Management of Extensive and Complex Scalp Defects in Patients of Neoplasm

廣泛與複雜性頭皮缺損於頭部腫瘤病人的處置與重建

陳建良(Chien-Lian Chen) ； 謝榮賢(Jung-Hsieh Hsieh) ； 湯月碧(Yueh-Bih Tang)

《中華民國整形外科醫學會雜誌》 18卷3期 (2009/09) Pp. 217-230

https://doi.org/10.7096/JPSA.200909.0217

摘要

背景：
病人若罹患頭部腫瘤經治療造成的嚴重複雜性缺損對於整形外科醫師而言仍是重建上的難題，因為常合併出現腦脊液漏、因鼻竇暴露而有細菌污染、接受過放射線或化學治療影響傷口癒合與功能及外觀上的考量。本篇研究的目的在分享我們處理這些嚴重缺損的經驗。
目的及目標：
在1993與2008年的十五年間，有十位病患因頭皮缺損接受各種自由皮瓣手術：四個股外側肌自由肌皮瓣、三個外側股自由皮瓣、三個闊背肌自由肌皮瓣與一個前臂橈動脈自由皮瓣。這些缺損非常複雜包含腦組織與硬腦膜暴露、放射線組織傷害、傷口感染與中樞神經感染。我們使用自由皮瓣來重建這些經清創或切除腫瘤合併或無放射線治療的缺損。病患的年齡為35至61歲不等，平均年齡為51.2歲。追蹤的時間為一至十年。我們分析病人的基本資料、既有疾病、手術適應症、皮瓣種類、缺損中暴露的組織及併發症與結果。也使用費雪精確檢定(Fisher's exact test)來分析腦脊液漏及術後併發症與死亡率之間的相關性。
結果：
所有病人都由我們的神經外科醫師轉診而來，都經過腫瘤切除手術加上或無放射線治療。在這十位病人中，六位有腦脊液漏；在這六位有腦脊液漏之病患中，一塊皮瓣完全壞死，另外兩塊有部份壞死需要清創及植皮手術來閉合傷口，四塊皮瓣完全存活且這六位病患術後都無腦脊液漏復發。相對而言，四位無腦脊液漏的病患所有的皮瓣都存活。術後初期的死亡率為10%而整體死亡率為20%。有一位病患死於術後1.5個月，死因為敗血症；令一位則於術後1.5年死於原有癌症。
結論：
雖然我們研究的病例數少且無統計上的意義，我們的結果顯示自由皮瓣手術在這些高危險群的病患可成功挽救性命並改善生活品質。與皮筋膜皮瓣比較，肌肉皮瓣合併植皮可以提供較佳的外觀。嚴重的中樞神經感染，復發的腦脊液漏與放射線造成的大面積傷害包含放射線骨頭壞死都可因使用自由皮瓣而成功治療。

並列摘要

Background:
Reconstruction of extensive and complex scalp defects in patients of neoplasm remains a significant challenge because of cerebrospinal fluid leak, bacterial contamination from sinus exposure, effect of radiation therapy, neoadjuvant or postoperative chemotherapy, and functional and cosmetic deformity from the size and location of the defect. In this series, we present our experience in the management of extensive defects
Materials and Methods:
Between 1993 and 2008, ten patients with scalp defects received reconstruction with a variety of free flaps: four free vastus lateralis muscle flaps, three anterolateral thigh flaps, three latissimus dorsi flaps with fasciocutaneous extension and one radial forearm flap. These defects had a wide spectrum of complexities including extensive multilaminar defects with exposed brain and dura, irradiation damage, infection of the wounds and central nervous systems. The flaps were used to cover the defects resulting from the radical debridement or tumor ablation with or without radiation in patients ranging from 35 to 61 years of age. Follow-up ranged from one to ten years. The patients' demographics, surgical indications, type of flaps and exposed structures, comorbidity, complications and outcomes were assessed. Fisher's exact test was used to evaluate the correlation between CSF leakage and postoperative complications and mortality.
Results:
All patients were referred from our neurologic surgeons after ablative surgery with or without adjuvant radiotherapy. Among the ten patients, six had a cerebrospinal fluid leak at the time of the reconstruction. Of the six patients, one had total flap loss requiring another free flap reconstruction and two had partial flap necrosis, demanding debridement and split-thickness skin grafting. Four flaps totally survived and the cerebrospinal fluid leak all resolved in the six patients. In comparison, of the four patients without a cerebrospinal fluid leak, all flaps survived. The perioperative mortality is 10% and the overall mortality is 20%. One patient died of sepsis 1.5 months later and the other one died of primary cancer 1.5 years after reconstruction.
Conclusion:
Although our case number is very small, our results support that free flap reconstruction is a life-saving procedure in this high-risk population and that success is possible. Comparing to fasciocutaneous flaps, muscle flaps with primary or secondary split-thickness skin grafting can provide better cosmetic result. Difficult problems, such as severe central nervous system infection, recurrent cerebrospinal fluid leaks and large irradiated wounds including osteoradionecrosis, can be managed and resolved successfully using this technique.

並列關鍵字

extensive and complex scalp defects ； free flap ； cerebrospinal fluid leak ； osteoradionecrosis