Fascia In Patients Research Articles

Novel sonographic method for the evaluation of the defects in the pubocervical fascia in patients with genital prolapse.

Novel sonographic method for the evaluation of the defects in the pubocervical fascia in patients with genital prolapse.

Relationship of Plantar Fascia Thickness and Preoperative Pain, Function, and Quality of Life in Recalcitrant Plantar Fasciitis.

The measurement of plantar fascia thickness has been advocated as a diagnostic and prognostic instrument in patients with plantar fasciitis, but there are no data relative to it in recalcitrant plantar fasciitis. The aim of the study is to evaluate the correlation between plantar fascia thickness and pain, functional score, and health perception in patients with this condition. Thirty-eight feet were studied with ultrasound and magnetic resonance imaging to measure plantar fascia thickness. The visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society Hindfoot Score (AOFAS), and SF-36 were then recorded for each patient. The relationship between the fascia and these scores was analyzed to evaluate the correlation of thickness with pain, functional level, and health perception of patients. In patients with recalcitrant plantar fasciitis, plantar fascia thickness did not correlate with pain (VAS), AOFAS, or any item of the SF-36. The thickness of the plantar fascia in patients with recalcitrant plantar fasciitis did not correlate with its clinical impact, and thus, we believe it should not be used in treatment planning. Level IV, case series.

Angiogenesis and VEGF-expressing cells are identified predominantly in the fascia rather than in the muscle during the early phase of dermatomyositis

BackgroundWe previously demonstrated that fasciitis is a common lesion in dermatomyositis (DM) and that DM-associated fasciitis is detectable, as the result of the increased vascularity in the fascia, by power Doppler ultrasonography. We aimed to investigate whether angiogenesis and vascular endothelial growth factor (VEGF)-expressing cells in the fascia are histologically demonstrated during the early phase of DM, and whether inflammation is involved in angiogenesis and an increased number of VEGF-expressing cells.MethodsWe prospectively evaluated 22 patients with DM and 11 patients with polymyositis (PM). Immunohistochemical staining for CD31, VEGF, and tumor necrosis factor-α (TNF-α) were performed on paraffin-embedded sections. The total vascular inflammation score (TVIS), angiogenesis score (AS), and numbers of VEGF-expressing and TNF-α-expressing cells were analyzed in the fascia and muscle.ResultsSignificant fasciitis was detected in most of the patients DM with or without myositis-specific/associated antibodies, while mild fasciitis was detected in four patients with PM, two of whom were positive for anti-aminoacyl-tRNA synthetase (anti-ARS) antibodies. The AS and the number of VEGF-expressing cells in the fascia of patients with DM were significantly greater than those of patients with PM; no significant difference was observed in muscle in patients with DM and PM. The number of VEGF-expressing cells in the fascia correlated with the AS of DM patients. In early-phase DM, the AS, the number of VEGF-expressing cells, and the TVIS in the fascia were significantly higher than in muscle. However, no significant differences were observed in these scores excluding the TVIS between muscle and the fascia in late-phase DM. In DM patients, the TVIS correlated with the AS in the fascia, while the number of TNF-α-expressing cells correlated with the TVIS and the number of VEGF-expressing cells in the fascia.ConclusionAngiogenesis, the number of VEGF-expressing cells, and the degree of inflammation were higher in the fascia in DM than in PM, and were increased predominantly in the fascia rather than in the muscle in early-phase DM. The degree of inflammation correlated with that of angiogenesis in the fascia of DM. The fascia can therefore be a primary site of inflammation and angiogenesis in the pathogenesis of DM.

Brief Report: Power Doppler Ultrasonography for Detection of Increased Vascularity in the Fascia: A Potential Early Diagnostic Tool in Fasciitis of Dermatomyositis

We previously demonstrated that fasciitis is a common lesion of dermatomyositis (DM) that is detectable early after disease onset by en bloc muscle biopsy combined with magnetic resonance imaging (MRI). Power Doppler ultrasonography (PDUS) is a useful method for detection of inflammation and vascularity in rheumatic diseases. We undertook this study to determine whether fasciitis was detectable by PDUS in patients with DM. We prospectively evaluated 7 patients with DM and 7 patients with polymyositis (PM) for the detection of fasciitis with PDUS. MRI and PDUS were both performed in all patients. Fasciitis was histologically confirmed by en bloc biopsy. Among all patients with DM, 4 showed signs of fasciitis on MRI, while increased blood flow signals were observed along the fascia by PDUS in 6 DM patients, including 4 patients with early disease (<2 months after the onset of muscle symptoms). Histologically, significant fasciitis was confirmed in 4 patients with DM. In the remaining 3 patients with DM, significant fasciitis was not evident histologically, but mild proliferation of capillaries and mild inflammation were notable in the area of the fascia. Immunohistochemical staining for CD31 indicated abnormal neovascular proliferation in the fascia in patients with DM. None of the PM patients showed signs of fasciitis or increased vascularity by MRI, PDUS, or en bloc biopsy. In our limited population, PDUS was useful for the detection of fasciitis associated with DM, especially in the early stage of disease. The increased blood flow signal as detected by PDUS is involved in angiogenesis accompanying fasciitis in patients with DM.

Expresión proteica de metaloproteinasa-2 (MMP-2) y su inhibidor tisular (TIMP-2) en aorta, fascia y plasma de pacientes con aneurisma de aorta abdominal

IntroductionThere are data that associates abdominal aortic aneurysms (AAA) with an increased prevalence of hernia disease. A possible structural alteration of extracellular matrix may be common in the degenerative process of the aortic wall and the abdominal fascia. ObjectiveDetermine the expression of matrix metalloproteinases-2 (MMP-2) and tissue inhibitor of metalloproteinases-2 (TIMP-2) in aortic wall tissue, abdominal fascia, and plasma of patients undergoing AAA versus patients with aortic occlusive disease (EAO). Material and methodsA pilot, prospective observational study was conducted, in which the protein expression of MMP-2 and TIMP-2 was analyzed in 10 patients with AAA, and in 10 with EAO, using an ELISA technique. Epidemiological data, history of hernias, and AAA diameters were collected. ResultsIn the subgroup of medium sized AAA with a history of hernia, over-expression of MMP-2 was found in fascia, and of TIMP-2 in aorta and fascia. As regards EAO without hernia (MMP-2 fascia: AAA=4.53 [3.11-6.90], EAO=1.87 [1.45-2.90], P=.04; TIMP-2 in aorta: AAA = 72.62 [9.26-161.12], EAO=9.79 [5.55-25.61], P=.04, and TIMP-2 in fascia: AAA=35.24 [13.15-61.08], EAO =4.98 [1.42-18.01], P=.02).The MMP-2 and TIMP-2 was increased in AAA fascia hernia disease compared with EAO without hernia (MMP-2: 4.31 [3.35-6.35] versus 1.87 [1.45-2.90], P=.009, and TIMP-2: 18.73 [7.76-57.97] versus 4.98 [1.42-18.01], P=.08).There was an increased TIMP-2 in the aortic wall, AAA (29.27 [14.05-140.30] vs. EAO 9.79 [6.19-32.74], P=.06). ConclusionsThe MMP-2 and TIMP-2 are increased in aorta and fascia of patients with AAA, especially in the medium size, suggesting a role in the etiology. The increase in MMP-2 and TIMP-2 in the presence of hernia, enhances the idea of a common pathogenic mechanism.

Laparoscopic Gastric Banding Can Interfere with Adequate Plication during Post-Bariatric Abdominoplasty

BACKGROUND: Bariatric patients often require post-weight loss abdominoplasty which involves plication of the rectus fascia. Complications related to rectus fascia plication in the presence of the laparoscopic gastric band (LGB) port such as port inversion and infection have not been well described in the literature (Figure 1).Figure 1: Inverted and infected port.The purpose of this study is to describe complications related to the rectus fascia plication in post-bariatric patients with LGB ports.1-4 METHODS: A retrospective chart review of patients with a history of LGB undergoing post-bariatric abdominoplasty between 2005 and 2013 was performed. Factors studied included age, gender, body mass index, port location, operative technique, complications and follow-up. RESULTS: Between 2005 and 2013, 178 patients underwent post-bariatric abdominoplasty in our institution. 19 (10.7%) patients had LGB. Average age was 39.8 (range, 17-67) years old. 4 patients were male and 15 female. In 14 patients, the port was located in the epigastrium. The remaining patients (26.3%) had ports in left upper quadrant (LUQ) of abdomen. Complete abdominal wall plication was possible in all patients with LUQ ports. 2 patients underwent port repositioning to the right upper quadrant due to medial port location. 1 patient who under port repositioning developed a superficial wound infection and another patient who did not undergo repositioning despite medial position developed postoperative dysphagia. Amongst patients with epigastric ports, 1 did not undergo any plication, 10 underwent only infraumbilical placation, and 3 underwent partial supraumbilical plication with suboptimal body contouring. 2 patients with infraumbilical plication developed postoperative dysphagia, and 1 developed hematoma. Wound dehiscence was not observed in any patients. CONCLUSIONS: Epigastric positioning of the port system limits rectus fascia plication. Postoperative dysphagia can occur following abdominoplasty with even limited plication of the rectus fascia in patients with epigastric ports. Lateral positioning of the LGB port during the initial surgery allows for complete rectus fascia plication during abdominoplasty after weight loss without the need for port repositioning.

Use of the Pectoralis Major, Serratus Anterior, and External Oblique Fascial Flap for Immediate One-stage Breast Reconstruction with Implant

Skin- or nipple-sparing mastectomy facilitates immediate one-stage reconstruction with an implant. Traditionally, an acellular dermal matrix or a muscle flap has been used because the inferolateral portion of the implant cannot be covered by the pectoralis major muscle. However, this method has drawbacks, including infection, cost, and donor-site morbidity. Therefore, we used an autologous conjoined fascial flap composed of the pectoralis major, serratus anterior, and external oblique fascia in patients with small-to-medium breasts. A series of 11 immediate breast reconstructions in 11 patients was carried out from March 2010 to June 2011. The conjoined fascial flap and smooth round implants were used in all patients. Postoperative photographs were evaluated by a blinded panel and scored on a four-point scale. Patient satisfaction was evaluated by a postoperative questionnaire that had five items designed to evaluate quality of life with the reconstruction. The mean body mass index was 23.2 kg/m(2), follow-up period was 30.9 months, and implant volume was 286.3 cc. Regarding complications, we observed one case of partial skin flap necrosis and one case of seroma accumulation in the axilla, both of which healed with conservative care. The mean overall breast satisfaction score was 3.18 ± 0.5. The conjoined fascial flap is a viable alternative for immediate one-stage breast reconstruction with an implant. We recommend appropriate patient selection with a body mass index greater than 20 kg/m(2) and small-to-medium sized nonptotic breasts. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Ultrasound morphology of plantar fascia in patients with diabetes mellitus

Ultrasound morphology of plantar fascia in patients with diabetes mellitus

Wound healing in acutely injured fascia.

Fascial healing following acute injury, such as that occurring during surgical procedures, is defined functionally. For example, failure of fascial healing following celiotomy is only identified when incisional hernias are diagnosed. Such hernias incur billions of dollars per year in medical costs. Despite the importance of fascial healing, there is a paucity of data regarding the quality such healing. In clinical settings, the quantification of fascial wound healing is limited to a binary state: either there is no clinically apparent functional deficit and full fascia healing is assumed, or an incisional hernia or other functional failure is visible and the fascia did not heal. There are no clinical methods to isolate and functionally test fascia in patients. Recent studies have revealed unexpected findings regarding the recovery of tensile strength, specific surgical methods that optimize fascial healing, and the potential impact of biological pharmaceuticals in eliminating fascial healing failure. However, much remains unknown about the biology of fascial healing.

Rectal Cancer: MR imaging of the mesorectal fascia and effect of chemoradiation on assessment of tumor involvement

To evaluate the impact of chemoradiation on the reliability of MRI in assessing tumor involvement of the mesorectal fascia in patients with rectal cancer. Presurgical MRI was performed in 150 patients; among them 85 had received neoadjuvant long-course chemoradiation. A standardized imaging protocol (1.5 Tesla [T] system, image voxel size 0.6 × 0.4 × 3 mm(3) ), standardized surgery, and histopathological examination were applied for the entire patient population. Images were analyzed to identify potential tumor involvement of the mesorectal fascia (minimum tumor distance to fascia ≤1 mm) and compared with histopathology as the reference standard. Results of nonirradiated and irradiated patients were compared to define the impact of chemoradiation on imaging reliability. In nonirradiated patients, MRI was reliable in predicting or excluding tumor involvement of the mesorectal fascia, positive predictive value 80%, negative predictive value 89%. The frequency of overestimating tumor involvement was significantly higher in irradiated patients (P = 0.005, positive predictive value 42%). Discussions about MRI assessment of tumor involvement of the mesorectal fascia as a basis for recommending neoadjuvant chemoradiation should focus on investigations that excluded irradiated patients, because MRI is less reliable after chemoradiation and tends to overestimate mesorectal tumor involvement.

Ultrasonographic findings of Achilles tendon and plantar fascia in patients with calcium pyrophosphate deposition disease

The aims of the study were to detect the frequency of involvement of the Achilles tendon and plantar fascia in patients with calcium pyrophosphate deposition disease (CPPD) by high-frequency gray-scale ultrasonography (US) and power Doppler sonography (PDS) and to correlate these findings with demographic and clinical data. Two groups of patients were enrolled: group I (38 patients with CPPD) and group II (22 patients with knee OA). US/PDS examination of the heels was performed to both groups. In the CPPD group, US/PDS examination of the Achilles tendon revealed: calcification in 57.9%, enthesophytosis in 57.9%, enthesopathy in 23.7%, vascular sign in 21%, bursitis in 13.2%, and cortical bone irregularity in 10.5%. US/PDS examination of plantar fascia in the CPPD group revealed: calcification in 15.8%, cortical bone irregularity in 78.9%, enthesophytosis in 60.5%, and planter fasciitis in 42.1%. In patients with CPPD, age was significantly correlated with enthesophytosis and deep retrocalcaneal bursitis (p = 0.01 and p = 0.04, respectively). Heel tenderness and posterior talalgia were significantly correlated with Achilles tendon enthesopathy, vascular sign, and deep retrocalcaneal bursitis (p = 0.0001 for each). Inferior talalgia was significantly correlated with plantar fasciitis (p = 0.0001). The sensitivity of ultrasonography for detection of calcifications in Achilles tendon and plantar fascia was 57.9% and 15.8%, respectively, and the specificity was 100% for both. To conclude, ultrasonographic Achilles tendon and plantar fascia calcifications are frequent findings in patients with CPPD. These calcifications have a high specificity and can be used as a useful indirect sign of CPPD.

Biomechanical properties of the rectovaginal fascia. Is it really a fascia?

&lt;em&gt;Background&lt;/em&gt;. The aim of this study was to find out whether the rectovaginal fascia was really a true fascia by comparing the mechanical properties and collagen content of the rectovaginal fascia in women operated for rectoceles to the abdominal fascia in patients having an abdominal hysterectomy. &lt;em&gt;Materials and Methods&lt;/em&gt;. Thirty patients were included. During operation for rectocele or hysterectomy a biopsy measuring 8 x 15 mm was taken from the rectovaginal fascia or abdominal fascia. Mechanical testing and measurement of collagen content was performed. &lt;em&gt;Results&lt;/em&gt;. A significant difference in mechanical strength of the tissue was found. If, however, the strength was corrected for collagen content there was no difference between the two groups. &lt;em&gt;Conclusion&lt;/em&gt;. The quality of collagen was comparable in the two groups. This adds further evidence to the existence of a distinct rectovaginal fascia.

The Component Separation Technique for Hernia Repair: A Comparison of Open and Endoscopic Techniques

The open components separation technique (CST) for hernia repair allows for autologous tissue repair with approximation of the midline fascia in patients with complex hernias. CST requires creation of large undermining skin flaps, whereas the endoscopic component separation technique (ECST) is performed without division of the epigastric perforating vessels and may minimize wound morbidity. A review of patient demographics and outcome measures of patients undergoing CST and ECST between November 2008 and February 2010 was performed. Twenty-five patients were identified who underwent either CST (14 patients) or ECST (11 patients). There were no differences in body mass index (CST 34.8 kg/m(2), ECST 37.5 kg/m(2), P = 0.45), operating room times (CST 268 minutes, ECST 252 minutes, P = 0.54), or hospital length of stay (CST 5 days, ECST 5.8 days, P = 0.78). Wound complications occurred less with ECST (9 vs 57%, P = 0.03). The time to resolution of wound complications in ECST was reduced *1 vs 4 months). No recurrences were seen in either group with a mean follow-up of 4months (range, 1 to 12 months). ECST and CST require similar operative times and hospital lengths of stay. ECST is associated with reduced wound complications compared with CST. Short-term recurrence rates with CST and ECST are comparable.

Plantar fasciitis (fasciosis) treatment outcome study: Plantar fascia thickness measured by ultrasound and correlated with patient self-reported improvement

Ultrasound, well recognized as an effective diagnostic tool, reveals a thickening of the plantar fascia in patients with plantar fasciitis/fasciosis disease. The authors hypothesized that ultrasound would also reveal a decrease in the plantar fascia thickness for patients undergoing treatment for the disease, a hypothesis that, heretofore, had been only tested on a limited number of subjects. They conducted a more statistically significant study that found that clinical treatment with injection and biomechanical correction does indeed diminish plantar fascia thickness as shown on ultrasound. The study also revealed that patients experience the most heightened plantar fascia tenderness toward the end of the day, and improvement in their symptomatic complaints were associated with a reduction in plantar fascia thickness. As a result, the authors conclude that office-based ultrasound can help diagnose and confirm plantar fasciitis/fasciosis through the measurement of the plantar fascia thickness. Because of the advantages of ultrasound—that it is non-invasive with greater patient acceptance, cost effective and radiation-free—the imaging tool should be considered and implemented early in the diagnosis and treatment of plantar fasciitis/fasciosis.

Effectiveness of adalimumab in treating patients with ankylosing spondylitis associated with enthesitis and peripheral arthritis

IntroductionThe purpose of this study was to investigate the effectiveness of adalimumab in enthesitis and peripheral arthritis in patients with ankylosing spondylitis (AS).MethodsAdults with active AS (Bath ankylosing spondylitis disease activity index [BASDAI] ≥ 4) received adalimumab 40 mg every other week with standard antirheumatic therapies in a 12-week, open-label study. Effectiveness in enthesitis was assessed using the Maastricht ankylosing spondylitis enthesitis score (MASES, 0-13) and by examining the plantar fascia in patients with enthesitis (≥ 1 inflamed enthesis) at baseline; effectiveness in peripheral arthritis was evaluated using tender and swollen joint counts (TJC, 0-46; SJC, 0-44) in patients with peripheral arthritis (≥ 1 swollen joint) at baseline. Overall effectiveness measures included Assessment of SpondyloArthritis International Society 20% response (ASAS20).ResultsOf 1,250 patients enrolled, 686 had enthesitis and 281 had peripheral arthritis. In 667 patients with MASES ≥ 1 at baseline, the median MASES was reduced from 5 at baseline to 1 at week 12. At week 12, inflammation of the plantar fascia ceased in 122 of 173 patients with inflammation at baseline. The median TJC in 281 patients with SJC ≥ 1 at baseline was reduced from 5 at baseline to 1 at week 12; the median SJC improved from 2 to 0. ASAS20 responses were achieved by 70.5% of 457 patients with no enthesitis and no arthritis; 71.0% of 512 patients with only enthesitis; 68.0% of 107 patients with only arthritis; and 66.7% of 174 patients with both.ConclusionsTreatment with adalimumab improved enthesitis and peripheral arthritis in patients with active AS.Trial registrationClinicalTrials.gov NCT00478660.

Multifragmented Cartilage Wrapped with Fascia in Augmentation Rhinoplasty

Dorsal nasal contour can be improved by using fragmented or crushed cartilage grafts wrapped with fascia in patients with dorsal nasal deformities. The authors obtain cartilage from the ear concha that is fragmented or crushed. Fascia is harvested from the temporal region. Multifragmented cartilage is wrapped with deep temporal fascia, making a roll. After creating a cavity in the nasal dorsum, the bone is rasped and the combined roll graft is introduced, and appropriate modeling of the graft is mandatory. The authors have operated on 115 patients with this procedure, 68 primary operations and 47 secondary operations, over a 13-year period. In the great majority of cases, results were excellent. To avoid deviation of the roll graft, it is important to prepare a straight cavity. Especially in secondary cases, seroma is manifested by swelling and reddish skin color, which is removed with a 2-mm incision made with a no. 15 knife and constant pressure over the nose for some minutes. The authors have observed only five primary cases with seroma and 13 secondary cases. This procedure in the authors' hands has given magnificent aesthetic long-lasting results and a "natural appearing" outcome.

SMALL INTESTINAL SUBMUCOSA BLADDER NECK SLINGS FOR INCONTINENCE ASSOCIATED WITH NEUROPATHIC BLADDER

We assess the results using small intestinal submucosa (SIS) for neuropathic urinary incontinence in a large single institutional experience. Ambulatory status was considered as a possible predictor of success. We retrospectively reviewed the charts of patients treated with SIS bladder neck sling procedures for neuropathic urinary incontinence with a leak point pressure less than 25 cm H2O and a minimum of 6 months followup. Continence was defined as wet (requiring pads or diapers) or dry (requiring no pads and dry underwear). Patients were classified as ambulatory (able to ambulate without assistance or using braces, crawling at home) or nonambulatory (confined to a wheelchair). Results were analyzed with regard to patient sex, ambulatory status and simultaneous bladder neck repair. A total of 21 females and 15 males 3 to 10 years old (mean age 9 years) were treated with SIS bladder neck slings (sling alone 27, bladder neck repair with SIS sling 9). Slings were performed along with reconstructive surgery in all cases (all had creation of urinary catheterizable channels and simultaneous or prior bladder augmentations). Minimum followup was 6 months (mean 15, range 6 to 42). Overall, 27 of the 36 patients (75%) are dry following bladder neck sling. In patients treated with the sling procedure alone 6 of 8 (75%) nonambulatory females and 8 of 10 (80%) ambulatory females were continent, and 3 of 4 (75%) nonambulatory males and 2 of 5 (40%) ambulatory males were dry. SIS has equivalent rates of continence compared to series using rectus fascia in patients with neuropathic urinary incontinence. The ambulatory status of males should be considered when determining which treatment option is best for the patient with myelodysplasia and neuropathic sphincteric incontinence, as in our series ambulatory males undergoing sling placement alone had a poor outcome.

The biology of hernia formation

Abdominal wall hernia is a multifactorial pathology involving both endogenous and exogenous factors. Male gender and familial history of inguinal hernia are important risk factors for primary inguinal hernia formation, whereas smoking and insufficient surgical technique is associated with recurrent inguinal hernia and incisional hernia formation. Moreover, alterations in collagen composition contribute to the formation of abdominal wall hernias. Apart from decreased levels of total collagen quantity in fascia, reduced collagen quality seems to be a key feature in many hernia patients. Especially, a decreased type I to III collagen ratio has been demonstrated in the fascia of patients with inguinal or incisional hernias, leading to thinner collagen fibers with less strength. These findings are also present in skin suggesting that abdominal wall hernia is a systemic disease. Increased collagen breakdown mediated by matrix metalloproteinase-2 (MMP-2) is suggested to be involved in inguinal hernia formation. Furthermore, systemically decreased type V collagen turnover leading to overall impaired collagen synthesis is present in patients with inguinal or incisional hernias. Published data point towards hernia disease as an inherited disease. The inheritance pattern and identification of gene defects for clinical use remain to be clarified.

Results of fascial augmentation in unilateral vocal fold paralysis.

The objective of this study was to evaluate the effects on voice quality of augmentation by injection of minced fascia in patients with unilateral vocal fold paralysis. Preoperative and postoperative voice samples from 14 patients (6 men and 8 women; mean age, 59 years) were analyzed by computerized acoustic analysis and blinded perceptual evaluation. Statistically significant improvements were seen in perturbation measurements (jitter and shimmer), noise-to-harmonics ratio, and maximum phonation time. A panel of evaluators rated 10 of the 14 postoperative voices as normal or near-normal. Injection laryngoplasty with minced fascia offers a new, effective, well-tolerated, and inexpensive method to medialize a paralyzed vocal fold. The graft seems to survive well, as indicated by good vocal results with a follow-up ranging from 5 to 32 months.

Collagen I/III and Matrix Metalloproteinases (MMP) 1 and 13 in the Fascia of Patients With Incisional Hernias

The late appearance of incisional hernias several years after laparotomy and the high recurrence rates after operation strongly imply the presence of a disorder of the connective tissue, although a specific defect in patients with incisional hernias has not yet been identified. In the present study we used both immunohistochemistry and Western blot analysis to evaluate the ratio of collagen I and III and the expression of the metalloproteinases (MMP) 1 and 13 in the fascia of patients with incisional or recurrent incisional hernias. Samples of healthy skin or stable skin scar in patients without hernias served as controls. Altogether, our data indicated a significantly decreased ratio of collagen I/III in the fascia of patients with incisional hernias and recurrent incisional hernias. Furthermore, in these patients the expression of MMP-1 was decreased compared to the controls, whereas MMP-13 could not be detected in any fascia sample, with or without hernias present. For the first time, our results give evidence of the existence of a possible collagen disorder in these patients. The decreased ratio of collagen I/III is explainable due to a relative increase of collagen type III, which is known to be characterized by thin fibril diameters and lowered mechanical strength. The altered collagen ratio might be the result of the decreased activity of MMP-1, whereas the absent MMP-13 expression did not seem to modify the scar formation. Thus, our data indicate the presence of collagen metabolic disorders in patients with incisional hernias and recurrent incisional hernias. Furthermore, these results might explain the poor results of a mesh-free hernia repair, which again builds up scar tissue of inadequate collagen composition and strength.