Effects of four types of perforator flaps pedicled with cutaneous neurotrophic vessels in repairing wounds on the volar side of hands
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摘要:
目的 探讨采用4种皮神经营养血管带蒂穿支皮瓣修复手部掌侧创面的效果。 方法 采用回顾性观察性研究方法。2012年5月—2021年7月，唐山市第二医院手外科收治122例符合入选标准的手部掌侧创面患者，其中男74例、女48例，年龄18~76岁，包括单纯手掌损伤者15例、单纯手指损伤者101例、手掌和手指同时受损者6例。创面面积为1.5 cm×1.2 cm~15.0 cm×6.0 cm，均经移植皮神经营养血管带蒂穿支皮瓣修复，其中移植带前臂内侧皮神经的尺动脉穿支皮瓣者16例、移植带掌背皮神经的掌背动脉穿支皮瓣者20例、移植带前臂外侧皮神经终末支的拇指指动脉背侧穿支皮瓣者21例、移植带指神经背侧支的第2~5指指动脉背侧穿支皮瓣者65例，皮瓣面积为1.8 cm×1.4 cm~20.0 cm×6.0 cm。术前行高频彩色多普勒超声检查对皮瓣穿支血管及皮神经进行定位和测量，术中均将皮瓣携带皮神经与受区神经吻合。将供瓣区创面直接闭合，或移植同侧大腿/前臂近端内侧游离中厚/全厚皮片修复。术后观察皮瓣与供瓣区移植皮片成活情况及供瓣区切口愈合情况。随访患者并于末次随访时，测量皮瓣静态两点辨别觉距离，参照Michigan手部功能问卷评定标准评估患者对皮瓣及供瓣区外观的满意度，根据中华医学会手外科学会上肢部分功能评定试用标准评定患手功能。 结果 术后，1例患者移植的带前臂内侧皮神经的尺动脉穿支皮瓣及2例患者移植的带指神经背侧支的第2~5指指动脉背侧穿支皮瓣远端部分坏死，经换药处理愈合；其余119例患者移植的皮瓣均成活。术后供瓣区移植皮片均成活，供瓣区切口均愈合。随访时间为10~36个月，平均16个月。末次随访时，带前臂内侧皮神经的尺动脉穿支皮瓣静态两点辨别觉距离为10~20 mm，皮瓣外观满意度评估：非常满意者10例、满意者6例，供瓣区外观满意度评估：非常满意者7例、满意者9例，患手功能评定：优者7例、良者7例、可者2例；带掌背皮神经的掌背动脉穿支皮瓣静态两点辨别觉距离为8~18 mm，皮瓣外观满意度评估：非常满意者13例、满意者7例，供瓣区外观满意度评估：非常满意者10例、满意者10例，患手功能评定：优者11例、良者7例、可者2例；带前臂外侧皮神经终末支的拇指指动脉背侧穿支皮瓣静态两点辨别觉距离为6~11 mm，皮瓣外观满意度评估：非常满意者17例、满意者4例，供瓣区外观满意度评估：非常满意者13例、满意者8例，患手功能评定：优者15例、良者6例；带指神经背侧支的第2~5指指动脉背侧穿支皮瓣静态两点辨别觉距离为5~12 mm，皮瓣外观满意度评估：非常满意者43例、满意者22例，供瓣区外观满意度评估：非常满意者47例、满意者18例，患手功能评定：优者39例、良者21例、可者5例。 结论 在高频彩色多普勒超声辅助下，应用4种皮神经营养血管带蒂穿支皮瓣修复手部掌侧不同类型创面，皮瓣血供可靠、切取方便，供区继发损伤小，术后皮瓣感觉恢复较好。 Abstract:Objective To investigate the effects of four types of perforator flaps pedicled with cutaneous neurotrophic vessels in repairing wounds on the volar side of hands. Methods A retrospective observational study was conducted. From May 2012 to July 2021, 122 patients with wounds on the volar side of hands who met the inclusion criteria were admitted to the Department of Hand Surgery of the Second Hospital of Tangshan, including 74 males and 48 females, aged 18-76 years. There were 15 cases of palm injury alone, 101 cases of finger injury alone, and 6 cases of simultaneous palm and finger injury. The wounds with area ranging from 1.5 cm×1.2 cm to 15.0 cm×6.0 cm were all repaired by transplantation of perforator flaps pedicled with cutaneous neurotrophic vessels, including 16 cases of the ulnar artery perforator flap carrying the medial antebrachial cutaneous nerve, 20 cases of the dorsal metacarpal artery perforator flap carrying the dorsal metacarpal cutaneous nerve, 21 cases of the digital artery dorsal perforator flap of thumb carrying the terminal branch of lateral antebrachial cutaneous nerve, and 65 cases of the digital artery dorsal perforator flap of the 2 nd to 5 th finger carrying the dorsal branch of digital nerve, with the sizes of flaps ranging from 1.8 cm×1.4 cm to 20.0 cm×6.0 cm. High-frequency color Doppler ultrasonography was performed to locate and measure the perforators and cutaneous nerves of the flaps preoperatively. The cutaneous nerves carried by the flaps were all anastomosed with the nerves at the recipient sites during the operation. The donor sites were closed directly or repaired with split- or full-thickness free skin graft from the ipsilateral thigh or proximal medial forearm. The survival of the flaps and skin grafts at the flap donor sites, and the healing of incisions at the flap donor sites were observed postoperatively. The patients were followed up, and at the last follow-up, the static two-point discrimination distances of the flaps were measured, the degree of satisfaction of patients with the appearances of the flaps and flap donor sites were evaluated based on the evaluation criteria of Michigan Hand Function Questionnaire, and the functions of the affected hands were evaluated according to the trial criteria for upper limb function evaluation of the Hand Surgery Society of the Chinese Medical Association. Results After surgery, the distal end of the ulnar artery perforator flap carrying the medial antebrachial cutaneous nerve transplanted in one patient and the digital artery dorsal perforator flap of the 2 nd to 5 th finger carrying the dorsal branch of digital nerve transplanted in two patients were partially necrotic but healed after dressing change; the flaps transplanted in the other 119 patients all survived. All skin grafts at the flap donor sites survived, and all incisions at the flap donor sites healed after surgery. The follow-up period was 10 to 36 months, with an average of 16 months. At the last follow-up, the static two-point discrimination distances of the ulnar artery perforator flaps carrying the medial antebrachial cutaneous nerve was 10 to 20 mm. Ten patients were strongly satisfied and 6 patients were satisfied in the evaluation of satisfaction with the appearance of the flaps. Seven patients were strongly satisfied and 9 patients were satisfied in the evaluation of satisfaction with the appearance of the flap donor sites. Functional evaluation of the affected hand was excellent in 7 cases, good in 7 cases, and fair in 2 cases. For the dorsal metacarpal artery perforator flap carrying the dorsal metacarpal cutaneous nerve, the static two-point discrimination distances of the flaps was 8 to 18 mm; 13 patients were strongly satisfied and 7 patients were satisfied in the evaluation of satisfaction with the appearance of the flaps; 10 patients were strongly satisfied and 10 patients were satisfied in the evaluation of satisfaction with the appearance of the flap donor sites; the functional evaluation of the affected hand was excellent in 11 cases, good in 7 cases, and fair in 2 cases. For the digital artery dorsal perforator flap of thumb carrying the terminal branch of lateral antebrachial cutaneous nerve, the static two-point discrimination distances of the flaps was 6 to 11 mm; 17 patients were strongly satisfied and 4 patients were satisfied in the evaluation of satisfaction with the appearance of the flaps; 13 patients were strongly satisfied and 8 patients were satisfied in the evaluation of satisfaction with the appearance of the flap donor sites; the functional evaluation of the affected hand was excellent in 15 cases and good in 6 cases. For the digital artery dorsal perforator flap of the 2 nd to 5 th finger carrying the dorsal branch of digital nerve, the static two-point discrimination distances of the flaps was 5 to 12 mm; 43 patients were strongly satisfied and 22 patients were satisfied in the evaluation of satisfaction with the appearance of the flaps; 47 patients were strongly satisfied and 18 patients were satisfied in the evaluation of satisfaction with the appearance of the flap donor sites; the functional evaluation of the affected hands were excellent in 39 cases, good in 21 cases, and fair in 5 cases. Conclusions With the assistance of high-frequency color Doppler ultrasonography, four types of perforator flaps pedicled with cutaneous neurotropic vessels which are used to repair different types of wounds on the volar side of the hand can have reliable blood supply, are easy to cut, cause minimal secondary damage to the donor area, and have good recovery of the flap sensation after surgery. -
Key words:
- Hand injuries /
- Surgical flaps /
- Perforator flap /
- Ultrasonography, Doppler, color /
- Cutaneous nerve /
- Wound repair
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参考文献
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1 带前臂内侧皮神经的尺动脉腕上穿支螺旋桨皮瓣修复机器绞伤致例1患者右手掌侧及右腕尺侧创面的效果。1A.术前，右手掌侧及右腕尺侧创面；1B.皮瓣设计；1C.皮瓣切取后即刻，止血钳指示尺动脉腕上穿支；1D.术后即刻皮瓣外观；1E.术后6个月,皮瓣外形良好，不臃肿，颜色与周围组织相近
2 带掌背皮神经的第2掌背动脉穿支皮瓣修复压砸伤致例2患者左手掌远端及中指近节掌侧创面的效果。2A.术前，左手掌远端及中指近节掌侧创面；2B.皮瓣切取中；2C.术后即刻皮瓣外观；2D.术后4个月,皮瓣外形良好；2E.术后4个月,左手各指掌屈活动良好；2F.术后4个月,左手背供区残留轻微线性瘢痕
3 带前臂外侧皮神经终末支的同指指动脉背侧穿支皮瓣修复机器绞伤致例3患者左拇指掌侧创面的效果。3A.术前，左拇指掌侧创面；3B.皮瓣切取中，下方手术镊指示前臂外侧皮神经终末支；3C.术后即刻皮瓣外观；3D.术后18个月皮瓣外形良好，供区仅残留轻微线性瘢痕；3E.术后18个月，左拇、小指对指活动良好
4 带指神经背侧支的同指指动脉背侧穿支皮瓣修复压砸伤致例4患者左手中、环指掌侧创面的效果。4A.术前，左手中、环指掌侧创面；4B.皮瓣设计；4C.术后即刻皮瓣外观；4D.术后6个月，皮瓣外形良好；4E.术后6个月，左手中、环指掌屈活动良好；4F.术后6个月，左手中、环指皮瓣供区植皮愈合良好，无明显凹陷，边缘残留轻微环形瘢痕
表1 4种皮神经营养血管带蒂穿支皮瓣修复122例患者手部掌侧创面后末次随访时的功能与外观情况
表1. Appearance and function of 122 patients with wounds on the volar side of hands repaired with four types of perforator flaps pedicled with cutaneous neurotrophic vessels at the last follow-up
皮瓣名称 例数 皮瓣静态两点辨别觉距离（mm） 患者对皮瓣外观的满意度（例） 患者对供瓣区外观的满意度（例） 患手功能（例） 非常满意 满意 非常满意 满意 优 良 可 带前臂内侧皮神经的尺动脉穿支皮瓣 16 10~20 10 6 7 9 7 7 2 带掌背皮神经的掌背动脉穿支皮瓣 20 8~18 13 7 10 10 11 7 2 带前臂外侧皮神经终末支的拇指指动脉背侧穿支皮瓣 21 6~11 17 4 13 8 15 6 0 带指神经背侧支的第2~5指指动脉背侧穿支皮瓣 65 5~12 43 22 47 18 39 21 5 
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