Rhee J S, Weisz D J, Hirigoyen M B, Sinha U, Alcaraz N, Urken M L
Department of Otolaryngology, Mount Sinai Medical Center, New York, NY, USA.
Arch Otolaryngol Head Neck Surg. 1997 Aug;123(8):823-9. doi: 10.1001/archotol.1997.01900080055006.
The desirability of restoring sensation to the upper aerodigestive tract has led to an expanded use of sensate flaps for reconstruction of mucosal defects. Sensation can be restored via preformed neural pathways through the anastomosis of recipient and donor nerves, provided that the sensate flap falls within the boundaries of the neurosome for the identified sensory nerve.
To perform detailed electrophysiologic mappings of neurosomes of potential sensate flap donor sites, to describe their variability, and to investigate the usefulness of intraoperative mapping in terms of flap design and harvesting.
A case series of 27 patients who were undergoing free flap reconstruction of various postablative head and neck defects were examined. Two silver-silver chloride recording electrodes were placed in direct contact with the dissected sensory nerve, and the overlying skin was either mechanically or electrically stimulated. Auditory feedback, as well as visualization of the responses on an oscilloscope, determined whether the stimulated area fell within the neurosome. This technique was applied to the lateral antebrachial cutaneous nerve of the radial forearm flap (n = 15), the lateral sural cutaneous nerve of the fibula flap (n = 5), the subcostal nerve of the iliac crest flap (n = 6), and the dorsal cutaneous rami of spinal nerve T-1 or T-2 of the scapula flap (n = 1).
The neurosome of the lateral antebrachial cutaneous nerve was relatively consistent with the variability only at the distal boundary (ie, the dorsum of the hand). The neurosome of the lateral sural cutaneous nerve was more variable, falling into 2 distinct innervation patterns: one showing innervation that was limited to the upper lateral and posterior portions of the calf and the other demonstrating significant extension into the lower half of the calf. The neurosome of the subcostal nerve showed little variability and consistently overlapped the proposed skin paddle. The neurosome of the T-1 or T-2 spinal nerve was mapped in 1 patient and is described.
The consistency of neurosomal boundaries is dependent on the donor site. Intraoperative mapping of flap donor sites may not only assure the harvesting of a true sensate flap, but may also allow for intraoperative decision making with regard to possible modifications of flap design and harvesting techniques. Two new sensate flaps from the iliac crest and scapula are accurately described.
恢复上呼吸道消化道感觉的需求促使带感觉神经的皮瓣在黏膜缺损重建中的应用不断增加。只要带感觉神经的皮瓣位于已确定感觉神经的神经束范围内，就可以通过受体神经与供体神经的吻合，利用预先形成的神经通路来恢复感觉。
对潜在带感觉神经皮瓣供区的神经束进行详细的电生理图谱绘制，描述其变异性，并研究术中图谱在皮瓣设计和切取方面的实用性。
对27例行各种头颈部肿瘤切除术后缺损游离皮瓣重建的患者进行了病例系列研究。将两根银-氯化银记录电极直接与解剖出的感觉神经接触，对其上方皮肤进行机械或电刺激。通过听觉反馈以及示波器上反应的可视化，确定受刺激区域是否在神经束范围内。该技术应用于桡侧前臂皮瓣的前臂外侧皮神经（n = 15）、腓骨皮瓣的腓肠外侧皮神经（n = 5）、髂嵴皮瓣的肋下神经（n = 6）以及肩胛皮瓣的胸1或胸2脊神经后支皮支（n = 1）。
前臂外侧皮神经的神经束相对一致，仅在远端边界（即手背）存在变异性。腓肠外侧皮神经的神经束变异性更大，分为两种不同的支配模式：一种显示支配范围仅限于小腿上外侧和后部，另一种则显示明显延伸至小腿下半部。肋下神经的神经束变异性较小，始终与拟用的皮岛重叠。对1例患者的胸1或胸2脊神经进行了神经束图谱绘制并进行了描述。
神经束边界的一致性取决于供区。术中对皮瓣供区进行图谱绘制不仅可以确保切取真正带感觉神经的皮瓣，还可以在术中就皮瓣设计和切取技术的可能调整做出决策。准确描述了来自髂嵴和肩胛的两种新的带感觉神经皮瓣。
