Comparative analysis of transnasal endoscopic reconstruction techniques for managing cerebrospinal fluid rhinorrhea in skull base defects.

The nasal skull base is located into the deep position of nasal cavity and closely related to important nerves and vessels. The complete removal of tumors in this area poses a complex surgical challenge.In order to investigate the clinical efficacy of utilizing free middle turbinate mucosa (FMT), fascia lata, and pedicled nasal septum flap (known as the Hadad-Bassagasteguy flap, HBF) for the treatment of cerebrospinal fluid (CSF) rhinorrhea, a retrospective analysis was conducted on clinical data from 65 patients who underwent skull base reconstruction following endoscopic resection of nasal-skull base tumors. The selection of the repair material was based on the size and location of the defect. For defects less than 1.5 cm (n = 24), FMT was chosen, while for defects greater than or equal to 1.5 cm (n = 16), HBF was preferred. In cases where HBF was not available or not suitable (specifically, when the defect was located on the posterior wall of the frontal sinus), fascia lata was selected (n = 25). The repair outcomes of all 65 patients were summarized, and subsequently, a comparison was made between the use of fascia lata and HBF. The overall success rate for one-time repairs was 93.8 %. Specifically, the success rates for repairs using FMT, fascia lata, and HBF were 91.7 %, 96.0 %, and 93.8 %, respectively. Throughout the follow-up period, there were 2 cases of postoperative CSF leakage out of 24 patients who underwent FMT reconstruction, 1 case out of 25 patients who underwent fascia lata reconstruction, and 1 case out of 16 patients who underwent HBF reconstruction. The occurrence of postoperative complications, such as intracranial infection, lung infection, and epistaxis, was observed in both the fascia lata group and the HBF group. However, there were no statistically significant differences between the two groups. The transnasal endoscopic reconstruction of skull base defect using HBF, fascia lata, and FMT demonstrated satisfactory repair effects in managing CSF rhinorrhea. Generally, FMT has been found to be a dependable repair material for small defects measuring less than 1.5 cm, while in the case of larger defects equal to or exceeding 1.5 cm, both HBF and fascia lata can be utilized with comparable repair outcomes. The selection of fascia lata becomes a viable option when HBF is unavailable or not suitable.

Prospective Outcomes of a Biological Resurfacing Arthroplasty with Fascia Lata Autograft (BioJoint) for the Treatment of Osteoarthritis of the Midtarsal Joint Complex.

OBJECTIVE: To determine the clinical, safety, and radiological outcomes after biological resurfacing arthroplasty for the treatment of osteoarthritis (OA) of one or more joints of the midtarsal joint complex. DESIGN: All prospectively followed patients with OA to one of or multiple joints of the midtarsal joint complex who were operated with a biological resurfacing arthroplasty with a fascia lata autograft (BioJoint procedure) were included. A total of 7 patients were included (5 males, 2 females), with a median age of 52 (interquartile range [IQR] 44-55) years. The primary outcome was the Numeric Rating Scale (NRS) for pain during walking 2 years postoperatively. Range of motion (ROM), revision rates, and complications were assessed. A postoperative MRI scan was performed to assess progression of OA, graft position and ingrowth, and the degree of bone marrow edema. RESULTS: There was a 100% follow-up of the patients (median follow-up: 33 [IQR 26-33] months). The NRS during walking improved from 6 preoperatively to 2 at 2 years postoperatively (P < 0.05). There were no reoperations nor severe complications. The limitations in the ROM remained limited in the majority of the cases. MRI at 2 years of follow-up showed no progression of OA, reduced bone marrow edema, and no loosening of the grafts. CONCLUSION: Biological resurfacing arthroplasty with a fascia lata autograft (BioJoint procedure) for OA to one or more joints in the midtarsal joint complex showed clinically relevant pain reduction during walking, improvement in clinical and radiological outcomes, and proved to be safe and durable.

Reconstruction of the severe Achilles tendon and soft-tissue loss with the bi-pedicled conjoined flap and vascularized fasciae latae: A consecutive case series of 15 patients.

BACKGROUND: Historically, the segmental loss of the Achilles tendon with overlying soft-tissue defects had been frequently reconstructed with the composite anterolateral thigh (ALTP) flap, including the iliotibial tract or fasciae latae. This study aimed to present our modified combination using the bi-pedicled conjoined flap with vascularized fasciae latae, for the approximately total reconstruction of the Achilles tendon and extensive soft tissue. METHODS: From May 2015 to March 2018, 15 patients (9 male and 6 female) with a mean age of 36 years (ranged, 18-52 years) underwent microvascular Achilles tendon reconstruction. Harvested on the abdomen and groin, the conjoined flap was chimeric with the vascularized fasciae latae. Primary donor-site closure was accomplished in all patients. A standard assessment of the functional and esthetical outcomes was completed. RESULTS: Mean follow-up time was 42 months (ranged, 32-48 months). The average dimension of the conjoined flap was 25 × 14 cm (ranged, 18 × 10-35 × 18 cm), and the average size of the folded fasciae latae was 15 × 6 cm (ranged, 12 × 5-25 × 8 cm). At the last follow-up, the Thompson test was negative in all patients. The mean American Orthopedic Foot and Ankle Society (AOFAS) score was 91.0. The mean Achilles tendon total rupture score (ATRS) was 18.5. The mean Vancouver Scar Scale (VSS) score was 3.0. CONCLUSIONS: The composite bi-pedicled flap including vascularized fasciae latae provides an alternative approach with great functional and esthetic outcomes, in selected patients who suffered severe Achilles tendon and skin defects. The one-stage procedure facilitates better rehabilitation postoperatively.

Management of Avascular Necrosis (AVN) of Femoral Head by Core Decompression with Tensor Fascia Lata (TFL) Muscle Pedicle Bone Graft.

Avascular necrosis (AVN) of femoral head is an increasingly common cause of musculoskeletal disability. Most of the cases caused by steroid induced and traumatic but idiopathic cause are not also uncommon. Almost all the patients presented with pain at the hip, limping gait, restricted movement and difficulty in waking and squatting and becomes disabled. Core decompression and muscle pedicle bone graft at stage IIA, IIB and III provides painless and mobile life. Core decompression supplemented with bone graft to enhance mechanical support and augment healing. We have started a prospective study for the treatment of AVN of Femoral head at stage IIA, IIB and III by core decompression and Tensor fascia lata muscle pedicle bone graft in the department of Orthopaedic surgery Bangabandhu Seikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2009 to December 2019. Aim of the study was to assess the effectiveness of core decompression and tensor fascia lata muscle pedicle bone graft in the treatment of AVN of femoral head at stage IIA, IIB and III. A total 48 patients and 65 hips were operated. Out of 48 patients, male was 30(62.50%) and female was 18(37.5%). Male-Female ratio was 1.66:1. Age of the patients ranging from 20 years to 50 years, mean age 36±4.65 years. According to aetiology corticosteroid induced was 47/65 (72.31%), idiopathic was 8(12.31%), post traumatic was 4(6.15%), ITP was 2(3.08%), ALL was 2(3.08%), and alcohol induced was 2(3.08%) of femoral head involvement. According to Ficat and Arlet's staging, stage IIA hip involvement was 28/65(43.08%), stage IIB was 32(49.23%) and stage III was 5(07.69%). All patients were treated with core decompression along with tensor fascia lata (TFL) muscle pedicle bone graft. All patients were followed clinically and radiologically at regular interval. Follow up period was 6 months to 10 years. Harris hip score (HHS) was used for evaluation of clinical outcome. Among the 65 hips, 24(36.92%) was excellent outcome (HHS >90), 30(46.15%) was good outcome (HHS: 80-90), 7(10.78%) was fair outcome (HHS: 70-79) and 4(6.15%) was poor outcome. For valid statistical analysis excellent and good results were grouped as satisfactory that was 54(83.07%) and fair and poor results were grouped as unsatisfactory that was11(16.93%), p value is <0.001 that is significant. It has been concluded that core decompression and TFL muscle pedicle bone graft is a pain relieving, head preserving procedure and improve hip function for the management of AVN of femoral head in stage IIA, IIB and III.

One-stage reconstruction of the complex defects of the Achilles tendon and the adjoining calcaneus using the chimeric superolateral thigh flap: A case report.

Reconstruction of the composite defects of the Achilles tendon and the overlying skin is a great challenge. Should the tendon insertion and adjoining calcaneal defects coexist, such reconstruction becomes far more complicated. A chimeric superolateral thigh flap based on the ascending branch of the lateral circumflex femoral artery provides all the components for this complex defect. We aim to illustrate a case underwent one-stage reconstruction of such defects with this chimeric flap. A 55-year-old man presented with composite defects of Achilles tendon (11 cm), adjoining calcaneus (2 × 2 × 3 cm), and the overlying skin (15 × 3.5 cm) due to unsuccessful repair for his right chronic Achilles tendon rupture, which was complicated by infection. This complex defect was reconstructed using a chimeric superolateral thigh flap consisting of the superolateral thigh skin (8.5 × 17.5 cm), full-thickness iliac bone (4 × 3 cm), and the intervening iliotibial tract preserving the fascia-bone junction, which substituted for the lost insertion of the Achilles tendon. Bone union and full weight bearing were achieved by 11 and 24 weeks, respectively, after surgery. Two debulking procedures were performed. Isometric plantar flexion muscle strength was comparable to the healthy side, but isotonic strength was somewhat reduced at 18 months after reconstruction. This chimeric flap provided all the possible components necessary for the complex Achilles tendon defect, and led functional outcomes.

Tensor fascia lata flow-through modification of the anterolateral thigh flap for the repair of through-and-through defects of the face.

The treatment of tumour recurrence or severe surgical complications in the head and neck region is often very complicated and limited. In particular, there is no suitable reconstruction strategy for patients whose necks are poor in blood vessels and whose anterolateral thigh (ALT) donor areas concurrently have only one available perforating branch. Therefore, a 'flow-through' technique was applied to fabricate chimeric ALT flaps for such patients. An ipsilateral tensor fascia lata flap was anastomosed to the distal end of the descending branch of the lateral circumflex femoral artery. Six patients were included in this study. All fabricated chimeric flaps were successfully prepared and remained viable. After follow-up (range 3-38 months), the patients were satisfied with their appearance and the incision lines had healed well. In patients with through-and-through defects of the face and with anatomical variations in the donor area, chimeric ALT flaps fabricated via the flow-through technique can provide double flaps and longer vascular pedicles, thereby enabling reconstruction.

Surgical Technique: Abductor Reconstruction With Gluteus Maximus and Tensor Fascia Lata in Revision Total Hip Arthroplasty.

BACKGROUND: Abductor deficiency in revision total hip arthroplasty (THA) is a common problem that can lead to pain, limping, and instability. Repair and reconstruction of the abductors is challenging, with a high rate of failure reported in the literature. The purpose of this study is to describe a simplified technique of abductor repair augmented with the transfer of gluteus maximus (Gmax) and the tensor fascia lata (TFL). METHODS: We describe a novel abductor reconstruction with transfer of the anterior 30% of Gmax and the posterior 70% of TFL to the vastus lateralis origin. These transfers can be used in isolation or to augment repair of torn abductors to the greater trochanter. The technique is simple and quick to perform via a lateral approach, requiring dissection of only two muscle slips and minimal additional soft tissue dissection. RESULTS: We describe the use and outcomes of this technique on three patients undergoing revision THA with severe and irreparable abductor deficiency. Although these patients reported improved function after the reconstruction, there was persistence of mild to moderate limping. CONCLUSION: Abductor reconstruction with partial transfers of Gmax and TFL is a promising approach to manage abductor deficiency in revision THA. Larger series are required to determine the efficacy of this technique for restoring abductor function and improving patient reported outcomes.

Free vascularized fascia lata flap for total columella reconstruction.

INTRODUCTION: Despite their relatively small size, columellar defects, including both external and internal elements, are exceedingly difficult to reconstruct. Local, regional, and distant flaps have been described for reconstruction. Herein, we present a novel technique for reconstruction of the columella using vascularized free fascia lata from the anterolateral thigh with structural replacement and skin grafting. METHODS: This novel technique utilizes a small anterolateral thigh flap, formed into vascularized fascia lata without the overlying subcutaneous fat or skin. The fascia lata is inset into the columellar and caudal septal defect after a cartilage framework is constructed and is microsurgically anastomosed to either distal facial or angular vessels. A skin graft from the ALT donor site is then secured over the fascia. RESULTS: This technique has been applied successfully in patients with either isolated columella or in multi-subunit reconstruction following total rhinectomy with no flap or reconstructive failures. Given the low morbidity of flap harvest and minimal access incisions, this has been reliably accomplished with short (1-2 day) hospital stays. CONCLUSION: Rapid and aesthetically acceptable reconstruction of total nasal columella defects in isolation or with additional nasal subunit reconstruction, is possible utilizing this novel technique. Here we discuss pearls and pitfalls of its use following surgical resection of malignancy.

Different anterolateral procedures have variable impact on knee kinematics and stability when performed in combination with anterior cruciate ligament reconstruction.

OBJECTIVE: The optimal anterolateral procedure to control anterolateral rotational laxity of the knee is still unknown. The objective was to compare the ability of five anterolateral procedures performed in combination with anterior cruciate ligament reconstruction (ACLR) to restore native knee kinematics in the setting of a deficient anterior cruciate ligament (ACL) and anterolateral structures. METHODS: A controlled laboratory study was performed using 10 fresh-frozen cadaveric whole lower limbs with intact iliotibial band. Kinematics from 0° to 90° of flexion were recorded using a motion analysis three-dimensional (3D) optoelectronic system, allowing assessment of internal rotation (IR) and anteroposterior (AP) tibial translation at 30° and 90° of flexion. Joint centres and bony landmarks were calculated from 3D bone models obtained from CT scans. Intact knee kinematics were assessed initially, followed by sequential section of the ACL and anterolateral structures (anterolateral ligament, anterolateral capsule and Kaplan fibres). After ACLR, five anterolateral procedures were performed consecutively on the same knee: ALLR, modified Ellison, deep Lemaire, superficial Lemaire and modified MacIntosh. The last three procedures were randomised. For each procedure, the graft was fixed in neutral rotation at 30° of flexion and with a tension of 20 N. RESULTS: Isolated ACLR did not restore normal overall knee kinematics in a combined ACL plus anterolateral-deficient knee, leaving a residual tibial rotational laxity (p=0.034). Only the ALLR (p=0.661) and modified Ellison procedure (p=0.641) restored overall IR kinematics to the normal intact state. Superficial and deep Lemaire and modified MacIntosh tenodeses overconstrained IR, leading to shifted and different kinematics compared with the intact condition (p=0.004, p=0.001 and p=0.045, respectively). Compared with ACLR state, addition of an anterolateral procedure did not induce any additional control on AP translation at 30° and 90° of flexion (all p>0.05), except for the superficial Lemaire procedure at 90° (p=0.032). CONCLUSION: In biomechanical in vitro setting, a comparison of five anterolateral procedures revealed that addition of either ALLR or modified Ellison procedure restored overall native knee kinematics in a combined ACL plus anterolateral-deficient knee. Superficial and deep Lemaire and modified MacIntosh tenodeses achieved excellent rotational control but overconstrained IR, leading to a change from intact knee kinematics. LEVEL OF EVIDENCE: The level-of-evidence statement does not apply for this laboratory experiments study.

A randomized trial of psychological intervention on perioperative anxiety and depression of patients with severe blepharoptosis undergoing autologous fascia lata frontal muscle suspension.

BACKGROUND: Perioperative negative emotion of surgical patients has a greater impact on surgical efficacy and prognosis. The study aimed to analyze the effect of psychological intervention on perioperative anxiety and depression of patients with severe blepharoptosis undergoing autologous fascia lata frontal muscle suspension, and provide a reference for improving and optimizing patient care plans. METHODS: Ninety-two patients with severe blepharoptosis who underwent autologous fascia lata frontal muscle suspension in our hospital from February 2018 to January 2020 were selected as the research subjects. Patients were numbered according to the order of operation, and were divided into a control group (46 cases) and an observation group (46 cases) using a numerical random table method. Patients in both groups received routine nursing intervention during the perioperative period, and patients in the observation group also received psychological intervention during this period. The two groups of patients were evaluated using the Hamilton Anxiety Scale (HAM-A) and Hamilton Depression Scale (HAM-D). Numerical rating scale (NRS) results for surgical site pain were evaluated and compared between the groups. The perioperative compliance rate and nursing satisfaction rate of the two groups of patients were investigated and compared. Intraoperative and postoperative complications were collected, sorted, and compared between the two groups of patients. RESULTS: (I) The HAM-A and HAM-D scores of the observation group before and after surgery were significantly lower than those of the control group (P<0.05). (II) The NRS scores of patients in the observation group were markedly lower than those in the control group at 6 h and 24 h postoperatively (P<0.05). (III) The intra- and post-operative complication rate of the observation group was lower than that of the control group (P<0.05). (IV) The compliance rate and the total satisfaction rate of patients with the perioperative care in the observation group was considerably higher compared to that of patients in the control group (P<0.05). CONCLUSIONS: Our results showed that psychological intervention can effectively alleviate the negative emotions in patients with severe blepharoptosis who underwent autologous fascia lata frontal muscle suspension, improve their compliance with medical care, reduce their pain, and increase their satisfaction rate. Therefore, psychological intervention has high clinical value.

Fascia lata packing and tension suturing for symptomatic pseudomeningocele after recurrent cervical intradural tumour resection.

In recurrent posterior cervical intradural tumour resections, serious complications can be developed. The dural can become affected by inflammatory factors or removed during tumor resection; if cerebrospinal fluid (CSF) leakage cannot be stopped by duraplasty, artificial meninges or fascia repair, large pseudomeningocele can develop posteriorly within the soft tissue of the neck. When the pressure of the CSF cannot be maintained steadily, persistent clinical symptoms can occur, such as postural headache or central fever. Moreover, the skin can also be penetrated in a few patients even after extension of the drainage duration, lumbar cistern drainage or skin suturing, leading to the induction of life-threatening intra-cranial infections. Is there a simple and effective surgical method to address this scenario? The aim of this study was, therefore, to investigate the effectiveness of fascia lata packing and tension suturing in the treatment of symptomatic pseudomeningocele after recurrent posterior cervical intradural tumour resection. In our study, nine consecutive spinal surgery patients were recruited from January 2008 to January 2018. All pseudomeningoceles were combined with postural headache, central neurological fever or wound non-union. There were 3 cases of melanocytoma, 3 cases of nasopharyngeal carcinoma metastasis, 2 cases of breast cancer metastasis, and 1 case of spinal canal lymphadenoma. Standard patient demographics, diagnosis, post-operative symptoms, wound healing time, and the largest pre- and last follow-up pseudomeningocele area on axial MRI sections were recorded. All cases were followed-up successfully, from 12 to 24 months, with an average of 15.3 months. Our observations indicate that all wounds healed successfully. The wound union time was 20.7 days on average. After wound union, these patients became symptom free. The largest cerebrospinal fluid area on axial MRI sections improved significantly from 42.9 ± 5.01 cm2 at p re-operation to 6.6 ± 1.89 cm2 at 1 year post-operation (P < 0.05); Our data indicate that .the proposed procedure is simple, safe and effective. And more importantly, it allows rapid closure of any cerebrospinal fluid leakage pools.

Robotic Sacral Colpopexy Using Autologous Fascia Lata Compared with Mesh.

Objective: The objective is to compare robotic sacral colpopexy (RSC) utilizing autologous fascia lata with RSC with synthetic mesh in the treatment of pelvic organ prolapse (POP). Methods: We performed a prospective nonrandomized case comparison trial at a single institution. We compared RSC utilizing either synthetic mesh or autologous fascia lata in women with symptomatic POP, stages II through IV. The primary outcome was anatomic prolapse recurrence determined by the Pelvic Organ Prolapse Quantification (POP-Q) examination. Secondary outcomes included patient-reported outcomes such as the Urogenital Distress Inventory-6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7). Complications were also recorded and categorized using the Clavien-Dindo (CD) system. The hypothesis is that autologous fascia lata would provide equivalent anatomic and patient-reported outcomes compared with mesh while eliminating mesh-related complications. Results: Sixty-four women underwent RSC with 19 (29.7%) receiving fascia lata graft. The overall operative time was greater in the fascia lata group with mean fascia lata harvest time of 24.8 ± 7.4 minutes. Intragroup comparisons of the fascia and mesh groups demonstrated significant improvement in pelvic measurements as well as patient-reported outcomes. Intergroup comparison demonstrated equivalent success rates at 12.1 ± 8.7 months follow-up. There was one apical failure in the fascia lata RSC group; however, the difference was not statistically significant (p = 0.30). Significant complications in the fascia lata harvest group included two CD-II and one CD-IIIb. In the mesh group there was one mesh erosion requiring surgical excision (CD-IIIb). Conclusion: This is the first comparison between RSC with autologous fascia lata and mesh. Short-term anatomic outcomes were similar with autologous fascia lata use without the risk of mesh erosion. Morbidity from graft harvest site was not trivial. These results emphasize the need for a randomized controlled trial.

Reconstructed Diaphragm by Fascia Lata: 13 Years In Vivo.

We report a case of resection of a reconstructed diaphragm with fascia lata after 13 years. A 66-year-old man was diagnosed with a solitary fibrous tumor of the pleura. Thirteen years prior, resection for left postoperative pleural dissemination of solitary fibrous tumor with diaphragmatic resection was performed, and left fascia lata was used for diaphragmatic reconstruction. He relapsed, and the diaphragm was re-resected and re-reconstructed with right fascia lata. The resected, reconstructed fascia lata had microvessels in the fibrous stroma, and it was observed that the autologous tissue had become more resistant to infection by obtaining a blood supply.

Massive Heterotopic Ossification of the Tensor Fascia Lata in a Bodybuilder Leading to Severe Hip Dysfunction: A Case Report.

CASE: A 42-year-old bodybuilder with no history of trauma presented to our clinic with persistent right hip pain and rapidly advancing joint stiffness. Imaging confirmed massive, mature heterotopic ossification predominantly involving the right tensor fascia lata. Six months after a tailored surgical removal, there were no signs of disability, pain, or clinical signs of recurrence, and the patient regained proper joint function. CONCLUSION: In massive heterotopic ossification, tailored surgical removal of the part of the lesion that is limiting function may result in a complete functional recovery.

Endoscopic Repair of Nasal Septal Perforations With Fascia Lata.

PURPOSE: Nasal septal perforation (NSP) consists of defects of mucosa, cartilage, and bone. Nasal septal surgery is by far the most common cause of NSP. Many surgical approaches have been described for NSP repair. In this study, the authors describe a novel technique for repairing all sizes of NSP using an only fascia lata graft. METHODS: The authors implemented a retrospective study design. Seventeen patients who underwent NSP repair between January 2016 and January 2019 were included to the study. Entire nasal surgical steps were performed under endoscopic view, harvested fascia lata graft is placed in tympanoplasty fashion after all edges of perforation is elevated and implantation bed is prepared. RESULTS: The mean size of the septal peforations were 18.52 ±â€Š4.17 mm horizontally, 11.52 ±â€Š3.42 mm vertically. The mean follow up period was 14.47 ±â€Š9.5 months (range: 2-36). In 15 of the 17 patients, total NSP closure was achieved (88,23%). CONCLUSIONS: Endoscopic close technique using fascia lata for nasal septal perforation closure is a safe and reliable technique with high success rate and it should be considered in patients with nasal septal perforation.

Extensive full thickness abdominal wall reconstruction using anterolateral thigh compound flap modifications.

PURPOSE: Abdominal wall reconstruction is challenging, which demands adequate skin coverage and structural support. The anterolateral thigh (ALT) flap including fascial portion can be useful in such cases. METHODS: Retrospective chart review of five patients that underwent complex abdominal wall defects reconstruction with ALT free flaps with fascia lata was conducted. Patient age ranged from 49 to 69 years (average: 57.4). The etiology of defects was infected liposuction site, small bowel perforation, esophageal cancer, diverticulum perforation, and Hartmann operation. The average size of the defect was 17.4 × 10 cm (9 × 9 ~ 21 × 18). Single-stage reconstruction using ALT flaps based on the lateral circumflex femoral artery was done in all patients. Exposed intestines were successfully covered and reinforced utilizing fascial component. RESULTS: The average size of the flap was 17.4 × 8 cm (9 × 9 cm ~25 × 10 cm). One partial flap necrosis, venous congestion, and infection occurred. These complications were treated successfully. During the follow-up (12-96 months, mean: 63), all patients achieved functional stabilization and returned to normal activities. CONCLUSION: ALT flap combined with its fascial component is useful for abdominal wall. It can be a reliable option in cases of intestinal exposure.

Duraplasty Using Autologous Fascia Lata and Latissimus Dorsi Free Flap for Chronic Cerebrospinal Fluid Leak.

Cerebrospinal fluid (CSF) leak is a common complication after cranial surgery. Therefore, after neurosurgical procedures it is crucial to obtain a dural repair that is complete and watertight. There are many techniques that have been described attempting to achieve this goal. However, there are complicating factors (eg, poor tissue viability, need for future radiation, comorbidities, infection, size of the dural defect, multiple operations) that may require a more comprehensive approach to achieve an optimal healing environment. The authors present a technique that uses a muscle free flap to vascularize an autologous fascia lata graft, preserving the viability of the graft and reinforcing its healing ability.The authors applied this technique to a single patient with chronic CSF leak from poor tissue healing after treatments for recurrent medulloblastoma. After harvesting a fascia lata graft with appropriate size, the graft was sutured into the dural defect in a watertight fashion. A latissimus dorsi muscle free flap was harvested and anastomosed to a saphenous vein Corlett loop/AV fistula to the facial artery. The flap was than sutured to the graft. A drain was left in place and a skin graft was applied to the muscle flap.At 8 months follow-up the patient was able to continue with her treatment and has had a stable repair without leak or breakdown. The authors present an algorithm to facilitate dural repair selection.Duraplasty using autologous fascia lata reinforced with a free muscle flap is an effective technique to control chronic CSF leaks, especially when the dura is poorly vascularized and less viable.

Cutdown Technique is Superior to Fascial Closure for Femoral Artery Access after Elective Endovascular Aortic Repair.

OBJECTIVES: Arterial access closure after endovascular aneurysm repair (EVAR) can be achieved using three different approaches: percutaneous closure devices, surgical exposure and direct suture ("cutdown"), and the less invasive fascial closure technique. The aim of this study was to report on the intra-operative, in hospital, and three month outcome of fascial closure and cutdown, and to determine risk factors for failure. METHODS: The primary outcome was assessed in 439 groins in 225 elective EVAR patients recruited consecutively and prospectively from February 1, 2011 to August 31, 2014. During the study period, fascial closure and cutdown were first and second line closing techniques. Compared with fascial closure, procedures completed with cutdown had lower BMI, thinner subcutaneous tissue of the groin and more complex femoral anatomy. Computed tomographic angiography (CTA) and duplex ultrasound (DUS) of the groin were performed pre-operatively and three months after EVAR. Retrospective review of medical records and CTA were used to determine intra-operative and in hospital outcome, and risk factors for failure. RESULTS: In total, 64%, 33%, and 3% were completed with fascial closure, cutdown, and closure device, respectively. Intra-operative, in hospital, and three month technical success rates of fascial closure vs. cutdown were 91% (283/310 groins) vs. 99% (114/115 groins), 89% (277/310 groins) vs. 99% (114/115 groins), and 89% (275/310 groins) vs. 99% (114/115 groins) (p < .001). Wound complications within three months were infrequent for both methods. No risk factor was significantly associated with failure after fascial closure. CONCLUSION: This study shows that cutdown is superior to fascial closure for femoral artery access after elective EVAR. In acute EVAR, however, fascial closure is still considered to be a good and fast method, and it has been kept in the present authors' armamentarium for this indication.

Reconstruction of complex soft tissue defects including tendons with anterolateral thigh flap extended to fascia lata: Long term recovery and functional outcomes.

BACKGROUND: We evaluated composite anterolateral thigh (ALT) flaps including vascularized fascia lata (FL), for stable soft tissue coverage and tendons restoration at various joint levels in a one-stage procedure. METHODS: We performed a retrospective investigation including 21 "functional" ALT flaps between November 2006 and December 2016. In all patients included, FL was shaped to anatomical reproduce a tendon structure. Functional analysis included range of motion and force assessment. Functional scores were established according to Chen classification, DASH, and LEFS score. Defects resulted from tumor excision, trauma, burn, or infection-debridement and were distributed in four main anatomical districts: knee (seven cases), ankle (six cases), forearm-elbow (four cases), and hand-wrist level (three cases). RESULTS: Nineteen flaps were raised as free flaps, while two as distally-based propeller flaps. Average follow-up was 38 months. Major complication requiring the harvest of a second flap was seen in two patients, whereas three flaps presented superficial necrosis and was treated in an outpatient regimen. We observed 81% of total ROM recovery compared to contralateral sides with 89% recovered articular stability. Best articulation outcomes were present in elbow reconstruction, while ankle reconstructions showed less articularity. Hospital stay was significantly reduced in hand and wrist functional reconstruction when compared with reconstruction at the ankle level (P < 0.05). CONCLUSION: The ALT flap extended to vascularized FL provides a particularly effective and resistant tissue that can be folded to reconstruct and support tendinous structures. This can restore functional and structural integrity after complex defects in a single stage procedure.

Feasibility of pedicled anterolateral thigh flap with tensor fascia lata and vastus lateralis for difficult abdominal wall closure.

PURPOSE: Long-term follow-up for pedicled anterolateral thigh (ALT) flap with vastus lateralis and tensor fascia lata for complex abdominal wall reconstruction is rarely reported. This study aimed to evaluate the feasibility of extended pedicled ALT flap. METHODS: This retrospective review was conducted at a single medical center between 2011 and 2018. A total of 35 patients with complex abdominal wall defects reconstructed with partition (n = 20) or pedicled ALT flap (n = 15) were enrolled. Data on gender, age, fascial defect size, operation time, hospital days, follow-up duration, and complications were obtained. Mann-Whitney test evaluated the differences in continuous data, and Chi-square test analyzed categorical data. RESULTS: The partition technique was associated with 10.15 cm (range 8-14 cm) mean defect size, 146 min average operation time, 13.5 hospital days, and 95.42 months of mean follow-up duration. Short- and long-term complications were observed in seven (35%) and six (30%) cases, respectively. The pedicled ALT flap technique was associated with 13.4 cm (range 10.6-16 cm), 342.86 min average operation time, 22.33 hospital days, and 69.4 months of mean follow-up duration. Short- and long-term complications were observed in six (40%) and five (33%) cases, respectively. Significant differences in defect size, operative time, hospital days, and donor-site skin graft loss (p < 0.05) were observed between the groups. CONCLUSIONS: Extended pedicled ALT flap is a reliable option for complex abdominal wall reconstruction. Compared with the partition technique group, the extended pedicled ALT group had closure of larger fascia defects. However, it was associated with a higher risk of donor-site skin graft loss and longer operative time and hospital days.