胫后动脉穿支皮瓣修复踝部软组织缺损

目的：探讨胫后动脉穿支皮瓣的临床应用疗效。方法采用胫后动脉穿支皮瓣以螺旋桨式旋转修复或以滑行推进的方式修复内踝软组织缺损6例,前踝软组织缺损3例,足跟后侧的软组织缺损13例。结果22例移植组织成活21例,1例皮瓣尖端坏死,经换药二期植皮后成活,成活率95.5%。术后经3～20个月随访,皮瓣外观、质地良好,痛温觉有一定的恢复。结论胫后动脉穿支皮瓣是修复内踝、前踝、足跟后侧软组织缺损的较佳方法。     

急诊修复拇指指腹缺损三种方法的研究

目的 报道采用不同方法急诊修复拇指指腹缺损的疗效。方法 采用示指背侧岛状皮瓣，拇指桡侧指动脉逆行岛状皮瓣转位有趾腹皮瓣游离移植三种方法，为21例线指指腹缺损进行急诊修复。结果 20例以瓣成活，1例失败。术后随访半年－2年，平均10个月。所有皮瓣血运，弹性，质地均良好。指腹二点分辨觉：示指背侧岛状皮瓣平均为92.mm，拇指桡侧动脉逆行岛状皮瓣平均为8mm，趾腹皮瓣平均为5.6mm。结论 急诊修复拇指指腹缺损首选趾腹皮瓣，其次为拇指桡侧指动脉逆行岛状皮瓣或示指背侧岛状皮瓣。     

Topographical anatomy of the anconeus muscle for use as a free flap

A small triangular anconeus muscle in the depth of the elbow is a continuation of the triceps brachii muscle and takes part in extension of the forearm. It is utilized clinically by certain surgeons as a muscle pedicle flap to cover defects around the elbow. However, there has been no report of an anconeus muscle free flap. This study provides the detailed anatomy of the anconeus muscle to encourage a safer utilization of it as a free flap. Thirty-four cadaveric upper extremities were treated by injections of colored latex, lead oxide, and methylene blue into the axillary artery. The average size of the muscle was 73.11 +/- 10.32 mm x 27.39 +/- 3.29 mm and the total area was 2002.48 +/- 33.95 mm2. The muscle received its blood supply from three sources: recurrent posterior interosseous artery, medial collateral artery, and posterior branch of the radial collateral artery. The recurrent posterior interosseous artery was constantly present. Its average outer diameter was 1.11 +/- 0.32 mm and its average length was 29.05 +/- 9.29 mm. The anconeus muscle free flap is large enough to cover a defect of 25.65 cm2 in either the hand or forearm, and the recurrent posterior interosseous artery and venae comitantes are suitable for microvascular anastomosis.     

Redefining the vascular anatomy of the peroneus brevis muscle flap

The peroneus brevis flap can be used as either proximally or distally based flap for coverage of small to medium‐sized defects in the lower leg. The purpose of this study was to clarify the vascular anatomy of the peroneus brevis muscle. An anatomical dissection was performed on 17 fixed adult cadaver lower legs. Altogether, 87 segmental branches (mean 5.1 ± 1.6 per leg) either from the fibular or anterior tibial artery to the muscle were identified. Sixty‐two were branches from the fibular artery (mean 3.4 ± 1.1 per fibular artery), whereas 25 (mean 1.4 ± 0.9 per anterior tibial artery) originated from the anterior tibial artery. The distance between the most distal vascular branch and the malleolar tip averaged 4.3 ± 0.6 cm. An axial vascular bundle to the muscle could be identified in all cadavers; in one leg two axial supplying vessels were found. Their average length was 5.5 ± 2.4 cm and the average arterial diameter was 1.1 ± 0.5 mm, the average venous diameter was 1.54 ± 0.7 mm. The constant blood supply to the peroneus brevis muscle by segmental branches from the fibular and tibial artery make this muscle a viable option for proximally or distally pedicled flap transfer. The location of the most proximal and distal branches to the muscle and conclusively the pivot points for flap transfer could be determined. Furthermore, a constant proximal axial vascular pedicle to the muscle may enlarge the clinical applications. Perfusion studies should be conducted to confirm these findings. © 2014 Wiley Periodicals, Inc. Microsurgery 35:39–44, 2015.     

The free fascio-peritoneal flap: an anatomical study

The blood supply of the periumbilical posterior rectus fascia and peritoneum was studied in 60 hemiabdomens on 30 fresh human cadavers. An umbilical peritoneal vascular pedicle deriving from the deep inferior epigastric artery was present in 95% of the specimens with a mean length of 6.5 cm and 15 cm including the deep inferior epigastric artery pedicle. The mean pedicle diameter was 1.5 mm (artery) or 2 mm (veins). The surface of the free fascio-peritoneal flap measures on average 15×8 cm. This thin flap is a good alternative for fascial coverage of exposed tendons and intraoral reconstruction, and if necessary the rectus abdominis muscle and a skin paddle can be included as a composite flap.     

远端蒂皮瓣或逆行岛状皮瓣转移术蒂部减张皮瓣的设计与应用

目的 探讨在远端蒂皮瓣或逆行岛状皮瓣蒂部设计减张皮瓣的可行性和临床应用效果.方法 临床应用胫后动脉内踝上皮支逆行岛状皮瓣修复9例,胫后动脉小腿内侧穿支远端蒂皮瓣修复2例,腓动脉外踝上皮穿支逆行岛状皮瓣修复8例,腓浅神经营养血管逆行岛状皮瓣修复4例,远端蒂腓肠神经营养血管皮瓣修复3例,掌背筋膜蒂逆行岛状皮瓣修复2例.蒂部减张瓣呈梭形或圆形,面积为1.0 am×1.0 cm～5.0 cm×3.5 cm.结果 28例皮瓣术后血运良好,无肿胀、淤血,全部成活,随访皮瓣质地良好,外形美观,供区均一期愈合,疗效满意.结论 在远端蒂皮瓣或逆行岛状皮瓣蒂部设计减张皮瓣是可行的.可有效地防止蒂部血管受压或血管网破坏而影响皮瓣的血运,是一种可靠的预防远端蒂皮瓣或逆行岛状皮瓣血供障碍的新方法.     

Free microvascular transfer of the acromiotrapezius osteomuscular flap in rats.

The acromiotrapezius-scapular spine osteomuscular flap is a new osteomuscular research model for use in microvascular free tissue transfer in rats. We performed anatomical studies to collect data on muscle weight, dimension, vessel calibre and bone size in 20 flaps. This flap has a triangular shape with an average size of 38 x 39 x 32 mm and an average weight of 1.25 g; the scapular spine of 20 mm in average length can be harvested with the flap. The pedicle can be taken in continuity with the cervical trunk (average diameter of artery and vein were 0.5 mm and 0.6mm, respectively, with an average pedicle length of 12 mm). The flap was harvested and transferred to the groin area of the same rat and anastomosed to the superficial epigastric vessels. Fifteen transplantations were performed and the 7-day flap survival was 93.3%. The acromiotrapezius flap is believed to be a new and reliable osteomuscular model in the rat.     

Free posterior tibial perforator flap: Anatomy and a report of 6 cases

Anatomy of cutaneous perforators of the posterior tibial artery were studied in 20 limbs of 10 cadavers. The majority of the perforators (n = 74, 61%) were located in the middle two quarters of the leg, at an average of 18.6 cm (s.d. 4.5 cm; range 10.5–26 cm) from the medial malleolus, or around 54% (s.d 16%) of the length of the leg. There were usually 3 or 4 perforators in this region, with an average caliber of 1.5 mm (s.d. 0.2 mm; range 1–2 m.m.) and an average length from the posterior tibial artery to the skin of 4.0 cm (s.d. 1.3 cm; range 2.5–6 c.m.). A free fasciocutaneous skin flap based on one of these perforators (the posterior tibial perforator flap, PTP flap) was successfully transplanted in 6 cases. This modified technique of the posterior tibial flap enables the surgeon to retain the posterior tibial artery when the skin of the medial aspect of the leg is chosen to be used as skin flap donor © 1997 Wiley-Liss, Inc MICROSURGERY 17:503–511 1996     

隐神经-大隐静脉营养血管与逆行胫后动脉皮支蒂复合瓣在足跟部瘢痕修复中的应用

目的：探讨应用隐神经-大隐静脉营养血管与逆行胫后动脉皮支蒂复合瓣修复足跟部瘢痕的疗效。方法：应用隐神经-大隐静脉营养血管与逆行胫后动脉皮支为蒂的复合瓣修复足跟部瘢痕共11例。设计的皮瓣面积为6cm×8cm～9cm×16cm。结果：11例患者皮瓣全部成活,创面Ⅰ期愈合,术后随访患者3～24个月,均取得满意效果。结论：隐神经一大隐静脉营养血管与逆行胫后动脉皮支蒂复合瓣相对较长,血供可靠,皮瓣可切取面积大,是修复足跟部瘢痕的理想皮瓣。     

Use of the medial adipofascial flap of the leg for coverage of full-thickness burns exposing the tibial crest

Bone exposure constitutes a frequent and difficult problem in burn patients. Where free flaps remain indicated in tibial osteomyelitis, a pedicled fascial or adipofascial flap provides an excellent alternative for coverage of simple tibial crest exposure. In fact, the adipofascial tissue of the anteromedial aspect of the leg can be mobilized over the whole length of the tibia. It is vascularized by the saphenous artery and the posterior tibial artery perforators. This pattern of blood supply allows a wide range of use for any size of burn defect in this area. Therefore, this local pedicled flap provides an excellent solution for coverage of the exposed tibia after severe burns.     

Reconstruction of recurrent pressure sores using free flaps.

The authors describe two successful reconstructions of recurrent pressure sores with free fasciocutaneous flaps. In Case 1, a free lateral thigh flap pedicled on the first and third direct cutaneous branches of the deep femoral vessels was used to cover a large recurrent sacral pressure sore. The vascular pedicle was dissected to the deep femoral trunk proximally and anastomosed to the inferior gluteal vessels. In Case 2, a free medial plantar flap was transferred to a recurrent ischial pressure sore. The vascular pedicle was dissected to the posterior tibial vessels proximally. The long vascular pedicle of the flap was passed through the femoral subcutaneous tunnel, and end-to-side microvascular anastomoses were performed to the superficial femoral trunk without any vein grafts. The authors advocate the use of free tissue transfer for recurrent pressure sore reconstruction.     

逆行岛状腓骨肌皮瓣再造足跟

目的探讨逆行岛状腓骨肌皮瓣的血供基础及足跟再造。方法应用解剖学的方法研究腓骨肌皮瓣血供及跟骨的生物力学特征,并在标本上进行摹拟手术。1998年5月为1例右足跟爆炸伤后2个月,全足跟缺损患者采用腓血管蒂逆行岛状腓骨肌皮瓣移位修复,腓骨瓣长14cm,带部分腓骨肌及(口)/(止)母长屈肌,皮瓣为14cm×12cm。结果①腓动脉下端与胫前、胫后动脉有丰富且粗大的吻合,完全可提供逆流供血;血管蒂旋转点因手术需要而定,最低点为外踝上6cm,此处血管蒂解剖可长达20cm;②该瓣的形态与跟骨的生物力学特征相适应,临床应用者术后腓骨肌皮瓣成活好,随访10个月获得满意效果。结论逆行岛状腓骨肌皮瓣可修复足跟严重缺损,尤其为跟骨及骰骨完全缺失者提供了一种新方法。     

Suprapopliteal flap

To investigate the cutaneous artery in the popliteal region, cadaver dissections were performed on 16 lower limbs. Two types of the cutaneous vessel have been found. One is the direct cutaneous vessel from the popliteal vessels; the other is the cutaneous vessel branching from the muscular vessel to the semimembranous muscle from the popliteal vessels. In our cadaver dissections, the latter was found consistently in the 16 lower limbs. The location of the vascular pedicle is 12.5 to 24.0 cm from the tibial condyle. The newly developed suprapopliteal flap supplied by this vessel is described. We applied this flap in four clinical patients: in one as a free flap, in the others as an island flap. Three (one free, two pedicled) flaps survived completely. The upper part of a pedicled flap partially necrosed. The operative procedure and the characteristics of the suprapopliteal flap are discussed. This flap can be used as a free flap and is also a versatile way to reconstruct soft tissue defects around the knee joint.     

健侧胫后血管皮瓣桥携带游离皮瓣临床应用

目的 探讨下肢大面积软组织缺损采用游离组织移植修复而受区载供血管可以供缝接时的解决办法,方法 在形态学观察及动脉压和血流量测定的实验基础上,设计以健侧胫后血管形成单一顺行皮瓣成桥及顺,逆行两皮瓣桥作为血管蒂而携带游离皮瓣移植修复。结果 采用健侧胫后血管形成顺行皮瓣桥携带游离皮瓣移植修复伤肢一处创面缺损８例,皮瓣全部成活,创面修复,采用健侧胫后血管形成顺－逆行两个皮瓣桥分别携带两个游离皮瓣同时修复伤     

血管化跖肌腱移植的供区解剖研究

目的 针对现有带血管肌腱移植供区的缺点,探寻新的供区。方法 以序贯检查者设计,对１０具新鲜尸体２０只小腿标本进行解剖学和组织学研究。结果 跖肌腱下部腱周膜与小腿深筋膜密切联系,其长度达１０ｃｍ以上,分布定,血管蒂达２～４ｃｍ。肌腱最大滑动距离在３～５ｃｍ。结论 该供区解剖稳定,肌血管化程度可靠,滑动性良好,临床应用可采用以胫后动脉分支为蒂的跖肌腱复合莫的的方法,或以胫后动脉主干为蒂的跖肌腱复合皮瓣     

Free vascularized fibular bone flap in the rat

Free vascularized fibula bone flap has been widely used in reconstruction of the mandible, long segment defect, congenital pseudarthroses, and osteomyelitis. Such applications stirred an interest in basic studies of bone biology, bone healing process, and incorporation of recipient bone defect. An experimental free vascularized fibula rat model is presented here for such investigations. We performed 16 angiograms and anatomic dissections in eight rats for collecting data on fibular length, blood supply, and the caliber of significant vessels. The fibula was harvested with part of the flexor hallucis longus muscle with an average length of 28 mm. The pedicle can be taken in continuity with the popliteal vessels (average diameter of 0.8 mm and 0.9 mm of artery and vein, respectively, with an average pedicle length of 14 mm). This vascularized fibula bone was harvested and transferred to the groin area of the same rat and anastomosed to the saphenous vessels. Twelve transplantations were performed, with a 7-day flap survival rate of 100%. The free fibula vascularized bone flap in the rat is a reliable model for further investigations.     

桥式交叉"T"形血管吻合游离背阔肌皮瓣移植修复小腿软组织缺损

目的 介绍改进桥式交叉游离皮瓣移植的手术方法并总结分析.方法 2003年9月至2007年5月,应用桥式交叉"T"形血管吻合游离背阔肌皮瓣移植方法修复小腿软组织缺损患者6例.男5例,女1例;年龄21～48岁(平均32岁).软组织缺损范围20 cm×9 cm～32 cm×11 cm.皮瓣血管蒂切取时携带肩胛下与旋肩胛血管,使蒂呈"T"形,将其与健侧小腿胫后动脉两断端行端端吻合,血管蒂行中厚网状游离植皮包裹,未用皮管,小腿供区切口直接缝合.结果 1例术后皮瓣远端发生小的表浅感染,换药2周后愈合,皮瓣全部成活,术后经过顺利,获得较满意的效果.随访6个月～4年(平均2.7年),未发现明显的供区功能障碍.供区与皮瓣外形较好,供区小腿经临床观察与多普勒检查证实胫后动脉通畅.结论 利用"T"形血管与胫后血管吻合,降低对侧小腿供区的损伤,只要血管吻合质量好,对皮瓣血供无影响.这种技术特别适用于小腿软组织缺损须行血管吻合的皮瓣修复、但肢体仅有一根主要血管的病例.     

Repair of severe composite tissue defects in the lower leg using two different cross-leg free composite tissue flaps

This article reports 2 cross-leg free composite tissue flaps for repairing the severe composite tissue defects in lower leg without suitable adjacent recipient vasculature for microvascular anastomosis. The osseous myocutaneous flap of ilium and tensor fascia lata pedicled with ascending branch of lateral femoral circumflex vessels and the osseous muscle flap of scapula and latissimus dorsi pedicled with subscapular vessels were performed, respectively, to reconstruct the bone and soft-tissue defects in the lower leg of 2 patients. Both donor vessels were the posterior tibial artery and great saphenous vein from the contralateral lower leg. The legs and the bone flaps were immobilized by an external fixator. The periods of pedicle division were 43 and 67 days, respectively, after transplantation. Both flaps survived after pedicle division and the patients regained the ability to walk. There were no such complications as joint stiffness or donor site morbidity except for a linear scar. The 2 cross-leg free composite tissue flaps were optional methods for salvaging limbs that were otherwise nonreconstructable. But the indication for cross-leg free-tissue flap should be limited strictly.     

Reconstruction of an upper posterior thigh extensive defect with a free split‐anterolateral thigh (s‐ALT) flap by perforator‐to‐perforator anastomosis: A case report

The anterolateral thigh (ALT) flap is one of the most commonly used flap worldwide in reconstructive surgery, as both free flap and pedicled local flap. Here, we report the use of a free split anterolateral thigh (s‐ALT) flap for reconstruction of a 14 cm × 16 cm soft tissue defect of the left upper posterior thigh region due to sarcoma resection in a patient. The ALT flap was harvested based on two musculocutaneous perforators from the right thigh and anastomosed to the contralateral descending branch of the lateral circumflex femoral artery (LCFA) in perforator‐to‐perforator manner, in order to gain more pedicle length and being able to cover the posterior thigh defect. The post‐operative course was uneventful and the patient was discharged at 1 week post‐operative. Eleven months after the operation, the aesthetic outcome was satisfactory with no functional deficit. Even though it requires technical skills and experience in perforator dissection, we believe that the s‐ALT flap anstomosed to the contralateral LCFA in perforator to perforator fashion, may be a good solution in case of such a difficultly located extensive defect of the posterior thigh.     

Microvascular transfer of anterior and posterior gracilis muscles in rats

A microvascular free muscle flap in rats using the anterior and posterior gracilis muscles with femoral vessels as its pedicle is presented. The gracilis muscles form a single unit supplied by the muscular branch artery and vein, averaging 0.3 mm and 0.4 mm in diameter, respectively. These small sizes preclude their use in transplantation. However, the muscular branch vessels in continuity with the femoral vessels can be used for the vascular pedicle in this muscle transplant. This muscle flap was transplanted to the contralateral femoral vessels by end-to-end anastomosis in 15 rats. Thirteen animals survived and 11 flaps were viable at 3 days for a success rate of 85%. The gracilis flaps averaged 674 mg in weight, 1.87 cm X 1.36 cm in size, and 7.23 mm in pedicle length. This free muscle flap model is reliable, relatively easy to perform, and provides adequate muscle bulk for pharmacologic and biochemical studies in transplanted muscle. No lower extremity complications were noted following femoral vessel ligations.