以肌间隔主干型旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣解剖特点与临床应用

杨林; 柳志锦; 程俊楠; 高钦锋; 杨成鹏; 刘胜哲; 张韬; 孙丰文; 黄永涛; 巨积辉

doi:10.3760/cma.j.cn501225-20220227-00039

以肌间隔主干型旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣解剖特点与临床应用

doi: 10.3760/cma.j.cn501225-20220227-00039

苏州瑞华骨科医院手外科，苏州　　215104

基金项目:

苏州市民生科技项目关键技术应用研究 SS202092

苏州市卫生科教临床重点病种诊疗技术专项 LCZX202026

苏州市企业工程技术研究中心专项 SZS2019263

苏州市姑苏卫生人才培养项目 GSWS2020116

苏州市科教兴卫青年科技项目 KJXW2019073

详细信息

通讯作者:
巨积辉，Email：jjh2006@263.net

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出版历程
- 收稿日期: 2022-02-27

Anatomical characteristics and clinical application of anterolateral thigh perforator flap pedicled with oblique branch trunk of lateral circumflex femoral artery in the muscular septum

Department of Hand Surgery, Suzhou Ruihua Orthopaedic Hospital, Suzhou 215104, China

Funds:

Key Technology Application Research of Suzhou Livelihood Science and Technology Project SS202092

Special Project on Diagnosis and Treatment Technology of Clinical Key Disease Species of Health Science and Education in Suzhou LCZX202026

Special Project of Suzhou Enterprise Engineering Technology Research Center SZS2019263

Suzhou Gusu Health Talent Training Project GSWS2020116

Youth Science and Technology Project Promoting Health Through Science and Education in Suzhou KJXW2019073

More Information

Corresponding author: Ju Jihui, Email: jjh2006@263.net

摘要

摘要: 目的探讨以肌间隔主干型旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣的解剖学特点，以及采用该皮瓣修复四肢皮肤软组织缺损的临床效果。方法采用回顾性观察性研究方法。2020年12月—2021年4月，苏州瑞华骨科医院收治符合入选标准的四肢皮肤软组织缺损患者59例，其中男46例、女13例，年龄20~81岁，清创后创面面积为8 cm×5 cm~38 cm×20 cm。根据创面情况，术前行彩色多普勒超声检查以定位健侧股前外侧区穿支，设计以旋股外侧动脉斜支为源动脉的股前外侧穿支皮瓣，行单侧皮瓣修复或双侧皮瓣串联修复（单侧皮瓣大小为7 cm×5 cm~37 cm×11 cm）；将供区创面直接拉拢缝合。记录术前标记股前外侧区穿支数量，术中观察到的旋股外侧动脉斜支主干与穿支走行特点以及穿支的数量、来源、类型；记录皮瓣修复方式、皮瓣切取时间；术后观察皮瓣成活情况、受区创面愈合时间、供区缝合口愈合情况；随访供受区恢复情况，于末次随访时，记录移植皮瓣处采用英国医学研究会的感觉分级量表评价的感觉功能、两点辨别觉，采用改良的皮瓣综合疗效评价表评定皮瓣修复疗效。结果术前共在股前外侧区标记穿支156条，术中共观察到穿支144条，其中98条来自旋股外侧动脉斜支，斜支第1穿支均为肌间隔穿支；肌间隔主干型旋股外侧动脉斜支发出后，在髂前上棘与髌骨外侧缘的连线中1/3与上1/3交界处多数可分为深支与浅支，深支主要走行于股中间肌和股外侧肌肌肉内，较少发出皮穿支；浅支多走行于股直肌与股外侧肌肌间隔内，且发出穿支至股前外侧区近端皮肤。56例患者行单侧皮瓣修复，3例患者行双侧皮瓣串联修复，单侧皮瓣切取时间为9~99 min。3例患者皮瓣术后48 h内发生动脉危象，经及时探查后成活；1例患者术后11 d皮瓣发生坏死，后行腹部刃厚皮片移植修复；其余皮瓣均顺利成活。受区创面愈合时间为术后10~42 d，供区缝合口均愈合良好。随访6~10个月，8例患者因移植皮瓣处臃肿于术后6个月行修薄整形术，其余患者移植皮瓣处外形佳、无骨髓炎等深部组织感染、质地柔软、弹性好、无疼痛且血运良好；供区均遗留线性瘢痕，肢体远端血运正常，膝关节活动度及股四头肌肌力无受限。末次随访时，患肢移植皮瓣处感觉功能恢复达S₁级者14例、S₂级者45例，两点辨别觉均仅有1个点，皮瓣修复疗效评定：优者24例、良者35例、可者3例。结论以肌间隔主干型旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣，具有供区相对隐蔽、可切取宽度大、术中操作简便等优点，在修复四肢皮肤软组织缺损的同时最大限度地保护了供区，是对经典股前外侧穿支皮瓣的有益补充。
- 创伤和损伤 /
- 穿支皮瓣 /
- 显微外科手术 /
- 创面修复 /
- 旋股外侧动脉斜支 /
- 肌间隔穿支
Abstract: Objective To explore the anatomical characteristics of the anterolateral thigh perforator flap pedicled with oblique branch trunk of lateral circumflex femoral artery in the muscular septum and the clinical effect of this flap in repairing skin and soft tissue defects in the extremities. Methods A retrospective observational study was conducted. From December 2020 to April 2021, 59 patients with skin and soft tissue defects in the extremities admitted to the Department of Hand Surgery of Suzhou Ruihua Orthopaedic Hospital met the inclusion criteria, including 46 males and 13 females, aged 20 to 81 years. The wound area after debridement ranged from 8 cm×5 cm to 38 cm×20 cm. According to the condition of the wound, the perforators in the anterolateral femoral region on the unaffected side were located by color Doppler ultrasound. The anterolateral thigh perforator flap with the oblique branch of lateral circumflex femoral artery as the source artery was designed, and the wound was repaired by unilateral flap or series combination of bilateral flaps (with the area of unilateral flap ranging from 7 cm×5 cm to 37 cm×11 cm). The wound of the donor site was sutured directly. The following items were recorded, including the number of perforators in the anterolateral femoral region marked before operation, the course characteristics of oblique branch trunk of lateral circumflex femoral artery and its perforators, and the number, origin, and type of perforators observed during operation, the flap repair mode and the flap harvest time. After operation, the survival condition of the flap, the wound healing time in the recipient site, and the suture healing in the donor area were observed, and the recovery of the donor and recipient areas was followed up. At the last follow-up, the sensation function evaluated by sensory rating scale of British Medical Research Association and two-point discrimination of the area transplanted with flap were recorded, and the improved comprehensive curative effect evaluation scale of flap was used to evaluate the repair effect of the flap. Results A total of 156 perforators were marked in the anterolateral femoral region before operation, and 144 perforators were observed during the operation, of which 98 came from the oblique branch of the lateral circumflex femoral artery, and the first perforator of the oblique branch was the intermuscular septal perforator. Once formed, most oblique branch trunk of lateral circumflex femoral artery in the muscular septum could be divided into the deep branch and the superficial branch at the middle and upper 1/3 junction of the line between the anterior superior iliac spine and the lateral edge of the patella, the deep branch mainly ran in the muscle of vastus intermedius and vastus lateralis, and rarely developed the skin perforators, while the superficial branch mainly ran in the muscular septum between the rectus femoris and the vastus lateralis, and grew out the perforators to the proximal skin of the anterolateral femoral region. Fifty-six patients were repaired with unilateral flap and 3 patients with bilateral flap in series combination, with the harvesting time of the unilateral flap ranged from 9 to 99 min. Three patients developed arterial crisis within 48 hours after operation and survived after timely exploration; the flap of 1 patient developed necrosis 11 days after operation and was repaired by abdominal split-thickness skin graft; the other flaps survived smoothly. The wound healing time in the recipient area was 10 to 42 days after operation, and the sutures in the donor area healed well. During the follow-up of 6 to 10 months, 8 patients underwent thinning and plastic surgery 6 months after operation because of bloating in the flap transplantation area, while the other patients had a good shape of the flap transplantation area, with no deep tissue infection such as osteomyelitis, with soft texture, good elasticity, no pain, and good blood circulation; all the donor areas were left with linear scars, normal blood circulation in the distal extremities, no limitation of knee joint motion or quadriceps muscle strength. At the last follow-up, the sensation function was restored in the flap transplantation area of the affected limb, including 14 cases of S₁ grade and 45 cases of S₂ grade; there was only one point of two-point discrimination; the curative effect evaluation of flap repair included excellent in 24 cases, good in 35 cases, and general in 3 cases. Conclusions The anterolateral thigh perforator flap pedicled with oblique branch trunk of lateral circumflex femoral artery in the muscular septum has the advantages of relatively concealed donor area, large cutting width, and simple operation during surgery. It protects the donor area to the greatest extent while repairing skin and soft tissue defects in the extremities, and is a useful supplement to the classic anterolateral thigh perforator flap.
- Wounds and injuries /
- Perforator flap /
- Microsurgery /
- Wound repair /
- Oblique branch of lateral circumflex femoral artery /
- Septocutaneous perforator
杨林：参与手术、资料收集、论文撰写；柳志锦、程俊楠、高钦锋、刘胜哲：术前评估及手术操作；杨成鹏、张韬、孙丰文、黄永涛：病历资料整理及分析；巨积辉：主刀手术、论文审定、理论指导、经费支持

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参考文献(34)

[1]	唐举玉,魏在荣,张世民,等.穿支皮瓣的临床应用原则专家共识[J].中国临床解剖学杂志,2016(1):4-5.DOI: 10.13418/j.issn.1001-165x.2016.01.002.
[2]	芮永军.股前外侧皮瓣在中国的研究进展[J].中华显微外科杂志,2020,43(4):313-325.DOI: 10.3760/cma.j.cn441206-20200628-00277.
[3]	张敬良.努力追求创面修复的“泳裤供区”理念[J].中华显微外科杂志,2020,43(1):3-4.DOI: 10.3760/cma.j.issn.1001-2036.2020.01.002.
[4]	MarucciaM,OrfaniotisG,CiudadP,et al.Application of extended bi-pedicle anterolateral thigh free flaps for reconstruction of large defects: a case series[J].Microsurgery,2018,38(1):26-33.DOI: 10.1002/micr.30141.
[5]	LimS,AtwiN,LongS,et al.Variations in the anterolateral thigh flap's vascular anatomy in African Americans[J].J Reconstr Microsurg,2018,34(4):300-306.DOI: 10.1055/s-0037-1604087.
[6]	WongCH,WeiFC,FuB,et al.Alternative vascular pedicle of the anterolateral thigh flap: the oblique branch of the lateral circumflex femoral artery[J].Plast Reconstr Surg,2009,123(2):571-577.DOI: 10.1097/PRS.0b013e318195658f.
[7]	刘胜哲,巨积辉,柳志锦,等.串并联双侧股前外侧超长穿支皮瓣修复四肢大面积创面的临床效果[J].中华烧伤杂志,2021,37(3):250-256.DOI: 10.3760/cma.j.cn501120-20200226-00096.
[8]	柳志锦,巨积辉,程俊楠,等.以旋股外侧动脉斜支为源动脉的股前外侧双叶穿支皮瓣修复四肢创面[J].中华显微外科杂志,2021,44(2):152-156.DOI: 10.3760/cma.j.cn441206-20210111-00012.
[9]	肖飞鹏,柳志锦,刘胜哲,等.综合评价量表在股前外侧皮瓣修复术后疗效评价中的应用[J].中国美容整形外科杂志,2021,32(6):348-351.DOI: 10.3969/j.issn.1673-7040.2021.06.010.
[10]	谢建华,刘海华,柴香林,等.基于“泳裤供区”理念选择应用ALTF修复前足软组织缺损[J].中华显微外科杂志,2021,44(3):329-332.DOI: 10.3760/cma.j.cn441206-20210126-00034.
[11]	ZeidermanMR,PuLLQ.Contemporary reconstruction after complex facial trauma[J/OL].Burns Trauma,2020,8:tkaa003[2022-02-27].https://pubmed.ncbi.nlm.nih.gov/32341916/.DOI: 10.1093/burnst/tkaa003.
[12]	郭鹏飞,王旭,魏爱周,等.基于供区保护理念的游离股前外侧分叶穿支皮瓣在头部电烧伤创面修复中的临床应用效果[J].中华烧伤与创面修复杂志,2022,38(1):77-80.DOI: 10.3760/cma.j.cn501120-20201111-00470.
[13]	杨力,蔡斌,薛君荣,等.个体化股前外侧皮瓣游离移植修复复杂难愈性创面的临床效果[J].中华烧伤杂志,2020,36(8):730-734.DOI: 10.3760/cma.j.cn501120-20190621-00281.
[14]	常树森,何春念,金文虎.股前外侧皮瓣的供区并发症[J].中华显微外科杂志,2018,41(1):101-104.DOI: 10.3760/cma.j.issn.1001-2036.2018.01.030.
[15]	高秋芳,张小锋,张万锋,等.股内侧肌穿支皮瓣修复游离股前外侧穿支皮瓣供区继发创面的临床效果[J].中华烧伤杂志,2019,35(1):65-68.DOI: 10.3760/cma.j.issn.1009-2587.2019.01.012.
[16]	臧梦青,朱珊,陈博,等.旋股外侧动脉斜支在带蒂股前外侧皮瓣中的应用[J].中华整形外科杂志,2019,35(10):995-999.DOI: 10.3760/cma.j.issn.1009-4598.2019.10.009.
[17]	ShenY,LuLG,LowDW,et al.Perforator navigation using color Doppler ultrasound and three-dimensional reconstruction for preoperative planning of optimal lateral circumflex femoral artery system perforator flaps in head and neck reconstruction[J].J Plast Reconstr Aesthet Surg,2019,72(6):990-999.DOI: 10.1016/j.bjps.2018.12.025.
[18]	柳志锦,巨积辉,刘胜哲,等.多种类型混合型供血的双叶股前外侧穿支皮瓣修复创面[J].中华手外科杂志,2021,37(2):125-128.DOI: 10.3760/cma.j.cn311653-20200226-00074.
[19]	LiuY,DingQ,ZangM,et al.Classification and application of the distally-based thigh flap based on the lateral circumflex femoral artery system[J].Ann Plast Surg,2017,78(5):497-504.DOI: 10.1097/SAP.0000000000000946.
[20]	程俊楠,柳志锦,杨林,等.基于解剖学研究的三级命名法在旋股外侧动脉主要分支命名中的应用探讨[J].中华解剖与临床杂志,2022,27(1):13-18.DOI: 10.3760/cma.j.cn101202-20210410-00093.
[21]	丁强,刘元波,臧梦青,等.以旋股外侧动脉不同分支为蒂的大腿反流灌注皮瓣的分型研究和临床应用[J].中华整形外科杂志,2017,33(z1):61-68.DOI: 10.3760/cma.j.issn.1009-4598.2017.s1.013.
[22]	DengC,NieK,WeiZ,et al.Is the oblique branch a preferable vascular pedicle for anterolateral thigh free flaps?[J].J Reconstr Microsurg,2018,34(7):478-484.DOI: 10.1055/s-0038-1639370.
[23]	WongCH.The oblique branch trap in the harvest of the anterolateral thigh myocutaneous flap[J].Microsurgery,2012,32(8):631-634.DOI: 10.1002/micr.22011.
[24]	刘族安,黄志锋,马亮华,等.股前外侧皮瓣斜支血管的认识及斜支“陷阱”的处理[J].中华显微外科杂志,2021,44(2):146-151.DOI: 10.3760/cma.j.cn441206-20200724-00299.
[25]	刘族安,马亮华,李汉华,等.罕见斜支型股前外侧游离皮瓣修复足部创面1例[J].中国临床解剖学杂志,2019,37(6):721-723.DOI: 10.13418/j.issn.1001-165x.2019.06.022.
[26]	KhoongYM,HuangX,GuS,et al.Imaging for thinned perforator flap harvest: current status and future perspectives[J/OL].Burns Trauma,2021,9:tkab042[2022-02-27].https://pubmed.ncbi.nlm.nih.gov/34926708/.DOI: 10.1093/burnst/tkab042.
[27]	廖瑞真,刘倚河,刘舜辉,等.彩色多普勒超声在旋股外侧动脉穿支皮瓣的临床应用价值[J].中国临床医学影像杂志,2018,29(3):206-208.DOI: 10.3969/j.issn.1008-1062.2018.03.015.
[28]	孙雪,魏在荣,金文虎,等.旋股外侧动脉斜支穿支的解剖学特点及其临床应用[J].中华显微外科杂志,2017,40(1):58-62.DOI: 10.3760/cma.j.issn.1001-2036.2017.01.016.
[29]	常树森,莫小金,魏在荣,等.遵义缝合法在股前外侧皮瓣供区缝合中的应用研究[J].中国修复重建外科杂志,2021,35(4):477-482.DOI: 10.7507/1002-1892.202008101.
[30]	胡涛涛,常树森,魏在荣,等.改良三纵五横法在股前外侧穿支皮瓣修复术前穿支定位中的应用研究[J].中国修复重建外科杂志,2021,35(8):1027-1032.DOI: 10.7507/1002-1892.202103074.
[31]	吴攀峰,黄承雄,卿黎明,等.联体穿支皮瓣游离移植修复四肢环形皮肤软组织缺损[J].中华手外科杂志,2021,37(5):325-328.DOI: 10.3760/cma.j.cn311653-20201117-00373.
[32]	柳志锦,巨积辉,刘胜哲,等.股前外侧区双叶穿支皮瓣的血供方式及临床应用[J].中华骨科杂志,2021,41(4):211-218.DOI: 10.3760/cma.j.cn121113-20200415-00259.
[33]	蒋丽雅,刘元波,臧梦青,等.以旋股外侧动脉斜支为蒂的逆行股前外侧皮瓣临床应用研究[J].中国修复重建外科杂志,2017,31(5):559-563.DOI: 10.7507/1002-1892.201612091.
[34]	赵书明,刘亚明,刘娜,等.CT血管造影辅助下逆行股前外侧穿支皮瓣修复膝周或小腿近端皮肤及软组织缺损的临床效果[J].中华烧伤杂志,2021,37(4):356-362.DOI: 10.3760/cma.j.cn501120-20200905-00401.

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1 以旋股外侧动脉斜支为源动脉的股前外侧穿支皮瓣设计示意图

注：图中虚线为髂前上棘与髌骨外侧缘的连线；虚线上左侧十字中心为轴心线上2/5与下3/5的交点，右侧十字中心为虚线中点

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2 59例四肢皮肤软组织缺损患者旋股外侧动脉斜支98条穿支位置分布

注：图中圆圈表示穿支穿出点，穿支在轴心线上相对位置=穿支到髂前上棘的纵向距离÷髂髌连线长度，髂髌连线为髂前上棘与髌骨外侧缘的连线

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3 以肌间隔主干型旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣修复患者因机器绞伤致左手背皮肤软组织缺损。3A、3B.分别为术前左手背创面与清创后左手背创面情况；3C.术前皮瓣设计；3D.术中切取皮瓣旋股外侧动脉斜支的肌间隔穿支；3E.皮瓣移植到受区后；3F.供区创面直接拉拢缝合后；3G.术后6个月，受区移植皮瓣处外观尚可，掌指关节伸展无受限；3H.术后6个月，供区缝合口瘢痕轻度增生

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