各种皮瓣在足底负重区恶性黑色素瘤术后缺损修复中的应用

目的：探讨足底内侧皮瓣、局部逆行岛状皮辫、外踝上穿支皮瓣、内踝上穿支皮瓣和游离股前外侧皮瓣修复足底负重区恶性黑色素瘤广泛切除术后缺损的优缺点。方法：浙江省肿瘤医院骨和软组织肿瘤外科2010-01-13-2013-12～25收治的23例足底负重区皮肤恶性黑色素瘤患者，进行原发灶广泛切除后分别采用足底内侧皮瓣、局部逆行岛状皮瓣、外踝上穿支皮瓣、内踝上穿支皮瓣及游离股前外侧皮瓣进行修复，对其临床资料和随访结果进行分析。结果：术后缺损面积为4cm×4cm～11cm×9cm，切取皮瓣面积5cmX5cm～12cm×10cm。14倒足底内侧皮瓣全部成活，其中皮瓣最大切取面积为7cm×7cm。1例局部逆行岛状皮瓣出现小部分坏死，二期愈合，4例外踝上及内踝上穿支皮瓣全部成活，其中皮瓣最大切取面积为12cm×10cm。4例游离股前外侧皮瓣中，3例成活，1例皮瓣出现远端部分浅表性坏死，经换药后愈合。所有患者无继发性渍疡出现，患足均可无痛行走。2例行足底内侧皮瓣修复术后出现局部复发。结论：各种皮瓣修复足底黑色素瘤术后缺损均可获得较好疗效，对较小足根部的缺损（直径〈8cm）首选足底内侧皮瓣，较大的缺损可采用内外踝上穿支皮瓣，有显微外科条件的可考虑游离股前外侧皮瓣修复局部皮瓣不能覆盖的缺损。

Application of various flaps for reconstruction of defects in weight bearing area of the foot after large resection in malignant melanoma

OBJECTIVE：To explore the advantages and disadvantages of the reconstruction of defects in weight bear ing area of the foot after large resection in malignant melanoma with medial plantar flap, reverse island flap, upper perforator flap of the lateral malleolus, upper perforator flap of the medial malleolus and free anterolateral thigh flap. METHODS： We treated 23 cases of cutaneous malignant melanoma whose primary loci located on weight bearing area of the foot be- tween January 13,2010 and December 25,2013. After wide exeition of primary foci, we used medial plantar flap, upper per- forator flap of the medial malleolus,upper perforator flap of the lateral malleolus,reverse island flap and free anterolateral thigh flap to reconstruct the defects. The clinical and follow-up data were analyzed. RESULTS：The area of defects ranged from 4 cm×4 cm to 11 cm×9 cm,and skin flaps was 5 cm×5 cm to 12 crux 10 cm in size. Forteen cases of medial plantar flaps survived, One of the biggest skin flaps was 7 cm × 7 em in size. one case of local reverse island flap had small necrosis area and healed late. All upper perforator flaps of the lateral malleolus survived,one of the biggest skin flaps was 12 cm× 10 cm in size. In all 4 cases of free anterolateral thigh flaps, three survived perfectly, one flap survived with partial necrosis and healed after changing dressings. There was no secondary ulcers and pain- walking. Two cases using medial plantar flap appeared local recurrence. CONCLUSIONS Various flaps can achieve good clinical effectiveness in treating defects of the foot after large resection in malignant melanoma. Small deficit （diameter〈8 cm） located in front of the heel should use medial plantar flap,wide defects can use the lateral branch pedicle flap. Free antero lateral thigh flap can be used for the defects which can not be covered by local flaps in hospitals with microsurgieal capacity.