Perforator based rectus free tissue transfer for head and neck reconstruction: New reconstructive advantages from an old friend
基于穿孔器的头部颈部重建游离直肌组织移植：来自老朋友的新重建优势

Received 1 May 2017
收稿日期： 2017-05-01

Received in revised form 26 June 2017
2017年6月26日收到修订后

Accepted 30 June 2017
录用日期： 2017-6-30

Available online
可在线 获取

Perforator rectus 穿孔器直肌

Head and neck reconstruction
头颈部重建

Deep inferior epigastric artery flap
深部上腹下动脉瓣

Reconstructive advantages
重建优势

Pedicle length 花梗长度

Free tissue transfe 游离组织输液

Free flap 自由翻盖

Perforator based flap 基于穿孔器的襟翼

© 2017 Elsevier Ltd. All rights reserved.
© 2017 爱思唯尔有限公司保留所有权利。

Many donor sites are used for autogenous transplantation to reconstruct soft tissue defects in the head and neck [1]. The ideal soft tissue donor site would have a long vascular pedicle, be accompanied by adipose tissue that is highly moldable so that the volume of adipose within the transplant can be customized, and would not contain muscle, so that the volume of the transplant is not affected by muscle atrophy.
许多供体位点用于自体移植，以重建头颈部软组织缺损[1]。理想的软组织供体部位应具有较长的血管蒂，并伴有高度可塑的脂肪组织，以便可以定制移植内的脂肪体积，并且不包含肌肉，因此移植的体积不受肌肉萎缩的影响。

While the rectus donor site has been well described in the literature [2-23], the majority of publications utilizing the rectus donor site in head and neck reconstruction describe the use of a musculocutaneous transplant (Table 1). The perforator based rectus transplant provides three critical reconstructive advantages over its musculocutaneous counterpart. The perforator based rectus transplant provides excellent pedicle length, which is useful in patients who have previously treated, vessel-poor necks and/or
虽然文献中对直肌供体位点有很好的描述[2-23]，但大多数利用直肌供体位点进行头颈部重建的文献都描述了肌肉皮肤移植的使用（表1）。与肌肉皮肤移植相比，基于穿支器的直肌移植具有三个关键的重建优势。基于穿孔器的直肠移植提供了出色的椎弓根长度，这对于既往接受过治疗、颈部血管不良和/或

defects that are distant from recipient vessels. Another advantage of this transplant is the ability to mold the adipose tissue. Because the perforators are identified, the adipose tissue can be safely trimmed and customized based upon the defect and the thickness of the transplant. This level of customization and control of the volume that is transplanted into the defect cannot be performed in a transplant where the perforators are embedded within muscle. Finally, the perforator based rectus transplant leaves the rectus abdominis muscle in situ and thus, there is not muscle in the donor tissue that will undergo atrophy and result in loss of the volume which that affects the long term reconstructive result [24,25]. The prevention of muscle atrophy and subsequent transplant volume loss is particularly important when reconstructing a contained space such as the orbit, for example. The combination of all three reconstructive advantages makes the perforator based rectus transplant an ideal donor site for many complex head and neck defects.
远离受体血管的缺陷。这种移植的另一个优点是能够塑造脂肪组织。由于穿孔器被识别，因此可以根据缺陷和移植厚度安全地修剪和定制脂肪组织。这种程度的定制和控制移植到缺损中的体积无法在穿孔器嵌入肌肉内的移植中执行。最后，基于穿支器的腹直肌移植使腹直肌原位，因此，供体组织中没有肌肉会萎缩并导致体积损失，从而影响长期重建结果[24,25]。例如，在重建封闭空间（例如眼眶）时，预防肌肉萎缩和随后的移植体积损失尤为重要。这三种重建优势的结合使基于穿支的直肌移植成为许多复杂头颈部缺损的理想供体部位。

We evaluated the use of the perforator based rectus transplant in patients with previously treated, vessel-poor necks, patients that required customization of the transplanted adipose tissue based upon body habitus and the dimensions of the defect, and patients with defects within a contained space in which transplanting
我们评估了基于穿支器的直肌移植在既往接受过治疗、颈部血管不良的患者、需要根据身体习惯和缺陷尺寸定制移植脂肪组织的患者以及移植的封闭空间内有缺陷的患者的使用情况。

Table 1 表1

Literature review of the utilization of the rectus donor site in head and neck reconstruction.
头颈部重建中直肌供体位点的利用文献综述.

muscle is not a viable option for long-term volume of the reconstruction.
肌肉不是长期重建体积的可行选择。

This retrospective case series included 30 patients with major defects of the head and neck reconstructed at the University of Michigan Health System, Ann Arbor, from May 2011 to September 2016.
该回顾性病例系列包括 2011 年 5 月至 2016 年 9 月在密歇根大学安娜堡分校卫生系统重建的 30 名头颈部主要缺损患者。

The perforator based rectus transplant was indicated if at least one of the following three reconstructive advantages were required. First, the long pedicle of the transplant would be required because vascular access was limited adjacent to the defect; second, the adipose tissue could be molded by trimming the adipose between the perforators in patients whose defect and/or body habitus required transplant customization; the third advantage was the ability to harvest a transplant that did not contain muscle so that the volume of the transplant was not affected by subsequent muscle atrophy. This third advantage was valuable for reconstructing in contained spaces were subsequent muscle atrophy would affect the function or appearance of the reconstruction.
如果需要以下三个重建优势中的至少一个，则需要基于穿支器的直肌移植。首先，需要移植的长蒂，因为缺损附近的血管通路受到限制;其次，脂肪组织可以通过修剪穿孔器之间的脂肪来成型，这些脂肪的缺陷和/或身体习惯需要移植定制的患者;第三个优点是能够收获不含肌肉的移植物，因此移植物的体积不会受到随后肌肉萎缩的影响。这第三个优点对于在封闭空间中重建很有价值，因为随后的肌肉萎缩会影响重建的功能或外观。

Patients were eligible if they had a defect of the head and neck that was reconstructed with a perforator based rectus transplant. There were 30 patients who met inclusion criteria for the study, 24 were male ( ) and 6 were female ( ). Mean age was 61 (5-96) years and mean follow-up was 16 (1-40) months. The indications for reconstruction were tumor ablation in 26 (86%), osteoradionecrosis (ORN) in 2 (7%), and secondary reconstruction in 2 (7%). The perforator based rectus transplant was used to reconstruct the oral cavity in 21 patients ( ), skull base/orbit in 4 (13%), maxilla in 2 (7%), tongue base in 2 patients ( ) and facial and neck skin in 1 patient (3%). There were 12 patients ( ) who had a previously dissected neck, 10 patients (33%) who had previously underwent chemoradiation treatment (CRT), and 3 patients (10%) that had previously underwent radiation treatment (RT). There were 12 patients ( ) who received postoperative CRT and 7 patients ( ) who received postoperative RT. The mean preoperative body-mass index (BMI) was 24 (17.6-31.8).
如果患者有头颈部缺损，并且通过基于穿孔器的直肌移植重建，则患者符合条件。有 30 名患者符合该研究的纳入标准，其中 24 名为男性 （ ），6 名为女性 （ ）。平均年龄为61（5-96）岁，平均随访时间为16（1-40）个月。重建指征为肿瘤消融26例（86%），放射性骨坏死（ORN）2例（7%），二次重建（7%）。基于穿孔的直肠移植用于重建 21 例患者的口腔 （ ）、4 例 （13%） 的颅底/眼眶、2 例 （7%） 的上颌骨、2 例 （ ） 的舌根和 1 例 （3%） 的面部和颈部皮肤。有 12 例患者 （ ） 既往有颈部解剖术，10 例患者 （33%） 既往接受过放化疗 （CRT），3 例患者 （10%） 既往接受过放疗 （RT）。术后CRT患者12例（ ），术后放疗7例（ ）。平均术前体重指数（BMI）为24（17.6-31.8）。

Periumbilical perforators were identified with a Doppler probe in all 30 patients. The three dominant cutaneous perforators were chosen. The key steps of the transplant harvest are illustrated in Fig. 1. The skin paddle is designed to capture periumbilical perforators, which provides the greatest thickness of adipose tissue and also maximizes pedicle length (Fig. 1a). The skin island was incised down to rectus fascia. The areolar tissue between the subcutaneous adipose and the rectus fascia was used as a surgical plane to elevate the skin paddle and locate the perforators (Fig. 1b). A Stevens tenotomy scissor or the spatulated end of a number 9 periosteal elevator was used for this dissection. Once the dominant perforators were identified, they were dissected from distal to proximal by first opening the rectus fascia around the perforator (Fig. 1c) and then incising the rectus fascia with a single tine of Stevens tenotomy scissors. The rectus muscle fibers were spread apart and cut to join the perforator branches. The pedicle was followed inferiorly, continuing to separate the rectus fibers and dividing the overlying anterior rectus sheath (Fig. 1d). The lateral aspect of the rectus muscle was retracted and left intact. Below the arcuate line, the pedicle is located on the deep side of the rectus muscle, and as a result the muscle fibers were separated but not transected to continue pedicle dissection. The pedicle was followed inferiorly toward the iliac artery and vein (Fig. 1e). Fig. 2 shows the elevation of the skin paddle, perforator identification, and incision of the anterior rectus sheath.
所有 30 例患者均使用多普勒探针鉴定了脐周穿支。选择三种主要的皮肤穿孔器。移植收获的关键步骤如图 1 所示。皮肤桨设计用于捕获脐周穿孔器，从而提供最大厚度的脂肪组织，并最大限度地延长椎弓根长度（图 1a）。皮肤岛被切成直肌筋膜。皮下脂肪和直肌筋膜之间的乳晕组织被用作手术平面，以抬高皮肤桨并定位穿孔器（图 1b）。史蒂文斯肌腱切开术剪刀或 9 号骨膜升降机的刮刀端用于该解剖。一旦确定了显性穿孔，首先打开穿孔器周围的直肌筋膜（图1c），然后用史蒂文斯肌腱切开术剪刀的单齿切开直肌筋膜，从远端到近端解剖它们。将直肌纤维分开并切割以连接穿支。椎弓根向下，继续分离直肌纤维并分裂上覆的前直肌鞘（图1d）。直肌的外侧缩回并保持完整。在弓形线下方，椎弓根位于直肌的深侧，因此肌纤维被分离但未横断以继续椎弓根夹层。椎弓根向下朝向髂动脉和静脉（图 1e）。图 2 显示了皮桨的抬高、穿孔器识别和前直肌鞘的切口。

If the patient had a low BMI, a larger paddle was elevated. If the patient had a high BMI, the paddle was contoured around the perforators to match the recipient defect. Adipose tissue was contoured by removing the adipose adjacent to the rectus sheath
如果患者的 BMI 较低，则较大的桨叶升高。如果患者的 BMI 较高，则在穿孔器周围勾勒桨叶以匹配受体缺陷。通过去除与直肌鞘相邻的脂肪来塑造脂肪组织的轮廓

Fig. 1. Harvest technique for the perforator based rectus free tissue transfer. (a) The template is designed to include the periumbilical perforators, which maximizes pedicle length and thickness of the adipose tissue. The incision is made around the template through skin, Camper's and Scarpa's fascia, to the rectus fascia. (b) Perforator identification is achieved by dissecting the areolar plane between the rectus fascia and the subcutaneous fat of the transplant. Stevens tenotomy scissors or a #9 elevator may be used to dissect this plane. Minimal retraction is performed on the transplant to avoid perforator injury. (c) Once the perforators are identified, perforator dissection is performed by opening the rectus fascia adjacent to the perforator. Once the Stevens tenotomy scissors are inserted into the rectus fascia, a single tine of the scissors is used to cut the rectus fascia. (d) The perforators are dissected to the pedicle, and pedicle dissection is performed, separating and spreading apart the rectus muscle fibers. The anterior rectus sheath is incised once the trajectory of the pedicle is identified. (e) Pedicle dissection is carried out toward the iliac artery and vein to maximize pedicle length.
图 1.基于穿孔器的无直肌组织转移的收获技术。（a） 模板设计为包括脐周穿孔器，从而最大限度地提高脂肪组织的椎弓根长度和厚度。切口在模板周围通过皮肤、Camper 和 Scarpa 筋膜到达直肌筋膜。（b） 通过解剖直肌筋膜和移植皮下脂肪之间的乳晕平面来实现穿支器识别。史蒂文斯肌腱切开剪刀或 #9 升降机可用于解剖该平面。对移植物进行最小回缩，以避免穿支损伤。（c） 一旦确定了穿孔器，通过打开与穿孔器相邻的直肌筋膜进行穿孔器解剖。将史蒂文斯肌腱切开术剪刀插入直肌筋膜后，使用剪刀的单个尖齿剪断直肌筋膜。（d） 将穿孔器解剖至椎弓根，并进行椎弓根解剖，分离并散开直肌纤维。一旦确定了椎弓根的轨迹，前直肌鞘就会被切开。（e） 向髂动脉和静脉进行椎弓根清扫术，以最大限度地延长椎弓根长度。

while preserving the identified perforator. The rectus muscle was reapproximated with 2.0 PDS and the rectus fascia was closed with "figure of 8 " 0.0 prolene suture. Taper needles were used.
同时保留已识别的穿孔器。直肌用 2.0 PDS 重新近似，直肌筋膜用“8 字形”0.0 脯氨酸缝合线闭合。使用锥形针。

Univariate data were tabulated on the three reconstructive advantages of the perforator rectus transplant: use of the transplant in a vessel-poor neck and/or lack of vascular access adjacent to the defect where this donor site provided maximum pedicle length without the need for vein grafting, need for moldable adipose in transplant customization, and reconstruction of defects within a contained space. Univariate data were also collected on BMI, technique of perforator identification, number of perforators, pedicle length, ischemia time, transplant survival, and major and minor complications. Major complications were those that included loss of the transplant, and return to the operating room for secondary reconstruction. Minor complications were those requiring medical treatment and local wound care that did not require return to the operating room.
单变量数据将穿支直肌移植的三个重建优势制成表格：在血管不良的颈部使用移植物和/或缺损附近缺乏血管通路，该供体部位提供最大椎弓根长度而无需静脉移植，移植定制中需要可塑脂肪，以及在封闭空间内重建缺陷。还收集了关于 BMI、穿孔器识别技术、穿孔器数量、椎弓根长度、缺血时间、移植存活率以及主要和次要并发症的单变量数据。主要并发症包括移植失败和返回手术室进行二次重建。轻微的并发症是那些需要医疗和局部伤口护理的并发症，不需要返回手术室。

Fig. 2. Left perforator based rectus template for tongue base defect. (a) Superior and inferior extensions were required for floor of mouth and glossotonsillar sulcus defects, respectively. The head is toward the top of this figure. (b) Elevation of skin and subcutaneous tissue was performed and periumbilical perforators were identified. (c) Rectus sheath was incised and muscle fibers were spread apart to join the perforators.
图 2.基于左穿支的舌根缺损的直肌模板。（a） 口底和舌扁桃体沟缺损分别需要上延伸和下延伸。头部朝向该图的顶部。（b） 抬高皮肤和皮下组织，并确定脐周穿孔器。（c） 切开直肠鞘，将肌纤维分开以连接穿孔器。

Table 2 表2

Reconstructive advantages. The number of patients benefiting from each of the 3 reconstructive advantages of the perforator based rectus transplant: long pedicle, moldable fat, and volume control within a contained space, and the number of patients who benefited from 1 or more reconstructive advantages of the perforator based rectus transplant.
重建优势。受益于基于穿孔器的直肌移植的 3 个重建优势中的每一个的患者人数：长蒂、可塑脂肪和封闭空间内的体积控制，以及受益于基于穿孔器的直肌移植的 1 个或多个重建优势的患者人数。

The reconstructive advantages are shown in Table 2. The first reconstructive advantage is pedicle length (Fig. 3). The mean pedicle length was (range, ). The perforator base rectus transplant was utilized in 11 patients (37%) that had either a vessel-poor neck from previous neck dissection and/or defects without adjacent vascular access. In these patients, the long pedicle provided by the perforator based rectus transplant was utilized to reach secondary recipient vessels without the use of vein grafts (Fig. 3). In the other 19 patients whom the long pedicle of the perforator rectus transplant was not necessary, 17 patients did not have a prior neck dissection, while 2 patients had a previously dissected neck but still had available adjacent recipient vessels.
重建优势如表2所示。第一个重建优势是椎弓根长度（图3）。平均椎弓根长度为 （范围， ）。11 例患者 （37%） 使用了穿支基底直肌移植，这些患者要么因先前的颈部清扫术导致颈部血管不足，要么没有相邻血管通路的缺陷。在这些患者中，基于穿孔器的直肌移植提供的长蒂用于到达次级受体血管，而无需使用静脉移植物（图 3）。在不需要穿支直肌移植长蒂的其他 19 例患者中，17 例患者既往未进行颈部清扫术，而 2 例患者先前有颈部解剖但仍有可用的相邻受体血管。

With respect to the second reconstructive advantage, the perforator rectus transplant was utilized as a donor site in order to provide moldable adipose for transplant customization for 17 patients (57%), due to the defect and/or the patient BMI and body habitus (Table 2). The use of this second reconstructive advantage was largely influenced by BMI. The identification and dissection of the perforators permitted customization of the amount of adipose tissue on the transplant, which was particularly useful in patients with elevated BMI. In the 17 patients where the adipose was customized 10 patients had oral cavity defects, 3 had defects of the orbit and skull base, 2 had maxilla defects, and 2 had tongue base defects. There were 13 patients in whom the reconstruction necessitated the preservation of all subcutaneous tissue harvested with the transplant and thus did not require moldable adipose tissue. Eleven of these patients were undergoing oral cavity reconstruction and had a low to normal BMI (range 17.6 -23.7) and one patient was undergoing orbit/skull base reconstruction and had a low BMI (17.9); as a result, all the adipose tissue harvested with the transplant was preserved to maintain optimal volume reconstruction. The thirteenth patient (BMI 25.8) whose reconstruction did not require moldable adipose had a soft tissue defect of the face and neck skin after osteoradionecrosis and all the adipose tissue harvested with the transplant was preserved.
关于第二个重建优势，穿支直肌移植被用作供体部位，以便为 17 名患者 （57%） 提供可塑的脂肪用于移植定制，原因是缺陷和/或患者的 BMI 和身体习惯（表 2）。这第二个重建优势的使用很大程度上受到BMI的影响。穿孔器的识别和解剖允许定制移植上的脂肪组织量，这对 BMI 升高的患者特别有用。在定制脂肪的17例患者中，10例患者存在口腔缺损，3例存在眼眶和颅底缺损，2例存在上颌骨缺损，2例存在舌根缺损。有 13 名患者的重建需要保留所有通过移植收获的皮下组织，因此不需要可塑的脂肪组织。其中 11 例患者正在接受口腔重建，BMI 低至正常（范围 17.6 -23.7），1 例患者正在接受眼眶/颅底重建，BMI 较低 （17.9）;结果，所有通过移植收获的脂肪组织都被保留下来，以保持最佳的体积重建。第13例患者（BMI 25.8）的重建不需要可塑性脂肪，放射性骨坏死后面部和颈部皮肤有软组织缺损，移植收获的所有脂肪组织均被保留。

With respect to the third reconstructive advantage, 25 patients (83%) had defects within a contained space that required the perforator-based transplant to provide robust and reliable volume reconstruction that would not be affected by muscle atrophy within the contained space (Table 2). Of these 25 patients, 19 patients had oral cavity defects, 4 patients had defects of the orbit and skull base, and 2 patients had base of the tongue defects. For the patients with the oral cavity and base of the tongue, this reconstructive advantage facilitated the maximal volume of the reconstruction in the oral cavity with less concern about loss of volume from muscle atrophy and impairment of speech and or swallowing function. For the patients with orbital defects, the volume in the contained space of the orbit could be maintained to prevent the appearance of a hollow orbit.
关于第三个重建优势，25 名患者 （83%） 在封闭空间内存在缺陷，需要基于穿孔器的移植提供强大可靠的体积重建，不会受到封闭空间内肌肉萎缩的影响（表 2）。在这25例患者中，19例患者有口腔缺损，4例患者有眼眶和颅底缺损，2例患者有舌根缺损。对于有口腔和舌根的患者，这种重建优势促进了口腔重建的最大体积，而较少担心肌肉萎缩导致的体积损失和言语和/或吞咽功能受损。对于有眼眶缺损的患者，可以保持眼眶包含空间的体积，以防止出现空心眼眶。

At least one reconstructive advantage of the perforator based rectus transplant was utilized in all 30 patients (100%) (Table 2). There were 17 patients ( ) who benefited from at least two reconstructive advantages, and 6 patients (20%) who benefited from all three reconstructive advantages of the perforator based rectus transplant. Figs. 4 and 5 describe two patients reconstructed with this transplant and highlight its reconstructive advantages.
所有 30 例患者 （100%） 都使用了基于穿支器的直肌移植的至少一项重建优势（表 2）。有 17 名患者 （ ） 受益于至少两个重建优势，6 名患者 （20%） 受益于基于穿孔器的直肌移植的所有三个重建优势。图 4 和图 5 描述了两名通过这种移植重建的患者，并强调了其重建优势。

The mean number of perforators supplying the transplant was 2.2 (1-4). The mean ischemia time was . The success rate of transplantation was . Two patients ( ) had complete loss of the transplant and required secondary reconstruction. There were no other major complications. Five patients (17%) had minor complications; 2 patients had a donor site hematoma, 2 patients had a neck hematoma and 1 patient had a donor site cellulitis.
提供移植物的平均穿孔数为 2.2 （1-4）。平均缺血时间为 。移植成功率为 。两名患者 （ ） 完全失去移植，需要二次重建。没有其他主要并发症。5例患者（17%）有轻微并发症;2例患者有供体部位血肿，2例患者有颈部血肿，1例患者有供体部位蜂窝织炎。

We have identified and described three reconstructive advantages of the perforator based rectus transplant, and the combination of these three advantages within one donor site make it an ideal soft tissue transplant for many complex head and neck defects. First, this donor site provides excellent pedicle length and the ability to reach recipient vessels in the vessel-poor neck without the use of vein grafts. In a traditional musculocutaneous rectus flap, the average pedicle length from the takeoff of the external iliac artery to the rectus muscle is [26]. In this series, mean pedicle length was , as the increased length is gained by tracing the pedicle through the muscle and fascia. In this series, ( 11 of 30 ) of patients avoided the need for vein grafting due to the pedicle length of this transplant. These 11 patients had a vessel-poor neck from previous neck dissection, and had another donor site been chosen, vein grafting would have likely been necessary to reach the recipient vessels. While vein grafting in free tissue transplantation has been well described, it is associated with
我们已经确定并描述了基于穿支器的直肌移植的三个重建优势，并且这三个优势在一个供体部位的结合使其成为许多复杂头颈部缺损的理想软组织移植。首先，该供体部位提供了出色的椎弓根长度，并且能够在不使用静脉移植物的情况下到达血管贫乏的颈部的受体血管。在传统的肌皮直肌皮瓣中，从髂外动脉起飞到直肌的平均椎弓根长度为 [26]。在这个系列中，平均椎弓根长度为 ，因为增加的长度是通过追踪椎弓根穿过肌肉和筋膜获得的。在该系列研究中， （30 例中的 11 例）患者由于这种移植的椎弓根长度而避免了静脉移植的需要。这 11 名患者在先前的颈部清扫术中颈部血管不足，如果选择了另一个供体部位，则可能需要静脉移植才能到达受体血管。虽然游离组织移植中的静脉移植已经得到了很好的描述，但它与

Fig. 3. Pedicle length provided by the perforator based rectus free tissue transfer. Pedicle length was measured intra-operatively. These patients were undergoing reconstruction of defects of the infrastructure maxilla (a) and tongue base (b). Mean pedicle length in this study was (9-18 cm).
图 3.由穿孔器提供的椎弓根长度基于直肌游离组织转移。术中测量椎弓根长度。这些患者正在接受上颌骨（a）和舌根（b）基础设施缺陷的重建。本研究中的平均椎弓根长度为 （9-18 cm）。

Fig. 4. (a) Preoperative photograph of a 60 year old woman who developed osteoradionecrosis after surgical and chemoradiation treatment of a T4a N1 M0 lacrimal gland adenocarcinoma. Previous surgery included right orbital exenteration with subtotal maxillectomy, right total parotidectomy, right selective neck dissection levels II-IV, and midface reconstruction with right thoracodorsal artery scapular tip free tissue transplant. This was followed by adjuvant chemoradiation. Four years after completion of treatment, she was free of disease but developed osteoradionecrosis of the sphenoid and frontal bone. (b) Template of the right perforator based rectus transplant in this patient. The head is toward the right in this figure. Resection of osteoradionecrotic tissue created an orbital defect, loss of the anterior cranial fossa floor, loss of the upper lateral frontal brow, and loss of the upper lateral aspect of the lateral orbital rim. (c) The transplant was based upon two perforators, the most dominant being in diameter and the second perforator . The head is toward the right in this figure. Pedicle length was in this patient. The prior thoracodorsal transplant was anastomosed to the right facial vessels, and the perforator based rectus transplant was anastomosed to the right superior thyroid artery and a tributary of the common facial vein. Excess pedicle length was . (d) and (e) Thirteen-month postoperative photographs. Note that the moldability of this transplant allowed the restoration of supraorbital rim projection without the use of an osseous transplant. The lack of muscle atrophy also prevented contraction within the orbit. All three reconstructive advantages of the perforator based rectus transplant were utilized in this patient. (d) Frontal view. (e) Right profile view.
图 4.（a） 一名 60 岁女性的术前照片，该女性在 T4a N1 M0 泪腺腺癌的手术和放化疗后出现放射性骨坏死。既往手术包括右眼眶切除术和颌骨次全切除术、右全腌腺切除术、右选择性颈部清扫术 II-IV 级，以及右胸尾动脉肩胛骨尖端游离组织移植的中面部重建。随后是辅助放化疗。完成治疗四年后，她没有疾病，但出现了蝶骨和额骨放射性骨坏死。（b） 该患者基于右穿孔器的直肌移植模板。在这张图中，头部朝向右边。放射性骨坏死组织切除可导致眼眶缺损、颅底前窝缺失、额上外侧眉缺失和眶外侧缘上外侧缺失。（c） 移植基于两个穿孔器，最主要的是 直径，第二个穿孔 器。在这张图中，头部朝向右边。该患者的椎弓根长度。 先前的胸腔移植吻合至右侧面部血管，基于穿支的直肌移植吻合至右侧甲状腺上动脉和面总静脉的支流。过多的椎弓根长度是 。（d） 和 （e） 13 个月的术后照片。请注意，这种移植的可塑性允许在不使用骨移植的情况下恢复眶上边缘投影。缺乏肌肉萎缩也阻止了眼眶内的收缩。 基于穿支的直肌移植的所有三个重建优势都用于该患者。（d） 正面视图。（e） 右侧剖面图。

an increased vascular complication rate, which is reported as high as in the head and neck .
血管并发症发生率增加，据报道与头部和颈部 一样高 。

The second important advantage provided by the perforator based rectus transplant in this study is the ability to provide highly moldable adipose tissue that permitted transplant customization. This is an inherent advantage of perforator based transplants
在本研究中，基于穿支器的直肌移植提供的第二个重要优势是能够提供高度可塑的脂肪组织，从而允许移植定制。这是基于穿支器的移植的固有优势
[29], and the adipose tissue on the perforator based rectus transplant could be molded by trimming the adipose between the perforators in patients whose defect and/or body habitus required transplant customization. This reconstructive advantage was critical in those patients with elevated BMI, where the thickness of the adipose tissue was greater than desired. In this series, of
[29]，基于穿孔器的直肌移植上的脂肪组织可以通过修剪穿孔器之间的脂肪来成型，这些脂肪存在于缺陷和/或身体习惯需要移植定制的患者中。这种重建优势对于BMI升高的患者至关重要，因为脂肪组织的厚度大于预期。在本系列中，

Fig. 5. (a) Preoperative template for the perforator based rectus transplant in a 5 year old girl with T4a N0 M0 rhabdomyosarcoma of the left orbit undergoing orbital exenteration and closed orbital reconstruction. Periumbilical perforators were located using SPY (black dot) and a Doppler (purple dot). Surrounding adipose tissue adjacent to the skin paddle was included for volume reconstruction of the orbit. (b) and (c) The perforator based rectus transplant is harvested and based upon two perforators. The adipose tissue was then molded to the volume of the orbital defect. The transplant does not contain any muscle fibers, maximizing pedicle length and avoiding muscle atrophy within the orbit. (d) This donor site provided of pedicle length, which reached the facial artery and facial vein. (e) 9-month postoperative photograph of the closed orbital reconstruction achieved with the perforator based rectus transplant. Similar to the case shown in Figure 10, the lack of muscle atrophy prevented contraction within the orbit.
图 5.（a） 一名患有左眼眶 T4a N0 M0 横纹肌肉瘤的 5 岁女孩接受眼眶切除和闭合眼眶重建的基于穿孔器的直肌移植术前模板。使用 SPY（黑点）和多普勒（紫点）定位脐周穿孔器。包括与皮肤桨相邻的周围脂肪组织，用于眼眶的体积重建。（b） 和 （c） 基于穿孔器的直肌移植是收获的，并且基于两个穿孔器。然后将脂肪组织塑造成眼眶缺损的体积。移植物不含任何肌肉纤维，最大限度地延长了椎弓根长度并避免了眼眶内的肌肉萎缩。（d） 该供体部位的 椎弓根长度，到达面动脉和面静脉。（e） 使用基于穿孔器的直肌移植实现闭合眼眶重建的术后 9 个月照片。与图10所示的情况类似，缺乏肌肉萎缩阻止了眼眶内的收缩。

patients (17 of 30) benefitted from this reconstructive advantage. Had we performed a non-perforator dissection, we would have been forced to include all of the adipose tissue within the dissection, regardless of the patient's BMI and the volume required for reconstruction. In contrast, performing a perforator based dissection facilitates the customization of the donor site based upon the thickness of the patient's periumbilical adipose tissue and the volume required for optimal reconstruction of the defect. When customizing the adipose tissue, we take care not to disturb the subdermal plexus, which could compromise the skin paddle.
患者（30 人中有 17 人）受益于这种重建优势。如果我们进行非穿支解剖，我们将被迫将所有脂肪组织纳入解剖中，无论患者的 BMI 和重建所需的体积如何。相比之下，进行基于穿支器的解剖有助于根据患者脐周脂肪组织的厚度和最佳重建缺损所需的体积定制供体部位。在定制脂肪组织时，我们注意不要干扰皮下神经丛，这可能会损害皮肤桨。

The third reconstructive advantage of this transplant is the ability to reconstruct volume within a contained space without the use of muscle. It is well documented that transplanted muscle undergoes denervation atrophy and subsequent reduction in volume . Over time, reconstruction of defects within contained spaces will undergo significant volume loss if muscle is transplanted into the defect, leading to up to reduction in muscle volume due to muscle atrophy alone at one year . Conversely, adipose-rich transplants have been shown to maintain long-term volume after surgery [24], suggesting that transplants with high adipose-to-muscle ratios are more likely to achieve reliable volume reconstruction over time. This finding is critically important for reconstruction of defects within a contained space, where muscle atrophy can significantly affect the cosmesis and function of the reconstruction. In this series, the defects within contained spaces were the orbit, oral tongue, and tongue base. Harvest of this donor site using a perforator base approach permitted reliable volume reconstruction of these contained spaces, without concern for long-term muscle atrophy.
这种移植的第三个重建优势是能够在不使用肌肉的情况下在封闭空间内重建体积。有据可查的是，移植的肌肉会经历去神经萎缩和随后的体积 减少。随着时间的流逝，如果将肌肉移植到缺损中，则在封闭空间内重建的缺损将发生显着的体积损失，导致仅在一年 内仅由于肌肉萎缩而导致肌肉体积 减少。相反，富含脂肪的移植已被证明可以在手术后保持长期体积[24]，这表明脂肪与肌肉比高的移植更有可能随着时间的推移实现可靠的体积重建。这一发现对于在封闭空间内重建缺陷至关重要，其中肌肉萎缩会显着影响重建的外观和功能。在这个系列中，包含空间内的缺陷是眼眶、口腔舌和舌根。使用穿孔器基础方法收获该供体位点可以可靠地重建这些包含的空间，而无需担心长期肌肉萎缩。

An important difference exists between the DIEP transplant initially described in 1994 by Allen et al. [30], and the perforator rectus transplant described in this paper. Our transplant is designed and centered around periumbilical perforators for two reasons. First, patients with malignancies of the upper aerodigestive tract have a lower BMI, and the periumbilical adipose is the thickest in this location. Second, designing the skin paddle in a more superomedial location also provided additional pedicle length to reconstruct defects using secondary recipient vessels for example in a vessel poor neck. As a result, this technique captures the thickest adipose tissue in the periumbilical region while maximizing pedicle length. An additional advantage the perfarot rectus does share with the DIEP transplant is the ability to close the abdominal wall primarily and without tension, which significantly lowers the incidence of hernia formation in this new donor site [31].
Allen等[30]于1994年首次描述的DIEP移植与本文描述的穿支直肌移植之间存在重要差异。我们的移植手术以脐周穿孔器为中心，有两个原因。首先，上呼吸消化道恶性肿瘤患者的BMI较低，脐周脂肪是该位置最厚的。其次，将皮肤桨设计在更上内侧的位置也提供了额外的椎弓根长度，以使用次级受体血管重建缺损，例如在血管不良的颈部。因此，该技术捕获了脐周区域最厚的脂肪组织，同时最大限度地延长了椎弓根长度。perfarot rectus与DIEP移植的另一个共同优势是能够主要闭合腹壁且无张力，这显著降低了该新供体部位疝气形成的发生率[31]。

Masià et al. [32] report on the use of the extended DIEP for head and neck reconstruction, also noting the long pedicle of this donor site as well as the ability to harvest a chimeric perforator flap for mucosal and external skin reconstruction. The harvest technique is similar to that which is described in this paper. An important difference is that the paper by Masià et al. [32] included myocutaneous perforator flaps, while this paper describes only cutaneous perforator based flaps. Another important difference is in patient selection: we selected patients whose defects were within contained spaces as a prime indication for the use of this donor site in order to avoid the associated muscle atrophy and loss of volume that would impact function.
Masià等[32]报道了使用扩展的DIEP进行头颈部重建，还指出该供体部位的长蒂以及收获嵌合穿孔皮瓣进行粘膜和外部皮肤重建的能力。收获技术与本文中描述的技术相似。一个重要的区别是，Masià等[32]的论文包括了肌皮穿孔皮瓣，而这篇论文只描述了基于皮肤穿孔的皮瓣。另一个重要的区别是患者选择：我们选择缺陷在封闭空间内的患者作为使用该供体部位的主要适应症，以避免相关的肌肉萎缩和体积损失，从而影响功能。

While outside the primary scope of the paper, the authors find several importance differences between the perforator rectus and the perforator based anterolateral thigh flap (ALT). The diameter of the perforators are typically larger in the rectus donor site. The perforators are also concentrated near the umbilicus. For these
虽然超出了本文的主要范围，但作者发现穿支直肌和基于穿支的大腿前外侧皮瓣 （ALT） 之间存在一些重要差异。在直肌供体部位，穿孔器的直径通常较大。穿孔器也集中在脐部附近。对于这些
two reasons, locating the primary angiosome and designing the skin paddle within the primary angiosome is more reliable in the rectus donor site. For defects requiring thick adipose tissue, the rectus donor site can often provide thicker adipose tissue, particularly in men with low BMI. Finally, when harvesting the perforator based rectus at the level of the umbilicus, a longer pedicle can be achieved with this donor site, compared to the ALT [32].
两个原因，定位原发性血管体并在原发性血管体内设计皮肤桨在直肌供体部位更可靠。对于需要较厚脂肪组织的缺陷，直肌供体部位通常可以提供较厚的脂肪组织，尤其是在 BMI 低的男性中。最后，当在脐部水平收获基于穿孔的直肌时，与ALT相比，该供体部位可以获得更长的椎弓根[32]。

Several limitations of this transplant exist. Harvesting a perforator based rectus transplant is more technically demanding compared to the traditional myocutaneous paddle. Dissection of the perforators results in greater harvest time, and we believe that close dissection of the perforators may result in greater risk of transplant necrosis. Finally, it can be difficult to localize the dominant perforator, and the inability to identify a dominant perforator may result in loss of the transplant.
这种移植存在一些局限性。与传统的肌皮桨相比，收获基于穿支器的直肌移植对技术要求更高。解剖穿孔器可延长收获时间，我们认为对穿孔器进行近距离解剖可能会导致更大的移植坏死风险。最后，可能难以定位显性穿孔，并且无法识别显性穿孔可能导致移植丢失。

Two patients in this study had flap failure, requiring secondary reconstruction. One patient who had loss of the transplant was undergoing reconstruction of a unilateral floor of mouth and oral tongue defect after resection of adenoid cystic carcinoma involving the sublingual gland. SPY imaging was used to identify candidate perforators. However, the dominant perforator that was chosen was found to be extremely diminutive with no decussation of the rectus fascia identified for the perforator. This transplant was based upon a diminutive secondary periumbilical perforator, in diameter.
本研究中有两名患者出现皮瓣衰竭，需要二次重建。一名移植失败的患者在切除涉及舌下腺体的腺样囊性癌后，正在接受单侧口腔底和口腔舌缺损的重建。SPY成像用于识别候选穿孔器。然而，发现选择的主要穿孔器非常小，没有为穿孔器识别出直肌筋膜的凹陷。该移植基于直径较小的次级脐周穿孔 器。

The second patient who had loss of the transplant had an orbital defect after orbital exenteration for mucoepidermoid carcinoma of the lacrimal gland. SPY imaging and Doppler was used to determine the location of the dominant perforator. This patient had a history of five full-term pregnancies, and we theorized that this might have resulted in collateral circulation, creating a vascular pattern in which the perforators were interlaced within the adipose and perhaps making her less suitable for a perforator-based transplant. We made our initial incision around the primary perforator, and dissected down to the rectus fascia. The location of the perforator at the level of the rectus fascia did not correlate to the position of the perforator on the skin. As a result the perforator could not be included in the skin paddle. Interestingly, there were no other large perforators. We observed an atypical vascular pattern of many small perforators with a dense cross-branching pattern in Campers fascia. We attempted this transplant based on this small perforator and do not know if the vascular pattern was a normal variant versus a change related to multiple pregnancies.
第二位移植失败的患者在泪腺粘液表皮样癌眼眶切除后出现眼眶缺损。SPY成像和多普勒用于确定显性穿支器的位置。这名患者有五次足月妊娠史，我们推测这可能导致侧支循环，形成一种血管模式，其中穿孔器在脂肪内交错，可能使她不太适合基于穿孔器的移植。我们在主穿孔器周围做了最初的切口，并解剖到直肌筋膜。穿孔器在直肌筋膜水平的位置与穿孔器在皮肤上的位置无关。因此，穿孔器无法包含在皮肤桨中。有趣的是，没有其他大型穿孔器。我们在Campers筋膜中观察到许多小穿孔的非典型血管模式，具有密集的交叉分支模式。我们尝试了基于这个小穿孔器的移植，但不知道血管模式是正常变异还是与多胎妊娠相关的变化。

Based on these two transplant failures, we have modified our approach. We perform an exploration of perforators from a lateral approach to identify and dissect the perforators. If a dominant perforator is not identified the elevation will not be completed. Some caution is advised if the patient has had multiple pregnancies, which may result in smaller periumbilical perforators.
基于这两次移植失败，我们修改了我们的方法。我们从横向方法对穿孔器进行探索，以识别和解剖穿孔器。如果未确定主要穿孔器，则不会完成抬高。如果患者有多胎妊娠，建议谨慎行事，这可能导致脐周穿支变小。

The ideal candidate for this flap is a soft tissue defect that requires a long pedicle, exists within a contained space such as the mandible or orbit, and requires customization of adipose tissue during the inset to optimize the reconstruction. Orbit defects undergoing closed orbit reconstruction, infrastructure maxilla defects, total glossectomy and extended hemiglossectomy defects, and edentulous lateral composite mandibulectomy defects are some examples of defects that are potentially ideal for use of the perforator rectus donor site.
这种皮瓣的理想候选者是软组织缺损，需要长蒂，存在于下颌骨或眼眶等封闭空间内，并且需要在插入过程中定制脂肪组织以优化重建。接受闭合眼眶重建的眼眶缺损、上颌骨基础设施缺损、全舌切除术和扩展半舌切除术缺损以及无牙颌外侧复合下颌切除术缺损是一些可能非常适合使用穿支直肌供体部位的缺陷示例。

Perforator transplants are increasing the options and flexibility of autogenous transplantation. In the rectus site, we have described three major reconstructive advantages of the perforator based rectus transplant: a long pedicle that prevents the need for vein grafting in the vessel-poor neck, moldable adipose tissue that permits transplant customization, and the ability to reconstruct defects within a contained space without the use of muscle. We believe that these reconstructive advantages make this donor site an excellent choice for complex soft tissue defects of the head and neck.
穿支移植增加了自体移植的选择和灵活性。在直肌部位，我们描述了基于穿孔器的直肌移植的三个主要重建优势：长蒂，可防止在血管不良的颈部进行静脉移植，可塑的脂肪组织允许移植定制，以及能够在不使用肌肉的情况下在封闭空间内重建缺陷。我们相信，这些重建优势使该供体部位成为头颈部复杂软组织缺损的绝佳选择。

None declared. 没有宣布。

Drs. Chepeha, Kang, and Spector had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The authors thank Anthony Baker, CMI, for illustrating the transplant harvest.
Chepeha、Kang 和 Spector 博士可以完全访问研究中的所有数据，并对数据的完整性和数据分析的准确性负责。作者感谢 CMI 的 Anthony Baker 对移植收获进行了说明。

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