RU2733163C2 - Method for elimination of defect of oral cavity mucous membrane - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to oncology, plastic surgery, maxillofacial surgery, dentistry, rehabilitation medicine. Performing the skin-fascial displaced flapping on the vascular pedicle in the genian and the submandibular region, removing the primary focus, lymphodissection on the side of the primary tumor with subsequent replacement of the defect in the oral cavity with a graft of the graft. Diameter and location of facial artery are evaluated by ultrasonic examination. Intraoral access is used to remove the primary focus, marking out the contour of the skin-fascial flap in the submandibular area of the ellipsoidal shape, wherein the upper edge of the flap is the lower edge of the body of the lower jaw, and the middle point of its upper boundary is the point of intersection of the facial artery of the lower jaw body, the lower border is the hyoid bone body level. Further, in the submandibular region, a skin incision is made along the lower outline of the graft marking, according to fig. 1, including a hypodermic neck muscle in the transplant. Flap is lifted to the lower edge of the mandibular body; the skin is incised along the upper contour of the flap in the projection of the facial vessels only to subcutaneous fat. Further, the skin is lifted 2 cm higher from the lower edge of the lower jaw body and 1–2 cm away from the facial artery and vein. Facial vessels are transected and ligated distally 2 cm from the lower edge of the lower jaw body, then a skin incision is made along the upper contour of the flap to a subcutaneous muscle of the neck inclusively. Marginal branch of the facial nerve is completely separated and a flap is exposed under it; the vascular pedicle of the flap is mobilized to the edge of the skin site. Then blunt and acute path of skin-fascial flap is peeled from surrounding tissues and flap is formed, which includes skin, subcutaneous fat, subcutaneous muscle of neck and soft tissue clutch around facial artery above lower edge of lower jaw body. Performing lymphadenectomy on neck, from submandibular region to area of oral cavity defect, tunnel is formed, and through it, by rotation method, flap is placed in the defect area and fixed with vicryl 4.0 threads to the surrounding tissues, after which the formed defect of the submandibular region is eliminated with local tissues.

EFFECT: disclosed method enables to close defects arising in surgical treatment of oral mucosa cancer and reduce length of rehabilitation in postoperative period; provide maximum plastic congruity by using a flap without including an anterior abdomen of the digastric muscle and mandibulohyoid muscle; improving the aesthetic effect and minimizing damage to the donor area.

1 cl, 1 ex, 4 dwg

Description

The invention relates to medicine, in particular to oncology, plastic surgery, maxillofacial surgery, dentistry, rehabilitation medicine, and can be used in the rehabilitation of cancer patients to restore the tissues of the floor of the mouth, tongue, cheeks, and oropharynx.

Many works are devoted to the replacement of defects in the oral cavity using free flaps on microvascular anastomoses. A known method of reconstruction of the tongue with extensive defects of the oral cavity, which consists in the fact that the resected tissues of the tongue and oral cavity are restored using an autograft formed from a free colonic-omental flap. The feeding vascular pedicle is formed by creating microvascular anastomoses between the middle colic artery and the vein and the branches of the external carotid artery and the internal jugular vein (RU 2391925 C1).

The advantages of this method are that in one surgical stage it is possible to restore the integrity of the tongue and the oral mucosa, improve tissue adaptation by comparing the oral epithelium and the intestinal flap mucosa, which reduces the frequency of fistula formation and reliably isolates the vessels of the neck due to additional covering the suture line of the mucous membranes with an omental fragment.

Along with the advantages, there are also disadvantages:

- a significant duration of the operation with the use of expensive microsurgical equipment in specialized clinics, the need for specially trained personnel,

- the limit of the use of the described method in patients after undergoing surgical interventions in the abdominal cavity in the history due to the adhesive process,

- limited possibility of using the method in patients with severe concomitant pathology due to the need for prolonged anesthesia,

- increased trauma due to intervention in several anatomical areas (neck and abdominal cavity),

- increased risk of surgical complications due to the creation of an additional wound for the collection of donor material,

- increased risk of obstruction (thrombosis) of vascular anastomoses and, as a consequence, necrotic complications.

A known method of reconstruction of defects in cancer of the oral mucosa by using a radial flap, the blood supply of which is restored due to microsurgical anastomosis between the radial artery and the comitant veins and branches of the external carotid artery and the internal jugular vein (Soutar DS et al. The radial forearm flap: a versatile Method for intra-oral reconstruction, British Journal of Plastic Surgery, Volume 36, Issue 1, 1983, pp. 1-8). The advantage of using a radial flap is to restore the integrity of the tongue and the floor of the mouth in one surgical step.

Despite the good functional and anatomical results, the method has several disadvantages:

- a significant duration of the operation using microsurgical techniques in specialized clinics, the need for specially trained personnel,

- limited use of the method in patients with severe concomitant pathology due to the need for prolonged anesthesia;

- cosmetic defect of the donor area;

- increased risk of surgical complications due to the creation of an additional wound for the collection of donor material;

- increased risk of obstruction (thrombosis) of vascular anastomoses and, as a consequence, necrotic complications.

There is a method of reconstruction of the tongue and the floor of the mouth (RU 2546097 C1) with a musculocutaneous flap, including the skin area of the anterior surface of the neck and the sternohyoid muscles, having blood supply from the branches of the superior thyroid artery. The formed flap is moved into the oral cavity, replacing the defect in the mucous membrane of the floor of the mouth with a skin area, and the soft tissues of the floor of the oral cavity, tongue, and submandibular region are restored with a muscle fragment of the flap.

However, the method has several disadvantages:

- in most cases, it is not possible to obtain a sufficient amount of plastic material to form a neo-language and replace larger defects in the floor of the oral cavity,

- does not have sufficient mobility and its use is limited to adjacent anatomical areas,

- cosmetic defect of the donor area.

The prototype of the invention is a method of surgical reconstruction of the oral mucosa, which consists in the use of a fascial-cutaneous displaced submental flap on a vascular pedicle, characterized in that the primary focus is removed, lymphadenectomy is performed on the side of the primary tumor, and in the presence of unilateral regional metastases, the upper the lateral pole of the submandibular salivary gland with the facial artery to the point of origin of the submental artery from the contralateral side along the lower edge of the arch of the lower jaw with unilateral inclusion of the anterior abdomen of the digastric muscle, the maxillary-hyoid muscle, followed by replacement of the defect in the oral cavity with the cutaneous area of the flap (RU 27060) The method allows to restore the integrity of the tongue and the floor of the oral cavity in one surgical stage without using complex microsurgical techniques, which allows the method to be widely used.

However, the known method has several disadvantages:

- difficult to apply in the presence of metastases in regional (submandibular) lymph nodes,

- unsatisfactory oncological result due to the possibility of metastases in the lymph nodes, which move with the tissue around the vascular pedicle of the displaced flap,

- increased trauma to the donor area due to the need to include the digastric muscle, the maxillary-hyoid muscle in the flap of the anterior abdomen,

- the inability to use to close small and medium defects of the oral mucosa due to the large size of the flap, since it includes the anterior abdomen of the digastric muscle, the maxillary-hyoid muscle and the fat cuff around the vascular pedicle,

- hair growth on the skin area of the flap.

The objective of the invention is to maintain the oncological efficiency of surgical treatment while improving the functional and aesthetic results.

The technical result of the claimed method is to preserve the function of swallowing and speech, reduce the trauma of the main stage of surgery, minimize additional surgical interventions such as: flap correction, reinnervation and shortening the length of hospital stay.

provides sufficient blood flow in the area of the fascial skin flap, due to the hemodynamically significant perforator from the facial artery. In turn, this minimizes the risk of postoperative complications.

The specified technical result in the implementation of the invention is achieved due to the fact that, as in the known method, a skin-fascial displaced flap on the vascular pedicle, formed in the chin and submandibular region, is used, the primary focus is removed, lymphadenectomy is performed on the side of the primary tumor, followed by replacement of the defect in the oral cavity with the skin area of the flap.

The peculiarity of the proposed method is that the diameter and location of the facial artery is assessed by ultrasound examination, the primary focus is removed by intraoral access, the contour of the fascial skin flap is marked in the submandibular region of an elliptical shape, and the upper border of the flap is the lower edge of the lower jaw body, and the midpoint its upper border is the place of intersection of the facial artery of the body of the lower jaw, the lower border is the level of the body of the hyoid bone, then in the submandibular region, a skin incision is made along the lower contour of the flap marking, according to Fig. 1, including the subcutaneous muscle of the neck in the graft, the flap is raised to the lower edge the body of the lower jaw in the subplatysmal plane, and the skin incision along the upper contour of the flap in the projection of the facial vessels is made only to the subcutaneous tissue, then the skin is raised 2 cm higher from the lower edge of the lower jaw body and 1-2 cm away from the facial artery and vein , facial vessels per dissect and ligate distally 2 cm from the lower edge of the body of the lower jaw, then along the upper contour of the flap the skin incision is made up to the subcutaneous muscle of the neck, inclusively, the marginal branch of the facial nerve is completely isolated and the flap is carried out under it, the vascular pedicle of the flap is mobilized to the edge of the skin area, then in a blunt and sharp way, the tissue of the fascial skin flap is exfoliated from the surrounding tissues and a flap is formed, including the skin, subcutaneous fat, the subcutaneous muscle of the neck and a soft tissue sleeve around the facial artery above the lower edge of the lower jaw body, lymphadenectomy is performed on the neck, a tunnel is formed from the submandibular region to the area of the oral cavity defect and through it, by rotation, the flap is placed in the defect area and fixed with 4.0 vicryl threads to the surrounding tissues, after which the resulting submandibular region defect is eliminated with local tissues.

The essence of the proposed method consists in the elimination of the defect in the oral mucosa with a skin-fascial flap, including the skin area of the submandibular region, subcutaneous fat, subcutaneous muscle of the neck. For additional blood supply to this flap, a complex of soft tissues is used, located around the facial artery and vein, from the level of the lower edge of the mandible and 2 cm long in the distal direction, with a perforating vessel emanating from the facial artery, located perpendicular to the skin of the fascial skin flap. This complex of soft tissues is designed to maintain the connection of the facial perforating vessels extending from the facial artery and located above the lower edge of the mandibular body with the flap. The formed flap is moved into the oral cavity, with a skin area in the plane of the oral mucosa.

In the submandibular region below the edge of the body of the lower jaw, there are only perforators of the level I facial artery, emanating directly from the facial artery, and perforators of the submental artery. Given the anatomical and topographic features of the submandibular flap, there is a very high probability of the absence of level I perforating vessels and the submental artery. The inclusion of level II facial artery perforators in the fascial skin flap with the subcutaneous muscle of the neck provides guaranteed perforating blood flow, eliminates the need to use a vascular pedicle along the graft width, which in turn minimizes donor damage and postoperative complications. The inclusion of level II facial artery perforators is achieved through the use of a complex of soft tissues (couplings) around the facial vessels (facial artery and vein) from the level of the lower edge of the lower jaw body and extending 2 cm in the distal direction and 1-2 cm to the sides.

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

FIG. 1 - marking of the submandibular flap: 1 - the facial artery and vein, 2 - the lower contour of the fascial skin flap, 3 - the lower edge of the lower jaw body, 4 - the upper contour of the fascial skin flap, 5 - the outer border of the soft tissue complex located around the facial vessels from the level of the lower edge of the body of the lower jaw and 2 cm long in the distal direction, designed to maintain the connection of the facial perforating vessels with the flap.

FIG. 2 - flap formation: 2 - lower contour of the fascial skin flap, 4 - upper contour of the fascial skin flap.

FIG. 3 - formed flap: 6 - formed submandibular flap, 7 - area of soft tissues designed to maintain the connection of the facial perforating vessels located above the lower edge of the mandibular body with the flap.

FIG. 4 - elimination of a defect in the oral mucosa; 8 - formed neoplasm.

The method is carried out as follows.

Before the operation, using ultrasound, the diameter and location of the facial artery is assessed (Fig. 1). The primary focus is removed by intraoral access. According to the size of the defect in the oral mucosa, the contour of the fascial skin flap is marked in the elliptical submandibular region. The upper border of the flap is the lower edge of the lower jaw body (the midpoint of its upper border is the intersection of the facial artery of the lower jaw body), the lower border is the level of the hyoid bone body. The horizontal dimensions of the flap can reach the angle of the mandible and the midline of the neck. Further, in the submandibular region, a skin incision is made along the lower contour of the flap marking, including the subcutaneous muscle of the neck in the graft (Fig. 1). Then the flap is lifted to the lower edge of the lower jaw body in the subplatysmal plane. The skin incision along the upper contour of the flap in the projection of the facial vessels is made only up to the subcutaneous tissue (Fig. 2). Further, the skin rises at least 2 cm higher from the lower edge of the body of the lower jaw and 1-2 cm away from the facial vessels (facial artery and vein). The facial vessels are crossed and ligated distally 2 cm from the lower edge of the mandible. The complex of soft tissues is designed to maintain the connection of the facial perforating vessels of the II level, located above the lower edge of the lower jaw body, with a flap. For better protection of the facial vessels, the periosteum of the mandible and the fascia of the masticatory muscle should be maximally preserved at the level of the preserved complex of soft tissues around the facial artery, as much as possible included in the flap. For the rest of the length along the upper contour of the flap, a skin incision is made up to and including the subcutaneous muscle of the neck. The marginal branch of the facial nerve must be fully traced and exposed to allow the flap to pass underneath. The vascular pedicle of the flap is mobilized to the edge of the skin area. In a blunt and sharp way, the tissues of the fascial skin flap are exfoliated from the surrounding tissues. Thus, a flap is formed, which includes skin, subcutaneous fat, subcutaneous muscle of the neck, a soft tissue sleeve around the facial artery above the lower edge of the mandible (Fig. 3). Next, lymphadenectomy is performed on the neck according to accepted standards. A tunnel is formed from the submandibular region to the area of the defect in the oral cavity. Through it, by the method of rotation, the flap is placed in the area of the defect (the receiving bed) and then fixed with 4.0 Vicryl threads to the surrounding tissues (Fig. 4). The resulting defect in the submandibular region (as a result of the graft harvest) is easily removed by local tissues, which in turn significantly reduces donor damage.

Clinical example of implementation.

Patient K., 60 years old, clinical diagnosis: C06.0 Cancer of the left cheek mucosa cT3N0M0, stage III.

Status localis upon admission: Neck and face configuration not changed. When examining the oral cavity: on the mucous membrane of the left cheek, an exophytic tumor is determined (1.5 cm above the level of the mucous membrane), the length from the wing-jaw fold to the commissure of the mouth is 6 cm, from the upper arch of the vestibule to the lower one - 4 cm. The neoplasm is wide base, soft-elastic consistency with areas of compaction, moderately painless on palpation. It has a bumpy surface, irregular shape, clear uneven contours, a folded surface, covered with a grayish bloom that cannot be removed with a spatula. Enlarged lymph nodes in the submandibular region (level Ib) on the left of a tight-elastic consistency up to 1.5 cm are detected by palpation.

Histological examination: The morphological picture is most consistent with verrucous squamous cell carcinoma.

Taking into account the data of histological examination and the prevalence of the tumor process, the patient was recommended to perform an operation in the volume: removal of the tumor of the mucous membrane of the left cheek with reconstruction with a submandibular flap, selective cervical dissection (levels I-III on the left).

Surgical protocol: When examining the oral cavity, an irregularly shaped tumor affects the mucous membrane of the left cheek from the commissure of the mouth to the mucous membrane of the alveolar ridge of the lower jaw on the left, up to the wing - the jaw folds up to 6 cm in size in the largest dimension. Removal of the tumor of the left cheek mucosa was performed under the ETN using a harmonic scalpel, 1 cm away from the visible borders of the tumor. Further, the contour of the submandibular fascial skin flap was marked, according to the size of the defect in the oral mucosa (Fig. 1). Skin incision in the upper third of the neck on the left (Fig. 2) with the formation of a submandibular flap 6x4 cm, including skin, subcutaneous fat, subcutaneous muscle of the neck, a complex of soft tissues around the facial artery above the lower edge of the mandible (Fig. 3). Further, the cervical skin flaps were separated and taken on the holders. The anterior edge of the sternocleidomastoid muscle is highlighted. The neurovascular bundle is exposed. During the revision, several densely elastic lymph nodes are noted at level I-II, ranging in size from 0.5 to 1.5 cm. Acute and blunt way mobilized and removed the neck tissue on the left (levels I-III). A tunnel is formed from the submandibular region to the defect area. Further, the submandibular flap was rotated through the subcutaneous tunnel to the area of the cheek defect and fixed with interrupted sutures to the edges of the mucous membrane defect, the integrity of the buccal mucosa was restored (Fig. 4). The flap is viable during revision. The wound on the neck was sutured tightly in layers, leaving a tubular drainage in the submandibular region on the left. Applied alcohol aseptic dressing. Installed nasogastric tube for feeding.

The postoperative period is smooth. The wounds healed by primary intention. The flap is viable, adapted satisfactorily, without signs of impaired blood supply. In the early postoperative period, food was administered through a nasogastric tube. From the 14th day, oral feeding was started. She was discharged from the hospital in satisfactory condition.

3 months after the operation, satisfactory functions of chewing, swallowing, speech production are noted, there are no signs of disease progression.

Thus, the proposed method can be used to eliminate defects arising from the surgical treatment of cancer of the oral mucosa.

The proposed method provides sufficient blood flow in the area of the fascial skin flap, due to the hemodynamically significant perforator from the facial artery. In turn, this minimizes the risk of postoperative complications. In the submandibular region, the resulting defect as a result of graft harvesting is easily eliminated by bringing the surrounding tissues closer and fixing, which in turn significantly reduces donor damage.

The proposed method in clinical practice allowed:

- to close the defects arising from the surgical treatment of cancer of the oral mucosa and to shorten the duration of rehabilitation in the postoperative period;

- to ensure maximum plastic congruence by using a flap without including the anterior abdomen of the digastric muscle and the maxillary-hyoid muscle;

- improve the aesthetic result and minimize damage to the donor area.

Claims (1)

A method for eliminating a defect in the oral mucosa, including the formation of a skin-fascial displaced flap on the vascular pedicle in the chin and submandibular region, removal of the primary focus, lymphadenectomy on the side of the primary tumor, followed by replacement of the defect in the oral cavity with the skin area of the flap, characterized in that ultrasound examination the diameter and location of the facial artery is assessed, the primary focus is removed by intraoral access, the contour of the fascial skin flap is marked in the submandibular region of an elliptical shape, and the upper border of the flap is the lower edge of the mandible body, and the midpoint of its upper border is the intersection of the facial artery of the lower body jaw, the lower boundary is the level of the body of the hyoid bone, then in the submandibular region, a skin incision is made along the lower contour of the flap marking, according to Fig. 1, including the subcutaneous muscle of the neck in the graft, the flap is raised to the lower edge of t ate the lower jaw, and the skin incision along the upper contour of the flap in the projection of the facial vessels is made only to the subcutaneous tissue, then the skin is lifted 2 cm higher from the lower edge of the lower jaw body and 1-2 cm away from the facial artery and vein, facial vessels cut and ligated distally 2 cm from the lower edge of the lower jaw body, then along the upper contour of the flap, a skin incision is made up to the subcutaneous muscle of the neck, inclusively, the marginal branch of the facial nerve is completely isolated and the flap is carried out under it, the vascular pedicle of the flap is mobilized to the edge of the skin area, then in a blunt and sharp way, the tissue of the fascial skin flap is exfoliated from the surrounding tissues and a flap is formed, including the skin, subcutaneous fat, the subcutaneous muscle of the neck and a soft tissue sleeve around the facial artery above the lower edge of the lower jaw body, lymphadenectomy is performed on the neck, a tunnel is formed from the submandibular region to the area of the oral cavity defect and through it, by rotation, a flap placed in the area of the defect and fixed it with 4.0 vicryl threads to the surrounding tissues, after which the resulting defect in the submandibular region is eliminated with local tissues.

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