下颌骨外旋径路切除晚期口咽癌的临床研究--附6例报告

目的探讨晚期口咽癌的手术入路和口咽缺损的一期修复。方法采用下颌骨外旋径路切除晚期口咽癌6例，其中口咽侧壁癌5例，舌根癌1例；口咽缺损均采用胸大肌肌皮瓣修复。结果全部病例随访2～7年，4例存活3～7年以上，2例分别于术后1，3年死于局部复发。1例咽瘘，3例短期食物返流入鼻腔。全部病例半年内吞咽、言语功能基本恢复。结论下颌骨外旋径路切除晚期口咽癌，具有视野开阔、直视下完整大块切除肿瘤、且便于修复缺损；胸大肌肌皮瓣修复口咽侧壁、舌根及软腭缺损效果良好。     

胸大肌肌皮瓣在头颈部组织缺损修复中的应用

目的　评价胸大肌肌皮瓣在头颈部各类病变术后组织缺损修复中的应用效果。方法　 1 998年 5月～2 0 0 3年 1 0月我科应用胸大肌肌皮瓣对 4 7例病人头颈部病变术后组织缺损进行Ⅰ期修复 ,皮瓣面积为5cm× 6cm～ 1 5cm× 30cm。结果　 4 4例 (93.6 %)胸大肌肌皮瓣完全存活 ,3例 (6 .4 %)胸大肌肌皮瓣部分坏死。结论　胸大肌肌皮瓣血供可靠、组织量多、修复操作简单 ,能满足头颈部各类病变术后组织缺损的修复。     

胸大肌肌皮瓣在鼻咽癌放疗后颈部残留或复发手术中的应用

目的 总结胸大肌肌皮瓣在修复鼻咽癌放疗后颈部转移灶残留或复发术后缺损中的应用。方法 回顾性分析27例鼻咽癌颈部转移灶残留或复发的患者，行根治性颈清扫术，对颈部皮肤缺损用胸大肌肌皮瓣修复。结果 1例患者术后3h死亡，1例术后发生乳糜漏，3例远端吻合口处有感染，5例肌皮瓣远端部分坏死，共有8例延迟愈合。26例患者均一期修复成功。3年生存率为52．4％。结论 鼻咽癌放疗后颈部转移灶残留或复发的挽救性手术应选择根治性颈清扫术；胸大肌肌皮瓣血供丰富，易成活，可取瓣面积大，能满足修复术后缺损的需要；术后患者颈部紧缩感明显减轻，颈部活动度较前改善。     

胸大肌肌皮瓣修复喉咽缺损的应用

目的探讨胸大肌肌皮瓣修复喉咽肿瘤术后组织缺损的疗效。方法收集1990年5月～2007年8月应用胸大肌肌皮瓣修复喉咽癌术后组织缺损患者59例。其中垂直半喉加部分喉咽切除23例,次全喉加部分喉咽切除12例,全喉切除加大部分喉咽切除10例,全喉加全喉咽和部分颈段食管切除14例,同期行颈廓清术109侧。手术后根据患者情况给予55～75 Gy的放射治疗。结果术后转移胸大肌肌皮瓣存活良好,成活率为96.6%。术后发生并发症11例,其中咽瘘6例占10.2%,胸部皮瓣边缘部分坏死3例占5.1%,胸大肌肌皮瓣坏死2例占3.4%。随访5年生存率35.6%。结论胸大肌肌皮瓣供区组织丰富、皮岛面积大且成活率高,修复喉咽肿瘤术后组织缺损取得了良好的效果,全部和部分喉功能保留率达到42.4%。     

胸大肌肌皮瓣卷筒在下咽颈段食管环周缺损修复中的应用

目的 探讨胸大肌肌皮瓣卷筒在晚期喉咽及颈段食管肿瘤切除术后环周缺损修复中应用的可行性及远期疗效.方法 回顾性分析2004年12月至2008年10月对30例头颈鳞癌原发灶肿瘤切除后出现下咽和颈段食管环周缺损的患者选择行胸大肌肌皮瓣卷筒修复的临床资料.其中下咽癌22例,颈段食管癌7例,喉癌术后放疗后复发累及下咽1例.术前接受放疗者5例,外院手术后复发者3例.采用全喉全下咽切除者12例,全喉全下咽切除颈段食管切除者18例,均行胸大肌肌皮瓣卷筒修复.结果 术后咽瘘4例,其中2例有术前放疗史,2例有糖尿病史,均换药治愈.2例患者出现吻合口狭窄,均位于口咽部上吻合口处,经反复扩张后缓解,术后吞咽功能均恢复.全部患者均进行随诊,术后随访时间8～56个月,中位随访时间18个月.以Kaplan-Meier法计算生存率,1年及3年生存率分别为71.4%及42.5%.结论 胸大肌肌皮瓣卷筒修复晚期咽喉及颈段食管肿瘤切除后的下咽和颈段食管环周缺损效果可靠.可用于放疗及手术后复发肿瘤切除后环周缺损的修复.     

胸大肌肌皮瓣修复气管造口复发癌术后的缺损

目的分析胸大肌肌皮瓣在修复气管造瘘口复发癌术后缺损中的应用。方法回顾分析1998~2003年随访资料完整的12例气管造瘘口复发癌患者,其中Ⅰ型4例,Ⅱ型5例,Ⅲ型3例,均用胸大肌肌皮瓣修补术后缺损。对复发癌灶扩大切除,缺损处单纯以胸大肌肌皮瓣修复9例,胸大肌皮瓣联合断层皮片修补3例。结果重建的喉咽腔无狭窄,无吞咽困难。8例皮瓣I期存活,1例肌皮瓣皮肤远端轻度坏死,3例出现咽瘘。随访3年以上,Ⅰ、Ⅱ型中各有3例无瘤存活,其余6例在1~2年内死亡。结论胸大肌肌皮瓣血供可靠、修复操作简单、组织量丰富,对挽救瘘口复发癌手术后巨大缺损应用价值较高。     

脱细胞真皮基质黏膜组织补片在咽部修复中的应用

目的 探讨脱细胞真皮基质黏膜组织补片（acellular dermal matrix，ADM）在咽部的修复作用。方法 2003年6月—2004年12月对18例患者行口咽、喉咽癌切除术，其中4例肿瘤原发于口咽和喉咽后壁，保留喉功能切除肿瘤，用ADM重建口咽和喉咽后壁；3例肿瘤原发一侧梨状窝侧壁和咽后壁，声带活动正常的，保留喉功能行咽后壁或侧壁切除术，将ADM缝在椎前筋膜和咽侧壁上关闭咽腔，用保留的胸锁乳突肌加固；对11例肿瘤累及颈段食管，声带活动受限及固定者，行喉全切除或喉咽全切除术，将ADM缝在椎前筋膜上重建喉咽后壁，用胸大肌肌皮瓣重建喉咽前壁和侧壁，重建密闭腔道。术后全部患者进行放射治疗，放疗剂量60～70Gy。结果 18例患者术后未发生排异反应，无咽瘘，创面均黏膜化。2例患者切口皮下感染，经换药后伤口愈合。所有患者均可经口进食。7例保留喉的患者恢复了喉功能，拔除气管套管，但其中3例进食流质时有轻度误咽。术后随访12～30个月，中位随访时间为19．38个月，补片移植区无排异反应、瘢痕和挛缩。随访18月以上11例，其中3例肿瘤复发，1例再次手术后健在，2例死于全身转移。结论 ADM来源方便，组织相容性好，厚薄适宜，手术操作简便，可联合胸大肌肌皮瓣或其他颈部组织修复咽部环周缺损，是一种新的安全有效的修复材料。     

口咽癌的外科治疗

目的：探讨口咽癌扩大切除一期再建的手术方法,观察并发症及术后语言、吞咽功能恢复情况。方法：30例口咽癌中软腭癌2例,扁桃体癌3例,咽侧壁癌16例,舌根癌9例;Ⅲ、Ⅳ期患者占63．3％（19／30）,颈淋巴结转移53．3％（16／30）。22例用下颌骨切开外旋或切除升支入路进行了肿块根治性切除,同期行颌下清扫术1例,肩胛舌骨肌上清扫术3例,根治性颈清扫术26例。咽部缺损用带蒂胸大肌皮瓣整复17例,胸锁乳突肌皮瓣4例,额顶部岛状皮瓣3例,斜方肌皮瓣和颈阔肌皮瓣各1例,游离前臂皮瓣＋带蒂复合瓣4例。手术＋放疗25例,单纯手术5例。结果：3年生存率为66．7％（14／21）。术后局部感染7例,涎瘘5例,皮瓣远端部分坏死4例,语言、吞咽功能基本恢复。结论：局部缺损范围和选择适宜的肌皮瓣是恢复腭咽闭合及舌可动性的主要因素,带蒂胸大肌皮瓣修复软腭、口咽侧壁及舌根大面积缺损效果良好。     

喉全切除后气管造瘘口复发癌缺损外科修复比较

目的探索喉全切除后气管造瘘口复发癌缺损外科修复的治疗效果。方法对18例喉全切除后气管造瘘口复发癌实施外科治疗。其中Ⅰ型7例,颈部单纯切口,胸大肌肌皮瓣修复颈部皮肤气管造瘘口缺损;Ⅱ型6例,颈肢或胸联合切口,前臂皮瓣或胸大肌肌皮瓣(游离前臂皮瓣5例,胸大肌肌皮瓣1例)修复部分喉咽切除;Ⅲ型3例,颈腹联合切口,游离空肠修复全喉咽、颈段食管;Ⅳ型2例,颈胸腹联合切口,胃上拉修复全喉咽、全食管。Ⅱ、Ⅲ、Ⅳ型的颈部皮肤气管造瘘口缺损均用胸大肌肌皮瓣修复。结果颈部缺损胸大肌肌皮瓣均成活;咽瘘4例(其中游离空肠1例,前臂皮瓣2例,胃上拉咽瘘出血1例);全部病例术后均能进食;随访6～74个月,3例出现不同程度吞咽梗阻。结论喉全切除后气管造瘘口复发癌外科治疗缺损,修复选择应根据原发肿瘤治疗的经过及气管造瘘口复发癌侵及范围来确定修复方法。     

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.     

Der infraklavikuläre Durchzug des M.-pectoralis-major-Lappens

BACKGROUND: The pectoralis major myocutaneous flap (PMMF) is an important reconstructive tool for lesions in the head and neck region. Using the supraclavicular route, the PMMF reliably transfers large amounts of well-vascularized skin and muscle into defects of the upper aerodigestive tract. However, limited length and arc of rotation as well as excessive bulk can be problematic. PATIENTS AND METHODS: In the current study, these problems have been addressed by passing the pedicle deeply to the clavicle. Following flap harvest, the pedicle was passed in the subclavicular plane in 15 head and neck cancer patients for primary and secondary reconstruction. RESULTS: Using this route it was possible to increase the medium length of PMMF to 3 cm compared to the supraclavicular route. No total flap necrosis occurred, however, temporary complications were observed in three of 15 cases (20%)--partial flap necrosis occurred in two cases and fistula formation was observed in one case. This rate is in accordance with complication rates described for the supraclavicular route. However, in long-term follow-ups we observed a fracture of the clavicle in two patients in whom, in contrast to the others, the periostium was not only prepared posteriorly but over the whole circumference. CONCLUSIONS: The subclavicular route for PMMF increases the length and arc of rotation available for reconstruction without compromising vascular supply to a higher degree than with the conventional supraclavicular route. Furthermore, this concept decreases the bulk of the PMMF pedicle which is functionally and cosmetically favourable. Thus, the subclavicular route of PMMF is safe and allows an extension of the reconstructive possibilities.     

Analysis of the efficacy of the pectoralis major myocutaneous flap in reconstructive head and neck surgery

IntroductionAlthough free flaps have been used predominantly in past decades for the soft tissue reconstruction of head and neck malignancies, Pectoralis major myocutaneous flap (PMMF) is still a reliable workhorse for patients with co-existing co-morbidities or low economic status where free flaps are not feasible.Patients and methodsIt was a retrospective study done on 36 patients of head and neck malignancies over the period of 5 years in which PMMF was used as a method of reconstruction in our hospital. Patients were followed up for a period of one year and outcome of PMMF was evaluated.ResultsOut of 36 patients 31 were of oral cancer and 5 were of carcinoma hypopharynx. Incidence of total flap necrosis was nil and partial flap necrosis was 16.6%. Orocutaneous fistula was found in 16.6%, wound dehiscence was in 19.4% and infection was found in 13.5% of patients. Non-flap related complications were found in 13.8% of patients. 35 out of 36 patients (97.2%) eventually achieved satisfactory surgical outcome of PMMF reconstruction.ConclusionPMMF is a reliable method of reconstruction for head and neck malignancies especially in basic healthcare settings. With minimal expertise and groundwork, it is still a cost-effective workhorse flap for head and neck reconstruction.     

胸大肌肌皮瓣在鼻咽癌放疗后颈部挽救性手术中的应用

目的总结胸大肌肌皮瓣在修复鼻咽癌放疗后颈部转移灶残留或复发根治术后缺损中的应用。方法回顾性分析27例鼻咽癌颈部转移灶残留或复发的病人,行根治性颈清扫术,对颈部皮肤缺损用胸大肌肌皮瓣修复。结果1例病人术后3 h死亡,26例病人均一期修复成功。1例术后发生乳糜漏,3例远端吻合口处有感染,5例肌皮瓣远端部分坏死,8例延迟愈合。3年生存率为52.4%。结论鼻咽癌放疗后颈部转移灶残留或复发的挽救性手术应选择根治性颈清扫术;胸大肌肌皮瓣血供丰富,易成活,可取瓣面积大,能满足修复术后缺损的需要。     

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。     

胸大肌肌皮瓣手术的并发症

目的：为了正确预防处理胸大肌肌皮瓣手术的各种并发症。方法：本文系统回顾分析了胸大肌肌肌皮手术的并发症。并对其预防和处理办法做了详尽讨论。结果：在５０例胸大肌肌皮瓣手术中１５例发生了不同程度的并发症。其中咽瘘３例，皮瓣部分坏死３例，颈动脉破裂２例，食管吻合口狭窄３例，脱皮２例，胸壁血肿感脓肿形成１例，癌肿肌蒂部种植１例，结论：只要处理和治疗正确及时，各种并发症是可以治愈的。     

Pectoralis major muscle flap use in a modern head and neck free flap practice

PurposePectoralis major muscle flaps (PMMF) are a commonly used reconstructive modality to repair head and neck defects. As the use of free flap reconstruction is increasingly practiced in the head and neck, the role of the PMMF may be changing as well. This study sought to analyze indications and outcomes for PMMF following head and neck resections from one surgeon's experience.Materials and methodsRetrospective review from December 1, 2013 through September 30, 2017 at a tertiary care academic medical center. Indications for the PMMF were examined as well as surgical outcomes. Basic demographic data, patient head and neck cancer history, history of radiation and/or chemotherapy, and history of previous reconstructive procedures were obtained and compared across all subjects.ResultsForty patients underwent a PMMF within the designated time frame. The majority of patients were male (83%) and the average age was 65 years (range 55.4–74.6 years). Of the 40 cases, 9 of the PMMFs were performed as primary reconstruction of the defect. In the remaining 31 cases, these flaps were utilized as a secondary reconstructive option following fistula formation (13), dehiscence (6), need for an additional flap for recurrent disease (6) infection (4), or major bleeding (2). In every case that it was utilized, the PMMF was the definitive reconstruction. Within the same time frame, 429 free flaps were performed by the same surgeon, with an average of 125 free flaps performed yearly. The rate of total flap failure overall was 3.9%. The other failed free flap reconstructive options used besides a PMMF were secondary free flaps (11), local wound care (4), or obturator placement (2). The secondary pectoralis flaps occurred following 7.2% of free flaps with total or partial failure that were performed within the same time range. The indications for the PMMF did not change or evolve during the time frame of the study.ConclusionsAlthough free flaps were performed with far greater frequency than PMMFs at our institution, the PMMF demonstrated continued utility as a secondary reconstructive option. For a surgeon who performs a high volume of free flaps, preservation of the pectoralis muscle and associated vasculature for possible later secondary reconstruction should be considered due to its strong efficacy.     

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。     

Reconstruction of complex oral defects using bi-paddle pectoralis major flap - technical modifications and outcome in 54 cancer patients

Objective  Reconstruction of locally advanced oral cancer presents a great challenge to the head and neck surgeon. The main goal of reconstruction is to provide intraoral lining and soft tissue cover. We discuss the use of Bipaddle pectoralis major myoculaneous flap (PMMF) and its modifications for reconstruction of complex oral defects following radical resection. Study Design  Retrospective analysis of prospective oral cancer data base. Setting  Tertiary Care Regional Cancer Center. Patients  Three hundred and ten patients were operated for oral carcinoma in this unit between 1993 and 2001. The oral cancer patients who required soft tissue reconstruction for lining and cover were analyzed. Patients in whom bipaddle PMMF were utilised were studied in terms of surgical technique, morbidity, function and cosmetic outcome. Results  Ninety-one (29.4 %) oral cancer patients required reconstruction for lining as well as cover. Of these, 54 (17.4 %) patients underwent a bipaddle PMMF flap reconstruction. Two horizontal skin islands were used in patients with lateral defects and two vertical islands in patients with central defects. There was no complication in 41 (76%) patients. Complete flap loss was seen in only one patient and differential flap loss in 2 patients (4 %) while seven (13 %) patients had only minor complication. All the patients received post-operative Radiotherapy. Good to average functional and cosmetic outcome was observed in 90% patients. Conclusions  Bipaddle PMMF offers an effective and leliahle reconstructive option for complex oral defects. By using certain technical modifications, majority of complex oral defects can be managed successfully using a Bipaddle PMMF. In a developing country like India with a large oral cancer disease burden Bipaddle PMMF should he used routinely for complex oral defects in view of its simplicity, versatility and reliability.     

颞肌筋膜瓣在颅面部肿瘤术后缺损修复中的应用

目的:探讨颞肌筋膜瓣(TMF)在修复颅面部肿瘤术后缺损中的应用。方法:根据缺损大小和部位 设计TMF,对10例颅面部肿瘤术后缺损患者进行修复,其中3例修复颅底缺损,5例修复口咽部缺损,2例修复 眶。结果:随访8～50个月,10例TMF全部成活;修复颅底者,未出现颅内感染及脑脊液漏;修复口咽者,语言、 吞咽功能无明显障碍;修复眶者解剖形态基本恢复,外观满意。结论:TMF是修复颅面部肿瘤术后缺损的理想选 择。