双侧扩张肩胛皮瓣在儿童、青少年大面积颌颈部瘢痕修复中的应用：7例报道

目的: 探讨应用双侧扩张肩胛皮瓣游离移植治疗儿童、青少年大面积颌颈部瘢痕的可行性。方法: 回顾2018年8月—2020年12月间,在上海交通大学医学院附属第九人民医院小儿整形病区接受双侧背部扩张皮瓣治疗大面积颌颈部瘢痕的儿童、青少年患者7例。所有患者瘢痕累及范围包括颈部及下颌、前胸部,颈部瘢痕累及颈前区及一侧或双侧颈外侧区,存在不同程度的颈部活动障碍、下颌骨发育不良。手术分为两期,Ⅰ期在双侧背部设计旋肩胛动脉扩张穿支皮瓣并植入扩张器,并行6~14个月的扩张;Ⅱ期行颌颈部瘢痕切除、松解,扩张皮瓣游离移植修复创面,吻合双侧面动、静脉与旋肩胛动脉及伴行静脉,供区创面直接缝合。结果: 7例患者中,出现扩张器植入后切口愈合不良、皮瓣破裂1例,经手术治疗后愈合并完成皮瓣扩张。注水壶堵塞1例,经注水壶外置后完成扩张。皮瓣移植后,1例患者出现皮瓣远端小面积缺血坏死,换药后创面愈合。术后随访6个月~2年,患者颌颈角恢复正常,颈部后伸、前屈、侧曲、旋转明显改善,功能改善满意。2例患者进行皮瓣修薄术及瘢痕条带松解术。结论: 旋肩胛动脉位置恒定,支配的背部皮肤面积大,经扩张后的双侧肩胛皮瓣游离移植可修复儿童、青少年颌颈部大面积瘢痕增生挛缩畸形,供区隐蔽、继发损伤小。     

Scapular free flap as a good choice for mandibular reconstruction: 119 out of 280 cases after resection of oral squamous cell carcinoma in a single institution

Microsurgical procedures for reconstruction after resection of head and neck tumours have become standardised and reliable. Among them, the scapular free flap is used less often, mostly to avoid excessive operating times. We hypothesise that complex reconstructions after resection of oral squamous cell carcinoma (OSCC) are successful even with time-consuming free flaps such as the scapular free flap. In this retrospective, single-centre study, we used the evaluation of medical records to investigate the postoperative outcome of microvascular reconstruction after ablative surgery of OSCC. Associations among the categorical variables were analysed using Pearson’s chi squared test or Fisher’s exact test. Among the continuous variables, the t test or Mann-Whitney U test were used as appropriate. For multivariate analysis, the logistic regression model was calculated. In the sample of 280 free flap reconstructions, we performed 142 radial forearm and 119 scapular free flaps. The American Society of Anesthesiology (ASA) score (p = 0.006) and the duration of the operation (p = 0.010) are independent factors which influence the need for operative revisions. The type of free flap is irrelevant for that. With 4.2% flap losses, scapular free flaps were successful; even in patients ≥ 70 years old (0 flap losses). Complex reconstructions after surgical resection of OSCC are successful even in aged patients. The scapular free flap is a good choice for mandibular reconstruction despite the time-consuming intraoperative repositioning of the patient. In an increasingly ageing group of patients, who have more vascular diseases, scapular free flaps could be a very successful alternative after ablative surgery of oral squamous cell carcinoma.     

Microsurgical tissue transfer for rehabilitation of the patient with cleft lip and palate.

OBJECTIVE: Three case reports of microsurgically revascularized tissue transfer for secondary closure of complex oronasal fistulae in cleft lip and palate patients are reported. One scapular and two radial forearm flaps were used in that respect; the scapular flap was transferred without a skin paddle and was left for secondary epithelialization whereas iliac crest bone was transplanted in the two patients with the forearm flaps in a further surgical step. CONCLUSIONS: These microsurgical flaps represent solutions in selected cases of oronasal fistulae in patients with cleft lip and palate with extensive scarring, large defects, or both. Alternative free flaps of the vast spectrum available today, however, also deserve consideration.     

肩胛骨瓣修复下颌骨缺损

作者选用旋肩胛血管为蒂的肩胛骨瓣修复部分下颌骨缺损8例,术后骨瓣全部成活。本文对肩胛骨瓣的设计、血管蒂的解剖、切取骨瓣及其移植方法作了介绍。应用肩胛骨瓣修复下颌骨缺损,可视受区需要设计为单纯骨瓣或骨肌皮瓣,骨瓣的长、宽、厚与下颌骨相似,外形恢复良好。骨瓣供区血管位置恒定,易于寻找,血管口径与受区血管接近,吻合后通畅率高,易成活。     

Treatment of severe atrophy of the maxilla with the prefabricated free vascularized fibula flap

Treatment of severe maxillary atrophy despite complex major surgery often ends up with an unsatisfactory result. This paper presents the augmentation of the maxilla with a prefabricated free vascularized fibula flap in combination with ITI implants (Straumann AG, Waldenburg, Switzerland) in 4 patients. The technique of prefabrication for the reconstruction of maxillofacial defects is described based on the experience with 17 patients. The key points of this treatment are i) preoperative planning and fabrication of the drilling template; ii) prefabrication of the fibula with ITI implants and performing of a 'vestibuloplasty" using a skin graft; iii) technical construction and fabrication of the suprastructure and the denture; iv) reconstruction of the maxilla using the prefabricated fibula as free vascularized flap. The reconstructions with the fibula flaps were successful and the 18 ITI implants that have been inserted showed good osseointegration without loss of attachment in all 4 patients after a mean observation period of 12 months.     

144例头颈部游离组织瓣移植患者的临床分析

目的:探讨采用头颈部游离组织瓣移植行头颈部重建的效果。方法:对1999年5月～2000年10月采用游离组织瓣移植行头预部重建的144例患者作回顾性研究,分析采用组织瓣的类型、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。结果:前臂皮瓣、腓骨瓣和腹直肌瓣为最常用的行头颈部重建的游离组织瓣,占全部皮瓣的94.7％;游离组织瓣移植的成功率为98％,术后血栓的发生率为6％,抢救成功率为66.7％;受区和供区总的并发症发生率为34％,但大多数并发症均不严重,没有造成明显的后果;吸烟、饮酒、放疗和患者年龄等均非影响游离组织瓣移植成功的重要因素。结论:头颈部游离组织瓣移植安全可靠,且优于传统的带蒂组织瓣移植,是头颈部重建的合理选择。     

Reconstructing wide palatomaxillary defects using free flaps combining bare serratus anterior muscle fascia and scapular bone.

PURPOSE: Wide palatomaxillary defects, mostly after tumor resections, can cause severe functional and esthetic problems. Although prosthetic obturator devices or local flaps are mostly adequate for uncomplicated small-size defects, free flaps are preferred for a 3-dimensional multitissue reconstruction of more complicated defects. Regarding the anatomical structure of the palatomaxillary region, the flap must be thin enough to separate the oral and nasal cavities while not compromising palatal function, yet rigid enough for adequate dental restoration. This goal is usually accomplished with a combined or complex free flap. Numerous free flaps containing both soft tissues and bone have been described in the literature. In this study, we present a novel use of the free scapular bone flap combined with serratus anterior fascia and its functional and esthetic results. PATIENTS AND METHODS: Nine cases are presented whose wide composite palatomaxillary defects were repaired with free angular scapular bone flap combined with serratus anterior fascia based on the subscapular vascular system, between 1999 and 2003. Scapular bone wrapped with the naked serratus anterior fascia, like a sandwich, was used to repair the palate. RESULTS: The naked fascia was epithelialized with the help of the surrounding mucosa in 4 to 6 weeks. Results were satisfying with regard to breathing, eating, speech, and facial contour after follow-ups for 2 months to 6 years. CONCLUSION: For the reconstruction of wide palatomaxillary defects, a combined flap of angular scapular bone wrapped with naked serratus anterior fascia was conceived useful for obtaining satisfactory functional and esthetic results.     

延长垂直下斜方肌岛状肌皮瓣修复重建大型头颈部缺损

颈横动脉供血的延长垂直下斜方肌岛状肌皮瓣(extended vertical lower trapezius island myocutaneous flap,eVLTIMF)用于修复重建大型头颈部缺损安全可靠。该瓣制备较简单,成活率高。供区较隐蔽,可直接关闭缝合,并发症少,肩部运动受影响较小;还可制备成折叠瓣,合并其他带蒂瓣或合并肩胛骨骨肌皮瓣修复特大洞穿性缺损或下颌骨缺损。eVLTIMF在头颈部大面积缺损修复,尤其是在晚期复发性头颈部肿瘤挽救手术后巨大缺损修复重建中起着重要作用。本文对斜方肌的临床应用解剖、 eVLTIMF瓣制备及其在颅颌面、口腔颌面和颌颈区缺损修复中的应用作一阐述。     

A novel osteogenic distraction device for the transversal correction of temporozygomatic hypoplasia

BackgroundHemifacial microsomia (HFM) is a congenital disorder characterized by craniofacial malformation of one or both sides of the lower face. Since these anomalies are associated with soft-tissue deficiencies, corrective surgery is often difficult. Bone grafts have typically been used for augmentation, but distraction osteogenesis now offers an alternative for many craniofacial deficiencies, but there are few if any appropriate distraction devices and surgical procedures for the augmentation of craniofacial transversal dimensions.MethodsThe aim of this study was to evaluate a technique for guided augmentation of craniofacial transversal dimensions through distraction osteogenesis. We tested the efficacy of a prototype distractor, developed in collaboration with Medartis, using cadavers and demonstrated its application for the correction of the transverse dimension of the temporozygomatic region in a patient with Goldenhar syndrome.ResultsCT scans showed a 4-mm transverse augmentation of the bony surface after 9 days and a 10-mm increase after 30 days. Upon removal of the distractor (60 days after the first surgery) CT indicated good bony fusion and a stable result in the transverse plane. Six months after removal of the distractor, 3D computed tomography confirmed the success of the transverse augmentation, as it appeared to be stable and reliable.ConclusionsDistraction osteogenesis, using our device, can be used to correct the transverse dimension of the temporozygomatic region in HFM patients. It should also be considered for the correction of residual postsurgical skeletal deficiency due to surgical relapse or deficient growth, and unsatisfactory skeletal contour.     

Prosthetic rehabilitation of a maxillary defect with a bone anchored prosthesis: A clinical report

Mucormycosis is an opportunistic fungal infection that frequently infects sinuses, brain, or lungs and arises mostly in immunocompromised patients. Although its occurrence in the maxilla is rare, debridement and resection of the infected and necrotic area is often the best treatment but usually results in an extensive maxillary defect. Protocols for prosthetic obturation versus microvascular reconstruction have been established and used effectively in tertiary institutions for patients with such large defects. Aramany Class VI defects involving more than half of the palatal surface can be managed effectively by surgical reconstruction using microvascular free flaps as a platform for supporting bone-anchored prostheses. Providing fixed prostheses may offer advantages over a conventional obturator prosthesis in terms of hygiene, function, and esthetics. Nonetheless, fixed prostheses retained by endosseous implants in patients with reconstructive osteomyocutaneous flaps often require a sequential team approach by the surgeon and prosthodontist. This clinical report describes the reconstruction of a maxilla by using a scapular free flap with subsequent prosthetic rehabilitation in a patient with maxillary sinus infection secondary to mucormycosis.     

Ridge augmentation by applying bioresorbable membranes and deproteinized bovine bone mineral: a report of twelve consecutive cases

OBJECTIVE: Lateral ridge augmentations are traditionally performed using autogenous bone grafts to support membranes for guided bone regeneration (GBR). The bone-harvesting procedure, however, is accompanied by considerable patient morbidity. AIM: The aim of the present study was to test whether or not resorbable membranes and bone substitutes will lead to successful horizontal ridge augmentation allowing implant installation under standard conditions. MATERIAL AND METHODS: Twelve patients in need of implant therapy participated in this study. They revealed bone deficits in the areas intended for implant placement. Soft tissue flaps were carefully raised and blocks or particles of deproteinized bovine bone mineral (DBBM) (Bio-Oss) were placed in the defect area. A collagenous membrane (Bio-Gide) was applied to cover the DBBM and was fixed to the surrounding bone using poly-lactic acid pins. The flaps were sutured to allow for healing by primary intention. RESULTS: All sites in the 12 patients healed uneventfully. No flap dehiscences and no exposures of membranes were observed. Nine to 10 months following augmentation surgery, flaps were raised in order to visualize the outcomes of the augmentation. An integration of the DBBM particles into the newly formed bone was consistently observed. Merely on the surface of the new bone, some pieces of the grafting material were only partly integrated into bone. However, these were not encapsulated by connective tissue but rather anchored into the newly regenerated bone. In all of the cases, but one, the bone volume following regeneration was adequate to place implants in a prosthetically ideal position and according to the standard protocol with complete bone coverage of the surface intended for osseointegration. Before the regenerative procedure, the average crestal bone width was 3.2 mm and to 6.9 mm at the time of implant placement. This difference was statistically significant (P<0.05, Wilcoxon's matched pairs signed-rank test). CONCLUSION: After a healing period of 9-10 months, the combination of DBBM and a collagen membrane is an effective treatment option for horizontal bone augmentation before implant placement.     

Bone augmentation using a synthetic bone graft in dogs

The aim of this investigation was to evaluate clinically and histologically the use of a synthetic bone graft (Ionogran®) alone and in combination with guided bone regeneration (GBR) for alveolar ridge augmentation. Five beagle dogs were used in this study. Prior to the augmentation procedure the maxillary and mandibular second, third and fourth premolars were extracted. Three months after the extractions, impressions from the area of the ridges were taken. Particles of Ionogran® were then placed under mucoperiosteal flaps in each quadrant. On the experimental sites, an expanded polytetrafluoroethylene barrier was placed between the flap and the particles. Impressions were retaken at 1 and 3 months after surgery. Three months after surgery, the animals were sacrificed and specimens were prepared for histological evaluation. Computer-assisted volumetric analyses from the casts revealed an increase in ridge volume from baseline in both groups at 1 and 3 months. There was no difference in the height of the augmentation between the test and control sites. The histological results of this study indicate that this new synthetic bone graft appears to be a safe biocompatible grafting material. There were no apparent histological differences between the graft alone and graft/GBR sites. In both groups, however, graft particles were surrounded by dense fibrous connective tissue and bone formation was limited to the graft bone interface.     

Functional and esthetic outcome enhancement of periodontal surgery by application of plastic surgery principles.

The closure of surgical wounds in a layer-by-layer fashion, a common principle of plastic surgery, is applied in this article to the field of periodontal surgery with the introduction of a new flap design. The suggested technique is indicated with all periodontal procedures that aim for hard and soft tissue augmentation (guided bone regeneration, mucogingival surgery, or plastic periodontal surgery) where passive, tension-free wound closure is fundamental for wound healing and a successful functional and esthetic outcome. By means of a series of incisions, buccal and lingual flaps are split several times; this results in a double-partial thickness flap and a coronally positioned palatal sliding flap, respectively. Thus, several tissue layers are obtained and the passive advancement of flaps becomes possible for the coverage of augmented areas. Wound closure with microsurgical suture material is accomplished in a multilayer approach, which ensures adaptation and closure of the outer tissue layers without any tension. Two case reports demonstrate the new plastic periodontal approach.     

Reconstruction following radical maxillectomy with flaps supplied by the subscapular artery.

The authors present their experience of 27 cases with repairs of defects following radical maxillectomies with free flaps. A total of 28 flaps were used (five latissimus dorsi, six scapula, 16 combination flaps of scapula and latissimus dorsi and one combination of scapula, latissimus dorsi and serratus anterior flap). Only one scapula flap was completely lost and in three cases where a combination of scapula and latissimus dorsi flap was used, partial necrosis of one component occurred. The authors first choice for reconstruction is a scapula bone flap raised on the angular artery combined with the latissimus dorsi flap. The combination of flaps with a long pedicle and of the bony and muscular components provides the surgeon with the option of customizing the flap to meet individual patient needs. For intraoral closure the authors prefer the latissimus dorsi muscle which rarely requires secondary procedures for prosthesis placement following epithelialization and atrophy. The main disadvantage of the flap is the difficulty of two teams working simultaneously, thus increasing the average operating time. All postoperative corrections and prosthetic rehabilitation should be postponed for at least 2 months following surgery because of postoperative swelling.     

肩胛区游离瓣在口腔颌面外科的应用——附21例临床报道

目的详细阐明肩胛区游离瓣的应用解剖、制做技术及临床应用。方法对我科自１９７９年以来，共完成的肩胛区游离瓣移植术２１例，进行了临床分析。结果肩胛区游离瓣以肩胛下血管为蒂，可设计为单纯皮瓣、骨瓣或复合瓣；２１例肩胛区游离瓣移植修复均获成功，主要不足为切取肩胛区游离瓣时，需要更换体位，手术时间相对延长。结论由于前臂桡侧游离皮瓣和腓骨肌皮瓣的广泛应用，肩胛区游离瓣的应用趋向减少。     

Rapid orthodontics with alveolar reshaping: two case reports of decrowding

Two case reports demonstrate a new orthodontic method that offers short treatment times and the ability to simultaneously reshape and increase the buccolingual thickness of the supporting alveolar bone. A 24-year-old man with a Class I severely crowded malocclusion and an overly constricted maxilla with concomitant posterior crossbites and a 17-year-old female with a Class I moderately to severely crowded malocclusion requested shortened orthodontic treatment times. This new surgery technique included buccal and lingual full-thickness flaps, selective partial decortication of the cortical plates, concomitant bone grafting/augmentation, and primary flap closure. Following the surgery, orthodontic adjustments were made approximately every 2 weeks. From bracketing to debracketing, both cases were completed in approximately 6 months and 2 weeks. Posttreatment evaluation of both patients revealed good results. At approximately 15 months following surgery in one patient, a full-thickness flap was again reflected. Visual examination revealed good maintenance of the height of the alveolar crest and an increased thickness in the buccal bone. The canine and premolars in this area were expanded buccally by more than 3 mm, and yet there had actually been an increase in the buccolingual thickness of the overlying buccal bone. Additionally, a preexisting bony fenestration buccal of the root of the first premolar was covered. Both of these findings lend credence to the incorporation of the bone augmentation procedure into the corticotomy surgery because this made it possible to complete the orthodontic treatment with a more intact periodontium. The rapid expansive tooth movements with no significant apical root resorption may be attributed to the osteoclastic or catabolic phase of the regional acceleratory phenomenon. Instead of bony "block" movement or resorption/apposition, the degree of demineralization/remineralization might be a more accurate explanation of what occurs in the alveolar bone during physiologic tooth movement in these patients.     

Gingival augmentation with a dermal allograft

Gingival augmentation surgery with soft tissue autografts long has been the standard for increasing the width of keratinized oral tissue. Acellular dermal allografts, which have been used for several years by reconstructive surgeons, are a novel technique for achieving increased gingival tissue in place of soft tissue autografts. This report describes a case of gingival augmentation via an acellular dermal allograft. Reduced morbidity from donor site grafts and increased patient acceptance, along with highly successful clinical results, are the primary advantages of this acellular dermal allograft.     

Ten-year follow-up in a maxillary sinus augmentation using anorganic bovine bone (Bio-Oss). A case report with histomorphometric evaluation

Several bone grafting materials have been used in sinus augmentation procedures. Bio-Oss (deproteinized and sterilized bovine bone) has shown to have osteoconductive properties and no inflammatory or adverse responses have been published. In spite of these successful results, histologic data regarding bone augmentation using Bio-Oss in humans is scarce. The purpose of this study was to analyse the amount of Bio-Oss ossification in a case of maxillary sinus augmentation, recording and comparing histomorphometric data 8 months, 2 and 10 years after surgery. This long-term histologic evaluation of retrieved specimens has been performed, comparing histomorfometric measures at different times. Eight months after surgery we observed in 20 different thin sections of the specimen a mean amount of bone tissue (including medullar spaces) of 29.8% (and 70.2% of Bio-Oss) +/- 2.6. At 2 years the bone tissue increased to 69.7% + 2.7 and 10 years after surgery it was 86.7% +/- 2.8. The comparison of the means for each time has shown a highly significant increasing trend in bone formation associated with Bio-oss resorption: at 8 months, 2 and 10 years.     

吻合两条静脉的头颈部游离组织瓣移植

目的 探讨吻合两条静脉的游离组织瓣移植在头颈部缺损修复中的可靠性和应用价值。方法 选择1999年9月-2003年4月完成的168例同时吻合两条静脉的头颈部游离组织瓣移植的患者为研究对象。168例患者中男92例,女76例,年龄11～79岁,平均44.6岁。分析肿瘤的部位和类型、缺损的范围、所采用游离瓣的设计、受区静脉的选择、血管吻合技术和游离瓣的成活情况及术后并发症的发生情况。结果 所采用的168块游离瓣中,腓骨瓣126块,前臂皮瓣32块,腹直肌皮瓣7块,肩胛瓣、空肠瓣和大腿前外侧皮瓣各1块。最常选用的受区静脉包括颈外静脉、面前静脉、面总静脉和颈内静脉,占全部受区静脉的86.0％。本组游离组织瓣的临床成活率为99.4％,术后1块腓骨瓣因动脉血栓而失败,但无1例游离瓣发生术中和术后静脉危象。结论 同时吻合两条静脉的头颈部游离组织瓣移植可有效防止或降低游离瓣静脉危象的发生机率,提高了游离组织瓣移植的成功率。     

钛网结合异体骨移植和人骨形成蛋白在上颌前牙种植前牙槽嵴骨增量中的应用研究（附1例报告）

编者按：本刊特邀美国德克萨斯健康研究中心牙学院Bing-Yan Wang副教授介绍1例在上颌前牙牙槽骨严重缺损区实现骨增量的病例。在拔牙同期用异体骨和Bio-Mend延展膜进行引导骨再生术后未获得满意骨量的情况下,无法进行种植手术,术者用钛网结合异体骨移植材料和人骨形成蛋白在种植体植入前修复上前牙区部分牙缺失部位的牙槽骨缺损,最终获得成功。通过这种方法扩大了在上前牙牙槽骨严重骨缺损区种植的适应证,为患者提供了除自体骨移植以外的另一个选择。