颞浅血管为蒂的帽状腱膜瓣修复头颈肿瘤术后缺损

OBJECTIVE: To evaluate the advantage and applications of pedicled galeal flap in head and neck region. METHODS: A consecutive series of 17 patients underwent surgical reconstruction with pedicled galeal flaps after head and neck tumor resection. The defects included nasopharynx, skull base, maxilla, orbital base, oropharynx and oral cavity and the size ranged from 5 cm x 5 cm to 10 cm x 10 cm. The technique for using this flap was described and application was illustrated with 3 case reports. RESULTS: Complete success of galeal flaps for the reconstruction of head and neck defects was achieved in 13 of the 17 cases (76.5%) and partial necrosis was observed in the remaining 4 cases (23.4%). Immediate wound complications occurred in four cases, which resolved spontaneously. Four delayed complications were observed in 4 of 9 survival cases that included trismus (3) and alopecia (1). CONCLUSION: Galeal flap is a thin, pliable and well vascularised reconstruction tissue and is highly reliable. The donor site morbidity is minor. We have found the flap to be useful in the reconstruction of a variety of defects in head and neck, especially in skull base, orbital base, nasopharynx and oropharynx.     

Role of the island deltopectoral flap in contemporary head and neck reconstruction

OBJECTIVES: The deltopectoral flap (DP) was originally described 40 years ago for head and neck reconstruction. Since that time, use of pedicled myocutaneous flaps and free tissue transfer has supplanted the DP flap as a first-line reconstructive tool. The island DP flap, a variation of the DP flap wherein the skin bridge is de-epithelialized, provides a source of thin and pliable tissue that can be useful for select head and neck reconstruction. The purpose of this review is to assess the utility of the island DP flap in contemporary head and neck reconstruction. METHODS: A retrospective review of 16 consecutive cases utilizing the island DP flap was performed. Indications, complications, and outcome were reviewed in an effort to determine the role of the island DP in contemporary head and neck reconstruction. RESULTS: Sixteen island DP flap procedures were successfully performed in 16 patients for a variety of reconstructions, including esophageal, laryngeal, cutaneous, and pharyngeal defects. The donor skin paddles averaged 22.4 cm2 (range, 14 to 40.8 cm2). There were no recipient site complications; however, there was 1 donor site hematoma that was managed with drainage. In all 16 cases, the island DP flap provided an appropriate source of donor tissue for reconstruction of limited defects of the pharynx, esophagus, and skin of the neck. CONCLUSIONS: The island DP flap is a reliable donor site that provides an excellent source of thin and pliable tissue for limited defects of the head and neck.     

The temporalis muscle flap for reconstruction after head and neck oncologic surgery.

OBJECTIVE: To explain the applications, technique, and potential complications of the temporalis muscle flap used for immediate or delayed reconstruction of head and neck oncologic defects. STUDY DESIGN: Fresh cadaver dissection and 5-year retrospective chart review. METHODS: A fresh cadaver dissection was performed to illustrate the surgical anatomy of the temporalis muscle flap with attention to specific techniques useful in avoiding donor site morbidity (facial nerve injury and temporal hollowing). A chart review was performed for 13 consecutive patients from the last 5 years who underwent temporalis muscle flap reconstruction after oncologic resection of the lateral and posterior pharyngeal wall, hard and soft palate, buccal space, retromolar trigone, and skull base. RESULTS: Patient follow-up ranged from 2 to 45 months. Nine patients had radiation therapy. There were no cases of flap loss. Resection of the zygomatic arch followed by wire fixation facilitates flap rotation and minimizes trauma to the flap during placement into the oropharynx. Preservation of the temporal fat pad attachment to the scalp flap decreases temporal hollowing and protects the facial nerve. Replacing the zygoma and preserving the anterior third of the temporalis muscle in situ further diminishes donor-site hollowing. CONCLUSIONS: Compared with other regional flaps, such as the pectoralis myocutaneous flap, the temporalis muscle flap is associated with low donor-site esthetic and functional morbidity and offers great flexibility in reconstruction. The temporalis muscle flap is a useful, reliable flap that belongs in the armamentarium of surgeons who are involved with reconstruction of head and neck tissue defects.     

Free posterior tibial flap for head and neck reconstruction after tumor expiration

BACKGROUND: Similar to the radial forearm flap, free tissue transfer of a fasciocutaneous flap is possible if the septocutaneous perforators of the posterior tibial vessels are preserved. OBJECTIVE: The authors report their clinical experience on using the free posterior tibial flap for primary reconstruction of head and neck defects after tumor extirpation. METHODS: Eleven patients were included between October of 2005 and March of 2007. Patients' clinical and demographic data were collected. The flap harvesting results and outcomes were retrospectively reviewed. Representative cases are presented for illustration. RESULT: There were nine men and two women, and their ages ranged from 34 to 83 (mean, 60.3) years. The flaps measured from 6 x 9 cm to 8 x 12 cm. Two cutaneous perforators were included in the majority of cases. The average flap thickness was 0.7 cm, and the average pedicle length was 14 cm. Flap survival was 100%. Skin grafts of all donor sites healed well. All patients were ambulatory early in the postoperative period, and there was no distal limb ischemia or cold intolerance on follow-up. Four patients needed postoperative adjuvant radiotherapy. CONCLUSION: Our study demonstrates that the posterior tibial flap is a safe and reliable flap for reconstruction of head and neck defects after tumor expiration. It has all the comparable properties of a radial forearm flap. In addition, a larger area of skin can be removed, and the graft donor site is less conspicuous.     

Parascapular free flaps in skin malignancies

This study was a retrospective review of a case series of nine patients, aged 40 to 83 years, presenting to the head and neck cancer department at Wake Forest Baptist Medical Center, with a diagnosis of head and neck cutaneous squamous cell carcinoma (SCC), requiring reconstruction after surgical resection. In this group of patients, parascapular fasciocutaneous free flaps proved to be a safe, reliable, and cosmetically effective choice for reconstruction of head and neck skin cancer defects. Choosing donor tissue from a relatively non-sun exposed area can prevent potential development of new malignancies that may arise from donor sites using sun-exposed skin. We discuss the benefits and versatility of the parascapular fasciocutaneous free flap and our experience in using this flap to reconstruct complex surgical defects.     

游离股前外侧皮瓣修复头颈肿瘤术后缺损

目的探索供区功能和外观损伤更小的游离股前外侧(anterolateralthigh,ALT)皮瓣修复技术,运用于头颈肿瘤术后缺损。方法2003年12月—2005年5月中国医科院肿瘤医院头颈外科用于头颈部手术缺损修复的游离股前外侧皮瓣8例。头颈部肿瘤手术缺损按受区部位分为口咽侧壁3例,舌活动部2例,颊黏膜、舌根和颅底各1例。结果8例游离ALT皮瓣手术均获成功。供区伤口一期愈合,未发现切口裂开,下肢运动和感觉功能障碍等手术并发症。8例皮瓣的穿支血管类型均为肌皮穿支,皮瓣应用面积为(4~8)cm×(5~10)cm。手术时间5~10h,平均7h。皮瓣切取制作时间65~115min,平均80min。结论游离股前外侧皮瓣具有修复技术可靠、供区部位隐蔽和并发症少等优点,是头颈部缺损修复的理想皮瓣之一。     

头颈部岛状肌皮瓣和皮瓣的改良设计及临床应用

目的　探讨制作单一血管为蒂的头颈部局部带蒂肌皮瓣或皮瓣的安全性。方法　解剖学观察20例胸肩峰动脉分支,观察最远入肌点走行特征。通过术前超声观察和术中透视法观察定位最远入肌点,在最远入肌点上方1～2 cm断离肌肉,形成单纯动静脉血管为蒂的胸大肌岛状肌肌皮瓣。利用同样的技术方法,设计岛状的胸锁乳突肌、下位斜方肌的岛状肌皮瓣。结果　解剖学观察胸肩峰动脉分支分为单支型12.5%（5/40）,双支型67.5%（27/40）,多支型20%（8/40）。术前超声定位胸大肌皮瓣的最远入肌点成功率为29.1%（14/48）,DSA成功显影乳内动脉穿支66.7%（12/18）,共完成胸大肌岛状肌皮瓣48例,乳内动脉岛状皮瓣12例,颏瓣18例,下位斜方肌岛状肌皮瓣4例,胸锁乳突肌岛状肌皮瓣4例,颈横血管岛状皮瓣3例,胸肩峰动脉穿支的岛状皮瓣3例。失败2例,1例为胸大肌肌皮瓣的岛状设计中电刀误伤胸肩峰动脉胸肌支;1例为颈横血管浅支,术中修复扁桃体癌咽侧壁缺损。3例胸大肌部分坏死,清理完坏死组织,换药后痊愈。结论　在头颈部设计单一血管为蒂的岛状肌皮瓣（皮瓣）的改良设计安全可行,在受区皮瓣容易塑形固定,供区不仅外形美观且功能保全。     

Flap Reconstruction of the Upper Face: Free Flaps VS. Lower Trapezius Myocutaneous Flap

ABSTRACT. The immediate one-stage reconstruction of the upper facial cutaneous defects were performed by using two different flaps. In the first representative patient a microvascular free flap was used; in a second case, the lower trapezius myocutaneous flap was used. Free flaps probably are ideal for the correction of such defects in one stage. This procedure requires specially trained surgical teams and longer operative time. A reliable alternative is the lower trapezius myocutaneous island flap. This offers a flap that is thin, hairless and of uniform thickness. The length and thickness of its pedicle allows excellent mobility and leaves no bulky neck deformity. Both these reconstructive techniques satisfy the need for viable replacement in large upper facial and scalp defects coupled with a satisfactory cosmetic outcome.     

下咽及颈段食管缺损修复的供区选择和临床评价

目的：探索下咽及颈段食管缺损的分类及不同类型缺损的修复方法选择原则和临床疗效。方法：2007—01—2012-06期间共行下咽及颈段食管缺损修复术39例。根据下咽及颈段食管缺损程度分为环周／近环周缺损组（A组,23例）和部分缺损组（B组,16例）;根据颈部血管状况分为颈部血管状况不良组（22例）和颈部血管状况良好组（17例）。供区选择主要根据缺损程度和颈部血管状况决定。A组采用股前外侧皮瓣8例、胃上提6例、桡侧前臂皮瓣3例、空肠瓣和胸大肌肌皮瓣各3例;B组采用舌骨下肌肌皮瓣8例、桡侧前臂皮瓣3例、胸大肌肌皮瓣5例。观察皮瓣的存活率、手术并发症、功能效果和肿瘤治疗的临床转归。结果：全组并发症发生率为12．8％（5／39）。A组空肠瓣、股前外侧皮瓣、胸大肌肌皮瓣坏死各1例,皮瓣坏死均发生在颈部血管状况不良组;B组发生咽瘘1例,无皮瓣坏死。全组2例未能经口进食,其余病例无进食障碍;保留喉功能16例均发音良好。全组2年、3年总生存率分别为72．1％和65．2％。结论：下咽及颈段食管缺损修复供区的选择应根据缺损程度、颈部血管状况和组织瓣的特性综合分析,个体化应用。个体化下咽及颈段食管修复可获得满意的临床疗效。     

带蒂肌皮瓣及脏器瓣在咽、食管缺损修复中的应用

目的 探讨带蒂组织瓣在咽、食管术后缺损修复中的应用。 方法 2002年1月至2011年12月山东大学齐鲁医院耳鼻咽喉科对因头颈部恶性肿瘤住院的患者行手术治疗,单独或联合应用胸大肌肌皮瓣、舌瓣、喉气管瓣、胃代食管术、结肠上徙术整复咽部及食管的术后缺损,共计186例,对此类患者进行随访并分析治疗效果。 结果 喉癌4例,喉癌术后复发14例,喉癌术后咽瘘4例,喉癌术后咽狭窄1例,下咽癌87例,下咽癌术后咽瘘11例,甲状腺癌5例,扁桃体癌2例,颈段食管癌38例。应用胸大肌肌皮瓣共71例;舌瓣联合喉气管瓣、胸大肌肌皮瓣运用2例,术后均拔除鼻饲管;喉气管瓣40例;胃代食管术58例,55例恢复吞咽功能,喉功能保留率53.4%;结肠上徙术共15例,13例恢复吞咽功能,喉功能保留率93.3%。 结论 带蒂组织瓣因其血供良好,制备简单,技术成熟,无需特殊手术技巧的优势,可满足耳鼻咽喉头颈外科术后修复与重建的要求,在头颈一期整复重建中发挥重要作用。     

胸大肌肌皮瓣在头颈肿瘤术后组织缺损修复中的应用

目的总结胸大肌肌皮瓣在头颈肿瘤术后组织缺损修复中的应用。方法回顾性总结2 0 0 7年1月～2 0 1 0年1 2月收治的3 6例患者因头颈部肿瘤手术后巨大组织缺损应用胸大肌肌皮瓣进行修复的临床资料。结果 32例(88.9%)胸大肌肌皮瓣完全存活,4例(11.1%)胸大肌肌皮瓣远端部分坏死。经换药、口腔护理等对症支持治疗后愈合。结论胸大肌肌皮瓣是一种临床应用广泛的修复材料。它具有丰富的组织量和确切的血液供应,修复操作简单,易存活,适用于头颈部肿瘤扩大切除术后组织缺损的即刻修复。     

头颈肿瘤术后缺损修复的现状与展望

目的目前头颈肿瘤术后缺损修复的主力皮瓣是穿支皮瓣,前臂皮瓣和股前外侧皮瓣则应用最为广泛。最近头颈邻近皮瓣得到重新开发和利用,包括锁骨上动脉皮瓣、胸肩峰动脉穿支皮瓣和颏下皮瓣,成为头颈部缺损修复新的热点。头颈修复在向着数字化、精准化方向发展的同时,供区功能的保留和受区器官功能重建也是未来发展的方向。近年来,组织工程学、活体组织器官的复合打印技术作为3D打印在头颈修复的潜在应用也得到了广泛探索。     

Microvascular tissue transplantation of the ear, nose and throat

Free tissue transfers are a versatile method of reconstruction in head and neck surgery. In the pharynx and oral cavity the functional result dictates the choice of flap. For these sites thin and pliant fasciocutaneous flaps are ideal tissue transfers, and we favour the radial forearm flap which is raised from the distal volar forearm. This flap is easy to dissect and the donor defect, which is grafted with split skin, does not inconvenience the patient. For reconstruction of thicker defects we prefer bulky myocutaneous flaps such as the latissimus dorsi, which has a reliable pedicle of adequate length. The rectus abdominis flap, if taken with peritoneum, is useful for reconstruction of large cheek defects involving all layers; the peritoneum replaces the oral mucosa. For hypopharyngeal reconstruction the free jejunal loop has advantages compared with local skin or myocutaneous flaps, since it is a one-stage procedure with a low rate of post-operative fistulae. In some cases of reconstruction of the oral cavity and oropharynx we have used a jejunal patch, but in general we prefer the radial forearm flap, since it is more resistant to mechanical trauma. The advantage of a free tissue transfer is its excellent blood supply, which makes it possible to apply these flaps in irradiated and infected tissue. It is important in microvascular tissue transfer to choose an appropriate flap for the size and depth of the resection. It is only necessary to be familiar with those transfers most commonly used in this region.     

Parietal occipital nape of neck flap. A myocutaneous flap for selected head and neck reconstruction

Reconstruction in head and neck surgery has been greatly advanced with the use of the pectoralis major and trapezius myocutaneous flaps. Most surgical defects can be repaired with one of these flaps alone, or in conjunction with cutaneous flaps. Specific problems, however, occur that cannot be successfully reconstructed by these standard flaps. The traditional scalp flaps are cutaneous flaps. Use of these flaps is limited because of their shortened arc of rotation and accompanying forehead deformity. Three patients underwent reconstruction with a parietal occipital nape of neck myocutaneous flap. Its advantages include the following: large segments of hairless skin from the contralateral side of the neck can be used, an extensive arc of rotation and distance can be achieved with excellent vascularity in the overlying skin, and cosmetic results are superior. Angiographic studies were used to demonstrate the vascular pattern and supply to this flap. Cadaver dissections were performed to determine the pattern of distribution of the perforating vessels to the skin from underlying muscle.     

Bipedicles chest flap: a novel technique for the reconstruction of anterior neck defect

This paper presents our surgical technique and the results of using bipedicled superior chest flaps for head and neck reconstructions. The study design consisted of a case series of surgical technique. The study was conducted at tertiary referral centers with otorhinolaryngology-head and neck surgery departments. In seven patients, we used bipedicled superior chest flaps for reconstruction of anterior cutaneous neck defects due to surgery for the recurrence of laryngopharyngeal carcinoma. The largest flap size was 45 × 14 cm. All donor sites were closed primarily with advancement in the lateral part and split thickness skin grafts in the superior midline of chest. The highest point of reconstruction was in the hypopharynx internally and hyoid externally. All flaps survived without major complications. A bipedicled upper chest flap can reliably cover the skin defects that create following salvage total laryngectomies in patients with advanced stage tumors with skin involvement.     

Microvascular free flaps in soft-tissue augmentation of the head and neck

The disadvantage of traditional methods for reconstruction of soft-tissue deficits providing symmetric restoration of head and neck contour are the need for multiple stages in the case of pedicle flaps and the unpredictable atrophy and resorption in the case of free nonvascularized dermis-fat grafts. In addition, unsightly donor defects may be an added disadvantage. A major use of free revascularized grafts and flaps is in the reconstruction of contour defects of the head and neck resulting from loss of soft tissue and bone. Soft-tissue augmentation can be achieved by the transfer of free cutaneous or musculocutaneous flaps. The ideal donor sites for such flaps are in areas of the body where large direct cutaneous or musculocutaneous flaps can be harvested with relatively long vascular pedicles, and where minimum morbidity and secondary deformity will occur from harvesting the flap. Microvascular flaps allow for tissue augmentation of the head and neck with restoration of symmetry without the problem of subsequent atrophy and resorption.     

Second primary squamous cell carcinoma arising in cutaneous flap reconstructions of two head and neck cancer patients

Early complications of myocutaneous flap transfers following surgical eradication of head and neck tumors have been extensively described. However, knowledge concerning long-term complications of these techniques remains limited. We report the cases of two patients with a prior history of squamous cell carcinoma of the head and neck (HNSCC), who developed a second primary SCC on the cutaneous surface of their flaps, years after reconstruction. Interestingly, it seems that the well-known risk of a second primary SCC in patients with previous head and neck carcinoma also applies to foreign tissues implanted within the area at risk. Given the important expansion of these interventions, this type of complication may become more frequent in the future. Therefore, long-term follow-up of patients previously treated for HNSCC not only requires careful evaluation of the normal mucosa of the upper aero-digestive tract, but also of the cutaneous surface of the flap used for reconstruction.     

Pulmonary atelectasis after reconstruction with a rectus abdominis free tissue transfer

BACKGROUND: Atelectasis is one of the most common postoperative complications encountered in head and neck surgery. Risk factors include preexisting pulmonary disease, the procedure performed, and the length of anesthetic. Regional flaps used to reconstruct defects in the head and neck predispose to radiographic atelectasis. The rectus abdominis myocutaneous flap is usually transferred as a free tissue transfer. Harvesting the flap results in abdominal wall pain and postoperative splinting that may contribute to an increased development of atelectasis. To our knowledge, this issue has not been previously examined. DESIGN: Retrospective review. RESULTS: Fifty-three patients underwent rectus abdominis myocutaneous free flap reconstruction following major ablative procedures for head and neck cancer. The flap size ranged from 5 x 7 to 25 x 27 cm. Most flaps were 8 x 15 cm. The cutaneous area transferred ranged from 35 to 600 cm(2) (mean, 120 cm(2)). These patients were compared with a group of 53 patients who were matched for age, sex, length of the procedure, and stage of disease. Postoperative atelectasis was radiographically detected in 37 (70%) of the patients who underwent rectus abdominis myocutaneous free flap reconstruction vs 41 (77%) of the controls. Major atelectasis was not encountered in any patient in either group. Patients with a larger cutaneous paddle (>120 cm(2)) had a higher atelectasis score than patients with smaller cutaneous paddles (< or =120 cm(2)) (P =.02). CONCLUSIONS: The incidence of radiographic postoperative atelectasis in patients undergoing rectus abdominis myocutaneous free tissue transfer is high. The degree of atelectasis is small, and the clinical correlation and relevance are minimal.     

The combined use of muscle flaps and alloplasts for tracheal reconstruction

This report documents our experience with a different concept in reconstructive head and neck surgery. This concept, we hoped, would enable us to reconstruct anatomic regions with a special contour that is otherwise difficult to achieve with conventional flaps and grafts. The first stage of this method includes implantation of a preshaped alloplastic material in a donor site of a commonly used myocutaneous flap and waiting 4 to 6 weeks for the implant to "take." The second stage includes raising the pedicled flap with the implant and transferring it to reconstruct the defect. As a model for this approach, tracheal defects in dogs were created and reconstructed. The technique used in this study can be specifically applied to reconstruction of tracheal defects, ie, subglottic stenosis, and also can be used for other defects in the head and neck region.     

Pulmonary Atelectasis After Reconstruction With a Latissimus Dorsi Myocutaneous Flap

Atelectasis is the most common postoperative complication encountered in head and neck surgery. Risk factors include preexisting pulmonary disease, type of surgery performed, and the length of anesthetic. It is controversial whether reconstruction of defects with regional myogenous flaps predisposes to atelectasis. The latissimus dorsi myocutaneous flap requires the patient to be placed on his side for a period of time. Whether it is the position or the surgery that contributes to the development of atelectasis has not been examined. Eighteen patients underwent latissimus dorsi myocutaneous flap reconstruction following major ablative procedures for head and neck cancer. The cutaneous area transferred ranged from 70 to 225 cm² (mean, 128 cm²). The flap size ranged from 7 × 10 to 15 × 15 cm. The majority of flaps were 10 × 15 cm or greater. These patients were compared to 18 patients who did not undergo pedicled myocutaneous chest flap reconstruction. Patients were matched for age, sex, length of operation, site of primary, and stage of disease. Postoperative atelectasis was radiographically detected in 89% of flap patients vs. 79% of controls. Major atelectasis was encountered in 16% of patients undergoing flap surgery vs. 11% of patients in the control group. Patients with large cutaneous paddles on their flaps (>120 cm²) had significantly more atelectasis than patients with smaller cutaneous paddles (P<.05, chi-squared). The incidence of radiographic postoperative atelectasis in patients having a latissimus dorsi myocutaneous flap is high. The size of the skin paddle harvested as well as the position change may contribute to this.