成人小腿内侧皮支链血管构筑的解剖学研究

赵风景; 朱雷; 姚笑笑; 卫顺学; 汤晓苹; 王庚伟

doi:10.3760/cma.j.cn501225-20231102-00174

成人小腿内侧皮支链血管构筑的解剖学研究

doi: 10.3760/cma.j.cn501225-20231102-00174

1.
杭州整形医院手外科，杭州　　310014
2.
杭州师范大学基础医学院，杭州　　311121

基金项目:

浙江省医药卫生科技项目 2022480357

详细信息

通讯作者:
赵风景，Email：landscape-81@163.com

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出版历程
- 收稿日期: 2023-11-02

Anatomical study of the architecture of the cutaneous branch-chained blood vessels in the medial lower leg in adult

1.
Department of Hand Surgery, Hangzhou Plastic Surgery Hospital, Hangzhou 310014, China
2.
Hangzhou Normal University School of Basic Medical Sciences, Hangzhou 311121, China

Funds:

Medical Health Science and Technology Project of Zhejiang Province of China 2022480357

More Information

Corresponding author: Zhao Fengjing, Email: landscape-81@163.com

摘要

摘要: 目的对小腿内侧皮支链进行血管构筑研究，探讨该区域皮支链皮瓣的设计和临床应用的解剖学基础。方法采用实验研究方法。2023年3—5月，对来自于杭州师范大学基础医学院的5具自愿捐献的新鲜成人（年龄50~70岁，均为男性）尸体标本进行解剖学研究。对5具尸体的各1条小腿标本行显微镜下精细解剖［其中1条小腿标本先行数字化X线摄影（DR）扫描后再行精细解剖］，观测并记录胫后动脉的走行、穿支数量、每个穿支穿出点与胫骨内侧髁的距离，胫后动脉穿支外径、蒂长，胫后动脉穿支与隐神经的水平距离，每条穿支穿过深筋膜后在浅筋膜内的走行及皮支链的分布。对1条小腿标本在硫酸钡灌注下行DR扫描，观察穿支间的皮支链式血管网（以下简称血管链）分布。将1条解剖后的小腿标本制成皮肤透明标本后，观察穿支分布及穿支间的血管链。结果 5条小腿标本中的胫后动脉上半部分位于比目鱼肌深面，下半部分位于腓肠肌内侧缘与趾长屈肌间隙内；共观测到胫后动脉穿支28条，每条小腿平均5.6条；穿支穿出点距胫骨内侧髁6.5~36.0 cm，主要分布在距胫骨内侧髁22.0（15.1，28.1）cm处，位于3~6区；胫后动脉穿支外径为0.7~1.1 mm，穿支蒂长1.0~4.5 cm；胫后动脉穿支与隐神经的水平距离为0.5~3.0 cm。显微镜下精细解剖显示，胫后动脉穿支穿过深筋膜后均有向上、向下的分支且行程较长，升支与降支相互纵向吻合，组成小腿内侧营养皮支链。DR扫描和皮肤透明标本均显示，胫后动脉穿支间形成纵向血管链，皮肤透明标本还显示纵向血管链包括分布于脂肪层内的直接连接血管和真皮下层的间接连接血管。结论小腿内侧皮支链血管是由胫后动脉穿支、直接连接血管、间接连接血管和交通支构筑的。皮支链皮瓣在血管解剖学构筑上是可靠的，可携带隐神经恢复部分感觉，形成较理想的皮瓣。
- 解剖学 /
- 外科皮瓣 /
- 穿支皮瓣 /
- 显微外科手术
Abstract: Objective To investigate the architecture of the cutaneous branch-chained blood vessels in the medial lower leg and provide the anatomical basis for design and clinical application of the cutaneous branch-chained flap from this region. Methods The experimental research method was used. From March to May 2023, the anatomical study was conducted on the 5 voluntarily donated fresh adult (aged 50 to 70 years, all male) cadaveric specimens from Hangzhou Normal University School of Basic Medical Sciences. The fine anatomy under microscope was performed on each lower leg specimens of 5 corpses (1 lower leg specimen was conducted with digital radiography (DR) scan before fine anatomy), to observe, measure, and record the course of posterior tibial artery, quantity of perforator, the distance between the perforating point of each perforator and the medial condyle of tibia, the external diameter of posterior tibial artery perforator, the length of perforator pedicle, the horizontal distance between the posterior tibial artery perforator and the saphenous nerve, and the course of each perforator within superficial fascia after crossing the deep fascia and the distribution of the cutaneous branch-chains. The DR scan under the perfusion of barium sulfate was conducted in one lower leg specimen to observe the distribution of cutaneous branch-chained vascular network (hereinafter referred to as vascular chain) between perforators. Transparent skin specimen was made from one leg specimen after anatomy to observe the distribution of perforators and vascular chains between perforators. Results In 5 lower leg specimens, the upper part of posterior tibial artery was located deep in soleus muscle, and the lower part was located between the medial edge of gastrocnemius muscle and flexor digitorum longus muscle. A total of 28 posterior tibial artery perforators were identified, with an average of 5.6 branches in each lower leg. The distance between the perforating point of perforator and the medial condyle of tibia ranged from 6.5 to 36.0 cm, mainly distributed at 22.0 (15.1, 28.1) cm from the medial condyle of tibia, in zones 3 to 6. The external diameters of perforators of posterior tibial arteries were 0.7-1.1 mm. The length of perforator pedicle was 1.0-4.5 cm, and the horizontal distance between the posterior tibial artery perforator and the saphenous nerve was 0.5-3.0 cm. The fine anatomy under microscope showed that the posterior tibial artery perforators had long upward and downward branches after crossing the deep fascia, and the ascending branches and descending branches were anastomosed longitudinally to form the nutrient cutaneous branch-chain in the medial lower leg. DR scan and transparent skin specimen both showed that longitudinal vascular chain was formed between the posterior tibial artery perforators, the transparent skin specimen also showed that longitudinal blood vessel chains included the direct connecting vessels in the adipose layer and the indirect connecting vessels in the subdermal layer. Conclusions The cutaneous branch-chained vessels in the medial lower leg are constructed by posterior tibial artery perforators, direct connecting vessels, indirect connecting vessels, and traffic branches. The cutaneous branch-chained flap is reliable in terms of vascular anatomy, and can carry the saphenous nerve for partial restoration of its sensation, thus it is an ideal flap.
- Anatomy /
- Surgical flaps /
- Perforator flap /
- Microsurgery
赵风景：研究设计与实施，资料采集，文章撰写与审定，理论指导，经费支持；朱雷：研究实施，资料采集；姚笑笑：研究实施，理论指导；卫顺学、汤晓苹、王庚伟：资料采集、整理及分析

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1 1具成人尸体标本的小腿内侧皮支链血管构筑观察。1A.精细解剖后肉眼观察可见多个胫后动脉穿支穿出点（绿色箭头）；1B.精细解剖后肉眼观察可见穿支点（绿色箭头）主要集中在3~6区（将体表接触到胫骨内侧髁处至内踝尖之间的皮肤均分为6个区间）；1C.显微镜下精细解剖，采用医用菲林尺测量胫后动脉穿支穿过深筋膜处外径；1D.显微镜下精细解剖，测量胫后动脉穿支（绿色箭头）与隐神经的水平距离；1E.精细解剖后肉眼观察胫后动脉穿支（绿色箭头）间在脂肪层内形成的直接连接血管（红色箭头）；1F.5倍显微镜下观察到的小腿内侧营养皮支链（红色箭头）；1G.5倍显微镜下观察到的胫后动脉穿支（绿色箭头）组成的小腿内侧营养皮支链（红色箭头）；1H.数字化X线摄影（DR）扫描可见胫后动脉穿支（绿色箭头）和各穿支发出上、下支并与上下位穿支的分支交通形成纵向皮支链式血管网（以下简称血管链，红色箭头）；1I.DR扫描可见胫后动脉穿支发出分支交通形成纵向血管链（红色箭头）；1J.皮肤透明标本显示，胫后动脉（黄色箭头）及其穿支（绿色箭头）及在真皮下层形成的间接连接血管组成纵向血管链（红色箭头）

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2 5具成人尸体标本的小腿胫后动脉28个穿支点到胫骨内侧髁的距离和到隐神经的水平距离

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参考文献(14)

[1]	汪坤菊,石小田,丁自海,等.腓动脉皮支链皮瓣的应用解剖[J].解剖学杂志,2020,43(4):309-312.DOI: 10.3969/j.issn.1001-1633.2020.04.008.
[2]	秦向征,李良昌,李光昭,等.小腿后外侧穿支皮支链的解剖学研究[J].中国临床解剖学杂志,2015,33(2):138-140.DOI: 10.13418/j.issn.1001-165x.2015.02.005.
[3]	AyyappanT,ChadhaA.Super sural neurofasciocutaneous flaps in acute traumatic heel reconstructions[J].Plast Reconstr Surg,2002,109(7):2307-2313.DOI: 10.1097/00006534-200206000-00022.
[4]	张永宏,沈国良,赵小瑜,等.邻近筋膜皮瓣修复胫前区骨或钢板外露小创面的临床效果[J].中华烧伤杂志,2018,34(12):907-909.DOI: 10.3760/cma.j.issn.1009-2587.2018.12.016.
[5]	许良,王楠,王利祥.胫后动脉穿支联合隐神经营养血管筋膜蒂皮瓣修复足底内侧创面[J].中华显微外科杂志,2020,43(1):10-14.DOI: 10.3760/cma.j.issn.1001-2036.2020.01.004.
[6]	巨积辉,周荣,刘跃飞,等.超长股外侧区内增压型穿支皮瓣修复足踝部创面的临床效果[J].中华烧伤杂志,2019,35(7):495-500.DOI: 10.3760/cma.j.issn.1009-2587.2019.07.004.
[7]	何晓清,杨曦,石岩,等.腓肠外侧浅动脉穿支皮瓣术中解剖学观察及临床意义[J].中国临床解剖学杂志,2023,41(2):132-136.DOI: 10.13418/j.issn.1001-165x.2023.2.03.
[8]	丁自海,王增涛,钟世镇.皮瓣解剖学研究的三个阶段[J].中华显微外科杂志,2010,33(3):180-181.DOI: 10.3760/cma.j.issn.1001-2036.2010.03.002.
[9]	张国雷,李文庆,朱小弟,等.手指筋膜蒂指掌侧固有动脉皮支链皮瓣修复指端软组织缺损13例[J].中华显微外科杂志,2019,42(3):275-276.DOI: 10.3760/cma.j.issn.1001-2036.2019.03.016.
[10]	王辉,杨晓溪,霍永鑫,等.尺动脉穿支血管链皮瓣修复吻合血管的前臂远端或腕部创面的临床效果[J].中华烧伤杂志,2021,37(7):635-639.DOI: 10.3760/cma.j.cn501120-20200422-00234.
[11]	MehrotraS.Perforator-plus flaps: a new concept in traditional flap design[J].Plast Reconstr Surg,2007,119(2):590-598.DOI: 10.1097/01.prs.0000239570.18647.83.
[12]	DrimourasG, KostopoulosE, AgiannidisC,et al. Redefining vascular anatomy of posterior tibial artery perforators: a cadaveric study and review of the literature[J].Ann Plast Surg,2016,76(6):705-712. DOI: 10.1097/SAP.0000000000000258.
[13]	JakubietzRG,NickelA,NeshkovaI,et al.Long-term patency of twisted vascular pedicles in perforator-based propeller flaps[J].Plast Reconstr Surg Glob Open,2017,5(10):e1544.DOI: 10.1097/GOX.0000000000001544.
[14]	PengP, DongZG, WeiJW,et al. Risk factors related to the partial necrosis of the posterior tibial artery perforator-plus fasciocutaneous flap[J].Eur J Trauma Emerg Surg,2022,48(2):1247-1253. DOI: 10.1007/s00068-021-01616-0.