CZl IZX]c^fjZh ^c I^hhjZ Hjg\Zgn
BVg^V O# H^Zb^dcdl :Y
Tissue Surgery L^i] &%% ;^\jgZh
BVg^V O# H^Zb^dcdl! B9! E...
531 downloads
5925 Views
5MB Size
Report
This content was uploaded by our users and we assume good faith they have the permission to share this book. If you own the copyright to this book and it is wrongfully on our website, we offer a simple DMCA procedure to remove your content from our site. Start by pressing the button below!
Report copyright / DMCA form
CZl IZX]c^fjZh ^c I^hhjZ Hjg\Zgn
BVg^V O# H^Zb^dcdl :Y
Tissue Surgery L^i] &%% ;^\jgZh
BVg^V O# H^Zb^dcdl! B9! E]9! 9HX 9^gZXidg d[ EaVhi^X Hjg\Zgn GZhZVgX] =ZVY! B^Xgdhjg\Zgn IgV^c^c\ 9ZeVgibZci d[ EaVhi^X Hjg\Zgn I]Z 8aZkZaVcY 8a^c^X ;djcYVi^dc 8aZkZaVcY D= JH6
7g^i^h] A^WgVgn 8ViVad\j^c\ ^c EjWa^XVi^dc 9ViV 6 XViVad\jZ gZXdgY [dg i]^h Wdd` ^h VkV^aVWaZ [gdb i]Z 7g^i^h] A^WgVgn A^WgVgn d[ 8dc\gZhh 8dcigda CjbWZg/ '%%*.'-&,+ >H7C"&%/ &"-*'((".,%"* >H7C"&(/ .,-"&"-*'((".,%"-
Z">H7C/ &"-)+'-"&'-"-
Eg^ciZY dc VX^Y"[gZZ eVeZg Heg^c\Zg"KZgaV\ AdcYdc A^b^iZY '%%+ 6eVgi [gdb Vcn [V^g YZVa^c\ [dg i]Z ejgedhZh d[ gZhZVgX] dg eg^kViZ hijYn! dg Xg^i^X^hb dg gZk^Zl! Vh eZgb^iiZY jcYZg i]Z 8deng^\]i! 9Zh^\ch VcY EViZcih 6Xi &.--! i]^h ejWa^XVi^dc bVn dcan WZ gZegdYjXZY! hidgZY dg igVch" b^iiZY! ^c Vcn [dgb dg Wn Vcn bZVch! l^i] i]Z eg^dg eZgb^hh^dc ^c lg^i^c\ d[ i]Z ejWa^h]Zgh! dg ^c i]Z XVhZ d[ gZegd\gVe]^X gZegdYjXi^dc ^c VXXdgYVcXZ l^i] i]Z iZgbh d[ a^XZcXZh ^hhjZY Wn i]Z 8deng^\]i A^XZch^c\ 6\ZcXn# :cfj^g^Zh XdcXZgc^c\ gZegdYjXi^dc djih^YZ i]dhZ iZgbh h]djaY WZ hZci id i]Z ejWa^h]Zgh# I]Z jhZ d[ gZ\^hiZgZY cVbZh! igVYZbVg`h! ZiX# ^c i]^h ejWa^XVi^dc YdZh cdi ^bean! ZkZc ^c i]Z VWhZcXZ d[ V heZX^ÑX hiViZbZci! i]Vi hjX] cVbZh VgZ ZmZbei [gdb i]Z gZaZkVci aVlh VcY gZ\jaVi^dch VcY i]ZgZ[dgZ [gZZ [dg \ZcZgVa jhZ# EgdYjXi a^VW^a^in/ I]Z ejWa^h]Zg XVc \^kZ cd \jVgVciZZ [dg ^c[dgbVi^dc VWdji Ygj\ YdhV\Z VcY Veea^XVi^dc i]ZgZd[ XdciV^cZY ^c i]^h Wdd`# >c ZkZgn ^cY^k^YjVa XVhZ i]Z gZheZXi^kZ jhZg bjhi X]ZX` ^ih VXXjgVXn Wn Xdchjai" ^c\ di]Zg e]VgbVXZji^XVa a^iZgVijgZ# Eg^ciZY ^c i]Z H^c\VedgZ
7H$@ND
. - , + * ) ( ' & Heg^c\Zg HX^ZcXZ 7jh^cZhh BZY^V heg^c\Zgdca^cZ#Xdb
Preface
> lVh kZgn Zci]jh^Vhi^X l]Zc > lVh VeegdVX]ZY ^c CdkZbWZg '%%) id ZY^i V Wdd` dc i^hhjZ hjg\Zgn ^c i]Z CZl IZX]c^fjZh ^c Hjg\Zgn hZg^Zh# > lVh Xdck^cXZY i]Vi ^i ldjaY WZ \gZVi id ]VkZ V Wdd` ^c V XdaaZXi^dc i]Vi hd ZaZ\Vcian h]dlh i]Z egd\gZhh ^c djg jcYZghiVcY^c\! ]VcYa^c\! VcY VeegdVX] id Y^[[ZgZci ineZh d[ i^hhjZh# I]Z \gZViZhi X]VaaZc\Z lVh id ZchjgZ i]Vi i]Z i^iaZ! CZl IZX]c^fjZh! lVh cdi b^haZVY^c\# Bn \dVa lVh id ÑcY XgZVi^kZ Xdc" ig^Wjidgh l^aa^c\ id h]VgZ i]Z^g cdkZa iZX]c^fjZh! l]^aZ Vi i]Z hVbZ i^bZ Zchjg^c\ i]Vi i]Z iZX]c^fjZh lZgZ je"id"YViZ Vi i]Z i^bZ d[ ejWa^XVi^dc# Id VX]^ZkZ i]^h \dVa! Wdd` egdYjXi^dc XdjaY cdi ZmXZZY dcZ nZVg VcY i]Z Xdcig^Wjidgh ]VY id Xdbb^i id h]VgZ i]Z^g bdhi ^ccdkVi^kZ VeegdVX]Zh id i^hhjZ hjg\Zgn l]^aZ bV^ciV^c^c\ hX]ZYjaZY YZVYa^cZh# I]^h lVh V X]VaaZc\^c\ iVh`! Wji bn XdaaVWdgVi^kZ Z[[dgih ^c i]Z ÑZaY dkZg eVhi YZXVYZ ZcVWaZY bZ id ÑcY XgZVi^kZ VcY hjeedgi^kZ hjg\Zdch l]d bZi i]dhZ gZfj^gZbZcih# ;^cVaan! i]Z egZhZciVi^dc d[ cZl iZX]c^fjZh ^c hjg\Zgn ]VY id WZ hjeedgiZY Wn i]Z ZmeZg^ZcXZ VcY gZejiVi^dc d[ i]Z hjg\Zdch l]d ^cigdYjXZY i]Zb# I]Z i^iaZ d[ i]Z Wdd`! I^hhjZ Hjg\Zgn! ZcXdbeVhhZY YZhXg^ei^dch d[ Y^[[ZgZci hjg\^XVa egdXZYjgZh eZg[dgbZY dc V kVg^Zin d[ i^hhjZ ineZh Wn ZmeZgih ^c i]Z ÑZaYh d[ eaVhi^X hjg\Zgn! dgi]deZY^X hjg\Zgn! ]VcY hjg\Zgn! Zhi]Zi^X hjg\Zgn! VcY \ZcZgVa hjg\Zgn# I]Z ilZakZ X]VeiZgh VgZ VggVc\ZY hd i]Vi V Y^gZXi a^c` Zm^hih WZilZZc i]Z gZXZcian ZhiVWa^h]ZY egdXZYjgZh VcY VaiZgcVi^kZ hjg\^XVa dei^dch# Dei^dch i]Vi VgZ iZX]c^XVaan edhh^WaZ VcY ZmeZg^bZciVaan egdkZc! Wji cdi Veea^ZY Xa^c^XVaan dc V gdji^cZ WVh^h dg ZkZcÄVh ^c i]Z XVhZ d[ [VXZ igVcheaVci"cdi eZg[dgbZY Vi i]^h bdbZci# I]Z Ñghi i]gZZ X]VeiZgh hjbbVg^oZ cZl iZX]c^XVa X]VaaZc\Zh ^c gZeV^g VcY gZhidgVi^dc d[ [jcXi^dc l^i]^c kZgn heZX^Va^oZY Xdbedh^iZ i^hhjZh! hjX] Vh i]Z i]dhZ d[ i]Z ]VcY dg i]Z aZ\# 8]VeiZg & hjbbVg^oZh i]Z Vji]dgÈh jc^fjZ XdcXZei VcY ZmeZg^ZcXZ l^i] dgi]d" eaVhi^X hjg\Zgn Vh Veea^ZY id a^bW hVakV\Z egdXZYjgZh# 8]VeiZg ' ^cigdYjXZh Xa^c^XVa Veea^XVi^dc d[ Xdbedh^iZ i^hhjZ Vaad\gV[i igVcheaVcih! hjX] Vh i]Z ]jbVc ]VcY! VWYdb^" cVa lVaa! `cZZ! aVgncm! igVX]ZV! cZgkZ! iZcYdc bjhXaZ! VcY idc\jZ# BZX]Vc^hb d[ VXi^dc d[ Y^[[ZgZci ^bbjcdhjeegZhh^kZ gZ\^bZch VcY i]Z^g h^YZ Z[[ZXih VgZ Y^hXjhhZY# 8]VeiZg ( ^cigdYjXZh kZghVi^aZ kVhXjaVg Xdbedh^i^dc d[ hbVaa ^cig^ch^X ÒVeh l^i]^c i]Z ]VcY Veea^ZY [dg dcZ"hiV\Z XdkZgV\Z d[ adXVa ]VcY YZ[ZXih l^i] i]Z VYkVciV\Z d[ ZVgan VXi^kZ bdW^a^oVi^dc# I]Zc! 8]VeiZg ) jc^fjZ YZhXg^WZh i]Z ^ciZ\g^in VcY bdW^a^in d[ i]Z hjWXjiVcZdjh i^hhjZ ha^Y^c\ hnhiZb# >i YZhXg^WZh i]Z Vji]dgÈh eZghdcVa ZmeZg^ZcXZ VcY e]^adhde]n dc ]dl Y^[[ZgZci i^hhjZ ineZh ^c djg WdYn VgZ ^ciZgXdccZXiZY VcY ^ciZgYZeZcYZci ^c i]Z^g [jcXi^dc# I]Z Vji]dg c^XZan ZmZbea^ÑZh i]^h gZaVi^dch]^e Wn egZhZci^c\ i]Z jc^fjZ dg\V" c^oVi^dc d[ i]Z bjai^b^XgdkVXjdaVg VWhdgW^c\ ha^Y^c\ hnhiZb# I]Z gdaZ d[ i]^h hnhiZb ^c IZcYdc i^hhjZ hjg\Zgn! ^cXajY^c\ ]jbVc iZcYdc Vaad\gV[i igVcheaVciVi^dc! ^h egZhZciZY# 8]VeiZg * ^h YZkdiZY id i]Z gZhidgVi^dc d[ cZgkZ [jcXi^dc jh^c\ cdkZa VeegdVX]Zh VcY ^cY^XVi^dch [dg eVi^Zcih l^i] Y^VWZi^X cZjgdeVi]n egdWaZbh VcY eVi^Zcih l^i] Vc`aZ VcY h]djaYZg eV^c hncYgdbZh# I]Z Vji]dgh ^cigdYjXZ i]Z^g YZcZgkVi^dc iZX]c^fjZ [dg eVi^Zci l^i] iZbedgdbVcY^WjaVg _d^ci egdWaZbh# v
vi
Preface
8]VeiZg + djia^cZh b^c^bVaan ^ckVh^kZ iZX]c^fjZh Veea^ZY [dg eZg^e]ZgVa cZgkZ egdW" aZbh ^c i]Z jeeZg ZmigZb^in# 9^[[ZgZci cZgkZ XdbegZhh^dc hncYgdbZh VgZ YZbdchigViZY k^V ZcYdhXden ! Vh VgZ i]Z gZhjaih d[ ZcYdhXde^XVaan Vhh^hiZY YZXdbegZhh^dc# 8]VeiZg , egZhZciÈh V hde]^hi^XViZY VeegdVX] id eZg[dgVidg ÒVe hjg\Zgn VcY ^iÈh Veea^XVi^dc id Y^[" [ZgZci i^hhjZh ineZh# I]Z Vji]dgÈh \dVa ^h id VX]^ZkZ i]Z WZhi VZhi]Zi^X djiXdbZ l]^aZ b^c^b^o^c\ Ydcdg h^iZ bdgW^Y^in# 8]VeiZg - ZbWVg`h dc V hZVgX] id gZYjXZ i]Z g^h`h d[ [gZZ ÒVe [V^ajgZ# BZi]dYh d[ ÒVe XdcY^i^dc^c\ VcY ]VcYa^c\ VgZ egZhZciZY WVhZY dc i]Z Vji]dghÈ WVh^X hX^ZcXZ ZmeZg^ZcXZ# 8]VeiZgh . VcY &% djia^cZ XjggZci hjg\^XVa iZX]c^fjZh Veea^ZY id i]Z bdhi ^bedgiVci dg\Vc ^c djg WdYnÄi]Z ]jbVc [VXZ# >c 8]VeiZg .! iZX]c^fjZh d[ [VXZ gZ_jkZcVi^dc! l^i] cdkZa VeegdVX]Zh id V kVg^Zin d[ X]VaaZc\^c\ eVi^Zci edejaVi^dch ^cXajY^c\ edhiWVg^Vig^X hjg\Zgn VcY =>K$6>9H eVi^Zcih! VgZ egZhZciZY# >c XdcigVhi id igVY^i^dcVaan VXXZeiZY VeegdVX]Zh! hjX] Vh Zhi]Zi^X hjg\Zgn! 8]VeiZg &% egZhZcih djg egZeVgVi^dc [dg i]Z bdhi X]VaaZc\^c\ egdXZYjgZ ^c i^hhjZ hjg\ZgnÄi]Z ]jbVc [VXZ igVcheaVciVi^dc# 8]VeiZgh && VcY &' hjbbVg^oZ i]Z bdhi XjggZci VeegdVX]Zh id i^hhjZ Zc\^cZZg^c\ VcY hiZb XZaa WVhZY i]ZgVe^Zh# I]Z egdh VcY Xdch d[ Xa^c^XVaan Veean^c\ Vgi^ÑX^Va i^hhjZ Xdc" higjXih VgZ egZhZciZY# BZi]dYh d[ hiZb XZaa bVc^ejaVi^dch VcY egdeV\Vi^dc ^cid i]Z Y^[[ZgZci i^hhjZ ineZh [dg ]ZVa^c\ VcY gZ\ZcZgVi^dc VgZ Y^hXjhhZY# > ]deZ i]Vi i]^h Wdd` l^aa cdi dcan ^cigdYjXZ cZl bZi]dYh VcY iZX]c^fjZh ^c i^hhjZ hjg\Zgn! Wji l^aa Vahd hi^bjaViZ e]^adhde]^XVa VcY Zi]^XVa Y^hXjhh^dch dc djg [jijgZ VeegdVX]Zh VcY a^b^iVi^dch ^c hjg\Zgn# BVnWZ lZ VgZ l^icZhh^c\ V bV_dg X]Vc\Z ^c i]Z ÑZaY d[ i^hhjZ hjg\Zgn VcY lZ l^aa WZ VWaZ! ^c i]Z cZVg [jijgZ! id eVgVe]gVhZ i]Z :XXaZh^VhiZh Ve]dg^hb i]Vi ÅI]ZgZ ^h hdbZi]^c\ cZl jcYZg i]Z hjc#Æ BVg^V O# H^Zb^dcdl 8aZkZaVcY! D]^d
Contents
& Dgi]deaVhi^X GZXdchigjXi^dc d[ i]Z 6gbh VcY AZ\h A# HXdii AZk^c # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #
&
' 8a^c^XVa 6eea^XVi^dc d[ 8dbedh^iZ I^hhjZ 6aad\gV[ih BVg^V O# H^Zb^dcdl! HV`^g JcVa VcY cYZm # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # #
&*.
vii
Contributors
chi^ijiZ! Jc^kZgh^in d[ 8Va^[dgc^V! >gk^cZ! DgVc\Z! 86 .'-+-! JH6 ?dhZe] 7V`]VX]! B9 >chi^iji 6fj^iV^c 8]^gjg\^Z EaVhi^fjZ! EZhhVX! 7dgYZVjm! ;gVcXZ E]^aa^e C# 7adcYZZa! B9! E]9 9ZeVgibZci d[ EaVhi^X VcY GZXdchigjXi^kZ Hjg\Zgn! Jc^kZgh^in =dhe^iVa chi^ijiZ [dg EZg^e]ZgVa CZgkZ Hjg\Zgn! >cX#! 7Vai^bdgZ! B9! JH6 =da\Zg :c\Za! B9 9ZeVgibZci d[ =VcY! EaVhi^X VcY GZXdchigjXi^kZ Hjg\Zgn! 7jgc 8ZciZg! 7cY^k^YjVah hjX] Vh 6bWgd^hZ EVg! VcY hd ^h VWdji &%% nZVgh daY# EgdWVWan i]Z Ñghi bdYZgc dgi]deVZY^X eaVhi^X XdaaVWdgVi^dc lVh WZilZZc H^g L# 6gWji]cdi AVcZ VcY H^g =VgdaY c &.&.! AVcZ! Vc dgi]deVZY^X hjg\Zdc! lgdiZ i]Z egZ[VXZ [dg c VYY^i^dc id jcYZghiVcY^c\ i]Z ^cY^XVi^dch [dg VbejiVi^dch VcY i]Z VaiZgcVi^kZh id a^bW hVakV\Z! hjX] Vh V egdhi]Zh^h! i]Z bdYZgc dgi]deVZY^X hjg\Zdc h]djaY jcYZghiVcY i]Vi i]ZgZ VgZ iZX]c^fjZh! WVhZY dc W^dbZX]Vc^Xh VcY hd[i i^hhjZ gZXdc" higjXi^dc! i]Vi ZcVWaZ i]Z ediZci^Va VbejiZZ id ]VkZ V WZiiZg [jcXi^dcVa gZh^YjVa a^bW#&( I]ZhZ iZX]c^fjZh ^cXajYZ ^haVcY eZY^XaZ dg [gZZ ÒVeh VcY ÑaaZi ÒVeh id egZhZgkZ cdi dcan hZch^W^a^in Wji aZ\ XdkZgV\Z# ;dg ZmVbeaZ! V eVi^Zci l^i] V hZkZgZ Xgjh] ^c_jgn id i]Z i^W^V Wji l^i] V cdgbVa [ddi VcY V cdgbVa `cZZ bVn gZfj^gZ gZhjg[VX^c\ dg `cZZ _d^ci egZhZgkVi^dc dg i]Vi i]Z [ddi WZ ÑaaZiZY Vh Vc ^haVcY eZY^XaZ ÒVe dg ZkZc Vh V [gZZ ÒVe id egdk^YZ WZadl"`cZZ XdkZgV\Z ;^\jgZ &"( # I]Z XdcXZei d[ ÑaaZi ÒVe XaVhh^ÑXVi^dch! ^cY^XVi^dch! VcY VcVanh^h d[ Xa^c^XVa kVajZ ]Vh WZZc lZaa YZhXg^WZY Wn c VYY^i^dc! lZ VgZ cdl
Orthoplastic Reconstruction of the Arms and Legs
a
3
b
Figure 1-2. a) Standard below-knee prosthesis on the left, an energy-absorbing ankle on the left. b) An upper extremity myoelectric prosthesis.
b
a
c Figure 1-3. a–c) Examples of foot filet flaps in below-knee amputation.
4
Tissue Surgery
a
b Figure 1-4. A transmetatarsal amputation augmented with a lateral arm free flap.
XdcXZcigVi^c\ dc i]Z VZhi]Zi^X VheZXih d[ edhi" igVjbVi^X gZXdchigjXi^dc0 VcY iZX]c^fjZh! hjX] Vh ZcYdhXde^X i^hhjZ ZmeVch^dc! XVc WZ Veea^ZY id i]Z igVjbVi^oZY a^bW! cdi dcan id gZaZVhZ Xdc" igVXijgZh Wji id gZhjg[VXZ i]Z a^bW [dg V bdgZ VZhi]Zi^XVaan VcY ehnX]dad\^XVaan eaZVh^c\ gZhjai ;^\jgZ &"* #''Ã'DcZ d[ i]Z e^dcZZgh d[ bdYZgc dgi]deaVhi^X hjg\Zgn ^h BVgXd a^oVgdk iZX]c^fjZ ]Vh ]VY V egd[djcY ^cÒjZcXZ dc adlZg ZmigZb^in VcY hdbZ jeeZg ZmigZb^in gZXdchigjXi^dch#(* I]Z VW^a^in id Yd Y^higVXi^dc dhiZd\ZcZh^h VcY Vc\jaVg XdggZXi^dc d[ Wdcn YZ[dgb^i^Zh VcY _jmiV"Vgi^XjaVg YZ[dgb^i^Zh ]Vh \gZVian VYkVcXZY a^bW hVakV\Z Wn egdk^Y^c\ [jcXi^dc^c\ ZmigZb^i^Zh# I]^c"l^gZ ÑmVi^dc ^h V kZgn edlZg[ja idda i]Vi! l]Zc XdbW^cZY l^i] b^Xgdhjg\Zgn! XVc hZgkZ lZaa i]Z cZZYh d[ ^c_jgn gZeV^g VcY ZaZXi^kZ gZXdchigjXi^dc d[ i]Z adlZg ZmigZb^in ;^\jgZ &"- #
Orthoplastic Reconstruction of the Arms and Legs
:mVbeaZh d[ adlZg"ZmigZb^in hVakV\Z ^cXajYZ i]Z jhZ d[ i]Z >a^oVgdk iZX]c^fjZ id iZbedgVg^an hiVW^a^oZ Vc ZmigZb^in# Hd[i i^hhjZ ldg` XVc WZ YdcZ VgdjcY i]Z [gVbZ! Z^i]Zg l^i] adXVa dg eZY^XaZ ÒVeh# I]Zc i]Z Y^higVXi^dc dg XdckZc"
5
i^dcVa WdcZ \gV[i^c\ l^i] i]Z >a^oVgdk [gVbZ XVc WZ eZg[dgbZY# >c i]Z aZ\! Vh lZaa Vh ^c i]Z Vgb! i]Z dhiZdXjiVcZdjh ÑWjaV XVc egdk^YZ je id '% Xb d[ ^ciZgXVaVgn kVhXjaVg^oZY WdcZ [dg [ZbdgVa dg i^W^V gZXdchigjXi^dc# I]Z ÑWjaV ^h lZaa
a
b
c
d
e Figure 1-5. a–e) An example of aesthetic considerations using tissue expansion to remodel soft tissue after limb salvage.
6
Tissue Surgery
a c
b
d
Figure 1-6. a–d) One-stage reconstruction illustrated with solid fixation of bone with Arbeitsgemeinschaft für Osteosynthesefragen (AO, Association for the Study of Osteosynthesis) principles and free tissue transfer combined.
hj^iZY [dg gZeV^g^c\ aVg\Z YZ[ZXih gZaViZY id igVjbV dg dhiZdbnZa^i^h ^c i]Z aZ\# >c i]Z [Zbjg! djg egZ[ZgZcXZ ^h id [daY i]Z ÑWjaV ^c ]Va[! id ^cXgZVhZ i]Z Xgdhh"hZXi^dcVa VgZV i]Vi b^b^Xh i]Z Y^VbZiZg d[ i]Z [Zbjg# I]Z Zkdaji^dc d[ [VhX^dXjiVcZdjh ÒVeh! edej" aVg^oZY Wn BVhfjZaZi VcY WVhZY dc Vc\^dhdbZh VcY eZg[dgVi^c\ kZhhZah! ]Vh VYYZY \gZVian id
i]Z VgbVbZciVg^jb d[ hd[i i^hhjZ gZXdchigjXi^kZ iZX]c^fjZh i]Vi ]VkZ VaadlZY adlZg a^bW hVakV\Z ^c XVhZh l]ZgZ hVakV\Z lVh [dgbZgan cdi edhh^WaZ#(+Ã(. Ijbdg gZeV^g ^c i]Z adlZg a^bW ]Vh WZZc Zc]VcXZY Wn i]Z dgi]deaVhi^X VeegdVX]# I]Z jhZ d[ h^bjaiVcZdjh [gZZ ÒVeh l^i] ijbdg Zmi^geV" i^dc VcY Vaad\gV[ih! Vh lZaa Vh i]Z >a^oVgdk
Figure 1-7. The osteocutaneous fibula in lower extremity tibia reconstruction.
Figure 1-8. The use of external ring fixation combined with soft tissue reconstruction.
Orthoplastic Reconstruction of the Arms and Legs
iZX]c^fjZ! ]Vh hVakV\ZY a^bWh i]Vi ldjaY ]VkZ egZk^djhan WZZc VbejiViZY# 6Zhi]Zi^X Xdch^YZg" Vi^dch ^c i]Z aZ\! Vh lZaa Vh ^c i]Z Vgb! XVc WZ hZgkZY Wn i^hhjZ ZmeVch^dc#
Other Applications of Orthoplastic Surgery DcZ d[ i]Z VgZVh ^c dgi]deaVhi^X hjg\Zgn i]Vi YZhZgkZh XdbbZci ^h dhiZdbnZa^i^h#)%!)& 6cn eVi^Zci l]d ZmeZg^ZcXZh hjeejgVi^dc ]Vh i]Z g^\]i id Vh` i]Z hjg\Zdc id ZmeaV^c ]dl ^i dXXjggZY# I]^h g^\]i lVh ed^ciZY dji Wn 8VggZa ^c &.&- VcY ^h hi^aa igjZ idYVn# 8^ZgcZn VcY BVYZg XaVhh^[n VYjai dhiZdbnZa^i^h Wn VcVidb^XVa ineZ VcY e]nh^dad\^XVa XaVhh# I]Z VcVidb^X ineZh VgZ bZYjaaVgn! hjeZgÑX^Va! adXVa^oZY! VcY Y^[[jhZ# I]Z e]nh^dad\^X XaVhhZh VgZ cdgbVa! Xdbegd" b^hZY! VcY igZVibZci"YZ[ZggZY# 6 Xa^c^XVa hiV\Z ^h egdYjXZY Wn XdbW^c^c\ VcVidb^X ineZ l^i] e]nh^dad\^XVa XaVhh# 7VhZY dc i]^h hiV\^c\
7
egdXZhh! Vh ^c ijbdg hjg\Zgn! i]Z igZVibZci djiXdbZh [dg adc\"hiVcY^c\ dhiZdbnZa^i^h XVc WZ egZY^XiZY#)' I]Z igZVibZci Va\dg^i]b ^ckdakZh i]Z Xd" deZgVi^dc d[ Wdi] i]Z hd[i"i^hhjZ VcY WdcZ hjg\Zdch# ;^ghi! gVY^XVa cZXgZXidbn VcY hZfjZh" igZXidbn ^h eZg[dgbZY dc Vaa cdck^VWaZ i^hhjZ VcY ^beaVcih# 6 ]ZVai]n ldjcY VcY ]ZVai]n WdcZ VgZ i]Zc ZhiVWa^h]ZY# I]^h egdXZhh d[iZc ^ckdakZh gZbdk^c\ ^beaVcih0 XgZVi^c\ Vcdi]Zg hiVWaZ XdchigjXi! hjX] Vh jhZ d[ i]Z >a^oVgdk dg ZmiZgcVa ÑmVi^dc0 igZVi^c\ YZVY heVXZ l^i] hd[i i^hhjZ iZX]c^fjZh! hjX] Vh [gZZ ÒVeh0 VcY hjWhZfjZcian gZXdchigjXi^c\ i]Z WdcZ ;^\jgZ &". # =neZg" WVg^X dmn\Zc ^h cdi ^bedgiVci ^c igZVi^c\ dhiZd" bnZa^i^h! ^ih XjggZci gdaZ ^c ZmigZb^in hVakV\Z WZ^c\ id Vj\bZci i]Z egdYjXi^dc d[ \gVcjaVi^dc i^hhjZ hd i]Vi Vcn i]gZViZcZY YnhkVhXjaVg a^bWh d[ Y^VWZi^X eVi^Zcih i]Vi VgZ cdi XVcY^YViZh [dg b^XgdgZXdchigjXi^dc dg bVXgdgZXdchigjXi^dc XVc WZ gZhjg[VXZY l^i] h`^c \gV[ih#)(!)) HdbZ eVi^Zcih jcYZg\d ViiZbeiZY a^bW hVakV\Z l^i] egdeZg eaVcc^c\ VcY ZmZXji^dc!
a
c b Figure 1-9. a–c) Osteomyelitis of the tibia with filling of the dead space with a free muscle flap after adequate sequestrectomy and split-thickness skin grafting.
8
Tissue Surgery
dcan id gZhjai ^c [V^ajgZ Vh V gZhjai d[ X]gdc^X hZeh^h! ^cigVXiVWaZ eV^c! dg aVX` d[ eVi^Zci YZh^gZ id Xdci^cjZ i]Z hVakV\Z egdXZYjgZh# >c XVhZh l]ZgZ XdbeaZm gZXdchigjXi^dc ]Vh WZZc jcYZg" iV`Zc id hVkZ i]gZViZcZY a^bWh! V XdcigVXi h]djaY WZ bVYZ l^i] i]Z eVi^Zci VcY i]Z [Vb^an ^cY^XVi" ^c\ i]Vi ^[ i]Z a^bW XVccdi WZ hVkZY Wn V XZgiV^c YViZ! VbejiVi^dc h]djaY WZ eZg[dgbZY# A^bW hVakV\Z ^c eVi^Zcih l^i] Y^VWZiZh ^h ZheZX^Vaan X]VaaZc\^c\! ^c i]Vi V ]^\] eZgXZciV\Z d[ Y^VWZi^Xh ZmeZg^ZcXZ cZjgdeVi]n VcY higjX" ijgVa X]Vc\Zh XVjhZY Wn cZjgdeVi]^X X]Vc\Zh ^c i]Z [ddi! gZhjai^c\ ^c VWcdgbVa higZhh id i]Z [ddi VcY aZVY^c\ id jaXZgVi^dc VcY h`^c WgZV`Ydlc#)* I]^h egdXZhh d[iZc gZhjaih ^c YZZe ^c[ZXi^dch ^c i]Z WdcZ VcY hd[i i^hhjZ! VcY WZXVjhZ Y^VWZiZh ^c]^W^ih ]ZVa^c\! i]ZhZ ^c[ZX" i^dch VgZ d[iZc gZh^hiVci id XdckZci^dcVa igZVi" bZci# I]Z Ñghi YZiZgb^cVi^dc [dg a^bW hVakV\Z ^c V Y^VWZi^X eVi^Zci ^h id YZiZgb^cZ ^cÒdl! V [VXi d[iZc dkZgadd`ZY Wn eg^bVgn XVgZ egdk^YZgh VcY ZkZc Wn dgi]deZY^hih# D[iZc! _jhi h^beaZ hiZci^c\ dg kVhXjaVg WneVhh egdXZYjgZh XVc Vj\bZci WaddY Òdl id i]Z a^bW! gZhjai^c\ ^c ]ZVa^c\ dg egdbdi^c\ ldjcY WZYh hj^iVWaZ [dg h^beaZ hdaji^dch! hjX] Vh h`^c \gV[ih dg adXVa ÒVeh#)+!), >[ aVg\Z VgZVh d[ i^hhjZ VgZ YZhigdnZY! gZhjai^c\ ^c YZVY heVXZ! dg ^[ aVg\Z VgZVh cZZY gZhjg[VX^c\! [gZZ i^hhjZ igVch[Zgh XVc WZ Xdch^Y" ZgZY! ^c Xdc_jcXi^dc l^i] dg V[iZg kVhXjaVg WneVhh egdXZYjgZh#)- I]Z VbejiVi^dc gViZ d[
a
a^bWh ^c Y^VWZi^Xh XVc WZ Vh ]^\] Vh *% Vi * nZVgh0 i]jh! Vaa ViiZbeih h]djaY WZ bVYZ id hVakV\Z i]Zb#).
The Future of Orthoplastic Surgery I]Z [jijgZ d[ dgi]deaVhi^X hjg\Zgn l^aa WZ WVhZY dc i]Z edhh^W^a^in d[ i^hhjZ igVcheaVciVi^dc# H]dgi d[ i]^h! i]Z jhZ d[ WdcZ Vaad\gV[ih Xdb" W^cZY l^i] hd[i i^hhjZ gZXdchigjXi^kZ iZX]c^fjZh ]VkZ WZZc Z[[ZXi^kZ ^c hVakV\^c\ a^bWh# Di]Zg dgi]deaVhi^X YdbV^ch ^cXajYZ gZXdchigjXi^c\ i]Z bVcY^WaZ l^i] g^\^Y ÑmVi^dc VcY kVhXjaVg^oZY WdcZ \gV[ih# I]^h gZXdchigjXi^dc egdWaZb ^h h^b^aVg id i]Vi XgZViZY Wn dhiZdbnZa^i^h ^c i]Z ZmigZb^i^Zh# D[iZc gVY^Vi^dc"^cYjXZY dhiZdcZ" Xgdh^h! dg ijbdgh l^i] adXVa^oZY h`^c ^c[ZXi^dc! gZfj^gZ ijbdg Zmi^geVi^dc! i^hhjZ YWg^YZbZci! bVcY^WjaVg hiVW^a^oVi^dc! VcY hd[i i^hhjZ XdkZg" V\Z# I]ZhZ egdXZYjgZh XVc WZ YdcZ Vh i]Zn VgZ ^c i]Z ZmigZb^i^Zh# 6cdi]Zg YdbV^c d[ dgi]deaVhi^X hjg\Zgn i]Vi ]Vh WZZc jcgZVa^oZY ^h i]Z cZZY [dg dgi]deaVhi^X hjg\Zgn d[ i]Z X]Zhi lVaa#*% 6ai]dj\] hd[i i^hhjZ egdXZYjgZh VgZ YZh^\cZY id igZVi bZY^Vhi^c^i^h VcY id ]Zae gZXdchigjXi i]Z X]Zhi lVaa! higjXijgVa ^chiVW^a^i^Zh! hjX] Vh hiZgcVa cdcjc^dc VcY X]gdc^X eV^c WVhZY dc hiZgcVa ^chiVW^a^in! XVc WZ igZViZY l^i] YZk^XZh hjX] Vh Xjhidb eaViZh ;^\jgZ &"&% #
b Figure 1-10. a–c) Sternal instability treated with custom plates.
c
Orthoplastic Reconstruction of the Arms and Legs
9
Conclusion B^c^bVaan ^ckVh^kZ dgi]deaVhi^X hjg\Zgn ]Vh WZZc lZaa YZkZadeZY# 8jggZci iZX]c^fjZh [dg i^hhjZ ZmeVch^dc VgZ gZaViZY id WVaaddc"Vhh^hiZY ZcYdhXde^X i^hhjZ ZmeVch^dc#*& ;gZZ"ÒVe egZ[VW" g^XVi^dc jh^c\ ZcYdhXde^X eaVXZbZci d[ i^hhjZ ZmeVcYZgh ]Vh WZZc lZaa ZhiVWa^h]ZY VcY gZYjXZh i]Z i^bZ cZZYZY [dg XdbeaZm a^bW gZXdchigjX" i^dc# L^i] b^c^bVaan ^ckVh^kZ hjg\Zgn VcY di]Zg iZX]cdad\^Zh! iZX]cdad\^Zh ^c hZVgX] d[ hjg\^XVa egdXZYjgZh l^aa cdi hZaa VcY WZ ]Zae[ja# I]Z [jijgZ d[ dgi]deaVhi^X hjg\Zgn ^h [jgi]Zg ^ciZ\gV" i^dc l^i] XdcXZeih ^c hd[i i^hhjZ VcY WdcZ iZX]" cdad\n VcY [jgi]Zg YZkZadebZci d[ a^bW hVakV\Z VcY gZXdchigjXi^dc#
&)# &*# &+#
&,# &-# &.# '%#
References &# AZk^c AH! 8dcY^i 9E# 8dbW^cZY ^c_jg^Zh/ hd[i i^hhjZ bVcV\ZbZci# 8a^c Dgi]de GZa GZh# &..+0 (', /&,'Ã &-&# '# LVc\ =! :gYbVcc 9! ;aZiX]Zg! AZk^c AH# 6ciZgdaViZgVa i]^\] ÒVe iZX]c^fjZ ^c ]VcY VcY jeeZg ZmigZb^in gZXdchigjXi^dc# IZX]c^f =VcY JeeZg :migZb Hjg\# '%%)0- ) /'*,Ã'+&# (# AZk^c AH! HZgVÑc 9# EaVciVg h`^c XdkZgV\Z# EgdW EaVhi GZXdchig Hjg\# &..&0& & /&*+Ã&-)# )# @ZaaZg G7! HdjaZ 9C! LZccWZg\ ?:! =VcaZn 9;# 9ZVa^c\ l^i] \Zd\gVe]^X kVg^Vi^dch ^c i]Z jhZ d[ ]dhe^iVah/ i]Z ZmeZg^ZcXZ d[ i]Z BV^cZ BZY^XVa 6hhZhhbZci ;djcYV" i^dc Dgi]deVZY^X HijYn chi^ijiZ [dg =VcY B^Xgdhjg\Zgn! Adj^hk^aaZ! @N! JH6# &&# :gYbVcc 9! AZZ 7! GdWZgih 89! AZk^c AH# BVcV\Z" bZci d[ aVlcbdlZg ^c_jg^Zh id i]Z adlZg ZmigZb^in ^c X]^aYgZc VcY VYdaZhXZcih# 6cc EaVhi Hjg\# '%%%0)*/ *.*Ã+%%# &'# AZk^c AH# Hd[i i^hhjZ XdkZgV\Z dei^dch [dg Vc`aZ ldjcYh# ;ddi 6c`aZ 8a^c# '%%&0+/-*(Ã-++# &(# :gYbVcc 9! HjcY^c 7! NVhj^ @! Ldc\ BH! AZk^c AH# B^Xgdhjg\^XVa [gZZ ÒVe igVch[Zg id VbejiVi^dc h^iZh/
'&# ''# '(# ')#
'*#
'+#
',# '-# '.# (%#
(&#
('#
^cY^XVi^dch VcY gZhjaih# 6cc EaVhi Hjg\# '%%'0)- ' / &+,Ã&,'# AZk^c AH! :gYbVcc 9!
Tissue Surgery )(# c VYY^i^dc! Ydcdg h^iZ bdgW^Y^in XVc WZ V egdWaZb ^c Vjidad\djh i^hhjZ \gV[i^c\# Egdhi]Zi^X bViZg^Vah VgZ Vcdi]Zg igZVibZci dei^dc [dg aVg\Z YZ[ZXih! Wji i]Zn ]VkZ Vaa i]Z bV_dg YgVlWVX`h d[ cdck^iVa bViZg^Va# 8dbedh^iZ i^hhjZ Vaad\gV[ih i]jh ]VkZ \gZVi ediZci^Va [dg gZXdchigjXi^c\ kVg^djh eVgih d[ i]Z WdYn# 8dbedh^iZ i^hhjZ ^h bdgZ ^bbjcd\Zc^X i]Vc igVcheaVciZY hda^Y dg\Vch# 6ai]dj\] XVgi^aV\Z! a^\VbZcih! VcY [Vi ]VkZ adl Vci^\Zc^X^in VcY WdcZ! bjhXaZh! cZgkZh! VcY kZhhZah ]VkZ bdYZgViZ Vci^\Zc^X^in! h`^c YZkZadeh i]Z bdhi hZkZgZ gZ_ZX" i^dc WZXVjhZ d[ i]Z VWjcYVcXZ d[ YZcYg^i^X XZaah ^c i]Z Ze^YZgb^h VcY YZgb^h#&
Clinical Composite Tissue Allotransplants 6YkVcXZh ^c igVcheaVciVi^dc ^bbjcdad\n ]VkZ deZcZY Y^hXjhh^dc dc i]Z gdji^cZ Xa^c^XVa Veea^" XVW^a^in d[ Xdbedh^iZ i^hhjZ Vaad\gV[ih# 6h d[ ?VcjVgn &! '%%*! bdgZ i]Vc *% Xdbedh^iZ i^hhjZ Vaad\gV[i igVcheaVcih ]VkZ WZZc eZg[dgbZY
ldgaYl^YZ! ^cXajY^c\0 ]VcY! VWYdb^cVa lVaa! `cZZh! ÒZmdg iZcYdc VeeVgVijh! cZgkZ! aVgncm! h`ZaZiVa bjhXaZ! idc\jZ! VcY igVX]ZV IVWaZ '"& #
Hand Transplants I]Z Ñghi ]VcY igVcheaVciVi^dc lVh eZg[dgbZY WZ[dgZ i]Z XnXadhedg^cZ ZgV d[ ^bbjcdhjeegZh" h^dc ^c &.+(#' I]Z eVi^Zci gZXZ^kZY hiZgd^Yh VcY VoVi]^deg^cZ ^bbjcdhjeegZhh^kZ igZVibZci# I]Z ]VcY lVh gZ_ZXiZY ( lZZ`h V[iZg igVcheaVciVi^dc# H^cXZ i]Z Ñghi hjXXZhh[ja ]VcY igVcheaVciVi^dc ^c &..-! ^c Andc(! '* igVcheaVcih + W^aViZgVa ^c &. eVi^Zcih ]VkZ WZZc gZedgiZY0 - + eVi^Zcih [gdb 8]^cV! * ( eVi^Zcih [gdb ;gVcXZ! ) ' eVi^Zcih [gdb 6jhig^V! ( [gdb >iVan! ' [gdb i]Z JH6! & [gdb 7Za\^jb! VcY & [gdb BVaVnh^V IVWaZ '"' #) >c HZeiZbWZg &..-! V iZVb ^c Andch! ;gVcXZ! eZg[dgbZY i]Z Ñghi hjXXZhh[ja ]jbVc ]VcY VaadigVcheaVci#( I]Zn igVcheaVciZY i]Z g^\]i ]VcY VcY Y^hiVa [dgZVgb [gdb V WgV^c"YZVY Ydcdg id V )-"nZVg"daY bVc l]dhZ dlc g^\]i ]VcY VcY Y^hiVa [dgZVgb ]VY WZZc VbejiViZY ^c V &.-. VXX^YZci# I]Z ^cYjXi^dc ^bbjcdhjeegZhh^kZ egdidXda Xdch^hiZY ^c^i^Vaan d[ Vci^i]nbdXniZ \adWja^c ,* b\$YVn [dg &% YVnh ! iVXgda^bjh VY_jhiZY id bV^ciV^c WaddY XdcXZcigVi^dch WZilZZc &% c\$bA VcY &* c\$bA Yjg^c\ i]Z Ñghi bdci]! bnXde]ZcdaViZ bd[Zi^a BB; ' \$ YVn ! VcY hiZgd^Yh egZYc^hdcZ! '*% b\ dc YVn & VcY gVe^Yan iVeZgZY id '% b\$YVn # 89'* bdcd" XadcVa Vci^WdYn lVh \^kZc dc YVn '+ VcY YVn &%%# BV^ciZcVcXZ i]ZgVen ^cXajYZY iVXgda^bjh id bV^ciV^c hZgjb XdcXZcigVi^dch WZilZZc * VcY &% c\$bA ! BB; ' \$YVn ! VcY egZYc^hdcZ '% b\$YVn Vi ( bdci]h! &* b\$YVn Vi + bdci]h #( 6i +"bdci] [daadl"je! egd\gZhh^dc d[ bdidg VcY hZchdgn [jcXi^dc lVh hVi^h[VXidgn# >c ?VcjVgn &...! hjg\Zdch ^c Adj^hk^aaZ! @ZcijX`n! eZg[dgbZY i]Z Ñghi ]jbVc ]VcY
11
12 Table 2-1. Number and Type of Composite Tissue Allografts Transplanted as of January 1, 2005, Worldwide Hand 13 unilateral, 6 bilateral Abdominal wall 9 Knee 3 femoral diaphysis, 5 whole knee Flexor tendon apparatus 2 Nonvascularized nerve 7 Larynx 1 Muscle 1 Tongue 1 Trachea 2
VaadigVcheaVci ^c i]Z Jc^iZY HiViZh#* I]Zn igVch" eaVciZY V Ydcdg ]VcY id V (,"nZVg"daY bVc l]dhZ dlc aZ[i ]VcY lVh adhi ^c Vc VXX^YZci ^c &.-*# EdhideZgVi^kZ ^bbjcdhjeegZhh^kZ i]ZgVen Xdch^hiZY d[ ^cigVkZcdjh WVh^a^m^bVW '% b\ dc YVnh % VcY ) ! iVXgda^bjh iVg\Zi igdj\] &* id '% c\$bA ! BB; & \ il^XZ YV^an! eaVhbV XdcXZc" igVi^dch WZilZZc ( VcY * c\$bA ! VcY egZYc^hdcZ ' b\$`\$YVn iVeZgZY id &% b\$YVn Wn ( bdci]h # CZjgdbjhXjaVg [jcXi^dc gZijgcZY bdgZ gVe^Yan ^c i]Z Vaad\gV[i ]VcY i]Vc ^i YdZh ^c gZeaVciZY ]VcYh! VcY i]ZgZ lVh aZhh hi^[[cZhh VcY ZYZbV# ;gZcX] VcY >iVa^Vc iZVbh ]VkZ gZedgiZY i]Z aVg\Zhi hZg^Zh d[ - ]VcY igVcheaVcih ^c + eVi^Zcih ) h^c\aZ VcY ' YdjWaZ igVcheaVcih #+ >c i]ZhZ ]VcYh! i]Z i^bZ WZilZZc VbejiVi^dc VcY igVch" eaVci gVc\ZY [gdb ( id '' nZVgh# I]Z aZkZa d[ VbejiVi^dc ^c i]Z gZX^e^Zcih lVh Vi i]Z lg^hi ^c + ]VcYh VcY Vi i]Z Y^hiVa [dgZVgb ^c '# 8daY ^hX]" Zb^V i^bZ gVc\ZY [gdb && id &'#* ]djgh# I]Z hZfjZcXZ d[ i]Z hjg\^XVa egdXZYjgZ lVh WdcZ ÑmVi^dc! gZkVhXjaVg^oVi^dc l^i] b^Xgdhjg\^XVa VcVhidbdhZh d[ Vi aZVhi dcZ VgiZgn VcY kZ^c! iZcYdc gZeV^g! cZgkZ XdVeiVi^dc! VcY h`^c XadhjgZ# I]Z ^bbjcdhjeegZhh^kZ egdidXda ^cXajYZY Vc ^c^i^Va ^cYjXi^dc i]ZgVen jh^c\ edanXadcVa Vci^" WdY^Zh dg Vci^"89'* bdcdXadcVa Vci^WdYn! iVXgda^bjh! BB;! VcY egZYc^hdcZ# BV^ciZcVcXZ i]ZgVen ^cXajYZY iVXgda^bjh WaddY aZkZah bV^c" iV^cZY WZilZZc * VcY &% c\$bA ! bnXde]ZcdaViZ bd[Zi^a & id ' \$YVn ! VcY egZYc^hdcZ '#* id ,#* b\$YVn # >c ild XVhZh! VYY^i^dcVa hjg\^XVa egdXZYjgZh lZgZ eZg[dgbZY#IZcYdch lZgZ h]dgi" ZcZY [dg WZiiZg lg^hi hiVW^a^in ^c dcZ XVhZ! VcY igVjbV id i]Z ZmiZchdg edaa^X^h adc\jh iZcYdc lVh gZeV^gZY ^c i]Z di]Zg# I]Z gZ]VW^a^iVi^dc egdidXda hiVgiZY Vh hddc Vh i]Z hlZaa^c\ hjWh^YZY VcY ^cXajYZY e]nh^di]Zg" Ven! ZaZXigdhi^bjaVi^dc! VcY dXXjeVi^dcVa i]ZgVen0 VcY i]ZgVen Xdci^cjZY [dg je id ') bdci]h# I]Z bZVc edhideZgVi^kZ ]dhe^iVa hiVn lVh ''#+ YVnh# Ild d[ i]Z + eVi^Zcih gZhiVgiZY
Tissue Surgery
i]Z^g egZk^djh _dWh l^i]^c * bdci]h d[ hjg\Zgn# 6cdi]Zg jcZbeadnZY eVi^Zci hiVgiZY id ldg` V[iZg hjg\Zgn# 6i aZVhi dcXZ! ZkZgn eVi^Zci ]VY h^\ch d[ h`^c gZ_ZXi^dc! Vi V bZVc d[ )% YVnh edhideZgVi^kZan# Ild eVi^Zcih ]VY V hZXdcY gZ_ZXi^dc Ze^hdYZ Vi Vc VkZgV\Z d[ -' YVnh edhideZgVi^kZan# 6[iZg &bdci]h! Y^hXg^b^cVi^kZ hZchVi^dc gZijgcZY VcY Xdci^cjZY id ^begdkZ i]ZgZV[iZg# Bdidg gZXdkZgn ]Vh WZZc \ddY ^c Vaa eVi^Zcih! ZcVWa^c\ i]Zb id eZg[dgb V cjbWZg d[ YV^an VXi^k^i^Zh! ^cXajY^c\ ZVi^c\! Yg^c`^c\! Yg^k^c\! h]Vk^c\! e]dc^c\! VcY lg^i^c\# ;jcXi^dcVa bV\cZi^X gZhdcVcXZ ^bV\^c\ gZkZVaZY egd\gZhh^kZ gZXdkZgn d[ hZchdg^bdidg VXi^kVi^dch d[ i]Z XdgiZm [dg i]Z ]VcY VgZV l^i]^c + bdci]h edhideZgVi^kZan! ^cY^XVi^c\ V \ddY YZ\gZZ d[ Xdgi^XVa gZ^ciZ\gVi^dc#, I]Z Ñghi ]VcY igVcheaVci lVh gZ"VbejiViZY WZXVjhZ i]Z eVi^Zci lVh cdcVY]ZgZci id e]nh^XVa i]ZgVen VcY ^bbjcdhjeegZhh^kZ igZVibZci# I]^h XVhZ h]dlh i]Z ^bedgiVcXZ d[ eVi^Zci hZaZXi^dc0 ^i Vahd YZbdchigViZh i]Z gZkZgh^W^a^in d[ ]VcY igVcheaVciVi^dc [dg XVhZh l^i] jcYZh^gZY Xdbea^" XVi^dch dg [dg eVi^Zcih l^i] jchVi^h[VXidgn gZhjaih# GZXZcian! dcZ d[ i]Z 8]^cZhZ gZX^e^Zcih ZmeZg^" ZcXZY gZ[gVXidgn gZ_ZXi^dc! l]^X] lVh igZViZY l^i] adXVa ^c_ZXi^dch d[ hiZgd^Yh# DcZ d[ i]ZhZ ^c_ZXi^dch lVh VXX^YZciVaan gZaZVhZY ^cid i]Z VgiZgn! l]^X] aZY id \gV[i adhh#) I]Z bV^c XdcXZgc l^i] ]VcY igVcheaVciVi^dc! Vh l^i] di]Zg 8I6 igVcheaVcih! ^h i]Z cZZY id
Table 2-2. Cases of Hand Transplantation as of January 1, 2005, Worldwide Date Location Transplant Type 1963 Ecuador Unilateral September 1998 Lyon (France) Unilateral January 1999 Louisville (KY, USA) Unilateral September 1999 Guangzhou (China) Unilateral September 1999 Guangzhou (China) Unilateral January 2000 Lyon (France) Bilateral January 2000 Guangxi (China) Unilateral January 2000 Guangxi (China) Unilateral March 2000 Innsbruck (Austria) Bilateral May 2000 Kuala Lumpur (Malaysia) Unilateral October 2000 Guangzhou (China) Bilateral August 2000 Monza (Italy) Unilateral January 2001 Harping (China) Bilateral February 2001 Louisville (KY, USA) Unilateral October 2001 Monza (Italy) Unilateral June 2002 Brussels (Belgium) Unilateral November 2002 Milan (Italy) Unilateral February 2003 Innsbruck (Austria) Bilateral May 2003 Lyon (France) Bilateral Total 19 patients 25 hands
Clinical Application of Composite Tissue Allografts
ZmedhZ eVi^Zcih id a^[Zadc\ ^bbjcdhjeegZhh^dc# >bbjcdhjeegZhh^kZ egdidXdah jhZY ^c ]VcY igVcheaVcih VgZ Vabdhi h^b^aVg id i]dhZ jhZY ^c hda^Y dg\Vc igVcheaVcih VcY jhjVaan ^cXajYZ V XdbW^cVi^dc d[ iVXgda^bjh! BB;! VcY egZYc^" hdcZ [dg ^cYjXi^dc i]ZgVen0 VcY iVXgda^bjh VcY BB; dg iVXgda^bjh VcY egZYc^hdcZ [dg bV^ciZ" cVcXZ i]ZgVen# 6ci^i]nbdXniZ \adWja^c 6IcigVkZcdjh Xdg" i^XdhiZgd^Yh lZgZ jhZY id igZVi gZ_ZXi^dc# D[ eVi^Zcih! + VgZ Va^kZ! VcY * ]VkZ [jcXi^dc^c\! k^VWaZ VWYdb^cVa lVaa Xdbedh^iZ \gV[ih# I]Z h`^c d[ i]Z VWYdb^cVa lVaa lVh b^aYan gZ_ZXiZY ^c ' eVi^Zcih! Wji i]Zn XdbeaZiZan gZXdkZgZY l^i] Xdgi^XdhiZgd^Y i]ZgVen# IgVcheaVciVi^dc d[ i]Z VWYdb^cVa lVaa lVh ZhhZci^Va [dg XdkZgV\Z d[ i]Z igVcheaVciZY k^hXZgVa Vaad\gV[ih VcY eVi^ZciÈh hjgk^kVa#
Knee Transplants >c &..)! =d[[bVc VcY @^ghX]cZg jhZY kVhXj" aVg^oZY WdcZ VaadigVcheaVciVi^dch id igZVi i]Z hZfjZaV d[ ijbdgh VcY igVjbV d[ i]Z aZ\h#&% I]gZZ eVi^Zcih gZXZ^kZY V [ZbdgVa Y^Ve]nh^h! VcY * eVi^Zcih gZXZ^kZY i]Z l]daZ `cZZ _d^ci l^i] ^ih ZmiZchdg hnhiZb# 6aa eVi^Zcih gZXZ^kZY VaadigVch" eaVcih [gdb 67D"bViX]ZY VcY =A6"b^hbViX]ZY Ydcdgh# GZX^e^Zcih gZXZ^kZY XnXadhedg^cZ 6 8h60 &#* b\$`\ >K ! VoVi]^deg^cZ &#* b\$`\ >K ! 6I< ) b\$`\ >K ! VcY bZi]naegZYc^hdadcZ '*% b\ [dg ^bbjcdhjeegZhh^dc [dg ( YVnh! V[iZg l]^X] 8h6 lVh gZYjXZY id +#% b\$`\ ED VcY VoVi]^d" eg^cZ id (#% b\$`\ ED# 6[iZg + bdci]h! VoVi]^d" eg^cZ lVh l^i]YgVlc! VcY eVi^Zcih lZgZ `Zei dc 8h6 VadcZ jci^a WdcZ Xdchda^YVi^dc d[ i]Z ild dhiZdidb^Zh lVh XdbeaZiZ# >c i]Z [Zbjg gZX^e^" Zcih! ^bbjcdhjeegZhh^kZ i]ZgVen lVh hideeZY ' nZVgh V[iZg hjg\Zgn# 6[iZg ' id * nZVgh d[ [daadl"je! i]Z Vaad\gV[i lVh [VkdgVWan ^ciZ\gViZY ^c ) eVi^Zcih! VcY i]Z gVc\Z d[ bdi^dc d[ i]Z `cZZ lVh hVi^h[VXidgn#-!&& =dlZkZg! & [Zbjg Vaad\gV[i VcY ( `cZZ Vaad\gV[ih lZgZ gZeaVXZY l^i] Vjid\gV[ih dg egdhi]Zi^Xh WZXVjhZ d[ ^c[ZXi^dc# Dc i]Z WVh^h d[ i]^h egZa^b^cVgn hijYn VcY Y^hXjhh^dch Vi i]Z HZXdcY >ciZgcVi^dcVa Hnbedh^jb dc 8I6 IgVcheaVciV" i^dc ^c Adj^hk^aaZ! i]Z [daadl^c\ XdcXajh^dch
14
lZgZ gZVX]ZY/ & kVhXjaVg^oZY [ZbdgVa Y^Ve]nh^h igVcheaVciVi^dc VcY `cZZ _d^ci Vaad\gV[ih h]djaY WZ Xdch^YZgZY i]Z aVhi X]d^XZ d[ igZVibZci0 ' ^cigVbZYjaaVgn dhiZdhnci]Zh^h VeeZVgh id d[[Zg WZiiZg gZhjaih i]Vc ZmiZgcVa ÑmVi^dc dg eaViZ dhiZdhnci]Zh^h0 ( XnXadhedg^cZ 6 VcY VoVi]^d" eg^cZ ^bbjcdhjeegZhh^dc egdidXdah ]VkZ cd VYkZghZ ^beVXi dc WdcZ ]ZVa^c\! Wji i]Zn Y^Y cdi hjeegZhh VXjiZ dg X]gdc^X Ze^hdYZh d[ gZ_ZX" i^dc0 ) hncdk^Va bZbWgVcZh! Vh i]Z eg^bVgn iVg\Zi d[ gZ_ZXi^dc! gZfj^gZ a^[Zadc\ ^bbjcdhje" egZhh^dc0 * kVhXjaVg^oZY WdcZ Vaad\gV[ih! Vh adl"Òdl dg\Vch! bVn ]VkZ V ]^\] g^h` d[ i]gdb" Wdh^h VcY cZXgdh^h0 + bdgZ hijY^Zh VgZ gZfj^gZY id YZiZgb^cZ dei^bVa XdaY ^hX]Zb^V i^bZ VcY dei^bVa hidg^c\ iZbeZgVijgZ [dg WdcZ \gV[ih0 , cZjgdeVi]^X Vgi]gdeVi]n XdjaY dXXjg Vh V gZhjai d[ WdcZ VcY _d^ci YZcZgkVi^dc0 VcY - WZXVjhZ i]Z egdXZYjgZ ^h XdbeaZm! ^i h]djaY WZ eZg[dgbZY ^c hZaZXiZY XZciZgh Wn hjg\Zdch l^i] VYZfjViZ WVX`\gdjcYh VcY iZX]c^XVa h`^aah#
Flexor Tendon Apparatus Transplants >c &.-- VcY &.-.! <j^bWZgiZVj Zi Va# gZedgiZY ' kVhXjaVg^oZY Y^\^iVa ÒZmdg iZcYdc VeeVgVijh VaadigVcheaVcih#&' 7di] eVi^Zcih ]VY WZZc deZg" ViZY dc hZkZgVa i^bZh l^i] jchVi^h[VXidgn gZhjaih# DcZ Vaad\gV[i lVh [gdb V a^k^c\ cdcgZaViZY Ydcdg l]dhZ a^iiaZ Ñc\Zg ]VY id WZ VbejiViZY id egdk^YZ i]Z gZfj^h^iZ i^hhjZh# I]Z WaddY \gdje VcY i]Z =A6 d[ Ydcdg VcY gZX^e^Zci lZgZ cdi ^YZci^XVa# B^mZY anbe]dXniZ gZVXi^dc lVh cdcgZVXi^kZ# I]Z hZXdcY Vaad\gV[i lVh [gdb V XVYVkZg Ydcdg# I]Z 67D \gdje lVh ^YZci^XVa! VcY i]ZgZ lVh cd bV_dg =A6 ^cXdbeVi^W^a^in WZilZZc i]Z Ydcdg VcY gZX^e^Zci# I]Z iZcYdc Vaad\gV[ih ^c Wdi] XVhZh lZgZ WVhZY dc i]Z jacVg kZhhZah# 6[iZg ^chZi d[ i]Z \gV[ih! i]Z jacVg VgiZg^Zh d[ i]Z Ydcdg VcY i]Z gZX^e^Zci lZgZ VcVhidbdhZY# KZcdjh VcVhid" bdhZh lZgZ eZg[dgbZY WZilZZc i]Z jacVg kZ^ch ^c i]Z a^k^c\ cdcgZaViZY Ydcdg VcY WZilZZc i]Z Ydcdg jacVg kZ^c VcY i]Z hjeZgÑX^Va [dgZVgb kZ^c ^c i]Z hZXdcY Vaad\gV[i# 7di] eVi^Zcih gZXZ^kZY 8h6 bdcdi]ZgVen!, b\! [dg dcan + bdci]h WZXVjhZ d[ i]Z adl Vci^\Zc^X^in d[ i]Z iZcYdc higjXijgZh#I]Z \gV[ih lZgZ VXXZeiZY l^i]dji gZ_ZXi^dc! VcY i]Z kZhhZah gZbV^cZY eViZci# 6[iZg & nZVg! VXi^kZ ÒZm^dc d[ Ñc\Zgh ^c Wdi] eVi^Zcih ]VY ^begdkZY# >c i]Z a^k^c\ cdc" gZaViZY iZcYdc Vaad\gV[i! i]Z gVc\Z d[ bdi^dc lVh ^begdkZY [gdb cdcZ egZdeZgVi^kZan id ,* l^i]
Tissue Surgery
Vc ZmiZch^dc YZÑX^i d[ &* ^c i]Z egdm^bVa ^ciZg" e]VaVc\ZVa _d^ci VcY id *% ^c i]Z Y^hiVa ^ciZge]V" aVc\ZVa _d^ci! l^i] Vc ZmiZch^dc YZÑX^i d[ )*# I]ZgZ lVh cd X]Vc\Z ^c i]Z gVc\Z d[ bdi^dc ^c i]Z bZiVXVgede]VaVc\ZVa _d^ci# >c i]Z hZXdcY Vaad\gV[i! i]Z gVc\Z d[ bdi^dc ^begdkZY [gdb cdcZ egZdeZgVi^kZan id -% ^c i]Z egdm^bVa ^ciZg" e]VaVc\ZVa _d^ci! l^i] cd ZmiZch^dc YZÑX^i! VcY id ** ^c i]Z Y^hiVa ^ciZge]VaVc\ZVa _d^ci! l^i] Vc ZmiZch^dc YZÑX^i d[ (*#
Nerve Transplants BVX`^ccdc Zi Va#Èh hZg^Zh d[ , eVi^Zcih l^i] eZg^e]ZgVa cZgkZ Vaad\gV[ih ^h i]Z dcan gZedgiZY hZg^Zh l^i] adc\ [daadl"je#&( D[ , Vaad\gV[ih! ) lZgZ jhZY ^c i]Z Vgbh VcY ( ^c i]Z aZ\h# 6aa eVi^Zcih ]VY igVjbVi^X ^c_jg^Zh d[ i]Z^g Vgbh dg aZ\h VcY bVhh^kZ eZg^e]ZgVa cZgkZ YZÑX^ih i]Vi XdjaY cdi WZ gZXdchigjXiZY Wn XdckZci^dcVa bZVch# I]Z \gV[ih lZgZ ]VgkZhiZY [gdb i]Z a^bWh d[ XVYVkZg Ydcdgh VcY lZgZ egZhZgkZY ^c XdaY ^hX]Zb^V Vi *8 [dg , YVnh WZ[dgZ ^beaVciVi^dc# I]^h YZaVn lVh eaVccZY id YZXgZVhZ i]Z ^bbjcd\Zc^X^in d[ i]Z igVcheaVci Wn YZXgZVh^c\ i]Z ZmegZhh^dc d[ B=8 bV_dg ]^hidXdbeVi^W^a^in XdbeaZm dc i]Z hjg[VXZ d[ XZaah# BVX`^ccdc Zi Va# h]dlZY i]Vi & lZZ` d[ XdaY egZhZgkVi^dc YdZh cdi YZXgZVhZ i]Z cjbWZg d[ k^VWaZ Ydcdg HX]lVcc XZaah Wji YdZh gZYjXZ i]Z ZmegZhh^dc d[ bV_dg ]^hidXdbeVi^W^a^in XdbeaZm XaVhh >> bdaZXjaZh Xg^i^XVa id I"XZaa ^bbjcdVXi^kVi^dc#&)!&* >c V h]ZZe bdYZa! ^cXgZVh" ^c\ i]Z aZc\i] d[ XdaY egZhZgkVi^dc gZkZVaZY adl Vaad\gV[i ^bbjcd\Zc^X^in! Vh bZVhjgZY Wn YZXgZVhZY VcY VaiZgZY anbe]dXni^X ^cÑaigVi^dc ^cid i]Z cZgkZ Vaad\gV[ih#&+ I]Z aZc\i] d[ i]Z cZgkZ YZ[ZXi lVh &' Xb id (, Xb# 7ZXVjhZ hbVaa"Y^VbZiZg cZgkZ Vaad\gV[ih VgZ WZiiZg kVhXjaVg^oZY i]Vc aVg\Z cZgkZ Vaad\gV[ih! YZeZcY^c\ dc i]Z egdm^bVa cZgkZ hijbe Y^Vb" ZiZg! ( id &% XVWaZh lZgZ jhZY# I]Z bZVc idiVa aZc\i] d[ i]Z Vaad\gV[i jhZY ^c dcZ eVi^Zci lVh &.% Xb gVc\Z/ ,' id (*% Xb # I]Z Ñghi * eVi^Zcih gZXZ^kZY 8h6 '%% id (%% c\$bA WaddY aZkZah ! VoVi]^deg^cZ & id &#* b\$`\$YVn ! VcY egZYc^" hdcZ ^c^i^Vaan %#'* id %#* b\$`\$YVn VcY iVeZgZY d[[ dkZg ) id - lZZ`h # IVXgda^bjh * id &* c\$bA$ WaddY aZkZah gZeaVXZY 8h6 [dg i]Z aVhi ' eVi^Zcih# >bbjcdhjeegZhh^kZ i]ZgVen lVh bV^ciV^cZY [dg + bdci]h V[iZg ÑcY^c\ Zk^YZcXZ d[ cZgkZ gZ\Zc" ZgVi^dc I^cZaÈh h^\c Y^hiVa id i]Z \gV[i# I]Z
Clinical Application of Composite Tissue Allografts
bZVc YjgVi^dc d[ ^bbjcdhjeegZhh^dc lVh &bdci]h gVc\Z/ &' id '+ bdci]h # GZ_ZXi^dc ^c dcZ eVi^Zci aZY id \gV[i adhh ) bdci]h V[iZg igVch" eaVciVi^dc# I]Z + di]Zg eVi^Zcih gZXdkZgZY Y^hiVa hZch^W^a^in# 6aa gZXdkZgZY hZchVi^dc! VcY ( gZXdk" ZgZY bdidg VW^a^i^Zh# CdcZ d[ i]Z eVi^Zcih h]dlZY Vcn Zk^YZcXZ d[ YZiZg^dgVi^dc d[ cZgkZ [jcXi^dc V[iZg i]Z l^i]YgVlVa d[ ^bbjcdhjeegZhh^kZ i]ZgVen#&(
15
YZ\aji^i^dc V[iZg ( bdci]h# 8jggZcian! i]Z eVi^Zci iVa`h l^i] V cVijgVa VcY ^ciZaa^\^WaZ kd^XZ! [ZZYh ]^bhZa[ l^i]dji Vhe^gVi^dc! VcY ]Vh Vc ^begdkZY hZchZ d[ iVhiZ VcY hbZaa#&- ;djg nZVgh V[iZg igVch" eaVciVi^dc! aVgnc\ZVa ZaZXigdbnd\gVe]n gZkZVaZY gZ"^ccZgkVi^dc d[ i]Z aVgnc\ZVa bjhXaZ#&. EdiZci^Va XVcY^YViZh [dg aVgnc\ZVa igVcheaVc" iVi^dc ^cXajYZ Ve]dc^X eVi^Zcih l^i] aVgnc\ZVa igVjbV! aVg\Z WZc^\c X]dcYgdbVh! dg aVgnc\ZVa XVgX^cdbV l]d VgZ XVcXZg"[gZZ [dg * nZVgh#
Larynx Transplants >c &..-! HigdbZ Zi Va# eZg[dgbZY i]Z Ñghi hjXXZhh" [ja aVgncm igVcheaVciVi^dc#&,!&- I]Z gZX^e^Zci lVh V )%"nZVg"daY Ve]dc^X bVaZ l]d ]VY hjhiV^cZY V Xgjh] ^c_jgn id ]^h aVgncm '% nZVgh WZ[dgZ# I]Z Ydcdg lVh V )%"nZVg"daY bVaZ l]d ]VY Y^ZY [gdb V gjeijgZY XZgZWgVa VcZjgnhb# IgVch" eaVciZY XdbeaZm ^cXajYZY i]Z YdcdgÈh aVgncm! i]ngd^Y \aVcY! eVgVi]ngd^Y \aVcYh! * g^c\h d[ igVX]ZV! VcY bdhi d[ i]Z YdcdgÈh e]Vgncm! id l^YZc i]Z gZX^e^ZciÈh e]Vgncm# >c i]Z gZX^e^Zci! VgiZg^Va VcVhidbdhZh lZgZ eZg[dgbZY id i]Z hjeZg^dg i]ngd^Y VgiZg^Zh W^aViZgVaan! VcY kZcdjh VcVhidbdhZh lZgZ eZg[dgbZY id i]Z Xdbbdc [VX^Va kZ^c dc i]Z g^\]i h^YZ VcY id i]Z ^ciZgcVa _j\jaVg kZ^c dc i]Z aZ[i h^YZ# I]Z eVi^ZciÈh g^\]i gZXjggZci aVgnc\ZVa cZgkZ VcY Wdi] hjeZg^dg aVgnc\ZVa cZgkZh lZgZ XdVeiZY id i]Z YdcdgÈh cZgkZh# I]Z eVi^Zci gZXZ^kZY bjgdbdcVW"89( * b\$ YVn ! XnXadhedg^cZ 6 *%% b\$YVn ! bZi]naegZY" c^hdadcZ *% b\$YVn! l^i] i]Z YdhZ YZXgZVhZY id '% b\$YVn Wn edhideZgVi^kZ YVn ) ! VcY BB; & \ il^XZ YV^an Yjg^c\ i]Z Ñghi lZZ` V[iZg hjg\Zgn# HjWhZfjZcian! i]Z eVi^Zci gZXZ^kZY XnXadhedg^cZ! BB;! VcY egZYc^hdcZ ^c egd\gZhh^kZan YZXgZVh" ^c\ YdhZh# H^m bdci]h V[iZg igVcheaVciVi^dc! i]Z eVi^ZciÈh WaddY egZhhjgZ VcY hZgjb XgZVi^c^cZ lZgZ ZaZkViZY VcY lZgZ igZViZY Wn VYY^i^dcVa Vci^]neZgiZch^kZ Ygj\h VcY Wn YZXgZVh^c\ i]Z 8h6 YdhZ# 6i &* bdci]h! dcZ Ze^hdYZ d[ gZ_ZXi^dc lVh dWhZgkZY VcY bVc^[ZhiZY Wn gZYjXi^dc ^c i]Z fjVa^in d[ i]Z kd^XZ VcY jai^bViZan Ve]dc^V# I]Z aVgncm gZijgcZY id cdgbVa l^i]^c ( YVnh d[ igZVi" bZci l^i] ]^\] YdhZh d[ egZYc^hdcZ# I]Zc! 8h6 lVh gZeaVXZY l^i] iVXgda^bjh# I]Z eVi^ZciÈh e]dcVi^dc ^begdkZY hiZVY^an VcY WZXVbZ hiVWaZ Vi cdgbVa aZkZah &+ bdci]h V[iZg igVcheaVciVi^dc# 6i &+ bdci]h! i]Z e^iX] d[ i]Z kd^XZ X]Vc\ZY VcY WZXVbZ bdgZ cVijgVa# 6i (+ bdci]h! i]Z heZZX] d[ i]Z eVi^Zci lVh Vabdhi cdgbVa# I]Z eVi^Zci dWiV^cZY Z[ÑX^Zci
Muscle Transplants >c &..-! kVhXjaVg^oZY h`ZaZiVa bjhXaZ Vaad\gV[i^c\ lVh YdcZ id XdkZg V aVg\Z YZ[ZXi ^c i]Z hXVae d[ V gZcVa igVcheaVci eVi^Zci l]d lVh dc X]gdc^X ^bbjcdhjeegZhh^kZ i]ZgVen 8h6 VcY egZYc^" hdcZ #'% 6[iZg i]Z hZXdcY XVYVkZg^X gZcVa igVch" eaVci! hfjVbdjh XZaa XVgX^cdbV YZkZadeZY ^c i]Z hXVae# I]Z ijbdg lVh ZmX^hZY! VcY i]Z YZ[ZXi lVh gZXdchigjXiZY l^i] V XVYVkZg^X kVhXjaVg^oZY gZXijh [Zbdg^h bjhXaZ ÒVe# I]Z eVi^Zci gZXZ^kZY bZi]naegZYc^hdadcZ! & \! VcY gVWW^i Vci^i]nbdXniZ \adWja^c! &#* b\$`\ >K! WZ[dgZ gZkVhXjaVg^oVi^dc# =Z lVh gZijgcZY ^bbZ" Y^ViZan id ]^h WVhZa^cZ ^bbjcdhjeegZhh^kZ gZ\^bZc d[ egZYc^hdcZ VcY 8h6#6 bjhXaZ W^dehn ' lZZ`h V[iZg igVcheaVci gZkZVaZY eZg^kVhXjaVg anbe]dXni^X ^cÑaigVi^dc! VcY BB; &%%% b\ ED W#^#Y# lVh VYb^c^hiZgZY! VcY i]Z YdhZ d[ 8h6 lVh ^cXgZVhZY# 6i &- lZZ`h! BB; lVh hideeZY! VcY i]Z eVi^Zci lVh `Zei dc X]gdc^X 8h6 VcY egZYc^hdcZ# I]^h eVi^Zci ^h hi^aa jcYZg ^bbjcd" hjeegZhh^dc [dg `^YcZn igVcheaVci l^i] cd gZedgiZY Xdbea^XVi^dch#
Tongue Transplants Dc ?jan &.! '%%(! i]Z ldgaYÈh Ñghi idc\jZ igVch" eaVciVi^dc lVh eZg[dgbZY! ^c V eVi^Zci l^i] idc\jZ XVcXZg#'& Cd gZedgi dc i]Z ^bbjcdhje" egZhh^dc egdidXda lVh \^kZc [dg i]^h egdXZYjgZ# I]Z eVi^Zci lVh Y^hX]Vg\ZY [gdb i]Z ]dhe^iVa & bdci] V[iZg hjg\Zgn l^i] V igVX]Zdhidbn VcY V \Vhigdhidbn# 6[iZg - bdci]h! i]ZgZ lVh cd h^\c d[ gZ_ZXi^dc! VcY i]Z eVi^Zci lVh VWaZ id hlVaadl ]^h hVa^kV VcY hdbZ Òj^Yh# 6ai]dj\] idc\jZ igVcheaVci gZegZhZcih V egdb^h^c\ VaiZgcVi^kZ [dg XdckZci^dcVa idc\jZ gZXdchigjXi^dc! ^i ^h jca^`Zan id gZhidgZ V hZchZ d[ iVhiZ# Adc\Zg [daadl"je ^h cZZYZY id VYYgZhh i]^h ^hhjZ#
16
Trachea Transplants IgVcheaVciVi^dc d[ i]Z ]jbVc igVX]ZV gZbV^ch Vc jchdakZY iZX]c^XVa egdWaZb WZXVjhZ i]Z igVX]ZV aVX`h d[ V lZaa"YZÑcZY WaddY hjeean# 6ai]dj\] V cjbWZg d[ ZmeZg^bZciVa VeegdVX]Zh ]VkZ WZZc hijY^ZY id hdakZ i]^h egdWaZb!'' dcan V [Zl ViiZbeih id igVcheaVci i]Z igVX]ZV ^c ]jbVch ]VkZ WZZc gZedgiZY# >c &.,.! GdhZ Zi Va# gZedgiZY V ]ZiZgdide^X ^beaVciVi^dc Wn lgVe" e^c\ i]Z igVX]ZV ^c i]Z hiZgcdXaZ^YdbVhid^Y bjhXaZ#'( I]gZZ lZZ`h aViZg! dgi]dide^X ^b" eaVciVi^dc lVh eZg[dgbZY! VXXdbeVc^ZY Wn V kVhXjaVg^oZY bjhXjaVg hZXi^dc [gdb i]Z hiZgcd" XaZ^YdbVhid^Y# 6[iZg . lZZ`h! VcY l^i]dji ^bbjcdhjeegZhh^dc egdidXda! cd h^\ch d[ gZ_ZX" i^dc dg ^hX]Zb^V lZgZ VeeVgZci# =dlZkZg! cd [jgi]Zg ^c[dgbVi^dc dc i]Z adc\"iZgb gZhjaih ^h VkV^aVWaZ# AZkVh]dk VcY XdaaZV\jZh gZedgiZY i]Z hZXdcY XVhZ d[ ]jbVc igVX]ZVa igVcheaVciVi^dc ^c &..(#') 6 ')"nZVg"daY ldbVc l^i] ^Y^deVi]^X ÑWgdh^c\ bZY^Vhi^c^i^h V[[ZXi^c\ i]Z i]dgVX^X hZ\bZci d[ i]Z igVX]ZV gZXZ^kZY Vc Vaad\gV[i gZeaVXZbZci d[ i]Z Y^hiVa igVX]ZV lgVeeZY l^i] dbZcijb# 6ai]dj\] i]Z eVi^Zci lVh dc XnXadhedg^cZ 6 ^bbjcdhjeegZhh^dc! ZVgan gZ_ZXi^dc V[iZg &% YVnh lVh igZViZY Wn ^cXgZVh^c\ i]Z YdhZ d[ ^bbj" cdhjeegZhh^dc# I]Z [jcXi^dcVa djiXdbZ V[iZg ' bdci]h d[ igVcheaVciVi^dc lVh \ddY# =dlZkZg! egd\gZhh^kZ hiZcdh^h ZkZcijVaan gZfj^gZY eZgbV" cZci hiZci^c\ d[ i]Z igVX]ZV# >c '%%)! @aZeZi`d Zi Va# gZedgiZY ]ZiZgdide^X igVX]ZVa igVcheaVciVi^dc l^i] dbZcijb lgVee^c\ ^c i]Z VWYdbZc#'* 6 *,"nZVg"daY eVi^Zci l^i] X]gdc^X dWhigjXi^kZ ejabdcVgn Y^hZVhZ VcY adl"hZ\bZci igVX]ZVa hiZcdh^h lVh VXXZeiZY [dg ajc\ igVcheaVciVi^dc VcY '"hiV\Z igVX]ZVa VaadigVcheaVciVi^dc# 9jg^c\ ajc\ igVcheaVciV" i^dc! i]Z igVX]ZV lVh lgVeeZY l^i] dbZcijb ^c i]Z VWYdbZc# Ig^eaZ ^bbjcdhjeegZhh^kZ i]ZgVen lVh hiVgiZY l^i] ^cigVkZcdjh XnXadhed" g^cZ 6! BB;! VcY Xdgi^XdhiZgd^Yh! VcY lVh bV^c" iV^cZY dgVaan i]ZgZV[iZg# :^\]i bdci]h V[iZg ajc\ igVcheaVciVi^dc! * Xb d[ igVX]ZVa hZ\bZci lVh ZmX^hZY! VcY i]Z YZ[ZXi lVh XadhZY l^i] cd cZZY [dg igVX]ZVa Vaad\gV[i igVcheaVciVi^dc# I]ZgZ[dgZ! i]Z igVX]ZVa Vaad\gV[i lVh ]VgkZhiZY VcY ^ckZhi^" \ViZY XdbeaZiZan# =ZbVidmna^c"Zdh^c hiV^c^c\ gZkZVaZY k^iVa XVgi^aV\Z XdkZgZY Wn gZhe^gVidgn Ze^" i]Za^jb# I]Z igVX]ZVa lVaa lVh ]^\]an kVhXjaVg" ^oZY! ^cY^XVi^c\ Vaad\gV[i k^VW^a^in l^i]dji h^\ch d[ gZ_ZXi^dc#
Tissue Surgery
Immunosuppressive Drugs Currently Used in Composite Tissue Allograft Transplants 8jggZcian! ^bbjcdhjeegZhh^kZ Ygj\h VgZ jhZY id ^cYjXZ! bV^ciV^c! VcY igZVi VXjiZ Ze^hdYZh d[ \gV[i gZ_ZXi^dc IVWaZ '"( # 6aa XjggZci ^bbjcd" hjeegZhh^kZ Ygj\h iVg\Zi VXi^kVi^dc d[ I XZaah! egd" YjXi^dc d[ Xnid`^cZh! XadcVa ZmeVch^dc! dg V XdbW^cVi^dc d[ Vaa i]ZhZ [VXidgh IVWaZ '")0 ;^\jgZ '"& #'+
Immunosuppression Induction Protocols I]Z V^b d[ ^cYjX^c\ ^bbjcdhjeegZhh^dc V[iZg igVcheaVciVi^dc ^h id hjeegZhh i]Z ^bbjcZ hnhiZb [dg V h]dgi eZg^dY ' lZZ`h id gZYjXZ i]Z edh" h^W^a^in d[ ]neZgVXjiZ l^i]^c &% YVnh V[iZg igVch" eaVci VcY VXjiZ gZ_ZXi^dc l^i]^c ( bdci]h V[iZg i]Z igVcheaVci #'+ Table 2-3. Immunosuppressive Therapy Regimens Used in Transplanting Composite Tissue Allografts Maintenance Transplant Induction Therapy Therapy Hand ATG Tacrolimus Anti-CD25 MoAb MMF Tacrolimus Prednisone MMF Basiliximab Prednisone Abdominal wall Anti-CD52 MoAb Tacrolimus (alemtuzumab) Daclizumab Vascularized bone ATG CsA CsA Azathioprine Azathioprine Prednisone Nonvascularized CsA or tacrolimus CsA or tacrolimus nerve Azathioprine Azathioprine Prednisone Prednisone Vascularized tendon CsA CsA Nonvascularized CsA CsA trachea MMF MMF Larynx OKT3 CsA or tacrolimus CsA MMF MMF Prednisone Muscle ATG CsA Prednisone ATG antithymocyte globulins MMF mycophenolate mofetil CsA cyclosporine A OKT3 anti-CD3 antibody
Clinical Application of Composite Tissue Allografts
17
Table 2-4. Immunosuppressive Drugs used in Transplanting Composite Tissue Allografts Drug Mechanism of Action Lymphocyte-Depleting Agents Antithymocyte globulins/Antilymphocyte globulin (ATG/ALG) Binds multiple antigens on lymphocytes and causes complement mediated lysis and opsonization Anti-CD3 antibody (OKT3) Blocks T-cell CD3 receptor and causes complement mediated lysis and opsonization Interleukin-2 Receptor Antagonists Daclizumab Binds Interleukin-2 receptor and down-regulates Basiliximab Binds Interleukin-2 receptor and down-regulates Cytokine Gene Expression Blockers Steroids Blocks the transcription of cytokine genes Nonspecific actions to decrease immune reactivity Calcineurin Inhibitors Cyclosporine Inhibits calcineurin, and Interleukin-2 production Tacrolimus (FK-506) Inhibits calcineurin, and Interleukin-2 production Antiproliferative Agents Mycophenolate mofetil (MMF) Blocks de novo purine synthesis Azathioprine Blocks synthesis TOR (Target of Rapamycin) Inhibitor Sirolimus Blocks IL-2–induced cell cycle progression
OKT3
Sirolimus
TCR-CD3 Engagement to APC Glucocorticoids
Antigen Presenting Cell
X
IL-2 receptor expression
X on T cells
CsA/Tacrolimus IL-2 binding to IL-2 receptor
X
X IL-1, IL-6 release
T cell G0 phase
IL-2 release
T cell G1 phase IL-2 receptor signal
ATG
X
X
X
T cell depletion T cell M phase
T cell differentiation
X MMF/AZA
T cell G2 phase
T cell S phase T cell proliferation
X MMF/AZA
Figure 2-1. Mechanisms and sites of action of different immunosuppressive drugs
Basiliximab Daclizumab
Sirolimus
18
>cYjXi^dc egdidXdah Xdch^hi d[ V ,"YVn id &)" YVn XdjghZ d[ igZVibZci# >bbjcdhjeegZhh^kZ Ygj\h Xdbbdcan jhZY [dg ^cYjXi^dc i]ZgVen VgZ edanXadcVa Vci^i]nbdXniZ \adWja^ch 6Ic XVhZh l]ZgZ Xdgi^" XdhiZgd^Yh Yd cdi hjeegZhh VXjiZ ViiVX`h d[ gZ_ZX" i^dc! i]Z Ygj\h jhZY ^c ^cYjXi^dc i]ZgVen 6I< VcY D@I( dg bV^ciZcVcXZ i]ZgVen iVXgda^bjh VcY h^gda^bjh XVc WZ jhZY# Ide^XVa Xdgi^XdhiZ" gd^Yh VcY ide^XVa iVXgda^bjh ]VkZ hjXXZhh[jaan igZViZY gZ_ZXi^dc ^c gZX^e^Zcih d[ Xdbedh^iZ i^hhjZ \gV[ih#'+
8VaX^cZjg^c >c]^W^idgh 8nXadhedg^cZ 6 VcY ;@"*%+ 8VaX^cZjg^c ^h V e]dhe]ViVhZ i]Vi ^h ^bedgiVci [dg >A"' \ZcZ igVchXg^ei^dc VcY gZaZVhZ Wn I XZaah# E]dhe]dgnaVi^dc VcY YZe]dhe]dgnaVi^dc d[ heZX^ÑX egdiZ^ch ]Zae gZ\jaViZ Xnid`^cZ egd" YjXi^dc ^c I XZaah# 7di] 8h6 VcY iVXgda^bjh VgZ egdYgj\h0 i]Zn cZZY id [dgb V XdbeaZm l^i] XZa" ajaVg egdiZ^ch XVaaZY Å^bbjcde]^a^chÆ WZ[dgZ ZmZgi^c\ i]Z^g Z[[ZXih# 8nXadhedg^cZ 6 W^cYh id XnXade]^a^c! l]ZgZVh iVXgda^bjh W^cYh id ;@" W^cY^c\ egdiZ^ch# 6[iZg i]Z Ygj\h VgZ WdjcY!
Tissue Surgery
i]Zn gZcYZg i]Z XVaX^cZjg^c XdbeaZm ^cVXi^kZ! egZkZci^c\ hjWhZfjZci \ZcZ igVchXg^ei^dc d[ >A" '! i]ZgZWn gZYjX^c\ i]Z egdYjXi^dc d[ >A"'! V `Zn Xnid`^cZ [dg I"XZaa ZmeVch^dc! VcY d[ di]Zg Xnid`^cZh#', 8nXadhedg^cZ 6 ^h V bZiVWda^iZ ZmigVXiZY [gdb Ig^X]dYZgbV edanhedgjb [jc\jh# 8nXadhedg^cZ 6 ^h ]^\]an heZX^ÑX [dg I XZaah VcY ^c]^W^ih i]Z VXi^" kVi^dc d[ Wdi] 89) VcY 89- # I]Z Z[[ZXih d[ 8h6 ^c hjeegZhh^c\ >A"' egdYjXi^dc XVc WZ gZkZghZY Wn Y^hXdci^cj^c\ i]Z Ygj\# I]Z Z[[ZXi d[ 8h6 ^c WadX`^c\ >A"' gZaZVhZ XVc WZ ^cXgZVhZY l]Zc jhZY ^c XdbW^cVi^dc l^i] Xdgi^XdhiZgd^Yh#'+Ã'IVXgda^bjh ;@"*%+ ^h V bZiVWda^iZ d[ Vc VXi^" cdbnXZiZ! HigZeidbnXZh ihj`jWVZch^h! VcY ^h Vc Z[[ZXi^kZ VaiZgcVi^kZ id XnXadhedg^cZ# I]Z higjX" ijgZ d[ iVXgda^bjh ^h Y^[[ZgZci [gdb i]Vi d[ 8h6! VcY i]Z bZX]Vc^hb d[ VXi^dc ^h h^b^aVg id i]Vi d[ XnXadhedg^cZ# >c k^igd! iVXgda^bjh VeeZVgh id WZ &%% i^bZh bdgZ ediZci i]Vc 8h6#'. IVXgda^bjh hjeegZhhZh igVchXg^ei^dc d[ Xnid`^cZh >A"'! >A"(! >A")! >A"*! >;C"H! VcY IC;"B! Vh lZaa Vh \gVcjad" XniZ bVXgde]V\Z Xdadcn hi^bjaVi^c\ [VXidg#(% 7di] iVXgda^bjh VcY 8h6 ]VkZ h^b^aVg gZcVa VcY ]ZeVi^X idm^X^i^Zh! Wji i]Zn Y^[[Zg ^c di]Zg idm^X h^YZ Z[[ZXih# EVi^Zcih igZViZY l^i] iVXgda^" bjh ]VkZ V ]^\]Zg ^cX^YZcXZ d[ Y^VWZiZh bZaa^ijh Wji V adlZg ^cX^YZcXZ d[ ]neZgiZch^dc! ]neZg" a^e^YZb^V! VcY ]^ghji^hb#(& IVXgda^bjh ^h bdgZ ediZci i]Vc 8h6 ^c Zc]VcX^c\ eZg^e]ZgVa cZgkZ gZ\ZcZgVi^dc VcY ^h i]ZgZ[dgZ Xdbbdcan jhZY ^c ]jbVc ]VcY igVcheaVciVi^dc#('
H^gda^bjh IDG >c]^W^idg H^gda^bjh gVeVbnX^c ^h higjXijgVaan h^b^aVg id iVXgda^bjh VcY ^h ZmigVXiZY [gdb i]Z VXi^cd" bnXZiZ HigZeidbnXZh ]n\gdhXde^Xjh# H^gda^bjh! a^`Z iVXgda^bjh! W^cYh id ;@"W^cY^c\ egdiZ^c"&'! Wji jca^`Z iVXgda^bjh! ^i YdZh cdi ^c]^W^i XVaX^" cZjg^c e]dhe]ViVhZ# H^gda^bjh WadX`h XVaX^jb" ^cYZeZcYZci ZkZcih Yjg^c\ i]Z ih ^bbjcdhjeegZhh^kZ Z[[ZXi ^h Wn ^c]^W^i^c\ IDG iVg\Zi d[ gVeVbnX^c ! l]^X] ^h Vc ^bedgiVci ZconbZ ^c I"XZaa egda^[ZgVi^dc# IDG ^c]^W^idg! jca^`Z XVaX^cZjg^c ^c]^W^idgh! [V^ah id ^ciZg[ZgZ ^c i]Z ZVgan ZkZcih V[iZg I"XZaa VXi^kVi^dc# =dlZkZg! ^i dkZgXdbZh di]Zg 8h6"gZh^hiVci eVi]" lVnh ^c I"XZaa VcY 7"XZaa hi^bjaVi^dc# I]ZgZ[dgZ! ^i ^c]^W^ih i]Z egda^[ZgVi^dc VcY bVijgVi^dc d[ 7 XZaah! l]^X] aZVYh id ZmigZbZ YZegZhh^dc d[ ]dhi VaadVci^WdY^Zh V[iZg Vaad\gV[i^c\ ^c V hZch^" i^oZY ]dhi#(%
Clinical Application of Composite Tissue Allografts
6YY^c\ h^gda^bjh id XdbW^cVi^dc gZ\^bZch ]Vh VaadlZY i]Z YdhZ d[ XVaX^cZjg^c ^c]^W^idgh id WZ gZYjXZY! i]jh YZXgZVh^c\ i]Z cZe]gdidm^X^in VhhdX^ViZY l^i] XVaX^cZjg^c ^c]^W^idgh l^i]dji YZXgZVh^c\ \gV[i hjgk^kVa#(( I]Z bV^c h^YZ Z[[ZXih d[ h^gda^bjh VgZ ]neZgX]daZhiZgdaZb^V! aZj`d" eZc^V! VcY i]gdbWdXnideZc^V0 VcY! jca^`Z XVaX^" cZjg^c ^c]^W^idgh! ]neZgiZch^dc! cZe]gdidm^X^in! VcY ]ZeVididm^X^in VgZ cdi Xdbbdc#'+
8dgi^XdhiZgd^Yh 8dgi^XdhiZgd^Yh VgZ cdcheZX^ÑX Vci^"^cÒVbbV" idgn V\Zcih i]Vi ^c]^W^i Xnid`^cZ egdYjXi^dc Wn I XZaah VcY bVXgde]V\Zh# >c i]Z ^c^i^Va e]VhZ d[ igVcheaVciVi^dc! i]Zn V[[ZXi Xnid`^cZ \ZcZ igVc" hXg^ei^dc VcY ^c]^W^i i]Z hZXgZi^dc d[ hZkZgVa ^bedgiVci Xnid`^cZh! hjX] Vh >A"&! >A"'! >A"+! IC;"C!VcY >;C"H!l]^X] VgZ ^bedgiVci ^c ^cÒVb" bVidgn gZVXi^dch# 8dgi^XdhiZgd^Yh lZgZ dg^\^cVaan jhZY id igZVi VXjiZ Ze^hdYZh d[ gZ_ZXi^dc ^c eVi^Zcih dc VoV" i]^deg^cZ bV^ciZcVcXZ i]ZgVen# 8jggZcian! adlZg YdhZh d[ Xdgi^XdhiZgd^Yh VgZ jhZY ^c XdbW^cVi^dc l^i] di]Zg ^bbjcdhjeegZhh^kZ V\Zcih dg ^c h]dgi XdjghZh d[ ]^\] YdhZh id igZVi VXjiZ gZ_ZXi^dc# 8dg" i^XdhiZgd^Yh VgZ Vahd jhZY id igZVi \gV[i"kZghjh" ]dhi Y^hZVhZ V[iZg WdcZ bVggdl igVcheaVciVi^dc VcY id b^c^b^oZ ]neZghZch^i^k^in gZVXi^dch XVjhZY Wn ^cYjXi^dc ^bbjcdhjeegZhhVcih! hjX] Vh bdcdXadcVa Vci^WdY^Zh VcY Vci^i]nbdXniZ \adWja^c#'+ I]Z bV_dg VYkZghZ Z[[ZXih d[ ]^\] YdhZh d[ Xdg" i^XdhiZgd^Yh VgZ bndeVi]n! Y^VWZiZh! lZ^\]i \V^c! [gVXijgZ! eZei^X jaXZgh! \Vhigd^ciZhi^cVa WaZZY" ^c\! deedgijc^hi^X ^c[ZXi^dch! VcY eddg ldjcY ]ZVa^c\#
6ci^egda^[ZgVi^kZ 6\Zcih 6oVi]^deg^cZ! V ejg^cZ VcVad\jZ! ]Vh WZZc jhZY Xa^c^XVaan h^cXZ &.+(# >i X]Vc\Zh ^c i]Z a^kZg id +"bZgXVeidejg^cZ! i]Zc ZciZgh i]Z XZaa id WZ XdckZgiZY id +"bZgXVeidejg^cZ g^WdcjXaZdi^YZ! l]^X] gZhZbWaZh ^cdh^cZ bdcde]dhe]ViZ# I]^h higjXijgVa gZhZbWaVcXZ ^ciZg[ZgZh l^i] i]Z XZa" ajaVg hnci]Zh^h d[ 9C6! GC6! VcY di]Zg Xd[VX" idgh# >i VXih ZVgan Yjg^c\ i]Z egda^[ZgVi^kZ XnXaZ d[ Z[[ZXidg I"XZaa VcY 7"XZaa XadcZh# GZXZcian! ^i ]Vh WZZc gZeaVXZY Wn BB;! l]^X] ^h bdgZ Z[[ZXi^kZ Yjg^c\ i]Z Ñghi & id ( nZVgh V[iZg igVcheaVci# I]Z bV_dg idm^X h^YZ Z[[ZXih d[ VoVi]^deg^cZ VgZ
19
WdcZ bVggdl hjeegZhh^dc! ]ZeVididm^X^in! VcY ^cXgZVhZY g^h` d[ bVa^\cVcXn# I]Z ^bbjcdhjeegZhh^kZ VXi^k^in d[ BB; ^h i]gdj\] ^c]^W^i^dc d[ i]Z ejg^cZ hnci]Zh^h eVi]lVn# >i ^h V ediZci! gZkZgh^WaZ! cdcXdbeZi^i^kZ ^c]^W^idg d[ ^cdh^cZ bdcde]dhe]ViZ YZ]nYgd\Z" cVhZ# >cdh^cZ bdcde]dhe]ViZ YZ]nYgd\ZcVhZ ^h Vc ZhhZci^Va ZconbZ [dg 9C6 hnci]Zh^h ^c Wdi] I XZaah VcY 7 XZaah0 i]jh BB; hZaZXi^kZan WadX`h egd" a^[ZgVi^dc d[ I XZaah VcY hjeegZhhZh Vci^WdYn [dgbVi^dc Wn 7 XZaah! heVg^c\ WdcZ bVggdl VcY eVgZcX]nbVa XZaah! l]^X] gZan bdgZ dc i]Z hVakV\Z eVi]lVn [dg ejg^cZ hnci]Zh^h#() I]Z h^YZ Z[[ZXih d[ BB; ^cXajYZ Y^Vgg]ZV! Zhde]V\^i^h! VcY \Vhig^i^h# I]Z g^h` d[ aZj`deZc^V VcY deedgijc^hi^X ^c[ZXi^dch ^h h^b^aVg ^c Wdi] BB; VcY VoVi]^deg^cZ#'+
>ciZgaZj`^c"' GZXZeidg 6ciV\dc^hih I]Z >A"' gZXZeidg ^h V XdbeaZm d[ hZkZgVa igVch" bZbWgVcZ edaneZei^YZ X]V^ch# 9VXa^ojbVW OZcVeVm VcY WVh^a^m^bVW H^bjaZXi VgZ heZ" X^ÑX bdcdXadcVa Vci^WdY^Zh i]Vi W^cY id i]Z Vae]V X]V^c d[ >A"' gZXZeidgh# I]Z Xa^c^XVa jhZ d[ i]ZhZ V\Zcih lVh VhhdX^ViZY l^i] cd bV_dg h^YZ Z[[ZXih! hjX] Vh bVa^\cVcXn dg deedgijc^hi^X ^c[ZXi^dch! l]Zc XdbeVgZY id eaVXZWd#(*
Anbe]dXniZ"9ZeaZi^c\ 6\Zcih 6ci^"89( Vci^WdYn D@I( ^h V bdjhZ"YZg^kZY bdcdXadcVa Vci^WdYn i]Vi W^cYh id i]Z 89( \an" XdegdiZ^c dc i]Z I"XZaa hjg[VXZ! egZkZci^c\ Vci^\Zc W^cY^c\ id i]Z Vci^\Zc gZXd\c^i^dc XdbeaZm VcY WadX`^c\ XZaa"bZY^ViZY Xnididm^X" ^in# I]Z h^YZ Z[[ZXih d[ D@I( gVc\Z [gdb V b^aY Òja^`Z ^aacZhh id V a^[Z"i]gZViZc^c\ h]dX`a^`Z gZVXi^dc Xnid`^cZ gZaZVhZ hncYgdbZ ! ZcXZe]V" adeVi]n! cZe]gdeVi]n! VcY ]nediZch^dc# 8nid`^cZ gZaZVhZ hncYgdbZ XVc WZ b^c^b^oZY Wn ]^\] YdhZh d[ hiZgd^Yh V [Zl ]djgh WZ[dgZ VYb^c^higV" i^dc d[ D@I(#(+ 6ci^i]nbdXniZ \adWja^c 6I
Clinical Application of Composite Tissue Allografts ',# A^j ?! ;VgbZg ?9 ?g! AVcZ LH! Zi Va# 8VaX^cZjg^c ^h V Xdbbdc iVg\Zi d[ XnXade]^a^c"XnXadhedg^cZ 6 VcY ;@7E";@*%+ XdbeaZmZh# 8Zaa# &..&0++/-%,Ã-&*# '-# 7dgZa ?;# 8nXadhedg^cZ"6ÄegZhZci ZmeZg^bZciVa hiVijh# IgVcheaVci EgdX# &.-&0&(/())Ã()-# '.#
Venous and Arterial Anatomy of the Hand and Fingers I]ZgZ VgZ ild kZcdjh hnhiZbh ^c i]Z ]VcY/ V YZZe hnhiZb l^i] hbVaa! ]VgYan k^h^WaZ XdcXdb^" iVci kZ^ch gjcc^c\ l^i] i]Z VgiZg^Zh0 VcY V bdgZ hjeZgÑX^Va! aVg\Z"XVa^WgZ XjiVcZdjh hnhiZb#)%Ã)( KZcdjh kVakZh VgZ Xdch^hiZcian [djcY ^c kZ^ch l^i] V XVa^WgZ d[ %#' bb dg aVg\Zg# I]Z dcan ^bedgiVci ZmXZei^dc XdcXZgc^c\ i]Z egZhZcXZ d[ i]ZhZ kVakZh hZZbh id WZ i]Z kZcdjh VgX]Zh
i]Vi Vaadl Z^i]Zg gVY^Va"jacVg dg eVabVg"YdghVa YgV^cV\Z! hjX] Vh kZ^ch XadhZ id Vaa _d^cih VcY hjWYZgbVa kZ^ch dc i]Z YdghVa! eVabVg! VcY aViZgVa hjg[VXZh d[ i]Z ]VcY VcY Ñc\Zgh# ;^cVaan! i]Z dg^ZciVi^dc d[ i]Z kZcdjh kVakZh ^cY^XViZh i]Vi i]Z Y^gZXi^dc d[ i]Z kZcdjh Òdl \ZcZgVaan ^h [gdb i]Z eVabVg id i]Z YdghVa h^YZ d[ i]Z ]VcY! VcY [gdb i]Z hjeZgÑX^Va id i]Z YZZe kZ^c hnhiZb# 6aa VgiZg^Zh d[ i]Z ]VcY VcY Ñc\Zgh dg^\^cViZ [gdb i]Z bV^c [dgZVgb kZhhZah/ i]Z gVY^Va! jacVg! VcY VciZg^dg VcY edhiZg^dg ^ciZgdhhZdjh VgiZg^Zh# I]ZhZ VgiZg^Zh VgZ i]Z ig^WjiVg^Zh id i]Z kVhXjaVg" ^in d[ i]Z lg^hi! l]^X] VeeZVgh id WZ i]Vi d[ ild eVabVg hjeZgÑX^Va eVabVg VcY YZZe eVabVg VgX] VcY i]gZZ YdghVa XVgeVa VgX]Zh WVhVa bZiVXVgeVa VgX]! YdghVa ^ciZgXVgeVa VgX]! YdghVa gVY^dXVgeVa VgX]0 ;^\jgZh ("&V VcY ("&W #))Ã), I]Z Xdbbdc Y^\^iVa VgiZg^Zh jhjVaan WgVcX] d[[ i]Z hjeZgÑX^Va eVabVg VgX] id Y^k^YZ ^cid i]Z gVY^Va VcY jacVg egdeZg Y^\^iVa VgiZg^Zh Vi i]Z aZkZa d[ i]Z bZiVXVgeVa ]ZVY# I]Z eVabVg bZiV" XVgeVa VgiZg^Zh VgZ [ZY Wn i]Z YZZe eVabVg VgX]# 6[iZg gjcc^c\ Vh V h^c\aZ kZhhZa! ZVX] eVabVg bZiVXVgeVa VgiZgn Y^k^YZh ^cid ild VcY Zm^ih aVi" ZgVaan [gdb jcYZg i]Z eVabVg eaViZ id XgVYaZ i]Z bZiVXVgeVa ]ZVY dg id XdccZXi l^i] V Xdbbdc Y^\^iVa VgiZgn# I]Z [djg YdghVa bZiVXVgeVa VgiZg^Zh VgZ WVhZY dc i]Z i]gZZ YdghVa XVgeVa VgX]Zh#(' >bedgiVci [dg jcYZghiVcY^c\ i]Z \gZVi kZghV" i^a^in d[ ^cig^ch^X ÒVeh WVhZY dc i]^h cZildg` ^h i]Z [VXi i]Vi ZVX] VgiZgn XdccZXih l^i] i]Z eVabVg VgiZg^Va hnhiZb! Wdi] egdm^bVaan VcY Y^hiVaan# I]Z bV^c XdccZXi^c\ kZhhZa ^h i]Z eVabVg eZg[dgVidg ^c i]Z lZW heVXZ! jhjVaan [dgb^c\ i]Z [ZZY^c\ kZhhZa [dg i]Z YdghVa bZiVXVgeVa VgiZgn ÒVe ;^\jgZh ("&V VcY ("&W #('
23
24
Tissue Surgery
Radial artery to index
Common palmar digital arteries
Dorsal metacarpal arteries
Thumb artery Superficial palmar arch Dorsal carpal branch of ulnar artery
Palmar intercarpal arch
Ulnar artery Anterior interosseous
Basal metacarpal arch
Deep palmar arch
Dorsal intercarpal arch Dorsal radiocarpal arch Ulnar artery
Radial artery Retinacular and compartmental collateral branches
Radial artery
a
b
Posterior division of anterior interosseous artery
Figure 3-1. (a) Arterial anatomy of the palm. (b) Dorsum of the hand.
Principles of Intrinsic Flap Design I]Z gVe^Y Zkdaji^dc d[ hjg\^XVa VcY iZX]c^XVa ZmeZgi^hZ VcY ^cXgZVh^c\ VcVidb^XVa VcY Xa^c^XVa `cdlaZY\Z ]Vh aZVY id V ]^\] hiVcYVgY d[ hd[i i^hhjZ gZXdchigjXi^dc d[ i]Z ]VcY# >c XdcigVhi id igVY^i^dcVa Y^hiVci eZY^XaZ ÒVeh! ^cig^ch^X ÒVeh eZgb^i ^bbZY^ViZ ldjcY XadhjgZ VcY ZVgan VXi^kZ bdW^a^oVi^dc VcY e]nh^XVa i]ZgVen# I]^h dcZ"hiV\Z XdcXZei Vkd^Yh i]Z YgVlWVX`h d[ Y^hiVci eZY^XaZ ÒVeh! hjX] Vh bjai^eaZ egdXZ" YjgZh! ZmiZcYZY ^bbdW^a^oVi^dc! egdadc\ZY i^bZ d[[ ldg`! VcY ^cXgZVhZY igZVibZci Xdhi# 7Zh^YZh V hdjcY `cdlaZY\Z d[ i]Z VcVidbn! gZXdchigjXi" ^c\ YZ[ZXih ^c i]Z ]VcY gZfj^gZh Vc Va\dg^i]b^X VeegdVX] id hZaZXi i]Z ^YZVa ÒVe ^c i]Z eVgi^XjaVg Xa^c^XVa h^ijVi^dc# 6 i]dgdj\] VcVanh^h d[ i]Z YZ[ZXi ^h i]Z Ñghi hiZe ^c i]Z gZXdchigjXi^dc Va\d" g^i]b VcY ]Vh id egZXZYZ i]Z hZaZXi^dc d[ Vcn gZXdchigjXi^kZ egdXZYjgZ# 9ZX^h^dch VgZ WVhZY dc i]Z ZkVajVi^dc d[ & i]Z h^oZ d[ i]Z YZ[ZXi! ' i]Z adXVi^dc d[ i]Z YZ[ZXi! ( Vcn b^hh^c\ i^hhjZ Xdb" edcZcih! ) i]Z YZ\gZZ d[ hZchVi^dc gZfj^gZY! * igZVibZci dei^dch! + XdcigV^cY^XVi^dch id igZVi" bZci! VcY , i]Z eZghdcVa egdÑaZ d[ i]Z eVi^Zci# 6aa [VXidgh cZZY id WZ VhhZhhZY id YZiZgb^cZ l]Zi]Zg i]Z YZ[ZXi XVc WZ gZXdchigjXiZY Wn adXVa bZVch dg l]Zi]Zg V Y^hiVci eZY^XaZ ÒVe! dg ZkZc
V [gZZ ÒVe! ^h ^cY^XViZY# ;aVe X]d^XZ Vahd YZeZcYh bdgZ dc i]Z eVi^ZciÈh egdÑaZ i]Vc dc i]Z X]VgVX" iZg^hi^Xh d[ i]Z YZ[ZXi# L]ZcZkZg edhh^WaZ! i]Z eVi^ZciÈh YZh^gZh VcY ZmeZXiVi^dch h]djaY WZ Y^h" XjhhZY WZ[dgZ hjg\Zgn id Vkd^Y aViZg egdWaZbh l^i] jch^\]ian Ydcdg h^iZh! ^beV^gZY bdW^a^in d[ Y^\^ih! dg di]Zg edhh^Wan jceaZVhVci gZhjaih# >c VYY^i^dc id Va\dg^i]b^X egdWaZb hdak^c\! ZkZgn hjg\Zdc ]Vh id Xdch^YZg i]Z iZX]c^XVa VheZXih ^c YZh^\c^c\ ÒVeh ^c i]Z ]VcY VcY Ñc\Zgh# I]Z [daadl^c\ eg^cX^eVah bVn VeeZVg ig^k^Va! Wji bVcn ÒVe [V^ajgZh XVc WZ igVXZY WVX` id Vc Zggdg ^c eaVcc^c\ i]Z ÒVe ;^\jgZ ("' / &# 6YZfjViZ ÒVe h^oZ0 '# 6YZfjViZ aZc\i] VcY VgX d[ gdiVi^dc i]Vi ^h! cd iZch^dc dg `^c`^c\ d[ i]Z eZY^XaZ 0 (# 6YZfjViZ egdiZXi^dc d[ eZg[jh^dc cd ^cVe" egdeg^ViZ iZch^dc dc i]Z eZY^XaZ ÒVeh 0 )# I]Z adXVi^dc d[ V h`^c ^haVcY ^c Vc Vm^Va ^haVcY dg ^c YdghVa bZiVXVgeVa ÒVeh0 VcY *# I]Z adXVi^dc d[ eZg[dgVidgh ^c Vm^Va ^haVcY ÒVeh# I]Z fj^X`Zhi! ZVh^Zhi! VcY hV[Zhi bZi]dYh WZhi hj^iZY [dg i]Z eVi^Zci h]djaY WZ jhZY id dWiV^c i]Z WZhi edhh^WaZ djiXdbZ# I]Z ^YZVa hdaji^dc ^h Xdch^YZgZY id WZ V ÒVe i]Vi & bZZih i]Z
Advanced Concepts in Vascularized Tissue Transfer in the Hand
Size Location What is missing?
Reconstruction with local means possible
Yes
No Free flaps Distant pedicle flaps
Flap characteristics: Qualities of tissue needed in the flap Size of the flap, etc.
Availability of flap options Personal profile Donor site considerations
Flap selection
Design of the flap Figure 3-2. Algorithm for analyzing a defect before designing any flap.2
gZfj^gZbZcih d[ i]Z eVi^Zci! ' ]Vh VXXZeiVWaZ Ydcdg"h^iZ bdgW^Y^in! VcY ( ^h i]Z aZVhi iZX]c^" XVaan Y^[ÑXjai#
Classification of Intrinsic Flaps >cig^ch^X ÒVeh! VcY ÒVeh ^c \ZcZgVa! XVc WZ XaVh" h^ÑZY VXXdgY^c\ id & kVhXjaVg VcVidbn! ' i]Z^g bZi]dY d[ jhZ! ( i]Z i^hhjZ XdbedcZcih i]Zn ^cXajYZ! ) i]Z eZg[jh^dc eViiZgc VciZ\gVYZ dg gZigd\gVYZ ! dg * i]Z adXVi^dc d[ i]Z Ydcdg h^iZ# ;aVeh VgZ \ZcZgVaan Y^k^YZY ^cid gVcYdb" eViiZgc ÒVeh VcY Vm^Va"eViiZgc ÒVeh# 7ZXVjhZ d[ i]Z g^X] kVhXjaVg cZildg` YZhXg^WZY VWdkZ! ÒVeh XVc WZ WVhZY dc egdm^bVa dg Y^hiVa eZY^XaZh# Egdm^bVaan WVhZY ÒVeh VgZ XVaaZY ÅVciZ\gVYZ ÒVeh#Æ ;aVeh i]Vi VgZ cdjg^h]ZY Wn Y^hiVa ^cÒdl VgZ XVaaZY ÅgZigd\gVYZ ÒVeh#Æ
25
Xgdhh"Ñc\Zg ÒVe dg i]Z i]ZcVg ÒVe0 VcY Vm^Va" eViiZgc ÒVeh! i]Z egdidineZh d[ l]^X] lZgZ i]Z A^iiaZg ÒVe dg i]Z =^a\Zc[ZaYi ÒVe aViZg YZhXg^WZY Wn ;djX]Zg Vh i]Z Å`^iZ ÒVeÆ ! Wdi] jhZY Vh ]Zi" ZgdY^\^iVa ÒVeh [dg gZXdchigjXi^c\ i]Z ejae d[ i]Z i]jbW# Dc i]Z WVh^h d[ i]ZhZ XaVhh^X YZhXg^ei^dch VcY dc VYY^i^dcVa VcVidb^X hijY^Zh! bdY^ÑXV" i^dch! VcY gZÑcZbZcih! cZl ineZh d[ ÒVeh ]VkZ WZZc YZkZadeZY VcY VgZ YZhXg^WZY ^c bdgZ YZiV^aZY WZadl#
Cross-Finger Flaps I]Z XaVhh^X ÅXgdhh"Ñc\ZgÆ ÒVe ]Vh WZZc bdY^ÑZY ^cid hZkZgVa [dgbh# 6aa i]ZhZ [dgbh VgZ eg^cX^" eVaan Xdch^YZgZY id WZ gVcYdb"eViiZgc ÒVeh! Vai]dj\] hbVaa Vm^Va XjiVcZdjh WgVcX]Zh bVn WZ ^cXajYZY ^c hdbZ bdY^ÑXVi^dch! Vh [dg ZmVbeaZ ^c i]Z 8"g^c\ ÒVe! l]^X] XdciV^ch YZÑcZY kZhhZah id Zc]VcXZ ^ih kZghVi^a^in VcY bdW^a^in#(+ I]Z 8" g^c\ ÒVe ^h Z^i]Zg V egdm^bVaan dg Y^hiVaan WVhZY ÒVe i]Vi Xdch^hih d[ i]Z hZb^"X^gXjb[ZgZcXZ d[ i]Z Y^\^i ;^\jgZ ("( #)I]Z ÅXgdhh"Ñc\ZgÆ ÒVe XVc XdkZg aVg\Zg XdbeaZm YZ[ZXih ^c i]Z Y^hiVa b^YYaZ e]VaVcm VcY XVc Vahd WZ gZ"^ccZgkViZY! Wji ^ih VgX d[ gdiVi^dc ^h a^b^iZY WZXVjhZ d[ i]Z h]dgi eZY^XaZ# I]ZgZ[dgZ! i]Z bdhi ^bedgiVci eg^cX^eaZ ^c eaVcc^c\ V Xgdhh"Ñc\Zg ÒVe ^h id hfjVgZ i]Z YZ[ZXi VcY id VY_jhi i]Z aZkZa d[ i]Z YZ[ZXi ^c i]Z Y^\^i id i]Z Proximally based C-ring flap
Palmar digital nerve Digitally based C-ring flap
Traditional Flaps HZkZgVa ^cig^ch^X ÒVeh ]VkZ WZZc jhZY ^c gZXZci YZXVYZh# 6bdc\ i]Z bdgZ [gZfjZcian ZbeadnZY VgZ gVcYdb"eViiZgc ÒVeh! l]^X] VgZ i]Z XaVhh^X
Digital nerve Figure 3-3. Steps in elevating the C-ring digital flap.
26
Tissue Surgery
aZkZa d[ i]Z ÒVe id Vkd^Y iZch^dc dc i]Z ÒVe# HdbZ iZbedgVgn ÒZm^dc d[ i]Z Ydcdg dg gZX^e^" Zci Ñc\Zg bVn WZ cZXZhhVgn id gZYjXZ iZch^dc dc i]Z ÒVe# I]Z aVg\Zhi ÒVe XVc WZ gV^hZY dc i]Z b^YYaZ e]VaVcm# I]Z eVgViZcdc bjhi WZ egZ" hZgkZY id hZXjgZ \gV[i^c\ Vi i]Z Ydcdg h^iZ# 9dcdg h^iZ bdgW^Y^in XVc WZ Xdch^YZgVWaZ ^[ i]Z hZb^" X^gXjb[ZgZcXZ d[ i]Z Y^\^i ^h gV^hZY#
I]Z iZX]c^fjZ [daadlh i]Z ÅdeZc i]Z Yddg" XadhZ i]Z YddgÆ eg^cX^eaZ# 6[iZg ZaZkVi^c\ i]Z h`^c d[ i]Z Ydcdg h^iZ Vh V eZY^XaZY kVhXjaVg^oZY YZgbVa ÒVe ÅdeZc i]Z YddgÆ ! i]Z hjWXjiVcZdjh i^hhjZ ^h ZaZkViZY ^c i]Z deedh^iZ Y^gZXi^dc Wn eaVX^c\ ^ih WVhZ VY_VXZci id i]Z gZX^e^Zci Ñc\Zg! egZhZgk^c\ i]Z eVgViZcdc# I]Z hjWXjiVcZdjh ÒVe ^h i]Zc Ò^eeZY dkZg a^`Z i]Z eV\Z d[ V Wdd` VcY hjijgZY ^cid i]Z YZ[ZXi# 6[iZg i]Z hjWXjiVcZ" djh ÒVe ^h ^chZi! i]Z eZY^XaZY kVhXjaVg^oZY YZgbVa ÒVe ^h hZlc WVX` ^cid ^ih WZY ÅXadhZ i]Z YddgÆ ! VcY V i^Z"dkZg YgZhh^c\ ^h Veea^ZY# 6 hea^i"i]^X`cZhh h`^c \gV[i HIHi ^h ZkZc bdgZ ^bedgiVci ^c gZkZghZ eZY^XaZ ÒVeh# 6ciZ\gVYZ ÒVeh jhjVaan Yd cdi ZmXZZY Vc VgX d[ gdiVi^dc d[ .% id &'%! l]^X] \gZVian gZYjXZh i]Z g^h` d[ `^c`^c\# GZkZghZ eZY^XaZ ÒVeh [gZfjZcian ]VkZ VgXh d[ gdiVi^dc d[ &-%# >c i]ZhZ ÒVeh! ^[ i]Z eZY^XaZ ^h cdi adc\ Zcdj\] id Vaadl V l^YZ VgX! `^c`^c\ d[ i]Z eZY^XaZ XVc _ZdeVgY^hZ kZcdjh djiÒdl# 6YY^c\ &% id &* bdgZ aZc\i] id i]Z eZY^XaZ! Vkd^Y^c\ i]Z jhZ d[ cVggdl ijccZah [dg i]Z eZY^XaZ! VcY jh^c\ V addhZ XadhjgZ d[ i]Z ldjcY! h]djaY WZ ^cXajYZY ^cid i]Z ÒVe YZh^\c id Vkd^Y i]ZhZ Xdbea^XVi^dch#
28
Tissue Surgery
Antegrade and Retrograde Homodigital Artery Flaps =dbdY^\^iVa ^haVcY ÒVeh! VciZ\gVYZ dg gZkZghZ! XVc WZ ZbeadnZY id gZeV^g kVg^djh ineZh d[ YZ[ZXih [gdb XdbeaZm ^c_jg^Zh d[ i]Z ]VcY! ZheZ" X^Vaan l]Zc ZVh^Zg iZX]c^fjZh! hjX] Vh Xgdhh" Ñc\Zg ÒVeh! VgZ cdi edhh^WaZ Vh V gZhjai d[ hZkZgZ bjai^eaZ Ñc\Zg ^c_jg^Zh# I]ZhZ ÒVeh gZan dc dcZ d[ i]Z Y^\^iVa VgiZg^Zh dg dc V eZg[dgVidg WgVcX]^c\ d[[ i]ZhZ kZhhZah! id\Zi]Zg l^i] i]Z^g XdcXdb^iVci kZ^ch! l]^X] VgZ egdiZXiZY dc i]Z eVabVg h^YZ Wn i]Z E VcY 9>E _d^cih0 i]ZgZ[dgZ! i]ZhZ ÒVeh VgZ ^cY^XViZY [dg Y^hiVa ]dbd"Y^\^iVa YdghVa YZ[ZXih! ZheZX^Vaan dkZg ZmedhZY _d^cih VcY Ñc\Zgi^e ^c_jg^Zh! l^i] VXXZeiVWaZ Ydcdg h^iZ bdgW^Y^in# 6 [jaa"i]^X`cZhh h`^c \gV[i [dg i]Z Ydcdg h^iZ ^h gZfj^gZY#
Heterodigital Island Flaps =ZiZgdY^\^iVa VgiZg^Va^oZY ÒVeh VgZ jhZ[ja [dg gZhjg[VX^c\ aVg\Z YZ[ZXih ^c i]Z ]VcY! Vh lZaa Vh i]Z eVabVg! YdghVa! VcY aViZgVa VheZXih d[ VY_VXZci Ñc\Zgh i]Vi VgZ idd W^\ [dg adXVa igVch" edh^i^dc ÒVeh# I]Z ÒVeh VgZ i]^c VcY ea^VWaZ! VcY i]Z bdgW^Y^in id i]Z Ydcdg Ñc\Zg ^h
Retrograde pedicle design (Homodigital island flap) Figure 3-6. Design of a reverse homodigital artery flap.1
b^c^bVa# I]Z ÒVe ^h WVhZY dc i]Z Y^\^iVa VgiZgn d[ Vc VY_VXZci Ñc\Zg! VcY ^c hdbZ XVhZh ^cXajYZh V kZ^c [gdb i]Z Ydghjb d[ i]Z Ñc\Zg# I]^h kZ^c ^begdkZh ÒVe ]ZbdYncVb^Xh VcY egZkZcih kZcdjh Xdc\Zhi^dc ^c i]Z ÒVe! l]^X] XVc dXXjg ^c ^haVcY ÒVeh [gdb i]Z Ñc\Zgh i]Vi YZeZcY hdaZan dc i]Z kZcVZ Xdb^iVciZh d[ i]Z Y^\^iVa VgiZgn#*. >[ V adc\Zg gZVX] ^h gZfj^gZY! i]Z ]ZiZgdY^\^iVa VgiZg^Va^oZY ÒVe XVc WZ ZmiZcYZY Wn Y^k^Y^c\ i]Z YdghVa kZ^c# DcXZ i]Z ÒVe ]Vh WZZc igVch[ZggZY! i]Z kZcdjh eZY^XaZ d[ i]Z ÒVe XVc WZ gZXdccZXiZY b^Xgdhjg\^XVaan#+% 8a^c^XVa XVhZh gZedgiZY Wn IV^ Zi Va# h]dlZY XdbeaZiZ ÒVe hjgk^kVa l^i] cd edhideZgVi^kZ kZcdjh ÒVe Xdc\Zhi^dc VcY cdgbVa hZchVi^dc ^c i]Z Ydcdg Ñc\Zg ejae ;^\jgZ (", #
Heterodigital, Reversed Neurovascular Island Flaps =ZiZgdY^\^iVa! gZkZghZY cZjgdkVhXjaVg ^haVcY ÒVeh VgZ YZh^\cZY dc i]Z Ydghd"aViZgVa VheZXi d[ i]Z b^YYaZ e]VaVcm d[ i]Z VY_VXZci jc^c_jgZY Ñc\Zg# I]Zn VgZ ^cY^XViZY [dg gZeV^g^c\ ZmiZc" h^kZ YZ[ZXih ^c Ñc\Zgh i]Vi XVccdi WZ gZXdc" higjXiZY jh^c\ di]Zg ÒVeh VcY Vh Vc VaiZgcVi^kZ id b^Xgdhjg\^XVa gZXdchigjXi^dc# I]Z aZc\i] d[ i]Z kVhXjaVg eZY^XaZ Vaadlh V l^YZ VgX d[ igVch" edh^i^dc [dg XdkZg^c\ YZ[ZXih ^c i]Z b^YYaZ VcY ^cYZm Ñc\Zgh# 6 Y^\^iVa 6aaZcÈh iZhi VcY 9deeaZg ZmVb^cVi^dc bjhi XdcÑgb i]Z eViZcXn d[ i]Z Y^\^iVa VgiZg^Zh d[ i]Z ^c_jgZY VcY VY_VXZci Ydcdg Ñc\Zgh egZdeZgVi^kZan# >[ V cZjgdkVhXjaVg ÒVe ^h id WZ XgZViZY! V YdghVa hZchdgn WgVcX] d[ i]Z Y^\^iVa cZgkZ XVc WZ Y^hhZXiZY VcY ViiVX]ZY id i]Z ÒVe# 6[iZg Y^hhZXi^c\ i]Z Xdbbdc Y^\^iVa VgiZgn WZilZZc i]Z ^c_jgZY Ñc\Zg VcY i]Z ÒVe"Ydcdg Ñc\Zg! i]Z VgiZgn ^h igVchZXiZY WZ[dgZ ^ih W^[jgXV" i^dc0 VcY i]Z Y^\^iVa VgiZgn ^h ^YZci^ÑZY je id ^ih W^[jgXVi^dc ^c i]Z eVab#I]Z XdckZg\^c\ WgVcX]Zh VgZ bdW^a^oZY Vh V Xdci^cjdjh kVhXjaVg eZY^XaZ [dg i]Z ÒVe! hd i]Vi kVhXjaVg^oVi^dc ^h egdk^YZY Wn V gZkZghZ Òdl i]gdj\] i]Z egdm^bVa igVch" kZghZ Y^\^iVa eVabVg VgX] d[ i]Z ^c_jgZY Ñc\Zg#+& 9Zhe^iZ i]Z edhh^W^a^in d[ dcZ"hiV\Z gZXdchigjX" i^dc! ZVgan edhideZgVi^kZ bdW^a^oVi^dc! \ddY [jcXi^dcVa gZXdkZgn! VcY hVi^h[VXidgn XdhbZi^X VcY hZchdgn gZhjaih! i]^h iZX]c^fjZ ]Vh Y^hVYkVc" iV\Zh! l]^X] ^cXajYZ i]Z hVXg^ÑXZ d[ i]Z Xdbbdc Y^\^iVa VgiZgn! Vh lZaa Vh i]Z cZZY id k^daViZ V ]ZVai]n Ñc\Zg#
Advanced Concepts in Vascularized Tissue Transfer in the Hand
29
Figure 3-7. (above) Preoperative injury. Extensive injury to the radial side of the palm with damage to the radial digital artery of the index finger precludes harvesting the heterodigital arterialized flap from the ulnar side of the index finger, as this would risk necrosis of the donor finger. As the flap came from the noncontiguous side of the ring finger, vein division was necessary to facilitate transfer of
the flap. (below) Postoperative healing. Both the flap and the full-thickness skin graft have healed well. (Tay SC, Teoh LC, Tan SH, et al. Extending the reach of the heterodigital arterialized flap by vein division and repair. Plast Reconstr Surg. 2004;114(6):1450–1456.)
Thenar Flaps Based on the Superficial Palmar Branch of the Radial Artery
d[ i]Z i]ZcVg [VhX^V VcY Xdch^hiZcian \^kZh eZg[d" gVi^c\ WgVcX]Zh id i]Z i]ZcVg [VhX^dXjiVcZdjh VgZV# I]Z eVabVg VheZXi d[ i]Z i]ZcVg Zb^cZcXZ ^h Xdch^hiZcian ^ccZgkViZY Wn i]Z XjiVcZdjh WgVcX] d[ i]Z bZY^Vc cZgkZ! VcY i]Z gVY^Va VheZXi ^h ^ccZgkViZY Wn i]Z hjeZgÑX^Va WgVcX] d[ i]Z gVY^Va cZgkZ VcY i]Z aViZgVa VciZWgVX]^Va XjiVcZdjh cZgkZ#&&!,)!,*!,, c i]ZhZ XVhZh! i]Z e^kdi ed^ci ^h adXViZY Vi i]Z egdm^bVa e]VaVc" \ZVa aZkZa# HZchdgn ^ccZgkVi^dc d[ i]Z VgZV ^h bV^can egdk^YZY Wn i]Z YdghVa WgVcX] d[ i]Z jacVg cZgkZ# >c i]Z hZchViZ ÒVe! i]Z ^ccZgkVi^c\ cZgkZ ^h hjijgZY id i]Z eVabVg Y^\^iVa cZgkZ Vi i]Z Y^hiVa e]VaVc\ZVa _d^ci ;^\jgZ ("&& # I]Z VgiZg^Va WaddY hjeean d[ i]^h gZkZghZ ÒVe ^h ZchjgZY Wn Xdbbjc^XVi^dc WZilZZc i]Z gVY^Va
Advanced Concepts in Vascularized Tissue Transfer in the Hand
31
YZh^\c! VcY ]ZcXZ i]Z kZghVi^a^in! d[ i]ZhZ adXVa ÒVeh ;^\jgZ ("&' #.%Ã.( >c &..,! ild bV_dg YZkZa" debZcih ^c i]Z ÒVe lZgZ gZedgiZY/.% VcÅZmiZcYZY! gZkZghZ! YdghVa bZiVXVgeVa VgiZgn ÒVe!Æ YZh^\cZY Wn @VgVXVaVg Zi Va#.'0 VcY V ÅgZkZghZ YdghVa bZiVXVgeVa VgiZgn Xdbedh^iZ ÒVeÆ XdciV^c^c\ V kVhXjaVg hZ\bZci d[ WdcZ# KVg^djh Vji]dgh gZedgiZY Xdbedh^iZ ÒVeh ^cXajY^c\ iZcYdc hZ\bZcih#-,!--
Extended Dorsal Metacarpal Artery Flaps I]Z ZmiZcYZY YdghVa bZiVXVgeVa VgiZgn ÒVe ^h V gZXZcian YZhXg^WZY kVg^Vi^dc d[ i]Z YdghVa bZiV" XVgeVa VgiZgn 9B86 ÒVe#.) I]Z VgX d[ gdiVi^dc XVc WZ bVg`ZYan ZcaVg\ZY Wn jh^c\ i]Z Ñghi eZg" [dgVidg kZhhZa ^c i]Z egdm^bVa e]VaVcm Vi i]Z bdhi Y^hiVa WVhZ d[ i]Z ÒVe# I]^h kZhhZa Vahd [dgbh i]Z WVhZ d[ i]Z b^Ye]VaVc\ZVa ^haVcY ÒVe VcY [ZZYh i]Z hjWXjiVcZdjh VgiZg^Va cZildg`# I]Z Figure 3-10. Arterial anatomy of the little finger. (Schmidt HM, Lanz U. Chirurgische Anatomie der Hand. New York: Georg Thieme Verlag, 2003.)
VcY jacVg eVabVg Y^\^iVa VgiZg^Zh d[ i]Z a^iiaZ Ñc\Zg! i]gdj\] i]Z YdghVa dg eVabVg VgiZg^Va VgXVYZ# I]ZgZ[dgZ! egZdeZgVi^kZ Y^\^iVa 6aaZc iZhih VcY 9deeaZg ZmVb^cVi^dc d[ i]Z eVabVg Y^\^iVa VgiZg^Zh VgZ ^cY^heZchVWaZ [dg VhhZhh^c\ i]Z kVh" XjaVijgZ d[ i]Z a^iiaZ Ñc\Zg# >c XdcigVhi id di]Zg XdckZci^dcVa ÒVeh ! hjX] Vh i]Z Xgdhh"Ñc\Zg ÒVe VcY i]Z i]ZcVg ÒVe! i]^h ÒVe ^ckdakZh V h^c\aZ"hiV\Z egdXZYjgZ l^i]dji egdadc\ZY ^bbdW^a^oVi^dc# >i ^h V kZghVi^aZ ÒVe lZaa hj^iZY [dg Xdbea^XViZY Ñc\Zg ^c_jg^Zh l^i] hjWhiVci^Va eVabVg i^hhjZ YZ[ZXih! VcY ^i Vaadlh eg^bVgn Ydcdg"h^iZ XadhjgZ l^i]dji [jaa" dg hea^i" i]^X`cZhh h`^c \gV[ih#
Flaps Based on the Dorsal Metacarpal Network I]Z Ydghjb d[ i]Z ]VcY ^h ^cXgZVh^c\an jhZY Vh V hdjgXZ d[ kVg^djh ^cig^ch^X ÒVeh! l^i] V l^YZ gVc\Z d[ YZh^\ch VcY i^hhjZ XdbedcZcih#-+Ã-I]ZhZ ÒVeh VgZ Z^i]Zg egdm^bVaan VciZ\gVYZ YdghVa bZiVXVgeVa VgiZgn dg Y^hiVaan gZkZghZ YdghVa bZiVXVgeVa VgiZgn WVhZY# I]Z Y^hiVaan WVhZY ÒVeh ^c i]Z ]VcY VgZ XVaaZY ÅgZkZghZ YdghVa bZiVXVgeVa VgiZgn ÒVehÆ VcY ÅZmiZcYZY gZkZghZ YdghVa bZiVXVgeVa VgiZgn ÒVeh#Æ ;^ghi YZiV^aZY ^c &..%! i]ZhZ ÒVeh VgZ jhZY ^cXgZVh^c\an#-,!-. BdgZ [dXjh dc i]Z kVhXjaVg VcVidbn ^c i]Z aVhi YZXVYZ ]Vh XaVg^ÑZY i]Z
Figure 3-11. Diagram of the reverse ulnar hypothenar flap. The flap is designed over the distal half of the ulnar aspect of the hypothenar eminence. UPDA ulnar palmar digital artery; PP pivot point of the reverse flap; SPA superficial palmar arch; DUN dorsal branch of the ulnar nerve. (Omokawa S, Yajima H, Inada Y, et al. A reverse ulnar hypothenar flap for finger reconstruction. Plast Reconstr Surg. 2000;106(4):828–833.)
32
Tissue Surgery
Figure 3-12. Vascular network supplying dorsum of the hand: (1) rete carpi dorsale, (2) dorsal carpal arch, (3) dorsal metacarpal artery (DMCA), (4) junctura tendineae, (5) cutaneous perforator from DMCA, (6) continuation of DMCA to join the confluence of common digital artery and digital arteries, (7) lateral terminal branches of DMCA anastomosing (C) with dorsal branches of digital artery, (8) deep palmar arch, (9) proximal communication perforator between DMCA and palmar metacarpal artery (PMCA), (10) superficial palmar arch, (11) PMCA,
(12) distal communicating perforator between DMCA and PMCA, (13) common digital artery, (14) digital artery to the neighboring finger, (15) digital artery to the same finger,(a-d) dorsal branches of the digital artery.(Vuppalapati G,Oberlin C, Balakrishnan G. Distally based dorsal hand flaps: clinical experience, cadaveric studies and an update. Br J Plast Surg. 2004;57(7):653–667. Copyright (2004), with permission from The British Association of Plastic Surgeons.)
YdghVa bZiVXVgeVa VgiZgn VcY i]Z ^ciZgdhhZdjh [VhX^V bjhi WZ ^cXdgedgViZY ^cid i]Z eZY^XaZ ;^\jgZ ("&( # 6h ^c di]Zg 9B86 ÒVeh! i]Z ^ciZgiZcY^cdjh XdccZXi^dch ]VkZ id WZ Y^k^YZY ^c hdbZ ^chiVcXZh VcY h]djaY WZ gZeV^gZY V[iZg ÒVe igVch[Zg# Id hZXjgZ kZcdjh djiÒdl! V &"Xb hig^e d[ hjWXjiVcZdjh i^hhjZ h]djaY WZ ^cXajYZY# ;aVeh WVhZY dc i]ZhZ Y^hiVa eZg[dgVidgh ZVh^an gZVX] i]Z Ydghjb d[ i]Z Ñc\Zgi^eh! cV^a WZY! dg i]Z Y^hiVa aViZgVa VheZXi d[ i]Z Y^\^ih ;^\jgZ ("&( #
WZilZZc i]Z ZmiZchdg iZcYdch! dg i]gdj\] dcZ d[ i]ZhZ iZcYdch l]Zc V hZ\bZci ^h ^cXajYZY ^c i]Z ÒVe! l^i]dji Y^hijgW^c\ i]Z i]^c WgVcX]Zh d[ i]Z YdghVa bZiVXVgeVa VgiZgn id i]Z WdcZ hZ\" bZci! i]Z iZcYdc hZ\bZci! VcY i]Z h`^c eVYYaZ ;^\jgZ ("&) # KjeeVaVeVi^ Zi Va#.+ jhZY V Xdbedh^iZ gZkZghZ YdghVa bZiVXVgeVa VgiZgn ÒVe id Wg^Y\Z V hZ\bZci d[ hZkZgZ Xdbb^cji^dc d[ i]Z egdm^" bVa e]VaVcm l^i] i]Z adhh d[ i]Z hZ\bZciVa ZmiZchdg iZcYdc ^c i]Z ^cYZm Ñc\Zg# I]^h ÒVe ^cXajYZY V kVhXjaVg^oZY hZ\bZci d[ ZmiZchdg iZcYdc [gdb i]Z ZmiZchdg ^cY^X^h VcY Xdgi^XVa WdcZ [gdb i]Z hZXdcY bZiVXVgeVa WdcZ# HVciV" 8dbWV Zi Va# gZXdchigjXiZY i]Z egdm^bVa e]VaVcm d[ i]Z Ñ[i] Ñc\Zg l^i] V XdbedjcY dhiZd"[VhX^d"XjiVcZdjh YdghVa bZiVXVgeVa ÒVe#-@V`^cd`^ Zi Va#.- igZViZY X]gdc^X dhiZdbnZa^i^h ^c i]Z egdm^bVa e]VaVcm d[ i]Z b^YYaZ Ñc\Zg Wn ^chZgi^c\ V hbVaa e^ZXZ d[ i]Z ^ciZgdhhZdjh bjhXaZ hjeea^ZY Wn V gZkZghZ Òdl d[ i]Z hZXdcY YdghVa bZiVXVgeVa VgiZgn ^cid i]Z WdcZ bVggdl heVXZ! V[iZg gVY^XVa YWg^YZbZci#
Composite Dorsal Metacarpal Artery Flaps I]Z Xdbedh^iZ! gZkZghZ! YdghVa bZiVXVgeVa VgiZgn ÒVe ^h iZX]c^XVaan bdgZ YZbVcY^c\ i]Vc i]Z XdckZci^dcVa YdghVa bZiVXVgeVa VgiZgn ÒVe# I]Z hZ\bZciVa WaddY hjeean id i]Z bZiVXVgeVah VcY ZmiZchdg iZcYdch.*Ã., jcYZga^cZh i]Z ^bedgiVcXZ d[ ^cXajY^c\ i]Z YdghVa bZiVXVgeVa VgiZgn ^c i]ZhZ ÒVeh# =ZcXZ! i]Z Y^hhZXi^dc bjhi egdXZZY
Figure 3-13. Extended reverse dorsal metacarpal artery flap. (Vuppalapati G, Oberlin C, Balakrishnan G. Distally based dorsal hand flaps:clinical experience,cadaveric studies and an update. Br J Plast Surg. 2004;57(7):653–667. Copyright (2004), with permission from The British Association of Plastic Surgeons.)
Advanced Concepts in Vascularized Tissue Transfer in the Hand
33
Figure 3-14. Composite reverse dorsal metacarpal artery flap. (Vuppalapati G, Oberlin C, Balakrishnan G. Distally based dorsal hand flaps: clinical experience, cadaveric studies and an update. Br J Plast Surg. 2004;57(7):653–667. Copyright (2004), with permission from The British Association of Plastic Surgeons.)
Free “Kite” Flap I]Z Ñghi [gZZ b^Xgdhjg\^XVa `^iZ ÒVe lVh gZedgiZY Wn 8 HG6 XdjghZh [gdb i]Z gVY^Va VgiZgn * Xb egdm^bVa id i]Z gVY^dXVgeVa _d^ci! WZcZVi] i]Z WgVX]^dgVY^Va^h bjhXaZ! id ZbZg\Z dc i]Z YdghVa hjg[VXZ d[ i]Z ZmiZchdg gZi^cVXj" ajb# >c i]Z VcVidb^X hcj[[Wdm! i]Z &!' >8 HG6 VcVhidbdhZh l^i] i]Z gVY^Va VgiZgn dg i]Z gVY^d" XVgeVa VgX] ;^\jgZ ("&, # I]^h kZhhZa! WVhZY dc ^ih Y^hiVa VcVhidbdi^X XdccZXi^dc id i]Z gVY^Va VgiZgn! ^h i]Z ÅVhXZcY^c\ ^gg^\Vi^c\ WgVcX]Æ YZhXg^WZY Wn OV^YZbWZg\ Zi Va#&(' I]^h kZhhZa ^h VXijVaan hjeZgÑX^Va id i]Z ZmiZchdg gZi^cVXjajb! gVi]Zg i]Vc dc i]Z eZg^dhiZjb! Vh dg^\^cVaan YZhXg^WZY# I]Z '!( >8 HG6 dg^\^cViZh [gdb i]Z VciZg^dg ^ciZgdhhZdjh VgiZgn dg i]Z edhiZg^dg Y^k^h^dc d[ i]Z VciZg^dg ^ciZgdhhZdjh VgiZgn# >i ^h hjeZgÑX^Va id i]Z ZmiZchdg gZi^cVXjajb! Y^gZXian dkZg A^hiZgÈh ijWZgXaZ! VcY VcVhidbdhZh l^i] i]Z YdghVa ^ciZg" XVgeVa VgX]! i]Z YdghVa gVY^dXVgeVa VgX]! dg i]Z )i] :86# >ih cjig^Zci VgiZgn WgVcX]Zh eZcZigViZ YZZean ^cid XVcXZaadjh WdcZ# A^`Z i]Z &!' >8 HG6! i]Z '!( >8 HG6 XVc WZ ZVh^an ]VgkZhiZY VcY jhZY Vh V kVhXjaVg^oZY eZY^XaZ WdcZ \gV[i# I]Z VgX d[ gdiVi^dc ^h \gZViZg VcY XVc gZVX] i]Z Zci^gZ egdm^bVa gdl! bV`^c\ ^i jhZ[ja [dg Z^i]Zg @^Zc" WX`Èh Y^hZVhZ dg hXVe]d^Y cdcjc^dch ;^\jgZ ("&, # I]Z )i] :86 dg^\^cViZh [gdb i]Z edhiZg^dg Y^k^h^dc d[ i]Z VciZg^dg ^ciZgdhhZdjh VgiZgn dg ^ih Ñ[i] ZmiZchdg XdbeVgibZci WgVcX] VcY
36
Tissue Surgery
R S
1,2 IC SRA
RA
Figure 3-17. Vascularized pedicle bone graft based on the 1,2 intercompartmental supraretinacular artery.The incision is curvilinear, allowing wide exposure for scaphoid vascular bone graft elevation and osteonecrosis visualization.1
VcVhidbdhZh l^i] i]Z YdghVa ^ciZgXVgeVa VcY gVY^dXVgeVa VgX]Zh# I]Z *i] :86 ^h i]Z aVg\Zhi d[ i]Z [djg YdghVa kZhhZah# >i ^h adXViZY ^c i]Z gVY^Va Òddg d[ i]Z Ñ[i] ZmiZchdg XdbeVgibZci! eVhh^c\ Vi i^bZh i]gdj\] i]Z )!* hZeijb# I]^h kZhhZa ^h hjeea^ZY Wn i]Z edhiZg^dg Y^k^h^dc d[ i]Z VciZg^dg ^ciZgdhhZdjh VgiZgn VcY VcVhidbdhZh Y^hiVaan l^i] i]Z YdghVa ^ciZgXVgeVa VgX]# >ih aVg\Z Y^Vb" ZiZg! jacVg adXVi^dc VlVn [gdb gZfj^gZY XVe" hjadidbn ^cX^h^dch ! VcY bjai^eaZ VcVhidbdhZh bV`Z ^i V YZh^gVWaZ hdjgXZ d[ gZigd\gVYZ WaddY Òdl# I]Z YdghVa gVY^dXVgeVa VgX] VcY i]Z YdghVa hjegVgZi^cVXjaVg VgX] egdk^YZ ^bedgiVci VcVhid" bdi^X XdccZXi^dch id i]ZhZ [djg kZhhZah! Vaadl^c\ ZVX] id hZgkZ Vh V Y^hiVaan WVhZY dg gZkZghZ"Òdl eZY^XaZ \gV[i ^YZci^XVa ^c eg^cX^eaZ id i]Z gVY^Va [dgZVgb ÒVe# I]Z &!' >8 HG6 lVh i]Z bdhi jhZ[ja
[dg igZVi^c\ hXVe]d^Y cdcjc^dch VcY EgZ^hZgÈh Y^hZVhZ0 VcY i]Z *i] VcY )i] :86 lVh i]Z WZhi eZY^XaZ \gV[i [dg igZVi^c\ @^ZcWX`Èh Y^hZVhZ ;^\jgZ ("&- # Id Vkd^Y iZX]c^XVa e^i[Vaah VcY id ^begdkZ Xa^c^XVa djiXdbZ! Vaa kVhXjaVg^oZY eZY^XaZ WdcZ \gV[ih bjhi ]VkZ V eZY^XaZ d[ hj[ÑX^Zci aZc\i] id gZVX] i]Z gZX^e^Zci h^iZ l^i]dji iZch^dc# I]Z kVh" XjaVg eZY^XaZ h]djaY egZ[ZgVWan ^cXajYZ cjig^Zci kZhhZah i]Vi hjeean Wdi] Xdgi^XVa VcY XVcXZaadjh WdcZ#)+ >c @^ZcWX`Èh Y^hZVhZ! gZkVhXjaVg^oVi^dc l^i] V kVhXjaVg WjcYaZ dg kVhXjaVg^oZY WdcZ \gV[i XVc WZ eZg[dgbZY ZkZc ^c VYkVcXZY XVhZh! egdk^YZY i]Vi Vc ^ciVXi XVgi^aV\Z h]Zaa ^h egZhZci l^i]dji [gVXijgZ dg [gV\bZciVi^dc VcY cd Vgi]gdh^h ^h [djcY# GZkVhXjaVg^oVi^dc ^h V ad\^XVa VaiZgcVi^kZ id adVY"VaiZg^c\ egdXZYjgZh VcY ^h ZheZX^Vaan ViigVXi^kZ ^c jacVg"cZjigVa dg "edh^i^kZ kVg^VcXZ XVhZh l]Zc gVY^Va h]dgiZc^c\ ^h XdcigV^cY^XViZY# 8dcigV^cY^XVi^dch ^cXajYZ hiV\Z >K Y^hZVhZ VcY ajcViZ [gVXijgZh l^i] Zmigjh^dc dg hZeVgVi^dc d[ i]Z [gV\bZcih# >c EgZ^hZgÈh Y^hZVhZ! kVhXjaVg^oZY WdcZ \gV[ih VgZ XdcigV^cY^XViZY ^c lg^hih l^i] aZkZa >> dg >>> hXVe]d^Y cdcjc^dc VYkVcXZY XVgeVa XdaaVehZ HC68 VcY ^c lg^hih l^i] V gVY^dXVgeVa _d^ci Vgi]gdh^h#&** HVjZgW^Zg VcY 7^h]de&&+ gZedgiZY ZmXZaaZci VcY egdb^h^c\ gZhjaih l^i] i]^h bZi]dY i]Vi VgZ XdbeVgVWaZ id i]Z gZhjaih YZhXg^WZY VWdkZ# I]Z W^dad\n VcY ZmeZg^bZciVa bdYZah d[ [gVX" ijgZ ]ZVa^c\ l^i] kVhXjaVg^oZY WdcZ \gV[ih ]VkZ XaZVgan h]dlc i]Z VYkVciV\Zh dkZg XdckZci^dcVa \gV[i^c\#&'% KVhXjaVg^oZY eZY^XaZY WdcZ \gV[ih [gdb i]Z Ydghjb d[ i]Z Y^hiVa gVY^jh d[[Zg i]Z VYY^i^dcVa VYkVciV\Z d[ V h^c\aZ ^cX^h^dc [dg \gV[i ]VgkZhi VcY Ydcdg h^iZ egZeVgVi^dc! l^i]dji ediZci^Va ^c_jgn id i]Z eVabVg XVgeVa a^\VbZcih# ;VhiZg jc^dc i^bZh VcY i]Z VW^a^in id gZkVhXjaVg" ^oZ cZXgdi^X WdcZ! ^c VYY^i^dc id i]Z iZX]c^XVa ZVhZ d[ ]VgkZhi! ]VkZ bVYZ i]ZhZ \gV[ih Vc ^bedg" iVci idda [dg ]VcY hjg\Zgn#
Summary
Figure 3-18. Intraoperative view: the 4th extensor compartment artery (ECA) is ligated distal to the bone graft and centered proximal to the radiocarpal joint margin. It is elevated, including the overlying 4th ECA, based on an orthograde 4th ECA pedicle with retrograde flow from the 5th ECA.1
>ciZchZ VcVidb^XVa hijY^Zh VcY gZhjai^c\ bdY^Ñ" XVi^dch d[ igVY^i^dcVa ÒVeh ]VkZ aZVY id ZmX^i^c\ WgZV`i]gdj\]h ^c i]Z XdcXZeih d[ ^cig^ch^X ÒVeh VcY kVhXjaVg^oZY i^hhjZ igVch[Zgh ^c i]Z ]VcY# I]Z kVg^Zin d[ dei^dch cdl VkV^aVWaZ ]Vh hjW" hiVci^Vaan Zc]VcXZY i]Z gZXdchigjXi^kZ dei^dch! ZkZc ^c XdbeaZm Xa^c^XVa h^ijVi^dch#
Advanced Concepts in Vascularized Tissue Transfer in the Hand
References &# 6YVc^ G! 8VhiV\cZii^ 8! AVcY^ 6# 9Z\adk^c\ ^c_jg^Zh d[ i]Z ]VcY VcY Ñc\Zgh# 8a^c Dgi]de# &..*0(&)/&.Ã'*# '# 7gdlc G:! Odd` :h]^YV D! >`jiV N! HjcV\VlV I! Zi Va# 6WYjXidg Y^\^i^ b^c^b^ bjhXjadXjiVcZdjh ^haVcY ÒVe Vh Vc deedh^" i^dc igVch[Zg/ V XVhZ gZedgi# ? =VcY Hjg\ P6bR# '%%(0'- & /&(%Ã&('# -# A^hiZg ># Ajb" Wg^XVah# EaVhi GZXdchig Hjg\# '%%'0&&% * /&''*Ã&'(&# &.# ! H]VgoZg A6! Zi Va# GZk^h^iVi^dc d[ i]Z kVhXjaVg VcVidbn d[ i]Z ajbWg^XVa VcY ^ciZg" dhhZdjh bjhXaZh# EaVhi GZXdchig Hjg\# &..,0.. ( /,-*Ã ,.%# '*# HVabdc B# AZh VgiZgZh YZ aV eZVj# EVg^h/ BVhhdc :Y! &.(+# '+# 7ZcZ B9! EZigdaVi^ B! GV^bdcY^ E! Zi Va# GZkZghZ YdghVa Y^\^iVa ^haVcY ÒVe# EaVhi GZXdchig Hjg\# &..)0.( ( /**'Ã **,# ',# :VgaZn B?# I]Z hZXdcY YdghVa bZiVXVgeVa VgiZgn cZj" gdkVhXjaVg ^haVcY ÒVe# ?=VcY Hjg\ P7gR#&.-.0&) ) /)()Ã ))%# '-# =dÒZ]cZg =! E^ZgZg ^cd I! JX]^YV 6! Zi Va# KVhXjaVg^oZY [gZZ cV^a \gV[ih cdjg^h]ZY Wn VgiZg^Va ^cÒdl [gdb i]Z kZcdjh hnhiZb# EaVhi GZXdchig Hjg\# &..%0-* ' /'(.Ã ')*0 Y^hXjhh^dc )+Ã,# (-# FjVWV 66! 9Vk^hdc EB# I]Z Y^hiVaan"WVhZY YdghVa bZiVXVgeVa VgiZgn ÒVe# 7g ? EaVhi Hjg\# &..%0)( & /'-Ã (.# (.# IgVc`aZ B! HVjZgW^Zg B! =Z^ibVcc 8! Zi Va# GZhidgVi^dc d[ i]jbW hZch^W^a^in l^i] i]Z ^ccZgkViZY Ñghi YdghVa bZiVXVgeVa VgiZgn ^haVcY ÒVe# ? =VcY Hjg\ P6bR# '%%(0'- * /,*-Ã,++# )%# Cnhigdb 6! ;g^YZc ?! A^hiZg lV^ B! Zi Va# >ccZgkViZY gVY^Va i]ZcVg ÒVe [dg hZchdgn gZXdchigjXi^dc d[ Ñc\Zgh# ? =VcY Hjg\ P6bR# &..+0'& ( /(,(Ã(-%# ,+# HX]b^Yi =B! AVco J# 8]^gjg\^hX]Z 6cVidb^Z YZg =VcY# CZl Ndg`/ I]^ZbZ KZgaV\! '%%(# ,,# Dbd`VlV H! B^ojbdid H! ;j`j^ 6! Zi Va# >ccZgkViZY gVY^Va i]ZcVg ÒVe XdbW^cZY l^i] gVY^Va [dgZVgb ÒVe igVch[Zg [dg i]jbW gZXdchigjXi^dc# EaVhi GZXdchig Hjg\# '%%&0&%, & /&*'Ã&*)# ,-# IhV^ IB! HVWVeVi]n HG! BVgi^c 9# GZkVhXjaVg^oVi^dc d[ V Ñc\Zg l^i] V i]ZcVg b^c^"[gZZ ÒVe# ? =VcY Hjg\ P6bR# &..&0&+ ) /+%)Ã+%+# ,.# O]Vc\ ;=! <jd NM! O]dc\ `Z\jX]^ G! CV`VbjgV I# HZXdcY YdghVa bZiVXVgeVa VgiZgn bjhXaZ ÒVe/ Vc VY_jcXi ^c i]Z igZVi" bZci d[ X]gdc^X e]VaVc\ZVa dhiZdbnZa^i^h# ? =VcY Hjg\ P6bR# '%%)0'. & /).Ã*(# ..#
39 &%.# IhV^ IB! BVi^`d ?9! 7gZ^YZcWVX] L! Zi Va# KZcdjh ÒVeh ^c Y^\^iVa gZkVhXjaVg^oVi^dc VcY gZeaVciVi^dc# ? GZXdc" hig B^Xgdhjg\# &.-,0( ' /&&(Ã&&.# &&%# Gdjm ?A# PKVhXjaVg^oZY WdcZ igVch[Zgh ^c i]Z lg^hi VcY ]VcYR# 8]^g BV^c# '%%(0'' ) /&,(Ã-*# &&&# =VZgaZ B! KVcYZejiiZ / i]Z VcVidb^XVa WVh^h d[ kVhXjaVg^oZY eZY^XaZ WdcZ \gV[ih WVhZY dc i]Z XVc^cZ Y^hiVa gVY^jh VcY jacV# ? =VcY Hjg\ P6bR# '%%%0'* & /()Ã)*# &'%# HjcV\VlV I! 7^h]de 6I! BjgVbVihj @# GdaZ d[ XdckZc" i^dcVa VcY kVhXjaVg^oZY WdcZ \gV[ih ^c hXVe]d^Y cdc" jc^dc l^i] VkVhXjaVg cZXgdh^h/ V XVc^cZ ZmeZg^bZciVa hijYn# ? =VcY Hjg\ P6bR# '%%%0'* * /-).Ã-*.# &'&# 9d^ @! DYV I! Hdd"=Zdc\ I! Zi Va# ;gZZ kVhXjaVg^oZY WdcZ \gV[i [dg cdcjc^dc d[ i]Z hXVe]d^Y# ? =VcY Hjg\ P6bR# '%%%0'* ( /*%,Ã*&.# &''# H]^c 6N! LZ^chiZ^c AE! 7^h]de 6I# @^ZcWdX`Èh Y^hZVhZ VcY \dji# ? =VcY Hjg\ P7gR# &...0') ( /(+(Ã(+*# &'(# c gZVa^in! l]Zc lZ e^cX] i]Z h`^c VcY igVXi! lZ XVc ^bV\^cZ i]Z XdbeaZiZ hjWXjiV" cZdjh VcY h`^c gZh]Ve^c\ ^c Vaa ZaZbZcih i]Vi lZ bdkZ VcY dWhZgkZ V[iZg igVXi^dc# Egdd[ d[ i]^h bVn WZ dWiV^cZY Wn h^bean bdk^c\ dcZÈh Ñc\Zgh/ Yjg^c\ ÒZm^dc! i]Z ÒZmdg iZcYdc bdkZh adc\^ijY^cVaan Vi aZVhi ' Xb ^c i]Z eVab d[ i]Z ]VcY Wji l^i]dji Vcn XjiVcZdjh igVchaVi^dc# ;dg YZXVYZh! i]Z hX^Zci^ÑX ZmeaVcV" i^dch [dg i]^h e]ZcdbZcdc lZgZ a^b^iZY id i]Z cdi^dc d[ k^gijVa heVXZ dg i]Z Zm^hiZcXZ d[ addhZ XdccZXi^kZ i^hhjZ! Wji i]Z W^dbZX]Vc^XVa [djcYV" i^dch [dg i]ZhZ i]Zdg^Zh lZgZ bdgZ i]Vc kV\jZ# >c i]Z eVhi *% nZVgh! gZhZVgX] ]Vh WZZc dc i]Z b^Xgd" hXde^X aZkZa0 i]Z \adWVa XdcXZei d[ bZhdhe]Zg^X" ^in ]Vh WZZc VWVcYdcZY# 6h i^bZ ]Vh \dcZ Wn! VcY Vh gZhZVgX]Zgh ]VkZ ZmVb^cZY i]ZhZ cdi^dch bdgZ XadhZan! cZl ]nedi]ZhZh ]VkZ ZbZg\ZY Xdc" XZgc^c\ i]Z dg\Vc^oVi^dc d[ i]Z hjWXjiVcZdjh i^hhjZh#&!'!(
LZ ]VkZ eZg[dgbZY .* k^YZd dWhZgkVi^dch l^i] [jcXi^dcVa VcVanhZh! Z^i]Zg Y^gZXian jcYZg i]Z h`^c dg XadhZ id iZcYdch! bjhXaZ! dg cZgkZh h]ZVi]h! Yjg^c\ hjg\^XVa ]jbVc Y^hhZXi^dch! jh^c\ a^\]i b^XgdhXden bV\c^ÑXVi^dc t'* # I]^h \a^Y^c\ dg ha^Y^c\ d[ i^hhjZ! l]^X] ^h igVY^i^dcVaan XVaaZY ÅXdccZXi^kZÆ dg ÅVgZdaVgÆ dg ÅaddhZ i^hhjZ VcY eVgViZcdc VgdjcY i]Z iZcYdch!Æ ]Vh WZZc [dg V adc\ i^bZ Xdch^YZgZY id WZ ÅeVX`^c\ i^hhjZ!Æ l]^X] Ñaah heVXZh WZilZZc VcY l^i]^c dg\Vch#>c gZVa^in!i]^h i^hhjZ ]Vh V bZX]Vc" ^XVa ÑcVa^in! Vaadl^c\ bdkZbZcih WZilZZc i]Z higjXijgZh ^i XdccZXih! egZhZgk^c\ bdW^a^in VcY ^cYZeZcYZcXZ WZilZZc dg\Vch VcY! ^c eVgi^" XjaVg! WZilZZc iZcYdch VcY h`^c# I]^h i^hhjZ ^h ^bedgiVci id i]Z cjig^i^dc d[ i]Z higjXijgZh ZbWZYYZY ^c ^i VcY Vh V [gVbZ [dg WaddY VcY anbe] kZhhZah# >ih bZX]Vc^XVa ^bedgiVcXZ ^h bV_dg0 ^i Y^b^" c^h]Zh [g^Xi^dc l]^aZ Vaadl^c\ ZVhn YZ[dgbVW^a" ^in# 8dbedhZY d[ ^ciZgil^c^c\ bjai^Y^gZXi^dcVa ÑaVbZcih! l]^X] XgZViZ eVgi^i^dch ZcXadh^c\ kVX" jdaVg h]VeZh! i]^h i^hhjZ ^h XVaaZY i]Z bjai^b^Xgd" kVXjdaVg XdaaV\Zcdjh VWhdgW^c\ hnhiZb BK86H id Zbe]Vh^oZ ^ih [jcXi^dcVa ^beVXi ;^\jgZ )"& # I]^h i^hhjZ ]Vh WZZc hijY^ZY kZgn a^iiaZ WZXVjhZ ^i ]VY WZZc ZmeaV^cZY ^c egZk^djh YZXVYZh Wn i]Z XdcXZei d[ k^gijVa heVXZ dg d[ Y^[[ZgZci [VhX^V gZeVgi^i^dc l^i] higVi^ÑXVi^dc ^cid hjeZgÑX^Va dg egd[djcY aVnZgh# c di]Zg ldgYh! ^ih gdaZ ^h id ZchjgZ i]Z YncVb^Xh d[ bdkZbZci VcY id gZh^hi i]Z h]dX`h i]Vi i]^h bdkZbZci XgZViZh# I]Z higjXijgZ Vahd ]Vh V bZbdgn hd i]Vi ^i gZijgch id ^ih ^c^i^Va edh^" i^dc WZilZZc bdkZbZcih ;^\jgZ )"' # I]Z h^YZh d[ i]Z kVXjdaZh! l]^X] VgZ ^ciZg" il^cZY! VgZ XdbedhZY d[ XdaaV\Zc ÑWZgh! bdhian ineZ > '( ! >>>! >K! VcY K># I]Zn VgZ dg\Vc^oZY dc hZkZgVa aZkZah ^c Y^[[ZgZci Y^gZXi^dch! Wji ]VkZ cd gZ\jaVg! WVh^X eViiZgc# I]Z^g Y^VbZiZg gVc\Zh [gdb V [Zl id hZkZgVa YdoZc b^XgdbZiZgh! VcY i]Zn kVgn ^c aZc\i]! i]jh \^k^c\ Vc dkZgVaa Y^h" dg\Vc^oZY! X]Vdi^X VeeZVgVcXZ# BV\c^ÑXVi^dc gZkZVah aViZgVa bdY^ÑXVi^dch d[ i]Z XdaaV\Zc
Figure 4-2. MVCAS under the electron microscope. a) Histological and collagenous continuity between the epitendon and MVCAS. b) Sketch of this organization, in vacuoles. c) 3D tissue supports. d) 3D vacuola. (A.D.F. Video-Productions with special permission)
43
ÑWZgh ^c i]Z kVXjdaZ! hj\\Zhi^c\ i]Z a^c`^c\ d[ egdiZd\anXVc X]V^ch# I]ZhZ kVXjdaZh XdciV^c V ]^\]an ]nYgViZY egdiZd\anXVc \Za ,% i]Vi XVc X]Vc\Z h]VeZ Yjg^c\ bdkZbZci Wji l]dhZ kdajbZ gZbV^ch XdchiVci# I]Z^g a^e^Y XdciZci ) ^h ]^\]# EgdiZd\anXVch VgZ egdiZ^ch i]Vi VgZ \anXd" hnaViZY Wn XdkVaZci ViiVX]bZci d[ ]^\]an Vc^dc^X \anXdhVb^cd\anXVch hja[ViZY edanhVXX]Vg^YZh # 6h V gZhjai d[ i]Z^g higdc\ cZ\Vi^kZ X]Vg\Z! \anXdhVb^cd\anXVch ViigVXi XdjciZg"^dch VcY lViZg bdaZXjaZh ^cid i]Z i^hhjZ# I]^h VW^a^in ZcYdlh egdiZd\anXVch l^i] i]Z^g jc^fjZ e]nh^" XVa X]VgVXiZg^hi^Xh! Vaadl^c\ i]Zb id Ñaa i]Z ^cigVkVXjdaVg heVXZh VcY id X]Vc\Z h]VeZ l]Zc gZfj^gZY# I]Z WdcYh WZilZZc i]Z XdaaV\Zc ÑWg^ah VcY i]Z egdiZd\anXVc"Zcg^X]ZY kVXjdaVg Òj^Y b^\]i WZ XdbedhZY d[ ineZ K> XdaaV\Zc! V jc^fjZ XdaaV\Zc i]Vi dXXjgh ^c i]Z [dgb d[ WZVYZY ÑaVbZcih VcY i]Vi ^h d[iZc [djcY Vi i]Z ^ciZg[VXZ WZilZZc ineZ > XdaaV\Zc VcY i]Z hjggdjcY^c\ ZmigVXZaajaVg bVig^m# IneZ K> XdaaV\Zc ^h XdbedhZY d[ Wdi] \adWjaVg YdbV^ch VcY V h]dgi! ig^eaZ"]Za^XVa YdbV^c +% cb adc\ ! VcY ^i VhhZbWaZh id [dgb V higjXijgZ gZhZbWa^c\ V eZVga cZX`aVXZ# 8daaV\Zc > ÑWg^ah Vahd ^ciZgVXi heZX^ÑXVaan l^i] hbVaa egdiZd\anXVch! hjX] Vh YZXdg^c! l]ZgZVh aVg\Z egdiZd\anXVch egdk^YZ ]nYgVi^dc VcY hlZaa^c\
44
egZhhjgZ! d[iZc ^c VhhdX^Vi^dc l^i] i]Z cdchja" [ViZY \anXdhVb^cd\anXVc ]nVajgdcVc# Dl^c\ id i]Z^g XVeVX^in id ViigVXi lViZg bdaZXjaZh! aVg\Z egdiZd\anXVc bdaZXjaZh Vaadl BK86H id gZh^hi XdbegZhh^dc! jca^`Z XdaaV\Zc ÑWg^ah! l]^X] gZh^hi iZch^dc Wn ZmiZcY^c\ VcY gZigVXi^c\ jcYZg bZX]Vc^XVa higZhh# I]Z XdaaV\Zc [gVbZldg` VcY i]Z ^cigVkVXjdaVg heVXZh \^kZ [dgb VcY hiVW^a^in id i]Z i^hhjZ#
Microvacuola Biomechanical Behavior: A Dynamic Absorbing System I^hhjZ VYVeiVi^dc id bZX]Vc^XVa higZhh ldjaY hZZb id ]VkZ ild VheZXih/ & Zchjg^c\ i]Z Xdb" eaZiZ bdkZbZci d[ i]Z iZcYdc VcY ' egZhZgk^c\ eZg^e]ZgVa i^hhjZ hiVW^a^in# =dl YdZh i]Z BK86H VXXdbea^h] i]ZhZ iVh`h4 I]Z hnhiZb d[ b^XgdkVXjdaVg cZildg`h! ^c he^iZ d[ ^ih X]Vdi^X VheZXi! ldg`h VXXdgY^c\ id V XZgiV^c cjbWZg d[ gjaZh#+
6 8]Vdi^X EViiZgc 9ncVb^X HnhiZb I]Z ÑWg^aaVg [gVbZldg` d[ i]Z kVXjdaZh ^h ehZj" Yd\ZdbZig^X! edan\dcVa! VcY iZcYh id WZ h^b^aVg id ehZjYd^XdhV]ZYgVa hd i]Vi ^i XVc bdY^[n ^ih h]VeZ VcY Ñaa heVXZ Vh ^i dXXje^Zh hjg[VXZh Vh Z[ÑX^Zcian Vh edhh^WaZ#6ai]dj\] i]Z \adWVa VheZXi d[ i]Z higjXijgZ ^h X]Vdi^X! i]Z ]^ZgVgX]^XVaan VggVc\ZY! [gVXiVaan h]VeZY kVXjdaZh [dgb aVg\Z ehZjYdedanZYgVa [gVbZldg`! l]^X] bVn heVc hZkZgVa eVgi^Va hjWjc^ih! VcY ZkZc h]^[i WVX` VcY [dgi]# I]Z gZhjai^c\ XdcÑ\jgVi^dc ^h ]^\]an Z[Ñ" X^Zci! XdbW^c^c\ \gZVi bZX]Vc^XVa higZc\i] VcY a^\]icZhh# I]^h ÒZm^WaZ! egZ"higZhhZY edan\dcVa VgX]^iZXijgZ ^h VWaZ id VhhjbZ bVcn h]VeZh! i]ZgZWn egdk^Y^c\ hiVW^a^in VcY ha^Y^c\! aZVY^c\ id WZiiZg bZiVWda^hb VcY i]ZgZ[dgZ egdadc\^c\ i]Z a^[Z d[ i]Z i^hhjZ# I]^h iZcYZcXn id \ZdbZig^X [dgbh ^h ^cig^\j^c\ WZXVjhZ ^i ^h [djcY ^c Vaa aZkZah d[ a^k^c\ bViiZg VcY hZZbh id WZ i]Z Wj^aY" ^c\ WadX` i]Vi ]Vh YZkZadeZY Yjg^c\ i]Z XdjghZ d[ Zkdaji^dc# >[ i]Z b^XgdkVXjdaVg hnhiZb ^h i]dj\]i d[ Vh V h]dX` VWhdgWZg! i]Z gZh^hiVcXZ ^i d[[Zgh ^h Ñghi b^c^bVa VcY i]Zc ^cXgZVhZh Vh i]Z adVY ^cXgZVhZh# CZkZgi]ZaZhh! Vh V h]dX` VWhdgWZg! ^ih [jcXi^dc ^h id bV^ciV^c i]Z eZg^e]ZgVa higjXijgZh XadhZ id! Wji cdi ^c XdciVXi l^i]! i]Z WdY^an VXi^dc ^c egd\gZhh# I]Z g]Zdad\^XVa gZaVi^dch]^e0 i]Vi ^h!
Tissue Surgery
i]Z adXVa gZaVi^dch]^e WZilZZc gZhigV^ci VcY Y^h" iZch^dc! XVccdi WZ Vc jca^b^iZY! a^cZVg! VcY ZaVhi^X hnhiZb! cdg XVc ^i WZ]VkZ eaVhi^XVaan l^i] V a^b^i^c\ eaViZVj# Dc i]Z XdcigVgn! ^i WZ]VkZh bdgZ a^`Z gjWWZg WZXVjhZ i]Z XdaaV\Zc ÑWZgh XVccdi WZ higZiX]ZY ^cYZÑc^iZan Wji bVn hjYYZcan gjeijgZ# I]ZgZ[dgZ! l]n i]Z kVXjdaZh XadhZhi id i]Z bdk^c\ higjXijgZ jcYZg\d bVm^bVa YZ[dgbVi^dc l]ZgZVh i]dhZ i]Z [Vgi]Zhi VlVn ]VgYan X]Vc\Z h]VeZ ^h V fjZhi^dc i]Vi gZbV^ch id WZ VchlZgZY ;^\jgZ )"( # I]Z ÑWZgh gZVggVc\Z i]ZbhZakZh ^c gZhedchZ id i]Z adXVa higZhh! i]ZgZWn ZmeaV^c^c\ i]Z hd"XVaaZY ÑcVa a^cZVg hi^[[Zc^c\ gZhjai^c\ [gdb i]Z Veea^XV" i^dc d[ i]Z higZhh/ Vh i]Z higZhh ^cXgZVhZh! i]Z ÑWZgh WZXdbZ bdgZ Va^\cZY ^c i]Z Y^gZXi^dc d[ i]Z higZhh# =dlZkZg! i]Z ZcZg\n hidgZY ^c i]Z ÑWZgh jcYZg iZch^dc \gVYjVaan WZXdbZh adlZg i]Z \gZViZg i]Z Y^hiVcXZ [gdb i]Z higZhh! hd i]Z [dgXZh gZhjai^c\ [gdb i]Z ehZjYda^cZVg hi^[[Zc^c\ VgZ VWhdgWZY! VcY i]Z higjXijgZh WZXdbZ hiVW^a^oZY# LZ gZ[Zg id i]^h cdi^dc Vh ÅXdbW^cZY igVchb^i" iZY VcY VWhdgWZY higZhhÆ0 i]Vi ^h! ZVX] ÑWZg ^h egZhigZhhZY VcY XdccZXiZY id ^ih cZ^\]Wdg^c\ ÑWZg Wn V bdaZXjaVg VY]Zh^kZ a^c`# L]Zc iZch^dc ^h Veea^ZY id i]Z a^c`! i]Z VY_VXZci ZaZbZci jcYZg" \dZh iZch^dc VcY YZXgZVhZh ^c h^oZ a^iiaZ Wn a^iiaZ jci^a ^i YZ[dgbh# 6aa d[ i]Z XdbedcZci eVgih i]Zc ijgc hd Vh id WZ dg^ZciZY Vh [Vg Vh edhh^WaZ ^c i]Z Y^gZXi^dc d[ i]Z Veea^ZY [dgXZ! l]^X] ^h XdcigdaaZY id Vkd^Y gjeijgZ# I]^h ^ciZgeaVn WZilZZc kVXj" daZh VcY ÑWg^ah XgZViZh bZX]Vc^XVa hiVW^a^in WZilZZc i]Z [dgXZh d[ adXVa XdbegZhh^dc VcY dkZgVaa iZch^dc# I]Z gZhjai^c\ ZfjVi^dc ^h dcZ d[ Zfj^a^Wg^jb! bV^ciV^c^c\ h]VeZ! VcY igVchb^h" h^dc d[ ^c[dgbVi^dc# I]Vc`h id i]ZhZ ZmeaVcVi^dch! ^i ^h ZVh^Zg id jcYZghiVcY ]dl i]Z ha^Y^c\ hnhiZb WZilZZc bVcn iZcYdch ^ch^YZ i]Z Xdbbdc XVgeVa h]ZVi] egdk^YZh XdbeaZiZ ^cYZeZcYZcXZ WZilZZc i]Z iZcYdch d[ ZVX] Ñc\Zg#
BK86H VcY cYZZY! i]ZgZ ^h cd heVXZ dg lVaa l]ZgZ ^i ^h cdi id WZ [djcY# :kZc higjX" ijgZh hjW_ZXi id a^iiaZ bdkZbZci! hjX] Vh cZgkZh VcY i]Z eZg^dhiZjb!VgZ hjggdjcYZY Wn i]^h ÑWg^a" aVg i^hhjZ cZildg`! Wji l^i] Y^[[ZgZcXZh ^c i]Z cZildg` ^ihZa[ VcY ^c i]Z h^oZ d[ i]Z kVXjdaZh# >cYZZY! ^i hZZbh i]Vi BK86H dXXjgh ZkZgn" l]ZgZ ^c i]Z WdYn VcY i]Vi ^i Vaadlh higjXijgZh id VYVei Z^i]Zg id ^ciZgcVa XdchigV^cih dg id i]Z ZmiZgcVa Zck^gdcbZci# HZZc ^c i]ZhZ iZgbh! i]Z l]daZ higjXijgZ d[ i]Z WdYn bVn WZ Xdch^YZgZY Vh Vc ^bbZchZ XdaaV\Zc cZildg`! Y^[[Zg^c\ VXXdgY^c\ id i]Z gdaZh ^i bjhi eZg[dgb VcY i]Z higZhhZh ^i bjhi jcYZg\d# >c [VXi! BK86H VcY i]Z ]jbVc WdYn ldjaY hZZb id WZ dcZ VcY i]Z hVbZ i^hhjZ# A^k^c\ bViiZg ]Vh YZkZadeZY l^i]^c i]Z [gVbZldg` d[ V bjai^b^XgdkVXjdaVg X]Vdi^X hnhiZb! ^cXajY^c\ ZkZgn XZaa- VcY ]Vh VXfj^gZY V [dgb i]Vc`h id e]nh^XVa [dgXZh. l]^X] ]VkZ hjW" _ZXiZY ^i id Vc ^cXgZVh^c\ XdbeaZm^in l^i]^c i^bZ VcY heVXZ#
BK86H 6[iZg IgVjbV dg EVi]dad\n I]^h ha^Y^c\ i^hhjZ ^h hjeedhZY id ZkdakZ! VcY ZVX] i^bZ i]ZgZ ^h V X]Vc\Z ^c i]Z bZX]Vc^XVa Xdc" higV^ci egZhhjgZ! lZ^\]i! iZbeZgVijgZ! V\Z^c\ !
i]ZgZ ^h V e]nh^dad\^XVa gZhedchZ VcY VYVeiVi^dc id i]Z cZl bZX]Vc^XVa h^ijVi^dc# I]Z BK86H ^h V kZgn [gV\^aZ i^hhjZ i]Vi ^h WVhZY dc V egZX^hZ WVaVcXZ WZilZZc i]Z [gVbZ! XdbedhZY d[ XdaaV\Zc bdaZXjaZh! VcY i]Z ^ch^YZ d[ i]Z kVXjdaV d[ \anXda^XVch jcYZg egZhhjgZ# =dlZkZg! Vh i]Z bZX]Vc^XVa higZhhZh X]Vc\Z! Vh i]Z eVi]dad\^Zh VeeZVg VcY jc[dgZhZZVWaZ cZZY Vg^hZh id VYVei! di]Zgh [VXidgh hjX] Vh ^cÒVbbV" i^dc! ZYZbV! V\^c\! igVjbV! dWZh^in ^ciZgkZcZ id XgZViZ X]Vc\Zh ^c h]VeZ ;^\jgZ )") # :YZbV ^h i]Z h^beaZhi hiViZ d[ V\\gZhh^dc# >i XVc WZ VXXdbbdYViZY l^i] ^cigVkVXjdaVg ]neZg" egZhhjgZ VcY XdaaV\Zc^X Y^hiZch^dc VcY l^i]dji Vcn dg\Vc^X i^hhjZ YZhigjXi^dc# 7ji i]Z ÑWg^aaVg Y^higVXi^dc XVjhZY Wn ^cigVkVXjdaVg ]neZg" egZhhjgZ ^h i]Zc jcVWaZ id Y^hiZcY [jgi]Zg! VcY Vh V XdchZfjZcXZ! id ^chjgZ bdkZbZci# i ^h cdi hjYYZc X]Vc\Z Wji gVi]Zg hadl VcY egd\gZhh^kZ X]Vc\Z ^c i]Z e]nh^XVa WVaVcXZ d[ [dgXZh ^ch^YZ ]jbVc i^hhjZ# 6\Z^c\! WZXVjhZ d[ i]Z adhh d[ ^ciZgcVa WVh^X fjVa^i^Zh d[ i]Z B8K6H! ^h i]Z bVc^[ZhiVi^dc d[ i]Z \gVk^iVi^dcVa ÅgZkZc\ZÆ dc i]Z BK86H ^ciZgcVa egZ"iZch^dc# I]^h ^h cdi i]Z XVhZ [dg dWZh^in! l]^X] XVc WZ V XVhjVa X^gXjbhiVcXZ# >i ^h ZVhn id jcYZghiVcY i]Vi i]Z kVXjdaV ^h ÑaaZY Wn VY^edXniZh gZeaVX^c\ \anXda^XVch# 6i i]Z WZ\^cc^c\! kVXjdaV VcY ÑWZgh VgZ ^c Y^hiZch^dc! bdkZbZci ^h hadlZY! VcY \gVk^" iVi^dc WZXdbZh bdgZ ^bedgiVci# 7ji i]^h Ñghi hiV\Z ^h gZkZgh^WaZ! i]Vc`h id V egd\gZhh^kZ adhh d[ lZ^\]i! l]^X] bjhi cdi WZ idd fj^X`# >c i]Z hZXdcY hiV\Z! lZ^\]i ^h ^cXgZVh^c\! VcY kVXjdaV VgZ ^c ZmigZbZ Y^aViVi^dc# I]Zc! ÑWZgh VgZ cdi dcan ^c Y^hiZch^dc Wji WZXVjhZ d[ i]Z Z[[ZXih d[ \gVk^iVi^dc! i]Zn VgZ ^c Y^aVXZgVi^dc VcY ^c hZVgX] d[ V bZ\VkVXjdaV igVch[dgbVi^dc! l]^X] ^c ijgc l^aa WZ ÑaaZY Wn VY^edXniZh# Hd! WdYn [dgb X]Vc\Zh l^i] dWZh^in# 6i i]^h hiV\Z! V gZijgc id i]Z dg^\^cVa bdge]dad\n ^h ^bedhh^WaZ!
VcY dcan hjg\Zgn l^aa gZXgZViZ i^hhjZ iZch^dc Wn gZhZXi^c\ ZmXZhh h`^c VcY [Vi#
6cVidb^XVa 8dcXajh^dch I]^h cZl XdcXZei d[ BK86H ZcVWaZh jh id Y^hXjhh hdbZ WVh^X VcY igVY^i^dcVa Vhhjbei^dch VWdji i]Z cVijgZ d[ i^hhjZ VcY! eVgi^XjaVgan ^c ]VcY VcVidbn! id Y^hXjhh e]nh^dad\n VcY gZXdchigjX" i^kZ hjg\Zgn# HdbZ igVY^i^dcVaan ]ZaY XdcXZeih VgZ Vi kVg^VcXZ l^i] VcVidb^XVa gZVa^in VcY h]djaY WZ X]Vc\ZY# I]Z i^bZ ]Vh XdbZ id XdcÑgb hdbZ VcVidb^XVa igji]h VcY id Y^hXVgY YZÑc^i^kZan XZgiV^c egZXdcXZ^kZY ^YZVh VWdji i]Z ]VcY# ;dg ZmVbeaZ!i]Z i^bZ"]dcdjgZY aVndji d[ i]Z h]ZVi]h ^c i]Z ]VcY bjhi WZ XdbeaZiZan gZXdch^YZgZY# I]Z cdi^dc d[ V ]^hidad\^XVa Y^[[ZgZcXZ WZilZZc i]Z eVgViZcYdc VcY i]Z XVgeVa h]ZVi]! VcY i]Z igVY^i^dcVaan VXXZeiZY cdi^dc d[ V e^hidc bVX]^cZ bZX]Vc^hb [dg ha^Y^c\ e]ZcdbZcdc bjhi Vahd WZ gZXdch^YZgZY# L]Zc i]^h egZhhjgZ ^cXgZVhZh! i]Z WVaVcXZ ^h Y^hijgWZY! VcY i]Z hnhiZb gZhedchZ ^h V X]Vc\Z ^c V W^\ kVXjdaV l^i] YZhigjXi^dc dg adXVa Y^hiZc" h^dc d[ i]^h XdaaV\Zc^X [gVbZ! l]^X] ^h jcVWaZ id gZh^hi i]Z egZhhjgZ# L]Zc i]^h ]neZgegZhhjgZ ^h XVjhZY Wn Vc ^ciZgcVa h^ijVi^dc! hjX] Vh V
Subcutaneous Tissue Function: The Multimicrovacuolar Absorbing Sliding System in Hand and Plastic Surgery
a^\VbZci Wji Vahd Wn gZeZi^i^kZ ZmiZgcVa bdkZ" bZcih ! i]Z ÑWg^aaVg [gVb^c\ gjeijgZh! Y^aViZh! VcY i]Zc WZXdbZh Y^ajiZY# 6aa d[ i]ZhZ odcZh l^i] W^\\Zg kVXjdaVg dg\Vc^oVi^dch i]Zc _d^c bVcn di]Zgh! [dgb^c\ V bZ\VkVXjdaV l^i] XZaa bZiVeaVh^V Vi i]Z ^ccZg hjg[VXZ! cZl W^dbZX]Vc" ^XVa gZhedchZ bdgZ VYVeiZY [dg egZhZgk^c\ ajWg^" ÑXVi^dc! \a^Y^c\! VcY VYVeiZY kdajbZh# I]^h igVch[dgbVi^dc XVc WZ dWhZgkZY Vaa Vadc\ i]Z ÒZmdg dg ZmiZchdg iZcYdc h]ZVi]h# LZ XVc ÑcY ) WVh^X ineZh d[ BK86H igVch[dg" bVi^dch ;^\jgZ )"* / &# IneZ > ^h i]Z WVh^X ha^Y^c\ hnhiZb hjggdjcY^c\ Vaa i]Z iZcYdch! l^i]dji Vcn ZmiZgcVa bZX]Vc" ^XVa higZhh# '# IneZ >> h]dlh V bZ\VkVXjdaV ^ckdak^c\! Wji WaddY hjeean ^h hi^aa egZhZgkZY ^c egdiZXiZY VgZVh# (# IneZ >>> ^h jcYZg higdc\ XdchigV^cih l^i] V W^\ bZ\VkVXjdaV! VcY dcan V [Zl odcZh [dg WaddY hjeean! i]Vc`h id k^cXjaV# )# IneZ >K ]Vh cd ZmiZgcVa WaddY hjeean# I]^h igVch[dgbVi^dc XVc WZ Vahd dWhZgkZY Yjg^c\ V ]jbVcÈh a^[Z# 6i i]Z edhiZg^dg [VXZ d[ i]Z ZaWdl i]Z daZXgVcdc ! ]n\gdbV XVc WZ cdi^XZY! VcY ]n\gdbV ^h V igVch[dgbVi^dc d[ i]Z BK86H dg\Vc^oVi^dc XVjhZY Wn YV^an gZeZi^i^kZ ZmiZgcVa egZhhjgZ Vaa a^[Z adc\#
47
I]^h igVch[dgbVi^dc XVc Vahd WZ dWhZgkZY l]Zc YgV^c^c\ aVg\Z XdaaZXi^dch d[ hjWVWYdb^" cVa anbe]dXZaZh V [Zl lZZ`h V[iZg eVg^Zid" VWYdb^cVa ]ZbVidbV# I]Z W^\ XVk^in i]Vi gZhjaih ^h V bZ\VkVXjdaV l^i] ^ccZg bZiVeaVh^V# 8dcigVgn id egZk^djh gZedgih! i]Z ZmiZch^dc d[ i]Z Y^\^iVa kVhXjaVg hnhiZb ^h cdi aZhh Z[[ZXi^kZ# >i VYVeih ^ihZa[ ^c V kZgn Y^[[ZgZci bVccZg! hd i]Vi kVhXjaVg Òdl eZgh^hih#I]^h ^h eVgi^XjaVgan i]Z XVhZ ^c i]Z Y^\^iVa XVcVa! l]ZgZ i]Z ]nedi]Zh^h i]Vi i]Z iZcYdc ^h aZhh lZaa kVhXjaVg^oZY VcY [gV\^aZ ^h ^cXdggZXi# I]Z bZi]dY d[ [jcXi^dc^c\ ^h h^bean Y^[[ZgZci Vh V gZhjai d[ X^gXjbhiVcXZh ^c i]Z Y^\^iVa XVcVa! l]ZgZ iZcYdc igVXi^dc egdYjXZh Vgi^XjaVg ÒZm^dc# I]Z gZaVi^dch]^e WZilZZc iZcYdc bdkZ" bZci VcY i]Z gZhjai^c\ Y^\^iVa bdge]dad\n ^h \ZdbZig^XÄVabdhi a^cZVgÄVcY ^h kZgn Y^[[ZgZci [gdb i]Z h^ijVi^dc i]Vi eZgiV^ch ^c i]Z eVab# ;jgi]ZgbdgZ! i]^h Y^\^iVa bdkZbZci XgZViZh hjYYZc ]^\] egZhhjgZ l^i] VciZg^dg XdbegZhh^dc odcZh i]Vi VgZ ^cXdbeVi^WaZ l^i] V kVhXjaVg Ze^" iZcY^cZjb hnhiZb# >[ i]Z eVabVg hnhiZb lZgZ id Zm^hi ^c i]Z Y^\^i! ^i ldjaY aZVY id ^cigVhncdk^Va WaZZY^c\# I]ZgZ[dgZ! i]Z kZhhZah bjhi WZ YdghVaan edh^i^dcZY! i]Z hjeean cZildg` WZ^c\ a^b^iZY id i]Z egdiZXiZY odcZh i]Vi VgZ cZVg i]Z Vgi^XjaVg odcZh VcY XVc i]ZgZ[dgZ VXXdbbdYViZ iZcYdc ZmXjgh^dc! Vkd^Y^c\ i]Z hig^XijgZ VcY XdbegZh" h^dc i]Vi ldjaY dXXjg ^[ i]Z kZhhZah lZgZ VciZg^" dgan eaVXZY! _jhi YZZe id i]Z _d^ci ÒZm^dc [daY#
a
Figure 4-5. a) The MVCAS disappears in its basic network under mechanical constraint and adapts to the new situation with a megavacuola response. b) Different MVCAS distributions in the common carpal sheath. c) The digital canal is an efficient adaptation of the MVCAS as a megavacuola with vincula: type III. d) A proposed new layout of the sliding sheaths in the finger flexor system. (A.D.F. VideoProductions with special permission)
b
c
d
48
Tissue Surgery
a
b
I]ZgZ VgZ i]gZZ _d^cih VcY i]gZZ k^cXjaV# >c [VXi ^c AVi^c! ^i ldjaY WZ k^cXjaVZ# I]Z kVhXjaVg VcVidbn ZchjgZh i]Z Y^\^iVa iZcY^cdjh WaddY hjeean jcYZg ZmigZbZ W^dbZX]Vc^XVa higZhh# I]Z hjeean ^h XdbeVgVWaZ id V h`^c higjXijgZ! VcY djg XdbejiZg^oZY hijY^Zh gZeZViZYan X]VaaZc\Z i]Z ]nedi]ZhZh i]Vi egdedhZ aZhh lZaa kVhXjaVg^oZY odcZh ^c i]Z ÒZmdg iZcYdc# IZcYdc VcY Ze^iZcdc kVhXjaVg^oVi^dch VgZ Xdci^cjdjh# I]Z cdi^dc d[ iZcYdc ]nedkVhXjaVg^oVi^dc ^h edejaVg! Wji ^ih edejaVg^in ^h lVc^c\! VcY id Xdc" i^cjZ id WZa^ZkZ ^c ^i Xdbegdb^hZh djg k^h^dc d[ iZcY^cdjh kVhXjaVg^in# I]Z igjZ h^ijVi^dc XVc WZ kZg^ÑZY Wn add`^c\ Vi i]Z hZfjZci^Va e^XijgZh d[ iZcYdc kVhXjaVg^oV" i^dc ^c odcZh >>>! >K! VcY K! h]dl^c\ gZVa WaddY Òdl ;^\jgZ )"+ # A^`Z ZkZgn dg\Vc! i]Z kVhXjaVg^oVi^dc d[ i]Z iZcYdc ]Vh VYVeiZY id ^ih [jcXi^dc# I]Z cdi^dc d[ i]Z cVijgZ d[ bZX]Vc^XVa [jcXi^dc WZilZZc i]Z Y^\^iVa h]ZVi] VcY i]Z XVgeVa h]ZVi] VcY i]Z cdi^dc d[ i]Z egZeji^Va hig^c\ Vahd ]VkZ id WZ YZZean Y^hXjhhZY# KVhXjaVg^oVi^dc ^h Xdci^cjdjh VcY eZgbVcZci# I]ZgZ ^h cd VgZV l^i]dji WaddY hjeean# IZcYdc! Ze^iZcdc! VcY BK86H VgZ hjeea^ZY Wn i]Z hVbZ kVhXjaVg hnhiZb# IZcYdch VgZ cdi ]nedkVhXjaVg# 6aa d[ i]ZhZ dWhZgkVi^dch VgZ ^ccdkVi^kZ! ^c i]Vi i]Zn ^cigdYjXZ V cZl XdcXZei/ i]Z ha^Y^c\ jc^i XdbedhZY d[ i]Z iZcYdc VcY ^ih hjggdjcY^c\ h]ZVi]h#
Figure 4-6. Vascularization is continuous and permanent. a) Tendons are not hypovascular. Like every organ, vascularization is adapted to its function. b) Bleeding of the flexor profundus at A3 pulley level. (A.D.F. Video-Productions with special permission)
Djg [dgZ\d^c\ dWhZgkVi^dch! l]^X] VgZ Zk^" YZcXZ d[ gZVa ]^hidad\^XVa Xdci^cj^in WZilZZc i]Z eVgViZcdc! i]Z Xdbbdc XVgeVa h]ZVi]! VcY i]Z ÒZmdg iZcYdch! h]dl i]Z eZg[ZXi kVhXjaVg^oVi^dc d[ i]^h [jcXi^dcVa ZchZbWaZ# ;gdb cdl dc! Vcn ^cXa^cVi^dc id VXXZei EdiZcoVÈh eg^cX^eaZ!iZcYdc VY]Zh^dch!VcY gZXdc" higjXi^dc d[ i]Z Y^\^iVa h]ZVi] jh^c\ V h^a^Xdc gdY h]djaY \^kZ lVn id di]Zg eg^cX^eaZh/ 6 iZcYdc ]Vh dei^bVa [jcXi^dc dcan l]Zc ^i ^h hjggdjcYZY Wn ^ih dg^\^cVa ha^Y^c\ h]ZVi] VcY ^ih kVhXjaVg ]Zg^iV\Z# 6 iZcYdc dcan VY]ZgZh l]Zc ^i ^h Vgi^ÑX^Vaan hZeVgViZY [gdb ^ih dlc ha^Y^c\ h]ZVi] dg l]Zc i]Z ]Vgbdcn WZilZZc i]Z iZcYdc VcY i]Z h]ZVi] ]Vh WZZc ^ciZggjeiZY# 6 iZcYdc ^h dcan dcZ d[ i]Z ^ciZgkZc^c\ ZaZ" bZcih ^c i]Z igVchb^hh^dc d[ V [dgXZ i]gdj\] i]Z ha^Y^c\ jc^i# ;dg odcZh >>>! >K! VcY K! lZ lVciZY id YZÑcZ V Y^[[ZgZci gdaZ [dg i]Z iZcYdc! ^c i]Z gZVa^oVi^dc VcY i]Z igVchb^hh^dc d[ V [dgXZ# I]Z iZcYdc ^h cdi V igVchb^hh^dc WZai VXi^c\ ^c i]Z XVgeVa h]ZVi] hjggdjcYZY Wn V k^gijVa heVXZ0 cdg ^h ^i Vc dg\Vc i]Vi ^h VkVhXjaVg dg dcan kZgn ha^\]ian kVh" XjaVg^oZY# I]Z iZcYdc ^h cdi cdjg^h]ZY Wn i]Z hncdk^Va Òj^Y Wji Wn ^ih dlc kVhXjaVg hnhiZb! a^`Z ZkZgn dg\Vc# I]Z iZcYdc ^h dcZ d[ i]Z bV^c Xdchi^ijZci ZaZbZcih! Wji ^i XVc cd adc\Zg WZ Y^h" VhhdX^ViZY [gdb ^ih h]ZVi]! i]Vc`h id BK86H#
Subcutaneous Tissue Function: The Multimicrovacuolar Absorbing Sliding System in Hand and Plastic Surgery
49
E]nh^dad\^XVa 8dcXajh^dch
Hjg\^XVa 8dcXajh^dch
I]ZgZ ^h cd ]^hidad\^XVa Y^[[ZgZcXZ WZilZZc i]Z eVgViZcYdc VcY i]Z XVgeVa h]ZVi]# I]Z VcX^Zci iZgb eVgViZcYdc i]jh ^cXajYZh i]Z l]daZ d[ i]Z eZg^e]Zg^X ha^Y^c\ hnhiZb XVaaZY bjai^b^Xgd" kVXjdaVg XdaaV\Zc^X VWhdgW^c\ hnhiZb! l]^X] ^h bVYZ d[ W^aa^dch d[ b^XgdkVXjdaVh VcY ÑWZgh [gVbZ# I]Z BK86H ^h i]Z egdm^bVa ]^hidad\^XVa Xdci^cjVi^dc d[ i]Z eZg^bnh^jb egd[jcYjh aVnZg! VcY ^i Y^[[ZgZci^ViZh [jcXi^dcVaan id WZXdbZ i]Z Y^\^iVa h]ZVi]# >c [VXi! ^i ^h i]Z hVbZ higjXijgZ hZZc [gdb Y^[[ZgZci VheZXih jcYZg Y^[[ZgZci bZX]Vc^XVa X^gXjbhiVcXZh# 6h hddc Vh Vc ZmiZg" cVa dg ^ciZgcVa [VXidg ^cXgZVhZh ^ciZgcVa egZh" hjgZ! i]Z Y^hig^Wji^dc X]Vc\Zh ^c V bZ\VkVXjdaV! l^i] V hZaZXi^kZ WaddY eZY^XaZ ^c egdiZXiZY VgZVh# I]Z cdi^dc d[ V e^hidc bVX]^cZ bZX]Vc^hb ^h [VahZ VcY dWhdaZiZ VcY bjhi WZ gZeaVXZY Wn V hnhiZb^X XdcXZei# I]ZgZ ^h cdi V YjVa^in WZilZZc i]Z kVhXjaVg hnhiZb ^c i]Z iZcYdch VcY V eZg^e]ZgVa hncdk^Va kVhXjaVg hnhiZb l^i]dji Xdbbjc^XVi^dc# I]Z Y^\^iVa XVcVa ^h Vc Z[ÑX^Zci VYVeiVi^dc d[ i]Z BK86H Vh V bZ\VkVXjdaV l^i] k^cXjaV hnhiZb# Hd i]Z Y^\^iVa VcY XVgeVa h]ZVi]h Yd cdi ]VkZ i]Z hVbZ ha^Y^c\ hnhiZb#
KVhXjaVg^oZY ;aZmdg IZcYdc >haVcY ;dgZVgb IgVch[Zg# I]^h cZl bVccZg d[ jcYZghiVcY^c\ i]Z iZcYdc e]nh^dad\n ^cigdYjXZh V XdbeaZiZan Y^[[ZgZci XdcXZei d[ gZXdchigjXi^dc/
Figure 4-7. The transfer of a sliding flexion unit composed of a flexor tendon and its surrounding sheaths in a reverse island pedicled manner. 1st stage: Mesotendon identification. 2nd stage: Section of FSIVth flexor sublimis of the ring finger and ulnar pedicle. Island ulnar tendon transfer isolated. 3rd stage: Insertion of the island transfer into digital zone. 4th stage: Tendon sutures outside of the No Man’s Land and pulley reconstruction. (A.D.F. VideoProductions with special permission)
>i Zbe]Vh^oZh i]Z iZcYdc"h]ZVi] XdjeaZ VcY i]Z bV_dg gdaZ d[ iZcYdc kVhXjaVg^oVi^dc l^i] eZg^e]ZgVa XdaaV\Zc dg\Vc^oVi^dc# >i ^h ^che^gZY Wn W^dad\^XVa XdchZfjZcXZh VcY egdedhZh i]Z igVch[Zg d[ V ha^Y^c\ jc^i Xdb" edhZY d[ V ÒZmdg iZcYdc VcY ^ih hjggdjcY^c\ h]ZVi]h ^c V gZkZghZ"^haVcY"eZY^XaZ bVccZg ^c dcZ h^c\aZ deZgVi^dc! i]jh Vkd^Y^c\ i]Z ild"hiV\Z egdXZYjgZ [dg hZXdcYVgn gZeV^g ;^\jgZ )", # I]^h cZl iZX]c^fjZ ^h jhZY idYVn ^c Xa^c^XVa XVhZh id gZXdchigjXi Ñc\Zg ÒZmdg hnhiZbh ^c \gVYZh >>> VcY >K d[ 7dnZhÈh XaVhh^ÑXVi^dc# Ild WVh^X eg^cX^eaZh d[ i]^h cZl XdcXZei ]VkZ id WZ gZheZXiZY# I]Vi ^h! i]Z iZcYdc XVc dcan WZ XdcXZ^kZY d[ & Vh kVhXjaVg^oZY! VcY ' Vh Vc ZaZbZci ^c VhhdX^Vi^dc l^i] ^ih hjggdjcY^c\ h]ZVi]h id [dgb V ha^Y^c\ jc^i# Id Xdc[dgb id i]ZhZ ild WVh^X eg^cX^eaZh! i]Z egdedhZY cZl iZX]c^fjZ bjhi hVi^h[VXidg^an VchlZg i]gZZ WVh^X fjZhi^dch/
1st stage
2nd stage
3rd stage
4th stage
50
Tissue Surgery
1st stage
2nd stage
3rd stage
&# L]^X] ha^Y^c\ odcZ bjhi WZ jhZY id gZeaVXZ odcZh > VcY >>! hjW_ZXi id hd bVcn egdWaZbh VcY Xdbea^XVi^dch4 I]Z bZhdiZcdc VcY ^ih kVhXjaVg WgVcX]Zh egdk^YZ gZVa kVhXjaVg^oVi^dc d[ i]Z ÒZmdg iZcYdc VcY i]Z ha^Y^c\ XVgeVa h]ZVi]! Wdi] Zmig^ch^XVaan VcY ^cig^ch^XVaan# I]Z higjXijgZ i]jh igVch[ZggZY ^h V gZVa ha^Y^c\ higjXijgZ i]Vi VagZVYn Zm^hih ^c V cVijgVa hiViZ ^c odcZh >>>! >K! VcY K# I]Z eg^cX^eaZ ^h id gZeaVXZ i]Z Y^\^iVa ha^Y^c\ odcZh > VcY >>! i]Z bdhi [gZfjZcian gZXdchigjXiZY odcZh! Wn i]Z cVijgVa ha^Y^c\ odcZh d[ i]Z lg^hi VcY i]Z eVab! i]Vi ^h! odcZh >>>! >K! VcY K# 7ZXVjhZ i]Z iZcYdc jhZY [dg i]Z gZXdchigjXi^dc ^h igVch" [ZggZY l^i] ^ih dlc h]ZVi]! ^i YdZh cdi cZZY VY]Z" h^dc l^i] i]Z cZ^\]Wdg^c\ i^hhjZ id hjgk^kZ! VcY Vcn VY]Zh^dc [dgbVi^dc ^h gZYjXZY! aZVY^c\ id ^begdkZY [jcXi^dcVa gZhjaih# EdiZcoVÈh WVh^X eg^cX^eaZ d[ i]Z VWhdajiZ cZXZhh^in [dg VY]Zh^dc XVc i]jh WZ Y^hXVgYZY# I]Z ild"hiV\Z egdXZYjgZ ^h cdl Xdch^YZgZY dWhdaZiZ# ;jgi]ZgbdgZ! i]Z igVch[ZggZY iZcYdc ^h V gZVa ÒZmdg iZcYdc l^i] Vaa ^ih dg^\^cVa fjVa^i^Zh d[ gZh^hiVcXZ VcY ÒZm^W^a^in# IZX]c^XVaan! i]Z hjijgZh VgZ eaVXZY djih^YZ ÅCd BVcÈh AVcY!Æ VcY i]Z ha^Y^c\ jc^i! XdbedhZY d[ i]Z iZcYdc VcY i]Z XVgeVa h]ZVi]! ^h ^chZgiZY WZilZZc ejaaZnh 6& VcY 6)#
4th stage
Figure 4-8. 1st stage: The mesotendon and ulnar artery branches. Flexor superficialis section at the tendinomuscular junction and at the level of decussation. 2nd stage: The flexion sliding unit after revascularization. 3rd stage: Forward translation of the sliding unit transfer. 4th stage: Before inserting and pulley reconstruction. (A.D.F. Video-Productions with special permission)
'# L]Vi l^aa WZ i]Z kVhXjaVg^oVi^dc d[ i]Z gZeaVXZ" bZci ÒZm^dc higjXijgZ4 KVhXjaVg^oVi^dc ^h ZchjgZY Wn V egZgZi^cVXjaVg bZhdiZcdc! l^i] WgVcX]Zh ^hhj^c\ [gdb i]Z jacVg VgiZgn ;^\jgZ )"- # 6cVidb^XVa gZb^cYZg/ Vi i]Z ^c[Zg^dg i]^gY d[ i]Z lg^hi! _jhi WZ[dgZ i]Z ÒZmdg gZi^cVXjajb XVge^ dg i]Z VccjaVg a^\VbZci! i]Z jacVg VgiZgn \^kZh d[[ ild dg i]gZZ WgVcX]Zh VWdji & bb ^c Y^VbZ" iZg# I]ZhZ WgVcX]Zh eVhh i]gdj\] i]Z Xdbbdc XVgeVa h]ZVi] idlVgY i]Z hjeZgÑX^Va ÒZmdg iZcYdch! ZheZX^Vaan i]dhZ d[ i]Z b^YYaZ Ñc\Zg! i]Z g^c\ Ñc\Zg! VcY i]Z a^iiaZ Ñc\Zg! Wn lVn d[ V ÑcZ igVcheVgZci bZhdiZcdc! l]^X] VXih Vh V bZhZciZgn# I]^h kVhXjaVg VeegdVX] id i]Z ÒZmdg hnhiZb VcY i]Z Xdbbdc XVgeVa h]ZVi] ^h bVYZ Y^hiVa id i]Z iZcYdc"bjhXaZ _jcXi^dc! i]jh eZg" b^ii^c\ i]Z VYVeiVi^dc d[ i]Z XdcXZei d[ gZigd" \gVYZ ^haVcY igVch[Zgh id ejgZan iZcY^cdjh higjXijgZh# I]^h kVhXjaVg^oVi^dc ^h dcZ d[ i]Z eg^cX^eVa Y^[[ZgZcXZh [gdb i]Z gVY^Va VgiZgn"WVhZY ÒVe WZXVjhZ ^i ^h YZkZadeZY ^c i]Z iZcYdc odcZ VcY cdi ^c i]Z bjhXaZ odcZ# EjgZan iZcY^cdjh igVch" [Zgh XVc WZ [djcYZY dc i]Z XdcXZei d[ kVhXjaVg" ^oZY iZcYdc ^haVcY igVch[Zgh! l]^X] gZegZhZcih V [jcYVbZciVa X]Vc\Z ^c i]Z XdcXZei d[ iZcYdc gZXdchigjXi^dc#
Subcutaneous Tissue Function: The Multimicrovacuolar Absorbing Sliding System in Hand and Plastic Surgery
6XXdgY^c\ id i]Z hVbZ eg^cX^eaZ! VcY jh^c\ i]Z hVbZ hjg\^XVa iZX]c^fjZ! ^i ^h edhh^WaZ id XVggn dji cdi dcan ejgZ iZcY^cdjh kVhXjaVg igVch[Zgh bdhi d[iZc l^i] i]Z hjeZgÑX^Va ÒZmdg iZcYdc d[ i]Z g^c\ Ñc\Zg ! Wji Vahd V XjiVcZd"iZcY^cdjh igVch[Zg! VcY ZkZc i]Z ig^eaZ igVch[Zg d[ h`^c! iZcYdc! VcY WdcZ# (# =dl l^aa i]^h ha^Y^c\ jc^i WZ eaVXZY ^cid ÅCd BVcÈh AVcYÆ4 CdlVYVnh! i]Z iZX]c^fjZ d[ ^haVcY gZigd\gVYZ [dgZVgb igVch[Zg ^h jhZY id igVch[Zg V [dgZVgb dg lg^hi higjXijgZ i]Vi ^h eZY^XaZY dc Vc VgiZg^Va Vm^h# ;dg gZigd\gVYZ kVhXjaVg^oZY iZcYdc igVch" [Zg! dcan i]Z jacVg"WVhZY eZY^XaZ ^h hj^iVWaZ! dl^c\ id ^ih Y^hiVaan WVhZY eVabVg ed^ci d[ gdiV" i^dc VcY id ^ih WgVcX] igVchb^hh^dc Vi Vc ZmXaj" h^kZan iZcY^cdjh aZkZa# 8dbW^cZY ;aZmdg IZcYdc VcY H`^c >haVcY ;dgZVgb IgVch[Zg# >c hdbZ XVhZh! l]Zc i]Z dkZgan^c\ h`^c ^h ZmigZbZan hXVggZY VcY d[ eddg fjVa^in! eVgi^Xj" aVgan Vi i]Z WVhZ d[ egdm^bVa dg b^YYaZ e]VaVcm! ^i ^h ^bedhh^WaZ id gZeaVXZ i]Z [>Zmdg iZcYdc VcY VX]^ZkZ ZVgan bdi^dc# H`^c d[ i]^h hdgi ^cZk^iVWan WgZV`hYdlcdgY^Zh!Xdbegdb^h^c\i]Z[jcXi^dcVa gZhjai0 i]ZgZ[dgZ! ^i h]djaY WZ gZeaVXZY# >c i]Z Y^hiVa i]^gY d[ i]Z [dgZVgb! i]Z jacVg eZY^XaZ cdi dcan hZcYh WgVcX]Zh id i]Z ÒZmdg
Figure 4-9. a) Diagram of the different vascular branches emerging from the ulnar artery before Guyon’s canal entrance. Bone, skin, flexor tendons. b) Ulnar artery dissection before Guyon’s canal entrance. c) A bayonet-shaped incision including an outline of the skin flap is traced on the medial side of the forearm. d) Raising of the composite flexor tendon and skin flap island transfer for tendon repair and digital palmar resurfacing. Before and after tourniquet release. e) Other multiple combinations: combined island flexor superficialis tendon and palmaris longus transfer for flexor and pulley reconstruction. f) The double flexor tendons and double skin flaps transfer. g) The composite skin, flexor tendon, and bone transfer. (A.D.F. Video-Productions with special permission)
a
51
hjeZgÑX^Va^h iZcYdch Wji Vahd id i]Z h`^c# I]ZhZ WgVcX]Zh VgZ ZVh^an ^YZci^ÑZY! WZ^c\ XadhZ id i]Z bZhdiZcYdc WgVcX]Zh VcY d[ hj^iVWaZ Y^VbZiZg! Vaadl^c\ h^bjaiVcZdjhan Xdbedh^iZ igVch[Zg d[ h`^c VcY iZcYdc# i bV`Zh jhZ d[ V a^k^c\ iZcYdc ^haVcYÄi]Vi d[ V i]^c bZhdiZcYdc l^i] kVhXjaVg WgVcX]Zh! egdk^Y^c\ V eZg[ZXi WaddY hjeean id Vaa VgZVh! Wdi] Zmig^ch^X VcY ^cig^ch^X# >i i]jh Vkd^Yh VY]Zh^dch VcY ^begdkZh i]Z kVhXjaVg^in d[ i]Z hjggdjcY^c\ i^hhjZh# 7ZXVjhZ i]Z igVch[Zg ^h V gZVa ÒZmdg iZcYdc VcY cdi V h^beaZ bndiZcY^" cdjh higjXijgZ! ^i gZiV^ch ÒZm^W^a^in! ea^VW^a^in! VcY gZh^hiVcXZ VcY Vaadlh i]Z XdggZXi iZch^dc
b
c
d
e
f
g
52
id WZ VX]^ZkZY# 7ZXVjhZ kVhXjaVg^oVi^dc ^h egZ" hZgkZY! Vaa h]ZVi]h VgZ gZiV^cZY# I]Z BK86H [dgbZgan eVgViZcdc VcY! ^c eVgi^XjaVg! i]Z XVgeVa h]ZVi] l]^X] ^h igVchedhZY ^cid ÅCd BVcÈh AVcYÆ gZiV^c i]Z jcgZhig^XiZY \a^Y^c\ bdkZbZci d[ i]Z iZcYdc# I]Z iZcYdc igVch[Zg ^h Veegdm^bViZan &- Xb id '% Xb adc\# I]^h aZc\i] Vaadlh ZVhn gZXdchigjX" i^dc d[ Vcn ineZ d[ ÒZmdg iZcYdc YZ[ZXi! [gdb i]Z ejae id i]Z XVgeVa VgZV# I]jh! i]Z iZcYdc VcVhidbdhZh VgZ cdi jcYZg iZch^dc VcY a^Z djih^YZ ÅCd BVcÈh AVcY#Æ 7ZXVjhZ d[ i]Z kZgn Y^hiVa gdiVi^dc ed^ci VcY i]Z bZhdiZcYdc eaVh" i^X^in VcY kZghVi^a^in! eaVXZbZci VcY VcX]dg^c\ cZZY ViiZci^dc Wji XVc WZ eZg[dgbZY l^i]dji Y^[ÑXjain# I]Z deZgVi^dc ^h eZg[dgbZY ^c i]Z hVbZ lVn Vh V XaVhh^X gZkZghZY"Òdl gVY^Va dg jacVg [dgZVgb ÒVe# I]Z bZhdiZcY^cdjh kVhXjaVg WgVcX]Zh VgZ VcVidb^XVaan XdchiVci! VcY i]Z Y^hhZXi^dc l^aa iV`Z Veegdm^bViZan i]Z hVbZ Vbdjci d[ i^bZ Vh V gZkZghZY"Òdl [dgZVgb h`^c ÒVe Veegdm^" bViZan .% b^cjiZh # I]^h dcZ"hiV\Z egdXZYjgZ gZiV^ch Vaa \a^Y^c\ hjg[VXZh! l]^X] bZVch i]Vi gZX^e^Zci WZY egZeVgVi^dc Wn V ehZjYdhncdk^Va h]ZVi] jh^c\ V h^a^XdcZ gdY ^h jccZXZhhVgn# =dlZkZg! Vaa ejaaZnh ]VkZ id WZ gZeV^gZY XVgZ[jaan/ i]Z igVX" i^dc ZmZgiZY Wn i]^h ineZ d[ iZcYdc ^h \gZViZg WZXVjhZ i]Z gZh^hiVcXZ ^h aZhh# 8dbeVgZY l^i] i]Z di]Zg [dgZVgb igVch[Zgh VcY i]Z^g ediZc" i^Va [dg Xdbedh^iZ igVch[Zgh! i]Z dcan dcZ i]Vi Vaadlh h^bjaiVcZdjh igVchedh^i^dc d[ h`^c! WdcZ! VcY iZcYdc ^h i]Z gVY^Va [dgZVgb ÒVe# =dlZkZg! i]^h ÒVe YdZh cdi Vaadl igVch[Zg d[ i]Z Xdbbdc XVgeVa h]ZVi] VcY i]Z ÒZmdg iZcYdc WZXVjhZ i]Z gVY^Va eZY^XaZ hjeea^Zh i]Zb dcan Vi i]Z bndiZcY^cdjh aZkZa VcY ^ih gdiVi^dc ed^ci ^h idd egdm^bVa# I]Z cZl iZX]" c^fjZ d[ Xdbedh^iZ igVch[Zg ^h heZX^ÑXVaan XdcÑcZY id i]Z jacVg kVhXjaVg hnhiZb VcY bVn WZ XdckZc^Zcian `cdlc Vh i]Z jacVg igV^a hnhiZb# I]Z bV^c Y^hVYkVciV\Z d[ djg iZX]c^fjZ ^h i]Z cZZY id igVchZXi i]Z jacVg eZY^XaZ# =dlZkZg! ^c djg ZmeZg^ZcXZ l^i] bdgZ i]Vc )*% XVhZh d[ Vaa kVg^Zi^Zh d[ jacVg igVch[Zgh! cd jcYZ" h^gVWaZ adc\"iZgb Z[[ZXih! hjX] Vh eVgZhi]Zh^V dg [jcXi^dcVa YZÑX^ih! ]VkZ WZZc ZcXdjciZgZY & nZVg V[iZg hjg\Zgn# >i ^h cZkZgi]ZaZhh egZ[ZgVWaZ id gZhidgZ VgiZg^Va Xdci^cj^in l^i] Z^i]Zg V kZcdjh \gV[i dg V kVhXjaVg egdhi]Zh^h ' bb ^c Y^VbZiZg#
Tissue Surgery
Results of Tendon Reconstruction :kVajVi^c\ i]Z gZhjaih d[ XdbeaZm iZcYdc gZXdc" higjXi^dc ^h Y^[ÑXjai WZXVjhZ i]Z kVg^VWaZh VgZ idd cjbZgdjh V\Z d[ i]Z eVi^Zci0 egdXZYjgZh jhZY0 ineZ d[ ^c_jgn0 VXXdbeVcn^c\ cZgkZ! WdcZ! dg kVhXjaVg ^c_jg^Zh0 VcY ZheZX^Vaan VhhdX^ViZY h`^c egdWaZbh # LZ egZ[Zg i]Z IjW^VcV XaVhh^ÑXVi^dc hnhiZb&' WZXVjhZ ^i ^h WVhZY dc egdm^bVa ^ciZg" e]VaVc\ZVa _d^ci bdkZbZci!l]^X] ^c djg de^c^dc Y^heaVnh i]Z eg^cX^eVa Z[[ZXi d[ i]Z ÒZmdg iZcYdc igVch[Zg# I]Z Vg^i]bZi^XVa VYY^i^dc d[ YZ\gZZh WZilZZc ZmiZch^dc VcY ÒZm^dc XdbeVgZY l^i] i]Z ]nedi]Zi^XVa bVm^bjb Vbea^ijYZ! l]^X] YdZh cdi Y^hi^c\j^h] WZilZZc i]Z bZiVXVg" ede]VaVc\ZVa _d^ci VcY i]Z egdm^bVa ^ciZg" e]VaVc\ZVa dg i]Z Y^hiVa ^ciZge]VaVc\ZVa _d^cih! hZZbh ^cVYZfjViZ [dg i]^h hdgi d[ hVakV\Z h^ijV" i^dc# BZiVXVgede]VaVc\ZVa _d^ci bdkZbZci ^h gVgZan VaiZgZY hjWhiVci^Vaan# I]Z eg^cX^eVa V^b ^c i]ZhZ XVhZh ^h id gZhidgZ Z[[ZXi^kZ VcY jhZ[ja [jcXi^dc! ^cXajY^c\ \g^e! VcY ZheZX^Vaan id gZhidgZ \ddY egdm^bVa ^ciZge]VaVc" \ZVa _d^ci bdkZbZci# Djg gZhjaih h]dl i]Vi +) eZgXZci d[ i]ZhZ ZmigZbZ hVakV\Z ÒZmdg iZcYdc h^ijVi^dch VX]^ZkZY Vc ZmXZaaZci! kZgn \ddY! dg \ddY gZhjai VcY lZgZ \gZVian ^begdkZY ^c V h^c\aZ deZgVi^dc# I]ZhZ gZhjaih ]VkZ id WZ XdbeVgZY l^i] Vc VkZgV\Z d[ ** ^c gZhjaih ejWa^h]ZY [dg h^b^aVg XVhZh ^c hZg^Zh jh^c\ i]Z ild"hiV\ZY egd" XZYjgZ l^i] dg l^i]dji V h^a^XdcZ gdY# I]Z iZX]" c^fjZ Vahd egdYjXZh [VkdgVWaZ igde]^X X]Vc\Zh# ;^c\Zg h`^c WZXdbZh bdgZ hjeeaZ VcY hZch^i^kZ! _d^cih VgZ aZhh hi^[[ VcY VgZ bZX]Vc^XVaan VXi^kZ! VcY ÒZm^dc ^h ^begdkZY# 6aa i]^h iZhi^ÑZh id \ddY W^dad\^XVa gZXdkZgn# Djg gZhjaih bjhi WZ ^begdkZY Wn V WZiiZg jcYZghiVcY^c\ d[ ÒZmdg iZcYdc W^dad\n VcY i]Z gZhidgZY \a^Y^c\ bZX]Vc^hb# I]^h cZl iZX]c^fjZ hZZbh id \^kZ WZiiZg [jcXi^dcVa eZg[dgbVcXZ VcY gZYjXZh i^bZ adhi [gdb ldg`# LZ egZhZci V XdbeaZiZan cZl VeegdVX] id ÒZmdg iZcYdc gZXdchigjXi^dc [dg bV_dg hVakV\Z hjg\Zgn# I]Z jhZ d[ Vc ^haVcY ÒZmdg iZcYdc! kVh" XjaVg^oZY i]gdj\] i]Z jacVg bZhdiZcYdc! l^i] Vaa ^ih \a^Y^c\ hjg[VXZh ^ciVXi! hZZbh id WZ V bV_dg VYkVcXZ ^c YZVa^c\ l^i] VY]Zh^dch VcY ]Vh i]Z VYYZY bZg^i d[ WZ^c\ V dcZ"hiV\Z egdXZYjgZ# I]ZhZ ineZh d[ jacVg kVhXjaVg^oZY iZcYdc dg iZcYdc VcY h`^c igVch[Zgh l^i] bjai^eaZ Veea^XV" i^dch VcY \ddY [jcXi^dcVa gZhjaih XdjaY hZi V igZcY ^c iZcYdc gZXdchigjXi^kZ hjg\Zgn# :kZc ^[ i]^h cZl egdXZYjgZ gZhidgZh [jcXi^dc! ^i XVccdi WZ jhZY ^c hdbZ X^gXjbhiVcXZh# ;dg
Subcutaneous Tissue Function: The Multimicrovacuolar Absorbing Sliding System in Hand and Plastic Surgery
ZmVbeaZ! ^i XVccdi WZ jhZY l]Zc Vaa i]Z di]Zg Ñc\Zgh ]VkZ jcYZg\dcZ iZcdanh^h# LZ Vahd `cdl cdl i]Z XdbeaZm^in d[ Vaa i]Z ha^Y^c\ i^hhjZ VgdjcY i]Z iZcYdc VcY ]dl i]Z iZcYdc VcY h]ZVi] ]VkZ id WZ Xdch^YZgZY id\Zi]Zg Vh V ha^Y^c\ jc^i# Jh^c\ V XdbeaZiZ ÒZm^dc hnhiZb XdbedhZY d[ i]Z ÒZmdg iZcYdc! Y^\^iVa h]ZVi]! VcY Vaa i]Z ejaaZnh VeeVgVijh hZZbZY id WZ i]Z eZg[ZXi gZXdchigjXi^dc#
Human Allotransplant of a Digital Flexor System Vascularized on the Ulnar Pedicle >c a^\]i d[ djg ZmeZg^ZcXZ! i]Z ^YZV d[ V h^bjaiVcZdjh iZcYdc VcY ejaaZn kVhXjaVg^oZY VaadigVcheaVci YZkZadeZY \gVYjVaan# CdckVhXj" aVg^oZY ]dbd\gV[ih d[ Vc Zci^gZ ÒZmdg iZcYdc XdbeaZm! dg^\^cVaan eZg[dgbZY Wn :# EZVXdX`! ]VY WZZc gZedgiZY id egdYjXZ jcZkZc [jcXi^dcVa gZhjaih ^c hZkZgVa XVhZh# I]ZhZ gZhjaih lZgZ YdjWi" aZhh ZmeaV^cZY Wn Vc ^bbjcdad\^X gZhedchZ XVjhZY Wn iZcYdc XZaa XdbedcZcih!, Vai]dj\] i]ZgZ ^h a^iiaZ dg cd Vci^\Zc^X^in id i]Z XdaaV\Zc iZcYdc higjXijgZ# I]ZhZ iZcYdc ]dbd\gV[ih lZgZ cdckVhXjaVg^oZY! iV`Zc [gdb XVYVkZgh! VcY Z^i]Zg hidgZY Wn YZZe"[gZZo^c\ dg egZhZgkZY ^c 8^Va^i# I]Z ^cigdYjXi^dc d[ XnXadhedg^cZ ^c &.-% X]Vc\ZY i]Z ^cY^XVi^dch VcY ^begdkZY hjXXZhh gViZh ^c kVhXjaVg^oZY VaadigVcheaVciVi^dch# Adl! cdcidm^X bV^ciZcVcXZ YdhZh lZgZ egZhXg^WZY [dg i]ZhZ gZaVi^kZan lZV` Vci^\Zc^X^in"gZhedchZ dg\Vch# @cdlaZY\Z d[ i]Z heZX^ÑX VcVidb^X higjX" ijgZ d[ i]Z jacVg kVhXjaVg cZildg`! ZmeZg^ZcXZ ^c ]dbdiZcYdc \gV[ih! i]Z jhZ d[ adl"YdhZ XnXadhedg^cZ! VcY i]Z cZXZhh^in id ^begdkZ [jcX" i^dcVa gZhjaih ]VkZ Vaa XdbW^cZY id egdYjXZ V hjXXZhh[ja ]jbVc kVhXjaVg^oZY VaadigVcheaVci d[ V XdbeaZiZ Y^\^iVa hnhiZb Wn b^Xgdhjg\Zgn#
Transplantation Technique I]Z dg^\^cVa igVcheaVciVi^dc egdXZYjgZ! WVhZY dc djg `cdlaZY\Z d[ i]Z jacVg WaddY hjeean d[ i]Z ÒZmdg hjeZgÑX^Va^h! ZheZX^Vaan d[ i]Z g^c\ Ñc\Zg! ]Vh WZZc eZg[dgbZY [gdb V a^k^c\ Ydcdg# HdbZ gZÑcZbZcih VcY bdY^ÑXVi^dch lZgZ
53
VYdeiZY [dg i]Z hZXdcY XVhZ [gdb XVYVkZg Ydcdg# I]Z Y^[[ZgZci WgVcX]Zh d[ i]Z jacVg eZY^XaZ ^c i]Z [dgZVgb VgZ ^YZci^ÑZY# I]dhZ hjeean^c\ i]Z h`^c VcY XdccZXiZY l^i] i]Z [dgZVgb VciZg^dg kZcdjh hjeZgÑX^Va cZildg` VcY i]Z ÒZmdg iZcYdch VgZ hZaZXiZY# Id Vkd^Y deZc^c\ i]Z Y^\^iVa h]ZVi] VcY i]jh ^cYjX^c\ iZcYdc VY]Zh^dch! lZ aZ[i i]Z ild ÒZmdg iZcYdch ^c eaVXZ ^c i]Z Y^\^iVa XVcVa# I]Z hjeZgÑX^Va VgXVYZ ^h XaVbeZY VcY igVchZXiZY WZilZZc i]Z i]^gY VcY [djgi] Xdbbdc eVabVg Y^\^iVa VgiZg^Zh# I]Z [jcXi^dcVa jc^i! XdbedhZY d[ i]Z ÒZmdg iZcYdch VcY i]Z Zci^gZ ejaaZn hnhiZb! ^h i]Zc hZeVgViZY [gdb i]Z Y^\^iVa WdcZ h`ZaZidc# I]^h Y^hhZXi^dc ^h bVYZ ^c i]Z hjWeZ" g^dhiZVa eaVcZ Vadc\ i]Z h`ZaZidc d[ egdm^bVa b^YYaZ! VcY Y^hiVa e]VaVcm# I]Z iZcYdc h]ZVi] ^h cdi deZcZY# I]Z XdaaViZgVa eZY^XaZ ^h ^cXajYZY ^c i]Z igVch[Zg# I]Z jacVg eZY^XaZ ^h a^\ViZY VWdkZ i]Z WgVcX] hjeean^c\ i]Z h`^c VcY XdccZXiZY l^i] i]Z kZcdjh hjeZgÑX^Va cZildg` ;^\jgZ )" &% # KZgn \ddY [jcXi^dcVa gZhjaih lZgZ VeeVgZci V[iZg ) bdci]h# Lg^hi hlZaa^c\ Y^hVeeZVgZY a^iiaZ Wn a^iiaZ! VcY WZXVjhZ i]Z eVi^Zci ]VY cd VXi^kZ bdi^dc egZdeZgVi^kZan! i]Z [jcXi^dcVa gZhjai l^i] V gVc\Z d[ bdi^dc ^c ÒZm^dc d[ -% ^c i]Z egdm^" bVa ^ciZge]VaVc\ZVa _d^ci! cd ZmiZch^dc YZ[ZXi! VcY ** d[ ÒZm^dc ^c i]Z Y^hiVa ^ciZge]VaVc\ZVa _d^ci l^i] Vc ZmiZch^dc YZ[ZXi d[ (* lVh Xdch^Y" ZgZY ZmXZaaZci# I]Z VkZgV\Z idiVa VXi^kZ ÒZm^dc ZfjVaaZY Vabdhi i]Z gVc\Z d[ eVhh^kZ bdi^dc VkV^aVWaZ# I]^h Ñc\Zg ^h cdl kZgn [jcXi^dcVa VcY eZg[ZXian VYVeiZY#
Conclusion I]Z egZhZciZY iZX]c^fjZ ^h V hiZe idlVgY V cZl ineZ d[ gZXdchigjXi^dc ^c ]VcY hjg\Zgn# >i XVc WZ jhZY cdi dcan [dg i]Z ÒZmdg hnhiZb! Wji Vahd [dg WdcZ VcY _d^cih# ;dg i]Z bdbZci! bZY^XdaZ\Va XdchigV^cih VgZ hZkZgZ! VcY ZmVXi^c\ Xg^iZg^V bjhi WZ bZi WZ[dgZ Vcn igVcheaVci XVc WZ eZg[dgbZY# HjX] XdchigV^cih bVn Y^b^c^h] dkZg i^bZ! VcY iZX]c^fjZh d[ gZeV^g VcY gZXdchigjXi^dc! hjX] Vh i]dhZ YZhXg^WZY ]ZgZ! l^aa YZkZade [gZZan [dg jhZ ^c hZaZXiZY eVi^Zcih# 9Zhe^iZ i]Z hjXXZhh d[ i]^h iZX]c^fjZ! ^i h]djaY WZ gZhZgkZY [dg XdbeaZm XVhZh ^c l]^X] XdckZci^dcVa iZX]c^fjZh VgZ cdi edhh^WaZ#
54
Tissue Surgery
a
b
c Figure 4-10. Flexor tendon unit allotransplantation program. a) A monoflexor superficialis allotransplant after tourniquet release. b) A bi flexor superficialis and profundus allotransplant after milking and washing, to be placed in a sterile refrigerated container. c) Layout of the allotransplant before inserting. d) Insertion and anastomoses. (A.D.F. Video-Productions with special permission)
d
References ,# &# Hb^i] ?L! 7Zaa^c\Zg 8c/ IjW^VcV G! ZY^idg# IgV^i YZ aV 8]^gjg\^Z YZ aV BV^c! Kda# ># EVg^h/ BVhhdc! &.-+# '# HX]Vio`Zg ?! 7gVcZbVg` E># >cigVk^iVa dWhZgkVi^dc dc i]Z b^XgdkVhXjaVg VcVidbn VcY b^XgdX^gXjaVi^dc d[ i]Z iZcYdc# 6XiV Dgi]de HXVcY# &.+.0&'+ hjeea/&Ã'(# (# AjcYWdg\ YZVh ^c =VcY ;aZmdg IZcYdc Hjg\Zgn# 7dgYZVjm/ :Y# >chi^iji 6fj^iV^c YZ aV BV^c! '%%&# *# <j^bWZgiZVj ?8! HZcijXf"G^\Vaa ?! EVcXdc^ 7! 7d^aZVj G! Bdjidc E! 7V`]VX] ?# >cigdYjXi^dc id i]Z `cdlaZY\Z d[ hjWXjiVcZdjh ha^Y^c\ hnhiZb ^c ]jbVch# 6cc 8]^g EaVhi :hi]i# '%%*0*% & /&.Ã()# +# <j^bWZgiZVj ?8! 9ZaV\Z ?! Bdga^Zg E# ?djgcZn id i]Z iZcYdc VcY hViZaa^iZ h]ZVi] VgZVh0 ^c k^kd VcVid" b^XVa dWhZgkVi^dch d[ ÒZmdg iZcYdc kVhXjaVg^oVi^dc VcY hjggdjcY^c\ h]ZVi]h K^YZdÑab! () b^c# 7gjhhZah >ciZgcVi^dcVa Hnbedh^jb/ IZcYdc AZh^dch! >c_jg^Zh
-# .# &%#
&&#
&'# &(#
VcY GZeV^g# i ]Vh WZZc hj\\ZhiZY i]Vi ?VbZh AZVgbdci]! B9! V cZjgdhjg\Zdc [gdb HXdiaVcY! h]djaY WZ Xdch^YZgZY Vh i]Z e^dcZZg! ^[ cdi i]Z Ñghi! eZg^e]" ZgVa cZgkZ hjg\Zdc#& >[ i]Vi hj\\Zhi^dc ^h VXXZeiZY! i]Zc Å^ccdkVi^dcÆ ^c eZg^e]ZgVa cZgkZ hjg\Zgn ldjaY WZ gZaViZY id i]Z XdcXZeih AZVgbdci] ^cigdYjXZY# 6bdc\ i]ZhZ ldjaY WZ i]Z YZhXg^e" i^dc d[ hjg\^XVa iZX]c^fjZh! hjX] Vh YZXdbegZhh" ^c\ i]Z eZg^e]ZgVa cZgkZh! i]Z bZY^Vc cZgkZ XdbegZhh^dc Vi i]Z lg^hi!' VcY i]Z hjWbjhXjaVg igVchedh^i^dc d[ i]Z jacVg cZgkZ [dg XdbegZhh^dc d[ i]Z jacVg cZgkZ ^c i]Z XjW^iVa ijccZa#( AZVg" bdci] Vahd YZhXg^WZY kVg^Vi^dch ^c eZg^e]ZgVa cZgkZh!) i]Z [jcXi^dc d[ eZg^e]ZgVa cZgkZh! a^`Z i]Z hnbeVi]Zi^X cZgkZh!* VcY i]Z ^YZV i]Vi V eZg^e]ZgVa cZgkZ XdjaY WZ gZhZXiZY id igZVi eV^c#+ >c a^cZ l^i] i]ZhZ XdcXZeih! i]Zc! Å^ccdkVi^dcÆ l^aa WZ Xdch^YZgZY Vh ^YZVh i]Vi aZVY id cZl hjg" \^XVa egdXZYjgZh gZaViZY id i]Z eZg^e]ZgVa cZgkZ! l]Zi]Zg i]ZhZ cZl egdXZYjgZh Wj^aY dc ZVga^Zg YZhXg^ei^dch d[ cZjgdVcVidbn dg dc ZVga^Zg egd" XZYjgZh i]Vi ]VkZ WZZc eaVXZY cdl dc V Ñgb Zk^YZcXZ WVhZ# Å>ccdkVi^dcÆ Vahd ^bea^Zh ÅcZl!Æ VcY [dg i]Z ejgedhZh d[ i]^h X]VeiZg! i]Z i^bZ"a^cZ l^aa WZ l^i]^c i]Z aVhi * nZVgh# I]Z XdcXZeih i]Vi Ñi ^cid i]^h YZÑc^i^dc VgZ & igZVi^c\ i]Z hnbeidbh d[
cZjgdeVi]n Wn YZXdbegZhh^c\ eZg^e]ZgVa cZgkZh! ' igZVi^c\ adc\ cZgkZ \gV[ih l^i] Vc Vaad\gV[i! ( igZVi^c\ h]dgi cZgkZ \Veh l^i] V XdcYj^i! VcY ) eVgi^Va _d^ci YZcZgkVi^dc [dg gZa^Zk^c\ eV^c! Zbe]Vh^o^c\ i]Z `cZZ! Vc`aZ! VcY h]djaYZg#
Decompressing Nerves to Treat Symptomatic Neuropathy I]Z ]nedi]Zh^h i]Vi i]Z hnbeidbh d[ cZjgdeV" i]n XdjaY WZ igZViZY Wn YZXdbegZhh^c\ V eZg^e]" ZgVa cZgkZ lVh d[[ZgZY ^c &.--, VcY hjeedgiZY ^c V Y^VWZi^X gVi bdYZa ^c &..&- VcY &..)#. I]^h ]nedi]Zh^h lVh XdcÑgbZY Wn V hZeVgViZ iZVb ^c '%%( ^c i]Z gVi bdYZa VcY ^cXajYZY i]Z ÑcY^c\ i]Vi ^cigVcZjgVa cZjgdanh^h lVh d[ VYYZY kVajZ ^c ^begdk^c\ \V^i#&% I]Z ]nedi]Zh^h lVh Xdc" ÑgbZY nZi V\V^c ^c '%%* ^c i]Z hVbZ bdYZa! Wji i]^h i^bZ ÑcY^c\h ^cXajYZY ^c[dgbVi^dc heZX^ÑXVaan dc i]Z Xdbbdc eZgdcZVa cZgkZ VcY i]Z \VhigdXcZb^jh bjhXaZ#&& I]Z Ñghi Xa^c^XVa gZedgi d[ i]Z Veea^XVi^dc d[ i]ZhZ XdcXZeih id eVi^Zcih l^i] hnbeidbVi^X Y^VWZi^X cZjgdeVi]n lVh ^c &..'!&' VcY i]^h Veea^XVi^dc ]Vh WZZc Xdc" ÑgbZY Wn \gdjeh [gdb \ZcZgVa hjg\Zgn ^c &..*!&( eaVhi^X hjg\Zgn ^c '%%%&)!&* VcY '%%&!&+ edY^Vig^X [ddi VcY Vc`aZ hjg\Zgn ^c '%%(!&, dgi]deZY^X [ddi VcY Vc`aZ hjg\Zgn ^c '%%)!&- VcY cZjgdhjg" \Zgn ^c '%%)#&. 6i i]Z XdgZ d[ i]^h XdcXZei ^h i]Vi i]Z cZjgd" eVi]n ^ihZa[ gZcYZgh i]Z eZg^e]ZgVa cZgkZ hjhXZe" i^WaZ id XdbegZhh^dc# I]^h [VXi lVh YdXjbZciZY [dg Y^VWZiZh ^c i]Z higZeidodidX^c gVi bdYZa ^c &.--#'% >c i]Z egZhZcXZ d[ V edh^i^kZ I^cZa h^\c VcY Vc Veegdeg^ViZ ]^hidgn! XVgeVa ijccZa YZXdb" egZhh^dc XdjaY WZ YdcZ [dg eVi^Zcih l^i] Y^VWZiZh VcY bZY^Vc cZgkZ hnbeidbh# 8dbegZhh^dc d[ i]Z bZY^Vc cZgkZ Vi i]Z lg^hi! i]Z jacVg cZgkZ Vi i]Z ZaWdl! VcY i]Z gVY^Va hZchdgn cZgkZ ^c i]Z
55
56
[dgZVgb XdcXZeijVaan \^kZ i]Z e]nh^XVa ÑcY^c\h VcY hnbeidbh d[ V Y^hiVa hZchdgn cZjgdeVi]nÄ V Å\adkZ Y^hig^Wji^dcÆÄWji ldjaY WZ gZaViZY id i]gZZ hZeVgViZ cZgkZ XdbegZhh^dch# =dlZkZg! ^c i]Z eVi^Zci l^i] Y^VWZiZh! l]dhZ cZgkZh VgZ hjhXZei^WaZ id XdbegZhh^dc! i]ZhZ i]gZZ hZeVgViZ ÅbdcdcZjgdeVi]^ZhÆ XVc XdZm^hi# 6eean^c\ i]^h XdcXZei id i]Z aZ\h ^YZci^ÑZh XdbegZhh^dc d[ i]Z Xdbbdc eZgdcZVa cZgkZ Vi i]Z `cZZ! i]Z YZZe eZgdcZVa cZgkZ dkZg i]Z Ydghjb d[ i]Z [ddi! VcY i]Z i^W^Va cZgkZ ^c i]Z [djg bZY^Va Vc`aZ ijccZah cdi _jhi i]Z iVghVa ijccZa # 6 edh^i^kZ I^cZa h^\c dkZg i]Z i^W^Va cZgkZ Vi i]Z bZY^Va Vc`aZ ]Vh V edh^i^kZ egZY^Xi^kZ kVajZ d[ .' ^c ^YZci^[n^c\ i]Z eVi^Zci l^i] Y^VWZiZh l]d ldjaY dWiV^c gZa^Z[ [gdb eV^c VcY gZXdkZgn d[ hZch^W^a^in ^[ i]Z [djg bZY^Va Vc`aZ ijccZah lZgZ YZXdbegZhhZY IVWaZ *"& #'& >c V gZigdheZXi^kZ hZg^Zh d[ *% eVi^Zcih! cd jaXZgVi^dch dg VbejiVi^dch dXXjggZY Yjg^c\ V bZVc [daadl"je d[ )#* nZVgh V[iZg cZgkZ YZXdb" egZhh^dc! l]ZgZVh! jaXZgVi^dch c &' VcY VbejiVi^dch c ( Y^Y dXXjg ^c i]Z XdcigVaVi" ZgVa aZ\ ^c l]^X] cd cZgkZ lVh YZXdbegZhhZY#'' I]^h Y^[[ZgZcXZ ZhiVWa^h]ZY i]Vi i]Z cVijgVa ]^h" idgn d[ Y^VWZi^X cZjgdeVi]n XVc WZ X]Vc\ZY Wn YZXdbegZhh^c\ i]Z eZg^e]ZgVa cZgkZh ^c i]Z aZ\# I]gZZ gZk^Zlh d[ i]^h hjW_ZXi VeeZVgZY ZVgan ^c '%%)#&-!'(!') I]Z >ciZgcVi^dcVa CZjgdeVi]n 9ZXdbegZhh^dc GZ\^hign cZjgdeVi]ngZ\^hign# Xdb ! gZegZhZcih V bjai^XZciZg egdheZXi^kZ hijYn l^i] eVi^Zcih WZ^c\ ^cXajYZY [dg YZXdbegZhh^dc ^[ i]Zn ]VkZ & cZjgdeVi]n! ' V edh^i^kZ I^cZa h^\c dkZg i]Z ZmeZXiZY h^iZ d[ cZgkZ ZcigVebZci! ( [V^aZY bZY^XVa bVcV\ZbZci! VcY ) hjg\^XVa
Table 5-1. Results of Studies Treating Diabetic Neuropathy with Posterior Tibial Nerve Decompression Patients Nerves Patients Improved (%) Study (n) (n) Pain Sensibility 1992, Dellon12 31 32 85 72 1995, Wieman13 33 26 92 72 2000, Caffee14 58 36 86 50 2000, Aszmann15 16 12 NA 69 16 2001, Tambwekr 10 10 80 70 2003, Wood17 33 33 90 70 2004, Biddinger18 15 22 86 80 2004, Valdivia19 60 60 85 85 29 2004, Lee 46 46 92 92 2005, Steck32 25 25 84 72 49 49 90 72 2005, Rader89 Total 376 351 88 78 NA not available
Tissue Surgery
YZXdbegZhh^dc Vh YZhXg^WZY Wn 9Zaadc'*Ã'. d[ i]Z Xdbbdc eZgdcZVa cZgkZ Vi i]Z `cZZ! i]Z YZZe eZgdcZVa cZgkZ Vi i]Z Ydghjb d[ i]Z [ddi! i]Z iVghVa ijccZa! i]Z bZY^Va VcY aViZgVa eaVciVg ijccZah! dg i]Z XVaXVcZVa ijccZa ;^\jgZ *"& # I]^h XdcXZei d[ YZXdbegZhh^dc lVh ZmiZcYZY id X]Zbdi]ZgVen"^cYjXZY cZjgdeVi]n WVhZY dc V gVi bdYZa d[ X^heaVi^c cZjgdeVi]n ^c '%%&#(% I]Z Ñghi eVi^Zcih l^i] X]Zbdi]ZgVen"^cYjXZY cZjgdeVi]n hZXdcYVgn id X^heaVi^c VcY IVmda lZgZ igZViZY l^i] YZXdbegZhh^dc ^c '%%)#(& I]^h Ñghi gZedgi XdciV^ch _jhi - eVi^Zcih# 6aa ]VY gZa^Z[ d[ eV^c VcY gZXdkZgn d[ hZchVi^dc [gdb YZXdb" egZhh^dc d[ jeeZg VcY adlZg ZmigZb^in cZgkZh# 8]Zbdi]ZgVen gZ\^bZch i]Vi XdciV^c k^cXg^h" i^cZ0 eaVi^c XdbedjcYh! hjX] Vh X^heaVi^c dg XVgWdeaVi^c0 iVmda0 dg i]Va^Ydb^YZ XVc XVjhZ V hZchdgn cZjgdeVi]n i]Vi ^h ine^XVaan Y^hiVa VcY hnbbZig^XVa! a^`Z Y^VWZi^X cZjgdeVi]n# I]^h cZj" gdeVi]n ^h d[iZc eV^c[ja# ;dg X^heaVi^c VcY IVmda! i]Z eZg^e]ZgVa cZgkZ ^h hjhXZei^WaZ id XdbegZh" h^dc Wn i]Z W^cY^c\ d[ i]Z X]Zbdi]ZgVeZji^X V\Zci id ijWja^c ^c i]Z cZgkZÈh VmdeaVhb! l]^X] YZXgZVhZh i]Z hadl XdbedcZci d[ VciZgd\gVYZ igVchedgi# I]Z eV^c bVn WZ hZkZgZ Zcdj\] [dg i]Z eVi^Zci id hide X]Zbdi]ZgVen! Vi l]^X] i^bZ cZgkZ YZXdbegZhh^dc ldjaY WZ Veegdeg^ViZ# ;dg di]Zg eVi^Zcih! cZjgdeVi]n hnbeidbh! l]^X] VgZ YdhZ"gZaViZY! bVn ^begdkZ V[iZg XZhhVi^dc d[ X]Zbdi]ZgVen# >[ i]Z hnbeidbh eZgh^hi VcY VgZ Y^hVWa^c\! V edh^i^kZ I^cZa h^\c ^YZci^ÑZh i]Z adXVi^dc d[ i]Z eZg^e]ZgVa cZgkZ XdbegZhh^dc h^iZ# DeZgVi^kZ egdXZYjgZh ^c i]Z aZ\ [dg X]Zbdi]ZgVen"^cYjXZY cZjgdeVi]n VgZ i]Z hVbZ Vh i]dhZ [dg Y^VWZi^X cZjgdeVi]n eVi^Zcih# I]Z Ñghi gZedgi d[ YZXdbegZhh^dc ^c eVi^Zcih l^i] cZjgdeVi]n d[ jc`cdlc XVjhZ lVh ^c '%%)#'& CZjgdeVi]n d[ jc`cdlc XVjhZ ^h YZÑcZY Vh V Y^hiVa! Y^[[jhZ! aVg\Z"ÑWZg! hnbbZig^X cZjgdeVi]n VcY ^i ^h ZhhZci^Vaan i]Z hVbZ Vh i]Z ineZ [dg l]^X] eV^c ^h gZa^ZkZY VcY hZch^W^a^in ^h gZhidgZY [dg eVi^Zcih l^i] Y^VWZi^X cZjgdeVi]n! Vh YZhXg^WZY VWdkZ VcY ^c IVWaZ *"&# Ild bdgZ hijY^Zh lZgZ egZhZciZY Vi bZZi^c\h ^c '%%)&. VcY ^c '%%*(' gZaVi^kZ id i]^h \gdje d[ eVi^Zcih l^i] cZjgdeVi]n d[ jc`cdlc XVjhZ IVWaZ *"' # I]^h hjW\gdje d[ eVi^Zcih ^h Vahd gZedgiZY Vi i]Z LZW h^iZ \^kZc VWdkZ# DjiXdbZh gZaViZY id YZXdbegZhh^dc d[ eZg^e]" ZgVa cZgkZh ^c eVi^Zcih l^i] hnbeidbh VgZ gZaViZY ^ci]Zh]dgiiZgbidgZa^Z[ d[ eV^cVcY^begdkZbZci ^c hZchVi^dc IVWaZ *"& # HZXdcYVgn djiXdbZh lZgZ gZaViZY id YZXgZVhZY eV^c VcY bZY^XVi^dc VcY i]ZgZ[dgZ id YZXgZVhZh ^c i]Z Xdhi d[ i]Vi
Innovations in Peripheral Nerve Surgery
Figure 5-1. Decompression of the four medial ankle tunnels. a) The medial ankle region contains the tibial nerve, which passes through four discreet anatomical tunnels, each of which must be decompressed. The tarsal tunnel itself is opened by dividing the flexor retinaculum to expose the tibial vessels and the tibial nerve. In this region, high origins of the calcaneal nerve are identified, and a high division of the tibial nerve is identified, if present. In this region, the tibial nerve is neurolyzed internally, if needed, and sympathetic innervation of the tibial artery can be disrupted. b) The abductor hallucis brevis muscle is retracted (not divided) after incising its superficial fascia. In 50% of patients, a
57
small branch from the medial plantar nerve innervating the skin of the heel-arch region is present and is preserved. When the muscle is retracted, the thick fascia providing the roof of the medial and lateral plantar tunnels is identified. c) The roof of the medial plantar tunnel has been incised, and the roof of the lateral plantar tunnel is being incised. d) The septum between the two tunnels has been cauterized and is being incised to permit the removal of this “T” shaped structure, releasing the medial and lateral plantar nerves into the plantar aspect (porta pedis) of the foot. e) The incised calcaneal tunnel is shown, and the “T” structure is being removed.
58 Table 5-2. Results of Studies Treating Neuropathy of Unknown Cause with Posterior Tibial Nerve Decompression Patients Nerves Patients Improved (%) Study (n) (n) Pain Sensibility 2004, Valdivia19 40 40 90 80 2004, Lee21 40 40 80 80 2005, Steck32 26 26 88 68 Total 106 106 85 72
bZY^X^cZ# 6 Xg^i^XVa djiXdbZ ^h i]Z X]Vc\Z ^c [gZfjZcXn d[ jaXZgVi^dc! VbejiVi^dc! dg Wdi]# I]^h [gZfjZcXn ^h ZmeZXiZY id WZ '#( eZg nZVg! dg V XjbjaVi^kZ [gZfjZcXn d[ & d[ + Y^VWZi^X eVi^Zcih# CdcZ d[ i]Z hijY^Zh ^c IVWaZ *"& ]VkZ gZedgiZY V cZl jaXZg dg V cZl VbejiVi^dc ^c Vcn d[ i]Z eVi^Zcih l]d jcYZglZci cZgkZ YZXdb" egZhh^dc [dg hnbeidbh d[ Y^VWZi^X cZjgdeVi]n# c i^bZ! ^bbjcdhjeegZhh^kZ gZ\^bZch i]Vi VgZ ZkZc aZhh Y^[ÑXjai [dg i]Z eVi^Zci l^aa WZ ^cigdYjXZY! VcY eVi^Zcih gZfj^g^c\ ZmiZch^kZ Vbdjcih d[ eZg^e]" ZgVa cZgkZ l^aa ]VkZ i]Z^g YZ[ZXih gZXdchigjXiZY l^i] cZgkZ Vaad\gV[ih# 6ai]dj\] eZg]Veh [ZlZg i]Vc V YdoZc Xa^c^XVa cZgkZ Vaad\gV[ih ]VkZ WZZc eZg[dgbZY ^c i]Z eVhi &+ nZVgh! i]^h cjbWZg l^aa ^cXgZVhZ Vh di]Zg eZg^e]ZgVa cZgkZ XZciZgh VgZ VeegdkZY id jhZ i]^h VeegdVX] id cZgkZ gZXdchigjXi^dc#
Figure 5-2. Use of nerve allograft to reconstruct a peripheral nerve defect. The pale segment of nerve in the center is the allograft, sutured to the recipient’s common peroneal nerve to the right, with connection to the sciatic nerve’s common peroneal nerve component to the left. The patient recovered foot dorsiflexion and sensation to the dorsum of the foot. (Courtesy of Michael Rose, MD, and Andrew Elkwood, MD, Short Hills, New Jersey)
59
Nerve Conduits BdgZ i]Vc ild YZXVYZh ]VkZ eVhhZY h^cXZ ZmeZg" ^bZciVa bdYZah d[ cZjgVa gZ\ZcZgVi^dc! jh^c\ kVg^djh bViZg^Vah [dg cZgkZ XdcYj^ih! lZgZ Ñghi jhZY id bZVhjgZ cZjgdigde]^X hjWhiVcXZh VcY id ^cigdYjXZ hjWhiVcXZh gZaViZY id i]Z cZgkZ gZ\Zc" ZgVi^dc egdXZhh#)& 6ai]dj\] h^a^XdcZ X]VbWZgh lZgZ Vbdc\ i]Z ZVga^Zhi XdcYj^ih jhZY ZmeZg^" bZciVaan! cZgkZh Yd cdi gZ\ZcZgViZ bdgZ i]Vc &% bb ^c i]Zb! eg^bVg^an WZXVjhZ i]Zn VgZ cdc" edgdjh# ;jgi]ZgbdgZ! h^a^XdcZ VgdjcY V cZgkZ ^h dcZ bdYZa d[ X]gdc^X cZgkZ XdbegZhh^dc#)' CZgkZ gZ\ZcZgVi^dc i]gdj\] V gZ\^dc d[ Xdb" egZhh^dc ^c Vc Vc^bVa bdYZa YdZh dXXjg! Wji i]Zc i]Z cZgkZ [V^ah! V\V^c WZXVjhZ d[ X]gdc^X XdbegZhh^dc#)( H^a^XdcZ ]Vh WZZc jhZY [dg bVcn nZVgh id Xdc" cZXi cZgkZh i]Vi ldjaY di]Zgl^hZ ]VkZ jcYZg" \dcZ eg^bVgn gZeV^g! Wji ZkZc i]Z bdhi gZXZci gZedgi d[ i]^h VeegdVX]! ^c '%%)! YZhXg^WZh i]Z cZXZhh^in d[ gZbdk^c\ i]Z h^a^XdcZ [gdb eVi^Zcih Vh V gZhjai d[ adc\"iZgb egdWaZbh l^i] hnbe" idbh d[ XdbegZhh^dc dg eV^c#)) I]Z Ñghi ZkZg gVcYdb^oZY bjai^XZciZg! Wa^cYZY hijYn d[ V cZgkZ XdcYj^i [dg gZXdchigjXi^c\ V hZchdgn cZgkZ YZ[ZXi ^c i]Z ]VcY lVh gZedgiZY ^c '%%% Wn LZWZg Zi Va#)* I]Z XdcYj^i lVh V edgdjh! edan\anXda^X VX^Y Ec '%%)! ^hdaViZY YZcZgkVi^dc d[ i]Z aViZgVa ]jbZgVa Ze^XdcYnaZ Wn gZhZXi^c\ i]Z WgVcX]Zh d[ i]Z edhiZg^dg XjiVcZdjh cZgkZ d[ i]Z Vgb VcY [dgZVgb lVh YZhXg^WZY Vi i]Z 6bZg^XVc 6hhdX^V" i^dc d[ =VcY Hjg\Zgn bZZi^c\#-) I]Z ^ccZgkVi^dc d[ i]Z bZY^Va ]jbZgVa Ze^XdcYnaZ lVh YZhXg^WZY ^c '%%* Vi i]Z 6bZg^XVc HdX^Zin [dg EZg^e]ZgVa CZgkZ# I]^h cZgkZ lVh cdiZY Yjg^c\ gZhZXi^dc d[ i]Z bZY^Va ^ciZgbjhXjaVg hZeijb Yjg^c\ hjWbjh" XjaVg igVchedh^i^dc d[ i]Z jacVg cZgkZ# 8VYVkZg Y^hhZXi^dch gZkZVaZY i]Vi ^i dg^\^cViZh [gdb i]Z gVY^Va cZgkZ ^c i]Z Vm^aaV ^c Vaa XVhZh! l^i] dcZ XVhZ ]Vk^c\ V Xdcig^Wji^dc [gdb i]Z jacVg cZgkZ ^c i]Z Vm^aaV Vh lZaa# I]^h cZgkZ XVc WZ gZhZXiZY Vi i]Z ^chZgi^dc d[ i]Z bZY^Va ^ciZgbjhXjaVg hZeijb ^cid i]Z bZY^Va Ze^XdcYnaZ [dg i]Z igZVibZci d[ bZY^Va Ze^XdcYna^i^h Å\da[ZgÈh ZaWdlÆ #-*!-+ IZbedgdbVcY^WjaVg _d^ci IB? eV^c ^h Vcdi]Zg ZmVbeaZ d[ YZW^a^iVi^c\ _d^ci eV^c#
66
Tissue Surgery
Figure 5-10. Results of anterior shoulder denervation. A typical patient preoperatively and 6 months after surgery, showing increased range of motion.
6ai]dj\] IB? eV^c ^h iVj\]i igVY^i^dcVaan id WZ gZaViZY id YZciVa bVadXXajh^dc! ^i ^[ d[iZc Xdch^YZgZY id WZ eVgi d[ i]Z hnbeidb XdbeaZm ^c WgVX]^Va eaZmjh XdbegZhh^dc! ^c i]Z i]dgVX^X ^caZi i]dgVX^X djiaZi hncYgdbZ VcY XZgk^XVa hegV^c# I]Z IB? XVc WZ i]Z XZciZg d[ gZ[ZggZY eV^c [gdb i]Z XZgk^XVa eaZmjh! Vh ^c i]Z ild Xa^c^XVa ZmVbeaZh \^kZc VWdkZ! [gdb i]Z bVm^a" aVgn h^cjh^i^h ^c[gVdgW^iVa cZgkZ ! dg [gdb i]^gY bdaVg egdWaZbh hjeZg^dg VcY ^c[Zg^dg VakZdaVg cZgkZh # I]^h gZ[ZggVa eViiZgc ^h WZhi jcYZghiddY Wn gZaVi^c\ ^i id i]Z gZXZci ^iZgVi^dc d[ i]Z bVcn ZVga^Zg eVeZgh i]Vi YZhXg^WZ i]Z ^ccZgkV" i^dc d[ i]Z IB?! [gdb WgVcX]Zh d[ i]Z ig^\Zb^cVa cZgkZ Y^k^h^dc K'! i]Z bVcY^WjaVg cZgkZ# I]Z aViZgVa VheZXi d[ i]Z IB? ^h ^ccZgkViZY Wn i]Z Vjg^XjadiZbedgVa cZgkZ WZ[dgZ ^i e^ZgXZh i]Z iZbedgVa [VhX^V id ^ccZgkViZ i]Z egZVjg^XjaVg VcY iZbedgVa gZ\^dc# I]Z bZY^Va VheZXi d[ i]Z IB? ^h ^ccZgkViZY Wn V WgVcX] [gdb i]Z cZgkZ i]Vi ^ccZgkViZh i]Z bVhhZiZg bjhXaZ _jhi WZ[dgZ i]Vi cZgkZh XgdhhZh WZilZZc i]Z Xdgdcd^Y VcY XdcYnaVg egdXZhhZh! Vi i]Z bVcY^WjaVg cdiX]#+- 6YY^i^dcVa bZY^Va ^ccZgkVi^dc bVn XdbZ [gdb i]Z cZgkZ id i]Z aViZgVa eiZgn\d^Y bjhXaZ#+9Zhe^iZ ZmiZch^kZ egdidXdah [dg bVcV\^c\ IB? eV^c! ^[ i]Zn [V^a! ZcYdhXde^X dg deZc egdXZYjgZh ViiZbei id i^\]iZc i]Z a^\VbZcih d[ i]Z IB? dg
id gZh]VeZ dg gZXdchigjXi i]Z _d^ci ^ihZa[# I]ZhZ egdXZYjgZh XaVhh^XVaan \^kZ ^bbZY^ViZ gZa^Z[! Wji eV^c gZXjgh ^c ( id + bdci]h# BjX] d[ i]^h hjXXZhh ^h a^`Zan gZaViZY id XdbeaZiZan YZcZgkVi^c\ i]Z IB?! VcY i]Z gZXjgg^c\ eV^c ^h XVjhZY Wn gZ^ccZgkVi^dc d[ i]Z _d^ci dg igjZ cZjgdbV [dgbVi^dc# Dc ?VcjVgn '-! '%%*! i]Z Ñghi ViiZbei id YZcZg" kViZ i]Z IB? lVh eZg[dgbZY ;^\jgZ *"&&V ^c V eVi^Zci l]d ]VY i]gZZ egZk^djh egdXZYjgZh! ild ZcYdhXde^X VcY dcZ deZc#-,6 egZVjg^XjaVg ^cX^h^dc lVh bVYZ! VcY i]Z jeeZg edgi^dc d[ i]Z bVcY^WjaVg gVbjh lVh VeegdVX]ZY! jh^c\ V Y^ajiZ Ze^cZe]g^cZ hdaji^dc id Xdcigda WaZZY^c\ VcY ^cigVdeZgVi^kZ ZaZXig^XVa hi^bjaVi^dc id ^YZc" i^[n i]Z [VX^Va cZgkZ WgVcX]Zh ;^\jgZ *"&&W # I]Z Vjg^XjadiZbedgVa cZgkZ bdkZh [gdb edhiZg^dg id VciZg^dg VXgdhh i]^h edgi^dc d[ i]Z bVcY^WaZ VcY bVn WZ ^YZci^ÑZY Vi i]^h ed^ci ;^\jgZ *" &&W VcY [daadlZY id i]Z aViZgVa IB? XVehjaZ! VcY gZhZXiZY ;^\jgZ *"&&X # 6 WgVcX] id i]Z ZjhiV" X]^Vc ijWZ XVc WZ ^YZci^ÑZY VcY h]djaY Vahd WZ gZhZXiZY WZXVjhZ i]^h WgVcX] bVn XgZViZ gZ[ZggZY dg cZjgdbVidjh eV^c ^c i]Z ZmiZgcVa VjY^idgn bZVijh l]^X] ^i Y^Y ^c i]^h eVi^Zci! egZkZci^c\ ]Zg [gdb lZVg^c\ ]Zg ]ZVg^c\ V^Y # I]Z WgVcX] [gdb i]Z cZgkZ id i]Z bVhhZiZg ^h Y^[ÑXjai id ^YZci^[n! Wji ^i lVh VeegdVX]ZY ^c i]^h eVi^Zci Wn ZmiZcY^c\ i]Z ^cX^h^dc idlVgY i]Z bVcY^WjaVg
Innovations in Peripheral Nerve Surgery
67
a
b
c
d
Figure 5-11. Denervation of the temporomandibular joint (TMJ). a) Preoperative view of the TMJ outlined with innervation, from the auriculotemporal nerve to the lateral and the masseteric nerve to the medial side of the joint capsule. b) Intra-operative view, with the blue vessel loop on a facial nerve branch (note nerve stimulator in use) and white vessel loop on branch of auriculotemporal
nerve. c) After resection of the auriculotemporal nerve, its proximal end is placed deep to the mandibular ramus (dark hole and arrow). The specimen is lying on the cheek skin. d) The branch of the masseteric nerve to the joint capsule is approached by elevating the masseter from the mandibular ramus (white area) and then grasping the nerve with a right-angle clamp, reaching behind the condyle.
Vc\aZ! ZaZkVi^c\ i]Z bVhhZiZg [gdb i]Z bVcY^WaZ! VcY Y^hhZXi^c\ hjeZg^dgan idlVgYh i]Z cdiX]# >c i]^h adXVi^dc! V g^\]i Vc\aZ XaVbe XVc WZ eaVXZY edhiZg^dgan! VcY i]Z ^ccZgkVi^dc d[ i]Z bZY^Va IB? XVc WZ Y^hgjeiZY ;^\jgZ *"&&X # >i bVn WZ i]Vi dcan V eVgi^Va! aViZgVa IB? YZcZgkVi^dc ^h cZZYZY [dg bdhi eVi^Zcih l^i] ^cigVXiVWaZ IB? eV^c# ;dg eaVhi^X hjg\Zgn! i]Z XdcXZei d[ eVgi^Va _d^ci YZcZgkVi^dc deZch V cZl VgZV [dg eVi^Zci XVgZ! eZgb^ii^c\ gZa^Z[ d[ eV^c VcY gZhidgVi^dc d[
[jcXi^dc i]gdj\]dji i]Z WdYn [dg i]dhZ l^i] _d^ci eV^c#
References &# 9Zaadc 6A! 6bVY^d E8! ?VbZh G# AZVgbdci]/ i]Z Ñghi eZg^e]ZgVa cZgkZ hjg\Zdc# ? GZXdchig B^Xgdhjg\# '%%%0 &+/'&(Ã'&+# '# AZVgbdci] ?G# I]Z eg^cX^eaZ d[ YZXdbegZhh^dc ^c i]Z igZVibZci d[ XZgiV^c Y^hZVhZ d[ eZg^e]ZgVa cZgkZh# Hjg\ 8a^c Cdgi] 6b# &.((0&(/.%*Ã.&(#
68 (# AZVgbdci] ?G# IZX]c^fjZ [dg igVcheaVci^c\ i]Z jacVg cZgkZ# Hjg\ # I]Z gZaVi^dc d[ i]Z ajbWVg hnbeVi]Zi^X dji dl id i]Z he]^cXiZg Vc^ ^ciZgcjh# 6b ? E]nh^da# &.'.0-./+-+Ã+.&# +# AZVgbdci] ?G! Bdci\dbZgn =! 8djchZaaZg KH# GZhZX" i^dc d[ hZchdgn cZgkZh d[ eZg^cZjb ^c XZgiV^c ^gg^iVi^kZ XdcY^i^dch d[ i]Z ZmiZgcVa \Zc^iVa^V# 6gX] Hjg\# &.((0 '+/*%Ã+(# ,# 9Zaadc 6A# Dei^b^hb ^c Y^VWZi^X cZjgdeVi]n# 6cc EaVhi Hjg\# &.--0'%/&%(Ã&%*# -# 9Zaadc :H! 9Zaadc 6A# ;jcXi^dcVa VhhZhhbZci d[ cZjgdad\^X ^beV^gbZci/ igVX` VcVanh^h ^c Y^VWZi^X VcY XdbegZhh^dc cZjgdeVi]^Zh# EaVhi GZXdchig Hjg\# &..&0 --/+-+Ã+.)# .# 9Zaadc :H! 9Zaadc 6A! HZ^aZg L6 >K# I]Z Z[[ZXi d[ iVghVa ijccZa YZXdbegZhh^dc ^c i]Z higZeidodidX^c"^cYjXZY Y^VWZi^X gVi# B^Xgdhjg\# &..)0&*/'+*Ã'+-# &%# @VaZ 7! Nj`hZa ;! 8Za^`do 7! H^gkVcX^ H! :g\jc D! 6gWV` H# :[[ZXi d[ kVg^djh cZgkZ YZXdbegZhh^dc egdXZYjgZh dc i]Z [jcXi^dch d[ Y^hiVa a^bWh ^c higZeidodidX^c ^cYjXZY Y^VWZi^X gVih/ [jgi]Zg dei^b^hb ^c Y^VWZi^X cZjgdeVi]n# EaVhi GZXdchig Hjg\# '%%(0&&&/''+*Ã'','# &&# 9Zb^g N! HVg^ 6! H^Zb^dcdl B# >beVXi d[ ZVgan YZXdb" egZhh^dc dc YZkZadebZci d[ hjeZg^bedhZY cZjgdeVi]n ^c Y^VWZi^X gVih# EVeZg egZhZciZY Vi i]Z 6bZg^XVc 6hhdX^Vi^dc [dg Hjg\Zgn d[ i]Z =VcY VccjVa bZZi^c\! EjZgid G^Xd! ?VcjVgn &*! '%%*# &'# 9Zaadc 6A# IgZVibZci d[ hnbeidbh d[ Y^VWZi^X cZjgd" eVi]n Wn eZg^e]ZgVa cZgkZ YZXdbegZhh^dc#EaVhi GZXdchig Hjg\# &..'0-./+-.Ã+.,# &(# L^ZbVc I?! EViZa Kchi^ijiZ [dg EZg^e]ZgVa CZgkZ Hjg\Zgn ;Zaadlh]^e
69 *,# 9Zaadc 6A# EVgi^Va YdghVa lg^hi YZcZgkVi^dc/ gZhZXi^dc d[ Y^hiVa edhiZg^dg ^ciZgdhhZdjh cZgkZ# ? =VcY Hjg\# &.-*0 &%6/*',Ã*((# *-# 9Zaadc 6A! BVX`^ccdc H:! 9VcZh]kVg 6# IZgb^cVa WgVcX] d[ VciZg^dg ^ciZgdhhZdjh cZgkZ Vh hdjgXZ d[ lg^hi eV^c# ? =VcY Hjg\# &.-)0&.7/(&+Ã(''# *.# L^a]Zab 6# Ojg :cil^X`ajc\h\ZhX]^X]iZ YZg c/ >chVaa ?C! HXdii LC! ZY^idgh# Hjg\Zgn d[ i]Z @cZZ# E]^aVYZae]^V/ L#7# HVjcYZgh 8d#! '%%%/&,,'Ã&,-+# ,%# DÈ8dccZg 9# H^cjh IVgh^ HncYgdbZ# 6 8a^c^XVa :ci^in# ? 7dcZ ?d^ci Hjg\# &.*-0)%6/,'%# ,&# 8VcVaZ HI# 6c`aZ ^c_jg^Zh# >c/ 8VbeWZaaÈh DeZgVi^kZ Dgi]deZY^Xh! Kda# '! .i] ZY#! &..-/&%.+Ã&%.,# ,'# 7dWZg\ ?! @Va^h] HG! 7Vc`h 6H# 6c`aZ XdcY^i^dch# >c/ BX
70 ,.# B^aaZg HA! i bVn WZ hd ^c ZmeZgi ]VcYh! Wji XVgeVa ijccZa gZaZVhZ ^h YdcZ Wn bVcn hjg" \Zdch l^i]dji heZX^Va^oZY igV^c^c\ ^c ]VcY hjg\Zgn# I]Z Xdbea^XVi^dch gZedgiZY ^c i]Z a^iZgVijgZ VcY ZcXdjciZgZY ZkZc Wn heZX^Va^oZY ]VcY hjg\Zdch VgZ h^bean idd ]^\]# I]^h iZX]" c^fjZ XVgg^Zh V g^h` WZXVjhZ i]Z VcVidb^XVa higjXijgZh XVccdi WZ k^hjVa^oZY Vi Vaa i^bZh Yjg^c\ i]Z egdXZYjgZ/ i]ZgZ ^h V ÅWa^cYÆ ZaZbZci ^ckdakZY# LZ VgZ jh^c\ V b^c^bVaan ^ckVh^kZ iZX]c^fjZ l^i] V h]dgi ^cX^h^dc ^c i]Z eVab#) I]^h iZX]" c^fjZ! l]^X] gZfj^gZh kZgn [Zl ^chigjbZcih VcY V heZXjajb [dg i]Z ÅZcYdhXde^XÆ eVgi! ^h ZVhn id aZVgc# I]Z deZgVi^dc ^h eZg[dgbZY l^i] i]Z eVi^Zci jcYZg Vc Z^i]Zg WgVX]^Va eaZmjh WadX`
73
dg adXVa VcZhi]Zh^V# 6 idjgc^fjZi id dWiV^c V WaddYaZhh ÑZaY ^h ZhhZci^Va# I]Z eg^cX^eaZ ^h id deZgViZ [gdb Y^hiVa id egdm^" bVa# I]Z ^cX^h^dc [daadlh i]Z adc\^ijY^cVa XgZVhZ WZilZZc i]Z i]ZcVg VcY ]nedi]ZcVg Zb^cZcXZ ;^\jgZ +"( VcY XVc WZ WZilZZc &- bb VcY '* bb adc\# >i a^Zh dkZg i]Z Y^hiVa i]^gY d[ i]Z XVgeVa ijccZa# I]Z hjWXjiVcZdjh i^hhjZ ^h hZeV" gViZY Ydlc id i]Z eVabVg VedcZjgdh^h# I]Z [VhX^V ^h Y^k^YZY! VcY ^ih ZY\Zh VgZ gZigVXiZY l^i] '"egdc\ZY h`^c ]dd`h# I]Z ÒZmdg gZi^cVXjajb ^h ZmedhZY! VcY ^ih Y^hiVa eVgi Y^k^YZY# I]Z bZY^Vc cZgkZ VcY ^ih bdidg WgVcX] VgZ ^YZci^ÑZY# L]ZcZkZg Vine^XVa bjhXjaVijgZ ^h [djcY! Vi i]^h dg Vcn di]Zg ed^ci ^c i]Z XVgeVa ijccZa! Vc Vine^XVa bdidg WgVcX] kVg^Vi^dc bjhi higdc\an WZ hjheZXiZY# 6aa VcVidb^XVa kVg^Vi^dch+ d[ i]Z bdidg WgVcX] bjhi WZ `Zei ^c b^cY id `ZZe i]Z egdXZYjgZ hV[Z# I]Z YZZe igVchkZghZ XVgeVa a^\VbZci ^h Xji l^i] V &* WaVYZ [dg &% bb id &* bb ^c V egdm^bVa Y^gZXi^dc! [jgi]Zg Zmedh^c\ i]Z bZY^Vc cZgkZ# 7Z[dgZ i]Z ÑcVa gZaZVhZ! V ijccZa ^h XgZViZY jh^c\ V cZZYaZ ]daYZg Vh ijccZa^c\ [dgXZeh! hegZVY^c\ i]Z i^hhjZ WZilZZc i]Z eVabVg VedcZjgdh^h VcY i]Z egdm^bVa eVgi d[ i]Z ÒZmdg gZi^cVXjajb VcY i]Z [dgZVgb [VhX^V ;^\jgZ +")V # 6 heZXjajb l^i] V WaVYZ aZc\i] d[ *% bb ^h ^chZgiZY ^cid i]Z ijccZa VcY \Zcian deZcZY ;^\jgZ +")W # I]Z ^ch^YZ d[ i]Z ijccZa ^h k^hjVa^oZY! Z^i]Zg Wn V a^\]i hdjgXZ ViiVX]ZY id i]Z heZXjajb dg Wn Vc ZmiZgcVa a^\]i# 6c ZmXZaaZci ÅZcYdhXde^XÆ k^Zl Ydlc i]Z jcY^k^YZY eVgi d[ i]Z ÒZmdg gZi^cVXj" ajb VcY i]Z [dgZVgb [VhX^V ^h dWiV^cZY ;^\jgZ +"*V #
Figure 6-3. Small incision for minimally invasive, open carpal tunnel surgery. The motor branch of the median nerve has been dissected.
74
Tissue Surgery
Figure 6-4. a) Tunneling with the needle holder (see text). b) Speculum inserted for viewing the undivided part of the flexor retinaculum and forearm fascia.
GZi^cVXjajb VcY [VhX^V! `Zei iVji l^i] i]Z heZXjajb! VgZ Y^k^YZY l^i] i]Z hXVaeZa dg! gVgZan! l^i] hX^hhdgh# I]Z [VhX^V ^h Y^k^YZY je id ( Xb egdm^bVa id i]Z lg^hi XgZVhZ ;^\jgZ +"*W # IZcd" hncdkZXidbn ^h edhh^WaZ l^i]dji ZcaVg\^c\ i]Z h`^c ^cX^h^dc# I]Z dcan ^cY^XVi^dch id deZc i]Z h`^c ^cX^h^dc Ydlc id i]Z lg^hi XgZVhZ VgZ ^c g]ZjbVid^Y dg Y^Vanh^h eVi^Zcih ^c l]db aVg\Z Vbdjcih d[ egda^[ZgVi^kZ hncdk^i^h dg Vbnad^Y i^hhjZ cZZY id WZ ZmX^hZY# =ZbdhiVh^h ^h VX]^ZkZY l^i] W^edaVg XdV\jaV" i^dc0 V YgV^c ^h gVgZan cZXZhhVgn# 6 Wja`n YgZhh^c\
^h Veea^ZY# LZ egZ[Zg id ^bbdW^a^oZ i]Z lg^hi [dg V lZZ` ^c V YdghVa hea^ci# L^i] hdbZ gdji^cZ! i]^h deZgVi^dc iV`Zh VWdji &% b^cjiZh [gdb h`^c ^cX^" h^dc id Ñc^h]^c\ i]Z YgZhh^c\# I]Z iZX]c^fjZ XdbW^cZh i]Z VYkVciV\Z d[ adl bdgW^Y^in d[ i]Z ZcYdhXde^X VeegdVX] l^i] i]Z \gZViZg hV[Zin d[ i]Z deZc bZi]dY# Jh^c\ V hbVaa! hiVcYVgY hZi d[ dgY^cVgn ]VcY hjg\Zgn ^chigj" bZcih bV`Zh hjg\Zgn kZgn Xdhi"Z[[ZXi^kZ ÅhV[Zg" [VhiZg"X]ZVeZgÆ # LZ ]VkZ jhZY i]^h bZi]dY ^c bdgZ i]Vc )%%% eVi^Zcih VcY gZXdbbZcY ^i l^i]dji Vcn ]Zh^iVi^dc#
Figure 6-5. “Endoscopic” view with speculum. a) The undivided part of the flexor retinaculum and forearm fascia are clearly visible, as are the blades of the speculum. b) The flexor and adjacent forearm fascia completely divided.
Minimally Invasive and Endoscopic Techniques in Peripheral Nerve Surgery of the Hand and Forearm
75
Pronator Syndrome Egdm^bVa bZY^Vc cZgkZ XdbegZhh^dc ^h bjX] aZhh Xdbbdc i]Vc XVgeVa ijccZa hncYgdbZ! VcY ^i bVn WZ dkZgadd`ZY WZXVjhZ i]Z Vhhd" X^ViZY hnbeidbh VcY e]nh^XVa h^\ch bVn WZ kV\jZ# EgdcVidg hncYgdbZ gZhZbWaZh XVgeVa ijccZa hncYgdbZ ^c i]Vi cjbWcZhh dXXjgh ^c i]Z hVbZ Y^\^ih! lZV`cZhh bVn YZkZade ^c i]Z i]ZcVg bjhXaZh! VcY eV^c ^h gZedgiZY ^c i]Z lg^hi VcY [dgZVgb# EVgZhi]Zh^V d[ i]Z bZY^Vc" ^ccZgkViZY Ñc\Zgh l^i]dji e]nh^XVa h^\ch d[ XVgeVa ijccZa dg X]gdc^X eV^c ^c i]Z egdm^bVa eVabVg gZ\^dc d[ i]Z [dgZVgb gZh^hiVci id XdchZg" kVi^kZ igZVibZci h]djaY WZ Xdch^YZgZY id WZ i]Z gZhjai d[ XdbegZhh^dc d[ i]Z bZY^Vc cZgkZ ^c i]Z egdcVidg ijccZa# I]Z ediZci^Va h^iZh d[ XdbegZh" h^dc! ]dlZkZg! VgZ cdi dcan ^c i]Z egdcVidg bjhXaZ0 i]ZgZ[dgZ! ^i ldjaY WZ bdgZ VYZfjViZ id iZgb i]^h XdcY^i^dc Åegdm^bVa bZY^Vc cZgkZ XdbegZhh^dc#Æ I]Z bdhi egdm^bVa ediZci^Va higjXijgZ i]Vi XVc XdbegZhh i]Z bZY^Vc cZgkZ i]Z a^\VbZci d[ Higji]Zgh# I]^h ÑWgdjh WVcY gjch [gdb V hjegV" XdcYnad^Y egdXZhh id i]Z bZY^Va Ze^XdcYnaZ! VcY i]Z bZY^Vc cZgkZ eVhhZh WZcZVi] ^i# 6ai]dj\] i]Z hjegVXdcYnad^Y egdXZhh ^h [djcY ^c dcan ( d[ eVi^Zcih! i]Z a^\VbZci d[ Higji]Zgh ^h ediZc" i^Vaan egZhZci ^c ZkZgndcZ0 i]jh! i]Z egdm^bVa bZY^Vc cZgkZ h]djaY WZ ZmeadgZY egdm^bVa id i]Z ZaWdl id WZ hjgZ i]Z cZgkZ ^h cdi XdbegZhhZY Vi i]^h aZkZa# I]Z cZmi higjXijgZ i]Vi XVc XdbegZhh i]Z bZY^Vc cZgkZ ^h i]Z aVXZgijh ÑWgdhjh#I]Z bZY^Vc cZgkZ i]Zc eVhhZh i]gdj\] i]Z egdcVidg ijccZa! l]^X] ^h [dgbZY Wn i]Z ild ]ZVYh d[ i]Z egdcVidg iZgZh! l^i] i]Z^g iZcY^cdjh dg^\^ch VcY ÑWgdjh ZY\Zh# >c VYY^i^dc! di]Zg ÑWgdjh WVcYh bVn Xdchig^Xi i]Z cZgkZ Vh ^i eVhhZh i]gdj\] i]^h bjhXaZ# 9^hiVa id i]Z egdcVidg!i]Z cZgkZ eVhhZh i]gdj\] V iZcY^cdjh VgX [dgbZY Wn i]Z dg^\^c d[ i]Z ÒZmdg Y^\^idgjb hjeZgÑX^Va^h ;9H #, L]Zc YZXdbegZhh^c\ i]Z cZgkZ! ^i ^h l^hZ id [daadl i]Z V[dgZbZci^dcZY XdjghZ VcY cdi id aZVkZ Vcn d[ i]Z XdbegZhh^dc h^iZh jcgZaZVhZY# I]ZgZ[dgZ! ^c i]Z eVhi, VcY hi^aa idYVn! adc\ ^cX^h^dch! [gdb &' Xb id '% Xb! ]VkZ WZZc hj\\ZhiZY#* 6h ^c XVgeVa ijccZa hncYgdbZ! i]Z V^b d[ hjg\Zgn ^c egdcVidg hncYgdbZ ^h i]Z XdbeaZiZ YZXdbegZhh^dc d[ i]Z bZY^Vc cZgkZ# 6aa d[[ZcY" ^c\ iZcY^cdjh VcY ÑWgdjh higjXijgZh Xgdhh^c\
Figure 6-6. Skin incision for a minimally invasive approach to pronator tunnel release.
i]Z bZY^Vc cZgkZ bjhi WZ gZaZVhZY# I]Z ÒZh]n eVgih d[ i]Z bjhXaZh ^ckdakZY VgZ cZkZg Åd[[ZcY" ^c\Æ higjXijgZh VcY XVc WZ aZ[i ^ciVXi# I]^h X^g" XjbhiVcXZ bV`Zh i]Z hjg\Zgn aZhh Åd[[Zch^kZÆ VcY deZch i]Z Yddg [dg V b^c^bVaan ^ckVh^kZ VcY ZcYdhXde^X VeegdVX]# ;daadl^c\ \j^YZa^cZh [dg hV[Z ZcYdhXde^X hjg\Zgn! lZ ZmedhZ i]Z bZY^Vc cZgkZ i]gdj\] V ("id")"Xb igVchkZghZ ^cX^h^dc ' Xb id ( Xb Y^hiVa [gdb i]Z XjW^iVa XgZVhZ! dc i]Z jacVg"eVabVg VheZXi d[ i]Z [dgZVgb ;^\jgZ +"+ # I]Z [VhX^V ^h ZmedhZY WZilZZc i]Z ÒZmdg XVge^ gVY^Va^h VcY egdcVidg iZgZh# I]Z bZY^Vc cZgkZ XVc WZ ZVh^an adXViZY ]ZgZ Wn eVaeVi^dc ;^\jgZ +",V # I]Z [VhX^V ^h deZcZY! VcY i]Z bjhXaZ WZaa^Zh VgZ gZigVXiZY gVY^Vaan VcY jacVgan l^i] Veegdeg^ViZan h^oZY AVc\ZcWZX` gZigVXidgh WaVYZ ( Xb l^YZ VcY * Xb id + Xb adc\ # 6 hZa["gZiV^c^c\ gZigVXidg bVn WZ ]Zae[ja Y^higVXi^c\ i]Z ldjcY bVg\^ch ^c i]Z Y^hiVa"egdm^bVa Y^gZXi^dc# I]Z cZgkZ ^h Y^h" hZXiZY l^i] ZVhZ jcYZg Y^gZXi k^h^dc Vh [Vg Vh edhh^WaZ ;^\jgZ +",W # 6 hjWXjiVcZdjh ijccZa ^h XgZViZY Y^hiVaan VcY egdm^bVaan# 6 ."id"&&"Xb heZXjajb ^h ^cigd" YjXZY! VcY [dgZVgb [VhX^V VcY bjhXaZ gVe]Z VgZ igVchZXiZY Ñghi ^c V egdm^bVa Y^gZXi^dc# I]Z ZcYdhXdeZ ^h ^cigdYjXZY! VcY Y^hhZXi^dc XVgg^ZY dji Vh YZhXg^WZY [dg i]Z hjg\Zgn d[ XjW^iVa ijccZa hncYgdbZ# I]Z ÑWgdjh VgXVYZh VcY di]Zg Xdc" hig^Xi^c\ WVcYh l^i]^c i]Z egdcVidg VcY egdm^" bVa id ^i VgZ Y^k^YZY! VcY i]Z cZgkZ ^h XdbeaZiZan YZXdbegZhhZY je id - Xb egdm^bVa id i]Z XjW^iVa XgZVhZ ;^\jgZ +"- # I]Z bjhXaZh i]ZbhZakZh VgZ aZ[i ^ciVXi# I]Z hVbZ egdXZYjgZ ^h YdcZ ^c V Y^hiVa
76
Tissue Surgery
Figure 6-7. a) Exposure of the forearm fascia in a direct approach to dissecting the median nerve. b) Further direct dissection of the median nerve (left distal).The muscular nerve branches, and first fibrous arcade are distal to the nerve.
Y^gZXi^dc# 6aa WgVcX]Zh d[ i]Z cZgkZ XVc WZ k^hj" Va^oZY! ^YZci^ÑZY! VcY egdiZXiZY# ;^Wgdjh VgXVYZh ^c i]Z egdcVidg ijccZa VgZ Y^k^YZY ;^\jgZh +".V VcY +".W # I]Z VciZg^dg ^ciZgdhhZjh cZgkZ XVc WZ [daadlZY VcY ^h Xdb" eaZiZan YZXdbegZhhZY ;^\jgZ +"&% # 6i i]Z ZcY d[ i]Z ZcYdhXde^X gdjiZ! i]Z ;9H VgX ^h adXViZY VcY Y^k^YZY ;^\jgZ +"&& # 6 hjXi^dc YgV^c ^h ^chZgiZY VcY i]Z ldjcY XadhZY# 6 Wja`n YgZhh^c\ ^h Veea^ZY! VcY i]Z jeeZg Vgb ^h XVhi ^c eaVhiZg d[ EVg^h [dg ' YVnh# EdhideZgVi^kZan! eVi^Zcih VgZ ZcXdjgV\ZY id bdkZ i]Z Vgb! l]^X] ^h egdiZXiZY dcan Wn Vc ZaVhi^X WVcYV\Z#
Figure 6-8. Endoscopic view of the fibrous arcade in the proximal pronator tunnel.
Figure 6-9. Fibrous arcade in the distal part of pronator tunnel a) before and b) after endoscopic release.
Minimally Invasive and Endoscopic Techniques in Peripheral Nerve Surgery of the Hand and Forearm
Figure 6-10. Endoscopic view of the anterior interosseus nerve branching off median nerve and crossing under the tendinous edge (right).
Figure 6-11. Endoscopic view of the flexor digitorum superficialis arc before division.
LZ XVc dcan gZedgi egZa^b^cVgn gZhjaih ^c * eVi^Zcih! Wji i]Zn VgZ kZgn ZcXdjgV\^c\# 6aa eVi^Zcih lZgZ hjXXZhh[jaan gZa^ZkZY d[ i]Z^g hnbe" idbh VcY ]VY [jaa gVc\Z d[ ZaWdl bdi^dc l^i]^c * id + YVnh# I]Z aZVhi lZ XVc hVn Vi i]^h ZVgan hiV\Z ^h i]Vi i]Z gZhjaih d[ ZcYdhXde^X bVcV\ZbZci d[ i]^h cZgkZ ZcigVebZci VgZ ZfjVa id i]Z deZc bZi]dY Wji i]Vi bdgW^Y^in ^h bjX] aZhh VcY ZVgan gZ]VW^a^iVi^dc bjX] [VhiZg#
Anterior Interosseus Syndrome 8a^c^XVaan! i]Z VciZg^dg ^ciZgdhhZjh hncYgdbZ ^h bjX] bdgZ dWk^djh VcY ZVh^Zg id Y^V\cdhZ i]Vc i]Z egdcVidg hncYgdbZ#, EVi^Zcih egZhZci l^i]
77
lZV`cZhh dg eVahn d[ i]Z bjhXaZh ^ccZgkViZY Wn i]Z VciZg^dg ^ciZgdhhZjh cZgkZ! i]Z ÒZmdg edaa^X^h adc\jh! i]Z ÒZmdg Y^\^idgjb egd[jcYjh id i]Z ^cYZm Ñc\Zg! VcY i]Z egdcVidg fjVYgVijh# >c Xdc" igVhi id egdcVidg hncYgdbZ! ZaZXigdbnd\gVe]n d[ i]Z ;EA ^h jhjVaan ]Zae[ja id XdcÑgb i]Z Y^V\" cdh^h# 6ciZg^dg ^ciZgdhhZjh eVahn bVn WZ XVjhZY Wn V cZjg^i^h EVghdcV\Z"IjgcZg hncYgdbZ ! l]^X] bjhi WZ gjaZY dji Wn V cZjgdad\^hi WZ[dgZ hjg\Zgn# 6ai]dj\] Xa^c^XVa ÑcY^c\h jhjVaan ^YZci^[n i]Z h^iZ d[ XdbegZhh^dc! [VhX^XjaVg XdbegZhh^dc l^i]^c i]Z bZY^Vc cZgkZ bVn Xdc[djcY i]Z adXVi^dc#- 6ai]dj\] lZ Yd cdi eZg[dgb Vc ^ciZg" cVa cZjgdanh^h ^c Vaa XVhZh d[ VciZg^dg ^ciZgdhhZjh hncYgdbZ!lZ XdbeaZiZan YZXdbegZhh i]Z bZY^Vc cZgkZ Vh YZhXg^WZY [dg egdcVidg hncYgdbZ! ^c VYY^i^dc id V bZi^Xjadjh YZXdbegZhh^dc d[ i]Z VciZg^dg ^ciZgdhhZjh cZgkZ VcY Vaa ^ih WgVcX]Zh# I]Z b^c^bVaan ^ckVh^kZ VcY ZcYdhXde^X VeegdVX]! cVijgVaan! ^h h^b^aVg id i]Vi ^c i]Z egd" cVidg hncYgdbZ# LZ gdji^cZan ^YZci^[n i]Z aZkZa l]ZgZ i]Z VciZg^dg ^ciZgdhhZjh WgVcX]Zh d[[ i]Z bZY^Vc cZgkZ hiZb Wn cZjgdjaigVhdjcY egZ" deZgVi^kZan hd i]Vi i]Z h`^c ^cX^h^dc XVc WZ eaVXZY bdgZ egZX^hZan# I]Z VciZg^dg ^ciZgdhhZjh WgVcX] ^h ^YZci^ÑZY VcY [daadlZY id ^ih bjhXjaVg WgVcX]Zh! ZheZX^Vaan i]Z dcZ ^ccZgkVi^c\ i]Z ÒZmdg edaa^X^h! id bV`Z hjgZ ZkZgn ediZci^Va XdbegZhh^dc ^h VYYgZhhZY# 6i i]^h hiV\Z d[ djg ZcYdhXde^X ZmeZg^ZcXZ! lZ WZa^ZkZ i]^h Y^hhZX" i^dc h]djaY WZ YdcZ jcYZg Y^gZXi k^h^dc# DcXZ Vaa Xdchig^Xi^c\ ZaZbZcih ]VkZ WZZc gZaZVhZY! i]Z bZY^Vc cZgkZ ^h ZcYdhXde^XVaan YZXdbegZhhZY Vh YZhXg^WZY VWdkZ#
Cubital Tunnel Syndrome I]Z dkZgVaa hjXXZhh gViZ d[ i]Z Y^[[ZgZci hjg\^XVa egdXZYjgZh [dg XjW^iVa ijccZa hncYgdbZ! l]^X] ^h i]Z hZXdcY bdhi [gZfjZci cZgkZ ZcigVebZci d[ i]Z Vgb! ^h WZilZZc -% VcY .%#* Hi^aa! i]Z YZWViZ dc ^c h^ij Åh^beaZÆ cZgkZ YZXdbegZhh^dc kZghjh VciZg^dg igVchedh^i^dc Xdci^cjZh#.!&%!&& >[ ^c h^ij YZXdbegZhh^dc \^kZh i]Z hVbZ \ddY hjXXZhh gViZ!&'!&( dcZ ldjaY i]^c` i]Vi V XdbeaZm egdXZYjgZ! hjX] Vh i]Z VciZg^dg igVch" edh^i^dc d[ i]Z jacVg cZgkZ! ZheZX^Vaan ^ih bdhi V\\gZhh^kZ hjWbjhXjaVg kZgh^dc! ldjaY ]VkZ cd eaVXZ# L]n ldjaY V hjg\Zdc jccZXZhhVg^an g^h` ediZci^Va Xdbea^XVi^dch! hjX] Vh YZkVhXj" aVg^oVi^dc d[ i]Z cZgkZ! eV^c[ja ZmiZch^dc d[
78
ZaWdl! V cZl XdbegZhh^dc h^iZ Wn `^c`^c\! VcY eZg^cZjgVa ÑWgdh^h4 I]ZhZ VgZ dcan V [Zl ZmVbeaZh d[ ediZci^Va Xdbea^XVi^dch d[ VciZg^dg igVchedh^i^dc# 6 hjg\Zdc hZZ`^c\ VYk^XZ [gdb cX# ^h ^cigdYjXZY VcY hadlan VYkVcXZY Y^hiVaan ;^\jgZ +"&* # A^[i^c\ je i]Z hd[i i^hhjZ ZckZadeZ d[ i]Z [dgZVgb l^i] i]Z Y^h" hZXidg XgZViZh V \ZcZgdjh heVXZ id k^Zl i]Z cZgkZ VcY ^ih hjggdjcY^c\ VcVidbn# 6aa Y^hhZXi^dc VcY Xjii^c\ ^h YdcZ l^i] Wajci"i^eeZY hX^hhdgh
Figure 6-12. Retrocondylar dissection of the ulnar nerve through a small incision. The nerve is always identifiable by the vasa nervorum.
Minimally Invasive and Endoscopic Techniques in Peripheral Nerve Surgery of the Hand and Forearm
79
WZilZZc &,Xb VcY '( Xb adc\# JcYZg bdc^idg k^h^dc! i]Z [dgZVgb [VhX^V ^h Y^k^YZY id V ed^ci &%Xb id &)Xb Y^hiVaan [gdb i]Z Ze^XdcYnaZ ;^\jgZ +"&+ # 8VgZ bjhi WZ iV`Zc cdi id ^c_jgZ i]Z XjiVcZdjh cZgkZ WgVcX]Zh dg i]Z kZ^ch i]Vi bVn Xgdhh i]Z [VhX^V# DcXZ i]Z [VhX^V ]Vh WZZc Y^k^YZY! i]Z ZcYdhXdeZ ^h XVgZ[jaan ejaaZY WVX`! VcY [jgi]Zg Y^hhZXi^dc ^h XVgg^ZY dji XadhZ id i]Z cZgkZ# I]Z cZmi hiZe ^h id Y^k^YZ i]Z ild bjhXjaVg ]ZVYh d[ i]Z ÒZmdg XVge^ jacVg^h VcY id gZaZVhZ d[ Vaa ÑWgdjh WVcYh Xgdhh^c\ i]Z cZgkZ# 9^hiVaan [gdb DhWdgcZÈh a^\VbZci! i]Z [VhX^V WZilZZc i]Z ild ]ZVYh d[ i]Z ÒZmdg XVge^ jacVg^h ;8J ^h Figure 6-13. Distal tunneling of the cubital tunnel (see text).
a
c
b
d
Figure 6-14. a) Speculum inserted for initial viewing of the distal cubital tunnel. b) Ulnar nerve entering the cubital tunnel under Osborne’s ligament (cubital retinaculum). c) Speculum view of scissors about to cut Osborne’s ligament and
the first part of the flexor carpi ulnaris (FCU) fascia. d) Osborne’s ligament and the first part of the FCU fascia released. The scissors blades are under the first fibrous arcade between the two heads of the FCU.
80
Tissue Surgery
Figure 6-15. Endoscopic dissection 10 cm to 12 cm from the ulnar epicondyle.
Figure 6-16. Dissecting scissors “en route,” dividing the superficial forearm fascia 8 cm to 10 cm from the retro-condylar groove. A tiny nerve, identifiable by the vasa nervorum, crosses fascia distal from the scissors.
Y^k^YZY# 6Wdji ( Xb Y^hiVa [gdb i]Z bZY^Va Ze^XdcYnaZ! i]Z Ñghi ÑWgdjh VgXVYZ XVc WZ adXViZY VcY Y^k^YZY# I]Zc i]Z gVe]Z WZilZZc i]Z ild bjhXjaVg ZaZbZcih d[ i]Z ;8J ^h igVchZXiZY! VcY Vaa Xdchig^Xi^c\ ZaZbZcih je id V Y^hiVcXZ d[ eZg]Veh &' Xb bZVhjgZY [gdb i]Z b^YYaZ d[ i]Z gZigdXdcYnaVg \gddkZ VgZ Y^k^YZY# >c i]Z XdjghZ d[ i]^h Y^hhZXi^dc! Vaa bjhXaZ WgVcX]Zh XVc WZ hZZc VcY egdiZXiZY ;^\jgZ +"&, # LZ ]VkZ gZ\j" aVgan dWhZgkZY VcY Y^k^YZY Y^hi^cXi ÑWgdjh VgXVYZh Vi * Xb! , Xb! VcY . Xb [gdb i]Z Ze^Xdc" YnaZ ;^\jgZ +"&- # Dcan gVgZan ^h ^i cZXZhhVgn id
Xa^e dg XVjiZg^oZ V kZhhZa# AVm VY^edhZ hd[i i^hhjZ d[ i]Z [dgZVgb! Vh hdbZi^bZh hZZc ^c ZaYZgan ldbZc! bV`Zh i]Z Y^hhZXi^dc Y^[ÑXjai! bV^can WZXVjhZ i]Z dei^X cZZYh gZeZViZY XaZVc^c\ VcY hdbZ addhZ [Viin i^hhjZ bjhi WZ gZbdkZY# Egdm^bVaan! i]Z ijccZa gdd[ ^h YZXdbegZhhZY ^c i]Z hVbZ [Vh]^dc# I]Z [VhX^V! Wji cdi i]Z ^ciZgbjhXjaVg hZeijb! ^h Y^k^YZY - Xb id &% Xb [gdb i]Z gZigdXdcYnaVg \gddkZ# Cd Xdchig^Xi^c\ ZaZbZcih ]VkZ WZZc dWhZgkZY ^c i]^h VgZV# 6 8= - hjXi^dc YgV^c bVn WZ ^chZgiZY! VcY V Wja`n YgZhh^c\ Veea^ZY# I]Zc i]Z idjgc^fjZi ^h
Figure 6-17. Magnified endoscopic view of nerve branches in the cubital tunnel.
Minimally Invasive and Endoscopic Techniques in Peripheral Nerve Surgery of the Hand and Forearm
81
addhZcZY# EVi^Zcih VgZ VaadlZY id bdkZ i]Z^g ZaWdl Wji VgZ ^chigjXiZY id Vkd^Y gZhi^c\ i]Z Vgb ^c ÒZm^dc [dg ) id + lZZ`h! id egZkZci hZXdcYVgn cZgkZ hjWajmVi^dc# 6[iZg ( YVnh! Vc ZaVhi^X ZaWdl WVcYV\Z ^h egZhXg^WZY [dg ) id + lZZ`h# Id kVa^YViZ i]Z cZZY [dg Vc ZmiZch^kZ Y^hiVa gZaZVhZ d[ i]Z jacVg cZgkZ ^c eVi^Zcih l^i] XjW^iVa ijccZa hncYgdbZ! lZ ZkVajViZY i]Z jacVg cZgkZ VcVidbn ^c ^ih Y^hiVa XdjghZ ^c i]Z [dgZVgb WZilZZc i]Z ild ]ZVYh d[ i]Z ;8J# 6aa XVYVkZg heZX^bZch hijY^ZY h]dlZY Zk^YZcXZ d[ [VhX^Va WVcYh Xgdhh^c\ i]Z jacVg
cZgkZ dc ^ih gdjiZ WZilZZc i]Z ild ]ZVYh d[ i]Z ;8J# 6[iZg i]Z ^ciZgbjhXjaVg hZeijb WZilZZc i]Z ild ]ZVYh d[ i]Z ;8J lZgZ Y^h" hZXiZY! i]gZZ Y^hi^cXi odcZh d[ [VhX^Va i]^X`Zc" ^c\! hZZc Vh k^h^WaZ WVcYh! lZgZ ZcXdjciZgZY ;^\jgZ +"&.V # I]Z Ñghi WVcY lVh hZZc ( Xb [gdb i]Z b^YYaZ d[ i]Z gZigdXdcYnaVg \gddkZ! VcY ^i lVh &#* Xb l^YZ! ZcY^c\ )#* Xb [gdb i]Z b^YYaZ d[ i]Z \gddkZ# I]Z hZXdcY WVcY dg^\^" cViZY * Xb Y^hiVa id i]Z b^YYaZ d[ i]Z \gddkZ VcY lVh cVggdlZg! bZVhjg^c\ dcan %#* Xb ^c l^Yi]# >i ZcYZY *#* Xb Y^hiVa [gdb i]Z \gddkZ# I]Z i]^gY WVcY dg^\^cViZY , Xb Y^hiVa [gdb i]Z \gddkZ# I]^h WVcY lVh i]Z bdhi egdb^cZci VcY bZVhjgZY ' Xb ^c l^Yi]# I]^h WVcY ZmiZcYZY je id . Xb [gdb i]Z b^YYaZ d[ i]Z \gddkZ ;^\jgZ +"&.W # I]Z gZhjaih [gdb i]^h egdXZYjgZ VgZ ZcXdjgV\" ^c\# 7ZilZZc BVgX] '%%& VcY ;ZWgjVgn '%%*! VWdji &*% eVi^Zcih jcYZglZci i]^h egdXZYjgZ! d[ l]^X] .* gZedgiZY ^begdkZbZci d[ hnbeidbh l^i]^c ') ]djgh V[iZg hjg\Zgn VcY Xdci^cjZY id ^begdkZ i]ZgZV[iZg# I]ZgZ lZgZ cd gZXjggZcXZh# EdhideZgVi^kZ cZgkZ hjWajmVi^dc Y^Y cdi dXXjg# >c i]Z adc\Zg iZgb! .( d[ eVi^Zcih ]VY ZmXZaaZci VcY \ddY gZhjaih0 bdgZ i]Vc .% ]VY [jaa ZaWdl bdi^dc l^i]^c ' YVnh V[iZg hjg\Zgn VcY i]Z gZhi! l^i]^c V lZZ`# >c ,* eVi^Zcih! i]Z [daadl^c\ Xdbea^XVi^dch lZgZ [djcY# 6a\dYnhigde]n YZkZadeZY ^c & eVi^Zci! VcY i]Z gZhjai lVh eddg# I]ZgZ lZgZ ) XVhZh d[ hjeZgÑX^Va ]ZbVidbV# 6aa gZhdakZY l^i]^c V lZZ`! VcY cd eVgi^XjaVg igZVibZci lVh
Figure 6-18. The 3rd fibrous arcade at the distal end of the cubital tunnel about 9 cm from the retro-condylar groove.The two layers of dissection are shown: the superficial fascia already split, and the arcade close to the nerve before release.
Figure 6-19. a) Cadaver dissection of the ulnar nerve in the cubital tunnel showing fibrous thickening around the nerve. b) “Anterior transposition” of the ulnar nerve demonstrating the possibility of a new nerve compression and kinking against the cut edge of the fascia and fibrous arcade.
82
cZXZhhVgn# >c . eVi^Zcih! ]neZhi]Zh^V YZkZadeZY ^c i]Z h`^c ^ccZgkViZY Wn i]Z jacVg VciZWgVX]^Va XjiVcZdjh cZgkZ! bdhi a^`Zan [gdb higZiX]^c\ d[ i]Z cZgkZ Yjg^c\ i]Z ijccZa^c\ egdXZYjgZ# >c Vaa Wji & eVi^Zci! ]neZhi]Zh^V gZhdakZY l^i]^c ( bdci]h# I]Z VYkVciV\Zh d[ djg ZcYdhXde^X iZX]c^fjZ [dg XjW^iVa ijccZa hncYgdbZ VgZ bV^can ^ih h^b" ea^X^in VcY adl bdgW^Y^in# I]Z cZgkZ ^h Z[ÑX^Zcian YZXdbegZhhZY dkZg V adc\ Y^hiVcXZ ^c ^ih dlc ]VW^iVi# AZh^dch d[ XjiVcZdjh cZgkZ WgVcX]Zh VgZ Vkd^YZY WZXVjhZ d[ i]Z kZgn hbVaa ^cX^h^dc# I]Z hd[i i^hhjZ ZckZadeZ dkZg i]Z jacVg cZgkZ gZbV^ch ^ciVXi VcY hiVW^a^oZh i]Z cZgkZ# Cd hXVgh ^beV^g i]Z [gZZ \a^Y^c\ d[ i]Z i^hhjZ aVnZgh#
Tennis Elbow (Including Radial Tunnel Syndrome) I]Z XVjhZ d[ X]gdc^X eV^c ^c i]Z aViZgVa ZaWdl! hdbZl]Vi b^haZVY^c\an iZgbZY ÅiZcc^h ZaWdl!Æ ^h hi^aa jc`cdlc! l]^X] bVn WZ l]n V kVg^Zin d[ hjg\^XVa egdXZYjgZh ]VkZ WZZc YZhXg^WZY id igZVi ^i! ^cXajY^c\ YZcZgkVi^dc!&- ZmiZchdg iZcYdc gZaZVhZ!&* VcY YZXdbegZhh^dc d[ i]Z edhiZg^dg ^ciZgdhhZjh cZgkZ E>C #&+ Hjg\Zgn! ^c djg de^c^dc! ^h ^cY^XViZY ^[ gZeZViZY ViiZbeih d[ cdcdeZgVi^kZ igZVibZci ]VkZ [V^aZY# Dcan ^c VWdji &% d[ djg eVi^Zcih! l]ZgZ hnbe" idbh VcY e]nh^XVa h^\ch hj\\Zhi Vc ^hdaViZY Ze^XdcYna^i^h! Yd lZ a^b^i hjg\Zgn id i]Z Ze^Xdc" YnaVg VgZV! YZcZgkVi^c\ i]Z aViZgVa ZaWdl VcY gZaZVh^c\ Vaa ZmiZchdgh dg^\^cVi^c\ [gdb i]Z aViZgVa Ze^XdcYnaZ# >c Vaa di]Zg XVhZh! lZ XdbW^cZ i]^h egdXZYjgZ l^i] V YZXdbegZhh^dc d[ i]Z E>C# I]Z gZVhdc [dg i]^h XdbW^cVi^dc ^h i]Vi bdhi d[iZc i]Z aViZgVa Ze^XdcYnaZ VcY i]Z gVY^Va ijccZa VgZ ZfjVaan iZcYZg# 7di] XdcY^i^dch hZZb ^chZeVgVWan XdccZXiZY id jh VcY VgZ Vabdhi ^cY^hi^c\j^h]VWaZ Wn Xa^c^XVa ZmVb^cVi^dc# :aZX" igdbnd\gVe]n ^h gVgZan ]Zae[ja [dg eVi^Zcih l^i] iZcc^h ZaWdl Wji bVn egdkZ jhZ[ja ^[ V E>C eVahn ^h egZhZci# ;dg bVcn nZVgh! lZ ]VkZ jhZY hiVcYVgY ^cX^" h^dch l^i] a^iiaZ bdY^ÑXVi^dc [gdb i]dhZ hZZc ^c bdhi iZmiWdd`h#)!* HXVgh [gdb i]ZhZ ^cX^h^dch XVjhZ egdWaZbh! cdi dcan VZhi]Zi^XVaan# I]Z bdgZ ZmiZch^kZ i]Z ^cX^h^dc! i]Z ]^\]Zg i]Z g^h` d[ hZk" Zg^c\ dcZ d[ i]Z bVcn XjiVcZdjh cZgkZ WgVcX]Zh ^c i]^h VgZV VcY id egdYjXZ V eV^c[ja cZjgdbV# I]ZgZ ^h ]VgYan Vcn hd[i i^hhjZ eVYY^c\ dc i]Z Ze^XdcYnaZ! hd i]Z hXVg bVn iZi]Zg Ydlc id
Tissue Surgery
i]Z WdcZ! WZXdbZ eV^c[ja! VcY ^beV^g bdi^dc# BdgZdkZg! id Vaadl VXXZhh id i]Z gVY^Va ijccZa! ^i bjhi WZ [V^gan adc\! je id &% Xb dg bdgZ# ;daadl^c\ djg eg^cX^eaZh [dg b^c^bVaan ^ckVh^kZ VcY ZcYdhXde^X iZX]c^fjZh! lZ cdl eZg[dgb i]Z XdbW^cZY deZgVi^dc [gdb V )"Xb ^cX^h^dc dkZg i]Z gVY^Va ijccZa ;^\jgZ +"'% ! VWdji * Xb Y^hiVa [gdb i]Z Ze^XdcYnaZ# I]Z ^cX^h^dc ^h dWa^fjZ dg igVchkZghZ! YZeZcY^c\ dc i]Z Y^gZXi^dc d[ i]Z h`^c XgZVhZh! l]^X] VgZ ZVh^an YZiZXiZY Wn a^\]ian hfjZZo^c\ i]Z h`^c# L]Zc Zmedh^c\ i]Z [VhX^V! Vaa XjiVcZdjh WgVcX]Zh d[ i]Z VgZV bjhi WZ egdiZXiZY# L^i] i]Z ijccZa^c\ [dgXZeh! lZ XgZViZ V heVXZ ^c i]Z eZg^Ze^XdcYnaVg VgZV ;^\jgZ +"'& # 6c ^aajb^cViZY heZXjajb WaVYZ aZc\i] . id && Xb ^h ^chZgiZY! \^k^c\ V eZg[ZXi k^Zl d[ i]Z Ze^XdcYnaZ VcY ^ih hjggdjcY" ^c\ higjXijgZh ;^\jgZ +"''V # I]gdj\] i]Z heZXjajb!lZ Xdci^cjZ l^i] i]Z Ze^[VhX^Va YZiVX]" bZci d[ i]Z ÒVeh! i]ZgZWn hZkZg^c\ i^cn eV^c" igVchb^ii^c\ WgVcX]Zh d[ i]Z YdghVa XjiVcZdjh VciZWgVX]^Va cZgkZ# 6cdi]Zg hbVaa cZgkZ WgVcX] gjcc^c\ l^i] i]Z gVY^Va ^ciZgbjhXjaVg hZeijb ^h XVjiZg^oZY VWdji ( Xb egdm^bVa d[ i]Z Ze^XdcYnaZ# I]Z cZmi hiZe ^h i]Z XdbeaZiZ gZaZVhZ d[ Vaa ZmiZchdg iZcYdc dg^\^ch WZilZZc Ze^XdcYnaZ VcY gVY^Va ]ZVY! aZVk^c\ i]Z _d^ci XVehjaZ ^ciVXi ;^\jgZ +"''W # :mXZaaZci k^h^dc Vaadlh [dg bZi^Xjadjh ]ZbdhiV" h^h l^i] V W^edaVg b^Xgd [dgXZeh# I]Z gVY^Va cZgkZ ^h VeegdVX]ZY igVchbjhXj" aVgan ^c ^ih eaVcZ WZilZZc i]Z ZmiZchdg Y^\^idgjb VcY i]Z ZmiZchdg XVge^ gVY^Va^h WgZk^h#, >[ i]Z
Figure 6-20. Incision, following the skin crease, for a minimally invasive approach to the peri-epicondylar area and radial tunnel of the posterior interosseus nerve.
Minimally Invasive and Endoscopic Techniques in Peripheral Nerve Surgery of the Hand and Forearm
Figure 6-21. Insertion of the speculum (blade length, 11 cm) for viewing the peri-epicondylar area.
cZgkZ ^h ZmeadgZY ^c XdccZXi^dc l^i] i]Z egdXZ" YjgZ YZhXg^WZY VWdkZ! lZ Xdci^cjZ id hZeVgViZ i]Z VedcZjgdh^h WZilZZc i]Z YZhdg^\^cViZY bjhXaZh VcY YZkZade i]Z eaVcZ [gdb i]ZgZ# >[ gVY^Va cZgkZ YZXdbegZhh^dc ^h YdcZ Vh V hZeVgViZ deZgVi^dc! ^i ^h ZVh^Zg id deZc i]Z gVe]Z WZilZZc i]Z ZmiZchdg XVge^ gVY^Va^h WgZk^h VcY i]Z ZmiZc" hdg Y^\^idgjb bdgZ Y^hiVaan# 6[iZg ZciZg^c\ i]Z ^ciZgbjhXjaVg eaVcZ! Y^h" hZXi^dc ^h jhjVaan Wajci! VcY aVg\Z AVc\ZcWZX`h VgZ ^chZgiZY id gZigVXi i]Z WgVX]^dgVY^Va^h bjhXaZ bVhh VcY i]Z ZmiZchdg bjhXaZh id Z^i]Zg h^YZ! Zmedh^c\ i]Z E>C# 6h V gZhjai d[ i]Z kZgn hbVaa
83
^cX^h^dc! i]^h eVgi d[ i]Z deZgVi^dc ^h iZY^djh VcY Y^[ÑXjai VcY gZfj^gZh ZmeZg^ZcXZ l^i] Y^hhZXi^c\ i]Z VcVidbn VgdjcY ;gd]hZÈh VgXVYZ# >i Vahd gZfj^gZh ZmXZaaZci Vhh^hiVcXZ WZXVjhZ i]Z gZigVX" idgh bjhi WZ ejaaZY [V^gan ]VgY Wji! Vi i]Z hVbZ i^bZ! cd egZhhjgZ ^h VaadlZY dc i]Z cZgkZ WgVcX]Zh# JhjVaan ^cX^h^c\ i]Z iZcY^cdjh bVg\^c d[ i]Z ZmiZchdg XVge^ gVY^Va^h WgZk^h \gZVian ]Zaeh id ZmedhZ i]Z hje^cVidg bjhXaZ VcY ;gd]hZÈh VgXVYZ Vi ^ih egdm^bVa ZY\Z# LZ Y^k^YZ i]Z VgXVYZ VcY Vaa VedcZjgdi^X eVgih d[ i]Z hje^cVidg! Wji cdi i]Z ÒZh]n eVgi d[ i]Z bjhXaZ# HdbZi^bZh kVh" XjaVg WjcYaZh Xgdhh^c\ i]Z E>C bjhi WZ ]Zbd" Xa^eeZY dg XVjiZg^oZY# LZ eVaeViZ XVgZ[jaan ^c V egdm^bVa Y^gZXi^dc Vadc\ i]Z gVY^Va cZgkZ! jcYZg i]Z WgVX]^dgVY^Va^h! [dg bdgZ egdm^bVa XdbegZhh^dc h^iZh# 6 hjXi^dc YgV^c bVn WZ ^chZgiZY! VcY i]Z ldjcY ^h ValVnh XadhZY ^c ild aVnZgh! jh^c\ ^cigVXjiVcZdjh h`^c XadhjgZ# 6c jeeZg Vgb YdghVa hea^ci ^h Veea^ZY [dg ' YVnh# 6[iZglVgYh! eVi^Zcih VgZ ^chigjXiZY id bdkZ i]Z^g ZaWdl! l]^X] ^h egdiZXiZY Wn Vc ZaVhi^X WVcYV\Z# E]nh^di]ZgVen ^h egZhXg^WZY ^[ cZXZhhVgn# LZ ]VkZ jhZY i]^h b^c^bVaan ^ckVh^kZ iZX]" c^fjZ h^cXZ ;ZWgjVgn '%%) ^c VWdji '% eVi^Zcih# >i ^h bjX] idd ZVgan id gZXdbbZcY ^i! ZheZX^Vaan [dg gVY^Va cZgkZ YZXdbegZhh^dc Åi]gdj\] V `Zn]daZÆ WZXVjhZ ^i ^h iZX]c^XVaan fj^iZ YZbVcY" ^c\# LZ ]VkZ WZZc ^begZhhZY! ]dlZkZg! l^i] i]Z kZgn adl bdgW^Y^in VcY \ddY [jcXi^dcVa gZhjaih# EVi^Zcih gZ\V^cZY [jaa gVc\Z d[ bdi^dc ZVga^Zg i]Vc l^i] djg XdckZci^dcVa bZi]dY! l]^X]
Figure 6-22. a) Endoscopic view of the peri-epicondylar area. The lateral epicondyle and extensor tendon origins are visible. b) The peri-epicondylar area after release of the extensor tendon origins.
84
Tissue Surgery
gZfj^gZY ^bbdW^a^oVi^dc [dg - id &' YVnh# 6aa eVi^Zcih lZgZ YZa^\]iZY l^i] i]Z ^cXdche^Xjdjh hXVg! ZheZX^Vaan i]dhZ l]d ]VY V aVg\Zg adc\^ijY^" cVa hXVg [gdb V egZk^djh deZgVi^dc dc i]Z di]Zg ZaWdl#
Radial Sensory Nerve Compression :cigVebZci d[ i]Z gVY^Va hZchdgn cZgkZ GHC Vi i]Z b^Y [dgZVgb ^h XZgiV^can aZhh [gZfjZci i]Vc i]Z XdbegZhh^dc cZjgdeVi]^Zh bZci^dcZY VWdkZ# CZkZgi]ZaZhh! ^i ^h V XVjhZ d[ X]gdc^X eV^c VcY Y^hXdb[dgi ^c i]Z gVY^Va [dgZVgb# BVcn eVi^Zcih l^i] i]^h ZcigVebZci VgZ gZ[ZggZY l^i] V Y^V\cdh^h d[ YZ FjZgkV^cÈh iZcYdkV\^c^i^h# I]Zn h]djaY WZ XVgZ[jaan ZmVb^cZY id ZmXajYZ i]Z Y^V\cdh^h d[ GHC XdbegZhh^dc# 7di] XdcY^" i^dch XVc Zm^hi Vi i]Z hVbZ i^bZ# I]Z GHC ^h jhjVaan XdbegZhhZY WZilZZc i]Z iZcY^cdjh ZY\Zh d[ i]Z ZmiZchdg XVge^ gVY^Va^h adc\jh VcY i]Z WgVX]^dgVY^Va^h WZilZZc i]Z b^Y" VcY Y^hiVa i]^gY d[ i]Z gVY^Va [dgZVgb# I]Z V^b d[ hjg\Zgn ^h id gZaZVhZ i]Z [VhX^V WZilZZc i]ZhZ bjhXaZh# 8dckZci^dcVa hjg\Zgn l^i] V +"Xb h`^c ^cX^h^dc ^h Z[[ZXi^kZ#&, Djg '"Xb igVchkZghZ ^cX^h^dc ^h Vi i]Z _jcXi^dc d[ i]Z b^Y VcY Y^hiVa i]^gY d[ i]Z gVY^Va X^gXjb" [ZgZcXZ d[ i]Z [dgZVgb# I]Z GHC ^h ^YZci^ÑZY VcY Y^hhZXiZY ;^\jgZ +"'( # 8VgZ bjhi WZ iV`Zc cdi id ^c_jgZ Vcn di]Zg XjiVcZdjh cZgkZh ^c i]^h VgZV# I]Z ijccZa^c\ ^h YdcZ Vh YZhXg^WZY VWdkZ! VcY i]Z ZcYdhXdeZ ^h \Zcian ^cigdYjXZY# 7Z^c\ hd
Figure 6-23. Dissection of RSN through a small incision on the forearm.
Figure 6-24. Endoscopic view of a partially divided fascia between the tendons of brachioradialis (right) and the extensor carpi radialis longus muscles (left).
XadhZ id i]Z cZgkZ VcY ldg`^c\ i]gdj\] V kZgn hbVaa ^cX^h^dc! i]Z ZcYdhXdeZ bjhi Vahd WZ gZbdkZY XVgZ[jaan id Vkd^Y ^c_jg^c\ i]Z cZgkZ l^i] i]Z ZY\Zh d[ i]Z Y^hhZXidg# 6h i]Z ZcYdhXdeZ ^h bdkZY [dglVgY VcY i]Z Y^hhZXi^dc egdXZZYh! i]Z _jcXi^dc WZilZZc i]Z iZcYdch d[ i]Z WgVX]^d" gVY^Va^h VcY i]Z ZmiZchdg XVge^ gVY^Va^h adc\jh XVccdi WZ b^hhZY#I]Z [VhX^V WZilZZc i]Z iZcYdch ^h ^cX^hZY! VcY i]Z ^cX^h^dc ^h XVgg^ZY [jgi]Zg jci^a i]Z ÒZh]n eVgi d[ i]Z bjhXaZh ^h gZVX]ZY ;^\jgZ +"') # 6i i]Z bV\c^ÑZY h^\]i d[ i]Z h]Vge iZcY^cdjh ZY\Z d[ i]Z WgVX]^dgVY^Va^h! dcZ b^\]i WZ iZbeiZY id ^cX^hZ i]^h iZcYdc! l]^X] ^h cdi cZXZhhVgn VcY! ^c djg de^c^dc! ldjaY dcan XgZViZ hXVgg^c\# L]Zc YZ FjZgkV^cÈh iZcYdkV\^c^i^h gZfj^gZh hjg\Zgn Vh lZaa! ^i XVc WZ eZg[dgbZY i]gdj\] i]Z hVbZ ^cX^h^dc# ;dg i]^h ejgedhZ! V hbVaaZg ZcYd" hXdeZ Y^hhZXidg ^h jhZY# L^i] i]Z GHC Vh V \j^YZ" a^cZ! i]Z gdd[ d[ i]Z Ñghi ZmiZchdg XdbeVgibZci! l]^X] ^h jhjVaan i]^X`ZcZY! ^h [djcY# 6 hXVaeZa l^i] V &* WaVYZ VcY V adc\ ]VcYaZ ^h ^cigdYjXZY! VcY i]Z XdbeVgibZci ^h ^cX^hZY# I]Z XdbeVgi" bZci bVn WZ gZaZVhZY l^i] i]Z hXVaeZa dg hX^h" hdgh# >[ Vc VXXZhhdgn XdbeVgibZci ^h egZhZci! i]^h ^h YZVai l^i] h^b^aVgan# I]Z gZhjaih VgZ jhjVaan kZgn \ddY# Cd deZc hjg\^XVa bZi]dY [dg i]^h Xdc" Y^i^dc aZVkZh i]Z YZa^XViZ GHC hd jcY^hijgWZY Vh i]^h ZcYdhXde^X egdXZYjgZ# I]Z ZmigV igdjWaZ ^h i]ZgZ[dgZ _jhi^ÑZY! ^c djg de^c^dc# 6[iZg YZXdb" egZhh^c\ i]Z GHC! l^i] dg l^i]dji gZaZVhZ d[ i]Z Ñghi iZcYdc XdbeVgibZci! lZ Veean V i]jbW he^XV [dg ( id ) YVnh#
Minimally Invasive and Endoscopic Techniques in Peripheral Nerve Surgery of the Hand and Forearm
References &%# &# 6\ZZ ?B! BX8Vggdaa =G! Cdgi] :G# :cYdhXde^X XVgeVa ijccZa gZaZVhZ jh^c\ i]Z h^c\aZ egdm^bVa ^cX^h^dc iZX]" c^fjZ# =VcY 8a^c# &..)0&%/+),Ã+*.# '# 8]dl ?8# :cYdhXde^X gZaZVhZ d[ i]Z XVgeVa a^\VbZci/ V cZl iZX]c^fjZ [dg XVgeVa ijccZa hncYgdbZ# 6gi]gdhXden# &.-.0*/&.Ã')# (# 7gdbaZn i lVh \ZcZgVaan V\gZZY i]Vi i]Z ^cigVbjhXjaVg Y^hhZXi^dc gZfj^gZY id Y^hhZXi [gZZ i]Z bjhXjadXjiVcZdjh ^cY^gZXi eZg[dgVidg lVh kVhian Y^[[ZgZci [gdb i]Vi gZfj^gZY id Y^hhZXi V hZeidXjiVcZdjh dg Y^gZXi eZg[dgVidg# ;j 8]Vc LZ^&( Vg\jZh i]Vi V igjZ eZg[dgVidg ^h V XjiVcZdjh kZhhZa i]Vi eZcZigViZh bjhXaZ! ^c VYY^" i^dc id e^ZgX^c\ i]Z [VhX^V id gZVX] i]Z h`^c# =Z YZg^kZh i]Z ldgY ÅeZg[dgVidgÆ [gdb i]Z AVi^c eZg[dgVgZ! bZVc^c\ Åid WdgZ i]gdj\]!Æ VcY hjeedgih i]Z k^Zl i]Vi Y^gZXi XjiVcZdjh kZhhZah dg i]dhZ eVhh^c\ WZilZZc bjhXaZh hZeidXjiVcZ" djh gZfj^gZ h^beaZg Y^hhZXi^dc iZX]c^fjZh VcY i]jh Yd cdi gZegZhZci ÅigjZÆ eZg[dgVidg ÒVeh# I]Z ÅigjZÆ eZg[dgVidg dg bndXjiVcZdjh ÒVeh VgZ cdl cVbZY VXXdgY^c\ id i]Z hdjgXZ kZhhZa# =dlZkZg! hZkZgVa Y^[[ZgZci bndXjiVcZdjh eZg[d" gVidg ÒVeh bVn WZ YZg^kZY [gdb V h^c\aZ hdjgXZ kZhhZa# >c i]ZhZ XVhZh! i]Z bjhXaZ i]gdj\] l]^X] i]Z eZg[dgVidg eVhhZh ^h VWWgZk^ViZY VcY ^iVa^" X^oZY id ^cY^XViZ i]Z VcVidb^X dg^\^c d[ i]Z ÒVe#
Tissue Surgery
I]jh! A8;6E"ka gZ[Zgh id i]Z bndXjiVcZdjh eZg[dgVidg YZg^kZY [gdb i]Z aViZgVa X^gXjbÒZm [ZbdgVa VgiZgn VcY eZg[dgVi^c\ i]Z kVhijh aViZgV" a^h0 i]Vi ^h! i]Z VciZgdaViZgVa i]^\] ÒVe 6AI # I]Z hiVcYVgY^oZY cdbZcXaVijgZ ^h gVi]Zg XjbWZg" hdbZ VcY ^h eZg]Veh bdgZ jhZ[ja Vh V gZigdheZX" i^kZ idda0 edejaVg cVbZh! hjX] Vh Å6AI ÒVe!Æ VgZ hi^aa ^c Xdbbdc jhZ#
Perforator Flap Surgery I]Z hjXXZhh d[ Vaa hjg\^XVa egdXZYjgZhÄZheZ" X^Vaan eZg[dgVidg ÒVe hjg\ZgnÄa^Zh ^c i]Z eaVc" c^c\#6[iZgZkVajVi^c\i]ZadXVi^dcVcYY^bZch^dch d[ i]Z YZ[ZXi VcY i]Z \ZcZgVa XdcY^i^dc d[ i]Z eVi^Zci! Vc Veegdeg^ViZ eZg[dgVidg ÒVe h]djaY WZ hZaZXiZY# EZg[dgVidg ÒVeh bVn WZ gV^hZY Z^i]Zg eZY^XaZY dg [gZZ! VcY YjZ Xdch^YZgVi^dc h]djaY WZ \^kZc id i]ZViZg ad\^hi^Xh VcY VYZfjViZ eZg^ VcY edhi"deZgVi^kZ bdc^idg^c\# EgZdeZgVi^kZ ^ckZhi^\Vi^kZ iddah bVn ^cXajYZ Xdadg 9jeaZm hXVcc^c\! Vc deZgVidg"YZeZcYZci Wji jhZ[ja lVn d[ k^hjVa^o^c\ i]Z eZg[dgVidg kZhhZah WZ[dgZ]VcY# 9jeaZm hXVcc^c\ XVc VhhZhh i]Z cjbWZg! adXVi^dc! VcY h^oZ d[ eZg[dgVidgh VcY Vahd Zhi^bViZ i]Z Òdl i]gdj\] i]Z kZhhZah# 9jeaZm hXVcc^c\ ^h bdgZ Z[[ZXi^kZ [dg hdbZ eZg[dgVidg ÒVeh i]Vc di]Zgh#&) 6aiZgcVi^kZan! V h^beaZ ]VcY"]ZaY *"B=o id -"B=o 9deeaZg Òdl bZiZg XVc adXViZ VjY^WaZ eZg[dgVidgh# :mVb^c^c\ i]Z Ydcdg VgZV [dg hXVgg^c\! i^hhjZ kdajbZ VcY fjVa^in! VcY adXVa h`^c aVm^in ^h ^ckVajVWaZ# 9^hhZXi^c\ i]Z eZg[dgVidg ÒVe ^ihZa[ ^h bZi^Xj" adjh VcY gZfj^gZh V WaddYaZhh ÑZaY! l^YZ Zmed" hjgZ d[ i]Z kZhhZah! adjeZ bV\c^ÑXVi^dc! VcY XVgZ[ja a^\Vi^dc d[ Vaa h^YZ WgVcX]Zh d[ i]Z kZhhZah ;^\jgZ ,"& # I]Z eZY^XaZ ^h [gZZY Wn hea^ii^c\ i]Z bjhXaZ ÑWgZh Vadc\ i]Z a^cZ d[ i]Z bjhXaZ! id gZYjXZ bjhXaZ YVbV\Z VcY hjWhZfjZci [jcX" i^dcVa YZÑX^i# CZgkZh h]djaY Vahd WZ egZhZgkZY# EdhideZgVi^kZ XVgZ ^h i]Z hVbZ Vh i]Vi [dg di]Zg [gZZ ÒVeh# I]Z bV^c VYkVciV\Z d[ eZg[dgVidg ÒVeh ^h i]Z^g adl Ydcdg h^iZ bdgW^Y^in# I]Z bV_dg^in d[ S
Figure 7-1. a,b) Preoperative pictures of a middle-aged woman with invasive ductular breast carcinoma of the left breast, immediately after open biopsy through a supra-areolar scar. c) Intraoperative picture (right cranial; left caudal) of the dissection of a lateral perforator of the left rectus abdominis muscle between the umbilicus and the pubis. The fat of the flap, seen in the top of the picture, is folded medially; the deep (rectus) fascia (bottom of the picture) and muscle are split; and the deep inferior epigastric vessels are dissected from in between. The perforator has been isolated (white arrow), as well as the medial and lateral branches of the motor nerves (black arrows). Wide exposure and a bloodless field are the keys to success. d,e) Postoperative images after skin-sparing mastectomy, immediate autologous breast reconstruction with a DIEAP flap, nipple reconstruction, and areolar tattooing.
a
b
c
d
e
89
90
Ydcdg h^iZh VgZ YZh^\cZY id WZ XadhZY Y^gZXian! VcY i]Z jcYZgan^c\ bjhXaZ VcY ^ih cZgkZ hjeean VgZ egZhZgkZY0 i]ZgZ[dgZ! i]ZgZ ^h cd [jcX" i^dcVa YZÑX^i VcY cd gZfj^gZbZci [dg bZh] XadhjgZ# 7n k^gijZ d[ WZ^c\ bjhXaZ"heVg^c\! i]Z eZg[d" gVidg ÒVe ^ihZa[ ^h i]^c VcY ea^VWaZ! XdbedhZY d[ dcan h`^c! hjWXjiVcZdjh i^hhjZ VcY eZg]Veh [VhX^V#I]Z kVhXjaVg ^ciZ\g^in d[ i]Z ÒVe ^h ZchjgZY Vh adc\ Vh i]Z Vc\^dhdbZ eg^cX^eaZ ^h VY]ZgZY id0 i]ZgZ[dgZ! i]Z ÒVeh bVn WZ Vh aVg\Z dg Vh hbVaa Vh gZfj^gZY# 7ZXVjhZ cd bjhXaZ ^h iV`Zc l^i] i]Z ÒVe! ^i ^h cdi egdcZ id Vigde]n dg bjhXaZ ÑWgdh^h i]Vi b^\]i aZVY id h]g^c`V\Z dg Y^hidgi^dc l^i] i^bZ# EZg[dgVidg ÒVeh bVn WZ bVYZ hZchViZ ^[ ]VgkZhiZY l^i] i]Z^g cZgkZ hjeean#&* I]Z kVhXjaVg eZY^XaZ XVc WZ bVYZ Vh adc\ dg Vh h]dgi Vh gZfj^gZY! i]Z Y^VbZiZg d[ i]Z eZg[dgVidg gVgZan WZ^c\ Vc ^hhjZ# :k^YZcXZ Vahd hj\\Zhih [VhiZg gZXdkZgn l^i] eZg[dgVidg ÒVeh! aZVY^c\ id h]dgiZg ]dhe^iVa hiVnh&+! aZhh VcVa\Zh^V&,! VcY bdgZ Xdhi" Z[[ZXi^kZ XVgZ#&+ I]Z Y^hVYkVciV\Zh d[ eZg[dgVidg ÒVeh VgZ aVg\Zan gZaViZY id i]Z aZVgc^c\ XjgkZ# >c^i^Vaan! Y^hhZXi^dc iV`Zh adc\Zg! aZVY^c\ id ZmiZcYZY deZgVi^c\ i^bZh ^c i]Z WZ\^cc^c\ d[ i]Z aZVgc^c\ XjgkZ# I]Z hiVcYVgY eaVhi^X hjg\Zgn iZX]c^fjZh d[ bZi^Xjadjh Y^hhZXi^dc! WaddYaZhh ÑZaY! VcY hd dc! ]VkZ id WZ g^\dgdjhan Veea^ZY# I]Z eZg[dgVidg kZhhZah bVn WZ hbVaa VcY egdcZ id heVhb# I]Zn VgZ! ]dlZkZg! gZaVi^kZan gdWjhi# I]Z ldghi ^chjai i]Vi XVc WZ Veea^ZY id Vcn eZg[dgVidg ÒVe ^h igVX" i^dc dg Vkjah^dc d[ i]Z eZg[dgVidgh Yjg^c\ i]Z Y^hhZXi^dc Vh i]Zn ZciZg i]Z ÒVe# EZg[dgVidg ÒVeh aZcY i]ZbhZakZh id WZ^c\ jhZY Vh Z^i]Zg eZY^XaZY dg [gZZ ÒVeh# I]Zn VgZ ^YZVa Åa^`Z"[dg"a^`ZÆ i^hhjZ gZeaVXZbZcih ^c i^hhjZ gZhjg[VX^c\ ldg` WZXVjhZ d[iZc dcan h`^c VcY hd[i i^hhjZ VgZ gZhZXiZY dg adhi# I]Z ea^VWaZ ÒVeh VgZ ZmXZaaZci [dg i]Z Y^[ÑXjai Xdcidjg gZhjg[VX^c\ VhhdX^ViZY l^i] bjX] ]ZVY VcY cZX` hjg\Zgn# Dg\Vch hj^iZY id gZXdchigjXi^dc l^i] i]^c eZg[dgVidg ÒVeh ^cXajYZ i]Z eZg^cZjb! kV\^cV! idc\jZ! VcY eZc^h0 VaiZgcVi^kZan! i]Z Wja`n eZg" [dgVidg ÒVeh 9>:6E VcY H":6E ÒVe# >ih jhZ[jacZhh Vg^hZh [gdb i]Z aVg\Z VgZV d[ adlZg VWYdb^cVa i^hhjZ i]Vi XVc WZ hjhiV^cZY dc V h^c\aZ eZg[dgVidg VcY i]Z [VXi i]Vi i]Z jcYZgan^c\ hjWXjiVcZdjh i^hhjZ ^h i]^X`# I]Z gZhjaiVci aVg\Z! hd[i! Wja`n ÒVe Xdb" edhZY d[ h`^c VcY hjWXjiVcZdjh [Vi ^h Vc ^YZVa Åa^`Z"[dg"a^`ZÆ bViX] [dg WgZVhi gZXdchigjXi^dc ;^\jgZ ,"& #&-!&. I]Z Zchj^c\ ÒVe! XdbedhZY d[ dcan h`^c VcY [Vi! Veegdm^bViZh i]Z h]VeZ! iZmijgZ! VcY bdkZ" bZci d[ i]Z WgZVhi# I]Z Xdadg bViX] ^h jhjVaan VYZfjViZ# >c V hjWXjiVcZdjh dg h`^c"heVg^c\ bVhiZXidbn! i]Z h`^c ZckZadeZ d[ i]Z dg^\^cVa WgZVhi ^h egZhZgkZY VcY i]Z 9>:6E ÒVe ^h YZ"Ze^i]Za^Va^oZY VcY Wjg^ZY# @dh]^bV'% egZhZciZY V kVg^Vci d[ i]Z 9>:6E ÒVe i]Vi ]Z cVbZY i]Z ÅeVgVjbW^a^XVa eZg[dgV" idgÆ EJE ÒVe# EZY^XaZ Y^hhZXi^dc lVh a^b^iZY id i]Z eZg[dgVidg kZhhZah hjeZgÑX^Va id i]Z VciZg^dg gZXijh h]ZVi]0 i]jh! Ydcdg bdgW^Y^in lVh b^c^" b^oZY Wn egZhZgk^c\ i]Z ^ciZ\g^in d[ i]Z VciZg^dg gZXijh h]ZVi]# I]Z ÒVe lVh gVe^Yan VcY ZVh^an ]VgkZhiZY! dWk^djhan Vi i]Z ZmeZchZ d[ eZY^XaZ aZc\i] VcY XVa^WZg# I]Z ÒVe lVh Veea^ZY bV^can id gZeV^g hjeZgÑX^Va YZ[ZXih l^i] hjeZgÑX^Va gZX^e^Zci kZhhZah'& dg Vh V YZ"Ze^i]Za^Va^oZY ÒVe jcYZg hjWXjiVcZdjh XdkZg#'' 9dcdg [jcXi^dcVa bdgW^Y^in ]Vh WZZc hijY^ZY ^ciZch^kZan VcY XdbeVgZY Y^gZXian V\V^chi i]Z igVchkZghZ gZXijh VWYdb^c^h bndXjiVcZdjh IG6B ÒVe# I]Z VYkVciV\Zh d[ i]Z 9>:6E dkZg i]Z IG6B ÒVe ^c VWYdb^cVa lVaa higZc\i] ]VkZ WZZc YZhXg^WZY!'( ^c Wdi] gZigdheZXi^kZ') VcY egdheZXi^kZ'* hijY^Zh0 ^c VYY^i^dc! i]Z Xdhih VcY WZcZÑih&+ VcY i]Z gZYjXi^dc ^c edhi"deZgVi^kZ eV^c&, ]VkZ WZZc ^YZci^ÑZY# I]Z hjeZg^dg \ajiZVa VgiZgn eZg[dgVidg H"c VYY^i^dc! i]Z aViZgVa [ZbdgVa XjiVcZdjh cZgkZ XVc WZ egZhZgkZY l^i] i]Z ÒVe id bV`Z i]Z ÒVe hZchViZ# I]Z 6AI ÒVe bVn Vahd WZ jhZY Vh V eZY^XaZY ÒVe [dg gZXdchigjXi^c\ i]Z \gd^c VcY eZg^cZjb# I]Z gZhjai^c\ Ydcdg"h^iZ hXVg [gdb ]VgkZhi^c\ i]Z A8;6E"ka ÒVe ^h WZiiZg VXXZeiZY ^c dg^ZciVa hdX^Zi^Zh i]Vc ^c LZhiZgc dcZh WZXVjhZ d[ XjaijgVa VcY VeeVgZa Y^[[ZgZcXZh# I]Z i]dgVXdYdghVa VgiZgn eZg[dgVidg ÒVe I" 96E YZhXg^WZY Wn 6c\g^\^Vc^ ^c &..*'- ^h V aVi^h" h^bjh Ydgh^ bndXjiVcZdjh ÒVe l^i]dji i]Z bjhXaZ XdbedcZci# I]Z bV^c eZg[dgVidgh Vg^hZ [gdb i]Z YZhXZcY^c\ WgVcX] d[ i]Z i]dgVXdYdg" hVa kZhhZa ^c i]Z egdm^bVa [gZZ ZY\Z d[ i]Z aVi^h" h^bjh Ydgh^ bjhXaZ# I]Z eZg[dgVidgh VgZ [Zl VcY [Vg WZilZZc! VcY i]Z Vc\^dhdbZh VgZ aVg\Z ^c i]Z edhiZg^dg i]dgVm# I]Z Vc\^dhdbZh a^Z adc\^ijY^" cVaan0 i]jh! V aVg\Z ÒVe XVc gZa^VWan WZ ]VgkZhiZY dc V hbVaa eZg[dgVidg# 6h V gZhjai d[ i]Z eVjX^in d[ eZg[dgVidgh! egZdeZgVi^kZ YjeaZm hXVcc^c\ ^h gZXdbbZcYZY#'. I]Z deedgijc^in id egZhZgkZ i]Z aVg\Zhi bjhXaZ aVi^hh^bjh Ydgh^ ^h ]VgY id gZh^hi! VcY i]Z I"96E ÒVe ^h \gdl^c\ ^c edejaVg" ^in# 6i egZhZci! i]Z ÒVe ^h jhZY Vh V eZY^XaZY ÒVe [dg gZXdchigjXi^c\ aViZgVa WgZVhi YZ[ZXih V[iZg WgZVhi XdchZgkVi^dc hjg\Zgn(%!(& VcY Vh V [gZZ ÒVe [dg aVg\Z YZ[ZXih gZfj^g^c\ gZhjg[VX^c\# 6 aVg\Z cjbWZg d[ di]Zg eZg[dgVidg ÒVeh ]VkZ WZZc YZhXg^WZY# >c hdbZ XVhZh! Y^hhZXi^c\ V eZg" [dgVidg ÒVe b^\]i WZ ZVhn! Wji l]Zc hVXg^ÑX^c\
91
V bjhXaZ YdZh cdi aZVkZ Vcn [jcXi^dcVa YZÑX^i! [dg ZmVbeaZ! Vh ^c V \gVX^a^h eZg[dgVidg ÒVe! Y^hhZXi^dc bVn WZ jccZXZhhVgn# 6i i]^h bdbZci! i]Z h^oZ d[ i]Z eZg[dgVidg kZhhZah YZiZgb^cZh i]Z cjbWZg VcY h^oZ d[ h`^c ÒVeh ]VgkZhiZY# ;aVe ]VgkZhi dc kZgn hbVaa kZhhZah ^h iZX]c^XVaan kZgn YZbVcY^c\! gZfj^g^c\ bjX] h`^aa VcY heZX^Va^hi Zfj^ebZci id \gVhe i]Z ÑcZ &'$% hjijgZh gZfj^gZY id hjijgZ i]Z %#( bb id %#* bb Y^VbZiZg eZg[dgVidg kZhhZah# >bbZY^ViZ i]^cc^c\ d[ eZg[dgVidg ÒVeh Vaadlh i]Z ÒVe id WZ iV^adgZY id i]Z YZ[ZXi Vi i]Z i^bZ d[ ^c^i^Va hjg\Zgn VcY bVn egZkZci i]Z cZZY [dg V hZXdcYVgn egdXZYjgZ# HjX] ^cigVdeZgVi^kZ YZWja`^c\ dg Åb^Xgd"a^eZXidbnÆ gZfj^gZh `cdl^c\ i]Z ZmVXi adXVi^dc VcY WgVcX]^c\ d[ ZVX] eZg[dgVidg VcY YjZ XVgZ ^[ ÒVe kVhXjaVg^in ^h cdi id WZ Xdbegdb^hZY#'%!(' L^i] i]Z ^cXgZVh^c\ hV[Zin VcY ZmeZgi^hZ d[ eZg[dgVidg"WVhZY hjg\Zgn! Vc VYkVcXZY [dgb d[ ÒVe ]VgkZhi ]Vh YZkZadeZY i]Vi eaVXZh ZkZc bdgZ eg^dg^in dc i]Z Ydcdg h^iZ# >c ZhhZcXZ! [gZZ"hinaZ [gZZ ÒVe hjg\Zgn Vaadlh i]Z hjg\Zdc id hZaZXi i]Z i^hhjZ X]VgVXiZg^hi^Xh bdhi hj^iZY id i]Z YZ[ZXi dg V h^iZ egZ[ZggZY Wn i]Z eVi^Zci#(( I]Z Ydcdg VgZV ^h bVeeZY l^i] i]Z ]VcY"]ZaY 9deeaZg Òdl bZiZg! VcY i]Z eZg[dgVidg kZhhZa ^h bVg`ZY#I]Z ÒVe YZh^\c ^h XZcigZY dc i]Z hZaZXiZY eZg[dgVidg# I]Z i^hhjZ ÒVe ^h gV^hZY hjegV" dg hjW"[VhX^Vaan Vh gZfj^gZY! VcY i]Z eZg[dgVidg kZhhZa ^h Y^hhZXiZY ^c V gZigd\gVYZ [Vh]^dc jci^a Zcdj\] aZc\i] dg VYZfjViZ kZhhZa h^oZ ^h VX]^ZkZY# I]ZgZ VgZ cd VcVidb^XVa a^b^iVi^dch id Y^hhZX" i^dc WZXVjhZ Z^i]Zg i]Z ^cigVbjhXjaVg dg hZeiVa XdjghZ XVc WZ [daadlZY# 6aiZgcVi^kZan! l^i]dji 9deeaZg ÒdlbZign! i]Z hjg\Zdc bVn ]VgkZhi V [gZZ"hinaZ [gZZ ÒVe [gdb V WdYn h^iZ l^i] l]^X] ]Z dg h]Z ^h hjg\^XVaan [Vb^a^Vg# I]jh! V eZg[dgVidg ÒVe bVn WZ ]VgkZhiZY [gdb i]Z i]^\]! WVhZY dc ZmeZg^ZcXZ VcY `cdlaZY\Z d[ Wdi] i]Z a^`Zan Vc\^dhdbZ Y^hig^Wji^dc VcY i]Z jhjVa adXVi^dc d[ hj^iVWaZ eZg[dgVidgh#(( >i bVn ^cYZZY WZ Vh =VaadX` egZY^Xih() i]Vi ^c i]Z [jijgZ! eZg[dgVidg"id"eZg[dgVidg [gZZ ÒVeh VcY [gZZhinaZ [gZZ ÒVeh bVn bV`Z `cdl^c\ i]Z kVhXjaVg dg^\^c dg hdjgXZ kZhhZa ^ggZaZkVci WZXVjhZ dcan i]Z hjegV[VhX^Va adXVi^dc d[ i]Z bV_dg eZg[dgVidgh 3%#* bb bVeeZY Wn IVnadg VcY EVabZg l^aa WZ d[ Vcn h^\c^ÑXVcXZ# I]jh! i]Z Ve]dg^hb d[ :XXaZh^VhiZh i]Vi! Åi]ZgZ ^h cd cZl i]^c\ jcYZg i]Z hjcÆ l^aa WZ XdcÑgbZY# DcXZ V\V^c! Vcn h`^c eVYYaZ l^aa WZ V ediZci^Va Ydcdg h^iZ! VcY i]Z jcYZgan^c\ hdjgXZ kZhhZa cZZY cdi WZ `cdlc#
92
Tissue Surgery
References '%# &# 7adcYZZa EC! KVc AVcYjni @=! BdchigZn H?! Zi Va# I]Z Å
'&#
''#
'(#
')#
'*#
'+#
',# '-# '.#
(%# (&# ('#
((# ()#
Ze^\Vhig^X eZg[dgVidg ÒVe VcVhidbdhZY id i]Z ^ciZgcVa bVbbVgn VgiZgn# 7g ? EaVhi Hjg\# &..)0),/).*Ã*%&# @dh]^bV >! Bdg^\jX]^ I! HdZYV H! IVcV`V =! JbZYV C# ;gZZ i]^c eVgVjbW^a^XVa eZg[dgVidg"WVhZY ÒVeh# 6cc EaVhi Hjg\# &..'0'./&'Ã&,# @dh]^bV >! >cV\VlV @! Jgjh]^WVgV @! Bdg^\jX]^ I# DcZ"hiV\Z [VX^Va Xdcidjg Vj\bZciVi^dc l^i] ^cigVdgVa igVch[Zg d[ V eVgVjbW^a^XVa eZg[dgVidg VY^edhVa ÒVe# EaVhi GZXdchig Hjg\# '%%&0&%-/.--Ã..)# @dh]^bV >! >cV\VlV @! NVbVbdid B! Bdg^\jX]^ I# CZl b^Xgdhjg\^XVa WgZVhi ZXdchigjXi^dc jh^c\ [gZZ eVgV" jbW^a^XVa eZg[dgVidg VY^edhVa ÒVeh# EaVhi GZXdchig Hjg\# '%%%0&%+/+&Ã+*# 7adcYZZa C! 7dZX`m L9! KVcYZghigVZiZc ! HV^h]d =! @VlVYV H! =VbVcV`V I! JbZYV C! Bdg^\jX]^ I# ;adl i]gdj\] i]^c aVi^hh^bjh Ydgh^ eZg[d" gVidg ÒVe [dg gZeV^g d[ hd[i"i^hhjZ YZ[ZXih ^c i]Z aZ\h# EaVhi GZXdchig Hjg\# &...0&%(/&)-(Ã&).%# BVgY^c^ H! IhV^ ;8! LZ^ ;8# I]Z i]^\] Vh V bdYZa [dg [gZZ hinaZ [gZZ ÒVeh# 8a^c EaVhi Hjg\# '%%(0(%/),(Ã)-%# =VaadX` E ^h Xdbbdcan jhZY Xa^c^XVaan! bdhi a^`Zan WZXVjhZ i]Zn VgZ ^ckVh^kZ! hjWhiVci^Vaan ^cXgZVhZ hjg\^XVa i^bZ! dg ZkZc gZfj^gZ V hZXdcY hjg\Zgn# LZ ]VkZ h]dlc ^c Y^[[ZgZci ZmeZg^bZciVa bdYZah i]Vi VXjiZ >E! Zc]VcXZbZci d[ ÒVe hjg" k^kVa! VcY ^begdkZY b^XgdkVhXjaVg gZeZg[jh^dc XVc WZ VX]^ZkZY cdi dcan Wn egZXaVbe^c\ i]Z ÒVe eZY^XaZ! Wji Vahd Wn ^cYjX^c\ Vc ^hX]Zb^V" gZeZg[jh^dc ZkZci ^c V WdYn VgZV Y^hiVci [gdb i]Z ÒVe WZ[dgZ ZaZkVi^dc# I]^h cZl! VXjiZ ÅgZbdiZ ^hX]Zb^V egZXdcY^i^dc^c\Æ egdXZYjgZ XVc WZ Veea^ZY cdc^ckVh^kZan Wn Veean^c\ V idjgc^fjZi h]dgian WZ[dgZ ÒVe ^hX]Zb^V# I]Z Z[[ZXi^kZcZhh d[ VXjiZ gZbdiZ >E ]Vh WZZc XdcÑgbZY Wn di]Zg Vji]dgh ^c aVg\Z Vc^bVa bdYZah# I]Z jhZ d[ V idjgc^fjZi id ^cYjXZ a^bW ^hX]" Zb^V WZ[dgZ ÒVe ^hX]Zb^V XdjaY egdk^YZ V cZl! VaiZgcVi^kZ! cdc^ckVh^kZ gZbdiZ >E egdidXda! Vai]dj\] aViZ gZbdiZ >E b^\]i WZ Z[[ZXi^kZ dcan ^c bjhXaZ ÒVeh# =dlZkZg! i]Z edhh^WaZ [jijgZ Xa^c^XVa Veea^XVi^dc [dg aViZ >E ^h ZaZXi^kZ ÒVe hjg\Zgn! l]ZgZVh VXjiZ gZbdiZ >E XdjaY ZkZc WZ jhZY id XgZViZ ZbZg\ZcXn ÒVeh#
6ai]dj\] i]Z ldgY eaVhi^X ^h YZg^kZY [gdb i]Z cY^V# L^i]^c i]ZhZ ZVgan =^cYj iZmih! edhh^Wan lg^iiZc bdgZ i]Vc '+%% nZVgh V\d! a^Z YZhXg^ei^dch d[ cdhZ! ZVg! VcY a^e gZXdchigjXi^dch jh^c\ iZX]c^fjZh gVc\^c\ [gdb eZY^XaZ ÒVeh id [gZZ Vjid\Zcdjh h`^c \gV[ih#&Ã( =ZaaZc^hi^X! GdbVc! VcY 7noVci^cZ e]nh^X^Vch YZkZadeZY [jgi]Zg WVh^X gZXdchigjXi^kZ eg^cX^" eaZh VcY iZX]c^fjZh! hjX] Vh iZch^dcaZhh hjijgZ a^cZh! i]Z YWg^YZbZci d[ ZmedhZY WdcZ! VcY i]Z jhZ d[ ÒVeh id Vkd^Y i]Z Y^hidgi^dc d[ [VX^Va [ZVijgZh VhhdX^ViZY l^i] eg^bVgn XadhjgZ! W^eZY^XaZ VYkVcXZbZci ÒVeh [dg [VX^Va YZ[ZXih! jcYZgb^c^c\ i^hhjZh WZ[dgZ ldjcY XadhjgZ! i]Z g^h` d[ cZXgdh^h ^[ i]Z h`^c VadcZ lVh jcYZg" b^cZY! VcY i]Z Ñghi hjeZg^dgan WVhZY cVhdaVW^Va ÒVe#&!) 9Zhe^iZ Xdci^cjZY jhZ d[ ZhiVWa^h]ZY bZi]dYh! i]Z [Vaa d[ GdbZ ^c i]Z Ñ[i] XZcijgn VcY i]Z hjWhZfjZci hegZVY d[ WVgWVg^Vc ig^WZh VcY 8]g^hi^Vc^in i]gdj\]dji i]Z B^YYaZ 6\Zh Wgdj\]i Vc jc[dgijcViZ ]Vai ^c i]Z VYkVcXZbZci d[ gZXdc" higjXi^kZ hjg\Zgn# I]Z Vibdhe]ZgZ d[ i]Z i^bZ lVh VeeVgZci ^c i]Z &(i] XZcijgn! l]Zc EdeZ >ccdXZci >>> heZX^ÑXVaan egd]^W^iZY hjg\^XVa egdXZYjgZh# I]Z VYkZci d[ i]Z GZcV^hhVcXZ ^c i]Z &)i] XZcijgn Wgdj\]i V gZW^gi] d[ hX^ZcXZ VcY bZY^X^cZ VcY Vc ZcY id i]Z hiV\cVi^dc i]Vi ]VY WZ[VaaZc i]Z ldgaY d[ hjg\Zgn# iVa^Vc BZi]dYÆ Yjg^c\ i]Z hZXdcY ]Va[ d[ i]Z &+i] XZcijgn#&!*!+ I]Z bdYZgc ZgV d[ gZXdchigjXi^kZ eaVhi^X hjg\Zgn lVh higdc\an ^cÒjZcXZY Wn V h^beaZ aZiiZg! ejWa^h]ZY ^c &,.& ^c V AdcYdc \ZciaZbVcÈh bV\Vo^cZ! Wn V 7g^i^h] hjg\Zdc cVbZY AjXVh! dc cVhVa gZXdchigjXi^dc jh^c\ Vc >cY^Vc [dgZ]ZVY ÒVe#, K^agVn EVe^c 7aV^g! H^g =VgdaY 9Za[ VcY >> ^c^i^ViZY bdYZgc gZXdchigjXi^kZ hjg\Zgn Wn ^cigdYjX^c\ Xgdhh"aZ\ ÒVeh! ijWZ ÒVeh! VcY YZaVnZY igVch[Zg d[ adc\ eZY^XaZ ÒVeh#-!. I]Z YZkZadebZci d[ b^Xgd ^chigjbZcih! ÑcZ hjijgZ bViZg^Va! VcY i]Z W^cdXjaVg deZgVi^c\ b^XgdhXdeZ Wn i]Z 8Vga"OZ^hh 8dbeVcn ^c i]Z b^Y"&.*%h gZkdaji^dc^oZY i]Z ÑZaY d[ eaVhi^X VcY gZXdchigjXi^kZ hjg\Zgn VcY aZVY id i]Z W^gi] d[ b^Xgdhjg\Zgn# ;gdb i]^h i^bZ dc! eaVhi^X hjg" \Zdch lZgZ cd adc\Zg a^b^iZY id adXVa eZY^XaZY ÒVeh VcY hddc YZkZadeZY b^XgdkVhXjaVg i^hhjZ igVcheaVciVi^dc# Hddc! hZkZgVa cZl b^XgdkVhXj" aVg ÒVeh lZgZ ^cigdYjXZY! ^cXajY^c\ i]Z Ñghi Vjidad\djh igVch[Zg d[ dbZcijb Wn 9dcVaY BXAZVc ^c &.+.! i]Z Ñghi [gZZ iZbedgVa h`^c ÒVe Wn =Vg^^ VcY D]bdg^ ^c &.,'!&% i]Z [gZZ aVi^hh^" bjh Ydgh^ ÒVe Wn Da^kVg^ ^c &.,+!&& VcY i]Z [gZZ igVchkZghZ gZXijh VWYdb^c^h ÒVe Wn =dahigb ^c &.,.!&' Vbdc\ bVcn di]Zgh# I]^h ]^hidg^XVa dkZgk^Zl YdXjbZcih Vc ^cXgZVhZ ^c XdbeaZm^in VcY kVg^Zin d[ gZXdc" higjXi^kZ egdXZYjgZh dkZg i^bZ# =dlZkZg! i]Z ^cigdYjXi^dc d[ i]Z Vm^Va eViiZgc eZY^XaZ VcY [gZZ ÒVeh dg ZkZc i]Z aViZhi ^ccdkVi^dc d[ eZg[d" gVidg WVhZY ÒVeh&(Ã&, VgZ VhhdX^ViZY l^i] ]^\]Zg g^h`h [dg ÒVe cZXgdh^h Vh V gZhjai d[ ^hX]Zb^V dg gZeZg[jh^dc ^c_jgn# I]^h g^h` Zbe]Vh^oZh i]Z cZXZhh^in id ZmeadgZ VXjiZ VcY aViZ ÒVe egZXdcY^i^dc^c\#
Ischemia Reperfusion Injury I^hhjZ ^hX]Zb^V VcY gZeZg[jh^dc ^ckdakZ XdbeaZm bZX]Vc^hbh i]Vi ]VkZ cdi nZi WZZc XdbeaZiZan ^YZci^ÑZY dg jcYZghiddY# =dlZkZg! gZeZg[jh^c\ i^hhjZh V[iZg VXjiZ ^hX]Zb^V ^c^i^ViZh X]Vc\Zh ^c adXVa kVhXjaVg idcZ! XdV\jaVi^dc! VcY W^dX]Zb^XVa! bdaZXjaVg! VcY XZaajaVg VaiZgVi^dch i]Vi VgZ XdaaZXi^kZan XVaaZY Å^hX]Zb^V"gZeZg[jh^dc ^c_jgn#Æ&-!&. I]Z VXi^kVi^dc d[ cZjigde]^a \gVcjad" XniZh Wn dmn\Zc"[gZZ gVY^XVah VcY XdchZXji^kZ
Tissue Surgery
ZcYdi]Za^Va ^c_jgn VgZ i]Z XZcigVa egdXZhhZh ^c ^hX]Zb^V"gZeZg[jh^dc ^c_jgn#'%!'& CZjigde]^a VXi^kVi^dc VcY je"gZ\jaVi^dc d[ XdggZhedcY^c\ gZXZeidgh ^c i]Z edhiXVe^aaVgn kZcjaZh aZVYh id VY]Zh^dch WZilZZc l]^iZ XZaah VcY ZcYdi]Za^jb! l]^X] XVc WZ k^hjVa^oZY Wn ^c"k^kd b^XgdhXden Vh aZj`dXniZ Åhi^X`^c\Æ VcY Ågdaa^c\#Æ HZ\bZciVa kZhhZa dXXajh^dc dXXjgh Vh V gZhjai d[ i]^h aZj`dXniZ"ZcYdi]Za^jb ^ciZgVXi^dc! aZVY^c\ id aZj`dXniZ b^\gVi^dc ^cid i^hhjZ! ^cXgZVhZY egd" YjXi^dc d[ dmn\Zc"[gZZ gVY^XVah! VcY i^hhjZ" YVbV\^c\ ZconbZh# I]Z aVX` d[ kZcdjh gZÒdl dXXjgh ^c i^hhjZh V[iZg egdadc\ZY ^hX]Zb^V VcY ^h XVjhZY Wn ^ggZkZgh^WaZ XVe^aaVgn YVbV\Z VcY idiVa dg hjWidiVa kVhXjaVg dXXajh^dc#''!'( ;^cVaan! XZaa YZVi] dXXjgh Vh V gZhjai d[ i]Z ^cÒjm d[ ediVh" h^jb! bZY^Vidgh! VcY dmn\Zc"[gZZ gVY^XVah! Vh lZaa Vh i]gdj\] YZXgZVhZY ^cigVXZaajaVg 6IE Xdc" XZcigVi^dch VcY ]nedm^V#') GZeZg[jh^dc d[ ^hX]Zb^X i^hhjZh ^h ZhhZci^Va [dg hjgk^kVa! Vai]dj\] ^i Vj\bZcih i^hhjZ YVbV\Z ^cYjXZY Wn ^hX]Zb^V# I]ZgZ[dgZ! ^i ^h Vahd iZgbZY ÅgZÒdl eVgVYdm#Æ&-!'*
The Delay Procedure >c gVih! igVchkZghZ gZXijh VWYdb^c^h bjhXjadXj" iVcZdjh IG6B ÒVeh hjgk^kZY adc\Zg V[iZg hjg\^XVa YZaVn#'+ >c gZaViZY gZhZVgX]! GZhi^[d Zi Va# gZedgiZY Vc ^cXgZVhZ ^c bZVc kZhhZa Y^VbZiZg VcY hjeZg^dg Ze^\Vhig^X VgiZgn Òdl ^c &* eVi^Zcih & lZZ` V[iZg V egZa^b^cVgn IG6B ÒVe YZaVn#', I]ZhZ ÑcY^c\h VgZ Xdch^hiZci l^i] egZk^djh VcVidb^X hijY^Zh Wn IVnadg VcY XdaaZV\jZh! l]d gZedgiZY i]Vi i]Z VgiZg^Va X]d`Z kZhhZa hnhiZb Y^aViZY ^c i]Z gZXijh bjhXaZ VcY i]Vi kZcdjh kVakZ ^cXdbeZiZcXZ VaadlZY kZcdjh YgV^cV\Z idlVgY i]Z hjeZg^dg Ze^\Vhig^X hnhiZb#'- I]ZhZ YViV lZgZ XdcÑgbZY ^c di]Zg Xa^c^XVa hijY^Zh#(%!(& Hjg\^XVa YZaVn h`^c ^cX^h^dc Ydlc id [VhX^V h]djaY WZ Y^hi^c\j^h]ZY [gdb ejgZ kVhXjaVg YZaVn a^\Vi^dc d[ dcZ d[ i]Z Ydb^cVci kZhhZah d[ V ineZ"( bjhXaZ VXXdgY^c\ id BVi]Zh VcY CV]V^Èh XaVhh^ÑXVi^dc#(&!(' IG6B ÒVe YZaVn ]Vh WZZc egd" bdiZY , YVnh! ' lZZ`h! VcY je id & bdci] WZ[dgZ ÒVe igVch[Zg# I]Z YZaVn e]ZcdbZcdc ]Vh l^YZan WZZc jhZY Xa^c^XVaan id ^begdkZ ÒVe hjgk^kVa ^c i]Z Y^hiVa edgi^dc d[ Vm^Va eViiZgc ÒVeh! Wji ^ih bV^c Y^h" VYkVciV\Zh VgZ i]Z cZZY [dg V hZXdcY hjg\^XVa egdXZYjgZ VcY VcZhi]Zh^V VcY i]jh VYY^i^dcVa Xdhih [dg Wdi] ]ZVai] hnhiZb VcY eVi^Zcih#
Remote Ischemic Preconditioning of Flaps: Current Concepts
Classic Local Ischemic Preconditioning (“Preclamping”) Bjggn Zi Va# lZgZ i]Z Ñghi id YZhXg^WZ >E dg ÅegZ" XaVbe^c\Æ [dg i]Z ]ZVgi ^c &.-+#(( H^b^aVg gZhjaih ]VkZ WZZc gZedgiZY [dg di]Zg dg\Vc hnhiZbh! hjX] Vh i]Z a^kZg() VcY i]Z `^YcZn#(* KVg^djh hijY^Zh gZedgi i]Z hjXXZhh d[ >E ^c ÒVeh#(+Ã)% BdjchZn Zi Va#! lZgZ i]Z Ñghi id gZedgi i]^h e]Z" cdbZcdc ^c V edgX^cZ aVi^hh^bjh Ydgh^ ÒVe bdYZa ^c &..'#(, 8Vgdaa Zi Va# dWhZgkZY ^c V gVi aVi^hh^bjh Ydgh^ bdYZa i]Vi >E! Wdi] ^bbZY^ViZan egZdeZgVi^kZan VcY ') ]djgh WZ[dgZ ÒVe ^hX]" Zb^V! h^\c^ÑXVcian gZYjXZY bjhXaZ ÒVe cZXgd" h^h#(+ 6cdi]Zg hijYn gZedgiZY i]Z ^cÒjZcXZ d[ ^hX]Zb^X egZXdcY^i^dc^c\ dc i]Z gZh^hiVcXZ d[ h`^c VcY bndXjiVcZdjh ÒVeh V[iZg adc\ ^hX]Zb^X eZg^dYh ^c V gVi bdYZa#)% 8g^i^XVa ^hX]Zb^V i^bZ! i]Z i^bZ Vi l]^X] *% d[ i]Z ÒVe WZXdbZh cZXgdi^X! ^h egdadc\ZY h^\c^ÑXVcian Wn egZXdcY^" i^dc^c\# KVhdheVhb VcY aVX` d[ XVe^aaVgn gZÒdl lVh ViiZcjViZY Wn VXjiZ ^hX]Zb^X egZXdcY^i^dc" ^c\ ^c Vc ^c k^kd b^XgdhXde^X hijYn d[ gVi XgZ" bVhiZg bjhXaZ ÒVeh#(-!(. IdiVa cZXgdh^h ^c ÒVeh ^h gVgZ VcY ^h jhjVaan [djcY dcan V[iZg kVhXjaVg i]gdbWdh^h d[ i]Z eZY^XaZ dg egdadc\ZY ^hX]Zb^X eZg^dYh# BdgZ" dkZg! ^i ^h bdhi egdWVWan cdi egZkZciVWaZ Wn ^hX]" Zb^X egZXdcY^i^dc^c\# Dc i]Z di]Zg ]VcY! eVgi^Va ÒVe cZXgdh^h dg [Vi i^hhjZ cZXgdh^h dXXjgh ^c je id (% d[ XZgiV^c ÒVeh! hjX] Vh i]Z eZY^XaZ IG6B#',!)& I]ZhZ Xdbea^XVi^dch XdjaY WZ ediZc" i^Vaan YZXgZVhZY Wn >E# Bdhi gZXZci hijY^Zh gZedgi h^\c^ÑXVci gZYjXi^dc ^c i]Z ZmiZci d[ ÒVe cZXgd" h^h ^c hiVcYVgY bdYZah# =dlZkZg! XaVhh^X adXVa >E ]Vh gVgZan WZZc jhZY Xa^c^XVaan!', bdhi a^`Zan WZXVjhZ ^i h^\c^ÑXVcian ^cXgZVhZh deZgVi^kZ i^bZ VcY ^h ^ckVh^kZ#
95
LZ h]dlZY ^c V gVi VY^edXjiVcZdjh ÒVe bdYZa i]Vi VXjiZ >E VcY ÒVe hjgk^kVa XVc WZ Zc]VcXZY cdi dcan Wn egZXaVbe^c\ i]Z ÒVe eZY^XaZ Wji Vahd Wn ^cYjX^c\ Vc ^hX]Zb^VÄgZeZg[jh^dc ZkZci ^c V WdYn VgZV Y^hiVci [gdb i]Z ÒVe WZ[dgZ ZaZ" kVi^dc#)+ 6c ^ckVh^kZ egdXZYjgZ! XaVbe^c\ i]Z [ZbdgVa VgiZgn ^h Vh Z[[ZXi^kZ Vi egZXdcY^i^dc^c\ i]Z ÒVe Vh V cdc^ckVh^kZ idjgc^fjZi Veea^ZY id i]Z gVi ]^cY a^bW [daadlZY Wn (% b^cjiZh a^bW gZeZg[jh^dc ;^\jgZh -"& VcY -"' # 6 hZXdcY hijYn [dXjh^c\ dc gZbdiZ >E d[ h`ZaZiVa bjhXaZ h]dlZY i]Vi Wdi] XaVhh^X VcY gZbdiZ VXjiZ >E ^begdkZY b^XgdX^gXjaVi^dc d[ bjhXaZ ÒVeh V[iZg ^hX]Zb^V#), 7di] egZXdcY^i^dc^c\ egdidXdah ^begdkZY gZY WaddY XZaa kZadX^in ^c i]Z VgiZg^daZh VcY XVe^aaVg^Zh! ^begdkZY XVe^aaVgn Òdl ;^\jgZ -"(V ! VcY YZXgZVhZY cZjigde]^a VXXjbjaVi^dc ^c i]Z edhiXVe^aaVgn kZcjaZh ;^\jgZ -"(W # 8Ve^aaVgn cd"gZÒdl VcY aZj`dXniZ"ZcYdi]Za^Va VY]Zh^dch VgZ i]Z XZcigVa b^XgdX^gXjaVidgn eViiZgch i]Vi YZiZgb^cZ i]Z hZkZg^in d[ ^hX]Zb^V" gZeZg[jh^dc ^c_jgn ^c i]Z XgZbVhiZg bdYZa# I]Z cjbWZg d[ iZbedgVg^an VY]Zg^c\ aZj`dXniZh gdaaZgh Y^Y cdi Y^[[Zg h^\c^ÑXVcian ^c Vcn d[ i]Z ZmeZg^bZciVa \gdjeh ^c djg hZg^Zh ;^\jgZ -") # I]ZhZ ÑcY^c\h b^\]i WZ id i]Z gZhjai d[ V h]dgiZg ^hX]Zb^X eZg^dY i]Vc jhZY Wn di]Zg Vji]dgh#(-!(. =dlZkZg! ^c djg de^c^dc! Vc ^hX]Zb^X eZg^dY d[ ) ]djgh ^h gVgZ ^c V Xa^c^XVa hZii^c\! hd lZ! Vh ]VkZ di]Zgh!)- jhZY ' ]djgh d[ ^hX]Zb^V ^c djg ZmeZg^" bZcih# >c XdcigVhi id di]Zg Vji]dgh!(-!(.!)- lZ jhZY V b^XgdkVhXjaVg XaVbe Y^gZXian dc i]Z ÒVe eZY^XaZ id egZkZci VYY^i^dcVa a^bW ^hX]Zb^V! l]^X] ValVnh dXXjgh l]Zc XaVbe^c\ V hZ\bZci d[
Remote Ischemic Preconditioning >c &..(! Egon`aZc` Zi Va# Ñghi dWhZgkZY i]Vi gZ\^dcVa >E d[ i]Z ]ZVgi cdi dcan egdiZXih i]dhZ bndXniZh hjW_ZXiZY id Wg^Z[ XdgdcVgn dXXajh^dc [gdb ^hX]Zb^V"gZeZg[jh^dc ^c_jgn Wji Vahd a^b^ih ^c[VgXi h^oZ ^c gZbdiZ Åk^g\^cÆ bndXVgY^jb ^c V XVc^cZ bdYZa#)' KZgYdjl Zi Va# lZgZ i]Z Ñghi id gZedgi V gZVa gZbdiZ >E d[ i]Z ]ZVgi Wn bZhZc" iZg^X VgiZgn dXXajh^dc ^c V gVi bdYZa#)( I]Z egd" iZXi^kZ ^cÒjZcXZ d[ a^bW ^hX]Zb^V dc bndXVgY^Va ^c[VgXi^dc ]Vh Vahd WZZc gZedgiZY Wn 7^gcWVjb Zi Va# VcY DmbVc Zi Va#))!)*
Figure 8-1. A noninvasive tourniquet (Martin, Tuttlingen, Germany) applied to the hind limb of a rat to induce ischemia.
96
Tissue Surgery
100 90 80 70 60 50 40 30 20 10 0
CG
PG*
FG*
TG* *pE [dg \adWVa egdiZXi^dc d[ h`ZaZiVa bjhXaZ V\V^chi ^hX]Zb^X cZXgdh^h ^c V aVg\Z Vc^bVa bdYZa# I]gZZ &%"b^cjiZ XnXaZh d[ dXXajh^dc VcY gZeZg[jh^dc ^c V e^\ ]^cY a^bW jh^c\ V idjgc^fjZi h^\c^ÑXVcian gZYjXZY ^c[VgXi^dch d[ i]Z aVi^hh^bjh Ydgh^! \gVX" ^a^h! VcY gZXijh VWYdb^c^h bjhXaZh Wn **! +%! VcY **! gZheZXi^kZan! XdbeVgZY id V Xdcigda
Figure 8-2. Clamping the femoral artery is as effective at preconditioning the flap as a noninvasive tourniquet applied to the rat hind limb followed by 30 minutes limb reperfusion.27 Average flap necrosis was 68.2% (q18.1%) in the control group (CG), 11 q 8.38% in the preclamping group (PG), 12.5 q 5.83% in the femoral ischemic group (FG), and 24 q 11.75% in the tourniquet group (TG). All preconditioned animals had a significantly smaller area of flap necrosis than did the control animals (*p < 0.001 vs. CG). The differences between PG, FG and TG groups were not significant.
\gdje# L]Zi]Zg gZbdiZ ^hX]Zb^X egZXdcY^i^dc" ^c\ XdjaY WZ ^cYjXZY Wn V aViZ bZX]Vc^hb lVh Vahd YZiZgb^cZY#*% 6 gVi ]^cY a^bW lVh hjW_ZXiZY id &% b^cjiZh d[ ^hX]Zb^V VcY (% b^cjiZh d[ gZeZg[jh^dc l^i] V idjgc^fjZi ') ]djgh WZ[dgZ ÒVe ^hX]Zb^V# I]^h egdidXda ^cXgZVhZY gZY WaddY XZaa kZadX^in ^c i]Z XVe^aaVg^Zh VcY Ñghi"dgYZg VgiZg^daZh VcY kZcjaZh VcY ^cXgZVhZY XVe^aaVgn Òdl! Vh lZaa Vh YZXgZVhZY aZj`dXniZ hi^X`^c\ ^c V XgZbVhiZg bdYZa VcY i]jh! ViiZcjViZY ZVgan ^hX]Zb^V"gZeZg[jh^dc ^c_jgn ^c bjhXaZ ÒVeh# Dc i]Z di]Zg ]VcY! ^i Y^Y cdi ^begdkZ ÒVe hjgk^kVa ^c VY^edXjiVcZdjh ÒVeh# I]ZhZ ÑcY^c\h ^cY^XViZ
8 7 6
mm/s*cap
5 4 3 2 1 0
CG
cIP
rIP *pE VgZ ^cYjXZY Wn Y^[[ZgZci bZX]Vc^hbh# 6 [Zl hijY^Zh ]VkZ [dXjhZY dc i]Z edhh^WaZ bZX]Vc^hbh d[ gZbdiZ >E# IV`Vd`V Zi Va# ^ckZhi^" \ViZY i]Z ^ckdakZbZci d[ VYZcdh^cZ gZXZeidgh ^c i]Z bZX]Vc^hb d[ gZbdiZ >E d[ i]Z ]ZVgi Wn gZcVa ^hX]Zb^V# I]Z ^begdkZbZci d[ bndXVgY^Va ZcZg\n bZiVWda^hb ^cYjXZY Wn XaVhh^X VcY gZbdiZ >E lVh VWda^h]ZY ^c gVWW^ih Wn WadX`^c\ VYZcdh^cZ gZXZeidgh#*& 9^X`hdc Zi Va# edhijaViZY i]Vi gZbdiZ >E ^h ^c^i^ViZY Wn V ]jbdgVa bZX]V" c^hb WZXVjhZ i]Z kZcdjh Z[ÒjZci [gdb V egZXdc" Y^i^dcZY ]ZVgi d[ V Ydcdg gVWW^i! igVch[jhZY id Vc gZX^e^Zci Vc^bVa! aZVY id i]Z hVbZ Z[[ZXi Vh ÅegZXaVbe^c\Æ ^c V Xdcigda \gdje#*' >c XdcigVhi! HX]dZbV`Zg VcY kVc =Z^_c^c\Zc dWhZgkZY i]Vi VciV\dc^o^c\ i]Z WgVYn`^c^c ' gZXZeidg VWda" ^h]ZY i]Z egdiZXi^kZ Z[[ZXi d[ gZbdiZ XVgY^VX >E! l]ZgZVh V h^bjaVi^dc d[ WgVYn`^c^c gZaZVhZ Wn adXVa ^cigV"VgiZg^Va ^c[jh^dc XdjaY b^b^X gZbdiZ >E ^c V gVi bdYZa# I]ZhZ gZhjaih hjeedgi i]Z ]nedi]Zh^h i]Vi gZbdiZ >E VXih i]gdj\] hZchdgn cZgkZ hi^bjaVi^dc ^c ^hX]Zb^X dg\Vch#*( Djg YViV h]dl i]Vi ^hX]Zb^X egZXdcY^i^dc^c\ VcY Zc]VcXZbZci d[ ÒVe hjgk^kVa XVc WZ VX]^ZkZY cdi dcan Wn egZXaVbe^c\ i]Z ÒVe eZY^XaZ Wji Vahd Wn ^cYjX^c\ Vc ^hX]Zb^VÄgZeZg[jh^dc ZkZci ^c V WdYn VgZV Y^hiVci [gdb i]Z ÒVe WZ[dgZ ZaZkV" i^dc# I]ZhZ ÑcY^c\h ^cY^XViZ i]Vi gZbdiZ >E ^c ÒVeh bjhi WZ V hnhiZb^X e]ZcdbZcdc VcY cdi bZgZan V adXVa gZVXi^dc ^c i]Z ÒVe ^ihZa[#
clP*
rlp* *pE ^h cdi nZi YZiZgb^cZY# Ild iZbedgVaan VcY bZX]Vc^hi^XVaan Y^hi^cXi ineZh d[ egdiZXi^dc VgZ ^cYjXZY Wn egZXdcY^i^dc^c\ hi^bja^/ VXjiZ VcY YZaVnZY#*)!** KVg^djh [VXidgh! hjX] Vh c^ig^X dm^YZ CD !**!*+ ]ZVi h]dX` egdiZ^ch!*,Ã*. VYZcdh^cZ!+%!+& 6IE"hZch^i^kZ @ X]VccZah!+' XnXaddmn\ZcVhZ"'!+( dg WgVYn`^c^c i]gdj\] hZchdgn cZgkZ hi^bjaV" i^dc!*( hZZb id WZ ^ckdakZY ^c ^hX]Zb^X egZXdc" Y^i^dc^c\# =dlZkZg! i]Z egdiZXi^kZ Z[[ZXih d[ VXjiZ egZXdcY^i^dc^c\ VgZ ^cYZeZcYZci d[ egdiZ^c hnc" i]Zh^h! l]ZgZVh YZaVnZY egZXdcY^i^dc^c\ gZfj^gZh YZ cdkd egdiZ^c hnci]Zh^h#** C^ig^X dm^YZ bVn WZ XZcigVa id i]Z bZX]Vc^hb d[ ^hX]Zb^X egZXdcY^i^dc^c\# EZgVaiV Zi Va# [djcY ^c V gVi bdYZa d[ ]ZeVi^X ^hX]Zb^V"gZeZg[jh^dc i]Vi VYZcdh^cZ dg CD VYb^c^higVi^dc WZ[dgZ ^hX]Zb^V h^bjaViZY i]Z Z[[ZXi d[ egZXdcY^i^dc^c\! l]ZgZVh ^c]^W^i^dc d[ CD hnci]Zh^h Za^b^cViZY i]Z egdiZXi^kZ Z[[ZXi d[ ]ZeVi^X egZXdcY^i^dc" ^c\#+) LZ XdcÑgbZY i]ZhZ YViV ^c ild hijY^Zh d[ VY^edXjiVcZdjh+* VcY bjhXaZ++ ÒVeh# >c XdcigVhi id djg YViV! EZgVaiV Zi Va# dWhZgkZY V Xdci^cj^c\ egdiZXi^kZ Z[[ZXi d[ Zmd\Zcdjh CD V[iZg ZcYd\Z" cdjh CD hnci]Zh^h lVh WadX`ZY Wn Cc LVc\Èh hZg^Zh! Wdi] i]Z Veea^XVi^dc d[ hdY^jb c^igdegjhh^YZ VcY i]Z egZXaVbe^c\ lZgZ eZg[dgbZY ') ]djgh WZ[dgZ ÒVe ^hX]Zb^V id VhhZhh i]Z egdiZ^c"hnci]Zh^h"YZeZcYZci Z[[ZXi d[ YZaVnZY ^hX]Zb^X egZXdcY^i^dc^c\ ^c ÒVeh# Id i]Z WZhi d[ djg `cdlaZY\Z! i]Z gdaZ d[ ZcYd\Zcdjh CD hnci]Zh^h ^c i]Z bZX]Vc^hbh d[ VXjiZ XaVhh^X egZXaVbe^c\ dg gZbdiZ ^hX]Zb^X egZXdcY^i^dc" ^c\ d[ ÒVeh ]Vh cdi WZZc gZedgiZY# >c V gVWW^i Ze^\Vhig^X ^haVcY ÒVe bdYZa! CD hZgjb XdcXZcigVi^dch ^cXgZVhZY V[iZg ÒVe ^hX]" Zb^V l]Zc XdbeVgZY id cdc"^hX]Zb^X Xdcigdah! VcY A"C6B: VcY ]ZeVg^c hjeegZhhZY CD egdYjXi^dc#,) Dh]^bV! i]Z ^ckZhi^\Vidg! Xdc" XajYZY i]Vi CD ^h dcZ d[ i]Z [VXidgh gZhedch^WaZ [dg ^hX]Zb^V"gZeZg[jh^dc ^c_jgn! Vai]dj\] ]Z Y^Y cdi VhhZhh i]Z cZXgdh^h gViZ d[ i]Z ÒVeh# I]Z VWdkZ hijY^Zh XdcÑgb i]Z gZhjaih d[ di]Zg Vji]dgh! Vai]dj\] Dh]^bVÈh XdcXajh^dc lVh ]^\]an heZXjaVi^kZ# BdgZdkZg! CD ^h ^ckdakZY ^c i]Z cVijgVa YZ[ZchZ V\V^chi ^hX]Zb^V gZeZg[jh^dc ^c_jgn Wji cdi ^c ^cYjX^c\ ^i# Di]Zg hijY^Zh gZedgi V edhh^WaZ Xnididm^X VXi^dc [dg CD WZXVjhZ ^i YVbV\Zh ]nYgdmna"[gZZ gVY^XVah ^c bdYZah d[
Tissue Surgery
kZcdjh ÒVe dWhigjXi^dc#,( =dlZkZg! i]ZhZ ÑcY" ^c\h XVc cZ^i]Zg WZ XdcÑgbZY cdg Y^hegdkZY Wn djg gZhjaih WZXVjhZ djg bdYZa Y^Y cdi [dXjh dc kZcdjh ^hX]Zb^V# I]Z YViV h]dl i]Vi CD ^h ^bedgiVci ^c i]Z bZX]Vc^hb d[ >E WZXVjhZ VYb^c^hiZg^c\ V CD" Ydcdg WZ[dgZ ^hX]Zb^V h^bjaViZh i]Z Z[[ZXi d[ >E! l]ZgZVh i]Z jcheZX^ÑX WadX`^c\ d[ CD hnci]Zh^h Wn A"C6B: Za^b^cViZh i]Z egdiZXi^kZ Z[[ZXi d[ ÒVe egZXdcY^i^dc^c\ i]gdj\] egZXaVbe^c\! Vh lZaa Vh i]gdj\] gZbdiZ >E# 7di] CD VcY VXjiZ >E a^`Zan ^c^i^ViZ V XVhXVYZ i]Vi ^cXgZVhZh i]Z hnc" i]Zh^h d[ ZcYd\Zcdjh CD i]gdj\] ZCDH dg ^CDH WZXVjhZ i]Z Zmd\Zcdjh CD Veea^XVi^dc VadcZ ^h ^chj[ÑX^Zci id egdiZXi V\V^chi ^hX]Zb^V" gZeZg[jh^dc ^c_jgn! dcXZ i]Z ZcYd\Zcdjh CD hnci]Zh^h ^h WadX`ZY# I]ZhZ YViV egdk^YZ V WZiiZg jcYZghiVcY^c\ d[ i]Z bZX]Vc^hbh d[ VXjiZ >E d[ ÒVeh VcY VgZ i]Z WVh^h [dg [jijgZ hijY^Zh#
References &# 8^VhX]^c^ B! 7ZgcVgY HA# =^hidgn d[ eaVhi^X hjg\Zgn# ]iie/$$lll#ZbZY^X^cZ#Xdb$eaVhi^X$ide^X)((#]ib# 6XXZhhZY BVgX] '%%&# '# BX8Vgi]n ?cigdYjXi^dc# >c/ BX8Vgi]n ?cY^Vc bZi]dYh [dg idiVa cVhVa gZXdchigjXi^dc# 8a^c EaVhi H g\# &.-(0&% ) /+(*Ã+),# )# AVhXVgVidh ?! 8d]Zc B! Kdgdh 9# EaVhi^X hjg\Zgn d[ i]Z [VXZ ^c 7noVci^jb ^c i]Z [djgi] XZcijgn# EaVhi GZXdchig H g\# &..-0&%' ) /&',)Ã&'-%# *# 7ZccZii ?E# 6heZXih d[ i]Z ]^hidgn d[ eaVhi^X hjg\Zgn h^cXZ i]Z &+i] XZcijgn# ? G HdX BZY# &.-(0,+ ' / &*'Ã&*+# +# B^XVa^ iVa^Vc Xdcig^Wji^dc id eaVhi^X hjg\Zgn# 6cc EaVhi H g\# &..(0(& + /*++Ã*,&# ,# BV]dc"9Zg^ 7! DÈAZVgn ?E# I]Z W^gi] d[ bdYZgcÅeaVhi^`Æ eaVhi^X hjg\Zgn# 6b H g\# &..)0+% . /,&.Ã,'%# -# BX9dlZaa ;# EaVhi^X hjg\Zgn ^c i]Z ilZci^Zi] XZcijgn# 6cc EaVhi H g\# &.,-0& ' /'&,Ã'')# .# HiVg` G7# I]Z ]^hidgn d[ eaVhi^X hjg\Zgn ^c lVgi^bZ# 8a^c EaVhi H g\# &.,*0' ) /*%.Ã*&+# &%# IVbV^ H# =^hidgn d[ b^Xgdhjg\ZgnÄ[gdb i]Z WZ\^cc^c\ jci^a i]Z ZcY d[ i]Z &.,%Èh# B^Xgdh g\Zgn# &..(0&)/+Ã&(# &&# Da^kVg^ C# I]Z aVi^hh^bjh Ydgh^ ÒVe# 7g ? EaVhi H g\# &.,+0'./&'+Ã&'-# &'# =dabhigb =# I]Z [gZZ VWYdb^cdeaVhin VcY ^ih jhZ ^c WgZVhi gZXdchigjXi^dc# HXVcY ? EaVhi GZXdchig H g\# &.,.0&(/)'(# &(# 6aaZc G?! IgZZXZ E# 9ZZe ^c[Zg^dg Ze^\Vhig^X eZg[dgVidg ÒVe [dg WgZVhi gZXdchigjXi^dc# 6cc EaVhi H g\# &..)0('/('Ã(-# &)# 6aaZc G?! IjX`Zg 8# HjeZg^dg \ajiZVa VgiZgn eZg[dgVidg [gZZ ÒVe [dg WgZVhi gZXdchigjXi^dc# EaVhi GZXdchig H g\# &..*0.*/&'%,Ã&'&'# &*# 6c\g^\^Vc^ 8! ckZhi# &.,-0+&/&&+&Ã&&+,# ''# H^Zb^dcdl B! LVc\ LO! 6cYZghdc hZcWZg\ ?H! I]dbhdc ?>/ Xa^c^XVa hijY^Zh# EaVhi GZXdchig H g\# &..,0../ &'&,Ã&''(# '-# GZhi^[d G?! I]dbhdc ?>>! CV]V^ ;! 7g^ZY ?I! :VkZh ;;# IG6B ÒVe kVhXjaVg YZaVn [dg ]^\]"g^h` WgZVhi gZXdc" higjXi^dc# EaVhi GZXdchig H g\# &..*0.+ , /&+&*Ã&+''# (&# :gYbVcc 9! HjcY^c 7B! Bdfj^c @?! Ndjc\ =! hX]Zb^X egZXdcY^" i^dc^c\ Vi V Y^hiVcXZ/ gZYjXi^dc d[ bndXVgY^Va ^c[VgXi h^oZ Wn eVgi^Va gZYjXi^dc d[ WaddY hjeean XdbW^cZY l^i] gVe^Y hi^bjaVi^dc d[ i]Z \VhigdXcZb^jh bjhXaZ ^c i]Z gVWW^i# 8^gX aVi^dc# &..,0.+ * /&+)&Ã&+)+# DmbVc I! 6gVY B! @aZ^c G! 6kVodk C! GVW^cdl^io 7# A^bW ^hX]Zb^V egZXdcY^i^dch i]Z ]ZVgi V\V^chi gZeZg[j" h^dc iVX]nVgg]ni]b^V# 6b ? E]nh^da# &..,0',( ) Ei ' / =&,%,Ã&,&'# @cihX]Zg BK! HX]^gbWZX` :J! BZc`Z =! @aVg :! bea^XVi^dch d[ ]ZVi h]dX` egdiZ^c ^cYjXi^dc id ^cXgZVhZ idaZgVcXZ d[ ^hX]" Zb^V"gZeZg[jh^dc ^c_jgn# ? AVW 8a^c BZY# &..+0&'-/ '*&Ã'*-# A^aaZ H! Hj 8N! HX]dZaaZg I! Zi Va# >cYjXi^dc d[ ]ZVi"h]dX` egdiZ^c ,' ^c gVi h`ZaZiVa bjhXaZ YdZh cdi ^cXgZVhZ idaZg" VcXZ id ^hX]Zb^V"gZeZg[jh^dc ^c_jgn# B hXaZ CZgkZ# &...0''/(.%Ã(.(# LVc\ 7=! NZ 8! HiV\\ 86! Zi Va# >begdkZY [gZZ bjhXjad" XjiVcZdjh ÒVe hjgk^kVa l^i] ^cYjXi^dc d[ ]ZVi h]dX` egdiZ^c# EaVhi GZXdchig H g\# &..-0&%& ( /,,+Ã,-)# EVc\ 8N! CZa^\Vc E! O]dc\ 6! =Z L! Mj =! ;dggZhi 8G# :[[ZXidg bZX]Vc^hb d[ VYZcdh^cZ ^c VXjiZ ^hX]Zb^X egZXdcY^i^dc^c\ d[ h`ZaZiVa bjhXaZ V\V^chi ^c[VgXi^dc# 6b ? E]nh^da# &..,0',(/G--,Ã-.*# Nd`diV G! ;j_^lVgV =! B^nVbVZ B! Zi Va# IgVch^Zci VYZcdh^cZ ^c[jh^dc WZ[dgZ ^hX]Zb^V VcY gZeZg[jh^dc egdiZXih V\V^chi bZiVWda^X YVbV\Z ^c e^\ ]ZVgih# 6b ? E]nh^da# &..*0'+-/=&&).Ã&&*,# EVc\ 8N! CZa^\Vc E! Mj =! Zi Va# GdaZ d[ 6IE"hZch^i^kZ @ X]VccZah ^c ^hX]Zb^X egZXdcY^i^dc^c\ d[ h`ZaZiVa bjhXaZ V\V^chi ^c[VgXi^dc# 6b ? E]nh^da# &..,0',(/ =))Ã*&# <jd N! 7Vd L! Lj L?! H]^cbjgV @! IVc\ MA! 7daa^ G# :k^YZcXZ [dg Vc ZhhZci^Va gdaZ d[ XnXaddmn\ZcVhZ"' Vh V
+)#
+*#
++#
+,#
+-# +.#
,%#
,&# ,'#
,(#
,)#
bZY^Vidg d[ i]Z aViZ e]VhZ d[ ^hX]Zb^X egZXdcY^i^dc^c\ ^c b^XZ# 7Vh^X GZh 8VgY^da# '%%%0.* + /),.Ã)-)# EZgVaiV 8! 8adhV 9! =diiZg >/ i]Z gdaZ d[ c^ig^X dm^YZ# B^Xgdh g\Zgn# '%%'0'' + /'',Ã'(&# 8]Zc ?M! 7Zggn A8! IVccZg B! 8]Vc\ B! BnZgh GE! BZng^X` 7# C^ig^X dm^YZ Ydcdgh gZ\jaViZ c^ig^X dm^YZ hnci]VhZ ^c Wdk^cZ ejabdcVgn VgiZgn ZcYdi]Za^jb# ? 8Zaa E]nh^da# '%%&0&-+ & /&&+Ã&'(# GV`]^i G9! :YlVgYh G?! BVgWZg BH# C^ig^X dm^YZ! c^igViZh VcY ^hX]VZb^X egZXdcY^i^dc^c\# 8VgY^dkVhX GZh# &...0)( ( /+'&Ã+',# 8dgYZ^gd Ec^i^Vi^dc d[ b^XgdkVhXjaVg egdiZXi^dc Wn c^ig^X dm^YZ ^c aViZ egZXdcY^i^dc^c\# ? GZXdchig B^Xgdh g\# '%%%0&+ - /+'&Ã+'-# Dh]^bV =# I]Z ^cÒjZcXZ d[ h`^c ÒVe ^hX]Zb^V dc hZgjb c^ig^X dm^YZ XdcXZcigVi^dch# B^Xgdh g\Zgn# &..+0&, ) / &.&Ã&.,#
9 Advances in Facial Aesthetic Surgery: New Approaches to Old Problems and Current Approaches to New Problems James E. Zins and Andrea Moreira-Gonzalez
Introduction 6h djg a^kZh WZXdbZ [dgZkZg bdgZ ]ZXi^X! bZc VcY ldbZc ^c i]Z Jc^iZY HiViZh VgZ WZXdb^c\ bdgZ i^bZ XdchX^djh VcY aZhh VXXZei^c\ d[ hjg\^XVa egdXZYjgZh gZfj^g^c\ egdadc\ZY gZXdk" Zgn# I]^h X^gXjbhiVcXZ ]Vh aZY id ^cXgZVh^c\ ViiZci^dc WZ^c\ eV^Y id aZhhZg dg b^c^bVaan ^ckVh^kZ egdXZYjgZh gVi]Zg i]Vc igVY^i^dcVa dcZh# I]Z bZY^V! i]Z >ciZgcZi! VcY iZaZk^h^dc h]dlh ]VkZ edejaVg^oZY bVcn d[ i]ZhZ iZX]c^fjZh# 6ai]dj\] hdbZ d[ i]ZhZ iZX]c^fjZh bVn WZ Z[[ZX" i^kZ! bVcn ]VkZ cdi WZZc ]ZaY id hig^Xi hX^Zci^ÑX g^\dg# I]Z gZXZci edejaVg^in d[ hjg\^XVa egdXZYjgZh [dg i]Z XdggZXi^dc d[ bVhh^kZ lZ^\]i adhh ]Vh bVg`ZYan ^cXgZVhZY i]Z edejaVg^in VcY ^cX^YZcXZ d[ eaVhi^X hjg\Zgn egdXZYjgZh [dg XdggZXi^c\ h`^c ZmXZhh# >c [VXi! eaVhi^X hjg\Zgn XdggZXi^dc [dg eVi^Zcih l]d ]VkZ jcYZg\dcZ WVg^Vig^X hjg\Zgn ^h egZY^XiZY id WZ dcZ d[ i]Z [VhiZhi"\gdl^c\ VgZVh d[ eaVhi^X hjg\Zgn ^c i]Z Zchj^c\ nZVgh# 6Zh" i]Zi^X [VX^Va XdggZXi^dc ^c i]ZhZ eVi^Zcih gZfj^gZh heZX^Va Xdch^YZgVi^dch VcY kVg^Vi^dch dc XjggZci iZX]c^fjZh# ;^cVaan! Vai]dj\] cZl igZVibZcih [dg =>K$ 6>9H ]VkZ egdadc\ZY hjgk^kVa! i]Zn ]VkZ Vahd gZhjaiZY ^c V cZl \gdje d[ eVi^Zcih l^i] [VX^Va YZ[dgb^i^Zh i]Vi VgZ VbZcVWaZ id eaVhi^X hjg\Zgn XdggZXi^dc# =ZgZ! lZ gZk^Zl i]Z VWdkZ ide^Xh VcY djg egZ" [ZggZY bZi]dYh [dg igZVi^c\ i]Zb#
hjg\Zgn! VcY di]Zg hjg\^XVa hjWheZX^Vai^Zh# KVh" XdcZo lVh i]Z Ñghi id edejaVg^oZ i]Z ZcYdhXde^X Wgdla^[i l]Zc ]Z gZVa^oZY i]Vi Vc Ådei^XVa XVk^inÆ XdjaY WZ YZkZadeZY i]gdj\] V hjWeZg^dhiZVa [dgZ" ]ZVY Y^hhZXi^dc#&!' I]Z egdXZYjgZ lVh hddc ede" jaVg^oZY Wn di]Zgh VcY h^cXZ ]Vh WZXdbZ l^YZan VXXZeiZY#(Ã&% Bdhi hjg\Zdch [Vkdg i]Z hjWeZg^dh" iZVa VeegdVX]! Wji i]Z hjW\VaZVa VeegdVX] ^h egZ" [ZggZY Wn di]Zgh#&&Ã&) I]Z ZcYdhXde^X VeegdVX] Y^[[Zgh XdcXZeijVaan [gdb i]Z igVY^i^dcVa XdgdcVa dg ]V^ga^cZ Wgdla^[i# I]Z ZcYdhXde^X VeegdVX] YZeZcYh cdi dc bZX]Vc^XVa ZaZkVi^dc Wn h`^c dg hXVae ZmX^h^dc Wji dc lZV`Zc^c\ i]Z VciV\dc^hi^X V[[ZXi d[ i]Z YZegZhhdg bjhXaZh d[ i]Z [dgZ]ZVY i]Z Xdggj\V" idgh! egdXZgjh! VcY dgW^XjaVg^h dXja^ # I]^h lZV`" Zc^c\ d[ i]Z YZegZhhdgh Vaadlh i]Z [dgZ]ZVY ZaZkVidg [gdciVa^h id [jcXi^dc l^i] aZhh deedh^" i^dc! gZhjai^c\ ^c Wgdl ZaZkVi^dc# 8g^i^XVa id i]Z hjXXZhh d[ i]Z hjWeZg^dhiZVa Wgdla^[i VgZ i]Z [da" adl^c\ egZgZfj^h^iZh/ &# L^YZ gZaZVhZ d[ i]Z VgXjh bVg\^cVa^h dg eZg^" dhiZjb d[ i]Z hjegVdgW^iVa g^b! i]Z hjeZg^dg iZbedgVa a^cZ! VcY i]Z iZbedgVa a^\VbZci '# 6aiZgVi^dc Wn gZhZXi^dc d[ i]Z YZegZhhdg bjhXaZh d[ i]Z [dgZ]ZVY! Vaadl^c\ i]Z [gdciVa^h id ldg` gZaVi^kZan jcdeedhZY (# 6YZfjViZ egZYdb^cVcian aViZgVa ÑmVi^dc d[ i]Z [dgZ]ZVY hd[i i^hhjZh
Browlift
8dckZghZan! e^i[Vaah ^cXajYZ ^cVYZfjViZ gZaZVhZ d[ i]Z VgXjh bVg\^cVa^h! ^cVYZfjViZ bjhXaZ ZmX^h^dc! VcY ^cVYZfjViZ ÑmVi^dc# 8dbbdc edhideZgVi^kZ egdWaZbh! i]ZgZ[dgZ! ^cXajYZ i]Z [daadl^c\/
:cYdhXde^X hjg\Zgn XVbZ gZaVi^kZan aViZ id eaVhi^X hjg\Zgn# I]Z ZcYdhXde^X Wgdla^[i lVh ^cigdYjXZY ^c &..*! adc\ V[iZg ZcYdhXde^X egdXZYjgZh lZgZ XdbbdceaVXZ ^c \ZcZgVa hjg\Zgn! \ncZXdad\^X
&# JcYZgXdggZXi^dc d[ Wgdl ZaZkVi^dc! ZheZ" X^Vaan aViZgVaan# I]^h aVX` d[ VYZfjViZ aViZgVa ZaZkVi^dc gZhjaih egZYdb^cVcian [gdb ^cVYZ" fjViZ aViZgVa hd[i i^hhjZ gZaZVhZ dg ^cVYZfjViZ ÑmVi^dc#
101
102
Tissue Surgery
'# DkZgXdggZXi^dc d[ i]Z Wgdl bZY^Vaan# DkZg" XdggZXi^dc bZY^Vaan gZhjaih [gdb ^begdeZg hjg\^" XVa eaVcc^c\ VcY ^h i]Z Y^gZXi gZhjai d[ Xdggj\Vidg gZhZXi^dc# (# GZXjggZcXZ d[ Xdggj\Vidg ]neZgVXi^k^in gZhjai^c\ [gdb ^cVYZfjViZ Xdggj\Vidg gZhZXi^dc# >c di]Zg ldgYh! ^i bVn WZ i]Z hjg\Zdc l]d [V^ah i]Z eVi^Zci! gVi]Zg i]Vc i]Z egdXZYjgZ i]Vi aZVYh id aZhh"i]Vc"^YZVa gZhjaih# EgdeZg eVi^Zci hZaZXi^dc ^h Vahd Xg^i^XVa ^[ eaZVh" ^c\ gZhjaih VgZ id WZ dWiV^cZY# 8ZgiV^c eVi^Zcih l^i] Wgdl eidh^h VgZ XaZVgan cdi \ddY XVcY^YViZh [dg i]Z ZcYdhXde^X Wgdla^[i# HjX] eVi^Zcih ]VkZ ]^\] ]V^ga^cZh dg bVg`ZY dg hZkZgZ ZnZWgdl eidh^h# I]Z eVi^Zci l^i] i]Z ]^\] ]V^ga^cZ ^h WZiiZg VYYgZhhZY Wn V igVY^i^dcVa ]V^ga^cZ Wgdla^[i ^cX^" h^dc! gVi]Zg i]Vc Wn V ejgZ ZcYdhXde^X VeegdVX]# >[ i]Z ]V^ga^cZ ^cX^h^dc ^h jhZY! i]Z ]V^ga^cZ XVc WZ adlZgZY! ^c VYY^i^dc id i]Z Wgdl WZ^c\ ZaZkViZY! i]ZgZWn h]dgiZc^c\ i]Z [dgZ]ZVY VcY \^k^c\ i]Z eVi^Zci V bdgZ ndji][ja VeeZVgVcXZ# 6aiZgcVi^kZan! i]Z ]V^ga^cZ VcY Vc ZcYdhXde^X
a
VeegdVX] XVc WZ XdbW^cZY! Vh YZhXg^WZY Wn GVb^gZo#(!) I]Z eVi^Zci l^i] V ]ZVkn Wgdl VcY hZkZgZ Wgdl eidh^h ^h egdWVWan WZhi VeegdVX]ZY Wn ZmX^h^dcVa hjg\Zgn id bVm^b^oZ [dgZ]ZVY ZaZkVi^dc# BZVch d[ ÑmVi^dc ]VkZ Vahd ZkdakZY dkZg i]Z eVhi &% nZVgh# :Vgan ZcYdhXde^X VeegdVX]Zh jhZY WdahiZg YgZhh^c\h! hjijgZh dg! bdgZ Xdbbdcan! eZgXjiVcZdjh hXgZl ÑmVi^dc#+!&& I]Z eZgXjiVcZ" djh hXgZl lVh eaVXZY i]gdj\] i]Z aViZgVa ZcYd" Wgdl ^cX^h^dc VcY ^cid i]Z djiZg iVWaZ d[ i]Z h`jaa# 6 hiVeaZ lVh i]Zc jhZY WZ]^cY i]Z hXgZl id bV^ciV^c [dgZ]ZVY ZaZkVi^dc! dcXZ i]Z hXVae VcY [dgZ]ZVY ]VY WZZc ejaaZY edhiZg^dgan# 6ai]dj\] Z[[ZXi^kZ! i]^h VeegdVX] gZhjaiZY ^c igVXi^dc dc i]Z hXVae i]Vi dXXVh^dcVaan XVjhZY ]V^g adhh# ;jgi]Zg! eVi^Zcih lZgZ fj^iZ VkZghZ id i]Z ZmedhZY hXgZlh ^c i]Z^g hXVae VcY lZgZ Y^heaZVhZY Vi i]Z ^YZV d[ ]Vk^c\ hXgZlh ^c i]Z^g h`jaah# EZgXjiVcZdjh hXgZlh ]VkZ WZZc gZeaVXZY Wn di]Zg iZX]c^fjZh! ^cXajY^c\ gZhdgWVWaZ eaViZh! hXgZlh VcY hjijgZ! i]Z :cYdi^cZ YZk^XZ! dg i]Z Xdgi^XVa"ijccZa iZX]c^fjZ#&*Ã&- LZ jhZ i]Z
b
Figure 9-1. a) Preoperative view of 43-year-old woman with eyebrow ptosis treated by endoscopic subperiosteal browlift using the cortical tunnel technique for fixation, a cheeklift, and submental liposuction. b) The patient 1 year later.
Advances in Facial Aesthetic Surgery: New Approaches to Old Problems and Current Approaches to New Problems
Xdgi^XVa"ijccZa iZX]c^fjZ! [gdb XgVc^d[VX^Va hjg\Zgn# DWa^fjZ ]daZh VgZ Yg^aaZY ^c Vc VciZg^dg VcY edhiZg^dg Y^gZXi^dc i]gdj\] i]Z aViZgVa hXVae ^cX^h^dc jhZY Yjg^c\ i]Z ZcYdhXde^X VeegdVX]# 6 hjijgZ ^h eVhhZY i]gdj\] i]^h Xdgi^XVa ijccZa! i]Z [dgZ]ZVY Ve ^h \gVheZY [gdb ^ih YZZe hjg[VXZ! VcY i]Z hjijgZ ^h i^ZY# I]Z Xdgi^XVa ijccZa XVc WZ Yg^aaZY kZgn hjeZgÑX^Vaan VcY! i]jh! eZcZigVi^dc d[ i]Z ^ccZg iVWaZ Vkd^YZY# I]Z h`jaa ^c i]^h VgZV bVn WZ dcan , bb dg - bb i]^X`#&. I]Z Xdgi^XVa iZX]c^fjZ ^h [Vhi! ZVh^an VXXdbea^h]ZY! VcY gZfj^gZh cd ZmeZch^kZ YZk^XZh# ;^mVi^dc ^h Veea^ZY aViZgVaan dcan VcY! V\V^c! ^i ^h Y^[ÑXjai id dkZgXdg" gZXi aViZgVaan VcY ZVhn id dkZgXdggZXi bZY^Vaan# >cigVdeZgVi^kZ i^bZ gZfj^gZY [dg Yg^aa^c\ d[ i]Z ijccZa ^h ( b^cjiZh# LZ ]VkZ ]VY cd Xdbea^XV" i^dch l^i] i]Z Xdgi^XVa ijccZa ^c bdgZ i]Vc &%% XVhZh ;^\jgZ ."& #
Midface Correction >ciZgZhi ^c XdggZXi^c\ YZ[ZXih d[ i]Z b^Y[VXZ WZ\Vc ^c i]Z ZVgan &..%h VcY ]Vh Xdci^cjZY h^cXZ# HiVcYVgY [VXZa^[i VeegdVX]Zh [dg XdggZXi^c\ i]Z b^Y [VXZ ^c i]Z hjW"HB6H eaVcZ! i]Z hjWeZg^dh" iZVa eaVcZ! VcY i]Z hjWXjiVcZdjh eaVcZ! ]VkZ Vaa WZZc gZXdbbZcYZY# K^gijVaan Vaa bdYZgc hjW" HB6H [VXZa^[i egdXZYjgZh i]Vi egdk^YZ VYZfjViZ b^Y[VXZ XdggZXi^dc ^ckdakZ gZaZVh^c\ i]Z bV_dg on\dbVi^X XjiVcZdjh a^\VbZci VcY i]Z jeeZg bVhhZiZg^X XjiVcZdjh a^\VbZcih! l^i] dg l^i]dji bVaVg [Vi eVY gZedh^i^dc^c\#'%Ã'. I]ZhZ egdXZ" YjgZh Y^[[Zg ^c i]Z Vbdjci d[ h`^c jcYZgb^c^c\! i]Z bZi]dY d[ ÑmVi^c\ bdW^a^oZY b^Y[VXZ higjX" ijgZh! VcY i]Z bVc^ejaVi^dc d[ i]Z bVaVg [Vi eVY# 6c ZmiZch^dc d[ i]Z ZcYdhXde^X Wgdla^[i VeegdVX] [dg b^Y[VXZ XdggZXi^dc ]Vh WZZc edej" aVg^oZY Wn V cjbWZg d[ Vji]dgh#(%Ã(( I]ZhZ Vji]dgh jhZ Z^i]Zg i]Z hjWeZg^dhiZVa (%Ã(( dg i]Z hjW\VaZVa VeegdVX]#6ai]dj\] XaVhh^XVaan YZhXg^WZY Vh ^cZ[[ZXi^kZ ^c i]Z adc\"iZgb!ÅheVcc^c\ hjijgZhÆ ]VkZ \V^cZY ^c edejaVg^in# A^iiaZÈh [VXZa^[i iZX]c^fjZ bV`Zh jhZ d[ hjX] hjijgZh VcY ^h XdcXZeijVaan VeeZVa" ^c\#()Ã(* A^iiaZ XdbW^cZh Vc ZcYdhXde^X VeegdVX] [gdb i]Z iZbedgVa VgZV l^i] ^cigVdgVa ZmedhjgZ d[ i]Z bVm^aaV# 6[iZg iZbedgVa Y^hhZXi^dc! ]Z bV`Zh Vc ^cigVdgVa ^cX^h^dc VcY ZmedhZh i]Z bVm^aaV! i]Z e^g^[dgb VeZgijgZ! VcY i]Z on\d" bVi^X Zb^cZcXZ# I]Zc! i]gdj\] i]Z ^cigVdgVa gdjiZ! ]Z eaVXZh V hjijgZ dc i]Z a^cZ ^ciZghZXi^c\
103
i]Z aViZgVa XVci]jh kZgi^XVaan! l^i] V a^cZ YgVlc ]dg^odciVaan [gdb i]Z VaVg WVhZ# 6i i]Z ^ciZghZX" i^dc d[ i]ZhZ ild a^cZh! ]Z \gVheh i]Z hd[i i^hhjZ [gdb i]Z ^cigVdgVa VeegdVX]! dc i]Z jcYZghjg" [VXZ d[ i]Z X]ZZ` hd[i i^hhjZ# I]^h heVcc^c\ hjijgZ ^h i]Zc eVhhZY i]gdj\] i]Z bdji] id i]Z iZbed" gVa ^cX^h^dc VcY hZlc id i]Z iZbedgVa^h [VhX^V egdeZg# 6 hiVcYVgY [VXZa^[i ^cX^h^dc ^h i]Zc bVYZ V[iZg i]Z VWdkZ ^cX^h^dch VgZ XadhZY# 6c ZmiZcYZY hjWXjiVcZdjh [VXZa^[i ^h i]Zc [daadlZY Wn ]dg^" odciVa eaVXVi^dc d[ i]Z hd[i i^hhjZh ^c i]Z adlZg [VXZ#()Ã(* KVhXdcZo ]Vh iV`Zc V Y^[[ZgZci VeegdVX]#(+Ã(, =Z VeegdVX]Zh i]Z bVaVg [Vi eVY VcY ZaZkViZh i]Z b^Y[VXZ i]gdj\] Vc VciZg^dg ]V^ga^cZ hjWXjiVcZ" djh VeegdVX]# I]gdj\] i]^h VeegdVX]! i]Z bVaVg [Vi eVY ^h ZmedhZY! l^i] Y^hhZXi^dc ZmiZcY^c\ bZY^Vaan idlVgY i]Z cVhdaVW^Va [daY# I]Z bVaVg [Vi eVY ^h i]Zc \gVheZY i]gdj\] i]Z hjWXjiVcZ" djh Y^hhZXi^dc! Vadc\ i]Z kZgi^XVa a^cZ XdggZ" hedcY^c\ id i]Z aZkZa d[ i]Z aViZgVa XVci]jh# HZkZgVa heVcc^c\ hjijgZh VgZ i]Zc eaVXZY i]gdj\] i]Z bVaVg [Vi eVY! Y^gZXiZY hjeZg^dgan VcY edhiZ" g^dgan! VcY ViiVX]ZY id i]Z ^ciZgbZY^ViZ iZbedgVa [VhX^V# 6ai]dj\] i]^h VeegdVX] ^h Z[[ZXi^kZ! i]Z YgVlWVX` ^h i]Vi i]Z VciZg^dg ]V^ga^cZ ^cX^h^dc bVn WZXdbZ k^h^WaZ# BdgZ gZXZcian!KVhXdcZo gZX" dbbZcYZY i]^h egdXZYjgZ egZYdb^cVcian [dg ZaYZgan eVi^Zcih! l]d ldjaY WZ bdgZ VXXZei^c\ d[ i]^h VciZg^dg ^cX^h^dc# =ZhiZgÈh VeegdVX] id i]Z b^Y[VXZ ]Vh WZZc V hjWeZg^dhiZVa VeegdVX] i]gdj\] V adlZg ZnZa^Y ^cX^h^dc#(- ;dg i]Z eVhi &% nZVgh! i]Z =ZhiZg \gdje ]Vh \V^cZY kVhi ZmeZg^ZcXZ l^i] i]Z hjWeZg^dhiZVa adlZg ZnZa^Y VeegdVX] VcY ]Vh kVg^ZY i]Z^g iZX]c^fjZ V cjbWZg d[ i^bZh# I]Z^g XjggZci iZX]c^fjZ ^h i]Vi d[ V adlZg ZnZa^Y! hjW" eZg^dhiZVa! ZcYdhXde^XVaan Vhh^hiZY VeegdVX] id i]Z b^Y[VXZ# 8VgZ[ja ViiZci^dc id aViZgVa XVci]jh hjeedgi VcY XdchZgkVi^kZ gZhZXi^dc d[ i]Z adlZg ZnZa^Y h`^c ^h Xg^i^XVa id i]Z^g gZhjaih#(. I]Z aZVgc" ^c\ XjgkZ id i]^h egdXZYjgZ ^h lZaa gZXd\c^oZY! VcY ZmeZg^ZcXZ ^h cZXZhhVgn id Vkd^Y adlZg ZnZa^Y Xdbea^XVi^dch# Djg VeegdVX] id i]Z b^Y[VXZ ^h h^b^aVg id A^iiaZÈh# >c i]Z ndjc\Zg eVi^Zci! lZ XdbW^cZ i]Z ZcYdhXde^X iZbedgVa VeegdVX] l^i] i]Z ^cigV" dgVa VeegdVX] VcY Vkd^Y i]Z [VXZa^[i XdbedcZci d[ i]Z deZgVi^dc ;^\jgZ ."' # I]^h XdbW^cVi^dc \^kZh Xdch^hiZci! VYZfjViZ b^Y[VXZ ZaZkVi^dc l^i]dji adlZg ZnZa^Y Xdbea^XVi^dch# I]Z deZgV" i^dc ^h cdi Xdbea^XVi^dc"[gZZ! ]dlZkZg# IgVch^Zci WjXXVa"WgVcX] lZV`cZhh dXXjgh ^c Veegdm^bViZan &* d[ djg eVi^Zcih# Id ZchjgZ VYZfjViZ gZaZVhZ
104
Tissue Surgery
a
b
Figure 9-2. a) Preoperative view of a 52-year-old woman who underwent an endoscopically assisted cheeklift, with a combined intraoral incision and spanning sutures from the intraoral soft tissues to the temporalis fascia proper. b) The patient 1 year later.
i]gdj\] i]Z ^cigVdgVa VeegdVX]! lZ higZiX] i]Z hd[i i^hhjZh d[ i]Z X]ZZ` l^i] Vc ^cYZm Ñc\Zg eaVXZY i]gdj\] i]Z ^cigVdgVa ^cX^h^dc# I]^h higZiX]^c\ ^h i]Z egdWVWaZ XVjhZ d[ i]Z WjXXVa cZgkZ cZjgdegVm^V# >c VYY^i^dc! hd[i i^hhjZ ^c[ZX" i^dc! egZhjbVWan gZaViZY id i]Z XdbW^cZY ^cigV" dgVa VcY iZbedgVa VeegdVX]Zh! dXXjgh ^c VWdji &% d[ djg eVi^Zcih# Id b^c^b^oZ gZXdkZgn i^bZ! b^c^bVaan ^ckV" h^kZ hjijgZ iZX]c^fjZh ]VkZ WZZc YZkZadeZY! ^cXajY^c\ i]Z b^c^bVa VXXZhh XgVc^Va hjheZch^dc B68H"a^[i ! WVgWZY hjijgZh! VcY i]Z ZcYdhXde^" XVaan Vhh^hiZY X]ZZ` a^[i jh^c\ i]Z :cYdi^cZ b^Y[VXZ YZk^XZ 8dVei 8d# #&+!)% I]Z hjg\^XVa dji" XdbZh d[ i]ZhZ iZX]c^fjZh ]VkZ cdi WZZc ejW" a^h]ZY0 ]dlZkZg! Vi aZVhi dcZ hijYn YdXjbZcih hjWhiVci^Va Xdbea^XVi^dch l^i] i]Z WVgWZY hjijgZh#)& >c hjbbVgn! heVcc^c\ iZX]c^fjZh ldg` WZhi ^c ndjc\Zg eVi^Zcih# 8dbea^XVi^dch XVc ^cXajYZ VhnbbZign! igVch^Zci WjXXVa cZgkZ lZV`cZhh! VcY ^c[ZXi^dc#
Perioral Rejuvenation I]Z eZg^dgVa VgZV ]Vh Vahd gZXZ^kZY ^cXgZVh^c\ ViiZci^dc ^c gZXZci nZVgh# I]^h VgZV ^h d[iZc ^cVY" ZfjViZan VYYgZhhZY Wn XZgk^Xd[VX^Va g]ni^YZX" idbn VadcZ# 6\^c\ d[ i]Z eZg^dgVa VgZV ^h ZmVXZgWViZY Wn V cjbWZg d[ [VXidgh gZaViZY id Wdi] WdcZ VcY hd[i i^hhjZ# EZg]Veh bdhi ^bedg" iVci ^h i]Z adhh d[ i]Z VakZdaVg g^Y\Z VcY iddi] hjeedgi#)' Iddi] adhh aZVYh id VakZdaVg g^Y\Z gZhdgei^dc! bVcY^WjaVg dkZgXadhjgZ gZYjXZY kZg" i^XVa [VX^Va ]Z^\]i! VcY bVm^aaVgn gZigjh^dc# L^i] V aVX` d[ hjeedgi! i]Z jeeZg a^e aZc\i]Zch a^`Z V XjgiV^c! VcY i]Z kZgb^a^dc ^ckZgih# 8dggZXi^c\ i]ZhZ egdWaZbh gZfj^gZh V bVm^aad[VX^Va egdhi]" dYdci^X VeegdVX]! ^cXajY^c\ YZcijgZ [VWg^XVi^dc VadcZ dg XdbW^cZY l^i] WdcZ \gV[i^c\ VcY dhhZd" ^ciZ\gViZY ^beaVci iZX]c^fjZh# L^i] i]Z YZkZadebZci d[ h`^c aVm^in! kZgi^XVa g]ni^Yh WZ\^c id VeeZVg! Vi Ñghi dcan l^i] Vc^bV" i^dc#6h V\^c\ Xdci^cjZh!i]Z kZgi^XVa a^cZh WZXdbZ egZhZci Vi gZhi# I]ZhZ kZgi^XVa g]ni^Yh gZ ZXi i]Z
Advances in Facial Aesthetic Surgery: New Approaches to Old Problems and Current Approaches to New Problems
eZgeZcY^XjaVg a^\VbZcidjh ViiVX]bZcih [gdb i]Z dgW^XjaVg^h dg^h VcY i]Z bjhXaZ id YZgb^h# I]Zn VgZ XaZVgan bdgZ Xdbbdc ^c ldbZc VcY gVgZan hZZc ^c bZc# ;jgi]Zg kZgi^XVa g]ni^Yh VgZ bdgZ Xdbbdc ^c ;^ioeVig^X` > VcY >> [ZbVaZ h`^c ineZh# LZ egZhjbZ! l^i]dji egdd[! i]Vi i]^h ^cXgZVhZY [gZfjZcXn ^h i]Z gZhjai d[ V YZXgZVhZ ^c i]Z hjWXjiVcZdjh i^hhjZ d[ i]Z jeeZg a^e ^c i]Z ;^ioeVig^X` > VcY >> [ZbVaZ h`^c ineZh# I]Z Ydlcijgc d[ i]Z XdgcZgh d[ i]Z bdji] ^h V Xdbbdc XdbeaV^ci d[ ldbZc l^i] [VX^Va V\^c\# I]^h Ydlcijgc ^h Y^[ÑXjai id XdggZXi l^i] V [VXZ" a^[i VadcZ# 8aZVgan! i]Z bdhi Z[[ZXi^kZ ejaa ^h VXXdbea^h]ZY l]ZgZ h`^c aVm^in ^h i]Z \gZViZhi0 i]Vi ^h! V Y^gZXi Wgdla^[i ^h bdgZ Z[[ZXi^kZ i]Vc V XdgdcVa Wgdla^[i [dg i]Z XdggZXi^c\ Wgdl eidh^h# I]ZgZ[dgZ! dcan & Xb d[ h`^c cZZY WZ ZmX^hZY id ZaZkViZ i]Z Wgdl & Xb l^i] V Y^gZXi Wgdla^[i! l]ZgZVh ' Xb id '#* Xb d[ hXVae cZZYh id WZ ZmX^hZY [dg ZkZgn XZci^bZiZg d[ ZnZWgdl ZaZkV" i^dc ^c V XdgdcVa Wgdla^[i# H^b^aVgan! VY_jhi^c\ i]Z YdlcijgcZY XdgcZgh d[ i]Z bdji] Vi i]Z aZkZa d[ i]Z Xdbb^hhjgZ ^h V bZX]Vc^XVaan bdgZ Z[[ZXi^kZ i]Vc XdggZXi^c\ i]Z Ydlcijgc i]gdj\] V [VXZa^[i ^cX^h^dc# :mX^h^dcVa VcY cdcZmX^h^dcVa iZX]c^fjZh ]VkZ WZZc jhZY id XdggZXi i]Z Z[[ZXih d[ V\^c\ dc i]Z eZg^dgVa VgZV# I]ZhZ iZX]c^fjZh VgZ ZbeadnZY l^i] dg l^i]dji V kVg^Zin d[ gZhjg[VX^c\ bZi]dYh# :miZgcVa ^cX^h^dcVa iZX]c^fjZh ^cXajYZ h]dgiZc" ^c\ i]Z a^e l^i] V \jaa"l^c\ ZmX^h^dc Vi i]Z VaVg WVhZ id XdggZXi i]Z adc\ jeeZg a^e0 Zc]VcX^c\
Figure 9-3. The gull-wing excision at the base of the nose to shorten the upper lip and lip-lift procedure by direct excision of skin above the vermilion-cutaneous junction. (Reprinted from Plastic Surgery 2/e, Mathes SJ, chapter: Face Lift (Lower Face): Current Techniques by Fardo D, Zins JE, Nahai F, ©2005 Elsevier Inc. With permission from Elsevier.)
105
i]Z kZgb^a^dc Wn ZmX^h^c\ i]Z jeeZg a^e Vi i]Z kZgb^a^dc"XjiVcZdjh _jcXi^dc VcY VYkVcX^c\ i]Z kZgb^a^dc ;^\jgZ ."( 0 VcY a^[i^c\ i]Z XdgcZg d[ i]Z a^e id XdggZXi i]Z YdlcijgcZY XdgcZgh d[ i]Z bdji] ;^\jgZ .") #)(Ã*% I]Z dWk^djh YgVlWVX` d[ i]ZhZ iZX]c^fjZh ^h i]Z ZmiZgcVa hXVg i]Vi bVn WZ VZhi]Zi^XVaan jcVX" XZeiVWaZ# >c djg ZmeZg^ZcXZ! 8D' aVhZg gZhjg[VX" ^c\ dkZg i]Z hXVg Vi i]Z i^bZ d[ ZmX^h^dcVa hjg\Zgn \gZVian gZYjXZh i]Z k^h^W^a^in d[ i]Z hXVg# L^i] gZ\VgY id h]dgiZc^c\ i]Z jeeZg a^e! XZgiV^c egZXZeih h]djaY WZ [daadlZY# I]Z ^YZVa eVi^Zci [dg a^e h]dgiZc^c\ ]Vh Vc V\^c\ [VXZ ^c l]^X] i]Z aZc\i] d[ i]Z jeeZg a^e ^h \gZViZg i]Vc i]Z kZgi^XVa Y^hiVcXZ [gdb i]Z Xdbb^hhjgZ id i]Z hd[i i^hhjZ bZcidc! l^i] V YZXgZVhZ ^c jeeZg ^cX^hdg h]dl# >[ jeeZg ^cX^hdg h]dl ^h aZhh i]Vc ( bb! kZgi^XVa h]dgiZc^c\ l^i] V \jaa"l^c\ ^cX^" h^dc l^aa gZYjXZ i]Z ZYZcijadjh add` VcY Zc]VcXZ i]Z VeeZVgVcXZ d[ i]Z adlZg [VXZ# =dlZkZg! ^[ jeeZg ^cX^hdg h]dl ^h VagZVYn cdgbVa! [jgi]Zg jeeZg a^e h`^c ZmX^h^dc l^aa XgZViZ i]Z VeeZVg" VcXZ d[ kZgi^XVa bVm^aaVgn ZmXZhh VcY! i]ZgZ[dgZ! h]djaY WZ Vkd^YZY# >c VYY^i^dc! i]dhZ eVi^Zcih l]d VagZVYn ]VkZ Vc VgX]ZY VeeZVgVcXZ d[ i]Z jeeZg a^e VgZ cdi XVcY^YViZh [dg h]dgiZc^c\ d[ i]Z jeeZg a^e WZXVjhZ h]dgiZc^c\ l^aa Zc]VcXZ i]Z VgX]ZY VeeZVgVcXZ VcY XgZViZ Vc jccVijgVa gZhjai# 6 XdgcZg"d["i]Z"a^e a^[i! Vh edejaVg^oZY Wn 6jhi^c VcY LZhi^c! l^aa XdggZXi i]Z YdlcijgcZY XdgcZgh d[ i]Z bdji]#)) I]^h iZX]c^fjZ ^h
106
Tissue Surgery
Figure 9-4. a) Corner of the lip lift performed by marking the commissure. b) Drawing a line from the commissure 11 mm long medially along the vermilioncutaneous junction and drawing a second line from “A” laterally toward the top of the ear. These lines create a triangle with the apex of the triangle at “A” and the base at “B-C.” The vertical distance from “A” is 5 mm for minimal lip elevation, 7 mm for moderate elevation (most common), and 9 mm for high elevation. (Reprinted from Plastic Surgery 2/e, Mathes SJ, chapter: Face Lift (Lower Face): Current Techniques by Fardo D, Zins JE, Nahai F, ©2005 Elsevier Inc. With permission from Elsevier.)
eZg[dgbZY Wn Ñghi ^YZci^[n^c\ VcY bVg`^c\ i]Z Xdbb^hhjgZ# 6 a^cZ ^h i]Zc YgVlc bZY^Vaan Vadc\ i]Z kZgb^a^dc [dg Veegdm^bViZan && bb adc\! VcY V hZXdcY a^cZ ^h YgVlc [gdb i]Z Xdbb^hhjgZ aVi" ZgVaan idlVgYh i]Z ide d[ i]Z ZVg# I]Z ig^Vc\aZ i]jh XgZViZY Wn XdccZXi^c\ i]ZhZ ild a^cZh h]djaY ]VkZ V WVhZ d[ * bb ^[ b^c^bVa ZaZkVi^dc ^h gZfj^gZY ! , bb [dg bdYZgViZ ZaZkVi^dc ! dg . bb [dg bVg`ZY ZaZkVi^dc #)(!)) I]Z ig^Vc\aZ ^h i]Zc XadhZY Vh V higV^\]i a^cZ! XdggZXi^c\ i]Z YdlcijgcZY XdgcZgh d[ i]Z bdji] ;^\jgZ ."* # CdcZmX^h^dcVa XdggZXi^dc d[ eZg^dgVa V\^c\ XVc WZ eZg[dgbZY Wn Vjidad\djh dg cdcVjidad" \djh ÑaaZgh# ;Vi \gV[i^c\! Vh edejaVg^oZY Wn
8daZbVc! ]Vh WZXdbZ Wn [Vg i]Z bdhi Xdbbdc Vjidad\djh egdXZYjgZ [dg hd[i i^hhjZ Vj\bZciV" i^dc# 8daZbVc ]Vh ]VY ZmXZaaZci gZhjaih l^i] [Vi ^c_ZXi^dc [dg a^e Vj\bZciVi^dc! XdggZXi^dc d[ i]Z bVg^dcZiiZ a^cZh! X]^c Vj\bZciVi^dc! VcY egZ_dla Vj\bZciVi^dc# 6ai]dj\] 8daZbVc dWiV^ch Xdc" h^hiZcian ZmXZaaZci gZhjaih!di]Zgh ÑcY i]ZhZ gZhjaih Y^[ÑXjai id gZegdYjXZ# 8daZbVcÈh hjXXZhh VeeZVgh id WZ i]Z gZhjai d[ bZi^Xjadjh iZX]c^fjZ# Bdhi ^bedgiVcian! ]Z ^c_ZXih hbVaa Vbdjcih d[ [Vi i]gdj\] bVcn ijccZah Vi kVg^djh aZkZah d[ i]Z h`^c VcY hd[i i^hhjZ ZckZadeZ#*&!*' >c cdc"Vjidad\djh kdajbZ Vj\bZciVi^dc! ]nVajgdc^X VX^Y GZhinaVcZ! BZY^X^h E]VgbVXZj"
Figure 9-5. a) Preoperative view of a 59-year-old woman with downturned corners of the mouth. b) The patient 1 year later.
Advances in Facial Aesthetic Surgery: New Approaches to Old Problems and Current Approaches to New Problems
a
107
b
Figure 9-6. a) Preoperative view of a 68-year-old woman who underwent a facelift and perioral phenol-croton oil peel using 50% phenol and 1.1% croton oil. b) The patient 1 year later. (Reprinted from Plastic Surgery 2/e, Mathes SJ, chapter: Face Lift (Lower Face): Current Techniques by Fardo D, Zins JE, Nahai F, ©2005 Elsevier Inc. With permission from Elsevier.)
i^XVa 8dge#0 =naV[dgb! >cVbZY 8dge# ]Vh gZeaVXZY XdaaV\Zc XdbedjcYh Vh i]Z bdhi edejaVg ÑaaZg# 6XXdgY^c\ id i]Z 6bZg^XVc HdX^Zin [dg 6Zhi]Zi^X EaVhi^X Hjg\Zgn! ]nVajgdc^X VX^Y ^c_ZXi^dch ]VkZ WZXdbZ i]Z Ñ[i] bdhi"Xdbbdc cdchjg\^XVa XdhbZi^X egdXZYjgZ! V[iZg Wdija^" cjb idm^c 6! aVhZg ]V^g gZbdkVa! b^XgdYZgb" VWgVh^dc! VcY X]Zb^XVa eZZa^c\ iZX]c^fjZh# 6eegdm^bViZan --%!%%% ]nVajgdc^X VX^Y ^c_ZX" i^dch lZgZ eZg[dgbZY Wn WdVgY"XZgi^ÑZY eaVhi^X hjg\Zdch! didaVgnc\dad\^hih! VcY YZgbVidad\^hih ^c '%%)! VXXdgY^c\ id HdX^Zin hiVi^hi^Xh#*( 8dbbdc VgZVh [dg ]nVajgdc^X VX^Y ^c_ZXi^dch ^cXajYZ i]Z cVhdaVW^Va [daYh! i]Z ig^Vc\aZ WZilZZc i]Z VaVg WVhZ VcY i]Z cVhdaVW^Va [daYh! i]Z Xdb" b^hhjgZ! VcY i]Z jeeZg VcY adlZg a^eh# c [VXi! bZc ^c i]Z^g b^Y",%h VcY -%h VgZ ^YZVa eVi^Zcih [dg Y^gZXi cZX` h`^c ZmX^h^dc# I]Z gZhjaih l^i] Y^gZXi cZX` h`^c ZmX^h^dc l^aa WZ hjeZg^dg id i]dhZ d[ XZgk^Xd[VX^Va g]ni^YZXidbn WZXVjhZ! dcXZ V\V^c! h`^c ZmX^h^dc ^h WZ^c\ eZg[dgbZY Y^gZXian dkZg i]Z VgZV l]ZgZ h`^c ZmXZhh VcY aVm^in VgZ i]Z \gZViZhi# I]ZhZ eVi^Zcih ^ckVg^VWan ]VkZ gZh^YjVa ZmXZhh h`^c ^[ XZgk^Xd[VX^Va g]ni^Y" ZXidbn ^h eZg[dgbZY# ;jgi]Zg! \^kZc i]ZhZ eVi^ZcihÈ V\Z! i]^h deZgVi^dc ^h fj^X`Zg! hV[Zg! VcY i]Z hXVgh iZcY id WZ cdcegdWaZbVi^X ;^\jgZh ."&%V! ."&%W! ."&%X! VcY ."&%Y #
Postbariatric Surgery K$6>9H ]Vh ^cXgZVhZY i]Z cjbWZg d[ gZfjZhih [dg hjg\Zgn ^c i]^h eVi^Zci edejaVi^dc#,,!,- =^\]an V\\gZhh^kZ Vci^gZigdk^gVa i]ZgVen ^h egdadc\^c\ gZb^hh^dch ^c i]ZhZ eVi^Zcih Wji ]Vh Vahd aZY id V XaZVg a^edYnhigde]n hnc" YgdbZ X]VgVXiZg^oZY Wn XZcigVa dWZh^in VcY eZg^e]ZgVa hd[i i^hhjZ Vigde]n# HeZX^ÑXVaan! i]ZhZ eVi^Zcih Y^heaVn [VX^Va" lVhi^c\ hncYgdbZ! l]^X] ^h X]VgVXiZg^oZY Wn V adhh d[ hjWbVaVg hd[i i^hhjZ i]Vi ^cXgZVhZh i]Z YZei] d[ i]Z cVhdaVW^Va [daY VcY i]Vi ZmV\\ZgViZh i]Z egdb^cZcXZ d[ i]Z on\dbV# I]^h YZ\gZZ d[ [VX^Va lVhi^c\ ^h kVg^VWaZ VcY ^h \gVYZY & id )! & WZ^c\ i]Z bdhi b^aY VcY ) i]Z bdhi hZkZgZ#,.
I]^h hncYgdbZ ]Vh WZZc gZXd\c^oZY dcan h^cXZ &..-! hd [Zl gZedgih d[ hjg\^XVa igZVibZci [dg i]ZhZ eVi^Zcih ]VkZ WZZc ejWa^h]ZY! VcY cd aVg\Z hZg^Zh ^h VkV^aVWaZ# I]Z VeegdVX] id i]ZhZ eVi^Zcih ^h cdi higV^\]i[dglVgY# I]Zn bVn ]VkZ hjWbZciVa VcY hjWbVcY^WjaVg a^edYnhigde]n# =dlZkZg! i]^h a^edYnhigde]n iZcYh id WZ aZhh [Viin! bdgZ ÑWgdjh! VcY cdi ZVh^an VbZcVWaZ id gdji^cZ a^edhjXi^dc# I]ZgZ[dgZ! jaigVhdjcY"Vhh^hiZY a^edhjXi^dc ^h bdgZ Z[ÑXVX^djh VcY ^h gZXdbbZcYZY ;^\jgZ ."&' # ;VX^Va Vigde]n! Vh YZhXg^WZY VWdkZ! ]Vh WZZc igZViZY l^i] [Vi ^c_ZXi^dch! YZgb^h [Vi \gV[ih! VcY H^aVhi^X hjWbVaVg ^beaVcih#-%Ã-( I]Z hijY^Zh X^iZY VWdkZ VgZ hbVaa gZigdheZXi^kZ eVi^Zci hZg^Zh l^i] h]dgi [daadl"jeh0 i]jh! djiXdbZh YViV VgZ Xjg" gZcian lZV`# 8dcXZeijVaan! [Vi ^c_ZXi^dch id gZX^e^Zci VgZVh d[ hd[i i^hhjZ Vigde]n VgZ egdWaZbVi^X# I]Z h]dgi" iZgb gZhjaih d[ i]Z VWdkZ hijY^Zh Yd cdi XdcigV" Y^Xi i]^h cdi^dc# ;^cVaan! hjWbVaVg ^beaVci
114
Tissue Surgery
Figure 9-12. Preoperative a) frontal and b) lateral view of a 35-year-old [[man/woman]] with HIV-associated lipodystrophy characterized by submental and submandibular fat excess and peripheral wasting after highly aggressive antiretroviral therapy (HAART). c) Frontal and d) lateral view of the patient 6 months later.
Advances in Facial Aesthetic Surgery: New Approaches to Old Problems and Current Approaches to New Problems
Vj\bZciVi^dc! ^c i]Z VWhZcXZ d[ ^c[ZXi^dc VcY Zmigjh^dc! ]Vh ediZci^Va [dg adc\"iZgb hjXXZhh# I]ZgZ[dgZ! lZ Zbeadn hjWbZciVa VcY hjWbVc" Y^WjaVg a^edhjXi^dc jh^c\ jaigVhdjcY"Vhh^hiZY iZX]c^fjZh [dg hjWbZciVa a^edYnhigde]n VcY i]Z dWijhZ XZgk^XdbZciVa Vc\aZ VcY H^aVhi^X hjWbV" aVg ^beaVci Vj\bZciVi^dc id gZeV^g hjWbVaVg hd[i i^hhjZ Vigde]n#
Conclusion >c XdcXajh^dc! ZcYdhXde^X VcY b^c^bVaan ^ckV" h^kZ iZX]c^fjZh VgZ gZXZ^k^c\ ^cXgZVh^c\ ^ciZgZhi [gdb eVi^Zcih VcY i]Z bZY^V# I]Z ZcYdhXde^X Wgdla^[i! ZcYdhXde^XVaan Vhh^hiZY b^Y[VXZ dg deZc b^Y"[VXZ XdggZXi^dc! gZ_jkZcVi^dc d[ i]Z eZg^dgVa VgZV! VcY VciZg^dg"dcan VeegdVX]Zh id i]Z cZX` VcY i]Z gZhjaih ]VkZ WZZc ^aajhigViZY ]ZgZ# EaVhi^X hjg\Zgn V[iZg bVhh^kZ lZ^\]i adhh l^aa WZXdbZ ^cXgZVh^c\an Xdbbdc dkZg i]Z cZmi hZkZgVa nZVgh# 6 ad\^XVa VeegdVX] id igZVi^c\ i]ZhZ eVi^Zcih ^h Vahd YZhXg^WZY# ;^cVaan! WZXVjhZ d[ ^begdkZY hjg" k^kVa l^i] cZlZg igZVibZcih [dg =>K! eVi^Zcih l^i] a^edYnhigde]n V[iZg 6>9H igZVibZci l^aa ^cXgZVh^c\an hZZ` eaVhi^X hjg\Zgn XdggZXi^dc# I]Z eaVhi^X hjg\Zdc ^h lZaa VYk^hZY id WZ egZeVgZY id igZVi i]ZhZ cZl eVi^Zci edejaVi^dch#
References &# 8dgZ ># :cYdhXde^X Wgdla^[i# 8a^c EaVhi Hjg\# &..*0''/+&.Ã+(&# '# Dha^c 7! 8dgZ ! 6a"=V`ZZb BH! GdhZcWZg\ AO! ! 6a"=V`ZZb BH! GdhZcWZg\ AO! 8dhiV";ZggZ^gV 6! K/ [VXZ eZZa gZhjaih l^i] Y^[[ZgZci XdcXZcigV" i^dch d[ e]Zcda VcY Xgdidc d^a# EaVhi GZXdchig Hjg\# '%%%0&%*/&%+&Ã&%-(0 Y^hXjhh^dc &%-)Ã&%-,# *-# =ZiiZg <E# 6c ZmVb^cVi^dc d[ i]Z e]Zcda"Xgdidc d^a eZZa! eVgi >>>/ i]Z eaVhi^X hjg\ZdcÈh gdaZ# EaVhi GZXdchig Hjg\# '%%%0&%*/,*'Ã,+(# *.# =ZiiZg <E# 6c ZmVb^cVi^dc d[ i]Z e]Zcda"Xgdidc d^a eZZa! eVgi >>/ i]Z aVn eZZaZgh VcY i]Z^g Xgdidc d^a [dgbj" aVh# EaVhi GZXdchig Hjg\# '%%%0&%*/')%Ã')-0 Y^hXjhh^dc ').Ã'*&# +%# =ZiiZg <E# 6c ZmVb^cVi^dc d[ i]Z e]Zcda"Xgdidc d^a eZZa! eVgi >/ Y^hhZXi^c\ i]Z [dgbjaV# EaVhi GZXdchig Hjg\# '%%%0&%*/'',Ã'(.0 Y^hXjhh^dc ').Ã'*&# +&# HidcZ E6! AZ[Zg Ac egZhh# ,)# K"^c[ZXiZY
117
eVi^Zcih/ gZhjaih d[ i]Z deZc"aVWZa hijYn K:9H# '%%(0&,/'),&Ã'),,# -'# AZkVc E! C\jnZc I=! AVaaZbVcY ;! BVoZi^Zg A! B^bdjc B! GdoZcWVjb L! Zi Va# 8dggZXi^dc d[ [VX^Va a^edVigde]n ^c =>K"^c[ZXiZY eVi^Zcih dc ]^\]an VXi^kZ Vci^gZigdk^gVa i]ZgVen Wn ^c_ZXi^dc d[ Vjidad\djh [Viin i^hhjZ# 6>9H# '%%'0&+/&.-*Ã&.-,# -(# HZggV"GZcdb ?B! ;dciYZk^aV ?# IgZVibZci d[ [VX^Va [Vi Vigde]n gZaViZY id igZVibZci l^i] egdiZVhZ ^c]^W^idgh Wn Vjidad\djh [Vi ^c_ZXi^dc ^c eVi^Zcih l^i] ]jbVc ^bbj" cdYZÑX^ZcXn k^gjh ^c[ZXi^dc# EaVhi GZXdchig Hjg\# '%%)0&&)/**&Ã***0 Y^hXjhh^dc **+Ã**,#
10 Perspectives for Facial Allograft Transplantation in Humans Maria Z. Siemionow and Galip Agaoglu
Introduction I]Z [VXZ ^h V [jcXi^dcVa Vh lZaa Vh Vc Zhi]Zi^X eVgi d[ i]Z WdYn# >i ^h i]Z l^cYdl i]gdj\] l]^X] lZ ^ciZgVXi l^i] di]Zgh/ ild i]^gYh d[ djg Xdbbj" c^XVi^dc ^h i]gdj\] cdckZgWVa [VX^Va ZmegZhh^dch# GZXdchigjXi^c\ eVgi^Va dg [jaa [VX^Va YZ[dgb^i^Zh XVjhZY Wn Wjgch! igVjbV! dg ijbdgh hi^aa X]Va" aZc\Zh bdhi gZXdchigjXi^kZ hjg\Zdch# I]Z ^YZVa gZXdchigjXi^kZ egdXZYjgZ h]djaY VYYgZhh Wdi] i]Z [jcXi^dcVa VcY Zhi]Zi^X jc^ih d[ i]Z [VXZ#
Conventional Reconstructive Methods 8dckZci^dcVa bZi]dYh [dg gZXdchigjXi^c\ [VX^Va YZ[dgb^i^Zh ^cXajYZ h`^c \gV[ih! adXVa VcY Y^hiVci ÒVeh! egZ[VWg^XViZY ÒVeh! ZmeVcYZY ÒVeh! VcY [gZZ ÒVeh# I]Z hjXXZhh d[ i]ZhZ bZi]dYh kVg^Zh# HjXXZhh[ja gZhjaih ]VkZ WZZc dWiV^cZY V[iZg idiVa [VXZ gZhjg[VX^c\ jh^c\ bdcdWadX` [jaa" i]^X`cZhh h`^c \gV[ih#&!' 6ai]dj\] Xdadg VcY iZmijgZ bViX]Zh VgZ gZVhdcVWan hVi^h[VXidgn ^c i]Z h]dgi iZgb! i]Z adc\"iZgb [daadl"je ^h jhjVaan VhhdX^ViZY l^i] h`^c \gV[i XdcigVXijgZh VcY Xdadg X]Vc\Zh i]Vi gZhjai ^c Vc jchVi^h[VXidgn ÑcVa djiXdbZ# H^cXZ i]Z ^cigdYjXi^dc d[ egZ[VWg^XViZY ÒVeh ^c gZXdchigjXi^c\ [VX^Va hjWjc^ih!( hVi^h[VXidgn gZhjaih ]VkZ WZZc gZedgiZY l^i] egZ[VWg^XVi^dc VcY ZmeVch^dc d[ i]Z cZVgWn cdgbVa i^hhjZh#)!* 6m^Va eViiZgc ÒVeh! egZ[VWg^XViZY [gdb i]Z hjegV" XaVk^XjaVg h`^c jh^c\ VciZWgVX]^Va [VhX^V WVhZY dc i]Z gVY^Va kZhhZah! ]VkZ WZZc jhZY id gZXdc" higjXi i]Z Zci^gZ [VXZ V[iZg hZkZg Wjgch#+ Jc[dg" ijcViZan! ^c [VX^Va Wjgch! i]Z VY_VXZci h`^c ^h Vahd eVgi^Vaan dg XdbeaZiZan ^ckdakZY! bV`^c\ VYZ" fjViZ gZXdchigjXi^dc Vabdhi ^bedhh^WaZ#
I^hhjZ ZmeVcYZgh ]VkZ WZZc Veea^ZY id ZmeVcY i]Z VY_VXZci h`^c id VX]^ZkZ hj[ÑX^Zci i^hhjZ d[ ^YZci^XVa Xdadg VcY iZmijgZ [dg [VX^Va gZXdchigjX" i^dc,Ã. I^hhjZ ZmeVcYZgh XVc Vahd WZ jhZY id XgZViZ [jaa"i]^X`cZhh h`^c \gV[ih [dg XdbeaZiZ dg eVgi^Va gZhjg[VX^c\ d[ i]Z [VXZ#&% 6h l^i] egZ[VW" g^XViZY ÒVeh ]dlZkZg! VY_VXZci h`^c bVn WZ ^ckdakZY ^c i]Z ^c_jgn! l]^X] bVn egd]^W^i i]Z jhZ d[ i^hhjZ ZmeVcYZgh# Di]Zg ediZci^Va egdW" aZbh gZaViZ id i]Z X]d^XZ d[ ZmeVcYZg! i]Z h^iZ d[ ^chZgi^dc d[ i]Z ZmeVcYZg! i]Z ZaZkVi^dc VcY hjijg^c\ d[ i]Z ZmeVcYZY ÒVe! VcY i]Z bVcV\Z" bZci d[ i]Z [gZZ bVg\^ch d[ i]Z ÒVeh#. I]Z Ñghi [gZZ"i^hhjZ igVch[Zg lVh eZg[dgbZY id gZXdchigjXi Wjgc YZ[dgb^i^Zh#&& I]^h ^ccdkV" i^dc aZY id Zcdgbdjh VYkVcXZh ^c gZXdchigjXi^kZ b^Xgdhjg\Zgn! VcY Y^[[ZgZci ineZh d[ [gZZ i^hhjZh lZgZ igVch[ZggZY [gdb Y^hiVci eVgih d[ i]Z WdYn id gZXdchigjXi [VX^Va YZ[dgb^i^Zh# I]Z [VX^Va hjWjc^i VeegdVX]! ^cigdYjXZY Wn 7jg\Zi! lVh WVhZY dc bdY^[n^c\ i]Z gZX^e^Zci YZ[ZXi VcY Ydcdg i^hhjZ#&' ;ZaYbVc ^cigdYjXZY Åi]Z h^c\aZ h]ZZi XdcXZeiÆ ^c gZhjg[VX^c\ d[ i]Z l]daZ [VXZ V[iZg [VX^Va Wjgch#&( I]^h XdcXZei aZY id V W^aVi" ZgVa! ZmiZcYZY hXVejaVg"eVgVhXVejaVg [gZZ ÒVe! ^cXdgedgVi^c\ W^aViZgVa hjeZgÑX^Va X^gXjbÒZm hXVejaVg kZhhZah! i]Vi lVh jhZY [dg idiVa [VXZ gZhjg[VX^c\ ^c eVi^Zcih l^i] hZkZgZ [VX^Va Wjgch l^i] \ddY"id"[V^g gZhjaih#&) 6ai]dj\] kVg^djh ineZh d[ [gZZ ÒVeh ]VkZ WZZc jhZY [dg gZXdc" higjXi^c\ i]Z [VXZ! i]Z [jcXi^dcVa VcY VZhi]Zi^X djiXdbZ ]VkZ cdi WZZc dei^bjb# B^aaZg Zi Va#gZedgiZY i]Z Ñghi hjXXZhh[ja gZeaVc" iVi^dc d[ i]Z Zci^gZ hXVae#&* I]ZgZV[iZg! gZeaVciV" i^dch d[ bVcn XVhZh d[ eVgi^Va dg XdbeaZiZ hXVae Vkjah^dch lZgZ gZedgiZY! ^cXajY^c\ [dgZ]ZVY! ZVg! ZnZWgdl! VcY ZnZa^Y! l^i] VWjcYVci gZ\gdli] d[ ]V^g VcY gZijgc d[ hXVae hZch^W^a^in#&+ HjXXZhh[ja gZeaVciVi^dc d[ Y^[[ZgZci VkjahZY hZ\bZcih d[ i]Z
119
120
Tissue Surgery
[VXZ! ^cXajY^c\ i]Z cdhZ! ZVg! VcY jeeZg VcY adlZg a^eh! Vahd gZedgiZY#&,Ã&. 6ai]dj\] bVcn XVhZh d[ hXVae VcY [VXZ" hZ\bZci gZeaVciVi^dc ]VkZ WZZc gZedgiZY ldgaY" l^YZ! dcan ild hjXXZhh[ja XVhZh d[ idiVa [VXZ VcY hXVae gZeaVciVi^dc ]VkZ WZZc gZedgiZY#'%!'& >c i]Z Ñghi! gZeaVciVi^dc lVh eZg[dgbZY ^c ' e^ZXZh! WVhZY dc i]Z bZY^Va XVci]Va kZ^c VcY i]Z [VX^Va kZ^c VcY VgiZgn dc i]Z g^\]i h^YZ VcY i]Z aVW^Va VgiZgn l^i] ^ih kZ^c VcY hjeZgÑX^Va iZbedgVa VgiZgn VcY ild XdcXdb^iVci kZ^ch dc i]Z aZ[i h^YZ# I]gZZ nZVgh V[iZg gZeaVciVi^dc! i]Z eVi^Zci gZXdkZgZY hVi^h[VXidgn Vc^bVi^dc d[ i]Z dgVa bjhXjaVijgZ VcY egd[djcY \gdli] d[ ]V^g dc i]Z hXVae#'% >c i]Z hZXdcY XVhZ! i]Z [VXZ lVh VkjahZY Vh dcZ e^ZXZ! ^cXajY^c\ i]Z Zci^gZ hXVae! g^\]i ZVg! [dgZ]ZVY! ZnZWgdlh! g^\]i X]ZZ`! cdhZ! VcY jeeZg a^e# I]^h gZeaVciVi^dc lVh WVhZY dcan dc h^c\aZ hjeZgÑX^Va iZbedgVa VgiZgn VcY ild kZ^ch# ;djg bdci]h edhideZgVi^kZan! i]Z eVi^Zci ]VY ]V^g \gdli] VcY cdgbVa b^bZi^X [jcXi^dc#'& 7ZXVjhZ i]Z dei^bVa djiXdbZ lVh dWiV^cZY V[iZg gZeaVci" ^c\ i]Z VkjahZY hZ\bZcih d[ i]Z [VXZ VcY hXVae! ZkZgn Z[[dgi h]djaY WZ bVYZ id VX]^ZkZ hjXXZhh[ja gZeaVciVi^dc! ZkZc ^[ i]Z VkjahZY hXVae VcY [VXZ XdciV^c hZkZgVa aVXZgVi^dch VcY Xdcijh^dch# 6ai]dj\] bVcn iZX]c^fjZh ]VkZ WZZc YZh" Xg^WZY [dg gZXdchigjXi^c\ hZkZgZ [VX^Va ^c_jg^Zh! idiVa gZhjg[VX^c\ d[ i]Z [VXZ l^i] V h^c\aZ hd[i! ea^VWaZ i^hhjZ! bViX]ZY ^c Xdadg VcY iZmijgZ! ^h Vabdhi ^bedhh^WaZ# I]ZgZ ^h h^bean cd hjX] i^hhjZ ^c i]Z WdYn i]Vi ^h d[ h^b^aVg fjVa^in i]Vi \^kZh i]Z X]VgVXiZg^hi^Xh d[ V cdgbVa [VXZ# I]Z ÑcVa djiXdbZ V[iZg Vaa i]ZhZ XdckZci^dcVa gZXdchigjX" i^kZ egdXZYjgZh ^h [Vg [gdb ^YZVa WZXVjhZ i]Zn gZhjai ^c V i^\]i! bVh`"a^`Z [VXZ l^i] aVX` d[ [VX^Va ZmegZhh^dc VcY Vc jchVi^h[VXidgn XdhbZi^X VeeZVgVcXZ# GZXZci VYkVcXZh ^c Xdbedh^iZ i^hhjZ Vaad\gV[i igVcheaVciVi^dc ]VkZ ^c^i^ViZY V cZl eZg^dY ^c i]Z ÑZaY d[ gZXdchigjXi^kZ hjg\Zgn#
igVcheaVcih ]VkZ WZZc eZg[dgbZY id ^begdkZ! gVi]Zg i]Vc id hVkZ! i]Z fjVa^in d[ a^[Z d[ eVi^Zcih l^i] Y^hVW^a^i^Zh# H^cXZ i]Z Ñghi hjXXZhh[ja ]VcY igVcheaVciVi^dc ^c &..-! bdgZ i]Vc *% 8I6 igVch" eaVcih ]VkZ WZZc XVgg^ZY dji ldgaYl^YZ ^cXajY" ^c\ '* ]VcYh! . VWYdb^cVa lVaa igVcheaVcih! `cZZh! , cZgkZ Vaad\gV[ih! ' ÒZmdg iZcYdc VeeV" gVijh! & aVgncm! & h`ZaZiVa bjhXaZ! VcY & idc\jZ igVcheaVci#'(Ã(* I]Z jai^bViZ \dVa [dg 8I6 igVcheaVciVi^dc ^h i]Z ^cYjXi^dc d[ Ydcdg"heZX^ÑX idaZgVcXZ l^i]dji i]Z cZZY [dg X]gdc^X ^bbjcdhjeegZhh^dc# 9^[" [ZgZci higViZ\^Zh [dg idaZgVcXZ ^cYjXi^dc ]VkZ WZZc YZkZadeZY ^c ZmeZg^bZciVa hijY^Zh! ^cXajY" ^c\/ Xdhi^bjaVi^dc WadX`VYZ Wn jh^c\ Y^[[ZgZci bdcdXadcVa Vci^WdY^Zh! ^bbjcdVWaVi^dc l^i] ]ZbVidad\^X gZXdchi^iji^dc VcY Vaad\ZcZ^X b^mZY X]^bZg^hb# (+Ã(8jggZcian! WdcZ bVggdl igVcheaVciVi^dc ^h i]Z dcan Xa^c^XVa lVn id VX]^ZkZ idaZgVcXZ Wn ^cYjX" ^c\ b^mZY ]ZbVided^Zi^X X]^bZg^hb# I]^h idaZg" VcXZ lVh Ñghi cdi^XZY ^c V eVi^Zci l^i] bjai^eaZ bnZadbV l]d jcYZglZci WdcZ bVggdl VcY gZcVa igVcheaVciVi^dc V[iZg XdcY^i^dc^c\ l^i] V cdcbnZadVWaVi^kZ egdidXda d[ XnXade]dhe]V" b^YZ! Vci^i]nbdXniZ \adWja^c! VcY i]nb^X ^ggVY^Vi^dc# I]Z eVi^Zci lVh igZViZY dcan l^i] XnXadhedg^cZ 6 [dg ,( YVnh V[iZg igVcheaVci VcY i]Z `^YcZn lVh VXXZeiZY l^i]dji X]gdc^X ^bbj" cdhjeegZhh^kZ i]ZgVen#(. H^bjaiVcZdjh WdcZ bVggdl VcY gZcVa igVch" eaVciVi^dc ^h WZ^c\ eZg[dgbZY ^c 7dhidc l^i]dji adc\"iZgb ^bbjcdhjeegZhh^dc# Hd [Vg! Vaa i]Z \gV[ih ]VkZ WZZc VXXZeiZY#'- 6ai]dj\] Xa^c^XVa idaZgVcXZ ]Vh WZZc egdkZc ^c i]ZhZ eVi^Zcih! i]Zn cZZYZY idm^X egZXdcY^i^dc^c\ WZ[dgZ WdcZ bVg" gdl igVcheaVciVi^dc! l]^X] XVccdi WZ YdcZ l^i] Xdbedh^iZ i^hhjZ Vaad\gV[ih#
Clinical Applications of Composite Tissue Allografts
;VX^Va igVcheaVciVi^dc ^h i]Z cZmi hiZe ^c 8I6 igVcheaVciVi^dc id igZVi eVi^Zcih l]dhZ [VX^Va Y^h" Ñ\jgZbZci XVccdi WZ VYYgZhhZY Wn XdckZci^dcVa bZi]dYh d[ gZXdchigjXi^kZ hjg\Zgn# I]Z dcan hjXXZhh[ja hXVae igVcheaVciVi^dc lVh eZg[dgbZY WZilZZc ^YZci^XVa il^ch#)% 6 ldbVc ]VY *% id +% d[ ]Zg hXVae VkjahZY# >c^i^Va Xdk" ZgV\Z l^i] hea^i"i]^X`cZhh h`^c \gV[ih VcY hjWhZ" fjZci bjai^eaZ ejcX] \gV[ih [gdb ]Zg ^YZci^XVa il^c lZgZ eZg[dgbZY l^i] bdYZgViZ hjXXZhh# I]Z il^ch lZgZ =A6 ^YZci^XVa VcY ]VY ^YZci^XVa WaddY \gdjeh# B^mZY anbe]dXniZ gZVXi^dc lVh
I]Z Vhe^gVi^dc d[ hjg\Zdch [dg i^hhjZ igVcheaVc" iVi^dc YViZh WVX` id i]Z i]^gY XZcijgn 69! l]Zc i]Z hV^ciZY il^ch 8dhbVh VcY 9Vb^Vc Vbej" iViZY V \Vc\gZcdjh aZ\ d[ V GdbVc eVi^Zci VcY gZeaVXZY ^i l^i] V a^bW iV`Zc [gdb V YZVY Bddg#'' 6YkVcXZh ^c i]Z ÑZaY d[ gZXdchigjXi^kZ hjg\Zgn bVYZ i]Z [ZVh^W^a^in d[ Xdbedh^iZ i^hhjZ Vaad\gV[i 8I6 igVcheaVciVi^dc V Xa^c^XVa gZVa^in# 8I6
Facial Allograft Transplantation
Perspectives for Facial Allograft Transplantation in Humans
cdcgZVXi^kZ# ;gdb ]Zg ^YZci^XVa il^c! i]Z eVi^Zci gZXZ^kZY ' [gZZ hXVae ÒVeh bZVhjg^c\ &. Xb t (#* Xb VcY &, Xb t ( Xb! gZheZXi^kZan! ^c ild hZh" h^dch# I]Z ÒVeh lZgZ WVhZY dc hjeZgÑX^Va iZb" edgVa VgiZg^Zh# 6i + bdci]h [daadl"je! l^i]dji Vcn ^bbjcdhjeegZhh^kZ gZ\^bZc! i]Z ÒVeh egd" k^YZY VYZfjViZ ]V^g \gdli]# >i ^h Y^[ÑXjai id Vci^X^eViZ i]Z add` d[ V [VXZ V[iZg igVcheaVciVi^dc WZXVjhZ eVi^Zcih l^i] hZkZgZ [VX^Va Y^hÑ\jgZbZci jcYZg\d bjai^eaZ gZXdc" higjXi^kZ egdXZYjgZh# =dlZkZg! XdbejiZg hijY^Zh hj\\Zhi i]Vi i]Z [VXZ ldjaY Y^heaVn bdgZ d[ i]Z X]VgVXiZg^hi^Xh d[ i]Z gZX^e^Zci h`ZaZidc i]Vc d[ i]Z Ydcdg hd[i i^hhjZh#)& H`^c! Vh V XdbedcZci d[ 8I6! ^h Xdch^YZgZY id WZ i]Z bdhi Vci^\Zc^X i^hhjZ d[ i]Z WdYn# 6 kVhXjaVg^oZY h`^c Vaad\gV[i! jca^`Z cdckVhXjaVg" ^oZY h`^c Vaad\gV[i! ^h V \ddY hdjgXZ [dg YZcYg^i^X XZaah! l]^X] b^\gViZ [gdb i]Z Ydcdg id i]Z gZX^e" ^Zci i]gdj\] ]ZbVid\Zcdjh VcY anbe]Vi^X hnh" iZbh# I]ZhZ XZaah VgZ ^bedgiVci ^c Vaad\gV[i VXXZeiVcXZ# DkZg i]Z eVhi &* nZVgh! lZ ]VkZ [dXjhZY dc bZi]dYh id ^cYjXZ idaZgVcXZ [dg Xdbedh^iZ i^hhjZ igVcheaVcih# LZ jhZY Y^[[ZgZci bdYZah d[ ]^\]an Vci^\Zc^X 8I6 igVcheaVcih ]^cY a^bW! [jaa [VXZ! ]Zb^[VXZ VcY \gd^c h`^c ÒVe bdYZah ! ^cXajY^c\ h`^c! Vh V XdbedcZci d[ i]ZhZ igVcheaVcih! [dg idaZgVcXZ ^cYjXi^dc#)'Ã*( GZXdchigjXi^kZ hjg\Zdch ViiZbei^c\ id igVch" eaVci [VX^Va Vaad\gV[ih bjhi VYYgZhh hZkZgVa iZX]" c^XVa [ZVh^W^a^in VcY Veea^XVW^a^in ^hhjZh! YZkZade egdidXdah [dg a^[Zadc\ ^bbjcdhjeegZhh^dc! VcY gZhdakZ i]Z VhhdX^ViZY Zi]^XVa! hdX^Va! VcY ehnX]d" ad\^XVa XdcXZgch# Di]Zg ^hhjZh i]Vi Vahd cZZY id WZ VYYgZhhZY VgZ dWiV^c^c\ >chi^iji^dcVa GZk^Zl 7dVgY VeegdkVa! ^YZci^[n^c\ Veegdeg^ViZ gZX^e^" Zcih i]dgdj\] hXgZZc^c\ [dg ^cXajh^dc VcY ZmXaj" h^dc Xg^iZg^V! VcY ÑcY^c\ Veegdeg^ViZ Ydcdgh#
Technical Feasibility and Applicability I]Z djiXdbZ d[ XdckZci^dcVa gZXdchigjXi^kZ egdXZYjgZh ^h jchVi^h[VXidgn WZXVjhZ bdhi d[ i]Z i^hhjZh jhZY Yd cdi ]VkZ i]Z fjVa^in VcY X]VgVX" iZg^hi^Xh d[ i]Z [VXZ#6XXdgY^c\ id c^i^Vaan! cdi id [jgi]Zg Xdbea^XViZ i]^h VagZVYn Xdbea^XViZY egdXZYjgZ0 dcan h`^c h]djaY WZ igVcheaVciZY id i]Z [VXZ# DcXZ [VX^Va h`^c ÒVe igVcheaVciVi^dc ^h hjXXZhh[ja! di]Zg XdbedcZcih d[ i]Z [VXZ XVc WZ Xdch^YZgZY# DcZ d[ i]Z XgjX^Va ^hhjZh i]Vi h]djaY WZ Xdc" h^YZgZY l]Zc eaVcc^c\ [VX^Va igVcheaVciVi^dc! Vh l^i] Vcn b^Xgdhjg\^XVa egdXZYjgZ! ^h i]Z g^h` d[ [V^ajgZ d[ i]Z kVhXjaVg VcVhidbdhZh# KVhXjaVg [V^ajgZ! Y^V\cdhZY ^c i]Z ZVgan hiV\Zh d[ igVch" eaVciVi^dc! XVc WZ igZViZY Wn Zmeadg^c\ i]Z kVh" XjaVg eZY^XaZh VcY gZYd^c\ i]Z VcVhidbdhZh# >[ Vaa ViiZbeih id hVakV\Z i]Z ÒVe [V^a! i]Z gZhXjZ egdXZYjgZ h]djaY WZ eaVccZY VcY YZ[ZXi h]djaY WZ XdkZgZY l^i] kVhXjaVg^oZY h`^c ÒVeh dg Vjida" d\djh h`^c \gV[ih#
Experimental, Vascularized Nonfacial Skin Allografts =^cY A^bW 6aad\gV[i IgVcheaVci BdYZa LZ ]VkZ h]dlc i]Vi hiVWaZ Ydcdg"heZX^ÑX bjai^" a^cZV\Z X]^bZg^hb ^h VhhdX^ViZY l^i] ^cYjXi^dc d[ idaZgVcXZ ^c i]Z ]^cY a^bW Vaad\gV[ih! l]ZgZ i]Z h`^c XdbedcZci d[ i]Z igVcheaVci lVh kVhXjaVg^oZY# :meZg^bZciVa BdYZa# A^bW igVcheaVcih VXgdhh bV_dg ]^hidXdbeVi^W^a^in B=8 WVgg^Zgh lZgZ eZg[dgbZY WZilZZc [jaan Vaad\ZcZ^X 7C GI&c
122
VcY hZb^Vaad\ZcZ^X A7C GI&& c Ydcdgh VcY AZl^h gZX^e^Zcih A:L0 GI&a #)'Ã)+ >bbjcdhjeegZhh^kZEgdidXda# 9^[[ZgZci ^bbjcd" hjeegZhh^kZ egdidXdah d[ 8h6 VadcZ! XdbW^cZY 8h6 l^i] BC"I8G bdcdXadcVa Vci^WdYn BC" I8Gb6W ! VcY XdbW^cZY 8h6"Vci^"anbe]dXniZ hZgjb 6AH [dg Y^[[ZgZci eZg^dYh d[ i^bZ lZgZ jhZY# I]Z Z[ÑX^ZcXn d[ ^bbjcdhjeegZhh^kZ egd" idXdah VcY Ydcdg"heZX^ÑX X]^bZg^hb lVh Vh" hZhhZY Wn Òdl XnidbZign# 8a^c^XVa idaZgVcXZ VcY ^bbjcdXdbeZiZcXZ lZgZ XdcÑgbZY Wn h`^c \gV[i^c\ ^c k^kd VcY Wn b^mZY anbe]dXniZ gZVXi^dc ^c k^igd# 8dbW^cZY egdidXdah d[ 8h"$BC" I8Gb6W! VcY 8h6"6AH gZhjaiZY ^c adc\"iZgb hjgk^kVa VcY Ydcdg"heZX^ÑX idaZgVcXZ# A^bW Vaad\gV[ih Y^[[Zg [gdb Xdbedh^iZ [VX^Va Vaad\gV[ih WZXVjhZ i]Zn ]VkZ V WdcZ bVggdl ZaZbZci! l]^X] bVn WZ ZhhZci^Va ^c ^cYjX^c\ idaZgVcXZ#
KVhXjaVg^oZY H`^c c i]Z gZX^e^Zci Vc^bVa! V YZ[ZXi d[ i]Z hVbZ h^oZ lVh XgZViZY dc i]Z g^\]i h^YZ! VcY VgiZgn VcY kZ^c lZgZ VcVhidbdhZY ZcY" id"ZcY l^i] i]Z gZX^e^ZciÈh [ZbdgVa VgiZgn VcY kZ^c# >bbjcdhjeegZhh^kZ EgdidXda# KVhXjaVg^oZY h`^c Vaad\gV[i igVcheaVcih lZgZ igZViZY l^i] Y^[[ZgZci ^bbjcdhjeegZhh^kZ egdidXdah# I]Z Vc^bVah gZ" XZ^kZY BC"I8Gb6W!8h6!dg ;@*%+ bdcdi]ZgVen dg V XdbW^cVi^dc d[ BC"I8Gb6W"8h6 VcY BC" I8Gb6W";@*%+# >bbjcdhjeegZhh^kZ i]ZgVen hiVgiZY Vi i]Z YVn d[ igVcheaVciVi^dc VcY Xdci^cjZY[dg,YVnh#I]ZXdbW^cZY BC"I8Gb6W"
Tissue Surgery
8h6 VcY BC"I8Gb6W";@*%+ egdidXdah lZgZ Z[[ZXi^kZ ^c ^cYjX^c\ VcY bV^ciV^c^c\ X]^bZg^hb VcY hjWhiVci^Vaan ZmiZcYZY i]Z hjgk^kVa d[ i]Z kVhXjaVg^oZY h`^c Vaad\gV[i igVcheaVcih# I]ZhZ higViZ\^Zh XVc WZ Veea^ZY id di]Zg 8I6 VcY hda^Y dg\Vc igVcheaVcih# ;jgi]Zgh hijY^Zh dc YdhV\Z bdY^ÑXVi^dc VcY Vj\bZciVi^dc d[ X]^" bZg^hb l^i] WdcZ bVggdl igVcheaVciVi^dc VgZ XjggZcian jcYZglVn#
Experimental Facial Allograft Transplantations 6 8Vc^cZ BdYZa d[ =Zb^[VX^Va IgVcheaVci :meZg^bZciVa BdYZa# 6 ]Zb^[VX^Va igVcheaVci WZilZZc ' Yd\h lVh eZg[dgbZY id YZiZgb^cZ i]Z k^VW^a^in d[ V [VX^Va igVcheaVci jh^c\ [VX^Va VgiZgn VcY ZmiZgcVa _j\jaVg kZ^c Vh eZY^XaZh#*) 6 h`^c bjhXaZÒVe^ci]ZhjeZgÑX^VabjhXjadVedcZjgdi^X hnhiZb eaVcZ WVhZY dc i]Z [VX^Va VgiZgn VcY ZmiZgcVa _j\jaVg kZ^c lVh ]VgkZhiZY# >c i]Z gZX^e^Zci Vc^bVa! i]Z VgiZgn VcY kZ^c lZgZ VcVhidbdhZY id i]Z a^c\jVa VgiZgn VcY ZmiZgcVa _j\jaVg kZ^c! gZheZXi^kZan# >bbjcdhjeegZhh^kZ EgdidXda# 8nXadhedg^cZ 6 ) b\$`\$YVn VcY egZYc^hdcZ & b\$`\$YVn lZgZ \^kZc [dg ^bbjcdhjeegZhh^dc# I]Z ÒVe lVh gZ_ZXiZY Wn YVn +! VcY i]Z Yd\ lVh Zji]Vc^oZY# I]^h hijYn lVh VcVidb^XVa VcY cdi V iZhi d[ Vc ^bbjcdad\^XVa igVcheaVci bdYZa#
8dbedh^iZ ;jaa ;VX^Va"HXVae IgVcheaVci BdYZa LZ ViiZbeiZY id YZiZgb^cZ i]Z WZhi dei^dc [dg gZXdchigjXi^c\ i]Z [VXZ VcY hXVae0 l^i] i]Z gVi^d" cVaZ i]Vi Vaad\ZcZ^X igVcheaVciVi^dc ldjaY egd" k^YZ i]Z WZhi VZhi]Zi^X VcY [jcXi^dcVa gZhjaih# Dc i]Z WVh^h d[ djg &* nZVghÈ ZmeZg^ZcXZ l^i] Xdb" edh^iZ Vaad\gV[i igVcheaVciVi^dch! lZ ^cigdYjXZY V Xdbedh^iZ [jaa"[VX^Va VcY hXVae igVcheaVciVi^dc bdYZa ^c gVih id ZkVajViZ ^ih iZX]c^XVa [ZVh^W^a^in! ^bbjcdad\^XVa VheZXih! VcY ediZci^Va [dg [jijgZ Xa^c^XVa Veea^XVi^dch# :meZg^bZciVa BdYZa# 8dbedh^iZ idiVa [VX^Va VcY hXVae Vaad\gV[i igVcheaVcih lZgZ eZg[dgbZY WZilZZc AZl^h"7gdlc CdglVn A7C GI& Ydcdgh VcY AZl^h A:L! GI& gZX^e^Zcih#).!*% I]Z [jaa"
Perspectives for Facial Allograft Transplantation in Humans
[VX^VaÃhXVae ÒVe lVh ]VgkZhiZY Vh V h^c\aZ jc^i WVhZY dc i]Z W^aViZgVa Xdbbdc XVgdi^Y VgiZg^Zh VcY i]Z ZmiZgcVa _j\jaVg kZ^ch VcY ^cXajYZY i]Z Zci^gZ [VX^Va h`^c! hXVae! VcY ZmiZgcVa ZVgh# >c i]Z gZX^e^Zcih! i]Z [VX^Va h`^c VcY hXVae! ^cXajY^c\ i]Z ZmiZgcVa ZVg! lZgZ ZmX^hZY Vh V [jaa"i]^X`cZhh h`^c \gV[i ^c l]^X] i]Z [VX^Va cZgkZ VcY bjhXaZh lZgZ egZhZgkZY# I]Z eZg^dgW^iVa VcY eZg^dgVa gZ\^dch lZgZ Vahd egZhZgkZY id egZkZci [jcXi^dcVa YZÑX^ZcX^Zh! l]^X] XdjaY ^beV^g [ZZY^c\ dg WgZVi]^c\ ;^\jgZ &%"& # :^i]Zg i]Z Xdbbdc dg ZmiZgcVa XVgdi^Y VgiZg^Zh VcY i]Z VciZg^dg [VX^Va kZ^ch lZgZ jhZY [dg VcVhidbdhZh# >bbjcdhjeegZhh^kZ EgdidXda# I]Z Vc^bVah gZ" XZ^kZY 8h6 bdcdi]ZgVen &+ b\$`\$YVn l^i]dji gZX^e^Zci egZXdcY^i^dc^c\# I]ZgVen lVh WZ\jc i]Z YVn d[ hjg\Zgn! iVeZgZY id ' b\$`\$YVn dkZg ) lZZ`h! VcY i]Zc Xdci^cjZY Vi i]^h YdhZ jci^a i]Z ZcY d[ i]Z hijYn# I]Z ÒVeh hjgk^kZY '%% YVnh# I]^h hijYn XdcÑgbZY i]Z [ZVh^W^a^in VcY Veea^XVW^a^in d[ i]Z idiVa [VX^Va VcY hXVae Vaad\gV[i igVcheaVciVi^dc VXgdhh bV_dg ]^hidXdbeVi^W^a^in WVgg^Zgh VcY lVh i]Z Ñghi id XdcÑgb adc\"iZgb hjgk^kVa d[ [jaa"[VX^Va Vaad\gV[i igVcheaVcih jcYZg adl bV^ciZcVcXZ YdhZh d[ 8h6 bdcdi]ZgVen ^c V gVi bdYZa ;^\jgZ &%"' #
6 CZl Hjg\^XVa 6eegdVX] [dg ;jaa";VX^VaÃHXVae IgVcheaVci Id ^begdkZ hjgk^kVa! lZ bdY^ÑZY i]Z VgiZg^Va VcVhidbdhZh ^c i]ZhZ [jaa"[VX^VaÃhXVae Vaad\gV[i igVcheaVcih# :meZg^bZciVa BdYZa# ;jaa"[VX^VaÃhXVae Vaad\gV[i igVcheaVcih lZgZ YdcZ VXgdhh B=8 WVgg^Zgh WZilZZc [jaan Vaad\ZcZ^X 68> GI&V Ydcdg gVih VcY AZl^h GI& gZX^e^Zci gVih#*( I]Z Xdbedh^iZ [VX^Va"hXVae ÒVe! ^cXajY^c\ i]Z ZmiZgcVa ZVg XdbedcZci! lVh ]VgkZhiZY Vh YZhXg^WZY VcY lVh WVhZY dc W^aViZgVa Xdbbdc XVgdi^Y VgiZg^Zh VcY ZmiZgcVa _j\jaVg kZ^ch# >c i]Z gZX^e^Zci! i]Z [VX^Va h`^c VcY hXVae! ^cXajY^c\ i]Z ZmiZgcVa ZVgh! lZgZ ZmX^hZY Vh V [jaa"i]^X`cZhh \gV[i#>c Vaa igVcheaVcih! kZ^ch lZgZ VcVhidbdhZY id i]Z ZmiZgcVa _j\jaVg kZ^c dg id i]Z edhiZg^dg [VX^Va kZ^c dc i]Z aZ[i h^YZ VcY id VciZg^dg [VX^Va kZ^c dc i]Z g^\]i h^YZ# I]Z VgiZg^Va VcVhidbdhZh ^c i]Z gZX^e^Zcih lZgZ bdY^ÑZY Vh [daadlh# 6[iZg VcVhidbdh^c\ i]Z aZ[i Xdbbdc XVgdi^Y VgiZgn d[ i]Z ÒVe id i]Z
123
aZ[i Xdbbdc XVgdi^Y VgiZgn d[ i]Z gZX^e^Zci ZcY" id"h^YZ! i]Z g^\]i Xdbbdc XVgdi^Y VgiZgn d[ i]Z ÒVe lVh VcVhidbdhZY Z^i]Zg id i]Z aZ[i Xdbbdc XVgdi^Y VgiZgn d[ i]Z ÒVe! ZcY"id"h^YZ! dg ZcY"id" ZcY id i]Z hijbe d[ i]Z ^ciZgcVa XVgdi^Y VgiZgn dc i]Z aZ[i h^YZ d[ i]Z ÒVe! l]^X] lVh `Zei adc\ Yjg^c\ ]VgkZhi^c\# >bbjcdhjeegZhh^kZ EgdidXda# 6aa i]Z Vc^bVah lZgZ igZViZY l^i] 8h6! &+ b\$`\$YVn! WZ\^cc^c\ i]Z YVn d[ hjg\Zgn# I]Z YdhZ lVh iVeZgZY id ' b\$ `\ dkZg ) lZZ`h! i]Zc VcY bV^ciV^cZY Vi i]^h aZkZa# I]Z [VX^Va"hXVae ÒVeh hjgk^kZY [dg dkZg &-% YVnh# L^i] i]ZhZ bdY^ÑXVi^dch! V W^eZY^XaZY Xdb" edh^iZ [VX^Va"hXVae ÒVe lVh kVhXjaVg^oZY Wn V h^c\aZ Xdbbdc XVgdi^Y VgiZgn d[ i]Z gZX^e^Zci! l^i]dji Y^hhZXi^c\ i]Z di]Zg Xdbbdc XVgdi^Y VgiZgn# I]^h bdY^ÑXVi^dc YZXgZVhZY bdgiVa^in igZbZcYdjhan Wn gZYjX^c\ XZgZWgVa ^hX]Zb^V i^bZ! WaZZY^c\! VcZhi]Zh^V i^bZ! VcY Xdbea^XV" i^dch VhhdX^ViZY l^i] W^aViZgVa Xdbbdc XVgdi^Y VgiZgn Y^hhZXi^dc! hjX] Vh kV\jh VcY e]gZc^X cZgkZ ^c_jg^Zh ^c i]Z gZX^e^Zcih# LZ WZa^ZkZ i]^h eViiZgc d[ VgiZg^Va VcVhidbdh^h ldjaY WZ V \ddY X]d^XZ ^c [jijgZ [VX^Va Vaad\gV[i igVcheaVcih ^c ]jbVch#
8dbedh^iZ =Zb^[VX^Va IgVcheaVci BdYZa LZ ^cigdYjXZY V ]Zb^[VX^Va Vaad\gV[i igVcheaVci bdYZa! l]^X] ^h aZhh iZX]c^XVaan X]VaaZc\^c\ i]Zc i]Z [jaa"[VX^Va Vaad\gV[i igVcheaVci# >c i]^h bdYZa! lZ ^ckZhi^\ViZY i]Z YZkZadebZci d[ deZgVi^dcVa idaZgVcXZ VXgdhh bV_dg ]^hidXdbeVi^W^a^in WVgg^Zgh# :meZg^bZciVa BdYZa# 8dbedh^iZ ]Zb^[VX^Va Vaad\gV[ih lZgZ igVcheaVciZY [gdb hZb^Vaad\ZcZ^X AZl^h" 7gdlc CdglVn A7C GI& VcY [jaan Vaad\ZcZ^X 68> GI&V gVih id AZl^h GI& gZX^e^Zcih#*& 8dbedh^iZ ]Zb^[VX^Va ÒVeh! ^c" XajY^c\ i]Z ZmiZgcVa ZVg VcY i]Z hXVae! WVhZY dc i]Z Xdbbdc XVgdi^Y VgiZgn VcY ZmiZgcVa _j\jaVg kZ^c! lZgZ ]VgkZhiZY [gdb i]Z aZ[i h^YZ d[ i]Z Ydcdgh# >c i]Z gZX^e^Zci! i]Z [VX^Va h`^c dc i]Z aZ[i h^YZ! ^cXajY^c\ ZmiZgcVa ZVg! lVh ZmX^hZY# 6[iZg hZii^c\ i]Z ÒVe! i]Z Ydcdg ZmiZgcVa _j\jaVg kZ^c lVh VcVhidbdhZY ZcY"id"h^YZ id i]Z gZX^e^Zci ZmiZgcVa _j\jaVg kZ^c! i]Zc i]Z Ydcdg XVgdi^Y VgiZgn lVh VcVhidbdhZY ZcY"id"h^YZ id i]Z gZX^e^Zci Xdbbdc XVgdi^Y VgiZgn#
124
Tissue Surgery
a
c
a
b
d
b
Figure 10-1. The full-facial allograft transplantation model across a major histocompatibility barrier. Preoperative views of the donor rat showing markings of the facial skin flap, the dorsal surface a and the ventral surface b. Preoperative views of the recipient rat showing markings of the skin to be excised before the donor facial skin transplant inset, the dorsal surface c and the ventral surface d. (Reprinted from Siemionow MZ, Agaoglu G. Allotransplantation of the Face: How Close Are We? Clinics in Plastic Surgery, Volume 32 (in press). Copyright 2005, with permission from Elsevier.)
Figure 10-2. The full-facial allograft transplantation model. Late post-transplant views of face allograft recipient on low-dose of cyclosporine A monotherapy at day 200 showing no signs of rejection. a) The frontal view. b) The lateral view. (Reprinted from Siemionow MZ, Agaoglus G. Allotransplantation of the Face: How Close Are We? Clinics in Plastic Surgery, Volume 32 (in press). Copyright 2005, with permission from Elsevier.)
Perspectives for Facial Allograft Transplantation in Humans
>bbjcdhjeegZhh^kZ EgdidXda# 7di] hZb^Vaad\Z" cZ^X VcY [jaan Vaad\ZcZ^X Vaad\gV[i gZX^e^Zcih lZgZ igZViZY l^i] hiVcYVgY ^bbjcdhjeegZhh^kZ egdidXda d[ 8h6 bdcdi]ZgVen! &+ b\$`\$YVn! l]^X] lVh iVeZgZY id ' b\$`\$YVn dkZg ) lZZ`h VcY bV^ciV^cZY Vi i]^h aZkZa i]ZgZV[iZg# >c i]^h ZmeZg^bZciVa Xdbedh^iZ ]Zb^[VX^Va igVcheaVci bdYZa! lZ ZhiVWa^h]ZY deZgVi^dcVa idaZgVcXZ VcY VX]^ZkZY hjgk^kVa gViZh d[ )%% YVnh ^c i]Z hZb^Vaad\ZcZ^X VcY ((% YVnh ^c i]Z [jaan Vaad\ZcZ^X B=8 b^hbViX]ZY [VX^Va igVcheaVci gZX^e^Zcih ;^\jgZ &%"( # LZ VgZ ZcXdjgV\ZY Wn djg hjXXZhh l^i] bV^c" iV^c^c\ idiVa [VX^Va"hXVae Vaad\gV[i igVcheaVcih [dg bdgZ i]Vc '%% YVnh VcY Wn i]Z egdb^h^c\ gZhjaih lZ VX]^ZkZY ^c i]Z ]Zb^[VX^Va igVcheaVci bdYZa
125
jh^c\ V h^c\aZ ^bbjcdhjeegZhh^kZ V\Zci i]ZgVen l^i]dji cZZY [dg gZX^e^Zci XdcY^i^dc^c\# I]^h ZmeZg^bZciVa `cdlaZY\Z h]djaY hjeedgi [jijgZ Xa^c^XVa YZX^h^dch ^c i]^h X]VaaZc\^c\ egdXZYjgZ#
6 8VYVkZg^X 9^hhZXi^dc ^c EgZeVgVi^dc [dg V =jbVc ;VX^Va 6aad\gV[i IgVcheaVci LZ ]VkZ Y^hhZXiZY XVYVkZgh id XdcÑgb i]Z [ZVh^" W^a^in d[ [VX^Va ÒVe ]VgkZhi VcY id hjeedgi i]Z Veea^XVi^dc d[ [VX^Va Vaad\gV[i igVcheaVcih Vh V cZl igZVibZci [dg eVi^Zcih l^i] hZkZgZ [VX^Va YZ[dgb^i^Zh#** LZ XdbeVgZY i]Z ediZci^Va VgZV d[ XdkZgV\Z! iZmijgZ! VcY Xdadg bViX] d[ i]ZhZ gZXdchigjXi^kZ dei^dch# >c * XVYVkZgh! i]Z Xdb"
a
b
c
d
Figure 10-3. The hemi-facial allograft transplantation model. Preoperative view of the donor Lewis-Brown Norway rat showing markings of the facial skin flap a). Preoperative view of the recipient Lewis rat showing marking of the skin to be excised before the skin flap inset from the donor b). Immedi-
ate post-transplant view of the hemiface allograft recipient c). The recipient of hemifacial allograft 200 days after transplant shows no signs of rejection on a low maintenance dose of cyclosporine A monotherapy d).
126
edh^iZ [jaa"[VX^VaÃhXVae ÒVe lVh YZh^\cZY id ^cXdgedgViZ i]Z Zci^gZ [VX^Va h`^c! ^cXajY^c\ i]Z h`^c dkZg i]Z cdhZ! ZnZa^Yh! a^eh! Wdi] ZmiZgcVa ZVgh! VcY i]Z hXVae# I]Z ÒVe lVh ZaZkViZY ^c i]Z hjWeaVinhbVa eaVcZ ^c i]Z cZX`! ^c i]Z hjWhjeZg" ÑX^Va bjhXjadVedcZjgdi^X hnhiZb eaVcZ ^c i]Z [VXZ! VcY ^c i]Z hjW\VaZVa eaVcZ ^c i]Z hXVae# I]Z l]daZ ÒVe lVh WVhZY W^aViZgVaan dc i]Z ZmiZgcVa XVgdi^Y VgiZg^Zh Vh i]Z VgiZg^Va eZY^XaZh VcY dc i]Z ZmiZgcVa _j\jaVg VcY [VX^Va kZ^ch Vh i]Z kZcdjh eZY^XaZh ;^\jgZh &%") VcY &%"* # I]Z XdckZci^dcVa gVY^Va [dgZVgb! VciZgdaViZgVa i]^\]! W^eZY^XaZY YZZe ^c[Zg^dg Ze^\Vhig^X! VcY W^eZY^XaZY hXVejaVg"eVgVhXVejaVg ÒVeh lZgZ Vahd ]VgkZhiZY [gdb i]Z hVbZ XVYVkZgh# I]Z idiVa hjg[VXZ VgZVh d[ i]Z XgZViZY [VX^Va YZ[ZXih VcY VaiZgcVi^kZ ]VgkZhiZY XdckZci^dcVa ÒVeh lZgZ bZVhjgZY# BZi]naZcZ WajZ YnZ lVh ^c_ZXiZY [gdb i]Z ZmiZgcVa XVgdi^Y VgiZgn [dg k^hjVa^oVi^dc d[ i]Z [VX^Va"hXVae kVhXjaVg cZildg`# I]Z bZVc hjg[VXZ VgZV [dg i]Z XdbW^cZY [VX^Va"hXVae ÒVeh VcY [VX^Va ÒVeh l^i]dji hXVae lVh &&.' Xb' VcY +,* Xb'! gZheZXi^kZan# L]Zc XdbeVgZY id i]Z idiVa hjg[VXZ VgZV d[ i]Z [VX^Va" hXVae ÒVe! i]Z gVY^Va [dgZVgb ÒVe XdkZgZY &( d[ i]Z YZ[ZXi! i]Z VciZgdaViZgVa i]^\] ÒVe &.! i]Z W^eZY^XaZY YZZe ^c[Zg^dg Ze^\Vhig^X eZg" [dgVidg ÒVe (*! VcY i]Z W^eZY^XaZY hXVejaVg" eVgVhXVejaVg ÒVe )-! gZheZXi^kZan# 8dkZgV\Z d[ i]Z [VX^Va YZ[ZXi l^i]dji hXVae lVh ') [dg i]Z gVY^Va [dgZVgb ÒVe! () [dg i]Z VciZgdaViZgVa i]^\] ÒVe! +' [dg i]Z W^eZY^XaZY YZZe ^c[Zg^dg Ze^\Vhig^X eZg[dgVidg ÒVe! VcY -) [dg i]Z W^eZY" ^XaZY hXVejaVg"eVgVhXVejaVg ÒVe! gZheZXi^kZan ;^\jgZ &%"+ # I]Z eZg[jhZY YnZ lVh lZaa k^hjVa" ^oZY [gdb i]Z ZmiZgcVa XVgdi^Y VgiZgn je id i]Z iZgb^cVa WgVcX]Zh d[ i]Z [VX^Va VcY hjeZgÑX^Va iZbedgVa VgiZg^Zh# I]^h XVYVkZg^X hijYn XdcÑgbZY i]Vi cdcZ d[ i]Z XdckZci^dcVa XjiVcZdjh Vjid\Zcdjh ÒVeh ldjaY XdkZg V idiVa [VX^Va YZ[ZXi# =dlZkZg! V eZg[ZXi bViX] d[ i]Z iZmijgZ! ea^VW^a^in! VcY Xdadg d[ [VX^Va h`^c l^aa a^`Zan dcan WZ VX]^ZkZY Wn igVcheaVci^c\ i]Z [VX^Va h`^c [gdb V ]jbVc Ydcdg#
BdX` ;VX^Va IgVcheaVciVi^dc ^c EgZeVgVi^dc [dg V =jbVc ;VX^Va 6aad\gV[i IgVcheaVci GZXZcian! lZ ]VkZ eZg[dgbZY V bdX` [VX^Va igVch" eaVciVi^dc Wn ]VgkZhi^c\ V idiVa [VX^Va"hXVae ÒVe
Tissue Surgery
[gdb i]Z Ydcdg VcY igVch[Zgg^c\ i]Z ÒVe id i]Z gZX^e^Zci XVYVkZgh#*+ >c i]Z Ydcdg! lZ ]VkZ bZVhjgZY i]Z i^bZ d[ [VX^Va"hXVae ÒVe ]VgkZhi^c\! i]Z aZc\i] d[ i]Z VgiZg^Va VcY kZcdjh eZY^XaZh VcY hZchdgn cZgkZh! l]^X] lZgZ ^cXajYZY ^c i]Z [VX^Va ÒVeh# >c i]Z gZX^e^Zci! lZ ]VkZ ZkVajViZY i]Z i^bZ d[ [VX^Va h`^c ]VgkZhi Vh V ÅbdcdWadX`Æ [jaa"i]^X`cZhh \gV[i! i]Z VcX]dg^c\ gZ\^dch [dg i]Z ^chZi d[ i]Z Ydcdg [VX^Va ÒVeh VcY i]Z i^bZ hZfjZcXZh [dg i]Z kVhXjaVg eZY^XaZh VcVhidbdhZh VcY cZgkZh XdVeiVi^dch# >c i]Z Ydcdg XVYVkZg i]Z bZVc ]VgkZhi^c\ i^bZ d[ i]Z idiVa [VX^Va"hXVae ÒVe ]VgkZhi lVh '(*#+' q '&#.) b^cjiZh# I]Z bZVc aZc\i] d[ i]Z hjegVdgW^iVa! ^c[gVdgW^iVa! bZciVa! VcY \gZVi Vjg^XjaVg cZgkZh lVh &#* q %#&*! '#)+ q %#'*! (#%' q %#(&! VcY +#&& q %#)' Xb! gZheZXi^kZan# I]Z bZVc aZc\i] d[ i]Z ZmiZgcVa XVgdi^Y VgiZgn! [VX^Va VcY ZmiZgcVa _j\jaVg kZ^ch lVh * q %#('! (#&* q %#('! VcY *#,- q %#*Xb! gZheZXi^kZan# >c i]Z gZX^e^Zci XVYVkZg i]Z bZVc ]VgkZhi^c\ i^bZ d[ [VX^Va h`^c Vh V ÅbdcdWadX`Æ [jaa"i]^X`cZhh \gV[i lVh ),#* q (#*( b^cjiZh# I]Z bZVc i^bZ [dg i]Z egZeVgVi^dc d[ i]Z VgiZg^Va VcY kZcdjh eZY^XaZh VcY hZchdgn cZgkZh [dg i]Z [jijgZ VcVh" idbdhZh VcY XdVeiVi^dc lVh (% q % b^cjiZh# I]Z bZVc i^bZ [dg i]Z [VX^Va ÒVe VcX]dg^c\ lVh ''#* q (#*( b^cjiZh# I]Z idiVa bZVc i^bZ d[ [VX^Va bdX` igVcheaVciVi^dc l^i]dji kZhhZah VcY cZgkZh gZeV^g lVh ('% q ,#%, b^cjiZh * ]djgh VcY '% b^cjiZh # 7VhZY dc VcVidb^XVa Y^hhZXi^dch ^c i]^h XV" YVkZg hijYn! lZ ]VkZ Zhi^bViZY i]Z i^bZ VcY hZfjZcXZ d[ i]Z [VX^Va ÒVe ]VgkZhi VcY ^chZi id b^b^X i]Z Xa^c^XVa hXZcVg^d d[ [VX^Va igVcheaVciV" i^dc egdXZYjgZ#
Immunosuppressive Strategies in Composite Tissue Allograft Transplants I]Z YZkZadebZci d[ ^bbjcdhjeegZhh^kZ V\Zcih XVc WZ Y^k^YZY ^cid eZg^dYh WZ[dgZ VcY V[iZg i]Z ^cigdYjXi^dc d[ XnXadhedg^cZ# 7Z[dgZ i]Z 8h6 ZgV! ^bbjcdhjeegZhh^kZ gZ\^bZch lZgZ cdchZaZX" i^kZ! Xdch^hi^c\ bV^can d[ idiVa WdYn dg idiVa anb" e]d^Y gVY^Vi^dc [daadlZY Wn i]Z ^cigdYjXi^dc d[ +"bZgXVeidejg^cZ! XnXade]dhe]Vb^YZ! VcY VoV" i]^deg^cZ# HiZgd^Yh lZgZ VYYZY id VoVi]^deg^cZ id ^begdkZ Z[[ZXi^kZcZhh VcY gZYjXZ idm^X^in# I]^h XdbW^cVi^dc d[ hiZgd^Yh VcY VoVi]^deg^cZ! l^i] dg l^i]dji Vci^anbe]dXniZ \adWja^c! lVh jhZY
a
b
c Figure 10-4. Dissection of the facial-scalp flap. a) After marking the vascular structure of the flap. b) Through a midline incision, the flap was elevated in the subplatysmal plane, including external jugular vein in the flap. (Siemionow MZ, Unal S, Agaoglu G, et al. What are alternative sources for total facial defect coverage? A cadaver study in preparation for facial allograft transplantation in humans. Plastic and Reconstructive Surgery (PRS-D-04-00324, in press) 2005.)
a
c) Elevation of the flap showing arterial network of the flap. 1) The common carotid artery. 2) The external carotid artery. 3) The superficial temporal artery. 4) The facial artery. 5) The lower border of mandible. (Reprinted from Siemionow MZ, Agaoglu G. Allotransplantation of the Face: How Close Are We? Clinics in Plastic Surgery, Volume 32 (in press). Copyright 2005, with permission from Elsevier.)
b
Figure 10-5. a) Harvested total facial-scalp flap. b) Harvested facial flap without scalp. (Siemionow MZ, Unal S, Agaoglu G, et al. What are alternative sources for total facial defect coverage? A cadaver study in preparation for facial allograft transplantation in humans. Plastic and Reconstructive Surgery (PRS-D-04-00324, in press) 2005.)
127
128
Tissue Surgery
a
b
Figure 10-6. Outline of the percentage of the conventional flaps that covers the surface area of a) a total facial scalp defect and b) a facial defect without scalp.
[dg VWdji ' YZXVYZh! jci^a V cZl ZgV d[ ^bbjcd" hjeegZhh^dc lVh WZ\jc l^i] i]Z ^cigdYjXi^dc d[ 8h6# 8nXadhedg^cZ lVh i]Z Ñghi heZX^ÑX Ygj\ id iVg\Zi I XZaah Wn ^c]^W^i^c\ I"XZaa"bZY^ViZY >A"' egdYjXi^dc! V XgjX^Va Xnid`^cZ [dg I"XZaa ZmeVc" h^dc# I]ZgZV[iZg! hZkZgVa cZl V\Zcih iVg\ZiZY I XZaah! ^ciZgaZj`^c gZXZeidgh! VcY kVg^djh I"XZaa gZXZeidgh! hjX] Vh bdcdXadcVa Vci^WdY^Zh D@I( ! XVaX^cZjg^c ^c]^W^idgh ;@*%+ ! cjXaZ^X VX^Y ^c]^W^idgh bnXde]ZcdaViZ bd[Zi^a BB; VcY ^c]^W^idgh d[ h^\cVah [dg I"XZaa Y^[[ZgZci^Vi^dc h^gda^bjh #)-!*,!*8dbedh^iZ i^hhjZ Vaad\gV[ih! jca^`Z hda^Y dg" \Vch! XdciV^c Y^[[ZgZci ineZh d[ i^hhjZ l^i] kVg^" VWaZ YZ\gZZh d[ Vci^\Zc^X^in# I]jh! id WZ hjXXZhh[ja! Vcn ^bbjcdhjeegZhh^kZ egdidXda h]djaY egZkZci gZ_ZXi^dc d[ Vaa i]ZhZ i^hhjZh# 9^[[ZgZci ^bbjcdhjeegZhh^kZ egdidXdah lZgZ jhZY ^c Wdi] ZmeZg^bZciVa VcY Xa^c^XVa 8I6 igVcheaVciVi^dch#
Experimental Immunosuppressive Protocols :meZg^bZcih dc Vc^bVah h]dl i]Vi Ydcdg" heZX^ÑX idaZgVcXZ XVc WZ VX]^ZkZY i]gdj\] hiVWaZ b^mZY Vaad\ZcZ^X X]^bZg^hb V[iZg WdcZ bVggdl igVcheaVciVi^dc#Bdhi d[ i]Z ZmeZg^bZciVa hijY^Zh dc 8I6 igVcheaVcih ]VkZ WZZc eZg[dgbZY dc
gdYZcih# 9^[[ZgZci ^bbjcdhjeegZhh^kZ V\Zcih ]VkZ WZZc jhZY Vh V bdcdi]ZgVen dg ^c Xdb" W^cVi^dc egdidXdah# >c djg aVWdgVidgn! ^c V gVi ]^cY a^bW igVcheaVciVi^dc bdYZa! l^i] dcan V h]dgi"iZgb i]ZgVen d[ XdbW^cZY 8h6 VcY BC"I"XZaa gZXZeidg bdcdXadcVa Vci^WdYn! lZ lZgZ VWaZ id ^cYjXZ adc\"iZgb! Ydcdg"heZX^ÑX idaZgVcXZ VXgdhh V B=8 WVgg^Zg! dWiV^c^c\ adc\"iZgb hjgk^kVa d[ i]Z Vc^bVah dkZg (*% YVnh l^i]dji gZX^e^Zci XdcY^i^dc^c\ VcY i]Z cZZY [dg X]gdc^X ^bbjcdhjeegZhh^dc# IdaZgVcXZ lVh XdcÑgbZY Wn h`^c \gV[i^c\ ^c k^kd VcY b^mZY anbe]dXniZ gZVXi^dc ^c k^igd# I]Z Vc^bVah gZ_ZXiZY i]^gY"eVgin \gV[ih! l]^X] ^cY^XViZ ^bbjcdXdbeZiZcXZ#), A^b^iZY cjbWZgh d[ ZmeZg^bZcih ]VkZ WZZc YdcZ dc aVg\Z Vc^bVah id ZkVajViZ i]Z Z[ÑXVXn d[ kVg^djh ^bbjcdhjeegZhh^kZ egdidXdah dc 8I6 igVcheaVcih# >c V hl^cZ bdYZa d[ a^bW igVcheaVc" iVi^dc! i]Z Vci^gZ_ZXi^dc Z[[ZXih d[ Y^[[ZgZci ^bbjcdhjeegZhh^kZ egdidXdah lZgZ VhhZhhZY ^c" XajY^c\ 8h6 VadcZ! 8h6$BB;! VcY ;@*%+" BB;#*.Ã+& I]Z ;@*%+"BB; XdbW^cVi^dc lVh i]Z bdhi hjXXZhh[ja ^c egZkZci^c\ Vaad\gV[i gZ_ZXi^dc VcY lVh Xdch^YZgZY id WZ V Xa^c^XVaan Veea^XVWaZ igZVibZci!*. Wji ^i lVh VhhdX^ViZY l^i] bdgZ idm" ^X^in l]Zc XdbeVgZY id 8h6$BB; egdidXda i]ZgVen#+% Eg^bViZh VgZ i]Z bdhi gZa^VWaZ bdYZah [dg 8I6 igVcheaVciVi^dc WZXVjhZ i]Zn VgZ XadhZan gZaViZY id ]jbVch# Eg^bViZh ]VkZ WZZc jhZY dcan ^c [Zl
Perspectives for Facial Allograft Transplantation in Humans
hijY^Zh Vh V bdYZa d[ 8I6 igVcheaVcih! VcY i]Z bdhi Xdbbdcan jhZY ^bbjcdhjeegZhh^kZ V\Zcih lZgZ 8h6 VcY hiZgd^Yh#+'!+(
Clinical Immunosuppressive Protocols A^[Zadc\ ^bbjcdhjeegZhh^dc ^h dcZ d[ i]Z ^bedgiVci ^hhjZh i]Vi cZZY id WZ Y^hXjhhZY l^i] eVi^Zcih Xdch^YZg^c\ [VX^Va igVcheaVciVi^dc# HiVc" YVgY igVcheaVciVi^dc egdidXdah ^cXajYZ cdcheZ" X^ÑX ^bbjcdhjeegZhh^kZ Ygj\h# I]Z cjbWZg d[ i]ZhZ Ygj\h ^h ^cXgZVh^c\ ZkZgn nZVg! VcY i]^h aVg\Z cjbWZg bVn d[[Zg Vc deedgijc^in id ÑcY ^YZVa gZ\^bZch# >bbjcdhjeegZhh^kZ egdidXdah Xdch^hi d[ ^c" YjXi^dc VcY bV^ciZcVcXZ i]ZgVe^Zh id egZkZci Vaad\gV[i gZ_ZXi^dc VcY h]dgi XdjghZh d[ ^ciZch^kZ i]ZgVe^Zh id hjeegZhh VXjiZ Ze^hdYZh d[ gZ_ZXi^dc# 8jggZcian! i]Z ^bbjcdhjeegZhh^kZ Ygj\h jhZY ^c i]Z ^cYjXi^dc egdidXdah d[ ^bbjcdhjeegZh" h^dc [dg 8I6 igVcheaVciVi^dc bV^can ^cXajYZ hiZ" gd^Yh! Vci^i]nbdXniZ \adWja^c 6Ichi^iji^dcVa GZk^Zl 7dVgY VeegdkZY i]Z Ñghi egdidXda [dg [VX^Va Vaad\gV[i igVcheaVciVi^dc ^c ]jbVch# EgZhZciZY Wn 9g# BVg^V H^Zb^dcdl! i]Z egdidXda gZfj^gZY &% bdci]h d[ YZWViZ dc i]Z bZY^XVa! Zi]^XVa! VcY ehnX]dad\^XVa ^hhjZh# I]Z ^cXajh^dc VcY ZmXaj" h^dc Xg^iZg^V [dg hXgZZc^c\ ediZci^Va XVcY^YViZh [dg [VX^Va igVcheaVciVi^dc lZgZ i]dgdj\]an ZkVa" jViZY# I]Z Ydcdg VcY gZX^e^Zci XdchZci [dgbh ]VkZ WZZc VeegdkZY# I]^h >G7 VeegdkVa VaadlZY jh id deZc i]Z ;VX^Va IgVcheaVciVi^dc Egd\gVb! l]ZgZ iZVbh d[ heZX^Va^hih! ^cXajY^c\ hjg\Zdch! ehnX]dad\^hih! ehnX]^Vig^hih! Zi]^X^hih! eVi^Zci VYkdXViZh! VcY bZY^V gZegZhZciVi^kZh l^aa ZkVaj" ViZ eVi^Zcih l^i] hZkZgZ [VX^Va YZ[dgb^i^Zh# 7VhZY dc i]^h ZkVajVi^dc! i]Z bdhi Veegdeg^ViZ XVcY^YViZh [dg [VX^Va igVcheaVciVi^dc l^aa WZ hZaZXiZY# I]Z fjZhi^dc gZbV^ch l]Zi]Zg ediZci^Va Ydcdgh VcY i]Z YdcdgÈh [Vb^a^Zh l^aa ZkZg VXXZei [VX^Va h`^c YdcVi^dc#6i i]^h ed^ci! lZ VgZ cdi hjgZ ]dl XadhZ lZ VgZ dg ]dl adc\ ^i l^aa iV`Z [dg i]Z Ñghi [VX^Va igVcheaVciVi^dc id WZ YdcZ# >i bVn cdi ]VeeZc [dg + bdci]h dg V nZVg# >i bVn cdi ]VeeZc ^c djg a^[Zi^bZ# 7ji ^i bVn Vahd ]VeeZc hddcZg i]Vc lZ ZmeZXi#
Conclusion EVi^Zcih a^k^c\ l^i] hZkZgZ [VX^Va YZ[dgb^i^Zh bVn l^h] id VhhjbZ i]Z g^h`h d[ Vaad\gV[i igVcheaVciVi^dc ^[ i]Zn ]VkZ i]Z X]VcXZ id dWiV^c V bdgZ cdgbVa VeeZVgVcXZ# ;VX^Va Vaad\gV[i igVcheaVciVi^dc ldjaY gZkdaji^dc^oZ i]Z ÑZaY d[ igVcheaVciVi^dc VcY gZXdchigjXi^kZ hjg\Zgn# I]Z VYkVciV\Zh VcY Y^hVYkVciV\Zh d[ i]^h egdb^h^c\ egdXZYjgZ h]djaY i]dgdj\]an WZ Y^hXjhhZY l^i] gZX^e^Zcih VcY i]Z^g [Vb^a^Zh IVWaZ &%"& # 6ai]dj\] i]Z a^`Za^]ddY d[ hjXXZhh
Perspectives for Facial Allograft Transplantation in Humans Table 10-1. Advantages and Disadvantages of Facial Allograft Transplantation Advantages Disadvantages • No donor site morbidity • Adequate matching between the • Complete facial reconstruction in donor and recipient is difficult single surgical procedure (age, sex, race) • Option for total external ear • Lifelong immunosuppression replacement or reconstruction • Increased risks of comorbidities • Better skin texture, pliability, and (diabetes, infections, color match lymphoproliferative disorder, avascular necrosis of bones) • Social, ethical, and psychological issues
VcY i]Z adc\"iZgb [jcXi^dcVa VcY Zhi]Zi^X gZhjaih gZbV^c jcXaZVg Vi i]^h i^bZ! [VX^Va Vaad\gV[i igVcheaVciVi^dc l^aa hdbZYVn WZXdbZ V gZVa^in# L]Zc i]^h i^bZ XdbZh! lZ WZa^ZkZ i]Vi lZaa ^c[dgbZY VcY ehnX]dad\^XVaan hiVWaZ eVi^Zcih h]djaY ]VkZ g^\]i id YZX^YZ l]Zi]Zg id jcYZg\d i]^h egdXZYjgZ#
References &# :g\jc HH! 8Z` 9>! 9Zb^g`ZhZc 8# >h [VX^Va gZhjg[VX^c\ l^i] bdcdWadX [jaa"i]^X`cZhh h`^c \gV[i V gZbZYn ^c mZgdYZgbV e^\bZcidhjb4 EaVhi GZXdchig Hjg\# '%%'0 &&%/&'.%Ã&'.(# '# 6h]Vaa cYjXi^dc d[ Ydcdg" heZX^ÑX idaZgVcXZ ^c gVi ]^cY"a^bW Vaad\gV[ih jcYZg Vci^" anbe]dXniZ hZgjb VcY XnXadhedg^cZ 6 egdidXda# ? =VcY Hjg\ P6bR# '%%'0',/&%.*Ã&&%(# ),# H^Zb^dcdl B! DgiV` I! >onX`^ 9! Zi Va# >cYjXi^dc d[ ida" ZgVcXZ ^c Xdbedh^iZ"i^hhjZ Vaad\gV[ih# IgVcheaVciVi^dc# '%%'0&*/&'&&Ã&'&,#
Tissue Surgery )-# H^Zb^dcdl B! DoZg @# 6YkVcXZh ^c Xdbedh^iZ i^hhjZ Vaad\gV[i igVcheaVciVi^dc Vh gZaViZY id i]Z ]VcY VcY jeeZg ZmigZb^in# ? =VcY Hjg\ P6bR# '%%'0',/*+*Ã *+-# ).# H^Zb^dcdl B! <doZa"JajhVa 7! JajhVa 6! Zi Va# ;jcXi^dcVa idaZgVcXZ [daadl^c\ [VXZ igVcheaVciVi^dc ^c i]Z gVi# IgVcheaVciVi^dc# '%%(0,*/&+%,Ã&+%.# *%# JajhVa 7# iZX]c^XVa VheZXih# EaVhi GZXdchig Hjg\# &..'0-./,%%Ã,%.# +)# B^aaZg AL# 8VgY^dkVhXjaVg idm^X^i^Zh d[ ^bbjcd" hjeegZhh^kZ V\Zcih# 6b ? IgVcheaVciVi^dc# '%%'0'/-%,Ã -&-# +*# :jkgVgY H! @Vc^iV`^h ?! 8aVjYn 6# H`^c XVcXZg V[iZg dg\Vc igVcheaVciVi^dc# C :c\a ? BZY# '%%(0()(/&+-&Ã&+.&# ++# ?dhi H8! 9ddaVW] K7! BVX`^ccdc H:! Zi Va# 6XXZaZgV"i^dc d[ eZg^e]ZgVa cZgkZ gZ\ZcZgVi^dc [daadl^c\ ;@*%+ VYb^c^higVi^dc# GZhidg CZjgda CZjgdhX^# '%%%0&,/(.Ã))#
Perspectives for Facial Allograft Transplantation in Humans +,# H^Zb^dcdl B! DobZc H! 9Zb^g N# EgdheZXih [dg [VX^Va Vaad\gV[i igVcheaVciVi^dc ^c ]jbVch# EaVhi GZXdchig Hjg\# '%%)0&&(/&)'&Ã&)'-# +-# EZi^i ;! EVgVh`ZkVh 6! B^cch 67! Zi Va# ;VXZ igVcheaVciV" i^dc/ l]ZgZ Yd lZ hiVcY4 EaVhi GZXdchig Hjg\# '%%)0 &&(/&)'.Ã&)((#
133 +.# O^Z\ZabVcc ?! c i]^h X]VeiZg! lZ gZk^Zl ( i^hhjZ Zc\^cZZg^c\ iZX]c^fjZh WZ^c\ YZkZadeZY idlVgY i]^h ZcY/ hiZb XZaah! edanbZgh! VcY \gdli] [VXidgh#
Stem Cells Jh^c\ hiZb XZaah ^c i^hhjZ Zc\^cZZg^c\ bV`Zh ^cij^i^kZ hZchZ VcY ]Vh \gZVi egdb^hZ# HiZb XZaah VgZ! Wn YZÑc^i^dc! bjai^ediZci VcY hZa[" gZ\ZcZgVi^c\! \^k^c\ i]Zb i]Z jc^fjZ ediZci^Va d[ bV^ciV^c^c\ XZaajaVg ]dbZdhiVh^h ^c [jcX" i^dcVa i^hhjZ [dg i]Z a^[Zi^bZ d[ i]Z dg\Vc^hb# Id WZ Veea^XVWaZ [dg i^hhjZ Zc\^cZZg^c\! i]Z hiZb XZaa bjhi Ñghi WZ Y^[[ZgZci^ViZY ^cid i]Z a^cZV\Z"Xdbb^iiZY XZaa ineZ d[ i]Z i^hhjZ d[ ^ciZgZhi# I]Zn bjhi i]Zc VhhZbWaZ ^cid Vc Veegd" eg^ViZ i]gZZ"Y^bZch^dcVa VgX]^iZXijgZ Y^XiViZY Wn i]Z [jcXi^dcVa gZfj^gZbZcih d[ i]Z i^hhjZ ^c
135
136
fjZhi^dc# Id jcYZghiVcY i]Z ediZci^Va d[ hiZb XZaah idlVgY i]^h ZcY! hZkZgVa eg^cX^eaZh d[ hiZb XZaa e]nh^dad\n bZg^i Y^hXjhh^dc# HiZb XZaah XVc WZ Y^k^YZY ^cid ild bV^c XaVhhZh! i]Z Ñghi d[ l]^X] ^h i]Z eajg^ediZci hiZb XZaah! l]^X] VgZ XVeVWaZ d[ Vhhjb^c\ Vaa ineZh d[ i^hhjZ! ZmXZei ZmigV"ZbWgndc^X bZbWgVcZh! bV`^c\ i]Zb ^cXVeVWaZ d[ \ZcZgVi^c\ ZbWgndc^X i^hhjZ# Eajg^ediZci XZaah VgZ [djcY Vh ZbWgndc^X hiZb XZaah ^c i]Z ^ccZg XZaa bVhh d[ i]Z WaVhidXnhi! Vh lZaa Vh ^c \Zgb XZaah d[ i]Z \dcVYVa g^Y\Z ^c i]Z [Zijh#)!* :bWgndc^X hiZb VcY \Zgb XZaah Y^[[Zg ^c hZkZgVa lVnh! ^cXajY^c\ i]Z XdcY^i^dch gZfj^gZY [dg ^hdaVi^dc! edejaVi^dc YdjWa^c\h! VcY hjgk^k" VW^a^in ^c XZaa XjaijgZ! l^i] ZbWgndc^X hiZb XZaah WZ^c\ dkZgVaa i]Z bdgZ gdWjhi d[ i]Z ild#+ :bWgn" dc^X hiZb XZaah XVc WZ bVc^ejaViZY ^cid V l^YZ" gVc\Z d[ XZaa ineZh! ^cXajY^c\ bjhXaZ XZaah! cZjgVa XZaah! kVhXjaVg ZcYdi]Za^jb! VcY ZcYdYZgbVa YZg^kVi^kZh#, 6ai]dj\] i]Z bdaZXjaVg bZX]V" c^hbh d[ ^c"k^igd hZa["gZcZlVa ]VkZ WZZc YZhXg^WZY ^c bjg^cZ XZaa edejaVi^dch! i]Z bZX]" Vc^hbh d[ ]jbVc ZbWgndc^X hiZb XZaa gZ\jaVi^dc gZbV^c jc`cdlc#I]Z hZXdcY bV_dg XaVhh d[ hiZb XZaa ^h i]Z bja" i^ediZci hiZb XZaa! l]^X] ^h Xdch^YZgZY id WZ i]Z d[[heg^c\ d[ eajg^ediZci XZaah VcY id WZ Y^gZXiZY ^cid bdgZ heZX^ÑX XZaa a^cZV\Zh# >c di]Zg ldgYh! bjai^ediZci hiZb XZaah VgZ aZhh eaVhi^X VcY bdgZ Y^[[ZgZci^ViZY i]Vc i]Z^g eajg^ediZci XdjciZg" eVgih# 6 Xdbbdc hdjgXZ d[ bjai^ediZci hiZb XZaah ^h i]Z VYjai ]jbVc! VcY i]Z bdhi ZmiZc" h^kZan X]VgVXiZg^oZY VgZ i]Z WdcZ bVggdl"YZg^kZY hiZb XZaah# I]ZhZ XZaah Xdch^hi d[ ild Y^hi^cXi hiZb XZaa edejaVi^dch/ & ]ZbVided^Zi^X hiZb XZaah! l]^X] VgZ gZhedch^WaZ [dg i]Z YZkZadebZci d[ i]Z Zci^gZ WaddY XZaa a^cZ! ^cXajY^c\ l]^iZ WaddY XZaah! gZY WaddY XZaah! VcY eaViZaZih0 VcY ' bZhZcX]nbVa hiZb XZaah! l]^X] \^kZ g^hZ id cjbZgdjh XdccZXi^kZ i^hhjZh! ^cXajY^c\ WdcZ! XVgi^aV\Z! VY^edhZ! bjhXaZ! iZcYdc! VcY cZjgVa i^hhjZ ^c Wdi] ^c"k^igd VcY ^c"k^kd hZii^c\h#. BZh" ZcX]nbVa hiZb XZaah VgZ egZhZci ^c VYjai WdcZ bVggdl! [Vi! bjhXaZ! VcY h`^c#&%
Applications of Stem Cells in Tissue Repair 6 gZXZci gZk^Zl d[ hiZb XZaa gZhZVgX] [dg i^hhjZ gZeV^g gZedgiZY ZcXdjgV\^c\ gZhjaih [gdb ZVgan ZmeZg^bZcih jh^c\ ZbWgndc^X hiZb XZaah [gdb gVih VcY b^XZ id gZeV^g cZgkZ VcY bjhXaZ i^hhjZ#
Tissue Surgery
:[[dgih id hZZY ]jbVc ZbWgndc^X hiZb XZaa YZg^kVi^kZh ^cid ]jbVc WZ^c\h VgZ dc\d^c\#&& 6YY^c\ id i]Z X]VaaZc\Z d[ ]jbVc Xa^c^XVa jhZ ^h gZXZci Zk^YZcXZ i]Vi B=8 XaVhh & egdiZ^ch! [djcY dc i]Z hjg[VXZ d[ Vaa cjXaZViZY XZaah gZhedch^WaZ [dg Vci^\Zc egZhZciVi^dc id I XZaah! VgZ ZmegZhhZY dc ]jbVc ZbWgndc^X hiZb XZaah l]^X] ^cXgZVhZ V[iZg Y^[[ZgZci^Vi^dc# I]^h bV`Zh i^hhjZ gZ_ZXi^dc Wn i]Z ]dhi Vaa i]Z bdgZ a^`Zan#&' LVnh id b^c^" b^oZ i]^h jcidlVgY Z[[ZXi ^cXajYZ YZkZade^c\ Vc ÅZbWgndc^X hiZb XZaa WVc`Æ i]Vi XdjaY bViX] XZaah id ^cY^k^YjVa eVi^Zcih0 \ZcZi^XVaan VaiZg^c\ XZaah id YZkZade V Åjc^kZghVa YdcdgÆ i]Vi YdZh cdi ZmegZhh B=8 egdiZ^ch! VcY YZkZade^c\ cjXaZVg igVch[Zg iZX]c^fjZh id YZg^kZ \ZcZi^XVaan bViX]ZY hiZb XZaah [dg ^cY^k^YjVa eVi^Zcih#&( 6Yjai hiZb XZaah! Vh bZci^dcZY ZVga^Zg! ]VkZ i]Z VW^a^in id Y^[[ZgZci^ViZ ^cid cjbZgdjh XZaa a^c" ZV\Zh# I]Z Vhhjbei^dc i]Vi i]Z^g [jcXi^dc ldjaY WZ a^b^iZY id i]dhZ d[ i]Z XZaa a^cZV\Zh egZhZci ^c i]Z dg\Vc d[ dg^\^cVa ]VgkZhi ]Vh cdi ]ZaY igjZ# Id YViZ! VYjai WdcZ bVggdl! WgV^c! h`ZaZiVa bjhXaZ! a^kZg! eVcXgZVh! [Vi! VcY h`^c Vaa ]VkZ WZZc h]dlc id edhhZhh egd\Zc^idg XZaah XVeVWaZ d[ Y^[" [ZgZci^Vi^c\ ^cid XZaa ineZh di]Zg i]Vc i]Z^g i^hhjZ d[ cVi^kZ dg^\^c#&& HiZb XZaah ^cigdYjXZY ^cid V cdkZa Zck^gdcbZci VgZ cdl WZa^ZkZY id jcYZg\d ÅgZegd\gVbb^c\Æ ^c gZhedchZ id adXVa h^\cVah ZaVWdgViZY Wn i]Z^g cZl hjggdjcY^c\h! Vai]dj\] i]^h gZegd\gVbb^c\ ^h eddgan jcYZghiddY#&' 6 WZiiZg jcYZghiVcY^c\ d[ i]ZhZ XZaajaVg bZX]" Vc^hbh ]Vh XdbZ [gdb hijY^Zh d[ hnci]Zi^X b^XgdZck^gdcbZcih i]Vi XaVg^[n i]Z gdaZ d[ bVig^m! \gdli] [VXidg! VcY XZaajaVg VY]Zh^dc XjZh ^c hiZb XZaa Y^[[ZgZci^Vi^dc VcY ]^hi^d\ZcZh^h#&) >c i]ZhZ hijY^Zh! adXVa aZkZah d[ Wdi] hdajWaZ VcY ^chdajWaZ bdaZXjaZh lZgZ hjhiV^cZY Vi i]Z h^iZ d[ XZaa igVcheaVciVi^dc# >c i]^h eVgi^XjaVg XVhZ! i]Z WgV^c lVh i]Z i^hhjZ bdYZa ^c fjZhi^dc# IgVch" eaVciVWaZ ÅcZd"i^hhjZhÆ lZgZ XgZViZY jh^c\ XZaah VhhZbWaZY l^i] XZaa"VY]Zh^kZ VcY XdcigdaaZY" gZaZVhZ b^XgdeVgi^XaZh! l^i] \gdli] [VXidg Ydh^c\ VcY hjWhZfjZci Z[[ZXi WZ^c\ XdcigdaaZY Wn kVgn^c\ Z^i]Zg i]Z cjbWZg d[ Y^hig^WjiZY b^X" gdeVgi^XaZh dg i]Z gViZ Vi l]^X] \gdli] [VXidg lVh gZaZVhZY [gdb i]ZhZ b^XgdeVgi^XaZh#&) 6h hjX]! i]ZhZ ÅcZd"i^hhjZhÆ lZgZ Z[[ZXi^kZan h]dlc id WZ Åegd\gVbbVWaZ#Æ 6hhZhh^c\ XZaa k^VW^a^in ]Vh WZZc i]Z hdjgXZ d[ ZmiZch^kZ gZhZVgX]! l^i] adXVa XZaa k^VW^a^in WZ^c\ YZiZgb^cZY l^i] i]Z bdYZa d[ i]gZZ"Y^bZch^dcVa! Zc\^cZZgZY h`ZaZiVa bjhXaZ XdchigjXih# Jh^c\ YjVa ÒjdgZhXZci hiV^c^c\ VcY Xdc[dXVa aVhZg hXVcc^c\ b^XgdhXden! i]Z k^VW^a^in d[ i]ZhZ XdchigjXih lVh YZiZgb^cZY V[iZg
Tissue Engineering: Current Approaches and Future Directions
XVa^WgVi^c\ i]Z VkZgV\Z ÒjdgdhXde^X ^ciZch^in eZg a^k^c\ XZaa#&* L]^aZ a^`Zan id WZ a^b^iZY Wn i]Z i]^X`cZhh d[ i]Z Zc\^cZZgZY i^hhjZ VcY Vbdjci d[ XZaajaVg egda^[ZgVi^dc egZhZci ^c i]Z hVbeaZ! i]^h iZX]c^fjZ gZegZhZcih V ediZci^Va VYkVcXZ ^c cdcYZhigjXi^kZ fjVci^iVi^kZ VcVanh^h d[ ^c"k^igd i^hhjZ XdchigjXih#&*
Biomaterials GZXZci ^ciZgZhi ^c W^dYZ\gVYVWaZ edanbZgh VcY di]Zg bViZg^Vah ]Vh aZY id Vc ZmX^i^c\ ZmeVch^dc d[ ediZci^Va igZVibZcih! Z^i]Zg VadcZ dg ^c Xdc" _jcXi^dc l^i] di]Zg bZi]dYh d[ i^hhjZ Zc\^cZZg" ^c\# 7^dYZ\gVYVWaZ egdYjXih VgZ i]dj\]i id ]VkZ Vi aZVhi ild ediZci^Va VYkVciV\Zh# ;^ghi! V hjW" hiVcXZ VWaZ id WZ Z[[ZXi^kZan XaZVgZY Wn i]Z WdYn ldjaY cdi ]VkZ id WZ gZbdkZY V[iZg jhZ Wn hZX" dcYVgn hjg\Zgn# HZXdcY! i]Z egd\gZhh^kZ adhh d[ bZX]Vc^XVa higZc\i] d[ i]Z bViZg^Va XdjaY Xdc" XZ^kVWan b^b^X i]Z cVijgVa ]ZVa^c\ egdXZhh#&+ I]ZhZ VYkVciV\Zh! ]dlZkZg! XdbZ l^i] V aVg\Z cjbWZg d[ di]Zg Xdch^YZgVi^dch! cVbZan! bdaZX" jaVg lZ^\]i! X]Zb^XVa Xdbedh^i^dc! bdge]dad\n! VYY^i^kZh! VcY Zck^gdcbZciVa XdcY^i^dch# HjXXZhh d[ Vc Zc\^cZZgZY i^hhjZ XdchigjXi ^c ijgc WZ" XdbZh ^c aVg\Z eVgi i]Z egdYjXi d[ i]Z ^ciZgVX" i^dc d[ i]ZhZ W^d"hXV[[daYh VcY XZaah! Z^i]Zg ^c h^ij dg bdW^a^oZY ^c k^igd# >c i]Z hZ\bZci id [daadl! cVijgVa VcY hnci]Zi^X edanbZgh! Vh lZaa Vh ^c_ZXi" VWaZ ]nYgd\Zah l^aa WZ Y^hXjhhZY ^c i]Z XdciZmi d[ i^hhjZ Zc\^cZZg^c\ VcY ldjcY gZeV^g# :Vgan ldg` l^i] X]dcYgdXniZh gZkZVaZY i]Z ^bedgiVcXZ d[ Vc V\VgdhZ hXV[[daY ^c gZ" Y^[[ZgZci^Vi^c\ XZaah Yjg^c\ i]Z ZmeVch^dc e]VhZ#&, H^cXZ i]^h i^bZ! gZhZVgX] idlVgY Zc\^" cZZg^c\ i^hhjZ hXV[[daYh [dg W^dZc\^cZZg^c\ Veea^XVi^dch ]Vh [daadlZY [djg \ZcZgVa eg^cX^eaZh/ & YZÑc^c\ V heVXZ i]Vi l^aa h]VeZ i]Z gZ\ZcZgVi" ^c\ i^hhjZ0 ' VYdei^c\ V iZbedgVgn [jcXi^dc ^c V YZ[ZXi l]^aZ cVi^kZ i^hhjZ gZ\ZcZgViZh0 ( [VX^a^iVi^c\ i^hhjZ ^c\gdli]0 VcY ) ^cXajY^c\ hZZYZY XZaah! egdiZ^ch! \ZcZh! dg Vaa ( id VXXZaZgViZ ldjcY ]ZVa^c\#&EZg]Veh i]Z aVg\Zhi VcY bdhi egda^ÑX VgZV d[ gZhZVgX] ^c edanbZg hXV[[daYh gZbV^ch ^c i]Z YdbV^c d[ h`ZaZiVa i^hhjZ Zc\^cZZg^c\# 6 gZXZci gZk^Zl d[ i]Z a^iZgVijgZ Wn Aj Zi Va# Y^hXjhhZh ^bedgiVci VheZXih d[ hXV[[daY YZh^\c! bViZg^Vah! VcY egdXZhh^c\ d[ h`ZaZiVa i^hhjZ XdchigjXih! l]^X] ^c bVcn X^gXjbhiVcXZh eVgVaaZa i]Z edanbZg X]VgVXiZg^hi^Xh jhZY [dg di]Zg Veea^XV" i^dch d[ i^hhjZ Zc\^cZZg^c\#&.
137
7Z\^cc^c\ l^i] YZh^\c! V WVh^X gZfj^gZbZci d[ edanbZg^X hXV[[daYh ^h W^dXdbeVi^W^a^in# ;VXidgh V[[ZXi^c\ i]^h gZfj^gZbZci ^cXajYZ i]Z X]Zb^hign VcY bdge]dad\n d[ i]Z XdchigjXi! Vh lZaa Vh i]Z egdXZhh d[ hnci]Zh^h ^ihZa[# GZh^YjVa X]Zb^XVah [gdb egdXZhh^c\ ]VkZ i]Z ediZci^Va d[ aZVX]^c\ [gdb i]Z hXV[[daY VcY VYkZghZan V[[ZXi^c\ Wdi] i]Z i^hhjZ XdchigjXi VcY i]Z cVi^kZ i^hhjZ ^c i]Z k^X^c^in d[ i]Z ^beaVci# I]Z egdeZgin d[ W^d" YZ\gVYVW^a^in d[ i]Z edanbZg hXV[[daY ^ihZa[ ^h cdi! ]dlZkZg! hj[ÑX^Zci id WZ Xa^c^XVaan Veea^XVWaZ l]Zc YZh^\c^c\ edanbZg^X hXV[[daYh# HZkZgVa XVhZh ]VkZ WZZc gZedgiZY ^c l]^X] i^hhjZ cZXgd" h^h dg jcidlVgY ^cÒVbbVi^dc ^c i]Z VgZV d[ ^beaVciVi^dc ]Vh dXXjggZY Vh V Y^gZXi gZhjai d[ edanbZg YZ\gVYVi^dc Wn cVijgVa ]dhi bZX]V" c^hbh i]Vi ^c ijgc _ZdeVgY^oZ i]Z dkZgVaa k^VW^a^in d[ i]Z gZeV^g#&. 6h V gZhjai! egZX^hZ VXXdjci^c\ d[ i]Z bZX]Vc^hb d[ edanbZg W^dYZ\gVYVW^a^in ^h Vc VWhdajiZ gZfj^gZbZci [dg hjXXZhh[ja i^hhjZ Zc\^cZZg^c\ Veea^XVi^dch# EdanbZg Zc\^cZZg^c\ V^bh id XdchigjXi V hXV[" [daY i]Vi egdk^YZh i]Z XZaajaVg hiVW^a^in cZXZhhVgn id ZcXdjgV\Z bVm^bVa XZaajaVg egda^[ZgVi^dc l^i] i]Z ^ciZci^dc d[ Veegdeg^ViZ ZmigVXZaajaVg bVig^m \ZcZgVi^dc# I]^h ZmigVXZaajaVg bVig^m ^c ijgc gZeaVXZh i]Z edanbZg^X hXV[[daY dg^\^cVaan ^c eaVXZ! Vh ^i WZXdbZh VWhdgWZY VcY ZmXgZiZY Wn i]Z WdYn# I]Z Xg^i^XVa higjXijgVa kVg^VWaZh d[ i]Z XZaajaVg Zck^gdcbZci cZXZhhVgn id ZhiVWa^h] VcY bV^ciV^c i^hhjZ [dgb VcY [jcXi^dc gZbV^c id WZ ^YZci^ÑZY# IdlVgY i]^h ZcY! higjXijgZÃbZX]Vc^" XVa VcVanh^h d[ XZaah VcY i]Z^g hjeedgi^c\ hXV[[daY l^i]^c i^hhjZ XdchigjXih VgZ WZ^c\ ^ckZhi^\ViZY ^c i]gZZ Y^bZch^dch jh^c\ Xdc[dXVa b^XgdhXden ^c gZÒZXi^dc bdYZ WVX`hXViiZgZY a^\]i id hZaZX" i^kZan k^hjVa^oZ b^XgdhigjXijgVa YZ[dgbVi^dc d[ i]Z hXV[[daY# I]Z YZ[dgbVi^dc dWhZgkZY Vi Wdi] bVXgd" VcY b^XgdhXde^X aZkZah Yjg^c\ i]Z Veea^XVi^dc d[ XdcigdaaZY! fjVci^ÑZY bZX]Vc^XVa adVYh ^c ijgc Vaadlh [dg VXXjgViZ X]VgVXiZg^oV" i^dc d[ higjXijgVa"bZX]Vc^XVa gZaVi^dch]^eh WZilZZc W^dbViZg^Vah VcY XZaa"hXV[[daY Xdc" higjXih#'% I]Z bViZg^Vah [dg edanbZg hXV[[daYh VgZ cjbZgdjh VcY YZeZcY id V aVg\Z ZmiZci dc i]Z ^cY^XVi^dc d[ i]Z i^hhjZ XdchigjXi ^c fjZhi^dc# CVijgVa edanbZgh! hjX] Vh hiVgX]"WVhZY edan" bZgh! VgZ Z[[ZXi^kZ eaVi[dgbh [dg bjg^cZ ÑWgd" WaVhi XZaa \gdli]#'& 8]^idhVc! V eVgi^Vaan YZVXZinaViZY YZg^kVi^kZ d[ X]^i^c! ^ihZa[ V cVijgVa edanbZg egdYjXi d[ ^chZXih! ldgbh! XgjhiVXZVch! VcY [jc\^! ]Vh WZZc egdkZY id WZ Xa^c^XVaan jhZ[ja Vh V W^dbViZg^Va# 8]^idhVc"XVaX^jb e]dhe]ViZ edanbZgh VgZ WZ^c\ hijY^ZY [dg ]jbVca^`Z
138
dhiZdWaVhi \gdli]! VcY X]^idhVc"i]^d\anXda^X VX^Y Xdc_j\ViZh ]VkZ h]dlc ^c"h^ij \Zaa^c\ egde" Zgi^Zh Vi e]nh^dad\^X iZbeZgVijgZh VcY e= l^i] heZX^ÑX h]VeZh h^b^aVg id cVi^kZ i^hhjZ#''!'( 8daaV\Zc ^h i]Z bV_dg XdbedcZci d[ i]Z ZmigVXZaajaVg bVig^m0 XdaaV\Zc ÑWZgh ]VkZ WZZc YZhXg^WZY Vh hXV[[daY^c\ W^dbViZg^Va [dg a^\VbZcidjh gZeaVXZbZci! l]ZgZVh XdaaV\Zc" X]dcYgd^i^c hja[ViZ bVig^m egdbdiZh X]dcYgd" XniZ egda^[ZgVi^dc VcY Y^[[ZgZci^Vi^dc ^c k^igd#')!'* CZlZg! hda^Y [gZZ"[dgb [VWg^XVi^dc iZX]c^fjZh! ^ckdak^c\ i]Z XdchigjXi^dc d[ i]gZZ"Y^bZch^dcVa dW_ZXih d[ YZh^gZY h]VeZh jh^c\ aVnZgZY bVcj[VX" ijg^c\ higViZ\^Zh! Vadc\ l^i] Xg^i^XVa"ed^ci Ygn^c\ i]Z ZmX]Vc\Z d[ Zi]Vcda l^i] a^fj^Y XVgWdc Y^dm^YZ Vi hZi egZhhjgZ ! XVc WZ jhZY id XgZViZ egZYZÑcZY VcY gZegdYjX^WaZ edgZh d[ kVg^djh h^oZh VcY ^ciZgXdccZXi^dch ^c XdaaV\Zc hXV[[daYh [dg dei^bVa igVchedgi d[ cjig^Zcih VcY dmn\Zc id i]Z XdchigjXi#'+ Hnci]Zi^X edanbZgh VgZ Vahd Xdbbdcan jhZY ^c gZhZVgX]! l]^X] ]Vh egdYjXZY Vi aZVhi dcZ Xa^c^XVaan jhZ[ja egdYjXi! 9ZgbV\gV[i edanaVX" i^YZ Xd"\anXda^YZ # =dlZkZg! hnci]Zi^X edanbZgh VgZ a^b^iZY Wn e]nh^XVa egdeZgi^Zh i]Vi VYkZghZan V[[ZXi i]Z^g YZ\gVYVi^dc egdÑaZh! ^cXajY^c\ V iZc" YZcXn id XgjbWaZ! ^cX^i^c\ bZX]Vc^XVa YVbV\Z id i^hhjZh! Vh lZaa Vh [dgZ^\c WdYn i^hhjZ gZVX" i^dch#', 6h V gZhjai! gZhZVgX]Zgh VgZ cdl iV`^c\ V^b Vi ÅhZb^"hnci]Zi^XÆ edanbZg YZg^kVi^kZh! l]^X] bVn VYYgZhh i]Z h]dgiXdb^c\h d[ hnc" i]Zi^X XdchigjXih l]^aZ h^bjaiVcZdjhan ^begdk" ^c\ dc VcY iV^adg^c\ cVijgVa edanbZgh id i]Z Veea^XVi^dc d[ ^ciZgZhi# ;dg ZmVbeaZ! X]^idhVc" edan\anXda^YZ ]nWg^Yh XVc bV^ciV^c ÑWgdWaVhi k^VW^a^in VcY he^cYaZ bdge]dad\n ^c XjaijgZ ZmeZg^bZcih#'- I]Z gZhZbWaVcXZ d[ X]^idhVc id i]Z XdbedcZcih d[ egdiZd\anXVch ^h XdcYjX^kZ id XZaajaVg ViiVX]bZci VcY Xdchi^iji^dcVa [jcXi^dc! VcY edan\anXda^X VX^Y hZgkZh Vh Vc Z[[ZXi^kZ hXV[" [daY l^i] ^ih ZmXZei^dcVa W^dXdbeVi^WaZ VcY W^d" YZ\gVYVWaZ egdÑaZ# H^b^aVgan! hiVgX] WaZcYZY l^i] Zi]naZcZ k^cna VaXd]da cVbZY H:K6"8 ! l]Zc gZ^c[dgXZY l^i] hnci]Zi^X ]nYgdmnVeVi^iZ![dgbZY V XVaX^jb e]dhe]ViZ aVnZg dc ^ih hjg[VXZ ^c h^ij! \^k^c\ i]Z XdchigjXi i]Z ediZci^Va id WdcY WdcZ l]Zc ^beaVciZY ^c k^kd#'. 6c VaiZgcVi^kZ id i]Z edanbZg^X hXV[[daYh YZhXg^WZY VWdkZ VgZ i]Z bdgZ gZXZci i^hhjZ Zc\^" cZZg^c\ VeegdVX]Zh Zbeadn^c\ ^c_ZXiVWaZ! ^c"h^ij \Za"[dgb^c\ bVig^m hnhiZbh# HjX] V YZa^kZgn hnhiZb ]Vh VYkVciV\Zh dkZg bdgZ ÅXdckZci^dcVaÆ edanbZg hXV[[daY iZX]c^fjZh! ^cXajY^c\ i]Z VW^a^in id Ñaa V YZ[ZXi d[ Vcn h]VeZ! i]Z ^cXdgedgV"
Tissue Surgery
i^dc d[ kVg^djh i]ZgVeZji^X V\Zcih! i]Z aVX` d[ gZh^YjVa hdakZcih! VcY cdchjg\^XVa eaVXZbZci#(% 7n YZÑc^i^dc! V \Za ^h V i]gZZ"Y^bZch^dcVa cZildg` hldaaZc Wn V hdakZci i]Vi XVc WZ XaVhh^" ÑZY VXXdgY^c\ id i]Z [Vh]^dc d[ i]Z cZildg` id l]^X] ^i ^h XdccZXiZY0 Z^i]Zg Wn X]Zb^XVa XdkV" aZci WdcYh dg e]nh^XVa [dgXZh# I]ZhZ \Za edan" bZgh VgZ XVeVWaZ d[ ^cXdgedgVi^c\ lViZg l^i]dji Y^hhdak^c\ i]Z edanbZg! \^k^c\ i]Zb i]Z X]VgVX" iZg^hi^Xh d[ hd[i i^hhjZ VcY V ]^\] eZgbZVW^a^in [dg dmn\Zc! cjig^Zcih! VcY lViZg"hdajWaZ bZiVWd" a^iZh#(& ;djg bV^c XaVhhZh d[ ^c_ZXiVWaZ \Za hnhiZbh ]VkZ WZZc ^ckZhi^\ViZY id YViZ# I]Zn VgZ i]Zg" bdgZkZgh^WaZ! e="gZkZgh^WaZ! ^dc^XVaan Xgdhh" a^c`ZY! VcY ]^\]"k^hXdh^in! h]ZVg"i]^cc^c\ \Zah# I]ZgbdgZkZgh^WaZ \Zah jcYZg\d e]VhZ igVch^" i^dc l^i] ^cXgZVh^c\ iZbeZgVijgZ l]Zc i]Z edanbZg XdcXZcigVi^dc ^h VWdkZ V Xg^i^XVa kVajZ# 6 hnci]Zi^X ZmVbeaZ ^h edanZi]naZcZ dm^YZ"W" egdenaZcZ dm^YZ"W"Zi]naZcZ dm^YZ E:D"EED" E:D ! l]^X] ]Vh gZXZcian WZZc Veea^ZY id [dgb V XVgi^aV\Z aVnZg dc ]dhi WdcZ! Vh lZaa Vh ^c_ZXiZY id [dgb XVgi^aV\Z ^c b^XZ#(' I]Z e="gZkZgh^WaZ \Zah! hjX] Vh X]^idhVch! VgZ X]Vg\ZY! lViZg"hdajWaZ \Za"[dgb^c\ edanbZgh ^c gZhedchZ id e= h]^[ih i]Vi ]VkZ WZZc hijY^ZY Vh ^c_ZXiVWaZ! gZhdgWVWaZ iZbeaViZh ^c WdcZ gZ\ZcZgVi^dc#(% >dc^XVaan Xgdhh" a^c`ZY \Zah VgZ lViZg"hdajWaZ X]Vg\ZY edanbZgh i]Vi [dgb \Zah l]Zc i]Z gZVXi l^i] Y^" dg ig^kV" aZci ^dch Z#\#! Va\^cViZ # 6ai]dj\] ^c"k^kd ZmeZg" ^bZcih ]VkZ hjXXZhh[jaan ZbeadnZY Va\^cViZ id YZa^kZg Vjidad\djh X]dcYgdXniZh! i]Z g^h` d[ Zc]VcXZY ^bbjcd\Zc^X^in VcY eddg W^dgZhdgW" VW^a^in ]VkZ gV^hZY XdcXZgch dkZg i]Z edhh^W^a^in d[ VYkZghZ i^hhjZ gZVXi^dch#(%!(( =^\]"k^hXdh^in h]ZVg"i]^cc^c\ \Zah! d[ l]^X] ]nVajgdc^X VX^Y ^h gZegZhZciVi^kZ! XVc WZ ^cigdYjXZY ^cid i^hhjZ i]gdj\] hbVaa"WdgZ cZZYaZh VcY XVc hjWhZ" fjZcian [dgb i]^X` \Zah dcXZ i]Z h]ZVg [dgXZ [gdb i]Z ^c_ZXi^dc ]Vh WZZc gZbdkZY# I]^h egdeZgin ]Vh WZZc bVc^ejaViZY id gZeV^g Xdcidjg YZÑX^ih ^c i]Z h`^c cdc"deZgVi^kZan#(% 6 XdbbZgX^Vaan VkV^aVWaZ ]nVajgdc^X VX^Y egdYjXi! GZhinaVcZ! ]Vh WZZc jhZY id Vj\bZci i]Z a^e Wji ^h cdi nZi VeegdkZY Wn i]Z ;96# Bdhi gZXZcian! hnci]Zi^X bViZg^Vah ]VkZ WZZc YZkZadeZY i]Vi VgZ XVeVWaZ d[ Vhh^hi^c\ i^hhjZ gZ\ZcZgVi^dc Wn b^b^X`^c\ bVig^m bZiVaadegdiZ^cVhZ"bZY^ViZY ^ckVh^dc d[ cVi^kZ ZmigVXZaajaVg bVig^m#() >c V Xg^i^XVa h^oZ YZ[ZXi ^c V XVakVg^Va WdcZ bdYZa! i]^h hnci]Zi^X \Za jcYZglZci V XZaa"bZY^ViZY bZX]Vc^hb d[ bVig^m WgZV`Ydlc! l]^X] dXXjggZY ^c iZbedgVa VcY heVi^Va hncX]gdcn l^i] ZcYd\Zcdjh WdcZ gZ\ZcZgVi^dc# >c XdcigVhi! bdgZ XdckZci^dcVa
Tissue Engineering: Current Approaches and Future Directions
W^dYZ\gVYVWaZ \Za edanbZgh VgZ YZcVijgZY Wn X]Zb^XVa eVi]lVnh! ^cYZeZcYZci d[ XZaajaVg ^ckV" h^dc VcY gZeV^g# 6c ^ciZgZhi^c\ VYYZcYjb id \Za Zc\^cZZg^c\! ^h V cZlZg VeegdVX] id \ZcZgVi^c\ \Za edanbZgh [dg i^hhjZ Zc\^cZZg^c\ Veea^XVi^dch/ e]didedan" bZg^oVi^dc# I]^h iZX]cdad\n ^h WVhZY dc i]Z VW^a^in d[ k^h^WaZ dg jaigVk^daZi a^\]i id ^ciZgVXi l^i] a^\]i"hZch^i^kZ XdbedjcYh e]did^c^i^V" idgh ^c i]Z \Za bVig^m id XgZViZ [gZZ gVY^XVah i]Vi! ^c ijgc! ^c^i^ViZ edanbZg^oVi^dc! [dgb^c\ Xgdhh" a^c`ZY ]nYgd\Zah# 6YkVciV\Zh d[ i]^h iZX]c^fjZ ^cXajYZ WZiiZg heVi^Va VcY iZbedgVa Xdcigda d[ edanbZg^oVi^dc! gVe^Y XjgZ gViZh! b^c^bVa ]ZVi egdYjXi^dc! VcY i]Z VW^a^in id WZ hnci]Zh^oZY ^c h^ij#(& 6ai]dj\] i]Z gZaVi^kZ eVjX^in d[ cdcidm^X bdcdbZgh VcY dg\Vc^X hdakZcih jhVWaZ [dg e]d" idedanbZg^oVi^dc ^h V XdcXZgc ^c ^c"k^kd Veea^XV" i^dch! XZgiV^c Veea^XVi^dch ]VkZ egdb^hZ [dg Xa^c^XVa jhZ# ;dg ZmVbeaZ! edank^cna VaXd]da ]nYgd\Zah jhZY ^c de]i]Vab^X bViZg^Vah VcY iZcYdc gZeV^g ! [dgbZY Wn XdckZci^dcVa [gZZoZ" i]Vl! X]Zb^XVa VaYZ]nYZ Xgdhha^c`^c\! dg gVY^V" i^dc egdXZhhZh ]VkZ igVY^i^dcVaan XgZViZY ]Vgh] Zck^gdcbZcih cdi XdbeVi^WaZ l^i] XZaajaVg VcY i^hhjZ k^VW^a^in# BdgZ gZXZci e]didedanbZg^oZY edank^cna VaXd]da ]nYgd\Zah ]VkZ! ]dlZkZg! hZZYZY ]jbVc YZgbVa ÑWgdWaVhih ^c XjaijgZ#(* >c"k^kd Veea^XVi^dch l^aa a^`Zan hddc [daadl#
Growth Factors ci ? E]VgbV# '%%(0'*+/&-(Ã&-.# ')# WVggV 8! KVXVci^ 8# EgZeVgVi^dc VcY JhZ d[ I]ZgbdhZch^i^kZ EdanbZgh# >c/ I^hhjZ :c\^cZZg^c\/ BZi]dYh VcY EgdidXdah# IdidlV C?/ =jbVcV EgZhh! &...# ((# KVXVci^ 86! AVc\Zg G! HX]add 7! KVXVci^ ?E# Hnci]Zi^X edanbZgh hZZYZY l^i] X]dcYgdXniZh egdk^YZ V iZbeaViZ [dg cZl XVgi^aV\Z [dgbVi^dc# EaVhi GZXdchi Hjg\# &..&0.*/-)(Ã-*%# ()# Ajida[ BE! AVjZg";^ZaYh ?A! HX]bdZ`Za =cd`jX]^ H! @^Yd`dgd B! Zi Va# >cYjXi^dc d[ kVhXjaVg ZcYdi]Za^Va \gdli] [VXidg Wn ÑWg^c Vh V YZgbVa hjWhigViZ [dg XjaijgZY h`^c hjWhi^ijiZ# EaVhi GZXdchi Hjg\# '%%(0&&&/&+(-Ã&+)*# )&# BZVcZn BjggVn B! G^XZ @! Lg^\]i G?! HeZXidg B# I]Z Z[[ZXi d[ hZaZXiZY \gdli] [VXidgh dc ]jbVc VciZg^dg Xgj" X^ViZ a^\VbZci XZaa ^ciZgVXi^dch l^i] V i]gZZ" Y^bZch^dcVa XdaaV\Zc cidh] L! ;j @! 7ajc` 7I! AVc\Zg G# 8dc" igdaaZY"gZaZVhZ d[ >c &.). ?VXdWhZc Zi Va#& VcY ^c &.*& AdgZco Zi ' Va# Ñghi gV^hZY i]Z edhh^W^a^in d[ ^c_ZXi^c\ WdcZ bVggdl ^cigVkZcdjhan id gZhXjZ aZi]Vaan ^ggVY^" ViZY Vc^bVah# >c &.+&! I^aa VcY BX8jaadX] h]dlZY i]Vi heaZZc"YZg^kZY ]ZbVided^Zi^X hiZb XZaah =H8 lZgZ VWaZ id gZXdchi^ijiZ gVY^Vi^dc" ^cYjXZY ]ZbVided^Zi^X [V^ajgZ ^c b^XZ#( 6i i]Vi i^bZ! =H8h lZgZ WZa^ZkZY id/ =VkZ i]Z XVeVX^in [dg gVY^degdiZXi^dc 7Z VWaZ id YZkZade XZaah d[ Vaa ]ZbVided^Zi^X a^cZV\Zh =VkZ i]Z XVeVX^in [dg hZa["gZcZlVa Hddc ^i WZXVbZ XaZVg i]Vi =H8h lZgZ dcan V [gVXi^dc d[ ]ZbVided^Zi^X XZaah VcY i]Vi i]Zn XdjaY WZ ]VgkZhiZY [gdb i]Z heaZZc dg WdcZ bVggdl# =ZbVided^Zi^X XZaah lZgZ hjW[gVXi^dcViZY WVhZY dc h^oZ! YZch^in! VcY i]Z ZmegZhh^dc d[ XZgiV^c XZaa hjg[VXZ bVg`Zgh#) 6eegdm^bViZan & ^c '!%%% bVggdl XZaah %#%* ^h V =H8#* 89() ^h V igVchbZbWgVcZ XZaa hjg[VXZ h^Vad" bjX^c egZhZci dc & id ) d[ hiZb XZaah VcY i]Z^g egd\Zcn* VcY dc kVhXjaVg ZcYdi]Za^Va XZaah#+ BdgZ i]Vc .% d[ 89() XZaah ZmegZhh Vci^\Zch i]Vi VgZ X]VgVXiZg^hi^X d[ Xdbb^ibZci id i]Z anbe]d^Y! bnZad^Y! dg Zgni]gd^Y a^cZV\Zh! VcY! i]ZgZ[dgZ! VgZ cdi Xdch^YZgZY hiZb XZaah l^i] eaj" g^ediZci gZXdchi^iji^kZ ediZci^Va#, 8Zaah i]Vi ^c^" i^ViZ adc\"iZgb bVggdl XjaijgZh! Åadc\"iZgb XjaijgZ ^c^i^Vi^c\ XZaah PAI8">8RÆ! ZmegZhh 89()
VcY Yd cdi ZmegZhh a^cZV\Z Vci^\Zch hjX] Vh 89(! 89)! 89-! 89&%! 89&)! 89&*! 89&.! 89'%! 89((! 89(-! VcY 89,& 89() A^cà XZaah # I]Z =H8 ^h XjggZcian YZÑcZY VcY jhZY Vh 89() 9GÃA^cÃ# 8Zaa hjg[VXZ bdaZXjaZh i]Vi VeeZVg id WZ jhZ[ja ^c hZaZXi^c\ eg^b^i^kZ VcY bjai^ediZci^Va hiZb XZaah V\V^chi Xdbb^iiZY egd\Zc^idg XZaah ^cXajYZ 89(-! =A6 XaVhh >> 9G Vci^\Zch! VcY I]n"& 89l.% # Dcan & d[ i]Z 89() XZaah Yd cdi ZmegZhh i]Z 89(- Vci^\Zc#- I]ZhZ 89() 89(- XZaah VeeZVg Vh ]dbd\Zcdjh eg^b^i^kZ WaVhi XZaah l^i] hZa["gZcZl^c\ ediZci^Va#6 hj[ÑX^Zci cjbWZg d[ ZVgan VcY eajg^ediZci ]ZbVided^Zi^X egd\Zc^" idg XZaah l^i] ^cYZÑc^iZ hZa["gZcZlVa ediZci^Va ^h gZfj^gZY [dg XdbeaZiZ VcY XdchiVci ]ZbVided^" Zi^X Zc\gV[ibZci V[iZg bnZadVWaVi^kZ i]ZgVen# >c ]jbVch! i]Z b^c^bjb cjbWZg d[ ZVgan egd\Zc" ^idg XZaah i]Vi l^aa hjeean XdbeaZiZ VcY eZgbV" cZci Zc\gV[ibZci ]Vh cdi nZi WZZc YZiZgb^cZY#
Sources of Hematopoietic Stem Cells =ZbVided^Zi^X hiZb XZaah XdbZ [gdb WdcZ bVggdl! [ZiVa a^kZg XZaah! eZg^e]ZgVa WaddY hiZb XZaah E7H8 ! ZbWgndc^X hiZb XZaah! jbW^a^XVa XdgY WaddY! VcY ^c"k^igd ZmeVch^dc d[ hiZb XZaah#
Hematopoietic Stem Cells From Bone Marrow I]Z igVY^i^dcVa bZi]dY d[ hiZb XZaa igVcheaVciV" i^dc lVh id ^c[jhZ Vc jcbVc^ejaViZY! XdbeaZiZ b^mijgZ d[ bVggdl XZaah# 6 [V^gan aVg\Z Vbdjci d[ XZaah lVh ^c[jhZY/ Vbdjcih ^c i]Z gVc\Z d[ %#) id &#' t &%- bdcdcjXaZVg XZaah BC8 $`\ WdYn lZ^\]i VgZ gZfj^gZY [dg V hiZb XZaa igVcheaVci l^i] V XdbeaZiZ bVggdl XZaa hjheZch^dc#. 6 hiZb
143
144
XZaa igVcheaVci l^i] XdbeaZiZ bVggdl n^ZaYZY V adlZg gViZ d[ \gV[i [V^ajgZ VcY V hjWhiVci^Vaan adlZg gZaVehZ gViZ# I]Z bVggdl hjheZch^dc Xdch^hih d[ V XdbeaZm ]ZiZgd\ZcZ^in d[ XZaah! ^cXajY^c\ i]Z ZhhZci^Va edejaVi^dc d[ =H8h# 6h ^c i]Z XVhZ d[ Vc Vaad\Z" cZ^X igVcheaVci! i]Z ^cXgZVhZY Y^hh^b^aVg^in WZ" ilZZc Ydcdg VcY gZX^e^Zci ldjaY XVjhZ hZkZgZ h^YZ Z[[ZXih! hjX] Vh \gV[i"kZghjh"]dhi"Y^hZVhZ# 9ZeaZi^dc d[ i]Z egdedgi^dc d[ bVggdl I XZaah Xdch^YZgVWan gZYjXZh i]Z [gZfjZcXn VcY hZkZg^in d[ A"(! A"&! VcY >A"-#
;VXidgh 6[[ZXi^c\ N^ZaY I]ZgZ VgZ hZkZgVa [VXidgh i]Vi V[[ZXi egd\Zc" ^idg XZaa bdW^a^oVi^dc V[iZg bnZadhjeegZhh^kZ X]Zbdi]ZgVen/ &# EgZk^djh l^YZ"ÑZaY gVY^di]ZgVen '# I]Z hZkZg^in d[ bnZadhjeegZhh^dc VcY i]Z gViZ d[ aZj`dXniZ gZXdkZgn (# I]Z YjgVi^dc d[ egZk^djh X]Zbdi]ZgVen )# I]Z cjbWZg d[ XnXaZh d[ X]Zbdi]ZgVen *# I]Z ^ciZgkVa WZilZZc egZk^djh X]Zbdi]ZgVen VcY bdW^a^oVi^dc +# :medhjgZ id Ygj\h idm^X id hiZb XZaah! hjX] Vh 78CJ VcY bZae]VaVc ,# I]Z VYY^i^dc d[ c XjggZci egdidXdah! e]ZgZh^h ^h jhjVaan ^c^i^ViZY &% id &- YVnh V[iZg
145
i]Z VYb^c^higVi^dc d[ adl"id"bdYZgViZ"YdhZ X]Zbdi]ZgVen&+ dg l]Zc i]Z aZj`dXniZ Xdjci g^hZh VWdkZ & t &%.$A VcY Xdci^cjZh jci^a Vc VgW^igVgn iVg\Zi! hjX] Vh (! t &%- bdcdcjXaZVg XZaah$`\ 7L! ^h gZVX]ZY#&. =dlZkZg! Y^[[ZgZci L78 Xdjcih VgZ jhZY [dg XdaaZXi^dc Wn Y^[[ZgZci Vji]dgh# I]Z bV^c ^cY^XVidg d[ =H8h l^i] gZXdchi^ij" i^kZ ediZci^Va ^c Ve]ZgZh^h egdYjXih ^h 8;J"c^i^Va YViV l^i] E7H8 VaadigVch" eaVcih _jhi^[n [jgi]Zg ZkVajVi^dc# >c i]Z adc\" iZgb! ^i ^h a^`Zan i]Z E7E8h l^aa gZeaVXZ WdcZ bVggdl Vh i]Z egZ[ZggZY hdjgXZ d[ ]ZbVided^Zi^X XZaah [dg igVcheaVciVi^dc#
Hematopoietic Stem Cells From Embryonic Stem Cells :bWgndc^X hiZb XZaah :H8h VgZ idi^ediZci XZaah ^hdaViZY [gdb i]Z ^ccZg XZaa bVhh d[ WaVhidXnhih# I]Zn XVc \^kZ g^hZ id ZkZgn XZaa ^c i]Z bVijgZ dg\Vc^hb#(+ I]gdj\]dji YZkZadebZci [gdb
148
WaVhidXnhi id [Zijh! idi^ediZci hiZb XZaah adhh i]Z^g idi^ediZcXn! l]^X] ^h gZeaVXZY Wn V a^b^iZY egd" \gVbb^c\ idlVgY ZcYdYZgb! bZhdYZgb! dg ZXidYZgb! VcY Vi aVhi h^c\aZ"i^hhjZ heZX^ÑX^in# Idi^ediZci hiZb XZaah XVc egdYjXZ XZaah i]Vi dg^\" ^cViZ [gdb Vaa i]gZZ \Zgb aVnZgh Wji cdi i]dhZ [gdb i]Z ZmigVZbWgndc^X higjXijgZh0 i]jh! i]Zn XVccdi [dgb i]Z XdbeaZiZ ZbWgnd# HZkZgVa hdajWaZ [VXidgh Y^gZXi i]Z Y^[[ZgZci^V" i^dc d[ bdjhZ :H8h0 [dg ZmVbeaZ! >A"+ Y^gZXih XZaah id i]Z Zgni]gd^Y a^cZV\Z(,0 >A"( Y^gZXih XZaah id WZXdbZ bVXgde]V\Zh! bVhi XZaah! dg cZjigd" e]^ah(-0 VcY gZi^cd^X VX^Y ^cYjXZh cZjgdc [dg" bVi^dc#(. CdcZ d[ i]Z \gdli] [VXidgh Y^gZXih Y^[[ZgZci^Vi^dc eVgi^XjaVgan id dcZ XZaa ineZ# Bdhi d[ i]Z \gdli] [VXidgh VgZ i]dj\]i id ^c]^W^i Y^[" [ZgZci^Vi^dc d[ heZX^ÑX XZaa ineZh! VcY i]^h ^c]^W" ^idgn Z[[ZXi ^h bdgZ Zk^YZci i]Vc Vc ^cYjXi^dc Z[[ZXi# c"k^igd ZmeVch^dc d[ egd\Zc^idg VcY edhiegd" \Zc^idg XZaah l^aa gZYjXZ i]Z cZZY [dg aZj`Ve]Zg" Zh^h VcY bVn ZmeVcY Vc Ve]ZgZh^h egdYjXi l^i] V adl cjbWZg d[ egd\Zc^idg XZaah id egdk^YZ hj[" ÑX^Zci XZaah# BdaZXjaVg Zc\^cZZg^c\ d[ XZaah ^h V cZl iZX]" cdad\n i]Vi ^h gZXZ^k^c\ bjX] ViiZci^dc# HiZb XZaah VgZ ViigVXi^kZ iVg\Zih [dg bdaZXjaVg Zc\^cZZg^c\ WZXVjhZ i]Zn ]VkZ hdbZ YZh^gVWaZ egdeZgi^Zh#*( c ]jbVc VYjai WdcZ bVggdl! i]Zn Xdbeg^hZ WZilZZc & ^c &%!%%% VcY & ^c &%%!%%% dg bdgZ d[ idiVa WaddY XZaah# 6Yjai hiZb XZaah VgZ ^YZci^ÑZY Wn ild bV^c X]VgVXiZg^hi^Xh/ XZaajaVg bdge]dad\n VcY heZX^ÑX bVg`Zg egdiZ^ch a^c`^c\ i]Zb id i]Z i^hhjZ dg dg\Vc ^c l]^X] i]Zn Zm^hi# Jci^a gZXZcian! ]jbVc VYjai hiZb XZaah lZgZ i]dj\]i id WZ YZkZadebZc" iVaan Xdbb^iiZY VcY VWaZ id Y^[[ZgZci^ViZ dcan ^cid XZaa a^cZV\Zh [gdb i]Z i^hhjZ ^c l]^X] i]Zn gZh^YZY# =dlZkZg! V cjbWZg d[ ZmeZg^bZcih ]VkZ h]dlZY i]Vi VYjai hiZb XZaah ]VkZ i]Z VW^a^in id Y^[[ZgZci^ViZ ^cid bjai^eaZ XZaa ineZh! Vc VW^a" ^in iZgbZY ÅeaVhi^X^inÆ dg ÅigVchY^[[ZgZci^Vi^dcÆ ;^\jgZ &'"& # =jbVc 6H8 hijY^Zh ]VkZ h]dlc Y^[[ZgZci^Vi^dc ^cid XVgY^VX bjhXaZ XZaah+&0 h`ZaZ" iVa bndWaVhih+'0 cZjgdZXidYZgbVa a^cZh! ^cXajY^c\ WgV^c XZaah d[ Vaa ineZh cZjgdch! da^\dYZcYgd" XniZh! VcY VhigdXniZh +(0 ]ZeVidXniZh VcY X]daVc" \^dXniZh+)0 Ze^i]Za^Va XZaah d[ i]Z h`^c! a^kZg! Y^\Zhi^kZ Zhde]V\ZVa! ^ciZhi^cVa! \Vhig^X VcY gZhe^gVidgn hnhiZbh+*0 VcY ZcYdi]Za^Va XZaah#++ IgVchY^[[ZgZci^Vi^dc hijY^Zh VgZ WVhZY dc i]Z ^YZV i]Vi i]Z eVgi^XjaVg Zck^gdcbZci YZiZgb^cZh i]Z YZkZadebZci d[ i^hhjZ"heZX^ÑX hiZb XZaah# H^\cVah [gdb V Y^hiVci dg VY_VXZci i^hhjZ b^\]i YZaVn i]ZhZ a^b^i^c\ h^\cVah VcY \j^YZ i]Z XZaah id Y^[[ZgZci^ViZ ^cid eVgi^XjaVg i^hhjZh#+, 6cdi]Zg ^bedgiVci X]VgVXiZg^hi^X d[ 6H8h ^h i]Z^g XVeVW^a^in id b^\gViZ [gdb i]Z^g c^X]Zh id h^iZh d[ i^hhjZ \gdli] VcY gZeV^g# 7dcZ bVggdl" YZg^kZY hiZb XZaah b^\gViZ [gdb WdcZ bVggdl id Y^[[ZgZci^ViZ VcY ^ciZ\gViZ ^cid h`^c! ajc\! ^ciZh" i^cZ! VcY hidbVX] i^hhjZh#+*
The Role of Stem Cells in Plastic Surgery
151
i^hhjZh Yjg^c\ ]jbVc YZkZadebZci# I]Zn gZh^YZ ^c i]Z VYjai WdcZ bVggdl! [Vi! bjhXaZ! h`^c! VcY ^c di]Zg i^hhjZh VcY ^c i]Z [ZiVa WdcZ bVggdl VcY a^kZg#,& >c VYY^i^dc id ediZci^Va jhZh ^c i^hhjZ Zc\^cZZg^c\ VcY XZaa"WVhZY i]ZgVen!,'!,( BH8h XVc WZ igVchYjXZY l^i] Y^[[ZgZci gZigdk^gVa VcY di]Zg kZXidgh VcY XVc WZ jhZY [dg hdbVi^X \ZcZ i]ZgVe^Zh d[ hnhiZb^X dg adXVa Y^hZVhZh# 7dcZ bVggdl higdbV ^h i]Z bV_dg hdjgXZ [dg BH8h ^c ]jbVch# BVggdl [gdb i]Z ^a^VX XgZhi ^h i]dj\]i id WZ bdhi hj^iVWaZ [dg ^hdaVi^c\ BH8h#,) =dlZkZg! i]Z cjbWZg d[ WdcZ bVggdl BH8h hjWhiVci^Vaan YZXgZVhZh l^i] V\Z0 i]jh! VaiZgcV" i^kZ hdjgXZh VgZ cZXZhhVgn [dg Vjidad\djh VcY Vaad\Zc^X jhZ#,* JbW^a^XVa XdgY WaddY ^h V g^X] hdjgXZ d[ hiZb VcY egd\Zc^idg XZaah! VcY i]Z gZhjaih d[ ^bbjcde]Zcdine^c\ VcY bdge]d" ad\^XVa hijY^Zh d[ XjaijgZY BH8"a^`Z XZaah [gdb ]jbVc jbW^a^XVa XdgY kZ^c hj\\Zhi i]Vi i]ZhZ XZaah XadhZan gZhZbWaZ XjaijgZY BH8h dWiV^cZY [gdb WdcZ bVggdl VcY di]Zg hdjgXZh#,&
Figure 12-1. Plasticity of stem cells. Adult stem cells have the ability to differentiate into multiple cell types. (ESC: Embryonic stem cells from the inner surface of the blastocyst).
>c i]Zdgn! i]ZhZ XZaah XdjaY WZ Y^[[ZgZci^ViZY ^c i]Z aVWdgVidgn VcY igVcheaVciZY WVX` ^cid i]Z hVbZ ^cY^k^YjVa [dg i^hhjZ gZeV^g! i]jh WneVhh^c\ i]Z cZZY [dg ^bbjcdhjeegZhh^dc# =dlZkZg! [dg hdbZ hiZb XZaa ineZh! Y^[ÑXjai^Zh ^c VXXZhh^c\ i]Z c^X]Z VcY ^hdaVi^c\ i]Z XZaah! adl [gZfjZcXn! eddg \gdli] ^c XZaa XjaijgZ! VcY gZhig^XiZY a^cZV\Z ediZci^Va bVn bV`Z i]Z^g jhZ ^begVXi^XVa [dg i^hhjZ Zc\^cZZg^c\#+-
Mesenchymal Stem Cells I]Z VYjai WdcZ bVggdl higdbV XdciV^ch V hjW" edejaVi^dc d[ cdc]ZbVided^Zi^X XZaah `cdlc Vh ÅbZhZcX]nbVa hiZb XZaahÆ dg ÅbZhZcX]nbVa egd" \Zc^idg XZaahÆ BH8h # I]Zn VgZ bjai^ediZci egZ" Xjghdgh i]Vi XVc YZkZade Z^i]Zg ^c k^igd dg ^c k^kd ^cid Y^hi^cXi bZhZcX]nbVa i^hhjZh! ^cXajY^c\ WdcZ! XVgi^aV\Z! [Vi! iZcYdc! bjhXaZ! VcY bVggdl higdbV! l]^X] bV`Zh i]Zb Vc ViigVXi^kZ XZaa hdjgXZ [dg i^hhjZ Zc\^cZZg^c\ hijY^Zh#+. I]Zn gZe" gZhZci dcan VWdji %#%& id %#%%& d[ i]Z bVggdl XZaah0 ]dlZkZg! WZXVjhZ i]Zn VY]ZgZ id \aVhh VcY eaVhi^X! i]Zn XVc ZVh^an WZ hZeVgViZY [gdb =H8h#,% BZhZcX]nbVa hiZb XZaah VgZ egZhZci ^c hZkZgVa
Stem and Progenitor Cells in Allogeneic Transplantation Hda^Y dg\Vc igVcheaVciVi^dc ]Vh WZXdbZ Vc Vabdhi dgY^cVgn igZVibZci [dg ZcY"hiV\Z dg\Vc [V^ajgZ# =dlZkZg! YZhe^iZ ^begdkZY ^bbjcdhje" egZhh^kZ gZ\^bZch! XjggZci ^bbjcdhjeegZhh^kZ Ygj\h VgZ [Vg [gdb ^YZVa0 X]gdc^X \gV[i gZ_ZXi^dc XVccdi WZ egZkZciZY0 VcY adc\"iZgb hjgk^kVa d[ Vaa \gV[ih ^h a^b^iZY# 8]gdc^X gZ_ZXi^dc ^h i]Z bV_dg XVjhZ d[ aViZ Vaad\gV[i adhh#,' I]Z a^[Zadc\ jhZ d[ ^bbjcdhjeegZhh^kZ Ygj\h ^h VhhdX^ViZY l^i] cjbZgdjh Xdbea^XVi^dch! ^cXajY^c\ eddg ldjcY ]ZVa^c\! deedgijc^hi^X ^c[ZXi^dch! Ygj\"gZaViZY idm^X^i^Zh! h`^c bVa^\" cVcX^Zh! adl"\gVYZ anbe]dbVh XVaaZY edhi" igVcheaVci anbe]degda^[ZgVi^kZ Y^hdgYZgh ! VcY ZcY"dg\Vc idm^X^in! ^cXajY^c\ gZcVa [V^ajgZ#,( 8dbedh^iZ i^hhjZ Vaad\gV[ih 8I6h VgZ V Xdb" W^cVi^dc d[ h`^c! iZcYdch! cZgkZh! bjhXaZ! dg WdcZ VcY bVn WZ i]Z cZmi [gdci^Zg ^c gZXdchigjX" i^kZ hjg\Zgn# 6eean^c\ 8I6h ^c ]jbVch ^h hjeedhZY id WZ V bdgZ Y^[ÑXjai i]Vc dg\Vc igVch" eaVciVi^dc WZXVjhZ,+ hdbZ d[ i]ZhZ i^hhjZh! hjX] Vh h`^c! VgZ WZa^ZkZY id WZ bdgZ Vci^\Zc^X i]Vc Vcn XdbedcZci d[ Vc dg\Vc igVcheaVci VcY WZXVjhZ ^ciVXi WdcZ bVggdl XdjaY WZ V Xdbed" cZci d[ i]Z \gV[i! hjeean^c\ V XdchiVci hdjgXZ d[ Ydcdg Vci^\Zch V[iZg igVcheaVci# Egdadc\ZY 8I6 hjgk^kVa ^h VX]^ZkVWaZ ^c Vc^bVah jh^c\ ^bbjcdhjeegZhh^kZ Ygj\h0,, ]dl"
152
Tissue Surgery
a
b
Figure 12-2. a) Intraosseous transplantation of the cellular bone-marrow-derived CD90 stem and progenitor cells as a therapeutic approach to composite limb allograft transplantation. b) Limb allograft recipients at 7 days posttransplantation after treatment with CD90 stem and progenitor cells without immunosuppression.
101
102
FL1-Height
103
RT1H – FITC n
a
104
104
egdadc\ZY ]^cY a^bW hjgk^kVa d[ gVih jh^c\ XZaajaVg VcY XgjYZ WdcZ bVggdl YZa^kZgn VYb^c^hiZgZY ^cigVdhhZdjhan#>c V hijYn d[ ^cigVdh" hZdjh ^cigVi^W^Va XZaajaVg 89.% hiZb XZaah igVcheaVciVi^dc! lZ egdadc\ZY i]Z hjgk^kVa d[ i]Z Vaad\ZcZ^X gVi ]^cY a^bWh je id &* YVnh l^i]dji ^bbjcdhjeegZhh^kZ Ygj\ i]ZgVen ;^\jgZ &'"' #-& >c i]^h hijYn! dl XnidbZig^X VcVanh^h gZkZVaZY V ]^\]Zg Ydcdg"heZX^ÑX X]^bZ" g^hb aZkZa ^c i]Z eZg^e]ZgVa WaddY d[ i]Z gZX^e^" Zcih [gdb Vaad\gV[i igZVibZci \gdje hiZb VcY egd\Zc^idg XZaah ^c_ZXi^dc ;^\jgZ &'"(V l]Zc XdbeVgZY l^i] i]Z X]^bZg^hb aZkZa ^c i]Z eZg^e]" ZgVa WaddY d[ i]Z gZX^e^Zcih [gdb Vaad\gV[i Xdcigda \gdje cd hiZb VcY egd\Zc^idg XZaah igZVibZci ;^\jgZ &'"(W # Jh^c\ kVhXjaVg^oZY WdcZ bVggdl igVcheaVciV" i^dc ^c gVi ]^cY a^bW VcY gVi kVhXjaVg^oZY \gd^c h`^c$WdcZ bdYZah! lZ egdadc\ZY Vaad\gV[i hjg" k^kVa [dg bdgZ i]Vc ,%% YVnh jcYZg h]dgi"iZgb ,"YVn igZVibZci l^i] XnXadhedg^cZ 6 VcY
103
RT1Hn/CD4 ± 0.6%
102
FL2-Height
101
RT1Hn – 12.6%
100
100
CD4+ - PE
RT1Hn/CD4 ± 3.4%
FL2-Height 101 102 103 100
CD4+ - PE
104
ZkZg! jh^c\ i]ZhZ Ygj\h [dg cdc"a^[Z"i]gZViZc^c\ Xdbedh^iZ i^hhjZ gZXdchigjXi^dc bVn cdi WZ Xa^c" ^XVaan _jhi^ÑZY ^c ]jbVch# 8gZVi^c\ Ydcdg" heZX^ÑX Vaad\gV[i idaZgVcXZ ldjaY WZ i]Z dei^bVa VeegdVX] [dg VX]^Zk^c\ eZgbVcZci Vaad\gV[i hjgk^kVa Wn Vkd^Y^c\ i]Z cZZY [dg adc\"iZgb ^bbjcdhjeegZhh^kZ igZVibZci VcY egZhZgk^c\ cdgbVa gZX^e^Zci ^bbjcZ [jcXi^dc#,KVg^djh ViiZbeih ]VkZ WZZc bVYZ id l^i]YgVl WVhZa^cZ ^bbjcdhjeegZhh^dc gZ\^bZch Wn ^cYjX" ^c\ igVcheaVciVi^dc idaZgVcXZ# DcZ d[ i]Z bdhi Z[[ZXi^kZ VcY WZhi"hijY^ZY VeegdVX]Zh id ^cYjXZ igVcheaVciVi^dc idaZgVcXZ ^h WdcZ bVggdl igVcheaVciVi^dc 7BI ! l]^X] gZhjaih ^c =H8 X]^bZg^hb# 7dcZ bVggdl igVcheaVciVi^dc ^h i]dj\]i id egdk^YZ Ydcdg"heZX^ÑX! ^bbjcZ"ida" ZgVcXZ ^cYjXi^dc Wn ZhiVWa^h]^c\ b^mZY anbe]d^Y X]^bZg^hb#,. 7dcZ"bVggdl"igVcheaVciVi^dc" ^cYjXZY =H8 bVXgdX]^bZg^hb XVc ^cYjXZ Ydcdg"heZX^ÑX idaZgVcXZ id V kVg^Zin d[ Vaad\gV[ih ^c hdbZ ZmeZg^bZciVa bdYZah#-% LZ h^\c^ÑXVcian
100
RT1Hn/CD4 ± 3.4%
101
102
FL1-Height
103
RT1H – FITC n
b
104
Figure 12-3. Flow cytometric analysis revealed a higher donor specific chimerism level in the peripheral blood of the recipients from a) allograft treatment group (stem and progenitor cells injection) when compared with b) the chimerism level in the peripheral blood of the recipients from allograft control group (no stem and progenitor cells treatment).
The Role of Stem Cells in Plastic Surgery
153
Vae]V"WZiV B"C I XZaa gZXZeidg bdcdXadcVa Vci^WdY^Zh#-' IdaZgVcXZ ^cYjXi^dc ^c Vaad\ZcZ^X Xdbedh^iZ i^hhjZ igVcheaVciVi^dch jh^c\ hiZb XZaa YZa^kZgn ^h V egdb^h^c\ VeegdVX] VcY ldjaY Vaadl i]Z ]VcY! aVgncm! iZcYdch! cZgkZh! VcYÄZkZc i]Z [VXZÄid WZ igVcheaVciZY l^i]dji a^[Z"i]gZViZc" ^c\ ^bbjcdhjeegZhh^kZ i]ZgVe^Zh#
a^cZV\Z! VcY i]Z ^ciZ\gVi^dc d[ i]Z cZlan [dgbZY i^hhjZ l^i]^c i]Z ]dhi i^hhjZ! ^h cZZYZY [dg i]^h VeegdVX]#-. >i ^h edhh^WaZ id Z^i]Zg ^c_ZXi dg id ^bbdW^a^oZ i]ZhZ [VXidgh dcid V hXV[[daY WZ[dgZ ^beaVciVi^dc#
Stem and Progenitor Cells in Tissue Engineering
GZXdchigjXi^c\ aVg\Z WdcZ hZ\bZcih ^h hi^aa V X]VaaZc\Z# Cd VeegdVX] hj\\ZhiZY hd [Vg ]Vh egdkZc id WZ ^YZVa# 7dcZ \gV[i bViZg^Va! Zc\^" cZZgZY l^i] dhiZd\Zc^X Xdbb^iiZY XZaah Xdb" W^cZY l^i] Vc dhiZdXdcYjXi^kZ hXV[[daY! XdjaY WZ V egdb^h^c\ VeegdVX]# HdbZ Vji]dgh gZedgi \ddY gZhjaih ^c WdcZ \gV[i Zc\^cZZg^c\ jh^c\ bjai^" ediZci hiZb VcY egd\Zc^idg XZaah#.% >c bdhi d[ i]Z gZedgiZY bdYZah!V aVg\Z hZ\bZciVa YZ[ZXi XgZViZY ^c V adc\ WdcZ lVh ÑaaZY l^i] V Xna^cYZg d[ ed" gdjh W^dXZgVb^X XVggn^c\ Vjidad\djh! ^c"k^igd" ZmeVcYZY! dhiZd\Zc^X egd\Zc^idgh#L]Zc higdbVa dhiZdegd\Zc^idgh lZgZ adXVaan YZa^kZgZY l^i] i]Z W^dXZgVb^X hXV[[daYh! hiZb XZaah Z[ÑX^Zcian egd" bdiZY i]Z ]ZVa^c\ d[ WdcZ YZ[ZXih d[ Xg^i^XVa h^oZh# HZkZgVa Xa^c^XVa ig^Vah VgZ jcYZglVn id gZ\ZcZgViZ WdcZ ^c ]jbVch V[iZg i]ZhZ hjXXZhh[ja gZhjaih ^c Vc^bVah#.& CZl `cdlaZY\Z VWdji hiZb VcY egd\Zc^idg XZaah VcY i]Z^g [jcXi^dc ^c i^hhjZ gZ\ZcZgVi^dc egdk^YZh V higdc\ WVh^h [dg jh^c\ i]Zb id bVcV\Z XgVc^d[VX^Va YZ[ZXih#
I^hhjZ Zc\^cZZg^c\ ^h V gVe^Yan \gdl^c\ VgZV h^cXZ ^i WZXVbZ [ZVh^WaZ id ^hdaViZ a^k^c\! ]ZVai]n XZaah [gdb i]Z WdYn! ZmeVcY VcY XdbW^cZ i]Zb l^i] W^dXdbeVi^WaZ XVgg^Zg bViZg^Vah! VcY gZigVcheaVci i]Zb ^cid eVi^Zcih#+, GZXZcian! bjX] ViiZci^dc ]Vh WZZc Y^gZXiZY id bjai^ediZci^Va ZbWgndc^X! eZg^dhiZVa! VcY bZhZcX]nbVa hiZb XZaah# I]Z ediZci^Va id Y^[[ZgZci^ViZ hiZb XZaah ^cid kVg^djh i^hhjZh ^h ^bedgiVci [dg gZ\ZcZgVi^kZ bZY^X^cZ0 ]dlZkZg! lZ Yd cdi nZi jcYZghiVcY i]Z Y^[[ZgZci^Vi^dc egdXZhhZh VcY ]dl id Y^gZXi i]ZhZ XZaah id YZkZade ^cid i]Z YZh^gZY i^hhjZh# :Vgan hijY^Zh jh^c\ WdcZ bVggdl higdbVa XZaah [dg i^hhjZ gZeV^g [dXjhZY dc i]Z gZeV^g d[ WdcZ YZ[ZXih#-( HdbZ egZXa^c^XVa bdYZah! Vh lZaa Vh Xa^c^XVa Veea^XVi^dch! XjggZcian WZ^c\ ZmeadgZY ^cXajYZ `ZgVi^cdXniZh dg YZgbVa ÑWgdWaVhih [dg Wjgc VcY ldjcY gZeV^g!-) X]dcYgdXniZh [dg XVgi^aV\Z gZeV^g!-* bndXniZh [dg bndXVgY^Va gZeV^g!-+ gZi^cVa e^\bZci Ze^i]Za^Va XZaah [dg V\Z" gZaViZY bVXjaVg YZ\ZcZgVi^dc!-, VcY HX]lVcc XZaa igVcheaVciVi^dc id gZhidgZ bnZa^c ^c 8CH aZh^dch#-I^hhjZ Zc\^cZZg^c\ jh^c\ Vc ^cY^k^YjVaÈh dlc WdcZ bVggdl"YZg^kZY BH8h id [dgb ^beaVcih ^c k^igd ^h i^bZ Xdchjb^c\# Ild VaiZgcVi^kZh VgZ jcYZg ^ckZhi^\Vi^dc# I]Z Ñghi ^h id egZ[VWg^XViZ XdbeaZm i^hhjZh l^i] Vaad\Zc^X BH8h# 6aad\Zc^X BH8h VgZ jhZY id \ZcZgViZ i^hhjZ [dg igVcheaVci! l]^X] bVn WZ hidgZY VcY ^beaVciZY aViZg# >c aVg\Z"Vc^bVa bdYZah! Ydcdg"YZg^kZY BH8h egdYjXZY gZ\ZcZgVi^kZ i^hhjZ h^b^aVg id i]Vi egdYjXZY Wn Vjidad\djh BH8h#+, :Vgan hijY^Zh h]dlZY i]Vi Wdi] Vc^bVa VcY ]jbVc BH8h Yd cdi ZmegZhh Xdhi^bjaVidgn Vci^\Zch VcY! i]jh! hZZb id WZ ^bbjcd"eg^k^aZ\ZY#-. I]Z hZXdcY VaiZgcVi^kZ jcYZg ^ckZhi^\Vi^dc ^h Y^gZXi ^c"k^kd bVc^ejaVi^dc d[ i]Z BH8h# 6 hZi d[ [VXidgh! l]^X] egdbdiZh X]ZbdViigVXi^dc d[ i]Z BH8h! i]Z^g h^iZ"heZX^ÑX b^idi^X ZmeVch^dc! i]Z^g ^cYjXi^dc ^cid VcY i]gdj\] V heZX^ÑX
HiZb 8Zaah ^c 7dcZ :c\^cZZg^c\
HiZb 8Zaah ^c 8Vgi^aV\Z :c\^cZZg^c\ 6gi^ÑX^Va XVgi^aV\Z [VWg^XViZY ^c k^igd jh^c\ i^hhjZ Zc\^cZZg^c\ ]Vh WZZc Veea^ZY id i]Z gZeV^g VcY gZ\ZcZgVi^dc d[ YVbV\ZY XVgi^aV\Z#.' KVg^djh hijY^Zh ]VkZ h]dlc i]Vi WdcZ bVggdl"YZg^kZY BH8h VgZ bdgZ egdb^h^c\ XVcY^YViZh [dg XVg" i^aV\Z VcY WdcZ i^hhjZ Zc\^cZZg^c\ i]Vc VgZ eg^bVgn X]dcYgdXniZh dg dhiZdXniZh! l]^X] VgZ Y^[ÑXjai id XjaijgZ VcY ZmeVcY#.( Egd\Zc^idg XZaah egda^[ZgViZ VcY Y^[[ZgZci^ViZ ^cid X]dcYgdXniZh V[iZg ^beaVciVi^dc ^cid i]Z YZ[ZXi! l]^X] ^h ^bedgiVci [dg gZ\ZcZgVi^c\ Zcdj\] XVgi^aV\Z id Ñaa i]Z YZ[ZXih# Dc i]Z di]Zg ]VcY! XdbeaZiZ gZh" idgVi^dc d[ XVgi^aV\Z ^h cdi edhh^WaZ hd [Vg! VcY i]Z cZlan [dgbZY XVgi^aV\Z l^i]^c i]Z hjggdjcY" ^c\ ]dhi i^hhjZ ^h gZfj^gZY id Y^[[ZgZci^ViZ ^cid [jaan bVijgZY X]dcYgdXniZh# I]Z XdbW^cVi^dc d[ BH8"WVhZY XZaa i]ZgVen VcY \ZcZ igVch[Zg d[ hZaZXiZY Y^[[ZgZci^Vi^c\ Xnid`^cZh bVn ]Zae ^c i]^h X]VaaZc\Z#+,
154
HiZb 8Zaah ^c LdjcY =ZVa^c\ :cYdi]Za^Va egd\Zc^idg XZaa i]ZgVen VcY i]ZgV" eZji^X kVhXjad\ZcZh^h ]VkZ kVg^djh ^bea^XVi^dch [dg eaVhi^X hjg\Zgn# GZXZcian! ZcYdi]Za^Va egd" \Zc^idg XZaa igVcheaVciVi^dc ]Vh WZZc jhZY id ^cXgZVhZ cZdkVhXjaVg^oVi^dc ^c i]Z egdWaZb VgZVh#.) 6[iZg ^c_ZXi^dc ^cid i]Z hnhiZb^X X^gXjaV" i^dc! ZcYdi]Za^Va egd\Zc^idg XZaah gZedgiZYan hZaZXi^kZan adXVa^oZY id i]Z ^hX]Zb^X i^hhjZh0 i]jh! i]ZhZ ZcYdi]Za^Va egd\Zc^idg XZaah bVn WZ ^bedg" iVci ^c hVakV\^c\ ^hX]Zb^X Veh# I]ZgZ[dgZ! i]Zg" VeZji^X kVhXjad\ZcZh^h ]Vh i]Z ediZci^Va id ^begdkZ Ve hjgk^kVa! ^begdkZ ldjcY ]ZVa^c\! VXXZaZgViZ i^hhjZ ZmeVch^dc! VcY [VX^a^iViZ i^hhjZ Zc\^cZZg^c\# :cYdi]Za^Va hiZb VcY egd\Zc^idg XZaah bVn WZ jhZ[ja [dg igZVi^c\ Xdbea^XViZY ldjcYh! hjX] Vh i]dhZ ^c eVi^Zcih l^i] Y^VWZiZh dg [gdb Wjgch! gZeaVX^c\ XZaah gVi]Zg i]Vc \gdli] [VXidgh VadcZ#
HiZb 8Zaah ^c IZcYdc :c\^cZZg^c\ >c kVg^djh ZmeZg^bZcih ÑWgdWaVhih dg WdcZ bVggdl"YZg^kZY bZhZcX]nbVa hiZb XZaah lZgZ ^beaVciZY ^cid ineZ > XdaaV\Zc \Zah id ^begdkZ iZcYdc VcY a^\VbZci gZeV^g#.* 6ai]dj\] W^d" X]Zb^XVa VcY ]^hidad\^XVa VcVanhZh gZkZVaZY ^b" egdkZY i^hhjZ VgX]^iZXijgZ! bdgZ gZhZVgX] ^h cZZYZY id ^begdkZ i]Z W^dbZX]Vc^XVa egdeZgi^Zh VcY [jcXi^dcVa^in d[ i]Z ^c_jgZY iZcYdc VcY id VhhjgZ XdbeaZiZ ]ZVa^c\ d[ i]Z iZcYdc VcY a^\V" bZci YZ[ZXih# I]Z jhZ d[ Zmd\Zcdjh \gdli] [VXidgh bVn ^begdkZ i]Z hjXXZhh d[ iZcYdc VcY a^\VbZci i^hhjZ Zc\^cZZg^c\#
The Future of Stem Cells 6YkVcXZh ^c \ZcZ"bdY^[n^c\ iZX]c^fjZh bVn Vaadl hiZb XZaah id WZ bdY^ÑZY Yjg^c\ i]Z^g Zm k^kd ZmeVch^dc0 i]jh! ^i bVn WZ edhh^WaZ id bV`Z V eVi^ZciÈh dlc hiZb XZaah ZkZc WZiiZg# ;dg ZmVbeaZ! ^c V \ZcZi^X Y^hZVhZ! gZeaVX^c\ V b^hh^c\ \ZcZ VXi^k^in dg h^aZcX^c\ V YZ[ZXi^kZ \ZcZ VXi^k" ^in bVn WZXdbZ edhh^WaZ# BdgZdkZg! Vjidad\djh hiZb VcY egd\Zc^idg XZaah ]VgkZhiZY [gdb Vc ^cY^k^YjVa VcY jhZY [dg hZa["i^hhjZ gZeV^g ^h ^bbjcdad\^XVaan ^YZVa# =dlZkZg! YZhe^iZ i]Z \gZVi ediZci^Va i]Vi hiZb VcY egd\Zc^idg XZaah d[[Zg [dg igZVi^c\ bVcn Y^hZVhZh VcY YZ[ZXih! bVcn X]VaaZc\Zh gZbV^c/
Tissue Surgery
&# 6aa hiZb XZaah ]VkZ id WZ Y^[[ZgZci^ViZY WZ[dgZ igVcheaVciVi^dc XVc WZ hjXXZhh[ja0 di]Zg" l^hZ! i]Z egZhZcXZ d[ ZkZc V h^c\aZ jcY^[[ZgZci^" ViZY hiZb XZaa i]Vi gZiV^ch i]Z XVeVW^a^in id Xdci^cjdjhan gZegdYjXZ bVn gZhjai ^c ijbdg [dgbVi^dc# '# L]Zc Y^[[ZgZci^ViZY hiZb XZaah VgZ cdi gZX" d\c^oZY Vh ÅhZa[ Æ Wn i]Z gZX^e^ZciÈh ^bbjcZ hnhiZb V[iZg Vc Vaad\ZcZ^X igVcheaVciVi^dc! Vc ^bbjcdad\^X gZhedchZ bVn egZkZci ^cXdgedgV" i^dc d[ i]Z Ydcdg XZaah# >c i]^h XVhZ! hiZb XZaah XdjaY WZ ^cY^k^YjVa^oZY l^i] \ZcZi^X bdY^ÑXV" i^dch! dg ^bbjcdhjeegZhh^kZ i]ZgVen XdjaY WZ jhZY ^c Xdc_jcXi^dc l^i] i]Z igVcheaVciZY XZaah# =Vk^c\ V aVg\Z edda d[ hiZb VcY egd\Zc^idg XZaah l^i] Y^[[ZgZci bV_dg ]^hidXdbeVi^W^a^in XdbeaZm WVX`\gdjcYh VcY jh^c\ i]Z bdhi Veegdeg^ViZ dcZh [dg i]Z igVcheaVciVi^dc XdjaY WZ Vcdi]Zg hdaji^dc# (# 6ai]dj\] hdbZ bZhZcX]nbVa a^cZV\Z" ^cYjX^c\ V\Zcih VgZ `cdlc! i]Z bdaZXjaVg YZiV^ah gZ\jaVi^c\ i]Z a^cZV\Z YZkZadebZci cZZY id WZ ^ckZhi^\ViZY# I]Z \ZcdineZ d[ ZVX] ^cY^k^YjVa YZiZgb^cZh i]Z hZXgZi^dc d[ \gdli] [VXidgh VcY Xnid`^cZh#-. >c VYY^i^dc! BH8 XjaijgZh h]dl Ydcdg"heZX^ÑX aZkZah d[ Xnid`^cZh# I]jh! i^hhjZ Zc\^cZZg^c\ Veea^XVi^dch bVn cZXZhh^iViZ eVi^Zci" heZX^ÑX YdhZh d[ a^cZV\Z"hi^bjaVi^c\ VcY a^cZV\Z" gZ\jaVi^c\ [VXidgh#-. )# HdbZ di]Zg egdWaZbh ^c hiZb XZaa i]ZgVen ^cXajYZ YZiZgb^c^c\ ]dl! l]ZgZ! VcY l]Zc id ^cigdYjXZ hiZb XZaa YZg^kVi^kZh ^cid V gZX^e^Zci0 l]Zi]Zg i]Z ediZci^Va d[ i]ZhZ XZaah l^aa X]Vc\Z dkZg i^bZ0 l]Zi]Zg higjXijgVa hXV[[daYh VgZ gZfj^gZY id \Zi i]Z YZh^gZY [dgb0 l]Zi]Zg i]Z ^beg^ci^c\ hiVijh d[ XZaah YZg^kZY [gdb ZbWgn" dc^X hiZb XZaah Y^[[Zgh [gdb VYjai XZaah0 VcY ]dl id Z[ÑX^Zcian Y^[[ZgZci^ViZ dg \ZcZi^XVaan iV^adg :H8h ^cid i]Z fjVci^in cZZYZY [dg igVcheaVciV" i^dc WZ[dgZ i]Z gZX^e^ZciÈh Y^hZVhZ ]Vh egd\gZhhZY idd [Vg#.+
References &# ?VXdWhdc AD! BVg`h :@! GdWhdc B?! Zi Va# :[[ZXi d[ heaZZc egdiZXi^dc dc bdgiVa^in [daadl^c\ m"^ggVY^Vi^dc# ? AVW 8a^c BZY# &.).0()/&*(-Ã&*)(# '# AdgZco :! Je]d[[ 9! GZ^Y IG! Zi Va# BdY^ÑXVi^dc d[ ^ggVY^Vi^dc ^c_jgn ^c b^XZ VcY \j^cZV e^\h Wn WdcZ bVggdl ^c_ZXi^dch# ? CVia 8VcXZg >chi# &.*&0&'/&.,Ã '%&# (# I^aa ?:! BX8jaadX] :6# 6 Y^gZXi bZVhjgZbZci d[ i]Z gVY^Vi^dc hZch^i^k^in d[ cdgbVa bdjhZ WdcZ bVggdl XZaah# GVY^Vi GZh# &.+&0&)/'&(Ã'''#
The Role of Stem Cells in Plastic Surgery )# Hb^i] AA! =Z^b[ZaY H# 8adcVa VcVanh^h d[ ]ZbVided^Zi^X hiZb"XZaa Y^[[ZgZci^Vi^dc ^c k^kd# EgdX CVia 6XVY HX^ JH6# &..&0--/',--Ã',.'# *# JX]^YV C! LZ^hhbVc >A# HZVgX]^c\ [dg ]ZbVided^Zi^X hiZb XZaah/ Zk^YZcXZ i]Vi I]n"&#& adl A^cÃHXV"& XZaah VgZ i]Z dcan hiZb XZaah ^c 8*,7A$@V"I]n"&#& WdcZ bVggdl# ? :me BZY# &..'0&,*/&,*Ã&-)# +# 6cYgZlh G9# EgZXjghdgh d[ Xdadcn"[dgb^c\ XZaah ^c ]jbVch XVc WZ Y^hi^c\j^h]ZY [gdb Xdadcn"[dgb^c\ XZaah Wn ZmegZhh^dc d[ i]Z 89(( VcY 89() Vci^\Zch VcY a^\]i hXViiZg egdeZgi^Zh# 7addY# &.-+0+,/-)'Ã-*-# ,# 7Vjb]jZiZg H! 9nWYVa C! @naZ 8! Zi Va# @! HiZlVgi ;B! 9ZVXdc 9B! Zi Va# 9ZiZXi^dc d[ V ]jbVc 8;8 l^i] V ]^\] egda^[ZgVi^kZ ediZci^Va# 7addY# &.-.0,)/+%.Ã+&'# &+# 9Zb^gZg I! 7jX`cZg 89! 7Zch^c\Zg L># Dei^b^oVi^dc d[ eZg^e]ZgVa WaddY hiZb XZaa bdW^a^oVi^dc# HiZb 8Zaah# &..+0&) & /&%+Ã&&+# &,# =d]Vjh H! ! Zi Va# IgVcheaVciVi^dc d[ Zcg^X]ZY 89()"edh^i^kZ Vjidad\djh bVggdl ^cid WgZVhi XVcXZg eVi^Zcih [daadl^c\ ]^\]"YdhZ X]Zbdi]Zg" Ven/ ^c jZcXZ d[ 89()"edh^i^kZ eZg^e]ZgVa"WaddY egd" \Zc^idgh VcY \gdli] [VXidgh dc Zc\gV[ibZci# ? 8a^c DcXda# &..)0&'/'-Ã(+#
155 '&# @VlVcd N! IV`VjZ N! LViVcVWZ I! HV^id H! 6WZ I! =^gVd 6! Zi Va# :[[ZXih d[ egd\Zc^idg XZaa YdhZ VcY egZaZj`V" e]ZgZh^h jhZ d[ ]jbVc gZXdbW^cVci \gVcjadXniZ Xdadcn"hi^bjaVi^c\ [VXidg dc i]Z gZXdkZgn d[ ]ZbVid" ed^Zh^h V[iZg WaddY hiZb XZaa Vjid\gV[i^c\ ^c X]^aYgZc# :me =ZbVida# &..(0'&/&%(Ã&%-# ''# HidgZ` ?! ! BVadcZn 9! LZVkZg 8=! 6eeZaWVjb ;G! GdlaZn H! 9Zb^gZg I! HVcYZgh ?! Zi Va# IgVcheaVciVi^dc d[ Vaad\ZcZ^X eZg^e]ZgVa WaddY hiZb XZaah bdW^a^oZY Wn gZXdbW^cVci ]jbVc \gVcjadXniZ Xdadcn"hi^bjaVi^c\ [VXidg# 7addY# &..*0-*/&+**Ã&+*-# ')# HX]b^io C! 9gZ\Zg E! Hjiidge B! Gd]lZYYZg :7! =V[ZgaVX] I! Ad[ Zg =! Zi Va# Eg^bVgn igVcheaVciVi^dc d[ Vaad\ZcZ^X eZg^e]ZgVa WaddY egd\Zc^idg XZaah bdW^a^oZY Wn Ña\gVhi^b \gVcjadXniZ Xdadcn"hi^bjaVi^c\ [VXidg # 7addY# &..*0-*/&+++Ã&+,'# '*# BV_da^cd >! HV\a^d ! Eg^XZ I=! 9VaZ 98! Zi Va# I]Z Z[[ZXih d[ YV^an gZXdbW^cVci ]jbVc \gVcjadXniZ Xdadcn" hi^bjaVi^c\ [VXidg VYb^c^higVi^dc dc cdgbVa \gVcjad" XniZ Ydcdgh jcYZg\d^c\ aZj`Ve]ZgZh^h# 7addY# &..(0 -&/&--(Ã&---# '.# @dgWa^c\ B! 8]Vbea^c G# EZg^e]ZgVa WaddY egd\Zc^idg XZaa igVcheaVciVi^dc/ V gZeaVXZbZci [dg bVggdl Vjid" dg Vaad\gV[ih# HiZb 8Zaah# &..+0&)/&-*Ã&.*# (%# @dgWa^c\ B! ;a^ZYcZg IB! E ^Z\Zg =# 8daaZXi^dc d[ aVg\Z fjVciVi^Zh d[ \gVcjadXniZ bVXgde]V\Z egd\Zc^idg XZaah 8;JX ^c bVc Wn bZVch d[ Xdci^cjdjh" dl aZj`Ve]Zg" Zh^h# HXVcY ? =VZbVida# &.-%0')/''Ã'-# (&# 8]Vd C?! HX]g^WZg ?G! 9 bdjhZ bdYZa d[ h`^c gZ_ZXi^dc# IgVch" eaVciVi^dc# &...0+,/&*.%Ã&*..# (-# L^aZh BK! @ZaaZg
Tissue Surgery *)# 9jcWVg 8:! :bbdch GK# onX`^ 9! DoZg @# >cigVdhhZjh ^c_ZXi^dc d[ i]Z Ydcdg"YZg^kZY WdcZ bVggdl hiZb VcY egd\Zc^idg XZaah ^cXgZVhZ Ydcdg"heZX^ÑX X]^" bZg^hb VcY ZmiZcYh Xdbedh^iZ i^hhjZ Vaad\gV[i hjgk^kVa# IgVcheaVci EgdX# >c egZhh# -'# H^Zb^dcdl B ! >onX`^ 9B! ^Za^ch`^ B# 9dcdg"heZX^ÑX idaZgVcXZ ^c [jaan bV_dg ]^hidXdbeVi^W^a^in bV_dg ]^h" idXdbeVi^W^a^in XdbeaZm"b^hbViX]ZY a^bW Vaad\gV[i igVcheaVcih jcYZg Vc Vci^"Vae]VWZiV I"XZaa gZXZeidg bdcdXadcVa Vci^WdYn VcY XnXadhedg^cZ 6 egdidXda# IgVcheaVciVi^dc# '%%(0,+ &' /&++'Ã&++-# -(# IV`V\^ @! Jg^hi BG# I]Z gdaZ d[ WdcZ bVggdl ^c WdcZ bdge]d\ZcZi^X egdiZ^c"^cYjXZY gZeV^g d[ [ZbdgVa bVhh^kZ Y^Ve]nhZVa YZ[ZXih# 8a^c Dgi]de GZaVi GZh# &.-'0 &,& /'')Ã'(&# -)# 8Vgh^c =! 6^cVjY E! AZ 7ZkZg =! G^kZh ?! AV`]Za 6! HiZe]VcVoo^ ?! Zi Va# 8jaijgZY Ze^i]Za^Va Vjid\gV[ih ^c
157
-*#
-+#
-,#
--# -.# .%#
.&#
.'# .(#
.)# .*#
.+#
ZmiZch^kZ Wjgc XdkZgV\Z d[ hZkZgZan igVjbVi^oZY eVi^Zcih/ V ÑkZ nZVg h^c\aZ"XZciZg ZmeZg^ZcXZ l^i] (% eVi^Zcih# 7jgch# '%%%0'+/(,.Ã(-,# EZiZghdc A! B^cVh I! 7g^iiWZg\ B! A^cYV]a 6# IgZVibZci d[ dhiZdX]dcYg^i^h Y^hhZXVch d[ i]Z `cZZ l^i] Vjidad\djh X]dcYgdXniZ igVcheaVciVi^dc/ gZhjaih Vi ild id iZc nZVgh# ? 7dcZ ?d^ci Hjg\ 6b# '%%(0-*"6 hjeea '/&,Ã')# IgVc C! A^ N! 7ZgigVcY H! 7Vc\gVio H! 8VgiZVjm ?E! Hidaio ?;! Zi Va# 6jidad\djh XZaa igVcheaVciVi^dc VcY XVgY^VX i^hhjZ Zc\^cZZg^c\/ ediZci^Va Veea^XVi^dch ^c ]ZVgi [V^ajgZ# 7^dg]Zdad\n# '%%(0)%/)&&Ã)&*# 7^cYZg H! HidaWV J! @gZWh >! @ZaacZg A! ?V]c 8! ;Z^X]i^c\Zg =! Zi Va# IgVcheaVciVi^dc d[ Vjidad\djh gZi^cVa e^\bZci Ze^i]Za^jb ^c ZnZh l^i] [dkZVa cZdkVhXjaVg^oVi^dc gZhjai^c\ [gdb V\Z"gZaViZY bVXjaVg YZ\ZcZgVi^dc/ V e^adi hijYn# 6b ? De]i]Vabda# '%%'0&((/'&*Ã''*# 8]Zc\ 7! 8]Zc # ;VWg^XVi^c\ Vjidad\djh i^hhjZ id Zc\^cZZg Vgi^ÑX^Va cZgkZ# B^Xgdhjg\Zgn# '%%'0''/&((Ã &(,# 8VeaVc 6>! 7gjYZg HE# BZhZcX]nbVa hiZb XZaah/ Wj^aY^c\ WadX`h [dg bdaZXjaVg bZY^X^cZ ^c i]Z '&hi XZcijgn# IgZcYh Bda BZY# '%%&0,/'*.Ã'+)# @dc :! BjgV\a^V 6! 8dgh^ 6! Zi Va# 6jidad\djh WdcZ bVggdl higdbVa XZaah adVYZY dcid edgdjh ]nYgdmnVeV" i^iZ XZgVb^X VXXZaZgViZ WdcZ gZeV^g ^c Xg^i^XVa"h^oZ YZ[ZXih d[ h]ZZe adc\ WdcZh# ? 7^dbZY BViZg GZh# '%%%0)./('-Ã((,# WgV]^b G:! Lj N! Ndjc\ Gc k^igd X]VgVXiZg^oVi^dc d[ bZhZcX]n" bVa hiZb XZaa"hZZYZY XdaaV\Zc hXV[[daYh [dg iZcYdc gZeV^g/ Z[[ZXih d[ ^c^i^Va hZZY^c\ YZch^in dc XdcigVXi^dc `^cZi^Xh# ? 7^dbZY BViZg GZh# '%%%0*&/'((Ã')%# E[ZcYaZg @8! @VlVhZ :# I]Z ediZci^Va d[ hiZb XZaah# DWhiZi 9H# HZZ =jbVc ^bbjcdYZÑX^ZcXn k^gjh$ Vjid^bbjcZ YZÑX^ZcXn hncYgdbZ 6aZbijojbVW! &( 6aad\Zc^X igVcheaVciVi^dc Xa^c^XVa Veea^XVi^dch! && VWYdb^cVa lVaa! &( WdcZ bVggdl! &*' [VXZ! &'%Ã&'( ÒZmdg iZcYdc! &)! *(Ã*) ]VcY! && `cZZ! &( aVgcnm! &* a^bW! &* bjhXaZ! &* cZgkZh! &) idc\jZ! &* d[ eZg^e]ZgVa WaddY hiZb"XZaa! &), egd\Zc^idg XZaah ^c! &*&Ã&*( hiZb XZaah ^c! &*&Ã&*( 6bejiVi^dc Y^VWZiZh VcY! [gZZ ÒVe VcY! '! ) 6ciZg^dg ^ciZgdhhZjh hncYgdbZ! ,, 6ciZg^dg a^eZXidbn! &%6ci^"89( Vci^WdYn D@I( ! &.! &'6ci^i]nbdXnaZ \adWja^c 6I:6E ÒVe! .%! .& 9ZcZgkVi^dc! +&Ã+, d[ ZaWdl! +& d[ `cZZ! +& d[ h]djaYZg! +(Ã+* d[ h^cjh iVgh^! +&Ã+( iZbedgdbVcY^WjaVg _d^ci! +*Ã +,
159
160
9ZcZgkVi^dc Xdc # lg^hi! +& 9ZgbV\gV[i! &(9^VWZiZh a^bW hVakV\Z VcY! cZgkZ YZXdbegZhh^dc ^c! *+Ã*9>:6E# HZZ 9ZZe ^c[Zg^dg Ze^\Vhig^X VgiZgn ÒVe 9^\^iVa ÒZm^dc hnhiZb kVhXjaVg^oZY! dc jacVg eZY^XaZ! *(Ã*) 9B86# HZZ 9dghVa bZiVXVgeVa VgiZgn ÒVe 9dghVa bZiVXVgeVa VgiZgn ÒVe 9B86 ! (&Ã('! (( 9dghVa bZiVXVgeVa ÒVe! (&Ã('! (( 9dlcijgc XdgcZgh d[ bdji]! &%*Ã &%,
:bWgndc^X hiZb XZaah :H8h ! ]ZbVided^Zi^X hiZb XZaah [gdb! &),Ã&):cYdhXde^X Wgdla^[i! &%&Ã&%( :cYdhXde^X ]VcY VcY cZgkZ hjg\Zgn! ,&Ã,' :H8# HZZ :bWgndc^X hiZb XZaah :miZchdg XdbeVgibZciVa VgiZg^Zh! (* ; ;VXZ! YZ[dgb^in d[! XdckZci^dcVa gZXdchigjXi^kZ bZi]dYh [dg! &&.Ã&'% ;VXZ! gZ_jckZcVi^dc d[! &%&Ã&%, Wgdla^[i! &%&Ã&%( X]ZZ`a^[i! &%) a^ea^[i! &%* b^Y[VXZ XdggZXi^dc! &%(Ã&%) eZg^dgVa! &%)Ã&%, ;VX^Va Vaad\gV[i igVcheaVciVi^dc! &'%Ã&'Veea^XVW^a^in d[! &'& Zi]^XVa Xdch^YZgVi^dch ^c! &(% [ZVh^W^a^in d[! &'& Ñghi ^chi^iji^dcVa gZk^Zl WdVgY VeegdkVa [dg! &(% [jaa"[VX^Va"hXVae! &''Ã&'(! &')! &'* ]Zb^[VX^Va! &''! &'(! &'*! &'+ ]jbVc! &'*Ã&'^bbjcdhjeegZhh^kZ higViZ\^Zh ^c! &'*Ã&(% ZmeZg^bZciVa! &'-Ã&'.
Index
egdidXdah! &'.Ã&(% ehnX]dad\^XVa Xdch^YZgVi^dch ^c! &(% hdX^Va Xdch^YZgVi^dch ^c! &(% ;6@# HZZ ;dXVa VY]Zh^dc `^cVhZ ;VhX^dXjiVcZdjh ÒVeh! + ;a^oVgdk iZX]c^fjZ! )Ã*! +Ã, >bbjcdhjeegZhh^kZ Ygj\h! [dg Xdbedh^iZ i^hhjZ Vaad\gV[ih! &+Ã'%! &'Vci^egda^[ZgVi^kZ V\Zcih! &. XVaX^cZjg^c ^c]^W^idgh! &Xdgi^XdhiZgd^Yh! &. ^cYjXi^dc egdidXdah! &+ ^ciZgaZj`^c"' gZXZeidg VciV\dc^hih! &. anbe]dXniZ YZeaZi^c\ V\Zcih! &.Ã'% bV^ciZcVcXZ egdidXdah! &gZ_ZXi^dc! &h^gda^bjh gVeVbnX^c ! &-Ã&. >chja^c \gdli] [VXidg >ciZgXdbeVgibZciVa hjegVgZi^cVXjaVg VgiZg^Zh! (* >ciZgaZj`^c"' >A"' gZXZeidg VciV\dc^hih! &. >ciZgaZj`^ch! &(. >cig^ch^X ÒVeh XaVhh^ÑXVi^dc d[! '*Ã(+ Vm^Va"eViiZgc eZg[jh^dc! ', Xgdhh"Ñc\Zg! '*Ã'+ YdghVa bZiVXVgeVa! (&Ã('! (( [gZZ Å`^iZ!Æ ((! () ]ZiZgdY^\^iVa ^haVcY! '-! '.
161
]ZiZgdY^\^iVa gZkZghZY cZjgdkVhXjaVg ^haVcY! ']dbdY^\^iVa ^haVcY! ']nedi]ZcVg! (%Ã(& gVcYdb"eViiZgc! ', i]ZcVg! '.Ã(% igVY^i^dcVa! '* kZcdjh! (( YZh^\c eg^cX^eaZh d[! ')Ã'* >E# HZZ >hX]Zb^X egZXdcY^i^dc^c\ >hX]Zb^V gZeZg[jh^dc ^c_jgn! .)Ã.YZaVn egdXZYjgZ! .) c^igdjh dm^YZ! gdaZ d[! .,Ã.egZXaVbe^c\! .* gZbdiZ ^hX]Zb^X egZXdcY^i^dc^c\! .*Ã., >hX]Zb^X egZXdcY^i^dc^c\ >E ! d[ ÒVeh! ]^hidgn d[! .(Ã.) >haVcY eZY^XaZ ÒVeh! ' ? ?d^ci YZcZgkVi^dc! +&Ã+* ZaWdl VcY `cZZ! +& h]djaYZg! +(Ã+* h^cjh iVgh^! +&Ã+( iZbedgdbVcY^WjaVg _d^ci! +*Ã+, lg^hi! +& @ @^ZcWX`Èh Y^hZVhZ! kVhXjaVg^oZY WdcZ \gV[ih VcY! ((Ã(+ @^iZ ÒVe# HZZ =^a\Zc[ZaYi ÒVe @cZZ igVcheaVcih! &(Ã&) A AVgncm igVcheaVcih! &* A^bW hVakV\Z! 'Ã, Y^VWZiZh VcY! A^ea^[i! &%* <jaa"l^c\ ZmX^h^dc! &%* A^eZXidbn! VciZg^dg! &%-Ã&&&! &&' A^edYnhigde]n! XdggZXi^dc d[! &&(Ã&&* A^iiaZg ÒVe! '* A^kZg XZaah! [ZiVa! ]ZbVided^Zi^X hiZb XZaah [gdb! &)) Anbe]dXniZ"YZeaZi^c\ V\Zcih! &.Ã'% B B68H"a^[i# HZZ B^c^bVa VXXZhh XgVc^Va hjheZch^dc
B6E@# HZZ B^id\Zc"VXi^kViZY egdiZ^c `^cVhZ BXAZVc! 9dcVaY! .) BZhZcX]nbVa hiZb XZaah BH8h ! VYkVcXZh ^c! &*& BZi]naegZYc^hdadcZ! &(! &* B^XgdkVXjaV! )(Ã)) B^Y[VXZ! XdggZXi^dc d[! &%(Ã&%) B^c^bVa VXXZhh XgVc^Va hjheZch^dc B68H"a^[i ! &%) B^id\Zc"VXi^kViZY egdiZ^c `^cVhZ B6E@ ! &(. BB;# HZZ BnXde]ZcdaViZ bd[Zi^a Bdji]! Ydlcijgc XdgcZgh d[! &%*Ã &%, BH8h# HZZ BZhZcX]nbVa hiZb XZaah Bjai^b^XgdkVXjaVg XdaaV\Zcdjh VWhdgW^c\ hnhiZb BK86H ! ))! )* V[iZg igVjbV! )* VcVidb^XVa XdcXajh^dch d[! )+Ã ),! )\adWVa^in! ))Ã)+ eVi]dad\n! )* e]nh^dad\^XVa XdcXajh^dch d[! ). hjg\^XVa XdcXajh^dch d[! ).Ã*' ^c k^kd dWhZgkVi^dch! )&Ã)' BjgdbdcVW"89(! &* BjhXaZ igVcheaVcih! &* BK86H# HZZ Bjai^b^XgdkVXjaVg XdaaV\Zcdjh VWhdgW^c\ hnhiZb BnXde]ZcdaViZ bd[Zi^a BB; ! &'! &(! &*! &+! &.! &'BndZaZXig^X egdhi]Zh^h! '! ( C CZX`! XZgk^Xd[VX^Va g]ni^YZXidbn! &%,Ã&&& Va^eZXidbn VcY eaVinhbVeaVhin! &%CZgkZh Vaad\gV[ih! *-Ã*. XdcYj^ih! *.Ã+& YZXdbegZhh^dc! **Ã*^c Y^VWZiZh! *+Ã*ZcYdhXde^X hjg\Zgn! ,&Ã,'! ,+Ã -( \gV[ih! *gZXdchigjXi^dc d[! *ineZh d[ XVaXVcZVa! *, aViZgVa eaVciVg! *,
162
CZgkZh Xdc # bZY^Va eaVciVg! +, bZY^Vc! ,'Ã,, edhiZg^dg ^ciZgdhhZjh! -'Ã-) edhiZg^dg i^W^Va! *, gVY^XVa! -) jacVg! ,,Ã-' CZgkZ igVcheaVcih! &)Ã&* CZjgdijWZ! *.Ã+& D D@I(# HZZ 6ci^"89( Vci^WdYn DcZ"hiV\Z gZXdchigjXi^dc! )! + Dgi]deaVhi^X hjg\Zgn! Xdhi Z[[ZXi^kZcZhh d[! ' DhiZdbnZa^i^h VcVidb^X ineZh d[! , e]nh^dad\^X XaVhhZh d[! , igZVibZci d[! ,ÃE EVgViZcYdc! ). EVgVjbW^a^XVa eZg[dgVidg EJE ÒVe# HZZ 9ZZe ^c[Zg^dg Ze^\Vhig^X VgiZgn ÒVe EVghdcV\Z"IjgcZg hncYgdbZ! ,, EVgi^Va _d^ci YZcZgkVi^dc! +&Ã++! +, E7H8# HZZ EZg^e]ZgVa WaddY hiZb"XZaa E9:6E! .% A8;6E"ja! -EJE! .% H"
