预扩张的脐旁穿支皮瓣修复肘关节瘢痕挛缩畸形

李广学 穆籣 刘岩 臧梦青 刘元波

·论著·

预扩张的脐旁穿支皮瓣修复肘关节瘢痕挛缩畸形

李广学1穆籣1刘岩1臧梦青2刘元波2

目的 探讨应用预扩张的脐旁穿支皮瓣修复烧伤后肘关节瘢痕挛缩畸形的临床效果。方法 回顾性分析2012年6月至2015年6月中国医学科学院整形外科医院应用预扩张的脐旁穿支皮瓣修复烧伤后肘关节瘢痕挛缩畸形患者18例，其中男11例，女7例；左侧8例，右侧10例。术前患侧肘关节活动明显受限。Ⅰ期手术于患侧腹部脐旁埋置扩张器，10～26周(平均18周)完成扩张后Ⅱ期行肘瘢痕切除、挛缩松解，带蒂脐旁穿支皮瓣转移覆盖肘部创面，3周后皮瓣断蒂。结果 皮瓣大小为16 cm×8 cm～30 cm×14 cm，所有供区直接拉拢缝合。18例皮瓣全部成活，2例皮瓣远端由于静脉淤血部分坏死，经换药处理后伤口愈合，有轻度的瘢痕增生，其他均Ⅰ期愈合。术后随访6～38个月(平均19个月)，肘关节功能恢复良好，6例患者进行皮瓣修薄手术。结论 预扩张的脐旁穿支皮瓣是一种有效的修复肘关节瘢痕挛缩畸形的方法。

肘关节；挛缩畸形；预扩张；脐旁穿支皮瓣

烧伤后肘关节瘢痕挛缩畸形是一种较为常见的烧伤畸形，导致肘关节功能下降，影响美观，严重影响患者的生活质量。预扩张的脐旁穿支皮瓣具有穿支血管恒定，供血范围大，皮瓣面积大，供区隐蔽等优点。本研究回顾性分析中国医学科学院整形外科医院整形十一科应用预扩张的脐旁穿支皮瓣修复烧伤后肘关节瘢痕挛缩畸形患者18例，并取得了满意的临床效果，现报道如下：

资 料 与 方 法

一、一般资料

2012年6月至2015年6月中国医学科学院整形外科医院应用预扩张的脐旁穿支皮瓣修复烧伤后肘关节瘢痕挛缩畸形患者18例，其中男11例，女7例；左侧8例，右侧10例；年龄4～46岁，平均18.8岁；其中13例热液烫伤，5例为火焰烧伤，烧伤后6个月至6年，中位时间为13个月。术前患侧肘关节活动明显受限，肘关节周围无残留的皮肤供形成局部皮瓣以修复瘢痕挛缩畸形。

二、手术方法

Ⅰ期手术置入扩张器。首先，标记患者肘部瘢痕及挛缩畸形，根据对侧肘关节情况及患侧挛缩程度估计缺损范围，皮瓣稍微大于缺损范围。然后，手持超声多普勒探测患侧肚脐周围，确定脐旁皮瓣至少包含两条穿支血管，皮瓣轴线为肚脐到同侧肩胛下角连线。皮瓣上缘作为切口置入扩张器，对于女性患者皮瓣上缘在乳房下皱襞以下，切开皮肤、皮下组织至腹外斜肌筋膜，在筋膜表面向下剥离，向中线位置剥离时应避免损伤脐旁的穿支血管，结扎剥离过程中遇到的其他穿支血管，最终在下位肋骨水平及上腹部形成大小合适的腔穴，置入合适的长方形扩张器。置入扩张器大小为300～800 ml，注射壶放置到外侧胸壁。术后第14天开始注水，1周1次，适当过度扩张便于取得足够的皮瓣及直接关闭供区，扩张10～26周，平均18周。

Ⅱ期取出扩张器，肘部挛缩松解、瘢痕切除，脐旁穿支皮瓣带蒂转移至肘部。首先再次手持多普勒确认脐旁穿支，透光实验观察皮瓣内血管的走形情况，标记皮瓣的范围，原手术切口作为皮瓣的上缘。手术时首先取出扩张器，一般保留扩张器包膜便于保护皮瓣内血管不受损伤，切取带蒂脐旁皮瓣，注意术中不必解剖脐旁穿支血管，避免穿支血管的损伤，皮瓣的蒂部稍宽以便包括脐旁穿支血管和皮管的形成。术中充分松解肘关节瘢痕挛缩，将皮瓣远端转移至肘部，如有皮瓣富余可以切除周围部分或全部的瘢痕组织，皮瓣近端形成皮管，留置伤口引流后腹部供区直接关闭，3周后行蒂部夹闭试验确认皮瓣的血供良好后断蒂，并可以进一步切除瘢痕以修复缺损。

结 果

扩张器置入术后未出现伤口血肿、感染等并发症，注水期间未出现扩张器破裂、注射壶渗漏等并发症。Ⅱ期皮瓣转移至皮瓣断蒂后18例皮瓣全部成活，2例皮瓣远端由于静脉淤血部分坏死，经换药处理后伤口愈合，有轻度的瘢痕增生，其他均Ⅰ期愈合。术后随访6～38个月，平均19个月，肘关节功能恢复良好，活动良好，外形良好，6例患者进行皮瓣修薄手术。

典型病例：患者，男，7岁。因烧伤后右肘部瘢痕挛缩畸形2年就诊。检查发现：右肘部、右前臂瘢痕挛缩畸形，范围约13 cm×10 cm，活动明显受限。Ⅰ期全麻行右侧腹部600 ml长方形扩张器置入，术后定期注水，术后5个月全麻下行扩张器取出，右肘部瘢痕挛缩松解、瘢痕切除，范围为18 cm×12 cm，将脐旁穿支皮瓣转移到右肘部及右前臂，皮瓣成活良好，无术后并发症，3周后行皮瓣断蒂，术后皮瓣全部成活，肘关节活动良好，功能明显改善，外形良好，效果满意(图1～6)。

讨 论

肘关节烧伤后瘢痕挛缩畸形通常采用局部整形进行修复，如单纯或改良的Z成形及易位皮瓣[1]、双蒂瘢痕组织瓣[2]、V-Z成形[3]、连续梯形皮瓣成形[4]、改良的八角形推进皮瓣[5]等。虽然局部整形能够改善肘关节的功能，但是局部瘢痕仍然残留甚至加重，影响美观。对于瘢痕挛缩畸形进行充分的松解、切除部分或全部瘢痕，在创面上进行游离皮片移植或皮瓣转移修复可以减少术后瘢痕的形成。如果患者瘢痕较浅、挛缩较轻，可以选择皮片游离移植，但是皮片移植后存在色素沉着、皮片收缩等问题，影响术后的功能和美观要求。如果对术后的功能或美观要求较高，或者瘢痕累及下方的肌肉、肌腱或骨骼等，则最好选择皮瓣转移修复。皮瓣修复可以采用临近的皮瓣或者远位的皮瓣进行修复，局部皮瓣可以采用桡动脉近端穿支的岛状脂肪筋膜皮瓣[6]、尺动脉近端穿支的脂肪筋膜皮瓣[7]、远端蒂臂内侧皮神经营养血管皮瓣[8]等，但肘关节周围的瘢痕挛缩畸形在切除瘢痕、松解挛缩畸形缺损较大时，依靠周围的局部皮瓣转移进行修复往往较为困难。因此只有远位的皮瓣游离移植或带蒂转移才能满足肘关节瘢痕挛缩畸形修复对于功能和美观的双重要求[9]，司婷婷等[10]报道应用侧胸部Ⅱ度烧伤愈合后任意超长皮瓣修复肘关节瘢痕挛缩畸形，虽然对于肘关节功能恢复有一定作用，但是恢复美观的作用却有限。

图1 术前右肘部瘢痕畸形及脐旁穿支皮瓣设计 图2 右侧腹部置入扩张器注水扩张5个月后 图3 肘部瘢痕挛缩松解、瘢痕切除后

图4 脐旁穿支皮瓣转移到右肘部及右前臂 图5 皮瓣断蒂拆线后即刻 图6 术后1年

1983年Taylor等[11]首次提出脐与肩胛下角连线为轴线的皮瓣，称为延伸的腹壁下动脉穿支皮瓣。之后其他学者将脐旁穿支皮瓣应用于乳房再造[12]和阴囊修复[13]。近年来带蒂脐旁穿支皮瓣转移主要应用于手以及前臂缺损的修复[14-16]，因为皮瓣蒂部较短很难用于肘部的修复，而预扩张的脐旁穿支皮瓣远端可以到达腋后线位置，长度明显增加，可以用于肘部缺损的修复，甚至是用于上臂缺损的修复。本研究有6例用于上臂及肘部烧伤后瘢痕挛缩畸形的修复，取得良好的功能和美观恢复，Zang 等[17]报道应用预扩张的带蒂脐旁穿支皮瓣修复上肢缺损，取得了良好的效果。

对脐旁皮瓣进行预扩张具有以下优点：(1)可以对皮肤进行充分的扩张，易于取得较大面积的皮瓣，便于供区切口的关闭，减少供区瘢痕增生；(2)扩张器置入的同时能够结扎皮瓣下方的肋间动脉穿支血管，使得皮瓣内穿支体区之间阻力性吻合和潜力性吻合[18]血管得以开放，起到皮瓣延迟的作用，达到增长皮瓣长度的目的，使得皮瓣的远端可以达到腋后线位置，便于大范围缺损的修复；(3)预扩张的脐旁皮瓣使得皮瓣的厚度得以变薄，更能与上肢皮肤厚度相适应，避免部分患者的Ⅱ期皮瓣修薄手术。本文中对于儿童和男性患者修复后不需要Ⅱ期皮瓣修薄，但是对于6例肥胖的女性，由于腹部皮下脂肪较厚，影响术后美观，需要皮瓣修薄手术。

诚然，应用预扩张的脐旁穿支皮瓣仍有一定的局限性。(1)整个操作步骤需要3～6个月时间，至少三次手术才能完成；(2)皮瓣切取过长时仍有远端坏死的可能，需要术中仔细判断皮瓣血运，及时进行处理；(3)扩张器置入、扩张注水可能发生并发症，需要进一步处理；(4)皮瓣转移后需要固定3周后断蒂，可能出现肩肘僵硬，部分患者尤其是老年患者可能不能耐受。因此，需要严格掌握手术适应证，对于大面积的肘关节及周围缺损的患者推荐采用该手术方式，并在术前对患者进行充分的教育，避免围手术期并发症的发生。

综上所述，预扩张的脐旁穿支皮瓣能够充分增加皮瓣的大小，对于选择合适的大面积肘关节瘢痕挛缩畸形患者，能够起到功能和美观双重修复的目的。

[1] Cartotto R, Cicuto BJ, Kiwanuka HN, et al. Common postburn deformities and their management[J]. Surg Clin North Am, 2014, 94(4): 817-837.

[2] 潘勇，卢丙仑，钱洪军，等.采用双蒂瘢痕组织皮瓣治疗关节部位的瘢痕挛缩畸形[J].中国美容医学，2007，16(6)：749-751.

[3] 刘宗超，马川，杨家福，等.V-Z皮瓣成形术矫正上肢关节瘢痕挛缩畸形[J].泸州医学院学报，2012，35(6)：612-614.

[4] Grishkevich VM. The post-burn elbow medial flexion scar contracture treatment with trapeze-flap plasty[J]. Burns, 2009, 35(2): 280-287.

[5] Hosny H, El-Shaer W. The eight-limb modified propeller flap--a safer new technique[J]. Burns, 2011, 37(5): 905-909.

[6] El-Khatib HA. Island fasciocutaneous flap based on the proximal perforators of the radial artery for resurfacing of burned cubital fossa[J]. Plast Reconstr Surg, 1997, 100(4): 919-925.

[7] El-Khatib HA, Mahboub TA, Ali TA. Use of an adipofascial flap based on the proximal perforators of the ulnar artery to correct contracture of elbow burn scars: an anatomic and clinical approach[J]. Plast Reconstr Surg, 2002, 109(1): 130-136.

[8] 岳江涛，姚文暾.远端蒂臂内侧皮神经营养血管皮瓣修复肘部瘢痕挛缩11例[J].中华烧伤杂志，2010，26(6)：459-460.

[9] Dehaan MR, Hammond DC, Mann RJ. Controlled tissue expansion of a groin flap for upper extremity Reconstruction[J]. Plast Reconstr Surg, 1990, 86(5): 979-982.

[10] 司婷婷，王一村，宋建星，等.侧胸部Ⅱ度烧伤愈合后任意超长皮瓣修复肘关节瘢痕挛缩畸形的研究[J].中国美容医学，2013，22(5)：511-514.

[11] Taylor GI, Corlett R, Boyd JB. The extended deep inferior epigastric flap: a clinical technique[J]. Plast Reconstr Surg, 1983, 72(6): 751-765.

[12] Schoeller T, Bauer T, Gurunluoglu R, et al. Modified free paraumbilical perforator flap: the next logical step in breast Reconstruction[J]. Plast Reconstr Surg, 2003, 111(3): 1093-1098; discussion 1099-1101.

[13] Kim KS, Noh BK, Kim DY, et al. Thin paraumbilical perforator-based cutaneous island flap for scrotal resurfacing[J]. Plast Reconstr Surg, 2001, 108(2): 447-451.

[14] Yilmaz S, Saydam M, Seven E, et al. Paraumbilical perforator-based pedicled abdominal flap for extensive soft-tissue deficiencies of the forearm and hand[J]. Ann Plast Surg, 2005, 54(4): 365-368.

[15] O′shaughnessy KD, Rawlani V, Hijjawi JB, et al. Oblique pedicled paraumbilical perforator-based flap for Reconstruction of complex proximal and mid-forearm defects: a report of two cases[J]. J Hand Surg Am, 2010, 35(7): 1105-1110.

[16] Kamath BJ, Verghese T, Bhardwaj P. "Wing flaps": perforator-based pedicled paraumbilical flaps for skin defects in hand and forearm[J]. Ann Plast Surg, 2007, 59(5): 495-500.

[17] Zang M,Zhu S,Song B,et al. Reconstruction of extensive upper extremity defects using pre-expanded oblique perforator-based paraumbilical flaps[J]. Burns, 2012, 38(6): 917-923.

[18] 陈世新，吴东方，丁茂超，等.穿支体区血管及其相互间吻合的3D可视化研究[J].中国临床解剖学杂志，2011，29(3)：237-242.

(本文编辑：李静)

李广学,穆籣,刘岩，等.预扩张的脐旁穿支皮瓣修复肘关节瘢痕挛缩畸形[J/CD]. 中华肩肘外科电子杂志,2016,4(1):24-28.

Reconstruction of elbow scar contracture using pre-expanded perforator-based paraumbilical flaps

LiGuangxue1,MuLan1,LiuYan1,ZangMengqing2,LiuYuanbo2.

1DepartmentofAestheticSurgery,PekingUniversityPeople′sHospital,Beijing100044,China;2DepartmentofPlasticandReconstructiveSurgery,PlasticSurgeryHospital,Beijing100144,China

Correspondingauthor:LiuYuanbo,Email：ybpumc@sina.com

Background The scar contracture of elbow joint is a common postburn deformity, limiting the joint range of motion, influencing beauty and the patient′s quality of life. For elbow scar contractures, the main surgical treatment is contracture release by removing the scar tissue and covering the defect with sufficient tissue. But it is still highly challenging to restore the functional and aesthetic elbow for large defect. Skin grafting is the simplest option to resurfacing the elbow defect, but it usually lead to poor functional and aesthetic results due to skin contraction and pigmentation. Various types of flaps have been suggested for reconstruction of elbow scar contracture. A Z plasty, V-Y flaps or a transpositional flap technique can be used to release a simple scar contracture. However, local and regional flaps are difficult to restore the large elbow defect after releasing the scar constracture due to the limited available surrounding tissue and limited skin flexibility. Therefore, a distant flap sometimes is needed to reconstruct the extensive defect of the elbow. The anterior truck provide abundant well-pefused flap, such as superficial inferior epigastric artery (SIEA) flap, intercostal artery flap and perforator-based paraumbilical flaps. However, the usage of these flaps was limited because of insufficient soft tissue when dealing with large defect, thick abdominal portion and limited pedicle length. The pre-expanded perforator-based paraumbilical flaps overcome these limitations and provide thin, reliable coverage with the best functional and aesthetic results. We present our experience in reconstructing elbow scar contracture using pre-expanded perforator-based paraumbilical flaps.Methods The elbow scar contracture was corrected in 18 cases with pre-expanded perforator-based paraumbilical flaps, with 8 cases in the left side and 10 cases in the right side including 11 male cases and 7 female cases. Aged 4 years to 46 years with an average age of 18.8 years. Burn injury causes: 13 cases were injuried with hot liquid and 5 case were flame burns, the median time was 18 months from 6 months to 6 years after burn. Elbow joint movement was obviously limited preoperatively, and there were no abundant skin surrounding the elbow to repair the defect after the scar contracture release.Operative method: During the first-stage procedure, the expander was implanted into the ispilateral normal abdominal subcutaneous tissues. First of all, the elbow scar and contracture deformity was marked, and the extent of the defect after scar contracture release was estimated according to the contralateral elbow joint and the extent of the ispilateral side. The flap for reconstruction was slightly larger than the defect. Then two large perforators were detected in the ipsilateral paraumbilical area with hand-held ultrasound Doppler, the axis of the flap was oriented along the axis between the umbilicus and the ipsilateral inferior angle of scapula. The incision was made at the superior edge of the flap. In women, the incision was made under the inframammary fold to prevent breast deformation. Then, we cut the skin, subcutaneous tissue to the superficial external oblique aponeurosis, stripping down along the fascia. We should carefully dissect medially beyond the lateral border of the rectus abdominis to avoid damage to the main paraumbilical perforators, the perforators encountering during the dissection were ligated with suture or bipolar coagulator. At last, an appropriate pocket was formed between the lower ribs and upper abdomen, a proper rectangular expander was implanted, the size of expander was 300 ml to 800 ml, and the expander valve was put at the lateral chest wall routinely. Expander was begun to inject with normal saline two weeks postoperatively, once a week until enough volume was achieved. The flap was usually over-expanded to obtain sufficient flap and direct closure of the abdominal donor site. The expansion time was 10 weeks to 26 weeks with an average time of 18 weeks. During the second-stage procedure, the expander was removed and the expanded perforator-based paraumbilical flaps was elevated and transferred to repair elbow skin defect after scar contracture resection and release. The paraumbilical perforators were relocated with hand-held ultrasound Doppler, transillumination test was used to observe the running situation of the flap vessel. The dimension of flap was marked and the previous incision served as the superior edge of the flap. Firstly, the expander was removed with capsule preserving to avoid damaging the underlying perforators. The pedicle was wide enough to include the identified perforators and facilitate the tube formation. However, there was no need to dissect the perforators intraoperatively. The elbow contracture was completely released, the flap transferred to repair elbow skin defect with part or entire scar tissue resection. The proximal part of flap was sutured to form the skin tube. The abdominal donor site was closed directly after wound drainage placement. The pedicle clamping test was done to confirm the good flap blood supply and the pedicle was divided 3 weeks postoperatively. The rest scar was excised and repaired. The extra proximal flap was re-inserted back to the abdominal donor site.Results There were no wound hematoma, infection and other complications after expander implantation. There were no expander rupture, leakage of injection pot and other complications during injection period. The size of expanded perforator-based paraumbilical flaps ranged from 16 cm × 8 cm to 30 cm × 14 cm, and all abdominal donor sites were closed directly. The donor sites were closed directly in all cases. All flaps survived, except for partial necrosis in two cases due to venous congestion, and they healed after dressing change with mild scar hypertrophy. After 6 months to 38 months (mean 19 months) follow-up, the function of elbow joint recovered well postoperatively. Flap debulking was done in 6 cases.Conclusion The pre-expanded perforator-based paraumbilical flap is an effective procedure for elbow joint scar contracture with extensive defect.

Elbow joint;Scar contracture;Pre-expanded;Perforator-based paraumbilical flaps

10.3877/cma.j.issn.2095-5790.2016.01.005

中央高校基本科研业务费专项资金资助(3332013160)

100044北京大学人民医院医疗美容科1；100144北京，中国医学科学院整形外科医院整形十一科2

刘元波，Email：ybpumc@sina.com

2016-01-05)