股薄肌在整形外科中的应用

股薄肌位于大腿内侧,以来自股深动脉股薄肌支和旋股内侧动脉为主要供血,支配股薄肌的神经多来自闭孔神经前支的分支。以该肌肉携带的皮瓣或以该血管蒂为穿支的股薄肌穿支皮瓣,近年来在整形外科领域得到了广泛的应用。本文就股薄肌肌皮瓣和穿支皮瓣在整形外科中的应用进行综述。     

股薄肌在软组织修复重建中的应用

目的探讨股薄肌肌瓣、肌皮瓣的临床解剖学结构及应用方法。方法自2007年1月至2017年6月对24例不同原因致软组织缺损患者,应用带蒂股薄肌肌瓣及肌皮瓣修复会阴软组织缺损8例;游离肌瓣移植治疗面瘫16例。结果 1例行肌皮瓣修复会阴缺损后,远端出现血运障碍,经换药3周后痊愈;1例行肌皮瓣阴道再造后,皮瓣全层出现缺血坏死,经清创肌瓣表面并游离植皮后痊愈。经电话及微信随访6周至9年,所有患者的肌皮瓣和肌瓣均成活良好,治疗效果较满意。结论股薄肌的位置表浅,血供丰富,血管神经走行固定,易于解剖,适用于会阴部软组织缺损修复及动力性面瘫的治疗,效果良好。     

阔筋膜张肌肌皮瓣的解剖研究与临床应用

目的　探索应用阔筋膜张肌肌皮瓣带蒂移转中 ,部分肌皮瓣发生血供障碍的原因。方法　对 16具 3 2侧用红色乳胶灌注的贮存成人尸体标本 ,进行解剖研究。结果　 12具 2 2侧肌皮瓣供血动脉走行在肌肉内 ;另有 2具 2侧肌内供血动脉与肌肉前缘较大分支并存 ;3具 4侧肌内供血动脉与肌肉深面疏松结缔组织内较大分支并存 ;3具 4侧供血动脉走行在肌肉浅面皮下组织内。解剖研究后临床又应用 8例 ,妥善保护了存在于肌肉前缘及其深浅面的血管 ,手术均获成功。结论该肌皮瓣的供血动脉不仅存在于肌肉内 ,有的在肌肉前缘或深面有较大分支 ,有的存在于肌肉浅面皮下组织内 ,手术中须避免其受到损伤 ,以确保肌皮瓣血供。     

会阴动脉跨区供血的股内侧皮瓣再造外阴一例

行女性外阴癌根治切除时通常是将小阴唇与大腿根部缝合 ,结果可导致尿道阴道前庭区外露并受磨擦 ,给生活带来极大不便。为此 ,我们为此类病例设计了以会阴动脉为蒂跨区供血的股内侧皮瓣即时转移修复的手术方法 ,获得良好效果。方法　用多普勒血流仪在阴唇后联合至阴股沟水平连线的中外 1/ 3处 ,测得会阴动脉的搏动及其向股内侧分支的走向。该搏动点与股动脉 (腹股沟中点下 2～ 3ｃｍ处可测得其搏动 )内侧的连线 ,可为设计皮瓣血供分布区提供参考。然后 ,根据癌切除后创面的大小形状 ,在股内侧制作相应的皮瓣。瓣蒂在会阴区 ,有利于皮瓣的旋…     

不同形式游离股深动脉蒂嵌合穿支肌皮瓣修复舌癌术后缺损的疗效观察

目的探讨不同形式游离股深动脉蒂嵌合穿支肌皮瓣的临床解剖及其在舌癌术后缺损修复中的应用。方法 2011年4月—2016年1月,采用不同形式股深动脉蒂嵌合穿支肌皮瓣修复44例舌癌术后缺损。男40例,女4例;年龄32~71岁,平均46.3岁。原发舌缘24例,舌腹17例,口底癌累及舌3例。病理类型均为鳞状细胞癌;按国际抗癌联盟(UICC)TNM分期:T4N0M0 16例,T4N1M0 11例,T3N1M0 9例,T3N2M0 8例。病程1~22个月,平均8.6个月。皮瓣切取范围为8.5 cm×4.0 cm~12.0 cm×6.5 cm,肌瓣切取范围为4.0 cm×3.0 cm~7.5 cm×5.0 cm。其中11例采用游离股深动脉蒂嵌合穿支大收肌肌皮瓣,大收肌穿支血管蒂长度为(8.3±0.5)cm;33例采用游离股深动脉蒂嵌合穿支股薄肌肌皮瓣,股薄肌穿支血管蒂长度为(8.1±0.8)cm。大腿内侧供区均直接拉拢缝合。结果术后游离股深动脉蒂嵌合穿支肌皮瓣均顺利成活,创面Ⅰ期愈合;供区切口均Ⅰ期愈合。所有患者均获随访,随访时间12~40个月,平均23.8个月。所有患者再造舌形态良好,舌体活动可,吞咽和语言功能恢复满意,无1例肿瘤局部复发。大腿内侧瘢痕位置隐蔽,仅遗留线状瘢痕。结论游离股深动脉蒂嵌合穿支肌皮瓣可以以不同形式切取,适用于舌癌术后缺损修复。     

下位斜方肌肌皮瓣修复支气管胸膜瘘三例

我们于 1999～ 2 0 0 0年应用斜方肌下部肌皮瓣移转修复支气管胸膜瘘并残腔 3例 ,全部成功。1　应用解剖　斜方肌上起自枕外隆突至第 12胸椎棘突之间 ,止于锁骨外侧 1/ 3、肩峰及肩胛岗 ,呈三角形。斜方肌血供主要是颈横动脉 ,该动脉在斜方肌深面分为深、浅两支。深支沿肩胛内侧缘深面下行 ,在菱形肌下缘发出一分支穿出深层 ,分布于斜方肌下部外侧及其皮肤。以深支为蒂形成下位斜方肌岛状肌皮瓣 ,其血管蒂较长 ,所带皮肤筋膜组织最远可达肩胛下角以下 10ｃｍ处[1 ] 。2　手术方法　自锁骨上凹找到颈横动脉 ,向后追踪其深支在脊柱与肩胛内侧…     

T形动脉蒂游离背阔肌肌皮瓣移植术

目的：探讨T形胸背动脉蒂游离背阔肌肌皮瓣修复前臂、小腿等创面的可行性。方法：设计以肩胛下动脉至旋肩胛动脉为短臂的T形胸背动脉蒂背阔肌肌皮瓣，将短臂嵌于剪断的受区动脉断端间，分别与远近端吻合，从而既保证了游离肌皮瓣的血供，又重建了受区主要动脉的连续性，结果：1999年10月－2001年12月，临床应用16例，背阔肌肌皮瓣完全成活15例，大部分成活1例，受区肢体的血供良好，结论：T形动脉蒂游离背肌肌皮瓣移植术是修复前臂，小腿深度皮肤软组织缺损的一种较好的方法。     

腓肠内侧动脉为蒂双叶肌皮瓣移植术

目的总结腓肠内侧动脉为蒂的双叶肌皮瓣移植术的临床应用结果。方法用腓肠内侧动脉为蒂的双叶肌皮瓣移植修复8例小腿近侧2/3胫前区软组织缺损(小腿上1/3有5例,中1/3有3例)。供区行一期中厚网孔状游离植皮修复。结果 8例患者经腓肠内侧动脉为蒂的双叶肌皮瓣游离移植修复的总体疗效较满意。供区游离植皮和双叶肌皮瓣全部成活。1例术后发生受区小的皮缘表浅感染,经伤口换药逐渐愈合。术后随访14个月至3年(平均2.2年月),供区愈合良好,未见明显的供区功能障碍;受区皮瓣质地、厚薄及颜色均较好,肢体功能恢复良好。结论该带蒂双叶肌皮瓣以腓肠内侧动脉为血供,具有血供丰富、血管解剖恒定、血管蒂长、肌瓣较薄等优点,适宜于修复小腿近侧2/3软组织缺损。     

腓动脉穿支远端蒂腓肠神经岛状筋膜肌皮瓣修复足踝骨髓炎创面

目的探讨以腓动脉穿支为蒂的腓肠神经岛状筋膜肌皮瓣逆向修复足踝骨髓炎创面的临床疗效。方法解剖10条小腿灌注标本，观察腓肠神经血管轴与腓肠肌内、外侧头肌支和肌皮穿支之间的交通吻合。临床应用远端蒂腓肠神经岛状筋膜肌皮瓣修复足踝骨髓炎创面5例。结果腓肠神经在穿出深筋膜前，其血管轴与两侧的腓肠肌肌支间各有2-4个吻合（筋膜下段）；在穿出深筋膜后，其血管轴与两侧的腓肠肌肌皮穿支间各有2-3个吻合（筋膜上段）。在腓肠肌腱腹交界的近侧2-4cm内，恒定有1-3支肌皮穿支血管与腓肠神经血管轴相交通。据此，临床设计切取以腓动脉最远端肌间隔穿支血管（外踝上5cm）供血的腓肠神经岛状筋膜肌皮瓣，逆向修复5例伴有死腔和骨髓炎感染的小腿下段和足踝创面。5例筋膜皮瓣面积12cm×6cm-17cm×9cm，携带的深层腓肠肌肉面积5cm×4cm-9cm×7cm。随访6个月～1年，皮瓣完全成活。结论腓动脉穿支远端蒂腓肠神经岛状筋膜肌皮瓣。血供可靠，转移方便，是修复小腿下段1／3和足踝部骨髓炎创面的好方法。     

阔筋膜的血供特点及其代瓣术的解剖学基础

应用显微外科解剖学方法，观察了３０侧成人大腿阔筋膜的血供来源和血管配布特点。发现大腿阔筋膜的营养动脉来自４个区域。股前上部阔筋膜的动脉来自股深动脉的起始部分支和缝匠肌外缘皮动脉的分支；股后阔筋膜的供应动脉来自股后皮神经的伴行动脉和动脉的分支；股外侧阔筋膜的动脉来自穿动脉的外侧肌间隔分支；股内侧阔筋膜的动脉则来自动脉自内侧肌间隔发出的分支以及较多的肌皮动脉阔筋膜支。本研究将为阔筋膜游离移植提供形态学基础。     

Blood supply and innervation of the supermedial thigh flap employed in one-stage reconstruction of the scrotum and vulva--an anatomical study

The supermedial thigh flap is an arterial and sensate flap. Anatomical studies reveal both large and small nutrient arteries. Its largest and most consistent artery is the superficial branch of the deep external pudendal artery, which constitutes the main circulation. The secondary blood supply to the base of the flaps is contributed by musculocutaneous perforators of the medial circumflex femoral artery. Subcutaneous branches of the superficial femoral artery, when present, are an additional source of arterial supply. Branches of the ilioinguinal nerve provide sensory innervation to the flaps.     

Use of gracilis musculocutaneous flap in urologic cancer surgery

The recently increased use of musculocutaneous flaps has revolutionized plastic surgery. The gracilis musculocutaneous flap, complete with its own blood and nerve supply, can be rotated on its vascular pedicle to close safely defects in the lower pelvis. This flap can be especially useful for patients with urogenital cancer when surgery, irradiation, or chemotherapy creates a wound too large for primary closure.     

高位皮动脉型股前外侧皮瓣的临床应用

目的探讨股前外侧皮瓣在缺乏第一肌皮动脉穿支或皮支细小时游离皮瓣的可能性。方法临床应用高位皮动脉为血管蒂的股前外侧游离皮瓣修复手足部皮肤缺损。结果本组应用5例皮瓣全部成活，一期修复后外观、感觉、功能均达到优良。结论高位皮动脉型股前外侧皮瓣具有血供可靠，切取面积大，手术操作简便等优点。当股前外侧皮瓣缺乏第一肌皮动脉穿支或皮支细小时，应用高位皮动脉为血管蒂的游离股前外侧皮瓣，是一种确实有效的手术方法。     

The distal gluteus maximus advancement musculocutaneous flap for coverage of trochanteric pressure sores

Large trochanteric pressure sores can be reconstructed with the superolateral advancement of the distal gluteus maximus-posterior thigh myofascial cutaneous flap. The flap has a dual blood supply derived from the gluteal system and the deep femoral artery. This makes the distal gluteus maximus advancement flap very reliable and versatile. It can be designed on the musculocutaneous perforators of the gluteal system alone or on its dual circulation. It has several advantages over previously described flaps for trochanteric pressure sores.     

Sensory reinnervation of a musculocutaneous flap: an experimental rabbit study.

Sensory neurotisation of a muscle (sensory nerve transfer to the motor nerve of a muscle) produces muscle sensibility, but not skin sensibility. How to achieve sensation of a musculocutaneous flap remains a challenge to reconstructive microsurgeons. The purpose of our study was to determine if multiple nerve grafts which were placed vertically between the neuromuscular entrance zone of a muscle and a target area of dermis on the overlying skin could improve sensation. Thirty-six gracilis musculocutaneous flaps (18 rabbits) were raised and divided into three groups: group 1 consisted of 12 sensory neurotised gracilis musculocutaneous flaps with five nerve grafts each; group 2 consisted of another 12 sensory neurotised gracilis flaps with 10 nerve grafts each; and the control group consisted of 12 sensory neurotised gracilis musculocutaneous flaps without any nerve grafts. All nerve grafts spanned the distance between the neuromuscular entrance zone of the gracilis muscle and a specified 3 cm diameter area of the skin island. The saphenous nerve (sensory) was coapted to the obturator nerve (motor nerve of the gracilis) in an effort to achieve improved sensation of the skin island in the musculocutaneous flaps. After 6 months, the flaps were individually evaluated using cortical somatosensory evoked potentials (CSSEP) using normal, painful, cold and hot stimuli. One unoperated rabbit was studied as the baseline CSEEP for comparison. Retrograde horseradish peroxidase (HRP) labelling was then performed to evaluate the possibility of newly established neural pathways. Results of the CSSEP testing revealed that flaps possessing 10 nerve grafts (group 2) demonstrated better sensation when compared to flaps possessing five nerve grafts (group 1) or no nerve grafts (control group). Furthermore, retrograde HRP labelling proved that a new neural pathway had been established from the skin island to the dorsal root ganglia of S1 and S2 via the interposed nerve grafts and the sensory neurotised gracilis muscle in groups 1 and 2 rabbits. The control group did not display any sensory regeneration.     

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.     

股后侧岛状皮瓣和肌皮瓣的临床应用

目的 探讨应用股后侧岛状皮瓣修复大转子、骶部等处软组织缺损的临床效果.方法 应用顺行股后侧岛状皮瓣修复大转子软组织缺损4例、骶部2例;逆行股后侧岛状皮瓣修复腘窝部皮肤缺损2例;肌皮瓣修复坐骨结节褥疮4例;供区直接缝合.结果 除 1例岛状皮瓣远端发生尖部坏死经植皮愈合外,余病例术后全部成活.随访1～5年,供区愈合良好、受区外形、质地及厚薄均较满意.结论 该皮瓣以臀下动脉股后皮支及股深动脉穿动脉为其血供,解剖恒定,具有血运丰富、血管蒂长和切取容易等优点,适宜修复大转子、骶部坐骨结节及腘窝部等处软组织缺损.     

不同肌皮支为蒂的股前外侧分叶皮瓣在四肢组织缺损中的应用

目的 探讨以不同肌皮支为蒂的股前外侧分叶皮瓣在四肢组织缺损修复中的临床应用价值.方法 2008年1月至2009年4月,针对80例股前外侧皮瓣移植患者手术中解剖学观察,依据不同患者血管肌皮支的特点,设计以不同平面旋股外侧动脉肌皮支为蒂的不同形状股前外侧分叶皮瓣,用于修复四肢2个以上独立创面的组织缺损,临床应用15例,其中男10例,女5例.组织缺损部位:手部4例,足部6例,小腿及足踝部5例.两处组织缺损区最大相距8 cm,单一创面缺损范围3.0cm×3.5 cm～8.0 cm×11.5 cm,单个皮瓣切取面积为5.0 cm×5.0 cm～9.0 cm×15.0 cm.结果 手术中解剖学观察显示:肌皮支出现率为100%,总能找到位于不同平面的两个独立肌皮支.组织瓣源血管均为旋股外侧动脉降支.肌皮支穿出点分布在股前外侧肌前侧半及其与股直肌的肌间隙内,沿髂前上棘与髌骨外上缘连线的轴线2～4 cm范围内;将轴线远1/2部分分成3段,粗大肌皮支在第一段的出现率为81%,第二段为67%,第三段为89%.术后15例患者皮瓣全部成活,无血管危象发生.术后获3～8个月随访,皮瓣质地柔软.6例因皮瓣臃肿于术后3周～3个月做皮瓣修薄术,外形满意.结论 以不同肌皮支为蒂的股前外侧分叶皮瓣是修复四肢复杂组织缺损的一种有效方法.

Abstract：

Objective To introduce ramified anterolateral femoral flaps pedicled with different musculocutaneous branches used for primary repair of soft-tissue defects at different regions of extremities. Methods From January 2008 to April 2009, 15 patients, 10 males and 5 females, were treated with an-terolateral thigh flaps for their soft-tissue defects at limbs which involved 4 hands, 6 feet and 5 legs and an-kles. Different shapes of anterolateral thigh flap were designed according to clinical anatomy and particular conditions of blood vessels and musculocutaneous branches in different cases. The flaps were ramified into 2 independent free flaps to repair 2 independent defects. The maximum distance between 2 defects was 8 cm. The area of defect ranged from 3.0 cm×3.5 cm to 8.0 cm×11.5 cm, and the flap area from 5.0 cm×5.0 cm to 9.0 cm×15.0 cm. Results According to clinical anatomy, the presence of sarco-cutaneous branches was 100%. The source blood vessel of the flaps was quadriceps artery of femur. The 15 patients were followed up from 3 to 8 months. The tissue grafts all survived and the flaps primarily healed at the recipient site. Revisions were done 3 weeks to 3 months after the primary operation to thin down the clumsy skin flaps in 6 cases, The shape and texture of the flaps were satisfactory. Conclusion Ramified anterolateral femoral flaps pedicled with different musculocutaneous branches provide an ideal way of repairing severe and complex soft-tissue defects at extremities.     

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.     

Scrotal reconstruction following fournier gangrene using the medial circumflex femoral artery perforator flap

Fournier gangrene can have devastating consequences. Often in the male, the testicles become exposed and demand both a functional and esthetic coverage. Local medial thigh cutaneous flaps usually still are available and have evolved to become a preferred solution. The medial circumflex femoral artery perforator (MCFAP) flap based on musculocutaneous perforators of the gracilis muscle represents yet another one of these options. As with all muscle perforator flaps, no muscle need be expended. A case report illustrates the role of the MCFAP flap for creation of a neoscrotum.