Strategies and clinical effects of free tissue flaps in repairing massive destructive burn wounds
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摘要:
目的 探讨游离组织瓣修复巨大毁损性烧伤创面的策略及临床效果。 方法 该研究为回顾性观察性研究。2014年6月—2023年10月,武汉大学同仁医院暨武汉市第三医院收治有53个符合入选标准的巨大毁损性烧伤创面的51例烧伤患者,其中男47例、女4例,年龄21~77岁。清创后需组织瓣修复的创面面积为20.0 cm×12.5 cm~50.0 cm×15.0 cm,急诊、早期、延期采用组织瓣修复创面。采用背阔肌肌皮瓣修复6个头面颈部创面、5个上肢创面和1个下肢创面,采用股前外侧皮瓣修复11个上肢创面和6个下肢创面,采用脐旁穿支皮瓣修复7个上肢创面、5个下肢创面和2个面颈部创面,采用下腹部皮瓣修复1个下肢创面,采用腹股沟皮瓣修复2个面颈部创面、2个上肢创面和1个下肢创面,采用肩胛皮瓣修复1个上肢创面,采用截肢后弃去的上肢的“剔骨瓣”修复1个躯干创面,采用大网膜瓣修复3个头面颈部创面、3个下肢创面和1个上肢创面。采用前述组织瓣联合移植修复4个创面,采用前述组织瓣分次移植修复3个创面。切取的单个组织瓣面积为15.0 cm×5.0 cm~45.0 cm×25.0 cm。根据情况增加动脉和静脉吻合以改善组织瓣循环。将供瓣区创面直接缝合或移植头部刃厚皮修复。记录治疗期间患者全身情况,术后观察组织瓣成活情况、受区创面愈合情况、保肢情况、供瓣区创面愈合情况和皮片存活情况。随访观察受区创面愈合情况。末次随访时,使用臂、肩、手残障评分表对保肢成功后的上肢功能进行评分,使用Holden步行能力分级评估下肢保肢成功患者的负重行走能力,采用利克特5级量表评价患者对疗效的满意度。 结果 治疗期间,1例头部电烧伤患者脑水肿加重,形成脑疝再次昏迷,经脱水、激素等治疗后苏醒,遗留右侧肢体不完全偏瘫；4例患者的休克症状加重,经补液抗休克并输入胶体后逐渐得到控制；1例患者于组织瓣移植术后发生出血性休克,经补液并输入红细胞悬液后得到纠正。术后3个组织瓣出现血管危象,经探查后2个成活、1个最终坏死；2个组织瓣部分坏死、5个组织瓣边缘少许坏死,均经组织瓣修整+负压封闭引流（VSD）+植皮治疗后愈合；其余组织瓣全部成活。术后12个受区创面残留坏死组织,经清创+VSD+植皮治疗后愈合；剩余41个受区创面愈合良好。39例患者的40个肢体创面中,5例患者的3个上肢和2个下肢截肢,其余34例患者的35个肢体保肢成功。供区创面均愈合良好,移植皮片均存活良好。随访6~52个月,所有毁损的头面颈部和躯干创面均修复良好,7个肢体创面于术后3~9个月再发溃烂,经清创引流和组织瓣修整后愈合。末次随访时,保肢成功的22个上肢功能评分为0~100分（平均50分）,13个下肢保肢成功的12例患者的Holden步行能力分级评级为Ⅴ级者8例、Ⅳ级者2例、Ⅲ级者2例,患者对疗效非常满意者33例、比较满意者12例、不太满意者6例。 结论 经全身情况的系统评估和治疗,选择合适修复时机,采用恰当的组织瓣修复巨大毁损性烧伤创面,有利于保障治疗安全、提高修复效果、减少供区损伤,最终获得修复效果的最大化。 Abstract:Objective To investigate the strategies and clinical effects of free tissue flaps in repairing massive destructive burn wounds. Methods This study was a retrospective observational study. From June 2014 to October 2023, 51 burn patients with 53 massive destructive burn wounds which met the inclusion criteria were admitted to Tongren Hospital of Wuhan University & Wuhan Third Hospital, including 47 males and 4 females, aged 21 to 77 years. After debridement, the wound area needed to be repaired by tissue flaps ranged from 20.0 cm×12.5 cm to 50.0 cm×15.0 cm. Emergency, early, or delayed transplantation of tissue flaps was performed to repair the wounds. Six head, face, and neck wounds, 5 upper limb wounds, and 1 lower limb wound were repaired with latissimus dorsi myocutaneous flaps. Eleven upper limb wounds and 6 lower limb wounds were repaired with anterolateral thigh flaps. Seven upper limb wounds, 5 lower limb wounds, and 2 face and neck wounds were repaired with paraumbilical perforator flaps. One lower limb wound was repaired with lower abdominal flap. Two face and neck wounds, 2 upper limb wounds, and 1 lower limb wound were repaired with inguinal flaps. One upper limb wound was repaired with scapular flap. One trunk wound was repaired with the "fillet flap" from the abandoned upper limb after amputation. Three head, face, and neck wounds, 3 lower limb wounds, and 1 upper limb wound were repaired with omental flaps. Four wounds were repaired by combined transplantation of the above-mentioned tissue flaps. Three wounds were repaired by fractional transplantation of the above-mentioned tissue flaps. The size of a single harvested tissue flap ranged from 15.0 cm×5.0 cm to 45.0 cm×25.0 cm. The arterial and venous anastomoses were added as the circumstances might require to improve tissue flap circulation. The wounds in the flap donor sites were sutured directly or repaired by split-thickness skin grafts from head. The general condition of patients during treatment was recorded. After surgery, the survival of tissue flaps, the healing of wounds in the recipient sites, limb salvage, the healing of wounds in the flap donor sites, and the survival of skin grafts were observed. The healing of wounds in the recipient sites was observed during follow-up. At the last follow-up, the upper limb function after successful limb salvage was evaluated by the Arm, Shoulder, and Hand Disability Scoring Scale, the weight-bearing walking ability of patients with successful lower limb salvage was evaluated by the Holden walking ability classification, and the patient's satisfaction with the efficacy was assessed by 5-grade Likert scale. Results During treatment, one case with electrical burn of the head suffered from aggravated cerebral edema, cerebral hernia and coma recurred. After dehydration, hormone therapy, and so on, the patient recovered and incomplete hemiplegia on the right limb was left. The shock symptoms of 4 patients got worse, which were gradually controlled after anti-shock with fluid supplement and colloid injection. One patient developed hemorrhagic shock after tissue flap transplantation, which was corrected by fluid infusion and red blood cell suspension transfusion. Vascular crisis occurred in 3 tissue flaps after surgery, of which 2 survived and 1 eventually became necrotic after exploration. Partial necrosis occurred in 2 tissue flaps and slight necrosis occurred at the edge of 5 tissue flaps, which all healed after tissue flap trimming, vacuum sealing drainage (VSD), and skin grafting treatment. All the other tissue flaps survived. There were 12 recipient wounds with residual necrotic tissue after surgery, which healed after debridement, VSD, and skin grafting treatment. The remaining 41 wounds healed well. Among the 40 limb wounds of 39 patients, 5 patients had 3 upper limb and 2 lower limb amputations. The remaining 35 limbs of 34 patients were successfully salvaged. The donor site wounds healed well, and the skin grafts survived well. During the follow-up of 6 to 52 months, all the head, face, neck, and trunk wounds were well repaired. The fester recurred in 7 limb wounds 3 to 9 months after surgery and healed after debridement, drainage, and tissue flap repair. At the last follow-up, the functional scores of 22 upper limbs after successful limb salvage ranged from 0 to 100 (with an average of 50), and the Holden walking ability classification of 12 patients with 13 lower limbs after successful limb salvage was level Ⅴ in 8 cases, level Ⅳ in 2 cases, and level Ⅲ in 2 cases. The patients were very satisfied with the efficacy in 33 cases, relatively satisfied in 12 cases, and not quite satisfied in 6 cases. Conclusions Systematic evaluation and treatment of the whole body condition, choosing the appropriate repair time, and using appropriate tissue flaps to repair massive destructive burn wounds will help ensure the safety of treatment, improve the repair effect, and reduce the injury of donor sites, thus optimizing the repair effect. -
参考文献
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图 1 采用“剔骨瓣”、股前外侧分叶皮瓣和腹股沟皮瓣修复例1患者躯干、右踝和足部巨大毁损性烧伤创面的效果。1A.入院时,左上臂环形坏死,左侧躯干大片皮肤炭化；1B.急诊行左上臂截肢后,前臂和手结构完好；1C.左侧躯干清创后创面形态；1D.切取的左上肢远端“剔骨瓣”基底面观；1E.“剔骨瓣”移植术后2.5个月,躯干残端形态；1F.伤后23 d,右踝环形皮肤坏死和足部远端干性坏死；1G.右踝和足部清创完毕后即刻,足残端骨外露,踝部大范围神经肌腱损伤裸露；1H.术中设计切取左侧股前外侧皮瓣；1I.左侧股前外侧皮瓣切取完毕分叶前,携带2条主要穿支；1J.股前外侧分叶皮瓣移植术后7 d,皮瓣存活良好；1K.伤后46 d,设计切取左侧腹股沟皮瓣；1L.随访8个月,右踝和足部创面愈合良好
图 2 采用背阔肌肌皮瓣联合脐旁穿支皮瓣修复例2患者右下肢巨大毁损性烧伤创面的效果。2A.急诊切痂术前,右膝周围可见大片皮肤焦痂；2B.伤后4 d,右下肢清创后,膝关节开放,髌骨缺如；2C.伤后4 d,设计背阔肌肌皮瓣和同侧脐旁穿支皮瓣；2D、2E.分别为组织瓣切取完毕和拼接后形态；2F.术后2 d,组织瓣成活；2G.随访6个月,右下肢修复良好；2H.随访6个月,2个供瓣区创面均愈合良好
图 3 采用背阔肌肌皮瓣修复例3患者头面颈部巨大毁损性烧伤创面的效果。3A.伤后6 d,右侧头面颈部创面皮肤坏死,右耳炭化；3B、3C.分别为伤后51 d,头面颈部清创前和清创后情况；3D.背阔肌肌皮瓣切取后即刻；3E.随访23个月,右侧头面颈部形态外观良好
Table 1. 不同致伤原因下51例患者的53个巨大毁损性烧伤创面部位分布（个）
致伤原因 例数 创面数 上肢 下肢 躯干 头面颈部 电烧伤 39 41 21 10 1 9 热压伤 3 3 2 1 0 0 热力烧伤 8 8 2 4 0 2 酸腐蚀伤 1 1 0 0 0 1 合计 51 53 25 15 1 12 注：2例电烧伤患者同时有2个部位的创面 
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