逆行面动脉-颏下动脉岛状肌皮瓣修复口腔颌面部缺损的探讨

目的评价逆行面动脉-颏下动脉岛状肌皮瓣修复口腔颌面部缺损的可行性。方法用逆行面动脉-颏下动脉岛状肌皮瓣修复18例恶性肿瘤切除术后口腔颌面部缺损。男性11例，女性7例，年龄28～90岁。舌鳞癌7例、颊黏膜鳞癌4例、腭鳞癌3例、口咽癌和面部皮肤基底细胞癌各2例。肌皮瓣面积最小为4．0cm×12．0cm，最大为5．0cm×15．0cm。结果17例肌皮瓣存活，1例缺血坏死。肌皮瓣受区外观满意、功能恢复良好，供区瘢痕隐蔽。经术后6～18个月，平均11．8个月随访，1例术后10个月对侧颈部淋巴结转移。结论逆行面动脉-颏下动脉岛状肌皮瓣是口腔颌面部中型缺损的理想修复材料。     

面动脉肌粘膜瓣(FAMM):一种新型的口内组织瓣

鼻唇瓣和颊粘膜瓣已在面中份重建中得到广泛应用,作者将两者结合,设计出以面动脉为蒂的新型轴型肌粘膜瓣,称之为面动脉肌粘膜瓣(FAMM),上蒂型或下蒂型均可。临床应用18例,仅1例失败。2例部分坏死。此瓣包括粘膜、粘膜下组织、少部分颊肌、口轮匝肌深层、面动脉和静脉丛,可用于修复口腔及鼻腔粘膜缺损。应用解剖面动脉为颈外动脉的分支,在嚼肌前缘绕过下颌骨下缘到达面部,其行程曲折,向上、前至口角外侧,位于笑肌、颧大肌和口轮匝肌浅层深面,颊     

颊肌肌粘膜瓣修复口腔癌术后缺损的临床研究

目的应用颊肌肌粘膜瓣修复口腔癌术后缺损10例.方法根据缺损大小和部位设计单侧或双侧,蒂在前或蒂在后的不规则梯形肌粘膜瓣。将其旋转修复不同部位缺损，6例修复舌、牙龈、口底、咽侧区，2例单侧修复翼下颌皱襞，2例双侧瓣修复口底正中缺损；结果本组病例肌粘膜瓣全部成活，l例近期有轻度开口受限，2周后恢复正常，口腔粘膜无明显修复痕迹及收缩现象。结论颊肌肌粘膜辨是口腔内软组织缺损理想的修复材料。     

面动脉岛状肌皮瓣修复口腔颌面部组织缺损96例临床分析

目的:评价应用下颌下区面动脉岛状肌皮瓣修复口腔颌面部组织缺损的临床效果.方法:选择2007年3月—2015年8月期间应用下颌下区面动脉岛状肌皮瓣修复96例口腔颌面部组织缺损的临床资料作回顾分析,其中顺行面动脉瓣46例,逆行面动脉瓣50例.观察患者近、远期临床效果,包括受区缺损情况、组织瓣成活情况、外形和功能,以及术后并发症.结果:下颌下区面动脉岛状肌皮瓣总成功率为96.9％ (93/96),顺行皮瓣成功率为95.7％ (44/46),逆行皮瓣成功率为98.0％(49/50).术后随访0.5～6 a,肌皮瓣受区外观及质地良好,语言及吞咽功能理想,供区瘢痕隐蔽;l例患者出现肿瘤复发;3例出现对侧颈淋巴结转移.结论:下颌下区面动脉岛状肌皮瓣可作为颌面部中、小型缺损修复较理想的选择,操作简单易行,其中逆行面动脉岛状肌皮瓣皮瓣不仅可修复颌面部中上1/3的组织缺损,且成活率高,美容效果理想.     

横向颈阔肌肌皮瓣和面动脉-颏下动脉岛状肌皮瓣修复颊黏膜癌术后缺损

目的：评价横向颈阔肌肌皮瓣和面动脉-颏下动脉岛状肌皮瓣修复颊黏膜癌术后缺损的可靠性。方法：27例颊黏膜鳞状细胞癌手术切除后组织缺损，用颈阔肌肌皮瓣修复15例，面动脉-颏下动脉岛状肌皮瓣修复12例。男19例，女8例；年龄38～74岁，平均56．4岁；T1NOM0期6例，T2N0M0期19例，T3N0M0期2例。皮瓣大小为4．0cm×8．0cm。5．0cm×11．0cm。结果：颈阔肌肌皮瓣存活13例，3例小部分坏死，成功率为86．7％（13／15），面动脉-颏下动脉岛状肌皮瓣成功率为91．7％（11／12）。全部病例经6—24个月复查，受区功能正常，供区外形良好。局部复发1例，颈部复发2例。结论：颈阔肌肌皮瓣和面动脉-颏下动脉岛状肌皮瓣均适于颊黏膜中、小型缺损修复。面动脉-颏下动脉岛状肌皮瓣可能比颈阔肌肌皮瓣更为可靠。     

去上皮逆行面动脉-颏下动脉颏下岛状瓣修复上颌术后缺损

目的：探讨去上皮逆行面动脉-颏下动脉颏下岛状瓣对上颌骨术后缺损的修复效果。方法：回顾性研究我科自2007年3月-2009年1月应用去上皮逆行面动脉-颏下动脉颏下岛状瓣修复上颌骨术后缺损病例13例。其中男9例。女4例。所有病例均经病理学检查确诊,其中10例诊断为上颌牙龈鳞状细胞癌,其余3例诊断为硬腭鳞状细胞癌。依据Brown等提出的上颌骨缺损分类法,术后缺损为2a型．用以同期修复的面动脉-颏下动脉岛状瓣长度约8～10cm．宽度约4～5cm。结果：面动脉-颏下动脉岛状瓣的存活率为92.3％（12／13）,未见供区并发症及面神经下颌缘支损伤。随访8～24个月．1例原发灶复发后死亡,2例颈淋巴结复发。结论：去上皮逆行面动脉-颏下动脉颏下岛状瓣具有安全、简单、易于改良等优点,适用于无区域性淋巴结转移的恶性肿瘤术后上颌骨缺损修复。     

鼻唇沟区域各型皮瓣设计原则及血供关系的研究

以面动脉为主血供的鼻唇沟区域各类岛状瓣、肌皮瓣及肌粘膜瓣近年来在颌面整形外科得到广泛的应用及发展。文章着重综述了按血供及修复的特点而设计不同类型的皮瓣。     

面动脉瓣修复口咽癌术后缺损

目的探讨面动脉瓣修复口咽癌术后缺损的效果及临床应用。 方法选择2008年5月至2014年1月中山大学孙逸仙纪念医院口腔颌面外科收治的口咽癌患者33例,行肿瘤扩大切除术同期采用顺行或逆行面动脉瓣修复组织缺损。 结果33例面动脉瓣中,逆行性皮瓣11例全部成活,而顺行性皮瓣成活18例、部分坏死2例、完全坏死2例。皮瓣成活病例伤口愈合良好,患者术后语音和吞咽功能得到恢复。 结论应用面动脉岛状肌皮瓣修复口咽癌切除术后缺损,制取技术简单,皮瓣血供明确,皮瓣成活率高,瘢痕较为隐蔽,是修复口咽癌切除术后缺损的理想皮瓣。     

面动脉-颏下动脉岛状肌皮瓣修复颊黏膜缺损（附13例报告）

目的：评价面动脉-颏下动脉岛状肌皮瓣（FSF）修复颊癌术后颊黏膜缺损的临床效果。方法：13例颊黏膜鳞状细胞癌手术切除后颊黏膜组织缺损,用FSF修复。本组病例中,男8例,女5例;平均年龄58.5岁;T2N0M0期7例,T3N0M0期6例。皮瓣大小为4.0 cm×8.0 cm～5.0 cm×10.0 cm。结果：面动脉-颏下动脉岛状肌皮瓣修复颊黏膜缺损手术成功率92.3%（12/13）。全部病例经12～24个月复查,受区功能正常,供区外形良好,有1例颈部肿瘤复发。结论：FSF适用于修复中型颊黏膜缺损。     

应用一侧颊肌粘膜瓣修复全下唇唇红缺损的初步报告

目的：介绍应用颊肌粘膜瓣修复全下唇唇红缺损的经验。方法：外伤和肿瘤切除后引起的4例全下唇唇红缺损行蒂在121角带血管蒂的颊肌粘膜瓣转移修复，术后观察红唇形态和功能的恢复情况。结果：全部颊肌粘膜瓣完全成活，无感染、血肿、导管或神经损伤及张121障碍。红唇的长度、高度、厚度及感觉都得到恢复。结论：蒂在121角的颊肌粘膜瓣能提供足够的组织修复全下唇唇红缺损，术后形态和功能恢复好，不需二期断蒂。     

Repair of oronasal fistula with split-skin graft on nasal side and mucosal flap on oral side

We repaired a case with a huge oronasal fistula using split thickness skin graft (STSG) on nasal side and mucosal flap on oral side. A 21-year-old man presented an oronasal fistula of the hard palate, measuring 2.0 x 1.2 cm. The fistula was 2 cm posterior to the incisive foramen. The scar tissue around the fistula was unhealthy. The defective nasal side was floored with a skin graft 1.5 cm x 2.0 cm in size and 12/1000 in thickness. The skin graft was sutured around to the fistula edge with 4-0 chromic suture. Donor site was a lateral aspect of the thigh. A laterally based oral mucosal flap, 2.5 x 2 cm, was designed, raised, and transposed to the defect. The secondary defect was covered with buccal mucosal graft. The oral mucosal flap was viable, the skin graft took, and no sign of recurrence of fistula was noted until one month postoperative. This method can be an alternative in repair of the oronasal defect when any local tissue for repair is not available or sufficient.     

Closure of palatal fistula with a local mucoperiosteal flap lined with buccal mucosal graft.

OBJECTIVE: Oro-nasal fistula is a common complication of palatoplasty. Current methods for fistula repair utilize mucoperiosteal flaps or pedicled flaps. These procedures are often cumbersome and leave a raw nasal surface, which may increase the incidence of postoperative risks and problems. In addition, the recurrence rate of the fistula is as high as 34%. We propose a simple two-layer method of fistula repair to avoid recurrences. DESIGN: A standard mucoperiosteal flap is raised on the oral side. A buccal mucosal graft is harvested from the cheeks and sutured to the nasal side of the flap that is then inset into the fistula. SETTING: Patients were either referred to the senior author's private practice (four patients) or were patients who had previously been operated on by the senior author himself (three patients). SUBJECTS: Study subjects consisted of seven patients, four males and three females, ages 14 months to 8 years. All patients had previously undergone cleft palate repair, complicated by subsequent oro-nasal fistula formation. INTERVENTIONS: All patients underwent oro-nasal fistula repair under general anesthesia with a local mucoperiosteal flap lined with buccal mucosal grafts placed on the nasal side of the flap. RESULTS: In all cases, the fistula was completely closed at first attempt without complications. Patients were followed for a minimum of 2 years, without evidence of recurrence. CONCLUSIONS: Our proposed surgical procedure for fistula closure using a standard mucoperiosteal flap lined with a buccal mucosal graft is a suitable alternative for the repair of postpalatoplasty oro-nasal fistulas. Further study and long-term follow-up is needed to establish this method as a new standard form of repair.     

Correction of alveolar cleft with calcium-based bone substitutes

The criterion standard of alveolar cleft repair is iliac crest bone graft before secondary canine eruption. Tooth eruption has never been shown to occur in synthetic bone substitute, and there is no ideal autologous bone graft for primary repair. This prospective study evaluated alveolar cleft grafting with a calcium substitute before primary canine eruption. Ten consecutive patients with complete cleft lip, palate, and unilateral alveolar cleft with reasonably aligned arches were grafted beginning in January 2003 to March 2007. Mean age at surgery was 10.4 months. Follow-up ranged from 3 to 7 years. Radiologic evaluation of alveolar ridge was performed at the age of 4.All 10 patients were operated on by the same surgeon using the same technique, that is, conservative elevation of nasal, oral, and anterior alveolar mucosal flaps around the cleft, closure of nasal and oral flaps, placement of 1 to 3 mL of calcium substitute paste or crystals in the pocket, and closure of the anterior alveolar mucosa. All 10 patients healed without complication. Clinical evaluation revealed a well-healed arch with primary canine growth in the area of the previous cleft. Adequate normal bone formation and often a descending secondary canine were radiologically confirmed. Calcium substitutes offer significant advantages over other biomaterials as well as autologous bone grafts particularly in the primary alveolar cleft reconstruction. Our study has shown for the first time that teeth can erupt through this material, which turns into a normal functioning bone in the alveolar ridge.     

Single layer closure of palatal fistula using anteriorly based dorsal tongue flap

Palatal fistulas are the common complications seen after cleft palate repair. Small fistula may be asymptomatic, the large ones produce various symptoms including regurgitation of fluids into nasal cavity and interference with normal speech. Although small fistulas can be successfully treated with local flaps such as palatal or buccal mucosal flaps, large fistulas pose difficulty. Because of rich blood supply, tongue is a suitable and convenient source of large flap. The anterior based dorsal tongue flap is a safe and effective method for closure of relatively large recurrent palatal fistula with out any functional impairment of donor site. This article describes one such case treated by single layer closure using anteriorly based tongue flap with excellent outcome.     

Superiorly based facial artery musculomucosal flap for large anterior palatal fistulae in clefts.

OBJECTIVE: An anterior hard palate fistula for which more than one attempt at repair using local tissue has failed is a difficult complication in cleft surgery. Prior to alveolar bone grafting, cleft patients have an open anterior maxillary arch that allows passage of a pedicled flap from cheek to hard palate. The superiorly based facial artery musculomucosal flap passed through the clefted alveolus is one of the newer techniques to solve this difficult problem. The aim of this study was to assess the validity of using a facial artery musculomucosal flap with an anterosuperiorly based pedicle with retrograde blood flow to repair a large anterior hard palate fistula when a lack of adequate local soft tissue precludes a local flap closure and the patient otherwise would need a tongue flap. RESULTS: Of 16 facial artery musculomucosal flaps in 14 children, 12 were successful, 2 suffered partial flap loss secondary to venous congestion, and 2 had complete flap failure. One had a small wound dehiscence that resulted in a small posterior fistula. CONCLUSION: An anterosuperiorly based facial artery musculomucosal flap is a viable option to close large anterior hard palate defects. Care needs to be taken to ensure adequate venous drainage. This flap obviates the need for a staged tongue flap repair for those patients with an open maxillary arch.     

Reconstruction of bilateral cleft lip and nose deformity

Bilateral cleft lip and nose deformity can be divided into several types according to the extent of the cleft, protruding premaxilla, size of prolabium and nose deformity. Many repair techniques introduced in the literatures were not perfect because of the change of facial profile under the influence of facial growth.The author uses 1-stage cheiloplasty with nose correction for bilateral cleft lip and nose deformity. Early lip adhesion is used before definitive corrections in wide-cleft patients. The lateral mucosal flaps are used for the lining of alveolar cleft. The lateral orbicularis oris peripheralis flaps with the mucosa approximate in front of premaxilla with creation of a buccal alveolar sulcus and continuity of an orbicularis oris muscle. The lateral orbicularis marginalis muscle flaps with white skin roll and vermillion are used for reconstruction of the Cupid's bow. To enhance the median tubercle, prolabial vermilliomucosal flap is inserted into the gap between an approximated orbicularis peripheralis flap and an approximated orbicularis marginalis flap. Z-plasty of the vestibular ridge and the fixation of lower lateral cartilages to dissect through alar rim excision achieve columella lengthening and tip projection. Lip scar revision is rare, but secondary nose correction using triple V-Y flap is frequent.     

Primary repair of the alveolar cleft

Nasoalveolar fistula and oropharyngeal fistula of the anterior palatal region are very commonly seen in cases when there are concomitant clefts of the lip and the palate. Absence of adequate tissue in that region complicates the treatment and necessitates new tissue transfers from near or distant tissues. Today, the techniques used for correcting cleft lip cannot successfully solve these 2 problems. In this study, we describe a technique that depends on the principle of using the lip mucosal tissues that remains during the Tennison cleft lip correction technique, with a flap designation, to correct the tissue defect of the cleft between the foramen incisivum and lip and the alveolar region. Twenty-two patients (13 boys and 9 girls), with ages ranging from 3 to 53 months (mean, 24 mo), with unilateral cleft lip and palate underwent surgery with this new technique. In all these patients, clefts in the anterior palatal and alveolar regions were successfully corrected. Fistula was observed in none of these patients in these regions. Through this method, clefts in the anterior palatal and alveolar regions can be corrected during repair of cleft lips.     

Reconstruction of palatal defect using mucoperiosteal hinge flap and pushback palatoplasty.

This article describes a simple, new surgical technique to provide a complete two-layer closure of palatal defect resulting from a surgical complication of trans palatal resection of skull base chordoma. The nasal layer was reconstructed with triangular shape oral mucoperiosteal turn over hinge flap based on anterior margin of palatal defect and rectangular shaped lateral nasal mucosal hinge flaps. The oral layer was reconstructed with conventional pushback V-Y advancement 2-flaps palatoplasty. Each layer of the flaps were secured with two key mattress suture for flap coaptation. This technique has some advantages: simple, short operation time, one-stage procedure, no need of osteotomy. It can close small- to medium-sized palatal defect of palate or wide cleft palate and can prevent common complication of oronasal fistula, which could be caused by tension.     

Two-stage reconstruction of bilateral alveolar cleft using Y-shaped anterior-based tongue flap and iliac bone graft.

OBJECTIVE: When an alveolar cleft is too large to close with adjacent mucobuccal flaps or large secondary fistula following a primary bilateral palatoplasty exists, a one-stage procedure for bone grafting becomes challenging. In such a case, we have used the tongue flap to repair the fistula and cleft alveolus followed by bone grafting to the cleft defect performed several months later. The purpose of this article is to report on our experiences with the use of an anteriorly based Y-shaped tongue flap to fit the palatal and labial alveolar defects and on the ultimate result of the bone graft. PATIENTS: A series of 14 patients were treated with this approach from January 1994 to December 1998. The average age of the patients was 15.8 years (range 5 to 28 years). The mean period of follow-up following the second stage bone graft operation was 45.9 months (range 9 to 68 months). In 9 of the 14 patients, the long-fork type of a Y-shaped tongue flap was used for extended coverage of the labial-side alveolar defects with the palatal fistula; in the remaining patients, the short-forked design was used. RESULTS: All patients demonstrated a good clinical result after the initial repair of cleft alveolus and palatal fistula. There was no fistula recurrence, although partial necrosis of distal margin in long-forked tongue flap occurred in one patient. Furthermore, the bone graft, which was performed an average of 8 months after the tongue flap repair, was always successful. Occasionally, transferred tongue tissue bulging interfered with the hygienic care of nearby teeth; however, these problems could be solved with proper contour-plasty performed afterward. No donor site complications such as sensory disturbance, change in taste, limitations in tongue movement, normal speech impairments, or tongue disfigurement were encountered. CONCLUSION: This two-stage reconstruction of a bilateral cleft alveolus using a Y-shaped tongue flap and iliac bone graft was very successful. It may be indicated for a bilateral cleft alveolus patient in which the direct closure of the cleft defect with adjacent tissue or the buccal flap is not easy because of scarred fibrotic mucosa and accompanied residual palatal fistula.     

Cleft palate repair using a marginal musculo-mucosal flap.

OBJECTIVE: To describe a modified procedure consisting of a mucoso-periosteal flap palatoplasty with a marginal musculo-mucosal flap (3M flap). This is also the first report of a primary repair for complete cleft palate using the 3M flap. We describe the lengthening effect of the nasal mucous layer of the soft palate and evaluate the fistula formation rate associated with this method. METHODS: This procedure has been performed on 21 patients with unilateral complete clefts and on 27 patients with incomplete clefts. A mucoso-periosteal flap raised from the hard palate was used mainly for closure of the cleft and not for the push-back. The 3M flap repaired the deficit of the nasal mucosa, making sure that the soft palate was lengthened. Intravelar veloplasty was performed also. RESULTS: The dimension of the nasal mucosal defect that can be filled with the 3M flap is 10 to 12 mm in length, oriented anterior-posterior, and 15 to 20 mm wide. Oronasal fistula formation was recognized in only 3 of 48 cases (2 of 21 complete clefts, 1 of 27 incomplete clefts) and were located at the hard-soft palate junction at the anterior portion of the 3M flap. CONCLUSIONS: This method has the theoretical advantages of (1) preventing fistula formation by filling the tissue deficiency with the 3M flap; (2) achieving better velopharyngeal function due to elongation of the soft palate and retropulsion of the muscular bundle, utilizing the 3M flap; and (3) minimizing maxillary growth retardation by adopting a non-push-back method of hard palate repair.