| Objective:Through the measurement of donor area and shape , perforating point, distribution ,anastomosis ,branches,and density of blood vessels ,we aimed to replenish the perforation and distribution in deep fascia of medial supramalleolar cutaneous branch of posterior tibial artery and finally to provide anatomical basis for design and practice of the surgery that can repair the skin and soft tissue defects of legs and feet with medial supramalleolar perforator flap of posterior tibial artery .Methods:1. Gross anatomy were performed on 20 lower extremities of formaldehyde fixed cadavers to identify the perforating point and distribution in both superficial and deep fascia of medial supramalleolar cutaneous branch of posterior tibial artery.2. After vascular casting with red emulsion ,hierarchy alkali corrosion were performed on 10 fresh adult cadavers(20 lower legs), then observe and measure the superficial perforating point, branches, distribution, anastomosis, donor area, shape and blood vessel density of the perforator in situ. Compared with the ink-perfusion method in the studies before, our method showed an more direct, clear and stereotype view and also a more precise measured value, especially the stereotype and in situ display features were easy for the anastomosis of blood vessels nearby and distribution of the branches.Results:1. location of the superficial perforating point of Medial supramalleolar cutaneous branch: the average length of the straight line from the tip of medial malleolus to the medial condyle of tibia was 32.78±1.82cm .The average projected length from the superficial perforating point to the tip of medial condyle is 8.18±1.76cm.And the rate between the two data above was 0.24±0.08.2. Branches and distributions of the medial supramalleolar cutaneous branch of posterior tibial artery: the superficial perforating point of the medial supramalleolar cutaneous branch of posterior tibial artery was taken as zero on the coordinate, the perforating point and the midpoint between the posterior border of medial malleolus and midpoint of tendo calcaneus was taken as y-axis,and make an perpendicular line across zero as x-axis.The coordinate devided the donor area into four quadrants. The second and third branches distributed more in the inner-superior and outer-inferior quadrants, the (Dmax/L)calculated was 1.47±0.31. 3. Anastomosis of the medial supramalleolar cutaneous branch of posterior tibial artery. The anastomosis of the posterior tibial artery were formed in the following directions with the following vessels: the posterior tibial artery in the inner-superior and superior direction, the skin perforator of anterior tibial artery in the inner direction, the malleolus branch of fibular artery in the inner-inferior direction, the anterior malleolar from the anterior tibial artery in the inner-inferior direction, the branches below medial malleolus from anterior tibial artery in the outer-inferior direction.4. The donor area measurement of the medial supramalleolar cutaneous branch of posterior tibial artery. The border was the most tiny branches perfused which we could distinguish. The whole area was 72±8 cm2 , among which the inner-superior quadrant was15±2 cm2 ,the outer-superior quadrant was 8±3 cm2,the inner-inferior quadrant was 25±4 cm2and the outer-inferior quadrant was 24±3 cm2 .The area was about 520±26cm2 using coordinate paper as measurement.5. The shaper of donor area was about an ellipse.6. The density of blood vessels in the donor area increased according to the following order: Outer-superior, inner-superior, outer-inferior, inner-inferior.Disscusion: 1. The blood-supply feature of supramalleolar cutaneous branch of posterior tibial artery: the superficial perforating points were concentrated mostly at the distance 8～12 cm on the line between the malleolus and condyle, which confirmed an relative fixed position of the superficial perforating point. The second and third branches were mostly distributed in the outer-inferior and inner-inferior quadrants, which demonstrated high density of blood vessels and plentiful blood-supply here. Because of the nutrient vessel chains of the saphenus nerve, anastomosis in the inner-superior and inner-inferior quadrants were more than the other two parts. The nutrient vessel in the inner-superior quadrant formed more than two stereotype anastomosis with the perforator of posterior tibial artery and also formed anastomosis with anterior malleolar artery and branches from fibular artery. The measured value were relatively exact taken the most tiny branch that could be perfused and identified. The inner-inferior and outer-inferior quadrants were large because there were no large branches under the medial supramalleolar cutaneous branch of posterior tibial artery, the main blood supply were from this vessel. The donor area were smaller in the inner-superior and outer-superior quadrants, the reason may be there were larger branches above the perforater at the distance of about 5cm.But because of the plentiful anastomosis of the intermuscular branch with vessels nearby, the real area may be expanded. 2. The merits of the flap using medial supramalleolar cutaneous branch of posterior tibial artery: The pedicle of the flap were superficial and relatively fixed which lead to a easy operation, no injury to the posterior artery and if there were injures of the posterior artery, the transplantation can still be applied.Because of the abandunt anastomosis between the branches and definite blood supply, the donor area could be designed into different shapes and different area according to the defects of the soft tissue. The cutaneous branch were used as the pedicle of the flap, under which condition the blood fluxion could satisfy the physical need of the body and circulation of the flap itself. If the were large enough ,the saphenus nerve could be taken with the flap to preserve the sensation of the flap and nerve nutriention to a degree.Conclusion:1. This experiment make a further confirmation on the blood-supply of the flap using medial supramalleolar cutaneous branch of posterior tibial artery. Compared with other flaps, This flap have a larger area and can be cut and transported easily. We also replenish anatomical data on the perforating point of medial supramalleolar cutaneous branch of posterior tibial artery and distribution in the deep fascia, which can demonstrate it was an ideal and practical method to repair defect of soft tissue on the leg and thign using medial supramalleolar cutaneous branch of posterior tibial artery as pedicle to design flap. 2. This experiment demonstrate the medial leg skin were supplied by medial supramalleolar cutaneous branch of posterior tibial artery,and the branch also have anastomosis with the blood vessel chains around saphenus nerve-great saphenous vein.So the medial supramalleolar cutaneous branch of posterior tibial artery can be projected on the skin as an axis, and take the tract of saphenous nerve as another axis to design two-axis flap. Or take the superficial perforating point as an axial point and the posterior as the pedicle to design two axial points flaps.This design fully used the abandunt anastomosis formed by the medial supramalleolar cutaneous branch to expanded the area that can be transplanted, and the posterior artery were used to extend the pedicle that can be transplanted, which will play an important role especially when the recipient site have no reliable vessels for anastomosis... |
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