股前外侧皮瓣修复上颌骨缺损术后面部软组织对称性感观分级

doi:10.19723/j.issn.1671-167X.2023.04.023

摘要/Abstract

摘要：

目的: 采用三维立体摄影测量与主观评价相结合的方法初步建立股前外侧皮瓣修复上颌骨缺损术后面部软组织对称性的感观分级系统。方法: 患者上颌骨因肿瘤侵犯而被行不同范围的切除, 同期行股前外侧皮瓣(anterolateral thigh flap, ALTF)修复。术后采用三维立体摄影技术获取患者三维面相, 以任意平面为对称面创建原始三维面相的镜像, 重叠配准原始面相与镜像后, 将患侧面部分为6个区域, 采用基于表面的色谱分析法测量患侧面部软组织三维变化。同时请20名非医学专业人员作为评价者对患者的三维面相进行主观评价, 并在Likert 5分量表中进行评分, 根据主观评分将面部软组织的对称性进行分级。应用SPSS 24.0统计软件对三维立体摄影测量结果与主观评价分级进行统计学分析。结果: 共有44例患者符合入组条件, 其中男性21例, 女性23例, 年龄19~79岁。按照主观评价得分将所有患者面部软组织对称性分为Ⅰ、Ⅱ、Ⅲ级。Ⅰ级患者面部基本对称, Ⅱ级患者面部略不对称, Ⅲ级患者面部明显不对称。Ⅰ、Ⅱ、Ⅲ级患者在眶下区及颧区的差异均有统计学意义(P < 0.05), Ⅰ级与Ⅲ级患者相比, 除眶下区与颧区外, 颊区与上唇区的差异也具有统计学意义(P < 0.05)。上颌骨缺损范围越大, ALTF修复后的患者面部对称性越差。结论: 不同范围上颌骨切除后经过单纯ALTF修复的患者其面部软组织依然会存在不同程度的不对称, 所引起的感观不适可分为三个等级, 等级越高表明面部软组织对称性越差; 眶下区与颧区是影响面部对称性感知的重要区域, 其次为颊区与上唇区, 临床医师在进行上颌骨缺损修复尤其是累及眶底的大范围缺损修复时, 应当重视这些区域的软组织支撑。

关键词: 上颌骨缺损, 股前外侧皮瓣, 三维立体摄影, 主观评价, 感观分级

Abstract:

Objective: To preliminarily establish a category of facial symmetry perception after maxillary reconstruction using anterolateral thigh flap (ALTF) by the methods of stereophotogrammetry and subjective assessment. Methods: The patients underwent maxillectomy due to neoplasms invasion, and all the maxillary defects were reconstructed using ALTF.Three-dimensional (3D) photographs were captured from the patients with a stereophotogrammatrical camera set-up.In the Geomagic software, the mirror image was created by reflecting along an arbitrary plane outside of the face.After the registration, the postoperative side on the original 3D photograph was segmented into 6 areas.The 3D change of the facial soft-tissue was measured using surface-based color map.Twenty laypeople took part in the study as observers, and they were asked to rate the 3D photographs using 5 point Likert-type scale according to their own aesthetic standard.The soft tissue asymmetry was graded according to the score.The collected data were subjected to statistical analysis using the SPSS 24.0 software. Results: In the study, 44 subjects were recruited (21 males and 23 females, age range from 19 to 79 years).The soft-tissue symmetry was graded into three levels according to the subjective scores.The grade Ⅰ was basically symmetrical.The grade Ⅱ was slightly asymmetrical.The grade Ⅲ was obviously asymmetrical.Statistically significant differences were found in the suborbital (P < 0.05) and zygomatic (P < 0.05) areas when comparing all grades of soft-tissue asymmetry, and in the buccal (P < 0.05) and superiolabial (P < 0.05) areas when comparing grades Ⅰ and Ⅲ.The extent of maxillary defect had significant impact on the symmetry of the midface soft-tissue after maxillary reconstruction. Conclusion: Varying extent maxillectomy would result in varying degrees of asymmetry, and cause different grades of symmetry perception even if they had been reconstructed using ALTF.The higher the grade, the worse the symmetry of facial soft-tissue.Suborbital and zygomatic areas were important aesthetic units that affected the facial symmetry perception, followed by buccal and superiolabial areas.The clinicians should pay attention to the soft-tissue support in these areas when reconstructing the maxillary defect, especially large defect with orbital floor involved.

Key words: Maxillary defect, Anterolateral thigh flap, Stereophotogrammetry, Subjective assessment, Perception category

中图分类号:

R782.4

黄莹,吴志远,周行红,蔡志刚,张杰. 股前外侧皮瓣修复上颌骨缺损术后面部软组织对称性感观分级[J]. 北京大学学报（医学版）, 2023, 55(4): 708-715.

Ying HUANG,Zhi-yuan WU,Xing-hong ZHOU,Zhi-gang CAI,Jie ZHANG. Category of facial symmetry perception after maxillary reconstruction using anterolateral thigh flap[J]. Journal of Peking University (Health Sciences), 2023, 55(4): 708-715.

图/表 12

图1

表1

图2

图3

表2

图4

表3

表4

表5

表6

表7

表8

参考文献 26

1	Piazza C , Paderno A , Del Bon F , et al. Palato-maxillary reconstruction by the angular branch-based tip of scapula free flap[J]. Eur Arch Otorhinolaryngol, 2017, 274 (2): 939- 945. doi: 10.1007/s00405-016-4266-0
2	于森, 王洋, 毛驰, 等. 1107例上颌骨缺损的临床分类及修复方法分析[J]. 北京大学学报(医学版), 2015, 47 (3): 509- 513.
3	Bianchi B , Ferri A , Ferrari S , et al. The free anterolateral thigh musculocutaneous flap for head and neck reconstruction: One surgeon's experience in 92 cases[J]. Microsurgery, 2012, 32 (2): 87- 95. doi: 10.1002/micr.20952
4	Lavadera P , Schultz J , Sinkin J . Orbital floor and maxillary reconstruction with titanium mesh and anterolateral thigh free flap[J]. Eplasty, 2019, 19 (7): 126- 130.
5	Eitezaz FA , Rashid M , Yousaf S , et al. Can the anterolateral thigh flap replace the rectus abdominis free flap in the reconstruction of complex maxillary defects?[J]. J Ayub Med Coll Abbottabad, 2018, 30 (1): 74.
6	刘志荣, 彭歆, 章文博. 游离腓骨瓣和股前外侧穿支皮瓣修复单侧上颌骨缺损患者的生存质量问卷调查研究[J]. 中华整形外科杂志, 2018, 34 (8): 644- 647.
7	Springer IN , Wannicke B , Warnke PH , et al. Facial attractiveness: Visual impact of symmetry increases significantly towards the midline[J]. Ann Plast Surg, 2007, 59 (2): 156- 162. doi: 10.1097/01.sap.0000252041.66540.ec
8	Berssenbrugge P , Lingemann-Koch M , Abeler A , et al. Mea-suring facial symmetry: A perception-based approach using 3D shape and color[J]. Biomed Tech (Berl), 2015, 60 (1): 39- 47.
9	Philipp MM , Angelika SE , Ute B , et al. Three-dimensional perception of facial asymmetry[J]. Eur J Orthod, 2011, 33 (6): 647- 653. doi: 10.1093/ejo/cjq146
10	Patel A , Islam SM , Murray K , et al. Facial asymmetry assessment in adults using three-dimensional surface imaging[J]. Prog Orthod, 2015, 16 (10): 36- 44.
11	Hallac RR , Feng J , Kane AA , et al. Dynamic facial asymmetry in patients with repaired cleft lip using 4D imaging (video stereophotogrammetry)[J]. J Craniomaxillofac Surg, 2017, 45 (1): 8- 12. doi: 10.1016/j.jcms.2016.11.005
12	Cassi D , Battistoni G , Magnifico M , et al. Three-dimensional evaluation of facial asymmetry in patients with hemifacial microsomia using stereophotogrammetry[J]. J Craniomaxillofac Surg, 2019, 47 (1): 179- 184. doi: 10.1016/j.jcms.2018.11.011
13	Brown J , Shaw RJ . Reconstruction of the maxilla and midface: Introducing a new classification[J]. Lancet Oncol, 2010, 11 (10): 1001- 1008. doi: 10.1016/S1470-2045(10)70113-3
14	Krzych J , Lach M , Joniec M , et al. The Likert scale is a powerful tool for quality of life assessment among patients after minimally invasive coronary surgery[J]. Kardiochir Torakochirurgia Pol, 2018, 15 (2): 130- 134.
15	Naini FB , Donaldson A , Cobourne MT , et al. Assessing the influence of mandibular prominence on perceived attractiveness in the orthognathic patient, clinician, and layperson[J]. Eur J Orthod, 2012, 34 (6): 738- 746. doi: 10.1093/ejo/cjr098
16	邢亚彬, 马爱霞. 欧洲五维健康量表EQ-5D-3L和EQ-5D-5L中文版比较的实证研究[J]. 上海医药, 2013, 25 (7): 31- 35.
17	萧宁, 王勇, 赵一姣. 三维颜面部软组织正中矢状面确定方法的研究进展[J]. 中华口腔医学杂志, 2018, 53 (7): 495- 499.
18	Verhoeven TJ , Coppen C , Barkhuysen R , et al. Three dimen-sional evaluation of facial asymmetry after mandibular reconstruction: Validation of a new method using stereophotogrammetry[J]. Int J Oral Maxillofac Surg, 2013, 42 (1): 19- 25.
19	Schoot RA , Hol MLF , Merks JHM , et al. Facial asymmetry in head and neck rhabdomyosarcoma survivors[J]. Pediatr Blood Cancer, 2017, 64 (10): 26508.
20	牛百平, 叶湘玉. 对面部畸形忍受程度的测量研究[J]. 中华口腔医学杂志, 1994, 29 (4): 213- 216.
21	Hohman MH , Kim SW , Heller ES , et al. Determining the threshold for asymmetry detection in facial expressions[J]. Laryngoscope, 2014, 124 (4): 860- 865.
22	Kim SW , Heller ES , Hohman MH , et al. Detection and percep-tual impact of side-to-side facial movement asymmetry[J]. JAMA Facial Plast Surg, 2013, 15 (6): 411- 416.
23	Alqattan M , Djordjevic J , Zhurov AI , et al. Comparison between landmark and surface-based three-dimensionalanalyses of facial asymmetry in adults[J]. Eur J Orthod, 2015, 37 (1): 1- 12.
24	Wang SJ , Zhang WB , Yao YM , et al. Factors Affecting volume change of anterolateral thigh flap in head and neck defect reconstruction[J]. J Oral Maxillofac Surg, 2020, 78 (11): 2090- 2098.
25	Brown J , Rogers SN , Mcnally DN , et al. A modified classification for the maxillectomy defect[J]. Head Neck, 2000, 22 (1): 17- 26.
26	柯杰, 陈华, 林珠. 西安市正常牙合的青少年软组织X线头影测量研究: 计算机辅助测量[J]. 华西口腔医学杂志, 1994, 12 (3): 188- 191.

Metrics

Viewed

Full text

Abstract

Cited

Shared

Discussed

Landmarks	Anatomical location
Endocanthion	Lower and innermost point at junction between upper and lower eyelids
Exocanthion	Outer skin junction, where upper eyelid meets lower; most lateral extent of lower eyelid
Nasion	Maximum concavity of nasal bridge in profile
Tragion	Midpoint of the tragus
Alare	Most lateral point on the alar contour
Subnasale	Midpoint on the nasolabial soft tissue contour between the columella crest and the upper lip
Labiale superius	Midpoint of the vermilion line of the upper lip
Cheilion	Point located at the labial commissure
Menton	Lowest median point on the lower border of the mandible
Gonion	Most lateral point on the mandibular angle
A’	One third of the mandibular margin
B’	The lower third of the line cheilion-alare
C’	Parallel line of line tragion-gonion that go through A’ and intersect with line tragion-B’, C’ is the intersection

Items	Ⅰ	Ⅱb	Ⅱd	Ⅲb	Ⅲd	Total
Male, n	1	6	7	2	5	21
Female, n	3	10	4	3	3	23
Total, n	4	16	11	5	8	44

Facial area	Mean rank			χ²	P
Facial area	Grade Ⅰ (n=15)	Grade Ⅱ (n=12)	Grade Ⅲ (n=17)	χ²	P
Suborbital	12.27	23.58	30.76	16.743	＜0.001^*
Zygomatic	12.27	23.50	30.82	16.731	＜0.001^*
Buccal	16.73	21.92	28.00	6.165	0.046^*
Masseteric	18.80	23.08	22.76	0.775	0.679
Nasal	17.47	23.58	26.18	3.781	0.151
Superiolabial	16.27	21.00	29.06	8.128	0.017^*

Facial area	Mean rank		Z	P
Facial area	Grade Ⅰ (n=15)	Grade Ⅱ (n=12)	Z	P
Suborbital	10.07	18.92	-2.879	0.004^*
Zygomatic	9.73	19.33	-3.123	0.002^*
Buccal	12.87	15.42	-0.830	0.407
Masseteric	13.40	14.75	-0.439	0.661
Nasal	12.00	16.50	-1.464	0.143
Superiolabial	12.53	15.83	-1.073	0.283

Facial area	Mean rank		Z	P
Facial area	Grade Ⅱ (n=12)	Grade Ⅲ (n=17)	Z	P
Suborbital	11.17	17.71	-2.037	0.042^*
Zygomatic	10.67	18.06	-2.303	0.021^*
Buccal	13.00	16.41	-1.063	0.288
Masseteric	14.83	15.12	-0.089	0.929
Nasal	13.58	16.00	-0.753	0.452
Superiolabial	11.67	17.35	-1.771	0.077