颧骨牵张成骨与游离腓骨复合瓣联合移植修复上颌骨大型缺损:一种新方法探讨

背景:上颌骨是面中部形态和功能基石,但由于结构复杂,上颌骨大型缺损的功能性修复极具挑战性。目的:建立一种颧骨牵张成骨和游离腓骨复合瓣联合移植修复上颌骨大型缺损新方法。设计:病例观察。单位:解放军二五二医院口腔科。对象:选择于2005-12在河北省保定市解放军二五二医院收治的1例上颌肌上皮瘤需要手术的患者,男,42岁,该患者2年前曾因上颌骨肿物于本医院接受肿物及双侧上颌骨次全切除术,病理诊断为肌上皮瘤,1年后,肿物复发并占据全部右上颌。为彻底切除肿瘤需行右侧上颌骨全切术。作者为该患者设计了双侧颧骨牵张成骨及后期游离腓骨瓣移植联合修复上颌骨缺损的治疗方案,患者对手术方案知情同意。方法:对患者行双侧颧骨内置弧形牵张成骨术及游离腓骨复合瓣移植。手术分两个阶段,第Ⅰ阶段:右上颌骨全切后行双侧颧骨牵张成骨术:首先,于双侧上颌骨缺损腔外侧剩余颧骨上以摆动锯及骨凿截骨制备长约10mm骨转移盘并以多枚钛钉可靠固定颧骨内置弧形骨牵张器,为防止骨牵张器暴露于与口腔相通的缺损腔中,右侧以带蒂颊脂垫覆盖骨牵张器底面。左侧因上次行上颌骨次全切术时已行植皮术,成活良好,无需特殊处理。常规冲洗后,除加力端由颞部软组织穿出外,全层缝合关闭伤口。术后延迟1周后以0.2mm/次,2次/d的速度行骨牵引,其中右侧共牵引21d,左侧共牵引16d。固定8个月。第Ⅱ阶段:沿面部原韦伯氏切口切开,暴露并卸下骨牵张器,见骨牵张区新骨生成良好,骨性支持在上颌骨底位建立,按照hidalgo和Peng的方法制备游离腓骨复合瓣,并于下颌骨内侧制作隧道,借助模板对腓骨进行塑形成上颌牙弓形态,然后将其置入上颌牙槽嵴位置,以钛板将腓骨瓣固定于双侧牵引至上颌骨低位的颧骨上,血管蒂经下颌内侧隧道入颈部,常规行血管吻合。通过此项手术,上颌骨缺损为腓骨长肌充填,上颌牙槽嵴由腓骨修复。术后以大体观察及全口曲面断层片观察牵张器和腓骨瓣状况以及成骨和重建质量。主要观察指标:大体观察和全口曲面断层片考察骨牵张器及腓骨瓣状况以及成骨、重建效果。结果:治疗过程中,牵张器状况良好和腓骨瓣顺利成活。通过颧骨牵张成骨,骨组织支持在上颌骨低位建立,面中部外形恢复,缺损腔缩小;通过腓骨复合瓣移植,缺损腔修复,上颌牙槽嵴重建,口鼻腔分离,上唇突度恢复。在2项技术联合修复下,患者面型恢复良好。结论:颧骨牵张成骨和游离腓骨复合瓣可联合应用修复上颌骨大型缺损。一种上颌骨大型缺损修复新方法成功建立。

Maxillary reconstruction with the distraction osteogenesis of zygoma and free fibula composite flap: Investigation of a new technique

BACKGROUND: The maxilla is the functional and aesthetic keystone of the midface. However, because of the irregularity and complexity, the functional reconstruction of large maxillary defect is a significant challenge.OBJECTIVE: To set up a new method for maxillary reconstruction by distraction osteogenesis of zygoma and free fibula composite flap.DESIGN: Case observation.SETTING: Department of Stomatology, the 252 Hospital of Chinese PLA.PARTICIPANTS: A patient who suffered from right total maxillectomy and left subtotal maxillectomy. The subject was proved by the Department of Stomatology, the 252 Hospital of Chinese PLA in November 2005. The procedure and consequences of the treatment were told to the patient and his wife before the operation. They greed and signed on the consent book.METHODS: The bilateral internal curve distraction osteogenesis of zygoma (first stage) and transfer of free fibula composite flap (second stage) were performed on the patient. First stage: Following the total maxillectomy, the distraction osteogenesis of zygoma was performed. First, the complete osteotomy was performed on the biliteral remaining zygoma with oscillating saw and osteotome. The transport disks distal to the defect about 10 mm in length were made. Then the internal curve distractors were installed with titanium screws bilaterally and the pedicled buccal fat pad was used to cover the right distractor and separate it from oral and nasal cavities. Due to the skin grafting had been undertaken in the former surgery, no special measure was needed in the left side. After irrigation with normal saline, the wounds were closed with the distraction activator exiting through the soft tissue in the temporal region. Distraction began after a week and proceeded at 0.2 mm twice per day for 21 consecutive days in the right side and 16 days in the left. Consolidation was fixed for eight months. Second stage: By the original Weber's incision, distractors were exposed and released. With new bone formed well in the distracted gap, the bony support was founded in the low position of maxilla. The free fibula composite flap was harvested and the medial-mandibular tunnel was made as described by hidalgo and Peng. After that, the flap was transferred to the recipient site with the pedicle through the tunnel into the neck, then with the help of surgical plate, the fibula bone was remodeled as maxillary arch and fixed to the "bony support" with titanium plates. Following that, the microvascular anastomoses were performed. By the measure, the maxillary cavity was filled by peroneus longus muscle and the maxillary alveolar process was rebuilt by fibula bone. During the procedure, the condition of the distractors and fibula flap, the effect of osteogenesis and the reconstruction was checked by general observation and panoramic film.MAIN OUTCOME MEASURES: The general condition of the distractors and the flap;the effect of osteogenesis and reconstruction.RESULTS: The distractors were in good condition and fibula healed well. By the distraction osteogenesis of zygoma, bony support was set up in the low position of maxilla, the midfacial appearance was restored and the defects was reduced. By the transfer of free fibula composite flap, the defect was restored, the maxillary alveolar process was rebuilt, the oronasal communication was closed, and the contour of upper lip was reestablished.CONCLUSION: The distraction osteogenesis of zygoma and free composite fibula flap can be used together for the reconstruction of large maxillary defects. A new method is set up for functional reconstruction of large maxillary defects.