颏下动脉带蒂皮瓣应用解剖研究

目的 解剖颏下动脉带蒂皮瓣,观察颏下动脉及其伴行静脉的走行和可能存在的变异及与周围重要结构的毗邻关系,并了解其支配区域组织的大小以及皮瓣所能覆盖的范围。方法 取15例(30侧)新鲜汉族成人头颅湿标本,动脉系统灌注混有红色染料的乳胶,静脉系统灌注混有蓝色染料的乳胶,进行大体和显微解剖,用游标卡尺测量及统计分析,主要参数包括：颏下动脉及其伴行静脉起始部直径、颏下动脉长度及主要分支、与主要体表标志的关系等,观察典型和变异标本并照相留存。经动脉灌注黑色墨水,观察颏下皮肤染色的范围,测量并统计颏下皮瓣的最大长度和宽度,观察皮瓣所能覆盖的范围。结果 颏下动脉恒定地起源于面动脉,平均长度(69.1±7.47)mm。其自面动脉发出处动脉直径为(1.6±0.47)mm,沿途分支为(6.5±1.09)支,其中支配二腹肌前腹分支较多并相对粗大,平均直径(1.1±0.25)mm。距离下颌骨下缘距离(5.4±1.63)mm。所有标本均只有一支颏下静脉伴行颏下动脉,均回流至面静脉。其静脉起始部位直径为(2.3±0.58)mm,距离下颌骨下缘距离为(15.4±3.29)mm。颏下皮瓣的大小因人而异,最大为84.6mm×53.5mm。结论 颏下动脉是颏下皮瓣的主要供血动脉,是面动脉恒定的分支。该皮瓣血液供应丰富,易取材,可以作为头颈部修复与重建材料的良好选择。     

Fibular and iliac crest osteomuscular free flap reconstruction of the oral cavity

A method for reconstruction of oral cavity soft tissues using segmentally or axially supplied free muscle flaps harvested as a unit with their bone components is presented. Both fibular/soleus and iliac crest/internal oblique free flaps are documented, and the pros and cons of each donor site are presented. Twenty-one patients, 17 with cancer or osteoradionecrosis and 4 with benign or congenital conditions of the mandible, have undergone this operation. Ten bone grafts were simultaneously embedded with osseointegrated implants. All free flaps except one survived and resulted in a smoothly mucosalized oral lining. Six patients have had their implants successfully uncovered, all of whom are wearing prostheses. Four other patients are using tissue-borne prostheses. Transfer of free, nonbulky muscle flaps for mucosalized oral soft-tissue reconstruction is feasible in selected patients using first the fibular and, second, the iliac donor site; this soft-tissue technique also contributes to prosthetic dental rehabilitation.     

Anatomical study and modified incision of the infrahyoid myocutaneous flap

Skin paddle necrosis and neck function damage, particularly rotation, are two problems associated with the infrahyoid myocutaneous flap clinical application. The aim of this study was to investigate vessel supply and drainage of the skin paddle and to report our modified flap incision technique. In this work, we conducted a cadaveric study and reviewed our experience with the modified incision and describe the surgical procedure. We confirmed the platysma muscle branch feeds the skin paddle overlying the infrahyoid myocutaneous flap. The length between the platysma muscle branch entry point and its originating point measured 3.38 (min 2.51, max 4.52) cm. The flap has two drainage systems. The skin paddle of the flap was drained by the anterior jugular vein and external jugular vein, respectively, or both. The infrahyoid muscles were drained by the superior thyroid vein. In the early four cases, where the platysma muscle branch was not protected, skin paddle necrosis appeared in two cases. In the later seven cases, which involved preservation of the platysma muscle branch, all flaps successfully survived. Patients in whom a modified incision was used all achieved both satisfactory rehabilitation of neck function and an adequate esthetic result. We conclude that the necrosis rate of the skin paddle of the flap can be reduced by carefully protecting its supply and drainage vessels. The modified incision can improve neck function postoperatively.     

Management of the flap tracheostomy. An experimental study.

The flap tracheostomy was studied in 25 adult canines to further investigate its best management. Tracheostomies were performed by employing the inverted U flap incision in the trachea. After decannulation, the flap was either formally resewn to the trachea, bluntly dissected from the surrounding soft tissues, or left in place. The time required for epidermal closure over the tracheostomy site was measured, along with fixation of skin to soft tissues in the area. Histologic examinations were made, and tracheal dimensions were calculated on sections through the stomal area. More rapid skin closure and less soft tissue fixation occurred in animals that underwent resuturing or release of the tracheal flap. In all groups, cartilage viability and regrowth were noted. Tracheal diameters were maintained in all groups, but smoother contouring was seen with resuturing. Additional support for the flap tracheostomy is provided from this animal experimentation.     

Anatomical and surgical study of the sphenopalatine artery branches

The sphenopalatine artery gives off two main branches: the posterior lateral nasal branch and the posterior septal branch. From 2007 to 2012 17 patients were treated with cauterization and/or ligature of the sphenopalatine artery with endonasal endoscopic approach. 90 nasal dissections were performed in 45 adult cadaveric heads. We evaluated the number of branches emerging from the sphenopalatine foramen and the presence of an accessory foramen. In the surgery group, we observed a single trunk in 76 % of the patients (13/17) and a double trunk in 24 % (4/17). We found an accessory foramen in four cases. We obtained a successful result in bleeding control in 88 % of the cases. In the cadaver dissection group, 55 nasal cavities had a single arterial trunk (61 %), 30 had 2 arterial trunks (33 %) and in only 5 nasal fossae we observed 3 arterial trunks (6 %). We were able to dissect four accessory foramina. We suggest that in most cases only one or two branches are found in the sphenopalatine foramen.     

胸廓内血管为蒂的肋骨复合组织瓣解剖学研究

目的 研究胸廓内血管及其前穿支对前胸壁组织供血的解剖学要点。方法 新鲜成人尸体胸部2具4侧,自胸廓内动静脉起始处分别灌注红、蓝乳胶颜料。观察胸廓内血管诸穿支供应胸部皮肤的范围;10%福尔马林固定的成人尸体胸部15具30侧,采用巨微解剖学方法,观察胸廓内血管及皮肤穿支在肌肉、皮下的走行,并且测量诸前穿支穿出胸壁的具体位置、长度、外径、分支数目、吻合情况。结果 胸廓内动脉穿支动脉多起自胸廓内动脉的内侧壁,前穿支的出现率以2、3穿支最常见,出现率为100%,且口径较为粗大,各穿支之间有丰富的血管吻合现象,穿支动脉的伴行静脉多为一支或缺失;前胸壁的肋骨、肋软骨、及肋间肌等结构,主要由胸廓内动脉及其分支和肋间后动脉供血。结论 胸廓内血管为蒂的肋骨复合组织瓣可用于面颈部软组织伴下颌骨缺损的修复。     

游离空肠段肠腺分泌规律及病理学变化

目的探讨游离空肠段肠腺分泌规律及其相应的病理学变化,为临床应用于气管重建提供依据。方法通过建立腹壁下去神经游离空肠的肠分泌动物实验模型,包括A组(无支架组)、B组(游离空肠联合镍钛合金内、外支架组)及C组(游离空肠联合镍钛合金外支架组),对比其术后肠分泌量的变化以及相应的病理学变化。结果①A、B、C三组术后早期肠分泌量增高,1月后肠分泌量显著减少并趋于稳定;B组和C组均比A组的分泌量大(P<0.05),1月后逐渐接近A组;B、C两组对比肠分泌量无显著差异(P>0.05);②移植空肠上皮腺体萎缩,肠黏膜上皮层变薄,微绒毛大部分脱落,部分吸收细胞空泡变性和坏死,杯状细胞减少;其中以B组改变最明显。结论去外源神经犬空肠段随着肠腺萎缩,肠腺分泌逐渐减少,术后60天左右趋于低水平;推断游离空肠重建气管是可行的。     

The lower trapezius flap. Vascular anatomy and surgical technique

The lower trapezius flap was first described in 1980 based on the transverse cervical artery. The older anatomical literature, however, describes the dorsal scapular artery as a major contributor of blood supply to the skin overlying the lower trapezius fibers. To clarify this, 30 dissections of this vascular region were performed. In 15 of 30 dissections, the dorsal scapular artery was dominant and the distal transverse cervical artery arose from the dorsal scapular. In nine of 30 dissections, the transverse cervical artery was dominant and the distal dorsal scapular artery arose from the transverse cervical. In six of 30 dissections, both proximal arteries were of equal caliber with no distal communication. We describe a surgical technique that makes use of the lower trapezius flap with inclusion of the dorsal scapular artery; this technique greatly extends the usefulness of the lower trapezius flap, while decreasing the morbidity caused by division of the upper portion of the trapezius muscle during flap harvest.     

Finger-free speech following total laryngectomy. Instrumentation and technic of surgical voice rehabilitation

Surgical voice restoration during and after total laryngectomy using Blom-Singer puncture and the glottoplasty techniques provide good results. There is no doubt that the proportion of patients with a good voice is higher after surgical voice restoration than with the use of the esophageal speech or electronic speaking aids. Nevertheless there are problems due to the shunt or the necessary daily changing of the prosthesis with its risks, and failures due to the tracheostomy, the prosthesis and the pharynx. In order to reduce these surgical problems we developed new instruments, a personal surgical procedure for restoration during and after laryngectomy using this set of instruments, a new type of prosthesis and a tracheostoma valve. This technique allows the patient to speak fluently without using his hands, to breathe and to swallow without aspirating.     

Anatomical and surgical particularities of cholesteatomas in children

In children, cholesteatoma is closely related to dysfunction of the eustachian tube and evolves inside a malleable temporal bone. The importance of auditory and speech functions in such patients has caused us to use a very particular clinical philosophy. At the present time we have studied 154 cases of cholesteatomas in children under 15 years old. The following three points have been shown: the pathogenesis of a cholesteatoma can be of the primary type, secondary (due to an unfavorable extension of retraction pocket or to squamous cell migration) or even be iatrogenic; anatomical and clinical findings (with X-ray studies) predicate the treatment used; surgical treatment frequently requires a "second-look" operation.     

Anatomical and surgical particularities of cholesteatomas in children

Summary In children, cholesteatoma is closely related to dysfunction of the eustachian tube and evolves inside a malleable temporal bone. The importance of auditory and speech functions in such patients has caused us to use a very particular clinical philosophy. At the present time we have studied 154 cases of cholesteatomas in children under 15 years old. The following three points have been shown: the pathogenesis of a cholesteatoma can be of the primary type, secondary (due to an unfavorable extension of retraction pocket or to squamous cell migration) or even be iatrogenic; anatomical and clinical findings (with X-ray studies) predicate the treatment used; surgical treatment frequently requires a second-look operation.Presented at the First European Congress of Oto-Rhino-Laryngology and Cervico-Facial Surgery, Paris, 26–29. September     

Temporal bone histopathology in experimental hypovitaminosis A.

Twenty-five years ago hearing loss was observed in some subjects during a comprehensive study of the effects of hypovitaminosis A on human volunteers. Experimental studies documenting histopathological changes in the temporal bone due to hypovitaminosis A are conflicting. Even the recent textbooks of otolaryngology and physiology make no mention of a role of vitamin A in the ear. To explore the role of vitamin A in the ear adult and weanling rats maintained on a diet totally lacking vitamin A were sacrificed at intervals. Their temporal bones were examined with the light microscope. After six weeks on a vitamin A free diet weanling rats showed hypertrophy of the periostial portions of the otic capsule. At 16 weeks a narrowing of the internal auditory canal due to bony exostoses was present. The neuroepithelia of the cochlea and the vestibular apparatus were histologically normal even in the longest surfiving animals. Adult rats maintained on a vitamin A free diet showed minimal thickening of the bone adjacent to the internal auditory meatus. The cochlea and the vestibular appartus in these animals remained normal throughout the 28-week experiment. Although we have demonstrated marked abnormalities of the otic capsule in hypovitaminosis A, our results do not support those of some earlier investigators who reported that atrophy of the cochlear and vestibular neuroepithelium occurred in the absence of dietary vitamin A.     

头颈肿瘤整形与修复专栏·颏下皮瓣的解剖观察及在头颈肿瘤切除术后重建中的应用

目的探讨颏下皮瓣的解剖基础及临床应用效果。方法①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48岁。尸体标本经股动脉灌注加入红色乳胶后,通过解剖观察颏下动脉的走形方向、周围分支及管径等基础指标;②回顾分析应用颏下皮瓣修复头颈部肿瘤切除术后软组织缺损10例患者的临床资料,其中男8例,女2例;年龄在55~75岁,平均年龄65.5岁。6例舌癌,3例口底癌,1例下咽癌。颏下皮瓣设计4 cm×6 cm~7 cm×8 cm大小。术后随访半年,对皮瓣存活、肿瘤复发、功能恢复及患者满意度等进行评估,分析其临床应用疗效。结果①8具标本中,16侧出现颏下动脉,颏下动脉起始处管径为（1.82±0.35）mm,沿途发出(2.1±0.4)支穿支至皮肤,皮穿支的管径（0.55±0.65）mm。颏下动脉主干全长（45.51±5.22）mm,其沿途发出的分支主要有颌下腺支、颈阔肌支、二腹肌支、下颌舌骨肌支、皮肤穿支。最终在颈前正中区域与对侧血管形成血管网相互吻合;②10例手术患者应用颏下皮瓣修复头颈部肿瘤切除术后软组织缺损术后1、3、6个月随访,发现颏下皮瓣存活良好,无其他并发症,肿瘤无复发。患者咀嚼、吞咽及言语功能基本正常,仰头无受限,自身对外形和功能都比较满意。结论颏下皮瓣具有安全、制备简单等优点, 是口腔恶性肿瘤术后软组织缺损修复的一种可靠术式, 临床上可予推广应用。     

聚丙烯网状材料与颈前皮瓣联合重建气管的实验研究

目的 通过构建犬颈段气管缺损与重建的实验动物模型,寻找一种通过一期手术即能与自体气管完全愈合为一体的人工气管材料和手术方法.方法 将8只犬一期手术切除3.5～4.0 cm长的颈部气管,采用可以永久保留在体内的聚丙烯网状材料与颈前皮瓣联合行气管重建,术后初期管腔内置入Z型金属覆膜气管支架,观察犬的生存期、生存质量,通过纤维气管镜、X线片及组织切片观察吻合口愈合情况及病理变化.结果 8只犬中1只犬因继发呼吸衰竭于术后2 d死亡,1只犬因吻合口感染术后10 d死亡.存活的6只犬中除1只并发轻度气管狭窄,其余5只犬生活质量好,术后第2 d即可正常饮水及进食,无呼吸困难等并发症.术后2、4、8周及6个月处死动物取出重建气管标本,见2周时有软组织长入聚丙烯网孔,使其硬度增加并具有一定的支撑度;4周时长入网孔的软组织增多;8周及6个月时软组织将聚丙烯网完全覆盖,并发生纤维化使网的支撑度明显增加.病理检查显示,术后2、4、8周时可见吻合口肉芽生长,术后6个月时肉芽组织较前缩小,皮瓣的鳞状上皮与黏膜的柱状上皮愈合良好.结论 具有良好的组织相容性的聚丙烯网状材料与颈前皮瓣联合一期成形重建气管可与自体气管融为一体,成为自体气管的一部分,此种重建气管方法有望应用到临床.     

聚丙烯网状材料与颈前皮瓣联合重建气管的实验研究

OBJECTIVE: Canine model established for tracheal defect reconstruction, to investigate the outcome of tracheal reconstruction with combination of polypropynene and flap. METHODS: About 3.5 to 4 centimeter cervical trachea was resected and replaced with artificial trachea made from monofilament knitted polypropylene and surgical flap. Covered stent was implanted postoperatively. Survival period and quality of life were recorded, bronchofibroscopy, X-ray films and HE sections were perfomed. RESULTS: Six dogs survived well and another two died. The causes of death were respiratory failure in 1 and infection in another. Stenosis of anastomosis in 1 was recorded during survival period. The dogs started drinking and eating on the second postoperative day, no dyspnea was found. The animals were sacrificed at 2, 4, 8 weeks and 6 months after surgery. Soft tissue growth was found in polypropynene net 2 weeks after surgery and more at 4 weeks. The polypropynene net was covered completely with soft tissue at 8 weeks and 6 months postoperatively, the hardness and sustentation degree were enhanced following the growth and fibrosis of soft tissue. The squamous epithelium and columnar epithelium were observed healing well by HE staining method. CONCLUSIONS: One-stage operative artificial trachea made from monofilament knitted polypropylene which has good histocompatibility and surgical flap is the closer artificial trachea to native trachea. It has a promising prospect in clinical use.     

Laser surgery - a new surgical method. Development - technic - indication

The development of lasers in medicine and the special types of laser for medical use are described. The main action and effectivity of the laser are explained its, advantages and disadvantages discussed. Finally a critical assessment is given.     

Mandibular distraction using a dynamic osteosynthesis system: MD-DOS. Concepts and surgical technic]

MD-DOS (mandibular distraction with a dynamic osteosynthesis system) is an intra-oral mandibular distractor that can be placed via the oral route, enabling application under local anesthesia. The aim of the article is to describe the technical-surgical aspects of the treatment concept, based on an initial experience of 35 cases. The device is characterised by a single horizontal posterior fixation screw-implant, a vertical hinge that copes with the lateral force vector in the condyles, a telescopic distraction module, and an anterior fixation unit that is fixed with monocortical screws. The main indication was mandibular lengthening in Angle Class II, deep bite cases. The third molars could be removed in the same session. Of importance was the horizontal placement of the posterior fixation unit (PFU), together with the distraction module, in order not to interfere with lateral jaw movements and with the lower sulcus. Equally important was the use of at least one 7.5 mm long osteosynthesis screw together with at least three 5.5 mm screws. Near complete mobilisation of the segments, firmly blocking the posterior fixation unit with the vertical hinge in a perpendicular position, and placing MD-DOS as close as possible to the dental arch, were also important parameters for success.