三维打印预成形钛网联合游离背阔肌肌瓣在头顶部鳞状细胞癌伴颅骨缺损治疗中的临床应用

马富鑫; 任盼; 曹瑾; 边永钎; 周加华; 赵聪颖

doi:10.3760/cma.j.cn501120-20201221-00538

三维打印预成形钛网联合游离背阔肌肌瓣在头顶部鳞状细胞癌伴颅骨缺损治疗中的临床应用

doi: 10.3760/cma.j.cn501120-20201221-00538

1.
空军军医大学第二附属医院整形烧伤科，西安　　710038
2.
空军军医大学第二附属医院神经外科，西安　　710038

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通讯作者:
赵聪颖，Email：xiaoyanmale20@126.com

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出版历程
- 收稿日期: 2020-12-21

Clinical application of three-dimensional printed preformed titanium mesh combined with free latissimus dorsi muscle flap in the treatment of squamous cell carcinoma with skull defect in the vertex

1.
Department of Burns and Plastic Surgery, the Second Affiliated Hospital of Air Force Medical University, Xi'an 710038, China
2.
Department of Neurosurgery, the Second Affiliated Hospital of Air Force Medical University, Xi'an 710038, China

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Corresponding author: Zhao Congying, Email: xiaoyanmale20@126.com

摘要

摘要: 目的探讨三维打印预成形钛网联合背阔肌肌瓣游离移植治疗头顶部鳞状细胞癌根治性切除术后伴颅骨缺损创面的临床效果。方法采用回顾性观察性研究方法。2010年1月—2019年12月，空军军医大学第二附属医院整形烧伤科收治5例符合入选标准的头顶部鳞状细胞癌伴颅骨侵袭患者，其中男4例、女1例，年龄50~65岁，原始病变面积为5 cm×4 cm~15 cm×8 cm。术前根据颅骨CT三维重建结果预估颅骨切除范围并采用三维打印技术预制钛网。Ⅰ期行肿瘤扩大切除后，头皮软组织缺损面积为8 cm×7 cm~18 cm×11 cm，采用预成形钛网修补，并采用面积为10 cm×9 cm~20 cm×13 cm的背阔肌肌瓣覆盖钛网，将胸背动静脉与一侧颞浅动静脉吻合，对供区肌肉断端行拉拢缝合或缝扎处理，将背部皮肤重新覆盖回供区。Ⅰ期术后第10天进行Ⅱ期手术，取患者股前外侧薄中厚皮片覆盖背阔肌肌瓣。统计Ⅰ期手术时长、术中出血量，观察Ⅰ期术后肌瓣及Ⅱ期术后皮片存活情况，随访并发症发生情况、头部外观、肿瘤有无复发。结果患者平均Ⅰ期手术时长为12.1 h，且术中出血量不超过1 200 mL，Ⅰ期术后肌瓣和Ⅱ期术后皮片全部存活良好。随访6~18个月，所有患者均无钛网外露或感染等并发症发生，头顶部受区外观形态良好，无肿瘤复发。结论应用三维打印预成形钛网联合背阔肌肌瓣游离移植加中厚皮覆盖修复头顶部鳞状细胞癌扩大切除术后伴颅骨缺损的创面，是一种有效、可靠的方法。该方法可在有效覆盖创面的同时，使受区和供区均获得良好的功能及外观。
- 癌，鳞状细胞 /
- 颅骨 /
- 打印，三维 /
- 修复外科手术 /
- 背阔肌 /
- 肌瓣 /
- 游离移植
Abstract: Objective To explore the clinical effects of three-dimensional printed preformed titanium mesh combined with latissimus dorsi muscle flap free transplantation in the treatment of wounds with skull defect after radical surgery of squamous cell carcinoma in the vertex. Methods A retrospective observational study was conducted. From January 2010 to December 2019, 5 patients with squamous cell carcinoma in the vertex accompanied with skull invasion who met the inclusion criteria were admitted to the Department of Burns and Plastic Surgery of the Second Affiliated Hospital of Air Force Medical University, including four males and one female, aged 50 to 65 years. The original lesion areas ranged from 5 cm×4 cm to 15 cm×8 cm. The titanium mesh was prefabricated via three-dimensional technic based on the result the scope of skull resection predicted with computerized tomography three-dimensional reconstruction before surgery. During the first stage, the soft tissue defect area of scalp (8 cm×7 cm to 18 cm×11 cm) after tumor enlargement resection was repaired with the preformed titanium mesh, and the titanium mesh was covered with latissimus dorsi muscle flap, with area of 10 cm×9 cm to 20 cm×13 cm. The thoracodorsal artery/vein was anastomosed with the superficial temporal artery/vein on one side. The muscle ends in the donor site were sutured together or performed with transfixion, and then the skin on the back were covered back to the donor site. On the 10th day after the first-stage surgery, the second-stage surgery was performed. The thin intermediate thickness skin graft was taken from the anterolateral thigh to cover the latissimus dorsi muscle flap. The duration and intraoperative blood loss of first-stage surgery were recorded. The postoperative muscle flap survival after the first-stage surgery and skin graft survival after the second-stage surgery was observed. The occurrence of complications, head appearance, and recurrence of tumor were followed up. Results The average first-stage surgery duration of patients was 12.1 h, and the intraoperative blood loss was not more than 1 200 mL. The muscle flaps in the first-stage surgery and the skin grafts in the second-stage surgery all survived well. During the follow-up of 6-18 months, no complications such as exposure of titanium mesh or infection occurred, with good shape in the recipient sites in the vertex, and no recurrence of tumor. Conclusions Three-dimensional printed preformed titanium mesh combined with latissimus dorsi muscle flap free transplantation and intermediate thickness skin graft cover is an effective and reliable method for repairing the wound with skull defect after extended resection of squamous cell carcinoma in the vertex. This method can cover the wound effectively as well as promote both recipient and donor sites to obtain good function and appearance.
- Carcinoma, squamous cell /
- Skull /
- Printing, three-dimensional /
- Reconstructive surgical procedures /
- Latissimus dorsi /
- Muscle flap /
- Free transplantation
马富鑫：收集资料、参与手术并且起草论文；任盼、曹瑾：参与手术、整理图片及论文数据；边永钎、赵聪颖：设计并实施手术；周加华：参与手术

所有作者均声明不存在利益冲突

内侧臂皮瓣在面颈部缺损整复中具有多种优势，但仍未得到充分利用，该皮瓣的主要不足是患者在皮瓣断蒂前必须保持被动固定姿势。该临床研究旨在介绍一种在不固定上肢情况下使用内侧臂皮瓣修复面颈部缺损的方法。该作者针对14例采用预扩张内侧臂皮瓣（15个）整复面颈部缺损患者的数据进行回顾性研究。采用吲哚菁绿血管造影检测穿支和评估皮瓣灌注情况，对所有皮瓣都进行转移前组织扩张。通过吲哚菁绿血管造影识别的所有穿支都在皮瓣分离过程中被直接看到。术中吲哚菁绿血管造影显示4例患者皮瓣灌注不良，结合临床观察，切除灌注不良部位。该组患者皮瓣大小为（203.9±75.2）cm²，组织扩张后长度为20~28 cm。将内侧臂供区直接关闭或使用另一个皮瓣来覆盖该处继发创面。所有皮瓣完全成活。术后随访1~22个月，所有患者及其家属都对结果感到满意。该研究显示，在组织扩张和吲哚菁绿血管造影的帮助下使用内侧臂皮瓣整复面颈部缺损可以提供足够的组织，并且不必在手术过程中固定上肢。

丁健科，编译自《J Craniofac Surg》，2021，32(4):1467-1471；马显杰，审校

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1 肿瘤扩大切除及钛网修补联合背阔肌肌瓣游离移植修复1例患者头顶部鳞状细胞癌根治性切除后伴颅骨缺损的创面。1A.Ⅰ期术前头颅CT三维重建结果，可见颅骨已被侵蚀伴局部缺损；1B.术中创面彻底清洗后；1C.将肿瘤扩大2 cm切除；1D.颅骨去除后的创面以可吸收性明胶海绵填塞止血；1E.将三维打印预成形钛网置入并固定；1F.将肌瓣中胸背动静脉与颞部受区颞浅动静脉吻合后；1G.Ⅰ期术后即刻，背阔肌肌瓣完整覆盖创面且血运良好；1H.Ⅰ期术后第10天取股前外侧薄中厚皮片覆盖肌瓣，皮片覆盖后打孔引流；1I.Ⅱ期术后7 d，打开敷料见皮片存活良好，肌瓣完全被覆盖；1J.Ⅱ期术后18个月随访时见头顶部外观良好，且肿瘤未复发

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表1 5例头顶部鳞状细胞癌伴颅骨缺损患者观察指标结果

患者编号 Ⅰ期手术时长（h） Ⅰ期术中出血量（mL）随访时间（个月）

1 12.0 1 000 6
2 11.0 1 200 16
3 12.5 1 200 8
4 13.0 1 000 18
5 12.0 1 200 12

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