胸肩峰动脉穿支皮瓣修复颈咽部软组织缺损

目的胸肩峰动脉穿支皮瓣（thoracoacromial artery perforator，TAAP）是近年来应用于颈部和咽部组织缺损的新技术，本文分析使用TAAP修复颈咽部缺损的经验。方法回顾分析2013年5月~2017年4月诊治20例TAAP修复咽瘘、咽部黏膜缺损和颈部皮肤缺损。本组患者年龄48~68岁，平均年龄53岁。下咽癌切除+全喉切除10例，保留喉功能的下咽癌切除7例，颈部皮肤缺损3例。咽部黏膜缺损4.5 cm×3 cm~6.5 cm×5 cm，颈部皮肤缺损5.5 cm×4 cm~8 cm×6 cm，皮瓣大小6 cm×4 cm~8 cm×6 cm。结果18例术后皮瓣成活，供区直接拉拢缝合，没有出现皮瓣坏死，其中15例行下咽黏膜修复的患者，术后2~5周恢复经口进食并行术后放疗，剂量60~67 Gy。另2例术中发现穿支血运障碍，更换成颏下皮瓣修复下咽缺损。随访3~36个月，1例术后14个月出现胸段食管癌，1例术后18个月出现纵膈淋巴结转移，均予以放化疗， 1例术后1年出现颈部淋巴结转移复发予以化疗，余病例无复发。结论胸肩峰动脉穿支皮瓣因为邻近颈部、血管相对恒定、皮瓣薄适用于修复咽部黏膜和颈段食管缺损；胸肩峰动脉为血管蒂的一蒂双岛的TAAP和胸大肌皮瓣同时修复复杂的颈部皮肤和咽部黏膜缺损。胸肩峰动脉穿支皮瓣的穿支细小，穿越锁骨下隧道时穿支区域和血管蒂不能扭曲，发现皮瓣血运异常应及时更换其他修复方法。

Defect repair of soft tissue in neck and pharynx with thoracoacromial artery perforator flap

ObjectiveThoracoacromial artery perforator (TAAP) flap is a new technology applied to defect repair of cervical and pharyngeal tissue in recent years. This paper shares our experience in the application of this flap for the repair of soft tissue defect in neck and pharynx.MethodsBetween May 2013 and April 2017, TAAP flaps were applied to repair pharyngeal fistulas, pharyngeal mucosa defect or neck skin defect in 20 patients. All patients ranged in age from 48 to 68 years old with an average of 53. Of all the 20 cases, 10 received resection of hypopharyngeal carcinoma and total laryngectomy, 7 received resection of hypopharyngeal carcinoma with reservation of laryngeal function, and 3 had neck skin defect. Pharyngeal mucosa defects ranged from 4.5 cm×3.0 cm to 6.5 cm×5.0 cm in size, neck skin defects ranged from 5.5 cm×4.0 cm to 6.0 cm×8.0 cm. The TAAP flaps ranged from 6.0 cm×4.0 cm to 8.0 cm×6.0 cm.ResultsThe TAAP flaps got survived without necrosis when the donor sites were closed directly in 18 cases. Of them, 15 receiving defect repair of pharyngeal mucosa got oral intake in 2 to 5 weeks after operation and were given postoperative radiotherapy with dose ranged from 60 Gy to 67 Gy. Intraoperative dysfunction of blood circulation occurred in 2 cases and submental flaps were applied to repair the hypopharyngeal defect instead. All the patients had been followed up for 3 to 36 months postoperatively. One patient developed thoracic esophageal carcinoma in the 14th month, and another got mediastinal lymph node metastasis in the 18th month, and they were given chemotherapy and radiotherapy. One patient with recurrence of cervical node metastasis in one year got chemotherapy. No recurrence occurred in the rest of the cases.ConclusionsWith advantages of being adjacent to neck, relatively stable vascularity and proper thickness, TAAP flap is suitable for the defect repair of neck skin and cervical esophagus. For the repair of complicated defects of neck skin and pharyngeal mucosa, the TAAP flap with TAAP as the vascular pedicle can be used in combination with pectoralis major myocutaneous flap. Because the arterial perforators of TAAP flap are very slender, intraoperative tortuosity of the perforators and pedicle should be avoided. Once abnormal blood supply of the TAAP flap is found, other repair method should be adopted immediately.