Clinical effects of thin anterolateral thigh perforator flaps combined with finger splitting and finger web plasty in sequential treatment of destructive wounds of total hand degloving
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摘要:
目的 探讨采用修薄的股前外侧穿支皮瓣联合分指及指蹼成形术序贯治疗全手脱套毁损性创面的效果。 方法 该研究为回顾性观察性研究。2012年1月2023年1月,宁波市第六医院收治15例符合入选标准的全手脱套毁损性创面患者,其中男10例、女5例,年龄17~75岁,创面均合并骨骼或肌腱外露。Ⅰ期皮瓣移植术前均急诊行清创+负压封闭引流处理,彻底清创后,创面面积为11.0 cm×3.0 cm~23.0 cm×13.5 cm。设计并切取一侧或双侧股前外侧穿支皮瓣（面积12.5 cm×5.0 cm~25.0 cm×15.5 cm）,并对皮瓣进行修薄处理修复手部皮肤软组织缺损。将供区创面直接缝合或取对侧大腿中厚皮片移植修复。根据需要,于皮瓣移植术后每隔约3个月行1次或多次分指+指蹼成形术,对皮瓣进行整复。Ⅰ期术后,观察皮瓣成活、并发症发生情况,供区创面愈合情况。随访时观测,皮瓣外观、两点辨别觉距离及手部功能等情况。末次随访时,根据中华医学会手外科学会上肢部分功能评定试用标准对患手功能进行评定。 结果 Ⅰ期术后,15例患者皮瓣均完全成活,其中1例患者皮瓣出现动脉危象,经探查并重新吻合血管后完全成活；供区创面全部愈合。Ⅰ期术后随访6~18个月,皮瓣外形稍臃肿,有少许色素沉着,两点辨别觉距离为8~11 mm；手指可完成屈伸、捏、握等基本生活动作。末次随访时,患手功能评定为优者3例、良者9例、可者3例。 结论 针对全手脱套毁损性创面,Ⅰ期采用游离移植一侧或双侧修薄的股前外侧穿支皮瓣进行修复,后期采用分指+指蹼成形术对皮瓣进行整复,可基本恢复患手生活所需的捏握功能,值得临床推广。 Abstract:Objective To investigate the clinical effects of thinned anterolateral thigh perforator flaps combined with finger splitting and finger web plasty in sequential treatment of destructive wounds of total hand degloving. Methods A retrospective observational study was conducted. From January 2012 to January 2023, a total of 15 cases who met the inclusion criteria with destructive wounds of total hand degloving were treated in Ningbo No.6 Hospital, including 10 males and 5 females, aged 17-75 years. The wounds were all combined with exposed bones and tendon. Debridement and vacuum sealing drainage were performed in all cases before flap transplantation in stage Ⅰ. After complete debridement, the wound area was 11.0 cm×3.0 cm-23.0 cm×13.5 cm. One or both anterolateral thigh perforator flaps with size of 12.5 cm×5.0 cm-25.0 cm×15.5 cm were designed and cut according to the defect area, and the flaps were thinned to repair the skin and soft tissue defects of the hand. The donor site was sutured directly or repaired with medium-thickness skin graft from the opposite thigh. According to the need, the flap was reconstructed by finger split and finger web plasty once or more times every 3 months after the flap transplantation. The survival and complications of flap and wound healing at the donor site were observed during the follow-up. The appearance of flap, two-point discrimination distance, and hand function were followed up after stage Ⅰoperation. At the final follow-up, the function of the affected hand was evaluated by the trial standards for evaluation of partial function of upper extremity by the Hand Surgery Society of Chinese Medical Association. Results After the operation of stage Ⅰ, all the 15 cases of patients with flap survived completely, including 1 case with arterial crisis of flap, which survived completely after exploring and re-anastomosis of blood vessels; all the wounds at the donor site healed. Follow-up for 6 to 18 months after stage Ⅰ, the flap was slightly swollen, with a little pigmentation, and the two-point discrimination distance in the finger flap was 8-11 mm. The fingers can complete the basic life functions such as flexion, extension, pinch, and grip. At the last follow-up, 3 cases were excellent, 9 cases were good, and 3 cases were acceptable. Conclusions For destructive wounds of total hand degloving, free transplantation of one or both thinned anterolateral thigh perforator flaps is used for repair in stage Ⅰ, and finger split and finger web plasty is used to repair the flaps in the later stage, which can basically restore the pinch and grip function of the affected hand, and is worthy of clinical promotion. -
Key words:
- Hand /
- Degloving injuries /
- Surgical flaps /
- Reconstructive surgical procedures /
- Wound repair
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参考文献
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图 1 游离移植右侧修薄股前外侧穿支皮瓣联合分指及指蹼成形术序贯治疗例1患者左手滚筒挤压致脱套毁损性创面的效果。1A、1B.分别为急诊术前患手掌侧、背侧观,第1~4指掌背侧皮肤软组织缺损,小指自掌指关节水平以远缺损；1C.皮瓣移植术前,根据患者手部创面大小和形状于右大腿外侧设计皮瓣；1D.术中于深筋膜浅层可见1条旋股外侧动脉降支穿支血管；1E、1F.分别为完全游离皮瓣后即刻患手背侧、掌侧观；1G、1H.分别为皮瓣移植术后即刻患手掌侧、背侧观；1I、1J.分别为皮瓣移植术后1个月患手掌侧、背侧观,皮瓣存活良好；1K、1L.分别为皮瓣移植术后4个月（第1次分指+指蹼成形术后1个月）患手掌侧、背侧观,皮瓣色泽良好；1M. 皮瓣移植术后4个月患手捏握功能良好；1N、1O.分别为皮瓣移植术后12个月（第2次分指+指蹼成形术后1个月）患手掌侧、背侧观,第1~4指掌侧、背侧皮瓣薄且色泽良好；1P.皮瓣移植术后12个月,1~4指捏握功能良好
图 2 游离移植双侧股前外侧穿支皮瓣联合分指及指蹼成形术序贯治疗例2患者右手滚筒挤压致脱套毁损性创面的效果。2A、2B.分别为急诊术前患手掌侧、背侧观,可见右手脱套毁损性创面；2C、2D.分别为清创+负压封闭引流手术后患手掌侧、背侧观,右拇指近节近端以远缺损,右中指中节中段以远缺损,右示、环、小指近节远端以远缺损,右手背部皮肤完全缺损；2E、2F.分别为根据患手创面的大小和形状于右、左大腿外侧设计皮瓣；2G、2H.分别为皮瓣移植前双侧股前外侧穿支皮瓣的正面、背面观；2I、2J.分别为皮瓣移植术后即刻患手背侧、掌侧观；2K、2L.分别为皮瓣移植术后2个月患手掌侧、背侧观,皮瓣存活良好；2M、2N.分别为皮瓣移植术后5个月（分指+指璞成形术后2个月）患手掌侧、 背侧观,皮瓣较薄、色泽良好；2O、2P.分别为皮瓣移植术后7个月患手捏握勺、笔情况,患手基本恢复生活所需的捏握功能
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