健肢小腿内侧皮瓣交腿桥接胸脐皮瓣游离移植的蒂部改良

The pedicle modification of grafting in free flap which use medial-lower-leg-flap with a healthy limb cross-leg bridging thoracic umbilical flap

目的探讨以健肢小腿内侧皮瓣交腿桥接胸脐皮瓣游离移植蒂部改良处理的方法和临床效果。方法2006年6月-2010年6月，对28例一侧小腿严重损伤导致大面积软组织缺损的患者，采取以健肢小腿内侧皮瓣交腿桥接胸脐皮瓣游离移植的方法修复，同时对其桥式蒂进行改良：设计胸脐皮瓣携带跨中线侧叶皮瓣；小腿内侧皮瓣呈舌形切取并携带内踝上穿支；在处理桥式蒂时，将交腿皮瓣近侧部分卷管，远侧由携带内踝上穿支的皮瓣作为后壁，以胸脐皮瓣携带的跨中线侧叶皮瓣作为前壁，二者瓦合，形成组合式皮管。外固定架双小腿平行固定。观察术后皮瓣成活情况、外形、色泽、弹性，以及有无瘢痕挛缩、功能障碍等。结果28例术后皮瓣全部成活，1例术后8h发生动脉危象，经检查认为是血压偏低、红细胞比积偏低所致，经输血、输液处理后危象缓解；1例术后12h因疼痛发生动脉危象，经镇静、镇痛后危象缓解；其他26例未发生血管危象。随访2～20个月，皮瓣区血运良好，色泽及弹性较好，外形不臃肿，感觉有一定恢复。双膝、踝关节无明显僵硬。结论以健肢小腿内侧皮瓣交腿桥接胸脐皮瓣游离移植修复严重小腿软组织缺损是临床上行之有效的良好手段，对蒂部进行改良之后，可以降低手术风险，减少并发症，提高术后护理效果，值得推广应用。

Objective To investigate the methods and effects of the pedicle modification in free flap which use medial-lower-leg-flap with a healthy limb cross-leg bridging thoracic umbilical flap. Methods From June 2006 to June 2010, twenty-eight cases with a large area of soft tissue defects caused by severe trauma were included in this study. We used The flap was used to repair the wound, the pedicle of the flap was improved which was designed by medial lower leg flap with a healthy limb cross-leg bridging thoracic umbilical flap：thoracic umbilical flap carrying the cross midlinc side flap. Medial lower leg flap in tongue cutting out and carrying on the medial malleolus perforator. In the processing of bridge-pedicled, we rolled the proximal porting of cross-leg flap, used medial malleolus perforator flap as a posterior wall and used thoracic umbilical flap carrying the cross midline lateral flap as anterior wall. Two portions formed a combined percutaneous tube. The two tile formmed a combined percutaneous tube. Fixing method for operation adopted external fixator which two legs were paralleling. Observation of postoperative flap survival situation, shape, color, elastic, scar eontracture, and dysfunction. Results Twenty-eight cases of postoperative all flaps survived. Vascular crisis was appeared in 2 cases after 8 hours. Upon examination that was low blood pressure, low hematocrit. In treatment of transfusion and infusion, crisis mitigated. In 1 case after 12 hours with pain occurred arterial crisis, which was reliefed with analgesia. There were no vascular crisis in other 26 cases. Followed up for 2-20 months, flap had good blood supply, color and good elasticity. The appearance was not bloated and sensory recoverred partly. There was no apparent stiffness in double knee, ankle joint. Conclusion Medial lower leg flap with a healthy limb cross-leg bridging thoracic free flap transplantation for repairing serious soft tissue defects of the leg is clinically proven good means. Based on the improvement of pedicle, it can reduce the risk and complications. At the same time, it can improve the postoperative nursing care effects. It is worthy of popularization and application.