主穿支皮神经营养血管皮瓣一期修复小腿及足踝部高能损伤创面

Donimant perforator neurocutaneous flaps for one-staged reconstruction of defects caused by high energy at lower legs, ankles and feet

目的探讨主穿支供血型小腿皮神经营养血管皮瓣一期修复小腿及足踝部创面的方法及效果。方法回顾性分析2003年7月至2011年2月，对收治的39例高能损伤导致的小腿及足踝部损伤，单独或组合选择腓动脉主穿支供血游离或穿支蒂腓肠神经营养血管皮瓣、外踝上穿支蒂腓浅神经营养血管皮瓣、胫后动脉主穿支供血游离或穿支蒂隐神经营养血管皮瓣进行一期修复。结果39例44处创面，采用腓动脉主穿支供血腓肠神经营养血管皮瓣32块（穿支蒂27块、游离5块），胫后动脉主穿支供血隐神经营养血管皮瓣6块（穿支蒂5块、游离1块），外踝上穿支蒂腓浅神经营养血管皮瓣6块，最大切取面积22cm×10cm。术后皮瓣均全部成活，平均住院23d（12～36d）。术后随访6～15个月，皮瓣质地优良，外形与足踝功能恢复满意，吻合神经者两点辨距觉2．5～5cm，未吻合神经者术后1年以上均存在保护性感觉。结论上述3种主穿支皮神经营养血管皮瓣血供确切，合理个体化选择应用可修复不同类型小腿及足踝部创面；一期修复解剖清晰、血管条件好、手术设计灵活，可减少感染机会及肉芽瘢痕，利于功能恢复并缩短治疗周期。

Objective To evaluate the therapeutic effect of donimant perforator neurocutaneous flaps for one-staged reconstruction of defects caused by high energy at lower legs, ankles and feet. Methods From July 2003 to Feb. 2011, 39 cases, with defects caused by high energy at lower legs, ankles and feet, were retrospectively studied. The defects were covered primarily by one or two perforator neurocutaneous flaps（free or pedicled） which were based on a dominant perforator arising from the posterior tibial or peroneal artery （ including the lateral superamalleolar perforating artery which is also from the peroneal vessel） respectively through sural, saphenous and superficial peroneal nerocutaneous vascular axis. Results 39 cases with 44 defects were treated by 32 sural neurocutaneous flaps based on the peroneal perforator （ 5 free and 27 pedicled） , 6 saphenous neurocutaneous flaps on the posterior tibial perforator（ 1 free and 5 pedicled） and 6 superficial peroneal ones on the lateral superamalleolar perforating artery. The largest flap size was 22 cm×10 cm. All flaps were survived successfully without necrosis. The average in-hospital time was 23 days （ ranged from 12-36 days）. Conclusions The three kinds of dominant perforator neurocutaneons flaps have reliable blood supply with a relatively large size. They can be chosen and designed individually for all kinds of defects over the lower leg, ankle and foot. There are many advantages in a primary procedure, such as easier dissection, better vessel status in or around recipient areas, less secondary necrosis and lower risk of chronic infection. Moreover, the reduction of granulation and scar tissues benefit functional rehabilitation.