两种血管化骨移植在下颌骨节段性缺损重建中的选择

Selection of fibular flap and iliac crest flap in the reconstruction of segmental mandibular defect

目的:探讨腓骨肌皮瓣与髂骨肌瓣在不同类型下颌骨节段性缺损修复重建中的选择。方法:从2008年6月至2015年6月,对38例腓骨肌皮瓣和髂骨肌瓣移植修复的下颌骨缺损病例进行回顾性研究,评价修复后的功能和外形、供区和受区并发症。参照Schultz分类方法:Ⅰ类缺损:10例;Ⅱ类缺损:18例;Ⅲ类缺损:6例;Ⅳ类缺损:4例。其中腓骨肌皮瓣26例,髂骨肌瓣12例。平均随访16个月。结果 :12例髂骨肌瓣和24例腓骨肌瓣完全存活。1例腓骨肌皮瓣静脉栓塞坏死,1例腓骨肌皮瓣皮瓣坏死。Ⅰ、Ⅱ缺损髂骨肌瓣外形和功能优于腓骨肌皮瓣。供、受区并发症发生率髂骨肌瓣(16.7%)小于腓骨肌皮瓣组(19.2%),供区均未出现明显功能障碍。结论:Ⅰ、Ⅱ类不伴口外皮肤缺损的下颌骨节段性缺损可优先选用髂骨肌瓣,伴口外皮肤缺损者选择腓骨肌皮瓣重建;Ⅲ、Ⅳ下颌骨节段性缺损选择腓骨肌皮瓣重建。

Objective： To explore which methods, the fibular flap or iliac crest flap, is better for the reconstruction of different segmental mandibular defects. Methods： A retrospective review of 38 cases microvascular mandibular reconstruction performed in our department from June 2008 to June 2016 using 2 different techniques, 26 （68.4%）fibula flaps and 12 （31.6%） iliac crest flaps. Functional and aesthetic results, and complications of recipient and donor sites were evaluated according the clinic data. Based on the Schultz classification system, there were 10 cases of type Ⅰ defect（a unilateral dentoalveolar defect not crossing the midline and not extending into the angle of the mandible）, 18 cases of type Ⅱ defect （a unilateral defect extending beyond the angle）, 6 cases of type Ⅲ defect （bilateral defect no involving the angles）, and 4 cases of type IV defect （a bilateral defect with extension into at least one angle）. The mean follow-up time was 16 months. Results： In all cases, 12 iliae crest flaps and 24 fibular flaps survived well. There were 1 vascularized fibular flap failure caused by venous thrombosis and one case of skin island necrosis. Functional and aesthetic results showed that iliac crest flap was much better than fibular flap in reconstruction of type Ⅰ and type Ⅱ defects. The complication rate of iliac crest group is lower than that of fibular flap group in both recipient and donor sites. No obvious disorder of dornor sites occured in both groups. Conclusions： Iliac crest and fibula free flaps are effective for restoring mandibular function by providing a rich bone stock. The iliac crest flap was more appropriate and may be selected in reconstruction of type Ⅰ and type Ⅱ defects without skin loss. The fibular flap should be chosen in other type segmental mandibular defect.