Pectoralis Major Flaps for Head and Neck Reconstruction-＂An Outcome Reappraisal＂

胸大肌皮瓣於頭頸部重建之探討

梁高議(Kao-Yi Liang) ； 許宏達(Honda Hsu) ； 鄭立福(Li-Fu Cheng) ； 黃介琦(Chieh-Chi Huang) ； 李俊達(Jiunn-Tat Lee) ； 簡守信(Sou-Hsin Chien)

《臺灣整形外科醫學會雜誌》 24卷3期 (2015/09) Pp. 197-206

摘要

背景：儘管胸大肌皮瓣在過去曾被廣泛的使用在頭頸部的重建，隨著顯微手術的進步，它們的角色有逐漸被取代的趨勢。然而，即使和游離皮瓣相比它們的併發症較高，但於特定的情況下，胸大肌皮瓣仍有其存在的意義。目的及目標：本文主要是評估該皮瓣應用於頭頸部重建的可靠性，並試著結合我們之前的解剖研究及相關文獻探討，整理出如何減少併發症產生的皮瓣拿取技術。材料及方法：我們收集了本院從民國九十六年九月至一百年八月，整整四年的期間內，所有頭頸部重建採用胸大肌皮瓣的病例。整理並分析他們的病灶、手術適應症及併發症產生的結果。皮瓣拿取的方法相較傳統的方式有些許修改，皮瓣在拿取時會根據所需大小，至少涵蓋第三內胸動脈或第四肋間動脈的穿通支，甚至胸外側動脈必要時也一併保留。另外，術中也會額外確保皮下通道有足夠的空間以防血管蒂被壓迫。結果：在這四年間，總共收集了51位病人，他們共接受了53次的胸大肌皮瓣頭頸部重建手術。除了其中的27例胸大肌皮瓣是直接作為第一線的重建選項（12例是癌症晚期或復發的病人、11例是頸部皮膚癌、3例是放射性骨壞死、1例是臉部動靜脈血管畸形），其餘的26例則是扮演游離皮瓣術後皮瓣壞死（12例）、治療瘻管形成（7例）或是用來覆蓋重要器官或植入物暴露（7例）的救火隊的角色。病人中有8例（15.1%）於術後產生相關的併發症︰其中較嚴重的併發症，如局部皮瓣壞死的共有兩例（3.8%），但壞死的皮瓣面積不大；其它較次要的併發症，如傷口裂開（5.7%）、傷口感染（3.8%）和瘻管產生（1.9%）等共有6例（11.3%）。不但所有的皮瓣都存活沒有死亡，其它不論較嚴重或較次要的併發症也都在適當的傷口照護下癒合而不需任何額外的手術處理。結論：對於胸大肌皮瓣的血管解剖分佈的情況有了更好的理解後，我們的結果顯示臨床使用該皮瓣的風險不但低且併發症的機率也可接受，故其在頭頸部重建的應用上仍然佔有無可取代的地位。

並列摘要

Background: Pectoralis major flaps used to be considered the ＂workhorse＂ of pedicled flaps for head and neck reconstruction; however, their roles are less effective nowadays with the advancement of microvascular free flap technique. Nevertheless, the pectoralis major flap still has its role under certain circumstances despite its relatively high complication rate as compared with free flap transfer. Aim and Objectives: The aim of this study was to evaluate the reliability of such a flap in selected cases of head and neck reconstruction, and with combination of our previous cadaver dissection and literature review, to refine the technique for better flap survival with fewer complications. Materials and Methods: We retrospectively reviewed the records of patients undergoing head and neck reconstruction with pectoralis major pedicled flap at our hospital from September 2007 to August 2011. Site of defect, indications and complications were assessed. Methods of harvesting the flaps were modified to include the 3rd perforating branch of the internal thoracic artery and/or the 4th intercostal perforating branch, with or without lateral thoracic artery, in accordance to the required size of skin paddle. Besides, spacious tunnel for pedicle passage was secured as well. Results: A total of 51 patients with 53 pectoralis major flaps for head and neck reconstruction in these four years were analyzed. Twenty-seven of fifty-three flaps were carried out as primary reconstructive procedures (12 cases for advanced or recurrent neoplasms, 11 cases for neck skin cancer, 3 cases for osteoradionecrosis, and 1 case for facial arteriovenous malformation), whereas 26 flaps were used as ＂salvage＂ procedures (reconstruction for fistula patching in 7 cases, after free flap failure in 12 cases, and coverage of exposed vital structures or prosthesis in 7 cases). Eight patients (15.1%) had complications. The overall major complication rate in our serials was 2 of 53 (3.8%) with minor skin paddle necrosis. Minor complications, such as wound dehiscence (5.7%), infection (3.8%) and fistula formation (1.9%), occurred in 6 of 53 flaps (11.3%). All flaps survived, and all major or minor complicated wounds healed by secondary intention without further surgical intervention. Conclusion: With better understanding of the vascular anatomic distribution of the pectoralis major flap, our results demonstrated that the flap remains an indispensible reconstruction option in head and neck surgery with low risk and an acceptable morbidity rate.

並列關鍵字

pectoralis major flap ； head and neck reconstruction