游离背阔肌肌皮瓣联合人工真皮及刃厚皮治疗下肢脱套伤的临床效果

Clinical effects of free latissimus dorsi myocutaneous flap combined with artificial dermis and split-thickness skin graft in the treatment of degloving injury in lower extremity

目的观察游离背阔肌肌皮瓣联合人工真皮及刃厚皮治疗下肢脱套伤的临床效果。方法采用回顾性观察性研究方法。2017年12月—2020年12月,宁波市第六医院收治8例下肢脱套伤致大面积皮肤软组织缺损患者,其中男5例、女3例,年龄39~75岁,创面面积为25 cm×12 cm~61 cm×34 cm。以携带12~15 cm宽背阔肌、皮瓣面积为20 cm×8 cm~32 cm×8 cm的游离背阔肌肌皮瓣修复骨/肌腱外露部位或功能区皮肤软组织缺损,其余缺损用双层人工真皮修复,将供瓣区直接缝合。待人工真皮完全血管化后,取大腿刃厚皮按1∶2~1∶4的比例扩展后移植修复残余创面,对供皮区行换药治疗。观察术后背阔肌肌皮瓣、人工真皮、刃厚皮成活情况,记录人工真皮移植和刃厚皮移植的间隔时间,观察供区愈合情况。随访观察术区外观和功能,于末次门诊随访时,采用英国医学研究会评定标准评估皮瓣感觉恢复情况,参照《手外科手术学》中的皮瓣综合评定标准评估皮瓣功能,采用温哥华瘢痕量表(VSS)评估下肢植皮区和大腿供皮区瘢痕情况,询问患者对疗效的满意度。结果6例患者背阔肌肌皮瓣均成活;2例患者背阔肌肌皮瓣出现远侧尖端部分坏死,坏死部分待刃厚皮移植时切除后直接植皮修复。8例患者移植的人工真皮均成活。7例患者移植的刃厚皮成活;1例患者移植的刃厚皮部分坏死,予以再次植皮修复。人工真皮移植和刃厚皮移植的间隔时间为15~26(20±5)d。背阔肌肌皮瓣供区术后均愈合,遗留线性瘢痕;大腿皮片供区术后瘢痕愈合。随访6~18(12.5±2.3)个月,皮瓣色泽、弹性与周围皮肤组织接近,下肢关节活动恢复正常;背部供区线性瘢痕未见增大,大腿供区无明显增生性瘢痕。末次门诊随访时,皮瓣感觉恢复至S2级或S3级;皮瓣功能为优者3例、良者4例、可者1例;下肢植皮区VSS评分为4~7(5.2±0.9)分,大腿供皮区VSS评分为1~5(3.4±0.8)分;患者对疗效表示比较满意。结论采用游离背阔肌肌皮瓣覆盖骨/肌腱外露或功能区创面,移植人工真皮与扩展后刃厚皮覆盖残余创面的方法,修复下肢脱套伤导致的大面积皮肤软组织缺损,切取自体皮瓣和皮片面积小,术后功能区恢复效果好,皮片移植区愈合质量佳。

Objective To observe the clinical effects of free latissimus dorsi myocutaneous flap combined with artificial dermis and split-thickness skin graft in the treatment of degloving injury in lower limbs.Methods A retrospective observational study was conducted.From December 2017 to December 2020,8 patients with large skin and soft tissue defect caused by degloving injury in lower extremity were admitted to Ningbo No.6 Hospital,including 5 males and 3 females,aged from 39 to 75 years,with wound area of 25 cm×12 cm-61 cm×34 cm.The free latissimus dorsi myocutaneous flap with latissimus dorsi muscle in the width of 12-15 cm and flap area of 20 cm×8 cm-32 cm×8 cm was used to repair the skin and soft tissue defect of bone/tendon exposure site or functional area.The other defect was repaired with bilayer artificial dermis,and the flap donor site was sutured directly.After the artificial dermis was completely vascularized,the split-thickness skin graft from thigh was excised and extended at a ratio of 1∶2 to 1∶4 and then transplanted to repair the residual wound,and the donor site of skin graft was treated by dressing change.The survival of latissimus dorsi myocutaneous flap,artificial dermis,and split-thickness skin graft after operation was observed,the interval time between artificial dermis transplantation and split-thickness skin graft transplantation was recorded,and the healing of donor site was observed.The appearance and function of operative area were followed up.At the last outpatient follow-up,the sensory recovery of flap was evaluated by British Medical Research Council evaluation criteria,the flap function was evaluated by the comprehensive evaluation standard of flap in OperativeHand Surgery,the scar of lower limb skin graft area and thigh skin donor area was evaluated by Vancouver scar scale,and the patient's satisfaction with the curative effects was asked.Results The latissimus dorsi myocutaneous flap survived in 6 patients,while the distal tip of latissimus dorsi myocutaneous flap was partially necrotic in 2 patient and was repaired by skin grafting after resection at split-thickness skin grafting.The artificial dermis survived in all 8 patients after transplantation.The split-thickness skin graft survived in 7 patients,while partial necrosis of the split-thickness skin graft occurred in one patient and was repaired by skin grafting again.The interval time between artificial dermis transplantation and split-thickness skin graft transplantation was 15-26(20±5)d.The donor site of latissimus dorsi myocutaneous flap healed with linear scar after operation,and the thigh skin graft donor site healed with scar after operation.The patients were followed up for 6-18(12.5±2.3)months.The color and elasticity of the flap were similar to those of the surrounding skin tissue,and the lower limb joint activity returned to normal.There was no increase in linear scar at the back donor site or obvious hypertrophic scar at the thigh donor site.At the last outpatient follow-up,the sensation of the flap recovered to grade S2 or S3;3 cases were excellent,4 cases were good,and 1 case was fair in flap function;the Vancouver scar scale score of lower limb skin graft area was 4-7(5.2±0.9),and the Vancouver scar scale score of thigh skin donor area was 1-5(3.4±0.8).The patients were fairly satisfied with the curative effects.Conclusions In repairing the large skin and soft tissue defect from degloving injury in lower extremity,to cover the exposed bone/tendon or functional area with latissimus dorsi myocutaneous flap and the residual wound with artificial dermis and extended split-thickness skin graft is accompanied by harvest of small autologous flap and skin graft,good recovery effect of functional area after surgery,and good quality of healing in skin grafted area.