Tissue Surgery - part 2 docx

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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. 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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. 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Introduction Venous and Arterial Anatomy of the Hand and Fingers 23 24 Tissue Surgery Radial artery to index Common palmar digital arteries... the C-ring digital flap 26 Tissue Surgery Reverse Cross-Finger Flaps Reversed flap covering recipient defect and reconstructing avulsed eponychial defect Intact skin island Defect Thin fullthickness skin graft Elevated thin full-thickness skin flap a c Elevated full-thickness subcutaneous flap with intact skin island Originally elevated thin full-thickness skin flap covering donor defect b No tie-over... of tissue needed in the flap Size of the flap, etc Cross-Finger Flaps 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 Classification of Intrinsic Flaps Proximally based C-ring flap Palmar digital nerve Digitally based C-ring flap Traditional Flaps Digital nerve Figure 3-3 ... Dorsal radiocarpal arch Ulnar artery Radial artery Retinacular and compartmental collateral branches Radial artery a b Figure 3-1 (a) Arterial anatomy of the palm (b) Dorsum of the hand Principles of Intrinsic Flap Design Posterior division of anterior interosseous artery Advanced Concepts in Vascularized Tissue Transfer in the Hand 25 Size Location What is missing? Reconstruction with local means possible... Originally elevated thin full-thickness skin flap covering donor defect b No tie-over dressing on skin graft covering reversed surface of reverse cross finger flap d e Tie-over dressing on donor area skin coverage Figure 3-4 Reversed cross-finger flap.3 . Unilateral June 20 02 Brussels (Belgium) Unilateral November 20 02 Milan (Italy) Unilateral February 20 03 Innsbruck (Austria) Bilateral May 20 03 Lyon (France) Bilateral Total 19 patients 25 hands Table 2- 1 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. 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 aZkZa