Daigeler Adrien, Schubert Cornelius, Hirsch Tobias, Behr Björn, Lehnhardt Marcus
Berufsgenossenschaftliche Unfallklinik Tübingen, Klinik für Hand-, Plastische, Rekonstruktive und Verbrennungschirurgie.
Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Klinik für Plastische Chirurgie und Schwerbrandverletzte.
Handchir Mikrochir Plast Chir. 2018 Apr;50(2):101-110. doi: 10.1055/s-0043-118597. Epub 2018 Feb 12.
There are many techniques to identify vessels in perforator surgery, each with specific disadvantages. Handheld Dopplers are easy to use, but inaccurate with respect to the exact localisation of the perforator. Angio-CT is invasive, time consuming, and expensive. In contrast, duplex sonography is a reliable, easy-to-use and availabe alternative for pre-, intra-, and postoperative visualisation of vessels. Power Doppler further increases sensitivity and allows visualisation of vessels smaller than 0.5 mm in diameter.
The use of duplex sonography and power Doppler in preoperative planning is illustrated in photographs that show how to identify the course of the septal vessel in free ALT flaps, to ensure that there are competent recipient vessels and to plan pedicled perforator flaps. In all 33 free flaps (21 ALT, 5 DIEAP, 4 FCI, 2 MSAP, 1 tib. post. perf. flap) for lower leg and breast reconstruction and 19 pedicled perforator flaps at the trunk and the extremities were harvested with this technique and used to cover post traumatic and tumour defects.
The detection accuracy of duplex sonography was 100 % with reference to the perforator being found within 0.5 cm of the duplexed point and the correct detection of the vessel course (septal vs. intramuscular). No flap loss was observed in this series. This is a non-invasive, reliable, and inexpensive, but time consuming and investigator-dependent technique.
By direct visualisation of the arteries and veins, the exact localisation of fascia penetration can be detected and flaps can then be better designed. Perforators can be centred in the flaps. The course of perforators can be visualised - especially in ALT flaps - and time consuming dissections through muscle can be avoided.
在穿支皮瓣手术中，有多种识别血管的技术，每种技术都有特定的缺点。手持多普勒仪使用简便，但在穿支的确切定位方面不够准确。血管CT具有侵入性，耗时且昂贵。相比之下，双功超声检查是一种可靠、易用且可用于术前、术中和术后血管可视化的替代方法。能量多普勒进一步提高了灵敏度，能够显示直径小于0.5毫米的血管。
照片展示了双功超声检查和能量多普勒在术前规划中的应用，说明了如何识别游离股前外侧皮瓣中隔血管的走行，确保有合适的受区血管，并规划带蒂穿支皮瓣。采用该技术共切取了33例用于小腿和乳房重建的游离皮瓣（21例股前外侧皮瓣、5例腹壁下动脉穿支皮瓣、4例腓肠内侧皮瓣、2例内侧股薄肌皮瓣、1例胫后穿支皮瓣）以及19例躯干和四肢的带蒂穿支皮瓣，用于覆盖创伤后和肿瘤缺损。
双功超声检查的检测准确性为100%，即穿支在双功超声检查点0.5厘米范围内被发现，且血管走行（隔支与肌内支）被正确检测。本系列未观察到皮瓣丢失。这是一种非侵入性、可靠且廉价的技术，但耗时且依赖操作者。
通过直接观察动脉和静脉，可以检测到筋膜穿透的确切位置，从而更好地设计皮瓣。穿支可以位于皮瓣中心。穿支的走行可以可视化——尤其是在股前外侧皮瓣中——并且可以避免耗时的肌肉分离。
