穿支皮瓣理念设计背阔肌瓣修复下肢缺损

背景：尽管胸背动脉穿支皮瓣能减轻供区损伤和避免受区臃肿，但是由于分离穿支相当费时，有人认为仅限于经验丰富医生并主张保留部分肌肉组织。 目的：探讨应用穿支皮瓣理念设计的背阔肌皮瓣游离移植修复下肢的移植方案及其修复效果。 方法：纳入17例需要皮瓣移植的患者，12例背阔肌肌(皮)瓣，3例保留部分肌袖的背阔肌瓣和2例分叶背阔肌组织瓣均采用穿支皮瓣理念设计，根据胸背动脉的供血范围，皮瓣靠前设计，以供区能直接拉拢缝合为度，切取时将胸背动脉外侧支的皮穿支包含在内。必要时可再向内侧切除背阔肌肌瓣以扩大移植组织块面积，有时为了修复两个相邻部位的缺损，可切取保留部分肌袖的背阔肌瓣和以胸背动脉外侧支营养的部分背阔肌肌瓣并形成分叶背阔肌组织瓣。组织瓣切取范围12 cm×8 cm~28 cm×17 cm。观察患者皮瓣移植后成活情况、皮瓣供区和受区的外形及功能。 结果与结论：皮瓣移植后1例血管危象发生，探查重新吻合血管后危象解除，所有皮瓣均成活；1例肌瓣植皮部分坏死，二期植皮修复；供区创面均直接拉拢缝合。15例患者随访3~18个月，其中2例皮瓣外形臃肿，影响穿鞋，二期行皮瓣修薄术。提示应用穿支皮瓣理念设计背阔肌瓣能有效减轻供区损伤和受区臃肿畸形，分叶背阔肌组织瓣能较好修复足底和足尖两处软组织缺损，结合穿支皮瓣理念、个性化设计不同形式的背阔肌瓣可满意修复较大下肢皮肤软组织缺损。 关键词：背阔肌瓣；下肢缺损；修复；皮瓣移植；穿支皮瓣

Improved latissimus dorsi flap free grafting based on perforator flap conception for repairing soft tissue defects in the lower extremity

BACKGROUND: Thoracodorsal artery perforator flap can relieve damage to donor site and avoid bulk in the recipient site, but dissociation of perforating branch took time. Some one believed that it should be done by very experienced physicians and some muscle tissues should be reserved. OBJECTIVE: To investigate the method, effectiveness and clinical application of improved latissimus dorsi flap based on perforator flap conception for reconstruction of soft tissue defects of lower extremity. METHODS: A total of 17 patients needing skin flap transplantation were selected. 12 latissimus dorsi musculocutaneous/ muscle flaps, 3 latissimus dorsi flaps with a few muscle and 2 double-leaf segmental latissimus dorsi compound flaps were designed based on perforator flap conception. According to the territory of latissimus dorsi musculocutaneous flap, a skin paddle in which anterior underlying muscle and main perforator was designed, extend about to the anterior edge of the latissimus dorsi muscle. An additional latissimus dorsi muscle flap was selected for soft tissue enlargement if necessary. Sometimes, double-leaf segmental latissimus dorsi musculocutaneous/muscle flap, including one muscle-sparing latissimus dorsi musculocutaneous flap and the other segmental latissimus dorsi muscle flap nourished by the lateral branches of the thoracodorsal vessels was selected to repair two adjacent defects. The harvested tissue area ranged from 12 cm×8 cm to 28 cm×17 cm. Survival state of skin flap, together with shape and function of donor site and recipient site of skin flap were observed. RESULTS AND CONCLUSION: Following skin flap transplantation, one case developed vascular crisis that was relieved following re-exploration for vessel anastomosis. All skin flap survived. Second-stage skin grafting was done on one muscle flap wound. All donor sites were sutured directly. After a follow-up of 3 to 18 months in 15 cases, only two cases received two-stage plastic operation because bulky flaps brought some trouble in wearing shoes. Improved latissimus dorsi flap based on perforator flap conception can reduce damage to the donor site and the receipt area bulk. Double-leaf segmental latissimus dorsi compound flaps can repair both heel and toe wound. The versatile latissimus dorsi flap designed using thoracodorsal artery perforator flap conception is an ideal flap for repairing widespread soft tissue defects in the lower extremity.