股前外侧区穿支动脉的形态学研究及皮瓣设计

目的探讨以旋股外侧动脉降支为蒂的皮瓣设计方法，以便增加术前多普勒定位的准确性。方法6具动脉灌注明胶-氧化铅混悬液的新鲜成人整尸标本，解剖观测股前外侧区穿支，通过血管造影术和拍摄X线片测量其直径、行程、分支和定位。用3D—doctor和Scion Image软件分别测量穿支供血的趋向性、三维重建和单穿支供血面积。结果股前外侧区共有外径大于0．5mm穿支16支，平均外径0．8mm，平均供血面积45．61cm^2，其中20％为肌间隙穿支，80％为肌皮穿支。平均蒂长为（3．15±1．43）cm。自旋股外侧动脉降支发出的穿支在浅筋膜中的平均长度为2．63cm。结论改良的氧化铅-明胶灌注技术可以为皮动脉和穿支皮瓣的研究提供高质量的血管造影图像。本研究发现股前外侧单穿支皮瓣的最大供血面积是30cm×20cm。以股前外侧区穿支设计的穿支皮瓣可以移植到下肢或身体其他部位。     

股前外侧皮瓣远侧肌皮穿支的解剖学研究与临床应用

目的 研究供养股前外侧皮瓣的远侧肌皮穿支的解剖特征及其在股前外侧皮瓣移植中的应用价值.方法 2007年7月至2009年12月,对10例新鲜尸体及96例应用股前外侧皮瓣修复创面病例的远侧肌皮支进行解剖学观察.临床应用股前外侧远侧肌皮穿支皮瓣修复四肢软组织缺损35例,男19例,女16例;年龄28～55岁,平均38.5岁;单瓣20例,分叶皮瓣15例.单瓣切取面积7 cm×15cm～9 cm×25 cm,分叶皮瓣切取面积5 cm×7 cm～8 cm×20 cm.皮瓣切取时间1～1.5 h.结果 组织瓣移植全部成活32例,部分性坏死3例.术后随访6～11个月,平均7.8个月.1例患者术后早期主诉膝关节不稳定感,术后6个月改善.尸体解剖研究发现:位于髂前上棘与髌骨外上缘连线远1/4段内的皮支均以肌皮穿支的形式出现,肌皮支穿出部位靠近股外侧肌前内缘,不超过肌肉横径1/2,一般在肌肉横径的1/3以内;远侧肌皮支主要来源于旋股外侧血管降支,1例2侧来源于股动脉,1例2侧来源于股深动脉穿支.临床解剖观察发现:94例出现2～5个远侧肌皮穿支,2例无远侧肌皮穿支,其主干旋股外侧动脉降支变异为直接肌皮支,近端有肌间隔肌皮支出现.结论 远侧肌皮穿支相对恒定,可以作为股前外侧皮瓣近侧肌皮支缺如病例的替代血管,也是实现分叶皮瓣移植的解剖基础.

Abstract：

Objective To investigate the anatomical characteristics and clinical application of the distal musculocutaneous perforators derived from the descending branch of lateral circumflex femoral artery in the anterolateral thigh flap transplantation. Methods From July 2007 to December 2009, the anatomic variations of musculocutaneous perforator were investigated in 96 cases who received anterolateral thigh flap and 10 preserved cadavers. Thirty-five cases who received the anterolateral thigh flap using the distal musculocutaneous perforators were included in the study. There were 19 males and 16 females. The age ranged from 28-55 years old, with an average of 38.5 years old. Single flap was used in 20 cases while lobulated flap in 15 cases. Single flap area ranged from 7 cm×15 cm to 9 cm×25 cm, lobulated flap ranged from 5 cm×7 cm to 8 cm×20 cm. Results The cadaver study found that the most musculocutaneous perforators were concentrated in the far fourth of the anterolateral thigh region. The musculocutaneous perforators commonly arose from the the lateral femoral circumflex artery. The perforator arose directly from the femoral artery or the deep femoral artery in one case separately. In the clinical study, 2-5 musculocutaneous perforators were found in 94 cases but not in the other 2 cases. The descending branch of lateral circumflex femoral artery became the direct m musculocutaneous perforator. The proximal intermuscularseptum perforator was found in 2 cases. Postoperative follow-up time ranged from 6-11 months. All flaps survived in the follow-up.Marginal necrosis was found in 3 cases. Only 1 case had complained of knee joint instability. Conclusion The results of this study suggest that the vascular anatomy of the distal musculocutaneous perforator was reliable. The perforator may serve as an option for proximal one in anterolateral thigh flap transplantation.     

Free anterolateral thigh flap raised on musculocutaneous perforators of rectus femoris muscle

The anterolateral thigh flap (ALTF) has been in wide clinical use for the last two decades, its major disadvantage has been its variable anatomy. We are presenting a case in which no substantial perforators were found to be arising from either the lateral septum of thigh or Vastus Laterlis muscle. In this case, instead of raising another flap, we used the same skin paddle raised on the musculocutaneous perforators of rectus femoris muscle.     

Preoperative assessment of anterolateral thigh flap cutaneous perforators by colour Doppler flowmetry.

An anterolateral thigh flap is very useful in head and neck reconstruction because of its long and large-caliber vascular pedicle, large skin territory and elevation simultaneous with tumour resection. However, the number and locations of cutaneous perforators vary individually, and thus, it is not widely used because flap elevation is often complicated and time-consuming owing to unexpected anatomical variations. To overcome this disadvantage, we assessed the number and locations of cutaneous perforators preoperatively by colour Doppler flowmetry. These data were compared with the intraoperative anatomical findings and their reliability evaluated. A total of 48 cutaneous perforators were found by preoperative colour Doppler flowmetry scanning of 17 anterolateral thigh flaps. All the perforators except two were found intraoperatively. Doppler scanning failed to detect four perforators. Colour Doppler flowmetry assessment therefore has a 92% true-positive rate and a 95.8% positive predictive value. All the flaps except one included multiple perforators, and sufficient blood circulation was observed in all cases. No flaps were unexpectedly changed to anteromedial thigh flaps or contralateral anterolateral thigh flaps because of inappropriate cutaneous perforators or the absence of perforators. Though this investigation is relatively time-consuming (30-40 min) and requires skill, it is very useful for preoperative flap planning and increases the reliability and safety of elevating an anterolateral thigh flap.     

股前外侧皮瓣穿支动脉定位方法的研究及临床应用

目的 探讨运用多普勒声波血流探测仪在股前外侧皮瓣(ALT)术前穿支动脉定位方法的改进,检测ABC法是否适用于中国人群.方法 参考ABC法对50例(100侧)健康成年志愿者双侧股前外侧区进行多普勒体表探测,记录探及的所有体表声波点坐标,运用统计学及数学方法分别分析声波点的分布规律,并分析体质量指数(BMI)与穿支分布规律之间的相关性.将总结的规律运用于5例临床接受ALT皮瓣手术患者,验证其临床价值,同时了解多普勒探测的准确性.结果 所有穿支点的总体分布接近于y轴(即髂-髌线)附近,以外侧1.0cm范围内分布最多,平均位于外侧约0.5cm处,穿支B与A、C之间的垂直距离平均在4.0cm左右(4.2cm);在髂-髌线中点水平及中点下方约4.0cm水平上穿支分布最为密集.本组临床患者探测准确率40%(6/15),错误率20%(3/15),探测误差平均1.34cm,在临床可接受的范围内;穿支B与A、C之间的垂直距离接近上述多普勒探测研究结果.本组患者BMI与穿支体表分布规律及探测误差之间的相关性均较差.结论 ABC法用于我国人群时应修改为:以髂-髌线中点外侧0.5cm处为B点,B点远、近端各4.0cm处分别为A点和C点;设计皮瓣时,无论多普勒探测结果如何,都应保证B点周围3.0cm范围及B点至其下方4.0cm之间区域被包括在皮瓣切取范围内.     

Anatomical variability of the anterolateral thigh flap perforators between sexes: a cadaveric study

Background

Anterolateral thigh flap (ALTF) has gain popularity as a workhorse flap in the management of simple as well as complex tissue defects. The purpose of this study was to investigate the differences in ALTF’s perforators’ location in male and female human cadavers.

Methods

The study involved 30 fresh human cadavers of both sexes. A total of 60 flaps were examined. The flaps were raised as originally designed. After location of vessels, the distance from the anterior superior iliac spine (ASIS) to subsequent perforators was measured. Also, the kind of the perforator, its diameter and origin were marked. Perforators were designated according to Yu’s classification (A, B, and C). The perforators were divided into thin (<0.5 mm), medium (0.5–1 mm), and thick (>1 mm). Ratio of the ASIS–patella distance to the distance of a given perforator from the ASIS (AP rate) was calculated.

Results

The mean AP rate (perforator location) was different in both sexes. Mean AP rate in men was calculated as 0.498 ± 0.117, and in women, 0.559 ± 0.114. Differences in AP rate between female and male were statistically significant (t = ?3.144; p < 0.002). Mean flap thickness was 3.65 cm in women and 1.17 cm in men (t = ?14.444; p < 0.00001). In men, 63 perforators originated from descending branch, and seven perforators originated from oblique branch. In women, there were 67 and one, respectively.

Conclusions

In men, perforators are located closer to the ASIS in comparison to women. Clinically significant perforators (Φ > 0.5 mm), in majority of cases, occur in A and B positions. Thickness of the flap was higher in women. The oblique branch was more common in men.     

Anatomical variations in the harvest of anterolateral thigh flap perforators: a cadaveric and clinical study

Background: The anterolateral thigh (ALT) flap has become increasingly popular due to its versatility and minimal donor site morbidity. Its major limitation has been uncertainty in predicting perforator anatomy, with the occasional absence of suitable perforators and high variability in their size and course. The variability of this anatomy has not been adequately explored previously. Methods: A cadaveric study was undertaken, in which 19 thighs (from 10 fresh cadavers) underwent contrast injection and angiographic imaging. Anatomical variations of the vasculature were recorded. A clinical study of 44 patients undergoing ALT flap reconstruction was also undertaken. Perforator anatomy was described in the first 32 patients, and the subsequent 12 patients underwent computed tomography angiography with a view to predicting individual anatomy and improving operative outcome. Results: Cadaver angiography was able to highlight and classify the variations in arterial anatomy, with four patterns observed and marked variability between cases. In 32 patients undergoing ALT flaps without preoperative CT angiography (CTA), five patients (16%) did not have any suitable perforators from the descending branch of the lateral circumflex femoral artery. By selecting the limb of choice with preoperative CTA, the incidence of flap unsuitability was reduced to 0%. Comparing CTA with Doppler, CTA was more accurate (sensitivity 100%) and provided more information. Conclusion: The perforators supplying the ALT flap show significant variability in location and course, with the potential for unsuitable perforators limiting flap success. Preoperative CTA can demonstrate the vascular anatomy and can aid perforator selection and operative success. © 2008 Wiley‐Liss, Inc. Microsurgery, 2009. [This is a corrected version of the abstract first published online on 22 October 2008 — the corrected version appears in print.]     

Lateral circumflex femoral arterial system and perforators of the anterolateral thigh flap: an anatomic study

The authors performed an anatomic study on 16 thighs of 11 fresh white cadavers at the Ludwig-Maximilian University of Munchen, Germany. They analyzed the anatomic pattern and caliber of both the lateral circumflex femoral arterial system and the perforators nourishing the anterolateral thigh flap. They found regularly a majority of musculocutaneous perforators, mainly in the central third of the thigh, arising from the descending branch of the lateral circumflex femoral artery. Despite the small number of cadavers, they identified several differences in the anatomy of the lateral circumflex femoral arterial system. These variabilities, especially regarding the descending branch and its perforators, could have clinical importance. They also suggest new dissection studies by comparing white and oriental anatomy. Their aim is to establish whether any difference in the variability of the lateral circumflex femoral arterial system could increase the popularity, currently greater in Eastern Europe, of the anterolateral thigh flap.     

The preexpanded anterolateral thigh free flap

The anterolateral thigh flap has many of the attributes of the ideal soft-tissue flap. However, a major detriment is the potential conspicuous donor site deformity, especially if skin grafted. In elective situations, preexpansion of the lateral thigh with subsequent transfer of even a wide anterolateral thigh flap can permit primary donor site closure and avoidance of a skin graft. This has been achieved successfully in 2 compliant patients, and is a reasonable solution to minimize the morbidity of this otherwise important donor site.     

Free anterolateral thigh flap in pediatric patients

The anterolateral thigh (ALT) flap represents a workhorse flap in reconstructive surgery. We describe our clinical experience with this flap in the pediatric population. A total of 20 patients with an average age of 9.5 years underwent a free ALT flap reconstruction. All flaps were commonly raised on 2 perforators. About 5 flaps were employed for head and neck reconstruction, 7 for upper and 8 for lower limb reconstruction. Traumatic defects and congenital malformations represented the predominant etiology. Sizable perforators were found in all patients. The caliber was smaller compared to adults, and the course of the perforator was shorter. There were no complete flap losses and no significant donor-site morbidity. Donor-site closure required closure with split-thickness skin grafts in 6 cases. Hypertrophic scars developed in 4 patients. Secondary procedures included flap debulking (5) and Z-plasties (2). In conclusion, children have well-developed perforators supplying the ALT flap. With proper technique, this flap can be harvested and employed safely and reliably for reconstruction of varied defects in children.     

股前外侧复合组织瓣的解剖研究

目的：探究股前外侧复合组织瓣的三维血管解剖分布。方法：10具新鲜尸体和10具防腐尸体，共40例成人下肢标本，30例经股动脉内灌注氧化铅-明胶混合液，10例经旋股外侧动脉灌注中国墨汁。获取旋股外例血管在皮肤，皮下组织、肌肉和骨的分布数据。结果：本组经股动脉内灌注氧化铅-明胶混合液的30例股外侧肌标本均属Ⅱ型，即含1个优势血管和2～3个次要血管。其优势动脉起自旋股外侧动脉横支和降支，2～3个次要血管起自股深动脉的第二、三穿动脉。优势动脉和次要动脉之间存在广泛的血管吻合，旋股外侧血管横支及降支均发出骨膜支，分布于股骨骨膜上。结论：旋股外侧血管区域供应三维的皮肤，皮下组织、肌肉和骨，为临床切取股前外侧复合组织瓣提供理论基础。     

First web-space reconstruction by the anterolateral thigh flap

Four patients with severe contracture of the first web space were treated with an anterolateral thigh perforator flap. The flap size ranged from 10 to 13 cm in length and from 7 to 8 cm in width. The donor site was closed directly and thinning of the flap was performed in all cases. All flaps survived and there were no re-explorations. Web space opening was maintained over the follow-up period. There was an average postoperative increase of the angle of the first web space of 61 degrees. The thinned anterolateral thigh flap provides a pliable vascularized tissue for resurfacing the skin after release of severe contracture of the first web space and represents a reliable alternative to other flaps.