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    顳肌筋膜瓣即刻修復上頜骨缺損的臨床觀察
    關鍵字:觀察,臨床,修復,GH,IJ,EF,CD,wx,AB,KL, 發布時間:2011-08-20

    ?28? 蝗鏖醫堂;Q!Q生2旦筮墊鲞筮!魍墾!迦!!!叢!l迫塑,星P:墊!Q:!堂:!Q:№:窆 顳肌筋膜瓣即刻修復上頜骨缺損的臨床觀察 王濤 (南京醫科大學口腔醫學研究所,南京醫科大學附屬口腔醫院頜面外科,江蘇南京210029) 【摘要】目的通過對顳肌筋膜瓣即刻修復上頜骨缺損病例的回顧性分析,評價其效果。方法2003年2月至2005 年7月,9例患者因上頜骨腫瘤進行上頜骨部分切除,術后即刻采用顳肌筋膜瓣修復重建。觀察顳肌筋膜瓣成活情況、 術后語音以及吞咽功能的恢復狀況。結果8例組織瓣全部成活,l例組織瓣部分成活。患者語言、吞咽、咀嚼功能恢復 基本滿意,、結論顳肌筋膜瓣修復上頷骨缺損安全可靠,是較為理想的方法。 【關鍵詞】顳肌筋膜瓣;上頜骨缺損;重建 ImmediatereconstructionofmaxillectomydefectsbyusingtemporalismyofascialflapWANGTao.Researchlnstitueof StomatologyofNanfingMedicidUniversity,DepartmentofOralandMaxiUofacialSurgery,StomatologicalHospitalAffiliated to №彬增MedicalUnwersity,Nanjing210029,China 【Abstract】Objective Toassesstheeffectofimmediatereconstructionofmaxillectomydefectsbyusingtemporalismyofascial flap.Methods NinepatientswereundergonepartialmaxillaeresectionbecauseofmaxillarylumorbetweenFebruary2003tOJu— ly2005,andimmediatelyreconstructthemaxillectomydefectsbyusingtemporalismyofascialflap.Thevitalit7ofthe,temporalis myofascialflap,functionofspeechandswallowing wasvaluated.Results Eighttemporalismyofascialflapssurvivedcompletely, Onetemporalismyofascialflappartialsurvivance,speechandchewingandswallowingfunctionweresatisfactorilyrecovered. Conclusion Temporalismyofascialflapisverysafeandreliable,SOitis agoodmethodtoreconstructthemaxi[1ectomydefects. 【Keywords】Temporalismyofascialflap;Maxillectomydefects;Reconstruction 上頜缺損是顏面缺損中較為嚴重的一種,患者不 僅面部畸形,而且影響咀嚼、發音等多種功能。過去對 這種缺損多采用贗復體修復,雖可使患者的面形及功 能部分恢復,但仍有較大缺陷。2003年2月至2005 年7月,我們對9例腭部、上頜骨惡性腫瘤的患者行腫 瘤擴大切除及上頜骨次全切除術,對術后的上頜缺損 采用顳肌筋膜瓣即刻修復,收到滿意效果,現報告 如下。 1資料與方法 1.1一般資料:本組9例患者中男6例,女3例,年齡 35—69歲。上腭鱗癌3例,腺樣囊性癌2例,上頜牙 齦癌2例,上頜竇癌l例,上頜成釉細胞瘤l例。所有 患者均采用保留眶下緣和眶下板的上頜骨部分切除,3 例患者同時切除部分顴骨、蝶骨翼外板、喙突等,術后 均采用顳肌筋膜瓣即刻轉移修復。 1.2手術方法:采用發際內半冠狀弧型切口,切開頭 皮前先在帽狀腱膜下注射含腎上腺素的生理鹽水,切 開深度達此層次,同時用頭皮夾止血,這樣既能減少出 血,又便于銳性分離。在顴弓上方1.5—2.0Cllfl處水 平切開顳肌深筋膜淺層,將其與皮瓣一起掀起,以便保 護面神經顴支。將附著于顴弓上的顳深筋膜深層松 解,以利于充分游離和轉移。顱頂部在顳上線切開顳 肌附著,切開時應盡量沿筋膜附著邊緣切開,與肌肉保 持一定距離,避免損傷肌肉內的血管,用骨膜剝離器將 顳肌筋膜瓣從顳窩向顴弓方向掀起,達顴弓平面時要 注意保護顳肌筋膜瓣深面的顳深動靜脈。然后將顳肌 筋膜瓣通過顴弓下隧道轉移到口腔內,轉移后將顳肌 筋膜瓣的筋膜面朝向口腔與周圍組織縫合,縫長線,置 油紗布和碘仿紗條打包同定。同時患側鼻孑L用裹有油 紗布的管狀物填塞,以便完全愈合后形成鼻道。術后 10~14d拆除口內打包。本組9例,應用全顳肌筋膜 瓣7例,2例采用部分顳肌筋膜瓣,均行冠狀劈開應用 前部分顳肌筋膜瓣。 2結果 本組8例顳肌筋膜瓣全部成活。拆除口內打包 時,可見顳肌筋膜瓣表面有肉芽組織生長。術后4~6 周創面縮小,裸露于口腔內顳肌筋膜瓣表面上皮化愈 合。3個月后顳肌筋膜瓣平滑,色澤、質地等與正常黏 膜相似。缺損處組織充填豐滿,將口腔與鼻腔成功地 分隔開。患者可正常進食和言語。l例因病灶超中 線,手術切除范圍接近對側牙槽突,單側顳肌筋膜瓣縫 合后張力較大,邊緣出現部分壞死,經修剪清創后剩余 萬方數據 換頁 蝗瘞醫堂;Q!!生2旦筮!Q鲞笙!翅墾!i!i型叢笪塑堡:墨業:墊!Q:y!!:iQ:盟!:2 部分存活,但留有口鼻瘺。3個月時面部外形基本對 稱,隨著時間延長,上頜骨切除較多的患者鼻翼根部出 現輕度塌陷,鼻孔與健側不對稱。經6個月~3年隨 訪,2例患者出現中度張口受限,未見復發病例。 3討論 上頜骨缺損若未即刻修復,常發生面部塌陷,組織 逐漸萎縮變薄,嚴重影響面容,并有嚴重語音含糊不 清,進食不便等缺陷。膺復體修復雖可緩解部分缺陷, 但很多患者因不同原因不便或不愿使用。采用顳肌筋 膜瓣修復上頜骨缺損有很多優點:顳肌筋膜瓣血供豐 富可靠…,易于成活,并發癥發生率低。供區與受區 相鄰,操作方便,供區傷口可一期關閉愈合,毛發生長 不受損。供瓣組織量大;體積足夠,可充填上頜骨切除 術后以及眶內容剜除術后所遺留的空腔,不會遺留明 顯面部凹陷畸形,且能完全分隔開口鼻腔,有利于患者 術后的語音和進食,提高生存質量。顳肌筋膜瓣暴露 于口腔內的創面,一般術后1—4個月筋膜表面即可完 成上皮化過程而不需植皮舊。J。供區切口線位于發際 內,被頭發遮蓋不易發現,外觀上無明顯畸形。另外如 缺損較小,需要較小的顥肌筋膜瓣時,可將顳肌筋膜瓣 行冠狀劈開,形成附著于喙突并分別以顳深前、后血管 為蒂的組織瓣,切取前部分顳肌筋膜瓣,將后部分顳肌 筋膜瓣向前移位,這樣可減小顳部的凹陷畸形。取瓣 后顳區可用硅橡膠或骨水泥等代用品襯墊,外形上也 無明顯畸形。總的來說顳肌筋膜瓣修復技術可靠,并 發癥發生率低,供區問題少,特別適合于年老體弱患 者,患者對面容及功能的恢復基本滿意。 在制備顳肌筋膜瓣時,依據缺損確定瓣的大小,考 慮到瓣移植成活后出現收縮的情況,所取組織瓣應較 缺損范圍稍大一些。本組有3例術后組織瓣收縮較明 顯,其中l例影響腭咽閉合。劈開組織瓣時,要注意保 護顳肌主要供應血管。顳肌瓣的冠狀或矢狀劈開是建 立在肌纖維結構和肌外供應血管的基礎上。顳肌的主 要動脈來自頜內動脈,其分支顳深淺動脈和顳深后動 脈分別供應顳肌前部的2l%和顳肌中部的41%,而來 自顳淺動脈的分支顳中動脈供應顳肌后部38%的區 域【41,這表明顳肌的冠狀劈開應有不同比例。因此, 作冠狀劈開時,需了解上述血供情況,根據修復需要選 擇劈開部位。顳肌的冠狀面血管網主要集中在內側和 外側,做矢狀劈開時應注意避開,以免引起血腫,導致 組織瓣不易從顴弓下隧道轉移,而且影響到組織瓣的 ?29? 成活。我們在術中冠狀劈開顳肌筋膜瓣,組織成活良 好,表明其符合解剖結構要求。在引瓣入口內缺損區 時,顴弓下隧道需寬松,以免組織瓣受壓。組織瓣就位 后應與周邊組織嚴密縫合,然后以油紗布包裹的碘仿 紗條打包加壓,這一措施能使顳肌筋膜瓣更好的與周 圍組織貼合,并且將顳肌筋膜瓣創緣與口腔隔離,有利 于患者早期口腔進食。本組中6例患者未置鼻飼管, 術后第2日便經口進流食,所轉移的顳肌筋膜瓣均愈 合良好。術后顳部傷口應置放引流,本組均采用1根 負壓引流管,然后顳部加壓包扎3—5d,防止顳部血腫 感染積膿,本組所有患者顥部創口均一期愈合。 顳肌筋膜瓣轉移后部分患者出現張口受限,其原 因可能為:①與手術操作和修復缺損范圍有關,如顳肌 筋膜瓣制備時受到損傷,轉移后隧道遺留死腔,轉移時 扭轉,牽拉喙突”』,愈合后出現瘢痕限制喙突的活動 等。②口腔內完全愈合后,肌筋膜瓣表面完全上皮化, 為瘢痕樣組織結構,刨面縮小,缺乏彈性,質地變硬,面 頰部向心性收縮,形成頜間瘢痕樣組織導致張口受限。 ③顳肌筋膜瓣制作隧道轉移時可能損傷翼外肌造成炎 癥纖維化,影響張口度。所有輕度張口受限患者,經過 積極張口訓練,基本都能達到或接近正常張口度。顳 肌筋膜瓣雖然供瓣組織量大,但對于過大的接近雙頜 的缺損,一側顥肌筋膜瓣顯然組織量不夠,若強行牽拉 縫合,雖能縫起來,但邊緣張力過大,可引起壞死,本組 的l例就是如此。所以對于波及或超過中線的上頜腫 瘤,術前對于切除術后缺損范圍要有預先的估計,如估 計范圍過大,要考慮雙側顳肌筋膜瓣或其他方法修復, 避免一側顥肌筋膜瓣縫合后張力過大。 參考文獻 [1]張念光。SammanH,TidemanH.顳肌筋膜瓣u腔愈合的臨床及組 組學研究[J].中華口腔醫學雜志.1997,32(3):146—148. [2]韓正學.顳筋膜顱骨瓣的研究進展[J].國外醫學口腔醫學分冊, 1997,24(4):207—209. [3]YucdA,Yazars.AydinY,eta1.Temporalisnlll¥cleflapforcraniofa— cialreconstructionaftertumorresection[J].JCraniofacSurg,2000, 11(3):258—264. [4]張念光.顳肌血管分布及其外科應用研究[J].中華口腔醫學雜 志,1997,32(2):272—275. [5]李秋松,王太周,袁賢瑞.帶蒂轉移顳肌筋膜瓣修補腦脊液鼻 漏[J].中國微侵襲神經外科雜志,2002,5(3):179—181. (收稿日期:2010—02—03) (本文編輯:常青) 萬方數據 換頁

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