-
传统皮瓣修复目的是使皮瓣成活并达到创面愈合,对于皮瓣受区形态和功能的恢复,尤其是皮瓣供区损伤问题,没有给予足够重视[1]。自杨果凡等[2]于1981年首次报道前臂皮瓣并应用于头颈部软组织修复后,其一度成为头颈部修复重建的主要手段[3-4]。然而,前臂皮瓣尚存在较为明显的缺陷,如牺牲测量桡动脉血管、需要开辟第二供区进行创面植皮、供区瘢痕明显且影响功能等[5-8]。1989年KOSHIMA等[9]报道以腹壁下动脉为蒂的下腹部皮瓣用于修复口底以及腹股沟缺损,被视为穿支皮瓣的研究开端。近年来,随着修复重建外科的不断发展,在保证修复重建效果的同时,尽可能减少供体区域损害已逐渐成为修复重建外科医生的共识[10]。以腹壁浅动脉和旋髂浅动脉为蒂的下腹部浅动脉穿支皮瓣,因其不涉及腹壁肌层和主干血管,可行“双组手术”以及供区并发症较少等优势,逐渐应用于口腔颌面部软组织缺损的修复重建[11-13]。本研究选择下腹部浅动脉穿支皮瓣与前臂皮瓣各15例,对两者供区远期并发症进行回顾性分析,探讨前者在临床应用中的价值与优势。现作报道。
-
观察组15例中14例皮瓣全部存活,1例术后72 h皮瓣颜色变紫,及时手术探查发现静脉回流受阻,去除吻合口栓子后,静脉血流速减慢,重新吻合通畅,皮瓣颜色未见明显好转,术后第10天,皮瓣部分坏死,创面延期愈合;供区创面经潜行分离后,均直接拉拢缝合,平均复查时间为7个月(术后3~15个月)。对照组15例皮瓣全部存活,供区创面均植皮修复,平均复查时间为8个月(术后3~15个月)。
-
2组病人主观评价中肌力减退情况差异无统计学意义(P>0.05),观察组感觉异常、供区外观主观评价情况均明显优于对照组(P < 0.01)(见表 1)。对于瘢痕位置的倾向性选择,30例回访病人中27例倾向瘢痕位于下腹部,表示无所谓的有1例,倾向于前臂的有2例。绝大部分病人表示前臂瘢痕容易暴露,影响美观。其中2例瘢痕倾向于前臂病人,均为行前臂皮瓣修复的男性病人,表示对瘢痕位置不在乎,认为其外观对生活影响不大。
分组 n 肌力减退 感觉异常 供区外观不满意 观察组 15 1(6.67) 1(6.67) 1(6.67) 对照组 15 5(33.33) 15(100.00) 11(73.33) P — >0.05△ < 0.01△ < 0.01△ △示Fisher′s确切概率法 表 1 2组病人供区功能主观评价情况比较[n;百分率(%)]
-
2组病人供区感觉与功能的客观检查中,观察组肌力减退、感觉异常情况均优于对照组(P < 0.05和P < 0.01)(见表 2)。供区外观客观检查结果显示,观察组病人瘢痕色泽、厚度、血管分布、柔韧度和总分均明显优于对照组(P < 0.01)(见表 3)。增生瘢痕及色素沉着典型病例见图 1。
分组 n 肌力减退 感觉异常 观察组 15 0(0.00) 1(6.67) 对照组 15 5(33.33) 15(100.00) P — < 0.05△ < 0.01△ △示Fisher′s确切概率法 表 2 供区功能客观检查情况比较[n;百分率(%)]
分组 n 色泽 厚度 血管分布 柔韧度 总分 观察组 15 0.73±0.70 0.87±0.64 1.00±0.66 1.07±0.59 3.67±1.45 对照组 15 2.40±0.63 2.60±0.63 2.13±0.64 2.47±0.74 9.60±1.40 t — 6.87 7.46 4.76 5.73 11.39 P — < 0.01 < 0.01 < 0.01 < 0.01 < 0.01 表 3 2组病人供区外观VSS量表评分比较(x±s;分)
下腹部浅动脉穿支皮瓣与前臂皮瓣供区远期功能恢复的比较
Comparison of the long-term functional recovery of the donor site between the superficial inferior abdominal artery perforator flap and forearm flap
-
摘要:
目的比较口腔癌病人同期应用下腹部浅动脉穿支皮瓣和前臂皮瓣供区术后远期并发症,评价下腹部浅动脉穿支皮瓣在临床应用中的价值。 方法回顾性分析因病灶扩大切除而行游离下腹部浅动脉穿支皮瓣(腹壁浅动脉穿支皮瓣或旋髂浅动脉穿支皮瓣)修复的口腔癌病人15例(观察组)临床资料,以及同期行前臂皮瓣修复的口腔颌面软组织缺损病人15例(对照组),比较2组病人术后供区远期并发症发生情况,包括感觉异常、瘢痕增生以及色素沉着等,并评估供区远期功能恢复情况。 结果观察组病人供区创面经潜行分离后,直接拉拢缝合,术后仅遗留线形瘢痕,对美观和功能影响较小;对照组病人供区创面均植皮修复,术后供区瘢痕增生和色素沉着较明显。病人皮瓣术后供区主观感受比较显示,2组肌力减退情况差异无统计学意义(P>0.05),观察组感觉异常、供区外观主观评价情况均明显优于对照组(P<0.01)。2组病人供区感觉与功能、外观的客观检查中,观察组肌力减退、感觉异常情况均优于对照组(P<0.05和P<0.01),瘢痕色泽、厚度、血管分布、柔韧度和总分亦均明显优于对照组(P<0.01)。 结论应用下腹部浅动脉穿支皮瓣修复,供区并发症少,对供区美观、功能影响小,是口腔颌面部软组织缺损修复的较好选择。 Abstract:ObjectiveTo evaluate the clinical value of the superficial inferior abdominal artery perforator flap in oral cancer patients by comparing the long-term complications of the donor site between the superficial inferior abdominal artery perforator flap and forearm flap. MethodsThe clinical data of 15 oral cancer patients(observation group) treated with free superficial inferior abdominal artery perforator flaps(superficial inferior epigastric artery perforator flaps or superficial circumflex iliac artery perforator flaps) for extensive resection of lesions and 15 oral and maxillofacial soft tissue defect patients(control group) treated with forearm flaps to repair at the same time were retrospectively analyzed.The long-term complications of the donor site(including paresthesia, hyperplasia of scar and pigmentation) were compared between two groups, and the long-term functional recovery of the donor site was evaluated in two groups. ResultsIn the observation group, the donor wound was directly pulled and sutured after stealth separation, and only linear scar was left after surgery, which had little effect on aesthetics and function.In the control group, the skin grafting was performed on the donor wounds, and the postoperative hyperplasia and hyperpigmentation of scars were obvious.The comparison results of the subjective feelings of patients in the donor site after skin flap surgery showed that there was no statistical significance in the decrease of muscle strength between two groups(P>0.05), and the paresthesia and subjective evaluation of the donor site appearance in observation group was significantly better than those in control group(P < 0.01).In the objective examination of the sensation, function and appearance of the donor site of patients in two groups, the muscle strength decreasing and paresthesia in observation group were better than those in control group(P < 0.05 and P < 0.01), and the color, thickness, vascular distribution, flexibility and total score of scar in observation group were also significantly better than those in control group(P < 0.01). ConclusionsThe superficial inferior abdominal artery perforator flap is a good choice for the repair of oral and maxillofacial soft tissue defects, which has less complications at the donor site and less influence on the appearance and function of the donor site. -
表 1 2组病人供区功能主观评价情况比较[n;百分率(%)]
分组 n 肌力减退 感觉异常 供区外观不满意 观察组 15 1(6.67) 1(6.67) 1(6.67) 对照组 15 5(33.33) 15(100.00) 11(73.33) P — >0.05△ < 0.01△ < 0.01△ △示Fisher′s确切概率法 表 2 供区功能客观检查情况比较[n;百分率(%)]
分组 n 肌力减退 感觉异常 观察组 15 0(0.00) 1(6.67) 对照组 15 5(33.33) 15(100.00) P — < 0.05△ < 0.01△ △示Fisher′s确切概率法 表 3 2组病人供区外观VSS量表评分比较(x±s;分)
分组 n 色泽 厚度 血管分布 柔韧度 总分 观察组 15 0.73±0.70 0.87±0.64 1.00±0.66 1.07±0.59 3.67±1.45 对照组 15 2.40±0.63 2.60±0.63 2.13±0.64 2.47±0.74 9.60±1.40 t — 6.87 7.46 4.76 5.73 11.39 P — < 0.01 < 0.01 < 0.01 < 0.01 < 0.01 -
[1] 唐举玉, 汪华侨, HALLOCK GG, 等. 关注皮瓣供区问题——减少皮瓣供区损害专家共识[J]. 中华显微外科杂志, 2018, 41(1): 3. doi: 10.3760/cma.j.issn.1001-2036.2018.01.001 [2] 杨果凡, 陈宝驹, 高玉智. 前臂皮瓣游离移植术(附56例报告)[J]. 中华医学杂志, 1981, 61(3): 139. doi: 10.3760/j:issn:0376-2491.1981.03.007 [3] ORANGES CM, LING B, TREMP M, et al. Comparison of anterolateral thigh and radial forearm free flaps in head and neck reconstruction[J]. In Vivo, 2018, 32(4): 893. doi: 10.21873/invivo.11325 [4] KIM MS, OH KH, CHO JG, et al. Assessment of chronological volume changes in radial forearm free flaps for tongue cancer[J]. ORL J Otorhinolaryngol Relat Spec, 2020, 6: 1. [5] KRANE NA, MOWERY A, AZZI J, et al. Reconstructing forearm free flap donor sites using full-thickness skin grafts harvested from the ipsilateral arm[J]. Otolaryngol Head Neck Surg, 2020, 162(3): 277. doi: 10.1177/0194599819901124 [6] PIRLICH M, HORN IS, MOZET C, et al. Functional and cosmetic donorsite morbidity of the radial forearm-free flap: comparison of two different coverage techniques[J]. Eur Arch Otorhinolaryngol, 2018, 275(5): 1219. doi: 10.1007/s00405-018-4908-5 [7] 姚麟, 郭萌萌, 邓璋, 等. 对偶三角瓣联合原位小面积全厚皮片修复前臂游离皮瓣供区缺损[J]. 中国口腔颌面外科杂志, 2020, 18(1): 64. [8] 洪鹏宇, 高陆, 邱冠华, 等. 前臂皮瓣与股前外侧皮瓣修复口腔癌术后缺损临床研究[J]. 口腔医学研究, 2019, 35(1): 46. [9] KOSHIMA I, SOEDA S. Inferior epigastric artery skin flaps without rectus abdominis muscle[J]. Br J Plas Surg, 1989, 42(6): 645. doi: 10.1016/0007-1226(89)90075-1 [10] 张敬良. 努力追求创面修复的"泳裤供区"理念[J]. 中华显微外科杂志, 2020, 43(1): 3. doi: 10.3760/cma.j.issn.1001-2036.2020.01.002 [11] 王宏伟, 郭兵, 马春跃, 等. 腹壁浅动脉穿支皮瓣修复口腔颌面部软组织缺损3例报道[J]. 中国口腔颌面外科杂志, 2018, 16(1): 78. [12] 王栋, 刘亮, 杨东昆, 等. 腹壁浅动脉穿支皮瓣一期修复口腔癌术后软组织缺损三例[J]. 中华显微外科杂志, 2019, 42(6): 579. doi: 10.3760/cma.j.issn.1001-2036.2019.06.016 [13] 阮敏, 马春跃, 周辉红, 等. 旋髂浅动脉穿支皮瓣修复颊癌术后缺损的临床应用[J]. 口腔医学研究, 2017, 33(9): 966. [14] 张铁柱, 毛驰, 姜颖, 等. 修复口腔缺损常用游离皮瓣供区表面感觉的研究[J]. 现代口腔医学杂志, 2007, 21(6): 573. doi: 10.3969/j.issn.1003-7632.2007.06.005 [15] SELBER JC, NELSON J, FOSNOT J, et al. A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: part Ⅰ. unilateral reconstruction[J]. Plast Reconstr Surg, 2010, 126(4): 1142. doi: 10.1097/PRS.0b013e3181f02520 [16] 崔秋菊, 毛驰, 栾修文, 等. 腓肠内侧动脉穿支皮瓣和前臂皮瓣的术后供区影响对比[J]. 口腔疾病防治, 2018, 26(8): 514. [17] 孔燕, 刘志华, 崔应麟. 延续综合护理及康复训练联合高压氧治疗对急性缺血性脑卒中病人Lovett肌力分级及NIHSS评分的影响[J]. 中国老年学杂志, 2018, 38(4): 793. doi: 10.3969/j.issn.1005-9202.2018.04.011 [18] 刘海兵, 唐丹, 曹海燕, 等. 温哥华瘢痕量表的信度研究[J]. 中国康复医学杂志, 2006, 21(3): 240. doi: 10.3969/j.issn.1001-1242.2006.03.015 [19] 刘亮, 张凯, 李建成, 等. 个性化前臂皮瓣在口腔颌面部缺损修复的临床观察[J]. 中华显微外科杂志, 2017, 40(1): 30. doi: 10.3760/cma.j.issn.1001-2036.2017.01.010 [20] 陈永锋, 张凯, 李建成, 等. 前臂皮瓣联合邻近组织瓣修复腭及上颌组织缺损早期疗效[J]. 中国修复重建外科杂志, 2011, 25(9): 1051. [21] 刘元波, 朱珊, 臧梦青, 等. 穿支皮瓣研究领域的新技术、新方法[J]. 中华整形外科杂志, 2019, 35(9): 835. doi: 10.3760/cma.j.issn.1009-4598.2019.09.001 [22] KANSY K, HOFFMANN J, ALHALABI O, et al. Long-term donor site morbidity in head and neck cancer patients and its impact on quality of life: a cross-sectional study[J]. Int J Oral Maxillofac Surg, 2019, 48(7): 875. doi: 10.1016/j.ijom.2019.01.009 [23] WANG F, DING X, ZHANG J, et al. Somatosensory changes at forearm donor sites following three different surgical flap techniques[J]. Int J Surg, 2018, 53: 326. doi: 10.1016/j.ijsu.2018.04.008 [24] 张凯, 王栋, 高廷益, 等. 彩色多普勒超声辅助下腹部浅动脉供血皮瓣修复颌面部软组织缺损[J]. 中华整形外科杂志, 2019, 35(12): 1200. doi: 10.3760/cma.j.issn.1009-4598.2019.12.007 [25] CHANG EI, LIU J. Prospective comparison of donor site morbidity following radial forearm and ulnar artery perforator flap harvest[J]. Plast Reconstr Surg, 2020, 145(5): 1267. doi: 10.1097/PRS.0000000000006790 [26] ITO O, IGAWA HH, SUZUKI S, et al. Evaluation of the donor site in patients who underwent reconstruction with a free radial forearm flap[J]. J Reconstr Microsurg, 2005, 21(2): 113. doi: 10.1055/s-2005-864844 [27] ORLIK JR, HORWICH P, BARTLETT C, et al. Long-term functional donor site morbidity of the free radial forearm flap in head and neck cancer survivors[J]. J Otolaryngol Head Neck Surg, 2014, 43(1): 1. doi: 10.1186/1916-0216-43-1 [28] 王晓敏, 张凯, 马士崟, 等. 腹壁浅动脉皮瓣的应用解剖研究[J]. 中国修复重建外科杂志, 2010, 24(11): 1357.