Okazaki Mutsumi, Asato Hirotaka, Takushima Akihiko, Sarukawa Shunji, Nakatsuka Takashi, Yamada Atsushi, Harii Kiyonori
Tokyo, Mitaka, Moroyama, and Sendai, Japan From the Departments of Plastic and Reconstructive Surgery of Graduate School of Medicine, University of Tokyo; Kyorin University; Saitama Medical School; and Tohoku University.
Plast Reconstr Surg. 2007 Apr 1;119(4):1223-1232. doi: 10.1097/01.prs.0000254400.29522.1c.
Few authors have reported the subsequent treatment for patients in whom free tissue transfers in the head and neck have failed as a result of vascular thrombosis.
Between 1993 and May of 2005, 502 free flaps were transferred after head and neck cancer ablation in the authors' hospital, 19 of which resulted in total necrosis caused by vascular thrombosis. The authors categorized these 19 cases into four groups and analyzed the salvage treatment.
For failed free jejunal transfer, early initiation of oral intake was obtained when another free jejunum was transferred. For failed free soft-tissue transfer for intraoral defects, reconstruction with common free (first choice) or pedicled flaps was used: a voluminous musculocutaneous flap for extensive defects, forearm flap or pedicled pectoralis major flap for intermediate defects, and direct closure for small defects of the oral floor. For failed secondary soft-tissue transfer to improve a certain function, salvage flap transfer was not chosen in the acute setting. For failed secondary maxillary reconstruction, simple reconstruction using the rectus abdominis musculocutaneous flap combined with costal cartilage achieved stable results. The overall success rate of the repeated free flap was 89 percent (eight of nine patients).
When a free flap is judged unsalvageable, surgeons should determine subsequent treatments, considering the success rate as one of the most important factors. The authors believe that simple reconstruction using a common free flap is the first choice in most cases. When regional or general conditions do not permit further free flap transfer or when defects are comparatively small, reconstruction with a pedicled flap or direct closure of the defect may be considered.
很少有作者报道对头颈部游离组织移植因血管血栓形成失败的患者进行后续治疗的情况。
1993年至2005年5月间，作者所在医院对头颈部癌症切除术后进行了502例游离皮瓣移植，其中19例因血管血栓形成导致完全坏死。作者将这19例病例分为四组并分析了挽救治疗方法。
对于游离空肠移植失败的情况，再次移植游离空肠时可早期开始经口进食。对于口腔内缺损游离软组织移植失败的情况，采用常用游离皮瓣（首选）或带蒂皮瓣进行重建：对于广泛缺损采用体积较大的肌皮瓣，对于中等缺损采用前臂皮瓣或带蒂胸大肌皮瓣，对于口底小缺损直接缝合。对于改善特定功能的二期软组织移植失败的情况，急性期不选择挽救性皮瓣移植。对于二期上颌骨重建失败的情况，采用腹直肌肌皮瓣联合肋软骨进行简单重建取得了稳定效果。再次游离皮瓣的总体成功率为89%（9例患者中的8例）。
当判断游离皮瓣无法挽救时，外科医生应确定后续治疗方法，将成功率作为最重要的因素之一加以考虑。作者认为，在大多数情况下，采用常用游离皮瓣进行简单重建是首选。当局部或全身情况不允许进一步进行游离皮瓣移植或缺损相对较小时，可考虑采用带蒂皮瓣重建或直接缝合缺损。
