Fascia lata can be harvested from high leg

In addition to cosmetic benefits, the site reduces the risk of pain from a herniated muscle belly.

Issue: July 1, 2002

ByThomas C. Naugle Jr., MD

Most surgeons agree that autogenous fascia lata is the best material for use in repairing ptosis with poor levator function. Failure (ie, ptosis) with lyophilized banked human fascia is 40% to 50% at 8 to 9 years, according to Crawford.

Probably the most common site of harvesting fascia lata is 6 cm to 7 cm above the lateral aspect of the knee. However, several complications may occur with this method: a conspicuous scar or keloid causing a severe cosmetic deformity (figures 1 and 2), significant hematoma formation or herniation of the muscle belly with possible severe pain (figure 2). There is little coverage of this last complication in the literature, and one would suspect it might be a frequent occurrence in a patient with highly developed quadriceps musculature. Additionally, freeing the tissues adjacent to the fascia lata at the distal end of the dissection with no direct visualization can be difficult despite the use of the fascia lata stripper.

Incision direction

In 1986, realizing the above problems, I began to change the direction of the incision. Instead of starting the dissection at the lateral aspect of the knee, I started it at the distal end. Obviously this method traverses the same course as the aforementioned dissection, but it leaves the incision higher on the leg with the advantage of the scar being covered by short-legged clothing.

With cadaver dissections, I have found the fascia nearer the iliac crest to be thicker than that found near the knee. In actual use, I have found that there is less tendency of the fascia lata to splay than with fascia near the knee. I cut thin strips of approximately 1.5-mm proportions in frontalis suspension to prevent bulkiness in the lid and brow.

I select an incision site halfway between the iliac crest and the greater trochanter because the site offers high-quality fascia that do not splay. By using a fiberoptic retractor one can visualize, looking toward the iliac crest and toward the inferior extent of the incision, the entire extent of the harvested area (figure 3). This offers the advantage of visualizing dissection from tissues from the fascia over the entire extent of the harvest area. It also allows the surgeon to cauterize bleeders over this entire area. This would apply not only to cauterization at the time of the operation, but also postoperatively, should a hematoma develop. Identifying a bleeding vessel at the distal end of a dissection commencing just lateral to the knee would be extremely difficult. For this same reason, one would not want to start an incision for harvesting fascia lata directly over the iliac crest.

Conspicuous scars at lateral aspect incision site.	There is a homologue of Scarpa’s fascia covering the fascia lata in this area that serves as a barrier against herniation of the muscle belly.
By using a fiberoptic retractor one can visualize, looking toward the iliac crest and toward the inferior extent of the incision, the entire extent of the harvested area.	The incision site can also be used to harvest a large graft for wrapping hydroxyapatite or other implant without untoward results.
There is less muscle mass of the tensor fascia lata and the gluteus medius between the iliac crest and greater trochanter, so there is less chance of herniation of the muscle belly.	The resultant scar is hidden by underwear and swimwear.

Additionally, there is less muscle mass of the tensor fascia lata and the gluteus medius between the iliac crest and greater trochanter, so ostensibly there would be less chance of herniation of the muscle belly (figure 4). Also, there is a homologue of Scarpa’s fascia covering the fascia lata in this area that serves as a barrier against herniation of the muscle belly (figure 5). In our series of 23 patients at the time of the original publication of this technique, and in our series now of 34 patients, there has been no herniation of the muscle belly. According to colleagues who have had this complication with a patient, pain can be severe and the best solution to this problem is unclear.

Advantages

The obvious advantage of an incision between the anterior iliac crest and the greater trochanter is that the resultant scar is hidden by underwear (figures 6 and 7) and swimwear. By contrast, a hypertrophic scar or keloid in the area just superior and lateral to the knee might manifest in a horrific aesthetic result.

This incision site can also be used to harvest a large graft for wrapping hydroxyapatite or other implant without untoward results. In our original series, one patient was 2 years of age and two were 3 years of age. None have experienced any problems to date.

With this incision the lateral femoral cutaneous nerve has generally been avoided, as it usually lies between its anterior and posterior branches. One patient experienced mild hypesthesia which resolved over a period of 12 months. Perhaps an anatomic variant was encountered. The patient was not particularly bothered by this problem.

To perform this technique properly, one should be familiar with the anatomy of the upper leg. The fascia is deeper than that lateral to the knee. For the first time in performing this technique, I would suggest the aid of a surgeon who has operated in this area.

For Your Information:

Thomas C. Naugle Jr., MD, can be reached at 2633 Napoleon Ave., Suite 814, New Orleans, LA 70115; (504) 899-1715; fax: (504) 897-2162. All figures reprinted from Ophthalmology, 1997; 104:1480-1488, with permission from Elsevier Science.

Reference:

Naugle TC, Fry CL, et al. High leg incision fascia lata harvesting. Ophthalmology. 1997; 104:1480-1488.