Grishkevich Viktor M
From the Department of Reconstructive and Plastic Surgery, A.V. Vishnevsky Institute of Surgery of the Russian Academy of Medical Sciences, Moscow, Russia.
J Burn Care Res. 2014 May-Jun;35(3):e143-50. doi: 10.1097/BCR.0b013e3182a2a74f.
Scar ulcers that spread over the Achilles tendon and posterior heel disturb patients by causing pain, impeding hygiene, and creating difficulty in finding appropriate shoe wear. As this region undergoes pressure, effective reconstruction is based on the flap use. The most popular flaps currently used are distally based sural fasciocutaneous flap, calcaneal artery skin flap, and free flaps. These flaps, however, are insensate, can create soft-tissue excess, and cause donor site morbidity. Ulcerous soft-tissue defects over Achilles tendon and posterior heel after burns, frost, and trauma were studied and reconstructed in 16 patients, using proximally based sural adipose-cutaneous flap, the anatomy of which was studied on lower extremities of 27 cadavers. Ulcerous soft-tissue defect consists of two parts: ulcer and surrounding pathologic scars that should be excised in one block. Resulting soft-tissue defects with exposed tendon and calcaneal bone varied from 6 to 20 cm in length and 6 cm in width. For such wound resurfacing a flap was developed that was sensate, thin, large, and having steady blood circulation. The flap was harvested from the lower third of the leg and lateral foot, consisting of skin and subcutaneous fat layer (without fascia), including the sural nerve and lesser vein. The blood supply was ensured through peroneal and anterior tibial artery perforators, which formed a vascular net in the flap. In 14 of 16 cases excellent and stable functional and good cosmetic results with acceptable donor site morbidity were achieved. In two patients the distal flap loss took place because of arteriitis obliterans (one case) and because of the cross-cutting of the sural nerve and vessels during previous surgeries (another case). Proximally based sural adipose-cutaneous/scar flap is the only flap that satisfies all requirements for Achilles tendon and posterior heel region resurfacing. The author believes that this technique, based on this flap use, is anatomically justified, clinically profitable, and should be considered as the first choice operation.
蔓延至跟腱和足跟后部的瘢痕溃疡会引发疼痛、影响卫生并导致难以找到合适的鞋履，从而给患者带来困扰。由于该区域承受压力，有效的重建手术需依赖皮瓣的使用。目前最常用的皮瓣是远端蒂腓肠肌筋膜皮瓣、跟骨动脉皮瓣和游离皮瓣。然而，这些皮瓣缺乏感觉，可能导致软组织过多，并引发供区并发症。对16例烧伤、冻伤和创伤后跟腱及足跟后部的溃疡软组织缺损患者进行了研究，并采用近端蒂腓肠脂肪皮瓣进行重建，该皮瓣的解剖结构在27具尸体的下肢上进行了研究。溃疡软组织缺损由两部分组成：溃疡和周围的病理性瘢痕，应整块切除。由此产生的伴有肌腱和跟骨外露的软组织缺损长度为6至20厘米，宽度为6厘米。为了覆盖此类创面，研发了一种有感觉、薄、大且血液循环稳定的皮瓣。该皮瓣取自小腿下三分之一和足外侧，由皮肤和皮下脂肪层（无筋膜）组成，包括腓肠神经和小静脉。通过腓动脉和胫前动脉穿支确保血供，这些穿支在皮瓣内形成血管网。16例中有14例获得了优异且稳定的功能和良好的美容效果，供区并发症可接受。2例患者出现远端皮瓣坏死，1例是由于闭塞性动脉炎，另1例是由于先前手术中腓肠神经和血管被横断。近端蒂腓肠脂肪皮/瘢痕瓣是唯一满足跟腱和足跟后部区域重建所有要求的皮瓣。作者认为，基于这种皮瓣使用的技术在解剖学上合理，临床上有益，应被视为首选手术。
