精准定位的微型股前外侧穿支皮瓣修复手指中等面积皮肤软组织缺损的效果

Effect of accurately localized mini anterolateral thigh perforator flap in repairing medium-sized skin and soft tissue defects in fingers

目的探讨采用精准定位的微型股前外侧穿支皮瓣修复手指中等面积皮肤软组织缺损的效果。方法该研究为回顾性观察性研究。2019年12月—2022年9月,温州医科大学附属第二医院收治15例符合入选标准的手指中等面积皮肤软组织缺损的患者,其中男12例、女3例,年龄23~62岁。清创后,创面均伴肌腱、骨、血管、神经外露,创面面积为4.0 cm×3.0 cm~8.0 cm×3.5 cm。术前对患者双下肢行CT血管造影和彩色多普勒超声检查精准定位股前外侧穿支情况。切取皮瓣(面积为6.0 cm×3.0 cm~11.0 cm×4.0 cm)时,对皮瓣进行削薄处理。将皮瓣的动静脉穿支分别与指动脉及掌背静脉吻合,如受区存在撕脱伤、感染或烧伤,则将皮瓣携带的主干动静脉血管与桡动脉及其伴行静脉进行吻合;将皮瓣携带的股外侧皮神经与指神经的残端吻合。术中观察患者皮瓣内旋股外侧动脉穿支类型,并与术前血管定位情况进行比对。术后,密切观察皮瓣成活情况及不良反应。随访时,观察皮瓣色泽、质地及外形,观察供区创面愈合情况。末次随访时,测量患指指腹两点辨别觉距离,采用中华医学会手外科学会上肢部分功能评定试用标准对患指的功能进行评价,观察患指关节活动情况;记录患者主诉皮瓣切取对下肢造成不良影响的情况。结果术中观察到11例患者皮瓣的穿支为旋股外侧动脉降支、2例患者皮瓣的穿支为旋股外侧动脉斜支、2例患者皮瓣的穿支为旋股外侧动脉横支,均与术前血管定位情况相符。术后,皮瓣均顺利成活且未发生血管危象和感染。术后随访6~12个月,皮瓣色泽、质地优良且外形佳,供区创面仅遗留线性瘢痕。末次随访时,患指指腹两点辨别觉距离为7~11 mm,患指功能评定为优者6例、良者6例、可者3例,患指关节屈伸功能均未受影响;2例患者主诉切取皮瓣后大腿外侧有麻木感,13例患者主诉皮瓣切取对下肢无不良影响。结论利用CT血管造影和彩色多普勒超声检查可精准定位股前外侧区穿支,术前精准定位穿支情况可减轻术中切取皮瓣时对供区的损伤,对移植皮瓣进行削薄处理并重建手指感觉可最大限度地恢复患指外形和功能,因此采用微型股前外侧穿支皮瓣修复手指中等面积皮肤软组织缺损,是一种有效且可靠的治疗方式。

Objective To explore the effect of accurately localized mini anterolateral thigh perforator flap in repairing medium-sized skin and soft tissue defects in fingers.Methods The study was a retrospective observational study.From December 2019 to September 2022,15 patients with medium-sized skin and soft tissue defects who met the inclusion criteria in fingers were admitted to the Second Affiliated Hospital of Wenzhou Medical University,including 12 males and 3 females,aged 23 to 62 years.After debridement,the wounds were all accompanied by exposed tendons,bones,vessels and nerves,with an area from 4.0 cm×3.0 cm to 8.0 cm×3.5 cm.Computed tomography angiography and color Doppler ultrasonography examinations were performed on both lower limbs of the patient before surgery to accurately locate the anterolateral thigh perforators.When the flap with area from 6.0 cm×3.0 cm to 11.0 cm×4.0 cm was harvested,the flap was thinned.The artery and vein perforators of the flap were anastomosed respectively with the digital artery and dorsal metacarpal vein.If there was avulsion injury,infection,or burn in the recipient area,the main arterial and veinous vessels carried by the skin flap was anastomosed with the radial artery and accompanying vein.The lateral thigh cutaneous nerve carried by the flap was anastomosed with the stump of the digital nerve.The types of perforators of the lateral thigh artery were observed during operation and compared with the location of the vessels before operation.After operation,the survival and adverse complication of the flap were closely observed.During follow-up,the skin flap color,texture,and shape were observed;the wound healing in donor area was observed.At the last follow-up,the two-point discriminative distance of the affected finger pulp was measured,and the function of the affected finger was evaluated using the trial standard for the evaluation of functions of upper limbs of Hand Surgery Society of Chinese Medical Association,and the interphalangeal joint movement of the affected finger was observed;the patients'complaints about the adverse effects of flap resection on lower limbs were recorded.Results During the operation,it was observed that the perforators of the flaps in 11 patients were the descending branch of the lateral circumflex thigh artery,in two patients,the perforators of skin flaps were the oblique branch of the lateral thigh artery,and the perforators in another two patients were the transverse branch of the lateral circumflex thigh artery,which were consistent with the preoperative vascular localization.After operation,all flaps survived without vascular crisis and infection.The patients were followed up for 6-12 months,the flaps had excellent color,texture,and appearance;only linear scars remained on the donor wound.At the last follow-up,the two-point discrimination distance in the finger pulp was 7-11 mm;the affected finger function was rated as excellent in 6 cases,good in 6 cases,and fair in 3 cases;the flexion and extension function of the finger was not affected;two patients complained of numbness in the lateral thigh after excision of the skin flap,and the other 13 patients had no complain of adverse complaints.Conclusions The perforating branch in lateral thigh region can be accurately located by computed tomography angiography and color Doppler ultrasonography,accurate positioning of perforators before operation can reduce the damage to the donor area during the incision of the flap,the appearance and function of the affected finger can be restored to the maximum extent by thinning the transplanted flap and rebuilding the finger sensation.Therefore,it is an effective and reliable way to repair the medium-sized skin and soft tissue defects of fingers with the mini thigh anterolateral perforator flap.