【作者】 魏建伟；

【导师】 倪江东； 董忠根；

【作者基本信息】 中南大学 ， 临床医学， 2013， 博士

【摘要】 目的：建立较理想的肌间隔穿支蒂和穿支筋膜皮肤蒂皮瓣的兔实验模型；比较这两种皮瓣的可靠性,探讨筋膜皮肤蒂在穿支筋膜皮肤蒂皮瓣(简称穿支筋膜蒂皮瓣)的动脉供血和静脉回流中的作用及其程度和机制；总结胫后动脉穿支蒂和穿支筋膜蒂皮瓣的临床经验。方法：对17只新西兰大白兔行建模观察,分别观察后肢大体解剖,乳胶硫酸钡灌注标本X线摄片和显微解剖,及隐血管肌间隔穿支皮瓣和穿支筋膜皮肤蒂皮瓣成活情况。8只兔两侧后肢以膝关节下3.0cm附近的隐血管穿支为旋转点,分别切取隐血管肌间隔穿支筋膜蒂皮瓣(筋膜蒂长2.Ocm,宽1.5cm,皮岛长6.0cm,宽3.0cm)及穿支蒂皮瓣(长轴部分大小为2.0cm×1.5cm+6.0cm×3.0cm)；9只兔两侧后肢皮瓣根据蒂部不同随机分成3组(每组各6例)：A组(隐动脉肌间隔穿支蒂皮瓣),B组(结扎穿支动、静脉的筋膜皮肤蒂皮瓣)和C组(保留穿支动脉而结扎穿支静脉的筋膜皮肤蒂皮瓣)；观察术后7天皮瓣成活率。经隐动脉的穿支动脉(2例)及经股静脉的穿支静脉(3例)灌注亚甲蓝；术后10天完全成活的肌间隔穿支蒂及穿支筋膜蒂皮瓣各2例行乳胶硫酸钡股动脉灌注,标本X线摄片及显微解剖,2例完全成活的穿支筋膜蒂皮瓣行乳胶硫酸钡经隐静脉灌注,标本X线摄片；经隐动脉的穿支动脉及经股静脉的穿支静脉行泛影葡胺造影各2例。回顾性分析68例胫后动脉穿支筋膜蒂皮瓣及19例胫后动脉穿支蒂皮瓣的临床资料。结果：隐血管发出3-5支肌间隔穿支,膝关节平面下3.Ocm附近的穿支位置相对恒定,较粗大,外径(0.36±0.06)mm,出现率为100%,以该穿支处为旋转点建模的穿支蒂皮瓣及穿支筋膜蒂皮瓣的成活率分别90.8%和77.0%。兔隐动脉肌间隔穿支筋膜蒂和穿支蒂皮瓣皮瓣的成活率分别为94.0%±9.9%和90.4%±22.5%(P>0.05)。A组、B组和C组的皮瓣成活率分别为83.8%±23.7%,45.7%±25.3%和55.0%±47.2%,三组间差异无统计学意义。亚甲蓝灌注穿支动脉发现亚甲蓝首先经伴行穿支静脉回流,随后其部分经位于筋膜皮肤蒂的穿支静脉间吻合及下方的穿支静脉回流。亚甲蓝灌注股静脉的穿支静脉发现亚甲蓝主要经血管蒂的穿支静脉回流。完全成活皮瓣乳胶硫酸钡动脉灌注标本发现,作为血管蒂的穿支动脉及穿支静脉的分支分布于整个皮瓣；而筋膜蒂基底部下方的穿支动脉及穿支静脉仅与近蒂端的部分皮瓣的血管相连；筋膜蒂基底部的穿支静脉与其下方的穿支静脉间吻合较多,且这些吻合又与周围皮肤的浅静脉及胫前静脉的穿支静脉间存在数条吻合。经股静脉的穿支静脉泛影葡胺造影显示造影剂通过血管蒂的穿支静脉回流,筋膜蒂上未见明显造影剂。胫后动脉穿支筋膜蒂皮瓣和穿支蒂皮瓣的部分坏死率分别为19.1%和21.1%(P>0.05)。结论：1.以兔膝关节下3cm左右的隐血管穿支为蒂的穿支皮瓣和包含该穿支的穿支筋膜蒂皮瓣是研究肌间隔穿支蒂和穿支筋膜蒂皮瓣较理想的动物模型。2.兔隐动脉肌间隔穿支筋膜皮肤蒂皮瓣主要是由穿支蒂动脉供血和静脉回流,筋膜皮肤蒂对皮瓣的动脉血供和静脉回流起部分作用。皮瓣的静脉血可通过筋膜蒂基底部以远的同源穿支静脉及与这些穿支静脉相联系的其他浅静脉和深静脉回流。3.胫后动脉穿支筋膜蒂皮瓣与穿支蒂皮瓣可靠性无明显差别。更多还原

【Abstract】 Objective:The purpose of the present study is to explore and set up the more ideal model of intermuscular septum perforator pedicled flap and perforator-plus fascicutaneous flap in rabbit, to explore the role of the fasciocutanoeus pedicle in arterial blood supply and veneous drainage of the perforator-plus fascicutaneous flap by comparing the survial rate of two kinds of flaps, and summarize the clinical experience of the posterior tibial artery perforator pedicled flap and perforator-plus fasciocutaneous flap.Methods:In the experiment of creating the flap models,17New Zealand rabbits were performed gross anatomy of the leg, radiograph and microanatomy of legs which were injected with barium sulfate-latex, and sapehenous artery perforator pedicled flap and perforator-plus fascicutaneous flap. Sixteen legs of8rabbits were randomly divided into2groups:one group was used to harvest sapehenous artery perforator-plus fascicutaneous flaps (the pedicle length of2.0cm and width of1.5cm, the skin island demension of6.0cm×3.0cm), and the other to harvest sapehenous artery perforator pedicled flaps (demensions of long axis part:2.0cm×1.5cm plus6.0cm×3.0cm), with the pivot point locating at3.0cm below the knee joint. According to the defferent pedicles,18legs of9New Zealand rabbits were randomly devided into3groups:group A(perforator pedicled flap), group B(fasciocutaneous pedicled flap without perforator at the base of the pedicle), and group C (fasciocutaneous pedicled flap with perforator artery but without perforator vein at the base of the pedicle). At7days postoperatively, all the flaps’survival rates were recorded. The flaps, just being elevated from the legs, were executed injection of methylene blue from the perforator artery of the sapheneous artery (2cases) and the perforator vein of the femoral vein (3cases). The sapehenous artery perforator pedicled flaps (n=2) and perforator-plus fascicutaneous flaps (n=2), which had survived completely10days postoperatively, were injected barium sulfate-latex from femoral artery, and the specimens were performed radiograph and microanatomy. Two sapehenous artery perforator-plus fascicutaneous flaps, which had survived completely10days postoperatively, were injected barium sulfate-latex from sapehnous vein, and the specimens were performed radiograph. The meglumini diatrizoici radiography were taken by means of manual control infusion of the contrast medium via perforator artery of the saphenous artery (n=2) and perforator vein of thefemoral vein (n=2). We retrospectively reviewed the data of the posterior tibial artery perforator pedicled flaps (n=19) and perforator-plus fasciocutaneous flaps (n=68) and summarized the clinical experiences of both flaps.Results:The saphenous vessel gives out3to5intermuscular perforators from the knee joint to the ankle joint, and the location of perforator at3.0cm below the knee joint is relatively constant and sizable, and its ocurrence rate is100%and its external diameter is (0.36±0.06)mm. Pivoting on this perforator, survival rates of sapehenous artery perforator pedicled flap and perforator-plus fascicutaneous flap were90.8%and77.0%, respectively, in the experiment of creating the flap models. In the formal experiment, survival rates of sapehenous artery perforator pedicled flap and perforator-plus fascicutaneous flap were90.4%±22.5%and94.0%±9.9%, respectively (P>0.05). Survival rates of group A, B and C were83.8%±23.7%,45.7%±25.3%and55.0%±47.2%, respectively (P>0.05). Injection of methylene blue through perforator artery from saphenous artery showed that the blood in flap was mainly drained by the perforaor vein from the saphenous vein at the base of the flap, some blood was drained via anastomosis between perforator veins in the fasciocutaneous pedicle. Injected survival flaps with barium sulfate-latex showed, branches of perforator artery and vein as the vessel pedicle distributed the whole flap, the perforator artery and vein below the base of the fasciocutaneous pedicle anastomosed with the vessels in part of the flap near the pedicle; there were abundant anastomoses between perforator vein at the base of the pedicle and perforator vein below the former, and these anastomoses linked with both many little superficial veins and perforator vein of the anterior tibial vein distal to and around the fasciocutaneous pedicle. The meglumini diatrizoici radiography showed that the blood in veins was mainly drained by the perforaor veins at the base of the pedicle, and no contrast medium was seen on the fasciocutaneous pedicle. At the time of review, follow-up of all the patients was carried out, there was no complete necrosis flap in this series. Necrosis rates of the posterior tibial artery perforator pedicled flaps and perforator-plus fasciocutaneous flaps were21.1%and19.1%(P>0.05).Conclusions:(1) Based on the perforator from the saphenous vessel at3.0cm below the knee joint, the sapehenous artery perforator pedicled flap and perforator-plus fascicutaneous flap in rabbit is an ideal experimental model which can serve as the flap models for additional studies in this field.(2) With respect to sapehenous artery perforator-plus fascicutaneous flap, the perforator is the main approach for arterial supply and venous drainage of the flap, and the fasciocutaneous pedicle can play a part role in both terms above. The venous blood can be drained via not only the homologous perforator vein distal to the base of the flap but also the superficial vein and perforator vein from other main vessel which anamoses with the peforator veins from the saphenous vessel.(3) There is no difference between the posterior tibial artery perforator pedicled flap and perforator-plus fasciocutaneous flap in reliability.更多还原