臀上、臀下动脉穿支皮瓣的解剖学研究

目的 为了克服传统臀大肌肌皮瓣切取肌肉所带来的缺点，继承其血运好、组织量大的优点，寻找改进手术操作的解剖学基础。方法 采用5具10侧成人尸体，对臀上动脉、臀下动脉及其相应区域皮肤的穿支血管分布情况，包括主干血管、穿支血管的走行层次、数量、管径及分布、穿出位置及体表投影、相应区域神经分布情况进行大体解剖学研究。另对6例12侧成年女性双侧臀上动脉穿支分布区，应用多普勒超声血流探测仪进行穿支定位。结果 臀上动脉、臀下动脉起于髂内动脉，臀上动脉穿支分布区域集中在坐骨旁及臀大肌中部，数量约为10～15支，穿支血管的长度3～8cm，其外径约为1～1．5mm。这些穿支血管穿过臀大肌及筋膜直接供应相应区皮肤。来自腰神经背支的臀上皮神经越过髂棘在髂后上嵴外侧穿出深筋膜，向臀部走行，与血管穿支密切相邻．支配臀部皮肤感觉。在皮瓣上缘切口处注意分离直径合适的神经，与皮瓣一同切取，可与受区相应神经(如为乳房再造可与第4肋问神经)相吻合。在成人6例12侧女性患者，用多普勒超声血流探测仪进行定位，每侧可明确定位3～5支，均集中于由髂后上嵴、股骨大转子及坐骨结节所形成的三角区内，此为穿支血管的体表投影区域。结论 臀上动脉穿支血管分布区域恒定，管径粗细合适，切取该区域皮瓣，完全可以不携带肌肉，既包含了肌皮瓣血运好、组织量大的优点，又克服了切取肌肉所带来的缺点，临床应用多普勒血流探测仪进行穿支血管定位，简单可靠。切取皮瓣可同时携带臀上神经，为与受区神经吻合成为可能。由于臀下动脉穿支分布区为臀部负重部位，且臀下动脉主干与坐骨神经毗邻，因此，建议临床上尽量不采用臀下动脉穿支皮瓣。臀上动脉穿支皮瓣预期可行带蒂移植用于修复骶尾部褥疮等创面，也可成为乳房再造又一供区。

Anatomy study of superior and inferior gluteal artery perforator flap

OBJECTIVE: To find anatomic basis for clinically modifying technique of harvesting superior and inferior gluteal artery perforator flap, in order to avoid muscle lossing in conventional superior and inferior myocutaneous flaps, keep the advantage such as large rich supplied volume soft tissue. METHODS: 5 cases 10 sides adult cadaver were used to study the numbers, position, Course of superior and inferior gluteal artery perforators. The position of perforators was located by ultrasound Doppler in 6 cases and 12 sides in patient's superior and inferior gluteal area. RESULTS: Superior and inferior gluteal artery originated from internal iliac artery. Several main perforators of large caliber were found in the paraischia and central portions of the gluteal muscle, its number was 10 - 15. The length of the vessels varies from 3 to 8 cm and their diameter from 1 - 1.5 mm. These significant perforators pass through the muscle itself and the fascial portion of the muscle to the overlying skin on the gluteal region. The dorsal branches of nervorum lumbalium perforate the deep fascia just above the iliac crest, lateral to the posterior superior iliac spine. If a nerve branch with a substantial diameter crosses the incision line, the nerve can be harvested within the flap. This nerve can be anastomosed to the anterior ramus of the lateral branch of the 4th intercostals nerve. In adult female, 3 - 5 perforators were located by ultrasound Doppler. They distributed in the triangle area among posterior superior iliac crest, the great trochanter and the coccyx. CONCLUSIONS: The area and diameter of perforators of superior gluteal artery were relatively confirmed. It's possible to harvest the perforator flap without any muscle. It has the advantage of conventional myocutaneous flap with out of its disadvantages. It's easy to detect those perforator by ultrasound Doppler clinically. The nerve can be harvested and anastomosed simutaneously. Because the inferior gluteal area is a weight loading area, we suggested to use superior gluteal artery perforator flap. This flap can be transferd pediclely to treat sacral pressure sores or to be transfered freely for the breast reconstruction.