return to: Reconstructive Procedures Protocols

Note: last updated before 2015

GENERAL CONSIDERATIONS

1. Indications
   1. Suspension of facial tissues in surgery for facial paralysis or ptosis correction. Consider alternatives: cadaver fascia lata or Gore-Tex.
   2. Obliteration of the frontal sinus
   3. Dural patch and repair in lateral and anterior skull base surgery
2. Contraindications
   1. Previous traumatic or surgical injury to the fascia lata
   2. A relative contraindication would be cases in which an alternative repair material such as Gore-Tex or temporalis fascia would serve equally well without the need for a second surgical site.
   3. Infection at the intended recipient site is a contraindication to free fascia graft placement.
3. Pertinent Anatomy
   1. The fascia lata envelops the muscles of the upper leg. Laterally, this fascia coalesces to a much thicker ileotibial band. This fascial band runs from the iliac crest to the tibia. It is narrow distally and much broader proximally. Several muscles in the upper leg have fibrous attachments to this fascial band. The planes just superficial and deep to this band are essentially avascular. The ileotibial band lies under the subcutaneous tissue.
   2. Because the band is much broader proximally, this is the ideal place to obtain the largest sheet of fascial tissue. More distally the band is thicker but narrow. Robust thin strips are best harvested more distally.
   3. The longitudinal integrity of the ileotibial band should never be completely disrupted during fascial harvest.

PREOPERATIVE PREPARATION

1. Evaluation
   1. If a longitudinal incision is considered, this should be discussed with the patient. Some patients will find this objectionable and an alternative plan for harvest or an alternative harvest site will need to be chosen.  This would include a discussion regarding the potential for muscle herniation, through the fascial defect, in the lateral leg leading to obvious assymetry.
   2. Through history and physical exam, exclude any previous trauma to the donor site.
2. Potential Complications
   1. Acute hematoma
   2. Seroma requiring serial aspiration or drainage
   3. Prolonged postoperative pain
   4. Unsightly Muscle herniation
   5. Infection at the donor site

NURSING CONSIDERATIONS

1. Room Setup
   1. See Basic Soft Tissue Room Setup
2. Instrumentation and Equipment
   1. Standard
      1. Minor Instrument Tray, Otolaryngology
      2. Bipolar Forceps Trays
   2. Special
      1. Iowa Hickman catheter insertion guide, 12-3/8 in
      2. Crawford fascia stripper
      3. Long scissors (mayo, stevens)
3. Medications (specific to nursing)
   1. Antibiotic ointment
   2. 1% lidocaine with 1:100,000 epinephrine
4. Prep and Drape
   1. Standard prep, 10% provodone iodine
   2. Drape
      1. Impervious drape under leg: The entire lateral upper leg from the knee to the iliac crest is prepped and draped off with sterile towels. This site may be covered with a split sheet until the harvest is performed, at which time the split sheet is cut over the harvest site.
      2. Square off fascia site
      3. Split sheet
5. Drains and Dressings
   1. Fluffs, sterile, 5-pack x 3
   2. Kerlix 4 in roll
   3. Ace bandage (elastic), 4 in
6. Special Considerations
   1. Depending on the procedure with which the harvest will be in conjunction, the protocol may be altered.
   2. It is beneficial to have the ipsilateral hip elevated on a small pillow to improve access to the upper lateral leg.
   3. The approach most frequently used when harvesting a sheet or patch graft is through a longitudinal incision.
   4. If long strips are required without making a long incision, the fascia lata stripper is utilized. 
   5. Hand held lit retractors may be of benefit for long strips as well.

ANESTHESIA CONSIDERATIONS

1. General
   1. See primary head and neck protocol
2. Specific
   1. Anesthesia tubing, IV lines, arterial lines, and blood pressure cuff should not run along the side of the patient in a location that would hinder access to the upper lateral leg.

OPERATIVE PROCEDURE

1. Harvest of a Sheet of Fascia Through a Longitudinal Incision
   1. A longitudinal incision, approximately 3-5 cm long, is made along the lateral thigh, the center of which lies over the junction of the upper and middle one-third of the upper leg.
   2. The incision is carried down to the ileotibial band of the fascia lata.
   3. If overlying fat is also to be harvested, Bovie cautery should not be used.
   4. Overlying fat is dissected off of the fascia bluntly in the area of the fascia to be harvested.
   5. The medial longitudinal incision in the fascia is made, followed by the lateral longitudinal incision. This defines the width of the graft. Great care should be taken when making these incisions that the underlying muscle is not incised.
   6. The distal transverse incision through the fascia is then made, and the fascia is gently elevated off of the underlying muscle. The muscle should not be violated in any way. Finally, the proximal transverse incision is made and the graft delivered.
   7. The wound is closed in two layers using 4-0 monocryl deep and 5-0 monocryl in running buried subcuticular fashion.
2. Harvest of a Long Thin Strip of Fascia Using the Fascia Lata Stripper
   1. A horizontal incision approximately 4 cm in length is made 8 cm above the knee over the ileotibial tract.
   2. The incision is carried down to the fascial layer.
   3. A 1.5 cm transverse incision is made in the fascia and a 2-0 silk suture is placed in the proximal edge to assist in threading this through the fascia lata stripper.
   4. The fascia lata stripper is engaged and, with the stripper held as close to the leg as possible, it is pushed superiorly while gentle tension is held on the silk suture pulling the fascia through the stripper.
   5. The fascia stripper is triggered, which cuts the fascial strip proximally.
   6. Several strips may be harvested as needed.
   7. The incision is closed, and a pressure dressing is applied to the lateral leg and held in place with an Ace wrap. A small Penrose drain is placed in the wound with a sleeper stitch through it.

POSTOPERATIVE CARE

1. If a suction drain is placed, it is removed when drainage is below 30 cc in 24 hours.
2. When a Penrose drain is used, it can usually be removed on postoperative day 1 and the sleeper stitch tied.
3. If after the drain is removed, a seroma develops, it can usually be managed with pressure dressings using an Ace wrap and serial aspirations.

REFERENCES

Wheatcroft SM, Vardy SJ, Tyers AG. Complications of fascia lata harvesting for ptosis surgery. Br J Ophthalmol. 1997;81:581-583.