Basic Principles of Skin, Bone, Cartilage,

Tendon and Nerve Grafts

Dr. Mohamed Mamdouh Abdelhalim, MD

Lecturer of Plastic, Burn and Maxillofacial surgery,
Ain Shams University
 Causes of Tissue Deficiency

 Trauma.
 Surgical Resection.
 Congenital Anomalies.

Reconstruction

Tissue transplantation
 Reconstruction

Forms and Structure

Safety Function
 Balance of Reconstruction

Donor Site Defect Reconstruction

Reconstruction Ladder
 Nomenclatures

 Graft
 Vascularized Graft.
 Autograft.
 Isograft.
 Allograft (homograft)
 Xenograft.
 Tissue Transplantation in Plastic
Surgery
 Skin.
 Bone.
 Cartilage.
 Nerve.
 Tendon.
 Fat.
 Fascia.
 Blood Vessel.
Skin Graft
Types of Skin Grafts
Harvesting of STSG
Meshed Graft
FTSG
 Skin Graft Contraction
 Contraction (Skin)
– Primary contraction
– Secondary Contraction
 Contracture (Joint)
 Skin Graft Donor Site

1. Full thickness 2. Split thickness

 no epidermal elements, thus:
donor site must be closed.
– It must be from an area has
skin redundancy.
 harvested with a scalpel.
 FTSG more primary
contraction than STSG
 Common donor sites are: back
of ear, arm, supraclavicular,  Common donor sites are:
groin, lower abdomen… etc
 Leaves adnexal remnants such
as hair follicles and sweat
glands, foci from which
epidermal cells: can
repopulate and resurface the
donor site.
 It is usually harvested with
humpy knife or electric
dermatome (0.15 inches).
 STSG more Secondary
contraction than FTSG
thighs, scalp, back, arms, legs
…etc.
 Graft Survival (Take)
3 phases:

 Plasmatic imbibition (<3 days)  nutrients from

bed by diffusion.

 Inosculation (3-5 days)  cut ends of the vessels

connect with bed vessels.

 Angiogenesis (> 5 days)  new vessels into graft

 Graft Take Failure
By four main mechanisms:

 Poor wound bed

– tendons or bone
– radiation
 Sheer (Tie-over ?)
 Hematoma/seroma
 Infection
– (Bacterial level > 105 are clinically significant)
 Free Composite Graft

 Contains two or more tissue (dermis-cartilage,

dermofat, skin-muscle.

 Need well-vascularized bed.

 Poor re-vascularization and graft taking.

 Composite Grafts in Plastic Surgery

 Nose (from ear or nasal septum)

- Nasal ala
- Columella
- Lateral nasal wall
- Nasal roof and lining reconstruction
- Septal perforation
 Ear
- Helical rim
- Chonca
- Tragus
 Nipple (opposite nipple)
Bone Transplantation
 Bone Transplantation
 Both bone autograft and allografts are used for bone defect
reconstruction
 Bone xenografts are not used nowadays because of sequester
of all viable osteocyte
 Cortical or cancellous bone graft
 Revascularization of cortical grafts may take a few months
 Revascularization of cancellous bone grafts are more rapid
 Healing of vascularized bone grafts are better. Particularly
suitable in a field after trauma, chronic scarring, or prior
radiation. Biomechanically are superior to non-vascularized
grafts
 Bone Graft Donor Areas
 Cranium (cortical)
 Thorax (split rib grafts)
 İliac ( good quality cortical and cancellous bone
source)
 Tibia (cancellous )
 Others
- Distal radius, proximal ulna (hand surgery)
- Fibula (esp. vascularized flap)
- Metatarsal
Bone Transplantation

 Osteoinduction.

 Osteoconduction.
 Osteoinduction

 Induce new bone Formation

 Osteoinduction implies the recruitment of
immature cells and the stimulation of these
cells to develop into osteoblasts
 Osteoconduction

 Guide-Line effect
 Osteoconduction is the ability of bone-
forming cells in the grafting area to move
across a scaffold and slowly replace it with
new bone over time. Osteoconductive
materials serve as a scaffold onto which
bone cells (osteoblasts and osteocytes) can
attach, migrate, grow and/or divide.
Cartilage Grafts
 Cartilage Grafts

 Cartilage has no intrinsic blood supply.

 The use of cartilage autografts is widespread and includes

nasal, auricular, craniofacial skeleton, and joint reconstruction

 Cartilage is weakly antigenic

Donor Areas for Cartilage Graft
 Choose according to aim
- Costal cartilage(7,8 & 9. ribs)
Ear reconstruction
Nasal dorsal and alar area reconstruction
- Ear cartilage:
Lower eyelid support
Nipple-areola reconstruction
Orbital floor reconstruction
Tempromandibular joint repair
- Nasal septal cartilage
Aesthetic Rhinoplasty and Nasal reconstruction
Tendon Grafts
 Tendon Grafts

 Only autograft
 Only if primary or delayed primary repair is
not feasible
 Contraindicated if there is stiff joints,
adherent extensor tendons, and inadequate
skin cover
Donor Areas for Tendon Graft
 Palmaris longus
(usually)
 Plantaris
 Middle 3 toes extensor
tendons
Nerve Grafts
 Nerve Healing

 To achieve full recovery, the nerve must

undergo three main processes: Wallerian
degeneration (the clearing process of the
distal stump), axonal regeneration, and end-
organ re-innervation.
 Nerve Grafts
 Nerve grafts are segments of nerve or nerve-like
material that are used to reconstruct damaged nerves
in the body.

 When there is a nerve gap that cannot be repaired

with sutures alone, a graft is needed.

 The “graft” serves as a bridge for a reconstructed

nerve to grow across
 Nerve Grafts
 The nerve graft acts as a biologic conduit for
the regenerating axons.

 Vascularized nerve grafts are theoretically

advantageous particularly in scarred beds.

 Other “conduits” used as nerve grafts have

included autologous vein, silicone tube
seeded with Schwann cells.
Donor Areas for Nerve Graft

 Sural N. (most common)

 Sapheneous
 Lateral femoral cutaneous nerve
 Medial antebrachial cutaneous nerve
 Lateral antebrachial cutaneous nerve
 Dorsal antebrachial cutaneous nerve
 Superficial radial nerve
Thank You