Cutaneous Transplantation

Overview

The first microvascular cutaneous transplant, a groin flap, was performed in 1972 by Daniel and Taylor. Over the next decade, the free groin flap gained acceptance and was used as an alternative to pedicle flaps. The free groin flap was only used when a pedicle flap was impractical, this policy being due to certain difficulties with the former. The superficial circumflex iliac vessels are small, and although the deep circumflex iliac vessels are larger (Taylor et al. 1979, Sec. 3.7), the arterial anatomy is variable and dissection is tedious and difficult compared with other cutaneous transplants. In addition, the flap is often too bulky and sometimes hair-bearing.

In recent years, a great many different microvascular cutaneous transplants with larger, more reliable vessels have been introduced. Because these flaps do not have the disadvantages of the groin flap, their benefits relative to pedicle flaps can be fully realized. The free groin flap has come to be used relatively rarely, and in its place, other flaps are now used to provide skin cover.

When compared with pedicle flaps, these microvascular procedures have the following advantages:

• 1. They permit immediate or early elevation of the extremity — a feature that is particularly important after major trauma, where there is a tendency toward edema and joint stiffness

• 2. They permit immediate or early joint mobilization and hand therapy

• 3. A transplant can be chosen that is non-hair-bearing and has a size and thickness that match the recipient problem

• 4. A composite flap can be used to treat loss of both soft tissue and bone or joint. Occasionally, tendons can also be included in the transplant

• 5. The procedure can be performed in a single operation (Freedlander et al. 1986)

Cutaneous transplantation is indicated when cosmetic considerations make cutaneous cover desirable. Such situations are encountered less often when treating extremity defects than when reconstructing the face. More frequently, cutaneous transplants are performed for the accompanying subcutaneous fatty tissue they provide, particularly when subsequent tendon reconstruction will be needed. Cutaneous transplants are also indicated when sensation in the transplant is important (Fig. 2–1). As discussed in Chapter 1, muscle transplantation is preferable where infection has been a problem, for extremely large wounds, to fill dead space, or to provide cover where shearing movement of the transplant on the deeper structures is a problem.