| Background and Objectives:With the development of modern industry and modernization, the defects of skin and other tissues caused by the traffic accident and external injury are increasing; with the aggravation of the environmental pollution, the patients suffered by tumor are increasing; after excising the tumor, the defect needs to be filled and covered; with the development of the living standard, more and more patients concern about the outline after the surgery. Which kind of tissue flap can be used in different parts and different defects? This problem has been researched by the surgeons and anatomic researchers for a very long time.Prof. XU reported the anatomical basis of the free anterolateral thigh flap, and LUO used it in clinic. This flap was an ideal one with many advantages such as the distinct anatomic landmark, the long pedicle, large area, the thick diameter, the covert donor site, less variation and easy to be incised. This flap was widely used in a short period of time, and there were more and more reports about the anatomical basis and clinical application appeared in the journals.In 2005, LIU reported the clinical application of the lobulated musculo-cutaneous flap pedicled with descending branches of the lateral femoral circumflex artery. This flap took the descending branches of the lateral femoral circumflex artery as the pedicle, and adjusted the position and size according to the space of the different muscular branches and the shape and size of the defect. 8 surgery cases were performed and the results were very satisfied. This technique was a new one and it was easy to be operated, and it's worthy to be widely used. But the anatomical basis were not been reported.On the foot and ankle part, the defects of the soft tissue with the reveal of the bone, nickelclad, and the tendon were frequent problems in clinical world. There were many methods to deal with these situations, but there were insufficient in every method, and particularly there were methods with complicated technique and high failure rate, so it was difficult to be generalized and applied in the basic hospital.In 2003, DENG reported the technique of repairing the defect of soft tissue on the ankle and lower leg with the short fibular muscle flap, and got the satisfied curative effect. It showed that the short fibular muscle was supplied by the peroneal artery, in contusions of the soft tissue, the nutrient vessels of the short fibular muscle were rare to be injured, so when many other methods could not be used because of the defect of the vessels, the short fibular muscle flap could still be used. At the same time, the technique was simple, needed only a short time and could gain a high achievement ratio, and hardly any influence in shape and function to the donor site.On the other hand, the shortage of this flap was noticeable, because the flap was attached with no skin, it could only used to supply the defect and cover the wound surface, but it could not reconstruct the skin, so it needed to transplant the skin after the muscle flap was used.Hidalgo first reported the technique of repairing the defects of mandible with the free fibula flap in 1989 and this technique became the classic one after that because of the good result. This technique showed us that the fibula flap, the peroneal muscle flap and the musculo-cutaneous flap could be combined and used together and the combined tissue flap could be designed and incised according to the characteristic of the recipient site.After years of research on the clinical application and the anatomical basis of the fibula flap, the blood supply and the clinical technique of the flap were cleared, but there is rare data about the blood supply of the long fibular muscle and short fibular muscle, and the cutaneous arteries related, especially the characteristic that the reversed combined flap was suitable or not to repair the defect of the foot and the lower 1/3 of the leg, there is also no detailed document about the technique of the surgery, so the forward research is need to be done.With the development of the research in the human anatomy and the computer technique in the medical practice, it's possible to study the human body in 3-D space. Human structures showed in the visualized model have been widely used and become more and more important in teaching and clinical practice. Based on the research of the 3-D reconstruction, the operate scheme could be formulated, and the theorhetical environment of the operation could be established. in the surgery teaching and emulate training, the 3-D reconstruction and human body visualization could not be substituted and there were very widely prospect. In recent years, there were many reports about the 3-D reconstruction and human body visualization. It's a well-rounded technique on the research of the vessels to study the regional vessels in the 3-D space after the perfusion of the vessels, the contrast radiography and 3-D reconstruction.In this technique, the vessels were perfused with the radio-opaque material and CT scanned, the 3-D reconstruction software was used to reconstruct the vessels and other structures. In the 3-D structure, the bones, muscles, skin, and vessels could be viewed in different layers and different aspect, the structures could be viewed separately or combined. To one region, the cause and the distribution of the vessels could be viewed directly, it could apply the well-defined anatomical basis for the tissue flap.However, there were many problems still not be resolved, such as if the virtual structure can represent the human specimen? What is the difference between them? Which one is better? What is the superiority and limitations of them?In this article, 26 lower extremities were used, the micro, macro anatomic techniques and the 3-D reconstruction were used to study: (1) the anatomical basis of the lobulated myocutaneous flap pedicled with the descending branch of the lateral femoral circumflex artery; (2) With the same techniques, the blood supply, the flap area, the rotation point and the clinical announcements and other things were studied to show the anatomical basis on the reversed fibular musclo-cutaneous flap; (3) We compared the virtual vessels of the lower extremity with the real specimen, to study if the virtual structure can represent the real structure, and the difference between them, and the superiority and limitations of each one.Methods:(1) 20 fresh lower extremity specimens were used in this study with arteries injected with red lactoprene. The specimens were dissected and the originations, courses, branches and the distributions were studied at the descending branches of the lateral femoral circumflex arteries. The points where the descending branches entered the vastus lateralis muscle, and the branches, distributions and the anastomosis in the muscle were also researched. In the leg, the short fibular muscle and long fibular muscle were dissected and the originations, courses, branches and the distributions of the peroneal artery, especially the musculo-cutaneous perforator arteries were studied in the skin and sub tissues.(2) Another 6 specimens, arteries were injected with the mixture of the lead oxide and gelatin, and CT scaned. 3D software were used to reconstruct the arteries and their branches in the lower extremity. In the 3-D structure, the position of the descending branch of the lateral femoral circumflex artery, the vastus lateralis muscle, the skin of the anterolateral thigh and femur were viewed carefully, to apply the visualized anatomical basis for the lobulated myocutaneous flap pedicled with the descending branch of the lateral femoral circumflex artery.In the lateral leg, the distribution and the anastomoses of the vessels and the structures around were viewed carefully, to apply the visualized anatomical basis for the design and clinical application of the reversed fibular musclo-cutaneous flap.(3) 4 fresh lower extremities were infused with the radio-opaque material by the arteries and veins respectively to be subjected to spiral CT scanning, 3D-reconstruction were conducted to obtain 3D vessels. The specimens were dissected to show the vessel system. Compare the images of the 3D-reconstruction and the photos of the anatomical specimens, to see if the virtual structures can represent the real specimen, and if not, what the difference is and what's their superiority and the limitations.Results:1. 80.8% descending branches were come from the lateral femoral circumflex artery and the average external diameters were 3.7 mm. the artery laid deep the rectus femoris muscle, and ran downwards along the anterior border of the vastus lateralis muscle, and branched into medial branches and collateral branches at the point 9.0cm from the starting point. The collateral branches nutrient the vastus lateralis muscle, the average length of the vascular pedicle was 80.5 mm. the arteries gave off 6.7 branches in average to the vastus lateralis muscles and the skin of the anterolateral thigh, the average diameters were 1.0mm, the length between the neighboring branches were 18.6mm, and there were apparente anastomosis between the neighboring branches in the muscles The last part of the collateral branches inosculated with the lateral superior genicular artery in the vastus lateralis muscle, and ran down near the knee, and jointed the arterial rete of the knee.Except 1 case, there were 63 cutaneous arteries were found in 25 specimens, the diameters of the cutaneous arteries were 0.8mm, in these arteries, 23.8% were spatium intermusculare perforators and 76.2% were musculo-cutaneous perforators. In 15 cases of 26, there were 19 high cutaneous artery branches were found with the diameter of 0.8mm.2. the diameter of the originate peroneal artery was 3.7mm, the artery gave off many muscular branches to the soleus muscle, long flexor muscle of great toe, long fibular muscle, short fibular muscle and the skin. The first nutrient truncus arteriosis was given off 52.1mm from the originate of the peroneal artery, the diameter was 3.0mm. At the middle of the leg, the peroneal artery gave off many arcuate arteries, the average diameter of the largest one was 1.5mm. The arcuate arteries passed by the fibula and went downwards along the fibula and gave off 2-4 branches to the short fibular muscle. The fibular artery gave off 5.4 cutaneous arteries, passed through the spatium intermusculare between the soleus muscle and the long fibular muscle to the skin and sub tissue of the lateral leg. The diameter of the cutaneous artery was 0.7mm, and there were 2 veins accompanied with the artery. The pedicle of the perforator arteries from the fibular artery was 3.5cm. The last part of the fibular artery with the diameter of 1.2 mm, passed through the interosseous membrane of the leg and branched into the ascending branch and the descending branch. The descending branch ran downward along the fibula and the anterior border of the lateral malleolar, and inosculated to the lateral anterior malleolar artery and formed the lateral anterior malleolar artery arch, the diameter of the arch was 1.3mm. Upside of the muscle belly of the short fibular muscle, the superficial peroneal artery, which came from the anterior tibial artery and with the diameter of 1.8mm, ran forward and passed through the interosseous membrane and laid between the long fibular muscle and the anterior muscles of the leg. The average nutrient arteries of the superficial peroneal nerve were 5.4, which include the superficial peroneal artery, the ascending and descending branches of the perforators from the fibular artery, and the cutaneous artery from the dorsal pedis artery.3. Uaing the 3-D software, the independent bones, vessels, skin and muscles. The reconstructed structure could be showed separately, or combined. The structure could be viewed from different layer and different aspect.The reconstruction image showed that the descending branch of the lateral femoral circumflex artery gave off a series of branches to the vastus lateralis muscle, and part of the vessels went straight through the vastus lateralis muscle to the deep fascia and the skin. There were many anastomoses among the arteries in the muscles, the deep and superficial fascia. These results applied the visualized anatomical basis to the muscle flap, skin flap and the musculo-cutaneous flap pedicled with the descending branch of the lateral femoral circumflex artery.The reconstructed image showed that there were many communicating branches between the peroneal artery and the anterior tibial artery and the posterior tibial artery, and there were plenty of anastomoses between the vessels to the short fibular muscle, the cutaneous arteries and the main artery trunk. Using the photoshop CS, the image of the anatomical specimen and the 3-D reconstructed structures could be showed in one photo after the adjustment of the position and transparent. The images of the anterolateral vessels in the specimen and the 3-D reconstructed structure could be showed in one photo, and be compared intuitionally. Known from the composite graph, the information content in the 3-D picture were more than that of the specimen photo, the former could show all vessel branches of different layers and different directions, but the specimen photo could only show the vessels in one single layer, and the information covered by the deep tissue could not be viewed . But the shortage of the 3-D image was easy to be found, compared to the real object, the 3-D vessels were obviously enlarged and rough, and the plane graphs collected from the 3-D software were not clear enough. Because of the errors on the image, it was not suitable for data capture. And to the anatomical specimen, the origin, cause, distribution and anastomoses of the vessels could be seen clearly, and it was suitable for data capture, but it could not show multi layer organization in one specimen.Conclusions:1.from the descending branches of the lateral femoral circumflex artery, the muscle flap can be developed which pedicled with the muscular branches, and the skin flap can be developed pedicled with the myocutaneous branch. Utilizing the different locations of the branches, the space between the flaps can be adjusted according to the shape and the location of the recipient site. The lobulated myocutaneous flap pedicled with the descending branch of the lateral femoral circumflex artery is a excellent choice to restore the complex wounds or the cut through wounds2. The reversed long and short fibular musculo-cutaneous flap pedicled with the cutaneous arteries and the end arteries of the middle and lower part of the leg can be designed and be used to repair the defect of the foot and the lower leg.3. The method of angiography and 3D-reconstruction is very good for observing the 3D vessels from different aspects and different layers, but the 3D-reconstruction can not totally represent the traditional anatomical specimens.
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