远端携带一部分背阔肌的下位斜方肌肌皮瓣手术设计和初步临床应用

Flap design and preliminary clinical experience of the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle

目的探讨应用远端携带一部分背阔肌的下位斜方肌肌皮瓣带蒂移位修复不同部位缺损的可行性和疗效。方法2014年12月—2019年12月,采用远端携带一部分背阔肌的下位斜方肌肌皮瓣修复不同部位缺损13例。其中男10例,女3例;年龄29~83岁,平均52.1岁。恶性肿瘤切除后遗留创面12例,其中头颈部肿瘤6例、肩背部肿瘤5例、胸背部肿瘤1例;4例合并创面感染、骨外露,1例合并颅骨缺损、硬脑膜外露,1例合并创面感染、颅骨坏死、脑脊液漏。交通事故伤1例,导致肩背部感染创面、骨外露。创面范围为11 cm×7 cm~23 cm×15 cm。肌皮瓣切取范围为25 cm×8 cm~40 cm×14 cm。依据供、受区的空间位置关系,采取螺旋桨皮瓣(8例)或经皮下隧道岛状皮瓣(5例)移位方式,将肌皮瓣移位至受区修复创面。供区直接拉拢缝合(9例),张力过大者行游离植皮(2例)或转移皮瓣(2例)修复。结果术后2例肌皮瓣远端4 cm出现坏死,清创后1例采用局部皮瓣修复,1例行转移肋间动脉穿支皮瓣修复;余11例肌皮瓣全部成活,无动静脉危象发生,供、受区创面Ⅰ期愈合。13例均获随访,随访时间1~48个月,平均7.4个月。所有皮瓣颜色、质地良好。随访期间1例患者因肿瘤复发再次行肿瘤切除,1例头皮血管肉瘤患者术后4个月因不明原因胸腔出血死亡;余肿瘤患者未见肿瘤复发,缺损处肌皮瓣覆盖稳定,感染控制。结论远端携带一部分背阔肌的下位斜方肌肌皮瓣可用于修复合并重要组织、结构暴露及感染等难治性创面。

Objective To explore the reliability and effectiveness of soft tissue defect reconstruction using the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle.Methods Between December2014 and December 2019,13 patients underwent the reconstruction of soft tissue defects in various sites using the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle.There were 10 males and 3 females,with an average age of 52.1 years(range,29-83 years).Twelve wounds were resulted from resection of various malignant tumor,including 6 cases of head and neck tumors,5 cases of shoulder and back tumors,1 case of chest and back tumors.Among the 12 cases,4 cases were complicated with wound infection and bone exposure,1 case with skull defect and cerebral dura exposure,and 1 case with wound infection,skull necrosis,and cerebrospinal fluid leakage.One case was injured in a traffic accident,which resulted in infection wound in the back and shoulder and bone exposure.The sizes of the defect and musculocutaneous flap ranged from 11 cm×7 cm to 23 cm×15 cm and 25 cm×8 cm to 40 cm×14 cm,respectively.According to the spatial relationship between the donor and recipient sites,propeller flaps(8 cases)or percutaneous tunnel island flaps(5 cases)were used to transfer the myocutaneous flap to the recipient area to repair the wound.The donor site was directly closed and sutured in 9 cases,and those with excessive tension were repaired with free skin grafts in 2 cases or transferred flaps in 2 cases.Results After the operation,necrosis of the distal 4-cm of the musculocutaneous flap occurred in 2 cases.After debridement,the resultant wounds were reconstructed using a local flap and a posterior intercostal artery perforator flap,respectively.The remaining 11 myocutaneous flaps survived completely without arteries and veins crisis.The wounds in the donor and recipient areas healed by first intention.All the patients were followed up 1 to 48 months(mean,7.4 months).The color and texture of the flap were good.During the follow-up,1 patient underwent tumor resection again due to tumor recurrence,and 1 patient with a scalp hemangiosarcoma died due to unexplained thoracic hemorrhage.Tumor recurrence was not found in the remaining patients.The musculocutaneous flap coverage was stable and the infection was controlled.Conclusion The lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle can be an alternation option to reconstruct refractory wounds with exposure of vital structures and organs and infection.