RU2391062C1 - Method of dermepenthesis of investing tissue defects of distal part of lower extremity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely the reconstructive surgery, and may be used to replace investing tissue of distal part of lower extremity at its traumatic defects exposing the subject structures. Before it the area of the defect is measured. Then form a flap on the Sural artery backflow with the inclusion of v. Parva, oriented along the axis of the flap. Flap is rotated to the site of the defect and the donor wound is covered with perforated split transplant. During the preoperative period according to the Doppler study the small subcutaneous vein and the distal septal-cutaneous perforator are labeled from the basin of the fibular artery. The musculocutaneous flap of muscle thickness not less than 0.5 cm, in the form of a tennis racket is formed, placing the pedicle of a dermal-fat component width of 2 cm, and the fascial-fat not less than 4 cm, and the flap itself strictly the along the median line of the rear surface of the tibia at the level of the calf muscle and on the lateral edge of the Achilles tendon in the distal part. The flap is formed with inclusion of the medial cutaneous nerve in the upper and the middle thirds and Sural nerve in the lower third of the lower leg and is rotated in the point positioned not less than 1 cm proximal to the distal cutaneous septal perforator.

EFFECT: method allows to reduce the treatment and improve fates by reducing the amount of Sural flap necrosis.

1 ex, 7 dwg

Description

The invention relates to medicine, specifically to reconstructive surgery. It is used to replace the integumentary tissues of the distal lower limb with its traumatic defects with exposure of the underlying structures.

A known method of vascularized plasty is a skin flap on a feeding leg cut from distant parts of the body (Italian flap) (1). The disadvantage of this method is that the flap is raised without taking into account angioarchitectonics, which requires compliance with certain proportions of the length and width of the flap, as a result of which its area and mobility are limited. Methods of vascularized skin grafting with islet flaps on the retrograde blood flow of the anterior or posterior tibial arteries are also known. The disadvantages of these methods is that when one of the main arteries is crossed, the volumetric blood flow in the distal extremities is significantly reduced, and if one of them is damaged, the use of these methods of skin grafting is contraindicated (2).

The closest to the proposed method, in terms of its technical solution, is the method of skin plasty that we adopted for the prototype using a sural fascial and fascial tibial flap isolated on the peripheral sural artery from the peroneal artery pool with v. Parva. (3). According to this method, the sural artery and the small saphenous vein are included in the feeding leg of the flap, and the median cutaneous nerve of the lower leg in v / 3, c / 3 and the sural nerve in n / 3 of the lower leg are excluded, which makes the flap lose an additional source of blood supply. The disadvantages of the method include the fact that the separation of the nerve from the sural flap is dangerous in terms of damage to the sural artery, since the sural artery and nerve in c / 3 of the lower leg in some cases are closely intertwined. Moving the flap to the donor area through the formed subcutaneous canal can cause compression of the feeding leg in people with increased development of subcutaneous fat.

The essence of the invention lies in the combination of essential features sufficient to achieve the desired technical result, consisting in reducing the time and improving treatment outcomes by reducing the number of necrosis of the sural flap

This essence lies in the fact that the method of skin plasty of defects of integumentary tissues of the distal lower extremity includes measuring the area of the defect, forming a flap on the retrograde blood flow of the sural artery with the inclusion of v. Parva oriented along the axis of the flap. The method includes rotation of the flap to the site of the defect and sheltering the donor wound with a split perforated graft. In the preoperative period, according to a Doppler study, a small saphenous vein and a distal septal-skin perforant from the peroneal artery pool are marked. A skin-muscle flap is formed with a thickness of at least 0.5 cm in the form of a "tennis racket", having a feeding leg having a skin-fat component 2 cm wide, and a fascial-fat component of at least 4 cm, and the flap itself is strictly according to the midline of the posterior surface of the tibia at the level of the calf muscles and along the lateral edge of the Achilles tendon in the distal part. The flap is formed with the inclusion of the medial cutaneous nerve in the upper and middle third and the sural nerve in the lower third of the lower leg and rotate it at a point located at least 1 cm proximal to the distal skin-septum perforant.

Dopplerographic examination, in the preoperative period, of the small saphenous vein allows you to accurately determine its position and place a flap along it.

Dopplerographic examination, in the preoperative period, of a distal septal-skin perforant from the peroneal artery pool, allows you to accurately determine the position of the perforator and the rotation point of the flap, as well as choose the perforant that is most suitable for ensuring the required length of the feeding leg.

The formation of a musculocutaneous flap with a thickness of at least 0.5 cm ensures the precise inclusion of the neurovascular bundle, which is located between the heads of the gastrocnemius muscle, in the flap.

The formation of the flap in the form of a "tennis racket" allows you to close the donor wound of the area of the supply leg first, and the neurovascular bundle laid in the canal without pressure using a skin-fat strip of the supply leg 2 cm wide.

The feeding leg, having a width of the fascial-fat component of at least 4 cm, provides sufficient nutrition for the flap.

The location of the flap strictly along the midline of the posterior surface of the lower leg at the level of the calf muscles, along the edge of the Achilles tendon in the distal part, ensures the inclusion of the sural artery and septum-skin perforant necessary for feeding the flap.

Mandatory inclusion of the medial cutaneous nerve in the upper and middle third and the sural nerve in the lower third of the lower leg provides additional blood supply to the flap, since each nerve is equipped with its own vessels that feed this nerve and have perforants that feed the skin.

Rotation of the pedicle at a point located at least 1 cm proximal to the distal skin-septum perforant allows rotation of the pedicle by an angle of 180 ° without changing the volumetric blood flow through this perforant.

The method is illustrated by the drawings and photographs, where in Fig.1. marking the flap in the form of a "tennis racket" is shown taking into account the rotation point, which is 1 cm proximal to the distal septum-skin perforant, figure 2 shows the flap fence, figure 3 is a photograph of the lower limb of the patient with the flap taken, .4 is a diagram of the proximal part of the flap, Fig. 5 is a diagram of the feeding legs of the flap, Fig. 6 shows a photo of the patient's lower limb after surgery, Fig. 7 shows a photo with a soft tissue defect of n / 3 lower leg.

The method is as follows.

On the basis of a dopplerographic study conducted in the preoperative period, the location of the small saphenous vein 1, dermal septum perforant 2, from the peroneal artery pool, and the flap rotation point 3 located 1 cm proximal to the distal dermal septum are determined (see Fig. 1) perforant 2. The flap is marked up in the form of a "tennis racket", with the handle (feeding leg) 4 facing in the distal direction. The midline of the flap runs in the projection of the calf muscles along the midline of the posterior surface of the lower leg 5, and in the projection of the Achilles tendon along its lateral edge 6. According to preliminary marking (see Figs. 2, 3, 4), the musculocutaneous is raised in the distal direction a flap with calf muscle 7, with a muscle thickness of at least 0.5 cm, on the retrograde blood flow of the sural artery 8. The flap includes the medial cutaneous nerve 9 in v / 3 and c / 3 and the sural nerve in n / 3 of the lower leg, and small saphenous vein 1, oriented along the flap. The feeding leg 4 of the flap is cut out in such a way (see Fig. 5) so that its skin-fat component 10 has a width of 2 cm and the fascial-fat component 11 is at least 4 cm. A channel is formed by cutting the skin and soft tissues to the defect site. The flap is rotated and sutured to the recipient area (see Fig.6), the leg 4 is placed in the formed channel. The size of the donor wound is reduced by sewing the subcutaneous base to the subfascial extension of the calf muscle. The wound, which was not covered, is closed with a split perforated skin graft, 0.3-0.5 mm thick. The intake area of the supply leg is stitched primary (see pos. 12 in FIG. 6).

Clinical example.

Patient K., 18 years old, September 18, 2008, as a result of an accident, received an injury to his right lower leg with a soft tissue defect in n / 3. (see Fig.7). 10/02/2008 skin plastic surgery was performed with a sural muscle-muscle flap. In the preoperative period, a Doppler study of the small saphenous vein and distal septum-skin perforant was performed. They drew a flap in the form of a "tennis racket" taking into account the rotation point, which was 1 cm proximal to the distal septum-skin perforant. The flap was isolated together with the calf muscle 1 cm thick, including the small saphenous vein, the medial cutaneous nerve of the calf, and the sural artery. The direction of the axis of the flap, at the level of the calf muscles, is strictly along the midline of the posterior surface of the lower leg and along the edge of the Achilles tendon in the distal part to the point of rotation. The flap was selected so that its feeding leg had a skin-fat component 2 cm wide and a fascial-fat component 4 cm wide. The flap was rotated and laid in a channel formed by a cut of skin and soft tissues to the defect site, while the rotation point was 1 cm proximal to the distal dermal septum perforant. Sewing the subcutaneous base to the subfascial extension of the calf muscle, the size of the donor wound was reduced. The wound that was not covered was closed with a 0.4 mm thick split perforated skin graft. The site of intake of the feeding leg was sewn primarily.

The patient with the achieved result is satisfied.

Information sources

1. Zoltan J. Operational technique and conditions for optimal wound healing. Hungarian Academy of Sciences Publishing House, Budapest, 1983, p. 110.

2. Ostrovsky N.V., Grishkevich V.M .: Topographic, anatomical, and clinical aspects of the use of a fascial cutaneous flap on the inner surface of the leg. Clinical Surgery, 1992, No. 7, pp. 27-30.

3. Aoki S., Tanuma K., Mizuno H., Ogawa R., Ozawa H., Hyakusoku H .: Clinical and vascular anatomical study of distally based sural flap. Ann Plast Surg. 2008 Jul; 61 (1): 73-8.

Claims (1)

The method of skin plasty of defects of integumentary tissues of the distal lower extremity, including measuring the area of the defect, forming a flap on the retrograde blood flow of the sural artery with the inclusion of v. Parva, oriented along the axis of the flap, rotation of the flap to the defect site, covering the donor wound with a split perforated graft, characterized in that in the preoperative period, according to Dopplerographic examination, they mark a small saphenous vein and distal septum-skin perforant from the peroneal artery pool, form a skin-muscle muscle a flap with a muscle part thickness of at least 0.5 cm in the form of a “tennis racket”, having a feeding leg having a skin-fat component 2 cm wide, and a fascial-fat component not less than 4 cm, and the flap itself is strictly along the midline of the posterior surface of the lower leg at the level of the calf muscles and along the lateral edge of the Achilles tendon in the distal part, including the medial cutaneous nerve in the upper and middle third and the sural nerve in the lower third of the lower leg, and rotate it in a point located at least 1 cm proximal to the distal skin-septum perforator.

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