MOT TRITONG H(?P DIEU TRI LOC DA BIU \ A Dl/ONG VAT BANG V^T DA THEN - DUI KET HQfP GHEP DA MONG
Nguyen Thanh Nhu", Mai Trpng Tudng". Nguyin Hd Vinh Phudc', , Dang Quang Tuan*. Mai Ba Tiln Dung*
TOM TAT
Mff dau: Ldc loan bp da duong vSt va biu do t^i nan ddi hdi phai dugc ghep da che phu.
Myc tieu: bao cao mot tmdng hgp dugc dilu Ui bSng da mdng ghep len than ducmg vat va diing vat da Singapore lao hinh biu.
Benh nhan va phmmg phap nghien cmi: Md ta mdt imdng hop lam sang. Benh nhan dugc phlu thuat lai khoa Nam Hpc benh vien Binh Dan dl ghep da mdng che phu duong vat va tao hinh biu bang v^t da Singapore sau khi bi ldc loan bp da bp sinh due do lai nan.
Ket qua va ban lu?n: L.T.H., sl hi so 209/13165, dugc phlu thuSl gh6p da mong than duong vat va tao hinh tiii biu bing vat da Singapore hai ben ngay 28/07/2009. Sau ml 2 thang, benh nhan sinh boat tinh due binh ihudng va biu mdi phii da kin, thdm my. Duong vat, linh hoan. neu chdn uong da bung, da diii se can phau thuait lln sau tach ra; m^t khac. kha nSng co gian khi cuong - xiu cua duong vat hi han che.
Ket luan: Ghep da mdng len than duong vat va tao hinh biu bang vat da Singapore cho Uudng hgp ldc loan bo da viing sinh due, giiip bao tdn chiic nang va dat yeu cau tham my ctia duong vat va biu.
Tir khda: Mat da duang vdt - biu, mdnh ghep da mong, vat then - diii ABSTRACT
SPLIT-THICKNESS SKIN GRAFT AND PUDENDAL-THIGH FLAP FOR TREATMENT OF PENILE-SCROTAL SKIN LOSS: A CASE REPORT.
Introduction: Complete penile-scrotal skin loss caused by trauma requiring skin coverage.
Objective: we reported a case of using split-thickness skin graft for penile coverage and Singapore flap for scrotal reconstmction.
Patient and methods: A case report smdy. The patient had gerulal skin loss after Uauma, underwent a surgical tieatment at the department of andrology, Binh Dan hospital, for penile coverage by split- thickness skin graft and scrotal reconstmction by Singapore flap.
Results and discussions: L.T.H., document number: 209/13165, underwent split-thickness skin graft for penile coverage and Singapore flap for scrotal reconstmction on July 28"' 2(K)9. Two months later, patient had normal sexual intercourses, and the neoscrotum had skin covered and a good cosmetic appearance. If the penis and the testes had been tunnelled in abdomen and thighs, a second operation would have been done to detach them from skin pouches. Moreover, the flaccid - erect state of the penis would have been affected.
Conclusions: Split-thickness skin graft for penile coverage and Singapore flap for scrotal reconstmction for penile-scrotal skin loss help to preserve function and cosmetic appearance of the perus and scrotum.
Key words: Penile-scrotal skin loss, pudendal-thigh flap, split-thickness skin graft MODAU . .
Mil loan bp da than duong v^i va da biu vSn thinh thoang xay ra d cac tinh ding bang song Ciiu Long do may dudi ldm cuin vao quin. Ngoai chan thuemg, vel thuang da duong vat biu c6 the do hda khi, bong, hoai thu Foamier"'... Xii Iri thudng gap la phlu thuat chdn duang vat vao dudi da bung va chon mdi ben linh ho^n vao ben diii tuang irng. Benh nhan se can dugc phlu tiiuat lan sau de tach cac CO quan nay ra; mSt khac, kha n5ng co gian khi cuong - xiu cua duong vat bi h?n che.
Myc tieu
Bao cao mpt Uudng hgp dugc dieu tri mot thi bang ghep da mdng len than ducmg vat va diing vat da Singapore tgo hinh biu.
TRU'OfNG H<?P L A M SANG
B?nh nhan L.T.H, sl hi so 209/13165, ngu tai Sdc Trang, bi canh qu^t may du6i tdm cuon vao quin diii, lam ldc to&n bd da biu va duang vat. Benh nhan dugc benh vien dia phuong khau di'nh
' Khoa Nam Hpc, benh vien Binh Dan, TP. Ho Chi Minh.
" Khoa Vl Phau Tao Hinh. benh vifn Chan thuong Chinh Hinh. TP. H6 Chi Minh.
Dia chi hSn lac: TS.Nguyen Thanh Nhu DT: 0903698912 Email: [email protected]
573
da, nhung 4 ngay sau. da bp sinh due bi nhilm trung hoi, nen benh nhan dugc chuyen len benh viSn Binh Dan. Do loan bd da bd sinh due hi hoai tir den, mung mii, nen benh nhan dugc mo khin ngay 11/07/2009 dl ell bo loan bd da bj ldc (bao gdm toan bp da than duong vat va da biu, con lai khoang 1 cm niem mac bao qui dau) va md bang quang ra da. Hai tinh hoan va than duong vgt duoc de hd (hinh
! ) •
17 ngay sau. benh nhan dugc md ghep da mdng lay tii dui phai len than duong vat, va vat da- can dili - then (vat Singapore) hai ben de lao Uii biu mdi chiia hai linh hoan (hinh 2-5).
Diln lien sau md thuan lgi dli vdi da ghep Uen tiian duong vat, vat da diii - then ca hai ben deu bi hoai tu khd diu xa, khoang VA vat da ben phai va 1/5 vat da ben Uai (hinh 6). 3 tuan sau ph5u thuat benh nhan dugc xuat vien, di lieu binh thudng, chiic nang cuong tdt. Hai tuSn sau dd, khi tai kham, benh nhan da giao hop lai binh thudng, phin da biu tan lao hi hoai Hi khd dugc cit lpc (hinh 7).
Ba tuan sau niia, khi tai kham, ghi nhin da biu da mpc che kin biu (hinh 8).
BAN LUAN
Ldc da duong vai - biu thudng do may nong nghiep cudn vao quan, keo m^nh ra. Neu da bj rach van cdn cudng thi c6 the khau dinh I^i dugc, neu khong con cudng thi nen diing bien phap che phii da khac"". Trong tmdng hgp chi da than ducmg vat bi ude loan bp, thi viec diing vat da biu che phu la mpt bien phdp don gian, huu hieu (kha nang cuong - xiu) va tham my (khdng de lai s?o)"^'. Vat da biu se co han che khi benh nhSn ram long biu va can hai lln phau thu^l""". Neu bj mit toka h6 da duang vat va biu thi xu ly da che phii rieng re lirag co quan.
Dirong vat
Chon duang vat Uong da bung cd nhung bat tien sau:
Da bung day, co gian kem nen anh hudng ldi sy cuong va thSm my.
Benh nhan can dugc phau thual hai lan, ISn sau dl cat duong vat khdi cuing da bung.
Giiia hai lan phau Ihual, duong vit bj chdn dinh Uong da bung gay trd ng^i nhilu cho sinh boat ciia benh nhan.
• Cam giac da kem.
Do v^y, hien nay phucmg phap che phii da ducmg vat dugc ua chupng la ghep da mdng (split- thickness skin graft)'". Dp day da ghep vao khoang 0,016 - 0,018 in.
Benh nhan ctia chiing tdi hoan loan hai long vdi da mdng ghep than duang vat (tham my, sy cuong - xiu), dii dl lai seo Uen dui phai kha rpng. Chirc nang cuong binh thudng, giao hgp khong trd ngai sau mo 4 luin.
Biu
Mat da biu khoang 50% dien tich thudng cd thi khau kin dugc ngay lin diu. Mil da biu rpng CO the dieu tti bang each chdn tinh hoan Uong 6 da diii'"', hay che phii bang gac udt Uong vai tuan rli ghep da mdng ludi*''"".
Ghep da mdng cd bat lpi la**':
• Khdng thyc hien dugc Uong tmdng hgp mat da biu do nhilm trung.
Ddi hoi thdi gian cham si5c vlt thuong lau dai.
• Da biu mdi khdng co cam giac.
Sii dung cac vat da canh biu ttanh dugc cac nhugc dilm tten. Tuy nhiSn cSc vat da dugc su dung uudc day cd nhugc diem sau:
Vat da CO tiion (gracilis) ik vat da - co. ddi hdi phai hy sinh co thon'^'.
V^l da dui uudc vdi vung da co sy chi phdi ciia ihin kinh chiu - ben va sinh due - diii, co the din den hoai tii vung cho da*'°'.
• Tuong ty vdi vat da diii sau ciia Douglas, viing da cho cin dugc ghep da mdng'^.
Vgt da then - diii dya Uen cuong mach - tiiin kinh phia sau (dpng mach chau none vk thin kinh chau ndng) dugc Wee va Joseph sii dung lin diu tien nam 1989 di tgo liinh am dao"^. Vgt da nay cdn gpi ia vgt da Singapore do dupc cdng bl lin diu tien tai dao quIc do. Vat da nky sau do da dugc img dung de igo hinh cac co quan viing chgu va sinh due nhu tao hinh viing ch^u d nam gidi'^', tao hinh am hp' ', nieu dao nii"*" va tao hinh biu'*'^'. Theo Karaca! va cdng sy, b6nh nhan khdng c6 cam giac di cam d vat da. Ngoai ra, benh nhan chi cin phiu thual mdt lan. s?o da nim d ranh ben, nen dupc che diu tot .
Day la Uudng hgp dau lien chiing tdi sir dung vat da then - dtii tten lim sang va cung la lin dau tien ung dung vat da nay vao tgo hinh biu. Nhin chung ciing nhu Karacal'*', chiing toi ghi nhgn vgt 574
da - can nay de liy, khdng gay seo viing cho xiu (seo theo ranh ben), de lanh, tao Uii bin mdi dgt yeu cau tham mJ va cd cam giac da biu tot. Tuy nhien, vi ciing la lan dau tiiyc hien, nen da diu xa ciia vat da chua lanh lot, bi hoai tii mot phin nhd. Tuy nhien, sau do, toan bd biu cung duoc phii tron da.
KETLUAN
Mat loan bd da duong vat va biu cin dugc phu da. Trong khi ghep da mdng len duong vat da trd thanh chpn lya duy nhit, dgt yeu ciu thim my va chiic nang, tap hinh biu vin cdn la van de khd.
Vgt da Singapore cd thi la cau tra ldi cho bai loan nay nhd dgt ygu cau thim my, chiic nang. phiu thugt mpt thi, da c6 cam giac va khdng kho thuc hien.
Hinh 2. Duong rgch da ciia vgt da- cdn Singapore bin phdi.
Hinh 3. Vgt Singapore ben phdi dd tdch xons
_,. ^ - :-^.\
Hinh 4. Tiii biu mai dtrac hinh thdnh bdi hai vgt Singapore.
Hinh 7. Sau mo 5 tudn. Hinh 8. Sau mo 8 tudn.
TAI LIf U THAM KHAO
1. McAninch JW. Management of genital skin loss. Urol Clin North Amer 16:387-397,1989.
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2. Armenakas NA. McAninch JW. Genital reconsUuction after major skin loss. In Traumatic and reconsuuctive urology. Saunders, Philadelphia, 1996, 699-713.
3. Aycan K. A new technique in scrotal reconstmction: short gracilis flap. Urology 6: 1254-1256, 2003.
4. Balakhrisana C. Srolal avulsion: a new technique of reconstmction by split skin graft. Br J Plasi Surg9: 38-42, 1956
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2004Nov;64(5):1030.
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8. Kara9al N, Livaoglu M, Kutlu N, Arvas L. Scrotum reconstmction with neurovascular pedicled pudendal tiiigh flaps. Urology. 2007 Jul;70(l):170-2.
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10. Milland DR. Scrotal construction and reconstruction. Plast ReconsU Surg 38:10-15,1966.
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12. Nguyen Thanh Nhu, Dang Quang Tuin. Vgt da biu trong vet Ihuong mat da ducmg vat. Hpi nghi Tilt Nieu - Thin hpc TP. Hd Chi Minh, 11/2008.
13. Ninomiya R, Kishi K, Imanishi N, Nakajima H, Nakajima T. Reconstruction of vulva using pudendal thigh gluteal fold bilobed flap. J Plast ReconsU Aestiiet Surg. 2009 Jul 10.
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16. Zom KC, Bzrezinski A, St-Denis B, Corcos J. Female neo-urethral reconstmction with a modified neurovascular pudendal thigh flap (Singapore flap): initial experience. Can J Urol. 2007 Feb;14(l):3449-54.
