分叶股前外侧穿支皮瓣在血管蒂保护中的作用研究
|
摘要
目的探讨增加蒂部一叶瓣的分叶股前外侧穿支皮瓣修复四肢软组织缺损创面的临床疗效。方法 2014年1月—2017年1月,采用增加蒂部一叶瓣的分叶股前外侧穿支皮瓣修复四肢软组织缺损创面24例。其中男15例,女9例;年龄5~64岁,中位年龄33.5岁。上肢创面8例,合并桡骨茎突骨骨折1例,伸指肌腱外露3例,肱桡肌肌腱外露1例。下肢创面16例,合并跟骨或跖骨、趾骨骨折4例,跟腱离断1例,趾长伸趾肌腱、趾长屈趾肌腱外露8例。创面范围为8 cm×5 cm~18 cm×12 cm。根据创面大小及缺损区域,常规超声多普勒探查旋股外侧动脉穿支(2~5支)并标记;将不规则创面分解成多个部分(分2~4叶)分别计算面积,皮瓣切取范围9 cm×6 cm~20 cm×14 cm,最大单叶瓣切取面积24 cm×6 cm;分叶血管蒂长7~12 cm;蒂部联合创面嵌入分叶瓣面积5 cm×3 cm~7 cm×5 cm。结果术后皮瓣全部成活,无动、静脉危象发生。24例均获随访,随访时间2~28个月,平均9个月。1例合并跟骨骨折行内固定患者皮瓣修复后伴窦道形成,经常规换药后3个月愈合。所有皮瓣均菲薄,无需二次修薄;5例合并骨折者软组织均Ⅰ期愈合。所有患者受区腕关节、踝关节跖屈、背屈功能正常。结论设计增加蒂部一叶瓣的分叶股前外侧穿支皮瓣修复四肢软组织缺损安全可靠,是减少游离股前外侧穿支皮瓣动、静脉危象的方法之一。
Objective To evaluate the effectiveness of anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap for repairing extremities soft tissue defect. Methods Between January 2014 and January 2017, 24 patients with extremities soft tissue defects were treated by anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap. There were 15 males and 9 females, with a median age of 33.5 years(range, 5-64 years). Wounds located in upper limb in 8 cases, complicated with radial styloid fracture in 1 case, extensor tendon exposure in 3 cases, and brachioradialis muscle tendon exposed in 1 case. Wounds located in lower extremity in 16 cases, complicated with calcaneal or metatarsal, phalangeal fractures in 4 cases, Achilles tendon departure in 1 case, toe long extensor tendon and flexor digitorum longus tendon exposed in 8 cases. The wound area ranged from 8 cm×5 cm to 18 cm×12 cm.According to wound size, anterolateral thigh perforators were detected by conventional ultrasound Doppler(2-5 perforators). The irregular wounds were decomposed into multiple parts and the leaf number(2-4 leaves) of polyfoliate flap depended on the part number of the wound. The flap area ranged from 9 cm×6 cm to 20 cm×14 cm, and the largest area of single leaf was 24 cm×6 cm. The vascular pedicle length ranged from 7 cm to 12 cm. The foliate flap area with protecting pedicle ranged from 5 cm×3 cm to 7 cm×5 cm. Results All the flaps survived, and no vascular crisis occurred.All the patients were followed up 2-28 months(mean, 9 months). Sinus occurred in 1 case of calcaneal fracture after flap repair, and the sinus was healed after 3 months by conventional dressing. All the flaps were thin and had a good texture.Healing of soft tissue was found in 5 patients with fracture. The wrist and ankle plantar flexion and dorsiflexion function of recipient site were normal in all patients. Conclusion It is safe and reliable to repair the extremities soft tissue defect with anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap. And it is one of the ways to reduce the vascular crisis of the anterolateral thigh free perforator flap.
Objective To evaluate the effectiveness of anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap for repairing extremities soft tissue defect. Methods Between January 2014 and January 2017, 24 patients with extremities soft tissue defects were treated by anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap. There were 15 males and 9 females, with a median age of 33.5 years(range, 5-64 years). Wounds located in upper limb in 8 cases, complicated with radial styloid fracture in 1 case, extensor tendon exposure in 3 cases, and brachioradialis muscle tendon exposed in 1 case. Wounds located in lower extremity in 16 cases, complicated with calcaneal or metatarsal, phalangeal fractures in 4 cases, Achilles tendon departure in 1 case, toe long extensor tendon and flexor digitorum longus tendon exposed in 8 cases. The wound area ranged from 8 cm×5 cm to 18 cm×12 cm.According to wound size, anterolateral thigh perforators were detected by conventional ultrasound Doppler(2-5 perforators). The irregular wounds were decomposed into multiple parts and the leaf number(2-4 leaves) of polyfoliate flap depended on the part number of the wound. The flap area ranged from 9 cm×6 cm to 20 cm×14 cm, and the largest area of single leaf was 24 cm×6 cm. The vascular pedicle length ranged from 7 cm to 12 cm. The foliate flap area with protecting pedicle ranged from 5 cm×3 cm to 7 cm×5 cm. Results All the flaps survived, and no vascular crisis occurred.All the patients were followed up 2-28 months(mean, 9 months). Sinus occurred in 1 case of calcaneal fracture after flap repair, and the sinus was healed after 3 months by conventional dressing. All the flaps were thin and had a good texture.Healing of soft tissue was found in 5 patients with fracture. The wrist and ankle plantar flexion and dorsiflexion function of recipient site were normal in all patients. Conclusion It is safe and reliable to repair the extremities soft tissue defect with anterolateral thigh polyfoliate perforator flap plus pedicle with one foliate flap. And it is one of the ways to reduce the vascular crisis of the anterolateral thigh free perforator flap.
引文
1徐达传,钟世镇,刘牧之,等.股前外侧部皮瓣的解剖学一个新的游离皮瓣供区.临床应用解剖学杂志,1984,2(3):158-160.
2 季卫平,李浩,黄颖宝,等.股部皮穿支的数字化解剖学研究.中华整形外科杂志,2012,28(2):96-100.
3顾立强,朱庆棠,汪华侨,等.显微外科血管吻合新技术专题座谈会专家意见.中华显微外科杂志,2014,37(2):105.
4 施海峰,芮永军,陆征峰,等.血管吻合术后晚期突发危象的处理.中华手外科杂志,2015,31(6):448-450.
5王剑利,赵刚,王五洲,等.游离皮瓣移植1270例回顾性研究.中华显微外科杂志,2012,35(3):189-193.
6陈元庄,黄远翘,莫华贵.微血管吻合器在游离皮瓣移植术中的应用.中华显微外科杂志,2014,37(2):167-169.
7 侯书健,程国良,方光荣,等.拇指及手指再造手术血管危象164例临床分析.中华显微外科杂志,2005,28(2):130-132.
8段维轶,徐中飞,刘法昱,等.游离组织瓣修复口腔颌面-头颈部缺损244例.中华显微外科杂志,2014,37(5):444-448.
9 李学渊,王扬剑,章伟文,等.端侧吻合与端端吻合法在游离穿支皮瓣修复手部软组织缺损病例中的对比研究.中华显微外科杂志,2016,39(1):8-11.
10Pohlenz P,Klatt J,Schon G,et al.Microvascular free flaps in head and neck surgery:complications and outcome of 1000 flaps.Int J Oral Maxillofac Surg,2012,41(6):739-743.
11 熊胜,巨积辉,金光哲,等.吻合血管术后55例血管危象探查体会.中华手外科杂志,2011,27(5):284-286.
12袁灼辉,赵军,王鹏程,等.静脉皮瓣移植术后血管危象的原因及处理.实用手外科杂志,2015,29(2):184-185.
13 王澍寰,韦加宁,田光磊,等.手外科学.北京:人民卫生出版社,1999:80-81.
14方伟,郭曙光,陈翠菊,等.下肢再灌注损伤并发骨筋膜室综合征的治疗.中华普通外科杂志,2005,20(8):535-536.
15 郭建兴.腘血管损伤致小腿骨筋膜室综合征的治疗体会.实用骨科杂志,2014,20(8):763-764.
16刘会仁,曹磊,王立新,等.组织移植修复肢体严重损伤发生血管危象的原因分析.中华显微外科杂志,2010,33(2):161-162.
17 张世民,唐茂林,章伟文,等.中国穿支皮瓣的名词术语与临床应用原则共识(暂定稿).中华显微外科杂志,2012,35(2):89-92.
18胡锐,任义军,严立,等.股前外侧皮瓣联合髂胫束移植修复小儿足踝部软组织缺损.中华显微外科杂志,2014,37(5):457-460.
19 谭琪,刘光军,王谦,等.分叶式股前外侧穿支皮瓣修复四肢复杂性皮肤软组织缺损.中华创伤杂志,2014,30(8):793-794.
20郭翱,尤灵建,李俊,等.股前外侧皮瓣联合股直肌肌腱瓣移植修复前臂软组织伴肌腱缺损.中华手外科杂志,2011,27(2):92-93.
21 陈洁,蒋灿华,李宁,等.静脉改形联合微血管吻合器在头颈部缺损重建口径不等血管吻合中的应用.中华显微外科杂志,2015,38(6):546-549.
22常树森,魏在荣.穿支皮瓣术前影像学导航技术的研究进展.中国临床解剖学杂志,2016,34(5):596-598.
23 Taylor GI,Coflett RJ,Dhar SC,et al.The anatomical(angiosome)and clinical territories of cutaneous perforating arteries:development of the concept and designing safe flaps.Plast Reconstr Surg,2011,127(4):1447-1459.
24吴攀峰,唐举玉,李康华,等.旋股外侧动脉降支分叶穿支皮瓣临床应用16例.中华显微外科杂志,2015,38(6):526-529.
2 季卫平,李浩,黄颖宝,等.股部皮穿支的数字化解剖学研究.中华整形外科杂志,2012,28(2):96-100.
3顾立强,朱庆棠,汪华侨,等.显微外科血管吻合新技术专题座谈会专家意见.中华显微外科杂志,2014,37(2):105.
4 施海峰,芮永军,陆征峰,等.血管吻合术后晚期突发危象的处理.中华手外科杂志,2015,31(6):448-450.
5王剑利,赵刚,王五洲,等.游离皮瓣移植1270例回顾性研究.中华显微外科杂志,2012,35(3):189-193.
6陈元庄,黄远翘,莫华贵.微血管吻合器在游离皮瓣移植术中的应用.中华显微外科杂志,2014,37(2):167-169.
7 侯书健,程国良,方光荣,等.拇指及手指再造手术血管危象164例临床分析.中华显微外科杂志,2005,28(2):130-132.
8段维轶,徐中飞,刘法昱,等.游离组织瓣修复口腔颌面-头颈部缺损244例.中华显微外科杂志,2014,37(5):444-448.
9 李学渊,王扬剑,章伟文,等.端侧吻合与端端吻合法在游离穿支皮瓣修复手部软组织缺损病例中的对比研究.中华显微外科杂志,2016,39(1):8-11.
10Pohlenz P,Klatt J,Schon G,et al.Microvascular free flaps in head and neck surgery:complications and outcome of 1000 flaps.Int J Oral Maxillofac Surg,2012,41(6):739-743.
11 熊胜,巨积辉,金光哲,等.吻合血管术后55例血管危象探查体会.中华手外科杂志,2011,27(5):284-286.
12袁灼辉,赵军,王鹏程,等.静脉皮瓣移植术后血管危象的原因及处理.实用手外科杂志,2015,29(2):184-185.
13 王澍寰,韦加宁,田光磊,等.手外科学.北京:人民卫生出版社,1999:80-81.
14方伟,郭曙光,陈翠菊,等.下肢再灌注损伤并发骨筋膜室综合征的治疗.中华普通外科杂志,2005,20(8):535-536.
15 郭建兴.腘血管损伤致小腿骨筋膜室综合征的治疗体会.实用骨科杂志,2014,20(8):763-764.
16刘会仁,曹磊,王立新,等.组织移植修复肢体严重损伤发生血管危象的原因分析.中华显微外科杂志,2010,33(2):161-162.
17 张世民,唐茂林,章伟文,等.中国穿支皮瓣的名词术语与临床应用原则共识(暂定稿).中华显微外科杂志,2012,35(2):89-92.
18胡锐,任义军,严立,等.股前外侧皮瓣联合髂胫束移植修复小儿足踝部软组织缺损.中华显微外科杂志,2014,37(5):457-460.
19 谭琪,刘光军,王谦,等.分叶式股前外侧穿支皮瓣修复四肢复杂性皮肤软组织缺损.中华创伤杂志,2014,30(8):793-794.
20郭翱,尤灵建,李俊,等.股前外侧皮瓣联合股直肌肌腱瓣移植修复前臂软组织伴肌腱缺损.中华手外科杂志,2011,27(2):92-93.
21 陈洁,蒋灿华,李宁,等.静脉改形联合微血管吻合器在头颈部缺损重建口径不等血管吻合中的应用.中华显微外科杂志,2015,38(6):546-549.
22常树森,魏在荣.穿支皮瓣术前影像学导航技术的研究进展.中国临床解剖学杂志,2016,34(5):596-598.
23 Taylor GI,Coflett RJ,Dhar SC,et al.The anatomical(angiosome)and clinical territories of cutaneous perforating arteries:development of the concept and designing safe flaps.Plast Reconstr Surg,2011,127(4):1447-1459.
24吴攀峰,唐举玉,李康华,等.旋股外侧动脉降支分叶穿支皮瓣临床应用16例.中华显微外科杂志,2015,38(6):526-529.