RU2604028C2 - Method of single-stage elimination of through combined defect of lower face area - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, surgery. Through orofacial defects are removed in one stage after radical resection. Epithelial lining of oral cavity, soft-tissue component, skin, facial skeleton are restored. Two autografts are formed simultaneously. They are moved into defect area. Microsurgical management of anastomosis of flaps' vessels and receiving bed is made. Mandibular defect is removed with bone fragment of fibular autograft. Bone fragment of flap is fixed with titanium plates to fragments remaining after resection of mandibular body. Musculocutaneous fragment is used to restore soft and covering tissues of chin area. Tissues in area of oral cavity bottom are restored with radial autograft skin platform. Flap edges are connected to mucous membrane along perimeter of defect.

EFFECT: method allows to close through combined defects of orofacial area in one surgical stage by using two autografts - fibular and radial.

1 cl, 8 dwg, 1 ex

Description

The invention relates to medicine, in particular to reconstructive surgery, can be used in the rehabilitation of cancer, trauma patients for a one-stage elimination of end-to-end combined orofacial defects with the restoration of the epithelial lining of the oral cavity, soft tissue component, skin, facial skeleton.

A known method of eliminating combined defects of the facial skeleton (RU 2233125 C1). The method consists in the fact that the closure of the defect is carried out by a revascularized autograft, which includes a portion of the iliac crest in combination with the internal oblique muscle of the abdomen.

The method allows to improve blood supply to the bone part of the autograft by connecting additional vascular collaterals through the internal oblique muscle of the abdomen included in the autograft. This makes it possible to take a long autologous bone graft and ensures the safety of the necessary osteotomy, which improves the functional and aesthetic effect.

However, the known method has several disadvantages, such as:

- the length of the bone fragment of the graft is limited to 15 cm, given its anatomical features,

- the internal lining of the oral cavity is restored not by epithelial tissues, but by muscle, which can lead to cicatricial deformation of the soft tissues of the oral cavity,

- when closing external defects, the muscle fragment is covered with a free split skin graft, which does not in all cases provide a complete graft engraftment and promotes full epithelization.

There is a method of using rib-muscle autografts for the elimination of extensive combined defects in cancer patients (Reshetov I.V., Kravtsov S.A., Matorin O.V., Polyakov A.P., Filyushin M.M., Ratushny M.V. The use of rib-muscle autografts for the elimination of extensive combined defects in cancer patients. Annals of plastic, reconstructive and aesthetic surgery. - 2002. - No. 3. P. 38-54.).

The method consists in the use of skin-muscle-bone-bone cost-effective autografts to eliminate the combined defects of the cranial-maxillofacial zone, and the walls of the orbit, maxillary sinus, alveolar process of the upper jaw and branches and body of the lower jaw, and muscular-skin muscle are restored with a rib fragment with a portion of the autograft, defects in the base of the skull and dura mater are closed and extensive defects in the integumentary tissues of the face are eliminated. The broadest muscle of the back is used as a muscle portion if it is necessary to eliminate an extensive soft tissue defect and the use of a long vascular pedicle, the front dentate muscle - in the absence of the need to use a large muscle portion and a long vascular pedicle, the pectoralis major muscle - in patients with severe concomitant pathology in in order to reduce the time of surgery, or the rectus abdominis muscle, in patients who have contraindications for the formation of pneumothorax. The method provides the ability to include in the autograft any required volume of tissue, the formation of a bone fragment up to 25 cm long, the formation of a long vascular pedicle, does not lead to functional disorders in the donor area after the graft has been taken.

However, the method has several disadvantages, such as;

- in most cases, when the graft is formed, the pleural cavity is opened, which can lead to complications from the respiratory system,

- when eliminating the defect with a skin-muscle-bone graft, in most cases, isolation of the rib fragment of the autograft with a muscular “clutch” is necessary, which can lead to a violation of the blood supply to the muscular portion of the graft,

- the lack of the possibility of dental implantation in the rib fragment of the autograft,

- the need for repeated corrective operations.

Closest to the claimed invention is a method of forming a transplant to close defects of the lower jaw (RU 2133590 C1). Adopted as a prototype. The method consists in producing a wedge-shaped osteotomy of the tibia with a wedge angle of 45 or 60 ° to the periosteum while maintaining the supply vessels, while the chin wedge angle is 45 °, and the wedge angle for the mandibular angle is 60 °. The method provides improved aesthetic and functional results of treatment. The advantages of this method are the possibility of restoring extended defects of the lower jaw, achieving the optimal geometric shape of the reconstructed lower jaw from a linear fibular autograft, maintaining reliable blood supply to the graft (endostal and periosteal) due to the preservation of the periosteum throughout.

However, the use of only a peroneal autograft does not provide restoration of both the epithelial lining of the oral cavity and the integumentary tissues of the face with extensive defects.

The objective of the invention is a one-stage elimination of end-to-end combined orofacial defects with the restoration of the epithelial lining of the oral cavity, soft tissue component, skin, bone structures of the facial skeleton.

These technical (therapeutic) results in the implementation of the invention are achieved due to the fact that, as in the known method, the restoration of the lower jaw is carried out by a peroneal autograft.

This problem is solved by the fact that two autografts are simultaneously formed - a musculocutaneous-skeletal fibula and a skin-fascial radiation one, osteotomies of the bone fragment of the fibular autograft are performed, a stereolithographic model of the lower jaw is used to model and fix the bone fragment of the fibroblast with the titanium plates and the autograft isotransplant the fibular autograft is transferred to the neck and placed in the position of the body of the lower jaw, after which the distal bone fragment The peroneal autograft graft is fixed with titanium plates to the lower jaw body fragment on the right, the proximal fibrous autograft is fixed with titanium plates to the mandibular body fragment on the left, the vascular pedicle of the fibular autograft is carried to the neck vessels, then two microvascular anastomoses and microvascular aneurysms are formed under the optical enlargement artery, fibular vein and recipient vein, radiation autograft after intersection the vascular pedicle is transferred to the oral cavity, tissue is restored in the area of the bottom of the oral cavity and the fibular autograft is covered, then separate nodular sutures are placed between the edge of the tongue resection and the skin area of the radiation autograft and the mucosa of the vestibule of the oral cavity and the skin area of the radiation autograft, the vessels of the neck and under optical magnification, the formation of microvascular anastomoses between the radial artery and the recipient artery, radial vein and p tsipientnoy vein, after which the soft tissues of the submandibular and submental areas restore musculocutaneous fragment fibular autograft.

The invention is illustrated by a detailed description, clinical example and illustrations, which depict:

FIG. 1 - Scheme for eliminating the end-to-end combined defect of the lower face zone; 1 - radiation autograft; 2 - vascular leg of a radiation autograft; 3 - a bone fragment of the fibular autograft; 4 - muscle fragment of the fibular autograft; 5 - skin fragment of the fibular autograft; 6 - vascular leg of the fibular autograft.

FIG. 2 - Scheme of the final location of autografts after reconstructive surgery; 1 - radiation autograft; 3 - a bone fragment of the fibular autograft; 5 - skin fragment of the fibular autograft.

FIG. 3 - a) the formation of a block of tissues, including soft tissues of the bottom of the oral cavity, a fragment of the body of the lower jaw, tissue of the submandibular and chin areas, submandibular case on the left; b) the type of wound after removal of the drug.

FIG. 4 - a) marking of the fibular autograft; b, c) modeling of a bone fragment using a stereolithographic model; d, e) metal osteosynthesis.

FIG. 5 - Osteosynthesis of a bone fragment of the fibular autograft to fragments of the body of the lower jaw on the right and left.

FIG. 6 - a) marking of the radiation autograft; b) a formed radiation autograft.

FIG. 7. a, b - the final form of the wound.

FIG. 8 a, b, c — the patient’s appearance 21 days after reconstruction.

The method is as follows.

Under endotracheal anesthesia, a radical stage is performed in a radical volume with the formation of postoperative defects and with the release of recipient vessels in the case of simultaneous plastic surgery. In the case of delayed grafting, postoperative scars are excised, the edges of the wound are mobilized and the recipient vessels are secreted. The purpose of the manipulations is to prepare the recipient wound and blood vessels for plastic surgery.

Given the defect obtained, the formation of the second team of surgeons of the cutaneous-musculoskeletal fibular autograft on the fibular arteries and veins is performed. According to modeling using a stereolithographic model of the lower jaw, osteotomies of the bone fragment of the fibular autograft are performed. In the osteotomy area, the bone fragment of the fibular autograft is modeled according to the stereolithographic model of the lower jaw, metal osteosynthesis is performed using titanium plates. The vascular leg is crossed, the fibular autograft is transferred to the neck. The bone fragment of the fibular autograft is installed in the position of the lower jaw, the distal fragment of the fibular autograft is fixed to the fragment of the lower jaw on the right with titanium plates, the proximal fragment of the fibular autograft is fixed to the fragment of the body of the lower jaw on the left with titanium plates. The vascular leg of the fibular autograft is carried out to the vessels of the neck. Under optical magnification, two microvascular anastomoses are formed between the fibular artery and the recipient artery, the fibular vein and the recipient vein. The soft tissue of the submandibular and chin regions is restored by the musculoskeletal fragment of the peroneal autograft.

At the same time, the third team of surgeons on the left forearm form a skin-fascial beam autograft on the radial artery and veins. A radiation autograft after crossing a vascular pedicle is transferred to the oral cavity. Tissue in the area of the bottom of the oral cavity is restored by the skin site of the radiation autograft and the fibular autograft is covered. Separate nodal sutures are placed between the edge of the tongue resection and the skin area of the radiation autograft and the mucous membrane of the vestibule of the oral cavity and the skin area of the radiation autograft. The leg of the radiation autograft is carried out to the vessels of the neck. Under optical magnification, microvascular anastomoses are formed between the radial artery and the recipient artery, the radial vein and the recipient vein.

For explanation, a scheme is presented for eliminating the end-to-end combined defect of the lower face zone with radial cutaneous-fascial and fibular dermal-musculoskeletal autografts (Fig. 1), as well as a diagram of the final location of the radial and fibular autografts after reconstructive surgery (Fig. 2).

Clinical example

Patient B., 39 years old, diagnosis: cancer of the mucous membrane of the alveolar bone of the lower jaw IVa Art. pT4aN0M0.

The patient underwent surgery: resection of the tongue, bottom of the oral cavity, block resection of the lower jaw, soft tissues of the chin, supra-mychioid lymphadenectomy on the left neck (ND I-III), supra-mychioid lymphadenectomy on the neck on the right (ND I-III), simultaneous microsurgical removal an orofacial defect with a peroneal musculoskeletal autograft, a skin-fascial beam autograft, tracheostomy. A defect in the lower jaw was formed according to J. Brian Boyd LCL CM.

A skin incision was made in the submandibular and chin areas, bordering the infiltration of the skin, then the skin incision was extended into the right and left submandibular areas parallel to the body of the lower jaw and along the sternocleidomast to the right and left to the middle third of the neck. Removed I, II, III groups of l / nodes on the left and right with the preservation and allocation throughout the facial arteries and veins on both sides. On the right marked branching of the facial vein into 3 branches.

During the audit of the oral cavity: in the mucous membrane of the alveolar process of the lower jaw, an infiltrative tumor was determined from 43 teeth to 36 teeth with spreading to the mucosa of the bottom of the oral cavity. Instability of 33 and 34 teeth was noted. In the area of the body of the lower jaw on the left, tumor infiltration was determined, spreading to the submental and submandibular region on the left.

An incision was made in the mucosa along the lower surface of the tongue, the bottom of the oral cavity, and the buccal-gingival pocket in the region of the vestibule of the oral cavity. The lower lip is mobilized from the body of the lower jaw. Mandibulotomy was performed between 43 and 44 teeth and between 37 and 38 teeth. A tissue block was formed and removed, including soft tissues of the bottom of the oral cavity, a fragment of the body of the lower jaw, tissue of the submandibular and chin areas, submandibular case on the left (Fig. 3a, b). An urgent cytological examination of scrapings from tissues along the edges of the tumor growth resection was not detected.

At the same time, the second surgical team on the left shin formed a musculocutaneous peroneal autograft on the fibular artery and veins (Fig. 4a). The size of the skin site of the fibular autograft was 10 × 5 cm, the length of the bone fragment of the fibular autograft was 8 cm. According to the modeling using a stereolithographic model of the lower jaw, an osteotomy was performed at a distance of 4 cm from the distal edge of the bone fragment of the fibular autograft (Fig. 4b, c). In the osteotomy area, the bone fragment of the peroneal autograft was modeled according to the stereolithographic model of the lower jaw, metal osteosynthesis was performed using titanium plates (Fig. 4d). After crossing the vascular pedicle, the fibular autograft was transferred to the neck. The bone fragment of the fibular autograft is installed in the position of the lower jaw, the distal fragment of the fibular autograft is fixed to the fragment of the lower jaw on the right with titanium plates, the proximal fragment of the fibular autograft is fixed to the fragment of the body of the lower jaw on the left, fixed with titanium plates (Fig. 5). The vascular leg of the fibular autograft is carried out to the vessels of the neck.

Under optical magnification, two microvascular anastomoses were formed between the peroneal artery and the left facial artery of the end-to-end type, the fibular vein and the left facial vein of the end-to-end type. The start of blood flow. Vital fibular autograft restored.

At the same time, the third team of surgeons on the left forearm according to the marking (Fig. 6a) formed a skin-fascial radial autograft on the radial artery and veins and saphenous vein of the forearm (Fig. 6b). The size of the skin site of the radiation autograft was 13 × 7 cm. After crossing the vascular pedicle, the radiation autograft was transferred to the oral cavity. The skin area of the radiation autograft restored tissue in the area of the bottom of the oral cavity. Separate nodal sutures were placed between the edge of the tongue resection and the skin area of the radiation autograft and the mucosa of the vestibule of the oral cavity and the skin area of the radiation autograft. The vascular leg of the radiation autograft is carried out to the vessels of the neck. Under optical magnification, three microvascular anastomoses were formed between the radial artery and the right facial artery of the end-to-end type, the radial vein and the right 1 branch of the facial vein of the end-to-end type, the saphenous vein of the forearm, and 2 branch of the right facial vein of the type "end to end", 3 branches of the facial vein are stitched. The start of blood flow. The viability of the radiation autograft has been restored. The soft tissue of the submandibular and submental areas was restored using a fascial-fascial beam autograft (Fig. 7a, b).

The skin in the region of the left forearm and left lower leg was restored by a split autodermal autograft. Formed middle tracheostomy.

On the 7th day, computed tomography of the skull was performed, in which adequate fixation of the bone fragment of the fibular autograft in the position of the body of the lower jaw was revealed.

Peroneal and radiation autografts completely took root. The patient was decanulated on the 21st day after the operation, nutrition was restored through the mouth (Fig. 8 a, b, c). The function of the left lower and upper limbs is not impaired.

The use of the proposed method in clinical practice made it possible to achieve the following results:

- use is possible regardless of previous treatment (radiation therapy or surgery);

- applicable regardless of the resection stage, both simultaneously with the removal of the tumor, and delayed;

- restore the epithelial lining of the oral cavity, soft tissue component, skin, bone structures of the facial skeleton after surgical treatment with autologous tissues in one surgical stage;

- applicable with a deficiency of plastic material and a pronounced cicatricial process on the head and neck;

- eliminate the defect without interventions in the abdominal cavity and the use of visceral grafts;

- restore defects of various configurations and sizes;

- the shelter of the fibula, restoring the lower jaw, with a thin skin-fascial beam autograft creates favorable conditions for dental implantation and rehabilitation of the dentition;

- the absence of the need for complex modeling and location of the skin portion of the fibular autograft helps to reduce the risk of necrosis of the skin portion of the autograft.

The use of the claimed invention in the clinic showed that the method allows to close the end-to-end combined defects of the orofacial region in one surgical stage, to restore the epithelial lining of the oral cavity, soft tissue component, integumentary tissues, bone structure using two microsurgical autografts - fibular and radiation.

Claims (1)

The method of one-stage elimination of the end-to-end combined defect of the lower zone of the face, including resection of the lower jaw and tongue, isolation of the vessels of the neck, the formation of the fibular autograft to restore the lower jaw, soft tissues of the submandibular and chin areas, characterized in that two autografts are simultaneously formed - a cutaneous-muscular-bone fibular and cutaneous-fascial radiation, produce osteotomy of the bone fragment of the fibular autograft, according to the stereolithographic model of the lower a bone fragment of the fibular autograft is modeled and fixed with titanium plates, then the vascular pedicle is crossed, the fibular autograft is transferred to the neck and placed in the position of the lower jaw body, after which the distal bone fragment of the fibular autograft is fixed with titanium plates to the fragment of the proximal lower body the autograft is fixed with titanium plates to a fragment of the body of the lower jaw on the left, the vascular pedicle of the fibula of the autograft is carried out to the vessels of the neck, then under the optical magnification, two microvascular anastomoses are formed between the fibular artery and the recipient artery, the fibular vein and the recipient vein, the radial autograft is transferred to the oral cavity after the intersection of the vascular pedicle, and the tissue is recovered in the uterine cavity autograft, then separate nodal sutures are placed between the edge of the tongue resection and the skin site of the radiation autograft and the mucous membrane the door of the oral cavity and the skin area of the radiation autograft, the leg of the radiation autograft is carried out to the vessels of the neck and under optical magnification microvascular anastomoses are formed between the radial artery and the recipient artery, the radial vein and the recipient vein, after which the soft tissues of the submandibular and chin-muscular regions recover fibular autograft.

Images