显微外科皮瓣修复[足母]甲瓣供区的临床应用

目的探讨应用显微外科皮瓣对[足母]甲瓣供区进行修复的临床疗效,并对皮瓣选择做出分析。方法应用5种近位足部带蒂皮瓣和2种远位游离皮瓣对57例[足母]甲瓣供区软组织缺损进行修复。其中近位带蒂皮瓣33例:带蒂足跗外侧动脉皮瓣2例,以第1跖背动脉的跖蹼穿支为蒂的足背逆行皮瓣15例,带第1跖背动脉的足背逆行皮瓣3例,顺行足第2趾胫侧皮瓣11例,逆行足底内侧皮瓣2例,足部皮瓣供区行全厚皮片游离植皮。远位游离皮瓣24例:游离腹股沟皮瓣13例,游离股前外侧皮瓣11例。皮瓣供区均直接缝合。结果57例皮瓣中53例成活良好;以第1跖背动脉的跖蹼穿支为蒂的足背逆行皮瓣3例远端部分坏死,经换药治疗后创面愈合;游离腹股沟皮瓣1例术后发生血管危象,经血管探查术后未缓解,Ⅱ期行游离植皮修复[足母]甲瓣供区创面。术后随访2~12个月,行走姿态良好。结论合适的显微皮瓣技术可以良好的修复[足母]甲瓣供区创面,保全肢体的完整性,减少医源性损伤,患者更容易接受[足母]甲瓣移植的手术方式。皮瓣选择不应只关注[足母]趾供区的修复,更应合理运用显微皮瓣技术,重视供、受区的平衡。     

五个组织瓣组合移植修复全手脱套伤伴五指缺损

目的　探讨用双足供区 5个组织瓣的组合移植 ,修复全手脱套伤伴 5指缺损的优缺点。方法　 1999年 7月 ,为 1例患者设计并应用了该新术式。 ( 1)患侧供足 :设计并切取以足背动脉为蒂的携带甲瓣的足背皮瓣 ,修复手背、虎口及重建拇指。足背动静脉与桡动静脉吻合 ,大隐静脉与头静脉吻合。切取以第一、二趾足底总动脉为蒂的第二足趾游离移植再造示指。第二足趾的桡侧趾足底固有动脉通过血管桥接与足背皮瓣的足底深支作串联吻合 ;尺侧趾足底固有动脉与另一组足内侧皮瓣的足底深支作串联吻合 ;趾静脉与足背皮瓣远端及前臂背侧浅静脉吻合。 ( 2 )健侧供足 :设计并切取以足背动脉为蒂的携带第二足趾的足内侧皮瓣 ,修复手掌、虎口及重建中指。足背动静脉与尺动静脉吻合 ,大隐静脉与前臂内侧浅静脉吻合。足背创面用中厚皮片植皮。结果　 5个移植组织瓣全部成活。术后随访 2个多月 ,虎口大小基本同健侧 ,再造拇指对指、掌侧外展功能基本恢复。重建 3指的痛觉开始恢复。足部活动时无不适感。结论　该术式是修复全手脱套伤伴 5指缺损方法中最新最佳的一种方法     

足部动脉系统解剖学研究与以跖底动脉为蒂足部组织游离移植术

目的寻求一种更为安全、有效的足部组织游离移植再造拇、手指及关节功能的新方法,进一步提高手术成功率。方法对足部跖底与跖背动脉系统进行显微解剖学研究。设计并应用逆行游离、吻合跖底动脉的足部组织游离移植术治疗76例拇、手指及手部关节缺损患者,其中第二足趾移植58例,第二足趾复合组织移植4例,近侧趾间关节移植8例,(?)甲瓣移植6例。分析总结其疗效。结果第一跖底动脉解剖恒定,到第二足趾的分支粗于第一跖背动脉。75例患者全部成活,移植部位外观良好,功能明显改进,总成活率为98．7%。另1例行第二足趾游离移植再造拇指术患者因顽固性动脉痉挛而改用锁骨下皮管包埋。结论应用逆行游离跖底动脉为蒂的足部组织游离移植术可以克服其它方法存在的血管解剖变异较大、操作复杂、费时等不足,提高了手术效率和成功率。     

足部游离组织瓣移植修复手部相应组织缺损的疗效

目的 总结足部组织瓣移植修复手部相应组织缺损的临床效果。方法 应用足部游离组织瓣（９种类型）种植修复手部组织缺损１３１例。（１）拇及手指缺损７１例：用第二足趾移植４２例,Ｍｕ甲皮瓣２６例,部分第二足趾移植３例再造手指、拇指;（２）手背及手掌皮肤缺损及虎口挛缩４３例：应用足背皮瓣１２例,足底内侧皮瓣７例,趾腹皮瓣６例及第二趾蹼皮瓣１８例修复皮肤缺工开大虎口;（３）掌骨或掌指关节缺损１７例：选用第一跖趾关节皮瓣修复１２例,第二跖骨皮瓣修复５例。结果 ６例失败,１２５例组织瓣成活,成活率为９５．３％。手部功能恢复较为满意,１０例足部供区出现瘢痕不愈或步行时疼痛等并发症。结论 选择足部相应部位组织瓣修复手部组织缺损,特别是复合性组织缺损,效果满意。但仍可存在一定的失败率及造成足部区部分功能丧失。     

Foot and ankle reconstruction: An experience on the use of 14 different flaps in 226 cases

The aim of this report was to present our experience on the use of different flaps for soft tissue reconstruction of the foot and ankle. From 2007 to 2012, the soft tissue defects of traumatic injuries of the foot and ankle were reconstructed using 14 different flaps in 226 cases (162 male and 64 female). There were 62 pedicled flaps and 164 free flaps used in reconstruction. The pedicled flaps included sural flap, saphenous flap, dorsal pedal neurocutaneous flap, pedicled peroneal artery perforator flap, pedicled tibial artery perforator flap, and medial plantar flap. The free flaps were latissimus musculocutaneous flap, anterolateral thigh musculocutaneous flap, groin flap, lateral arm flap, anterolateral thigh perforator flap, peroneal artery perforator flap, thoracdorsal artery perforator flap, medial arm perforator flap. The sensory nerve coaptation was not performed for all of flaps. One hundred and ninety‐four cases were combined with open fractures. One hundred and sixty‐two cases had tendon. Among 164 free flaps, 8 flaps were completely lost, in which the defects were managed by the secondary procedures. Among the 57 flaps for plantar foot coverage (25 pedicled flaps and 32 free flaps), ulcers were developed in 5 pedicled flaps and 6 free flaps after weight bearing, and infection was found in 14 flaps. The donor site complications were seen in 3 cases with the free anterolateral thigh perforator flap transfer. All of limbs were preserved and the patients regained walking and daily activities. All of patients except for one regained protective sensation from 3 to 12 months postoperatively. Our experience showed that the sural flap and saphenous flap could be good options for the coverage of the defects at malleolus, dorsal hindfoot and midfoot. Plantar foot, forefoot and large size defects could be reconstructed with free anterolateral thigh perforator flap. For the infected wounds with dead spce, the free latissimus dorsi musculocutaneous flap remained to be the optimal choice. © 2013 Wiley Periodicals, Inc. Microsurgery 33:600–604, 2013.     

趾部游离皮瓣修复指腹缺损的临床应用

目的 总结应用趾部游离皮瓣修复手指指腹缺损的临床效果.方法 对手指指腹缺损采用第一足趾腓侧或第二足趾胫侧游离皮瓣修复25例,皮瓣切取面积大小为2.0 cm×3.0 cm～3.5 cm×4.5cm,进行趾底动脉.指固有动脉,皮下静脉-指背静脉吻合重建皮瓣血液循环,趾底神经-指同有神经重建感觉.结果 25例皮瓣全部成活,术后出现血管危象2例,行手术探查后重新吻合血管成活,3个月后行皮瓣整形手术12例.术后随访2个月～2年,平均10个月,手指功能与外观均满意,指腹饱满,感觉及运动恢复正常,两点辨别觉为4～6 mm.结论 应用趾部游离皮瓣修复手指指腹缺损可获较好的临床效果.     

Anatomical Differences Between Foot and Hand Web Space Reconstruction

The differences in the anatomy of the foot and the hand may affect the dorsal flap design for web space reconstruction. In this study, the authors aimed to identify the differences in web space anatomy of the foot and the hand and provide a guideline of flap design for web space reconstruction in the foot and the hand. The right hands and right feet of adult volunteers were measured, including surgical landmarks (i.e., the dorsal prominence of proximal interphalangeal and metacarpophalangeal joints [or metatarsophalangeal joints]), proximal phalangeal length, tip of the web space, and width of web space. The web spaces and other parameters were analyzed and compared between the foot and the hand by using a paired t test with p < .05 to indicate statistical significance. A total of 108 web spaces of the foot and hand from 18 adult volunteers were analyzed. The parameters that were significantly different between the foot and the hand included (1) proximal phalangeal length (34.63 vs 60.16 mm), (2) average web height ratio (0.72 vs 0.51), (3) average web width ratio (0.69 vs 0.81), (4) mean slope angle (4.89° vs 19.26°), and (5) average abduction angle (25.33° vs 31.07°). In conclusion, the foot web space had a higher slope angle, less abduction angle, and shorter proximal phalangeal length. Therefore, the flap design for foot web space reconstruction requires a longer and narrower flap than the design for the hand. The recommended flap design length should be at least 72% of proximal phalangeal length for the foot versus 51% for the hand, and the width should be at least 69% of the distance between the tips of adjacent metatarsophalangeal joints for the foot versus 81% for the hand.     

跗外侧动脉皮瓣移植修复手足皮肤缺损

目的探讨跗外侧动脉皮瓣移植修复手足部皮肤缺损的临床效果。方法在足背外侧设计以足背动脉为蒂的跗外侧动脉皮支穿出点为中心的逆行皮瓣修复手足部皮肤缺损,皮瓣的足背外侧皮神经在足部与跖底神经吻合,手部动脉与桡动脉浅支吻合,神经与桡神经浅支吻合,足外侧供区用腹股沟全厚皮打包植皮。结果手术时间:带蒂皮瓣转移85～240min,平均160min;游离皮瓣185～425min,平均430min。术后51例皮瓣全部成活。35例随访8～36个月,平均19个月,跗外侧动脉皮瓣及植皮全部成活,感觉、外形良好,不需要二期整形。结论跗外侧动脉皮瓣逆行转移修复手足部皮肤缺损,皮瓣薄、有神经支配、解剖位置恒定。     

第一趾蹼处三叶皮瓣治疗多手指屈曲畸形

目的 介绍应用第一趾蹼处三叶皮瓣治疗多手指屈曲畸形的临床效果。方法 对5例11指屈曲畸形的患者，应用第一趾蹼处拇趾腓侧皮瓣、第二趾趾腹皮瓣及跖底皮瓣组成的三叶皮瓣进行修复。皮瓣以第一跖背或跖底动脉为主干，带跖背静脉，与患指掌侧总动脉或掌浅弓及掌背静脉吻合。结果 术后皮瓣全部存活。4例获得6个月～2年随访，1例失访。4例9指伸直位，手指伸屈功能良好，皮瓣饱满，质地及外形好。皮瓣两点分辨觉为5～7mm。足部供区有瘢痕，行走无影响。结论 第一趾蹼处三叶皮瓣是修复相邻2～3指严重瘢痕增生或手指严重屈曲畸形矫形术后掌侧软组织缺损的理想皮瓣之一。     

拇趾甲皮瓣及尺动脉腕上皮支下行支皮瓣瓦合并髂骨植骨再造拇指末节缺损

目的探讨拇趾甲皮瓣及尺动脉腕上皮支下行支皮瓣瓦合并髂骨植骨再造拇指末节缺损的临床疗效。方法对7例拇指末节缺损患者分别采用吻合血管拇趾甲皮瓣修复拇指背侧皮肤及指甲缺损、尺动脉腕上皮支下行支皮瓣修复拇指末节掌侧皮肤缺损、末节指骨缺损取髂骨移植。拇趾甲皮瓣供区采用游离植皮5例,同侧第2趾胫侧方皮瓣顺行覆盖2例;尺动脉腕上皮支下行支皮瓣供区均直接缝合。结果 7例拇趾甲皮瓣及尺动脉腕上皮支下行支皮瓣均顺利成活,伤口一期愈合。其中1例拇趾甲皮瓣供区植皮出现部分坏死,经换药后愈合。末节植骨愈合时间为8~11周,平均10周。去除内固定物后行规律功能锻炼。所有患者获随访6~15个月,平均8个月,移植组织成活及拇指指甲生长良好,指腹皮瓣两点辨别觉为8~10 mm(平均9 mm);足部供区皮瓣及植皮无破溃,足部功能未受影响。结论采用拇趾甲皮瓣及尺动脉腕上皮支下行支皮瓣瓦合并髂骨植骨再造拇指末节能较好地恢复拇指外形及功能,是一种较好的临床治疗方法。     

逆行第一跖背动脉岛状皮瓣修复(足母)趾腓侧游离皮瓣供区创面

目的应用逆行第1跖背动脉岛状皮瓣修复趾腓侧游离皮瓣的供区,为减少显微外科供区损伤提供新方法。方法2000年2月至2004年6月,对12例拇指及其他手指软组织缺损,采用趾腓侧游离皮瓣移植修复。根据第1跖背动脉和跖底动脉在跖趾关节处存在恒定的交通支的解剖学基础,切取逆行第1跖背动脉岛状皮瓣修复趾供区创面,足背供区直接缝合。结果12例趾腓侧游离皮瓣和逆行第1跖背动脉岛状皮瓣移植全部成活,平均随访10个月,皮瓣外观和功能恢复良好。趾腓侧游离皮瓣平均两点辨别觉为6mm,逆行第1跖背动脉皮瓣为10mm。结论在趾腓侧游离皮瓣移植修复拇指或其他手指软组织损伤的同时,应用逆行第1跖背动脉岛状皮瓣完善修复趾供区创面,达到了＂双赢＂的手术目的。     

The first dorsal metacarpal artery neurovascular island flap

A first dorsal metacarpal artery island flap from the index finger was used in 20 cases for reconstruction of defects in the hand. In six cases it was used as a neurovascular flap for sensory resurfacing of the thumb and in five cases for release of a contracted first web. One flap underwent necrosis and there was a complication in one donor site.     

Microvascular soft tissue reconstruction of the digits.

INTRODUCTION: Composite tissue loss to digits following trauma may require flap coverage. Local reconstruction techniques are popular but can result in a functional limitation at the donor site. Small free flaps though complex, may provide a superior alternative. METHOD: We retrospectively reviewed the case-notes of all patients who had a small free flap to a digit following trauma. The time period was 4 years (2000-2004). Sixteen patients with 18 digital free flaps were identified. These comprised of 10 venous flow-through flaps, one lateral arm flap, one great toe to thumb pulp transfer, three first web space flaps from the foot, one medial plantar flap and two free posterior interosseous flaps. All 16 patients were invited for clinical review at an out-patients clinic. Ten patients (11 flaps) attended follow-up. Standardised assessment of outcome in terms of scar quality at both the recipient and donor sites, sensibility, range of motion and function of the hand was completed. RESULTS: Overall the average follow-up period was 14 months, with 16 out of 18 flaps surviving. Of the patients that attended for clinical review, the majority recovered excellent function of the hand (quick-DASH--av. 5.7) with satisfactory aesthetics, minimal pain or limitations in range of motion. The flaps were all soft and durable. Ten flaps recovered protective but not discriminative sensation (only one flap was innervated). The three patients whose donor site was the first-web space of the foot developed significant hypertrophic scarring. CONCLUSION: Small free flaps provide an acceptable method of reconstructing digital defects. Venous flow-through flaps provided the best overall results in this series. The donor site for first-web space flaps is probably unacceptable.     

手指再造手术中砪甲瓣供区的修复

目的 探讨手指再造手术中砪甲瓣供区的修复方法。 方法 从1998年12月至2010年12月,共修复砪甲瓣供区511例,分别应用足背皮瓣32例、第1跖背皮瓣24例、第2跖背皮瓣21例、踝前皮瓣14例、跗内侧皮瓣17例、跗外侧皮瓣79例、跖底皮瓣106例、第2趾皮瓣79例、小腿中下段皮瓣15例以及游离皮瓣124例。 结果 皮瓣成活良好,术后经过6个月～11年随访,见皮瓣质地良好,外形满意,砪趾活动及负重行走、跑跳等皆不受影响。 结论 砪甲瓣供区的修复方法较多,各有优缺点,以跖底皮瓣及游离腹股沟皮瓣为优。     

Extremity reconstruction using the "fillet of sole" flap

Foot skin can be used in traumatic nonreplantable leg amputations as an immediate neurovascular free flap for proximal stump reconstruction. The thick, glabrous skin on the sole of the foot provides durable, sensate coverage. The flap is large, avoids a secondary donor site, and can survive on either the dorsalis pedis or posterior tibial artery if one preserves the connecting deep plantar branch of the dorsalis pedis artery. Two cases of immediate stump reconstruction using the "fillet of sole" flap are presented.     

游离胫后动脉穿支皮瓣修复手、足背皮肤缺损

目的 探讨游离胫后动脉穿支皮瓣修复手、足背皮肤缺损的方法与疗效.方法 自胫骨粗隆平面至内外踝连线等分成6段,在近端第2、3段胫骨内缘设计皮瓣,切取胫后动脉穿支皮瓣,并携带2～3束隐神经,游离移植修复手、足背皮肤缺损,缺损面积:3.0cm×7.5 cm～6.0 cm×12.0 cm.结果 2009年1月至2010年12月,临床应用11例,皮瓣完全成活.随访3～10个月,皮瓣质地柔软,色泽红润,两点辨距觉达7～10 mm,小腿供区只存留较小的线状切口瘢痕,功能及外形均较满意.结论 胫后动脉穿支皮瓣不损伤胫后动脉主干,皮瓣薄且供区相对隐蔽,感觉可部分或全部恢复,是修复手、足背皮肤缺损的较理想术式.     

Reverse-flow first dorsal metacarpal artery flap for index fingertip reconstruction

Dorsum of the hand is an ideal skin-flap donor site for coverage of hand or finger defects. We elevated 8 reverse-flow first dorsal metacarpal artery flap in 9 patients for soft-tissue cover of index fingertip injuries distal to distal interphalangeal joint with exposed bone. In 3 patients, the digital branch of the superficial radial nerve was coapted to the digital nerve. All flaps healed uneventfully, except for 1 patient in which partial necrosis of the flap occurred. Postoperative follow-up was 4-12 months (mean, 8 months). Reverse-flow first dorsal metacarpal artery flap is a good alternative for reconstruction of index fingertip injuries.     

Innervated free flaps for foot reconstruction: a review

Whether to provide a sensate plantar weight-bearing flap to reconstruct the foot remains an unanswered, but frequently asked, question. It has been more than a decade since Graham and Dellon reviewed this subject. Increasing emphasis on outcome analysis of microsurgical reconstruction has prompted this new review. All published peer-reviewed literature related to reconstruction of the plantar surface of the foot was reviewed to identify whether the flaps were 1) local, regional or distant; 2) innervated or non-innervated and, if innervated, then 3) identified as to the donor and the recipient peripheral nerves. Outcome measures included direct measurement of sensibility, development of ulceration, and activities of daily living. It was concluded that it is still not possible to determine that innervated flap reconstruction of the weight-bearing portion of the foot is critical for either durability or ambulation. It is recommended that the original nerves that innervate the flap be blocked prior to harvest to improve flap design, i.e., that the flap actually contains the intended nerve. It is recommended that appropriate donor nerves are selected to innervate the flaps, e.g., the calcaneal nerve should be used to reinnervate heel reconstructions (rather than the sural nerve), and medial/lateral plantar branches be used to reinnervate the arch and the forefoot. Reinnervating a muscle flap with a sensory nerve will permit reinnervation of the muscle and the overlying skin, but whether this provides a superior result in durability and gait remains to be seen.     

足部皮瓣治疗多指指背复合组织缺损

目的 介绍足部皮瓣治疗多指指背复合组织缺损的临床应用.方法 临床应用7例19指,均为2～4指指背复合组织缺损伤,并伴有伸肌腱缺损及指骨或指间关节外露,并指后指背创面大小为5.0 cm×1.5 cm～9.0 cm×2.5 cm.以(足母)趾腓侧、跖侧界线及第一、二跖骨间隙为轴线设计皮瓣,形状同并指后指背创面,面积稍大.皮瓣切取时携带大隐静脉、趾背静脉和第一跖背、跖底动脉及神经,分别与相应患指指背静脉及指固有动脉、神经吻合.保留趾短或趾长伸肌腱于皮瓣内,以修复指背缺失的伸肌腱.结果 术后皮瓣全部存活,皮瓣质地及外形好,皮瓣两点分辨觉为6～8mm.患指伸指功能得到重建,主、被动屈伸活动恢复满意.足部供区瘢痕轻微,功能良好,外形美观.结论 足背、趾蹼及(足母)趾腓侧复合皮瓣是治疗多指指背复合组织缺损较好的方案之一.     

足背动脉内侧筋膜支为蒂的足内侧皮瓣移植

目的报道足背动脉内侧筋膜支为蒂的足内侧皮瓣的设计及临床应用结果。方法对足内侧区皮肤筋膜血供的进一步观测,发现足背动脉内侧筋膜支恒定,为该区的重要血供来源。据此设计了可达10cm×8cm 的足内侧皮瓣。临床用于修复足背、踝部、前足、小腿下端及手部软组织缺损18例。结果术后皮瓣全部成活,效果良好,供区损害轻。结论足背动脉内侧筋膜分支是足内侧皮瓣的可靠血管蒂。该皮瓣是修复足背、踝部、小腿下端及前足软组织缺损的一种理想的组织瓣。