指背筋膜皮瓣的解剖学基础与临床应用
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摘要
研究背景:临床上指端的缺损是手外科常见的指端损伤,主要是指在手指末节范围内的软组织缺损,伤因包括切割、挤压、挫裂、离断等,在手外科临床工作中较为常见,几乎占手外科急诊的1/3。指端缺损的处理,应根据患者的伤情、年龄、职业要求等因素综合考虑。如粗糙有力的手(建筑、种田等)和细腻灵巧的手(弹琴等)对修复重建的要求并不一样。指端组织缺损的治疗方法多种多样,包括:①保守疗法,等待二期愈合。②离断组织原位缝合。③游离植皮(全厚皮片或真皮下血管网皮片)。④足趾复合组织块移植。⑤缩短指骨直接缝合。⑥皮瓣移植。⑦吻合血管的指尖再植。⑧吻合血管的足趾、趾腹移植。总的来看,不同的指端缺损类型,其修复治疗有一定的原则,但并无确定的模式。
临床大约有1/3的指端损伤需用皮瓣修复。指端缺损采用皮瓣修复的指征有以下几点:①保留长度非常重要,如拇指。②有深部组织裸露,如骨和肌腱等。③能保留指甲。
依皮瓣与伤指的关系,可将其分为下列3种。
(1)局部皮瓣:取自伤指,种类和改进方法繁多,解剖比较容易,供区损伤少。
(2)手区域内的近位皮瓣:取自伤指以外的患侧手部,适用于修复较大面积指端损伤。有时供区破坏较大,如邻指皮瓣、鱼际皮瓣以及不同指的血管神经蒂岛状皮瓣(littler皮岛)等。
(3)远位皮瓣:取自伤手以外的皮瓣,需强迫体位交叉固定和二期断蒂,如腹股沟皮瓣、锁骨下皮瓣和臂部皮瓣。
筋膜皮瓣是修复指端缺损的一种重要的局部皮瓣修复方法,关于指背筋膜皮瓣的临床和基础研究前人已经做了大量的工作,但是给人的只是一些文字、示意图或粗糙的临床图片,缺乏立体直观的解剖学依据。
目的:介绍一种修复指端皮肤缺损的指动脉背侧支逆行筋膜蒂岛状皮瓣的解剖学基础与临床应用。
方法:以中节指固有动脉背侧支为筋膜蒂设计皮瓣,切取手指背侧筋膜皮瓣,逆行修复指端的皮肤缺损。
结果:本次临床应用指背筋膜瓣,受区皮瓣成活良好,外观满意,供区给予植皮,供区外观满意且手指功能不受影响,受区及供区的疤痕不明显。
结论:此皮瓣具有手术操作简便、不损伤指固有动脉及神经,血管蒂长、旋转弧大和成功率高等优点,是修复手指皮肤缺损较理想的方法。
Background: Defect of finger tip is the commom finger tip injury in hand surgery clinically. It is major the defect of soft tissue in the extent of finger paratelum. The injury causes include cutting、crushing、cracking、mutilation and ect. It is very commom in the clinical work of hand surgery, Almost 1/3 of emergency in hand surgery.
Treatment of fmger tip defect is considered according to the factors including trauma condition、age、requirement of profession and ect. For example, the requirements of reparation and reconstitution are different between rough vigorous hands(building、farming) and delicate smart hands(palying piano).There are lots of treatments for finger tip tissue defect, including:①conservative treatment, waiting for per secundam intentionem.②Suturing mutilated tissue in situ.③Free dermatoplasty(full thick skin graft or subdermal vascular plexus free skin graft).④Digiti pedis complex tissue mass graft.⑤Decurtating bones of fingers and suturing directly.⑥skin flap transplantation.⑦Reimplanting vascular inosculated in finger tip.⑧Reimplanting vascular inosculated in digiti pedis and abdomen of toes. In all, There are different principle of reparation treatment in different defect type of finger tip, but the mode are not definitive.
Clinically about 1/3 of finger tip injury needs skin flap reparation.The indication for skin flap reparation including:①Remaining the lenghth is very important, such as thumb.②There deep tissue is exposed, such as bone and tendon and etc.③It can remain the finger nail.
According to the relationship between skin flap and injury finger, it can be divided into 3 kinds listed below.
(1) regional flap: It is obtained from the injury finger,category and improving methods were various, easy to dissect and little injury to donor site.
(2) Periposition flap on hands: It was obtained from injury hand except the injury finger, It can be use to repair a large area injury in finger tip. Somtimes,The injury to donor site are great, such as cross finger flap、thenar flap and vascular nervous islet flap in different fingers and so on.
(3) Distant skin flap: It is obtained from the place except the injury hand, It needs compulsive position crossing fixure and cutting the pedicel in second stage, such as femoris fissure flap、subclavicular flap、rump flap and so on.
Objective: To introduce the clinical application and anatomic foundation of the reverse fascial pedicle island Flap of the digital artery dorsal branches in repairing finger skin defect.
Methods: By use of the dorsal branches of midplate Digital artery as the fascial pedicel, the reverse island flap was designed.and was get to repair finger skin defect
Results: The reverse fascial pedicle island Flap of the digital artery dorsal branches survived,the patient was satisfied with the consequence, the appearance of the donor site where was dermatoplasty was contented .and the function of interphalangeal joint was satisfactory,the scar was small.
Conclusion: These Flaps have the advantages of an extended skin paddle and aversatile pivot point on the phalanx,and they allow Coverage of wide and distal defects.
临床大约有1/3的指端损伤需用皮瓣修复。指端缺损采用皮瓣修复的指征有以下几点:①保留长度非常重要,如拇指。②有深部组织裸露,如骨和肌腱等。③能保留指甲。
依皮瓣与伤指的关系,可将其分为下列3种。
(1)局部皮瓣:取自伤指,种类和改进方法繁多,解剖比较容易,供区损伤少。
(2)手区域内的近位皮瓣:取自伤指以外的患侧手部,适用于修复较大面积指端损伤。有时供区破坏较大,如邻指皮瓣、鱼际皮瓣以及不同指的血管神经蒂岛状皮瓣(littler皮岛)等。
(3)远位皮瓣:取自伤手以外的皮瓣,需强迫体位交叉固定和二期断蒂,如腹股沟皮瓣、锁骨下皮瓣和臂部皮瓣。
筋膜皮瓣是修复指端缺损的一种重要的局部皮瓣修复方法,关于指背筋膜皮瓣的临床和基础研究前人已经做了大量的工作,但是给人的只是一些文字、示意图或粗糙的临床图片,缺乏立体直观的解剖学依据。
目的:介绍一种修复指端皮肤缺损的指动脉背侧支逆行筋膜蒂岛状皮瓣的解剖学基础与临床应用。
方法:以中节指固有动脉背侧支为筋膜蒂设计皮瓣,切取手指背侧筋膜皮瓣,逆行修复指端的皮肤缺损。
结果:本次临床应用指背筋膜瓣,受区皮瓣成活良好,外观满意,供区给予植皮,供区外观满意且手指功能不受影响,受区及供区的疤痕不明显。
结论:此皮瓣具有手术操作简便、不损伤指固有动脉及神经,血管蒂长、旋转弧大和成功率高等优点,是修复手指皮肤缺损较理想的方法。
Background: Defect of finger tip is the commom finger tip injury in hand surgery clinically. It is major the defect of soft tissue in the extent of finger paratelum. The injury causes include cutting、crushing、cracking、mutilation and ect. It is very commom in the clinical work of hand surgery, Almost 1/3 of emergency in hand surgery.
Treatment of fmger tip defect is considered according to the factors including trauma condition、age、requirement of profession and ect. For example, the requirements of reparation and reconstitution are different between rough vigorous hands(building、farming) and delicate smart hands(palying piano).There are lots of treatments for finger tip tissue defect, including:①conservative treatment, waiting for per secundam intentionem.②Suturing mutilated tissue in situ.③Free dermatoplasty(full thick skin graft or subdermal vascular plexus free skin graft).④Digiti pedis complex tissue mass graft.⑤Decurtating bones of fingers and suturing directly.⑥skin flap transplantation.⑦Reimplanting vascular inosculated in finger tip.⑧Reimplanting vascular inosculated in digiti pedis and abdomen of toes. In all, There are different principle of reparation treatment in different defect type of finger tip, but the mode are not definitive.
Clinically about 1/3 of finger tip injury needs skin flap reparation.The indication for skin flap reparation including:①Remaining the lenghth is very important, such as thumb.②There deep tissue is exposed, such as bone and tendon and etc.③It can remain the finger nail.
According to the relationship between skin flap and injury finger, it can be divided into 3 kinds listed below.
(1) regional flap: It is obtained from the injury finger,category and improving methods were various, easy to dissect and little injury to donor site.
(2) Periposition flap on hands: It was obtained from injury hand except the injury finger, It can be use to repair a large area injury in finger tip. Somtimes,The injury to donor site are great, such as cross finger flap、thenar flap and vascular nervous islet flap in different fingers and so on.
(3) Distant skin flap: It is obtained from the place except the injury hand, It needs compulsive position crossing fixure and cutting the pedicel in second stage, such as femoris fissure flap、subclavicular flap、rump flap and so on.
Objective: To introduce the clinical application and anatomic foundation of the reverse fascial pedicle island Flap of the digital artery dorsal branches in repairing finger skin defect.
Methods: By use of the dorsal branches of midplate Digital artery as the fascial pedicel, the reverse island flap was designed.and was get to repair finger skin defect
Results: The reverse fascial pedicle island Flap of the digital artery dorsal branches survived,the patient was satisfied with the consequence, the appearance of the donor site where was dermatoplasty was contented .and the function of interphalangeal joint was satisfactory,the scar was small.
Conclusion: These Flaps have the advantages of an extended skin paddle and aversatile pivot point on the phalanx,and they allow Coverage of wide and distal defects.
引文
1.BUNCKE H J.Forty years of microsuigery:what next[J]handsurg,1995,20(3,Pt2):34-35.
2.Le FOURN,CWEN,PANNIER M.Distally based sural fasciomauscular flap:anaomic study and application for filling leg or foot defect[J].plast Reconstr surg,2001,107:67-72.
3.WEE J T K.Reconstruction of the lower leg and foot with the rewerse-pedicled tibiled anterior tibial flap:preliminary report of a new fasciocutaneous flap[j].Brit.J Plast Surg,986,39:327-337.
4.Teran P,Araya E,Casado C.Reconstruction of a pulp defect using a free finger-pulp flap from a non-replantable digit.Br J Plast Surg,2002,55(2):158-159.
5.丁自海,王增涛.手外科学解剖学图鉴[M].济南:山东科学技术出版社2007.
6.Al-Qattan M M.Technical modifications and extended applications of the distally based adipofascial flap for dorsal digital defects.Ann Plast Surg,2004,52(2):168-173..
7.PRASAD JS R,GUNHA-GOMES D,CHAUDHARIC,et,al.The venoneuroadipofascial pedicled distally basded sural island myofasciocutaneous and muscle flaps:anatomical basis of a new concept[J].Brit J Plast Sural 2002,55:203-209.
8.BrunelliF,VigAsioA,ValeutiP,et al.Arterial anatomy and clinica lapplication of the dorsoulnar flap of the thumb[J].JHandSurg,1999,24(4):803-805.
9.YangD,MorrisSF.Vascular basis of dorsal digital and metacarpal skin flaps[J].JHandSurg(Am),2001,26(1):142-146.
10.OmokawaS,TanabkaY,RyuJ,et al.Anatomical consideration of reversed flow island flap transfers from the midpalm for finger reconstruction[J].PlastReconstSurg,2001,108(3):2020～2025.
11.陈玉兵,王丽丽,房辉赞,等.邻指逆行指动脉皮瓣修复手指末节皮肤脱套伤.中国 修复重建外科杂志,2003,17(3):236.
12 NakaimaH,ImanishiN,FukuzumiS,et al.Accompanying arteries of the lessersaphenousvein and suralnerve:anatomic study and its clinical applications[J].PlastReconstrSurg,1999,103(1):104～120.
13.PRASAD J S R,CUNHA-GOMES D,CHAUDHARI C,et al.The venoneuroadipofacial pedicled distally based sural island myofasciocutaneous and muscle flaps:anaromical basis of a new concept[J].Brit Plast Surg,2002,55:203-209.
14.CHANG S M,HOU CL.Chain-linked direction vascular plexuses of the integument and link-pattern vascularized flaps in distal extremities[J]plast Rwxonstr surg,2002,110:2103-2015
15.TIMMONS M J.The deep wenous system and reverse flow flap[J].Brit J Plast Surg,1994,47:290-291.
16.Del PINSL F,TAYLOR G I,The deep wenous system and reverse flow flap[J].Brit J Plast Surg,1993,46:652-664
17.TOUAM C,OSTOUCHER P,BHAIA A,et al.Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg,theankle,and the foot[j].plast Reonstr surg,2001,107:383-392
18.EKeramidas,SRodopoulou,NMetaxotos,et al.Reverse dorsal digital and intercommissural flaps used for digital reconstruction[J].British Journal of Plastic Surgery,2004,57(1):61-65
19.Bene MD,Petrolat IM,Raimondi P,et al.Reverse dorsal digita island flap.Plast Reconstr Surg,1994,93(3):552-557.
20.PelissierP,Casoli V,Bakhach J,et al.Reverse dorsal digital and metacarpal flaps:a review of 27 cases.Plast Reconstr Surg,1999,103(1):159-165.
21.Pelissier,Casoli,Bakhach,et al.Reverse dorsal digital and metacarpal flaps:A Review of 27 cases[J].Plast Reconstr Surg,1999,103(1):159-165.
22.钟世镇,徐达传,丁自海.显微外科临床解剖学[M]济南:山东科学技术出版社,2000.
23.侯春林,张世民.筋膜皮瓣与筋膜蒂组织瓣[M].上海:上海科学技术出版社2000.
24.Pelissier p,Casoli v,Bakhach J,Martion D,Baudel J.Reverse corsal digital and metacarpal flaps:a review of 27 cases.Plast Reconstr surg:1999,103:159-165.
25.Bene MD,Petroati M,Raimondi P,Trenolada C,Muset A.Reveerse dorsal digital ialand flap.plast reconsry surg,1994,93:552-557.
26.于杰,何阿玲,钟桂午,等.带蒂组织瓣在上肢火器伤修复中的应用.中国修复重建外科杂志,2003,17(4):326-327.
27.李建军,吴恙,陈有光,等·前臂逆行筋膜皮瓣与筋膜瓣的临床应用[J]·中华显微外科杂志,1998,21:139-140.
20.Gunasekar V uppalapati,C Oberlin,G Balakrishnan.Distally based dorsal hand flaps:clinical experience,cadaveric studies and anupdate[J].British Journal of Plastic Surgery,2004,57(7):595-704.
21.何葆华,朱晞,周吉林,等.拇指背尺侧逆行岛状皮瓣的应用解剖[J].中国临床解剖志,2003,21(1):44～46.HeBH,ZhuX,ZhouJL,etal.Appliedanatomyofthereverseislan dflapindorsulnarthumb[J].ChinJClinAnat,2003,21(1):44～46.
22.黄启顺,洪光祥,王发斌,等.同指掌侧脂筋膜瓣翻转修复指背皮肤及软组织缺损.中华骨科杂志,2001,21(10):616-618.
23.Masquele AC,Vslenti P.Dorsocommissural flaps.Apropos of a clinical case.Ann Chir Plast Esthet,1996,41:269-276.
24 侯春林,顾玉东.皮瓣外科学[M].上海:上海科学技术出版社2006.
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26.顾玉东,四肢的显微外科修复[M].上海:上海医科大学出版社,1999.
27 valenti P,Masquelet AC,Begue T,Anatomic basis of a dorsocommissural flap from the 2nd,3rd and 4th intermetacarpal spaces.Surg Radiol Anat,1990,12:235-239.
28 钟世镇,显微外科解剖学基础[M].北京:科学出版社,1995.
29.杨志明,陈尔瑜.带血管蒂组织瓣移植术[M].成都:四川科学技术出版社 1998.
30.张世民,陈忠伟.前臂远端蒂筋膜皮瓣的静脉回流[J].手外科杂志,1992,8(2):72-73
31.廖进民,钟世镇,苗华.四肢皮神经营养血管筋膜皮瓣的应用解剖[J].中华国际医学杂志,2002,2(4):353-356
32.李罗珠,于益鹏,孙步梅.邻指指背筋膜蒂皮瓣一期修复手指掌侧电击伤.中国修复重建外科杂志,2002,16(2):133.
33.torii S,Namiki Y,Mori R,Reverse flow island flap:clinical report and wenous drainage.plast Reconstr surg,1987,79:600-609.
2.Le FOURN,CWEN,PANNIER M.Distally based sural fasciomauscular flap:anaomic study and application for filling leg or foot defect[J].plast Reconstr surg,2001,107:67-72.
3.WEE J T K.Reconstruction of the lower leg and foot with the rewerse-pedicled tibiled anterior tibial flap:preliminary report of a new fasciocutaneous flap[j].Brit.J Plast Surg,986,39:327-337.
4.Teran P,Araya E,Casado C.Reconstruction of a pulp defect using a free finger-pulp flap from a non-replantable digit.Br J Plast Surg,2002,55(2):158-159.
5.丁自海,王增涛.手外科学解剖学图鉴[M].济南:山东科学技术出版社2007.
6.Al-Qattan M M.Technical modifications and extended applications of the distally based adipofascial flap for dorsal digital defects.Ann Plast Surg,2004,52(2):168-173..
7.PRASAD JS R,GUNHA-GOMES D,CHAUDHARIC,et,al.The venoneuroadipofascial pedicled distally basded sural island myofasciocutaneous and muscle flaps:anatomical basis of a new concept[J].Brit J Plast Sural 2002,55:203-209.
8.BrunelliF,VigAsioA,ValeutiP,et al.Arterial anatomy and clinica lapplication of the dorsoulnar flap of the thumb[J].JHandSurg,1999,24(4):803-805.
9.YangD,MorrisSF.Vascular basis of dorsal digital and metacarpal skin flaps[J].JHandSurg(Am),2001,26(1):142-146.
10.OmokawaS,TanabkaY,RyuJ,et al.Anatomical consideration of reversed flow island flap transfers from the midpalm for finger reconstruction[J].PlastReconstSurg,2001,108(3):2020～2025.
11.陈玉兵,王丽丽,房辉赞,等.邻指逆行指动脉皮瓣修复手指末节皮肤脱套伤.中国 修复重建外科杂志,2003,17(3):236.
12 NakaimaH,ImanishiN,FukuzumiS,et al.Accompanying arteries of the lessersaphenousvein and suralnerve:anatomic study and its clinical applications[J].PlastReconstrSurg,1999,103(1):104～120.
13.PRASAD J S R,CUNHA-GOMES D,CHAUDHARI C,et al.The venoneuroadipofacial pedicled distally based sural island myofasciocutaneous and muscle flaps:anaromical basis of a new concept[J].Brit Plast Surg,2002,55:203-209.
14.CHANG S M,HOU CL.Chain-linked direction vascular plexuses of the integument and link-pattern vascularized flaps in distal extremities[J]plast Rwxonstr surg,2002,110:2103-2015
15.TIMMONS M J.The deep wenous system and reverse flow flap[J].Brit J Plast Surg,1994,47:290-291.
16.Del PINSL F,TAYLOR G I,The deep wenous system and reverse flow flap[J].Brit J Plast Surg,1993,46:652-664
17.TOUAM C,OSTOUCHER P,BHAIA A,et al.Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg,theankle,and the foot[j].plast Reonstr surg,2001,107:383-392
18.EKeramidas,SRodopoulou,NMetaxotos,et al.Reverse dorsal digital and intercommissural flaps used for digital reconstruction[J].British Journal of Plastic Surgery,2004,57(1):61-65
19.Bene MD,Petrolat IM,Raimondi P,et al.Reverse dorsal digita island flap.Plast Reconstr Surg,1994,93(3):552-557.
20.PelissierP,Casoli V,Bakhach J,et al.Reverse dorsal digital and metacarpal flaps:a review of 27 cases.Plast Reconstr Surg,1999,103(1):159-165.
21.Pelissier,Casoli,Bakhach,et al.Reverse dorsal digital and metacarpal flaps:A Review of 27 cases[J].Plast Reconstr Surg,1999,103(1):159-165.
22.钟世镇,徐达传,丁自海.显微外科临床解剖学[M]济南:山东科学技术出版社,2000.
23.侯春林,张世民.筋膜皮瓣与筋膜蒂组织瓣[M].上海:上海科学技术出版社2000.
24.Pelissier p,Casoli v,Bakhach J,Martion D,Baudel J.Reverse corsal digital and metacarpal flaps:a review of 27 cases.Plast Reconstr surg:1999,103:159-165.
25.Bene MD,Petroati M,Raimondi P,Trenolada C,Muset A.Reveerse dorsal digital ialand flap.plast reconsry surg,1994,93:552-557.
26.于杰,何阿玲,钟桂午,等.带蒂组织瓣在上肢火器伤修复中的应用.中国修复重建外科杂志,2003,17(4):326-327.
27.李建军,吴恙,陈有光,等·前臂逆行筋膜皮瓣与筋膜瓣的临床应用[J]·中华显微外科杂志,1998,21:139-140.
20.Gunasekar V uppalapati,C Oberlin,G Balakrishnan.Distally based dorsal hand flaps:clinical experience,cadaveric studies and anupdate[J].British Journal of Plastic Surgery,2004,57(7):595-704.
21.何葆华,朱晞,周吉林,等.拇指背尺侧逆行岛状皮瓣的应用解剖[J].中国临床解剖志,2003,21(1):44～46.HeBH,ZhuX,ZhouJL,etal.Appliedanatomyofthereverseislan dflapindorsulnarthumb[J].ChinJClinAnat,2003,21(1):44～46.
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