腹部皮瓣和植皮联合负压封闭引流修复手部大面积皮肤脱套伤及缺损

【】　目的　探讨大面积手部皮肤脱套伤并缺损的修复方式。　方法　2005年6月－2010年1月，应用腹部皮瓣包埋和游离中厚皮片植皮结合负压封闭引流（vacuumsealingdrainage，VSD）技术治疗手部大面积皮肤脱套伤合并缺损12例，其中男8例，女4例；年龄21~56岁，平均34岁。机器绞伤9例，车祸伤3例。所有损伤均合并肌腱、关节或骨质外露；软组织缺损范围为9cm×8cm~25cm×18cm。受伤至手术时间4~17h，平均6.5h。手掌及手指缺损部位采用腹部带蒂皮瓣包埋；手掌及手指以外肌肉、筋膜完好的部位采用大腿游离中厚皮片植皮，再于植皮表面覆盖VSD敷料，接负压行持续吸引；所有患者均二期断蒂并进行分指或皮瓣成形手术。　结果　术后2例手指部分皮瓣或植皮坏死，2例小部分皮瓣及植皮边缘坏死，经单纯换药后逐渐愈合，1例缺损较大、较深，先行换药，待创面肉芽新鲜后行二期植皮手术，愈合良好。其余皮瓣及植皮均成活，创面Ⅰ期愈合；供区植皮均成活，切口均Ⅰ期愈合。12例均获6~42个月随访，2例手指末节软组织缺损严重、血运差，术后7~10d末节坏死后短缩；3例掌侧皮瓣移植后较臃肿；其余外观均较满意。所有患者创面愈合后1个月内深、浅感觉功能均稍差，3~6个月逐渐恢复，但手指精细感觉恢复差，两点辨别觉为6~13mm，平均9.5mm。所有患手平均掌指关节主动活动50°，指间关节20°。　结论　腹部皮瓣包埋和游离中厚皮片植皮结合VSD技术能较好地修复手部大面积皮肤脱套伤并缺损，是一种实用、安全且简便的手术方法。【Abstract】　Objective　Toinvestigatetheidealrepairmethodforlarge-areahandavulsedwoundandsofttissuedefects.　Methods　FromJune2005toJanuary2010,12patientswithlarge-areahandavulsedwoundandsofttissuedefectswererepairedwithabdominalskinflapsandskingraftingcombinedwithvacuumsealingdrainagetechnique.Thepatientsincluded8malesand4femaleswiththeiragerangedfrom21to56yearsaveragingat34years.Thecausesofinjuryweremachinetwistinjuryin9casesandroadaccidentinjuryin3cases.Alltheinjuriescombinedwithexposureoftendon,jointorbone.Theareaofdefectsrangedfrom8cm×9cmto18cm×25cm.Thetimebetweeninjuryandoperationwas4to17hoursaveragingat6.5hours.Thepalmofhandandfingerswererepairedbyabdominalpedicleskinflaps,andthedorsumofhandandwristwererepairedbyskingraftingcombinedwithvacuumsealingdrainage.About3weekslater,allpediclesoftheabdominalflapswerecutoffandflapsplastywerecarriedout.　Results　Allpatientswerefollowedupfrom6to42monthswithanaverageperiodof17months.Alloftheflapsandskingraftssurvived.Only6patientshaddistaledgepartialnecrosis,andallofthemhealedafterashorttimeofdressingchangesorsecond-stageskingrafting.Allskingraftsofthedonorsitessurvivedandallthewoundshealedbyfirstintention.Alltheinjuredhandsrecoveredwelltotheiroriginalshapeandfunctionexceptpartialbadskinsensation.Thesenseoftwo-pointdiscriminationwasfrom6mmto13mmwithanaveragedistanceof9.5mm.Theactivemotionofmetacarpophalangealjointsaveragedat60°,andtheinterphalangealarticulationsaveragedat30°.　Conclusion　Abdominalskinflapsandskingraftingcombinedwithvacuumsealingdrainagetechniquecanbeusedtorepairlarge-areahandavulsedwoundandsofttissuedefects,anditispractical,safeandsimple.