腓肠内侧动脉穿支带蒂岛状皮瓣临床应用分析

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腓肠内侧动脉穿支带蒂岛状皮瓣临床应用分

【摘要】目的分析腓肠内侧动脉穿支带蒂岛状皮瓣修复小腿上2/3软组织缺损的临床应用效果。方法自2003年5月~2008年1月,应用腓肠内侧动脉穿支带蒂岛状皮瓣修复22 例膝和小腿上2/3软组织缺损,年龄20~53 岁,平均35 岁。其中,膝关节周围8 例,小腿上2/3 14 例。供区均选用同侧小腿。结果 2 例术后发生表浅感染,经更换敷料逐渐愈合,皮瓣全部成活,取得了较满意的效果。没有发现明显的供区功能障碍。结论该皮瓣以腓肠内侧动脉的肌皮穿支为血供,具有血供丰富、血管解剖恒定、血管蒂长以及皮瓣较薄的优点,带蒂岛状移植适宜修复膝和小腿上2/3软组织缺损。

【关键词】穿支皮瓣;带蒂移植;缺损

Abstract:Objective To analysis the results of clinical application of the medial sural artery perforator pedicled island flap for the coverage of soft tissue defects around the knee joint or upper two third of lower leg.Methods From May 2003 to January 2008,22 patients(16 men,6 women)with soft tissue defects around the knee joint or upper two third of lower leg underwent reconstruction with the medial sural artery perforator pedicled island flap.Of them,8 case recipient site were located on around the knee joint region,14 cases upper two third of lower leg.They ranged in age from 20 to 53 years(mean,

35y).The donor leg was ipsilateral in all cases.Results Two cases sustained superficial infection postoperation and the gradual wound healed by daily wound dressings.All the flaps had survived completely without major complication and obtained satisfactory clinical results,There was no remarkable donor site morbidity.Conclusion The medial sural artery perforator flap is nourished by the musculocutaneous perforater of the medial sural artery.The flaps seem to has highly vascularize,a constant vascular anatomy and a long vascular pedicle.The flap is thin and suitable for the coverage of soft tissue defects around the knee joint or upper two third of lower leg.

Key words:perforator flap;pedicled transfer;defect

随着显微解剖学研究的深入和穿支皮瓣技术的发展,穿支皮瓣的供区在逐渐增加。腓肠内侧动脉的肌皮穿支为血供的带蒂岛状皮瓣是近年来新的穿支皮瓣供区[1]。自2003年5月至2008年1月,我们应用这种新的术式,替代传统的腓肠肌内侧头肌瓣或肌皮瓣的术式,修复膝关节周围或小腿中、上1/3软组织缺损伴骨和肌腱外露创面22 例,由于不切取肌肉,不牺牲肌肉功能,取得了较好的治疗效果,现报告如下。

1 临床资料

1.1 一般资料本组22 例,男16 例,女6 例,年龄20~53 岁,平均35 岁。均为外伤性膝关节周围和小腿上2/3软组织缺损伴

骨和肌腱外露创面,2 例伴有髌骨骨折,8 例伴有胫骨平台骨折,4 例伴有胫骨上端骨折,伴有胫骨远端和跖骨骨折各1 例。损伤原因:交通事故伤14 例,机械性损伤5 例,重物砸伤3 例。缺损部位:膝关节周围8 例;小腿上1/3 9 例,小腿中1/3 5 例。左侧10 例,右侧12 例。手术时机:16 例为急性创伤所致,14 例急诊手术修复,2 例因局部污染较重,分别于清创术后5 d与7 d,待创面干净后手术。另6 例为骨折内固定术后皮肤坏死创面,行择期手术修复。软组织缺损面积:3 cm×4.5 cm~5.5 cm×6.5 cm。均切取同侧腓肠内侧动脉穿支带蒂岛状皮瓣修复,切取面积最大6.5 cm×8 cm,最小4 cm×5 cm。

1.2 手术方法采用腰麻或硬脊膜外麻醉,取平卧位,膝与髋关节稍屈曲并外旋。也可采用俯卧位。采用俯卧位时,应先行术侧在上侧卧位创面清创,然后取俯卧位切取皮瓣,皮瓣切取成功后再改侧卧位。术前应先行皮瓣设计,从皱褶中点至内踝中点划纵线,以此线为轴,用Doppler血流测定仪在距皱褶10~17 cm的范围内探测腓肠内侧动脉的肌皮穿支,多数为1~4支,选择较大的一支为皮瓣中心点。比受区创面稍大设计皮瓣,在充气止血带下手术,但不驱血,有利于术中辨认肌皮血管穿支。先切开皮瓣内侧缘至腓肠肌内侧头肌膜下,提起皮瓣创缘,很容易发现穿支血管经腓肠肌内侧头肌腹穿出后,垂直进入深筋膜至小腿后内侧皮肤。然后,顺穿支血管从远向近端解剖血管蒂,一旦游离出的血管蒂长度能达到受区要求后,再切开皮瓣四周。检查皮瓣血供良好后,经皮下隧道将岛状皮瓣转移至受区。供区缝合有张力时需行游离植皮。

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