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SKIN PLASTY (plastic surgery)

Skin plastic surgery is the largest section of plastic surgery. Its methods are very diverse. Most often in clinical practice, an autoplastic technique of operations is used, both with a free and non-free skin flap.

Non-free skin grafting . The basic principle of non-free skin grafting is cutting out a skin flap on a feeding pedicle together with the underlying adipose tissue, in which the blood vessels feeding the flap pass. In this case, the leg of the flap should be wide, not bend, not have tension, not be squeezed by a bandage, etc.

The simplest type of skin non-free plasty is method of refreshing and tightening the edges of wounds. Often this type of skin grafting is carried out with the help of additional skin incisions that form triangular, oval and other types of skin flaps (methods of A.A. Limberg, Joseph), which move relative to their feeding legs and allow closing skin defects - wounds, ulcers, defects skin after excision of scars. In this type of skin grafting, the skin flap is cut out from the tissues located in close proximity to the defect.

In cases where the tissues adjacent to the skin defect are not enough to close it, it is used plasty with a skin flap on a leg. The skin flap is cut out in a part of the body remote from the defect to be closed. Examples of the type of plasty with a skin flap on a leg can be the “Italian method”, the plasty with a “bridge flap” according to N.V. Sklifosovsky and Sontag, the plasty according to the method of V.P. Filatov “Filatov stem”.

Method "Italian plastic" on the leg more appropriate. After the flap has healed in the area of ​​the defect, its pedicle is transected. In our country, the development of the method of plastic surgery with a skin flap on a leg is associated with the names of N.A. Bogoraz, N.N. Blokhin, B.V. Parin.

Plastic "bridge method" according to N.V. Sklifosovsky consists in the fact that a skin-fatty tape is cut out on the back or on the stomach, which is cut off to the fascia and the wound under it is sutured. The skin flap remaining on two legs is lifted and the area of ​​the limb with a tissue defect is brought under it, to which this flap is sutured. This plastic method is quite effective, but has limited application.

Dermal method plastics according to V.P. Filatov - "Filatov stem"is as follows: a skin flap separated in the form of a tape is sutured in the form of a tube. The wound under it is sutured tightly. Usually such a flap is cut out from the skin of the abdomen, gluteal region, thigh or shoulder. After harvesting the flap, it is “trained” by daily pulling with a rubber strip of one of the legs of the flap, starting from 10 minutes to 1-2 hours for 2-4 weeks. During this time, the blood supply is restructured, and the flap begins to feed through the leg that was not pinched. The transfer of the flap stem to the tissue defect to be closed is most often carried out through the patient's hand, to which the flap is sutured with the end that has lost the ability to blood supply to the flap tissues. After complete engraftment of the leg of the flap to the hand, it is crossed in the area of ​​the other leg, which is brought to the area of ​​the tissue defect and fixed to it. After 3 weeks, the flap is cut off by hand and the process of plastic surgery of the skin defect is completed.

The success of skin grafting according to the method of V.P. Filatov is ensured by a good blood supply to the tissues of the flap. With the help of the Filatov stem, it is possible to form the nose, eyelids, lips, ears, cheeks. The Filatov stem is of particular importance for the plastic closure of a skin defect formed from a trophic ulcer, as well as skin defects of the limb stump.

Free skin graft . This type of skin grafting is used to close large skin defects. Most often it is used to close the wound surface after skin burns. There are various methods of free skin grafting, each of which has its own indications.

Reverden-Yanovich-Chainsky method consists in the fact that on a healthy part of the body, pieces of skin 0.5 cm in size are excised with a razor along with the papillary layer of the skin and placed on a granulating wound surface. This method of plasty cannot be used to close skin defects on the face, as well as in the area of ​​​​the joints due to the possibility of formation of dense scars.

Thiersch's methodconsists in cutting out epidermal skin flaps and laying them on a wound surface prepared for plasty. The cut flaps are 1.5x3.0 cm in size. They are usually taken in the thigh area. On top of the wound, closed with a skin flap, an aseptic dressing with antibiotics is applied.

Widespread in plastic surgery for closing skin defects received method of skin plasty with a perforated flap. A loose skin graft is usually taken from the abdomen. Before fixing the skin graft on the wound surface, perforations are made with a scalpel over its entire area. To the edges of the skin defect, the flap is fixed with sutures. An aseptic bandage is applied on top.

In cases where it is necessary to close large skin defects, the skin flap is taken using special devices - dermatomes, the designs of which are very diverse. Manual, electric and pneumatic dermatomes allow cutting out skin flaps different thickness and squares. Dermatomal cutting out of the skin graft is of great importance in the treatment of deep skin burns.

In clinical practice, it is often necessary to use a combination of skin grafting methods, since it is difficult to give preference to any one grafting method.

Among the methods of skin plastics brephoplastic skin grafting should be distinguished - transplantation of skin grafts taken from the corpses of 6-month-old fetuses. The types of plastics and the method of taking the graft are no different from those described above. The advantage of brefoplastic skin grafting is that the embryonic skin has weak antigenic properties and well survives on the wound surface. This eliminates the need to select a donor for group compatibility.

VASCULAR PLASTY

Progress in biology, medicine, and chemistry has made it possible to widely introduce into vascular surgery the complete replacement of entire segments of blood vessels, including the aorta and vena cava, with various types of grafts and prostheses. Behind last years in vascular plastic surgery, autografts from veins, homografts from arteries are used. However, alloplastic prostheses are most often used.

Venous autograft well accustomed to the tissue of the vessel. It is nourished by the blood flowing through it. At the same time, venous autoplasty is not without drawbacks. These include the possibility of developing an aneurysm in the wall of the transplanted vein, as well as obstruction of the autograft either due to the cicatricial process or due to the process of thrombus formation.

The possibility of harvesting cadaveric arterial grafts with the help of special conservation made it possible to use them for prosthetics of the main vessels. To do this, prostheses taken from a corpse are frozen and dried (lyophilization of the graft). However, vascular alloplasty has found the widest distribution in vascular plastic surgery. For this, special synthetic prostheses are used, which replace various parts of the vessels or perform a bypass shunting of impassable sections of the vessels. For suturing vessels between themselves and with prostheses in Lately special sewing machines are used.

PLASTY OF PERIPHERAL NERVE DEFECTS

Plastic methods for replacing defects in peripheral nerve trunks are used in cases where, due to the significant length of the defect (10 or more cm), it is not possible to bring the ends of the nerve together.

In clinical practice, it is used patchwork method nerve, proposed and implemented in 1872 by Letyevan. In this case, a special nerve suture is used.

Nerve trunk defect plasty can be performed using autografts, which are segments of cutaneous nerves taken in those areas where collateral innervation is possible. The negative point of nerve plasty with an autograft is the discrepancy between the diameter of the affected nerve and the graft.

A nearby muscle bundle can be used as a graft for plasty of the nerve trunk defect. This bundle is sutured to the site of the defect in the nerve trunk (Murphy-Moskovich method).

The desire to find a way to replace large defects in the nerve trunks led to the idea of ​​using preserved nerves taken from animals and humans for plastic surgery. Such a graft is stored for a long time, can always be pre-prepared and have the required length and be used at any time. For the preservation of nerves, a 5-12% formalin solution is used. Clinical practice has shown that the best grafts are nerve trunks taken from a calf. They are rich in nerve fibers and poor in collagen tissue.

Control questions

1. The concept of skin plastics (KP).

2. Classification of skin plastics.

3. Main types of free skin grafting.

4. The main types of non-free skin plastics.

5. Combined skin grafting.

6. Indications for skin grafting.

7. Contraindications for skin grafting.

The task of skin plastic surgery is the art of partial or complete restoration of the appearance, shape and function of various organs and areas of the human body that have been damaged or lost as a result of trauma, disease, as well as due to malformations or age-related changes.

Skin - integumentary tissue that protects the body from external adverse influences, through which the body is interconnected with the external environment. It ensures the constancy of the body's environment, without which metabolic processes cannot proceed correctly. total area skin is on average 1600 cm 2. The thickness of the skin reaches 1 mm, on the palms the thickness of the skin is 1.5-2 mm, on the soles - up to 3 mm.

Assessing the importance of skin structures for wound healing, it is appropriate to emphasize the dual mechanism of this process. Wounds heal as a result of epithelialization from the edges of the wound and the convergence of the edges of the wound by the connective tissue, which occurs due to contraction of the fibrous tissue that develops at the bottom of the wound.

The non-free type of KP includes methods in which the moved skin flap is left in constant connection with the donor site (KP with local tissues) or temporary - for the period of engraftment in a new place (plasty from distant parts of the body) on a temporary feeding leg.

KP methods in which the area of ​​skin transferred to a new site is completely separated from the donor site are called free skin grafting, and the flap resulting from this can be split or full-thickness. Depending on the thickness of the graft, 2 types of free skin grafting are respectively distinguished: split-flap grafting and full-thickness flap grafting.

In practice, it is often necessary to use both free and non-free skin grafting at the same time, which makes it possible to distinguish combined methods of KP.

In non-free KP, the presenting tissues and skin from distant areas are used to replace defects.

For plasty with local tissues, the edges of the wound are mobilized and brought together with sutures, through notches and skin incisions are made to relieve tissue tension and freely connect the edges of the wound.

This group also includes the rotational method, when the mobilized flap is rotated to the defect and fixed with separate sutures.

The classic method of plasty with local tissues is the movement of oncoming triangular-shaped flaps along A.A. Limberg. It is used after excision of tightening scars, with small pigmented tumors, long-term non-healing wounds on the limbs.

Plastic surgery with skin from distant parts of the body consists in transferring the skin on a feeding leg, often in several stages.

One of the methods of non-free skin grafting is the Italian method: a tongue-shaped flap is cut out, it is fixed with sutures on the defect, and the donor site is closed with local tissues.

Of the other methods, plastic with bridge-like flaps and a round stem according to V.P. is widely used. Filatov.

Last method is multi-stage, but it is justified in plastic surgery when closing defects on the face and when it is necessary to close a volumetric tissue defect on the supporting surface of the foot.

With all methods of non-free KP, the flap includes skin, subcutaneous tissue, fascia with blood vessels supplying the flap. The fixation of the flaps is carried out without any tension on the feeding leg.

With free transplantation, skin flaps are completely isolated from the circulatory system and placed on the defect for ingrowth.

Engraftment of free skin grafts is carried out in three stages. Literally from the first minutes, the skin graft adheres to the bottom of the wound, during which fibrin falls out between both wound surfaces. In the following hours and days, the graft is nourished by the diffusion of cell-rich tissue fluid, which maintains cellular metabolism at the proper level. Thin grafts, consisting predominantly of the epithelium and having no blood vessels (Thirsch flap), can immediately use tissue fluid and in the following days are completely content with such an interstitial blood supply. This is the basis for the unpretentiousness of thin skin flaps for nutrition and the possibility of their engraftment on a wound with poor conditions for its own blood supply. Conversely, with thick skin grafts that include a layer of the dermis, nutrition occurs only when tissue fluid enters the vessels of the graft. Revascularization, and with it the final engraftment of the skin graft, is carried out within an interval of up to 2 weeks due to vascular germination. The degree of restoration of blood circulation in different transplants is different. Their thickness and healing mechanism are decisive. Circulation in the newly sprouted capillaries becomes significant only from about the 7th - 8th day and is established in one direction. When using a free graft, it is necessary to take into account its tendency to mobile wrinkling, which occurs due to the contraction of collagen fibers. Secondary wrinkling occurs during the healing process, due to the formation of scars under the skin flap. The thinner the graft, the more pronounced it is. Conversely, a more powerful whole skin flap undergoes less retraction.

The ratio of tissues at the site of graft engraftment certainly plays an important role. An immovable base (bones, fascia) does not cause the graft to wrinkle, while transplanting it to muscles or very mobile areas of the body (neck) causes a significant reduction in the area of ​​the transplanted skin.

Sensory innervation of the transplanted skin appears after 3-6 months due to the ingrowth of nerve fibers from the edges of the wound and from its depth. After 1-1.5 years, this process is completed completely. Recovery occurs in the following sequence: first, tactile sensitivity appears, then pain and thermal perceptions.

Appearance loosely transplanted skin is restored due to the formation of connective and adipose tissue within a few months.

Plastic surgery of skin defects with split dermatomal flaps is currently widely used (I. Paget, 1939). In the absence of skin deficiency, it is more expedient to close the defect with a solid perforated graft. With extensive wound surfaces, the split flap is dissected and transplanted in the form of postage stamps, placing them from each other at a distance equal to the width of the "stamp" (Gabarro's method, 1943).

Among the methods of full-layer plasty, the Dregstedt-Wilson-Parin method is most widely used for closing defects on the face, hand, and joint area. The flap is cut out at the donor site, separated from the subcutaneous tissue, perforated and transferred to the defect. It is fixed with separate sutures in the state of tension of the flap, a pressure bandage is applied. According to the same rules, skin reimplantation is performed according to V.K. Krasovitov (1935) with extensive scalped wounds. Plastic skin-fat flaps with vascular anastomoses are possible, i.e. free transplantation of a segment of the skin and subcutaneous fat using intervascular anastomosis. The most important prerequisite for successful transplantation, for example, when eliminating a skin defect after tumor removal, is the presence of healthy skin in the hypogastric region or on the back of the foot with a well-pulsing artery and at least one vein with sufficient drainage capacity.

Combined skin grafting includes a combination of non-free grafting with free grafting. The classic option is the method of A. K. Tychinkina (1960). Indications for its use are, first of all, defects on the supporting surface of the foot.

According to the period from the moment the defect occurs to the moment of its closure, its plasticity is divided into primary and secondary. Skin grafting of postoperative and fresh wounds in the first hours after injury is called primary.

Secondary is called KP of wounds after the formation of granulations (early plastic) or with long-term non-healing wounds and ulcers (late plastic).

Indications for primary skin grafting:

Accidental wounds;

Scalped wounds;

Wounds after excision of limited burns;

Postoperative wounds (after removal of tumors, hemangiomas);

Malformations (syndactyly, phalanging of the hand, forearm);

Wounds after excision of dermogenic contractures, extensive scars.

Indications for secondary skin grafting:

Granulating wounds;

Long-term non-healing wounds;

Ulcers of various origins.

For the implementation of the primary CP, the following methods can be applied:

Mobilization of wound edges with and without laxative incisions;

Plastic surgery with split flaps;

Skin reimplantation according to Krasovitov;

Moving opposite triangular flaps along Limberg;

Italian way.

The following methods can be used for secondary CP:

Mobilization of the edges of the wound;

split flap;

Moving counter triangular flaps;

Plastic stem Filatov;

Combined KP. Contraindications for primary skin grafting are as follows:

Lack of confidence in reliable excision of the edges of the wound;

Impossibility to subject tissues to primary excision due to extensive damage

The need to use plastic methods that cannot be used in first aid;

Unreliability of hemostasis;

The severity of the general condition of the patient.

Special requirements should be imposed in the primary plastic wounds of the hand. In this case, it is necessary to intervene immediately, and the intervention must be exhaustive and final.

Skin plasty is a surgical operation to replace skin defects that have arisen after injuries, burns or surgical interventions. However, now it has become popular to do plastic surgery simply at will. Initially, it was believed that it was necessary to resort to such methods only in exceptional cases, when it was necessary to correct the defect after any damage to the upper layers of the epidermis.

History of skin grafting

Skin surgeries to restore the nose were used in ancient Egypt, as well as in ancient India many years before our era. Plastic surgery using skin plastics is described in the works of A. Celsus. In 1597, a treatise on plastic surgery by G. Tagliacozzi was published in Bologna, which describes a method for transplanting a skin flap taken from the upper limb to replace the cut off parts of the face, in particular for nose plastic surgery.

Skin plasty was further developed in the works of domestic scientists. Yu. K. Shimanovsky in 1865 published a fundamental guide to plastic surgery "Operations on the surface human body».

In 1869, J. Reverden justified and performed free skin grafting.

Russian surgeons P. Ya. Pyasetskip (1870), A. O. Yatsenko (1871), S. M. Yanovich-Chainsky (1870) improved free skin plastic surgery. The method of operation with a round skin stalk on a feeding leg, which was widely used in plastic surgery, was developed in 1916 by V.P. Filatov.

In 1930, Douglas (V. Douglas), and in 1937 Dragstedt and Wilson (L. Dragstedt, N. Wilson) proposed a method of skin surgery with perforated skin flaps, which was improved during the Great Patriotic War B. V. Larin (1943), Yu. Yu. Dzhanelidze (1945), N. N. Blokhin (1946).

A new stage in the development of techniques began after the creation of the dermatome by Padgett (E. S. Padgett, 1939), M. V. Kolokoltsev (1947 - adhesive, 1952 - electric disc), which made it possible to perform surgery with split skin grafts of various thicknesses.

Types of skin plastics

There are primary and secondary (early and late) skin grafting. Primary is performed in the next few hours after injury, secondary - after the formation of granulations (early operation), ulcers and long-term non-healing wounds (late skin grafting). Depending on the source of the skin area to be taken, autoplasty, homoplasty and heteroplasty are distinguished; according to the modern nomenclature, homoplastic is alloplasty, heteroplastic is xenoplastic.

Indications for skin surgery

Reconstructive surgery is indicated for wounds accompanied by extensive skin defects (for example, with scalped wounds of the lower leg, hand), immediately after surgical treatment or at a later date, after the formation of granulations, when a secondary suture cannot be applied to the wound.

Also, a similar technique is used to close defects formed after excision of deforming scars, neoplasms, tuberculous skin lesions, during plastic surgery in maxillofacial surgery, during operations for elephantiasis and malformations of the limbs (for example, syndactyly). Plastic surgery has been especially widely used in the treatment of burns to close granulating wounds after necrectomy.

Contraindications

Skin plasty is prohibited in severe condition, exhaustion of the patient, elevated temperature and significant bacterial contamination of the wound, sepsis. The thing is that such operations are quite difficult to tolerate by the body.

Preoperative preparation during secondary skin grafting is of great importance for graft engraftment. It includes a complete high-calorie nutrition of the patient with a sufficient amount of proteins and vitamins, blood transfusion, as well as preparation of the tissue defect area to be closed. With long-term non-healing wounds and ulcers, preparation for skin surgery includes cleaning the wound surface from necrotic tissues, eliminating pathogenic microbial flora and acute inflammatory process. For this purpose, treatment with dressings with various antiseptic solutions, sulfonamides, antibiotics and enzymes is used, taking into account the phase of the wound healing process. Granulations and scars are excised, the bottom of the ulcer or wound is carefully treated. Plastic surgery of fresh wounds is performed after full surgical treatment, as well as under local or general anesthesia, depending on the surface area of ​​the operated area.

Skin grafting methods

The following methods of such an operation are proposed:

• free skin plastic;
• not free;
• on the feeding leg;
• combined.

Loose skin grafting

When using this method, skin areas are completely separated from the donor site and transplanted to the defect area. A distinction is made between split and full-layer skin grafts in free skin grafting.

J. Reverdon (1889) transplanted on a granulating surface small areas epidermis with an area of ​​2 - b mm 2. SM Yanovichaisky (1870) transplanted skin grafts 4 - 12 mm 2 in size containing the epidermis and part of the dermis, successfully using this method for the first time to close defects after gunshot wounds.

Davis (J. S. Davis, 1914) transplanted skin grafts, including up to 8/4 of the entire thickness of the skin.

Thiersh (K. Thierscn, 1874) proposed a technique for the operation with a thin split graft containing only the epidermis. Small thin strips of the epidermis were cut with a special knife and transplanted onto granulating wounds.

Ollier (L. Ollier, 1872) performed plastic transplants of large sizes, up to 4 - 8 cm later he used transplants for skin plastics in the entire thickness of the skin.

Blair (V. P. Blair) and Brown (J. B. Brown, 1929) used a manual method of splitting the skin, with which they managed to obtain dermoepithelial grafts of various areas with a thickness of 0.3 - 0.4 mm.

The dermatomal operation with a split calibrated, that is, a predetermined thickness, graft has become widespread.

In our country, the works of N. N. Blokhin, B. A. Petrov, M. V. Kolokoltsev, E. I. Shumilkina, T. Ya. Aryev, A. K. Tychinkina and other surgeons are devoted to such surgery with a split dermatome graft. In the dermatome technique, thin skin grafts are placed on a previously prepared wound surface and covered with a pressure bandage. On the second day, a careful dressing change is mandatory to avoid displacement of the graft with a dried bandage. Thicker dermatome grafts are used for operations on the face, palmar surfaces of the hands, in the area of ​​the joints and plantar surfaces of the feet. The skin area used for plastic surgery (donor) is covered with a sterile bandage; it can be reused for plasty after 8-10 days, and if necessary - repeatedly, which is especially important in the treatment of extensive burns.

B. A. Petrov (1950), Mowlem Mowlem, 1952) and Jackson Jackson, 1952) used this technology with ribbon-like alternating cleaved and homotransplants to close wounds after extensive burns. K. p. was made at the end of the 3rd week after the burn. Auton with homotraisilantates covers the entire wounded surface. Homotransplants slowly dissolve, autografts, gradually growing to the sides, cover the granulations. Thin flaps with a thickness of 0.1 - 0.2 mm are used; they engraft better than thick ones, do not require fixation to the edges of the wound and are almost not subject to retraction. With an insufficient supply of skin, with extensive burns, Gabarro (R. Gabarro, 1943) proposed a "vintage" method - with small rectangular grafts.

Lawson (O. Lawson, 1870) and A. S. Yatsenko (1871) offered full-layer free plasticity. The sizes of grafts are 2-4 or 6 mm 2 . Krause (F. Krause) in 1893 applied transplants up to 20-25 cm 2 .

P. Ya. Pyasetsky (1870), for better engraftment, immersed skin grafts into holes, which he had previously made in granulations. This "submersible" method of skin transplantation was later improved by Brown (W. Braun, 1920) and Alglav (G. Alglave, 1927). Brown transplanted small epidermal grafts with a granulation needle. Alglav loaded full-thickness skin grafts under the granulations or into wells created by scraping the granulations. A perforated sieve flap is used to close large skin defects. Douglas first applied circular incisions in the graft area, after which the skin flap was cut off, leaving round skin areas for the donor wound to be healed. Dragenet and Wilson made linear incisions on the skin graft. The donor wound was sutured tightly. The creation of holes in the graft contributed to good drainage of the wound and made it possible to increase the area of ​​the graft.

One of the varieties of full-layer free skin plasty is the replantation of skin flaps completely torn off at the time of injury, proposed by V.K. Krasovitov in 1935. The method of replantation of skin flaps to Krasovitov for scalped wounds of the head and limbs is successfully used in emergency surgery. When contaminated, scalped skin is washed with soap and a brush in running water, oil stains are removed with ether, after which the skin flap is immersed in rivanol solution.

The subcutaneous tissue is removed using a dermatome, the skin flap is dried and transplanted to the wound. Skin replantation is acceptable within 6 hours after injury, however, methods have been developed that can significantly lengthen the viability of the skin flap.

Non-free skin grafting

This technique includes grafting with local tissues and grafts from distant parts of the body on a temporary pedicle. K. i. local tissues is carried out by mobilization of the wound or with the help of additional (laxative) incisions. To prevent tension on the edges, one or two parallel cuts are made on the edges. Small notches are also applied to the entire thickness of the skin near the wound. For large wounds, sliding figured methods of operations are used. Various variants of longitudinal incisions have been developed for closing round defects in wounds of various shapes (oval, triangular, rectangular), as well as sliding flaps for plastics of square defects - at the suggestion of Yu. K. Shimanovsky (1864).

Operation by counter movement of adjacent triangular flaps was recommended by A. A. Limberg in 1963; it is used to close skin defects after excision of tightening scars in the area of ​​the joints of the extremities, face, small skin tumors, as well as for long-term non-healing wounds of the extremity. Triangular flaps are cut out of the skin together with subcutaneous tissue so that the angles of their tops are equal to 30-45 or 60°. Triangular flaps with an angle of 30° are used on the face, where the blood supply conditions are better. On the extremities, it is recommended to use flaps with an angle of 45 or 60 °, which provide better blood supply. The flaps are separated and after hemostasis they are mutually moved and brought together with sutures without tension.

Bridge skin grafting

The bridge-like method of the operation consists in closing skin defects with the help of bridge-like flaps, including the skin and subcutaneous tissue. To close the wounds of the hand or forearm, a bridge flap is cut out from the skin of the anterior or lateral surface of the abdomen. Such plastic surgery on the leg is also used to close wounds in the area of ​​​​the joints by moving the skin flap adjacent to the wound (Indian method). Relatively rarely (mainly for large ventral hernias), cutis-subcutis recommended by S. P. Shilovtsev is used.

Combined Methods

N. V. Almazova (1923) used the Indian method for plastics of tissue defects on the face.

This method is also used to close defects in the limb stump. The wound surface formed at the site of the displaced flap, if necessary, is closed with a split skin graft. With the Italian method, a pedicled flap is cut out in areas of the body remote from the defect. The method is used more often to close skin defects on the limbs (hands, lower legs, groans). The first stage of the operation includes cutting out a skin flap, suturing the donor wound, and fixing the graft to the edges of the skin defect. At the second stage, its leg is cut off (after the engraftment of the flap). With the help of the Italian method it is possible to close skin defects with an area of ​​45-70 cm 2 .

To close more extensive defects, a combined operation is used, in which the flap bed is closed with a split graft. One of the methods of combined K. p. is the Tychinkina method, which includes three stages. Initially, a skin flap with a wide base is cut out and it is separated from the underlying tissues. The wound surface of the feeding leg of the flap and the entire wound area of ​​the donor site are closed with a split skin autograft, after which the cut flap is returned to its place and fixed with sutures. After 2 weeks, the flap is again separated from the bed, granulations are removed on its inner surface and sutured to the refreshed edges of the defect. After 4-5 weeks, the feeding leg is cut off. This method is especially indicated when closing defects on the "working" surfaces of the limbs.

Filatov's method of plasty with a round skin stalk is widely used in plastic surgery in maxillofacial surgery to replace various defects of the face, on the hand, with fistulas of the pharynx, esophagus, and larynx.

N. A. Bogoraz used the Filatov stem to create a penis. The Filatov stem can be formed in various areas of the body. To form a flap, two parallel incisions are made so that the length is 3-4 times the width of the graft. After otsenarovka the skin wound is sutured, the stem is formed from the flap by applying interrupted explanatory sutures. The edges and legs of the stem are especially carefully formed, avoiding tension in the seams. After 12-14 days, one of the feeding legs of the stem is cut off and transplanted to the area of ​​the defect, if the stem is located near the defect. When the stem is located at a considerable distance from the defect, the end of the stem is first transplanted to the hand or forearm, and after a while its other end is transplanted to the defect area. Before stem migration, a test is carried out to assess the state of blood supply by pulling the base of the remaining stem with a thin rubber band. It is also used to train the blood supply of the stem by clamping the legs 2-3 times a day, gradually increasing the time for applying a tourniquet or clamp from 5 minutes to 2 hours for 2-4 weeks.

A semi-lunar incision is made on the brush, corresponding to the size and shape of the end of the stem. Perhaps closer to the base of the stem circularly dissect skin, fiber is excised for 1.5-2 cm, after which the end of the stem is cut off, immersed and fixed with catgut sutures to the bottom of the wound of the hand. Interrupted silk sutures are applied to the skin of the stem and the wound of the hand. The second leg of the stem is cut off after 6 weeks. and produce plastic defect. To close the defect, one can first implant one stem or alternatively implant both stem legs near the defect, followed by defect plasty.

Curly stems are proposed for rhinoplasty: four-legged, in the form of the letter "T", a cross with the formation of three stems at one end.

Depending on the purpose of plastic surgery, to close the defect, a complete or partial straightening of the stem is performed. The skin scar is excised along the stem, the incision is deepened, concentric adhesions are dissected and the subcutaneous tissue is dissected with longitudinal incisions and partially or completely excised.

When performing rhinoplasty, the stem is completely freed from subcutaneous tissue, preserving the supply vessels. When performing plastic surgery of the cheeks with cosmetic purpose to restore the contours, as well as in the plastic of the plantar surfaces of the foot, the subcutaneous tissue is left in required quantity. For tamponade of bone cavities, the distal part of the stem is used after excision of the skin. The proximal part of the stem is straightened and used to close the skin defect.

The average duration of plasty with a migrating round Filatov stem is 3- per month. It includes five stages: stem formation (2-4 weeks), stem migration to the raceme (4-6 weeks), stem transfer from the raceme to the defect (4-6 weeks), cutting off the stem from the raceme and spreading on the defect ( 3-8 sub.) and leg correction (3-6 weeks).

The disadvantage of plastic surgery with the Filatov stem, in addition to the duration, is the difference in the color of the skin of the stem and the skin around the defect, which is important when performing plastic surgeries on the face. L. M. Obukhova, for cosmetic purposes, suggested deepithelization of the stem during facial plastic surgery. After excision of the epithelium, a gradual formation of a thin flat pinkish scar occurs. The stem takes on a color close to the color of the face.

V. P. Filatov proposed, in addition to the typical, so-called. sharp stem with one feeding leg. One end of the sharp stem is left free or can be used to close the defect; due to its good blood supply, such a stem is also used to create complex transplants.

After the surgical procedure, a bandage is applied to the donor wound and the area of ​​the skin graft, which is recommended to be moistened with fir balm to prevent drying and facilitate change. The sutures are removed on the 6th or 8th day.

After surgery: results

The most common complications after surgery are suppuration, partial or complete necrosis of the graft. They are observed with tension and insufficient vascularization of the graft. According to most authors, engraftment of skin grafts occurs in 90-96% of cases.

The term (synonyms: skin grafting or transplantation, dermoplasty) combines surgical operations, the general purpose of which is to restore the skin that has been lost or damaged due to diseases or traumatic effects.

Indications for skin grafting

The skin performs many functions: protective (barrier), receptor, metabolic and thermoregulatory; in addition, it has great aesthetic value. The dermal layer is easily damaged by many external factors(physical, chemical and biological). In a number of diseases of internal organs or systemic disorders, the skin is also involved in the pathological process. Although its regenerative abilities are high, in many cases they are insufficient, and then surgical intervention is required to restore defects. Below are the most common situations in which skin grafting is performed.

burns

Combustiologists (specialists in the treatment of thermal injuries) have extensive experience in skin grafting. Burns, especially deep and extensive ones, are almost always treated with dermoplasty, since the loss of a significant part of the skin without its adequate restoration usually leads to death. After stopping a critical condition and healing wounds, the patient often undergoes repeated operations to eliminate massive scars and contractures (adhesions that limit the range of motion) to improve the functional and aesthetic result of treatment.

Wounds

With various mechanical effects on the body, significant volumes of soft tissues, including skin, can be lost. Such wounds almost always heal by secondary intention - with the formation of rough and large scars. Skin grafting can speed up recovery and optimize patient outcomes.

bedsores

In severe bedridden patients with care errors (untimely turning over of the body, the appearance of folds on bed linen, crumbs falling on it, constant humidity, etc.), necrotic tissue changes easily appear in places of prolonged compression - bedsores. They are characterized by poor healing and a tendency to further spread, so skin grafting is often used to successfully treat them.

Trophic ulcers

Trophic and neurotrophic ulcers are formed in areas suffering from oxygen starvation and innervation disorders under the following conditions:

• venous congestion in the legs with varicose veins;
• foot angiopathy in diabetes mellitus;
• obliterating atherosclerosis or endarteritis of the extremities;
• peripheral nerve injury.

Adequate therapy of such pathologies is challenging task, since it occurs against the background of a general decrease in the body's defenses and a local disturbance of tissue metabolism. Closure of ulcerative defects with skin flaps is the best way to correct them surgically.

Superficial tumors

Removal of melanoma (a tumor consisting of pigment cells) and some other malignant neoplasms of the skin "according to the protocol" requires a wide excision (removal) of the surrounding soft tissues to reduce the likelihood of "skipping" cancer cells. After oncological operations, extensive defects remain that require plastic replacement.

tattoos

Tattoo removal is not always possible with the help of gentle procedures (for example,). With the location of the coloring matter in the deep layers of the skin, the removal of a pattern that has become unnecessary to its owner is possible only together with a section of the dermis. The resulting wound surface, especially when located in open areas of the body, is closed with a transplanted skin flap or local tissues.

Types of dermoplasty

Applied types of skin grafting have several classifications, the most significant of which is surgical, dividing all transplants into connected and free.

Non-free (bound) skin grafting

With this type of transplantation, the transplanted skin flap retains a mechanical connection with its original place (bed); plastic can be local and remote.

Local plastic- movement of skin flaps adjacent to the wound, on which additional (relaxing and shaping) incisions can be made to facilitate manipulation (approximate edges without undue tension).

Distant bonded plasty requires cutting out a flap in another part of the body. Example: for the treatment of an extensive wound of the hand in the abdomen or chest, a flap is created in the form of a bridge, under which the injured limb is brought and sutured. When a piece of skin "grabs" in a new place, its "legs" are cut off, both wounds are sutured and healed until complete healing. There are several varieties of this technique: Italian and Indian methods, Filatov flap and many others; in practice, a combination of different options is possible.

Benefits of bonded plasty: good survival of skin flaps.
Disadvantages: local transplantation is limited in the presence of extensive defects; remote plasty requires multi-stage operations, which takes a lot of time and brings considerable discomfort to the patient.

Loose skin grafting

With free plastic surgery, a donor skin fragment is taken from another part of the body, which is completely cut off and immediately placed in a new place. When closing cosmetically and functionally significant areas (face, hand, genitals, areas of large joints), a full-thickness flap is used (for the entire thickness of the skin), in most other situations - a split one (including only the epidermis and a thin surface layer of the dermis). The site can be solid (it is often notched in many places for better extensibility - the “sieve” or “mesh” method) or be a lot of small fragments (“stamps”) laid at a certain interval.

To take a split flap, there are special devices (dermatomes) that allow you to accurately adjust the thickness of the taken fragment. Since the growth layer of the skin is preserved and there is no need for a special closure of the donor surface, the dermis gradually restores spontaneously; after which we will allow re-sampling of the material at this place.

Advantages of free plastics: good cosmetic result, the possibility of closing large defects.
Disadvantages: there may be difficulties with engraftment of the fragment in a new place, taking a full-thickness flap creates problems with closing the donor site.

Skin plasty is a surgical technique aimed at obtaining a functional and aesthetic result in the treatment of many external defects by transplanting dermal fragments.

CHAPTER 17 PLASTIC (RECOVERY) SURGERY

CHAPTER 17 PLASTIC (RECOVERY) SURGERY

The field of surgery concerned with restoring the form and function of tissues and organs is called plastic or reconstructive surgery.

The task of plastic surgery is the elimination of various defects, they can be congenital or acquired, arise as a result of injuries, diseases, surgical interventions and cause functional or anatomical changes. Any surgical operation contains elements of plastic surgery, as it involves the restoration of tissues and organs.

IN ancient india to restore the nose defect, plastic surgery was performed with a skin flap on a leg, cutting it out on the forehead. The method came to Europe and is still called the "Indian method of rhinoplasty". In Italy, in the 15th century, another method of rhinoplasty appeared - they used the skin of the shoulder area, it was called Italian. N.I. Pirogov (1852) developed a method of osteoplastic amputation of the foot, which provides a good supporting function of the limb. V.P. Filatov (1917) proposed the transplantation of a migratory skin stalk (Filatov stalk). Ts. Ru and P.A. Herzen (1907) developed an ante-thoracic esophagoplasty with a loop of the small intestine.

Nowadays, plastic surgery has acquired a leading role in all areas of surgery, and a new section has appeared - organ and tissue transplantation. In addition to purely surgical problems, its task is to study the issues of conservation of organs and tissues, tissue compatibility.

Types of plastic surgery

Depending on the source of transplanted tissues or organs, there are the following types of transplantation.

Autogenous transplantation: the donor and recipient are the same person.

Isogenic transplantation: donor and recipient are identical twins.

Syngeneic transplant: donor and recipient are first-degree relatives.

Allogeneic transplant: donor and recipient are of the same species (human-to-human transplant).

Xenogeneic transplantation: donor and recipient belong to different types(transplantation from animals to humans).

Prosthetics of organs and tissues using synthetic materials, metals or other inorganic substances.

The most widely used autoplasty, as well as prosthetics of organs and tissues. Xenoplasty (heart biovalves, vascular xenografts, embryonic tissues) is rarely used because of the difficulty of overcoming tissue incompatibility.

Types of tissue plastics

Tissue transplantation is possible with complete separation of the graft from maternal tissues - loose plastic, or transplant. There are the following types.

Transplantation of tissues and organs - moving them from one part of the body to another or from one organism to another.

Replantation - the affected tissues and organs are transplanted back to their original place (scalp, severed limbs or their fragments).

Implantation - tissues or cells are transferred to a nearby area.

not free,connected, or plasticity on a feeding leg, provides for the connection of the cut tissue flap with the original bed until the displaced part completely grows into a new place.

Skin plasty

Skin grafting is the most common type of tissue grafting. Skin autoplasty, its free or non-free variant, is more often used.

Loose skin grafting

Free skin grafting has a century-long history. In 1869 J.L. Reverden (J.L. Reverden) first transferred several small pieces of skin to a non-healing granulating surface in the elbow area. Subsequently, S. Shklyarovsky (1870), A.S. Yatsenko (1871),

M.S. Yanovich-Chainsky (1871), as well as J.S. Davis (J.S. Davis, 1917) developed and improved the grafting of skin in small pieces on the granulating surfaces of wounds in detail.

Yatsenko-Reverden method

Under local anesthesia with a scalpel or razor, small grafts (a thin layer of the epidermis) 0.3-0.5 cm in diameter are cut off from the outer surface of the thigh, forearm or anterior abdominal wall and transferred in a tile-like manner to the wound. Then, a bandage with indifferent fat (vaseline oil) is applied to the wound with transplants for 8-10 days. The method is rarely used due to the rapid destruction of the epidermis.

Yanovich-Chainsky-Davis method

The grafts are prepared to contain all layers of the skin, since full-layer grafts do not autolyse or dislodge. Pieces of skin are placed in a checkerboard pattern on the granulating surface at a distance of 2.5-5 mm from one another.

Thiersch's method

With a razor or a sharp knife, strips of the epithelium are cut off to the tops of the papillary (Malpighian) layer 2-3 cm wide and 4-5 cm long. It is better to form grafts on the anterior surface of the thigh. The surface of the defect is covered with wide epidermal strips of skin and an aseptic dressing is applied on the 6-10th day. This method allows you to achieve good long-term results. It is more suitable for the treatment of long-term non-healing wounds and trophic ulcers.

Lawson-Krause method

A large graft cut into the entire thickness of the skin is transferred to the granulating surface and fixed with separate sutures to the edges of the defect. Disadvantages of the method: a transplant taken in the entire thickness of the skin takes root worse; the large size of the flap makes it difficult to close the donor site.

With the introduction of the dermatome into clinical practice, it became possible to take a flap of any area and thickness. Currently, manual and electrodermatomes are used; with their help, extensive skin defects (up to 2000 cm 2 in area) can be covered in one step. With the use of

By forming a dermatome, it is possible to obtain long split skin flaps consisting of the epidermis and part of the skin itself. The transplant is taken under general anesthesia. Through cuts of a certain length are applied in a checkerboard pattern on the resulting split thin flap with a special apparatus. When such a graft is stretched, it is possible to obtain a surface with an area 3-6 times greater than its original dimensions. Mesh autografts are widely used to close extensive wounds (Fig. 179).

Non-free skin grafting

Non-free skin grafting involves the formation of a flap of skin and subcutaneous tissue that maintains a connection with the mother tissue through the feeding leg. The pedicle of the flap must be wide enough to ensure a good blood supply. The leg should not be squeezed with a bandage, and when moving the flap, twisting of the leg around the longitudinal axis should be avoided.

Local (regional) skin grafting performed using the surrounding tissues by moving them.

In some cases, after mobilization of the surrounding tissues, the skin defect can be sutured in the usual way.

Relaxation incisions, made at a distance of several centimeters from the edges of the defect, allow you to bring the edges of the wound closer together and suture.

Z-shaped plasty is used for skin deformation with rough scars to restore normal ratios of body parts altered by scar adhesions. After excision of scar tissues, skin flaps are cut out and moved (Fig. 180).

A rotating tongue-shaped skin flap is cut out on a healthy skin area next to the defect and, by moving it, the defect is closed (for example, rhinoplasty according to the Indian method). The donor area is closed with a free skin flap or sutured in the usual way (Fig. 181 a).

Plasty by moving the flap from distant parts of the body, they are used in cases where there are no tissues in the defect circumference suitable for the formation of a flap.

Direct transplant a skin flap from distant parts of the body is used if it is possible to closely compare the donor site and the defect site, i.e. make a one-time closure of the defect - the Italian method (Fig. 181, b, c, 182, see color incl.).

Rice. 180.Options for closing skin defects. Roman numerals indicate the types of operations, Arabic - the stages of operations, Latin letters - landmarks of movement.

bridge plastic, recommended by N.V. Sklifosovsky, is used for plastic surgery of skin defects of the fingers, hand, forearm. The donor site can be a skin flap on the abdomen, in the area of ​​the forearm. Two parallel incisions are made in the area of ​​the donor site, a skin area is mobilized between them - a “bridge” is created, under which the damaged fragment of the limb (finger, forearm) is placed so that the detached flap covers the defect. The flap is sutured to the wound. Engraftment, as with the Italian method, occurs on the 10-15th day. At this time, it is possible to cut off the flap from the pedicle.

Rice. 181.Plasty with a skin flap on a pedicle using Indian (a) and Italian (b, c) methods.

Migratory flap plasty involves the formation of a flap in distant parts of the body, it is gradually moved to the defect.

stalked flap are formed by stitching the edges of the skin flap together with the formation tubular stem in the form of a suitcase handle - "Filatov stem" (Fig. 183). On the anterior surface of the abdomen, two parallel incisions are made (1) to the muscle fascia (the length of the skin incisions depends on the size of the defect), the edges of the skin-fat flap are sutured (2), and the place where the flap was taken is sutured (3, 4). The ratio of the length of the skin stalk to the width is not more than 3:1. After 10-14 days, blood vessels sprout into the stem, after 4 weeks the end of the stem is cut off, sutured to the arm (5, 6), and after 10-14 days it is sewn into the defect site (7, 8).

Rice. 183.Skin plasty with a tubular skin flap (“Filatov stem”). Explanation in the text.

Round migratory stemare used in the plastic surgery of extensive skin defects, trophic ulcers and non-healing amputation stumps, facial plastic surgery (creating an artificial nose, lips, closing the "cleft palate"), in surgery of the esophagus, pharynx, trachea, in vaginal plastic surgery in case of its atresia and in the treatment hermaphroditism.

If, for some reason, autotransplantation cannot be performed, allotransplantation is used.

allotransplantation

Skin allotransplantation is used for extensive burns or in cases where the general severe condition of the patient (intoxication, sepsis)

sis, etc.) does not allow the use of one or another modification of autoplasty.

Fresh and preserved skin allografts are used in the early stage of burn disease (on days 14-21) or after excision of necrotic tissues. Short-term (for 2-3 weeks) coverage of a large surface with a graft improves the general condition of the patient. Often, autotransplantation is combined with allo- and even xenotransplantation.

Brephoplasty- transplantation of the skin of a stillborn fetus (gestation period is not more than 6 months). With this type of allotransplantation, it is necessary to take into account the isoserological compatibility of the donor and recipient.

Currently, for large skin defects, free transplantation of a segment of the skin and subcutaneous adipose tissue with vascular anastomosis using microsurgical techniques is increasingly being used. In this case, the presence of a well-pulsing artery and at least one vein with sufficient drainage capacity is mandatory, vessels of small diameter are sutured under a microscope.

Muscle plastic

Leg muscle transplant sometimes used for filling bone cavities in patients with chronic osteomyelitis and bronchial fistulas. Regional muscle plasty is used to close defects in the muscles of the abdominal wall, in the plastic of inguinal hernias, hernias of the white line of the abdomen, to eliminate the insolvency of the anal sphincter.

Transplantation of muscles on the leg is possible, provided that blood circulation and innervation are preserved. Tissue flaps, including an artery, allow for the replacement of extensive tissue defects.

Free muscle plasticity used in surgical practice to stop bleeding from parenchymal organs, filling damaged sinuses of the dura mater.

Tendon and fascia plasty

Tendons are transplanted to restore the lost functions of the limb, as well as the functions of a group of paralyzed muscles. In this case, the tendons of neighboring potentially healthy synergistic muscles are implanted into paralyzed ones.

Tendon plasty with primary suture is performed for tendon ruptures. If diastasis is detected between the ends of the damaged

Rice. 184.Tendon plasty: a-c - options for local plastic surgery.

tendon, various options are used local plastic surgery(Fig. 184).

Fascia plasty is used in plastic surgery. Free plasty with a flap of the fascia lata is used to strengthen the joint capsule, replace a defect in the dura mater, and form an artificial rectal sphincter. Canned fascia allografts can be used. Fascia plasty is used to close tissue defects in hernias of the spinal cord and abdominal wall.

Bone grafting

To restore the lost functions and cosmetic form of the organ, bone grafting is performed using bone grafting, eliminating the defect of the cranial vault or jaw, while restoring the shape and functions of the organ.

not freeplastic was first used by N.I. Pirogov (1852), who performed osteoplastic amputation of the foot with restoration of the support function of the lower limb. R. Greeley and Yu.K. Shimanovsky developed osteoplastic amputation of the lower leg.

Osteotomy according to the “Russian lock” method (N.V. Sklifosovsky) is used to fix bone fragments. In craniotomy, skin and bone grafts are used to close tissue defects.

freebone grafting is used in the form of autotransplantation or allotransplantation.

Autotransplantation is used to fix bone fragments in case of delayed consolidation of fractures in false joints, to fill bone defects in chronic osteomyelitis.

Bone allografts are preserved by lyophilization or quick freezing (-70 to -196°C). Transplanted allografts dissolve after 2-3 years without inhibiting the ability of the bone to regenerate in the transplant area. Bone allografts are used as fixators during operations on the spine, resection of a joint or bone section.

Nerve plasty

The purpose of surgical intervention for injuries of the nerve trunk is to bring its ends closer together and eliminate the causes that interfere with regeneration. The use of microsurgical techniques has increased the efficiency of plastic surgeries on the nerves.

Options for operations on peripheral nerves are different: primary or secondary suture, nerve transplantation, neurolysis. The primary suture is used during the operation - during the primary surgical treatment of the wound against the background of a good general condition of the patient, the absence of crushing of tissues in the wound, with an injury prescription of not more than 12 hours. In other cases, nerve restoration is postponed, secondary stitching of the transected nerve is performed.

Before suturing the nerve, both of its stumps are resected within healthy tissue in the transverse direction. Sutures are placed on the connective tissue sheath without piercing the "cables" of the nerve itself, using atraumatic needles and threads 6/0 or 7/0.

When applying an epineural suture, tension should be avoided, for which it is necessary to mobilize the ends of the nerve. With a significant defect of the nerve, its transplantation is performed.

Vascular plastics

Restoration of blood supply to organs is increasingly being used. Use a manual or mechanical (hardware) seam. Microsurgical vascular technique allows restoring the patency of vessels up to 1-2 mm in diameter.

Used in vascular surgery autografts veins and arteries or synthetic prostheses from dacron, teflon, teflon-

Rice. 185.Prosthesis of an artery: a-d - stages of suturing a vascular prosthesis.

fluorolone, polytetrafluoroethylene, etc. The replacement of arteries with an autovein is widely used. The wall of the implanted vein thickens with time, “arterializes”, aneurysms are observed very rarely.

Of particular importance in vascular plastics is vascular prosthetics(Fig. 185). Vascular prostheses are used for vascular resection, bypass grafting, or for "synthetic patches" (eg, aortic plasty). In some cases, preserved allografts (umbilical cord vessels) or xenografts are used.

Organ transplant

Transplantation of organs and tissues has become increasingly important in recent years. More than 130,000 kidney transplants, about 6,000 heart transplants, more than 4,000 liver transplants, and 1,500 pancreas transplants have been performed worldwide. The maximum follow-up period after kidney transplantation exceeds 25 years, heart - 15 years, liver - 12 years, pancreas - 5 years. In our country, more kidney transplants are performed (about 7,000 operations), transplantations of the liver and pancreas have begun, since 1987 heart transplants have been resumed.

Allotransplantation of organs from donors at the stage of brain death is used, organs of a corpse or close relatives are less often used (transplantation of only paired organs, such as a kidney, is possible).

Preservation of tissues and organs

Tissues and organs of people who died as a result of accidents (traumas) or died suddenly from various causes (for example, myocardial infarction, cerebral apoplexy) are suitable for transplantation. Contraindications for the removal and preservation of tissues and organs are such causes of death as poisoning, AIDS, malignant tumors, malaria, tuberculosis, syphilis, etc. It is advisable to take from a potential donor internal organs immediately after the declaration of brain death. Tissues (skin, tendons, cornea, etc.) are removed and preserved in the first 6 hours after death.

The removal of tissues and organs for transplantation is carried out in special rooms in compliance with the rules of asepsis and antisepsis. The taken tissues and organs are thoroughly washed from blood and tissue fluid and then preserved using various methods.

Placement in solutions containing antiseptics or antibiotics, followed by storage in cooled solutions, plasma or blood of the recipient.

Rapid freezing at temperatures from -183 ?С to -273 ?С with subsequent storage at temperatures from -25 ?С to -30 ?С.

Lyophilization (freezing followed by vacuum drying) is used to preserve bones.

Immersion in paraffin, solutions of aldehydes (formaldehyde, glutaraldehyde). In special containers, tissues and organs from the laboratory are delivered to the clinic, where they are kept in special solutions at a temperature of 4 °C.

Complete engraftment of tissues and organs is observed during autotransplantation, transplantation from identical twins (syngeneic, or isotransplantation). With allo or xenogenic transplantation, a rejection reaction develops - a reaction of transplant immunity.

transplantation immunity response

The reaction of transplantation immunity (graft-versus-host disease - GVHD) develops in the recipient within 7-10 days after transplantation and is aimed at transplant rejection. Cells of the immune system, in particular T-killers, play a direct role in the rejection reaction, but macrophages and T-lymphocytes are involved in the implementation of the process.

In the first 4-5 days after transplantation, engraftment of the transplanted tissue occurs, the recipient's immunocompetent cells in this

period identify foreign antigen. From the 4-5th day, microcirculation is disturbed in the transplanted tissue, edema develops, invasion of the transplanted organ by mononuclear cells begins. T-lymphocytes acquire cytotoxic properties, and the B-lymphocyte system synthesizes antibodies, as a result, the allograft or xenograft is rejected. Repeated allotransplantation from the same donor causes a transplant immune response 2 times faster, since the body is already sensitized.

The modern immunological concept of tissue and organ transplantation is associated with the interaction of subpopulations of T- and B-lymphocytes, where the leading role is assigned to subpopulations of T-lymphocytes (helper, killer and suppressor cells).

Each living organism has a certain immune status, and its assessment creates the basis for typing the immune compatibility of the donor and recipient. According to the basic laws of genetics, each individual has HLA-sublocus antigens, referred to as tissue compatibility antigens, they are localized in cell membranes. The presence of several SD- and LD-determinants of the HLA complex determines the difficulties that accompany the selection of compatible donor and recipient. The probability of selecting an identical genotype is no more than 1:640,000.

The selection of a donor and recipient is based on immunological typing according to the main systems of antigens: AB0, Rh (erythrocyte antigens) and HLA (leukocyte antigens - histocompatibility antigens). The creation of organ banks that record and register thousands of recipients facilitates the selection of organs. Special recipient cards contain complete information about the immunological, hematological and clinical status of recipients. There are several such banks in Europe.

In order to increase the efficiency of allotransplantation, various activities are carried out.

Nonspecific immunosuppression - blockade of the recipient's immunocompetent system with antimitotic agents (azathioprine), glucocorticoids (prednisolone) and antilymphocyte sera. As a result of such exposure, a state of immunodeficiency is formed in recipients and resistance to infections is sharply reduced.

Replacement of the recipient's hematolymphoid system before allotransplantation by total radiation suppression of lymphoid tissue, followed by transplantation of the donor's bone marrow.

Selective elimination of T-killer cells with simultaneous stimulation of the activity of T-suppressor cells. A similar selective action is characterized by cyclosporine.

From the point of view of tissue compatibility, transplantation of one's own organ or tissues is ideal.

Replantation

Replantation of a severed limb or its fragment is possible in the first 6 hours after injury, provided that the severed limb is stored at a temperature of 4 °C, with perfusion of its vessels before transplantation. After the primary surgical treatment, the bone is restored, then the plastic surgery of the vein and artery is performed, after which the nerves, muscles, tendons, fascia, and skin are sutured. In the postoperative period, measures are taken to prevent the syndrome of traumatic toxicosis, using hypothermia, an abacterial environment.

kidney transplant

Kidney transplantation is widely used today. The indication for kidney transplantation is its functional insufficiency with increasing uremia. The kidney is usually transplanted in a heterotopic position - it is placed retroperitoneally in the iliac fossa. The blood flow is restored by anastomosing the vessels of the donor kidney with the common iliac artery and vein of the recipient; ureter is implanted in bladder(Fig. 186). Before surgery and in the immediate postoperative period, hemodialysis sessions are performed to reduce uremia. A sign of kidney rejection is the appearance of lymphocytotoxins in the blood and lymphocytes in the urine.

Rice. 186.Heterotopic kidney transplantation: 1 - iliac artery; 2 - iliac vein; 3 - ureter; 4 - bladder; 5 - transplanted kidney.

Liver transplant

The indication for liver transplantation is its rapidly progressive insufficiency (cirrhosis, malignant tumors, atresia of the biliary tract in newborns).

After removal of the recipient's liver, the allogeneic liver is transplanted into a normal bed in the right upper sector of the abdominal cavity. (orthotopic transplant).

For heterotopic transplantation the donor liver is placed in another area of ​​the recipient's abdominal cavity.

Liver function for a short period can be supported by short-term extracorporeal perfusion of the liver of a corpse or animal (pig, calf).

Heart transplant

Heart transplantation is performed in severe heart failure associated primarily with progressive cardiomyopathy, aneurysms of the left ventricle of the heart, uncorrected congenital heart defects, including a two-chambered heart, atresia of the right atrioventricular (tricuspid) valve, etc.

The rationale for heart transplantation in the clinic was the experimental studies of A. Carrel (1905) and V.P. Demikhov (1946-1960). A. Kantrowitz in New York repeated a similar operation on an infant. Later it turned out that the first attempt at heart transplantation was made in 1964 in the state of Mississippi by the American J. Hardy, who performed xenotransplantation of the heart of a chimpanzee to a 68-year-old patient.

The heart is implanted in an orthotopic position (in place of the removed organ) under cardiopulmonary bypass. The recipient leaves the posterior wall of both atria with the mouths of the vena cava, thus preserving the zone of autonomic innervation of the heart. Transplantation begins with the suturing of the posterior wall of the left atrium, the interatrial septum and the right atrium, then the aorta and pulmonary trunk are connected.

Signs of heart rejection are first detected on the ECG (tachycardia, extrasystole, a decrease in the voltage of the teeth). Repeat endocardial biopsies of the heart confirm the diagnosis.

The use of a mechanical heart is of particular importance. Currently, an artificial heart with a pneumatic drive is used for short-term replacement of the heart in the absence of a donor.

Transplantation of endocrine glands

The clinic uses transplantation of the thyroid gland, pituitary gland, adrenal glands, testis, pancreas.

Free transplantation of endocrine glands has been performed for a long time, but the functions of the glands are realized only until the implanted tissues are resorbed. Transplantation of endocrine glands on a vascular pedicle preserves the entire structure and function of the gland.

The collection of endocrine glands for transplantation is performed in the first 6-10 hours after death. At the same time, the vascular pedicle of the gland is isolated with washing of the vessels with special solutions and then frozen at a temperature of -196 °C. Most often, the vessels of the glands anastomose with the femoral or brachial artery. The functional effect of transplantation is clearly manifested: after the transplantation of the testis, inhibition and inertia disappear in men, ejaculation appears; in women after ovarian transplant menstruation appears; with myxedema, thyroid transplantation is effective; tetany, convulsions are eliminated by transplantation of parathyroid glands; in diabetes insipidus, pituitary transplantation significantly reduces the feeling of thirst. In addition to effective transplantation of the pancreas (body, tail, lobe) with vascular anastomosis in the iliac fossa, a hormonal effect was obtained by transplantation of isolated islets of Langerhans or the smallest fragments of the pancreas into the liver through the portal vein.