改良的胸大肌岛状肌皮瓣在头颈外科的应用

目的 总结保护供区胸大肌功能和颈部外形美观的改良式胸大肌岛状肌皮瓣安全制作方法 .方法 采用改良的胸大肌岛状肌皮瓣修复头颈部缺损17例,其中6例复发性喉癌和下咽癌,4例下咽癌,3例舌根癌,2例复发性上颌窦癌,1例扁桃体癌,1例术后下咽癌术后咽瘘.术前超声检查标记胸肩峰动脉胸肌支走行,以胸肌支最下一个分支进入胸肌的起始位置(最下入肌点)和内乳动脉第四肋间穿支连线为轴设计单血管蒂的岛状肌皮瓣;在皮瓣顶部切口水平向外沿腋前线向上切开;保留胸内侧和部分胸外侧神经;维持胸大肌锁骨部完整,经锁骨上或锁骨下将肌皮瓣送到受区.结果 术中发现胸肩峰动脉胸肌支最下入肌点全部分布在胸肋部,该点距锁骨中点最下缘平均(4.9±1.2)cm(x±s,下同),术前超声定位最下入肌点的准确率为76.5%(13/17);内乳动脉的第四肋间穿支距离胸骨外侧缘(1.8±0.5)cm.17例胸大肌岛状肌皮瓣中,除1例下咽癌术中解离血管蒂时损伤血管放弃外,其余16例均成活,手术成功率为94.1%.术后1例舌根癌患者胸大肌远端与残舌分离,通过换药缝合后痊愈;2例出现术后咽瘘,均系放疗后复发下咽癌,换药后创面愈合.术后4周至3个月复查,胸大肌功能正常,颈部外形良好.结论 改良胸大肌岛状肌皮瓣不仅保留了胸大肌结构和功能,实现高位缺损的修复,还维持颈部和上胸部良好外观.术前超声检查标记胸肩峰动脉的胸肌支走行和最下入肌点位置有利于术中准确操作.     

头颈局部皮瓣岛状设计的策略和临床应用

头颈肿瘤外科切除后的重建修复经历了快速发展的过程,从早期选择轴型皮瓣局部重建,到后期游离皮瓣重建。皮瓣的“血管供应单元”（angiosome）概念提出后,穿支皮瓣应运而生。无论是局部还是游离穿支皮瓣制作,都已从肥厚蒂部的传统轴型皮瓣过渡到岛状轴型穿支皮瓣。岛状皮瓣设计遵循“点-线-面”的设计方法,即先利用超声等各种手段先确定穿支皮瓣的从源动脉穿出点,再确定轴型血管的走行,最终确定皮瓣切取的面积、形态和方位。在头颈部局部皮瓣的修复重建中,胸大肌的岛状设计不仅供区胸大肌功能得到最大限度保留,受区皮瓣容易塑形,且术后并发症明显减少。岛状设计可以运用到头颈部其他局部皮瓣的改良设计,如内乳穿支、颏瓣、锁骨上瓣、胸肩峰动脉穿支、下位斜方肌穿支等。本文对头颈局部岛状皮瓣概念、设计理论、设计技巧及临床应用做一阐述。     

胸肩峰动脉穿支皮瓣的应用解剖研究

摘要：目的为胸肩峰动脉穿支皮瓣的临床应用提供解剖学基础。方法取新鲜成人尸体8具,其中男7具,女1具;死亡年龄30~73岁,平均年龄48岁。尸体标本经股动脉灌注加入氧化铅的红色凝胶后,在上至锁骨,下至第五肋,外至腋前线,内至胸骨旁的区域内通过解剖和影像学方法观察胸肩峰穿支动脉的出现率、位置、走行与周围血管的吻合,并测量胸肩峰动脉穿支管径及蒂长。结果8具标本 16侧均出现胸肩峰动脉皮穿支,从胸大肌锁骨头和胸肋头间的肌间隙穿出,管径平均0.84 mm;蒂长平均7.12 cm;与胸外侧动脉,胸廓内动脉来源血管吻合丰富。结论胸肩峰动脉穿支皮瓣穿支出现率高,位置恒定,血管蒂长与周围血管吻合丰富,皮瓣切取范围大,设计灵活,不损伤胸大肌,可用于头颈颌面部的组织缺损修复。     

介绍一种双面皮瓣——用于咽和颈段食管重建的改进胸大肌皮瓣

改进的胸大肌皮瓣是于共腹面再加植断层厚皮,造成双面皮瓣,作为重建咽和颈段食管之用。该肌皮瓣的血供来自胸肩峰动脉的胸支,亦有来自胸外侧动脉和胸最上动脉,并可直接从腋动脉分出。该动脉干锁骨的外侧和中间的1/3处穿过筋膜,在胸小肌的上缘,走向胸大肌的腹面,供应胸肌和乳房,并与乳房内动脉的肋间支和胸外侧动脉吻合。胸前、外侧神经来自第五、六、七颈神经臂丛的外侧索,其行径与供应胸大肌的动静脉平行。取肌皮瓣的方法是于一周前,先在前胸壁定出胸支动脉的走向,依缺陷的大小于胸大肌处作新月形切口,形成岛状肌蒂,仔细保留血供,并于其腹面再加植断层厚皮造成双面皮瓣,复回原处,保存一周。保存的优点是保证移植皮瓣的存     

头颈外科

930005胸大肌肌皮瓣的血管解剖学研究/李晓明一尹中华耳鼻咽喉科杂志一1992,27 (增刊)一5一7 通过尸体解剖测量、选择性动脉造影和前列腺素E:血管内灌注法,对胸大肌肌皮瓣(文内简作PMMF)的血管解剖学进行了研究。发现74 .47写的胸肩峰动脉发自腋动脉第二段,其胸肌支起始处的最小外径为o.22mm,最大外径为4.00mm,平均外径为2.olmm。后者与胸大肌本身还发出皮肤穿支供应胸大肌表面皮肤的血液。胸外侧动脉也是胸大肌肌皮瓣血供的重要来源。在某些情况下胸肩峰动脉可以发生异常或病理性闭塞。根据本研究结果,作者对胸大肌肌皮瓣手术提出了一些…     

胸肩峰动脉穿支皮瓣修复颈咽部软组织缺损

目的胸肩峰动脉穿支皮瓣（thoracoacromial artery perforator,TAAP）是近年来应用于颈部和咽部组织缺损的新技术,本文分析使用TAAP修复颈咽部缺损的经验。方法回顾分析2013年5月~2017年4月诊治20例TAAP修复咽瘘、咽部黏膜缺损和颈部皮肤缺损。本组患者年龄48~68岁,平均年龄53岁。下咽癌切除+全喉切除10例,保留喉功能的下咽癌切除7例,颈部皮肤缺损3例。咽部黏膜缺损4.5 cm×3 cm~6.5 cm×5 cm,颈部皮肤缺损5.5 cm×4 cm~8 cm×6 cm,皮瓣大小6 cm×4 cm~8 cm×6 cm。结果18例术后皮瓣成活,供区直接拉拢缝合,没有出现皮瓣坏死,其中15例行下咽黏膜修复的患者,术后2~5周恢复经口进食并行术后放疗,剂量60~67 Gy。另2例术中发现穿支血运障碍,更换成颏下皮瓣修复下咽缺损。随访3~36个月,1例术后14个月出现胸段食管癌,1例术后18个月出现纵膈淋巴结转移,均予以放化疗, 1例术后1年出现颈部淋巴结转移复发予以化疗,余病例无复发。结论胸肩峰动脉穿支皮瓣因为邻近颈部、血管相对恒定、皮瓣薄适用于修复咽部黏膜和颈段食管缺损;胸肩峰动脉为血管蒂的一蒂双岛的TAAP和胸大肌皮瓣同时修复复杂的颈部皮肤和咽部黏膜缺损。胸肩峰动脉穿支皮瓣的穿支细小,穿越锁骨下隧道时穿支区域和血管蒂不能扭曲,发现皮瓣血运异常应及时更换其他修复方法。     

胸背动脉穿支皮瓣的解剖学研究及其在头颈修复中的意义

目的探讨胸背动脉穿支皮瓣的解剖学基础及其在头颈修复中的临床意义。方法解剖新鲜成人尸体5具,观察、测量胸背动脉穿支皮瓣供血穿支的数目、类型、管径、蒂长、走行、出筋膜后轴向及源血管外径,并对其定位。结果胸背动脉穿支44支,其中肌皮穿支35支、肌间隔/直接皮穿支9支。胸背动脉内侧支的肌皮穿支数占38.6%。胸背动脉外侧支的皮穿支数占54.5%,大部分位于背阔肌前缘2?cm之内。最粗穿支血管平均蒂长（12.41±2.84）cm。肩胛下动静脉外径（3.59±0.62）、（3.75±0.41）mm,胸背动静脉外径（2.71±0.43）、（2.98±0.18）mm。结论胸背动脉的穿支血管解剖位置较为恒定,穿支皮瓣制作方便,其管径及蒂长均适宜头颈肿瘤术后缺损的修复。     

游离股前内侧嵌合穿支肌皮瓣在舌癌术后舌再造中的临床应用

目的探讨游离股前内侧嵌合穿支肌皮瓣在舌癌术后舌再造中的应用。方法2015年6月—2018年11月应用股前内侧嵌合穿支肌皮瓣对14例舌癌患者舌颌颈联合根治术后同期行舌及口底缺损修复,口底腔隙同时用不同来源肌瓣充填。肿瘤根治术后形成6.0 cm×4.0 cm～12.0 cm×7.0cm大小缺损,应用游离股前内侧嵌合穿支肌皮瓣修复,皮瓣面积为8.0 cm×4.0 cm～13.0 cm×8.0cm,肌瓣体积为4.0 cm×3.0 cm×2.0 cm～7.0 cm×5.0 cm×4.0 cm,术中将股前内侧穿支血管蒂的动脉与甲状腺上动脉吻合,伴行静脉与甲状腺上静脉或颈内静脉吻合。结果所有患者股前内侧穿支恒定存在,其中来源于股动脉主干7例（50%）,血管蒂长度为(7.8±0.4)cm;来源于旋股外侧动脉主干4例（28.6%）,血管蒂长度为(8.2±0.5)cm;来源于旋股外侧动脉降支3例（21.4%）,血管蒂长度为(7.4±0.3)cm。肌瓣来源于股直肌为8例,肌瓣来源于股内侧肌为6例。其中8例血管蒂类型为1支动脉2支静脉,6例血管蒂类型为1支动脉1支静脉,甲状腺上静脉为首选的受区静脉,游离股前内侧穿支动脉伴行静脉与甲状腺上静脉端端吻合14例,其中8例的第2支伴行静脉另外与颈内静脉端侧吻合8例。术后皮瓣全部顺利成活,供区愈合良好。术后随访12～40个月,平均18.8个月,游离股前内侧穿支皮瓣修复舌外形不臃肿,两点辨别觉距离为8～15 mm,舌运动未见明显受限;大腿功能未见明显影响,可正常行走及进行相关日常活动。结论股前内侧嵌合穿支肌皮瓣是舌癌术后采用皮瓣移植再造舌的理想选择。     

应用周边穿支皮瓣作为股前外侧皮瓣皮穿支血管缺失时的替代方案研究

目的 探讨当股前外侧皮瓣可用皮穿支血管(简称皮穿支)缺失时,应用周边穿支皮瓣作为替代方案完成修复过程.方法 2010年8月至2012年8月,8例头颈鳞状细胞癌患者在股前外侧皮瓣制备中发现皮穿支缺失或不足,尝试采用同侧阔筋膜张肌皮瓣(5例),股前内侧皮瓣(3例)进行替代.结果 全部8例替代皮瓣的制备均获得成功,无需再次选择新的供区.皮瓣制备时间50～85 min.5例阔筋膜张肌皮瓣血管蒂长度6～10 cm,血管蒂动脉外径2.5 ～3.0 mm,静脉外径2.5～3.5 mm.3例股前内侧皮瓣中,血管蒂长度10～15 cm,1例采用股直肌支为蒂,动静脉外径均为1.0 mm,另两例以旋股外侧动脉降支为蒂,动脉外径分别为3.5和3,0 mm,静脉外径均为3.5 mm.7例供区直接拉拢缝合,l例植皮.8例皮瓣全部成活,未发生供区并发症.结论 阔筋膜张肌皮瓣和股前内侧皮瓣可作为股前外侧皮瓣可用皮穿支缺失时的良好替代方案.     

改良血管蒂胸锁乳突肌岛状瓣修复下咽部缺损

目的 探讨应用改良血管蒂胸锁乳突肌岛状瓣修复下咽癌切除术后缺损的效果.方法 2003年12月至2010年9月应用以甲状腺上动脉胸锁乳突肌支为血管蒂,以中下段胸锁乳突肌胸骨头为主的改良胸锁乳突肌肌皮瓣一期修复12例梨状窝鳞癌术后缺损患者,年龄47 ～ 72岁,中位年龄59岁,均未接受过术前放疗;肿瘤分期参照2002年UICC分期:T2NOM0 5例,T3N1 M0 5例,T4N1M0 2例.结果 2例原发T4期患者肿瘤侵犯甲状软骨板及患侧甲状腺,未保留喉功能;2例T3期患者侵犯梨状窝前壁,患侧声带固定,1例侵及杓区,均未保留喉功能;3例T3和5例T2期患者保留喉功能.12例肌皮瓣全部成活.随访7 ～88个月,中位数30个月.4例患者术后15～ 32个月死于肿瘤复发和远处转移,8例生存至今,其中4例已生存5年以上.结论 利用显微外科精细解剖血管化蒂部的岛状胸锁乳突肌皮瓣具有成活率高且制作容易,创伤小等优点,是修复下咽部缺损的良好修复方式之一.     

Experience with the modified pectoralis major myocutaneous flap.

Results of 75 reconstructions with a modified pectoralis major myocutaneous flap are described in patients with advanced (stages III and IV) head and neck tumors between 1982 and 1986. The course of the supplying thoracoacromial artery was determined with angiographic studies and was found to follow the middle clavicular line in most cases. The pectoralis major muscle was mobilized up to its acromial attachment, which made the bridging of considerable distances possible between the site of the removed tumor and the donor site. The bulk of the pedicle was reduced at the same time without endangering the safety of the blood supply of the pectoralis major myocutaneous flap. The flaps were viable in the 70 evaluable patients. Partial necroses were observed in three cases. Postoperative fistulas were encountered in 13 patients (surgical closure was necessary in three). Reconstruction with the pectoralis major myocutaneous flap is a safe and versatile procedure, yielding good clinical and functional results in patients with advanced head and neck tumors.     

The trapezius myocutaneous flap. Dependability and limitations

Many reports of the trapezius myocutaneous flap have centered on a single form of the flap. However, three distinct myocutaneous segments, the superior, the lateral island, and the extended island flaps, can be harvested from the trapezius muscle and its overlying skin. Fifty-five patients underwent reconstruction for head and neck defects using 56 trapezius myocutaneous flaps consisting of 28 superior, 24 lateral island, and four extended island flaps. The four vascular supplies of the trapezius muscle are discussed, with emphasis on the variable nature of the transverse cervical and dorsal scapular arteries. Major complications developed in two of 28 superior, five of 24 lateral island, and one of four extended island flaps. The superior flap, although the most dependable, has the most limited range of application. Both the lateral and extended island flaps have a broader range of clinical application, but their usefulness may be limited by previous neck surgery or occult neoplasm in the neck, as well as by the variable vascular supply. Due to the above limitations, 30% of our attempts to utilize the lateral island flap had to be aborted at the time of surgery and an alternate means of reconstruction used. The trapezius myocutaneous flaps are excellent reconstructive tools for selected defects.     

The trapezius myocutaneous flap.

The three trapezius myocutaneous flaps remain valuable adjuncts in head and neck reconstructive surgery. Overall, the lower vertical trapezius flap has the most versatility and reliability, and the least morbidity. There are several advantages of this flap compared to the pectoralis myocutaneous (PMC) flap. It has a thin vascular pedicle, and thus does not add excessive bulk to the neck, as the PMC can. Also, the skin island has less subcutaneous tissue and therefore more pliability than the PMC, which is a definite advantage for oral cavity and oropharyngeal defects. The trapezius flap generally has less hair than the PMC flap, and the donor scar is better hidden.     

A porcine model for multiple musculocutaneous flaps

The purpose of this study was to develop and describe in detail a reproducible porcine model for musculocutaneous flap study. The model was required to demonstrate the following: 1. consistent, easily identifiable anatomical landmarks for muscles and muscular vascular pedicles; 2. flap survival, consistent with the musculocutaneous perforator arrangement of blood supply; 3. ease of islanded- or free-flap formation; 4. arrangement of flaps on each animal, allowing paired studies of control and experimental flaps; and 5. a maximum number of flaps per animal, without undue morbidity or mortality. Pilot dissections were made of the pectoralis, trapezius, latissimus dorsi, gracilis, biceps femoris, and tensor fasciae latae muscles and their major vascular pedicles. After establishing the anatomical landmarks, we formed musculocutaneous flaps at each site to verify the above five requirements. A total of 72 muscle/vessel pedicle dissections were performed, incorporating formation of 61 island musculocutaneous flaps. The skin component overlying an islanded muscle block survived in 60 instances, confirming the reliability of the flap model. We concluded that five pairs of musculocutaneous flaps could be fashioned on one pig, using the bilateral control/experimental paradigm if desired. The pectoralis, latissimus dorsi, trapezius, gracilis, and biceps femoris muscles were used. The ventral muscle group (pectoralis, gracilis) was raised in one operating session, and the lateral muscles (trapezius, latissimus dorsi, biceps femoris) were raised in one further session per side. Three new porcine flaps are described--the pectoralis, biceps femoris, and trapezius. Morbidity was confined to mild splinting of the limbs for one day. This is also the first example of the use of ten musculocutaneous island flaps on one pig, and represents an opportunity for performing physiological, pathological, or pharmacological experiments on the musculocutaneous flap.     

上颌窦恶性肿瘤术后缺损及修复方法

目的探讨上颌窦恶性肿瘤术后缺损的外科重建及贋复体修复。方法60例上颌窦恶性肿瘤术中采用带蒂额瓣、胸锁乳突肌皮瓣、颞肌筋膜瓣、胸大肌皮瓣及腭瓣修复软组织缺损18例,术后选用贋复体修复50例。结果术后语音、吞咽、通气功能及面容恢复良好者占68.3%,一般占20%,较差者占11.7%。胸大肌皮瓣与腭部裂开3例,边缘坏死1例,内眦部皮肤瘘口3例,开口受限8例。结论外科重建与贋复体并用即刻修复上颌窦恶性肿瘤术后缺损,方法简便、经济,贋复体周围软组织良好的固位形和封闭性是功能恢复及面容美观的关键。     

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。     

10种移植物修复头颈缺损的体会

１９８３年１２月－１９９４年１２月应用１０种组织瓣修复头颈肿瘤切除术后缺损１０３例，其中吻合血管的髂骨游离移植１１例，带血管蒂的上斜方肌肌皮瓣７例，后置舌瓣２例，胸大肌肌皮瓣３０例，舌骨下肌皮瓣２２例，前额皮瓣２０例，外侧斜方肌肌皮瓣４例，胸锁乳突肌肌皮瓣２例，。胸锁乳突肌锁骨瓣２例，颈阔肌肌皮瓣３例。作者对不同移植物的利弊，适应证和临床应用体会进行了讨论。     

The rhombotrapezius myocutaneous and osteomyocutaneous flaps

As more radical surgery is being performed for head and neck cancer, an increasing variety of flaps for reconstruction have been developed. The more common myocutaneous flaps for large defects are the pectoralis major, trapezius, and latissimus dorsi flaps. The lower trapezius flap, which is used for reconstruction of large lateral facial defects, is a relatively thin flap. The rhombotrapezius flap described in this article provides bulk for augmentation of facial defects. The flap, which includes the trapezius and rhomboid muscles, also offers a longer pedicle with a greater arc of rotation. This flap may include the medial border of the scapula when bone is necessary. The addition of the rhomboid muscles incorporates the dorsal scapular artery, which gives an additional blood supply to the flap. We believe that the rhombotrapezius, myocutaneous, and osteomyocutaneous flaps have a significant advantage over previously described flaps in the treatment of defects that need greater bulk and length for adequate reconstruction.