延长颏下动脉穿支皮瓣血管蒂修复口腔颌面部缺损的临床应用

doi:10.3969/j.issn.1005-4979.2022.01.005

摘要/Abstract

摘要：

目的：本研究通过延长颏下动脉穿支皮瓣（submental artery perforator flap，SMAPF）血管蒂的3种方法修复口腔颌面部距供区较远的缺损，并对其可行性及临床效果评价。方法：选取自2019年1月—2021年2月于中国医科大学附属口腔医院颌面头颈肿瘤外科就诊并收治，行同侧颏下动脉穿支皮瓣手术修复口腔及颌面头颈部恶性肿瘤术后缺损的15个病例。术中通过精细解剖并依次切断颏下动脉进入下颌舌骨肌的穿支、下颌下腺的穿支及切断下颌舌骨肌神经，记录利用上述3种方式行穿支皮瓣血管蒂延长术前后差值的数据。结果：皮瓣修复范围从口腔内至颌面部，大小为3.5 cm×6.0 cm~6.5 cm×16.0 cm。通过切断颏下动脉进入下颌舌骨肌的穿支后血管蒂可延长（0.9±0.2） cm，切断颏下动脉进入下颌下腺穿支后的血管蒂可延长（2.0±0.2） cm，切断下颌舌骨肌神经后血管蒂可延长（1.8±0.2） cm，血管蒂最长可延长5.5 cm。在2~25个月的随访中，15例患者的皮瓣均完全成活，血供较好，术后即刻及随访中无1例皮瓣出现供血不足、坏死或发生面神经功能障碍等供区并发症。结论：颏下动脉穿支皮瓣可以通过切断颏下动脉进入下颌舌骨肌的穿支、下颌下腺穿支及切断下颌舌骨肌神经进行血管蒂延长进而延长旋转半径来修复口腔颌面部缺损。该技术对于修复颌面部距供区远处的中小型缺损具有更多临床应用的选择性和指导意义。

关键词: 延长血管蒂, 颏下穿支皮瓣, 修复缺损

Abstract:

Objective: To study and evaluate the clinical effects of elongating the pedicle of the submental artery perforator flap used to repair the oral and maxillofacial defects far away from the donor sites. Methods: From January 2019 to February 2021, 15 cases of oral and maxillofacial head and neck malignant tumors were treated with submental artery perforator flaps to repair postoperative defects in Oral and Maxillofacial Oncology Center, Hospital of Stomatology, China Medical University. During the operation, the perforators of the submental artery into the mylohyoid muscle, the perforators into the submandibular gland, or the mylohyoid nerve were dissected and ligated by microdissection. The differences of elongation numerical results before and after perforation treatment of the submental artery perforator flap pedicles were recorded. Results: The range of flap repair covered from the oral cavity to the maxillofacial region. The size of the flap ranged from 3.5 cm×6.0 cm to 6.5 cm×16.0 cm respectively. The length of submental artery perforator flap pedicles can be extended by(0.9±0.2) cm after ligating the perforators into the mylohyoid muscle; (2.0±0.2) cm after ligating the perforators into the submandibular gland; and(1.8±0.2) cm after ligating the mylohyoid nerve. The longest vascular pedicle could be extended by 5.5 cm. During the follow-up period of 2-25 months, all flaps survived with good blood supply in 15 patients, and no donor site complications such as flap with insufficient blood supply, necrosis, or facial nerve dysfunction were found immediately after surgery or in follow-up visits. Conclusion: Submental artery perforator flaps can repair oral and maxillofacial defects by elongating the length and rotation radius of vascular pedicles through ligating the submental artery perforators into the mylohyoid muscle, perforators into the submandibular gland and mylohyoid nerve. This technique has more clinical application selectivity and guiding significance to repair small and medium-sized maxillofacial defects far away from the donor sites.

Key words: prolonging the vascular pedicle, submental perforator flap, reconstruct defect

李思思, 赵坤明, 谭学新. 延长颏下动脉穿支皮瓣血管蒂修复口腔颌面部缺损的临床应用[J]. 《口腔颌面外科杂志》, 2022, 32(1): 24-28.

LI Sisi, ZHAO Kunming, TAN Xuexin. Submental artery perforator flap: Pedicle elongation for reconstruction of oral and maxillofacial defects[J]. 《Journal of Oral and Maxillofacial Surgery》, 2022, 32(1): 24-28.

https://journal06.magtech.org.cn/Jweb_joms/CN/Y2022/V32/I1/24

图/表 3

图1 各颏下动脉穿支切断示意图 A. 各穿支和神经解剖位置，虚线表示皮瓣旋转半径可修复范围；B. 下颌下腺穿支位置及切断后示意图；C. 下颌舌骨肌神经及下颌舌骨肌穿支切断后解剖示意图。

Figure 1 Schematic diagram of submental artery perforators dissection and transection

表1 3种方式延长颏下动脉穿支血管蒂的数值结果

Table 1 Numerical results of three ways to elongate the vascular pedicles of submental artery perforator flaps

病例	年龄/岁	性别	病理诊断	缺损部位	皮瓣大小/cm	切断后的血管蒂长度/cm
病例	年龄/岁	性别	病理诊断	缺损部位	皮瓣大小/cm	切断颏下动脉进入下颌舌骨肌穿支	切断颏下动脉进入下颌下腺穿支	切断下颌舌骨肌神经
1	46	女	鳞状细胞癌	右舌及口底	5.0×10.0	0.8	2.3	1.5
2	29	女	鳞状细胞癌	左舌	5.5×9.0	1.1	1.9	1.8
3	52	女	鳞状细胞癌	左舌	5.0×10.0	1.3	2.2	2.0
4	67	女	鳞状细胞癌	右舌及口底	5.5×12.0	1.2	2.0	1.6
5	44	男	鳞状细胞癌	左颊黏膜	5.0×9.0	0.9	1.8	1.5
6	61	男	鳞状细胞癌	左口咽	5.5×13.0	1.0	1.7	1.9
7	49	女	骨肉瘤	左下颌骨	5.5×12.0	0.7	1.9	2.0
8	70	男	鳞状细胞癌	右舌	5.0×10.0	0.6	2.1	1.7
9	66	女	Merkel细胞癌	左眶下	3.5×6.0	0.8	2.0	1.7
10	42	男	鳞状细胞癌	左耳廓	6.0×12.0	0.9	2.1	2.1
11	72	男	皮脂腺癌	左颊黏膜	5.0×8.5	1.0	2.0	1.5
12	59	男	腺样囊性癌	左下颌牙龈	5.0×9.0	0.7	1.6	1.6
13	62	男	鳞状细胞癌	左口咽	6.5×16.0	0.8	2.3	1.9
14	44	男	鳞状细胞癌	右颊黏膜	5.0×8.0	1.1	2.2	2.1
15	66	男	鳞状细胞癌	右腮腺	4.5×7.0	0.6	2.1	1.7

图2 左耳廓鳞状细胞癌扩大切除即刻延长的颏下动脉穿支皮瓣血管蒂修复缺损 A. 患者病灶大小及术前画线；B. 病灶切除后术区缺损范围；C. 全麻下设计颏下动脉穿支皮瓣大小；D、E. 颈淋巴结清扫同期制备颏下动脉穿支皮瓣，并将其无张力转移至缺损处；F. 皮瓣与缺损对位缝合；G、H. 患者术后随访皮瓣修复后的效果。

Figure 2 The extensive resection of left auricular SCC and simultaneous repair with the submental artery perforator flap with elongated vascular pedicle

参考文献 14

[1]	Martin D, Pascal JF, Baudet J, et al. The submental island flap[J]. Plast Reconstr Surg, 1993, 92(5): 867-873. pmid: 8415968
[2]	Kim JT, Kim SK, Koshima I, et al. An anatomic study and clinical applications of the reversed submental perforator-based island flap[J]. Plast Reconstr Surg, 2002, 109(7): 2204-2210. doi: 10.1097/00006534-200206000-00004 pmid: 12045537
[3]	Hayden RE, Nagel TH, Donald CB. Hybrid submental flaps for reconstruction in the head and neck: Part pedicled, part free[J]. Laryngoscope, 2014, 124(3): 637-641. doi: 10.1002/lary.v124.3 URL
[4]	Renfrew S, Cavanagh D. The discrimination between pinching and pressing of the skin; the basis of a clinical test[J]. Brain, 1954, 77(2): 305-313. pmid: 13190081
[5]	黄龙, 郭峰, 翦新春, 等. 颏下动脉穿支皮瓣修复口腔癌术后缺损的临床应用[J]. 中华口腔医学杂志, 2018, 53(01): 3-7.
[6]	殷杏, 魏偏偏, 孙畅, 等. 个体数据分析揭示汉族头面部测量特征的南北差异[J]. 解剖学杂志, 2020, 43(4): 313-321.
[7]	刘学峰. 辽宁汉族成人头面部形态特征[D]. 锦州: 辽宁医学院, 2011.
[8]	Ferrari S, Copelli C, Bianchi B, et al. The submental island flap: Pedicle elongation and indications in head and neck reconstruction[J]. J Craniomaxillofac Surg, 2014, 42(6): 1005-1009. doi: 10.1016/j.jcms.2014.01.025 pmid: 24642090
[9]	Multinu A, Ferrari S, Bianchi B, et al. The submental island flap in head and neck reconstruction[J]. Int J Oral Maxillofacial Surg, 2007, 36(8): 716-720. doi: 10.1016/j.ijom.2007.03.008 URL
[10]	Chen WL, Li JS, Yang ZH, et al. Two Submental island flaps for reconstructing oral and maxillofacial defects following cancer ablation[J]. J Oral Maxillofac Surg, 2008, 66(6): 1145-1156. doi: 10.1016/j.joms.2007.09.023 URL
[11]	Hayden RE, Nagel TH, Donald CB. Hybrid submental flaps for reconstruction in the head and neck: Part pedicled, part free[J]. Laryngoscope, 2014, 124(3): 637-641. doi: 10.1002/lary.v124.3 URL
[12]	Bertrand B, Honeyman CS, Emparanza A, et al. Twenty-five years of experience with the submental flap in facial reconstruction[J]. Plast Reconstr Surg, 2019, 143(6): 1747-1758. doi: 10.1097/PRS.0000000000005678 URL
[13]	Abouchadi A, Capon-Degardin N, Patenôtre P, et al. The submental flap in facial reconstruction: Advantages and limitations[J]. J Oral Maxillofac Surg, 2007, 65(5): 863-869. doi: 10.1016/j.joms.2006.05.063 URL
[14]	Bin X, Wu X, Huang L, et al. Surgical anatomy of the submental artery perforator flap and assessment for application in postoperative reconstruction following oral cancer surgery: A prospective clinical study[J]. Int J Oral Maxillo-fac Surg, 2021, 50(7): 879-886.

选择文件类型/文献管理软件名称

选择包含的内容