不同血管蒂皮神经营养血管皮瓣的比较研究

目的通过观察兔不同血管蒂皮神经营养血管皮瓣模型,分析不同蒂部结构对皮瓣成活的影响,探讨穿支蒂皮神经营养血管皮瓣最佳切取方法。方法健康新西兰大白兔40只,雌雄不限,体重2.5～3.0 kg。随机取一侧后肢外侧设计大小为7 cm×1 cm、蒂长0.5 cm的皮神经营养血管皮瓣。根据切取皮瓣蒂部的不同随机分为4组,每组10只。其中A组制备单穿支蒂皮神经营养血管皮瓣,B组为筋膜蒂皮神经营养血管皮瓣,C组为穿支筋膜蒂皮神经营养血管皮瓣,D组原位回植皮神经营养血管皮瓣。术后第7天观察皮瓣成活情况,记录成活率;应用激光多普勒血流探测仪监测皮瓣中段动脉血流灌注情况,测量血液灌流(perfusion unit,PU)值。结果术后A、B组皮瓣无明显肿胀,皮瓣近端色泽红润,远端苍白;C组皮瓣肿胀明显,但逐渐减退,皮瓣远端皮肤苍白;D组皮瓣逐渐变黑。术后第7天,A、B、C、D组皮瓣成活率分别为74.0%±2.7%、60.0%±2.5%、75.0%±3.5%、0,皮瓣中段PU值分别为83.39±4.25、28.96±13.49、81.85±5.93、8.10±3.36。以上两指标A、B、C组与D组比较,差异均有统计学意义(P<0.05);A、C组与B组比较,差异有统计学意义(P<0.05);A、C组间比较,差异无统计学意义(P>0.05)。结论兔单穿支蒂皮神经营养血管皮瓣血供可靠、成活面积稳定,早期皮瓣静脉回流障碍发生率低,是皮神经营养血管皮瓣较好的切取方法。     

小腿浅静脉-皮神经营养血管皮瓣修复骨外露缺损创面

目的 探讨小隐静脉-腓肠神经、大隐静脉-隐神经营养血管皮瓣修复小腿骨外露缺损创面的方法及疗效.方法 对18例各种原因造成的小腿软组织缺损、骨外露分别采用腓肠神经和隐神经营养血管皮瓣进行修复.应用腓肠神经皮瓣12例,其中近端蒂5例,远端蒂7例;隐神经皮瓣5例,其中近端蒂2例,远端蒂3例;两种皮瓣联合应用1例.结果 除早期1例皮瓣远端1～2cm宽的不同程度坏死经换药而愈外,余例皮瓣均成活,供、受区形态与功能恢复良好,3个月后X线片显示骨外露处骨质愈合良好.结论 此两种皮神经皮瓣血运丰富,抗感染力强,操作简便,是治疗小腿软组织缺损、骨外露、伴有内固定外露、骨感染的一种有效、安全的修复方法.     

带腓肠神经营养血管蒂逆行岛状皮瓣的临床应用

目的:总结带腓肠神经营养血管蒂逆行岛状皮瓣临床应用特点。方法:复习病例,回顾带腓肠神经营养血管蒂逆行岛状皮瓣修复软组织缺损的手术方法、皮瓣成活情况及治疗效果。结果:11例病例,9例皮瓣完全成活,2例术后部分坏死;11例手术均由小腿远端向近端游离血管蒂,6例皮瓣携带腓肠肌袖。结论:修复踝足区皮肤软组织缺损,运用带腓肠神经营养血管蒂逆行岛状皮瓣,不吻合血管,不牺牲主要血管,操作表浅,安全、可靠。     

腓肠神经营养血管皮瓣的临床应用

目的：探讨腓肠神经营养血管皮瓣的临床应用特点。方法：用逆行腓肠神经营养血管皮瓣对6例足踝及小腿软组织缺损病例进行修复,同时观察皮瓣血管蒂长度,腓肠神经及营养血管走行特点。结果：6例中5例完全成活,1例皮瓣远端坏死1cm,营养血管发出位置在外踝上5-7cm,血管蒂最长达22cm,腓肠神经都以内侧支为主,皮瓣切取用逆行分离法,结论：腓肠神经营养血管皮瓣切取简便,成功率高,最远可达足前中部,是足跟、踝、足背及小腿下1/3软组织缺损的理想供区。     

腓肠神经营养血管皮瓣修复小腿足踝部缺损

目的探讨带蒂腓肠神经营养血管皮瓣修复小腿及足踝部远端软组织缺损的疗效。方法应用带蒂腓肠神经营养血管皮瓣修复24例小腿及足踝部远端软组织缺损患者。缺损面积为5 cm×6 cm～12 cm×8 cm。结果3例皮瓣远端边缘部分坏死,经换药后愈合;21例皮瓣全部成活。其中4例术后皮瓣明显肿胀,2周后消退,皮瓣成活。24例均获随访,时间6个月～2年,足背外踝区早期感觉减退,6个月时21例皮瓣麻痹区缩小。皮瓣两点辨别觉〉2 cm者17例,7例足跟边缘区部分溃疡,换药后瘢痕愈合。皮瓣色泽、质地、弹性良好。结论应用腓肠神经营养血管皮瓣修复小腿下段及足踝部缺损手术操作简单,皮瓣血供充足,疗效可靠。     

小腿远端不同穿支蒂皮神经营养血管皮瓣的应用

目的 探讨应用小腿远端不同穿支蒂皮神经营养血管皮瓣修复小腿下段和足踝部软组织缺损的适应证和临床效果.方法 对24例小腿下段和足踝部软组织缺损的患者,优选5种不同的小腿远端穿支蒂皮神经营养血管皮瓣进行修复,其中腓动脉外踝后上穿支蒂腓肠神经营养血管皮瓣7例,外踝后穿支筋膜蒂腓肠神经营养血管皮瓣2例,腓动脉高位穿支蒂腓肠神经营养血管皮瓣2例,腓动脉外踝前上穿支蒂腓浅神经营养血管皮瓣8例,胫后动脉内踝上穿支蒂隐神经营养血管皮瓣5例.皮瓣切取面积为5 cm ×4 cm ～ 14 cm× 12 cm.结果 除了1例腓动脉外踝前上穿支蒂腓浅神经营养血管皮瓣发生远端部分坏死之外,其余皮瓣术后均顺利成活,切口均一期愈合.15例患者获得1～36个月的随访,皮瓣色泽、质地及厚薄较为满意,供、受区外形与功能恢复也较为满意.结论 根据小腿下段和足踝部软组织缺损的具体情况,并结合小腿远端不同穿支蒂皮神经营养血管皮瓣的特点,选择最适宜的皮瓣加以修复,多能以供区最小的代价获得最佳的受区效果.     

小隐静脉-腓肠神经营养血管皮瓣的临床研究

目的　报道远端蒂及近端蒂小隐静脉 腓肠神经营养血管皮瓣修复下肢软组织缺损的效果。　方法　采用近端蒂及远端蒂、带腓肠神经或不带腓肠神经的小隐静脉 腓肠神经营养血管皮瓣 ,修复 2 5例小腿胫前近、中、远段和踝周、足背及足跟皮肤缺损 ,皮瓣最小面积为 5cm× 4cm ,最大面积为10cm× 15cm。　结果　 2 5例中远端蒂皮瓣 2 2例 ,近端蒂 3例 ,不带腓肠神经的皮瓣 3例 ,皮瓣全部成活 ,皮瓣质地优良 ,外观及功能满意。　结论　该皮瓣可行近、远端蒂转移 ,皮瓣可带或不带腓肠神经 ,均有足够的血运。本皮瓣成活率高 ,操作简便 ,不牺牲主干血管 ,是修复小腿胫前、踝周及足跟部软组织缺损的理想皮瓣。     

小隐静脉栓塞对腓肠神经营养血管逆行皮瓣的影响

目的 探讨小隐静脉栓塞对小隐静脉-腓肠神经营养血管蒂逆行岛状皮瓣的影响.方法 于30只大白兔小腿后侧切取小隐静脉-腓肠神经营养血管蒂逆行岛状皮瓣,随机分为3组,每组10个皮瓣,第1组在蒂部保留小隐静脉干;第2组在蒂部远端1 cm将小隐静脉干结扎;第3组在蒂部远端1 cm栓塞小隐静脉干.结果 第1组皮瓣的小隐静脉充盈较第2、3组显著,且第1组皮瓣均有明显淤血、肿胀.第3组皮瓣存活率(87.5%)明显高于第1组(62.3%)和第2组(81.5%),差异均具有统计学意义(P＜0.01).结论 在小隐静脉远端栓塞或结扎阻断静脉血流灌人,均能显著提高远端蒂皮瓣的存活率;但在蒂部结扎小隐静脉影响皮瓣远端供血和皮瓣成活面积.     

腓肠神经营养血管皮瓣修复下肢远端软组织缺损的临床应用

目的：观察应用腓肠神经营养血管皮瓣修复下肢远端软组织缺损的临床效果。
方法:对9例下肢软组织缺损患者,以其腓肠神经营养血管为蒂,于小腿后侧切取皮瓣逆行或顺行转移至缺损区进行修复,观察术后皮瓣成活情况。
结果:术后供瓣区愈合良好,除1例皮瓣边缘坏死1.0 cm宽,1例边缘起小水泡外,其余均成活良好。切取皮瓣最大面积为16.5 cm×10.5 cm。修复后外形较满意,功能基本正常。
结论:腓肠神经营养血管蒂皮瓣切取简便,易存活,不损伤小腿主要动脉,是修复下肢远端软组织缺损的较好方法,适合在基层医院推广。

     

腓肠神经营养血管蒂逆行岛状皮瓣的临床应用

目的探讨应用腓肠神经营养血管蒂岛状皮瓣的临床效果。方法以小腿腓肠神经营养血管远端为蒂设计并切取皮瓣,逆行转移修复小腿下段、踝部及足跟部皮肤缺损16例。结果随访6个月～2年,16例皮瓣中除1例皮瓣远端边缘部分坏死外,其余皮瓣全部成活。结论腓肠神经营养血管蒂岛状皮瓣具有血供可靠、操作简单、成活率高以及不牺牲知名血管等特点,是修复小腿下段、踝部及足跟部皮肤软组织缺损的理想方法之一。     

Experience with the distally based sural neurofasciocutaneous flap supplied by the terminal perforator of peroneal vessels for ankle and foot reconstruction

The distally based sural fasciocutaneous flap has been proved an excellent option for coverage of the soft tissue defects of the lower third of the leg, ankle, and foot. In this article, we reported on a series of foot and ankle reconstructions with a distally based sural neurofasciocutaneous flap supplied by the terminal perforating branch of the peroneal artery. The vascular pedicle of the flap includes the terminal perforator branch of the peroneal artery and concomitant veins. The pivot point is approximately 5 cm above the tip of lateral malleolus. Fifteen patients with soft tissue defects of the foot and/or ankle underwent the procedures of reconstruction. The flaps were designed with the size measuring 8 x 9 cm to 13 x 31 cm. Thirteen flaps survived completely and 2 with partial or margin necrosis. Our experience has demonstrated that this sural flap with a thin perforator pedicle can be easily rotated, used for coverage of a large tissue defect including the forefoot area, and provide a good texture match and contour for the recipient area.     

The distally based posterolateral supramalleolar neurofasciocutaneous island flap for coverage defects over the distal third of the leg and foot

A traditional-designed distally based sural flap centralized on the axis of the (medial) sural nerve and the lesser saphenous vein has been used widely for coverage of the distal third of the leg, ankle, malleoli, and foot. However, a variety of 5% to 47% of flap necrosis after the flap elevation and transposition were recorded in the literature. The unreliability of the distal part of the flap, especially when skin paddle located at the proximal third of the leg is at least partly due to their subfascial coursing of the median superficial sural artery and the medial sural nerve as well as the lesser saphenous vein. Based on the anatomic characteristics of the sural nerve and previous angiographic studies, a longitudinal chain-linked axial vascular network along with the sural nerve and the lateral sural nerve had been demonstrated on the posterolateral side of the leg from lateral retromalleolar gutter to the fibular head. A distally based posterolateral supramalleolar neurofasciocutaneous island flap centralized on this longitudinal neurovascular network was designed and used to reconstruct and cover the defects over the distal third of the leg, lateral malleolus, foot, and Achilles tendon. In this report we retrospectively review the clinical outcomes. This flap was used in 11 patients, including six young children aged 3 to 6 years. All flaps survived fully without complications except one flap which experienced postoperative infection which was controlled by dressing change and antibiotic application. Relevant surgical anatomy and detailed surgical techniques for elevation of the flap and its versatile usage are presented. Risks leading to flap necrosis, safe pedicle design, and manipulations etc. are discussed. In conclusion, this distally based posterolateral supramalleolar neurofasciocutaneous island flap is reliable and very useful for covering defects over the distal leg, ankle, heel, foot, and Achilles tendon, especially in young children.     

顺逆结合法切取远端蒂腓肠神经营养血管皮瓣

目的探讨顺逆结合法切取远端蒂腓肠神经营养血管皮瓣的效果。方法2001年1月-2007年6月例行远端蒂腓肠神经营养血管皮瓣82例（84处），其中采用顺逆结合法切取皮瓣45例（46处），逆行法切取皮瓣37例（38处）。结果70处皮瓣完全成活，14处皮瓣远端部分坏死，顺逆结合法与逆行法切取皮瓣术后完全成活率分别为91.3%（42/46）及73.7%（28/38），差异显著（P〈0.05）。结论顺逆结合法切取皮瓣可准确定位腓动脉肌间隔穿支，必要时可及时调整皮瓣的位置，提高皮瓣的完全成活率，尤其适用于未行或无条件行彩超定位穿支者。     

不同节段的穿支蒂腓肠神经营养血管皮瓣修复下肢缺损

目的：探讨不同节段的穿支蒂腓肠神经营养血管皮瓣修复下肢缺损的适应证和临床效果。方法：2004年至2012年治疗13例下肢软组织缺损患者,男8例,女5例;年龄15～76岁,平均38．6岁。采用3种不同节段的穿支蒂腓肠神经营养血管皮瓣进行修复,包括外踝尖后上4～7 cm处腓动脉穿支蒂腓肠神经营养血管皮瓣修复足、踝部缺损8例;外踝尖后上9～11 cm处腓动脉穿支蒂腓肠神经营养血管皮瓣修复小腿下段缺损3例;外踝尖后上1～2 cm处外踝后动脉穿支蒂腓肠神经营养血管皮瓣修复足跟缺损2例。皮瓣切取面积为4．5 cm×2．5 cm～16 cm×10 cm。供瓣区创面移植皮片修复。结果：13例皮瓣术后均未发生血管危象及切口感染,皮瓣均顺利成活,切口均Ⅰ期愈合。8例患者获得随访,时间1～12个月,平均6个月,皮瓣色泽、质地良好,厚薄适中,无烫伤及溃疡发生;供、受区外形及功能恢复较为满意。结论：灵活选用不同节段的穿支蒂腓肠神经营养血管皮瓣修复下肢缺损,可获得理想效果。     

Lowering the pivot point of sural neurofasciocutaneous flaps to reconstruct deep electrical burn wounds in the distal foot

Due to the thinness of the skin and soft tissues in the foot, tendons and bones tend to become exposed and necrotic after injury; therefore, it is difficult to reconstruct foot injuries, especially distally. Reconstruction with free skin flaps is highly risky as it demands technologies and equipment, while patients suffer greatly from the use of cross-leg skin flaps. Sural neurofasciocutaneous flaps are often used for reconstruction of wounds in the lower leg, malleolus, and the proximal end of the foot but are not feasible for wound repair in the distal foot; this is because, with the pivot point of 5–7 cm above the tip of the lateral malleolus, the flaps are not able to cover defects in the distal foot. In this study, we used a sural neurofasciocutaneous flaps with a lowered pivot point for reconstruction of distal foot wounds caused by electrical burns. An ultrasound flow detector and Doppler flow imaging were used to detect the diameter, the perforating point and the blood flow of the lateral retromalleolar perforator. Twelve patients with the perforator diameter greater than 0.6 mm and the peak systolic flow more than 0.15 m/s were included. The pivot point of sural neurofasciocutaneous flaps was lowered to 0–3 cm above the tip of the lateral malleolus and the size of the flaps ranged from 6 cm × 5 cm to 12 cm × 18 cm. Eleven of the 12 flaps survived completely. One flap developed necrosis approximately 1 cm at the far point but was managed successfully by daily dressing. We demonstrated that lowering the pivot point of sural neurofasciocutaneous flaps is feasible for reconstruction of distal foot injury with the advantages of reliable blood supply and easy operation. The use of Doppler flow imaging provides useful information for the design of the flaps.     

腓肠神经营养血管逆行皮瓣修复儿童足踝部皮肤缺损

目的 探讨儿童腓肠神经营养血管逆行皮瓣临床应用的特点.方法 2002年1月至2007年1月,采用腓肠神经营养血管逆行皮瓣修复儿童足踝部皮肤软组织深度缺损16例,皮瓣切取面积为6.5 cm×5.0 cm～17 cm×10 cm,10例皮瓣上界超过小腿中上1/3交界处,其中2例上界达胭窝,1例上界在腘窝横纹上1.5 cm.结果 14例皮瓣全部成活;1例皮瓣远端部分坏死,1例远端浅表坏死,分别经二期缝合和换药后伤口自然愈合.经2～46个月随访,皮瓣均外观满意.结论 儿童腓肠神经营养血管逆行皮瓣存活的范围相对较大,皮瓣上界可超过小腿中上1/3交界处达腘窝横纹,是修复足踝部皮肤软组织深度缺损的理想方法.     

蒂部加强穿支血管的逆行腓肠神经营养血管筋膜皮瓣的应用

目的 报道蒂部加强穿支血管的逆行腓肠神经营养血管筋膜皮瓣的手术方法及临床应用效果.方法 切取腓肠神经营养血管筋膜皮瓣逆行转位修复肢体远端皮肤软组织缺损时,在蒂部或转轴点附近增加从深部血管发出的皮穿支以加强皮瓣的血供,提高手术成功率.结果 临床应用24例,皮瓣面积为25 cm×12 cm～8 cm×7 cm,创面面积为全足～7 cm×6 cm;修复范围:由踝部至全足底.24例皮瓣全部成活,无皮瓣肿胀及静脉淤血.随访6～12个月,皮瓣质地优良,外形与功能恢复满意.结论 筋膜蒂部加强穿支血管的逆行腓肠神经营养血管皮瓣,血供充足,增大了皮瓣的存活面积,提高了手术的成功率,为临床修复大面积软组织缺损提供了实用性的方法.     

Maximizing the reliability and safety of the distally based sural artery flap

Variations of the distally based sural artery flap have been used in the literature with varying success rates. This article stresses the axiality of this flap based on the sural nerve and the short saphenous vein. Forty distally based sural artery flaps were used for a variety of defects in the distal leg. In the proximal leg, the groove between the medial and lateral heads of the gastrocnemius muscle was explored to include the subfacial part of the medial sural nerve with the flap. The subfascial part of the nerve can consistently be included with the flap and gives off cutaneous supply to the tip of the flap to increase reliability of the distal part of the flap. The short saphenous vein should be harvested with an additional length to allow for supercharging or intermittent bleeding in the event of flap congestion. With this approach our success rate with this flap was 98%. To maximize the reliability of the distally based sural artery flap, the sural nerve and short saphenous vein must be included with the flap along its entire length.     

Reverse sural island flap elevated from the proximal third of the leg: its reliability and versatility in distal leg and foot reconstruction

Soft tissue loss around the distal third of the leg and foot has remained a considerable challenge. A reconstructive option providing supple tissue, while avoiding the complexity and the high technical demand of free flaps is a welcome alternative. The sural island flap largely satisfies these criteria. A number of authors have suggested raising the skin island from the junction of the middle and upper third of the leg to improve its reliability. However, raising the flap over the upper third of the leg may provide a larger amount of tissue and often makes dissection of its most distal perforator unnecessary. This study aims to assess the reliability and versatility of the reverse sural island flap elevated from the proximal third of the leg for soft tissue reconstruction of the distal leg and foot. Consecutive patients with soft tissue loss around the distal third of the leg and the ankle region requiring flap cover who met the inclusion criteria were managed using the distally based sural island flap elevated from the upper third of the leg. The outcome has been analysed. There were 15 patients, 11 males and four females with an age range of 22 to 54 years. Thirteen patients had distal third open tibial fractures while two had open calcaneal injuries. Nine resulted from motorcycle accidents, four from motor vehicular accidents while two were gunshot wounds. Flap sizes ranged from 10 × 7 cm to 22 × 12 cm. Thirteen flaps had full survival while two flaps had partial necrosis. All donor sites were skin grafted with 95% to 100% graft take. The use of the reverse sural island flap elevated from the proximal third of the leg for coverage of soft tissue defects of the distal leg and foot is safe and reliable in our experience. It provides a sizeable amount of soft tissue while maintaining a robust blood supply.