个性化重建板辅助游离腓骨重建上颌骨半侧缺损的优化设计

目的: 利用CAD/CAM以及3D打印技术体外辅助游离腓骨瓣重建上颌骨半侧缺损。方法: 利用CAD/CAM建立游离腓骨瓣重建上颌骨半侧缺损的三维模型,设计个性化重建板、截骨导板辅助重建完成,通过3D打印技术生成术前模型、截骨导板以及重建板,模型外科模拟手术。采用SPSS18.0软件包对数据进行统计学分析。结果: 快速建立了3段式游离腓骨重建上颌骨缺损的数字化模型,并设计生成原发灶截骨导板和重建辅助个性化重建板。定点测量显示,模型外科模拟重建精度与计算机模拟无显著差异（P>0.05）。结论: 优化设计的辅助措施和个性化重建板可以增加游离腓骨重建上颌骨缺损的准确性,有助于临床上精确外科重建。     

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.     

Prevention points for plate exposure in the mandibular reconstruction

IntroductionThe rate of complications for mandibular reconstruction after segmental mandibulectomy is higher with reconstruction plates than with vascularised bone grafts. We have experience of over 100 patients using reconstructive plates for reconstruction immediately after segmental mandibulectomy and have considered factors contributing to plate exposure.Patients and methodsSeventeen cases utilised our prevention methods in which reconstructive plates were used for mandibular reconstruction were reviewed. The flaps used with reconstruction plates were rectus abdominis myocutanenous flaps in 10 cases, anterolateral thigh flaps combined vastus lateralis muscle in four cases, and the omentum in one case; no flap was transferred in two cases.ResultsIn only one of 17 cases was a plate exposed at 3 months postoperatively. No plate exposure occurred during the follow-up period in the other 16 cases. Because no flap had been transferred in the patient with plate exposure, a possible contributing factor was the persistence of dead space beneath the plate.ConclusionThis series suggests that factors other than flap selection contribute to the exposure of reconstructive plates. Use of a reconstruction plate is a useful reconstructive method, especially for patients who cannot tolerate transfer of a vascularised bone graft.     

Virtual planning,simultaneous dental implantation and CAD/CAM plate fixation: a paradigm change in maxillofacial reconstruction

Prosthetic rehabilitation in patients undergoing reconstructive surgery using vascularized free flaps is challenging, and functional rehabilitation of the patient with a fixed prosthesis is rare. Virtually planned maxillofacial reconstruction including simultaneous dental implantation according to the prosthodontic ideal position of the implants could further enhance dental rehabilitation. The data of 21 patients undergoing fibula free flap reconstructive surgery with CAD/CAM patient-specific reconstruction plates during the years 2015–2018 were analysed, including the applicability of the virtual plan, flap survival, duration of surgery, ischemia time, simultaneous dental implantation, implant exposure, and postoperative complications. The virtual plan could be translated to surgery in all cases. In total, 76 dental implants were simultaneously placed during primary reconstruction in the 21 patients. For 38.1% of these patients, the implants could be uncovered in secondary surgery; the mean duration until exposure was 7.6 months. The implant survival rate was 97.4% (74/76). Wound infection requiring a secondary intervention occurred in 23.8% of patients during follow-up. Virtually planned reconstruction with a fibula free flap, simultaneous dental implantation, and CAD/CAM plates allows early and functional dental rehabilitation. A dental workflow should be integrated into the virtual planning, and prosthetically favourable implant positions should determine the position of the fibula segments.     

The CAD–CAM technique for mandibular reconstruction: An 18 patients oncological case-series

BackgroundModern techniques for mandibular reconstruction, such as CAD–CAM, offer new solutions for planning of reconstructive surgery in relation to the aesthetic outcome and the prosthetic rehabilitation.MethodsCAD–CAM reconstruction procedures using vascularised bone free-flap transfers and surgical guides to cut the mandible and fibula were performed in 18 cases of neoplasms. The planned surgery was used to design and manufacture customised surgical devices.ResultsThe mean follow-up was 12 months. All patients, except one, are alive without disease at the time of writing. Reconstructive microvascular flap survival was 100%. No major or minor microvascular complication occurred. No donor site complication was observed.ConclusionsCAD–CAM technology is a very useful way to obtain the native morphology of the mandible, especially when both bi-dimensional and tri-dimensional defects occur. The reconstruction protocol presented offers several benefits and few disadvantages, which are discussed in the article.     

腓骨肌皮瓣加种植体植入对颌面部软硬组织缺损的功能重建

目的:总结应用腓骨肌皮瓣游离移植对颌面部软硬组织缺损的功能重建的临床经验。方法:自2007～2011年7月,我科应用腓骨肌皮瓣一期修复下颌骨及周围软组织缺损11例,其中男性8例,女性3例,年龄33～67岁,其中左下颌牙龈鳞癌4例,右下颌牙龈鳞癌2例,右舌下腺腺样囊性癌1例,右口底鳞癌2例,左下颌黏液表皮样癌1例,成釉细胞瘤1例。其中磨牙后区粘液表皮样癌和成釉细胞瘤2例进行即刻种植。受区血管均为同侧,组织瓣均吻合1根动脉、2根静脉。动脉选用颈外动脉分支,静脉选用面总静脉、颈前静脉或颈外静脉,所有动静脉吻合均采用端端吻合法。分析皮岛的设计、大小、修复部位、存活情况等。结果:本组游离腓骨肌皮瓣11例全部成活,均携带1块皮岛,由一个穿支供养,皮岛最大6cm×4cm,最小3cm×2cm,皮岛均用于口内软组织缺损修复,2例即刻种植植入种植体6颗。术后面部外形、功能及咬合关系良好。语音功能基本正常。下肢功能在术后3～6个月恢复正常。结论:腓骨瓣的骨量充足,具有骨膜和骨髓双重血供,血运丰富,抗感染能力强,移植后易于成活。可根据需要做多段截骨塑形从而更加准确的恢复颌骨牙槽突形态。操作过程中远离头颈部,可以双组同时手术。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。游离腓骨瓣的皮岛不仅可用于口内外的软组织缺损修复,还可作为术后血供的观察窗。腓骨肌皮瓣在修复颌面部软硬组织缺损中具有血供安全可靠,塑形灵活,模拟外形准确,利于监测,并发症少等优点,是能够同时兼顾颌骨缺损及周围软组织缺损修复重建的理想方法。     

CAD/CAM guided secondary mandibular reconstruction of a discontinuity defect after ablative cancer surgery

A surgical guide is projected to aid the repositioning of the mandibular segments in their original locations, and a reconstruction bone plate is provided to support the fibula free flap. Computer-aided mandibular reconstruction involves three steps: virtual surgical planning, CAD/CAM and rapid-prototyping procedures for the design and manufacture of the customised surgical device and surgery. The duration of the reconstructive phase (<1.5 h intraoperative time) was reduced in comparison with traditional secondary mandibular reconstruction. The bone plate permitted the maximal restoration of the original facial and mandibular contours and the more precise positioning of the residual mandibular ramus in comparison with conventional procedures. No complication was noted during the mean follow-up period of 12 months. The protocol presented in this paper offers some benefits: 1) The virtual environment permitted ideal preoperative planning of mandibular segment repositioning in secondary reconstruction; 2) Intraoperative time was not consumed by approximate and repeated bone plate modelling; 3) Using CT data obtained before primary surgery, the reconstruction bone plate was designed using the original external cortical bone as a template to reproduce the ideal mandibular contour; 4) Prototyped resin models of the bone defect allowed the surgeon to train preoperatively by simulating the surgery.     

计算机辅助技术在下颌骨缺损修复中的应用

目的：探讨计算机辅助设计（computer aided design，CAD）和计算机辅助制作（computer aided manufactured，CAM）技术在下颌骨缺损修复中的应用。方法：7例下颌骨肿瘤切除后患者行血管化腓骨移植，16例下颌骨缺损患者行牵引成骨（distraction osteogenesis，DO）术，术前均行螺旋CT扫描，采用CAD—CAM技术制成与患者骨组织缺损完全相同的个体化实体模型，在模型上设计最佳手术方案，并根据模型预制钛板和成骨牵引器。术中按术前设计切除下颌骨病灶区骨段，血管化腓骨移植的患者根据术前设计进行腓骨塑形并固定；行DO患者根据术前设计制作传送盘和安装牵引器位置。结果：实体模型病变区测量数据与术中所见病变范围完全一致，预制的下颌骨重建钛板及牵引器形态与术中下颌骨外形匹配，能显著缩短手术时间并改善术后效果。术后X线片显示23例重建的下颌骨形态对称，面部外形恢复正常。结论：CAD—CAM技术为下颌骨病变的术前手术范围设计、移植骨形态设计和牵引器的个体化制作提供了实体模型，提高了手术的精确性，缩短了手术时间，降低了术后并发症。具有良好的辅助作用。     

Lateral mandibulectomy and partial glossectomy with plate application

The goals of composite resection with reconstruction plate application include removal of the primary tumor, any compromised portions of the mandible, and any involved lymph-bearing tissue. Recent advances in surgical technique and reconstruction have made this treatment a more appealing choice for patients. Although microvascular free flaps may be the treatment of choice in the younger patient with an excellent prognosis, the use of reconstruction plates with a myocutaneous flap remains a viable alternative for many patients with oral cancer. Regardless of the reconstructive technique utilized, both functional and aesthetic parameters must be addressed in treatment planning for patients with head and neck cancer.     

Beyond Rieger's original indication; the dorsal nasal flap revisited

IntroductionFew reconstructive options are available for nasal defects measuring >2 cm. Staged procedures are often utilized for nasal defect reconstruction, but they are not feasible in some patients.MethodsOut of 92 patients operated upon for nasal skin lesions between 2009 and 2011, patients who received reconstructive surgery with a dorsal nasal flap, nasal skin lesions located in lower half of nose (≤5 mm from the alar rim), defect diameter ≥3 cm were included in this study.ResultsPatients with nasal lesions larger than 3 cm who refused a staged procedure and were prone to compromised follow up underwent dorsal nasal flap reconstruction. Clear margins were obtained and no flap loss occurred. Minor complications occurred, such as flap dehiscence.ConclusionThe dorsal nasal flap can be effectively utilized for selected lesions as a surrogate for staged procedures that use various local flaps, such as the paramedian flap.     

颌面部爆炸伤软组织缺损早期修复的实验研究

将犬随机分为Ａ（即时）组、Ｂ（７２ｈ）组，采用ＫＴＹ－０４型雷管置于犬面颊部引爆致伤，造成软组织洞穿性缺损。Ａ组伤后即刻清创、隐动脉皮瓣立即移植修复皮肤缺损；Ｂ组伤后即刻清创，７２ｈ后二次清创，同时切取隐动脉皮瓣，吻合血管修复皮肤缺损，颊粘膜缺损两组均行局部拉拢缝合。术后观察１～６个月，Ａ组５例均失败；Ｂ组１５例，成功１２例，游离皮瓣成活率为８０％。实验结果表明口腔颌面部爆炸伤软组织缺损经早期清创，７２ｈ后扩创，用吻合血管游离皮瓣修复是可行的。     

Reconstruction possibilities after tumor surgery in the head-neck region

Surgery and radiotherapy are the most important primary modalities for treatment of head and neck cancer. After excision of a tumour, a considerable defect may remain. Reconstructive surgery may serve several purposes: closure of the defect and restitution of functions such as respiration, swallowing, speech and chewing. Also, an esthetically satisfying appearance is aimed at. The planning of reconstructive surgery starts as soon as a patient presents with a new cancer. The most appropriate procedure is selected by a team of specialists, consisting of head and neck surgeon, a plastic and reconstructive surgeon and a maxillofacial surgeon. For defects of the mouth and oropharynx, a microsurgical free flap is the most versatile and safe choice of reconstruction nowadays. Suitable donor areas are the forearm, iliac crest and abdominal wall and the fibula. The graft, which may consist of skin, fascia, muscle, bone or combinations thereof, is revascularised in the defect area after microsurgical anastomosis of its vascular pedicle. Success percentages are greater than 95% and postoperative morbidity is reduced in contrast to conventional methods.     

游离腹直肌皮瓣在口腔颌面大型缺损Ⅰ期修复中的应用

目的：探讨应用游离腹直肌皮瓣修复口腔颌面部癌术后大型缺损的可行性。方法：对18例口腔颌面部肿瘤切除术后大型缺损即刻游离移植腹直肌皮瓣修复,对临床资料进行分析和总结。结果：随访3～24个月,18例皮瓣完全成活,成活率100％。结论：腹直肌皮瓣游离移植是修复口腔颌面部大型缺损可靠和理想的方法。     

Development of a novel resection and cutting guide for mandibular reconstruction using free fibula flap

Introduction

The authors developed a semi-standardised resection and cutting guide for mandibular reconstruction with free fibula flap based on data of mandible sizes and angles.

Aesthetic and functional reconstruction with the trapezius osseomyocutaneous flap and dental implants in oral cavity cancer patients

The trapezius osseomyocutaneous flap is the only pedicled flap that is able to transfer vascularized bone for mandibular reconstruction as well as skin for intra-extra oral reconstruction. The trapezius muscle also helps to fill the defect created by the neck dissection and covers the vessels of the neck. This flap has been used in our maxillofacial surgery service during the past 14 years. In spite of having incorporated microvascular flaps in our reconstructive techniques it continues to be one of the flaps we use in selected patients for bone and soft tissue compound defects of the oral cavity. We describe in this article our experience using this flap with dental implants in order to achieve a functional reconstruction. We also discuss when we use this flap for mandibular reconstruction and when a free vascularized flap is used.     

Rehabilitation of long-term mandibular defects by whole-process digital fibula flap combining with implants: A case report

Currently, the gold standard and workhorse in mandibular reconstruction is the free vascularized fibula flap. Particularly for patients who have had mandibulectomy for a long time, it is still difficult to precisely reconstruct the mandibular contour and successfully restore the patient's chewing function and esthetics. For the restoration and rehabilitation of long-term mandibular abnormalities, three-dimensional (3D) virtual surgical planning (VSP) and 3D-printed surgical guides are essential. Digital design and manufacturing were used to improve the accuracy of prostheses and facilitate occlusal reconstruction. Therefore, equipped with the methods of 3D VSP, 3D-printed surgical guides, free vascularized fibular flap, and immediate dental implants, this clinical report provides a feasible solution for mandibular reconstruction.     

Anterolateral thigh myocutaneous flaps as the preferred flaps for reconstruction of oral and maxillofacial defects

BackgroundThe anterolateral thigh myocutaneous flap is one of the most commonly used flaps in reconstructive procedures, but its application in oral and maxillofacial defects has not been fully determined. Herein, we summarize the application of 1212 anterolateral thigh myocutaneous flaps in the repair of oral and maxillofacial defects and examine their benefits in maxillofacial reconstruction of these defects.MethodsPatients were recruited from February 2002 to June 2013 in the Department of Oral and Maxillofacial Surgery of Central South University. All patients underwent reconstructive surgery employing anterolateral thigh myocutaneous flaps. Patient ages ranged from 6 to 82 years with a mean age of 51.2 years. There are 1015 flaps showing single lobe and 197 flaps showing a multi-island pedicle and one of which carries the iliac bone. The largest area among the single flaps was 28 × 12 cm², and the smallest was 3 × 2 cm².ResultsAmong the 1212 transferred flaps, 1176 survived and 36 showed necrosis, a survival rate of about 97.0%. The common complications at flap donor site were poor wound healing (10.1%), localized paraesthesia (50.1%), and altered quadriceps force (11.0%). No cases presented with local serious complications, and 90% of patients achieved good functional recovery and aesthetically acceptable results after reconstruction of oral and maxillofacial defects at various locations using anterolateral thigh myocutaneous flaps. The time (23–121 min; average 51 min) for anastomosis of one vein and one artery was significantly less than that for two veins and one artery (45–153 min, average 83 min; p = 0.0003), which indicates one vein anastomosis can significantly reduce the operating time.ConclusionThe anterolateral thigh myocutaneous flaps can be easily obtained and can provide a good amount of muscle for filling dead space and fascia lata. These flaps can be prepared into a separate fat flap, multi-island fascia with iliac bone, and other composite pedicle flaps to meet the various requirements of oral and maxillofacial defects. The subcutaneous fat thickness of the anterolateral area can vary considerably and thus can be used to repair defects requiring different flap thickness. Therefore, the anterolateral thigh myocutaneous free flaps are more suitable for oral and maxillofacial defects than other flaps.     

面部口腔洞穿性缺损前臂皮瓣折叠修复临床研究

目的：总结前臂皮瓣折叠修复颌面部洞穿性缺损的临床应用及特点。方法：9例恶性肿瘤根治术后,颊部口腔软组织洞穿性缺损5例,颏部皮肤及下唇黏膜缺损3例,颊部、口腔及下颌骨硬软组织缺损1例。应用前臂皮瓣一期折叠修复口腔颌面部的洞穿性缺损,前臂皮瓣的一部分修复口腔黏膜,一部分修复面部缺损。结果：9例前臂皮瓣术后全部存活。术后随访2～48周,颌面部外形恢复及口腔功能恢复满意。结论：前臂皮瓣折叠修复颌面部洞穿性缺损效果可靠,外形满意,值得临床推广应用。     

游离前臂皮瓣移植修复口腔颌面部软组织缺损的临床研究

目的 探讨应用显微外科技术进行游离前臂皮瓣移植修复口腔颌面软组织缺损的方法.方法 应用游离前臂皮瓣移植对11例口腔癌切除后软组织缺损进行修复.结果 术后观察1～12个月,皮瓣均存活,口腔功能恢复良好,外形满意.结论 前臂皮瓣移植是修复口腔癌术后颌面软组织缺损较为理想的方法.     

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.