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前颅窝重建的分类与微血管皮瓣选择

Classification and Microvascular Flap Selection for Anterior Cranial Fossa Reconstruction.

作者信息

Vargo James D, Przylecki Wojciech, Camarata Paul J, Andrews Brian T

机构信息

Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas.

Department of Neurosurgery, University of Kansas, Kansas City, Kansas.

出版信息

J Reconstr Microsurg. 2018 Oct;34(8):590-600. doi: 10.1055/s-0038-1649520. Epub 2018 May 18.

Abstract

BACKGROUND

Microvascular reconstruction of the anterior cranial fossa (ACF) creates difficult challenges. Reconstructive goals and flap selection vary based on the defect location within the ACF. This study evaluates the feasibility and reliability of free tissue transfer for salvage reconstruction of low, middle, and high ACF defects.

METHODS

A retrospective review was performed. Reconstructions were anatomically classified as low (anterior skull base), middle (frontal bar/sinus), and high (frontal bone/soft tissue). Subjects were evaluated based on pathologic indication and goal, type of flap used, and complications observed.

RESULTS

Eleven flaps in 10 subjects were identified and anatomic sites included: low ( = 5), middle ( = 3), and high ( = 3). Eight of 11 reconstructions utilized osteocutaneous flaps including the osteocutaneous radial forearm free flap (OCRFFF) ( = 7) and fibula ( = 1). Other reconstructions included a split calvarial graft wrapped within a temporoparietal fascia free flap ( = 1), latissimus myocutaneous flap ( = 1), and rectus abdominis myofascial flap ( = 1). All 11 flaps were successful without microvascular compromise. No complications were observed in the high and middle ACF defect groups. Two of five flaps in the low defect group using OCRFFF flaps failed to achieve surgical goals despite demonstrating healthy flaps upon re-exploration. Complications included persistent cerebrospinal fluid leak ( = 1) and pneumocephalus ( = 1), requiring flap repositioning in one subject and a second microvascular flap in the second subject to achieve surgical goals.

CONCLUSION

In our experience, osteocutaneous flaps (especially the OCRFFF) are preferred for complete autologous reconstruction of high and middle ACF defects. Low skull base defects are more difficult to reconstruct, and consideration of free muscle flaps (no bone) should be weighed as an option in this anatomic area.

摘要

背景

前颅窝(ACF)的微血管重建面临着艰巨挑战。重建目标和皮瓣选择因ACF内缺损位置的不同而有所差异。本研究评估了游离组织移植用于挽救性重建低、中、高ACF缺损的可行性和可靠性。

方法

进行了一项回顾性研究。重建在解剖学上分为低位(前颅底)、中位(额骨/鼻窦)和高位(额骨/软组织)。根据病理指征和目标、所用皮瓣类型以及观察到的并发症对受试者进行评估。

结果

确定了10名受试者中的11个皮瓣,解剖部位包括:低位(=5)、中位(=3)和高位(=3)。11例重建中有8例采用了骨皮瓣,包括桡骨前臂游离骨皮瓣(OCRFFF)(=7)和腓骨(=1)。其他重建包括包裹在颞顶筋膜游离皮瓣内的颅骨劈开移植(=1)、背阔肌肌皮瓣(=1)和腹直肌肌筋膜瓣(=1)。所有11个皮瓣均成功,未出现微血管受损情况。高、中ACF缺损组未观察到并发症。低缺损组中使用OCRFFF皮瓣的5个皮瓣中有2个尽管在再次探查时皮瓣显示健康,但仍未达到手术目标。并发症包括持续性脑脊液漏(=1)和气颅(=1),1例受试者需要重新定位皮瓣,另1例受试者需要进行第二次微血管皮瓣移植以实现手术目标。

结论

根据我们的经验,骨皮瓣(尤其是OCRFFF)是高、中ACF缺损完全自体重建的首选。前颅底低位缺损更难重建,在该解剖区域应考虑选择游离肌皮瓣(无骨)作为一种选择。

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