Application strategies and clinical effects of superior gluteal artery perforator tissue flaps in repairing stage Ⅳ pressure ulcers in the sacrococcygeal region
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摘要:
目的 探讨臀上动脉穿支组织瓣在骶尾部Ⅳ期压疮修复中的应用策略及临床效果。 方法 该研究为回顾性观察性研究。2019年7月—2024年4月,南昌大学第一附属医院收治89例符合入选标准的骶尾部Ⅳ期压疮患者,其中男59例、女30例,年龄21~84岁。共89处骶尾部压疮,清创后创面面积为5.0 cm×4.0 cm~21.0 cm×21.0 cm。根据清创后创面形状、大小及深度,结合创周皮肤弹性与质地情况,以供区损伤最小化为原则,按以下3种情况切取相应形式的臀上动脉穿支组织瓣进行创面修复。（1）创面形状为圆形、面积为5.0 cm×5.0 cm~21.0 cm×21.0 cm、深度为1.0~3.5 cm者,采用臀上动脉穿支螺旋桨（肌）皮瓣、双叶臀上动脉穿支接力皮瓣、双侧臀上动脉穿支旋转皮瓣修复；（2）创面形状为椭圆形、面积为5.0 cm×4.0 cm~18.5 cm×10.5 cm、深度为1.0~3.0 cm者,采用臀上动脉穿支螺旋桨（肌）皮瓣、单侧臀上动脉穿支螺旋桨皮瓣联合对侧臀上动脉穿支V-Y推进皮瓣或拱顶石皮瓣修复；（3）创面形状为梭形,面积为7.0 cm×4.0 cm~17.5 cm×6.0 cm、深度为1.5~5.0 cm者,采用单侧或双侧臀上动脉穿支V-Y推进皮瓣、臀上动脉穿支拱顶石皮瓣或臀上动脉穿支拱顶石皮瓣联合臀大肌肌瓣修复。该组患者共使用40个臀上动脉穿支螺旋桨皮瓣（切取面积为11.0 cm×6.0 cm~17.0 cm×11.0 cm）、22个臀上动脉穿支螺旋桨肌皮瓣（切取面积为10.0 cm×5.0 cm~14.0 cm×8.0 cm）、7个双叶臀上动脉穿支接力皮瓣（主瓣切取面积为5.5 cm×5.5 cm~18.0 cm×11.5 cm,副瓣切取面积为4.5 cm×3.0 cm~11.0 cm×6.5 cm）、5个双侧臀上动脉穿支旋转皮瓣（双侧皮瓣总切取面积为20.0 cm×16.0 cm~26.0 cm×21.0 cm）、14个臀上动脉穿支V-Y推进皮瓣（切取面积为12.0 cm×10.0 cm~18.0 cm×18.0 cm）、13个臀上动脉穿支拱顶石皮瓣（切取面积为13.0 cm×6.5 cm~19.0 cm×18.0 cm）、3个臀大肌肌瓣（切取面积为8.0 cm×3.0 cm~15.0 cm×4.5 cm）。将供区创面均直接缝合。术后观察组织瓣存活情况并计算受区创面延迟愈合发生率,观察供区创面愈合情况；随访组织瓣的外观、质地及压疮有无复发。 结果 术后,所有双侧臀上动脉穿支旋转皮瓣、臀上动脉穿支V-Y推进皮瓣、臀上动脉穿支拱顶石皮瓣及臀大肌肌瓣存活良好；受区创面出现延迟愈合者6例,发生率为6.7%（6/89）。2例患者供区创面因术后出血导致切口开裂,经清创+负压封闭引流+换药后愈合；其余患者供区创面愈合良好。6例患者失访。83例患者随访3~48个月,其中4例患者死亡；余79例患者中3例因护理不当导致压疮复发,其余患者组织瓣外观良好、质地柔软且压疮未复发。 结论 根据骶尾部Ⅳ期压疮清创后创面形状、大小及深度等特点,个体化选择以臀上动脉穿支为蒂的皮瓣、肌皮瓣及皮瓣联合臀大肌肌瓣的组合组织瓣等进行修复,术后组织瓣存活良好且压疮复发少,临床修复效果较佳。 Abstract:Objective To explore the application strategies and clinical effects of superior gluteal artery perforator tissue flaps in repairing stage Ⅳ pressure ulcers in the sacrococcygeal region. Methods This study was a retrospective observational study. From July 2019 to April 2024, 89 patients with stage Ⅳ pressure ulcers in the sacrococcygeal region who met the inclusion criteria were admitted to the First Affiliated Hospital of Nanchang University, including 59 males and 30 females, aged 21 to 84 years. There were 89 sacrococcygeal pressure ulcers, with an area of 5.0 cm×4.0 cm-21.0 cm×21.0 cm after debridement. According to the shape, size, and depth of the wounds after debridement, combined with the elasticity and texture of the skin around the wounds, and the principle of minimizing damage to the donor area, the appropriate forms of superior gluteal artery perforator tissue flaps were cut for wound repair in the following three conditions. (1) For wounds with a round shape, an area of 5.0 cm×5.0 cm-21.0 cm×21.0 cm, and a depth of 1.0-3.5 cm, the superior gluteal artery perforator propeller flap or myocutaneous flap, bilobed superior gluteal artery perforator relay flap, and bilateral superior gluteal artery perforator rotational flap were used. (2) For wounds with an oval shape, an area of 5.0 cm×4.0 cm-18.5 cm×10.5 cm, and a depth of 1.0-3.0 cm, the superior gluteal artery perforator propeller flap or myocutaneous flap, unilateral superior gluteal artery perforator propeller flap combined with contralateral superior gluteal artery perforator V-Y advanced flap or keystone flap were used. (3) For wounds with a fusiformis shape, an area of 7.0 cm×4.0 cm-17.5 cm×6.0 cm, and a depth of 1.5-5.0 cm, the unilateral or bilateral superior gluteal artery perforator V-Y advanced flap, superior gluteal artery perforator keystone flap, or superior gluteal artery perforator keystone flap combined with gluteus maximus muscle flap were used. In this group of patients, a total of 40 superior gluteal artery perforator propeller flaps (with an resection area of 11.0 cm×6.0 cm-17.0 cm×11.0 cm), 22 superior gluteal artery perforator propeller myocutaneous flaps (with an resection area of 10.0 cm×5.0 cm-14.0 cm×8.0 cm), 7 bilobed superior gluteal artery perforator relay flaps (with a main flap resection area of 5.5 cm×5.5 cm-18.0 cm×11.5 cm and a side flap resection area of 4.5 cm×3.0 cm-11.0 cm×6.5 cm), 5 bilateral superior gluteal artery perforator rotational flaps (with a total resection area of 20.0 cm×16.0 cm-26.0 cm×21.0 cm on both sides), 14 superior gluteal artery perforator V-Y advanced flaps (with an resection area of 12.0 cm×10.0 cm-18.0 cm×18.0 cm), 13 superior gluteal artery perforator keystone flaps (with an resection area of 13.0 cm×6.5 cm-19.0 cm×18.0 cm), and 3 gluteus maximus muscle flaps (with an resection area of 8.0 cm×3.0 cm-15.0 cm×4.5 cm). The donor area wounds were all directly sutured. The survival of tissue flaps was observed and the incidence rate of delayed wound healing in the reception area was calculated, and wound healing in the donor area was observed. The appearance and texture of tissue flaps and recurrence of pressure ulcers were followed up. Results After surgery, all bilateral superior gluteal artery perforator rotational flaps, superior gluteal artery perforator V-Y advanced flaps, superior gluteal artery perforator keystone flaps, and gluteus maximus muscle flaps survived well. There were 6 cases of delayed wound healing in the reception area after surgery, with an incidence rate of 6.7% (6/89). Two patients had incision dehiscence in the donor area wounds due to postoperative bleeding, the wounds healed after debridement, vacuum sealing drainage, and dressing change. The wounds in the donor area of the remaining patients healed well. Six patients were lost to follow-up. Eighty-three patients were followed up for 3-48 months, of whom 4 patients died. Among the remaining 79 patients, 3 cases had pressure ulcers recur due to improper nursing, while the rest of the patients had tissue flaps with good appearance and soft texture and no recurrence of pressure ulcers. Conclusions Based on the characteristics of wound shape, size, and depth after debridement of stage Ⅳ pressure ulcers in the sacrococcygeal region, individualized selection of flap, myocutaneous flap, or a combination of flap and gluteus maximus muscle flap based on the perforating branch of the superior gluteal artery perforator can achieve good clinical repair results. The postoperative tissue flap survived well, with a good appearance, soft texture, and less recurrence of pressure ulcers. -
Key words:
- Pressure ulcer /
- Sacrococcygeal region /
- Surgical flaps /
- Debridement /
- Microsurgery /
- Skin and soft tissue defects /
- Wound repair
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邓如非：实施手术、采集资料、撰写论文；范宝文、宋松华、龙露瑶、陈燕微、陈嘉欣、纪如晨、张永宏、胡翔天、黄国能、姜臻宇、江澜：实施手术、采集资料、整理数据；邹立津、辛国华、曾元临、张友来：酝酿和设计研究、实施手术、修改论文、经费支持所有作者声明不存在利益冲突
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参考文献
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图 2 不同形式的臀上动脉穿支组织瓣修复骶尾部Ⅳ期压疮的手术示意图。2A.臀上动脉穿支螺旋桨（肌）皮瓣；2B.双叶臀上动脉穿支接力皮瓣；2C.双侧臀上动脉穿支旋转皮瓣；2D.臀上动脉穿支V-Y推进皮瓣；2E.臀上动脉穿支拱顶石皮瓣；2F.臀大肌肌瓣
注：各分图中左侧图为术前组织瓣设计、右侧图为组织瓣切取转移后
图 3 双叶臀上动脉穿支接力皮瓣旋转修复例1患者圆形骶尾部Ⅳ期压疮的效果。3A.术前创面情况及皮瓣设计；3B.术中游离臀上动脉穿支；3C.术中皮瓣旋转修复创面后即刻；3D.术后25 d,创面愈合良好
图 4 双侧臀上动脉穿支旋转皮瓣旋转修复例2患者圆形骶尾部Ⅳ期压疮的效果。4A.术前创面情况,创周可见潜行窦道；4B.Ⅰ期彻底清创后,创面巨大；4C.Ⅱ期术中皮瓣旋转修复创面后即刻；4D.Ⅱ期术后2 d,双侧皮瓣均存活良好
图 5 臀上动脉穿支螺旋桨皮瓣旋转修复例3患者椭圆形骶尾部Ⅳ期压疮的效果。5A.Ⅱ期术前创面情况及皮瓣设计；5B.Ⅱ期术中切取皮瓣,充分游离蒂部并保留多根穿支；5C.Ⅱ期术中皮瓣旋转修复创面后即刻；5D.Ⅱ期术后6个月随访,皮瓣外观良好,压疮未复发
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