臂外侧穿支皮瓣的解剖学研究及初步临床应用
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摘要
目的：通过研究臂外侧穿支血管的解剖学特点,寻求一种以臂外侧穿支为蒂的皮瓣,用于修复邻近部位的缺损,尤其是肘部的软组织缺损,并为臂外侧穿支皮瓣的设计及临床应用提供解剖学依据。
方法：新鲜成人上肢标本14侧,红色乳胶灌注。对臂外侧穿支血管分布情况,包括主干血管、穿支血管(直径≥0.5mm)的数目、长度、管径及分布、穿出位置及其在深筋膜表面的吻合情况等进行显微解剖学观察,根据穿支的位置,设计以臂外侧近端穿支、远端穿支为血管蒂的臂外侧穿支皮瓣并确定其旋转轴点、轴心线、分离平面和切取范围。在尸体标本上模拟手术成功后,应用于临床,观察手术效果。
结果：1、在14侧上臂标本中发现臂外侧的穿支血管来源广泛,由腋动脉、旋肱后动脉、肱动脉、桡侧副动脉等发出,其中桡侧副动脉是臂外侧皮瓣的主要血供动脉。2、在14侧上臂外侧共发现有63支穿支,平均为4.5支；直径大于0.5mm的有31支,其中发自桡侧副动脉的有20支,占64.52%,穿支起始处外径平均为(0.73±0.17)mm,穿深筋膜前平均长度(1.1±0.5)cm；发自肱动脉11支,占35.48%,穿支起始处外径平均为(0.71±0.24)mm,平均长度(1.9±0.8)cm。3、穿支出深筋膜后在深筋膜表面发出放射状分支,相邻穿血管相互吻合,形成纵向链式血管吻合,该血管吻合网血供稳定、可靠,是皮瓣血供的主要来源。4、根据解剖观测结果,设计了臂外侧近端蒂、远端蒂穿支皮瓣：点：近端蒂皮瓣旋转轴点位于肱骨外上髁上方14cm,桡侧副动脉近端穿支穿出点；远端蒂皮瓣旋转点位于肱骨外上髁上方3cm,桡侧副动脉远端穿支或肱动脉末端穿支穿出点。线：三角肌止点与肱骨外上髁之间的连线。面：在皮瓣轴线上切取含深筋膜的皮瓣,分离平面在深筋膜与肌膜之间,近端可取至三角肌止点下方5cm处,远端可取至肘横纹,前后界可达臂前后正中线。5、临床应用1例,皮瓣大小为8 cm×6 cm,皮瓣顺利成活,临床疗效满意。
结论：1.基本明确了臂外侧穿支血管的起源、数量、外径、位置及其在深筋膜表面的吻合情况,为上臂外侧中下部皮肤血管构筑提供了较确切的解剖学依据。2.根据臂外侧穿支血管的特点,设计了臂外侧穿支皮瓣,用于修复邻近部位软组织缺损,尤其是肘部、前臂上部软组织缺损,并为皮瓣设计提供了解剖学参考。3.该皮瓣血供稳定可靠,具有供区创伤小、手术操作方便、设计灵活的优点,临床应用1例,修复效果良好,初步证实临床应用的可行性,有待大量病例进一步证实。
Objective:To study the anatomical characteristic of perforators located at the lateral upper arm and to investigate the feasibility of employing the lateral upper arm perforator flap in clinical reconstruction,especially for recovering the defect of elbow.Through this study, we expect to provide anatomical basis for design and operation of the lateral upper arm perforator flap.
Methods:14 sides of fresh adult upper extremity cadavers,all cadavers were injected with red latex. Microsurgical observation was conducted regarding the distribution of arterial perforators including the source artery,perforator artery (calibra≥0.5mm), length,diameter, perforation site and its anastomosis with each other on the surface of deep fascia.According to the site of the perforator,upper arm flaps based on the distal perforator or the proximal perforator were designed,whose pivot point,axis,dissection layer as well as the vascular boundary were defined. In the body after a successful operation on the specimen simulation, clinical applications and observe operation effect.
Results:1. The origin of lateral upper arm perforators in the 14 side upper extremity cadavers are variable,it mainly are given off from axillary artery,posterior humeral circumflex artery,humeral artery and radial collateral artery.2.63 perforators were found in 14 cadavers,with an average of 4.5 perforators at each side perforators with a diameter greater than 0.5mm were 31.Among them,20 perforators with an average starting diameter of (0.73±0.17)mm and an average pre-fascial length of (1.1±0.5)cm.were from the radial collateral artery,which accounts for a proportion of 64.52%.11 perforators with an average starting diameter of (0.71±0.24)mm and pre-fascial length of (1.9±0.8)cm were given off from humeral artery, which accounts for a proportion of 35.48%.3. The perforators fan out at the surface of deep fascia,and the adjacent perforators interlink with each other to form longitudinal vascular anastomosis whose dominant vascular supply to the flap is stable, reliable.4. According the anatomical observation result, a distally based and proximally based upper arm perforator flap were designed:pivot point:the pivot point of proximally based upper arm perforator flap was located 14cm proximal to the lateral epicondyle of humerus, where perforator from radial collateral artery penetrate the deep fascia;the pivot point of distally based upper arm perforator flap was located 3cm proximal to the lateral epicondyle of humerus,where perforator from the end of humerus artery.Axis:the between insertion of the deltoid and lateral epicondyle of humerus.Plane:harvest the flap at the subfascial level,the proximal end can reach 5cm distal to insertion of deltoid,the distal end can reach the elbow crease,the anterior and posterior boundary can be close to the anterior and posterior line of upper arm.5.1 case of clinical application,whose size is about 8 cm X 6 cm.The flap survive uneventfully and the outcome was satisfactory.'
Conclusion:1.This research enables us to have a clear idea of the origin, number, diameter, location and their anastomosis on the surface of deep fascia,which could provide a definite anatomical support to the vascular structure of the middle-proximal part of upper arm. 2.according to the characteristic of the lateral upper arm perforators,we could design a proximally based perforator flap to repair the soft tissue defect of the axillary and proximal part of upper arm, while the distally based perforator flap could be used to repair the soft tissue defect of the elbow and proximal part of forearm.The lateral upper arm perforator flap with a vascular pedicle based on radial collateral artery can be freed to repair the defect of the hand and maxillofacial region.3. The blood supply to the lateral upper arm flap is reliable.it has the advantage of minimal trauma,easy dissection and flexible design,and has been proven applicable in clinic. we had 1 case of clinical application,whose outcome is quite satisfactory.
方法：新鲜成人上肢标本14侧,红色乳胶灌注。对臂外侧穿支血管分布情况,包括主干血管、穿支血管(直径≥0.5mm)的数目、长度、管径及分布、穿出位置及其在深筋膜表面的吻合情况等进行显微解剖学观察,根据穿支的位置,设计以臂外侧近端穿支、远端穿支为血管蒂的臂外侧穿支皮瓣并确定其旋转轴点、轴心线、分离平面和切取范围。在尸体标本上模拟手术成功后,应用于临床,观察手术效果。
结果：1、在14侧上臂标本中发现臂外侧的穿支血管来源广泛,由腋动脉、旋肱后动脉、肱动脉、桡侧副动脉等发出,其中桡侧副动脉是臂外侧皮瓣的主要血供动脉。2、在14侧上臂外侧共发现有63支穿支,平均为4.5支；直径大于0.5mm的有31支,其中发自桡侧副动脉的有20支,占64.52%,穿支起始处外径平均为(0.73±0.17)mm,穿深筋膜前平均长度(1.1±0.5)cm；发自肱动脉11支,占35.48%,穿支起始处外径平均为(0.71±0.24)mm,平均长度(1.9±0.8)cm。3、穿支出深筋膜后在深筋膜表面发出放射状分支,相邻穿血管相互吻合,形成纵向链式血管吻合,该血管吻合网血供稳定、可靠,是皮瓣血供的主要来源。4、根据解剖观测结果,设计了臂外侧近端蒂、远端蒂穿支皮瓣：点：近端蒂皮瓣旋转轴点位于肱骨外上髁上方14cm,桡侧副动脉近端穿支穿出点；远端蒂皮瓣旋转点位于肱骨外上髁上方3cm,桡侧副动脉远端穿支或肱动脉末端穿支穿出点。线：三角肌止点与肱骨外上髁之间的连线。面：在皮瓣轴线上切取含深筋膜的皮瓣,分离平面在深筋膜与肌膜之间,近端可取至三角肌止点下方5cm处,远端可取至肘横纹,前后界可达臂前后正中线。5、临床应用1例,皮瓣大小为8 cm×6 cm,皮瓣顺利成活,临床疗效满意。
结论：1.基本明确了臂外侧穿支血管的起源、数量、外径、位置及其在深筋膜表面的吻合情况,为上臂外侧中下部皮肤血管构筑提供了较确切的解剖学依据。2.根据臂外侧穿支血管的特点,设计了臂外侧穿支皮瓣,用于修复邻近部位软组织缺损,尤其是肘部、前臂上部软组织缺损,并为皮瓣设计提供了解剖学参考。3.该皮瓣血供稳定可靠,具有供区创伤小、手术操作方便、设计灵活的优点,临床应用1例,修复效果良好,初步证实临床应用的可行性,有待大量病例进一步证实。
Objective:To study the anatomical characteristic of perforators located at the lateral upper arm and to investigate the feasibility of employing the lateral upper arm perforator flap in clinical reconstruction,especially for recovering the defect of elbow.Through this study, we expect to provide anatomical basis for design and operation of the lateral upper arm perforator flap.
Methods:14 sides of fresh adult upper extremity cadavers,all cadavers were injected with red latex. Microsurgical observation was conducted regarding the distribution of arterial perforators including the source artery,perforator artery (calibra≥0.5mm), length,diameter, perforation site and its anastomosis with each other on the surface of deep fascia.According to the site of the perforator,upper arm flaps based on the distal perforator or the proximal perforator were designed,whose pivot point,axis,dissection layer as well as the vascular boundary were defined. In the body after a successful operation on the specimen simulation, clinical applications and observe operation effect.
Results:1. The origin of lateral upper arm perforators in the 14 side upper extremity cadavers are variable,it mainly are given off from axillary artery,posterior humeral circumflex artery,humeral artery and radial collateral artery.2.63 perforators were found in 14 cadavers,with an average of 4.5 perforators at each side perforators with a diameter greater than 0.5mm were 31.Among them,20 perforators with an average starting diameter of (0.73±0.17)mm and an average pre-fascial length of (1.1±0.5)cm.were from the radial collateral artery,which accounts for a proportion of 64.52%.11 perforators with an average starting diameter of (0.71±0.24)mm and pre-fascial length of (1.9±0.8)cm were given off from humeral artery, which accounts for a proportion of 35.48%.3. The perforators fan out at the surface of deep fascia,and the adjacent perforators interlink with each other to form longitudinal vascular anastomosis whose dominant vascular supply to the flap is stable, reliable.4. According the anatomical observation result, a distally based and proximally based upper arm perforator flap were designed:pivot point:the pivot point of proximally based upper arm perforator flap was located 14cm proximal to the lateral epicondyle of humerus, where perforator from radial collateral artery penetrate the deep fascia;the pivot point of distally based upper arm perforator flap was located 3cm proximal to the lateral epicondyle of humerus,where perforator from the end of humerus artery.Axis:the between insertion of the deltoid and lateral epicondyle of humerus.Plane:harvest the flap at the subfascial level,the proximal end can reach 5cm distal to insertion of deltoid,the distal end can reach the elbow crease,the anterior and posterior boundary can be close to the anterior and posterior line of upper arm.5.1 case of clinical application,whose size is about 8 cm X 6 cm.The flap survive uneventfully and the outcome was satisfactory.'
Conclusion:1.This research enables us to have a clear idea of the origin, number, diameter, location and their anastomosis on the surface of deep fascia,which could provide a definite anatomical support to the vascular structure of the middle-proximal part of upper arm. 2.according to the characteristic of the lateral upper arm perforators,we could design a proximally based perforator flap to repair the soft tissue defect of the axillary and proximal part of upper arm, while the distally based perforator flap could be used to repair the soft tissue defect of the elbow and proximal part of forearm.The lateral upper arm perforator flap with a vascular pedicle based on radial collateral artery can be freed to repair the defect of the hand and maxillofacial region.3. The blood supply to the lateral upper arm flap is reliable.it has the advantage of minimal trauma,easy dissection and flexible design,and has been proven applicable in clinic. we had 1 case of clinical application,whose outcome is quite satisfactory.
引文
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[2]钟世镇,孙博,刘牧之,等.皮瓣血供的解剖学类型[J].临床应用解剖学杂志,1984,2(1)：1.
[3]钟世镇.显微外科临床解剖学[M].济南.山东科技出版社,2000：52-53.
[4]Koshima I,Soeda S.Inferior epigastric artery skin flaps without rectus abdominis muscle[J].Br J Plast Surg,1989,42(7):645-648.
[5]张世民,徐达传,顾玉东.穿支皮瓣[J].中国临床解剖学杂志,2004,22(1)：32-33.
[6]李吉,姜树学,郝学春,等.臂外侧皮瓣显微外科解剖学.解剖学报,1983,14(4)：354.
[7]Hayashi A, Maruyama Y. Anatomical study of the recurrent flap of the uper arm[J]. Br J Plast Surg,1990,43 (4):300.
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