带血管蒂组织瓣移植在治疗四肢软组织肉瘤中的应用

目的 探讨带血管蒂组织瓣移植术在四肢软组织肉瘤中的应用与体会。 方法 回顾性分析2005年7月至2009年7月新疆医科大学附属肿瘤医院行带血管蒂组织瓣移植治疗16例四肢软组织肉瘤的临床资料。结果 1例足底内侧动脉皮瓣部分坏死,经二次游离皮片植皮后愈合。1例腓肠肌内侧头肌瓣结合游离植皮术后,边缘出现坏死,经换药后痂下愈合。其余14例病人组织瓣均全部存活,16例病人在生存期内同部位未见肿瘤复发。结论 四肢软组织肉瘤能够通过局部扩大切除术及带血管蒂的皮瓣移植术达到局部的控制,避免生存期内接受截肢术。     

带蒂组织瓣在肢体软组织肉瘤术后修复中的应用

目的:探讨带蒂组织瓣在肢体软组织肉瘤术后修复中的应用及疗效。方法:统计肢体软组织肉瘤术后软组织缺损患者23例,均行肿瘤广泛切除术联合带蒂组织瓣移植术治疗,观察组织瓣愈合情况,按MSTS评分评估肢体功能。结果:随访时间为3~24个月,平均12.57个月。2例因肿瘤转移至肺部分别于手术后10个月、16个月死亡,2例因术后肿瘤局部复发行截肢术,19例尚未发生肿瘤复发及肿瘤转移。MSTS肢体功能评分为7~29分,平均23.73分,优良率86.67%。结论:对于软组织肉瘤术后缺损,应用带蒂组织瓣移植可有效修复,同时能有效改善肢体功能。     

肩胛带骨肿瘤的外科治疗结果及评价

目的 探讨肩胛带骨肿瘤的手术切除方式、重建方法,观察术后功能恢复情况及临床结果.方法 回顾性分析1998年7月至2006年7月收治的71例肩胛骨周围骨肿瘤患者的病例资料,其中恶性肿瘤61例,骨巨细胞瘤10例.15例恶性肿瘤起源于肩胛骨,56例起源于肱骨近端.男42例,女29例;年龄11～62岁,平均36.5岁.手术方法:肩胛带离断术10例,单纯肩胛骨切除3例,肩胛骨切除、人工肩胛骨置换3例,部分肩胛骨及肱骨近端切除、假体置换8例,肱骨近端切除、假体置换47例.结果 10例骨巨细胞瘤患者肩周肌肉保留较好,术后MSTS功能评分平均28分.起源于肱骨近端的原发恶性骨肿瘤患者三角肌止点处均予以切除,术后肩外展30°～60°,MSTS功能评分平均23分.37例肱骨骨肉瘤患者中4例(10.8%)局部复发,2例骨转移,5例肺转移.7例转移患者均死亡.1例恶性骨巨细胞瘤患者出现肺转移死亡.3例尤文肉瘤患者出现肺转移死亡.5例肱骨及5例肩胛骨软骨肉瘤患者术后未见局部复发及转移.结论 肩胛带骨肿瘤切除、人工肱骨近端假体重建能保留完整肘部及手部功能、并发症少,是肩部恶性肿瘤的首选术式;肱骨近端骨肉瘤和下肢骨肉瘤比较预后较好;肱骨近端恶性肿瘤行关节内肿瘤切除和关节外肿瘤切除肿瘤的局部复发率接近,提示对多数肱骨近端恶性肿瘤可以采用关节内切除.     

修复上胸壁巨大肿瘤切除后缺损一例的早期效果

目的应用钛网、重建钢板及背阔肌带蒂肌皮瓣,修复上胸壁乳腺肉瘤样癌切除后巨大缺损1例,观察术后早期效果。方法于2006年2月收治1例56岁女性上胸壁乳腺肉瘤样癌患者,行肿瘤切除后缺损约20cm×15cm,钛网覆盖胸壁缺损,重建钢板连接双侧锁骨残端,右侧背阔肌带蒂肌皮瓣约20cm×15cm移位修复软组织缺损。结果患者术后3d脱呼吸机,反常呼吸较明显。2周皮瓣血运稳定后,用胸带固定胸廓,反常呼吸渐消失,皮瓣血供良好。复查胸片,钛网及重建钢板位置良好。术后1个月转入肿瘤科化疗。随访3个月,局部及全身无不适;双肩活动度前屈90°,外展90°;肿瘤未见复发。结论胸壁巨大缺损重建时应选择质地较硬的材料,重建钢板维持双侧锁骨的解剖位置,肩关节功能恢复好,背阔肌带蒂肌皮瓣可适当扩大切取。     

软组织重建在骨与软组织肿瘤外科治疗中的应用

目的回顾不同部位骨与软组织肿瘤切除术后软组织重建方法及临床疗效,探讨合理的软组织重建策略。方法 2003年6月-2010年12月,收治因骨或软组织肿瘤进行外科切除并接受皮瓣、肌瓣或肌皮瓣修复重建患者90例。其中男59例,女31例;年龄9～85岁,中位年龄37.2岁。骨原发或转移性肿瘤52例,软组织原发肿瘤38例。75例为肿瘤切除后一期软组织重建;7例因伤口不愈合行清创后软组织重建;8例因伤口感染行清创、负压封闭引流,二期软组织重建。皮瓣类型:腓肠肌肌瓣40例,背阔肌肌(皮)瓣6例,腹直肌肌(皮)瓣4例,臀大肌肌皮瓣、胸大肌肌瓣、交腹皮瓣各1例,局部转移皮瓣27例,带血管蒂皮瓣5例,单纯游离植皮5例。皮瓣范围为6.5 cm×4.5 cm～21.0 cm×9.0 cm。结果术后87例皮瓣成活;Ⅰ期愈合81例;Ⅱ期愈合6例,其中2例皮瓣部分坏死,经换药后成活,3例皮瓣延迟愈合,1例伤口轻度感染,经保守治疗后愈合。软组织重建失败3例,均为皮瓣坏死合并感染,经清创二次皮瓣转移后愈合。供区创面均Ⅰ期愈合,移植皮片完全成活。73例获随访,随访时间10～102个月,平均36.1个月。6例患者于术后2～27个月,平均8.2个月出现局部复发并接受二次手术切除。13例于术后6～34个月,平均19.2个月死于原发病。结论骨与软组织肿瘤切除后常造成较大的软组织缺损,选择适当的肌(皮)瓣进行软组织重建可以达到理想的伤口闭合,减少术后伤口并发症,有利于术后功能恢复。     

带蒂背阔肌Kiss皮瓣修复肿瘤切除术后胸壁皮肤软组织缺损的临床研究

目的探讨带蒂背阔肌Kiss皮瓣修复肿瘤切除术后胸壁皮肤软组织缺损的疗效。方法 2010年12月-2015年12月,收治15例胸壁肿瘤患者。男2例,女13例;年龄43~60岁,平均51.8岁。局部晚期乳腺癌11例,胸壁皮肤纤维肉瘤3例,胸壁放射性溃疡1例。病程6个月~8年,中位时间24.1个月。术中切除原发灶后,胸壁皮肤软组织缺损范围达17 cm×12 cm~20 cm×18 cm;采取带蒂背阔肌Kiss皮瓣移位修复创面,A、B两瓣大小相等,单个皮瓣切取范围为17 cm×6 cm~20 cm×9 cm;供区直接拉拢缝合。结果术后14例皮瓣顺利成活,创面Ⅰ期愈合;1例皮瓣远端坏死,经换药后延期愈合。供区切口均Ⅰ期愈合。患者均获随访,随访时间6个月~3年,平均21.6个月。术后皮瓣外观良好,蒂部无臃肿,对肩关节活动无明显影响。肿瘤患者均无局部复发,2例乳腺癌患者发生远处转移。供区切口遗留线性瘢痕。结论应用带蒂背阔肌Kiss皮瓣修复胸壁皮肤软组织缺损,手术操作简便,供区损伤小,术后恢复快,为后续治疗争取了时间。     

胸廓内动脉穿支皮瓣及背阔肌Kiss皮瓣在乳腺肿瘤切除术后胸壁缺损中的应用

目的探讨对侧胸廓内动脉穿支皮瓣及背阔肌Kiss皮瓣修复乳腺肿瘤切除术后胸壁软组织缺损的临床效果。方法回顾性分析大连医科大学附属第一医院2018年1月至2019年5月收治的6例乳腺肿瘤患者的临床资料,均为女性,年龄46~73岁,平均55.5岁,其中5例为局部晚期乳腺癌,1例为晚期乳腺癌。病程4个月至5年,中位时间20.1个月。4例患者行术前化疗。术中切除原发病灶后,局部皮肤软组织缺损范围达10 cm×15 cm^21 cm×31 cm,单独采取对侧胸廓内动脉穿支皮瓣或联合带蒂背阔肌Kiss皮瓣修复胸壁缺损,供区直接拉拢缝合,1例患者对侧乳房体积较大,同期行乳房缩小和乳房成形术。术后进行随访,观察皮瓣情况,以及肿瘤是否复发。结果6例胸廓内动脉穿支皮瓣切取范围为5 cm×12 cm^10 cm×23 cm,其中3例联合带蒂背阔肌Kiss皮瓣进行修复,两叶皮瓣每叶面积范围为5 cm×15 cm^7 cm×18 cm,6例患者皮瓣均成活,其中5例创面一期愈合,1例背部供区因张力稍大,出现皮下积液,经换药、引流后切口延期愈合。术后随访1~17个月,平均7.5个月,术区皮肤平整,皮瓣外观良好,对肩关节及腰部活动无影响,肿瘤均无局部复发,供区仅遗留线状瘢痕。结论应用对侧胸廓内动脉穿支皮瓣及背阔肌Kiss皮瓣修复乳腺肿瘤切除后巨大胸壁软组织缺损,无需血管吻合,手术简单,术后恢复快,并发症少,效果较好。     

应用游离皮瓣修复头皮恶性肿瘤术后缺损18例

目的探讨应用各种游离皮瓣修复头皮恶性肿瘤切除术后较大范围缺损的可行性和临床效果。方法2012年3月-2015年1月,采用游离皮瓣修复18例头皮恶性肿瘤切除术后皮肤软组织缺损。其中男13例,女5例;年龄18~72岁,平均49岁。鳞癌17例(均有瘢痕病史),隆突性纤维肉瘤1例。肿瘤扩大切除后缺损范围为15 cm×12 cm~22 cm×17 cm,切取皮瓣大小为17 cm×14 cm~24 cm×19 cm,其中应用股前外侧皮瓣5例,背阔肌肌皮瓣6例,胸背动脉穿支皮瓣3例,背阔肌肌瓣结合中厚植皮4例(肌瓣游离移植术后5~7 d行二期植皮)。皮瓣供区均植皮修复,肌瓣供区直接缝合。结果术后游离皮瓣成活13例,坏死1例;游离肌瓣全部成活,二期植皮后因枕部压迫致移植皮片局部坏死1例,经二次植皮后愈合。供区均Ⅰ期愈合,无血肿、血清肿发生;植皮均顺利成活。患者均获随访,随访时间5~33个月,平均20个月。3例患者分别于术后5、7、13个月因肿瘤颅内转移死亡。2例患者局部复发,再次切除后采用局部皮瓣移位或植皮修复。术后皮瓣外观较满意,4例因皮瓣臃肿行二期修薄术。皮瓣耐磨性好,随访期内无破溃发生。背阔肌肌瓣切取后未遗留明显功能障碍。结论综合供、受区特点选择合适的游离皮瓣移植修复较大范围头皮恶性肿瘤切除术后缺损是一种有效方法。     

手指软组织肉瘤的创面修复与重建

目的 回顾性分析手指原发软组织肉瘤病例,判断在根治肿瘤的同时是否能实施保指以满足手指外观功能的需要.方法 收集2007年4月至2009年11月期间11例手指软组织肉瘤保指的患者,采取肿瘤广泛切除后,对创面覆盖选用第一掌背动脉皮瓣7例,第二掌背动脉皮瓣修复4例;其中5例合并肌腱缺损患者同期行肌腱移植修复,1例骨质缺损行髂骨移植术.结果 术后6例接受新辅助化学治疗,1例接受辅助放射治疗.术后随访时间14个月至5年,9例肿瘤无复发,1例术后14个月肺转移死亡,1例肺转移带瘤生存.术后皮瓣全部存活,1例局部复发行截指.术后1年手指外观满意度为81％,功能评分为8～15分,平均12.6分,优或良10例,占91％.结论 建议对手指软组织肉瘤有保指可能时应尽可能实施保指,并同期进行功能重建.     

应用前侧皮瓣的半骨盆截肢术

 目的 探讨应用前方带股血管蒂的股四头肌肌皮瓣覆盖臀后部创面的半骨盆截肢术(前侧皮瓣半骨盆截肢术)的手术适应证、手术方法、患者预后和并发症情况。方法 自2009年4月至2010年10月,北京积水潭医院骨肿瘤科对10例患者采用前侧皮瓣半骨盆截肢术,男9例,女1例;年龄30~62岁,平均45岁。软骨肉瘤7例、上皮样肉瘤1例、多形性脂肪肉瘤1例、梭形细胞肉瘤1例。结果 9例患者获得随访,随访时间12~30个月,平均21.5个月。术后仅1例出现轻度皮缘坏死,无伤口感染者。局部复发3例(33.3%),2例软骨肉瘤、1例上皮样肉瘤。死亡3例(33.3%),包括复发的2例、另1例软组织脂肪肉瘤患者因肺转移死亡;1例复发患者带瘤存活;2例患者肺转移带瘤存活;余3例未见复发和转移。结论 前侧皮瓣半骨盆截肢术适用于：(1)臀后部软组织肿块侵及皮肤皮下或反应区到达皮下;(2)骨盆恶性肿瘤复发需行半骨盆截肢,原手术切口污染臀部软组织,无法使用常规后侧皮瓣;(3)臀部皮肤软组织因放疗等原因影响后侧皮瓣血运。此手术的必要条件是髂外血管到股血管通畅良好,可顺利游离且不在肿瘤反应区内。适应证明确的情况下,前侧皮瓣覆盖较常规后侧半骨盆截肢更便于操作和覆盖,便于获得更好的外科边界,术后并发症少。     

Latissimus dorsi pedicled flap for upper extremity soft-tissue reconstruction

The latissimus dorsi often is used as a functional muscle transfer to restore elbow and shoulder motion. Although less common, its use as a pedicled muscle flap with a split-thickness skin graft provides excellent soft-tissue coverage of large upper extremity wounds. Seven male patients ranging in age from 6-71 years were treated with a pedicled latissimus dorsi muscle flap and split-thickness skin graft for coverage of open wounds of the shoulder, arm, or elbow with exposed vital structures (mean wound size: 15x10 cm). The flap also was used as a functional muscle transfer in one patient to replace destroyed anterior and middle portions of the deltoid. Wounds resulted from trauma in three patients, infection following trauma in two, and sarcoma excision in two. All flaps healed well, and donor site morbidity was minimal. At mean 16-month follow-up (range: 3-41 months), all muscle flaps had contoured well, producing satisfactory cosmesis. Functional results were good, and all patients were satisfied with their outcome. The tendinous insertion is left intact to guard against excessive traction on the pedicle when the flap is used for soft-tissue coverage only.     

Coverage of complex defects of the shoulder girdle and posterior neck triangle following tumor resection

IntroductionNumerous pedicle and free flaps have been used to cover complex defects of the shoulder girdle and posterior neck triangle following tumor resection. We describe our choice of flap selection in these patients with case examples.Presentation of casesThree cases examples demonstrate our choice of flap selection. In the first case, an anterior shoulder girdle defect is covered by an anteriorly transposed latissimus dorsi muscle flap. The second case demonstrates the coverage of a posterior shoulder girdle defect by a posteriorly transposed latissimus dorsi muscle flap. Finally, the third case demonstrates the coverage of a posterior triangle neck defect using a superiorly transposed pectoralis major muscle flap. All reconstructions utilize muscle flaps (covered by split-thickness skin grafts) and not myocutaneous flaps.DiscussionWe demonstrate that these two pedicle muscle flaps are adequate for coverage of large complex defects of the shoulder girdle and posterior neck triangle. We also demonstrate the advantages of using muscle rather than myocutaneous flaps.ConclusionPedicle latissimus dorsi and pectoralis major muscle flaps are simpler and preferred over free flaps for coverage of complex defects of the shoulder girdle and posterior neck triangle. The use of muscle rather than myocutaneous flaps will reduce the size of the original defect, make flap design easier and reduce donor site morbidity.     

The Pedicled Latissimus Dorsi Flap for Shoulder Reconstruction After Sarcoma Resection

Background Tumor extirpation around the shoulder can result in large defects requiring coverage of allograft-alloprosthetic constructs and vital neurovascular structures. This study examined a single institution’s experience with the pedicled latissimus dorsi flap in reconstructing large shoulder defects after oncologic resection. Methods Using a prospectively maintained database, 33 consecutive patients were reviewed who had undergone a pedicled latissimus dorsi flap to reconstruct oncologic shoulder defects between 1994 and 2004. Wide excision or radical en-bloc resection of shoulder tissues was performed with defects often extending intra-articularly and to the level of the mid-arm. Patient demographics, comorbid conditions, pathology, adjuvant treatment, defect characteristics, skin paddle dimensions and operative records were evaluated. Outcome variables included major and minor complications, patient survival, and limb viability. Results Adjuvant therapy included chemotherapy in 18 patients, radiation therapy in 12 patients, and brachytherapy in 2 patients. Defects averaged 280.1 cm² (range 18–1,225 cm²). Mean skin paddle surface area was 118.9 cm² (range 21–350 cm²). There were 28 myocutaneous flaps and 5 muscle flaps. Materials for bony reconstruction included 13 allograft and alloprosthetic composites, 6 metallic prostheses, and 3 reconstructions using allograft alone. Two patients experienced partial skin flap necrosis. One patient developed local recurrence. Two patients required combined flaps. Conclusions Use of the pedicled latissimus dorsi flap in complex shoulder reconstructions provided ample well-vascularized soft tissue, minimized risk of infection, and maximized limb salvage. In our experience, the pedicled latissimus dorsi flap is an excellent choice for reconstruction of defects around the shoulder after tumor extirpation.     

One-stage reconstruction of facial paralysis associated with skin/soft tissue defects using latissimus dorsi compound flap.

Neurovascular free muscle transfer is now the mainstay for smile reconstruction in the treatment of established facial paralysis. Since facial paralysis due to ablative surgery or some specific disease sometimes accompanies defects of the facial skin and soft tissue, simultaneous reconstruction of defective tissues with facial reanimation is required. The present paper reports results for 16 patients who underwent reconstruction by simultaneous soft tissue flap transfer with latissimus dorsi muscle for smile reconstruction of the paralysed face. Soft tissue flaps comprised skin paddle overlying the latissimus dorsi muscle (n=6), serratus anterior musculocutaneous flap (n=5), serratus anterior muscle flap (n=2), and latissimus dorsi perforator-based flap with a small muscle cuff (n=3). The latissimus dorsi muscle can be elevated as a compound flap of various types, and thus offers the best option as a donor muscle for facial reanimation when soft tissue defects require simultaneous reconstruction.     

Reconstruction of extensive defects of the cranium using free-tissue transfer

Fourteen patients with large tissue deficits in the calvarium and orbits were reconstructed using microvascular free-tissue transfer (15 flaps). The etiology of these defects was skin neoplasms (seven), osteomyelitis (four), burn (two), and trauma (one). The free flaps used were the latissimus dorsi muscle flap with a split-thickness skin graft (seven), latissimus dorsi myocutaneous flap (two), rectus abdominis myocutaneous flap (three), radial forearm fasciocutaneous flap (two), and split-iliac crest flap (one). There was one postoperative death, one flap failure, two recurrences of neoplasm, and one loss of bone grafts and flap from infection. The free flaps can offer good results in patients undergoing wide resection in the cranium and orbits providing immediate repair with acceptable cosmetic result, minimized morbidity, and short hospitalization. However, immediate reconstruction following tumor resection carries a danger of positive margins discovered on permanent histologic sections or the difficulty in detecting recurrence underneath a bulky free flap.     

The latissimus dorsi musculocutaneous flap for extremity reconstruction in orthopedic surgery

The latissimus dorsi was transferred as a pedicle flap in ten patients and as a free vascular flap in ten others for extremity reconstruction. Group I comprised ten patients in whom the transfer was used solely to cover a skin or soft-tissue defect. Although there was partial necrosis of the transferred skin in one patient, the remaining nine patients obtained complete coverage without further reconstructive surgery. Group II comprised five patients in whom transfer of the latissimus dorsi was performed for active flexion or extension of the elbow or for abduction of the shoulder. Postoperatively, muscle strength obtained was classified from Grades 0 to 5 according to the muscle testing method. Three patients obtained muscle strength of Grade 3, while two obtained Grade 2. Group III comprised five patients who had brachial plexus palsy after high-dose irradiation. Coverage of the skin and soft tissue was performed after neurolysis of the brachial plexus palsy to free the tissue bed of scarred tissue. Postoperatively, sensory and motor disturbances were alleviated in four of five patients.     

Successful restoration of the trapezius muscle using pedicle latissimus dorsi. A case report

Reconstruction of the trapezius muscle using a pedicle latissimus dorsi flap was performed in a 27-year-old man with a large synovial sarcoma in his shoulder girdle. Size and location of the tumor required combined resection of surrounding muscles, including the trapezius, levator scapulae, and rhomboid major and minor. Thus, an extensive defect of the suspending muscles of the scapula was created after accomplishing an adequate resection of the tumor. The flap was performed to restore the trapezius functionally because there were no adjacent muscles available. The transferred muscle compensated for loss of the trapezius, thereby recovering excellent shoulder function. Although an opportunity of its application is thought to occur infrequently, the pedicle latissimus dorsi can activate scapular motion successfully in the absence of the levator scapulae. The technique may be extended to salvage failed conventional reconstruction after spinal accessory nerve palsy.     

Use of pedicled latissimus dorsi myocutaneous flap to reconstruct the upper limb with large soft tissue defects

ObjectiveTo report the technique of reconstruction of large skin and soft tissue defects in the upper extremity using pedicled latissimus dorsi myocu-taneous flaps.MethodsSix patients with large skin and soft tissue defects were included in this report. There were 5 trauma patients and the rest one needed to receive plastic surgery for his extremity scar. All wounds were in the upper extremity. The sizes of defects ranged from 15 cmx6 cm to 30 cmx18 cm. Pedicled latissimus dorsi myocutaneous flaps were designed according to the defect area and raised with part of latissi-mus dorsi. The thoracodorsal artery and its perforators were carefully protected during surgery.ResultsAll flaps healed primarily without flap congestion, margin necrosis or infection. The skin donor sites either received split-thickness skin graft (3 cases, mostly from the anterior thigh) or was closed primarily (3 cases) and had minimal morbidity. Follow-up of 6-12 months showed that the contour of flap was aesthetic and the function of limb was excellent.ConclusionOur experience indicates that the pedicled latissimus dorsi myocutaneous flap is favorable for reconstruction of large skin and soft tissue defects in the upper extremity.     

Latissimus dorsi flap closure of the irradiated clavicular wound

Partial or total resection of a previously irradiated clavicle and surrounding soft tissues is a difficult clinical problem. Attempts to close the defect with local tissue often result in wound breakdown and exposure of any remaining clavicle. Furthermore, the most appealing local muscle flap, the pectoralis major, is often unsuitable for reconstruction because of previous resection or radiation damage. Over a 3-year period, 8 patients had resection of a previously irradiated clavicle and surrounding soft tissues. Four underwent excision for sarcoma and four for osteoradionecrosis complicated by chronic wounds. All defects were reconstructed with a pedicled latissimus dorsi muscle flap. No patient had a flap failure, and all had closed wounds at a minimum 18-month follow-up. Our series demonstrates the success of latissimus dorsi flap coverage for post-claviculectomy defects in an irradiated field. To our knowledge, this is the first described series of such patients. The latissimus dorsi muscle flap should be considered for all difficult wounds involving the clavicle and surrounding soft tissues.