上頜骨重建的轉移瓣

1、,,1,MAXILLOFACIAL RECONSTRUCTION,2,Basic Introduction about Maxillofacial Reconstruction,Classification System for Maxillectomy and Midfacial Defects (1),3,Type 1 defects (limited maxillectomy): one or two walls of the

2、maxilla Type 2 defects (subtotal maxillectomy) the lower five walls with preservation of the orbital floorType 3 defects (total maxillectomy) all six walls of the maxillatype 3a (orbital content preservation)type 3b

3、(orbitalcontent exenteration)Type 4 defects (orbitomaxillectomy) the orbital contents and upper five walls of the maxilla, with preservation of the palate,4,Modified Maxillectomy Classification Scheme (2),5,Algorithm to

4、 Depict Tissue Options for Midface Reconstruction (3),6,Split thickness skin graftsLocal flaps Palatal mucoperiosteal island flapBuccal fat padRegional flapsDeltopectoralTemporalisSubmentalFree-bone grafts and fr

5、ee-tissue transferOsteocutaneousFasciocutaneousMyocutaneous ‘Sandwich’ wraps,Reconstructive Options,7,Split Thickness Skin GraftsLocal Flaps Regional Flaps,Split-Thickness Skin Graft (STSG),8,http://www.burnsurvivo

6、rsttw.org/burns/grafts.html,Surgical Technique,9,,Different thickness : (0.005-0.012 in), intermediate (0.012-0.018 in), or thick (0.018-0.030 in),,Postoperative Suggestions,10,Select different dressinglight to moderate

7、 exudate : polyurethane films;moderate : hydrocolloidsheavily : calcium alginates Pressure bandaging for at least 24–48 hours Persistent clinical signs of infection: A short course of topical antimicrobials Maintain

8、 until be removedable without traumaLeakage without infection need reinforce dressingWash donors sites gently and have A moisturiser applied at least twice daily Avoid UV exposure to the donor site,11,Local Flaps,Pala

9、tal mucoperiosteal island flapBuccal fat pad,Regional Flaps,Split Thickness Skin Grafts,Palatal mucoperiostealIsland Flap,12,Anastomosis of the greater palatine artery and the naso-palatine branch of the

10、 sphenopalatine arteryMucoperiosteum secured to hard palate by Sharpey’s fibers,Main Surgical Technique,13,,,,14,Surgical Case(4),Advantages and Disadvantages,15,Large surface area (15cm^2, 90% area)(5)Flap rotates 1

11、80o (6)Rapid reepithelialization (3months) (5)No donor site skin scarsSensate, excellent for introral defects,Limited pedicle length,Complications,16,17,Split Thickness Skin GraftsLocal Flaps Regional Flaps,Pala

12、tal mucoperiosteal island flapBuccal fat pad,Anatomy of Buccal Fat Pad (7),18,Average volume 10 cm3 ; average thickness 6mmFour processes: buccal, pterygoid, pterygopalatine, superficial and deep temporalThree lob

13、es: anterior, intermediate, and posterior,Surgical Technique (7),19,A vestibular incisionThe distobuccal depth of the maxillary tuberosityA single sharp scissor stab through the periosteum and scant buccinator muscleB

14、lunt dissection mobilizes the flap held with tissue forceps Pressure applied at the level of the zygomatic arch Fixed into bone with bur-holes or screws A surgical splint Instructed to not blow their nose forcefully

15、for at least the following 2 to 3 weeks,Schematic Surgical Technique,20,,,,,,,,Advantages and Disadvantages,21,Rapid reepithelializationEasy to harvestRich vascular supplyNo donor site skin scars,Only suitable for med

16、ium sized defects up to 4cm3Difficulty with fixationProne to dehiscence,Complications,22,Partial necrosisA small dehiscenceTrismus from scarring (retromolar trigone or buccal mucosa defects)A rare visible change in

17、facial contourThe low morbidity and failure rate,23,Split Thickness Skin GraftsLocal Flaps Regional Flaps,DeltopectoralTemporalisSubmental,Anatomy of Deltopectoral Flap,24,The vascularization of the DP flap: mainly

18、by anterior perforator branches of the internal mammary arteryThe vessels usually emerge through the pectoralis major muscle at the second and third intercostal spacesOne finger width lateral to the sternal border,Surg

19、ical Technique (8),25,Can include the lateral and posterior deltoid regions The maximum size of the pre-expanded flap: 10x20 cm2 12x22 cm2 Blunt strip an interspace between the deep fascial layer and the pectoralis ma

20、jor muscle and the deltoid muscle about 7 to 10 cm long on the inferior border of the clavicula Injection of sterile water into the expander twice a weekAblate scars in the face or neck Trace the extent of the tissue

21、defect with a piece of paperThe flap approximately 10% to 15% bigger than the defect spaceAblate partly anterior fibrous capsule of the expanderTubulate the pedicle of the expanded flap (2 cm beyond the ipsilateral pa

22、rasternal line)Close directly the donor defect3 weeks later separate the pedicle,Surgical Case (8),26,Advantages and Disadvantages,27,Larger than 1/3 of the area of the face or neckFreedom from a myogenous component

23、and ease of elevationPartial flap lossHematomaColor of the skin graft is darker than the normal skinDP flap are fat and clumsyDonor sites are morbid,Complications,28,Recipient site complications:Significant cutan

24、eous lossDiscarded skin paddle without negative case outcomeSkin paddle dehiscence, treated conservatively,Fistula, treated conservativelySeromaInfection requiring hyperbaric oxygen therapyHardware removal and even

25、tual free flap reconstructionInfection treated by incision and drainageDonor site complications:Chest wall dehiscenceRetained drainChest wall infectionSeromaHematoma,29,Split Thickness Skin GraftsLocal Flaps Re

26、gional Flaps,DeltopectoralTemporalisSubmental,Anotomy of Temporalis,30,Indications for the Temporalis Muscle Flap,31,Obliteration of oral defectsTemporomandibular joint reconstruction by gap arthroplastyCranial base

27、reconstructionObliteration of orbital defects after enucleationFacial reanimation surgeryMidface suspension or orbital repair with the coronoid process, attached to temporalis after maxillectomy,Surgical Case,32,Surgi

28、cal Technique,33,A hemicoronal incision The initial incision: at the level of the deep temporal fascia(bloodless)Safe until approximately 1 to 2 cm above the zygomatic archIncise the superficial layer thereThe dissec

29、tion subperiosteally along the zygomatic archExpose the entire temporalis muscle Prepare a subperiosteal tunnel for the transposition of the muscle to the recipient site sutured into position,Advantages and Disadvantag

30、es,34,Good option for patients unable to undergo free- tissue transferScar camouflaged in hairline Often requires zygoma osteotomy to rotate flapLimited bone stock, unsuited for osteointegrated

31、 implants,Complications,35,[10],36,Split Thickness Skin GraftsLocal Flaps Regional Flaps,DeltopectoralTemporalisSubmental,Anatomy of Submental Region,37,Surgical Technique (11),38,Within the mandibular margin at

32、least 1cm behind the ramusA subplatysmal dissection ensues elevating the skin islandDissection of the submental vessels by releasing the deep fascial attachments and ligating the perforating vessels to the submandibul

33、ar glandThe dissection should be carried out until sufficient length has been achieved to reach the distal edge of the defect,Surgical Case,39,40,Large flap size (7x15 cm) Superior skin color match Well hidden donor s

34、ite scarWide rotation arcThin, pliable skinNot suitable if patient has previous level 1 nodal diseasePoor primary closure if previous radiation therapy,Advantages and Disadvantages,Indications and Complications (12)

35、,41,ComplicationsPartial necrosis of the distal aspect of the flapTransient temporal nerve weaknessLimited mouth opening (20 mm)A donor-site deformity,Indications:Reconstruction of defects of the skull base,Orbit a

36、nd eyelids, cheek, tongue, maxilla, palate, Temporomandibular joint, and mandible up to the canine region,Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction on maxillectomy and midfacial

37、defects. Plast Reconstr Surg 2000; 105:2331–2346.Brown JS, Rogers SN, McNally DN, Boyle M. A modified classification for the maxillectomy defect. Head Neck 2000; 22:17–26.Neal D Futran, Eduardo Mendez. Developments in

38、reconstruction of midface and maxilla.Lancet Oncol 2006; 7: 249–58D. Henderson. The palatal island flap in the closure of oro-antral fistulae. British Journal of Oral Surgery (Ig74), 12, 141-146Moore BA, Magdy E, Nette

39、rville JL, Burkey BB. Palatal reconstruction with the palatal island flap. Laryngoscope 2003; 113:946–951.Gullane PJ, Arena S. Extended palatal island mucoperiosteal flap. Arch Otolaryngol 1985; 111:330–332.Kevin Arce,

40、 Buccal Fat Pad in Maxillary Reconstruction. Atlas Oral Maxillofacial Surg Clin N Am 15 (2007) 23–32Ma Xianjie, Repair of Faciocervical Scars by Expanded Deltopectoral FlapAnnals of Plastic Surgery ? Volume 61, Number 1

41、, July 2008Vijay R. Ramakrishnan,Improved Skin Paddle Survival in Pectoralis Major Myocutaneous Flap Reconstruction of Head and Neck Defects. Arch Facial Plast Surg. 2009;11(5):306-310Yun-Hua You. Reverse facial-Submen

42、tal artery island flap for the reconstruction of maxillary defects after cancer ablation.J Craniofac Surg 2009;20:2217-2220. Perminder S. Parmar and David P. Goldstein. The submental island flap in head and neck recons

43、truction. Current Opinion in Otolaryngology & Head and Neck Surgery 2009, 17:263–266 Imad Abu-El Naaj, The Use of the Temporalis Myofascial Flap in Oral Cancer Patients J Oral Maxillofac Surg 68:578-583, 2010,42,Ref