游离皮瓣桥式移植修复严重皮肤软组织缺损

The applications of cross-bridge free flap for reconstructions of severe soft tissue defects

目的探讨游离皮瓣桥式移植修复严重皮肤软组织缺损的临床效果。方法回顾性分析2008年2月至2017年2月空军军医大学第一附属医院收治的大面积皮肤软组织缺损且受区无可供吻合血管的患者资料。针对不同情况采用背阔肌肌皮瓣、股前外侧皮瓣或胸脐皮瓣修复缺损,通过同侧或对侧肢体动静脉血管为游离组织瓣提供临时血供,即游离皮瓣桥式供血。修复头面部和躯干缺损时桥接同侧前臂桡动脉、头静脉,修复小腿及足部缺损时桥接对侧胫后或胫前动静脉,皮瓣供区拉拢缝合或移植中厚皮片覆盖。待移植的组织瓣与受区充分建立侧支循环后(一般为术后5周),行血管断蒂。术后对皮瓣和皮片的成活情况、并发症发生情况进行观察和随访。结果共纳入12例患者,男9例,女3例,年龄18~59岁,头面部4例,臀部1例,小腿6例,足背1例,缺损面积为18.0 cm×7.0 cm~23.5 cm×13.0 cm,切取皮瓣面积20.0 cm×8.0 cm~25.0 cm×15.0 cm,其中应用背阔肌肌皮瓣修复10例,胸脐皮瓣修复1例,股前外侧皮瓣修复1例。术后1例出现血管危象,及时行血管探查发现为静脉血栓形成,清除血栓、重新吻合血管后移植物成活;1例背部供区所植皮片部分坏死,湿敷换药后愈合;其余病例移植物成活良好,供区亦恢复较好。有2例面部移植皮瓣较为臃肿,术后半年行皮瓣去脂修薄后外观得以改善。随访1~1.5年,所有病例转移皮瓣外形较为满意,色泽、质地与周围组织有一定差异,前臂及小腿血管供区无畸形及功能障碍,大腿皮片供区有色素沉着,部分伴浅表瘢痕。结论对于软组织缺损较大、损伤严重、无可供吻合血管的创面,应用游离皮瓣桥式移植修复可获得较好的效果。

Objective To investigate the application and efficacy of cross-bridge free flaps to repair severe soft tissue defects.Methods The clinical data of severe defects with vascular damage in the recipient site from February 2008 to February 2017 were retrospectively analyzed in the First Affiliated Hospital of Air Force Military Medical University.Latissimus dorsi myocutaneous flaps,anterolateral thigh flaps,or thoracomphalum flaps were applied in these cases.These flaps were nourished by ipsilateral or contralateral limb vessels,named as bridge blood supply.The radial artery and cephalic vein of the ipsilateral forearm were bridged to repair defects of the head,face,and trunk.The vessels of the unaffected lower extremity were bridged to repair leg and foot wounds.The flap donor sites were closed directly or covered by skin grafting.Division procedures were performed after circulation reestablishment for five weeks.The complications,survival of flaps and skin grafts were observed and followed up.Results A total of 12 patients were selected,including nine males and three females,aged 18-59 years old.The cases included four head and facial defects,one hip tumor excision,six lower extremities injuries,and one dorsal foot injury.The defect areas ranged 18.0 cm×7.0 cm-23.5 cm×13.0 cm,and the flaps size ranged 20.0 cm×8.0 cm-25.0 cm×15.0 cm.Latissimus dorsi myocutaneous flaps were applied in 10 cases.The other two cases were treated by a thoracic umbilical and an anterolateral thigh flap.The vascular crisis occurred in one case,and the graft survived well after the timely removal of the venous thrombosis.One case of partial skin graft necrosis occurred on the back donor site,which healed after dressing changes.The other donor sites recovered well.Two cases of flap bloating appearances were improved by thinning procedures six months later.The follow-ups lasted 1 to 1.5 years.The patients were satisfied with the appearance of the transferred flaps.The color and texture of the flaps were different from the surrounding areas.There were no malformations and functional disorders in donor sites of the extremities.Some pigmentation and superficial scar were left on the thighs.Conclusions For large and severe soft tissue defects where no anastomotic vessels were available,the application of free flap by bridge transplantation is an alternative with good outcomes.