Abstract Objective To investigate individualized forearm flap repair of soft tissue defects of the oral and maxillofacial feasibility and evaluation of its efficacy. Cases of 32 cases of oral and maxillofacial soft tissue defects forearm flap, designed according to the location and morphology of the defect analysis flap survival and flap repair effect. Results 32 flaps survived, the success rate of 100%. In this group were followed up for 6 to 36 months, to restore the function and appearance of oral and maxillofacial good. Conclusion the forearm flap design individualized tissue defects Phase I of maxillofacial reconstruction, safe and reliable, simple preparation, it is the ideal way to repair the soft tissues of the oral and maxillofacial defects, can significantly improve the quality of life of the patient.

Key words individualized design forearm flap soft tissue defects

    Oral and maxillofacial may lead to a large area of ​​soft tissue defects due to tumor or trauma, and seriously affect the appearance and function of the patient’s face. Especially in the late 1980s, with the head and neck functional repair concept proposed tissue defects once again become the focus of attention. Of March 2005 to February 2007 forearm flap microsurgical technique application for Phase I repair a variety of oral and maxillofacial soft tissue defects in 32 cases, and achieved good results, are as follows.

    1 Materials and Methods

    1.1 General Information

    In 32 cases of tongue cancer in 14 cases, seven cases of the floor of mouth cancer, oropharyngeal cancer patients on gum cancer, buccal cancer cases are squamous cell carcinoma; sublingual gland mucoepidermoid carcinoma, trauma sexual upper lip defect cases. 19 males and 13 females; aged 21 to 69 years, with an average of 42.3 years old. The flaps area of ​​4.0cm × 5.0cm ~ 7.0cm × 10.0cm.

    1.2 Methods

    1.2.1 All operations were performed using the method of “dual surgery" (two  team surgery). Vascular anatomy of the first team responsible for tumor or lesion resection plus neck dissection and subject area to prepare; another group is responsible forearm flap design, preparation, vascular anastomosis and wound closure.

    1.2.2 forearm flap design and harvesting technique routinely the bilateral forearms Allen experimental confirm the deep palmar arch, the superficial palmar arch and radial, ulnar artery is present and a good blood supply [1]. Asked recently whether the forearm intravenous drug use, especially the history of chemotherapy drugs. Surgery according to the location and morphology of the defect after resection of the tumor in the forearm telecentric end conformal design flap axis of the radial artery and vein and cephalic vein, according to the defect morphology Design, the boundary of the skin can be slightly smaller in its deep surface fascial flap, the remote does not exceed the first wrist crease. Cut forearm flap in avascularization state, as a sharp separation between the deep fascia and the muscle membrane to the midline, and pay attention as much reserves the cephalic vein and radial arteriovenous beam between the fascia. The flap in the recipient vessel prepared, after breaking the vascular pedicle to reduce flap ischemia time.

    1.2.3 The choice of recipient vessels by the District artery facial artery, thyroid artery, lingual artery; vein before the choice of vein, external jugular vein or the surface veins. All vascular anastomosis.

    1.2.4 Postoperative treatment routine use of antibiotics to prevent infection and vasodilators. Head braking and enhanced care and observation, to observe the subject area drainage situation.

    2 Results

    All 32 cases forearm flap survival and the success rate of 100%, one cases of oropharyngeal fistula edge flap after considering are not tightly closed due to intra-oral wound, the tight suture under local anesthesia in the mouth wound healing. Donor site skin graft effusion cases, after exclusion of effusion, pressurized guarantee healing. The follow-up period of 6 to 36 months, patients with postoperative facial appearance and function returned to normal.

    3 typical cases

    A patient, female, 52 years old, admitted to hospital because of left cheek new biological years. Preoperative biopsy: well-differentiated squamous cell carcinoma. Ripped through the defect anesthesia the left buccal carcinoma expand lymph node dissection resection Supraomohyoid, the cutting edge intraoperative frozen negative legacy about 5.5cm × 8.5cm size, including the cheek of the mouth, cut forearm flap conformal repair, flap survived completely local shape can be. 1-year follow-up without recurrence, as shown in Figure 1.

    4 Discussion

    Vascularized free flap for nearly 30 years, with the rapid development of microsurgical vascular anastomosis technique has been widely used in clinical instantly repair tissue defects of the maxillofacial. Forearm flap by Yang Guo of China where [2] in 1981 first reported. The flap anatomy constant superficial location, easy preparation, the vascular caliber thicker high survival rate, vascular pedicle up to 10cm, can repair almost any part of the oral and maxillofacial soft tissue defects, oral and maxillofacial surgery has become the most one of the commonly used free flap [3  6]. Shibahara et al [7] found through long-term research: forearm flap in oral and maxillofacial defects after varying degrees of recovery of sensory function of the flap, within 10 months after histological observation oral mucous membrane of skin-like changes, language the recovery of sharpness is equally satisfactory.

    Forearm flap is a the truncus arteriosus mesh vascular flap, the radial side flap blood supply from the radial artery, two constant accompanying veins. Cephalic vein forearm flap superficial vein reflux, the forearm flap veins optional cephalic vein or radial vein, cephalic vein diameter thicker wall is slightly thicker, with head and neck vein matching, clinical multi-use head vein vascular anastomosis, but as many reservations cephalic vein and radial cut flap moving the fascia tissue between the vein. Necessary, the choice of the agreement the two veins. Mao Chi et al [8] reported also match the two veins of head and neck free tissue flap is the most reliable way to prevent secondary thrombosis, which can effectively prevent or reduce the incidence of free flap venous crisis, even if a vein occurred the obstruction, adequate reflux is still available through a vein, to improve the success rate of free flap transfers.

    Forearm flap as a fasciocutaneous flap, less subcutaneous fat, soft texture, moderate thickness, suitable for repair of oral and maxillofacial irregular, complex soft tissue defects, especially the cheek ripped through the defect and half tongue defect, folded after affect the blood supply, local non-obvious the bloated [9]. According to the defect site and extent of the flap design personalized design, such as the repair defect of the tongue can be designed remote oval flap, not only conforms to the shape and function of the tongue body, while reducing the trauma. Forearm flap should avoid the monotony of the rectangular cut to be the size and shape of the unsatisfactory repeated trimming after prolonged surgery time, and easy to damage the blood vessels perforating branches supply the skin and increase the possibility of occurrence of vasospasm.

    The vascular anastomosis quality is the key to the survival of the flap, and consistent as possible under a microscope or magnifying glass. Vascular anastomosis to ensure that no tension, no twist at the anastomotic thrombosis instantly check vascular anastomosis patency, extension of the vascular anastomosis patency check again to be the mouth wound closed. Patency, repeated testing, if necessary, re-vascular anastomosis. I found two cases immediately after vascular anastomosis patency be intraoral wound Close poor patency check, re-line the vascular anastomosis, thus avoiding flap necrosis. The vascular pedicle Ministry should keep enough space, pressure prevent vascular pedicle. Retain the mandible surgery forearm flap vascular pedicle were confirmed by the inside of the mandible to prevent pressure on the vascular pedicle, affecting the blood supply. At the same time to avoid the suction tube and vascular pedicle the cross placed, so as to avoid damage to the vascular pedicle.

    The forearm flap cut the expense of a major blood vessels that supply and veins, radial artery reconstruction problem still controversial. Knobloch [10] after 2 years, the study found 114 cases of patients with forearm flap, radial artery resection did not damage the deep palmar arch and the superficial palmar arch blood flow palm blood supply through the ulnar artery and interosseous artery compensatory postoperative daily motor function of the hand without damage. The author observed the forearm flap cut hand function in patients with contralateral similar. Preoperative Allen test must line to ensure the blood supply and venous return of the hand after surgery [11].

    Forearm flap also has some disadvantages, such as donor site exposed, not after the flap was sutured directly obvious scar left after skin graft impede the beautiful young women is more difficult to accept. Motomura et al [12] in a conventional skin graft topical hydrocolloid and adhesion sponge to keep the moisture of the skin graft, the local aesthetic satisfactory results of 12 patients with skin graft survival.