RU2555110C1 - Method for plastic replacement of combined defects of eye socket and adjoining anatomical regions - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: anterior face tissue block is removed, and an orbital exenteration is performed. A plastic replacement of the face defect is conducted with using a periosteoaponeurotic flap. That involves forming a frontotemporal periosteoaponeurotic flap including a. frontalis, a. supraorbitalis, a. trochlearis. After the tissues are mobilised along the formed defect in the temporal, face bone and frontal regions, a tunnel is created with its origin in a helical root to an opposite eye brow. The flap is further turned over through the formed tunnel towards the defect, laid over it and sutured along the whole wound surface of the defect. The donor wound is closed.

EFFECT: method enables reducing an intraoperative injury rate, improving the blood supply of the used flap, shortening the patients' rehabilitation time.

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Description

The invention relates to medicine, namely to oncology, ophthalmology, plastic surgery, maxillofacial surgery, and can be used in reconstructive and reconstructive surgery. It can be used in patients for reconstruction of orbit defects and areas bordering on it, arising from malignant lesions, operations, radiation therapy, trauma and complications of specific infections. In the maxillofacial region and the orbit, there are various types and formations of formation, both of the primary lesion of the orbit tissue, and spreading from neighboring anatomical regions of the nasal cavity, ethmoid labyrinth cells, maxilla and sinus (basal cell carcinoma, squamous cell carcinoma, melanoma, various adenocarcinomas). The restoration of defects in this area involves the reconstruction of bone (if possible), skin, soft tissues. A severe cosmetic defect in the postoperative period dictates the need for plastic closure of the orbital defect, and requires the creation of the possibility of forming a cavity for wearing the prosthesis.

A known method of replacing a defect in the upper jaw using a muscle or musculocutaneous flap with the inclusion of the pectoralis major muscle in a delayed period. However, given the massiveness, the relative complexity of the formation of the flap, the presence of certain contraindications, this autograft is not always convenient for plastic surgery of the middle and orbital zones of the face. It is especially important when moving the flap into this zone to create a long and narrow muscle leg that does not interfere with head movements. A significant disadvantage of using this flap is the limitation of the patient’s head mobility, which requires subsequent repeated corrective surgery [Restorative surgery of the soft tissues of the maxillofacial region. Guide for doctors / P.Z. Arzhantsev, V.A. Vissarionov, B.N. Davydov et al .; Ed. A.I. Nerobeeva, N.A. Plotnikova. - M .: Medicine, 1997. - S. 54-58].

There is a method of plastic surgery of extensive defects of facial tissues by radical excision of a block of tissue of the cheek, lateral wall of the external nose and exentration of the orbit by combined closure of the wound bed with displaced and free flaps, while forming a mucous-cartilaginous flap, including a perichondrium from the nasal septum in the direction from the top to the base displace and reduce to contact with the remaining mucous membrane of the outer wall of the nasal cavity and stitch them on the drainage tube, the outer surface of the defect is restored navlivayut free skin-myofascial flap on a vascular pedicle, which simulate the contours of the face. The method is carried out using microsurgical technique. Subsequently, cosmetic correction of the flap is performed with the implantation of an ocular prosthesis in its tissue (Pat. No. 2069541, Reshetov I.V., Chissov V.I., Olshansky V.O., Bityutsky P.G., Kravtsov S.A., Trofimov E.I., Sdvizhkov AM, publ. 11/27/1996).

Disadvantages: 1 - two flaps are used (displaced mucous-cartilaginous and free);

2 - when taking a mucous-cartilaginous flap, a serious additional trauma to healthy tissues is applied, in particular cartilage of the nasal septum;

3 - for a free flap, the use of microsurgical equipment and specialists is necessary, and additional trauma to the donor site is also applied at the site of the capture of the musculoskeletal and fascial flap;

4 - for the final rehabilitation - installation of the prosthesis of the eyeball - an additional surgical operation is necessary to correct the bed.

A known method of simultaneous replacement of a combined defect of the upper jaw and orbit with a displaced flap from the temporal muscle [Plastic defect of the face with a displaced flap of the temporal muscle during surgery for locally advanced cancer of the upper jaw / Markov G.I. [et al.] // Bulletin of Otorhinolaryngology. - 2003. - No. 4. - S. 63-64.]. An incision is made from the lateral angle of the eye with a continuation to the temporal region. After mobilization of skin flaps, the temporal muscle is secreted and its leg is mobilized, attaching to the coronoid process of the lower jaw. The flap is turned inward at 100 °, placed on the defect of the orbit and upper jaw, stitched in layers with preliminary loose plugging of the operating cavity with a swab soaked in ambipore preparation. The skin flap moves to the place of the defect of the upper jaw and eye and is hemmed with an upholstered atraumatic suture, leaving rubber graduates in the orbit.

The disadvantages of this method are:

1 - causing additional serious injury to surrounding tissues (formation of the temporal flap), which entails a violation of the chewing function and, probably, the development of contracture;

2 - the flap has one feeding leg and if blood supply is disturbed, all layers of the flap die;

3. - for aesthetic and social rehabilitation, namely the establishment of an eye prosthesis, additional corrective surgical treatment is necessary to form the prosthetic bed.

A known method of plastic closure of defects of the base of the skull (Pat. No. 2347535, Gulyaev Dmitry Alexandrovich, Olyushin Victor Emelyanovich, Chebotarev Sergey Yakovlevich, publ. 02.27.2009), which consists in making a bicoronary incision of the skin and subcutaneous fat, performing phased dissection in the layer between the subcutaneous fat and the aponeurotic helmet in the frontal, parietal and temporal areas, in the temporal areas, special attention is paid to the preservation of the vascular bundles of the superficial temporal artery, gradually forming wide a cystic (up to 10 cm wide) periosteal-aponeurotic flap sufficient to close the bone defect, the latter is separated from the bone and, according to the type of an opral-shaped flap, is moved forward to the base of the skull, the flap is fixed to the base of the skull with bone sutures with additional sealing with the adhesive composition. The application of this method in a patient with a diagnosis of chordoma of the upper slope is described, in which tumor growth is noted with the destruction of the structures of the base of the skull, spreading to the middle and front cranial fossae, in both orbits (more to the right), in the ethmoid labyrinth, and nasopharynx. A planned surgical intervention was performed in the volume of removal of the tumor from transfacial, extended transetmoidal access with removal of the medial wall of both orbits and bilateral osteotomy of the upper jaw with primary plastic base of the skull, by forming a periosteal-aponeurotic flap after a bicoronary incision of the skin and subcutaneous fat, dissection into layer between the subcutaneous fat and the aponeurotic helmet in the frontal, parietal and temporal areas while maintaining the temporal vessel true beams.

The disadvantages of this method are:

1. A flap of this size is used to replace a bilateral defect on the base of the skull and is not shown to replace a defect in the orbit and surrounding tissues from the homolateral side.

2. High invasiveness of surgery.

3. Inadequate blood supply to the lower flap.

4. Not shown transplantation of a split skin autograft.

5. Long postoperative period.

A known method of plastic closure of defects in the face and orbit, which consists in removing a block of tissue on the front surface of the face, orbital exentation, plastic replacement of the face defect due to a muscle flap, cut out a skin-muscle-conjunctival flap with preservation of eyelashes, eyelids, skin corners of the eye, separate it from the underlying surface of the eye and the underlying tissues of the orbit and direct it to the temporal-zygomatic region, while maintaining neurovascular connections with the temporal-zygomatic zone, move the graft and close it defect in the face and orbit, cut out the upper portion of the graft from the muscle portion of the orbit bed, suture the edges of the bed with the flap of the eyelids moved along its edge, after the wound has completely healed, the second stage is implanted into the preserved palpebral fissure (Pat. No. 2132164, Chissov V.I. ., Reshetov I.V., Kravtsov S.A., Sdvizhkov A.M., Polyakov A.P., Bityutsky P.G., published on June 27, 1999).

This method is selected for the prototype.

The disadvantages of this method are:

1 - that cause additional serious injury to surrounding tissues (the formation of a flap from the dentate muscle);

2 - the flap has one feeding leg and with thrombosis of the vascular anastomosis there is a violation of blood supply and the death of all layers of the flap;

3 - the main advantage is the preservation of the eyelids, skin corners of the eye and ciliary edge, is not always possible due to the prevalence of the tumor process (stage III-IV).

The objective of the invention is to increase the efficiency of replacing an extensive combined defect of the orbit and adjacent anatomical regions, obtaining a good functional and cosmetic result, which will improve the quality of life of patients, their psychological and social rehabilitation.

The technical result consists in reducing the invasiveness of surgical intervention, improving the blood supply of the flap used, in providing the possibility of transplantation of a free skin graft, reducing the time of rehabilitation of patients.

This is achieved due to the fact that they form the frontotemporal periosteal-aponeurotic flap; after the mobilization of tissues along the edge of the formed defect in the temporal, zygomatic and frontal areas, a tunnel is formed, from the border of the anterior incision to the eyebrow of the opposite side, then the flap is overturned through the formed tunnel towards the defect, laid on it and fixed with sutures along the entire wound surface of the defect; the donor wound is sutured.

The frontotemporal periosteal-aponeurotic flap has smaller sizes compared to the prototype, respectively, the area of the donor site is smaller, which helps to reduce the invasiveness of the operation. The formation of the tunnel and the subsequent movement of the flap through it towards the defect serves to protect the flap from mechanical influences, which, of course, positively affects its viability in the postoperative period. The best, compared with the prototype, the blood supply of the flap is due to the inclusion of a flap a. frontalis, a. supraorbitalis, a. trochlearis, which provides high vitality and uniform nutrition of the flap (a. supraorbitalis, a. trochlearis are in the lower part of the flap). In view of the fact that this method is aimed at replacing combined defects of the orbit and regions adjacent to it, and not at replacing defects in the base of the skull (prototype), a split skin autograft can be transplanted. Reducing the area of the donor site, the best, compared with the prototype, the blood supply of the flap, the use of the technique of forming the tunnel can reduce the length of the patient’s stay in the hospital.

The proposed method is illustrated by the following figures:

FIG. 1 - localization of the lesion and incision line;

FIG. 2 - formed defect of the orbit, its surrounding tissues and the upper wall of the maxillary sinus;

FIG. 3 is a diagram of the formation of the frontotemporal periosteal-aponeurotic flap;

FIG. 4 - formed frontotemporal periosteal-aponeurotic flap with feeding arteries;

FIG. 5 is a diagram of the movement of the formed frontotemporal periosteal-aponeurotic flap;

FIG. 6 is a diagram of postoperative sutures.

The method is as follows: under general anesthesia, mark the incision line 1 around the lesion 2 and incision 3, running along the legs of the ear curl, the upper edge of the auricle to the parietal region along the posterior edge of the temporal muscle attachment and continuing as a coronary incision 4-5 cm from the midline in the opposite direction (Fig. 1), form a defect in the orbit, its surrounding tissues and the upper wall of the maxillary sinus 4 (Fig. 2) (removal of the tumor, excision of pathologically altered tissues, etc.) in accordance with about the standards of intervention in oncology and carry out an incision 3. Then produce the formation of the frontotemporal periosteal-aponeurotic flap 5 (Fig. 3). Find and mark the superficial temporal artery 6 (Fig. 4). Next, a dissection is performed in the layer between the subcutaneous fat 7 (Fig. 5) and the aponeurotic helmet 8 (Fig. 5) in the frontal, parietal and temporal areas while maintaining the temporal and frontal vascular bundles, preserving the peripheral parts of the facial nerve. The superficial fascia is cut off and raised together with its own temporal fascia, forming a flap 5 (Fig. 5), sufficient to close the defect 4 (Fig. 2). The next step is to mobilize the tissue along the edge of the defect 4. In the temporal, zygomatic and frontal areas, a tunnel 9 is formed (Fig. 5), from the leg of the ear curl to the eyebrow of the opposite side. The formed frontotemporal periosteal-aponeurotic flap 5 is tipped towards the defect 4 through the tunnel 9 (Fig. 5) and laid on the defect 4. The frontotemporal periosteal-aponeurotic flap 5 is tightly fixed to the entire wound surface of the defect 4. The donor site is sutured with leaving two tape drains 10 in the temporal and frontal areas (Fig. 6). An orbital defect over the flap is loosely swabbed with a gauze swab.

Clinical example.

Patient S., 30 years old, and / b No. 2013/19847. Diagnosis: Basal cell carcinoma of the outer corner of the right eye with extension to the eyelids, orbit, and zygomatic bone on the right. Condition after combined treatment (2006, 2011 for m / f). Relapse. The TNM stage is not staged.

Status localis: On the skin of the outer corner of the right eye, ulceration with decay in the center, spreading into the orbit, with destruction of the underlying bones is determined. The size of the tumor is up to 5.0 cm in diameter. Regional l / nodes are not increased. On CT scan from 10.3.13. - On the skin of the outer corner of the right eye and in the area of the zygomatic arch, an ulcerated tumor is determined, 4.7 × 2.8 cm in size, spreading to the outer parts of the orbit with destruction of the underlying bones. Given the histological nature of the tumor, the prevalence and localization of the process 10/29/13 performed a planned surgical intervention in the amount of skin removal with the tumor, orbital exentation on the right with the replacement according to the claimed method frontotemporal periosteal aponeurotic flap. After performing a skin incision that runs along the leg of the ear curl, the upper edge of the auricle to the parietal region along the posterior edge of the temporal muscle attachment and continues the coronary incision 4-5 cm from the midline in the opposite direction, dissection in the layer between subcutaneous fat and aponeurotic helmet in the frontal, parietal and temporal areas with the preservation of the temporal and frontal vascular bundles, the formation of the frontotemporal periosteal-aponeurotic flap, sufficient to replace the defect, moving the flap the flap was fixed through the tunnel to the entire wound surface of the defect using suture material, the wound was sutured.

The early postoperative period was uneventful, the sutures were phased out on days 7-12, wound healing by primary intention. The patient was discharged 10 days after surgery.

Claims (1)

The method of plastic replacement of combined defects of the orbit and adjacent anatomical regions, which consists in removing the tissue block of the anterior surface of the face, orbital exentation, in the plastic replacement of the face defect due to the periosteal-aponeurotic flap, characterized in that they form the frontotemporal periosteal-aponeurotic flap, including a. frontalis, a. supraorbitalis a. trochlearis; after mobilization of tissues along the edge of the formed defect in the temporal, zygomatic and frontal areas, a tunnel is formed, from the leg of the auricle curl to the brow of the opposite side, then the flap is tipped over through the formed tunnel to the defect side, laid on it and fixed with sutures along the entire wound surface of the defect; the donor wound is sutured.

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