Fascial Strip Research Articles

An effective and safe innovation for the management of vault prolapse

ObjectiveConsidering the great variety of techniques and disagreement about the ideal route, there is a need for a simple, safe and effective method for the management of vault prolapse.Study Design51 cases of post- hysterectomy vault prolapse: 45 following vaginal and 6 after total abdominal hysterectomy were treated surgically by anterior abdominal wall colpopexy with autogenous rectus fascia strips.ResultsExcept for minor complaints like vomiting, fever and urinary retention in 3.92% cases each (n = 2 each), no major complications were encountered. Moreover, no recurrence, thus far, on follow-up.ConclusionUsing autogenous rectus fascia strips in anterior abdominal wall colpopexy is not only simple, cheap and effective method of treating apical prolapse but is also devoid of any serious complications as described with other techniques.

Rectus fascia colpopexy for post-hysterectomy vault prolapse: a valid option

Considering the great variety of techniques and disagreement about the ideal route, there is a need for a safe, simple and effective method for the management of apical prolapse. Twenty seven cases of post- hysterectomy vault prolapse (twenty four following vaginal and three after total abdominal hysterectomy) were treated surgically by anterior abdominal wall colpopexy with autogenous rectus fascia strips. Except for minor complaints like- vomiting, fever and urinary retention in 3.7% cases each (n=1), no major complications were encountered. Moreover, no recurrence, on follow-up thus far. Using autogenous rectus fascia strips in anterior abdominal wall colpopexy is not only a simple, cheap and effective method of treating vault prolapse but is also devoid of any serious complications such as described with other techniques.

Inveterate Monteggia Injury. Results of 3 cases with the modified Bell-Tawse procedure

Purpose Monteggia injuries are a rare occurrence (2% of all elbow fractures), and inveterate cases are extremely unusual. We present 3 cases treated by means of open reduction and reconstruction of the annular ligament with a strip of triceps fascia. Materials and methods The mean age of the 3 patients was 7 years (range: 5-9). Two of them were male and all presented with type 1 Bado injuries on the right side. All 3 were treated by means of the Bell Tawse technique as modified by Lloyd-Roberts and Bucknill; one of the patients was also subjected to ulnar osteotomy. Results There were no complications. After a mean follow-up of 35 months (range: 9-84) all patients achieve a functional flexion-extension range. They experienced a slight loss of pronosupination but they reported no restrictions to their activities of daily living or any functional impairment. Conclusions The modified Bell-Tawse technique is an effective method, even if it leads to a slight loss of mobility, especially in terms of pronosupination. The long-term results of this technique are better than those achieved with a late excision of the dislocated radial head.

Lesión de Monteggia inveterada. Resultados con la técnica de Bell-Tawse modificada en tres casos

Purpose Monteggia injuries are a rare occurrence (2% of all elbow fractures), and inveterate cases are extremely unusual. We present 3 cases treated by means of open reduction and reconstruction of the annular ligament with a strip of triceps fascia. Case reports The mean age of the 3 patients was 7 years (range: 5–9). Two of them were male and all presented with type 1 Bado injuries on the right side. All 3 were treated by means of the Bell-Tawse technique as modified by Lloyd-Roberts and Bucknill; one of the patients was also subjected to ulnar osteotomy. Results There were no complications. After a mean follow-up of 35 months (range: 9–84) all patients achieve a functional flexion-extension range. They experienced a slight loss of pronosupination but they reported no restrictions to their activities of daily living or any functional impairment. Conclusions The modified Bell-Tawse technique is an effective method, even if it leads to a slight loss of mobility, especially in terms of pronosupination. The long-term results of this technique are better than those achieved with a late excision of the dislocated radial head.

The inguinal ligament and its lateral attachments: Correcting an anatomical error

The inguinal portions of the internal oblique and transversus abdominis muscles are generally described as arising from the inguinal ligament. Previous authors have shown that this description is incorrect. A new dissection study in 15 lightly embalmed cadavers confirms that in reality the inguinal portions of these muscles arise from a thickened strip of ilipsoas fascia that forms the superolateral part of the ilio-pectineal arch. Details are given of a new dissection technique that fully exposes the deep aspect of the inguinal ligament, without disrupting its continuity. The historical background of the persistent textbook error is explored. It originated at a time when there was widespread descriptive and semantic confusion regarding the structure now known as the inguinal ligament.

Incisuroplastia troclear e estabilização articular após transecção do ligamento cruzado cranial: Estudo clínico e radiográfico em cães

Avaliaram-se as alterações clínicas e radiográficas em nove cães adultos, após a transecção do ligamento cruzado cranial (LCCr) seguida da substituição ligamentar por retalho de fáscia lata, associada ou não à incisuroplastia troclear (ITR). O joelho direito (GI) foi submetido à ITR e posterior estabilização articular, e o esquerdo somente à substituição ligamentar (GC). Os animais foram avaliados nos períodos pré-operatório, pós-operatório (po) imediato e aos 30, 90 e 180 dias de po, período coincidente com o momento de eutanásia de subgrupos de três cães. A instabilidade articular e o grau de claudicação diminuíram significativamente durante o período de avaliação, apesar da instabilidade persistir durante a flexão articular. Observou-se decréscimo significativo do perímetro muscular da coxa aos 30 e 90 dias p.o. em ambos os grupos. Não foram evidenciadas alterações nos graus de extensão e flexão articulares, na rotação interna da tíbia, na amplitude de movimento articular ou de doença articular degenerativa (DAD) durante o período de avaliação em ambos os grupos. Conclui-se que a ITR, associada à técnica de estabilização articular, não produz alterações em nenhuma das variáveis estudadas em cães, quando comparada à estabilização intra-articular, isoladamente.

O centro instantâneo de movimento e vetor velocidade em joelhos submetidos a incisuroplastia troclear e estabilização articular após transecção do ligamento cruzado cranial em cães

Avaliou-se o centro instantâneo de movimento e vetor velocidade após a transecção do ligamento cruzado cranial (LCCr), seguida da substituição ligamentar por retalho de fáscia lata, associada ou não a incisuroplastia troclear (ITR) em nove cães adultos. O joelho direito (GI) foi submetido a ITR e posterior estabilização articular, e o joelho esquerdo submetido somente a substituição ligamentar (GC). Os animais foram avaliados nos períodos pré-operatório, pós-operatório imediato e aos 30, 90 e 180 de pós-operatório, correspondente ao momento de eutanásia de subgrupos de três animais. O centro instantâneo de movimento (CIM) e o vetor velocidade (Vv) resultante foram determinados por meio do deslocamento de pontos a partir da análise radiográfica dos joelhos. Todas as articulações apresentavam CIM e Vv normais antes da transecção do ligamento cruzado cranial. Após a estabilização articular, acompanhada ou não de ITR, observou-se o posicionamento normal do CIM e Vv resultante, em todos os períodos de avaliação, apesar da presença de movimento de gaveta em três animais de GC e dois de GI no pós-operatório imediato, em dois animais de cada grupo, aos 30 dias de avaliação, e em um animal em cada grupo nas avaliações subseqüentes. Conclui-se que a estabilização articular com retalho de fáscia lata, associada ou não a ITR, mantém a integridade biomecânica do joelho, quando considerados o CIM e o Vv.

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Introduction: Reconstruction of the elbow lateral collateral ligament complex (LCLC) for posterolateral rotatory instability remains a difficult procedure. We propose a novel technique to anatomically reconstruct the LCLC using a local transfer of split anconeus fascia (SAF). Materials and Methods: Ten paired, matched fresh frozen cadaver elbows were used. The LCLC was divided and subsequently reconstructed in 10 elbows while 10 were used as controls. A strip of anconeus fascia was detached from its origin and split down to its insertion on the ulna.

Modified Procedure for Secondary Facial Rehabilitation Following Total Bilateral Irreversible Peripheral Facial Palsy

We present the case of a middle-aged gentleman who developed total bilateral irreversible peripheral facial palsy over a period of 10 years, starting with palsy of the marginal mandibular and buccal branches of the facial nerve and progressing to the zygomatic and temporal branches. The patient did not develop any other neurological symptoms, and all neurological and other tests have remained negative over the last 10 years. Dripping of saliva and inability to close the mouth necessitated reanimation of the perioral region with the help of a fascia lata graft fixed to the fascia of the masseter muscles. The increasing lagophthalmos and associated eye problems were alleviated with a temporal muscle transposition combined with a lengthening procedure using the temporal fascia, passed through the upper and lower eyelids and hooked around the medial canthal ligament. The fascia strips were sutured not to the canthal ligament itself, but to each other, thereby placing equal self-adjusted tension on the upper and lower eyelids. Both operations were successful and improved eating and eye closure functions, allowing resolution of the eye symptoms.

Fascial patch technique for repair of complicated urethrovaginal fistula

Introduction The operative repair of urethrovaginal fistula due to tension-free vaginal tape (TVT) erosion is a challenging task, and coexisting stress urinary incontinence may complicate the situation even further. We present our technique for the repair of recurrent urethrovaginal fistula combined with stress urinary incontinence, occurring after previous removal of an eroded TVT and failed repair of the fistula. Technical Considerations With the patient in the dorsal lithotomy position, an inverted U-shaped incision was cut in the anterior vaginal wall, and a vaginal flap was developed. The Martius flap from the previous repair was identified and separated from the urethra, thereby disclosing a large fistula hole on the left side of the mid-urethra. Because the periurethral tissues were very friable and attenuated, only one-layer closure of the fistula hole with these tissues was feasible. Therefore, we opted to combine a pubovaginal fascial sling with a fascial patch graft, used to reinforce the fistula site. Through a low transverse abdominal incision, a 15 × 2-cm strip of rectus fascia was harvested. A 2 × 2-cm patch of fascia was excised from the strip and transfixed to the periurethral tissues, covering the sutured fistula site. The Martius flap was repositioned over the flap, and a pubovaginal sling procedure was done. The postoperative course was uneventful, the fistula has healed, and the patient regained full continence. Conclusions This technique can be used in complicated urethrovaginal fistula repair when the surrounding periurethral tissues have been devastated and can be combined with pubovaginal fascial sling placement.

Composite Anterolateral Thigh???Fascia Lata Flap: A Good Alternative to Radial Forearm???Palmaris Longus Flap for Total Lower Lip Reconstruction

Major defects of the lower lip are challenging to the reconstructive surgeon. The major goals in treating total lower lip defects are reconstruction of the external skin and mucosal lining and maintenance of oral competence and sphincter function. The authors describe reconstruction of total lower lip and larger full-thickness defects including the cheek and commissure by means of a composite anterolateral thigh-fascia lata free flap. The flap was harvested with 5-cm fascial extensions at the superior and inferior margins. The flap was folded over the fascia lata to restore the intraoral lining and cover the external skin defect. Fascia lata extensions were divided longitudinally into two fascial strips at both margins of the flap. Two strips were tunneled through the orbicularis muscle in the upper lip and sutured to each other and to the orbicularis muscle. The remaining two strips were anchored to the zygomatic bone periosteum by permanent sutures. This procedure was used in 11 patients. In all cases, disease was advanced squamosus cell carcinoma. The patients' ages ranged from 37 to 72 years. Nine patients had cancer of the lower lip and two patients had a buccal cancer involving the lip. The entire lower lip, bilateral modiolus, and part of the cheek were resected in all patients, and mandibulectomy was performed in three patients. Flap survival was 100 percent. One patient died 10 days after the operation because of cardiopulmonary arrest. At the end of the 1-year follow-up period, all patients had good oral continence at rest and had achieved sufficient oral competence when eating. Eight patients were able to resume a regular diet and two patients could eat a soft diet. This flap is a good choice for reconstruction of the extensive head and neck defects. We think that anterolateral thigh-fascia lata composite flap has maximum reconstructive capacity and minimal donor-site morbidity. This flap has many advantages over the radial forearm flap and should replace to the composite radial forearm palmaris longus tendon flap when total lower lip reconstruction is concerned.

Fascia is able to contract in a smooth muscle-like manner and thereby influence musculoskeletal mechanics

Summary With immunohistological analysis we demonstrate the presence of myofibroblasts in normal human fasciae, particularly the fascia lata, plantar fascia, and the lumbar fascia. Density was found to be highest in the lumbar fascia and seems to be positively related to physical activity. For in vitro contraction tests we suspended strips of lumbar fascia from rats in an organ bath and measured for responsiveness to potential contractile agonists. With the H1 antagonist mepyramine there were clear contractile responses; whereas the nitric oxide donator glyceryltrinitrate induced relaxation. The measured contraction forces are strong enough to impact upon musculoskeletal mechanics when assuming a similar contractility in vivo.

Repairation of defects of bones of foot and soft tissue by using composed tissue transfer

目的 研究解决足部创伤及疾病造成的足骨及软组织缺损的修复重建方法,减少和减轻足残疾和功能不良率,最大限度的恢复足功能和外型.方法对足背、前足、足跟、踝下等部位单纯软组织缺损,采用局部转移或旋转皮支皮瓣、筋膜皮瓣、游离皮瓣、全厚皮片植皮等方法修复;足底负重区采用预制皮瓣方法解决;前足、足跟及其它跗骨复合组织缺损采用带血管髂骨加皮瓣组织移植重建;内、外踝缺损应予以重建.结果 247例经上述方法处理,临床疗效满意.按美国AOFAS踝-足评分标准:优84例,良107例,可42例,差14例.结论髂骨为一扁平状骨,血运丰富,用于重建再造跖骨缺损尤其是多跖骨缺损、跟骨缺损时,接地稳定且触地面积大,便于负重、固定及承压.内、外踝可取带筋膜的髂骨和腓骨头重建骨及韧带缺损.组合带血管骨与皮瓣修复缺损,可将移植骨及皮瓣各自先充分对位满意后再行组合,较理想地恢复足的解剖和生理功能。

IN VIVO TENSION SUSTAINED BY FASCIAL SLING IN PUBOVAGINAL SLING SURGERY FOR FEMALE STRESS URINARY INCONTINENCE

In pubovaginal sling surgery arguments have focused on selecting stronger sling materials, better suturing methods and superior fixation techniques. However, the grounding information prerequisite for these arguments is still lacking, ie the in vivo tension sustained by the sling. We designed this study to obtain this information. A total of 10 female patients (mean age 65.4 years) underwent pubovaginal sling surgery while under epidural anesthesia. A strip of rectus fascia (2 x 6 cm) was isolated. Each end of the fascia was anchored with a 1-zero Prolene suture (Ethicon, Somerville, New Jersey). The fascial sling was placed over the proximal urethra. Both ends of the prolene (polypropylene) sutures were transferred to the lower abdominal incision and tied on each other. The fascial sling was adjusted just to touch the proximal urethra without elevating it. We hooked the tied polypropylene suture on a digital force gauge to measure the tension sustained by the fascial sling. Patients were instructed to cough, and the tension was measured at different bladder volumes (100, 200, 300, 400 ml) and in 2 positions (horizontal and operative table tilted head-up 20 degrees). Intravesical pressure was monitored with a pressure transducer to ensure adequate cough strength. We also investigated the in vitro length-tension relationship and tensile strength of 3 rectus fascia strips (0.5 x 6 cm) obtained from 3 of these patients. Mean tension +/- SEM sustained by the fascial sling during cough in the horizontal position was 0.046 +/- 0.004, 0.043 +/- 0.006, 0.0475 +/- 0.006 and 0.0485 +/- 0.007 kg at 100, 200, 300 and 400 ml bladder volume, respectively. Bladder volume did not statistically affect the sustained tension. The 20-degree head-up position also did not statistically change the tension sustained. In vitro study showed that the fascia strip could be stretched for a mean of 0.4 cm before sling tension began to increase. A mean load of 2.4 kg broke 0.5 x 6 cm strips. In the horizontal and mild tilting positions during an increase in intra-abdominal pressure, the fascial sling only sustains minor tension, which is far less than the maximal load needed to break fascial strips. The excellent elasticity of the fascia may dissipate the straining force and partly explains the measured small sustained tension.

A Minimally Invasive Technique for Harvesting Autologous Fascia Lata for Pubo-Vaginal Sling Suspension

To access donor site morbidity associated with harvesting of autologous fascia lata for pubo-vaginal sling suspension in treating stress urinary incontinence. A retrospective study was performed of 25 female patients who underwent pubo-vaginal sling suspension for stress urinary incontinence. Autologous fascia lata strip was harvested in all patients with a minimally invasive approach using a fascial stripper. Demographic, intraoperative, and immediate postoperative data were recorded to determine the incidence of complications. Follow-up data was reviewed for documentation of long-term complications. Adequate length of fascia lata was harvested in all of our patients. Ten patients required a single 2 cm incision just above lateral femoral epicondyle to harvest fascia lata. Twelve patients needed two incisions and remaining three required three incisions. There were no intraoperative complications. There was no incidence of wound related infection or hematoma in the immediate post-operative period. On follow-up no patient had bothersome problems pertaining to the site of graft harvesting. Harvesting fascia lata with fascial stripper is a minimally invasive which is easy to learn and provides an excellent fascial strip with minimal morbidity.

DOES RAPAMYCIN EFFECT WOUND HEALING?

A302 Aims: The use of rapamycin to prevent graft rejection in renal transplantation is well documented. However the inhibitory effect of rapamycin on fibroblasts has raised concerns about its effect on wound healing. Anecdotal reports have suggested an increased incidence of post transplant wound problems. In this study in pigs we investigated the effect of rapamycin on wound healing. Methods: Large White X Landrace pigs (n=12) weighing 22-30kg were subjected to a midline laparotomy. The sheath was closed with a continuous 0 Nylon suture and the skin with a continuous subcuticular 2/0 Nylon suture. The animals were randomized to receive either rapamycin 2mg orally daily or no treatment. The animals were sacrificed on the fifth postoperative day and the skin and fascia closure examined histologically (Haematoxylin-eosin and Chromotrop Aninline Blue [CAB]) and biochemically (hydroxyproline levels). The breaking strength of strips of skin and fascia were also measured. Results: One animal in the rapamycin treated group developed a full-thickness wound dehiscence on the 4th postoperative day and had to be sacrificed. The wounds of the remaining animals were intact at the time of sacrifice. The breaking strength of the fascia was lower in the rapamycin treated animals compared to the control animals (351±62g versus 444±54g). The breaking strength of the skin was the same in the two groups (239±34g versus 237±32g). The animals treated with rapamycin had lower hydroxyproline levels in both the fascia (28.7±11.8 versus 34.1±9.9 μg/ml) and the skin (12.3±3.7 versus 19.4±5.7 μg/ml) compared to control animals. On histological examination there were no differences in morphology or collagen staining between the two groups. Conclusions: These findings suggest that rapamycin impairs wound healing. Special attention should be given to wound closure and wound management in patients treated with rapamycin.

Changes in Tensile Strength of Cadaveric Human Fascia Lata After Implantation in a Rabbit Vagina Model

We determined changes in tensile properties after vaginal implantation of human cadaveric fascia lata. Baseline tensile properties were determined for freeze-dried, gamma irradiated human cadaveric fascia lata from 3 separate lots. Fascial strips (2 x 0.5 cm.) from 2 lots were implanted between the rectovaginal membrane and vaginal mucosa in New Zealand white rabbits. The strips were excised en bloc 12 weeks after implantation. Tensile property measurements were repeated and compared with pre-implantation values. Pre-implantation interlot and intralot variability in baseline tensile properties was significant. After implantation there was an approximate 90% decrease in tensile strength from baseline values. There was no gross evidence of graft autolysis. The decrease in tensile strength of cadaveric fascial graft was significant after implantation in this model.

Circumferential wrapping and clipping with temporalis fascia for treatment of unclippable intracranial aneurysms.

We utilized a clip-reinforced wrapping technique using temporalis fascia for treating unclippable aneurysms in 14 patients. Herein, we describe a modification of the clip- reinforced wrapping technique and report on the results. An appropriately sized strip of temporalis fascia is passed around the aneurysms with cuts made to accommodate perforating arteries. After applying fibrin glue, the aneurysm clip is positioned to secure the circumferential wrapping. Of the 14 patients, 4 (29%) were unclippable microbleb, 4 (29%) were wall defect, 3 (21%) were imperfect clipping due to the complexity of the aneurysm, 2 (14%) were bleb at the base of the aneurysm and 1 (7%) was a fusiform aneurysm. Multiple aneurysms were found in 6 (43%) patients and half (50%) of the 14 patients had MCA aneurysms. Postoperative angiography demonstrated no narrowing of parent arteries or enlargement of the aneurysms. No subsequent bleeding was observed during the 1 year follow-up period. These results suggest that circumferential wrapping-clipping with temporalis fascia and biological glue provides an alternative and safe method of treatment for unclippable intracranial aneurysms.

Reduction of diplopia following endoscopic orbital decompression: the orbital sling technique.

Although endoscopic orbital decompression has become the surgical treatment of choice for patients with proptosis from Graves disease, postoperative diplopia requiring corrective eye muscle surgery can occur in up to 63% of patients. The purpose of the study was to evaluate a new technique intended to reduce the incidence of diplopia following endoscopic orbital decompression. Case-control. Endoscopic orbital decompression was performed on 58 orbits in 37 patients with proptosis from Graves disease. The orbital sling technique, which makes use of a horizontal strip of periorbital fascia to prevent prolapse of the medial rectus muscle, was used on 20 orbits in 13 patients. Conventional endoscopic decompression was performed in 24 control subjects. The mean duration of follow-up was 3.3 +/- 1.3 years (range, 1.7-5.1 y). The incidence of new-onset or worsened diplopia following endoscopic decompression was significantly lower for the orbital sling group compared with control subjects (0% vs. 29.2%, respectively [ =.038]). No patients in the orbital sling group developed new-onset diplopia following surgery. Of the eight patients with pre-existing diplopia from the orbitopathy, double vision improved in four patients (50%) and was unchanged in the remaining four patients (50%). The mean reduction in proptosis was comparable for the orbital sling and control groups (5.1 +/- 1.1 mm vs. 5.0 +/- 1.9 mm, respectively [ P=.98]). CONCLUSIONS The preservation of a fascial sling overlying the medial rectus muscle during endoscopic orbital decompression appears to reduce the incidence of postoperative diplopia, while still allowing for a satisfactory reduction in proptosis. This modification of the standard decompression technique should be considered for the treatment of patients with proptosis.

Arthrolysis of the elbow and reconstruction of the collateral ligaments using a fascial strip of the triceps

Objective Anatomic reconstruction of the collateral ligament of the elbow. Restoration of stability and function of the elbow. Reduction of pain. Improvement of range of motion.