Orthoplastic Reconstruction of the Arms and Legs 9
Conclusion
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References
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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
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
Clinical Application of Composite Tissue Allografts 13
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Clinical Application of Composite Tissue Allografts 15
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16 Tissue Surgery
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Immunosuppressive Drugs
Currently Used in Composite
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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
X
X
X
X
X
X
XX
X
Antigen
Presenting
Cell
Glucocorticoids
OKT3
TCR-CD3
Engagement to APC
CsA/Tacrolimus
Sirolimus
IL-2 receptor expression
on T cells
IL-2 binding
to IL-2 receptor
T cell
G1 phase
T cell
G0 phase
IL-2 release
IL-2 receptor signal
IL-1, IL-6 release
ATG
T cell depletion
T cell
M phase
T cell
G2 phase
T cell
S phase
T cell
differentiation
MMF/AZA MMF/AZA
Sirolimus
T cell proliferation
Basiliximab
Daclizumab
Figure 2-1. Mechanisms and sites of action of different immunosuppressive drugs
18 Tissue Surgery
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References
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Clinical Application of Composite Tissue Allografts 21
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3
Advanced Concepts in Vascularized Tissue
Transfer in the Hand
Holger Engel and Günter Germann
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23
24 Tissue Surgery
Principles of Intrinsic Flap Design
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digital
arteries
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artery
to
index
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artery
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artery
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compartmental
collateral branches
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of anterior
interosseous
artery
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artery
radiocarpal arch
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intercarpal arch
Dorsal
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metacarpal arch
Dorsal
metacarpal
arteries
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palmar
arch
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intercarpal
arch
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artery
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interosseous
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artery
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branch of
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Figure 3-1. (a) Arterial anatomy of the palm. (b) Dorsum of the hand.
Advanced Concepts in Vascularized Tissue Transfer in the Hand 25
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Design of the flap
Qualities of
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Size of the flap, etc.
Personal profile
Donor site considerations
Reconstruction with
local means possible
Ye s N o
Figure 3-2. Algorithm for analyzing a defect before designing any flap.
2
Palmar digital
nerve
Digital
nerve
Digitally
based
C-ring flap
Proximally based
C-ring flap
Figure 3-3. Steps in elevating the C-ring digital flap.
26 Tissue Surgery
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a
b
c
d
e
Intact
skin
island
Defect
Reversed flap covering
recipient defect and
reconstructing avulsed
eponychial defect
Thin full-
thickness
skin graft
Originally elevated
thin full-thickness
skin flap covering
donor defect
Elevated thin
full-thickness
skin flap
Elevated full-thickness
subcutaneous flap with
intact skin island
No tie-over dressing on
skin graft covering
reversed surface
of reverse cross
finger flap
Tie-over dressing on donor
area skin coverage
Figure 3-4. Reversed cross-finger flap.
3