会厌瓣在下咽—颈段食管一期重建术中的应用

报告下咽癌切除术后，应用会厌剖开延伸的粘软骨膜瓣修复下咽颈段食管的粘膜缺损8例，术中分别采用会厌瓣和胸骨舌骨肌筋股瓣、会厌瓣和残存下咽粘膜瓣作复合修复，术后恢复良好的吞咽功能，无咽颈瘘发生．临床上虽可应用胃、空肠、结肠和胸大肌肌皮瓣代下咽颈段食管，但手术费时、复杂、病人痛苦大。本术式优点：就近取材，血运丰富，操作简便，成功率高，并发症少。     

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。     

Lateral upper arm free flap for primary reconstruction of pharyngeal defects in ablative oncological surgery. Report of six consecutive cases

Free microvascular flaps are an established method for soft tissue reconstruction following ablative oncological surgery in the head and neck. Functional reconstructions of the hypopharynx and the pharyngoesophageal segment (PES) are of particular relevance, as they are highly demanding surgical procedures. So far, the radial forearm free flap (RFFF) and the free jejunal transfer have been the transplants predominantly used for this purpose. The lateral upper arm free flap (LUFF) presents an alternative method for the fasciocutaneous tissue transfer. We report on our experience with the LUFF in a 56-year-old male patient with a pT3pN0M0 squamous cell carcinoma of the hypopharynx. A pharyngocutaneous fistula developed 5 days after pharyngolaryngectomy with bilateral neck dissection. The fistula was localized between the pharyngeal constrictor muscle and the esophagus and was closed with an LUFF from the left arm. Excellent flap adaptation to the remaining pharyngeal mucosa was observed. Although the length of the vascular pedicle and the diameter of the vessels in the LUFF are smaller than those in the RFFF, neither pedicle length nor vessel diameter proved to be a problem. The LUFF can be recommended as a well-vascularized, relatively safe and reliable flap for reconstruction of tubular structures such as the hypopharynx and the PES after tumor ablation and as an alternative to the RFFF. The flexibility of the LUFF allows surgeons to reconstruct the anatomy of the lost soft tissues as adequately as possible.     

Treatment of recurrent head and neck carcinoma involving the carotid artery: carotid reconstruction with ePTFE graft

The aim of our study is to investigate the feasibility of reconstructing the carotid artery using expanded polytetraflouroethylene (ePTFE) in patients with recurrent head and neck carcinoma involving the carotid artery. Ten patients, who had recurrent head and neck carcinoma involving the carotid artery, received carotid artery resection and reconstruction with ePTFE, tissue defects were repaired by pectoralis major myocutaneous flap. Results show that eight patients did not present any vascular and neurologic complications. One patient presented slight hemiparesis, another patient developed wound infection and pharyngocutaneous fistula. The mean follow-up period was 33.1 ± 16.0 months. The 2-year survival rate was 50% (5/10), and there was one patient who survived for 60 months without locoreginal recurrence or distant metastasis. En bloc resection of tumor and involved carotid-associated ePTFE reconstruction provide effective improvement in the locoregional control of the recurrent head and neck carcinoma. The pedicle pectoralis major myocutaneous flap can provide not only wound bed with affluent blood supply for the vascular grafts, but also reparation of skin or the tissue defects of oropharynx and hypopharynx.     

Modification of fasciocutaneous radial forearm free flap to achieve two-layer closure during reconstruction of circumferential hypopharyngeal defects

Circumferential defects of the hypopharynx are a reconstructive challenge. Various local, regional and free flaps have been described with each having advantages and disadvantages in terms of functional outcomes. The fasciocutaneous radial forearm free flap (RFFF) is one of the most common free flaps used for reconstructing circumferential hypopharyngeal defects. The skin paddle is pliable and reasonably matches the native hypopharyngeal wall. It is easy to raise, has predictable vascular anatomy and a long pedicle. Unlike the anterior lateral thigh (ALT) flap, the RFFF is associated with higher rates of pharyngo-cutaneous fistula. This was thought to be due to the difficulty in achieving two-layer closure. However, in a post treatment neck or in patient with large body habitus, the use of ALT or other free flaps may not be possible leaving the RFFF as the only viable option. To aim to reduce the risk of fistula and wound dehiscence, we describe a novel design of RFFF, which provides two-layer closure. We believe that our design gives the reconstructive surgeon another reconstructive option, which should be considered in challenging circumferential hypopharyngeal defects.     

Reconstruction of the hypopharynx with U-shaped pectoralis major myocutaneous flap after total pharyngo-laryngectomy

Resection of the whole circumference of the pharynx and esophagus is usually reconstructed with gastric pull-up, jejunum free graft or free forearm flap. The aim of this study was to assess the use of pectoralis major myocutaneous flap for closure of total pharyngeal defect. In 11 patients with hypopharynx and larynx cancer, total pharyngo-laryngectomy and excision of the cervical part of the esophagus and neck dissections were performed; the defects were closed with pectoralis major myocutaneous flaps. The skin island was sutured to prevertebral muscles, forming a letter U shape. Good healing was obtained in six patients, and five patients developed fistula that closed spontaneously within 3–4 weeks. The use of U-shaped pectoralis major myocutaneous flap, suturing it to prevertebral muscles, gives good functional results, and it is a simple and time-saving second choice method of reconstruction of the pharynx after total pharyngo-laryngectomy.     

Free tissue reconstruction of the hypopharynx after organ preservation therapy: analysis of wound complications

PURPOSE: Previous series have demonstrated a 77% rate of major wound complications in salvage surgery of the larynx following organ preservation protocols. The purpose of this study is to determine the incidence of wound complications in these patients when microvascular free tissue transfers are used for reconstruction of the hypopharynx. DESIGN: Retrospective case series. SETTING: Academic tertiary care center. PATIENTS AND METHOD: We reviewed the medical records of 42 patients with stage III and IV laryngeal squamous cell carcinoma treated with an organ-sparing protocol consisting of induction chemotherapy followed by definitive radiation therapy. Ten of these patients who required surgical salvage were reconstructed using radial forearm free tissue or lateral arm transfer and constitute the study group. MAIN OUTCOME MEASURES: Wound complications. RESULTS: Wound complications occurred in 2 patients (20%) undergoing free flap reconstruction of the hypopharynx after organ preservation protocols, which was significantly lower (P =.003) than previous reports using other forms of closure and/or reconstruction. One patient in this study group had a small pharyngocutaneous fistula that resolved with conservative therapy after 1 week. The other patient had a larger pharyngocutaneous fistula that resolved over 3 weeks. The mean interval from completion of the chemoradiation regimen to surgery was 21.3 months (range, 2-60 mo). The average free tissue flap size was 94.3 cm(2) (range, 45-165 cm(2)). Average harvest and ischemia times were 59 minutes (range, 41-87 min) and 187.7 minutes (range, 120-240 min), respectively. All flaps survived, and one patient had a minor donor site wound dehiscence. The average hospital stay was 7.8 days. There were no mortalities in this series. CONCLUSIONS: Our results suggest that free tissue transfer reconstruction of the hypopharynx is the preferred method of reconstruction following combined chemotherapy and radiation therapy protocols. Surgical complications are significantly reduced and hospital stays are minimized.     

Reconstruction of the through-and-through anterior mandibulectomy defect: indications and limitations of the double-skin paddle fibular free flap

Objectives/Hypothesis: The purpose of this report is to describe our recent experience using a double‐skin paddle fibular free flap (DSPFFF) for reconstruction of the through‐and‐through anterior mandibulectomy defect and to present a reconstructive algorithm based on the extent of lip and mental skin resection. Study Design: Retrospective review of 10 consecutive patients with through‐and‐through anterior mandibulectomy defects. Methods: Outcomes that were examined included methods of reconstruction based on the cutaneous defect, flap complications, fistula rate, and donor site complications. Results: Seven patients were reconstructed with a DSPFFF. For lip reconstruction, two patients were also concomitantly reconstructed with Karapandzic or lip advancement flaps. Three patients were reconstructed with both a fibular free flap and a second free flap (1 radial forearm fasciocutaneous flap and 2 anterolateral thigh flaps). The transverse dimensions of the DSPFFFs were as great as 15 cm. None of the patients developed a fistula. All free tissue transfers were successful. One patient developed partial loss of the fibular skin paddle used for submental skin replacement. Conclusions: DSPFFF is a safe and reliable way to reconstruct an anterior through‐and‐through mandibular defect. Indications for using a DSPFFF are 1) a cutaneous defect that lies at or below the plane of the reconstructed mandible, 2) a transverse width of the oral mucosa and cutaneous defect that does not exceed 15 cm (the approximate distance from the mid‐calf to the anterior midline), and 3) a lip defect that, if present, can be reconstructed with local flaps.     

Improvement of the radial forearm donor site by compression with hydrocolloid dressing and adhesive sponge

CONCLUSIONS: With our method, general improvement is obtained as compared with traditional split-thickness skin grafting of the radial forearm flap donor site. As our method is simple and easy, the same results can be obtained wherever and by whomever it is performed. OBJECTIVE: The radial forearm flap is associated with complications of graft take and a poor aesthetic appearance despite its usefulness in reconstructing the oral cavity and oropharynx. We describe a simple technique for improvement of the radial forearm donor site. PATIENTS AND METHODS: We studied 12 patients who underwent reconstruction with radial forearm free flaps following resection of oral or oropharyngeal tumors. We covered the donor site defect using traditional split-thickness skin grafts and performed aftercare with a hydrocolloid dressing and an adhesive sponge to retain moisture and apply compression. After the treatment series, color matching, texture matching, depressive deformity, and hypertrophic scar were evaluated. RESULTS: The results of comprehensive evaluation of the two patients with premature discontinuation of compression were good. One patient was assigned only 1 point for hypertrophic scar, and another only 1 point for color match. The evaluation of the other 10 patients was excellent.     

Carcinoma of the posterior wall of the hypopharynx: surgical treatment with larynx preservation

IntroductionPosterior pharyngeal wall is the most rare subsite for hypopharyngeal carcinomas. Because of its rarity, there are few studies published in the literature specifically concerning posterior pharyngeal wall carcinoma.ObjectivesTo report our functional results in patients with the carcinoma of the posterior wall of the hypopharynx after surgical treatment by resection via a lateral or infrahyoid pharyngotomy approach, with the preservation of the larynx and reconstruction with a radial forearm free flap.MethodsThe study included 10 patients who underwent surgery for a carcinoma of the posterior wall of the hypopharynx over a 6 year period. The associated postoperative morbidity was investigated and functional results were analyzed.ResultsNine patients had T3 lesions and one patient had a T2 lesion. The preferred approach to access the hypopharynx was a lateral pharyngotomy in 5 patients and lateral pharyngotomy combined with infrahyoid pharyngotomy in 5 patients with superior extension to oropharynx. The pharyngeal defects were reconstructed successfully with radial forearm free flaps. Four patients received adjuvant radiotherapy only, and 4 patients with N2b and N2c neck diseases received adjuvant chemoradiotherapy. The mean duration of hospitalization was 15.6 days (range, 10–21 days). All patients achieved oral intake in a median time of 74 days (range, 15–180). Decannulation was achieved in all patients and the median time for decannulation was 90 (range, 21–300 days). The mean followup duration was 38.3 months (range, 10–71 months) and 8 patients survived. One patient died due to regional recurrence in the retropharyngeal lymph nodes and 1 patient died due to systemic metastasis.ConclusionPrimary surgery is still a very effective treatment modality for the carcinoma of the posterior wall of the hypopharynx and does not permanently compromise the swallowing and laryngeal functions if pharyngeal reconstruction is performed with a free flap.     

Regional flaps in facial reconstruction

Soft-tissue defects of the head and neck that are too extensive to be reconstructed with local flaps without excessive impairment of either form or function usually require repair by some type of regional flap. Selection of a specific regional flap depends on the type of defect, i.e., its size and location, and on the intrinsic properties of the regional flap. Single pedicle peninsular or island axial pattern flaps are usually selected because of their improved blood supply compared with random flaps. For most skin defects of the face and neck requiring reconstruction with a regional flap, a medially based deltopectoral flap is usually preferable to musculocutaneous flaps because it is less bulky and produces less donor-site functional impairments. Likewise, for large defects of the upper or lower lip, a deltopectoral flap in most instances is the regional flap of choice for reconstruction. Nasal defects that require regional flaps for repair are reconstructed with various types of forehead flaps. The median flap remains the most useful because the donor site can be closed primarily, leaving a thin midline scar that is camouflaged relatively easily. For nasal defects that require a longer flap that can be provided by a median flap, the oblique forehead flap provides additional length sufficient to reach the base of the columella. Larger defects of the oral cavity and oral pharynx usually require regional or microsurgical flaps for reconstruction of soft-tissue deficits. In addition, mandibular reconstruction may be necessary. The pectoralis major musculocutaneous flap is the author's preferred choice of a regional flap for reconstruction of such defects. The flap readily reaches the oral cavity and oral pharynx and the muscle provides good coverage of the carotid artery when neck dissection has been accomplished. A great advantage of the flap is the ability to achieve reconstruction in one stage without the need for a controlled salivary fistula. Although the deltopectoral flap is the author's preferred regional flap for reconstruction of major defects of the hypopharynx, the pectoralis major musculocutaneous flap is the regional flap of choice when patients are severely malnourished or cachetic. Both flaps provide a source of nonirradiated skin and provide sufficient tissue for total reconstruction of the hypopharynx and cervical esophagus. Both methods of reconstruction, however, have a relatively high rate of stenosis of the distal anastomoses.     

耳后带蒂皮瓣在修复耳甲腔皮肤缺损中的应用

目的介绍耳甲腔皮肤缺损中,应用耳后带蒂皮瓣修复耳甲腔皮肤缺损的方法及术后效果。方法2016年对耳甲腔良性肿物术后耳甲腔缺损的3例女性患者于耳后、乳突区,做一“乒乓球拍样”带蒂皮瓣,于耳廓根部做一隧道,将带蒂皮瓣从耳廓根部隧道穿过之后,覆盖于耳甲腔皮肤缺损处,缝合后加压包扎。结果3例患者耳后切口均Ⅰ期愈合,皮瓣颜色、质地、弹性均良好,耳甲腔外观良好,耳后供区瘢痕几乎难以察觉。结论耳后带蒂皮瓣在修复耳甲腔皮肤缺损中,简单易行,术后疗效佳,无论操作上还是美学上,都符合要求,值得临床推广应用。     

印迹法耳后皮瓣制备及修复耳郭前部皮肤缺损的临床效果

目的 评估印迹法制备耳后皮瓣及修复耳廓前部皮肤缺损的临床效果。 方法 2013年3月至2015 年9月对31例耳郭肿物患者术后较大的皮肤缺损采用耳后皮瓣修复。以纱布印迹法制备耳后皮瓣,皮瓣蒂部根据缺损的位置可在上部或下部。皮瓣蒂部皮肤去上皮后,经制备的软骨窗转位至耳郭前部皮肤缺损区。 结果 术后转移皮瓣全部成活。随访6~24个月,转移皮瓣皮肤颜色与耳郭及其周围皮肤颜色相似,未发生畸形改变。 结论 耳后皮瓣修复耳郭前部缺损手术操作简单,术后皮瓣成活率高,且供瓣区位于耳后,瘢痕隐蔽,能取得满意的美学效果,是一种修复耳郭组织缺损较好的方法。     

Improvement of the radial forearm donor site by compression with hydrocolloid dressing and adhesive sponge

Conclusions. With our method, general improvement is obtained as compared with traditional split-thickness skin grafting of the radial forearm flap donor site. As our method is simple and easy, the same results can be obtained wherever and by whomever it is performed. Objective. The radial forearm flap is associated with complications of graft take and a poor aesthetic appearance despite its usefulness in reconstructing the oral cavity and oropharynx. We describe a simple technique for improvement of the radial forearm donor site. Patients and methods. We studied 12 patients who underwent reconstruction with radial forearm free flaps following resection of oral or oropharyngeal tumors. We covered the donor site defect using traditional split-thickness skin grafts and performed aftercare with a hydrocolloid dressing and an adhesive sponge to retain moisture and apply compression. After the treatment series, color matching, texture matching, depressive deformity, and hypertrophic scar were evaluated. Results. The results of comprehensive evaluation of the two patients with premature discontinuation of compression were good. One patient was assigned only 1 point for hypertrophic scar, and another only 1 point for color match. The evaluation of the other 10 patients was excellent.     

保留喉功能的下咽癌手术后缺损的修复

目的初步探讨在保留喉功能的下咽癌手术中,肿瘤切除后局部创面的修复方式。方法回顾性分析2013年3月~2018年3月33例下咽癌患者行保留喉功能肿瘤切除术后的临床资料,其中14例采用局部黏膜拉拢缝合,2例采用胸骨舌骨肌筋膜瓣修复缺损,4例采用异种牛脱细胞真皮基质修复膜,2例采用胸大肌皮瓣修复,4例锁骨上岛状皮瓣修复缺损,4例采用游离股前外侧皮瓣修复缺损,3例采用食管内翻拔脱胃上徙手术;观察缺损修复后患者伤口的愈合情况。结果33例患者喉功能良好,3例患者早期有轻微误吸,锻炼2周后即可正常进食。全部患者恢复吞咽功能,食管入口狭窄2例,后经局部扩张好转。咽瘘2例,局部换药1个月愈合。所有患者术后随访1年以上,生存率为78.79%（26/33）,目前正在随访中。结论在保留喉功能的下咽癌手术中,防止误吸和避免咽食管狭窄是肿瘤切除后修复的主要目标;根据患者的具体情况,选择适合患者的个体化修复方法,既可以恢复下咽的结构和功能,还可以避免不必要的副损伤。     

The increasing use of enteral flaps in reconstruction for the upper aerodigestive tract

The enteric flaps commonly used in free tissue head and neck reconstruction include the gastro-omental flap, the omental flap, and the free jejunal flap. These flaps have demonstrated excellent reconstructive results for defects of the oral cavity, oropharynx, hypopharynx, cervical esophagus, and contouring defects of the head and neck. Their main advantages include tissue pliability, tubed shape, ease of contouring, and the ability to secrete mucus. Recent studies report outcome measurements for flap loss, fistula rates, postoperative swallowing, speech, and cosmesis. Now that experience has been gained to the point of routine use of these flaps, randomized trials are needed to determine the functional advantages of the enteric flaps compared with other reconstructive options.     

Methods of closure for pharyngocutaneous fistula after laryngectomy

The majority of salivary fistulas after laryngectomy or after laryngo-pharyngectomy close spontaneously within 2-3 weeks, and the remaining require surgical reconstruction. In the years 1987-2000 the pharyngo-cutaneous fistula was closed in 19 patients. The fistula developed after laryngectomy because of larynx cancer T3 and T4. 13 patients were irradiated before. In all the patients laryngectomy was combined with unilateral or bilateral neck dissection. Salivary fistula was closed in one stage operation using pectoralis major myocutaneous flap: 1) skin island of the flap to replace defect of the neck skin and mobilized mucosa from inside, 2) skin island for lining and deltopectoral skin flap from outside, 3) skin island for lining and free split skin flap for external cover, 4) skin island of the flap divided in two paddeles, one for lining and another for external cover. Indications for each method were discussed. Very good result of total fistula closure was obtained in 15 out of 19 patients. The fistula occurred again in 4 patients, in two of them the failure was caused by cancer recurrence.     

Superficial temporal artery flap: a new option for posterior hypopharyngeal wall reconstruction

Reconstruction of hypopharynx after tumor resection remains a challenging problem for the head and neck surgeons. A new surgical technique was introduced to reconstruct the hypopharynx after tumor resection using the superficial temporal artery flap. Three patients with T3 carcinoma of the posterior hypopharyngeal wall who underwent surgical resection of the tumor with laryngeal preservation were reported using this method. The larynx functions were preserved successfully in all the patients. In all patients, the nasogastric tubes were removed within 20–50 days (mean 33 days). The tracheal tubes were plugged on days between 14 and 44 (mean 26th day) postoperatively. Then all patients received the postoperative radiotherapy. The tracheal tubes were removed successfully 5–7 months after surgery (mean 6 months) without the evidence of apnea. The speech function was excellent in all patients, which was evaluated according to the voice-related quality of life questionnaire. Although lymph node metastasis was detected in one patient 6 months after surgery, there were no evidences of flap complications in all the three patients. The superficial temporal artery flap is a new option for the posterior pharyngeal wall reconstruction in selected cases with the hypopharynx carcinoma. The larynx functions were preserved successfully.     

Analysis of various defects and reconstructive methods after invasive thyroid carcinoma resection

ObjectiveThe thyroid gland adjoins the trachea, pharynx, esophagus, carotid artery and cervical skin. Most thyroid carcinomas have been treated at lower stages; however, in some cases the carcinomas have invaded the surrounding organs. After resecting invasive thyroid carcinomas, the defects vary depending on the invasion area and organs affected; subsequent reconstructive methods vary depending on the size of defect and its components. This study analysed the pattern of defects and the reconstructive methods used following invasive thyroid carcinoma resection.MethodsFrom April 2011 to March 2021, 665 patients in Saitama Cancer Center (Saitama, Japan) were diagnosed with thyroid carcinoma and subsequently underwent thyroidectomies. In the 25 patients (3.8%), the thyroid carcinoma invaded surrounding organs and any reconstructive surgery—including end-to-end tracheal anastomosis and simple pharynx closure—was performed after thyroid carcinoma resection. The patients’ records were retrospectively reviewed, and the defects and subsequent reconstructive methods were analysed.ResultsWhen our new classification system was applied to the defects, the number of cases for each type was totaled: Tr0: 1; Tr1a: 3; Tr2b: 5; Tr3a: 1; La-Tr3b+PE2: 7; La-Tr3b+PE2+S2: 1; PE1: 1; PE1+S1: 2; S1: 2; S2: 2. For Tr0, a tracheal fenestration was performed after the tumor resection and the fenestration was closed with a hinge flap. For Tr1a defect, a tracheal fenestration was performed with cervical skin after the tumor resection and the tracheal fenestration was closed with a deltopectoral flap or pectralis major musculocutaneous flap. In one recent patient, the tracheal fenestration was reconstructed using free forearm flap and cervical skin, and the fenestration was closed with a hinge flap. For Tr2b defect, free forearm flap and costal cartilage graft reconstruction was performed after the tumor resection and the fenestration was closed with a hinge flap. For Tr3a defect, end-to-end anastomosis was performed in one patient. For La-Tr3b+PE2 defect, total pharyngolaryngectomy with free jejunal flap reconstruction was performed. For PE1 defect, a simple closure was performed in one patient and a PMMC muscle flap was used for covering the suture line in two patients. For S1 and S2 defect, PMMC flap or DP flap was used.ConclusionOur analysis of defects and reconstructive methods defines the complex defect patterns occurring after invasive thyroid carcinoma resection, describes the patterns of subsequent reconstructive methods.     

Free forearm skin flaps with microvascular anastomosis for pharyngeal reconstruction

Free forearm skin flap with microvascular anastomosis was used for tissue defect reconstruction in 4 patients after resection of the oropharynx, base of the tongue and ramus of the mandible. The vascular pedicle of the flap contained the radial artery and the cephalic vein. For microvascular anastomosis the facial artery was used in all the patients, the facial vein in 2 patients, the internal jugular vein in one patient and the external jugular vein in the other one. Good healing of the graft was obtained in 3 patients. In one patient partial necrosis developed. No patient had fistula.