基于穿支优选策略设计的薄型ALTF修复患儿手足皮肤软组织缺损的效果

李海; 肖顺娥; 魏在荣; 邓呈亮; 吴祥奎; 王旗

doi:10.3760/cma.j.cn501225-20250603-00254

基于穿支优选策略设计的薄型ALTF修复患儿手足皮肤软组织缺损的效果

doi: 10.3760/cma.j.cn501225-20250603-00254

遵义医科大学附属医院烧伤整形外科,遵义　563000

基金项目:

贵州省高层次创新型人才“千”层次人才 xmrc120240201

详细信息

通讯作者:
魏在荣,Email：weizr@zmu.edu.cn

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出版历程
- 收稿日期: 2025-06-03
- 网络出版日期: 2026-11-02

Efficacy of a thin ALTF designed based on an optimized perforator selection strategy for reconstructing skin soft tissue defects of the hand and foot in pediatric patients

Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, China

Funds:

High-level Innovative Talents "Thousand" Level Talents of Guizhou Province of China xmrc120240201

More Information

Corresponding author: Wei Zairong, Email:weizr@zmu.edu.cn

摘要

摘要: 目的探讨基于穿支优选策略设计的薄型股前外侧皮瓣（ALTF）修复患儿手足皮肤软组织缺损的效果。方法本研究为回顾性观察研究。2018年1月—2025年4月,遵义医科大学附属医院烧伤整形外科收治10例符合入选标准的手足皮肤软组织缺损患儿,其中男8例、女2例,年龄2~14岁。创面位于上肢者4例、位于足部者6例。彻底清创后,创面软组织缺损面积为5.0 cm×3.5 cm~16.0 cm×9.0 cm。术前,采用改良二纵五横新算法将股前外侧区分为Ⅰ、Ⅱ、Ⅲ、Ⅳ区,并探测各分区的穿支情况。基于探测结果,制订穿支优选策略：同等条件下优选Ⅱ区、Ⅲ区穿支；需要较长血管蒂或较薄皮瓣时,优选Ⅲ区、Ⅳ区穿支；需要携带髂骨瓣、较厚组织瓣或更倾向于分离肌间隙穿支时,优选Ⅰ区穿支。术中根据该策略及创面软组织缺损面积设计ALTF,并在浅筋膜浅层分离穿支,切取薄型ALTF。皮瓣面积为5.0 cm×3.5 cm~20.0 cm×6.0 cm。将皮瓣动、静脉分别与受区动、静脉行端端或端侧吻合,然后封闭受区创面。采用减张缝合封闭供区创面。记录术前股前外侧区各分区穿支分布及优选情况。以术中实际探查结果为金标准,记录术前优选穿支定位的准确性。术后观察皮瓣成活情况,记录血管危象、皮瓣下渗液等并发症发生情况,并记录合并骨折患儿和瘢痕挛缩畸形松解患儿拔除克氏针的时间。术后随访时,观察皮瓣色泽、质地、弹性及外形并记录是否有后期修薄需求,评估供受区瘢痕情况并记录后期修整情况。末次随访时,采用中华医学会手外科学会手功能评定试用标准评定患手功能,采用Maryland足评分评价患足功能。结果术前,本组10例患儿股前外侧区共探测到穿支25支,其中Ⅰ区5支、Ⅱ区7支、Ⅲ区9支、Ⅳ区4支；共优选穿支17支,其中Ⅰ区2支、Ⅱ区6支、Ⅲ区8支、Ⅳ区1支,即每例患儿优选1支或2支穿支。术前优选穿支定位的准确性为16/17。术后,1例患儿皮瓣下出现渗液,经换药引流后愈合；其余皮瓣均顺利成活,无一例发生血管危象。2例合并骨折的患儿于术后3个月内拔除克氏针；3例瘢痕挛缩畸形松解患儿于术后1个月拔除克氏针。术后随访6~60个月,皮瓣色泽、质地与周围正常皮肤基本一致,皮瓣弹性好,患儿家属无二期修薄需求。1例患儿术后3个月随访时自觉供区瘢痕增生明显,经相应治疗后缓解；其余患儿供受区均遗留线性瘢痕。末次随访时,手部创面评定为优者3例、良者1例,足部创面评定为优者5例、良者1例。结论基于穿支优选策略设计的薄型ALTF修复患儿手足部软组织缺损,术后皮瓣外观及质地良好,为患儿手足创面修复提供了有效选择。
- 儿童 /
- 手部损伤 /
- 外科皮瓣 /
- 皮瓣设计 /
- 薄型皮瓣 /
- 创面修复 /
Abstract: Objective To investigate the efficacy of a thin anterolateral thigh flap (ALTF) designed based on an optimized perforator selection strategy for reconstructing skin soft tissue defects of the hand and foot in pediatric patients. Methods This was a retrospective observational study. From January 2018 to April 2025, 10 pediatric patients (8 boys and 2 girls; aged 2-14 years) with hand and foot skin and soft tissue defects meeting the inclusion criteria were admitted to the Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University. The wounds were located on the upper limb in 4 cases and on the foot in 6 cases. After thorough debridement, the soft tissue defects ranged from 5.0 cm×3.5 cm to 16.0 cm×9.0 cm. Preoperatively, the anterolateral thigh region was divided into zones Ⅰ-Ⅳ using the modified two-longitudinal and five-transverse method, and perforators in each zone were detected with a handheld Doppler. Based on the detection results, an optimized perforator selection strategy was formulated: under equivalent conditions, perforators in zones Ⅱ and Ⅲ were preferred; when a longer vascular pedicle or a thinner flap was required, perforators in zones Ⅲ and Ⅳ were preferred; and when an iliac bone graft, a bulkier tissue component, or septocutaneous perforators were required, perforators in zone Ⅰ were preferred. Intraoperatively, the ALTF was designed according to this strategy and the defect size, perforators were dissected at the superficial layer of the superficial fascia, and a thin ALTF was harvested. The flap size ranged from 5.0 cm×3.5 cm to 20.0 cm×6.0 cm. The flap artery and vein were anastomosed end-to-end or end-to-side to the recipient artery and vein, respectively, and the recipient-site wound was then closed. All donor-site wounds were closed with tension-reducing sutures. The distribution and selection of perforators in each zone of anterolateral thigh region were recorded, and the accuracy of preoperative perforator selection was recorded using intraoperative exploration findings as the gold standard. Postoperatively, flap survival was observed; complications such as vascular crisis and subflap fluid collection were recorded; The time to Kirschner wire removal was recorded for pediatric patients with concomitant fractures and for pediatric patients with scar contracture release. During follow-up, flap color, texture, elasticity, and appearance were evaluated, the need for secondary thinning and scar revision was recorded, and hand and foot function was assessed at the last follow-up using the Hand Function Evaluation Standard of the Hand Surgery Society of the Chinese Medical Association and the Maryland Foot Score, respectively. Results A total of 25 perforators were detected preoperatively in the anterolateral thigh region of 10 pediatric patients, including 5 in zone Ⅰ, 7 in zone Ⅱ, 9 in zone Ⅲ, and 4 in zone Ⅳ. Of these, 17 perforators were selected as the preferred ones, including 2 in zone Ⅰ, 6 in zone Ⅱ, 8 in zone Ⅲ, and 1 in zone Ⅳ, with 1-2 preferred perforators selected for each patient. The accuracy of preoperative localization of the preferred perforators was 16/17. At 1 month postoperatively, serous exudation occurred beneath the flap in one patient and healed after dressing changes and drainage; all the other flaps survived uneventfully without vascular crisis. Kirschner wires were removed within 3 months postoperatively in 2 pediatric patients with concomitant fractures and at 1 month postoperatively in 3 pediatric patients with scar contracture release. All patients were followed up for 6-60 months. The color and texture of the flaps were similar to those of the adjacent normal skin, with good elasticity, and none of the patients' family members requested secondary thinning. One child presented with obvious hypertrophic scar at the donor site at 3 months of follow-up, which was relieved after corresponding treatment; linear scars were left at the donor and recipient sites of the other patients. At the last follow-up, the hand wounds were rated as excellent in 3 cases and good in 1, and the foot wounds as excellent in 5 cases and good in 1. Conclusions An ALTF designed based on an optimized perforator selection strategy yields flaps with good postoperative appearance and texture for reconstructing soft tissue defects of the hand and foot in pediatric patients, and represents an effective option for pediatric hand and foot wound repair.
- Child /
- Hand injuries /
- Foot injuries /
- Surgical flaps /
- Flap design /
- Thin flap /
- Wound repair
李海：开展手术、实施研究、负责论文选题与设计、起草并修改和完善论文、统计分析数据及疗效、解答相关问题；肖顺娥：参与手术、协助文章撰写；魏在荣：酝酿和设计试验、手术指导、内容审阅；邓呈亮：手术及写作指导、酝酿分析；吴祥奎：手术及数据收集；王旗：参与手术、资料分析

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参考文献(45)

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图 1 基于穿支优选策略设计的薄型股前外侧皮瓣修复患儿手部皮肤软组织缺损的效果。1A.清创后,左手背皮肤缺损,伴关节、骨、肌腱外露；1B.术前采用改良二纵五横新算法对股前外侧区进行分区,探测到穿支位于Ⅲ、Ⅳ区,根据受区创面及所需皮瓣蒂长度优选Ⅲ区穿支设计皮瓣（图片中的“×”号为优选穿支,“·”未非优选穿支）；1C.术中切取皮瓣,并证实穿支与术前定位一致；1D.皮瓣切取后,关闭受区阔筋膜,暴露受区浅筋膜深层脂肪,保留股外侧皮神经（显影铅线标记）；1E、1F.分别为受区、供区创面封闭后即刻；1G、1H、1I.分别为术后51个月随访时患手伸展、患手抓握、供区创面情况,受区皮瓣外观良好,色泽、质地与周围正常皮肤相近,皮瓣不臃肿,供区残留线性瘢痕

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