RU2004199C1 - Method for plasty of defect in fundus of oral cavity - Google Patents

Abstract

The invention relates to medicine, namely to maxillofacial surgery, and can be used in the surgical treatment of injuries and diseases of the oral cavity, accompanied by the formation of a soft tissue defect. The essence of the invention lies in the plastic defect of the skin-fascial-periosteal flap based on the latissimus dorsi, including the distal end with the skin located above it and the area of the periosteum of the iliac crest, while preserving the neurovascular bundle The advantage of the proposal lies in improving functional results.

Description

The invention relates to medicine, namely to maxillofacial surgery, and can be used in the surgical treatment of injuries and diseases of the oral cavity, accompanied by the formation of a soft tissue defect.

Conducted by research on patent and research literature, a number of methods for repairing defects in the bottom of the oral cavity have been identified.

The use of a split tongue for fixing a defect in the bottom of the oral cavity is known.

It is also known to use the masticatory muscle, which was cut off in the cranial region and fixed in a transverse position to the corner of the mouth, forming the muscle base of the bottom of the mouth.

For plasty of a defect in the bottom of the oral cavity, a skin flap on a leg from the forehead was also used.

However, all known methods are highly traumatic and technically difficult to implement.

A prototype of the present invention is a method for plasty of a defect in the bottom of the oral cavity, in which it was proposed to use a skin-fat-muscle flap based on the subcutaneous muscle of the neck to replace the defect in the soft tissues of the bottom of the mouth.

The proposed method has the following disadvantages:

The flap is cut out on the neck through the same incision through which the soft tissues of the bottom of the oral cavity are removed, which leads to the formation of a cosmetic defect - a scar that disfigures a person. It is known that even access to the thyroid gland is made from the above-chest section so that it is not visible on the front surface of the neck;

the subcutaneous muscle of the neck is "a thin layer of muscle fibers devoid of fascial cover and belongs to the group of facial muscles. It does not have its own neurovascular leg, and it is bloodshot due to musculocutaneous branches from neighboring muscle groups. Cutting out the flap leads to the intersection of these branches and the violation of the blood supply. Venous outflow is particularly affected. In this regard, this muscle cannot serve as the basis of the graft;

the addition of a skin-fat-muscle flap to the oral defect is accompanied by an inflection at the base, which also has an adverse effect on the blood supply to the transplant, causing atrophy and relapse of the disease;

the layers of the skin have anatomical features in that the skin, adipose tissue and subcutaneous muscle are firmly bonded to each other and it is impossible to separate them. When a flap is sutured to the edge of the lower jaw, dissimilar tissues are connected: the mucous membrane, periosteum with bone on one side and skin, muscle and fat on the other. This reduces

transplant strength. May lead to rejection and relapse.

A disadvantage of the method should also include the fact that in order to close defects in men, it is necessary to move the scalp.

An object of the invention is to prevent recurrence of the disease.

The method is carried out as follows. On the line drawn from the small tubercle of the humerus to the crests of the ilium, the skin, subcutaneous tissue and fascia are dissected. Throughout

from the small tubercle of the humerus to the iliac crest, the lateral (free) edge of the latissimus dorsi is exposed. In order to form a skin cover of the graft over the distal end of the latissimus dorsi, two ellipsoidal incisions of the skin and subcutaneous tissue are performed. The periosteum is separated under the distal end of the lateral section of the latissimus dorsi muscle with a boron and raspator

iliac wing crest. Thus, the periosteal part of the graft is formed. By making two cuts along the muscle fibers, the muscle part of the graft is cut out

U-shaped necessary width from the latissimus dorsi. The edge of the dissected own fascia of the latissimus dorsi muscle is sutured, thereby restoring the fascial capillary of the graft.

A skin-fascial-muscular-periosteal transplant based on the latissimus dorsi muscle is secreted obtuse in the direction from the bottom up, doping with cutaneous muscle vessels from the intercostal

arteries. The preparation of the graft is stopped in the upper third of its lateral section, since the main neurovascular bundle is introduced into it. To provide greater mobility and to prevent kink of the feeding leg, the fascial-muscular-muscular-periosteal transplant based on the latissimus dorsi muscle is cut off subperiostally in the proximal part from the small tubercle of the humerus and is made on a fixed neurovascular leg. Further, a skin-fascial-muscular-periosteal flap based on the latissimus dorsi is deployed at an angle of 60-70 ° in the frontal plane in the region of the neurovascular leg and the proximal end is sutured to the remaining part of the latissimus dorsi. This completely prevents squeezing, bending and tension of the neurovascular bundle. At the final stage of the operation, a subcutaneous tunnel on the neck is made from the area of the wound on the back so that it more freely passes through the formed graft. A skin-fascial-muscular-periosteal flap based on the latissimus dorsi muscle to the defect of the floor of the oral cavity is passed through this tunnel and layer-by-layer fixation is carried out so that the skin part of the graft is turned towards the oral cavity. Wounds on the neck and back are sutured in layers.

Compared with the prototype, the proposed method allows the formation of a graft, which includes all the components of the layers of the bottom of the oral cavity (skin, fascia, muscle). Thanks to the inclusion of the periosteum, homogeneous tissues (skin-mucosa, muscles - muscles, periosteum - periosteum) are layer-by-layer fixed. This contributes to the formation of interorgan vascular connections, the engraftment of all layers of the graft in the area of the suture line, the viability of the plastic zone is increased, and disease recurrence is eliminated. The inclusion of the latissimus dorsi muscle, which is well-supplied with the help of its own neurovascular leg in the graft structure, allows maintaining adequate blood supply to the skin and periosteal parts of the flap. Restoring the integrity of the fascial cases of the muscle flap makes it possible to increase its resistance to infection, which is especially important in conditions of a pre-infected oral cavity. Cutting off the flap from the bone landmarks and leaving it only on a fixed neurovascular pedicle prevents its bending, tension and squeezing. This completely eliminates the violation of blood supply to all components of the fascial-fascial and periosteal transplant and allows to maintain its viability in the long term after the postoperative period. Cutting off the flap from fixation sites to the bone increases its mobility. The graft can be moved to the area of any defect on the face and neck. In addition, flap cutting by

the developed technique provides skin, fascial. muscle periosteal parts of sufficient size, which allows without additional use of other tissues to successfully produce plastic of the defect in the bottom of the oral cavity of any size.

Sick G., 48 years old. I entered the surgical department complaining of pain, ulceration of the mucous membrane in the sublingual region of the bottom of the oral cavity. I got drunk three months ago when I accidentally discovered an ulceration in the tongue, which increased in size. It was treated as an outpatient. Objectively, the configuration of the face and neck has not been changed. An ulcer with uneven edges of the mucous membrane 1 x 1.5 cm in the region of the root is defined. Palpation of this area is painful. Based on the studies, a diagnosis was made of cancer of the mucous membrane of the bottom of the oral cavity. The patient underwent an operation - radical removal of a tumor of the bottom of the oral cavity with excision of the surrounding soft tissues and lymph nodes (operation Crail) with plastic closure of the resulting skin-fascia lobe of the neck muscle periosteal transplant on a fixed neurovascular pedicle based on the latissimus dorsi muscle From the midline incision in the neck from the chin to the sternum, bilateral ligation of the external somnole was performed arteries, excision of the tumor, mucous membrane, soft tissues of the bottom of the oral cavity, as well as groups of lymph nodes. The size of the defect formed was 9 x 5 cm. An incision in the skin of the subcutaneous tissue and fascia from the small tubercle of the humerus to the iliac crest along the lateral (free) edge of the left latissimus dorsi muscle revealed the latter. Above the distal end of the latissimus dorsi, two ellipsoid sections of the subcutaneous tissue and fascia were made. A graft skin cover of 9 x 5 cm was formed. Approaching the iliac wing crest, the periosteum was peeled off with a bur and a raspator above the distal end of the latissimus dorsi with an extension of 8x1 cm. 9 cm from the lateral margin along the muscle fibers, a longitudinal incision was made of the latissimus back muscles from the distal end to the proximal. The resulting skin-fascial-muscular-periosteal graft based on the latissimus dorsi muscle bluntly exfoliated from the underlying tissues to the upper third, since here

side of the lateral margin includes the main neurovascular bundle. The edge of the dissected fascia of the muscle part of the flap was stitched in separate sutures. Approaching the small tubercle of the humerus, the proximal end of the latissimus dorsi muscle flap was cut off from the attachment site. A skin-fascial-muscular-periosteal transplant based on the latissimus dorsi was deployed in the region of the neurovascular leg and sutured to the remaining part of the latissimus dorsi. Then, from the cut on the neck towards the upper corner of the wound, “and on the back a tunnel was made with a forceps to freely pass the formed graft. Through this tunnel, a skin-fascia-musculo-periosteal transplant based on the latissimus dorsi muscle was brought to a defect in the oral cavity so that its skin part turned into the oral cavity. Layer-by-layer fixation was carried out: the periosteal part of the graft - to the periosteum of the lower jaw; muscle parts - to the muscles of the neck;

Claims (1)

The claims METHOD FOR PLASTIC DEFECT OF THE BOTTOM OF THE ORAL CAVITY by cutting out the graft and its subsequent displacement into the area of the defect, characterized in that, in order to prevent relapse, the defect was plasticized by the skin integument to the oral mucosa. The wounds on the neck and back were sutured in layers. The postoperative period was uneventful. On the second day, the rubber was removed graduates on the neck and on the fourth day on the back. The wounds healed by primary intention. No temperature reaction noted. After 18 days, the patient was discharged from the hospital. After six months and 1 year was spent control study. The skin above the muscle part of the graft on the neck side was mobile. The skin part of the graft from the side of the oral cavity is normal, pale pink in color. The graft engraftment in the marginal zone is durable. There are no signs of inflammation. A reographic study showed that the vascular tone from the latissimus dorsi muscle is good. A skin-fascial-muscular-periosteal transplant based on the latissimus dorsi muscle has retained its viability. (56) Dentists, 1965, No. 5. p. 47 50, the skin-fascial-periosteal flap based on the latissimus muscle back, including the distal end with a skin located above it and a portion of the periosteum of the crest under the ileum, while maintaining the neurovascular bundle and then carry out layered fixation.