Free grafting of scapular flap for buccal reconstruction

Scapular flap free graft buccal reconstruction for the surgical treatment of oral and maxillofacial malignancies. The cheek is located on the side of the face and constitutes the side wall of the mouth. The upper boundary is the lower edge of the humerus and the zygomatic arch; the lower boundary is the lower edge of the mandible; the anterior boundary nasolabial fold, the anterior horn; the posterior border and the pterygopalatine ligament. These include skin, subcutaneous tissue, buccal fascia, buccal muscles, buccal fat, submucosal tissue, and mucous membranes. The subcutaneous tissue is loose, including the branch of the facial nerve and the trigeminal nerve, the facial artery, the anterior vein, and the buccal artery. The parotid duct is open to the buccal mucosa. Cheek cancer invades these structures and surrounding tissues. After surgical resection, it causes defects of different degrees and shapes. It not only affects important functions and appearances such as language, chewing, expression, but also causes psychological and mental trauma to the patient. Therefore, recovery function is required. And a reconstruction of the cheeks that reconciles both the shape and the shape. Treatment of diseases: oral and maxillofacial tumors Indication The scapular flap free graft buccal reconstruction is suitable for: 1. The patient is in good general condition and can withstand this operation. 2. The surgeon has skilled microsurgical vascular anastomosis techniques. 3. The donor area of the flap is relatively concealed, and the wound in the donor area can be directly closed without sacrificing the main blood vessel, and the flap area is large, which is suitable for the repair of a large defect of the cheek. Also suitable for the repair of facial defects. Contraindications 1. The patient's physical condition is poor, especially if the heart function is poor. 2. Obese patients cut this flap thicker and repair the swelling after cheek surgery. This patient is best not to use this flap. 3. The length of the vascular pedicle of the flap is limited, and the repair of the upper cheek defect is not applicable. Preoperative preparation 1. Surgical microscope and microsurgical vascular anastomosis instruments, surgical instruments are divided into two sets. 2. Preoperative oral cleaning. 3. With fresh blood 900 ~ 1200ml, 5% low molecular dextran 500ml. 4. The spine sacral artery was detected and labeled with ultrasound Doppler before surgery. 5. Clean the enema before going to bed 1 day before surgery. 6. Place a catheter on the morning of surgery. 7. The skin preparation and preoperative medication of the donor site and the recipient site are the same as the general surgical requirements. Surgical procedure The surgery was performed in two steps. The following buccal squamous cell carcinoma invades the mandibular vestibule as an example. Lesion removal 1 Incision design: the middle of the lower lip to the submandibular, neck design incision, methylene blue line. 2 lesion resection: routine neck dissection, preserve the facial artery and external jugular vein for anastomosis. The median lower lip was cut along the incision design line and the submandibular incision was made to separate the lip and lingual gingival mucosal flap. The incision was made at 1.5 cm normal mucosa outside the edge of the tumor to remove the buccal mucosa and myometrial lesions. Ligation of the parotid duct. Regular mandibular square cutting, washing, hemostasis. 2. Scapular flap cutting 1 Incision design: The end of the operation in the lesion area, the patient was changed to the prone position, and the scapular flap was cut. First marks the scapula, the lower scapula and the lateral edge of the scapula. The projection point of the surface of the scapula and the scapula is the intersection of the upper 2/5 and the lower 3/5 of the scapula to the scapular angle and the outer edge of the scapula. According to the range and shape of the buccal defect, the scapular flap can be placed against the scapula, down to the lower corner of the scapula 2.0cm, and the inner border to the spine is 2.0cm, and the outside is wrinkled. However, the three-sided hole must be included in the flap. 2 flap removal: along the outer edge of the flap and additional incision, cut the skin, subcutaneous tissue until the deep fascia, expose the deltoid muscle and retract upward, expose the three holes, retract the small round muscle inward, reveal the spiral shoulder The veins and veins were dissected and the vascular pedicle was about 5.0 cm long. Then the line was drawn along the flap, and the skin and subcutaneous tissue were cut to a sharp separation between the deep fascia and the sarcolemma. The flap was lifted to stop bleeding and stagnation. 3 The sutures in the donor site were sutured, separated along the wound edge, and the sutures and sutures were sutured. 3. Flap graft reconstruction 1 anastomotic blood vessels: After the donor site is closed, the patient is changed to the supine position. The free flap was transplanted into the buccal defect area of the mouth, and several needles were sutured. Under the operating microscope, the 9-0 non-invasive suture, the facial artery and the circumflex iliac artery, the external jugular vein and the scapular vein were respectively end-to-end anastomosis. 2 cheek reconstruction: the skin edge of the flap and the buccal defect mucosal wound margin and the mandibular lingual gingival wound edge, with 1-0 suture, intermittent suture. Lower lip and submandibular and cervical wounds are sutured in sequence 4. Place the negative pressure drainage tube A negative pressure drainage tube is placed on the front and back sides of the neck incision, and a negative pressure drainage tube in front of the neck can extend under the flap. complication 1. Intraoperative compression and flap hemostasis were not complete, and postoperative hematoma formation. 2. Anastomotic vasospasm, vascular pedicle distortion, anastomotic leakage and thrombosis. 3. Postoperative wound infection, because the operation through the mouth, long time, multiple changes in the patient's position during surgery can cause wound infection, resulting in flap rupture, partial necrosis, and even all necrosis.