外踝上逆行岛状皮瓣修复足远端皮肤缺损

我科自1995年12月开始采用外踝上逆行岛状皮瓣修复足远端皮肤缺损5例,取得满意效果。1　应用解剖腓动脉下行至外踝上5ｃｍ处,经胫腓骨骨间膜向前发出皮穿支,供应小腿外侧下部的皮肤,皮支穿过骨间膜后分为升支和降支,升支在趾长伸肌和腓骨短肌的肌间隔中下行,穿深筋膜至皮下,折返向上,供应小腿外侧下1/2的皮肤。降支位于深筋膜深面外踝前外侧的疏松组织中,分支分布于外踝前、足外侧皮肤,并与跗骨窦动脉,跗外侧动脉,足背动脉及足底外侧动脉形成网状吻合,通过血管网血流可逆行进入腓动脉皮支。2　手术方法根据皮肤缺损部位的形状及大小设计皮瓣…     

含深筋膜血管网的三种小腿后侧逆行筋膜皮瓣的临床应用

总结１９９４年１０月～１９９６年５月，应用三种小腿后侧逆行筋膜皮瓣的临床效果。利用腓肠浅动脉在小腿远端与腓动脉肌间隙支、胫后动脉穿支和腓动脉外踝支在深筋膜内的广泛吻合，分别设计成小腿后外侧逆行岛状筋膜皮瓣、后内侧逆行岛状筋膜皮瓣和后外踝逆行筋膜皮瓣。临床用于修复足跟及踝关节周围创面共１８例，皮瓣切取面积６ｃｍ×５ｃｍ～１５ｃｍ×８ｃｍ。术后皮瓣均全部成活，创面完全修复。认为，该组皮瓣血供可靠，切取方便，不牺牲主干血管，基本可满足小腿下段、足背、足跟及踝关节周围创面的修复。     

结扎腓动脉穿支的外踝上岛状皮瓣修复足背部软组织缺损

目的 报道应用结扎腓动脉穿支的外踝上逆行岛状皮瓣修复足背软组织缺损的临床效果. 方法 在小腿外侧设计结扎腓动脉穿支的以腓动脉终末穿支降支为血管蒂的外踝上逆行岛状皮瓣对足背软组织缺损进行修复7例,皮瓣面积15 cm×9 cm～7 cm×3 cm.结果 术后皮瓣全部成活,创面均一期愈合.经3～12月随访皮瓣外形、色泽、质地满意.踝关节活动良好. 结论 通过结扎腓动脉外踝上穿支利用该穿支降支在足背部丰富的血管吻合网提供皮瓣的血运,增加了血管蒂的旋转半径,方法 简便、安全,为修复足背尤其是前足背部软组织缺损提供了一种可取的方法 .     

以外踝前血管为蒂胫骨远端前外侧骨膜瓣移位术的应用解剖

目的　为外踝前血管胫骨远端前外侧骨膜瓣移位术提供解剖学依据。　方法　30 侧经动脉灌注红色乳胶的成年下肢标本,观测外踝前动脉的起源、走行、骨膜支及与腓动脉穿支降支的吻合关系。　结果　外踝前动脉有1~2支,起点在外踝尖上(1. 1±0 .4)cm,起始外径(1 .6±0 .4)cm,沿途发1~3支,外径为(0 .4~0 .8)mm的骨膜支分布胫骨远端外侧。腓动脉穿支起点在外踝尖上(5 .6±0. 5 cm),降支循外踝的前外侧下行,沿途向两侧发出 2~6 支外径为 0 .5~1. 0 mm的骨膜支滋养胫骨远端前外侧和外踝。两者吻合部位在外踝尖上(1. 7±0. 6)cm,距外踝前动脉起点外侧(2. 5±0 .6)cm。吻合后动脉经趾短伸肌后部,沿腓骨短肌腱的前缘前行,终支与跗外侧动脉、跟外侧动脉相吻合。　结论　以外踝前血管为蒂的胫骨远端前外侧骨膜瓣,可移位用于修复距骨颈骨折和距骨体缺血性坏死。     

外踝上动脉降支为蒂逆行岛状皮瓣修复足部软组织缺损

目的探讨应用外踝上动脉降支为蒂逆行岛状皮瓣修复足踝部、足中部、前足部皮肤和软组织缺损的疗效。方法应用外踝上动脉降支为蒂逆行岛状皮瓣修复足踝部、足中部、前足部皮肤和软组织缺损9例。结果6例逆行岛状皮瓣全部成活,3例皮瓣远端部分坏死,经换药或植皮后愈合。术后随访6个月～3年,皮瓣外观佳,功能好,无需二次皮瓣整形。结论外踝上动脉降支为蒂逆行岛状皮瓣皮下脂肪少、质地好、成活率高,不损伤主要血管,可较好地修复足部皮肤软组织缺损。     

带前臂外侧皮神经营养血管筋膜皮瓣的应用解剖

目的：为带前臂外侧皮神经及其营养血管筋膜皮瓣提供形态学基础。方法：在３２侧成人上肢标本上，观测前臂外侧皮神经营养血管及其周围皮肤的供血情况。结果：前臂外侧皮神经近侧的血供为肱动脉末端和桡动脉起始部的肌皮支，起始处外径分别为１．４ｍｍ、１．１ｍｍ，穿出深筋膜前长为１．９ｃｍ、１．４ｃｍ；远侧主要为桡动脉的粗大皮支，起始处外径为０．８ｍｍ，穿出深筋膜前长０．８ｃｍ；此外，桡动脉的茎突返支及掌浅支的皮支营养其远端。其神经支在神经束间或神经旁相互吻合构成纵向（链式）血管网，并借分支与筋膜皮支所形成的皮下筋膜血管网沟通。结论：可设计带前臂外侧皮神经及其营养血管的筋膜皮瓣，顺行或逆行转位修复邻近部位的软组织缺损。     

外踝上皮瓣修复足部软组织缺损20例及失败病例分析

目的探讨外踝上逆行岛状皮瓣修复足部远端软组织缺损的效果,分析失败病例原因和预防措施。方法应用腓动脉终末穿支的降支为血管蒂,行外踝上逆行岛状皮瓣修复前足和足外侧软组织缺损20例。结果 18例皮瓣成活,皮瓣质地优良,随访6~12个月,外观及功能满意。2例出现部分坏死,延误治疗。结论外踝上逆行岛状皮瓣是修复足部软组织缺损的良好皮瓣。该皮瓣切取方便,血供丰富,不损伤肢体主要血管。但病例选择不当,就会延误治疗,造成严重后果。     

腓动脉终末穿支降支蒂逆行腓浅神经营养岛状皮瓣的临床应用

目的 报道改进腓浅神经营养血管远端蒂皮瓣的手术方法和临床应用效果. 方法 利用腓动脉终末穿支的降支在外踝与源自胫前动脉的外踝前动脉及踝周血管网的逆向吻合,将转轴点下移,设计切取逆行腓浅神经营养血管岛状皮瓣转位修复足踝部软组织缺损创面. 结果 临床应用23例,皮瓣面积最大12 cm x 13 cm,最小5 cm×4 cm,逆行穿支血管蒂长5～10 cm.皮瓣完全成活21例,大部分成活2例.随访6～21个月,皮瓣质地优良,外形与功能恢复满意.结论 以腓动脉终末穿支降支为血管蒂的腓浅神经营养血管逆行岛状皮瓣血供可靠,转位更灵活方便,是修复足踝部软组织缺损的较好方法.     

腓肠神经营养血管远端蒂皮瓣小隐静脉的应用解剖

目的研究腓肠神经营养血管远端蒂皮瓣小隐静脉营养血管的来源。方法30侧动脉灌注红色乳胶成人下肢标本,以外踝尖为观测指标点,在其上10cm范围内,显微解剖观测远端蒂中的小隐静脉营养血管来源、分布与皮肤血管的关系,以及小隐静脉浅深交通支。结果由远及近,远端蒂部的小隐静脉营养血管来源于跟外侧动脉穿支、外踝后动脉穿支和腓动脉肌间隔穿支。上述动脉穿支2～5支,外径0.6～1.0mm,发深筋膜支、神经静脉营养支和皮支,形成深浅筋膜血管网、腓肠神经干血管链、小隐静脉旁血管链以及静脉壁血管网。小隐静脉浅深交通支1～2支,外径1.7±0.5mm,距外踝尖上3.4±0.9cm,汇入腓静脉。结论远端蒂的腓肠神经、小隐静脉筋膜及皮肤的营养血管同源。外踝尖上3～4cm处存在小隐静脉浅深交通支,远端蒂皮瓣旋转点设计于此处,有助于改善皮瓣静脉回流。     

腓骨肌腱鞘筋膜瓣与脂肪筋膜瓣联合移植修复足跟后深层组织缺损的解剖与应用

目的 为腓骨肌腱鞘筋膜瓣与脂肪筋膜瓣联合移植修复足跟后深层组织缺损提供应用解剖学基础.方法 ①5具(10侧)动脉灌注红色乳胶成人下肢防腐标本,解剖观测腓骨肌腱鞘筋膜及相邻脂肪筋膜血供的来源,测垦其血管管径及其走行、分支与分布情况.②8具(16侧)全身动脉灌注氧化铅一明胶混悬液的新鲜成人整尸标本,解剖下肢筋膜层组织,并取下拍摄X线片,观察腓骨肌腱鞘筋膜层与相邻脂肪筋膜层之间的血供及交通吻合情况.③将2具(4侧)下肢标本构建血管铸型图,直观地了解瓣区血管的走行、分布、吻合情况.并于临床应用了8例.结果 根据腓骨肌腱鞘的长度范围,重点观察了自外踝尖下4 cm至外踝尖上14 cm区域内腓骨肌腱鞘筋膜与相邻脂肪筋膜较为粗大的供血血管,联合筋膜瓣血供呈多源性分布:外踝尖上下4 cm瓣区主要有跟外侧动脉恒定发出3.7(2～5)支,外径(0.5±0.2)mm;外踝后动脉发出1.5(1～2)支,外径(0.6±0.2)mm;腓动脉穿支降支发出2.5(2～3)支,外径(0.5±0.2)mm.外踝尖4 cm以上腓骨肌腱鞘及相邻脂肪筋膜主要由腓动脉发出肌间隔支发出1.7(1～3)支,外径(1.0±0.2)mm以及腓动脉穿支升支的细小分支营养.以上各动脉支在腱周组织内恒定吻合,并发出多数细小分支构筑筋膜层丰富血管网.临床应用的8例术后转移筋膜瓣、移植皮片完全存活.随访3个月至2年,供、受区愈合良好,功能形态恢复满意.结论 可以上述血管之一为蒂,设计切取近端蒂携带腓骨肌腱鞘、滑筋膜瓣或逆行远端蒂携带脂肪筋膜、肌腱鞘筋膜瓣,联合修复小腿下段及足跟后难愈性中小面积缺损.     

跨区供血腓动脉外踝上穿支蒂腓浅神经营养血管皮瓣修复足前部缺损

目的 探讨改良腓浅神经营养血管皮瓣修复足前部缺损的手术方法及临床效果.方法 对足前部皮肤软组织缺损创面,设计切取以外踝上穿支或其降支为蒂,经其升支、胫前动脉皮穿支及腓浅动脉跨区供血的腓浅神经营养血管皮瓣修复.结果 2005年2月至2008年2月,于临床应用17例,最远修复至第2、3趾基底部及第5跖骨头负重区,最大切取面积20 cm×8 cm;皮瓣均全部成活,术后随访6～12个月,皮瓣质地优良,外形与足踝功能恢复满意.结论 该皮瓣神经血管丛粗大而丰富,蒂部供血确切,旋转修复距离可达足趾,适用于涉及足前部的足背中、大面积皮肤软组织缺损的修复.     

腓动脉皮支逆行岛状皮瓣的解剖与应用改进

目的探讨腓动脉皮支逆行岛状皮瓣的解剖学基础及临床应用效果。方法采用新鲜及防腐尸体下肢共25肢,对腓动脉皮支进行解剖学观测。于2003年9月~2005年6月收治足跖趾关节处软组织缺损患者10例,男8例,女2例。年龄21~55岁。其中背侧6例,跖侧4例,缺损范围10cm×6cm~15cm×10cm。应用带有外踝上11.0±1.7cm腓动脉固定皮支的腓动脉皮支逆行岛状皮瓣修复,皮瓣范围11.0cm×6.5cm~16.0cm×11.0cm。供区6例直接减张缝合,4例行自体游离皮片覆盖。结果解剖学观测外踝上11.0±1.7cm自腓动脉发出一固定皮支,起始点直径1.45±0.12mm,入深筋膜点距腓肠神经营养血管皮瓣轴线15.70±1.20mm。10例患者术后皮瓣均成活,血运良好,无静脉回流障碍;供区愈合良好。术后获随访6~12个月,皮瓣外形良好,质地、色泽与周边相似,足功能恢复良好,两点辨别觉11~18mm。结论腓动脉皮支逆行岛状皮瓣经改进后血运好,逆转距离长,修复范围大,操作简便,为临床修复足中远端软组织缺损提供了一种新方法。     

小腿外侧腓动脉皮支皮瓣的解剖与临床应用

目的研究以腓动脉皮支血管为蒂的小腿外侧皮瓣吻合血管游离移植的解剖学与临床应用。方法解剖20具40侧成人尸体小腿,测量小腿外侧腓动脉皮支的有关数据。多普勒血管仪测定30侧成人活体小腿外侧腓动脉皮支血管穿出点。临床行21例小腿外侧腓动脉皮支皮瓣吻合血管的游离移植手术。结果40侧小腿共观察到皮支140支,每侧1~7支不等,平均3.5支,其中一侧只有1支高位皮支。皮支的穿出点大多(76%)在腓骨头最凸点下方7~21 cm范围。每侧最粗的皮支动脉外径平均为(1.8±0.4)mm(1.4~2.9 mm),两条伴行静脉外径平均(3.0±0.5)mm和(2.4±0.4)mm。30侧活体小腿共测到小腿外侧皮支血管穿出点145个,平均每侧4.8个。临床切取皮瓣大小5.0 cm×3.5 cm~28 cm×11 cm,21块皮瓣均成活。结论小腿外侧皮瓣由不同数目的腓动脉皮支供养,其主皮支能满足显微外科吻合血管的要求。以皮支血管为蒂的小腿外侧游离皮瓣移植,比以腓血管为蒂创伤小、操作简单、血运重建符合生理。     

Laterale Supramalleolarlappenplastiken zur Defektdeckung im Sprunggelenks- und Fußbereich

Objective

Defect reconstruction by transposition of well-vascularized thin and pliable skin.

Indications

Defect coverage involving the antero- and dorsolateral distal one third of the lower leg, the dorsolateral and dorsomedial hindfoot and dorsal midfoot.

Contraindications

Severe peripheral arterial occlusive disease (PAOD), previous trauma at the anterolateral aspect of the lower leg and foot.

Surgical technique

Lateral fasciocutaneous supramalleolar flap with orthograde blood flow, fasciocutaneous lateral supramalleolar perforator flap with orthograde blood flow, adipofascial lateral supramalleolar flap with orthograde blood flow, lateral fasciocutaneous supramalleolar flap based on the lateral tarsal artery with retrograde blood flow, lateral fasciocutaneous supramalleolar flap based on the anterolateral malleolar artery with retrograde blood flow according to Oberlin.

Postoperative management

“Tie over” dressing for grafting site for 5 days (healing of split/full-thickness skin graft), complete immobilization of the lower leg for 7 days in a dorsal plaster splint (ensure that there is no pressure on the flap), progressive increase of range of motion after 1 week, postoperative standardized compression therapy, combined with scar therapy (silicone sheet).

Results

Reliable, excellent functional and aesthetic results with thin skin in small to midsize defects. Increasing morbidity of grafting site in larger flaps and risk of neuroma when the superficial peroneal nerve was exposed.     

Modified distally based sural neuro-veno-fasciocutaneous flap: anatomical study and clinical applications

The distally based sural neuro-veno-fasciocutaneous flap has been used widely for reconstruction of foot and ankle soft-tissue defects. The distal pivot point of the flap is designed at the lowest septocutaneous perforator from the peroneal artery of the posterolateral septum, which is, on average, 5 cm (4-7 cm) above the lateral malleolus. A longer neuro-veno-adipofascial pedicle would be needed to reversely reach the distal foot defect when the flap is dissected based on this perforating branch, which may result in more trauma in flap elevation and morbidity of the donor site. In this article, we explored new pivot points for this distally based flap in an anatomic study of 30 fresh cadavers. The results showed that the peroneal artery terminates into two branches: the posterior lateral malleolus artery and lateral calcaneal artery. These two branches also send off cutaneous perforators at about 3 and 1 cm above the tip of lateral malleolus, respectively, which can be used as arterial pivot points for the flap. A communicating branch between the lesser saphenous vein and the peroneal venae comitantes was found, accompanied by the perforator of the posterior lateral malleolus artery. This modified, distally based sural flap with lower pivot points was successfully transferred for repair of soft-tissue defects in 21 patients. The size of flaps ranged from 4 x 3 cm to 18 x 12 cm. All flaps survived without complications. Neither arterial ischemia nor venous congestion was noted. In conclusion, the vascular pivot point of a distally based sural flap can be safely designed at 1.5 cm proximal to the tip of the lateral malleolus. This modified flap provides a valuable tool for repair of foot and ankle soft-tissue defects.     

Technical refinement of the lateral supramalleolar flap

The lateral supramalleolar flap has proved to be versatile for managing a variety of skin defects of the foot, ankle and lower third of the leg. An anatomical study has shown the reliability of a subcutaneous vascular network, supplied by terminal branches of the perforating branch of the peroneal artery. Our technical refinement consists in designing the skin flap more proximally on the lateral aspect of the leg, and mobilising it on its vascular fascio-subcutaneous pedicle. The flap provides considerable possibilities for covering more distal skin defects of the lower extremity.     

扩展的小腿前外侧逆行岛状皮瓣的临床研究

目的 探讨应用小腿前外侧皮瓣的双重血供对可扩大皮瓣切取面积及提高旋转应用范围的可行性. 方法 在应用解剖学研究的基础上,设计以腓浅动脉和外踝上动脉为血管蒂的双重供血小腿前外侧逆行岛状皮瓣,临床应用60例.皮瓣切取面积最大26.0 cm×7.0 cm、蒂长6.0 cm,最小16.0cm×10.0 cm、蒂长8.0 cm,旋转轴点均在外踝前. 结果 皮瓣全部成活53例,占88.3%;大部分成活7例,占11.7%.术后随访6个月～3年,皮瓣在术后1年后出现保护性感觉,患者恢复行走功能. 结论 保留小腿前外侧供区的双重血供来源,可扩大小腿前外侧皮瓣的供血范围及切取面积,以此为包括前足的大面积足部软组织缺损的修复提供了可行性.     

远端蒂皮瓣或逆行岛状皮瓣转移术蒂部减张皮瓣的设计与应用

目的 探讨在远端蒂皮瓣或逆行岛状皮瓣蒂部设计减张皮瓣的可行性和临床应用效果.方法 临床应用胫后动脉内踝上皮支逆行岛状皮瓣修复9例,胫后动脉小腿内侧穿支远端蒂皮瓣修复2例,腓动脉外踝上皮穿支逆行岛状皮瓣修复8例,腓浅神经营养血管逆行岛状皮瓣修复4例,远端蒂腓肠神经营养血管皮瓣修复3例,掌背筋膜蒂逆行岛状皮瓣修复2例.蒂部减张瓣呈梭形或圆形,面积为1.0 am×1.0 cm～5.0 cm×3.5 cm.结果 28例皮瓣术后血运良好,无肿胀、淤血,全部成活,随访皮瓣质地良好,外形美观,供区均一期愈合,疗效满意.结论 在远端蒂皮瓣或逆行岛状皮瓣蒂部设计减张皮瓣是可行的.可有效地防止蒂部血管受压或血管网破坏而影响皮瓣的血运,是一种可靠的预防远端蒂皮瓣或逆行岛状皮瓣血供障碍的新方法.     

Fasziokutane Insellappen zur Defektdeckung am Sprunggelenk und am Rückfuß

Covering tertiary soft-tissue injuries on the ankle joint and on the calcaneal part of the foot has so far been the domain for free flap use. With the distally based neurocutaneous sural artery flap (sural flap) and the distally based lateral supramalleolar flap, there are now fasciocutaneous island flaps available which allow quick covering of injuries in this region, requiring only simple planning and no microsurgical techniques. When partially de-epithelialized, they are also suitable for filling cavities, as is necessary particularly after infected calcaneal osteosynthesis on the lateral calcaneal part of the foot. In our group of seven patients, sural flaps were used in five cases while two patients received lateral supramalleolar flaps. The injuries were covered with no difficulties. The flap sizes ranged from 3 × 3 to 15 × 7 cm. Donor sites were unproblematic. However, lifting a sural flap involves neurotomy of the sural nerve, and lifting the lateral supramalleolar flap involves neurotomy of the superficial peroneal nerve. Wound healing was delayed in three patients.