改良胸锁乳突肌皮瓣修复口腔颌面部肿瘤切除术后软组织缺损

MODIFIED STERNOCLEIDOMASTOID MYOCUTANEOUS FLAP FOR RECONSTRUCTION OF SOFT TISSUE DEFECTS FOLLOWING TUMORECTOMY OF MAXILLOFACIAL REGION

目的探讨改良胸锁乳突肌皮瓣修复口腔颌面部肿瘤切除术后软组织缺损的临床效果及预后。方法2001年4月-2007年1月,对43例颌面部恶性肿瘤根治术后软组织缺损患者采用同期改良胸锁乳突肌皮瓣修复。其中男31例,女12例;年龄25～76岁,平均58.5岁。病程25d～14个月,平均4.5个月。其中高分化鳞癌27例,中、低分化鳞癌14例,横纹肌肉瘤1例,腺样囊性癌1例。发病部位:舌25例,口底11例,下牙龈4例,颊黏膜3例。肿瘤临床分期:Ⅰ期3例,Ⅱ期13例,Ⅲ期7例,Ⅳ期20例。肿瘤切除后软组织缺损范围及术中切取皮瓣范围均为4cm×3cm～8cm×6cm。观察术后皮瓣的生长及伤口愈合情况,并随访术后患者吞咽、张口功能恢复情况。结果术后1周3例患者出现远端皮瓣1/4缺血性坏死,经抗炎治疗及局部冲洗换药后Ⅱ期愈合;其余皮瓣成活良好。供区2例感染伴积液,给予切开引流后Ⅱ期愈合;其余供区切口Ⅰ期愈合。术后48h未见皮瓣出现动、静脉危象。39例获随访,随访时间6个月～6年。3例颊黏膜癌患者的张口度均恢复到2指以上。术后24例舌癌患者吞咽及发音功能良好;3例需进软食,余均可进普食。26例随访超过2年者可见皮瓣上皮化生为口腔黏膜。4例术后6个月、2例术后1年肿瘤复发死亡。2例术后6个月同侧颈部淋巴结转移复发,再次手术治疗后存活至今。术后2年生存率为85%。结论改良胸锁乳突肌皮瓣修复口腔颌面部肿瘤切除术后软组织缺损,可及时恢复口腔颌面部功能,提高患者生存质量。

Objective To investigate clinical effect and prognosis of the modified sternocleidomastoid（MSCM） myocutaneous flap for reconstruction of tissue defects in patients with oral carcinomas undergoing tumorectomy.Methods From April 2001 to January 2007,43 patients with large or medium-sized tissue defects because of oral carcinomas radical operation were treated with MSCM myocutaneous flap.There were 31 males and 12 females with an average age of 58.5 years （25-76 years）.The disease course was 25 days to 14 months（4.5 months on average）.There were 27 cases of well-differentiated squamous cell carcinoma（SC）,14 cases of poorly-differentiated SC,1 case of rhabdomyosarcoma,and 1 case of adenoid cystic carcinoma.Affected locations were tongue in 25 cases,mouth floor in 11 cases,lower gingiva in 4 cases,and buccal mucous membranes in 3 cases.According to 2002 International Union Control Cancer criterion for clinical stage,there were 3 cases of stage I,13 cases of stage II,7 cases of stage III,and 20 cases of stage IV.Both the ranges of soft tissue defects and the flap were from 4 cm×3 cm to 8 cm×6 cm.The vitality of the flaps and the healing of wounds were observed postoperatively.The function restoration of deglutition and dehisce were observed during the follow-up period.Results Necrosis of quarter MSCM myocutaneous flap occurred in 3 cases 1 week after operation,wounds healed by secondary intention after dressing;other flaps were survival.Infection with fluidify occurred at the donor site of 2 cases,wounds healed by incision and drainage;other incision at the donor sites healed primarily.No arterial or venous crisis occurred in all 43 flaps after 48 hours of operation.Thirty-nine patients were followed up for 6 months to 6 years.The 3 patients with buccal carcinoma could open their mouths normally.The function of deglutition and pronunciation were recovered in 24 patients with tongue carcinoma.Only 3 patients needed to have soft diet after operation.In 26 patients who were followed up above 2 years,oral metaplasia of the the skin flaps epithelium was observed.Four patients and 2 patients recurred and died after 6 months and 1 year of operation,respectively.Two patients received the second operation after 6 months because of the metastatic lymph node,and survived up to now.The 2-year survival rate was 85%.Conclusion MSCM myocutaneous flap is simple to perform and effective in reconstruction of tissue defects for patients with oral carcinomas.It has active effect to recover the function of oral and maxillofacial region and elevate living quality of patients.