提高穿支血管蒂螺旋桨皮瓣静脉回流效能的实验与临床研究

Perforator pedicled propeller flap is a new reconstructive technique that combines the advantages of local perforator flap and the island rotational flap. It is simple and very useful in soft-tissue reconstruction of the extremities. However, clinical experience has shown that the 180-degree rotation perforator pedicled propeller flap has approximately 10% failure rate, mainly due to the insufficiency in venous drainage. Flap rotation and transportation cause the perforator pedicle torsion and tension, which is more prominent on the tiny perforator veins. Therefore, to enhance flap viability and reliability, there must carry out from the venous aspect to improve drainage. .The project is aimed to study the effect of different pedicle and flap management on blood flow haemodynamics and flap survival. It contains four part: animal experimental study, perforator anatomic study in human, finite element simulatioins study and clinical applications. After flap model establishment on SD rat, animals are divided into 36 groups to compare the influence of a series factors, including torsion with different flap rotation angle (0, 90, 120, 150, 180, 270 degrees), vascular pedicle length (5mm, 10mm), tension with flap stretching (yes/no), septum (yes/no), adipofascial (yes/no), surgical delay, and venous superdrainage with microsurgical anastomosis. Parameters in haemodynamics, flap survival area, and vascular histology after animal sacrifice are compared. Anatomic study is mainly focused on perforator mapping, vascular calibre, pedicle length, and the pattern of perforating artery/vein accompany. Digital finite element simulations study is focused on the relationship between torsion and vascular patency on two kind of perforator artery/venous accompany pattern. Based on these basic studies, clinical applications are carried out, especially the distally perforator pedicled propeller flaps for foot and ankle coverage in lower extremity, and hand and wrist reconstrucion in the upper extremity. .After final analysis and summary, we anticipate to draw a technical protocol and clinical guideline on perforator pedicled propeller flap.

穿支血管蒂螺旋桨皮瓣是将穿支皮瓣的理念与带蒂皮瓣的转移技术相结合而出现的创面修复新方法。但旋转180 的穿支血管蒂螺旋桨皮瓣，术后失败率在10%左右，这主要与皮瓣旋转导致的血管蒂扭曲有关。尤其是穿支静脉，因其管壁薄，内压低，在扭转应力的作用下更容易发生损伤和闭塞，导致皮瓣静脉回流障碍而坏死。因此，提高皮瓣的成活率和成活质量，必须从改善其静脉回流的角度入手。.本课题在建立大鼠背部穿支血管蒂螺旋桨皮瓣模型的基础上，从分组动物实验、穿支血管蒂解剖、扭转的有限元模拟和临床应用等方面，探讨下列因素对静脉血流动力学和皮瓣成活的影响：皮瓣旋转角度、穿支血管蒂长度、蒂部牵拉张力、动静脉伴行紧密程度、蒂部是否保留肌间隔组织、是否保留筋膜皮下组织、外科延迟术、吻合静脉建立额外的超回流通道等。在总结归纳实验和临床资料的基础上，期望能提出开展穿支血管蒂螺旋桨皮瓣的规范性技术建议，为临床进一步推广应用提供理论基础。

穿支血管蒂螺旋桨皮瓣是将穿支皮瓣的理念与带蒂皮瓣的转移技术相结合而出现的创面修复新方法。但旋转180°的穿支血管蒂螺旋桨皮瓣，术后失败率在10%左右，这主要与皮瓣旋转导致的血管蒂扭曲有关。尤其是穿支静脉，因其管壁薄，内压低，在扭转应力的作用下更容易发生损伤和闭塞，导致皮瓣静脉回流障碍而出现并发症。. 本课题通过大鼠动物实验研究、小腿解剖学研究、血管蒂扭转的有限元模拟研究和临床应用研究共4个方面，从皮瓣旋转角度、穿支血管蒂长度、蒂部牵拉张力、动静脉伴行紧密程度、是否保留筋膜皮下组织、吻合静脉建立额外的超回流通道等方面，探讨了这些因素对穿支血管通畅性及皮瓣成活率的影响。. 为提高临床开展穿支血管蒂螺旋桨皮瓣的成功率，本研究总结归纳出下列技术建议：（1）皮瓣设计要比创面至少扩大20%，防止在血管蒂扭转的基础上又增加牵拉张力的影响，（2）如果皮瓣旋转角度不超过120o，则无需对穿支血管做过度剥离（保留部分筋膜蒂）；（3）如果皮瓣旋转角度达到160°-180°，则需在显微镜下对穿支血管进行“裸化”，剔除一切影响旋转的筋膜结缔组织，避免卡压，（4）解剖裸化的血管蒂长度需至少达到2-3cm，以降低每单位长度上的扭转量（加捻密度，twist density），保证管腔内血流的通畅，（5）如果穿支动静脉间距超过5mm，则两侧的静脉血管在扭转后很容易打结交锁，显著降低其通畅性，此时应切取穿支筋膜蒂皮瓣，将旋转点放在筋膜蒂上，（6）皮瓣切取后，放回原位，在无任何扭转和张力的条件下，让血液充分灌注10分钟，解除穿支血管的痉挛收缩，（7）皮瓣旋转移位，血管蒂必定发生扭转，需防止成锐角打折；（8）皮瓣缝合时，先固定血管蒂轴点部位的二针，防止皮瓣遭受牵拉张力，（9）围手术期保证充足的循环血量，防止出现低血压而灌注不足，（10）术后密切观察，及时处理血液循环障碍，如皮瓣表面小切口放血等。