Functional failure of fascia lata allografts

Objectives: Fascia lata allografts are commonly used in urogynecologic procedures. Functional failure of several grafts has occurred, and such failure has been recognized as a materials problem in 12 patients. Study Design: Twelve patients with failure of an initial urogynecologic procedure performed with irradiated and freeze-dried donor fascia lata grafts underwent reoperation. Portions of the implanted fascia lata grafts could be retrieved in 7 cases. Graft specimens underwent histologic processing followed by hematoxylin and eosin staining. Results: Histopathologic analyses of the retrieved material demonstrated several ongoing processes in the failed grafts. A few grafts showed areas of ideal remodeling. Most grafts, however, showed areas of disorganized remodeling and areas of graft degeneration. Evidence of immune reaction to the graft was observed in some cases. Conclusion: The high materials failure rate associated with the use of irradiated and freeze-dried donor fascia lata grafts suggests that such tissue should not be used for urogynecologic procedures. (Am J Obstet Gynecol 1999;181:1339-46.)     

In Vivo Study to Assess the Viability and Mass Effect of Fascia Injection in Comparison with Block Fascia Graft

Recently, fat injection has gained favor among plastic surgeons for soft tissue augmentation. However, fat injections lose 50% of their volume after 1 year. The profession is in need of an injectable bulking material that gives a long-lasting improvement. Using 30 male rats, this study investigated the stability of the size and structure of the injected fascia autograft and compared it with surgically transplanted fascia. The fascia graft was harvested from the back of the rat, big, and divided into two equal pieces. The first piece was minced into a paste and injected subcutaneously on the anterior surface of the right ear. The other piece was transplanted subcutaneously on the anterior surface of the left ear. The grafts were observed for any sign of resorption over 1 to 6 months.Grossly, injection and transplantation sites were palpable at the end of the observation periods. Microscopic examination showed that injected fascia maintains its histomorphologic structure.These findings indicate that the injected fascia graft is well tolerated, and the size of the graft remained stable. According to this study, fascia injection can result in bulking material that gives a long-lasting improvement, and can be a viable alternative to other methods.     

Inguinal hernia: Measurement of the biomechanics of the lower abdominal wall and the inguinal canal

Background. The stability of the lower abdominal wall may play a considerable role in the development of inguinal hernia. Therefore, the strength of the individual wall layers needs to be quantified. Despite numerous advances in hernia repair, comparatively few systematic biomechanic and morphometric analyses have been performed. Our aim was to establish and apply a standardised procedure for testing the abdominal wall layers stability. Methods. After dissecting the abdominal walls of 16 cadavers into separate layers, we used a spherical punch and a force transducer to investigate the forces necessary to foraminate the layer. In addition, maximum tensile-strength and suction tests and histologic morphometry were performed. Results. The transversalis fascia was torn up on an average of 10.5 N, the peritoneum including pre- and subperitoneal tissue on 46.6 N, the aponeurosis of obliquus internus abdominis muscle on 51.7 N, and the aponeurosis of obliquus externus abdominis muscle on 92.6 N. Tensile tests of tissue strips obtained from defined areas showed comparable results. In contrast, surgical mesh revealed values between 60 and 150 N in punching tests. Left-right comparisons, as well as comparisons of the individual areas, revealed considerable intra- and inter-individual differences. Conclusions. Biological hernia repair should focus on a reinforcement of the tissue layers with the highest biomechanic stability. Reinforcement of the transversal fascia must be questioned according to our results of poor mechanical resistance.     

Videostroboscopic assessment of unilateral vocal fold paralysis after augmentation with autologous fascia

Vocal fold augmentation by injection laryngoplasty is a simple and fast procedure. The aim of this prospective study was to assess the glottal closure and the travelling mucosal wave by videostroboscopic images after autologous fascia augmentation in unilateral vocal fold paralysis (UVFP) with a special reference to objective analysis of voice. A total of 14 UVFP patients with poor voice and open glottal gap were assessed by videostroboscopy, blinded perceptual evaluation of running speech and acoustical analysis of sustained vowel. Data were collected before the procedure and at a supplementary evaluation 5–32 months (mean: 13 months) after injection of autologous fascia deep into the paralysed vocal fold. Mean age was 59 years; there were eight women and six men. Frame-by-frame video analysis revealed that before the operation 10 out of 12 had large glottal gaps without any contact between vocal folds on phonation. After the procedure seven gaps were completely closed, four partly, and two had no mucosal contact in stroboscopic examination. Maximum gap between vocal folds decreased from 7.21 units to 1.65 units (paired t-test P<0.001). Mucosal wave amplitude symmetry and phase synchrony were present in most subjects with partial closure and phase synchrony in every patient with a proper glottic closure. A panel of listeners rated voice to be significantly better (P<0.01) ) after the procedure, and the improvement in acoustical parameters was also statistically significant (P<0.01). There was a good correlation between objective voice analysis and videostroboscopy. Residual glottal gap was the major reason for less than optimal postoperative voice. No signs of hampered mucosal wave were noticed. Videostroboscopy and objective voice analysis suggest that augmentation by autologous fascia does not induce scar or fibrous tissue in the subepithelial space. Slight over-correction should be attempted initially in order to accomplish sufficient augmentation. This might enhance complete glottic closure and improve the outcome.     

A modified temporalis transfer in facial reanimation

A modified surgical procedure for temporalis transfer in facial reanimation of five consecutive cases is presented. Instead of the traditional stripping of the temporalis from its origin, its attachment at the coronoid removed, and to its end, the harvested fascia lata graft was sutured to lengthen the muscle's action. These fibres were then passed to the Orbicularis Oculi and Oris to aid in reanimation and to improve their tone. The procedure is less extensive, provides a direct line of pull with good functional results, no muscle atropy since vascularity and innervation is maintained. No complaints of paresthesia, hyposthesia or scar on donor leg was noticed. None of the patients required a revision of surgery for unacceptable contour or asymmetry. This simple procedure has helped reconstruction of natural symmetrical smile with highly successful results.     

Comparison of PTFE,pericardium bovine and fascia lata for repair of incisional hernia in rat model,experimental study

Incisional hernia is a frequent complication of abdominal surgery developing in 11–20 % of patients undergoing an abdominal operation. Regarding morbidity and loss of manpower, incisional hernias continue to be a fundamental problem for surgeons. In this experimental study, three commonly used mesh materials (Goretex PTFE; Tutoplast Fascia lata; Tutopatch Pericardium bovine) were compared according to effectiveness, strength, adhesion formation, histological changes, and early complications. Three groups, each consisting of 14 rats, have been formed as group A: polytetrafluoroethylene (PTFE), group B: pericardium bovine and group C: fascia lata. Evaluations were achieved at the end of the first and second postoperative week, respectively. Adhesion formation, wound maturation, bursting pressure, and tensile strength were evaluated. No statistically significant difference regarding adhesion formation was observed between groups although adhesion formation was less significant in PTFE and pericardium bovine groups than in the fascia lata group. Bursting pressure and tensile strength values were significantly higher in PTFE group than in the fascia lata group (P <0.05). No statistically significant difference was observed between groups regarding wound maturation. In this experimental model, PTFE and pericardium bovine were found to be superior to fascia lata in abdominal wall repair. Electronic Publication     

Fascia augmentation of the vocal fold: graft yield in the canine and preliminary clinical experience

INTRODUCTION: Glottal insufficiency resulting from vocal fold bowing, hypomobility, or scar is frequently treated by injection augmentation. Injection augmentation with fat, collagen, gel foam, polytef, and recently, fascia lata has been previously reported. Variable graft yield and poor host-tissue tolerance have motivated the continued search for an ideal graft substance. STUDY DESIGN: A prospective trial of autologous fascia augmentation of the vocal cord in the human and in an animal model. METHODS: Autologous fascia injection augmentation (AFIA) was evaluated in 8 canines and 40 patients at our institution between 1998 and 2000. The animal study compared graft yield from AFIA with autologous fat yield. The outcome measure was graft yield calculated from histological examination of larynges 12 weeks after injection augmentation. Clinical trial outcome measures included symptom surveys, acoustical voice analyses, and subjective voice assessments. Mean follow-up was 9 months. RESULTS: In the canine larynx, the mean graft yield for AFIA was 33% (range, 5%-84%) compared with autologous lipoinjection (47%; range, 7%-96%; P =.57). Subjective improvement in vocal quality was reported by 95% of patients (38 of 40) after AFIA. Preoperative and postoperative voice analysis data were obtained from 26 patients. Subjective voice rating demonstrated a significant improvement after AFIA (P <.0001). Acoustical parameters of jitter, shimmer, noise-to-harmonic ratio, phonatory range, and degree unvoiced improved significantly (P <.05) in all patients after fascia augmentation. CONCLUSIONS: Based on the animal study, we concluded that graft yields are excellent but variable for AFIA. The result is similar in variability and overall yield to autologous lipoinjection. Subjective and objective analyses of voice outcomes after AFIA are universally improved. Fascia appears to be an excellent alternative to lipoinjection in properly selected cases of glottic insufficiency.     

Medialization of paralyzed vocal fold does not increase respiratory resistance measured by impulse oscillometry

Injection laryngoplasty restores voice in subjects with unilateral vocal fold paralysis, but knowledge of its effects on airflow dynamics is limited. Impulse oscillometry (IOS) is a non-invasive technique to investigate airway resistance. It is easily performed during normal breathing. A prospective study was conducted in order to investigate the effects of autologous fascia injection on airflow dynamics. IOS, flow-volume spirometry, acoustic analysis of voice, voice handicap index (VHI) questionnaire and subjective dyspnoea score were recorded before and 5–11 months after the operation. There was no significant change in respiratory resistance (Rres) or other variables of IOS. FEV1/FVC decreased from 0.80 to 0.77 (P = 0.02), but other variables of spirometry did not change significantly. Acoustic properties of voice (noise-to-harmonics ratio, shimmer, jitter, maximal phonation time) and VHI improved significantly. No change in dyspnoea occurred. In conclusion, medializing of a paralysed vocal fold improves voice, but does not have a clinically significant adverse effect on breathing. Flow-volume spirometry is more sensitive than IOS to changes in airflow dynamics after medialization.     

筋膜减张法在妇科腹腔镜手术第一穿刺中的应用

目的为避免妇科腹腔镜手术第一穿刺可能出现的严重并发症腹膜后血管损伤,找到最安全、省力的穿刺方法。方法观察组252例,以筋膜减张法进行的闭合性穿刺,对照组130例按常规闭合性穿刺。筋膜减张法穿刺是在常规闭合性穿刺气腹针形成人工气腹后,用尖刀切开部分筋膜,再穿入穿刺套管。通过分析两组病例穿刺的安全性和易操作性,探索筋膜减张法穿刺的实用价值。结果临床观察组比对照组穿刺更省力,一次成功率高,穿刺深度可控性强。结论在妇科腹腔镜手术中第一穿刺采用筋膜减张法进行闭合性穿刺省力、省时,一次穿刺成功率高,安全可控制性强。更加适用妇科女医生的操作,有推广价值。     

Enhanced host perforant path innervation of neonatal dentate tissue after grafting to axon sparing,ibotenic acid lesions in adult rats

Summary This study examines to which extent developing dentate granule cells grafted into excitotoxic lesions of the adult rat fascia dentata can be appropriately innervated by the host brain. The lesions were induced by focal injections of ibotenic acid (IA) and resulted in localized dentate and hippocampal neuronal cell death, but sparing of the afferent connections, now deprived of their targets. One week later pieces of fascia dentata from new-born rats were grafted into the lesions. After 6 weeks to 9 months the recipient brains were processed and analyzed by cell stain, histochemistry, immunohistochemistry, anterograde nerve fiber degeneration methods, and electron microscopy. Dentate grafts survived well in the lesion area and became organo-typically organized. They contained the normal nerve cell types of the fascia dentata and hilus (CA4), including the peptidergic somatostatin-, cholecystokinin- and enkephalin-reactive ones. The grafts were innervated by AChE-positive, cholinergic fibers from the host septum, and perforant path fibers from the host entorhinal area. The presence of the latter were demonstrated by Timm staining and light and electron microscopy of anterograde axonal degeneration. When the extent and density of the host perforant path innervation was examined and mapped at the electron microscopical level the grafts in the IA-lesions were found to receive a more extensive and denser host innervation than grafts placed in the normal fascia dentata of adult rats without a preceding axon-sparing ibotenic acid lesion. In this way the results demonstrate that certain lesion types can enhance the innervation of intracerebral grafts by already mature neural pathways of the point-to-point type.