急诊组织瓣移植(位)修复伴有严重血管损伤的上肢复杂性组织缺损

目的 介绍急诊组织瓣移植或移位一期修复伴有严重血管损伤的上肢复杂性组织缺损的手术疗效.方法 对10例伴有严重血管损伤的上肢复杂性组织缺损的患者,在修复血管重建肢体血运的同时,根据组织缺损需要采用皮瓣、肌皮瓣、骨皮瓣甚至组织瓣组合移植的方法急诊进行一期修复.其中上臂肱动、静脉长段缺损,合并肱二头肌及上臂内侧大面积皮肤缺损,血管修复后背阔肌皮瓣移位覆盖创面并重建屈肘功能3例;肘部血管损伤合并肘关节周围大面积皮肤撕脱缺损,血管修复后移植胸脐皮瓣覆盖创面2例;前臂尺、桡动脉损伤合并皮肤肌肉缺损,血管修复后移植股前外侧皮瓣覆盖创面3例;前臂尺桡动脉损伤并尺桡骨缺损,血管修复后移植腓骨皮瓣重建尺骨缺损,二期再移植腓骨皮瓣重建桡骨缺损1例;前臂尺、桡动脉损伤合并桡骨及大面积皮肤缺损,血管修复后股前外侧皮瓣加髂骨皮瓣组合移植1例.结果 术后10例患肢及移位组织瓣全部存活.术后随访3～6个月,3例上臂损伤患者,肘关节最大屈曲度为105,屈肘肌力为M_3～M_4地,手功能恢复基本正常;肘及前臂损伤的7例患者,肢体及移植皮瓣完全存活,骨皮瓣和腕部已达骨性愈合,并恢复部分手功能.结论 对严重血管损伤且合并有复杂组织缺损的上肢损伤,急诊在施行血管修复重建肢体血运的同时,采用组织瓣单独或组合移植一期有效覆盖创面,可提高复杂性患肢的成活率,并为二期功能重建术提供良好的软组织条件.     

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。     

第二趾甲背皮瓣修复拇指背侧皮肤缺损

目的 探索对拇指背侧皮扶缺损进行修复的最佳方法。方法 根据拇指背侧皮肤及第一掌骨背侧皮肤缺损的范围，切取第二趾甲背侧皮瓣(或带足背皮瓣)移植．采用吻合足背动静脉-桡动静脉(鼻烟窝部)、头静脉-大隐静脉的方法重建血液循环进行修复。结果 拇指背侧皮肤缺损采用第二趾甲背皮瓣3例，拇指背侧皮肤合并第一掌骨背侧皮肤缺损采用第二趾甲背皮瓣带足背皮瓣、趾长伸肌腱1例进行移植修复，全部成功。术后经6个月～2．5年随访，手指外形基本恢复，外观好，皮肤两点辨别觉8～12mm。结论 采用第二趾甲背皮瓣移植修复是治疗外伤性拇指背侧皮肤缺损比较理想的方法。     

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.     

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。     

韧厚皮片结合封闭式负压吸引治疗感染性大面积皮肤缺损

肢体创伤后大面积皮肤缺损由于缺少皮肤屏障容易造成创面感染,大量细菌感染给临床治疗带来困难。自2004年8月以来我科收治的4例创伤后肢体大面积皮肤缺损创面感染患者,行创面换药清创,韧厚皮片移植结合封闭式负压吸引(VAC)覆盖创面,临床效果满意,肢体外观及功能良好,报告如下。临床资料1.一般资料:本组4例,均为男性;年龄24~45岁,平均年龄33.75岁。左上肢皮肤缺损合并感染2例,左上肢合并左肩背部大面积皮肤缺损感染并多根肋骨骨折血气胸1例,右下肢皮肤缺损合并感染1例;创伤面积分别为30cm×20cm、20cm×15cm、42cm×30cm、32cm×16cm;皮肤…     

背阔肌肌皮瓣移植修复上肢大面积复合组织缺损

目的:探讨应用背阔肌肌皮瓣修复上肢大面积复合组织缺损的疗效。方法:笔者单位自2006年3月起,用带蒂背阔肌肌皮瓣修复上肢皮肤肌肉缺损16例,并重建肱二头肌和肱三头肌功能;皮瓣切取面积为9cm×24cm~12cm×36cm。结果:所有的皮瓣全部存活,4例肌力恢复至M4,8例恢复到M3,随访2~6年,皮瓣外形练好,功能均达到重建。结论:应用背阔肌肌皮瓣修复上肢大面积皮肤、肌肉缺损时,能更好恢复伸屈肘关节的功能、外形,减少手术次数,减低并发症发生率,缩短住院时间,减少治疗费用,是修复上肢较大面积复合组织缺损的较佳方法。     

皮肤与骨骼复合缺损的修复

目的：探讨显微外科修复肢体骨与皮肤复合缺损的技术和效果。方法：39例肢体骨与皮肤复合缺损患接受显微外科手术：游离移植背阔肌肌皮瓣，而后髂骨植骨4例，移植髂骨皮瓣7例，移植腓骨皮瓣6例，组合移植背阔肌肌皮瓣与游离腓骨20例，组合移植双侧背阔肌肌皮瓣与游离腓骨2例。结果：移植组织完全成活30例，9例移植的（肌）皮瓣远端皮肤发生局部浅表坏死，经换药后愈合。移植骨术后12－18周与宿主骨牢固连接。平均随访3年6个月，修复肢体均恢复有用功能。14例12岁以下儿童，修复后下肢生长正常，未发生肢体不等长现象。结论：严格手术指征，准确操作、酌情选择不同皮瓣与骨复合组织移植的显微外科修复是治疗骨与皮肤缺损的有效手段。     

背阔肌肌皮瓣移位术在上臂大面积皮肤缺损中的应用

目的探讨采用背阔肌肌皮瓣治疗上臂大面积皮肤缺损的临床效果。方法采用背阔肌肌皮瓣治疗上臂大面积皮肤缺损9例,术后根据皮瓣成活情况进行评价。结果9例随访时间6周～4年,术后皮瓣完全成活8例,1例皮瓣远端边缘部分坏死。结论该皮瓣血供可靠,切取方便,应作为前臂大面积皮肤缺损治疗的首选。     

背阔肌肌皮瓣移植修复上肢大面积复合组织缺损

目的　探讨应用背阔肌肌皮瓣修复上肢大面积复合组织缺损的疗效。方法　用带蒂背阔肌肌皮瓣修复上肢皮肤肌肉缺损 3例 ,并重建肱二头肌和肱三头肌功能 ;游离背阔肌肌皮瓣修复上肢皮肤肌肉缺损 9例 ,其中 3例将胸背神经与桡神经缝合 ,另 6例将胸背神经与正中神经缝合。皮瓣切取面积为 7～ 15cm× 18～ 42cm。结果　 12例皮瓣全部存活 ,4例肌力恢复至M4,6例恢复到M3 ,2例为M3 -。结论　应用背阔肌肌皮瓣修复上肢大面积皮肤、肌肉缺损时 ,能恢复伸屈肘关节的功能及大部分伸屈手指的功能。     

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.     

旋股外侧动脉降支多叶组织瓣修复手部多部位软组织缺损

目的 探讨旋股外侧动脉降支多叶瓣修复手部多部位软组织缺损的手术方法和临床效果。方法对手部多部位软组织缺损15例,采用旋股外侧动脉降支多叶瓣修复,根据手部缺损情况设计股前外侧皮瓣,沿皮瓣穿支血管向远端继续解剖旋股外侧动脉降支,考虑好手部各缺损处间距,按需切取分叶穿支皮瓣、阔筋膜瓣、股直肌肌瓣、股外侧肌肌瓣、股中间肌肌瓣或旋股外侧动脉降支远端肌间隔瓣。形成以旋股外侧动脉降支为主干的一蒂多叶瓣,在肌瓣及阔筋膜瓣上植皮,一次修复手部多部位软组织缺损。 结果 术后无血管危象发生。修复各创面在肌瓣、阔筋膜瓣或旋股外侧动脉降支远端血管肌间隔上植皮均成活良好,外形无臃肿,植皮处恢复保护性感觉,供区创面愈合好,股四头肌肌力及膝关节屈、伸活动均正常。全部病例获得随访,随访时间6 ～ 20个月,平均8.7个月。按中华医学会手外科学会上肢部分功能评定标准：优3例,良9例,可3例,优良率80％。 结论 旋股外侧动脉降支多叶瓣能一次修复手部多部位软组织缺损,缩短手术时间及疗程,手部功能恢复良好,外形满意,是修复手部多部位软组织缺损的理想方法。     

Free tissue transfer: an advanced strategy for postinfection soft-tissue defects in the upper extremity

Surgical treatment of severe, necrotizing infections frequently leave compound defects that require complex reconstructive procedures. In the upper extremity, local flap coverage is limited because of the size of the lesions. Regarding the results of early microsurgical coverage of complex postinfectious defects of the lower extremity, the goal of this study was to evaluate the role of free tissue transfer in the treatment of severe infections in the upper extremity. Between 1994 and 1999, 24 patients with major defects as a result of severe necrotizing infections in the upper extremity underwent free tissue transfer. Parameters assessed included the success of infection control, flap survival rate, salvage of the extremity, and an outcome analysis by the Disability of Arm-Shoulder-Hand score and a visual analog scale. Patient age ranged from 17 to 75 years (average age, 50.8 years). Previous treatment of 11 patients in outlying hospitals included 4.2 operative procedures and a delay of admission to the authors' unit of 89 days. The average defect size after debridement was 10.0 x 14.4 cm. Twenty-four free flaps including 16 muscle or musculocutaneous flaps, 4 chimeric flaps from the subscapular system, and 4 osteocutaneous flaps were performed for reconstruction. The overall flap survival was 95.8%. One temporalis fascia flap (TPF) was lost as a result of vascular thrombosis, and three flaps underwent successful revision of the anastomoses. Eight patients required further minor surgical treatment. The Disability of Arm-Shoulder-Hand score yielded an average of 41.5 points, which represents a moderate impairment of activities of daily living. Visual analog scale assessment demonstrated an overall high satisfaction (9.5 points; range, 1-10 points). The data demonstrate that even in severe necrotizing infections resulting in complex acute or chronic defects, limb salvage and infection control can be achieved successfully with radical debridement and early free tissue transfer.     

上肢软组织缺损的皮瓣修复

目的 探讨应用皮瓣修复上肢软组织缺损的临床效果。方法总结1995年～2004年应用于上肢软组织修复的2512例患者、2609个皮瓣。其中应用传统皮瓣修复1992例(2089个皮瓣)，带蒂轴型皮瓣、肌皮瓣474例(474个)，游离皮瓣46例(46个)。就其手术疗效、各类皮瓣的优缺点和适应证进行分析。结果患者经1个月～9年随访，平均2．7个月。皮瓣完全成活2531个，占皮瓣总数的97．01％；完全坏死10个，占皮瓣总数的0．38％；部分坏死68个，占皮瓣总数的2．61％。传统皮瓣(2089个)术后有46个(2．2％)出现部分坏死；687个(32．9％)术后需行皮瓣去脂或整形。带蒂轴型皮瓣(474个)中有28个(5．9％)出现完全或部分坏死；82个(17．3％)术后需行整形或去脂。游离皮瓣(46个)中有4个(8．7％)出现完全或部分坏死，股前外侧皮瓣多数需行去脂术。结论传统皮瓣手术操作简便、成功率最高，但皮瓣质地差，需多次手术。带蒂皮瓣质地好、血管蒂恒定、移动范围广及手术操作相对简便，可行复合组织移植，但皮瓣成活率低于传统皮瓣，特别是逆行皮瓣的静脉回流是制约皮瓣成活的主要因素。游离皮瓣供区隐蔽，皮瓣质地好，外形与功能易于同时修复，但手术操作复杂，限制其应用。带血管蒂皮瓣是上肢组织缺损修复与功能重建的最佳方法。     

Reconstruction of soft tissue defects in the extremities with a pedicled perforator flap: series of 25 patients

Since the introduction of perforator-based flaps, new flaps have been described for reconstruction of soft tissue defects in the extremities. Pedicled perforator flaps, often called propeller flaps, are based on a single perforator and are local axial flaps that can be rotated up to 180(0) with the single perforator as the pivotal point. Pedicle perforator flaps have gained popularity because they have a shorter operating time than free flaps. However, some concern has been raised about their reliability. Here we report our results of 11 soft tissue reconstructions in the lower leg and 14 in the upper extremity. The defects were mostly traumatic or caused by release of burn scars. The mean size of the flaps in the lower leg was 52 cm(2) (range 126-15 cm(2)). In the upper extremity it was 24 cm(2) (range 12-35 cm(2)). All patients were followed until the wound had healed. In the upper extremity there was only one partial necrosis of the flap, and one patient had an infected wound. One haematoma was evacuated postoperatively, and all the rest healed uneventfully. In the lower leg we had one total necrosis and one partial necrosis of the flap and one infected wound. A free scapular flap was used for salvage in one case, and revision and skin grafting in two. The pedicled perforator flap is reliable, particularly in the upper extremity. The operation is quick and can be done under regional anaesthesia. The flap is thin and has a local texture that gives a good functional and aesthetic result. The pedicled perforator flap is a little unpredictable in the lower leg, probably because the directions of the vessels that arise from the perforator are not consistent.     

Free fillet flap application to cover forequarter or traumatic amputation of an upper extremity: A case report

Reusing tissue of amputated or unsalvageable limbs to reconstruct soft tissue defects is one aspect of the “spare parts concept.” Using a free fillet flap in such situations enables the successful formation of a proximal stump with the length needed to cover a large defect from forequarter amputation without risking additional donor‐site morbidity. The use of free fillet flaps for reconstruction after forequarter and traumatic upper extremity amputations is illustrated here in a case report. A 41‐year old patient required a forequarter amputation to resect a desmoid tumor, resulting in an extensive soft‐tissue defect of the upper extremity. A free fillet flap of the amputated arm and an additional local epaulette flap were used to reconstruct the defect. At 9 months after the procedure, a satisfactory result with a very well healed flap was attained. Free fillet flaps can be used successfully for reconstruction of large upper extremity defects, without risking additional donor‐site morbidity. © 2015 Wiley Periodicals, Inc. Microsurgery 36:700–704, 2016.     

游离腓动脉远端穿支腓肠神经营养血管皮瓣修复上肢皮肤缺损

目的 介绍游离腓动脉远端穿支腓肠神经营养血管皮瓣修复上肢皮肤缺损的手术方法.方法 2006年6月-2007年8月,应用游离腓动脉远端穿支腓肠神经营养血管筋膜蒂皮瓣修复上肢皮肤缺损6例,其中缝合皮神经4例.结果 术后6例皮瓣全部存活.随访时间为4个月至1.5年.皮瓣与供区皮肤外观基本一致,厚薄适中,弹性、质地好,外观满意;4例缝合皮神经的皮瓣感觉恢复至S2以上,余2例皮瓣恢复保护性感觉.结论 游离腓动脉远端穿支腓肠神经营养血管皮瓣是修复上肢软组织缺损的有效方法.     

The use of free anterolateral thigh flap for reconstructing soft tissue defects of the lower extremities

The goal of soft tissue reconstruction in the lower extremities is to provide a functional and cosmetically acceptable limb. The anterolateral thigh flap has become one of the most popular options for soft tissue defect reconstruction recently because of the large amount of skin available and the reliable and versatile nature of this material. The purpose of this article is to present our experiences with the free anterolateral thigh flap for the reconstruction of soft tissue defects of the lower extremity. From April 2002 to October 2003, 31 consecutive free anterolateral thigh flaps were used. There were 24 male and 7 female patients, and their ages were between 3 and 78 years. The size of the flaps ranged from 11 to 34 cm long and 6 to 16 cm wide. In 9 patients, the flaps were harvested in a flow-through manner to both reconstruct soft tissue defects and protect and maintain the vascular status of the lower extremities. In these patients, the pedicle was interposed between vascular gaps, either present or created, in the extremity. The patency of distal anastomosis with the course of the distal vessel was confirmed by using conventional Doppler flow monitoring in flow-through flaps. In 4 cases, thinning of the flap was performed. In 3 patients, flaps were used in a neurosensorial fashion. Four flaps required reoperation due to vascular compromises. While 3 of these were salvaged, 1 flap was lost due to recipient arterial problems. Sixteen cases underwent split-thickness skin grafting of the donor site. No infection or hematomas were observed. We conclude that the anterolateral thigh flap is an ideal and versatile material, especially for lower extremity reconstructions, with its functional and cosmetic advantages, and it can be considered a suitable alternative to the most commonly used conventional soft tissue flaps.     

旋股外侧动脉降支多叶组织瓣修复多指(趾)软组织缺损

目的 探讨应用旋股外侧动脉降支为蒂的一蒂多叶组织瓣一次修复多指(趾)软组织缺损的方法和临床效果.方法 2005年6月至2008年12月,收治8例多指(趾)软组织缺损患者,男5例,女3例;年龄22～38岁,平均27.6岁.设计以旋股外侧动脉降支的肌皮穿支或肌间隙穿支为蒂形成股前外侧穿支皮瓣,带股外侧皮神经前支;以股外侧肌肌支、股直肌肌支、股中间肌肌支、远端肌间隔支为分叶瓣,依受区缺损面积及各指(趾)蹼间距切取各组织瓣,在肌瓣上植全厚皮,一次修复手(足)部创面.结果 术后8例患者均未发生血管危象,植皮均成活.全部病例获6个月～3年(平均10.5个月)随访,修复各创面外形均良好,无臃肿,植皮处轻微挛缩.肌瓣植皮处恢复保护性感觉,各皮瓣两点辨别觉约8～10 mm.修复1例左足一至三趾软组织缺损病例,术后患足无疼痛及不适,负重行走正常;修复7例手部缺损病例,按中华医学会手外科学会上肢部分功能评定试用标准进行评价:优1例,良4例,可2例,优良率71%.结论 以旋股外侧动脉降支为蒂多叶组织瓣能一次修复多指(趾)软组织缺损,仅需吻合一组血管,无需行分指及整形手术,是修复多指(趾)软组织缺损的理想方法.