多种形式显微修薄穿支皮瓣在四肢创面修复中的应用

Therapeutic efficiency of multiple forms of microdissected perforator flaps in the reconstruction of limb defect

目的探讨多种形式显微修薄穿支皮瓣在四肢创面修复中的应用效果。方法回顾性分析2020年6月至2022年6月徐州仁慈医院手外科收治的采用显微修薄穿支皮瓣修复手足、四肢、腘窝等创面的患者资料。所有患者术前均行CT血管造影和彩色多普勒超声定位穿支血管,设计供区皮瓣,按照设计线逆行切取皮瓣,确认血运良好后显微镜下修薄皮瓣,血管蒂周围采用"虫蚀"技术掏剪脂肪颗粒,转移至受区,完成血管吻合,放置引流管。供区创面直接拉拢缝合。术后密切观察皮瓣血运情况。通过门诊、上门、微信等方式定期随访,记录感觉恢复情况及并发症。采用疗效满意度评分表对患者术后创面愈合、皮瓣形态、皮瓣感觉、皮瓣温度及供区瘢痕5个方面进行评价,分为优(2分)、良(1分)、可(0分)、差(-1分)4个等级,总分5~10分为满意,0~4分为一般,-1~-5分为不满意。结果共纳入16例患者,其中男8例,女8例;年龄26~65岁,平均45.9岁;上肢软组织缺损2例,手脱套伤2例,手部皮肤软组织缺损11例,腘窝软组织缺损1例;创面面积为3.0 cm×4.5 cm~13.0 cm×30.0 cm;采用游离腓肠内侧动脉穿支皮瓣修复4例,骨间背动脉穿支皮瓣修复1例,股前外侧穿支皮瓣修复6例,胸脐皮瓣修复1例,股前外侧穿支皮瓣联合旋髂浅动脉穿支皮瓣修复1例,旋髂浅动脉穿支皮瓣修复3例;切取皮瓣面积为3.5 cm×5.0 cm~9.5 cm×30.0 cm。术后15例皮瓣均顺利成活,1例术后1 d发生静脉危象,经探查重新吻接血管后成活,供受区伤口均一期愈合,无伤口感染、延迟愈合等并发症。随访7~18个月,平均12.1个月,皮瓣成活良好,无色素沉着、外观臃肿,无患者要求行二期修薄治疗。皮瓣感觉恢复轻触觉1例,恢复保护性感觉9例,仅恢复深触觉6例;随访中未见后期皮瓣明显增厚,1例患者出现皮瓣磨损。供区仅遗留线性瘢痕,外观及功能无明显异常。疗效满意度评价显示,患者均对治疗效果表示满意,评分6~9分,平均7.8分。结论显微修薄穿支皮瓣技术为美观且功能要求高的区域修复提供了一次性手术解决方案,可获得满意的临床效果。

Objective To investigate the therapeutic efficiency of multiple forms of microdissected perforator flaps in the reconstruction of limb defect.Methods The data of patients treated in the Department of Hand Surgery of Xuzhou Renci Hospital from June 2020 to June 2022 for repairing wound of hands,feet,limbs and popliteal fosses with microdissected perforator flap were retrospectively analyzed.CT angiography and color Doppler ultrasound were performed in all patients before surgery to locate perforator vessels,design the donor flap,and cut the flap retrograde according to the design line.After confirming good blood supple,the flap was harvested under the microscope,and fat particles were cut around the vascular pedicle by"insect eating"technique.After that,the flap was transferred to the recipient area,completed the vascular anastomosis,and placed the drainage tube.The donor site was closed directly.The blood circulation of the flap was observed closely after operation.Regular follow-up visits were conducted in outpatient clinics,door-to-door visits and WeChat to record sensory recovery and complications.Postoperative wound healing,flap shape,flap sensation,flap temperature and scar in donor area were evaluated using the efficacy satisfaction scale,which was divided into four grades:excellent(2 points),good(1 point),fair(0 point)and poor(-1 point).The total score of 5-10 was satisfactory,0-4 was average,and-1--5 was unsatisfactory.Results A total of 16 patients were included,including 8 males and 8 females.The age ranged from 26 to 65 years,with an average age of 45.9 years.There were 2 cases of upper limb soft tissue defect,2 cases of hand degloving injury,11 cases of hand skin soft tissue defect,and 1 case of popliteal soft tissue defect.The wound size ranged from 3.0 cm×4.5 cm to 13.0 cm×30.0 cm.Free medial sural artery perforator flap was used in 4 cases,interosseous dorsal artery perforator flap in 1 case,anterolateral femoral perforator flap in 6 cases,thoracic umbilical flap in 1 case,anterolateral femoral perforator flap combined with superficial circumflex iliac artery perforator flap in 1 case,and superficial circumflex iliac artery perforator flap in 3 cases.The size of the skin flap was 3.5 cm×5.0 cm-9.5 cm×30.0 cm.After operation,15 cases of flaps successfully survived,1 case of venous crisis occurred 1 day after operation,and successfully survived after exploration and re-anastomosis of blood vessels.The wounds in the donor area healed in one stage without wound infection,delayed healing and other complications.All patients were follow-up for 7 to 18 months(mean 12.1 months),the skin flap survived well,no pigmentation,bloated appearance,and no patients requested secondary thinning treatment.The skin flap sensation recovered light touch in 1 case,protective sense in 9 cases and deep touch only in 6 cases.No significant thickening of skin flap was observed in the later period of follow-up,and skin flap wear was observed in 1 patient.There were only linear scars left in the donor area,and there were no obvious abnormalities in appearance and function.Efficacy satisfaction evaluation showed that all patients were satisfied with the therapeutic effect,scoring 6-9 points,with an average of 7.8 points.Conclusion Microdissected perforator flap technique provides a one-stage surgical solution for aesthetic and functional areas with high requirements,and satisfactory clinical efficiencies can be obtained.