本文關(guān)鍵詞：嵌合穿支皮瓣的應(yīng)用解剖和臨床研究　出處：《浙江大學(xué)》2017年博士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 穿支定位 腓腸內(nèi)側(cè)動(dòng)脈穿支皮瓣 股前外側(cè)穿支皮瓣 腓骨皮瓣 內(nèi)鏡 嵌合皮瓣 手術(shù)設(shè)計(jì)

【摘要】：研究背景:隨著穿支皮瓣的發(fā)展和應(yīng)用,以穿支為基礎(chǔ)的分葉皮瓣設(shè)計(jì)被廣泛應(yīng)用。Hallock[1]受希臘神話中一種獅頭、山羊身體、蝎尾的怪獸奇美拉(Chimera)的啟發(fā),首先提出"嵌合皮瓣"(Chimeric flap),的概念。嵌合皮瓣的定義是在指同一供血系統(tǒng)的多個(gè)組織瓣(皮瓣骨、肌腱、筋膜、肌肉)通過獨(dú)立的血管供養(yǎng),但又共同起源于上一級(jí)母體血管蒂的一組皮瓣。臨床上應(yīng)根據(jù)嵌合皮瓣的設(shè)計(jì)應(yīng)根據(jù)供血系統(tǒng)的不同類型使用不同的類型的嵌合皮瓣。常用的嵌合穿支皮瓣供區(qū)有:帶腓動(dòng)脈嵌合穿支皮瓣[2];帶旋髂深動(dòng)脈嵌合穿支皮瓣[3];帶肩胛下血管嵌合穿支皮瓣[4];帶旋股外側(cè)動(dòng)脈嵌合穿支皮瓣[5];帶腹壁下動(dòng)脈嵌合穿支皮瓣[6];帶腓腸內(nèi)側(cè)動(dòng)脈嵌合穿支皮瓣[7]。腓腸內(nèi)側(cè)動(dòng)脈穿支(MSAP)皮瓣由于MSAP解剖恒定,供區(qū)位置隱蔽、血管蒂較長(zhǎng)、皮下脂肪少、供區(qū)損傷小,現(xiàn)腓腸內(nèi)側(cè)穿支皮瓣已成為頭頸部及四肢創(chuàng)面修復(fù),功能重建最常用的皮瓣之一。腓腸內(nèi)側(cè)動(dòng)脈嵌合穿支皮瓣具備腓腸內(nèi)側(cè)動(dòng)脈皮瓣的優(yōu)點(diǎn)外還兼具嵌合穿支皮瓣只需吻合一組血管即可多個(gè)所有組織瓣的血供,新穎實(shí)用,實(shí)現(xiàn)了創(chuàng)面的立體三維重建的優(yōu)點(diǎn)。隨著它的廣泛應(yīng)用,腓腸內(nèi)側(cè)動(dòng)脈系統(tǒng)的應(yīng)用解剖也逐漸受到重視�，F(xiàn)有的MSA系統(tǒng)的應(yīng)用解剖研究主要集中在MSAP的分布和辨識(shí),以及MSA及其分支在腓腸肌內(nèi)的分布和走行。ALT皮瓣一直被認(rèn)為理想的嵌合皮瓣之一,它具有較粗和穩(wěn)定的穿支,通常能夠提供2～3個(gè)較大的皮穿支供應(yīng)分葉的皮瓣。旋股外側(cè)動(dòng)脈易于分離,且大腿血供豐富,它的切取不會(huì)引起肌肉壞死,而且股前外側(cè)區(qū)可以提供較大量的皮膚筋膜組織和肌組織瓣,以適應(yīng)多種規(guī)模的修復(fù)重建手術(shù)。腓動(dòng)脈系統(tǒng)是經(jīng)典的嵌合皮瓣供區(qū),除了皮膚筋膜和少量肌肉組織外,腓動(dòng)脈系統(tǒng)提供了足量的骨組織。腓動(dòng)脈嵌合骨皮瓣可以用于多樣化的修復(fù)重建手術(shù)中。游離腓骨瓣是修復(fù)重建頭面部長(zhǎng)段骨缺損的可靠方法之一目前穿支皮瓣血管定位的方法主要有手持式超聲(Handled Doppler),彩色多普勒超聲(Color Duplex),計(jì)算機(jī)層析成像血管造影(Computed Tomographic Angiography,CTA),磁共振血流成像(MRA)和數(shù)字減影血管造影術(shù)(digital subtraction angiography,DSA)。不論何種方法,都有可能出現(xiàn)不準(zhǔn)確的情況。內(nèi)鏡技術(shù)已經(jīng)廣泛應(yīng)用于各個(gè)專科的診斷和治療。穿支游離皮瓣需要在肌肉內(nèi)分離血管蒂,以目前的技術(shù)要進(jìn)行內(nèi)鏡下的穿支分離仍然存在風(fēng)險(xiǎn)。但是在內(nèi)鏡下進(jìn)行穿支探查,以減少穿支變異帶來(lái)的供區(qū)大范圍損傷已經(jīng)有報(bào)道[8]。隨著計(jì)算機(jī)輔助設(shè)計(jì)和制造技術(shù)的精度迅速發(fā)展,虛擬手術(shù)設(shè)計(jì)技術(shù)正在影響和改變外科醫(yī)生對(duì)骨性重建手術(shù)的方案制定[9]。并使用3D打印技術(shù)構(gòu)建的骨模型上進(jìn)行數(shù)字化設(shè)計(jì)的截骨和鈦板塑形[10]。這些技術(shù)縮短了手術(shù)時(shí)間,減少了腓骨瓣失敗率,并獲得了更好的外觀和功能。第一部分腓腸內(nèi)側(cè)動(dòng)脈系統(tǒng)的應(yīng)用解剖研究方法:1.研究對(duì)象為4具成人尸體共8例下肢標(biāo)本進(jìn)行小腿內(nèi)側(cè)區(qū)解剖。2.發(fā)現(xiàn)腓腸內(nèi)側(cè)動(dòng)脈穿支后解剖并標(biāo)記,記錄穿支類型、數(shù)目、穿出深筋膜外徑、穿出點(diǎn)坐標(biāo)及與腓腸神經(jīng)的關(guān)系等。3.解剖并記錄腓腸內(nèi)側(cè)動(dòng)脈的分支類型,測(cè)量分支血管蒂長(zhǎng)(遠(yuǎn)端穿支點(diǎn)至分支匯入腓腸動(dòng)脈主干距離)和分支動(dòng)脈直徑、主干血管蒂長(zhǎng)(遠(yuǎn)端穿支點(diǎn)至腓腸動(dòng)脈匯入乆動(dòng)脈起點(diǎn))和主干動(dòng)脈直徑。4.統(tǒng)計(jì)分析腓腸內(nèi)側(cè)動(dòng)脈穿支來(lái)源于腓腸內(nèi)側(cè)動(dòng)脈的內(nèi)側(cè)或外側(cè)分支的情況,測(cè)量穿支出深筋膜處到分支血管的深度。結(jié)果:1.解剖4具成人尸體(男性3具,女性1具)共8例下肢標(biāo)本。其中7例發(fā)現(xiàn)腓腸動(dòng)脈穿支2支,1例發(fā)現(xiàn)穿支3支。全部穿支均為肌皮穿支。顯微手術(shù)放大鏡下測(cè)量穿支直徑0.68±0.19mm。穿支距離正中線水平距離3.88±1.22cm,穿支距離乆橫紋垂直距離8.94±2.11cm。位置坐標(biāo)以(x,y)表示。穿支距離腓腸神經(jīng)距離 3.49±0.77cm。2.8例下肢標(biāo)本腓腸內(nèi)側(cè)動(dòng)脈的分支類型中,有Ⅰ型0例(0%),ⅡA型2例(25%),ⅡB 型(62.5%),Ⅲ型1例(12.5%)。分支蒂長(zhǎng) 7.00±1.85cm,分支蒂動(dòng)脈直徑1.46±0.28mm。腓腸內(nèi)側(cè)動(dòng)脈主干蒂長(zhǎng)11.00±1.85cm,主干蒂動(dòng)脈直徑2.49±0.42mm。3.腓腸內(nèi)側(cè)動(dòng)脈自乆動(dòng)脈發(fā)出后,通常分為內(nèi)側(cè)和外側(cè)兩個(gè)分支血管。8例標(biāo)本中有7例屬于這種情況(1例有3個(gè)分支)。7例標(biāo)本共發(fā)現(xiàn)穿支15個(gè),其中8個(gè)分布于外側(cè)分支,7個(gè)分布于內(nèi)側(cè)分支。其中外側(cè)分支距離腓腸內(nèi)側(cè)動(dòng)脈穿支穿深筋膜處0.58±0.11cm,內(nèi)側(cè)分支距離距離腓腸內(nèi)側(cè)動(dòng)脈穿支穿深筋膜處0.87±0.45cm。t檢驗(yàn)t=1.72,P=0.11,P0.05,認(rèn)為無(wú)統(tǒng)計(jì)學(xué)差異。來(lái)自外側(cè)分支血管的穿支直徑0.79±0.21cm,來(lái)自內(nèi)側(cè)分支血管的穿支直徑0.61±0.12cm。t檢驗(yàn)t=1.91,P=0.078,P0.05,認(rèn)為無(wú)統(tǒng)計(jì)學(xué)差異。外側(cè)分支血管蒂部的直徑1.44±0.27mm,內(nèi)側(cè)分支蒂部直徑 1.27±0.32mm。t 檢驗(yàn) t=1.06,P=0.31,P0.05。結(jié)論:1.MSAP在8例下肢尸體標(biāo)本中平均每例有2.1支穿支。顯微手術(shù)放大鏡下測(cè)量穿支直徑0.68±0.19mm。穿支距離正中線水平距離3.88±1.22cm,穿支距離乆橫紋垂直距離8.94±2.11cm。2.8例下肢標(biāo)本MSP分支類型中,有Ⅰ型0例(0%),ⅡA型2例(25%),ⅡB型5例(62.5%),Ⅲ型1例(12.5%)。分支蒂長(zhǎng)7.00±1.85cm,分支蒂動(dòng)脈直徑1.46±0.28mm。腓腸內(nèi)側(cè)動(dòng)脈主干蒂長(zhǎng)11.00±1.85cm,主干蒂動(dòng)脈直徑2.49 ± 0.42mm。3.MSA內(nèi)、外側(cè)分支距離深筋膜穿支點(diǎn)的距離沒有統(tǒng)計(jì)學(xué)差異(t=1.72,P=0.11)。內(nèi)、外側(cè)分支發(fā)出的穿支直徑?jīng)]有統(tǒng)計(jì)學(xué)差異(P=0.078,P0.05)。MSA內(nèi)、外側(cè)分支蒂部動(dòng)脈的直徑?jīng)]有統(tǒng)計(jì)學(xué)差異(t=1.06,P=0.31)。術(shù)前影像學(xué)定位尋找較淺的分支可以減少肌肉內(nèi)血管分離的時(shí)間和難度。4.MSA分支和穿支的變異要求MSAP嵌合皮瓣術(shù)前精確的設(shè)計(jì),包括對(duì)穿支的定位,對(duì)分支類型及其與穿支關(guān)系的探查,對(duì)供區(qū)血管直徑及到創(chuàng)面距離的評(píng)估。第二部分內(nèi)鏡下穿支探查在穿支皮瓣的臨床應(yīng)用研究方法:1.MSAP皮瓣和ALT穿支皮瓣住院病例35人(其中分葉嵌合皮瓣10例,見第三部分)。術(shù)前彩色多普勒穿支定位,標(biāo)記穿支位置,直徑和血流參數(shù)。2.術(shù)中以4mm30°內(nèi)窺鏡探查標(biāo)記點(diǎn)穿支,記錄假陽(yáng)性和假陰性,進(jìn)行統(tǒng)計(jì)學(xué)分析。結(jié)果:1.病例35例,其中男性29例,女性6例。其中18(51.4%)例進(jìn)行MSAP皮瓣,17(48.6%)例為ALT穿支皮瓣。內(nèi)鏡下共查到可用穿支68支,術(shù)中檢測(cè)均能供養(yǎng)皮瓣。其中發(fā)現(xiàn)彩色多普勒超聲出現(xiàn)假陰性7例,假陽(yáng)性3例。敏感度=真陽(yáng)性/(真陽(yáng)性+假陰性)=61/(7+61)=89.7%。2.彩色多普勒超聲出現(xiàn)假陰性7例中,穿支直徑0.55±0.19cm;真陽(yáng)性61例中,穿支直徑0.76±0.23cm。t檢驗(yàn)有統(tǒng)計(jì)學(xué)差異。t=2.1,P=0.03,P0.05。假陽(yáng)性3例中,均為將小靜脈認(rèn)為穿支血管。結(jié)論:1.35例皮瓣內(nèi)窺鏡下共探到穿支68支,術(shù)中檢測(cè)均能供養(yǎng)皮瓣。其中發(fā)現(xiàn)彩色多普勒超聲出現(xiàn)假陰性7例,假陽(yáng)性3例。敏感度=真陽(yáng)性/(真陽(yáng)性+假陰性)=61/(7+61)=89.7%。假陰性7例,穿支直徑0.55±0.19cm,真陽(yáng)性61例,穿支直徑0.76±0.23cm。t檢驗(yàn)有統(tǒng)計(jì)學(xué)差異。t=2.1,P=0.03,P0.05。推測(cè)彩色多普勒超聲對(duì)較細(xì)穿支可能出現(xiàn)漏檢。假陽(yáng)性3例,均為將小靜脈認(rèn)為穿支血管。2.術(shù)中內(nèi)鏡下穿支探查可以調(diào)整皮瓣設(shè)計(jì),使穿支游離皮瓣手術(shù)更為精準(zhǔn)。同時(shí)能夠排除術(shù)前定位中的假陰性和假陽(yáng)性穿支,為穿支皮瓣的應(yīng)用提供保障,對(duì)嵌合穿支皮瓣尤為重要。第三部分嵌合穿支皮瓣對(duì)復(fù)雜創(chuàng)面的修復(fù)方法:1.對(duì)象為15例嵌合穿支皮瓣(包括ALT嵌合穿支皮瓣3例和MSAP嵌合皮瓣12例)游離移植進(jìn)行修復(fù)重建的患者,術(shù)前采用彩色多普勒定位和設(shè)計(jì)。2.術(shù)中內(nèi)鏡探查穿支,手術(shù)切取嵌合皮瓣并記錄嵌合皮瓣包括的組織瓣類型,皮瓣大小,厚度,穿支血管的數(shù)目,位置,分支血管的分型,血管蒂的長(zhǎng)度。3.術(shù)后即時(shí)觀察皮瓣血供情況,對(duì)血管危險(xiǎn)及時(shí)處理。隔天換藥,觀察記錄有無(wú)皮瓣相關(guān)并發(fā)癥的出現(xiàn)。術(shù)后3～6月隨訪皮瓣功能。結(jié)果:1.本組腓腸內(nèi)側(cè)動(dòng)脈嵌合穿支皮瓣12例。皮瓣成活情況:11例皮瓣存活。1例行雙葉嵌合皮瓣:一葉用于修復(fù)食管缺損另一葉用作觀察皮瓣,術(shù)后3天觀察皮瓣血管危象,探查見修復(fù)食管的皮瓣血運(yùn)好,而觀察皮瓣穿支血管栓塞,切除壞死皮瓣,創(chuàng)面拉攏縫合。小腿供區(qū)傷口愈合情況:5例直接拉攏縫合,7例植皮。15例供區(qū)Ⅰ期愈合,1例因術(shù)后供區(qū)部分腓腸肌內(nèi)側(cè)頭壞死行清創(chuàng)手術(shù)后愈合。術(shù)后3～6周隨訪皮瓣色澤與周圍正常皮膚相似,無(wú)臃腫,質(zhì)地柔軟。股前外側(cè)動(dòng)脈嵌合穿支皮瓣3例。2例存活,1例邊緣部分壞死。術(shù)后1例皮瓣臃腫二期行皮瓣修薄術(shù)。再造器官功能相關(guān)的并發(fā)癥包括食管瘺、尿道狹窄等。2.本組15例病例其中10例內(nèi)窺鏡下確認(rèn)穿支23支,超聲下出現(xiàn)假陰性2支,假陽(yáng)性1支。3.皮瓣選擇上如果皮瓣需要較薄,面積不太大的情況使用MSAP皮瓣;如果厚度要求不大,但面積需求大的供區(qū)選擇ALT皮瓣;此外,小腿穿支不穩(wěn)定的情況以ALT皮瓣備用。結(jié)論:1.嵌合穿支皮瓣損傷一處供區(qū),吻合一組血管的情況下修復(fù)重建了多種組織或多個(gè)創(chuàng)面。利用游離皮瓣自身的特點(diǎn),結(jié)合穿支和分支的解剖位置,可以完成復(fù)雜創(chuàng)面的修復(fù)和器官的再造。2.術(shù)前彩色多普勒穿支定位和術(shù)中內(nèi)鏡下穿支探查可以精確定位游離皮瓣的穿支情況,為嵌合穿支皮瓣的設(shè)計(jì)提供保障,有效避免了供區(qū)組織浪費(fèi),損傷。3.術(shù)中對(duì)結(jié)合多種輔助手段對(duì)嵌合皮瓣的設(shè)計(jì)是手術(shù)成敗的關(guān)鍵,這不僅需要精確的穿支定位,還需要術(shù)者對(duì)再造組織空間結(jié)構(gòu)的良好把握。第四部分?jǐn)?shù)字化及三維打印技術(shù)在嵌合游離腓骨皮瓣中的臨床應(yīng)用方法:研究對(duì)象為2009年8月至2016年12月行嵌合游離腓骨皮瓣修復(fù)手術(shù)19例,其中16例自2011年8月起應(yīng)用數(shù)字化及三維打印技術(shù)進(jìn)行輔助設(shè)計(jì),5例應(yīng)用手術(shù)導(dǎo)航系統(tǒng)進(jìn)行定位、追蹤或驗(yàn)證下頜骨的修復(fù)。年齡30～58歲,其中男性17人,女性2人。19例患者中14例為上/下頜骨腫瘤切除后,腓骨皮瓣再造,1例脛骨及4例為掌指骨及皮膚缺損后的再造。本組19例患者中,采用右側(cè)腓骨移植4例,左側(cè)15例;腓骨截骨最長(zhǎng)18cm;腓骨截為5段者1例,4段者2例,3段者11例,1段者5例;19例腓骨瓣均含穿支皮瓣,其中1例腓骨嵌合雙葉穿支皮瓣,皮瓣最大16cm×5cm。頜骨再造患者術(shù)前行上下頜骨薄層螺旋CT掃描三維重建后進(jìn)行模擬切除,利用鏡像功能恢復(fù)患側(cè)下頜骨形態(tài),制作CAD/CAM模型,用三維打印機(jī)制作實(shí)物模型、鏡像模型、在此基礎(chǔ)上根據(jù)切除范圍及截骨位置個(gè)性化設(shè)計(jì)腓骨修復(fù)方案并打印面部截骨導(dǎo)板及腓骨塑形導(dǎo)板,根據(jù)模型預(yù)先彎制鈦板;修復(fù)重建手部患者術(shù)前攝手部薄層螺旋CT,利用鏡像功能恢復(fù)患側(cè)掌、指骨形態(tài)。供區(qū)小腿術(shù)前血管造影后行螺旋CT掃描并將掃描數(shù)據(jù)輸入計(jì)算機(jī),應(yīng)用Amira3.1軟件重建腓骨、腓動(dòng)靜脈及腓動(dòng)脈穿支血管,再根據(jù)腓骨缺損長(zhǎng)短、形狀、血管蒂、腓動(dòng)脈穿支位置設(shè)計(jì)并三維打印腓骨截骨及塑形導(dǎo)板并設(shè)計(jì)腓骨及腓骨皮瓣切取的位置。術(shù)中受區(qū)根據(jù)截骨導(dǎo)板截除原發(fā)灶。供區(qū)根據(jù)腓動(dòng)脈穿支位置及皮膚或黏膜缺損設(shè)計(jì)皮瓣,應(yīng)用截骨導(dǎo)板及塑形導(dǎo)板指導(dǎo)腓骨皮瓣切取和腓骨塑形,塑形后的腓骨按術(shù)前設(shè)計(jì)固定,并用手術(shù)導(dǎo)航系統(tǒng)驗(yàn)證復(fù)位的正確性,縫合皮瓣,吻合血管。術(shù)后觀察皮瓣血供情況,對(duì)血管危險(xiǎn)及時(shí)處理。隔天換藥,觀察記錄有無(wú)皮瓣相關(guān)并發(fā)癥的出現(xiàn)。術(shù)后3～6月隨訪外形及功能。結(jié)果:本組19例腓骨嵌合穿支皮瓣18例成活,1例術(shù)后3天發(fā)現(xiàn)血管栓塞皮瓣壞死,去除皮瓣,腓骨表面骨膜,改游離腓骨移植。3月后檢查骨愈合良好。6月后所有病例復(fù)查經(jīng)臨床觀察及CT檢查證實(shí)骨愈合良好。術(shù)后外觀及功能的恢復(fù)均達(dá)到滿意效果。結(jié)論:數(shù)字化及三維打印技術(shù)在嵌合游離腓骨皮瓣的臨床應(yīng)用在術(shù)前能更直觀和深刻地了解病變部位的解剖結(jié)構(gòu)和病變范圍,在實(shí)體模型上預(yù)演手術(shù)經(jīng)過以最終確定手術(shù)方案,并能預(yù)知術(shù)后形態(tài)恢復(fù)的效果。提高手術(shù)的精確性和可控性,并減少了手術(shù)時(shí)間和創(chuàng)傷、最后達(dá)到修復(fù)的功能化和個(gè)體化。真正達(dá)到數(shù)字化外科手術(shù),還需要結(jié)合手術(shù)導(dǎo)航系統(tǒng)進(jìn)行定位,追蹤或驗(yàn)證。
[Abstract]:Background: with the development and application of perforating flaps, the design of the perforator based lobular flap is widely used. Hallock[1] is a lion, goat body, scorpion monster chimera in Greek Mythology (Chimera) inspired, first proposed "chimeric flap" (Chimeric flap), the concept of. The definition of chimeric skin flap is defined by a plurality of tissue flaps (flap, tendon, fascia and muscle) that are supplied by independent blood vessels, but they originate from a group of skin flaps at the same level. According to the design of the chimeric flap, different types of chimeric flaps should be used according to the different types of blood supply system. The common area for chimeric perforator flap with fibular artery perforator flap: chimeric [2]; with deep iliac circumflex artery perforator flap with chimeric [3]; chimeric [4] subscapular artery perforator flap; lateral femoral circumflex artery perforator flap with chimeric [5]; inferior epigastric artery perforator flap with chimeric [6]; the medial sural artery perforator flap chimeric [7]. The medial sural artery perforator (MSAP) flap has many advantages, such as the MSAP anatomy is constant, the location of the donor site is hidden, the vascular pedicle is longer, the subcutaneous fat is less, and the donor site injury is small. Now the medial sural perforator flap has become one of the most commonly used skin flap for head and neck and limb wound repair. The medial sural artery perforator flap has the advantage of the medial sural artery flap, and has a chimeric perforating flap. Only a group of blood vessels can be anastomosed, and the blood supply of multiple tissue valves can be achieved. It is novel and practical, and achieves the advantages of three-dimensional reconstruction of the wound. With its extensive application, the applied anatomy of the medial sural artery system has been gradually paid attention to. The applied anatomy of the existing MSA system mainly focuses on the distribution and identification of MSAP, as well as the distribution and walking of MSA and its branches in the gastrocnemius muscle. ALT flap has always been considered as one of the ideal chimeric skin flap. It has a thick and stable perforator. It usually provides 2~3 larger cutaneous perforator branches to provide lobulated skin flap. The lateral femoral artery is easy to separate, and the blood supply to the thigh is abundant. Its cutting will not cause muscle necrosis, and the anterolateral thigh area can provide a lot of skin fascial tissue and muscle tissue flap to adapt to various scale repair and reconstruction operation. The peroneal artery system is a classic chimeric flap donor area. In addition to the skin fascia and a small amount of muscle tissue, the peroneal artery system provides a full amount of bone tissue. The peroneal artery chimeric bone flap can be used in a variety of repair and reconstruction. Free fibula flap is a reliable method to repair segmental bone defects in the head minister vascular perforator flap positioning method mainly hand-held ultrasound (Handled Doppler), color Doppler ultrasound (Color Duplex), computed tomography angiography (Computed Tomographic Angiography, CTA), magnetic resonance imaging (MRA) and digital subtraction angiography (digital subtraction angiography, DSA). In any way, it is possible to have an inaccurate situation. Endoscopic techniques have been widely used in the diagnosis and treatment of various specialties. The perforator free flap needs to separate the vascular pedicles in the muscles, and there is still a risk for the current technique to separate the perforator from the endoscope. But endoscopic perforator exploration to reduce the wide range of donor damage caused by perforator variation has been reported to have been [8]. With the rapid development of computer aided design and manufacturing technology, virtual surgery design technology is affecting and changing the [9] of surgeons for bone reconstruction surgery. The osteotomy and [10] of the titanium plate were made on the bone model constructed by the 3D printing technique. These techniques shorten the operation time, reduce the failure rate of the fibula flap, and gain a better appearance and function. The first part of the study of the applied anatomy of the medial sural artery system: 1. the subjects were 4 adult cadavers, 8 cases of lower extremity specimens were dissected in the medial area of the calf. 2., after finding the perforating branches of the medial sural artery, it was anatomized and marked. The type and number of perforating branches, the outer diameter of the deep fascia, the coordinates of the perforating points and the relationship with the sural nerve were recorded. 3. types of branch of anatomy and record the medial sural artery, measuring the length of the pedicle branch (distal perforating branch into the sural artery to pivot distance) and branch artery vessel diameter, length of pedicle (distal sural artery into the person to wear the fulcrum of artery artery diameter and the starting point). 4. statistical analysis of the medial sural artery branches from the medial sural artery and the lateral branch of the medial sural artery. Results: 1. of 4 adult cadavers (3 males and 1 females) were dissected in a total of 8 lower extremities. Of these, 2 were found in 7 cases of the perforator of the sural artery, and 1 of the perforator branches were found in 3. All the perforating branches were myocutaneous perforator. The diameter of the perforator was 0.68 + 0.19mm under microsurgical magnifying microscope. Perforator distance midline horizontal distance of 3.88 + 1.22cm, the distance of people across perforator vertical distance of 8.94 + 2.11cm. The position coordinates are represented by (x, y). The distance between the perforator and the sural nerve was 3.49 + 0.77CM. Of the 2.8 cases of the branches of the medial sural artery, there were 0 cases (0%), 2 (25%), type II B (62.5%), and 1 (12.5%) of type II A. The pedicle of branch was 7 + 1.85cm, and the diameter of pedicle artery was 1.46 + 0.28mm. The length of the main pedicle of the medial sural artery is 11 + 1.85cm, and the diameter of the trunk pedicle is 2.49 + 0.42mm. 3. people from the medial sural artery artery, usually divided into medial and lateral branch vessels two. Of the 8 cases, 7 were in this case (1 with 3 branches). A total of 15 perforator branches were found in 7 specimens, of which 8 were distributed in the lateral branch and 7 in the medial branch. The lateral branch is 0.58 + 0.11cm from the medial sural artery perforating branch, and the medial branch is 0.87 + 0.45cm from the medial sural artery perforator. T test t=1.72, P=0.11, P0.05, that there is no statistical difference
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R622

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