三种不同类型组织瓣修复眶区组织缺损的回顾性分析

三种不同类型组织瓣修复眶区组织缺损的回顾性分析

吴旭彬阿不都克力木江·买买提姚志涛阿迪力江·赛买提居来提·吐尔逊安玮丁泰然张思敏买买提吐逊·吐尔地

本文来源：《中华整形外科杂志》2023年5月第39卷第5期

DOI:10. 3760 / cma.j.cn114453-20220908-00281

作者单位：新疆医科大学第一附属医院(附属口腔医院)口腔颌面创伤正颌外科新疆维吾尔自治区口腔医学研究所新疆医科大学口腔医学院基础教研室，乌鲁木齐830054

通信作者：买买提吐逊·吐尔地，Email: 529849593@qq.com

引用本文

吴旭彬, 阿不都克力木江·买买提, 姚志涛, 等. 三种不同类型组织瓣修复眶区组织缺损的回顾性分析 [J] . 中华整形外科杂志, 2023, 39(5) : 479-489. DOI: 10.3760/cma.j.cn114453-20220908-00281.

【摘要】

目的探讨3种不同类型组织瓣修复眶区恶性肿瘤扩大切除术后眶内组织缺损的临床效果及适应证。

方法回顾性分析2017年1月至2021年12月新疆医科大学第一附属医院(附属口腔医院)口腔颌面创伤正颌外科诊治的眶区恶性肿瘤患者的临床资料。术中行眶周恶性肿瘤扩大切除术及眶内容物剜除术，根据眶周软、硬组织及眶内容物缺损范围及患者情况，应用颞肌筋膜瓣联合全厚皮片(TMF-FTSG组)、带蒂胸大肌肌皮瓣(PMMF组)或游离股前外侧皮瓣(ALTF组)进行修复。术后对患者供、受区创面愈合情况、并发症等进行随访，并比较TMF-FTSG组患者术后3个月和术前张口度，比较3组患者术前和术后1年华盛顿大学生活质量问卷(UW-QOL)评分(共12个项目，每个项目赋值0~100分，分数越高恢复情况越好)。应用SPSS 26.0软件进行统计分析，计量资料以x±s表示，组内术前后数据比较采用配对t检验，P<0.05为差异有统计学意义。

结果共纳入22例患者，其中TMF-FTSG组8例，男4例，女4例，年龄(68.3±9.7)岁；PMMF组6例，男5例，女1例，年龄(65.8±7.8)岁；ALTF组8例，男3例，女5例，年龄(63.8±5.4)岁。22例中鳞状细胞癌12例，基底细胞癌8例，腺样囊性癌2例。TMF-FTSG组、PMMF组、ALTF组患者肿瘤切除后软组织缺损范围分别为4 cm×4 cm~7 cm×8 cm、4 cm×5 cm~9 cm×9 cm、5 cm×6 cm~14 cm×9 cm，切取组织瓣面积依次为5 cm×4 cm~8 cm×9 cm、5 cm×7 cm~10 cm×10 cm、10 cm×6 cm~20 cm×9 cm。术后20例受区及22例供区均一期愈合，2例受区二期愈合。术后随访(27.2±13.0)个月，PMMF组中有1例患者因肿瘤局部复发，术后13个月死亡；其余患者未见转移及复发情况。TMF-FTSG组术后3个月张口度[(3.60±0.36) cm]与术前[(3.84±0.15)cm]比较，差异无统计学意义(P>0.05)。UW-QOL评分显示，3组患者术后1年外形、情绪、焦虑得分均高于术前(P<0.05)，活动、肩膀得分均低于术前(P<0.05)；术后1年疼痛和娱乐得分，TMF-FTSG组均高于术前(P<0.05)，另外2组也高于术前，但差异无统计学意义(P>0.05)；3组患者术后1年吞咽、咀嚼、讲话、味觉、唾液得分与术前比较，差异均无统计学意义(P>0.05)。

结论在眶区恶性肿瘤术后组织缺损的修复中，应用3种不同类型的组织瓣均能获得良好的修复效果。TMF-FTSG对于骨缺损量较少的患者有一定优势；ALTF、PMMF更适合缺失组织量较大的患者；对于既往存在放疗史及受区血管条件不佳的患者，PMMF是一种有效的修复方式。

【关键词】眼肿瘤；颞肌筋膜瓣；股前外侧皮瓣；胸大肌肌皮瓣；修复外科手术

Retrospective analysis of three different types of tissue flaps in reconstruction of tissue defects of orbital region

Wu Xubin, Abudukelimujiang·Maimaiti, Yao Zhitao, Adilijiang·Saimaiti, Julaiti·Tuerxun, An Wei, Ding Tairan, Zhang Simin, Maimaitituxun·Tuerdi

Department of Oral and Maxillofacial Trauma and Orthognathic Surgery, the First Affiliated Hospital of Xinjiang Medical University(Affiliated Stomatological Hospital), Xinjiang Institute of Stomatology, Department of Basic Dentistry, Xinjiang Medical University School of Oral Stomatology, Urumqi 830054, China

Corresponding author: Maimaitituxun·Tuerdi, Email: 529849593@qq.com

【Abstract】

Objective To investigate the clinical effect of three different tissue flaps in repairing patients with orbital region tissue loss after enlarged resection of malignant tumors in the orbital region, as well as the indication.

Methods Retrospective analysis of data of patients with malignant tumors in the orbital region treated in the Department of Oral and Maxillofacial Trauma and Orthognathic Surgery, the First Affiliated Hospital of Xinjiang Medical University (Affiliated Stomatological Hospital) between January 2017 and December 2021. All patients underwent extensive resection of periorbital malignant tumors and enucleation of orbital contents, depending on defects in periorbital soft/hard tissues and orbital contents, temporalis myofascial flap combined with full thickness skin grafts (TMF-FTSG group), modified pectoralis major myocutaneous flap (PMMF group), and free anterolateral thigh flap (ALTF group) were used to repair the tissue defect. The wound healing and complications of the donor and recipient areas were followed up after operation, and degree of mouth opening in the TMF-FTSG group was compared at 3 months after operation and before operation. The University of Washington quality of life scale (UW-QOL) score was compared among the three groups before and 1 year after operation (a total of 12 items, each item was assigned from 0 to 100 points, the higher the score, the better the recovery). Statistical software SPSS 26.0 was used to analyze the data. The measurement data were expressed as Mean±SD, and the paired t-test was used to compare the preoperative and postoperative data within the group, the difference was statistically significant at a P value less than 0.05.

Results A total of 22 patients were enrolled. There were 8 patients in TMF-FTSG group, 4 males and 4 females, aged (68.3±9.7) years. There were 6 patients in PMMF group, 5 males and 1 female, aged (65.8±7.8) years. There were 3 males and 5 females in ALTF group, aged (63.8±5.4) years. There were 12 cases of squamous cell carcinoma, 8 cases of basal cell carcinoma and 2 cases of adenoid cystic carcinoma. The size of soft tissue defect after tumor resection in TMF-FTSG group, PMMF group and ALTF group was 4 cm×4 cm-7 cm×8 cm, 4 cm×5 cm-9 cm×9 cm and 5 cm×6 cm-14 cm×9 cm, respectively. And the size of flaps ranged from 5 cm×4 cm to 8 cm×9 cm, from 5 cm×7 cm to 10 cm×10 cm, and from 10 cm×6 cm to 20 cm×9 cm, respectively. All donor sites and 20 recipient sites recovered in stage Ⅰ, 2 recipient sites recovered in stage Ⅱ. The patients were monitored for a mean of (27.2 ±13.0) months. During the period of follow-up, one patient, reconstructed with PMMF, died 13 months after surgery due to local tumor recurrence, while the others did not experience metastasis or recurrence. In TMF-FTSG group, the mouth opening was (3.60±0.36) cm 3 months after operation and (3.84±0.15) cm before operation, with no significant difference (P>0.05). The UW-QOL scores of appearance, mood and anxiety in the three groups 1 year after operation were higher than those before operation (P<0.05), and the one year after operation’s scores of activity and shoulder were lower than those before operation (P<0.05). The UW-QOL scores of pain and recreation in TMF-FTSG group one year after operation were higher than those before operation (P<0.05), the other two groups were also higher than those before operation, but the difference was not statistically significant (P>0.05). There was no significant difference in the UW-QOL scores of swallowing, chewing, speech, taste, and saliva in the three groups at one year after operation and before operation (P>0.05).

Conclusion In the repair of tissue defects after operation of malignant tumors in the orbital region, three distinct types of tissue flaps can be utilized to repair tissue defects. TMF-FTSG has certain advantages for patients with minor bone defects, whereas ALTF and PMMF are more appropriate for patients with extensive tissue loss. PMMF is an effective method of repair for patients with a history of radiotherapy and poor vascular health in the recipient area.

【Key words】Eye neoplasms; Temporalis myofascial flap; Anterolateral thigh flap; Pectoralis major myocutaneous flap; Reconstructive surgical procedures

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: Ethical approval was given by the Medical Ethics Committee of the First Affiliated Hospital of Xinjiang Medical University（K202303-30）.

晚期眶区恶性肿瘤往往累及上下眼睑及眶周皮肤组织，甚至会累及眶内容物，并且破坏深面骨质。对于此类患者，手术是主要的治疗方式，病灶切除后常导致大面积组织缺损，有时甚至与鼻腔或窦腔相通，严重影响患者面部外形及功能。随着显微外科技术的发展，游离组织瓣成为修复颌面部大面积组织缺损的重要方式[1,2,3,4]。在游离组织瓣受到医疗技术及患者条件的限制时，带蒂组织瓣也是一种有效的修复方式。胸大肌肌皮瓣(pectoralis major myocutaneous flap，PMMF)及股前外侧皮瓣(anterolateral thigh flap，ALTF)是修复头颈部组织缺损常用的皮瓣。根据患者特定的缺损部位，我们将颞肌筋膜瓣联合全厚皮片(temporalis myofasical flap combined with full-thickness skin grafts，TMF-FTSG)也应用到眶区恶性肿瘤切除术后组织缺损的修复中。本研究对3种组织瓣修复眶区组织缺损的临床效果及各自的优缺点进行了回顾性总结，以为临床应用提供一定的依据。

资料与方法

一、资料选择

回顾性分析2017年1月至2021年12月新疆医科大学第一附属医院口腔颌面外科收治的眶区恶性肿瘤患者的临床资料。根据组织缺损所采用的组织瓣分为3组，即TMF-FTSG、PMMF组和ALTF组组。纳入标准：(1)眶周恶性肿瘤累及眶内容物，并行手术治疗；(2)采用TMF-FTSG、PMMF或ALTF修复病灶切除后缺损；(3)患者同意参加本研究。排除标准：(1)随访资料不完整；(2)患者及委托人拒绝本文使用相关资料。本研究经新疆医科大学第一附属医院伦理委员会批准(K202303-30)。患者对本研究均知情同意，并同意将其资料用于本研究。

二、治疗方法

(一)术前准备及修复方式选择

术前患者完善影像学检查、全身麻醉术前常规检查，如果肿瘤累及眶内组织则请眼科医生会诊，评估眶内组织受累情况。对于伴有眼球运动受限及视力降低或丧失者，行眶区恶性肿瘤扩大切除术+眶内容物剜除术+颈淋巴结清扫术，在术中快速冰冻确定切缘阴性后，综合考虑以下情况选择合适的修复方式：(1)患者术区组织缺损情况，如眶区皮肤缺损面积、是否有骨组织缺损、术区是否与鼻腔或鼻窦相通等；(2)患者全身情况，如年龄、性别、心脑血管疾病史、糖尿病史、呼吸系统病史等；(3)术前有无放疗史等。

对于仅伴有眶下缘及部分眶内侧壁骨组织缺失的患者，因其缺损面与鼻腔或鼻窦相通面积较小，选择TMF-FTSG进行修复；伴有眶底及眶内侧骨质缺失的患者，因缺损面完全与鼻腔或鼻窦相通，应用PMMF或ALTF进行修复；对于既往有放疗史的患者，一般选择PMMF进行修复。相比于颞肌筋膜瓣(temporalis myofasical flap，TMF)及PMMF，ALTF血管蒂变异可能性更大，术前需常规完善双下肢CT血管造影，观察旋股外侧动脉及其分支走行特点，并使用多普勒超声确定穿支位置。

(二)3种组织瓣修复眶区缺损

1．TMF-FTSG：

切除眶周原发灶后，由眶区缺损沿颞筋膜向后翻瓣，暴露颞筋膜及深面颞肌，根据缺损大小制备TMF，颞肌制备过程中下端应止于颧弓上方1 cm，避免损伤TMF的血供，然后将其旋转经过眶外缘表面填塞眶腔、上颌窦及鼻腔。用4-0丝线将TMF远端与鼻背皮下组织缝合固定，确定好TMF位置后，依次将TMF与术区皮下组织严密缝合；根据缺损范围于腹部制取全厚皮片，将其覆盖于TMF表面，以4-0丝线间断缝合固定皮片，以碘仿纱包反向加压包扎。若通过眶区术区无法制备TMF，可于颞部做补充切口。

2．PMMF：

采用改良PMMF的制备方法[5]，即皮岛设计完成后，切开皮肤及皮下组织，暴露皮岛周围的胸大肌肌束，从皮岛内侧切断胸大肌肌束及其在肋骨上的附着；由于胸大肌附着点止于第5肋骨，此处用手指在胸大肌内层筋膜与胸小肌之间直接钝性分离，在胸大肌深面可触及胸肩峰动脉血管神经束；为防止皮岛与肌肉分离，可将皮缘、皮下及肌肉断端用4-0丝线行间断缝合，游离翻起肌肉血管蒂达胸大肌锁骨部(锁骨下方4~5 cm)，胸大肌锁骨部血管蒂仅保留血管轴及其周围筋膜。以胸肩峰动脉为转折点穿过锁骨下隧道转入颈部及下颌骨表面皮下隧道，达到面中部术区，用4-0丝线固定皮瓣并分层缝合，修复软组织缺损。

3．ALTF：

以术前确定的穿支血管位置为中心，设计梭形皮瓣。在股外侧肌内侧设计皮瓣内侧切口，沿该切口切开皮肤、皮下组织及阔筋膜，长约7 cm,沿阔筋膜深面翻瓣探寻穿支，确认好合适穿支后，将内侧切口全部切开，之后沿穿支逆行解剖至旋股外侧动脉分支主干处。术中根据受区缺损范围切取皮瓣，必要时可适量携带皮瓣远心端的肌肉，以充填受区存在的窦腔；皮瓣血管根据管径及血管蒂的长度与颈外动脉的分支、颈内静脉或其属支、颈外静脉相吻合。

三、术后处理及随访

对于TMF-FTSG组的患者，术后第2天可适当下地活动，减少深静脉血栓形成风险；术后7 d拆除碘仿纱包，若发现皮片存在感染、坏死等情况，只要深面TMF血供良好，经过仔细换药，术区可二期愈合；术后10 d拆除头颈部术区缝线；根据患者病情必要时术后1个月可行肿瘤后续治疗。针对皮瓣的特殊性，PMMF及ALTF组的患者，需卧床5~7 d，轴线翻身，避免颈部过多活动，增加皮瓣血管危象风险；术后72 h内，每2小时观察皮瓣温度、肤色及质地，ALTF组患者可通过皮岛穿支点，使用超声进一步明确术后皮瓣动脉搏动情况；卧床期间，建议患者频繁进行踝泵运动；术后10 d拆除头颈部术区缝线。因眶区缺损位置较高，PMMF血管蒂长度有限，建议该组患者术后卧床期间头部可向患侧偏斜15°~30°，以减少血管蒂的张力。

术后通过门诊及电话对患者创面愈合情况、供区并发症等进行随访。

四、效果评估

记录TMF-FTSG组患者术前与术后3个月张口度(用直尺测量最大张口时上下中切牙的距离)；通过第4版华盛顿大学生活质量问卷(University of Washington quality of life scale，UW-QOL)[6]评估3组患者术后1年受区及供区恢复情况，并与术前比较。UW-QOL包括12个项目：疼痛、外形、活动、娱乐、吞咽、咀嚼、讲话、肩膀(感觉及运动)、味觉、唾液、情绪、忧虑，每个项目赋值0~100分，患者根据自身情况进行打分，分数越高代表患者恢复情况越好。

五、统计学分析

应用SPSS 26.0软件对数据进行统计学分析，计量资料以x

±s表示，TMF-FTSG组患者术前与术后3个月张口度比较，以及3种组织瓣组内术前与术后1年UW-QOL得分比较，采用配对t检验，以P<0.05为差异有统计学意义。

结果

一、一般资料

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