微循环监测方法在皮瓣断蒂前的应用

目的监测腹股沟外侧皮瓣微循环血流动态变化及其规律,为选择最佳断蒂时间提供可靠客观量化指标.方法应用激光多普勒血流计(LDF)对12例腹股沟外侧皮瓣移转面中点逐日进行微循环监测,皮瓣移植后第4 d起记录皮瓣蒂部阻断前、后LDF的灌注单位(perfusion units,PU)值变化情况.结果腹股沟外侧皮瓣微循环血流变化可分为两期,即术后前6 d的骤升期,PU值分别为2.83±0.46、3.21±0.41、3.66±0.43、4.77±0.71、7.08±0.37;术后6～11 d的平台期,PU值分别为7.53±0.41、7.57±0.62、7.70±0.44、7.60±0.26、7.58±0.17.本组断蒂时间为术后8～11 d. 结论腹股沟外侧皮瓣移转用以修复手背及腕部缺损,其微循环血流变化在平台期稳定期时,在阻断皮瓣蒂部后其PU值恢复到或超过阻断前水平的50%时进行断蒂,皮瓣全部成活.     

A quantitative examination of the use of fluorescein in predicting viability of skin flaps

The use of fluorescein as a predictor of skin viability in the rat flap model of avascular skin necrosis is well known in the field of plastic surgery. Inherent in this model are several faults that must be corrected if it is to become a valid standard. Fluorescence readings are one of the main variables in flap models. By carefully shaving rat backs with a double-edged razor, taking fluorescence readings in a uniformly darkened space, carefully tattooing the exact extent of both the bright and the mottled areas of fluorescence on the flap, and placing a plastic barrier between the flap and the body to prevent any part of the flap from acting as a graft, we were able to quantitatively predict which portions of a flap would survive and which would die after fourteen days. The bright fluorescent area (mean = 11.99 cm2, SEM +/- 0.53 cm2) is equal to the amount of tissue that will survive (mean = 11.91 cm2, SEM +/- 0.50 cm2; NS), while the sum of the nonfluorescent area and the mottled fluorescent area (mean = 27.69(2), SEM +/- 0.52 cm2) is equal to the amount of tissue that will die (mean = 27.99 cm2, SEM +/- 0.52 cm2; NS).     

A simple method for predicting survival of pedicled skin flaps before completely raising them

Background:

Pedicled skin and fasciocutaneous flaps are commonly used in plastic surgery. Once such a flap is completely raised on its pedicle it becomes defenceless against any possible necrosis.

Aim:

To use a simple method for raising such a flap in a manner that can predict the vascularity better, offering additional protection against necrosis.

Materials and Methods:

A total of 30 skin and fasciocutaneous flaps were raised in 27 patients. They were raised as bipedicle flaps; and the vascularity of the flap was tested by occluding the additional pedicle with a pedicle occlusion clamp. If the vascularity was found to be satisfactory the flap was primarily transferred; if found unsatisfactory it was either delayed or abandoned. The delayed flaps were again tested during transfer.

Results:

Nineteen (63.3%) flaps were primarily transferred, 11 (36.7%) flaps were delayed, and two (6.7%) delayed flaps displayed an unsatisfactory pattern during transfer. Twenty-two (73.3%) flaps fully survived and seven (23.3%) underwent partial thickness necrosis at the tip, which healed without any further surgical intervention, making 29 (96.7%) flaps clinically successful. There was major necrosis of one flap. All the flaps with a scar at the base survived.

Discussion:

The clinical success of 96.7% indicated a high-degree of predictability of flap survival through this method. Also, this method could safely assess the vascularity of flaps during primary transfer, during delayed transfer, and also those with a scar at the base.

Conclusions:

This technique is recommended in all major pedicled skin and fasciocutaneous flaps.KEY WORDS: Blood circulation, blood flow velocity, necrosis, skin transplantation, surgical flaps     

前列环素对任意型皮瓣成活影响的实验研究

为观察前列环素(PGI_2)对皮瓣成活的影响,以大白鼠背部设计超长任意型皮瓣模型,设立术前(预防组)、术后(治疗组)静脉给 PGI_2及生理盐水对照组,对皮瓣的血供、代谢和血液流变学等进行分析。结果表明治疗组皮瓣远端血流相对值为41.3%,对照组为22.4%,治疗组皮瓣成活率明显高于对照组,预防组与对照组相比无明显差异。提示:术后早期给予 PGI_2可以改善皮瓣的血流和血液流变状态,提高皮瓣成活面积。     

前列环素对任意型皮瓣成活影响的实验研究

为观察前列环素（ＰＧＩ２）对皮瓣成活的影响，以大白鼠背部设计超长任意型皮瓣模型，设立术前（预防组）、术后（治疗组）静脉给ＰＧＩ２及生理盐水对照组，对皮瓣的血供、代谢和血液流变学等进行分析。结果表明治疗组皮瓣远端血流相对值为４１．３％，对照组为２２．４％，治疗组皮瓣成活率明显高于对照组，预防组与对照组相比无明显差异。提示：术后早期给予ＰＧＩ２可以改善皮瓣的血流和血液流变状态，提高皮瓣成活面积。     

前列环素对任意型皮瓣成活影响的实验研究

为观察前列腺素（ＰＧＩ２）对皮瓣成活的影响，以大白鼠背部设计超长任意皮瓣模型，设立术前（预防组），术后（治疗组）静脉给ＰＧＩ２及生理盐水对照组，对皮瓣的血供，代谢和血液流变学等进行分析，结果表明治疗组皮瓣端血流相对值的４１．３％，对照组为２２．４５，治疗组皮瓣成活率明显高于对照组，预防组与对照相比地明显差异，提示：术后早期给予ＰＧＩ２可以改善皮瓣的血流和血液流变状态，提高皮瓣成活面积。     

胸肩峰皮瓣微循环监测及临床应用

目的　监测胸肩峰皮瓣微循环血流动态变化及其规律 ,为选择最佳断蒂时间提供可靠客观量化指标。　方法　应用激光多普勒血流计 (LDF)对 12例胸肩峰皮瓣转移面中点于术后 2～ 7天逐日进行微循环监测 ,皮瓣移植后第 4天起记录皮瓣蒂部阻断前、后LDF的PU(灌注单位 )值变化情况。　结果　胸肩峰皮瓣微循环血流变化可分为 2期 ,即术后前 4天的骤升期PU值分别为 3 5±1 3、4 5± 1 7、6 7± 2 9;术后 4～ 7天的平台期PU值分别为 7 4± 2 0、7 6± 2 3、7 3± 1 6。本组断蒂时间为术后 6～ 8天。　结论　胸肩峰皮瓣在转移修复面部缺损时 ,其微循环血流变化在平台期后期时 ,当阻断皮瓣蒂部后其PU值恢复到或超过阻断前水平的 5 0 %时进行断蒂 ,皮瓣全部成活。     

Comparative viability of expanded and unexpanded axial pattern skin flaps in pigs

A comparison of viable areas of axial pattern flaps post inset was made between expanded and non-expanded pig buttock island flaps. The deep circumflex iliac artery and vein supply approximately the proximal 14 x 10 cm area of this flap. Larger flaps were raised on expanded and control sides of eight pigs to determine if expansion increased the area of survival. In six of eight pigs whose initial tissue expansion did not create more than approximately a 50% increase in skin area, the expanded flaps had a statistically significant increase in viable skin area (proportionally) 10 days post inset than their control flaps (p less than 0.05). Two other pigs did not conform to this pattern. Their initial tissue expansion was greater than 50%, and the resulting area of flap viability was proportionally less in expanded flaps than the control flaps.     

一种新的皮肤活力检测方法的研究

探索一种四氮唑盐法对皮肤活力检测及其对储存异体皮质量鉴定的效果。方法以四氮唑盐法对猪皮片和人皮片活进行了实验性检测。对试剂的剂量,反应时间,皮片厚度,皮片面积、皮片重量等实验的选择进行了研究。     

Venous skin flaps: an experimental study and report of two clinical distal island flaps

An experimental study of saphenous flaps in 26 dogs is reported, which confirmed the work of Baek et al. (1985) that venous flaps can survive. In addition, it showed that venous island flaps could survive after division of the venous pedicle proximally or distally, or as free flaps, providing through flow was re-established by venous anastomoses. In this study no flaps survived on a single venous pedicle without through flow. Two successful clinical cases of venous flaps are also reported, in which through flow was re-established by a simple venous anastomosis. One of these flaps threatened to become necrotic until the thrombosed anastomosis was successfully redone.     

Effects of ozone gas on skin flaps viability in rats: an experimental study

Background: The main purpose of this study was to assess the effects of ozone gas on the viability of flaps for reconstruction and to determine the optimum application method. The antioxidant, immunomodulatory, and reperfusion effects of ozone gas have been previously assessed, and successful results have been reported. However, only one study has investigated the effect of ozone gas on flap viability. In the present study, it was hypothesised that the antioxidant and reperfusion effects of ozone gas would enhance flap viability.

Methods: Forty female Wistar rats were randomly divided into four groups of 10 rats each. A cranial-based, 3?×?11?cm modified McFarlane flap including the panniculus carnosus was raised from the dorsum of a rat and re-sutured to its own bed using 3/0 sharp propylene. Group 1 (n?=?10): no pharmacological agent was used after the operation. Group 2 (n?=?10): vegetable (olive) oil group; vegetable-oil-impregnated gauze was used as a dressing for 7 days. Group 3 (n?=?10): Vegetable (olive) oil with ozone peroxide group; vegetable oil with ozone peroxide-impregnated gauze was used as a dressing for 7 days. Group 4 (n?=?10): Hemo-ozone therapy group; hemo-ozone therapy was applied rectally once every day for 7 days. All rats were sacrificed at the end of week 1 and assessed macroscopically and histopathologically.

Results: The proportion of substantive necrosis was less in group 4 than in the other three groups. Survival area ratios were better in groups 2 and 3 than in group 1; however, there was no significant difference between groups 2 and 3. No significant differences in the histopathological scores were observed among the groups.

Conclusion: Ozone gas enhanced flap viability. No differences in flap viability were observed between the vegetable oil and vegetable oil with ozone peroxide groups. The greatest benefit ratios were found in the hemo-ozone therapy group.     

A simple and effective method of monitoring free skin flaps

Summary A simple and effective method of monitoring a free skin flap transfer when the flap skin color is white in spite of having a good blood circulation is described. It is easy to confirm that the anastomosed vessels are patent or not by visualizing the flap skin color, because erythema will appear after topical application of dinitrochlorobenzene even if skin color is white.     

小腿前外侧岛状皮瓣修复胫骨外露的解剖研究与临床应用

目的 探讨小腿前肌间隔动脉链为蒂的岛状皮瓣修复胫骨外露的术式及手术方法.方法 40侧成人尸体下肢标本经动脉灌注红色乳胶,4侧新鲜成人尸体下肢标本动脉造影,观测小腿前肌间隔内的胫前动脉穿支与腓动脉终末前穿支的位置、走行、外径及相互吻合.临床应用小腿前外侧岛状皮瓣转位修复胫骨外露11例.男7例,女4例;年龄20～59岁,平均36岁.结果 40侧标本腓骨长度为(32.3±2.4)cm.胫前动脉发出腓浅动脉、胫前动脉下段前肌间隔穿支,与腓动脉终末前穿支在小腿前肌间隔内相互吻合,形成动脉链,这三条动脉外径分别为(1.4±0.4)mm、(1.0±0.4)mm及(1.5±0.4)mm,动脉链吻合处外径为(0.6±0.2)mm.动脉链伴腓浅神经走行,营养神经和小腿前外侧皮肤.临床应用小腿前外侧岛状皮瓣修复胫骨外露的11例中,以胫前动脉下段前肌间隔穿支为蒂2例,以胫前动脉下段前肌间隔穿支的升支为蒂3例,以胫前动脉下段前肌间隔穿支的降支为蒂3例,以腓动脉终末前穿支升支为蒂3例.皮瓣切取面积7 cm×5 cm～13 cm×5 cm.随访1～3年,平均1.5年,11例皮瓣全部成活,无破溃、臃肿.结论 根据皮肤缺损部位、面积等灵活选用小腿前肌间隔内动脉链为血管蒂,设计前外侧岛状皮瓣修复胫骨外露,术式灵活,是修复胫骨外露的理想皮瓣.

Abstract：

Objective To explore surgical methods of repairing tibial skin defect using the anterolateral crural island flap.Methods The location,external diameters,anastomosis and distribution of perforators from the anterior tibial artery and the peroneal artery in the anterior septum were observed in 40 cadaveric specimens.Arterial angiography was performed in 4 fresh legs.Clinically,11 cases with tibial skin defect were repaired with the anterolateral crural island flap.There were 7 males and 4 females,with an average of 36 years (20-59 years).The area of the skin defect ranged from 6 cm×4 cm to 12 cm×4 cm.Results An arterial chain was formed by the interconnection of the superficial peroneal artery,the anterior septocutaneous perforator from distal part of the anterior tibial artery and the anterior end-perforator of the peroneal artery.It ran in the anterior septum and went along with the superficial peroneal nerve to supply blood to adjacent fascia and skin.The external diameters of the three perforators were (1.4±0.4) mm,(1.0±0.4) mm and (1.5±0.4) mm respectively,and the external diameter of the arterial chain was (0.6±0.2) mm.Clinically,we designed 4 methods to repair 11 cases of tibial skin defect successfully with the anterolateral cnnal island flap.The anterior septocutaneous perforator from distal part of the anterior tibial artery was used as pedicle in 2 cases;ascending branch of the anterior septocutaneous perforator from distal part of the anterior tibial artery was used as pedicle in 3 cases;descending branch of the anterior septocutaneous perforator from distalpart of the anterior tibial artery was used as pedicle in 3 cases;ascending branch of the anterior end-perforator of the peroneal artery was used as pedicle in 3 cases.The area of the flaps ranged between 7 cm×5 cm and 13 cm×5 cm.All patients were followed up with a mean time of 1.5 years.All flaps survived totally without diabrosis and swelling.Conclusion The anterolateral island flaps pedicled with perforators arising from the anterior septum of the lower leg is a good choice for surgeons to repair tibial skin defect.     

皮瓣和肌皮瓣在食管外科中的应用

食管切除后常用胃或结肠来进行重建,但对于一些病变位置过高、合并胃或结肠病变、胃或结肠已做过手术、局限性严重食管狭窄患者,可选择其他方法重建或修复。能用于修复及重建食管皮瓣、肌皮瓣有十余种,根据血供来源分为游离皮瓣及带蒂肌皮瓣。游离皮瓣需血管吻合,一旦出现血管阻塞,易发生皮瓣坏死,以选择带蒂肌皮瓣修复及重建食管为宜。胸大肌皮瓣及背阔肌皮瓣尽管血运丰富,但肌皮瓣臃肿,且难以形成管状重建全周食管。颈阔肌皮瓣面积大,多源性血液供应,单侧可用于修复颈段食管缺损,双侧能重建全周颈段食管,手术操作简便,疗效可靠,长期随访皮瓣无溃疡及毛发生长,且能耐受放疗,值得推广应用。     

Transcutaneous O2 and CO2 monitoring of neurosurgical patients: detection of air embolism

Transcutaneous oxygen tension (PtcO2) and transcutaneous carbon dioxide tension (PtcCO2) were monitored in 60 patients undergoing neurosurgical procedures. Twenty-six patients were in the sitting position and underwent routine monitoring for air embolism. Seventeen episodes of air embolism were diagnosed by precordial Doppler ultrasound or transesophageal echocardiography, and the PtcO2 decreased early during the course of each episode. The mean PtcO2 decrease was 48 +/- 35 mmHg. During ten episodes the end-tidal carbon dioxide tension (PETCO2) decreased but only after the PtcO2 had already begun to decrease. PtcCO2 increased during air embolism but PETCO2 changes preceded the change in PtcCO2 by 1-2 min. Transcutaneous values during air embolism were verified with simultaneous arterial blood gas values during six air embolism episodes. A strong positive correlation was found between transcutaneous and arterial oxygen and carbon dioxide tensions. Correcting the PtcCO2 by the patient's baseline PtcCO2/PaCO2 ratio, PtcCO2 monitoring correctly reflected hypocarbia, normocarbia, and hypercarbia in 92% of the cases. PtcO2 monitoring was useful in detecting venous air embolism and may respond sooner than PETCO2. PtcCO2 monitoring was not useful as an early detector of air embolism.