三维CT血管成像辅助设计下腹部皮瓣修复四肢大范围软组织缺损术后患者腹部功能恢复及满意度研究

The recovery of abdominal function and patients’satisfaction rate after the reconstruction of extensive soft tissue defects in limbs using lower abdominal flap based on three-dimensional computed tomography angiography

目的探讨三维CT血管成像(3D-CTA)辅助设计的下腹部皮瓣修复四肢大范围软组织缺损术后患者腹部功能恢复及满意度。方法回顾性分析2017年3月至2022年2月山东省立第三医院收治的四肢大范围皮肤软组织缺损患者的临床资料。患者被分为腹壁浅动脉(SIEA)组和腹壁下动脉穿支(DIEP)组,分别采用SIEA皮瓣、DIEP皮瓣进行组织缺损修复。根据3D-CTA检查明确双侧SIEA、腹壁浅静脉(SIEV)、DIEP的分布范围、血管管径,设计并切取SIEA皮瓣、DIEP皮瓣。比较术前3D-CTA检查显示的SIEA、SIEV走行分布情况与术中实际解剖情况是否一致,比较术前3D-CTA检查和术中实际测量的SIEA、SIEV的管径、血管蒂长度是否一致。观察术后皮瓣成活情况、伤口愈合情况,调查患者对创面修复情况是否满意。采用自制评估量表于术后1年评价腹部外形,总分5~25分,分数越高表示效果越佳;分别于术前、术后3个月、术后1年采用BREAST-Q量表中的腹部健康模块进行患者腹部功能满意程度评价,总分20~100分,分数越高表示满意度越高。符合正态分布的计量资料数据以±s表示,2组间比较采用独立样本t检验;腹部功能满意度评分比较时,2组间多个时间点总体比较行重复测量方差分析,组内术后3个月、1年和术前的评分比较行配对t检验。结果共纳入21例患者,男3例,女18例,年龄21~60岁,平均41岁。皮肤软组织缺损范围10.0 cm×5.0 cm~22.0 cm×14.0 cm,皮瓣切取范围11.0 cm×6.0 cm~23.0 cm×15.0 cm。SIEA组11例,DIEP组10例。术前3D-CTA检查显示的SIEA、SIEV走行分布情况与术中实际解剖观察相符;术前3D-CTA检查测量的SIEA、SIEV的管径、血管蒂长度和术中实际测量值比较,差异无统计学意义(P均>0.05)。术后所有皮瓣均无坏死出现,伤口愈合良好,患者对创面修复情况均表示满意。术后1年,SIEA组和DIEP组的腹部外形评分比较,差异无统计学意义[(21.96±3.51)分vs.(21.62±3.17)分,P>0.05]。SIEA组和DIEP组术前腹部功能满意度评分比较,差异无统计学意义[(87.56±5.70)分vs.(85.79±6.33)分,P>0.05];术后3个月和1年时,SIEA组得分均高于DIEP组[术后3个月,(77.62±7.68)分vs.(65.21±8.27)分;术后1年,(86.93±5.65)分vs.(77.59±5.92)分;P均<0.01],提示SIEA组术后的腹部功能满意度更高;SIEA组和DIEP组术后3个月得分均低于术前(P均<0.01);术后1年时,SIEA组得分与术前接近,差异无统计学意义(P>0.05),而DIEP组得分仍低于术前(P<0.01)。结论以SIEA皮瓣修复四肢大范围皮肤软组织缺损,不伤及腹壁深层组织,腹部功能及外形可基本恢复至术前水平,对供区影响小;术前3D-CTA辅助皮瓣设计能够弥补SIEA皮瓣供血血管在个体间解剖变异大的不足,达到和其他下腹部皮瓣一样的创面修复效果。

Objective To explore the recovery of abdominal function and and satisfaction rate in patients who received lower abdominal skin flap repair of extensive soft tissue defects in the limbs based on three-dimensional computed tomography angiography(3D-CTA)technology.Methods A retrospective study was performed to analyze clinical data from patients with extensive skin and soft tissue defects in the limbs,who were admitted to Shandong Provincial Third Hospital between March 2017 and February 2022.Patients were categorized into two groups:the superficial inferior epigastric artery(SIEA)group and the deep inferior epigastric perforator(DIEP)group,with SIEA flaps and DIEP flaps utilized respectively for tissue defect repair.Based on 3D-CTA imaging,the distribution range and vessel diameters of bilateral SIEA,superficial inferior epigastric veins(SIEV),and DIEP were delineated,facilitating the design and harvest of SIEA and DIEP flaps.Comparisons were drawn between preoperative 3D-CTA findings on the course and distribution of SIEA and SIEV,and intraoperative anatomical observations.In addition,the concordance between vessel diameters and pedicle lengths determined via preoperative 3D-CTA and intraoperative measurements was assessed.The flap survival,wound healing and surveyed patients’satisfaction with wound repair were analyzed.A customized evaluation scale was utilized to assess abdominal contour one year post-surgery,scoring from 5 to 25,with higher scores indicating better outcomes.The abdominal health module of the BREAST-Q scale evaluated patients’satisfaction with abdominal function preoperatively,three months postoperatively,and one year postoperatively,scoring from 20 to 100,with increasing scores indicating greater satisfaction.The measurement data that conform to the normal distribution were expressed as Mean±SD,and the comparison between the two groups was performed using independent samples t-test.The comparison were conducted at multiple time points,repeated measures analysis of variance was performed,and for the comparison of scores within the group,paired t-test was applied.Results A total of 21 patients were included,3 males and 18 females,with an age range of 21 to 60 years and a mean age of 41 years.The range of skin and soft tissue defects was from 10.0 cm×5.0 cm to 22.0 cm×14.0 cm,and the range of skin flap harvesting was from 11.0 cm×6.0 cm to 23.0 cm×15.0 cm.There were 11 cases in the SIEA group and 10 cases in the DIEP group.Preoperative 3D-CTA examination showed that the course and distribution of SIEA and SIEV were consistent with intraoperative anatomical observations.There was no statistically significant difference in the comparison of vessel diameters,pedicle lengths,and actual measurements between preoperative 3D-CTA examination and intraoperative measurements(all P>0.05).No flap necrosis occurred postoperatively,wound healing was uneventful in all cases.At 1 year postoperatively,there was no statistically significant difference in abdominal contour scores between the SIEA and DIEP groups[(21.96±3.51)points vs.(21.62±3.17)points,P>0.05].Comparison of preoperative abdominal function satisfaction scores between the SIEA and DIEP groups showed no statistically significant difference[(87.56±5.70)points vs.(85.79±6.33)points,P>0.05].However,at 3 months and 1 year postoperatively,the SIEA group had higher scores than the DIEP group[at 3 months postoperatively,(77.62±7.68)points vs.(65.21±8.27)points;at 1 year postoperatively,(86.93±5.65)points vs.(77.59±5.92)points;both P<0.01],indicating higher abdominal function satisfaction of the SIEA group postoperatively.The scores of both the SIEA and DIEP groups decreased at 3 months postoperatively compared to preoperative scores(both P<0.01).At 1 year postoperatively,the score of the SIEA group was similar to preoperative levels,with no statistically significant difference(P>0.05),while the score of the DIEP group remained lower than preoperative levels(P<0.01).Conclusion Reconstruction of extensive skin and soft tissue defects in the limbs using SIEA flaps,without injury to the deep tissues of the abdominal wall,allows for near-complete restoration of abdominal function and appearance to preoperative levels,with minimal impact on the donor site.Preoperative 3D-CTA reveals the anatomical variations in the vascular supply of SIEA flaps among individuals,achieving comparable wound repair outcomes to other lower abdominal flaps.