锁骨上动脉岛状瓣在头颈部修复重建中的应用

因肿瘤切除引起的头颈部软组织缺损或畸形,常采用各种带蒂或游离组织瓣移植,恢复其外形和功能。锁骨上动脉岛状瓣因具有皮瓣质地和颜色与头颈部相近、厚度适中、制备简便和供区并发症少等优点,近年来日益受到人们的关注。该文对锁骨上动脉岛状瓣的历史、应用解剖、组织瓣设计和制备及其在头颈重建外科中的应用作一综述。     

The submental island flap in head and neck reconstruction

The authors describe their experience with the submental island flap for the primary correction of head and neck deformities following oncologic surgery, over the past 5 years. The use of this flap is reported in 12 patients, with a mean age of 67 years, requiring facial or intraoral reconstruction. A brief review of the key points and some refinements in the operative technique are discussed. The reconstruction of defects with a submental island flap was successful in every patient. Complications encountered were one case of temporary palsy of the marginal mandibular branch of the facial nerve and one case of orocutaneous fistula. All the donor site defects were closed primarily. The submental island flap is an excellent choice for the reconstruction of head and neck defects because of its reliability, versatility, colour and texture match, and relative ease of application.     

Complications of free radial forearm flap transfers for head and neck reconstruction

Free tissue transfer using microvascular anastomosis has been established as an accepted maxillofacial reconstructive procedure. The free radial forearm flap (FRFF) has become a workhorse flap as a means of reconstructing surgical defects in the head and neck region. Since 1992, we have carried out 38 FRFF transfers in 37 patients for reconstruction after head and neck cancer ablative surgery. We present our clinical experience with head and neck reconstruction using the FRFF and the morbidity of the donor sites. Of the 38 FRFFs, 35 FRFFs were performed successfully. The survival rate of FRFF was 92%. Donor site complications included partial loss of skin graft in 4 donor sites (11%), abnormal sensations in 10 (26%), poor appearance in 3 (8%), and reduced grip strength in 4 (11%). Therefore, we believe that, because of the reliability, functional characteristics, and low donor site morbidity, the FRFF is a useful and versatile flap for reconstruction of head and neck defects.     

Vascularized cranial bone grafts for mandibular and maxillary reconstruction. The parietal osteofascial flap

The authors have performed 13 cases of vascularized cranial bone grafts for reconstruction of maxillofacial defects since 1986. Two types of flaps were used: the parietal osteofascial flap pedicled to the parieto-temporal fascia based on the superficial temporal artery and the temporalis osteomuscular flap pedicled to the temporalis muscle based on the deep temporal artery. Zygomatico-orbital complex, maxilla and mandible were reconstructed and hemifacial microsomia was also treated. The results of vascularized cranial bone grafts pedicled to fascia were as good as those of grafts pedicled to muscle. There were no major complications. Two types of vascularized cranial bone grafts seem to be useful in reconstruction of maxillofacial defects with avascular recipient beds because of their good blood supply. The parietal osteofascial flap has additional advantages including easy rotation of the flap to the defect, particularly a mandibular defect, and versatile use of fascia without bulkiness for reconstruction of soft tissue defects. This flap can be designed as a full- or partial-thickness cranial bone graft with good vascularity. In this paper, our technique for mandibular and maxillary reconstruction using the parietal osteofascial flap is introduced, and the results compared with our temporalis osteomuscular flap technique are reported.     

Pectoralis major flap for head and neck reconstruction in era of free flaps

The aim of this study was to evaluate factors affecting the selection of pectoralis major flap in the era of free tissue reconstruction for post ablative head and neck defects and flap associated complications. The records of patients who underwent various reconstructive procedures between July 2009 and December 2010 were retrospectively analysed. 147 reconstructive procedures including 79 free flaps and 58 pectoralis major flaps were performed. Pectoralis major flap was selected for reconstruction in 21 patients (36%) due to resource constrains, in 12 (20%) patients for associated medical comorbidities, in 11 (19%) undergoing extended/salvage neck dissections, and in 5 patients with vessel depleted neck and free flap failure salvage surgery. None of the flaps was lost, 41% of patients had flap related complications. Most complications were self-limiting and were managed conservatively. Data from this study suggest that pectoralis major flap is a reliable option for head and neck reconstruction and has a major role even in this era of free flaps. The selection of pectoralis major flap over free flap was influenced by patient factors in most cases. Resource constraints remain a major deciding factor in a developing country setting.     

Prelamination of the latissimus dorsi flap for reconstruction in head and neck surgery

Free microsurgical tissue transfer of the latissimus dorsi flap may be indicated for the restoration of intra- and extraoral defects, especially when a large-sized skin island flap is required. In many cases, use of the latissimus dorsi flap for coverage of large-sized intraoral defects results in bulkiness due to the proportion of subcutaneous fat. Prelamination of free flaps appears to be a promising technique to overcome this flap bulkiness. This modification in flap design could improve the postoperative functional outcome, as well as reduce donor site morbidity. This article presents four novel clinical cases, in which the patients underwent prelamination of the latissimus dorsi flap with local skin grafts during oral cancer treatment in order to reduce the thickness of the free flap and allow tension-free primary closure of the donor site. These attempts successfully covered large-sized intraoral defects, achieving good functional outcomes with minimal donor site morbidity.     

Platysma myocutaneous flap for reconstruction of skin defects in the head and neck

The platysma myocutaneous flap (PMF) is a common reconstructive option for defects in the head and neck region. Its applications have expanded from the reconstruction of intraoral defects to include laryngo-pharyngeal, lip, and cheek defects. The platysma flap can be superiorly, posteriorly, or inferiorly-based. The superiorly-based flap has a robust arterial blood supply but less efficient venous drainage, whereas the opposite is the case with the posteriorly-based flap. We present our results of using a superiorly based PMF flap for reconstruction of defects in the parotid, auricular/mastoid, and cheek regions after resection for squamous cell carcinoma. Of 11 patients, eight had no postoperative complications. The remaining three developed venous congestion of their flaps, in two of whom it led to secondary epidermolysis and limited skin loss. The venous congestion resolved with conservative management, and all flaps remained viable. The PMF flap is an alternative to more complex reconstructive options for skin defects of the auricular, parotid, and cheek regions, and gives a satisfactory cosmetic result.     

The pectoralis major flap in head and neck reconstruction: first 500 patients.

AIM: The aim of this study was to evaluate almost 20 years of using the pectoralis major flap in head and neck reconstruction at the Department of Maxillofacial Surgery, Zagreb. PATIENTS: In the period from 1981 to 1999, a total of 506 pectoralis major flaps were used for head and neck reconstruction in 500 patients. In all cases the flap was used after surgical resection of an advanced malignant tumour of the head and neck. RESULTS: The tumours were intraoral in 387 cases (77%), pharyngeal in 78 cases (15%) and on the skin in 10 cases (5%). The defect was located in the mucosal lining in 407 (81%), skin in 43 (8%), both intra- and extraoral in 53 (10%) patients. Bone defects occurred in 65 patients. In 31 patients (6%), the pectoralis major flap was used in combination with other flaps (deltopectoral, tongue, trapezius and free flaps). Complications occurred with 168 flaps (33%), but total flap necrosis was only seen in 10 patients (2%). Surgical treatment of complications was necessary in 87 patients (17%). CONCLUSION: Despite the increasing use of microvascular reconstruction, the pectoralis major myocutaneous flap continues to be the most universal major flap in head and neck reconstruction.     

46例口腔颌面部游离腓骨瓣移植的临床分析

目的 对46例口腔颌面部游离腓骨瓣移植作回顾性分析。方法 分析所采用排骨瓣的设计、受区血管、血管吻合方式和技术、组织瓣成活情况及术后并发症的发生情况，并分析有可能影响皮瓣成活的各种因素。结果 46例排骨瓣中41例用于下颌骨重建，5例用于上颌骨重建，其中44例获得成活，成功率为95.7%。1例排骨瓣因术中损伤血管而改用游离腓骨移植，另1例因静脉血栓而失败。组织瓣移植术后血栓的发生率为8.7%，抢救成功率为50％；受区和供区总的并发症发生率为21.7%，除了4例供区并发症外，其余的并发症的均不严重，没有造成明显的后果；吸烟、饮酒、放疗和年龄（高龄和儿童）等均非影响游离组织移植成功的重要因素。结论 游离腓骨瓣在颌骨缺损的修复中具有很大的灵活性，安全可靠，制备简便，供区并发症少，值得进一步推广和应用。     

Mandibular reconstruction in Goldenhar syndrome using temporalis muscle osteofascial flap

Goldenhar syndrome is a well-known developmental anomaly of the maxillofacial skeleton and hemifacial soft tissue. Maxillofacial anomalies of that syndrome can be managed by a variety of means such as inlay- or onlay-applied nonvascularized bone grafts, vascularized osteocutaneous/osseous flaps, or distraction osteogenesis. Vascularized full-thickness calvarial bone grafting is an important option for mandibular reconstruction for cases in which, for one reason or another, other techniques are not available, not applicable, or have failed. A mandibular defect of a 6-year-old boy presenting with bilateral preauricular skin tags, right microtia, right mandibular hypoplasia (with missing right condylar head and ascending ramus of the mandible) was reconstructed with right vascularized full-thickness calvarial bone grafting. Preoperative three-dimensional computed tomographic scans were used to acquire the stereolithographic biomodeling of the patient for assessing the amount of bone defect and precise planning of the surgery. Panoramic, anteroposterior, and lateral cephalograms and three-dimensional computed tomographic scans were obtained before and after the surgery and in the follow-up period for the evaluation of amount of relapse in the follow-up period. Clinical follow up and bone scintigraphy were used to assess the viability of transferred vascularized calvarial bone graft in the postoperative period. Plain radiographic evaluation with anteroposterior radiographs showed that mandibular symmetry increased and normooclusive closure of incisive teeth was achieved after surgery and retained in the postoperative period. Radiographs taken 1 year after surgery demonstrated that there was a slight relapse (1 mm) to the right side in the mandible when the results were compared with early postoperative ones. Postoperative three-dimensional computed tomographic evaluation of bony structures 3 months after operation showed that the transferred bone retained its volume. Sequential bone scintigraphies, performed to assess the vascularity of the grafts 1 week, 1 month, and 1 year after the operation, demonstrated the viability of transferred vascularized bone graft. The temporalis muscle osteofascial flap is a reliable method for mandibular reconstruction. It lessens the operative time, lessens surgical team labor, minimizes postoperative morbidity and discomfort, minimizes the hospital stay period, and minimizes financial expenses without renouncing the bone-healing capacity and increases aesthetic outcome by camouflaging the donor site scar in scalp and minimizing the facial scarring.     

股前外侧穿支嵌合皮瓣修复头颈肿瘤根治术后缺损

目的:探讨股前外侧穿支嵌合皮瓣的制备要点及修复头颈肿瘤根治术后缺损的优缺点。方法:2007年12月—2011年3月制备股前外侧穿支皮瓣,同时解剖保护血管蒂上的肌分支,设计一蒂多岛的穿支嵌合皮瓣修复66例头颈肿瘤根治术后缺损。舌、口底癌32例,舌根、咽侧癌30例,颊癌2例,颌骨中央性鳞癌1例,腮腺癌1例。切取股前外侧皮瓣面积7cm×4cm～16cm×7cm,肌瓣约3cm×4cm,观察并发症及受、供区功能恢复情况,总结穿支嵌合皮瓣制取技术及优点。结果:65例穿支嵌合皮瓣成活,成活率98.5%。1例术后5d出现危象,最终放弃,创口均Ⅰ期愈合。2例发现无合适穿支血管,改用股前内侧穿支皮瓣修复成功。术后随访0.5～3a,皮瓣6个月后萎缩停止,局部外形丰满,语言及吞咽功能恢复满意。供区均拉拢缝合,瘢痕隐蔽,下肢无功能障碍。结论:逆行和顺行解剖技术相结合是制备穿支嵌合皮瓣的理想手段,能够帮助外科医师克服穿支血管的解剖变异。股前外侧穿支嵌合皮瓣能提供不同类型的组织进行三维修复,减少术后并发症(感染、瘘、血肿等)的发生率,是头颈肿瘤术后复合组织缺损修复的理想选择之一。     

应用游离股前外侧穿支皮瓣修复头颈肿瘤根治术后缺损

目的 探讨游离股前外侧(anterolateral thigh flaps,ALT)穿支皮瓣在头颈部肿瘤根治术后缺损的修复重建中的应用价值。方法 回顾分析2010年1月—2011年1月中国医科大学附属口腔医院口腔颌面-头颈外科,口腔颌面外科,采用ALT穿支皮瓣游离移植修复23例头颈部恶性肿瘤患者接受根治术后的缺损,其中舌癌13例、颊癌3例、腭癌3例、口底癌2例、口咽癌2例。结果 23例皮瓣中,22例移植皮瓣成活,1例坏死,成活率为95.7%。患者下肢运动均未受影响,81.0%(17/21)的患者对供区外观满意,有38.1%(8/21)的患者感觉供区皮肤麻木,81.0%(17/21)的患者可以正常进食,85.8%(18/21)的患者发音可以被理解,3例患者不影响发音。结论 游离ALT穿支皮瓣是修复头颈部肿瘤根治术后缺损的理想皮瓣。其血运可靠,可切取面积大,对供区、受区影响较小,患者容易接受。     

Islanded facial artery osteomyomucosal/osseous flap in head and neck reconstruction

A local pedicled vascularized bone flap can prevent the morbidity and cost of free bone flap surgery in small segmental bone defects or long cartilaginous defects of the head and neck. Such flaps can also be useful in patients who are high risk for surgery. The periosteal vascularity of the mandible can be used to design islanded facial artery-based bone flaps, which can be utilized to that extent. Two patients with a small segmental mandibulectomy defect and one patient with a long cricotracheal resection defect underwent reconstruction using three different designs of islanded facial artery osteomyomucosal/osseous flap (iFOMM). The patients had a minimum follow-up period of 18 months. All flaps were successful, with satisfactory healing and without any functional deficit or disease at last follow-up.     

50例口腔颌面部游离前臂皮瓣移植的临床分析

目的：对50例口腔颌面部游离前臂皮瓣移植作回顾性分析。方法：1999年5月26日－2000年8月3日期间完成的连续50例游离前臂皮瓣移植，分析所采用组织瓣的设计，受区血管，血管吻合方式和技术，皮瓣成活情况及术后并发症的发生情况，并分析有可能影响皮瓣成活的各种因素。结果：50例前臂皮瓣全部成活，成功率100％，无一例发生全部或部分坏死，皮瓣术后血栓的发生率为6％，均为静脉血栓，抢救成功率为100％；受区和供区总的并发症发生率为28％，但大多数并发症均不严重，没有造成明显的后果，吸烟，饮酒，放疗和年龄（高龄和儿童）等均非影响游离组织瓣移植成功的重要因素。结论：游离前壁皮瓣在口腔颌面部缺损的修复中具有很大的灵活性，其制备简便，安全可靠，明显优于传统的带蒂组织移植，值得推广和应用。     

游离大腿前外侧皮瓣修复头颈部缺损的初步观察

目的探讨游离大腿前外侧皮瓣在头颈部缺损修复中的应用。方法回顾研究2002年1月至2006年1月完成的22例游离大腿前外侧皮瓣移植。分析采用组织瓣的设计、穿支血管的数目和类型、受区血管、血管吻合方式和技术、游离瓣成活情况及术后并发症，并分析有可能影响组织瓣成活的各种因素。结果22例中，皮瓣面积（7cm×5cm）～（16cm×8cm），平均11．1cm×6．9cm，除4块皮瓣携带2个穿支外，其余18块皮瓣均携带1个穿支。26个穿支中，20个为肌皮穿支，另外6个为隔皮穿支。1例游离瓣术后48h出现静脉危象，经抢救未成功后去除皮瓣。其余皮瓣术中、术后均未出现血管危象，并且全部成活。所有供区均直接拉拢缝合，除1例供区术后创口感染致二期愈合外，其余供区均一期愈合。结论游离大腿前外侧皮瓣克服了传统的前臂皮瓣和腹直肌皮瓣的缺点，在头颈部缺损的修复中具有较大的灵活性，值得进一步应用和观察。     

Role of real-time colour-flow Doppler in perforator free flap head and neck reconstruction

We discuss the use of real-time colour-flow Doppler ultrasound to optimally evaluate the vascular anatomy of patients receiving free perforator flap head and neck reconstruction. We explore the advantages of the technique and its role as a valuable adjunct for the planning and harvesting of perforator flaps.     

The submental island flap: Pedicle elongation and indications in head and neck reconstruction

BackgroundThe submental island flap is an axial pattern skin flap first described by Martin et al. in 1993. When used to reconstruct skin defects it matches the recipient site in terms of colour, texture and thickness. One of the main limitations to its application is the arc of the pedicle allowing coverage of only the lower two thirds of the face.MethodsA retrospective review was performed of all patients who had had a submental island flap reconstruction at the Operative Unit of Maxillo-Facial Surgery of the University Hospital of Parma, Italy, between 2001 and 2011.The Authors focused on the surgical technique adopted, the clinical indications and the results obtained. They analysed the different ways to elongate the pedicle and discuss their thoughts on the choice of reconstruction. A flowchart was created to help in the decisional process.ResultsBetween 2001 and 2011 the submental island flap was used to reconstruct head and neck defects in 22 patients. Thirteen patients had defects of the oral cavity; the remaining 9 patients had skin defects involving the pre-auricular region, the temporal area and the peri-nasal cheek skin.No major complications occurred and in one case a partial necrosis of the distal portion of the flap was observed. Five patients underwent surgical revision involving intraoral flap debulking 6–10 months after the primary procedure.Discussion and conclusionsThe techniques to elongate the pedicle used and described were: additional dissection of the pedicle, Y–V procedure, reverse flow flap, section of facial vein and microvascular anastomosis. Their choice is mainly conditioned by the site of the defect.     

Free and locoregional flap associations in the reconstruction of extensive head and neck defects

Head and neck surgical defects after oncological resection of advanced carcinoma involving the oral cavity are often composite and involve bone, mucosa, soft tissues and skin. For the most extensive defects, the simultaneous association of two free flaps is the best choice to improve the function of the preserved structures. This procedure is difficult and involves prolonged surgery, therefore it is only possible in selected patients. In some composite head and neck defects the association of free and locoregional flaps seems to be indicated. This study, discusses the use of free and locoregional flap association, focusing on its aesthetic advantages and functional results. From January 1995 to December 2006, 30 patients received simultaneous locoregional and free flap transfer for closure of post-ablative oral cavity defects. Microvascular tissue transfer included the radial forearm, anterolateral thigh, rectus abdominis, and fibula and iliac crest free flaps. Locoregional flaps included the cervicofacial, cervicopectoral, deltopectoral, pectoralis major, latissimus dorsi and posterior scalp flaps. Based on the good functional and aesthetic outcome and low rate of complications, the association of free and locoregional flaps represents a good reconstructive option for patients with extensive post-oncological composite head and neck defects.     

Infrahyoid myocutaneous flap in head and neck reconstruction: a systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to analyse the literature on the infrahyoid myocutaneous flap (IHMCF) and evaluate its clinical outcomes. The MEDLINE, Embase, Web of Science, Cochrane Library, and Scopus databases were searched (inception to December 31, 2021). Meta-analyses were then conducted to estimate the overall rates of partial flap loss, total flap loss, salivary fistula, and surgical revision. The 21 studies that met the inclusion criteria included 768 patients undergoing head and neck reconstruction with 773 IHMCF. The oral cavity (77.7%) and oropharynx (13.0%) were the most reconstructed sites. The meta-analyses estimated a pooled partial flap loss rate of 10.4% (99% confidence interval (CI) 5.4–16.7%), total loss rate of 1.8% (99% CI 0.8–3.2%), salivary fistula rate of 3.0% (99% CI 1.3–5.3%), and surgical revision rate of 1.9% (99% CI 0.7–3.7%). Fast flap harvesting and low donor site morbidity were other flap features. Previous thyroid surgery or neck dissection and advanced lymph nodal stage were considered contraindications to IHMCF reconstruction by most authors, while prior neck radiotherapy was reported as a relative contraindication. This pedicled cervical flap is a versatile and reliable reconstructive option for medium-sized head and neck defects. Careful preoperative assessment of the neck condition allows for its safe use.