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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S"in $lap Classification
Composition6Cutaneous
Fasciocutaneous
Musculocutaneous
&steocutaneous
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S"in $lap Classification
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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S"in $lap Classification
!peciali+ed 6 !ensory
Tendon
%air bearin"
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S"in $lap Classification
/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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S"in $lap Classification
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