Baker P A, Watson S B
Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK.
J Plast Reconstr Aesthet Surg. 2007;60(7):828-34. doi: 10.1016/j.bjps.2007.03.001. Epub 2007 Apr 19.
Restoration of lost opposition in the context of significant thenar soft tissue defects represents a tremendous reconstructive challenge. Free functioning muscle transfer has been described in this context and has the advantage of providing both a functioning muscle unit as well as soft tissue coverage in a single reconstructive procedure. It adds to the injured limb, and by sparing donor tendons avoids the need for re-education of motor function. We describe the use of a free innervated gracilis muscle flap for functional thenar reconstruction in two unique cases following extensive traumatic loss of thenar skin and musculature. Crucially, in each case, the recurrent motor branch of the median nerve had been destroyed at its point of insertion into the thenar muscle remnants.
To date, the main reported disadvantages of free functioning muscle transfer in thenar reconstruction include difficult flap dissections, donor site morbidity, inadequate strength and excursion of the transplanted muscle and excessively bulky flaps. Our aim was, as far as possible, to address these issues.
Each thenar defect was measured and a corresponding segment of gracilis muscle, measured in situ, was raised on the proximal neurovascular pedicle. End-side microvascular anastomosis was performed between the medial circumflex femoral artery and the radial artery. The venae comitantes of the pedicle were anastomosed end-end with those of the radial artery and also with the cephalic vein. Epineural anastomosis was performed between the motor branch of the obturator nerve and the recurrent motor branch of the median nerve. Each flap was covered with a split thickness skin graft.
Both flaps survived without any complication. Both patients regained excellent voluntary thumb opposition, sufficient to allow return to full-time employment, and had restoration of sufficient thenar bulk. This was achieved with minimal donor site morbidity.
Restoration of lost opposition, in the context of significant thenar soft tissue defects, can be achieved using a free functional gracilis flap. This produces clinically excellent functional results and can be carried out as a single stage reconstructive procedure. This is a novel application of a tremendously versatile donor muscle in functioning free muscle transfer.
在大鱼际软组织严重缺损的情况下恢复已丧失的对掌功能是一项巨大的重建挑战。在这种情况下，已有人描述了游离功能性肌肉移植，其优点是在单一重建手术中既能提供一个有功能的肌肉单元，又能覆盖软组织。它增加到受伤肢体上，并且通过保留供体肌腱避免了运动功能再训练的需要。我们描述了在两例大鱼际皮肤和肌肉广泛创伤性缺失后的独特病例中，使用游离带神经支配的股薄肌皮瓣进行大鱼际功能重建。至关重要的是，在每例病例中，正中神经的返支运动支在其插入大鱼际肌残余处已被破坏。
迄今为止，在大鱼际重建中，游离功能性肌肉移植主要报道的缺点包括皮瓣解剖困难、供区并发症、移植肌肉力量和活动度不足以及皮瓣过于臃肿。我们的目的是尽可能解决这些问题。
测量每个大鱼际缺损，在近端神经血管蒂上掀起一段在原位测量的相应股薄肌。在旋股内侧动脉与桡动脉之间进行端侧微血管吻合。蒂的伴行静脉与桡动脉的伴行静脉以及头静脉进行端端吻合。闭孔神经的运动支与正中神经的返支运动支进行神经外膜吻合。每个皮瓣覆盖以断层皮片。
两个皮瓣均存活，无任何并发症。两名患者均恢复了良好的拇指自主对掌功能，足以允许恢复全职工作，并且大鱼际丰满度得到恢复。这是以最小的供区并发症实现的。
在大鱼际软组织严重缺损的情况下，可使用游离功能性股薄肌皮瓣恢复已丧失的对掌功能。这产生临床上优异的功能结果，并且可作为单阶段重建手术进行。这是一种极其通用的供体肌肉在游离功能性肌肉移植中的新应用。
