大韓微細手術學會誌 Vo1. 20, No. 1, May, 2011 구개상악재건을위한유리피판술에서다양한공여부의선택 연세대학교원주의과대학성형외과교실, 연세대학교의과대학성형외과교실 2, 국민건강보험공단일산병원 3 윤도원 민희준 김지예 이원재 2 정 섬 3 정윤규 Abstract Selection of Various Free Flap Donor Sites in Palatomaxillary Reconstruction Do-won Yoon, M.D., Hee-jun Min, M.D., Ji-ye Kim, M.D. Won-jae Lee, M.D., Ph.D. 2, Seum Chung, M.D., Ph.D. 3, Yoon-kyu Chung, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Yonsei University, Wonju College of Medicine, Wonju, Korea Department of Plastic and Reconstructive Surgery Yonsei University, College of Medicine, Seoul, Korea 2 National Health Insurance Corporation Ilsan Hospital, Ilsan, Korea 3 Purpose: A palatal defect following maxillectomy can cause multiple problems like the rhinolalia, leakage of foods into the nasal cavity, and hypernasality. Use of a prosthetic is the preferred method for obturating a palate defect, but for rehabilitating palatal function, prosthetics have many shortcomings. In a small defect, local flap is a useful method, however, the size of flap which can be elevated is limited. In 12 cases of palatomaxillary defect, we used various microvascular free flaps in reconstructing the palate and obtained good functional results. Method: Between 1990 and 2004, 12 patients underwent free flap operation after head and neck cancer ablation, and were reviewed retrospectively. Among the 12 free flaps, 6 were latissimus dorsi myocutaneous flaps, 3 rectus abdominis myocutaneous flaps, and 3 radial forearm flaps. Result: All microvascular flap surgery was successful. Mean follow up time was 8 months and after the follow up time all patients reported satisfactory speech and swallowing. Wound dehiscence was observed in 4 cases, ptosis was in 1 case and fistula was in 1 case, however, rhinolalia, leakage of food, or swallowing difficultly was not reported in the 12 cases. Conclusion: We used various microvascular flaps for palatomaxillary reconstruction. For 3-dimensional flap needs, we used the latissimus dorsi myocutaneous flap to obtain enough volume for filling the defect. Two-dimensional flaps were designed with latissimus dorsi myocutaneous flap, rectus abdominis flap and radial forearm flap. For cases with palatal defect only, we used the radial forearm flap. In palatomaxillary reconstruction, we can choose various free flap techniques according to the number of skin paddles and flap volume needed. Key Words: Palatomaxillary, Palatal defect, Free flap 통신저자 : 정윤규강원도원주시일산동연세대학교원주의과대학성형외과학교실 Tel : 033-741-0114, Fax :033-732-4022, E-mail; ykchung@yonsei.ac.kr 8
윤도원외 : 구개상악재건을위한유리피판술에서다양한공여부의선택 서론근치적상악절제술후발생한구개결손은기능적, 심미적결함을발생시킨다 1. 구개결손을폐쇄시키기위해일차적으로인공전색자 (prosthetic obturator) 를사용되는것이일반적이고, 치아가없는경우에유용하다고알려져있지만통증, 궤양, 출혈, 악취, 구음장애, 비강으로의음식누출, 구강으로의비루등이발생할수있다 2. 국소피판술로는비중격피판, 설피판, 협점막피판, 인두피판등이있으나사용할수있는크기에제한이있고피부결손이함께동반되는경우국소피판만으로는해결이어렵다 3,8. 최근에는미세수술을이용한유리피판술이보편화되고있다. 근치적상악절제술후발생한결손부위의양과필요한피판의수에따라광배근피판, 복직근피판그리고요측전완피판등을적절하게선택할경우기능적, 심미적으로우수한결과를가져올수있다. 본저자들은다양한유리피판술을 12 예의구개상악결손에적용하여비교적좋은결과를얻었으며이에대한분석을하였다. 연구대상및방법 1990년부터 2004년까지종양으로인해상악절제술후 유리피판술을시행받은 12 명의환자를대상으로하였다. 수술직후한달동안급성합병증발생등을관찰하였으며, 이후 2~3 개월간격으로비음증, 비강으로음식누출, 과비음, 연하장애발생유무등을추적하였다. 이환자들은 Okay씨분류 (OK classification) 에따라구분하였다. 1명의환자가 class Ib, 그외 11 명은 class II 로구분되었다. class Ib는상악전구골 (premaxilla) 또는견치 (canine) 후방상악골치조 (maxillary alveolus) 를포함한동측의경구개를침범한결손을, class II 는일측의견치와특정범위지정없는경구개부위결손또는 50% 미만의횡행경구개결손을지칭한다 (Fig. 1) 5,8. 병리조직검사상편평세포암 (squamous cell carcinoma) 8례였고, 방추상세포암 (spinldle cell carcinoma), 육종 (leiomyosarcoma), 사기질모세포종 (ameloblas- Table 1. Pathologic diagnosis and defect distribution Pathology No of patient Class Ib Class II Total Squamous cell ca. 0 8 8 Spindle cell ca. 0 1 1 Leiomyosarcoma 0 1 1 Ameloblastoma 1 1 2 (ca.: carcinoma) Fig. 1. Okay classification Ib and II. Class Ib includes defects of premaxilla or any segment of alveolus posterior to the ipsilateral canine. 5 Class II represents any portion of hard palate, alveolus and only one canine. Also represents transverse palatectomy involving less than 50% of the hard palate. 8 9
대한미세수술학회지제 20 권제 1 호 2011 toma) 이각각 1례였다 (Table 1). 결과근치적상악절제술후안면피부, 코점막및경구개등 3개의피판과결손부위에충분한부피가필요했던경우는총 5예로모두광배근유리피판술 (latissimus dorsi myocutaneous free flap) 을시행하였다. 안면피부와경구개등 2개의피판이사용된경우는총 6예로광배근유리피판술 1예, 복직근피판술 (rectus abdominis Table 2. Patient summary Donor sites Skin paddles Age/Sex Dx. Follow up Complication Latissimus dorsi free flap Cheek, nose & palate 59/M Squamous cell ca. 8m Wound dehiscence 68/M Squamous cell ca. 2m 47/M Squamous cell ca. 6m 53/M Squamous cell ca. 22m Wound dehiscence 32/M Spindle cell ca. 15m Wound dehiscence Cheek ptosis Cheek & palate 47/M Squamous cell ca. 17m Wound dehiscence Rectus abdominis free flap 43/F Squamous cell ca. 36m 47/M Squamous cell ca. 18m 28/M Leiomyosarcoma 10m Radial forearm free flap 50/F Ameloblastoma 21m 66/M Squamous cell ca. 17m Fistula palate 38/M Ameloblastoma 20m (ca.: carcinoma, m: month) A B C D Fig. 2. Case 1. A 38-year-old man with maxillary sinus cancer. (Recipient artery: facial artery) (A) Preoperative view, (B) Specimen, (C) Designed flap, (D) Postoperative view, oral side (Split thickness skin graft is done on maxillary area). 10
윤도원외 : 구개상악재건을위한유리피판술에서다양한공여부의선택 myocutaneous free flap) 3예, 요측전완부피판 (radial forearm fasciocutaneous free flap) 2예를이용하였다. 경구개에 1개의피판만이필요한경우는 1예으로요측전완부피판을사용하였다 (Table 2). 유리피판은 12 명모두에서괴사없이생존하였으며광배근유리피판술을받은환자 4명에서피판봉합부열개가발생하여보존적치료, 일차봉합술및피부이식술로치료하였다. 뺨의하수가광배근유리피판술을시행받은환자 1예에서발생하였다. 12명의환자모두에서비음증이관찰되었으나알아들을수는있었으며, 연하장애는없었다. 1예에서누공으로인한비강으로음식누출이있었다. 증례 1 38세남자환자로좌측협부의부종으로사기질모세포종 (Ameloblastoma) 진단하에근치적상악절제술후생긴구개결손을요측전완부피판을시행하여치료하였다. 술후합병증없이완치되었다 (Fig. 2). 증례 2 50 세여자환자로우측협부의종괴를주소로내원하여사기질모세포종진단하에근치적상악절제술후생긴구개결손을요측전완피판을시행하여치료하였다. 술후합 A B C Fig. 3. Case 2. A 50-year-old woman with maxillary sinus cancer. (Recipient artery: facial artery) (A) Preoperative view, oral side, (B) Designed flap (Deepithelization is done on mid portion of flap and this area is located at maxillary area), (C) Postoperative view, oral side(two skin paddles is found on cheek and palate), (D) Postoperative AP view. D 11
대한미세수술학회지제 20 권제 1 호 2011 병증없이완치되었다 (Fig. 3). 증례 3 59 세남자환자로좌측협부의종괴를주소로내원하여편평세포암 (squamous cell carcinoma) 진단하에근치적상악절제술후생긴안저, 비강및상악동재건을위해광배근유리피판술을시행하여치료하였다. 술후피판봉합부열개가발생하여일차봉합술을시행하여치료하였다 (Fig. 4). 고찰근치적상악절제술후상악동재건을하는목적은비호흡 (nose breathing), 연하 (swallowing), 저작 (mastication) 과말하기 (speech) 등의기능적복구와얼굴의심미적복구를하는데있다 3. 상악동재건방법은지금까지도쟁점사항으로피판이발달하기전에는인공전색자 (prosthetic obturator) 가기능과얼굴형태를복구하기위한유일한방법이었다. 이인공전색자는말하거나먹을 10 때항상착용하여야하며, 끊임없는관리에도불구하고악취가나는점등사용하는데있어불편하여환자들이불만족을표현하는경우가많다 9. 근래에는미세수술방법의발전에따라유리피판술로골조직등복합조직을함께포함해서재건할수있게되었다 6,7. 하지만근치적상악절제술후정상치유과정과보조방사선치료 (adjuvant radiation therapy) 가피판부피감소및수축을일으킬수 있으므로이를고려하여재건을해야한다. 또한피판의무게가중력에의해처짐으로서창상열개 (wound dehiscence) 가발생하는것도고려하여야한다. 상악동재건에사용되는유리피판에는광배근피판, 복직근피판, 요측전완부피판등이있다. 광배근피판은충분한양의피부와근육을얻을수있고공여부의일차적봉합이가능할수있지만환자의나이가많을수록술후에어깨를들어올리는데어려움이생길수있다. 복직근피판은수술중앙와위를유지할수있고근육의양도충분하지만복벽의약화와이로인한탈장이발생할수있다. 요측전완부피판은피판의두께가얇아구개재건에매우유용하다 1,2. 특히우리나라환자의경우에는털이없는것이매력적이다. 그러나공여부의미용적결함과요골동맥을희생시켜야하는것이단점이다 9. 상악동재건에있어과거인공전색자및국소피판술을시행하여왔지만근래미세수술기법이발전함에따라유리피판을이용하는것이일반적이다 5. 유리피판술을시행하고자할때공여부의선택은시술자의성향에따라차이가있을수있지만어느특정한한곳의공여부만을고집하기보다는근치적상악절제술후발생한결손부위의양과부피, 그리고재건에사용될피판의수에따라결정해야할것이다. 안면부의피부및연부조직과구개의결손은근육과지방층이풍부하며크기가큰광배근피판과복직근피판이요측전완부피판보다유리할것이다. 반면조직결손부위의부피가작고피부의재건이중요한경우는요측전완부피판이적절할것이다 4. A B Fig. 4. Case 3. A 59-year-old man with maxillary sinus cancer. (Recipient artery: facial artery) (A) Intraoperative view, oral side (B) Postoperative AP view. 12
윤도원외 : 구개상악재건을위한유리피판술에서다양한공여부의선택 결론구개상악의재건에있어유리피판의공여부를선택할때조직결손부위의부피와필요한피판의수에따라다양한결정을해야한다. 광배근피판과복직근피판은결손부위부피가크고필요한피판의수가많은 3차원또는 2차원재건, 요측전완부피판은결손부위부피가작고또한필요한피판의수도적은 2차원또는 1차원재건에, 또한요측전완부피판은피판의두께가얇아경구개재건에있어더적합할것이다. REFERENCES 1. FILIZ KEYF. Obturator prostheses for hemimaxillectomy patients. Journal of oral rehabilitation. 2001; 28: 821-9. 2. M.HATOKO, T.HARASHINA, T.INOUE, I.TANAKA, K.IMAI. Reconstruction of palate with radial forearm flap; a report of 3 cases. British Journal of Plastic Surgery. 1990; 43: 350-4. 3. Eric M. Genden, Derrick I. Wallace, Devin Okay, Mark L. Urken. RECONSTRUCTION OF THE HARD PALATE USING THE RADIAL FOREARM FREE FLAP: INDI- CATION AND OUTCOMES. Wiley Periodicals, Inc. Head Neck. 2001; 26: 808-14. 4. Jin-Hwan Kim, Hyung-Ro Chu, Jeoung-Min Kang, Woo- Jin Bae, So-Jung Oh, Young-Soo Rho et al. Functional Benefit after Modification of Radial Forearm Free Flap for Soft Palate Reconstruction. Clinical and Experimental Otorhinolaryngology. 2008; 1: 161-5. 5. Eric M. Genden, Devin Okay, Marita T. Stepp, Rod P. Rezaee, Jacqueline S. Mojica, Daniel Buchbinder et al. Comparison of Functional and Quality-of-Life Outcomes in Patients With and Without Palatomaxillary Reconstruction. Arch otolaryngol head neck surg. 2003; 129: 775-80. 6. Masaki Fujioka, Isao Tasaki, Aya Yakabe, Satoru Komuro, Katsumi Tanaka. Reconstruction of Velopharyngeal Competence for Composite Palatomaxillary Defect With a Fibula Osteocutaneous Free Flap. The journal of craniofacial surgery. 2008; 19: 866-8. 7. Matthew M. Hanasono, Y. Etan Weinstock, Peirong Yu. Reconstruction of Extensive Head and Neck Defects with Multiple Simultaneous Free Flaps. Plastic and reconstructive surgery. 2008; 122: 1739-46. 8. Dustin Dalgorf, Kevin Higgins. Reconstruction of the midface and maxilla. Current opinion in otolaryngology & head and neck surgery. 2008; 16: 303-11. 9. MAGDY ELSHERBINY, ALI MEBED, HASSAN MEBED. Microvascular Radial Forearm Fasciocutaneous Free Flap for Palatomaxillary Reconstruction Following Malignant Tumor Resection. Journal of the Egyptian Nat. Cancer Inst. 2008; 20: 90-7. 10. H. Devlin, G.R. Barker. Prosthetic rehabilitation of the edentulous patient requiring a partial maxillectomy. J Prosthet Dent. 1992; 67: 223-7. 13