Autologous Fascial Grafts and Acellular Allografts

Introduction

Free fascial grafts and allogeneic options, such as acellular dermis like Alloderm, are available for use in various settings of head and neck reconstruction. There are many sources of these tissues including the fascia lata (FL), temporal fascia as well as those made from dermal sheets either autologous or “off the shelf” acellular versions. Not only are there many sources of these materials, but there are many uses. From soft tissue augmentation to supporting facial structures, surgeons have made many innovations using them to optimize function and form of the head and neck. In this chapter, we focus on a select few uses of these grafts. For instance, we describe the commonly used FL grafts in facial paralysis. We also demonstrates the use of Alloderm as a soft tissue augmentation material. The examples described are merely a sampling of the many uses of these tissues but highlight the potential of their use.

Key Operative Learning Points

• Soft tissue and defect assessment—What’s missing?

• Reconstructive goals

• Harvest and inset of FL graft

• Considerations for Alloderm placement

Preoperative Period

Patient selection may prove to be even more vital to reconstructive success than the technical aspects. The patient’s overall health and history may by default limit many surgical pathways. Additionally, the goals of care of the patient need to be verbalized, and both the surgeon and the patient should agree on the most reasonable reconstructive option in lieu of final treatment goals. Risks and benefits must be discussed in detail with consideration of the ultimate morbidity from reconstructive efforts such as the possibility of nonhealing wounds, increased donor sites and scarring, Alloderm-related infection or seroma, and future revision surgeries.

History

A history of wound healing issues, diabetes, and cardiopulmonary history should be obtained alongside our anesthesia colleagues to help be certain of adequate safety in proceeding with surgery. Nutrition should be assessed preoperatively as it bears direct consequences on wound healing. This is especially important when a second surgical site is created, as this is an additional wound, and this should be discussed at length with the patient.

• 1.

  History of present illness

  • a.

    Risk factors for complication: smoking, diabetes mellitus, vasculopathy, vascular injury, radiation, chemotherapy

  • b.

    Nutritional status

  • c.

    Facial paralysis due to resection of facial nerve, trauma, or idiopathic, for example, Bell’s palsy

• 2.

  Past medical history

  • a.

    Diabetes mellitus

  • b.

    Prior radiation to surgical field

  • c.

    Vasculopathy

  • d.

    Pulmonary disease

  • e.

    Cardiac disease

  • f.

    Immunosuppression

  • g.

    Chronic pain syndrome

  • h.

    Systemic vascular disease

• 3.

  Prior treatment of scalp, skull base, facial nerve, or parotid gland

  • a.

    Prior known cancer of the head and neck

  • b.

    Previous surgery of the head and neck

  • c.

    Previous chemotherapy or radiation

• 4.

  Current medications

  • a.

    Anticoagulants including antiplatelet agents and new generation coagulation cascade inhibitors

  • b.

    Herbal products

  • c.

    Allergies to antibiotics and pain medication

• 5.

  Social history

  • a.

    Psychologic: patient understands and can accept new deficits and issues related to reconstruction

  • b.

    Patient expectations

  • c.

    Support system: case manager or social worker is consulted to assess patient’s support system and needs

  • d.

    Goals of employment

  • e.

    Substance abuse, particularly narcotics

Fascia Lata

When to Consider Fascia Lata

Physical Examination

• 1.

  Face

  • a.

    Examination of the facial and trigeminal nerve and overall functional deficits

    • 1)

      Ptosis, facial nerve injury/paralysis

    • 2)

      Oral competence

    • 3)

      Signs and symptoms of dry eye

    • 4)

      Eye closure

  • b.

    Baseline symmetry of soft tissue structures, eyebrows, lips, eyelids

  • c.

    Location of rhytids, quality of skin, evidence of hypertrophic or keloid scarring

  • d.

    Neurovascular involvement

    • 1)

      Facial nerve involvement/resection

• 2.

  Health status

  • a.

    Nutrition/weight loss

  • b.

    Cardiovascular health

  • c.

    Pulmonary health

  • d.

    Mental status and sources of emotional support

  • e.

    Smoking status

  • f.

    Alcohol or narcotic addiction

Imaging

• Not usually necessary unless concern for recurrent disease

Indications (Fascia Lata Graft)

• Fascial sling for facial soft tissue support for facial nerve palsy following trauma, neoplasm, congenital sequelae, or cerebrovascular accident

• Can also be used as a sling for brow elevation, lip ptosis, and orbital support

• Autologous in nature, relatively infectious resistant, incorporates well

• Does not stretch such as seen in dermal grafts or Alloderm

• Minimal donor site morbidity

• Can be harvested endoscopically

Contraindications

• 1.

  Patient factors

  • a.

    Unstable health status

  • b.

    Poor nutrition

  • c.

    Inability to give informed consent

  • d.

    Inability to accept postoperative morbidity

  • e.

    Low Global Assessment of Functioning (GAF) or low social support

  • f.

    Smoking

  • g.

    Collagen-vascular disease

• 2.

  Surgical factors

  • a.

    Prior harvest of fascia from the area

  • b.

    Radiation to harvest area

  • c.

    Prior surgery or trauma to the leg

Preoperative Preparation

• 1.

  Evaluations by

  • a.

    Reconstructive surgeon

  • b.

    Anesthesiology

  • c.

    Physical medicine and rehabilitation

Operative Period

Anesthesia

• General

Positioning

• The entire face, neck, and selected donor site (lateral thigh and entire scalp and face) are sterilized and draped in the usual fashion.

• The surgery is done with the patient in a supine position or lateral to facilitate FL harvest but can also be repositioned for inset.

Perioperative Antibiotics

• Ideally, they are administered during induction of anesthesia and continued for 24 hours.

• Choices

  • Cefazolin

  • Clindamycin

  • Vancomycin

  • Ciprofloxacin

Monitoring

• Routine anesthesia care

• Muscle paralysis can be beneficial during FL harvest.