美容性第二足趾再造拇指术研究中的解剖学测量及临床应用
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摘要
目的：
测量正常人活体双侧第二趾、指,拇、拇趾甲相关数值,计算相应解剖部位甲指、趾相关比值,观察双皮瓣改形扩大远指间关节部位周长的第二足趾移植美容再造拇指的方法的临床疗效,比较第二足趾再造拇指甲床扩大术的两种方法临床疗效,观察施行于第二足趾再造拇指术中的美容整形方法解决再造拇指美观问题的临床效果。
方法：
1.对40位中国正常成人(男23,女17)人体双侧第二足趾、拇手指、拇趾的末节及其甲外露部进行测量,获取其长宽值及甲基部,远指间关节水平周长值,所测数据用SPSS19.0统计软件进行统计学分析,左右两侧数据均进行K-S(正态性)检验和T检验,分析整理,结果记录为均数±标准差(x±s,mm)
2.选取第二趾与拇指、拇趾与拇指的甲长均值、甲指长比(外露甲长/末节指趾长)分别进行比照；选取第二趾与拇指、拇趾与拇指的甲基部,远指间关节水平周长,指趾长周比(末节指趾长/相应水平周长),选取第二趾与拇指甲长宽比,分别观察分析相差值。
3.根据解剖学测量依据,对18例18指拇指缺损的患者,在常规第二足趾移植再造拇指术基础上,应用第二趾趾腹胫侧趾动脉皮瓣和拇趾腓侧皮瓣改形,扩大第二足趾远指间关节部位周长
4.对因外伤引起手指缺损施行第二足趾再造指术中20例患者,分为两组,根据解剖学测量依据,分别采用部分甲皱襞直接切除术或Adani矩形推进皮瓣术,均扩大指甲长度3mm,达到正常拇指甲长甲宽比值。于术中记录两组甲延长术手术时间；术后12月时,观察指甲扩大情况,甲光滑度,甲周瘢痕形成情况及患者自我满意度,两组进行对照评估。
5.在一组6例患者中施行第二足趾再造拇指术中,根据解剖学测量依据及前三部分研究获得的美容整形的关键点,选择相邻拇趾侧方皮瓣切取嵌入再造指远指间关节部延长指体周长、甲上皮近端皮肤部分切除术延长指甲及双侧指端膨起处皮肤切除,通过改变移植的第二足趾解剖学比例解决再造拇指的美观问题。
结果：
1.男女性左右侧拇指L1/L2与第二足趾L1/L2值,L1/W1均有显著性差异(P<0.05)；男女性左右侧拇指W1AW2与第二足趾W1/W2值,均有显著性差异(P<0.05)；男女性左右侧拇指与第二足趾C1/C2值,均有显著性差异(P<0.05)。
2.18例18指再造拇指及用于改形的双皮瓣全部存活,术后随访时间为6-17个月,按中华医学会手外科学会上肢部分功能评定试用标准评定：优15指,良3指,优良率为100%；再造指远指间关节水平指体周长平均延长10.27mm,再造指甲基部与指间关节部周长比达到了对侧拇指的正常比例。
3.第一组部分甲皱襞直接切除术手术时间平均7.5分钟；第二组Adani矩形推进皮瓣术组手术时间平均15分钟；术后12月时随访两组病例甲周皮肤均无坏死,甲床扩大长度两组均为均数2.7mm,再造指甲长甲宽比值均达到正常拇指解剖学比例；甲光滑度一致,无明显甲畸形发生。甲周均无不稳定瘢痕形成；部分甲皱襞直接切除术组患者自我满意度评分(MHQ)均数达12.1,Adani矩形推进皮瓣术组为11.8,两组对照无显著性差异。
4.6例患者平均随访18个月(6-24月),均取得了较大的外观改进及良好的功能,其中远指间关节部指体延长周长均值为10.7mm,指甲延长平均值为3.1mm,均达到了健侧拇指甲长宽比值及甲基远指间关节周长比值。1例患者嵌入皮瓣部分缺血坏死；再造指平均两点辨别觉10.1mm,皮瓣恢复保护性感觉。患者对再造指外观均满意。按照密歇根健康调查表评分,手术后外形满意度平均为12.5；疼痛程度19.56。
结论：
1.正常人活体双侧第二趾、指,拇、拇趾甲外露部分相关数据及比值为手足外科学提供了解剖学数据；根据拇指与第二足趾L1/W1, C1/C2比值明显性差异可选择第二趾趾甲延长及第二趾远趾间关节位指体周长扩大为第二趾改型再造拇指的关键点及方法。
2.应用第二趾胫侧趾动脉皮瓣和拇趾腓侧皮瓣改形的第二足趾移植再造拇指,扩大了远指间关节部位指体周长,外形及解剖学比例更接近正常拇指,方法可行,疗效可靠。
3.足趾再造指甲床扩大术的两种方法均手术简单,效果满意,甲皱襞直接切除法具有手术时间短,操作简便的优势。
4.根据解剖学测量研究获得的第二足趾矫形的三个关键点部位进行整形,使调整后解剖学比例达到与健侧拇指相近,可以解决再造拇指美观问题。
Objective:
To measure the absolute value of second toes, big toes, thumbs and their nail's width, length and circumference in-vivo and analyze the ratio of different between those value.To oberserve the effect of double flaps based on the same vascular pedicle employed for expanding finger's circumference on DIP level on toe-to-thumb transfer, compare the clinical outcomes of two kinds of nail bed expanding technique for the new aesthetic modifies in second toe-to-hand transfer surgery and investigate the treatment outcomes of the new aesthetic modifies in toe-to-thumb transfer surgery.
Methods:
1. The absolute value of second toes, big toes, thumbs and their nail's width, length and circumference were measured on40normal Chinese adult (23male,17female) on the double hands and feet. Combined with modern statistical techniques(SPSS19.0), we computed the value of corresponding anatomical site, to provide the anatomical data and analyze the ratio of different between those value.
2. There are significant diffirence of both sides and sex between the ratio of L1/L2, W1/W2, C1/C2. L1/W1of the second toes and the thumbs.
3.18cases of defected thumbs were treated with the techniques of transfer of second toe with double flaps based on the same vascular pedicle for reconstruction of thumb;. The second toe transferred along with the tibial digital artery flap from the second toe pulp and fibular flap from the big toe.
4.20cases suffered by finger defected were treated by second toe-to-hand transfer surgery. They were divided into two groups; During the operation,3mm length eponychium was resected for the first10cases and the Adani rectangular advanced flap was performed in the second10cases. The expanded nails were the same length. The operative times for only nail lengthening were recorded and the length of the nail, appearances, the scarring around the nail and patients self satisfaction comparison evaluation in two groups were compared12months postoperatively.
5. We describe a modified second toe transfer which addresses cosmesis in6patients. These include:1) Harvesting a flap from the adjacent side of the great toe and insetting it into the volar aspect of the second toe to give more bulk,2) Skin excisions are made on each side of the tip reduce the bulbous appearance, and3) Excision of part of the distal skin near the eponychium and advanced the eponychium flap to produce apparent lengthening of the nail.
Results:
1. There are significant diffirence of both sides and sex between the ratio of L1/L2, W1/W2, C1/C2. L1W1of the second toes and the thumbs.
2.18thumbs all survived. There was no flap loss. Follow-up duration raged from6-17months, According to the evaluation criteria for the finger replantation and reconstruction issued by Hand Surgery Society of Chinese Medical Association, results of15thumbs were graded as excellent while the results of3thumbs were fair. The reconstructed finger's circumference on DIP level were expanded10.27mm in average and the circumference radio between The overall satisfactory rate is100%.
3. The operation time of eponychium resection was an average of7.5minutes; The time of the Adani rectangular advanced flap average15minutes;12months postoperative follow-up, no skin necrosis around the nail in both groups cases; A bed expand length for the duration of2.7mm in both groups; The smoothness of the nail is consistent, without obvious deformity happened. The self satisfaction score (MHQ) of eponychium resection group is average of12.1; The score of the Adani rectangular advanced flap is average of11.8. The differences between the two groups were no statistically significant.
4. The mean follow up period was1.5yrs (6-36months). All six cases resulted in good function and improved cosmesis. Part of the great toe flap was lost in one case. The mean two-point discrimination in the transferred toes was10.1mm with protective sensation present in the flaps. The mean range of motion of the transferred toe was14to38o at the metatarsophalangeal joint,16to55°at the proximal interphalangeal joints, and20to36°in the distal interphalangeal joints.
Conclusion:
1. The absolute value of second toes, big toes, thumbs and their nail's width, length and circumference in-vivo are valuable supplement for the anatomical data. Based on the significant diffirence between the ratio of C1/C2. L1/W1of the second toes and the thumbs, the methods that the second toe's nail lengthening and circumference expanding can be chosed as the key points for the management of new aesthetic modifies in toe-to-thumb transfer surgery.
2. Thumb defect can be reconstructed by way of transfer of second toe with double flaps based on the same vascular pedicle. The appearance of the reconstructed thumb is more comparable to the normal thumb
3. Both of the two kinds of nail lengthening in second toe-to-hand transfer surgery are simply and effective; the results are satisfactory; the procedure of eponychium resection is of advantages of short operative time and easy and simple to handle.
4. This novel approach will allow patients to take advantage of the lower morbidity to the donor site afforded by second to thumb transfer, while providing the patient with a more aesthetic appearance of the new thumb.
测量正常人活体双侧第二趾、指,拇、拇趾甲相关数值,计算相应解剖部位甲指、趾相关比值,观察双皮瓣改形扩大远指间关节部位周长的第二足趾移植美容再造拇指的方法的临床疗效,比较第二足趾再造拇指甲床扩大术的两种方法临床疗效,观察施行于第二足趾再造拇指术中的美容整形方法解决再造拇指美观问题的临床效果。
方法：
1.对40位中国正常成人(男23,女17)人体双侧第二足趾、拇手指、拇趾的末节及其甲外露部进行测量,获取其长宽值及甲基部,远指间关节水平周长值,所测数据用SPSS19.0统计软件进行统计学分析,左右两侧数据均进行K-S(正态性)检验和T检验,分析整理,结果记录为均数±标准差(x±s,mm)
2.选取第二趾与拇指、拇趾与拇指的甲长均值、甲指长比(外露甲长/末节指趾长)分别进行比照；选取第二趾与拇指、拇趾与拇指的甲基部,远指间关节水平周长,指趾长周比(末节指趾长/相应水平周长),选取第二趾与拇指甲长宽比,分别观察分析相差值。
3.根据解剖学测量依据,对18例18指拇指缺损的患者,在常规第二足趾移植再造拇指术基础上,应用第二趾趾腹胫侧趾动脉皮瓣和拇趾腓侧皮瓣改形,扩大第二足趾远指间关节部位周长
4.对因外伤引起手指缺损施行第二足趾再造指术中20例患者,分为两组,根据解剖学测量依据,分别采用部分甲皱襞直接切除术或Adani矩形推进皮瓣术,均扩大指甲长度3mm,达到正常拇指甲长甲宽比值。于术中记录两组甲延长术手术时间；术后12月时,观察指甲扩大情况,甲光滑度,甲周瘢痕形成情况及患者自我满意度,两组进行对照评估。
5.在一组6例患者中施行第二足趾再造拇指术中,根据解剖学测量依据及前三部分研究获得的美容整形的关键点,选择相邻拇趾侧方皮瓣切取嵌入再造指远指间关节部延长指体周长、甲上皮近端皮肤部分切除术延长指甲及双侧指端膨起处皮肤切除,通过改变移植的第二足趾解剖学比例解决再造拇指的美观问题。
结果：
1.男女性左右侧拇指L1/L2与第二足趾L1/L2值,L1/W1均有显著性差异(P<0.05)；男女性左右侧拇指W1AW2与第二足趾W1/W2值,均有显著性差异(P<0.05)；男女性左右侧拇指与第二足趾C1/C2值,均有显著性差异(P<0.05)。
2.18例18指再造拇指及用于改形的双皮瓣全部存活,术后随访时间为6-17个月,按中华医学会手外科学会上肢部分功能评定试用标准评定：优15指,良3指,优良率为100%；再造指远指间关节水平指体周长平均延长10.27mm,再造指甲基部与指间关节部周长比达到了对侧拇指的正常比例。
3.第一组部分甲皱襞直接切除术手术时间平均7.5分钟；第二组Adani矩形推进皮瓣术组手术时间平均15分钟；术后12月时随访两组病例甲周皮肤均无坏死,甲床扩大长度两组均为均数2.7mm,再造指甲长甲宽比值均达到正常拇指解剖学比例；甲光滑度一致,无明显甲畸形发生。甲周均无不稳定瘢痕形成；部分甲皱襞直接切除术组患者自我满意度评分(MHQ)均数达12.1,Adani矩形推进皮瓣术组为11.8,两组对照无显著性差异。
4.6例患者平均随访18个月(6-24月),均取得了较大的外观改进及良好的功能,其中远指间关节部指体延长周长均值为10.7mm,指甲延长平均值为3.1mm,均达到了健侧拇指甲长宽比值及甲基远指间关节周长比值。1例患者嵌入皮瓣部分缺血坏死；再造指平均两点辨别觉10.1mm,皮瓣恢复保护性感觉。患者对再造指外观均满意。按照密歇根健康调查表评分,手术后外形满意度平均为12.5；疼痛程度19.56。
结论：
1.正常人活体双侧第二趾、指,拇、拇趾甲外露部分相关数据及比值为手足外科学提供了解剖学数据；根据拇指与第二足趾L1/W1, C1/C2比值明显性差异可选择第二趾趾甲延长及第二趾远趾间关节位指体周长扩大为第二趾改型再造拇指的关键点及方法。
2.应用第二趾胫侧趾动脉皮瓣和拇趾腓侧皮瓣改形的第二足趾移植再造拇指,扩大了远指间关节部位指体周长,外形及解剖学比例更接近正常拇指,方法可行,疗效可靠。
3.足趾再造指甲床扩大术的两种方法均手术简单,效果满意,甲皱襞直接切除法具有手术时间短,操作简便的优势。
4.根据解剖学测量研究获得的第二足趾矫形的三个关键点部位进行整形,使调整后解剖学比例达到与健侧拇指相近,可以解决再造拇指美观问题。
Objective:
To measure the absolute value of second toes, big toes, thumbs and their nail's width, length and circumference in-vivo and analyze the ratio of different between those value.To oberserve the effect of double flaps based on the same vascular pedicle employed for expanding finger's circumference on DIP level on toe-to-thumb transfer, compare the clinical outcomes of two kinds of nail bed expanding technique for the new aesthetic modifies in second toe-to-hand transfer surgery and investigate the treatment outcomes of the new aesthetic modifies in toe-to-thumb transfer surgery.
Methods:
1. The absolute value of second toes, big toes, thumbs and their nail's width, length and circumference were measured on40normal Chinese adult (23male,17female) on the double hands and feet. Combined with modern statistical techniques(SPSS19.0), we computed the value of corresponding anatomical site, to provide the anatomical data and analyze the ratio of different between those value.
2. There are significant diffirence of both sides and sex between the ratio of L1/L2, W1/W2, C1/C2. L1/W1of the second toes and the thumbs.
3.18cases of defected thumbs were treated with the techniques of transfer of second toe with double flaps based on the same vascular pedicle for reconstruction of thumb;. The second toe transferred along with the tibial digital artery flap from the second toe pulp and fibular flap from the big toe.
4.20cases suffered by finger defected were treated by second toe-to-hand transfer surgery. They were divided into two groups; During the operation,3mm length eponychium was resected for the first10cases and the Adani rectangular advanced flap was performed in the second10cases. The expanded nails were the same length. The operative times for only nail lengthening were recorded and the length of the nail, appearances, the scarring around the nail and patients self satisfaction comparison evaluation in two groups were compared12months postoperatively.
5. We describe a modified second toe transfer which addresses cosmesis in6patients. These include:1) Harvesting a flap from the adjacent side of the great toe and insetting it into the volar aspect of the second toe to give more bulk,2) Skin excisions are made on each side of the tip reduce the bulbous appearance, and3) Excision of part of the distal skin near the eponychium and advanced the eponychium flap to produce apparent lengthening of the nail.
Results:
1. There are significant diffirence of both sides and sex between the ratio of L1/L2, W1/W2, C1/C2. L1W1of the second toes and the thumbs.
2.18thumbs all survived. There was no flap loss. Follow-up duration raged from6-17months, According to the evaluation criteria for the finger replantation and reconstruction issued by Hand Surgery Society of Chinese Medical Association, results of15thumbs were graded as excellent while the results of3thumbs were fair. The reconstructed finger's circumference on DIP level were expanded10.27mm in average and the circumference radio between The overall satisfactory rate is100%.
3. The operation time of eponychium resection was an average of7.5minutes; The time of the Adani rectangular advanced flap average15minutes;12months postoperative follow-up, no skin necrosis around the nail in both groups cases; A bed expand length for the duration of2.7mm in both groups; The smoothness of the nail is consistent, without obvious deformity happened. The self satisfaction score (MHQ) of eponychium resection group is average of12.1; The score of the Adani rectangular advanced flap is average of11.8. The differences between the two groups were no statistically significant.
4. The mean follow up period was1.5yrs (6-36months). All six cases resulted in good function and improved cosmesis. Part of the great toe flap was lost in one case. The mean two-point discrimination in the transferred toes was10.1mm with protective sensation present in the flaps. The mean range of motion of the transferred toe was14to38o at the metatarsophalangeal joint,16to55°at the proximal interphalangeal joints, and20to36°in the distal interphalangeal joints.
Conclusion:
1. The absolute value of second toes, big toes, thumbs and their nail's width, length and circumference in-vivo are valuable supplement for the anatomical data. Based on the significant diffirence between the ratio of C1/C2. L1/W1of the second toes and the thumbs, the methods that the second toe's nail lengthening and circumference expanding can be chosed as the key points for the management of new aesthetic modifies in toe-to-thumb transfer surgery.
2. Thumb defect can be reconstructed by way of transfer of second toe with double flaps based on the same vascular pedicle. The appearance of the reconstructed thumb is more comparable to the normal thumb
3. Both of the two kinds of nail lengthening in second toe-to-hand transfer surgery are simply and effective; the results are satisfactory; the procedure of eponychium resection is of advantages of short operative time and easy and simple to handle.
4. This novel approach will allow patients to take advantage of the lower morbidity to the donor site afforded by second to thumb transfer, while providing the patient with a more aesthetic appearance of the new thumb.
引文
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