【摘要】：背景：顳淺血管束為蒂的額部皮瓣常用于頭面頸部組織缺損的修復(fù),因其動(dòng)脈血管解剖恒定、皮瓣組織豐富、供區(qū)隱蔽的特點(diǎn),是整形外科最為常用的皮瓣之一。由于顳淺靜脈分支與動(dòng)脈伴行關(guān)系不確切,臨床上存在皮瓣遠(yuǎn)端靜脈回流不暢、部分壞死的情況,一定程度上限制了皮瓣在臨床中的使用。另一方面,由于研究靜脈回流的難度大于動(dòng)脈供血,現(xiàn)有的研究手段及方法具有一定局限性,一定程度上限制了進(jìn)一步的深入研究。為了完善以顳淺血管為蒂的額部皮瓣術(shù)式,避免術(shù)后靜脈回流障礙的出現(xiàn),有必要進(jìn)一步詳細(xì)研究額顳部局部靜脈回流特點(diǎn)并總結(jié)規(guī)律。第一部分研究現(xiàn)有頭面部標(biāo)本的防腐及血管內(nèi)灌注方法加以改進(jìn),并使用12具人類尸體標(biāo)本采用分組對(duì)照的方法比較了三種不同的標(biāo)本制備及血管內(nèi)乳膠灌注方法,選出最適合于本研究項(xiàng)目的標(biāo)本制備方法。第二部分研究使用18具人體頭顱標(biāo)本,對(duì)顳淺動(dòng)脈流域內(nèi)的額顳部皮膚進(jìn)行詳細(xì)的動(dòng)靜脈血管解剖研究,觀察動(dòng)脈及靜脈分支在組織內(nèi)的分支走行規(guī)律,總結(jié)這一區(qū)域內(nèi)靜脈回流模式。對(duì)顳淺動(dòng)脈分支緊密伴行的細(xì)小附壁靜脈的管徑進(jìn)行了測(cè)量及分類研究,提出了附壁靜脈的分型和分支匯入點(diǎn)的保護(hù)措施,在此基礎(chǔ)上應(yīng)用靜脈回流模式對(duì)臨床上常見的幾種皮瓣的設(shè)計(jì)進(jìn)行分析,針對(duì)皮瓣出現(xiàn)靜脈回流障礙的原因提出了皮瓣設(shè)計(jì)的改進(jìn)原則。第三部分研究根據(jù)收集到的臨床頭面部DSA及CTA影像資料,對(duì)顳淺動(dòng)脈流域內(nèi)的額顳部皮膚進(jìn)行詳細(xì)的動(dòng)靜脈血管影像分析研究,觀察動(dòng)脈及靜脈分支在組織內(nèi)的分支走行規(guī)律,對(duì)解剖學(xué)研究所獲得的靜脈回流模式加以驗(yàn)證。研究發(fā)現(xiàn)影像學(xué)資料可以支持標(biāo)本解剖學(xué)研究所獲得的額顳部皮膚靜脈回流模式,CTA檢查可能更適合作為顳淺部皮瓣術(shù)前的影像學(xué)輔助檢查。第四部分研究針對(duì)解剖研究的結(jié)果和臨床觀察,提出吻合遠(yuǎn)端動(dòng)靜脈血管束的手術(shù)方案以改善皮瓣遠(yuǎn)端靜脈回流障礙。研究設(shè)計(jì)了兩組共15例患者的病例對(duì)照研究,吻合血管組獲得了全部成活的良好效果,而對(duì)照組則出現(xiàn)了不同程度的遠(yuǎn)端靜脈淤血以及皮瓣部分壞死。研究結(jié)果初步證實(shí)了根據(jù)額顳部皮膚靜脈回流特點(diǎn)所提出的皮瓣改進(jìn)設(shè)計(jì)可以改善皮瓣的遠(yuǎn)端靜脈回流。結(jié)論：額顳部皮膚的靜脈回流具有明顯的分區(qū)分層特性,各區(qū)域的靜脈回流在不同層面相互溝通形成由淺到深的靜脈回流網(wǎng)絡(luò)。臨床的皮瓣設(shè)計(jì)需考慮到這一區(qū)域靜脈回流的特點(diǎn)并加以改進(jìn),可以揚(yáng)長(zhǎng)避短發(fā)揮以顳淺血管為蒂的額部皮瓣的最大效能。
[Abstract]:Background: the frontalis flap pedicled with superficial temporal vascular bundle is often used to repair the head and neck tissue defect. Because of its constant arterial anatomy, abundant flap tissue and hidden donor area, it is one of the most commonly used flap in plastic surgery. Because of the inexact relationship between the branches of superficial temporal vein and the accompanying artery, the distal venous drainage and partial necrosis of the flap exist in clinic, which limits the use of the flap in clinic to a certain extent. On the other hand, because the study of venous reflux is more difficult than that of arterial blood supply, the existing research methods and methods are limited to some extent, which limits the further research. In order to perfect the operation method of frontalis flap pedicled with superficial temporal blood vessel and avoid the obstruction of venous reflux after operation, it is necessary to study the characteristics of local venous reflux in frontotemporal region in detail and summarize the rule. In the first part, the methods of anticorrosion and intravascular perfusion of head and face specimens were improved, and three different methods of preparation and intravascular emulsion perfusion were compared using 12 human cadavers. The most suitable specimen preparation method for this research project was selected. In the second part, 18 human head specimens were used to study the vascular anatomy of the frontotemporal skin in the superficial temporal artery basin, and to observe the branches of the arteries and veins in the tissues. To summarize the pattern of intraregional venous reflux in this area. The diameters of small parietal veins closely accompanied by the branches of superficial temporal artery were measured and classified. The classification of the vein attached to the wall and the protective measures of the entrainment point of the branches were put forward. On the basis of this, the design of some common flaps in clinic was analyzed by using venous drainage mode, and the improved principle of flap design was put forward in view of the reasons for the obstruction of venous reflux. In the third part, according to the clinical data of DSA and CTA, the arteriovenous images of frontotemporal skin in superficial temporal artery watershed were analyzed in detail, and the branches of artery and vein in tissues were observed. The pattern of venous reflux obtained by the Anatomy Institute was verified. It is found that the imaging data can support the frontotemporal skin venous drainage pattern CTA which obtained from the anatomical study may be more suitable for the imaging auxiliary examination of superficial temporal flap before operation. In the fourth part, according to the results of anatomical study and clinical observation, the surgical scheme of distal vascular bundle anastomosis was put forward to improve the obstruction of distal venous reflux of the flap. A case-control study of 15 patients in two groups was carried out. The vascular anastomosis group achieved good results of survival, while the control group showed different degrees of distal venous congestion and partial necrosis of the flap. The results preliminarily confirmed that the improved design of the skin flap based on the characteristics of frontotemporal skin venous drainage can improve the distal venous drainage of the flap. Conclusion: the venous reflux in frontotemporal skin has obvious zonal stratification and the venous reflux in different regions communicates with each other on different levels to form a superficial to deep venous reflux network. The clinical design of the flap needs to take into account the characteristics of the regional venous reflux and be improved to maximize the effectiveness of the frontalis flap pedicled with superficial temporal vessels.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R622
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本文編號(hào)：2162209