带蒂皮瓣治疗小腿和足踝部皮肤软组织缺损

目的探讨小腿和足踝部皮肤软组织缺损的手术方法及其疗效评价。方法1997年6月至2005年12月,43例小腿及足踝部皮肤软组织缺损的患者,男38例,女5例;年龄7～63岁,平均35岁;皮瓣面积4cm×3cm～25cm×15cm。采用9种带蒂的肌皮瓣和筋膜皮瓣进行治疗:(1)腓肠肌内、外侧头肌皮瓣带蒂转移修复小腿中上1/3合并膝关节前及内侧皮肤软组织缺损2例;(2)小腿前内侧交腿皮瓣修复小腿中段胫前皮肤软组织缺损2例;(3)带隐神经小腿内侧交腿皮瓣修复前足足底缺损1例;(4)带胫后动脉小腿内侧逆行岛状皮瓣修复足背部皮肤软组织缺损1例;(5)小腿内侧远端蒂筋膜皮瓣修复小腿中下1/3胫前皮肤软组织缺损2例;(6)腓肠神经营养血管蒂逆行岛状皮瓣修复小腿中下1/3、踝部及足跟皮肤软组织缺损17例;(7)隐神经营养血管蒂逆行岛状皮瓣修复小腿中下1/3、踝部及足背皮肤软组织缺损14例;(8)外踝上动脉逆行岛状皮瓣修复足背皮肤软组织缺损2例。(9)足内侧远端带蒂岛状筋膜皮瓣修复第一跖骨头处皮肤软组织缺损2例。结果43例皮瓣中有37例术后全部成活,创面一期愈合,1例皮瓣浅层坏死,5例皮瓣远端边缘少许坏死,经短期换药后愈合。所有病例均得到随访,皮瓣全部良好。结论治疗小腿和足踝部皮肤软组织缺损应严格掌握手术适应证,合理选择皮瓣种类。腓肠神经和隐神经营养血管蒂岛状皮瓣是较理想的修复小腿及足踝部软组织缺损的材料。     

皮瓣修复足跟部皮肤软组织缺损的研究进展

用于修复足跟部皮肤软组织缺损的皮瓣,主要分为知名血管皮瓣和非知名血管皮瓣,前者主要包含小腿外侧、内侧皮瓣和足背皮瓣等;后者主要包括足底内侧皮瓣、足外侧皮瓣、外踝上逆行岛状皮瓣,以及皮神经营养血管皮瓣（腓肠神经营养血管筋膜蒂皮瓣和隐神经营养血管皮瓣）等。本文对用于足跟部皮肤软组织缺损的各种皮瓣的解剖学基础和治疗优缺点进行综述。     

足跟部软组织缺损修复25例

目的 比较足跟部软组织缺损各类修复方法的优缺点。方法 通过6个月-7年随访，分析和比较8种类型的皮瓣：足底内侧岛状瓣7例、小腿前外侧逆行岛状皮瓣6例、外踝上逆行岛状皮瓣3例、小腿内侧逆行岛状皮瓣3例、腓肠神经营养血管皮瓣4例、带蒂足背皮瓣1例、游离股前外侧皮瓣4例、游离腓动脉皮瓣1例，共29个皮瓣修复足跟软组织缺损的效果。结果 29个皮瓣中27个皮瓣完全成活，2个部分坏死。足底内侧皮瓣的外形、质地最佳，有感觉功能，皮瓣与跟骨有良好的贴附，负重后表皮可形成较厚的角化，无冻伤、烫伤及溃疡形成，患足可以正常负重。游离股前外侧皮瓣及小腿前外侧逆行岛状皮瓣等带蒂皮瓣表皮均无明显角化，表面存在不同程度的磨损、水疱或溃疡，皮瓣与跟骨间存在不同程度的滑动，影响足跟完全负重。结论 采用足底内侧皮瓣修复效果最好，但修复面积有限,采用不同形式的小腿皮瓣修复效果无明显差别；游离股前外侧皮瓣适合修复大面积皮肤缺损。     

逆行腓肠神经营养血管皮瓣修复足踝部软组织缺损

目的观察腓肠神经营养血管皮瓣逆行转移修复足踝部及小腿软组织缺损的效果。方法设计带筋膜蒂的腓肠神经营养血管岛状皮瓣,逆行修复足踝部及小腿软组织缺损5例。同时,观察皮瓣的可切取范围、血液供应及静脉回流情况,营养血管在外踝与腓动脉穿通支的位置,以及血管蒂隧道的处理方案。结果足跟软组织缺损2例,外踝缺损1例,小腿内下端1例,跟腱外露1例,皮瓣最大面积16cm×12cm,全部成活。结论腓肠神经营养血管皮瓣血液循环丰富,成活率高,手术简单,是修复足踝部及小腿软组织缺损的理想皮瓣。     

逆行及顺行腓肠神经营养血管皮瓣的临床应用

目的探讨腓肠神经营养血管皮瓣逆行转移修复足背、足跟及踝部组织缺损,顺行转移修复膝部组织缺损的临床应用效果。方法在应用解剖及对成人小腿和足背长度测量基础上,设计带筋膜蒂的腓肠神经营养血管岛状皮瓣,逆行应用修复足背、足跟、足底及踝部软组织缺损,顺行应用修复膝部软组织的缺损。同时观察皮瓣的可切取范围、血液供应及静脉回流情况、营养血管在外踝上与腓动脉穿通支的位置及血管蒂隧道的处理方案。结果临床应用23例,其中修复足背组织缺损11例、足跟软组织缺损5例、膝软组织缺损3例、足底软组织缺损1例及外踝及足背联合缺损3例。皮瓣最大面积16cm×10cm,全部成活。结论腓肠神经营养血管皮瓣血液循环丰富,成活率高,是修复足背、足跟、踝部、足底及膝部软组织缺损的理想皮瓣。     

足跟部软组织缺损36例分析

目的 探讨足跟部软组织缺损的修复方法.方法 对36例足跟部软组织缺损患者分别采用足底内侧岛状皮瓣、足背岛状皮瓣以及小腿下内侧逆行筋膜蒂皮瓣进行修复.结果 术后皮瓣全部成活,质地优良.随访无一例足跟溃疡发生,足跟功能恢复正常.结论 足底内侧岛状皮瓣、足背岛状皮瓣以及小腿下内侧逆行筋膜蒂皮瓣血供可靠,取材容易,此三种皮瓣是修复足底软组织缺损较理想的组织材料;一般不宜皮片移植修复.     

外踝上逆行岛状皮瓣的临床应用

外踝上逆行岛状皮瓣的临床应用廉洪文，杨韩芳，潘换丽足背部的深度组织缺损，以往多用游离皮瓣或同侧小腿以一条主要血管为蒂的逆行岛状皮瓣修复。其或需复杂手术，或需付出牺牲小腿一条主要血管的代价。因此，我们自１９９２年９月以来，应用外踝上逆行岛状皮瓣修复７例...     

足跟部软组织缺损的显微外科治疗

自 1996年～ 2 0 0 0年应用皮瓣修复跟部软组织缺损 6 8例 ,其中岛状皮瓣 5 4例、吻合血管皮瓣 14例。计有足背皮瓣 2 4例、足外侧皮瓣 3例、足底内侧皮瓣 2 3例 ,小腿外侧逆行皮瓣 5例、小腿内侧皮瓣 11例、背阔肌皮瓣 2例。术后带蒂皮瓣有 4例边缘坏死 ,吻合血管失败 1例 ,其余全部成活。体会 :足跟周围岛状皮瓣是修复足跟软组织缺损的较理想的方法。足跟部软组织缺损的显微外科治疗@马维虎$甘肃省张掖地区医院骨科     

带腓肠浅血管蒂逆行筋膜岛状皮瓣修复小腿及足跟部组织缺损

:我院采用带腓肠浅血管逆行岛状皮瓣修复小腿及足跟部组织缺损的6例。其移植的皮瓣全部成活,切口一期愈合,所有修复的肢体均保留和恢复了功能,部分皮瓣感觉已恢复。带腓肠浅血管蒂逆行筋膜岛状皮瓣修复小腿及足跟部组织缺损$中国人民解放军第一八七医院骨科@许声联...     

皮神经伴行血管蒂逆行岛状皮瓣的临床应用

目的 :探讨皮神经伴行血管蒂逆行岛状皮瓣的临床应用。方法 :使用前臂外侧皮神经伴行血管蒂逆行岛状皮瓣修复腕掌、腕背及虎口部皮肤软组织缺损 5例。腓肠神经伴行血管蒂逆行岛状皮瓣修复小腿远端、足跟足背皮肤软组织缺损 10例。皮瓣切取面积 5 cm× 5 cm～ 15 cm× 9cm。结果 :15例皮瓣 ,13例完全成活。1例皮瓣远端边缘 0 .5 cm坏死 ,经换药后愈合。 1例皮瓣坏死 ,创面植皮后愈合。结论 :皮神经伴行血管蒂逆行岛状皮瓣血供可靠 ,切取简便、安全 ,不牺牲主要血管 ,是修复四肢皮肤软组织缺损较好的方法之一     

《整形外科手术图谱》出版

《整形外科手术图谱》出版由著名整形外科专家张涤生、辛时林、易传勋等教授主编，国内十余所医学院校的二十余位专家教授共同编著的大型专业参考书《整形外科手术图谱》已由湖北科技出版社出版发行。该书以其普及性与实用性为特点，通过近３０００幅精细逼真的线条图和彩...     

跗外侧动脉蒂小腿前外侧皮瓣的解剖基础与临床应用

目的 探讨跗外侧动脉蒂小腿前外侧皮瓣的解剖特点,以及修复足前部缺损的可行性.方法取20条经动脉灌注红色乳胶的成人下肢尸体标本,解剖观察其跗外侧动脉、腓动脉外踝上穿支、腓浅动脉等血管的分支、走行和吻合.据此设计跗外侧动脉蒂小腿前外侧皮瓣,对8例足前部组织缺损患者进行带蒂皮瓣转移修复.足背皮肤软组织缺损5例,足底皮肤软组织缺损3例.足前部缺损范围5 cm×4 cm ～ 9 cm×5 cm.供区游离植皮或直接缝合.跗外侧动脉、腓动脉穿支、胫前动脉穿支、腓浅动脉相互吻合,在足外侧、外踝前、小腿前外侧形成一条纵行血管轴.皮瓣范围6 cm×4 cm ～ 10 cm×6 cm.结果 术后8块皮瓣全部成活.所有患者均获随访,随访6～12个月,平均8个月,皮瓣色泽、质地、外形良好,皮瓣无溃疡发生.患者能自由行走.结论 以跗外侧动脉为蒂切取小腿前外侧皮瓣,皮瓣血运可靠,血管蒂长,可修复足前部任何区域,供区损伤小.     

应用逆行腓肠肌内外侧头肌皮瓣修复小腿中下1/3软组织缺损

目的 探讨逆行腓肠肌内、外侧头肌皮瓣修复小腿中下1/3软组织缺损的临床效果.方法 2000年8月至2009年12月对下肢中、下1/3软组织缺损采用逆行侧腓肠肌内、外侧头肌皮瓣进行修复5例.结果 5例肌皮瓣成活,软组织缺损区形态与功能修复良好.结论 应用逆行腓肠肌内、外侧头肌皮瓣修复下肢中、下1/3软组织缺损操作简单、安全,疗效可靠.     

Distally based superficial sural fasciomusculocutaneous flap: a reliable solution for distal lower extremity reconstruction

The objective of this study is to present a simple and rapid approach to elevate a consistent superficial sural fasciomusculocutaneous flap and show its clinical applications. All the patients with lower limb defects who underwent reconstruction using the distally based fasciomusculocutaneous sural flap were included in the study. The flap was elevated with a cuff of gastrocnemius muscle under the skin paddle, and the distal pedicle was dissected until 5 cm over the lateral malleolus. The donor site is primarily closed or skin-grafted. From March 2004 to August 2006, this distally based superficial sural fasciomusculocutaneous flap was applied to nine patients. All the defects resulted from traumatic injuries of the distal third of the leg, ankle, or foot, combined with bone or tendon exposure. Two flaps developed minor distal skin necrosis that recovered uneventfully with conservative therapy. The other flaps had an adequate postoperative evolution with good blood supply, contour, and function. The superficial sural fasciomusculocutaneous flap is a simple and consistent alternative for distal lower limb reconstruction, particularly when microsurgery is not available.     

Experience with peroneus brevis muscle flaps for reconstruction of distal leg and ankle defects

Objective:

Peroneus brevis is a muscle in the leg which is expendable without much functional deficit. The objective of this study was to find out its usefulness in coverage of the defects of the lower leg and ankle.

Patients and Methods:

A retrospective analysis of the use of 39 pedicled peroneus brevis muscle flaps used for coverage of defects of the lower leg and ankle between November 2010 and December 2012 was carried out. The flaps were proximally based for defects of the lower third of the leg in 12 patients and distally based for reconstruction of defects of the ankle in 26 patients, with one patient having flaps on both ankles.

Results:

Partial flap loss in critical areas was found in four patients requiring further flap cover and in non-critical areas in two patients, which were managed with a skin graft. Three of the four critical losses occurred when we used it for covering defects over the medial malleolus. There was no complete flap loss in any of the patients.

Conclusion:

This flap has a unique vascular pattern and fails to fit into the classification of the vasculature of muscles by Mathes and Nahai. The unusual feature is an axial vessel system running down the deep aspect of the muscle and linking the perforators from the peroneal artery and anterior tibial artery, which allows it to be raised proximally or distally on a single perforator. The flap is simple to raise and safe for the reconstruction of small-to moderate-sized skin defects of the distal third of the tibia and all parts of the ankle except the medial malleolus, which is too far from the pedicle of the distally based flap. The donor site can be closed primarily to provide a linear scar. The muscle flap thins with time to provide a good result aesthetically at the primary defect.KEY WORDS: Ankle defects, lateral malleolus defects, lower leg defect, muscle flap, peroneus brevis flap, pedicle flap, tendo achilles defects     

The distally based posterolateral supramalleolar neurofasciocutaneous island flap for coverage defects over the distal third of the leg and foot

A traditional-designed distally based sural flap centralized on the axis of the (medial) sural nerve and the lesser saphenous vein has been used widely for coverage of the distal third of the leg, ankle, malleoli, and foot. However, a variety of 5% to 47% of flap necrosis after the flap elevation and transposition were recorded in the literature. The unreliability of the distal part of the flap, especially when skin paddle located at the proximal third of the leg is at least partly due to their subfascial coursing of the median superficial sural artery and the medial sural nerve as well as the lesser saphenous vein. Based on the anatomic characteristics of the sural nerve and previous angiographic studies, a longitudinal chain-linked axial vascular network along with the sural nerve and the lateral sural nerve had been demonstrated on the posterolateral side of the leg from lateral retromalleolar gutter to the fibular head. A distally based posterolateral supramalleolar neurofasciocutaneous island flap centralized on this longitudinal neurovascular network was designed and used to reconstruct and cover the defects over the distal third of the leg, lateral malleolus, foot, and Achilles tendon. In this report we retrospectively review the clinical outcomes. This flap was used in 11 patients, including six young children aged 3 to 6 years. All flaps survived fully without complications except one flap which experienced postoperative infection which was controlled by dressing change and antibiotic application. Relevant surgical anatomy and detailed surgical techniques for elevation of the flap and its versatile usage are presented. Risks leading to flap necrosis, safe pedicle design, and manipulations etc. are discussed. In conclusion, this distally based posterolateral supramalleolar neurofasciocutaneous island flap is reliable and very useful for covering defects over the distal leg, ankle, heel, foot, and Achilles tendon, especially in young children.     

Experience with the distally based posterior tibial island flap

A series of ten patients is presented to demonstrate the use of the distally based posterior tibial island flap with or without a muscle component for reconstruction of the foot. Six patients had defects due to a road traffic accident, two had defects due to a work accident, one had extensive scar contractures after a deep burn and advanced Buerger’s disease in another. There was complete survival of all the flaps but one. Four flaps were fasciocutaneous and six myofasciocutaneous, including the medial hemisoleus muscle. This flap is very useful in lower extremity reconstruction, particularly in the lower third of the leg and foot due to its long vascular pedicle, availability of skin and muscle and ease of elevation. All the island flaps were based on the anastomosis between posterior tibial and peroneal arteries above the medial malleolus. Received: 16 December 1997 / Accepted: 1 July 1998     

应用穿支皮瓣治疗下肢远端慢性骨髓炎并皮肤缺损

目的 探讨游离或带蒂穿支皮瓣在治疗下肢远端慢性骨髓炎并皮肤缺损创面修复中的应用价值.方法 应用穿支皮瓣游离或带蒂移位修复胫前及足踝部慢性骨髓炎并皮肤缺损28例.游离移植13例:采用股前外侧穿支皮瓣修复胫前2例,踝前3例,足背2例,足跟2例;小腿外侧腓动脉穿支皮瓣修复足背4例.带蒂移位15例:胫后动脉穿支皮瓣修复胫前4例,修复内踝2例;腓动脉外踝后上穿支皮瓣修复足跟6例,外踝及足背各1例;第1跖背动脉穿支皮瓣修复近节(足母)趾背侧1例.抗生素液灌流伤口7例,万古霉素明胶海绵残腔填塞8例.结果 1例胫后动脉穿支皮瓣出现静脉回流不足,表浅坏死,自行愈合,其余皮瓣无坏死.随访6个月～2年,2例复发,分别经1次和2次手术后愈合,其余均一期愈合,皮瓣外形满意.3例行二期骨移植.最后一次随访时,患者可行走,患肢完全负重,按足部疾患治疗效果标准评定平均为84.5分.结论 游离或带蒂穿支皮瓣血供良好,可用于治疗残腔不大的慢性骨髓炎并皮肤缺损.     

Modified distally based sural neuro-veno-fasciocutaneous flap: anatomical study and clinical applications

The distally based sural neuro-veno-fasciocutaneous flap has been used widely for reconstruction of foot and ankle soft-tissue defects. The distal pivot point of the flap is designed at the lowest septocutaneous perforator from the peroneal artery of the posterolateral septum, which is, on average, 5 cm (4-7 cm) above the lateral malleolus. A longer neuro-veno-adipofascial pedicle would be needed to reversely reach the distal foot defect when the flap is dissected based on this perforating branch, which may result in more trauma in flap elevation and morbidity of the donor site. In this article, we explored new pivot points for this distally based flap in an anatomic study of 30 fresh cadavers. The results showed that the peroneal artery terminates into two branches: the posterior lateral malleolus artery and lateral calcaneal artery. These two branches also send off cutaneous perforators at about 3 and 1 cm above the tip of lateral malleolus, respectively, which can be used as arterial pivot points for the flap. A communicating branch between the lesser saphenous vein and the peroneal venae comitantes was found, accompanied by the perforator of the posterior lateral malleolus artery. This modified, distally based sural flap with lower pivot points was successfully transferred for repair of soft-tissue defects in 21 patients. The size of flaps ranged from 4 x 3 cm to 18 x 12 cm. All flaps survived without complications. Neither arterial ischemia nor venous congestion was noted. In conclusion, the vascular pivot point of a distally based sural flap can be safely designed at 1.5 cm proximal to the tip of the lateral malleolus. This modified flap provides a valuable tool for repair of foot and ankle soft-tissue defects.     

腓肠神经营养血管皮瓣修复小腿足踝部缺损

目的探讨带蒂腓肠神经营养血管皮瓣修复小腿及足踝部远端软组织缺损的疗效。方法应用带蒂腓肠神经营养血管皮瓣修复24例小腿及足踝部远端软组织缺损患者。缺损面积为5 cm×6 cm～12 cm×8 cm。结果3例皮瓣远端边缘部分坏死,经换药后愈合;21例皮瓣全部成活。其中4例术后皮瓣明显肿胀,2周后消退,皮瓣成活。24例均获随访,时间6个月～2年,足背外踝区早期感觉减退,6个月时21例皮瓣麻痹区缩小。皮瓣两点辨别觉〉2 cm者17例,7例足跟边缘区部分溃疡,换药后瘢痕愈合。皮瓣色泽、质地、弹性良好。结论应用腓肠神经营养血管皮瓣修复小腿下段及足踝部缺损手术操作简单,皮瓣血供充足,疗效可靠。