Application Of Three Kinds Of Perforator Flaps In Reconstruction Of Oral And Maxillofacial Soft Tissue Defects

Objective: The objective is to conduct retrospective analysis and to report typical cases,exploring the effect of anterolateral thigh perforator flap,medial sural artery perforator flap,and thoracodorsal artery perforator flap in reconstruction of oral and maxillofacial carcinoma solft tissue defects following radical resection of malignant tumor.Methods: Data of 79 patients with oral and maxillofacial malignant tumor were collected from September 2016 to March 2019,while all of the patients were from the second team Oral and Maxillofacial Surgery of The First Affiliated Hospital of Fujian Medical University.There are 34 cases of tongue carcinoma,21 cases of buccal carcinoma,9 cases of oropharyngeal carcinoma,7 cases of oral floor carcinoma,4 cases of maxillary sinus carcinoma,and 4 cases of palatal carcinoma inside.To repair the defect after tumor resection,we implemented anterolateral thigh perforator flaps for 66 cases,medial sural artery perforators flaps for 5 cases,and thoracodorsal artery perforator flaps for 8 cases.The sizes of the flap and the lengths of the pedicle were recorded during the operation.Moreover,the situation of the flap survival and the primary wound healing were observed after operation,and the incidence rate of postoperative complications was counted.Patients were then followed up for 12 months to investigate the individual oral function,donor site motor function,flap morphological changes,and patients’ satisfaction with the donor and recipient site.Results: The reconstructive surgery was successfully completed for all the 79 patients.Sizes of ALTPF,MSAPF,and TDAPF group were 5cm×6cm-8cm×20cm,6cm×3cm-6cm×4cm,and 6cm×8cm-15cm×9cm,respectively.The length of vascular pedicle was 6-12 cm in ALTPF group,6-9cm in MSAPF group,and 7-9cm in TDAPF group.Among the 66 cases of ALTPF,three cases had flap crisis.Two failed flaps were rescued successfully,and the other was repaired with radial forearm free flap.The overall success rate was 98.48%.Among five cases of MSAPF,two cases failed to rescue after flaps crisis.The total success rate was 60%.As for TDAPF group which has eight cases,all the flaps survived with the success rate of 100%.One patient in ALTPF group had skin necrosis due to excessive wound tension in the donor site,and it was healed after wound dressing.The donor sites of the remaining patients were free of complications,with good function,ideal aesthetics,and high satisfaction level.Conclusion: Free anterolateral thigh perforator flap,medial sural artery perforator flap and thoracodorsal artery perforator flap have their own advantages and disadvantages in the reconstruction of oral and maxillofacial soft tissue defect.ALTPF is widely applicable and can be applied to the repair and reconstruction of most middle and large oral and maxillofacial soft tissue defects.MSAPF is thin and soft,suitable for mouth,cheek and tongue.TDAPF is more suitable for large oral and maxillofacial soft tissue defects,especially those with high requirements for scar concealment in donor areas.For individual reconstruction of the oral and maxillofacial soft tissue defect,the choice of perforator flap according to the indication and feature of flaps is crucial for the restoration of patients’ function and aesthetics after operation.Objective: The objective of this study is to evaluate and compare the accuracy between three imaging techniques: HHD,CDU and CTA in preoperative perforator positioning of the ALTPF.Methods: 15 patients with oral carcinoma and soft tissue defects reconstruction by ALTPF from May 2018 to February 2019 were involved in this study.All patients received preoperative HHD,CDU,and CTA examination to determine the location of perforator derived from descending branch of the lateral circumflex femoral artery.The midpoint of the connecting line between the anterior superior spine and the lateral edge of patella was labeled as point O,and then the connecting line between the anterior superior spine and the lateral edge of patella was regarded as the Y-axis.The perpendicular line of the Yaxis that passes through the point O was set as the X-axis.The number of perforator as well as their coordinates in the coordinate system were measured and recorded.During the surgery,the perforator of the flap was examined,and the number of perforator vessels,the coordinates of the actual perforator position,as well as the thickness of the flap were recorded.The amount and the position of perforators detected during the operation were compared with the results obtained from the three different localization methods before operation.Finally,the accuracy of these three localization methods were evaluated by calculating their sensitivity(The number of perforators accurately positioned by localization methods/the number of perforators actually detected during surgery),positive predictive value(the number of perforators accurately positioned by localization methods /the number of perforators actually positioned by localization methods),and false positive rate(the number of perforators with a distance more than 2.0cm by localization methods compared with surgery+the number of perforators which preoperatively positioned but not found during surgery/ the number of perforators actually positioned by localization methods).Results: A total of 24 perforators were found in the operation,and 1.6(1-3)were found in each flap on average,with 3 in 2 cases,2 in 3 cases,and 1 in 7 cases.The sensitivity of HHD,CDU and CTA were 87.5%,87.5%,and100%,respectively.The positive predictive values were 77.78%,91.3%,and 96% respectively.The false positive rates were 22.22%,8.7%,and 4% respectively.Among the three methods,CTA has the highest sensitivity and positive predictive value,and the lowest false positive rate.The sensitivity of HHD was the same as that of CDU,but HHD has a lower positive predictive value and a higher false positive rate comparing with CDU.Conclusion: Three kinds of preoperative detection methods can all be used to locate the perforator vessels accurately.HHD is easy to operate and is time saving,while CDU can provide dynamic information of blood vessels.CTA is more accurate than the other two methods,but it is time-consuming and expensive.The combination of different examination methods is helpful to improve the accuracy of preoperative positioning of perforator vessels.