改良的胸大肌岛状肌皮瓣在头颈外科的应用

Appficaiotn of modified pectoralis major myocutaneous island flap in head and neck surgeries

目的总结保护供区胸大肌功能和颈部外形美观的改良式胸大肌岛状肌皮瓣安全制作方法。方法采用改良的胸大肌岛状肌皮瓣修复头颈部缺损17例，其中6例复发性喉癌和下咽癌，4例下咽癌，3例舌根癌，2例复发性上颌窦癌，1例扁桃体癌，1例术后下咽癌术后咽瘘。术前超声检查标记胸肩峰动脉胸肌支走行，以胸肌支最下一个分支进入胸肌的起始位置（最下入肌点）和内乳动脉第四肋间穿支连线为轴设计单血管蒂的岛状肌皮瓣；在皮瓣顶部切口水平向外沿腋前线向上切开；保留胸内侧和部分胸外侧神经；维持胸大肌锁骨部完整，经锁骨上或锁骨下将肌皮瓣送到受区。结果术中发现胸肩峰动脉胸肌支最下入肌点全部分布在胸肋部，该点距锁骨中点最下缘平均（4．9±1．2）cm（x^-±s，下同），术前超声定位最下入肌点的准确率为76．5％（13／17）；内乳动脉的第四肋间穿支距离胸骨外侧缘（1．8±0．5）cm。17例胸大肌岛状肌皮瓣中，除1例下咽癌术中解离血管蒂时损伤血管放弃外，其余16例均成活，手术成功率为94．1％。术后1例舌根癌患者胸大肌远端与残舌分离，通过换药缝合后痊愈；2例出现术后咽瘘，均系放疗后复发下咽癌，换药后创面愈合。术后4周至3个月复查，胸大肌功能正常，颈部外形良好。结论改良胸大肌岛状肌皮瓣不仅保留了胸大肌结构和功能，实现高位缺损的修复，还维持颈部和上胸部良好外观。术前超声检查标记胸肩峰动脉的胸肌支走行和最下入肌点位置有利于术中准确操作。

Objective To preserve the function of the donor site and good cervical shape, a modified pectoralis major myocutaneous island flap was designed. Methods The modified pectoralis major rnyocutaneous flaps were used to repair primarily the defect in head and neck surgery. In all 17 cases, six cases were patients with recurrence of larynx or hypopharynx cancer, four cases with hypopharynx cancer, three cases with base of tongue cancer, two cases with recurrence of maxillary cancer, one case with tonsillar cancer and one case with pharygeal fistula after hypopharyngeal cancer surgery. Before operation, ultrasound was used to mark the projection of the pectoral branches of thoracoacromial artery, and the pectoralis major myocutaneous were designed according to the axle between lowest entering muscle point of the artery and the fourth intercostals perforator spot of mammary artery ; the incision was designed to turn laterally in an oriental direction at the top of the flap and upward along the anterior axillary line; the internal pectoral nerve was reserved, as well as the partial lateral pectoral nerve. The flaps were transferred to recipient site either above or below the clavicle on the premise of the integrity of clavicular part. Results The distance of the lowest entering muscle point of pectoral branche measuring during operation, which was all in sternocostal part, to the midpoint of inferior clavicula margin was （4. 9 ± 1.2） cm（x^- ± s） , and in 76. 5% （13/17） of the patients, the location was coincidence by ultrasound. The length between entering muscle point and the fourth intercostals perforator spot of mammary artery was （ 1.8 ± 0. 5） cm. All the myocutaneous flaps were alive except one case. The flap was given up as a result of the vessel pedicel injure. The distal end of the flap was dehisced from the residual tongue in one case with base of tonque cancer and healed with changing dressing. Two pharyngeal fistulas in another two cases were healed with conserved treatment. The rate of the flap survival was 94. 1% （16/17）. Functions as adduction and adtorsion of major pectoral muscle were integrated within 4 weeks to 3 months. Also, the good looking of the neck and upper chest was maintained. Conclusions The location of pectoral branches of thoracoaeromial artery and the site of the lowest entering muscle point marked by ultrasound detection could help the design of the flap. The modified pectoral＇ s major myocutaneous flap designing presented better functional protection and reach longer distance and left a better looking for neck and upper chest.