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摘要:
目的 探讨头皮缺损伴颅骨外露创面的组织瓣修复策略。 方法 该研究为回顾性观察性研究。2019年1月—2023年12月,暨南大学附属广州红十字会医院收治18例符合入选标准的不同头皮缺损伴颅骨外露创面面积（以下简称头皮缺损面积）的患者,其中男13例、女5例,年龄17~59岁。清创后,头皮缺损面积为1 cm×1 cm~25 cm×25 cm。针对头皮缺损面积<9 cm2且周围头皮局部条件较好的患者,采用局部皮瓣（面积为2 cm×2 cm~5 cm×5 cm）进行创面修复；将皮瓣供区创面拉拢缝合,若缝合张力较大则取头部皮片进行创面修复。对于头皮缺损面积>9 cm2且≤1/4头皮总面积的患者,采用扩张皮瓣（面积为5 cm×3 cm~12 cm×12 cm）进行创面修复；将皮瓣供区创面直接拉拢缝合。对于头皮缺损面积>1/4头皮总面积且≤1/2头皮总面积的患者,采用游离股前外侧皮瓣（面积为9 cm×7 cm~29 cm×14 cm）进行创面修复；将皮瓣供区创面分层缝合,若张力较大则移植同侧大腿皮片进行修复。对于头皮缺损面积>1/2头皮总面积的患者,采用游离大网膜瓣（面积为28 cm×23 cm~29 cm×26 cm）+大腿皮片进行创面修复,并直接缝合切取大网膜瓣造成的腹部切口。记录术中移植的组织瓣类型。术后,观察组织瓣及受区移植皮片成活情况、皮瓣供区创面/切取大网膜瓣造成的腹部切口愈合情况。随访时,观察组织瓣成活情况、皮瓣供区创面/切取大网膜瓣造成的腹部切口瘢痕增生情况。末次随访时,复查头部CT评估颅骨有无坏死。 结果 针对本组病例头皮缺损伴颅骨外露创面,4例患者采用局部皮瓣修复,其中2例患者采用局部V-Y推进皮瓣修复,2例患者采用局部双蒂拱顶石皮瓣修复,术后皮瓣均完全成活。5例患者采用扩张皮瓣修复,其中1例患者埋置2个皮肤软组织扩张器,4例患者埋置1个皮肤软组织扩张器,术后扩张皮瓣均完全成活。7例患者采用游离股前外侧皮瓣移植修复,术后6例患者皮瓣完全成活,1例患者皮瓣远端坏死,经清创拉拢缝合后愈合良好。2例患者采用游离移植大网膜瓣+大腿皮片修复,术后大网膜瓣和受区移植皮片均存活良好。术后,皮瓣供区创面/切取大网膜瓣造成的腹部切口均愈合良好。术后随访6~24个月,组织瓣均存活良好,无颅骨外露；皮瓣供区创面/切取大网膜瓣造成的腹部切口瘢痕增生不明显。末次随访时,复查CT显示所有患者颅骨均无坏死。 结论 根据头皮缺损面积从小至大依次选择局部皮瓣、扩张皮瓣、游离股前外侧皮瓣、游离大网膜瓣+皮片修复创面,效果良好,值得临床推广。 Abstract:Objective To investigate the strategy of using tissue flaps for repairing scalp defects with exposed skull wounds. Methods This study was a retrospective observational study. From January 2019 to December 2023, 18 patients (13 males and 5 females, aged 17-59 years) with different scalp defect combined with skull exposure area (hereafter referred to as scalp defect area) who met the inclusion criteria were admitted to Guangzhou Red Cross Hospital of Jinan University. After debridement, the scalp defect area was 1 cm×1 cm to 25 cm×25 cm. For patients with scalp defect area < 9 cm2 and good local conditions of the surrounding scalp, local flaps with area of 2 cm×2 cm-5 cm×5 cm were used for wound repair. The wound in the donor site of the flap was pulled together and sutured. If the suture tension was large, the skin graft from the head was taken and transplanted for wound repair. For patients with scalp defect area > 9 cm2 and ≤1/4 of the total scalp area, expanded flaps with area of 5 cm×3 cm-12 cm×12 cm were used for wound repair. The wound in the donor site of the flap was pulled together and sutured directly. For patients with scalp defect area >1/4 and ≤1/2 of the total scalp area, free transplantation of anterolateral thigh flaps with area of 9 cm×7 cm-29 cm×14 cm were used for wound repair. The wound in the donor site of the flap was sutured in layers, and the skin graft from the ipsilateral thigh was transplanted for repair if the tension was large. For patients with scalp defect area >1/2 of the total scalp area, free greater omental flap (28 cm×23 cm-29 cm×26 cm in area) transplantation and thigh skin graft were used for wound repair. The abdominal incision caused by cutting the greater omental flap was sutured directly. The types of tissue flaps were recorded during operation. After operation, the survival of tissue flaps and skin graft in the recipient sites was observed, and the wound healing of flap donor sites/abdominal incision caused by cutting the greater omental flap was observed. During follow up, the survival of tissue flaps and the scar hyperplasia of flap donor site/abdominal incision caused by cutting the greater omental flap were observed. At the last follow-up, the skull necrosis was evaluated by computed tomography scan. Results For the scalp defect with exposed skull wounds in this group of cases, 4 cases were repaired with local flaps, of which 2 cases were repaired with V-Y advancement flaps, and 2 cases were repaired with local double-pedicle vault stone flaps. The flaps survived completely after operation. Five cases were repaired with expanded flaps, of which 1 patient was implanted with 2 skin and soft tissue expanders, and 4 patients were implanted with 1 skin and soft tissue expander. The expanded flaps survived completely after operation. Seven cases were repaired with free transplantation of anterolateral thigh flaps. After operation, the flap in 6 cases survived, and the distal end of the flap was necrotic in 1 case, and the wound healed well after debridement and suture. Two cases were repaired with free transplantation of greater omental flaps and thigh skin graft, and the greater omental flap and skin graft in the recipient site survived well after operation. After operation, the wound of flap donor site/abdominal incision caused by cutting the greater omental flap healed well. During follow-up, all tissue flaps survived well without skull exposure; the scar hyperplasia of flap donor site/abdominal incision caused by cutting the greater omental flap was not obvious. At the last follow-up, computed tomography scan showed that all patients had no skull necrosis. Conclusions According to the size of scalp defect, local flap, expanded flap, free anterolateral thigh flap, and free greater omental flap+skin graft are selected successively from small to large to repair the wounds, and the effect is good, which is worthy of clinical promotion. -
Key words:
- Surgical flaps /
- Wound healing /
- Scalp defect /
- Exposed skull
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李罡：手术操作、论文撰写、经费支持；张志：手术指导；孙敬恩：手术操作；林伟华：临床资料收集；李孝建：研究指导所有作者均声明不存在利益冲突
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参考文献
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图 1 采用头部扩张皮瓣修复例1患者电烧伤致头皮缺损伴颅骨外露创面的效果。1A.入院时,头部电烧伤致头皮坏死,头皮呈皮革样改变；1B.清创后分别在顶部和左侧颞部置入皮肤软组织扩张器,于距创缘1 cm处用缝线缝合到帽状腱膜层；1C.扩张器扩张2个月,注水量分别为350 mL（顶部）和260 mL（左侧颞部）；1D.Ⅱ期手术取出扩张器,分离扩张皮瓣；1E.转移扩张皮瓣修复头皮缺损伴颅骨外露创面,并行间断缝合后即刻；1F.术后1年,头皮愈合良好,仅部分切口遗留瘢痕
图 2 游离移植股前外侧皮瓣修复例2患者电烧伤致头皮缺损伴颅骨外露创面的效果。2A.入院时,头皮坏死；2B.清创后,头皮缺损面积约占头皮总面积的1/2；2C.切取右侧大腿股前外侧皮瓣中,携带2根穿支血管；2D.完全游离皮瓣；2E.移植皮瓣修复头皮缺损伴颅骨外露创面后即刻；2F.术后1年,皮瓣存活良好,颅骨外露得到有效修复
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