구강내연조직결손부재건시유리전완피판 (Radial Forearm Free Flap) 의유용성 구강내연조직결손부재건시유리전완피판 (Radial Forearm Free Flap) 의유용성 김남균 1 서동준 1 박세현 1 김형준 1,2 차인호 1,2 남웅 1,2 1 연세대학교치과대학구강악안면외과학교실, 2 연세대학교치과대학구강종양연구소 Abstract AVAILABILITY OF RADIAL FOREARM FREE FLAP IN RECONSTRUCTION OF INTRAORAL SOFT TISSUE DEFECTS : REVIEW OF 50 CASES Nam Kyun Kim 1, Dong Jun Seo 1, Se Hyun Park 1, Hyung Jun Kim 1,2, In Ho Cha 1,2, Woong Nam 1,2 1 Department of Oral and Maxillofacial Surgery, College of Dentistry, Yonsei University, Seoul, Korea 2 Oral Cancer Research Institute, College of Dentistry, Yonsei University, Seoul, Korea Purpose: The purpose of this clinical retrospective study was to evaluate our experience of radial forearm free flap for reconstruction of the oral cavity. Material and methods: From 1997 to 2006, 50 radial forearm free flaps were employed for head and neck reconstruction in 50 patients at department of oral and maxillofacial surgery, Yonsei University, Korea. Data were obtained from chart review, and clinical follow-up. Results: Patients age ranged from 26 to 82 years (mean 53.2). There were 39 men and 11 women. 43 of the 50(86%) patients had squamous cell carcinoma. The total flap survival were 47(94%), complication rate were revealed for 15(30%). Conclusion: In the reconstruction of soft tissue within the oral cavity, several free flaps have been used. Because of its constant anatomy, long pedicle allows a hypothetic vascular anastomosis in the contralateral neck, contourability for various type of oral defects, pliability and can be used simultaneous reconstruction in intraoral and extra oral defects, the radial forearm free flap constitutes one of the best choice of intraoral soft tissue reconstruction. Key words: Radial forearm free flap, Intraoral defect, Oral cavity reconstruction Ⅰ. 서론 구강암은구강내에발생하는심각한악성질환으로구강내거친반점, 궤양, 혹등이입술, 구강점막, 혀, 구강저등에자라게되며경부임파절로전이된다. 외과적절제는구강암치료의첫번째선택이며, 구강암절제를시행한환 자에있어재건은또다른도전으로받아들여졌다. 전통적으로, 악성종양의외과적절제후재건을위해국소적, 지역적피판 (loco-regional flap) 이사용되었다. 1960 년대에두경부결손부위의재건을위해삼각흉근피판 (deltopectoral flap) 이처음소개되었으나 1), 타액의감염에의한경부누공이만들어져, 이를막기위한이차적인수술을 본연구는학술진흥재단중점연구소연구비 (KRF-2005-005-J05904) 에의해지원되었습니다. 353
대한악안면성형재건외과학회지 : Vol. 30, No. 4, 2008 요하는단점을나타내었다. 1980 년대에이르러두경부결손부위의재건에대흉근피판 (pectoralis major myocutaneous flap) 이삼각흉근피판보다더대중화되었다. 그러나, 1990 년대이르러진보한미세혈관문합술의발달로유리전완피판 (radial forearm free flap) 이구강내결손부재건에최선의선택이되었다. 이피판은두경부수술시병소부와공여부에대한동시수술로수술시간단축이가능하며, 술중환자의자세를바꾸지않아도되고, 미세수술시중요하게여겨지는큰혈관직경과충분히긴혈관유경을가지고있으며, 조직을공여부에맞게잘접을수있어공여부조직과조화를잘이루는등의여러가지장점을가지고있다 2). 유리전완피판은 1981 년 Yang 등 3) 에의해처음소개되었고, 1983 년 Soutar 등 4) 이구강내결손부재건에최초로사용하였으며, Urken 등 5) 은혀절제후이피판을시용하여혀와그운동및감각까지재건한증례를발표하였다. 본연구에서저자들은구강내연조직결손부의재건에유리전완피판을이용하여만족할만한결과를얻었기에문헌고찰과함께보고하는바이다. Ⅱ. 연구대상및방법 1997 년 1 월부터 2006 년 12 월까지유리전완피판을이용한구강내결손부재건술을시행받은 50 명의환자를대상으로하였다. 49 명의환자에서구강내악성종양의절제술후유리전완피판을이용한결손부재건이시행되었으며, 1 명에서양성종양의절제술후시행되었다. 남성과여성의비율은 3.5:1(39:11) 이었다. 조직검사소견상편평상피세포암종이 42 증례 (84%) 였으며, 선양낭성암종, 골육종이각 2 증례로진단되었다 (Table 1). 종양의임상및방사선학적, 조직학적검사를시행한후종양절제술을시행하였다. 이번연구에는종양의조직학적 진단, 위치와크기및경부임파선전이여부가포함되었다. 또한, 유리전완피판의크기와문합한정맥과동맥의종류와갯수, 그리고형성된피판의갯수도포함되었다. 술후발생한두경부누공, 과다출혈, 재혈관문합, 피판의부분적괴사및피판의괴사에의한실패그리고공여부의건노출등의합병증도조사하였다. 피판은전완의외측에설계되어요골동맥 (radial artery) 과요측피정맥 (cephalic vein) 및동반정맥 (vena comitants) 를사용하였다. 모든환자들은술전 Allen s test 7) 를이용하여요골 (radius) 과자골 (ulnar) 쪽손바닥부위에서의적절한심장동맥궁 (deep palmar arch), 천장동맥궁 (superficial palmar arch) 의교통정도를확인하였다. 요골전완피판의거상을위해서 Yang 등 3) 에의해보고된측면접근법을사용하였으며, 가쪽아래팔피부신경 (lateral antebrachial cutaneous nerve) 의문합은시행하지않았다. 모든환자의공여부는대퇴부에서획득한부분층피판을이용하여피부이식을시행한후 tie-over dressing 을시행하였다. Ⅲ. 결과 50 명의환자들에서구강내종양절제술후유리전완피판을이용한재건을시행하였다. 종양의병기중 T2, N0, M0 병소가가장큰부분을차지하였다 (Table 2). 모든피판은근막피부피판을형성하였다. 평균피판의크기는장축과단축의길이로표시하였으며 5 3.5cm 에서 14 8cm 까지평균 6.03 5.8cm 로나타났다. 하나의증례에서두부분으로분리된피판을형성을하였다. 모든증례에서혈관의끝과끝을연결하는미세혈관봉합술을시행하였다. 요골동맥의문합을위해이용한수혜부동맥중상갑상동맥 (superior thyroid artery, n=37) 을가장많이이용하였다 (Table 3). 피판의충분히긴유경으로인하여절제부반대측상갑상동맥을이용한예도 3 증례에이른다. 안 Table 1. Diagnostic classification in 50 patients undergoing head and neck reconstruction Pathology No. of Patients(N=50) Squamous cell carcinoma (Recurrent) 43 (1) Adenoid cystic carcinoma 2 Osteosarcoma 2 Malignant fibrous histicytoma 1 Undifferentiated Carcinoma, Large cell type 1 Ameloblastoma 1 354
구강내연조직결손부재건시유리전완피판 (Radial Forearm Free Flap) 의유용성 Table 2. Tumor staging in 50 patients undergoing head and neck reconstruction No. of Patients (N=50) T staging N staging T1 7 (14%) N0 34 (68%) T2 19 (38%) N1 9 (18%) T3 10 (20%) N2a 0 (0%) T4 13 (26%) N2b 6 (12%) N/A 1 (2%) N2c 1 (1%) Table 3. Artery and veins in donor site used for vascular anastomosis Number of Vascular Anastomosis in vein 1 Cephalic vein or Vena comitante 11 2 Cephalic vein with Vena comitantes or 2 Vena comitantes 30 3 Cephalic Vein with 2 Vena comitantes 9 Table 4. Artery and veins in recipient site used for vascular anastomosis A) Artery Recipient Arteries Facial artery 12 Sup. thyroid artery 37 Ipsilateral 34 Controlateral 3 Ligual arteries 1 B) Vein Recipient veins Cephalic vein (N = 25) Vena comitantes (N = 78) Ext. Jug. V. 5 Ext. Jug. Vein 5 Int. Jug. V. 0 Int. Jug. V. 4 Ant. Jug. V. 3 Ant. Jug. V. 4 Mid. Jug. V. 1 Mid. Jug. V. 0 Facial Vein 10 Facial Vein 9 Sup. Thy. Vein 4 Superior Thyroid Vein 55 Retromandibular Vein 2 Retromandibular Vein 1 Note : Some patients had more than one vein anastomosis 355
대한악안면성형재건외과학회지 : Vol. 30, No. 4, 2008 Table 5. Complications of the recipient sites Complication No. Of Patients Flap loss 3 (6%) Partial flap loss 1 (2%) Fistula 6 (12%) Post Op. bleeding 1 (2%) Seroma 1 (2%) Infection 2 (2%) Venous Return Failure (Re-anastomosis) 1 (2%) 면동맥 (facial artery) 은총 12 증례에서사용되었고, 설동맥 (ligual artery) 이 1 증례에서사용되었다. 정맥문합술은각피판마다적게는하나의정맥에서많게는 3 개의정맥까지다양하게사용되었다 (Table 4). 하나의피판에평균 1.98 개의정맥을이용하였다. 상갑상정맥 (Superior thyroid vein) 이가장많이사용된정맥이었으며, 안면정맥 (facial vein), 외경정맥 (external jugular vein) 순으로사용되었다. 피판실패는총 3 증례였으며이에따른피판의성공률은 94%(N=47) 였다. 피판이괴사된 3 증례중하나의증례는대흉근피판을이용하여재건하였고, 다른한증례는부분층피부이식을이용하였으며, 나머지하나의증례는유리혈관화비골피판을이용하여재건하였다. 한증례에서수술후정맥순환이이루어지지않아수술후 2 일째재혈관문합을시행하였다. 그외의합병증은모두 11 증례에서나타났으며, 이중가장많이나타난합병증으로는누공 (N=6) 의형성이었으며, 피판의부분괴사 (N=1), 감염 (N=2), 수술부위출혈 (N=1), 장액종 (N=1) 순이었다. 이러한합병증들은피판의국소적소파술, 봉합술, 소독술등을이용한보존적처치술로치료하였으며, 양호한예후를보였다. 모든합병증유발율은 30% 로 (Table 5), 이는다른저자들의결과와유사하였다. Ⅳ. 고찰 두경부종양절제술후미세혈관문합술을이용한즉시재건술은이차재건술보다정상구강기능과심미성회복에매우큰이점을지닌다 9,10). 즉시재건술은미세혈관문합술의가장중요한요소인수혜부동맥과정맥을확보하기쉬우며, 수술부섬유화가없어접근이쉬우며, 명확한해부학적경계를얻을수있는등의장점을지닌다. 유리전완피판은두경부종양절제술후결손부재건에최선의선택이되었다. 이피판은두경부재건에있어여러 가지장점을지니고있다. 1) 다양한정맥혈관은피판에충분한혈류순환을허용한다. 요측피정맥 (cephalic vein) 과자측피정맥 (basilic vein) 그리고두개의동반정맥 (vena comitants) 이동맥과함께주행한다. 2) 혈관의유경은충분히길어서절제부반대측의수혜부혈관과혈관문합을할수있다. 본연구에서술자등은총 3 증례에서재건부반대측의수혜부혈관을이용하였다. 3) 이용가능한피부피판의크기는전완을모두사용할수있을정도로충분했으며, 피판을두부분으로분리하여형성하는것도가능하였다. 본연구에서술자등은 1 증례에서두부분으로분리된피판을획득구강내와피부의동시재건을시행할수있었다. 4) 피판의설계를 3 차원적으로시행할수있다. 구강내종양의절제후재건을필요로하는범위는국소적이지않고 2 차원적이지않다. 구강내구조는혀, 구강저, 치은, 편도와협점막등복잡하게연결되어있는형태를취하고있어, 구강암절제술시어느한정된부분만을절제하기어려우며, 따라서피판설계시이들의복잡한형태에맞게하나의피판을설계하거나, 피부와구강내의동시재건을위한, 두개의피판을이용할수있어야하며, 세개의피판을사용한증례도보고되고있다 12). 5) 충분한크기의혈관직경을가지고있어피판에충분한정도의혈류공급과동시에혈관문합을용이하게하며절제부반대측의혈관을이용하여문합이가능하다 13). 6) 수술중환자의자세변화없이두팀이함께수술을시행할수있어수술시간을단축시킬수있다는장점이있어환자의수술후예후에영향을미친다 14). 그러나, 전완부의혈관구조상심장동맥궁 (deep palmar arch), 천장동맥궁 (superficial palmar arch) 의해부학적변이가있어, Allen s test 에서만족스런결과를얻었어도찬것에견디지못하거나, 손의허혈증상이생길수있으며 6,7,8), 요골전완피판의형성시건방 (Para-tendon) 이손상받았을경우, 공여부의치유가상당히지연될수있으며, 이식한피부조직의괴사에의한건 (tendon) 노출이보고되고있으며 15), 요골신경의종말분지부가손상받음으로써국 356
구강내연조직결손부재건시유리전완피판 (Radial Forearm Free Flap) 의유용성 소적인불편감이생길수있다. 유리전완피판은요골을포함한피판을획득할수있으나, 본연구의모든증례에서는근막피부피판만을획득하였다. 피판형성시요골을피판에포함하면혈관화된골을얻을수있어유리한측면이있지만, 그양이한정되어있다. 골피부피판으로형성시얻어진요골은골질이좋지않아임플란트를식립할수없으며 Micheal 등 16) 의연구에따르면골결손부재건을위한요골피판의이용은술후보철적관점과하악골의형태적측면에서불리함을보인다고보고하였고, Richardson 등 17) 에의하면요골의채취후 17% 에서요골골절의합병증을보인다고보고하였다. 특히환자가노년여성일경우요골의채취는술후요골골절의가능성때문에금기시된다 18). 이에술자등은보다광범위한골결손부재건시에는유리전완피판보다는심장골회선동맥피판 (deep circumflex iliac artery flap) 이나유리혈관화비골피판 (free vascularized fibular flap) 을선호한다. 전체증례중피판의실패는총 3 증례 (6%) 에서보고되었는데, 이는유리전완피판을이용한두경부재건의보고들과비교하여유사하거나낮은수치를보인다. John 등 10) 은 8.8%, Vaughan 등 19) 은 7.5%, Urken 등 20) 은 6.5%, Schusterman 등 21) 은 5.5% 의피판실패율을보고하였다. 이는다른혈관화유리피판을이용한두경부재건시실패율과유사하다 22-24). 미세혈관문합술을이용한피판의성공률은미세문합술에영향을받으며, 외측상완피판 (lateral arm flap) 의경우 95.2% 25), 횡배곧은근육피부판 (transverse rectus abdominis myocutaneous flap) 의경우 100% 26), 전외측대퇴유리피판 (anterolateral thigh flap) 의경우 97% 27) 의성공률을보였다. 이들의성공률은저자등의유리전완피판을이용한재건과비슷한결과이다. Ⅴ. 결론 유리전완피판을이용한구강내연조직결손부의재건은미세혈관문합술을이용한다른피판을이용한재건술과비슷한성공률을가지고있으며, 피판의설계, 구강내적합성, 유경의길이와두께, 술식의편이성, 두팀의동시수술가능성등의다양한장점을가지고있어구강내연조직결손부재건에가장적합한피판이다. REFERENCES 1. V.Y. Bakamjian : A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg 36 : 173, 1965. 2. Zenn MR, Hidalgo DA, Cordeiro PG et al : Current role of the radial forearm free flap in mandibular reconstruction. Plast Reconstr Surg Apr 99 : 1012, 1997. 3. Yang G, Chen B, Gao Y : Forearm free skin flap transplantation. Natl Med J China 61: 139, 1981. 4. Soutar DS, Scheker LR, Tanner NS et al : The radial forearm flap: a versatile method for intra-oral reconstruction. Br J Plast Surg 36 : 1, 1983. 5. Urken ML, Weinberg H, Vickery C et al : The combined sensate radial forearm and iliac crest free flaps for reconstruction of significant glossectomy-mandibulectomy defect. Laryngoscope 102 : 543, 1992. 6. Kerawala CJ, Martin IC. Palmar arch backflow following radial forearm free flap harvest. Br J Oral Maxillofac Surg 41 : 157, 2003. 7. Nuckols DA, Tsue TT, Toby EB et al : Preoperative evaluation of the radial forearm free flap patient with the objective Allen s test. Otolaryngol Head Neck Surg Nov 123 : 553, 2000. 8. Varley I, Carter LM, Wales CJ et al : Ischemia of the hand after harvest of a radial forearm flap. Br J Oral Maxillofac Surg 46 : 403, 2008. 9. Boyd BJ, Morris S, Rosen IB et al : The through-andthrough oromandibular defect: rationale for aggressive reconstruction. Plast Reconstr Surg 93 : 44, 1994. 10. Jones NF, Johnson JT, Shestak KC et al : Microsurgical reconstruction of the head and neck: interdisciplinary collaboration between head and neck surgeons in 305 cases. Ann Plast Surg 36 : 37, 1996. 11. Martin HE, Munster H, Sugarbaker E : Cancer of the tongue. Arch Surg 41 : 888, 1940. 12. Dickson WA, Earley MJ : The shamrock flap : a threepaddle radial forearm flap. Br J Plast Surg Jul 43 : 486, 1990. 13. Soucacos PN, Beds AE, Xenakis TA et al : Forearm flap in orthopaedic and hand surgery. Microsurgery 13 : 170, 1992. 14. Farwell DG, Reilly DF, Weymuller EA et al : Predictors of perioperative complications in head and neck patients. Arch Otolaryngol Head Neck Surg 128 : 505, 2002. 15. Choi BH, You JH, Chung JH et al : Tendon Exposure As a Forearm Flap Donor Site Complication ; A Case Report. KAOMS 24 : 153, 1996. 16. Michael RZ, Hidalgo DA, Peter GC et al : Current role of the radial forearm free flap in mandibular reconstruction. Plast 99 : 1012, 1997. 17. Richardson D, Fisher SE, Vaughan ED et al : Radial forearm flap donor-site complications and morbidity: a prospective study. Plast Reconstr Surg 99 : 109, 1997. 18. Bardsley AF, Sutar DS, Elliot D et al : Reducing morbidity in the radial forearm flap donor site. Plast Reconstr Surg 86 : 287, 1990. 19. Vaughan ED : The radial forearm free flap in orofacial reconstruction. Personal experience in 120 consecutive cases. J Craniomaxillofac Surg 18 : 2, 1990. 20. Urken ML, Weinberg H, Buchbinder D et al : Microvascular free flaps in head and neck reconstruction - report of 200 cases and review of complications. Arch Otolaryngol Head Neck Surg 120 : 633, 1994. 21. Martin IC, Brown AE : Free vascularized fascial flap in oral cavity reconstruction. Head Neck 16 : 45, 1994 22. Brown JS, Magennis P, Rogers SN et al : Trends in head and neck microvascular reconstructive surgery in Liverpool(1992-2001). Br J Oral Maxillofac Surg 44 : 364, 357
대한악안면성형재건외과학회지 : Vol. 30, No. 4, 2008 2006. 23. Gonzalez-Garcia R, Rodriguez-Campo FJ, Naval-Gias L et al : Radial forearm free flap for reconstruction of the oral cavity : clinical experience in 55 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod Jul 104 : 29, 2007. 24. Chen CM, Lin GT, Fu YC et al : Complication of free readial forearm flap transfers for head and neck reconstruction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 99 : 671, 2005. 25. Marques Faria JC, Rodriques ML, Scopel GP et al : The versatility of the free lateral arm flap in head and neck soft tissue reconstruction : clinical experience of 210cases. J Plast Reconstr Anesthet Surg 61 : 171, 2006. 26. Ascherman JA, Seruya M, Bartsish SA : Abdominal Wall Morbidity following Unilateral and Lilateral Breat Reconstruction with Pedicle TRAM Flaps : An Outcomes Analysis of 117 Consecutive Patients. Plast Reconstr Surg 121 : 1, 2008. 27. Ozkan O, Coskunfirat OK, Ozgentas E : The Use of Free Anterolateral Thigh Flap for Reconstruction Soft Tissue Defects of the Lower Extremities. Ann Plast Surg 53 : 455, 2004. 저자연락처우편번호 120-752 서울시서대문구신촌동 134 연세대학교치과대학병원구강악안면외과남웅 원고접수일 2008년 6월 26일게재확정일 2008년 7월 9일 Reprint Requests Woong Nam Dept. of OMFS, College of Dentistry, Yonsei University 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752, Korea Tel: 82-2-2228-2971 Fax: 82-2-364-0992 E-mail: omsnam@yuhs.ac Paper received 26 June 2008 Paper accepted 9 July 2008 358