带皮神经血管丛的小腿筋膜皮下组织瓣

带皮神经血管丛的小腿筋膜皮下组织瓣张世民，张连生，刘大雄足部复杂创面的修复困难，常需用皮瓣覆盖。１９９２年以来，我们应用带皮神经血管丛的小腿筋膜皮下组织瓣修复足部创面，效果良好，报告如下。临床资料本组３例，男性，年龄１４～７Ｊ岁。均为足背软组织缺损，...     

以皮神经营养血管为蒂岛状皮瓣的基础研究

目的　阐述以皮神经营养血管为蒂岛状皮瓣的成活机制 ,以及它与筋膜蒂、静脉蒂岛状皮瓣三者的关系。方法　以新西兰大白兔为动物模型 ,根据以筋膜、静脉、皮神经三者相互组合为蒂 ,设计出 7组不同类型的皮瓣 ,每组 3只。应用放射性核素99mTcO-4 和99mTc -MAA来测定皮瓣的动脉供血和毛细血管静脉回流情况 ,以及与皮瓣成活的关系。结果　单纯以筋膜、静脉、皮神经为蒂的岛状皮瓣全部坏死。D组皮瓣 (蒂部组织为小隐静脉和筋膜组织 )成活率为 [(6 8.5 1± 5 .41) % , x±s ,下同 ] ,E组皮瓣(蒂部组织为小隐静脉和腓肠神经 )成活率为 (94.2 4± 3 .2 2 ) %。F组皮瓣 (蒂部组织为筋膜组织 ,含腓肠神经无小隐静脉 )成活率为 (73 .41± 6 .12 ) %。G组皮瓣 (蒂部组织为筋膜组织 ,含腓肠神经和小隐静脉 )成活率为 (98.5 4± 1.12 ) %。放射性核素99mTcO-4 检测结果 :皮神经营养血管蒂较单纯的筋膜蒂、静脉蒂有充分的动脉供血。包含浅静脉的皮瓣中 ,皮神经营养血管蒂皮瓣的99mTco-4 清除率最快。结论　神经旁组织因含有与神经伴行的营养血管 ,其分支与皮下血管网相吻合对皮瓣提供动脉供血 ;浅静脉对皮瓣提供血液回流 ,使皮瓣血液循环更为通畅。神经旁带少量 (0 .2cm)筋膜组织 ,可保证手术时蒂部神经营养血管不被破     

逆行腓肠皮神经营养血管筋膜肌皮瓣转移修复胫骨外露创面

自1992年法国Masquelet等报道表浅感觉神经主轴血管岛状皮瓣的解剖与临床应用研究以来，小腿后侧逆行腓肠皮神经营养血管筋膜皮瓣修复小腿远端或足踝软组织缺损逐渐成为临床较常选用术式。为了增加组织瓣血供，有学者在解剖学研究的基础上应用逆行腓肠筋膜肌皮瓣进行修复，获得成功。我们于2004年5月至2006年11月应用逆行腓肠皮神经营养血管筋膜肌皮瓣转移治疗胫骨外露5例，效果良好。     

皮瓣外科的研究进展

皮瓣外科在20世纪80～90年代获得了巨大发展,既有基础理论的创新,又有临床应用技术的进步。本文综述了皮瓣外科在血管体区、跨区血供、筋膜皮下组织瓣、皮神经营养血管皮瓣、逆流岛状皮瓣、远端蒂皮瓣、静脉回流、皮瓣供区处理和临床应用形式等方面的进展。     

前臂外侧皮神经营养血管皮瓣在虎口缺损中的临床应用

最近有关皮神经营养血管皮瓣的文章较多。本期有二篇采用前臂外侧皮神经营养血管皮瓣修复手部创面的文章。 皮神经营养血管皮瓣是筋膜皮瓣的特殊类型。由于皮神经是沿肢体纵轴走行，故若筋膜皮瓣带有皮神经，则必然带有皮神经营养血管。使皮神经营养血管皮瓣在纵轴方向切取范围大于一般筋膜皮瓣。但皮神经营养血管切取时。其蒂部应包含穿支血管，故有些文章又将此类皮瓣称为穿支皮瓣。穿支皮瓣是指动脉穿过深筋膜后其口径仍足以进行显微外科吻合的皮瓣。其穿支血管可以是肌间隔穿支或肌肉皮肤穿支。带蒂转移穿支皮瓣多属于肌间隔穿支皮瓣，临床应用最多的是以四肢主干动脉发出的最远侧肌间隔穿支（均在腕、踝关节上5cm左右）为血供的远端蒂皮瓣。因此，临床上在设计和切取此类皮瓣时．应同时注意皮神经营养血管和穿支血管对皮瓣的血供作用。[编者按]     

腓浅神经营养血管蒂皮瓣的解剖学及临床应用

近年来Masquelet(1992)，Morinasa(1994)，Batchelor(1995)等先后提出了小腿浅表感觉神经营养血管皮瓣的概念。Bertelli经血管铸型研究发现顺小腿皮神经纵轴存在一定数量的神经旁血管丛，其属于微细的动脉和静脉，走行之中可以进入神经内也可以远离神经。用皮神经及其周围筋膜组织为蒂的顺行或逆行岛状皮瓣修复全身各部位的皮肤软组织缺损具有血运可靠、手术简单、皮瓣感觉恢复好等优点，经临床应用效果满意。本对腓浅神经及其营养血管的解剖和临床应用作一综述。     

前臂外侧皮神经的血供特点与皮神经营养血管皮瓣的设计

目的：为临床设计带外侧皮神经营养血管筋膜皮瓣提供依据。方法：用显微解剖测量法、标本透明法研究前臂外侧皮神经外科解剖与头静脉的关系以及其神经血管皮肤穿支的位置、长度、对皮神经的营养形式等。结果：前臂外侧皮神经共有４支神经血管皮肤穿支,其全程由神经旁血管和主要动脉共同营养。前臂外侧皮神经前支与头静脉紧密伴行。结论：顺沿头静脉,可切取带外侧皮神经营养血管筋膜蒂或血管神经蒂岛状皮瓣,用于修复肘部、前臂远端１／３段和腕部等部位软组织缺损。     

带血管蒂组织瓣移位的历史、现状与展望

皮瓣外科的发展历史，在20世纪50年代以前，主要是带蒂转移的随意型皮瓣；50—60年代出现了肌瓣和轴型皮瓣；70年代随着显微外科组织移植的开展，吻合血管的游离皮瓣、肌皮瓣和肌骨皮瓣等获得了发展；80年代以来，皮瓣外科硕果纷呈，既有科学理论的进展，又有临床应用技术的进步，相继开发了主干动脉皮瓣、逆行岛状皮瓣、远端蒂皮瓣、筋膜皮瓣、肌间隔血管皮瓣、静脉皮瓣、真皮下血管网皮瓣、皮神经浅静脉营养血管皮瓣、穿支皮瓣等。其中我国在世界上最早报道或独自报道的皮瓣有10多个。在此期间带血管蒂皮瓣转移术，因其不需吻合血管，手术操作简便、安全、成功率高，已成为皮瓣移位最主要的方法，临床应用范围也日益扩大，理论也逐渐形成，并相继出版了《带血管蒂皮瓣肌皮瓣转移术》（孙弘，侯春林1988年）、《带血管蒂组织瓣移位术》（杨志明1988年）、《带血管蒂组织瓣移位手术图解》（侯春林1992年）、《筋膜瓣与筋膜蒂组织瓣》（侯春林，张世民2000年）及《皮瓣外科学》（侯春林，顾玉东2006年）。     

前臂外侧皮神经的血供特点与皮神经营养血管皮瓣的设计

目的：为临床设计带外侧皮神经营养血管筋膜皮瓣提供依据。方法：用显微解剖测量法、标本透明法研究前臂外侧皮神经外科解剖与头静脉的关系及其神经血管皮肤穿支的位置、长度、对皮神经的营养形式等。结果：前臂外侧皮神经共有４支神经血管皮肤穿点，其全程由神经旁血管和主要动脉共同营养。前臂外侧皮神经前支与头静脉紧密伴行。结论：顺沿头静脉，可切聚带外侧皮神经营养血管筋蒂或血管神经蒂岛状皮瓣，用于修复肘部、前臂远端１／     

筋膜瓣营养甲床回植治疗甲床剥脱

大面积甲床剥脱,临床可用皮瓣修复,各有利弊。筋膜瓣、皮下组织瓣和筋膜皮下组织瓣是在1981年Ponten首先介绍筋膜皮瓣的基础上发展起来的[1]。2003年2月至2005年5月我院应用筋膜瓣营养甲床回植治疗大面积甲床剥脱6例,效果满意,报道如下。1资料与方法     

股前外侧组织瓣临床应用112例分析

目的 总结分析股前外侧组织瓣解剖规律及其在组织缺损修复重建中的适应证和应用价值。方法1985年3月-2004年8月，对112例股前外侧组织瓣移植进行临床总结。其中男67例，女45例。年龄5～65岁，平均38．5岁。针对受区不同情况，将股前外侧组织瓣切取分为4类：吻合血管的游离皮瓣移植78例；吻合血管的游离脂肪筋膜瓣移植22例；带蒂顺行岛状皮瓣移位5例；远端为蒂逆行岛状皮瓣移位7例。对面、颈、肢体、躯干等部位的软组织缺损所致功能障碍或外观缺陷进行修复，并对术后效果和供区恢复情况进行评价。结果营养股前外侧组织瓣的动脉皮支出现率100％，具有肌间隙皮穿支（33％）和肌皮穿支（67％）两种基本解剖类型。组织瓣源血管均为旋股外侧动脉降支或横支。皮瓣移植成活107例，成活率达95．6％。术后33例获随访6个月～11年，远期随访效果满意率91％，供区无功能受限。结论股前外侧组织瓣解剖恒定，具有多种突出优点，是修复软组织缺损的理想材料。尤其是穿支皮瓣形式，可保持受区形态，降低供区损伤，成为应用趋势。     

A dye study in fresh cadavers to outline retrograde flaps of the lower limbs and to examine clinical implications

The reconstruction of distal lower limb defects to meet functional and cosmetic requirements is challenging. The aim of this study was to ascertain the safe hemodynamic territory of various retrograde flaps that are frequently used. We carried out a dye study on both lower limbs of ten fresh cadavers using methylene blue to assess the safe limit of retrograde flaps of different types (i.e., fasciocutaneous flap, adipofascial flap, and fasciocutaneous flap with adipofascial extension) based on the two lower perforators of the posterior tibial artery. The dye penetrated the vascular network up to 20 cm in the fasciocutaneous flaps from a point 8 cm proximal to the tip of the medial malleolus. The extent of the dye was 40 and 20% less in adipofascial flaps and fasciocutaneous flaps with adipofascial extension, respectively, compared to fasciocutaneous flaps. In live subjects, the safe territory is expected to be about 2 cm more in each flap, based on our clinical observations. These findings are of significance since such flaps can be safely selected for various defects depending on their location, their dimensions, and the availability of suitable local tissues.     

Distally based radial forearm flap with preservation of the radial artery: anatomic,experimental, and clinical studies

In this article we report on the anatomical, experimental, and clinical investigations of the distally adipofascial pedicled radial forearm flap based on the small perforators around the radial styloid process. There are about 10 small perforators (0.3-0.5 mm in diameter) from the distal radial artery around the radial styloid process. The longitudinal chain-linked vascular plexuses (suprafascial, paraneural, and perivenous) formed by the forearm ascending and descending branches of septofasciocutaneous perforators meet and cross over with the transverse carpal vascular plexuses around the radial styloid region. Based on these directional-oriented plexuses, distally based adipofascial pedicled radial forearm fasciocutaneous and adipofascial flaps were designed and successfully applied in 34 clinical cases. The pivot point was located at 1-2 cm above the radial styloid. The skin island plus adipofascial pedicle measured between 9-18 cm in length, with the adipofascial pedicle 3-4 cm in width. The length-to-width ratio is 3-5:1. The venous drainage of this distally based flap was investigated anatomically and experimentally. The cephalic vein has no positive role for venous drainage in distally based flaps. The difference between distally based flaps and reverse-flow flaps, clinical selection of fasciocutaneous and adipofascial flaps, advantages and disadvantages, and technical tips for operative success are discussed.     

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。     

Perforator plus flaps: Optimizing results while preserving function and esthesis

Background:

The tenuous blood supply of traditional flaps for wound cover combined with collateral damage by sacrifice of functional muscle, truncal vessels, or nerves has been the bane of reconstructive procedures. The concept of perforator plus flaps employs dual vascular supply to flaps. By safeguarding perforators along with supply from its base, robust flaps can be raised in diverse situations. This is achieved while limiting collateral damage and preserving nerves, vessels, and functioning muscle with better function and aesthesis.

Materials and Methods:

The perforator plus concept was applied in seven different clinical situations. Functional muscle and fasciocutaneous flaps were employed in five and adipofascial flaps in two cases, primarily involving lower extremity defects and back. Adipofascial perforator plus flaps were employed to provide cover for tibial fracture in one patients and chronic venous ulcer in another.

Results:

All flaps survived without any loss and provided long-term stable cover, both over soft tissue and bone. Functional preservation was achieved in all cases where muscle flaps were employed with no clinical evidence of loss of power. There was no sensory loss or significant oedema in or distal to the flap in both cases where neurovascular continuity was preserved during flap elevation. Fracture union and consolidation were satisfactory. One patient had minimal graft loss over fascia which required application of stored grafts with subsequent take. No patient required re-operation.

Conclusions:

Perforator plus concept is holistic and applicable to most flap types in varied situations. It permits the exercise of many locoregional flap options while limiting collateral functional damage. Aesthetic considerations are also addressed while raising adipofascial flaps because of no appreciable donor defects. With quick operating times and low failure risk, these flaps can be a better substitute to traditional flaps and at times even free tissue transfers.     

以上肢浅表皮神经伴行血管为蒂的岛状皮瓣的解剖学研究

对上肢浅表皮神经及其伴行血管与皮肤血供的关系进行显微解剖学研究后,设计出以上肢浅表皮神经伴行血管为蒂的岛状皮瓣。方法:新鲜成人上肢标本22侧,从肱动脉灌注红色乳胶后,对上肢浅表皮神经及伴行血管进行显微解剖。结果:(1)所有上肢皮神经都有来源于上肢知名血管的营养血管伴行。(2)与上肢浅表皮神经的伴行血管既营养神经,同时沿途又发出分支营养皮肤。(3)皮神经的伴行血管穿出深筋膜的部位有一定的规律性。结论;(1)上肢浅表皮神经的伴行血管为蒂的岛状皮瓣血供可靠,静脉回流充分,并可形成逆行蒂或顺行蒂岛状皮瓣。(2)以第2、3掌背皮神经伴行血管为蒂的岛状皮瓣,神经行走变异较多,伴行血管不稳定,临床选用时须慎重考虑。     

A new concept of vascular supply to the skin and classification of skin flaps according to their vascularization

The success of fasciocutaneous flaps is based on the existence of epifascial vascular networks and reliable blood supply. However, there has been no thorough classification of the vascular anatomy of the fascia and skin and there is some confusion in regard to cutaneous vascular nomenclature. We divide the vascular systems involved in the cutaneous circulation into four categories. This permits classification of skin flaps into five types (cutaneous, fasciocutaneous, adipofascial, septocutaneous, and musculocutaneous flaps). Fasciocutaneous flaps can be further divided into six types, according to the patterns of the vascular input to the fasciocutaneous plexus. This classification has been demonstrated to be related to clinical effects. Nine new free and island flaps are discussed.     

手及前臂皮神经营养血管蒂皮瓣的应用解剖

目的：观察手及前臂皮神经营养血管的情况，为设计以皮神经及其营养血管为蒂的岛状皮瓣提供形态学依据。方法：用红色氯仿油画染料灌注的20侧成人上肢标本，在手术显微镜下解剖并观测手及前臂 5条皮神经营养血管的来源、数目、外径，穿出深筋膜的位置，与皮神经及浅静脉的关系等项目。结果；营养动脉多以降支方式伴行在皮神经深面内侧，前臂皮神经的血管网可达神经两侧各2．5cm范围内的皮肤，5条皮神经的营养动脉外径接近，结论：手及前臂皮神经的营养血管血供可靠，可设计相应部位的岛状皮瓣。     

四肢筋膜蒂皮瓣改良手术的临床应用

目的对四肢筋膜蒂皮瓣手术方法进行改良及总结,进一步提高疗效。方法1999年2月～2005年12月,应用筋膜蒂皮瓣修复四肢皮肤、软组织缺损58例。男39例,女19例;年龄10～68岁,平均30岁。21例小腿中下段胫前皮肤缺损,12例足跟部皮肤缺损,16例踝关节皮肤缺损,3例膝关节周围皮肤缺损,1例骶尾部巨大褥疮,5例手腕背部皮肤缺损。创面范围5cm×3cm～18cm×12cm。根据创面不同采取四肢不同部位筋膜蒂皮瓣修复创面,其中4例前臂内侧皮神经、贵要静脉筋膜蒂皮瓣,1例前臂外侧皮神经、头静脉筋膜蒂皮瓣,3例顺行带隐神经、大隐静脉的筋膜蒂皮瓣,1例左大腿股后皮神经筋膜蒂皮瓣,32例带腓肠神经、小隐静脉逆行筋膜蒂皮瓣,17例带隐神经、大隐静脉筋膜蒂皮瓣。皮瓣范围6cm×4cm～18cm×13cm。供区创面39例直接缝合,19例取大腿或下腹部全厚皮片6cm×3cm～13cm×6cm植皮修复。结果术后16例皮瓣肿胀、淤血,经远端小切口切开放血3～5d,其中12例皮瓣成活,创面期愈合;4例远端皮缘部分坏死,经再次手术清创植皮后成活。余患者皮瓣均成活,创面期愈合。供区创面期愈合,植皮成活。58例患者均获随访1～20个月,平均8个月。皮瓣色泽正常,质地柔软,外形和功能满意。结论四肢筋膜蒂皮瓣是修复四肢皮肤、软组织缺损的理想治疗方法,通过手术方法的改良,可使皮瓣成活率进一步提高。     

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。