Bogle M, Kelly P, Shenaq J, Friedman J, Evans G R
Department of Plastic Surgery, The University of Texas, MD Anderson Cancer Center, Houston 77030, USA.
Head Neck. 2001 Jan;23(1):8-15.
Reconstruction after wide local excision of melanomas in the head and neck can be formidable. Many tumors lie close to vital structures, and excision must carefully balance preservation of form and function. For small defects, primary closure or skin grafting is satisfactory. However, it has become increasingly evident that more advanced reconstructive procedures can improve the outcome in terms of both function and aesthetics. This study was undertaken to determine the effectiveness of flap closure after wide local excision of melanomas in the head and neck and to develop a set of surgical recommendations on the basis of our experience.
We reviewed 35 patients who underwent 39 flap closures at The University of Texas, M. D. Anderson Cancer Center after wide local excision of head and neck melanomas. Local flaps were primarily used to close defects after the resection of superficial or intermediate-thickness melanomas. Pedicle and free flaps were used to cover larger defects resulting from the excision of extensive tumors. The flap closures were compared with an analogous database of 560 melanoma resections that underwent primary closure or skin grafting.
The mean age of the patient population was 57 years. The most common location for tumor presentation was the cheek, followed by the ear, forehead, and lip. Pathologic findings most commonly demonstrated superficial spreading melanoma, and the average defect size was 30.7 cm2. Local flaps were used most often for reconstruction. The only variable that significantly predicted local recurrence was the depth of the tumor. Local, pedicle, or free flaps did not decrease the ability of detecting local recurrence or increase this number compared with primary closure and skin grafting. Major postoperative complications were detected in seven patients. We found flap closure to achieve excellent functional and aesthetic results.
Although primary closure is the ideal method of reconstruction for small defects, flap closure provides a versatile and safe alternative when simple closure would yield unsatisfactory results. With careful planning, flap closure offers an exceptional functional and aesthetic result and may even enhance contour defects after extensive neck or parotid dissections. Moreover, our experience with flap closure did not appear to delay the detection of local recurrence and may have even served to decrease the incidence of local failure after wide local excision of head and neck melanomas.
头颈部黑色素瘤广泛局部切除术后的重建手术颇具挑战性。许多肿瘤紧邻重要结构，手术切除时必须在保留外形和功能之间仔细权衡。对于小的缺损，一期缝合或植皮效果良好。然而，越来越明显的是，更先进的重建手术在功能和美学方面都能改善治疗效果。本研究旨在确定头颈部黑色素瘤广泛局部切除术后皮瓣修复的有效性，并根据我们的经验制定一套手术建议。
我们回顾了35例在德克萨斯大学MD安德森癌症中心接受头颈部黑色素瘤广泛局部切除术后进行39次皮瓣修复的患者。局部皮瓣主要用于切除浅表或中厚层黑色素瘤后的缺损修复。带蒂皮瓣和游离皮瓣用于覆盖广泛肿瘤切除后产生的较大缺损。将皮瓣修复与一个包含560例接受一期缝合或植皮的黑色素瘤切除术的类似数据库进行比较。
患者的平均年龄为57岁。肿瘤最常见的发生部位是脸颊，其次是耳朵、前额和嘴唇。病理结果最常见的是浅表扩散型黑色素瘤，平均缺损面积为30.7平方厘米。局部皮瓣最常用于重建。唯一能显著预测局部复发的变量是肿瘤深度。与一期缝合和植皮相比，局部、带蒂或游离皮瓣并没有降低检测局部复发的能力，也没有增加局部复发的数量。7例患者出现了主要的术后并发症。我们发现皮瓣修复能取得优异的功能和美学效果。
虽然一期缝合是小缺损重建的理想方法，但当简单缝合效果不佳时，皮瓣修复提供了一种通用且安全的替代方案。通过精心规划，皮瓣修复能带来卓越的功能和美学效果，甚至可能改善广泛颈部或腮腺切除术后的轮廓缺损。此外，我们进行皮瓣修复的经验似乎并未延迟局部复发的检测，甚至可能降低了头颈部黑色素瘤广泛局部切除术后局部失败的发生率。
