自由式穿支皮瓣在臀部压疮修复中的应用

目的 探讨自由式穿支皮瓣在臀部压疮修复中的临床应用价值。方法 回顾性研究。纳入2013年12月-2019年7月苏州大学附属第二医院整形外科采用自由式穿支皮瓣修复臀部压疮患者39例,其中男22例、女17例,平均年龄71岁;骶尾部19例,股骨转子部9例,坐骨结节部7例,骶尾部合并股骨粗隆部4例。术前应用多普勒探查并标记出缺损周围血流流速超过2.5 cm/s的穿支血管,以此穿支为自由式穿支皮瓣的供血血管,以血管穿出点所在位置为旋转点,结合常规的皮瓣供区选择原则优选供区。常规行清创术,彻底切除溃疡周围坏死及失活组织,包括创面周围瘢痕及纤维化组织,直至创面新鲜。清创后创面组织活力好、无炎性反应患者行一期皮瓣修复术;清创术后创面组织活力较差、有潜在局部感染倾向患者,创面应用负压封闭引流装置,每次5～7 d,更换1～3次,待创面肉芽生长良好后行二期皮瓣修复术。39例患者臀部压疮修复共采用螺旋桨皮瓣34个、旋转皮瓣9个、V-Y推进皮瓣7个,其中单个皮瓣修复30例、组合皮瓣修复9例;皮瓣切取范围为10.5 cm×6.5 cm~22.0 cm×7.0 cm;供区均直接拉拢缝合。术后密切观察皮瓣成活情况,对症处理;随访术后功能、外形及复发情况。结果 术后37例切口一期愈合,皮瓣顺利成活;1例术后皮瓣下出血,皮瓣远端部分坏死,二次清创,游离皮瓣及周边软组织,拉拢缝合修复;1例静脉回流不畅,皮瓣淤血,针刺放血处理后,切口延迟愈合。供区切口均一期愈合。术后随访时间3~24个月,平均6个月。39例患者术后皮瓣供区与受区功能及外形均满意,其中2例因护理不当分别于术后半年和1年臀部压疮复发。结论 自由式穿支皮瓣既减少了传统轴型皮瓣或肌皮瓣的较大手术创伤,又避免在设计与操作中因血管解剖异常造成的困难,且血供可靠、操作简便,是修复压疮的理想皮瓣之一。

Application of freestyle perforator flap to repair pressure sores in the buttocks

Objective This study aimed to evaluate the use of freestyle perforator flap in repairing pressure sores in the buttocks.Methods From December 2013 to July 2019, we repaired 39 cases (22 males and 17 females; mean age=71 years) of pressure sores in the buttocks by using a freestyle perforator flap. Among the cases, 19 were in the sacral part, 9 in the femur trochanter, 7 in the ischial tuberosity, and 4 in the sacral part with femur trochanter. Before surgery, the perforator vessels with flow rate of more than 2.5 cm/s around the defect were detected and marked with Doppler. This perforator was used as the blood supply vessel of the free perforator flap. The position of the vascular perforator point was used as the rotation point, and the donor area was optimized in combination with the conventional flap donor area selection principle.After conventional surgical debridement by removing necrotic and inactivated tissues around the ulcer, including scar and fibrotic tissues around the wound, patients with good tissue vitality and no inflammatory reaction on the wound received one-stage flap repair. Conversely, patients with poor tissue vitality and potential tendency for local infection on the wound were subjected to applied vacuum-sealing drainage of the wound for 5-7 days, which were replaced three times, followed by flap repair until good granulation growth on the wound was achieved. During surgery, 34 propeller flaps, 9 rotating flaps, and 7 V-Y propelled flaps were used, among which 30 cases were repaired with single flap and 9 cases with combined flap. The flap resection ranged from 10.5 cm×6.5 cm to 22.0 cm×7.0 cm. All donor areas were sewed and stitched directly. Flap survivability was observed in terms of on time after operation, and treatment was adopted according the symptoms that appeared. Postoperative functional appearance and recurrence were followed-up.Results After operation, the wounds of 37 cases healed in the first stage, and all flaps survived successfully. One case suffered from postoperative bleeding that resulted in necrosis on the distal part; the necrotic tissue was debrided, and the residual flap was dissociated from the surrounding soft tissue and repaired in the secondary stage. One case showed congestion caused by poor venous circulation, and healing was delayed after acupuncture blood-letting treatment. All incisions in the donor area healed in the first stage. All patients were followed-up for 3-24 months (average=6 months) with satisfactory functional and aesthetic outcomes. Two cases recurred because of improper nursing.Conclusions The freestyle perforator flap can reduce the major surgical trauma of the traditional axial flap and musculocutaneous flap and can avoid the difficulties caused by abnormal vascular anatomy during design and operation. This method also has the advantages of reliable blood supply and easy operation. Two cases recurred because of improper nursing the freestyle perforator flap is ideal for repairing pressure sores in the buttocks.