外踝后穿支皮瓣

Lateral retromalleolar perforator flap

目的:介绍外踝后穿支皮瓣的血管解剖基础与初步临床应用经验。方法:解剖观察外踝后间隙内腓动脉终末支发出的筋膜皮肤穿支情况。临床切取外踝后穿支皮瓣修复足踝创伤缺损3例。结果:外踝后间隙长约4cm,前界为外踝及腓骨长短肌腱,后方为跟腱,表面为深筋膜覆盖,间隙内充满疏松脂肪组织。在外踝后间隙内走行的腓动脉终末支及其延续的跟外侧动脉,共发出2～3条皮肤穿支血管,口径0.1～0.8mm。一般0.5mm以上的穿支血管总能找到1条。外踝后间隙内的穿支血管与上方的腓动脉最远侧肌间隔穿支血管间,遵循“压力平衡规律”,穿支血管的“口径和间距”互补代偿,以保证该区域血供的稳定。临床上设计切取以外踝后穿支血管为蒂的远端蒂腓肠神经筋膜皮瓣,旋转轴点在外踝尖上1～2cm,面积10～14cm×4～6cm,修复3例足踝创面,皮瓣完全成活。结论:外踝后穿支皮瓣将腓肠神经营养血管皮瓣的旋转轴点下移,更适合修复足踝远侧的创面,且减少对小腿供区的损害。

Objective: To introduce the anatomical study and clinical experience of lateral retromalleolar perforator flap. Methods: Microsurgical anatomic study was carried out, and was focused on the distal perforators of the peroneal artery. Then three cases of distally based lateral retromalleolar perforator flaps were raised for heel coverage. Results: The terminal part of peroneal artery ran distally in the lateral retromalleolar space. The space was usually 4cm long, with its anterior border of lateral malleolus and fibular tendons, medial border of Achilles tendon, covered by deep fascia, and filled with areolar fatty tissue. In the space, there were about 2-3 fasciocutaneous perforators with caliber 0.1~0.8 mm, usually at least one greater than 0.5 mm. These perforators showed a good example of pressure equilibrium, with compensation in outer diameter and interval with each other. The perforating artery usually had one or two partner veins. In clinic, the three flaps, measured 10~14 cm×4~6 cm with pivot point 1~2cm above the tip of lateral malleolus, survived completely and smoothly. Conclusions: Compared to distally based sural flaps pedicled with the lowermost septocutaneous perforator (5cm above lateral malleolus), the flap pedicled with retromalleolar perforator (1~2 cm above lateral malleolus) has the advantage of moving the pivot point to more distal region, thus makes the flap reversely reach more distal region of the foot, and reduces the trauma and morbidity to lower leg donor site.