唇红缺损修复方法

相对于唇部大块软组织的缺损而言，唇红缺损对用来修复缺损的组织的质地、颜色等要求更高，以达到理想的美观效果，同时需要兼顾嘴唇以及口轮匝肌的功能。这篇文章主要是总结一下日常学习中了解到的唇红缺损的修复方法。

唇周粘膜/肌肉粘膜瓣

根据解剖学对唇和颊的定义，颊部为干湿线以内的粘膜部分，所以这种方法即通过滑行推进、旋转推进等方式利用嘴唇内侧、两侧口角后方的颊粘膜瓣/肌肉粘膜瓣来修复唇红缺损。

1. 利用嘴唇内的粘膜制备的单蒂或双蒂滑行黏膜瓣，可能存在术后发生嘴唇内卷的情况；旋转推进黏膜瓣造成的嘴唇内卷的情况则相对不明显。

2. 两侧口角后方的颊肌粘膜瓣可以用来修复大范围的唇红缺损，可提供较多粘膜及一部分肌肉用于修复而供区仍可一期缝合且无需二期手术断蒂是其优势。韩景健等¹介绍的方法如下:

   颊肌黏膜瓣以口角处颊肌与口轮匝肌交接处为蒂，其上界应尽可能在腮腺导管开口下1 cm，以免损伤腮腺导管，瓣的长度可达冀下颌缝，宽度可达2.5-3.0cm。根据实际缺损的大小确定颊肌黏膜瓣的长度和宽度，其长度一般大于缺损长度1.5- 2.0cm，以减少肌黏膜瓣旋转后蒂部的张力。根据以往的研究，颊肌黏膜瓣内存在面动脉前颊支，因此在设计时不存在长宽比的限制 。以美蓝标记肌黏膜瓣的切取范围。沿标记线切开黏膜、黏膜下层及颊肌，在颊肌的外面、颊筋膜深面疏松结缔组织内掀起颊肌黏膜瓣，以蒂部为轴，将其旋转覆盖红唇受区。如缺损区与口角颊肌黏膜瓣蒂部之间存有正常红唇组织，则需将其部分或全部切除。根据对侧正常红唇大小形态或术者的判断（如唇红完全缺损）修剪颊肌黏膜瓣大小和厚度，以形成丰满、对称的红唇。应注意不可修剪太薄，尤其是蒂部，以免影响瓣的血运。如同时合并唇部皮肤的缺损，可同时行游离植皮或皮瓣修复。供区直接拉拢缝合。术后于红唇切口涂红霉素软音，暴诏，并及时清理伤口处血痐。术后早期患者应进流质饮食，2d后可进半流质饮食。每日3次及进食后以氯已定漱口。术后7d拆线，拆线后可正常饮食。无需二次手术断蒂。

1. Watson²等设计了一种带神经制作的口轮匝肌粘膜瓣用于修复唇红缺损。手术方式如下：
   A vertical incision is made through mucosa and muscle from the free border of the lip at the junction of the normal lip and the defect. It is carried up to the buccal sulcus along which it runs to a point about one centimetre beyond the angle of the mouth. The flap is now undermined between muscle and skin right down to, and even beyond, the free border of the defect. The elasticity of the mucosa will then allow the flap to unroll and obliterate the defect by a combination of rotation and downward advancement (如下图所示).

1. 如果缺损区域较小，如因手术安全便边界需要而切除部分唇红，那么可以使用临近唇红组织设计弹性唇红瓣予以修复。

2. 李喆³等提出了一种改良斧形肌肉粘膜瓣修复半侧红唇缺损的方法（如下图，这个图示虽然引自原文，但是画的并不是很准确）。其优点在于可以通过唇红肌肉粘膜瓣的量来调整两侧嘴唇的厚度。
   

3. The running V-flap technique
   Nesrin等⁴在上唇唇红缺损修复时提出了The running V-flap的修复技巧，其手术方法如下：
   The distance between the midline of the area exhibiting vermilion deficiency in the upper lip and the vermilion of the lower lip is measured at rest. This measurement provides the required length of tissue advancement. The length of the V-flap should be 1.5 times greater than this value, and its width should enable the width of the tissue deficiency to form the V-flap floor. Those measurements are marked over the oral mucosa of the area exhibiting deformity. Running V-flaps are marked at both sides of the main V-flap in a manner ensuring half the width and length of the preceding flap (Figure 1A). If the main V-flap (Flap a) is planned to be large, then the number of following flaps should be increased accordingly. All flaps are raised off the muscles. If needed, muscle repair should be performed. Flap A is advanced to fill the defect. The donor site of flap A is closed by two B flaps raised from both sides. The donor sites of the b flaps are closed by the c flap. This procedure is continued based on the number of prepared flaps (Figure 1B). The number of running flaps are planned based on the size of the deficiency (Figure 1C).
   

舌背肌肉粘膜瓣

手术设计：首先切除下唇黏膜病变，深度达口轮匝肌，形成唇红黏膜缺损创面。根据切除后造成的缺损， 沿舌缘作一弧形切口， 长度与下唇缺损黏膜相近。切开黏膜，深度约0.5 cm，在肌层上方将黏膜潜行分离、掀起，制备成舌瓣。将舌瓣与下唇缺损对位缝合：先将舌腹切缘与唇红创面的舌侧连续缝合，再连续缝合舌背切缘与唇红创面的皮肤切缘。3 周后，将舌瓣断蒂，遗留的舌创面直接拉拢缝合，关闭下唇遗留创面。⁵

舌腹粘膜/肌肉粘膜瓣

The corners of lower lip are stretched by 2 sutures for better flap inset (Fig. 1B). The tumor is resected with a safe margin (1 cm in SCC and 0.5 cm in VC) in an approximately rectangular shape (Fig. 1C).The specimen is sent for histopathological free-border confirmation by frozen section (Fig. 1D). In most of our cases, only the vermilion and subcutaneous tissues are incised, thus preserving the orbicularis oris muscle, depressor labii inferioris muscle, and mentalis muscle. The flap consists of a longitudinal strip of the free border of the tongue nonkeratinized mucosal layer with/without submucosal muscular layers of the tongue and includes the terminal branch of the lingual artery. This strip extends between the angles of the mouth (actually a few millimeters longer than the angles to ensure adequate coverage in full lower lip defects and smaller in partial defects. The mucosal or myomucosal flap (depends on thickness of the defect) of the ventral tongue is designed according to the shape and size of the vermilion defect while the tongue is elevated (Fig. 1E). For better advancement of the flap, it is necessary to dissect the ventral mucosa of the tongue at least 1 cm lateral to the flap margins (Figs. 1F, G). The lip defect is covered by the tongue myomucosal flap, whereas the orbicularis oris muscle preserves the oral sphincter. The myomucosal tissue is sutured in 2 layers, joining the mucosal border of the tongue and the upper end of the skin (Fig. 1H). The tongue flap pedicle is cut off after 3 weeks, and the oral side of the vermilion is sutured (Fig. 1I). The donor site of the tongue is closed primarily. Moisturizing cream is applied for at least 2 months after surgery to prevent dryness and chapping of the new vermilion⁶.

交叉唇瓣法

即Abbe瓣的变化形式。如Mutsumi Okazaki等⁷的方法（如下图）。