下腹部联体穿支皮瓣游离移植修复四肢大面积软组织缺损的临床效果

钟硕; 刘林峰; 王云鹏; 李冉玥

doi:10.3760/cma.j.cn501225-20250127-00043

下腹部联体穿支皮瓣游离移植修复四肢大面积软组织缺损的临床效果

doi: 10.3760/cma.j.cn501225-20250127-00043

1.
山东第一医科大学附属省立医院手足与显微重建外科,济南　250021
2.
山东省公共卫生临床中心手足外科与修复重建病区,济南　250100

详细信息

通讯作者:
刘林峰,Email：sdslsz2024@163.com

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出版历程
- 收稿日期: 2025-01-27
- 网络出版日期: 2025-12-08

Clinical efficacy of free transplantation of the lower abdominal conjoined perforator flaps in repairing the extensive soft tissue defects in extremities

1.
Department of HandFoot and Reconstructive Microsurgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
2.
Department of Hand and Foot Surgery and Repair and Reconstruction of the Ward, Shandong Public Health Clinical Center, Jinan 250100, China

More Information

Corresponding author: Liu Linfeng, Email: sdslsz2024@163.com

摘要

摘要: 目的探讨下腹部联体穿支皮瓣游离移植修复四肢大面积软组织缺损的临床效果。方法该研究为回顾性观察性研究。2021年5月—2024年3月,2家医院共收治9例符合入选标准的四肢大面积软组织缺损患者,其中山东第一医科大学附属省立医院收治6例、山东省公共卫生临床中心收治3例。患者中男6例、女3例,年龄34~66岁。创面感染控制后,上肢软组织缺损面积为30 cm×10 cm~45 cm×18 cm,下肢软组织缺损面积为32 cm×12 cm~40 cm×9 cm。8例患者创面采用下腹部联体穿支皮瓣修复；1例患者创面面积过大,采用下腹部联体穿支皮瓣+撕脱皮肤制成的全厚皮片移植修复。用于修复上肢创面的皮瓣切取面积为30 cm×10 cm~45 cm×13 cm,用于修复下肢创面的皮瓣切取面积为32 cm×12 cm~40 cm×9 cm。腹部供区创面多可Ⅰ期直接缝合；对于局部张力较高的创面,利用供区“猫耳”软组织移植或撕脱皮肤回植修复,或暂用负压材料覆盖,待张力缓解后行Ⅱ期闭合。记录皮瓣携带的血管情况及血管吻合方式,术后观察皮瓣成活情况（包括血管危象发生情况）、供区创面愈合情况。随访时,观察皮瓣外观、质地、感觉恢复情况,以及供区瘢痕与并发症发生情况。末次随访时,参照利克特5级量表调查患者对受区及供区治疗效果的满意度。结果 4例患者皮瓣携带双侧旋髂浅动脉浅支（SCIA-SB）及腹壁浅动脉（SIEA）,2例患者皮瓣携带单侧SCIA-SB、双侧SIEA,3例患者皮瓣携带双侧SCIA-SB、单侧SIEA。1例患者因拟行血管吻合处存在长约3 cm血管缺损,术中切取同侧足背静脉进行桥接吻合；其余患者供受区血管直接吻合。术后皮瓣顺利成活,未发生血管危象。7例患者术后供区创面愈合良好；1例患者术后供区创面张力较高,行Ⅱ期皮片移植后愈合；1例患者术后腹部缝合口裂开,经换药后愈合。除1例患者失访外,其余8例患者获12~24个月随访,皮瓣质地柔软、无臃肿及溃疡,且均恢复保护性感觉；腹部供区仅遗留轻微瘢痕,无腹壁疝等并发症发生。末次随访时,患者对受区治疗效果的满意度评分为4~5分（平均4.6分）,对供区治疗效果的满意度评分为4~5分（平均4.2分）。结论下腹部联体穿支皮瓣可用于修复四肢大面积软组织缺损,术后受区外形良好,供区创面多可直接缝合且创面愈合后仅遗留轻微瘢痕,对供区外观及功能影响小,患者对供受区治疗效果满意。
- 创伤和损伤 /
- 穿支皮瓣 /
- 腹部 /
- 四肢 /
- 显微外科手术 /
- 联体皮瓣 /
- 旋髂浅动脉浅支 /
- 腹壁浅动脉 /
- 创面修复
Abstract: Objective To investigate the clinical efficacy of free transplantation the lower abdominal conjoined perforator flaps in repairing the extensive soft tissue defects in extremities. Methods This study was a retrospective observational study. From May 2021 to March 2024, 9 patients with extensive soft tissue defects in extremities meeting the inclusion criteria were admitted to the following two hospitals, including 6 cases in Shandong Provincial Hospital Affiliated to Shandong First Medical University and 3 cases in Shandong Public Health Clinical Center. There were 6 male patients and 3 female patients, aged 34 to 66 years. After the wound infection was controlled, the areas of soft tissue defects in the upper extremities ranged from 30 cm×10 cm to 45 cm×18 cm, and those in the lower extremities ranged from 32 cm×12 cm to 40 cm×9 cm. The lower abdominal conjoined perforator flaps were adopted for repairing the wounds in 8 patients. In one patient, a combined repair of flap and skin grafting was adopted due to the extensive wound area. The flap harvest areas were 30 cm×10 cm to 45 cm×13 cm for repairing the wounds in the upper extremities, and those were 32 cm×12 cm to 40 cm×9 cm for repairing the wounds in the lower extremities. Most wounds in the abdominal donor sites could be directly sutured in stage Ⅰ. If there was high local tension, the wounds were repaired by transplanting the "dog-ear" soft tissue or replanting the avulsed skin, or temporarily covered with negative pressure materials and closed in stage Ⅱ after tension relief. The carried blood vessels of the flaps and anastomosis methods were recorded. Postoperatively, the flap survival (including the occurrence of vascular crisis) and the wound healing in the donor sites were observed. During follow-up, the appearance, texture, and sensory recovery of the flaps, as well as the occurrence of scars and complications in the donor sites were observed. At the last follow-up, the 5-grade Likert scale was used to investigate the satisfaction of patients with the treatment effects in the recipient and donor sites. Results The flaps carried bilateral superficial branch of superficial circumflex iliac artery (SCIA-SB) and superficial inferior epigastric artery (SIEA) in 4 patients, the flaps carried unilateral SCIA-SB and bilateral SIEA in two patients, and the flaps carried bilateral SCIA-SB and unilateral SIEA in three patients. In one patient, due to a vascular defect of approximately 3 cm at the anastomosis site, an ipsilateral dorsal pedal vein was used for bridging anastomosis; the blood vessels in the donor and recipient sites were directly anastomosed in the remaining patients. Postoperatively, the flaps survived smoothly, without vascular crisis. Postoperatively, the wounds in the donor sites healed well in 7 patients, the wound in the donor site healed after stage Ⅱ skin grafting due to high tension in one patient, and one patient had dehiscence of the abdominal suture, which healed after dressing changes. Except for one patient lost to follow-up, the remaining 8 patients were followed up for 12 to 24 months. The flaps had a soft texture without swelling or ulceration, and protective sensation was recovered in all patients. Only MILD scars remained in the abdominal donor site, without complications such as abdominal hernia. At the last follow-up, the satisfaction scores of patients with the treatment effects in the recipient and donor sites were 4-5 (with the mean score of 4.6) and 4-5(with the mean score of 4.2), respectively. Conclusions The lower abdominal conjoined perforator flaps can be applied in repairing the extensive soft tissue defects in extremities. After the operation, the wounds in the donor sites can mostly be directly sutured. Only mild scars are left after wound healing, which has little impact on the appearance and function in the donor sites.
- Wounds and injuries /
- Perforator flap /
- Abdomen /
- Conjoined flap /
- Superficial branch of the superficial circumflex iliac artery /
- Superficial inferior epigastric artery /
- Wound healing /
钟硕：研究设计、资料收集和整理、手术实施、论文撰写；刘林峰、王云鹏：研究设计、手术实施和指导论文修改；李冉玥：资料收集和整理、指导论文修改

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图 1 采用下腹部联体穿支皮瓣修复例1患者左下肢创面的效果。1A.急诊术前左小腿近段以远至足背开放性损伤；1B.皮瓣修复术前创面情况；1C.术前皮瓣设计；1D.术中皮瓣切取后；1E.皮瓣修复术后即刻；1F.供区创面直接缝合后；1G.术后24个月,左下肢外形不臃肿；1H.术后24个月,供区遗留线性瘢痕

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图 2 采用股前外侧皮瓣+下腹部联体穿支皮瓣+皮片移植修复例2患者右上肢创面的效果。2A.右上肢肘关节至手掌指关节皮肤广泛脱套,桡腕及腕掌关节脱位合并神经、动脉、肌腱及肌肉组织损伤；2B.股前外侧皮瓣修复术前创面情况；2C.股前外侧皮瓣修复创面术后；2D.拟行下腹部联体穿支皮瓣修复术前创面情况；2E.下腹部联体穿支皮瓣切取后即刻；2F、2G.分别为术中下腹部联体穿支皮瓣移植和撕脱皮肤制成的全厚皮片回植术后创面修复情况；2H.下腹部联体穿支皮瓣供区创面缝合后即刻；2I.下腹部联体穿支术后24个月,右上肢外形良好；2J.术后24个月,腹部皮瓣供区有瘢痕增生

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