RU2769627C1 - Method for replacing combined defects of the orbit and nose area - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to oncology, ophthalmology, reconstructive plastic surgery and maxillofacial surgery. Resection of nasal tissues and exenteration of the orbit are performed. A parietal-temporal-frontal periosteal-aponeurotic flap is formed, including a. frontalis, a. supraorbitalis, a. temporalis superficialis. The skin-fat island component is mobilized simultaneously from the frontal region. After tissue dissection along the edge of the formed defect in the fronto-zygomatic region, a tunnel is formed from the nasal septum to the lateral edge of the eyebrow of the affected side. Then, the isolated tissue complex is passed through the formed tunnel to the area of ​​the defect and fixed with sutures: the skin-fat component is sutured to the nose defect, and the periosteal-aponeurotic component is fixed in the orbital cavity. The donor bed is sutured in a line.

EFFECT: method allows to reduce the invasiveness of surgical intervention, reliably eliminate the communication of the nasal cavity with the external environment, carry out early prosthetics, optimize the aesthetic results of treatment and reduce the rehabilitation time of patients.

1 cl, 1 ex, 6 dwg

Description

The invention relates to medicine, namely to oncology, ophthalmology, plastic surgery, maxillofacial surgery, and can be used in reconstructive and restorative surgery. It can be used in patients for the reconstruction of orbital defects and through defects of the nose resulting from malignant lesions, surgical interventions, radiation therapy, trauma and infectious complications. In the region of the orbit and the region of the nose, there are formations of various types and volumes, both of the primary lesion of the tissues of the orbit, and those spreading from neighboring anatomical regions of the nasal cavity, cells of the ethmoid labyrinth, maxilla and sinus (basal cell carcinoma, squamous cell carcinoma, melanoma, various adenocarcinomas) . Restoration of defects in this area involves the reconstruction of the 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 bed for the exoprosthesis.

A known method of replacing the defect of the upper jaw using a muscle or musculoskeletal flap with the inclusion of the pectoralis major muscle in the delayed period (Restorative surgery of soft tissues of the maxillofacial region. A guide for doctors / P.Z. Arzhantsev, V.A. Vissarionov, B. N. Davydov and others, edited by A. I. Nerobeev, N. A. Plotnikov, Moscow: Medicine, 1997, pp. 54-58). The disadvantages of this method are the massiveness of the flap, the significant remoteness of its recipient zone, which requires the inclusion of a distal zone with low perfusion in the flap and creates a risk of partial or complete necrosis of the flap. In addition, significant shortcomings are a pronounced aesthetic and functional deficit of the donor area, as well as limited mobility of the patient's head, which requires subsequent re-corrective surgery.

A known method of plasty of extensive facial tissue defects after radical excision of a block of tissues of the cheek, the side wall of the external nose and exenteration of the orbit by the combined closure of the wound bed with displaced and free flaps, while forming a muco-cartilaginous flap, including the perichondrium of the nasal septum in the direction from the top to the base , displaced and reduced to contact with the remaining mucous membrane of the outer wall of the nasal cavity and stitched on the drainage tube, the outer surface of the defect is restored with a free cutaneous-muscular-fascial flap on a vascular pedicle, which is used to model the contours of the face. The method is carried out using microsurgical techniques. Subsequently, cosmetic correction of the flap is performed with implantation of an ocular prosthesis in its tissue (Method of plastic surgery of extensive facial defects. Reshetov I.V., Chissov V.I. et al. Patent RU 2069541). The disadvantages of this method are: the use of two flaps (displaced muco-cartilaginous and free); causing additional injury to healthy tissues of the body during the collection of the muco-cartilaginous flap, namely the cartilage of the nasal septum and the donor bed of the skin-muscular-fascial flap; the use of microsurgical techniques to close the defect, which requires specialists and equipment not available everywhere.

There is a known method of plastic closure of facial and orbital defects after removal of a block of tissues of the anterior surface of the face, exenteration of the orbit, plastic replacement of the defect due to the muscle flap, while cutting out the skin-muscle-conjunctival flap with the preservation of eyelashes, eyelids, skin corners of the eye, separating it from the subject surface of the eye and underlying tissues of the orbit and direct it to the temporo-zygomatic region, while maintaining neurovascular connections with the temporo-zygomatic zone, move the graft and close the defect of the face and orbit with it, cut out the orbital bed in the upper part of the graft from the muscular portion of the orbit, sew the edges of the bed with a displaced eyelid flap along its edge, after complete healing of the wound, the second stage is implanted into the remaining palpebral fissure of the ocular endoprosthesis (Method of plastic closure of facial and orbital defects. Chissov V.I., Reshetov I.V. et al. Patent RU 97113728) . The disadvantages of this method are: significant additional traumatization of surrounding tissues (formation of a flap from the serratus muscle); the flap has one feeding leg and in case of thrombosis of the vascular anastomosis there is a violation of the blood supply and the death of all layers of the flap; in addition, the condition for this type of plastic is the preservation of the eyelids, skin corners of the eye and the ciliary edge, which is often impossible due to the prevalence of the tumor process.

A known method of plastic closure of the combined defect of the orbit and adjacent anatomical regions using the frontal-temporal periosteal-aponeurotic flap after exenteration of the orbit and removal of tissues of the anterior surface of the face. Frontotemporal periosteal-aponeurotic flap, including a. frontalis, a. supraorbitalis, a. trochlearis is mobilized, a tunnel is formed along the edge of the formed defect in the temporal, zygomatic and frontal regions, from the pinna of the auricle to the eyebrow of the opposite side. Then the flap is tilted through the formed tunnel towards the defect, placed on it and fixed with sutures over the entire wound surface of the defect. The donor wound is sutured. (The method of plastic closure of the combined defect of the orbit and the anatomical regions adjacent to it. Zaderenko I.A. et al. Patent No. RU 2555110). The disadvantage of this method is the limited plastic resources for closing combined defects of the orbital cavity and tissues of the external nose, which are often formed when the tumor is localized in the medial parts of the orbit. This method was chosen by the authors for the prototype.

The technical result of the invention is to increase the efficiency of replacing an extensive combined defect of the orbit, the anatomical regions bordering it, in particular through defects in the nasal cavity, maxillary sinus and ethmoid labyrinth, obtaining a good functional and cosmetic result, which will improve the quality of life of patients, their psychological and social rehabilitation .

The technical result is achieved due to the fact that the parietal-temporal-frontal periosteal-aponeurotic flap is formed, including a. frontalis, a. supraorbitalis, a. temporalis superficialis, the skin-fat island component is mobilized simultaneously from the frontal region. After tissue dissection, a tunnel is formed along the edge of the formed defect in the fronto-zygomatic region, from the nasal septum to the lateral edge of the eyebrow of the affected side. Then, the isolated tissue complex is passed through the formed tunnel to the area of the defect and fixed with sutures: the skin-fat component is sutured to the nose defect, and the periosteal-aponeurotic component is fixed in the orbital cavity. The donor bed is sutured in a line.

The proposed method is illustrated by figures 1-6.

Fig. 1 - preoperative marking

Fig. 2 - localization of the defect

Fig. 3 - stage of dissection of the periosteal-aponeurotic flap

Fig. 4 - stage of moving the periosteal-aponeurotic flap in the subcutaneous tunnel to the area of the orbital defect

Fig. 5 - stage of dissection of the frontal skin-fat flap

Fig. 6 - view after suturing postoperative wounds

The method is carried out as follows: under general anesthesia, the incision line is marked around the lesion 1 (Fig. 1) and incision 2 (Fig. 1, 2), running along the leg of the ear curl, the upper edge of the auricle into the parietal region along the posterior edge of the attachment of the temporal muscle and continuing as a coronal incision to the middle of the eyebrow of the opposite side with cutting out the skin-fat area of the frontal region, namely in the superciliary region in projection a. supraorbital is, which is included in the flap corresponding to the size of the alleged defect 3 (Fig. 2). Next, the tissues of the orbit area affected by the pathological process are removed, as a result of which a defect in the orbit, surrounding tissues and a through defect of the nose are formed. Then, along the incision line 2 (Fig. 1, 2), a dissection is made in the layer between the subcutaneous fat and the aponeurotic helmet in the frontal, parietal and temporal regions with the preservation of the temporal, parietal and frontal vascular bundles, preserving the branches of the facial nerve, the skin and subcutaneous fiber throughout and allocate the parietal-temporal-frontal periosteal-aponeurotic flap 4 (Fig. 3-6). Skin-fat component 5 (Fig. 3-6) simultaneously cut out in the frontal region. Find and mark the superficial temporal artery 6 (Fig. 3, 4). The superficial fascia, together with the dermal-fat part, is cut off and lifted along with its own temporal fascia, forming a parietal-temporal-frontal periosteal-aponeurotic flap 4 (Fig. 3-6), sufficient to close the defect. The next step is to mobilize the tissues along the edge of the formed defect 3 (Fig. 2). In the zygomatic and frontal region, a tunnel 7 is formed (Fig. 4) from the nasal septum to the lateral edge of the eyebrow of the affected side. The formed frontal-temporal periosteal-aponeurotic tissue complex is carried out to the defect area through a tunnel, then the parietal-temporal-frontal periosteal-aponeurotic flap 4 (Fig. 3-6) is tightly fixed with interrupted sutures to the entire wound surface of the defect, the skin-fat component 5 ( Fig. 3-6) is sutured to the edges of the nose defect. The donor bed is sutured in line leaving four rubber graduates in the temporal, frontal, parietal and occipital regions. The cavity of the orbit over the flap is loosely plugged with a gauze ointment swab for 9 days.

Clinical example

Patient X., 68 years old. Diagnosis: Uveal melanoma of the right orbit T3bN0M0, stage IIIa.

Status localis: On examination, the entire right eyeball is occupied by a pigmented formation, the skin of the eyelid is hyperemic, there is a spread of hyperpigmented formation on the skin of the infraorbital region 2 cm below the edge of the lower eyelid.

According to MRI of the facial skeleton with intravenous contrast as of 07.12.2020: The right eyeball was totally replaced by tumor tissue, with spread into the retrobulbar tissue, invasion into the optic nerve, distal parts of the medial and lateral rectus muscles of the eye, with spread into the anterior parts of the orbit. There were no reliable signs of destruction of the orbital walls. The total size of the tumor is 42×34×32 mm. Edema of periorbital soft tissues.

According to PET/CT of the whole body with 18P-FDG dated February 15, 2021: On a series of CT scans and reconstructed positron emission tomograms, focal accumulation of 18P-FDG is determined in the soft tissue formation of the orbit, which totally occupies its volume (normal anatomical structures in the orbital cavity are not differentiated) , up to SUVmax 23.08 with dimensions of 47×40×34 mm, without obvious signs of bone tissue destruction, with thinning of the lateral plasty of the ethmoid bone on the left and the upper wall of the intracranial sprouting (ICI), without signs of intracranial growth. Taking into account the histological nature of the tumor, the prevalence and localization of the process, a planned surgical intervention was performed in the amount of exenteration of the tissues of the right orbit, removal of the skin of the infraorbital region, plastic surgery of the defect with a temporal-parietal fascial flap with the inclusion of a skin-fat frontal flap. After a coronal incision of the scalp from the temporal region on the right to the parietal region. The skin-fat flap was separated, in its projection a periosteal-aponeurotic flap was isolated, the size corresponding to the size of the defect, with an additionally included frontal skin-fat flap (skin area 4×1.5 cm). The flap was moved and laid over the entire area of the orbital defect, the right nasal slope was formed from the frontal part of the flap and sutured to the medial wall of the orbit. The wound on the scalp was sutured with separate interrupted sutures, 4 rubber graduates were installed.

The postoperative period is calm, the sutures are gradually removed on the 9-12th day, the wound heals by primary intention. The patient was discharged on the 9th day after the operation.

Claims (1)

A method for replacing combined defects of the orbit and the nose, which consists in the fact that they form a parietal-temporal-frontal periosteal-aponeurotic flap, including a. frontalis, a. supraorbital, a. temporalis superficial is, the cutaneous-fat island component is mobilized simultaneously from the frontal region, after tissue dissection, a tunnel is formed along the edge of the formed defect in the fronto-zygomatic region, from the nasal septum to the lateral edge of the eyebrow of the affected side, then the isolated tissue complex is passed through the formed tunnel to the area defect and fixed with sutures: the skin-fat component is sutured to the nasal defect, and the periosteal-aponeurotic component is fixed in the orbital cavity, while the donor bed is sutured in line.

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