动力性肌肉游离移植修复晚期面瘫的应用解剖与三维可视化研究
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摘要
研究背景:
晚期面瘫形成的原因复杂,常常给神经、肌肉的修复带来非常大的困难。由于面神经损伤最终导致面肌萎缩、变性,成为无功能的纤维组织,故晚期面瘫修复最常用的术式是带血管神经蒂的动力肌游离移植。
国内外学者已开发出多种带血管神经肌肉游离移植修复面瘫的供区,包括颞肌、胸锁乳突肌、胸小肌、背阔肌、股薄肌、腹内斜肌、前锯肌、股二头肌短头等供区一期或二期法修复部分面部表情。王炜所设计的节段性断层背阔肌游离移植,可一期完成跨面神经移植和带血管神经肌肉移植修复面下2/3瘫,术后效果好,在静态及微笑时两侧表情丰富、对称。杨大平劈开股直肌的两块亚单位Ⅰ期游离移植治疗面瘫,静态与动态下口角对称。
尽管整形外科专家开发了不少肌瓣供区,大部分供肌由于受解剖形态所限,在临床应用上各有其适应性。而背阔肌、前锯肌肌纤维斜行,血供为多源性,支配神经长,股直肌、股薄肌神经血管呈节段性分布,因此背阔肌、前锯肌、股直肌、股薄肌作为供区肌在面瘫的修复中有广阔的前景。肌肉游离移植后肌瓣的臃肿与血肿对面瘫的恢复不利,克服肌瓣的臃肿,获得数目多而细小的肌瓣更有利于面部表情肌的重建。如何对供区进行解剖并获得适合的小面积肌瓣,在术前必须有明确的了解。上述供肌内神经、血管的分布类型、外径、伴行关系等解剖资料尚不全面,影响肌瓣的设计和手术开展,因此有必要对背阔肌、前锯肌、股直肌、股薄肌进一步显微解剖。
带血管神经蒂肌肉游离移植修复面瘫的效果受诸多因素影响,肌瓣的血液供应情况是一个非常重要的方面。肌肉血供的显示以往较常用的方法是墨汁透明法,血管铸型扫描电镜法可拍摄器官结构微血管构筑的立体照片。不少学者在明胶氧化铅血管灌注的基础上进一步采用X片的拍摄,对背阔肌、股直肌、股薄肌等动脉造影,显示出肌内血管的二维图形,肌内血管显示清晰。但这些方法尚难以描述供体肌及其血管、神经的复杂立体关系,不能直观、形象地显示供体肌及其血管、神经的立体构筑,不便于合理地进行分叶肌瓣的术前设计。解剖学、影像学与计算机三维软件的结合使血管的三维可视化成为可能。利用动脉标识技术,CT扫描,选择合适的三维软件重建供区肌内血管与肌瓣的三维数字化模型,是完善肌瓣设计的有效手段。
带血管神经蒂肌肉游离移植修复面瘫的效果与移植肌的收缩力也有非常密切的关系,游离肌肉移植后收缩力过强或过弱影响面部外观和表情。因而术前准确估计达到预期效果所需移植肌大小及术后移植肌收缩效果预测是术者和患者最关心的问题,也是目前尚未解决的难题。有限元分析是模拟软组织变化的最有效的方法。Kober等应用有限元方法模拟分析咀嚼肌的活动形态。周伊顗成功建立了眼球-眼外肌肌肉驱动有限元模型,模拟眼肌的活动,分析眼外肌肌力大小、应力应变分布。如何建立移植肌-下面部皮肤皮下组织有限元模型,进行力加载和位移加载,在模拟分析中达到预期面瘫修复效果所需的移植肌瓣大小及术后移植肌收缩效果,是本研究进一步探讨的方向。
目的:
1.通过背阔肌、前锯肌、股直肌、股薄肌肌内血管神经的显微解剖,观测肌内神经、血管的分布类型、外径、伴行关系及血管神经蒂的长度,为分叶肌瓣与组合肌瓣游离移植修复晚期面瘫提供解剖学资料。
2.构建供体肌及其神经、血管的三维数字化模型,直观、形象地显示血管、神经的走行、分布、吻合与毗邻关系,进行基于肌肉血管、神经构筑的分叶肌瓣立体设计,为分叶肌瓣游离移植修复晚期面瘫提供三维可视化解剖基础和手术参数。
3.建立肌肉驱动的移植肌-下面部皮肤皮下组织复合体三维有限元模型,应用模型模拟分析面瘫动力肌移植所需肌肉大小和术后移植肌收缩效果。材料与方法
1.显微解剖:在20例经血管灌注的防腐与新鲜成人尸体标本上,以佩带式显微镜解剖观察背阔肌、前锯肌、股直肌、股薄肌肌内血管神经分布特点。观测下列指标:①背阔肌的形态特点,背阔肌内神经与血管的分布类型,肌内节段动脉长度、外径与神经支的长度、横径,神经与血管在肌内的伴行关系;②前锯肌的形态特点,前锯肌的动脉来源、分布类型,动脉的外径、长度,胸长神经及其分支的横径、长度及分布特点,血管与神经的毗邻关系;③股直肌的形态特点,股直肌内动脉的来源、长度、外径,动脉的分布类型,神经支的分布特点与肌内的血管神经束;④股薄肌的形态特点,股薄肌内动脉来源、外径、长度,神经支的横径、长度及在肌内的可分离长度,肌内血管神经的毗邻关系。
2.供体肌血管三维重建、神经标示与分叶肌瓣设计:对2具新鲜成人标本采用改良的羧甲基纤维素-氧化铅血管标识技术标识血管,经螺旋CT扫描获得序列Dicom数据,导入Mimics软件,利用软件提供的阈值法、区域生长法、Boolean运算、Mask编辑法等分割工具分割感兴趣结构,面重建肌肉及其血管,并进行基于肌内显微解剖结果的三维神经标示,构建供体肌及其神经、血管的三维数字化模型。通过交互观察、利用模拟手术工具,进行基于肌肉血管、神经构筑的分叶肌瓣立体设计,并测量血管蒂的长度和肌瓣的长度、宽度、厚度。
3.有限元分析:利用Mimics10.0软件平台,进行基于影像的个体化下面部皮肤皮下组织建模,导入ANSYS软件,与基于术前计划或术式的移植肌实体模型进行搭接运算,生成移植肌-皮肤皮下组织复合实体模型;选取单元类型、材料属性,进行自由网格划分,建立肌肉驱动的下面部皮肤皮下组织复合有限元模型;在模型有效性验证满意后,施加约束条件,分别进行27N肌力加载和8mm纵向位移加载求解,观察肌肉收缩效果,估计达到预期效果所需要移植肌的横断面积。
结果:
1.背阔肌、前锯肌、股直肌、股薄肌的显微解剖:
①背阔肌动脉主干长度为25.0±5.8mm,背阔肌动脉内侧支的长度为24.8±6.0mm,起始外径为1.5±0.2mm,外侧支的长度为30.4±8.1mm,起始外径为1.8±0.3mm。背阔肌节段动脉的分布可分为两大类型:第Ⅰ型(均衡型),第Ⅱ型(羽状型)。段动脉分布到相应的节段肌瓣,分为内1段、内2段、内3段、外1段、外2段、外3段、外4段。段动脉的外径大于0.5mm,内侧段动脉较外侧段动脉长。胸背神经在肩胛骨下角平面附近分为内上支与外下支,其分支与段动脉的伴行率90%以上。
②前锯肌肌束在起点的宽度25.7±2.9mm,厚度为6.0±0.7mm,肌束在前锯肌支入肌点处宽度20.7±3.0mm,厚度7.9±0.7mm。胸背动脉前锯肌支一支型占62.5%,二支型占37.5%。第一支前锯肌支的外径为1.5±0.4mm,长度为50.0±5.2mm,第二支前锯肌支的外径为2.0±0.5mm,长度为57.1±6.3mm,分支沿肌束间入肌。胸长神经的横行分支数有3-10支,胸外侧动脉与胸长神经之间相距48.0±6.3mm,胸背动脉的前锯肌支与胸长神经之间末端的距离0-3.3mm。
③股直肌的动脉血管分为3种类型:Ⅰ型,单支优势动脉5%;Ⅱ型,股直肌下动脉为优势血管80%;Ⅲ型,股直肌上动脉或股直肌中动脉与股直肌下动脉均为优势血管占15%。股直肌神经主干长度为14.8±1.3(12.7-17.9)cm,平均外径1.6±0.2mm,股直肌神经支的浅支与深支至股直肌中1/3部内侧缘与股直肌下动脉的前支、后支一起伴行入肌,75%股直肌标本中有神经血管的中间支出现,走行在肌的中1/3部。
④股薄肌上中1/3的血供来源于股深动脉、闭孔动脉、旋股内侧动脉、旋股外侧动脉等。股深动脉发出的股薄肌支是股薄肌上、中1/3部最主要和恒定的血供,管径较粗,在股薄肌上部长度平均达132.9(120.0-155.6)mm。股薄肌下1/3部动脉分支较短较细小。股薄肌神经起始处的横径1.9±0.3(1.3-2.6)mm,从起始处至入肌点的神经主干长度为5.7±0.5(4.3-6.9)cm,股薄肌前部神经支可分离长度为8.6±1.4(6.6-11.7)cm,后部神经支可分离长度为9.4±1.4(6.8-12.8)cm。40%标本的股薄肌内有2个血管神经束,45%股薄肌内有3个以上的血管神经束。
2.供体肌血管三维重建、神经标示与分叶肌瓣设计:①CT图像:二维断面图像清晰、对比度好、无明显伪影,可显示0.5mm细小血管,血管分割容易、定位方便、测量准确。②供体肌-血管-神经三维数字模型:可准确、清楚、立体地显示血管的走行、分布和空间毗邻关系;肌肉内神经的分支分布,神经支与血管的伴行关系均可显示。模型立体感强,直观、形象,能根据需要进行交互观察,任意缩放、旋转、移动,可单独显示或组合显示,还可透明观察和分色观察。③分叶肌瓣的立体设计:肌瓣立体感强,直观、形象;能任意交互观察;可准确测量血管蒂的长度,肌瓣的长、宽、厚度,为手术提供精确参数。背阔肌节段肌瓣的三维模型显示了背阔肌内、外侧区5个节段肌瓣的血管蒂与肌瓣的立体形态,外1段、外2段上部较厚,中下部较薄,内1段较内2段、内3段薄;股直肌可分离为2-3个分叶肌瓣,中间部肌瓣较薄较短;股薄肌内可截取前后2个分叶肌瓣。
3.建立的移植肌-皮肤皮下组织复合体三维有限元模型由移植肌和下面部皮肤皮下组织组成,与CT重建的实体影像比较,几何相似性良好。模型可以任意旋转和缩放,可根据不同研究情况添加肌肉和调整肌肉位置。整个模型共有2978个节点,10666个单元。其中移植肌564个节点,1918个单元,所有单元形态较为规则。以肌力27N加载时,上唇纵向最大位移为3.9047mm,应力应变分布沿肌肉起点至止点渐增加;加载纵向位移8mm分析时,总反作用力即为所需肌力,共为55.431N,求得所需肌肉横断面积约为149.8mm~2。肌肉驱动下面部皮肤皮下组织的运动过程可动画显示,直观逼真。
结论:
1.以背阔肌神经动脉内、外侧支为蒂可剪裁一蒂双叶肌瓣、双蒂双叶肌瓣或一蒂三叶肌瓣;以背阔肌血管前锯肌支为蒂可截取4-5个条束状的肌瓣,以背阔肌血管为蒂可设计背阔肌与前锯肌联合肌瓣:以股直肌神经血管为蒂可将股直肌分离为2-3个分叶肌瓣,以股薄肌神经血管为蒂,可将股薄肌分裂为2-3个分叶肌瓣。这些分叶肌瓣有足够的神经血管蒂长度,可供重建晚期面瘫的面上1/3与面下2/3表情肌功能。
2.在供体肌、血管三维重建的基础上,进行基于相应肌解剖的三维神经标示,可构建出供体肌-血管-神经三维数字模型,直观、形象地显示了肌内神经、血管的主要分支和伴行关系,可进行基于血管神经分布的分叶肌瓣术前的立体设计和观测,为动力肌游离移植修复面瘫提供手术参数,为教学、科研提供数字化模型。
3.基于影像与术前计划或手术所建立的移植肌-下面部皮肤皮下组织有限元模型几何相似性和力学相似性好,为动力肌游离移植修复面瘫手术提供了一种可定量化术前设计、术后效果评估的方法。
主要创新点:
1.通过对晚期面瘫肌移植常用供体肌内、外神经血管的针对性解剖观测,获得有利于供区分叶肌瓣剪裁设计的系统性解剖学资料,为动力肌游离移植修复晚期面瘫提供形态学基础。
2.在供体肌、血管三维重建的基础上,进行基于相应肌解剖的三维神经标示,构建出供体肌-血管-神经三维数字模型。该模型直观、形象地显示了肌内神经、血管的主要分支分布及神经、血管的大致伴行关系。
3.提出了基于血管、神经分支分布立体设计分叶肌瓣的新理念,在供体肌-血管-神经三维数字模型上进行分叶肌瓣的立体设计和测量,为动力肌游离移植修复晚期面瘫提供了手术参数,可为教学、科研提供数字模型。
4.首次建立了肌肉驱动的移植肌-下面部皮肤皮下组织复合体三维有限元模型,为动力肌游离移植修复晚期面瘫手术提供了可定量化术前设计、术后效果评估的方法。
Background:
Facial paralysis is syndrome of autokinetic movement and functional incapacitation in emotional expression caused by surgical trauma,edema, inflammation,tumor and operation in which make irreversibility injury of facial nerve.Injury of facial nerve ultimately induces facial muscles to myatrophy, denaturation and nonfunctioning fibrous tissue.Patients with facial paralysis may experience several limitations.They may have difficulty with speech,eating and may experience drooling.Furthermore,these patients may have significant ophthalmic complications from loss of the blink reflex,upper and lower eyelid retraction and lagophthalmos.It is our challenging goal as reconstructive surgeon to reestablish facial symmetry,tone and coordinated animation of the paralyzed face.Several procedures to restore facial function had been advocated in the past.Complicated reconstruction of late facial palsy may need rectification many times.It is badly in need of uncovering ideal donor site to simultaneously repair upper 1/3 and lower 2/3 facial muscle function.
With the development of microsurgical technique,neurovascular free-muscle transferd to treat facial paralysis has been a favourite procedure for facial animation. The donor sites include temporalis,latissimus dorsi muscle,gracilis,serratus anterior muscle,sternocleidomastoid,pectoralis minor and caput breve musculi bicipitis femoris.Wang wei utilized one-stage microvascular free transfer of the split latissimus dorsi muscle for reanimation of long-standing facial paralysis.The procedure was focused on the distortion of commissure.It was evaluated regarding symmetry and balance of facial tone at rest,sufficient muscle power upon voluntary contraction,synchronicity and naturalness of expression upon emotional facial movements,especially upon smiling,and given a score according to the Harii's Grading Scale.As a result,the operation provided a natural or near-natural smile.To overcome drawbacks of the two-stage method,Da Ping Yang used split rectus femoris muscle to reconstruct symmetric smile.
To sum up,there is a broad spectrum of dynamic and static reconstructive techniques available to reanimate the paralyzed face,part of them was limited to clinical application.Although voluntary movement may be improved,no method restores the lost spontaneous involuntary movement associated with emotion.The suitability of each restorative technique is related to the location,cause,duration of the facial nerve injury and prognosis of the patients.Furtheremore,anatomy of donor muscle flap has intimate correlation with the effect of reconstruction.The latissimus dorsi muscle and serratus anterior muscle are not only characterized by oblique muscle fiber but also have abundant blood supply and long nerve pedicle.According to the reports,rectus femoris muscle and gracilis are more suitable to reconstruction of facial paralysis,in which consist of segmented distribution of vascular nerve. However,there are some unfavourable factors such as clumsy flap and hematoma muscle,which need surgical revision.Enough petty musle flap units profit to facial muscles reconstruction.So,the microdissection of latissimus dorsi muscle,serratus anterior muscle,rectus femoris muscle and gracilis is necessary.
The clinical effect of surgical recovery from facial paralysis is influenced by many factors,among which blood supply of donor muscle plays an important role. Intramuscularly vascular anastomotic mode and blood-supply area irritating are mainly based on the range of perfused ink in blood vessel.Stereophotograph of micro-angioarchitecture can be demonstrated by scanning electron microscope.
Vascular injection of a radiopaque medium is a rapid and precise technique,and the modified vascular injection technique with gelatin lead-oxide mixture,in particular, can provide excellent 2D images of the blood vessels subjected to X-ray.But the two-dimensional images cannot display the three-dimensional distribution and relationship of the intramuscularly blood vessels.The combination of anatomy, imageology,and computer technique makes it possible for 3D visualization of blood vessels.Focusing on the design of segmented muscle flaps,the methods of perfusing with red latex,modern technique in imageology and computer image processing are utilized to reconstruct of 3D models of intramuscularly blood vessels.
The post-operated effect of surgical repairing facial paralysis is interesting to both the doctor and patients.In the procedure of muscle transfer,excess or poor contraction force of the donor muscle has disadvantages to expressional symmetry. Although the size and constriction of segmental muscle flaps have influences on the effect of reconstruction,it is hard to estimate pre-operation.Finite element analysis is the most effect method in simulating the contraction of soft tissue.Kober displayed the action of masticatory muscles with ANSYS software.Zhou Yiyi established the finite element models of eyeball and ocular muscles,exerted outside forces on the structure for nonlinear computation and got the distributions of displacement,stress and strain,discussed the relationship among eye's structure,outside force and move. The results corresponded with the basic theory of ophthalmologyand imulae their loads and movements according to their normal or abnormal status.By the methods of computer tomography,image processing,3D reconstruction wih CAD modeling and FEA,the construction of finite element model of complex transplanted muscleskin of lower face drived by constriction and displacement can be completed,and we will testify whether it can analyse the size and constraction of segmented muscle flap or not during sham operated.
Objective:
1.To provide morphology basis of latissimus dorsi muscle,serratus anterior muscle,rectus femoris muscle,gracilis and get segmental and combined muscle flaps.
2.To explore the 3D model and design of segmented latissimus dorsi muscle, rectus femoris muscle,and gracilis muscle flaps.
3.To set up finite element model of complex transplanted-muscle and skin of lower face driving by facial muscles,simulate and analyse the muscle contraction and displacement during sham operated.
Method:
1.Microdissection:The morphological features of latissimus dorsi muscle, serratus anterior muscle,rectus femoris muscle,gracilis were observed and measured on 20 adult cadavers,the following indexes were observed:distribution pattern of the intramuscularly artery,separated length of nerve branch,the relationship between the intramuscularly artery and nerve branch.The length and outside diameter of the artery and nerve branch were measured.
2.3D reconstruction of artery in donor muscle,mark of nerve branch and design of segmented muscle flap:first,2 fresh adult cadaver specimens were perfused with modified lead oxide-gelatine mixture,then subjected to CT,and then the latissimus dorsi muscle,rectus femoris muscle,gracilis were dissected,scaned by computer tomography again.The images of CT scanning of the latissimus dorsi muscle,rectus femoris muscle and gracilis were digitally analyzed using MIMICS 10.0 software. The CT images were firstly segmented by using segmentation tools,such as thresholding,region growing,dynamic region growing,Boolean operations,edit masks to extract different tissues.Then the 3D models of latissimus dorsi muscle, rectus femoris muscle,gracilis and their arteries were reconstructed.The nerve branchs were marked according the microdissection to get 3D models of the muscles and intramuscular blood vessels and nerve branch.The 3D models of segmented muscle flaps were designed in 3D space,and the length,width and thickness of the neurovascular pedicle were measured.
3.Finite element analysis:The dicom data of head and face got by computerized tomography was imported to Mimics10.0.Subdivision and 3D model of the skin of lower face was reconstructed.Subsequently,the 3D model of lower face and the model of transplanted-musle were calculated by lap joint.After seting up compound solid model of transplanted-muscle and skin of lower face,choosed the type of the unite,attribute of materials,divided free mesh and built finite element model of transplanted-muscle and skin of lower face.The efficacy of the finite element model was testified,exerted constrained condition by loaded with 27N muscle force and 8mm displacement in lenth wise.Then the effect of muscle constriction was observed,the area of cross section of transplanted-muscle was estimated in order to get good results in muscle transfer for facial paralysis.
Results:
1.Microdissection of latissimus dorsi muscle,serratus anterior muscle,rectus femoris muscle and gracilis:
①The length of latissimus dorsi artery was 25.0±5.8 mm.The length of medial branch of latissimus dorsi artery was 24.8±6.0 mm and its origin outside diameter was 1.5±0.2 mm.The length of lateral branch of latissimus dorsi artery was 30.4±8.1 mm and its origin outside diameter was 1.8±0.3 mm.There were two types of artery attribution:balanced type and plumatus type.The segmented artery attributed to the segmented muscle flap.It consisted of the first medial segment,the second medial segment,the third medial segment,the first lateral segment,the second lateral segment,the third lateral segment,the fourth lateral segment.The outside diameter of segmental artery was over 0.5 mm and the medial segmented arteries were longer than lateral arteries.The thoracodorsal nerve had two funicles that independently innervated to the medial and lateral portions of the muscle at inferior angle of scapula.The rate of comitant relationship between artery and nerve branch was over 90%.
②The muscle bundle of serratus anterior muscle was 25.7±2.9 mm,6.0±0.7 mm in width and thickness at starting point,while at the insertion was 20.7±3.0 mm and 7.9±0.7 mm.62.5 percent cases were consistently supplied by a single dominant branch of the thoracodorsal artery and innervated by the long thoracic nerve and 37.5%specimens were supplied by two branches of the thoracodorsal artery.The first and second serratus artery was respectively 2.0±0.5 mm,1.5±0.4 mm in outside diameter and 50.0±5.2 mm,57.1±6.3 mm in length.The laterigrade branch of long thoracic nerve was 3-10.The distance between lateral thoracic artery and long thoracic nerve was 48.0±6.3 mm,while it was 0-3.3 mm in distance between the terminal of long thoracic nerve and serratus artery.
③The rectus femoris muscle consisted of three intramuscular vascular patterns: The rectus femoris muscle received a single vascular pedicle(5 percent),a dominant vascular pedicle,inferior artery of rectus femoris muscle(80 percent),or two dominant vascular pedicles,the superior artery or middle artery and inferior artery of rectus femoris muscle(15 percent).The rectus femoris nerve was 14.8±1.3 (12.7-17.9) cm in length and 1.6±0.2 mm in outside diameter.The superficial branch and deep branch of rectus femoris nerve was accompanied with anterior branch and posterior branch of rectus femoris inferior artery at the middle part of rectus femoris. 75 percent of specimens had middle neurovascular branch.
④The blood supply of upper and middle 1/3 part of gracilis muscle came from deep femoral artery.The gracilis branch of deep femoral artery was 3.0(2.2～4.3) mm in origin diameter and 132.9(120.0～155.6) mm in length.The gracilis nerve was 1.9±0.3(1.3-2.6) mm in transverse diameter and 5.7±0.5(4.3-6.9) cm in length.The separated length of anterior gracilis nerve branch was 8.6±1.4(6.6-11.7) cm and the posterior gracilis nerve branch was 9.4±1.4(6.8-12.8) cm.There were 2 neurovascular tracts in 40 percents specimen and above 3 neurovascular tracts in 45 percents specimen.
2.3D reconstruction of artery in donor muscle,mark of nerve branch and design of segmented muscle flap:①The transverse images of modified lead-oxide filled arteries had a distinct rim and a steady density.There were no obvious constructed defects like“burring”,“vacuolus”in the 2D images.The thresholding-based segmentation of the blood vessels was simple and accurate.Minute blood vessel in 0.5 mm can be displayed,segmented and measured.②the 3D model of artery were very clear,smooth and continuous.The modality,spatial location and the adjacent relationship of arteries and nerve branch were perfectly visualized.The 3D model also displayed the branching,distribution of the nerve branchs and their relationship with aretry.All reconstructed structures could be displayed separately,in a group or as a whole.They could also be shown in different color modes,transparent styles and various vascular densities by adjusting parameters.③The 3D models of segmented muscle flaps in latissimus dorsi muscle,rectus femoris muscle and gracilis displayed intramuscularly pedicle of blood supply,nerve branch and morphous of the muscle flap.The 3D model of segmented latissimus dorsi muscle flap demonstrated segmented artery of medial branch and lateral branch.It also reflected three-dimensional morphous of the muscle flap,in which the superior part of the first and second lateral segmented muscle flaps were thicker than the middle and inferior parts,and the medial part of the first segmented muscle flap was thinner than the second and the third segmented muscle flaps.The rectus femoris muscle was split into 2-3 segmented muscle flaps and the middle sub-muscle flap was shorter and thinner than the others.The gracilis can be split to anterior and posterior muscle flaps.
3.The compound transplanted muscle and inferior prosopo-skin 3D finite element model consisted of donor muscle and inferior prosopo-skin,which had good geometric similarity with the entity image.The model can be rotated and zoomed arbitrarily,added and regulated the muscle.It had well arranged 2978 nodes and 10666 units,among them including 564 nodes and 1918 units.Loading with 27N,the biggest displacement in length was 3.9047 mm,while Loading with 8mm,the biggest muscle force was 55.431N,which whould get from transplanted muscle with 149.8mm area of cross section.
Conclusions:
1.Having an intimate knowledge of microanatomy about the latissimus dorsi muscle,serratus anterior muscle,rectus femoris muscle and gracilis had helpful for reconstruction of facial muscle with segmented units of these muscles.①With the pedicle of the segmented vascular nerve,the latissimus dorsi muscle was split to double sub-muscle flaps with single pedicle or double pedicles or three sub-muscle flaps with one pedicle.②With the pedicle of serratus anterior artery,serratus anterior muscle was split to 4-5 fascicularis muscle flaps.With the pedicle of latissimus dorsi artery,the combined latissimus dorsi muscle and serratus anterior muscle flap was designed.③The rectus femoris can be split to 2-3 segmented muscle flaps with the pedicle of rectus femoris nerve and artery.④The gracilis was split to 2-3 segmented muscle flaps with the pedicle of gracilis nerve and artery.
2.The carboxymethyl cellulose-lead oxide was favourable material in blood vessel perfusion.With the arteriography and MIMICS software,3D reconstruction of intramuscularly artery had been succeeded.The 3D model of segmented latissimus dorsi muscle,rectus femoris muscle and the gracilis muscle flap can be used for design of muscle transfer.
3.The complex 3D finite element model of the transfer-muscle and lower skin of face based on entity image and preoperative plan had good geometric similarity and mechanics similarity.It can be applied to quantify the design of pre-operation and evaluate the effect of free muscle transfer for the treatment of long-standing facial paralysis.
晚期面瘫形成的原因复杂,常常给神经、肌肉的修复带来非常大的困难。由于面神经损伤最终导致面肌萎缩、变性,成为无功能的纤维组织,故晚期面瘫修复最常用的术式是带血管神经蒂的动力肌游离移植。
国内外学者已开发出多种带血管神经肌肉游离移植修复面瘫的供区,包括颞肌、胸锁乳突肌、胸小肌、背阔肌、股薄肌、腹内斜肌、前锯肌、股二头肌短头等供区一期或二期法修复部分面部表情。王炜所设计的节段性断层背阔肌游离移植,可一期完成跨面神经移植和带血管神经肌肉移植修复面下2/3瘫,术后效果好,在静态及微笑时两侧表情丰富、对称。杨大平劈开股直肌的两块亚单位Ⅰ期游离移植治疗面瘫,静态与动态下口角对称。
尽管整形外科专家开发了不少肌瓣供区,大部分供肌由于受解剖形态所限,在临床应用上各有其适应性。而背阔肌、前锯肌肌纤维斜行,血供为多源性,支配神经长,股直肌、股薄肌神经血管呈节段性分布,因此背阔肌、前锯肌、股直肌、股薄肌作为供区肌在面瘫的修复中有广阔的前景。肌肉游离移植后肌瓣的臃肿与血肿对面瘫的恢复不利,克服肌瓣的臃肿,获得数目多而细小的肌瓣更有利于面部表情肌的重建。如何对供区进行解剖并获得适合的小面积肌瓣,在术前必须有明确的了解。上述供肌内神经、血管的分布类型、外径、伴行关系等解剖资料尚不全面,影响肌瓣的设计和手术开展,因此有必要对背阔肌、前锯肌、股直肌、股薄肌进一步显微解剖。
带血管神经蒂肌肉游离移植修复面瘫的效果受诸多因素影响,肌瓣的血液供应情况是一个非常重要的方面。肌肉血供的显示以往较常用的方法是墨汁透明法,血管铸型扫描电镜法可拍摄器官结构微血管构筑的立体照片。不少学者在明胶氧化铅血管灌注的基础上进一步采用X片的拍摄,对背阔肌、股直肌、股薄肌等动脉造影,显示出肌内血管的二维图形,肌内血管显示清晰。但这些方法尚难以描述供体肌及其血管、神经的复杂立体关系,不能直观、形象地显示供体肌及其血管、神经的立体构筑,不便于合理地进行分叶肌瓣的术前设计。解剖学、影像学与计算机三维软件的结合使血管的三维可视化成为可能。利用动脉标识技术,CT扫描,选择合适的三维软件重建供区肌内血管与肌瓣的三维数字化模型,是完善肌瓣设计的有效手段。
带血管神经蒂肌肉游离移植修复面瘫的效果与移植肌的收缩力也有非常密切的关系,游离肌肉移植后收缩力过强或过弱影响面部外观和表情。因而术前准确估计达到预期效果所需移植肌大小及术后移植肌收缩效果预测是术者和患者最关心的问题,也是目前尚未解决的难题。有限元分析是模拟软组织变化的最有效的方法。Kober等应用有限元方法模拟分析咀嚼肌的活动形态。周伊顗成功建立了眼球-眼外肌肌肉驱动有限元模型,模拟眼肌的活动,分析眼外肌肌力大小、应力应变分布。如何建立移植肌-下面部皮肤皮下组织有限元模型,进行力加载和位移加载,在模拟分析中达到预期面瘫修复效果所需的移植肌瓣大小及术后移植肌收缩效果,是本研究进一步探讨的方向。
目的:
1.通过背阔肌、前锯肌、股直肌、股薄肌肌内血管神经的显微解剖,观测肌内神经、血管的分布类型、外径、伴行关系及血管神经蒂的长度,为分叶肌瓣与组合肌瓣游离移植修复晚期面瘫提供解剖学资料。
2.构建供体肌及其神经、血管的三维数字化模型,直观、形象地显示血管、神经的走行、分布、吻合与毗邻关系,进行基于肌肉血管、神经构筑的分叶肌瓣立体设计,为分叶肌瓣游离移植修复晚期面瘫提供三维可视化解剖基础和手术参数。
3.建立肌肉驱动的移植肌-下面部皮肤皮下组织复合体三维有限元模型,应用模型模拟分析面瘫动力肌移植所需肌肉大小和术后移植肌收缩效果。材料与方法
1.显微解剖:在20例经血管灌注的防腐与新鲜成人尸体标本上,以佩带式显微镜解剖观察背阔肌、前锯肌、股直肌、股薄肌肌内血管神经分布特点。观测下列指标:①背阔肌的形态特点,背阔肌内神经与血管的分布类型,肌内节段动脉长度、外径与神经支的长度、横径,神经与血管在肌内的伴行关系;②前锯肌的形态特点,前锯肌的动脉来源、分布类型,动脉的外径、长度,胸长神经及其分支的横径、长度及分布特点,血管与神经的毗邻关系;③股直肌的形态特点,股直肌内动脉的来源、长度、外径,动脉的分布类型,神经支的分布特点与肌内的血管神经束;④股薄肌的形态特点,股薄肌内动脉来源、外径、长度,神经支的横径、长度及在肌内的可分离长度,肌内血管神经的毗邻关系。
2.供体肌血管三维重建、神经标示与分叶肌瓣设计:对2具新鲜成人标本采用改良的羧甲基纤维素-氧化铅血管标识技术标识血管,经螺旋CT扫描获得序列Dicom数据,导入Mimics软件,利用软件提供的阈值法、区域生长法、Boolean运算、Mask编辑法等分割工具分割感兴趣结构,面重建肌肉及其血管,并进行基于肌内显微解剖结果的三维神经标示,构建供体肌及其神经、血管的三维数字化模型。通过交互观察、利用模拟手术工具,进行基于肌肉血管、神经构筑的分叶肌瓣立体设计,并测量血管蒂的长度和肌瓣的长度、宽度、厚度。
3.有限元分析:利用Mimics10.0软件平台,进行基于影像的个体化下面部皮肤皮下组织建模,导入ANSYS软件,与基于术前计划或术式的移植肌实体模型进行搭接运算,生成移植肌-皮肤皮下组织复合实体模型;选取单元类型、材料属性,进行自由网格划分,建立肌肉驱动的下面部皮肤皮下组织复合有限元模型;在模型有效性验证满意后,施加约束条件,分别进行27N肌力加载和8mm纵向位移加载求解,观察肌肉收缩效果,估计达到预期效果所需要移植肌的横断面积。
结果:
1.背阔肌、前锯肌、股直肌、股薄肌的显微解剖:
①背阔肌动脉主干长度为25.0±5.8mm,背阔肌动脉内侧支的长度为24.8±6.0mm,起始外径为1.5±0.2mm,外侧支的长度为30.4±8.1mm,起始外径为1.8±0.3mm。背阔肌节段动脉的分布可分为两大类型:第Ⅰ型(均衡型),第Ⅱ型(羽状型)。段动脉分布到相应的节段肌瓣,分为内1段、内2段、内3段、外1段、外2段、外3段、外4段。段动脉的外径大于0.5mm,内侧段动脉较外侧段动脉长。胸背神经在肩胛骨下角平面附近分为内上支与外下支,其分支与段动脉的伴行率90%以上。
②前锯肌肌束在起点的宽度25.7±2.9mm,厚度为6.0±0.7mm,肌束在前锯肌支入肌点处宽度20.7±3.0mm,厚度7.9±0.7mm。胸背动脉前锯肌支一支型占62.5%,二支型占37.5%。第一支前锯肌支的外径为1.5±0.4mm,长度为50.0±5.2mm,第二支前锯肌支的外径为2.0±0.5mm,长度为57.1±6.3mm,分支沿肌束间入肌。胸长神经的横行分支数有3-10支,胸外侧动脉与胸长神经之间相距48.0±6.3mm,胸背动脉的前锯肌支与胸长神经之间末端的距离0-3.3mm。
③股直肌的动脉血管分为3种类型:Ⅰ型,单支优势动脉5%;Ⅱ型,股直肌下动脉为优势血管80%;Ⅲ型,股直肌上动脉或股直肌中动脉与股直肌下动脉均为优势血管占15%。股直肌神经主干长度为14.8±1.3(12.7-17.9)cm,平均外径1.6±0.2mm,股直肌神经支的浅支与深支至股直肌中1/3部内侧缘与股直肌下动脉的前支、后支一起伴行入肌,75%股直肌标本中有神经血管的中间支出现,走行在肌的中1/3部。
④股薄肌上中1/3的血供来源于股深动脉、闭孔动脉、旋股内侧动脉、旋股外侧动脉等。股深动脉发出的股薄肌支是股薄肌上、中1/3部最主要和恒定的血供,管径较粗,在股薄肌上部长度平均达132.9(120.0-155.6)mm。股薄肌下1/3部动脉分支较短较细小。股薄肌神经起始处的横径1.9±0.3(1.3-2.6)mm,从起始处至入肌点的神经主干长度为5.7±0.5(4.3-6.9)cm,股薄肌前部神经支可分离长度为8.6±1.4(6.6-11.7)cm,后部神经支可分离长度为9.4±1.4(6.8-12.8)cm。40%标本的股薄肌内有2个血管神经束,45%股薄肌内有3个以上的血管神经束。
2.供体肌血管三维重建、神经标示与分叶肌瓣设计:①CT图像:二维断面图像清晰、对比度好、无明显伪影,可显示0.5mm细小血管,血管分割容易、定位方便、测量准确。②供体肌-血管-神经三维数字模型:可准确、清楚、立体地显示血管的走行、分布和空间毗邻关系;肌肉内神经的分支分布,神经支与血管的伴行关系均可显示。模型立体感强,直观、形象,能根据需要进行交互观察,任意缩放、旋转、移动,可单独显示或组合显示,还可透明观察和分色观察。③分叶肌瓣的立体设计:肌瓣立体感强,直观、形象;能任意交互观察;可准确测量血管蒂的长度,肌瓣的长、宽、厚度,为手术提供精确参数。背阔肌节段肌瓣的三维模型显示了背阔肌内、外侧区5个节段肌瓣的血管蒂与肌瓣的立体形态,外1段、外2段上部较厚,中下部较薄,内1段较内2段、内3段薄;股直肌可分离为2-3个分叶肌瓣,中间部肌瓣较薄较短;股薄肌内可截取前后2个分叶肌瓣。
3.建立的移植肌-皮肤皮下组织复合体三维有限元模型由移植肌和下面部皮肤皮下组织组成,与CT重建的实体影像比较,几何相似性良好。模型可以任意旋转和缩放,可根据不同研究情况添加肌肉和调整肌肉位置。整个模型共有2978个节点,10666个单元。其中移植肌564个节点,1918个单元,所有单元形态较为规则。以肌力27N加载时,上唇纵向最大位移为3.9047mm,应力应变分布沿肌肉起点至止点渐增加;加载纵向位移8mm分析时,总反作用力即为所需肌力,共为55.431N,求得所需肌肉横断面积约为149.8mm~2。肌肉驱动下面部皮肤皮下组织的运动过程可动画显示,直观逼真。
结论:
1.以背阔肌神经动脉内、外侧支为蒂可剪裁一蒂双叶肌瓣、双蒂双叶肌瓣或一蒂三叶肌瓣;以背阔肌血管前锯肌支为蒂可截取4-5个条束状的肌瓣,以背阔肌血管为蒂可设计背阔肌与前锯肌联合肌瓣:以股直肌神经血管为蒂可将股直肌分离为2-3个分叶肌瓣,以股薄肌神经血管为蒂,可将股薄肌分裂为2-3个分叶肌瓣。这些分叶肌瓣有足够的神经血管蒂长度,可供重建晚期面瘫的面上1/3与面下2/3表情肌功能。
2.在供体肌、血管三维重建的基础上,进行基于相应肌解剖的三维神经标示,可构建出供体肌-血管-神经三维数字模型,直观、形象地显示了肌内神经、血管的主要分支和伴行关系,可进行基于血管神经分布的分叶肌瓣术前的立体设计和观测,为动力肌游离移植修复面瘫提供手术参数,为教学、科研提供数字化模型。
3.基于影像与术前计划或手术所建立的移植肌-下面部皮肤皮下组织有限元模型几何相似性和力学相似性好,为动力肌游离移植修复面瘫手术提供了一种可定量化术前设计、术后效果评估的方法。
主要创新点:
1.通过对晚期面瘫肌移植常用供体肌内、外神经血管的针对性解剖观测,获得有利于供区分叶肌瓣剪裁设计的系统性解剖学资料,为动力肌游离移植修复晚期面瘫提供形态学基础。
2.在供体肌、血管三维重建的基础上,进行基于相应肌解剖的三维神经标示,构建出供体肌-血管-神经三维数字模型。该模型直观、形象地显示了肌内神经、血管的主要分支分布及神经、血管的大致伴行关系。
3.提出了基于血管、神经分支分布立体设计分叶肌瓣的新理念,在供体肌-血管-神经三维数字模型上进行分叶肌瓣的立体设计和测量,为动力肌游离移植修复晚期面瘫提供了手术参数,可为教学、科研提供数字模型。
4.首次建立了肌肉驱动的移植肌-下面部皮肤皮下组织复合体三维有限元模型,为动力肌游离移植修复晚期面瘫手术提供了可定量化术前设计、术后效果评估的方法。
Background:
Facial paralysis is syndrome of autokinetic movement and functional incapacitation in emotional expression caused by surgical trauma,edema, inflammation,tumor and operation in which make irreversibility injury of facial nerve.Injury of facial nerve ultimately induces facial muscles to myatrophy, denaturation and nonfunctioning fibrous tissue.Patients with facial paralysis may experience several limitations.They may have difficulty with speech,eating and may experience drooling.Furthermore,these patients may have significant ophthalmic complications from loss of the blink reflex,upper and lower eyelid retraction and lagophthalmos.It is our challenging goal as reconstructive surgeon to reestablish facial symmetry,tone and coordinated animation of the paralyzed face.Several procedures to restore facial function had been advocated in the past.Complicated reconstruction of late facial palsy may need rectification many times.It is badly in need of uncovering ideal donor site to simultaneously repair upper 1/3 and lower 2/3 facial muscle function.
With the development of microsurgical technique,neurovascular free-muscle transferd to treat facial paralysis has been a favourite procedure for facial animation. The donor sites include temporalis,latissimus dorsi muscle,gracilis,serratus anterior muscle,sternocleidomastoid,pectoralis minor and caput breve musculi bicipitis femoris.Wang wei utilized one-stage microvascular free transfer of the split latissimus dorsi muscle for reanimation of long-standing facial paralysis.The procedure was focused on the distortion of commissure.It was evaluated regarding symmetry and balance of facial tone at rest,sufficient muscle power upon voluntary contraction,synchronicity and naturalness of expression upon emotional facial movements,especially upon smiling,and given a score according to the Harii's Grading Scale.As a result,the operation provided a natural or near-natural smile.To overcome drawbacks of the two-stage method,Da Ping Yang used split rectus femoris muscle to reconstruct symmetric smile.
To sum up,there is a broad spectrum of dynamic and static reconstructive techniques available to reanimate the paralyzed face,part of them was limited to clinical application.Although voluntary movement may be improved,no method restores the lost spontaneous involuntary movement associated with emotion.The suitability of each restorative technique is related to the location,cause,duration of the facial nerve injury and prognosis of the patients.Furtheremore,anatomy of donor muscle flap has intimate correlation with the effect of reconstruction.The latissimus dorsi muscle and serratus anterior muscle are not only characterized by oblique muscle fiber but also have abundant blood supply and long nerve pedicle.According to the reports,rectus femoris muscle and gracilis are more suitable to reconstruction of facial paralysis,in which consist of segmented distribution of vascular nerve. However,there are some unfavourable factors such as clumsy flap and hematoma muscle,which need surgical revision.Enough petty musle flap units profit to facial muscles reconstruction.So,the microdissection of latissimus dorsi muscle,serratus anterior muscle,rectus femoris muscle and gracilis is necessary.
The clinical effect of surgical recovery from facial paralysis is influenced by many factors,among which blood supply of donor muscle plays an important role. Intramuscularly vascular anastomotic mode and blood-supply area irritating are mainly based on the range of perfused ink in blood vessel.Stereophotograph of micro-angioarchitecture can be demonstrated by scanning electron microscope.
Vascular injection of a radiopaque medium is a rapid and precise technique,and the modified vascular injection technique with gelatin lead-oxide mixture,in particular, can provide excellent 2D images of the blood vessels subjected to X-ray.But the two-dimensional images cannot display the three-dimensional distribution and relationship of the intramuscularly blood vessels.The combination of anatomy, imageology,and computer technique makes it possible for 3D visualization of blood vessels.Focusing on the design of segmented muscle flaps,the methods of perfusing with red latex,modern technique in imageology and computer image processing are utilized to reconstruct of 3D models of intramuscularly blood vessels.
The post-operated effect of surgical repairing facial paralysis is interesting to both the doctor and patients.In the procedure of muscle transfer,excess or poor contraction force of the donor muscle has disadvantages to expressional symmetry. Although the size and constriction of segmental muscle flaps have influences on the effect of reconstruction,it is hard to estimate pre-operation.Finite element analysis is the most effect method in simulating the contraction of soft tissue.Kober displayed the action of masticatory muscles with ANSYS software.Zhou Yiyi established the finite element models of eyeball and ocular muscles,exerted outside forces on the structure for nonlinear computation and got the distributions of displacement,stress and strain,discussed the relationship among eye's structure,outside force and move. The results corresponded with the basic theory of ophthalmologyand imulae their loads and movements according to their normal or abnormal status.By the methods of computer tomography,image processing,3D reconstruction wih CAD modeling and FEA,the construction of finite element model of complex transplanted muscleskin of lower face drived by constriction and displacement can be completed,and we will testify whether it can analyse the size and constraction of segmented muscle flap or not during sham operated.
Objective:
1.To provide morphology basis of latissimus dorsi muscle,serratus anterior muscle,rectus femoris muscle,gracilis and get segmental and combined muscle flaps.
2.To explore the 3D model and design of segmented latissimus dorsi muscle, rectus femoris muscle,and gracilis muscle flaps.
3.To set up finite element model of complex transplanted-muscle and skin of lower face driving by facial muscles,simulate and analyse the muscle contraction and displacement during sham operated.
Method:
1.Microdissection:The morphological features of latissimus dorsi muscle, serratus anterior muscle,rectus femoris muscle,gracilis were observed and measured on 20 adult cadavers,the following indexes were observed:distribution pattern of the intramuscularly artery,separated length of nerve branch,the relationship between the intramuscularly artery and nerve branch.The length and outside diameter of the artery and nerve branch were measured.
2.3D reconstruction of artery in donor muscle,mark of nerve branch and design of segmented muscle flap:first,2 fresh adult cadaver specimens were perfused with modified lead oxide-gelatine mixture,then subjected to CT,and then the latissimus dorsi muscle,rectus femoris muscle,gracilis were dissected,scaned by computer tomography again.The images of CT scanning of the latissimus dorsi muscle,rectus femoris muscle and gracilis were digitally analyzed using MIMICS 10.0 software. The CT images were firstly segmented by using segmentation tools,such as thresholding,region growing,dynamic region growing,Boolean operations,edit masks to extract different tissues.Then the 3D models of latissimus dorsi muscle, rectus femoris muscle,gracilis and their arteries were reconstructed.The nerve branchs were marked according the microdissection to get 3D models of the muscles and intramuscular blood vessels and nerve branch.The 3D models of segmented muscle flaps were designed in 3D space,and the length,width and thickness of the neurovascular pedicle were measured.
3.Finite element analysis:The dicom data of head and face got by computerized tomography was imported to Mimics10.0.Subdivision and 3D model of the skin of lower face was reconstructed.Subsequently,the 3D model of lower face and the model of transplanted-musle were calculated by lap joint.After seting up compound solid model of transplanted-muscle and skin of lower face,choosed the type of the unite,attribute of materials,divided free mesh and built finite element model of transplanted-muscle and skin of lower face.The efficacy of the finite element model was testified,exerted constrained condition by loaded with 27N muscle force and 8mm displacement in lenth wise.Then the effect of muscle constriction was observed,the area of cross section of transplanted-muscle was estimated in order to get good results in muscle transfer for facial paralysis.
Results:
1.Microdissection of latissimus dorsi muscle,serratus anterior muscle,rectus femoris muscle and gracilis:
①The length of latissimus dorsi artery was 25.0±5.8 mm.The length of medial branch of latissimus dorsi artery was 24.8±6.0 mm and its origin outside diameter was 1.5±0.2 mm.The length of lateral branch of latissimus dorsi artery was 30.4±8.1 mm and its origin outside diameter was 1.8±0.3 mm.There were two types of artery attribution:balanced type and plumatus type.The segmented artery attributed to the segmented muscle flap.It consisted of the first medial segment,the second medial segment,the third medial segment,the first lateral segment,the second lateral segment,the third lateral segment,the fourth lateral segment.The outside diameter of segmental artery was over 0.5 mm and the medial segmented arteries were longer than lateral arteries.The thoracodorsal nerve had two funicles that independently innervated to the medial and lateral portions of the muscle at inferior angle of scapula.The rate of comitant relationship between artery and nerve branch was over 90%.
②The muscle bundle of serratus anterior muscle was 25.7±2.9 mm,6.0±0.7 mm in width and thickness at starting point,while at the insertion was 20.7±3.0 mm and 7.9±0.7 mm.62.5 percent cases were consistently supplied by a single dominant branch of the thoracodorsal artery and innervated by the long thoracic nerve and 37.5%specimens were supplied by two branches of the thoracodorsal artery.The first and second serratus artery was respectively 2.0±0.5 mm,1.5±0.4 mm in outside diameter and 50.0±5.2 mm,57.1±6.3 mm in length.The laterigrade branch of long thoracic nerve was 3-10.The distance between lateral thoracic artery and long thoracic nerve was 48.0±6.3 mm,while it was 0-3.3 mm in distance between the terminal of long thoracic nerve and serratus artery.
③The rectus femoris muscle consisted of three intramuscular vascular patterns: The rectus femoris muscle received a single vascular pedicle(5 percent),a dominant vascular pedicle,inferior artery of rectus femoris muscle(80 percent),or two dominant vascular pedicles,the superior artery or middle artery and inferior artery of rectus femoris muscle(15 percent).The rectus femoris nerve was 14.8±1.3 (12.7-17.9) cm in length and 1.6±0.2 mm in outside diameter.The superficial branch and deep branch of rectus femoris nerve was accompanied with anterior branch and posterior branch of rectus femoris inferior artery at the middle part of rectus femoris. 75 percent of specimens had middle neurovascular branch.
④The blood supply of upper and middle 1/3 part of gracilis muscle came from deep femoral artery.The gracilis branch of deep femoral artery was 3.0(2.2～4.3) mm in origin diameter and 132.9(120.0～155.6) mm in length.The gracilis nerve was 1.9±0.3(1.3-2.6) mm in transverse diameter and 5.7±0.5(4.3-6.9) cm in length.The separated length of anterior gracilis nerve branch was 8.6±1.4(6.6-11.7) cm and the posterior gracilis nerve branch was 9.4±1.4(6.8-12.8) cm.There were 2 neurovascular tracts in 40 percents specimen and above 3 neurovascular tracts in 45 percents specimen.
2.3D reconstruction of artery in donor muscle,mark of nerve branch and design of segmented muscle flap:①The transverse images of modified lead-oxide filled arteries had a distinct rim and a steady density.There were no obvious constructed defects like“burring”,“vacuolus”in the 2D images.The thresholding-based segmentation of the blood vessels was simple and accurate.Minute blood vessel in 0.5 mm can be displayed,segmented and measured.②the 3D model of artery were very clear,smooth and continuous.The modality,spatial location and the adjacent relationship of arteries and nerve branch were perfectly visualized.The 3D model also displayed the branching,distribution of the nerve branchs and their relationship with aretry.All reconstructed structures could be displayed separately,in a group or as a whole.They could also be shown in different color modes,transparent styles and various vascular densities by adjusting parameters.③The 3D models of segmented muscle flaps in latissimus dorsi muscle,rectus femoris muscle and gracilis displayed intramuscularly pedicle of blood supply,nerve branch and morphous of the muscle flap.The 3D model of segmented latissimus dorsi muscle flap demonstrated segmented artery of medial branch and lateral branch.It also reflected three-dimensional morphous of the muscle flap,in which the superior part of the first and second lateral segmented muscle flaps were thicker than the middle and inferior parts,and the medial part of the first segmented muscle flap was thinner than the second and the third segmented muscle flaps.The rectus femoris muscle was split into 2-3 segmented muscle flaps and the middle sub-muscle flap was shorter and thinner than the others.The gracilis can be split to anterior and posterior muscle flaps.
3.The compound transplanted muscle and inferior prosopo-skin 3D finite element model consisted of donor muscle and inferior prosopo-skin,which had good geometric similarity with the entity image.The model can be rotated and zoomed arbitrarily,added and regulated the muscle.It had well arranged 2978 nodes and 10666 units,among them including 564 nodes and 1918 units.Loading with 27N,the biggest displacement in length was 3.9047 mm,while Loading with 8mm,the biggest muscle force was 55.431N,which whould get from transplanted muscle with 149.8mm area of cross section.
Conclusions:
1.Having an intimate knowledge of microanatomy about the latissimus dorsi muscle,serratus anterior muscle,rectus femoris muscle and gracilis had helpful for reconstruction of facial muscle with segmented units of these muscles.①With the pedicle of the segmented vascular nerve,the latissimus dorsi muscle was split to double sub-muscle flaps with single pedicle or double pedicles or three sub-muscle flaps with one pedicle.②With the pedicle of serratus anterior artery,serratus anterior muscle was split to 4-5 fascicularis muscle flaps.With the pedicle of latissimus dorsi artery,the combined latissimus dorsi muscle and serratus anterior muscle flap was designed.③The rectus femoris can be split to 2-3 segmented muscle flaps with the pedicle of rectus femoris nerve and artery.④The gracilis was split to 2-3 segmented muscle flaps with the pedicle of gracilis nerve and artery.
2.The carboxymethyl cellulose-lead oxide was favourable material in blood vessel perfusion.With the arteriography and MIMICS software,3D reconstruction of intramuscularly artery had been succeeded.The 3D model of segmented latissimus dorsi muscle,rectus femoris muscle and the gracilis muscle flap can be used for design of muscle transfer.
3.The complex 3D finite element model of the transfer-muscle and lower skin of face based on entity image and preoperative plan had good geometric similarity and mechanics similarity.It can be applied to quantify the design of pre-operation and evaluate the effect of free muscle transfer for the treatment of long-standing facial paralysis.
引文
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