Abstract
目的
探讨 Flow-through 嵌合旋股外侧动脉降支穿支皮瓣移植修复四肢合并深部死腔的皮肤软组织缺损的可行性及疗效。
方法
2014 年 5 月—2017 年 6 月，收治 6 例合并深部死腔、骨缺损或骨关节与肌腱外露的四肢皮肤软组织缺损患者。患者均为男性；年龄 26～60 岁，平均 44 岁。致伤原因：交通事故伤 4 例，机器绞轧伤 1 例，重物砸伤 1 例。损伤部位：下肢 5 例，上肢 1 例。创面范围 7 cm×4 cm～26 cm×10 cm。合并骨缺损 3 例，骨关节及肌腱外露 3 例，慢性骨髓炎 2 例，主干动脉损伤 2 例。采用 Flow-through 嵌合旋股外侧动脉降支穿支皮瓣移植修复，股外侧肌瓣填塞深部死腔，穿支皮瓣覆盖浅表创面。肌瓣切取范围 5 cm×2 cm～20 cm×5 cm，穿支皮瓣切取范围 10 cm×5 cm～28 cm×11 cm。供区直接闭合。
结果
术后皮瓣均顺利成活，受区创面与供区切口均Ⅰ期愈合。患者均获随访，随访时间 3～24 个月，平均 10 个月。所有皮瓣颜色、质地良好，重建的主干动脉通畅，患肢末梢血运良好。皮瓣供区仅遗留线性瘢痕，股四头肌肌力正常，膝关节活动无影响。
结论
Flow-through 嵌合旋股外侧动脉降支穿支皮瓣移植不仅能实现创面的立体修复，而且不牺牲受区主干血管，是修复四肢合并深部死腔、伴（或不伴）受区主干动脉缺损的有效方法之一。
Keywords: 旋股外侧动脉降支穿支皮瓣, Flow-through, 嵌合皮瓣, 四肢, 创面修复
Abstract
Objective
To investigate the feasibility and efficacy of the Flow-through chimeric anterolateral thigh perforator (ALTP) flap for one-stage repair and revascularization in complex defects of the extremities.
Methods
Between May 2014 and June 2017, 6 patients with soft tissue defects on the limbs combined with dead space, bone defects, or tendon and joint exposure, were reconstructed with the Flow-through chimeric ALTP flap. All 6 patients were male. The patients’ mean age was 44 years (range, 26-60 years). The mechanisms of injury were traffic accidents in 4 cases, wringer injury in 1 case, and bruise injury caused by heavy object in 1 case. The defects located at the lower extremity in 5 cases and at the upper extremity in 1 case. The area of the wound ranged from 7 cm×4 cm to 26 cm×10 cm. There were 3 cases of bone defect, 3 cases of joint and tendon exposure, 2 cases of chronic osteomyelitis, and 2 cases of main artery injury. The muscle flap was inserted into the deep dead space, with perforator flap for superficial defect. The area of perforator flap ranged from 10 cm×5 cm to 28 cm×11 cm and the area of muscle flap ranged from 5 cm×2 cm to 20 cm×5 cm. The defects on the donor sites were closed directly.
Results
All the flaps were survival without infection and vascular crisis. The wounds of recipient and donor sites healed at first intention. The patients were followed up 3- 24 months (mean, 10 months). Good color and texture of flaps was achieved. The reconstructed main artery patency was achieved and the end of the affected limb was well transported. Only linear scar left on the donor site on thigh with no malfunction.
Conclusion
The Flow-through chimeric ALTP flap can construct three-dimensional soft tissue defects without sacrificing the recipient vessels. The Flow-through chimeric ALTP flap is an reliable and ideal method for reconstruction of complex wounds in the limbs with dead space and with or without recipient major vessels injury.
Keywords: Anterolateral thigh perforator flap, Flow-through, chimeric flap, extremity, wound repair
旋股外侧动脉降支血管体区穿支皮瓣具有血供可靠、可切取面积大、解剖较为恒定、血管蒂长及口径粗等优点，临床应用广泛。除单纯穿支皮瓣外，还衍生了 Flow-through、联体、分叶、嵌合、显微削薄等特殊形式穿支皮瓣[1-6]。对于深部组织缺损同时合并主干血管损伤的严重肢体损伤，临床处理十分棘手，部分创面经久不愈，形成慢性骨髓炎，最终导致截肢等严重后果。对于此类创面的修复，传统肌皮瓣由于肌瓣与皮瓣不能分离，不能实现创面的立体修复；肌瓣与皮瓣组合移植可达有效修复，但供区损伤大、手术风险高，临床应用受限[7-9]。2014 年 5 月—2017 年 6 月，我们采用 Flow-through 嵌合旋股外侧动脉降支穿支皮瓣移植术式，修复合并深部死腔、骨缺损或骨关节与肌腱外露的四肢皮肤软组织缺损 6 例，获得了满意的临床效果。报告如下。
1. 临床资料
1.1. 一般资料
本组患者均为男性；年龄 26～60 岁，平均 44 岁。致伤原因：交通事故伤 4 例，机器绞轧伤 1 例，重物砸伤 1 例。损伤部位：下肢 5 例，其中左侧小腿 3 例，右侧小腿 2 例；左手 1 例。患者入院前均接受 1 次及以上清创或修复手术。受伤至本次入院时间为 3～14 d，平均 7 d。入院检查：皮肤软组织缺损且合并不同程度死腔，创面感染或渗出明显；创面范围 7 cm×4 cm～26 cm×10 cm；合并骨缺损 3 例，骨关节及肌腱外露 3 例，慢性骨髓炎 2 例，主干动脉损伤 2 例。
1.2. 手术方法
患者于全麻后取平卧位，止血带下清创，彻底清除创面变性、坏死及炎性肉芽组织和坏死骨质。游离受区血管，测量所需血管蒂长度。依据创面形状、面积、合并死腔大小、所需血管蒂长度，选择对侧肢体设计 Flow-through 嵌合旋股外侧动脉降支穿支皮瓣。采用“逆行四面解剖法”切取皮瓣[1, 10]，穿支显露后，于穿支旁分开股外侧肌及股直肌肌间隙，顺穿支游离合适的穿支蒂长度，转而显露分离出旋股外侧动脉降支血管，确认其至肌肉的分支及至皮瓣的穿支，分别以各分支为蒂切取肌瓣和穿支皮瓣，直至汇入旋股外侧降支血管主干，各独立组织瓣完全游离后逐一检查其血运，确定血运可靠后依据所需血管蒂长度断蒂。肌瓣切取范围 5 cm×2 cm～20 cm×5 cm，穿支皮瓣切取范围 10 cm×5 cm～28 cm×11 cm。采用肌瓣填塞死腔，穿支皮瓣覆盖浅表创面，将旋股外侧动脉降支近端与受区主干动脉近端吻合，其远端与受区主干动脉远端吻合，并吻合其伴行静脉。皮瓣供区创口直接闭合。对于软组织条件好、未合并感染的非主要创面，在穿支皮瓣手术的基础上联合植皮手术进行创面修复。
2. 结果
术后皮瓣均顺利成活，未发生血管危象与感染，皮瓣受区创面与供区切口均Ⅰ期愈合。患者均获随访，随访时间 3～24 个月，平均 10 个月。所有皮瓣颜色、质地良好，重建的主干动脉通畅，患肢末梢血运良好，冬天无变凉、怕冷情况。皮瓣供区仅遗留线性瘢痕，股四头肌肌力正常，膝关节活动无影响。
3. 典型病例
患者 男，46 岁。交通事故伤致左小腿皮肤软组织缺损，内踝骨缺损合并骨与肌腱外露及深部死腔。伤后至手术时间为 1 d，创面面积为 7 cm×6 cm。设计并切取 Flow-through 嵌合旋股外侧动脉降支穿支皮瓣，其中采用大小为 5 cm×4 cm 的股外侧肌瓣填塞深部死腔，大小为 10.0 cm×6.5 cm 的旋股外侧动脉降支穿支皮瓣覆盖浅表创面。为避免牺牲胫后动脉主干，将旋股外侧动脉降支近端与胫后动脉近端吻合，其远端与胫后动脉远端吻合，并吻合其伴行静脉 2 根。皮瓣供区直接缝合，小腿近端创面植皮修复。术后皮瓣成活良好，创面及供区切口均Ⅰ期愈合。患者获随访 23 个月，皮瓣颜色、质地好，外形不臃肿。供区仅遗留线性瘢痕，大腿功能无影响。见图 1。
图 1.
A typical case
典型病例
a. 术前创面；b. 术前皮瓣设计；c. 术中切取皮瓣；d. 血运重建示意图；e. 术后即刻创面；f. 术后供区直接闭合；g. 术后 23 个月受区；h. 术后 23 个月供区
a. The wound before operation; b. Flap designed before operation; c. Flap harvested during operation; d. Reconstruction diagram of blood supply; e. The wound at immediate after operation; f. The donor site sutured directly; g. The recipient site at 23 months after operation; h. The donor site at 23 months after operation
4. 讨论
4.1. Flow-through 嵌合旋股外侧动脉降支穿支皮瓣的定义
Flow-through 嵌合旋股外侧动脉降支穿支皮瓣是指在旋股外侧动脉降支血管体区切取一个旋股外侧动脉降支穿支皮瓣，同时切取一个或多个股外侧肌瓣，各组织瓣仅以穿支与旋股外侧动脉降支连接，股外侧肌瓣用于填塞深部死腔，穿支皮瓣覆盖浅表创面，移植时将旋股外侧动脉降支的近端与受区主干动脉近端吻合、其远端与受区主干动脉远端吻合，并吻合其伴行静脉，由此重建多个组织瓣的血液循环并重建受区主干动脉连续性。该术式是 Flow-through 旋股外侧动脉降支穿支皮瓣和嵌合旋股外侧动脉降支穿支皮瓣技术的组合，是由旋股外侧动脉降支穿支皮瓣衍生的一种新的皮瓣类型[11-12]。
4.2. Flow-through 嵌合旋股外侧动脉降支穿支皮瓣的优点与适应证
该皮瓣不仅保留了 Flow-through 旋股外侧动脉降支穿支皮瓣的优势，在重建皮瓣血液循环的同时可以重建受区缺损的主干动脉（或避免牺牲受区主干动脉），其重建的皮瓣血流动力学最接近生理（可平衡和缓冲血流），可以降低皮瓣血管危象的发生率[13-16]；同时吸取了嵌合旋股外侧动脉降支穿支皮瓣的优点，股外侧肌瓣血供好，抗感染能力强，股外侧肌瓣与旋股外侧动脉降支穿支皮瓣仅通过旋股外侧动脉降支穿支相连，各组织瓣均有一定自由度，股外侧肌瓣可自由填充死腔，皮瓣自由覆盖体表创面，该皮瓣移植仅需吻合一组母体血管，不仅能实现创面的立体修复，而且重建或不牺牲受区血管，取得了满意的修复效果[17-19]。该术式适用于四肢合并深部死腔和主干动脉损伤的创面修复，同时也适合不伴主干动脉缺损、合并深部死腔创面的重建，应用 Flow-through 技术可以避免牺牲肢体主干动脉。
4.3. Flow-through 嵌合旋股外侧动脉降支穿支皮瓣存在问题与注意事项
Flow-through 嵌合股前外侧穿支皮瓣需要切取一级源血管（旋股外侧动脉降支）和股外侧肌瓣，创伤相对较大，出血较多，应注意术中止血和术后引流。各组织瓣都有旋股外侧动脉降支分出的独立营养血管支配，皮瓣移植时要注意理顺血管蒂，防止扭转与卡压。
综上述，Flow-through 嵌合旋股外侧动脉降支穿支皮瓣在修复浅表创面的同时，可以一期重建肢体主干动脉缺损和有效填塞深部死腔，是修复合并深部死腔与主干动脉缺损的肢体创面的有效方法之一。
Funding Statement
国家自然科学基金资助项目（81472104）
National Natural Science Foundation of China (81472104)
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