扩张穿支皮瓣游离移植治疗儿童严重瘢痕挛缩畸形的效果

Effects of free transplantation of expanded perforator flaps in the treatment of severe scar contracture deformities in children

目的探讨采用扩张穿支皮瓣游离移植治疗儿童严重瘢痕挛缩畸形的效果。方法2010年1月—2018年12月,空军军医大学西京医院收治18例、南方医科大学深圳医院收治3例严重瘢痕挛缩患儿。这21例患儿中,男14例、女7例,年龄3~12岁,颈胸粘连15例、颏胸粘连5例、踝关节挛缩1例。根据瘢痕挛缩位置、预计松解后创面大小选定穿支皮瓣的供瓣区和扩张器容量,置入扩张器对皮瓣进行扩张。待扩张至适当容量后,切除松解挛缩瘢痕,依创面设计穿支皮瓣游离移植,皮瓣面积14cm×6cm^18cm×15cm。统计扩张皮瓣部位,扩张器个数、置入部位、额定容量及注射壶放置位置,皮瓣成活情况,并发症情况,供区修复情况,随访情况。结果本组患儿中,采用扩张胸背动脉穿支皮瓣16例、扩张旋肩胛动脉穿支皮瓣3例、扩张股前外侧穿支皮瓣2例;单纯皮瓣供区扩张14例,同时行供瓣区旁扩张7例。21例患儿共置入34个扩张器,其中皮瓣下21个、瘢痕旁6个、供瓣区旁7个;扩张器额定容量200mL者26个、400mL者8个,注射壶外置8个、内置26个。21个皮瓣均完全成活。1例患儿术后5d出现血管危象,行探查及再吻合。供瓣区创面直接缝合者19例,2例患儿侧胸部供瓣区遗留小创面移植供瓣区旁薄中厚皮修复。随访6~36个月,皮瓣修复处质地及颜色与周围皮肤接近;8例患儿颈部皮瓣稍显臃肿需行减脂手术,其余病例外形良好;各部位活动功能基本恢复正常,挛缩均无复发。结论采用扩张穿支皮瓣游离移植治疗儿童严重瘢痕挛缩畸形,可获得较好的外观、质地及功能恢复,疗效长期稳定。

Objective To explore the effects of using free transplantation of expanded perforator flaps in the treatment of severe scar contracture deformities in children.Methods From January 2010 to December 2018,18 pediatric patients with severe scar contracture were admitted to Xijing Hospital of Air Force Medical University,and 3 pediatric patients with severe scar contracture were admitted to Shenzhen Hospital,Southern Medical University.There were 14 males and 7 females among the 21 pediatric patients,who were 3-12 years old,with 15 cases of cervicothoracic adhesion,5 cases of chin-chest adhesion,and 1 case of ankle joint contracture.According to the location of scar contracture and the size of wound after release,the donor site of perforator flap and expander volume were selected,and the expander was inserted to expand the flap.After expanding to proper volume,the contracted scar was resected and released.The perforator flap was designed and transplanted freely according to the wound.The flap area ranged from 14 cm×6 cm to 18 cm×15 cm.The location of the expanded flaps,the number,location,rated volume,and the location of injection port of the inserted expanders,the survival condition of flaps,the complications,the repair of donor sites,and the follow-ups were analyzed.Results Among this group of pediatric patients,16 cases used expanded thoracodorsal artery perforator flap,3 cases used expanded circumflex scapular artery perforator flap,and 2 cases used expanded anterolateral thigh perforator flap,with 14 cases of pure donor site expansion and 7 cases of donor site expansion together with expansion beside donor site.Thirty-four expanders were inserted in 21 pediatric patients,with 21 under flaps,6 near scars,and 7 near donor sites.The rated volumes of 26 expanders were 200 mL,while those of the remaining 8 expanders were 400 mL.Eight injection ports were placed externally,while the rest were placed internally.All the 21 flaps survived completely.Vascular crisis occurred in 1 pediatric patient 5 days after operation,and exploratory operation and reanastomosis were performed.The donor sites of 19 pediatric patients were closed directly,while the small wounds in lateral thoracic donor sites of 2 pediatric patients were repaired with thin intermediate split-thickness skin graft collected beside the donor site.Follow-up for 6 to 36 months showed that the texture and color of area repaired by the flaps were close to the surrounding skin.The flaps in the neck region of 8 pediatric patients were slightly bulky,requiring debulking operation,while the other cases had good appearance.The movement function of the involved regions was basically restored to normal,and no recurrence of contracture occurred.Conclusions Free transplantation of expanded perforator flaps can achieve favorable appearance,texture,and function restore in treating severe scar contracture deformities in children,and the curative effect is stable and lasts long.