Abdominal function and appearance of patients after repairing the extensive skin and soft tissue defects in the limbs with two types of lower abdominal tissue flaps
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摘要:
目的 研究用2种下腹部组织瓣修复四肢大面积皮肤软组织缺损后患者的腹部功能与外形。 方法 采用回顾性临床对照研究方法。2016年6月—2022年10月，山东省文登整骨医院骨手显微外科收治符合入选标准的四肢大面积皮肤软组织缺损患者17例，其中男2例、女15例，年龄21~60岁，缺损范围为15.0 cm×10.0 cm~23.0 cm×15.0 cm。按照采用的修复方法，将患者分为采用腹壁下动脉穿支（DIEP）皮瓣游离移植修复缺损创面的DIEP皮瓣组（9例）和采用保留部分肌肉的横行腹直肌肌皮瓣游离移植修复缺损创面的保留部分肌肉的横行腹直肌肌皮瓣组（8例）。术后1、3、5、7、14 d，采用自制组织瓣血运评估量表对组织瓣血运进行评价；术后12个月，采用皮瓣疗效满意度评分标准评价患者对组织瓣修复疗效的满意度；术前、术后3个月、术后12个月，采用自制腹壁强度评价量表对腹壁强度进行评价；术后12个月，采用自制腹部外形评价量表对腹部瘢痕情况、腹部对称程度、脐部外形及复位情况、穿衣过程中腹部隆起情况、腹部两侧褶皱形成情况进行评价。对数据行重复测量方差分析、独立样本 t检验、配对样本 t检验、Fisher确切概率法检验。 结果 术后1、3、5、7、14 d，2组患者组织瓣血运评分均无明显变化，组间比较差异均无统计学意义（ P>0.05）。术后12个月，DIEP皮瓣组患者对组织瓣修复疗效的满意比为8/9，与保留部分肌肉的横行腹直肌肌皮瓣组的7/8相近（ P>0.05）。2组患者术前腹壁强度相近（ P>0.05），DIEP皮瓣组患者术后3、12个月腹壁强度均明显强于保留部分肌肉的横行腹直肌肌皮瓣组（ t值分别为3.09、3.02， P<0.05）；与组内术前比较，DIEP皮瓣组患者术后3个月腹壁强度及保留部分肌肉的横行腹直肌肌皮瓣组患者术后3、12个月腹壁强度均明显减弱（ t值分别为6.04、9.71、2.91， P<0.05），DIEP皮瓣组患者术后12个月腹壁强度无明显变化（ P>0.05）。术后12个月，2组患者腹部瘢痕情况、腹部对称程度、脐部外形及复位情况、穿衣过程中腹部隆起情况、腹部两侧褶皱形成情况评分均相近（ P>0.05）。 结论 游离移植DIEP皮瓣和保留部分肌肉的横行腹直肌肌皮瓣修复四肢大面积皮肤软组织缺损都能获得良好的修复效果，包括良好的组织瓣血运和腹部外形，患者对组织瓣修复疗效的满意度均较高；但DIEP皮瓣较保留部分肌肉的横行腹直肌肌皮瓣在术后远期腹壁强度恢复方面更优，应用前景更为广阔。 Abstract:Objective To study the abdominal function and appearance of patients after repairing the extensive skin and soft tissue defects in the limbs with two types of lower abdominal tissue flaps. Methods A retrospective clinical controlled study was conducted. From June 2016 to October 2022, 17 patients with extensive skin and soft tissue defects in the limbs who met the inclusion criteria were admitted to the Department of Bone Hand Microsurgery of Shandong Wendeng Orthopedic Hospital, including 2 males and 15 females, aged 21-60 years, with a defect ranging from 15.0 cm×10.0 cm to 23.0 cm×15.0 cm. According to the applied repair method, the patients were divided into deep inferior epigastric perforator (DIEP) flap group (9 cases) with the defect wound being repaired by the DIEP flap and muscle sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap group (8 cases) with the defect wound being repaired by the MS-TRAM flap. On post surgery day (PSD) 1, 3, 5, 7, and 14, the blood supply of the tissue flaps was evaluated using a self-made tissue flap blood supply evaluation scale. At 12 months after surgery, the patients' satisfaction with the efficacy of tissue flap repair was evaluated using the satisfaction score standard for flap efficacy. Before surgery and at 3 and 12 months after surgery, a self-made abdominal wall strength evaluation scale was used to evaluate the strength of abdominal wall. At 12 months after surgery, a self-made abdominal appearance evaluation scale was used to evaluate the condition of abdominal scars, degree of abdominal symmetry, the appearance and restoration of umbilicus, abdominal protrusion during dressing, and formation of folds on both sides of the abdomen. Data were statistically analyzed with analysis of variance for repeated measurement, independent sample t test, paired sample t test, and Fisher's exact probability test. Results On PSD 1, 3, 5, 7, and 14, there was no significant change in the blood supply score of tissue flaps of patients in the two groups, and there was no statistically significant difference between the two groups ( P>0.05). At 12 months after surgery, the satisfaction ratio of patients in DIEP flap group with tissue flap repair efficacy was 8/9, which was close to 7/8 in MS-TRAM flap group ( P>0.05). The preoperative abdominal wall strength of patients between the two groups was similar ( P>0.05), while the abdominal wall strength of patients in DIEP flap group was significantly stronger than that in MS-TRAM flap group at 3 and 12 months after surgery (with t values of 3.09 and 3.02, respectively, P<0.05). Compared with the preoperative strength within each group, the abdominal wall strength of patients in DIEP flap group at 3 months after surgery and in MS-TRAM flap group at 3 and 12 months after surgery decreased significantly (with t values of 6.04, 9.71, and 2.91, respectively, P<0.05), which did not change significantly in DIEP flap group at 12 months after surgery ( P>0.05). At 12 months after surgery, the scores of abdominal scars, degree of abdominal symmetry, the appearance and restoration of umbilicus, abdominal protrusion during dressing, and formation of folds on both sides of the abdomen of patients were similar between the two groups ( P>0.05). Conclusions Free transplantation of DIEP flap and MS-TRAM flap to repair the extensive skin and soft tissue defects in the limbs can achieve good repair results, including good blood supply of tissue flap and abdominal shape, and the patients' high degree of satisfaction with the efficacy of tissue flap repair. However, DIEP flap is superior to MS-TRAM flap in terms of long-term postoperative abdominal wall strength recovery, showing a broader prospect of application. -
参考文献
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1 三维CT血管造影（CTA）辅助腹壁下动脉穿支（DIEP）皮瓣游离移植修复例1鳞状细胞癌患者左大腿外侧皮肤癌变组织切除后形成的创面。1A.术前大腿外侧创面；1B、1C、1D.分别为术前采用三维CTA检查明确的穿支血管数量、走行及体表位置；1E.设计DIEP皮瓣；1F.切取DIEP皮瓣后即刻；1G.皮瓣转移至受区缝合后即刻；1H.缝合损伤腹壁后即刻；1I.设计脐部重建位置；1J.术后1年，皮瓣外形、颜色良好；1K.术后1年，供区仅留有线性瘢痕，腹部对称程度高（左侧为正面观、右侧为侧面观）；1L.术后1年，腹壁强度较好
注：横箭头指示腹壁下动脉主干，竖箭头指示腹壁下动脉的穿支血管
2 三维CT血管造影（CTA）辅助保留部分肌肉的横行腹直肌肌皮瓣游离移植修复例2患者左大腿外侧交通伤后创面。2A.术前大腿外侧清创后创面；2B.术前采用三维CTA检查，明确腹壁下动脉（箭头所示）走行及体表位置（上图为矢状面图像，下图为三维图像）；2C.设计保留部分肌肉的横行腹直肌肌皮瓣；2D.切取保留部分肌肉的横行腹直肌肌皮瓣后即刻；2E.皮瓣转移至受区缝合后即刻；2F.术后1年，肌皮瓣外形、颜色良好；2G.术后1年，供区正面观仅见线性瘢痕，腹部对称程度高；2H.术后1年，供区侧面观仅见线性瘢痕，腹部外形佳
表1 2组四肢大面积皮肤软组织缺损患者临床资料比较
表1. Comparison of clinical data between two groups of patients with extensive skin and soft tissue defects in the limbs
组别 例数 性别（例） 年龄 （岁， 身体质量指数（kg/m 2， 创面面积（cm 2， 皮瓣面积（cm 2， 男 女 腹壁下动脉穿支皮瓣组 9 1 8 36±6 22±3 253±72 285±87 保留部分肌肉的横行腹直肌肌皮瓣组 8 1 7 37±5 23±3 260±76 291±90 统计量值 — t=0.23 t=0.33 t=0.19 t=0.14 P值 1.000 0.816 0.746 0.850 0.886 注：“—”表示无此项 
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表2 2组四肢大面积皮肤软组织缺损患者术后不同时间点组织瓣血运评分比较（分，
表2. Comparison of tissue flap blood supply scores at different time points after surgery between two groups of patients with extensive skin and soft tissue defects in the limbs
组别 例数 1 d 3 d 5 d 7 d 14 d 腹壁下动脉穿支皮瓣组 9 3.91±0.08 3.85±0.07 3.82±0.10 3.76±0.13 3.75±0.14 保留部分肌肉的横行腹直肌肌皮瓣组 8 3.95±0.09 3.88±0.09 3.85±0.11 3.79±0.12 3.77±0.12 t值 0.97 0.77 0.58 0.49 0.31 P值 0.347 0.452 0.564 0.630 0.758 注：处理因素主效应， F=1.74， P=0.309；时间因素主效应， F=1.63， P=0.352；两者交互作用， F=1.01， P=0.473
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表3 2组四肢大面积皮肤软组织缺损患者不同时间点腹壁强度评分比较（分，
表3. Comparison of abdominal wall strength scores at different time points between two groups of patients with extensive skin and soft tissue defects in the limbs
组别 例数 术前 术后3个月 术后12个月 t 1值 P 1值 t 2值 P 2值 腹壁下动脉穿支皮瓣组 9 4.8±0.5 2.7±0.9 4.7±0.4 6.04 <0.001 0.21 0.835 保留部分肌肉的横行腹直肌肌皮瓣组 8 4.7±0.4 1.3±0.8 3.6±0.9 9.71 <0.001 2.91 0.011 t值 0.16 3.09 3.02 P值 0.872 0.007 0.008 注：处理因素主效应， F=5.30， P=0.012；时间因素主效应， F=4.73， P=0.020；两者交互作用， F=4.91， P=0.019； t值、 P值为2组间各时间点比较所得； t 1值、 P 1值， t 2值、 P 2值分别为组内术后3、12个月和术前比较所得
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表4 2组四肢大面积皮肤软组织缺损患者术后12个月腹部外形评分比较（分，
表4. Comparison of abdominal appearance scores at 12 months after surgery between two groups of patients with extensive skin and soft tissue defects in the limbs
组别 例数 腹部瘢痕情况 腹部对称程度 脐部外形及复位情况 穿衣过程中腹部隆起情况 腹部两侧褶皱形成情况 腹壁下动脉穿支皮瓣组 9 3.3±1.0 4.6±0.5 4.5±0.8 4.7±0.8 4.4±0.7 保留部分肌肉的横行腹直肌肌皮瓣组 8 3.5±0.9 4.5±0.5 4.3±0.7 4.5±0.7 4.3±0.6 t值 0.43 0.33 0.39 0.48 0.35 P值 0.672 0.743 0.698 0.635 0.731
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