形成手外科医による整容的重度四肢外傷再建

Aesthetic Reconstruction of Severe Limb Injury by a Plastic Hand Surgeon

はじめに

　形成外科医にとって手外科領域の登竜門となる手術は，切断指に対する再接着術である。また，指尖損傷に対するoblique triangular flap，逆行性指動脈皮弁などの有茎皮弁や，hemi pulp transfer，wrap around flapなどの遊離皮弁は，軟部再建の手技習得に重要な手術となる。切断指再接着術からマイクロサージャンとしてのキャリアをスタートさせる形成外科医は，技術面において重度四肢外傷に対する軟部組織再建を担う準備はできていると考える。

　しかし，重度の四肢外傷に対する軟部再建は，単なる技術的な習熟度以外にも，さまざまな能力が求められる。その中でも特に重要なのは，損傷組織の状態を正確に評価し，治療の適切なステップを迅速かつ的確に進める判断力と実行力である。本稿では，形成外科医が多く経験する切断指・指尖再建と，形成外科医があまり経験しない重度四肢外傷再建との違い，軟部組織再建における実際の取り組み，および整形外科とのコラボレーション治療の実際について述べる。

　The differences between the replantation of amputated fingers and the treatment of severe limb injuries are significant. While finger injuries often involve microsurgical techniques to reconnect vessels, nerves, bone, and tendons, severe limb injuries demand early interventions such as antibiotic administration and debridement, followed by reconstruction of bones and soft tissues. Collaboration between plastic surgeons and orthopedic specialists is crucial. Inappropriate decisions can have serious consequences. The treatment approaches differ in part due to variations in vessel size and location between limbs and fingers. Success in fingertip reconstruction relies on surgical skill, accurate tissue assessment, and strategic planning, all of which improve with experience.

　In soft tissue reconstruction, the choice of recipient vessels for free flaps is of paramount importance. Decisions are based on the zone of injury (ZOI), considering the vesselʼs health and position. Surgeons need the ability to assess the vesselʼs condition visually. Techniques such as end-to-end and flow-through anastomosis, both of which impact reconstruction success, may be applicable. The design and selection of skin flaps prioritize aesthetics, considering texture, color, thickness, and contour. It is preferable to source skin flaps from non-exposed areas. Each flap method has pros and cons, and decisions should account for the injuryʼs shape, connecting vessels, flap size, and hair growth patterns.