Goals and Basic Concepts
The main goal of reconstructive surgery is to correct functional disorders or anatomical changes. The need for such interventions arises when defects of various origins are present.
Tissue defects can be:
- Congenital — developmental anomalies formed intrauterinely.
- Acquired — developing during life due to mechanical damage (trauma), destructive diseases, or as a result of radical surgical interventions (e.g., after tumor removal).
Historical Stages of Development
Plastic surgery has a rich history that began long before the advent of modern medicine. Key milestones in its development include:
- Ancient India: Nose plastic surgery using a pedicled skin flap was first described. The tissue was carved directly on the patient's forehead. This technique went down in history as the "Indian method".
- Italy (15th century): An alternative option for nose reconstruction was developed — the so-called "Italian method", in which the defect was closed with skin taken from the shoulder area.
- Russian Empire (1852): Outstanding surgeon N.I. Pirogov proposed the method of osteoplastic foot amputation. This innovation made it possible to form a stump with excellent weight-bearing function, which is critical for further rehabilitation.
- Early 20th century (1907): Surgeons Ts. Roux and P.A. Herzen performed antethoracic esophagoplasty using a loop of the small intestine.
- USSR (1917): V.P. Filatov developed a unique technique for transplanting a migrating skin pedicle (known as the "Filatov pedicle"), which revolutionized the closure of extensive defects.
Currently, an independent, high-tech branch has separated from plastic surgery — organ and tissue transplantation. It solves specific tasks: refining surgical transplantation techniques, developing methods for preserving harvested organs, and overcoming tissue incompatibility barriers.
Classification by Transplant Source
Depending on who the tissue donor is for the recipient, several types of transplantation are distinguished:
- Autogenic transplantation (autoplasty): The donor and recipient are the same person. This is the most widely used method in practice, as it completely eliminates the rejection reaction.
- Isogenic transplantation: Transplantation between genetically identical organisms — monozygotic twins.
- Syngeneic transplantation: The donor is a first-degree relative (e.g., parents or children).
- Allogeneic transplantation (alloplasty): Transplantation of organs or tissues from human to human. Belonging to the same biological species does not eliminate the need for immunosuppression to prevent rejection.
- Xenogeneic transplantation (xenoplasty): The donor and recipient belong to different biological species (animal-to-human transplantation). Due to severe immune reactions, it is extremely used rarely. An exception is tissues devoid of pronounced antigenic properties: biological heart valves, vascular xenografts, and embryonic tissues.
- Prosthetics (explantation): The introduction of non-living materials into the body — synthetic polymers, metals, and other inorganic substances. This approach is exceptionally widespread in modern surgical practice.
Types of Tissue Plastic Surgery
Depending on the degree to which connection with the donor site is preserved, two fundamentally different approaches to tissue mobilization are distinguished.
1. Free plastic surgery (free transplantation) This method is characterized by complete physical and vascular separation of the transplant from the recipient bed. It includes:
- Proper transplantation — the transfer of tissues to another area of the body or to another organism.
- Replantation — the return of lost tissues strictly to their former anatomical site (e.g., engraftment of a torn-off scalp, fingers, or limb fragments).
- Implantation — the transfer of cells or tissues into a nearby anatomical region.
2. Non-free (pedicled) plastic surgery Also known as flap surgery with a feeding pedicle. The essence of the method is that the carved tissue flap retains a connection with its original bed (via a skin-subcutaneous or vascular pedicle). This connection ensures autonomous blood supply to the mobilized fragment until it fully grows into the new site and receives nutrition from the surrounding tissues of the recipient zone.
Briefly: answers to topical questions
What types of skin grafts are distinguished depending on the thickness of the harvested layer?
Depending on the thickness of the harvested layer, split-thickness and full-thickness skin grafts are distinguished.
- Split-thickness graft — harvested at 3/4 of the skin thickness, includes the epidermis and part of the dermis. It does not wrinkle, and its blood supply is restored on the 2nd–4th day.
- Full-thickness graft — provides better shape restoration and is more resistant to external influences, but often becomes pigmented, which reduces the cosmetic outcome.
What clinical and morphological types of allograft rejection are distinguished by the time of onset?
The sources directly describe the accelerated rejection reaction (second set), which occurs during re-transplantation of tissues with the same antigens. It is characterized by the absence of a prolonged vascularization phase, a shortened induction phase of the immune response, and rapid vascular thrombosis when an organ is transplanted on a vascular pedicle. Acute graft rejection is also mentioned, but the sources do not provide a complete classification of the clinical and morphological types of rejection by time of onset.
What methods of organ and tissue preservation are used in transplantology?
The following methods of organ and tissue preservation are used in transplantology:
- Chilled solutions — placement in solutions with antiseptics and antibiotics, recipient plasma or blood; liquid nutrient media are also used for bone grafts.
- Freezing — rapid freezing at temperatures from −183 to −273 °C followed by storage at −25…−30 °C.
- Lyophilization — freezing followed by vacuum drying; used, in particular, for bones.
- Chemical preservation — immersion in paraffin or aldehyde solutions, such as formaldehyde and glutaraldehyde.
- Boiling and maceration are also used for bone grafts.
Which types of flap transfer belong to local tissue plastic surgery according to Limberg?
Local tissue plastic surgery according to A.A. Limberg's method (Z-plasty) includes transposition, or the counter-transfer of triangular flaps.
- Counter-exchange — formed skin-fat flaps mutually exchange places, moving them toward each other, one over the other.
The apex of the first triangular flap moves into the base angle of the second, and the apex of the second into the base angle of the first. This ensures an even distribution of scar tissues and elongation in a given direction.
For quick memorization of the classification by source, use the chain from the closest to the artificial: Auto (myself) → Iso (copy/twin) → Syn (family blood) → Allo (another person) → Xen (animal) → Ex (non-living prosthesis).
Class and exam questions
What does the term "replantation" mean and when is it used?
Replantation is a type of free grafting in which affected or traumatically severed tissues (for example, a torn-off limb or scalp) are reattached to their original anatomical site.
Why is xenotransplantation used to a limited extent?
Tissue transplantation from animals to humans is fraught with insurmountable problems of tissue incompatibility and acute rejection. Therefore, the clinic uses only specially processed xenografts (e.g., biological heart valves).
What is the main advantage of autotransplantation?
In autoplasty, the donor and recipient are the same person, which guarantees absolute tissue compatibility and a complete absence of the risk of immune rejection of the transplanted flap.
Why is a "vascular pedicle" needed in pedicled grafting?
The feeding pedicle maintains the connection of the carved flap with the maternal bed, providing it with an adequate blood supply until it finally grows into the new area.
What else to study on this topic
- Mechanisms of Tissue Compatibility and Immunological Rejection
- Methods of Preservation of Donor Organs and Tissues
- Technique of creating a Filatov pedicle flap
- Blood supply characteristics of pedicled skin flaps
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Other topics in "CHAPTER 17. PLASTIC (RECONSTRUCTIVE) SURGERY"
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