基于显微外科技术的穿支皮瓣修复体表恶性肿瘤切除后继发创面

Using perforator flaps with the microsurgical technique for repairing secondary wounds after resecting superficial malignant tumors

目的探讨基于显微外科技术的穿支皮瓣修复体表恶性肿瘤切除后继发创面的临床效果。方法收集广西玉林市第一人民医院2018年1月至2021年1月收治的各类体表恶性肿瘤患者,完善检查行多学科会诊初步诊断,根据术前拟定诊断采用相应彻底切除原则,联合术中切缘快速病理检查进行肿瘤切除,或采取减瘤姑息切除后,遗留创面采用基于显微外科技术的穿支皮瓣游离移植修复。根据手术体位需要、缺损面积及需组织量大小、血管口径及长度等实际情况,分别选择旋股外侧动脉降支穿支皮瓣、胸背动脉穿支皮瓣、腹壁下动脉穿支皮瓣、旋髂浅动脉穿支皮瓣。观察患者术后情况。结果共纳入29例,男19例,女10例,年龄28~69岁。肿瘤位于头面部13例、上肢4例、下肢6例、胸部6例。鳞状细胞癌12例、基底细胞癌4例、软组织肉瘤9例、晚期乳腺癌4例。切除肿瘤后遗留创面9.0 cm×7.5 cm~22.0 cm×17.0 cm。采用旋股外侧动脉降支穿支皮瓣修复创面20例,胸背动脉穿支皮瓣4例,腹壁下动脉穿支皮瓣4例,旋髂浅动脉穿支皮瓣1例。皮瓣大小10.0 cm×9.0 cm~24.0 cm×18.0 cm。术后1例出现静脉回流障碍,探查桥接静脉后成活,1例动脉危象患者不同意探查,皮瓣坏死后改植皮修复。其余病例皮瓣均顺利成活。25例患者达到R0切除,随访时间半年至2年,肿瘤均无复发,局部外观平整。4例晚期乳腺癌患者行减瘤姑息切除,创面修复局部无再发,生存期内生活质量改善。供区直接缝合关闭13例,余16例收拢创面后移植头部刃厚皮片修复,供区未遗留功能障碍。结论基于显微外科技术的穿支皮瓣能较好地解决体表恶性肿瘤扩大切除后遗留的较大的复杂创面,是体表恶性肿瘤外科治疗的重要保障。

Objective To investigate the clinical effect of using perforator flaps with the microsurgical technique in repairing secondary wounds after resecting superficial malignant tumors.Methods A retrospective observational study was conducted in patients with superficial malignant tumors admitted to the Yulin NO.1 People’s Hospital from January 2018 to January 2021.After comprehensive examinations and multidisciplinary consultations,tumors were completely or palliatively resected based on results of the preoperative diagnosis and the intraoperative fast pathological test of cutting edge.Perforator flaps were used to repair the secondary wounds with microsurgical technique.The type of perforator flaps,including the lateral femoral circumflex artery perforator flap,the thoracodorsal artery perforator flap,the inferior epigastric artery perforator flap,the superficial iliac circumflex artery perforator flap,were decided by the intraoperative position,the defect size,the caliber and length of the blood vessel,etc.Postoperative conditions of the patients were observed.Results Twenty-nine cases were included,with 19 males and ten females,aged from 28 to 69 years.Locations of the tumors included head and face(13 cases),upper extremity(four cases),lower extremity(six cases),and chest wall regions(six cases).The pathological type included 12 cases of squamous cell carcinoma,four of basal cell carcinoma,nine of sarcoma,and four of advanced breast cancer.The size of the wound after tumor resection ranged from 9.0 cm×7.5 cm to 22.0 cm×17.0 cm.There were 20 cases repaired with the lateral femoral circumflex artery perforator flap,four with the thoracodorsal artery perforator flap,four with the inferior epigastric artery perforator flap,and one with the superficial iliac circumflex artery perforator flap.The size of the flap ranged from 10.0 cm×9.0 cm to 24.0 cm×18.0 cm.One case had venous reflux obstruction and survived after exploringa bridging vein.One case suffered from the arterial crisis.Since this patient refused the exploration surgery,the skin-grafting was used to repair after flap necrosis.In addition,the other flaps survived successfully.Twenty-five patients achieved R0 resection.No recurrence was observed,and the appearance of the tumor was smooth after half a year to two years of follow-up.Four cases of advanced breast cancer were treated with palliative resection.The wounds were repaired and showed no recurrence.The quality of life was improved in the survival period.The donor site was closed directly in 13 cases,and thick skin grafting was used to cover the remaining 16 cases.No dysfunction was left.Conclusions Using perforator flaps with microsurgical technique can repair the large and composite wound after extensive resection of malignant tumors.It is an essential guarantee for surgical treatment of body surface malignant tumors.