摘要
目的
评估因口腔癌联合根治软组织缺损行游离股前外侧肌皮瓣修复,术后皮瓣供区并发症及功能恢复情况,为合理选择和改良供区手术方案,减少供区并发症提供参考。
方法
选取2011年2月1日至5月1日在中南大学湘雅二医院口腔颌面外科门诊及住院部所有复查的病人中因口腔癌联合根治软组织缺损,并于Ⅰ期行游离股前外侧肌皮瓣修复手术的患者61例。查阅所有患者入院期间的临床病历资料,排除既往史有中枢性疾病及骨关节炎等影响下肢运动的病例。实际纳入统计的为60例。在同一名临床经验丰富的康复科医生的协助下,通过评估表测量加问卷调查(见附录1)的方式描述性分析患者术后供区功能恢复情况及相关并发症。采用SPSS17.0对数据进行统计学分析。
结果
所有患者均完成评估表及问卷调查表,随访时间32天-1287天,平均319天。男性52例,女性8例。年龄25岁-68岁,平均(51.75±10.29)岁。皮瓣制备面积2cm×4cm-6cm×22cm,肌肉切取面积2cm×2cm-6cm×7cm。皮瓣成功59例,成功率为98.3%,1例皮瓣因术后出现静脉危象完全坏死。供区直接缝合58例,供区植皮2例。近期供区并发症包括：供区伤口感染6例,占病例总数10%,血肿1例,伤口裂开1例。无肌肉坏死及植皮坏死的病例。远期并发症包括：患侧股四头肌肌力减弱的7例。出现供区皮肤感觉异常的50例(约83.3%)。其中供区外上份感觉减退的10例,外中份感觉减退的39例,感觉消失1例,外下份感觉减退40例,感觉消失5例,无感觉过敏及倒错的病例。2例出现供区寒冷耐受不良。3例患者认为供区疤痕严重影响外观。无供区髋膝关节活动受限,肌肉疝出的病例。
结论
1、制备游离股前外侧肌皮瓣术后患者供区的感觉障碍分布于股前外侧区,主要集中在股前外侧的中下区,其主要原因与损伤股外侧皮神经有关。
2、制备游离股前外侧肌皮瓣的面积越大,皮瓣位置越靠近股外侧上份,股前外侧区出现感觉障碍的概率越大。
3、制备游离股前外侧肌皮瓣的肌瓣大小对术后肌力影响较小。
4、游离股前外侧肌皮瓣供区部位隐蔽,患者易于接受。
Objective
To investigate the donor-site complications of the free anterolateral myocutaneous flap which used to repair the soft tissue defects caused by the oral carcinoma operation. And make an assessment for the functional recovery of the donor-site. Provide clinical guidance on choosing a better method to make free anterolateral thigh flap in order to reduce the complications in donor-site.
Methods
61 patients from February 1st,2011 to May 1st,2011 who have reexamination in the second XiangYa Hospital,Central South University were selected. They all have suffered the resection of oral and maxillofacial malignant and inⅠphase reconstruction with free anterolateral myocutaneous flap. Consult their medical records, patients with preoperative donor-site morbidity from cerebral dysfunction or osteoarthritis of the lower extremities were excluded. So, we actually selected 60 patients. With the help of a same Rehabilitation practitioner who have rich clinical experience, several variables were assessed in the intraoperative and postoperative period, and a questionnaire was given to patients(Appendix 1). The data were analysed by descriptive analysis and T test using SPSS 17.0 software package.
Results
All patients finished the evaluation table and questionnaire. All patients were followed up for 32-1287days (mean:319 days). There were 52 males and 8 females aged 25-68 years old (mean:51.75±10.29 years old). The free flaps ranged in size from 2cmx4cm-6cm×22cm, and muscle flap were 2cmx2cm-6cmx7cm. The survival rate was 98.3% with only 1 total flap loss due to not reversible venous thrombosis. Primary skin closure on donor-site was performed in 58 patients. Skin grafting was performed in 2 patients. Early postoperative donor-site complications included:infection (n=6), wound dehiscence (n=1), and hematoma (n=1), no skin graft necrosis, no muscle necrosis. The long-term complications included muscle weakness (n=7), unsatisfactory scar appearance (n=3), sensory disturbance (n=50), in anterolateral thigh upper region sensory hypoesthesia (n=10), in anterolateral thigh middle region sensory hypoesthesia (n=39) and sensory deprivation (n=1), in anterolateral thigh lower region sensory hypoesthesia (n=40) and sensory deprivation (n=5). Two patients had intolerance to cold. No muscle herniation, no limitation of range of motion of hip and knee.
Conclusions
1. Sensory disturbance occurred in anterolateral thigh region of the donor-site especially concentrated in middle and lower area after free anterolateral myocutaneous flaps were made. It was related to damage of lateral femoral cutaneous nerve.
2.The bigger size and higher position we make free anterolateral myocutaneous flap, the more risk we will have sensory disturbance on donor-site.
3.Muscle weakness were not significantly related to sacrifice of the size of vastus lateralis muscle.
4.Few patients were bothered by the appearance of the scar because of the hidden donor-site of the free anterolateral thigh flap.
引文
[1]Rodrigues,V.C.,Moss,S.M.,Tuomainen,H.Oral cancer in the UK:To screen or not to screen.Oral Oncology.1998,34:454-464.
[2]Parkin,D.M.,pisani,P.,Ferlay,J.Global cancer statistics.CA:A Cancer Journal for Clinicians.1999,49:33-64,31.
[3]向旭,吴汉江.舌鳞癌连续整块切除术预后及其影响因素的临床研究：[硕士学位论文].长沙：中南大学,2010.
[4]徐达传,钟世镇,刘牧之,等.股前外侧部皮瓣的解剖学[J].临床应用解剖学杂志,1984,2(3)：158-160.
[5]罗力生,高建华,陈林峰,等.股前外侧皮瓣及其游离移植的应用.第一军医大学学报,1984,4(4)：1.
[6]Xu Da-chuan, Zhong Shi-zhe, Kong Ji-ming, et al. Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg,1988,82:305.
[7]罗盛康,W. Raffoul, P.Heieili,等.欧洲人股前外侧皮瓣应用解剖和临床应用.中国临床解剖学杂志,2000,18(4)：379-382.
[8]Gedebou TM, Wei FC, Lin CH, et al. Clinical experience of 1284 free anterolateral thigh flaps [J]. Handchir Mikrochir Plast Chir,2002,34(4):239-244.
[9]Patrick D. Addison, MD, MB,et al. Compartment Syndrome After Closure of the Anterolateral Thigh Flap Donor Site:A Report of Two Cases.Annals of Plastic Surgery,2008,60(6):635-638.
[10]章汉平.辅助评分法动态观察指导治疗筋膜间室综合症.湖北中医杂志,2003,25(1)：10.
[11]J. Odili,E. Wilson,J.S. Chana. Muscle herniation:A complication at the anterolateral thigh perforator flap donor site. Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62,1530-1533.
[12]文根,吴旭华,柴益民,等.股前外侧皮瓣供区并发症的分析.中国修复重建外科杂志,2009,23(10)：1177-1179.
[13]Kimata Y,Uchiyama K,Ebihara S,et al. Anterolateral thigh flap donor-site complications and morbidity.Plast Reconstr Surg.2000 Sep;106(3):584-589.
[14]Wolff KD,Grundmann A. The free vastus lateralis flap:an anatomic study with case reports.Plast Reconstr Surg.1992 Mar;89(3):469-75;discussion 476-7.
[15]Kuo YR,Jeng SF,Kuo MH,et al.Free anterolateral thigh flap for extremity reconstruction:clinical experience and functional assessment of donor site.Plast Reconstr Surg.2001 Jun;107(7):1766-71.
[16]龚朝建.股前区皮下脂肪厚度的测量及皮肤穿支血管的临床应用解剖研究.[硕士学位论文].长沙：中南大学湘雅二医院,2009.
[17]王铠,谭宏宇,吴汉江,等.游离股前外侧单叶(肌)皮瓣制备的外科技术.中华口腔医学杂志,2010,45(8)：490-491.
[18]徐达传,阮默,张春,等.股前外侧部皮瓣的进一步解剖学研究——高位皮动脉与皮瓣血供的分型.中国临床解剖学杂志,2002,20(6)：410.
[19]纪树荣,常华,庞红,等.康复学.实用手法肌力检查图解.北京：高等教育出版社,2003.5-7.
[20]陈文彬,潘祥林,康熙雄,等.诊断学(第6版).北京：人民卫生出版社,2007.214.
[21]Ariyan S.The pectoralis major myocutaneous flap:a versatile flap for reconstruction in the head and neck[J].Plast Reconstr Surg,1979,63:73-81.
[22]罗欣荣,贺湘波,喻建军.胸大肌肌皮瓣65例.实用医学杂志,2003,19(12)：1399.
[23]杨果凡,陈宝驹,高玉智等.游离皮瓣移植在整复外科的应用.中国医科大学学报,1980,4：16-22.
[24]王玉明.前臂皮瓣临床应用存在的问题.贵州医药,1992,16(6)：333-334.
[25]Pennington DM, Pelly A.The rectus abdominis myocutaneous free flap[J]. Br J Plast Surg,1980,33:277.
[26]Jones N, Sekhar L, Schramm V.Free rectus abdominis muscle flap reconstruction of the middle and posterior cranial fossa[J]. Plant Reconstr Surg, 1986,78:471.
[27]Urken ML.Rectus abdominis.In:Urken ML, Cheny ML, Sullivan MJ,Biller HF(eds) An atlas of regional and free flaps for head and neck reconstruciton[M]. Raven Press,New York,1995:119.
[28]Kroll SS,Reece GP,Miller MJ,et al.Comparison of the rectus abdominis free flap with the pectoralis major myocutaneous flap for reconstructions in the head and neck[J]. Am J Sure,1992,164:615.
[29]毛驰,俞光岩,彭歆,等.游离腹直肌皮瓣在口腔颌面部缺损修复中的应用.口腔颌面外科杂志,2001,11(4)：346-348.
[30]D'Este S.La technique de l'amputation de la mammelle pourcarcinoma mammaire[J].Rev Chir,1912,45:164-165.
[31]Quillen C, Shearin J, Georgiade N. Use of latissimus dorsi myocutaneous island flap for reconstruction in the head and neck area. PlastReconstrSurg,1978,62: 113.
[32]Maxwell G, Manson P, Hoopes J. Experiences with thirteen latissimus dorsi myocutaneous free flaps. Plast Reconstr Surg,1979,64:1.
[33]Luo S,Raffoul W,Luo J,et al. Anterolateral thigh flap:A review of 168 cases.Microsurgery,1999,19:232-238.
[34]张世民,徐达传,顾玉东.穿支皮瓣[J].中国临床解剖学杂志,2004,22(1)：32-33.
[35]Koshima I,Soeda S.Inferior epigastric artery skin flaps without rectus abdominis muscle[J].Brit J Plast Surg,1989,42:645-648.
[36]Kimura N, Satoh K. Consideration of a thin flap as an entity and clinical applications of the thin anterolateral thigh flap.Plast Reconstr Surg 1996;97:985-992
[37]Wei FC,Jain V,Celik N,et al.Have we found an ideal soft-tissue flap? an experience with 672 anterolateral thigh flaps[J].Plast Reconstr Surg, 2002,109:2219-2226.
[38]戴捷,周晓,喻建军,等.穿支皮瓣移植修复头颈肿瘤术后洞穿性缺损.组织工程与重建外科杂志,2009,5(3)：153-155.
[39]张世民,徐达传,俞光荣,等.穿支皮瓣的发展与临床应用进展.中国临床解剖学杂志,2006,24(2)：229-231.
[40]刘会仁,李瑞国,曹磊,等.旋股外侧动脉降支分叶肌皮瓣的设计与临床应用[J].中华显微外科杂志,2006,29(1)：10-13.
[41]康庆林,曾炳芳,柴益民,等.以旋股外侧动脉降支为蒂的股前外侧和内侧双叶皮瓣移植术[J].中华骨科杂志,2007,27(8)：600-603.
[42]Gedebou TM, Wei FC, Lin CH, et al. Clinical experience of 1284 free anterolateral thigh flaps [J]. Handchir Mikrochir Plast Chir,2002,34(4):239-244.
[43]吴汉江,朱兆夫,刘金兵,等.246块游离股前区(肌)皮瓣修复口腔颌面部恶性肿瘤切除后缺损.第八次全国口腔颌面--头颈肿瘤会议,2009,24.
[44]喻建军,周晓,陈杰,等.股前外侧皮瓣修复口底癌术后缺损[J].现代肿瘤医学,2008,16,(6)：942-944.
[45]王铠,谭宏宇,吴汉江,等.以旋股外侧动脉降支为蒂的穿支嵌合皮瓣修复口腔颌面部缺损.中华整形外科杂志,2009,25(6)：422-424.
[46]Joan E. Lipa, M.D., M.Sc.,et al. Patient-reported donor-site morbidity following anterolateral thigh free flaps. J Reconstructive Microsurgery,2005,21(6): 365-369.
[47]Lin CH,Wei FC,Lin YT,et al. Lateral circumflex femoral artery system:warehouse for functional composite free tissue reconstruction of the lower leg.J Trauma,2006,60(5):1032-1036.
[48]鳥飼阳子,等.肥胖症诊断标准的变迁.日本医学介绍,2006,27(2)：63-65.
[49]Pribaz JJ, Orgill DP, Epstein MD, Sampson CE, Hergrueter CA. Anterolateral thigh free flap. Ann Plast Surg 1995;34:585-592.
[50]Zhang Q,Qiao Q,Gould El,et al. Study of the neural and vascular anatomy of the anterolateral thigh flap.J Plast Reconstr Aesthet Surg,2008.[Epub ahead of print].
[51]劳镇国,于国中,刘均墀,等.股神经与股四头肌的解剖学研究和临床应用.中华显微外科杂志,1998,21(3)：189-191.
[52]江奕恒,李学雷,石小田,等.股前外侧单一高位穿支供血区域的形态学研究与皮瓣设计.中国临床解剖学杂志,2007,25(5)：497—501.
[53]Koshima, I. Personal communication (at the Annual Meeting of the Japanese Society of Reconstructive Microsurgery in Osaka, Japan) on November 15, 1996.
[54]Choi SW,Park JY,Hur MS,et al. An anatomic assessment on perforators of the lateral circumflex femoral artery for anterolateral thigh flap. J Craniofac Surg,2007,18(4):866-871.
[55]Wong CH,Wei FC,Fu B,et al. Alternative vascular pedicle of the anterolateral thigh flap:the oblique branch of the lateral circumflex femoral artery.Plast Reconstr Surg,2009,123(2):571-577.
[56]吴毅.等速肌肉功能测试和训练技术的基本原理和方法.中国康复医学杂志,1999,14(1)：44-45.
[57]唐竹吾,孙廷魁,张书琴,等.下肢神经之肌支的测量及其分布.解剖学报,1963,6(3)：311-318.
[58]邱立新,赵士杰,汪亚晴,等.股外侧皮神经前支的应用解剖学研究.中华口腔医学杂志,]995,30(2)：99-100.
[59]余国荣,陈秀清,奚翠萍,等.股外侧皮神经及其营养血管皮瓣的应用解剖.湖北医科大学学报,2000,21(1)：53-54.
[60]杨学斌,陈德松,李忠玉,等.股外侧皮神经的临床解剖.中国临床解剖学杂志.中国临床解剖学杂志,1993,11(2)：106-108.
[61]Li Li-pin g, Peter C. Ne ligan O,等. Anterolateral thigh perforator free flaps transplantation for repair of head an dextremeties soft tissue defects after tumor resection. [J] Clinical Rehabilitative Tissue Engineering Research.2007 June,11(25):5027-5031.
[62]高建华,罗力生,陈林峰,等.股前外侧皮瓣主要皮血管的体表定位.临床应用解剖学杂志,1984,2(3)：161-163.
[63]杨学斌,陈德松,劳杰,等.股外侧皮神经切取后对供区的影响.实用显微外科杂志,1994,17(3)：222-223.
[1]Rodrigues,V.C.,Moss,S.M.,Tuomainen,H.Oral cancer in the UK:To screen or not to screen.Oral Oncology.1998,34:454-464.
[2]Parkin,D.M.,pisani,P.,Ferlay,J.Global cancer statistics.CA:A Cancer Journal for Clinicians.1999,49:33-64,31.
[3]向旭,吴汉江.舌鳞癌连续整块切除术预后及其影响因素的临床研究：[硕士学位论文].长沙：中南大学,2010.
[4]徐达传,钟世镇,刘牧之,等.股前外侧部皮瓣的解剖学[J].临床应用解剖学杂志,1984,2(3)：158-160.
[5]罗力生,高建华,陈林峰,等.股前外侧皮瓣及其游离移植的应用.第一军医大学学报,1984,4(4)：1.
[6]Xu Da-chuan, Zhong Shi-zhe, Kong Ji-ming, et al. Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg,1988,82:305.
[7]罗盛康,W. Raffoul, P.Heieili,等.欧洲人股前外侧皮瓣应用解剖和临床应用.中国临床解剖学杂志,2000,18(4)：379-382.
[8]Gedebou TM, Wei FC, Lin CH, et al. Clinical experience of 1284 free anterolateral thigh flaps [J]. Handchir Mikrochir Plast Chir,2002,34(4):239-244.
[9]Kimata Y,Uchiyama K,Ebihara S,et al. Anterolateral thigh flap donor-site complications and morbidity.Plast Reconstr Surg.2000 Sep;106(3):584-589.
[10]冯运垒,叶淦湖,腾范文,等.旋股外侧血管蒂复(联)合组织瓣移植的解.剖学基础明.中国临床解剖学杂志,2004,22(5)：533-535.
[11]刘均挥.吻合血管的股前外侧皮瓣移植术明.中华显微外科杂志,1989,14：243-245.
[12]张春,陈土根,徐德洪,等.股前外侧皮瓣血管的变异与处理[J].中国临床解剖学杂志,1995,13(1)：65-66.
[13]张春,吴恙,陈中,等.股前外侧皮瓣血管类型的临床观察与研究[J]中国临床解剖学杂志,2001,19(3)：197-199.
[14]钱金岳,徐达传,汪宏文.再论股前外侧皮瓣[J].中国临床解剖学杂志,1999,17(3)：280-281.
[15]徐达传,阮默,张春,等.股前外侧部皮瓣的进一步解剖学研究——高位皮动脉与皮瓣血供的分型.中国临床解剖学杂志,2002,20(6)：410.
[16]许亚军,寿奎水,芮永军,等.600例股前外侧皮瓣移植术的临床应用经验[J].中华整形外科杂志,2005,21(6)：418-420.
[17]Kimata Y,Uchiyama K,Ebihara S, et al.Anatomic variations and technical problems of the anterolateral thigh flap:a report of 74 cases[J].Plast Reconstr Surg,1998,102 (5):1517-1523.
[18]高建华,罗力生,陈林峰,等.股前外侧皮瓣主要皮血管的体表定位.临床应用解剖学杂志,1984,2(3)：161-163.
[19]WeiFC, Jain V, Celik N, et a.l We found an Ideal soft tissue flap:an experience with 672 anterolateral thigh flaps [J]. Plast Reconstr Surg,2002,109(7):2219-2226.
[20]Valdatta L, Tuinder S, BuoroM, et a.l Lateral circum flex femoral arterial system and perforators of the anterolateral thigh flap:an anatomic study[J]. Ann P last Surg,2002,49(2):145-150.
[21]Kuo YR, Seng Feng J, Kuo FM, et a.l Versatility of free anterolateral thigh flap for reconstruction of soft tissue defects:review of 140 cases[J]. Ann Plast Surg, 2002,48(2):161-166.
[22]龚朝建.股前区皮下脂肪厚度的测量及皮肤穿支血管的临床应用解剖研究.[硕士学位论文].长沙：中南大学湘雅二医院,2009.
[23]罗力生,张立宪,王志学,等.股前外侧皮瓣的血管分型[J].第一军医大学学报,1989,9(2)：169.
[24]张启旭,乔群,陈光宇,等.股前外侧组织瓣临床应用112例分析.中国修复重建外科杂志,2006,20(5)：541.
[25]王晓峰,申明亮,翟严军,等.游离股前外侧皮瓣切口顺序的改良.实用手外科杂志,2008,22(4)：210.
[26]刘均墀.吻合血管的股前外侧皮瓣移植术明.中华显微外科杂志,1989,14：243-245.
[27]Y. G. SONG, G. Z. CHEN, Y. L. SONG. The free thigh flap:a new free flap concept based on the septocutaneous artery.British Journal of Plastic Surgery (1984)37:150.
[28]Zhou G, Q iao Q, Chen GY, et a.l Clinical experience and surgical anatomy of 32 free anterolateral th igh flap transp lantations [J]. Br J Plast Surg,1991,44(2): 91-96.
[29]Chen HC, Tang YB. Anterolateral thigh flap:an ideal soft tissue flap[J].Clin Plast Surg,2003,30(3):383-401.
[30]吴汉江,朱兆夫,刘金兵,等.246块游离股前区(肌)皮瓣修复口腔颌面部恶性肿瘤切除后缺损.第八次全国口腔颌面--头颈肿瘤会议,2009,24.
[31]喻建军,周晓,陈杰,等.股前外侧皮瓣修复口底癌术后缺损[J].现代肿瘤医学,2008,16,(6)：942-944.
[32]Ozkan O, Mardini S, Chen HC, et al. Repair of buccal defects with anterolateral thigh flaps[J]. Microsurgery,2006,26(3):182-189.
[33]Huang CH, Chen HC, Huang YL. Comparison of the radial forearm flap and the thinned anterolateral thigh cutaneous flap for reconstruction of tongue defects:an evaluation of donor-site morbidity [J]. Plast ReconstrSurg,2004,114(7): 1704-1710.
[34]杨熙鸿,彭汉伟,郭海鹏,等.股前外侧皮瓣在口腔肿瘤术后缺损修复中的初步应用[J].中国修复重建外科杂志,2005,22(9)：1139-1141.
[35]Shieh S J, Chiu HY, Yu JC, et al. Free an terolateral thigh flap for reconstruction of head and neck defects following cancer ablation [J].Plast Reconstr Surg,2000, 105(7):2349-2357.
[36]Kimura N,Satoh K, Hasum I T,et al. Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients. Plast Reconstr Surg,2001,108 (S):1197-1210.
[37]张世民,徐达传,俞光荣,等.穿支皮瓣的发展与临床应用进展.中国临床解剖学杂志,2006,24(2)：231.
[38]Hallock GG. Have we found an ideal soft tissue flap? An experience with 672 anterolateral thigh flaps (Discussion) [J]. Plast Reconstr Surg,2002,109(7): 2219-2226.
[39]文根,吴旭华,柴益民,等.股前外侧皮瓣供区并发症的分析.中国修复重建外科杂志,2009,23(10)：1177-1179.
[40]J. Odili,E. Wilson,J.S. Chana. Muscle herniation:A complication at the anterolateral thigh perforator flap donor site. Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62,1530-1533.
[41]Patrick D. Addison, MD, MB,et al. Compartment Syndrome After Closure of the Anterolateral Thigh Flap Donor Site:A Report of Two Cases.Annals of Plastic Surgery,2008,60(6):635-638.
[42]Wolff KD，Grundmann A. The free vastus lateralis flap:an anatomic study with case reports.Plast Reconstr Surg.1992 Mar;89(3):469-75;discussion 476-7.
[43]Kuo YR,Jeng SF,Kuo MH,et al.Free anterolateral thigh flap for extremity reconstruction:clinical experience and functional assessment of donor site. Plast Reconstr Surg.2001 Jun; 107(7):1766-71.
[44]朱孜冠,唐举玉.股前外侧穿支皮瓣的研究进展.中国临床解剖学杂志2010,28(3)：347-349.