带双侧颞浅动静脉额支筋膜蒂的额部轴型扩张皮瓣修复下颌部瘢痕

Repair of scars in submaxillary region using expanded forehead axial flaps with fascia pedicles carrying bilateral frontal branches of superficial temporal artery and vein

目的 了解带双侧颞浅动、静脉额支筋膜蒂的额部轴型扩张皮瓣（下称额部双蒂轴型扩张皮瓣）修复下颌部瘢痕的可行性. 方法 2005年7月-2009年12月,笔者对南京军区福州总医院第一附属医院烧伤整形科收治的16例下颌部瘢痕患者,采用额部双蒂轴型扩张皮瓣进行修复.手术分3期进行：术前应用超声多普勒血流探测仪探测出颞浅动、静脉及其额、顶分支的位置和走行方向.Ⅰ期手术时,以颞浅动、静脉为蒂,在额肌下进行剥离,形成容纳扩张器的皮肤软组织腔隙,置人适当大小的扩张器.注水扩张结束后进行Ⅱ期手术,取出扩张器,切取额部双蒂轴型扩张皮瓣修复下颌部瘢痕,供瓣区直接拉拢缝合.Ⅲ期手术为皮瓣断蒂、蒂部修整及瘢痕修复术. 结果本组患者轴型皮瓣面积25 cm×6 cm～33 cm×16 cm,扩张时间3～5个月,平均3.6个月,其中10例联合应用颈部皮肤扩张术治疗,皮瓣均成活,伤口愈合.1例患者Ⅱ期手术后出现皮瓣远端部分回流障碍,经予解痉、促皮瓣静脉回流等综合处理后康复.供区创面愈合,发际无瘢痕性脱发,毛发生长正常.3例女性患者中,2例皮瓣未携带前发际处毛发;另1例下颌部术区携带前发际少量毛发,其与要求作络腮胡塑形的2例男性患者于出院1～3个月后行激光脱毛处理,效果较好.其他男性患者对术区须发不作特殊处理或自行用剃须刀塑形.16例患者均获6～24个月随访,皮瓣及胡须（女性患者除外）外形美观,无臃肿,色泽、质地较好,颈部活动功能明显改善. 结论 额部双蒂轴型扩张皮瓣除可促进皮瓣的新生血管化、提供更大面积的薄型皮瓣外,剩余扩张皮肤可以直接缝合于发际缘,不需植皮,降低了供瓣区继发畸形的发生率.皮瓣携带部分毛发经旋转后可直接进行胡须重建,使男性患者外形更加美观.

Objective To study the feasibility of applying expanded forehead axial flaps with fascia pedicles carrying bilateral frontal branches of superficial temporal artery and vein（expanded forehead axial flap with double pedicels in brief, EFAF-DP） in repairing scars in submaxillary region. Methods Sixteen patients with mandibular scars hospitalized in Department of Burns and Plastic Surgery of the First Hospital Affiliated to Fuzhou General Hospital in Nanjing Military Area Command from July 2005 to December 2009 were repaired with EFAF-DP. The operation consisted of 3 stages. Before operation, the location and course of superficial temporal arteries and veins （STAV） and their frontal and parietal branches were identified with Ultrasonic Doppler blood flow detector. In stage Ⅰ , STAV were dissected from the frontalis muscle as a pedicle to form a skin soft tissue space to hold the dilator of a proper size. In stage Ⅱ , after gradual dilation by repeated filling with saline, the dilator was removed. EFAF-DP was dissected to repair mandibular scar. Donor site was closed with sutures. In stage Ⅲ , flap pedicles were divided and pruned. Results Flap sizes ranged from 25 cm ×6 cm to 33 cm × 16 cm. The duration of dilation was 3-5 months, with 3.6 months in average. Ten patients underwent the operation of EFAF-DP transplantation and cervical skin dilatation. All flaps survived with healing of wounds. Disorder of venous return at the distal end of one flap was seen after second stage surgery, and it was corrected after comprehensive treatment including relieving spasm and improving venous return. Donor site wounds healed with normally grown hair without cicatricial alopecia along the hairline. Few hairs grew around mandible in one female patient out of the three（no hair grew on flaps of other two patients）. This female patient and two male patients requesting for beard plasty received laser depilation treatment 1 to 3 months after discharge, with good result. Other male patients received no special treatment for their beard, and they shaped their beard with shaver. Sixteen patients were followed up for 6 to 24 months, and the shape of the flaps and beard （excluding female patients） were satisfactory with good appearance, satisfactory skin color and texture. The mobility of neck was obviously improved. Conclusions EFAF-DP provides bigger areas of a thin flap besides promoting vascularization of new vessels of flap. Extra expanded skin can be directly sutured at the fringe of hairline, which makes skin grafting unnecessary, and decreases the incidence of secondary deformity in donor sites. Some hair carried by the flaps can be directly used for beard reconstruction after rotation to help the male patients have a better appearance.