小隐静脉-腓肠外侧神经蒂逆行皮瓣解剖及临床应用研究

目的 介绍小隐静脉-腓肠外侧神经蒂逆行皮瓣的应用解剖及临床应用经验。方法 取5具新鲜尸体（10侧下肢）分别沿髂外动脉插管，加压注入红色乳胶，观测小腿后外侧不同阶段小隐静脉、腓肠外侧神经滋养血管的来源及对相应部位皮肤的血供。临床设计小隐静脉-腓肠外侧神经蒂逆行皮瓣修复小腿下段、踝部及足跟创面9例。结果 小腿后外侧上、中、下1／3段分别由腓肠浅动脉、胫后动脉肌皮穿支、腓动脉肌间隙穿支所发出的血管滋养小隐静脉-腓肠外侧神经，形成了以神经、血管为中心的串状动脉网，与深筋膜层血管网及皮下血管网相互吻合。临床应用9个皮瓣（9例），完全成活，足跟及足外侧缘无感觉丧失区。结论 小隐静脉-腓肠外侧神经蒂逆行皮瓣血运丰富、成活可靠，是修复下肢皮肤、软组织缺损的有效方法。     

腓肠外侧神经-小隐静脉血管蒂皮瓣的解剖学观察与临床应用

目的 通过对以腓肠外侧神经-小隐静脉血管为蒂的皮瓣的解剖学观察,探讨其临床应用效果,并对该术式进行评价.方法 10侧下肢灌注红色乳胶,20只截肢的下肢行解剖观察;临床于小腿设计以腓肠外侧神经-小隐静脉血管为蒂皮瓣修复下肢组织缺损,术中保留腓肠内侧神经,不结扎小隐静脉的远心端.结果 小腿存在以皮神经、小隐静脉为中心的血管网,与深筋膜、皮下血管网相互吻合;腓肠内、外侧神经平均距外踝上(8.5士0.8)cm;63例临床应用效果良好,足跟及足外侧感觉恢复满意.结论 保留腓肠内侧神经对保留足部感觉有积极意义,腓肠外侧神经-小隐静脉血管蒂皮瓣血运丰富、成活可靠.     

小腿浅静脉皮神经皮瓣修复足远端创面

目的探索大隐静脉-隐神经营养血管皮瓣和小隐静脉-腓肠神经营养血管皮瓣修复同侧足远端创面。方法临床应用13例修复足远端创面,以踝上3～5cm作为旋转点,保留2cm皮肤及3～4cm筋膜蒂,保护链状血管连续性,明道真皮下潜行分离形成隧道,旋转点以三角瓣覆盖并总结皮瓣成活的规律及形成系列方法。结果 13例皮瓣均成活,其中1例远端1.5cm出现暗红,经拆线减张、换药后愈合。结论隐神经、腓肠神经及大隐静脉、小隐静脉周围均有血管网伴行,大隐静脉-隐神经营养血管皮瓣、小隐静脉-腓肠神经营养血管皮瓣形成远端蒂移位修复小腿或中后足部创面,也可修复同侧足远端创面。皮瓣血运可靠,不牺牲主要血管,是小腿及全足部创面的良好供区。     

皮神经营养血管皮瓣修复小腿下段及足踝部缺损

目的探讨皮神经营养血管皮瓣在小腿下段及足踝部组织缺损修复中的应用效果。方法应用腓肠神经营养血管逆行皮瓣9例(其中不吻合小隐静脉者3例,吻合小隐静脉6例),隐神经营养血管逆行皮瓣3例(均吻合浅静脉),足背皮神经营养血管顺行或逆行皮瓣3例(其中足背内侧皮神经2例,足背外侧皮神经1例)。皮瓣面积最大16cm×10cm熏最小5cm×4cm。血管蒂长4～10cm,蒂宽3～4cm。结果临床应用15例,12例全部成活。2例未吻合小隐静脉的腓肠神经营养血管逆行皮瓣因静脉回流障碍远端部分坏死,二期植皮而愈;1例隐神经营养血管逆行皮瓣移位修复胫骨下端骨髓炎,感染灶导致皮瓣局部坏死,感染控制后局部皮瓣转移而愈;1例足跟部溃疡。结论腓肠神经、隐神经及足背皮神经营养血管皮瓣是修复小腿下段及足踝部组织缺损的理想皮瓣,可顺行或逆行移位,常规吻合浅静脉、缝合皮神经,有助于皮瓣成活及感觉功能恢复。     

小隐静脉-腓肠神经营养血管岛状皮瓣的应用

目的探讨用小隐静脉-腓肠神经营养血管逆行岛状皮瓣修复下肢远端软组织缺损的效果.方法用小隐静脉-腓肠神经营养血管逆行岛状皮瓣修复踝周、足跟、足底及足背皮肤软组织缺损26 例,皮瓣面积为6 cm×5 cm～22 cm×10 cm,筋膜蒂长6～13 cm.结果随访时间6～46个月,皮瓣全部成活.皮瓣与周围皮肤颜色一致、质地柔软,外观及功能满意.结论小隐静脉-腓肠神经营养血管逆行岛状皮瓣血供可靠,不损伤主干血管,切取容易,是修复踝周、足跟、足底及足背皮肤软组织缺损的理想皮瓣.     

吻合小隐静脉的腓肠神经营养皮瓣在骨科中的临床应用

目的 探讨吻合小隐静脉的逆行腓肠神经营养血管皮瓣在骨科中的临床应用效果.方法 2004年7月-2009年10月,采用吻合小隐静脉的逆行腓肠神经营养血管皮瓣修复小腿中下段、足背皮肤缺损25例,均为不同程度的皮肤缺损,骨质、肌腱外露,术中将皮瓣近端小隐静脉与受区大隐静脉或其属支、腓肠神经与已断裂隐神经、足背皮神经近端相接合.结果 25例皮瓣均成活,外观、感觉良好.术后随访16例,时间10个月～2年,足部外形良好,皮瓣质地、色泽与周边相似,足功能恢复良好.结论 吻合小隐静脉及腓肠神经改善了腓肠神经营养血管皮瓣静脉回流,扩大了皮瓣的修复范围,能够修复足背远端至跖趾关节皮肤缺损,感觉恢复快,较容易成活.     

小隐静脉-腓肠神经营养血管皮瓣的临床研究

目的　报道远端蒂及近端蒂小隐静脉 腓肠神经营养血管皮瓣修复下肢软组织缺损的效果。　方法　采用近端蒂及远端蒂、带腓肠神经或不带腓肠神经的小隐静脉 腓肠神经营养血管皮瓣 ,修复 2 5例小腿胫前近、中、远段和踝周、足背及足跟皮肤缺损 ,皮瓣最小面积为 5cm× 4cm ,最大面积为10cm× 15cm。　结果　 2 5例中远端蒂皮瓣 2 2例 ,近端蒂 3例 ,不带腓肠神经的皮瓣 3例 ,皮瓣全部成活 ,皮瓣质地优良 ,外观及功能满意。　结论　该皮瓣可行近、远端蒂转移 ,皮瓣可带或不带腓肠神经 ,均有足够的血运。本皮瓣成活率高 ,操作简便 ,不牺牲主干血管 ,是修复小腿胫前、踝周及足跟部软组织缺损的理想皮瓣。     

10例带腓肠神经小隐静脉和深筋膜蒂逆行岛状皮瓣的临床治疗

目的探论腓肠神经小隐静脉和深筋膜蒂逆行岛状皮瓣的临床应用和治疗效果。方法以带腓肠神经小隐静脉和深筋膜蒂逆行岛状皮瓣治疗10例小腿远端、踝部、足跟及足背部外伤性软组织缺损、贴骨瘢痕、溃疡。结果 8例皮瓣成活良好,伤口Ι期愈合;1例皮瓣远端边缘0.5cm坏死,经清创、换药2周后伤口愈合;1例皮瓣坏死,创面后经植皮愈合。结论腓肠神经伴行血管蒂逆行岛状皮瓣血供可靠,切取简单安全,不牺牲主要血管,覆盖范围广,是修复小腿下段、踝部、足部软组织缺损较好方法     

改良腓肠神经营养血管皮瓣修复足背软组织缺损

目的总结吻合小隐静脉的远端蒂腓肠神经营养血管皮瓣修复足背软组织缺损的经验，探讨本术式皮瓣的血循环特点、成活机制及术中注意事项。方法对2003年10月-2007年6月采用吻合小隐静脉的远端蒂腓肠神经营养血管皮瓣修复足背软组织缺损20例的病例资料进行回顾性分析，该20例足背均为不同程度的软组织缺顺，术中将皮瓣近端小隐静脉与受区大隐静脉或其属支吻合。结果20例术后皮瓣均成活，无静脉回梳障碍等并发症发生。仅1例远端部分坏死，经换药后愈合。术后随访6个月～4年，足部外形良好，皮瓣质地、色泽与周边相似，足功能恢复良好。结论吻合小隐静脉改善了腓肠神经营养血管皮瓣静脉回流，为皮瓣建立了通畅的静脉回流系统，改变了皮瓣血液循环模式，扩大了皮瓣的修复范围及能力，可使皮瓣向肢端延伸，能够修复足背远端软组织缺损，为临床修复足中远端软组织缺损提供了一种新方法。     

高能量损伤致足踝部软组织缺损的创面修复

目的探讨不同种类皮瓣修复高能量损伤致足踝部软组织缺损的技术要点和临床疗效。方法以腓动脉穿支为远端蒂的腓肠神经营养血管皮瓣修复踝周前外侧、足背近端、足跟外侧创面19例,以胫前动脉穿支为远端蒂的腓浅神经营养血管皮瓣修复踝周前内侧、足背部、足跟内侧创面10例,以腓动脉的终末穿支为远端蒂的外踝上皮瓣修复外踝部、足背近端创面5例,以足底内侧皮瓣修复足跟底部负重区创面3例。结果本组34例皮瓣完全成活,1例皮瓣远端表皮坏死,2例皮瓣远端部分坏死,经局部换药后痊愈,未再次手术。术后随访6~12个月,成活皮瓣外观、质地和厚度与足踝部受区相似,负重区无溃疡发生,有保护性感觉,两点辨别觉5~10 mm。结论根据病情合理选择不同种类皮瓣修复足踝部软组织缺损可有效提高皮瓣成活率并重建肢体功能。     

腓肠神经-小隐静脉逆行岛状肌皮瓣的局部解剖与临床应用

目的：介绍腓肠神经-小隐静脉逆行岛状肌皮瓣的局部血管解剖研究与临床应用经验。方法解剖3个成人小腿灌注标本,观察腓肠神经-小隐静脉血管轴与腓肠肌内外侧头肌支和肌皮穿支之间的吻合关系,根据观察结果设计以腓动脉肌间隔穿支供血的逆行岛状腓肠肌皮瓣修复4例足踝部创面,皮瓣面积10～16 cm ×6～9 cm。结果在腓肠神经穿出深筋膜前,腓肠神经-小隐静脉血管轴与两侧的腓肠肌肌支间各有2～4个吻合。在穿出深筋膜后,与两侧的腓肠肌肌皮穿支间各有2～3个吻合。在腓肠肌腱腹交界（约为小腿中点）的近侧2～4 cm 内,有1～3支肌皮穿支血管与腓肠神经血管轴相交通。据此设计的肌皮瓣完全成活。结论腓肠神经-小隐静脉逆行岛状肌皮瓣血供可靠、转移方便,较传统的腓肠神经营养血管皮瓣可切取面积更大,是修复足踝部组织缺损的好方法。     

儿童腓肠神经营养血管逆行岛状皮瓣移植11例

目的 分析儿童腓肠神经营养血管皮瓣解剖及移植特点，比较小隐静脉结扎与否对皮瓣成活的影响。方法 11例儿童腓肠神经营养血管皮瓣移植修复足跟部皮肤缺损，其中3例术中结扎小隐静脉。皮瓣均成水滴状设计，开放外踝后方皮肤通道。结果 11例皮瓣均成活，5例术后皮瓣远端部分皮下组织液化。结论 腓肠神经营养血管皮瓣移植是治疗儿童足跟部皮肤缺损的有效方法。结扎小隐静脉对皮瓣成活无明显影响。切取皮瓣上界不超过小腿后部中上1/3处，两侧不超过侧中线；皮瓣成水滴状设计，开放外踝后方皮肤通道，及细致的显微外科操作，均是保证皮瓣移植成功的重要因素。     

腓肠神经营养血管远端蒂皮瓣小隐静脉的应用解剖

目的研究腓肠神经营养血管远端蒂皮瓣小隐静脉营养血管的来源。方法30侧动脉灌注红色乳胶成人下肢标本,以外踝尖为观测指标点,在其上10cm范围内,显微解剖观测远端蒂中的小隐静脉营养血管来源、分布与皮肤血管的关系,以及小隐静脉浅深交通支。结果由远及近,远端蒂部的小隐静脉营养血管来源于跟外侧动脉穿支、外踝后动脉穿支和腓动脉肌间隔穿支。上述动脉穿支2～5支,外径0.6～1.0mm,发深筋膜支、神经静脉营养支和皮支,形成深浅筋膜血管网、腓肠神经干血管链、小隐静脉旁血管链以及静脉壁血管网。小隐静脉浅深交通支1～2支,外径1.7±0.5mm,距外踝尖上3.4±0.9cm,汇入腓静脉。结论远端蒂的腓肠神经、小隐静脉筋膜及皮肤的营养血管同源。外踝尖上3～4cm处存在小隐静脉浅深交通支,远端蒂皮瓣旋转点设计于此处,有助于改善皮瓣静脉回流。     

The distally based lateral sural neuro-lesser saphenous veno-fasciocutaneous flap: anatomical basis and clinical applications

Background

Soft tissue management around the lower third of the leg and foot presents a considerable challenge to the plastic surgeon. The aim of this research was to investigate the anatomical relationships of artery, nerve, vein and other adjacent structures in the posterolateral region of the calf, and our experience with using a distally based island flap pedicled with the lateral sural nerve and the lesser saphenous vein for soft tissue reconstruction of lower third of leg, foot, and ankle defects in 15 patients.

Materials and methods

Five fresh cadavers (ten lower limbs) were infused with colored red latex. The origin of the nutrient vessel of the lesser saphenous vein and the lateral sural nerve was identified. Based on the anatomical studies, an island flap supplied by the vascular axis of the lesser saphenous vein and the lateral sural nerve was designed for clinical reparative applications in 15 cases.

Results

The nutrient vessel of the lesser saphenous vein and the lateral sural nerve originates from the superficial sural artery, musculocutaneous perforators of the posterior tibial artery, and septocutaneous perforators of the peroneal artery in different segment of the calf. Meanwhile, these vessels have many sub-branches nourishing subcutaneous tissue and skin, form a favorable vascular chain around the nerve and the vein, and also communicate with vascular plexus of superficial and deep fascia. Among 15 flaps, 13 showed complete survival (86.66 %), while marginal flap necrosis occurred in one patient (6.67 %) and distal wound dehiscence in another (6.67 %). Their appearance and function were satisfactory, with feeling maintained in the heel and lateral side of the foot.

Conclusions

The distally based flap pedicled with the lateral sural nerve and lesser saphenous vein was a reliable source for repairing soft tissue defects in the lower leg and foot due to its advantages of infection control, high survival rate, and sufficient blood supply without the need to sacrifice a major blood vessel.     

吻合小隐静脉的腓肠神经营养血管皮瓣修复跟骨感染创面

目的报道应用吻合小隐静脉的腓肠神经营养血管皮瓣修复跟骨感染创面的临床效果。方法应用吻合小隐静脉的腓肠神经营养血管皮瓣修复跟骨感染软组织缺损创面11例,创面面积最大12cm×18cm,最小8cm×10cm,切取皮瓣面积最大14cm×20cm．最小8cm×10cm。在转移皮瓣时将小隐静脉与创面周围大隐静脉属支吻合。结果11例皮瓣术后均无明显肿胀、瘀血等现象。其中10例顺利成活,1例皮瓣因创面感染未控制致部分坏死,清创游离植皮后治愈。其中10例获4～36个月随访,平均18．4个月,按照美国足踝外科协会评分系统踝一后足评分系统（总分100分）进行评分,最高得分97分,最低84分,平均93．5分,皮瓣外形、色泽及足踝部功能满意。结论应用吻合小隐静脉的腓肠神经营养血管皮瓣修复跟骨感染所致的足跟部皮肤软组织缺损,操作简单,皮瓣成活率高,抗感染能力强,有利于骨感染创面的愈合临床效果好。     

Clinical and anatomical study of the distally based lesser saphenous veno-lateral sural neurocutaneous flap for lower extremity coverage

Background

The distally based sural flap has been widely and successfully used to reconstruct soft tissue defects of the distal third of the lower leg and foot. Sensory loss and venous congestion are possible complications of this treatment, but there has been limited research focused on improving the sensory loss and veneous congestion. This study aimed to determine the spatial relationship between the lesser saphenous vein and the cutaneous nerves, the venous anatomy in the lower leg, and the nerve distribution in the lateral dorsum of the foot, and we presented our clinical experience.

Materials and methods

Twenty freshly amputated lower limbs were dissected in the 2 h following amputation. The lesser saphenous vein, medial/lateral sural nerve, and sural nerve were identified. Based on the anatomical studies, an island flap supplied by the vascular axis of the lesser saphenous vein and the lateral sural nerve was designed for clinical reparative applications in 24 cases.

Results

We indicated the spatial relationship between the lesser saphenous vein and the cutaneous nerves and the venous anatomy in the lower leg. Among 24 flaps, 21 showed complete survival (87.5 %), while marginal flap necrosis occurred in two patients (8.33 %) and distal wound dehiscence in another (4.17 %). No symptomatic neuromas were observed. Their appearance and functioning were satisfactory, with filling maintained in the heel and lateral side of the foot.

Conclusion

The distally based lesser saphenous veno-lateral sural neurocutaneous flap provides effective coverage of variable-sized soft tissue defects on the lower third of the lower leg and foot, without sensory loss and venous congestion.     

腓肠神经-小隐静脉营养血管远端蒂皮瓣动脉穿支的应用解剖

目的研究腓肠神经-小隐静脉营养血管远端蒂皮瓣动脉穿支的分布规律及临床应用。方法对30侧动脉灌注红色乳胶成人下肢标本,解剖观测远端蒂部的动脉来源及分布。2003年1月～2004年8月,在解剖学研究的基础上,临床采用低旋转点的腓肠神经-小隐静脉营养血管远端蒂皮瓣36例。其中男21例,女15例。年龄6～66岁,平均35.2岁。足跟及足底部皮肤缺损18例,足背部缺损10例,中前足缺损8例,均伴有骨、肌腱外露。缺损范围:3.5cm×2.5cm～17.0cm×11.0cm,切取皮瓣4cm×3cm～18cm×12cm。结果远端蒂动脉穿支2～5支,来源于跟外侧动脉穿支及外踝后动脉穿支,外径0.6±0.2mm和0.8±0.2mm,距外踝尖上1.0±1.3cm和2.8±1.0cm。腓动脉肌间隔穿支0～3支,出现率依次为96.7%、66.7%和20.0%,外径0.9±0.3、1.0±0.2和0.8±0.4mm,距外踝尖上5.3±2.1、6.8±2.8和7.0±4.0cm。动脉穿支发出皮支、皮神经浅静脉营养支和深筋膜支,形成腓肠神经-小隐静脉营养血管链和深、浅筋膜血管网。临床应用36例皮瓣全部成活,仅3例术后皮瓣边缘少量坏死,经换药后愈合。所有患者经8～16个月随访,供区外形良好,患肢能正常行走,皮瓣感觉逐步恢复。结论以外踝后动脉穿支为蒂,皮瓣旋转点在外踝尖上3.0cm。以跟外侧动脉穿支为蒂,皮瓣旋转点近外踝尖平面。     

Maximizing the reliability and safety of the distally based sural artery flap

Variations of the distally based sural artery flap have been used in the literature with varying success rates. This article stresses the axiality of this flap based on the sural nerve and the short saphenous vein. Forty distally based sural artery flaps were used for a variety of defects in the distal leg. In the proximal leg, the groove between the medial and lateral heads of the gastrocnemius muscle was explored to include the subfacial part of the medial sural nerve with the flap. The subfascial part of the nerve can consistently be included with the flap and gives off cutaneous supply to the tip of the flap to increase reliability of the distal part of the flap. The short saphenous vein should be harvested with an additional length to allow for supercharging or intermittent bleeding in the event of flap congestion. With this approach our success rate with this flap was 98%. To maximize the reliability of the distally based sural artery flap, the sural nerve and short saphenous vein must be included with the flap along its entire length.     

腓肠神经营养血管肌皮瓣的解剖与临床应用

目的 探讨腓肠神经营养血管肌皮瓣转移修复足踝部软组织缺损的解剖学依据及其临床应用效果.方法 对30侧成人下肢灌注标本进行解剖,系统观测小腿后区浅层中血管神经的分支、分布及相互交通吻合情况.在此基础上,2004年2月以来应用逆行腓肠神经营养血管肌皮瓣修复足踝部软组织缺损7例.结果 以腓肠神经、小隐静脉及股后皮神经的营养血管为主的浅筋膜血管网与深部的腓肠肌内外侧头有恒定的交通吻合,吻合支均为2～3支,腓肠肌内、外侧头肌皮穿支分别位于内外侧头肌间沟两侧(1.8±0.5)cm、(3.7±0.9)cm,内侧头的肌皮穿支较外侧粗大,位置恒定,更靠近中线.7例肌皮瓣的肌肉面术中可见渗血活跃,血供良好,皮瓣均成活,所有病例均经2～6个月以上随访,骨髓炎治愈,肌皮瓣外形满意.结论 带部分腓肠肌内外侧头肌肉的逆行腓肠神经营养血管皮瓣可以良好成活,手术操作简便,系足踝部软组织缺损可以选择的供区.