1. Grafts, Flaps and Tissue Transplantation
Yağmur AYDIN, M.D.
University of Istanbul, Cerrahpasa Medical Faculty
Department of Plastic, Reconstructive and Aesthetic Surgery

2. Causes of Tissue Deficiency
Trauma
Tumoral resection
Congenital anamolies
RECONSTRUCTION
Tissue transplantation

3. RECONSTRUCTION
Form and Structure
Function
Safety

4. BALANCE in RECONSTRUCTION
Donor Area
Defect Restoration

5. RECONSTRUCTION LADDER
Free Flaps
COMPLEX
Regional Flaps
Local Flaps
Skin Graft
Primary Closure
SIMPLE
Secondary Healing

6. Nomenclature
Graft: tissue separated from its donor bed and relies on ingrowth of new vessels from the recipient tissues
Vascularized graft (or flap): remains attached to donor blood supply or becomes revascularized via microvascular anastomoses to recipient vessels
Autograft : tissue transplanted from one location to another within the same individual.
İzograft : tissue transplanted from a genetically identical donor to the recipient (syngeneic mice or human monozygotic twins)
Allogreft (homograft) : tissue transplanted between unrelated individuals of the same species
Xenogreft (hetereograft) : tissue transplanted between different species

7. Tissue Transplantation
Autologous
Skin
Dermis, fat, fascia
Cartilage
Bone
Muscle
Nerve
Allogeneic
Xenogeneic
Alloplastic materials
Metallic
Seramic
Polimeric

8. Tissue Transplantation
Basis of modern Plastic Surgery
Limited donör area for autologous tissue transplantation
Nonautologous tissues (Allogeneic, Xenogeneic) may be used for tissue deficiency
They are rejected because of foreign body antigens
Long term immunosupression need to survive longer

9. Advantages of Autologous Tissue Transplantation
Easy integration
No rejection response
No fibrous capsule formation around the transplant

10. Disadvantages of autologous tissue transplantation
Donor area morbidity
Limited supply
More complex and longer operation
Resorption and deformation

11. Immunologic Response to Allogeneic and Xenogeneic Tisuues
Cellular response (T cells)
Humoral immunologic response(B lymphocytes)
Matching of HL-A, HL-B ve HL-DR antigens are important factor in long term survival
Hyperacute rejection occurs within the first few minutes to hours after transplantation
Rejection response is less to tissues which have few cells and lesser vascularity (cornea, cartilage)

12. Biomaterials
Metals: used in plating systems for craniomaxillofacial internal fixation (Stainless steel, cobalt-chromium, pure titanium, titanium alloys,and gold )
Calcium ceramics: used as bone graft substitutes
(Hydroxyapatite, Tricalcium phosphate, hydroxyapatite cement)
Polymers: used in both bone and soft tissue reconstruction and augmentation (silicone, polyurethane, polyesters, nylon, polyethylene, polypropylene, cyanoacrylates)
Biologic materials: used in the treatment of depressed scars and facial wrinkles (collagen, fibrel, hyaluronic acid)

13. Advantages of Biomaterials
No donor site morbidity
Less operative time
Easy availability and unlimited supply
Fabricated according to patient needs
No resorption or deformation

14. Ideal Implant Biocompatible Nontoxic Nonallergenic Noncarcinogenic
Easy to shape, remove, and sterilize
Resistant to strain
Able to be fabricated into specifically required forms
Productive of no foreign-body inflamatuary response
Mechanically reliable
Resistant to resorption and deformation
Nonsupportive of growth of microorganism
Radiolucent ( not interfere with CT and MR imaging)

15. Disadvantages of Biomaterials
Rejection
Infection
Implant malposition or extrusion
Implant defects (broken, punctured)
Fibrosis around the implant because of foreign body response

16. Tissue Transplantation in Plastic Surgery
Skin
Autograft, allograft, xenograft
Bone
Autograft, allograft
Cartilage
Nerve
Tendon
Only Autograft
Fascia

17. Skin Anatomy

18. Skin Embryology Derived form both ectoderm and mesoderm
Ectodermal skin appendages develop with formation of epidermis at 11 weeks of gestation and complete at 5 months
Suface of Ectoderm : Epidermis,Pilosebaceous glands, Apocrine and eccrine sweat glands, Hair follicles, Nail units
Neuroectoderm: melamocytes, nerves, and specialized sensory units
Mesoderm : Sructural components of dermis
(macrophages, mast cells, Langerhan’s cells, Merkel cells, fibroblasts, blood and lymphatic vessels)

19. Skin Functions The skin is the largest organ of the body
Protect underlying structures from enviromental trauma by entry of pathogens and potentially toxic substances
Must allow considerable compressions and extentions
Passive regulation of intracellular fluid balance and active regulation of body temperature

20. Skin Grafts

21. Skin Autograft full thickness or partial thickness
require a recipient bed that is well vascularized and free of devitalized tissue and no bacterial contamination (<105 microorganisms per gram of tissue)
Close contact between the skin graft and its recipient bed is essential
hematoma beneath the graft and insufficent immobilization are common causes of graft failure
To optimize take of a skin graft, the recipient site must be prepared before grafting

22. Skin Graft Survival
The transplanted skin derives its initial nutrition via serum from the recipient site in a process called “plasmatic imbibition” last for 24 to 48 hours
The graft then gains blood supply from the recipient bed by ingrowths of blood vessels. This process of “inosculation“ begins within 48 hours

23. Skin Autograft
full thickness
partial thickness

25. Partial Thickness Skin Grafts
Consist of entire epidermis and a portion of dermis
A thin split-thickness harvest site will generally heal within 7 days
SSG’s can be taken from anywhere on the body
The abdominal wall, buttocks, and thigh are common donor sites for SSG’s

26. Skin Graft Donor Site Healing
The donor site epidermis regenerates from the immigration of epidermal cells originating in the hair follicle shafts and adnexal structures left in the dermis
A thin split-thickness harvest site (less than 10/1,000 of an inch) will generally heal within 7 days
Full-thickness skin graft harvest sites heal by primary intention

28. Most Common Causes of Autolous Skin Graft Failure
Hematoma, Seroma
Infection (> 105 organism/1gr tissue)
Shear force ( inadequate immobilization)
Poor vascularized bed (fibrozis, radiotherapy; exposed bone, cartilage, or tendon devoid of its periosteum, perichondrium, or paratenon)

29. Full Thickness Skin Graft
contains the entire dermis (adnexal structures such as sweat glands, sebaceous glands, hair follicles, and capillaries)
Usually harvest from skin is thin(upper eyelid, postauricular area, or supraclavicular area). Other harvest sites are hairless groin, antecubital fossa, distal forearm, prepuce
FSG harvest sites can be closed primarily or applied a SSSG from another body part

30. Advantages &Disadvantages
Full thickness skin graft
Split thickness skin graft
Require well-vascularized bed
prone to increased graft contraction and hypertrophic scarring
Poor color and texture match
abnormal pigmentation
Less than ideal cosmetic result
highly susceptible to trauma
Better graft “take
Large available donor site
Expansion of the split-thickness skin graft by meshing with expansion ratios from 1:1.5 to 1:9
Take under less favorable condition
The less secondary contracture
Good color and texture match
Excellent cosmetic result
Potential for growth
less reliable graft “take
Limited donor site

31. Sensory return
Graft sensation is regained as nerves grow into the graft
Sensory recovery begins at around 4-5 weeks and is completed by months
Pain,light touch, and temperature return in that order

32. Skin Allografts
Skin allograft was the first “organ” transplant achieved and constituted the foundation of modern transplant immunology
strongly antigenic and is subject to rejection ( 10 days in burns)
Obtained from relatives or human corpse (frozen and stored)
beneficial in large burns (> % 50) as a biologic dressing
Frozen and stored or may be used immediately with cyclosporine immunusupression

33. Skin Xenografts
Pig skin grafts can be used as temporary biologic dressings in large burns
Hyperacute rejection occurs within the first few minutes to hours after transplantation
Advantages
Cheap, easy availablility, easy storage and sterility

34. Skin Flaps

35. Skin Flaps Unlike a graft, a flap has its own blood supply
Consist of skin and subcutaneous tissue that are transferred from one part of the body to another with a vascular pedicle or attachment to the body being maintained for nourishment

36. When skin flaps are used?
Covering recipient beds that have poor vascularity
Reconstructing the full thickness of the eyelids, lips, ears, nose, and cheeks; and padding body prominencies (i.e., for bulk and contour)
It is necessary to operate through the wound at a later date to repair underlying structures
Muscle flaps may provide a functional motor unit or a means of controlling infection in the recipient area

37. The Cutaneous Arteries
arise directly from the underlying source (segmental or distributing) arteries, or indirectly from branches of those source arteries to the deep tissues
From here the cutaneous arteries follow the connective tissue framework of the deep tissues, either between (septocutaneous) or within the muscles (musculocutaneous)
They then pierce that structure, usually at fixed skin sites. ultimately reaching the subdermal plexus
Direct Cutaneous Vessels
Indirect Cutaneous Vessels
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)

38. Skin Blood Vessels

40. Patterns of Blood Supply to the Skin
Direct cutaneous pedicle
Fascicutaneous pedicle
Musculocutaneous pedicle

41. Skin Flap Classification
Proximity to defect : Local
Distant

42. Skin Flap Classification
Composition: Cutaneous
Fasciocutaneous
Musculocutaneous
Osteocutaneous

43. Skin Flap Classification
Method of movement: Advancement
Rotation
Transposition
Interpolation
Free

48. Transposition Flap

49. Bilobed Flap

50. Z Plasty
revise and redirect existing scars or provide additional length in the setting of scar
Angles of Z-plasty Theoretical gain in length(%)

51. Skin Flap Classification
Specialized : Sensory
Tendon
Hair bearing

52. Skin Flap Classification
Blood supply : Random
Axial pattern
Fasciocutaneus
Musculocutaneous

53. Old Fashioned Classification of Skin Flaps

54. based on the circumflex superficial iliac artery and vein
Vascular territories of the most commonly used axial pattern flaps
Groin Flap
based on the circumflex superficial iliac artery and vein

55. Skin Flap Classification
Manipulation before transfer
Delay
Expansion
Prefabrication
Prelamination

56. Other Flaps Muscular Bone Visceral organ (jejenum, sigmoid colon)
Omentum

57. Free Composite Grafts
Contain two or more tissue (dermis-cartilage, dermofat, skin-muscle, pulpa)
Need well-vascularized bed
Poor vascularization and graft taking
Stasis and necrosis in the graft because of insufficent venous and lymphatic return
Results is not optimal
Limited size
Contraction
Contur problem because of bowing

58. Enhancing Survival of Composite Grafts
Well vascularized bed, no fibrosis
Atrumatic technique
Postoperative cooling
> 5 mm distant from the nearest vascular bed is at risk for necrosis
Center of graft is never more than 5-8 mm away from a blood supply

59. Composite Grafts in Plastic Surgery
Nose (from ear or nasal septum)
Nasal ala
Columella
Lateral nasal wall
Nasa roof and lining reconstruction
Short nose
Septal perforation
Ear
Helical rim
Chonca
Tragus
Eyebrow (scalp)
Nipple (opposite nipple or ear lobule)
Eyelid (septal chondromucosal graft)

61. Bone Transplantation
Both bone autograft and allografts are used for bone defect reconstruction
Bone xenografts are not used nowadays because of sequester of all viable osteocyte
Cortical or cancellous bone graft
Revascularization of cortical grafts may take a few months
Revascularization of cancellous bone grafts are more rapid
Healing of vascularized bone grafts are better. Particularly suitable in a field after trauma, cronic scarring, or prior radiation. Biomecanically are superior to nonvascularized grafts

62. Bone Graft Donor Areas Cranium (cortical) Thorax (split rib grafts)
İliac ( good quality cortical and cancellous bone source)
Tibia (cancellous )
Others
Distal radİUs, proXimal ulna (hand surgery)
Fibula (esp. vascularized flap)
Metatars

63. Tendon Grafts
Only if primary or delayed primary repair is not feasible
Contrindicated if there is stiff joints, adherent extensor tendons, and inadequate skin cover
Only autograft
Unacceptable amount of host reaction and adhesion after allografts and xenografts

64. Donor Areas for Tendon Graft
Palmaris longus (usually)
Plantaris
Middle 3 toes extensor tendons

65. Cartilage Grafts Cartilage has no intrinsic blood supply
The use of cartilage autografts is widespread and includes nasal, auricular, craniofacial skeleton, and joint reconstruction
Cartilage is immunologically privileged due to the shielding of chondrocytes by its matrix, which is only weakly antigenic
Both chondrocytes and matrix are subject to xenogeneic mechanisms of rejection with a generally poorer outcome in comparison. There is only small number of usage

66. Donor Areas for Cartilage Graft
Choose according to aim
Costal cartilage(7,8 ve 9. ribs)
Ear reconstruction
Nasal dorsal and alar area reconstruction
Ear cartilage:
Lower eyelid support
Nipple-aerola reconstruction
Orbita floor reconstruction
Temporomandibular joint repair
Nasal septal cartilage
Aestetic Rhinoplasty and Nasal reconstruction

67. Nerve Grafts
The nerve graft acts as a biologic conduit for the regenerating axons
Vascularized nerve grafts are theoretically advantageous particularly in scarred beds
Other “conduits” used as nerve grafts have included autologous vein, silicone tube seeded with Schwann cells, and freeze fractured autologous muscle

68. Donor Areas for Nerve Graft
Sural sinir (most often)
N. Safeneous
Lateral femoral cutaneous nerve
Medial antebrachial cutaneous nerve
Lateral antebrachial cutaneous nerve
Dorsal antebrachial cutaneous nerve
Superficial radialal nerve
Servikal plexus cutaneous nerves
Interkostal nerve