穿支螺旋桨皮瓣修复背阔肌肌皮瓣供区缺损

Primary donor-site closure of a large latissimus dorsi myocutaneous flap using the perforator propeller flap technique

目的探讨应用穿支蒂螺旋桨皮瓣修复背阔肌肌皮瓣供区缺损的可行性和技术要点。方法2012年7月至2019年1月,中国医学科学院整形外科医院瘢痕综合治疗中心采用背阔肌肌皮瓣修复创面24例,男9例,女15例,年龄4~81岁,平均43.6岁。术前应用超声多普勒血流探测仪,探查背阔肌前缘和后缘附近的穿支血管并进行标记。术中根据拟修复缺损的大小、形状,切取背阔肌肌皮瓣,修复缺损;依据术前穿支血管探查结果,掀起1块或多块穿支蒂螺旋桨皮瓣,转移修复背阔肌肌皮瓣供区缺损。观察术后效果。结果24例背阔肌肌皮瓣术后均成活,包括带蒂肌皮瓣22块,游离肌皮瓣2块,面积16 cm×11 cm^33 cm×17 cm,宽度9~20 cm。24例均应用穿支蒂螺旋桨皮瓣修复背阔肌肌皮瓣供瓣区,其中12例应用1块螺旋桨皮瓣,11例应用2块,1例应用3块,共37块穿支皮瓣,包括36块肋间后动脉穿支皮瓣,1块自由设计穿支皮瓣。螺旋桨皮瓣的面积13 cm×5 cm^23 cm×14 cm,血管蒂长度3~6 cm,皮瓣旋转角度90°~180°,所有螺旋桨皮瓣的供瓣区都直接关闭。术后1块肋间后动脉穿支皮瓣完全坏死,清创后另行植皮修复;1块肋间后动脉穿支皮瓣远端2 cm坏死,经换药处理后创面愈合;其他35块皮瓣全部成活,没有出现任何严重的并发症。24例均获1~38个月随访,平均7个月,随访期间4例肿瘤患者出现肿瘤复发,需再次实施肿瘤切除术;所有患者对术后术区功能和美学效果均满意。结论应用穿支蒂螺旋桨皮瓣修复背阔肌肌皮瓣供区缺损,在确保切取一个宽大的肌皮瓣用于缺损修复的同时,还可以确保背部肌皮瓣供区能直接关闭。

Objective To explore the feasibility and technical tips of donor-site reconstruction of the latissimus dorsi myocutaneous flap using the perforator propeller flap technique.Methods Between July 2012 and January 2019,a total of 24 patients,including 9 males and 15 females,underwent reconstructions of defects in various locations using the latissimus dorsi myocutaneous flap.The average patient age was 43.6 years(range,4-81 years).Before surgery,perforators adjacent to the latissimus dorsi muscle were explored using an ultrasound Doppler probe and marked on the skin.A latissimus dorsi myocutaneous flap was elevated according to the resultant defect following the removal of the lesion and transferred to reconstruct the defect.The donor-site defects were reconstructed using one,dual,or even triple perforator propeller flap.Results All the 24 myocutaneous flaps survived completely.The dimension and width of the myocutaneous flaps ranged from 16 cm×11 cm to 33 cm×17 cm and 9 cm to 20 cm,respectively.The donor-site defects of the myocutaneous flap were all closed by perforator propeller flaps including 22 pedicled flaps and 2 free flaps.The defect was reconstructed by one perforator propeller flap in 12 patients,two flaps in 11,and three flaps in the remaining one patient.There were 36 posterior intercostal artery perforator propeller flaps and one freestyle perforator propeller flap.The size,pedicle length,and rotation angle of the propeller flaps were 13 cm×5 cm to 23 cm×14 cm,3 cm to 6 cm,and 90 to 180 degrees,respectively.All the donor sites of the perforator propeller flaps were closed primarily.Total necrosis of the propeller flap occurred in one patient and small-sized distal flap necrosis in another one.The remaining propeller flaps survived completely.All patients were followed up for one to 38 months and the mean follow-up time was 7 months.Tumor recurrence was noticed in four patients.All patients were satisfied with the final functional and aesthetic outcomes.Conclusions Using the perforator propeller flaps could guarantee not only harvesting a wide latissimus dorsi myocutaneous flap,but also primary donor-site closure of the myocutaneous flap,and therefore greatly improve the versatility and capability of the latissimus dorsi myocutaneous in defect reconstruction.