骶尾部褥疮显微外科修复方法的总结与改进

目的总结应用显微外科技术修复骶尾部褥疮及改进手术方法的临床效果。方法采用随意旋转皮瓣、臀大肌皮瓣及设计以臀骶或腰部动脉皮穿支为蒂的穿支蒂皮瓣修复骶尾部褥疮35例。结果30例皮瓣包括所有穿支蒂皮瓣全部成活,伤口Ⅰ期愈合,5例出现边缘坏死、伤口感染等并发症。褥疮面积最大12 cm×11 cm,最小6cm×5 cm。随访6个月~3年,皮瓣质地优良,外形满意,2例褥疮复发。结论应用显微外科技术修复骶尾部褥疮可取得满意的效果。穿支蒂皮瓣设计灵活,切取方便,血供可靠,是一种较好的修复方法。     

双侧反向臀上动脉远侧穿支V-Y推进筋膜皮瓣修复骶部巨大褥疮

目的:笔者设计了一种双侧反向臀上动脉远侧穿支V-Y推进筋膜皮瓣,关闭巨大骶部溃疡,以增加皮瓣推进量,避免臀大肌功能性缺损。方法:清创后V-Y推进皮瓣标记于双侧臀部。在缺损近侧掀起筋膜皮瓣,在远侧臀大肌肌肉附件里保留臀上动脉远侧穿支,直至获得足够的皮瓣前移。结果:用此方法治疗15个直径7～15cm的骶部褥疮的患者,没有出现皮瓣坏死和溃疡复发,91%的皮瓣Ⅰ期愈合。结论:此技术使皮瓣推进量增加,皮瓣存活可靠,并保留了双侧臀部和臀大肌功能。     

应用多层次滑移单侧臀大肌推进肌皮瓣修复骶部褥疮

脊柱骨折并截瘫及长期卧床患者,因护理不当极易发生骶尾部褥疮,随着显微外科技术的应用,手术治疗骶尾的褥疮已成为首选,单侧或双侧臀大肌推进肌皮瓣,因供区可直接缝合,手术较为简便,临床上得到广泛应用,并有大量报道。本文介绍一种改良的单侧臀大肌推进肌皮瓣,其推进幅度大,修复面积广,临床应用取得满意疗效。 临床资料 本组共5例,均为男性,年龄17～52岁。其中脊柱骨折并截瘫3例,全身多发骨折1例,有机磷中毒昏迷史1例。病程3～5个月,褥疮面积4cm×6cm～9cm×10cm,均有不同程度的骶骨外露。 1.皮瓣设计:与传统的V-Y臀大肌推进肌皮瓣一样,在褥疮的一侧设计一个三角形皮瓣,三角的底边为褥疮边缘,首先用Doppler测定肌皮动脉穿支,并在皮肤表面标出,皮瓣内应包含至少一到两支动脉,皮瓣的脊柱缘宽应不小于褥疮的宽度。与传统的V-Y推进皮瓣不同的是,V型切口做成锯齿状切口,每侧约3～4个锯齿即可,两侧对称。 2皮瓣切取:皮瓣切取前应彻底切除炎性糜烂的褥疮皮缘,清理炎性肉芽组织,对于骶骨外露者,将骶骨表层骨质凿除,再以碘伏液浸泡创面5分钟。沿设计     

介绍一种治疗骶部褥疮的新方法

骶尾部是最容易发生褥疮的部位,而臀部皮瓣是治疗该部位最常用的皮瓣供区,由于褥疮局部血循较差,或缝合后切口张力较大,采用常规的局部切除或局部皮瓣转移方法治疗,失败率较高[1-2]。自2005年2月以来,应用Ichioka等[3]介绍的远侧穿支为血供的V-Y前移皮瓣方法治疗,取得满意效果,现介绍如下。1手术方法褥疮用美蓝染色,标记需切除的范围,行褥疮清创术,切除周边瘢痕,包括滑囊与骨性突起,设计V-Y前移皮瓣,底边的宽度与褥疮直径相当,三角尖部接近大粗隆。先切开V形上下缘至深筋膜下平面,在切口内侧(骶旁区)从肌肉与筋膜之间向外侧分离皮瓣,向外…     

难治性褥疮的综合治疗

目的总结难治性褥疮的临床治疗经验。方法1998年5月~2005年3月,收治22例29处褥疮患者,年龄36~92岁。褥疮范围4cm×2cm~18cm×15cm。骶尾部18处,坐骨结节部6处,股骨大转子部5处。口服肠内营养素,创口采用五黄一号药纱布贴敷包扎8~15d后手术。其中3例合并糖尿病术前采用胰岛素控制血糖。根据患者年龄、褥疮部位、范围及深度等选择皮瓣类型。采用局部皮瓣修复3处,皮瓣范围6cm×4cm~12cm×10cm;筋膜皮瓣修复10处,皮瓣范围10cm×7cm~20cm×17cm;臀大肌皮瓣修复9处,皮瓣范围13cm×11m~17cm×14cm;股二头肌长头肌皮瓣修复6处,皮瓣范围11cm×6cm~14cm×7cm;直接缝合修复1处。术后睡气流悬浮床7~14d。结果22例29处褥疮,术前加强营养支持,创口用五黄一号换药,治疗8~15d,血红蛋白超过100g/L,白蛋白超过30g/L,褥疮部位坏死组织脱净,肉芽组织红润,创面分泌物减少,创周无红肿,全身营养状况明显改善。术后皮瓣均成活,切口期愈合。获随访6个月~5年,原手术部位无褥疮复发,皮瓣质地柔软,外形满意。结论应用综合方法治疗难治性褥疮效果显著,手术成功率高。     

穿支蒂皮瓣修复臀骶部软组织缺损

目的探讨应用穿支蒂皮瓣修复臀骶部软组织缺损的手术方法及临床效果。方法1998年以来临床应用8例,其中男5例,女3例。年龄15～79岁。根据缺损部位及大小设计以臀部、骶旁或腰动脉的皮穿支为血管蒂的轴型穿支蒂皮瓣移位修复臀骶部褥疮、溃疡及外伤性软组织缺损创面。切取皮瓣达6cm×5cm～19cm×11cm,穿支血管口径1.3～2.1mm,游离穿支血管蒂长度为2.5～4.5cm。结果皮瓣全部成活,伤口期愈合。随访6～24个月,皮瓣质地优良,外形满意,溃疡无复发。结论穿支蒂皮瓣设计灵活,切取方便,血供可靠,不损伤臀部肌肉,供区无需植皮,是修复臀骶部软组织缺损创面的理想方法。     

蝴蝶形皮瓣修复骶部大面积褥疮

目的报告蝴蝶形皮瓣修复骶部大面积褥疮的临床结果。方法自2006年3月至2010年10月间,应用这种技术修复6例(男5例,女1例)骶部大面积褥疮。年龄22~58岁,平均38岁。其中完全性脊髓损伤3例,烫伤2例,脑梗塞1例。均为骶部Ⅳ度褥疮,深度达骨面。创面大小:12cm×14cm~13cm×18cm。每侧皮瓣均以第4腰动脉穿支为蒂,皮瓣轴斜向髂前上棘,皮瓣的外形类似一只蝴蝶。供区缺损一期缝合。结果 1例术后发生表浅感染,经更换敷料逐渐愈合。所有患者经26~52个月随访(平均38个月),皮瓣全部成活。所有缺损均修复成功,没有发生伤口血肿与裂开。骶部褥疮没有复发,取得了较满意的效果。结论蝴蝶形皮瓣技术是修复骶部褥疮较好的治疗方法,当病例选择适当时,并发症少,成功率高。     

改良足外侧皮瓣修复足跟后侧区皮肤软组织缺损

目的 报道一种V-Y推进轴型皮瓣修复足跟后侧区皮肤软组织缺损。方法 将足外侧皮瓣设计成梭形或三角形，带蒂向后、内侧推进覆盖创面，供区直缝合。结果 临床应用7例，皮瓣均完全成活，供区伤口Ⅰ期愈合。结论 V-Y推进足外侧皮瓣既保留了传统足外侧皮瓣的优点，又简化了手术操作，减少了术后供区并发症，是足跟后侧区创面修复的一种较为理想手段。     

桡动脉远侧穿支筋膜蒂皮瓣的临床应用

目的:总结桡动脉远侧穿支筋膜蒂皮瓣修复手腕部软组织缺损的疗效。方法:对15例手腕部软组织缺损病例,采用桡动脉远侧穿支筋膜蒂皮瓣进行修复,皮瓣最大面积12cm×7cm,最小面积7.5cm×3.5cm,平均10cm×5.5cm,结果:15例皮瓣完全成活,随访2个月～1年,皮瓣质地良好,外观功能满意。结论:桡动脉远侧穿支筋膜蒂皮瓣切取方便,血供丰富,为一种修复手腕部软组织缺损的简单、安全、可靠的方法。     

保留部分皮蒂的小腿穿支皮瓣V-Y推进修复足跟部皮肤缺损

目的探讨保留部分皮蒂的小腿穿支皮瓣V-Y推进修复足跟部皮肤缺损的临床效果。方法 2011年3月至2014年3月,应用保留部分皮蒂的小腿穿支皮瓣V-Y推进修复足跟部皮肤缺损≤4.0cm创面6例,创面范围为4.5cm×2.5cm~7.0cm×4.0cm,平均缺损面积5.5cm×3.3cm,皮瓣面积最小12.0cm×5.0cm,最大23.0cm×8.0cm,平均17.0cm×6.5cm。结果本组6例皮瓣全部成活,创面Ⅰ期愈合,V形皮瓣转移后切口Y形直接缝合,切口均愈合良好。随访时间6~12个月,皮瓣血运良好,外形无臃肿,质地与周围组织接近,供瓣区外形无影响,踝关节活动无障碍,足跟部皮瓣耐压良好,均未出现溃疡。结论保留部分皮蒂的小腿穿支皮瓣V-Y推进修复足跟部皮肤缺损,对供区影响小,皮瓣外形美观,值得临床推广。     

Interdigitating fasciocutaneous gluteal V-Y advancement flaps for reconstruction of sacral defects

The authors describe a modification of the classic gluteal bilateral V-Y advancement flap for sacral defect closure. After initial debridement, the V-Y design is marked on both sides of the defect. The incision is carried down to the fascia of the underlying gluteus maximus muscle. The upper and lower arms of the flaps are elevated and advanced on the gluteal muscle toward the midline, interdigitating each opposing arm. The overall result is a zigzag, broken midline suture. This procedure was carried out in 14 patients with sacral pressure sores and in 1 patient with a chronic pilonidal sinus. All flaps survived without major problems. There were no recurrences during the 6 to 16 months of follow-up. The interdigitating fasciocutaneous V-Y gluteal flap design is effective in breaking the midline vertical scar and preserving the gluteus maximus muscle.     

Perforator propeller flaps for sacral and ischial soft tissue reconstruction

The perforator-based flaps in the sacral and ischial region is designed according to the localization of perforators that penetrate the gluteus maximus muscle, reach the intra-fascial and supra-fascial planes with the overlying skin forming a rich vascular plexus. The perforator-based flaps described in this article are highly vascularized, have minimal donor site morbidity, and do not require the sacrifice of the gluteus maximus muscle. In a period between April 2008 and March 2009, six patients with sacral pressure sore were reconstructed with propeller flap method based on superior gluteal and parasacral artery perforators. One flap loss was noted. Three cases of ischial pressure sore were reconstructed with longitudinal propeller flap cover, based on inferior gluteal artery perforator. One flap suffered wound infection and dehiscence. Two cases of pilonidal sinus were reconstructed with propeller flap based on parasacral perforators. Both the flaps survived without any complications. Donor sites were closed primarily. In the light of this, they can be considered among the first surgical choices to re-surface soft tissue defects of the sacral and ischial regions. In the series of 11 patients, two patients (18%) suffered complications.     

The gluteal perforator-based flap in repair of pressure sores.

The gluteal perforator-based flap is designed according to the localisation of sacral perforator vessels. These vessels penetrate the gluteus maximus muscle and reach the intrafascial and suprafascial planes, and the overlying skin forming a rich vascular plexus. The gluteal perforator-based flaps described in this paper are highly-vascularised, have minimal donor site morbidity, do not require the sacrifice of the gluteus maximus muscle and rarely lead to post-operative complications. We believe these easy-to-perform flaps might be considered as the first choice in the repair of gluteal pressure sores.     

Bilateral gluteus maximus myocutaneous advancement flaps: sacral coverage for ambulatory patients

The standard gluteus maximus myocutaneous flap, though an excellent procedure for coverage of sacral soft-tissue defects, has several disadvantages. It is usually quite bulky, and risks hip instability in the ambulatory patient. Bilateral gluteus maximus myocutaneous advancement flaps obviate these problems. The superior half of each gluteus maximus muscle, with overlying skin island, is released from its origin and insertion. The superior gluteal artery is identified and preserved. Each myocutaneous unit may be advanced to the midline. The line of cleavage between units preserves normal contour. Donor-site deformity is closed in the V-Y advancement fashion. Hip instability is thus avoided. This technique is useful in the management of sacral defects in the ambulatory patient.     

Reconstruction of an extensive vulvectomy defect using the gluteus maximus fasciocutaneous V-Y advancement flap

Effective management of a vulvar wound resulting from oncological ablative surgery poses a formidable task for the reconstructive surgeon. During the past two decades, numerous procedures have been described in an effort to provide stable, sensate coverage that minimizes deformity and preserves function, often in the setting of concomitant radiation. At the authors' institution, a fasciocutaneous V-Y advancement flap based on the gluteus maximus has been adopted as a common approach to this problem. They present their institutional experience with this procedure. A 10-year chart review (1991-2001) yielded a series of 20 vulvectomy patients, all of whom were reconstructed by the same surgeon using ischial fasciocutaneous V-Y flaps based on perforators from the inferior border of the gluteus maximus muscle. Patients underwent vulvectomy for recurrent or advance-stage vulvar cancer, or extensive carcinoma in situ. Squamous cell carcinoma was the most common pathology (N = 13). Fifteen patients had bilateral V-Y flaps; the remainder had unilateral procedures. Six patients underwent prior radiation therapy. Two patients had delayed reconstruction for vaginal stenosis. Flap survival was 100%. There were no major complications, early or late. Minor complications were limited to localized areas of delayed healing, all of which responded to conservative measures. Functional outcome was excellent in all patients. At an average follow-up of 44 months, there were five episodes of recurrent disease necessitating surgical intervention. Based on this series, the gluteus maximus V-Y advancement flap provides a straightforward and reliable method to recruit local tissue for stable coverage of these often difficult-to-manage wounds.     

Gluteus maximus myocutaneous flap in the repair of sacral and gluteal decubitus ulcers]

16 cases of decubitus ulcers in the sacral, ischiadic and great trochanter regions were treated with rotating myocutaneous flap of the caudal portion of the gluteus maximus from 1983 to 1989. They were followed up for 3 to 68 months, with the exception of 4 patients. The results were excellent. 30 gluteus regions were studied in 15 cadavers. It was found that the caudal 3/4 of the gluteus maximus muscle was supplied by the inferior gluteal artery, and a flap measuring 12.9 x 9.7 cm could be formed therein with easy dissection. The flap tolerates pressure well. Unilateral flap is adequate to cover a decubitus ulcer within a diameter of 10cm, while bilateral flaps are necessary for a larger ulcer.     

修复严重放射性溃疡的临床研究

【摘要】〓目的〓使用皮瓣或肌皮瓣对严重放射性溃疡进行修复的临床经验。方法〓对我科在2010年1月至2012年1月,采用各种皮瓣或肌皮瓣方法修复治疗的22例放射溃疡患者病例进行回顾性分析,其中使用背阔肌皮瓣4例,侧腹壁皮瓣3例,脐旁皮瓣3例,股前外侧皮瓣4例,胸大肌皮瓣6例,臀大肌皮瓣2例。 结果〓22例患者中有2例出现了皮瓣远端局部坏死,经换药治疗后创面闭合。其他20例皮瓣全部成活,伤口一期愈合。经1~2年随访,15例患者皮瓣外观良好,质地柔软,临床溃疡无复发。结论〓临床采用皮瓣或者肌皮瓣治疗严重放射性溃疡,能够获得良好治疗效果,并能有效预防溃疡复发,值得推广。     

穿通支皮瓣修复臀骶部褥疮的临床疗效

目的观察及评价采用穿通支皮瓣修复臀骶部褥疮的临床疗效。方法对26例臀骶部褥疮患者，按照缺损创面的位置和大小分类设计臀部、骶部穿通支岛状皮瓣或穿通支推进皮瓣进行修复。所切取皮瓣最大面积达20cm×15cm，穿通支外径在1．1mm以上，游离穿通支血管蒂长度为2．0～3．5cm。结果患者行皮瓣移植术后无皮瓣坏死、创面感染、瘘管形成等术后并发症，创面愈合较快。出院后随访患者6～24个月，皮瓣质地柔软，外形满意，局部褥疮未复发。结论穿通支皮瓣设计灵活、切取方便、血供可靠、不损伤臀部肌肉，供区大部分能直接缝合，是修复臀骶部褥疮的良好办法。     

The gluteus maximus muscle flap for reconstruction of sacral chordoma defects

Four patients diagnosed with sacral chordoma underwent reconstruction with the gluteus maximus flap using an approach based on available muscle remnants and their residual blood supply. The entire unilateral gluteus maximus muscle was turned over to fill the defect in 2 patients. The flap was based on 1 or 2 gluteal vessels, depending on vessel availability following tumor resection. When all 4 major pedicles had been ligated, bilateral advancement gluteal muscle flaps based on their distal blood supply were used (patient 3). A longitudinally split flap was used for secondary reconstruction of a partially obliterated defect (patient 4). Over a mean follow-up period of 8 months, there was no wound breakdown and all patients were ambulant.