Vranckx J J, Den Hondt M, Delaere P
Department of Plastic and Reconstructive Surgery, KU Leuven University Hospitals, Leuven, Belgium.
Department of ENT, Head and Neck Oncology, KU Leuven University Hospitals, Leuven, Belgium.
J Reconstr Microsurg. 2014 Mar;30(3):145-52. doi: 10.1055/s-0033-1361928. Epub 2014 Jan 7.
Complex tracheal and laryngeal defects can be reconstructed using prelamination and prefabrication techniques. Three clinical situations are described in detail in the article. In short segment restenosis defects within scarred surroundings, we restore the fibrocartilaginous defect with a radial forearm fascia flap prelaminated with buccal mucosa or cartilage. This provides a newly vascularized inner lining to the tracheal defect and restores the tubular convexity. For long segment defects we need a technique that can withstand respiratory forces. We use a heterotopic prefabrication strategy to vascularize a tracheal allograft wrapped in forearm fascia. Chimerism is created by replacing donor respiratory epithelium with buccal mucosa of the recipient. After orthotopic transfer, this chimerism allows immunosuppression to be tapered and stopped when bronchoscopy shows mucosal integrity of the new trachea, since the recipient epithelium replaces the allogeneic inner tracheal lining by means of a chronic rejection process. A distinct situation occurs after resection of a unilateral larynx tumor, which usually results in a total laryngectomy with loss of both vocal cords, since reconstruction of the hemilarynx is considered too complex. First, we prefabricate a nearby four-ring autologous tracheal segment using radial forearm fascia. In a second stage, this orthotopically vascularized trachea restores the laryngeal structure with the aim to conserve one vocal cord and thus speech. Orthotopic and heterotopic prelamination and prefabrication strategies offer efficient and reproducible solutions for the restoration of challenging short and long segment tracheal defects, as well as unilateral laryngeal defects. The series in this review article are based on previous studies and case reports. The level of evidence is III-"Study of nonconsecutive patients, without a universally applied gold standard: case-control study".
复杂的气管和喉部缺损可采用预层压和预制技术进行重建。本文详细描述了三种临床情况。在瘢痕化环境中的短节段再狭窄缺损中，我们用预层压颊黏膜或软骨的桡侧前臂筋膜瓣修复纤维软骨缺损。这为气管缺损提供了新血管化的内衬，并恢复了管腔凸度。对于长节段缺损，我们需要一种能承受呼吸力量的技术。我们采用异位预制策略，使包裹在前臂筋膜中的气管同种异体移植物血管化。通过用受体的颊黏膜替代供体呼吸上皮来产生嵌合体。原位转移后，当支气管镜检查显示新气管黏膜完整时，这种嵌合体允许逐渐减少并停止免疫抑制，因为受体上皮通过慢性排斥过程取代了同种异体气管内衬。单侧喉肿瘤切除后会出现一种特殊情况，通常会导致全喉切除，双侧声带丧失，因为半喉重建被认为过于复杂。首先，我们用桡侧前臂筋膜预制一个附近的四环自体气管段。在第二阶段，这个原位血管化的气管恢复喉部结构，目的是保留一条声带，从而保留发声功能。原位和异位预层压及预制策略为修复具有挑战性的短节段和长节段气管缺损以及单侧喉缺损提供了有效且可重复的解决方案。本综述文章中的系列病例基于先前的研究和病例报告。证据级别为III级——“对非连续患者的研究，无普遍适用的金标准：病例对照研究”。
