RU2301038C2 - Method for preparing cutano-osteo-muscular graft for substituting mandible defect - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves making incision in skin, fascia, musculus latissimus dorsi, in rib projection zone selected as transplant. Subperiosteal rib resection is carried out with fragment of required length being produced. Rib fragment is placed into pocket on intercostals vascular fascicle. The pocket is formed between the musculus latissimus dorsi and skin. The rib fragment is modeled corresponding to mandible segment shape under substitution, before being placed into the pocket.

EFFECT: enhanced effectiveness in forming inferior oral cavity atrium fornix; provided increase in additional blood supply.

2 cl, 5 dwg

Description

The invention relates to medicine, namely to maxillofacial surgery, and can be used in the preparation of a musculocutaneous flap to replace a defect in the lower jaw, including the elimination of extended defects associated with a deficiency of soft tissues of the bottom of the mouth, lower face and neck.

A known method of lower jaw plastic surgery for malignant neoplasms (RU 2030169, bull. No. 7, 03/10/95), including a rectangular incision of the skin, fascia, latissimus dorsi in the area of the projection of the ribs selected as a transplant, subperiosteal resection of the ribs with the formation of a fragment of the required length formation of a vascular pedicle. Tuck the lower soft tissue part of the flap under the rib fragment, wrap it, forming a bone-fat-muscle flap in the form of a sleeve, and hold until maturing - the formation of new vascular connections between the rib fragment and the soft tissues surrounding it for a certain time. The resulting flap has the following layers: skin, fatty tissue, muscle, bone, muscle, fatty tissue, skin. After biological preparation performed in this way, the flap is moved to the region of the lower jaw flaw on an elongated vascular pedicle. Using the ribs eliminate the defect of the lower jaw. The method adopted for the prototype.

However, the bone graft with this method of preparation is located in the defect area low - in the position of the lower edge of the body of the lower jaw, due to a sufficiently thick layer of soft tissues surrounding the bone on all sides (muscle, subcutaneous fat, skin). At the same time, the vestibule arch is not restored. All this complicates prosthetics or makes it impossible at all. Before prosthetics, additional corrective operations are necessary (vestibuloplasty, moving the rib to the position of the alveolar process of the lower jaw).

The technical result achieved by the invention is to reduce the thickness of the soft tissue layer above the rib fragment, which allows you to set the rib in the position of the alveolar process of the lower jaw, to form the lower arch of the vestibule of the oral cavity, thereby creating optimal conditions for rational dental prosthetics.

The essence of the invention is to achieve the technical result in a method of preparing a musculocutaneous flap for replacing a defect in the lower jaw, including an incision in the skin, fascia, latissimus dorsi in the projection area of the rib selected as a graft, subperiosteal resection of the rib with the formation of a fragment of the required length , the formation of a vascular feeding leg, the placement of the rib fragment in the tissue for the formation of new vascular connections between the fragment of the rib and the surrounding tissues, with this rib fragment is placed in a pocket formed between the latissimus dorsi and skin.

Before placing the rib fragment in the pocket, it is advisable to simulate it in the form of a replaceable segment of the lower jaw.

Placing a rib fragment above the muscle part of the flap significantly reduces the thickness of the soft tissue layer above it, which further simplifies the entire procedure for the distribution and fixation of flap tissue in the recipient zone. The costal graft of such a flap can be easily located in the position of the alveolar process of the lower jaw, above it there is a thin layer of skin that allows you to form the lower arch of the vestibule of the oral cavity. Due to this, optimal conditions are created for rational dental prosthetics (including dental implants), which, in turn, ensures the restoration of the chewing function in full. The muscle part of the flap is located under the rib and, after being transferred to the recipient area, serves to replace the soft tissue flaw in the bottom of the mouth, chin and submental areas, thereby preventing the formation of closed cavities.

When the flap is transferred to the recipient zone, there is no risk of damage to the parietal pleura (and therefore pneumothorax), since the rib occupies a position above the latissimus dorsi, which greatly facilitates and accelerates the intervention, and reduces the risk of pulmonary complications.

Due to fusion with the soft tissues surrounding it, the rib receives additional blood supply and becomes practically inaccessible to microbial contamination, and hence suppuration around.

It should be noted that the fence of such a flap does not aggravate the course of the postoperative period and does not impair the aesthetic and functional characteristics of the donor area.

In figures 1-5 shows a diagram of a method.

The method is carried out, for example, as follows.

An incision is made 1 of the skin, fascia, latissimus dorsi (HMS) at the level of the projection of the rib lying below the planned one to be taken as a graft and extended upward along the front edge of the HMS (Fig. 1). After dissection of the dentate muscles, they reach the lower edge of the formed rib 2. Distal subperiosteal resection of the rib section of small length sufficient to visualize the vascular bundle and proximal section of the sufficient length necessary to give mobility to the vascular pedicle 3 and its location without tension and bending at the stage moving the rib fragment in the tissue for maturation. After dissection of the intercostal muscles, the rib is separated from the parietal pleura. Distally cross the vascular bundle 4 and raise the costal fragment 5 on the vessels supplying it 3. Simulate the costal fragment 5 in the form of a lost portion of the lower jaw. Between the SHMS 6 and the skin 7, a pocket 9 is formed in the subcutaneous fat 8, into which the rib fragment 5 is placed until it ripens (Fig. 2). The wound is sutured (Fig.3). After maturation of the flap and completion of the consolidation of fragments of the simulated rib (on average 100 days after the intervention), the second stage of the operation is performed. Cut the skin part of the flap above the rib according to a pre-made template in accordance with the size and location (relative to the rib) of the skin and (or) the mucous membrane of the oral cavity and form a skin-musculoskeletal flap on the vascular pedicle, move it to the region of the lower jaw flaw and soft tissue through a tunnel formed under the head of the pectoralis major muscle. The continuity of the lower jaw is restored by a fragment of the modeled rib, fixing it in the position of the alveolar process of the lower jaw, and the defect of the periandibular soft tissues and the mucous membrane of the bottom of the mouth - using SHMS and skin flap. To increase the vitality of the skin part of the flap, the latter is cut out in excess and epidermalized around the entire perimeter to a width of 2.0 cm.

Wounds in the donor and recipient areas are sutured in layers, leaving tubular drains for vacuum.

The method is illustrated by the following example.

Patient S., 46 years old, was admitted to the hospital with a diagnosis of Deformation of the lower zone of the face. Defect of the lower jaw from 46 to 36 teeth. Soft tissue defect in the bottom of the oral cavity, submental and submental areas. Condition after combined treatment of lower jaw sarcoma.

On the posterior-lateral surface of the left half of the chest in the projection of the lower edge of the XI rib according to the markings applied to the skin, an incision was made to the fascia fascia with a length of 25.0 cm, which corresponded to the lower edge of the planned islet of skin. Further, retreating 2.0 cm down from the edge of the intended islet of skin, we crossed the SHMS. The skin incision was extended upward parallel to the front edge of the ShMS, and posteriorly along the line paravertebralis sin. The formed muscle-skin flap was separated from the chest and lifted up. After this, a subperiosteal resection of the X rib at its distal end was performed, the band was crossed and the intercostal vascular bundle was crossed. A subperiostal resection of the X rib section was proximal enough to form a mobile vascular pedicle of the flap to prevent stretching or pinching of the latter at the stage of the location of the rib segment in the pocket. After intersection of the intercostal muscles, the resected rib fragment was separated from the parietal pleura and raised upward on the intercostal vascular bundle, while maintaining the integrity of the parietal pleura. Above and below the ribs brought together and fixed in this position with the help of pulley seams.

Next, the costal flap located on the intercostal vascular bundle was modeled according to the shape of the lost segment of the chin. A pocket was formed in the subcutaneous fat between the SHMS and the skin, corresponding to the parameters of the formed rib fragment, in which the latter was placed so as not to overstretch or squeeze the vessels supplying it (a. Et v. Thoracodorsalis). The wound was sutured in layers leaving tubular drainage in a vacuum.

After 4 months, when the formation of new vascular connections between the fragment of the rib and the surrounding tissues, the second stage of the operation was performed.

In the donor area, a skin site was formed, necessary to replace the flaw in the tissues of the bottom of the mouth, the chin and submental areas (Fig. 4). This skin area was divided into two fragments 10 and 11 by epidermisation of its middle part 12. The musculoskeletal flap on the vascular pedicle was moved to the area of the lower jaw flaw (Fig. 5) and the rib fragment 5 restored its continuity, the skin area 11 eliminated the deficiency mucous membrane of the bottom of the oral cavity, skin area 10 was replaced by a flaw in the skin of the submental and submental areas, a defect of the bottom of the mouth and the anterior surface of the neck was replaced by a fragment 6 of the latissimus dorsi muscle, which was part of the flap. A de-epidermal skin area 12 was used to repair the lower lip.

Wounds in the donor and recipient areas were sutured in layers, leaving tubular drainage in a vacuum.

Postoperative course without complications. The wounds healed by primary intention. Sutures were removed on the 14th day.

After 6 months, the patient underwent dental prosthetics.

Thus, a through long-term defect of the chin of the lower jaw was compensated, and an extensive defect in the periandibular soft tissues and the mucous membrane of the bottom of the mouth was removed. At the same time, due to its preliminary preparation, a fragment of the rib of a complex transplant could be positioned in the position of the alveolar process of the lower jaw, and due to modeling, it was possible to reconstruct the lost segment of the jaw as accurately as possible. In addition, a layer of soft tissues with a minimum thickness remained above the rib, which subsequently ensured a dental prosthetics.

The use of the invention allows to simultaneously eliminate end-to-end extended defects of the lower jaw, combined with extensive flaws of the maxillary soft tissues. In this case, the bone fragment of the complex transplant is located in the position of the alveolar process of the lower jaw under a fairly thin layer of soft tissue, while the lower arch of the vestibule is formed. All this creates optimal conditions for rational dental prosthetics (including implants).

Claims (2)

1. A method of preparing a skin-musculoskeletal flap to replace the defect of the lower jaw, including a cut of the skin, fascia, latissimus dorsi in the area of the projection of the rib selected as a transplant, subperiosteal resection of the rib with the formation of a fragment of the required length, the formation of a vascular feeding leg, room rib fragment in the tissue, characterized in that the rib fragment on the intercostal vascular bundle is placed in a pocket formed between the latissimus dorsi and skin. 2. The method according to claim 1, characterized in that before placing the rib fragment in the pocket, it is modeled in the form of a replaceable segment of the lower jaw.

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