李廣學(xué) 穆籣 劉巖 臧夢(mèng)青 劉元波

·論著·

預(yù)擴(kuò)張的臍旁穿支皮瓣修復(fù)肘關(guān)節(jié)瘢痕攣縮畸形

李廣學(xué)1穆籣1劉巖1臧夢(mèng)青2劉元波2

目的 探討應(yīng)用預(yù)擴(kuò)張的臍旁穿支皮瓣修復(fù)燒傷后肘關(guān)節(jié)瘢痕攣縮畸形的臨床效果。方法 回顧性分析2012年6月至2015年6月中國(guó)醫(yī)學(xué)科學(xué)院整形外科醫(yī)院應(yīng)用預(yù)擴(kuò)張的臍旁穿支皮瓣修復(fù)燒傷后肘關(guān)節(jié)瘢痕攣縮畸形患者18例，其中男11例，女7例；左側(cè)8例，右側(cè)10例。術(shù)前患側(cè)肘關(guān)節(jié)活動(dòng)明顯受限。Ⅰ期手術(shù)于患側(cè)腹部臍旁埋置擴(kuò)張器，10～26周(平均18周)完成擴(kuò)張后Ⅱ期行肘瘢痕切除、攣縮松解，帶蒂臍旁穿支皮瓣轉(zhuǎn)移覆蓋肘部創(chuàng)面，3周后皮瓣斷蒂。結(jié)果 皮瓣大小為16 cm×8 cm～30 cm×14 cm，所有供區(qū)直接拉攏縫合。18例皮瓣全部成活，2例皮瓣遠(yuǎn)端由于靜脈淤血部分壞死，經(jīng)換藥處理后傷口愈合，有輕度的瘢痕增生，其他均Ⅰ期愈合。術(shù)后隨訪6～38個(gè)月(平均19個(gè)月)，肘關(guān)節(jié)功能恢復(fù)良好，6例患者進(jìn)行皮瓣修薄手術(shù)。結(jié)論 預(yù)擴(kuò)張的臍旁穿支皮瓣是一種有效的修復(fù)肘關(guān)節(jié)瘢痕攣縮畸形的方法。

肘關(guān)節(jié)；攣縮畸形；預(yù)擴(kuò)張；臍旁穿支皮瓣

燒傷后肘關(guān)節(jié)瘢痕攣縮畸形是一種較為常見的燒傷畸形，導(dǎo)致肘關(guān)節(jié)功能下降，影響美觀，嚴(yán)重影響患者的生活質(zhì)量。預(yù)擴(kuò)張的臍旁穿支皮瓣具有穿支血管恒定，供血范圍大，皮瓣面積大，供區(qū)隱蔽等優(yōu)點(diǎn)。本研究回顧性分析中國(guó)醫(yī)學(xué)科學(xué)院整形外科醫(yī)院整形十一科應(yīng)用預(yù)擴(kuò)張的臍旁穿支皮瓣修復(fù)燒傷后肘關(guān)節(jié)瘢痕攣縮畸形患者18例，并取得了滿意的臨床效果，現(xiàn)報(bào)道如下：

資 料 與 方 法

一、一般資料

2012年6月至2015年6月中國(guó)醫(yī)學(xué)科學(xué)院整形外科醫(yī)院應(yīng)用預(yù)擴(kuò)張的臍旁穿支皮瓣修復(fù)燒傷后肘關(guān)節(jié)瘢痕攣縮畸形患者18例，其中男11例，女7例；左側(cè)8例，右側(cè)10例；年齡4～46歲，平均18.8歲；其中13例熱液燙傷，5例為火焰燒傷，燒傷后6個(gè)月至6年，中位時(shí)間為13個(gè)月。術(shù)前患側(cè)肘關(guān)節(jié)活動(dòng)明顯受限，肘關(guān)節(jié)周圍無殘留的皮膚供形成局部皮瓣以修復(fù)瘢痕攣縮畸形。

二、手術(shù)方法

Ⅰ期手術(shù)置入擴(kuò)張器。首先，標(biāo)記患者肘部瘢痕及攣縮畸形，根據(jù)對(duì)側(cè)肘關(guān)節(jié)情況及患側(cè)攣縮程度估計(jì)缺損范圍，皮瓣稍微大于缺損范圍。然后，手持超聲多普勒探測(cè)患側(cè)肚臍周圍，確定臍旁皮瓣至少包含兩條穿支血管，皮瓣軸線為肚臍到同側(cè)肩胛下角連線。皮瓣上緣作為切口置入擴(kuò)張器，對(duì)于女性患者皮瓣上緣在乳房下皺襞以下，切開皮膚、皮下組織至腹外斜肌筋膜，在筋膜表面向下剝離，向中線位置剝離時(shí)應(yīng)避免損傷臍旁的穿支血管，結(jié)扎剝離過程中遇到的其他穿支血管，最終在下位肋骨水平及上腹部形成大小合適的腔穴，置入合適的長(zhǎng)方形擴(kuò)張器。置入擴(kuò)張器大小為300～800 ml，注射壺放置到外側(cè)胸壁。術(shù)后第14天開始注水，1周1次，適當(dāng)過度擴(kuò)張便于取得足夠的皮瓣及直接關(guān)閉供區(qū)，擴(kuò)張10～26周，平均18周。

Ⅱ期取出擴(kuò)張器，肘部攣縮松解、瘢痕切除，臍旁穿支皮瓣帶蒂轉(zhuǎn)移至肘部。首先再次手持多普勒確認(rèn)臍旁穿支，透光實(shí)驗(yàn)觀察皮瓣內(nèi)血管的走形情況，標(biāo)記皮瓣的范圍，原手術(shù)切口作為皮瓣的上緣。手術(shù)時(shí)首先取出擴(kuò)張器，一般保留擴(kuò)張器包膜便于保護(hù)皮瓣內(nèi)血管不受損傷，切取帶蒂臍旁皮瓣，注意術(shù)中不必解剖臍旁穿支血管，避免穿支血管的損傷，皮瓣的蒂部稍寬以便包括臍旁穿支血管和皮管的形成。術(shù)中充分松解肘關(guān)節(jié)瘢痕攣縮，將皮瓣遠(yuǎn)端轉(zhuǎn)移至肘部，如有皮瓣富余可以切除周圍部分或全部的瘢痕組織，皮瓣近端形成皮管，留置傷口引流后腹部供區(qū)直接關(guān)閉，3周后行蒂部夾閉試驗(yàn)確認(rèn)皮瓣的血供良好后斷蒂，并可以進(jìn)一步切除瘢痕以修復(fù)缺損。

結(jié) 果

擴(kuò)張器置入術(shù)后未出現(xiàn)傷口血腫、感染等并發(fā)癥，注水期間未出現(xiàn)擴(kuò)張器破裂、注射壺滲漏等并發(fā)癥。Ⅱ期皮瓣轉(zhuǎn)移至皮瓣斷蒂后18例皮瓣全部成活，2例皮瓣遠(yuǎn)端由于靜脈淤血部分壞死，經(jīng)換藥處理后傷口愈合，有輕度的瘢痕增生，其他均Ⅰ期愈合。術(shù)后隨訪6～38個(gè)月，平均19個(gè)月，肘關(guān)節(jié)功能恢復(fù)良好，活動(dòng)良好，外形良好，6例患者進(jìn)行皮瓣修薄手術(shù)。

典型病例：患者，男，7歲。因燒傷后右肘部瘢痕攣縮畸形2年就診。檢查發(fā)現(xiàn)：右肘部、右前臂瘢痕攣縮畸形，范圍約13 cm×10 cm，活動(dòng)明顯受限。Ⅰ期全麻行右側(cè)腹部600 ml長(zhǎng)方形擴(kuò)張器置入，術(shù)后定期注水，術(shù)后5個(gè)月全麻下行擴(kuò)張器取出，右肘部瘢痕攣縮松解、瘢痕切除，范圍為18 cm×12 cm，將臍旁穿支皮瓣轉(zhuǎn)移到右肘部及右前臂，皮瓣成活良好，無術(shù)后并發(fā)癥，3周后行皮瓣斷蒂，術(shù)后皮瓣全部成活，肘關(guān)節(jié)活動(dòng)良好，功能明顯改善，外形良好，效果滿意(圖1～6)。

討 論

肘關(guān)節(jié)燒傷后瘢痕攣縮畸形通常采用局部整形進(jìn)行修復(fù)，如單純或改良的Z成形及易位皮瓣[1]、雙蒂瘢痕組織瓣[2]、V-Z成形[3]、連續(xù)梯形皮瓣成形[4]、改良的八角形推進(jìn)皮瓣[5]等。雖然局部整形能夠改善肘關(guān)節(jié)的功能，但是局部瘢痕仍然殘留甚至加重，影響美觀。對(duì)于瘢痕攣縮畸形進(jìn)行充分的松解、切除部分或全部瘢痕，在創(chuàng)面上進(jìn)行游離皮片移植或皮瓣轉(zhuǎn)移修復(fù)可以減少術(shù)后瘢痕的形成。如果患者瘢痕較淺、攣縮較輕，可以選擇皮片游離移植，但是皮片移植后存在色素沉著、皮片收縮等問題，影響術(shù)后的功能和美觀要求。如果對(duì)術(shù)后的功能或美觀要求較高，或者瘢痕累及下方的肌肉、肌腱或骨骼等，則最好選擇皮瓣轉(zhuǎn)移修復(fù)。皮瓣修復(fù)可以采用臨近的皮瓣或者遠(yuǎn)位的皮瓣進(jìn)行修復(fù)，局部皮瓣可以采用橈動(dòng)脈近端穿支的島狀脂肪筋膜皮瓣[6]、尺動(dòng)脈近端穿支的脂肪筋膜皮瓣[7]、遠(yuǎn)端蒂臂內(nèi)側(cè)皮神經(jīng)營(yíng)養(yǎng)血管皮瓣[8]等，但肘關(guān)節(jié)周圍的瘢痕攣縮畸形在切除瘢痕、松解攣縮畸形缺損較大時(shí)，依靠周圍的局部皮瓣轉(zhuǎn)移進(jìn)行修復(fù)往往較為困難。因此只有遠(yuǎn)位的皮瓣游離移植或帶蒂轉(zhuǎn)移才能滿足肘關(guān)節(jié)瘢痕攣縮畸形修復(fù)對(duì)于功能和美觀的雙重要求[9]，司婷婷等[10]報(bào)道應(yīng)用側(cè)胸部Ⅱ度燒傷愈合后任意超長(zhǎng)皮瓣修復(fù)肘關(guān)節(jié)瘢痕攣縮畸形，雖然對(duì)于肘關(guān)節(jié)功能恢復(fù)有一定作用，但是恢復(fù)美觀的作用卻有限。

圖1 術(shù)前右肘部瘢痕畸形及臍旁穿支皮瓣設(shè)計(jì) 圖2 右側(cè)腹部置入擴(kuò)張器注水?dāng)U張5個(gè)月后 圖3 肘部瘢痕攣縮松解、瘢痕切除后

圖4 臍旁穿支皮瓣轉(zhuǎn)移到右肘部及右前臂 圖5 皮瓣斷蒂拆線后即刻 圖6 術(shù)后1年

1983年Taylor等[11]首次提出臍與肩胛下角連線為軸線的皮瓣，稱為延伸的腹壁下動(dòng)脈穿支皮瓣。之后其他學(xué)者將臍旁穿支皮瓣應(yīng)用于乳房再造[12]和陰囊修復(fù)[13]。近年來帶蒂臍旁穿支皮瓣轉(zhuǎn)移主要應(yīng)用于手以及前臂缺損的修復(fù)[14-16]，因?yàn)槠ぐ甑俨枯^短很難用于肘部的修復(fù)，而預(yù)擴(kuò)張的臍旁穿支皮瓣遠(yuǎn)端可以到達(dá)腋后線位置，長(zhǎng)度明顯增加，可以用于肘部缺損的修復(fù)，甚至是用于上臂缺損的修復(fù)。本研究有6例用于上臂及肘部燒傷后瘢痕攣縮畸形的修復(fù)，取得良好的功能和美觀恢復(fù)，Zang 等[17]報(bào)道應(yīng)用預(yù)擴(kuò)張的帶蒂臍旁穿支皮瓣修復(fù)上肢缺損，取得了良好的效果。

對(duì)臍旁皮瓣進(jìn)行預(yù)擴(kuò)張具有以下優(yōu)點(diǎn)：(1)可以對(duì)皮膚進(jìn)行充分的擴(kuò)張，易于取得較大面積的皮瓣，便于供區(qū)切口的關(guān)閉，減少供區(qū)瘢痕增生；(2)擴(kuò)張器置入的同時(shí)能夠結(jié)扎皮瓣下方的肋間動(dòng)脈穿支血管，使得皮瓣內(nèi)穿支體區(qū)之間阻力性吻合和潛力性吻合[18]血管得以開放，起到皮瓣延遲的作用，達(dá)到增長(zhǎng)皮瓣長(zhǎng)度的目的，使得皮瓣的遠(yuǎn)端可以達(dá)到腋后線位置，便于大范圍缺損的修復(fù)；(3)預(yù)擴(kuò)張的臍旁皮瓣使得皮瓣的厚度得以變薄，更能與上肢皮膚厚度相適應(yīng)，避免部分患者的Ⅱ期皮瓣修薄手術(shù)。本文中對(duì)于兒童和男性患者修復(fù)后不需要Ⅱ期皮瓣修薄，但是對(duì)于6例肥胖的女性，由于腹部皮下脂肪較厚，影響術(shù)后美觀，需要皮瓣修薄手術(shù)。

誠(chéng)然，應(yīng)用預(yù)擴(kuò)張的臍旁穿支皮瓣仍有一定的局限性。(1)整個(gè)操作步驟需要3～6個(gè)月時(shí)間，至少三次手術(shù)才能完成；(2)皮瓣切取過長(zhǎng)時(shí)仍有遠(yuǎn)端壞死的可能，需要術(shù)中仔細(xì)判斷皮瓣血運(yùn)，及時(shí)進(jìn)行處理；(3)擴(kuò)張器置入、擴(kuò)張注水可能發(fā)生并發(fā)癥，需要進(jìn)一步處理；(4)皮瓣轉(zhuǎn)移后需要固定3周后斷蒂，可能出現(xiàn)肩肘僵硬，部分患者尤其是老年患者可能不能耐受。因此，需要嚴(yán)格掌握手術(shù)適應(yīng)證，對(duì)于大面積的肘關(guān)節(jié)及周圍缺損的患者推薦采用該手術(shù)方式，并在術(shù)前對(duì)患者進(jìn)行充分的教育，避免圍手術(shù)期并發(fā)癥的發(fā)生。

綜上所述，預(yù)擴(kuò)張的臍旁穿支皮瓣能夠充分增加皮瓣的大小，對(duì)于選擇合適的大面積肘關(guān)節(jié)瘢痕攣縮畸形患者，能夠起到功能和美觀雙重修復(fù)的目的。

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李廣學(xué),穆籣,劉巖，等.預(yù)擴(kuò)張的臍旁穿支皮瓣修復(fù)肘關(guān)節(jié)瘢痕攣縮畸形[J/CD]. 中華肩肘外科電子雜志,2016,4(1):24-28.

Reconstruction of elbow scar contracture using pre-expanded perforator-based paraumbilical flaps

LiGuangxue1,MuLan1,LiuYan1,ZangMengqing2,LiuYuanbo2.

1DepartmentofAestheticSurgery,PekingUniversityPeople′sHospital,Beijing100044,China;2DepartmentofPlasticandReconstructiveSurgery,PlasticSurgeryHospital,Beijing100144,China

Correspondingauthor:LiuYuanbo,Email：ybpumc@sina.com

Background The scar contracture of elbow joint is a common postburn deformity, limiting the joint range of motion, influencing beauty and the patient′s quality of life. For elbow scar contractures, the main surgical treatment is contracture release by removing the scar tissue and covering the defect with sufficient tissue. But it is still highly challenging to restore the functional and aesthetic elbow for large defect. Skin grafting is the simplest option to resurfacing the elbow defect, but it usually lead to poor functional and aesthetic results due to skin contraction and pigmentation. Various types of flaps have been suggested for reconstruction of elbow scar contracture. A Z plasty, V-Y flaps or a transpositional flap technique can be used to release a simple scar contracture. However, local and regional flaps are difficult to restore the large elbow defect after releasing the scar constracture due to the limited available surrounding tissue and limited skin flexibility. Therefore, a distant flap sometimes is needed to reconstruct the extensive defect of the elbow. The anterior truck provide abundant well-pefused flap, such as superficial inferior epigastric artery (SIEA) flap, intercostal artery flap and perforator-based paraumbilical flaps. However, the usage of these flaps was limited because of insufficient soft tissue when dealing with large defect, thick abdominal portion and limited pedicle length. The pre-expanded perforator-based paraumbilical flaps overcome these limitations and provide thin, reliable coverage with the best functional and aesthetic results. We present our experience in reconstructing elbow scar contracture using pre-expanded perforator-based paraumbilical flaps.Methods The elbow scar contracture was corrected in 18 cases with pre-expanded perforator-based paraumbilical flaps, with 8 cases in the left side and 10 cases in the right side including 11 male cases and 7 female cases. Aged 4 years to 46 years with an average age of 18.8 years. Burn injury causes: 13 cases were injuried with hot liquid and 5 case were flame burns, the median time was 18 months from 6 months to 6 years after burn. Elbow joint movement was obviously limited preoperatively, and there were no abundant skin surrounding the elbow to repair the defect after the scar contracture release.Operative method: During the first-stage procedure, the expander was implanted into the ispilateral normal abdominal subcutaneous tissues. First of all, the elbow scar and contracture deformity was marked, and the extent of the defect after scar contracture release was estimated according to the contralateral elbow joint and the extent of the ispilateral side. The flap for reconstruction was slightly larger than the defect. Then two large perforators were detected in the ipsilateral paraumbilical area with hand-held ultrasound Doppler, the axis of the flap was oriented along the axis between the umbilicus and the ipsilateral inferior angle of scapula. The incision was made at the superior edge of the flap. In women, the incision was made under the inframammary fold to prevent breast deformation. Then, we cut the skin, subcutaneous tissue to the superficial external oblique aponeurosis, stripping down along the fascia. We should carefully dissect medially beyond the lateral border of the rectus abdominis to avoid damage to the main paraumbilical perforators, the perforators encountering during the dissection were ligated with suture or bipolar coagulator. At last, an appropriate pocket was formed between the lower ribs and upper abdomen, a proper rectangular expander was implanted, the size of expander was 300 ml to 800 ml, and the expander valve was put at the lateral chest wall routinely. Expander was begun to inject with normal saline two weeks postoperatively, once a week until enough volume was achieved. The flap was usually over-expanded to obtain sufficient flap and direct closure of the abdominal donor site. The expansion time was 10 weeks to 26 weeks with an average time of 18 weeks. During the second-stage procedure, the expander was removed and the expanded perforator-based paraumbilical flaps was elevated and transferred to repair elbow skin defect after scar contracture resection and release. The paraumbilical perforators were relocated with hand-held ultrasound Doppler, transillumination test was used to observe the running situation of the flap vessel. The dimension of flap was marked and the previous incision served as the superior edge of the flap. Firstly, the expander was removed with capsule preserving to avoid damaging the underlying perforators. The pedicle was wide enough to include the identified perforators and facilitate the tube formation. However, there was no need to dissect the perforators intraoperatively. The elbow contracture was completely released, the flap transferred to repair elbow skin defect with part or entire scar tissue resection. The proximal part of flap was sutured to form the skin tube. The abdominal donor site was closed directly after wound drainage placement. The pedicle clamping test was done to confirm the good flap blood supply and the pedicle was divided 3 weeks postoperatively. The rest scar was excised and repaired. The extra proximal flap was re-inserted back to the abdominal donor site.Results There were no wound hematoma, infection and other complications after expander implantation. There were no expander rupture, leakage of injection pot and other complications during injection period. The size of expanded perforator-based paraumbilical flaps ranged from 16 cm × 8 cm to 30 cm × 14 cm, and all abdominal donor sites were closed directly. The donor sites were closed directly in all cases. All flaps survived, except for partial necrosis in two cases due to venous congestion, and they healed after dressing change with mild scar hypertrophy. After 6 months to 38 months (mean 19 months) follow-up, the function of elbow joint recovered well postoperatively. Flap debulking was done in 6 cases.Conclusion The pre-expanded perforator-based paraumbilical flap is an effective procedure for elbow joint scar contracture with extensive defect.

Elbow joint;Scar contracture;Pre-expanded;Perforator-based paraumbilical flaps

10.3877/cma.j.issn.2095-5790.2016.01.005

中央高?；究蒲袠I(yè)務(wù)費(fèi)專項(xiàng)資金資助(3332013160)

100044北京大學(xué)人民醫(yī)院醫(yī)療美容科1；100144北京，中國(guó)醫(yī)學(xué)科學(xué)院整形外科醫(yī)院整形十一科2

劉元波，Email：ybpumc@sina.com

2016-01-05)