Clinical application effects of the "three-source and four-line method" in the design and harvest of anterolateral lower leg perforator flaps
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摘要:
目的 探讨“三源四线法”在小腿前外侧穿支皮瓣设计与切取中的临床应用效果。 方法 该研究为回顾性病例系列研究。2023年8月—2024年7月,苏州瑞华骨科医院手外科收治24例、足踝外科收治6例符合入选标准的手、足创面患者,其中男22例、女8例,年龄18~58岁。清创后单个创面面积为2.0 cm×1.5 cm~15.0 cm×4.5 cm。采用“三源四线法”,将腓骨小头与外踝尖的连线记为C线,即腓骨的体表标志线；C线向前侧平移1.5 cm记为B线,即腓浅动脉穿支皮瓣的轴心线；C线向前侧平移3.0 cm记为A线,即胫前动脉穿支皮瓣的轴心线；C线向后侧平移1.5 cm记为D线,即腓动脉穿支皮瓣的轴心线。另使用彩色多普勒超声探测仪分别沿着A、B、D线探测3种来源的穿支,以此设计和切取小腿前外侧穿支皮瓣修复创面。共切取皮瓣35块,单块皮瓣切取面积为2.5 cm×2.0 cm~16.0 cm×5.0 cm。将供区创面均直接拉拢缝合。术中记录实际使用穿支的总数量,不同来源穿支的数量、口径及血管蒂长度,穿支入皮点至其相应轴心线的垂直距离。术后观察皮瓣成活情况。随访记录皮瓣色泽、质地和外形情况及供区瘢痕情况。末次随访时,使用皮瓣综合评价量表评定皮瓣修复效果,并计算皮瓣修复效果的优良率。 结果 术中实际使用穿支38条。其中,6条穿支来源于胫前动脉,口径平均0.47 mm；血管蒂长度平均4.33 cm；穿支入皮点至A线的垂直距离平均0.48 cm。20条穿支来源于腓浅动脉,口径平均0.51 mm；血管蒂长度平均5.25 cm；穿支入皮点至B线的垂直距离平均0.54 cm。12条穿支来源于腓动脉,口径平均0.72 mm；血管蒂长度平均4.13 cm；穿支入皮点至D线的垂直距离平均0.43 cm。术后所有皮瓣顺利成活。术后随访6~15个月时,皮瓣色泽良好、质地柔软、外形无明显臃肿,供区仅遗留线性瘢痕。末次随访时,皮瓣综合评价量表评分为82~94分,皮瓣修复效果的优良率为100%（35/35）。 结论 “三源四线法”具有操作简便、定位准确等优势,有助于小腿前外侧穿支皮瓣术前灵活设计、术中安全切取,具有较高的临床应用价值。 Abstract:Objective To explore the clinical application effects of the "three-source and four-line method" in the design and harvest of anterolateral lower leg perforator flaps. Methods This study was a retrospective study of case series. From August 2023 to July 2024, the patients with hand or foot wounds who met the inclusion criteria were admitted to Suzhou Ruihua Orthopedic Hospital, including 24 patients from the Department of Hand Surgery and 6 patients from the Department of Foot and Ankle Surgery. There were 22 males and 8 females, aged 18 to 58 years. After debridement, the single wound area ranged from 2.0 cm×1.5 cm to 15.0 cm×4.5 cm. By applying the "three-source and four-line method", the line connecting the fibular head and the tip of the lateral malleolus was defined as Line C, representing the surface landmark line of the fibula; Line B was defined as Line C shifted 1.5 cm anteriorly, representing the axis of the superficial peroneal artery perforator flap; Line A was defined as Line C shifted 3.0 cm anteriorly, representing the axis of the anterior tibial artery perforator flap; Line D was defined as Line C shifted 1.5 cm posteriorly, representing the axis of the peroneal artery perforator flap. Then the color Doppler ultrasound detector was employed to identify perforators from the three vascular origins along Lines A, B, and D, respectively. Accordingly, anterolateral lower leg perforator flaps were designed and harvested to repair the wounds. A total of 35 flaps were harvested, with the single flap area ranging from 2.5 cm×2.0 cm to 16.0 cm×5.0 cm. All the donor site wounds were closed by direct suturing. During surgery, the total number of actually used perforators, as well as the number, caliber, and vascular pedicle length of perforators from different sources were recorded; the vertical distances from the perforators' skin entry points to their corresponding axes were measured. After surgery, flap survival was observed. During follow-up, the color, texture, and appearance of the flaps and the scar condition of donor sites were recorded. At the final follow-up, the flap repair outcome was evaluated using the flap comprehensive rating scale, and the excellent and good rate of flap repair outcome was calculated. Results During surgery, a total of 38 perforators were actually used. Among them, 6 perforators originated from the anterior tibial artery, with a mean caliber of 0.47 mm, a mean vascular pedicle length of 4.33 cm, and a mean vertical distance from the perforators' skin entry point to the Line A of 0.48 cm. Twenty perforators originated from the superficial peroneal artery, with a mean caliber of 0.51 mm, a mean vascular pedicle length of 5.25 cm, and a mean vertical distance from the perforators' skin entry point to the Line B of 0.54 cm. Twelve perforators originated from the peroneal artery, with a mean caliber of 0.72 mm, a mean vascular pedicle length of 4.13 cm, and a mean vertical distance from the perforators' skin entry point to the Line D of 0.43 cm. After surgery, all flaps survived smoothly. Follow up for 6-15 months showed the flaps exhibited favorable color, soft texture, and no obvious bulkiness; only linear scars were left at the donor sites. At the final follow-up, the scores of flap comprehensive rating scale ranged from 82 to 94 points and the excellent and good rate of flap repair outcome was 100% (35/35). Conclusions The "three-source and four-line method" has the advantages of simple operation and accurate perforator localization. It is helpful for flexible preoperative design and safe intraoperative harvest of the anterolateral lower leg perforator flaps with high clinical application value. -
Key words:
- Surgical flaps /
- Perforator flap /
- Microsurgery /
- Wound repair /
- Three-source and four-line method
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参考文献
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图 1 采用“三源四线法”和彩色多普勒超声定位小腿前外侧穿支
注：C线为腓骨小头与外踝尖的连线,即腓骨的体表标志线；B线为C线向前侧平移1.5 cm所得,即腓浅动脉穿支皮瓣的轴心线；A线为C线向前侧平移3.0 cm所得,即胫前动脉穿支皮瓣的轴心线；D线为C线向后侧平移1.5 cm所得,即腓动脉穿支皮瓣的轴心线；图中“×”为彩色多普勒超声定位的穿支位置
图 2 应用“三源四线法”设计和切取腓动脉穿支皮瓣修复例1患者右手创面的效果。2A.清创术后患者右手示、中指创面；2B.术中应用“三源四线法”设计皮瓣；2C.术中探测到2条穿支,均来源于腓动脉；2D.皮瓣切取后拟转移至受区；2E.皮瓣修复后即刻受区外观；2F.将供区创面直接拉拢缝合后；2G.术后9个月,皮瓣色泽良好、外形无明显臃肿；2H.术后9个月,供区遗留线性瘢痕
图 3 应用“三源四线法”设计和切取腓浅动脉穿支皮瓣修复例2患者左手创面的效果。3A.清创术后患者左手示指创面；3B.术中应用“三源四线法”设计皮瓣；3C.术中探测到替代穿支后,调整皮瓣切取位置；3D.术中溯源结果显示替代穿支来源于腓浅动脉；3E.皮瓣修复后即刻受区外观；3F.将供区创面直接拉拢缝合后；3G.术后10个月,皮瓣色泽良好、外形无明显臃肿；3H.术后10个月,供区遗留线性瘢痕
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