Clinical application of expanded internal mammary artery perforator flap combined with vascular supercharge in reconstruction of faciocervical scar
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摘要:
目的 总结扩张的胸廓内动脉穿支（IMAP）皮瓣联合血管增压在面颈部瘢痕整复中的临床应用经验。 方法 采用回顾性观察性研究方法。2012年9月—2021年5月，上海交通大学医学院附属第九人民医院收治23例符合入选标准的烧创伤后面颈部瘢痕患者，其中男18例、女5例，年龄11~58岁，均采用扩张的IMAP皮瓣整复。Ⅰ期根据瘢痕部位和范围在前胸置入1个或2个合适额定容量的皮肤软组织扩张器，术中注意保护IMAP、锁骨上动脉胸支和胸外侧动脉，术后注入生理盐水进行扩张。Ⅱ期行皮瓣转移术，术前使用彩色多普勒超声血流探测仪明确优势IMAP。切除面颈部瘢痕，形成面积为9 cm×7 cm~28 cm×12 cm的创面，术中注意保留颞浅动静脉或面动静脉穿支。以优势IMAP为蒂，根据瘢痕切除后创面面积和位置设计皮瓣：对于中小面积的创面，采用IMAP单蒂皮瓣转移修复；对于缺损面积较大者，利用吲哚菁绿血管造影（ICGA）评价前胸各血管的供血范围，当IMAP不足以供养整块皮瓣时，利用锁骨上动脉胸支或胸外侧动脉进行血管增压，设计双蒂皮瓣。根据供受区间的距离，选择带蒂或游离转移皮瓣。转移皮瓣后再次行ICGA判断皮瓣血供。将供瓣区直接拉拢缝合。统计皮肤软组织扩张器置入个数、额定容量、注射生理盐水量和扩张周期，优势IMAP位置，采用皮瓣总个数和不同血管蒂类型皮瓣个数、皮瓣面积，Ⅱ期术后皮瓣存活情况、供受区常见并发症发生情况和随访情况。 结果 共置入25个皮肤软组织扩张器，皮肤软组织扩张器额定容量为200~500 mL，注射生理盐水量855~2 055 mL，扩张周期4~16个月。术前在第2肋间（20侧）或第3肋间（5侧）探及优势IMAP。共切取25个扩张皮瓣，其中2个IMAP带蒂皮瓣、11个IMAP游离皮瓣、4个锁骨上动脉胸支带蒂+IMAP游离皮瓣、8个IMAP+胸外侧动脉游离皮瓣，皮瓣面积10 cm×8 cm~30 cm×14 cm。Ⅱ期术后3例患者出现皮瓣尖端坏死，经常规换药后愈合；1例患者IMAP和面动脉吻合处出现血管蒂局部扭转、血栓栓塞，手术探查取出血栓、重新吻合血管后，血供恢复正常。14例患者在Ⅱ期术后1~6个月进行了皮瓣修薄手术。随访4个月~9年，所有患者皮瓣外观良好，面颈部功能改善，供区可见线性瘢痕形成；1例女性患者出现明显乳头移位，双侧乳房不对称。 结论 扩张IMAP皮瓣颜色、质地与面颈部皮肤组织匹配，且切取后对胸部供区的损伤小，联合血管增压可灵活设计双蒂皮瓣，进一步改善血供，扩大皮瓣切取面积，是大面积面颈部瘢痕整复的良好选择。 Abstract:Objective To summarize the clinical experience of expanded internal mammary artery perforator (IMAP) flap combined with vascular supercharge in reconstruction of faciocervical scar. Methods The retrospective observational study was conducted. From September 2012 to May 2021, 23 patients with postburn or posttraumatic faciocervical scars who met the inclusion criteria were admitted to Shanghai Ninth People's Hospital of Shanghai Jiao Tong University School of Medicine, including 18 males and 5 females, aged from 11 to 58 years, all of whom were reconstructed with expanded IMAP flaps. At the first stage, one or two skin and soft tissue expander (s) with appropriate rated capacity were implanted in the anterior chest area according to the location and size of the scars. The IMAP, thoracic branch of supraclavicular artery, and lateral thoracic artery were preserved during the operation. The skin and soft tissue expanders were inflated with normal saline after the operation. The flaps were transferred during the second stage. The dominant IMAP was determined preoperatively using color Doppler ultrasound (CDU) blood flow detector. The faciocervical scars were removed, forming wounds with areas of 9 cm×7 cm-28 cm×12 cm, and the perforators of superficial temporal artery and vein or facial artery and vein were preserved during the operation. The flaps were designed according to the area and size of the wounds after scar resection with the dominant IMAP as the pedicle. Single-pedicle IMAP flaps were used to repair small and medium-sized wounds. For larger defects, the blood perfusion areas of vessels in the anterior chest were evaluated by indocyanine green angiography (ICGA). In situations where the IMAP was insufficient to nourish the entire flap, double-pedicle flaps were designed by using the thoracic branch of supraclavicular artery or lateral thoracic artery for supercharging. Pedicled or free flap transfer was selected according to the distance between the donor areas and recipient areas. After transplantation of flaps, ICGA was conducted again to evaluate blood perfusion of the flaps. The donor sites of flaps were all closed by suturing directly. Statistics were recorded, including the number, rated capacity, normal saline injection volume, and expansion period of skin and soft tissue expanders, the location of the dominant IMAP, the total number of the flaps used, the number of flaps with different types of vascular pedicles, the flap area, the flap survival after the second stage surgery, the occurrence of common complications in the donor and recipient areas, and the condition of follow-up. Results Totally 25 skin and soft tissue expanders were used in this group of patients, with rated capacity of 200-500 mL, normal saline injection volume of 855-2 055 mL, and expansion period of 4-16 months. The dominant IMAP was detected in the second intercostal space (20 sides) or the third intercostal space (5 sides) before surgery. A total of 25 expanded flaps were excised, including 2 pedicled IMAP flaps, 11 free IMAP flaps, 4 pedicled thoracic branch of supraclavicular artery+free IMAP flaps, and 8 free IMAP+lateral thoracic artery flaps, with flap areas of 10 cm×8 cm-30 cm×14 cm. After the second stage surgery, tip necrosis of flaps in three patients occurred, which healed after routine dressing changes; one patient developed arterial embolism and local torsion on the vascular pedicle at the anastomosis of IMAP and facial artery, and the blood supply recovered after thrombectomy and vascular re-anastomosis. Fourteen patients underwent flap thinning surgery in 1 month to 6 months after the second stage surgery. The follow-up for 4 months to 9 years showed that all patients had improved appearances of flaps and functions of face and neck and linear scar in the donor sites of flaps, and one female patient had obvious nipple displacement and bilateral breast asymmetry. Conclusions The expanded IMAP flap is matched in color and texture with that of the face and neck, and its incision causes little damage to the chest donor sites. When combined with vascular supercharge, a double-pedicle flap can be designed flexibly to further enhance the blood supply and expand the flap incision area, which is a good choice for reconstruction of large faciocervical scar. -
Key words:
- Surgical flaps /
- Face /
- Neck /
- Cicatrix /
- Perforator flap /
- Internal mammary artery /
- Skin and soft tissue expansion /
- Vascular supercharge
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参考文献
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2 扩张的胸廓内动脉穿支皮瓣游离移植整复例1患者口周烧伤后瘢痕。2A.Ⅰ期术前口周瘢痕情况；2B.扩张5个月后供区外观；2C.Ⅱ期术中游离胸廓内动脉第2穿支（黄色箭头）；2D.Ⅱ期术中将皮瓣游离转移至口周缝合后；2E.随访3年，皮瓣颜色、质地与周围组织相近
3 扩张的锁骨上动脉胸支带蒂联合胸廓内动脉穿支（IMAP）游离皮瓣整复例2患者颈部创伤后瘢痕挛缩畸形。3A.Ⅰ期术前颏颈部瘢痕情况；3B.扩张完成后前胸外观；3C.Ⅱ期术中切除颈部瘢痕、松解粘连，分离受区面动静脉（蓝色箭头），供区解剖胸廓内动脉第3穿支（黄色箭头）和锁骨上动脉胸支（白色箭头）；3D.Ⅱ期术中吲哚菁绿血管造影（ICGA）前皮瓣外观；3E.Ⅱ期术中ICGA提示锁骨上动脉胸支单蒂皮瓣远端灌注不足；3F.Ⅱ期术中同时开放IMAP和锁骨上动脉胸支，ICGA显示皮瓣血运良好；3G.Ⅱ期术后9个月颈部仰头功能改善；3H.Ⅱ期术后9个月颈部轮廓正常
4 扩张的胸廓内动脉穿支（IMAP）+胸外侧动脉游离皮瓣整复例3患者面颈部烧伤后瘢痕。4A.Ⅱ期术前右侧颈部、胸部皮肤扩张及左面部瘢痕情况；4B.Ⅱ期术中游离皮瓣，解剖右侧胸廓内动脉第3穿支（黄色箭头）和胸外侧动脉（白色箭头）；4C.Ⅱ期术中吲哚菁绿血管造影（ICGA）前皮瓣外观；4D.Ⅱ期术中夹闭胸外侧动脉，行ICGA显示IMAP最大灌注期供血不佳；4E.Ⅱ期术中夹闭IMAP，行ICGA显示胸外侧动脉最大灌注期供血不佳；4F.Ⅱ期术中同时开放IMAP和胸外侧动脉，再次行ICGA显示皮瓣血运良好；4G.Ⅱ期术中将右侧前胸皮瓣转移至左侧面颈部；4H.随访3年，中下面部皮瓣颜色、质地与周围正常皮肤相近，恢复了正常的下颌轮廓
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