腹壁下动脉穿支血管构造在腹壁下动脉穿支皮瓣修薄中的应用

Thinning of the deep inferior epigastric artery perforator flap based on the vascular structure of the arterial perforator

目的应用影像学技术研究腹壁动脉穿支血管构造以及血供扩散模式，以指导腹壁下动脉穿支皮瓣（DIEP）修薄。方法临床影像学研究：15例拟行DIEP皮瓣手术患者，术前行腹部CT血管显影检查，观察腹壁浅层动脉穿支血管构造及毗邻关系。解剖影像学研究：取10具新鲜尸体的腹壁标本，将造影剂欧乃派克从动脉穿支灌注入皮瓣，在灌注过程中应用三维CT连续扫描，将所获得的数据在CT工作站上进行图像重建，并分析DIEP皮瓣动脉穿支血管构造及血供扩散过程。结果临床影像学研究中75条粗大穿支（直径〉0．5mm）以及解剖影像学研究中40条粗大穿支（直径〉0．5mm）纳入本研究。动脉穿支血管构造：穿支自腹直肌前鞘发出后，相对直接穿过腹壁深层脂肪、Scarpa’s筋膜以及腹壁浅层脂肪，进入真皮下血管网，分支均在Scarpa’s筋膜之上。血供扩散模式：穿支体间血供扩散只通过穿支体之间的连接血管即choke血管进行，穿支体内血供扩散方式包括真皮下血管网以及已存在的穿支体血管结构2种方式。结论根据DIEP皮瓣动脉穿支血管构造及扩散过程研究结果，Scarpa’s筋膜之下的有限修薄是安全的，Scarpa’s筋膜之上的极限修薄需根据DIEP皮瓣血供分区来进行。

Objective To explore flap thinning based on the study of the arterial structure and blood perfusion of the deep inferior epigastrie artery perforator （DIEP） flap using computed tomography （CT） angiography. Methods Clinical imaging study： Preoperative CT angiography was performed in 15 patients with DIEP flap reconstruction to investigate the vascular structure of arterial perforator. Cadaverie imaging study： 10 abdominal specimens harvested from fresh cadavers were cannulated with trocar and injected with contrast medium in the deep inferior epigastric artery perforator. During the perfusion of the contrast medium in the flap, the flap was scanned by three-dimensional CT. The CT data was then sent to CT workstation and the images were processed and reformatted to study the vascular structure of arterial perforators and the blood perfusion. Results 75 artery perforators in clinical study and 40 artery perforators in cadaveric study were chosen and analyzed. The major deep inferior epigastric artery perforators run directly across the deep layer of adipose tissue without bifurcating beneath the Scarpa＇s fascia. Above the Scarpa＇s fascia, the artery perforators bifurcate and ultimately terminate in the subdermal vascular plexus. Blood perfusion mode ： The subdermal vascular plexus served as the only pathway for blood perfusion between perforasomes. There are two different pathways for blood perfusion in the perforasome： the subdermal plexus and the existing vascular structure of perforator. Conclusions Based on the vascular structure of arterial perforator and blood perfusion of the DIEP flap, thinning of the DIEP flap under the Scarpa＇s fascia is safe while thinning above the Scarpa＇s fascia should performed according to the blood supply zone of the DIEP flap.