以肌内主干型旋股外侧动脉斜支为蒂股前外侧穿支皮瓣的临床应用

Clinical application of anterolateral thigh perforator flap pedicled with oblique branch in intramuscular of lateral circumflex femoral artery

目的探讨以肌内主干型旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣的特点及临床应用。方法回顾分析2020年12月-2021年4月收治的25例四肢皮肤软组织缺损患者临床资料,其中男16例,女9例;年龄14~75岁,中位年龄43岁。创面部位:手部13例,前臂2例,小腿2例,足踝部8例。创面范围为6cm×4cm~35cm×22cm。24例外伤患者受伤后均急诊入院,1例糖尿病足部感染患者外院治疗无效后入院;入院后0~56d(中位时间22d)行皮瓣手术。25例患者共切取26侧大腿皮瓣,单侧皮瓣切取范围7cm×5cm~40cm×10cm。术中统计穿支类型、口径、位置等数据,重点观察肌内主干型斜支的解剖学特点。记录皮瓣切取时间;术后观察皮瓣成活情况及创面愈合时间;末次随访时采用肖飞鹏等皮瓣综合疗效评价表,从供区、受区、医患主观满意度3个方面评定皮瓣修复疗效。结果肌内主干型旋股外侧动脉斜支发出后,在肌间隔内斜向外下方走行2~3cm后进入股外侧肌,并发出穿支营养皮肤。25例26侧大腿术前共标记61条穿支,术中实际出现70条,其中来自横支9条、降支29条、斜支32条,所有斜支穿支均为肌皮穿支。25例患者均获随访,随访时间6~10个月,平均8个月。单侧大腿皮瓣切取时间13~90min,平均48min。1例(1侧)糖尿病患者皮瓣术后1个月完全坏死,行植皮修复;1例术后发生动脉危象,经及时探查后成活;其余皮瓣均顺利成活。受区创面愈合时间为10~44d,平均19d;大腿供区切口均Ⅰ期愈合。末次随访时,皮瓣色泽质地良好,感觉恢复至S1~S2。供区仅遗留线性瘢痕,未出现瘢痕挛缩及疼痛等不适,无其他严重并发症发生。皮瓣综合疗效评价表评分为74~93分,平均88分;其中优10例、良13例、可2例,优良率92%。结论肌内主干型斜支并不少见,其主干走行及穿支分布有规律性。提高对该类型斜支的认知程度,术中采用恰当切取方法,可以提高皮瓣切取成功率。

Objective To explore the characteristics and clinical application of the anterolateral thigh flap pedicled with the oblique branch in the intramuscular of lateral circumflex femoral artery.Methods The clinical data of25 patients with skin and soft tissue defects of extremities admitted between December 2020 and April 2021 were retrospectively analyzed,including 16 males and 9 females,aged 14-75 years,with the median age of 43 years.The defect site included 13 cases of hand,2 cases of forearm,2 cases of calf,and 8 cases of foot and ankle.The wound area ranged from 6cm×4cm to 35cm×22cm.Twenty-four patients with trauma were admitted to hospital immediately after injury,and 1 patient with diabetic foot infection was transferred to the hospital after ineffective treatment in other hospital.Flap surgery was performed from 0 to 56 days(median,22 days)after admission.A total of 26 thigh flaps were harvested in 25patients,with unilateral flaps in size of 7cm×5cm to 40cm×10cm.The type,caliber,and location of the perforating branch were recorded during the operation,and the anatomical characteristics of the oblique branch of the intramuscular trunk were mainly observed.The flap harvesting time was recorded;the flap survival and wound healing time were observed;at last follow-up,XIAO Feipeng et al.flap comprehensive efficacy evaluation table was used to evaluate the effectiveness of flap repair from three aspects of donor site,recipient site,and subjective satisfaction of doctors and patients.Results After the oblique branch in intramuscular of lateral circumflex femoral artery was sent out,it ran 2-3 cm obliquely laterally and inferiorly in the intermuscular septum and then entered the vastus lateralis muscle,and sent out perforating branches to nourish the skin.A total of 61 perforating branches were marked in 26 thighs of 25 patients before operation,and 70 perforating branches were found during operation,including 9 transverse branches,29descending branches,and 32 oblique branches,all of the oblique branches were musculocutaneous perforators.All 25patients were followed up 6-10 months,with an average of 8 months.The time of unilateral thigh flap harvesting ranged from 13 to 90 minutes,with an average of 48 minutes.One patient with diabetes developed disturbance of blood supply and complete necrosis of the flap at 1 month after operation,and then the flap was repaired with skin graft;1 case developed arterial crisis after operation,which survived after timely exploration;and the rest of the flaps survived smoothly.The wound healing time of the recipient site ranged from 10 to 44 days,with an average of 19 days,and the donor site of the thigh healed by first intention.At last follow-up,the color and texture of the flap was good and the sensation recovered to S1-S2.Only linear scar was left in the donor site,no scar contracture,pain,and other discomfort occurred,and no other serious complications occurred.Evaluated by flap comprehensive efficacy evaluation table,the score was 74-93,with an average of 88,of which 10 cases were excellent,13 cases were good,and 2 cases were fair,with an excellent and good rate of 92%.Conclusion The intramuscular trunk oblique branch is not uncommon,and its trunk course and perforators distribution are regular.To improve the understanding of this type of oblique branch and adopt appropriate methods during operation can improve the success rate of skin flap extraction.