RU2381754C1 - Method of trunk skin defect plasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to surgery and can be applied for trunk skin defect plasty. It involves a circular excision of the nidus. Three equidimensional pedicle flaps located round the defect at the angle 120°, blade-shaped at the right angle are cut out. The flaps are displaced towards the defect centre while keeping them connected with underlying tissues. Skin edges of the flap right angles are sutured in the middle of corium. The donor wound edges and the displaced flaps are sutured.

EFFECT: method allows eliminating excess stress in tissues, providing mobility and good blood supply of the flaps.

1 ex, 3 dwg

Description

The invention relates to medicine, namely to oncology, and can be used in the surgical treatment of benign and malignant neoplasms of the skin of the extremities or other extensive pathological foci with plastic replenishment of a round-shaped postoperative defect.

The entire variety of plastic options with local tissues can be divided, depending on the method of moving the flaps, into the following types: sliding, rotational and transposition.

Sliding flaps mobilize in one direction, towards the defect. Rotational flaps move around a certain point and maintain a given radius. Transposition refers to a flap that is detached and mobilized towards the defect and transferred through an incomplete skin bridge to a new location.

With more or less significant skin defects, flaps on the wide leg of the skin surrounding the defect can be used. The founder of this method is considered Yu.K. Shimanovsky (Shimanovsky YK Operations on the surface of the human body. Kiev, 1869), which systematized all operations with the movement of skin flaps, placing them depending on the shape of the defect.

With the quadrangular shape of the defect, cuts are made on the continuation of two opposite sides of the quadrangle. After separating the flaps, they are shifted towards each other. With triangular skin defects, arcuate incisions are made towards the apex of the triangle from two adjacent corners. Oval defects can be eliminated by tightening the edges of the skin after separation or after additional arcuate incisions along the sides of the defect. A round defect can be closed with two sickle-shaped flaps or turned into a quadrangular and closed accordingly.

A.A. Limberg for the first time proved that by the method of rearranging flaps on the counter, it is possible not only to replace one area of the skin with another, but also significantly increase the distance between two organs displaced by scars. The principle of plasticity with oncoming triangular flaps consists in the fact that between the two points that tighten one or another area of the skin, the first incision is made, which is usually carried out along the cicatricial cord or along the crest of the fold. From both ends of this section in opposite directions, two more sections are made at one angle or another to the first. The magnitude of the angle at which these cuts are made depends on how much the flaps need to be moved or how much the distance between the two tightening points needs to be increased (A. Limberg, Mathematical substantiation of plastics on the surface of the human body. Medgiz, 1946).

It should be noted that the above options for plastic local tissues according to the method of movement are classified as transpositional flaps. They are used with great success with minor defects: membranous folds of the skin at the inner edge of the eyelids (epicanthus), improper location of the angle of the mouth, eyebrows, cicatricial cords of the oral mucosa, extensive scars of the neck, with contractures of the fingers, knee, etc. The authors propose to cut out tissues in the form of skin-fat flaps, while the blood supply to the flap is insufficient even with slight skin tension and in some cases leads to necrosis of the flap or its part.

The movement of the sliding flap is based on the principle of its direct “sliding”. The closure of a rectangular skin defect can be carried out by moving the flap in the forward direction. For this, an incision is made in the skin and subcutaneous tissue of the maximum possible length. The flap exfoliates at the level of subcutaneous fat over its entire area, moves in the forward direction and is fixed to the edge of the defect. Blood supply is due to the subcutaneous leg of the flap.

One commonly used type of sliding flap is V-Y plastic. The principle of the method is that initially a V-shaped incision is made immediately at the base of the skin defect. After complete mobilization of the V-flap, it is moved to the area of the defect and fixed to the edges of the wound. The donor wound is closed by direct suturing, and a line resembling the letter Y is formed, which determined the name of this technique (Esser J.F. Island flaps. NY State J Med, 1917).

V-Y-plastic is used for minor skin defects of the face, in addition, the leg of the sliding flap can limit the limit of displacement of the flap. The area and mobility of the sliding flap are limited due to the characteristics of the donor zone, therefore it is not always possible to completely fill the wound defect.

The aim of the invention is the elimination of excess tension in the tissues and the preservation of full blood supply to the flaps.

This goal is achieved by the fact that after a wide circular excision of the tumor on the body from nearby tissues, three equally sized skin flaps are cut out, located around a circular defect at an angle of 120 °, having the shape of a blade. Then, flaps are mobilized in the distal directions by dissecting fiber from all sides, and, if necessary, muscle fascia. The obtained flaps are shifted to the center of the postoperative wound, a suture is placed on the skin edges of the right angles of the flaps strictly in the middle of the corium, which ensures their matching. The edges of the donor wound and displaced flaps sew together. Skin sutures are removed on 12-14 days.

Thus, this method of plasty of defects in the skin of the body combines elements of sliding and rotation.

Analysis of known methods and the proposed method for plastics defect skin limbs allows us to state that it is new and has differences from those used.

The novelty of the method lies in the fact that three equally sized skin flaps are cut from nearby tissues located around a circular defect at an angle of 120 °, having the shape of a blade. Then, flaps are mobilized in the distal directions by dissecting fiber from all sides, and, if necessary, muscle fascia. The obtained mobile flaps are displaced to the center of the postoperative wound, a suture is placed on the skin edges of the right angles of the flaps strictly in the middle of the corium, which ensures their matching. The edges of the donor wound and displaced flaps sew together. Skin sutures are removed on 12-14 days.

In open sources of information in Russia, the CIS countries and abroad, a similar method could not be found.

The method of plastics defect of the skin of the trunk is industrially applicable. It can be reproduced and repeated many times in healthcare, medical institutions of surgical and oncological profile.

The method of plastics defect of the skin of the body is as follows. After a wide circular excision of the tumor on the trunk, three identical-sized skin-fat flaps with the shape of a blade located at an angle of 120 ° around the circular defect are cut from nearby tissues. Fatty tissue, fascia of the underlying muscle are cut, then the flaps are mobilized in the distal directions by dissecting the fiber from all sides, and if necessary, the muscle fascia, which can limit the movement of the flaps. The obtained mobilized, movable flaps are shifted to the center of the defect, a suture is placed on the skin edges of the right angles of the flaps strictly in the middle of the corium, which ensures their matching. The edges of the donor wound and displaced flaps sew together. Skin sutures are removed on 12-14 days.

An example of a specific application of the method of plastics defect of the skin of the trunk

Patient S., born in 1959, medical history No. 8605 / n, turned to the Department of Plastic and Reconstructive Surgery, RNII on November 13, 06, with complaints of the presence of a pigmented formation on the skin of the back. Since August 2006, after an injury to a long-existing nevus of the skin, slight growth and hyperpigmentation were noted. The result of a cytological study from 11/13/06 was epithelial cell pigment melanoma. Diagnosis: Melanoma of the skin of the back stage II, clinical group 2.

Locally: on the skin of the interscapular region, a pigmented formation with a diameter of 1.2 cm is visualized, with an even contour and a shiny surface. Regional lymph nodes are not enlarged (Figure 1).

11/14/06, held AGHT. From 16.11. on November 30, 2001, the patient received a course of remote gamma therapy on the primary lesion and axillary lymph nodes on both sides with dose fractionation of 3 Gy. The total focal dose was isoeffect 40 Gy.

12/03/06, after neoadjuvant chemoradiation treatment, an operation was performed - a wide excision of the melanoma of the back skin with plastic with a three-lobed skin flap.

Under local anesthesia with a 0.2% lidocaine solution with an adrenaline addition of 1: 10000, a circular skin incision was made in the interscapular region according to the marking, skin, subcutaneous tissue, fascia to the muscles were cut, the skin-fascial flap with the formation highlighted, removed. A thorough hemostasis was carried out. Three adjacent skin flaps were cut from nearby tissues, located around the defect at an angle of 120 °, having the shape of a blade (Figure 1). Then made the mobilization of the flaps in the distal directions by dissecting fiber and muscle fascia from all sides (Figure 2). The obtained mobile flaps were moved to the center of the postoperative wound, and a suture was placed on the skin edges of the right angles of the flaps in the middle of the corium, which ensured their matching. The edges of the donor wound and three-lobed flaps are sutured without tension between them with single seams. The wound is drained by rubber graduates. The postoperative period was uneventful, ischemia, necrosis of the flaps was not observed. Primary healing. Sutures were removed on the 12th day. The patient was discharged in satisfactory condition.

Histological analysis (No. 839553) - melanoma from epithelial cells, Clark invasion level - X degree, Breslow tumor thickness - 3 mm, small melanin content in the tumor, removed within healthy tissues.

12/15/06 - upon examination revealed: the skin in the area of the postoperative wound is light pink in color, from the surrounding tissue does not differ (Figure 3). The patient does not show complaints.

The technical and economic efficiency of using three-lobed flaps to close rounded defects of the skin of the trunk allows you to evenly distribute the skin load in the area of the postoperative wound, avoid excessive tension in the tissues, maintain blood circulation and eliminate complications associated with complete necrosis of the flaps, promotes wound healing by first intention, prevents the wound edges from diverging. and the formation of pathological scars. This method increases the radicalism of surgical intervention, accelerates medical and social rehabilitation; improves the quality of life of patients.

Claims (1)

The method of plasty of a defect in the skin of the trunk, including a wide circular excision of the pathological focus, characterized in that they cut out three uniformly sized flaps on the supply leg, located around the defect at an angle of 120 °, having the shape of a blade with a right angle, the flaps are shifted to the center of the defect, keeping them connection with the underlying tissues, a suture is placed on the skin edges of the right angles of the flaps in the middle of the corium, the edges of the donor wound and the displaced flaps are sutured together.

Images