改良CT血管造影术辅助基于浅筋膜穿支的股前外侧皮瓣穿支评估与偏心设计的前瞻性研究

张月恒; 崔文举; 宋坤修; 孙乐刚; 王芳; 刘小智; 邓志洋; 张志强; 刘永涛

doi:10.3760/cma.j.cn501225-20220902-00376

改良CT血管造影术辅助基于浅筋膜穿支的股前外侧皮瓣穿支评估与偏心设计的前瞻性研究

doi: 10.3760/cma.j.cn501225-20220902-00376

1.
滨州医学院附属医院手（显微）外科，滨州　　256600
2.
滨州医学院附属医院放射科，滨州　　256600
3.
滨州医学院附属医院口腔颌面外科，滨州　　256600
4.
滨州医学院附属医院手术室，滨州　　256600

基金项目:

山东省省级临床重点专科学科建设 SLCZDZK-0303

详细信息

通讯作者:
刘永涛，Email：Liuyongtao197007@163.com

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出版历程
- 收稿日期: 2022-09-02

A prospective study of the perforator evaluation and eccentric design of anterolateral thigh flap based on superficial fascial perforators assisted by modified computed tomography angiography

1.
Department of HandMicrosurgery, the Affiliated Hospital of Binzhou Medical University, Binzhou 256600, China
2.
Department of Radiology, the Affiliated Hospital of Binzhou Medical University, Binzhou 256600, China
3.
Department of OralMaxillofacial Surgery, the Affiliated Hospital of Binzhou Medical University, Binzhou 256600, China
4.
Operating Room, the Affiliated Hospital of Binzhou Medical University, Binzhou 256600, China

Funds:

Clinical Specialty Key Construction Foundation of Shandong Province of China SLCZDZK-0303

More Information

Corresponding author: Liu Yongtao, Email: Liuyongtao197007@163.com

摘要

摘要: 目的通过改良CT血管造影（CTA）术，探讨基于浅筋膜穿支的股前外侧皮瓣术前全程穿支评估与术中偏心设计，并观察其临床效果。方法采用前瞻性观察性研究方法。2021年1月—2022年7月，滨州医学院附属医院手（显微）外科和口腔颌面外科共收治符合入选标准的12例口腔颌面部肿瘤患者及10例上肢开放性损伤伴大面积软组织缺损患者，其中男12例、女10例；年龄33~75岁，平均56.6岁。口腔颌面部肿瘤患者均在同期行肿瘤扩大切除+根治性颈部淋巴结清扫术后采用股前外侧皮瓣重建口腔或颌面；上肢软组织缺损患者在Ⅰ期行彻底清创后，于Ⅱ期采用股前外侧皮瓣修复创面。清创后创面面积为3.5 cm×3.5 cm~25.0 cm×10.0 cm，所需皮瓣面积为4.0 cm×4.0 cm~23.0 cm×13.0 cm。术前对股前外侧皮瓣供区行改良CTA检查，改良CTA的参数设置主要为降低管电压和管电流，增加造影剂剂量及双时相扫描。将获取的图像数据上传至GE AW 4.7工作站，采用容积再现功能进行可视化重建并对全程穿支评估。术前根据前述评估进行穿支及其源动脉信息的体表标记，术中根据所需皮瓣面积及形状设计和切取以可见的浅筋膜穿支为中心的偏心皮瓣。对皮瓣供区创面行直接缝合或全厚皮片移植修复。对比改良CTA检查与传统CTA检查的总辐射剂量。统计改良CTA下双侧皮瓣供区的穿支穿出点分布及浅筋膜穿支长度、走行。将术前观测的目标穿支类型、数目、来源，穿支穿出点分布及其源动脉管径、走行、分支情况与术中进行对比。观测术后供区创面愈合、受区皮瓣成活情况。随访皮瓣质地、外观，口腔及上肢功能，股部供区功能。结果改良CTA检查的总辐射剂量小于传统CTA检查。共观察到双侧供区穿支48支，其中31支（64.6%）向外下方走行、9支（18.8%）内下方走行、6支（12.5%）外上方走行、2支（4.2%）内上方走行，浅筋膜穿支平均长度为19.94 mm。术前观测到的目标穿支来源及其源动脉管径、走行、分支与术中探查到的基本一致；术前观察到肌间隙型（含肌皮-肌间隙）穿支15支、肌皮型穿支10支，与术中探查一致；术前体表穿支穿出点标记与术中实际穿支穿出点距离为（0.38±0.11）mm。术后皮瓣均成活，无血管危象发生；5例患者植皮供区创面及17例患者直接拉拢缝合供区创面均愈合良好。术后随访2个月~1年，平均8.2个月，皮瓣质地柔软、轻度臃肿；口腔颌面部肿瘤患者的饮食、闭开口活动无障碍，舌癌患者的言语功能轻度障碍但能完成基本的语言交流，上肢软组织损伤患者腕及肘关节、前臂旋转功能无明显受限；股部供区无明显紧绷感，髋、膝关节活动无受限。结论对股前外侧皮瓣供区行改良CTA可视化重建，能够评估全程穿支，尤其是浅筋膜穿支，将该皮瓣用于重建口腔或颌面及修复上肢皮肤软组织缺损可取得良好效果。术前明确穿支类型、数目、来源以及穿支穿出点分布及其源动脉的管径、走行、分支，实现了以浅筋膜穿支整体为中心的股前外侧皮瓣偏心设计，有较强的指导价值。
- 外科皮瓣 /
- 血管造影术 /
- 计算机断层扫描术 /
- 创面修复 /
- 股前外侧皮瓣 /
- 穿支
Abstract: Objective To explore the preoperative whole perforator evaluation and intraoperative eccentric design of anterolateral thigh flap (ALTF) based on superficial fascial perforators by modified computed tomography angiography (CTA), and the clinical effects were observed. Methods A prospective observational study was adopted. Twelve patients with oral and maxillofacial tumors and 10 patients with open injury of the upper limb with large soft tissue defects were hospitalized in the Department of Hand & Microsurgery and Department of Oral & Maxillofacial Surgery of Affiliated Hospital of Binzhou Medical University from January 2021 to July 2022, with 12 males and 10 females, aged from 33 to 75 years, an average age of 56.6 years. The wounds of the patients with oral and maxillofacial tumors were reconstructed by ALTF after the extensive tumor resection and radical cervical lymph node dissection in the same stage; the wounds of the patients with skin and soft tissue defect on the upper limb were covered by ALTF in stage Ⅱ after debridement in stage Ⅰ. After debridement, the area of wound was 3.5 cm×3.5 cm-25.0 cm×10.0 cm and the area of the required flap area was 4.0 cm×4.0 cm-23.0 cm×13.0 cm. Modified CTA scan was performed on the donor site of ALTF before the operation, with the parameters of modified CTA being set to mainly reduce the tube voltage and tube current, and increase the contrast dose and the dual phase scan. The acquired image data were sent to GE AW 4.7 workstation and adopted the volume reconstruction function for visual reconstruction and evaluation of the whole perforator. The information of perforator and source artery was marked on the body surface before operation according to the above evaluation. During the operation, an eccentric flap centered on the visible superficial fascia whole perforator was designed and cut according to the desired flap area and shape. The donor sites of the flap were repaired by direct sutures or full-thickness skin grafts. The total radiation dose was compared between the modified CTA scan and the traditional CTA scan. The distribution of outlet point of perforator of double thighs, the length and direction of superficial fascia perforators based modified CTA were recorded. The type, number, and origin of the target perforator, distribution of of outlet point of perforator, and the diameter, course, and branch of the source artery observed before the operation were compared with those observed during the operation. The healing of donor site wound and the survival of flaps in recipient site were observed after operation. The texture and appearance of flap, oral and upper limb functions, and the functions of femoral donor sites were followed up. Results The total radiation dose of modified CTA scan was lower than that of the traditional CTA scan. A total of 48 perforators of double thighs were observed, among which, 31 (64.6%) perforators went outward and downward, 9 (18.8%) perforators went inward and downward, 6 (12.5%) perforators went outward and upward, and 2 (4.2%) perforators went inward and upward, and the average length of superficial fascia perforators was 19.94 mm. The preoperative observed type, number, and source of the perforator, the distribution of the outlet point of the perforator, diameter, course, and branches of the source artery were basically consistent with the intraoperative exploration. The types of 15 septocutaneous (including musculoseptocutaneous) perforators and 10 musculocutaneous perforators observed before the operation was consistent with intraoperative exploration. The distance between the mark of the surface perforator point and the actual exit point of the perforator during operation was (0.38±0.11) mm. All flaps survived without vascular crisis. The donor site wounds of 5 cases of skin grafting and 17 cases of direct suturing wounds healed well. The postoperative follow-up was 2 months to 1 year, with an average of 8.2 months, the flaps were soft and slightly bloated; the function of diet and mouth closing was accessible in patients with oral and maxillofacial tumors, the speech function was mildly impaired in patients with tongue cancer, but they could complete basic oral communication; the wrist and elbow joints and forearm rotation function were not significantly limited in patients with upper limb soft tissue injuries; there was no obvious tightness in the donor sites, and the function of the hip and knee joints was not limited. Conclusions The whole perforator and even the subcutaneous perforator of the donor site of ALTF can be evaluated by modified CTA, and the flap can be used in oral or maxillofacial reconstruction and repair of skin and soft tissue defects of upper limbs to achieve good results. By clarifying the type, number, and source of the perforator, the distribution of the outlet point of the perforator, diameter, course, and branches of the source artery before the operation, the eccentric design of the ALTF based on the superficial fascia perforator was realized. This study has strong guiding value.
- Surgical flaps /
- Angiography /
- Computed tomography /
- Wound repair /
- Anterolateral thigh flap /
- Perforator
张月恒：酝酿和实验设计、论文撰写、数据与图片收集、图片处理；崔文举：CT血管造影术操作，进行图片处理指导；宋坤修：对文章的知识性内容进行批阅、手术实施；孙乐刚、王芳、刘小智、邓志洋：手术实施；张志强：术中图片拍摄；刘永涛：酝酿和实验设计，论文指导、手术实施

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参考文献(19)

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1 改良CT血管造影技术下可视化重建图像中22例患者股前外侧皮瓣穿支穿出点分布图

注：坐标原点为髂前上棘与髌骨外侧缘连线中点，绿色圆半径为30 mm，红色圆半径为50 mm，红点代表穿支穿出点在此坐标中的分布

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2 采用改良CT血管造影技术辅助基于浅筋膜穿支的股前外侧皮瓣修复舌下腺腺样囊性癌患者创面。2A、2B.分别为右、左侧浅筋膜穿支正位观察；2C、2D.分别为右、左侧浅筋膜穿支斜位观察；2E、2F.分别为右、左侧穿支来源及源动脉观察；2G.右侧穿支为肌间隙穿支类型；2H.左侧穿支为肌皮穿支类型；2I.皮瓣设计；2J.术中探及源动脉走行、管径与术前观测相当，穿支类型与图2G一致；2K.完整切取皮瓣；2L.受区清创后创面；2M.术后即刻；2N.术后5个月随访，皮瓣成活良好；2O.术前可视化重建中目标穿支全程展现

注：箭头示穿支，其中红色箭头示目标穿支

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3 采用改良CT血管造影技术辅助基于浅筋膜穿支的股前外侧皮瓣修复口底鳞状细胞癌者创面。3A、3B.分别为右、左侧浅筋膜穿支正位观察，其中图3B中a点为穿支穿出点，b点为可观测的浅筋膜穿支末端与浅表静脉相连；3C、3D.分别为右、左侧浅筋膜穿支斜位观察，其中图3D中a点为穿支穿出点，b点为可观测的浅筋膜穿支末端；3E.右侧穿支起源于旋股外侧动脉降支（dLCFA），为肌皮型，穿支近段显影不清；3F.左侧穿支起源于dLCFA，为肌皮型，穿支近段显影尚可；3G.皮瓣设计；3H.术中探及源动脉走行、管径、分支与术前观测一致，蓝色箭头示源动脉分支与图3F一致；3I.浅筋膜穿支走行、管径与术前观测一致，蓝色箭头示浅筋膜穿支与图3B、3D一致；3J、3K.皮瓣完整切取；3L.受区清创后创面；3M.术后即刻；3N. 术后1个月随访，皮瓣成活良好；3O. 术前可视化重建中目标穿支全程展现

注：箭头示穿支，其中红色箭头示目标穿支

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