游离腓动脉远端穿支腓肠神经营养血管皮瓣修复上肢皮肤缺损

目的 介绍游离腓动脉远端穿支腓肠神经营养血管皮瓣修复上肢皮肤缺损的手术方法.方法 2006年6月-2007年8月,应用游离腓动脉远端穿支腓肠神经营养血管筋膜蒂皮瓣修复上肢皮肤缺损6例,其中缝合皮神经4例.结果 术后6例皮瓣全部存活.随访时间为4个月至1.5年.皮瓣与供区皮肤外观基本一致,厚薄适中,弹性、质地好,外观满意;4例缝合皮神经的皮瓣感觉恢复至S2以上,余2例皮瓣恢复保护性感觉.结论 游离腓动脉远端穿支腓肠神经营养血管皮瓣是修复上肢软组织缺损的有效方法.     

Caveats of Local Fasciocutaneous Flaps for Distal Leg Defects—Anatomical Study and Clinical Application

The present trend for the management of distal leg defects is to opt for a free flap with local flaps being relegated to the backseat. We studied the perforator anatomy of the distal leg in the Indian population to see if there were any ethnic differences and then correlated it with a clinical study of local flaps used for the coverage of distal leg defects. A prospective observational study was carried out in 2 phases—anatomical study and clinical study from December 2018 to March 2020. In the anatomical study, 8 fresh cadavers, i.e., 16 lower limbs were dissected and the perforator anatomy in the distal leg was identified. In the clinical study, all patients undergoing local, pedicled fasciocutaneous flap cover for defects involving distal third leg were included with ages between 15 and 60 years. In the anatomical study, posterior tibial artery perforators in the distal-most part were found as a group of up to 3 perforators. In the clinical study, a total of 47 patients were included with a mean age of 38.0 ± 10.9 (range 17-55) years and female:male ratio being 1:2.6. The largest defect size was 120 cm² (mean 28.2 ± 23.8 [range 6-120] cm²) and the most commonly used flap was the reverse sural artery flap in 20 (42.6%) cases. Overall, complications were seen in 7 (14.9%) cases and there was no case of flap failure. Thus, local flaps are an excellent option for coverage of distal leg defects and offer results comparable to free flaps.     

The 'propeller' distal anteromedial thigh perforator flap. Anatomic study and clinical applications.

BACKGROUND: The leg and peripatellar region have always been known as a poor source of available flaps. One flap donor site that has proven to be adequate is the distal anteromedial half of the thigh. Due to the potential and plentiful vascular sources of this anatomic region we decided to study the distal anteromedial thigh and its clinical applications. ANATOMIC STUDY: Sixteen cryopreserved inferior limbs were latex-injected in the femoral artery and the skin perforators of the distal anteromedial thigh and their source vessels were studied. CLINICAL STUDY: In a period between December 2000 and June 2005, skin islands from the distal anteromedial aspect of the thigh of six patients were transferred, as local perforator flaps, to reconstruct the peripatellar region and upper leg soft tissue defects. Every flap was based on a single adequate perforator vessel. The tissue was rotated, as a 'propeller', through 180 degrees and the flap was named 'the propeller distal anteromedial thigh perforator flap'. RESULTS: In the distal anteromedial thigh the anatomic variability includes not only perforator vessels but also their source vessels. Skin perforators can come from each of the deep vessels. Our clinical results, with a follow up of 1-4 years, show no total flap losses. Partial necrosis > 20% happened in one diabetic patient. CONCLUSION: The propeller distal anteromedial thigh perforator flap can be reliably transferred based on only one adequate perforator vessel. It reduces the morbidity and improves the availability of the distal anteromedial thigh as a flap donor site and represents an additional reconstructive option for knee and upper leg defects.     

邻近非主干血管蒂(肌)皮瓣转移修复小腿中下段软组织缺损

目的探讨以邻近非主干血管为蒂皮瓣转移修复小腿中下段皮肤缺损的优化选择。方法分析42例病例，应用4种邻近非主干血管为蒂皮瓣进行修复。小腿中下段软组织缺损周围皮肤条件良好者，选择邻近的逆行腓肠神经、隐神经营养血管皮瓣或腓肠肌皮瓣；如周围皮肤有较轻损伤，用腓肠肌皮瓣；皮肤缺损范围大者，组合逆行腓肠神经营养血管皮瓣与肌瓣或腓肠肌皮瓣；创面较小，选用比目鱼肌肌瓣或腓骨短肌瓣。结果所有病例随访6～12个月，成活37例，5例远端少部分坏死，2例局部皮瓣转移修复，1例肌瓣转移，2例肉芽组织生长后植皮修复。结论邻近非主干血管为蒂皮瓣转移修复小腿中下段皮肤缺损是最佳修复方式，不同的术式可满足各种创面的要求。     

选择性利用游离皮瓣修复手、腕部软组织缺损

目的探讨多种游离皮瓣精细修复手、腕部软组织缺损的临床效果。方法针对手腕部软组织的缺损面积及形状等特点,对比分析皮瓣部位的质地、纹理,选取与手腕部相近似的5种游离皮瓣进行精细修复187例。修复方式：足底内侧动脉穿支皮瓣修复手掌及大鱼肌处软组织缺损49例．小腿后侧皮瓣修复全手掌侧软组织缺损46例,小腿外侧皮瓣修复手背软组织缺损42例,足背皮瓣修复手背软组织缺损伴伸肌腱缺损42例,髂腹股沟皮瓣修复手腕部软组织缺损8例。结果本组187例中185例皮瓣顺利成活,2例皮瓣远端少量坏死,经植皮后愈合。随访187例,随访时间6个月～3年,皮瓣质地良好,无明显臃肿,两点辨别觉6～9mm,手部经功能康复训练后,优96例,良71例。可20例,功能恢复满意。结论根据创面缺损形状与大小,选择不同游离皮瓣修复手、腕部软组织缺损,能达到精细修复目的．大大地提高了手功能。     

Lappenplastiken zur Defektdeckung am distalen Unterschenkel

Soft tissue defects in the distal lower leg region are challenging to treat, especially in trauma cases. To achieve early closure of the defect, pediculated adipofascial or muscle flaps can be used as well as free flaps. The pediculated adipofascial suralis flap has a reliable blood supply and a broad radius so this flap can be used for almost every defect location on the distal lower leg except for defects larger than 10?×?10 cm. The donor site defect does not lead to major problems and is well tolerated. The soleus flap can cover defects in the middle third and proximal distal third of the lower leg with its muscle. The donor site defect is occasionally associated with reduced calf functioning but is tolerated well most of the time. Because of these advantages, the pediculated adipofacial suralis flap and the soleus muscle flap can be used instead a microvascular free flap for the closure of defects in the distal lower leg region.     

Perforator Propeller Flap “Relay” for Distal Lower Extremity Soft Tissue Reconstruction

The peroneal artery perforator propeller flap is commonly used for distal lower extremity reconstruction; however, closure of the donor site defect can limit the utility of this flap. To overcome this limitation, we introduced a perforator propeller flap relay technique to reconstruct the donor-site defect. Between July 2015 and February 2019, the propeller flap relay technique was applied in 9 patients. In each case, a peroneal artery perforator propeller flap was transferred to repair a defect in the distal lower leg or the foot. In addition, a neighboring perforator propeller flap was transferred to close the donor-site defect. The peroneal artery perforator propeller flaps ranged from 14 × 4 to 29 × 8 cm² in size. Donor-site closure was accomplished using the relaying propeller flaps based on perforators from the peroneal, medial sural, and lateral sural arteries. Normal contour of the lower leg was preserved with acceptable scars. Additional time for the second flap procedure was less than 1 hour in each case. One peroneal artery perforator flap presented with partial flap necrosis. Other flaps survived completely without complication. Coverage of the donor-site defects of the peroneal artery perforator flaps can be achieved using various perforator propeller flaps. The perforator propeller flap relay technique allows surgeons to harvest a large peroneal artery perforator flap without being limited by significant donor-site morbidity. This technique can reconstruct defects at distal lower extremity with low morbidity and improved overall reconstructive results.     

前足皮肤缺损的皮瓣修复

目的总结不同类型皮瓣修复前足部皮肤缺损的疗效。方法根据前足皮肤缺损的部位,采用不同类型的外科皮瓣修复50例,其中交腿皮瓣2例,带蒂逆行岛状皮瓣20例,吻合血管的游离皮瓣28例。结果除3例带蒂逆行岛状皮瓣远端部分坏死,行植皮创面愈合外,其余皮瓣全部成活。创面一期愈合47例,二期愈合3例;术后皮瓣整形17例。随访6个月～2年,足部功能及外形恢复较满意。结论根据足部皮肤缺损的部位、面积大小及周围组织条件．选择不同娄型外科皮瓣修兔创面．可获得满意效果．     

游离胸背动脉穿支皮瓣桥式移植修复小腿软组织缺损

目的总结游离胸背动脉穿支皮瓣或肌瓣桥式移植修复小腿软组织缺损的临床应用效果。方法自2006年9月至2009年1月,应用游离胸背动脉穿支皮瓣或肌瓣桥式移植修复小腿软组织缺损11例,缺损范围4cm×8cm至8cm×22cm。皮瓣切取连带肩胛下与旋肩胛血管,血管蒂呈T形,与健侧小腿胫后动脉行端端吻合,血管蒂用中厚网状游离植皮覆盖。结果除1例术后皮瓣远端发生小的表浅感染,经换药后愈合外,本组皮瓣全部成活。术后随访9个月至3.6年(平均2.9年),没有发现明显的供区功能障碍,供区与受区外形较好,健侧小腿经临床观察与Doppler检查,胫后动脉通畅。结论本方法适用于修复四肢软组织缺损后,患者仅存1条主要动脉者;行桥式游离胸背动脉穿支皮瓣或肌瓣移植不损伤健侧小腿胫后动脉,降低了对供区的损伤。     

以旋股外侧动脉降支供血的游离组织瓣修复小腿软组织缺损

目的 探讨以旋股外侧动脉降支逆行转位供血的游离组织瓣修复严重的小腿创伤伴软组织缺损的临床效果.方法 对小腿软组织损伤严重且无可携带游离组织瓣的血管,以旋股外侧动脉降支的远端为蒂,将其近端与游离组织瓣的动脉吻接,大隐静脉或小隐静脉与游离组织瓣的动脉伴行静脉吻接,2004年10月至2009年12月,采用该方法修复小腿软组织缺损36例,其中携带背阔肌肌皮瓣15例,股前外侧皮瓣12例,胸脐皮瓣9例.结果 36例游离皮瓣(肌皮瓣)均顺利成活,无一例出现血管危象,随访6个月至2.5年,皮瓣外形及功能恢复均较满意.结论 在小腿无可供吻合的血管时,应用以旋股外侧动脉降支逆行转位供血的游离组织瓣修复小腿软组织缺损,是一种切实有效的手术方法.

Abstract：

Objective To investigate the therapeutic effect of free tissue flap anastomosed with reverse descendant branch of lateral femoral circumflex artery for severe soft tissue defect at leg. Methods The severe soft tissue defect at leg, without any vessels for anastomosis of free tissue flap, was reconstructed with free tissue flap, which was anastomosed with proximal end of descendant branch of lateral femoral circumflex artery and great saphenous vein. From Oct. 2004 to Dec. 2009, 36 cases were treated with 15 cases of latissimus dorsi musculocutaneous flaps, 12 cases of anterolateral femoral flaps,and 9 cases of thoracoumbilicus flaps. Results All the 36 free flaps survived completely. The patients were followed up for 6 months to 2. 5 years with good cosmetic results. Conclusions It is effective and practical to repair the severe soft tissue defects at legs with the reverse descendant branch of lateral femoral circumflex artery to carry the free flaps.     

吻合血管的足内侧穿支皮瓣的应用解剖与临床应用

目的 研究足内侧穿支皮瓣的应用解剖及修复手部软组织缺损的临床效果.方法 10侧成人足踝标本经胴动脉注入红色乳胶液,解剖观测足底内侧动脉穿支血管在足内侧区的分布、起源等.临床设计吻合血管的足内侧穿支皮瓣修复手部软组织缺损11例,软组织缺损面积2 cm×2 cm～9cm×4 cm.结果 足底内侧动脉向<足母>展肌和趾短屈肌肌间隙内发出2支相对恒定的足底内侧皮穿支,供养足底内侧皮瓣;向<足母>展肌和舟楔骨间隙内发出2支相对恒定的足内侧皮穿支,供养足内侧皮瓣.11例足内侧穿支皮瓣完全成活,皮瓣面积2 cm×3 cm～11 cm×5 cm.随访6～24个月,皮瓣质地优良,外形与功能恢复满意,供区愈合良好.结论 以足内侧穿支血管营养的足内侧穿支皮瓣血供可靠,质地优良,是修复手部软组织缺损的良好选择.     

Reverse sural artery flap: caveats for success

Complex open wounds of the distal third of the leg and ankle remain a reconstructive challenge for the plastic surgeon. In many cases, these wounds are best addressed with a free tissue transfer. Although this group has performed more than 400 free flaps to the leg during the past 6 years, free tissue transfer can be an arduous operation that requires a team approach and substantial donor site morbidity for the patient. In recent years, the authors have favored the reverse sural artery fasciocutaneous flap in 11 patients for its ease of dissection, limited morbidity, and preservation of major vessels to the limb. Caveats for successful performance of the reverse sural artery flap include Doppler evidence of patent peroneal perforators, placement of a lazy T-shape skin paddle over the distal gastrocnemius muscle bellies, inclusion of the lesser saphenous vein to augment venous drainage, and, lastly, careful dissection to provide a wide adipofascial pedicle.     

The Distally Pedicled Peroneus Brevis Muscle Flap Anatomic Studies and Clinical Applications

Defects in the distal third of the lower leg with bone or tendon exposure may require local or free flap reconstruction. For small and moderate lesions, the distally pedicled peroneus brevis muscle flap may be an effective procedure with less morbidity than a free tissue transfer. Six cadaveric specimens were dissected to determine the location of distal pedicles and the flap type. This flap was found to be a Type IV flap, and the location of distal pedicle was always located within 6 cm from the fibula tip. This flap was performed on 6 patients to cover defects in the distal third of the lower leg. The defect areas were the pretibial region in 2 cases, the lateral malleolus in 3 cases, and the Achilles tendon in 1 case. The peroneus brevis muscle was detached from the uppermost point of the fibula to obtain enough length to cover the defect. All flaps survived except 1 that experienced distal flap necrosis. Minor complications included skin graft failure in 2 cases. However, the final results demonstrated a smooth contour that eliminated dead space. Limited donor site morbidity was obtained in all cases. The distally peroneus brevis muscle flap therefore offers an alternative for reconstructive surgeons dealing with soft tissue defects of the lower leg.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.