RU2715615C1 - Method for elimination of extensive hard palate defect - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to maxillofacial surgery, and is applicable for elimination of extensive hard palate defect. Mucous membrane of the oral cavity is incised by 0.8–1.2 cm from the bony edges of the extensive hard palate defect on both sides, two mucous flaps are separated and cut out, which are tilted to the center of extensive hard palate defect, brought together and fixed with each other with the help of suture material. Access to recipient vessels – facial artery, facial and submental veins is performed through an incision of skin, subcutaneous fat, intrinsic fascia of neck in submandibular area, along upper neck fold. Recipient vessels are separated and transected. Tunnel is formed in a submucosal layer extending from the soft palate further parallel the wing-mandibular fold along an inner surface of the lateral mandibular side anterior to the projection of the anterior border of the masseter in the submandibular region. At preoperative preparation stage, preliminary projection of medial gastrocnemius artery is pre-marked, required shape and area of skin-fascial medial gastrocnemius autograft taking into account extensive hard palate defect in recipient area. Dissecting of skin-fascial medial gastrocnemius autograft on vascular pedicle – medial iliac artery and veins start with anterior approach. Skin and subcutaneous fat are incised along the medial border of the skin-fascial medial gastrocnemius autograft. Dissection is performed until a medial gastrocnemius artery is detected. Then, the fascia of the shin is dissected; along the direction of the medial gastrocnemius artery, it is released from the medial gastrocnemius muscle by intramuscular dissection. Small vascular perforators are alloyed and crossed during preparation. Dissection is continued in the proximal direction to the level of the projection of the popliteal fossa, where the mouth of the medial gastrocnemius artery is visualized in the popliteal artery. That is followed by a semi-oval incision of skin, subcutaneous fat and shin fascia preserving the vascular pedicle to extend it into a lateral border of a skin-fascial medial gastrocnemius autograft. Skin-fascial medial gastrocnemius autograft is modeled on a vascular pedicle with respect to the area and shape of the extensive hard palate defect. Vascular pedicle of the skin-fascial medial gastrocnemius autograft in the popliteal artery is excised by pre-ligating. Postoperative wound is closed in the donor zone. Vascular pedicle of the skin-fascial medial gastrocnemius autograft is inserted through a tunnel formed in the submucosal layer into a submandibular region. Skin-fascial medial gastrocnemius autograft on the vascular pedicle is fixed in the previously formed receptor bed to the mucous flaps by U-sutures. Using the microsurgical technique, the dermal-fascial medial gastrocnemius autograft is revascularized by imposing vascular anastomoses between the medial and frontal arteries, as well as by the medial gastrocnemius veins and the facial and submental veins in the submandibular region. Wounds are layer-by-layer closed in layers.

EFFECT: method enables reducing autograft autopsy injury, improving functional and aesthetic effects in donor area due to simpler anatomy of shin, defect closure of donor area without using splitted skin autograft and expanders, as well as location of donor area in less significant aesthetic zone.

1 cl, 5 dwg, 2 ex

Description

This invention relates to medicine, namely to maxillofacial surgery, and is intended to eliminate an extensive defect of the hard palate.

A known method of eliminating an extensive defect of the hard palate.

According to the method, the elimination is carried out using a revascularized skin-fascial radiation autograft.

A receptive bed is formed in the region of an extensive defect of the hard palate by cutting the mucous membrane of the oral cavity and separating it.

Next, the recipient vessels are isolated - the facial artery and veins by cutting the skin and subcutaneous fat in the submandibular region, they are crossed.

A tunnel is formed in the submucosal layer of the cheek, extending from the soft palate, then parallel to the pterygo-mandibular fold along the inner surface of the lateral part of the lower jaw anterior to the projection of the anterior edge of the chewing muscle into the submandibular region.

Mark the boundaries of the skin-fascial beam autograft in the lower third of the forearm, taking into account the area and shape of the receiving bed. The projection of the vascular pedicle of the radial artery and veins of the fascial and fascial radial autograft is noted.

In the area of previously performed marking of the lower third of the forearm, a semi-oval incision of the skin, subcutaneous fat, fascia of the forearm is laterally performed, then the incision is extended in the projection of the vascular pedicle - radial artery and veins to the ulnar fossa.

Then, the incision is performed along the previously performed medial border of the marking and connected to the proximal point of the incision. In the lower third of the forearm of the skin-fascial beam autograft, the vascular pedicle is ligated and transected. A vascular pedicle, consisting of a radial artery and two veins, is proximal in the vertical incision in the intermuscular septum to the point where the radial artery leaves the brachial artery.

They perform modeling of a skin-fascial beam autograft on a vascular pedicle, taking into account the shape and area of an extensive defect of the hard palate. After the radial artery leaves the brachial artery, they pre-alloy and cross the vascular pedicle. A skin-fascial beam autograft is taken on a vascular pedicle — a radial artery and veins.

The wound of the forearm is sutured, and the defect of the donor zone is closed with a split skin autograft taken from the outer surface of the thigh.

A skin-fascial radiation autograft on a vascular pedicle is placed in the area of the receptive bed and fixed to the oral mucosa along the perimeter of an extensive defect of the hard palate.

The vascular leg of the skin-fascial beam autograft is passed through a previously formed tunnel to the recipient vessels - the facial artery and veins. Microvascular anastomoses are applied to the facial and radial arteries, facial and radial veins of the cutaneous-fascial beam autograft. The wound is sutured in layers. [Eric M. Genden et al. Head and neck, "Reconstruction of the hard palate using the radial forearm free flap: indications and outcomes", 2004; p.p. 808-814].

One of the main disadvantages of this method is the pronounced damage to the donor zone, characterized by functional and aesthetic disorders:

- increased injuries, namely the loss of the main vessel of the forearm - the radial artery, the cessation of blood flow in the distal segment of the radial artery, which subsequently leads to blood supply to the hand only due to the ulnar artery and the remaining anterior and posterior interosseous branches. In some cases, ischemia of the hand is possible, due to vascular abnormalities.

- violation of statodynamic functions: a decrease in grip strength with the hand, as well as a possible limitation of extension in the wrist joint when the tendons are damaged;

- the length of the vascular pedicle reaches a maximum of 12 cm;

- the donor area needs free plastic to close the wound, in an aesthetically significant area. In some cases, necrosis of a split skin autograft occurs, which can lead to exposure of the tendon and healing of the wound by secondary intention, the development of gross cicatricial changes in the skin;

- the appearance of the donor zone after taking the skin-fascial beam autograft and closing the defect with a free split skin autograft is aesthetically unappealing.

In addition, when using this method, there is a drawback on the part of the recipient area, namely, pronounced edema of the skin-fascial radiation autograft, due to a change in the blood flow of the through type to the terminal, which can cause "functional disorders in the recipient area.

The technical result of this invention is to reduce the invasiveness of the autograft sampling, increase the functional and aesthetic effects in the donor area due to the simpler anatomy of the leg, close the defect in the donor area without using a split skin autograft and expanders, and also place the donor area in a less significant aesthetic area.

The technical result is achieved by the fact that in a method of eliminating an extensive defect of the hard palate by forming a perceptive bed with an incision of the oral mucosa, separating it, followed by isolation of the recipient vessels of the facial artery and veins in the submandibular region, intersecting them, forming a tunnel in the submucosal layer of the cheek extending from the soft palate parallel to the pterygo-mandibular fold along the inner surface of the lateral part of the lower jaw anterior to the projection of the anterior edge muscle in the submandibular region, followed by the removal of the skin-fascial autograft on the vascular pedicle, its fixation to the receptive bed and the vascular pedicle of the skin-fascial autograft through the formed tunnel, followed by revascularization of the skin-fascial autograft, which is a distinctive formation of carried out using cuts of the oral mucosa, retreating 0.8-1.2 cm from the bone edges of an extensive defect of the palate on both sides and separating the mucous membrane of the oral cavity, the two mucous flaps obtained are knocked over to the center of the vast defect of the hard palate, draw together and fix them together, creating a lining between the mucous membranes of the oral cavity and nose, as recipient vessels together with the facial artery and a submental chin vein is used, and a skin-fascial medial calf autograft on a vascular pedicle consisting of medial gastrocnemius arteries and veins with a length of 14-16 cm, followed by a vascular pedicle in the formed tunnel, fixation of a skin-fascial medial gastrocnemic autograft on the vascular pedicle to the mucous flaps in the region of an extensive hard palate defect, its revascularization by applying anastomoses between the medial gastrocnemius and facial , medial gastrocnemius veins and facial and submental veins in the submandibular region, followed by suturing wounds.

The method is as follows (Fig. 1-5)

Prepare a receiving bed (1).

Cuts (2) of the oral mucosa are performed, retreating 0.8-1.2 cm from the bony edges of the vast defect (3) of the hard palate on both sides, two mucous flaps (4) are cut off and cut out, which overturn to the center of the vast defect (3) hard palate, bring them together and fix them together using suture material, thereby creating an inner lining between the mucous membranes of the oral cavity and nose.

Access to the recipient vessels - the facial artery (5), the facial (6) and the submental (7) veins is performed through an incision in the skin, subcutaneous fat, and the own fascia of the neck in the submandibular region, along the upper cervical fold. Recipient vessels are isolated and crossed, taken on holders.

A tunnel (8) is formed in the submucosal layer, extending from the soft palate (9) further parallel to the pterygo-mandibular fold along the inner surface of the lateral part of the lower jaw anterior to the projection of the anterior edge of the chewing muscle into the submandibular region.

At the preoperative preparation stage, preliminary marking of the projection of the medial gastrocnemius artery is performed (10), the necessary shape and area of the cutaneous-fascial medial gastrocnemius autograft are outlined (11), taking into account the extensive defect (3) of the hard palate in the recipient region. Dissection of the skin-fascial medial gastrocnemius autograft (11) on the vascular pedicle (12) - the medial gastrocnemius artery (10) and veins (13) begin with anterior access.

An incision is made in the skin (14) and subcutaneous fat (15) along the medial border (16) of the skin-fascial medial gastrocnemius autograft (11). Dissection is performed until the medial gastrocnemius artery is detected (10). Then, the fascia (17) of the lower leg is dissected, along the medial gastrocnemius artery (10), it is released from the medial gastrocnemius muscle (18) by intramuscular dissection. During the preparation of small vascular perforants dope and cross. Dissection is continued in the proximal direction to the projection level of the popliteal fossa (19), where the mouth of the medial gastrocnemius artery (10) is visualized in the popliteal artery (20). Next, a semi-oval incision is made in the skin (14), subcutaneous fat (15) and fascia (17) of the lower leg with the preservation of the vascular pedicle (12) and extend it to the lateral border region (21) of the fascial-fascial medial calf autograft (11).

Modeling of the skin-fascial medial gastrocnemius autograft (11) on the vascular pedicle (12) relative to the area and shape of the extensive defect (3) of the hard palate is performed. The vascular leg (12) of the cutaneous-fascial medial gastrocnemius autograft (11) in the area of the popliteal artery (20) is cut off, pre-ligating. A postoperative wound in the donor area is sutured in layers.

The vascular leg (12) of the skin-fascial medial gastrocnemius autograft (11) is passed through the tunnel (8) previously formed in the submucosal layer into the submandibular region.

A skin-fascial medial gastrocnemius autograft (11) on a vascular pedicle (12) is fixed in a previously formed receptive bed (1) to the mucous flaps with U-shaped sutures.

Using the microsurgical technique, the skin-fascial medial gastrocnemius autograft (11) is revascularized by applying vascular anastomoses between the medial gastrocnemius (10) and facial arteries (5), as well as the medial gastrocnemius veins (13) and facial (6) and submental chin veins (7) in the submandibular region. Wounds in layers are sutured in layers.

Example 1

Patient X., was in the Department of Oral and Maxillofacial Surgery of FSBI TsNIIS and ChLH with the diagnosis: Post-traumatic defect and deformation of the middle zone of the face. Extensive defect of the hard palate. Partial tooth loss in the upper jaw. Condition after a gunshot wound. "

From the anamnesis it is known that, more than three years ago, an injury was received as a result of a gunshot wound. In addition to primary surgical treatment of the wound and metal osteosynthesis of the upper jaw at the place of residence, reconstructive plastic surgery was not performed.

Clinical examination noted asymmetry of the face due to indentation of the middle zone of the face. When examining the oral cavity in the area of the hard palate, a through bony and soft-tissue extensive defect of the hard palate, 4.5 cm x 6.0 cm in size, and also partial loss of the teeth of the upper jaw were noted.

At the stage of preoperative preparation, the clinical picture of the donor area was assessed for the absence of diseases from the vessels of the lower extremities, as well as autoimmune diseases of the endocrine system.

According to additional examination methods - angiography, ultrasound examination of the vessels of the lower extremities, the anatomical and topographic features, the blood flow velocity of the medial gastrocnemius artery were evaluated.

The clinical picture of the recipient area was also evaluated using multispiral computed tomography of the head and neck in angiography mode.

In the clinic, after a complete clinical, laboratory and instrumental examination under conditions of combined endotracheal anesthesia, an operation was performed to eliminate an extensive hard palate defect by the proposed method.

Prepared a receptive bed.

The mucous membranes of the oral cavity were made, retreating 0.8 cm from the bone edges of the vast defect of the hard palate on both sides along its perimeter, the mucous membrane of the oral cavity of the vast defect of the hard palate was separated on both sides. The obtained two mucous flaps were knocked over to the center of an extensive defect of the hard palate, brought together and fixed them together using suture material, thereby creating an inner lining between the mucous membranes of the oral cavity and nose.

An assessment was made of the area and shape of an extensive defect of a hard round sky 5.0 × 6.5 cm in size.

Access to the recipient vessels - the facial artery, facial and submental chin veins was made through a skin incision in the left submandibular region along the upper cervical fold, parallel to the edge of the lower jaw. By the method of acute and blunt dissection, subcutaneous fatty tissue and the neck's own fascia were dissected in layers. The vessels were isolated - the facial artery, facial and submental veins. Vessels were taken on hold.

A tunnel was formed in the submucosal layer of the cheek, going from the soft palate further parallel to the pterygo-mandibular fold along the inner surface of the lateral part of the lower jaw anterior to the projection of the anterior edge of the chewing muscle to the recipient vessels - the facial artery, facial and submental veins into the left submandibular region.

The projection of the medial gastrocnemius artery was marked taking into account the data of Dopplerography, angiography, as well as the shape and area of the extensive defect of the hard palate on the posterior surface of the right lower leg. Fence skin-fascial medial gastrocnemius autograft performed by front access.

We performed an incision of the skin and subcutaneous fat along the medial border of the marking of the cutaneous-fascial medial gastrocnemius autograft. By the method of blunt and acute dissection, they reached the medial gastrocnemius artery and dissected the fascia of the lower leg. In the course of the medial gastrocnemius artery, its separation from the medial head of the gastrocnemius muscle was performed by intramuscular dissection. During the preparation, small vascular perforants were doped and crossed. We went in the proximal direction to the projection level of the popliteal fossa, where the medial gastrocnemius artery was visualized from the popliteal artery. Then, a semi-oval incision was made of the skin, subcutaneous fat, fascia of the leg with the preservation of the vascular pedicle along the lateral border of the cutaneous-fascial medial gastrocnemius autograft and passed to the medial gastrocnemius artery, and the skin-fascial medial gastrocnemius autograft was isolated.

A correction was made to the shape, area and volume of the cutaneous-fascial medial gastrocnemius autograft, taking into account the individual characteristics of the presented clinical case. The vascular pedicle, consisting of the medial gastrocnemius arteries and veins, was cut off after preliminary ligation. The length of the vascular pedicle was 14 cm. The postoperative wound in the donor area was sutured in layers.

The vascular leg of the cutaneous-fascial medial gastrocnemius autograft was passed through a tunnel into the left submandibular region, which was previously formed in the submucosal layer.

A skin-fascial medial gastrocnemius autograft was fixed in a previously formed receptive bed to mucous flaps in the area of an extensive defect of the hard palate with U-shaped sutures.

Using the microsurgical technique, the skin-fascial medial gastrocnemius autograft was revascularized by applying vascular anastomoses between the medial gastrocnemius and facial arteries of the end-to-end type, as well as the medial gastrocnemic veins and the frontal and submental choroidal veins of the inferior sublingual.

The wound of the left submandibular region was sutured in layers.

In the postoperative period, infusion, antibacterial, anti-inflammatory, hormonal, analgesic, anticoagulant, antifungal therapy were performed; dressings.

Parenteral nutrition was prescribed for three days of the postoperative period, a nasogastric tube was installed for the period of early postoperative rehabilitation. When ultrasound examination was clearly audible pulsation of the vascular pedicle throughout.

As a result of the operation, an extensive defect of the hard palate was eliminated using a revascularized skin-fascial medial gastrocnemius autograft and conditions were created for restoration of the dentofacial function by manufacturing a complete removable orthopedic construction.

Example 2

Patient C was treated at the Department of Oral and Maxillofacial Surgery of FSBI TsNIIS and ChLH with the diagnosis: Extensive hard palate defect. Condition after complex treatment for carcinoma of the mucous membrane of the hard palate. "

From the anamnesis it is known that for the first time the patient noticed the formation on the mucous membrane of the hard palate about 10 years ago. A biopsy was performed in one of the city’s hospitals, and carcinoma of the mucous membrane of the hard palate was detected. The courses of CLT, SOD 40 Gy were carried out, orofacial resection of the hard palate, nasal cavity, nasopharynx, removal of the submandibular case on the right was performed, microsurgical oroplasty was performed with a skin-fascial beam autograft.

In the postoperative period, due to hemodynamic disorders of the autograft, its removal was performed. An additional course of HLG, SOD 30 Gy. Subsequently, the patient was under the supervision of a cancer dispensary at the place of residence, without negative dynamics.

In a clinical examination, the configuration of the face is not changed. When examining the oral cavity in the area of the hard palate, a through bony and soft-tissue extensive defect of the hard palate with a size of 5.0 cm × 6.0 cm was noted.

In order to eliminate an extensive defect of the hard palate, reconstructive plastic surgery according to the proposed method using a revascularized skin-fascial medial calf autograft is recommended.

At the stage of preoperative preparation, the clinical picture of the donor area was assessed for the absence of diseases from the vessels of the lower extremities, as well as autoimmune diseases. According to additional examination methods - angiography and ultrasound examination of the vessels of the lower extremities, the anatomical and topographic features and the blood flow velocity of the medial gastrocnemius artery were evaluated. The clinical picture of the recipient area was also evaluated using multispiral computed tomography of the head and neck in angiography mode.

Prepared a receptive bed.

Cuts of the oral mucosa were performed, retreating 1.2 cm from the bone edges of the vast palate of the hard palate on both sides along its perimeter, the mucous membrane of the oral cavity of the vast palate of the palate was separated on both sides. The obtained two mucous flaps were knocked over to the center of an extensive defect of the hard palate, brought together and fixed them together using suture material, thereby creating an inner lining between the mucous membranes of the oral cavity and nose.

An assessment was made of the area and shape of an extensive defect of a hard round sky of 5.5 cm × 7.0 cm.

Access to the recipient vessels - the facial artery, facial and submental chin veins was made through a skin incision in the left submandibular region along the upper cervical fold parallel to the edge of the lower jaw. By the method of acute and blunt dissection, subcutaneous fatty tissue and the own fascia of the neck are dissected in layers. Traced and highlighted vessels - the facial artery, facial and submental veins. Vessels taken to the holders.

A tunnel was formed in the submucosal layer of the cheek, extending from the soft palate, then parallel to the pterygo-mandibular fold along the inner surface of the lateral part of the lower jaw anterior to the projection of the anterior edge of the chewing muscle to the recipient vessels - the facial artery, facial and submental chin veins into the left submandibular region.

Marked the projection of the medial gastrocnemius artery, taking into account the data of Dopplerography, angiography, as well as the shape and area of the extensive defect of the hard palate on the posterior surface of the right lower leg.

Fence skin-fascial medial gastrocnemius autograft performed by front access. We performed an incision of the skin and subcutaneous fat along the medial border of the marking of the cutaneous-fascial medial gastrocnemius autograft. By the method of blunt and acute dissection, they reached the medial gastrocnemius artery and dissected the fascia of the lower leg. In the course of the medial gastrocnemius artery, its separation from the medial head of the gastrocnemius muscle was performed by intramuscular dissection. During the preparation, small vascular perforants were doped and crossed. We went in the proximal direction to the projection level of the popliteal fossa, where the medial gastrocnemius artery was visualized from the popliteal artery. Next, a semi-oval incision was made in the skin, subcutaneous fat, fascia of the lower leg, while maintaining the vascular pedicle along the lateral border of the cutaneous-fascial medial gastrocnemius autograft, passed to the medial gastrocnemius artery, thereby isolating the skin-fascial medial calf autograft.

A correction was made to the shape, area and volume of the cutaneous-fascial medial gastrocnemius autograft, taking into account the individual characteristics of the presented clinical case. The vascular pedicle — the medial gastrocnemius artery and veins were cut off, after ligation. The length of the vascular pedicle was 16 cm. The postoperative wound in the donor area was sutured in layers.

The vascular leg of the cutaneous-fascial medial gastrocnemius autograft was passed through a tunnel into the left submandibular region, which was previously formed in the submucosal layer.

A skin-fascial medial gastrocnemius autograft was fixed in a previously formed receptive bed to mucous flaps in the area of an extensive defect of the hard palate with U-shaped sutures.

Using the microsurgical technique, the skin-fascial medial gastrocnemius autograft was revascularized by applying vascular anastomoses between the medial gastrocnemius and facial arteries of the end-to-end type, as well as the medial gastrocnemic veins and the frontal and submental choroidal veins of the inferior sublingual.

In the postoperative period, they carried out infusion, antibacterial, anti-inflammatory, hormonal,

analgesic, anticoagulant, antifungal therapy; daily dressings.

Parenteral nutrition was prescribed for three days after the postoperative period.

As a result of the operation, an extensive defect of the hard palate was eliminated using a revascularized skin-fascial medial calf autograft.

The proposed method has the following advantages:

- increased functional effect, by reducing the invasiveness of the method of picking up a skin-fascial medial gastrocnemius autograft, and as a result of minimal damage from the donor zone, accelerated rehabilitation.

- the absence of violations of the statodynamic functions of the lower extremities, since tendons are not affected during the autograft isolation.

- the length of the vascular pedicle can reach 14-16 cm, depending on the dissection level of the medial gastrocnemius artery, which makes it possible to use an autograft with more extensive defects.

- the wound of the donor zone does not need free plastic surgery, since the defect is covered with local tissues, which improves the aesthetic effect.

Claims (1)

A way to eliminate an extensive defect of the hard palate by forming a receptive bed with an incision of the mucous membrane of the oral cavity, its separation, followed by the allocation of recipient vessels - the facial artery and veins in the submandibular region, their intersection, the formation of a tunnel in the submucosal layer of the cheek, coming from the soft palate parallel to the pterygoid the mandibular fold along the inner surface of the lateral part of the lower jaw anterior to the projection of the anterior edge of the chewing muscle into the submandibular region, the subsequent fence of the skin-fascial autograft on the vascular pedicle, its fixation to the receiving bed and the vascular pedicle of the skin-fascial autograft through the formed tunnel, followed by revascularization of the skin-fascial autograft, characterized in that the formation of the receptive bed is carried out using a cut of the mucous membrane retreating 0.8-1.2 cm from the bone edges of an extensive defect of the hard palate on both sides and separating the mucous membrane of the cavity and the mouth, the two mucous flaps obtained are knocked over to the center of the vast defect of the hard palate, draw together and fix them together, creating a lining between the mucous membranes of the oral cavity and nose, as the recipient vessels along with the facial artery and vein, use the submental chin vein, and as a cutaneous -fascial autograft on a vascular pedicle using a skin-fascial medial calf autograft on a vascular pedicle - medial gastrocnemius arteries and veins, 14-16 cm long, followed by con distal leg in the formed tunnel, fixation of a skin-fascial medial gastrocnemius autograft on the vascular pedicle to the mucosal flaps in the region of the extensive hard palate defect, its revascularization by application of anastomoses between the medial gastrocnemius and facial arteries, medial gastrocnemial veins and the submental and submental hyoid subsequent suturing of wounds.

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