经口内入路切除下颌骨良性肿瘤及同期血管化腓骨肌瓣精确重建下颌骨

Resection of mandibular benign tumors by transoral approach and use of intraoral microvascular anastomosis for segmental mandibular reconstruction with vascularized fibula osseous flap: a pilot study in 4 consecutive patients

目的 :首次介绍口内入路行下颌骨良性肿瘤切除和显微血管吻合的腓骨肌瓣即刻精确重建的经验。方法 :2018年1月—3月,对我科收治的4例下颌骨良性肿瘤患者行经口内入路的下颌骨节断性切除及显微血管吻合的腓骨肌瓣即刻重建术。3例术前行虚拟手术计划设计,并行钛板数字化压模成型。术中先在口内颊部显露面动、静脉并保护,按截骨导板完成下颌骨节断性切除和腓骨瓣塑形、钛板固定后,用导航验证重建下颌骨的位置。显微镜下将腓动脉与面动脉作端-端吻合,腓静脉与面静脉用微血管吻合器Coupler吻合。术后常规采用手提超声多普勒监测血管血流信号;术后1周复查全景片,检查重建下颌骨的位置。结果:4例患者均顺利完成经口内入路的下颌骨节断性切除、腓骨重建,其中3例顺利完成口内显微血管吻合,1例因术区瘢痕、面静脉不理想而引至下颌下吻合。术后超声多普勒监测显示血流信号正常,口内及供区伤口均一期愈合。术中导航及术后全景片显示重建的下颌骨位置理想,咬合关系正常,面部外形对称,无面瘫及开口受限。结论:经口内入路行下颌骨良性肿瘤的节断性切除及腓骨肌瓣精确重建和口内显微血管吻合是完全可行的,能够达到口外入路同样的效果,同时口外无瘢痕。

PURPOSE： To introduce our experience in transoral segmental mandibulectomy of benign tumor and intraoral microvascular anastomosis for mandibular reconstruction with vascularized fibula osseous flap. METHODS： Between January and March 2018, transoral segmental mandibulectomy of benign tumor and intraoral microvascular anastomosis for mandibular reconstruction with vascularized fibula osseous flap were performed in 4 patients in our department.Preoperative virtual surgical planning, prebending of reconstruction plate and intraoperative navigation for confirmation of neomandibular site were performed in 3 patients. Facial artery and vein were exposed to protect at intraoral buccal regionprior to segmental mandibulectomy and shaping of grafted fibula. Intraoral microvascular anastomosis of facial artery and peroneal artery in an end-to-end fashion, whereas facial vein and peroneal vein in an end-to-end fashion with the Coupler. Conventional postoperative monitoring of blood flow signal was conducted with hand-held ultrasound doppler.Panoramic radiographs were taken to assess the neomandible on day 7 postoperatively. RESULTS： Successful transoral segmental mandibulectomy was completed in 4 patients and intraoral microvascular anastomosis for mandibular reconstruction with vascularized fibula osseous flap was completed in 3 patients. Microvascular anastomosis at submandibular region was done in another patient because intraoral facial vein was not suitable. Normal blood flow signal was displayed on hand-held ultrasound Doppler. Intraoral and donor site wounds were healed uneventfully. Ideal neomandible and good occlusion were observed in postoperative panoramic radiographs. Symmetric facial appearance and no restriction of mouth opening were achieved in all patients. All patients were satisfied with the surgical results.CONCLUSIONS： It is feasible to avoid extraoral incision by transoral segmental mandibulectomy of benign tumor and intraoral microvascular anastomosis for mandibular reconstruction with vascularized fibula osseous flap. The same postoperative results of transoral approach as that of extraoral approach can be achieved.