Effect of accurately localized mini anterolateral thigh perforator flap in repairing medium-sized skin and soft tissue defects in fingers
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摘要:
目的 探讨采用精准定位的微型股前外侧穿支皮瓣修复手指中等面积皮肤软组织缺损的效果。 方法 该研究为回顾性观察性研究。2019年12月—2022年9月，温州医科大学附属第二医院收治15例符合入选标准的手指中等面积皮肤软组织缺损的患者，其中男12例、女3例，年龄23~62岁。清创后，创面均伴肌腱、骨、血管、神经外露，创面面积为4.0 cm×3.0 cm~8.0 cm×3.5 cm。术前对患者双下肢行CT血管造影和彩色多普勒超声检查精准定位股前外侧穿支情况。切取皮瓣（面积为6.0 cm×3.0 cm~11.0 cm×4.0 cm）时，对皮瓣进行削薄处理。将皮瓣的动静脉穿支分别与指动脉及掌背静脉吻合，如受区存在撕脱伤、感染或烧伤，则将皮瓣携带的主干动静脉血管与桡动脉及其伴行静脉进行吻合；将皮瓣携带的股外侧皮神经与指神经的残端吻合。术中观察患者皮瓣内旋股外侧动脉穿支类型，并与术前血管定位情况进行比对。术后，密切观察皮瓣成活情况及不良反应。随访时，观察皮瓣色泽、质地及外形，观察供区创面愈合情况。末次随访时，测量患指指腹两点辨别觉距离，采用中华医学会手外科学会上肢部分功能评定试用标准对患指的功能进行评价，观察患指关节活动情况；记录患者主诉皮瓣切取对下肢造成不良影响的情况。 结果 术中观察到11例患者皮瓣的穿支为旋股外侧动脉降支、2例患者皮瓣的穿支为旋股外侧动脉斜支、2例患者皮瓣的穿支为旋股外侧动脉横支，均与术前血管定位情况相符。术后，皮瓣均顺利成活且未发生血管危象和感染。术后随访6~12个月，皮瓣色泽、质地优良且外形佳，供区创面仅遗留线性瘢痕。末次随访时，患指指腹两点辨别觉距离为7~11 mm，患指功能评定为优者6例、良者6例、可者3例，患指关节屈伸功能均未受影响；2例患者主诉切取皮瓣后大腿外侧有麻木感，13例患者主诉皮瓣切取对下肢无不良影响。 结论 利用CT血管造影和彩色多普勒超声检查可精准定位股前外侧区穿支，术前精准定位穿支情况可减轻术中切取皮瓣时对供区的损伤，对移植皮瓣进行削薄处理并重建手指感觉可最大限度地恢复患指外形和功能，因此采用微型股前外侧穿支皮瓣修复手指中等面积皮肤软组织缺损，是一种有效且可靠的治疗方式。 -
关键词:
- 穿支皮瓣 /
- 显微外科手术 /
- 指 /
- 超声检查，多普勒，彩色 /
- 计算机体层摄影血管造影术 /
- 股前外侧穿支皮瓣 /
- 皮肤软组织缺损 /
- 创面修复
Abstract:Objective To explore the effect of accurately localized mini anterolateral thigh perforator flap in repairing medium-sized skin and soft tissue defects in fingers. Methods The study was a retrospective observational study. From December 2019 to September 2022, 15 patients with medium-sized skin and soft tissue defects who met the inclusion criteria in fingers were admitted to the Second Affiliated Hospital of Wenzhou Medical University, including 12 males and 3 females, aged 23 to 62 years. After debridement, the wounds were all accompanied by exposed tendons, bones, vessels and nerves, with an area from 4.0 cm×3.0 cm to 8.0 cm×3.5 cm. Computed tomography angiography and color Doppler ultrasonography examinations were performed on both lower limbs of the patient before surgery to accurately locate the anterolateral thigh perforators. When the flap with area from 6.0 cm×3.0 cm to 11.0 cm×4.0 cm was harvested, the flap was thinned. The artery and vein perforators of the flap were anastomosed respectively with the digital artery and dorsal metacarpal vein. If there was avulsion injury, infection, or burn in the recipient area, the main arterial and veinous vessels carried by the skin flap was anastomosed with the radial artery and accompanying vein. The lateral thigh cutaneous nerve carried by the flap was anastomosed with the stump of the digital nerve. The types of perforators of the lateral thigh artery were observed during operation and compared with the location of the vessels before operation. After operation, the survival and adverse complication of the flap were closely observed. During follow-up, the skin flap color, texture, and shape were observed; the wound healing in donor area was observed. At the last follow-up, the two-point discriminative distance of the affected finger pulp was measured, and the function of the affected finger was evaluated using the trial standard for the evaluation of functions of upper limbs of Hand Surgery Society of Chinese Medical Association, and the interphalangeal joint movement of the affected finger was observed; the patients' complaints about the adverse effects of flap resection on lower limbs were recorded. Results During the operation, it was observed that the perforators of the flaps in 11 patients were the descending branch of the lateral circumflex thigh artery, in two patients, the perforators of skin flaps were the oblique branch of the lateral thigh artery, and the perforators in another two patients were the transverse branch of the lateral circumflex thigh artery, which were consistent with the preoperative vascular localization. After operation, all flaps survived without vascular crisis and infection. The patients were followed up for 6-12 months, the flaps had excellent color, texture, and appearance; only linear scars remained on the donor wound. At the last follow-up, the two-point discrimination distance in the finger pulp was 7-11 mm; the affected finger function was rated as excellent in 6 cases, good in 6 cases, and fair in 3 cases; the flexion and extension function of the finger was not affected; two patients complained of numbness in the lateral thigh after excision of the skin flap, and the other 13 patients had no complain of adverse complaints. Conclusions The perforating branch in lateral thigh region can be accurately located by computed tomography angiography and color Doppler ultrasonography, accurate positioning of perforators before operation can reduce the damage to the donor area during the incision of the flap, the appearance and function of the affected finger can be restored to the maximum extent by thinning the transplanted flap and rebuilding the finger sensation. Therefore, it is an effective and reliable way to repair the medium-sized skin and soft tissue defects of fingers with the mini thigh anterolateral perforator flap. -
参考文献
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1 精准定位穿支并设计微型股前外侧穿支皮瓣以及分离皮神经过程。1A.根据术前精准定位穿支穿出点（蓝色标记点）设计微型股前外侧穿支皮瓣；1B.切取皮瓣过程中，图片中蓝色箭头指示分离的皮神经
2 采用精准定位的微型股前外侧穿支皮瓣修复例1患者被他人咬伤后致右手中指皮肤软组织缺损的效果。2A.清创后创面伴肌腱外露；2B.术前行下肢CT血管造影检查定位髂-髌连线中点附近的穿支，确定目标穿支为肌间隙型（红色箭头指示）；2C.彩色多普勒超声检查定位图2B中目标穿支入皮点（红色区域指示），图片中的蓝色正方形线框表示穿支血管在彩色多普勒下的显像；2D.以穿支穿出点为中心设计拟切取皮瓣范围；2E.切取皮瓣过程中，在断蒂前对皮瓣进行去脂削薄处理；2F.皮瓣与受区缝合后即刻；2G、2H.分别为术后6个月随访时显示患指外观及右手抓握功能，均恢复良好
3 采用精准定位的微型股前外侧穿支皮瓣修复例2患者因重物砸伤致左手拇指皮肤软组织缺损的效果。3A.左侧图示术前行下肢CT血管造影检查，定位股前外侧穿支皮瓣的髂-髌连线中点3 cm圆径内的肌间隙穿支为目标穿支（红色箭头指示），右侧图示左侧图的横断面大致位置（红色水平线指示），其中黄色线段为髂-髌连线长度；3B.采用彩色多普勒超声检查定位的穿支穿出点（红色标记点），并标记皮瓣切取范围；3C.术中显露血管穿支，与图3A探查结果一致；3D.术中切取皮瓣（左侧图）及携带血管蒂的游离皮瓣外观（右侧图）；3E.皮瓣与缺损手指创面缝合后即刻；3F.术后6个月随访时，患指正面及侧面观（左侧图和中间图）和活动情况（右侧图）良好
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