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III. ХИРУРГИЯ
PLASTIC REMOVAL OF POST-BURN SCAR DEFORMATION OF POPLITEAL REGION USING SUBCUTANEOUS PEDICLE PROPELLER FLAP (SPPF)
Muradov M., Sadykov T.
National Scientific Center of Surgery named after A.N. Syzganov, Almaty, Kazakhstan, Reconstructive, plastic and aesthetic microsurgery department
Abstract
Recovery of function of the lower extremity at various cicatricial deformities of popliteal region has not lost its relevance for today. Features of anatomical structure and functional load of this zone require the use of one-step methods for plastic, allowing to obtain good functional and aesthetic result. Priority direction of modern plastic surgery is the use of technology-propeller flaps.
UDC 616:089.844:616.5.004.64
About the authors:
Mismil I. Muradov - head of the department of microsurgery of the NSCS n/a Syzganov, can. med., a high level certificate physician, surgeon; Timur A. Sadykov - doctor microsurgeon.
Key words:
Wounds, wound defects, plastic, propeller flaps, perforator flaps.
Тамыр аякшасында Tepi-май пропеллер кесшд1 колдануымен лзе асты саласында кушктен кейш тыртык деформациялануды пластикалык турде жою
Мурадов М., Садыков Т.
А.Н.Сь№анов атындаш Улттык, шлыми хирургия орталыш,
реконструктивл, пластикалык пен эстетикалык микрохирургия ôeëiMrneci, Алматы, Кдзакстан Ацдатпа
Kà3ipri тацда аяшныц те асты жагыныц турл'1 тыртык деформациялануы кезнде аярына катысты функцияларын бурынры калпына келт'ру квкейкест болуда.
Бул аймаеыныц анатомиялык к±рылысы жэне функционалдык жуктемеа пластиканыц бipкадамды эд 'ю 'ш колдануын талап етед '1, ондай жайт жаксы функционалдык пен эстетикалык нэтижеге колжетюзуге болады. Замануи пластикалык хирургияныц басымды багыты пропеллер тэpiздi кесiндi технологиясын колдану болып табылады.
Авторлар туралы:
Мурадов Мисмил Исламулы - А.Н. Сызганов атын. YfXO микрохирургия бвл1мшес1нщ мецгеруш1а, м.г.к., жорарры санатты дэргер; Садыков Тимур Эш1мулы -дэр!гер-микрохирург.
Тушн сездер:
жара, жара акаульры, пластика, пропеллер тэр1зд1 кесшдю, перфораторлык
Пластическое устранение послеожоговой рубцовой деформации подколенной области с применением кожно-жирового пропеллерного лоскута на сосудистой ножке
Мурадов М., Садыков Т.
Национальный научный центр хирургии им. А.Н. Сызганова,
отделение реконструктивной, пластической и эстетической микрохирургии, Алматы, Казахстан Аннотация
Восстановление функции нижней конечности при различных рубцовых деформациях подколенной области не потеряло своей актуальности на сегодняшний день. Особенности анатомического строения и функциональной нагрузки этой зоны требуют использования одношагового метода пластики, что позволяет получить хороший функциональный и эстетический результат. Приоритетным направлением современной пластической хирургии является использование технологии пропеллерного лоскута.
Об авторах:
Мурадов Мисмил Исламович
- заведующий отделением микрохирургии ННЦХ им. Сызганова, к.м.н., врач высшей категории, хирург, e-mail: mismil@yandex.ru;
Садыков Тимур Ашимович
- врач микрохирург, e-mail: sadikov.t@mail.ru
Ключевые слова:
раны, раневой дефект, пластика, пропеллерный лоскут, перфораторный лоскут.
Aim of study
Improve the functional and aesthetic results of treatment patients with post-burn scar deformation of popliteal region using technology of plastic by propeller flap based on perforating artery of the posterior tibial artery basin.
Material and methods
In Reconstructive, plastic and aesthetic microsurgery department of the National Scientific Center of Surgery named after A.N. Syzganov for the period 2005-2013 years, 19 patients were operated with post-burn defects and deformations of covering tissues of popliteal region, who underwent reconstruction using cutaneous -fascial perforator flap. Males treated 17 patients, female - 2. All patients were young, working age (18 - 27 years). Burns were received by flame. Time of received burns was from 5 to 17 years. All patients, previously, underwent surgery in burn centers from 3 to 5 times. Main operational manual was dermatomal skin plastic and plastic by local cicatricial tissues. Patients long time, with periods of 6-12 months, were on hospitalization. At the time of admission patients were considered "hopeless" and had II-III group of disability.
In all cases there was a malfunction of the lower extremity as decmogenne flexion contracture in the knee joint region. There was also a cosmetic defect by type "sail" and covering tissues scar changes.
Preoperative examination included a definition of color, type of scars, presence of trophic ulcers, area, density, displaceability of changed covering tissues. The angle of maximum extension in the knee joint was measured. Herewith 12 patients had 120-125 degrees angle. 7 patients had the amplitude of the extension 180 degrees, but the tension tightening popliteal region scars caused pain and cracking, bleeding of these scars. In 2 cases there was the presence of trophic ulcers size 2x3 cm.
Depth of cicatricial tissue degeneration was determined by ultrasound scanning. Changes in tissues were determined at depths from 0.5 cm to 1.2 cm. Border of the superficial fascia of the shin did not differentiate and had cartilage density.
Speed of linear flow in the posterior tibial artery was on average 55 cm per second, foot arteries -22 cm per second. In all cases perforating artery was differentiated, coming from the popliteal artery diameter of 0.8 - 1 mm.
In order to diagnose arterial patency of the extremity was performed arteriography. Data discrepancies of ultrasound and angiography were not.
Operations were performed under spinal anesthesia. First of all, ultrasonography control of
the perforating vessels was performed. Marked area of scar deformation and appropriate in size to alleged defect area on the back area of the shin.
Under the 5-multiply increase excision of all scar-changed tissue of the popliteal region was performed, preventing movement of the knee joint. Redressation of the joint was performed. Average area of formed defect of covering tissues consisted 74 cm2. Further along the marked lines produced selection of skin-fat-fascial flap on the vessel from the basin of the posterior tibial artery. The length of the pedicle ranged from 3 to 6 cm. After cutting out perforator flap intersected and tied proximal portion of the feeding tissue vessels. Further was performed displacement of tissues with the rotation of the flap at 90 degrees. Previously, in 7 patients, we used skeletization throughout the pedicle. Currently, the most widely use technique is Pedicle Perforator Propeller Flap. Herewith skeletonization of vascular pedicle was performed partially and leaves 1-2 cm of fascial link. It provides a secure rotation of the flap on 180 degrees and more, with good adaptation, protecting vessels from kink or over-stretching. Underflap space was drained by active drainage. Donor zone defect in 12 patients managed to close by V-Y plastic with local tissues. In other observations was used skin graft.
Examples of clinical cases using SPPF
Patient S., 27 years old. Sent to hospital after repeated attempts of plastic scar deformation of popliteal region and removal flexion contracture of the knee joint.
Clinic conducted appropriate examination. Doppler method located perforating vessels, on the back surface of the shin and planned design of skin-subcutaneous perforator propeller flap (SPPF) based on the perforator of the posterior tibial artery basin. Determined area of excision of pathological covering tissue, planned design of skin-fascial perforator propeller flap sizes 17 x 11 cm, which, after dissection and visualization of vascular pedicle rotated on 90 degrees axillary, adapted on the prepared recipient wound bed. Wound closed completely without tissue tension. Donor area was closed by skin graft. Postoperative course was without features. Patient was discharged on 10 day after surgery.
Observation after 12 months demonstrates a complete recovery of the skin of the popliteal region, transplanted flap thickness and the color is similar to the surrounding tissues of femor and shin, has mobility and resistance to mechanical stress, easily taken in the fold. Movement of the knee is in full volume. Patient is completely satisfied with the outcome of treatment.
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 2(43)-2015
Results
All patients recovered and were discharged from the clinic. All operated patients had total healing of transplanted flaps. In one case postoperative period was complicated by underflap hematoma, which was promptly diagnosed and successfully drained. Pyesis and edge necrosis of flaps was not. As complications, inherent in any kind of plastic with any flaps, in our patients with propeller flaps were observed: in all cases the swelling, up to 3 days; venous stasis in limited areas of flaps in four cases. Complete loss of flaps as a result of thrombosis of feeding artery or any other reasons, in observed cases was not. In cases of venous stasis to prevent necrosis of stagnant areas of the flap used drugs, having vasodilating effect (papaverine, nitroglycerin), hirudotherapy. All these complications were not critical and were solved by conservative measures.
Using the propeller flaps in the treatment of scar deformity of popliteal region allowed to inflict minimum damage to the donor area, which in all, except one, healed by primary intention. In one case there was an edge necrosis of the split skin flap and healing was by secondary intention.
The flaps that moved to the wound defect area were similar in structure and color to the surrounding tissues. They did not change the contours of the recipient zone and at the same time allowed to recreate a full resistant soft-tissue and skin integument, recover functional condition of injured area of the body with minimal aesthetic damage.
Discussion
Described technique of removing scar deformity of popliteal region with the transposition of SPPF
has a several advantages over alternative methods of reconstruction of defects of popliteal region. Particularly it allows to provide: low traumatization of donor area, completely preserve the main blood flow, axial blood circulation in the flap, perform plastic without imposing microvascular anastomosis by one team of surgeons, acceptable result after one stage of plastic, and also to get wear resistant to loads skin without excessive volume of flap.
The obtained results show the effectiveness of plastic propeller flaps on a selected vascular pedicle, especially for the closing of small and medium-sized wound defects on the extremities. In carrying out this method is replaced by the lost skin closest to it on the anatomical characteristics of the transposition flap by from a nearby area, which allows for restoration of function with minimal aesthetic damage and at one stage. The described technique of local flaps can not yet be named as perfect, complications can occur inherent in any kind of plastic with any flaps, but the development and introduction of reconstructive and plastic surgery techniques with the propeller flap, of course, will increase the efficiency of treatment of patients with deep wound defects.
Conclusion
1. Using of plastic by local scar tissues and skin grafts in the treatment of post-burn defects of popliteal region of the lower extremity should be limited because of the unsatisfactory functional result.
2. In removal of post-burn scar deformity of popliteal region it is preferable to use plastic with the use of subcutaneous pedicle propeller flap.
Pic. 2:
Stage of marking SPPF and area of the replaced defect.
Pic. 3:
Selection of the perforant artery feeding flap.
Pic. 4:
View of lifted up flap after dissection, visualization of perforants, forming the feeding pedicle.
Pic. 5:
View of the flap after axial rotation and adaptation into the recipient area of the wound defect.
Pic. 6:
Common view of the final stage of operation.
References
1. Blondeel P.N., Morris S.F., Hallock G.G., Neligan P.C. Perforator Flaps: anatomy, technique and clinical applications.- QMP, Inc.,- 2006.- 1098 p.
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3. Hallock G.G. The propeller flap version of the adductor muscle perforator flap for coverage of ischial or trochanteric pressure sores. Ann. Plast. Surg. - 2006. -Vol.56. - 540-542 p.
Lin T.S., Jeng S.F., Chiang Y.C. Resurfacing with full-thickness skin graft after debulking procedure for bulky flap of the hand. J. Trauma. - 2008. - Vol. 65. - 123-126 p.
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9. Baghaki S, Cevirme M, Diyarbakirli M, Tatar C, Aydin Y. Locoregional use of lateral thoracic artery perforator flap as a propeller flap. Ann Plast Surg. 2015 May;74(5):532-5.
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Pic. 7:
Long-term outcome, 20 months after surgery; no recidive of the disease, patient is completely satisfied with the condition of the skin integument, contour of the shin and lower extremity function.
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