中国修复重建外科杂志

中国修复重建外科杂志

肋间后动脉穿支皮瓣修复背阔肌皮瓣供区创面

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目的 探讨应用背阔肌皮瓣修复肢体大面积复合组织缺损联合接力肋间后动脉穿支皮瓣修复供区创面的可行性及疗效。 方法 2016 年 1 月—2017 年 5 月,收治肢体大面积复合软组织缺损患者 9 例。男 8 例,女 1 例;年龄 21~56 岁,中位年龄 33 岁。交通事故伤 8 例,伤后至皮瓣修复时间为 1~3 周,平均 13 d;股内侧肌纤维肉瘤切除后缺损 1 例。缺损部位:上臂 5 例,大腿 4 例。创面缺损范围为 20 cm×12 cm~36 cm×27 cm。合并肱二头肌缺损 2 例,肱三头肌缺损 3 例,股二头肌缺损 2 例,股四头肌缺损 2 例;肱骨骨折 2 例;肱动脉破损 2 例,股动脉离断缺损合并腓总神经及胫神经离断缺损 1 例。采用背阔肌皮瓣修复创面及重建肌肉功能,皮瓣切取范围为 22 cm×13 cm~39 cm×28 cm,肌瓣范围为 12 cm×3 cm~18 cm×5 cm。重建上肢功能采用带蒂皮瓣修复,重建下肢功能采用游离皮瓣移植修复(胸背神经与受区神经肌支吻合)。供区采用大小为 10 cm×5 cm~17 cm×8 cm 的肋间后动脉穿支皮瓣修复。第 2 供区直接拉拢缝合。 结果 术后皮瓣均顺利成活,创面及供区切口均Ⅰ期愈合。患者均获随访,随访时间 10~19 个月,平均 13 个月。末次随访时,皮瓣外观、质地良好;5 例肌力恢复至 4 级,4 例恢复至 3 级;背阔肌皮瓣切取后肩关节活动度为 40~90°,平均 70°。背阔肌皮瓣两点辨别觉为 9~15 mm,平均 12.5 mm;肋间后动脉穿支皮瓣两点辨别觉为 8~10 mm,平均 9.2 mm。第 2 供区仅残留线状瘢痕。 结论 采用背阔肌皮瓣修复肢体大面积复合组织缺损联合接力肋间后动脉穿支皮瓣供区创面,在修复供、受区缺损同时重建肌肉功能,降低了供区并发症发生率。

Objective To investigate the feasibility and effectiveness of the latissimus dorsi myocutaneous flap in repair of large complex tissue defects of limb and the relaying posterior intercostal artery perforator flap in repair of donor defect after latissimus dorsi myocutaneous flap transfer. Methods Between January 2016 and May 2017, 9 patients with large complex tissue defects were treated. There were 8 males and 1 female with a median age of 33 years (range, 21-56 years). The injury caused by traffic accident in 8 cases, and the time from post-traumatic admission to flap repair was 1-3 weeks (mean, 13 days). The defect in 1 case was caused by the resection of medial vastus muscle fibrosarcoma. There were 5 cases of upper arm defects and 4 cases of thigh defects. The size of wounds ranged from 20 cm×12 cm to 36 cm×27 cm. There were biceps brachii defect in 2 cases, triceps brachii defect in 3 cases, biceps femoris defect in 2 cases, quadriceps femoris defect in 2 cases, humerus fracture in 2 cases, brachial artery injury in 2 cases, and arteria femoralis split defect combined with nervus peroneus communis and tibia nerve split defect in 1 case. The latissimus dorsi myocutaneous flaps were used to repair the wounds and reconstruct the muscle function. The size of the skin flaps ranged from 22 cm×13 cm to 39 cm×28 cm; the size of the muscle flaps ranged from 12 cm×3 cm to 18 cm×5 cm. The wounds were repaired with pedicle flaps and free flaps in upper limbs and lower limbs, respectively. The donor sites were repaired with posterior intercostal artery perforator flaps. The size of flaps ranged from 10 cm×5 cm to 17 cm×8 cm. The second donor sites were sutured directly. Results All the flaps survived smoothly and the wounds and donor sites healed by first intention. All patients were followed up 10-19 months (mean, 13 months). At last follow-up, the flaps had good appearances and textures. The muscle strength recovered to grade 4 in 5 cases and to grade 3 in 4 cases. After latissimus dorsi myocutaneous flap transfer, the range of motion of shoulder joint was 40-90°, with an average of 70°. The two-point discrimination of latissimus dorsi myocutaneous flap was 9-15 mm (mean, 12.5 mm), and that of posterior intercostal artery perforator flap was 8-10 mm (mean, 9.2 mm). There were only residual linear scars at the second donor sites. Conclusion The latissimus dorsi myocutaneous flap combined with posterior intercostal artery perforator flap for the large complex tissue defects and donor site can not only improve the appearance of donor and recipient sites, but also reconstruct muscle function, and reduce the incidence of donor complications.

关键词: 背阔肌皮瓣; 肋间后动脉穿支皮瓣; 接力皮瓣; 软组织缺损; 供区

Key words: Latissimus dorsi myocutaneous flap; posterior intercostal artery perforator flap; relaying flap; soft tissue defect; donor site

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