游离组织瓣修复晚期颅底肿瘤术后组织缺损

目的 总结游离皮瓣在晚期颅底肿瘤术后组织缺损中修复的效果及适应证.方法 回顾性分析中国医学科学院肿瘤医院头颈外科1999年3月-2009年3月颅底手术后组织缺损修复的游离皮瓣共25例,其中背阔肌肌皮瓣9例,腹直肌肌皮瓣6例,腹壁下动脉穿支皮瓣4例,股前外侧皮瓣3例,前臂皮瓣2例,腓骨骨肌皮瓣1例.颅底缺损类型分别为颅骨25例次,脑膜10例次,脑组织3例次,鼻腔鼻窦13例次,黏膜14例次,皮肤20例次.结果 23例(92%)游离皮瓣全部成活,1例皮瓣坏死,1例部分坏死.5例(20%)患者出现术后中枢神经系统并发症,其中脑疝死亡1例,颅内感染2例和脑脊液漏2例.结论 游离组织瓣修复技术可靠,适用于晚期颅底复发肿瘤,同时涉及皮肤或黏膜手术缺损的修复.     

颅颌面联合切除术后大型缺损的游离组织瓣修复

目的 探讨游离组织瓣修复颅颌面联合切除术后大型缺损的应用价值。方法 自1980年7月以来,对25例恶性肿瘤侵及颅底的患者,共32块组织瓣进行各类游离组织瓣修复术,其中胸大肌肌皮瓣15例,胸大肌皮瓣联合前臂桡侧皮瓣5例,背阔肌肌皮瓣5例（其中2例联合前锯肌）。结果 除1例死于急性脑水肿外,无其它严重并发症发生,本组技术开展早期组织瓣移植后血管危象出现率较高（3/7）,其主要表现为静脉吻合口栓塞,而以后的出现率则明显降低（2/25）。25例游离组织瓣,除1例前臂皮瓣全部坏死及1例胸大肌皮瓣坏死外,其余全部成活。结论 游离组织瓣修复颅颌面联合切除术后大型缺损克服了早期带蒂组织皮瓣修复中长度及组织量不啼,并减少了术后脑脊液漏等并发症,有利于患者术后外形及功能恢复。     

游离组织瓣在头颈外科修复中的应用

目的 探讨游离组织修复技术在头颈外科修复中的应用。方法 统计分析用游离组织瓣修复60例各种头颈部组织缺损,其中男39例,女21例,年龄15～78岁;肿瘤性病变35例,其中恶性肿瘤30例;非肿瘤性病变25例。游离组织瓣的选择;前臂游离皮瓣32例,腓骨肌皮瓣14例,腹直肌瓣8例,背阔肌瓣1例,游离空肠2例,腓骨肌皮瓣与前臂皮瓣联合3例。结果 60例患者组织瓣中57例全部成活,2例组织瓣大部分成活,坏死1例,成功率98％。各种并发症有13例,发生率21％。结论 游离组织瓣是头颈部缺损较好的修复材料,可最大限度的恢复功能与外形。     

锁骨上皮瓣修复头颈缺损9例临床分析

目的　探讨锁骨上皮瓣在头颈肿瘤缺损修复中的应用。方法　回顾性分析2017年1月~2020年12月于扬州大学附属苏北人民医院收治的应用锁骨上皮瓣修复头颈缺损的9例患者临床资料,通过研究其头颈肿瘤缺损的原因、术前放疗史、手术方式、皮瓣尺寸及术后愈合情况等因素,探讨锁骨上皮瓣的制备技巧、应用指征及术后并发症的处理。结果　9例患者均为男性,年龄51~79岁。3例一期修复包括1例下咽癌,1例舌根恶性肿瘤,1例鼻咽癌继发颈部淋巴结转移癌;6例二期修复包括1例下咽癌术后继发颈部淋巴结转移癌,1例喉癌术后继发气管造瘘口癌,1例喉及食管癌术后吻合口瘘,3例下咽癌术后咽瘘。2例咽瘘患者采用锁骨上皮瓣联合胸大肌皮瓣修复缺损,7例患者单独采用锁骨上皮瓣修复。术中所取锁骨上皮瓣宽度为4~8 cm,长度为6~15 cm。8例术后随访皮瓣存活,1例术后皮瓣坏死,清创换药后愈合。1例下咽癌术后患者皮瓣存活,但食管入口肿瘤复发予以放射性粒子植入,局部未控,术后第11个月死亡。结论　锁骨上皮瓣是喉咽及颈部皮肤术后缺损较为理想的修复组织瓣,技术比较成熟,术中应注意皮瓣血管的保护,治疗效果比较可靠。     

游离组织瓣修复头颈部术后缺损并发组织瓣坏死的原因分析

目的探讨游离组织瓣修复头颈部术后缺损并发组织瓣坏死的原因,以期提高手术成功率。方法对63例应用游离组织瓣修复的头颈恶性肿瘤术后缺损的临床资料进行回顾性分析。结果术后出现血管危象11例,危象发生率17．46％。其中静脉危象9例,动脉危象2例,最终皮瓣坏死4例,坏死率6．35％。与术后并发症有关的术前因素包括年龄、糖尿病、高凝状态、长期吸烟史及长期适量饮酒史;术中因素包括血管蒂过长、吻合血管组数;术后因素包括术后引流及激素治疗。结论对拟行游离组织瓣修复头颈部术后缺损的患者,进行完善的术前评估,严格掌握手术适应证以及周全的术中、术后处理是减少手术并发症、提高成功率的关键。     

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。     

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。     

游离腓骨肌皮瓣及CT血管造影技术在颌面部软硬组织缺损功能性重建中的应用

目的：评估应用游离腓骨肌皮瓣功能性重建口腔颌面部软硬组织缺损及术前增强CT血管造影检查的临床价值。方法：口腔癌患者8例,应用游离腓骨肌皮瓣一期修复下颌骨及周围软组织缺损,血管吻合采用端端吻合法,分析腓骨肌皮瓣的设计、大小、修复部位和存活情况等。术前行供瓣区增强CT断层扫描血管造影（CTA）排查腓骨肌皮瓣血管变异。结果：1例牙龈癌患者存在腓动脉与胫后动脉共干,改用其他肌皮瓣修复;余7例游离腓骨肌皮瓣全部成活,均携带1块皮岛,皮岛6cm×2cm～10．0cm×3．5cm,用于口内软组织缺损修复。术后语音功能基本正常,面部外形、功能及咬合关系良好。下肢功能在术后2周～2个月恢复正常。结论：术前CTA检查对游离腓骨肌皮瓣的供区评价具有十分重要的应用价值。游离腓骨肌皮瓣的骨量充足,具有骨膜和骨髓双重血供,抗感染能力强。可根据需要做截骨塑形从而更加准确地恢复颌骨牙槽突形态,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。游离腓骨瓣的皮岛还可作为术后血供的观察窗,是能够同时兼顾颌骨缺损及周围软组织缺损功能修复重建的理想方法。     

双岛胸大肌皮瓣在头颈肿瘤切除、重建术中的应用

目的 探讨双岛胸大肌皮瓣在头颈肿瘤术后组织缺损修复重建应用的效果及优点。方法 应用双岛胸大肌皮瓣,对头颈肿瘤术后组织缺损的8例患者进行修复重建。结果 重建后的咽腔无狭窄,颈部皮肤均成活。皮瓣I期愈合7例;皮瓣重建颈部皮肤面边缘轻度坏死1例,经处理后愈合。患者于术后8～12d(平均10d)开始进食;术后14～20d(平均16d)出院。结论 双岛胸大肌皮瓣血供丰富,组织量多,是同时修复头颈肿瘤术后皮肤、黏膜双重缺损的优选方法。     

胸大肌肌皮瓣在耳鼻咽喉头颈外科中的应用

目的探讨胸大肌肌皮瓣在耳鼻咽喉头颈外科手术中的应用方法及临床效果.方法1983至2001年手术治疗了247例头颈部肿瘤患者,用胸大肌肌皮瓣或联合其它组织瓣如胸三角皮瓣、裂层皮片、喉气管瓣、舌根瓣、胃瓣、胸骨舌骨肌筋膜瓣、胸锁乳突肌骨膜瓣、会厌瓣等对术中组织缺损进行了整复.结果247例胸大肌肌皮瓣修复术中,肌皮瓣坏死3例,咽瘘31例,切口感染42例,吻合口狭窄4例,严重出血3例.除3例外余者均恢复正常吞咽功能.结论胸大肌肌皮瓣供血可靠,成活率高,操作简单,能满足头颈部手术中广泛组织缺损的修复和功能重建,使部分晚期头颈肿瘤患者通过手术得以根治,以获得较好的生活质量.     

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。     

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。     

Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction

OBJECTIVE: To determine the incidence and causes of perioperative complications in patients who undergo microvascular free flap procedures for reconstruction of the head and neck. SETTING: Academic tertiary care medical center.Patients and METHODS: A total of 400 consecutive microvascular free flap procedures were performed for reconstruction of the head and neck, with 95% of the defects arising after the treatment of malignancies. Flap donor sites included radial forearm (n = 183), fibula (n = 145), rectus abdominis (n = 38), subscapular system (n = 28), iliac crest (n = 5), and a jejunal flap. Patient-related characteristics (age; sex; diagnosis; comorbidity level; tumor stage; defect site; primary vs secondary reconstruction; and history of surgery, radiation therapy, or chemotherapy) and the incidence of perioperative complications were recorded prospectively over a 7-year period. RESULTS: The perioperative mortality was 1.3%. Overall, perioperative complications occurred in 36.1% of all cases. Free flaps proved to be extremely reliable, with a 0.8% incidence of free flap failure and a 3% incidence of partial flap necrosis. Perioperative medical complications occurred in 20.5% of cases, with pulmonary, cardiac, and infectious complications predominating. Multivariate statistical analysis showed significant relationships between the incidence of perioperative complications and preoperative comorbidity level as indicated by American Society of Anesthesiologists (ASA) status (P =.02). CONCLUSIONS: The present study confirms that free flaps are extremely reliable in achieving successful reconstruction of the head and neck. The incidence of perioperative complications is related to preoperative comorbidity level.     

吻合血管的双游离瓣技术在大型头颈部缺损修复中的应用

目的　分析双游离瓣技术在大型头颈部缺损修复中的应用价值。方法　对 2 0 0 0年 3月～ 2 0 0 2年 1月期间完成的 33例利用双游离瓣行大型头颈部缺损修复的病例作回顾性研究 ,分析所采用游离瓣的类型、受区血管、游离瓣成活情况及术后并发症的发生情况 ,并分析有可能影响游离瓣成活的各种因素。结果　 33例患者中 2 3例采用腓骨瓣 +前臂瓣 ,6例采用腓骨瓣 +腹直肌皮瓣 ,4例采用前臂瓣 +腹直肌皮瓣 ;除 1例采用串联瓣的形式外 ,其余 32例患者的两块游离瓣均采用不同的受区血管 ,其中 14块游离瓣采用了对侧颈部的受区血管 ;6 6块游离瓣中 ,1块腓骨瓣和 1块腹直肌皮瓣因静脉栓塞而失败 ,其余的 6 4块瓣均成活 ;受区和供区总的并发症发生率为 39 4 % ( 13 33) ,但大多数并发症均不严重 ,没有造成严重的后果。结论　大型头颈部缺损的双游离瓣修复安全可靠 ,能较好地恢复患者的外形和功能 ,提高了患者的生存质量     

吻合血管的双游离瓣技术在大型头颈部缺损修复中的应用

目的 分析双游离瓣技术在大型头颈部缺损修复中的应用价值。方法 对2000年3月～2002年1月期间完成的33例利用双游离瓣行大型头颈部缺损修复的病例作回顾性研究，分析所采用游离瓣的类型、受区血管、游离瓣成活情况及术后并发症的发生情况，并分析有可能影响游离瓣成活的各种因素。结果 33例患者中23例采用腓骨瓣 前臂瓣，6例采用腓骨瓣 腹直肌皮瓣，4例采用前臂瓣 腹直肌皮瓣；除1例采用串联瓣的形式外，其余32例患者的两块游离瓣均采用不同的受区血管，其中14块游离瓣采用了对侧颈部的受区血管；66块游离瓣中，1块腓骨瓣和1块腹直肌皮瓣因静脉栓塞而失败，其余的64块瓣均成活；受区和供区总的并发症发生率为39．4％(13／33)，但大多数并发症均不严重，没有造成严重的后果。结论 大型头颈部缺损的双游离瓣修复安全可靠，能较好地恢复患者的外形和功能，提高了患者的生存质量。     

Results of Free Flap Reconstruction After Ablative Surgery in the Head and Neck

Objectives

Due to the complex anatomy and function of the head and neck region, the reconstruction of ablative defects in this area is challenging. In addition, an increasing interest in improving the quality of life of patients and achieving good functional results has highlighted the importance of free flaps. The aim of this study was to summarize the results of free flap reconstruction and salvage of free flaps in a single institute, and to analyze differences in the results by the flap donor site, recipient site, and learning curve.

Methods

The medical records of patients who underwent free flap reconstruction from 2004-2012 were reviewed retrospectively. One hundred and fifty free flaps were used in 134 patients, who had an average age of 57.7 years. The types of flaps applied, primary defect sites, success rates, results of salvage operations for compromised flap, and the learning curve were analyzed.

Results

The anterolateral thigh flap was preferred for the reconstruction of head and neck defects. The overall success rate was 90.7%, with 14 cases of failure. A total of 19 salvage operations (12.7%) for compromised flap were performed, and 12 flaps (63.2%) were salvaged successfully. Dependency on the facial vessels as recipient vessels was statistically different when oral and oropharyngeal defects were compared to hypopharyngeal and laryngeal defects. The learning curve for microvascular surgery showed decrease in the failure rate after 50 cases.

Conclusion

The free flap technique is safe but involves a significant learning period and requires careful postoperative monitoring of the patient. Early intervention is important for the salvage of free flaps and for lowering the failure rate.     

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.     

Surgical techniques and results of lateral thoracic cutaneous, myocutaneous, and conjoint flaps for head and neck reconstruction

BACKGROUND: This paper aims at presentation of our surgical techniques and results of the lateral thoracic (LT) flaps for head and neck reconstructions. METHOD: There were seven LT cutaneous, seven LT myocutaneous, and two LT conjoint myocutaneous flaps for reconstruction of head and neck mucosal or cutaneous defects. RESULTS: The largest flap size was 22 cm x 13 cm. All donor sites were closed primarily. The highest point of reconstruction was in the nasopharynx internally and zygoma externally. All flaps survived without major complication. CONCLUSIONS: The LT flap has the versatility of cutaneous, myocutaneous, and conjoint flaps with pectoralis major or latissimus dorsi myocutaneous flaps to reconstruct large surgical defects. It has a large, reliable surface area, a long pedicle to reach nasopharynx and zygoma, and has less bulky muscle to facilitate tubular reconstruction of circumferential pharyngeal defect, one-stage operation, esthetic hidden donor site scar in axillary region, and minimal donor site morbidity. It is an additional reliable pedicle flap in our armamentarium for reconstruction of both cutaneous and mucosal defects in the head and neck region.     

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.