Surgical designs and clinical effects of pedicled transfer of extended lower trapezius musculocutaneous flap in repairing massive wounds in the shoulder and back
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摘要:
目的 探讨以肩胛背动脉为蒂的超长下位斜方肌肌皮瓣（e-LTMF）带蒂转移修复肩背部巨大创面的手术设计与临床效果。 方法 该研究为回顾性病例系列研究。2009年1月—2023年4月,中国医学科学院北京协和医学院整形外科医院收治41例符合入选标准的肩背部巨大创面患者,其中男26例、女15例,年龄4~83岁。根据创面性质与手术时机选择手术设计,将采用常规e-LTMF修复的15例患者纳入常规组,将采用远端携带部分背阔肌的改良e-LTMF修复的15例患者纳入改良组,将采用预扩张e-LTMF修复的11例患者纳入预扩张组。常规组患者创面面积为7 cm×5 cm~21 cm×12 cm,肌皮瓣切取面积为7 cm×5 cm~33 cm×10 cm；改良组患者创面面积为16 cm×8 cm~28 cm×18 cm,肌皮瓣切取面积为25 cm×8 cm~40 cm×12 cm；预扩张组患者创面面积为12 cm×8 cm~36 cm×12 cm,肌皮瓣切取面积为22 cm×8 cm~35 cm×15 cm。将肌皮瓣行螺旋桨旋转转移或经皮下隧道岛状转移至受区。对供区创面行直接拉拢缝合、局部皮瓣转移或皮片移植修复。术后,观察肌皮瓣成活情况,统计肌皮瓣完全成活率与坏死发生率,记录坏死肌皮瓣的处理方式与转归。随访时,观察肌皮瓣外观与质地、患侧上肢及受区肩背部活动功能恢复情况、肿瘤患者复发情况以及供区创面愈合情况。 结果 术后,41例患者中38例患者术后肌皮瓣全部成活,肌皮瓣完全成活率为92.7%（95%CI为80.6%~97.5%）；3例患者发生肌皮瓣坏死,肌皮瓣坏死发生率为7.3%（95%CI为2.5%~19.4%）。其中,常规组1例患者发生肌皮瓣全部坏死,经皮片移植后创面愈合；改良组2例患者发生肌皮瓣远端坏死,经换药后创面愈合。术后随访1~48个月,肌皮瓣的色泽、质地与受区周围正常皮肤相近,患侧上肢及受区肩背部活动未见明显受限,肿瘤患者未见肿瘤复发,供区创面均愈合良好。 结论 e-LTMF的3种手术设计可用于修复不同复杂程度的肩背部巨大创面,术后肌皮瓣成活情况、外观与质地,患侧上肢和受区肩背部活动功能恢复情况,以及供区创面愈合情况均较佳。其中常规e-LTMF可用于单纯皮肤软组织缺损；远端携带部分背阔肌的改良e-LTMF可用于合并重要组织结构暴露、创面感染或死腔形成的复杂创面；预扩张e-LTMF可用于需更大面积肌皮瓣覆盖的择期修复创面。 Abstract:Objective To explore the surgical designs and clinical effects of pedicled transfer of extended lower trapezius musculocutaneous flap (e-LTMF) based on the dorsal scapular artery in repairing massive wounds in the shoulder and back. Methods This study was a retrospective case series study. From January 2009 to April 2023, 41 patients with massive wounds in the shoulder and back who met the inclusion criteria were admitted to Plastic Surgery Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College, including 26 males and 15 females, aged 4 to 83 years. The surgical design was selected according to the nature of the wound and the timing of surgery. The 15 patients repaired with the conventional e-LTMF were included in conventional group, the 15 patients repaired with the modified e-LTMF incorporating a distal segment of the latissimus dorsi muscle were included in modified group, and the 11 patients repaired with the pre-expanded e-LTMF were included in pre-expanded group. The wound areas ranged from 7 cm×5 cm to 21 cm×12 cm and the harvested musculocutaneous flap areas ranged from 7 cm×5 cm to 33 cm×10 cm in patients in conventional group. The wound areas ranged from 16 cm×8 cm to 28 cm×18 cm and the harvested musculocutaneous flap areas ranged from 25 cm×8 cm to 40 cm×12 cm in patients in modified group. The wound areas ranged from 12 cm×8 cm to 36 cm×12 cm and the harvested musculocutaneous flap areas ranged from 22 cm×8 cm to 35 cm×15 cm in patients in pre-expanded group. The musculocutaneous flaps were transferred to the recipient sites by propeller rotation or as islands through subcutaneous tunnels. The donor site wounds were repaired by direct suture, local flap transfer, or skin grafting. After surgery, the survival of musculocutaneous flaps was observed, the complete survival rate and the necrosis rate of musculocutaneous flaps were calculated, and the management and outcome of the necrotic musculocutaneous flaps were recorded. During follow-up, the appearance and texture of the musculocutaneous flaps, the functional recovery of the affected upper limb and the shoulder and back at recipient sites, the tumor recurrence in patients with tumors, and the wound healing at donor sites were observed. Results After surgery, among the 41 patients, the musculocutaneous flaps survived completely in 38 patients, with a complete survival rate of musculocutaneous flaps of 92.7% (with a 95% CI of 80.6% to 97.5%). The necrosis of the musculocutaneous flaps occurred in 3 patients, with a necrosis rate of musculocutaneous flaps of 7.3% (with a 95% CI of 2.5% to 19.4%). Among them, total necrosis of the musculocutaneous flaps occurred in one patient in conventional group, whose wound healed after skin grafting. Distal necrosis of the musculocutaneous flap occurred in two patients in modified group, whose wounds healed after dressing change. During the follow-up of 1 to 48 months after surgery, the color and texture of the musculocutaneous flaps were similar to those of the normal skin surrounding the recipient sites, no obvious limitation was observed in the motion of the affected upper limb or the shoulder and back at recipient sites, and no tumor recurrence was observed in patients with tumors. The wounds at donor sites all healed well. Conclusions The three surgical designs of e-LTMF can be used to repair massive wounds of varying complexity in the shoulder and back, with fairly good postoperative musculocutaneous flap survival, appearance and texture, functional recovery of the affected upper limb and the shoulder and back at recipient sites, and donor site wound healing. Among them, the conventional e-LTMF can be used for simple skin and soft tissue defects, the modified e-LTMF incorporating a distal segment of the latissimus dorsi muscle can be used for complex wounds complicated by exposure of critical structures, wound infection, or dead-space formation, and the pre-expanded e-LTMF can be used for elective reconstruction of wounds requiring larger musculocutaneous flap coverage. -
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图 1 以DSA为蒂的e-LTMF的血供解剖基础及3种手术设计下的肌皮瓣切取范围示意图
注：DSA为肩胛背动脉,PICA为肋间后动脉背侧支穿支,EVP为皮瓣外血管通道,e-LTMF为超长下位斜方肌肌皮瓣；左侧示肌皮瓣血流动力学机制：DSA主干血流可经术中保留的EVP（紫色方框所示）,即肋间后动脉背侧支穿支升支与降支之间的交通支,向皮瓣远端跨区供血,红色虚线箭头示血流方向；右侧示3种手术设计下的肌皮瓣切取范围的叠加对比：蓝色区域为常规e-LTMF,橙色区域为远端携带部分背阔肌的改良e-LTMF,绿色区域为预扩张e-LTMF；图中4条水平参考线自上而下分别为第2、3胸椎水平、肩胛下角水平、第12胸椎水平及Tuffier线
图 2 采用常规e-LTMF修复例1患者项背部血管瘤切除后巨大创面的效果。2A.术前项背部外观,示病灶范围及肌皮瓣设计；2B.术前CT血管造影影像,示DSA走行；2C.术中病灶完整切除后即刻,示切除的肿瘤；2D.术中以DSA为蒂掀起肌皮瓣后即刻,背阔肌被完整保留；2E.术后10 d,肌皮瓣全部成活,供受区创面愈合良好；2F.术后4个月随访时,肌皮瓣色泽与受区周围正常皮肤相近
注：e-LTMF为超长下斜方肌肌皮瓣,DSA为肩胛背动脉
图 3 采用远端携带部分背阔肌的改良e-LTMF修复例2患者左肩胛区隆突性皮肤纤维肉瘤扩大切除后巨大创面的效果。3A.术前左肩胛区外观,示病灶范围及肌皮瓣设计；3B.术中扩大切除肿瘤后即刻,遗留创面伴肩关节囊外露；3C.术中结扎第六肋间后动脉背侧支穿支主干、保留皮瓣外血管通道完整性后即刻；3D.术中以DSA为蒂掀起远端携带部分背阔肌的改良肌皮瓣后即刻；3E.术中肌皮瓣转移就位、创缘缝合后即刻；3F.术后23 d,肌皮瓣全部成活,供受区创面愈合良好；3G、3H.分别为术后13个月随访时受区正面观与侧面观,肌皮瓣色泽与受区周围正常皮肤相近,缺损修复区外形平整
注：e-LTMF为超长下斜方肌肌皮瓣,DSA为肩胛背动脉
图 4 采用预扩张e-LTMF修复例3患者右肩背部先天性巨痣切除后巨大创面的效果。4A.Ⅰ期皮肤软组织扩张器置入术前外观,示右肩背部先天性巨痣范围及肌皮瓣设计；4B.扩张39周、Ⅱ期术前,左侧背部扩张后肌皮瓣供区；4C、4D.分别为术中以DSA为蒂掀起预扩张肌皮瓣后即刻的肌皮瓣浅面观与深面观,背阔肌及皮肤软组织扩张器包膜被完整保留,肌皮瓣深面可见代偿增粗的血管网；4E.术中肌皮瓣经皮下隧道跨中线岛状转移就位后即刻；4F.术后21 d,肌皮瓣全部成活,供受区创面愈合良好
注：e-LTMF为超长下斜方肌肌皮瓣,DSA为肩胛背动脉
Table 1. 3组肩背部巨大创面患者的临床资料
组别 例数 性别（例） 年龄（岁, 病因（例） 男 女 恶性肿瘤 良性肿瘤 瘢痕 外伤 常规组 15 8 7 29±15 9 4 2 0 改良组 15 11 4 49±18 12 0 0 3 预扩张组 11 7 4 8±6 0 6 5 0 注：常规组患者采用常规超长下位斜方肌肌皮瓣（e-LTMF）修复,改良组患者采用远端携带部分背阔肌的改良e-LTMF修复,预扩张组患者采用预扩张e-LTMF修复 
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