Touam C, Rostoucher P, Bhatia A, Oberlin C
Service de Chirurgie Orthopédique et Traumatologique, H pital Bichat, Paris, France.
Plast Reconstr Surg. 2001 Feb;107(2):383-92. doi: 10.1097/00006534-200102000-00013.
Skin defects over the lower one-fourth of the leg and over the foot are difficult to cover. Two types of pedicled fasciocutaneous flaps used to cover such defects were studied: the lateral supramalleolar flap and the distally based sural neurocutaneous flap. The series consisted of 27 and 36 cases, respectively. The lateral supramalleolar flap was used 27 times: for skin defects over the ankle (4), foot (16), and leg (7). The distally based sural neurocutaneous flap was used 42 times: over the foot (24), ankle (13), and leg (5). Fourteen of these patients were 65 years of age or older, and local vascularity was diminished in 16 cases. The flaps were evaluated clinically twice: in the immediate postoperative period for survival or for partial or total flap necrosis, and again to determine the presence of pain at the donor or recipient sites and the cosmetic appearance. Thirty-nine patients (62 percent) were reviewed subsequently, with a mean follow-up of 5 years for the supramalleolar flap and 2 years for the sural neurocutaneous flap. The results were evaluated for the presence or absence of pain, the appearance of the flap, the disability due to the insensate nature of the flap, and the presence or absence of secondary ulceration. Painful neuromata were noted in three cases with the sural neurocutaneous flap, whereas complete necrosis of the supramalleolar artery flap occurred in three patients. The distally based sural neurocutaneous island flap is very reliable, even in debilitated patients. Though the lateral supramalleolar artery flap offers the possibility of covering the same areas as the sural neurocutaneous flap, it is much less reliable in the presence of diminished local vascularity (18.5 percent failure rate as compared with 4.8 percent for the sural neurocutaneous flap). Because the procedure can cover extensive defects and is easy to perform, the distally based sural neurocutaneous flap was the method of choice for covering skin defects over the foot, heel, ankle, and the lower one-fourth of the leg. The lateral supramalleolar artery flap is indicated only when the sural neurocutaneous flap is contraindicated.
小腿下四分之一及足部的皮肤缺损难以覆盖。我们研究了两种用于覆盖此类缺损的带蒂筋膜皮瓣：外踝上外侧皮瓣和远端蒂腓肠神经营养血管皮瓣。该系列分别包括27例和36例。外踝上外侧皮瓣使用了27次：用于踝关节（4例）、足部（16例）和小腿（7例）的皮肤缺损。远端蒂腓肠神经营养血管皮瓣使用了42次：用于足部（24例）、踝关节（13例）和小腿（5例）。这些患者中有14例年龄在65岁及以上，16例局部血运减少。对皮瓣进行了两次临床评估：术后即刻评估皮瓣存活情况或部分或完全坏死情况，再次评估以确定供区或受区是否存在疼痛以及外观情况。随后对39例患者（62%）进行了复查，外踝上外侧皮瓣平均随访5年，腓肠神经营养血管皮瓣平均随访2年。评估结果包括有无疼痛、皮瓣外观、皮瓣感觉缺失导致的功能障碍以及有无继发性溃疡。腓肠神经营养血管皮瓣有3例出现疼痛性神经瘤，而外踝上外侧动脉皮瓣有3例发生完全坏死。远端蒂腓肠神经营养血管岛状皮瓣非常可靠，即使在身体虚弱的患者中也是如此。虽然外踝上外侧动脉皮瓣有可能覆盖与腓肠神经营养血管皮瓣相同的区域，但在局部血运减少的情况下可靠性要低得多（失败率为18.5%，而腓肠神经营养血管皮瓣为4.8%）。由于该手术能够覆盖广泛的缺损且操作简便，远端蒂腓肠神经营养血管皮瓣是覆盖足部、足跟、踝关节及小腿下四分之一皮肤缺损的首选方法。仅在腓肠神经营养血管皮瓣禁忌时才选用外踝上外侧动脉皮瓣。
