口腔颌面部游离组织瓣移植受区血管制备困难时的处理  

Management of difficult recipient vessel preparation in microsurgical reconstruction for oral and maxillofacial defects with free flaps

作　　者：吴立萌 蒋灿华[1] 陈洁[1] 李宁[1] 闵安杰[1] 高兴[1] 翦新春[1] 

机构地区：[1]中南大学湘雅医院口腔颌面外科,长沙410008

出　　处：《中华显微外科杂志》2016年第2期114-118,共5页Chinese Journal of Microsurgery

基　　金：国家自然科学基金（81271154）;中南大学湘雅医院临床科研基金（2015102）

摘　　要：目的探讨采用游离组织瓣修复口腔颌面部缺损出现受区血管制备困难或缺乏时的解决方案，并评价其临床效果。方法2012年5月至2015年5月，共收治口腔颌面部缺损患者739例，采用游离组织瓣移植761块．37例术中出现受区血管制备困难或缺乏，其中口腔癌单纯手术后复发12例，手术及放疗后复发10例，第二原发癌5例，放射性颌骨骨髓炎7例，外伤或感染后组织缺损与畸形3例。40块组织瓣中股前外侧皮瓣23块，腓骨（皮）瓣10块，前臂皮瓣7块。单独或联合采用超长组织瓣血管蒂制备、血管移植、血管转位、静脉改形、端侧吻合、血流桥接等方法均顺利完成受区血管的制备与吻合，详细记录所采用的技术方法、吻合口即刻通畅率、皮瓣成活率以及术后并发症等相关情况。结果37例患者40块组织瓣，共计完成87条血管91个吻合口的吻合，受区血管位于颈部同侧50条，多为前次颈清扫术中保留或不在手术野中的血管（甲状腺上动脉、甲状腺下动脉、颈横动脉、颈内静脉主干）、前次手术移植的组织瓣血管蒂或已结扎的血管残端（面动脉残端、颈内或颈外静脉残端）。受区血管位于对侧37条，多为面动脉、甲状腺上动脉与颈内静脉属支。超长组织瓣血管蒂制备31例，动脉与静脉移植各2例，血管转位4例，静脉改形5例，端侧吻合9例，血流桥接技术1例。吻合口即刻通畅率100％，皮瓣成活率97．5％。结论口腔癌术后和（或）放疗后复发、发生第二原发癌、放射性颌骨骨髓炎以及外伤感染导致的组织缺损或畸形是游离组织瓣移植时颈部受区血管制备困难或缺乏的主要原因，选择合适的组织瓣与受区血管，灵活运用超长组织瓣血管蒂制备、血管移植、血管转位、静脉改形、端侧吻合及血流桥接等技术仍然可以获得较高的成功率。Objective To investigate the management of difficult recipient vessel preparation in microsurgical reconstruction for oral and maxillofacial defects with free flaps and to assess the clinical outcome. Methods A total number of 739 patients with oral and maxillofacial defects underwent consecutive free flap reconstruction with 761 free flaps from May, 2012 to May, 2015. There were 37 patients who could not find or lack of proper recipient vessels for microvascular anastomosis during operation. Among them, 22 were recurrent oral cancer after tumor ablation, 10 of them undrewent post-operative radiotherapy; 5 were second primary oral cancer, 7 diagnosed with osteoradionecrosis, and 3 suffered from oral and maxillofacial defect and deformity caused by trauma or inflammation. Forty free flaps including 23 anterolateral thigh flaps （ALT）, 10 fibular flaps and 7 radial forearm flaps were harvested. Meth- ods and techniques used during the operation, instant patency rate after anastomosis, the overall survival rate of free flaps, and post-operative complications were recorded. Results Ninety-one anastomoses were performed between 87 pairs of vessels in 37 patients. Fifty recepient vessels were located on ipsilateral side of neck, and the most fre- quently used recipient vessels were those preserved or not being damaged in former operation and radiation, former transferred free flap vascular pedicles and residual ends of the ligated vessels. Thirty-seven recepient vessels were found on the contralateral side of neck. Thirty-one cases of long-pedicle flap harvesting, 2 cases of vein and artery grafting, 4 cases of vessel transposition, 5 cases of phleboplasties, 9 cases of end-to-side anastomoses, and 1 case of flow-through technique were applied in recipient vessels preparation alone or in combination. The patency rate of anastomosis during operation was 100% and the overall survival rate of free flaps was 97.5%. Conclusion Re-current oral cancer after tumor ablation, second primary oral cancer, osteoradionecrosis and

关 键 词：颌面部缺损 外科皮瓣 受区血管 显微外科 

分 类 号：R782[医药卫生—口腔医学]