血管移植加长血管蒂游离皮瓣移植治疗大面积皮肤缺损

Repairing the large skin defect by transplantation of the free lengthened vascular pedicel flap

目的探讨加长血管蒂的游离皮瓣移植术治疗创伤性大面积皮肤缺损、肌腱及骨外露伴创面感染病例的手术方法及疗效。方法2000年3月至2004年11月,对6例骨与肌腱外露、皮肤缺损伴创面邻近血管损伤、抽脱及闭塞的慢性感染病例行游离皮瓣移植术,男4例,女2例;年龄17～36岁,平均24岁。皮肤缺损面积最大30cm×15cm,最小20cm×10cm。应用修复的皮瓣种类:背阔肌肌皮瓣3例,阔筋膜张肌肌皮瓣2例,前臂皮瓣1例。静脉移植加长皮瓣动、静脉血管蒂最长15cm,最短5cm,平均8cm。移植皮瓣面积最大32cm×17cm,最小22cm×12cm。在距创面稍远的正常部位,解剖出支配受区的动、静脉,应用静脉移植的方法,做端侧吻合,引出支配受区的动、静脉到创面作供血动脉,切取术前设计的游离皮瓣,将皮瓣动、静脉与引到创面邻近的供血动、静脉做端端吻合,皮瓣血循环恢复后,皮瓣创面彻底止血,缝合覆盖创面。结果随访10个月～5年,平均2年3个月。6例皮瓣全部成活。4例胫、腓骨开放性骨折伴骨缺损、骨外露患者中,3例伤口一期愈合,1例因创缘肌肉发生缺血性坏死致皮瓣着床困难、创面感染,而延迟愈合。结论静脉移植搭桥加长供血动、静脉的手术方法是保证游离皮瓣高质量血管吻合的有效手段,特别适用于创面为慢性感染或其邻近血管发生损伤、抽脱、闭塞等情况。

Objective To investigate the method and result to repair large skin defect associated with infection and exposure of tendon and bone by using free lengthened vascular pedicel skin flap. Methods From March 2000 to November 2004, 6 chronic infective cases of skin defect associated with exposure of tendon and bone, vascular injury, abstraction and embolism were treated by free flap. The patients included 4 males, 2 females, with the mean age of 24 years （range, 17-36 years）. The skin defects ranged from 20 cm×10 cm to 30 cm×15 cm. The free flaps ranged from 22 cm×12 cm to 32 cm×17 cm. In normal tissue beside the lesion, artery and vena were dissected, using the method of vena transplantation and end-to-side anastomosis, then the artery and vena were transplanted from recipient site to wounded area as supplied artery and vena, at last the designed free flap dissected previously was anastomosed to artery and vena between free flap and supplied blood vessels. The wound was closed after the recovery of blood circulation of the flap. Results All cases were followed up 10 months to 5 years （with the mean of 2 years and 3 months）. The flaps in 6 cases all survived. There were 3 primary healing in 4 cases with open tibia and fibula frac- tures associated with bone defect and bone exposure. Delayed healing occurred in 1 patient due to muscle necrosis and the infection of wound. Conclusion It is an effective method by using vena bridging and lengthened vascular pedicel of free flap as to promote the vasculalization of free flap, and this method is especially suitable to the wound with chronic infection or vascular injury, as well as abstraction and embolism or even associated with exposure of tendon and bone.