穿支蒂皮瓣vs穿支筋膜蒂皮瓣哪一个的静脉回流更好？张世民

穿支蒂皮瓣 vs 穿支筋膜蒂皮瓣：哪一个的静脉回流更好？perforator-pedicled flaps vs perforator-plus pedicled flaps:which one has a better venous drainage?,同济大学附属同济医院 骨科 张世民学术博客: ,四肢远端蒂皮瓣的二种类型,蒂部的类型与衍变,筋膜皮肤蒂（全层厚度，半岛状）筋膜皮下蒂（不带皮肤，岛状） 包括：皮神经营养血管筋膜蒂 浅静脉营养血管筋膜蒂穿支血管蒂（不解剖肌间隔）穿支血管筋膜蒂穿支血管蒂（彻底解剖松解肌间隔）,1 筋膜皮肤蒂，半岛状皮瓣,1980年代，Ponten提出筋膜皮瓣之后看到穿支，仍保留宽的筋膜皮肤担心单独的穿支不够旋转发生在筋膜皮肤蒂上,2 筋膜蒂，岛状,1980年代，稍后一些切除蒂部表面的皮肤，筋膜蒂岛状旋转发生在筋膜蒂上,保留肌间隔,3 穿支蒂，保留肌间隔,再后，医生的认识越来越深，胆子越来越大仅穿支蒂，转移方便但保留肌间隔，不作进一步游离解剖旋转发生在肌间隔？,Microsurgery, 2004, 24(6): 430-436,Microsurgery, 2009, 29(3): 205-213,4 穿支蒂，保留周围筋膜组织,没有肌间隔的外踝后间隙穿支蒂周围筋膜组织旋转发生在？,Plast Reconstr Surg, 2007, 120(3): 697-704,4.1 螺旋式进步：穿支筋膜蒂？,轴型穿支随意型筋膜蒂？折中的办法？血流更好？能否改善静脉回流？,我们对皮瓣术后淤血肿胀的比较,半定量法,Ann Plast Surg, 2012, online,5 穿支蒂，彻底松解游离,穿支血管游离的越彻底，皮瓣旋转后的血液循环就越安全裸化，骨化尤其静脉回流防止损伤血管！显微镜下解剖游离Hikko Hyakusoku, Marco Pignatti, Rei Ogawa,Geoffrey G. Hallock, Musa Mateev, Alexandru V. Georgescu,Shimpei Ono, Salvatore DArpa, Isao Koshima, Teo,穿支血管蒂螺旋桨皮瓣Perforator pedicled propeller flap,PRS 2011集中反映在该会议共识中,穿支血管蒂螺旋桨皮瓣Perforator pedicled propeller flap,并发症，与穿支血管的流量不足（内在因素或外在因素）有关，与血管蒂周围的筋膜松解不足有关，尤其是静脉周围均匀的分布扭力，完全的松解游离穿支血管至最大长度（到源血管），对减少血管并发症的危险，至关重要,我们的疑问：肌间隔穿支蒂皮瓣,只要看到、确认了穿支血管在肌间隔内，均不去进一步切开肌间隔，即并不进一步解剖、游离穿支血管，优点：避免了损伤穿支血管的风险，肌间隔有一定的深度（2-3cm），即代表了穿支血管有一定的长度，可以承担皮瓣的扭转角度，穿支血管在肌间隔的夹持下共同旋转，可防止血管的锐性折角，肌间隔坚韧，可防止穿支血管遭受牵扯拉力，对穿支血管有保护作用。,Chang SM, Tao YL, Zhang YQ. The distally perforator pedicled propeller flap. Plast Reconstr Surg. 2011; 128(5): 575e-577e. Reply by Pignatti,穿支血管蒂螺旋桨皮瓣：手术步骤,1 术前试着确定穿支血管： Doppler，Duplex，CTA，MRA，解剖学知识，术中有目的的观察2 术前初步设计皮瓣：轴点两侧宽度相等3 穿支血管蒂的手术探查4 穿支血管的选择与皮瓣再调整5 穿支血管蒂的游离解剖6 穿支皮瓣的游离切取7 穿支蒂皮瓣旋转8 术后观测与护理,穿支血管蒂的游离解剖,为了达到180旋转，必须要有一定的血管蒂长度来分担扭转穿支血管游离得越彻底，皮瓣越安全 (Teo, Pignatti)肌皮穿支：肌肉内解剖，长度至少2cm切除血管蒂周围的筋膜纤维束fascial strand around perforator，尤其穿静脉周围肌间隔穿支，间隔内解剖游离 intraseptal dissection and freeingLengthy perforators must be preferred when wide rotation is planned, like in 180 degree propeller flaps. By distributing torsion over a longer vessel, long perforators are less prone to buckling and occlusion.Complete skeletonization of the perforator, free of restriction,Teo TC. Perforator local flaps in lower limb reconstructionJ. Cir Plast Iberlatinamer, 2006; 32(1):15-17.Teo TC. The propeller flap conceptJ. Clin Plast Surg, 2010; (37): 615-626.Pignatti M, Pasqualini M, Governa M, et al. Propeller flaps for leg reconstructionJ. J Plast Reconstr Aesthet Surg, 2008; 61(7):777-783,皮瓣试行旋转，观察血管蒂,放松止血带，皮瓣放回原位，观察血循等待10min，让皮瓣灌注，因操作而发生痉挛的血管蒂自我松弛试行旋转，蒂部扭曲？Torsion? Twisting? Buckling? Kinking?顺时针？逆时针？所需的旋转角度最小？至多180仍有紧张、束缚的纤维索？进一步松解首先缝合固定血管蒂两侧的2针，保证穿支血管不受牵拉张力stretching供区，必要时植皮。不要强行在张力下直接缝合，止血带效应： (1)影响皮瓣，(2)影响远侧肢体,临床应用体会：case 1, F, 62,开放性Pilon骨折，术后内踝皮肤坏死,穿支血管，1动脉2静脉,术后3周,Case 2, M, 23, 掌背动脉远侧穿支皮瓣,改进静脉回流的方法,从瓣部考虑： 加大皮瓣长度，减少转移后的牵拉张力 静脉吻合 venous supercharge, superdrainage 增加筋膜蒂？ 肝素渗血 蚂蟥吸血 浅静脉干插管放血 -从蒂部考虑： 增加穿支静脉的回流效能 enhance efficacy of venous drainage,国外学者的新思路,从穿支血管蒂的角度，提高回流效能 venous efficacy现象：穿支蒂皮瓣切取之后，放回原位均表现为良好的动脉灌注和静脉回流，一切血液循环障碍均是发生在皮瓣旋转之后。旋转角度越大，对穿支血管蒂的扭曲就越大。伴行的穿支静脉位于动脉的两侧，承受了更多的扭转应力；静脉管壁薄，内压低，对扭转应力也更为敏感，因此较动脉更容易出现扭曲、狭窄、卡压、闭塞等，这也是皮瓣术后静脉回流障碍多见的原因穿支血管需游离出一定的长度才能分担转扭应力，且术中要切除穿支血管蒂周围所有的筋膜纤维束带，即完全裸化穿支血管蒂，才能将180的扭转应力平滑的分布于一定长度的穿支血管上,今天的论点,轴型穿支血管随意型筋膜蒂，对皮瓣血循的影响：动脉方面：增加？盗血？静脉方面：倒灌？引流？综合效应：保留蒂部筋膜组织，好？不好？更差？,PK,穿支筋膜蒂,纯穿支蒂,穿支血管蒂（不解剖肌间隔）穿支血管筋膜蒂,穿支血管蒂，裸化穿支血管（彻底解剖松解肌间隔）,从4个方面,说明：裸化穿支血管蒂，更优有限元模拟分析动物实验人的活体实验临床应用存在问题,纯穿支蒂,文献1：有限元模拟计算,Wong 2007，应用非线性有限元模拟，分析了穿支血管的直径、内压、长度、旋转角度等因素对皮瓣灌注的影响，结论：为保持通畅，穿支血管直径1mm，扭转180，蒂长3cm，且周围血压要稳定，不可出现低血压。,模型,直径1mm长30mm腔内充盈液体,扭转角度对静脉的影响更大超过180，应变急剧变化，说明静脉闭塞动脉在360仍通畅,静脉,动脉,血管长度超过3cm时，应力急剧下降,血管直径1mm，应力最小,文献2：动物实验,大鼠实验cranial epigastric artery true perforator flaps，on a single perforator不切断血管，仅进行血管蒂的旋转扭转超过180，皮瓣成活面积急剧下降,文献3：临床,2010年Schaverien，106例胫后动脉穿支蒂岛状皮瓣，均螺旋桨样，其中72%修复小腿下1/3、10%修复足部和踝部，88%的创面与骨折有关，60%有胫骨髓内钉；皮瓣平均旋转角度160（60 180 ）结果8.5%皮瓣完全坏死，12%皮瓣部分坏死。,切取技巧先前后切开，深筋膜下掀起保留所有的穿支远近皮桥完整阻断近侧皮桥，阻断其他穿支观察血循,文献4：临床,Soft tissue defect over the medial malleolus and damaged Achilles tendon. Exploratory incision in search of a perforator preoperatively localised by Doppler. The perforator vessel nourishing the flap. Pivot point of the 180 rotation.The propeller flap has been completely harvested and rotated. The skin island was planned to preserve the superficial sural artery flap as a secondary surgical option.Postoperative results after 6 months. The moderate thickness of the flap has allowed reconstruction with an adequate contour of the ankle.,Clin Plastic Surg，2010； 37: 615626,两个穿支共同为蒂？扭结在一起,文献5：教程讲座,(A) Traumatic soft tissue loss on the medial malleolus with exposure of the tibia. After the main perforator, arising from the posterior tibial artery, has been located with a handheld Doppler ultrasound scanner, the flap is planned around it. (B) A generous exploratory incision is made on the posterior border of the flap and the perforatoron which the flap is based is visualized. (C, D) Meticulous dissection of the perforator. To avoid vascular compromise the perforator should be skeletonized completely by dividing all the fascial strands that could causeextrinsic compression, particularly of the venae comitantes, once the flap is rotated. (E, F) The flap, completely islanded on a single perforator, is then rotated to cover the defect. (G) Result at 1 month after surgery.,J Hand Surg 2011;36A:853863,The extent of dissection of the perforator depends on the degree of flap rotation required. One has to balance the risk of greater perforator dissection with the benefit of greater flap mobility. The perforator is dissected to the point at which the flap can be rotated easily into the defect by carefully dividing any fibrous strands along the pedicle that impede this rotation. In flaps that need to rotate 180, it is a good idea to see which rotation (clockwise or counter-clockwise) results in a greater twisting or kinking of the pedicle and choose the appropriate direction of rotation.,文献6：临床,综述性文章,文献7：临床综述,24个腹部整形的病人fluorescent dye indocyanine green was injected intravenously before and after conversion of a perforator flap with an intact skin bridge into an islanded perforator flapmeasured by dynamic laser induced fluorescence videoangiography,活体观察实验,文献8：活体实验,实验设计先带皮桥，静脉注射吲哚青绿 荧光素；再切断皮桥，注射观察染色，尤其末端的染色,两组的动脉血压、心率无差别,切断皮桥,I 区，离蒂部最远,问题：先带皮桥注射，再切断皮桥成纯穿支注射，二次注射，有后遗作用？静脉充血淤滞？ stasis of the contrast caused by congestion,不太可能： (1) the stasis must occur after the contrast reaches the area, because stasis before contrast injection would lead to reduced inflow of contrast;(2) perfusion is evaluated by both mean pixel intensity and perfusion index; (3) retention of the contrast after previous injection can be excluded because of short half-life (3 to 4 minutes) and a long period between the two injections.,研究结论,This study demonstrates that conversion of a perforator flap with an intact skin bridge at the base into an islanded perforator flap increases peripheral tissue perfusion将穿支皮瓣蒂部的皮桥切断，将增加皮瓣远侧的血液灌注皮桥的盗血作用 hemodynamic steal四肢 In the authors experience, dividing the skin bridge when designing islanded perforator flap in the upper/lower extremity and the trunk exhibits the same clinical increase in vascularization and color as in the lower abdominal flaps. However, to determine whether this effect is present in other perforator flaps warrants further studies.,总结,国外的资料总结，这类皮瓣的整体血液循环并发症发生率在10-20左右，大多与静脉回流障碍有关。皮瓣很少完全坏死，即便有部分坏死（主要为皮肤干痂），深筋膜等软组织也很好，植皮即可解决上肢的穿支血管蒂短，扭曲后容易出现问题；下肢，胫后动脉穿支优于腓动脉穿支：肌间隔松弛，静脉伴行好。躯干：穿支血管粗大,下肢临床应用的系统综述：Gir P, Cheng A, Oni G, Mojallal A, Saint-Cyr M. Pedicled-Perforator (Propeller) Flaps in Lower Extremity Defects: A Systematic Review. J Reconstr Microsurg. 2012 Jun 19. Epub ahead of print,我的认识,国外众多学者的研究结论，必定有其道理换个视角看问题，我们要重视、要研究消化吸收提高创新，更高的成活率与成活质量真的比保留筋膜蒂好？,方的？圆的？,2根？3根？,临床对策,临床实际中，根据术中对穿支血管蒂的观察，具体分析，灵活选用：如果发现了良好的穿支（粗、伴行好），可以尝试裸化、骨化血管蒂 pure perforator ，裸化可能更好如果穿支不理想，则保留肌间