Jones N F, Johnson J T, Shestak K C, Myers E N, Swartz W M
Division of Plastic and Reconstructive Surgery, University of Pittsburgh, PA, USA.
Ann Plast Surg. 1996 Jan;36(1):37-43. doi: 10.1097/00000637-199601000-00008.
Three hundred five microsurgical free flaps have been performed for defects of the head and neck by a team of two head and neck surgeons and two plastic surgeons over a 9-year period, with a success rate of 91.2%. The most common flaps used were the jejunum (89), radial forearm (57), rectus abdominis (48), latissimus dorsi (40), scapular (32), fibula (15), and iliac crest (11). Thirty-three flaps required reexploration for anastomotic thrombosis or hematoma (10.8%), of which 18 flaps were salvaged (54.5%). Thirteen flap failures occurred in 113 patients who had received preoperative irradiation (11.5%), but this was not statistically significant. Seven flaps failed in 20 patients who required an interposition vein graft (35%) and this was statistically significant. Ninety patients (31.5%) developed a major complication other than anastomotic thrombosis or death. Despite postoperative intensive care nursing and monitoring, 18 patients died postoperatively in the hospital (6.3%). The average hospital stay was 21.1 days with a range from 5 to 95 days. During this 9-year time period, various free flaps have evolved as the preferred choice for free flap reconstruction of a specific defect of the head and neck. The latissimus dorsal muscle flap surfaced with a nonmeshed split-thickness skin graft is the optimal free flap for reconstruction of the scalp and skull, whereas a multiple-paddle latissimus dorsi musculocutaneous flap is the best flap for reconstruction of complex defects of the middle third of the face and maxilla. The radial forearm flap and free jejunal transfer have become the preferred choices for intraoral reconstruction and pharyngo-esophageal reconstruction, respectively. There still remains no universally accepted flap for mandibular reconstruction, but the fibular osteocutaneous flap and a reconstruction plate protected by a radial forearm flap have largely superseded the iliac crest and scapular osteocutaneous flaps. Radical resection of tumors of the head and neck with immediate reconstruction by microsurgical free tissue transfer followed by adjuvant radiation therapy provides the best possible chance for cure and functional and social rehabilitation of the patient.
在9年的时间里，由两名头颈外科医生和两名整形外科医生组成的团队为头颈缺损患者实施了305例显微外科游离皮瓣手术，成功率为91.2%。最常用的皮瓣是空肠瓣（89例）、桡侧前臂皮瓣（57例）、腹直肌皮瓣（48例）、背阔肌皮瓣（40例）、肩胛皮瓣（32例）、腓骨皮瓣（15例）和髂嵴皮瓣（11例）。33例皮瓣因吻合口血栓形成或血肿需要再次探查（10.8%），其中18例皮瓣得以挽救（54.5%）。113例术前接受过放疗的患者中有13例皮瓣失败（率为11.5%），但这无统计学意义。20例需要植入静脉移植的患者中有7例皮瓣失败（率为35%），这具有统计学意义。90例患者（31.5%）出现了除吻合口血栓形成或死亡以外的严重并发症。尽管术后进行了重症护理和监测，但仍有18例患者在术后死于医院（死亡率为6.3%）。平均住院时间为21.1天，范围为5至95天。在这9年期间，各种游离皮瓣已逐渐成为头颈特定缺损游离皮瓣重建的首选。带非网状断层皮片的背阔肌皮瓣是头皮和颅骨重建的最佳游离皮瓣，而多叶背阔肌肌皮瓣是面部中三分之一和上颌骨复杂缺损重建的最佳皮瓣。桡侧前臂皮瓣和游离空肠移植分别已成为口腔内重建和咽食管重建的首选。下颌骨重建仍然没有一种被普遍接受的皮瓣，但腓骨骨皮瓣和由桡侧前臂皮瓣保护的重建钢板已在很大程度上取代了髂嵴和肩胛骨皮瓣。对头颈肿瘤进行根治性切除，立即通过显微外科游离组织移植进行重建，随后进行辅助放疗，为患者提供了最佳的治愈机会以及功能和社会康复的可能。
