Kokosis George, Phillips Brett T, Soo Joanne, Poveromo Luke, Erdmann Detlev, Mantyh Christopher R, Migaly John, Levinson Howard
Department of Plastic and Reconstructive Surgery, MD Anderson Cancer Center, Houston, TX.
Duke University School of Medicine, Durham, NC.
Ann Plast Surg. 2019 Feb;82(2):218-223. doi: 10.1097/SAP.0000000000001672.
Primary perineal closure following abdominal perineal resection (APR) is reported to have a wound complication rate as high as 66%, whereas flap reconstruction reduces wound complications to 15% to 35%. A modified de-epithelialized V-Y fasciocutaneous flap aims to further improve results in this patient population.
To study the breaking force of a simple interrupted suture in either skin or subcutaneous fat, various quantitative assessments were performed in a porcine flap model using uniaxial static tensile testing with an Instron tensiometer, with a single or triple row of 3 Vicryl sutures in both skin and fat.An outcomes analysis was performed in 24 patients who underwent modified V-Y flap reconstruction after APR. Primary outcome was wound complications including infection, dehiscence, seroma, hematoma, and pelvic fluid collections.
Tensile strength of sutures anchored in skin was found to be up to 8 times stronger than sutures anchored in subcutaneous fat in a single row and 3 times as strong in 3 rows (breaking force, 500.2 N vs 263.7 N). In our patient cohort of 24 irradiated cancer patients, 10 (42%) had wound healing complications. Wound dehiscence of various degrees accounted for 80% of these complications. Five patients with wound complications (50%) had associated pelvic fluid collections (infection, 1; wound dehiscence, 4). Minor dehiscence was more likely to occur after suture removal and less likely to be associated with pelvic collections compared to patients with major dehiscence. Our study yields total complication rates lower than what is reported in the literature for anterolateral thigh or gracilis flap including much lower infection rates, and almost similar results to the commonly used vertical rectus myocutaneous muscle.
Tension-free de-epithelialized V-Y flap use after APR effectively reconstructs the defect while eliminating an additional donor site. Benchtop studies suggest enhanced flap integrity yielded by layered closure. Wound complications can be managed with local care in their majority (90%). Staggering or delaying suture removal can decrease minor dehiscence. Based on analysis of our results, review of the literature and consideration of donor site morbidity, we believe that modified V-Y flap is the best approach for APR reconstruction in irradiated patients.
据报道，腹会阴联合切除术（APR）后进行一期会阴缝合的伤口并发症发生率高达66%，而皮瓣重建可将伤口并发症发生率降至15%至35%。改良的去上皮化V-Y筋膜皮瓣旨在进一步改善该患者群体的治疗效果。
为研究单纯间断缝合在皮肤或皮下脂肪中的抗拉力，在猪皮瓣模型中使用Instron张力计进行单轴静态拉伸试验，在皮肤和脂肪中分别采用单排或三排3-0薇乔缝线进行各种定量评估。对24例行APR后改良V-Y皮瓣重建的患者进行结果分析。主要结局是伤口并发症，包括感染、裂开、血清肿、血肿和盆腔积液。
发现单排固定在皮肤中的缝线抗张强度比固定在皮下脂肪中的缝线高8倍，三排时高3倍（抗拉力，500.2 N对263.7 N）。在我们24例接受放疗的癌症患者队列中，10例（42%）出现伤口愈合并发症。各种程度的伤口裂开占这些并发症的80%。5例有伤口并发症的患者（50%）伴有盆腔积液（感染1例；伤口裂开4例）。与严重裂开的患者相比，轻微裂开更可能在拆线后发生，且与盆腔积液的相关性较小。我们的研究得出的总并发症发生率低于文献报道的大腿前外侧或股薄肌皮瓣的发生率，包括更低的感染率，且与常用的腹直肌肌皮瓣结果几乎相似。
APR后使用无张力去上皮化V-Y皮瓣可有效重建缺损，同时消除额外的供区。体外研究表明分层缝合可增强皮瓣完整性。大多数伤口并发症（90%）可通过局部处理。错开或延迟拆线可减少轻微裂开。基于对我们结果的分析、文献回顾以及对供区发病率的考虑，我们认为改良V-Y皮瓣是放疗患者APR重建的最佳方法。
