带蒂穿支岛状皮瓣中单穿支动脉灌注多穿支血管区域现象研究

Pedicled perforator flaps have the advantages of "like tissues restore like" and easy manipulation etc. However, to date, there are still lack of scientific data concerning choosing principles of its donor and pedicle,especially, lack of one perforator's safe range of perfusion. Recently, we found an interesting phenomenon,ie,one perforator capturing multiple perforator angiosomes. Its existence also is proven by Taylor and many authors. Based on this phenomenon, its anatomical basis is the linking among perforator angiosomes is true anastomoses, without choke anastomoses. Based on this phenomenon, we consider if an ideal flap donor, which means only true anastomoses connecting perforator angiosomes in the donor, can be identified, the phenomeon of one perforator capturing multiple perforator angiosomes can occur in the pedicled perforator flap. In addition, dynamic infrared thermography is introduced into choosing choke anastomoses and perforator angiosomes, which make the ideal donor possible. We hypothesizes: By combining dynamic infrared thermography and flap surgical delay, we can define the ideal donor nearby the recipient. Moreover,Based on the results of positive relationship between the perforator flow rate and range of perfusion, we conclude that we can get a correlation formula between the perforator flow rate and range of perfusion. Then we utilize the reverse engineering to confirm the accuracy of the correlation formula. Based on the formula, we can use it to identify an appropriate perforator as the pedicle of pedicled perforator flaps.

带蒂穿支岛状皮瓣技术具备相似组织替代、手术操作简单等优点，但缺乏科学选择皮瓣供区和蒂部穿支的依据，造成其安全性受到质疑。本项研究拟（1）以所发现的带蒂穿支岛状皮瓣中出现的单穿支动脉灌注多穿支血管区域现象为基础，结合红外线热成像技术和皮瓣延迟技术，建立在受区附近筛选和制备理想皮瓣供区的方法，使皮瓣供区内穿支血管区域间只有真正吻合这一种链接方式，实现单穿支灌注多穿支血管区域现象，打破单穿支仅能灌注1个半穿支血管区域理论；（2）基于穿支血流率与灌注区域呈正相关的研究结果，采用源动脉插管四维CT血管造影技术，通过对理想皮瓣供区内穿支动脉血流率与灌注区域的相关性研究，建立相关方程；并基于反向工程技术及蒂部穿支血流率在皮瓣切取后增大等研究结果，验证其可靠性；建立以预切取皮瓣内穿支血管区域数量为切入点，筛选蒂部穿支动脉的方法，为带蒂穿支岛状皮瓣技术的临床应用提供科学依据。

带蒂穿支岛状皮瓣具备相似组织替代、手术操作简单等优点；但术后常出现皮瓣尖端坏死或完全坏死，造成需要皮瓣覆盖的组织外露（失败率：7-9.4%）。目前研究证据表明，生理状态下的单个穿支血管只能灌注1个半穿支血管区域；如果穿支血管区域数量超过2个且彼此之间链接的方式是扼流吻合，远隔蒂部穿支血管的穿支血管区域一定会发生坏死，临床上表现为皮瓣尖端坏死。因此，要安全切取带蒂穿支岛状皮瓣需要解决下列问题：首先，术前需要在皮瓣供区识别皮瓣供区内含有多少个穿支血管区域及其之间的链接方式；其次，如果穿支血管区域数量大于2个且彼此之间为扼流吻合，需要对皮瓣供区做预处理，使其内的扼流吻合转化为直接吻合，降低血液循环阻力，扩大单穿支血管的灌注区域。本项研究采用红外线热成像技术，发现在红外线热成像上，皮瓣供区内的穿支血管区域表面呈现白色的热点；在其间的扼流区域，如果穿支血管区域间是直接吻合链接，则在红外线热成像上呈现为白色条带状，相反，如果是扼流吻合链接，则呈现为红色；基于此我们建立了识别皮瓣供区内穿支血管区域数量及其链接方式的方法。对于穿支血管区域数量大于2个且彼此之间为扼流吻合的皮瓣供区，我们采用皮瓣外科延迟的方法预先处理皮瓣供区。我们发现在红外线热成像上，皮瓣延迟处理后的皮瓣供区由预处理前的红白相间图案转化为白色的片状；动脉血管造影证实皮瓣外科延迟将穿支血管区域间的扼流吻合链接转化为直接吻合链接。基于外科延迟后皮瓣供区的红外线热成像及相应温度变化，我们建立了预测皮瓣外科延迟后最佳皮瓣切取时间的判断方法，其灵敏度为84.6%、特异性为77.3%，优于以延迟时间作为预测的方法（灵敏度为38.5%、特异性为90.9%）。另外，在皮瓣外科延迟处理后的皮瓣供区，我们通过VEGF受体阻滞剂阻断的VEGF的作用后，发现内源性VEGF与外科延迟后早期的扼流血管扩张和后期的微血管生成呈明显正相关，皮瓣外科延迟效应的直接启动因素是内源性VEGF，为皮瓣供区的化学处理奠定科学基础。