Puri Vinita, Mahendru Sanjay, Rana Roshani
Department of Plastic, Reconstructive Surgery and Burns, Seth G.S. Medical College and King Edward Memorial Hospital, Parel, Mumbai 400 012, India.
J Plast Reconstr Aesthet Surg. 2007;60(12):1331-7. doi: 10.1016/j.bjps.2007.07.003. Epub 2007 Aug 23.
This study was undertaken in an attempt to improve the versatility of the posterior interosseous artery flap (PIA flap) and to decrease flap complication rate. The PIA flap was used for resurfacing 25 cases of the hand and distal forearm over a 2-year period. Observations were made on the anatomy of the PIA flap and its distal reach. Doppler analysis was made a mandatory part of the preoperative planning. Flaps were also raised from the zone of injury if Doppler confirmed the presence of good perforators. No attempt was made to identify the anastomosis between the anterior interosseous artery (AIA) and the PIA prior to flap raising since its presence was ascertained preoperatively with a Doppler and flap raising could begin straightway, saving precious tourniquet time. The surgical technique was further modified to include a large amount of fascia and subcutaneous tissue with the flap. This could perhaps be the reason for survival of larger flaps, absence of venous congestion and the low complication rate seen in our series. These flaps were used to resurface defects involving the dorsum of the hand, palm, distal forearm, wrist and fingers (both dorsal and volar surfaces). The distal reach of the flap was improved by exteriorising the pedicle and bowstringing it across the wrist which was kept in extension. The flap could thus easily reach the distal interphalangeal joint. This exteriorised pedicle was covered with a split thickness skin graft and was divided 3 weeks later under local anaesthesia making it a two-stage procedure. Adipofascial and osteocutaneous PIA flaps were also used depending on the requirement. Out of 25 flaps, 23 were of the adipofascial variety and one each of the fascial and osteocutaneous type. The majority of the patients were between 21 and 30 years old. Trauma was the leading cause of tissue deficit in our series (19/25). Within the trauma group occupational mishap (entrapment of hand in roller machine, presser machine, etc.) was the leading cause, road traffic accident being the next most common. The most common site of defect was the dorsum of the hand (14/25). The largest flap measured 12x8cm and the smallest flap measured 3x2cm. Only three minor complications were noted, two cases of partial flap loss (one of them needing a secondary procedure of debridement and grafting) and one partial graft loss in the case of fascial flap which needed regrafting. Importantly no evidence of venous congestion was noted in any of the flaps.
本研究旨在提高骨间后动脉皮瓣（PIA皮瓣）的通用性并降低皮瓣并发症发生率。在2年期间，使用PIA皮瓣为25例手部和前臂远端进行创面修复。对PIA皮瓣的解剖结构及其远端延伸范围进行了观察。术前规划中强制进行多普勒分析。如果多普勒证实存在良好的穿支血管，皮瓣也可从损伤区域掀起。在掀起皮瓣之前，未尝试识别骨间前动脉（AIA）与PIA之间的吻合情况，因为术前已通过多普勒确定其存在，可直接开始掀起皮瓣，节省宝贵的止血带时间。手术技术进一步改良，在皮瓣中包含大量筋膜和皮下组织。这可能是我们系列中较大皮瓣存活、无静脉淤血且并发症发生率低的原因。这些皮瓣用于修复涉及手背、手掌、前臂远端、腕部和手指（背侧和掌侧）的缺损。通过将蒂部引出并在保持伸展的腕部呈弓弦状，改善了皮瓣的远端延伸范围。皮瓣因此可轻松到达远侧指间关节。这个引出的蒂部覆盖有断层皮片，并在3周后在局部麻醉下切断，使其成为一个两阶段的手术。根据需要还使用了脂肪筋膜和骨皮PIA皮瓣。在25个皮瓣中，23个是脂肪筋膜型，筋膜型和骨皮型各1个。大多数患者年龄在21至30岁之间。在我们的系列中，创伤是组织缺损的主要原因（19/25）。在创伤组中，职业事故（手被卷入滚筒机、压机等）是主要原因，道路交通事故是第二常见原因。最常见的缺损部位是手背（14/25）。最大的皮瓣尺寸为12×8cm，最小的皮瓣尺寸为3×2cm。仅记录到3例轻微并发症，2例皮瓣部分坏死（其中1例需要进行清创和植皮的二次手术），1例筋膜皮瓣出现部分植皮坏死，需要再次植皮。重要 的是，在任何皮瓣中均未发现静脉淤血的迹象。
