Clinical efficacy of anterolateral thigh free fat flap transplantation with vascular anastomosis for reconstructing facial depressed scars
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摘要:
目的 探讨吻合血管的股前外侧游离脂肪瓣（以下简称脂肪瓣）移植整复面部凹陷性瘢痕的临床效果。 方法 该研究为回顾性观察性研究。2017年6月—2023年9月, 空军军医大学第一附属医院共收治12例符合入选标准的面部凹陷性瘢痕患者, 其中男5例、女7例, 年龄15~67岁。术前使用患者和观察者瘢痕评估量表（POSAS）评估患者面部瘢痕情况, 同时测得瘢痕凹陷面积为5 cm×4 cm~14 cm×7cm、深度为6~12 mm, 采用脂肪瓣进行移植整复。切取的脂肪瓣面积为6 cm×5 cm~15 cm×8 cm, 血管蒂长度为4~7 cm；术中观察到其携带穿支血管数量为1支者2例、2支者7例、3支者3例。将脂肪瓣移植至受区, 并将其携带的穿支和穿支伴行静脉的主干血管与受区动静脉吻合。直接缝合供区创面。术后, 观察脂肪瓣成活情况及是否有血管危象、供区切口愈合情况。随访时, 观察患者面部外形, 记录受区远期再治疗情况, 观察供受区切口瘢痕形成情况并评估供区肢体的功能。末次随访时, 采用POSAS中的观察者量表和患者自评量表2个子量表分别评估受区瘢痕情况。 结果 1例患者在术后24 h内因渗血出现轻度血肿, 经及时清除血肿并加强引流后, 脂肪瓣成活；其余患者脂肪瓣均完全成活, 且未发生血管危象。1例患者供区切口在术后7 d出现感染, 经及时换药后愈合；其余患者供区切口均顺利愈合。随访6~26个月, 所有患者面部对称性均获得显著改善, 外观丰满自然。2例患者分别于术后6个月和10个月接受自体颗粒脂肪补充移植, 1例患者于术后12个月行局部脂肪抽吸修整。供受区瘢痕轻微；供区未出现功能障碍, 患肢运动和感觉均正常。末次随访时, 观察者量表评估显示, 受区瘢痕的血管分布、厚度、粗糙度、柔韧性、色素沉着及总体评价评分分别为（2.1±0.5）、（1.9±0.7）、（3.0±0.7）、（2.1±1.2）、（3.8±1.1）、（2.8±0.5）分, 均明显低于术前的（4.2±0.9）、（5.1±1.0）、（4.2±1.5）、（4.6±1.4）、（4.8±1.2）、（5.2±1.0）分（t值分别为7.24、11.70、4.31、9.57、4.17、9.30, P < 0.05）；患者自评量表评估显示, 受区瘢痕的疼痛、瘙痒、颜色、硬度、形状、厚度、总体评价评分分别为（1.3±0.5）、（1.3±0.4）、（1.9±1.0）、（2.3±1.1）、（1.8±0.8）、（1.9±0.8）、（1.9±0.7）分, 均明显低于术前的（2.9±1.0）、（2.6±0.9）、（4.2±1.5）、（5.3±2.0）、（4.0±1.2）、（4.6±1.3）、（4.8±1.4）分（t值分别为6.09、5.20、8.07、9.17、8.00、8.60、8.81, P < 0.05）。 结论 吻合血管的脂肪瓣移植可安全有效地整复面部凹陷性瘢痕, 显著改善外观及瘢痕症状, 术后远期效果稳定, 患者满意度高, 具有临床应用价值。 Abstract:Objective To investigate the clinical efficacy of anterolateral thigh free fat flap (hereinafter referred to as fat flap) transplantation with vascular anastomosis for reconstructing facial depressed scars. Methods This study was a retrospective observational study. Twelve patients (5 males and 7 females, aged 15-67 years) with facial depressed scars who met the inclusion criteria were treated at the First Affiliated Hospital of Air Force Medical University from June 2017 to September 2023. Before surgery, the patient and observer scar assessment scale (POSAS) was used to evaluate the facial scar condition of the patients. Scar depression area was measured ranging from 5 cm×4 cm to 14 cm×7 cm, with a depth from 6 to 12 mm. All cases were reconstructed with fat flaps. The harvested fat flaps ranged 6 cm×5 cm to 15 cm×8 cm in size, with vascular pedicle lengths ranging from 4 to 7 cm. Intraoperatively, the number of perforator vessels observed was as follows: 1 perforator in 2 cases, 2 perforators in 7 cases, and 3 perforators in 3 cases. Fat flaps were transplanted to the recipient sites, with the main trunks of its perforator vessels and accompanying veins anastomosed to the recipient arteries and veins. Donor site wounds were closed primarily. Postoperatively, the survival of fat flap, vascular crisis, and the healing of donor site incision were observed. During follow-up, the facial contour was observed, the long-term reintervention at recipient sites was recorded, and the scars formed at both donor and recipient incisions were observed. The function of donor limb was assessed. At the last follow-up, the scar condition at recipient site was evaluated using the two subscales of POSAS (the observer scale and the patient self-rating scale), respectively. Results One patient developed a mild hematoma due to bleeding within 24 hours after surgery. After timely removal of the hematoma and enhanced drainage, the fat flap survived. The fat flaps of the other patients survived completely with no vascular crisis occurred. The donor site incision of 1 patient developed infection 7 days after surgery and healed after timely dressing changes, while the donor site incisions of the remaining patients all healed smoothly. During the follow-up of 6-26 months, significant improvement in facial symmetry was observed in all patients, with natural fullness achieved. Autologous microlipofilling was performed in 2 patients at 6 months and 10 months postoperatively, respectively. Local liposuction contouring was conducted in 1 patient at 12 months postoperatively. The scars at the donor and recipient sites were mild. No functional impairment at donor sites was recorded, and the motor and sensory functions of the affected limbs were normal. At the last follow-up, the observer scale assessment showed that the scores for vascularity, thickness, roughness, pliability, pigmentation, and overall assessment of the scars in the recipient areas were 2.1±0.5, 1.9±0.7, 3.0±0.7, 2.1±1.2, 3.8±1.1, and 2.8±0.5, respectively, which were significantly lower than 4.2±0.9, 5.1±1.0, 4.2±1.5, 4.6±1.4, 4.8±1.2, and 5.2±1.0 before surgery (with t values of 7.24, 11.70, 4.31, 9.57, 4.17, and 9.30, respectively, P < 0.05). The patient self-rating scale assessment showed that the scores for pain, pruritus, color, stiffness, irregularity, thickness, and overall satisfaction of the scars in the recipient areas were 1.3±0.5, 1.3±0.4, 1.9±1.0, 2.3±1.1, 1.8±0.8, 1.9±0.8, and 1.9±0.7, respectively, which were significantly lower than 2.9±1.0, 2.6±0.9, 4.2±1.5, 5.3±2.0, 4.0±1.2, 4.6±1.3, and 4.8±1.4 before surgery (with t values of 6.09, 5.20, 8.07, 9.17, 8.00, 8.60, and 8.81, respectively, P < 0.05). Conclusions Transplantation of the fat flaps with vascular anastomosis can safely and effectively reconstruct facial depressed scars, and significantly improve the aesthetic contour and scar-related symptoms. This technique yields stable long-term outcomes with high patient satisfaction, demonstrating high value of clinical application. -
Key words:
- Cicatrix /
- Microsurgery /
- Surgical flaps /
- Free fat flap /
- Face depression /
- Wound repair
本文亮点(1) 采用吻合血管的股前外侧游离脂肪瓣移植整复面部凹陷性瘢痕, 术后面部外观恢复良好, 瘢痕改善明显。(2) 该手术长期效果稳定, 为面部凹陷性瘢痕患者提供了一种可靠的整复方法。 -
参考文献
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图 1 采用吻合血管的股前外侧游离脂肪瓣移植整复患者面部凹陷性瘢痕的效果。1A、1B.分别为术前患者面部正面观、右侧面观, 可见右侧面部凹陷, 皮肤表面瘢痕增生；1C.术中画线标记凹陷区域范围、受区切口位置和长度；1D.成功切取股前外侧游离脂肪瓣即刻；1E.将脂肪瓣移植至受区缝合后即刻；1F、1G和1H.分别为术后9个月随访时, 患者正面观、右半侧面观和右侧面观, 可见脂肪瓣成活, 面部较对称
Figure 1. The effect of anterolateral thigh free fat flap transplantation with vascular anastomosis for reconstructing the facial depressed scar in a patient
表 1 吻合血管的股前外侧游离脂肪瓣移植整复12例面部凹陷性瘢痕患者的术前和术后POSAS评分比较（分, x±s）
Table 1. Comparison of POSAS scores before and after anterolateral thigh free fat flap transplantation with vascular anastomosis for reconstructing facial depressed scars in 12 patients
时间点 观察者量表 患者自评量表 血管分布 色素沉着 厚度 粗糙度 柔韧性 总体评价 疼痛 瘙痒 颜色 硬度 形状 厚度 总体评价 术前 4.2±0.9 4.8±1.2 5.1±1.0 4.2±1.5 4.6±1.4 5.2±1.0 2.9±1.0 2.6±0.9 4.2±1.5 5.3±2.0 4.0±1.2 4.6±1.3 4.8±1.4 术后 2.1±0.5 3.8±1.1 1.9±0.7 3.0±0.7 2.1±1.2 2.8±0.5 1.3±0.5 1.3±0.4 1.9±1.0 2.3±1.1 1.8±0.8 1.9±0.8 1.9±0.7 t值 7.24 4.17 11.70 4.31 9.57 9.30 6.09 5.20 8.07 9.17 8.00 8.60 8.81 P值 ＜0.001 ＜0.001 ＜0.001 ＜0.001 ＜0.001 ＜0.001 ＜0.001 ＜0.001 ＜0.001 ＜0.001 ＜0.001 ＜0.001 ＜0.001 注：术后时间点指末次随访时；POSAS为患者和观察者瘢痕评估量表, 包含观察者量表和患者自评量表2个部分, 评分越低表示越接近正常皮肤 
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