股前外侧穿支皮瓣修复烟雾病血运重建术后头皮缺损7例

Repair of scalp defect with anterolateral thigh perforator flap after revascularisation of moyamoya disease:a report of 7 cases

目的探讨采用游离股前外侧穿支皮瓣(ALTPF)修复烟雾病血运重建术后头皮缺损的临床疗效。方法自2020年5月至2022年7月,河南省人民医院(郑州大学人民医院)手足显微外科共收治烟雾病血运重建术后并发头皮坏死缺损患者7例,其中男4例,女3例,年龄33~59岁,平均43岁;左侧颞部5例,右侧颞部2例;头皮缺损面积4.5 cm×5.5 cm~7.5 cm×9.5 cm;Ⅰ期行扩创VSD敷料覆盖,待伤口情况稳定后,行穿支血管超声定位,确保血管条件良好后,行ALTPF移植;将旋股外侧动脉降支与颞浅动脉行端侧吻合,将旋股外侧动脉降支伴行静脉与颞浅静脉行端端吻合。术后通过电话、微信及门诊复查相结合的方式随访,观察皮瓣外形、质地、供区情况,比较手术前、后患者神经系统的变化,并通过简易精神状态评价量表(MMSE)评估其认知功能,通过日常生活能力量表(ADL)评估其日常生活活动能力。结果本组7例皮瓣均顺利成活,1例术后6 h发生血管危象,进行手术探查后消除;7例患者均获随访,时间7~33(平均19)个月,皮瓣外观满意,质地柔软,颜色与受区无明显差异,大腿供区愈合良好,无明显瘢痕增生,采用徒手肌力检查(MMT),本组患者肢体肌力术前和术后均为平均4级,无改变;采用Ashworth评定量表,本组患者肢体肌张力术前和术后,平均1级,无改变;采用Berg平衡量表评估患者的平衡功能,术前和术后均为平均42分,无改变;本组患者术前、术后肢体感觉无改变;采用MMSE,本组患者术前和术后均为平均25分。采用改良Barthel指数评分标准,本组患者术前平均75分,术后平均79分,且患者的ADL均有不同程度改善。结论采用游离ALTPF修复烟雾病血运重建术后头皮缺损,可快速闭合创面,避免感染,修复后外观满意,对患者神经系统无影响。

Objective To investigate the clinical effect of free anterolateral thigh perforator flap(ALTPF)in reconstruction of temporal scalp defect after blood circulation reconstruction surgery for moyamoya disease.Methods From May 2020 to July 2022,7 patients with scalp defect after revascularisation of moyamoya disease were treated in Department of Hand and Foot Microsurgery,Henan Provincial People’s Hospital(People’s Hospital of Zhengzhou University).The patients were 4 males and 3 females,aged 33-59 years old,at 43 years old in average.There were 5 defects in left tempus and 2 in right tempus.The sizes of scalp defect were 4.5 cm×5.5 cm-7.5 cm×9.5 cm.Debridement and VSD management were primarily performed.After wounds were stabilised,ultrasound location of perforator vessels of ALTPFs was performed.Having confirmed that the perforator vessels were suitable for the surgical requirements,flap transfers were then performed.The descending branch of the lateral femoral circumflex artery was end-to-side anastomosed with the superficial temporal artery,and the descending branch of the lateral femoral circumflex vein was end-to-end anastomosed with the superficial temporal vein.Postoperative follow-up was conducted through outpatient clinic visits,telephone and WeChat reviews.Appearance,texture of ALTPFs and the flap donor sites were observed in follow-ups.Comparisons of the changes of nervous system before and after surgery were made.Cognitive function of the patients was assessed with the Mini Mental State Examination(MMSE),together with the Activities of Daily Living(ADL).Results All 7 flaps survived.One flap had vascular compromise 6 hours after surgery,and was rectified after surgical intervention.All the patients were included in the postoperative follow-up for 7-33(average 19)months.All flaps had good appearance with soft texture.There was no obvious difference in colour comparing with the skin around the recipient region.The donor sites healed well without hypertrophic scar.Examinations of nervous system of the patients were found the same as that before surgery.Using Manual Muscle Testing(MMT),the average limb muscle strength of the patients was 4 before surgery and 4 after surgery,without change;Using the Ashworth assessment scale,the average preoperative and postoperative limb muscle tension in this group of patients was 1,without change;The Berg balance scale was used to evaluate the patient's balance function,with an average score of 42 before surgery and 42 after surgery,without any changes;There was no change in limb sensation before and after surgery;Using the MMSE,the average preoperative score and postoperative score of this group of patients were 25 points,without any change.Using the modified Barthel index scoring standard,the average preoperative score for this group of patients was 75 points,and the average postoperative score was 79 points,and the ADL of the patient had improved to various levels.Conclusion Reconstruction of scalp defect with free ALTPF after revascularisation of moyamoya disease has obvious advantages,such as it closes the wound quickly,prevents infection and achieves a good appearance.This surgical procedure can produce a good clinical effect.