【作者】 樊立洁；

【导师】 赵士芳； 陈关福；

【作者基本信息】 浙江大学 ， 口腔临床医学， 2002， 博士

【摘要】 颊脂垫(Buccal Fat Pad)位于面颊两测深部，充填于颊间隙、颞下间隙和翼腭窝内。在口腔内由于肿瘤切除、外伤等原因造成的软组织缺损时，可以用脂肪组织瓣来修复。但颊脂垫作为一种特殊的脂肪组织，对其基础研究甚少，一些临床现象尚无法解释。尤其是颊脂垫瓣修复缺损后，其表面上皮化的上皮来源争论甚多。 近来，研究表明脂肪细胞具有多分化潜能，同时脂肪细胞本身又能够分泌多种细胞因子。同时有关生长因子与损伤修复方面也有大量的研究，但涉及脂肪细胞与生长因子的相关性研究尚未见报道。 本研究通过尸体解剖，对颊脂垫的大小、形态及血供等方面进行了较详细的解剖学研究，为临床带血管蒂颊脂垫移位设计和临床应用 带吊炯憎垫的暴硼及其临床应用研兜提供形态学基础；以动物实验为基础，对无召盖带蒂烦脂垫组织瓣移植修复口腔内软组织缺损的愈合过程进行了全面的组织学及临床观察，对其生长愈合的相关机制进行初步探讨；总结57 N的临床应用病例并对其进行归纳分析，以探讨带蒂颊脂垫组织治的临床应用价值．第一部分 颊脂垫的应用解剖研究 10例（20侧）福尔马林固定的成人头颅标本，其中男6例，女4例，平均年龄为42岁。2例（4侧）新鲜头颅标本．男！例，女！例。通过血管铸型和尸体解剖，观察颊脂垫供养血管的分布，并测量出颊脂垫各部的体积和主耍营养血管的外径，并且对口腔颌面部恶性肿瘤根治术后28例颊脂垫形态进行观察。 结果发现：颊脂垫是由一个体部和体部延伸的四个突所组成，位于颊间隙、颁下间隙和翼胯窝内．颊脂垫有一个完整的包膜，且与周围组织连接疏松，仅有少数菲菏的纤维束与周围的骨膜或肌膜连接而被固定．颊脂垫有多源性的血供，其周围的咬肌、额肌等血管均有小分支进人颊脂垫，颊脂垫的主要血管是颌内动脉的颊支和额深支以及面动脉的颊支，其分支在颊脂垫内存在广泛吻合． 通过对颊脂垫的大小、形态及血供等方面的研究，为临床带血管 蒂颊脂垫的移位设计和临床应用提供形态学基础．颊脂垫作为口腔移 植的理想部分为体部、颊突、翼突和颔突前部，这4部分连接成一扁 长形的脂肪块（6．scm X 3．scm X 0．6cul），分离操作容易．由于额突后 部和翼聘突位置深，体积小，操作困难，这两部分不宜使用．上颌动 脉和翼静脉丛紧贴在颊脂垫的深面与翼外肌之间穿行，术中应轻巧 地、紧贴包膜钝性分离颊脂垫，避免损伤血管．下齿槽神经和舌神经 在颊脂垫的深面与翼内肌之间穿行，术中亦应注意保护． －3－ 帚帚须励垫的思础及其临床应用研兜 颊脂垫的血供来源丰富，且在颊脂垫内存在广泛的吻合，不会因 缺血产生坏死和自溶；由于可作供体的颊脂垫体积有限，对修复大面 积的软组织缺损难以满足。 第二部分 无覆盖带蒂颊脂垫组织瓣移植修复口腔内软组织 缺损大体和组织学观察 对28只健康成年家兔随机分组：其中实验纽14只，对照组14只， 雌雄各半．实验组右恻颊部人为造成 1．scm X！．scm的缺损区，深达肌 层，从颊部切口轻轻提取颊脂垫的前部，并游离改形成为蒂在后的颊 脂垫瓣，与周围组织在无张力的情况下缝合．对照组，人为造成同实 验组一样的缺损区，不用任何组织修复。于术后48h、IWk、2wk、4Wb． 6wb、swk、10’vk处死一组实验组、一组对照组，分别观察愈合情况。 结果显示：术后全部动物存活，伤口愈合良好，无感染．二周无 覆盖颊脂垫区明显水肿，表面有淡黄色物质覆盖；在大量的脂肪组织 表面可见新生的基底细胞，同时可见基底细胞移行区和上皮爬行区。二 周，水肿明显泊退，缺损修复区四周有上皮爬行。办币周创面完全上皮 化，再生的粘膜类似癌痕样；上皮较簿，表面有不全角化，近上皮区 脂肪组织较远离上皮区的脂肪组织纤维化完全．8～10周，再生的粘胺 上皮较厚，粉红色，类似周围正常组织：粘膜上皮成熟，上皮表面不 全角化达卜 层，基底细胞呈栅栏状排列，脂肪组织基本上纤维化． 主要是胶原纤维和成纤维细胞．创面平坦，面积无明显变化．对照组： 开始上皮化时间及完全上皮化所需时间均较实验组延迟l～2周，新生 上皮较薄，其上皮来源为周围正常粘膜上皮的移行．上皮下方为大量 的疤痕组织增生。创面凹陷，面积缩小．新形成的上皮粉红色与白色 相间． －4． 帚办以肠垫的基础及美临床应用研大 以上结果表明：颊脂垫组织活获取容易，供区与受区近，尤其是颊部软组织缺损，可在同一切口完成，不需开辟另外手术野．该组织瓣有丰富的营养血管，具有较强的抗感染能力和组织修复能力．同时颊胎垫移植修复缺损区，上皮形成较快，有利于创面的愈合，表面自行上皮更多还原

【Abstract】 Buccal fat pad (BFP) is important in the oral cavity and is of special clinical importance. However, this mass of specialized fatty tissue was not widely clinically applied until recently. The healing process of BFP as an uncovered fat pad is unusual. For the pedicled graft, the anatomic region is consistent, there is good vascularization and ease of access, there is proximity between the donor site and the recipient site, and the donor site is concealed; surgery has no influence on appearance or function. Scientists and clinicians are unable to study the detailed histological changes in clinic. The aim of this paper is to report on the use of the BFP pedicled graft in the reconstruction of oral defects, and to give a report on histological changes during the healing process, based on animal experiments; possible clinical applications will be discussed.On the basis of cadaveric dissection, we observe the size, shapeand blood supply of buccal fat pad, providing morphology basic for its design of clinical application. Furthermore, on the basis of animal experiment, we observe the histological changes and the whole healing process of the buccal fat pad as an uncovered pedicled graft for reconstruction the defects.The pedicled buccal fat pad graft is that anatomical region is consistent, good vascularization, ease of access, proximity of the donor site to the recipient site, the donor is concealed, and surgery has no influence on appearance and function. Buccal fat pad is an ideal filling material for reconstruction defects in oral cavity. Epithelial grow faster by 1-2 weeks using the buccal fat pad than other flaps to repair intraoral defects. It takes about 4~6 weeks to form complete epithelial. There was difference between reconstructive mucosa and normal buccal mucosa in histology. We studied the origin of epithelium, transition from surrounding normal epithelium is an important cause by series sections, but can’t rule out cells implantation.Now, lots of studies certified that fat cells actively secrete many members of the cytokine family. Many researches have done on growth factors and reconstruction; however, the relation of fat cells and cytokines hasn’t been reported. In our research work, we study the expression of EGFR and TGFfl in the process of buccal fat pad as an uncovered pedicled graft.Part I Anatomical observation of the buccal fat padOur findings are based on 10(6men, 4 female) cadaver dissections and two vascular casting. The buccal fat pad, consisting one body and four extensions (buccal, pterygoid, pterygopalatal, temporal), is situated in buccal space, infratemporal space, and pterygomandibular space and pterygopalatal fossa. The buccal fat pad is enclosed by a thin and transparent membrane and connected loosely with the surrounding tissues. Buccal fat pad has several resources providing for blood supply. The minor branches are from surrounding masster and temporalis, the major arterial blood supply is buccal and deep temporal branches of the maxillary artery, the branches of facial artery.Providing the morphology bases for designing of clinical application, we observed the size, shape and blood supply of the buccal fat pad. The ideal portions (the main body, buccal extension pterygoid extension and the anterior of temporal extension) can be used in clinical application. Their altogether volume is 6.8 cm X 3.8cm X 0.6cm. The posterior of temporal extension and ptergopalatal extensions cannot be used because they are deep and small volume.Part II Gross and histological observation of the buccal fat pad asan uncovered pedicled graft28 adult rabbits, mean weights from 2.5kg to 3.0kg, were used in this study; 14 rabbits comprised the experimental groups, F/M=1:1. These 14 rabbits were randomly divided into 7 groups, F/M=1:1.The remaining 14 rabbits were used as control groups. In each group, an area of 1.5*1.5cm at buccal mucosa was surgically excised; the area was then covered by uncovered BFP. The surgically exposed areas in the control gr更多还原