RU2773137C1 - Method for reconstructive surgery in patients with malignant tumors of the oral mucosa - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to reconstructive surgery of the head and neck for malignant tumors. Soft-tissue defects of the oral mucosa are replaced simultaneously using a tunneled islet musculomucosal graft t-FAMMIF. The graft is cut out through intraoral and cervical accesses. At the same time, after the mobilization of the vascular pedicle through the subcutaneous tunnel, the graft is carried out under the marginal branch of the facial nerve to ensure the arc of rotation. Then the mobilization and transposition of Bichat’s pads are performed by intraoral access. Next, Bichat’s pads are distributed evenly in the area of the donor bed. Then they are fixed to the edges of the defect with a continuous atraumatic thread.

EFFECT: method makes it possible to replace the resected fragments with tissues of similar composition with the reconstruction of the original shape of the resected organ without additional incisions on the neck and face, achieve epithelization of the donor bed without the formation of pronounced scars, accelerate rehabilitation, improve speech and the act of swallowing, reduce the time of hospitalization.

1 cl, 1 ex

Description

The invention relates to medicine, namely to reconstructive surgery of the head and neck for malignant tumors.

The invention can be used for simultaneous elimination of oral cavity defects of various localization, which occur as a result of resection for tumor-like formations, including malignant tumors, excision of scar tissues, severe atrophy, cicatricial contracture of the tongue, which impede the processes of chewing and swallowing and speech function. Reconstruction in the course of operations makes it possible to eliminate disorders in patients that lead to the impossibility of independent nutrition, speech impairment and, accordingly, to an unsatisfactory quality of life.

From the prior art, a method is known for reconstructing defects in cancer of the oral mucosa and submandibular gland using a radial free forearm flap, which is characterized by a surgically simple process of cutting out, good blood supply, has a long vascular pedicle, but has a pronounced skin defect in the area of flap sampling (Soutar D.S. et al., The radial forearm flapza versatile method for intrairal reconstruction, Brit. J. Plast. Surg. 1983; 86:1).

The known method is acceptable for reconstruction after resection of malignant neoplasms, however, in aged patients with comorbidities in the presence of unilateral metastases to regional lymph nodes, in particular, to the submandibular lymph nodes, as well as pronounced changes in the donor bed, it is far from always possible to use it.

The closest in technical essence to the proposed method is a method for reconstructing defects that occur during the surgical treatment of cancer of the oral mucosa, providing for the simultaneous elimination of a defect in the bottom of the oral cavity and the surface of the tongue from the displaced submental flap (patent for invention RU 2706031 C1, publ. 13.11.2019 ). This method was chosen by the authors for the prototype.

The prototype is implemented by using a musculoskeletal displaced submental flap on a vascular pedicle, in which, after removal of the primary focus, lymph node dissection is performed on the side of the primary tumor and, in the presence of unilateral regional metastases, the upper lateral pole of the submandibular salivary gland with the facial artery is isolated to the place of origin of the submental artery from the contralateral sides along the lower edge of the arch of the lower jaw with unilateral inclusion of the anterior belly of the digastric muscle, maxillohyoid muscle, followed by replacement of the defect in the oral cavity with the skin area of the flap.

The disadvantage of the prototype is that in the oral cavity the soft tissue defect is replaced not by the mucous membrane, but by the skin, often with abundant hair growth, which causes certain disorders. Also, taking into account the fact that muscle fragments are included in the flap, the thickness of the flap significantly exceeds the volume of the defect and this affects the mobility of the tongue, which leads to unsatisfactory rehabilitation of patients, namely the deterioration of speech.

Currently, in reconstructive surgery in a very complex category of patients, there is a need for new effective from the point of view of function and less traumatic methods for the simultaneous elimination of defects in the oral cavity.

The objective of the invention is to develop a method for reconstructing defects in cancer of the oral mucosa, providing anatomical restoration and improving the function of the resected organ, reducing trauma without compromising radicality and minimizing complications.

The task is achieved by the method of reconstructive surgery by one-stage replacement of soft tissue defects in patients with malignant tumors of the oral mucosa (T2 - T4) using a muco-muscular flap from the facial vessels (FAMM), where as a muco-muscular flap from the facial vessels (FAMM ) using a tunnelized islet muco-muscular flap (t-FAMMIF), which is cut out through a combined approach with the inclusion of the facial artery and facial vein without an incision in the skin of the nasolabial fold, and after complete mobilization of the vascular pedicle through the subcutaneous tunnel, the muco-muscular flap is carried out under the marginal branch of the facial nerve to provide an arc of rotation with subsequent closure of the donor bed. Next, the flap under the jaw is transferred to the oral cavity and fixed to the edges of the defect, making up for the tissue deficiency with the restoration of the anatomy of the resected organ.

The closure of the donor bed is performed using the cheek's own adipose tissue without additional incisions. By intraoral access, the mobilization and transposition of Bish's lumps are performed, which are distributed evenly in the area of the donor bed and then fixed to the edges of the defect with a continuous atraumatic thread.

The technical result achieved by implementing the proposed method is that the resected fragments are replaced by tissues of similar composition. Due to the properties of the mucosa and submucosa, which has good extensibility, it is possible to restore the original shape of the resected organ, which has a positive result on rehabilitation, improvement of speech and swallowing. Also, when using this flap, no additional incisions are made on the neck and face, everything is done through intraoral and cosmetic access for cervical lymph node dissection, which also has a positive effect on the social rehabilitation of patients. It is also important that in the early stages after the operation, complete epithelialization of the donor bed occurs without the formation of pronounced scars, which also speeds up rehabilitation and reduces the time spent by patients at the hospital stage, which entails a reduction in the costs of the institution.

The method is carried out as follows.

At the first stage, cervical lymph node dissection is performed (through a cosmetic incision) with preservation of the facial vessels, as well as with the preservation of the external jugular vein, since often the venous outflow from this flap is carried out into the saphenous vein system.

At the second stage, resection of the primary focus is performed within healthy tissues. The defect size and configuration are then determined.

At the third stage, the flap is marked on the buccal mucosa. The boundaries of the flap are - in front of 1 cm from the commissure, from below 0.3-0.5 cm above the alveolar-buccal sulcus, from above 0.3 cm below the external opening of the excretory duct of the parotid salivary gland, behind 0.5 cm from the projection of the branch of the lower jaws. The incision is started in front, dissecting the mucous membrane, the buccal muscle, then the facial artery is visualized, which is crossed and ligated, then the incision is continued in the anterior-posterior direction until the vein is visualized, which is also crossed and ligated. Further, tissue dissection is continued strictly behind the vessels to exclude the possibility of crossing the branches of the facial nerve. Then the incision is extended along the lower edge with a dissection of the mucous membrane and buccal muscle until the vessels are visualized. Next, dissection of the vascular pedicle is performed through a previously performed cervical incision. After dissection of the vascular pedicle, the flap is passed through the subcutaneous tunnel to the neck under the marginal branch of the facial nerve and moved under the jaw to the defect zone. Fixation to the edges of the defect with an atraumatic thread.

Then, through the intraoral access, the mobilization and transposition of Bish's lumps are carried out, which are evenly distributed and fixed with a continuous suture to the edges of the defect.

Hemostasis is carried out using bipolar electrocoagulation during the operation.

Clinical example

Patient K., aged 53, complained about the presence of a formation in the tissues of the floor of the oral cavity. During the examination, squamous cell carcinoma of the mucous membrane of the tissues of the floor of the mouth T3N1M0 was morphologically verified. According to ultrasound, the lymph nodes of the neck on the right are not enlarged. On the left side of the lower jaw, hypoechoic lymph nodes up to 1.6 × 1.4 cm, 1.6-0.7 cm are determined, in the upper third of the neck there is a rounded lymph node 0.6 cm. The submandibular salivary gland is 3.7 × 1, 2 cm, the ducts are dilated. On CT in the anterior-left parts of the tissues of the floor of the oral cavity, an area of tissue compaction is determined, accumulating a contrast agent up to 3.1 × 1.5 × 3.2 cm in size. The infiltrate is closely adjacent to the muscles of the floor of the oral cavity. In the left submandibular region, the lymph node is up to 1.8 × 1.6 cm, along the jugular vein on the left, lymph nodes are determined up to 1.2 × 0.7 cm.

The patient underwent an operation in the volume of the marginal resection of the lower jaw from projection 3 on the right to 6 on the left, tissues of the floor of the mouth, atypical resection of the tongue with the restoration of the defect with a tunnelized islet muco-muscular flap on the facial vessels, selective lymph node dissection on the right (levels 1-3), modified cervical lymph node dissection on the left (1-5 levels).

The flap was cut out through a combined approach (intraoral and cervical) with the inclusion of both the facial artery and the facial vein. An incision in the projection of the nasolabial fold was not made. After mobilization of the vascular pedicle through the subcutaneous tunnel, the flap was passed under the marginal branch of the facial nerve to increase the arc of rotation.

The muco-muscular flap was cut out on the supply vessels, then the flap was passed through the submandibular canal into the oral cavity and fixed to the edges of the defect, a stump of the tongue was formed. The flap area was restored by mobilization and transposition of Bish's fat pads. A nasal probe was placed. Tracheostomy was not performed taking into account the preservation of the mandibular arch.

Histological examination of the surgical material showed that the tumor corresponded to moderately differentiated squamous cell carcinoma, 10 mm thick, the resection margin was within healthy tissues, in 1 lymph node there was metastasis of squamous cell carcinoma without extracapsular growth. In terms of combined treatment, adjuvant radiation therapy was performed on the oral cavity and regional zones ROD 2 Gy SOD 50 Gy.

In the postoperative period, the patient received standard antibacterial and non-steroidal anti-inflammatory therapy for 5 days. Dressings were performed daily, and the oral cavity was treated with antiseptic solutions. Nutrition through the nasoesophageal tube was carried out for 7 days.

As a result of the application of the method developed by us, the defect in the tissues of the floor of the oral cavity, tongue and part of the resected jaw was eliminated with the help of an islet muco-muscular tunneled flap. In the postoperative period, the patient regained nutrition through natural pathways and speech, and conditions were created for further rehabilitation, including prosthetics.

The method has a number of advantages.

1. This method can be used in patients with malignant tumors of the oral cavity who need to restore the resected fragment.

2. Reconstruction is performed in one stage with resection of the primary lesion and cervical lymph node dissection, which allows the patient to be rehabilitated as soon as possible.

3. Allows you to recreate the three-dimensional structure of the tongue, tissues of the floor of the mouth and jaw.

4. The defect is replaced with a similar tissue.

5. No additional incisions on the neck and face are required.

6. It is possible to use in realized regional metastases with adequate dissection.

7. There is no defect in the donor bed.

8. There is no need for a second team of surgeons, as when using revascularized flaps.

Thus, based on our own data and literature data, the use of a tunneled islet muco-muscular flap on facial vessels has a number of advantages over the use of regional and revascularized flaps and may set a new standard in oral reconstructive surgery.

Claims (1)

A method for reconstructive surgery in patients with malignant tumors of the oral mucosa by simultaneous replacement of soft tissue defects, characterized in that a tunneled islet t-FAMMIF islet mucomuscular flap is used as the FAMM muco-muscular flap, which is cut out through the intraoral and cervical access, and after To mobilize the vascular pedicle through the subcutaneous tunnel, the flap is carried out under the marginal branch of the facial nerve to provide an arc of rotation, then mobilization and transposition of Bish's lumps are performed by intraoral access, which are distributed evenly in the area of the donor bed and then fixed to the edges of the defect with a continuous atraumatic thread.