上颌骨重建的转移瓣

,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 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 (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 Depict Tissue Options for Midface Reconstruction (3),6,Split thickness skin graftsLocal flaps Palatal mucoperiosteal island flapBuccal fat padRegional flapsDeltopectoralTemporalisSubmentalFree-bone grafts and free-tissue transferOsteocutaneousFasciocutaneousMyocutaneous Sandwich wraps,Reconstructive Options,7,Split Thickness Skin GraftsLocal Flaps Regional Flaps,Split-Thickness Skin Graft (STSG),8,/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 exudate : polyurethane films;moderate : hydrocolloidsheavily : calcium alginates Pressure bandaging for at least 2448 hours Persistent clinical signs of infection: A short course of topical antimicrobials Maintain 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,Palatal 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 sphenopalatine arteryMucoperiosteum secured to hard palate by Sharpeys fibers,Main Surgical Technique,13,14,Surgical Case(4),Advantages and Disadvantages,15,Large surface area (15cm2, 90% area)(5)Flap rotates 180o (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,Palatal 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 lobes: 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 muscleBlunt 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 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 medium 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 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 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,Surgical 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 major 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 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 parasternal 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 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 cutaneous lossDiscarded skin paddle without negative case outcomeSkin paddle dehiscence, treated conservatively,Fistula, treated conservativelySeromaInfection requiring hyperbaric oxygen therapyHardware removal and eventual free flap reconstructionInfection treated by incision and drainageDonor site complications:Chest wall dehiscenceRetained drainChest wall infectionSeromaHematoma,29,Split Thickness Skin GraftsLocal Flaps Regional Flaps,DeltopectoralTemporalisSubmental,Anotomy of Temporalis,30,Indications for the Temporalis Muscle Flap,31,Obliteration of oral defectsTemporomandibular joint reconstruction by gap arthroplastyCranial base reconstructionObliteration of orbital defects after enucleationFacial reanimation surgeryMidface suspension or orbital repair with the coronoid process, attached to temporalis after maxillectomy,Surgical Case,32,Surgical 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 dissection 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 Disadvantages,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 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 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 submandibular 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 site 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),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 and 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 defects. Plast Reconstr Surg 2000; 105:23312346.Brown JS, Rogers SN, McNally DN, Boyle M. A modified classification for the maxillectomy defect. Head Neck 2000; 22:1726.Neal D Futran, Eduardo Mendez. Developments in reconstruction of midface and maxilla.Lancet Oncol 2006; 7: 24958D. Henderson. The palatal island flap in the closure of oro-antral fistulae. British Journal of Oral Surgery (Ig74), 12, 141-146Moore BA, Magdy E, Netterville JL, Burkey BB. Palatal reconstruction with the palatal island flap. Laryngoscope 2003; 113:946951.Gullane PJ, Arena S. Extended palatal island mucoperiosteal f