低旋转点腓肠神经筋膜皮瓣修复足部中远端组织缺损的临床应用(1)
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[摘要]目的：探讨应用低旋转点腓肠神经筋膜皮瓣修复足部中远端组织缺损的方法。方法：降低腓肠神经筋膜皮瓣的旋转点至外踝尖0～3cm范围,使皮瓣旋转后可以达到足远端，皮瓣一期转移，共修复10例，皮瓣面积5cm×6cm～12cm×18cm。结果：9例皮瓣全部成活，1例皮瓣远端出现约2cm2左右皮肤坏死，后行换药、植皮修复。结论：降低腓肠神经筋膜皮瓣的旋转点可用于修复足远端皮肤软组织缺损，解决了足部中远端组织缺损修复这一难题；其血供安全可靠，切取转移简便易行，拓展了该皮瓣的应用范围。
[关键词]腓肠神经筋膜皮瓣；足部；软组织缺损
[中图分类号]R622[文献标识码]A[文章编号]1008-6455(2011)03-372-03
Make down the pivot point of sural neurofasciocutaneous flap to reconstruct tissue defects of middle or distant foot
XU Jin1,WANG Ming-gang1,LI Yong2,WU Zhu-ming2,YU Yong2
(1.Department of Plastic Surgery,Anhui Provincial Hospital,Hefei 230000,Anhui,China 2.Department of Burn and Plastic Surgery,The Third People`s Hospital of Bengbu,Bengbu 233000,Anhui,China)
Abstrac:ObjectiveTo approach the method of reconstruct tissue defects of middle or distant footby make down the pivot point of sural neurofasciocutaneous flap.MethodsWe had used lower pivot point sural neurofasciocutaneous flaps in ten patients for reconstruction oftissue defects of distant foot by electrical injuries or traumatisms scince 2006. The size of the flap ranged from 6cm×5cm～12cm×18cm,and the pivot point is at the range of 0～3cm above the lateral malleolus. ResultsNine flaps survived completely. In one flap,superficial necrosis about 2cm in distal parts occured and managed successfully by change of dressing and split-thickness skin graft.ConclusionMake down the pivot point flaps can procure enough length to transfer and repair defects at distal end of foot with a safety blood supply.The flap is easily to operated, quick and safe,do not injury major arteries and it expand the application of sural neurofasciocutaneous flap.
Key words: sural neurofasciocutaneous flap;foot;soft tissue defect
足部中远端组织缺损临床较为多见，但由于足部中远皮肤软组织菲薄，损伤后多有伴肌腱、骨质外露甚至坏死，修复较为困难。常用的方法有交腿皮瓣、游离皮瓣等，技术要求高或患者痛苦大，临床应用受到限制。我科自2006年初至2010年11月利用低旋转点腓肠神经筋膜皮瓣转移修复足部中远端组织缺损获得良好效果。
1资料和方法
1.1一般资料：本组10例,男性9例，女性1例，年龄18～55岁，其中烧伤/电烧伤8例，外伤2例。伤后6h～3天入院，创面位于足背中远1/2至足趾范围，皮肤软组织缺损，均伴有趾、跖骨或肌腱外露坏死。入院1～3天内行扩创、行低旋转点腓肠神经筋膜皮瓣转移一期修复创面，皮瓣面积5cm×6cm～12cm×18cm，蒂宽约4cm(表1)。
1.2 手术方法：①术前超声多普勒血管探测仪探听外踝后间隙处穿支血管，并标记；麻醉成功后，常规消毒铺巾，不驱血，抬高患肢10min后，置气囊止血带；先行扩创，去除坏死组织；②皮瓣设计：以外踝与跟腱中点至腘窝中点连线为皮瓣的轴线，即小隐静脉与腓肠神经的体表投影。旋转点距外踝尖0～3cm，蒂宽4cm，皮瓣边缘略大于受区1～2cm；③皮瓣逆行切取，小心解剖外踝后间隙，通常在外踝尖至踝上3cm范围内能找到2～3支穿支血管，以此作为旋转点，重新调整皮瓣高度，于深、浅筋膜之间形成蒂部，结扎切断高位的肌间隔穿支，保护蒂部。沿设计线从近心端和两侧切开皮瓣达深筋膜层，确认腓肠神经包含在皮瓣内，并随时缝合深筋膜与皮瓣下的软组织，避免深筋膜从皮瓣分离，充分保护皮瓣血运；于深筋膜下逆行分离并掀起皮瓣和筋膜蒂，明道或遂道转移至受区，供区以中厚皮片移植 ......
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