RU2717222C1 - Method for eliminating subtotal through defect of anterior palate and orinasal anastomosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to maxillofacial surgery, and can be used for elimination of subtotal through defect of anterior hard palate and orinasal anastomosis, which can occur as a result of resection of tumour growths, traumatic injuries, congenital malformations. Anastomosis is removed by forming a sensory bed and closing the defect with a soft-tissue axial flap. At that formation of the sensory bed is carried out by mobilization by dissection of adjacent to the defect and orinasal anastomosis of oral cavity mucosa, elimination of orinasal anastomosis by approach, invagination and fixation, by means of submerged U-shaped sutures, free edges of the oral mucosa along the middle line of the subtotal through defect of the anterior part of the hard palate and the orinasal anastomosis with formation of the inner lining of the sensory bed. As soft-tissue axial flap cheek axial mucous-muscular flaps are used on facial arteries with reverse direction of blood flow on both sides, which rotate in region of formed receiving bed, sutured together between them and with edge of receiving bed.

EFFECT: method allows increasing functional and aesthetic effect, reducing traumatism of the method.

1 cl, 1 ex, 4 dwg

Description

This invention relates to medicine, namely to maxillofacial surgery, and can be used to eliminate the subtotal end-to-end defect of the anterior hard palate and nasal anastomosis, which can occur as a result of resection due to tumor formations, traumatic injuries, congenital malformations.

There is a method of eliminating subtotal end-to-end defects of the anterior hard palate and nasal anastomosis using a revascularized axial musculocutaneous thoracodorsal flap.

The skin area of the revascularized musculoskeletal thoracodorsal flap is cut out in accordance with the size of the subtotal penetrating defect of the anterior hard palate and rotonosal anastomosis.

The flap is taken on the vascular pedicle (thoracodorsal vascular bundle) for subsequent revascularization through the vessels of the face. A revascularized axial musculocutaneous thoracodorsal flap is placed in the area of the defect and the nasal anastomosis in the form of a duplicate with de-epidermization along the inflection line, which allows to immediately eliminate the subtotal transverse defect of the anterior hard palate and the nasal anastomosis [Nerobeev A.I. Restoration of tissue of the head and neck. - M .: Medicine. - 1988. - S. 131-141].

The disadvantage of this method is the large thickness of the revascularized axial musculoskeletal thoracodorsal flap, and therefore the bulk tissue array for a long time prevents the adequate performance of the functions of swallowing, chewing food, and phonation.

Closest to the proposed method is a method of eliminating a subtotal end-to-end defect of the anterior hard palate and rotonosal anastomosis with a revascularized axial de-epidermized skin-fascial radial rag. [E.V. Verbo, A.I. Nerobeev; Reconstruction of the face with revascularized autografts - M: OJSC "Publishing House" Medicine ", - 2008. - S. 138-153].

The method consists in conducting a bordering incision of soft tissues in the region of the subtotal penetrating defect of the anterior hard palate and rotonosal anastomosis, retreating 1.5-2 mm from the edge of the defect. The perceiving surface is formed by excision of the mucous edge adjacent to the defect. An axial de-epidermized skin-fascial radial flap is moved to the formed perceiving surface in the region of the anterior hard palate and the nasal anastomosis, revascularization is performed through the facial vessels.

The axial skin-fascial radial flap is taken by linear incision of the skin and subcutaneous fat of the flexion surface of the forearm in accordance with the specified parameters of the skin-fascial site of the flap.

Cut the skin, subcutaneous fat, superficial fascia of the flexion surface of the forearm. Then, in the block with the underlying tissues, the skin-fascial site of the flap is separated from the underlying muscles (radial flexor of the wrist, superficial flexor of the fingers, long palmar muscle). Allocate a vascular bundle - the radial artery and adjacent veins to the point where they flow into the brachial artery and vein. The distal and proximal ends of the vessels are ligated. The skin area of the obtained axial dermal-fascial radiation flap is de-epidermized.

In accordance with the dimensions of the subtotal penetrating defect of the anterior hard palate and the nasal anastomosis, a revascularized axial skin-fascial radial rag is formed with revascularization through the facial artery and vein, and fixed with interrupted sutures in the region of the subtotal penetrating defect of the anterior part of the hard palate and the nasal anastomosis edge to edge.

To close the donor defect, split skin from the thigh is used. [E.V. Verbo, A.I. Nerobeev; Reconstruction of the face with revascularized autografts - M .: OJSC "Publishing house" Medicine ", - 2008. - S. 46-50].

The disadvantage of this method is the large thickness of the revascularized axial skin-fascial radial flap, in comparison with the recipient zone and, as a result of this, difficulty in chewing, swallowing, and speech formation.

In addition, the disadvantages of this method from the donor region include ischemia of the upper limb against the background of the development of radial artery dysfunction, the inability to close the donor defect with local tissues, the need to use a free split skin autograft to close the defect in the donor zone.

Also, after the formation of the flap, the invasiveness increases and discomfort for the patient is created due to its location in a prominent place.

The technical result of this invention is to increase the functional and aesthetic effect, reducing the invasiveness of the method.

The technical result is achieved by the fact that in the method of eliminating the subtotal end-to-end defect of the anterior hard palate and nasal anastomosis by forming the receptive bed and closing the defect with a soft-tissue axial flap, a distinctive feature is that the formation of the receptive bed is carried out by mobilization by dissection of the mucosa adjacent to the defect and the nasal anastomosis. the oral cavity, the elimination of the nasal anastomosis by convergence, intussusception and fixation of the free edges of the oral mucosa according to the single line of the subtotal end-to-end defect of the anterior hard palate and mouth-nasal anastomosis with the formation of the inner lining of the receptive bed, and as a soft-tissue axial flap, use the buccal axial mucus-muscular flaps on the facial arteries with a reversible direction of blood flow from two sides that rotate into the region of the formed receptive bed , stitch them together and with the edge of the perceiving bed. The method is as follows (Fig. 1-4): Preparation of the receiving bed (1) after preliminary hydrotreating of soft tissues with a solution of Ubestezin 4% - 5.0 ml, carried out by a bordering incision (2), 1.5-2 mm from the edge subtotal end-to-end defect of the anterior part of the hard palate and rotonosal anastomosis (3). Then, through acute dissection, the edges of the mucous membrane are mobilized by 1.0-2.0 cm, the free edges of the mucous membrane are invaginated and brought together along the midline (4) of the subtotal end-to-end defect of the anterior hard palate and rotonosal anastomosis (3) and fix them together using submersible U-shaped seams.

Mark the planned buccal axial mucus-muscular flap (5) on the facial artery with a reversible blood flow direction, including the adjacent part of the buccal muscle (6) on the mucous membrane of the cheek, indicating the boundaries of the buccal axial mucus-muscular flap (5) on the facial artery, including the adjacent part buccal muscle in accordance with the shape and size of the defect. The borders of the flap: posterior-upper border (7), retreating 4.5-5 mm from the outlet mouth of the duct of the parotid salivary gland, posterior-lower - in the projection of the pterygo-mandibular suture (8), front - posterior by 1-0.8 cm from the commissure of the lips. The buccal axial mucus-muscular flap is cut out, the width of which is 2-2.5 cm, the length is 7-8 cm. An incision of the mucous membrane of the cheek and buccal muscle is performed. Under the buccal muscle, the feeding flap (5) of the facial artery (9) is identified, dissection is performed between the perforators of the facial artery and the buccal-pharyngeal fascia towards the base of the vascular pedicle, and the facial artery (9) is ligated at the base of the vascular pedicle.

Thus, a buccal axial mucus-muscular flap (5) is obtained on the facial artery (9) with a reverse blood flow direction, including the mucous membrane of the cheek, the adjacent part of the buccal muscle (6) and the nourishing facial artery (9) with a reverse direction of blood flow (FAMM- flap). Hemostasis is carried out using bipolar electrocoagulation during the operation.

Such manipulation is carried out from the opposite side.

Formed FAMM-flaps rotate in the area of the receiving bed. The edges of the FAMM-flaps with interrupted sutures are fixed to the edges of the defect (3) and to each other.

Compared FAMM-flaps in combination with the previously formed inner lining of the receiving bed (1) reliably disconnect the oral and nasal cavities, eliminating the subtotal transverse defect of the anterior hard palate and the nasal anastomosis (3).

Example

Patient A. was in the department of reconstructive maxillofacial surgery, microsurgery and ectoprosthetics of FSBI TsNIIS and ChLH with the diagnosis: Subtotal transient defect of the anterior part of the hard palate, nasal anastomosis.

During external examination in the oral cavity: In the area of the hard palate in the anterior section there is a through extensive defect of the hard palate, mouth-nasal anastomosis, with dimensions 25 × 55 mm. The edges are even, sounding is painless. In the area of soft and hard palate, multiple normotrophic scars.

After a complete clinical and laboratory examination, the clinic performed the operation of the proposed method.

After preliminary hydropreparation of the soft tissues of the anterior hard palate and rotonosal anastomosis with Ubestezin solution 4% - 5.0 ml, a bordering incision was made, 1.5 mm indented from the edge of the subtotal through defect of the anterior hard palate and rotonosal anastomosis. Then, through acute dissection, the edges of the mucous membrane are mobilized by 1.0 cm, invaginated and brought together along the midline of the subtotal end-to-end defect of the anterior hard palate and rotonosal anastomosis using submersible U-shaped sutures.

Marking of the planned buccal axial axial mucus-muscle flaps on the facial artery from two sides was carried out in accordance with the shape and size of the defect. The borders of the flaps: the posterior-upper border is 5 mm higher than the outlet mouth of the duct of the parotid salivary gland, the posterior-inferior border is in the projection of the pterygo-mandibular suture, the anterior one is posterior to 0.8 cm from the lip commissure. A flap was cut, 2 cm wide, 7 cm long. An incision was made in the mucous membrane of the cheek and buccal muscle. The facial artery feeding the flap was identified under the buccal muscle, dissection was performed between the perforators of the facial artery and the buccal-pharyngeal fascia towards the base of the vascular pedicle, and the facial artery is ligated at the base of the vascular pedicle.

Similar manipulation is carried out from the opposite side. Thus, axial buccal mucus-muscular flaps were obtained on the facial arteries with a reverse direction of blood flow, including the mucous membrane of the cheek, adjacent parts of the buccal muscles and the nourishing facial arteries - FAMM-flaps. Hemostasis was performed using bipolar electrocoagulation during the operation.

Formed FAMM-flaps rotated in the area of the receiving bed. The edges of the FAMM-flaps with interrupted sutures are fixed to the edges of the defect and to each other.

In the postoperative period, infusion, antibacterial, anti-inflammatory, desensitizing analgesic therapy were performed; parenteral nutrition, antiseptic treatment of the oral cavity.

Postoperative patient rehabilitation for a week.

As a result of the operation, the subtotal end-to-end defect of the anterior hard palate and the mouth cavity were eliminated using two buccal axial mucus-muscular flaps on the facial artery with a reversed blood flow direction of FAMM-flaps. The patient as a result of surgical treatment eliminated the message between the nasal and oral cavity.

Thus, the proposed method can be used to eliminate subtotal end-to-end defects of the anterior hard palate and rotonosal anastomosis in patients after a series of operations for congenital clefts, resections for benign hard palate formations, traumatic injuries, bisphosphonate necrosis.

The proposed method has several advantages, such as:

The ability to eliminate subtotal end-to-end defects of the anterior hard palate and rotonosal anastomosis with the most anatomically and physiologically similar tissue - buccal axial mucus-muscular flaps on the facial artery with a reversed direction of blood flow of FAMM-flaps, which has the necessary mucous membrane.

The ability to eliminate subtotal end-to-end defects of the anterior section of the hard palate with relatively small donor damage, which reduces the invasiveness of the method and the likelihood of complications from the donor zone.

The use of soft tissues adjacent to the defect allows you to create an internal lining of the nasal cavity, and FAMM-flap tissue to bring sufficient blood supply to this area, thereby ensuring the safety and reliability of this method.

The anatomical proximity of the donor zone to the recipient allows you to create an optimally smooth and even surface without creating an excess of replanted tissues, thus not making breathing and passage of solid and liquid food difficult.

Claims (1)

A method for eliminating a subtotal end-to-end defect of the anterior hard palate and rotonosal anastomosis by forming a receptive bed and closing the defect with a soft-tissue axial flap, characterized in that the formation of the receptive bed is carried out by mobilization by dissection of the oral mucosa adjacent to the defect and rotonosal anastomosis, elimination of the rotonosal anastomosis by approach, invagination and fixation, using submersible U-shaped sutures, free edges of the oral mucosa along the midline of the subtotal squaw defect of the anterior part of the hard palate and the nasal anastomosis with the formation of the inner lining of the receptive bed, and as a soft tissue axial flap, use the buccal axial mucus-muscular flaps on the facial arteries with a reversible direction of blood flow from two sides, which rotate into the region of the formed receptive bed, stitch them between themselves and with the edge of the perceiving bed.

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