Endoscopic Harvesting of Autogenous Fascia Lata

Raman Malhotra, F.R.C.Ophth.*, Dinesh Selva, F.R.A.N.Z.C.O.†, and Jane M. Olver, F.R.C.S., F.R.C.Ophth.‡

*Corneo Plastic Unit, Queen Victoria Hospital, East Grinstead, Sussex, United Kingdom; †Department of Ophthalmology &Visual Sciences, University of Adelaide and South Australian Institute of Ophthalmology, Adelaide, Australia; ‡Oculoplastic

and Orbital Service, The Western Eye Hospital and Department of Ophthalmology, Charing Cross Hospital,London, United Kingdom.

Purpose: To describe a technique of endoscopic harvesting of autogenous fascia lata.Methods: A retrospective, noncomparative clinical study to evaluate the technique of videoendoscope

assistance in harvesting autogenous fascia lata was conducted during a 1-year period in 2002. A small incisionapproximately 2 cm long is made over the lateral aspect of the thigh, either as a low or high approach. A sheathed4-mm rigid 0- or 30-degree endoscope is used to visualize the length of the fascia lata along both its superficialaspect and its undersurface. Standard endoscopic brow lifting instruments are then used to dissect a length offascia under direct visualization.

Results: Three patients underwent harvesting of autogenous fascia lata under endoscopic visualization (2high-thigh and 1 low-thigh technique). Adequate lengths of fascia lata, approximately 12 cm long, were harvestedand no complications occurred. The endoscope was particularly useful in identifying the anatomical structuresadjacent to the fascia. The technique was easy to use, but took twice as long as traditional harvesting techniques.

Conclusions: Videoendoscopy allows complete visualization of anatomical structures during harvesting ofautogenous fascia lata. It highlights the anatomy for teaching and provides an alternative approach to conven-tional harvesting methods.

Autogenous fascia lata (AFL) is commonly used byophthalmic plastic surgeons for procedures such as

frontalis suspension ptosis surgery and lower eyelidslings in facial palsy. Traditional techniques for harvest-ing AFL use direct exposure with long incisions, or afasciotome passed “blindly” in the lateral aspect of theupper leg through a short skin incision.

The development of videoendoscopic techniques inophthalmic plastic surgery allows a direct view, at highmagnification and with good illumination, enabling min-imally invasive subcutaneous surgery. In addition to itsuse during brow-lift surgery, the videoendoscope is use-ful in the removal of periorbital lesions,1 potentiallyuseful in orbital surgery,2 and is a valuable adjunct inallowing complete visualization while supervising train-ees during subperiosteal orbital surgery.3 Its use alreadyis established in lacrimal and orbital decompressionsurgery.4–8

The use of the videoendoscope in assisting with AFLharvesting was first reported by Tucker et al.9 in 1997 forobtaining a large sheet of AFL for inguinal hernia repair.We describe 2 endoscopic approaches for assisting in theharvesting of AFL strips that allow good visualizationthroughout the procedure. The traditional fasciotome isnot used in either of these approaches.

METHODS

A retrospective, noncomparative clinical study to evaluatethe technique of videoendoscope assistance in harvesting AFLwas conducted during a 1-year period in 2002. A sheathed,4-mm, rigid 0- or 30-degree endoscope is used to visualize thefascia, along both its superficial aspect and undersurfacethrough a small incision less than 2 cm long, made over thelateral aspect of the thigh (either a high10 or low11 approach).Standard endoscopic brow lifting instruments are used to dis-sect a 12-cm length of fascia lata (FL) under endoscopicvisualization. Neither ethics committee nor institutional reviewboard approval was required for this study.

High Thigh Approach:10 The skin incision is made in aLanger line that bisects a line between the anterior iliac crestand the greater trochanter. Further dissection through fat andthe cobweblike homologue of Scarpa fascia exposes the under-lying FL. Fascia is exposed in all directions, and inferior bluntdissection under endoscopic visualization—using a periostealelevator and endoscopic Metzenbaum scissors (EMS) to dividecross-fibers—is continued to 10 cm to 12 cm below the inci-sion. Superior, anterior, and posterior FL cuts are made under

Accepted for publication March 7, 2007.The author has no financial or proprietary interest in this study.Address correspondence and reprint requests to Dr. Raman Mal-

hotra, Corneo Plastic Unit, Queen Victoria Hospital, Holtye Road,East Grinstead, Sussex RH19 3DZ, United Kingdom. E-mail:malhotraraman@hotmail.com

DOI: 10.1097/IOP.0b013e3181469cbd

Ophthalmic Plastic and Reconstructive SurgeryVol. 23, No. 5, pp 372–375©2007 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.

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direct exposure to define the strip width, followed by separationof the deep surface of the FL from the underlying musculatureusing an elevator under endoscopic visualization. While anassistant maintains gentle traction on the FL strip, the anteriorand posterior FL strip incisions are then continued inferiorlyunder endoscopic visualization using EMS, taking care not totraumatize the underlying musculature. An inferior FL cut ismade before finally excising a 10- to 12-cm strip. The deeptissue is closed in 2 layers with 4/0 absorbable sutures beforethe skin is sutured with 4/0 Prolene.

Low Thigh Approach:11 A short skin incision is made 10 cmto 14 cm above the knee joint (adult measurements), along aline from the head of the fibula to the anterior iliac crest. Withthe knee in the flexed position, further dissection through fatexposes the iliotibial tract at the lateral part of the FL. Thesubcutaneous tissue is undermined using periosteal elevatorsfor blunt dissection under endoscopic visualization, and thecross-fibers found high on the anterior surface of the FL aredivided to expose the vertical fibers visible on the anterior FLsurface (Fig. 1). The anterior plane (subcutaneous) and, follow-ing incision of the FL, the posterior plane (subfascial, Fig. 2)are gently opened to a point 12 cm above the incision usingblunt dissection under endoscopic visualization (Fig. 3). Long,vertical cuts are made with the EMS (width of strip, approxi-mately 12 mm) (Fig. 4A, B). Tapered superior FL cuts aremade to complete the FL strip (Fig. 4C, D) and the endoscopicgraspers are used to pull down the distal end of the strip out ofthe wound (Fig. 5). The deep tissue is closed with 4/0 absorb-able suture and the skin with 4/0 Prolene.

RESULTS

Three patients underwent harvesting of AFL under endo-scopic visualization. Two patients underwent a high-thigh ap-proach and 1 patient underwent a low-thigh approach. AFL washarvested for brow suspension ptosis surgery in 2 patients (1female age 16 years and 1 male age 63 years) and for a lowereyelid fascial sling in 1 patient (a 56-year-old man). All surgery

FIG. 1. Step 1: Clean the anterior surface. A sheathed endoscope and elevator are passed through a low-thigh incision. Cross-fibersoverlying the fascia lata, found higher in the thigh, are undermined using elevators under endoscopic visualization. Cross-fibers on theanterior surface are divided using scissors under endoscopic visualization.

FIG. 2. Step 2: Clear the posterior surface. Endoscopic view ofthe connective tissue sheath (epimysium) overlying quadriceps(underlying fascia lata) being divided using the elevator in thesub-fascial plane (posterior plane).

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was performed under general anesthesia. In all cases, 10 cm to12 cm of FL was harvested. No hematoma or other complica-tions occurred. The endoscope was of particular use in identi-fying and therefore avoiding anatomic structures related to theFL; e.g., fine blood vessels.

Although the technique was relatively straightforward, theseinitial cases took twice as long as conventional harvestingtechniques with a fasciotome.

No complications or unexpected additional surgical traumaresulted from the use of the endoscope or endoscopic browinstruments during the surgical procedure. No herniation ofthe muscle belly following the low approach was notedpostoperatively.

DISCUSSION

The video-endoscope is emerging as a useful adjunct tofacial plastic surgery1–5 and is widely used by oculoplasticsurgeons for brow and forehead lifting and endoscopiclacrimal surgery. Videoendoscopy has the advantage ofproviding a high level of local illumination and highmagnification for the operating surgeon and for observ-ers. Furthermore, it affords the opportunity to recordsurgery on video and later view the procedure, particu-larly for the purposes of teaching.

The use of the videoendoscope in assisting with FLharvesting was first reported by Tucker et al.9 for a largesheet of FL for inguinal hernia repair. It provides com-plete visualization of the anatomic structures duringharvesting of AFL. We evaluated our endoscopic AFL

FIG. 3. Step 3: Measure the length. Rigid endoscope twothirds of the way along the required length of fascia lata, indi-cated by a cutaneous line marked above the incision.

FIG. 4. Step 4: Cut the fascia. Use endoscopic Metzenbaum scissors to cut the fascia lata along its vertical length under endoscopicvisualization. A and B, Longitudinal cuts. C and D, Cut the distal end with endoscopic Metzenbaum scissors, tapering the stripto an apex.

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harvesting technique in the harvesting of a linear stripusing both the high and low approach. Each approachwas equally efficacious and the choice reflected the usualAFL harvest site of the individual surgeon. Although thepreliminary cases were performed under general anes-thesia, this technique could easily be done under tumes-cent local anesthesia. No irrigation or insufflation wasrequired and direct endoscopic visualization facilitatedthe technique. These 3 preliminary cases each took longerthan when using traditional techniques because the tech-nique was being developed. Other disadvantages of endo-AFL harvesting are the cost of the equipment and the needfor the surgeon to be skilled with the endoscope. These arenot seen as major hurdles, because many oculoplastic sur-geons already own and use endoscopic equipment.

Endoscopic harvesting of AFL offers the benefit overconventional techniques of highlighting the anatomy forteaching and it provides an alternative approach to con-ventional harvesting. This may be of benefit in the rareinstance where conventional techniques, for exampleusing a fasciotome, fail to harvest sufficient material, acomplication encountered by 2 of the authors.

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FIG. 5. Step 5: Grasp and pull out the fascia. Use endoscopic graspers to pull down the distal end of the fascia lata strip underendoscopic visualization and out of the wound. A, The graspers catch the apex of the fascia lata strip. B, The strip is pulled downthe leg toward the entry wound. C, The strip is pulled out of the wound. D, The fascia lata strip is placed flat ready to divide in 4or 5 lengths.

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