Reconstruction of the mouth floor with two kinds of flaps and grafts

Two kinds of flaps and graft reconstruction were used for surgical treatment of tongue cancer. The tongue defect repair after the removal of tongue cancer was mostly simple suture before the 1970s 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. Treating diseases: tongue cancer Indication 1. The patient is in good general condition and can withstand this operation. 2. It is suitable for cases where a large number of holes are worn through the mouth and a 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 for their own contraindications. Preoperative preparation 1. Carefully check the blood vessels in the receiving area and the two donor areas before surgery to ensure that there are no abnormalities. 2. Surgical microscope and microscopic vascular 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 for 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 operation was divided into three groups, and the lesion resection was performed simultaneously with the forearm ulnar flap removal. For example, a large-scale penetration defect of the mandibular body, part of the tongue, and the skin of the jaw and underarm is infringed. 11.1 1. Lesion removal 1 Incision design: Incision and neck dissection and pectoralis major myocutaneous flap incision were made in 1.5 cm normal tissue outside the boundary of the lesion, and the line was drawn with methylene blue. 2 lesion resection, conventional neck dissection, preservation of the facial artery, such as facial artery invasion, anatomy of the superior thyroid artery, free external jugular vein, in preparation for anastomosis. Neck dissection to the submandibular area, to the bottom of the mouth, mandible. The lesion in the tongue area was removed by conventional three-dimensional resection, and the wound was washed and hemostasis was stopped. 2. Forearm ulnar flap removal and transplantation 1 flap design: centered on the ulnar artery and the main vein, the flap was designed on the ulnar side of the forearm according to the size and shape of the mouth defect. For details, see Forearm ulnar flap (folding) free graft buccal reconstruction. 2 flap removal: according to the forearm ulnar flap removal routine, 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 forearm wound. 3 flap transplantation: the recipient is ready, the forearm ulnar flap is broken, transplanted in the defect area of the mouth, the skin of the flap is lateral to the mouth, and the lateral side of the wound is laterally. Under the operating microscope, the 9-0 line was used, and the ulnar artery was anastomosed with the facial artery or the superior thyroid artery, the main vein and the external jugular vein. The skin flap of the flap and the margin of the tongue and mandibular buccal gingival mucosa were sutured intermittently with 1-0 suture. 3. Pectoralis major musculoskeletal flaps are harvested and transplanted After the ulnar flap of the forearm was cut, the third operation was performed to cut the pectoralis major myocutaneous flap. 1 musculoskeletal flap removal: draw a line along the chest incision, cut the skin, subcutaneous tissue until the deep fascia layer, turn the skin flap, freely dissect the pedicle of the thoracic and shoulder arteries, and then cut the flap along the musculocutaneous incision Area skin, subcutaneous tissue, muscle until rib periosteum, in the 7th rib of the medial and lateral margin of the musculocutaneous flap, incision of the periosteum, exfoliation, where the ribs are cut with the ribs according to the required length of the bone, and the ribs are broken. The muscle section of the musculocutaneous flap is sutured to prevent the periosteum from detaching from the musculocutaneous flap. The musculocutaneous flap is lifted together with the rib flap, and the wound is ligated to stop bleeding. 2 Pectoralis major musculoskeletal flap transplantation submandibular and mandibular reconstruction: the vascular pedicle of the pectoralis major musculocutaneous flap was twisted and rotated to the submandibular area. The two ends of the mandible are drilled with bone drills, respectively. The ribs of the musculoskeletal flap were drilled separately. The bilateral bone fractures were ligated with a 0.35 mm diameter stainless steel wire. The cutaneous flap of the musculocutaneous flap and the margin of the jaw and the infraorbital defect were sutured with a 1-0 suture. . 3 Close the neck, chest wound and place the negative pressure drainage tube: rinse, completely stop bleeding, suture the neck and chest wound with 1-0 suture layer by layer. 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.