改良皮肤微小三角瓣联合口轮匝肌瓣功能性分区重建修复单侧不完全性唇裂

Repairing unilateral incomplete cleft lip functionally and sub-regionally with modified micro-triangular skin flap and orbicularis oris muscle flaps

目的:探讨应用改良皮肤微小三角瓣联合口轮匝肌瓣功能性分区重建的方法修复单侧不完全性唇裂的临床效果。方法:回顾性分析2020年4月至2023年2月西安交通大学第一附属医院整形美容颌面外科收治的单侧不完全性唇裂患儿临床资料。参考上唇健侧解剖结构标记手术定点,采用短直线结合微小三角瓣法设计皮肤切口:沿人中嵴方向设计短直线切口,于患侧红唇缘上方皮肤设计微小三角瓣,插入对侧唇峰处,降低患侧唇峰,延长人中嵴。将口轮匝肌分割为5个肌肉瓣分3区进行重建,恢复上唇与鼻底亚单位结构,重建唇珠、人中嵴结构,纠正向健侧偏斜的鼻小柱,抬高鼻基底。术后从主观评价和客观测量2个方面对手术效果进行评价:(1)主观评价,由未参与手术的2位整形外科医师通过患儿术前和末次随访时的照片,对手术后瘢痕情况、唇弓连续性、唇峰高度、鼻底宽度、鼻孔对称性和人中嵴高度进行总体效果评分,外形较差为1分,一般为2分,满意为3分。(2)客观测量,由未参与手术的1位整形外科医师通过Image-Pro Plus 6.0软件测量双侧红唇厚度、双侧唇峰口角距、双侧人中嵴长度、双侧鼻翼唇峰距、双侧鼻底宽度,计算非对称率(|健侧数值-患侧数值|/健侧数值×100%),数值越接近于0,表示两侧差异性越小、越对称。采用描述性方法进行统计分析,非正态分布的计量资料用M(Q_(1),Q_(3))表示。结果:共纳入32例单侧不完全性唇裂患儿,其中男19例,女13例,年龄3个月至1岁6个月。患儿术后切口均一期愈合,无局部感染、出血、切口裂开等并发症。术后随访6~24个月,患儿红唇形态饱满,连续性良好,唇珠明显,人中嵴结构立体,双侧对称性良好,遗留瘢痕小,修复效果满意。患儿手术效果主观评价平均总体得分为2.66分,其中唇弓连续性得分最高(2.84分),鼻孔对称性得分最低(2.38分);客观测量结果显示,双侧鼻底宽度[2.60%(1.02%,7.08%)]与双侧人中嵴长度[3.95%(2.03%,5.98%)]的非对称率最低。结论:改良皮肤微小三角瓣联合口轮匝肌瓣功能性分区重建的方法能够修复上唇亚单位结构,较好地恢复上唇和鼻基底的对称性,是修复单侧不完全性唇裂的有效方法。

Objective To investigate the clinical effect of repairing unilateral incomplete cleft lip functionally and sub-regionally with modified micro-triangular skin flap and orbicularis oris muscle flaps.Methods A retrospective study was conducted in the patients with unilateral incomplete cleft lip,who underwent repair at Department of Plastic,Aesthetic and Maxillofacial Surgery,the First Affiliated Hospital of Xi’an Jiaotong University from April 2020 to February 2023.Surgical landmarks were fixed according to the anatomical structure of non-cleft side.Short straight skin incisions were designed along the philtral column.A micro-triangular flap was designed above the vermilion margin of the affected lip,which was inserted into the contralateral lip peak to lower the lip peak and lengthen the philtral column.The orbicularis oris muscle was reconstructed with five muscle flaps in three areas to create a good sub-structure of the upper lip and the nasal floor.The vermilion tubercle and philtral column were reconstructed.Deviation of nasal columella was corrected and the nasal floor was elevated.The outcomes were assessed through subjective evaluation and objective anthropometric measurements.(1)Subjective outcomes were assessed by two plastic surgeons together who were not included in this study.The following parameters were assessed:scar appearance,Cupid’s bow continuity,lip pick height,alar base width,nostril symmetry,philtral ridge contour.Each parameter was graded from 1 point(poor),2 points(average),or 3 points(good).(2)Objective measurements were taken by one plastic surgeon who was not included in this study using the Image-Pro Plus 6.0.Measurements were included bilateral vermilion thickness,bilateral length of lip pick to cheilion,bilateral philtral column length,bilateral length of Cupid’s pick to ala nasi,bilateral alar base width.Asymmetry ratio=|non-cleft counts-cleft counts|/non-cleft counts×100%,and a value closer to 0 would mean the less different,the more symmetrical.Statistical analysis was performed using descriptive methods.Non-normal distributed measurement datas were expressed by M(Q_(1),Q_(3)).Results A total of 32 patients of unilateral incomplete cleft lip were enrolled,including 19 males and 13 females,aged 3-18 months.All patients were primary healing,and no serious complications(i.e.,infection,hematoma,wound dehiscence)occurred.The postoperative follow-up time was 6-24 months.The patients were satisfied with the results,including favorable red lip contour,good continuity,obvious vermilion,cubical philtrum column,good symmetry of bilateral structure and sub-structure and light scar.The overall score of the subjective evaluation was 2.66 points.Cupid’s bow continuity got the highest score(2.84 points),and nostril symmetry got the lowest score(2.38 points).Objective measurements indicated excellent parameters were bilateral alar base width[2.60%(1.02%,7.08%)]and bilateral philtral length[3.95%(2.03%,5.98%)].Conclusion Repairing unilateral incomplete cleft lip functionally and sub-regionally with modified micro-triangular skin flap and orbicularis oris muscle flaps can create a good sub-structure of the upper lip contour,and bring a significant improvement in the upper lip and the nasal floor symmetry,which is an effective method for incomplete unilateral cleft lip repair.