摘要
目的：探讨以主干血管及筋膜皮肤为蒂的逆行岛状皮瓣的皮肤筋膜蒂对皮瓣成活影响及其在皮瓣静脉回流中作用；总结以骨间背侧血管和筋膜皮肤为蒂及以胫后血管和筋膜皮肤为蒂的的逆行岛状皮瓣的临床经验。
方法：预实验选用健康新西兰大白兔9只,在动物解剖、亚甲蓝灌注、乳胶硫酸钡溶灌注标本及解剖观察的基础上,设计并切取不同大小及不同蒂部处理方式的隐血管逆行岛状皮瓣,观察记录术后皮瓣成活情况。正式实验选用健康新西兰大白兔15只,以蒂部情况不同分为4组：A组皮瓣皮肤筋膜蒂宽设计为0cm,B组皮瓣皮肤筋膜蒂宽设计为0.5cm,C组皮瓣皮肤筋膜蒂宽设计为1.5cm,D组皮瓣皮肤筋膜蒂宽设计为1.5cm(蒂部仅含隐动脉,于旋转点处结扎伴行的隐静脉)；蒂长均为3.Ocm,以踝关节上2.0cm为旋转点,皮瓣大小均设计为7.0cm×3.0cm。另行E组为原位皮瓣完全游离后回植组。切取皮瓣,观察记录术后皮瓣成活情况。使用SPSS17.0统计软件进行统计分析。并行亚甲蓝灌注、乳胶硫酸钡灌注标本X线摄片及显微解剖、泛影葡胺造影研究不同蒂部处理方式的皮瓣的动脉供血和静脉回流。收集2002年1月至2013年1月我科所行的以骨间背侧血管及筋膜皮肤为蒂的逆行岛状皮瓣57例,以胫后血管及筋膜皮肤为蒂的逆行岛状皮瓣40例临床资料,并总结临床经验。
结果：兔隐动脉类似于人体胫后动脉,于兔后肢设计的逆行隐血管岛状皮瓣符合经典带主干血管逆行岛状皮瓣定义。预实验中以皮肤筋膜蒂宽1.5cm,设计的皮瓣均完全成活。蒂部不同处理方式的兔隐血管逆行岛状皮瓣共30例(每组6例)。A组：3例皮瓣完全成活；3例皮瓣近端发生部分坏死,平均成活面积比率为85.6%；B组：4例皮瓣完全成活；2例皮瓣近端发生部分坏死,平均成活面积比率为88.1%；C组：6例皮瓣均完全成活；D组：4例皮瓣完全成活,1例皮瓣发生部分坏死,1例皮瓣全部坏死,平均成活面积比率为73.83%；E组6例皮瓣均发生完全坏死。在A,B,C三组,随着蒂部筋膜皮肤组织宽度增加,皮瓣坏死例数逐渐减少,皮瓣成活面积比率递增。A,B,C,D四组间两两比较采用秩和检验(Mann-Whitney U test),差异无统计学意义。亚甲蓝灌注、乳胶硫酸钡灌注标本X线摄片及显微解剖可见筋膜皮肤蒂部存在较多的“迷宫式’’静脉吻合及静脉穿支间吻合。泛影葡胺灌注造影结果显示皮瓣的静脉回流从静脉主干回流,筋膜皮肤蒂部未见明显静脉回流。以骨间背侧血管及筋膜皮肤为蒂的逆行岛状皮瓣57例,52例皮瓣完全成活,5例部分坏死,皮瓣的完全成活率为91.2%(52/57)。以胫后血管及筋膜皮肤为蒂的逆行岛状皮瓣40例,38例完全成活,2例部分坏死,皮瓣的完部分坏死率为5.0%(2/40),6例皮瓣上界达到胭窝横纹的皮瓣均获完全成活。
结论：1.以兔隐血管及筋膜皮肤为蒂的逆行岛状皮瓣模型是较好模拟临床以主干血管及皮肤筋膜为蒂的逆行岛状皮瓣动物模型。2.以兔隐血管及筋膜皮肤为蒂的逆行岛状皮瓣的静脉回流主要通过主干静脉的逆静脉瓣回流,筋膜皮肤蒂对皮瓣的静脉回流起部分作用,其机制是通过皮肤筋膜蒂部的穿支与皮瓣内穿支静脉间吻合实现。3.隐血管蒂周围带一定宽度筋膜皮肤蒂对兔隐血管逆行岛状皮瓣的成活有一定的改善作用。4.血管蒂周围带筋膜皮肤组织有利于逆行骨间背侧血管岛状皮瓣的成活及皮瓣的切取。5.以胫后血管及筋膜皮肤为蒂的逆行岛状皮瓣成活可靠。
Objective:To explore the influence of the fasciocutaneous pedicle to the survival of the reverse island flap and the role of the fasciocutaneous pedicle to the venous return of the flap.To summarize the clinical experience of the reverse posterior tibial vessels island flap and posterior interosseous vessels island flap in fasciocutaneous-pedicle form.
Method:In the preliminary experiment,9New Zealand rabbits were performed anatomy,injection of methylene blue, barium sulfate-latex injection, and retrograde island flap based on saphenous vessels with various sizes and different pedicles. According to the defferent pedicles,15New Zealand rabbits were devided into five groups:group A(retrograde island flap without fasciocutaneous pedicle); group B(retrograde island flap with0.5-cm-wide fasciocutaneous pedicle); group C (retrograde island flap with1.5-cm-wide fasciocutaneous pedicle); group D (retrograde island flap with1.5-cm-wide fasciocutaneous pedicle but without saphenous vein). All the flaps were designed with the demension of7.0cm×3.0cm, the pedicle length of3.0cm, and the pivot point locating at2.0cm bove the medial malleolous. The flaps in group E was elevated and sutured in situ. At7to10days postoperatively, all the flaps'survival rates were recorded. All the data was analyzed by SPSS17.0. The arterial supply and venous drainage of various flaps were observed and recorded when the flaps were executed injection of methylene blue, barium sulfate-latex, and meglumini diatrizoici. We retrospectively reviewed the data of both57retrograde island flap based on dorsal interosseous vessels and fasciocutaneous tissues and40retrograde island flap based on posterior tibial vessels and fasciocutaneous tissues from Department of Orthopaedics, Second Xiangya Hospital, Central South University, Changsha, China between January2002and January2013, and summarized the clinical eaperiences of both flaps.
Results:The saphenous vessels is similar to the posterior tibial vessels in human, and retrograde island flap based on the saphenous vessels in rabbit is a good experimental model which may serve as a reproducible and reliable flap model for additional studies in this field. In the preliminary experiment, all the flaps based on the saphenous vessels and fasciocutaneous pedicle of1.5cm in width survived completely.Thirty retrograde island flaps with various pedicles were devided into five groups (6flaps in each group). In group A,3flaps survived uneventfully, the other3flaps developed partial necrosis, and the average survival rate was85.57%. In group B,4flaps survived uneventfully, the other2flaps developed partial necrosis, and the average survival rate was88.10%. In group C, all the flaps survived uneventfully and no flap developed partial necrosis. In group D,4flaps survived uneventfully, one flap developed partial necrosis, complete necrosis occurred in the other flap, and the average survival rate was73.83%. In group E, all the flaps developed complete necrosis. Comparison between every two groups was performed using Mann-Whitney U test, and there was no significant difference in the survival rate. Among group A, B and C, the survival rate increasing along with the increased width of the fasciocutaneous pedicle. Through the injection of methylene blue, and radiograph and microanatomy of specimens which were injected with barium sulfate-latex,"puzzle" anastomosis and anastomosis between perforator veins could be observed on the fasciocutaneous pedicle. However, the injection of meglumini diatrizoici showed that the blood in veins was mainly drained by the perforaor veins from the main vessel, and no blood was seen in 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. Of57retrograde island flap based on dorsal interosseous vessels and fasciocutaneous tissues,52(91.2%) flaps survived uneventfully and distal partial necrosis occurred in5(8.8%) flaps. Of40retrograde island flap based on posterior tibial vessels and fasciocutaneous tissues,38(95.0%) flaps survived uneventfully, distal partial necrosis occurred in5(5.0%) flaps, and6flaps with the top edge propelling the popliteal fossa horizontal grain survived completely.
Conclusion:(1) The retrograde island flap based on the saphenous vessels and fasciocutaneous tissues in rabbit is a good experimental model which may serve as a reproducible and reliable flap model for additional studies in this field.(2) The veneous blood in the retrograde island flap based on the saphenous vessels and fasciocutaneous tissues in rabbits were drained by the main vein through going against the venous valve. The fasciocutaneous pedicle could play partial role in drainage of the veneous blood in the flap, by means of anastomosis between perforator veins.(3) In the rabbits, the fasciocutaneous tissue along with the main vessel can improved the reliability of the retrograde island flap.(4) The attached fasciocutaneous pedicle can facilitate harvesting the retrograde dorsal interosseous vessels flap and improve the viability of the flap.(5) The retrograde island flap based on posterior tibial vessels and fasciocutaneous tissues is reliable.
引文
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