Clinical application effects of the "novel three-vertical five-horizontal method" for perforator localization in anterolateral thigh chimeric flaps
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摘要:
目的 探讨“新型三纵五横法”在股前外侧嵌合皮瓣穿支定位中的临床应用效果。 方法 该研究为回顾性病例系列研究。2021年6月—2023年6月,遵义医科大学附属医院收治15例符合入选标准的肢体毁损性创面患者,创面位于上肢者5例、下肢者10例,清创后创面面积为12 cm×5 cm~22 cm×7 cm。采用“新型三纵五横法”,以髂前上棘为P点,髌骨外上缘为A点、股骨外上髁为B点,分别引出1条直线称为PA、PB线,连接P点与A点和B点的中点（C点）,得到PC线；从PA线中点引一垂线为E线,将E线向近端平移5 cm为D线,向远端分别平移5、10、15 cm为F、G、H线；PA线和PB线分别与D、E、F、G、H线相交,形成Ⅰ、Ⅱ、Ⅲ、Ⅳ区,以此区域为皮瓣穿支位置设计并切取股前外侧嵌合皮瓣修复创面。皮瓣切取面积为13.0 cm×6.0 cm~23.0 cm×8.0 cm。将供区创面直接缝合。术中记录观察到的各区域内穿支数量、来源及穿支入皮点至PC线的垂直距离。术后观察皮瓣存活情况。随访时观察皮瓣色泽、质地、外形及并发症情况。 结果 术中共观察到75条穿支,其中Ⅰ区内18条穿支（3条来源于股前外侧动脉斜支、15条来源于股前外侧动脉降支）、Ⅱ区17条穿支（均来源于股前外侧动脉降支）、Ⅲ区21条穿支（均来源于股前外侧动脉降支）,Ⅳ区19条穿支（12条来源于股前外侧动脉降支、7条来源于大腿下段周边血管）。24条穿支入皮点位于PC线上,51条穿支入皮点位于PC线旁,其至PC线的垂直距离均<1.0 cm。术后1例患者皮瓣远端出现淤紫,2例患者皮瓣边缘少量渗液,均经换药后愈合；其余患者皮瓣顺利成活。术后6~40个月随访时,皮瓣色泽、质地、外形均良好,无并发症发生；供区瘢痕增生不明显,无肌疝发生。 结论 “新型三纵五横法”可有效定位股前外侧嵌合皮瓣穿支,方法简单、可靠,基于该方法设计与切取的股前外侧嵌合皮瓣修复肢体毁损性创面的临床效果良好,值得推广。 Abstract:Objective To evaluate the clinical application effects of the "novel three-vertical five-horizontal method" for perforator localization in anterolateral thigh chimeric flaps. Methods This study was a retrospective study of case series. From June 2021 to June 2023, 15 patients with destructive limb wounds who met the inclusion criteria were admitted to the Affiliated Hospital of Zunyi Medical University. The wounds were located on the upper limbs in 5 cases and the lower limbs in 10 cases, with a post-debridement area ranging from 12 cm×5 cm to 22 cm×7 cm. The "novel three-vertical five-horizontal method" was employed. The anterior superior iliac spine was defined as Point P, the superolateral border of patella was defined as Point A, and the lateral femoral epicondyle was defined as Point B, then Lines PA and PB were drawn, respectively. The point C, the midpoint between Point A and Point B, was connected with Point P to form line PC. A perpendicular line was drawn from the midpoint of Line PA as Line E. Line E was translated 5 cm proximally to form Line D, while Lines F, G, and H were drawn 5, 10, and 15 cm distally, respectively. The intersections of Lines PA and PB with Lines D, E, F, G, and H were defined as Zones Ⅰ, Ⅱ, Ⅲ, and Ⅳ, respectively. These zones served as the guide for designing and harvesting the anterolateral thigh chimeric flaps to repair the wounds. The area of harvested flap ranged from 13.0 cm×6.0 cm to 23.0 cm×8.0 cm. The donor site wounds were closed directly. During surgery, the number and origin of perforators observed in each zone, as well as the vertical distance from the perforator's skin entry point to Line PC, were recorded. After surgery, flap survival was observed. During follow-up, the color, texture, appearance, and occurrence of complications of flaps were observed. Results During surgery, a total of 75 perforators was identified. Their distribution by zone was as follows: 18 perforators in Zone Ⅰ (3 originating from the oblique branch of anterolateral thigh artery and 15 originating from the descending branch of anterolateral thigh artery), 17 perforators in Zone Ⅱ (all originating from the descending branch of anterolateral thigh artery), 21 perforators in Zone Ⅲ (all originating from the descending branch of anterolateral thigh artery), and 19 perforators in Zone Ⅳ (12 originating from the descending branch of anterolateral thigh artery and 7 originating from the peripheral vessels in distal thigh). The 24 perforators' skin entry points were located directly on Line PC, while 51 perforators' skin entry points were located adjacent to it, with the vertical distances to Line PC all less than 1.0 cm. After surgery, one patient developed distal flap bruising, and two patients had minor exudation at the flap margin, which all healed after dressing change. The flaps in the remaining patients survived smoothly. During the follow-up period of 6 to 40 months, all flaps demonstrated favorable color, texture, and appearance, with no complications observed; the scars in donor sites were mild, with no muscle herniation. Conclusions The "novel three-vertical five-horizontal method" method can effectively locate anterolateral thigh chimeric flap perforators. The method is simple and reliable. The anterolateral thigh chimeric flaps designed and harvested based on this method have good clinical effect in repairing destructive limb wounds, which is worthy of promotion. -
参考文献
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图 1 “新型三纵五横法”定位股前外侧嵌合皮瓣穿支
注：P点为髂前上棘,A点为髌骨外上缘,B点为股骨外上髁,C点为A点和B点的中点,O点为PA线中点；PA线为髂前上棘与髌骨外上缘的连线,PB线为髂前上棘与股骨外上髁的连线,PC线为髂前上棘与C点的连线,E线为过O点垂直于PA线的线,D线为E线向近端平移5 cm所得,F线为E线向远端平移5 cm所得,G线为E线向远端平移10 cm所得,H线为E线向远端平移15 cm所得；PA和PB线分别与D、E、F、G、H线相交,形成4个梯形区域即Ⅰ、Ⅱ、Ⅲ、Ⅳ区
图 2 应用“新型三纵五横法”设计携带扩筋膜的游离股前外侧嵌合皮瓣修复例1患者右手毁损性创面的效果。2A.清创后,见右手掌皮肤软组织缺损,桡侧3指及掌部组织缺失,环指指深屈肌腱部分缺损,小指中远节坏死；2B.采用“新型三纵五横法”设计携带扩筋膜的游离股前外侧嵌合皮瓣；2C.术中切取皮瓣时可见携带的阔筋膜；2D.完整切取的皮瓣；2E、2F.分别为皮瓣游离移植术后即刻,右手掌侧、桡侧外观；2G、2H.分别为术后1年随访时,右手掌侧、尺侧外观
图 3 应用“新型三纵五横法”设计携带肌瓣的游离股前外侧嵌合皮瓣修复例2患者左下肢毁损性创面。3A.清创后,见左小腿前侧大面积皮肤缺损,胫骨外露伴骨质缺损,深部可见死腔形成；3B.清创后见左小腿内侧大面积皮肤缺损,胫骨外露伴骨质缺损；3C.采用“新型三纵五横法”设计携带肌瓣的游离股前外侧嵌合皮瓣；3D.术中切取皮瓣时可见携带的肌瓣；3E.完整切取的皮瓣；3F.将皮瓣分为两叶,转移覆盖创面后即刻外观；3G.分别为术后1年随访时,小腿内侧、外侧皮瓣外观
Table 1. 15例肢体毁损性创面患者各区域内股前外侧嵌合皮瓣穿支情况
区域 数量（条） 穿支来源（条） 穿支入皮点至PC线的垂直距离（cm） 股前外侧动脉斜支 股前外侧动脉降支 大腿下段周边血管 Ⅰ区 18 3 15 0 <0.6 Ⅱ区 17 0 17 0 <0.8 Ⅲ区 21 0 21 0 <1.0 Ⅳ区 19 0 12 7 <1.0 合计 75 3 65 7 注：PC线为髂前上棘与髌骨外上缘和股骨外上髁中点的连线 
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