TCNCYH Phu trwang 77(6) 2011
U'NG DUNG VAT DUI TRU'DC NGOAl TRONG TAO HINH
T 6 N KHUYI^T R O N G P H A N M ^ M
VUNG C6 MAT
Le Dipp Linh, VQ Ngpc Lam va CS B$nh vi$n Trung tmng Quan dQi 108 Vat dui tnfoc ngodi (Anterolateral thigh flap - ALT flap) Id d^ng v^t da duvc cip mdu bdi cdc m^ch xuydn nudi da tCr nhdnh xudng cua ddng mach mO dui ngodi dux?c sd dung rdng rdi di t^o hinh vung cd m$t. Nghidn cdu nhdm (1) ddnh gid kha ndng Cmg dung vat ALT trong ff o hinh tdn khuyit rdng phin mim vung cd mdt Kit qud cho thiy ty 1$ vat sdng 94,1%, kit qud xa tdt chiim 84%, khd Id 16%, khdng cd kit qud kdm. TCr dd cd the kit luan, viec phau tich vat trdn Idm sdng thudn Ici vd tuxrng ddi di ddng. U'ng dgng vat ALT trong tao hinh ton khuyit phin mem vung cd mdt rit linh hoat, kit qud tdt cao.
TIP khoa: Vat dui truac ngodi
I. OAT V A N O ^
Khuyet hdng Idn p h i n mem vung ed mgt do nhilu nguyen nhdn (sau cat cdc u lanh tfnh, dc tinh, seo bdng hay di chung vet thuang, ehln thuang...) la mdt trong nhung khd khdn trong phiu thugt tgo hinh. Vdi su- phat triln eiia ky thudt vi phau vd cdc cdng trinh nghien cuu sdu v l sg- d p mdu eho da, viee tim tdi nhung chat lieu phu hp-p cho vCjng cd mat vdi nhung yeu d u khd khat khe nhu khdi lup-ng ldn, chat lup-ng tuang thfch vdi da vung cd mat, It de lai di chung vung lay vat da cho ra ddi hang logt cdc vgt da nhu vgt ba canh ba, vgt d n g tay quay, vgt thup-ng ddn...Mdi vgt deu cd nhung uu nhup-c d i l m rieng, cd gid trj rieng trong moi trudng hprp. Nam 1984, l l n ddu tien Song vd cdng sg- thdng bao nghien cuu ve giai phiu cua vgt dui trudc ngodi (Antero lateral thigh Flap - ALT Flap) nhu la 1 vgt da can cd thd dung vdi ky thudt vi p h i u [1]. Nam 1988, vat ndy dup-c Xu [2] dp dgng tren Idm sdng, vd vdi nhung uu diem ndi bat cua vat ndy nen ALT da trd thdnh 1 vgt da dup-c s u dgng nhilu den muc nhieu p h i u thudt vien ndi tilng trong ITnh vg-c tgo hinh nhu Fu Chan Wei, Jeng Feng Seng h l u nhu chl dung duy nhat vgt nay cho t i t ca cac tgo hinh phan mdm. Nam 2002, Wei da su dgng tdi 672 vgt ALT [3], nam 2009 Chen bao cao su dgng han 1000 vat
Tgi Viet Nam, vgt ALT l l n d i u tien dup-c su dgng tgi benh vien Trung uang Qudn dpi 108 (2004), sau dd cung dup-c ung dung tai
mdt sd ca sd nhu Bdnh vipn Saint Paul [4, 5], Bpnh vipn Vidt Oii-c. Da ed nhO-ng bao cdo ve vipc su dgng vgt dui trudc ngoai. Tuy nhien v i n chua cd nghien cuu sdu v l ung dgng lam sang cho tgo hinh khuyet rpng vCing cd mgt.
Chinh vi the chiing tdi t i l n hdnh nghidn cuu ndy vdi mge tieu:
Danh gia kha nang ung dung vat ALT trong tgo hinh tdn k h u y l t rpng p h i n m i m vung CO mgt.
II. o6i TygNG vA PHyoNO
PHAP 1. Ddi tup-ng nghien c u u : gdm 34 trudng hp-p cd tdn khuyet phin m i m vung ed mat do cac nguyen nhan khde nhau, dup-c tgo hinh bdng vgt ALT tgi BVTWQO 108 tu thang 9 nam 2006 den 10 nam 2010.2. Phueng phap nghien c u u
Bdnh nhdn dup-c khdm xet d l y du tdn thuang, ldm ede xet nghipm d n thiet cho gdy md npi khi quan.
2.1. Tieu chuin lam doi twtyng nghien ctru C h i n dodn khuylt phin m i m vung cd mat (do eat cdc khdi bpnh ly, spo...).
The trgng chung va xet nghipm cho phep phiu thugt gdy me ndi khi quan.
Khdng cd tdn thuang tgi vung diii dg- kiln l l y vgt ALT
Bpnh nhdn ddng y p h i u thudt vd tham gia nghien cuu.
TCNCYH Phu trwang 77(6) -2011
2.2. Qui trinh phau thu$t: Thudng chia 2 kip md
Kip 1: Cdt tdn thuang vd bdc 10 cdc mgch nhgn: Tdn thuang du(?c cit bd theo dg- kiln, neu lien quan den tdn thuang xuang nhu him dudi, ham trdn d n phgc hinh ngay thi cd t h i su dgng vgt xuang kit hp-p, thudng Id su dgng vgt xuang mdc. Vipc phiu tich cdc mgch nhdn du9C Idm trudc khi d t bd tdn thuang, vl se chu dOng vd bao vd cdc mgch ndy tdt han, trdnh vd tinh gdy tdn thuang cae mgch trong qua trinh d t tdn thuang, nhat la nhO-ng trudng hp-p phuc tgp, chay mdu nhieu, tdn thuang d gin vdi vung cho mgch. Thudng tim cdc ddng mgch nhu dpng mgch mdt, giap trgng tren vd tmh mgch mdt hodc cdc nhdnh khde eua tTnh mgch canh ngodi.
Kip 2: Bdc vgt ALT: Xdc djnh dudng chuln dich I I dilm ndi giua gai chgu trudc tren vd bd ngoai xuang banh che cung ben. Ddnh diu diem giua, xac djnh 1 vdng trdn dudng kinh 6cm cd tdm la diem giua, cdc nhanh mgch xuydn eiia vat ALT chii yeu tap trung d trong dien tich eua hinh trdn ndy. Ve dien tich vgt djnh lay theo nhu d u su dung. Rgch bd trudc trong ciia vgt trudc, thudng di theo Idp tren can dui tu trong ra ngoai den gdn khu vu-c vdng trdn trung tdm thi di xudng dudi cdn de tim mgch xuyen, cung cd the tim mgch xuyen trudc rdi mdi rgch cdn di xudng, tuy theo tung trudng hp-p cd d n bao tdn hay su dgng nhieu thdnh phin can dui trong vgt hay khdng. Bdc vgt theo ky thudt ngup-c ddng, tim ede mgch
xuydn trudc rdi di theo cdc mgch xuydn vao den bd mgch xudng cua mgch mO dui ngoai, lly chilu ddi cudng vgt theo vj tri vd dd ddi cua mgch nhdn dd bdc Id tCi- trudc.
Chuyin vgt Idn, ndi mgch vd su dgng vgt ALT theo ydu d u tgo hinh. Ddng cdc vlt md, ghdp da mdng vung lly vgt nlu d n thilt.
2.3. Ddnh gii kit qua trin lim sing - Kit qui gin (Dlnh gid sau md):
+ Tdt: Vgt da sdng todn bd, vlt md liln da ky diu, phgc hdi hinh the vd thim m9 tdt, chuc ndng nai cho khdng Inh hudng.
+ Khd: Vgt da sdng todn bd hodc chi thieu dudng 1 phin nhd, v i n dam bdo duprc mge dieh tgo hinh, hodc vung lly vgt chdm liln d n dilu trj bd sung.
+ Kdm: Vgt hogi tu todn bd hole phin Idn, khdng cd gid trj tgo hinh, hodc viing cho vgt bi anh hudng ndng n l chuc ndng (nhilm tning, hoai tu ca vung dui, thodt vj ca ndng...)
- Kit qua xa (Ddnh gid sau 6 thdng):
+ Tdt: Vgt sdng todn bd, dam bao hinh thi, tham my tdt, chuc nang nai cho vgt binh thudng.
+ Khd: Vgt dam bao vai trd tgo hinh, cd thi can sua chua bd sung, vung cho vgt anh hudmg nhp chuc nang (di Igi cdn khd khdn, thoat vi ea nhp).
+ Kem: Vgt xa hda, khdng dam bao vai trd tgo hinh, d n phau thudt Igi. Hodc vung cho vgt anh hudng ndng n l chuc ndng (thodt vj ndng d n phiu thudt sua chua, mit chuc ndng nhdm ca trudc dui...)
K^T QUA
Bang 1. Nguydn nhan vd kich thux3>c vgt tgo hInh Kich thud'c
Nguyen nhan Cdt cac u lanh tinh
Cat tdn thuang ung thu hoge hogi tu di chung xg tn
Cat tdn thuang spo hodc di chung chan thuang
So lup-ng
13 13 8
Len nhat Rpng/dai
(cm) 10x21 10x23 16x25
Nhd nhdt Rpng/dai
(cm) 6 x 1 2 6 x 1 0 6 x 1 8
Trung binh Rpng/dai
(cm) 7,8x19 8,3x17,6
8,9x21
8
TCNCYH Phi^ trwang 77(6) 2011 Tdn thuang do nguyen nhdn spo bdng vd di chung chin thuang cd kieh thude Idn nhit (8,9 x 21cm), tdn thuang sau cat cdc khdi u lanh tinh kich thudc nhd nhit
Kit qua
n
%
Bang 2.
Tdt 30
88,2
Ket qua gdn Kha
2 5,9
Kdm
2 5,9
Ty Id vgt sdng cua nghidn cuu tuang ddi eao (94,1%), dup-c tinh bao gdm sd bdnh nhdn dgt kit qua kha vd tdt.
Ket qua
n
%
Bang 3. Ket qud xa
Tdt Kha 21 4 84 16
Kem
0 0
Kit qua xa tdt chiem 84%, khd Id 16%, khdng cd kit qua kdm.
IV. BAN LUAN
Ve nguyen nhan tdn thuang ehiing tdi thay khd da dgng, phong phu vdi nhieu hinh thai khac nhau, tdn thuang da dan thuan, tdn thuang da kit hp-p vdi phin mem khde hoge vdi tdn thuang xuang. TT lp benh nhdn ung thu da hoac ung thu xam nhiem da vd phin mim, bpnh nhdn hogi tu phan mim do xg tri ung thu khd cao (38,2%). Nhung benh nhdn ndy thudng ed tdn thuang phuc tap, de tdi phai hoac kit qua dieu tri khdng cao. Kich thudc tdn thuang Idn nhat chiing tdi tao hinh bdng vgt ALT Id tren 1 benh nhdn spo di chung bdng todn bd phin mat, cd, vgt dup-c lly gin nhu tdi da (16 x 25 em), kich thudc vgt nhd nhat la 6 x 10 cm. Dieu nay cho thay dup-c tfnh linh hogt cua vgt ALT, khac vdi mpt sd dgng vgt da tg- do dang trge mgch nhu vgt ba, cgnh ba thi khd cd t h i lly kfch thudc vat qua be dup-c, cdc tdc gia nhu Koshima, Wei cung cd nhdn xet tuang tg-. Fu Chen Wei su dgng vgt ALT kich thudc nhd nhat Id 3 X 3 cm de tgo hinh khuylt mu ehdn [6]. Kich thudc vgt trung binh chiing tdi su dgng Id 8,33 x 19,2 cm, kieh thudc nay cung tuang duang vdi cac tie gia nudc ngoai. Kich thudc vgt dup-c su dgng chu yeu phg thudc kich thudc tdn thuang, ngodi ra cdn yeu td kha nang ddng vlt md trg-c tiep nai cho vat.
Qua 34 trudng hgp lam sang, danh gia din
thdi dilm bpnh nhdn ra vipn, chiing tdi thay tf le vgt sdng rit eao, 32/34 trudng hp-p, chilm 94,1%. So vdi cdc tdc gia nhu Hung Chi Chen (tl le thdnh cdng la 98%) [4], chiing tdi cung ed tf Id thdnh cdng tuang ddi eao. Mpt phin do kT thudt su dgng eac vgt tu* do cua cdc phiu thugt vidn tgi ca sd chiing tdi kha dn djnh, kinh nghipm tdt, mpt phin do vgt ALT chf dung cho mge dich tgo hinh (che phii hoge ddn) nen d l thdnh edng han cae vgt tg- do dung de phgc hdi chuc nang. Chiing tdi gap 2 trudng hp-p that bgi, mpt do benh nhdn ed tiln su Luput ban dd, sau khi ndi mgch, dpng mgch co that vd d p mdu kem, vgt dup-c thdo bd, mpt trudng hp-p do sO- dgng cudng mgch vgt qua ddi Igi d vung cd di dpng nen bj gip cudng sau md. Vgt phai thdo bd vd su dgng vgt ALT dui cdn Igi. Kit qua sau md vgt thu 2 tdt.
Sau 6 thang, ti lp tdt dgt 84%. Chiing tdi nhdn thiy rang, sau phiu thudt, vgt ALT mdng di rat nhanh, da phin da vgt mim mgi, mdu sic cung it bi biln ddi, tuy nhien d l tgo hinh nhung vung da tinh t l nhu da mgt hoge da cd thi vin edn nhung ylu td chua hoan todn phu hp-p nhu mdu sdc, tinh trgng Idng cua vgt, hoge kha ndng bilu cam do khdng cd he thdng ca bam da bdm vdo da vgt. Chiing tdi khdng gap trudng hp-p ndo ed biln chung tgi nai cho vgt nhu thoat vj diii hoge giam chuc nang vgn dpng cae nhdm ca trudc
TCNCYH Phu trwang 77(6) 2011
diii. Cac bpnh nhdn sau phau thudt diu phgc hdi tdt kha nang lao ddng.
V. K^T LUAN
Vgt ALT cd t h i su dgng rit linh hogt t h i hipn d cich su dgng, nai su dgng, sue sdng tdt, kich thudc dao ddng Idn, ldn tdi 16x25cm vin dam bao d p mdu tdt. Ngup-e Igi, cd t h i lly kich thude rit nhd md vin chua nhdnh mgch xuyen nudi da, nhieu mgch xuydn ndn cd t h i chia nhieu vgt chung cudng mgch.
Kit qua xa su dgng vgt ALT cho tgo hinh cdc tdn khuyet phin mim vung dau cd dgt 84%
logi tdt. Khdng gdp nhung biln chung Idn d vung cho vgt.
TAI LIEU THAM KHAO
1. Song Y. G, Chen G.Z, Song Y.L (1984).
The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg, 37: 149-159.
2. Xu D.C, Zhong S.Z., Kong J.M et al (1988). Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg, 82: 305 - 310.
3. Wei F.C., Jain V., Celik N et al (2002).
Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps.
Plast Reconstr Surg, 109: 2219 - 2226.
4. Nguyin Tdi Sen (2005). Vgt da can diii trudc ngodi trong tgo hinh khuylt hdng phan mim vung hdm mdt. Tgp ehi Y hpc Vidt Nam, sd 6, 8.
5. Phgm Th| Vl^t Dung, Trln Ddng Khoa, Trln Thilt Sen vd c^ng sy (2010). Cac ddc dilm giai phiu u-ng dgng cua vgt da edn diii trudc ngodi. Tgp chl Y hpc Vidt Nam, 374 (2):
420 - 425.
6. Yang W.G., Chiang Y.C., Wei F.C et al (2006). Thin anterolateral thigh perforator flap using a modified perforator microdissection technique and its clinical application for foot resurfacing'' Plast Reconstr Surg, 119 (7):
2327-2328.
Summary
ANTEROLATERAL THIGH FLAP - CLINICAL APPLICATION IN THE CERVICO FACIAL SOFT TISSUE DEFECT RECONSTRUCTION
Anterolateral thigh flap (ALT flap) was first found and used by Song in 1984. Classified in the perforator type flaps, ALT flap is blood supplied by the perforators of the descending branch of the lateral circumflex thigh artery. The flap is the first choice in many eases, those need a large soft tissue for reconstruction, especially in the cervicofacial area thanks to many advantages of the flap:
constants and relievable anatomic structure, large blood supply, flexible in use as well as other advantages. From 1.2006 to 9. 2010, 34 ALT flaps were used for patients with soft tissue defects in cervico facial area. The outcome is considerable with the main following conclusions: The flap is harvested relatively easy in clinical practice. The use of the ALT flap is flexible with good result in reconstruction of soft tissue defects in cervico facial area.
Keywords: Anterolateral thigh flap
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