后外侧入路在上颌骨切除术中的临床应用
摘要
背景
目前，上颌骨切除术的各种手术入路各有利弊，大多遗留术后咀嚼、语言、吞咽等功能障碍，尤其是对颜面容貌美的影响较大，同时，传统内侧切口围手术期放疗时有洞穿性空洞的发生。为尽量减少颜面中央区域皮肤软组织疤痕，减少或避免内侧切口围手术期放疗可能出现的毁容性空洞事件的发生，提高患者术后的生命质量，有必要发展和创新上颌骨切除术的手术入路。
目的
根据上颌骨及面部软组织的解剖学特点，设计并提出上颌骨切除术的后外侧入路，经临床实践，对上颌骨切除术的后外侧入路进行初步的综合评价。
方法
在分析及评价现今上颌骨切除术各种入路基础上，根据头颈部外科手术入路的设计原则，提出了“内眦-下睑下缘-颧弓前缘-发际-耳屏前-耳垂下-下颌角后下-下颌骨缘下”这一新的上颌骨切除术手术入路（简称后外侧入路）。现对采用这一新的手术入路行上颌骨恶性肿瘤切除术的8例患者的临床资料进行回顾性分析与初步的临床评价。
结果
围手术期无病例死亡。手术切口一期愈合好，颜面部切口瘢痕明显减少，均存留患侧面部塌陷，皮瓣翻揭区面部的精细表情受到不同程度影响。保留眼球者均无视力模糊。其中1例术后1月出现右腭部约1*0.5cm大小穿孔，与鼻腔相通；1例术后3个月出现右眼轻度复视，经保守治疗后恢复；1例术后7月复发；1例术后放疗，没有出现颜面中央区毁容的洞穿性空洞。
结论
后外侧手术入路其方法可行，是一种确有临床应用价值的手术入路，与现今各种入路相比，具有下列的优点：①术野暴露更充分；②切口相对隐蔽、颜面中央区可见疤痕减少；③切口下方径路稍加改变，即可在同一术野完成选择性颈廓清及上颌骨的修复重建；④理论上该入路可减少围手术期放疗内侧切口（Weber-Fergusson切口）颜面中央区毁容的洞穿性空洞事件的发生。但同时存在比传统内侧入路创伤较大的缺点。本入路丰富和发展了上颌骨切除术的手术入路，为上颌骨切除术患者手术入路更加个性化的选择提供了多样化的备选方案。
Background
At present, there are disadvantages and advantages of all kinds of approaches during themaxilla resection, most of which have different problems after surgery, such as impediment inmastication, speaking and deglutition, in particular the bad influence of appearance. Besides,during the radiotherapy of traditional interior incision perioperation, holes appear. In order todecrease the scar of skin tissue left after surgery and the possible occurrence of disfigured holesemerged during the radiotherapy of traditional interior incision perioperative period and promotepatient’s life quality, it is inevitable and necessary to develop and initiate a new kind of approachthat is more suitable for the maxillectomy.
Objective
According to the anatomy characteristics of maxilla and skin tissue, posterior lateral approachof maxilla resection is designed and set forth. From the clinical experience, premiercomprehensive evaluation will be made to this approach.
Method
On the basis of the analysis and comments of the current approach in accordance withdesigning principles of the head and neck’s surgery approach, a new approach of maxillaresection is developed, which starts from angulus oculi medialis, then inferior lower eyelidinferior，anterior ansa capitis, hair boundary, anterior antilobium, lower earlobe, posteriorinferior angulus mandibulae, then ends in the lower limb of mandibula. In this article, the clinical materials of 8 patients who have come through the maxillectomy of malignancy in this approachwill be reviewed and analyzed and a premier clinical conclusion will be made.
Result
None of the patients die in the perioperation. The surgery incision heals up quite well in thefirst period, the scar left on the face after operation is apparently lessened; the situation of facialsubsiding remains and the eyesight of those with eyeballs are good. In one case, a hole of about1*0.5cm connected with the nasal cavity appears in the right palate after one month of thesurgery. In another case, the right eye of the patient has slight diplopia problem after 3 months,which, though, has been cure after conservative treatment. In another case, it recrudesces after 7months.
Conclusion
Posterior lateral approach of maxilla resection works with its clinical operation values.Compared with the current approaches, it distinguished itself from the others from several aspect,such as larger view of surgery operation, lessened scars left on the face for its hidden surgeryposition, easier reconstruction of maxilla and optional radical neck dissection in the sameoperation view when the lower-part incision approach is changed a bit and theoretical decreaseof the disfigured holes’appearance in the central facial part of the interior incision inperioperation. However, it has disadvantages like significant wound left. This approach enrichesand develops the approachs of the maxillectomy, providing various operational choice forpatients that need maxilla resection more personally.
目前，上颌骨切除术的各种手术入路各有利弊，大多遗留术后咀嚼、语言、吞咽等功能障碍，尤其是对颜面容貌美的影响较大，同时，传统内侧切口围手术期放疗时有洞穿性空洞的发生。为尽量减少颜面中央区域皮肤软组织疤痕，减少或避免内侧切口围手术期放疗可能出现的毁容性空洞事件的发生，提高患者术后的生命质量，有必要发展和创新上颌骨切除术的手术入路。
目的
根据上颌骨及面部软组织的解剖学特点，设计并提出上颌骨切除术的后外侧入路，经临床实践，对上颌骨切除术的后外侧入路进行初步的综合评价。
方法
在分析及评价现今上颌骨切除术各种入路基础上，根据头颈部外科手术入路的设计原则，提出了“内眦-下睑下缘-颧弓前缘-发际-耳屏前-耳垂下-下颌角后下-下颌骨缘下”这一新的上颌骨切除术手术入路（简称后外侧入路）。现对采用这一新的手术入路行上颌骨恶性肿瘤切除术的8例患者的临床资料进行回顾性分析与初步的临床评价。
结果
围手术期无病例死亡。手术切口一期愈合好，颜面部切口瘢痕明显减少，均存留患侧面部塌陷，皮瓣翻揭区面部的精细表情受到不同程度影响。保留眼球者均无视力模糊。其中1例术后1月出现右腭部约1*0.5cm大小穿孔，与鼻腔相通；1例术后3个月出现右眼轻度复视，经保守治疗后恢复；1例术后7月复发；1例术后放疗，没有出现颜面中央区毁容的洞穿性空洞。
结论
后外侧手术入路其方法可行，是一种确有临床应用价值的手术入路，与现今各种入路相比，具有下列的优点：①术野暴露更充分；②切口相对隐蔽、颜面中央区可见疤痕减少；③切口下方径路稍加改变，即可在同一术野完成选择性颈廓清及上颌骨的修复重建；④理论上该入路可减少围手术期放疗内侧切口（Weber-Fergusson切口）颜面中央区毁容的洞穿性空洞事件的发生。但同时存在比传统内侧入路创伤较大的缺点。本入路丰富和发展了上颌骨切除术的手术入路，为上颌骨切除术患者手术入路更加个性化的选择提供了多样化的备选方案。
Background
At present, there are disadvantages and advantages of all kinds of approaches during themaxilla resection, most of which have different problems after surgery, such as impediment inmastication, speaking and deglutition, in particular the bad influence of appearance. Besides,during the radiotherapy of traditional interior incision perioperation, holes appear. In order todecrease the scar of skin tissue left after surgery and the possible occurrence of disfigured holesemerged during the radiotherapy of traditional interior incision perioperative period and promotepatient’s life quality, it is inevitable and necessary to develop and initiate a new kind of approachthat is more suitable for the maxillectomy.
Objective
According to the anatomy characteristics of maxilla and skin tissue, posterior lateral approachof maxilla resection is designed and set forth. From the clinical experience, premiercomprehensive evaluation will be made to this approach.
Method
On the basis of the analysis and comments of the current approach in accordance withdesigning principles of the head and neck’s surgery approach, a new approach of maxillaresection is developed, which starts from angulus oculi medialis, then inferior lower eyelidinferior，anterior ansa capitis, hair boundary, anterior antilobium, lower earlobe, posteriorinferior angulus mandibulae, then ends in the lower limb of mandibula. In this article, the clinical materials of 8 patients who have come through the maxillectomy of malignancy in this approachwill be reviewed and analyzed and a premier clinical conclusion will be made.
Result
None of the patients die in the perioperation. The surgery incision heals up quite well in thefirst period, the scar left on the face after operation is apparently lessened; the situation of facialsubsiding remains and the eyesight of those with eyeballs are good. In one case, a hole of about1*0.5cm connected with the nasal cavity appears in the right palate after one month of thesurgery. In another case, the right eye of the patient has slight diplopia problem after 3 months,which, though, has been cure after conservative treatment. In another case, it recrudesces after 7months.
Conclusion
Posterior lateral approach of maxilla resection works with its clinical operation values.Compared with the current approaches, it distinguished itself from the others from several aspect,such as larger view of surgery operation, lessened scars left on the face for its hidden surgeryposition, easier reconstruction of maxilla and optional radical neck dissection in the sameoperation view when the lower-part incision approach is changed a bit and theoretical decreaseof the disfigured holes’appearance in the central facial part of the interior incision inperioperation. However, it has disadvantages like significant wound left. This approach enrichesand develops the approachs of the maxillectomy, providing various operational choice forpatients that need maxilla resection more personally.
引文
[1]孙坚.上颌骨的缺损重建与修复.口腔颌面外科杂志,2005,15( 1):5-8.
[2] Muzaffar AR, Adams WP, Hartog JM, et al Maxillary Reconstruct ion: Functional andAesthetic Considerations. Plastic and reconstruct ion surgery, 1999, 104 ( 7 ): 3172-2184.
[3] Gregory RP, Greggory ET, Arthur OR. Prosthodontic principles in the framework design ofmaxillary obturator prostheses. The Journal Of Prosthetic Dentistry, 2005, 93(5):405- 411.
[4]张洁,杨洁,黄罡,等.钛支架式赝覆体在一侧上颌骨缺损修复中的应用.口腔颌面修复学杂志,2008,9(4):277- 279.
[5]牛学刚,赵铱民.上颌骨缺损的种植赝复体修复治疗.国际口腔医学杂志,2006,33( 4) : 306-308.
[6]李军,孙坚,马洪涛.个体化钛支架在构筑颌骨三维形态中的应用.口腔颌面外科杂志,2003,13( 1 ):17- 20.
[7]Michael MP, Donald AS. Otolaryngology[J]. W.B Saunders Company,Philadelphia,1973;4812489.
[8] Weber-Fergusson, Lawson W , Naidu RK. Combinedmedian mandibulotomy maxillectomy[J]. Arch Otolaryngol Head Neck Surg, 1990;116(5):596-599.
[9]黎介寿,吴孟超,姜四长.手术学·耳鼻咽喉科卷[M].人民军医出版社,北京,1994;3482349.
[10]王天铎,樊忠.实用耳鼻咽喉科学[M].山东科学技术出版社,1997;383-384.
[11] Eugene NM. Operative otolaryngology Head and Neck Surgery [ J ]. W. B.Saunders Company. Philadelphia, 1997; 100-107.
[12] Conley J , Price JC. Sublabial approach to the nasal and nasopharyngeal cavit- ies [J]. Am JSurg, 1979;138: 6152618.
[13] Sobol SM , Wood B, Levine H. An approach to total maxillectomy with emphasis onorbital preservation [J]. Plast Reconstr Surg, 1982; 69 (6):945.
[14]何琪懿,苏炳泽.周学军改良面中部掀翻进路行上颌骨切除术的临床探讨[J] .山东医，2009，49（36）：82-83
[15]孙文忠，徐志文，李纪辉，朱汉平，陆成华，邓鹏.面掀翻及改良半面掀翻联合鼻内镜技术在鼻科手术中的应用[J].临床耳鼻咽喉头颈外科杂志，2006，21（11）：504-506
[16]孙坚,李军,叶为民.上颌骨全切除术改良的手术径路[ J].口腔颌面外科杂志,2000,10( 3)：203-205
[17]王翰章.中华口腔科学[M].人民卫生出版社，2000；180-185
[18] Yousif NJ , Gosain A , Matloubl HS, etal The nasolabial fold: An anatomic and histologicreappraisal, Plast Reconstr Surg, 1994, 93: 60）
[19] Mitz V , Peyronie M .The superficial musculoaponeurotic system (SMAS) in the parotidand cheek area.Plast Reconstr Surg, 1976, 58: 80）
[20] Freilinger G, Gruber H, HappakW , et al1Surgical anatomy of them inicmuscle system andthe facial nerve: Impo trance for reconstructive and aesthetic surgery1P last Reconstr Surg,1987, 80: 686
[21]姜平.面部软组织层次结构的解剖学研究进展[J] .中国临床解剖学杂志, 1998,16(3): 279-283.
[22] Williams PL, Warwick R. Gray’s anatomy [M]. 36th ed. Edinburgh:Churchill Livingstone,1980:736-741.
[23] Spiro RH, Strong EW, Shah JP. Maxillectomy and its classification [J]. Head and NeckSurg, 1997，19(3):309
[24]承翼南，陈重光.上颌骨切除术临床分型的探讨[J].口腔医学，2003，23（1）：28
[25]温玉明.口腔颌面外科肿瘤学[M].北京:人民卫生出版社，2004：562
[26]周正炎.上颌骨切除术的整复及其综合治疗[J].口腔颌面外科杂志，1997，7（2）：124
[27]李云峰,李静平,何军.面部除皱术的应用解剖研究[J].齐齐哈尔医学院学报,2007,28（3）294-295），
[28]翟红宇.改良全面部除皱术[J].河北医药，2009，31（22）3100-3101
[29]黄选兆，汪吉宝，孔维佳.实用耳鼻喉咽喉头颈外科学[M] .北京:人民卫生出版社,2008: 248- 250.
[30]周树夏.手术学全集,口腔颌面外科卷[M].北京:人民军医出版社,2004: 324.
[31] Howard DJ, Lundvj. The role of midfacial degloving in modern rhinological practice[J] . JLaryngolOtol, 1999, 113: 885- 887.
[32]张代杰,魏奉才,王勇.面中掀翻术治疗上颌骨肿瘤[ J] .山东大学学报(医学版) , 2005, 43( 11 ) : 29-32.
[33]韩琳，孙庚林，吴炜，李克莉.经口进路行上颌骨切除术.[J].医科大学学报.2006.12(4).
[34] Brow ne JD. The mid facial degloving procedure for nasa,l sinus, and nasopharyngealtumors [ J ]. Otolaryngol Clin North Am, 2001, 34( 6 ): 1095-1104
[35] Krause GE, Jafek BW. A modification of the midface degloving techniqu e [ J].aryngoscope, 1999, 109( 11 ): 1781-1784.
[36]孔维佳.耳鼻咽喉头颈外科新进展[ M ] .北京:人民卫生出版社,2002: 400- 404.
[37] Carlos M. Rivera-Serrano, MD, Ramon Terre-Falcon, MD, Umamaheswar Duvvuri, MD,PhD.Combined approach for extensive maxillectomy technique and cadavericdissection[ J ].American J of Otolarngology，2010:1-5
[38]申庸凡.应用改良径路行上颌骨切除术4例[ J] .口腔医学研究，2007，23（3）：352-353
[1]黄选兆，汪吉宝，孔维佳.实用耳鼻喉咽喉头颈外科学[ M ] .北京:人民卫生出版社,2008: 248- 250.
[2]舒继红，蒋成义，韩跃锋，詹晓东.鼻侧切开术中泪道的处理方法[J] .中国耳鼻咽喉头颈外科，2005,12（10）：649-650.
[3]周树夏.手术学全集,口腔颌面外科卷[M] .北京:人民军医出版社, 2004: 324.
[4]黎介寿,吴孟超,姜四长.手术学·耳鼻咽喉科卷[M ].人民军医出版社,北京, 1994;3482349.
[5]王天铎,樊忠.实用耳鼻咽喉科学[M] .山东科学技术出版社, 1997; 383-384.
[6] Conley J , Price JC. Sublabial approach to the nasal and nasopharyngeal cavit- ies [J]. Am JSurg, 1979;138: 6152618.
[7] Howard DJ, Lundvj. The role of midfacial degloving in modern rhinological practice[J] . JLaryngolOtol, 1999, 113: 885- 887.
[8]张代杰,魏奉才,王勇.面中掀翻术治疗上颌骨肿瘤[ J] .山东大学学报(医学版) ,2005, 43( 11 ) : 29-32.
[9] Brow ne JD. The mid facial degloving procedure for nasa,l sinus, and nasopharyngealtumors [ J ]. Otolaryngol Clin North Am, 2001, 34( 6 ): 1095-1104
[10] Krause GE, Jafek BW. A modification of the midface degloving technique [J]. aryngoscope,1999, 109( 11 ): 1781-1784.
[11]孔维佳.耳鼻咽喉头颈外科新进展[ M ] .北京:人民卫生出版社,2002: 400- 404.
[12]何琪懿,苏炳泽.周学军改良面中部掀翻进路行上颌骨切除术的临床探讨[J] .山东医，2009，49（36）：82-83
[13]孙文忠，徐志文，李纪辉，朱汉平，陆成华，邓鹏.面掀翻及改良半面掀翻联合鼻内镜技术在鼻科手术中的应用[J].临床耳鼻咽喉头颈外科杂志，2006，21（11）：504-506
[14] Carlos M. Rivera-Serrano, MD, Ramon Terre-Falcon, MD, Umamaheswar Duvvuri, MD,PhD.Combined approach for extensive maxillectomy:technique and cadavericdissection[ J ].American J of Otolarngology，2010 1-5
[15]申庸凡.应用改良径路行上颌骨切除术4例[ J] .口腔医学研究，2007，23（3）：352-353
[16]孙坚,李军,叶为民.上颌骨全切除术改良的手术径路[ J] .口腔颌面外科杂志,2000, 10 ( 3)：203-205
[17] Sun J, Shen Y, Weng YQ, Li J, Zhang ZY. Lateral lip-splitting approach for total andsubtotal maxillectomy. J Oral Maxillofac Surg. 2009 Jun;67(6):1197-205.
[2] Muzaffar AR, Adams WP, Hartog JM, et al Maxillary Reconstruct ion: Functional andAesthetic Considerations. Plastic and reconstruct ion surgery, 1999, 104 ( 7 ): 3172-2184.
[3] Gregory RP, Greggory ET, Arthur OR. Prosthodontic principles in the framework design ofmaxillary obturator prostheses. The Journal Of Prosthetic Dentistry, 2005, 93(5):405- 411.
[4]张洁,杨洁,黄罡,等.钛支架式赝覆体在一侧上颌骨缺损修复中的应用.口腔颌面修复学杂志,2008,9(4):277- 279.
[5]牛学刚,赵铱民.上颌骨缺损的种植赝复体修复治疗.国际口腔医学杂志,2006,33( 4) : 306-308.
[6]李军,孙坚,马洪涛.个体化钛支架在构筑颌骨三维形态中的应用.口腔颌面外科杂志,2003,13( 1 ):17- 20.
[7]Michael MP, Donald AS. Otolaryngology[J]. W.B Saunders Company,Philadelphia,1973;4812489.
[8] Weber-Fergusson, Lawson W , Naidu RK. Combinedmedian mandibulotomy maxillectomy[J]. Arch Otolaryngol Head Neck Surg, 1990;116(5):596-599.
[9]黎介寿,吴孟超,姜四长.手术学·耳鼻咽喉科卷[M].人民军医出版社,北京,1994;3482349.
[10]王天铎,樊忠.实用耳鼻咽喉科学[M].山东科学技术出版社,1997;383-384.
[11] Eugene NM. Operative otolaryngology Head and Neck Surgery [ J ]. W. B.Saunders Company. Philadelphia, 1997; 100-107.
[12] Conley J , Price JC. Sublabial approach to the nasal and nasopharyngeal cavit- ies [J]. Am JSurg, 1979;138: 6152618.
[13] Sobol SM , Wood B, Levine H. An approach to total maxillectomy with emphasis onorbital preservation [J]. Plast Reconstr Surg, 1982; 69 (6):945.
[14]何琪懿,苏炳泽.周学军改良面中部掀翻进路行上颌骨切除术的临床探讨[J] .山东医，2009，49（36）：82-83
[15]孙文忠，徐志文，李纪辉，朱汉平，陆成华，邓鹏.面掀翻及改良半面掀翻联合鼻内镜技术在鼻科手术中的应用[J].临床耳鼻咽喉头颈外科杂志，2006，21（11）：504-506
[16]孙坚,李军,叶为民.上颌骨全切除术改良的手术径路[ J].口腔颌面外科杂志,2000,10( 3)：203-205
[17]王翰章.中华口腔科学[M].人民卫生出版社，2000；180-185
[18] Yousif NJ , Gosain A , Matloubl HS, etal The nasolabial fold: An anatomic and histologicreappraisal, Plast Reconstr Surg, 1994, 93: 60）
[19] Mitz V , Peyronie M .The superficial musculoaponeurotic system (SMAS) in the parotidand cheek area.Plast Reconstr Surg, 1976, 58: 80）
[20] Freilinger G, Gruber H, HappakW , et al1Surgical anatomy of them inicmuscle system andthe facial nerve: Impo trance for reconstructive and aesthetic surgery1P last Reconstr Surg,1987, 80: 686
[21]姜平.面部软组织层次结构的解剖学研究进展[J] .中国临床解剖学杂志, 1998,16(3): 279-283.
[22] Williams PL, Warwick R. Gray’s anatomy [M]. 36th ed. Edinburgh:Churchill Livingstone,1980:736-741.
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