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PubMed2002

The utility of both muscle and fascia flaps in severe upper extremity trauma.

BACKGROUND: Severe isolated upper extremity injuries are rarely lethal; however, they invariably are resource intensive, create significant disability, and promote resistance to a return to gainful employment. Appropriate soft tissue restoration is an essential component of any treatment protocol, and often requires a vascularized flap to protect the superficial neurovascular and musculotendinous structures. A basic schema to facilitate flap selection in the upper extremity is introduced. METHODS: The role of local muscle and fascia flaps or free tissue transfers for severe upper extremity injuries was retrospectively reviewed from a two-decade experience. Excluding digital injuries, primary treatment of soft tissue traumatic wounds requiring some form of vascularized flap occurred in 33 limbs in 31 patients. The choice of flap donor site, type, specific complications and benefits as related to the severity of injury, and the effect of timing of wound closure were compared. RESULTS: Initial coverage after significant upper extremity trauma in these 33 limbs required 16 local fascia flaps, 22 free flaps, 1 multistaged distant pedicled flap, and 1 local muscle flap. Flaps were selected in a nonrandom fashion on the basis of wound location, severity of injury, and flap availability. Complication rates were similar for local fascia and free flaps. The upper extremity could be divided into three regions that were differentiated according to the observed incidence of flap preference. Free flaps were more commonly used for hand and wrist wounds, or anywhere the defect was moderately large in size or extremely severe in overall injury. Local fascia flaps were a simpler option most applicable for the central upper limb. Local muscles as flaps were intentionally avoided to minimize any functional derangement. CONCLUSION: A schema to guide flap selection for upper extremity coverage is introduced that is predicated on using the best available option. The shoulder girdle and axilla are reached by many local trunk muscle or fascia flaps. The central upper limb about the elbow often is conducive to coverage with specific local fascia flaps. The distal upper extremity may be best served by a free flap, as would any large wound in all upper limb regions.

Activities of Daily Living↗
PubMed2001

Histology of injected autologous fascia in the paralyzed canine vocal fold.

OBJECTIVE: To evaluate the histology of minced and injected autologous fascia graft in the augmentation of unilateral vocal fold paralysis. STUDY DESIGN: Prospective study using a canine model. METHODS: Nine dogs were operated. At first, a piece of fascia was harvested from fascia lata and minced into tiny chips with a scalpel. Cutting off a section of the recurrent nerve paralyzed the right vocal fold. The minced fascia-paste (0.1 mL) was injected using a pressure syringe into the paralyzed thyroarytenoid muscle under direct laryngoscopy. Two animals were killed at 3 days, one at 10 days, three at 6 months, and three at 12 months postinjection. Each dog underwent laryngectomy and serial coronal sections of paraffin blocks from the posterior part of the vocal folds were made. RESULTS: The dogs experienced no complications perioperatively or during follow-up. Under microscopy, muscle of the paralyzed vocal fold was atrophied in comparison to the contralateral control. There was an acute inflammatory reaction induced by the graft. This did not exist in the specimens taken at 6 and 12 months. No extensive edema, areas of necrosis, or formation of granulomas was seen at any time. Maturation of the graft was characterized by active collagen remodeling up to 12 months. At that time the graft consisted of firm, condensed fibrous tissue. Scar formation around the graft was moderate, and the subepithelial layer of the vocal fold remained undisturbed. Each graft consisted of singular foreign bodies from the polyamide mincing plate. We cannot exclude that their presence would have had an impact on the final architecture of the graft. CONCLUSION: In a canine vocal fold, the free fascia graft is well tolerated and after 12 months a well-organized, collagen rich tissue is seen on histological sections. The findings are in accordance with clinical studies applying free fascia grafts.

Animals↗
PubMed2002

Use of homograft dehydrated temporal fascia in tympanoplasty.

OBJECTIVE: To investigate the results of myringoplasty operations using homograft dehydrated fascia temporalis (Tutoplast) and compare these with those performed with autograft fascia temporalis. STUDY DESIGN: Prospective cohort. SETTING: University hospital. PATIENTS: Forty-three adult patients (> or =18 years of age) with central, dry perforations of pars tensa with intact ossicular chains. INTERVENTION: Tympanoplasty with an endaural approach and underlay technique was performed. Homograft dehydrated temporal fascia was used in 22 patients, and autograft was used in the remaining 21 patients. MAIN OUTCOME MEASURES: Preoperative and postoperative air-bone gap and speech reception threshold levels and postoperative compliance values of the homograft and autograft groups were compared. RESULTS: Postoperative perforations were encountered in two patients (9.1%) from the homograft group and three patients (14.2%) from the allograft group. Significant postoperative improvements in air-bone gap and speech reception threshold values were detected for both groups (p < 0.05). Although the mean compliance of the tympanic membranes was significantly lower in the homograft group, no statistically significant difference was observed between groups when the postoperative air-bone gap and speech reception threshold values were compared. CONCLUSION: Homograft temporal fascia can be used in tympanoplasty with the same success rate of autograft temporal fascia without impeding hearing. Its main advantages are the reduction in the duration of surgery and the length of preauricular and postauricular incisions. However, the advantages of the dehydrated homograft temporal fascia should be weighed against its cost and risk of transmission of viral and prion-mediated diseases.

Adult↗
PubMed2004

A comparison of cartilage palisades and fascia in tympanoplasty after surgery for sinus or tensa retraction cholesteatoma in children.

OBJECTIVE: To compare cartilage palisades with fascia grafting in reconstruction of the eardrum after surgery for sinus or tensa retraction cholesteatoma in children, with respect to postoperative drum retraction and perforation, cholesteatoma recurrence, and hearing. MATERIAL: From March 1995 to October 2000, a total of 64 children, aged 5 to 15 years, underwent surgery for either sinus or tensa retraction cholesteatoma. The eardrum was reconstructed using cartilage palisades in 32 children and fascia or perichondrium in 32 children. Postoperatively, the patients were seen as out-patients and were recently reevaluated by otomicroscopy and audiometry. MAIN OUTCOME MEASURES: Postoperative drum retraction and perforation, cholesteatoma recurrence, and hearing (pure tone average, speech reception threshold, and air-bone gap). RESULTS: All patients in the palisade group and all but one patient in the fascia group attended the follow-up examination. In the palisade group, the mean follow-up period was 37 months (range, 3-65 mo) and in the fascia group 52 months (range, 17-75 mo). Two (6%) retractions and no perforations were found in the palisade group, versus 12 (36%) retractions and 4 perforations (12%) in the fascia group at follow-up (both significant differences). No cholesteatoma recurrence occurred. Late hearing results in sinus cholesteatomas were significantly better in the palisade group. CONCLUSIONS: The comparison of fascia and cartilage palisade grafting for drum reconstruction after tensa cholesteatoma surgery in children indicates that the palisade technique may be superior in respect to prevention of drum retraction and perforation. Further, in sinus cholesteatoma surgery, the long-term hearing results are better when grafting cartilage palisades.

Adolescent↗
PubMed2005

A randomized controlled trial comparing fascia lata and synthetic mesh for sacral colpopexy.

OBJECTIVE: To compare the objective anatomic outcomes after sacral colpopexy performed with cadaveric fascia lata and polypropylene mesh. METHODS: Patients undergoing a sacral colpopexy were randomized to receive either fascia lata or polypropylene mesh in a double-blinded fashion. Data were collected at 6 weeks, 3 months, 6 months, and 1 year postoperatively. The main outcome measures were pelvic organ prolapse quantification (POP-Q) system stage and individual POP-Q points over time. Objective anatomic failure was defined as POP-Q stage 2 or more at any point during the follow-up period. Proportions of patients with objective anatomic failure at 1 year in each group were compared using the chi(2) test. Mean POP-Q points and stage at 1 year were compared by using the independent samples t test. RESULTS: One hundred patients were randomized to receive either fascia (n = 46) or mesh (n = 54). Of the 89 patients returning for 1-year follow-up, 91% (41/45) of the mesh group and 68% (30/44) of the fascia group were classified as objectively cured (P = .007). We found significant differences between the mesh and fascia groups with respect to the 1-year postoperative comparisons of points Aa, C, and POP-Q stage. There were no differences between the 2 groups with respect to points TVL (total vaginal length), GH (genital hiatus), PB (perineal body), Ap or Bp (2 points along the posterior vaginal wall). CONCLUSIONS: Polypropylene mesh was superior to fascia lata in terms of POP-Q points, POP-Q stage, and objective anatomic failure rates. LEVEL OF EVIDENCE: I.

Adult↗
PubMed2004

Abdominal sacral colpopexy using autologous fascia lata.

PURPOSE: Numerous techniques and materials have traditionally been used to correct vaginal vault prolapse, including cadaveric fascia, synthetic materials and autologous rectus fascia. We report our experience with autologous fascia lata used for abdominal sacral colpopexy. MATERIALS AND METHODS: A retrospective review identified all women who underwent abdominal sacral colpopexy using autologous fascia lata for vaginal vault prolapse with at least 18 months of followup. Preoperative and postoperative pelvic organ prolapse quantification (POP-Q) scores, relevant clinical and operative parameters, treatment efficacy, harvest site morbidity and patient satisfaction were assessed. RESULTS: Ten women underwent this procedure between 1999 and 2001. Mean patient age was 68.3 years (range 55 to 82). Followup was 19 to 42 months (mean +/- SD 30.5 +/- 7.78). Preoperatively POP-Q stages were II to IV in 3, 5 and 2 cases, respectively. Postoperative POP-Q scores improved to and remained at stage II or lower in all 10 patients. Mean operative time was 182 +/- 40.94 minutes (range 136 to 265). Mean blood loss was 107.5 +/- 50.07 cc (range 50 to 200). There was no morbidity associated with fascia lata harvest. Eight of the 9 women alive at review completed and returned the survey. When asked if they could return to how they were before surgery, would they still have the same procedure done and would they recommend the procedure to a friend, all respondents answered yes to each question. CONCLUSIONS: Autologous fascia lata compares favorably in efficacy to that reported for other materials in the contemporary literature and it is not associated with any significant morbidity.

Aged↗
PubMed1994

Plantar fascia rupture associated with corticosteroid injection.

A series of 37 patients, all with a presumptive diagnosis of plantar fascia rupture, is presented. All had had prior heel pain diagnosed as plantar fasciitis, and all had been treated with corticosteroid injection into the calcaneal origin of the fascia. One third described a sudden tearing episode in the heel, while the rest had a gradual change in symptoms. Most of the patients had relief of the original heel pain, which had been replaced by a variety of new foot problems, including dorsal and lateral midfoot pain, swelling, foot weakness, metatarsal pain, and metatarsal fracture. In all 37 patients, there was a palpable diminution in the tension of the plantar fascia on the involved side, and footprints often showed a flattening of the involved arch. Magnetic resonance imaging done on one patient showed attenuation of the plantar fascia. From these observations and data, the author concluded that plantar fascia rupture had occurred. Treatment following rupture included supportive shoes, orthoses, and time. The majority had resolution of their new symptoms, but this often took 6 to 12 months to occur. In the remainder, there were persisting symptoms. Corticosteroid injections, although helpful in the treatment of plantar fasciitis, appear to predispose to plantar fascia rupture.

Adrenal Cortex Hormones↗
PubMed1998

Effect of varying arch height with and without the plantar fascia on the mechanical properties of the foot.

A biomechanical model was used to calculate the mechanical properties of the foot at a load of 683 newtons, while changing arch height with and without the plantar fascia. An increase in arch height from 20 mm to 60 mm decreased predicted vertical displacement of the foot from 11.8 mm to 5.5 mm with the plantar fascia intact and from 13.5 mm to 7.5 mm without the plantar fascia. The amount of horizontal elongation decreased from 8.6 mm to 8.4 mm with the plantar fascia and increased from 9.8 mm to 11.7 mm without. A 60-mm arch height yielded a 40% increase in horizontal elongation and a 36% increase in vertical displacement when the plantar fascia was cut, whereas a 20-mm arch height yielded a 13% increase in horizontal elongation and a 14% increase in vertical displacement. A change in arch height from 20 mm to 60 mm increased stiffness of the foot with and without the plantar fascia.

Biomechanical Phenomena↗
PubMed2003

Quantitative analysis of collagen and elastic fibers in the transversalis fascia in direct and indirect inguinal hernia.

PURPOSE: Our previous studies demonstrated structural and quantitative age-related changes of the elastic fibers in transversalis fascia, which may play a role in inguinal hernia formation. To verify whether there were differences in the extracellular matrix between direct and indirect inguinal hernia, we studied the amount of collagen and elastic fibers in the transversalis fascia of 36 male patients with indirect inguinal hernia and 21 with direct inguinal hernia. MATERIAL AND METHODS: Transversalis fascia fragments were obtained during surgical intervention and underwent histological quantitative analysis of collagen by colorimetry and analysis of elastic fibers by histomorphometry. RESULTS: We demonstrated significantly lower amounts of collagen and higher amounts of elastic fibers in transversalis fascia from patients with direct inguinal hernia compared to indirect inguinal hernia patients. The transversalis fascia from direct inguinal hernia patients showed structural changes of the mature and elaunin elastic fibers, which are responsible for elasticity, and lower density of oxytalan elastic fibers, which are responsible for resistance. These changes promoted loss of resiliency of the transversalis fascia. CONCLUSION: These results improve our understanding of the participation of the extracellular matrix in the genesis of direct inguinal hernia, suggesting a relationship with genetic defects of the elastic fiber and collagen synthesis.

Adult↗
PubMed1996

The anatomy of lamina pretrachealis fasciae cervicalis.

The definitions concerning the fascia pretrachealis is either contradictory or insufficient in anatomy textbooks. The fascia pretracheatis is clinically important in the procedure of tracheostomy, mediastinascopy and also in tracheal and bronchial trauma. The anatomy of the fascia pretrachealis (extension, relation and the attachments) was reexamined using cadaveric preparations and the clinical value of the fascia is reinforced. The fascia pretrachealis is attached to the upper brim and to the oblique line of the thyroid cartilage and continued its course on the anterior surface of the trachea and fused with the advantitia of arch of the aorta, posterior aspect of pulmonary artery and the pericardium. Laterally it is attached to the cartilagenous part of the trachea. Also contraversial literature concerning description of the fascia pretrachealis has been evaluated.

Aged↗
PubMed2002

Ultrasonographic evaluation of plantar fascia bands. A retrospective study of 211 symptomatic feet.

The authors measured the thickness of the medial, central, and lateral bands of the plantar fascia using ultrasonographic techniques in 109 symptomatic patients with 211 painful heels. Plantar fasciitis was diagnosed by the presence of plantar heel pain and tenderness of the plantar fascia on palpation and was correlated with plantar fascia thickness. All of the symptomatic feet had medial band tenderness, with an average thickness of 5.9 mm, 68% had central band tenderness, with an average thickness of 5.3 mm, and 26% had lateral band tenderness, with an average thickness of 4.4 mm. The average thickness of all symptomatic bands was 5.35 mm, which was significantly greater than that for all asymptomatic bands, which was 2.70 mm. There were also significant differences in the thickness of the three plantar fascia bands in symptomatic patients. A plantar fascia index was established consisting of the ratio of the mean thickness of symptomatic medial, central, and lateral plantar fascia bands to that of asymptomatic bands; for this study, the index value is 1.98 (5.35/2.70 mm).

Adolescent↗
PubMed1999

Anatomical study of the temporal fasciae and fat pads.

BACKGROUND AND AIM: Although a great number of studies have been published on the anatomy of the various fascial layers in the temporal region and the interposed fat pads, there is still uncertainty regarding the organization of the temporal fasciae, above all at the level of the zygomatic arch, and the relationships between the latter and the frontal branch of the facial nerve. This study aimed to describe the anatomy of the temporal fasciae and their relationships both with the interposed fat pads and with the frontal branch of the facial nerve. METHODS: The study was carried out in 10 heads from fresh cadavers which were used to dissect the different tissue layers at the level of the temporo-zygomatic arch. RESULTS: The results of the dissections made in this study confirm the existence of three over-lying fascial layers (superficial temporal fascia, intermediate temporal fascia and deep temporal fascia), interposed by the same number of fat pads (superficial, intermediate and deep). The frontal branch runs below the superficial fat pad in close contact with the periosteum of the zygomatic arch. CONCLUSIONS: The authors suggest adopting a single nomenclature to describe the fasciae and the fat pads in the temporal region.

Adipose Tissue↗
PubMed2000

[Innervation of Denonvilliers' recto-vesical fascia. Anatomical study].

OBJECTIVE: Dissection of Denonvilliers' rectovesical fascia allows easy cleavage of the prostatorectal and prostatovesical spaces. Its lateral limit in the "neurovascular pedicles" justifies its resection during radical prostatectomy. The objective of this study was to define the course and to observe the structure of nerves crossing the rectovesical fascia, as the sheaths of these nerves may be invaded by prostatic adenocarcinoma tumour cells. MATERIAL AND METHODS: After dissection of a fresh cadavre to define the relations of this fascia with the pedicles, rectovesical fascia biopsies were taken during radical prostatectomies. Transverse sections were performed and examined histologically. RESULTS: Certain nerves, derived from the neurovascular pedicle of the inferior hypogastric plexus, cross the rectovesical fascia to innervate the prostate. CONCLUSION: This confirms the importance of complete resection of the rectovesical fascia during radical prostatectomy for cancer, not only for surgical reasons, but also to ensure oncologically satisfactory surgery, i.e. with healthy resection margins.

Aged↗
PubMed2001

Pubovaginal sling using cadaveric fascia and bone anchors: disappointing early results.

PURPOSE: Pubovaginal sling procedures offer highly effective treatment for patients with female stress urinary incontinence. A recent modification of this technique is the use of cadaveric fascia lata as a sling material supported with titanium anchors placed bilaterally in the pubic bone. We reviewed our experience with this procedure and assessed our outcome. MATERIALS AND METHODS: A total of 154 consecutive patients underwent a bone anchored, cadaveric fascia pubovaginal sling procedure by a single surgeon from July 1998 to June 1999. All patients were evaluated preoperatively with a detailed history, pelvic examination and radiographic or multichannel video urodynamic studies to diagnose stress urinary incontinence. Our technique begins with the nonincision placement of titanium bone anchors transvaginally into the pubic bone bilaterally. A 2 cm. wide tunnel is created bluntly beneath the vaginal epithelium between the 2 puncture sites with a right angle clamp. A 2 x 7 cm. strip of cadaveric fascia is then passed through the tunnel, into the retropubic space and secured to 2-0 polypropylene sutures attached to the anchors. After securing the sling, the transvaginal puncture sites are closed with 2-0 polyglactin sutures. Patients were seen postoperatively at 6 weeks, and 3 and 6-month followup. Patient age averaged 60 years (range 38 to 85), with an overall average length of followup from surgery of 10.6 months (range 6 to 16). All patients were mailed a self-administered questionnaire and participated in a telephone interview with an office nurse to retrospectively assess outcome and evaluate for recurrent stress urinary incontinence. Recurrent stress urinary incontinence was graded as 0-none, 1-rare, 2-moderate and 3-severe. Repeat pubovaginal sling procedure that was performed in patients with grades 2 to 3 stress urinary incontinence was considered a failure for the purpose of our study. RESULTS: Of all 154 patients 58 (37.6%) had recurrent moderate to severe (grades 2 to 3) stress urinary incontinence at followup. A total of 26 patients underwent a second pubovaginal sling procedure for a reoperation rate of 16.9%. Intraoperative findings at reoperation revealed the titanium anchors to be in position, the polypropylene sutures to be intact, and retropubic fibrosis and scarring of the urethropelvic ligament suggesting appropriate retropubic placement of the sling in all cases. Uniformly all allogenic cadaveric fascia used for sling material appeared to be fragmented, attenuated or simply absent. Average time to reoperation was 9 months (range 3 to 15). CONCLUSIONS: Early results using a bone anchored cadaveric fascia pubovaginal sling procedure were discouraging. Based on findings at reoperation, we attribute this result to the failure of our sling material and have abandoned the use of cadaveric fascia allografts in all pubovaginal slings at our institution.

Adult↗
PubMed2001

Current status of fascia lata allograft slings treating urinary incontinence: effective or ephemeral?

PURPOSE: The aim of this article is to review the current state and technique of pubovaginal sling construction using cadaveric allograft fascia lata. MATERIALS AND METHODS: A MEDLINE search was conducted to identify articles in the current literature addressing applications of cadaveric allograft fascia lata for surgical reconstructive procedures. RESULTS: Current series evaluating cadaveric fascia lata allografts for pubovaginal sling find equivalent short-term outcomes when compared to autograft fascia. Long-term follow-up is not yet available for these series. Variability in tissue processing or host factors may account for some failures with cadaveric fascial slings. CONCLUSIONS: Cadaveric fascia lata allografts are associated with reasonable efficacy and safety. Longer follow-up is needed. Further study of the relationship between tissue processing methods, surgical techniques, host factors, and outcome is indicated to better assess the long-term role of cadaveric fascia lata allograft for pubovaginal sling.

Fascia Lata↗
PubMed2001

Genetic material is present in cadaveric dermis and cadaveric fascia lata.

PURPOSE: We determined whether genetic material is present in the commercially processed cadaveric allografts used in sling surgery. MATERIALS AND METHODS: We evaluated 16 samples from 2 commercial sources of human allograft, including 8 each of freeze-dried gamma irradiated cadaveric fascia lata and acellular cadaveric dermis. Fresh human rectus fascia and sterile saline served as positive and negative controls, respectively. All samples underwent a standard proteinase K/sodium dodecyl sulfate/phenol extraction technique to isolate DNA. Polymerase chain reaction was done to amplify the retrieved DNA material, spectrophotometry to quantify DNA concentration and agarose gel electrophoresis to determine the size of DNA fragments. RESULTS: Of the 16 samples tested from 2 commercial sources of human allograft fascia 14 (87.5%) contained DNA. Mean DNA concentration plus or minus standard error was 258.3 +/- 80.1 and 272.8 +/- 168.8 microg./gm. tissue for cadaveric fascia lata and cadaveric dermis, respectively. Polymerase chain reaction amplified DNA segments of 2,000 bp from 1 of each of the 8 samples of cadaveric fascia lata and cadaveric dermis. CONCLUSIONS: Freeze-dried gamma irradiated cadaveric fascia lata and acellular cadaveric dermis contained intact DNA.

Bioprosthesis↗
PubMed2002

Heel spur formation and the subcalcaneal enthesis of the plantar fascia.

OBJECTIVE: To describe the structure and significance of subcalcaneal heel spurs associated with the plantar fascia. METHODS: The enthesis of the plantar fascia was removed from 17 elderly cadavers by sagittal saw cuts either side of the medial tuberosity, radiographs were taken, and the tissue was processed for routine histology. Sagittal sections were stained with toluidine blue, Masson's trichrome, or alcian blue, and sections were matched with the corresponding radiographs. RESULTS: Spurs develop on the deep surface of the plantar fascia but their formation is heralded by degenerative changes that occur within it. According to differences between small and large spurs, we propose that there are 3 stages in their development: (1) an initial formation of cartilage cell clusters and fissures at the plantar fascia enthesis; (2) thickening of the subchondral bone plate at the enthesis as small spurs form; (3) development of vertically oriented trabeculae buttressing the proximal end of larger spurs. The spurs grow by a combination of intramembranous and chondroidal ossification. CONCLUSION: Contrary to popular belief, subcalcaneal heel spurs cannot be traction spurs as they do not develop within the plantar fascia itself. They are thus fundamentally different from heel spurs in the Achilles tendon. We suggest instead that they develop as a consequence of degenerative changes that occur in the plantar fascia enthesis.

Aged↗
PubMed1992

[The anatomical assessment of the renal fascia in the normal subject by using computed tomographic equipment with advanced technology].

One hundred patients, affected with diseases not involving the peri-renal and pararenal spaces, have been examined in order to evaluate the visibility of the renal fasciae, using a CT scanner provided with high spatial and contrast resolution. The anterior renal fascia has been recognized in 71% of cases on the right side and in 88% on the left. The posterior renal fascia had 96% of positive bilateral detectability. The latero-conal fascia was detected in 83% of cases on the right and in 91% on the left. The inter-renal fascia was recognized in 25% of cases, at the pancreas or, more frequently, on caudal planes. The peri-renal septa were seen in 58% of cases, mainly on the left side. Compared to previous data reported by other authors, the visibility of the renal fasciae has been increased by the greater spatial and contrast resolution offered by the new CT scanner, thus allowing better anatomical evaluation of peri and para-renal spaces.

Adult↗