endonasal transcribriform (EET) resection of anterior skull base (ASB) tumors results in large defects that may extend the entirety of the cribriform plate. Endoscopic repair of these cribriform defects can often be challenging. We describe our reconstruction technique for large ASB defects after EET resection of ASB tumors. This triple-layer technique is comprised of autologous fascia lata, acellular dermal allograft, and a vascularized pedicled nasoseptal flap (PNSF). The technique is described and postoperative cerebrospinal fluid (CSF) leak rate is evaluated. Retrospective review over a 2-year period identified 10 patients who underwent a purely EET approach for resection of ASB tumors. Patients who underwent combined cranionasal approaches and those treated for ASB encephaloceles were excluded from this study. After tumor resection, patients underwent triple-layer reconstruction using autologous fascia lata inlay, acellular dermal allograft inlay/overlay, followed by a PNSF to reconstruct the cribriform defect. No postoperative lumbar drainage was used. The average cribriform defect size was 9.1 (range, 5.0-13.8) cm(2) . All 10 patients underwent successful reconstruction with a postoperative CSF leak rate of 0% without the use of postoperative lumbar drainage. The mean follow-up period was 7.4 (range, 2-17) months. The mean age was 45.8 (range, 15-81) years with 30% of the patients being females. The triple-layer reconstruction technique is effective in reconstructing large ASB defects after endoscopic resection of the cribriform plate. We feel that the use of postoperative lumbar drainage is not necessary when using this repair technique.

Fascial sling technique for dural reconstruction after translabyrinthine resection of acoustic neuroma: technical note

Reconstruction of presigmoid dural defects after resection of acoustic neuromas via the translabyrinthine approach is paramount to prevent postoperative CSF leakage. However, primary dural reapproximation and achieving a watertight closure of the dural defect in this anatomical region are quite difficult. Standard closure techniques after the translabyrinthine approach often involve packing an abdominal fat graft that plugs the dural defect and mastoidectomy cavity. This technique, however, may pose the risk of direct compression of the fat graft on the facial nerve and brainstem. Nonetheless, even with the evolution in dural repair techniques, postoperative CSF leaks can still occur and provide a route for infection and meningitis. In this report, the authors describe a novel dural "sling" reconstruction technique using autologous fascia lata to repair presigmoid dural defects created after translabyrinthine resection of acoustic neuromas. The fascia lata is sewn to the edges of the presigmoid dural defect to create a sling to suspend the fat graft within the mastoidectomy defect. A titanium mesh plate embedded in porous polyethylene is secured over the mastoidectomy defect to apply pressure to the fat graft. In the authors' experience, this has been a successful technique for dural reconstruction after translabyrinthine removal of acoustic neuromas to prevent postoperative CSF leakage. There were no cases of CSF leakage in the first 8 patients treated using this technique. The operative details and preliminary results of this technique are presented.

Surgical application of fascia lata as a pericardial substitute in rabbits

To use fascia lata instead of pericardium and observe the presence of adhesions. Twenty rabbits were divided into two group of ten. In group A, a 1×1 cm segment of pericardium was excised and resutured. In group B excised pericardium was substituted for autologous fascia lata. In the comparison of microscopic adhesion rate between two groups A, B after eight weeks, there was no significant statistical difference. Fascia lata is safe and it can be substituted for pericardium especially in repeat sternotomy in repairing congenital heart defects to avoid heart injury.

Autologous Fascia Lata Graft for Contour Restoration and Camouflage in Tertiary Rhinoplasty

Tertiary rhinoplasty is a surgical procedure to correct nasal deformities that have been developed after prior unsuccessful surgeries. Such surgery requires complicated manipulations and tissue grafting for proper restoration. In the current study, we report the use of fascia lata graft combined with cartilage grafts for contour restoring and camouflage. Twenty-three patients who had severe nasal deformities were included, of whom 14 were men and 9 were women. Their ages ranged between 24 and 34 years (mean, 29 y). All patients were twice previously operated on by surgeons other than the authors. An informed consent was obtained from all patients. After harvesting the costal cartilage, the fascia lata graft (mean size, 2-3 cm) was uniformly harvested from the right lateral thigh. Application of the fascia lata and the cartilage graft was achieved through the open rhinoplasty incision. The fascia lata was applied over the cartilage in the dorsal region in 20 patients (86.9%), applied over the reconstructed alar and dome area in the nasal tip in 8 patients (34.7%), and applied over both areas simultaneously in 4 patients (17.3%). Postoperative follow-up was between 14 and 35 months (mean, 24.5 mo); clinical evaluation, photographic documentation, and a questionnaire form related to donor-site morbidity and patient satisfaction were applied after 12 months of the follow-up period. Results showed that all patients had an improved aesthetic result, and no apparent irregularities were observed in the integument of the aesthetic lines. No complications or no requirement for revision surgery was observed later on. In conclusion, refinements of the nasal dorsum and the nasal tip in tertiary rhinoplasty are indeed important and difficult to be managed. Placing the fascia lata over the applied cartilage grafts provide a good cover that conceals the possible irregularities or distortions that may appear in the late postoperative period.

Histomorphological Changes of Tutoplast‐Processed Fascia Lata Grafts in a Rabbit Rhinoplasty Model

Tutoplast-processed fascia lata (TPFL) is a commercially available homograft that has been successfully used as graft tissue for rhinoplasty. The present study evaluates the histomorphological changes of TPFL in a rabbit rhinoplasty model. Prospective study using a rabbit model. Animal laboratory of the Asan Medical Center. The study used 15 New Zealand White rabbits. Each rabbit was implanted with a TPFL (experimental group) and autologous fascia lata (control group) graft of equal size into the nasal dorsum. Rabbits were killed at 1, 3, and 6 months, and the grafts were removed and microscopically assessed for fibroblast proliferation, neovascularization, inflammation, and thickness. For TPFL grafts, the degree of inflammation significantly decreased between 1 and 3 months (P = .041). The degree of fibroblast proliferation continually increased over time. There was a mild degree of neovascularization for the TPFL graft at 1 month. The degree of neovascularization increased between 3 and 6 months (P = .041). For the degree of inflammation, fibroblast proliferation, and neovascularization, there was no significant difference between TPFL and autologous fascia lata at 6 months. Mean thickness analysis showed that there was no significant thickness reduction in both TPFL and autologous fascia lata grafts at 6 months. The TPFL grafts showed negligible resorption rates and favorable tissue reactions in the rabbit rhinoplasty model.

Optimierte Frontalissuspension zur Korrektur der komplizierten Ptosis

Complicated ptosis can be corrected by frontal suspension with autologous fascia lata. Via an open approach, the fascia is implanted between the brow and the tarsal plate behind the septum. The oblique implantation between the tarsus and the brow preserves the flexibility of elevation, closure and blinking of the upper lid. Additionally, the skin crease is improved by this technique.

Frontalis sling procedure for ocular myasthenia gravis

A 39-year-old woman was diagnosed with myasthenia gravis when she was 8 years old. Although many treatments – such as cholinesterase inhibitors and steroids – had been given to the patient, her condition did not improve sufficiently. As she demonstrated bilateral 3 mm levator function without any eye movement disturbances, bilateral frontalis sling procedures were performed with an autologous fascia lata. One year after the operation, the operated upper eyelids showed symmetrically appropriate heights with good functional outcome. A sling procedure with an autologous fascia lata was suitable for correcting poor levator function of an ocular myasthenia gravis case.

Arch of Corneal Opacity

cally and cosmetically optimal. In summary, for infectious necrotizing scleritis that requires surgical therapy, we recommend using an autologous fascia lata graft for the sclera repair. For large defects and severely inflamed cases, a combined transplantation of fascia lata with amniotic membrane is useful. Author Affiliations: Department of Ophthalmology, Ehime University School of Medicine, Toon City (Drs Zheng, Kodama, Goto, and Ohashi), Department of Ophthalmology, Matsuyama Red Cross Hospital (Dr Kodama), and Department of Ophthalmology, Takanoko Hospital, Matsuyama (Dr Goto), Ehime, Japan. Correspondence: Dr Zheng, Department of Ophthalmology, E h i m e U n i v e r s i t y S c h o o l of Medicine, Ehime 791-0295, Japan (xzheng@m.ehime-u.ac .jp). Financial Disclosure: None reported.

Brow suspension using 3-0 Prolene

Sir, We read with interest your publication of Garrott et al's1 recent case series, highlighting the long-lasting benefit of 2-0 Prolene brow suspension for congenital ptosis. Our experience of ∼10 years of performing suture brow suspension in children and adults, for a number of different indications, echoes these findings. In addition, we found that repeat brow suspension, when necessary, was a more straightforward undertaking using this technique. This technique avoids the sequelae of autologous fascia lata harvesting2 and the soft tissue complications associated with the use of mersilene mesh.3 A retrospective case note review highlighted 41 eyes having undergone brow suspension surgery using 3-0 Prolene over a 9-year period (2001–2009) at our institute. All cases with a levator function of <5 mm were included in the analysis, irrespective of cause of ptosis and age, to provide a realistic clinical picture. Mean age at operation was 23 years (range 1–74 years). Recorded palpebral aperture improved significantly following the surgery (P<0.0005; mean 4 mm pre-operation, 7 mm post-operation). The majority were free from complications, although seven (17%) experienced a recurrence of their ptosis requiring a further operation and five (12%) experienced discomfort or a lump at the site of the suture knot. The Kaplan–Meier plot shows the cumulative survival for the group (Figure 1). Figure 1 Kaplan–Meier plot demonstrating cumulative survival for brow suspensions using 3-0 Prolene. Unfortunately, no randomized controlled trials have been undertaken to determine the optimal material for brow suspension surgery. We commend Garrott et al for publishing their long-term outcomes and agree that fascia lata brow suspension is not a prerequisite for successful, long-lasting brow suspension surgery in children. Indeed fascia lata use is not without its complications, at both the harvesting site2 and through proposed contracture of the fascia lata itself leading to variability in the cosmetic results.4 In addition, we suggest a Prolene sutured brow suspension can be used in a broader group of patients, to provide adults with ptosis and poor levator function, a cosmetically and functionally satisfactory result in the long-term. It is worth noting that we have performed this procedure under local anaesthesia in a small number of adults. It is an easily reversible and repeatable procedure.

Management of the Delayed Traumatic Medial Telecanthal Deformity

The normal shape of the medial canthus is a very important aesthetic and functional determinant of the eyes. Disruption of the medial canthal ligament (through trauma or cancer resection, for example) can lead to medial telecanthal deformities, including shortened palpebra, obtuse-angled medial canthi with infraplacement, increased intercanthal distance, and an absent naso-orbital valley. The authors describe the successful application of microscrew and microplate fixation for medial canthoplasty. Thirty-eight patients (38 eyes) with unilateral medial telecanthal deformity were included in this series. For 31 patients, a self-tapping, titanium, low-profile head microscrew was propelled into the solid bone on the posterior aspect of the anterior lacrimal crest at the estimated attachment position of the medial canthal ligament, without a predrilled hole. For the remaining patients, four required placement of a microplate into which the wire could be affixed and three required autologous fascia lata graft injections into the soft tissue because of prior loss. Preoperative and postoperative measurements of each patient's lateral displacement distance were recorded and compared. The patients corrected with microscrews only were divided into three preoperative groups. The patients in group 1 had a displacement distance between 4 mm and 6 mm (seven patients); group 2, between 7 mm and 9 mm (20 patients); and group 3, more than 9 mm (four patients). Postoperative lateral displacement measurements showed that the displacement distance was less than or equal to 2 mm in 27 patients, about 3 mm in one patient, and about 5 mm in the remaining three patients. Of the entire series, the majority (84.2%) of the patients were successfully corrected, with a difference in the canthal distance between their two eyes of less than or equal to 2 mm. For comparison, 60.5% of the patients had a preoperative difference of 7 to 9 mm. Based on the outcomes obtained in this series of 38 patients, the authors' titanium microscrew and microplate approach is shown to be an excellent choice for correcting medial telecanthal deformity. The technique, when applied in appropriate cases, achieves optimal anatomic outcomes while minimizing facial incisions.

Glottal Reconstruction with a Tissue Engineering Technique Using Polypropylene Mesh: A Canine Experiment

The larynx must be resected in some cases of cancer or stenosis, and various techniques are generally employed to fill the resulting defect. No ideal way, however, has been established to restore vocal function after this form of insult. The aim of this preliminary feasibility study in a canine model was to investigate the effectiveness of a polypropylene-based tissue engineering approach to repair a partial glottal defect. Eight dogs were used in this study. A laryngeal defect involving resection of the left vocal fold was created through a thyroid cartilage window. A scaffold made of polypropylene and collagen was preclotted and wrapped with autologous fascia lata, inserted through the window, and sutured to the laryngeal defect in 5 dogs. The defect was reconstructed with an adjacent sternohyoid muscle flap in 3 control dogs. The surgical site was evaluated 3 months after operation by fiberscopic examination, computed tomographic imaging, histologic evaluation, and study of excised larynges. On fiberscopic examination, the experimental group implants were completely covered with regenerated mucosa in all cases, and a favorable vocal fold contour was found in 4 of the 5 cases. One case was characterized by a concave vocal fold shape and red granulation. In the control group, the muscle flap was replaced by scarred mucosa with a concave vocal fold contour in 2 cases, and there was soft white granulation at the anterior resected edge in the third case. The histologic data revealed the regeneration of lined epithelium, subepithelial tissue, and muscle structure in both groups. The excised larynx phonatory data revealed reduced vibratory amplitude in the experimental group compared with the control group; however, excised phonation was not achieved in 2 of the 3 cases in the control group. This polypropylene-based tissue engineering technique appears to be a viable tool for glottal reconstruction; however, additional refinement is required to maximize long-term phonatory function.

Combination of Autologous Fascia Lata and Fat Injection Into the Vocal Fold via the Cricothyroid Gap for Unilateral Vocal Fold Paralysis

To apply the technique of injection of a combination of autologous fascia lata and fat into the vocal fold via the cricothyroid gap for unilateral vocal fold paralysis and to evaluate the therapeutic effect in 12 patients who underwent the procedure. Retrospective analysis of 12 patients. Academic research. A mixture of autologous fascia lata and fat was injected into the thyroarytenoid muscle of the paralyzed vocal fold in 12 patients. Videolaryngostroboscopy was performed to observe the changes to the vocal fold. The patients' phonatory function before and after surgery was assessed by computerized acoustic analysis and by blinded perceptual evaluation. Videolaryngostroboscopy demonstrated that the paralyzed vocal folds in these patients were pushed medially after the procedure. Statistically significant improvements were found in the perturbation measurements (jitter and shimmer), harmonics to noise ratio, and maximum phonation time. Ratings by a panel of voice experts also showed each voice to be statistically significantly improved after the procedure. No complications were noted. A combination of autologous fascia lata and fat injected into the vocal fold for unilateral vocal fold paralysis is a safe and effective therapy.

Horizontal mattress technique for superior oblique suture spacer

Superior oblique tendon overaction and Brown syndrome have been managed surgically by means of tenotomy/tenectomy, use of a silicon expander, and elongation with autologous fascia lata. These solutions are problematic with respect to corrective precision, injury and complications, or surgical difficulty. We present a simple "mattress" suture spacer technique that allows a precise and secure intraoperative adjustment.

Congenital ptosis: Long-term outcome of frontalis suspension using autogenous temporal fascia or fascia lata in children

Children with severe congenital blepharoptosis are at risk of developing amblyopia. For this reason, ptosis repair is indicated as soon as the diagnosis is made. Frontalis suspension of the upper lid is an effective and simple method of treatment. This study reports on the long-term outcome of frontalis suspension surgery for congenital ptosis using autogenous sling material. Twelve children with severe congenital ptosis underwent frontalis suspension surgery using autologous fascia lata or temporal fascia. The results were assessed with a mean follow-up period of 8 years. Eleven children had good or excellent functional and aesthetic results. There were no cases of recurrence or overcorrection. Frontalis suspension using autologous material is a harmless procedure, which does not alter the upper eyelid structures. It is an effective procedure in the long term. In our opinion, it is the technique of choice to treat young children with severe congenital ptosis.

Duraplasty Using Autologous Fascia Lata Reenforced by On-site Pedicled Muscle Flap: Technical Note

Postoperative cerebrospinal fluid (CSF) leak is a common complication in the practice of neurosurgery, and various surgical techniques were described to overcome and manage this problem. Besides not applying watertight closure of the duraplasty, the inviability and the poor vascularization of the graft and/or the dura (eg, reoperations, multiple operations, or cranial radiotherapy) may lead to delayed healing of the suture site and resultant persistent CSF leaks. We present a simple technique that uses on-site muscle flap with pedicle to supply and vascularize the autologous fascia lata, preserving the viability of the graft and reenforcing its healing ability. We applied this technique in 6 patients with postoperative CSF leaks. After harvesting a fascia lata graft with appropriate size from the patients, the graft was sutured to dural defect in watertight fashion. The suboccipital, temporal, and temporal muscles in 4 patients who had posterior fossa duraplasty, in 1 patient who had pterional craniotomy, and in 1 patient who had subtemporal craniotomy, respectively, were dissected, stretched, and sutured to the fascia graft covering the dura graft suture site and then reinforced by Tisseel fibrin glue (Baxter Healthcare Corporation, Deerfield, IL). Postoperatively, CSF lumbar drain was kept open for 72 hours with pressure wound dressing. The technical nuances are illustrated. Cerebrospinal fluid leaks were controlled successfully in 5 patients without recurrence. One patient with posterior fossa duraplasty had recurrence of CSF leak that required reexploration 21 days after the first surgery and a second dural repair in a site distant from the fascia lata attachment. During reexploration intraoperatively, the fascia lata graft was inspected and studied, which has shown the healing of the dura graft site and the graft neovascularization. Duraplasty using autologous fascia lata reenforced by on-site pedicled muscle flap is an effective technique to control CSF leak, especially when dura is poorly vascularized and less viable. The unfortunate recurrence of CSF leak and reexploration in the seventh patient helped us to observe the effectively healed dural defect with profound early postoperative vascularization of the graft, supporting our idea about the effectiveness of this technique.

Upper lid orbicularis oculi muscle strip and sequential brow suspension with autologous fascia lata is beneficial for selected patients with essential blepharospasm

Severe cases of blepharospasm resistant to botulinum toxin represent a challenging clinical problem. Over the last 10 years, we have adopted a staged surgical management of these cases with an initial upper lid orbicularis myectomy (combined with myectomy of procerus and corrugator supercilius as appropriate) and then 4-6 months later a brow suspension with autologous fascia lata. The aim of this study was to assess the outcome of this staged surgical approach. A questionnaire was sent to all patients who had undergone the procedure and the clinical records reviewed. Fourteen patients had undergone the procedure of which 13 were alive. They were sent a questionnaire and 10 of them responded. All had both procedures. Eight of the 10 reported great benefit from the surgery, one some benefit, and one was worse off. All patients still required botulinum toxin injections after the surgery. Majority, but not all, of the patients in our series greatly benefitted from this staged surgical approach.

“GASKET-SEAL” WATERTIGHT CLOSURE IN MINIMAL-ACCESS ENDOSCOPIC CRANIAL BASE SURGERY

Transnasal endoscopic cranial base surgery is a novel minimal-access method for reaching the midline cranial base. Postoperative cerebrospinal fluid leak remains a persistent challenge. A new method for watertight closure of the anterior cranial base is presented. To achieve watertight closure of the anterior cranial base, autologous fascia lata was used to create a "gasket seal" around a bone buttress, followed by application of a tissue sealant such as DuraSeal (Confluent Surgical, Inc., Waltham, MA). The gasket-seal closure was used to seal the anterior cranial base in a series of 10 patients with intradural surgery for suprasellar craniopharyngiomas (n = 5), planum meningiomas (n = 3), clival chordoma (n = 1), and recurrent iatrogenic cerebrospinal fluid leak (n = 1). Lumbar drains were placed intraoperatively in five patients and remained in place for 3 days postoperatively. After a mean follow-up period of 12 months, there were no cerebrospinal fluid leaks. The gasket-seal closure is an effective method for achieving watertight closure of the anterior cranial base after endoscopic intradural surgery.

Use of Conjunctiva-Müller Muscle Pedicle Flap in Surgical Treatment of Necrotizing Scleritis

To describe a new surgical technique for scleral repair in eyes with necrotizing scleritis. The surgical technique involved placing an autologous fascia lata graft over the scleral defect and covering the graft with an inferiorly based conjunctiva-Müller muscle pedicle flap from the upper eyelid. The flap pedicle was divided 2 months after the initial procedure. The medical records of 2 patients (2 eyes) who underwent a scleral repair with this technique were reviewed. Both patients had progressive, diffuse scleral necrosis secondary to rheumatoid arthritis, and were receiving immunosupressive therapy. One patient had previously undergone unsuccessful scleral reconstructions with patch grafting. In both cases, the eye integrity was preserved after repair with conjunctiva-Müller muscle flap, and postoperative visual acuity improved. No complication developed during follow-up periods of 28 and 54 months. Conjunctiva-Müller muscle pedicle flap may provide efficient and safe scleral repair in eyes with necrotizing scleritis.

Transvaginal repair of enterocele and vaginal vault prolapse using autologous fascia lata graft

The aim was to describe the operative technique of transvaginal repair of enterocele and apical prolapse using autologous fascia lata and report intra- and postoperative complications and long-term outcome. A retrospective chart review of 74 consecutive patients who had repair of a symptomatic enterocele and vaginal vault prolapse or uterine prolapse from January 1987 to August 1999. All patients were followed for a minimum of 3 months and 61 were available for long-term evaluation at 18-106 months (median 52 months). Intra- and postoperative complications were few. Pelvic examination at long-term follow-up disclosed a recurrence rate for enterocele of 1.7%, vaginal vault prolapse of 8.3%, and cystocele of 15%. Ninety-one per cent were subjectively satisfied with the relief of mechanical vaginal symptoms. Only 35% (6/17) were cured of constipation. Out of the 22 women who were sexually active after the procedure, 12 (54%) experienced improved quality. Repair of the posterior compartment defect and suspension of the vaginal vault using autologous fascia lata graft provides acceptable intra- and postoperative complication and long-term results.