Chen Xiao-hong, Han De-min, Huang Zhi-gang, Fang Ju-gao, Ni Xin, Zhou Wei-guo, Wang Qi, Li Ping-dong
Beijing Tong Ren Hospital, Capital Medical University, Key Laboratory of Otorhinolaryngology Head and Neck Surgery, Ministry of Education, Beijing, China.
Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2009 Jan;44(1):31-5.
To preserve the function of the donor site and good cervical shape, a modified pectoralis major myocutaneous island flap was designed.
The modified pectoralis major myocutaneous flaps were used to repair primarily the defect in head and neck surgery. In all 17 cases, six cases were patients with recurrence of larynx or hypopharynx cancer, four cases with hypopharynx cancer, three cases with base of tongue cancer, two cases with recurrence of maxillary cancer, one case with tonsillar cancer and one case with pharyngeal fistula after hypopharyngeal cancer surgery. Before operation, ultrasound was used to mark the projection of the pectoral branches of thoracoacromial artery, and the pectoralis major myocutaneous were designed according to the axle between lowest entering muscle point of the artery and the fourth intercostals perforator spot of mammary artery; the incision was designed to turn laterally in an oriental direction at the top of the flap and upward along the anterior axillary line; the internal pectoral nerve was reserved, as well as the partial lateral pectoral nerve. The flaps were transferred to recipient site either above or below the clavicle on the premise of the integrity of clavicular part.
The distance of the lowest entering muscle point of pectoral branche measuring during operation, which was all in sternocostal part, to the midpoint of inferior clavicula margin was (4.9 +/- 1.2) cm (average +/- s), and in 76.5% (13/17) of the patients, the location was coincidence by ultrasound. The length between entering muscle point and the fourth intercostals perforator spot of mammary artery was (1.8 +/- 0.5) cm. All the myocutaneous flaps were alive except one case. The flap was given up as a result of the vessel pedicle injure. The distal end of the flap was dehisced from the residual tongue in one case with base of tongue cancer and healed with changing dressing. Two pharyngeal fistulas in another two cases were healed with conserved treatment. The rate of the flap survival was 94.1% (16/17). Functions as adduction and adtorsion of major pectoral muscle were integrated within 4 weeks to 3 months. Also, the good looking of the neck and upper chest was maintained.
The location of pectoral branches of thoracoacromial artery and the site of the lowest entering muscle point marked by ultrasound detection could help the design of the flap. The modified pectoral' s major myocutaneous flap designing presented better functional protection and reach longer distance and left a better looking for neck and upper chest.
为保留供区功能及良好的颈部外形，设计一种改良胸大肌肌皮岛状皮瓣。
采用改良胸大肌肌皮瓣一期修复头颈外科缺损。17例患者中，喉或下咽癌复发6例，下咽癌4例，舌根部癌3例，上颌癌复发2例，扁桃体癌1例，下咽癌术后咽瘘1例。术前采用超声标记胸肩峰动脉胸肌支的走行投影，以动脉最低入肌点与乳腺动脉第4肋间穿支点的连线为轴设计胸大肌肌皮瓣；皮瓣顶端切口向外侧呈“人”字形转向，沿腋前线向上；保留胸内侧神经及部分胸外侧神经。在锁骨部分完整的前提下，将皮瓣转移至锁骨上或锁骨下受区。
术中测量胸肌支最低入肌点均在胸肋部，至锁骨下缘中点的距离为（4.9±1.2）cm（均值±标准差），超声定位符合率为76.5%（13/17）。动脉入肌点与乳腺动脉第4肋间穿支点的距离为（1.8±0.5）cm。除1例因血管蒂损伤放弃皮瓣外，其余肌皮瓣全部成活。1例舌根部癌患者皮瓣远端与残留舌体分离，换药后愈合。另2例咽瘘经保守治疗愈合。皮瓣成活率为94.1%（16/17）。胸大肌内收及内旋功能在4周~3个月内恢复。颈部及上胸部外形良好。
超声探测胸肩峰动脉胸肌支走行及最低入肌点位置有助于皮瓣设计。改良胸大肌肌皮瓣设计能更好地保护功能，转移距离更远，颈部及上胸部外形良好。
