股前外侧血流桥接嵌合穿支皮瓣游离移植治疗伴主干动脉缺损的上肢复合组织缺损的临床效果

刘飞; 闫炜琪; 马强; 刘亦斌; 杨智斌

doi:10.3760/cma.j.cn501225-20231103-00176

股前外侧血流桥接嵌合穿支皮瓣游离移植治疗伴主干动脉缺损的上肢复合组织缺损的临床效果

doi: 10.3760/cma.j.cn501225-20231103-00176

1.
宁夏医科大学总医院手足踝外科，银川　　750001
2.
宁夏医科大学总医院烧伤整形美容科，银川　　750001
3.
陆军军医大学（第三军医大学）第二附属医院整形美容科，重庆　　400037

基金项目:

宁夏回族自治区自然科学基金项目 2022AAC03610

宁夏回族自治区重点研发计划项目 2020BEG03025

详细信息

通讯作者:
杨智斌，Email：yangzhibin321@163.com

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出版历程
- 收稿日期: 2023-11-03

Clinical effect of anterolateral thigh flow-through chimeric perforator free flap transplantation in the treatment of upper limb complex tissue defects with main artery injury

1.
Department of Hand, Foot and Ankle Surgery, General Hospital of Ningxia Medical University, Yinchuan 750001, China
2.
Department of Burns, Plastic and Cosmetic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750001, China
3.
Department of Plastic and Cosmetic Surgery, the Second Affiliated Hospital of Army Medical University (the Third Military Medical University), Chongqing 400037, China

Funds:

Natural Science Foundation Project of Ningxia Hui Autonomous Region of China 2022AAC03610

Key Research and Development Project of Ningxia Autonomous Region of China 2020BEG03025

More Information

Corresponding author: Yang Zhibin, Email: yangzhibin321@163.com

摘要

摘要: 目的探讨股前外侧血流桥接嵌合穿支皮瓣游离移植治疗伴主干动脉缺损的上肢复合组织缺损的临床效果。方法该研究为回顾性观察性研究。2019年5月—2022年1月，宁夏医科大学总医院手足踝外科收治11例符合入选标准的伴主干动脉缺损的上肢复合组织缺损患者，其中男7例、女4例，年龄18~56岁。清创后，皮肤软组织缺损面积为20 cm×6 cm~32 cm×10 cm，无效腔或深部组织裸露面积为7 cm×4 cm~10 cm×7 cm。3例患者桡动脉缺损，长度为4~7 cm；2例患者尺动脉缺损，长度为5~8 cm；4例患者尺、桡动脉均缺损，长度为3~7 cm；2例患者尺、桡动脉及肱动脉均缺损，长度为4~8 cm。设计并切取股前外侧血流桥接嵌合穿支皮瓣，切取皮瓣面积为22 cm×7 cm~32 cm×11 cm、嵌合肌瓣面积为7 cm×4 cm~10 cm×7 cm，“T”形血管蒂中桥接血管的长度为4~8 cm。移植皮瓣时，将血管蒂近端同受区血管近端吻合、血管蒂远端同前臂远端较正常的血管吻合，利用肌瓣填塞无效腔。对组织瓣供区创面采用直接闭合或移植皮片处理。术后，观察皮瓣血运及成活情况、远端肢体成活情况、移植皮片成活情况。术后2~4周，行CT血管造影（CTA）检查，观察吻合动脉近远端的通畅情况。随访时观察皮瓣质地、供区创面愈合情况。结果 1例患者（前臂完全离断）于术后第5天出现肢体远端血运障碍，CTA检查提示桥接的动脉和皮瓣远端吻合口动脉均栓塞，急诊探查显示远端肢体肌肉及皮肤软组织坏死较多，遂行截肢术；其余10例患者皮瓣均未发生血管危象且全部成活，远端肢体全部成活，供区移植皮片成活良好。术后2~4周，吻合的动脉近远端通畅情况良好。随访11~37个月，皮瓣质地良好，所有供区创面愈合良好。结论运用股前外侧血流桥接嵌合穿支皮瓣修复伴主干动脉缺损的上肢复合组织缺损可提高保肢成功率，值得在临床推广。
- 显微外科手术 /
- 穿支皮瓣 /
- 上肢 /
- 股前外侧皮瓣 /
- 血流桥接皮瓣 /
- 嵌合皮瓣 /
- 创面修复
Abstract: Objective To investigate the clinical effect of anterolateral thigh flow-through chimeric perforator free flap transplantation in the treatment of upper limb complex tissue defects with main artery injury. Methods The study was a retrospective observational study. From May 2019 to January 2022, 11 patients with upper limb complex tissue defects combined with main artery injury who met the inclusion criteria were admitted to the Department of Hand, Foot and Ankle Surgery of General Hospital of Ningxia Medical University, including 7 males and 4 females, aged from 18 to 56 years. After debridement, the area of skin and soft tissue defects was from 20 cm×6 cm to 32 cm×10 cm, and the exposed area of dead cavity or deep tissue was from 7 cm×4 cm to 10 cm×7 cm. Three patients had radial artery defects with a length of 4 to 7 cm; two patients had ulnar artery defects with a length of 5 to 8 cm; 4 patients had defects in both ulnar and radial arteries with a length of 3 to 7 cm; and in two patients, the ulnar, radial and brachial arteries were all defective with a length of 4 to 8 cm. The anterolateral thigh flow-through chimeric perforator flap was designed and cut. The skin flap area was from 22 cm×7 cm to 32 cm×11 cm, the chimeric muscle flap area was from 7 cm×4 cm to 10 cm×7 cm, and the length of the flow-through vessel in the "T" shaped vessel pedicle was from 4 to 8 cm. When transplanting the skin flap, the proximal end of the vascular pedicle was anastomosed with the proximal end of the recipient site, and the distal end of the vascular pedicle was anastomosed with the more normal blood vessel at the distal end of the forearm; the invalid cavity was filled with the muscle flap. The donor site wounds of tissue flap were closed directly or treated with skin grafting. After operation, the blood supply and survival of the flap, the survival of the distal limb, and the survival of the skin graft at the flap donor site were observed. Computed tomography angiography (CTA) was performed to observe the patency of the proximal and distal anastomotic arteries from 2 to 4 weeks after surgery. During follow-up, the texture of the flap, the survival of the grafted skin and the healing of the donor area were observed. Results One patient (complete forearm disconnection) developed distal limb blood disorder on 5 days after surgery. CTA examination suggested embolization of the distal anastomosis of the flow-through artery. more muscle and skin and soft tissue necrosis of the distal limb showed in emergency exploration. So, amputation was performed ultimately. No vascular crisis occurred in the skin flaps of the remaining 10 patients, and all skin flaps, distal limbs and the skin grafts in flap donor sites survived well. Two to 4 weeks after surgery, the proximal and distal ends of the anastomosed arteries were good in the patency. Follow-up for 11-37 months, the flap texture was good, and all donor site wounds healed well. Conclusions The use of anterolateral thigh flow-through chimeric perforator flap to repair upper limb complex tissue defects accompanied by main artery injury can improve the success rate of limb salvage, which can be promoted in clinical practice.
- Microsurgery /
- Perforator flap /
- Upper extremity /
- Anterolateral thigh flap /
- Flow-through flap /
- Chimeric flap /
- Wound repair
刘飞：酝酿设计研究、论文撰写与修改、实施手术、数据收集、经费支持；闫炜琪、刘亦斌：实施手术、数据收集；马强：数据收集与整理；杨智斌：研究指导

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1 采用股前外侧血流桥接嵌合穿支皮瓣游离移植修复因交通伤致患者左上肢广泛皮肤软组织脱套伤的疗效。1A、1B.分别为术前前臂肌肉被碾挫后坏死情况及广泛皮肤软组织脱套情况；1C.术中扩大清创，切开上臂及前臂脱套皮肤软组织后，可见广泛的肌肉、肌腱碾挫，前臂掌侧浅层肌肉大部分毁损，皮肤大面积脱套伤且部分脱套皮肤无血运，肱动静脉断裂且存在长段挫伤，黄色箭头示肱动脉近（右侧箭头）远（左侧箭头）端挫裂伤断端；1D.清创后可见肘关节脱位且关节外露，正中神经、尺神经、桡神经连续性存在，前臂深部肌肉部分残留，将脱套无血运皮肤软组织修剪为全厚皮；1E.切取的股前外侧血流桥接嵌合穿支皮瓣；1F.利用皮瓣血管桥接修复肱-桡动脉，黄色箭头示桥接血管近远端；1G.皮瓣与受区缝合后即刻；1H.术后4周行左上肢CT血管造影检查，黄色箭头示桥接血管近远端血流通畅；1I、1J、1K、1L.分别为术后6个月手指功能、腕关节功能、皮瓣外观、肘关节功能恢复情况

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