应用岛状烦肌粘膜瓣修复部分舌缺损

目的:探索一种用相同或相似组织修复舌缺损的方法,介绍岛状颊肌粘膜瓣修复部分舌缺损的经验。方法:应用以面动静脉为蒂的岛状颊肌粘膜瓣修复16例舌癌切除后的部分舌缺损。结果:16例患者术后岛状颊肌粘膜瓣全部完全成活,效果满意。无血肿、感染、腮腺导管损伤、面神经损伤和开口功能障碍等并发症,舌的形态、功能良好。1例半舌切除后的患者术后肌电图显示,颊肌粘膜瓣内的肌肉获得神经再支配且运动良好。结论:面动静脉岛状颊肌粘膜瓣组织学上类似于舌组织,血运丰富,转移灵活,可以获得神经再支配,有重建舌的运动功能的潜能,是修复舌缺损的一个良好选择。     

The buccinator musculomucosal island flap for partial tongue reconstruction

BACKGROUND: Ideal tongue reconstruction after partial or total glossectomy should be accomplished with like tissue. The buccinator musculomucosal island flap is similar to lingual tissue, consisting of thin, pliable mucosa of mucus production, with high cell renewal rate and minimal scar formation, excellent color, contour, texture match, and buccinator muscle fibers over the flap's entire length, providing tongual muscle reconstruction without a conspicuous donor site. STUDY DESIGN: The buccinator musculomucosal island flap, based on the facial artery and vein, is designed in a shuttle or in a fish-mouth fashion, encompassing the oral commissure anteriorly. If the flap design is made in a three-leaf shape, a larger flap will be obtained without an oral corner deformity or mouth opening difficulty. The flap is safe and simple to raise. The pedicle of the flap is longer and quite reliable and has a wide range of applicability. The flap may be used for reconstruction of the partial glossectomy defect (tongual defect was not more than half a tongue). The surgeon must know about possible anatomic variations, especially in the venous system, and plan to raise a contralateral buccinator musculomucosal island flap if homolateral facial vascular variation jeopardizes the flap's survival. RESULTS: The flap was successfully used for partial tongue reconstruction in 16 patients, and all flaps have survived without complications. Satisfactory results (including configuration and function of the neotongue) were achieved. Electromyographic studies performed on one patient with half glossectomy revealed reinnervation of the muscle in the flap with active motion of the reconstructed tongue. CONCLUSION: The buccal musculomucosal island flap based on the facial artery and vein is a better reconstruction option with the same or similar kind of tissue as the tongue and, with the addition of the reinnervated flap, offers the potential for improved physiologic motion.     

Lateral arm free flap for oral tongue reconstruction: an analysis of surgical details, morbidity, and functional and aesthetic outcome

The purpose of this study was to report the effectiveness of the lateral arm free flap (LAFF) in the reconstruction of oral tongue defects, the subsite in which it may have advantage over the other donor sites. This is a retrospective analysis of 48 consecutive cases of LAFF used for the reconstruction of partial glossectomy defects for squamous cell carcinoma of the oral tongue. Primary defect and donor-site morbidity and the functional and aesthetic outcomes were assessed in 37 evaluable patients, with a minimum of 6 months follow-up. Patient-reported Visual Analog Scale score from 0 (minimum satisfaction) to 10 (maximum satisfaction) was used to evaluate the aesthetic outcome. The follow-up was for 6 to 52 months (mean, 24 months). The flap was successful in 45 (93.8%) patients. The commonest observed donor-site morbidity was a broad scar, but it did not cause much patient dissatisfaction because it could be covered with appropriate dressing. Speech was normal or near-normal in all patients. Poor functional outcome was associated with adjuvant postoperative radiotherapy. The visual analog scale score for the aesthetic satisfaction (mean [standard deviation]) was 6.58 (1.82) for primary site and 7.13 (1.99) for the donor site. LAFF is an excellent option for the reconstruction of partial glossectomy defects of oral tongue without significant involvement of the floor of mouth and base of tongue.     

Reconstruction after total or subtotal glossectomy

Total or subtotal resection of the tongue for malignant lesions creates difficult reconstructive problems. Though the introduction of myocutaneous flaps revolutionized the reconstruction of the oral cavity, most patients with total and subtotal (more than 75 percent) glossectomy require laryngectomy as a concommittant or subsequent procedure to prevent persistant aspiration. Two groups of patients have been compared in this study. Group I consisted of 10 patients in whom an attempt was made to preserve voice with a total (4 patients) or subtotal (6 patients) glossectomy without laryngectomy. To decrease the chance of aspiration, the tip of the epiglottis was sutured to the posterior pharyngeal wall (epiglottopexy). This additional surgical step allowed swallowing without aspiration by blocking the glottic entrance. Group II consisted of six patients who underwent total glossectomy and laryngectomy. They had reconstruction with a pectoralis myocutaneous flap in one stage. These patients were rehabilitated without any major morbidity and they resumed an oral diet within 3 weeks after surgery. The muscle bulk of the flap and the additional protection of the airway by epiglottopexy in Group I were the keys to successful reconstruction.     

Increased midsagittal tongue velocity as indication of articulatory compensation in patients with lateral partial glossectomies

BACKGROUND: The purpose of this study was to describe the impact of partial lateral glossectomy on midsagittal tongue movement during speech. METHODS: Using B-mode ultrasound, the midsagittal tongue movement of 10 patients with lateral partial glossectomy during a standardized reading passage was analyzed before and after surgery. Six normal adults served as control speakers. The main outcome measure was the tongue velocity during speech. The technique of defect reconstruction (local vs flap) was included as a covariate in the analysis. RESULTS: Following the surgery, all patients significantly increased the velocity of the midsagittal tongue movements during the reading passage. CONCLUSION: The results demonstrated that the patients with partial glossectomy compensated for the lateral tongue resections by increasing the velocity of the residual tongue during speech. The study provides first insights into the biomechanical aspects of spontaneous articulatory compensation following lateral tongue resections.     

Functional comparison after reconstruction with a radial forearm free flap or a pectoralis major flap for cancer of the tongue.

OBJECTIVE: Numerous patients in Taiwan with tongue carcinoma require tongue reconstruction. We compared the abilities of 2 methods of tongue reconstruction to reserve tongue function. STUDY DESIGN AND SETTING: Sixty patients underwent resection of the tumors and reconstruction with a pectoralis major flap or a radial forearm flap. The Chinese articulation test was used to evaluate the place and manner of error production, and a questionnaire on dietary habits was used to evaluate deglutition 6 months to 10 years after reconstruction. RESULTS: Patients with the free flap had more intelligible speech. The questionnaire study showed no significant difference between the 2 groups in swallowing rating. Motility caused by flap pliability increased speech intelligibility more than it did on swallowing function. CONCLUSION: Our experience in a few selected patients shows that the functional outcome of tongue surgery is related to the reconstruction methods used (for speech) and to the extent of tongue resection (for swallowing).     

The transverse musculocutaneous gracilis flap for chest wall reconstruction in male patients with Poland's syndrome

Poland's syndrome represents a congenital unilateral deformity of the breast, chest wall, and upper limb with extremely variable manifestations. In most cases, the problem is mainly cosmetic, and the reconstruction of the chest wall should use a method designed to be performed easily and to achieve minimal scarring and donor site morbidity. We describe using a transverse musculocutaneous gracilis (TMG) flap for chest wall and anterior maxillary fold reconstruction in three male patients. In two patients, only the pectoralis major muscle was missing. In the third case, the ipsilateral latissimus dorsi muscle was also absent. The indication for surgical treatment was purely cosmetic. In all patients, a free TMG flap was performed to reconstruct the anterior axillary fold and the soft tissue defect. There was no flap loss, and all three patients had a clearly improved appearance of the chest wall. In this article, we demonstrate our experience with the use of a TMG flap for chest wall reconstruction in male patients with Poland's syndrome. © 2013 Wiley Periodicals, Inc. Microsurgery, 2013.     

Functional reconstruction of glossectomy defects: the vertical rectus abdominus myocutaneous neotongue

The vertical rectus abdominus myocutaneous (VRAM) flap is a valuable option for tongue reconstruction. However, the traditional inset (skin to remaining oral mucosa) obviates a more anatomic reconstruction. Eight patients underwent total or subtotal glossectomy with VRAM reconstruction. The muscle inset was supported at the inferior mandibular border attached to the remaining lingual mucosa or gingiva. The neotongue, consisting of skin and subcutaneous fat, was sutured posteriorly to the remaining tongue base, and the other surfaces were trimmed and left unsutured. Reconstruction was successful in all patients. The neotongue assumed palatal configuration, and within 2 weeks uniform granulation tissue followed by mucosalization occurred. One year postoperatively, all patients tolerated ad lib diets, spoke intelligibly, were gastrostomy tube and tracheotomy free and had no evidence of aspiration. This neotongue sits on the mandible under voluntary control, permitting effective obturation against the hard palate and providing successful speech and swallowing.     

Free flap reconstruction of oral composite defect complicated by intraoperative cardiac arrest: A case report

We report the case of intraoperative cardiac arrest of a patient undergoing free tissue harvest for an oral composite defect and subsequent completion of reconstruction with simultaneous double flaps. A 54‐year‐old man with advanced carcinoma of the tongue underwent near‐total glossectomy, segmental mandiblectomy, and bilateral neck dissections. We planned a fasciocutaneous anterolateral thigh flap to reconstruct the glossectomy defect, and a fibula osteocutaneous flap for the mandible defect. After the fibula flap harvest, the patient suffered a cardiac arrest. After a 4‐min code, the patient regained a sinus rhythm and became hemodynamically stable. We completed the cancer resection and banked the pedicled, osteotomized fibula flap in the lower extremity. We took the patient back to the operating room on postoperative day number 5 for successful reconstruction with simultaneous fibula and ALF flaps. The microvascular surgeon must always be poised to rapidly address intraoperative complications that may critically compromise the success of the free flap or, more seriously, jeopardize the patient's life. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

改良前臂皮瓣在舌和口底联合缺损修复中的应用

目的：介绍改良游离前臂皮瓣在舌、口底缺损修复中的应用效果。方法：应用改良前臂皮瓣同期游离移植修复因舌癌行扩大根治切除术后的舌、底联合缺损13例,术中根据舌、口底和牙槽骨缺损的大小设计、制备、利用改良前臂皮瓣;术中常规掀起前臂皮瓣皮岛,并保留血管蒂周围蜂窝结缔组织,形成包绕桡动静脉、头静脉的蜂窝结缔组织袖,游离移植于口内,吻合血管,再造舌并修复口底缺损。结果：前臂皮瓣全部成活,患侧颌面形态和舌外形恢复满意,舌动度较好,语音较清晰。结论：改良前臂皮瓣具有血管恒定,切取制备容易,组织量较丰富,具有较广的适应证,是同期修复舌癌术后舌和口底联合缺损的比较满意的方法,值得推广应用。     

Reconstructive indications of simultaneous double free flaps in the head and neck: A case series and literature review

Extensive and complex defects of the head and neck involving multiple anatomical and functional subunits are a reconstructive challenge. The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps in head and neck oncological surgery. This is a retrospective review of 21 consecutive cases of head and neck malignancies treated surgically with resection and reconstruction with simultaneous use of double free flaps. Nineteen of 21 patients had T4 primary tumor stage. Eleven patients had prior history of radiotherapy or chemo‐radiotherapy. Forty‐two free flaps were used in these patients. The predominant combination was that of free fibula osteo‐cutaneous flap with free anterolateral thigh (ALT) fascio‐cutaneous flap. The indications of the simultaneous use of double free flaps can be broadly classified as: (a) large oro‐mandibular bone and soft tissue defects (n = 13), (b) large oro‐mandibular soft tissue defects (n = 4), (c) complex skull‐base defects (n = 2), and (d) dynamic total tongue reconstruction (n = 2). Flap survival rate was 95%. Median follow‐up period was 11 months. Twelve patients were alive and free of disease at the end of the follow‐up. Eighteen of 19 patients with oro‐mandibular and glossectomy defects were able to resume an oral diet within two months while one patient remained gastrostomy dependant till his death due to disease not related to cancer. This patient had a combination of free fibula flap with free ALT flap, for an extensive oro‐mandibular defect. The associated large defect involving the tongue accounted for the swallowing difficulty. Simultaneous use of double free flap aided the reconstruction in certain large complex defects after head and neck oncologic resections. Such combination permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications is proposed. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

游离股前外侧组织瓣修复全舌或近全舌切除术后组织缺损

目的探讨游离股前外侧组织瓣在全舌或近全舌切除术后组织缺损修复的治疗效果。方法2015年3月-2018年5月,收治15例舌癌(全舌或近全舌切除)患者,肿瘤根治术后应用股前外侧组织瓣同期修复,皮瓣大小为6 cm×10 cm^8 cm×15 cm,对其临床资料进行回顾性分析,术后要求患者定期到门诊复查。结果15例皮瓣均成活,术后发生血管危象1例,经探查及相应处理后完全成活。术后于门诊随访12~48个月,平均30个月,舌部受区皮瓣成活良好,术后6个月患者张口度、咀嚼功能恢复良好,但是吞咽及语音功能欠佳;大腿供区运动功能良好,无麻木、疼痛不适。结论全舌或近全舌切根治术后遗留的组织缺损,以游离股前外侧组织瓣进行修复重建,可以较好的恢复舌的部分功能及外形。     

Tongue reconstruction with minimal donor site morbidity using a deep inferior epigastric perforator (DIEP) free flap in a 6‐year‐old girl

Tongue reconstruction was performed using a deep inferior epigastric perforator (DIEP) free flap in a 6‐year‐old girl with undifferentiated sarcoma of the tongue. After hemi‐glossectomy with upper neck dissection, a 3‐lobed DIEP free flap was used for the reconstruction. Donor site was closed primarily with suturing umbilicus in proper position. No flap loss, leakage, or infection occurred. Postoperatively, the patient was able to consume a normal diet without difficulty or aspiration and displayed good speech function. No donor site morbidity, e.g., herniation or bulging, was observed, and the patient was able to perform their normal daily activities. DIEP flaps provide a pliable skin paddle, an adequate amount of adipose tissue, and reduced donor site morbidity, even in children. We did not have any difficulty harvesting the DIEP flap or with the microvascular anastomosis. We consider DIEP free flaps to be the ideal option for pediatric tongue reconstruction. © 2013 Wiley Periodicals, Inc. Microsurgery 33:487–490, 2013.     

Reconstruction for total and near-total glossectomy defects

Reconstruction of total or near-total glossectomy defects has been challenging and the functional outcomes are often disappointing. In this article, the 10-year experience of total or near-total tongue reconstruction at the University of Texas M.D. Anderson Cancer Center is reviewed. The trends of surgical and functional outcomes, length of hospital stay, and choices of flaps and recipient vessels are identified. In addition, the investigators' experience, as well as a literature review, of sensory and motor reinnervation for tongue reconstruction is presented.     

Lateral arm free flap in oral cavity reconstruction: a functional evaluation

By use of sophisticated techniques now available from the science of Speech Pathology, we can now document, quantify, and critically analyze the surgeon's reconstructive efforts in the oral cavity. Using these methods, we have evaluated the neurotized lateral arm free flap in six patients receiving oral reconstruction. Two of these are reported in detail. This study has provided a protocol that results in the objective analysis of swallowing, articulation, and range of tongue motion and sensation. All of these tests can be routinely performed by a speech pathologist to document both operative performance as well as patient progress in speech and swallowing. It would appear that we have quantified evidence that the neurotized lateral arm free flap may represent a significant step forward in reducing the morbidity of total and subtotal glossectomy by providing a truly functional reconstruction.     

Autologous breast reconstruction with the transverse myocutaneous gracilis flap: aesthetic improvements with tissue expansion before free flap transfer

The transverse myocutaneous gracilis (TMG) flap provides an alternative to commonly used free flaps from the lower abdomen and buttocks for breast reconstruction. Excellent aesthetic results can be achieved in primary breast reconstruction after subcutaneous and skin-sparing mastectomy. However, in delayed breast reconstruction after mastectomy, an obvious skin island and conspicuous scars often compromise the final appearance. A two-stage approach with tissue expansion of the skin followed by free deepithelialised TMG flap reconstruction avoids these disadvantages and leads to improved aesthetic results. We treated two patients who asked for an autologous breast reconstruction after mastectomy due to primary breast cancer. Reconstruction with lower abdominal tissue was not feasible in one patient because of a previous abdominoplasty and in the other because of insufficient lower abdominal tissue. Both patients declined an implant-based breast reconstruction as well as a procedure using a flap from the buttock, favouring reconstruction with autologous tissue from the superior inner thigh. In the first stage, a tissue expander was inserted endoscopically assisted via a transaxillary approach. The expander was gradually filled over a 3-month period and finally replaced by a free deepithelialised TMG flap. The postoperative period was uneventful in both patients. We achieved satisfying results in both patients with good breast symmetry and uniform colour of the breast skin. Disadvantages and limitations of traditional one-stage breast reconstructions by free TMG flaps can be avoided by this two-stage approach. This reconstructive procedure leads to inconspicuous scars and a matching skin colour of both breasts. Level of Evidence: Level V, therapeutic study.     

Functional restoration after subtotal glossectomy and laryngectomy

Extensive resection of carcinoma that involves the tongue base and supraglottic larynx is accompanied by significant potential morbidity and mortality. This is often indicated by poor rates of cure and the limited palliation afforded by radiotherapy alone. Removal of a significant portion of the posterior tongue frequently results in intractable aspiration. Techniques in reconstruction of the oropharyngeal defect and tongue base have included primary closure, random flaps, and myocutaneous flaps. Each of these techniques has been successful, to some degree, in resurfacing pharyngeal defects. However, the functional results in regard to deglutition are less than satisfactory as a result of aspiration. Frequently, simultaneous or delayed total laryngectomy is performed to deal with the pulmonary complications. Various types of laryngoplasty do not uniformly correct the problems of aspiration and deglutition associated with subtotal glossectomy. Our experience includes eight patients who had advanced squamous cell carcinoma of the tongue base, vallecula, and the supraglottic larynx. All patients underwent partial or subtotal glossectomy and laryngectomy. The mucosal defect was reconstructed with pectoralis myocutaneous flap. In order to reestablish voice, a primary tracheopharyngeal shunt was created with the use of a portion of cricoid and upper trachea. The majority of these patients have had successful rehabilitation of deglutition, mastication, and speech.     

T3 and T4 cancer of the oral cavity, surgical treatment with oral tongue resection

Amputation of the oral tongue is required to treat T3 and T4 bilateral tumors of the anterior two third of the tongue with or without extension to the floor of the mouth. This partial glossectomy was performed initially for 27 patients and as salvage therapy for 35 patients with recurrent diseases. The reconstruction required a flap in all cases, including 8 microvascular free flaps. Two months after surgery, two third of patients had a satisfactory swallowing hability. The functional results were worst for patients operated after radiotherapy. Actuarial survival rates were 37.5% and 22.1% at 3 and 5 years respectively. The survival rate of patients who had surgery as primary modality of treatment was significantly better as compared with those who had radiotherapy before surgery (p=0,018). This surgery offers a perfect control of tumors of the anterior floor and oral tongue and good rehabilitation provided by the conservation of the posterior tongue.     

The transverse musculocutaneous gracilis free flap for breast reconstruction: experience with 6 cases

Introduction

Microsurgical techniques have allowed reconstronstruction procedures after mastectomy to take a qualitative leap with the development of different technical options. Although the abdomen is the main donor area destined for breast reconstruction, occasionally this skin is not sufficient or unsuitable for this purpose. In these cases, alternative donor areas are required, such as the flap of the transverse myocutaneous gracilis (TMG) muscle. The objective of this study is to evaluate the reliability of the TMG flap and the level of patient satisfaction with the result obtained.

Material and methods

During a nine-month period in 2009, 72 breast reconstructions were performed, of which 17 required the use of free flaps. In 7 of these cases, the abdominal wall could not be used as a donor area; therefore 6 of them opted for the TMG flap. The surgical technique and its results have been analysed, as well as the patient satisfaction with the results obtained using a questionnaire.

Results

There was no total or partial loss of the flap or other complications at the transfer level. There was minor dehiscence in the donor area in 3 of the cases. The patients classified the results of the reconstruction as satisfactory or good.

Conclusions

The TMG flap is a good technical option, comparable to abdominal flaps, for patients with small or medium sized breasts which require reconstruction with autologous tissue. The evaluation of the results by the patients was satisfactory or good.     

颏下岛状瓣修复舌癌切除术后舌与口底组织缺损

目的评价颏下岛状瓣修复舌组织缺损的临床效果及其应用价值。方法1997年3月~2004年10月,对9例舌癌患者在行舌颌颈联合根治术后所形成的舌或舌与口底组织缺损,应用颏下岛状瓣修复。其中男6例,女3例,年龄48~71岁。右半侧舌5例,左半侧舌4例,其中病变侵及口底者4例。组织缺损范围4.2 cm×3.2 cm~5.5 cm×4.0 cm。修复所用组织瓣大小为6.0 cm×3.0 cm~7.0 cm×4.0 cm。以颏下动脉为蒂8例,颏下动脉联合颌外动脉近心端为蒂1例。结果术后8例颏下岛状瓣成活。修复后舌体静态形态佳;动态表现前伸、上举、侧向运动不受限,语音清晰,吞咽功能良好,未发生任何并发症。3例术后3周放疗。随访1~36个月,舌无异常变化。1例组织瓣坏死脱落,创面自然愈合。结论颏下岛状瓣修复舌缺损,手术方法简便,并能提供足量组织同时修复口底缺损。