以胸廓内动脉穿支为蒂的预扩张胸三角皮瓣游离移植整复面部瘢痕的临床效果

何林; 朱婵; 贾晶; 周林; 张卓; 舒茂国

doi:10.3760/cma.j.cn501225-20220123-00012

以胸廓内动脉穿支为蒂的预扩张胸三角皮瓣游离移植整复面部瘢痕的临床效果

doi: 10.3760/cma.j.cn501225-20220123-00012

何林¹,
朱婵²,
贾晶¹,
周林¹,
张卓¹,
舒茂国^1, ,

1.
西安交通大学第一附属医院整形美容颌面外科，西安　　710061
2.
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

基金项目:

陕西省重点研发计划 2023-YBSF-179

西安交通大学第一附属医院新医疗新技术 XJYFY-2020W13

详细信息

通讯作者:
舒茂国，Email：shumaoguo@163.com

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出版历程
- 收稿日期: 2022-01-23

Clinical effects of free pre-expanded internal thoracic artery perforator pedicled deltopectoral flap transfer in facial scar reconstruction

1.
Department of Plastic, AestheticMaxillofacial Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
2.
Department of Burns and Cutaneous Surgery, Burn Center of PLA, the First Affiliated Hospital, Air Force Medical University, Xi'an 710032, China

Funds:

Key Research and Development Plan of Shaanxi Province of China 2023-YBSF-179

New Medical Technology of the First Affiliated Hospital of Xi'an Jiaotong University XJYFY-2020W13

More Information

Corresponding author: Shu Maoguo, Email: shumaoguo@163.com

摘要

摘要: 目的探讨通过彩色多普勒超声行术前血管评估，选取合适的胸廓内动脉穿支并以其为蒂，行预扩张胸三角皮瓣游离移植整复面部瘢痕的临床效果。方法采用回顾性观察性研究方法。2017年9月—2021年3月，西安交通大学第一附属医院收治11例符合入选标准的面部瘢痕患者，其中男6例、女5例，年龄16~58（31±12）岁，瘢痕面积7 cm×5 cm~14 cm×9 cm，均采用以胸廓内动脉穿支为蒂的预扩张胸三角皮瓣游离移植整复。手术分2期或3期进行，术前用彩色多普勒超声对胸廓内动脉血管穿支进行评估。Ⅰ期行皮肤软组织扩张器（以下简称扩张器）置入术，于胸壁置入1个额定容量为400~600 mL的圆柱形扩张器，扩张3~4个月，注水量为扩张器额定容量的1.2~1.5倍。Ⅱ期行瘢痕切除+预扩张胸三角皮瓣游离移植术，皮瓣切取面积为9 cm×7 cm~16 cm×10 cm。将皮瓣血管蒂（胸廓内动脉肋间穿支血管）与面动静脉或者颞浅动静脉进行端端吻合，供区创面直接缝合。5例患者因皮瓣蒂部臃肿在Ⅱ期术后3~6个月行Ⅲ期皮瓣修薄术。在末次手术后6个月统计皮瓣存活、并发症发生情况，并采用塞姆斯温斯坦单丝测验评价皮瓣感觉，将皮瓣与周围正常皮肤颜色进行对比来评价色泽，采用利克特5级量表评价患者的疗效满意度。结果末次手术后6个月，11例患者皮瓣全部存活良好。1例患者皮瓣移植术后出现静脉危象，行二次血管吻合后皮瓣成活；1例患者在Ⅰ期扩张器置入术后出现血肿，清除后未影响后续治疗；所有患者均无感染、扩张器外露等并发症发生。末次手术后6个月，患者皮瓣感觉：9例达到保护性感觉减弱及以上，1例保护性感觉缺失，1例仅存在深部触压觉；患者皮瓣色泽：3例与周围正常皮肤颜色非常接近，6例与周围正常皮肤颜色接近，2例与周围正常皮肤颜色有差异；患者的疗效满意度：2例非常满意，6例满意，2例一般满意，1例有点不满意。结论对于大面积面部瘢痕，通过彩色多普勒超声行术前血管评估，选取合适的单一胸廓内动脉穿支作为血管蒂进行预扩张胸三角皮瓣游离移植整复安全有效。术后患者面部皮瓣颜色与周围正常皮肤组织接近，并可恢复部分感觉，患者对疗效的满意度高。
- 瘢痕 /
- 面部 /
- 穿支皮瓣 /
- 超声检查，多普勒，彩色 /
- 显微外科手术 /
- 皮肤扩张术 /
- 胸廓内动脉
Abstract: Objective To explore the clinical effects of free pre-expanded deltopectoral flap transfer in facial scar reconstruction by selecting appropriate internal thoracic artery perforator as the pedicle through preoperative color Doppler ultrasonic vascular assessment. Methods A retrospective observational study was conducted. From September 2017 to March 2021, 11 patients with facial scar who met the inclusion criteria were admitted to the First Affiliated Hospital of Xi'an Jiaotong University, including 6 males and 5 females, aged 16-58 (31±12) years. The scar with area ranging from 7 cm×5 cm to 14 cm×9 cm was reconstructed by free pre-expanded internal thoracic artery perforator pedicled deltopectoral flap transfer. The operation was performed in 2 or 3 stages. Before operation, color Doppler ultrasonography was performed to evaluate the internal thoracic artery perforator. In the first stage, skin and soft tissue expander (hereinafter referred to as expander) implantation was performed, and a cylindrical expander with rated capacity of 400 to 600 mL was placed in the chest wall. The expansion time was 3 to 4 months, and the water injection volume reached 1.2-1.5 times of the rated capacity of expander. In the second stage, scar excision+free pre-expanded deltopectoral flap transfer was performed, with harvested flap area ranging from 9 cm×7 cm to 16 cm×10 cm. The vascular pedicle of flap (intercostal perforator of internal thoracic artery) was anastomosed end-to-end to the facial artery and vein or superficial temporal artery and vein. The wound in donor site was closed directly. Third stage operation thinning was performed at 3-6 months after the second stage operation in 5 patients because of bloated flap pedicle. At 6 months after the last operation, the flap survival and complications were recorded, the sensation of flap was evaluated by Semmes-Weinstein monofilament test, the color of flap was evaluated by color contrast of the flap to surrounding normal skin, and the curative effect satisfaction degree of patients was evaluated by 5-grade Likert scale. Results At 6 months after the last operation, all the flaps of 11 patients survived well. One patient experienced venous congestion after flap transplantation, but the flap survived after re-anastomosis. One patient experienced hematoma after the first stage operation of expander implantation, but the rest treatment was not influenced after hematoma removal. No complications such as infection or expander exposure occurred in any patient. At 6 months after the last operation, the sensation of flap of patient was as follows: 9 cases recovered to protective sensation decrease or better, 1 case had protective sensation defect, and 1 case only had deep touch and pressure sensation; the color of flap of patient was as follows: 3 cases were very close to the color of surrounding normal skin, 6 cases were close to the color of surrounding normal skin, and 2 cases were different to the color of surrounding normal skin; the curative effect satisfaction degree of patients was as follows: 2 patients were very satisfied, 6 patients were satisfied, 2 patients were somewhat satisfied, and 1 patient was a little not satisfied. Conclusions The large area facial scar can be treated safely and effectively by free pre-expanded deltopectoral flap with appropriate single internal thoracic artery perforator as vascular pedicle selected through vascular assessment by color Doppler ultrasonography before operation. After operation, the color of flap of patients is close to the surrounding normal skin and the sensation of flap can be partially recovered, with high curative effect satisfaction degree of patients.
- Cicatrix /
- Face /
- Perforator flap /
- Ultrasonography, Doppler, color /
- Microsurgery /
- Skin expansion /
- Internal thoracic artery
何林：手术操作、数据收集、论文撰写、经费支持；朱婵：瘢痕治疗、论文审阅、数据处理；贾晶、周林、张卓：手术操作、数据收集；舒茂国：手术指导、论文审阅

所有作者均声明不存在利益冲突

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参考文献(36)

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1 以胸廓内动脉穿支为蒂的预扩张胸三角皮瓣游离移植整复例1患者面部瘢痕伴眼球外露的效果。1A.Ⅰ期术前可见右面部瘢痕、右眼睑缺损、右侧鼻翼部分缺损，瘢痕挛缩致下睑严重外翻及鼻翼、口角牵拉变形；1B.胸壁置入的皮肤软组织扩张器注水扩张完成后，扩张皮肤无破溃；1C.皮瓣预处理后；1D.切取以胸廓内动脉第2肋间穿支为蒂的预扩张胸三角皮瓣；1E.Ⅱ期皮瓣移植术后即刻；1F.Ⅲ期术后半年，面部外观良好，皮瓣颜色与周围正常皮肤接近，右眼睑缺损得到修复

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2 移植2种扩张皮瓣整复例2患者双侧面部瘢痕的效果。2A.左面部Ⅰ期术前，瘢痕色泽较深，伴口角牵拉变形；2B.右面部Ⅰ期术前，瘢痕色泽不均，伴口角牵拉变形；2C.左面部置入的皮肤软组织扩张器注水扩张完成后；2D.切取以胸廓内动脉第2肋间穿支为蒂的预扩张胸三角皮瓣；2E、2F.分别为左面部、右面部Ⅱ期术后1年，面部外观良好，左面部皮瓣颜色与周围正常皮肤一致，右面部皮瓣颜色与周围正常皮肤非常接近

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