Buccal reconstruction with two kinds of skin flaps and composite grafts

Two kinds of flaps combined with graft graft 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, and 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 1. The patient is in good general condition and can withstand this operation. 2. The surgeon has a skilled microsurgical vascular anastomosis technique. 3. It is suitable for cases where the cheek is extensively worn and the flap is difficult to repair. Contraindications 1. The patient's physical condition is poor and it is difficult to withstand this major operation. 2. The two types of flaps selected have their own contraindications. Preoperative preparation 1. The blood vessels in the receiving area and the two donor areas should be carefully examined before surgery to ensure no abnormalities. 2. Surgical microscope and microvascular anastomosis instruments, surgical instruments are divided into three sets. 3. 3 days before surgery, the oral cavity was washed with 1:5000 furancillin solution and 3% hydrogen peroxide solution, 3/d for 3 consecutive days. 4. With fresh blood 1200 ~ 1500ml, 5% low molecular weight dextran 500ml and heparin and other intraoperative use. 5. 1 day before surgery, clean the mouth and clean the enema before going to bed. 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 three groups at the same time. Take a wide range of hole-breaking defects in the mandible and cheek skin with cheek cancer as an example. Lesion removal 1 Incision design: Incision was designed in 1.5 cm normal tissue outside the boundary of the lesion, neck dissection and pectoralis major myocutaneous flap incision, and the line was painted with methylene blue. 2 lesion resection: conventional neck dissection, but retain the facial artery. If the facial artery is violated, the superior thyroid artery is preserved, and the external jugular vein is also preserved for vascular anastomosis. The skin, subcutaneous tissue, muscle and intraoral mucosa were cut along the entire incision line of the lesion, and the parotid duct was ligated. The mandibular body is removed by conventional methods, flushed and hemostasis. 2. Forearm ulnar flap removal and transplantation 1 flap design: centered on the ulnar artery and the main vein, according to the size and shape of the medial defect of the mouth, the flap was designed on the ulnar side of the forearm. For details, see Forearm ulnar flap (folding) free graft buccal reconstruction. 2 flap removal: according to the forearm ulnar flap cut conventional, cut the skin, subcutaneous tissue along the design line, free vascular pedicle and peeling flap. The full thickness of the lower abdomen was removed to repair the wound in the forearm donor area. 3 flap free transplantation: the recipient area is ready, the forearm ulnar flap is broken, transplanted in the buccal defect area, the skin of the flap is lateral to the mouth, and the wound is laterally outward. Under the operating microscope, 9-0 non-invasive suture, ulnar artery and facial artery, and the main vein and the external jugular vein were end-to-end anastomosis. Skin flap wound and buccal defect mucosal wound margin were sutured with 1-0 suture. 3. Pectoralis major musculoskeletal flaps are harvested and transplanted 1 musculoskeletal flap cutting: draw a line along the incision, cut the skin, subcutaneously until the deep fascia layer, open the skin flap, dissect the vascular pedicle of the thoracic and shoulder arteries, and then cut the skin and subcutaneous along the incision line of the myocutaneous flap. Tissue, muscle until rib periosteum, at the 8th rib of the medial and lateral margin of the musculocutaneous flap, cut the periosteum, peel off, cut the ribs on both sides of the flap with ribs, and suture the periosteum to the muscle section of the musculocutaneous flap. The anti-bone flap and the musculocutaneous flap are detached, the musculocutaneous flap is turned up together with the ribs, and the ligature is ligated to stop bleeding 2 pectoralis major musculoskeletal flap transfer reconstruction: the vascular pedicle of the pectoralis major musculocutaneous flap was twisted and rotated to the buccal defect area. The two ends of the mandible are drilled with a bone drill. The ribs of the skeletal muscle flap were also drilled separately, and the bilateral bone ends were ligated with stainless steel wire. The skin flap of the musculocutaneous flap and the wound of the cheek defect were sutured with a 1-0 suture. 3 Close the neck, chest wound and place the negative pressure drainage tube: After flushing and stopping bleeding, suture the neck and chest wounds layer by layer with 1-0 suture. A negative pressure drainage tube is placed on both sides of the muscle vascular pedicle. complication 1. Muscular vascular pedicle and anastomotic vasospasm, compression, anastomotic leakage, thrombosis, etc. 2. Flap, musculoskeletal flap and muscle vascular pedicle hemorrhage, hematoma formation. 3. Maxillofacial neck wound infection. This operation is large, the number of ligatures is too many, the internal disinfection is difficult, the operation time is long, the trauma is large and other factors can often cause postoperative wound infection, resulting in flap rupture or partial necrosis, or even necrosis. 4. The tension in the chest and abdomen donor area is large after suturing, and the suture removal too early can cause the wound to split and delay healing.