Clinical application effects of vertical mattress suture combined with teardrop-shaped end-to-side arterial anastomosis technique in free flap transplantation for repairing limb wounds
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摘要:
目的 探讨垂直褥式缝合联合水滴形动脉端侧吻合技术在游离皮瓣移植修复四肢皮肤软组织缺损创面中的临床应用可行性、安全性及效果。 方法 该研究为回顾性病例系列研究。遵义医科大学附属医院烧伤整形外科2023年3月—2024年12月收治41例符合入选标准的四肢皮肤软组织缺损创面患者,其中男29例、女12例,年龄39~74岁。清创后创面面积为5.8 cm×3.5 cm~17.5 cm×6.6 cm,采用游离股前外侧穿支皮瓣、胸背动脉穿支皮瓣、背阔肌肌皮瓣、腓肠内侧动脉穿支皮瓣修复,皮瓣面积为8.0 cm×4.0 cm~19.5 cm×7.0 cm。因受区动脉出现粥样硬化,甚至动脉内膜分层或供受区动脉直径显著不匹配,采用垂直褥式缝合联合水滴形动脉端侧吻合技术行供受区动脉吻合。供区创面经减张后直接闭合。术中观察受区动脉粥样硬化,甚至动脉内膜分层或与供受区动脉直径显著不匹配的情况。术后观察皮瓣完全存活情况,并计算皮瓣完全存活率。统计术后并发症发生情况。术后随访时,观察存活皮瓣的色泽、质地和臃肿情况,以及供区瘢痕增生情况。术前及末次随访时,分别采用上肢功能指数（UEFI）及足部功能指数（FFI）评定上下肢创面患者患肢功能恢复情况。末次随访时,统计患者对供受区外观及患肢功能恢复的满意度。 结果 术中观察到23例患者受区动脉吻合口区域动脉存在粥样硬化,甚至动脉内膜分层；18例患者皮瓣动脉直径与受区动脉直径存在显著差异,两者之比为1.0∶1.5~1.0∶3.3,平均为1.0∶2.4。术后40例患者皮瓣完全存活,皮瓣完全存活率为97.6%（40/41）。术后,5例感染性创面患者缝合口延迟愈合,经换药后愈合。所有患者术后住院期间未发生动脉危象。术后随访6~18个月,存活皮瓣色泽及质地与受区皮肤相似,外形饱满不臃肿。供区仅存在线性瘢痕,未见明显增生性瘢痕形成。术前,上肢UEFI为29~54分,平均41分；末次随访时,上肢UEFI为59~72分,平均65分。术前,下肢FFI为43~87分,平均73分；末次随访时,下肢FFI总分为15~42分,平均29分。末次随访时,28例下肢创面患者中24例可在无辅助工具帮助下行走,患者对供受区外观及患肢功能恢复均表示满意。 结论 垂直褥式缝合联合水滴形动脉端侧吻合技术,可有效实现动脉内膜外翻对合,减少动脉吻合口形成夹层、狭窄风险,显著提高吻合口通畅率。该技术应用于游离皮瓣移植修复四肢创面术中能有效预防动脉危象,术后皮瓣存活率高,患者满意度高,在临床中具有一定的应用价值。 Abstract:Objective To explore the clinical feasibility, safety, and effects of vertical mattress suture combined with teardrop-shaped end-to-side arterial anastomosis technique applied in free flap transplantation for repairing limb wounds. Methods This study was a case series study. From March 2023 to December 2024, 41 patients with skin and soft tissue defect wounds in limbs who met the inclusion criteria were admitted to the Department of Burn and Plastic Surgery of the Affiliated Hospital of Zunyi Medical University. Among them, there were 29 males and 12 females, aged from 39 to 74 years. After debridement, the wound areas ranged from 5.8 cm×3.5 cm to 17.5 cm×6.6 cm. The wounds were repaired with free anterolateral femoral perforator flaps, thoracodorsal artery perforator flaps, latissimus dorsi myocutaneous flaps, and medial sural artery perforator flaps, with flap areas of 8.0 cm×4.0 cm to 19.5 cm×7.0 cm. Due to atherosclerosis or even intimal delamination of recipient arteries, or significant mismatch in arterial diameters between the donor and recipient sites, the vertical mattress suture combined with teardrop-shaped end-to-side arterial anastomosis technique was used for arterial anastomosis of in the donor and recipient sites. The wounds in the donor site were directly closed after reducing tension. During the operation, the situation of atherosclerosis, intimal delamination, or significant mismatch in arterial diameters between the donor and recipient sites was observed. After surgery, the complete survival of the flaps was observed, and the complete flap survival rate was calculated. The occurrence of postoperative complications was recorded. During the follow-up after surgery, the color, texture, and hypertrophy of the surviving flaps, as well as scar hyperplasia in the donor site were observed. Before surgery and at the final follow-up, the functional recoveries of the affected limbs were assessed in patients with wounds in upper and lower limbs using the upper limb function index (UEFI) and foot function index (FFI), respectively. At the final follow-up, the satisfaction of patients with the appearance of the donor and recipient sites and the function of the affected limbs were recorded. Results During the operation, it was observed that 23 patients had atherosclerosis in the recipient artery anastomosis area, even with intimal delamination; in 18 patients, there was a significant difference in the diameter of the flap artery and the recipient artery, with the ratio ranging from 1.0:1.5 to 1.0:3.3, with an average of 1.0:2.4. After surgery, 40 patients had complete flap survival, with a complete flap survival rate of 97.6% (40/41). After surgery, five patients with infectious wounds had delayed suture healing, which healed after dressing changes. No arterial crisis occurred in all patients during hospitalization after surgery. During follow-up of 6 to 18 months after surgery, the surviving flaps had similar color and texture to the recipient skin, with a full appearance but not bloated. Only linear scars occurred in the donor site, with no obvious hypertrophic scar. Before surgery, the UEFI of upper limbs ranged from 29 to 54, with an average of 41; at the final follow-up, the UEFI of upper limbs ranged from 59 to 72, with an average of 73. Before surgery, the FFI of lower limbs ranged from 43 to 87, with an avarage of 73; at the final follow-up, the FFI of lower limbs ranged from 15 to 42, with an average of 29. At the final follow-up, 24 out of 28 patients with wounds in lower limbs were able to walk without the assistance of auxiliary tools; patients were satisfied with the appearance of the donor and recipient sites, as well as the functional recovery of the affected limbs. Conclusions The vertical mattress suture combined with teardrop-shaped end-to-side arterial anastomosis technique effectively achieves the eversion and apposition of the arterial intima, reduces the risk of dissection and stenosis at the arterial anastomosis site, and significantly improves the patency rate of the anastomosis site. This technique applied in free flap transplantation for repairing limb wounds can prevent arterial crisis, with high flap survival rate and satisfaction of patients after surgery, thus having application value in clinical practice. -
Key words:
- Microsurgery /
- Surgical flaps /
- Extremities /
- End-to-side anastomosis /
- Atherosclerosis /
- Wound repaiar
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参考文献
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图 1 垂直褥式缝合联合水滴形动脉端侧吻合技术示意图。1A.用11号手术刀反挑切开受区动脉上壁；1B.用显微剪刀将受区动脉上壁吻合口修剪为水滴形；1C.以倾斜45°左右的角度,将皮瓣动脉断端修剪成适配受区动脉吻合口的水滴形；1D.第1次垂直褥式外翻缝合吻合供受区动脉进针顺序；1E.于水滴形吻合口底部行垂直褥式外翻缝合的第2定位针；1F.采用垂直褥式外翻缝合完成吻合口前、后壁的缝合
图 2 垂直褥式缝合联合水滴形动脉端侧吻合技术的临床应用。2A.术中显示受区动脉与皮瓣动脉直径存在显著差异；2B.受区动脉与皮瓣动脉行端侧吻合后即刻；2C.垂直褥式缝合联合水滴形动脉端侧吻合后
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