Muscle Hernia Repair at Fascia Lata Autograft Donor Site

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The muscles of the thigh are divided into 3 compartments formed by the deep avascular fascia lata. As the facia lata extends laterally it coalesces into the thick iliotibial tract, which acts as a site of muscular insertion, most notability for the tensor fascial lata that sits within the tract.^1-2 Due to its abundant surface area, tensile strength, firmness, and ease of harvest that can be tailored to the reconstructive goal, the fascia lata has been widely adopted for use as an autologous graft for soft tissue reconstruction by a wide variety of surgical specialties.^2-10 The graft is commonly used for frontalis suspension procedures by ophthalmologists and pubovaginal sling procedures by gynecologists, and it is a reliable dural substitute used extensively by neurosurgeons in skull base reconstruction.^2,10-13 It is particularly useful in the repair of cerebrospinal fluid leaks that require a reliable watertight seal.^13-15

Despite advances in biocompatible synthetics and ongoing research on alternative allografts and xenografts, autologous fascia lata remains the preferred tissue of choice owing to several advantages.^10-11,15 The autograft is readily available, free of cost, poses minimal risk of immune rejection and inflammatory response, promotes fibroblast migration, and can become well vascularized.^12,15 Various techniques for harvesting fascia lata have been described, some requiring strippers, endoscopes, or even stainless-steel plates.^14,16-17 However, typical acquisition occurs through a linear subcutaneous incision along the lateral thigh above the iliotibial tract.^10,13 To preserve some integrity of the tract, incisions should avoid severing connection to the lateral intermuscular septum and should leave several centimeters of fascia superior to the lateral knee and inferior to the iliac crest intact.² The size of the graft and incision parameters can thus be adjusted to surgical needs.

As with all clinical procedures, there are contraindications and complications associated with the fascia lata graft. It is not ideal for patients with previous injury to the fascia lata or for patients sensitive to anesthetics or lengthy procedures, as harvesting can add 45 to 60 minutes of surgical time.^10,14 While overall morbidity is considered low, the most reported complications are cosmetic deformity owing to conspicuous scar or keloid formation, muscle herniation, hematoma, seroma, and persistent pain or weakness of the donor leg.¹² Donor site complications are also affected by excessive graft harvesting, as traditional techniques are effectively fasciectomies that leave a sizeable fascial defect.^13-14 In the past decade, concerns for these risks have prompted specialists to consider more prompt reconstruction of the fascia defect at the donor site to minimize adverse outcomes.^13-14

A 43-year-old male was referred for repair of a left thigh fascial defect associated with painful muscle herniation. Two years prior to consult the patient had a left orbit osteoma compressing his eye that was removed endoscopically and complicated by a postoperative cerebrospinal fluid leak. Treatment at the time proceeded with skull base reconstruction using fascia lata from the left thigh. Repair was successful, but the patient developed a vastus lateralis muscle herniation at the donor site within a short time after his surgery. A primary repair of the fascial defect was attempted not long after but proved unsuccessful and subsequent magnetic resonance imaging (MRI) confirmed a persistent fascial defect (Figure 1). The symptoms were primarily numbness, a noticeable bulge that made the patient self-conscious, muscle spasms, and bouts of debilitating pain of the lateral thigh with walking or strenuous weight-bearing activity. Scar tissue tethering skin to the underlying muscle caused further distress by pulling skin in and out with basic movements of the leg (Figure 2). Due to these symptoms, the patient was unable to ambulate for extended periods of time and lost his employment.

Figure 1. MRI shows (A) defect in the facia lata overlaying the vastus lateralis, with herniation of the proximal vastus lateralis muscle and (B) defect measures 6.2 cm (axial plane) x 13 cm (craniocaudal plane) at time of consult.

Figure 2. Preoperative view of the left thigh showing herniating bulge at fascia lata graft donor site.

Surgical revision and repair with mesh placement was planned. The repair began with excision of the prior scar and elevation of the skin on either side to reveal a 14 × 10-cm fascia lata defect (Figure 3). A 2-cm rim under the fascia was elevated to allow inlay of the mesh. A piece of GoreTex dualmesh measuring 18 × 8 cm was then placed underneath the fascia as an underlay to prevent muscle herniation and sutured into the fascia (Figure 4). This mesh has a smooth undersurface that we placed in contact with the muscle layer to allow for unrestricted gliding. The outer surface is rough allowing for tissue ingrowth.

Figure 3. Interoperative view of herniated vastus lateralis muscle.

Figure 4. GoreTex dualmesh used to secure the repaired 14 x 10-cm fascia lata defect and associated muscle herniation.

There were no associated complications. The patient was discharged with crutches and instructions for minimal weight bearing on his left leg for 3 weeks. At 3-month follow-up, he only had minimal and occasional pain and was able to ambulate normally. The contour of his leg was much improved (Figure 5).

Figure 5. (A) frontal and (B) lateral view: Healed donor site at 2-month follow-up.

Symptomatic muscle hernias of the leg are rarely encountered in the surgical setting, as most cases respond to conservative treatment or remain asymptomatic.¹⁸ Their etiology is secondary to a fascial defect of either congenital or acquired origin.¹⁸ With particular consideration for the herniation of the vastus lateralis muscle secondary to a facial defect, the few reports in plastic surgery literature have thus far been attributed to direct trauma of the thigh, total hip arthroplasty, and fascia attenuation at the anterolateral thigh flap donor site.¹⁹ However, fascia lata harvest should also be considered a potential cause. Preliminary literary review might not make that obvious, as most articles just describe “muscle belly herniation” or “muscle prolapse” as a possible morbidity. While the incidence of symptomatic muscle herniation post facial lata harvest is unknown, incidence of muscle herniation presence post-harvest through traditional techniques has an estimated range of up to 36% across the literature.¹² Of note, the study reporting the highest incidence of herniation also required a greater width of graft tissue, measuring 20 cm.¹²

Nonetheless, the extensive use of autologous fascia lata as a dural substitute for skull base reconstruction poses a risk for muscle hernias in patients such as the one presented in this case.^12-15 The largest donor-site morbidity study focused on patients with skull base defects after endoscopic surgery who required a fascia lata graft. That study reported 11.36% of their patients experienced thigh muscle prolapse.¹² In our patient, prompt closing of the residual fascial defect left after graft harvesting might have minimized symptomatic muscle herniation at the original time of closure and use of a biocompatible material at the donor site from the beginning might have prevented a secondary revision being necessary.^13-14 As symptomatic muscle herniation of the leg is most common in young, active males, these patients would be most likely to benefit from immediate repair of the fascial defect to decrease the risk of a symptomatic hernia.¹⁸ Hernia reconstruction clearly benefitted our patient. However, it is not considered standard to fully reconstruct the fascia lata harvest site, and different specialties have tailored techniques. Thus, there is no consensus on the best method to minimize post-harvest morbidity. Furthermore, while mesh was preferred in our patient’s case, other authors have had promising results by using a collagen sheet substitute from bovine pericardium.^12-13 Of course, these solutions are not perfect. Giovannetti et al still reported herniation in 1 out of the 3 patients they treated with immediate fascial defect reconstruction using bovine pericardium.¹² Future studies incorporating a collection of surgical specialties and biocompatible materials is needed to prove efficacy.

Finally, the value of imaging should not be understated. Currently, MRI is the gold standard for assessing fascial diseases, but high-resolution ultrasound has shown its effectiveness as a rapid, cheap imaging modality for targeted visualization.^20-21 For our patient, medical history was a strong indicator for an MRI but lower extremity herniations or unknown etiology may benefit from starting with an ultrasound and moving towards MRI as index of suspicion for fascial defect increases.