【作者】 牙祖蒙；

【导师】 陈宗基；

【作者基本信息】 中国协和医科大学 ， 整形外科学， 2000， 博士

【摘要】 反流轴型皮瓣的成活机理及临床应用研究 【目的】(1)建立反流轴型皮瓣的动物实验模型，为该种皮瓣的研究、开发、应用提供必要工具；(2)通过动物实验，观察反流轴型皮瓣成活过程中微循环的变化规律，了解皮瓣动脉供血和静脉回流的途径及动力，探索皮瓣的成活机理；(3)回顾总结临床所应用的反流轴型皮瓣的血运及成活情况，评价该种皮瓣的安全可靠程度，结合动物实验结果，对皮瓣血运并发症的发生、发展和预防进行分析讨论，以期更好的开发和应用反流轴型皮瓣。 【方法】(1)用大体解剖、墨汁灌注等方法观察了5只Wistar大白鼠背部皮肤的血供来源、分布及吻合情况，发现旋髂深血管供养腰背部皮肤，其管径较粗，动静脉紧密伴行，血管轴向与中线成直角相交，左右对称，在中线区有明显的吻合支。因此，形成了以左旋髂深血管为蒂，以左右旋髂深血管吻合网为轴的横形皮瓣，面积为8.0×2.5cm，跨中线长度4.0cm，皮瓣形成后原位缝合，作为反流轴型皮瓣的实验模型。(2)按上述方法形成Wistar大白鼠腰背部反流轴型皮瓣30例，观察术前及术后6h、24h、48h、72h、7天、14天皮瓣的相关临床指标和近端、中线区、远端的微循环形态学及动力学变化：包括皮瓣微循环动态观察，微血管压力、密度、管径的测定，皮瓣组织血流量的检测以及血管构筑变化的展示。(3)对1981～1999我科所应用的139例反流轴型皮瓣的血运及成活情况，包括皮瓣完全成活率，部分成活率，完全坏死率，动脉缺血、静脉淤血发生率，动脉缺血、静脉淤血致皮瓣坏死率等指标进行统计，并与我院同期顺流轴型皮瓣的相关指标作比较，评价反流轴型皮瓣的安全度；结合动物实验结果对皮瓣血运障碍尤其是静脉淤血的发生、发展和转归进行分析。 【结果】(1)在Wistar大白鼠腰背部所形成的以左旋髂深血管为蒂以左右旋髂深血管吻合网为轴的横形皮瓣30例，其轴心血管和吻合支出现率为100％，术后完全成活率100％，未发生皮瓣损伤和感染，微循环观察方便易行，可重复性强，效果良好。(2)术前动脉的血流由两侧流向中线，静脉血流由中线向两侧回流；皮瓣形成后，可见血液由蒂部动脉经中线区吻合支流入中线以远区域，而中线以远区域的静脉血流则通过静脉吻合支流向近端；术前、术后均未观察到静脉瓣膜。(3)术前动脉灌注压在中线两侧无显著差异(p=0.73)，即不存在灌注压差。术后皮瓣近端动脉灌注压72h内逐渐升高，而中线区及远端的灌注压显著下降，近端和远端平均微动脉灌更多还原

【Abstract】 Objectives (1) To establish an experimental model for reverse flow axial skin flap. (2) To investigate the pathway and power of artery inflow and venous outflow of the reverse flow flap and then to analyse it’s survival mechanisms. (3) To retrospect the the complications about circulation of the reversed-flow flaps used clinically. On the basis of experimental study and clinical review, the reliability and the circulatory complications of the reverse flow flaps are evaluated.Methods (1)The cutaneous vascular anatomy over the dorsum of Wistar rats was studied by means of anatomical dissection, Chinese ink injection into axial arteries and hyalining technique. It demonstrated that the rat’s dorsal skin derives its blood supply from lateral thoracic artery, 10th posterior intercostal artery and deep circumflex iliac artery. Among the three groups of vessels, the deep circumflex iliac artery is the most suitable axial vessel for establishing reversed-flow flap model for experimetal study because of it’s territory, size, axial orientation and especially the anastomosis across midline. So a flap measuring 8.0 X 2.5cm based on left deep circumflex iliac artery was designed over the rat’s dorsum with 4.0cm of it’s length crossing midline. The flap was immediately sutured to their respective beds then the viability was observed. (2)With the established experimental model, assessment of the arterial perfusion, venous drainage and the survival area of the flaps were made clinically. In the pedicle, midline and distal region of the flap, the dynamic microcirculation, the number, caliber, pressure and microvasculature were investigated respectivelly at 6h, 24h, 48h, 72h, 7 and 14day after operation. At the same time the blood flow of flap was meassured in the same region.(3) 139 cases of reverse flow flap used clinically were reviewed. They included retroauricular flaps based on superficial temporal artery, auricular composite flaps based on supraocular vessels, submental flaps based on contralateral submental vessels, cervico-scapulo-dorsal reverse-flow flaps and pudendal-thigh flaps. The rates of complete survival, partial survival, total loss, inadequate arterial perfusion, venous congestion, and the rate of flap failure attributed to ischemia or inadequate venous outflow were assessed In order to evaluate the reliability of reverse flaps, these parameter were in compared with that of anterograde flow axial flaps used in our hospital during the same time. Combined with the results of the experiment, the disorder or failure of flaps circulation were discussed in detail.Results: (1)The model flaps designed over the dorsum of Wistar rat revealed the anatomical and physiological characteristic of reversed-flow axial flap. Survival of thirty更多还原