逆行腓肠肌肌皮瓣的解剖学研究和临床应用
|
摘要
目的 探讨逆行腓肠肌肌皮瓣临床应用的可行性。方法 ① 在14具(28侧)成人尸体标本上，对腓肠肌形态和血供进行巨微解剖观测。② 在2例新鲜的腓肠肌标本上进行动脉温0.9％生理盐水连续灌注后美蓝灌注并行血管造影。在1侧成人下肢进行在体小腿动脉造影，经DSA摄片观察腓肠肌的血管走向，了解腓肠肌内外侧头之间、腓肠肌内侧头和比目鱼肌之间的交通支的出现位置。③ 以腓肠肌内侧头肌皮瓣修复2例小腿下1／3的皮肤软组织缺损。结果 ① 逆行腓肠肌肌皮瓣的血供为多源性，主要为腓肠肌与比目鱼肌的交通支，该交通支的最低位置出现在腓肠肌内侧头肌腹的下1／4～1／5处，腓肠肌之间的最低交通支的出现一般在腓肠肌内侧头肌腹的下1／3～1／4处。临床上分离腓肠肌内外侧头肌腹之间的上3／4的逆行腓肠肌内侧头肌皮瓣的血供是有保障的。② 新鲜标本的解剖发现腓肠肌内外侧头之间的血管联系丰富，从腓肠肌内侧头动脉灌注的美蓝可以使腓肠肌外侧及与比目鱼肌的最低交通支蓝染。动脉造影显示腓肠肌内外侧头动脉来源于胭动脉，腓肠肌内外侧头之间存在很多交通支。腓肠肌内侧头动脉终末支与比目鱼肌血管存在广泛吻合。③ 2例病人中有1例皮瓣成活良好，另1例由于下肢浅静脉被过度破坏，静脉淤血肌皮瓣远端部分坏死。结论 逆行腓肠肌肌皮瓣的确可以成活，而且具有解剖位置恒定表浅、手术可一期完成、不牺牲下肢主要血管的优点，对于小腿中下段的洞腔性缺损的修复较为有效。由于静脉回流略显不足虽修复范围较广但不宜作为首选。
objective to investigate the feasibility of clinical application of inferiorly based gastrocnemius muscle flap(IBGMF). Methods (1)To survey the morphosis and blood supply of gastrocnemius muscle flap on 14cadavers(28 specimens).(2)Two fresh gastrocnemius muscle specimens were warmed and flushed with warm 0.9%NaCl then injecting 0.1%methylene blue through the medial sural artery. The arterial communication between the gastrocnemius were identified by radiography When it was cannulated and injected with iopamidole acid.Two specimens were dissected to find the location of anastomotic and the caliber was measured under microscope. Arteriography was carried out under DSA on one patients to find the location of the lowermost arterial anastomosis between lateral and medial gastrocnemius muscle heads and the anastomosis from soleus. (3)The distally pedicle medial gastrocnemius muscle flap have been used to repair the defects in lower 1/3 limb in two patients. Result ㏕he reverse gastrocnemius muscle flap has multip
l- blood supply. It is mainly supplied by anastomosis from soleus. The anastomosis is invariably deteced in the lower fourth. The lowest anastomotic between the gastrocnemius muscle heads is not found at a constant level, it is invariably found in the lower third of the medial head's length. It is said that about upper there-quarters of the medial head can be safely detached from lateral
head in clinical.(2) Dissecting in two fresh specimens, we can find there is a lot of anastomotic arteriole between the muscle heads . After injecting methylene blue through medial sural arteries, the anastomosis of the arterial networks of the heads is depicted, the anastomosis from soleus is also dyed . Arteriograph showed that the medial sural artery arises from the popliteal artery around the keen joint line. There are a lot of anastomotic arteriole can be found between medial and lateral artery and the soleus .(3)The flap was survived in one patient and in another the flap was partially necrosis in distal fifth because of insufficient venous flow. Conclusion The inferiorly based hemigastrocnemius muscle flap for defects of the middle and distal third of the tibia might be both reliable and applicable. Its wide area of rotation, its easy-going dissection, and its reliable vascular pedicle are distinct advantages. Its insufficient venous flow sometimes makes it impossible to use. However, it might be help
ful in difficult situation .
objective to investigate the feasibility of clinical application of inferiorly based gastrocnemius muscle flap(IBGMF). Methods (1)To survey the morphosis and blood supply of gastrocnemius muscle flap on 14cadavers(28 specimens).(2)Two fresh gastrocnemius muscle specimens were warmed and flushed with warm 0.9%NaCl then injecting 0.1%methylene blue through the medial sural artery. The arterial communication between the gastrocnemius were identified by radiography When it was cannulated and injected with iopamidole acid.Two specimens were dissected to find the location of anastomotic and the caliber was measured under microscope. Arteriography was carried out under DSA on one patients to find the location of the lowermost arterial anastomosis between lateral and medial gastrocnemius muscle heads and the anastomosis from soleus. (3)The distally pedicle medial gastrocnemius muscle flap have been used to repair the defects in lower 1/3 limb in two patients. Result ㏕he reverse gastrocnemius muscle flap has multip
l- blood supply. It is mainly supplied by anastomosis from soleus. The anastomosis is invariably deteced in the lower fourth. The lowest anastomotic between the gastrocnemius muscle heads is not found at a constant level, it is invariably found in the lower third of the medial head's length. It is said that about upper there-quarters of the medial head can be safely detached from lateral
head in clinical.(2) Dissecting in two fresh specimens, we can find there is a lot of anastomotic arteriole between the muscle heads . After injecting methylene blue through medial sural arteries, the anastomosis of the arterial networks of the heads is depicted, the anastomosis from soleus is also dyed . Arteriograph showed that the medial sural artery arises from the popliteal artery around the keen joint line. There are a lot of anastomotic arteriole can be found between medial and lateral artery and the soleus .(3)The flap was survived in one patient and in another the flap was partially necrosis in distal fifth because of insufficient venous flow. Conclusion The inferiorly based hemigastrocnemius muscle flap for defects of the middle and distal third of the tibia might be both reliable and applicable. Its wide area of rotation, its easy-going dissection, and its reliable vascular pedicle are distinct advantages. Its insufficient venous flow sometimes makes it impossible to use. However, it might be help
ful in difficult situation .
引文
1．王义彪，柏树令，高景恒．小腿组织瓣的类型及计算机优选系统．实用美容整形外科杂志，1994，5(4)：201-206
2．谭金海，陈振光．组织瓣移位修复小腿骨、软组织缺损的解剖与临床．临床外科杂志 2001，9(4)253—255。
3．候春梅，程绪西，贾淑兰，等．比目鱼肌瓣移位修复小腿慢性骨髓炎软组织缺损．中华显微外科杂志，1996，19(3)：173—175
4. McCraw, JB.,and Fishman,JH., and Sharer, LA.:The versatile gastronemius myocutaneous flap. Plast .Reconstr .Surg. 1978,62(1): 15-23.
5. Feldman,JJ.,et al :The medial gastronemius myocutaeous flap. Plast. Reconstr. Surg.1978 , 61(4) : 531-536.
6．程绪西，尹大庆，荣国威，等．腓肠肌内侧头推进肌皮瓣移位修复小腿远端骨外露创面．中华骨科杂志 1984，4(3)166—168。
7．朱盛修，李主一，王锡琏，等．腓肠肌-皮肤瓣治疗下肢火器性慢性骨髓炎．中华外科杂志．1981，19(9)：571-572
8. Bashir ,AH.,:Inferiorly-based gastrocnemius muscle flap in the treatment of war wound of the middle and lower third of the leg. Br. J. Plast. Surg. 1983 , 36 (3): 307-309.
9．柏树令，李吉．腓肠肌肌皮瓣的显微外科解剖学．中国医科大学学报 1982，11(4)：11-15
10. CH.Tsetsonis, OS.Kaxira, DH.Laooulakos et al. The arterial communication between the gastrocnemius muscle heads: a fresh cadaveric study and clinical implications. Plast. Reconstr. Surg.2000,105(1):94-98.
11. Tsetsonis,CH.,et al. The inferiorly based gastrocnemius muscle flap :anatomic aspects. Plast. Reconstr.Surg.2000,106(6): 1312-1315.
12．庞水发，朱家恺．腓肠肌内侧头肌皮瓣移植术．1991，14(2)122-124．
13．陈玲珑，蓝宝金，郑明，等．腓肠肌内外侧血管解剖特点及在小腿创伤修复中的意义．中国临床解剖学杂志．1998，16(4)：297～298
14．张发惠，郑和平，王树锋，等．腓肠肌移位重建伸膝功能的应用解剖 中国临床解剖学杂志 1995 13(3)182—184。
15．朱盛修，张伯勋．带血管蒂皮瓣或肌皮瓣移位修复下肢创伤软组织缺损．中华外科杂志 1987，25(4)226—227
16. Fourn, BL. N.Caye.M.Panner.Distally based sural fasciomuscular flap : anatomic study and application for filling leg or foot defects. Plast .Recontr. Surg.2001,107(1):67-72.
17．陆春才，戴茂松，陈雨田．腓肠肌逆行转移的应用解剖学．解剖学杂志，1988，1 1(1)：10-13
18. A Atchabahian, AC. Masquelet. The distally based medial gastrocnemius flap: case report and anatomic study. Plast .Recontr.Surg.1996,98(7):12531-256.
19．康安，熊明根，张世民．远端蒂皮辦的静脉回流．中国临床解剖学杂志 200119(2)188—190。
20．张世民，刘大雄，张连生，等．远端蒂皮瓣的血液循环特征及临床意义．中国临床解剖学杂志 1998，16(2)103—106。
21．林昂如，金明新，狄勋元．腓肠肌内侧头肌皮瓣交腿移植修复小腿严重开放骨折．中国临床解剖学杂志 1994，12(3)：225—226。
22．徐旭纯，王丹，杨文龙．腓肠肌肌皮瓣修复胫前软组织缺损．四川医学2001，22(8)723—723。
23．王洪业 沈成 陆廷仁，等．切断肌肉起点的腓肠肌肌皮瓣移位术20例报告．中华显微外科杂志 1999，13(2)77—78。
24. CH.Tsetsonis,OS.Kaxira,DH.Laoulakos etal. The venous communication between the gastrocnemius muscle heads. Plast.Recontr.Surg.2000, 105(4)1357-1360.
25．戴松茂，董任章，石荣炳，等．腓肠肌瓣、肌皮瓣的临床应用．中华显微外科杂志 1988，11(1)：56-57。
26．秦荣生，王侠，陈育哲，等．小腿腓肠肌部分切除塑造小腿外形．中华整形外科杂志 2003，19(2)85～87。
2．谭金海，陈振光．组织瓣移位修复小腿骨、软组织缺损的解剖与临床．临床外科杂志 2001，9(4)253—255。
3．候春梅，程绪西，贾淑兰，等．比目鱼肌瓣移位修复小腿慢性骨髓炎软组织缺损．中华显微外科杂志，1996，19(3)：173—175
4. McCraw, JB.,and Fishman,JH., and Sharer, LA.:The versatile gastronemius myocutaneous flap. Plast .Reconstr .Surg. 1978,62(1): 15-23.
5. Feldman,JJ.,et al :The medial gastronemius myocutaeous flap. Plast. Reconstr. Surg.1978 , 61(4) : 531-536.
6．程绪西，尹大庆，荣国威，等．腓肠肌内侧头推进肌皮瓣移位修复小腿远端骨外露创面．中华骨科杂志 1984，4(3)166—168。
7．朱盛修，李主一，王锡琏，等．腓肠肌-皮肤瓣治疗下肢火器性慢性骨髓炎．中华外科杂志．1981，19(9)：571-572
8. Bashir ,AH.,:Inferiorly-based gastrocnemius muscle flap in the treatment of war wound of the middle and lower third of the leg. Br. J. Plast. Surg. 1983 , 36 (3): 307-309.
9．柏树令，李吉．腓肠肌肌皮瓣的显微外科解剖学．中国医科大学学报 1982，11(4)：11-15
10. CH.Tsetsonis, OS.Kaxira, DH.Laooulakos et al. The arterial communication between the gastrocnemius muscle heads: a fresh cadaveric study and clinical implications. Plast. Reconstr. Surg.2000,105(1):94-98.
11. Tsetsonis,CH.,et al. The inferiorly based gastrocnemius muscle flap :anatomic aspects. Plast. Reconstr.Surg.2000,106(6): 1312-1315.
12．庞水发，朱家恺．腓肠肌内侧头肌皮瓣移植术．1991，14(2)122-124．
13．陈玲珑，蓝宝金，郑明，等．腓肠肌内外侧血管解剖特点及在小腿创伤修复中的意义．中国临床解剖学杂志．1998，16(4)：297～298
14．张发惠，郑和平，王树锋，等．腓肠肌移位重建伸膝功能的应用解剖 中国临床解剖学杂志 1995 13(3)182—184。
15．朱盛修，张伯勋．带血管蒂皮瓣或肌皮瓣移位修复下肢创伤软组织缺损．中华外科杂志 1987，25(4)226—227
16. Fourn, BL. N.Caye.M.Panner.Distally based sural fasciomuscular flap : anatomic study and application for filling leg or foot defects. Plast .Recontr. Surg.2001,107(1):67-72.
17．陆春才，戴茂松，陈雨田．腓肠肌逆行转移的应用解剖学．解剖学杂志，1988，1 1(1)：10-13
18. A Atchabahian, AC. Masquelet. The distally based medial gastrocnemius flap: case report and anatomic study. Plast .Recontr.Surg.1996,98(7):12531-256.
19．康安，熊明根，张世民．远端蒂皮辦的静脉回流．中国临床解剖学杂志 200119(2)188—190。
20．张世民，刘大雄，张连生，等．远端蒂皮瓣的血液循环特征及临床意义．中国临床解剖学杂志 1998，16(2)103—106。
21．林昂如，金明新，狄勋元．腓肠肌内侧头肌皮瓣交腿移植修复小腿严重开放骨折．中国临床解剖学杂志 1994，12(3)：225—226。
22．徐旭纯，王丹，杨文龙．腓肠肌肌皮瓣修复胫前软组织缺损．四川医学2001，22(8)723—723。
23．王洪业 沈成 陆廷仁，等．切断肌肉起点的腓肠肌肌皮瓣移位术20例报告．中华显微外科杂志 1999，13(2)77—78。
24. CH.Tsetsonis,OS.Kaxira,DH.Laoulakos etal. The venous communication between the gastrocnemius muscle heads. Plast.Recontr.Surg.2000, 105(4)1357-1360.
25．戴松茂，董任章，石荣炳，等．腓肠肌瓣、肌皮瓣的临床应用．中华显微外科杂志 1988，11(1)：56-57。
26．秦荣生，王侠，陈育哲，等．小腿腓肠肌部分切除塑造小腿外形．中华整形外科杂志 2003，19(2)85～87。