不同类型游离穿支皮瓣组合在四肢复杂创面修复中的临床应用

李海; 肖顺娥; 邓呈亮; 吴必华; 吴祥奎; 张天华; 刘志远; 魏在荣

doi:10.3760/cma.j.cn501225-20220720-00300

不同类型游离穿支皮瓣组合在四肢复杂创面修复中的临床应用

doi: 10.3760/cma.j.cn501225-20220720-00300

遵义医科大学附属医院烧伤整形外科，遵义医科大学组织损伤修复与再生医学省部共建协同创新中心，遵义　　563003

基金项目:

省部共建协同创新中心项目 2020-39

详细信息

通讯作者:
邓呈亮，Email：cheliadeng@sina.com

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出版历程
- 收稿日期: 2022-07-20

Clinical application of combination of different types of free perforator flaps in the repair of complex wounds in extremities

Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, the Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi 563003, China

Funds:

Collaborative Innovation Center of Chinese Ministry of Education 2020-39

More Information

Corresponding author: Deng Chengliang, Email: cheliadeng@sina.com

摘要

摘要: 目的探讨不同类型游离穿支皮瓣组合在四肢复杂创面修复中的临床应用效果。方法采用回顾性观察性研究方法。2018年1月—2022年6月，遵义医科大学附属医院收治11例符合入选标准的四肢复杂创面患者，其中男8例、女3例，年龄28~55岁，创面位于上肢者4例、下肢者7例，均采用不同类型游离穿支皮瓣组合进行修复。清创后，创面面积为7.0 cm×6.0 cm~28.0 cm×12.0 cm。应用穿支皮瓣组合类型为旋股外侧动脉降支穿支3叶皮瓣者6例、旋股外侧动脉降支联合斜支穿支皮瓣者2例、旋股外侧动脉降支穿支分叶皮瓣联合对侧足底内侧动脉穿支皮瓣者2例、双侧旋股外侧动脉降支穿支皮瓣联合𧿹甲瓣者1例，单个皮瓣切取面积为2.0 cm×2.0 cm~25.0 cm×6.0 cm。对供瓣区创面行直接拉拢缝合或移植皮片/皮瓣修复。游离移植皮瓣时，根据皮瓣实际携带穿支情况进行裁剪、分叶，并将供区与受区血管进行端端或端侧吻合。术后观察原发受区移植皮瓣成活情况、是否发生血管危象，供瓣区创面愈合情况及供瓣区移植的皮片/皮瓣存活情况。随访时，观察原发受区移植皮瓣血运、外观及质地，同时观察足底受区负重情况以及皮瓣有无滑动、溃疡、窦道，手部外观及功能；观察供瓣区并发症情况。结果术后，1例患者原发受区移植皮瓣发生血管危象，经探查+静脉移植桥接后成活；1例患者原发受区移植股前外侧分叶皮瓣中的1叶发生部分坏死，经换药+皮片移植后痊愈；其余9例患者原发受区移植不同类型穿支皮瓣均成活。术后，直接缝合的供瓣区创面愈合良好，供瓣区移植的皮片或皮瓣均存活良好。随访3~24个月，原发受区移植皮瓣血运、外观及质地均良好，其中2例应用股前外侧皮瓣联合足底内侧皮瓣修复足底缺损者足底受区能负重活动，其皮瓣质地与足底正常皮肤接近，无皮瓣滑动、溃疡或窦道形成，1例采用双侧股前外侧皮瓣联合𧿹甲瓣修复手部联合前臂软组织缺损者手部尤其是拇指外观与功能均良好；供瓣区仅遗留线性瘢痕，无其他明显并发症。结论采用不同类型游离穿支皮瓣组合修复四肢复杂创面安全性高、疗效佳，并发症少，是一种可靠的临床方案。
- 穿支皮瓣 /
- 显微外科手术 /
- 四肢 /
- 软组织缺损 /
- 创面修复
Abstract: Objective To investigate the clinical application effects of combination of different types of free perforator flaps in the repair of complex wounds in extremities. Methods A retrospective observational study was conducted. From January 2018 to June 2022, 11 patients with complex wounds in extremities who met the inclusion criteria was admitted to the Affiliated Hospital of Zunyi Medical University, including 8 males and 3 females, aged 28 to 55 years. The wounds in the upper extremities in 4 cases and in the lower extremities in 7 cases were repaired with different combination of free perforator flaps. After debridement, the wound area was 7.0 cm×6.0 cm-28.0 cm×12.0 cm. A combination of different types of perforator flaps were applied, including the perforator tri-leaf flap of the descending branch of the lateral femoral circumflex artery in 6 cases, the descending branch of lateral femoral circumflex artery combined with oblique branch perforating branch flap in 2 cases, the lobulated flap of the descending branch of the lateral femoral circumflex artery combined with the contralateral medial plantar artery perforator flap in 2 cases, and the bilateral perforator flap of the descending branch of lateral femoral circumflex artery combined with great toe nail flap in 1 case, with the size of a single flap ranged from 2.0 cm×2.0 cm-25.0 cm×6.0 cm. The donor site was repaired by direct suture, skin grafting, or flap transplantation. During free flap transplantation, the flap was cut and split according to the distribution of perforators, and end-to-end or end-to-side anastomosis was performed between the donor area and the recipient area. After surgery, the survival of transplanted flap in the primary recipient site, the occurrence of vascular crisis, the wound healing in the flap donor site, and the survival of transplanted skin or flap in the flap donor site were observed. During follow-up, the blood supply, appearance and texture of the transplanted flap in the primary recipient site were observed; and at the same time, the weight bearing of the plantar receiving area, the presence of sliding, ulcers, and sinus tracts of the flap, and the appearance and function of the hand were observed; the complications in the donor area were observed. Results After surgery, one patient's transplanted flap in the primary recipient site had vascular crisis but survived after exploration+vein graft bridging; partial necrosis occurred in one lobe of anterolateral thigh lobulated flap transplanted to the primary recipient site in one patient and recovered after dressing change+skin grafting, and the different types of perforator flap transplanted to the primary recipient site in the other 9 patients all survived. After surgery, the wound with direct suture at the donor site healed well, and the skin or flap transplanted to the donor area survived well. During 3-24 months of follow-up, the blood supply, appearance, and texture of the transplanted flap at the primary recipient site were good. In two patients, the anterolateral thigh flap combined with the medial plantar flap were used to repair plantar defects. The plantar receiving area was able to bear weight, and the texture of the flaps in the recipient area was close to the normal plantar skin, without flap sliding, ulcer, or sinus tract formation. In one patient, bilateral anterolateral thigh flap combined with great toe nail flap were used to repair hand combined with soft forearm defect, and the appearance and function of hand, especially thumb were good. Only linear scar was left in the donor site without other obvious complications. Conclusions The combination of different types of perforator flaps is a reliable clinical method to repair complex wounds in extremities with high safety, good efficacy, and less complications.
- Perforator flap /
- Microsurgery /
- Extremities /
- Soft tissue defect /
- Wound repair
李海：酝酿和设计研究、实施手术、采集资料、分析数据与撰写文章；肖顺娥：实施手术、修改文章；邓呈亮：酝酿和设计研究、采集资料、分析数据、修改文章；吴必华、吴祥奎、张天华：实施手术；刘志远：随访病例；魏在荣：指导手术、经费支持

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1 旋股外侧动脉降支3叶皮瓣游离移植修复患者右手爆炸伤创面。1A、1B.分别为伤后清创即刻背侧、屈侧情况，可见右手虎口区、环指桡侧、小指桡侧皮肤软组织缺损，肌腱外露，第2掌骨以远复合组织缺损，中指掌指关节以远、环指近节近端以远缺损，用克氏针固定脱位的第1掌腕关节，用克氏针固定并复位骨折的环指、小指指骨；1C.设计股前外侧皮瓣；1D.切取的皮瓣携带4条穿支，皮瓣分为3叶，其中1叶嵌合肌肉瓣；1E、1F.分别为术后即刻背侧、屈侧情况；1G、1H.分别为术后11个月随访时背侧、屈侧情况，皮瓣存活良好，拇指、小指抓握功能及虎口张开情况良好

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