大收肌穿支皮瓣的解剖分类及其在头颈重建领域的应用

Anatomical classification of adductor magnus perforator flap and its application in head and neck reconstruction

目的探讨大收肌穿支皮瓣的解剖分类及其在头颈重建领域的应用。方法回顾性队列研究2017年1月至2020年1月湖南省肿瘤医院应用游离大收肌穿支皮瓣移植修复的27例口腔肿瘤病例资料,其中男24例,女3例,年龄31~56岁。包括舌癌15例,牙龈癌9例,口颊癌3例,肿瘤根治术后遗留的继发软组织缺损范围为5.0 cm×3.5 cm~11.0 cm×8.0 cm。根据穿支血管蒂发出位置将大收肌穿支分为3类,包括:①肌间隙穿支,穿支血管自股薄肌和大收肌之间发出或者穿过少许大收肌;②大收肌中层穿支,穿支血管自大收肌深浅两层之间走行;③大收肌深层穿支,穿支血管自大收肌和半膜肌之间走行。采用描述性方法进行分析。结果所有病例中大收肌穿支恒定存在,共发现62支大收肌穿支,具体解剖分类包括:①类12支,②类31支,③类19支。27例病例游离大收肌穿支皮瓣具体切取形式包括①类3例、②类16例、③类8例。本组皮瓣全部存活,供区均直接闭合。18例穿支血管蒂动脉与甲状腺上动脉吻合,伴行静脉与甲状腺上静脉吻合;9例穿支血管蒂动脉与面动脉吻合,伴行静脉与面静脉吻合。随访12~40个月,患者对皮瓣外观满意,吞咽、语言功能满意,供区仅遗留线性瘢痕,大腿功能未见明显影响。随访期间3例患者肿瘤局部复发,再次行肿瘤根治术并以带蒂胸大肌皮瓣转移修复;2例发生颈部淋巴结转移,再次行颈部淋巴清扫术。结论大收肌穿支皮瓣质地柔软,穿支血管解剖恒定,可选择供区位置及具体形式灵活,皮瓣供区损伤小,是头颈肿瘤术后重建的理想选择。

Objective To investigate the anatomical classification of adductor magnus perforator flap and its application in head and neck reconstruction.Methods From January 2017 to January 2020,Hunan Cancer Hospital treated 27 cases of oral tumor patients(15 cases of tongue cancer,9 cases of gingival cancer and 3 cases of buccal cancer),including 24 males and 3 females,aged 31-56 years old.The course of disease was 1-12 months.Secondary soft tissue defects with the sizes of 5.0 cm×3.5 cm to 11.0 cm×8.0 cm were left after radical resection of the tumors,and were repaired with free adductor magnus perforator flaps.The flaps based on the origing locations of perforator vessels were divided into three categories:①intramuscular perforator:vessel originated between the gracilis muscle and the adductor magnus or passed through a few adductor magnus muscles;②adductor magnus middle layer perforator:vessel run between the deep and superficial layers of adductor magnus;③adductor magnus deep layer perforator:vessel run between the deep layer of adductor magnus and the semimembranous muscle.Descriptive analysis was used in this research.Results Perforator vessels of adductor magnus were found in all cases,with a total of 62 perforator branches of adductor magnus.The anatomical classification of the perforator vessels was as follows:12 branches for class①,31 branches for class②and 19 branches for class③.The vascular pedicles of the free adductor major perforator flaps included type①for 3 cases,type②for 16 cases and type③for 8 cases.All 27 flaps survived and the donor sites were closed directly.In 18 cases,the perforator arteries and the venae comitan were respectively anastomosed with the superior thyroid arteries and veins.In 9 cases,the pedicle arteries and the venae comitan were respectively anastomosed with the facial arteries and veins.Follow up for 12-40 months showed that the appearances of the flaps and the swallowing and language functions of patients were satisfactory,apart from linear scars were left in the donor sites with no significant affect on the functions of thigh.Local recurrence occurred in 3 cases and radical surgeries were performed again followed by repairs with pedicled pectoralis major myocutaneous flaps.Cervical lymph node metastasis occurred in 2 cases and cervical lymph node dissection was performed again.Conclusions The adductor magnus perforator flap has soft texture,constant perforator vessel anatomy,flexible donor location and harvesting forms,and less damage to the donor site.It is an ideal choice for postoperative reconstruction in head and neck tumors.