| Introduction and Objective:With the development and application of perforator free flaps,perforating flap-based flap design is widely used.Hallock first proposed the concept of a chimeric flap:multiple tissue flaps are fed through separate vessels that eventually converge to the common trunk.Hallock inspired by the Greek mythology of a lion head,goat body,scorpion monster Chimera(Chimera),first proposed "chimeric flap"(Chimeric flap),the concept.The chimeric flap is defined as a group of skin flap that refers to multiple tissue flap(flap bone,tendon,fascia,muscle)that is fed through an independent blood vessel,but co-originated from the upper parental vascular pedicle valve.Clinically flap design should be based on chimeric flap should be based on different types of blood supply system using different types of chimeric flap.Commonly used chimeric perforator flap for the area are:peroneal artery chimeric perforator flap,articular iliac artery perforator flap,subscapular vascular chimeric perforator flap,lateral femoral artery perforator flap,subendrenal artery perforator flap and medial sural artery perforator flap.(MSAP)flap as MSAP dissection is constant,for the location of the location of hidden,longer vascular pedicle,less subcutaneous fat,for the area of injury is small,is the medial sural perforation flap has become the head and neck and limbs Wound repair,functional reconstruction of one of the most commonly used flaps.The medial sural artery of the sural artery has the advantages of the medial artery flap of the sural intussus and the chimeric perforator flap.The blood vessels of all tissues can be ensured by a group of blood vessels,which is novel and practical.The advantages of three-dimensional reconstruction of the wound.With its wide application,the dissection of the medial sural artery system has also been taken seriously.The application of existing MSA system is mainly focused on the distribution and identification of MSAP,as well as MSA and its branches in the gastrocnemius muscle distribution and travel.At present,the methods of perforator flap vascular location are mainly Handled Doppler,Color Duplex,Computed Tomographic Angiography(CTA),Magnetic Resonance Angiography(MRA)And digital subtraction angiography(DSA).In any case,there may be inaccurate situation.Endoscopic techniques have been widely used in the diagnosis and treatment of various specialties.Perforating free flaps require separation of the vascular pedicle within the muscle,and the current technique is still at risk for perforating the endoscope.However,it has been reported that perforation in the endoscope to reduce the variation of the donor site caused by extensive damage to the donor site.,&Lt.With the rapid development of computer-aided design and manufacturing technology precision,virtual surgery design technology is affecting and changing the surgeon’s plan for bone reconstruction surgery.,We began to use synthetic materials to construct bone models for digitally designed osteotomy and titanium plate shaping.,This technique shortens the operative time,reduces the bone flap failure rate,and obtains the better appearance and the function.Part I Applied anatomy of medial sural artery systemMethod:1.A total of 8 adult lower limb specimens were examined in the medial region of the calf.2.The number of piercing branches,the diameter of piercing the deep fascia,the coordinates of the punctured points and the relationship with the sural nerve were recorded.3.(Distance from distal fulcrum to the main branch of the sural artery)and arterial diameter,the length of the main vascular pedicle(distal fulcrum to the origin of the popliteal artery into the popliteal artery)was measured,And arterial diameter.4.statistical analysis of perforating branch from the inside and outside the case,the statistics branch to the depth of a branch.Result:1.Anatomical specimens of adult lower limb were 8 cases.Including 7 males and 1 female.Seven of them were found to have 2 branches of the sural artery,of which 1 was found to have 3 branches.All perforators are perforating the skin.Microsurgery under the microscope to measure perforation diameter 0.68±0.19mm.perforation distance from the median horizontal distance 3.88±1.22cm,perforation distance popliteal striated vertical distance 8.94±2.11cm.The position coordinates are denoted by(x,y).perforation distance of the sural nerve distance 3.49±0.77cm.2.There were 2 cases(ⅡA type),ⅡB type(62.5%)and Ⅲ type(12.5%).branch pedicle length 7.00±1.85cm,branch pedicle artery diameter 1.46±0.28mm.The length of the medial artery of the sural medial artery was 11.001.85cm,and the main pedicle artery diameter was 2.49±0.42mm.3.Since the medial sural artery of the calf is delivered from the popliteal artery,it is usually divided into the medial and lateral branches.This was the case in 7 of 8 specimens(3 in 1 case).There were 15 perforators in 7 specimens,of which 8 were distributed in the lateral branch and 7 in the medial branch.The lateral branches were 0.58± 0.11cm away from the deep fascia perforating point and the medial branch was 0.87±0.45cm away from the deep fascia perforator.T test t=1.72,P=0.11,P>0.05,that no significant difference.The diameter of the perforator from the outside was 0.79± 0.21 cm,and the diameter of the perforator from the inside was 0.61±0.12 cm.T test t=1.91,P=0.078,P>0.05,that no significant difference.Diameter of the lateral branch pedicle 1.44±0.27mm,diameter of the medial branch pedicle 1.27±0.32mm.T test was 1.06,P=0.31,P>0.05.Conclusions:1.MSAP in 8 cases of specimens in each case there are two perforation.Microsurgery under the microscope to measure perforation diameter 0.68± 0.19mm.The perforation distance from the midline was 3.88 ± 1.22cm,and the vertical distance of perforating branch was 8.94 ±2.11cm.2.There were 2 cases(ⅡAtype),IIB type(62.5%)and III type(12.5%).Branch pedicle length 7.00±1.85cm,branch pedicle artery diameter 1.46±0.28mm.The length of the medial artery of the sural medial artery was 11.00±1.85cm,and the main pedicle artery diameter was 2.49±0.42mm.3.There was no significant difference in distance between the medial and lateral branches of MSA(P>0.05).(P=0.078,P>0.05).Conclusion:There is no significant difference in the diameter of perforator between the medial and lateral branches.The diameters of the pedicle arteries in the medial and lateral branches were not statistically different(t=1.06,P=0.31).Finding a lighter branch in preoperative imaging can reduce the time and difficulty of intramuscular vascular dissociation.4.The variation of branching and perforating branches required the precise design of the MSAP chimeric lobular flap,including the location of the perforator,the type of branching and its relationship with the perforator,the assessment of the diameter of the donor site and the distance to the wound.Part II Clinical application of endoscopic perforator detection in bilobed chimeric flapMethod:1.Thirty-five inpatients with MSAP flap and ALT perforator flap were identified by color Doppler perforator,perforator location,diameter and blood flow parameters.2.Intraoperative 4mm 30° endoscopic probe mark perforation,false positive and false negative records,for statistical analysis.Result:1.Of the 35 cases,29 were male and 6 were female.18(51.4%)had MSAP flaps and 17(48.6%)had ALT free flaps.(Figure)Endoscopic exploration to the available perforation 68,intraoperative detection can support the flap.Which found false-negative color Doppler in 7 cases,false positive in 3 cases.Sensitivity= true positive/(true positive + false negative)= 61/(7 + 61)= 89.7%.2.False negative in 7 cases,perforation diameter 0.55 ± 0.19cm,true positive in 61 cases,perforation diameter 0.76 ± 0.23cm.T test were statistically significant.T=2.1,P=0.03,P&It;0.05.false positive in 3 cases,the small vein that are perforating vessels.Conclusions:1.Endoscopic exploration can be used to support 68 branches,intraoperative detection can support the flap.Which found false-negative color Doppler in 7 cases,false positive in 3 cases.Sensitivity = true positive/(true positive + false negative)= 61/(7 + 61)= 89.7%.False negative in 7 cases,perforation diameter 0.55±0.19cm,true positive in 61 cases,perforation diameter 0.76±0.23cm.T test were statistically significant.T = 2.1,P = 0.03,P&It;0.05.False positive in 3 cases,are considered to be small veins perforating vessels.2.Intraoperative endoscopic perforator exploration can be adjusted flap design,so that perforation free flap surgery is more accurate.And to exclude false-positive and false-positive punctures in the preoperative localization,and to provide a guarantee for the application of chimeric dissociated free flaps.Part III Reconstruction of complex defection with Chimeric perforator flapMethod:1.Fifteen patients(including 3 cases of ALT chimeric flap and 12 cases of MSAP chimeric flap)were treated with free graft implantation,and color Doppler localization and design were used in the study.2.Intraoperative endoscopic exploration of perforation.The chimeric flap was cut and the types of flap,flap size,thickness,number of perforated vessels,location,branching blood vessel type,length of vascular pedicle were recorded.3.Immediate observation of blood supply to the flap,timely treatment of vascular risk.The other day dressing,observe the presence of flap-related complications.The flap function was followed up 3-6 months after operation.Result:1.This group of 12 cases of medial sural artery occlusal perforation flap.Flap survival:11 cases of flap survival.1 case of double-leaf chimeric flap:one leaf for the repair of esophageal defects in the other leaf for the observation of the flap,3 days after the observation of the flap vascular crisis,see the repair of esophageal flap blood vessels,and observation Flap perforation vascular embolization,removal of necrotic flaps,wound to stretch the suture.Leg for wound healing:5 cases directly to the suture,7 cases of skin graft.15 cases for the first phase I healing,1 case due to postoperative donor area muscle necrosis debridement after surgery.In 3 to 6 weeks follow-up,the flaps survived,no bloated,soft texture.In the 3 cases of anterolateral femoral artery,2 cases survived,1 case has partly necrosis.2.In this group of 15 cases of endoscopic confirmed perforation in 23,ultrasound under the false negative 2,false positive 1.3.If the thickness of the flap is thin,the area is not too large to use the MSAP flap;if the thickness is not required,but the area is large demand for the choice of the ALT flap.Conclusions:1.Split chimerism free flaps were used to repair and reconstruct multiple tissues or multiple wounds in the same donor site and one vessel.Using the characteristics of the free flap itself(thickness of the fascia,etc.),combined with perforation and branch of the anatomical location,can complete the complex wound repair and organ reconstruction.2.Preoperative positioning of color Doppler perforator and percutaneous endoscopic perforation can accurately locate the perforation of the free flap,which provides a guarantee for the design of the dissociated chimeric free flap and avoids the waste of tissues.3.The design of lobulated chimeric flap is the key to the success or failure of the operation.This requires not only accurate positioning of the perforator,but also the surgeon’s good grasp of the spatial structure of the reconstructed tissue.Part Ⅳ Application of digital and three-dimensional printing technology in chimeric free fibular flapMethod:1.Free fibula chimeric flap in 19 patients,three-dimensional thin-layer CT,the use of mirror function to restore ipsilateral mandible morphology,the production of CAD/CAM model,osteotomy guide plate and bite plate.Or the thin section of the CT camera,the use of mirror function to restore ipsilateral thumb phalanx morphology.2.Endoscopic exploration to confirm perforation after surgery,according to skin or mucosal defect design flap.The fibular flap was cut and reconstructed using the guide and model.3.Postoperative blood supply to the flap was observed and timely treatment of vascular risk.The other day dressing,observe the presence of flap-related complications.The flap function was followed up from March to June.Result:1.A total of 19 patients underwent preoperative design with digital and three-dimensional printing techniques for free fibula chimeric flap surgery.Aged 30 to 58 years old,including 17 men,2 females.Of the 19 patients,14 were treated with upper/mandibular tumors,the reconstruction of the fibula flap,1 case of tibia and 4 cases of palmar phalanx and skin defects.2.The group of 19 cases of chimeric flap 18 cases survived,1 case of vascular thrombosis flap necrosis,change from the fibula transplantation.Postoperative appearance and function is good.Conclusions:1.Digital and three-dimensional printing technology in the clinical application of free fibula flap in the preoperative can be more intuitive and profound understanding of the lesion site of the anatomical structure and lesion range,the physical model of the pre-operation after surgery to finalize the surgical program,and can predict Postoperative morphological recovery effect.Improve the accuracy and control of surgery,and reduce the operation time and trauma,and finally to achieve the functional and personalized repair.Truly digital surgery,but also need to combine the surgical navigation system for positioning,tracking or verification. |
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