股前外侧区穿支血管三维重建与修薄皮瓣血供关系的研究

发布时间：2018-01-03 06:39

本文关键词：股前外侧区穿支血管三维重建与修薄皮瓣血供关系的研究　出处：《南方医科大学》2007年博士论文　论文类型：学位论文

【摘要】： 修薄皮瓣的应用是显微外科的一个发展趋势，削薄型股前外侧皮瓣的应用，近年来有所报道。但皮瓣削薄后，坏死率较高，尤其是修复颌面部洞穿性缺损、舌体再造等方面坏死率更高。目前，解决这一问题的焦点集中在针对皮瓣穿支动脉蒂的保护。应用显微解剖的方法修薄穿支血管蒂中央部半径2cm内的脂肪筋膜岛，保护穿支蒂中央部份的分支免受损伤。这种显微解剖的手术方法仅仅是保证血管蒂中央区域的供血，而如何保证削薄皮瓣中央区周围区域或远离穿支血管蒂区的血供，尤其是如何预测削薄皮瓣的成活范围，如何设计修薄皮瓣以保证其血运，皮瓣能够修到多薄多大?这些问题至今仍未解决，这也是削薄型股前外侧皮瓣推广应用不够的原因。本课题以解剖学研究为基础，应用数字化成像技术、影像学手段，对不同厚度股前外侧皮瓣的血管形态和功能作了研究；同时，应用激光多普勒技术监测皮肤血灌注量，探讨了皮瓣远侧和近侧穿支血管、前后筋膜皮支、脂肪筋膜层血管交通等对皮瓣各区域皮肤灌注量的影响。目的 1．观测股前外侧区体被组织穿支动脉的走行、吻合方式、立体结构特点等，为临床修薄皮瓣应用提供形态学依据。 2．应用数字化成像技术及影像学手段，观察和测量股前外侧皮瓣各层次的血管形态，探讨皮瓣不同层次、不同区域血管的功能和皮瓣的血流方式、特点，为皮瓣修薄提供血管功能的参考依据。 3．观测股前外侧皮瓣不同层次血管交通对皮瓣不同区域皮肤灌注量的影响，探讨皮瓣修薄后皮肤血流动力学的变化，为皮瓣修薄的可能厚度、范围、手术方法提供参考依据。 4．探讨和建立一种能够保证修薄皮瓣血供，提高修薄皮瓣移植成功率的手术设计和手术方法，使之易于推广应用。材料和方法选用3例防腐固定处理的成人下肢标本，2例成人新鲜尸体，4例成人新鲜下肢。所有标本皮肤、软组织无破溃及损伤。 1．明胶一氧化铅动脉灌注：对2具新鲜全尸行股动脉一次性全身动脉血管灌注；4具新鲜下肢标本进行动脉血管灌注造影。血管造影后，冷却保存。 2．巨微解剖：从外科层掀起股前外侧区体被组织，标志外径为0.5mm的穿支血管，追踪其来源、走行，解剖追踪旋股外侧动脉的分支、形态、走行、分布等解剖结构，观察股前外侧区穿支动脉的立体网络结构和特点，以及各区域血管外径，记录和描述观察数据和结果。 3．X线摄片(CR)：在股前外侧区层次解剖和该区体被组织显微层次解剖过程的每一步之后，行X线拍摄。 4．螺旋CT扫描：每一解剖步骤之后，利用16排螺旋CT对标本进行断层扫描。 5．血管三维重建及可视化处理：把各个螺旋CT扫描数据集分别导入电脑，应用Minic8.11软件，分别重建各支穿支及其分支和相联密切的微血管，并行可视化处理，观察各穿支的分支分布情况以及穿支区域间吻合交通情况，各个穿支区域范围。 6．患者5名，青年男性，年龄17-31岁，车祸伤致足踝部皮肤软组织大面积缺损，行股前外侧皮瓣游离移植修复足踝部皮肤软组织缺损。用Permed激光多普勒监测仪监测股前外侧皮瓣皮肤的血流量。观测前后筋膜支、脂肪筋膜层的交通支对皮瓣灌注的影响。 7．修薄型股前外侧皮瓣的手术设计根据本文研究成果，设计皮瓣修薄的手术方法，并应用于临床实践，取得满意效果。结果 (一)股前外侧区皮瓣修薄对皮瓣穿支血管三维重建的形态结构的影响 1．皮瓣未修薄组和保留筋膜支的皮瓣修薄组二者5支穿动脉三维重建的血管形态、结构和分布范围是一致的。5支穿动脉的三维血管形态均基本完整显示股前外侧区动脉血管构造的镂空立体结构，直观立体的显示了皮瓣深层的筋膜支及其分出皮支，同时也显示出较粗大的真皮下血管。逼真地再现了股前外侧区下半呈“蜘蛛痣”或“蜘蛛网”样的真皮下血管网结构。 2．破坏筋膜支的皮瓣修薄组皮瓣近侧部各穿支其三维重建的血管形态，仅显示出该穿支发出的筋膜支及其入皮动脉，而与入皮动脉相连的真皮下血管网未显示，其范围面积为：长度为后筋膜支的长度，宽度为入皮动脉的投影长度。皮瓣远侧部各穿支其三维重建的血管形态，不但显示穿支及直接入皮动脉，而且清晰显示真皮下血管网结构(即完整显示下半区血管“蜘蛛网”样结构)，远侧部各穿支血管的三维形态显示的范围均覆盖整个下半区区域，面积约为16cm×12cm，下半区各穿支血管三维形态通过真皮下血管网有机地融合为一体，并相对独立于相邻区域。 (二)股前外侧区皮瓣修薄过程的穿支动脉X线二维形态学的研究 1．皮瓣未修薄组股前外侧区体被组织未修薄前拍摄X线片，可见下行的前筋膜皮支及向后外下行的后筋膜皮支，以及在脂肪筋膜层、真皮下血管网的血管内网络结构，各穿支动脉之间彼此吻合；前筋膜支与旋股外侧动脉各穿支吻合，其终未端与膝上外侧动脉穿支形成微细的吻合，后筋膜支终未端与股深动脉的穿支形成较为粗大的血管交通。股前外侧区单穿支供血面积29.3cm~2～52.9cm~2不等，供血面积最大的单穿支是旋股外侧动脉降支第一穿支，该穿支发出最长的后筋膜支，且后筋膜支发出较多的下行支，穿支区域间血管吻合的交通支较为粗大，多为真性吻合，且界线不易界定。因此，股前外侧皮瓣切取的总面积大约为26cm～30cm×16cm～21cm范围。 2．保留动脉筋膜皮支皮瓣修薄组的X线二维血管形态旋股外侧动脉近侧穿支发出后筋膜支，并间隔发出下行分支，穿支区域血管形态呈现“纲目”样结构，穿支面积明确而狭长，面积约为长6～13cm×2～3cm。旋股外侧动脉远端穿支呈放射状发出直接入皮动脉，形成“蜘蛛痣”样结构，入皮动脉在真皮下长直且粗大，穿支区域血管呈现“蜘蛛网”样结构。并可见较粗大入皮动脉在真皮下的走行时间隔发出返支的断端，数量约5～7个，穿支供血面积约为12cm×10cm。在X线片中，前筋膜支、最粗长的后筋膜支、远端粗大长直的真皮下血管三者在股前外侧区的中远部形成一个明确的“三角形”血管形态结构，呈现出股前外侧区的动脉供血的主干，其供血面积约为22cm×12cm。膝上外侧动脉穿支区域与旋股外侧动脉降支远端穿支的穿支区域间存在“阻塞性吻合”(即其血管吻合点为血管口径变细处)。即这两穿支区域间界线较为明确，而股深动脉穿支与后筋膜支间见较粗大的交通支，他们之间存在真性吻合。 3．股前外侧皮瓣血管管径测量结果 1组：股前外侧近侧区域真皮下血管管径：0.29～0.41mm。 2组：股前外侧远侧区域直皮下血管管径：0.65～0.68mm。 3组：前、后筋膜支起始部血管管径：0.82～1.38mm。 4组：前、后筋膜支终未端血管管径：0.65～0.81mm。 (三)高位皮动脉型股前外侧皮瓣修薄的应用解剖学高位皮动脉的源动脉存在差异。高位皮动脉进入皮瓣浅筋膜后，发出前、后筋膜支，前、后筋膜支在股前外侧区中远部呈“根须”样结构，发出二级筋膜支浅出至真皮下血管网，二级筋膜支终未端在皮瓣中远部分布相对分散。X线片上见股前外侧区远、近部真皮下血管网形态基本一致，管径大小较均匀。 (四)股前外侧皮瓣穿支动脉三维重建与可视化研究 1．旋股外侧动脉各穿支动脉三维形态的比较以旋股外侧动脉各穿支动脉为起点行血管三维重建，可见它们的分布区域和可视化图像是一致的。二者均可显示前、后筋膜支和远侧穿支区域的部分真皮下血管，同时也可显示股深动脉穿支的血管形态。而股前外侧区近侧部和膝上外侧动脉穿支区域未见显示。股前外侧皮瓣各穿支的主要血管交通吻合是一致的，主要供血区域也是一致，其范围为旋股外侧动脉降支远、近穿支前内侧2-3cm连线至股深动脉穿支区域。 2．旋股外侧动脉高位皮动脉的血管三维形态高位皮动脉穿支区域约30cm×20cm，中央区域血管密度较高，皮动脉穿支蒂位于中央区中上1／4处，周围区域血管三维形态呈网络状。侧面观可见血管分支丰富，并见多级分支。调整三维重建参数，可重建不同穿支动脉主要供血区域(解剖学供区)和邻近供血区域(动力学供区)。 (五)股前外侧皮瓣血管血液动力学初步研究双穿支蒂供血、夹闭筋膜支、阻断脂肪筋膜层均对皮瓣皮肤灌注量有显著影响。 (六)削薄型股前外侧皮瓣临床应用体会(皮瓣设计与手术方法) 根据上述应用基础研究结果，在设计以近侧穿支为蒂偏心型穿支蒂修薄皮瓣时，应尽量保留穿支发出的后膜皮支，穿支蒂放在皮瓣近侧。在穿支蒂远侧2cm范围内斜坡修薄，远侧区域仅保留真皮下2～3mm脂肪层；穿支蒂近侧2cm范围内显微镜下去除大脂肪球，近侧区域保留真皮下小颗粒脂肪层，这样修薄后皮瓣周围皮缘出血良好，移植后皮瓣成活良好。结论股前外侧区穿支血管三维形态的结构特点，有利于股前外侧皮瓣修薄应用。
[Abstract]:The application of thin flap is a development trend of microsurgery, using thin anterolateral thigh flap, flap in recent years have been reported. But after thinning, the necrosis rate is high, especially the repair of maxillofacial perforating defects, tongue reconstruction and other aspects of higher necrosis rate. At present, the focus of solving this problem focus on the protection for perforating artery pedicle flap. Methods the microsurgical repair of adipofascial perforator pedicled island thin central part within a radius of 2cm, protect the perforating branch pedicel central part from damage. But this method of microdissection is only to ensure that the central region of the vascular pedicle blood supply, and how to ensure the cutting area around the thin the central flap or away from the perforator branch area of blood supply, especially how to predict the cutting of thin flap survival area, how to design a thinning flap to ensure the blood supply of skin flap can repair how thin these problems to much? It is still unsolved. This is also the reason why the flaps of the thin anterolateral thigh flap are not popularized enough.
This subject is based on the anatomical study of digital imaging technology, imaging, vascular morphology and function of different thickness of anterior thigh lateral flap were studied; at the same time, the application of laser Doppler technique for monitoring the blood perfusion of the skin flap, distal and proximal perforator vessels before and after FFTNA, fat fascia on the skin flap of the regional traffic perfusion.
objective
1. observation of the perforating artery of the anterolateral thigh body, the way of the perforating artery, the way of anastomosis and the characteristics of the stereoscopic structure, provide the morphological basis for the application of the clinical thinning flaps.
2., using digital imaging technology and imaging methods, we observed and measured the blood vessel morphology of different levels of anterolateral thigh flap, explored the function of different levels, different areas of blood vessels and the blood flow pattern of flap, and provided reference basis for skin flap repair.
3., the effect of different levels of blood vessel traffic on the skin perfusion volume in different regions of the anterolateral flap of the observation stock, and to explore the changes of skin hemodynamics after skin flap repair, so as to provide reference for the possible thickness, scope and operative method of skin flap repair.
4. to explore and establish an operation design and operation method that can guarantee the blood supply of the thin skin flap and improve the success rate of the thin flap transplantation, so that it is easy to popularize and apply.
Materials and methods
3 adult cadaver specimens, 2 fresh adult cadavers and 4 adult fresh lower limbs, were selected and treated with antiseptic fixation. All specimens were skin and soft tissue had no rupture and injury.
1. gelatin litharge arterial infusion: 2 fresh cadaver femoral artery one-time systemic arterial perfusion; 4 fresh lower limb specimens of artery angiography. Angiography after preservation, cooling.
2. macromicrodissection: off the anterolateral tegumental tissue from surgical layer, mark diameter perforator 0.5mm, trace its origin, course, branch of anatomy, tracing the lateral circumflex femoral artery morphology, walking, distribution of anatomical structure, observe the anterolateral thigh perforators of the vertical structure and characteristics the network, as well as regional vascular diameter, record and describe observation data and results.
3. X ray photography (CR): after each step of the anterolateral thigh region and the microscopic anatomical process of the body, the X-ray film was taken.
4. spiral CT scan: after each anatomic step, the specimen was scanned with 16 rows of spiral CT.
5. vessels for 3D reconstruction and visualization processing: the spiral CT scan data set were introduced into computer, using Minic8.11 software, the branches and its branches were reconstructed and connected closely microvessel, parallel visual processing, observe the distribution of each branch and regional perforator perforator anastomosis traffic, each perforator region.
5 of 6. patients, young men, aged 17-31 years old, suffered from a large area of skin and soft tissue defects in foot and ankle caused by traffic accident. The anterolateral thigh flap was free to repair skin and soft tissue defects of ankle and foot.
The blood flow volume of the anterolateral thigh flap was monitored by Permed laser Doppler monitor. The effects of fascial branches and fascial branches on the skin perfusion were observed before and after the observation.
Surgical design of 7. thin anterolateral thigh flaps
According to the results of this study, the surgical method of skin flap repair was designed and applied to clinical practice, and satisfactory results were obtained.
Result
(1) the influence of the flap thinning on the morphological structure of the three-dimensional reconstruction of the perforating vessels of the flap
1. flaps in the unthinned and preserved fasciocutaneous flaps
Two 5 perforating artery reconstruction of vascular morphology, structure and distribution is consistent with the.5 team in the arterial vascular morphology were showed complete three-dimensional hollow three-dimensional structure of anterolateral femoral arterial vascular structure, visual display the deep fascia flap into branches and cutaneous branches, but also showed relatively large the subdermal vascular network. To realistically reproduce the vascular structure of anterolateral area is half the "spider" or "spider web" like leather.
2. skin flap repair group that destroys fascial branches
The proximal portion of the flap vascular morphology of each branch in the 3D reconstruction, only showing the perforating branches and enter a fascia cutaneous artery, which is connected with the cutaneous artery into the subdermal vascular network did not show the range of area: the length of posterior aponeurosis branch length, width of the projection length into the cutaneous artery.
Vascular morphology of distal portion of the perforator flap in the 3D reconstruction, not only shows the perforator and directly into the cutaneous artery, and clearly show the subdermal vascular network structure (i.e. the complete display "bottom half vascular spider web like structure), display three-dimensional morphology of distal part of the perforator range were covering half the area the whole area is about 16cm *, 12cm, the second half of the perforator 3D integrated organically subdermal vascular network through, and is independent from the adjacent area.
(two) the study of the X-ray two-dimensional morphology of the perforator artery of the anterolateral thigh flap
1 skin flap repair thin group
The anterolateral area was not tissue thinning radiographs before, after FFTNA visible down the front fascia cutaneous branch and the rear outer downward, and the fat fascia vascular network within the vascular network structure of leather, the perforating artery anastomosis; the front fascia and the branch of the lateral circumflex femoral artery the perforator anastomosis, end and lateral genicular artery perforator anastomosis after the formation of a fine, aponeurosis branch end form a relatively thick vessel traffic and deep femoral artery perforator. The anterolateral area of single perforator area 29.3cm~2 ~ 52.9cm~2 range, single perforator is the largest area of the descending branch of lateral circumflex femoral artery first the perforator perforator, issued after the longest branch and branch of the fascia fascia, a descending branch of perforator regional vascular anastomosis branches are more thick, more true and consistent, is not easy to define boundaries. Therefore, the anterolateral thigh flap. The total area is about 26cm to 30cm x 16cm ~ 21cm.
2. X-ray two-dimensional vascular morphology in the repair group of the cutaneous branch of the preserved artery fasciocutaneous branch
The lateral circumflex femoral artery proximal perforator fascial branches after the issue, and the interval down branch, regional perforator "plants" like structure, clear and narrow perforator area, an area of about 6 ~ 13cm * 2 ~ 3cm.
The lateral femoral circumflex artery perforator distal radial emitted directly into the cutaneous artery, the formation of "spider" structure into the cutaneous artery in the dermis under long straight and thick perforator regional vascular cobweb like structure. The coarse and visible cutaneous artery in the dermis under the travel time across the back ends of a one, about 5 ~ 7, perforator area is about 12cm * 10cm.
In X-ray, the front fascia, the long thick fascia, distal thick long straight subdermal vascular three in the anterolateral area of the distal part of the formation of a clear "triangle" vascular structure, showing the main artery of anterolateral femoral region, the blood supply area of approximately 22cm * 12cm.
The lateral superior genicular artery perforator region and lateral femoral circumflex artery descending "obstructive perforator branch anastomosis between the distal perforator region" (i.e., the point for vascular anastomosis vascular caliber thin section). The two branches of borderline between regions is relatively clear, but the deep femoral artery perforator and posterior aponeurosis branch communicating branch between the coarse the existence of true agreement between them.
Measurement of vascular diameter of 3. femoral anterolateral flaps
1 groups: subdermal vascular diameter of the anterolateral anterolateral femoral region: 0.29 to 0.41mm.
The 2 group: the direct subcutaneous vascular diameter of the anterolateral thigh region: 0.65 ~ 0.68mm.
3 groups: anterior, posterior fascial branch vascular diameter: 0.82 ~ 1.38mm.
The 4 groups: anterior and posterior fascia branch end end vascular diameter: 0.65 ~ 0.81mm.
(three) applied anatomy of the anterolateral thigh flap of the high cutaneous artery type
High cutaneous artery source artery. A high cutaneous artery into the differences between the superficial fascia flap, anterior, posterior aponeurosis branch, anterior, posterior aponeurosis branch in the anterolateral region of middle and far section was "roots" - like structure, a two class aponeurosis branch vascular network, two class aponeurosis branch end relative scattered in the middle and far section of the flap cloth. X-ray see anterolateral distal, proximal subdermal vascular network morphology is basically the same, the diameter is uniform.
(four) three-dimensional reconstruction and visualization of the perforating artery of the anterolateral thigh flap
A comparison of the three-dimensional morphology of the perforator arteries of the 1. lateral femoral circumflex artery
Each of the lateral femoral circumflex artery perforating artery reconstruction for the starting point for the regional distribution of blood vessels, visible and visual image which is consistent. The two can be displayed before, after some portion of the dermis fascial branches and distal perforator area under the blood vessels, but also can display the deep femoral artery perforator blood tube and anterolateral form. Area of the proximal portion and the lateral superior genicular artery perforator region no display. The main vascular transport of anterolateral thigh flap the perforator anastomosis is the same, the main blood supply area is consistent, the scope for the descending branch of lateral circumflex femoral artery, anterior medial 2-3cm even nearly wear line to the deep femoral artery perforator region.
The three-dimensional morphology of the high cutaneous artery of the 2. lateral femoral circumflex artery
High cutaneous artery perforator area is about 30cm * 20cm, the central region of the high density, skin perforator artery located in the central area in 1 / 4, the surrounding area form a three-dimensional vascular network. Side view visible vascular branches and rich, multi-level branch.
Three dimensional reconstruction parameters can be adjusted to reconstruct the main blood supply region (anatomical donor area) and adjacent blood supply region (dynamic donor area) in different perforating arteries.
(five) preliminary study on blood vessel hemodynamics of the anterolateral thigh flap
The double perforating pedicle supplied blood, clipped the fascia branch and blocked the fat fasciae, which had a significant effect on the skin perfusion.
(six) the experience in the clinical application of the thin anterolateral thigh flap (flap design and surgical method)
According to the application of basic research results, in the design of the proximal perforator perforator flap Dixiu thin eccentric type, should be kept out after perforator perforator on cutis, proximal perforator flap. On the far side of the range of 2cm slope thinning, the distal region only preserved subcutaneous fat layer of 2 ~ 3mm the proximal perforator; range of 2cm microscope removed big fat ball, the proximal region preserved subcutaneous fat layer of small particles, such as thinning flap around the edge of skin bleeding is good, after transplantation of flap was good.
conclusion
The three-dimensional morphological structure of the perforating vessels in the anterolateral thigh region is beneficial to the application of the anterolateral thigh flap.

【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2007
【分类号】：R322

【参考文献】