四肢大面积皮肤软组织缺损的修复方案

Clinical application effect of repairing large area of skin and soft tissue defects of extremities

目的探讨修复四肢大面积皮肤软组织缺损的手术方法和临床疗效。方法回顾性分析2005年10月至2019年2月台州骨伤医院手创伤科收治的四肢大面积皮肤软组织缺损病例的临床资料。对于四肢创面缺损较大,不伴有功能性肌肉缺损的病例,采用游离股前外侧皮瓣;对伴有功能性肌肉缺损的病例,采用背阔肌肌皮瓣;对伴有大段骨缺损的病例,采用股前外侧皮瓣联合腓骨皮瓣;对伴有6 cm以下骨缺损的病例,采用以旋髂浅动脉为蒂的骨皮瓣进行一期修复。供区创面一期关闭。术后对供、受区外形和功能进行随访。结果共纳入45例,男33例,女12例,年龄21~65岁,平均35.2岁。四肢创面缺损大小7 cm×6 cm~32 cm×12 cm,伴骨缺损14例,采用游离股前外侧皮瓣修复17例,面积为11 cm×7 cm~30 cm×12 cm;背阔肌肌皮瓣修复14例,面积为10 cm×7 cm~32 cm×12 cm;股前外侧皮瓣联合腓骨皮瓣修复6例,2个皮瓣面积分别9 cm×6 cm~16 cm×8 cm、6 cm×4 cm~9 cm×5 cm;以旋髂浅动脉为蒂的骨皮瓣修复8例,面积为7 cm×6 cm~13 cm×8 cm。术后45例皮瓣44例成活,有1例游离股前外侧皮瓣修复足背创面术后出现血管危像,经过探查后还是坏死,最后取另一侧股前外侧皮瓣重新修复成活。术后随访0.5~13年,平均4年,家庭随访17例,来院复诊21例,微信随访7例,皮瓣质地、外形满意,四肢功能恢复优良,皮瓣两点辨距觉为5~10 mm;供区创口愈合良好,功能无明显影响,除背阔肌肌皮瓣供区外其余无明显瘢痕增生。结论根据四肢大面积皮肤软组织缺损的大小、深浅及伴有肌腱肌肉、骨骼缺损的不同,选择合理的方案进行修复,术后可获得良好的外观和功能,而且对供区损伤较小。

Objective This clinical study describes the surgical methods and clinical effects for large skin and soft tissue defects of the extremities.Methods Between October 2005 and February 2019,the patients with large skin and soft tissue defects of the extremities were hospitalized in the Department of Hand Surgery of the Orthopedic Hospital of Taizhou.The choice of flaps for primary phase repair was determined by the degree and the type of defect,including anterolateral thigh(ALT)flap,latissimus dorsi myocutaneous flap(LDMF),combined free ALT flap and osteocutaneous fibula flap and vascularized iliac osteocutaneous flap based on superficial circumflex iliac artery(SCIA).The donor site was primarily closed.And the appearance and function of donor and recipient sites were followed up.Results Forty-five cases were performed in this study.There were 33 males and 12 females.The ages of the patients ranged from 21 to 65 years with an average of 35.2 years.The size of the defects ranged from 7 cm×6 cm to 32 cm×12 cm,with bone defects in 14 cases.The recipient sites included the free ALT flap in 17(ranged from 11 cm×7 cm to 30 cm×12 cm),LDMF in 14(ranged from 10 cm×7 cm to 32 cm×12 cm),ALT(ranged from 9 cm×6 cm to 16 cm×8 cm)+osteocutaneous fibula flap(ranged from 6 cm×4 cm to 9 cm×5 cm)in 6,and iliac osteocutaneous flap based on SCIA(ranged from 7 cm×6 cm to 13 cm×8 cm).Among the 45 cases,44 cases survived.There was one case with dorsal foot defect,which reconstructed by ALT flap,had vascular crisis after surgery.Although the vascular exploration was timely,the flap eventually necrotic.The ALT flap on the other side was successfully reapplied.Patients were followed up for average 4 years(ranging from 1-13 years),and all of them were satisfied with the function and final aesthetic outcomes.The two-point discrimination of the flap was 5 mm to 10 mm.The donor site healed well.There was no obvious scar hyperplasia except the latissimus dorsi donor.Conclusions According to the size and depth of the large area of skin and soft tissue defects of extremities,and whether there are tendon,muscle and bone defects,a reasonable scheme is selected for repair,which can obtain good appearance and function after surgery,and less damage to the donor site.