三种游离穿支皮瓣修复足背及前足组织缺损

Repair of forefoot or acrotarsium tissue defect with three different free perforator flaps

目的探讨游离膝降动脉穿支皮瓣、隐动脉穿支皮瓣及股前外穿支皮瓣修复足背及前足软组织、复合组织缺损的疗效。方法纳入2010年8月至2014年10月35例足背及前足组织缺损患者,创面面积为9 cm×4.5 cm^26 cm×13 cm。采用游离膝降动脉穿支皮瓣修复12例(A组),游离隐动脉穿支皮瓣修复8例(B组),游离股前外穿支皮瓣修复15例(C组)。若为开放性损伤,则在皮瓣移植术前应用负压封闭引流装置覆盖5~7 d。结果术后34例皮瓣全部成活,仅1例(女童,7岁)股前外穿支皮瓣远端1/3坏死,2周后经削痂植皮后创面愈合。术后随访3~38个月,平均12.3个月。皮瓣修复后外形大多令人满意,术后3个月A组有3例、B组有2例进行二次修薄手术。A组有1例出现小腿持续肿胀,1例出现供区切口愈合不良;B组有5例出现供区肢体持续肿胀,3例出现供区切口愈合不良,4例供区远端出现皮疹。结论游离膝降动脉穿支皮瓣及游离隐动脉穿支皮瓣修复后大多需行二次修薄手术。游离股前外穿支皮瓣质地好,切取面积大,可避免二次修薄手术,受区影响较小,但仅可用于单纯足背或前足软组织覆盖。游离膝降动脉穿支皮瓣可制备皮-骨或皮-肌(肌腱)复合瓣用于修复足部复合组织缺损。

Objective To evaluate clinical efficacy of the treatment for forefoot or acrotarsium tissue defect with three different free perforator flaps. Methods Thirty-five cases of forefoot or acrotarsium tissue defect were involved in this study from August 2010 to October 2014, and the wound sizes varied from 9 cm× 4. 5 cm to 26 cm× 13 cm. Twelve cases were repaired by free descending genicular artery perforator flaps （group A）, 8 cases were repaired by free saphenous artery perforator flaps （group B）, 15 cases were repaired by free anterolateral thigh perforator flaps （group C）. All open wounds had debridement and were covered by vacuum sealing drainage for 5-7 days before operation. Results Flaps of 34 cases survived, free anterolateral thigh perforator flap of 1 case （7 years old, female） had partly necrosis, and was healed 2 weeks after skin graft. After a follow-up period of 3-38 months （average, 12.3 months） postoperatively, appearance of most flaps was satisfactory, 2 cases in group A and 2 cases in group B had flap thinning operation in 3 months postoperatively. In group A, I case had leg swelling at the donor site, and I case had poor healing at the donor site. In group B, 5 cases had leg swelling at the donor site, 3 cases had poor healing at the donor site, and 4 cases had leg rash at the donor site. Conclusion Thinning operation mostly needed after repairment with free descending genicular artery perforator flaps and free saphenous artery perforator flaps. Secondary orthopaedic surgery might be avoided and the donor site might be less affected after repairment with free anterolateral thigh perforator flaps, which could only be used for soft tissue covering. Free descending genicular artery perforator flaps can be prepared for skin-bone flap or skin-tenden flap to cure complicated foot tissue defect.