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Chinese Journal of Reparative and Reconstructive Surgery logoLink to Chinese Journal of Reparative and Reconstructive Surgery
. 2019 Feb;33(2):190–194. [Article in Chinese] doi: 10.7507/1002-1892.201810025

高频彩色多普勒超声联合宽景成像在股前外侧穿支皮瓣术前导航中的应用

Application of high frequency color Doppler ultrasound combined with wide-field imaging in the preoperative navigation of anterolateral thigh perforator flap surgery

Yu GUO 1, Zairong WEI 1,*, Kewei ZENG 1, Fengling ZHANG 1, Chengliang DENG 1, Wenduo ZHANG 1, Dali WANG 1
PMCID: PMC8337604  PMID: 30739413

Abstract

Objective

To investigate the application of high frequency color Doppler ultrasound (HFCDU) combined with wide-field imaging in the preoperative navigation of anterolateral thigh perforator flap graft.

Methods

Between January 2017 and March 2018, 28 patients with skin and soft tissue defects were treated, including 22 males and 6 females, with an average age of 33.5 years (range, 17-66 years). The causes of injury included 2 cases of scald scar, 7 cases of heavy object crushing injury, 12 cases of traffic accident injury, 4 cases of fall injury, 2 cases of machine injury, and 1 case of infection ulcer. Injury sites included 6 cases of hand and wrist, 12 cases of lower leg, 10 cases of foot. After debridement, the wound area ranged from 6.0 cm×3.5 cm to 24.0 cm×9.0 cm, and all patients were treated with free circumflex femoral artery perforator flap graft. Combo of HFCDU and wide-field imaging navigation were done preoperatively to detect the origin, quantity, course, surface location, hemodynamic characteristics, and the relationship with body area of perforator branch of lateral circumflex femoral artery. According to the perforator information displayed by wide-field imaging of source artery, the dominant perforator was determined to be a pedicle for designed flap. The flap size ranged from 7.0 cm×4.5 cm to 26.0 cm×7.0 cm. The flap donor area was sutured directly.

Results

The dominant perforator was successfully detected by HFCDU combined with wide-field imaging in 28 patients before operation. The existence of the perforator was confirmed during operation, and the location was accurate. The course characteristics of the perforate were consistent with the results of wide-field imaging. The grafted flaps survived completely among 27 patients after operation. Necrosis at the edge of the flap was observed in 1 patient, which healed after dressing change. All patients were followed up 3-12 months, with an average of 9 months. All the flaps have good blood supply, good elasticity and shape. The donor areas healed perfectly.

Conclusion

Using HFCDU and wide-field imaging navigation for designing of anterolateral thigh perforator flaps can clearly show the characteristics of perforators, hemodynamic information, and the relationship with body area, so that the surgeons can understand the perforators more accurately and intuitively, and improve the success and efficiency of flap graft surgery.

Keywords: High frequency color Doppler ultrasound, wide-field imaging, wound repair, anterolateral thigh flap

1984 年徐达传等[1]报道了股前外侧穿支皮瓣，1993 年 Koshima 等[2]将该皮瓣应用于软组织缺损修复重建，并获得了良好效果。此后，旋股外侧动脉降支穿支皮瓣应用越来越广泛，目前已成为修复重建领域的“万能皮瓣”。然而，该皮瓣的缺点在于旋股外侧动脉穿支血管存在一定解剖变异[3]，增加了皮瓣制备的难度和不确定性。为了提高皮瓣切取的成功率，避免不必要的手术切口和损伤，目前许多学者采用高频彩色多普勒超声（high frequency color Doppler ultrasound，HFCDU）术前定位穿支血管，取得了较为满意的效果[4-7]。但由于彩超探头面积限制，不能将目标血管整体、直观地显示，手术医师术前无法全方位掌握血管解剖信息[8]。因此 Weng 等[9]提出了宽景成像，又称全景超声成像，它利用先进的计算机图像处理程序，在实时超声的基础上自由移动超声探查，可以将一系列二维血管图像拼接为一幅连续的直观图像，从而弥补以上不足。2017 年 1 月—2018 年 3 月，我们将 HFCDU 联合宽景成像用于术前探测股前外穿支血管情况，指导术中皮瓣设计，现回顾分析患者临床资料，探讨该方法的临床应用前景。报告如下。

1. 临床资料

1.1. 一般资料

纳入标准：① 年龄>17 岁；② 拟接受股前外侧游离皮瓣手术。排除标准：① 有高血压、糖尿病、血管疾病及其他重大疾病史者；② 有供区大腿手术史者；③ 大腿皮下脂肪厚度超过 4 cm 者；④ 有精神疾病史，不能配合检查者。2017 年 1 月—2018 年 3 月，28 例患者符合选择标准纳入研究。本研究获遵义医学院附属医院医学伦理委员会批准（编号：伦审[2017]1-021 号）。患者均同意接受 HFCDU 联合宽景成像，并签署知情同意书。

本组男 22 例，女 6 例；年龄 17～66 岁，平均 33.5 岁。致伤原因：烫伤瘢痕 2 例，重物砸伤 7 例，交通事故伤 12 例，摔伤 4 例，机器绞伤 2 例，感染溃疡 1 例。损伤部位：手、腕部 6 例，小腿 12 例，足 10 例。受伤至手术时间 2～38 d，平均 9 d。

1.2. 治疗方法

1.2.1. 术前探查

采用 LOGIQ e 型 GE 彩色多普勒超声诊断仪［通用电气医疗系统（中国）有限公司］，12L 探头，选用“下肢动脉”模式，频率 4～12 MHz，深度 20～40 mm，速度标尺为 1 cm／s（低速），HFCDU 调节到最为敏感且不产生噪音。彩色多普勒取样框的偏转与血流方向一致，血流方向与声束夹角（校正角）<60°，调节 Scale 至合适。患者取仰卧位，双下肢伸直，选择健侧大腿，连接髂前上棘（P 点）至髌骨外侧（A 点）为 A 线，髂前上棘（P 点）至股骨外上髁（B 点）为 B 线。超声探头自旋股外侧动脉起始点沿降支血管走行方向向下寻找穿支血管，在 A 线中点附近，以及 A、B 线之间重点探测[10]，显示旋股外侧动脉源动脉长轴声像图，沿主干向下探寻穿支，记录穿支血供来源、数量、走行方向，比较穿支管径粗细、流速快慢、穿肌肉走行的长短。标记穿支体表位置。然后转换成宽景成像模式，采集穿支及其源动脉的全景图像并保存。

1.2.2. 皮瓣设计

通过 HFCDU 探测的穿支直径、血流速度，结合宽景成像显示的源动脉、穿支血管与体区关系来全方位选择优势穿支，根据创面形状和大小设计皮瓣，皮瓣面积较创面面积扩大 10%～20%。

1.2.3. 手术方法

患者于气管插管全麻后，常规消毒铺巾，由两组医生进行手术，一组行创面清创，分离受区需要吻合的血管备用，清创后创面范围为 6.0 cm×3.5 cm～24.0 cm×9.0 cm。另一组沿术前设计线切开皮瓣内侧缘皮肤至阔筋膜内血管，掀起阔筋膜[11]，根据术前标记寻找优势穿支，根据全景图像解剖穿支，验证其定位的精确性。离断皮瓣后完全覆盖创面，吻合皮瓣与受区血管。受区神经根据需求，术中将股外侧皮神经带入皮瓣内，与受区神经吻合，创缘间断缝合。本组切取皮瓣范围为 7.0 cm×4.5 cm～26.0 cm×7.0 cm，供区直接拉拢缝合。

1.3. 术后处理

术后常规行抗感染、抗血管痉挛、扩容、持续吸氧等对症治疗，护架烤灯局部保暖，皮瓣移植术后严密观察 5～7 d。通过观察皮瓣的色泽、弹性、温度、毛细血管充盈及针刺判断皮瓣血运。术后 12～14 d 拆线，根据肢体情况逐渐开始功能锻炼。

2. 结果

28 例患者术前利用 HFCDU 结合宽景成像均成功探测到优势穿支，术中证实该穿支存在，定位准确，走行特点与宽景图结果一致。术后 27 例皮瓣完全成活；1 例皮瓣边缘局部坏死，经换药后愈合。患者均获随访，随访时间 3～12 个月，平均 9 个月。皮瓣血运佳、弹性好，供区及受区外形、功能均良好。

3. 典型病例

患者 男，50 岁。因“机器绞伤致右上肢广泛皮肤软组织缺损 9 h”入院。急诊行清创、负压吸引等处理，伤后 12 d 于气管插管全麻下手术。术前检查示右前臂上段、远端、小指处皮肤软组织缺损，面积分别约 8 cm×7 cm、11 cm×7 cm、4 cm×2 cm。创面肉芽鲜红，右手第 1 掌骨外露，第 1 腕掌关节、第 1 掌指关节外露并关节囊缺损。予以 HFCDU 探测左大腿，沿旋股外侧动脉降支探寻，共探测 3 支穿支，选择直径较粗、流速较快、走行较短的穿支行宽景成像，见图 1。根据宽景图像更直观地观察穿支走行及与周围解剖关系，确定优势穿支为蒂，依据创面形状设计皮瓣，皮瓣面积为 24 cm×7 cm。切取皮瓣，术中注意保护股外侧皮神经，受区扩创后吻合皮瓣内血管与受区血管，创缘间断缝合，其余创面植皮修复。供区直接拉拢缝合。术后常规行抗炎、抗凝、补充血容量等治疗。术后皮瓣完全成活，术后 12 d 拆线。术后 12 个月，皮瓣血运好、弹性佳，供、受区外形、功能均较佳。见图 2。

图 1.

Preoperative detection of perforating branches of descending branch of lateral circumflex femoral artery in left thigh by HFCDU in the typical case

典型病例术前 HFCDU 探测左大腿旋股外侧动脉降支穿支情况

红色为动脉血流影像　a. 旋股外侧动脉降支主干；b. 降支矢状图；c. 穿支在股直肌走行；d. 穿支出肌点；e. 降支携带优势穿支宽景成像　A：降支 a：优势穿支 RF：股直肌 VI：股中间肌 F：皮下脂肪层

Red indicated arterial blood flow imaging　a. The main branch of the lateral femoral artery descending; b. Descending sagittal diagram; c. Wear through the rectus femoris muscle; d. Wear expenditure muscle points; e. Wide-field imaging of descending branch with dominant perforating branch　A: Descending branch a: Dominant penetrating branch RF: Rectus femoris VI: Medial femoral muscle F: Subcutaneous fat layer

图 1

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图 2.

Appearance of the typical case before and after operation

典型病例手术前后外观

a. 术前创面情况；b. 皮瓣设计（红点处为优势穿支投影点）；c. 皮瓣游离中；d. 皮瓣覆盖前臂远端创面；e. 术后 12 个月供瓣区愈合良好；f. 术后 12 个月受区皮瓣成活良好

a. Preoperative wound appearance; b. Flap design (red point indicated the dominant perforating branch projection point); c. Free flap; d. Flap covered the forearm distal wound; e. The donor site healed well at 12 months after operation; f. The flap survived well at 12 months after operation

图 2

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4. 讨论

股前外侧皮瓣因其供皮面积大、血管口径粗、部位隐蔽等特点，已成为临床常用的皮瓣之一。但其穿支存在一定的解剖变异，许多研究[12-18]指出，股前外侧皮瓣穿支可由旋股外侧动脉降支、斜支、横支、升支发出，甚至旋股外侧动脉主干、股深动脉、股总动脉发出；且其位置多变，发出方式多样，数量不定。这些变异降低了临床医生切取穿支皮瓣的成功率且耗费大量时间。因此，许多血管影像学技术逐渐被研究，如便携式多普勒超声，其根据穿支血流的信号来确定位置，使用简便、无创，但无法成像，无法提供血液动力学信息，假阳性、假阴性率高[19]；CT 血管造影（CTA）虽成像明确可靠，能够显示管径 0.3 mm 以上的穿支血管[20]，但有辐射影响及造影剂过敏风险，并且费用较高；磁共振血管成像（MRA）显影良好，没有辐射，但费用高，对于装有金属内置物的患者不能使用；数字减影血管造影（DSA）能清楚显示血管，但属于有创检查，患者及操作者均需暴露在 X 线下。

HFCDU 具有无创、实时、动态、廉价、多切面扫查的特点，应用 HFCDU 进行皮瓣术前检查既能够定位穿支，显示其数目、起源、走行及出肌点，又可记录其血流方向、速率等血流动力学参数。但因探头限制，其成像呈节段性，单独使用无法连续成像。朱艳珊等[21]指出宽景成像技术在下肢动脉检查中的应用，克服了超声探头面积的限制，可以实时、连续显示整条血管。本组 28 例患者术前利用 HFCDU 结合宽景成像可以将穿支位置、肌肉内的走行以及与体区之间的吻合在同一视野显示，使术者能更直观、全面了解穿支解剖信息，选择优势穿支；同时还可确定共干穿支，行分叶皮瓣手术[22]。本组术后 1 例皮瓣边缘发生坏死，考虑与切取皮瓣面积过大有关，因该坏死面积较小，经换药后逐渐愈合。该技术不足在于 HFCDU 不能探见直径<0.6 mm 的穿支血管；另外宽景成像因角度问题，不能将优势穿支及源动脉完整地显示在 1 张图上。

进行术前探测时需要注意以下问题：① 操作者需具有相应的皮瓣解剖知识和彩超操作知识，反复探测取得清晰的图像及可靠的数据；② 操作时动作需轻柔，压力太大将导致血管受压变形；③ 宽景成像时需缓慢、沿直线移动探头，且探头尽量垂直于扫描面；④ 探查中遇到疑难、特殊情况时，需及时与手术医生沟通解决。

综上述，HFCDU 联合宽景成像精确导航使穿支的选择更为合理，手术更简便、安全、高效。随着该技术逐步普及，可能成为术前探测的常规手段。

Funding Statement

国家临床重点专科建设项目（国卫办医函[2013]544号）；贵州省科技厅联合基金（黔科合LH字[2017]7117号）

National Clinical Key Speciality Construction Project of China [(2013)544]; Joint Funds of Guizhou Provincial Science and Technology Department [(2017)7117]

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