侧颌颈部真皮下血管网皮瓣的解剖学基础

目的：为侧颌颈部真皮下血管网皮瓣提供形态学基础。方法：①2例新鲜成人尸体头颈部标本,分别灌注红色乳胶及明胶墨汁,切取皮瓣,后者制成透明标本;②在10侧头面部铸型标本上,观测侧颌颈部皮肤和皮瓣蒂部的动脉血管分布及静脉回流。结果：侧颌颈部皮肤血供主要来源于面动脉、颞浅动脉、枕动脉的分支,亦有甲状腺上动脉的终末支分支营养,并具有一定的方向性。其蒂部血供来源于颞浅动脉小穿支形成的真皮下血管网。颞浅动脉和面动脉的小穿支在侧颌颈区相互吻合。结论：侧颌颈部真皮下血管网皮瓣可以依赖于耳前蒂部小穿支真皮下血管网供血成活,但临床应用时应考虑其方向性。     

Arterial anatomy of the lateral orbital and cheek region and arterial supply to the “peri-zygomatic perforator arteries” flap

Arterial anatomy of the lateral orbital and cheek region and subsequently of the “peri-zygomatic perforator arteries” flap is described, based upon the dissection of the 24 human cadaver head halves. Each specimen was dissected in subdermal, first fascial and deep level. The subdermal vascular network of lateral orbital and cheek region, its orientation and contributing arteries were studied. Origin, perforation sites and diameters of transverse facial, zygomaticoorbital, zygomaticofacial and zygomaticotemporal arteries were also described and measured. Our findings support the view that the cheek island flap used for lower eyelid is a reverse flow axial pattern flap. It includes arterioles of the transverse facial artery, which are part of the subdermal vascular plexus and are uniformly longitudinally oriented. The flap receives its blood supply via perforators of the zygomaticoorbital, zygomaticofacial and zygomaticotemporal arteries, which are connected via their terminal branches with transverse facial artery.     

轴型真皮下血管网皮瓣的应用解剖

目的　为临床应用轴型真皮下血管网皮瓣 (ASVNF)提供解剖学依据。方法　对 12侧下肢标本进行了解剖学观察。重点解剖观察股前外侧ASVNF和隐血管ASVNF的轴心血管在浅筋膜层的走行、分支、真皮下血管网 (SVN)的构筑和皮瓣超薄范围等情况。结果　肌皮穿支穿出深筋膜层后向周围不同方向发出三种分支 ,其中SVN分支斜穿较少浅筋膜后很快进入真皮下层形成吻合稠密的SVN ,制备股前外侧ASVNF应采用“圆形”超薄法。直接皮肤血管在浅筋膜层纵行途中主要向两侧及浅面发出分支 ,制备隐血管ASVNF应采用“U形”超薄法。SVN分支在真皮下层反复分支形成“血管树”或“蜘蛛痣”状血管网 ,且血管网之间稠密吻合。结论　不同血供类型ASVNF的超薄方法应不同。     

远端蒂腓浅神经营养血管肌皮瓣的解剖与临床应用

目的探讨腓浅神经营养血管为蒂的肌皮瓣修复小腿远端及足踝部皮肤软组织缺损伴骨缺损慢性骨髓炎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,系统观测腓浅神经及其营养血管的来源、走行、分布、吻合及外径;3侧成人新鲜下肢标本墨汁灌注,观测腓浅神经营养血管的墨染范围;在此基础上,自2009年6月以来,应用远端蒂腓浅神经营养血管肌皮瓣修复小腿远端及足踝部皮肤软组织缺损伴骨缺损慢性骨髓炎者12例。结果腓浅神经营养血管发自胫前动脉穿支,其血管在其神经束间及神经旁相互吻合构成丰富的血管网,并借分支与皮下筋膜血管网沟通,并与腓骨长肌、趾长伸肌的肌支有恒定的吻合,营养筋膜皮肤。12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,术后3~6个月随访12例肌皮瓣均存活,慢性骨髓炎治愈,外形满意。结论腓浅神经营养血管的肌皮瓣转位修复小腿远端及足踝部特殊创面是较佳的选择,该肌皮瓣具有血供可靠,预后良好等优点。     

带腓浅神经及其营养血管筋膜皮瓣的应用解剖

目的：提供带腓浅神经及其营养血管筋膜皮瓣的形态学依据。方法：在３２侧成人下肢标本上,观测了腓浅神经及其营养血管、周围皮肤的血供情况。结果：腓浅神经（皮下段）近侧的血供为腓浅动脉深支的皮动脉、第１支肌间隔动脉,起始处外径分别为０．８ｍｍ、１．１ｍｍ;第１支肌间隔动脉穿出深筋膜前长为１．８ｃｍ。远侧则为腓动脉穿支之升支、降支的皮支和足背动脉皮支,起始处外径分别为０．９ｍｍ、０．７ｍｍ和０．８ｍｍ,穿出深筋膜前长分别为１．２ｃｍ、０．７ｃｍ和０．８ｃｍ。其神经支在神经干内或旁彼此吻合,构成纵向链式血管网,并借分支与皮肤、皮下及筋膜血管网沟通。结论：可设计带皮神经及其营养血管筋膜皮瓣,顺行或逆行转位修复邻近部位软组织缺损     

以颞浅血管为蒂的耳后乳突区皮瓣的应用解剖

在17侧防腐尸体上于颞浅动脉内推注染料,观察其对耳后乳突区皮瓣的血供。耳后乳突区皮肤的血供除来自耳后动脉外.还有颞浅动脉顶支发出的耳后支直接分布。顶支与耳后动脉之间有一血管吻合区域.临床6例活体观察证实了上述结果。应用以颞浅血管为蒂的耳后乳突区皮瓣,进行颜面器官的修复再造14例,获得良好效果。     

缝匠肌穿支皮瓣的应用解剖学研究

目的　明确缝匠肌肌皮动脉穿支和肌间隙穿支的分布区域特征,为缝匠肌穿支皮瓣的临床应用提供解剖学依据。 方法　逐层解剖12侧经红色乳胶灌注的成人下肢新鲜标本,观察缝匠肌动脉血供特征、穿支数目及优势血管分布。 结果　由各动脉发出进入缝匠肌及其表面皮肤的穿支血管有7~12支,其中以缝匠肌中、上段穿支分布较为集中,主要为股动脉发出。肌皮穿支有3~4支,平均管径(1.30±　0.15)mm,蒂长(1.10±0.10)cm;肌间隙穿支2~3条,管径(1.20±0.20)mm,蒂长(1.15±0.15)cm。此外,旋股外侧动脉发出一较长肌间隙穿支,管径(1.35±0.05)mm,蒂长(7.20±1.40)cm,可达缝匠肌中段。 结论 缝匠肌中、上段穿支较多而位置相对恒定,设计缝匠肌皮瓣游离移植修复组织缺损是切实可行的。     

大鼠腹壁浅动脉穿支皮瓣的解剖学

目的探讨大鼠腹壁浅动脉穿支皮瓣的解剖学特点,为该皮瓣切取提供解剖学依据。方法 SD大鼠27只,7只行大体解剖,描述该皮瓣的解剖学特点;20只经颈总动脉行明胶-氧化铅灌注,并通过图片处理技术测量相关数据。结果腹壁浅动脉由股动脉发出后在穿浅筋膜处发出第1个分支,随即分为内外侧支,分别与胸外侧动脉和胸背动脉吻合。其外径在股动脉发出处为(0.46±0.02)mm,在穿经浅筋膜处为(0.46±0.02)mm,其营养面积为(18.37±3.67)cm2,其与胸背动脉的吻合区距离腋下水平线和腹中线分别为(5.34±0.86)cm和(4.38±0.38)cm;与胸外侧动脉的吻合区距离腋下水平线和腹中线分别为(6.28±0.69)cm和(2.04±0.33)cm。结论大鼠腹壁浅动脉解剖位置和外径恒定,是游离皮瓣移植、皮瓣动脉增压、血流动力学研究等的理想模型。     

肢体真皮下血管网

目的：研究肢体真皮下血管网的构成和形态。方法：成人前臂和小腿27例，乳胶或碳素墨水灌注，结合巨微解剖和组织学方法观察真皮下血管网的动脉来源及其在皮肤内的走行、分支、吻合。结果：前臂和小腿的真皮下血管网来源于直接皮动脉、肌皮动脉和隔皮动脉，而以后者为主。动脉在真皮下层的行程较长，走行方向与皮肤表面平行，相互吻合成较粗的血管网。后者进一步逐级分支、吻合，形成完整的真皮下血管网。结论：肢体真皮下血管网位于真皮下层，在皮肤和浅筋膜之间，是皮肤血供的直接来源，也是超薄皮瓣容易成活的解剖学基础。     

前臂皮瓣筋膜血管的解剖学

系统并定量研究前臂皮瓣筋膜的血管，以补文献之不足并为临床应用提供形态学基础。对１４例成人标本进行了巨微解剖，组织透明，切片观察和图像分析，前臂筋膜四种动脉来源以肌间隙皮动脉为主，肌间隔或肌间隔皮动脉吻合成链，各种源动脉在深筋膜有浅，深支而以浅支多而粗，深筋膜浅，深血管网也以前者较密，深筋膜血管组织面积比值大于浅筋膜。深筋膜血管特别是深筋膜浅血管网是前臂筋膜皮瓣的血供基础，筋膜蒂宜放在血管链状吻合处     

同体两侧股前外侧皮瓣的解剖学对比

目的 探讨同体两侧股前外侧（ALT）皮瓣的解剖学差异,为术前进行供侧大腿选择的必要性提供解剖学依据。 方法 10具新鲜尸体标本（共20例）上行双侧ALT皮瓣制取,寻找皮瓣的营养穿支,记录穿支类型和数量,并逆向追溯到血管蒂;测量各穿支、血管蒂的长度和管径,统计学数据采用均值±标准差。 结果 10具标本中有3具两侧股前外侧皮瓣为肌间隔穿支和肌皮穿支双供血型;其余7具两侧穿支类型不同。7具标本两侧皮瓣的穿支数量不同,另外3具的穿支数量相同。肌间隔穿支走行于股直肌与股外侧肌之间的肌间隙内,肌皮穿支或垂直或斜形穿过股外侧肌,其穿支长度各异。皮瓣穿支全部发自旋股外侧动脉（LCFA）降支的有14例,另有6例（30%,源于5具标本）皮瓣既有降支又有斜支参与供血,其中1具标本两侧均由斜支与降支双重供血,其余4具标本均只有1侧为斜支与降支双重供血。10具标本共20例皮瓣的两侧主要穿支和血管蒂管径及长度差别不大(P>0.05)。 结论 同体两侧股前外侧皮瓣的营养穿支在类型、数量、走行、血管蒂来源上存在差异,穿支的种类及走行对于皮瓣制取的难易及操作时间有直接影响。术前进行供侧大腿的选择有助于股前外侧皮瓣精准、快捷的制取。     

Anatomical study on arteries of fasciae in the forearm fasciocutaneous flap

The arteries of the forearm flap were studied systematically and quantitatively to determine the survival mechanism of fasciocutaneous flaps and provide morphological basis for clinical application. Fourteen forearms from fresh adult cadavers were investigated by methods of dissection under operating and biological microscopes, tissue clearing, tissue sectioning, and image analysis. There were four arterial types in the forearm flaps in which the intermuscular space cutaneous artery was predominant in number. Both intermuscular space cutaneous arteries and intermuscular septal cutaneous arteries anastomosed by branches as arterial chains along the intermuscular spaces and septa where the stem arteries ran through. Arteries of each type gave off epi- and subfascial branches to the deep fascia, and the former were greater in number and larger in diameter. In the same way, the vascular network was thicker in the epifascial level than that in the subfascial level. The percentage of the area of blood vessels in deep fascia (Aa%) was larger than that of the superficial fascia. In the forearm, the deep fascial vasculature is the main pathway through which the fasciocutaneous flap gains its blood supply, and the epifascial vascular network is especially important. It would be better to select the fascial pedicle where the arterial chain exists.     

Clinical anatomy of the arterial supply of the human patellar ligament

The arterial supply of the human patellar ligament has been systematized on 20 knee joints. After intravascular injection of colored natural latex, the blood supply to the extensor apparatus of the knee was studied by anatomical dissection and tissue transparentation techniques. Three arterial pedicles (superior, middle and inferior) were observed placed on each side of the patellar ligament. Medial pedicles had their origin from the descending and the inferior medial genicular arteries. The lateral pedicles took their origin from the lateral genicular arteries and the recurrent tibial anterior artery. Two main vascular arches anastomosed with these pedicles: the retropatellar and the supratubercular. Both arterial pedicles and anastomotic arches gave rise to a peritendinous network, characterized by a high vascular density next to poles of the patellar ligament. Only the anastomotic arches gave rise to collateral vessels that pierced the tendon, which revealed two vascular segments in the arterial supply of the patellar ligament (bipolar pattern). The upper segment was supplied by deep vessels from the retropatellar arch, whereas the inferior segment received superficial vessels from collaterals of the supratubercular arch. These intratendinous vessels anastomosed in the middle third of the patellar ligament.     

逆行缝匠肌皮瓣修复小腿皮肤缺损应用解剖学

目的为设计逆行缝匠肌皮瓣转位修复小腿皮肤缺损提供解剖学基础。方法解剖观测40侧缝匠肌的动脉来源、走行、外径、分布及吻合。取4侧新鲜成尸下肢标本进行动脉造影,观察缝匠肌内动脉吻合。结果营养缝匠肌的动脉为6～7支,呈节段性分布,缝匠肌的上1/5段动脉来源于旋髂浅动脉、旋股外侧动脉或股深动脉,中2/5段动脉来源于股动脉,下2/5段动脉来源于隐动脉。隐动脉起点位于内收肌结节上(10.2±1.0)cm处,外径(1.5±0.2)mm,向下发出3～5个分支入缝匠肌,隐动脉终末支在膝下内侧参与膝关节网。缝匠肌的各节段动脉在肌内分为4～7支沿缝匠肌纵轴走行,相邻动脉的分支在肌内形成链型吻合,吻合处外径0.3mm左右。深筋膜表面有皮动脉和肌皮动脉形成的链式血管吻合网,营养缝匠肌表面的皮肤。结论缝匠肌内动脉链型吻合为逆行缝匠肌皮瓣供血,扩大了该肌皮瓣的切取长度,故以隐动静脉为血管蒂的逆行缝匠肌皮瓣可修复小腿中下段软组织缺损。     

吻合臂内侧皮神经及其血管筋膜皮瓣的解剖与临床

目的:为带臂内侧皮神经及其营养血管筋膜皮瓣提供形态学基础。方法:在32侧成人上肢标本上,观测臂内侧皮神经营养血管及其周围皮肤的供血情况。结果:臂内侧皮神经的血供为尺侧上副动脉肌间隔皮支、肱动脉肌间隔皮支和尺侧下副动脉肌间隔皮支,起始处外径分别为1.0mm、0.6mm和0.7mm,穿出深筋膜前长为1.5cm、1.1cm和1.2cm。其神经支在神经束间或神经旁相互吻合构成丰富的血管网,并借分支与筋膜皮支所形成的皮下筋膜血管网沟通。结论:可设计成带臂内侧皮神经及其营养血管的筋膜皮瓣,顺行或逆行转位修复邻近部位的软组织缺损。     

内踝区动脉网的显微解剖与隐神经营养血管远端蒂皮瓣的设计

目的：为隐神经营养血管远端蒂皮瓣设计提出解剖学依据。方法：30侧经动脉灌注红色乳胶成年下肢标本，解剖观测内踝区动脉来源、分支、分布及吻合。结果：内踝区动脉有9个来源，构成3条纵向的血管网：(1)内踝前动脉和踝上支的前纵向血管网；(2)骨皮穿支的中纵向血管网；(3)胫后动脉肌间隙支和踝管动脉穿支的后纵向血管网。形成3个层面的血管网：(1)骨膜血管网；(2)深筋膜血管网；(3)皮神经浅静脉血管网。内踝区骨膜、筋膜、大隐静脉、隐神经和皮肤的营养血管同源。结论：内踝区血供来源为多源性，有明显的方向性，吻合十分丰富，可以设计3种包含浅深筋膜、皮神经、浅静脉及其营养血管的小腿内侧远端蒂皮瓣：(1)以胫后动脉肌间隙支为蒂，旋转轴点在内踝最凸出点上3cm；(2)以内踝前动脉筋膜穿支为蒂；(3)以踝管区动脉穿支为蒂，旋转轴点在内踝最凸出点平面。     

Anatomical study of perforator arteries in the distally based radial forearm fasciosubcutaneous flap

We investigated the anatomical vascular basis of the forearm fasciosubcutaneous flap (FSC-F), fed by the distal perforator arteries of the fascia. This type of flap was proposed, in hand reconstructive surgery, to avoid the disadvantages caused by axial-pattern reverse radial forearm fasciocutaneous flap, based on ligation and rotation of the radial artery (RA). In eight fresh cadaveric forearms, the RA was injected slowly with acrylic resin and the superficial flexor compartment was dissected. Then the FSC-F was raised from the lateral margins of the sample to the median RA axis, and the collaterals of the RA (number, interval of origin, and caliber) were evaluated. The fascial branches of RA (mean number +/- SD: 20 +/- 3) originated mainly from the radial and ulnar sides of the RA. In the distal forearm the vessels were more numerous (mean value = 11.3 vs. 8.9; Student's t-test, P < 0.05) but smaller in diameter (mean value = 0.45 mm vs. 0.63 mm; Student's t-test, P < 0.05). The perforator arteries forked in a T-shape following the main axis of the forearm and anastomosed in the fascial plane, forming longitudinal fan-shaped arterial chains giving rise to the vascular epifascial network. Histological (hematoxylin-eosin, azan-Mallory, Weigert) and immunohistochemical (anti-von Willebrand factor) study of the FSC-F at different levels of sampling was also carried out. The epifascial branches of distal sections were smaller in diameter (78.3 +/- 35.5 microm) than those of intermediate (105.7 +/- 28.7 microm; Newman-Keuls test, P < 0.01) and proximal (116.8 +/- 31.2 microm; Newman-Keuls test, P < 0.001) sections. Our findings indicate that the perforator arteries and epifascial branches are smaller in the distal forearm, so that during surgical dissection, the safety distance from the radial styloid should take into account that also in the presence of a sufficient number of vessels in the distal forearm their caliber could be inadequate to the hemodynamic request of the flap. Thus, rather than on a theoretic distance from the radial styloid, the length of the flap should be based on an accurate evaluation of the individual vascularization of the forearm case by case.     

足内侧穿支皮瓣设计的解剖基础

目的    为足内侧穿支皮瓣的临床应用提供解剖基础。  方法　对8侧乳胶灌注的成人下肢标本足内侧区进行显微解剖,观测各穿支血管的位置、数目、外径、蒂长及吻合等情况。  结果　足内侧区皮肤的血供有：足底内侧动脉、内踝前动脉、跗内侧动脉和母趾胫侧动脉。足底内侧动脉浅支穿母展肌在舟骨粗隆附近浅出,外径（1.08±0.20）mm;深支从母展肌和趾短屈肌的间隙内向足底内侧平均发出5.3支穿支,平均外径（0.63±0.25）mm,蒂长（0.93±0.31）cm;内侧深支的内侧支由舟骨粗隆前（1.92±0.61）cm处从母展肌上缘浅出至足内侧。母趾胫侧动脉从第一跖趾关节近侧（2.03±0.56）cm处穿出至足内侧。足底内侧动脉浅支、内侧深支的内侧支与内踝前动脉、跗内侧动脉吻合形成展肌上缘动脉弓,动脉弓的远端与母趾胫侧动脉相吻合。  结论　足内侧穿支皮瓣可设计以不同的穿支为蒂进行带蒂转移,修复前足、踝部及足跟周围软组织缺损,也可设计游离皮瓣修复手指掌侧软组织缺损。     

带腓肠外侧皮神经及其营养血管筋膜皮瓣的应用解剖

目的 为带腓肠外侧皮神经及其营养血管筋膜皮瓣的临床应用提供解剖学基础.方法 在32例成人下肢标本上,对腓肠外侧皮神经及其营养血管进行解剖观测.结果 腓肠外侧皮神经在腓骨头平面上方 7.1±2.4cm处起于腓总神经,分布于小腿后外侧上半或上2/3的皮肤.其营养动脉主要为:腓肠外侧皮动脉:起自腘动脉,在腓骨头平面上方5.0±1.5cm处浅出,外径为0.9±0.3mm;肌间隔筋膜皮支:起自胫后动脉和腓动脉,分别在腓骨头平面下方9.2±3.8cm和15.8±3.8cm处浅出,外径为0.7±0.3mm和0.9±0.4mm.该营养动脉除在腓肠外侧皮神经周围或其内呈链式吻合外,还发出筋膜皮支与邻位的皮动脉连接.静脉血可沿伴行静脉或小隐静脉及其属支回流至深静脉.结论 以腓肠外侧皮神经及其营养血管为蒂,可设计成顺行或逆行转位筋膜皮瓣,修复邻近部位的软组织缺损.     

The proximal radial artery perforator flap (PRAP-flap): an anatomical study for its use in elbow reconstruction

We investigated the anatomical vascular basis of the proximal radial artery perforator flap (PRAP-flap) and we report here the first clinical application in a case of reconstructive surgery as an alternative to traditional regional fasciocutaneous pedicled flaps or microsurgery solutions. In 16 unembalmed cadaveric forearms, the radial artery was slowly injected with acrylic resin through the brachial artery and the superficial flexor compartment was dissected. The flap was raised from the lateral and medial sides of the forearm toward the axis represented by the radial artery, and the characteristics (number, diameter, site and interval of origin, and course) of its collaterals were evaluated. In the proximal forearm, the vessels were less numerous (mean values 8.6 vs. 11.5, P < 0.05) but larger in diameter (mean values 0.7 vs. 0.4 mm, P < 0.05) than in the distal forearm. The first four proximal perforator arteries originated within a mean distance of 4.3 cm from the origin of the radial artery, with a 95% confidence interval of 3.8–4.8 cm. The perforator arteries followed the axis of the forearm and anastomosed in the fascial plane, forming longitudinal fan-shaped arterial chains, giving rise to an epifascial vascular network. This anatomical study allowed us to plan and perform a PRAP-flap in a 35-year-old woman who was suffering from comminuted fractures of the olecranon and distal epiphysis of the humerus and soft tissue loss from traumatic injury of the elbow. From the antebrachial surface, a proximally based radial forearm fasciocutaneous flap was raised, with a vascular pedicle of 16 × 5 cm, a cutaneous island of 4 × 5 cm, and a pivot point 5 cm from the interepicondylar line. The flap showed good immediate and long-term viability: it was completely incorporated with good pliability and the patient regained good functional quality of the elbow joint. The anatomical features and the demonstrative reconstructive result obtained in the here-reported surgical case support the clinical evidence that a reliable forearm skin paddle may be raised on a subcutaneous fascial axial pedicle supplied only by proximal perforators of the radial artery. The so-obtained PRAP-flap is useful for the coverage of elbow defects when other reconstructive options are no longer available.