九种游离足部皮瓣及复合皮瓣在手外科的应用

从1987年以来,临床应用9种吻合血管的足部游离皮瓣或复合皮瓣治疗22例手外伤,包括:①带趾长伸肌腱的足背、趾蹼、趾腹、趾背复合皮瓣;②第二跖趾关节复合皮瓣;③躅甲瓣;④第一趾蹼皮瓣;⑤只吻合动脉、神经的(足母)趾腓侧趾腹皮瓣;⑥带足背皮瓣的躅甲瓣;⑦带足背皮瓣的第二足趾;⑧带腓浅神经的足背皮瓣;⑨带第二跖骨的第一趾蹼皮瓣。均获满意效果。就足部皮瓣的选择原则、应用指征、优缺点及手术注意事项等进行了讨论。     

联体婴儿畸形手术分离一例

联体婴儿畸形手术分离一例荣俊良花德发病例女，８个月。于１９９３年１１月１０日，以不对称联体儿、外寄生胎型入院治疗（图１）。检查：体重７ｋｇ，图１联体儿，术前胸腹部联体，蒂部约８ｃｍ×６ｃｍ。正常患儿发育为５个月婴儿，生理功能及神经系统发育正常；寄生胎...     

Neurovascular free foot flaps in reconstruction of the mutilated hand.

The neurovascular free flap from the first web region of the foot affords unrivalled potential for refurbishing sensibility to the denervated hand. Its greatest application is when no conventional island flap tissue remains for transfer. Its two-point discrimination is only moderate, but when used for thumb reconstruction, its sensibility is adequate because no functional substitute exists. Functionally and cosmetically it is superior to other methods of thumb reconstruction because of its pulp, size, and nail availability. There are no finger identification problems and secondary donor defects are minimal.     

叠加供血皮瓣在手外科的应用

目的探讨叠加供血皮瓣在手外科的应用。方法1998年3月～2003年12月,应用非主干血管皮瓣加皮神经营养皮瓣修复手部皮肤缺损35例,面积1cm×1cm～6cm×8cm。结果术后33例成活,2例由于皮瓣设计不当坏死,术后随访6～12个月,皮瓣质地、色泽与周围正常组织相似,无臃肿。结论叠加供血皮瓣供血可靠、切取方便,是修复手部皮肤缺损理想皮瓣。     

Neurovascular free flaps from the foot for innervation of the hand.

Microneurovascular flaps from the first web space of the foot offer a solution to upgrade sensibility of the denervated hand. Based on the dorsalis pedis artery, it allows simple dissection and a large vessel for easy and safe anastomosis. Seven cases are presented in which combinations of the first web anatomy for a variety of denervation injuries were used. The technique is ideally suited in those cases where no areas of island flap tissue are available for transfer.     

The role of microsurgical free flaps in foot and ankle surgery

Microsurgery is clearly an extremely useful adjunct in foot and ankle reconstruction. It requires careful planning between the microsurgeon and vascular, podiatric, and orthopedic surgeons. Ideally, each member of the team should have a special focus on limb salvage. The more experienced the microsurgeon and the better the planning the higher the chance of success. Current success rates in large microsurgical centers exceed 95% free flap survival. Skill in choosing the appropriate flap and optimizing how it is inset ensure an optimal aesthetic and functional result while minimizing the need for later revisions. Adding microsurgical free flaps to the armamentarium of limb salvage surgeons ensures a much higher salvage rate in limbs that heretofore posed too large of a reconstructive challenge and, therefore, were amputated. Current efforts should be directed toward the salvage of only those feet that will be functional, while avoiding limb salvage surgery in other cases. Microsurgical salvage should not be undertaken simply because it is technically feasible. The patient who undergoes 10 to 15 procedures over a 2 to 3 year interval and has a viable, but minimally functional, limb has not been helped. One, therefore, must be sure that the functional salvage can be performed within a defined number of operations in a given time. If not, a below-knee amputation should be considered strongly.     

Little flaps in hand surgery

Cutaneous flaps, with spontaneous healing and skin grafts, are parts of the armaentarium of plastic surgeons. Many publications have emphasized the use of island flaps or distant flaps for soft tissue reconstruction of the hand. We will only focus on random flaps in this work. We will describe the different techniques and indications.     

Specific complications associated with different types of intrinsic pedicle flaps of the hand

One hundred eight pedicle flaps intrinsic to the hand were performed in 98 male and 10 female patients averaging 36 years of age for digit-level trauma in 19 thumbs, 27 index, 50 long, 8 ring, and 4 small fingers. Specific flaps employed were 79 antegrade proper digital artery, 10 reverse proper digital artery, 6 reverse second dorsal metacarpal artery, 5 antegrade first dorsal metacarpal artery, 6 reverse dorsal ulnar artery of thumb, and 2 dorsal middle phalangeal flaps. The final average total active motion in the fingers was 235 degrees. Complications in 42 cases (39% actively smoking) included 10 partial flap losses, 13 cases of superficial epidermolysis, 4 cases of venous congestion, 4 superficial infections, 3 deep infections, and 8 cases of delayed healing at the wound margin. Second surgeries required were 3 debridements of deep wound infections, 3 revisions of the distal fingertip, and 9 full-thickness skin grafts. Specific associations of complications with flap type were between antegrade proper digital artery flaps and partial flap loss, epidermolysis, delayed wound healing, and infections at the distal margin but no cases of venous congestion. Reverse-flow flaps experienced venous congestion and epidermolysis but no partial flap losses or infection.     

Reconstruction of the foot with microvascular free flaps

Reconstruction of the foot using microvascular flaps has been widely performed in the last 15 years but the choice of flap to repair some areas in the foot remains controversial. We present a series of 128 free flaps to the foot performed during the period of 1975–1990. One hundred and seventeen had a successful outcome (91%). The etiology of the problem was traumatic in 94, congenital in 10, tumor in 9, and chronic ulcerations due to vascular problems in 15. The indications for a specific flap depended on the site and extension of the foot problem, and were divided into four groups:

• 1 Dorsum of the foot. Cutaneous parascapular flap was the best choice.
• 2 The sole-weight-bearing area. We favored the use of the latissimus dorsi muscle flap covered with a split thickness skin graft, done immediately. A proper tailoring of the flap and postoperative care by the patient are very important to maintain the result without ulceration. Tactile sensation does not seem to be essential.
• 3 The area over the calcaneus tendon. We have used cutaneous flaps such as the parascapular and lateral arm flap or fascial flaps covered by split thickness skin grafts (STSG). The fascia used were the serratus or the parascapular.
• 4 Complex trauma problems with extensive skin loss or chronic ulcerations due to vascular diseases: the latissimus dorsi musculocutaneous or muscle plus STSG was mostly used.

The overall number of donor areas were 5 groins, 48 parascapular, 2 gluteal fold flaps, 4 lateral arm, 61 latissimus dorsi, and 8 fascial flaps. © 1994 Wiley-Liss, Inc.     

Clinical applications of free temporoparietal flaps in hand reconstruction

Vascularized temporoparietal fascia can be used to cover deficits up to 14.0 X 12.0 cm in the hand or fingers. The tissue is thin, pliable, and has a smooth gliding surface advantageous to tendon function. Through scalp incisions, with meticulous yet straightforward dissection, this fascia can be isolated as a vascular island based on the superficial temporal artery system. Vessels are large and the anatomy is constant. Technique and clinical applications are discussed in detail.     

Refinements in hand coverage with microvascular free flaps.

The specialized tissue requirements or dorsal and palmar skin are analyzed and options for full-thickness replacement outlined in detail. Thoughtful and accurate preoperative planning is the key to success. Dorsal coverage with a variety of pedicled and free fasciocutaneous flaps are quite satisfactory. Palmar coverage is more difficult and the need for sensation more critical. Free vascularized temporoparietal fascial flaps covered with full-thickness skin grafts are currently the treatment of choice for most complex wounds.     

一蒂串联皮瓣在手外科的应用

目的探讨一蒂串联皮瓣在手外科的应用价值。方法临床应用胫前-足背动脉及伴行静脉为蒂的前踝上皮瓣及足背皮瓣4例,胫后-足底内侧动脉及其伴行静脉为蒂的小腿内侧皮瓣、足内侧皮瓣5例。皮瓣的平均面积依次分别为16cm×8cm、15cm×7cm、10cm×9cm和9cm×6cm。结果9个病人所有皮瓣全部成活,较好地覆盖了手掌及手背或前臂大面积皮肤缺损。皮瓣质地薄,不臃肿。结论一蒂串联皮瓣是修复大面积手掌、手背皮肤缺损的有效方法;具有手术风险相对较低,手术成功率高的优点;但由于对小腿及足破坏较大应严格掌握适应证。     

Mechanical sensibility in free and island flaps of the foot

Mechanical sensibility in 20 free skin flaps and four dorsalis pedis island flaps, used for the reconstruction of foot defects, was analyzed with conventional clinical methods and by determining sensibility thresholds to vibration frequencies of 20, 80, and 240 Hz. To eliminate inter-individual variability, a score was calculated for each frequency by dividing the thresholds determined for each flap with values obtained from the corresponding area on the uninjured foot. The soft tissue stability of the reconstruction was assessed. Patients were divided into three groups according to the scores. In the group of flaps with the best sensibility, the threshold increases were low at all frequencies. In the group with intermediate sensibility, the relative threshold increases were greater, the higher the frequency. In the group with the poorest sensibility, no thresholds were obtained with 240 Hz frequency and the thresholds increases were very high at all frequencies. Sensibility was not related to the length of follow-up time, nor to the type or size of the flap. However, flap sensibility was closely associated with that of the recipient area, where sensibility was usually inferior to that of normal skin. The island flaps generally had better sensibility than the free flaps. There was a good correspondence between the levels of sensibility determined by clinical and quantitative methods. The quantitative data on the level of sensibility obtained with the psychophysical method were found to be reliable and free from observer bias, and are therefore recommended for future studies. The degree of sensibility may have contributed to, but was not essential for, good soft-tissue stability of the reconstruction.     

Innervated free flaps for foot reconstruction: a review

Whether to provide a sensate plantar weight-bearing flap to reconstruct the foot remains an unanswered, but frequently asked, question. It has been more than a decade since Graham and Dellon reviewed this subject. Increasing emphasis on outcome analysis of microsurgical reconstruction has prompted this new review. All published peer-reviewed literature related to reconstruction of the plantar surface of the foot was reviewed to identify whether the flaps were 1) local, regional or distant; 2) innervated or non-innervated and, if innervated, then 3) identified as to the donor and the recipient peripheral nerves. Outcome measures included direct measurement of sensibility, development of ulceration, and activities of daily living. It was concluded that it is still not possible to determine that innervated flap reconstruction of the weight-bearing portion of the foot is critical for either durability or ambulation. It is recommended that the original nerves that innervate the flap be blocked prior to harvest to improve flap design, i.e., that the flap actually contains the intended nerve. It is recommended that appropriate donor nerves are selected to innervate the flaps, e.g., the calcaneal nerve should be used to reinnervate heel reconstructions (rather than the sural nerve), and medial/lateral plantar branches be used to reinnervate the arch and the forefoot. Reinnervating a muscle flap with a sensory nerve will permit reinnervation of the muscle and the overlying skin, but whether this provides a superior result in durability and gait remains to be seen.     

Radial forearm flaps for reconstruction in hand surgery.

Thirty-seven patients were treated using distally-based island radial forearm flaps. There were 31 men and six women. Reconstructed sites involved the dorsum of the hand (n = 17), the thumb (n = 11), the fingers (n = 5), the first web (n = 3), and the palm (n = 1). Sensory flaps were transferred in 15 cases, osteocutaneous flaps in six, and tendocutaneous flaps in eight. All the flaps survived. There were five donor-site complications, but no functional disturbances. Three patients had symptoms of cold intolerance. There were no radial fractures. In the six cases with osteocutaneous flaps, a mean of 2.6 months (range 2-3) was needed to obtain bony union. Among the eight cases with tendocutaneous flaps, postoperative tenolysis was required in two cases, and finally seven achieved a satisfactory outcome. The mean moving 2-point discrimination of the sensory flaps was 13 mm.     

不同类型皮瓣修复足踝部软组织缺损的临床效果

目的探讨不同类型皮瓣修复足踝部软组织缺损的临床效果。方法对30例足踝部软组织缺损患者进行皮瓣修复,其中足底内侧皮瓣修复足跟部软组织缺损7例,股前外侧皮瓣修复足背、足内侧软组织缺损12例,腓肠神经营养血管皮瓣修复足踝部软组织缺损11例。结果患者均获得随访,时间1~5年。29例皮瓣完全成活,仅1例股前外侧皮瓣发生坏死,二次手术给予植皮。13例患者因皮瓣臃肿,二期行皮瓣修整术;2例患者因术后长期从事体力劳动足跟部发生溃疡;其余患者皮瓣质地柔软,踝关节功能恢复满意。供区均未出现并发症。足底内侧皮瓣修复患者皮瓣感觉功能完全恢复,股前外侧皮瓣修复患者感觉均部分恢复,5例吻合神经腓肠神经营养血管皮瓣患者于术后3~5个月感觉功能完全恢复,剩余患者感觉功能部分恢复。结论足底内侧皮瓣、股前外侧皮瓣、腓肠神经营养血管皮瓣各有优缺点,应根据足踝部软组织缺损面积、部位的不同选择合适的皮瓣,以提高皮瓣成活率,重建肢体功能。