保留感觉的改良指固有动脉阶梯递进皮瓣修复指端皮肤缺损

Advanced sensate proper digital artery escalating flaps for repair of fingertip skin defect

目的探讨通过保留感觉的改良指固有动脉阶梯递进皮瓣修复指端皮肤缺损的可行性。方法2012年1月-2015年2月收治15例（17指）指端皮肤缺损伴肌腱或指骨外露患者，其中男9例，女6例；年龄7—55岁，平均41岁。致伤原因：重物砸伤5例，刀割伤4例，机器绞伤4例，包块切除术后2例。采用改良锯齿状切口指固有动脉阶梯递进式皮瓣修复手指末节皮肤缺损，皮瓣携带指固有动脉及神经，I期重建指腹精细感觉，避免钩甲畸形。根据中华医学会手外科学会上肢部分功能评定试用标准对关节功能进行评定。结果15例（17指）固有动脉阶梯递进皮瓣完全成活，1例因术后负痛功能锻炼不佳导致中节指间关节僵硬，经锻炼后好转。2例远端指腹缺损多，术后指甲稍弯曲。随访6～14个月，平均8个月，患指外观及感觉良好，皮瓣两点分辨率6—8mm，无直线瘢痕产生，指尖无触痛，功能恢复良好，供瓣区无明显瘢痕增生，甲床生长可，无明显勾甲畸形。关节功能评定：优16指，良1指。结论改良指固有动脉阶梯递进皮瓣血供可靠，术后皮瓣感觉良好，无钩甲畸形及直线瘢痕，是修复指端皮肤缺损的理想方法之一。

Objective To investigate the feasibility of advanced sensate proper digital artery escalating flaps in reconstruction of fingertip skin defect. Methods Between January 2012 and February 2015, 15 cases （17 fingers） of fingertip skin defect accompanied with exposed tendon or phalange were treated, including 9 males and 6 females, with mean 41 years of age （range, 7-55 years）. Injury resulted from hit by heavy objects in 5 cases, knife cutting in 4, machine twist injury in 4 and mass resection in 2. Fingertip defects were covered with the flaps carrying proper digital artery and nerves in order to one-stage reconstruct finger pulp epicritic sensibility and avoid onychogryphosis. Joint function was assessed with the standard set up by Chinese Medical Association Hand Surgery Branch. Results All flaps survived. One case had ankylosis of the middle interphalangeal joint caused by poor weight-bearing exercise and was improved after exercise. Two cases with large defect in the distal finger pulp had slight onychogryphosis after operation. Period of follow-up was 6-14 months （ mean, 8 months）. The injured fingers showed good appearance and sense, with two-point discrimination of the flap ranging from 6-8 ram. There was no linear scar or tenderness in the finger tip. Hypertrophic scar was not obvious in the flap donor area. Function assessment was excellent in 16 fingers and good in 1 finger. Conclusion The flaps result in good blood supply, good sense, no onychogryphosis and no linear scar and are easy to be operated, indicating an ideal method to reconstruct fingertip defect.