改良动脉化静脉皮瓣修复手指软组织缺损
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摘要
目的探讨一种改良动脉化静脉皮瓣修复手指软组织缺损的疗效。方法 2017年1月—2018年4月,收治16例手指软组织缺损患者。男12例,女4例;年龄24～74岁,平均41岁。软组织缺损原因:瘢痕挛缩切除后1例,机器绞压伤15例。拇指3例,示指5例,中指4例,环指2例,小指2例;手指掌侧缺损4例,背侧缺损12例。软组织缺损范围为3 cm×2 cm～10 cm×3 cm。于前臂掌侧设计并切取改良动脉化静脉皮瓣,皮瓣完全游离前在显微镜下剔除部分脂肪组织,并结扎皮瓣内2根静脉间的所有细小分支,游离移植修复创面。皮瓣切取范围为3.5 cm×2.5 cm～10.5 cm×3.5 cm。供区游离植皮修复(1例)或直接缝合(15例)。结果术后1例皮瓣发生静脉危象;15例皮瓣均顺利成活,其中3例皮瓣术后出现轻度至中度肿胀,未作特殊处理,1周后自行愈合。供区植皮成活,切口Ⅰ期愈合。术后13例获随访,随访时间8～16个月,平均11个月。患者皮瓣质地软、耐磨,外形满意。末次随访时,皮瓣感觉单丝触压觉测试为2.83～4.56 g,平均4.01 g;静态两点辨别觉为6～20 mm,平均12 mm。结论改良动脉化静脉皮瓣通过改善动脉化静脉皮瓣内的动静脉分流,减轻术后静脉回流不畅,修复手指软组织缺损可获得较好疗效。
Objective To summarize the effectiveness of modified arterialized venous flaps in repairing soft tissue defect of fingers. Methods Between January 2017 and April 2018, 16 patients with soft defects of fingers were treated. There were 12 males and 4 females, with an average age of 41 years(range, 24-74 years). One case was resulted from resection of cicatricial contracture and 15 cases was caused by mechanical strangulation. The defects located at thumb in 3 cases, index finger in 5 cases, middle finger in 4 cases, ring finger in 2 cases, and little finger in 2 cases; and at the palmar aspect in 4 cases, and dorsal aspect in 12 cases. The size of defect ranged from 3 cm×2 cm to 10 cm×3 cm. All flaps were harvested from the palmar aspect of the ipsilateral forearm. The distal ports of the two veins were ligation.Partial fat was eliminated and the all connecting minute branches between the two veins were ligation under microscope in order to achieve the thorough shunt restriction. Then the flaps were positioned over the recipient site without inversion.The size of flap ranged from 3.5 cm×2.5 cm to 10.5 cm×3.5 cm. All donor sites were directly sutured except that 1 case was recovered with free skin graft. Results All flaps survived entirely except that 1 case happened vein crisis. Three flaps demonstrated mild-to-moderate venous congestion without any treatment and the swelling of flaps gradually subsided after 1 week. Skin grafting at donor site survived and all incisions healed by first intension. Thirteen patients were followed up 8-16 months(mean, 11 months). The textures and appearances of the flaps were satisfactory. At last follow-up, the mean size of the Semmes-Weinstein(SW) monofilament test of the flaps was 4.01 g(range, 2.83-4.56 g); the mean static two-point discrimination of the flaps was 12 mm(range, 6-20 mm). Conclusion Modified arterialized venous flaps with thoroughly restriction of arteriovenous shunting can offer decreased congestion of venous flaps and improve survival rate.Better effectiveness can be achieved by using this flap to repair soft tissue defect of finger.
Objective To summarize the effectiveness of modified arterialized venous flaps in repairing soft tissue defect of fingers. Methods Between January 2017 and April 2018, 16 patients with soft defects of fingers were treated. There were 12 males and 4 females, with an average age of 41 years(range, 24-74 years). One case was resulted from resection of cicatricial contracture and 15 cases was caused by mechanical strangulation. The defects located at thumb in 3 cases, index finger in 5 cases, middle finger in 4 cases, ring finger in 2 cases, and little finger in 2 cases; and at the palmar aspect in 4 cases, and dorsal aspect in 12 cases. The size of defect ranged from 3 cm×2 cm to 10 cm×3 cm. All flaps were harvested from the palmar aspect of the ipsilateral forearm. The distal ports of the two veins were ligation.Partial fat was eliminated and the all connecting minute branches between the two veins were ligation under microscope in order to achieve the thorough shunt restriction. Then the flaps were positioned over the recipient site without inversion.The size of flap ranged from 3.5 cm×2.5 cm to 10.5 cm×3.5 cm. All donor sites were directly sutured except that 1 case was recovered with free skin graft. Results All flaps survived entirely except that 1 case happened vein crisis. Three flaps demonstrated mild-to-moderate venous congestion without any treatment and the swelling of flaps gradually subsided after 1 week. Skin grafting at donor site survived and all incisions healed by first intension. Thirteen patients were followed up 8-16 months(mean, 11 months). The textures and appearances of the flaps were satisfactory. At last follow-up, the mean size of the Semmes-Weinstein(SW) monofilament test of the flaps was 4.01 g(range, 2.83-4.56 g); the mean static two-point discrimination of the flaps was 12 mm(range, 6-20 mm). Conclusion Modified arterialized venous flaps with thoroughly restriction of arteriovenous shunting can offer decreased congestion of venous flaps and improve survival rate.Better effectiveness can be achieved by using this flap to repair soft tissue defect of finger.
引文
1徐永清,何晓清.皮瓣外科的新进展.中国修复重建外科杂志,2018, 32(7):781-785.
2黄良库,许玉本,李鹏,等.游离桡动脉掌浅支皮瓣修复手指软组织缺损.中国修复重建外科杂志,2018, 32(7):955-958.
3程定,胡俊生,崔树英,等.桡动脉穿支腕横纹皮瓣桥接修复手指环形缺损疗效观察.中国修复重建外科杂志,2017, 31(7):837-840.
4杨焕友,王斌,黄蕾,等.同指近节指动脉背侧支皮瓣修复末节缺失的指中节脱套伤.中国修复重建外科杂志,2018, 32(11):1446-1449.
5 Nakayama Y, Soeda S, Kasai Y. Flaps nourished by arterial inflow through the venous system:an experimental investigation. Plast Reconstr Surg, 1981,67(3):328-334.
6谢振荣,肖军波,雷彦文,等.提高动脉化静脉皮瓣成活的几个关键问题.中华显微外科杂志,2011,34(4):347-349.
7陈文锋,李征,吴立业,等.乌拉地尔减少动脉化静脉皮瓣血流灌注量的作用.中华显微外科杂志,2018, 41(4):368-370.
8 Lin YT, Henry SL, Lin CH, et al. The shunt-restricted arterialized venous flap for hand/digit reconstruction:enhanced perfusion,decreased congestion, and improved reliability. J Trauma, 2010,69(2):399-404.
9 Lam WL, Lin WN, Bell D, et al. The physiology, microcirculation and clinical application of the shunt-restricted arterialized venous flaps for the reconstruction of digital defects. J Hand Surg Eur Vol,2013, 38(4):352-365.
10 Lin YT, Hsu CC, Lin CH, et al. The position of'shunt restriction'along an arterialized vein affects venous congestion and flap perfusion of an arterialized venous flap. J Plast Reconstr Aesthet Surg, 2016, 69(10):1389-1396.
11 Weng W, Zhang F, Zhao B, et al. The complicated role of venous drainage on the survival of arterialized venous flaps. Oncotarget,2017,8(10):16414-16420.
12 Moshammer HE, Schwarzl FX, Haas FM, et al. Retrograde arterialized venous flap:an experimental study. Microsurgery,2003, 23(2):130-134.
13李瑞华,阚世廉,许效坤,等.动脉化静脉皮瓣两种灌流方式比较的实验研究及临床应用.中华手外科杂志,2006, 22(4):242-244.
14刘学贵,张铭盛,杨俊贵,等.改良动脉化游离静脉皮瓣的临床应用.中华手外科杂志,2007,23(4):224-226.
15 Giesen T, Forster N, Kiinzi W, et al. Retrograde arterialized free venous flaps for the reconstruction of the hand:review of 14 cases.J Hand Surg(Am), 2014, 39(3):511-523.
16白印伟,李征,余少校,等.前臂掌侧游离动脉化静脉皮瓣修复手部皮肤软组织缺损的疗效观察.中国修复重建外科杂志,2014,28(3):362-365.
17 Lombardo GAG, Tamburino S, Tarico MS, et al. Reverse flow shunt restricted arterialized venous free flap. J Hand Surg(Am),2018,43(5):492.e1-492.e5.
18杨帅智,陈禄,郑灿镔,等.分叶串联游离静脉皮瓣在双手指近中节软组织缺损修复中的应用.中国修复重建外科杂志,2016,30(4):440-443.
19黄辉强,郑晓东,张敬良,等.微型动脉化静脉皮瓣修复50例指端皮肤缺损.中华显微外科杂志,2016, 39(2):188-191.
20崔建德,刘学贵,杨俊贵,等.带掌长肌腱的控制皮下静脉属支动脉化静脉皮瓣在修复手部复合组织缺损中的应用.中华显微外科杂志,2017, 40(2):195-198.
21 Nakazawa H, Nozaki M, Kikuchi Y, et al. Successful correction of severe contracture of the palm using arterialized venous flaps. J Reconstr Microsurg, 2004, 20(7):527-531.
2黄良库,许玉本,李鹏,等.游离桡动脉掌浅支皮瓣修复手指软组织缺损.中国修复重建外科杂志,2018, 32(7):955-958.
3程定,胡俊生,崔树英,等.桡动脉穿支腕横纹皮瓣桥接修复手指环形缺损疗效观察.中国修复重建外科杂志,2017, 31(7):837-840.
4杨焕友,王斌,黄蕾,等.同指近节指动脉背侧支皮瓣修复末节缺失的指中节脱套伤.中国修复重建外科杂志,2018, 32(11):1446-1449.
5 Nakayama Y, Soeda S, Kasai Y. Flaps nourished by arterial inflow through the venous system:an experimental investigation. Plast Reconstr Surg, 1981,67(3):328-334.
6谢振荣,肖军波,雷彦文,等.提高动脉化静脉皮瓣成活的几个关键问题.中华显微外科杂志,2011,34(4):347-349.
7陈文锋,李征,吴立业,等.乌拉地尔减少动脉化静脉皮瓣血流灌注量的作用.中华显微外科杂志,2018, 41(4):368-370.
8 Lin YT, Henry SL, Lin CH, et al. The shunt-restricted arterialized venous flap for hand/digit reconstruction:enhanced perfusion,decreased congestion, and improved reliability. J Trauma, 2010,69(2):399-404.
9 Lam WL, Lin WN, Bell D, et al. The physiology, microcirculation and clinical application of the shunt-restricted arterialized venous flaps for the reconstruction of digital defects. J Hand Surg Eur Vol,2013, 38(4):352-365.
10 Lin YT, Hsu CC, Lin CH, et al. The position of'shunt restriction'along an arterialized vein affects venous congestion and flap perfusion of an arterialized venous flap. J Plast Reconstr Aesthet Surg, 2016, 69(10):1389-1396.
11 Weng W, Zhang F, Zhao B, et al. The complicated role of venous drainage on the survival of arterialized venous flaps. Oncotarget,2017,8(10):16414-16420.
12 Moshammer HE, Schwarzl FX, Haas FM, et al. Retrograde arterialized venous flap:an experimental study. Microsurgery,2003, 23(2):130-134.
13李瑞华,阚世廉,许效坤,等.动脉化静脉皮瓣两种灌流方式比较的实验研究及临床应用.中华手外科杂志,2006, 22(4):242-244.
14刘学贵,张铭盛,杨俊贵,等.改良动脉化游离静脉皮瓣的临床应用.中华手外科杂志,2007,23(4):224-226.
15 Giesen T, Forster N, Kiinzi W, et al. Retrograde arterialized free venous flaps for the reconstruction of the hand:review of 14 cases.J Hand Surg(Am), 2014, 39(3):511-523.
16白印伟,李征,余少校,等.前臂掌侧游离动脉化静脉皮瓣修复手部皮肤软组织缺损的疗效观察.中国修复重建外科杂志,2014,28(3):362-365.
17 Lombardo GAG, Tamburino S, Tarico MS, et al. Reverse flow shunt restricted arterialized venous free flap. J Hand Surg(Am),2018,43(5):492.e1-492.e5.
18杨帅智,陈禄,郑灿镔,等.分叶串联游离静脉皮瓣在双手指近中节软组织缺损修复中的应用.中国修复重建外科杂志,2016,30(4):440-443.
19黄辉强,郑晓东,张敬良,等.微型动脉化静脉皮瓣修复50例指端皮肤缺损.中华显微外科杂志,2016, 39(2):188-191.
20崔建德,刘学贵,杨俊贵,等.带掌长肌腱的控制皮下静脉属支动脉化静脉皮瓣在修复手部复合组织缺损中的应用.中华显微外科杂志,2017, 40(2):195-198.
21 Nakazawa H, Nozaki M, Kikuchi Y, et al. Successful correction of severe contracture of the palm using arterialized venous flaps. J Reconstr Microsurg, 2004, 20(7):527-531.