Reversely Tubed Deltopectoral Flap as a Salvage Procedure for Failed Microvascular Flap Reconstruction of Intraoral Defects -- Report of Two Cases

利用反向管型三角肌胸肌筋膜皮瓣救援自由皮瓣重建失敗後的口內缺損－個案報告

鄭穎(Yin Cheng) ； 楊弘維(Hung-Wei Yang) ； 戴浩志(Hao-Chih Tai) ； 鄭乃禎(Nai-Chen Cheng)

《臺灣整形外科醫學會雜誌》 29卷2期 (2020/06) Pp. 134-143

摘要

Background: The choice of regional flap to salvage failed free flap reconstruction of intraoral defect is limited. The deltopectoral (DP) fasciocutaneous flap had been widely used in head and neck reconstruction before microvascular reconstructive procedures were developed. DP flap was employed to resurface the intraoral defect by de-epithelializing the skin bridge, conversion of the skin flap into an island, and tunneling the dermal pedicle subcutaneously. However, distal flap necrosis was the most common complication. Aim and Objectives: This study aimed to describe a modified surgical technique of reverse tubing of DP flap without de-epithelization to decrease the complication of distal flap necrosis in secondary reconstruction of intraoral defects after failed free tissue transfer. Materials and Methods: Between 2012 and 2016, we applied a reversely tubed DP flap in two cases of failed intraoral free flap reconstruction. In contrast to the conventional DP flap, the tubed portion of the DP flap was designed as the skin surface facing inward and the fascia layer facing outward. The flap was delivered through a created submental tunnel to resurface the intraoral defect. No de-epithelialization of the tubed part was required with this design, thus avoiding the compromise of blood supply to the distal portion. The exposed raw surface of the tubed portion was covered with split-thickness skin graft. Results: The post-operative course was uneventful. The flap survived well and subsequent DP flap division was performed smoothly 3 weeks later. The two patients experienced oral function recovery without postoperative complications. Conclusion: The reversely tubed DP flap appears to be an accessible and reliable flap that can provide thin and pliable skin for intraoral reconstruction. It is therefore a viable option after failed microvascular reconstruction for intraoral defects.

關鍵字

reverse tubing ； deltopectoral flap ； intraoral reconstruction

並列摘要

背景：救援自由皮瓣重建失敗後之口內缺損時，能選擇的局部皮瓣種類並不多。在顯微重建手術盛行之前，三角肌胸肌筋膜皮瓣（DP皮瓣）為廣泛用於頭頸重建的術式之一。此皮瓣在用於重建口內缺損時，過去會移去中段皮瓣之表皮層，以作為經過皮下之部分。然而，遠端部分皮瓣壞死為最常見之併發症。目的及目標：我們報告了兩個病例，利用改良版的反向管型DP皮瓣來救援自由皮瓣重建失敗後的口內缺損，其方法不需要局部去表皮層，且有機會減少遠端部分皮瓣壞死之風險。材料及方法：在2012至2016年中，我們在兩個病例上，利用了反向管型DP皮瓣來處理自由皮瓣重建失敗後的口內缺損。有別於傳統方法，皮瓣會以皮膚部分在內，筋膜部分在外，捲成管狀。再將皮瓣經由已做好的下頷通道，放入口內。此方式不需額外去除部分表皮層，因此可降低皮瓣遠端循環之影響。而外露之筋膜部分，則以分層皮膚移植覆蓋。結果：兩個病例於術後病程皆恢復順利，且皮瓣成功存活。並在術後三週接受第二階段之皮瓣分離手術。病患之口部功能在後續恢復良好且無額外併發症。結論：因為反向管型DP皮瓣具備薄及柔軟的特性，而且方法簡單和可靠。所以在處理自由皮瓣重建失敗後的口內缺損，此皮瓣可考慮為一個適合的選澤。