游离肋骨-前锯肌-皮肤复合组织瓣修复大面积颅骨缺损(1)
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[摘要]目的：探讨吻合血管的游离肋骨-前锯肌-皮肤复合组织瓣修复大面积颅骨缺损的临床应用价值。方法：设计以胸背血管为营养血供的游离肋骨-前锯肌-皮肤复合组织瓣，用以修复大面积颅骨缺损10例。结果：10例患者，组织瓣完全成活9例，坏死1例。随访1～10年，患者术后外观满意，无感染、皮下积液等并发症发生。结论：游离肋骨-前锯肌-皮肤复合组织瓣可以很好地完成大面积颅骨缺损的修复，是一种理想的自体修复材料。
[关键词]颅骨缺损；颅骨成形；肋骨-前锯肌-皮肤复合组织瓣；显微外科
[中图分类号]R622 [文献标识码]A [文章编号]1008-6455(2012)01-0009-03
Reconstruction of large skull defect using rib-anterior serratus muscle-skin composite flap
SHU Chang,TAO Ying-xue,ZHU Jun,FU Ai-jun,LI Jian-min,TAO zhi-lu
(1. Department of Plastic Surgery,The Affiliated Hospital of Hebei United University,Tangshan 063000,Hebei,China; 2. Editorial Office of Publishing Management Center of Hebei United University;3. Department of Neurosurgery,The Affiliated Hospital of Hebei United University)
Abstract: Objective To investigate the application of rib-anterior serratus muscle-skin composite flap in reconstruction of large skull defect. Methods Ten cases of large skull defect were repaired using revascalarized rib-anterior serratus muscle-skin composite flap,which blood supply was chest-ridge blood vessels. Results The composite tissue flap survived with primary healing in 9 cases,while necrosis occurred at one case. From 1 to 10 years follow-up, the postoperative appearance was satisfactory,and no complications such as infection and subscalp hydrops were found. Conclusions The free rib-anterior serratus muscle-skin composite flap is an ideal autogenous repair material,which can be best used in reconstruction of large skull defect.
Key words:skull defect;cranioplasty;rib-anterior serratus muscle-skin composite flap; microsurgery
因外伤、肿瘤、颅内疾病等原因去骨瓣减压所致的大面积颅骨缺损临床上很常见。其修复在颅颌面外科中仍是一个具有挑战性的难题。1983～2010年，我院应用吻合血管的肋骨-前锯肌-皮肤复合组织瓣修复大面积颅骨缺损10例，取得了良好效果。
1 资料和方法
1.1 临床资料：本组10例，均为男性，年龄19～35岁，颅骨最大缺损面积12cm×14cm，最小8cm×8cm。致伤原因：交通事故5例，工矿外伤4例。木棒击伤1例。颅骨缺损部位：颞部8例；颞顶部1例；颞顶额1例。单侧颅骨缺损8例，双侧缺损2例。伤后距颅骨成形时间：3个月～10年。
1.2 手术方法：手术分胸部组和头部组，同时进行。
1.2.1 胸部组：按颅骨缺损面积，切取带血管蒂游离肋骨前锯肌皮瓣。
切口设计：先在腋前线确定第6 肋骨的位置, 再根据颅骨缺损的面积, 确定所需含肋骨的根数和表层皮肤的范围。自腋顶部沿背阔肌前缘至骼前上嵴的连线。先只切开腋部, 沿背阔肌前缘向后钝性剥离, 并牵开背阔肌, 即可见由该肌中段进入肌肉的胸背血管神经束和在前锯肌表面的胸背血管的前锯肌支, 随后设计制做以胸背血管为蒂的肋骨一前锯肌一皮肤复合组织瓣。若取3根肋骨, 应选用第5～7肋，扩大原切口, 向前暴露出所需肋骨。切取组织瓣时，应边切边做边缘固定缝合。自第7肋骨下缘和前锯肌肋骨附着点的下缘, 切开前锯肌、肋间外肌下缘的骨膜, 并用摇摆锯按受区所需肋骨的实际长度先横断肋骨达1/2厚度 ......
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