扩张胸背动脉穿支皮瓣游离移植整复烧伤后颈部瘢痕挛缩畸形的临床效果

计鹏; 曹涛; 张智; 张月; 胡世均; 王军昌; 韩超; 王璟; 石继红; 胡大海; 陶克

doi:10.3760/cma.j.cn501120-20211231-00426

扩张胸背动脉穿支皮瓣游离移植整复烧伤后颈部瘢痕挛缩畸形的临床效果

doi: 10.3760/cma.j.cn501120-20211231-00426

1.
空军军医大学第一附属医院全军烧伤中心，烧伤与皮肤外科，西安　　710032
2.
亳州市人民医院烧伤整形科，亳州　　236814
3.
石河子市人民医院烧伤整形科，石河子　　　　832099

基金项目:

国家自然科学基金面上项目 82172209

详细信息

通讯作者:
陶克，Email：taoke918@fmmu.edu.cn

计量
- 文章访问数: 4512
- HTML全文浏览量: 202
- PDF下载量: 50
- 被引次数: 0
出版历程
- 收稿日期: 2021-12-31

Clinical effects of free transplantation of expanded thoracodorsal artery perforator flaps in reconstructing cervical cicatrix contracture deformity after burns

1.
Department of Burns and Cutaneous Surgery, Burn Center of PLA, the First Affiliated Hospital of Air Force Medical University, Xi'an 710032, China
2.
Department of Burns and Plastic Surgery, Bozhou City People's Hospital, Bozhou 236814, China
3.
Department of Burns and Plastic Surgery, Shihezi City People's Hospital, Shihezi 832099, China

Funds:

General Program of National Natural Science Foundation of China 82172209

More Information

Corresponding author: Tao Ke, Email: taoke918@fmmu.edu.cn

摘要

摘要: 目的探讨应用扩张胸背动脉穿支皮瓣游离移植整复烧伤后颈部瘢痕挛缩畸形的临床效果。方法采用回顾性观察性研究方法。2018年5月—2021年4月，空军军医大学第一附属医院收治11例符合入选标准的烧伤后颈部瘢痕挛缩畸形患者，其中男3例、女8例，年龄5~46岁，瘢痕挛缩畸形病程5个月~8年，颈部瘢痕挛缩程度为Ⅰ度者1例、Ⅱ度者9例、Ⅲ度者1例。Ⅰ期根据颈部瘢痕大小在背部置入1个额定容量为200~600 mL的长方形皮肤软组织扩张器（以下简称扩张器），扩张时间为4~12个月，总注射生理盐水量为扩张器额定容量的3.0~3.5倍。Ⅱ期切取面积为10 cm×7 cm~24 cm×13 cm的扩张胸背动脉穿支游离皮瓣，修复瘢痕切除松解后形成的面积为9 cm×6 cm~23 cm×12 cm的创面。将胸背动静脉的主干与面动静脉进行端端吻合，供区直接拉拢缝合。术后14 d观察皮瓣成活情况、皮瓣供区愈合情况；随访时观察皮瓣外观、瘢痕增生挛缩情况，颈部功能恢复情况，皮瓣供区瘢痕增生情况。结果术后14 d，10例患者皮瓣成活；1例患者皮瓣中央皮肤出现瘀斑和表皮坏死，经2周换药治疗后愈合。术后14 d，11例患者皮瓣供区均愈合良好。术后随访6~12个月，10例患者皮瓣质地、色泽与受区周围皮肤接近，1例患者皮瓣轻度臃肿；11例患者皮瓣和皮瓣供区瘢痕增生挛缩不明显，颈部功能恢复良好。结论采用扩张胸背动脉穿支皮瓣整复烧伤后颈部瘢痕挛缩畸形后，颈部外观、功能恢复良好，且皮瓣供区损伤小，值得临床借鉴应用。
- 烧伤 /
- 颈 /
- 瘢痕 /
- 穿支皮瓣 /
- 扩张术 /
- 挛缩
Abstract: Objective To explore the clinical effects of free transplantation of expanded thoracodorsal artery perforator flaps in reconstructing cervical cicatrix contracture deformity after burns. Methods A retrospective observational study was conducted. From May 2018 to April 2021, 11 patients with cervical cicatrix contracture deformity after burns who met the inclusion criteria were admitted to the First Affiliated Hospital of Air Force Medical University, including 3 males and 8 females, aged 5 to 46 years, with a course of cervical cicatrix contracture deformity of 5 months to 8 years. The degree of cervical cicatrix contracture deformity was degree Ⅰ in one patient, degree Ⅱ in nine patients, and degree Ⅲ in one patient. In the first stage, according to the sizes of neck scars, one rectangular skin and soft tissue expander (hereinafter referred to as expander) with rated capacity of 200 to 600 mL was placed in the back. The expansion time was 4 to 12 months with the total normal saline injection volume being 3.0 to 3.5 times of the rated capacity of expander. In the second stage, free expanded thoracodorsal artery perforator flaps with areas of 10 cm×7 cm to 24 cm×13 cm were cut out to repair the wounds with areas of 9 cm×6 cm to 23 cm×12 cm which was formed after cervical cicatectomy. The main trunk of thoracodorsal artery and vein were selected for end-to-end anastomosis with facial artery and vein, and the donor sites were directly closed. The survival of flaps and healing of flap donor sites were observed on the 14^th day post surgery. The appearances and cicatrix contracture deformity of the flaps, recovery of cervical function, and scar hyperplasia of donor sites were followed up. Results On the 14^th day post surgery, the flaps of ten patients survived, while ecchymosis and epidermal necrosis occurred in the center of flap of one patient and healed 2 weeks after dressing change. On the 14^th day post surgery, the flap donor sites of 11 patients all healed well. During the follow-up of 6-12 months post surgery, the flaps of ten patients were similar to the skin around the recipient site in texture and color, while the flap of one patient was slightly swollen. All of the 11 patients had good recovery of cervical function and no obvious scar hyperplasia nor contracture in the flaps or at the donor sites. Conclusions Application of expanded thoracodorsal artery perforator flaps can restore the appearance and function of the neck, and cause little damage to the donor site in reconstructing the cervical cicatrix contracture deformity after burns, which is worthy of clinical reference and application.
- Burns /
- Neck /
- Cicatrix /
- Perforator flap /
- Dilatation /
- Contracture
计鹏、曹涛：数据分析、文章撰写；张智、张月：数据整理与数据分析；胡世均、王军昌、韩超、王璟：数据采集；石继红、胡大海、陶克：研究指导、获取研究经费、论文修改

所有作者均声明不存在利益冲突

烧伤后上下唇畸形在面部极其突出，对患者的心理状态影响很大，并可能会导致患者与社会的隔绝。嘴唇结构复杂，重建上唇和下唇的亚单位对于整形外科医师而言是一项复杂而且富有挑战性的工作。皮片移植被广泛应用于面部缺损的修复，虽然这项技术简单而安全，但术后可能会出现严重的皮片挛缩和色素沉着；局部皮瓣转移受到供瓣区不足、皮瓣设计复杂和供区瘢痕的限制；游离皮瓣，例如游离的股前外侧皮瓣和前臂皮瓣虽被报道能获得足够组织量用于面部修复，但该类手术需要训练有素的外科医师具有高超的显微外科技能。尽管上述这些方法可以覆盖面部的创面，但由于皮片颜色与受区皮肤不匹配、游离皮瓣厚度和质地与受区皮肤差异大，常常难以获得满意的效果。

上海交通大学医学院附属第九人民医院章一新教授团队在《Burns & Trauma》发文《Pre-expanded bipedicled visor flap: an ideal option for the reconstruction of upper and lower lip defects postburn in Asian males》。该研究团队尝试以双侧颞浅血管为蒂，将预扩张的头皮瓣转移修复大面积的上下唇缺损；术后皮瓣修整和激光治疗可以用来改善亚洲男性的胡须。这种采用改良的预扩张头皮瓣修复上下唇缺损的方法能够同时重建多个面部亚单位，能够提供与受区颜色、质地接近的皮肤组织，并且供区无继发畸形。

该研究表明，预扩张双蒂头皮瓣是一种有效且可靠的再造亚洲男性上下唇的方法，且具有良好的外观和功能效果。通过这种改进的方法，可以根据供区的亚单位类型，准确地获得较佳的术后效果。尽管这种方法需要进行多阶段的手术，但这种方法显著提高了患者的生活质量，有效解决了患者的心理负担。该研究证实了预扩张的双蒂头皮瓣修复上下唇的可行性，初步证实其具有推广的潜力，但为了确认既定技术的效果，仍需进一步的推广验证。

丁健科，编译自《Burns Trauma》,2020,8:tkaa005；马显杰，审校

HTML全文

参考文献(36)

[1]	吴琛,邹同荣,陈思思.扩张后胸三角皮瓣修复颈部瘢痕挛缩畸形的应用[J].中国美容整形外科杂志,2019,30(7):408-410,432.DOI: 10.3969/j.issn.1673-7040.2019.07.007.
[2]	唐银科,楚菲菲,马显杰.四类预扩张皮瓣对面颈部亚单位病损的修复效果分析[J].中华整形外科杂志,2020,36(10):1088-1094.DOI: 10.3760/cma.j.cn114453-20200507-00268.
[3]	刘士强,马显杰.皮肤软组织扩张术的应用进展与展望[J].中华整形外科杂志,2019,35(10):949-952.DOI: 10.3760/cma.j.issn.1009-4598.2019.10.001.
[4]	冯登超,武斌,杨喜明.胸背动脉穿支皮瓣游离移植修复面颈部大面积瘢痕的临床疗效[J].西部医学,2016,28(4):487-489.DOI: 10.3969/j.issn.1672-3511.2016.04.012.
[5]	ZeidermanMR, PuLLQ. Contemporary reconstruction after complex facial trauma[J/OL]. Burns Trauma,2020,8:tkaa00 3[2021-12-31].https://pubmed.ncbi.nlm.nih.gov/32341916/.DOI: 10.1093/burnst/tkaa003.
[6]	AkitaS, HayashidaK, TakakiS, et al. The neck burn scar contracture: a concept of effective treatment[J/OL].Burns Trauma,2017,5:22[2021-12-31]. https://pubmed.ncbi.nlm.nih.gov/28717655/.DOI: 10.1186/s41038-017-0086-8.
[7]	蔡海军,谭静雷.扩张后随意型皮瓣修复术治疗面颈部烧伤后瘢痕[J].中华全科医学,2016,14(5):777-779.DOI: 10.16766/j.cnki.issn.1674-4152.2016.05.027.
[8]	ChenBG,SongHF,XuMH,et al.Reconstruction of cica-contracture on the face and neck with skin flap and expanded skin flap pedicled by anterior branch of transverse cervical artery[J].J Craniomaxillofac Surg,2016,44(9):1280-1286.DOI: 10.1016/j.jcms.2016.04.020.
[9]	OgawaR.Surgery for scar revision and reduction: from primary closure to flap surgery[J/OL].Burns Trauma,2019,7:7[2021-12-31]. https://pubmed.ncbi.nlm.nih.gov/30891462/.DOI: 10.1186/s41038-019-0144-5.
[10]	任静,韩岩,王白石,等.全厚植皮与扩张胸三角皮瓣转移修复面部大面积皮肤缺损[J].中国美容整形外科杂志,2017,28(10):596-598.DOI: 10.3969/j.issn.1673-7040.2017.10.005.
[11]	SongBQ, ZhaoJH, GuoSZ,et al.Repair of facial scars by the free expanded deltopectoral flap[J].Plast Reconstr Surg,2013,131(2):200e-208e.DOI: 10.1097/PRS.0b013e3182789c02.
[12]	何秀叶,宋慧锋,许明火,等.超量预制颌颈部扩张皮瓣进行面颊部亚单位的美学修复[J].中华医学美学美容杂志,2017,23(4):226-228.DOI: 10.3760/cma.j.issn.1671-0290.2017.04.004.
[13]	杨喆,刘伟,李养群,等.扩张的颈肩峰区锁骨上皮瓣修复面颈部软组织缺损[J].中国美容医学,2015,24(9):1-5.DOI: 10.15909/j.cnki.cn61-1347/r.000429.
[14]	于东宁,沈余明,陈欣.带血管蒂的邻位动脉穿支轴型皮瓣修复患者面颈部瘢痕畸形的效果[J].中华烧伤杂志,2019,35(12):848-854.DOI: 10.3760/cma.j.issn.1009-2587.2019.12.004.
[15]	马显杰.颈横动脉颈段皮支轴型皮瓣的临床应用[J].中华整形烧伤外科杂志,1993,9(1):22-24.DOI: 10.3760/j.issn:1009-4598.1993.01.014.
[16]	RamirezCA,FernandesRP.The supraclavicular artery island and trapezius myocutaneous flaps in head and neck reconstruction[J].Oral Maxillofac Surg Clin North Am,2014,26(3):411-420.DOI: 10.1016/j.coms.2014.05.009.
[17]	杨忠全,郭志权,岳瑞祥,等.2800例面颈部创面的美学修复[J].中华烧伤杂志,2012,28(4):269-270.DOI: 10.3760/cma.j.issn.1009-2587.2012.04.012.
[18]	王爱武,杨壮群.扩张胸背动脉穿支皮瓣修复面颈部瘢痕远期疗效观察[J].中国医疗美容,2016,6(11):31-33.DOI: 10.3969/j.issn.2095-0721.2016.11.016.
[19]	侯健,宋慧锋,陈保国,等.预扩张颈横动脉前穿支皮瓣与预扩张胸部随意皮瓣接力整复大面积面颈部瘢痕的临床效果[J]. 中华烧伤杂志,2021,37(4):350-355.DOI: 10.3760/cma.j.cn501120-20201023-00445.
[20]	SongBQ,XiaoB,LiuCH,et al. Neck burn reconstruction with pre-expanded scapular free flaps[J].Burns,2015,41(3):624-630.DOI: 10.1016/j.burns.2014.08.015.
[21]	ZhangYX, HayakawaTJ, LevinLS, et al. The economy in autologous tissue transfer: part 1. The kiss flap technique[J]. Plast Reconstr Surg,2016,137(3):1018-1030.DOI: 10.1097/01.prs.0000479971.99309.21.
[22]	TashiroK,YamashitaS,ArakiJ,et al. Preoperative color Doppler ultrasonographic examination in the planning of thoracodorsal artery perforator flap with capillary perforators[J].J Plast Reconstr Aesthet Surg,2016,69(3):346-350.DOI: 10.1016/j.bjps.2015.10.026.
[23]	MiyamotoS, ArikawaM, KagayaY, et al.Septocutaneous thoracodorsal artery perforator flaps: a retrospective cohort study[J].J Plast Reconstr Aesthet Surg,2019,72(1):78-84.DOI: 10.1016/j.bjps.2018.08.026.
[24]	FerrariM, SahovalerA, ChanHHL, et al.Scapular tip-thoracodorsal artery perforator free flap for total/subtotal glossectomy defects: case series and conformance study[J].Oral Oncol,2020,105:104660.DOI: 10.1016/j.oraloncology.2020.104660.
[25]	黄广涛,魏在荣,黄丽,等.二纵三横法在胸背动脉穿支皮瓣穿支定位及深度创面修复中的临床应用效果[J].中华烧伤与创面修复杂志,2022,38(2):165-169.DOI: 10.3760/cma.j.cn501120-20201207-00519.
[26]	王晓峰,李学渊,丁文全,等.胸背动脉穿支皮瓣的显微解剖及临床应用[J].中华显微外科杂志,2020,43(5):481-485.DOI: 10.3760/cma.j.cn441206-20200528-00244.
[27]	BidrosRS, MetzingerSE, GuerraAB. The thoracodorsal artery perforator-scapular osteocutaneous (TDAP-SOC) flap for reconstruction of palatal and maxillary defects[J]. Ann Plast Surg,2005,54(1):59-65. DOI: 10.1097/01.sap.0000139561.64564.d7.
[28]	董琛,余州,马显杰.皮肤软组织扩张方法与机制的研究进展[J].中华实验外科杂志,2019,36(8):1513-1517.DOI: 10.3760/cma.j.issn.1001-9030.2019.08.057.
[29]	AustadED, PasykKA, McClatcheyKD, et al.Histomorphologic evaluation of guinea pig skin and soft tissue after controlled tissue expansion[J].Plast Reconstr Surg,1982,70(6):704-710.DOI: 10.1097/00006534-198212000-00008.
[30]	LiHZ,WangZ,GuB,et al.Postburn neck reconstruction with preexpanded upper back perforator flaps: free-style design and an update of treatment strategies[J].Ann Plast Surg,2018,81(1):45-49.DOI: 10.1097/SAP.0000000000001491.
[31]	刘毅.重视供区的美容修复[J].中华烧伤杂志,2020,36(2):81-84.DOI: 10.3760/cma.j.issn.1009-2587.2020.02.001.
[32]	杜伟力,沈余明,胡骁骅,等.供瓣区美学修复方法的探讨[J].中华烧伤杂志,2020,36(2):97-105.DOI: 10.3760/cma.j.issn.1009-2587.2020.02.004.
[33]	TawaP, FoirestC, TankéréF, et al. Tongue reconstruction by thoracodorsal perforator flap: a new harvesting technique to reduce morbidity[J]. Ann Chir Plast Esthet,2019,64(4):368-373. DOI: 10.1016/j.anplas.2019.01.001.
[34]	LengletM, DastS, DessenaL, et al. Extension of the thoracodorsal artery perforator flap's pedicle: anatomical study[J]. Ann Chir Plast Esthet,2017,62(4):327-331. DOI: 10.1016/j.anplas.2017.01.001.
[35]	胡长青,连勇,白晓亮,等.游离胸背动脉穿支皮瓣修复小腿远端及足踝部创面九例[J].中华烧伤杂志,2018,34(4):240-242.DOI: 10.3760/cma.j.issn.1009-2587.2018.04.009.
[36]	马显杰, 丁健科. 皮肤软组织扩张术在儿童体表病损修复中的应用[J]. 中华烧伤与创面修复杂志,2022, 38(4): 301-305. DOI: 10.3760/cma.j.cn501120-20211019-00359.

1 右侧背部扩张胸背动脉穿支皮瓣游离移植整复例1患者火焰烧伤后颈部瘢痕挛缩畸形。1A.入院时，烧伤后颈部瘢痕挛缩畸形17个月余；1B.Ⅱ期术中设计右侧背部扩张胸背动脉穿支皮瓣；1C.完整剥离扩张皮瓣、离断血管蒂部中；1D.皮瓣切取后即刻；1E.右侧背部皮瓣供区缝合情况；1F.Ⅱ期术后即刻，扩张皮瓣重建颈部外观；1G.术后6个月随访，颈部皮瓣色泽接近面部正常皮肤，颈部功能恢复良好，皮瓣无明显瘢痕增生挛缩；1H.术后6个月随访，背部皮瓣供区瘢痕增生不明显

下载: 全尺寸图片幻灯片

2 左侧背部扩张胸背动脉穿支皮瓣游离移植整复例2患者热液烫伤后颈部瘢痕挛缩畸形。2A.入院时，烧伤后颈部瘢痕挛缩畸形48个月余；2B.Ⅱ期术中设计左侧背部扩张胸背动脉穿支皮瓣；2C.颈部瘢痕切除松解后创面情况；2D.扩张胸背动脉穿支皮瓣切取后即刻；2E.皮瓣切取后皮瓣供区缝合情况；2F.术后即刻，扩张皮瓣重建颈部外观；2G.术后6个月随访，左侧肩关节活动正常，皮瓣供区瘢痕增生不明显；2H. 术后6个月随访，皮瓣存活好，色泽与受区周围皮肤接近，颈部功能恢复良好，皮瓣瘢痕增生不明显

下载: 全尺寸图片幻灯片