大鼠穿支蒂皮瓣的实验研究

目的建立穿支血管蒂皮瓣的动物实验模型，探讨蒂部穿支血管对皮瓣血供的影响。方法选择30只雄雌不限SD大鼠，分成1个实验组和2个对照组，每组10只，实验组为穿支血管蒂皮瓣组，对照1组为皮下蒂皮瓣组，对照2组为随意皮肤蒂皮瓣组，实验组进行血管造影及组织学检查。结果大鼠腹部皮肤穿支血管起源于腹壁上动脉深支，于腹直肌鞘两侧穿出，共8～10支，穿支垂直间距0．4-1．0cm，以左上第2穿支外径粗大，一条肌皮穿支血管可供养大鼠腹部皮肤81．5％。结论穿支血管蒂皮瓣血供来源于穿支血管，切取穿支血管蒂皮瓣面积比随意皮肤蒂皮瓣面积大，并可提供多种皮瓣设计的选择。     

保留穿支蒂皮瓣筋膜组织对大鼠背部皮瓣成活影响的实验研究

目的 探讨保留皮瓣穿支蒂部的筋膜对大鼠背部皮瓣成活的影响,探讨血流动力学改变方式及机制。方法 自2016年1—4月,安徽医科大学第一附属医院整形外科选取30只健康SD大鼠,雌雄不限,在大鼠右侧背部建立大小为8.0 cm×2.0 cm的局部原位皮瓣模型,随机分为A、B、C 3组,10只/组。A组为穿支皮瓣组,B组为穿支筋膜蒂皮瓣组,C组为随意皮瓣组。A、B组大鼠以右侧肋间后血管为皮瓣的穿支血管。术后观察皮瓣颜色、肿胀及坏死情况,计算术后7、14 d 3组皮瓣的成活率;术后7 d内对3组皮瓣血流灌注值进行比较;术后7、14 d用明胶-氧化铅灌注进行背部皮瓣造影,观察皮瓣血管结构变化情况。结果 术后7、14 d,A、B组成活率显著高于C组,其中B组成活率高于A组,3组皮瓣成活面积比较,差异具有统计学意义（P<0.05）,术后7 d与14 d比较,差异无统计学意义（P>0.05）;明胶-氧化铅灌注造影显示,B组皮瓣血管真性吻合数较其他组明显增多。结论 保留皮瓣穿支蒂和周围部分筋膜比单纯保留穿支或筋膜更加有利于皮瓣成活。     

带蒂腹壁下动脉穿支皮瓣修复大腿肿瘤术后创面

目的 探讨腹壁下动脉穿支皮瓣修复大腿肿瘤切除术后创面的效果.方法 自2002年1月至2009年1月,采用腹壁下动脉穿支皮瓣修复大腿肿瘤切除术后创面15例,皮瓣面积13 cm×10 cm～40 cm×10 cm,血管蒂长11～16 cm.根据缺损区皮肤松弛程度决定采用直接缝合或皮瓣移植修复.结果 术后14例皮瓣全部成活,1例皮瓣远端坏死约4 cm×1 cm,经换药创面痊愈.10例获随访1个月至2年,皮瓣色泽、质地与外形良好,患者行走及下蹲功能很好.结论 带蒂腹壁下动脉穿支皮瓣能修复大腿肿瘤切除术后创面,皮瓣范围大、供区隐蔽,效果理想.     

皮神经营养血管对扩大穿支蒂皮瓣存活面积的实验研究

目的 探讨皮神经营养血管对扩大穿支皮瓣存活面积的机制.方法 雄性SD大鼠30只,10只用于灌注解剖研究大鼠背部穿支血管、皮神经走行;20只随机分为两组,均设计3 cm×10 cm以旋髂深动脉皮穿支为蒂的背部长轴皮瓣,实验组皮瓣长轴与后正中线成0°、对照组呈30°.术后1 d、7 d尾静脉注射荧光素钠观察皮瓣血流情况;术后7d观察两组皮瓣存活率,并观察皮瓣的血管网分布.结果 大鼠旋髂深动脉皮穿支恒定,背部皮神经纵向分布,有丰富的血管网伴行.术后1 d实验组的血流灌注面积为42.85%,对照组皮瓣为37.94%,二者差异无统计学意义(P＞0.05);术后7 d两组皮瓣血流灌注面积分别为84.07%、58.55%,皮瓣存活面积分别为83.93%、59.95%,差异均有统计学意义(P＜0.01).术后7 d实验组皮瓣血管网密度高于对照组.结论 皮神经营养血管改善穿支皮瓣存活状况,沿皮神经走向切取穿支皮瓣可明显增大皮瓣存活面积.     

腓动脉穿支蒂腓肠神经营养血管皮瓣的临床应用

目的探讨应用改进腓肠神经营养血管皮瓣修复小腿下段及足踝部皮肤软组织缺损的手术方法及临床效果。方法1999年1月~2004年11月,在腓动脉肌间隔支与腓肠神经血供的解剖基础上临床应用22例。其中男14例,女8例。年龄5~54岁。根据缺损部位及大小设计以腓动脉小腿下段穿支为血管蒂及转轴点,沿腓肠神经营养血管轴线切取皮瓣,逆行移位修复小腿下段及足踝部皮肤软组织缺损。应用腓动脉终末穿支蒂皮瓣13例,腓动脉第2穿支蒂皮瓣8例,第3穿支蒂皮瓣1例。切取皮瓣范围13 cm×12 cm~30 cm×20 cm,穿支血管蒂长1.7~3.0 cm,穿支血管蒂发出部位位于外踝上4.5~8.0 cm,血管外径1.0~1.2 mm。结果术后22例皮瓣全部成活,随访6~18个月,皮瓣外形及功能恢复满意。其中4例腓肠神经与受区感觉神经吻合,术后1年感觉恢复好,两点辨别觉为10~13 mm。结论腓动脉穿支蒂腓肠神经营养血管皮瓣手术操作简便,血供可靠,切取面积大,适用于修复小腿下段及足踝部大面积皮肤软组织缺损。     

双血管蒂腹壁下动脉穿支皮瓣在即刻乳房重建中的应用

目的 探讨双血管蒂腹壁下动脉穿支皮瓣在即刻乳房重建中的临床应用效果。方法 回顾性分析2023年5月至2023年9月收治的6例行双血管蒂腹壁下动脉穿支皮瓣即刻乳房重建患者的临床资料。患者平均年龄39.17(30～47)岁,体重指数(body mass index, BMI)22.2～26.5 kg/m²。2例患者行保留乳头乳晕的全乳切除术,4例患者行保留皮肤的全乳切除术;4例患者行腋窝淋巴结清扫术,2例患者行前哨淋巴结活检术;6例患者均行双血管蒂腹壁下动脉穿支皮瓣即刻乳房重建术。结果 切取供区皮瓣大小20 cm×10 cm～26 cm×14 cm,皮瓣厚度2.8～4.0 cm,手术时间473～690 min。6例皮瓣术后全部成活,无明显并发症出现。术后复查,6例患者均乳房外形及对称性良好,乳房质地柔软,患者满意度高。结论 使用双血管蒂腹壁下动脉穿支皮瓣即刻重建乳房,手术安全性高,术后乳房外形美容效果及乳房质地好,患者满意度较高。本术式适用于健侧乳房较大,或根治术后胸壁缺损较大,或腹壁脂肪量相对较少,或腹部有竖切口手术史的患者。     

腓动脉穿支腓肠神经营养血管远端蒂皮瓣修复足踝部软组织缺损

目的探讨腓动脉穿支腓肠神经营养血管远端蒂皮瓣修复足踝部大面积软组织缺损的临床疗效。方法采用腓动脉穿支腓肠神经营养血管远端蒂皮瓣治疗16例足踝部大面积软组织缺损患者,缺损范围17 cm×7 cm^20 cm×13 cm。切取皮瓣面积为18 cm×8 cm^21 cm×14 cm。结果术后14例皮瓣完全成活;2例皮瓣远端边缘坏死,经清创换药后愈合。患者均获得随访,时间3~12个月。皮瓣色泽、质地、血运良好,无破溃。结论腓动脉穿支腓肠神经营养血管远端蒂皮瓣不破坏小腿主干血管,同时切取皮瓣面积更大,供血可靠,是修复足踝软组织缺损的较好方法。     

带蒂穿支皮瓣临床相关应用之浅见

穿支皮瓣的概念始于20世纪80年代后期,是以管径细小的皮肤穿支血管(穿动脉和穿静脉)供血的轴型皮瓣。其特征是以穿支血管为蒂,无论其来源于肌肉还是肌间隔,术中需解剖游离出穿支血管,即直接供养皮瓣的血管蒂,而不带上深部主干血管。1989年,I Koshima 和 S Soeda 首先报道的肌皮穿支血管蒂皮瓣作吻合移植修复腹股沟部缺损和舌缺损,自此穿支血管又与吻合移植皮瓣联系紧密。     

腓动脉及穿支血管蒂皮瓣移位修复膝关节周围软组织缺损

目的 探讨应用腓动脉及穿支血管蒂皮瓣顺行移位修复膝关节软组织缺损的手术方法和临床效果.方法 2007年10月-2008年1月,收治3例车祸致膝关节周围软组织缺损患者.男2例,女1例;年龄分别为18、31、42岁.1例骨盆及股骨骨折伴胭窝部皮肤软组织缺损,骨折切开复位内固定术并膝关节清创术后2周;1例因胫骨平台骨折切开复位内固定术后皮肤坏死3周;1例胫骨平台开放骨折伴内侧髁部皮肤软组织缺损,清创外固定术后3周.皮肤软组织缺损大小分别为16 cm×9 cm、11 cm×6 cm及14 cm×7 cm.术中分离显露包含于皮瓣内的1～2支腓动脉穿支,于腓动脉穿支发出,远端结扎切断腓动脉及静脉,向近端游离腓血管至腓骨头下7～9cm,以此为旋转点,连同皮瓣向近端移位修复缺损.切取皮瓣大小分别为18 cm×10 cm、12 cm×7cm及15 cm×8 cm,血管蒂长10～17 cm.供区创口两端直接缝合,中部残留创面以游离皮片移植修复.结果 术后3例皮瓣全部成活.供区与创面均Ⅰ期愈合,植皮均成活.3例均获随访,随访时间分别为6、8及11个月.皮瓣色泽、质地良好,外形满意.根据改良HSS膝关节评分标准,膝关节功能均为优.结论 腓动脉及穿支血管蒂营养皮瓣血管蒂长,蒂部细小易移位且不易受压,血供可靠,切取范围大,外形美观,用于膝关节皮肤软组织缺损的修复临床效果满意.     

小腿远端蒂穿支皮瓣修复足踝创面的蒂部改进

目的 介绍将小腿穿支蒂皮瓣的“孤立穿支蒂”改进为“穿支筋膜皮下蒂”的手术技术,探讨改善皮瓣静脉回流、提高临床可靠性的应用效果. 方法 依据小腿后侧穿支血管的位置,设计偏心的螺旋桨样岛状皮瓣.穿支血管轴点近侧的皮瓣头部(大桨)切为筋膜皮瓣,轴点与受区创面间的皮瓣尾部(小桨)切为真皮下血管网皮瓣,至少保留穿支血管蒂一侧1/4象限的筋膜皮下组织,形成“穿支筋膜皮下蒂”.自2008年1月至2010年12月,临床应用12例,旋转180°修复足踝创面.术后观测皮瓣肿胀程度和成活及功能恢复情况. 结果 本组胫后动脉穿支7例,腓动脉穿支5例,近侧筋膜皮瓣(大桨)面积4 cm×8 cm ～6 cm×18 cm,远侧真皮下血管网皮瓣(小桨)面积2 cm×2 cm～4 cm×4 cm.术后皮瓣肿胀较轻,按顾玉东法评定,9例低于2级,2例为3级,仅最大的1例为4级,皮瓣远端有部分浅层坏死.平均随访13个月,创面治愈.患者恢复行走和穿鞋功能. 结论 采用保留部分筋膜皮下组织的穿支蒂部改进法,在增加皮瓣静脉回流通道、降低术后肿胀程度、提高临床安全性的同时,皮瓣仍能获得180°的平滑旋转,效果优良,值得推广.     

Duplex ultrasound imaging in free transverse rectus abdominis muscle, deep inferior epigastric artery perforator, and superior gluteal artery perforator flaps: early and long-term comparison of perfusion changes in free flaps following breast reconstruction

OBJECTIVE: Our objective was to assess the hemodynamic differences in free DIEP (deep inferior epigastric artery perforator flap), S-GAP (superior gluteal artery perforator flap) flaps versus TRAM (transverse rectus abdominis muscle) flaps and to analyze any perfusion change due to perforator dissection (study 1). To examine the hypothesis as to whether flap perfusion is maintained through the pedicle (study 2), we also compared short- and long-term DIEP flap perfusion. MATERIAL AND METHODS: Blood volume flow, velocity, and diameter of the donor and recipient vessels of 4 TRAM flaps, 5 S-GAP flaps, and 17 DIEP flaps were examined preoperatively on day 5 and also 18 months postoperatively using duplex ultrasound. RESULTS: The greatest volume flow and velocity are measured in the TRAM flaps, followed by S-GAP and DIEP flaps. Blood flow in the musculocutaneous and perforator flaps is twice as great as in the donor vessels, which is proof of flap hyperperfusion. SUMMARY: The minimum perfusion requirement is easily satisfied in musculocutaneus and free perforator flaps. In the long term, DIEP flap perfusion increases 13%, which assumes that DIEP flap perfusion is maintained on the pedicle.     

Pedicled superior epigastric perforator flap for reconstruction of a soft tissue defect at the ventral thoracic wall

The purpose of this paper is to present a new method of ventral chest wall reconstruction utilizing skin and fat from the abdominal wall pedicled on the superior epigastric artery and its comitant veins without sacrificing the rectus abdominis muscle. In a patient with a 13 × 15 cm left parasternal soft tissue defect of the thoracic wall, a paraumbilical perforator flap of skin and subcutaneous tissue was elevated with meticulous preparation of the perforators to the right superior epigastric vessels without sacrificing any muscle. The skin and fat island with its vascular pedicle was drawn through an epigastric subcutaneous tunnel to the ventral thorax and placed into the defect. Postoperative flap perfusion measured by laser Doppler flowmetry was excellent, abdominal wall reconstruction was easy, and 3 months after operation, the ability to perform sit-ups was as good as before the operation. In two further patients, we found the vascular anatomy to be unsuitable for this flap. The pedicled superior epigastric perforator (SEP) flap is suitable in certain cases but unreliable for reconstruction of soft tissue defects at the chest wall. Further investigations and operating experience may provide additional knowledge to allow wider and more secure use of the SEP flap.     

四维CT血管显影在腹壁下动脉穿支血管构造基础研究中的应用

目的 应用四维CT血管显影研究腹壁下动脉穿支的血管构造.方法 2008年10月至2009年5月,取10具新鲜尸体腹壁标本,在腹壁下动脉的不同水平段将造影剂欧乃派克灌注入皮瓣,包括腹壁下动脉主干、内排分支、外排分支、外排单根穿支、内排单根穿支,在灌注过程中应用四维CT进行扫描(三维CT加上时间轴称之为四维),将所获得的数据在CT工作站上进行图像重建与分析.结果 腹壁下动脉穿支在Scarpa筋膜(腹壁浅筋膜深层)浅面以及真皮下两个层次产生分支,最终走向真皮下血管网.腹壁中线两侧穿支吻合发生在真皮下血管网,较稀疏.皮瓣内血流的分布包括真皮下血管网以及已存在的血管结构2种途径.皮瓣灌注最好的区域是血管蒂同侧腹直肌的表面,其次是血管蒂同侧腹直肌的外侧,再其次是对侧腹直肌表面,灌注最差的是对侧腹直肌外侧.结论 四维CT血管显影是一种有效地研究腹壁下动脉穿支在浅筋膜内结构的方法.     

Refinements in vaginal reconstruction using rectus abdominis flaps

An improved method for vaginal reconstruction after pelvic exenteration or abdominal perineal resection is provided by the distally based rectus abdominis flap. This extended flap carries a skin paddle from the upper abdomen on the rectus abdominis muscle and deep inferior epigastric vascular pedicle. The skin paddle is inversely tubed to form a vaginal pouch and delivered transpelvically to the perineum. In addition to providing a vaginal reconstruction for sexual function, this reconstruction lessens pelvic wound complications in the exenteration patient by filling endopelvic dead space and revascularizing these frequently irradiated wounds. This method provides a neovagina with a single flap and does not involve additional donor sites in the thighs. Transpelvic passage from above not only fills endopelvic dead space better than thigh flaps, but also it allows retention of a vaginal cuff in supralevator resections. Another significant advantage of this reconstruction is its great reliability with minimal incidence of paddle loss. This flap design illustrates a type of flap refinement in which specific flaps can carry tissue from adjacent vascular territories because of anastomotic vessels between the two vascular territories, such as the vascular watershed between the deep inferior epigastric and superior epigastric vessels in this case.     

Immediate autologous breast reconstruction using muscle-sparing TRAM flaps with superficial epigastric system turbocharging: a salvage option

Current breast reconstruction trends favor the use of muscle-sparing abdominal flaps to minimize abdominal morbidity. When compared to the transverse rectus abdominis myocutaneous (TRAM) flap, the muscle-sparing deep inferior epigastric perforator (DIEP) flap and the superficial inferior epigastric artery (SIEA) flap are common options that minimize donor-site morbidity. For patients with inadequate flap perfusion via either system, alternative surgical options that permit preservation of the abdominal musculature are limited. Using both the DIEP and SIEA systems, the authors describe a turbocharged construct that also facilitates flap perfusion without the need for violation of the anterior rectus sheath. This turbocharged system can provide adequate blood supply in a flap with questionable DIEP or SIEA perfusion alone.     

下腹部横行腹直肌肌皮瓣联合腹壁下动脉穿支皮瓣乳房再造术

目的 探讨应用下腹部腹直肌肌皮瓣联合腹壁下动脉穿支皮瓣行乳房再造的手术方法，并分析其适应证。方法 以健侧腹直肌为肌蒂、患侧腹壁下动、静脉穿支为吻合血管蒂形成下腹部横行腹直肌肌皮瓣与腹壁下动脉穿支联合皮瓣，将腹壁下动、静脉与患侧胸背血管或胸廓内血管相吻合，进行乳房再造。结果 自2003年以来，于临床应用17例，所有皮瓣皆成活，随访3～12个月，再造乳房外形满意。结论 下腹部腹直肌肌皮瓣联合腹壁下动脉穿支皮瓣，具有血运可靠、提供组织量丰富、塑形自由度大、供区损伤较小等优点，尤适宜需要移植体积多以及胸廓内血管受损的乳房再造患者。     

吲哚菁绿荧光造影在背部扩张穿支皮瓣设计中的应用

目的探究吲哚菁绿荧光造影(indocyanine green angiography,ICGA)在采用扩张穿支皮瓣修复大面积缺损中的应用价值。方法回顾分析2018年10月至2019年10月,上海交通大学医学院附属第九人民医院收治的22例使用背部扩张穿支皮瓣行面颈部缺损修复的病例资料,其中,男12例,女10例,年龄4~26岁,平均19岁,均为烧伤后下面部、颈部软组织损伤患者,以背部为供区,设计单蒂或多蒂扩张穿支皮瓣进行治疗。术中切取皮瓣后保留主要穿支进行ICGA,评价穿支的血供范围,确定是否采用增压方式将皮瓣设计为多蒂皮瓣,皮瓣转移至面颈部、切口缝合后,再次行ICGA,判断皮瓣血运情况。术后统计皮瓣坏死等并发症发生情况。结果22例皮瓣平均大小27 cm×17 cm。在ICGA的指导下,15例设计为单蒂,其中5例带蒂颈浅动脉皮瓣,10例游离旋肩胛动脉穿支皮瓣;7例采用增压方式设计为多蒂皮瓣,包括2例带蒂颈浅动脉皮瓣+旋肩胛动脉穿支增压,5例游离旋肩胛动脉穿支皮瓣+胸背动脉穿支增压。术后静脉栓塞1例,重新吻合后血供恢复正常;术后1周20例皮瓣完全存活,2例尖端坏死,伤口换药后恢复。随访5~16个月,皮瓣色泽、质地均良好,面颈部功能改善。结论ICGA可作为一项安全、有效的术中检测手段,指导选择合适的穿支,判断是否采用血管增压的临床决策,优化皮瓣设计,提高手术成功率。     

Microvascular transfer of the rectus abdominis muscle and myocutaneous flap in rats

A rat microvascular free rectus myocutaneous flap model with a superior epigastric vessel pedicle is presented. The rectus muscle has a predictable ?flow-through”? axial vascular system consisting of superior and inferior epigastric vessels anastomosing under the fascial sheath, and six to seven musculocutaneous perforating branches to the skin. The superior epigastric artery and vein, averaging 0.45 mm and 0.5 mm in diameter, can be used as the vascular pedicle in muscle or myocutaneous flap transplantation. Eight muscle and 15 myocutaneous flaps were transplanted to the groin. The myocutaneous flaps averaged 3.5 cm by 1.2 cm in size; the pedicle length averaged 11 mm. The 5 day survival was 100% for muscle flaps and 67% for myocutaneous flaps. The rectus myocutaneous flap is believed to be the first true myocutaneous model in the rat. © 1993 Wiley-Liss Inc.     

Colour Doppler ultrasound evaluation of haemodynamic changes in free tram flaps and their donor sites.

Colour Doppler ultrasound (US) was used to measure the blood flow in the donor and recipient arteries as well as in the deep superior epigastric artery of 10 patients having free transverse rectus abdominis myocutaneous (TRAM) flaps. The peak, minimum and mean velocities, the diameter of the vessel, and the resistance index of both the deep superior and inferior epigastric arteries and thoracodorsal arteries were recorded preoperatively and at 4-6 and 15-30 days postoperatively. Colour Doppler US showed increased minimum velocity and decreased resistance index in the pedicle (p < 0.05) throughout the follow-up when compared with the baseline. In the ipsilateral superior epigastric artery the mean and minimum velocities increased (p < 0.05) while the resistance index decreased (p < 0.05) during the first month postoperatively. No changes were recorded in the opposite epigastric arteries or in the control vessel (opposite thoracodorsal artery). In all patients the diameter of the deep inferior epigastric artery was larger than that of the superior epigastric and remained so after the transfer. From the fourth to the thirtieth postoperative day blood flow increased in the free TRAM flap, presumably because of decreased vascular resistance. Blood flow also increased in the superior epigastic artery on the donor side after free TRAM transfer as expected (indicating the delay phenomenon), but harvesting the flap did not affect the circulation in the opposite rectus abdominis muscle. The inferior epigastric arterial system was dominant in all patients.