摘要
目的探索应用游离及带蒂腓动脉小腿后外侧肌间隔主穿支(外径≥1.00mm者)供血型小腿后外侧皮神经营养血管皮瓣个体化“精确”自由修复全身不同创面的解剖基础、手术设计方案及相关理论依据,总结该皮瓣的技术要点并提出临床应用建议。
方法
一、应用解剖研究
1、乳胶、泛影葡胺混合液灌注新鲜小腿标本20侧,通过直接解剖及CT扫描数据导入Mimics软件平台后虚拟解剖观察2种方法,研究：①小腿后外侧皮神经营养血管皮瓣的血管网分布规律及解剖分型,腓肠神经构成的解剖差异,以及二者间的关联；②腓动脉小腿后外侧肌间隔主穿支的分布规律、解剖分型及其临床意义；③计算机辅助图形技术在本皮瓣研究中的应用价值。2、3侧新鲜小腿标本制成单穿支皮瓣模型,经供血穿支分别行血管造影及亚甲蓝染色灌注逐层解剖：①观察皮瓣血管网的动态和静态X线影像学特点,研究该皮瓣的大致循环途径；②观察皮瓣各层染色情况和范围,从另一角度分析其血管网分布规律,进一步为临床提供切取超薄皮瓣和筋膜瓣/筋膜皮肤瓣的解剖依据。
二、临床应用研究
1、血流动力学研究
应用彩色超声多普勒血流成像技术(Color Doppler Flow Imaging, CDFI)测定36块腓动脉主穿支小腿后外侧皮神经营养血管皮瓣供血皮穿支的术前、术后血流速度变化,应用统计学方法比较其差异,从血流动力学角度解释该皮瓣的跨区供血机制,结合相关理论,探讨其临床意义。
2、个体化手术设计及临床应用
基于腓动脉主穿支以及皮瓣血管网的解剖分布和分型,设计三种腓动脉主穿支供血型小腿后外侧皮神经营养血管皮瓣基本术式(最低位穿支蒂、不同节段穿支蒂,吻合穿支游离皮瓣),结合超薄皮瓣、筋膜皮肤瓣、复合组织瓣、双叶皮瓣及逆行吻合皮神经重建皮瓣感觉功能技术用于142例全身不同部位创面的“精确”自由修复,术中对关键解剖要素进行观察。通过文献复习,并对照本中心以往病例回顾结果对其临床应用效果做出评价,提出详细的个体化皮瓣设计方案和手术技术建议。
3、腓动脉主穿支术前体表定位研究
通过137例术前CDFI腓动脉小腿后外侧肌间隔主穿支体表定位的临床应用,分析其彩超影像特点及误差原因,根据该组90例术前仅通过彩超影像选择的90条皮瓣供血穿支的术中探查和选择结果,计算该法用于术前确定皮瓣供血血管的准确率。将52例患者小腿CTA数据在设备自带软件及Mimics软件平台上进行三维重建和分割、组合、着色,获得腓动脉小腿后外侧肌间隔主穿支的解剖图像资料,据此或结合CDFI超声影像设计皮瓣。评价CTA和CDFI各自的优、缺点,提出临床应用建议。
4、通过病例回顾和文献查询,探讨手术时机及术后循环检测方法
结果
一、解剖研究部分
每侧小腿平均有腓动脉主穿支3.3条,分布于小腿第2-9段(按腓骨头与外踝间连线自上而下等分9段计),外径1.53±0.40mm(1.00～3.02mm),71.2%分布于第5～8段,以第6段最多,占25.8%；最粗一支外径1.87±0.48mm(1.30～3.02mm),81.0%分布于第3～6段；最低一支外径1.37±0.27mm(1.00～1.92mm),分布于第6-9段,其中65%位于第7-8段,第8段占40%。按临床意义和解剖形态可将腓动脉主穿支分为3个类型：①Ⅰ型,根部外径1.68±0.43mmm,绝对血管蒂长平均5.8cm,走行迂曲,分支多而粗,共31条,占47%,分布于小腿第2-9段(74.2%分布于第3,6-8段),按照其肌间隔筋膜皮肤支数量又可分为a、b2个亚型；②Ⅱ型,解剖形态介于Ⅰ型和Ⅲ型之间,根部外径1.45±0.34mmm,绝对血管蒂长平均4.0cm,走行较为平直,共21条,占32%,分布于小腿第2-8段(71.4%分布于第5,6段)；③Ⅲ型,较为短小,多为典型的肌间隔皮穿支,根部外径1.29±0.20mmm,绝对血管蒂长平均2.2cm,共14条,占21%,分布于小腿第2,5-9段(71.4%分布于第7-9段)。
该皮瓣供区血管网主要由真皮下血管网和深筋膜层血管网2层构成,二者借皮动脉相互沟通。深筋膜层血管网中可呈明显的纵向链式吻合者共有三条：①内侧血管链(腓肠神经／腓肠内侧皮神经营养血管链,简称内侧链)；②中央血管链(腓肠神经交通支营养血管链,简称中央链)；③外侧血管链(腓肠外侧皮神经营养血管／,J、腿后外侧肌间隔吻合链,简称外侧链)。20侧小腿中腓肠神经吻合型14侧,非吻合型4侧,双腓肠神经型2侧。由于腓肠内侧皮神经走行深浅,腓肠神经合成位置高低以及腓肠内、外侧皮神经和交通支的粗细不同,深筋膜层血管网也存在差异,按整个供区直视下测得的理想皮瓣轴线可分为3种类型：①Ⅰ型(中央型),大致相当于内、外侧链间的中线,共12侧,占60%；②Ⅱ型(内侧型)：皮瓣理想轴线偏向内侧链,共计5侧,占25%；③Ⅲ(外侧型)：皮瓣理想轴线偏向外侧链,共计3侧,占15%。
在Mimics10.01软件平台上,可对血管、骨骼、肌肉、皮肤等进行分割以及任意组合三维重建。重建出的组织结构可赋色,呈现出与正常组织颜色接近的直观鲜明图像。所有腓动脉主穿支均可显示,12侧灌注质量较高的标本能看到其终末筋膜皮肤支,但深筋膜层和皮肤血管网无法显示。在虚拟环境中,可任意角度观察穿支血管的形态特征,测量解剖数据,做出与实体解剖一致的血管分型。
皮瓣模型DSA影像可以观察到三条血管链及大致为穿支动脉→深筋膜层动脉网→浅静脉网→穿支静脉的循环通路；亚甲蓝灌注解剖观察到皮肤着色范围的中轴线与皮瓣理想轴线基本一致,真皮下及深筋膜浅面染色较深且与皮肤染色范围基本相同,皮下脂肪层仅有较为散在的着色点。
二、临床研究部分
38块腓动脉主穿支供血型小腿后外侧皮神经营养血管皮瓣,其供血穿支术前收缩期峰值流速(peak systolic flow velocity, PSFV)为24.68±15.15cm/s,术后PSFV为38.65±16.96cm/s。其中游离移植共12块,术前PSFV为14.19±6.28cm/s,术后为32.69±15.86cm/s；带蒂移植共26块,术前PSFV为29.52±15.65cm/s,术后为41.40±17.04.86cm/s,经配对t检验,p值均<0.0001,提示术后流速较术前显著增加。
术前仅依据CDFI超声影像选择的90条皮瓣供血穿支中,准确率为77.8%(假阳性8条,12条不是最优选择),其中用于最低位穿支蒂皮瓣修复足踝创面的供血穿支定位准确率为91.2%。穿支血管肌间隔段和其发出的终末筋膜皮肤支穿过深筋膜进入皮下的超声影像均较易显示和辨别,但对Ⅰ型血管的全段追踪显示较为困难,容易误判；术前穿支血管口径测量值与术中直接测量结果呈正相关,且数值较为接近。CTA三维重建可清晰显示大体解剖结构,103侧小腿平均每侧可辨认出腓动脉小腿后外侧肌间隔主穿支2.3条(1-4条),绝大部分为Ⅰ型及Ⅱ型血管,小腿第8-9段除3侧外其余均不能显示出穿支血管。同时做了CTA和CDFI的94侧小腿中有63条腓动脉分支须借助CDFI方能与单纯的肌肉或腓骨营养支进行准确鉴别；单纯应用CTA或结合CDFI挑选出的游离移植皮瓣供血血管,术中探查准确率为100%。CT资料可以导入Mimics软件平台重建出对不同解剖结构进行任意分割、筛选和组合后的三维图像,模拟皮瓣设计切取。
142例临床手术中,最低位主穿支蒂螺旋桨状皮瓣修复足踝部软组织缺损组68例,所选穿支位于外踝上方5～14cm范围内；穿动脉外径1.02±0.23mm(1.00～1.62mm),其中Ⅲ型血管49条,Ⅰ型血管12条,Ⅱ型血管7条。不同节段主穿支蒂皮瓣修复小腿软组织缺损组31例,所选穿支位于外踝上方12-21cm,穿动脉外径1.39±0.43mm(1.00～2.10mm),其中Ⅰ型血管17条,Ⅱ型血管10条,Ⅲ型血管4条。吻合穿支游离移植组43例,所选穿支位于外踝上14-25cm,分布于小腿第2-6段；外径1.52±0.73mm(1.10～2.30mm),其中Ⅰ型血管35条,Ⅱ型血管7条,Ⅲ型血管1条。穿动脉有两条伴行静脉,根部可汇成1条,外径均粗于动脉(1.2-2.3倍)。能够在手术范围内基本确定腓肠神经解剖类型的共112侧：吻合型96侧,多数腓肠神经交通支粗大并走行表浅,非吻合型16侧,占14.3%,其中单独由腓肠外侧皮神经构成或交通支构成者5侧,占31.3%。全部142侧小腿观察到腓肠内侧皮神经粗大且走行表浅者57侧,仅占40.1%,102侧深筋膜层血管网可以根据术中情况大致作出分型：中央型63侧,占61.8%；内侧型17侧,占16.7%；外侧型22侧,占21.6%。本组皮瓣均全部成活,术后未观察到缺血或淤血。随访2-37个月,皮瓣质地优良,外形平整美观；随访超过1年者,重建感觉的皮瓣两点静态辨别觉6～12mm,且逆行吻合法与传统方法在效果上无明显区别。螺旋桨皮瓣及皮肤筋膜瓣技术的应用使大部分小腿供区可直接缝合,修复足踝者外形轮廓接近正常；超薄皮瓣技术修复手背和前足背者皮瓣厚度与受区基本一致；双叶皮瓣、复合组织瓣技术在复杂创面修复中的应用均取得满意效果。
我中心自2005年以后逐渐开始在临床应用本皮瓣,自2010年10月以后其使用比例已经占除手指小创面外各类创面修复的85.3%,游离皮瓣的98.5%。回顾2000-2005年的597例类似创面修复,使用外科皮瓣达17种,游离皮瓣中选择最多的是胸脐皮瓣和股前外侧皮瓣。无论从供区牺牲、手术适应症、修复效果及手术操作时间看,本皮瓣均具有明显优势。
结论
1、该皮瓣本质上是经皮神经营养血管轴跨区供血的特殊类型穿支皮瓣：①血供符合生理、安全可靠：相对粗大腓动脉主穿支保证了皮瓣的供血能力,基于深筋膜层血管网解剖分型的个体化皮瓣轴线设计确保了皮瓣具有完整、合理的供血途径；术后供血穿支血流动力学的改变进一步增加了皮瓣的血液灌注量；完全经穿支伴行静脉回流,不存在浅静脉“逆流”淤血问题。②穿支蒂设计使皮瓣具有自由的旋转修复角度,按螺旋桨皮瓣切取不仅修复外形美观,而且最大程度节省皮肤,减少小腿美容破坏。③腓动脉主穿支外径满足皮瓣游离移植吻合需要,修复部位不再受到限制。
2、穿支血管的形态学研究和解剖分型对于准确、灵活的个体化皮瓣设计(例如供血穿支的选择以及骨皮瓣、多叶皮瓣、嵌合皮瓣的设计切取等)和提高手术操作的准确性及效率具有重要指导意义。腓动脉主穿支的分布规律为本皮瓣三种基本术式设计及其手术适应症提供了解剖依据。
3、皮瓣血管网的解剖分布和构成特征为切取超薄皮瓣及皮肤筋膜瓣提供了依据,前者用于修复皮肤较薄的受区时一般不存在外观臃肿问题,后者可使大部分供区创面直接缝合,仅在小腿遗留线状瘢痕。
4、皮穿支术后收缩期峰值血流速度的显著增加从血流动力学角度解释了该皮瓣穿支经低阻力皮神经营养血管供血渠道远距离跨区供血现象,符合非牛顿流体特性。该结论提示,对供血穿支的充分游离并结扎其所有无关分支有助于改善皮瓣循环。
5、就本皮瓣而言,CDFI彩超影像是现阶段最重要的术前穿支血管体表定位方法,虽然CTA三维重建可以直观显示穿支血管形态及邻近组织的解剖结构,准确进行血管分型,模拟手术设计,但对于较细小的穿支、穿支末梢和小腿下1/3穿支血管不能显示或显示不充分,二者各有优缺点,具有互补性。CT扫描和计算机辅助虚拟三维图形技术在解剖研究、术前穿支血管定位定型以及手术教学等方面均具有应用前景,但当前不仍不能替代常规方法。
6、本皮瓣综合了皮神经营养血管皮瓣、穿支皮瓣和游离皮瓣各自优点,结合超薄皮瓣、皮肤筋膜瓣、复合组织瓣、组合皮瓣、多叶皮瓣等技术及本研究首次提出的逆行吻合神经法重建皮瓣感觉功能,可以自由、准确、高效修复全身不同部位创面。
7、早期创面修复在减少感染机会、简化手术操作、缩短治疗周期,促进骨折愈合和肢体功能康复等方面具有重要意义,但须遵循损伤控制原则。术后皮瓣循环监测,特别是激光多普勒血流仪等客观监测方法对于确保手术成功率具有重要的临床意义。
Objective To explore the anatomical bases, individual flap planning and relevant theoretical foundations of free and pedicled sural flap supplied by a dominant peroneal perforating artery (DPPA, with a diameter≤1.0mm) arising from the posterolateral intermuscular septum through neurocutaneous vascular axis for repairing of defects located anywhere, and put forward technique suggestions and related clinical guidelines.
Methods
1-Applied anatomical research
(1)20fresh legs were injected with the mixture of red latex and cardiografin. After CT scanning, direct dissection and virtual three-dimension research were performed to explore:①the distribution and anatomic classification of vascular networks of sural flap, the anatomic variation of the sural nerve and the relationship between them;②The anatomic distribution and classification of DPPAs and their clinical significances;③The value of computer aided three-dimension technique in the research of this flap.(2) Flap models were harvested from three fresh legs and DSA was performed through the simulated blood supply DPPA to observe both static and dynamic images of the flap's vascular networks and then methylene blue injection and dissection to observe dyeing of different tissue layers which also help to understand the distribution of vascular networks for harvesting super-thin flap and adipofascial/cutaneoadipofascial flap.
2. clinical research
(1) Hemodynamic reach of the flap
The peak systolic flow velocities (PSFV) of the blood supply pedicles in36flaps were measured before and after operation and statistically compared. The phenomenon of crossing angiosomes supply of the flap was explained from a hemodynamic view and its clinical significances were discussed.
(2) individual optimal flap planning and clinical application
Based on the distribution and anatomic classification of the DPPA and vascular networks, three basic surgical methods (flap pedicled on the lowest DPPA for repairing defects near the ankle, flap pedicled on the different DPPA for that of the leg and free flap) were designed and combined individually with techniques of super-thin flap, cutaneoadipofascial flap, combined-tissue flap and double-leaf flap to repair different defects in142cases. We also developed a reverse method for flap innervation. The essential anatomic data observed during operation were recorded. In order to assess the clinical results and significances of the flap, a large number of relating papers were reviewed and the similar cases treated earlier in our center were studied retrospectively. Detailed techniques of flap planning and harvesting were described for our new methods.
(3) Preoperative locating and assessment of DPPA
137cases'preoperative CDFI data were compared with intraoperative findings. The causes of false negative and false positive were analyzed to improve examination techniques.90DPPAs in90cases chosen as the blood supply pedicles only with CDFI preoperatively were used to calculate the rate of accuracy of this method for flap planning by comparing with the actual design and harvesting of the flap. CTA was also used for locating and assessment of the peroneal perforators in52cases. The stacked imaging data of CTA were inputted into the platform of Mimics image processing software to gain more detailed and accurate surface3-D models for the surgeons to design flaps. We compared the advantages and disadvantages of CDFI with those of CTA as a way to locate and choose a suitable DPPA for optimal flap planning preoperatively and thus offered clinical suggestions.
(4) The timing after injury for defects repairing using this flap and vascular monitoring after operation were discussed with literature and case reviews.
Results
1.anatomical research
The average number of the DPPAs observed in each leg was3.3with the average diameter of1.53±0.40mm (1.00-3.02mm). They located in the second to ninth segments of the line from the fibular caput to the tip of lateral malleolus which was equally divided into nine segments, and71.2%of which located in the fifth to eighth segments. The largest DPPAs averaged1.87±0.48mm (1.30～3.02mm) and mostly located in the third to sixth (81%). The lowest DPPAs located from the sixth to ninth with an average diameter of1.37±0.27mm (1.00～1.92mm) and mostly, the seventh to ninth (65%).40%of the lowest DPPAs appeared in the eighth. According to their clinical significances and morphological characteristics, those perforators were classified into three types:
Type Ⅰ
Type Ⅰ perforators had the longest pedicle (averaged5.8cm) and the average diameter of their root segments was the largest(1.68±0.43mm) comparing with other two types. They detoured before appearing at the location of posterolateral intermuscular septum and with many large branches to supply the neighboring muscles and fibula. There were31type Ⅰ perforators (47%of the total66DPPAs) and mostly located in the third, and the sixth to eighth segments. According to the number of cutaneo-fascial branches of intermuscular septum, they were classified into two subtypes:type Ⅰ a and type Ⅰ b.
Type Ⅱ
The morphological characteristics of Type Ⅱ perforators were between type Ⅰ and Ⅲ. The average length of their pedicles and average diameter of their roots were respectively4.0cm and1.45±0.34mm.21type Ⅱ perforators were found during dissection located mostly in the second to ninth segments of the leg. They were relatively straight and with less and smaller branches than the type I vessels.
Type III
Type Ⅲ DPPA was short, small, straight and the typical intermuscular septum perforator primarily supplying the skin and fascia. There were totally14Type Ⅱ DPPAs (21%) in this group located mostly in the seventh to ninth segments with an average length of2.2cm and root diameter of1.29±0.20mm.
Subdermal and deep fascial vascular plexus mainly constituted the flap's blood supply networks and they were connected by skin arteries. Three obvious longitudinal vascular chains were observed on the deep fascia:①the internal chain (the neurocutaneous vascular axis of the sural nerve and the medial cutaneous nerve of calf);②the medial chain (the nerocutaneous vascular axis of the sural communicating nerve);③the lateral chain (the neurocutaneous vascular axis of the lateral cutaneous nerve of calf and the vascular chain of the posterolateral intermuscular septum). In the20legs,14sural nerves originated from the union of the lateral and medial cutaneous nerve of calf,4just from one of them and2from both of them without combining. The deep fascial vascular network varied with the anatomic variation of the sural nerve and could be classified into three types according to the optimal axis for mapping a large flap obtained by direct observation and measuring:
Type Ⅰ (medial type)
The axis divided the space between the internal and lateral vascular chain and found in14legs (60%).
Type Ⅱ (internal type)
The axis was leaning to the internal vascular chain. This type was found in5legs (25%).
Type Ⅲ (lateral type)
The axis was leaning to the lateral vascular chain and was found in3legs (15%).
On the platform of Mimics image processing software (version:10.01), the artery, bone, muscle, fascia and skin could be showed separately or combined in vivid colors, and viewed at different angles. All DPPAs could be recognized in3D images, but only in12of the legs, the terminal branches of the DPPA were seen. The morphological characteristics of DPPAs could be demonstrated or measured from different angles of view, and the anatomic types decided. The vascular networks of the deep fascia and skin didn't present in any of the images.
The DSA of the flap models demonstrated the three vascular chains of the deep fascia described in direct anatomic dissection, and the most probable vascular circuit was:DPPA→vascular chains of deep fascia→superficial veins→comitant veins of DPPA. The dyeing maps of methylene blue proved that the optimal flap designing axes differed in accord with the different types of vascular networks of deep fascia. The dyeing areas and color depth of different layers of the flaps showed that the deep fascial and subdermal vascular plexuses were the most important blood supply networks. There were only interspersal dyeing dots or small areas observed on the layer of subcutaneous fat.
2. Clinical research
The mean PSFV of the pedicles of all38flaps were24.68±15.15cm/s preoperatively and38.65±16.96cm/s postoperatively. The preoperative and postoperative mean PSFV in the group of free flap were14.19±6.28cm/s and32.69±15.86cm/s respectively, and29.52±15.65cm/s and41.40±17.04cm/s in the pedicled group. By paired t-test, the postoperative PSFV was significantly higher than the preoperative PSFV (P<0.0001).
Of the90DPPAs selected just with CDFI as the blood supply vessels for flap planning,9were false-positive and12were not the optimal ones, so the rate of accuracy was77.8%. What should be demonstrated was that if just consider the pedicled flaps based on the lowest DPPA, the rate of accuracy was91.2%. The intermuscular septum segment and the terminal branches of DPPA as well as how those branches passed through the deep fascia could be seen in ultrasound images, but it's hard for CDFI to detect and show the full-length of those long perforators such as type Ⅰ DPPA and thus false results could occur.52patients (103legs) underwent CTA examination to locate and assess DPPA for flap planning preoperatively, and averaged2.3DPPAs as well as the neighboring anatomic structures could be shown in each leg. Most of the DPPAs seen in CTA images were type Ⅰ or type Ⅱ vessels, and except3 legs we didn't found any DPPA shown in the eighth to ninth segments. In94legs using both CTA and CDFI for flap mapping preoperatively, there were63branches of peroneal artery shown in CTA images could only be differentiated from the pure nutrient branches of bone and muscle with the help of CDFI. In those patients if we could choose a DPPA as the blood supply vessel for free flap designing in CTA images with or without the help of CDFI, the accuracy rate was100%. CTA data could be inputted into the platform of Mimics image processing software for the surgeon to reconstruct different anatomic structures separately or combinedly to gain more detailed and accurate3-D images or even design and harvest flap in virtual environments.
Of the total142cases of clinical operation, the blood supply DPPAs were located above the lateral malleolus in the range5.0-14cm (the diameters of the DPPAs averaged1.02±0.23mm, ranged1.00～1.62mm) which included49type Ⅲ,12type Ⅰ and7type Ⅱ vessels in the group of propeller flaps based on the lowest DPPA for repairing defects near the ankle (68cases), and in the range12～21cm (diameters averaged1.39±0.43mm, ranged1.00～2.10mm) which included17type Ⅰ,10type Ⅱ, and4type Ⅲ vessels in the group of pedicled flaps based on the DPPAs from different leg segments for defects of the leg, and in the range14～25cm (the second to sixth segments, and diameters averaged1.52±0.73mm, ranged1.10~2.30mm) which included35type Ⅰ,7type Ⅱ, and1type Ⅲvessels in the group of free flaps. Each DPPA had two comitant veins which could syncretize into one and were larger than the artery (1.2～2.3times in diameter).112cases'anatomic types of sural nerve could be decided in the operating field. There were96sural nerves of union type, and the sural communication nerve was superficial and larger than the medial cutaneous nerve of calf in most cases. There were16sural nerves of non-union type, and in5of which, the sural nerve was formed just by the lateral cutaneous nerve of calf or the sural communicating nerve. We found that the medial cutaneous nerve of calf was superficial and large in57cases, and that accounted only for16.7% of all142cases. The types of vascular networks on the deep fascia could roughly be decided in102cases, which included63(62.8%) of medial type,17(16.7%) of internal type and22(21.6%) of lateral type. All flaps survived without necrosis and no vascular problem occurred. The Follow-up in all patients for2to27months revealed that the texture, appearance and color of the flaps were all satisfactory. In those who were followed up for more than one year and the flaps were innervated, static two point discrimination was6～12mm. Moreover, we didn't find obvious difference in the results of inervation between our new reversed method and the traditional way. Using the techniques of propeller flap and cutaneoadipofascial flap, most of the donor sits could be closed, and in those for repairing defects of the ankle and foot, the shape of recipient sites were nearly normal. The defects over dorsal hand and foot could be covered without bulking by using super-thin technique. All of the complicated defects were efficiently and freely reconstructed with other advanced techniques of the flap, such as composite-tissue and double-leaf flap, and the results were satisfactory.
The flap has been clinically used in our center since October,2005. Because it's so versatile and efficient, after2010,85.3%of all kinds of defects (except small ones of the finger) were repaired with this flap, which even accounted for98%of free flaps used. We retrospected597similar cases treated in our center from2000to2005, and found that17kinds of surgical flaps were used; the most frequently applied free flaps were thoraco-umbilical and anterolateral thigh flaps. In many ways such as donor sacrifice, operation indications, repairing effects, and operating time, the new flap was much better than traditional ones.
Conclusions
1. This flap is a special perforator one supplied through neurocutaneous vascular axis:
①blood supply is safe and sufficient.
DPPA, the relatively large perforator is able to perfuse enough blood into the flap, and the individual axis for flap planning based on the type of the vascular chains of the deep fascia ensures the flap's integrate and reasonable circulation network. The significantly increased PSFV of the perforator on which the flap is based further enhances blood supply, and there is no problem of reverse-flowing by the small saphenous vein.
②Tt is a perforator flap.
The pedicle can be rotated freely without bulking and if designed as a propeller flap the cosmetic results are satisfactory both at donor and recipient sites.
③With a relatively large diameter, the DPPA can be anastomosed easily, and the flap transplanted freely to repair any defects without limits of location.
2.The morphologic research and anatomic classification of DPPA benefits individual and accurate flap planning, such as choosing an optimal perforator as the blood supply pedicle for a specific flap, and the tactics for efficiently designing and harvesting the composite-tissue flap, the multi-leaf flap, and even the assembled flap or the chimeric flap. The distribution characteristics of DPPA provide the anatomical bases for the design of the three elementary types of the flap.
3. The form and distribution of the flap's vascular networks in different layers of tissue provides anatomic basis for designing and harvesting the super-thin and cutaneoadipofascial flap. There is no bulking in recipient sites using the super-thin flap, and most of the donor sits can be closed directly with the techniques of cutaneoadipofascial flap.
4. The phenomenon of crossing angiosomes of the flap's blood supply through neurocutaneous vascular axis can be explained from a hemodynamic view by the significantly increasing of PSFV at the perforator on which the flap based, and which obeys the rules of non-Newtonian fluid indicating that the blood supply pedicle should be dissected thoroughly and all irrelevant branches arising from it cut and ligated.
5.CDFI is one of the most important methods for locating DPPAs preoperatively.3-D images of CTA can provides direct and vivid images of anatomic structures for the surgeon to learn the locations and types of DPPAs before operation and even planning and harvesting the flap in virtual environments, but the peripheral branches of DPPA, and most of the DPPAs located in the distal third of the leg can not be shown. CTA and CDFI have their own advantages and disadvantages and are complementary for flap planning preoperatively. The techniques of computer-assisted 3D image processing is useful and with brilliant prospects in anatomic research, locating and morphological assessment of perforators, and surgical training, but can not take the place of traditional ways at the present time.
6.This kind of flap combines the advantages of the nerocutaneous flap, the perforator flap and the free flap, and with the techniques of the super-thin, cutaneoadipofascial, composite-tissue, assembled and multi-leaf flap, as well as our new reversed method of innervation, it can be used to repair any defects anywhere freely, accurately and efficiently.
7.There are benefits from early repairing of defects, such as reduced risk of infection, easier flap designing and transplanting, shortened in-hospital time, bone healing and better functional rehabilitation of limbs, but the principles of damage control should be obeyed. Vascular monitoring of the flap, especially those by objective methods, such as laser Doppler flowmetry is important to ensure the survival of the flap.
引文
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