大面积皮肤软组织缺损伴严重感染创面的修复

目的探讨大面积皮肤软组织缺损感染创面的修复方法。方法对15例大面积皮肤软组织缺损伴创面严重感染的患者,经积极换药后均行两次清创手术,首先采用异体皮片移植暂时覆盖创面,再行自体皮肤移植或皮瓣转移修复创面。结果术后经6个月至4年的随访,自体的皮肤和皮瓣移植后均完全成活,创面修复良好。患者平均住院时间38d。结论两次彻底清创和异体皮片移植暂时覆盖创面是修复大面积皮肤软组织缺损严重感染创面的有效方法,值得推广应用。     

难治性感染缺损创面的整形外科修复

目的探讨各种难治性感染缺损创面的治疗方法。方法21例各种难治性感染缺损创面的患者,经全身支持治疗、积极换药后分别行两次清创手术,通过异体皮移植暂时覆盖创面,后再行自体皮肤移植或皮瓣转移最终修复创面。结果移植皮肤和皮瓣均完全愈合,创面得到有效修复,平均住院时间42d。结论通过异体皮移植暂时覆盖创面结合两次彻底清创手术,再综合应用整形外科的各项技术进行难治性感染缺损创面修复的方法,可行有效,值得推广。     

膝部严重烧创伤后皮肤软组织缺损的系统治疗

目的 探讨膝部严重烧(创)伤后皮肤软组织缺损的系统治疗方法. 方法 选择2009年1月-2011年12月笔者单位收治的20例严重烧(创)伤后膝部皮肤软组织缺损的患者,膝部皮肤缺损面积为5 cm×4 cm～30 cm×20 cm.创面行早期积极清创、VSD治疗、滴注冲洗控制感染,采用游离皮片+皮瓣或单纯皮瓣移植修复.皮瓣移植包括8例局部皮瓣移植,12例游离皮瓣移植.局部皮瓣包括局部旋转或易位皮瓣6例,隐动脉皮瓣2例.12例游离皮瓣包括股前外侧皮瓣8例,背阔肌肌皮瓣4例.皮瓣面积6 cm×5 cm～32 cm×22 cm.创面愈合后早期进行膝关节康复训练.结果 采用游离皮片+皮瓣移植术的15例患者皮瓣移植后完全成活,其中13例完全愈合,2例因感染出现少部分皮片成活欠佳,经补充植皮后创面愈合.另5例单纯皮瓣移植患者中1例游离皮瓣下发生感染,经持续滴注冲洗、湿敷换药、手术清创并封闭创面后愈合.术后随访1～3年,膝关节活动良好. 结论 采用包括积极清创、VSD治疗、滴注冲洗技术及自体大张皮片和(或)皮瓣移植等方法,并结合早期有效的康复训练在内的系统治疗,是修复膝部严重皮肤软组织缺损的有效方法.     

桥式皮瓣联合游离植皮负压封闭引流修复下肢大面积环形软组织缺损

目的 探讨健侧胫后血管皮瓣桥携带游离皮瓣的桥式皮瓣联合游离植皮负压封闭引流(VSD)治疗下肢严重创伤后大面积环形软组织缺损的临床应用价值.方法 2008年1月至2010年6月,应用桥式皮瓣联合游离植皮VSD治疗11例患者,年龄15～52岁,平均32.5岁,男性7例,女性4例,均为下肢严重创伤后深部组织裸露或坏死感染的大面积环形软组织缺损,6例同时合并骨折.经彻底清创后,对不稳定骨折行外固定支架固定或简便内固定,然后采用VSD治疗1 ～2次,每次5～7d.待创面肉芽组织生长较新鲜后,采用桥式皮瓣移植修复患侧骨及深部组织裸露的创面,皮瓣周围残留的创面采用游离植皮VSD覆盖修复.术后对皮瓣移植区及皮片植皮区的存活情况和愈合质量进行随访.结果 11例患者经清创负压封闭引流5～14 d后,创面肉芽组织生长良好.再次清创后应用桥式皮瓣移植联合游离植皮VSD覆盖治疗,皮瓣移植区组织全部成活且质地、外观满意,感染控制良好,未形成窦道.6例游离植皮区由于面积较大术后遗留部分散在创面,4例经再次植皮,2例经积极换药后均完全消灭创面,游离皮瓣移植成功率100％.术后随访5～ 24个月,平均10.6个月,皮瓣质地柔软,外形良好,患肢功能恢复满意.结论 对于严重创伤后深部组织裸露的下肢大面积环形软组织缺损,VSD覆盖技术可有效修复创面,最大限度地恢复患肢的功能.     

多部位撕脱伤的整形修复与探讨

目的 探讨不同部位皮肤软组织撕脱的处理及撕脱皮瓣保留再利用与舍弃条件的判定.方法 回顾性总结并分析58例撕脱伤的整形修复,依据撕脱面积大小与形态,选择创面的最佳修复方法.即:①撕脱皮肤"反鼓"制成中厚皮片移植,或创面清创异体皮移植,Ⅱ期自体皮置换移植; ②局部皮瓣移植覆盖祼露的神经、血管、骨关节及睾丸,其他创面自体皮片移植;③保留部分撕脱皮肤的皮瓣原位移植;④扩张后皮瓣移植覆盖裸露颅骨.结果 本组58例患者,经异体皮移植、自体皮移植、皮瓣及扩张后皮瓣修复,Ⅰ期切口愈合46例,延期愈合10例,仅2例出现部分撕脱皮肤制成的皮瓣移植后尖端坏死,经再次手术修复创面愈合.肢体截除4例,其中1例延期截肢.41例获随访6个月,修复处完全愈合,被修复的肢体恢复全部或部分功能.结论 撕脱伤皮肤利用成功与否,直接关系治疗时间的长短和供皮区瘢痕的多少,并与术后外观和功能恢复呈正比.     

皮耐克修复手外伤皮肤软组织缺损的临床应用

目的探讨皮耐克在手外伤皮肤软组织缺损中的临床应用效果。方法 2015年7月至2016年6月,48例患者采用皮耐克修复手外伤皮肤软组织缺损创面,其中31例患者二期联合使用皮片移植术修复创面,对手部外观与功能进行回顾性分析。结果本组所有患者均随访3个月以上,15例患者单纯用皮耐克修复创面,31例皮肤缺损较大患者联合二期植皮修复创面,2例患者创面感染,再次清创后行皮瓣修复术。所有患者创面修复后外形良好,随访均未见明显局部瘢痕增生或挛缩。按照王宗立手部功能效果的评定标准,优30例,良11例,可6例,差1例,优良率85.4%。结论皮耐克可单独用于手外伤小面积皮肤软组织缺损创面,对于大面积皮肤软组织缺损创面可联合自体皮片移植进行修复,该项技术具有操作简单、手术风险小、副损伤小、临床效果确切等特点,是手外伤皮肤软组织缺损创面修复的一种可靠方法,值得临床推广。     

创面转化后大张自体皮移植修复肢体大范围感染创面

目的探讨对肢体创伤后大范围感染创面,应用异种皮移植创面转化后大张自体皮移植修复的临床效果。方法自2003年4月以来我科收治的3例创伤后肢体大范围皮肤缺损、创面感染患者,行创面分次清创,以新鲜猪皮移植做创面转化,术后5～7d异种皮成活后将其去除,采用大张自体中厚皮片移植修复创面。结果3例感染创面经异种皮移植创面转化后,移植大张自体中厚皮片均全部成活,随访7～18个月,肢体功能和外观良好。结论分次清创、异种皮移植创面转化后大张自体中厚皮片移植修复方法,操作简便、可行、安全,经初步临床应用效果良好,为肢体创伤感染创面的修复提供一种新的选择。     

异体脱细胞真皮基质与自体皮片复合移植的临床应用

目的:探讨异体脱细胞真皮基质与自体皮片复合移植修复大面积深度烧伤及瘢痕切除后皮肤缺损创面及其愈合后皮肤的外形和功能。方法:应用异体脱细胞真皮基质与自体刃厚皮片组成复合皮移植,以自体刃厚皮片移植作为对照,采用一步移植法治疗切痂后大面积深度烧伤创面及瘢痕切除后皮肤缺损共56例患者60处创面,观察术后皮片的成活情况、外形及功能恢复情况并随访。结果:60处创面全部愈合,移植皮片生长良好,瘢痕增生不明显,未见明显挛缩,皮肤弹性较好。在6～12个月的观察期内,自体刃厚皮片与异体脱细胞真皮基质复合移植后,功能和形态优于单纯自体刃厚皮片移植;随访2年复合移植未发现明显的排异反应。结论:异体脱细胞真皮基质与自体皮片复合移植修复大面积深度烧伤及瘢痕切除后皮肤缺损创面愈合良好,无瘢痕增生,皮肤外观功能满意,无排异反应。     

异体脱细胞真皮基质与自体皮片复合移植的临床应用

目的:探讨异体脱细胞真皮基质与自体皮片复合移植修复大面积深度烧伤及瘢痕切除后皮肤缺损创面及其愈合后皮肤的外形和功能。方法:应用异体脱细胞真皮基质与自体刃厚皮片组成复合皮移植,以自体刃厚皮片移植作为对照,采用一步移植法治疗切痂后大面积深度烧伤创面及瘢痕切除后皮肤缺损共56例患者60处创面,观察术后皮片的成活情况、外形及功能恢复情况并随访。结果:60处创面全部愈合,移植皮片生长良好,瘢痕增生不明显,未见明显挛缩,皮肤弹性较好。在6～12个月的观察期内,自体刃厚皮片与异体脱细胞真皮基质复合移植后,功能和形态优于单纯自体刃厚皮片移植;随访2年复合移植未发现明显的排异反应。结论:异体脱细胞真皮基质与自体皮片复合移植修复大面积深度烧伤及瘢痕切除后皮肤缺损创面愈合良好,无瘢痕增生,皮肤外观功能满意,无排异反应。     

整形外科原则在早期汶川地震伤员救治中的应用

目的 探索地震早期整形外科医生介入软组织创伤救治的方法. 方法 对软组织创伤分类并仔细清创,应用整形外科原则,对皮肤软组织缺损的创面应用皮片、皮瓣移植等组织移植方法修复;不伴组织缺损的颅颌面部裂伤应用整形外科精细缝合技术封闭伤口.感染严重一次清创难以彻底的选择普通换药或VAC引流,待创面条件改善后应用整形外科技术处理. 结果 本组102例伤员中76例一期愈合;16例感染切开引流或烧伤伤员经过2～3次清创换药后延期愈合;3例四肢植皮区边缘皮片少量坏死,经换药后愈合,所有皮瓣全部成活;7例经换药或VAC引流后二期创面植皮或皮瓣转移全部成活. 结论 整形外科医生早期、及时参与救治地震中软组织创伤可获得满意的功能和形态修复,对于伤员的心理康复也意义重大.     

One-stage treatment of infected bone defects of the tibia with skin loss by free vascularized osteocutaneous grafts

Twenty-six patients who had an infected nonunion or segmental defect of the tibia with skin loss were treated in one stage with debridement and a free vascularized osteocutaneous fibula or iliac graft. Successful control of infection, closure of skin defects, and incorporation of bone union were achieved in all patients except one. In an average follow-up of 39 months, no recurrence of infection was seen. There were four stress fractures of the grafted fibula; these healed within 2 months with cast immobilization. Graft hypertrophy was common in the fibula grafts, but it took 1 1/2 years for hypertrophy of the graft to be strong enough to remove external supports without stress fracture or an additional cancellous bone graft. The use of a one-stage free vascularized osteocutanous graft for the management of infected bone defects of the tibia with skin loss is effective because extensive debridement can remove all devitalized and infected tissue and can increase vascularity in the region of infection and osseous defect to enhance antibiotic delivery. © 1995 Wiley-Liss, Inc.     

Free-flap resurfacing of tissue defects in the foot due to large gouty tophi

Background: Large or extensive gouty tophi on the feet can cause functional impairment, drainage sinus, and infected necrosis, finally resulting in complex soft‐tissue defects with tendon, joint, bone, nerve, and vessel exposure. Reconstruction of complex soft‐tissue defects of the foot is still challenging. The purpose of this report was to review the outcomes of free‐flap reconstructive surgery for treating the metatarsal joint defects of the feet caused by chronic tophaceous gout. Methods: Ten patients who had large tophus masses (>5 cm) and ulceration on the feet were admitted to our hospital between September 2006 and September 2010. Six patients underwent free‐flap reconstruction after debridement to resurface the circumferential wound, protect the underlying structures, and provide a gliding surface for exposed tendons. The patients' age, sex, comorbidities, location and size of the defects, reconstructive procedures, surgical outcomes, complications, follow‐ups, and recurrence of tophaceous gout were reviewed and recorded. Results: The mean patient age was 49.8 years (range, 36–72 years). The average skin defect size was 92.2 cm². Five patients were treated using free anterolateral thigh flaps, and 1, using a free medial sural flap. These free flaps were safely raised and showed excellent functional and cosmetic results, with a mean follow‐up of 31.7 months (range, 7–50 months). Conclusion: Chronic tophaceous gout can cause severe skin infection and necrosis, even resulting in deformity or sepsis if left untreated. Surgical debridement is inevitable in patients with extensive wounds. We reconstructed the large, ulcerative skin and soft‐tissue defects on the dorsum of the foot by performing free‐flap reconstruction after adequate debridement and achieved good functional and cosmetic results. © C 2011 Wiley Periodicals, Inc. Microsurgery, 2011.     

Masquelet技术结合小腿皮瓣治疗胫骨感染性骨缺损伴广泛软组织缺损的疗效分析

目的:探讨Masquelet技术结合小腿皮瓣治疗胫骨感染性骨缺损伴广泛软组织缺损的疗效。方法:回顾性分析2016年3月至2019年6月解放军联勤保障部队第九二〇医院骨科采用Masquelet技术结合小腿皮瓣治疗的23例胫骨感染性骨缺损伴有广泛胫前软组织缺损患者资料。其中男15例,女8例;年龄18~59岁（平均38.4岁...     

波动式负压封闭引流在复杂创面植皮术中的应用

目的 探讨应用波动式负压封闭引流（vacuum sealing drainage,VSD）防治复杂创面皮片移植术并发症的临床效果.方法 彻底清创,待创面新鲜时,取中厚或全厚皮片,整张移植皮片,VSD敷料结合半透膜覆盖.皮片移植区周围皮肤乙醇脱碘后,植皮区安装VSD装置,40 kPa（300 mmHg）负压0.5h与16.6～17.3 kPa（125～130mmHg）负压3h,交替抽吸,若渗出液较多,适当增大负压,同时缩短间隔,主动吸引出皮片下及周围腔隙内积液,使皮片与受区紧密贴合,7d拆除VSD.结果 共治疗22例,1例患者肌腱裸露部位少许皮肤坏死渗出,清创后,应用VSD促进创面愈合;其余21例皮片存活良好,无皮片下积液或感染.随防6～18个月,效果满意.结论 采用VSD与皮片移植术相结合,既能抽吸渗液,避免感染,促进皮片与基底愈合,缩短病程;又可避免皮片及周围皮肤因长时间肿胀的大压力而致的组织坏死,对于部分复杂创面是一种较理想的修复手段.     

Application of VSD technique in adults with chronic osteomyelitis of the extremities combined with soft tissue defects

To investigate the clinical application of vacuum sealing drainage (VSD) in chronic osteomyelitis of the extremities combined with soft tissue defects in adults. This study retrospectively included 32 adult patients with clearly diagnosed chronic osteomyelitis of the extremities combined with local soft tissue defects, and the trauma was covered by VSD after debridement, osteotomy, and vancomycin-laden bone cement filling of the occupancy, and the trauma was covered by selecting a suitable flap transfer repair according to the site and extent of the soft tissue defect after the trauma condition was suitable, and the secondary trauma was taken from the abdominal full-thickness skin free skin slice graft, according to whether the skin graft area was performed. The skin flap hematoma and infection rate, as well as the skin flap survival rate and implant fixation time were compared and analysed between the two groups. The primary outcome is the implant fixation time, and the secondary outcome is the skin fragment survival rate. In 32 patients, VSD was performed on the bone cement surface to cover the trauma, and 33.2 to 39.8 kPa continuous vacuum sealing drainage was set. The average VSD time duration before soft tissue coverage was 47.87 ± 23.14 days, and the average number of VSD use was 7.18 ± 3.23. The use of VSD before soft tissue coverage did not cause complications such as negative pressure could not be maintained, vacuum sealing drainage was not smooth, skin blistering, trauma. Among the 32 patients, 12 cases of soft tissue coverage were followed by trauma free skin grafting with packing + VSD, and 20 cases were fixed with packing alone, and the duration of continuous packing and fixation of free skin pieces in the VSD group was significantly less than that in the control group (P = .006). The survival rate was significantly higher than that of the control group (P = .019). VSD in adult patients with chronic osteomyelitis of the extremities combined with soft tissue defects can effectively improve the trauma condition, provide the possibility of second-stage soft tissue coverage, and significantly shorten the preparation time for soft tissue coverage. In addition, when soft tissue coverage trauma is performed, VSD combined with skin graft packing technique can significantly improve the survival rate of skin pieces, shorten the time of skin graft fixation.     

Reconstruction of soft tissue defects of the lower limb using the free serratus anterior flap

Objective: To present the application and clinical results of soft tissue reconstruction of the lower limb with the free serratus anterior muscle flap. Methods: Twenty Chinese adult cadavers were studied to determine detailed anatomical information about the serratus anterior muscle flap. From 1997 to 2007, 82 patients with soft tissue defects of the lower limbs were treated with free serratus anterior muscle flaps and skin grafts. There were 24 females and 58 males, aged from 22 to 63 years (mean 34). The patients were followed up for an average of 30 months (range, 8 months–5 years). Results: All flaps survived except for one, in which necrosis occurred. Six patients developed partial necroses of the muscle flap or skin graft. Five of them healed with debridement or wound care, and one healed with a repeat skin graft. There was no notable donor site morbidity. Dysfunction of the shoulder was not found in any of the patients. Conclusion: The serratus anterior muscle flap is a good option for the treatment of soft tissue defects of the lower limb. This muscle flap has many advantages owing to its anatomical features.     

多种背阔肌瓣游离移植修复下肢缺损

目的 寻找应用背阔肌瓣游离移植修复下肢缺损的方法.方法 1996年2月-2008年2月,笔者单位应用游离背阔肌瓣修复下肢皮肤及组织缺损患者42例,其中膝部4例,小腿22例,足、踝部15例,膝下至足背严重撕脱1例.清创后采用背阔肌肌皮瓣、背阔肌肌瓣植皮、保留肌袖的背阔肌穿支皮瓣、分叶背阔肌组织瓣修复创面.组织瓣切取范围18 cm×8 cm～40 cm × 18cm.结果 除3例患者术后发生血管危象,2例供区植皮和1例肌瓣植皮部分坏死外,其余患者创面均一次性愈合.随访3～24个月,6例患者皮瓣外形臃肿,影响穿鞋,再次行皮瓣修薄术;3例肌瓣植皮区有轻度瘢痕挛缩.结论 个性化设计不同形式的背阔肌瓣,可满足下肢皮肤软组织缺损的修复.     

Split thickness porcine graft in the treatment of close-range shotgun wounds to extremities with vascular injury

The use of split thickness porcine skin grafts as a biologic dressing to cover exposed vascular anastomoses was evaluated in three patients who sustained close-range shotgun wounds to the thigh, causing massive soft tissue injuries and injuries to the superficial femoral artery, saphenous vein, and superficial femoral vein in each patient. In addition, one patient also had a fracture of the distal femur. Operative management consisted of extensive debridement, ligation of the femoral and saphenous veins, and vein graft reconstitution of the superficial femoral artery. The patient with associated femoral fracture was treated with balanced skeletal traction. The porcine skin grafts were changed every twenty-four to forty-eight hours, using sterile technic and general anesthesia as indicated.The porcine skin grafts appeared to protect the vein grafts from infection and trauma during the multiple dressing changes and contributed to limb salvage in two patients in whom the vein graft could be approximated to a viable muscle bed. Amputation was required in the third patient after rupture of the vein graft, which was suspended across a large soft tissue cavity and could not be approximated to a viable muscular bed. The intraoperative and postoperative management of such injuries is discussed in detail. In view of this experience, it appears that judicious use of split thickness porcine skin grafts as a biologic dressing may permit limb salvage in selected cases in which no viable soft tissue remains to cover a vascular anastomosis after soft tissue debridement is completed.     

皮肤牵张闭合器在儿童肢体创面缺损的治疗应用

目的:回顾性分析可调式皮肤牵张闭合器在儿童大面积肢体创面缺损的临床应用价值。方法:自2017年1月至2019年1月,应用可调式皮肤牵张闭合器处理儿童严重下肢创面缺损患儿11例,男9例,女2例,年龄4～12(8.3±2.7)岁,均为单侧下肢大面积创面缺损,其中车祸伤致肢体皮肤缺损4例,骨筋膜室切开减压术后无法缝合关闭3例,下肢骨折内固定术后钢板外露3例,皮肤撕脱伤清创缝合术后大面积缺血坏死1例。创面宽度(5.6±1.2) cm,长度(7.0±1.6) cm,均已行VSD负压引流、扩创缝合等处理,其中4例已行游离皮片植皮,2例已行局部皮瓣转移手术处理,植皮或皮瓣手术失败,前期治疗效果均不佳。结果:术后经持续牵引5～14(10.5±2.6) d后创面闭合,未再行植皮或者皮瓣修复处理。无创缘血供不佳、皮肤感染坏死、末梢感觉障碍等并发症发生。11例患儿均获随访,随访时间3～18(8.9±3.8)个月。创缘皮肤呈线性愈合,瘢痕轻微。结论:通过可调式皮肤牵张闭合器治疗儿童大面积肢体创面缺损,符合Wolff定律及组织自然重建理念,为治疗儿童肢体皮肤及软组织缺损提供了一种可供选择的有效方法。