Hamdi Moustapha, Van Landuyt Koenraad, Monstrey Stan, Blondeel Phillip
Department of Plastic Surgery Department, Gent University Hospital, Gent, Belgium.
Plast Reconstr Surg. 2004 Apr 1;113(4):1175-83. doi: 10.1097/01.prs.0000110332.74289.2b.
Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.
传统的游离皮瓣，如桡侧臂皮瓣、臂外侧皮瓣和肩胛皮瓣，由于供区一期缝合的限制，很少足以覆盖上肢的大面积皮肤缺损。肌肉或肌皮瓣更多地用于这些缺损。然而，它们会导致大量肌肉组织的牺牲以及随之而来的供区并发症。穿支皮瓣或联合皮瓣是覆盖大面积缺损的更好选择。将肌肉用作联合皮瓣的一部分仅限于非常特殊的适应证，所需肌肉量限制在最小程度以降低供区并发症。作者报告了1999年12月至2002年3月期间治疗的一系列12例上肢广泛缺损患者。平均缺损大小为21×11cm。7例患者使用了穿支皮瓣（5例胸背动脉穿支皮瓣和4例腹壁下深动脉穿支皮瓣）。5例患者需要联合皮瓣，即基于单个蒂的两种不同类型组织的组合（1例患者为肩胛皮瓣与胸背动脉穿支皮瓣联合，4例患者为胸背动脉穿支皮瓣与背阔肌劈开联合）。1例患者，对腕部的腹壁下深动脉穿支皮瓣立即进行手术去脂以立即获得薄覆盖。平均手术时间为5小时20分钟（范围为3至7小时）。除1例联合皮瓣因术后血肿导致皮肤部分坏死外，所有皮瓣均完全存活。所有病例均获得了充分的覆盖和完全的伤口愈合。穿支皮瓣可成功用于覆盖肢体的大面积缺损，供区并发症最小。联合皮瓣提供大量组织、广泛的活动度以及易于塑形、造型和去脂。
