CT血管造影在背阔肌皮瓣游离移植修复头皮撕脱伤创面中的应用

APPLICATION OF COMPUTED TOMOGRAPHIC ANGIOGRAPHY IN REPAIRING SKIN DEFECT AFTER SCALP AVULSION WITH FREE LATISSIMUS DORSI FLAP TRANSPLANTATION

目的探讨CT血管造影(computed tomographic angiography,CTA)及三维重建技术在背阔肌皮瓣游离移植修复头皮撕脱伤伴大面积颅骨外露创面中的应用价值。方法 2007年10月-2012年6月,收治9例严重头皮撕脱伤伴大面积颅骨外露女性患者。年龄23～54岁,平均38岁。致伤原因:机器绞伤6例,交通事故伤2例,高处坠落伤1例。其中3例伤后行头皮原位回植后坏死,6例行清创包扎。伤后至入院时间8 h～7 d,平均1 d。头皮撕脱范围为头皮面积的75%～90%,平均81%;颅骨外露范围为头皮面积的55%～70%,平均63%;2例伴单侧耳廓撕脱。术前对面颈部及背部血管行CTA及三维重建,分析颞浅动、静脉,面动脉,颈外静脉和胸背动、静脉解剖结构并测量管径。根据CTA检查结果,7例以背阔肌皮瓣修复创面,2例以背阔肌肌瓣联合植皮修复。7例患者根据术前设计顺利完成手术;2例术前颞浅血管显示较差者,以大隐静脉作为移植血管与相关血管吻合。背阔肌皮瓣切取范围20 cm×14 cm～25 cm×20 cm,供区减张缝合后植皮修复;肌瓣切取面积分别为23 cm×16 cm及16 cm×10 cm,供区直接缝合。结果术中血管管径测量结果与术前比较差异较小,不影响血管吻合。手术时间6～8 h,平均6.5 h。术后背阔肌肌(皮)瓣及植皮均成活,创面Ⅰ期愈合;供区切口Ⅰ期愈合。患者均获随访,随访时间3个月～2年,平均6个月。皮瓣质地柔软,皮肤无破溃。结论采用背阔肌皮瓣游离移植修复头皮撕脱伤伴大面积颅骨外露创面时,术前可行CTA检查明确供、受区可供吻合的血管解剖结构及管径,指导手术方案设计及实施,以缩短手术时间,提高术中血管吻合准确率。

Objective To investigate the clinical value of computed tomographic angiography （CTA） and threedimensional reconstruction technique in repairing scalp avulsion wound with large skull exposure by the free latissimus dorsi flap transplantation. Methods Between October 2007 and June 2012, 9 female patients with serious scalp avulsion and large skull exposure were treated, aged 23-54 years （mean, 38 years）. The injury causes included machine twist injury in 6 cases, traffic accident injury in 2 cases, and falling from height injury in 1 case. Before admission, 3 patients had scalp necrosis after scalp in situ replantation, and 6 patients underwent debridement and dressing. The time from injury to admission was 8 hours to 7 days （mean, 1 day）. The avulsed scalp area ranged from 75% to 90% of the scalp area （mean, 81%）; the exposed skull area ranged from 55% to 70% of the scalp area （mean, 630/0）. Two patients had unilateral auricle avulse. CTA was used to observe the superficial temporal artery and vein, facial artery, external jugular vein, dorsal thoracic artery and vein, and measure the blood vessel diameter before operation. According to the CTA results, the latissimus dorsal skin flaps were desinged to repair wounds in 7 cases, the latissimus dorsal muscle flaps combined with skin graft were used to repair wounds in 2 cases. According to preoperative design, operation was successfully completed in 7 cases; great saphenous vein was used as vascular graft in 2 cases having poor images of superficial temporal vessels. The size of latissimus dorsal skin flaps ranged from 20 cm x 14 cm to 25 cm x 20 cm; the donor site was repaired with skin graft. The size oflatissimus dorsal muscle flaps were 23 cmx 16 cm and 16 cmx 10 cm; the donor site was directly sutured. Results The blood vessel diameter measured during operation was close to the