摘要
目的：进行头长肌的解剖学研究，为头长肌瓣的设计和手术操作提供理论基础；并介绍头长肌瓣移植缩小腭咽腔、岛状颊肌粘膜瓣移植延长软腭、自体颗粒脂肪注射移植增高咽后壁矫正腭咽闭合不全的临床实践。
方法：对14侧头长肌标本进行解剖学研究，观测头长肌的位置、形态、大小、毗邻关系、血液供应、神经支配；设计头长肌瓣，蒂可在上，也可在下；并应用双侧上蒂头长肌瓣移植缩小腭咽腔术修复腭裂4例。应用蒂在后的血管神经蒂岛状颊肌粘膜瓣延长软腭修复腭裂11例、矫正腭咽闭合不全22例。应用自体颗粒脂肪移植增高咽后壁治疗腭裂5例，腭咽闭合不全患者5例。
结果：应用上蒂头长肌瓣移植于腭咽部缩小腭咽腔术共治疗4例患者；3例患者手术成功，无感染、血肿、颈交感神经干损伤、睡眠呼吸暂停等并发症出现；1例头长肌瓣移植术后出现悬雍垂及软腭复裂，当即行单侧岛状颊肌粘膜瓣移植修复之，之后又出现软腭后部分复裂，一年后行软腭复裂修复术后而愈。2例患者配合术后随访，一例术后3．5月随访，另一例随访2次，分别为术后2．5年和4．5年，2例随访结果均显示软腭、咽壁活动度较前增加，腭咽闭合不全率减小，腭咽闭合功能改善明显。
应用岛状颊肌粘膜瓣延长软腭术共治疗33例患者，术后共随访21例，其中腭裂10例、腭咽闭合不全11例，随访时间2月～4．5年。除2例患者由于术后岛状颊肌粘膜瓣尖端部分坏死，出现软腭腭瘘，因瘘口较小(直径均小于2mm)，未行腭瘘修复术；其余患者术后均恢复良好，无切口裂开、颊瓣坏死、腮腺导管损伤或阻塞、面神经损伤，无张口受限、瘢痕挛缩及咀嚼障碍等严重并发症发生。随访结果显示患者语音清晰度增加、鼻音减轻，软腭延长明显、腭咽闭合不全率减小、腭咽闭合功能改善明显。
应用自体脂肪颗粒移植增高咽后壁术共治疗患者10例，全部随访，随访时间2月～12月。术后无感染、血肿、睡眠呼吸暂停等并发症。除1例患者移植的脂肪量少而致咽后壁增高效果不明显外，其余患者均达到了增高咽后壁的效果。
结论：头长肌瓣血运好，易成活，具有神经支配移植后不萎缩，具有运动功能，可以起到缩小腭咽腔、重建或加强腭咽括约肌功能，适用于软腭和咽壁运动度不好、咽腔宽大的患者。上蒂头长肌瓣也可用于软腭缺损的修复再造、颅底的修复等；下蒂头长肌瓣可用于口咽部、舌根、舌体后部缺损等的修复再造。
蒂在后的血管神经蒂岛状颊肌粘膜瓣，血运好，易成活，由于具有神经支配瓣内肌肉不萎缩，瓣具有一定的厚度和硬度，可以阻挡软腭向前回缩，术后软愕延长显著,远期效果持久恒定。术后早期不需配戴牙垫,不需要施行二期断蒂术,腭部创伤小,避免或减小对上颌骨及牙弓的生长发育的影响。适合于软腭短小、软组织发育不良、裂隙大的腭裂和腭咽闭合不全患者。
自体颗粒脂肪取材容易,来源丰富,无排异反应,是良好的组织填充材料;自体颗粒脂肪移植增高咽后壁明显,可单独应用于腭咽间隙小于5mm的腭咽闭合不全患者;也可以联合其它手术方法应用于咽后壁运动不良的腭裂及腭咽闭合不全患者的患者的治疗。
Objective:Perform anatomic study on longus capitis and provide theoretical basis for the design and operative procedure of longus capitis muscle flaps.Introduce the clinical application of longus capitis muscle flaps,buccinator musculomucosal island flaps and posterior pharyngeal wall augmentation with autologous fat for cleft palate or velopharyneeal insufficiency.
Methods:Perform anatomical investigations in fourteen sides cadavers.Observe the position,morphology,size,adjaceney,blood supply.nerve inner- vations of longus capitis.Design longus capitis muscle flaps pedicled superiorly or inferiorly.Transplantation of longus capitis muscle flaps were performed in four cleft palate patients to narrow velopharyngeal space and reconstruct the velopharyngeal sphincter.Transplantation of buccinator musculomucosal island flaps were performed in eleven cleft palate patients and twenty-two velopharyngeal insufficiency patients. Posterior pharyngeal wall augmentation with autologous fat were performed in four cleft palate patients and six velopharyngeal insufficiency patients.
Results:Four cleft palate patients were treated with longus capitis muscle flaps.Three patients got satisfactory results without complications such as infection.hematoma.cervical sympathetic trunk injury and obstructive sleep apnea.One patient got cleft relapse at uvula and soft palate.The cleft was repaired with a transferred buccinator musculomucosal island flap immediately,but a cleft reccurred at the soft palate and it healed after another soft palate repair performed one year later.Two patients followed up and both got definitive increases in movement of soft palate and pharyngeal wall and got significant enhancement in velopharyngeal closure function.
Thirty-three patients were treated with buccinator musculomucosal island flaps.Twenty-one patients followed up.Two got fistulae at the soft palate because of partial necrosis at the end of buccinator musculomucosal flaps but no further treatment were demanded because the diameter of fistulae were both no more than two millimeter.The other patients had no severe complications such as facial nerves injuries.limitation in mouth opening or mastication difficulty.The follow-up results shew that the patients got definitive decrease of hypernasality and increases in speech articulation.length of soft palate,and got significant enhancement in velopharyngeal closure function.
Ten patients were treated with posterior pharyngeal wall augmentation with autologous fat.All the ten patients follwed up.Nine the patients got satisfactory results in thicking posterior pharyngeal wall without complications such as infection,hematoma,and obstructive sleep apnea.One patient had not obvious result because of less volume of transpanted fat.
Conclusions:The longus capitis muscle flaps are rich in blood supply,easily survived and have movement function to narrow velopharyngeal "space and reconstruct the velopharyngeal sphincter.The longus capitis muscle flaps pedicled superiorly are designed for cleft palate or velopharyngeal insufficiency with large velopharyngeal space or weak mobility of pharyngeal wall and soft palate.The longus capitis muscle flaps pedicled superiorly are also suitable to repair defect of soft palate and skull base.The longus capitis muscle flaps pedicled inferiorly are suitable to repair the defect of pars oralis pharyngis,tongue base and posterior portion of tongue body.
The buccinator musculomucosal island flaps pedicled posteriorly are rich in blood supply,easily survived and can prolong the soft palate significantly,no need for wearing teeth pad or a second stage operation of pedicle division.This method is designed for cleft palate or velopharyngeal insufficiency with large cleft and short soft palate but with good mobility of pharyngeal wall.
Autologous fat is a good kind of filling material because it has rich resources,can be obtained easily and has no rejection.Posterior wall augmentation with autologous fat can result in thickening and forwards-moved posterior wall.This method is suitable for velopharyngeal insufficiency with small velopharyngeal gap no more than five millimeter,and it's also suitable for larger gap combined with other conventional operation.
引文
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