用于颌骨重建的腓骨肌瓣的制备

自 198 9年Ｈｉｄａｌｇｏ最先报道腓骨肌瓣在颌面外科的应用后 ,由于腓骨肌瓣具有诸多的优良特性 ,近年来已迅速广泛用于修复下颌骨缺损。作者在上海九院参与了 6例血管化腓骨肌瓣制备 ,游离移植修复下颌骨缺损 ,积累了一些经验 ,本文就用于颌骨重建的腓骨肌瓣的制备作一临床探讨。材　料　和　方　法1　临床资料 :　 6例男性患者 ,年龄 18～ 35岁 ,其中造釉细胞瘤 3例 ,角化囊肿 2例 ,下颌骨巨细胞瘤 1例。下颌骨缺损最短 6 5ｃｍ ,最长 16ｃｍ ,平均10 2 5ｃｍ。移植腓骨长度 :最短 7ｃｍ ,最长 17ｃｍ ,平均11 75ｃｍ。2　腓骨肌瓣的…     

两种血管化游离骨肌瓣移植修复下颌骨缺损临床分析

目的:评价血管化游离髂骨肌瓣和腓骨肌瓣移植修复下颌骨缺损的临床效果,比较两种修复方法的优缺点。方法:对44例血管化髂骨肌瓣和腓骨肌瓣移植修复下颌骨缺损的病例进行回顾性研究,分析两种骨肌瓣修复后对患者面部外形与口腔功能的影响,对比供受区并发症的差异。结果:20例髂骨肌瓣,24例腓骨肌瓣均成活;二者在恢复面部外形与口腔功能上无明显差异,在移植骨长度上,两者有明显不同。结论:血管化游离髂骨肌瓣与腓骨肌瓣作为下颌骨缺损修复的常用方法,可以满足不同类型下颌骨缺损修复的需要,但根据两种骨肌瓣的特点,对于缺损长度低于8 cm,可优先考虑髂骨瓣,而缺损范围大于8 cm的可选腓骨瓣。     

应用腓骨肌瓣-种植体一期功能性修复下颌骨

目的 应用显微外科和种植技术,在切除肿瘤和下颌骨同时即刻行腓骨肌瓣游离移植,并同期植入种植体,对腓骨肌瓣的特点,术中注意事项,义齿修复前准备等问题进行讨论。方法 对２例下颌骨成釉细胞瘤患者在切除肿瘤和下颌骨同时行腓骨肌瓣游离移植,并植入种植体共５枚。结果 术后一年观察,移植骨存活良好,种植体与移植骨之间为骨性结合,义齿修复后功能恢复良好。     

应用腓骨肌瓣180°折叠即刻种植牙植入修复下颌骨缺损

目的 :切除下颌骨肿瘤,同期应用血管化腓骨肌瓣180折叠即刻种植牙植入骨中修复下颌骨缺损 ,探讨腓骨肌瓣折叠及即刻种植牙植入的手术特点。方法 :对1例下颌骨造釉细胞瘤的病人行肿瘤及下颌骨切除的同时将腓骨肌瓣180折叠并移植至缺损部即刻植入种植牙一枚。结果 :六个月后曲面断层片显示种植体骨整合愈合情况良好。结论 :腓骨肌瓣180折叠即刻种植体植入可以一次手术达到恢复有牙患者下颌骨应有高度和连续性及咀嚼功能的目的     

三维模拟技术在游离腓骨瓣移植重建下颌骨缺损中的应用

目的探讨在游离腓骨肌瓣移植修复下颌骨缺损过程中应用三维模拟技术（CAD/CAM）的方法。方法对11例患者（成釉细胞瘤8例,骨化性纤维瘤1例,下颌牙龈癌2例）术前应用三维模拟技术进行模拟手术,利用快速成型机制作出与患者下颌骨实际大小和外形完全一致的实体模型和手术辅助导板,在模拟修复完成的下颌骨模型上预成形重建钛板。手术中,一组根据术前设计的截骨方案切除病变下颌骨;另一组利用辅助导板在不断蒂状态下对腓骨进行精确的分段截骨,将截开的腓骨段准确塑形后,用预成形重建钛板加以固定,待受区准备完成后断蒂移植。结果11例患者移植的腓骨肌（皮）瓣均存活,术中移植腓骨所截取的长度合适,截骨、塑形、定位速度明显加快。术后随访1~24个月,影像学检查显示患者下颌骨重建形态及固位良好,颞下颌关节就位准确,口内检查剩余牙列咬合关系恢复正常。结论在游离腓骨肌（皮）瓣移植修复下颌骨缺损中应用三维模拟技术,不仅能够降低手术难度与风险,节省手术时间,还可提高手术质量,保证手术效果。     

血管化游离腓骨瓣在下颌骨重建中的应用

目的评价应用血管化游离腓骨瓣移植重建下颌骨的临床疗效。方法对6例下颌骨缺损患者采用血管化游离腓骨瓣同期移植修复。结果5例腓骨肌瓣完全成活,1例腓骨肌皮瓣移植患者皮岛坏死,但腓骨瓣成活：所有患者术后外形良好,术后3个月x线片示移植骨无吸收,骨断端愈合良好;所有患者均行走正常,无1例出现踝关节不稳定。结论血管化游离腓骨瓣血供良好,骨量充足,易于塑形,适合于下颌骨缺损的重建。     

游离腓骨肌(皮)瓣修复下颌骨缺损的临床研究

目的:总结应用游离腓骨肌(皮)瓣修复下颌骨缺损的经验。方法:根据32例患者下颌骨缺损的部位和特征,对腓骨肌瓣进行塑形,重建钛板固定,恢复下颌骨的形态和功能。结果:31例腓骨肌(皮)瓣修复下颌骨缺损患者获得成功,1例失败。结论:游离腓骨肌(皮)瓣是修复下颌骨缺损的一种理想方法。     

游离腓骨肌(皮)瓣在下颌骨缺损修复重建中的应用

目的总结游离腓骨肌(皮)瓣一期重建下颌骨节段性缺损的方法、经验和临床效果。方法对11例下颌骨节段性缺损的患者同期采用游离腓骨瓣进行重建,其中腓骨肌瓣6例,腓骨肌皮瓣5例。对术后供区和受区的功能和外形进行评价,分析总结临床方法和经验。结果11例血管化游离腓骨肌(皮)瓣移植全部成功,所有病例供区伤口均一期愈合,供区下肢均无明显功能障碍,患者术后面部外形对称,张口度3.5～4.2cm。结论游离腓骨肌(皮)瓣是重建下颌骨节段性缺损的理想方法。     

游离组织瓣移植同期修复下颌骨放射性骨坏死术后缺损

目的　探讨游离组织瓣移植在晚期下颌骨放射性骨坏死治疗中的可靠性和应用价值。方法　采用游离组织瓣移植同期修复11例晚期下颌骨放射性骨坏死术后缺损的患者。分析原发肿瘤的部位和类型、放疗剂量、缺损的范围、所采用游离瓣的设计、受区血管的选择、游离瓣的成活情况及术后并发症的发生情况。结果　11例患者共采用15块游离组织瓣修复缺损,包括12块游离腓骨瓣、2块腹直肌皮瓣和1块前臂皮瓣。1例患者采用3块游离瓣修复(腓骨瓣、腹直肌瓣和前臂瓣),2例患者采用2块游离瓣修复(腓骨瓣和腓骨瓣,腓骨瓣和腹直肌瓣),余9 例患者各采用1块游离瓣修复。全部游离瓣均获得成活,无1例出现血管危象及组织瓣的全部或部分坏死。全部患者术后放射性骨坏死的症状均完全缓解,外形和功能也得到了不同程度的恢复,随访期间未见有肿瘤和放射性骨坏死复发。结论　对于晚期的下颌骨放射性骨坏死,采用病灶切除同期游离组织瓣移植是有效可行的方法,游离腓骨瓣是修复下颌骨缺损的首选。     

超声检查在腓骨肌(皮)瓣修复下颌骨缺损中的作用

目的　研究超声检测技术在腓骨肌 (皮 )瓣修复下颌骨缺损过程中的作用。方法　 9例腓骨肌 (皮 )瓣修复下颌骨缺损的病例 ,术前彩超检查以确定腓动脉是否单独存在 ,带皮瓣修复者 ,将腓动脉皮支体表定位。单纯腓骨瓣转移者 ,术后超声多普勒听诊仪检测移植瓣动脉的血流情况。结果　 9例腓动脉均单独存在 ,术后腓骨瓣及所带皮瓣全部存活。彩超检查确定腓动脉皮支的位置及数量 ,便于所带皮瓣的术前设计和术中操作 ;超声多普勒听诊检查结果准确地反映了移植瓣动脉的血流状态。结论　超声检查在腓骨肌 (皮 )瓣修复下颌骨缺损术前观察腓血管的结构 ,术后监测组织瓣的存活性方面有重要意义     

基于三维CT重建的快速成型技术在下颌骨重建的临床应用

目的 评价基于三维CT重建的快速成型技术在下颌骨重建中的作用。 方法 本组选取7例下颌骨病变病例,术前均采用基于三维CT重建的快速成型技术,制作下颌骨实体模型,并在实体模型上设计下颌骨切骨范围和拟用髂骨瓣或腓骨瓣的骨量和形态。术中按拟定方案切除下颌骨病变,并同期以钛板、血管化游离腓骨瓣或髂骨瓣修复下颌骨缺损,术后定期观察随访。 结果 采用游离髂骨瓣移植修复者3例,游离腓骨瓣移植者3例,单纯以重建钛板固定者1例。移植骨块均顺利成活。已随访6个月~2年。下颌骨形态和面型基本对称,无下颌偏颌。余留牙咬合关系同术前,张口度正常,咀嚼和语音功能恢复良好。 结论 基于三维CT重建的快速成型技术为下颌骨缺损的个体化和功能性修复提供良好桥梁。     

血管化平行折叠腓骨瓣重建下颌骨肿瘤术后骨缺损

目的：探讨应用血管化平行折叠腓骨瓣重建下颌骨肿瘤术后骨缺损的临床效果。方法 ：采用血管化游离平行折叠腓骨肌皮瓣修复重建下颌骨肿瘤术后缺损9例,男6例,女3例,年龄17-61岁,平均37岁;其中,折叠修复5例,部分折叠修复4例,下颌支缺损仅行单层腓骨修复。结果：9例患者术后移植腓骨肌皮瓣均成活,颌面部及腿部术区创口一期愈合,颌面部外形满意,无开口受限,语音清晰,吞咽功能基本正常,下肢腓骨供区无明显并发症。术后3例行二期种植义齿修复,4例因经济原因行可摘义齿修复,2例暂未行义齿修复。已行修复病例义齿与余留牙咬合关系基本正常,咀嚼功能恢复良好。术后6个月复查,全景片提示移植腓骨愈合良好,移植骨高度较正常下颌骨略低。所有病例均随访1-3 a,均无复发。所有患者自我评估对颌面部外形满意。结论：应用血管化平行折叠腓骨瓣技术重建下颌骨缺损,克服了传统腓骨瓣修复后骨质高度不足的缺点,为义齿修复提供足够的骨量,能获得良好的颌面部美学形态和功能效果。     

Concomitant reconstruction of mandibular basal and alveolar bone with a free fibular flap

Repair of long-span mandibular defects with a free fibular flap is now a routine procedure. However, the bone height of the neo-mandible after reconstruction with a fibular flap is about half that of the dentulous mandible. When a fibular graft is placed only at the inferior border of the mandible, the resulting vertical discrepancy between the graft segment and the occlusal plane can adversely affect implant mechanics or denture stability and retention. To overcome these problems, we developed a technique for two-strut type mandibular reconstruction. A vascularized fibular segment is used to reconstruct the inferior basal portion of the neo-mandible, while a non-vascularized residual fibular segment is used to simulate the superior alveolar portion. We used this technique in 22 patients. Graft survival, graft resorption, and the ability to place implants were assessed as compared with those after the conventional one-strut type technique. The fibular segment grafted to the alveolar region was removed in one patient with intraoral wound dehiscence and in two with postoperative infection. All vascularized fibular flaps were successful. The resorption rate was 13.6+/-7.2% for non-vascularized segments and 3.0+/-3.7% for vascularized segments. Dental implants were placed in five of our 22 patients. The crown:fixture length ratio was improved to 1:1.7, as compared with a ratio of 1:1.21 with use of a conventional fibular flap. We conclude that our technique is very easy and safe and provides substantially improved lower-lip and cheek support and implant-prosthetic mechanics than conventional procedures for the repair of long-span mandibular defects.     

Functional reconstruction of mandible by using vascularized fibular free flap and one-stage rehabilitation of the implant]

OBJECTIVE: To study the characteristics of the vascularized fibular free flap and the possibility of the insertion of implant at the same time. METHODS: The microvascular surgical procedure and implant technique were used in the treatment of two cases suffered from mandibular ameloblastoma. After tumor resection by partial mandiblectomy, graft of vascularized fibular free flap was performed with simultaneous insertion of 5 implant. RESULTS: One year later, the grafted bone was survival, the osseointegration was proceeded between the implant and grafted bone. The functional reconstruction of the mandible was excellent after prosthetic denture. CONCLUSION: This is a good approach to rehabilitate bone function by using vascularized fibular free flap and one-stage implant placement.     

The use of free fibular flap for functional mandibular reconstruction.

PURPOSE: The purpose of this investigation is to document our experience using the free vascularized fibular flap for comprehensive reconstruction of discontinuity defects in the mandible, after combined resections of malignant and aggressive odontogenic tumors, with special emphasis on functional aspect of the reconstruction process. MATERIALS AND METHODS: The study group consisted of consecutive patients treated for reconstruction of discontinuity defects of the mandible, using the fibular vascularized free flap, between 1997-2002. All procedures were performed in the same hospital and by the same surgical team. RESULTS: A total of 13 patients (9 males, 4 females) were treated in our department in a period of 6 years for reconstruction of discontinuity mandibular defects using the free fibula vascularized flap. Wound healing disturbances at the donor site occurred in 4 cases. Two flaps were lost, 1 because of total failure in a patient who was heavily irradiated because of osteosarcoma, the other because of resorption of the bone tissue transfer in a case of total avulsion of the mandible caused by a fall from height. CONCLUSION: Fibula free vascularized flap is a safe and reliable method for comprehensive functional and esthetic mandibular defect reconstruction. Our protocol has a significant impact on preserving the patients quality of life.     

带血管蒂腓骨组织瓣游离移植修复下颌骨缺损的临床研究

目的:评价带血管蒂腓骨组织瓣游离移植修复下颌骨缺损的临床应用价值。方法:对25例患者用腓骨瓣游离移植修复下颌骨缺损。手术采取血管吻合、坚固内固定方法恢复下颌骨形态及完整性。其中22例患者为单纯腓骨瓣移植,3例患者为携带肌皮瓣或皮瓣的腓骨瓣移植,3例患者还同期植入种植体共5枚。结果:25例患者平均随访917个月,成功率为96%。3个患者的5枚种植体均达到良好的骨整合效果,并已行上部义齿的修复。62% 的患者可正常进食,余38%的患者可进软食。96%的患者面部外形的恢复达满意或较为满意。所有患者均能正常行走,无1例出现踝关节不稳定。结论:带血管蒂的游离腓骨组织瓣具有众多其它自体骨组织瓣不可比拟的优点, 是下颌骨缺损修复重建的最佳方法之一。     

Preoperative three-dimensional reconstruction in vascularized fibular flap transfer

ObjectiveThe objective of this study was to investigate the added value of preoperative computerized tomographic angiography (CTA) and three-dimensional reconstruction of the lower limb in vascularized fibular flap transfer.MethodsEighteen patients who underwent mandibular or maxillary reconstruction with a vascularized fibular flap were studied retrospectively by image analysis. The original DICOM data of preoperative CTA were analysed and applied to the reconstruction of the lower limb using SimPlant Pro software (version 11.04).ResultsThe course of the peroneal artery in 17 patients was the same except for one patient. The peroneal artery originates from the posterior tibial artery. The original external diameters of the peroneal artery were 2.99 ± 0.64 mm. The perpendicular lengths from fibular head to the origin of the peroneal artery and to the fibular perforator vessel were 42.88 ± 8.84 mm and 174.55 ± 25.62 mm, respectively.ConclusionThe course of peroneal artery was relatively invariable, its original external diameter was thick. Preoperative CTA and three-dimensional reconstruction of the lower limb, which are noninvasive, accurate and direct-viewing methods, play an important, preoperative role in vascularized fibular flap transfer for lower limb vascular assessment.     

腓骨肌皮瓣加种植体植入对颌面部软硬组织缺损的功能重建

目的:总结应用腓骨肌皮瓣游离移植对颌面部软硬组织缺损的功能重建的临床经验。方法:自2007～2011年7月,我科应用腓骨肌皮瓣一期修复下颌骨及周围软组织缺损11例,其中男性8例,女性3例,年龄33～67岁,其中左下颌牙龈鳞癌4例,右下颌牙龈鳞癌2例,右舌下腺腺样囊性癌1例,右口底鳞癌2例,左下颌黏液表皮样癌1例,成釉细胞瘤1例。其中磨牙后区粘液表皮样癌和成釉细胞瘤2例进行即刻种植。受区血管均为同侧,组织瓣均吻合1根动脉、2根静脉。动脉选用颈外动脉分支,静脉选用面总静脉、颈前静脉或颈外静脉,所有动静脉吻合均采用端端吻合法。分析皮岛的设计、大小、修复部位、存活情况等。结果:本组游离腓骨肌皮瓣11例全部成活,均携带1块皮岛,由一个穿支供养,皮岛最大6cm×4cm,最小3cm×2cm,皮岛均用于口内软组织缺损修复,2例即刻种植植入种植体6颗。术后面部外形、功能及咬合关系良好。语音功能基本正常。下肢功能在术后3～6个月恢复正常。结论:腓骨瓣的骨量充足,具有骨膜和骨髓双重血供,血运丰富,抗感染能力强,移植后易于成活。可根据需要做多段截骨塑形从而更加准确的恢复颌骨牙槽突形态。操作过程中远离头颈部,可以双组同时手术。腓骨的高度和宽度以及皮质骨的厚度也十分适合牙种植体的植入。游离腓骨瓣的皮岛不仅可用于口内外的软组织缺损修复,还可作为术后血供的观察窗。腓骨肌皮瓣在修复颌面部软硬组织缺损中具有血供安全可靠,塑形灵活,模拟外形准确,利于监测,并发症少等优点,是能够同时兼顾颌骨缺损及周围软组织缺损修复重建的理想方法。