摘要目的 介绍将小腿穿支蒂皮瓣的“孤立穿支蒂”改进为“穿支筋膜皮下蒂”的手术技术,探讨改善皮瓣静脉回流、提高临床可靠性的应用效果. 方法 依据小腿后侧穿支血管的位置,设计偏心的螺旋桨样岛状皮瓣.穿支血管轴点近侧的皮瓣头部(大桨)切为筋膜皮瓣,轴点与受区创面间的皮瓣尾部(小桨)切为真皮下血管网皮瓣,至少保留穿支血管蒂一侧1/4象限的筋膜皮下组织,形成“穿支筋膜皮下蒂”.自2008年1月至2010年12月,临床应用12例,旋转180°修复足踝创面.术后观测皮瓣肿胀程度和成活及功能恢复情况. 结果 本组胫后动脉穿支7例,腓动脉穿支5例,近侧筋膜皮瓣(大桨)面积4 cm×8 cm ～6 cm×18 cm,远侧真皮下血管网皮瓣(小桨)面积2 cm×2 cm～4 cm×4 cm.术后皮瓣肿胀较轻,按顾玉东法评定,9例低于2级,2例为3级,仅最大的1例为4级,皮瓣远端有部分浅层坏死.平均随访13个月,创面治愈.患者恢复行走和穿鞋功能. 结论 采用保留部分筋膜皮下组织的穿支蒂部改进法,在增加皮瓣静脉回流通道、降低术后肿胀程度、提高临床安全性的同时,皮瓣仍能获得180°的平滑旋转,效果优良,值得推广.

abstractsObjective To introduce the operative technique of pedicle evolution from isolated perforator to perforator-plus-adipofascial,and investigate its clinical results in venous drainage and safety in distallybased sural flaps. Methods After identifying the proper viable perforators,the whole flap was designed in an eccentric propeller shape,with the perforating vessels corresponding to the pivot point.The proximal larger blade was a fasciocutaneous flap, while the distal smaller blade was a subdermal vascular plexus flap,preserving at least a quarter area of adipofascial tissue around the perforator.From January 2008 to December 2010, we performed distally perforator-adipofascial pedicled sural fasciocutaneous propeller flap in 12 patients,with 180 degrees rotation to cover foot and ankle defects.Postoperatively,flap swelling,survival and functional recovery were evaluated. Results There were 7 posterior tibial artery perforator flaps from the posteromedial and 5 peroneal artery perforator flaps from the posterolateral sural region. The proximal fasciocutaneous flap measured 4 cm × 8 cm-6 cm × 18 cm, and the distal cutaneous flaps measured 2 cm × 2cm-4 cm × 4 cm.Flap swelling was noted under grade 2 in 9 cases,grade 3 in 2 cases,and grade 4 in 1case with some distal superficial skin necrosis,which occurred in the largest flap in our series.All flaps survived eventfully.After average 13 months follow up,the wound were cured successfully,and all patients recovered walking and shoe wearing function. Conclusion Pedicle evolution by keeping some adipofascial tissue around the pivot perforator, can preserve more venous return routes and relieve flap swelling. This technique should be recommended in perforator pedicled propeller flaps,as it enhances flap safety,and without increasing the difficulty of 180 degrees rotation.