股前外侧嵌合穿支肌皮瓣的制备方式及优化策略研究

Combination mode and optimization strategy of harvest procedure of anterolateral thigh chimeric perforator myocutaneous flap

目的 总结股前外侧嵌合穿支肌皮瓣制备方式及优化策略。方法 回顾分析2015年6月—2021年12月收治的359例口腔肿瘤患者临床资料。男338例,女21例;年龄28~59岁,平均35.7岁。舌癌161例,牙龈癌132例,口颊癌66例。按照国际抗癌联盟(UICC)TNM分期:T4N0M0137例,T4N1M0166例,T3N1M043例,T3N2M013例。病程1~12个月,平均6.3个月。肿瘤根治术后遗留软组织缺损范围为5.0 cm×4.0 cm~10.0 cm×7.5 cm,均采用游离股前外侧嵌合穿支肌皮瓣移植修复。肌皮瓣制备包括4个步骤:步骤1显露并分离穿支血管,穿支血管主要来自斜支和降支外侧支;步骤2分离穿支血管蒂主干并确定肌瓣血管蒂来源,包括斜支、降支外侧支和降支内侧支3个来源;步骤3确定制备肌瓣的来源,包括股外侧肌和股直肌2个来源;步骤4确定肌瓣制备形式,包括主干肌支型、主干远端型和主干侧边型3种形式。结果 术中共切取359块游离股前外侧嵌合穿支肌皮瓣,股前外侧穿支均恒定存在。其中,皮瓣穿支血管来自斜支127例、降支外侧支232例,肌瓣血管蒂来自斜支94例、降支外侧支187例、降支内侧支78例,肌瓣来源于股外侧肌308例、股直肌51例,制备形式包括主干肌支型154例、主干远端型78例、主干侧边型127例。皮瓣切取范围为6.0 cm×4.0 cm~16.0 cm×8.0 cm,肌瓣范围5.0 cm×4.0 cm~9.0 cm×6.0 cm。316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;43例穿支血管蒂动脉与面动脉吻合,伴行静脉与面静脉吻合。术后6例发生血肿、4例发生血管危象,经急诊探查后7例成功挽救,1例皮瓣部分坏死(经换药后愈合),2例皮瓣完全坏死(采用胸大肌皮瓣补救)。患者均获随访,随访时间10~56个月,平均22.5个月。皮瓣外观满意,患者吞咽、语言功能恢复满意。供区仅遗留线性瘢痕,大腿功能未见明显影响。随访期间23例发生肿瘤局部复发,16例发生颈部淋巴结转移。患者3年生存率为38.2%(137/359)。结论 在股前外侧嵌合穿支肌皮瓣制备关键环节做出灵活而有明确分类的选择,可以最大程度优化手术流程,增加手术安全性,降低手术难度。

Objective To summarize the combination methods and optimization strategies of the harvest procedure of anterolateral thigh chimeric perforator myocutaneous flap.Methods A clinical data of 359 cases of oral cancer admitted between June 2015 and December 2021 was retrospectively analyzed.There were 338 males and 21females with an average age of 35.7 years (range,28-59 years).There were 161 cases of tongue cancer,132 cases of gingival cancer,and 66 cases of buccal and oral cancer.According to the Union International Center of Cancer (UICC) TNM staging,there were 137 cases of T4N0M0,166 cases of T4N1M0,43 cases of T3N1M0,13 cases of T3N2M0.The disease duration was 1-12 months (mean,6.3 months).The soft tissue defects in size of 5.0 cm×4.0 cm to 10.0 cm×7.5 cm remained after radical resection were repaired with the free anterolateral thigh chimeric perforator myocutaneous flaps.The process of harvesting the myocutaneous flap was mainly divided into 4 steps.Step 1:exposing and separating the perforator vessels,which mainly came from the oblique branch and the lateral branch of the descending branch.Step 2:isolating the main trunk of the perforator vessel pedicle and determining the origin of the vascular pedicle of muscle flap,which was came from oblique branch,lateral branch of the descending branch,or medial branch of the descending branch.Step 3:determining the source of muscle flap,including lateral thigh muscle and rectus femoris muscle.Step 4:determining the harvest form of muscle flap,which included muscle branch type,main trunk distal type,and main trunk lateral type.Results The 359 free anterolateral thigh chimeric perforator myocutaneous flaps were harvested.In all cases,the anterolateral femoral perforator vessels existed.The perforator vascular pedicle of the flap came from the oblique branch in 127 cases and the lateral branch of the descending branch in 232 cases.The vascular pedicle of muscle flap originated from the oblique branch in 94 cases,the lateral branch of the descending branch in 187 cases,and the medial branch of the descending branch in 78 cases.The muscle flaps harvested from the lateral thigh muscle in 308 cases and the rectus femoris muscle in 51 cases.The harvest forms of muscle flaps included 154 cases of muscle branch type,78 cases of main trunk distal type,and 127 cases of main trunk lateral type.The size of skin flaps ranged from 6.0 cm×4.0 cm to 16.0 cm×8.0 cm,and the size of muscle flaps range from 5.0 cm×4.0 cm to 9.0 cm×6.0 cm.In 316 cases,the perforating artery anastomosed with the superior thyroid artery,and the accompanying vein anastomosed with the superior thyroid vein.In 43 cases,the perforating artery anastomosed with the facial artery,and the accompanying vein anastomosed with the facial vein.After operation,the hematoma occurred in 6 cases and vascular crisis in 4 cases.Among them,7 cases were successfully saved after emergency exploration,1 case had partial necrosis of skin flap,which was healed after conservative dressing change,and 2 cases had complete necrosis of skin flap,which was repaired by pectoralis major myocutaneous flap.All patients were followed up 10-56 months (mean,22.5 months).The appearance of the flap was satisfactory,and the swallowing and language functions were restored satisfactorily.Only linear scar left in the donor site with no significant effect on thigh function.During follow-up,23 patients had local tumor recurrence and 16 patients had cervical lymph node metastasis.The 3-year survival rate was 38.2%(137/359).Conclusion The flexible and clear classification of the key points in the harvest process of anterolateral thigh chimeric perforator myocutaneous flap can optimize the protocol to the greatest extent,increase the safety of the operation,and reduce the difficulty of the operation.