Tongue reconstruction with free radial forearm flap

Forearm radial free flap reconstruction for the repair of tongue defect after tongue cancer resection. The free radial flap of the forearm was first proposed by Yang Guofan in 1979 through anatomical research, and was called "Chinese flap" by foreign countries. 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. Treating diseases: tongue cancer Indication In addition to the majority of the tongue and the bottom part of the defect, there are defects in the buccal, maxillary, ankle and other parts of the forearm can be used for reconstruction of the free flap of the forearm. The repair of the face can be arbitrarily selected. Therefore, the survival rate of free flap transplantation in the mouth is broken. Contraindications Contraindications are relative, but should be considered carefully if: 1. A patient who is old and weak and has severe arteriosclerosis. 2. Young people are afraid of affecting the appearance because they need skin grafting on the forearm. 3. There is obvious scar on the skin of the donor area. 4. Forearm area blood vessels are used for long-term infusion of antibiotics or chemotherapy drugs. 5. The forearm donor area and the neck receiving area are ultrasonically tested for variability. Preoperative preparation 1. Ultrasound Doppler detects the vascular behavior of the donor and recipient regions. 2. Design the size range of the donor flap. 3. Prepare the skin on the inside of the forearm and upper arm. 4. Matching blood. Surgical procedure The surgical sub-division area and the donor area were simultaneously performed. The affected area was performed according to the conventional tongue and neck combined with radical surgery, and the forearm free flap was prepared for the bed, mainly the selection of blood vessels. The arteries generally use the external maxillary artery or the superior thyroid artery. We believe that the superior thyroid artery is more desirable because there are more branches of the external jaw artery and fewer branches of the superior thyroid artery. In addition, the preparation of the mouth tunnel should be made on the same side of the affected artery, and if necessary, on the opposite side (the healthy side). 1. The donor site cuts the flap (1) Design: It should be on the left side of the upper limb forearm, and the telecentric end should be at the lateral line of the wrist. According to the size and shape of the defect, the corresponding flap should be designed, generally 6~7cm long and 5~6cm wide. Large can make the repaired tongue too bloated, too small to cover the wound. The perimeter of the flap is marked with methylene blue and fixed with iodine. (2) Disinfect the upper tourniquet: routinely disinfect the upper tourniquet, wrap the hand and upper arm with a disinfectant towel, place the entire hand on the small table covered by the disinfectant towel, drive the blood of the forearm with a blood-strap, and then on the upper arm Will have been attached to the tourniquet, pumping and pressurizing, the general pressure is between 37 ~ 40kPa (280 ~ 300mmHg) is appropriate, then start timing, the time limit is 1h, should not be too long. (3) Flap: Cut the skin and subcutaneous tissue according to the design line to reach the superficial fascia. When separating the flap, care should be taken to prevent the subcutaneous tissue from detaching from the vascular pedicle and sutured if necessary. The deep side of the flap should include a part of the tendon sheath of the tendon of the diaphragm, the anterior muscle, the flexor digitorum, the flexor digitorum, the radial flexor, and the longissimus, which are carefully separated at the temporal sulcus. The radial artery and its accompanying veins are ligated and disconnected separately. Note that the radial artery at the distal end of the flap should be long-term, so that it is convenient to check for patency after anastomosis. Then along the surface of the interosseous muscle, the deep muscle space of the diaphragm is separated upward. The vascular pedicle should be kept 8 ~ 12cm long, because the artery is accompanied by the accompanying vein, and the reflux vein is mainly the cephalic vein. In terms of importance, both are equally important, so they should be equally cared for. The two walk on different planes, the cephalic vein is in the superficial subcutaneous tissue layer, and the radial artery is in the deep muscle gap. When separating, attention should be paid not to damage the blood vessel itself, and the lateral branch should pay attention to ligation and hemostasis. The operation has been nearly 1 hour. Before the blood vessel is disconnected, the tourniquet is relaxed and the bleeding is completely stopped. At the same time, the pulsation of the radial artery is also checked, and it is absolutely necessary to ensure that there is no blood leakage in the wound. (4) Broken stipulation: After the preparation of the receiving area is completed, it will start to break off the veins and veins. The order of the disconnection is the posterior arterial vein, which is cut with microsurgical scissors. The broken end is required to be neat and not skewed. Then, 1:1 flushing with heparin and 0.5% procaine is used for blood vessel rinsing, in order to remove blood clots. Reduce vasospasm, prevent thrombosis, and improve vascular patency. The free free flap was wrapped with saline gauze for application in the receiving area. (5) Close the donor site wound: continue to treat the proximal end of the vascular end, ligature the iliac artery and its accompanying vein. It is better to repair the wounds left in the donor area with full thickness skin. Cover the dressing and apply pressure dressing. The full thickness skin can be taken from the inside of the ipsilateral upper arm or from the ipsilateral thoracic side. Taking the chest wall as an example, the long axis of the skin should be parallel to the ribs, and the length may be slightly longer than the length of the defect area after the flap is taken, and the transverse diameter may be slightly smaller than the transverse diameter of the defect area, generally not More than 1/3 of the size of the skin area, longer than and less than 1/3 of the donor area defect, can use the elasticity of the skin, directly suture the wound without tension, and the donor area of the full thickness skin can be directly sutured No trauma and no wrinkles and other deformities. 2. Lesion resection (1) Resection of the primary lesion: Another surgical group underwent conventional combined surgery of the tongue and neck. (2) Anatomy of the affected area vessels: After the removal of the primary lesion, the movements and veins of the affected area are sought. The choice of arterial and vein in the affected area is relatively large in the neck, and it is relatively easy. Because the blood vessels in the neck are rich, the general arterial selection is first of all the upper thyroid artery, because it has a relatively small branch of blood vessels, the diameter of the tube is about 2 to 3.5. Mm, similar to the diameter of the radial artery, the anastomosis is not difficult; the second is the selection of the external jugular artery segment, the thickness of which is similar to the radial artery, but there are many branches, easy to form a thrombus; in addition, there are also selective selection of the lingual artery and superficial temporal artery. The artery is supplied to the blood, and the vein is generally selected from the anterior branch of the external jugular vein, the posterior branch of the face, the lingual vein or the external jugular vein. In special cases, the internal jugular vein can also be used. (3) Preparation of the tunnel: firstly selected in the submandibular region of the ipsilateral mouth, or in the bottom region of the healthy side, corresponding to the middle segment of the mandibular lingual muscle, separating the muscle fibers, so as to make a passage between the mouth and the jaw. In order to make the channel size moderate and not infarction, you can use a piece of unfolded gauze to roll into a gauze. It can be pulled back and forth 2~3 times through the above tunnel, so that the vascular pedicle can pass very smoothly, so as to avoid postoperative operation. Edema compresses blood vessels. (4) Reconstruction of the tongue: After the completion of the preparation work, the transplantation is started. The vascular pedicle of the free flap of the temporal side is first introduced from the oral cavity and through the tunnel of the mouth to the submandibular area or the neck. The wound edge and the free flap in the oral cavity are fixed in place by intermittent. 2 anastomotic blood vessels. It is generally more accurate to perform under a surgical microscope. A small vessel clamp is placed on both ends of the anastomosis to block blood flow. Flush blood vessels and surgical fields with saline such as heparin. Although this does not improve the patency rate, the surgical field after rinsing is not as sticky as washing with saline alone, and it can keep the field moist and easy to see the blood vessel wall. After trimming the connective tissue of the excess adventitia, a 9-0 non-invasive suture was used for end-to-end anastomosis in the order of 6-12-3-9 points, followed by intermittent sutures. 8 needles are appropriate, can also be added to 10 needles, the margin should be moderate, too large and easy to cause narrowing of the anastomosis, affecting blood flow, too small and easy to slip, blood leakage, but also need to re-seal, generally 1.5mm As well. And full-layer suture, such as good vision, can also be used without a microscope, directly sutured with the naked eye, and finally should be checked under the operating microscope to ensure reliability, in the absence of blood leakage, first open the telecentric side of the blood vessel clamp After that, release the proximal vascular clamp and let the blood flow quickly through the anastomosis, so that even if there is a small thrombus, it can rush to the end of the radial artery. Check the anastomosis should first check for leakage. Whether the anastomosis is unobstructed or not, the problem that often needs to be considered is the cause of vasospasm or anastomosis. Vasospasm will affect the patency rate. Generally, topical application of 1% to 2% papaverine, do not massage the blood vessels, and then check the blood vessels after a few minutes. At this time, the surgical site can be lowered, which often helps to relieve vasospasm. Check the anastomosis is smooth, you can do a smooth test at the distal end of the anastomosis: use the No. 2 jewelry , just clamp the blood vessel at the distal end of the anastomosis, the force of the clip just blocks the blood flow, and then use another No. 2 jewelry Squeeze the blood downstream of the blood vessel, continue to block the blood vessel with the forceps away from the anastomosis, and relax the forceps near the anastomosis. If the anastomosis is smooth, the blood flow quickly fills the empty blood vessel through the anastomosis. This test only uses When you have doubts about the smoothness of blood vessels. For general oozing, it can be ignored. If there is obvious blood leakage, it should be supplemented with needles and seams. After the anastomosis of the artery is completed, the vein is anastomosed. At this time, a vein is obviously oozing, or the cephalic vein or the accompanying vein is matched with the selected vein or facial vein, and the affected vein is blocked. Flow, disconnected blood vessels, the proximal end of the affected vein is clamped with a small blood vessel clamp, and the cephalic vein of the flap or the accompanying vein can be clipped on a small blood vessel, or not. Depending on the amount of blood flow back, more than the upper clip, and vice versa. The anastomosis method and the examination of the venous anastomosis are as described above After the arteriovenous anastomosis, let it clear for a few minutes, in order to further confirm its patency rate, to ensure that the flap survives, it is necessary to have blood clots or small blood clots, all from the end of the radial artery. The author used the method of bloodletting at the distal end of the radial artery to locate and untie the distal ligament of the radial artery with the mark. The distal part of the radial artery was hemorrhaged for about 30 seconds. If the bleeding is sprayed, it will be stored. The small thrombus in the flap is completely rushed out, which can completely avoid the postoperative vascular crisis, thereby improving and ensuring the survival rate of the flap. This is one of the important means to ensure success. In the vascular anastomosis, generally before the blood vessel is disconnected, low-molecular dextran (generally less than 20,000 molecular weight) is applied before the small blood vessels are anastomosed. The purpose is to dilute the blood with dextran, reduce the viscosity and improve the effect of microcirculation. The lower the molecular weight, the stronger its microcirculation. (5) suture flap: after the vascular anastomosis is smooth, the edge of the flap is obviously oozing. At this time, the flap can be repaired, or the tongue can be reconstructed. According to the shape requirement, the edge is firstly stitched and stitched. Then, the rigorous intermittent suture is performed. It is best to suture the subcutaneous tissue and the skin. The suture should be used with the 4th line to reduce the cutting action of the thin line on the tongue tissue, so that the wound is easily broken. Between the mandibular ligament muscle and the contralateral lingual muscle left at the bottom of the resection, a number of needles are intermittently sewn so that the reconstructed tongue has a raised edge, and the tissue of the free flap and the middle portion can be appropriately Stitching. Make it look like a normal tongue shape, suture the edges in turn, eliminate the oral planing surface, and leave a long line when suturing. Then place the iodine spun yarn gauze on the skin surface of the flap, and pack, ligation and fix with the long line. This can not only protect the flap, but also increase the local pressure, reduce the local venous congestion of the flap, promote the effect of venous return, thereby reducing the formation of thrombus, and the survival rate is greatly improved, but it should be inconvenient to observe the color of the flap. note. The neck wound was completely hemostasis, and the negative pressure drainage tube was placed as usual, sutured layer by layer, and appropriately pressurized. complication 1. Thrombosis occurs at the anastomosis, resulting in partial or total necrosis of the flap. 2. Secondary infection after surgery.