足底内侧静脉皮瓣修复（足母）甲瓣供区的临床应用

足底内侧静脉皮瓣修复（足母）甲瓣供区的临床应用

邹时雨王克列肖春生张宜之陈品琨代力臻杨延军张子清

本文来源：《中华整形外科杂志》2023年5月第39卷第5期

DOI:10. 3760 / cma.j.cn114453-20211027-00421

作者单位：深圳市龙岗区骨科医院手外科，深圳518116

通信作者：王克列，Email：80761608@qq.com

引用本文

邹时雨, 王克列, 肖春生, 等. 足底内侧静脉皮瓣修复（足母）甲瓣供区的临床应用 [J] . 中华整形外科杂志, 2023, 39(5) : 496-501. DOI: 10.3760/cma.j.cn114453-20211027-00421.

【摘要】

目的探讨应用足底内侧静脉皮瓣修复(足母)甲瓣供区的临床效果及可行性。

方法回顾性分析2020年1月至2021年6月深圳市龙岗区骨科医院应用足底内侧静脉皮瓣修复(足母)甲瓣或部分(足母)甲瓣移植再造手指供区的患者临床资料。术中足底内侧静脉皮瓣供区采用游离全厚皮片移植修复。术后观察皮瓣成活情况并随访皮瓣外观、感觉恢复及并发症发生情况，根据Maryland足功能评定标准评价足部功能。

结果共纳入6例患者，男5例，女1例，年龄14~28岁，平均22岁；(足母)甲瓣创面面积2.2 cm× 3.7 cm~5.5 cm× 7.0 cm，足底内侧静脉皮瓣切取面积为2.5 cm× 3.8 cm~5.5 cm× 7.1 cm。术后6例皮瓣均成活良好，2例出现水疱。术后随访3~18个月，平均 9个月，所有皮瓣外观均无臃肿，颜色、质地佳，无破溃，疼痛，两点辨距觉7~10 mm，第2、3供区隐蔽。根据Maryland足功能评定标准，6例均评为优。

结论应用足底内侧静脉皮瓣修复(足母)甲瓣供区，具有供区隐蔽、皮瓣不臃肿、质地好、成活率高、感觉恢复可的优点，是一种有效的修复方法。

【关键词】外科皮瓣；足底内侧皮瓣；静脉皮瓣；甲瓣供区；创面修复

基金项目：深圳市龙岗区科技发展专项资金(LGKCYLWS2019000843,LGKCYLWS2020113)

Clinical application of medial plantar venous flap for repairing great toenail flap donor site

Zou Shiyu, Wang Kelie, Xiao Chunsheng, Zhang Yizhi, Chen Pinkun, Dai Lizhen, Yang Yanjun, Zhang Ziqing

Department of Hand Surgery, Longgang Orthopedic Hospital of Shenzhen, Shenzhen 518116, China

Corresponding author: Wang Kelie, Email: 80761608@qq.com

【Abstract】

Objective To explore the clinical efficacy and feasibility of applying a medial plantar vein flap to repair the great toenail flap donor site.

Methods A retrospective analysis was performed on the clinical data of patients who underwent great toenail flap or partial great toenail flap transplantation for finger reconstruction from January 2020 to June 2021 in Longgang Orthopedic Hospital of Shenzhen. During the operation, the donor site of the great toenail flap was repaired with medial plantar venous flaps, and the donor site of the medial plantar venous flaps was repaired with a free full-thickness skin graft. The survival of the flap was observed and the appearance, sensation, and complications of the flap were followed up. The foot function was evaluated by the Maryland foot function evaluation standard.

Results A total of 6 cases were enrolled, including 5 males and 1 female with an average of 22 years, ranged from 14-28 years old. The wound area of the great toenail flap was 2.2 cm×3.7 cm-5.5 cm×7.0 cm, and the skin flap was 2.5 cm×3.8 cm-5.5 cm×7.1 cm. All flaps survived. 2 cases developed tension blisters. All patients were followed up for 3-18 months, with an average of 9 months. And all flaps had no swollen appearance, good color, texture, and no ulcers or pain. Two-point discrimination was 7-10 mm, and the second/third donor area was concealed. According to the Maryland foot function evaluation standard, all 6 cases were rated as excellent.

Conclusion The application of the medial plantar vein flap to repair the donor area of the great toenail flap is an effective repair method. The donor area is concealed, the flap is not bloated, the texture is good, the survival rate is high, and the sensation recovered satisfactory.

【Key words】Surgical flaps; Medial plantar flap; Venous flap; Donor area of great toenail flap; Wound repair

Fund program: Special Fund for Science and Technology Development of Longgang District, Shenzhen (LGKCYLWS2019000843, LGKCYLWS2020113)

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: This study was conducted in accordance with the Helsinki Declaration.

手外科临床工作中常常遇到外伤导致的手指不同程度缺失，一旦手指缺失，往往给患者带来身体和心理的双重创伤。手指再造是恢复患者手指外形和功能的有效途径，而(足母)甲瓣由于其再造手指逼真的外形及良好的功能，一经报道就被广泛应用于临床，成为手指再造的理想方案之一。但(足母)甲瓣切取后随之而来的创面修复问题成为困扰临床医生的一大难题。目前常见的修复方法有植皮修复和皮瓣修复。植皮往往不易成活、不耐磨、易形成贴骨瘢痕，造成足趾疼痛[1,2,3,4,5,6]。皮瓣如足背逆行岛状皮瓣[7,8]、腓动脉穿支皮瓣[3]、小腿内侧动脉穿支皮瓣[1]、股前外侧动脉穿支皮瓣[9]、腹股沟皮瓣[10]等，则存在皮瓣臃肿或供区相对不隐蔽或容易色素沉着等缺陷。而足底内侧静脉皮瓣既有供区隐蔽、皮瓣菲薄、外形不臃肿的优势，又有操作简单、质地耐磨等优点[11,12,13,14,15]。笔者近年采用足底内侧静脉皮瓣修复了6例(足母)甲瓣切取患者的供区，获得了满意效果。

资料与方法

一、资料选择

回顾性分析2020年1月至2021年6月深圳市龙岗区骨科医院采用足底内侧静脉皮瓣修复(足母)甲瓣或部分(足母)甲瓣移植再造手指供区的患者临床资料。纳入标准：（1）采用(足母)甲瓣或部分(足母)甲瓣再造手指；（2）采用足底内侧静脉皮瓣修复(足母)甲瓣供区。排除标准：随访资料不全。

本研究已参考赫尔辛基宣言。手术前向患者详细介绍了手指再造及供区修复的各种手术方案优缺点，与患者讨论后最终选择了此种手术方案，与患者签署手术知情同意书。

二、方法

(一)手术方法

1．皮瓣设计：

(足母)甲瓣切取后创面止血，冲洗，根据创面外形、大小设计及裁剪样布。于同侧或对侧足底内侧依据浅表静脉走行设计足底内侧静脉皮瓣。足底内侧皮下可见多条明显的由足底斜向足背的静脉及其间交通的静脉网，选择2~3条与(足母)甲瓣供区待吻合血管口径相近的浅静脉作为皮瓣动静脉，以选取的2~3条浅静脉为中心设计皮瓣。

2．皮瓣切取：

切开皮瓣近端皮肤，显露近端静脉血管，细心分离选择的2~3条静脉，必要时可向近端延长切口，直至游离的静脉血管蒂达足够长度，以满足受区吻合需要。结扎皮瓣边缘非选择的静脉。然后于所选择静脉的深层、(足母)展肌的表面由背侧向足底侧游离切取皮瓣，注意保持所选择的静脉位于皮瓣内。皮瓣切取后创面止血，冲洗，于小腿上段内侧或腹股沟区切取面积相近的全厚皮片修复。

3．皮瓣移植：

将足底内侧静脉皮瓣移植至(足母)甲瓣供区，理顺皮瓣内血管蒂，以5-0或6-0缝线固定皮瓣远端。显微镜下去除血管外膜，调整缝合张力，以10-0无损伤缝线将皮瓣内较细的浅静脉与第1趾背、第2趾背或(足母)趾腓侧趾底动脉，较粗的浅静脉与(足母)趾趾背静脉吻合。创面止血、冲洗，闭合伤口，放置引流，石膏托固定足部于休息位。

(二)术后处理

术后予抗感染、抗痉挛、抗凝、卧床制动、烤灯保暖、抬高患肢等治疗，绝对卧床休息7 d。术后10 d指导患者逐渐开始行足部功能训练。

(三)随访与效果评价

术后观察皮瓣成活情况并随访皮瓣外观、感觉恢复及并发症发生情况，根据Maryland足功能评定标准评价足部功能。

结果

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足底内侧静脉皮瓣修复（足母）甲瓣供区的临床应用