显微削薄腹壁下动脉穿支皮瓣修复肢体皮肤软组织缺损

Microscope-assisted thinning of inferior epigastric artery perforator flap in repairing large skin and soft tissue defects of limbs

目的探讨显微削薄的腹壁下动脉穿支皮瓣修复肢体皮肤软组织缺损的临床疗效。方法回顾性分析2018年6月—2020年9月广州和平骨科医院手显微四科收治肢体软组织缺损患者8例,男性6例,女性2例;年龄24~55岁,平均35.4岁;道路交通伤5例,机器绞伤3例。于显微镜下修剪、削薄腹壁下动脉穿支皮瓣,游离移植修复前臂7例,膝关节部1例。修复的皮肤软组织缺损面积17.0cm×6.0cm~36.5cm×10.0cm,手术切取的皮瓣面积18.0cm×7.0cm~37.0cm×11.0cm。皮瓣供区创面均直接闭合。术前先用便携式多普勒探测仪探测腹壁区穿支血管位置并标记,术中用组织剪均匀平行剪除皮瓣内大部分浅筋膜层脂肪,血管蒂部周围削薄在10倍显微镜下进行,注意保留穿支血管及其浅筋膜内分支和真皮下血管网,保留穿支血管周围3cm袖口状组织,血管吻合将皮瓣内腹壁下动脉与供区动脉作端端或端侧吻合、伴行静脉及腹壁浅静脉与供区伴行静脉或皮下浅静脉作端端吻合。术后予以烤灯、观察皮瓣血运及抗感染、抗凝、抗痉挛治疗,并通过门诊、电话、微信随访患者皮瓣修复后的外形、感觉、活动功能等临床治疗效果。结果移植8例皮瓣7例成活,均未出现血管危象;1例皮瓣远端2.0cm×1.0cm面积皮肤坏死,经换药后创面完全愈合。术后随访3~18个月,皮瓣外观不臃肿,质地及颜色与受区周围组织接近,恢复保护性感觉5例。结论削薄后的腹壁下动脉穿支皮瓣修复肢体皮肤软组织缺损,皮瓣外观及功能良好、厚薄适中,供区隐蔽、损伤小,是修复肢体皮肤组织缺损较为理想的方法。

Objective To investigate the clinical effect of microscope-assisted thinning of inferior epigastric artery perforator flap in repairing skin and soft tissue defects of limbs.Methods Eight patients with soft tissue defect in limbs treated in the 4th Ward of Hand Microsurgery of Guangzhou Heping Orthopaedic Hospitall from Jun.2018 to Sep.2020 were retrospectively analyzed.The patients ranged in age from 24 to 55(35.4 on average)years and included 6 males and 2 females.The thinned deep inferior epigastric perforator flap under microscope was used to repair the skin defect,including 7 cases of forearm and 1 case of knee joint.There were 5 cases of traffic injuries and 3 cases of mechanical injuries.The area of repaired skin and soft tissue defect was 17.0cm×6.0cm-36.5cm×10.0cm,and the area of surgically removed flap was 18.0cm×7.0cm-37.0cm×11.0cm.All the flap donor wounds were closed directly.The position of perforating artery in the abdominal wall area was detected and marked before surgery with a portable doppler detector.During the operation,most of the fat in the superficial fascial layer in the skin flap was cut evenly and parallel with tissue shear.Thinning around the vessel pedicle was performed under 10 times magnified view of the microscope.Attention should be paid to the preservation of the perforator vessels,their superficial intrafascial branches and the subdermal vascular network.A 3-cm cufflike tissue around the perforator vessel should be reserved.The inferior epigastric artery inside the flap was anastomosed with the donor artery end to end or side,and the accompanied vein and superficial epigastric vein were anastomosed with the donor vein or subcutaneous superficial vein end to end.The flap was warmed with a heating lamp after surgery,blood supply of the flap was observed,and the"anti-infection,anti-coagulation,anti-spasm"treatment was performed after the operation.Patients were investigated and interviewed through outpatient,telephone and WeChat to summarize the clinical treatment effect of appearance,sensation,activity function after flap repair.Results Of the 8 perforators flaps,7 flaps survived completely without vascular crisis.The distal skin necrosis of 1 case was about 2.0cm×1.0cm,and the wound healed completely after dressing change.Postoperative follow-up of 3-18 months showed that the skin flap was not swollen in appearance,and its texture and color were close to the surrounding tissues of the recipient area.Protective sensation recovered in 5 of all patients.Conclusion The thinned inferior epigastric artery perforator flap can be used to repair the large skin and soft tissue defects of the limb,which can obtain good appearance and function,conceal the donor area and have little damage,and the flap is of moderate thickness.It is an ideal method to repair the skin tissue defects of the limb.