| To reconstruct the oral and maxillofacial tissue defection or deformity caused by tumor resection, burns and other reasons, surgeons always use the pedicle or free tissue transfer flap. The tissue flaps we commonly use in clinical contain antebrachial flap, pectoralis major myocutaneous flap, latissimus dorsi myocutaneous flap, rectus abdominis myocutaneous flap and anterolateral thigh flap, etc. These tissue flaps all have deficiencies in different degrees. The supraclavicular artery island flap has the similar color and texture of the face and neck, and its thickness is moderate, preparation is simple with less complications. On account of advantages above, much attention has paid on this flap in recent years. Though there were lots of studies and reports in foreign literatures about the anatomy of supraclavicular artery flap, the results were not the same. Recently some domestic researchers focused on the study of the superficial branch of the transverse cervical artery, and its clinical application in tongue defection, but the study on nutrient vessel of the flap which is the branch of the superficial branch of the transverse cervical artery has not been discussed deeply. There was no domestic related research reported. Based on the cadaver specimen of Chinese adult, this study reported the blood vessels distribution of the supraclavicular artery island flap, and operated on the cadaver specimen to have an intimate knowledge of the flap preparation. Also in this study, we constructed the defection after tongue cancer resection in clinical, to providing basic operation skills of the tissue flap using in the oral and maxillofacial defects or deformity.Objective:To understand the blood vessels distribution of the supraclavicular artery island flap, and finish the cadaver specimen simulation operation based on the outcome of the anatomy study.Methods:Choose10adult cadaver specimen cases20sides (6men cases and4women cases), fixed at least2months in formalin as our specimen. Design the cut line which extend inside to the sternum line, down to the fourth ribs level and outside to the armpit line, and cut the skin along the line, turned the tissue flap from the surface of the pectoralis major muscle to the superior margin of the clavicle. Then get rid of the clavicle and the inside8cm segment of the first rib, exposing the subclavian artery. Perfuse the intubation through the subclavian artery with lamps-gelatin solution. Two hours later, dissect the specimen and observe the branch of the thyrocervical trunk and the branches, starting positions, pathway, and the diameters of the transverse cervical artery and the supraclavicular artery, and also observe the concomitant vein. Carry out the data processing with the SPSS11.0software, blood vessels length and pipe diameter data were recorded in the form of mean±standard deviation, and compared left and right side length and diameter data of blood vessels through t-test. If t<0.05, we can conclude that there exists a statistically significant difference. Undertake the simulation operations in four sides of two specimens, preparing the supraclavicular flaps.Results:In the10cases20sides’specimens, transverse cervical artery all appeared, and14sides (70%) originated from thyrocervical trunk, the left6sides (30%) originated directly from the subclavian artery. After the transverse cervical artery originated from the thyrocervical trunk or the subclavian artery, it extended to the lateral and back2-3cm above the clavicle, going through the deep part of the sternocleidomastoid muscle, the internal jugular vein and the omohyoid muscle, and the superficial part of the scalenus muscle, phrenic nerve and brachial plexus. Above internal1/3of clavicle, transverse cervical artery diverged out cervical cutaneous branches going down and forward. The cutaneous branches went across the collarbone and had small braches dispersed to the supraclavicular fossa, the skin and subcutaneous tissue of the protothorax. Above the1/3of the clavicle, at the exterior edge of the trapezius muscle, the transverse cervical artery diverged out the deep branch and the superficial branch. The deep branch went down, back and inside to the deep trapezius muscle, the superficial branch went up, outside and back to the1-2cm exterior edge of the trapezius muscle, then the supraclavicular artery was diverged. Supraclavicular artery was erupted from the transverse cervical artery, then went backward, down and outside at the anterior border of the trapezius muscle and the superficial of the accessory nerve, across the superficial of the trapezius muscle and the acromial end of clavicle, going along the superficial surface of the deltoid fascia, and gradually diverged small branches through the deep fascia which providing nutrition to the shoulder skin and subcutaneous tissue. Supraclavicular artery also has branches into the trapezius muscle in the way. The starting point of transverse cervical artery to the starting point of supraclavicular artery was4.23±0.48cm (the left4.25±0.52cm, the right4.21±0.46cm). The starting point of supraclavicular artery to the branch through the deep fascia was3.84±0.34cm (the left3.85±0.34cm, the right3.82±0.36cm). The starting point of the supraclavicular artery to the branch issued in the deep fascia was7.87±0.19cm (the left7.89±0.18, the right7.85±0.21). The diameter of the transverse cervical artery at the starting point was2.79■0.20mm (the left2.79±0.19mm, the right2.78±0.21mm). The diameter of the supraclavicular artery at the starting point was1.16±0.09mm (the left1.17±0.09mm, the right1.15±0.10mm). The data of the both sides had no significant statistical significance. There were two accompany veins with the supraclavicular artery which flowing into the external jugular vein. The running course of the transverse cervical artery and supraclavicular artery:arteries went along after the lower sternocleidomastoid and then went backward and outside above2-3cm of the clavicle, then crossed above1-2cm of the clavicle and the exterior edge of the trapezius, at last went over the acromial end of clavicle and the surface of the deltoid muscle. According to the transverse cervical artery and supraclavicular artery, mark line along the arteries, and then design a vascular pedicle in the range of2cm up and down areas. Firstly cut the skin from the distant part of the flap skin, subcutaneous tissue, deltoid muscle and fascia, to the surface of the deltoid muscle, and then turned up the organization flap. In the proximal flap, find the supraclavicular artery and vein through scenography. Mark the cut line and the vessel at the proximate of the flap, and then cut the skin and subcutaneous tissue to the plastyma muscles surface, dissecting along the blood vessel line, leaving muscular fasciae of both sides about4cm. In the procedure, we cut the deep branch of the transverse cervical artery, and dissected to the starting point of the transverse cervical artery, paying attention to keep the external jugular vein. Keeping the starting point of transverse cervical artery and external jugular vein as the axis point, transfer the tissue flap to the head and neck defect area. If the flap was transplanted as a free tissue flap, the transverse cervical artery should be cut off at the starting point, and at the same time the external jugular artery or vein should be cut off to be the vascular anastomosis.Conclusion:this research shows that the supraclavicular artery was diverged from the superficial branch of the transverse cervical artery, and the two company veins drained into the transverse cervical vein and the external jugular vein. And Lamberty’s research shows that93%of the supraclavicular arteries were diverged from the transverse cervical vein, and the left7%were from the suprascapular artery. Pallua researched on19cases38sides of cadaver specimen, and concluded that all the supraclavicular arteries were from transverse cervical artery with two company veins, one was company with clavicle draining into the transverse cervical vein, and the other one was the branch of the external jugular vein. Vinh’s study of20cases40sides of the cadaver shows that supraclavicular artery was from the transverse cervical artery with two company veins draining into the transverse cervical vein. The research of Abe with65cases130sides of Japanese cadavers supraclavicular area vascular anatomy studies show that only104sides (80%) have supraclavicular artery,72%of them were not through the clavicle or acromion but to the neck, and company vein draining into the external jugular vein. This research shows that:the cervical cutaneous branches were diverged from the transverse cervical artery above the inside1/3part of clavicle, and above the middle1/3part of clavicle, the transverse cervical artery divided into deep and superficial branches. The supraclavicular artery originated from the superficial branch of the transverse cervical artery. And Vinh etc research shows that:90%of the supraclavicular artery was diverged from transverse cervical artery above the1/3part of the clavicle, and the left10%was diverged from the transverse cervical artery above the lateral1/3of the clavicle. This research shows that:the starting point of the transverse cervical artery to point of the supraclavicular artery branch issued in the deep fascia was about7.9cm, which shows that supraclavicular artery island flap can be prepared with longer vascular pedicle, reaching to the surface defect in the central facial area. The diameter of the transverse cervical artery at the starting point was about2.7mm and the outside diameter of the supraclavicular artery at the starting point was about1.1mm, which shows that the supraclavicular artery island flap can be used as a free tissue flap with the transverse cervical artery as the anastomosis, and the supraclavicular artery was short and thin, which cannot be used as the anastomosis. Therefore, as a pedicle transfer flap, the supraclavicular artery island flap can be used to reconstruct the buccal, parotideomasseteric region, tongue, mouth floor area, neck and chest tissue defection; and on the other hand, as a free transfer flap, it can be used to repair tissue defection of any parts.Objective:To study the application of the supraclavicular artery island flap to repair the defect of the feasibility of the tongue.Methods:Choose three patients aged48-62(two male and one female, and the average age is54.6) in department of stomatology of Nanjing General Hospital of Nanjing Military Command during March to July,2011. Two of their UICC clinical stage were T2N0M0, and the other one was T2N1M0. No radiotherapy or chemotherapy was taken for therapy preoperative. Under the general anesthesia, we firstly finished the tongue-neck association radical operation. The pedicle supraclavicular artery island flap was then transferred for repairing, with the area of (4cm×6cm) -(5cm×10cm), and4.3cmx7.6cm on average. The donor side can be sutured up directly. The surgical method:firstly finished the neck dissection and tumor resection, and during the operation, paid attention to the anatomic structure and protect the transverse cervical artery and vein, and the external jugular vein. According to the defect size, design a spindle flap upper the surface of the clavicle, the shoulder and the deltoid muscle. According to the transverse cervical artery and supraclavicular artery, mark line along the arteries, and then design a vascular pedicle in the range of2cm up and down areas. Firstly cut the skin from the distant part of the flap skin, subcutaneous tissue, deltoid muscle and fascia, to the surface of the deltoid muscle, and then turned up the organization flap. In the proximal flap, find the supraclavicular artery and vein through scenography. Mark the cut line and the vessel at the proximate of the flap, and then cut the skin and subcutaneous tissue to the plastyma muscles surface, dissecting along the blood vessel line, leaving muscular fasciae of both sides about4cm. In the procedure, we cut the deep branch of the transverse cervical artery, and dissected to the starting point of the transverse cervical artery, paying attention to keep the external jugular vein. Keeping the starting point of the transverse cervical artery and the proximal part of the external jugular vein as axis points, transferred the tissue flap to the defection areas, and then continuously sutured the surrounding edge and the flap. Through the follow-up, observe the tongue shape, function recovery and donor side complication, then valuate the effect of restoration.Results:Followed up one to six months after the operation, all parts of the flap completely survived. Tongue shape recuperated good recovery, voice and swallowing function also recovered well. Shoulder donor side was secluding, and the shoulder function has not been affected.Conclusion:Supraclavicular artery island flap has the similar color and texture of the maxillofacial and neck areas. The thickness of the flap is moderate, and the surface is smooth and glabrous. Besides the advantages that vascular anatomy of the flap is constant, flap preparation is simple with little trauma and less donor complications, we also can use it as a pedicle transfer flap and no need to vascular anastomosis. Above all, the supraclavicular artery island flap is an ideal tissue flap for tongue defection. |
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