横过中线的肩胛游离皮瓣移植

目的 鉴于肩胛背部受旋肩胛动脉浅皮支、胸背动脉肌皮穿支、颈横动脉浅皮支及肋间后动脉皮支重叠供血，互相存在广泛的吻合网，探讨是否可以安全的形成扩大的肩胛皮瓣。方法本组应用横过脊柱中线的肩胛游离皮瓣移植，治疗下颌颈部严重瘢痕挛缩８例。结果 除２例远１５cm而达对侧肩胛区，扩大了肩胛皮瓣的切取面积，增加了临床应用范围。结论 横过中线的肩胛皮瓣设计应以旋肩胛动脉水平支为轴线，与其成角设计可能出现远端血障碍。     

向上臂延伸的肩胛游离皮瓣的临床应用研究

目的 应用向上臂延伸的肩胛游离皮瓣一期修复面颈部和上唇瘢痕切除后创面.方法 在设计肩胛游离皮瓣时,应用常规的肩胛旁皮瓣修复面颈部瘢痕切除后所遗创面,同时,将肩胛皮瓣向上臂后内侧延伸,延伸部分用以修复上唇缺损.结果 本组6例,均为烧伤后上唇、面颈部瘢痕患者,皆应用向上臂延伸的肩胛皮瓣修复上唇、面颈部瘢痕切除后所遗创面,背部肩胛旁皮瓣面积为22 cm×11 cm～40.0 cm x 9.5 cm,平均36.57 cm×10.20 cm,向上臂延伸的皮瓣面积为7 cm×4 cm～12 cm×4 cm,平均10.32 cm×3.67 cm,皮瓣全部成活.结论 向上臂延伸的肩胛游离皮瓣,其延伸部分的血供除来自旋肩胛动脉的分支血管外,旋肩胛动脉和旋肱后动脉之间还存在直接交通支血管,旋肱后动脉切断后,旋肩胛动脉通过上述直接交通支血管可以供应旋肱后动脉在上臂的皮肤分布区;将肩胛游离皮瓣向上臂延伸,可在修复面颈部瘢痕挛缩的同时,修复上唇缺损,皮瓣血运可靠,手术效果良好.     

横过中线的肩胛游离皮瓣移植

目的鉴于肩胛背部受旋肩胛动脉浅皮支、胸背动脉肌皮穿支、颈横动脉浅皮支及肋间后动脉皮支重叠供血,互相存在广泛的吻合网,探讨是否可以安全的形成扩大的肩胛皮瓣。方法本组应用横过脊柱中线的肩胛游离皮瓣移植,治疗下颌颈部严重瘢痕挛缩８例。结果除２例远端表皮坏死外,其余全部成活。本组病例皮瓣切取的最大切取面积为３１ｃｍ×３４ｃｍ,越过中线最长１５ｃｍ而达对侧肩胛区,扩大了肩胛皮瓣的切取面积,增加了临床应用范围。结论横过中线的肩胛皮瓣设计应以旋肩胛动脉水平支为轴线,与其成角设计可能出现远端血运障碍。皮瓣成活的机理可能与两侧肩胛区水平支间的吻合支有关。     

横过中线的肩胛游离皮瓣移植

目的鉴于肩胛背部受旋肩胛动脉浅皮支、胸背动脉肌皮穿支、颈横动脉浅皮支及肋间后动脉皮支重叠供血,互相存在广泛的吻合网,探讨是否可以安全的形成扩大的肩胛皮瓣。方法本组应用横过脊柱中线的肩胛游离皮瓣移植,治疗下颌颈部严重瘢痕挛缩8例。结果除2例远端表皮坏死外,其余全部成活。本组病例皮瓣切取的最大切取面积为31cm×34cm,越过中线最长15cm 而达对侧肩胛区,扩大了肩胛皮瓣的切取面积,增加了临床应用范围。结论横过中线的肩胛皮瓣设计应以旋肩胛动脉水平支为轴线,与其成角设计可能出现远端血运障碍。皮瓣成活的机理可能与两侧肩胛区水平支间的吻合支有关。     

三维重建术前优化设计腹前外侧跨区游离穿支皮瓣修复四肢软组织缺损

目的探讨三维重建术前优化设计腹前外侧跨区游离穿支皮瓣修复四肢软组织缺损的临床疗效。方法选择2017年10月至2020年1月宁波市第六医院手外科收治的手、前臂、足部及踝关节软组织缺损20例,其中手及前臂组织缺损17例,踝关节及足部软组织及复合组织缺损3例,肢体软组织缺损面积为6 cm×8 cm～36 cm×18 cm。临床结合CTA及三维重建术前优化设计并切取游离跨区穿支皮瓣20例,设计了以下5种皮瓣组合方式:①腹壁下动脉加腹壁上动脉游离穿支皮瓣;②旋髂浅动脉加旋髂深动脉游离穿支皮瓣;③旋髂浅动脉穿支加腹壁下动脉穿支游离穿支皮瓣;④旋髂浅动脉穿支加腹壁浅动脉游离穿支皮瓣;⑤腹壁下穿支动脉加腹壁浅动脉游离穿支皮瓣。皮瓣营养总面积分别为(272.3±12.5)cm2、(107.4±9.3)cm2、(193.6±24.2)cm2、(155.2±20.1)cm2、(203.7±16.3)cm2。术后通过来院门诊复诊随访,观察皮瓣外形、质地、血运、颜色、修复肢体的活动功能、供区恢复及功能情况,供区均予一期直接缝合。结果本组20例腹前外侧跨区穿支皮瓣中,18例顺利成活,1例术后出现部分坏死,经换药后...     

“接力皮瓣”在皮肤软组织扩张术修复严重烧伤瘢痕中的应用

目的 探讨“接力皮瓣”在皮肤软组织扩张术修复严重烧伤瘢痕中的应用。方法 利用皮瓣“接力”的原理,在皮瓣供区附近进行接力扩张,用第二个扩张皮瓣产生的组织量来覆盖第一个扩张皮瓣遗留的缺损,将此技术应用于肩胛背扩张皮瓣修复大面积颏颈粘连。主皮瓣为携带旋肩胛动脉与颈浅动脉双重血供的轴型皮瓣,经软组织扩张后形成大面积皮瓣,以携带颈浅动脉穿支的肩部皮肤为蒂,旋转至前胸部与颈前区,修复颏颈/颏胸粘连的大面积瘢痕。接力皮瓣的扩张器埋置在主皮瓣下方的腰背部,以携带穿支的螺旋桨皮瓣方式或随意皮瓣方式,向上方转位修复肩胛部供区缺损。结果 共12例患者纳入本研究,男9例,女3例,年龄5～45岁(平均24.7岁),均为烧伤后大面积颈胸部瘢痕挛缩。肩胛区扩张器300～800 mL,腰背部扩张器80～300 mL。肩胛区扩张皮瓣面积430～840 cm²,腰背部接力扩张皮瓣附近可探及1～4支肋间后动脉穿支(平均2.3支),通常设计以此为蒂的螺旋桨皮瓣旋转修复肩胛部供区。术后随访9～40个月,所有患者颏颈粘连均未复发,颈部皮肤外形及质地良好,背部供区直接闭合,遗留线状瘢痕。结论 接力扩张技术能最...     

肩胛皮瓣游离移植修复面颈部皮肤缺损

目的　总结 1982年～ 1998年应用不同形状的肩胛皮瓣游离移植治疗面颈部损伤 10 3例。方法　游离皮瓣包含旋肩胛动脉升支、降支、水平支的肩胛背部皮瓣 ,设计范围为 :向上越过肩胛冈达肩峰连线 ,向下可平双侧髂嵴连线 ,两侧至腋中线的整个背部。结果　手术取得良好效果。术后随访 5 8例 ,随访时间 3个月～ 10年。面颈部功能恢复良好 ,外形满意 ,但患者均需要进行二次皮瓣修薄术。结论　应用肩胛皮瓣的最大范围可达45 cm× 16 cm。皮瓣的设计横向越过背部中线达对侧肩胛区 ,向上越过肩胛冈 ,向下达双侧髂嵴平面 ;在皮瓣适当部位开窗均不影响游离皮瓣的血运。皮瓣供区范围广 ,血供丰富 ,更适用于儿童面颈部修复     

游离髂腹部穿支皮瓣的临床应用

目的 介绍选择供血血管的游离髂腹部穿支皮瓣的临床应用体会.方法 设计选择供血血管及穿支为蒂的髂腹部游离皮瓣移植修复四肢软组织缺损,临床应用30例,其中以旋髂浅动脉为蒂12例,以旋髂深动脉及穿支为蒂14例,以旋髂浅深动脉共干为蒂4例.皮瓣切取面积最大22.0cm×10.0cm,最小8.0cm×6.0cm.结果 术后所有皮瓣均顺利存活,供区创面直接缝合.随访时间3～6个月.修复前臂及小腿(12例)皮瓣外观满意;修复手及足踝部(18例)皮瓣较臃肿,二期行整形术.供区仅遗留线条瘢痕,未出现任何并发症.结论 髂腹部皮瓣供区隐蔽,供皮量大,是修复四肢软组织缺损的良好供区;但供血血管有旋髂浅动脉及旋髂深动脉两类,且穿支或皮支的解剖有一定变异,具体手术时应根据供血血管的口径、走行灵活选择.     

下腹部浅动脉游离皮瓣修复上肢皮肤软组织缺损

目的 总结下腹部浅动脉游离皮瓣修复上肢不同部位皮肤软组织缺损的临床应用及疗效. 方法 对伴有深部组织外露的上肢软组织缺损42例,分别采用以旋髂浅动脉为蒂的皮瓣修复13例,以旋髂浅动脉为蒂的骨皮瓣修复5例,以腹壁浅动脉为蒂的皮瓣修复11例,皮瓣近端以旋髂浅动脉及腹壁浅动脉的外侧支为血供,皮瓣远端以第四腰动脉前支的肌皮动脉穿支为血供的多皮支供血皮瓣7例,以旋髂浅腹壁浅动脉共干、腹壁浅动脉分出的内侧支及外侧支、旋髂浅动脉发出深支和浅支三种形式设计双叶皮瓣修复6例.皮瓣面积最大为9 cm×30 cm,最小为5cm×6cm. 结果 术后皮瓣全部成活,术后随访6～24个月,外形良好,皮瓣质地柔软,皮瓣恢复保护性感觉,有排汗功能,皮瓣供区仅留线状瘢痕. 结论 下腹部浅动脉游离皮瓣修复上肢皮肤软组织缺损,皮瓣质地较簿,供区可直接缝合等优点,是修复上肢皮肤软组织缺损的一种较理想方法.     

旋髂浅动脉穿支游离皮瓣修复小儿足背皮肤软组织缺损

目的:研究应用旋髂浅动脉穿支游离皮瓣修复小儿足背皮肤软组织缺损伴肌腱或骨外露创面的临床疗效。方法:回顾性分析2014年1月-2016年9月收治的13例足背部皮肤软组织缺损伴肌腱或骨外露患儿,一期清创行VSD覆盖,二期采用旋髂浅动脉穿支游离皮瓣覆盖创面,供区全部直接缝合。结果:所有患儿皮瓣全部存活,创面得到了有效修复;移植皮瓣未见明显色素沉着、无肌腱粘连,足背部外观恢复满意,下肢负重、行走功能正常;供区仅遗留线性瘢痕,部位隐蔽不易察觉。结论:对于足背部皮肤软组织缺损伴肌腱或骨外露的患儿,采用旋髂浅动脉穿支游离皮瓣移植修复,疗效可靠,是理想的治疗方法。     

Pedicled perforator flaps in breast reconstruction: a new concept.

INTRODUCTION: Pedicled perforator flaps have not been widely described for the breast. The aim of this study is to report our clinical experience with pedicled perforator flaps in breast reconstruction. MATERIAL AND METHODS: Between May 2000 and May 2003, pedicled perforator flaps were used in 31 patients. The indications were immediate partial breast reconstruction and thoracic reconstruction for carcinomatous mastitis or tumour recurrence. Perforators were identified by Doppler preoperatively. The Doppler-located thoracodorsal artery perforator (TDAP) or another perforator such as the intercostal artery perforator (ICAP) was looked for. If the perforators had good calibers, the flaps were then based solely on these perforators. If the perforators were tiny but pulsating, the TDAP flap was harvested as a muscle-sparing latissimus dorsi type I (MS-LD I) with a small piece of muscle (4x2 cm) included to protect the perforators. If the perforators were not-pulsating, a larger segment of the LD muscle was incorporated to include the maximum of perforators (MS-LD II flap). The nerve that innervates the rest of the LD muscle was always spared. If most of the LD was included in the flap, the flap was then classified as MS-LD III. RESULTS: The mean flap dimensions were 20x8 cm. Using this algorithm, the TDAP flap was harvested in 18 cases and the ICAP flap in three cases. In addition, there were 10 MS-LD flaps with a variable amount of muscle. In addition, one parascapular flap was dissected. A successful flap transfer was achieved in all but three patients, in whom limited partial necrosis occurred. Seroma was not encountered at the donor sites of the perforator flaps (0%) compared to four (40%) after a MS-LD flap. CONCLUSION: Our results show that pedicled perforator flaps are additional options for breast surgery and that they may be used whenever an adequate perforator can be found. This technique is safe and reliable if the algorithm described is used when choosing a flap.     

Extended rat-ear flap model: a new rodent model for studying the effects of vessel supercharging on flap viability

A new extended rat-ear flap model, with both an axial and a random component, is described. The flap is based on an axial supply by the posterior auricular artery and the posterior facial vein. The random portion, consisting of the rat dorsum, is capable of being supercharged at two separate sites-in the scapular and pelvic regions. There are several advantages to this composite flap. It is a combined axial and random flap. When used as a free flap, the viability of the axial portion serves as an indicator for anastomotic patency. The random portion allows for the investigation of the effects of pharmaceutical manipulation or surgical intervention, e.g., flap supercharging. The results indicate that the axial supply alone can cover approximately 50 percent of the extended rat-ear flap. Moreover, adding supercharging perforators to the random portion significantly increases the area of flap survival. Of interest, an axial vascular supply, coupled with more distal dorsal perforators (pelvic) than proximal (scapular) perforators, may increase survival for the so-called "watershed" area in the middle of the random portion of the flap. Additionally, this study also investigated the relative importance of arterial supply vs. venous drainage, using the extended rat-ear flap model. The flap was either supercharged with both the perforators of the scapular and pelvic arteries, or both scapular and pelvic veins. The results of the study suggests that augmenting venous drainage provides statistically significant improvement (87 percent vs. 51.6 percent) in increasing flap survival, when compared to augmenting the arterial supply. Arterial supercharging provided no improvement in flap survival, when compared to no supercharging (axial vessels + arterial supercharging, 51.6 percent vs. axial vessels alone, 49.9 percent). The results also suggest that providing adequate venous outflow is more important than providing additional arterial blood, and that impaired venous outflow may contribute to some cases of flap failure. However, it should be kept in mind that the best flap survival occurs with both arterial and and venous supercharging.     

The profunda femoris artery "fourth perforator" island flap: a new perforator flap in lower-limb reconstruction

Although the lateral thigh flap has been well described as a fasciocutaneous flap based on one or more of the four perforators of the profunda femoris artery, the role for these individual perforators as perforator flaps has not been described. These profunda femoris artery perforators offer a particularly useful option in lower-limb reconstruction. In fact, a perforator flap based on the profunda femoris artery fourth perforator (PFA-P4) has not been described to our knowledge. We describe the utility of the PFA-P4 flap, offering modes of preoperative imaging and a role for its use in lower-limb reconstruction. Computed tomographic angiography (CTA) was able to identify the location and course of a PFA-P4, and Doppler ultrasound confirmed the CTA findings. A FA-P4 flap was designed and harvested, with direct closure of the donor site achieved. There were no operative complications. Perforator flaps based on the perforating branches of the profunda femoris artery have not been widely described, largely due to individual variability in perforator anatomy. With the advent of CTA for perforator mapping, the "freestyle" nature of such flaps is eliminated, and perforator flaps such as the PFA-P4 flap can be planned and harvested safely and confidently.     

胸背动脉肌皮穿支皮瓣的解剖学研究与临床意义

目的探讨背阔肌肌皮穿支皮瓣的解剖学基础及临床应用的可行性。方法①在15具（30侧）防腐成人尸体标本上,对背阔肌及其主要血供进行巨微解剖学观察。②对1具（2侧）防腐成人尸体标本作背阔肌肌皮穿支皮瓣及肌瓣与穿支肌皮瓣分离的共蒂“扇形”瓣模拟手术。结果①在32侧标本中,共发现血管外径大于0．5mm的肌皮穿支102支,其中来自胸背动脉内侧支的穿支数为56支（占55％）,来自胸背动脉外侧支的穿支数为46支（占45％）。每侧标本内侧支平均发出1．9支（在1-3支之间变化）,外侧支平均发出1．8支（在1-3支之间变化）。②胸背动脉内、外侧支的肌皮穿支外径大于0．5mm的穿支血管主要集中在距神经血管窗下约8．5cm（变化在6．4-9．2cm之间）范围内。结论胸背动脉的肌皮穿支血管位置恒定,管径粗,蒂长,适宜制作成肌皮穿支肌皮瓣或“扇形”瓣。     

An anatomic study of the superficial peroneal nerve accessory artery and its perforators, and clinical application of superficial peroneal nerve accessory artery perforator flaps

In the 1990s, skin island flaps supplied by the vascular axis of sensitive superficial nerves, like the sural and saphenous nerves, were introduced. Flaps supplied by the superficial peroneal nerve accessory artery (SPNAA), however, are still not commonly used. The aim of this study is to understand the anatomic structure of the SPNAA and its perforators in the anterior intermuscular septum and to use SPNAA perforator flaps in the clinic. We dissected 16 cadavers and assessed the location and number of the SPNAA, its perforators, and the septocutaneous perforators originating from the anterior tibial artery. A SPNAA perforator flap was applied to 12 patients, the free flap was applied to 11 patients, and the pedicled flap was applied to 1 patient. SPNAA varied from 7 to 16 cm in length, with an average of 4.5 perforators to supply the lateral aspect. An average of 3.13 septocutaneous perforators originated from the anterior tibial artery. The mean size of the SPNAA perforator flaps was 65.5 cm. The complete follow-up period was 3-20 months. Although 1 flap was lost as a result of arterial thrombosis, the procedure was successful in the remaining 11 patients. In addition, reduced flap thickness made them more esthetically appealing. SPNAA perforator flaps could be an excellent alternative to perforator flaps that use the lower leg as a donor site.     

Reliable harvest of a dorsal scapular artery perforator flap by augmenting its perfusion

Despite confirmation of a reliable perforasome in the dorsal scapular artery in an anatomic study, a true perforator flap has not been recommended in previous clinical studies because of concerns regarding insufficient perfusion in the distal region. In this report, we present two cases of reconstruction for occipital defects caused by tumor extirpation using pedicled dorsal scapular artery perforator flaps without a muscle component. To secure the perfusion of the dorsal scapular artery perforator flap, inclusion of an additional perforator was attempted for perfusion augmentation. The second dorsal scapular artery perforator was harvested in one case. In an additional case, the sixth dorsal intercostal artery perforator with a branch that directly connected with the dorsal scapular artery within the trapezius muscle was additionally harvested. The flaps survived without any perfusion‐related complications, including tip necrosis, and no donor site morbidities were observed. We suggest that a perfusion augmented dorsal scapular artery perforator flap by harvesting multiple perforators could be a safe and useful alternative for reconstructive surgery of head and neck defects. © 2014 Wiley Periodicals, Inc. Microsurgery 36:152–156, 2016.     

Reconstruction of soft tissue defects of the Achilles tendon with rotation flaps,pedicled propeller flaps and free perforator flaps

Introduction. Soft tissue defects exposing the Achilles tendon are challenging. Local perforator flaps represent a valuable option gaining increasing popularity. Despite preoperative planning an adequate perforator cannot always be found intraoperatively. The free peroneal artery perforator flap can serve as a back‐up option limiting the donor site morbidity to the same extremity without sacrificing major vessels or nerves. Methods. Nine patients with soft tissue defects exposing the Achilles tendon were treated with local perforator flaps, seven were scheduled for 180° propeller flap coverage after Doppler‐ultrasound examination. However, in two patients (22%) no adequate perforators were found intraoperatively. As the perforators for the free peroneal artery perforator flap were routinely mapped out, this flap was harvested for microsurgical reconstruction. Results. One patient with a 180° propeller flap developed a partial flap necrosis, another patient developed superficial epidermolysis, both requiring skingrafting. No complications were seen with free tissue transfer. Conclusion. Pedicled perforator flaps as propeller flaps add options to the armamentarium of microsurgeons. Despite thorough preoperative planning the surgeons must be prepared to perform a different method of reconstruction if inadequate vessels are encountered. To limit additional donor site morbidity, local options are preferred. The free peroneal artery perforator flap represents a good option as it matches the original tissue properties closely. The complication rate of propeller flaps in this series is tolerable. Propeller flaps should therefore be considered an alternative but not as a replacement of local fasciocutaneous flaps. © 2010 Wiley‐Liss, Inc. Microsurgery 30:608–613, 2010.     

The medial sural artery perforators: anatomic basis for a surgical plan

We performed an anatomic study on 20 fresh lower limbs. Resin was injected in the popliteal artery. Medial sural artery perforator flaps were sculptured according to anatomic markings. On average, length of flaps was 12.9 cm, width was 7.9 cm; all 38 perforators were musculocutaneous: 1 perforator was always found (on average, 1.9 per flap). All perforators gathered between 7 and 18 cm from the popliteal crease; 34.2% of perforators arose on the midline of the medial head of gastrocnemius muscle; before entering the fascia, the perforator artery diameter was on average 0.5 mm. Two configurations of the intramuscular course of perforators were found. Sixty-six percent of perforators originated from the lateral branch of the medial sural artery, 34% from the medial one. These results improve the anatomic knowledge of the medial posterior calf region and allow us to describe a convenient plan to make flap sculpturing easier.     

Free DIEAP and SGAP flap breast reconstruction after abdominal/gluteal liposuction.

Perforator flaps are widely used in our unit for breast reconstruction. They provide ample tissue with minimal donor site morbidity together with long lasting aesthetic results. Increasing number of patients may have liposuction procedure which may jeopardise areas such as the abdomen and the buttock which are the donor sites for perforator-free flaps in breast reconstruction. Therefore, liposuction has been considered as a relative contraindication of raising perforator flaps. Six patients who had previous liposuction of the donor sites underwent autologous breast reconstruction with perforator-free flaps. Colour Duplex imaging was obtained in all cases preoperatively in order to evaluate the blood supply to the flap and to map the perforators. There were five deep inferior epigastric artery flaps (DIEP) and one superior gluteal artery perforator (SGAP) flap used. Total flap survival was obtained in all cases. Postoperative course was uneventful. Our results showed that raising perforator flaps after liposuction of the donor sites is possible. Preoperative radiological evaluation of the perforators is mandatory for such difficult cases.     

血管变异型前臂背侧皮瓣修复手部皮肤软组织缺损

目的 探讨骨间后动脉血管变异时前臂背侧皮瓣的切取方法.方法 以骨间后动脉为蒂逆行岛状皮瓣转移修复手部皮肤软组织缺损时,遇到血管变异共9例,采取以骨间后动脉桡侧支为蒂切取逆行岛状前臂背侧皮瓣、以骨间后动脉近端为蒂切取游离骨间后动脉皮瓣、以骨间后动脉穿支为蒂切取游离前臂背侧穿支皮瓣等方法,进行皮瓣转移或移植修复手部创面.结果 9例皮瓣中有8例顺利存活;1例术后2 d皮瓣远端出现肿胀、青紫、小水泡,及时对症处理,5 d后部分皮缘形成干痂,皮瓣颜色恢复正常,脱痂后存活.9例随访3个月至2年,皮瓣质地柔软,弹性好,外形满意.结论 以桡骨间后动脉侧支为蒂的前臂背侧皮瓣逆行转移,以骨间后动脉近端或骨间后动脉穿支为蒂的前臂背侧皮瓣游离移植修复手部创面,是解决骨间后动脉血管变异较理想的方法.