彩色多普勒超声辅助下超薄胸背动脉穿支皮瓣的切取方案及临床应用效果

赵书明; 刘娜; 刘学亮; 冀少林

doi:10.3760/cma.j.cn501225-20231012-00111

彩色多普勒超声辅助下超薄胸背动脉穿支皮瓣的切取方案及临床应用效果

doi: 10.3760/cma.j.cn501225-20231012-00111

1.
华北医疗健康集团邢台总医院骨三科，邢台　　054000
2.
华北医疗健康集团邢台总医院医务部，邢台　　054000
3.
山东大学附属山东省立第三医院创伤与手足外科，济南　　250031

基金项目:

河北省重点研发计划自筹项目 182777243

详细信息

通讯作者:
冀少林，Email：315509203@qq.com

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出版历程
- 收稿日期: 2023-10-12

Cutting scheme and clinical application effects of ultrathin thoracodorsal artery perforator flap assisted by color Doppler ultrasound

1.
The Third Department of Orthopedics, Xingtai General Hospital of North China Medical and Health Group, Xingtai 054000, China
2.
Department of Medical Affairs, Xingtai General Hospital of North China Medical and Health Group, Xingtai 054000, China
3.
Department of Trauma and Hand and Foot Surgery, Shandong Provincial Third Hospital Affiliated to Shandong University, Jinan 250031, China

Funds:

The Self-funded Project of the Key Research and Development Plan of Hebei Province of China 182777243

More Information

Corresponding author: Ji Shaolin, Email: 315509203@qq.com

摘要

摘要: 目的探讨彩色多普勒超声辅助下超薄胸背动脉穿支皮瓣的切取方案及临床应用效果。方法该研究为回顾性历史对照研究。将2017年2月—2019年10月华北医疗健康集团邢台总医院骨三科（以下简称本科室）收治的20例符合入选标准且采用根据术者临床经验设计、切取的超薄胸背动脉穿支皮瓣修复四肢皮肤软组织缺损的患者作为对照组，其中男16例、女4例，年龄（37±5）岁；将2019年11月—2022年12月本科室收治的21例符合入选标准且采用在彩色多普勒超声辅助下设计、切取的超薄胸背动脉穿支皮瓣修复四肢皮肤软组织缺损的患者作为超声辅助组，其中男15例、女6例，年龄（38±6）岁。清创后，四肢皮肤软组织缺损范围5.0 cm×4.0 cm~19.0 cm×8.0 cm，胸背动脉穿支皮瓣面积为6.0 cm×5.0 cm~20.0 cm×9.0 cm。将供瓣区创面直接拉拢缝合。统计超声辅助组患者彩色多普勒超声检查耗时、费用，比较术前彩色多普勒超声探查到的胸背动脉穿支血管数量、类型、位置和术中实际探查情况是否一致。记录2组患者皮瓣完整切取耗时。术后1、3、5、7、14 d，采用皮瓣血运评估量表评估2组患者皮瓣血运情况。术后14 d，观察2组患者皮瓣成活情况并计算皮瓣成活面积百分比。术后6个月，采用利克特5级量表评估2组患者对治疗效果的满意度并计算满意率。结果超声辅助组患者术前彩色多普勒超声检查耗时为（10.5±2.3）min、费用为120元；术前通过彩色多普勒超声探查并标记出21条胸背动脉穿支血管，其中8条（38.10%）1型穿支血管，10条（47.62%）2型穿支血管和3条（14.29%）3型穿支血管，术前探查到的胸背动脉穿支血管数量、类型、位置与术中探查情况一致。超声辅助组患者皮瓣完整切取耗时（41±10）min，明显短于对照组的（63±12）min（ t=6.32， P<0.05）。术后1、3、5、7、14 d，超声辅助组患者皮瓣血运评分均明显优于对照组（ t值分别为6.67、7.48、8.03、8.75、7.99， P<0.05）。术后14 d，超声辅助组仅1例患者皮瓣部分坏死，对照组6例患者皮瓣全部或部分坏死；超声辅助组患者皮瓣成活面积百分比为（99±8）%，明显高于对照组的（87±8）%（ t=4.57， P<0.05）。术后6个月，2组患者对治疗效果的满意率无明显差异（ P>0.05）。结论术前行彩色多普勒超声探测穿支血管的数量、类型及位置等的准确率高；根据不同穿支血管类型设计超薄胸背动脉穿支皮瓣切取方案，能缩短手术时间，提高皮瓣的成活率。
- 创伤和损伤 /
- 超声检查，多普勒，彩色 /
- 穿支皮瓣 /
- 超薄皮瓣 /
- 创面修复
Abstract: Objective To explore the cutting scheme and clinical application effects of ultrathin thoracodorsal artery perforator flap assisted by color Doppler ultrasound. Methods This study was a retrospective historical control study. From February 2017 to October 2019, 20 patients who were admitted to the Third Department of Orthopedics of Xingtai General Hospital of North China Medical and Health Group (hereinafter referred to as our department), met the inclusion criteria, and underwent repair of skin and soft tissue defects of extremities with ultrathin thoracodorsal artery perforator flap designed and harvested based on the surgeon's clinical experience were selected as control group, including 16 males and 4 females, aged (37±5) years. From November 2019 to December 2022, 21 patients who were admitted to our department, met the inclusion criteria, and underwent repair of skin and soft tissue defects of extremities with ultrathin thoracodorsal artery perforator flap designed and harvested under the assistance of color Doppler ultrasound were selected as ultrasound-assisted group, including 15 males and 6 females, aged (38±6) years. After debridement, the area of skin and soft tissue defects of extremities ranged 5.0 cm×4.0 cm to 19.0 cm×8.0 cm, and the area of thoracodorsal artery perforator flaps ranged 6.0 cm×5.0 cm to 20.0 cm×9.0 cm. The wounds in flap donor sites were closed directly. For patients in ultrasound-assisted group, the time and cost required for color Doppler ultrasound examination were recorded, and the number, type, and location of thoracodorsal artery perforator vessels detected by preoperative color Doppler ultrasound were compared with those of intraoperative actual detection. The time required for complete flap harvest of patients in 2 groups was recorded. On postoperative day (POD) 1, 3, 5, 7, and 14, the blood perfusion of flaps in the 2 groups of patients was assessed using a flap perfusion assessment scale. On POD 14, flap survival of patients in 2 groups was observed, and the percentage of flap survival area was calculated. In postoperative 6 months, satisfaction of patients with the treatment outcome in the 2 groups was assessed using 5-grade Likert scale, and the satisfaction rate was calculated. Results For patients in ultrasound-assisted group, the time required for preoperative color Doppler ultrasound examination was (10.5±2.3) min, and the cost was 120 yuan; 21 thoracodorsal artery perforator vessels were detected and marked using preoperative color Doppler ultrasound, including 8 (38.10%) type 1 perforator vessels, 10 (47.62%) type 2 perforator vessels, and 3 (14.29%) type 3 perforator vessels; the number, type, and location of thoracodorsal artery perforator vessels detected preoperatively were consistent with those detected intraoperatively. The time required for complete flap harvest of patients in ultrasound-assisted group was (41±10) min, which was significantly shorter than (63±12) min in control group ( t=6.32, P<0.05). On POD 1, 3, 5, 7, and 14, the blood perfusion scores of flaps of patients in ultrasound-assisted group were significantly better than those in control group (with t values of 6.67, 7.48, 8.03, 8.75, and 7.99, respectively P<0.05). On POD 14, only one patient in ultrasound-assisted group had partial flap necrosis and 6 patients in control group had complete or partial necrosis of the flap; the percentage of flap survival area of patients in ultrasound-assisted group was (99±8)%, which was significantly higher than (87±8)% in control group ( t=4.57, P<0.05). In postoperative 6 months, there was no significant difference in the satisfaction rate of patients with the treatment outcome between the two groups ( P>0.05). Conclusions Preoperative color Doppler ultrasound is highly accurate in detecting the number, type, and location of perforator vessels. The cutting scheme of ultrathin thoracodorsal artery perforator flaps can be designed according to the different types of perforator vessels, with shorted flap cutting time and improved flap survival rate.
- Wounds and injuries /
- Ultrasonography, Doppler, color /
- Perforator flap /
- Ultrathin flap /
- Wound repair
赵书明：病历资料收集、手术操作、论文撰写、论文审定、经费支持；刘娜、刘学亮、冀少林：手术设计、手术操作、数据统计、论文修改

所有作者均声明不存在利益冲突

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参考文献(21)

[1]	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.
[2]	刘安铭,欧昌良,周鑫,等.胸背动脉穿支皮瓣在修复手背软组织缺损中的临床应用[J].中华显微外科杂志,2020,43(2):176-178.DOI: 10.3760/cma.j.cn441206-20190609-00200.
[3]	江从航,王先成,李晓芳,等.带蒂胸背动脉穿支皮瓣整复腋窝中重度瘢痕挛缩畸形的效果[J].中华烧伤杂志,2020,36(6):480-483.DOI: 10.3760/cma.j.cn501120-20190322-00133.
[4]	ChimH,Cohen-ShohetRN,ChopanM,et al.Supine harvest of vascularised scapular bone grafts-anatomical study and clinical application[J].Injury,2022,53(3):1038-1043.DOI: 10.1016/j.injury.2021.11.031.
[5]	徐宏征,张书诺,章一新,等.红外热成像技术与彩色多普勒超声在股前外侧穿支皮瓣术前穿支血管探测中的比较[J].中华显微外科杂志,2021,44(4):388-391.DOI: 10.3760/cma.j.cn441206-20210319-00084.
[6]	HortaR,MachadoP,HortaP.Reconstruction of an axillary postburn scar contracture with a previously burned thoracodorsal artery perforator flap[J].Microsurgery,2023,43(1):91-92.DOI: 10.1002/micr.30989.
[7]	NatalwalaI,LeeCYV,KayS.The posterior approach to the thoracodorsal vessels for microsurgical free tissue transfer[J].JPRAS Open,2023,37:77-81.DOI: 10.1016/j.jpra.2023.06.010.
[8]	ThomasB,FalknerF,GazyakanE,et al.The conjoined latissimus dorsi and parascapular free flap for reconstruction of extensive soft tissue defects[J].Oper Orthop Traumatol,2023,35(3/4):205-222.DOI: 10.1007/s00064-023-00806-w.
[9]	武雷,丁英状,郝敏如,等.两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[J].中华烧伤与创面修复杂志,2023,39(10):959-967.DOI: 10.3760/cma.j.cn501225-20230428-00145.
[10]	SteinA,AtlanM,HervochonR,et al.Reconstruction by thoracodorsal perforator flap after petrosectomy[J].Ann Chir Plast Esthet,2021,66(1):100-105.DOI: 10.1016/j.anplas.2020.04.003.
[11]	宋达疆,李赞,章一新,等.胸背动脉前锯肌支在带蒂背阔肌肌皮瓣移植乳房再造中的补救作用[J].中华整形外科杂志,2022,38(6):612-618.DOI: 10.3760/cma.j.cn114453-20210219-00070.
[12]	董凯旋,张俊裕,罗浩天,等.CT血管成像和彩色多普勒超声在腓动脉穿支皮瓣术前穿支评估的对比研究[J].中华显微外科杂志,2023,46(1):76-81.DOI: 10.3760/cma.j.cn441206-20220711-00143.
[13]	MayerHF,Piedra BuenaI,PetersenML.The value of preoperative computed tomography angiography (CT-A) in patients undergoing delayed latissimus dorsi flap breast reconstruction after axillary lymph node dissection or irradiation and suspicion of pedicle injury[J].J Plast Reconstr Aesthet Surg,2020,73(11):2086-2102.DOI: 10.1016/j.bjps.2020.08.096.
[14]	吴双江,王雷,刘一秀,等.CT血管成像及三维重建辅助设计与彩色多普勒超声在口腔癌术后缺损股前外侧皮瓣修复重建中的应用比较[J].中华整形外科杂志,2022,38(10):1102-1110.DOI: 10.3760/cma.j.cn114453-20210428-00189.
[15]	张凯,王栋,高廷益,等.彩色多普勒超声辅助下腹部浅动脉供血皮瓣修复颌面部软组织缺损[J].中华整形外科杂志,2019,35(12):1200-1204.DOI: 10.3760/cma.j.issn.1009-4598.2019.12.007.
[16]	SahovalerA,LowH,LaxagueF,et al.Variations of the thoracodorsal axis: application for scapular tip free flap harvesting[J].Oral Maxillofac Surg,2022,26(4):619-623.DOI: 10.1007/s10006-021-01037-8.
[17]	胡瑞斌,周丹亚,王欣,等.游离胸背动脉穿支皮瓣整复面部亚单位大面积瘢痕的临床效果[J].中华烧伤杂志,2020,36(7):586-589.DOI: 10.3760/cma.j.cn501120-20190505-00223.
[18]	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.
[19]	计鹏,曹涛,张智,等.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[J].中华烧伤与创面修复杂志,2022,38(4):328-334. DOI: 10.3760/cma.j.cn501120-20211231-00426.
[20]	HomsyC,TheunissenT,SadeghiA.The thoracodorsal artery perforator flap: a powerful tool in breast reconstruction[J].Plast Reconstr Surg,2022,150(4):755-761.DOI: 10.1097/PRS.0000000000009576.
[21]	GattoA,ParisiP,BrambillaL,et al.Thoracodorsal artery perforator flap, muscle-sparing latissimus dorsi, and descending branch latissimus dorsi: a multicenter retrospective study on early complications and meta-analysis of the literature[J].J Plast Reconstr Aesthet Surg,2022,75(11):3979-3996.DOI: 10.1016/j.bjps.2022.06.083.

下载: 全尺寸图片幻灯片

1 3种类型的胸背动脉穿支血管的彩色多普勒超声图像和在皮瓣中的分布示意图。1A、1B、1C.分别为1、2、3型穿支血管的彩色多普勒超声图像，其中1型穿支血管基本垂直于深筋膜，到达浅层皮下组织；2型穿支血管与深筋膜成一定角度，斜穿过深层皮下组织，到达浅层皮下组织；3型穿支血管沿深筋膜走行数厘米，分散分布于深筋膜和脂肪层；1D、1E、1F.分别为1、2、3型穿支血管在皮瓣中的分布示意图

注：横箭头指示穿支血管主干，竖箭头指示穿支血管在皮瓣内的分布

下载: 全尺寸图片幻灯片

2 彩色多普勒超声辅助下游离移植超薄胸背动脉穿支皮瓣修复患者左足跟腱区域皮肤软组织坏死创面的效果。2A.术前清创后创面，可见跟腱外露；2B.术前采用彩色多普勒超声探测胸背动脉穿支血管情况，穿支血管类型为2型；2C.术中皮瓣设计；2D.切取皮瓣后即刻（横箭头指示皮神经，竖箭头指示胸背动脉穿支血管）；2E.皮瓣内皮神经和受区周围皮神经吻合后（箭头指示神经吻合处）；2F.皮瓣转移至受区并缝合后即刻；2G.术后6个月随访，皮瓣不臃肿；2H.术后6个月随访，供区仅遗留线性瘢痕

下载: 全尺寸图片幻灯片

表1 2组四肢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 limb skin and soft tissue defects

组别	例数	性别（例）		年龄（岁， x ¯ ± s ）	身体质量指数（kg/m ²， x ¯ ± s ）	清创后创面面积（cm ²， x ¯ ± s ）	皮瓣面积（cm ²， x ¯ ± s ）
组别	例数	男	女	年龄（岁， x ¯ ± s ）	身体质量指数（kg/m ²， x ¯ ± s ）	清创后创面面积（cm ²， x ¯ ± s ）	皮瓣面积（cm ²， x ¯ ± s ）
对照组	20	16	4	37±5	23±3	102±23	105±26
超声辅助组	21	15	6	38±6	22±3	107±25	109±28
统计量值		χ ²=0.41		t=0.58	t=1.07	t=0.67	t=0.47
P值		0.523		0.566	0.293	0.510	0.639
注：对照组患者由术者根据临床经验设计、切取超薄胸背动脉穿支皮瓣；超声辅助组患者术前行彩色多普勒超声检查确定胸背动脉穿支血管数量、类型及位置等，并根据检查结果设计、切取超薄胸背动脉穿支皮瓣

下载: 导出CSV

表2 2组四肢皮肤软组织缺损患者术后不同时间点超薄胸背动脉穿支皮瓣的血运评分比较（分， x ¯ ± s ）

表2. Comparison of blood flow scores of ultrathin thoracodorsal artery perforator flaps at different postoperative time points between two groups of patients with limb skin and soft tissue defects

组别	例数	1 d	3 d	5 d	7 d	14 d
对照组	20	3.61±0.09	3.53±0.13	3.51±0.15	3.50±0.11	3.52±0.12
超声辅助组	21	3.82±0.11	3.80±0.10	3.85±0.12	3.83±0.13	3.86±0.15
t值		6.67	7.48	8.03	8.75	7.99
P值		<0.001	<0.001	<0.001	<0.001	<0.001
注：对照组患者由术者根据临床经验设计、切取皮瓣；超声辅助组患者术前行彩色多普勒超声检查确定胸背动脉穿支血管数量、类型以及位置等，并根据检查结果设计、切取皮瓣；处理因素主效应， F=12.75， P<0.001；时间因素主效应， F=11.92， P<0.001；两者交互作用， F=10.81， P<0.001