应用颈浅动脉皮瓣修复颈部放射性溃疡

Repair of neck radiation ulcer with superficial cervical artery flap

目的探讨应用颈浅动脉皮瓣修复颈部放射性溃疡的方法和临床效果。方法2016年1月至2019年6月,暨南大学附属广州红十字会医院烧伤整形科采用颈浅动脉皮瓣修复颈部放射溃疡11例。溃疡发生距放疗平均13.4年,面积1 cm×2 cm~3 cm×7 cm,广泛纤维化。术前取材病理检查,清创宽度包括溃疡及周围纤维化组织,控制深度,避免损伤颈部大血管。清创后创面大小6 cm×9 cm~8 cm×13 cm。以肩峰水平脊柱旁4~5 cm处为皮瓣旋转点,以术前多普勒血流探测仪探测的颈浅动脉筋膜皮支血管走行方向为长轴设计皮瓣,旋转点到皮瓣近侧缘的距离大于其到创面近侧缘距离约2 cm,皮瓣大小超出创面大小约2 cm。分离出蒂部血管后顺行切取皮瓣,转移到颈部修复放射性溃疡切除后缺损。供区边缘适当游离2~3 cm,如缝合张力较小可行真皮层远位减张直接缝合,如张力较大则采用部分缝合,缩小创面后以中厚皮片移植修复。观察患者术后情况。结果本组11例患者的溃疡组织病理检查均提示明显纤维组织增生胶原化并小灶状钙化,局部区域坏死,间质大量淋巴细胞、单核细胞等慢性炎性细胞并少量中性粒细胞等急性炎性细胞浸润,排除肿瘤复发。11例患者中4例行供瓣区预扩张,其余7例均为皮瓣一期切取后转移,皮瓣大小8 cm×11 cm~10 cm×15 cm。8例采用颈肩胛皮瓣修复,3例采用颈背皮瓣修复。供瓣区8例真皮层远位减张后直接缝合,3例缩小创面后中厚皮片移植修复。其中10例皮瓣完全成活,伤口一期愈合。1例皮瓣远端小范围坏死,通过创面换药和二期植皮后痊愈。随访6~24个月,溃疡无复发。所有患者放射性溃疡均得到有效修复,术区外观、功能良好。结论颈部放射性溃疡是颈部放疗后较严重的远期并发症,颈浅动脉皮瓣靠近颈部、血运丰富、解剖恒定、供区隐蔽,是治疗颈部放射性溃疡切实可行的方法之一。

Objective To explore the method and clinical effect of repairing neck radiation ulcer with superficial cervical artery flap.Methods January 2016 to June 2019,11 cases of neck radiation ulcer were repaired with superficial cervical artery flap.The ulcer occurred 13.4 years after radiotherapy on average,with an area between 1 cm×2 cm and 3 cm×7 cm,extensive fibrosis.After pathological examination,surgical removal of ulcer and surrounding fibrotic tissue,and avoid injuring the neck’s main blood vessels.Wound size after debridement:6 cm×9 cm-8 cm×13 cm.The flap rotation point is 4-5 cm beside the spine on the acromion level.The flaps were designed along the skin branch of the superficial cervical artery which located by the Doppler blood flow detector.The distance from the rotation point to the flap’s proximal edge is about 2 cm longer than that of the wound’s proximal edge.The size of the flap is about 2 cm larger than the wound.Then the flaps were excised from far to near after exposing the pedicle.The flap was then transferred to the neck to repair the defect formed by the radiation ulcer’s excision.If the tension is low,the donor sites were dissociated about 2-3 cm,then sutureddirectly after reducing tension.If the tension is high,part of the donor site was sutured to reduce the area and then grafted with medium-thickness skin.The postoperative changes of the patient were carefully observed.Among them,7 cases underwent one-stage operation,4 cases underwent two-stage operation after the donor area’s pre-expansion.Results All patients with radiation ulcers were healed completely.The appearance and function of the operation area were good.Followed up for 6-24 months,no recurrences of radiation ulcer were observed.Among them,the flaps of 10 cases survived completely,and the wound healed in one stage.The distal area of the flap necrosed in one case,and repaired by dressing change and skin grafting.Conclusions Radiation ulcer of the neck is a serious long-term complication after radiotherapy.Once it occurs,it is difficult to heal by conservative treatment.Skin grafting is difficult to survive as well.The superficial cervical artery flap has a constant and abundant blood supply and a hidden donor area,which is a feasible method for the treatment of radiation ulcer of the neck and reconstruction of the function.