Gur Ersin, Tiftikcioglu Yigit Ozer, Ozturk Kerem
Department of Plastic Reconstructive and Aesthetic Surgery, Ege University Faculty of Medicine, İzmir, Turkey.
Department of Ear, Nose and Throat, Ege University Faculty of Medicine, İzmir, Turkey.
Microsurgery. 2023 Mar;43(3):245-252. doi: 10.1002/micr.30953. Epub 2022 Sep 2.
The thoracoacromial vessels (TA) are one of the options as recipient for free flaps in head and neck reconstruction when the neck is depleted. However, it has limitations such as need of vein graft or kinking and being under pressure on clavicle. The authors describe a new modification of using pectoral branch of TA as recipient vessel.
Between July 2019 and January 2022, 8 patients (1 female, 7 male) underwent head and neck reconstructions with free flaps. Age of patients ranged from 53 to 73 years old. All surgeries were because of SCC. Defects were including 3 total lower lip, 2 pharyngoesophageal defects, 1 cheek, lower and upper lip, 1 mandible, cheek and mount floor and 1 tongue and mount floor. Defects were between 12 × 5 cm and 21 × 9 cm. Pectoral branch of TA was transposed to the depleted neck as pectoral muscle flap to prevent kinking and pressure. Over the clavicle, the proximal root of the pedicle of muscle was found and dissected distally until tensionless anastomoses could be accomplished between the muscle and free flaps. ALT, MSAP, and Radial forearm free flaps were used as free flaps. In one patient the fibula and ALT flaps were used as flow through so the pedicle of ALT flap was anastomosed to pectoral muscle pedicle. Pectoral muscle was rotated 180° on its horizontal axis after finishing anastomoses to guard anastomoses from radiated neck skin. Muscle was fixed to sternocleidomastoid muscle with sutures to maintain its position. All donor sites were closed primarily.
The diameter of recipient artery was between 1 and 1.6 mm. The veins were approximately same as arteries. All anastomosis were performed end-to-end fashion. Three patients needed skin grafts to closure of tight radiated neck skin. Complications as 1 hematoma and 1 wound dehiscence were salvaged successfully. All flaps survived. Patients were followed up between 2 and 6 months. Our first patient died at post-operative 6th month so long follow-up could not be achieved. The final outcomes such as chewing, oral competence and swallowing were successful for remaining patients.
Transposing TA as pectoral muscle flap to the neck can decrease need of vein graft and prevent kinking or pressure of the pedicle on the clavicle.
胸肩峰血管（TA）是颈部血管资源耗竭时用于头颈部重建游离皮瓣受区血管的选择之一。然而，它存在一些局限性，如需要静脉移植或血管扭曲以及在锁骨处受压。作者描述了一种将TA的胸肌支作为受区血管的新改良方法。
2019年7月至2022年1月期间，8例患者（1例女性，7例男性）接受了游离皮瓣头颈部重建手术。患者年龄在53至73岁之间。所有手术均因鳞状细胞癌（SCC）所致。缺损包括3例全下唇、2例咽食管缺损、1例颊部及上下唇、1例下颌骨、颊部及口底、1例舌及口底。缺损范围在12×5cm至21×9cm之间。将TA的胸肌支作为胸肌瓣转移至血管耗竭的颈部，以防止血管扭曲和受压。在锁骨上方找到肌蒂近端并向远端解剖，直至肌瓣与游离皮瓣之间能进行无张力吻合。使用股前外侧皮瓣（ALT）、肩胛下动脉穿支皮瓣（MSAP）和桡侧前臂游离皮瓣作为游离皮瓣。1例患者使用腓骨瓣和ALT瓣进行串联吻合，因此将ALT瓣的蒂与胸肌蒂进行吻合。吻合完成后，将胸肌在其横轴上旋转180°，以保护吻合口免受颈部放疗皮肤的影响。用缝线将肌肉固定于胸锁乳突肌以维持其位置。所有供区均一期关闭。
受区动脉直径在1至1.6mm之间。静脉直径与动脉大致相同。所有吻合均采用端端吻合方式。3例患者需要植皮以闭合颈部放疗后紧绷的皮肤。1例血肿和1例伤口裂开等并发症均成功处理。所有皮瓣均存活。患者随访2至6个月。我们的首例患者在术后第6个月死亡，因此未能实现长期随访。其余患者的最终结果，如咀嚼、口腔功能和吞咽功能均良好。
将TA作为胸肌瓣转移至颈部可减少静脉移植的需求，并防止蒂部在锁骨处扭曲或受压。
