嵌合穿支皮瓣的应用解剖和临床研究

发布时间：2017-12-26 22:37

本文关键词：嵌合穿支皮瓣的应用解剖和临床研究　出处：《浙江大学》2017年博士论文　论文类型：学位论文

【摘要】：研究背景:随着穿支皮瓣的发展和应用,以穿支为基础的分叶皮瓣设计被广泛应用。Hallock[1]受希腊神话中一种狮头、山羊身体、蝎尾的怪兽奇美拉(Chimera)的启发,首先提出"嵌合皮瓣"(Chimeric flap),的概念。嵌合皮瓣的定义是在指同一供血系统的多个组织瓣(皮瓣骨、肌腱、筋膜、肌肉)通过独立的血管供养,但又共同起源于上一级母体血管蒂的一组皮瓣。临床上应根据嵌合皮瓣的设计应根据供血系统的不同类型使用不同的类型的嵌合皮瓣。常用的嵌合穿支皮瓣供区有:带腓动脉嵌合穿支皮瓣[2];带旋髂深动脉嵌合穿支皮瓣[3];带肩胛下血管嵌合穿支皮瓣[4];带旋股外侧动脉嵌合穿支皮瓣[5];带腹壁下动脉嵌合穿支皮瓣[6];带腓肠内侧动脉嵌合穿支皮瓣[7]。腓肠内侧动脉穿支(MSAP)皮瓣由于MSAP解剖恒定,供区位置隐蔽、血管蒂较长、皮下脂肪少、供区损伤小,现腓肠内侧穿支皮瓣已成为头颈部及四肢创面修复,功能重建最常用的皮瓣之一。腓肠内侧动脉嵌合穿支皮瓣具备腓肠内侧动脉皮瓣的优点外还兼具嵌合穿支皮瓣只需吻合一组血管即可多个所有组织瓣的血供,新颖实用,实现了创面的立体三维重建的优点。随着它的广泛应用,腓肠内侧动脉系统的应用解剖也逐渐受到重视。现有的MSA系统的应用解剖研究主要集中在MSAP的分布和辨识,以及MSA及其分支在腓肠肌内的分布和走行。ALT皮瓣一直被认为理想的嵌合皮瓣之一,它具有较粗和稳定的穿支,通常能够提供2～3个较大的皮穿支供应分叶的皮瓣。旋股外侧动脉易于分离,且大腿血供丰富,它的切取不会引起肌肉坏死,而且股前外侧区可以提供较大量的皮肤筋膜组织和肌组织瓣,以适应多种规模的修复重建手术。腓动脉系统是经典的嵌合皮瓣供区,除了皮肤筋膜和少量肌肉组织外,腓动脉系统提供了足量的骨组织。腓动脉嵌合骨皮瓣可以用于多样化的修复重建手术中。游离腓骨瓣是修复重建头面部长段骨缺损的可靠方法之一目前穿支皮瓣血管定位的方法主要有手持式超声(Handled Doppler),彩色多普勒超声(Color Duplex),计算机层析成像血管造影(Computed Tomographic Angiography,CTA),磁共振血流成像(MRA)和数字减影血管造影术(digital subtraction angiography,DSA)。不论何种方法,都有可能出现不准确的情况。内镜技术已经广泛应用于各个专科的诊断和治疗。穿支游离皮瓣需要在肌肉内分离血管蒂,以目前的技术要进行内镜下的穿支分离仍然存在风险。但是在内镜下进行穿支探查,以减少穿支变异带来的供区大范围损伤已经有报道[8]。随着计算机辅助设计和制造技术的精度迅速发展,虚拟手术设计技术正在影响和改变外科医生对骨性重建手术的方案制定[9]。并使用3D打印技术构建的骨模型上进行数字化设计的截骨和钛板塑形[10]。这些技术缩短了手术时间,减少了腓骨瓣失败率,并获得了更好的外观和功能。第一部分腓肠内侧动脉系统的应用解剖研究方法:1.研究对象为4具成人尸体共8例下肢标本进行小腿内侧区解剖。2.发现腓肠内侧动脉穿支后解剖并标记,记录穿支类型、数目、穿出深筋膜外径、穿出点坐标及与腓肠神经的关系等。3.解剖并记录腓肠内侧动脉的分支类型,测量分支血管蒂长(远端穿支点至分支汇入腓肠动脉主干距离)和分支动脉直径、主干血管蒂长(远端穿支点至腓肠动脉汇入乆动脉起点)和主干动脉直径。4.统计分析腓肠内侧动脉穿支来源于腓肠内侧动脉的内侧或外侧分支的情况,测量穿支出深筋膜处到分支血管的深度。结果:1.解剖4具成人尸体(男性3具,女性1具)共8例下肢标本。其中7例发现腓肠动脉穿支2支,1例发现穿支3支。全部穿支均为肌皮穿支。显微手术放大镜下测量穿支直径0.68±0.19mm。穿支距离正中线水平距离3.88±1.22cm,穿支距离乆横纹垂直距离8.94±2.11cm。位置坐标以(x,y)表示。穿支距离腓肠神经距离 3.49±0.77cm。2.8例下肢标本腓肠内侧动脉的分支类型中,有Ⅰ型0例(0%),ⅡA型2例(25%),ⅡB 型(62.5%),Ⅲ型1例(12.5%)。分支蒂长 7.00±1.85cm,分支蒂动脉直径1.46±0.28mm。腓肠内侧动脉主干蒂长11.00±1.85cm,主干蒂动脉直径2.49±0.42mm。3.腓肠内侧动脉自乆动脉发出后,通常分为内侧和外侧两个分支血管。8例标本中有7例属于这种情况(1例有3个分支)。7例标本共发现穿支15个,其中8个分布于外侧分支,7个分布于内侧分支。其中外侧分支距离腓肠内侧动脉穿支穿深筋膜处0.58±0.11cm,内侧分支距离距离腓肠内侧动脉穿支穿深筋膜处0.87±0.45cm。t检验t=1.72,P=0.11,P0.05,认为无统计学差异。来自外侧分支血管的穿支直径0.79±0.21cm,来自内侧分支血管的穿支直径0.61±0.12cm。t检验t=1.91,P=0.078,P0.05,认为无统计学差异。外侧分支血管蒂部的直径1.44±0.27mm,内侧分支蒂部直径 1.27±0.32mm。t 检验 t=1.06,P=0.31,P0.05。结论:1.MSAP在8例下肢尸体标本中平均每例有2.1支穿支。显微手术放大镜下测量穿支直径0.68±0.19mm。穿支距离正中线水平距离3.88±1.22cm,穿支距离乆横纹垂直距离8.94±2.11cm。2.8例下肢标本MSP分支类型中,有Ⅰ型0例(0%),ⅡA型2例(25%),ⅡB型5例(62.5%),Ⅲ型1例(12.5%)。分支蒂长7.00±1.85cm,分支蒂动脉直径1.46±0.28mm。腓肠内侧动脉主干蒂长11.00±1.85cm,主干蒂动脉直径2.49 ± 0.42mm。3.MSA内、外侧分支距离深筋膜穿支点的距离没有统计学差异(t=1.72,P=0.11)。内、外侧分支发出的穿支直径没有统计学差异(P=0.078,P0.05)。MSA内、外侧分支蒂部动脉的直径没有统计学差异(t=1.06,P=0.31)。术前影像学定位寻找较浅的分支可以减少肌肉内血管分离的时间和难度。4.MSA分支和穿支的变异要求MSAP嵌合皮瓣术前精确的设计,包括对穿支的定位,对分支类型及其与穿支关系的探查,对供区血管直径及到创面距离的评估。第二部分内镜下穿支探查在穿支皮瓣的临床应用研究方法:1.MSAP皮瓣和ALT穿支皮瓣住院病例35人(其中分叶嵌合皮瓣10例,见第三部分)。术前彩色多普勒穿支定位,标记穿支位置,直径和血流参数。2.术中以4mm30°内窥镜探查标记点穿支,记录假阳性和假阴性,进行统计学分析。结果:1.病例35例,其中男性29例,女性6例。其中18(51.4%)例进行MSAP皮瓣,17(48.6%)例为ALT穿支皮瓣。内镜下共查到可用穿支68支,术中检测均能供养皮瓣。其中发现彩色多普勒超声出现假阴性7例,假阳性3例。敏感度=真阳性/(真阳性+假阴性)=61/(7+61)=89.7%。2.彩色多普勒超声出现假阴性7例中,穿支直径0.55±0.19cm;真阳性61例中,穿支直径0.76±0.23cm。t检验有统计学差异。t=2.1,P=0.03,P0.05。假阳性3例中,均为将小静脉认为穿支血管。结论:1.35例皮瓣内窥镜下共探到穿支68支,术中检测均能供养皮瓣。其中发现彩色多普勒超声出现假阴性7例,假阳性3例。敏感度=真阳性/(真阳性+假阴性)=61/(7+61)=89.7%。假阴性7例,穿支直径0.55±0.19cm,真阳性61例,穿支直径0.76±0.23cm。t检验有统计学差异。t=2.1,P=0.03,P0.05。推测彩色多普勒超声对较细穿支可能出现漏检。假阳性3例,均为将小静脉认为穿支血管。2.术中内镜下穿支探查可以调整皮瓣设计,使穿支游离皮瓣手术更为精准。同时能够排除术前定位中的假阴性和假阳性穿支,为穿支皮瓣的应用提供保障,对嵌合穿支皮瓣尤为重要。第三部分嵌合穿支皮瓣对复杂创面的修复方法:1.对象为15例嵌合穿支皮瓣(包括ALT嵌合穿支皮瓣3例和MSAP嵌合皮瓣12例)游离移植进行修复重建的患者,术前采用彩色多普勒定位和设计。2.术中内镜探查穿支,手术切取嵌合皮瓣并记录嵌合皮瓣包括的组织瓣类型,皮瓣大小,厚度,穿支血管的数目,位置,分支血管的分型,血管蒂的长度。3.术后即时观察皮瓣血供情况,对血管危险及时处理。隔天换药,观察记录有无皮瓣相关并发症的出现。术后3～6月随访皮瓣功能。结果:1.本组腓肠内侧动脉嵌合穿支皮瓣12例。皮瓣成活情况:11例皮瓣存活。1例行双叶嵌合皮瓣:一叶用于修复食管缺损另一叶用作观察皮瓣,术后3天观察皮瓣血管危象,探查见修复食管的皮瓣血运好,而观察皮瓣穿支血管栓塞,切除坏死皮瓣,创面拉拢缝合。小腿供区伤口愈合情况:5例直接拉拢缝合,7例植皮。15例供区Ⅰ期愈合,1例因术后供区部分腓肠肌内侧头坏死行清创手术后愈合。术后3～6周随访皮瓣色泽与周围正常皮肤相似,无臃肿,质地柔软。股前外侧动脉嵌合穿支皮瓣3例。2例存活,1例边缘部分坏死。术后1例皮瓣臃肿二期行皮瓣修薄术。再造器官功能相关的并发症包括食管瘘、尿道狭窄等。2.本组15例病例其中10例内窥镜下确认穿支23支,超声下出现假阴性2支,假阳性1支。3.皮瓣选择上如果皮瓣需要较薄,面积不太大的情况使用MSAP皮瓣;如果厚度要求不大,但面积需求大的供区选择ALT皮瓣;此外,小腿穿支不稳定的情况以ALT皮瓣备用。结论:1.嵌合穿支皮瓣损伤一处供区,吻合一组血管的情况下修复重建了多种组织或多个创面。利用游离皮瓣自身的特点,结合穿支和分支的解剖位置,可以完成复杂创面的修复和器官的再造。2.术前彩色多普勒穿支定位和术中内镜下穿支探查可以精确定位游离皮瓣的穿支情况,为嵌合穿支皮瓣的设计提供保障,有效避免了供区组织浪费,损伤。3.术中对结合多种辅助手段对嵌合皮瓣的设计是手术成败的关键,这不仅需要精确的穿支定位,还需要术者对再造组织空间结构的良好把握。第四部分数字化及三维打印技术在嵌合游离腓骨皮瓣中的临床应用方法:研究对象为2009年8月至2016年12月行嵌合游离腓骨皮瓣修复手术19例,其中16例自2011年8月起应用数字化及三维打印技术进行辅助设计,5例应用手术导航系统进行定位、追踪或验证下颌骨的修复。年龄30～58岁,其中男性17人,女性2人。19例患者中14例为上/下颌骨肿瘤切除后,腓骨皮瓣再造,1例胫骨及4例为掌指骨及皮肤缺损后的再造。本组19例患者中,采用右侧腓骨移植4例,左侧15例;腓骨截骨最长18cm;腓骨截为5段者1例,4段者2例,3段者11例,1段者5例;19例腓骨瓣均含穿支皮瓣,其中1例腓骨嵌合双叶穿支皮瓣,皮瓣最大16cm×5cm。颌骨再造患者术前行上下颌骨薄层螺旋CT扫描三维重建后进行模拟切除,利用镜像功能恢复患侧下颌骨形态,制作CAD/CAM模型,用三维打印机制作实物模型、镜像模型、在此基础上根据切除范围及截骨位置个性化设计腓骨修复方案并打印面部截骨导板及腓骨塑形导板,根据模型预先弯制钛板;修复重建手部患者术前摄手部薄层螺旋CT,利用镜像功能恢复患侧掌、指骨形态。供区小腿术前血管造影后行螺旋CT扫描并将扫描数据输入计算机,应用Amira3.1软件重建腓骨、腓动静脉及腓动脉穿支血管,再根据腓骨缺损长短、形状、血管蒂、腓动脉穿支位置设计并三维打印腓骨截骨及塑形导板并设计腓骨及腓骨皮瓣切取的位置。术中受区根据截骨导板截除原发灶。供区根据腓动脉穿支位置及皮肤或黏膜缺损设计皮瓣,应用截骨导板及塑形导板指导腓骨皮瓣切取和腓骨塑形,塑形后的腓骨按术前设计固定,并用手术导航系统验证复位的正确性,缝合皮瓣,吻合血管。术后观察皮瓣血供情况,对血管危险及时处理。隔天换药,观察记录有无皮瓣相关并发症的出现。术后3～6月随访外形及功能。结果:本组19例腓骨嵌合穿支皮瓣18例成活,1例术后3天发现血管栓塞皮瓣坏死,去除皮瓣,腓骨表面骨膜,改游离腓骨移植。3月后检查骨愈合良好。6月后所有病例复查经临床观察及CT检查证实骨愈合良好。术后外观及功能的恢复均达到满意效果。结论:数字化及三维打印技术在嵌合游离腓骨皮瓣的临床应用在术前能更直观和深刻地了解病变部位的解剖结构和病变范围,在实体模型上预演手术经过以最终确定手术方案,并能预知术后形态恢复的效果。提高手术的精确性和可控性,并减少了手术时间和创伤、最后达到修复的功能化和个体化。真正达到数字化外科手术,还需要结合手术导航系统进行定位,追踪或验证。
[Abstract]:Background: with the development and application of perforating flaps, the design of the perforator based lobular flap is widely used. Hallock[1] is a lion, goat body, scorpion monster chimera in Greek Mythology (Chimera) inspired, first proposed "chimeric flap" (Chimeric flap), the concept of. The definition of chimeric skin flap is defined by a plurality of tissue flaps (flap, tendon, fascia and muscle) that are supplied by independent blood vessels, but they originate from a group of skin flaps at the same level. According to the design of the chimeric flap, different types of chimeric flaps should be used according to the different types of blood supply system. The common area for chimeric perforator flap with fibular artery perforator flap: chimeric [2]; with deep iliac circumflex artery perforator flap with chimeric [3]; chimeric [4] subscapular artery perforator flap; lateral femoral circumflex artery perforator flap with chimeric [5]; inferior epigastric artery perforator flap with chimeric [6]; the medial sural artery perforator flap chimeric [7]. The medial sural artery perforator (MSAP) flap has many advantages, such as the MSAP anatomy is constant, the location of the donor site is hidden, the vascular pedicle is longer, the subcutaneous fat is less, and the donor site injury is small. Now the medial sural perforator flap has become one of the most commonly used skin flap for head and neck and limb wound repair. The medial sural artery perforator flap has the advantage of the medial sural artery flap, and has a chimeric perforating flap. Only a group of blood vessels can be anastomosed, and the blood supply of multiple tissue valves can be achieved. It is novel and practical, and achieves the advantages of three-dimensional reconstruction of the wound. With its extensive application, the applied anatomy of the medial sural artery system has been gradually paid attention to. The applied anatomy of the existing MSA system mainly focuses on the distribution and identification of MSAP, as well as the distribution and walking of MSA and its branches in the gastrocnemius muscle. ALT flap has always been considered as one of the ideal chimeric skin flap. It has a thick and stable perforator. It usually provides 2~3 larger cutaneous perforator branches to provide lobulated skin flap. The lateral femoral artery is easy to separate, and the blood supply to the thigh is abundant. Its cutting will not cause muscle necrosis, and the anterolateral thigh area can provide a lot of skin fascial tissue and muscle tissue flap to adapt to various scale repair and reconstruction operation. The peroneal artery system is a classic chimeric flap donor area. In addition to the skin fascia and a small amount of muscle tissue, the peroneal artery system provides a full amount of bone tissue. The peroneal artery chimeric bone flap can be used in a variety of repair and reconstruction. Free fibula flap is a reliable method to repair segmental bone defects in the head minister vascular perforator flap positioning method mainly hand-held ultrasound (Handled Doppler), color Doppler ultrasound (Color Duplex), computed tomography angiography (Computed Tomographic Angiography, CTA), magnetic resonance imaging (MRA) and digital subtraction angiography (digital subtraction angiography, DSA). In any way, it is possible to have an inaccurate situation. Endoscopic techniques have been widely used in the diagnosis and treatment of various specialties. The perforator free flap needs to separate the vascular pedicles in the muscles, and there is still a risk for the current technique to separate the perforator from the endoscope. But endoscopic perforator exploration to reduce the wide range of donor damage caused by perforator variation has been reported to have been [8]. With the rapid development of computer aided design and manufacturing technology, virtual surgery design technology is affecting and changing the [9] of surgeons for bone reconstruction surgery. The osteotomy and [10] of the titanium plate were made on the bone model constructed by the 3D printing technique. These techniques shorten the operation time, reduce the failure rate of the fibula flap, and gain a better appearance and function. The first part of the study of the applied anatomy of the medial sural artery system: 1. the subjects were 4 adult cadavers, 8 cases of lower extremity specimens were dissected in the medial area of the calf. 2., after finding the perforating branches of the medial sural artery, it was anatomized and marked. The type and number of perforating branches, the outer diameter of the deep fascia, the coordinates of the perforating points and the relationship with the sural nerve were recorded. 3. types of branch of anatomy and record the medial sural artery, measuring the length of the pedicle branch (distal perforating branch into the sural artery to pivot distance) and branch artery vessel diameter, length of pedicle (distal sural artery into the person to wear the fulcrum of artery artery diameter and the starting point). 4. statistical analysis of the medial sural artery branches from the medial sural artery and the lateral branch of the medial sural artery. Results: 1. of 4 adult cadavers (3 males and 1 females) were dissected in a total of 8 lower extremities. Of these, 2 were found in 7 cases of the perforator of the sural artery, and 1 of the perforator branches were found in 3. All the perforating branches were myocutaneous perforator. The diameter of the perforator was 0.68 + 0.19mm under microsurgical magnifying microscope. Perforator distance midline horizontal distance of 3.88 + 1.22cm, the distance of people across perforator vertical distance of 8.94 + 2.11cm. The position coordinates are represented by (x, y). The distance between the perforator and the sural nerve was 3.49 + 0.77CM. Of the 2.8 cases of the branches of the medial sural artery, there were 0 cases (0%), 2 (25%), type II B (62.5%), and 1 (12.5%) of type II A. The pedicle of branch was 7 + 1.85cm, and the diameter of pedicle artery was 1.46 + 0.28mm. The length of the main pedicle of the medial sural artery is 11 + 1.85cm, and the diameter of the trunk pedicle is 2.49 + 0.42mm. 3. people from the medial sural artery artery, usually divided into medial and lateral branch vessels two. Of the 8 cases, 7 were in this case (1 with 3 branches). A total of 15 perforator branches were found in 7 specimens, of which 8 were distributed in the lateral branch and 7 in the medial branch. The lateral branch is 0.58 + 0.11cm from the medial sural artery perforating branch, and the medial branch is 0.87 + 0.45cm from the medial sural artery perforator. T test t=1.72, P=0.11, P0.05, that there is no statistical difference
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R622

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