Reconstruction of tongue and mouth floor with subhyoid myocutaneous flap

Sublingual musculocutaneous flap and reconstruction of tongue and mouth for the repair of tongue defect after tongue cancer resection. The sublingual myocutaneous flap was first proposed by Wang Hongshi in the 1980s. It is a musculocutaneous flap with a sublingual muscle group pedicled with the superior thyroid artery. It is used to reconstruct the tongue and the bottom of the mouth. The flap technique is simple in operation, rich in blood supply, strong in anti-infective force, and close to the oral cavity, so the survival rate is high. Before the 1970s, most of the tongue defect repair after tongue cancer resection was simple suture to achieve the purpose of eliminating the wound. The tongue has been used to restore the tongue function after tongue cancer resection, but it is inconvenient and not popular because it is used for assisting eating and language. By the end of the 1970s, due to the continuous development of maxillofacial surgery, especially microsurgery, it opened up a new way for the reconstruction of tongue cancer after resection. In 1975, the Japanese hero of Tian Dai proposed to reconstruct the base of the tongue with a sternocleidomastoid composite flap. In 1977, Lesh proposed a pedicled thoracic triangle flap to repair the defects of the tongue, the mouth and the lower jaw. In 1978, Matutic reported the use of a chest lock. Reconstruction of the mastoid muscle plus the frontal flap for the tongue. In 1980, Wang Hongshi and others proposed the reconstruction of the tongue with the sublingual muscle flap. All of the above are tongue reconstruction with regional flap pedicle transfer. The advantage is that the operation is simpler than the free flap, and the survival rate of the flap is higher. It is a kind of tongue re-establishment method used in clinical practice. However, its shortcoming is that tongue cancer tends to metastasize early, and regional flaps are sometimes difficult to select. At the same time, the elimination of the donor area has to be designed separately. It often causes difficulties in surgery, and also causes more trauma and more bleeding. The patient's recovery from health also has an impact. Due to the progress of microsurgery, in 1977, Panje used the free inguinal flap to repair the soft tissue defect in the mouth. In 2 cases, the repair of 2 cases of tongue excision was successful. In 1979, Brien et al applied the defect of the foot to repair the defect of the mouth. In 1980, the Longzheng Hospital first successfully reconstructed the shape and function of the tongue with the forearm free flap transplantation. The flap has a high survival rate, a large blood vessel, and an easy anastomosis. The flap itself has a good texture, a moderate thickness, and is easy to shape. It is an ideal free flap for repairing and reconstructing the tongue defect. There are many ways to reconstruct the tongue. In addition to the above, there are the medial flap, the latissimus dorsi flap, the medial flap of the upper arm and the scapular flap; the pedicle flap and the pectoralis major and frontal flaps. You can choose according to the actual situation and possibility of the defect, as well as the experience of the surgeon. Applied anatomy of the tongue: The tongue is a muscular organ, the first 2/3 is the tongue, the second 1/3 is the tongue root, and the front and back are bounded by the contour nipple. The tongue is the active part, and the tongue is divided into the left and right halves. There are bacteria, filamentous and lobulated papilla on the back of the tongue. The nipples are closely connected to the muscles, and the mucosa of the tongue is smooth and thin. The tongue muscles are divided into two groups: the inner and the extralingual muscles. The intralingual muscles include the supra-lingual and inferior longitudinal muscles, the transverse muscles of the tongue and the rectus abdominis muscles. The extra-lingual muscles include the genioglossus, the hyoid bones, the styloids, the lingual muscles, and the pharyngeal muscles. Except for the accessory nerve and the vagus nerve pharynx, the rest are dominated by the hypoglossal nerve. The blood supply of the tongue is abundant, and its artery is the deep artery of the lingual artery and its terminal branch. Treating diseases: tongue cancer Indication Sublingual musculocutaneous flap and fundus reconstruction are applicable to: 1. The neck has been cleaned at the same time, and the external carotid artery system has not been damaged. 2. The patient's neck skin is easy to pull the suture. Contraindications 1. The superior thyroid artery has been treated with chemotherapy. 2. The defect range is too large, and the local skin scar tissue is obvious. Preoperative preparation 1. Matching blood. 2. Prepare the tracheostomy bag. Surgical procedure 1. Design and incision An incision parallel to the lateral side of the sternohyoid muscle and an incision parallel to the inferior border of the hyoid bone and the upper sternum are made into a rectangular flap of about 10 cm x 4 cm in size. 2. Cut the skin, subcutaneous tissue, muscles When the musculocutaneous flap is turned up from the thyroid capsule (including part of the capsule), but when it is separated to the upper side of the thyroid, special attention should be paid to protecting the superior thyroid artery and not to be damaged. Because it serves as the blood supply artery of the musculocutaneous flap. The vein associated with the artery is used as a reflux vein, and when the nerve is needed, the sublingual nerve branch supporting the ribbon muscle is selected. After dissecting the sternohyoid muscle and sternal thyroid muscle on the sternal notch, along the deep surface of the muscle, including the superficial layer of the thyroid capsule, it is separated upwards, close to the upper thyroid gland, and the upper thyroid artery is cut and distributed to the gland. Finely branching, retaining the trunk of the superior thyroid artery and its branches into the ribbon muscle, separating it from the thyroid gland. At the upper end, the band muscle is cut at the end point of the band muscle at the thyroid cartilage and the hyoid bone to form an island flap with a vascular nerve banding muscle. As much as possible, a vascular nerve pedicle is added to increase the musculature. The blood supply of the valve is conducive to repair, but sometimes the vascular pedicle on one side can be cut off in order to facilitate the transfer of the musculocutaneous flap. 3. Flap transfer After the tongue cancer is removed, the flap can be transferred into the entrance, the sternum end of the flap is sutured to the root edge of the tongue, and the other end of the flap reconstructs the free end of the tongue, so that the flap needs to be folded and folded at 180°, pay attention to keep The supply of blood vessels is not overly distorted. 4. Close the donor site wound The defect in the anterior cervical region is then repaired by the thoracic triangle flap, and the defect at the thoracic and thoracic peak can be directly pulled to eliminate the wound. Place a negative pressure drain tube. 5. It is estimated that the postoperative may affect the airway patency, and the tracheostomy should be performed before the extubation. complication 1. The edema and hematoma at the base of the base of the tongue can be complicated by obstruction of the respiratory tract and should be closely observed. 2. Hemostasis or small blood vessels in the muscle fibers ooze, can be combined with mouth and neck hematoma. 3. Neck scar contracture, affecting the neck head and back tilt function. 4. The flap is over-twisted, causing partial or most necrosis of the flap.