HOI CHAN THUONG CHJNH HINH VIET NAM - HOI NGHj KHOA HOC TOAN QUOC LAN T H U IX
TAO HINH CAC KHUYET PHAN MEM CHI D l l ^ B A N G VAT DUI TRlTOTC NGOAI Nguyen Dinh Minh*, Tran Thiet Son** va CS
TOMTAT
Muc tieu: (1) Mo ta ky thuat boc vat diii trUdc ngoai tU do va vat cudng lien ngUdc dong (2) Nhan xet mgt sd ket qua tao hinh cac khuyet phan mem viing chi dUdi bang vat diii trUdc ngoai, qua do rut ra Uu nhUdc diem, chi djnh ciia ky thuat.
Doi tUdng va phUdng phap nghien cu'u:
1/2007 den 3/2010 , 20 vat diii trUdc ngoai dUdc sir dung de che phii khuyet phan mem chi dUdi, trong d6l7 vat dUdc sir dung dUdi dang vat tU do cd ndi mach vi phau, 2 vat cudng ngoai vi diing de che phii khuyet phan mem viing gdi hoac 1/3 tren cang chan va 1 vat cudng ngoai vi ket hdp ndi mach tai dau xa ciia vat.
Ket qua: 17 vat diii trUdc ngoai tU do che phii cac khuyet phan mem viing rgng viing cd ban chan va 1/3 giu'a, dUdi cang chan cho ket qua tdt d 14 vat, 2 vat hoai tir toan bg va 1 vat hoai tir l/3.Trong 3 vat cudng ngoai vi cd 1 vat hoai tir do kich thUdc vat ldn. Vat cd kich thUdc trung binh 22,5xK),6 cm.
Ket luan: Vat diii trUdc ngoai la vat tUdng ddi hang dmh vdi cac nhanh xuyen xuat phat tir nhanh xudng ciia dgng mach mu diii ngoai. Vdi viing chi dUdi vat sir dung kha linh boat vdi vac dang vat tU do, cudng lien trung tam hay ngoai vi va cho ket qua rat tdt ve mat tham my tai ndi nhan vat cung nhu it gay anh hUdng ve mat chu'c nang tai viing diii cho vat.
Til* khoa: khuyet phan mem, vat 6u\
trUdc ngoai, chi dUdi.
SUMMARY
RECONSTRUCTION OF LOWER
EXTREMITY'S SKIN DEFECTS BY THE ANTEROLATERAL THIGH FLAP Objectives: (1) Description harvest technical of free anterolateral thigh flap and distal pedicle flap (2) reviews some results of reconstruction major defects in the lower extremities by anterolateral thigh flap, to draw the advantages and disadvantages, indications of techniques.
Methods: 1/2007 to 3/2010, 20 anterolateral thigh flap to be used to cover the lower extremities defects, 17 flap was used as a free flap, 2 peripheral pedicles flap used to cover the knees or leg and 1 distal pedicle flap with anastomose artery in the other end of flap. Results: 17 free anterolateral thigh flaps cover the defects of the ankle and feet and 1 / 3 middle, lower leg for good results in 14 flaps, two flap necrosis and a whole flap necrosis 1/3 of flap. In 3 distal pedicle flaps, a flap necrosis due to large size. The average flap size 22,5 x 10.6 cm.
Conclusion: Anterolateral thigh flap is constant with the peforator from descent of the lateral circonflex femoral artery. With the lower extremities defects, flap is quite flexible becase it can be used as free flaps, central or distal pedicle flap for very good results aesthetically in ties as well as receive little influence in the region functionally for thigh flap.
Keyword: skin defects, anterolateral thigh flap, lower extremity.
I. OATVANOE
Cac khuydt phhn mem chi dudi la mdt thucmg tdn rat hay gap trong cdp cuu ngoai khoa, hay sau cac phlu thuat cSt bd seo bdng
* Bd mdn Phdu thudt Tgo hinh, Truang Dgi hoc Y Hd ndi
** Khoa Phdu thudt tao hinh Benh vien Xanh Pdn Hd ndi 432
Y HOC VIET NAM THANG 10 - 3 0 2/2010
hay khdi u cua chi dudi. Muc dich ciia phau thuat tao hinh bao gdm che phii, ddn td chuc tai cho va cdn giiip dilu tri cac vet thuong nhiem trimg tai cho. Cd rk nhieu phuang phap tao hinh dimg dk che phii cac tdn khuyet neu tren, tuy nhien vat diii trudc ngoai (DTN) van la mdt chat lieu hang dau dugc sir dung d chi dudi do vat cd kha nang dugc sir dung linh boat, da dang thich nghi vdi timg loai tdn thucmg, nhu vat cd cudng xudi ddng hay ddng, vat tu do... Vat DTN vdi ngudn chit lieu ldn gdm da, can, ca dap img dugc nhu cdu trong tao hinh khdng chi ve mat chiic nang ma cdn ve mat tham my do chat lieu tuang ddng khi tao hinh viing chi dudi.
Chiing tdi tien hanh nghien eim viec sir dung vat DTN cho cac khuyet phan mem vimg chi dudi nhim Muc tiiu: (1) Md ta ky thuat sir dung vat dui trudc ngoai cd cudng mach nudi va tu do (2) Danh gia ket qua tao hinh cac khuyet phan mem viing chi dudi bang vat diii trudc ngoai, qua dd riit ra uu nhugc diem, chi dinh cua ky thuat.
II. DOI TUONG VA PHUONG PHAP NGHIEN CQU Tir thang 1/2007 din 3/2010, 20 vat diii trudc ngoai dugc sir dung de che phu khuyet phdn mSm chi dudi, trong dd 17 vat dugc sir dung dudi dang vat tu do cd ndi mach vi phau, 2 vat cudng ngoai vi dimg de che phii khuyet phdn mem vimg gdi hoac 1/3 tren cdng chan va 1 vat cudng ngoai vi ket hgp noi mach tai dau xa cua vat.
Vat da cdn DTN dugc thiet ke theo hinh dang ciia khuyet phdn mem. Mdt dudng ndi gai chau trudc tren va bd ngoai xuang banh che dugc coi la true chinh cua vat nay. Xac dinh cac nhanh mach nudi da bang may doppler cdm tay. Dudng raeh da ben trong vat dugc thuc hien ddu tien nham bdc Id vach gian ca thing diii va rdng ngoai. Tim nhanh
xuyen da qua ca hay nhanh xuyen vach, tim nhanh xudng ciia ddng mach mii diii ngoai, nai xuat phat cua cac nhanh xuyen. Bdc Id nhanh xudng den nguyen uy. Phau tich nhanh xuyen qua ca rdng ngoai. Raeh bd ngoai ciia vat hay khdng tuy vao chat lieu can tao hinh cua vat. Vat da cdn dugc tach rdi khdi noi cho, vat cdn md se de lai phdn da tren vat.
Trong trudng hgp vat DTN cd cudng ndi, viec phau tich cudng mach tiiy thudc vao dang cudng nudi xudi ddng hay ngugc ddng, cat ddu xa ciia nhanh xudng sat vdi nai tach ra ciia nhanh xuyen hay cat dau gan nhanh xudng neu la cudng ngugc ddng. Khdang each di ddng ciia vat phu thudc vao chieu dai ddng mach xudng va nhanh xuyen ra da den vat. Vat se dugc cat rdi cudng mach xudng va chuyen den viing cdn tao hinh d chan neu sir dung d dang tu do, sau dd tai lap tudn hoan ciia vat nhd ky thudt vi phdu mach mau.
Ddng mach ciia vat dugc ndi vdi ddng mach chay trudc hay chay sau, tmh mach dugc ndi vdi cac tinh mach ndng ciia chdn. Nai cho vat d diii dugc ddng true tiep hay dung manh ghep da ddy toan bd.
Chiing tdi danh gia hieu qua sir dung ciia vat tren 1dm sang, benh nhdn dugc theo ddi ket qua 3 thang mdt ldn va kk qua xa dugc danh gia sau phdu thudt 9 thang.
III. KET QUA
17 vat diii trudc ngoai tu do che phii cac khuyet phdn mem viing rdng viing cd ban chdn va 1/3 gifta, dudi cang chdn cho ket qua tdt d 14 vat, 2 vat hoai tir toan bd va 1 vat hoai tir 1/3.Trong 3 vat cudng ngoai vi cd 1 vat hoai tir do kich thudc vat ldn, sau dd vat dugc lang mdng ghep lai vao tdn khuyet kieu ghep da day toan bd, da ghep sdng hoan toan.
Vat cd kich thudc trung binh 22,5x10,6 cm.
Chieu dai ldn nhdt ciia vat dugc ldy la 46 cm.
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HOI CHAN THUONG CHINH HINH VIET NAM - HOI NGHj KHOA HOC TOAN QUOC LAN T H U IX
chieu rdng ldn nhdt la 14 cm. Vdi dien tich neu tren vat cd kha nang che phii hdu bet cac tdn khuyet, cd 5 trudng hgp vat chi che phu dugc dien tich tir 60% den 90% tdn khuyet tdn do kich thudc ciia tdn khuyet kha ldn, phdn vat khdng che phii dugc bd sung bang ghep da mdng.
Phdn loai tdn thuang cho thay phdn ldn trudng hgp khuyet phdn mem la do tai nan giao thdng 15 ca (75%) cdn lai 3 trudng hgp tdn thuang loet ldu lien (15%)) va 2 trudng hgp che phii seo bdng gay co keo viing cd chdn. Ve phdn bd tdn thuang, chiing tdi sir dung vat diii trudc ngoai tu do 8 trudng hgp cd thuang tdn d ban chdn (40%), 4 trudng hgp bi thuang tdn viing cang ban chan (20%), 3 trudng hgp chi thuang tdn d ban chdn, ngoai ra cd 2 benh nhdn bi khuyet phdn mem viing khoeo va mat ca trong.
Kit qua xa, tdt ca cac benh nhdn sau phdu thudt deu cd kha nang van ddng tdt, vat diii trudc ngoai cd do dan hdi tdt, do co keo ciia vat khdng dang ke, khdng gdy co keo hoac anh hudng tdi van ddng. Mau sac vat rdt tuang ddng vdi viing da tai chi dudi.
IV. BAN LUAN
Trong nghien ciiu cua chiing tdi, vat dui trudc ngoai dugc sir dung chii yeu dudi dang vat da cdn cd kbd nang tram bit va dii do day de ddn cac tdn khuyet mdt da tai vimg chi dudi. Vat diii trudc ngoai cd cac uu diem cd the dap ling dugc nhu cdu che phii tai chi dudi dd la: vat cd kich thudc ldn, cd th8 che phu tdn khuyet rdng, do day ciia vat rdt phii hgp vdi td chiic da va phan m6m ciia chi dudi, vat dugc cdp mau tot, cd the diing d6 che phii be mat loet ldu lien hay nhilm triing.
Vdi cac thuang tdn tai viing mu ban chdn, chimg tdi ket hgp sir dung ky thudt vi phdu tich lam mdng vat khdng chi tang cudng sire
song ciia vat ma cdn lam cho vat cd do day phii hgp vdi da vimg mu chdn.
Tai vi tri ldy vat, hdu h8t cac trudng hgp lay chilu ngang vat dudi 10 cm chiing tdi co the khau ddng nai cho vat true tiep, cac trudng hgp cdn lai dugc ghep da bd xung ngay thi ddu hoac thi sau.
Ddi vdi vat diii trudc ngoai dugc sir dung dudi dang vat tu do, chung tdi cd mdt nhan xet dd la vat cd cudng mach rdt hang dinh vdi kich thudc dii ldn de cd the de dang ndi mach vi phdu. Cac nhanh xuyen cua vat theo nghien ciiu ciia chiing tdi cho thdy tap trung chil yeu tai vimg trung tam, neu chia dui (tir gai chau trudc tren den bd ngoai xuang banh che) ra lam 16 khodng thi cac nhanh xuyen nay ludn tap trung d khoang 8 hoac 9 ciia dui. Da sd cac nhanh xuyen ciia vat la nhanh xuyen ca-da (67%o), cac nhanh nay chay ngoan ngoeo trong ca trudc khi di ra da vi vay cdn phdi ty my trong phdu tich cac nhanh xuyen nay.
Vat diii trudc ngoai cudng ngugc ddng dung de che phii cac khuyet phdn mem vimg quanh gdi va khoeo ludn la chdt lieu dugc uu tien hang ddu vi tinh tuang ddng ve mat td chirc va an toan khi bdc vat. Cac vat ngugc ddng khi sii' dung nhanh xuyen cang cao thi kha nang vuan xa ciia vat cang ldn ban do tan dung dugc chieu dai cua nhanh xudng.
Trong nghien ciiu nay chung tdi manh dan sir dung hai vat diii trudc ngoai cudng ngoai vi md rdng vat den tan mao chau (vat dai 43 va 29 cm), nhd vay vat cd the vuon xa tdi tan viing cd chan. Dac biet, de tang sire sdng cho vat chiing tdi da sir dung them mgt nhanh xuyen cho vimg fasciae latae ndi vao mach tai nai nhan. Hoac vdi ddu vuan xa ciia vat chiing tdi sir dung ky thudt Colson (lam mdng vat de lai mang mach dudi da) d6 dam bao sire sdng tai dau xa cua vat.
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V. KET LUAN
Vat diii trudc ngoai la vat tuong ddi hang dinh vdi cac nhanh xuyen xudt phat tir nhanh xudng cua ddng mach mii diii ngoai. Vdi viing chi dudi vat sir dung kha linh boat vdi vac dang vat tu do, cudng lien trung tdm hay ngoai vi va cho kk qua rat tot vl mat thdm my tai nai nhdn vat cQng nhu it gdy anh hudng ve mat chiic nang tai viing diii cho vat.
TAI UEU THAM KHAO
1. Geoffrey G. Hallock, MD. The Proximal Pedicled Anterolateral Thigh Flap for Lower Limb Coverage. Ann Plast Surg.
2005;55: 466-469.
2. Hallock GG. Lov^er extremity muscle perforator flaps for lower extremity reconstruction. Plast Reconstr Surg.
2004;114:1123-1130.
5.
Koshima I, Kawada S, Etoh H, et al.
Flow-through anterior thigh flaps for one- stage reconstruction of soft-tissue defects and revascularization of ischemic extremities. Plast Reconstr Surg.
1995;95:252-260.
Omer O et al. The Use of Free Anterolateral Thigh Flap for Reconstructing Soft Tissue Defects of the Lower Extremities. Ann Plast Surg.2004;53: 455-461
Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg. 1984;37:149-159.
Yildirim S, Avcy' G, Akan M, et al.
Anterolateral thigh flap in the treatment of postbum flexion contractures, of the knee. Plast Reconstr Surg.
2003;111:1630-1637.
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