【作者】 陈铭锐；

【导师】 钟世镇； 王成琪；

【作者基本信息】 第一军医大学 ， 临床解剖学， 2002， 博士

【摘要】 目的 本课题的研究目的包括以下6项内容：(1)对皮瓣的动、静脉系统，特别是静脉系统进行解剖学研究，探索皮瓣内轴心动、静脉走行及分支分布规律；(2)阐明皮瓣内深、浅静脉系或伴行静脉与非伴行静脉的起始、走行、引流范围及交通途径；(3)观测皮瓣深、浅静脉干及其交通支内静脉瓣部位、形态、功能及对静脉间血液流通的影响；(4)明确皮瓣的动、静脉伴行特点与静脉回流规律；(5)确定皮瓣静脉回流的主渠道；(6)为皮瓣游离移植吻合静脉的选择，提供解剖学依据，并对跨区供血皮瓣静脉回流与交通、非生理性皮瓣的血液循环进行探索。通过上述研究，进一步阐明皮瓣静脉的立体构筑，探求其机理，并完善解剖学资料，以期为皮瓣的应用指征、吻合静脉的选择及危象的处置等，提供解剖学基础，更好地指导临床皮瓣外科。方法 (1)采用新鲜成人尸体双下肢标本，于股动脉及足背静脉网顺、逆行插管，分别注入8％明胶碳素墨汁，尔后行股动脉灌注及局部注射福尔马林防腐。切取皮瓣流水冲洗，酒精梯度脱水，二甲苯透明，冬青油内保存。(2)采用新鲜成人尸体上、下肢标本，于股动脉灌注红色乳胶，足背静脉网顺、逆行及股静脉加压灌注蓝色乳胶，福尔马林溶液防腐。新鲜男性成人尸体1具，于双侧股动脉插管内分别先后行8％明胶碳素墨汁→14％氨水→红色乳胶溶液灌注，至趾腹颜色由黑变红为止，流水冲洗6小时。另取新鲜成人尸体之肩胛皮瓣，股前外侧皮瓣，胸脐皮瓣及膝上内侧皮瓣，冲洗、防腐处理后，再于动脉灌注8％明胶墨汁溶液。(3)采用1例新鲜尸体左下肢标本制备过氯乙烯动(红)、静(蓝)脉分色铸型标本。(4)右下肢冷藏标本，于股动脉灌注红色乳胶，再于股静脉及大隐静脉顺、逆行灌注含硫酸钡混悬液之蓝色乳胶，福尔马林防腐，然后切取皮瓣，摄取x线片。(5)右下肢新鲜标本，制备组织切片。将标本冲洗、固定后，于动脉插管内灌注8％明胶墨汁，至浅表皮肤均匀变黑并可见静脉内有灌注液溢出即行停止。放置3天后，取4块右股前外侧皮瓣、4块小腿内侧皮瓣之墨染明显区域，经酒精梯度脱水、二甲苯及冬青油先后透明、石蛤包埋，连续水平及垂直切片，其厚度分别为 15、20及 100 u m，fiE染色，组织显微镜下观测。结果 门）亘接皮动脉或肌皮动脉，在体被组织逐步浅出的整个行程中，不断发出分支并分别在深筋膜层、皮下组织（浅筋膜）层、真皮下层、乳头下层和乳头层内形成五级具有鉴别特征的皮肤微循环血管网（血管树）。（2）体被组织静脉血管网由浅入深分为五层：皮肤乳头层。乳头下层、真皮下层、皮下组织层和深筋膜层。山乳头下层浅出的小动脉分支及末支，在真皮乳头层内形成毛细血管网，迂曲盘旋并返折形成微血管拌，延续、下降、吻合形成毛细血管后微静脉。毛细血管后微静脉相互吻合、汇合形成集合微静脉并伴行动脉进入乳头下层，组成乳头下层微静脉网。乳头下层微静脉和集合微静脉经2～4级汇合后，即向深面走行汇入真皮下层微静脉网或丛。多数真皮下层微静脉。小静脉伴行动脉进入皮下组织层、深筋膜层，并与皮下组织层和深筋膜层动脉分支的伴行静脉汇合，分别形成皮下组织层、深筋膜层静脉网，进而汇入轴心动脉的伴行静脉。而真皮下血管网中与动脉不伴行的微静脉汇合成为小静脉，并逐渐聚集增粗，汇合加入浅非伴行静脉属支或即为属支的起点。结论 门）皮瓣静脉构筑可分为5层血管网，吻合交通丰富；（2）皮瓣血管多为动、静脉伴行，皮瓣轴心动脉的伴行静脉是皮瓣血液回流的主渠道，为游离移植时的首选吻合静脉，而浅非伴行静脉的回流起辅助作用。（3）深、浅静脉间可经交通支、穿支吻合支而绕过静脉瓣进行沟通。更多还原

【Abstract】 Objectives:The purposes of the present study are as follows:(1) Anatomical study inclulding observation and measurement on arterial,especially venous system of flap was performed to attempt to illuminate the regular patterns of the distribution of the arteries,veins and their branches in the axial vascular skin flap. (2) Fathoming the origination,distribution,drainage scope and communicating path of deep and superficial veins or accompanied and unaccompanied veins. (3) Elucidating the positions,shape and functions of venous valves in deep and superficial venous stem and its communicating branches,observing their affects on the venous blood circulation. (4) Clarifying the accompanied characters of the veins and arteries of the flap and the reflux routes of vein. (5) Confirming the main channels of venous reflux of flap. (6) Providing anatomical evidence for the selection of vein engrafting in flap free grafting or transplantation. Study the vein reflux and communication of flap whose blood supply is trans-section and clarify the blood circulation of non-physical flap. Through all of the work mentioned above,elucidating the stereo architecture of flap vein and ensuring the mechanism inside,provide anatomical basis for the applying characteristic,selection of engraft vein and the treatment of the circulation crisis.Methods:(1) Using both lower limbs of fresh adult cadavers,cannulas inserted forward from femoral artery and backward from dorsal venous networks of foot to inject 8% gelatin carbonic ink,intra-femoral and local inject formalin to prevent rot. Gutted flap washed by current water,dehydrate using graded ethanol,vitrification by dimethylbenzene and deposited in holly oil. (2) Using both upper and lower limbs of a fresh adult cadaver,inject red gelatin into femoral,forward and backward injecting the blue gelatin withhigh pressure into femoral vein with formalin preventing rot. As for fresh male adult cadaver,inject 8% gelatin carbonic ink,14% ammonia and red gelatin until the ventral skin of the toe turn red from black,washing 6 hours by flowing water. Cutting the scapular flap,anterolateral femoral flap,chest-umbilicus flap and medial superior genicular flap,after washing and rot prevention,inject 8% gelatin ink solution into artery. (3) Left lower limb was used to prepare artery(red) and vein(blue) color cast specimens using perchloroethylene.(4) Deep freezed right lower limb sample,injecting red gelatin into femoral artery,forward and backward injecting blue latex with barium sulfate into femoral vein and great saphenous vein,cuting flap after dealing with formalin and get x-ray photos. (5) Fresh right lower limb sample:making tissue into slice samples,after washing and fixation,injecting 8% gelatin ink into artery by cannulas until the superficial skin turn black equally and injection solution overflow from the vein. Get 4 right anterolateral femoral flaps and 4 left scapular flaps which were dyed obviously after 3 days,dehydrate by graded ethanol,vitrification and paraffin embeded,horizontally and vertically sliced continuously,thickness is 15,20 and lOOjtim respectively,HE dyed,observed under microscope.Results:(1) Direct cutaneous artery or musculo-cutaneous artery,in the procedure of common integument tissue being shallowed up step by step,continuously sending out branches to deep fascia layer,superficial fascia layer,hypodermis layer,hypopapilla layer and papilla layer to form the five-grade cutaneous microcirculation "blood vessel tree" of the skin blood vessel network that can be identified. (2) Common integument tissue venous vessel network can be divided into five layers from superficial layer to deep layer:cutaneous papillary layer,hypopapillary layer,hypodermis layer,subdermal layer and deep fascia layer.The artery branch and arteriole that shallowed up from hypopapillar layer get to papillar layer to form vessel network,circuitous and twisted,reflux and anastomose to become postcapillary micro veins and endothelial venule,then anastomose each other and accompanied with artery to ente更多还原