连续双翼皮瓣成形指蹼一期分离短指并指畸形的灵活应用

Multiple digit symbrachydactyly web space reconstruction using dorsal contiguous gullwing flaps

目的探讨灵活应用改良的连续双翼皮瓣成形指蹼修复3个及以上手指并连的短指并指畸形的安全性及临床效果。方法回顾性分析2018年1月至2021年1月重庆医科大学附属儿童医院收治的3个及以上手指并连的短指并指畸形患儿临床资料。设计背侧改良的连续双翼皮瓣,每个皮瓣远端之间不留间隙,结合锯齿状对偶皮瓣分离指体后,指蹼及指体的创面大部分可关闭,对于部分病例残余的少许皮肤缺损,取腕部掌尺侧全厚皮片植皮。2例患儿采用了改良设计和原设计的混合使用方案。统计术中血管情况、植皮情况、手术时间、术后手指血供以及伤口愈合等级;随访并采用改良Withey评分法评价术后效果。结果共纳入21例患儿,男13例,女8例,年龄6个月~6岁,平均20个月。其中,3指并指13例,4指并指8例,涉及50个指蹼,合并虎口狭窄或部分并连8例。其中19例患儿所有指蹼并连程度均大于或等于手指长度的一半,2例3指并连者有1个指蹼并连达手指一半长度。本组病例均在2 h内完成所有患指的分离;术中6个指蹼由于血管起始处偏浅,结扎了1侧血管,术后手指血运均正常;12个手指有小块植皮。术后无伤口感染、皮肤及植皮坏死发生。术后随访3~37个月,平均10个月。所有成形指蹼形态自然,掌指横纹水平的指蹼宽度均不小于该水平处手指根部宽度的1/3,与手掌、手指的比例协调;指蹼深度均能达到或略深于掌指横纹水平,手指长度相对于手掌大小仍显短小;均无继发性手指屈-伸活动障碍、侧偏及旋转畸形发生。术后外观均能被患儿家长接受,手腕供区瘢痕不明显。所有随访病例的改良Withey评分均为0分。结论改良连续双翼皮瓣可安全地同时分离多个手指的短指并指,可不需要植皮或者植皮面积很小,适用于并连皮肤较紧张的多个手指的短指并指畸形。对于3个指蹼的并连皮肤紧张度不一致的病例,推荐连续双翼皮瓣的改良设计和原设计的联合应用。

Objective To investigate the safety and effectiveness of modified contiguous gullwing flaps for web space reconstruction of multiple digit symbrachydactyly.Methods A retrospective analysis was performed on patients of multiple digit symbrachydactyly who underwent surgery in the Children’s Hospital of Chongqing Medical University from January 2018 to January 2021.The modified dorsal contiguous gullwing flaps were designed to reconstruct the web space without leaving a gap between the distal ends of each flap.After separating the fused digits with a zigzag incision,most of the wounds could be closed directly.For a few cases of the skin defect,the skin grafts harvested from the palmer-ulnar site of the ipsilateral wrist was used to cover the wound.In 2 cases,the modified design and the original design were used in combination.Intraoperative findings of the digital proper arteries,skin grafts,operation time and the finger blood supply,and the postoperative data of wound healing grade were recorded.The results were followed up and evaluated by a modified Withey scale.Results A total of 21 patients were enrolled,including 13 males and 8 females,ranging in age from 6 months to 6 years old with an average age of 20 months.Among them,there were 13 cases of three-fingered syndactyly and 8 cases of four-fingered syndactyly,with a total of 50 webs.Among them,8 cases were combined with the first web stenosis or partial syndactyly.In 19 cases,the degree of syndactyly was at least the half length of fingers,and the remaining 2 cases had mild symptoms.All operations could be finished within 2 hours.During the operation,one side digital artery in 6 webspaces was ligatured owing to the bifurcation point was too distal,and the vascular perfusion was normal.Small pieces of skin grafts were used in 12 fingers,the wound healed in one stage with no wound infection,and skin graft necrosis occurred.After 3-37 months of follow-up(average of 10 months),the shape of the formed webspace was natural,and the width of the webspace at the level of the metacarpophalangeal crease was not less than one-third of the width of the finger,which was coordinated with the proportion of the palm and fingers.The depth of the webs could reach or exceed the level of the metacarpophalangeal crease.The fingers were still shorter according to the size of the palm.No secondary flexion deformity,lateral deviation deformity,and rotation deformities occurred.The appearance was acceptable to the parents and no hypertrophy scar was noticed.The score evaluated by the modified Withey scale of the follow-up cases was 0.Conclusions Using the modified contiguous gullwing flap could separate multiple fingers symbrachydactyly in one stage operation safely without skin grafting or small-size skin grafting.The procedure is mainly indicated for those cases with tight skin syndactyly.The combined application of the modified design and the original design of the contiguous gullwing flap could be recommended for patients whose skin tension is different between the three coterminous webspaces.