面部软组织缺损重建中游离皮瓣选择策略与进展

文献信息

中文摘要

背景： 面部软组织缺损的重建在整形、修复重建及头颈外科中仍是一项要求很高的任务，因为面部兼具美学单元与口腔闭合、言语、吞咽、呼吸、眼睑保护及面部表情等基本功能。缺损的严重程度、深度和组成是皮瓣选择的主要决定因素，尤其当缺损超出皮肤和皮下组织，暴露口腔、咽、鼻腔、颅底或关键结构时。
方法： 本叙述性综述总结了关于面部软组织重建中游离皮瓣选择的证据和技术进展。通过PubMed、Web of Science和Google Scholar，使用“面部软组织缺损”“游离皮瓣”“穿支皮瓣”和“虚拟手术规划”等术语的组合检索文献。优先纳入系统综述、荟萃分析、临床系列研究以及2019年至2026年间发表的研究，同时保留具有奠基意义的经典显微外科报告。
结果： 游离皮瓣的选择应遵循一个整合的三维矩阵：缺损特征×患者特征×机构资源。股前外侧皮瓣仍是中等至大型缺损的主力皮瓣，因为其厚度、长血管蒂、阔筋膜可用性以及神经获取。桡前臂游离皮瓣对于唇、眼睑、鼻衬里和口腔衬里的薄而柔顺的覆盖仍具有价值。腹壁下深穿支皮瓣可用于大体积轮廓恢复。当颜色匹配、供区并发症或体型使传统主力皮瓣不理想时，应考虑其他软组织选择，包括上臂外侧、肩胛旁和腓肠内侧动脉穿支皮瓣。
结论： 面部软组织重建不仅要求皮瓣存活，还要求恢复轮廓、感觉、口腔闭合、面部运动、供区可接受性以及患者报告的生活质量。应将CTA、选择性超声、虚拟手术规划、术中吲哚菁绿血管造影和结构化术后监测等成熟技术与增强现实、人工智能决策支持、机器人辅助吻合、人工血管导管以及同种异体或异种移植等发展中工具区分开来。未来研究应聚焦于多中心登记、标准化结局指标、成本效益分析以及经外部验证的决策支持模型。

英文摘要

BACKGROUND: Reconstruction of facial soft tissue defects remains a demanding task in plastic, reconstructive, and head and neck surgery because the face combines aesthetic units with essential functions such as oral competence, speech, swallowing, breathing, eyelid protection, and facial expression. The severity, depth, and composition of the defect are the primary determinants of flap selection, especially when defects extend beyond skin and subcutaneous tissue to expose the oral cavity, pharynx, nasal cavity, skull base, or critical structures.
METHODS: This narrative review summarizes evidence and technical progress regarding free flap selection for facial soft tissue reconstruction. Literature was identified through PubMed, Web of Science, and Google Scholar using combinations of the terms "facial soft tissue defect," "free flap," "perforator flap," and "virtual surgical planning." Priority was given to systematic reviews, meta-analyses, clinical series, and studies published between 2019 and 2026, while classic microsurgical reports were retained when foundational.
RESULTS: Free flap choice should be guided by an integrative three-dimensional matrix: defect characteristics×patient profile×institutional resources. The anterolateral thigh flap remains a workhorse for moderate to large defects because of its thickness, long pedicle, availability of fascia lata, and nerve harvest. The radial forearm free flap remains valuable for thin and pliable resurfacing of the lips, eyelids, nasal lining, and oral lining. The deep inferior epigastric perforator flap is useful for large-volume contour restoration. Additional soft tissue options-including the lateral arm, parascapular, and medial sural artery perforator flaps-should be considered when color match, donor-site morbidity, or body habitus makes traditional workhorse flaps suboptimal.
CONCLUSIONS: Facial soft tissue reconstruction requires not only flap survival but also restoration of contour, sensation, oral competence, facial animation, donor-site acceptability, and patient-reported quality of life. Mature technologies such as CTA, selective ultrasound, virtual surgical planning, intraoperative indocyanine green angiography, and structured postoperative monitoring should be distinguished from evolving tools such as augmented reality, artificial intelligence decision support, robotic-assisted anastomosis, artificial vascular conduits, and allogeneic or xenogeneic transplantation. Future research should focus on multicenter registries, standardized outcome measures, cost-effectiveness analyses, and externally validated decision-support models.