RU2380053C2 - Meloplasty technique with using pectoral flap with double dermal bed - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns maxillofacial surgery and can be applied for meloplasty in through defects. A pectoral musculocutaneous flap with the axial blood flow with double dermal bed. A flap pedicle is delivered under the collar bone further in the subcutaneous tunnel on the neck and cheek area towards the defect zone. The defect is built.

EFFECT: method allows ensuring blood supply of the flap with improved cosmetic effect.

1 ex, 8 dwg

Description

The invention relates to medicine, mainly to reconstructive surgery for tumors of the head and neck.

There is a known technique for operations with a through defect of the cheek using the Filatov stem. (Gunshot wounds to the face, ENT organs and neck, under the editorship of MB Shvyrkov. Moscow, “Medicine”, 2001, analogue). In patients with penetrating wounds of the buccal region, a plastic technique was developed by Filatovsky stem. To form the latter, tissues of the inner surface of the shoulder are used, since it is closest to the face and the skin of this area is pale in color, thin, elastic and similar in texture to the skin of the face. Under local anesthesia, a skin tape with one feeding leg with a small layer of fatty tissue on the inner surface of the shoulder is cut out, twisted into a tube and sutured. The free end is spread on a granular surface and sewn. Using plaster bandages, the hand is fixed to the head in such a position that the stem is not twisted or stretched. After 2-3 weeks, the stem is cut off from the spread area, the latter is modeled and sutured. Thus, the operation is performed in two stages: the first is the formation of the Filatov stem, the second stage is the cutting off of the flap leg and the final closure of the defect with modeling of the cheek.

The closest in technical essence is the method of plasty with a complex flap with the inclusion of the pectoralis major muscle. (Restorative surgery of the soft tissues of the maxillofacial region, under the editorship of A.I. Nerobeev, N.A. Plotnikov. Moscow, "Medicine", 1997, prototype) First, after appropriate measurements, they draw the direction of the vascular bundle on the chest , which goes in a straight line from the humeral chest groove to the xiphoid process. The length of the flap is cut according to the distance from the humeral groove to the distal edge of the defect. At its lower end, the contours of the future skin site are drawn with an oblique line. Then, according to the intended pattern, the skin-fat layer is sequentially dissected along the front surface of the muscle. Tissue is widely dissected in the subclavian region, away from the line of projection of the great vessels, exposing the muscle. The edges of the wound along the skin-fat pad are separated to the sides, maintaining the unity of the muscle-fat layer of the future flap. During dissection of the tissue along the inner portion of the flap along the sternum, perforating vessels intersect in each intercostal space. To prevent displacement of subcutaneous adipose tissue, it is sutured to the muscle part of the flap and, stepping aside 1 cm, dissect the muscle.

Raising the lower edge of the muscle and freeing its inner surface from the pectoralis minor muscle, note the direction and nature of the main vascular bundle, in accordance with which the dissection of muscle tissue along the vessels to the clavicle is continued. Then the musculocutaneous flap is thrown over the clavicle and, depending on the nature of the operation, it is brought in the subcutaneous tunnel to the defect in the cheek area with the skin area inward, thereby performing plastic surgery on the cheek mucosa (inner lining). With this method of plastics, there is a need to form the skin of the cheek (outer lining) by using plastics with a free split skin graft, usually from the front surface of the thigh. In this case, the material is taken to close the wound surface of the flap using a dermatome, as a rule, delayed for 2-3 days. Then the split skin graft is sutured to the area of the skin defect. Holding the feeding leg of the flap over the collarbone subsequently limits the free movement of the neck by pulling the corresponding half of the neck due to shortening of the leg by 3-5 cm and an aesthetic defect.

In this case, the feeding leg sharply protrudes on the lateral surface of the neck, causing pronounced deformation of the contours of the neck, sharply reducing cosmetic results. In addition, the re-extension of the flap leg on the clavicle reduces blood supply and increases the incidence of regional flap necrosis. In addition, the split skin graft subsequently sharply differs in color from the skin adjacent to the defect tissue and, as a rule, sinks in relation to them.

The objective of the invention is to improve the functional and aesthetic results of reconstructive surgery using a pectoral flap with a double skin site, reducing the time of the operation, its invasiveness and postoperative rehabilitation of patients.

This technical result is achieved as follows. Under endotracheal anesthesia with artificial ventilation of the lungs in the position of the patient lying on his back, marking the incision (figure 1). It passes along the projection of the vascular bundle, which goes in a straight line from the humeral groove to the apex of the xiphoid process, while the length of the flap should be maximum and the distal part of the skin area reaches the epigastric region. The contours of the future skin site are planned on the flap axis, taking into account the double distance between the most distant points of the defect, after which it is divided into two symmetrical parts. Distal will be used to create the inner lining, proximal - for the outer.

The skin, subcutaneous fat is sequentially dissected. The edges of the wound are divided to the sides, while avoiding the excessive displacement of the skin-fat layer from the muscle layer to maintain axial circulation. Then, a dissection of the pectoralis major muscle is performed, which is 1-2 cm larger than the skin-fat areas. Separate the flap from the pectoralis minor muscle. At the same time, the direction of the main neurovascular bundle is determined. After the flap is isolated, the skin-fatty part of the flap is sutured to the muscle flap to prevent displacement and trauma of the axial vessels. The base of the flap is made as narrow as possible, including only the artery, vein and muscle fragment 1-2 cm in thickness (figure 2).

Stupidly and acutely separate the skin and subcutaneous tissue, go to the lower edge of the clavicle in its middle third. Then carry out the separation of soft tissues from the lower and rear parts of the clavicle in such a way that they form a tunnel under the clavicle (figure 3). On the neck, at the lower edge of the defect, the skin and subcutaneous fat are separated off towards the clavicle. Thus, a subcutaneous tunnel is formed, which connects to that formed under the collarbone, being a conductor for the feeding leg of the flap created on the front chest to the buccal region.

After the tunnel is completed, the flap legs are rotated, while the rotation angle can approach 180 °, which in no way affects the trophism of the flap tissues. The latter is carried through the tunnel into the prepared defect box. Under the preparation refers to a wide excision of the tumor, in addition, the removal of non-viable, necrotic, macerated tissues to visually healthy, with severe bleeding in the section (figure 4).

Hemming the flap to the donor bed is performed in layers (Fig. 5), while over-tightening the ligatures should be avoided, since this causes trophic disturbance in the area of the junction of the flap with the bed. First, the distal skin part of the flap (skin inside) is sutured with the mucous membrane of the edges of the defect - an internal lining is created. The peculiarity is that the distal part of the skin site of the flap is first sutured with the skin inward to the nearest defect point (with respect to the feeding leg of the flap), and then sutured around the circumference. Further, for simultaneous plasty of the cheek and the creation of its outer lining, the flap is folded in half in such a way that it becomes possible to stitch the skin site with the edges of the defect skin round. The peculiarity is that the proximal part of the skin site of the flap is first sutured by the skin outward to the farthest point of the defect (relative to the feeding leg of the flap), and then sutured around the circumference. The operation ends with active drainage (Fig.6).

List of explanatory materials

Figure 1 illustrates the layout of sections before surgery.

Figure 2 displays the stage of execution of the fence flap.

Figure 3 represents the stage of the flap under the collarbone.

Figure 4 illustrates the view of the recipient bed after removal of the tumor.

Figure 5 indicates the step of suturing the flap into the recipient bed.

6 is a view of the patient after surgery.

An example implementation of the claimed method

We give the following observation as an example. Patient V., 56 years old, was admitted to the department on October 15, 2004 with complaints of a decaying tumor of the left cheek. From the anamnesis: at the beginning of 2004, the patient noted the appearance of a tumor, did not seek help, for the last 3 months there has been increased tumor growth with soft tissue decay and the formation of a through hole with salivation, which led to a malnutrition of the patient and forced him to turn to the Surgery Center for help Head-neck. " Upon receipt, the general condition is satisfactory, the skin is of a normal color. During external examination - a tumor on the left cheek with a size of 12 × 13 cm with a through defect (Fig.7). An ultrasound of the abdominal cavity and neck without features, an x-ray of the chest organs without pathology, with endoscopic examination of the ear, throat and nose, there is no data for the tumor. Given the clinical picture and the data of additional research methods, the patient is shown surgical treatment. November 3, 2004 the patient underwent a combined operation: resection of the left cheek and Crail’s operation on the left. The defect of the skin and soft tissues on the cheek on the left is replaced by a musculocutaneous flap from the anterior chest wall according to the specified method. A large fragment of m.pectoralis major was taken with a skin area of 20 × 15 cm on the feeding leg with the inclusion of the branches of the thoracoacromial artery, rotated 180 degrees, carried out in a subcutaneous tunnel under the collarbone and laid on the neck wound according to the method described above. The postoperative period was uneventful. Primary healing. Sutures were removed on the 12th day (Fig. 8). Postoperative histology No. 25163-25181 from 8.11.04, in the preparation: skin, fiber, skeletal muscle with a tumor - squamous cell carcinoma without keratinization. In the lymph nodes reactive hyperplasia. Clinical diagnosis: Cancer of the left cheek T4N0M0, stage IV. At the follow-up examination after a year, the patient's condition is satisfactory, there is no data for tumor recurrence, the skin sites of the flap on the surface and the inner surface of the cheek are completely viable.

Claims (1)

The method of plasty of the cheek with its through defects, which consists in using a pectoral flap with axial blood supply and creating the inner lining of the defect with the skin of its distal part, characterized in that, for the purpose of simultaneous reconstruction of the buccal region, the specified muscle-skin flap with a double skin platform, proximal part of which is used for the external lining, and the feeding leg of the flap is then carried out under the collarbone and then in the subcutaneous tunnel on the neck and cheek area into the defect zone.

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