Grafts-Flaps and Tissue Transplantation

7/24/2019 Grafts-Flaps and Tissue Transplantation

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Grafts, Flaps and TissueTransplantation

Yamur AYDIN, M.D.

University of Istanbul, Cerrahpasa Medical FacultyDepartment of Plastic, Reconstructive and esthetic !ur"ery


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Causes of Tissue

D ici ncy

Trauma

Tumoral resection

Con"enital anamolies

RECONSTRUCTION

Tissue transplantation


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RECONSTRUCTION

FunctionForm and !tructure

!afety


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BALANCE in RECONSTRUCTION

Defect RestorationDonor rea


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RECONSTRUCTION LADDER

!IMP#$

#ocal Flaps

Primary Closure

!econdary %ealin"

C&MP#$' Re"ional Flaps

!(in Graft

Free Flaps


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Graft:tissue separated from its donor bed and relies

on in"ro)th of ne) vessels from the recipient tissues*ascuari!"# $raft %&r fa'(:remains attached todonor blood supply or becomes revasculari+ed viamicrovascular anastomoses to recipient vessels

Aut&$raft : tissue transplanted from one location to

another )ithin the same individual)!&$raft :tissue transplanted from a "eneticallyidentical donor to the recipient -syn"eneic mice orhuman mono+y"otic t)ins.

A&$r"ft %*&m&$raft( :tissue transplanted bet)eenunrelated individuals of the same species+"n&$r"ft %*"t"r"&$raft( :tissue transplantedbet)een different species

Nomenclature


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Tissue Transplantation

utolo"ous !(in Dermis, fat, fascia Cartila"e /one Muscle 0erve

llo"eneic'eno"eneic

lloplastic materials Metallic !eramic Polimeric


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Tissue Transplantation

/asis of modern Plastic !ur"ery#imited don1r area for autolo"ous tissue

transplantation0onautolo"ous tissues -llo"eneic,'eno"eneic. may be used for tissuedeficiencyThey are re2ected because of forei"n bodyanti"ens#on" term immunosupression need to survivelon"er


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Advantages of Autologous Tissue

Transplantation

$asy inte"ration

0o re2ection response

0o fibrous capsule formation aroundthe transplant


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Disadvantages of autologous

tissue transplantation

Donor area morbidity

#imited supply

More comple3 and lon"er operation

Resorption and deformation


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Immunologic Response to Allogeneic

and Xenogeneic Tisuues

Cellular response -T cells.%umoral immunolo"ic response-/lymphocytes.

Matchin" of %#4, %#4/ ve %#4DR anti"ens areimportant factor in lon" term survival%yperacute re2ection occurs )ithin the first fe)minutes to hours after transplantation

Re2ection response is less to tissues )hichhave fe) cells and lesser vascularity -cornea,cartila"e.


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iomaterials

5 Metals6used in platin" systems for cranioma3illofacial internal

fi3ation-!tainless steel, cobalt4chromium, pure titanium, titaniumalloys,and "old .

7 Calcium ceramics6used as bone "raft substitutes-%ydro3yapatite, Tricalcium phosphate, hydro3yapatite cement.

8 Polymers6used in both bone and soft tissue reconstructionand au"mentation -silicone, polyurethane, polyesters, nylon,

polyethylene, polypropylene, cyanoacrylates.

9 /iolo"ic materials6used in the treatment of depressed scarsand facial )rin(les -colla"en, fibrel, hyaluronic acid.


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Advantages of iomaterials

0o donor site morbidity

#ess operative time

$asy availability and unlimited supply

Fabricated accordin" to patient needs

0o resorption or deformation


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Ideal Implant

/iocompatible0onto3ic0onaller"enic0oncarcino"enic

$asy to shape, remove, and sterili+eResistant to strainble to be fabricated into specifically re:uired formsProductive of no forei"n4body inflamatuary response

Mechanically reliableResistant to resorption and deformation0onsupportive of "ro)th of microor"anismRadiolucent - not interfere )ith CT and MR ima"in".


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Disadvantages of

iomaterialsRe2ection

Infection

Implant malposition or e3trusion

Implant defects -bro(en, punctured.

Fibrosis around the implant because offorei"n body response


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Tissue Transplantation in

!lastic Surgery!(in

uto"raft, allo"raft, 3eno"raft

/one

uto"raft, allo"raftCartila"e

uto"raft, allo"raft, 3eno"raft

0erveuto"raft, allo"raft

Tendon &nly uto"raft

Fasciauto"raft, allo"raft


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S"in Anatomy


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S"in Em#ryology

Derived form both ectoderm and mesoderm

$ctodermal s(in appenda"es develop )ith formationof epidermis at 55 )ee(s of "estation and completeat ; months

!uface of $ctoderm 6 $pidermis,Pilosebaceous "lands,pocrine and eccrine s)eat "lands, %air follicles, 0ail units

0euroectoderm6 melamocytes, nerves, and speciali+ed

sensory unitsMesoderm6 !ructural components of dermis

-macropha"es, mast cells, #an"erhan


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S"in $unctions

The s(in is the lar"est or"an of the bodyProtect underlyin" structures from

enviromental trauma by entry of patho"ensand potentially to3ic substancesMust allo) considerable compressions ande3tentions

Passive re"ulation of intracellular fluidbalance and active re"ulation of bodytemperature


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S"in %rafts


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S"in Autograft

full thic(ness or partial thic(nessre:uire a recipient bed that is )ell vasculari+ed andfree of devitali+ed tissue and no bacterialcontamination -=5>;microor"anisms per "ram oftissue.

Close contact bet)een the s(in "raft and its recipientbed is essentialhematoma beneath the "raft and insufficentimmobili+ation are common causes of "raft failure

To optimi+e ta(e of a s(in "raft, the recipient site mustbe prepared before "raftin"


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S"in %raft Survival

The transplanted s(in derives its initialnutrition via serum from the recipient sitein a process called ?plasmatic imbibition@

last for 79 to 9A hoursThe "raft then "ains blood supply from therecipient bed by in"ro)ths of blood

vessels This process of ?inosculation?be"ins )ithin 9A hours


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S"in Autograft

full thic(ness

partial thic(ness


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S"in %raft Donor Site

'ealingThe donor site epidermis re"enerates fromthe immi"ration of epidermal cells ori"inatin"

in the hair follicle shafts and adne3alstructures left in the dermis

thin split4thic(ness harvest site -less than5>5,>>> of an inch. )ill "enerally heal )ithin

B daysFull4thic(ness s(in "raft harvest sites heal byprimary intention


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(ost Common Causes of

Autolous S"in %raft $ailure

%ematoma, !eroma

Infection - 5>; or"anism5"r tissue.!hear force - inade:uate immobili+ation.

Poor vasculari+ed bed -fibro+is,

radiotherapyE e3posed bone, cartila"e, ortendon devoid of its periosteum, perichondrium,or paratenon.


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$ull T&ic"ness S"in %raft

contains the entire dermis -adne3al structures suchas s)eat "lands, sebaceous "lands, hair follicles,and capillaries.

Usually harvest from s(in is thin-upper eyelid,postauricular area, or supraclavicular area. &therharvest sites are hairless "roin, antecubital fossa,distal forearm, prepuce

F!G harvest sites can be closed primarily or applied

a !!!G from another body part


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Re:uire )ell4vasculari+ed bedprone to increased "raftcontraction and hypertrophicscarrin"

Poor color and te3ture matchabnormal pi"mentation#ess than ideal cosmetic resulthi"hly susceptible to trauma

/etter "raft ?ta(e#ar"e available donor site$3pansion of the split4thic(nesss(in "raft by meshin" )ithe3pansion ratios from 565; to56

Ta(e under less favorable condition

The less secondary contracture

Good color and te3ture match

$3cellent cosmetic result

Potential for "ro)th

less reliable "raft ?ta(e#imited donor site

Full thickness skin graft Split thickness skin graft

Advantages )Disadvantages


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Sensory return

Graft sensation is re"ained as nerves"ro) into the "raft

!ensory recovery be"ins at around 94;)ee(s and is completed by 57479months

Pain,li"ht touch, and temperature returnin that order


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S"in Allografts

!(in allo"raft )as the first ?or"an@ transplantachieved and constituted the foundation of moderntransplant immunolo"y

stron"ly anti"enic and is sub2ect to re2ection - 5> daysin burns.

&btained from relatives or human corpse -fro+en andstored.

beneficial in lar"e burns - ;>. as a biolo"icdressin"

Fro+en and stored or may be used immediately )ithcyclosporine immunusupression


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S"in $laps


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*&en s"in flaps are used+

Coverin" recipient beds that have poor vascularity

Reconstructin" the full thic(ness of the eyelids, lips,ears, nose, and chee(sE and paddin" bodyprominencies -ie, for bul( and contour.It is necessary to operate throu"h the )ound at alater date to repair underlyin" structures

Muscle flaps may provide a functional motor unit or ameans of controllin" infection in the recipient area


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T&e Cutaneous Arteries

arise directly from the underlyin" source -se"mental or distributin". arteries,or indirectly from branches of those source arteries to the deep tissuesFrom here the cutaneous arteries follo) the connective tissue frame)or( ofthe deep tissues, either bet)een %s"'t&cutan"&us.or )ithin the muscles%muscu&cutan"&us(They then pierce that structure, usually at fi3ed s(in sites ultimatelyreachin" the subdermal ple3us

Schematic diagram of the direct (d) and indirect (i) cutaneous perforators of a source artery and

their relationship to the deep fascia (arrow), the intermuscular septa and muscle (shaded area)

Direct Cutaneous *esselsIndirect Cutaneous *essels


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!atterns of lood Supply to t&e S"in

Direct cutaneous pedicle

Fascicutaneous pedicle

Musculocutaneous pedicle


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S"in $lap Classification

Pro3imity to defect 6 #ocalDistant


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Composition6Cutaneous

Fasciocutaneous

Musculocutaneous

&steocutaneous


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Method of movement6 dvancement

Rotation

Transposition

Interpolation

Free


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Transposition Flap


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/ilobed Flap

- !l t


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- !lasty

revise and redirect existing scars or

provide additional length in the setting o

scar

Angles of Z-plasty heoretical gain in length(!)"#-"# $%

&%-&% %#

'#-'# %

%-% ##

*#-*# $#


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!peciali+ed 6 !ensory

Tendon

%air bearin"


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/lood supply 6 Random

3ial pattern

FasciocutaneusMusculocutaneous


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Old $as&ioned Classification

of S"in $laps


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*ascular territories of the mostcommonly used a3ial pattern flaps

+roin Flap

ased on the circumflex

superficial iliac artery and vein


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Manipulation before transfer

Delay

$3pansionPrefabrication

Prelamination


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Ot&er $laps

Muscular

/one

*isceral or"an -2e2enum, si"moid colon.&mentum


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$ree Composite %rafts

Contain t)o or more tissue -dermis4cartila"e,dermofat, s(in4muscle, pulpa.

0eed )ell4vasculari+ed bed

Poor vasculari+ation and "raft ta(in"

!tasis and necrosis in the "raft because ofinsufficent venous and lymphatic return

Results is not optimal #imited si+e

Contraction

Contur problem because of bo)in"


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En&ancing Survival of

Composite %raftsHell vasculari+ed bed, no fibrosis

trumatic techni:ue

Postoperative coolin" ; mm distant from the nearest vascularbed is at ris( for necrosis

Center of "raft is never more than ;4A mma)ay from a blood supply

C it % ft i !l ti


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Composite %rafts in !lastic

Surgery

0ose -from ear or nasal septum. 0asal ala Columella #ateral nasal )all 0asa roof and linin" reconstruction !hort nose !eptal perforation

$ar %elical rim Chonca Tra"us

$yebro) -scalp.0ipple -opposite nipple or ear lobule.$yelid -septal chondromucosal "raft.


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one Transplantation

/oth bone auto"raft and allo"rafts are used for bonedefect reconstruction/one 3eno"rafts are not used no)adays because ofse:uester of all viable osteocyte

Cortical or cancellous bone "raftRevasculari+ation of cortical "rafts may ta(e a fe) monthsRevasculari+ation of cancellous bone "rafts are morerapid%ealin" of vasculari+ed bone "rafts are better Particularlysuitable in a field after trauma, cronic scarrin", or priorradiation /iomecanically are superior to nonvasculari+ed"rafts


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one %raft Donor Areas

Cranium -cortical.Thora3 -split rib "rafts.

liac - "ood :uality cortical and cancellous bonesource.Tibia -cancellous .&thers

Distal radUs, pro'imal ulna -hand sur"ery. Fibula -esp vasculari+ed flap.Metatars


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Tendon %rafts

&nly if primary or delayed primary repair isnot feasible

Contrindicated if there is stiff 2oints, adherente3tensor tendons, and inade:uate s(in cover

&nly auto"raft

Unacceptable amount of host reaction andadhesion after allo"rafts and 3eno"rafts


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Donor Areas for Tendon %raft

Palmaris lon"us -usually.

Plantaris

Middle 8 toes e3tensor tendons


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Cartilage %rafts

Cartila"e has no intrinsic blood supplyThe use of cartila"e auto"rafts is )idespread andincludes nasal, auricular, craniofacial s(eleton, and

2oint reconstructionCartila"e is immunolo"ically privile"ed due to theshieldin" of chondrocytes by its matri3, )hich is only)ea(ly anti"enic/oth chondrocytes and matri3 are sub2ect to

3eno"eneic mechanisms of re2ection )ith a "enerallypoorer outcome in comparison There is only smallnumber of usa"e


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Donor Areas for Cartilage

%raftChoose accordin" to aim Costal cartila"e-B,A ve ribs.

$ar reconstruction 0asal dorsal and alar area reconstruction

$ar cartila"e6 #o)er eyelid support 0ipple4aerola reconstruction

&rbita floor reconstruction Temporomandibular 2oint repair 0asal septal cartila"e

estetic Rhinoplasty and 0asal reconstruction


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Nerve %rafts

The nerve "raft acts as a biolo"ic conduit for there"eneratin" a3ons

*asculari+ed nerve "rafts are theoreticallyadvanta"eous particularly in scarred beds

&ther ?conduits@ used as nerve "rafts haveincluded autolo"ous vein, silicone tube seeded

)ith !ch)ann cells, and free+e fracturedautolo"ous muscle

D A f N


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Donor Areas for Nerve

%raft!ural sinir -most often.0 !afeneous#ateral femoral cutaneous nerve

Medial antebrachial cutaneous nerve#ateral antebrachial cutaneous nerveDorsal antebrachial cutaneous nerve

!uperficial radialal nerve!ervi(al ple3us cutaneous nervesInter(ostal nerve

Grafts-Flaps and Tissue Transplantation

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