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Skin Grafts in Cutaneous Oncology* Enxertia De Pele Em Oncologia

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Skin Grafts in Cutaneous Oncology* Enxertia De Pele Em Oncologia RevABDV81N5.qxd 07.11.06 17:07 Page 465 465 Artigo de Revisão Enxertia de pele em oncologia cutânea* Skin grafts in cutaneous oncology* José Anselmo Lofêgo Filho1 Paula Dadalti2 Diogo Cotrim de Souza3 Paulo Roberto Cotrim de Souza4 Marcos Aurélio Leiros da Silva5 Cristina Maeda Takiya6 Resumo: Em oncologia cutânea depara-se freqüentemente com situações em que a confec- ção de um enxerto é uma boa alternativa para o fechamento do defeito cirúrgico. Conhecer aspectos referentes à integração e contração dos enxertos é fundamental para que os cirur- giões dermatológicos procedam de maneira a não contrariar princípios básicos do trans- plante de pele. Os autores fazem uma revisão da classificação e fisiologia dos enxertos de pele, acrescendo considerações cirúrgicas determinantes para o sucesso do procedimento. Palavras-chave: Neoplasias cutâneas; Transplante de pele; Transplante homólogo Abstract: In cutaneous oncology, there are many situations in which skin grafts could be a good alternative for closing surgical defect. Dermatological surgeons should have enough knowledge about graft integration and contraction in order to not contradict the basic prin- ciples of skin transplantation. The authors review skin graft classification and physiology and make some surgical considerations on successful procedures. Keywords: Skin neoplasms; Skin transplantation; Transplantation, homologous INTRODUÇÃO Enxerto é parte de um tecido vivo transplanta- tológica. São simples quando apresentam um único do de um lugar para outro no mesmo organismo ou tipo de tecido e compostos quando constituídos de em organismos distintos.1 Contudo, a utilização da dois ou mais tipos de tecidos. Em oncologia cutânea, terminologia enxerto para designar uma modalidade um enxerto composto é usado quando o defeito cirúrgica, apesar de errônea, tornou-se coloquial. Os cirúrgico a ser coberto requer mais suporte interno, termos apropriados para designar o procedimento como acontece nas reconstruções situadas na orelha cirúrgico que envolve a transferência da pele de uma e asa nasal.2,3 Nessas reconstruções tridimensionais a região para outra, mediante perda total de continui- cartilagem auricular é incluída em busca de melhorar dade com sua área doadora, são enxertia ou trans- a performance do enxerto. plante de pele. Segundo sua fonte de obtenção, podemos Existem quatro diferentes classificações para classificá-los também em autólogos, quando doador os enxertos. Uma, baseia-se em sua constituição his- e receptor são o mesmo indivíduo; alógenos ou * Trabalho promovido pelo Curso de Pós-Graduação em Dermatologia da UFRJ e realizado no Hospital Geral de Bonsucesso, Hospital de Força Aérea do Galeão e Universidade Federal do Rio de Janeiro - (UFRJ) - Rio de Janeiro (RJ), Brasil. • Conflito de interesse declarado: Nenhum. 1 Mestre em Dermatologia pela Universidade Federal do Rio de Janeiro (UFRJ) - Rio de Janeiro (RJ), Brasil. 2 Doutora em Dermatologia da Universidade Federal do Rio de Janeiro (UFRJ). Médica do Hospital Central Aristarcho Pessoa - Rio de Janeiro (RJ), Brasil. 3 Acadêmico do 3º Ano de Medicina da Universidade Gama Filho, Rio de Janeiro (RJ), Brasil. 4 Chefe da Clínica Dermatológica do Hospital Geral de Bonsucesso - Rio de Janeiro (RJ), Brasil. 5 Chefe do Serviço de Cirurgia Plástica do Hospital de Força Aérea do Galeão - Rio de Janeiro (RJ), Brasil. 6 Professora Adjunta do Departamento de Histologia da Universidade Federal do Rio de Janeiro (UFRJ) - Rio de Janeiro (RJ), Brasil. ©2006 by Anais Brasileiros de Dermatologia An Bras Dermatol. 2006;(5):465-72. RevABDV81N5.qxd 07.11.06 17:07 Page 466 466 Lofêgo JA, Dadalti P, Cotrim D, Cotrim PR, Leiros da Silva MA, Takyia CM. homólogos, quando doador e receptor são diferen- mosam comunicando a superfície do enxerto à do tes, porém da mesma espécie; e heterólogos ou leito receptor (fase inosculatória). O enxerto encon- xenoenxertos, quando doador e receptor são de tra-se ainda fragilmente fixado, podendo estar cianó- espécies diferentes.4,5 Na prática dermatológica os tico. O surgimento e proliferação de novos vasos é autoenxertos são os mais empregados já que os que irá garantir a sobrevivência da pele transplanta- aloenxertos e xenoenxertos são temporários e fun- da. Fluxo sangüíneo verdadeiro ocorre do quinto ao cionam apenas como curativos biológicos estimulan- sétimo dia do pós-operatório (fase de revasculariza- do a cicatrização.6,7 ção).4,5 Uma terceira classificação tem por base a espes- Yamagushi e cols.10 estudaram o envolvimento sura. Os enxertos de espessura total contêm epider- de uma quarta fase, a fase de ativação dos queratinó- me e toda a derme incluindo as estruturas anexiais. citos, na cicatrização dos enxertos cutâneos. Num Os enxertos de espessura parcial contêm epiderme e estudo experimental a ativação dos queratinócitos foi apenas parte da derme. Estes últimos se subdividem avaliada pelo marcador de proliferação celular Ki-67, em finos, médios e grossos, de acordo com a quanti- e a adesão da célula matriz, pela marcação de B1 inte- dade de derme existente no enxerto8 (Tabela 1). grina. A expressão de Ki-67 e B1 integrina foi observa- Por fim, os enxertos cutâneos podem ser classi- da apenas nos enxertos de espessura parcial. Por ficados de acordo como foram processados. Após a serem mais delgados, eles permitem melhor embebi- coleta, os enxertos podem ser processados de modo ção na fase inicial da enxertia e necessitam de menor a expandi-los, o que pode ser feito na sala de cirurgia, suprimento sangüíneo a partir do leito subjacente. por meio de um expansor que os transforma numa No entanto a ocorrência da ativação dos queratinóci- malha ampliada semelhante a uma rede (mesh tos pode vir a ser uma razão adicional que facilita a grafts), ou em laboratório, mediante cultura de célu- integração dos enxertos de espessura parcial quando las. Os queratinócitos cultivados podem ser de ori- comparados aos de espessura total. gem autóloga ou alogênica e podem ser aplicados O preparo da solução anestésica utilizada nas associados ou não a um substituto dérmico.9 enxertias de pele costuma incluir substância vaso- A situação clínica determina o tipo de enxerto constritora em concentrações variadas. Solução anes- a ser colocado. tésica contendo epinefrina em solução 1: 100.000 parece aumentar levemente o risco de complicações, FISIOLOGIA DOS AUTOENXERTOS como perda parcial do enxerto e necrose epidérmi- A cicatrização da ferida após a enxertia de pele ca, na primeira semana da enxertia.11 O risco/benefí- se processa por dois eventos característicos e seqüen- cio relacionado ao uso da epinefrina deve ser avalia- ciais. do em cada situação clínica isoladamente. Em cir- cunstâncias cujo leito receptor esteja com sua vascu- A - Integração larização comprometida ou em tabagistas, o uso iso- As características clínicas da integração dos lado de lidocaína parece ser vantajoso no que se refe- enxertos autólogos são aderência, perfusão e viabili- re à integração. dade do segmento de pele transferido, o que depen- de obrigatoriamente de sua vascularização. B - Contração Nas primeiras 24 horas após a enxertia o plas- Uma vez integrado a seu leito receptor e a par- ma que transuda da área receptora é absorvido pelo tir do 10º dia, a ação de miofibroblastos e proteínas enxerto formando uma malha de fibrina que serve contráteis promove a contração do enxerto. Esse para sua fixação e nutrição (fase de embebição plas- processo pode durar seis meses e traz prejuízo cos- mática). Na seqüência, pequenos capilares se anasto- mético. Os miofibroblastos (fibroblastos do tecido de granulação) desenvolvem características bioquímicas e ultra-estruturais de células musculares lisas, incluin- TABELA 1: Tabela de mensuração da espessura dos do a presença de microfilamentos e a expressão da enxertos parciais. Tais referências são úteis na regu- actina alfa de músculo liso. Atribui-se a eles, além da lagem do dermátomo antes da coleta do enxerto função retrátil na contração das feridas, a síntese de 12 Espessura do Polegadas Milímetros componentes da matriz extracelular. Os enxertos enxerto podem afetar a população de miofibroblastos na feri- da, dependendo do percentual de derme enxertado. Fino 0,005 a 0,012 0,12 a 0,30 Em enxertos espessos os miofibroblastos encontram- Médio 0,012 a 0,018 0,30 a 0,45 se em menor proporção, sendo a retração tecidual Grosso 0,018 a 0,030 0,45 a 0,76 menos evidente.13 An Bras Dermatol. 2006;(5):465-72. RevABDV81N5.qxd 07.11.06 17:07 Page 467 Enxertia de pele em oncologia cutânea 467 A fibronectina, elemento de sustentação da seca e se desprende espontaneamente de seu sítio de matriz provisória, desaparece quando as fibras coláge- implantação.1 O uso de aloenxertos de pele cadavéri- nas já se encontram orientadas. Em enxertos de ca são mais seguros e economicamente viáveis do que espessura total, sua intensidade e distribuição são outras coberturas biológicas temporárias, como marcadas de forma menos evidente, desaparecendo xenoenxerto porcino e membrana aminiótica. precocemente em comparação aos enxertos de espes- Apresentam rápida aderência e menor potencial de sura parcial.14 Tais observações revelam uma associa- antigenicidade em comparação com as demais.17 ção entre a presença de fibronectina e miofibroblas- Essas coberturas temporárias muitas vezes tos, e desta com a contração dos enxertos. são usadas com o intuito de preparar o leito da feri- Stephenson e cols.15 realizaram um estudo cujo da para uma cobertura definitiva. Sobre áreas avas- objetivo era avaliar a suposição de que os enxertos
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