Forearm ulnar flap transplantation for mouth floor reconstruction

Anterior ulnar flap transplantation for reconstruction of tongue defect after tongue cancer resection. Before the 1970s, simple direct sutures were used to achieve the purpose of eliminating wounds. The tongue has been used to restore the tongue function after tongue cancer resection, but it is inconvenient and not popular because it is used for assisting eating and language. By the end of the 1970s, due to the continuous development of maxillofacial surgery, especially microsurgery, it opened up a new way for the reconstruction of tongue cancer after resection. In 1975, the Japanese hero of Tian Dai proposed to reconstruct the base of the tongue with a sternocleidomastoid composite flap. In 1977, Lesh proposed a pedicled thoracic triangle flap to repair the defects of the tongue, the mouth and the lower jaw. In 1978, Matutic reported the use of a chest lock. Reconstruction of the mastoid muscle plus the frontal flap for the tongue. In 1980, Wang Hongshi and others proposed the reconstruction of the tongue with the sublingual muscle flap. All of the above are tongue reconstruction with regional flap pedicle transfer. The advantage is that the operation is simpler than the free flap, and the survival rate of the flap is higher. It is a kind of tongue re-establishment method used in clinical practice. However, its shortcoming is that tongue cancer tends to metastasize early, and regional flaps are sometimes difficult to select. At the same time, the elimination of the donor area has to be designed separately. It often causes difficulties in surgery, and also causes more trauma and more bleeding. The patient's recovery from health also has an impact. Due to the progress of microsurgery, in 1977, Panje used the free inguinal flap to repair the soft tissue defect in the mouth. In 2 cases, the repair of 2 cases of tongue excision was successful. In 1979, Brien et al applied the defect of the foot to repair the defect of the mouth. In 1980, the Longzheng Hospital first successfully reconstructed the shape and function of the tongue with the forearm free flap transplantation. The flap has a high survival rate, a large blood vessel, and an easy anastomosis. The flap itself has a good texture, a moderate thickness, and is easy to shape. It is an ideal free flap for repairing and reconstructing the tongue defect. There are many ways to reconstruct the tongue. In addition to the above, there are the medial flap, the latissimus dorsi flap, the medial flap of the upper arm and the scapular flap; the pedicle flap and the pectoralis major and frontal flaps. You can choose according to the actual situation and possibility of the defect, as well as the experience of the surgeon. Treating diseases: tongue cancer Indication Forearm ulnar flap transplantation endoscopic reconstruction is applicable to: 1. The patient is in good general condition and can undergo this operation. 2. Bottom of the mouth, part of the tongue and tongue tie. Contraindications 1. The brachial artery blood supply is not suitable for this operation. 2. Patients with scars on the ulnar side of the forearm should not cut the flap. Preoperative preparation 1. Surgical microscope and microvascular surgical instruments. The surgical instruments are prepared in two sets. 2. Wash the mouth with 1:5000 furancillin solution and 3% hydrogen peroxide solution 3 days before surgery. 1 day before surgery, oral treatment. 3. Ultrasound Doppler detection of donor and recipient vessels. 4. With fresh whole blood 600 ~ 900ml. 5% low molecular weight dextran 500ml for intraoperative use. Used in heparin surgery. 5. Clean the enema before going to bed 1 day before surgery. 6. Place the catheter on the morning of the operation. 7. The skin preparation and preoperative medication of the surgical site in the donor and recipient areas are the same as the general surgery. Surgical procedure The operation was divided into two simultaneous operations. For example, the squamous cell carcinoma in front of the mouth is invaded by the tongue ligament and part of the tongue. Lesion removal 1 Incision design: 1.5cm normal mucosa outside the tumor boundary and bilateral incision lymphatic dissection required to design the incision, methylene blue line. 2 lesion resection: the middle of the lower lip to the infraorbital, median gingival and vestibular mucosa full-thickness incision, exposing the labial surface of the mandibular region, the sacral end of the incision extended to the lower jaw. Conventional bilateral supraorbital lymphadenectomy, but need to retain 1 lateral artery and external jugular vein for anastomosis. The square osteotomy of the lower edge of the mandible is preserved or the teeth of the affected area are removed to flatten the alveolar process. The lesion was excised 1.5 cm along the outer edge of the lesion, and the ruptured end of the genioglossus and genioglossus was fixed in the sacral region through the suture, preventing the tongue from falling and stopping bleeding. 2. Forearm ulnar flap excision 1 flap design: use the methylene blue to draw the ulnar artery and the direction of the vein, and design the diamond flap around the two vessels. 2 flap removal: the tourniquet on the upper arm after forearm blood transfusion. The skin is designed along the flap to cut the skin, subcutaneously to the deep fascia and the sarcolemma, and the lower ulnar artery between the ulnar wrist flexor and the longissimus dorsi is ligated and ligated in the lower boundary of the flap (the wrist side). The suture is sutured under the skin flap to prevent the ulnar artery from detaching from the flap. Care is taken to protect the ulnar nerve located deep in the ulnar artery. Ligation and cutting of the main vein and suturing and fixing it under the skin flap. The fixed line of the two blood vessels was pulled, the flap was sharply dissected, the blood vessel was dissected, the blood vessel was ligated, and the branch was ligated to the muscle, and the flap was completely released and returned to the original position. At the upper end of the flap (elbow side), the skin is cut along the ulnar artery and the skin is subcutaneously removed. The longissimus dorsi and the ulnar wrist flexor are respectively removed from the ulnar side, and the length of the ulnar artery is determined by the need of the area. Separate the essential veins. The area to be received is ready to cut off the vascular pedicle. 3. Flap transplantation endoscopic reconstruction 1 vascular anastomosis: after the flap was broken, it was transplanted into the defect area of the mouth. At the same time, another operation was performed to repair the forearm wound with a full-thickness skin patch of the lateral chest or lower abdomen or a skin flap with a subcutaneous vascular network. The ulnar artery and the facial artery, the superior vein and the external jugular vein were anastomosed at the lower end of the surgical microscope (×6) with a 9-0 non-invasive suture. Two-port reconstruction: the a-valve of the diamond-shaped flap and the tongue and abdomen were sutured to restore the tongue ligament and the shape of the tongue and abdomen. The b-valve repaired the alveolar ridge, and the c and d flaps repaired the bilateral sac defect. 4. suture the wound and place the negative pressure drainage tube The endothelium flap, the lower lip, and the submandibular and infraorbital wounds were sutured in layers with a 1-0 suture. Place a vacuum suction tube. complication 1. Anastomotic vasospasm, vascular pedicle twist, anastomotic leakage, hematoma formation and vascular embolization. 2. Postoperative wound infection. Oral contamination surgery, long time, trauma, and more ligatures, often cause infection after surgery. 3. For the first two reasons, it may cause partial or even necrosis of the flap. 4. Forearm donor site wound hemostasis is not complete, postoperative hematoma formation, can lead to partial or even necrosis of the skin graft. 5. When the forearm flap is cut, the level is not properly grasped, the tendon is exposed, and the tendon adheres to the tendon after skin grafting, which affects the function of the forearm.