Mericli Alexander F, Martin Justin P, Campbell Chris A
Charlottesville, Va. From the Department of Plastic Surgery, University of Virginia Health System.
Plast Reconstr Surg. 2016 Mar;137(3):1004-1017. doi: 10.1097/01.prs.0000479973.45051.b6.
Prior radiation therapy, pelvic dead space, and a dependent location contribute to perineal dehiscence rates as high as 66 percent after primary closure of pelvic wounds. Various regional flaps have been described to reconstruct pelvic defects, but an algorithmic pairing of individual flaps to specific anatomical regions has not been described.
A retrospective review of a prospectively maintained database was performed to identify consecutive pelvic reconstructions from 2010 to 2013 with at least 6 months' follow-up. Pelvic defects and resulting flaps were described by anatomical subunits involved: anterolateral thigh flap for mons, gracilis flap for labia majora and introitus, vertical rectus abdominis myocutaneous flap for vagina and/or perineal raphe, and gluteus musculocutaneous flap for isolated perianal defects.
Twenty-seven women and three men underwent consecutive pelvic reconstruction with a mean age of 60 years (range, 26 to 83 years) and a mean body mass index of 28 kg/m(2) (range, 17 to 40 kg/m(2)). Twenty-one patients (70 percent) had prior radiation therapy. In total, 45 flaps were performed according to the subunit principle. Three patients had a minor dehiscence (<5 cm), one patient had a major dehiscence, and one required reoperation for abscess. There were two partial flap losses necessitating débridement and readvancement of the flap. Twenty-five percent of female patients were sexually active after vaginal reconstruction.
The pelvic subunit principle provides an effective algorithm for choosing the ideal pedicled flap for each region involved in acquired pelvic defects. This algorithm is based on individual attributes that make each flap most appropriate for each subunit. Complications were minimal and patient satisfaction with appearance and function was excellent.
既往放疗、盆腔死腔以及位置低垂等因素导致盆腔伤口一期缝合后会阴裂开率高达66%。已有多种局部皮瓣用于重建盆腔缺损，但尚未有将个体皮瓣与特定解剖区域进行算法匹配的描述。
对前瞻性维护的数据库进行回顾性分析，以确定2010年至2013年间连续进行的盆腔重建病例，且随访时间至少6个月。根据所涉及的解剖亚单位描述盆腔缺损及所用皮瓣：股前外侧皮瓣用于阴阜，股薄肌皮瓣用于大阴唇和阴道口，腹直肌肌皮瓣用于阴道和/或会阴缝，臀大肌肌皮瓣用于孤立的肛周缺损。
27名女性和3名男性连续接受盆腔重建，平均年龄60岁（范围26至83岁），平均体重指数28 kg/m²（范围17至40 kg/m²）。21例患者（70%）曾接受过放疗。总共根据亚单位原则进行了45例皮瓣手术。3例患者出现轻度裂开（<5 cm），1例患者出现重度裂开，1例因脓肿需要再次手术。有2例皮瓣部分坏死，需要进行清创和皮瓣再次推进。25%的女性患者在阴道重建后恢复了性生活。
盆腔亚单位原则为为获得性盆腔缺损所涉及的每个区域选择理想的带蒂皮瓣提供了一种有效的算法。该算法基于使每个皮瓣最适合每个亚单位的个体特征。并发症极少，患者对外观和功能的满意度很高。
