筋膜皮肤蒂在穿支筋膜皮肤蒂皮瓣中动脉供血及静脉回流的作用及其机制的实验研究

Both the perforator pedicled propeller flap and perforator-plus fasciocutaneous flap in the limbs have been widely used in clinical practice. The distinction in the tissue structure between both flaps lies in that the latter contains the fasciocutaneous pedicle besides the perforator pedicle. If both flaps are based on the same perforator, which one is preferable in reliability and viable dimensions? Whether the role of the fasciocutanoeus pedicle in arterial blood supply and veneous drainage in the latter is positive? What are the degree, pathway and mechanism of the role? These questions remain unclear. This puzzles the suegeons when either flap is choosed in clinic. According to our preliminary clinical experience and pilot experiment in rabbits, we note that the fasciocutanoeus pedicle may play a positive role in the viability of the perforator-plus fasciocutaneous flap, and we hypothesize that this role mainly results from improvement of venous drainage of the flap. We will develop a saphenous artery perforator pedicled flap model and a saphenous artery perforator-plus fascicutaneous flap model in the hind legs of the minipig. Self-control study in the two flaps and randomized controlled study in five kinds of flaps based on differrent pedicles will be carried out. Sevaral methods, including measure of flap survival size, near-infrared fluorescence-guided imaging with indocyanine green, fluorescent microsphere technique, barium sulfate-latex angiography and histological section technique, will be used in this study. We will study the role of the fasciocutanoeus pedicle in arterial supply and veneous drainage of the perforator-plus fascicutaneous flap, and its degree, pathway and haemodynamics mechanism. Our findings will provide guidance and experimental evidence for optimal choice of either flap in clinic.

肢体穿支蒂皮瓣和穿支筋膜（皮肤）蒂皮瓣均在临床上广泛应用。两者间的组织结构差异在于后者还包含筋膜（皮肤）蒂。后者是否比前者成活面积更大尚无定论；筋膜（皮肤）蒂对后者的动脉供血及静脉回流的作用尚不清楚。这些问题造成了临床医生选用这两种皮瓣的困惑。我们在临床及前期兔实验中初步观察到，筋膜（皮肤）蒂对穿支筋膜（皮肤）蒂皮瓣的成活起一定的积极作用，我们推测该作用可能主要是筋膜（皮肤）蒂促进了皮瓣的静脉回流。本课题拟首先在小型猪后肢建立隐动脉穿支蒂皮瓣和隐动脉穿支筋膜皮肤蒂皮瓣模型；采用两种皮瓣自身对照和五种不同蒂部形式皮瓣随机分组比较，通过观察皮瓣成活面积，吲哚菁绿注射后近红外荧光成像，荧光微球灌注，乳胶硫酸钡灌注标本X线摄片，及组织切片等方法，阐明筋膜皮肤蒂在猪隐动脉穿支筋膜皮肤蒂皮瓣中动脉供血及静脉回流的作用及其程度、途径及血流动力学机制，为临床上最佳化选用这两种皮瓣提供实验依据。

研究背景：肢体穿支蒂皮瓣和穿支筋膜（皮肤）蒂皮瓣均在临床上广泛应用。两者间的组织结构差异在于后者还包含筋膜（皮肤）蒂。筋膜（皮肤）蒂对后者的动脉供血及静脉回流的作用尚不清楚。.主要研究内容：在兔的双侧明胶氧化铅灌注的后肢标本，行大体解剖、显微解剖和X线观察。双侧后肢以膝下3.0cm附近穿支血管为旋转点切取皮岛大小为6.0×3.0cm的穿支蒂和穿支筋膜皮肤蒂皮瓣。以膝关节下3cm附近隐血管穿支为旋转点切取皮瓣，根据蒂部不同皮瓣随机分为两组：穿支蒂组切取隐动脉穿支蒂皮瓣，穿支筋膜蒂组切取隐动脉穿支筋膜皮肤蒂皮瓣。术前，术后1h、6h、1d、3d、5d、7d、10d，应用激光多普勒血流仪测量两组皮瓣的血流灌注量。根据蒂部不同随机将皮瓣分为5组，A组（隐动脉穿支蒂皮瓣）、B组（隐动脉穿支筋膜皮肤蒂皮瓣）、C组（结扎隐动脉穿支动、静脉的筋膜皮肤蒂皮瓣）、D组（结扎隐动脉穿支静脉保留穿支动脉的穿支筋膜皮肤蒂皮瓣）、E组（结扎隐动脉穿支动脉保留穿支静脉的穿支筋膜皮肤蒂皮瓣），术后7d观察皮瓣成活率。通过亚甲蓝及泛影葡胺灌注，观察穿支之间的吻合；作为血管蒂的穿支的血供范围；皮瓣内的静脉血回流方式。.重要数据和结果：兔后肢隐血管发出3~5根穿支，膝下3.0cm附近发出的穿支恒定（100%）、粗大（外径0.35±0.05mm）。包含膝下3.0cm附近穿支的皮岛大小为6.0×3.0cm的隐血管穿支蒂皮瓣和穿支筋膜皮肤蒂皮瓣的平均坏死率分别为2.3%和13.5%。穿支蒂组和穿支筋膜蒂组皮瓣的血流灌注量在各区域、各时间点的差异无统计学意义（P>0.05）；两组皮瓣成活率分别为94.0%±11.8%和96.7%±6.9%（P>0.05）。A组、B组、C组、D组和E组皮瓣的平均成活率分别为86.5%±18.2%、97.7%±4.6%、32.8%±26.8%、60.8%±38.4%和51.2%±31.3%（P<0.05）；皮瓣成活率A组高于C组、B组高于C组、B组高于E组，差异均有统计学意义（P<0.05）。.科学意义：以膝下3.0cm附近穿支的兔隐血管穿支蒂皮瓣和穿支筋膜皮肤蒂皮瓣是研究肢体肌间隔穿支蒂皮瓣和穿支筋膜皮肤蒂皮瓣良好的模型。兔隐动脉穿支蒂皮瓣若转换为穿支筋膜皮肤蒂皮瓣不能显著增加皮瓣的成活率和血流灌注量；穿支血管对兔隐动脉穿支筋膜皮肤蒂皮瓣的成活起主要作用，筋膜皮肤蒂起了次要作用。