Monaco Casian, Stranix John T, Lee Z-Hye, Hirsch David, Levine Jamie P, Saadeh Pierre B
*Department of Plastic and Reconstructive Surgery, NYU Langone Medical Center †Oral Maxillofacial Surgery, Lenox Hill Hospital, New York, NY.
J Craniofac Surg. 2017 Jan;28(1):93-96. doi: 10.1097/SCS.0000000000003228.
In select patients with advanced disease resulting in large composite tissue defects, consideration is often given to multiple flap reconstruction. The authors propose an alternative option. Using virtual surgical planning the authors demonstrate how modest sacrifice in projection translates into a substantial decrease in the volume and surface area of soft tissue needed, in turn maximizing soft tissue coverage with a single fibula free flap. The authors used 3-dimensional virtual surgery to simulate angle-to-angle reconstructions using free fibula flaps. The reference 3-segment reconstruction was done using symphyseal projection to the plane perpendicular to the anterior nasal spine, a customary landmark. Additional simulations were then performed using recessed projections 0.5 mm, 1 cm, 1.5 cm, and 2 cm posterior to anterior nasal spine plane. Program analytics were used to calculate the surface area and volume of the floor of mouth. With projection recessed by 1 cm, surface area decreased 22% to 14 cm. With projection recessed by 2 cm, surface area decreased 44% to 10 cm. With a 3-segment construct converted to a 2-segment construct, surface area decreased 22% to 14 cm. This demonstrates for the first time an official analysis of an intraoperative modification that sacrifices little and gains a lot. Ultimately, 1 compound flap can be used in extensive reconstructions with increased confidence that it will not be overly stressed.
对于因晚期疾病导致大面积复合组织缺损的特定患者，通常会考虑采用多种皮瓣重建。作者提出了另一种选择。通过虚拟手术规划，作者展示了如何在投影上进行适度牺牲，从而大幅减少所需软组织的体积和表面积，进而用单个游离腓骨皮瓣最大限度地覆盖软组织。作者使用三维虚拟手术来模拟使用游离腓骨皮瓣进行点对点重建。参考的三段式重建是通过耻骨联合投影到垂直于前鼻棘的平面来完成的，这是一个常用的标志点。然后在前鼻棘平面后方0.5毫米、1厘米、1.5厘米和2厘米处使用凹陷投影进行额外的模拟。使用程序分析来计算口腔底部的表面积和体积。当投影凹陷1厘米时，表面积减少22%至14平方厘米。当投影凹陷2厘米时，表面积减少44%至10平方厘米。当三段式结构转换为两段式结构时，表面积减少22%至14平方厘米。这首次展示了对一种术中改良的正式分析，这种改良牺牲小而收获大。最终，单个复合皮瓣可用于广泛的重建，并且更有信心它不会承受过大压力。
