Perifascial Areolar Tissue Research Articles

Efficacy of Fat and Perifascial Areolar Tissue Graft in Refractory Esotropia: A Case Report

Purpose: This case report presents a novel approach for the management of refractory esotropia using adhesiolysis and fat and perifascial areolar tissue (PAT) transplantation.Case summary: A 62-year-old male presented with left eye strabismus fixus following iatrogenic medial rectus (MR) muscle injury and medial orbital wall fracture during endoscopic sinus surgery. One month later, he underwent MR laceration repair and orbital wall reconstruction. Despite three subsequent interventions for exotropia and its subsequent conversion to esotropia, the left eye esodeviation progressively worsened, culminating in strabismus fixus. Initial examination revealed significant left eye esotropia with fixed gaze and 5-mm enophthalmos. Surgery included implant removal, adhesiolysis between the eyeball and surrounding tissues, scar and MR recession, and placement of a fat and PAT graft on the medial aspect of the eyeball to prevent postoperative re-adhesion. Three years of follow-up demonstrated sustained orthophoria in primary gaze with improved extraocular muscle function and enophthalmos.Conclusions: Fat and PAT graft has potential in oculoplastics for preventing re-adhesion and augmenting orbital volume in patients with refractory restrictive strabismus due to multiple surgeries.

A Patient With Exposed Costal Cartilage After Microtia Surgery Successfully Treated With Perifascial Areolar Tissue Grafting

Postoperative costal cartilage exposure is a troublesome complication following costal cartilage grafting for microtia. The authors report a case of attempted recovery using perifascial areolar tissue (PAT) transplantation that achieved favorable results. The patient was a 13-year-old boy, who developed a 27 × 11 mm2 skin ulcer with a 6 × 3.5 mm2 area of exposed cartilage at the helix 1 month after ear ablation surgery. PAT harvested from above the trapezius muscle was grafted onto the ulcer. The wound was closed 14 days later using a split-thickness skin graft from the head. PAT transplants can be harvested from anywhere in the body, are minimally invasive, and are highly flexible. This case demonstrates that, although factors such as the extent and location of cartilage exposure must be considered, PAT transplants are an option for microtia salvage surgery.

Effect of Basic Fibroblast Growth Factor in Perifascial Areolar Tissue Transplant

Abstract Background: Perifascial areolar tissue (PAT) transplant is a technique in which a sheet of connective tissue on the fascia is harvested and transplanted to the wound bed. PAT engraftment fails when the exposed area of tendons, bones, or artificial materials is large. On the other hand, combination of tissue transplant and basic fibroblast growth factor (bFGF) improves the survival rate of the transplanted tissue. Methods: A wound model was created in which the artificial material was exposed on rats' backs. All the rats underwent PAT transplant, but the rats were divided into two groups according to the PAT processing method beforehand. In one group, the PAT was immersed in water for injection before transplant (bFGF[–] group), and in the other group, the PAT was immersed in bFGF product (bFGF[+] group). Specimens were collected 7 days after surgery to assess the histologic thickness of the PAT and the gene expression in the PAT. Results: The thickness of the PAT in the tissue slices was significantly higher in the bFGF(+) group than in the bFGF(–) group. Expressions of CD34 and COL3A1 were significantly higher in the bFGF(+) group than in the bFGF(–) group. Conclusion: The results of this study indicate that adding bFGF to the PAT transplant may promote PAT engraftment and wound healing by increasing angiogenesis and may increase granulation formation, which may result in a stronger covering that prevents the prosthesis from being exposed.

Perifascial areolar tissue graft promotes angiogenesis and wound healing in an exposed ischemic component rabbit model.

Multiple studies have reported the use of perifascial areolar tissue (PAT) grafts to treat wounds involving exposed ischemic tissues, avascular structures, and defective membrane structures. Our objective was to assess the quantitative effects of PAT grafts and their suitability for wounds with ischemic tissue exposure and to qualitatively determine the factors through which PAT promotes wound healing and repair. We conducted histological, immunohistochemical, and mass spectrometric analyses of the PAT grafts. PAT grafts contain numerous CD34+ progenitor/stem cells, extracellular matrix, growth factors, and cytokines that promote wound healing and angiogenesis. Furthermore, we established a male rabbit model to compare the efficacy of PAT grafting with that of an occlusive dressing treatment (control) for wounds with cartilage exposure. PAT grafts could cover ischemic components with granulation tissue and promote angiogenesis. Macroscopic and histological observations of the PAT graft on postoperative day seven revealed capillaries bridging the ischemic tissue (vascular bridging). Additionally, the PAT graft suppressed wound contraction and alpha smooth muscle actin (αSMA) levels and promoted epithelialization. These findings suggested that PAT can serve as a platform to enhance wound healing and promote angiogenesis. This is the first study to quantify the therapeutic efficacy of PAT grafts, revealing their high value for the treatment of wounds involving exposed ischemic structures. The effectiveness of PAT grafts can be attributed to two primary factors: vascular bridging and the provision of three essential elements (progenitor/stem cells, extracellular matrix molecules, and growth factors/cytokines). Moreover, PAT grafts may be used as transplant materials to mitigate excessive wound contraction and the development of hypertrophic scarring.

A Case of Open Zone Ⅰ Extensor Tendon Rupture Reconstructed by External Oblique Muscle Aponeurosis with Perifascial Areolar Tissue

A Case of Open Zone Ⅰ Extensor Tendon Rupture Reconstructed by External Oblique Muscle Aponeurosis with Perifascial Areolar Tissue

Skin Grafting on Wound with Exposed Bone

Introduction: In general, exposed bone wounds are covered with flaps. If the wound is small, skin grafting with perifascial areolar tissue can be performed for resurfacing; however, it is not suitable for large bone-exposed wounds exceeding 5 cm in length.Methods: Six patients underwent skin grafting for bone-exposed wounds at our medical center between 2014 and 2020. In all cases, a suitable local flap donor site could not be found around the wound, and a suitable donor vessel to anastomose the free flap was difficult to find. After a sequestrectomy, slit artificial dermis was applied to the wounds, and basic fibroblast growth factor was sprayed. Ointment-impregnated gauze was applied to the wounds. After confirming the creation of a suitable wound bed, skin grafting was performed.Results: In all cases, after skin grafting, the exposed bone wounds were closed. Four cases were due to extensive burns, one was due to malignant tumor resection, and one was due to exposed bone after injury. For burn injuries, suitable skin flap donors were difficult to find. Three cases of bone exposure involved the skull, and the rest involved the anterior surface of the tibia. Four cases required split-thickness skin grafts (including two mesh skin grafts), and two required full-thickness skin grafts. Covering a wound after skin grafting took 3 weeks to 3 months (median, 1 month), which is much longer than the time taken when using a skin flap. Conclusion: Even for exposed bone wounds with poor blood circulation, a good wound bed can be created by the combination of artificial dermis and bFGF, and wound closure can be achieved by skin grafting. Bone-exposed wounds should be closed early using a skin flap. However, when the patient’s general condition is poor or when temporary closure is difficult due to the unavailability of a suitable donor, wound closure by skin grafting is a simple and useful treatment option, although it takes a long time.

A Novel Model of Perifascial Areolar Tissue Transplant in Rats.

Background Perifascial areolar tissue (PAT) transplant is a method of transplanting loose connective tissue harvested in a sheet form from above the fascia to the wound bed and is effective for wounds with exposed ischemic tissue. However, the engraftment mechanism is unknown, and no animal models of PAT transplant for wound healing exist. Methods In this study, we harvested connective tissue from the backs of Wistar rats in a sheet form to simulate a human PAT transplant. The PAT was affixed to exposed bone of the head. Results In the PAT(+) group, the wound areas gradually decreased due to epithelialization and contraction. The wound area of the PAT(+) group was significantly smaller than that of the PAT(-) group. Conclusions This clinically relevant rat model is useful for elucidating the mechanism of the PAT transplant and establishing a reliable surgical method.

One-Stage Perifascial Areolar Tissue and Skin Grafting Combined with Negative Pressure Wound Therapy for a Refractory Wound with an Exposed Elbow Joint and Extensive Skin Defect

One-Stage Perifascial Areolar Tissue and Skin Grafting Combined with Negative Pressure Wound Therapy for a Refractory Wound with an Exposed Elbow Joint and Extensive Skin Defect

A Perifascial Areolar Tissue Graft With Topical Administration of Basic Fibroblast Growth Factor for Treatment of Complex Wounds With Exposed Tendons and/or Bones

The management of wounds with tendon and/or bone exposure is challenging because of the insufficient blood supply to the wound bed. We describe our experience with 19 patients using a perifascial areolar tissue (PAT) graft with topical administration of basic fibroblast growth factor (bFGF) in the treatment of complex wounds with exposed tendons and/or bones in the extremities. Using a PAT graft is minimally invasive and technically easy, and the donor site is relatively preserved. However, PAT grafts for the treatment of a complex wound with large areas of exposed tendons and/or bones have sometimes failed to survive because of insufficient vascularization of the wound bed. Therefore, topical administration of bFGF, which promotes angiogenesis, was added to the graft. All grafts showed good graft survival and successfully covered the tendons and bones. Topical administration of bFGF accelerated vascularization in the PAT graft and facilitated wound healing by increasing the blood supply to the wound bed and achieved success with the PAT graft. In conclusion, using a PAT graft with topical administration of bFGF is a suitable option for the treatment of complex wounds with a large proportion of exposed tendons and/or bones. With minimal damage to the tissues near the wound, the PAT graft can be a useful option for limb salvage and could become a valuable tool for reconstructive surgeons.

Clinical application of subdermal areolar tissue and superficial fascia graft as a new material for coverage of small exposure of bone cortex or orthopaedic fixation device

Background: The presence of cortical bone, tendon that has been exposed by defects, may result in infection or osteomyelitis. In such cases, perifascial areolar tissue grafting (PATG) may be performed as a minimally invasive surgical procedure. However, perifascial areolar tissue (PAT) is located deep in the subcutaneous layer. It was considered that grafting of the superficial vascular network might enable less invasive surgery. This study reports use of subdermal areolar tissue (SAT) and superficial fascia (SF) to close avascular areas.Methods: This study treated eight areas of exposed bone, tendon, or orthopaedic fixation device in seven patients treated in the department between 2010–2013. The patients included five men and two women aged 15–80 years. Subdermal areolar tissue grafting (SATG) was performed on four areas, and superficial fascia grafting (SFG) on the remaining four areas. In all cases, split thickness skin graft (STSG) was used to cover the grafted tissue in a single procedure.Result: The tissue grafted successfully in seven areas, and primary engraftment of the skin grafts was also achieved in three areas treated with SATG and one area treated with SFG. Additional skin grafting was performed to achieve closure in one site treated with SATG and two sites treated with SFG. The tissue graft became necrotic in one site treated with SFG. There were no problems at any donor sites and no graft site infections or other complications.Conclusion: SATG and SFG achieved good clinical results for the closure of exposed avascular tissue or artifacts.

Perifascial areolar tissue grafting for treating syndactyly with bone fusion in patients with Apert syndrome

Complete syndactyly with bone fusion in patients with Apert syndrome was treated using perifascial areolar tissue (PAT) grafts via a two-stage surgery (i.e. bone separation using inter-bone PAT graft insertion followed by web separation and reconstruction with full-thickness skin grafts). This technique is easy and created nail folds for fingertips.

The availability of perifascial areolar tissue graft for deep cutaneous ulcer coverage

Soft tissue defects or skin ulcers associated with tendon or bone exposure located distally on the extremities are always difficult to treat. The introduction of the vacuum-assisted closure (VAC) and dermal templates has led to major changes in ulcer treatment strategies. However, it is necessary to find an alternative method to treat these defects when VAC is not available. Perifascial areolar tissue (PAT) is the loose connective tissue on the deep fascia that could be a candidate for repairing soft tissue defects or skin ulcers. Grafting PAT on the exposed bone or tendon, including a wide coverage of well-vascularized tissue surrounding the granulation tissue, can prepare the wound to be subsequently closed by a skin graft. In this study, the PAT was used in various situations and its optimal usage and outcomes were evaluated. A total of 13 PAT grafts were performed and were especially useful for covering narrow ulcers with narrow tendon exposure and filling fistula areas. In comparison to other cases, covering the exposed cortical bone ulcers seemed to be more difficult to perform. However, an option for these ulcers could be the exposure of bone marrow and usage of intraosseous blood flow. It was also possible for the simultaneous engraftment of PAT and skin in narrow areas and could be an alternative in cases of small concave ulcers or fistulae. The PAT graft is a simple and minimally invasive procedure that can be a good alternative when VAC is not available.

A novel graft material for preventing cerebrospinal fluid leakage in skull base reconstruction: technical note of perifascial areolar tissue.

Objectives Perifascial areolar tissue (PAT), a layer of loose connective tissue on the deep fascias with a rich vascular plexus, serves as a vital cover over defects with scarce vascularity. We report the usefulness of PAT as a nonvascularized alternative to flaps for reconstruction of dural defects in skull base surgery and transsphenoidal surgery while evaluating its effect on control of cerebrospinal fluid (CSF) leakage. Design A retrospective chart analysis was performed on patients who had undergone repair of a dural defect with PAT during skull base surgery or transsphenoidal surgery between December 2004 and October 2011. Results Twenty-one patients were included: 11 patients had received surgical treatment and/or irradiation. Fourteen of the 21 patients had pre- and/or intraoperative CSF leakage. Only one patient (4.8%) had postoperative CSF leakage requiring additional surgical repair. Ten patients underwent postoperative irradiation from 1 to 15 months after transplant of the PAT. None of the patients had postoperative CSF leakage after irradiation. Conclusion We successfully repaired dural defects using PAT in skull base surgery and transsphenoidal surgery, even in patients with a history of multiple operations and radiotherapy. PAT may serve as a valuable tool for skull base reconstruction.

Adhesiotomy with grafting of fat and perifascial areolar tissue for adhesions of extraocular muscles after trauma or surgery

To investigate the effect of adhesiotomy with grafting of fat and perifascial areolar tissue (A-GFPAT) on eyes with restricted eye movements after trauma or surgery. Single-center retrospective interventional, consecutive case series. Twenty-four eyes of 24 patients that underwent A-GFPAT were studied. The changes in the eye movements was evaluated by the Hess area ratio (HAR %) and in the binocular single vision (BSV) field scores. The HAR % was significantly improved by the A-GFPAT, from 50.9 ± 32.0% (±SD) to 66.4 ± 28.2% at the final visit (Student's t test; P < 0.01). Nine of the 24 cases (37.5%) had an improvement of the final HAR % by >10%. The preoperative mean BSV field score was 15.4 ± 13.3, which improved significantly to 25.9 ± 10.5 after the A-GFPAT (P < 0.001). Thirteen cases (56.5%) had an improvement of the final BSV score by more than 5 points. There were improvements of both HAR % (50%) and BSV score (54.5%) by more than 50% after A-GFPAT in patients with old orbital fractures. All patients who had been treated with Lactosorb earlier had an improvement of the BSV score, while those treated with endoscopic transmaxillary reduction and balloon technique had a lower chance of improvement (20%). Our new technique of A-GFPAT leads to improvements of eye movements that had been limited by the adhesion of orbital soft tissue and periorbita with less adverse effects. We recommend our surgical procedure for eyes with restrictive eye movements or pain caused by adhesions following trauma or ocular surgery.

The versatile perifascial areolar tissue graft: Adaptability to a variety of defects

Reconstruction using flaps with good blood circulation is appropriate for covering an intractable ulcer or a fistula in which tendon or bones are exposed. A non-vascularised perifascial areolar tissue (PAT) graft can also survive in such an area. This study reports the versatile application of a PAT graft for use as a non-vascularised graft material. A total of 32 patients were treated between April 2004 and December 2010 (16 men and 16 women). The donor sites were the inguinal region in 20, the thigh in 11, and the subclavian region in one. There were 13 inlay grafts to the dead space after tumour resection, eight closures for cerebrospinal fluid leakage, seven skin ulcers with exposed bones and tendons, three fistulas, and one vascular leak of the common carotid artery. The total survival rate of the grafts was 91%. The complications associated with this procedure included infection in 9% and seroma in the donor site in 19%. However, all cases improved after conservative treatment. The PAT is a pliable loose areolar tissue with a rich vascular plexus, and the harvesting technique is quite simple and minimally invasive. The PAT graft could therefore represent an alternative for flaps that are used as a free graft material for the reconstruction of such defects as intractable skin ulcers, fistulas or dead spaces that usually require reconstruction with vascularised flaps.

Histologic Study of Perifascial Areolar Tissue Implanted in Rabbit Vocal Folds: An Experimental Study

Perifascial areolar tissue (PAT) consists of loose areolar tissue with viscoelastic properties that are similar to those found in tissues in the superficial layer of the vocal fold. The aim of this study was to quantify the inflammatory process and the collagen content of the graft, as well as that of the host tissue, after placement of a strip of PAT into the rabbit vocal fold. Surgeries were performed on 30 rabbits. The grafts were implanted in pockets that were surgically created in the right vocal fold. The left vocal fold (control group) was subjected only to surgical manipulation. The animals were divided into 3 groups for evaluations at 15 days, 3 months, and 6 months, and their larynx tissues were subsequently reviewed by histology. The grafts were characterized by disorganized and thick collagen bundles and were identified in all study groups. The collagen density stayed constant over time. There was an acute inflammatory response induced by the graft at 15 days that did not exist in the specimens taken at 3 and 6 months. Deposition of collagen fibers in the lamina propria was observed starting at 15 days after the operation and was more intense in the experimental vocal fold than in the control vocal fold. Our findings indicated that PAT has a low tendency for promoting an inflammatory response. However, there was a loss of the original architecture of the graft tissue and a greater deposition of collagen in the implanted vocal folds than in the control group.

Perifascial Areolar Tissue Graft as a Nonvascularized Alternative to Flaps

Perifascial Areolar Tissue Graft as a Nonvascularized Alternative to Flaps

大腿部をｄｏｎｏｒとする顔面神経再建の有用性と可能性

われわれは耳下腺癌の皮膚欠損を伴う顔面神経合併切除に対して前外側大腿皮弁と大腿神経外側広筋枝や大腿皮神経で即時顔面神経再建を行っている。2003年10月から2008年12月までに，10例の耳下腺癌の顔面神経合併切除例に対して大腿神経外側広筋枝または大腿皮神経を用いて即時顔面神経再建を行った。移植した神経はnon-vascularized graft 5例，non-vascularizedとvascularized graftの併用5例であった。9例は前外側大腿皮弁を1例はperifascial areolar tissue（PAT）を同時に移植した。術後の顔面機能評価は柳原の40点法で行い，評価できた8例の点数は16～34点であった。大腿部は耳下腺癌の再建donorとして神経だけではなく皮弁，PAT，筋膜など様々な組織を複合して利用できる。

Expansion of Fascial Flaps

In order to meet the requirements of large defects created by sacral and trochanteric pressure ulcers, tensor fasciae latae and lumbosacral fasciocutaneous flaps were expanded with a silicone expander in six patients (10 flaps). In 8 of the flaps the location of pressure ulcers was trochanteric, and in 2 it was sacral. In each case the period of expansion was 4 weeks. Histopathologic examination after expansion showed an increase in the vascularity and overall thickness of fascia in both types of flaps. After 4 weeks of expansion, the perifascial areolar tissue was replaced with thick granulation tissue in the tensor fasciae latae flaps. This markedly vascular layer of granulation tissue interposed between the fasciae and the subcutaneous tissue augmented the internal matrix of the flap, thereby lowering the potential for shearing during flap elevation. Conceivably, owing to the absence of an areolar tissue layer in the lumbosacral fasciocutaneous flaps, no layer of granulation tissue was observed. The average thickness of the fibrous capsule formed around the expanders was 573.2 microns, which was composed of three structurally different zones. Prior tissue expansion obviously assisted primary closure of the flap donor site. In addition, it seems that the tissue-expansion process rendered the distal portion of fascial flaps more robust because of increased vascularity. It is therefore proposed that preparatory tissue expansion of fascial flaps has several advantages. The obvious benefits include the ability to close larger defects while closing the donor site primarily. As a result of this study, the additional benefits may include a reduction in the mechanical shear potential of these flaps and an improvement in their vascularity.