Wang Howard T, Erdmann Detlev, Olbrich Kevin C, Friedman Allan H, Levin L Scott, Zenn Michael R
Division of Plastic and Reconstructive Surgery, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
Plast Reconstr Surg. 2007 Mar;119(3):865-72. doi: 10.1097/01.prs.0000240830.19716.c2.
Reconstruction of major neurosurgical resections can present a significant challenge because of the morbidity of radiation therapy, cerebrospinal fluid leaks, bacterial contamination from sinus exposure, and functional and cosmetic deformity from the size and location of the defect. The authors present their experience with free tissue reconstruction of scalp and calvarial defects. In particular, the authors examine their results in relation to major comorbidities, such as preoperative cerebrospinal fluid leak, history of smoking, and perioperative radiation therapy.
From 1997 to 2004, 22 patients requiring neurosurgical or head and neck resection for cancer from a single institution who underwent reconstruction with 24 flaps were examined retrospectively. Factors examined included patient demographics, indication for surgery, type of flap used, exposed critical structures, comorbidity, complications, and outcomes.
Of the 22 patients, seven had a cerebrospinal fluid leak present at the time of their reconstructive surgery. Of the seven, one patient died as a result of a stroke postoperatively. Of the remaining six patients, two had partial flap necrosis (33 percent). However, all six flaps survived, with resolution of cerebrospinal fluid leak. In comparison, of the 15 patients (17 flaps) without a cerebrospinal fluid leak, three had partial flap necrosis (18 percent; not significant). With regard to smoking status, the partial flap necrosis rate was 30 percent in smokers versus a rate of 14 percent in nonsmokers, although this was not statistically significant. Only one patient who received perioperative radiation (11 of 22 patients) developed partial flap necrosis.
The authors' data support the concept that free tissue transfer is a viable option in reconstruction of cranial defects. Although complications can occur in this high-risk population, successful reconstruction with free flaps was possible. Difficult problems, such as recurrent cerebrospinal fluid leaks and large irradiated wounds, can be managed and resolved successfully using this technique.
由于放射治疗的发病率、脑脊液漏、鼻窦暴露导致的细菌污染以及缺损大小和位置引起的功能和美容畸形，重大神经外科切除术后的重建可能是一项重大挑战。作者介绍了他们在头皮和颅骨缺损游离组织重建方面的经验。特别是，作者研究了与主要合并症相关的结果，如术前脑脊液漏、吸烟史和围手术期放射治疗。
回顾性研究了1997年至2004年期间，来自单一机构的22例因癌症需要进行神经外科或头颈切除并接受24块皮瓣重建的患者。研究的因素包括患者人口统计学、手术指征、使用的皮瓣类型、暴露的关键结构、合并症、并发症和结果。
22例患者中，7例在重建手术时存在脑脊液漏。其中7例患者中，1例术后因中风死亡。其余6例患者中，2例出现部分皮瓣坏死（33%）。然而，所有6块皮瓣均存活，脑脊液漏得到解决。相比之下，15例无脑脊液漏的患者（17块皮瓣）中，3例出现部分皮瓣坏死（18%；无统计学意义）。关于吸烟状况，吸烟者的部分皮瓣坏死率为30%，非吸烟者为14%，尽管这无统计学意义。仅1例接受围手术期放疗的患者（22例患者中的11例）出现部分皮瓣坏死。
作者的数据支持游离组织转移是颅骨缺损重建的可行选择这一概念。尽管在这个高风险人群中可能会出现并发症，但使用游离皮瓣成功重建是可能的。使用该技术可以成功处理和解决诸如复发性脑脊液漏和大的放疗伤口等难题。
