TAP CHI Y DU'O'C LAM S A N G 108 T^p 9 - So 3 /2014
Sir dung vat da nhanh xuyen hai cuong mach ty do vung lu-ng khac ben trong tao hinh di chung bong toan bo vung mat
Clinical Study of Dorsal Double Pedicled Perforator Free Flap to Reconstruct of Severe Whole Face Scar in Post Burn Patients
Vu Quang Vinh, Tran Van Anh, Vien BongLeHihi Trdc Tong Thanh Hai, Hoang Thanh TuSn,
Nguyen Gia Tien
Muc tieu: Tai tao khuon mat sau bdng van luon la thach thUc cua cac phau thuat vien tao hinh. Cac phuong phap tao hinh kinh dien mdi chi dap Ung dugc mot phan ddi hdi ve do rdng, mdng va sUtuong ddng ve mau s^c. Nam 2011 chung toi da tien hanh nghien cUu vat da hai cuong nhanh xuyen tU do tai vung lUng, vat dO rong cd the lam mdng rong rai va dap Ung dugc cac dang tdn khuyet khac nhau, t h | m chf cd the sCrdung tai tao toan bg khuon mat mot thi dem lai ket qua tot ve chUc nang va tham my. Benh nhdn vd phuang phap: 2^ benh nhan vdi 8 nam va 13 nUtCr 15 den 48 tudi dugc dieu tri tai khoa PTTH- Vien Bdng tU 1/2011 den 12/ 2013 vdi chan doan seo co keo cd mat mUc do nang. 21 vat da nhanh xuyen hai cuong t g do khac ben dugc thiet ke tai vung lung bao gdm nhanh xuyen ddng mach mu vai va nhanh xuyen dgng mach lien sudn sau khac ben. Mach nhan la bd mach th^i duong ndng va bo mach mat cung ben. Vung giUa hai cuong mach dugc lam mdng. Kfch thudc vat tdi da dat dugc la 35 x 20cm.
Ketqud: 19 vat sdng hoan toan va hai vat bi hoai tU mot phan. Vung cho vat dugc ghep da trung binh chephCi. Benh nhan dat dugc yeu cau vechUcnang va tham my. Ket luan: Wat nhanh xuyen hai cudng tU do vung lung khac ben la su lua chgn mdi trong phau thuat tai tao mat cd. Vat co do tin cay cao, co cau true v^ mau sac tuong ddng vdi vung tai tao
Tdkhod: vat sieu mdng, vat ndi mach dau xa, vat hai cudng, vat nhanh xuyen
Summary:
Objectives: Nowadays, the face and neck reconstruction for post burn patients always challenged the plastic surgeons. The materials are requested to be large, thin and same color, texture with face area.
Conventional methods are till not yet satisfied this request. Perforator supercharge super-thin flap was introduced in 1994 by Hyakusoku and Gao, The super-thin flap Is a distinctively thin flap primary thinned to the layer where the subdermal vascular network can be seen through minimal fat layer. For the reconstruction of severely disfigured neck and face, large and thin flap such as the occipito-cervico- dorsal (OCD) "super-thin flap" should be harvested from the dorsal region with surpercharging of the circumflex scapular vessels. Recently, we have applied dorsal double contralateral peri^orators "super- thin" free flap for reconstruction of whole face severe scar contracture in post burn patients. Subjects and
Phan biln klioa HQC: PGS.TS, NGUYEN BAC HUNG
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol9-N"3/2014
Methods: Twenty one patients included 8 male and 13 female were admitted at Department of Plastic and Reconstructive Surgery of National Institute of Burn since January, 2011 to December, 2013. Range of age from 15 to 48 years old. Twenty one dorsal double contralateral perforators free flaps were designed in the dorsal. Flap with circumflex scapular artery perforator and contralateral posterior intercostal perforators including of the flap was designed at dorsal. Recipient are superficial temporal artery and contralateral facial artery or contralateral superficial temporal artery. The fate tissue between two pedicles was thinned before pedicles dividing. Maximum we can be obtained 35x20cm. Detail of technique will be discussed in our paper. Results: Nineteen flaps survived completely and two flaps happened a part necrosis. The donor site was covered by using split full-thickness skin graft. The patients were satisfied with both cosmetically and functionally. Conclusion: Dorsal double perforators super thin free flap is new option in severe neck contracture scar reconstruction.
Keywords: Super-thin flap. Super-charging flap, Bipedicle flap, Perforator flap.
1 . fiat van de
Trong phau thuat tao hinh, ngay nay chat lieu tao hinh chiem mot vai t r d het sUc quan trgng trong che phu cac ton khuyet sau phau thuat u bUdu, mat da va to chUc phan mem sau tai nan va dac biet nhu'ng ton khuyet sau khi giai phdng seo do tdn thuang bdng gay nen. Cac phuong phap tao hinh kinh dien nhU ghep da, vat da tai chd nhU vat limberg, hai thuy, ba thuy, vat da cd cudng mach n h u vat CO nguc Idn, vat co bam da cd, vat cO Uc don chum, vat tren d d n . . . va phuang phap gian t d chUc .... trong mdt t h d i gian dai da t r d thanh sU lua chgn chu yeu cCia cac phau thuat vien tao hinh. Tuy nhien, tai tao di chUng bdng toan bg viing mat hien nay van dang la thach thUc cua cac phau thuat vien tao hinh tren the gidi. Mot sd vat da tU do kinh dien cung da dugc sCf d u n g t r o n g tai tao mat nhUng do han che ve kfch thudc va do day nen chUa dem lai hieu qua cao trong dieu tri. Them nUa, di chUng seo bdng ciia cac benh nhan t h u d n g khdng gidng nhau ve vi tri t d n t h u a n g nen ddi hdi vat da phai dugc thiet ke linh hoat tuy theo hinh dang t d n khuyet sau khi giai phdng seo. Cac chat lieu tao hinh ddl hdi phai du rdng, mdng va tUdng d d n g ve mau sac dang t r d thanh yeu cau ddi hdi cac bac sy tao hinh tiep tuc t i m kiem. Nam 2010, Hyakusoku va cgng sU da chuyen giao ky thuat vat da sieu m d n g hai cudng nhanh xuyen t u do tai vung lung cho Vien Bdng Le HUu Trac'. Ky thuat nay da dem lai hieu qua t o t cho tai tao seo do dl chUng bdng toan bg vung mat.
Hieu qua cua phUdng phap se dugc danh gia va ban luan t r o n g bai bao cua chung t d i .
2. D d i tuang va phUdng phap nghien cufu 2.1. Ddi tuang nghien cdu
21 benh nhan (13 nCr va 8 nam) tudi tU 15 d^n 48 dugc chan doan (bang 3.1) seo co keo nCfa mat- ed do di chUng b d n g , dUdc t h u d u n g tai khoa Phau thuat tao hinh Vien b d n g Le HQu Trac tU 1 /2011 den thang 12/2013.
2.2. Phuang phap nghien cdu
Chung tdi chia t h a n h hai loai vat nhanh xuyen hai cudng t u d o doi ben:
- Loai I: Nhanh xuyen d d n g mach mu vai + Nhanh xuyen d g n g mach lien sUdn sau ddi ben.
- Log! 2: Nhanh xuyen d d n g mach mu vai + Nhanh xuyen d d n g mach m u vai doi ben
2.2. /. Cdc budcphau thuat - Budc I: Vd cam va xi!f ly seo b d n g
+ Ap d u n g p h u o n g phap gay m e ndi khf qu3n cho tat ca cac benh nhan nghien cu'u.
+ Rach da, cat b d het t d chUc x d seo den md lanh m e m mai. Cam mau ky dien cat.
+ Phau tfch t i m b d mach nhan la bd mach thai dUdng n d n g va b d mach mat ben ddi dien {Neu ap d u n g dang vat loai 1). Phau tfch bd mach thai dUPng ndng ca hai ben (Neu ap d u n g dang vat loai 2)
- 6 t / d c 2 ; T h i e t k e v a t
TAP CHi Y DU'O'C LAM S A N G 108 Tgp 9 - S 6 3/2014
+ Vat dugc t h i e t ke theo hinh dang va kfch thudc t o n khuyet.
T h u d n g chung tdi thiet ke theo ddn vi tham my cua mat, cam.
+ Nhanh xuyen d g n g mach mu vai la hang d j n h nen 6ugc lUa chgn n h u tam cua vat, nhanh xuyen dong mach lien sudn cung ben se dugc xac djnh bang Doppler cam tay. Vj trf nhanh xuyen can t u o n g Ung vdi vi t r i d d n g mach mat hoac d d n g mach thai duong ndng tai noi nhan vat. (Hinh 1).
- e u d c 3 : Phau tfch vat
+ Rach het Idp da tU dau m u t v a t v a gidi han hai ben theo dUdng ve.
+ Bdc tach vat den d u n g Idp can sau, xac dinh nhanh xuyen d g n g mach m u vai va phau tfch dgc theo hudng di cua true mach den gdc ndi nd tach ra tU ddng mach vai dudi.
+ Phau tich nhanh xuyen d g n g mach lien sudn sau ddi ben. Theo kinh nghiem cua chung tdi nhanh xuyen d d n g mach lien sudn sau VI va VII t u o n g ddi hang djnh va dugc lua chgn cho phau thuat. Nhanh xuyen dugc phau tfch den gdc cua nd khi d d dai va khau kfnh bd mach vUa du se dugc phan chia chuan bj cho ndi mach.
+ Tien hanh b d b d t m d t r o n g khocing giufa cua hai bu mach cCia vat bang keo t h u d n g , phan m d xung quang hai bu mach khdng dugc lam m d n g trdnh lam t d n t h u a n g nhanh xuyen, vUa cat m d vda
quan sat t i n h trang va mau s^c mau chciy ra tU vat, neu thay mau cd mau t h a m t h i dUng lai ngay.
-I- Vung cho vat khau kfn m d t phan va ghep da xe ddi che p h u .
- S u d c 4 ; Khau ndi mach mau
-I- Vat da dugc chuyen den vung nhan. Bd mach mu vai dUOc khau ndi vdi b d mach thai dUdng ndng.
Nhanh xuyen d g n g mach lien sudn sau dugc khau ndi vdi d g n g mach mat cung ben (Dang vat 1). Hai b d mach mu vai va hai bd mach thai dUong n d n g (Dang vat 2). NhUng mau chdt cua ky t h u a t se dugc m d ta ky t r o n g phan ban luan.
- Vat da dugc khau kin va dat dan luu ap lUc am.
2.2.2. Ddnh gid ket qud -I-Co sd danh gia k e t q u d :
-Tinh trang sdng cua vat va tinh trang noi cho vat - Tinh trang lien vet m d
- Mdc do phuc hdi chdc nang va tham my sau m d + Ket qua gan:
- T o t : vat sdng hoan toan, vung cho va nhan vat lien seo t o t . ChUc nang va t h a m my dugc phuc hdi.
- Vda: Vat thieu d u d n g va hoai tCr 1/3 vat. Phai ghep da bd xung. Vet m o lien ky 2. ChUc nang va tham my cd cai thien.
- Xau: Vat hoai t d tren 1 /3. Chdc nang van d d n g va t h a m my khdng cai thien.
3. Ket qua
Bang 3 . 1 : Lien quan giufa v i tri t a o hinh, kfch thUdc vat va vi tri nhanh xuyen va bien chuTng sau mo Table!:
N"
1 2 3 4
5 Tuoi Gicri 25/Nani 40/Nam 22/NLi 29/Nam
16/Nam
Vi tri tai tao Mat Mat Mat Mat Toan bg mat
Nhanh NXl BMMV
(Trai) BMMV (Trai) DMMV (Trai) BMMV
(Trai) DMMV (Trai)
xuyen NX2 NXLSS V
(Phai) NXLSS VII
(Phai) NXLSS VI
(Phai) NXLSS V
(Phai) NXLSS VII
(Phai)
Mach TDN Trai Trai Trai Trai
Trai nhan
BMM Phai Phai Phai PhSi Phai
- Kich thadc vat 33x9cm 30x14cm 28x10cm 35x1Scm 29x14cm
Bien chu'ng Khong Khong Khong Hoai tCf mpt phan
Khong
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- CLINICAL MEDICINE AND PHARMACY Vol 9 - N"3 /2014
Bang 3 . 1 : (tiep theo)
Tuoi Gidi
Nhanh xuyen
TDN DMIVl
- Kich thucfc vat Bien chu'ng
6 7 8 9 10 n 12 13 14 15 16 17 18 19 20 21
34/Nam 35/NO 22/Nil 15/Nam
23/NO 26/Na 25/Nam 23/Nam 34/Nii 33/Ni3 26/NO 48/NO 40/NCt 30/NO 40/Na 28/NO
Mat Toan bo mat
Ma + c6 Toan mat Mat Toan bp mat
Mat Mat Mat Mat Mat Toan bo mat
Mat Toan bp mat
Mat Mat
BMMV (Trai) BMMV
(Phai) BMMV (Trai) BMMV
(Trai) BMMV
(Trai) BMMV
(Trai) BMMV
(Phai) BMMV (Trai) BMMV
(Trai) BMMV
(Trai) BMMV
(Trai) BMMV
(Trai) DMMV
(Trai) DMMV (Phai) BMMV (Phai) DMMV (Trai)
NXLSS VII (PhJi) NXLSSV
(Trai) NXLSS VI
(Phai) DMMV
(Phai) NXLSS VII
(PhJi) NXLSS VII
(Phai) NXLSS VII
(Trai) NXLSS V
(PhSi) NXLSS VII
(Phai) NXLSS VI
(Phai) NXLSS V
(PhSi) NXLSS VII
(Phai) NXLSS VII
(PhSi) NXLSSV
(Trai) NXLSS VII
(Trai) NXLSS V
(PhSi) Trai Phai Trai Trai va
phai Phai Trai Phai Trai Trai Trai Trai Trai Trai PhJi Phai Trai
PhSi Trai PhSi
Trai PhSi Trai PhSi PhSi PhSi Phai Phai Phai Trai Trai PhSi
31x1Scm 27x21 cm 34x19cm 41xl4cm 31x14cm 28x19cm 31x20cm 24x14cm 32xl4cm 28x17cm 24x16cm 29x14cm 24x1 Scm 27x21 cm 28x14cm 30x9cm
Khong Khong Khong Khong Khong Hoai tCf mpt phan
Khong Khong Khong Khong Khong Khong Khong Khong Khong Khong
NX: Nhanh xuyen; TDN: D d n g mach thai dUdng ndng; D M M : O d n g mach m a t BMMV: Odng mach mu vai; DMLSS: D d n g mach lien sUdn sau
Bang 3.2. DUdng kinh nhanh xuyen Dudng l<rnh (mm)
S6trucJnghop(n = 21) DJcjng l<inh trung binh
0,5 5
1 14
1,5 2 1,0 ±0,5 m m
TAP CHI Y DL/qyC U M S A N G 10i Tap 9 - S o 3/2014
D u d n g kfnh t r u n g binh nhanh xuyen 1,0 ± 0,5 mm. Kich thudc nhanh xuyen nhd nhat 0,5mm chiem hai t r u d n g hgp. D u d n g kfnh nay du de dam b^o cap mau cho vat
Bang 3.3. Chieu dai nhanh xuyen lien siidn sau Chieu dai
(cm) So tr Jdng hop ( n = 9) Tyle(%)
2,5<
3
14,29%
2,6-3,4
16 76,19%
>3,5
2
9,52%
Chieu dai 2,6cm den 3,4cm gap da sd cac trUdng hgp chiem 76,19%. Kich thudc nay dcim bao cho su linh d g n g khi thiet ke vat.
Bang 3.4: Ket q u a sau m d K^tqua
Tot Trung binh
Xau Tong
Solugng 19
2 0 21
Tyle 90,48%
9.52%
0 100%
4. Ban l u a n
Tai tao toan bo khudn mat mat sau di chu'ng bdng va chan thUdng van dang la thach thifc vdi phau t h u a t vien tao hinh. Cac p h u o n g phap phau thuk kinh dien khdng t h e sd d u n g dugc. Yeu cau cac chat lieu tao hinh v u n g mat ph^i dat dugc dp mdng, tUdng d d n g ve mau sac va quan t r g n g nhat phai du rdng va cd n g u d n cap mau t i n cay de cd the md mieng, mui va mat t r o n g m o t thi mo vi day la cac giac quan quan t r g n g can thiet dam bao chdc nang song va cho phep cham sdc sau m d dan gian hdn. Hien nay, p h u a n g phap dan t d chUc dugc ua chudng nhat ^•". Tuy nhien, do t h d i gian dai va benh nhan di chu'ng b d n g t o a n b g v u n g mat da lanh cdn it nen viec t i m vj t r i dat tui la rat khd khan. Nam 2007, c h u n g tdi da ap d u n g vat da sieu m d n g cham cd lUng cd ndi mach vi phau tai dau xa cho tai tao mdt nda k h u d n mat bj b d n g acid cho m o t benh nhan rat t h a n h c d n g ^ Nhung do phSi sU d u n g
cudng cham nen cung quay cdn han che, kfch thudc vat chua du Idn de tai tao toan b g khudn mat.
Nam 2010, Giao su Hyakusoku da chuyen giao ky t h u a t vat tU do hai cudng nhanh xuyen lay tai v u n g lung, vat hon ban cac ky t h u a t da ap d u n g trUdc do nhU: vat dugc cap mau bdi hai nhanh xuyen, m o t den tU d d n g mach m u vai va m o t den t d nhanh xuyen d d n g mach lien sUdn sau ben doi dien.
Do vay, kfch thUdc dCi rong cho phep thiet ke vat theo bat cd dang t d n khuyet nao sau khi c i t b d seo.
Da v u n g lung lan can t d n khuyet nen dcim bSo do t u o n g d d n g ve cau true. Dac biet do cd sU cap mau tin cay nen cd the lam m d n g vat chi giU lai Idp m d m d n g 5 m m va dam rdi mach mau dudi da dat dUdc tieu chi do m d n g khi tao hinh vung cam co
Nam 2011 den nay, 21 vat da hai cudng nhanh xuyen t u do ddi ben da dugc chung tdi ap d u n g thanh cdng t r o n g tai tao toan bd khudn mat- co.
Nhanh xuyen d d n g mach lien sudn sau VI hoac VII da dugc xac dinh trudc m d b^ng sieu am Doppler 8MHZ. D d n g mach thai d u o n g ndng va ddng mach mat ddi ben dugc lua chgn lam mach nhan. Qua kinh nghiem phau tfch nhanh xuyen lien sUdh sau cho thay day la mach nhd kfch thUdc t r u n g binh 1,0
± 0,5 m m (Bang 3.2) va chieu dai t r u n g binh > 3,5cm (Bang 3.3) du de ndi mach. NhUng t r o n g m d t sd trUdng hgp thi su chenh lech ve d u d n g kinh mach cho (Nhanh xuyen d g n g mach lien sUdn sau) va mach nhan {Ddng mach mat) ddi hdi phau t h u a t vien ph^i cd ky t h u a t noi mach t o t Hai t r u d n g h o p b d mach xuyen d u d n g kfnh 0,5mm chung tdi chi ndi dugc d g n g mach cdn hdi lUu t i n h mach cOa nd se dugc dan iuu qua t m h mach cua d g n g mach m u vai.
Ket qua vat van sdng hoan t o a n ma khdng cd bat cU bien chufng nao.Chieu dai vat Idn nhat chung tdi cd t h e lay dUdc vdi chieu dai len tdi 35crn va chieu rdng la 20cm (Bang 3.1).
Tren 21 benh nhan dugc phau t h u a t cd hai benh nhan bj hoai tCr m o t nUa vat va m d t phan t u vat. TrUdng h g p benh nhan hoai tCr m o t phan t u v a t , theo nhan d i n h cCia chung tdi do loi phau tich d d n g mach m u vai, nhUng sU cap mau nhanh xuyen lien sudn Vll van tdt. Sau ngay t h d nhat, vat t i m nhe VA
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JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 9 • tf3 72014
vat nai cap mau cCia dpng mach m u vai. Chung toi d l / doan vat se hoai tCf %, sau ngay thu" hai mau s i c vat dien bien tot han mau hong lan dan ve phl'a vung cap mau cua d p n g mach mu vai. Sau ngay thtjf 7, vung hoai til chi con l^. Dieu nay co the giSi thfch thay theo thuyet cua Cormacic va Lamberty l<hi m p t vOng giai phau thieu mau, vung giai phau lan can se m d rong su cap mau sang v i i n g thieu mau do cac choke vessels giaa hai mang mach duoc m d ra.
Chinh tCf su that bai nay chung toi da quyet djnh tai tao toan bp khuon mat b i n g vat da hai cuong nay vi cho rang trong m o t dieu kien nao do cuong phu la nhanh xuyen dpng mach lien su6n sau se m d rong vung cap mau cua no. (Hinh 2 va 3) Do vay, vat co dp tin cay cao.
Trong tai tao t d n khuyet dai va rong vung mat Chung toi ap dung sil dung vat vdi hai nhanh xuyen dong mach mu vai hai ben va mach nhan la hai bo mach thai duong nong dat ket q u ^ tdt.
Thdi gian phau thuat trung binh cho m p t ca tai tao toan bp khudn mat cCia chung tdi mat khpSng 8,5 tieng rut ngSn 3 tieng so vdi ca dau tien do chung tdi chia lam hai kfp phau thuat song song va da lam chu ky t d t thuat thdi gian t i m mach va phau tich mach da nhanh hon.
5. Ket luan
Vat da hai cudng nhanh xuyen t y do ddi ben lay vung lung la vat da cd dp tin cay, d u rdng va gan tdn khuyet do vay cd sy t u o n g d d n g ve mau sSc. Day la m o t chat lieu tao hinh t d t cho tai tao t d n t h u o n g bdng toan bp vung mat.
T a l l i e u t h a m k h i o
1. Tsai FC. A new method: Perforator-based tissue expansion for a preexpanded free cutaneous perforator flap. Burns 2003; 29:845-848.
2. Margulis A, Agam K, Icekson M, Dotan L, Yanko- Ara R, Neuman R. The expanded supraclavicular flap, prefabri- cated with thoracoacromial vessels, for reconstruction of postburn anterior cervical contractures. Plast Reconstr Surg. 2007:119:2072- 2077; discussion 2078-2079
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3. Huang WC, Chen HC, Wei FC, Cheng IVIH, Schnur DP. Chimeric flap in clinical use. Clin Plast Surg.
2003;30:457-467.
4. Hyakusoku, H., Pennington, D. G., and Gao, J. H.
Microvas- cular augmentation of the super-thin occipito-cervicordorsal flap. Br. J. Piast. Surg. 47:
465,1994
J. Vinh VQ, Van Anh T, Nam I, Ogav^a R, Hyakusoku H.
Reconstruction of Acid Injured Face v^ith Occipito- Cervico-Dorsal (OCD) "Super-thin Flaps". Plast Reconstr Surg.Plast Reconstr Surg. 2009 Jul;
124(l):167e-9e.
6. Hyakusoku, H., and Gao, J. H. The "super-thin" flap.
Br. J. Plast. Surg. 47:457,1994.
7. Hyakusoku, H., Gao, J. H., Pennington, D. G., et al.
The microvascular augmented subdermal vascular network (ma-SVN) flap: Its variations and recent development in using intercostal perforators. Br. J.
Plast. Surg. 55:402,2002.
8. Ogawa, R, Hyakusoku, H, IVlurakami, M, Aoki, R, Tanuma, K., and Pennington, D. G. An anatomical and clinical study of the dorsal intercostal cutaneous perfora- tors: Its application to free microvascular augmented sub- dermal vascular network (ma-SVN) flaps. Br. J. Plast. Surg. 55:396,2002.
9. Ogawa R, Murakami M, Vinh VQ, Hyakusoku H.
Clinical and anatomical study of superficial cervical artery flaps: Retro- spective study of reconstructions with 41 flaps and the fea- sibility of harvesting them as perforator flaps. Plast Reconstr Surg. 2006; 118:95-101.
10. OgawaR, HyakusokuH, Iwakiril, AkaishiS.
Severeneckscar contraaure reconstruaed with a ninth dorsal intercostal perforator augmented "super- thin flap." 4nnPtost Surg. 2004; 52:216-219.
11. Vinh VQ, Ogawa R, Iwakiri I, Hyakusoku H, Tanuma K. Clinical and anatomical study of cervicopectoral superthin flaps. Plast Reconstr Surg. 2007;
119:1464-1471.
12. Abe M, Murakami G, Abe S, Sakakura Y, Yajima T.
Supra- clavicular artery in Japanese: An anatomical basis for the flap using a pedicle containing a cervical, non-perforating cuta- neous branch of the superficial cervical artery. Okajimas Folia Anat ./pn. 2000;77:149-154.
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13. Vinh VQ, Ogawa R, Van Anh T, Hyakusoku H.
Reconstruction of neck scar contractures using supraclavicular flaps: Retrospective study of 30 cases.P/asfffeconstrSurg. 2007; 119:130-135.
Hinh 1: So do thiet ke vat
Thiet ke vat hai cudng
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 9 - N"3 ;2014
tiH
. ^
* f
Sau mo 1 nam
Hinh 2: Benh nhdn CAD 15 tuoi bong hod chdt
Thiet ke vat
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TAP CHi Y DU'O'C LAM SANG 108 Tap 9 - sa 3 /2014
Sau mo 1 nam Hinh 3: Benh nhan NTT bong add
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