Reconstruction following radical maxillectomy with flaps supplied by the subscapular artery.

The authors present their experience of 27 cases with repairs of defects following radical maxillectomies with free flaps. A total of 28 flaps were used (five latissimus dorsi, six scapula, 16 combination flaps of scapula and latissimus dorsi and one combination of scapula, latissimus dorsi and serratus anterior flap). Only one scapula flap was completely lost and in three cases where a combination of scapula and latissimus dorsi flap was used, partial necrosis of one component occurred. The authors first choice for reconstruction is a scapula bone flap raised on the angular artery combined with the latissimus dorsi flap. The combination of flaps with a long pedicle and of the bony and muscular components provides the surgeon with the option of customizing the flap to meet individual patient needs. For intraoral closure the authors prefer the latissimus dorsi muscle which rarely requires secondary procedures for prosthesis placement following epithelialization and atrophy. The main disadvantage of the flap is the difficulty of two teams working simultaneously, thus increasing the average operating time. All postoperative corrections and prosthetic rehabilitation should be postponed for at least 2 months following surgery because of postoperative swelling.     

Free-flap reconstruction of the scalp: donor selection and outcome

Wide, complex defects of the scalp caused by various insults always represent reconstructive challenges for surgeons. Our study group consisted of 18 patients (14 males and 4 females) with a mean age of 40.2 years. Nineteen free-tissue transfers were used to reconstruct the scalp defects. The selected cases included 8 latissimus dorsi muscle flaps, 3 latissimus dorsi myocutaneous flaps, 2 rectus abdominis muscle flaps, 3 omental flaps, 1 scapular flap, 1 radial forearm flap, and 1 groin flap. Twelve patients had acute or subacute wounds resulting from trauma or craniotomy, 4 had primary cancer, and 2 had neurofibromatosis. Commonly used recipient vessels were the superficial temporal artery and vein. No flap procedure had morbidity due to vessel compromise, and the overall flap success rate was thus 100%. No major donor-site morbidity was observed. All cases underwent primary closure of donor sites except for one receiving split-thickness skin grafting. In cases where muscle or omental free flaps covered skin grafts, patients were more satisfied because of increased durability and well-fitted wigs. We advocate variable free-tissue transfers for the reconstruction of large defects of the scalp related to the sizes, sites, and extents of the involvement.     

游离组织辦在口腔颌面-头颈肿瘤缺损修复中的应用:2549例临床分析

目的:探讨不同游离组织瓣在口腔颌面-头颈肿瘤缺损与修复中的应用价值。方法:回顾分析1979年1月～2006年12月间,我院口腔颌面外科所行血管化游离组织瓣移植患者2549例,共制备皮瓣2684块:软组织瓣包括前臂皮瓣、背阔肌皮瓣、胸大肌皮瓣、股前外侧皮瓣、肩胛皮瓣等;骨组织瓣包括腓骨肌皮瓣、髂骨肌皮瓣、肩胛骨肌皮瓣等。分别用于修复舌、腭、颊、口底、颌骨及面颈部大面积复合缺损。统计各年代游离组织瓣移植的成功率,分析失败原因。结果:游离组织瓣移植成功率从80年代初期(92%)至今(98.5%),呈逐年升高趋势,2684块皮瓣总成功率达96.80%。前臂皮瓣是最常用的游离组织瓣(64.12%),胸大肌皮瓣和背阔肌皮瓣在修复大面积复合缺损常被采用,各种骨肌(皮)瓣应用于颌骨缺损修复成为近年的热点。大范围复合组织缺损的救治性手术常需要多个游离组织瓣联合修复重建。结论:血管化游离组织瓣移植是口腔颌面-头颈肿瘤手术根治的保障,更是术后缺损修复的主要手段。前臂皮瓣是修复舌、颊、腭等软组织缺损的首选瓣,胸大肌与背阔肌(皮)瓣适合修复体积较大的缺损,腓骨、髂骨肌瓣是上、下颌骨缺损最常用的修复手段。其他不常用的组织瓣,应根据不同适应证进行选择。采用不同组织瓣修复口腔颌面部缺损,对患者术后外形及功能具有重要意义。     

Transformation of a vascularised iliac crest or scapula bone to a pedicled osteomuscular transplant for reconstruction of distant defects in the head and neck region: A new method of transforming two island flaps to one longer island flap

ObjectiveBone defects in the maxillofacial region after ablative surgery require reconstructive surgery, usually using microvascular free flaps. This paper presents a new method of reconstructing extensive defects in patients not suitable for microvascular surgery using prefabrication of a vascularised osteomuscular flap from the scapula or iliac crest bone.MethodsThree patients who were treated with this new technique are presented. Two patients (one mandibular defect and one defect in the maxillary region) received prefabricated osteomuscular flaps from the iliac crest bone using the latissimus dorsi muscle as a pedicle. One patient also presenting a mandibular defect after tumour surgery received a scapula transplant for reconstruction of the defect using the pectoralis major muscle as pedicle.ResultsIn all three cases vital bone could be transplanted. The pedicle was strainless in all three cases. Minor bone loss could be seen initially only in one case. The results are stable now and one patient received dental implants for later prosthetic treatment.ConclusionThe presented two-step surgery provides an excellent method for reconstruction of bony defects in the maxillofacial region in patients where microvascular surgery is not possible due to reduced state of health or lack of recipient vessels.     

Vascularized cranial bone grafts for mandibular and maxillary reconstruction. The parietal osteofascial flap

The authors have performed 13 cases of vascularized cranial bone grafts for reconstruction of maxillofacial defects since 1986. Two types of flaps were used: the parietal osteofascial flap pedicled to the parieto-temporal fascia based on the superficial temporal artery and the temporalis osteomuscular flap pedicled to the temporalis muscle based on the deep temporal artery. Zygomatico-orbital complex, maxilla and mandible were reconstructed and hemifacial microsomia was also treated. The results of vascularized cranial bone grafts pedicled to fascia were as good as those of grafts pedicled to muscle. There were no major complications. Two types of vascularized cranial bone grafts seem to be useful in reconstruction of maxillofacial defects with avascular recipient beds because of their good blood supply. The parietal osteofascial flap has additional advantages including easy rotation of the flap to the defect, particularly a mandibular defect, and versatile use of fascia without bulkiness for reconstruction of soft tissue defects. This flap can be designed as a full- or partial-thickness cranial bone graft with good vascularity. In this paper, our technique for mandibular and maxillary reconstruction using the parietal osteofascial flap is introduced, and the results compared with our temporalis osteomuscular flap technique are reported.     

144例头颈部游离组织瓣移植患者的临床分析

目的:探讨采用头颈部游离组织瓣移植行头颈部重建的效果。方法:对1999年5月～2000年10月采用游离组织瓣移植行头预部重建的144例患者作回顾性研究,分析采用组织瓣的类型、受区血管、血管吻合方式和技术、组织瓣成活情况及术后并发症的发生情况。结果:前臂皮瓣、腓骨瓣和腹直肌瓣为最常用的行头颈部重建的游离组织瓣,占全部皮瓣的94.7％;游离组织瓣移植的成功率为98％,术后血栓的发生率为6％,抢救成功率为66.7％;受区和供区总的并发症发生率为34％,但大多数并发症均不严重,没有造成明显的后果;吸烟、饮酒、放疗和患者年龄等均非影响游离组织瓣移植成功的重要因素。结论:头颈部游离组织瓣移植安全可靠,且优于传统的带蒂组织瓣移植,是头颈部重建的合理选择。     

Reconstructing wide palatomaxillary defects using free flaps combining bare serratus anterior muscle fascia and scapular bone.

PURPOSE: Wide palatomaxillary defects, mostly after tumor resections, can cause severe functional and esthetic problems. Although prosthetic obturator devices or local flaps are mostly adequate for uncomplicated small-size defects, free flaps are preferred for a 3-dimensional multitissue reconstruction of more complicated defects. Regarding the anatomical structure of the palatomaxillary region, the flap must be thin enough to separate the oral and nasal cavities while not compromising palatal function, yet rigid enough for adequate dental restoration. This goal is usually accomplished with a combined or complex free flap. Numerous free flaps containing both soft tissues and bone have been described in the literature. In this study, we present a novel use of the free scapular bone flap combined with serratus anterior fascia and its functional and esthetic results. PATIENTS AND METHODS: Nine cases are presented whose wide composite palatomaxillary defects were repaired with free angular scapular bone flap combined with serratus anterior fascia based on the subscapular vascular system, between 1999 and 2003. Scapular bone wrapped with the naked serratus anterior fascia, like a sandwich, was used to repair the palate. RESULTS: The naked fascia was epithelialized with the help of the surrounding mucosa in 4 to 6 weeks. Results were satisfying with regard to breathing, eating, speech, and facial contour after follow-ups for 2 months to 6 years. CONCLUSION: For the reconstruction of wide palatomaxillary defects, a combined flap of angular scapular bone wrapped with naked serratus anterior fascia was conceived useful for obtaining satisfactory functional and esthetic results.     

Latissimus dorsi free flap reconstruction of anterior skull base defects

IntroductionSurgery of extensive skull base tumour results of a defect of soft and hard tissue and dura. Free flap reconstruction provides tissue to restore the defect and separate the intracranial content from the bacterial flora of the nasal fossae. Vertical and transverse rectus abdominis myocutaneous free flap are usually used. This study was designed to compare our experience of latissimus dorsi free flap reconstruction of extensive skull base defects after tumour resection with the literature concerning the use of other types of free flaps.Material and methodAll extensive skull base tumour resections with latissimus free flap reconstruction made in the head and neck oncology unit of the Institut Curie, Cancer Centre, between January 2004 and December 2009 were reviewed.ResultsTwo infectious complications were observed (11.7%), two cases of CSF leak (11.7%), one case of wound dehiscence following tumour resection comprising the nasal skin (5.9%) and one case of partial distal necrosis of the flap in a zone of skin resection (5.9%) were observed. No flaps were lost. Two latissimus dorsi donor site haematomas were observed (11.7%).ConclusionWhen reconstruction of extensive skull base defect need free flap, the latissimus dorsi free flap is a reliable solution.     

Reconstruction for large defects of the scalp and cranium.

Thirty-one patients with large scalp and cranium defects were reconstructed with free tissue transfer and scalp flaps. Twenty-eight of the defects resulted after tumour resection, two after infection and one after an extensive burn. Thirty-one free flaps (mainly the latissimus dorsi myocutaneous and the radial forearm fasciocutaneous) and five large (> 200 cm2) scalp flaps were used. Major complications occurred in one patient who developed meningitis and finally died (3.2%), and in one patient who lost a latissimus dorsi flap (3.2%). There were no other significant problems with the remaining patients. All other free flaps and scalp flaps survived. Primary reconstruction with free tissue transfer was our first choice of treatment because of the wide spectrum of advantages of free flaps. However, in a limited number of cases there was an indication for large scalp flaps, which, when properly designed, gave satisfactory results.     

背阔肌、前锯肌单蒂双岛肌皮瓣修复上颌骨大型缺损

目的 :采用背阔肌、前锯肌单蒂双岛肌皮瓣修复上颌骨扩大切除术后的大型缺损 ,为此类组织缺损寻求一种理想的外科修复方法。方法 :根据胸背血管在背阔肌内走行的解剖部位设计成单蒂双岛肌皮瓣。胸背动脉内、外侧枝的背阔肌肌皮瓣修复口内外或面眶区硬软组织缺损 ;胸外侧动脉的前锯肌肌瓣插入背阔肌内作为充填上颌骨或颅底缺损的空腔 ,并详细介绍手术方法。结果 :共施手术 8例 ,肌皮瓣全部成活 ,肤色、质地、形态以及轮廓的恢复均较满意。结论 :背阔肌、前锯肌单蒂双岛肌皮瓣修复上颌骨扩大切除术后的大型缺损有其优越性 ,其充足的肌量对面部轮廓的恢复可起到满意的效果。     

Indications for the scapular flap in reconstructions of the head and neck

Composite free flaps that are available for reconstructions of the head and neck include those from the fibula, iliac crest, radial forearm, and scapula, but only that from the scapula precludes two-team operating, and consequently adds a further 2–3 h to the operating time. Here we clarify the indications for the subscapular system of composite flaps, and discuss their unique properties in terms of reliability of the bony segment, their resistance to atherosclerosis, and the diversity of the skin and muscular components that are available. We have had favourable results in composite resections of the anterior mandible that required substantial resections of the anterior tongue. In extensive oropharyngeal resections that require a segmental resection of the mandible, the skin island is reliable and provides sufficient bulk to reduce the risk of dehiscence and maintain a narrowed oropharynx to improve speech and swallowing. In reconstructions of the midface a combination of the latissimus dorsi and the scapula that is based on the angular branch of the thoracodorsal vessel (thoracodorsal angular flap) allows for a long pedicle, and adequate muscle and bone for high and low maxillectomy defects. We present a consecutive series of 46 patients who document the use of this option in routine head and neck practice.     

Free and locoregional flap associations in the reconstruction of extensive head and neck defects

Head and neck surgical defects after oncological resection of advanced carcinoma involving the oral cavity are often composite and involve bone, mucosa, soft tissues and skin. For the most extensive defects, the simultaneous association of two free flaps is the best choice to improve the function of the preserved structures. This procedure is difficult and involves prolonged surgery, therefore it is only possible in selected patients. In some composite head and neck defects the association of free and locoregional flaps seems to be indicated. This study, discusses the use of free and locoregional flap association, focusing on its aesthetic advantages and functional results. From January 1995 to December 2006, 30 patients received simultaneous locoregional and free flap transfer for closure of post-ablative oral cavity defects. Microvascular tissue transfer included the radial forearm, anterolateral thigh, rectus abdominis, and fibula and iliac crest free flaps. Locoregional flaps included the cervicofacial, cervicopectoral, deltopectoral, pectoralis major, latissimus dorsi and posterior scalp flaps. Based on the good functional and aesthetic outcome and low rate of complications, the association of free and locoregional flaps represents a good reconstructive option for patients with extensive post-oncological composite head and neck defects.     

Superiorly based facial artery musculomucosal flap for large anterior palatal fistulae in clefts.

OBJECTIVE: An anterior hard palate fistula for which more than one attempt at repair using local tissue has failed is a difficult complication in cleft surgery. Prior to alveolar bone grafting, cleft patients have an open anterior maxillary arch that allows passage of a pedicled flap from cheek to hard palate. The superiorly based facial artery musculomucosal flap passed through the clefted alveolus is one of the newer techniques to solve this difficult problem. The aim of this study was to assess the validity of using a facial artery musculomucosal flap with an anterosuperiorly based pedicle with retrograde blood flow to repair a large anterior hard palate fistula when a lack of adequate local soft tissue precludes a local flap closure and the patient otherwise would need a tongue flap. RESULTS: Of 16 facial artery musculomucosal flaps in 14 children, 12 were successful, 2 suffered partial flap loss secondary to venous congestion, and 2 had complete flap failure. One had a small wound dehiscence that resulted in a small posterior fistula. CONCLUSION: An anterosuperiorly based facial artery musculomucosal flap is a viable option to close large anterior hard palate defects. Care needs to be taken to ensure adequate venous drainage. This flap obviates the need for a staged tongue flap repair for those patients with an open maxillary arch.     

肩胛骨瓣修复下颌骨缺损

作者选用旋肩胛血管为蒂的肩胛骨瓣修复部分下颌骨缺损8例,术后骨瓣全部成活。本文对肩胛骨瓣的设计、血管蒂的解剖、切取骨瓣及其移植方法作了介绍。应用肩胛骨瓣修复下颌骨缺损,可视受区需要设计为单纯骨瓣或骨肌皮瓣,骨瓣的长、宽、厚与下颌骨相似,外形恢复良好。骨瓣供区血管位置恒定,易于寻找,血管口径与受区血管接近,吻合后通畅率高,易成活。     

Combined latissimus dorsi-serratus anterior/rib composite free flap in mandibular reconstruction.

The serratus anterior/rib composite flap can be used alone or in combination with a latissimus dorsi myocutaneous flap in mandibular reconstruction. The combined flap is particularly useful in reconstructing large anterior mandibular defects, and 4 cases are described which illustrate its use both as a pedicled flap and as a free tissue transfer.     

延长垂直下斜方肌岛状肌皮瓣修复重建大型头颈部缺损

颈横动脉供血的延长垂直下斜方肌岛状肌皮瓣(extended vertical lower trapezius island myocutaneous flap,eVLTIMF)用于修复重建大型头颈部缺损安全可靠。该瓣制备较简单,成活率高。供区较隐蔽,可直接关闭缝合,并发症少,肩部运动受影响较小;还可制备成折叠瓣,合并其他带蒂瓣或合并肩胛骨骨肌皮瓣修复特大洞穿性缺损或下颌骨缺损。eVLTIMF在头颈部大面积缺损修复,尤其是在晚期复发性头颈部肿瘤挽救手术后巨大缺损修复重建中起着重要作用。本文对斜方肌的临床应用解剖、 eVLTIMF瓣制备及其在颅颌面、口腔颌面和颌颈区缺损修复中的应用作一阐述。     

Use of microvascular free flaps in the reconstruction of the anterior and middle skull base

Different reconstruction techniques of the anterior and middle skull base as consequence of a defect after surgical treatment of neoplastic pathologies are described in the literature. The aim of the present study is to present our experience regarding the use of microvascular free flaps for reconstruction of the anterior or middle skull base after large defects caused by removal of malignant neoplasms. From 2000 to 2004, in the Department of Maxillo-Facial Surgery of the University of Rome "La Sapienza" and "Tor Vergata," 13 surgical procedures for reconstruction of anterior and middle skull base defects by free flaps were performed in 11 patients. Data on patient demographics, histopathology, location and size of defect, type of reconstruction, and postoperative complications were obtained from medical record charts. A safe soft tissue closure of the intracranial space was achieved in all patients. Defect repair was accomplished by revascularized transfer of rectus abdominis flaps in seven cases, latissimus dorsi muscle flaps in two patients, radial forearm flap in one case, and fibula flap in one case. There were two total flap losses; the secondary defect repair was accomplished in both cases by revascularized transfer of latissimus dorsi muscle flap. No donor site complications were observed in all the flaps. The mean operation time was 85 hours; patients were hospitalized for a mean period of 14 days. The method of choice for the reconstruction of anterior or middle skull base defect should be based upon careful evaluation of the single case and, particularly, the localization and entity of the residual defect. For defects that require large amounts of soft tissue, the latissimus dorsi free flap and the rectus abdominis free flap are the best appropriate choices for reconstructive procedures for anterior and middle skull base tumors.     

口腔颌面缺损游离组织移植修复138例临床分析

目的探讨影响游离组织移植成功的因素,为各种游离组织瓣在口腔颌面头颈外科的应用提供临床参考。方法收集2005年1月～2008年6月进行游离移植的138例组织瓣,其中前臂皮瓣46例,游离背阔肌瓣10例,股前外侧皮瓣3例,足背皮瓣1例;腓骨肌瓣39例,腓骨肌瓣联合小腿外侧皮瓣36例,髂骨肌瓣3例。修复良性肿瘤术后缺损者41例,恶性肿瘤术后缺损者96例,发育畸形1例。血管吻合采用改良的二定点吻合法。结果 138例游离移植的组织瓣的成功率为99%以上,有1例足背皮瓣在术后7天出现静脉危象,第8天皮瓣坏死。1例腓骨肌瓣联合小腿外侧皮瓣患者手术后12h出现动脉危象,经抢救成活。2例前臂皮瓣和1例腓骨瓣术后24小时内出现静脉危象,经过重新吻合后抢救成功;1例前臂皮瓣在术后第6天出现静脉危象,抢救成功。其它132例游离组织瓣均达到Ⅰ期临床愈合。结论影响游离组织瓣移植成活的因素很多,血管吻合技术以及吻合后血管蒂的摆放是成功的关键。为了防止术后静脉危象的出现,在可能的情况下尽量吻合2根静脉。     

Parry-Romberg综合征19例报道

目的 回顾分析Parry-Romberg综合征的临床特征、诊断要点，并探讨5种血管化游离组织瓣(腹股沟真皮脂肪瓣、大网膜瓣、背阔肌瓣、前锯肌瓣、背阔肌-前锯肌-蒂双瓣)行颜面萎缩畸形整复的临床价值。方法 对19例Parry—Romberg综合征患者进行回顾性研究．分析病程、发病部位，临床表现、游离组织瓣的选择、术后随访功能恢复情况．探讨不同组织瓣行颜面萎缩畸形充填整复的适应证和优缺点。本组病例中男性9例，女性l0例。年龄12-48岁，中位年龄23岁。右侧11例，左侧8例。病程4-16a，中位病程9a。病损涉及半侧颜面组织，如皮肤、皮下组织、肌、软骨及骨．造成部分或全部萎缩。结果 19例患者全部用游离组织瓣修复，其中腹股沟真皮脂肪瓣ll例，大网膜瓣4例，背阔肌瓣2例．前锯肌瓣1例，前锯肌瓣 背阔肌-蒂双瓣l例。所有组织瓣均经血管吻合，除l例腹股沟真皮脂肪瓣因术后感染发生部分坏死液化外，其余均全部成活(94．7％)，术后随访6个月-5a，除3例因局部臃肿等原因需行二期修复外．颜面凹陷畸形得到满意修复。结论 应用吻合血管的游离组织移植技术矫正Parry-Romberg综合征颜面萎缩畸形，恢复和重建颜面形态和丰满度，有着良好的效果。腹股沟真皮脂肪瓣具有供区隐蔽，组织供应量大，且其吸收有一定自限性等特点。最多用于这种畸形的填塞修复。前锯肌或联合背阔肌瓣，由于可以同期进行神经吻合的动力性修复，且血管蒂解剖恒定．值得推荐应用。而大网膜瓣由于需剖腹．患者易产生恐惧心理而拒绝,宜作二线选择。     

Intra- und postoperatives Monitoring von Lappentransplantaten

Background

According to Schmelzeisen et al. (1996), the failure rate for microvascular free flaps is 5%. While surface tissue oxygenation can be assessed clinically, if necessary by a puncture, the oxygen supply to deeper areas mostly cannot be checked. We therefore wished to find whether measurement of tissue pO₂ would prove to be an objective and practical technique that could be used for continuous and accurate intra- and postoperative evaluation of flap perfusion.

Material and methods

A Clark-type microcatheter was used intra- and postoperatively to monitor tissue pO₂ in 5 pedicled pectoralis major flaps and 32 free revascularized flaps (9 jejunal flaps, 5 latissimus dorsi flaps, 6 radial forearm flaps and 12 scapular flaps).

Results

The mean values for tissue pO₂ were significantly lower in pedicle grafts than in free revascularized flaps. Within in each flap group the pO₂ values measured did not vary significantly over an observation period of up to 77.2 h after transplantation.

Conclusions

Continuous measurement of tissue pO₂ by means of a Clark-type microcatheter combined with clinical examination constitutes a reliable method of monitoring tissue oxygenation in pedicle grafts and free revascularized flaps during the intra- and postoperative phases. Analysis of small and of wide fluctuations in pO₂ values may help in the diagnosis of early arterial and venous obstructions in flaps and may in the future result in new insights into the tissue oxygenation in surgical flaps allowing some alleviation of the problems currently experienced in clinical monitoring.