RU2436531C2 - Method of one-stage elimination of through defect of nose, suborbital area and lower eyelid in case of anophthalmos - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: claimed invention relates to field of medicine, namely to maxillofacial surgery and can be used for elimination of through defects of middle zone of face, which resulted from block tumour resection, severe mechanical traumas and gunshot wounds. Essence of method lies in closing defect with skin flap in form of duplicature, deepidermised on bend line. As flap used is modeled revasculariesed skin-fascial radial flap. Flap is made in form of defect, 8-10 cm wide, 10-12 cm long. Flap is laid with skin inside, parallel to direction of vascular fascicle, repeating contours of nose, suborbital area and lower eyelid. Remaining part of flap is used to form external lining.

EFFECT: application of claimed invention makes it possible to increase esthetic and functional results of operation.

1 ex, 6 dwg

Description

This invention relates to medicine, namely to maxillofacial surgery, and can be used to eliminate end-to-end defects in the middle zone of the face resulting from block resection of tumors, severe mechanical injuries and gunshot wounds.

There is a method for the simultaneous elimination of extensive through defects in the middle zone of the face in the infraorbital region, lower eyelid and nose region with a flap with the inclusion of the pectoralis major muscle on the feeding leg, in which a long narrow muscle flap is cut with a skin-fascial site without cutting off the vascular pedicle, with its rotation in side of the defect. The laying of a musculocutaneous flap is carried out in the form of a duplicate with epidermization in the area of the inflection [A.I. Nerobeev. Restoration of tissue of the head and neck. - M.: Medicine. - 1988. - c.l03-131].

The disadvantage of this method is the high morbidity, a cosmetically pronounced defect in the donor region and a wide detachment of tissues along the formation of a subcutaneous tunnel on the neck.

Closest to the proposed method is a method for the instant elimination of through defects in the nose, infraorbital region and lower eyelid using a free skin-muscle thoracodorsal flap. The skin area of the musculoskeletal thoracodorsal flap is cut out in sufficiently large sizes, in accordance with the size of the extensive through defect, including defects in the infraorbital region, the nose and lower eyelid. The flap is taken on the vascular pedicle for subsequent revascularization through the vessels of the neck. The musculoskeletal thoracodorsal flap is placed in the form of a duplicate with epidermalization along the inflection line, which allows simultaneous replacement of defects in the inner and outer lining of several anatomical areas of the face [A. Nerobeev. Restoration of tissue of the head and neck. - M.: Medicine. - 1988. - C.131-141].

The disadvantage of this method is the large thickness of the musculoskeletal thoracodorsal flap, poor mobility of the array of muscle tissue, which makes it difficult to plan the flap for simultaneous replacement of defects in the middle zone of the face if it is necessary to recreate its contours (zygomatic, zygomatic bends, lower eyelid).

The technical result of this invention is to increase the aesthetic and functional effect.

The technical result is achieved by the fact that in the method of simultaneously eliminating the through defect of the nose, infraorbital region and lower eyelid during anophthalmos using a skin flap in the form of a duplicate that is epidermized along the inflection line to close the defect, a distinctive feature is that a simulated revascularized skin is used as a flap -fascial radiation flap in the form of a double leaf 8-10 cm wide, 10-12 cm long, lay it with the skin inside with duplication parallel to the vascular the beam, repeating the contours of the nose, infraorbital region and lower eyelid, followed by the formation of the outer lining with the rest of the flap.

The method is as follows:

Before surgery, the planned flap in the forearm is marked with a marker, indicating the course of the vascular bundle. In the lower third of the forearm, in the center of the projection of the radial artery and vein, according to a pre-prepared paper stencil made according to the shape of the defect with the calculation of the reconstruction of the future internal and external lining, the outline of the figured skin-fascial site of the modified form (in the form of a double leaf) 8-10 cm wide is drawn 10-12 cm long (figure 1).

According to the standard method, a beam of skin-fascial flap is raised in the following sequence: an incision is made in the area of the distal epiphysis of the radius bone 2-3 cm long. The vascular bundle, radial artery and vein are isolated and taken to the holder. Then, departing 10-12 cm from the incision (the length of the skin-fascial site), an incision is made in the projection of the vascular bundle to the proximal radial bone epiphysis. Dull and sharp paths pass between the radial flexor of the wrist and brachioradialis muscle. In the lower third of the forearm, a curly cut-fascial site with a width of 8-10 cm, a length of 10-12 cm is cut out with a fringing incision according to a preliminary marking. The skin is fixed to the underlying fascia. The fascia is peeled from the tendon of the ulnar flexor of the wrist, the tendon of the long palmar muscle, the tendon of the muscle of the deep flexor of the fingers (figure 2). Spend a ligation of the vascular bundle in the distal and proximal sections. The flap is cut off (figure 3).

Carry out the preparation of the receptive bed (figure 4). Upper and lower eyelid tissues are uncovered along old scars. The base and end section of the nose are diverted downward, reaching symmetry with the contralateral side (Fig. 5). In the submandibular region, the external jugular vein and facial artery are isolated.

The taken skin-fascial radial flap is transferred to a prepared receiving bed on the face. The vascular leg is passed through a previously formed subcutaneous tunnel in the submandibular region, where anastomoses with recipient vessels are applied (Fig. 6).

In the conditions of microsurgical technique, anastomoses are applied: the facial artery with a flap artery of the end-to-end type, and the bifurcation of the external jugular vein with the flap veins of the end-to-end type. The vascular pedicle without torsion and kink preserves the longitudinal direction with a laminar flow of blood. The skin-fascial site of the flap is laid with the skin inside along the perimeter of the defect in the form of a duplicate, parallel to the course of the vascular bundle, repeating the contours of the nose, infraorbital region and lower eyelid and filling the cavity of the defect. while completely excluding compression on the walls of the vessels of the soft tissues of the flap. The area of inflection of the flap is epidermized to the width and length of its fixation to the edges of the defect. The remaining part of the flap form the outer lining (Fig.6).

Example

Patient Ch., Was in the Department of Oral and Maxillofacial Surgery of FSI Central Research Institute for Hygiene and Chornophilia with a diagnosis of Combined end-to-end defect of the middle zone of the face after a gunshot wound (subtotal defect of the nose and infraorbital region on the right). Anophthalmus on the right. Lower eyelid defect on the right.

From an anamnesis in 2007, was injured as a result of a gunshot wound. At the place of residence, primary surgical treatment of head wounds was performed. To continue treatment and a number of reconstructive and reconstructive operations to close the defect, he was sent to the Central Research Institute of Nuclear Medicine and ChLH.

An external examination of the head and neck revealed an asymmetry of the middle zone of the face due to a through defect in the back and slope of the nose with a transition to the infraorbital region on the right, anophthalmos on the right, absence of 2/3 of the lower eyelid. The end section of the nose is deformed, sharply shifted up. Nasal passages are free; through them, a sharply deformed septum of the nose and synechia of the left nasal passage is visible. When examining the profile, deformation (retraction) of the contour of the middle zone of the face was revealed. Opening the mouth 4-5 cm, the movements of the lower jaw in full, painless. There is no oral communication.

In the clinic, after a complete clinical and laboratory examination in the conditions of ETN, the operation of the proposed method was performed.

Before surgery, the planned flap in the forearm is marked with a marker, indicating the course of the vascular bundle. In the lower third of the forearm, in the center of the projection of the radial artery and vein, according to a pre-prepared paper stencil made according to the shape of the defect with the calculation of the reconstruction of the future internal and external lining, the outline of the figured fascial and fascial site of the modified form (in the form of a double leaf) 10 × 9 cm in size is drawn.

According to the standard method, a beam of skin-fascial flap is raised in the following sequence: an incision is made in the area of the distal radial pineal gland of a radius of 2 cm long. A vascular bundle, including the radial artery and vein, is isolated and fixed on a holder. Then, backing 10 cm from the incision (the length of the skin-fascial site), an incision is made in the projection of the vascular bundle to the proximal epiphysis of the radius. Dull and sharp paths pass between the radial flexor of the wrist and brachioradialis muscle. In the lower third of the forearm, a curved cutaneous-fascial flap measuring 10 x 9 cm is cut out with a fringing incision according to a preliminary marking. The skin is fixed to the underlying fascia. The fascia is peeled from the tendon of the ulnar flexor of the wrist, the tendon of the long palmar muscle, the tendon of the muscle of the deep flexor of the fingers. Spend a ligation of the vascular bundle in the distal and proximal sections. The flap is cut off.

Prepare the receiving bed. Upper and lower eyelid tissues are uncovered along old scars. The base and end section of the nose are diverted downward, reaching symmetry with the contralateral side. In the submandibular region, the external jugular vein and facial artery are isolated.

The taken skin-fascial radial flap is transferred to a prepared receiving bed on the face. The vascular leg is passed through a previously formed subcutaneous tunnel in the submandibular region, where anastomoses with recipient vessels are applied.

In the conditions of microsurgical technique, anastomoses are applied:

facial artery with flap artery of the end-to-end type, and bifurcation of the external jugular vein with flap veins of the end-to-end type. The vascular pedicle without torsion and kink maintains its longitudinal direction with a laminar flow of blood. A skin-fascial flap is placed along the perimeter of the defect in the form of a duplicate, parallel to the course of the vascular pedicle, repeating the contours of the nose and filling the cavity of the defect. In this case, compression of the flap of the vessel walls by soft tissues was completely excluded. The area of inflection of the flap is epidermized to the width and length of its fixation to the edges of the defect. The remaining part of the flap forms the outer lining.

In the postoperative period, infusion, antibacterial, anti-inflammatory, analgesic therapy, dressings are performed.

As a result of the operation, the through defect of the nose, infraorbital region and lower eyelid was closed, the eye cavity was isolated from the nasal cavity.

Thus, the proposed method can be used to eliminate the through defect of the nose, infraorbital region and lower eyelid with anophthalmus in patients after block resection of tumors, severe mechanical injuries and gunshot wounds.

The proposed method has several advantages, such as:

the possibility of simultaneous closure with the help of a revascularized skin-fascial radial flap of extensive through defects in the middle area of the face (anatomically complex area), including several anatomical areas, such as the infraorbital region, the lower eyelid and nose;

the possibility of replacing defects of the middle zone of the face with the help of a thin skin-fascial radiation flap with the reconstruction of contours (cheek-eye, cheekbone bends, lower eyelid) and obtaining good aesthetic results;

simultaneous compensation of the inner and outer lining of the nose, closing the message of the eye with the nasal cavity and communication with the oral cavity with anophthalmos.

Claims (1)

A method for simultaneously eliminating a through defect in the nose, infraorbital region and lower eyelid during anophthalmus using a skin flap in the form of a duplicate that is epidermized along the inflection line to close the defect, characterized in that the modeled revascularized skin-fascial radiation-shaped flap made using the flap made according to the shape of the flap is made , 8-10 cm wide, 10-12 cm long, which is laid with the skin inside with duplication parallel to the course of the vascular bundle, repeating the contours of the nose, infraorbital region and the lower eyelid with the subsequent formation of the outer lining of the remaining part of the flap.

Images