以颞浅筋膜岛状瓣为携带的扩张预构皮瓣的临床应用研究

Clinical application of prefabricated induced expanded flap carried by the superficial temporal fascial flap

目的:探讨以颞浅血管为蒂的颞浅筋膜瓣为携带的扩张预构皮瓣的手术设计、操作技巧和一些应该注意的问题,并应用于面部组织缺损的修复。方法:手术分两期进行,术前应用超声多普勒血流测定仪探测出颞浅动脉及其额、顶分支的位置和走行方向;I期手术时,以颞浅动、静脉为蒂,形成颞浅筋膜岛状瓣,筋膜瓣的大小为5×4cm～8cm×7cm(平均为6.8cm×5.2cm);分别在颈部、耳后乳突区和额部进行剥离,形成容纳扩张器的皮肤软组织腔隙;将颞浅筋膜瓣转移至该腔隙内,舒展地固定于已剥离好的腔隙的皮瓣深面,在筋膜瓣下埋置适当大小的扩张器。注水完毕后,进行II期手术,取出扩张器,形成以颞浅筋膜瓣为携带的预构皮瓣,修复面部组织缺损。预构皮瓣的大小为8cm×4cm～17cm×7cm(平均11.89cm×6.39cm),供瓣区直接拉拢缝合或另行植皮修复。为确保皮瓣转移安全,对7例预构皮瓣进行了术前延迟处理。结果:临床应用10例,其中预构颈部皮瓣4例、预构耳后乳突区皮瓣5例、预构额部皮瓣1例。除1例耳后乳突区预构皮瓣发生远端小面积坏死外,其余皮瓣全部成活。除1例耳后供瓣区区需另行植皮修复外,其余供瓣区直接拉拢缝合。扩张时间3～5个月,平均4.05个月。结论:皮瓣预构技术可摆脱人体固有的皮肤血管构筑的限制,在原不存在轴型血管的部位形成轴型皮瓣,或将任意型皮瓣转化为轴型皮瓣,是对传统皮瓣形成技术的一种改良,是皮瓣外科学领域的一项新进展。组织扩张技术在皮瓣预构中的作用,除可促进皮瓣的新生血管化,提供更大面积的薄型皮瓣外,还有助于皮瓣供区的关闭,降低供瓣区继发畸形的发生率。

Objective To investigate the operative methods, skills of prefabricated induced expanded flaps which carriers are superficial temporal fascial flaps pedicled on the parietal branches of the superficial temporal vessels for reconstruction of facial defects. Methods The operation can be subdivided into two stages. The superficial temporal vessels and its parietal branches can be detected and marked before operations. At the first-stage, a fascial flap based on the parietal branches of the superficial temporal vessels was raised, and the size of the fascial flap varies from 5cmx 4cm to 8cmx7cm and the average size was 6.8cmx5.2cm. The pedicle of the fascial flap was wrapped with a piece of silicone sheet. The donor sites, including cervical, postauricular-mastoid and forehead regions, were dissected to form a soft tissue pocket for the expander. The fascial flap based on the parietal branches of the superficial temporal vessels was leaded into the soft tissue pocket through a subcutaneous tunnel which was previously made from the pedicle to the soft tissue pocket. The fascial flap was made flat and anchored beneath the donor flap. Then an expander with appropriate size was buried beneath the fascial flap. 2 to 3 weeks later, the flap began to be expanded. When fully expanded, the expander was removed at the second-stage operation. Based on the parietal branch of the superficial temporal vessels, the flap, which used the superficial temporal fascial flap as a carrier, was elevated and transferred to resurface the wound while the scar or the naevus on the face had been resected. The size of the flaps ranged from 8cmx4cm to 17cmx7cm and the average size was 11.89cmx6.39cm. The donor sites were sutured directly or covered with splitted-thickness free skin grafting. Results 10 cases have been treated with the method mentioned above. 4 cervical flaps, 5 postauricular-mastoid flaps and 1 forehead flap were involved. All the flaps survived totally postoperatively except one flap with distal necrosis which was transferred from postauricular-mastoid region. All the donors were closed directly expect one postauriclar-mastoid flap which was covered with splitted-thickness free skin grafting. Flap delay procedures have been performed on 7 patients before flap＇s transfer. The expansion time ranged from 3 to 5 months and the average time is 4.05 months. Conclusions Techniques of flap prefabrication can help plastic surgeon to overcome the limit of the inherent vasculature of human body. An axial flap can be fashioned at the region without axial vascular vessels, or a random flap can be transformed to an axial flap by this technique. Techniques of flap prefabrication is modified and refined pattern of the traditional skin flaps. Flap expansion can not only induce the neovascularization of prefabricated flaps, but also offer large and thin flaps simultaneously. Furthermore, tissue expansion can help to close the donor sites, and reduce the secondary deformities of the donors.