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Chinese Journal of Reparative and Reconstructive Surgery logoLink to Chinese Journal of Reparative and Reconstructive Surgery
. 2022 Dec;36(12):1512–1518. [Article in Chinese] doi: 10.7507/1002-1892.202207012

以肌内主干型旋股外侧动脉斜支为蒂股前外侧穿支皮瓣的临床应用

Clinical application of anterolateral thigh perforator flap pedicled with oblique branch in intramuscular of lateral circumflex femoral artery

Lin YANG 1,2, Zhijin LIU 1,2, Junnan CHENG 1,2, Qinfeng GAO 1,2, Chengpeng YANG 1,2, Shengzhe LIU 1,2, Tao ZHANG 1,2, Fengwen SUN 1,2, Yongtao HUANG 1,2, Jihui JU 1,2,*
PMCID: PMC9763071  PMID: 36545860

Abstract

Objective

To explore the characteristics and clinical application of the anterolateral thigh flap pedicled with the oblique branch in the intramuscular of lateral circumflex femoral artery.

Methods

The clinical data of 25 patients with skin and soft tissue defects of extremities admitted between December 2020 and April 2021 were retrospectively analyzed, including 16 males and 9 females, aged 14-75 years, with the median age of 43 years. The defect site included 13 cases of hand, 2 cases of forearm, 2 cases of calf, and 8 cases of foot and ankle. The wound area ranged from 6 cm×4 cm to 35 cm×22 cm. Twenty-four patients with trauma were admitted to hospital immediately after injury, and 1 patient with diabetic foot infection was transferred to the hospital after ineffective treatment in other hospital. Flap surgery was performed from 0 to 56 days (median, 22 days) after admission. A total of 26 thigh flaps were harvested in 25 patients, with unilateral flaps in size of 7 cm×5 cm to 40 cm×10 cm. The type, caliber, and location of the perforating branch were recorded during the operation, and the anatomical characteristics of the oblique branch of the intramuscular trunk were mainly observed. The flap harvesting time was recorded; the flap survival and wound healing time were observed; at last follow-up, XIAO Feipeng et al. flap comprehensive efficacy evaluation table was used to evaluate the effectiveness of flap repair from three aspects of donor site, recipient site, and subjective satisfaction of doctors and patients.

Results

After the oblique branch in intramuscular of lateral circumflex femoral artery was sent out, it ran 2-3 cm obliquely laterally and inferiorly in the intermuscular septum and then entered the vastus lateralis muscle, and sent out perforating branches to nourish the skin. A total of 61 perforating branches were marked in 26 thighs of 25 patients before operation, and 70 perforating branches were found during operation, including 9 transverse branches, 29 descending branches, and 32 oblique branches, all of the oblique branches were musculocutaneous perforators. All 25 patients were followed up 6-10 months, with an average of 8 months. The time of unilateral thigh flap harvesting ranged from 13 to 90 minutes, with an average of 48 minutes. One patient with diabetes developed disturbance of blood supply and complete necrosis of the flap at 1 month after operation, and then the flap was repaired with skin graft; 1 case developed arterial crisis after operation, which survived after timely exploration; and the rest of the flaps survived smoothly. The wound healing time of the recipient site ranged from 10 to 44 days, with an average of 19 days, and the donor site of the thigh healed by first intention. At last follow-up, the color and texture of the flap was good and the sensation recovered to S1-S2. Only linear scar was left in the donor site, no scar contracture, pain, and other discomfort occurred, and no other serious complications occurred. Evaluated by flap comprehensive efficacy evaluation table, the score was 74-93, with an average of 88, of which 10 cases were excellent, 13 cases were good, and 2 cases were fair, with an excellent and good rate of 92%.

Conclusion

The intramuscular trunk oblique branch is not uncommon, and its trunk course and perforators distribution are regular. To improve the understanding of this type of oblique branch and adopt appropriate methods during operation can improve the success rate of skin flap extraction.

Keywords: Perforator flap, anterolateral thigh perforator flap, lateral circumflex femoral artery, oblique branch

作为修复肢体创面的主力皮瓣之一，股前外侧皮瓣在临床上应用广泛，经典股前外侧皮瓣多以旋股外侧动脉降支为血管蒂[1]。随着临床应用增多，许多学者发现降支穿支存在一定程度变异，往往会导致皮瓣切取失败。此时，利用其他来源穿支切取皮瓣是一种可供选择的中转方案。作为旋股外侧动脉降支穿支缺如或变异时的有益补充，以斜支为蒂切取股前外侧穿支皮瓣成为近年研究热点[2]。有学者认为，相较于旋股外侧动脉降支，斜支具有肌间隙穿支比例较高、手术切取时间短、供区更加隐蔽、切取后可供直接缝合宽度相对大等优点，或可成为股前外侧穿支皮瓣的首选血管蒂[3]。然而，当前国内外对于旋股外侧动脉斜支的概念存在争议，对于其主干走行特点、穿支分布规律等缺乏系统研究[4-5]，如遇斜支位于股外侧肌内，术中易损伤斜支血管，导致皮瓣切取失败或放弃手术。2020年12月—2021年4月，苏州大学附属瑞华医院在以斜支为源动脉的股前外侧穿支皮瓣修复肢体创面患者中，发现肌内主干型斜支25例26侧。现对其特点及术中应对策略进行总结，为切取以斜支为蒂的股前外侧穿支皮瓣提供参考。报告如下。

1. 临床资料

1.1. 一般资料

本组男16例，女9例；年龄14～75岁，中位年龄43岁。致伤原因：机器或重物挤压伤10例，交通事故伤6例，机器绞伤3例，热压伤3例，冲压伤1例，切割伤1例，糖尿病足部感染皮肤坏死1例。创面均合并不同程度骨与深部组织外露，缺损部位：手部13例，前臂2例，小腿2例，足踝部8例。创面范围6 cm×4 cm～35 cm×22 cm。24例外伤患者受伤后均急诊入院，1例糖尿病足部感染患者外院治疗无效后转入我院；入院后0～56 d（中位时间22 d）行皮瓣手术。

1.2. 手术方法

1.2.1. 穿支定位

术前常规采用高频彩色超声对患者股外侧区穿支血管定位：以髂髌连线为轴心线，探测该线两侧各3 cm范围内的穿支，并测量其口径，于体表相应位置进行标记。标记所有探测到的穿支，重点关注髂髌连线中点附近及中点近端的粗大穿支。此外，本组25例患者因存在受区主干血管缺损，在彩色超声定位基础上加行受区及供区数字减影血管造影定位。

1.2.2. 受区准备与处理

1例糖尿病足感染患者入院后积极换药及控制血糖后行皮瓣手术。24例外伤患者入院后均予以急诊清创，根据创面污染程度、清创后软组织条件或皮肤软组织缺损严重程度，判断是否一期行皮瓣修复。本组3例患者清创后创面污染程度轻且皮肤软组织缺损严重无法行回植手术，予以急诊皮瓣修复；21例一期行清创、血管神经肌腱探查修复、撕脱皮肤回植或封闭式负压吸引后，二期行皮瓣覆盖。二期皮瓣切取前对受区再次清创，切除失活及坏死组织，生理盐水、3%过氧化氢溶液、稀聚维酮碘溶液反复冲洗创面，解剖分离合适的血管作为皮瓣供血动脉，并做好标记。根据受区创面缺损情况绘制样布。

1.2.3. 皮瓣设计与切取

设计以斜支为蒂股前外侧穿支皮瓣修复创面。设计方法：① 参考术前穿支定位，以髂髌连线为轴心线，以近端较粗大穿支为皮瓣轴心点；② 提捏法判断供区可供直接缝合宽度，根据样布大小，在保证供区可直接拉拢缝合前提下设计皮瓣，若皮瓣宽度过大，则设计双叶皮瓣或切取双侧股前外侧穿支皮瓣，对样布进行裁剪、拼接等二次设计；③ 若进行分叶设计，尽量保证每叶皮瓣均有穿支进入。本组共切取双叶皮瓣7例、双侧大腿股前外侧穿支皮瓣1例。

皮瓣切取：自内侧缘切开皮肤，于阔筋膜下方、肌膜上方掀起皮瓣，仔细分离皮下筋膜组织，参考术前定位标记寻找穿支，若术野内无明显粗大穿支，可纵向延长皮瓣内侧缘寻找穿支。保留所有肉眼可见的穿支，选择合适穿支为目标穿支。确认目标穿支后，切开皮瓣周缘，暴露股直肌与股外侧肌的肌间隔，观察目标穿支来源及口径，若穿支为肌皮穿支，无论术野中有无斜支，均应考虑穿支是由斜支发出的可能。仔细分离皮下筋膜，逆向解剖穿支及源动脉，游离至足够长度血管蒂后断蒂。若穿支来自斜支且斜支主干位于肌内，首先需要在穿支出肌处对血管进行逆向追溯，可用组织剪撑开血管上方肌肉，逐层锐性分离，直至将血管蒂完全暴露，再从穿支入肌处仔细分离血管的左、右、下3个面，注意结扎沿途肌支，减少术中出血，保证术野清晰，直至游离出适当长度的血管蒂。根据受区需要设计血流桥接型（3例）、嵌合型（2例）等特殊形式穿支皮瓣。将皮瓣移植覆盖受区，供区皮下减张美容缝合。本组25例患者共切取26侧大腿皮瓣，单侧切取范围为7 cm×5 cm～40 cm×10 cm。

1.3. 术后处理及疗效观测指标

术后常规制动、烤灯照射、抗凝、抗痉挛、抗感染治疗，密切关注皮瓣血液循环情况，防止皮瓣动静脉危象发生。皮瓣成活后积极行康复功能锻炼。

术中观察斜支解剖学特点，统计斜支发出穿支类型、口径、位置等数据，重点分析肌内主干型斜支走行特点。记录患侧皮瓣切取时间；术后观察皮瓣成活情况及创面愈合时间；末次随访时采用肖飞鹏等[6]皮瓣综合疗效评价表，从供区、受区、医患主观满意度3个方面评定皮瓣修复疗效，共100分，其中优90～100分，良75～89分，可60～74分，差<60分。

2. 结果

2.1. 肌内主干型旋股外侧动脉斜支主干及穿支的解剖学特点

肌内主干型旋股外侧动脉斜支发出后，与股神经的1条分支及2条伴行静脉共同包绕于筋膜鞘内，沿股中间肌与股直肌的肌间隔内斜向外下方走行。其主干在走行2～3 cm后进入股外侧肌，并分为深支与浅支，均营养大腿近端的股中间肌与股外侧肌。斜支的浅支可于肌内发出皮肤穿支，穿支多位于髂髌连线中点近端，少数也可出现在中点以远。本组25例26侧大腿供区，术前共标记61条穿支，术中实际出现70条，其中来自横支9条、降支29条、斜支32条，所有斜支穿支均为肌皮穿支。

2.2. 临床结果

25例患者均获随访，随访时间6～10个月，平均8个月。本组单侧皮瓣切取时间13～90 min，平均48 min。1例（1侧）糖尿病患者皮瓣术后1个月出现血供障碍，皮瓣完全坏死，行植皮修复；1例术后发生动脉危象，经及时探查后成活；其余皮瓣均顺利成活。受区创面愈合时间为 10～44 d，平均19 d；大腿供区切口均Ⅰ期愈合。末次随访时，皮瓣色泽质地良好，感觉恢复至S1～S2。供区仅遗留线性瘢痕，未出现瘢痕挛缩及疼痛等不适，无其他严重并发症发生。皮瓣综合疗效评价表评分[6]为74～93分，平均88分；其中优10例、良13例、可2例，优良率92%。见图1、2。

图 1.

A 38-year-old male patient who suffered a hot compression injury on the back of right hand, and the wound was repaired with a free left anterolateral thigh perforator flap

患者，男，38岁，游离左股前外侧穿支皮瓣修复右手背热压伤创面

a. 术前创面外观；b. 扩创后创面缺损情况；c. 参考彩色多普勒超声定位，以髂髌连线中点近端粗大穿支为蒂设计股前外侧穿支皮瓣；d. 术中见斜支在髂前上棘下方16 cm处发出穿薄层肌肉穿支；e. 皮瓣修复术后即刻外观；f. 供区直接拉拢缝合；g. 术后10 d皮瓣成活；h. 术后10个月皮瓣外形无臃肿；i. 术后10个月供区外观

a. Preoperative appearance; b. Wound defect after wound expansion debridement; c. With reference to the location of color Doppler ultrasound, the anterolateral thigh perforator flap pedicled with the thick perforator of the midpoint of the iliopatellar line was designed; d. During the operation, the oblique branch sent out the perforator in the thin layer of muscle at the 16 cm below the anterior superior iliac spine; e. Appearance immediately after flap repair; f. The donor area was directly closed and sutured; g. The flap survived at 10 days after operation; h. The appearance of the flap was not bloated at 10 months after operation; i. Appearance of donor site at 10 months after operation

图 1

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图 2.

A 54-year-old male patient who suffered the skin and soft tissue defects of right thumb and the back of right hand due to strangulation, and the defect was repaired with free left anterolateral thigh perforator flap combined with the second toe of the left foot

患者，男，54岁，游离左股前外侧穿支皮瓣联合游离左足第2趾再造修复机器绞伤致右拇指及右手背皮肤软组织缺损

a. 术前创面外观；b. 分叶设计股前外侧穿支皮瓣；c. 术中见斜支在髂前上棘下方14 cm、降支在髂前上棘下方17 cm处发出穿肌皮穿支；d. 术中斜支与降支行内增压处理；e. 游离左足第2趾设计；f. 左足第2趾切取完毕；g. 修复创面及拇指术后即刻外观；h、i. 左大腿及左足供区直接拉拢缝合；j. 术后6个月皮瓣外形稍臃肿；k、l. 术后6个月左大腿及左足供区外观

a. Preoperative wound appearance; b. Split design of anterolateral thigh perforator flap; c. During the operation, the oblique branch was 14 cm below the anterior superior iliac spine, and the descending branch sent out musculocutaneous perforator in 17 cm below the anterior superior iliac spine; d. Pressurization treatment of oblique branch and descending branch during operation; e. Design of free second toe of left foot; f. The free second toe of left foot was cut off; g. The appearance after repair of the wound and thumb; h, i. Direct suture of the donor area of left thigh and foot; j. The shape of the flap was slightly bloated at 6 months after operation; k, l. The appearance of the donor area of the left thigh and left foot at 6 months after operation

图 2

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3. 讨论

文献报道旋股外侧动脉降支的穿支存在一定程度变异[7-8]。若术中未发现降支发出穿支或降支穿支过于细小，此时可选择其他来源穿支切取股前外侧穿支皮瓣。Wong等[9]发现在横支下方、降支外侧存在1条旋股外侧动脉分支，发出穿支营养股前外侧区皮肤的上半部分，将其命名为“斜支”。随后，有学者提出斜支可能成为股前外侧穿支皮瓣的首选血管蒂[10-11]。然而，目前国内外对于斜支的认识和研究不够全面，部分术者对斜支主干位置、穿支特点认识不足，极易在解剖过程中损伤该血管，导致切取失败或术后皮瓣坏死、斜支陷阱（即股前外侧穿支皮瓣下方的股外侧肌由降支供养，而上方皮肤血供由隐蔽在肌内的斜支支配，以降支为蒂切取肌皮瓣，会出现肌肉成活而部分皮瓣坏死）的发生[12]。我们在针对降支穿支缺如或较细的情况，开展以斜支为蒂股前外侧穿支皮瓣的临床应用中，同样发现上述问题。结合本组25例26侧临床经验，我们认为当斜支主干出现在股外侧肌内，术中打开股外侧肌与股直肌肌间隔仅可见降支而无明显斜支时，最有可能导致斜支血管损伤，这种情况不仅出现在肌皮瓣中，在单纯皮瓣中也常有发生。此类型斜支可称为肌内主干型斜支。

3.1. 肌内主干型斜支解剖特点

既往有学者提出，相较于降支，斜支有着更高的肌间隔穿支比例[13]。柳志锦等[14]对36例以斜支为源动脉的皮瓣穿支进行统计，斜支肌间隔穿支占61.2%，肌皮穿支占38.8%。以肌间隔穿支为目标血管在减少供区损伤的同时，有效缩短了皮瓣切取时间，因此大多数学者将注意力集中在斜支的高肌间隔穿支上，忽略了肌内主干型斜支。本研究发现，若术野中未找到斜支，或仅在近端根部见斜支入肌时，其第1皮穿支多为肌皮穿支，且主要形态学特点如下：斜支主干自旋股外侧动脉、股动脉或股深动脉发出后，与股神经的分支及2条静脉伴行，但只沿股中间肌与股直肌的肌间隔内斜向外下方走行很短距离后便进入股外侧肌，大多在髂髌连线中上1/3交界处分为深、浅2支，浅支穿浅层肌肉，深支穿厚层肌肉，深、浅2支的分支主要分布于股中间肌与股外侧肌，也可均于肌内发出皮肤穿支。以此型斜支皮穿支为血管蒂，需切开股外侧肌对穿支及主干进行游离。因为只有打开股外侧肌才可在肌肉深面看见斜支主干，在打开肌间隔时，往往只可见降支主干，若未考虑斜支的存在，极易误认为穿支由降支发出，此时需要术者仔细观察穿支发出位点和走行方向，才能辨别其来源。

3.2. 肌内主干型斜支的切取策略

Wong[12]提出对穿支由主干位于股外侧肌内斜支发出的情况，可逆行切开覆盖在斜支上方的股外侧肌，充分暴露其主干来保证顺利切取皮瓣。我们认为要真正解决肌内主干型斜支的临床应用问题，需要做到以下几点：① 充分认识斜支的高出现率。既往文献报道斜支出现率为3.3%～58%[3-4]，但部分学者仍将斜支视为变异。柳志锦等[14]对106例股前外侧穿支双叶皮瓣进行研究发现，斜支的穿支数量与降支相差不大，斜支应当是旋股外侧动脉的正常分支之一。② 熟悉斜支主干的走行特点及穿支分布规律。为达到精确化、个性化穿支修复原则[15-16]，要求在保证创面修复效果同时尽量减少供区损伤。术中遇到肌内主干型斜支时，需要对位于肌内部分的主干进行解剖，只有在掌握斜支主干走行规律的前提下，才能进行精确解剖，减少供区损伤。根据文献和本研究数据统计发现斜支的穿支多在髂髌连线中点近端，因此在该区域出现肌皮穿支，即使术野中未出现斜支也要考虑到穿支是发自斜支的可能。

术中若遇到肌内主干型斜支，我们认为可分为以下几步进行操作，来提高皮瓣切取成功率。第一步，暴露穿支及主干走行，于穿支出肌处对穿支进行逆向追溯，仔细分离，暴露其完整走行。第二步，根据其走行特点游离穿支，注意结扎沿途分支及保护股神经分支。第三步，结扎斜支主干的远端。穿支完全游离后，开始分离斜支主干的远端，在穿支发出位置下方约1 cm处结扎斜支，避免过度解剖增加损伤，若需要切取血流桥接型皮瓣，可根据受区需要适度延长。第四步，游离斜支主干近端直至所需长度的血管蒂。

3.3. 以肌内主干型斜支为蒂的股前外侧穿支皮瓣优缺点及注意事项

本组25例成功切取26侧肌内主干型斜支为蒂股前外侧穿支皮瓣，在应用方面与降支并无明显差异，同时具备以下优势：① 斜支穿支位置更靠大腿近端，切取位置更加隐蔽，符合“泳裤理论”[17-18]的要求。② 以传统降支为蒂设计股前外侧皮瓣，供区可直接缝合的宽度为8 cm左右[19]，而正常成人大腿周径自上而下逐渐缩小，大腿近端切取后可直接缝合的宽度较远端更大。本研究以斜支为蒂的皮瓣术后直接缝合宽度可达9～10 cm，部分患者甚至达12 cm。当然，对于患者可缝合宽度的测量可在术前用“提捏法”进行大致判断，我们认为以9 cm为宜。③ 既往文献报道[20]，股前外侧区的皮穿支大多聚集在髂髌连线中1/3，且由近及远穿支口径呈降低趋势。而斜支位于降支近端，穿支口径相对较大，皮瓣血供丰富；缺点是相较于肌间隙斜支，肌内主干型斜支解剖相对复杂，增加了术中操作时间及手术难度。

应用肌内主干型斜支为蒂切取皮瓣需要注意以下几点：① 斜支在髂髌连线中上1/3交界附近可分为深、浅2支，深支主要营养股外侧肌的上半部分，浅支主要营养股外侧区上半部分的皮肤，但2支均有可能发出皮肤穿支。术中如果确定所见2条及以上穿支均由斜支发出，需要考虑到2条穿支分别来自斜支的深支与浅支。深、浅2支在肌内走行不同，若要同时应用深、浅支的穿支，会增加源动脉分离难度，术者需有足够耐心。② 根据上述斜支特点，肌内主干型斜支同样可以设计和切取双叶、血流桥接型、嵌合型、联体等特殊形式穿支皮瓣。在逆行游离过程中需要注意对沿途斜支发出的粗大肌支仔细分离和标记，以便于断蒂后对于血管蒂的进一步处理。③ 对于临床经验较少者，不易发现肌内主干型斜支，可采用CT血管造影[21]联合数字减影血管造影或其他多种影像学定位结合的方式，在术前判断是否存在斜支，术中才能有的放矢。

综上述，肌内主干型斜支主干走行及穿支分布有其规律性，了解此类斜支的解剖学特点，才能做到个性化、精确化设计和切取股前外侧皮瓣，提高皮瓣切取成功率。

利益冲突　在课题研究和文章撰写过程中不存在利益冲突；基金经费支持没有影响文章观点和对研究数据客观结果的分析及其报道

伦理声明　研究方案经苏州大学附属瑞华医院伦理委员会批准（RHGK2022024）

作者贡献声明　杨林：参与手术、资料收集、论文撰写；柳志锦、高钦锋、刘胜哲、程俊楠：术前评估及手术操作；杨成鹏、张韬、孙丰文、黄永涛：病例资料整理及分析；巨积辉：主刀手术、论文审定、理论指导

Funding Statement

苏州市姑苏卫生人才计划项目（2020075）；苏州市民生科技项目关键技术应用研究（SS202092）；苏州市卫生科教临床重点病种诊疗技术专项（LCZX202026）；苏州市企业工程技术研究中心专项（SZS2019263）；苏州市姑苏卫生人才培养项目（GSWS2020116）；苏州市科教兴卫青年科技项目（KJXW2019073）

Health Talents Program of Suzhou Gusu District (2020075); Key Technology Application Research of Suzhou MinSheng Science and Technology Project (SS202092); Special Project on Diagnosis and Treatment Technology of Clinical Key Disease Species of Suzhou (LCZX202026); Special Project of Suzhou Enterprise Engineering Technology Research Center (SZS2019263); Suzhou Gusu Health Talent Training Project (GSWS2020116); Suzhou Science and Education Health Promotion Youth Science and Technology Project (KJXW2019073)

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Articles from Chinese Journal of Reparative and Reconstructive Surgery are provided here courtesy of Sichuan University

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