Free Fillet Flap Reconstruction after Resection of Malignant Tumor Involving Major Joint

以自由菲力皮瓣重建大關節癌症截肢術後缺損

張耀元(Yao-Yuan Chang) ； 張世幸(Shih-Hsin Chang) ； 董光義(Kwang-Yi Tung) ； 蕭弘道(Hung-Tao Hsiao) ； 黃德揚(Te-Yang Huang)

《臺灣整形外科醫學會雜誌》 19卷3期 (2010/09) Pp. 274-282

https://doi.org/10.7096/TJTSPS.201009.0274

摘要

背景：
肩膀與肱骨近端的軟組織和骨腫瘤常需要施行前半部截肢術，且會有廣泛的軟組織缺損與骨頭外露。有很多重建的方法已經被提出來過，但是這些方法大多有其侷限性。皮膚移植在需放射性治療的傷口上是不可靠的，局部皮瓣只能用於小範圍的傷口，而如果腫瘤侵犯到了血管，帶莖皮瓣也不可行。除此之外，這些廣泛性傷口的重建常導致皮瓣供應區的併發症。
目的及目標：
我們報告三個因為惡性腫瘤接受前半部截肢術的病人，接受取自截肢上的自由菲力皮瓣重建。我們同時嘗試在整個菲力皮瓣剝離完成後再行血管結紮。
材料及方法：
從2008年3月到2009年9月，在馬偕醫院有三個病人因爲惡性腫瘤接受前半部截肢術，他們三個都有廣泛的軟組織缺損與肩胛骨的外露。其中兩位是男性，一位是女性。病理報告有兩位是軟骨肉瘤(chondrosarcoma)，一位是惡性纖維性組織細胞瘤(malignant fibrous histiocytoma)。平均的皮膚缺損是344平方公分（240~440平方公分）。三個病人都接受取自截肢上的自由菲力皮瓣重健。
結果：
自由菲力皮瓣取自截肢上的腕部至cubital area，所有的屈肌肌肉群都被保留在皮瓣中。肱血管被保留下來當做皮瓣血管，並與腋血管或鎖骨下血管吻合。皮瓣的皮膚區塊平均大小是506平方公分（280~810平方公分）。缺血時間是從腋血管結紮開始計算，至動脈吻合結束爲止，三個病人的缺血時間都小於三十分鐘。平均的手術時間是372分鐘，平均住院天數是44天。
組織缺損都可被自由菲力皮瓣完全的覆蓋，而且不需要其他皮瓣或皮膚供應區。全部的自由菲力皮瓣都存活，沒有邊緣壞死、傷口裂開或是感染的情況。
結論：
在前半部截肢術後，自由菲力皮瓣是一個可信賴的重建方法，且可以得到令人滿意的結果。在我們的經驗，廣泛性的大範圍傷口可以用自由菲力皮瓣成功的重建，即使是在放射性治療的傷口上。缺血時間在我們的方法裡也被減少。

並列摘要

Background:
Soft tissue and bony tumors of shoulder or proximal humerus may require extended forequarter amputation and the soft tissue defect can be extensive with bone exposed. Several reconstructive methods have been brought out. However, most of these methods have limitations. Skin graft is not reliable on irradiated wounds. Local flap, pedicle flap are limited to small defects. Pedicle flap is not available when the tumor invades the nourishing vessels of the region. Besides, reconstruction of these tissue defects often leads to donor site morbidities.
Aim and Objectives:
We presented three cases who received forequarter amputation because of malignant tumors involving in shoulder or humerus and reconstructed by free fillet flaps from amputated limbs. We also attempt to reduce the ischemic time in technique by postponing the ligation of the vessels after completion of the fillet flap dissection.
Materials and Methods:
Between March 2008 to September 2009, three patients received forequarter amputation due to malignant tumor and presented with large tissue defects and bone exposures in Mackay Memorial Hospital. Two of them were male and one was female. All of them have scapula exposure after forequarter amputation. The pathology reports in two of them were chondrosarcoma, and the other was malignant fibrous histiocytoma (MFH). Average skin defect after forequarter amputation was 344 cm^2(240~440 cm^2). All of them received free fillet flap harvested from the amputated limb.
Result:
The fillet flaps were harvested from the wrist to cubital area. All the flexor muscle groups were preserved in the flap. The brachial vessels were used as pedicles and anastomosed to axillary or subclavian vessels. The average skin paddle of the fillet flaps was 506 cm^2(280~810 cm^2). The average time of flap harvesting was 88 minutes. The ischemic time was calculated from ligation of axillary vessels to arterial anastomosis of the flap, and was less than 30 minutes in three cases. The mean blood loss during free fillet flap harvesting and reconstruction was about 83 ml. The average operation time was 372 minutes. The average hospitalization days was 44 days.
The tissue defects can be fully covered by the free fillet flaps harvested from amputated limbs, and no further donor site was needed. The flaps all survived well without marginal skin necrosis, dehiscence or infection.
Conclusion:
Free fillet flap is a reliable and replicable reconstruction method after forequarter amputation and gives satisfied result. In our experience, extensive defects can be reconstructed successfully with the free fillet flap, even in irradiated wounds. The ischemic time can be reduced in our methods.

並列關鍵字

free fillet flap ； reconstruction ； forequarter amputation ； forearm/surgery Introduction dissection