带蒂额肌帽状腱膜复合组织瓣Ⅰ期修复颅底缺损——附3例报告

目的;探讨颅内联合手术后颅底中央区穿通性缺损Ⅰ期修复重建的新方法。方法：采用带血管蒂的额肌帽状腱膜复合组织瓣修复重建３例颅底恶性肿瘤切除术后颅底中央区组织缺损,其中正中双蒂额肌帽状腱膜复合组织瓣２例,正中双蒂额肌帽状腱膜颅骨瓣１例。     

带蒂额肌帽状腱膜复合组织瓣Ⅰ期修复颅底缺损——附3例报告

目的:探讨颅面联合手术后颅底中央区穿通性缺损I期修复重建的新方法.方法:采用带血管蒂的额肌帽状腱膜复合组织瓣修复重建3例颅底恶性肿瘤切除术后颅底中央区组织缺损,其中正中双蒂额肌帽状腱膜复合组织瓣2例,正中双蒂额肌帽状腱膜颅骨瓣1例.取瓣面积可达8cm×15cm左右.结果:用该瓣修复的3例患者无并发症发生.结论:带蒂额肌帽状腱膜复合组织瓣血管恒定、血供好、组织薄、带有硬性支撑并可弯曲成形,取瓣径路与手术切口一致,不影响美观.因此,该组织瓣为修复颅底中央区穿通性组织缺损的一种新方法.     

内镜下带血管蒂鼻中隔黏骨膜瓣修复颅底缺损

目的 探讨内镜下应用带血管蒂的鼻中隔黏骨膜瓣修复颅底硬膜缺损的方法及疗效.方法 回顾性分析2008年7月至2010年3月间收治的8例应用带血管蒂的鼻中隔黏骨膜瓣鼻内镜下修复术后颅底硬膜缺损及创伤性脑脊液鼻漏患者的临床资料及随访结果.8例患者均为男性,年龄28～60岁,平均年龄41岁.其中前颅底血管外皮瘤1例、嗅神经母细胞瘤1例(Kadish C型)、筛窦癌1例、鼻咽癌放疗后局部复发3例、颅底类癌1例、脑脊液鼻漏伴反复颅内感染1例.其中前颅底缺损6例,中颅底缺损2例.手术采用内镜经鼻入路,直视下获取以鼻后动脉为蒂的一侧鼻中隔黏骨膜瓣.组织瓣覆盖硬膜缺损后,周缘敷以明胶海绵,并用生物蛋白胶固定,鼻内以碘仿纱条、水囊及膨胀海绵支撑.术后5～7 d撤除全部鼻内支撑物.结果 1例鼻中隔瓣部分坏死,其余7例鼻中隔瓣全部成活.1例术后7 d有脑脊液鼻漏,再次手术探查以腹部脂肪封堵漏口成功,术后随访6～24个月,颅底组织愈合良好,无延迟性脑脊液漏及颅内感染发生.结论 内镜经鼻入路采用带血管蒂鼻中隔黏骨膜瓣修复颅底硬膜缺损是一种可靠的颅底重建方法.

Abstract：

Objective To introduce a method and the clinical effects of repairing skull base defects and dural defects using vascular pedicled nasoseptal mucoperiosteal flaps through an endoscopic endonasal approach. Methods The clinical and follow-up data for 8 patients who underwent endoscopic endonasal reconstruction of skull base defects and cerebrospinal fluid rhinorrhea with a vascular pedicled nasoseptal mucoperiosteal flap between July 2008 and March 2010 were retrospectively reviewed. All patients were male. The age of these patients ranged from 28 to 60 years (average 41 years). The diagnosis for these patients included one hemoangiopericytoma of the anterior skull base one olfactory neuroblastoma (type of Kadish C) , one ethmoid sinus cancer, three local recurrent cancers of the nasopharynx after radiotherapy,one carcinoid of skull base and one traumatic cerebrospinal fluid rhinorrhea with recurrent intracranial infection. There were six anterior skull base defects and two middle cranial fossa defects. An endoscopic endonasal surgical approach was used for the repair. A pedicled flap using the nasal septal mucoperiosteum based on the posterior nasal artery was harvested from the ipsilateral side. The tissue flap was used to cover the dural defects. The margin was covered with gelatin sponge and fixed with fibrin glue. The nasal cavity was packed with iodoform gauze, a Foley catheter balloon and Merocel in this sequence to secure the flap in place. Nasal packing was removed 5 to 7 days postoperatively. Results Partial septal flap necrosis was found in one case, but the flaps in the other 7 cases survived. A postoperative cerebrospinal fluid leak occurred in one case 7 days after surgery. This was re-explored and successfully repaired with abdominal fat.All cases healed well, with no delayed cerebrospinal fluid leaks or intracranial infections during the 6 to 24 months follow-up period. Conclusion The vascular pedicled nasoseptal mucoperiosteal flap is a reliable choice for endoscopic endonasal skull base reconstruction.     

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.     

头颈部肿瘤组织缺损应用带蒂复合肌皮瓣修复体会

我科自１９９４～１９９７年间应用带血管蒂的胸大肌皮瓣和斜方肌低位岛状肌皮瓣Ⅰ期修复头颈部恶性肿瘤患者组织缺损１０例。其中胸大肌皮瓣修复８例，２例部分坏死，均为口腔内组织缺损病例；斜方肌低位岛状肌皮瓣修复组织缺损２例，均成活。胸大肌皮瓣和斜方肌低位岛状肌皮瓣具有蒂长，供皮区面积大，血供可靠，二者相互补充能满足大部分头颈部肿瘤术后的缺损修复和功能重建。作者认为，保证肌血管蒂的血流畅通和术后应用有效的抗生素是保证肌皮瓣成活的首要因素。对于口腔缺损区修复，保持口腔清洁、干燥及正确的护理对口腔内组织瓣的成活也致关重要。     

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。     

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。     

带蒂肌骨膜瓣修复气管壁缺损

气管壁缺损修复困难。报告７例采用带蒂胸锁乳突肌肌骨膜瓣或胸大肌肌皮骨膜瓣修复气管壁部分缺损的经验，除１例局部感染失败外，均获成功。讨论了该手术的主要优点及操作技巧。有血供的骨膜瓣具备良好的成骨能力，符合气管壁的特殊要求。本手术操作简单，值得推广。     

耳后带蒂复合组织瓣在开放式乳突切开+鼓室成形术中的应用

目的 探讨耳后带蒂复合组织瓣乳突腔填塞应用于开放式乳突切开+鼓室成形术的疗效及其操作要点.方法 回顾性分析十堰市太和医院耳鼻咽喉头颈外科完成的45例(45耳)开放式乳突切开+鼓室成形术患者的临床资料,术中均选用耳后带蒂肌骨膜瓣和外耳道皮瓣复合瓣行乳突腔填塞,分析术后干耳时间、听力变化和相关并发症的发生及手术技巧等.结果...     

经鼻内镜下带血管蒂组织瓣颅底重建术

内镜经鼻扩大入路颅底手术可以成功处理颅底区域广泛的病变,而术后硬膜缺损范围和复杂性可与开放式颅面切除术后相仿.此时能否在内镜下对颅底缺损进行一期重建是达成手术目的、保障安全的必要条件.以往使用游离的、非血管化组织或材料修复此类复杂颅底缺损,失败比例很高.而近年来采用带血管蒂的局部或区域组织瓣修复颅底复杂的硬膜缺损技术取得长足进步,成功率显著提高.本文就经鼻内镜下应用不同的带血管蒂组织瓣修复颅底缺损技术进行综述.     

The pericranial flap for reconstruction of anterior skull base defects

In 1981, the senior author first reported the use of the pericranial flap for support of the brain following resection of the anterior skull base. Since the initial report, considerable experience has been gained with this flap. It is currently deployed via a bifrontal craniotomy and is placed primarily as a support beneath the frontal lobes. The pericranial flap may also be used to repair dural laceration and defects. The sinonasal surface is routinely grafted with split-thickness skin or dermis. This technique provides an excellent barrier between the sinonasal cavity and the cerebrospinal fluid, establishing a tough, fibrous platform. Herniation of intracranial contents has not occurred. One major complication has been reported in which radiation necrosis occurred during postoperative therapy, leading to progressive devitalization of the pericranial flap. Ultimately, dural repair and closure with a latissimus dorsi free flap was required. The pericranial flap repair of anterior skull base defects has a 90% complication-free and 95% overall success rate. It is simple and extremely effective. Bone grafting has not been necessary in our experience.     

Anterior skull base reconstruction with the pericranial flap after craniofacial resection.

No one reconstructive method is always satisfactory, especially when considering repair of a region such as the anterior skull base. Increased morbidity and mortality is directly related to failure of the reconstruction to adequately isolate the cranial cavity from the respiratory tract. Those surgeons performing craniofacial resections for lesions of the paranasal sinuses and anterior skull base must be familiar with a variety of reconstructive techniques which they can utilize depending upon the surgical defect that must be closed. For those small to moderate size defects of the anterior fossa we recommend using the inferiorly based pericranial flap to effect a repair. For larger defects extending laterally from the midline to involve a portion of the orbital roof, a laterally based flap of temporalis and pericranium can be used to provide successful anterior skull base reconstruction. Larger defects of the cranio-orbito-facial region will require additional methods of repair utilizing distant vascularized flaps.     

Frontal pericranial and muscle flaps in repairing anterior skull base defect

Frontal craniotomy incision was used for operations on ethmoidofrontal benign and malignant tumors involving anterior skull base, traumatic C.S.F. rhinorrhea and congenital meningoencephalocele. Since 1982, 21 patients have had their surgical or traumatic defects repaired with frontal pericranial flap covered with muscle flap. Both flaps were tailored to support the cranial contents. No cerebrospinal fluid leakage and meningitis occurred postoperatively in our series. The technique provides a significant advantage over previously described procedures.     

耳后穿支皮瓣在外耳道缺损中的应用

手术切除外耳道新生物是外耳道皮肤缺损最常见的原因。传统的方法是取大腿内侧中厚皮片修复缺损,由于移植片固定困难,加之局部血供建立较慢,常有皮片不成活或愈合不良引起外耳道狭窄。我科2005-04-2013-04应用耳后穿支皮瓣修复外耳道皮肤缺损区11例,取得满意疗效,现报告如下。1资料与方法 1.1临床资料11例患者,男6例,女5例;年龄24~68岁,平均42岁。均为外耳道新生物需切除的患者。新生物病理诊断：乳头状瘤6例,黑色素瘤2例,血管瘤、耵聍腺瘤、瘢痕增生各1例。     

带蒂鼻中隔黏膜瓣在侵及前颅底鼻腔鼻窦恶性肿瘤切除术颅底重建中的应用

目的　回顾性分析应用带蒂鼻中隔黏膜瓣修复内镜下切除侵及颅底鼻腔鼻窦恶性肿瘤术后颅底缺损的效果。方法　2008年9月～2016年5月内镜下切除侵及颅底鼻腔鼻窦恶性肿瘤31例,应用以鼻后中隔动脉和筛前-筛后动脉为供血的两种类型带蒂鼻中隔黏膜瓣,修复重建前颅底切除后较大颅底缺损。结果　31例患者前颅底重建均一次性修补成功。1例肿瘤复发二次手术患者术后发生脑脊液漏,给予椎管置管引流1周愈合;1例术后10 d撤出鼻腔填塞物后出现脑脊液鼻漏,颅内感染3例,余无颅内出血或血肿等并发症发生。术后随访3～66个月见黏膜瓣愈合良好,无移植瓣膜坏死和脑膜脑膨出发生。结论　血管化带蒂鼻中隔黏膜瓣是内镜颅底外科的一种首选的、可靠的前颅底修补用材料。     

The posterior pedicle inferior turbinate flap: a new vascularized flap for skull base reconstruction

BACKGROUND: Expanded endonasal approaches (EEA) for the resection of lesions of the anterior and ventral skull base can create large defects with a significant risk of postoperative cerebrospinal fluid (CSF) leaks or exposure of the internal carotid artery. In these cases, a reconstruction using a vascularized flap facilitates rapid and complete healing of the defect. The Hadad-Bassagasteguy flap (HBF), a posterior pedicle nasoseptal flap, is our preferred reconstructive option; however, a prior posterior septectomy or prior wide sphenoidotomies preclude its use. We have developed two additional pedicled flaps to reconstruct these selected patients: the transpterygoid temporoparietal fascia flap, which is suitable for large defects, and the posterior pedicle inferior turbinate flap (PPITF), the subject of this paper. METHODS: We developed a flap comprising the inferior turbinate mucoperiosteum pedicled on the inferior turbinate artery, a terminal branch of the posterior lateral nasal artery, which arises from the sphenopalatine artery. We retrospectively reviewed the clinical data of four patients who underwent a skull base reconstruction using a PPITF. RESULTS: Four patients underwent a reconstruction with the PPITF after undergoing an EEA that produced a skull base defect associated with a CSF fistula (n = 2), an exposed internal carotid artery (n = 1), or a basilar aneurysm clip (n = 1). All patients had undergone posterior septectomies as part of previous EEAs. All flaps healed uneventfully and covered the entire defect. CONCLUSION: The PPITF is a viable reconstructive option for patients with skull base defects of a limited size defect and in whom the HBF is not available.     

Endoscopic skull base reconstruction with the nasoseptal flap: complications and risk factors

European Archives of Oto-Rhino-Laryngology - The endoscopic endonasal approach is increasingly being used for resection and reconstruction of anterior skull base lesions. The vascularized...