Clinical effects of various special forms of the descending branch of the lateral circumflex femoral artery perforator flaps in repairing high-voltage electrical burn wounds on the wrist
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摘要:
目的 探讨多种特殊形式旋股外侧动脉降支（DLCFA）穿支皮瓣修复腕部高压电烧伤创面的临床效果。 方法 该研究为回顾性观察性研究。2014年9月—2024年6月,首都医科大学附属北京积水潭医院收治符合入选标准的腕部高压电烧伤男性患者79例,其年龄为20~62岁,腕部高压电烧伤创面（下称腕部创面）分型为Ⅱ型或Ⅲ型。伤后早期,对患者腕部行清创术,根据创面情况及皮瓣适应证,单独采用血流桥接、分叶、嵌合、血流桥接-分叶、分叶-嵌合、血流桥接-嵌合、血流桥接-分叶-嵌合DLCFA穿支皮瓣或者联合采用血流桥接-嵌合DLCFA穿支皮瓣与阔筋膜张肌肌皮瓣修复创面。采用直接拉拢缝合或皮片移植方式修复供瓣区创面。记录术中切取各类DLCFA穿支皮瓣数及其修复的各型腕部创面数、供瓣区创面封闭情况,统计术后皮瓣成活情况、是否发生血管危象、创面或者缝合口愈合情况、血流桥接皮瓣重建动脉通畅情况。随访时,观察皮瓣外形、瘢痕形成情况,以及大腿肌疝发生情况。 结果 术中,切取11个血流桥接DLCFA穿支皮瓣修复11个Ⅱ型腕部创面,切取13个分叶DLCFA穿支皮瓣修复9个Ⅱ型和4个Ⅲ型腕部创面,切取16个嵌合DLCFA穿支皮瓣修复16个Ⅱ型腕部创面,切取11个血流桥接-分叶DLCFA穿支皮瓣修复5个Ⅱ型和6个Ⅲ型腕部创面,切取10个分叶-嵌合DLCFA穿支皮瓣修复5个Ⅱ型和5个Ⅲ型腕部创面,切取6个血流桥接-嵌合DLCFA穿支皮瓣修复6个Ⅱ型腕部创面,切取7个血流桥接-分叶-嵌合DLCFA穿支皮瓣修复7个Ⅲ型腕部创面,另切取5个血流桥接-嵌合DLCFA穿支皮瓣联合阔筋膜张肌肌皮瓣修复5个Ⅲ型腕部创面。74例患者供瓣区创面经直接缝合封闭,5例患者供瓣区创面经皮片移植封闭。术后,3例患者皮瓣发生血管危象,其中动脉危象1例、静脉危象2例,经急诊血管探查等处理后皮瓣成活；其余皮瓣完全成活。术后,3例患者皮瓣下方有渗出,经换药治疗后封闭；其余患者创面或缝合口均愈合。动脉造影显示,35例行血流桥接皮瓣移植患者术后重建动脉全部通畅。随访3个月~1年期间,20例患者皮瓣臃肿,其余患者皮瓣外形良好；行创面直接缝合的供瓣区遗留线性瘢痕,供瓣区创面植皮区片状瘢痕增生不明显；未出现大腿肌疝。 结论 充分利用穿支皮瓣优势,采用多种特殊形式DLCFA穿支皮瓣修复腕部高压电烧伤立体性损伤创面,既使供区损伤最小化,又使受区得到良好修复,近期随访外观较佳。 Abstract:Objective To explore the clinical effects of various special forms of the descending branch of the lateral circumflex femoral artery (DLCFA) perforator flaps in repairing high-voltage electrical burn wounds on the wrist. Methods This study was a retrospective observational study. From September 2014 to June 2024, 79 male patients with high-voltage electrical burns on the wrist, aged 20 to 62 years and met the inclusion criteria, were admitted to Beijing Jishuitan Hospital Affiliated to Capital Medical University, with wrist high-voltage electrical burn wound (hereinafter referred to as wrist wound) types being classified as type Ⅱ or type Ⅲ. In the early stage after injury, debridement was performed on the patients' wrists. Based on the wound condition and flap indications, the flow-through, lobed, chimeric, flow-through-lobed, lobed-chimeric, flow-through-chimeric, or flow-through-lobed-chimeric DLCFA perforator flap was employed individually, and the flow-through-chimeric DLCFA perforator flap and tensor fascia lata myocutaneous flap were employed in combination to repair the wounds. The donor site wounds were repaired using direct sutures or skin grafting. The number of various DLCFA perforator flaps resected during surgery and the number of various types of wrist wounds repaired were recorded, as well as the closure status of the donor site wound. The postoperative flap survival, occurrence of vascular crisis, wound or suture site healing, and patency of the reconstructed artery in flow-through flaps were recorded. During follow-up, the appearance of the flap, scar formation, and the presence of thigh muscle herniation were observed. Results Intraoperatively, 11 flow-through DLCFA perforator flaps were resected to repair 11 type Ⅱ wrist wounds, 13 lobed DLCFA perforator flaps were resected to repair 9 type Ⅱ and 4 type Ⅲ wrist wounds, 16 chimeric DLCFA perforator flaps were resected to repair 16 type Ⅱ wrist wounds, 11 flow-through-lobed DLCFA perforator flaps were resected to repair 5 type Ⅱ and 6 type Ⅲ wrist wounds, 10 lobed-chimeric DLCFA perforator flaps were resected to repair 5 type Ⅱ and 5 type Ⅲ wrist wounds, 6 flow-through-chimeric DLCFA perforator flaps were resected to repair 6 type Ⅱ wrist wounds, 7 flow-through-lobed-chimeric DLCFA perforator flaps were resected to repair 7 type Ⅲ wrist wounds, and 5 flow-through-chimeric DLCFA perforator flaps combined with tensor fascia lata myocutaneous flaps were resected to repair 5 type Ⅲ wrist wounds. Seventy-four patients had their donor site wounds closed by direct suturing, while 5 patients had their donor site wounds closed by skin grafting. Postoperatively, the flaps in 3 patients developed vascular crisis, including 1 case of arterial crisis and 2 cases of venous crises but survived after emergency vascular exploration and other treatments; the remaining flaps survived completely. Postoperatively, 3 patients had seepage beneath their flaps, which were closed after dressing changes; the remaining patients' wounds or suture sites all healed. Anteriography showed that all reconstructed arteries in 35 patients who underwent flow-through flap transplantation were patent postoperatively. During the follow-up period of 3 months to 1 year, 20 patients had bloated flap, while the rest had good flap appearance; linear scars were left in the donor sites that underwent direct wound closure, and the skin-grafted areas of the donor site wounds showed no significant patchy hypertrophic scarring; no thigh muscle herniation occurred. Conclusions Taking the full advantage of perforator flaps, various special forms of the DLCFA perforator flaps are used to repair the three-dimensionally injury wounds caused by high-voltage electrical burns on the wrist, which not only minimizes the damage to the donor site but also allow the recipient site to be well repaired, showing good appearance in the recent follow-up. -
参考文献
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图 1 采用右下肢嵌合旋股外侧动脉降支（DLCFA）穿支皮瓣修复例1患者Ⅱ型左腕部高压电烧伤创面的效果。1A、1B.分别为术前左腕部创面腕屈侧、腕背侧观；1C.左腕部切开减张术后即刻；1D.术前上肢动脉造影显示尺动脉栓塞,桡动脉通畅；1E.彻底清创,去除坏死屈指肌肉,保留屈指肌腱和正中神经,左腕部形成死腔；1F.设计大小为24 cm×11 cm的右下肢DLCFA穿支皮瓣；1G.切取嵌合股外侧肌肌瓣的DLCFA穿支皮瓣；1H.皮瓣转移至左腕部,肌瓣填塞腕部死腔；1I.术后2周,皮瓣存活良好,创面愈合；1J.术后2周,右大腿供瓣区愈合
图 2 采用左下肢分叶-嵌合旋股外侧动脉降支（DLCFA）穿支皮瓣修复例2患者Ⅱ型右腕部高压电烧伤创面及右拇指Ⅲ度高压电烧伤创面的效果。2A.术前右腕部及右拇指创面；2B.术前右上肢动脉造影显示尺动脉栓塞,桡动脉通畅；2C.急诊行腕部切开减张后即刻；2D.设计总大小为23 cm×9 cm的左下肢分叶DLCFA穿支皮瓣；2E.切取皮瓣并分为2叶,在近端2条穿支附近携带部分股外侧肌,形成分叶-嵌合皮瓣；2F.皮瓣转移至右腕及右手,近端分叶嵌合皮瓣覆盖腕部死腔及创面,远端分叶皮瓣覆盖拇指创面；2G.术后2周,供瓣区缝合口愈合良好；2H.术后6个月,皮瓣存活良好,稍臃肿
图 3 采用右下肢血流桥接-分叶旋股外侧动脉降支（DLCFA）穿支皮瓣修复例3患者Ⅱ型右腕部高压电烧伤创面及右手Ⅲ度高压电烧伤创面的效果。3A.右腕部及右手创面；3B.右上肢动脉造影显示尺、桡动脉全部栓塞,骨间血管通畅；3C.设计总大小为30 cm×11 cm的右下肢分叶DLCFA穿支皮瓣；3D.腕部及手部创面彻底清创,血流桥接-分叶DLCFA穿支皮瓣切取完成后即刻；3E.转移皮瓣,近端分叶皮瓣覆盖腕部,远端分叶皮瓣覆盖手部,降支主干远端与手部尺动脉端端吻合；3F.术后右上肢动脉造影显示,重建尺动脉通畅；3G.术后6个月,皮瓣存活良好,手部皮瓣臃肿；3H.术后6个月,供瓣区遗留线性瘢痕
图 4 采用右下肢血流桥接-嵌合旋股外侧动脉降支（DLCFA）穿支皮瓣联合阔筋膜张肌肌皮瓣修复例4患者Ⅲ型右腕部高压电烧伤创面的效果。4A、4B.分别为术前右腕部创面腕屈侧、腕背侧观；4C.右腕部彻底清创去除所有坏死组织后即刻；4D.设计大小分别为21 cm×13 cm和27 cm×14 cm的右下肢DLCFA穿支皮瓣与阔筋膜张肌肌皮瓣；4E.切取的血流桥接-嵌合股外侧肌肌瓣的DLCFA穿支皮瓣；4F.切取的阔筋膜张肌肌皮瓣；4G.皮瓣转移至右腕部创面,DLCFA穿支皮瓣覆盖腕掌部创面,阔筋膜张肌肌皮瓣覆盖腕背侧创面,DLCFA主干近端与尺动脉端端吻合,阔筋膜张肌肌皮瓣血管与DLCFA主干串联吻合；4H、4I.分别为术后12个月受区腕屈侧、腕背侧观,皮瓣存活良好且不臃肿；4J.术后12个月,供瓣区创面植皮区片状瘢痕增生不明显
皮瓣类型 皮瓣数 修复的腕部高压电烧伤创面分型 Ⅱ型 Ⅲ型 血流桥接DLCFA穿支皮瓣 11 11 0 分叶DLCFA穿支皮瓣 13 9 4 嵌合DLCFA穿支皮瓣 16 16 0 血流桥接-分叶DLCFA穿支皮瓣 11 5 6 分叶-嵌合DLCFA穿支皮瓣 10 5 5 血流桥接-嵌合DLCFA穿支皮瓣 6 6 0 血流桥接-分叶-嵌合DLCFA穿支皮瓣 7 0 7 血流桥接-嵌合DLCFA穿支皮瓣联合阔筋膜张肌肌皮瓣 5 0 5 注：DLCFA为旋股外侧动脉降支 
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