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Analysis and Summary: Reconstructive Methods of Lateral Skull Base Defects after Radical Tumor Resection in 62 Cases
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摘要:
目的 对侧颅底肿瘤根治术后不同修复重建方法进行分析、总结。 方法 本研究为回顾性分析。研究对象为2012年1月1日至2019年12月31日北京协和医院口腔科和耳鼻咽喉科行侧颅底肿瘤根治术及修复重建的患者。依据缺损情况(不伴皮肤缺损、伴皮肤缺损、伴下颌骨体部及升支缺损)进行不同方法的修复重建，并观察患者出院时伤口愈合情况及重建效果。 结果 共62例患者(63次缺损修复术)纳入本研究。其中不伴皮肤缺损34例、伴皮肤缺损23例、伴下颌骨体部及升支缺损5例，组织瓣成活率为98.41%(62/63)，伤口一期愈合率为90.48%(57/63)。不伴皮肤缺损患者中，采取游离脂肪填充修复6例、颞肌瓣联合游离脂肪填充修复14例、胸锁乳突肌瓣或联合颞肌瓣修复13例、颞肌瓣联合颌下腺瓣修复1例；其中2例术后出现脑脊液漏，换药后延期愈合；34例患者术后均未发生感染与脂肪液化，组织瓣成活率为100%，伤口一期愈合率为94.12%(32/34)。伴皮肤缺损患者中，缺损直径≤3 cm者5例，均采用颈面部推进皮瓣联合颞肌瓣和/或胸锁乳突肌瓣修复，皮瓣成活率为100%，伤口一期愈合率为100%；缺损直径＞3 cm者18例(19次缺损修复术)，其中行股前外侧肌皮瓣修复8例、胸大肌等带蒂皮瓣修复6例、前臂皮瓣联合带蒂皮瓣或局部组织瓣修复2例、胸大肌皮瓣或联合颈面部推进皮瓣及颌下腺瓣修复2例、腹直肌皮瓣修复1例，1例曾行大剂量放疗患者采用股前外侧肌皮瓣修复后3 d出现静脉栓塞，后改用胸大肌皮瓣救援修复后一期愈合；1例采用股前外侧肌皮瓣移植患者术后第2天出现血肿，清除血肿后伤口一期愈合；1例腹直肌皮瓣修复患者术后出现脑脊液漏，换药后皮损延期愈合；2例采用胸大肌等带蒂皮瓣修复后出现远端小面积坏死，经换药后伤口延期愈合；余患者的伤口均一期愈合，一期愈合率为84.21%(16/19)，皮瓣成活率为94.74%(18/19)。伴下颌骨体部及升支缺损患者中，采用腓骨肌皮瓣、游离肋骨移植联合颞肌瓣、股前外侧-股骨肌皮瓣移植修复分别2例、2例、1例，皮瓣均完全成活、伤口一期愈合。10例患者累及硬脑膜造成颅内外沟通，其中7例无术后并发症患者一期愈合，3例脑脊液漏患者经换药后延期愈合。行一期面神经重建患者24例，其中采用耳大神经移植重建12例，舌下神经8例，咬肌神经(+/-)耳大神经3例，股外侧皮神经1例；13例获得随访，面神经功能均获得不同程度的恢复。 结论 侧颅底肿瘤根治性切除术后应根据缺损范围选用不同的重建方式。对于不伴皮肤缺损者，可采用颞肌瓣联合游离脂肪填充或局部组织瓣修复；伴皮肤缺损直径≤3 cm者，可采用颈面部推进皮瓣联合局部组织瓣修复；伴皮肤缺损直径＞3 cm者，股前外侧肌皮瓣是较佳的修复方法。多次手术和术前放疗血管状态不佳或无法进行显微外科手术的患者，可选用胸大肌等带蒂皮瓣；若缺损累及颧弓以上，则可联合颈面部推进皮瓣及局部组织瓣修复；较大范围骨缺损，应酌情修复骨缺损。如条件许可，应争取一期重建面神经缺损。 Abstract:Objective To explore the methods for the reconstruction of lateral skull base defects after radical tumor resection. Methods Patients who underwent lateral skull base radical tumor resection and reconstruction from January 1, 2012 to December 31, 2019 in the Department of Stomatology and Otorhinolaryngology in Peking Union Medical College Hospital, were enrolled in this retrospective study. These patients were divided into three subgroups depending on the type of defects. Group I, patients without skin defects; Group Ⅱ, patients with skin defects; Group Ⅲ, patients with larger jaw defects. Different reconstructive methods were applied for the three groups. Results Sixty-two patients (63 procedures of defect repair) were enrolled in this study. The survival rate of tissue flap was 98.41%(62/63), and the primary wound healing rate was 90.48% (57/63). There were 34 patients in Group I. Among them, 6 cases received free fat transplantation; 14 cases were repaired with fat transplantation combined with local flaps; 13 cases were repaired with sternocleidomastoid muscle flap or combined temporal muscle flap; 1 case was repaired with temporal muscle flap combined with submandibular gland flap. Among them, two patients had postoperative cerebrospinal fluid leakage and delayed healing after dressing change. All patients had no postoperative infection and fat liquefaction, and the wounds healed by primary intention. The survival rate of tissue flap was 100%, and 94.12% (32/34) of the wounds healed by primary intention. There were 23 patients in Group Ⅱ. Five patients whose skin defects were less than 3 cm were reconstructed with local tissue flaps combined with advancement flaps; all flaps survived completely and the wounds healed by primary intention. The survival rate of tissue flap was 100%, and the primary wound healing rate was 100%. For those skin defects greater than 3 cm, free anterolateral thigh flaps were applied in 8 patients, pedicle flaps such as pectoralis flaps in 6 patients, 2 cases used forearm flap combined with pedicle skin flap or local tissue flap, 2 cases had pectoralis major myocutaneous flap or combined cervical and facial propulsion skin flap and submandibular gland flap, 1 case had rectus abdominis skin flap. One of the patients who had undergone high-dose radiotherapy developed venous embolism 3 days after repair with the anterolateral thigh myocutaneous flap, which was later repaired with pectoralis major myocutaneous flap rescue, and the remaining flaps survived completely; 1 patient with anterolateral thigh flap transplantation developed recipient hematoma on the second postoperative day, and the wound recovered after hematoma evacuation. One patient with rectus abdominis muscle repair developed cerebrospinal fluid leakage after surgery, and the skin lesions had delayed healing after dressing change. Two cases were repaired with pectoralis major myocutaneous flap and other pedicle skin flaps, and there was a small area of necrosis at the distal end. The wounds had delayed healing after dressing change. The wounds of the remaining patients healed at first stage; the first-stage wound-healing rate was 84.21% (16/19), and the flap survival rate was 94.74%(18/19). There were 5 patients in Group Ⅲ; 2 cases were reconstructed with fibular flap; 2 cases were reconstructed with free rib graft combined with temporal flap; 1 patient underwent femur-anterolateral thigh osteomyocutaneous free flap reconstruction. There were 10 patients whose tumors invaded the bones of the skull base and caused intracranial and external communication after surgery. Seven of them had no postoperative complications, and the remaining three had post-operative cerebrospinal fluid leakage, which delayed healing after dressing changes. There were 24 patients received simultaneous facial nerve reconstruction, including 12 cases reconstructed with greater auricular nerve transplantation, 8 cases with hypoglossal nerve, 3 cases with masseter nerve (+/-) greater auricular nerve, and 1 case with lateral femoral cutaneous nerve. Thirteen patients were followed up, and all had varying degrees of recovery of facial nerve function. Conclusions Different reconstruction regimens should be taken according to different types of defects after radical tumor resection. The patients without skin defects can be reconstructed with the temporal muscle flap combined with autologous fat grafting or local tissue flaps. The patients with skin defects smaller than 3 cm can be reconstructed with the cervicofacial advancement flap combined with local tissue flaps. The most reliable free flap for lateral skull base reconstruction is the anterolateral thigh flap for the patients with skin defects larger than 3 cm. For those patients who were not suitable for microsurgical reconstructive operation, the pectoralis major muscle flap repair should be selected. If the defect is above the zygomatic arch, it is better to choose the pectoralis major muscle flap combined with cervicofacial advancement flap or local tissue flaps. The bone defect should be reconstructed appropriately if the patients presented with a large jaw defect. If conditions permit, the facial nerve defect reconstruction should be applied simultaneously. -
Key words:
- lateral skull base tumors /
- defects /
- reconstruction /
- local tissue flaps /
- pedicled flap /
- free flap
作者贡献：朱智慧、侯樱子负责研究设计、数据分析、论文撰写；赵瑞琪、吴立萌、雷争辉负责标本留取及临床资料收集；冯国栋、高志强负责临床手术实施；张韬负责临床手术实施，指导研究设计、数据分析及修改论文。利益冲突：无 -
图 2 病例1重建术前与术后图像
A.术前图像；B.术前MRI示右侧颞骨乳突部广泛骨组织破坏伴软组织密度团块影，上鼓室扩大，听小骨破坏；C.右侧颞骨、部分颧弓、腮腺及面神经、颞颌关节及下颌骨髁突切除术后缺损；D.制备10 cm×20 cm股前外侧肌皮瓣；E.股前外侧肌皮瓣修复术区；F.术后皮瓣像
图 3 病例2重建术前与术后图像
A.右侧外耳道鳞状细胞癌伴绿脓杆菌感染；B.术前增强MRI示右侧外耳道及周围不规则软组织占位；C. 术中缺损图像；D.术中修复完成；E.术后出院时重建效果，示术区愈合良好；F.术后闭眼功能良好
图 4 病例3重建术前与术后图像
A. 术前MRI示右侧髁突前方见一不规则形软组织信号，与右侧咬肌与翼外肌、髁突前缘分界不清(箭头)；B. 术前切口线；C.右腮腺、颌下、头皮联合入路右髁突肿瘤切除术+右颧弓裂开+颞肌瓣转位+肋骨移植+钛板钛钉植入术；D、E.患者术后18个月正、侧面平视图
图 5 病例4重建术前与术后图像
A.术前口内咬合关系紊乱；B.术前MRI示左侧髁状突恶性肿瘤可能(箭头)；C.左侧髁突肿物、颞下颌关节、下颌骨升支及部分颧弓切除术后缺损；D.制备腓骨肌皮瓣；E.钛板固定腓骨与下颌骨体；F.术后曲面X线片示颌面部对称性较术前改善
图 6 病例5重建术前与术后图像
A.术前增强CT示左侧腮腺区上部软组织肿块影，考虑恶性肿瘤复发可能；B.术前切口线；C.术中左腮腺、左颞骨、左侧髁状突切除后致缺损；D.制备15 cm×7 cm股前外侧肌皮瓣携带4 cm×1 cm股骨块的复合组织瓣；E.股骨块修复下颌骨髁状突；F.术后2年正面视图；G、H.术后2年口内咬合关系及曲面X线片
表 1 62例侧颅底肿瘤根治术患者(63次手术)缺损类型及修复方法
缺损类型 修复方法 手术例次(n) 愈合情况 不伴皮肤缺损 游离脂肪填充 6 均一期愈合 颞肌瓣联合游离脂肪填充 14 2例出现脑脊液漏，延期愈合；12例一期愈合 胸锁乳突肌瓣或联合颞肌瓣 13 均一期愈合 颞肌瓣联合颌下腺瓣 1 一期愈合 伴皮肤缺损 直径≤3 cm 颈面部推进皮瓣联合颞肌瓣和/或胸锁乳突肌瓣 5 均一期愈合 直径＞3 cm 股前外侧肌皮瓣 8* 1例出现静脉栓塞，改用胸大肌皮瓣后一期愈合；余均一期愈合 胸大肌等带蒂皮瓣 6 2例出现远端小面积坏死，延期愈合；4例一期愈合 前臂皮瓣联合带蒂皮瓣或局部组织瓣 2 均一期愈合 胸大肌皮瓣或联合颈面部推进皮瓣及颌下腺瓣 2 均一期愈合 腹直肌皮瓣 1 出现脑脊液漏，延期愈合 伴下颌骨体部及升支缺损 腓骨肌皮瓣 2 均一期愈合 游离肋骨移植联合颞肌瓣 2 均一期愈合 股前外侧-股骨肌皮瓣 1 一期愈合 *1例股前外侧肌皮瓣修复后出现静脉栓塞，二次手术改用胸大肌皮瓣修复且一期愈合 
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表 2 一期面神经功能重建患者临床资料(n=24)
神经选择 患者例数
(n)随访例数
(n)末次随访时House-Brackmann分级(n) Ⅰ级 Ⅱ级 Ⅲ级 Ⅳ级 耳大神经 12 7 5 1 1 0 舌下神经 8 4 0 0 2 2 咬肌神经(+/-)耳大神经 3 1 0 0 1 0 股外侧皮神经 1 1 0 0 0 1
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