RU2341215C1 - Way of reconstruction of upper jaw - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: make preliminary autografting of an ileal osteal-muscular-osteal autograft on a forearm. Place in defect of the upper jaw the dermal-muscular-osteal autograft representing a fragment of an ileal bone, covered with dermal-fascial portion of a radial flap with formation of a uniform vascular bed between a radial artery and a vein and a deep artery bending around an ileal bone and a vein as a part of the flap.

EFFECT: allows framing conditions for dental implantation, to confirm absence of a tumour morphologically before performance of the second stage.

1 ex, 5 dwg

Description

The invention relates to medicine, namely to reconstructive plastic surgery of the maxillofacial region, and can be used when performing cancer operations, as well as in the case of traumatic lesions.

There is a method of eliminating defects of the upper jaw and oral cavity arising from the resection of the upper jaw, hard palate, and the alveolar process of the upper jaw (Possibilities of using revascularized autografts for the plastic removal of combined facial defects. Verbo E.V. Abstract for the degree of Doctor of Medical Sciences. Moscow , 2005). The known method is a microsurgical autotransplantation of a complex skin-muscle-bone autograft on a single vascular pedicle with the inclusion of the latissimus dorsi and reconstruction of the alveolar process of the upper jaw with a rib fragment of the autograft with restoration of the integrity of the hard palate of the musculoskeletal portion of the flap.

The disadvantages of this method include:

- the inability to restore bones - palatine processes of the upper jaw;

- a significant excess of soft tissue flap covering the bone fragment, which creates unfavorable conditions and technical difficulties for the introduction of dental implants into the bone and performing dental prosthetics;

- insufficient strength and thickness of the bone fragment of the skin-muscle-rib flap.

The closest method of the same purpose is the method of restoration of the upper jaw, hard palate and alveolar process by autotransplantation of a musculoskeletal flap with the inclusion of the iliac crest, using which the hard palate and alveolar process of the upper jaw are restored with a bone fragment, and the skin area of the flap is removed mucosal defect of the hard palate and restore the integrity of the mouth Russia, Chissov V.I., Panchenko V.V., Reshetov I.V., Filyushin M.M. Russian Journal of Oncology. 2007, No. 3, pp. 9-13, M .: Medicine). Adopted for the prototype.

The vascular leg feeding the flap, formed in accordance with the known method, are the deep envelopes of the ilium of the artery and vein. The insufficient length of this vascular pedicle is the cause of many difficulties in performing the reconstruction of the upper jaw. Namely:

- the frequent need for the use of autovenous inserts for revascularization in the formation of the iliac musculoskeletal autograft;

- the impossibility of simultaneous fixation of the bone fragment of the flap in the necessary orthodontic position to perform dental implantation;

- the need for repeated corrective surgery to place the bone fragment of the flap in the necessary orthotopically correct position for osseointegration of dental implants and subsequent dental prosthetics.

In addition, the disadvantages of the known method that impede the achievement of the following therapeutic results are:

- a significant excess of soft tissues of the flap - muscles and subcutaneous fat covering the bone fragment, which creates unfavorable conditions and technical difficulties for the introduction of dental implants into the bone and performing dental prosthetics;

- the absence of a thin epithelial surface that mimics the oral mucosa.

The invention is aimed at solving the problem of orthotopic reconstruction of the upper jaw, hard palate and alveolar process of the upper jaw after radical removal of the tumor, as well as in the case of traumatic lesions, including the creation of optimal conditions for the osseointegration of dental implants and dental prosthetics.

Using in clinical practice the proposed method allows to achieve several technical (therapeutic) results:

- the possibility of simultaneous restoration of the hard palate and alveolar processes of the upper jaw with a bone fragment of the iliac crest of a prefabricated flap, as well as fixing the bone fragment of the flap in the necessary orthodontic position to perform dental implantation by lengthening the feeding leg of the flap - the distal portion of the radial artery and vein;

- the absence of the need for repeated corrective surgery to place the bone fragment of the flap in the necessary orthotopically correct position for osseointegration of dental implants and subsequent dental prosthetics;

- lack of need for the use of autovenous inserts for revascularization of the autograft;

- elimination of technical difficulties and improving the conditions for the introduction of dental implants into the bone and performing dental prosthetics by reducing the thickness of the soft tissues covering the bone fragment of the flap;

- the possibility of replacing a mucosal defect and restoring the integrity of the oral cavity with a thin skin-fascial portion of a radial flap covering a fragment of the ileum facing the oral cavity;

- the ability to fully visually and morphologically confirm the absence of tumor recurrence before performing the plastic stage due to the fact that microsurgical reconstruction of the upper jaw is performed in a delayed manner;

- functional and social rehabilitation of patients with locally advanced malignant tumors of the upper jaw.

These technical and therapeutic results in the implementation of the invention are achieved due to the fact that, as in the known method, the restoration of the upper jaw, hard palate and alveolar process is carried out by autotransplantation of a musculoskeletal skin flap, and the restoration of the hard palate and alveolar process of the upper jaw carry out a bone fragment of the iliac crest, and the elimination of the mucous membrane defect of the hard palate and the restoration of the integrity of the oral cavity - the skin area of the flap.

A feature of the proposed method is that for the reconstruction of the upper jaw autotransplantation of a prefabricated skin-muscle-bone autograft obtained by preliminary autograft of the iliac musculoskeletal autograft on the forearm and representing a fragment of the ilium covered with skin-fascial fascial is carried out with the formation of a single vascular bed between the radial artery and vein and the deep envelope of the iliac artery th and vein in the flap.

The invention consists in the following.

The inventors have developed a two-stage method for microsurgical reconstruction of the upper jaw after surgical removal of malignant tumors, as well as in the case of traumatic lesions. The first stage of the operation consists in transferring the formed ileo-musculoskeletal flap to the forearm and forming a single vascular bed between the radial artery and vein and the deep envelope of the iliac artery and vein in the flap. Thereby, an increase in the length of the vascular pedicle of the flap is achieved, which becomes equal to the sum of the length of the radial artery and the artery enveloping the ilium. The increase in the length of the vascular pedicle of the flap avoids the need to use autovenous inserts for revascularization of the autograft, as well as the need for repeated corrective surgery to place the bone fragment of the flap in the necessary orthotopically correct position for osseointegration of dental implants and subsequent dental prosthetics. The second stage of the operation consists in the fact that after engraftment of the ileal flap on the forearm, a prefabricated autograft is mobilized, which includes the autotransplanted previously iliac musculoskeletal flap and a delayed microsurgical reconstruction of the upper jaw is performed. A prefabricated autograft is a fragment of the ilium, covered with a thin skin-fascial portion of the radial flap, which faces the oral cavity and serves to replace the mucosal defect and restore the integrity of the oral cavity. Moreover, the thickness of the skin-fascial portion of the radial flap is adequate for the osseointegration of dental implants.

The fact that microsurgical reconstruction of the upper jaw is performed in a delayed order provides an additional opportunity to fully confirm visually and morphologically the absence of tumor recurrence before performing the plastic stage.

The method is as follows.

In the patient's position on the back with the left upper limb allotted according to the standard method, a block resection of the upper jaw is performed with the removal of the alveolar process and the hard palate. A diagram of a postoperative defect after removal of a tumor with resection of the hard palate and alveolar ridge is shown in FIG. At the same time as the resection stage, the second team of surgeons takes an ileal musculoskeletal autograft with the inclusion of a fragment of the iliac wing crest, corresponding in size to the defect in the hard palate and alveolar process of the upper jaw, and a skin portion of the flap. The length of the feeding leg of the autograft - the deep envelopes of the ilium of the artery and vein is 5-6 cm.

On the left forearm in the lower third along the front surface, a semi-oval skin incision is made, the base facing the ulnar fossa. The radial artery and vein are identified and crossed with ligation of the distal segments of blood vessels and the application of a clip on the proximal segments. The formation of the distal half of the skin-fascial radial graft of the forearm in the skin-fascial block, including the distal sections of the radial artery and vein. Next, the iliac musculoskeletal flap is transferred to the left forearm, the donor wound is sutured in layers with active drainage.

Figure 2 presents a diagram of the first stage of prefabrication - autotransplantation of a revascularized musculoskeletal flap with the inclusion of a fragment of the iliac crest on the forearm:

1 - mobilized by half the required size of the distal portion of the radiation skin and fascial flap,

2 - a bone fragment of the formed musculoskeletal iliac autograft,

3 - deep envelope of the ilium artery and iliac vein musculoskeletal flap,

4 - a distal portion of the radial artery and veins of the skin-fascial flap of the forearm,

5 - microvascular anastomoses between the supply vessels of autografts.

The next stage is the formation of microvascular anastomoses under the optical magnification between the radial artery and the deep ileal envelope of the iliac artery and the radial vein and the deep ileal envelope of the flap vein according to the “end-to-end” type. After the start of blood flow and restoration of blood supply to the iliac autograft, its bone fragment (from the crest of the iliac wing) is placed under the fascial-fascial flap of the forearm, mobilized by 1/2 of the required size, the area of microsurgical anastomoses is covered with soft tissues of the iliac flap. Schemes for the final stage of prefabrication and prefabricated autograft are presented in Figs. 3 and 4, where 1 is the distal portion of the radial skin-fascial flap, 2 is a fragment of the iliac crest, 6 is a single vascular bed of the feeding leg of the prefabricated autograft.

1.5-2 months after the engraftment of the ileal flap on the forearm and confirmation of the absence of tumor recurrence, a delayed microsurgical reconstruction of the upper jaw is performed (Figure 5). According to the accepted method, the proximal vascular leg of the radial skin-fascial flap is isolated and its proximal skin-fascial portion is formed. The entire prefabricated autograft is mobilized.

A donor wound on the forearm is sutured. Then, in the submandibular region, the facial artery and vein are isolated and a subcutaneous tunnel into the oral cavity is formed. A transoral flap is placed in the oral cavity, its bone fragment (2) is fixed in the position orthotically necessary for dental implantation. This possibility is provided by the necessary length of the vascular pedicle (6) of the prefabricated flap in the position of the hard palate and alveolar process of the upper jaw. A thin skin-fascial portion of the radial flap (1), covering the ilium fragment (2), is facing the oral cavity, it replaces the mucous membrane defect and restores the integrity of the oral cavity. Perform osteosynthesis according to the accepted method. The vascular leg of the flap is carried out from the oral cavity in the subcutaneous tunnel into the submandibular region, where microvascular anastomoses with facial vessels are formed under optical magnification (7). The viability of the flap is restored. After engraftment of the autograft, osseointegration of dental implants and dental prosthetics are performed.

Clinical example.

Patient P. 32 years old, with a diagnosis of Chondrosarcoma of the upper jaw on the right. Condition after repeated surgical treatment in 2005-2006 Continued tumor growth. Condition after surgical treatment in 2007 Tracheostomy. Condition after delayed microsurgical reconstruction of the upper jaw in 04.2007 Tracheostomy.

Morphology: 1. No. 0557166-76 / OP (dated 02.2007) - moderately differentiated G2 chondrosarcoma, growing into the dermal layer of the skin. 2. No. 072310-17 / OP (dated 04.2007) - no tumor elements were found in soft tissue fragments from the edges of the upper jaw resection. Lymph node with a site of adjacent bone tissue.

From the anamnesis: sick since 2003, when a tumor of the upper jaw appeared on the right. In 2005, the tumor was removed by the dentist at the place of residence. Morphologically, no diagnosis was made. Rapid tumor growth was noted. The patient himself several times removed the exophytic component of the tumor. In 06.2006 he was examined in the OD of Lipetsk. A morphological diagnosis was also not made. For examination and treatment sent to MNIII them. P.A. Herzen. 02.21.2007, the operation was performed: Block resection of the upper jaw, and the microsurgical prefabrication of the flap on the left forearm was performed using the ileal musculoskeletal autograft using the described technique. For the second stage of surgical treatment - microsurgical reconstruction of the upper jaw - re-hospitalized after 2 months in the Moscow Research Institute of Medicine. P.A. Herzen.

04/17/2007, the operation was performed: Delayed microsurgical reconstruction of the upper jaw with a prefabricated skin-muscle-bone autograft from the left forearm.

On the left forearm, a single complex composite autograft has been formed, including a previously transplanted iliac skin-muscle-bone flap and a radial skin-fascial flap. Nutrition of the flap on a single vascular pedicle - the radial artery and vein. The flap is cut off and moved to the face. The vascular leg of the flap is held in the subcutaneous tunnel to the recipient vessels. Microvascular anastomoses between the facial and radial arteries of the end-to-end type and the facial and radial veins of the end-end type were formed under optical magnification using microsurgical techniques. Flap viability restored. The bone fragment of the flap is located in the position of the resected upper jaw on the right, the hard palate and the alveolar process of the upper jaw. The mucous membrane of the hard palate was restored with a skin portion of the radiation fragment of the flap. The postoperative period is smooth. The flap has taken root. The wounds healed by primary intention. In satisfactory condition, the patient was discharged from the hospital to perform dental implantation in a specialized hospital.

The inventive method has significant advantages and meets the criteria of patentability.

Claims (1)

The method of reconstruction of the upper jaw by autotransplantation of a musculoskeletal skin flap, including the restoration of the hard palate and alveolar process of the upper jaw by a bone fragment of the iliac crest, the elimination of a mucosal defect in the hard palate and the restoration of the integrity of the oral cavity by the skin site of the flap, characterized in that the reconstruction of the upper jaw carried out by autotransplantation of a prefabricated skin-muscle-bone autograft obtained by preliminary autotransplant ileo-musculoskeletal autograft transplantation on the forearm and is a fragment of the ilium, covered with a skin-fascial portion of the radial flap with the formation of a single vascular bed between the radial artery and vein and the deep iliac artery and vein enveloping the flap.

Images