Method for repairing nasopharyngeal skull base necrosis by using free anterior lateral femoral muscle flap

Abstract

The invention discloses a method for repairing nasopharyngeal skull base necrosis by using a free anterior lateral femoral muscle flap. The method comprises the following steps: cutting off the nasopharyngeal skull base necrosis to obtain a lesion area to be repaired; manufacturing a repairing skin flap; the nasopharynx skull base necrosis is repaired. According to the method, the free anterior lateral muscle flap is designed, so that the method is a new, effective and safe new method for severe nasopharyngeal skull base necrosis, in particular to nasopharyngeal skull base necrosis of bilateral internal carotid artery necrosis. According to the method, the tissue amount is enough, the length can be designed, and blood supply is rich, so that the clinical treatment effect is improved, the life quality of a patient is improved, and the time and economic cost of the patient are saved.

Description

Technical Field

[0001] The present invention relates to the technical field of skin repair, and in particular to a method for repairing nasopharyngeal skull base necrosis by using a free anterolateral thigh myocutaneous flap. Background Art

[0002] Nasopharyngeal carcinoma (NPC) is a malignant tumor originating in the nasopharynx. Its incidence in my country is 3.26 per 100,000 patients, and radiotherapy is the preferred treatment option. Nasopharyngeal skull base necrosis (NPC) is one of the most serious complications of combined radiotherapy-based NPC treatment. Clinical symptoms include headache and a foul odor. In severe cases, NPC may develop intracranial infection or risk of fatal hemorrhage. Currently, NPC is categorized according to its severity, including conservative treatment (such as anti-infectives, irrigation, and local debridement) and surgical treatment.

[0003] The temporalis muscle originates from the superior temporal line and inserts on the coronoid process of the mandible, extending anteriorly to the lateral orbital margin and posteriorly to the temporo-occipital junction. The deep surface of the temporalis muscle adheres closely to the squamous portion of the temporal bone, forming the outer boundary of the temporal and infratemporal fossae; its superficial surface is the deep temporal fascia. The deep temporal fascia continues superiorly with the pericranium and inferiorly, approximately 2 cm above the zygomatic arch, dividing into two deep and superficial layers that fuse with the zygomatic arch periosteum and then continue inferiorly with the masseter parotid capsule. Between the two layers of the deep temporal fascia lies the superficial temporal fat pad, through which the temporal branch of the facial nerve passes. The temporalis muscle flap has a rich blood supply and substantial volume. It can be rotated with the pedicle to repair adjacent nasopharyngeal skull base defects and is currently a commonly used repair material for nasopharyngeal skull base necrosis.

[0004] When deciding whether to use a temporal muscle flap as a tissue material for repairing nasopharyngeal skull base necrosis, we need to assess the severity of the necrosis and the condition of the temporal muscle flap itself. For example, if the temporal muscle itself is damaged by lesions, radiation therapy, or other surgeries, the blood supply may be compromised; if the lesion is extensive and exceeds the length of the temporal muscle, using bilateral temporal muscle flaps will increase operative time, make wound packing difficult, and increase trauma; and if the temporal muscle flap is used for repair, it may affect mastication and swallowing function. Therefore, for severe nasopharyngeal skull base necrosis, especially involving necrosis of the nasopharynx, oropharynx, or bilateral internal carotid arteries, it is crucial to select a repair material with sufficient tissue volume, appropriate length, and a rich blood supply. Summary of the Invention

[0005] In order to overcome the deficiencies of the prior art, the present invention provides a method for repairing nasopharyngeal skull base necrosis using a free anterolateral thigh myocutaneous flap to solve the above-mentioned traditional technical problems.

[0006] The present invention is implemented by the following technical solutions:

[0007] A method for repairing nasopharyngeal skull base necrosis using a free anterolateral thigh myocutaneous flap comprises the following steps:

[0008] S1: Resection of nasopharyngeal skull base necrosis to obtain the lesion area to be repaired

[0009] S2: Creation of repair flap

[0010] Using ultrasound imaging equipment, ultrasonic imaging is performed on the patient's neck and thigh blood vessels to obtain an image of the recipient blood supply in the neck and an image of the blood supply and perforator distribution of the anterolateral femoral myocutaneous flap in the thigh. A repair flap is produced based on the images of the blood supply and perforator distribution of the lesion area to be repaired and the anterolateral femoral myocutaneous flap in the thigh obtained in step S1;

[0011] S3: Repair of nasopharyngeal skull base necrosis

[0012] The lesion area to be repaired is repaired using a repair flap through vascular anastomosis under a microscope.

[0013] Furthermore, in step S1, the specific operation of obtaining the lesion area to be repaired is:

[0014] CTA imaging equipment and MRI enhanced scanning equipment were used to obtain CTA images and MRI enhanced scanning images of the patient's nasopharyngeal skull base necrosis respectively; the CTA images and MRI enhanced scanning images were compared and analyzed to determine the patient's resected nasopharyngeal skull base necrosis area and the lesion area to be repaired.

[0015] Furthermore, in step S2, the specific steps of making the repair flap are as follows:

[0016] In the thigh, the descending branch and perforating branches of the lateral circumflex femoral artery are used as the vascular pedicle. The size of the flap is designed according to the lesion area to be repaired. The skin is incised according to the designed incision. The vascular pedicle of the lateral circumflex femoral artery and vein is dissected and protected. A suitable anterolateral thigh muscle flap is prepared. The vascular pedicle of the lateral circumflex femoral artery and vein is ligated and cut off, and the incision is sutured layer by layer.

[0017] Furthermore, in step S2, the flap size is designed according to the lesion area to be repaired, with the designed area being (10-15) cm×(8-10) cm and the designed length of the vascular pedicle being (12-15) cm.

[0018] Furthermore, in step S1, the specific operations for removing the nasopharyngeal skull base necrosis and obtaining the lesion area to be repaired are as follows:

[0019] First, a 2-cm arcuate incision is made along the inferior margin of the mandible. The skin, subcutaneous tissue, and platysma muscle are incised. A flap is made deep to the platysma muscle. The facial artery and vein, and the marginal mandibular branch of the facial nerve are identified and protected. The facial nerve and its branches are then ligated, cut, and marked for future use.

[0020] Next, continue the incision upward along the midline of the face to the midline of the lower lip, cut to the median surface of the mandible, and separate along the surface of the mandible to expose the median surface of the mandible. Use a small 6-hole titanium plate to shape and mark it;

[0021] Finally, an electric saw is used to split the mandible along the mandible, and under an endoscopic system, the nasopharyngeal skull base necrotic lesion is removed. During the operation, the internal carotid artery is dissected and protected or ligated according to the situation.

[0022] Furthermore, in step S3, the specific steps of using the repair flap to repair the excised portion of the lesion area to be repaired are:

[0023] The repair flap is transferred to the oropharynx, nasopharynx, parapharynx, and skull base areas of the lesion to be repaired, and enters the oropharynx, nasopharynx, parapharynx, and skull base areas through the submandibular parapharyngeal space tunnel. The flap is sutured and fixed to the incision edge of the oropharynx, parapharynx, and floor of mouth areas. The repair flap is packed and fixed. Under a microscope, the lateral femoral circumflex artery is micro-anastomosed to the facial artery, and the lateral femoral circumflex vein is micro-anastomosed to the facial vein and posterior mandibular vein using a venous anastomosis device. Examination showed that the flap had a good blood supply. The remaining wounds in the mouth were sutured in layers, the mandible was anatomically repositioned, and a titanium plate pre-punched before osteotomy was used for rigid internal fixation. The submandibular, lower lip, and leg incisions were sutured in layers.

[0024] Compared with the prior art, the present invention has the following beneficial effects:

[0025] 1. The method of the present invention designs a free anterolateral thigh muscle flap to treat severe nasopharyngeal skull base necrosis, especially nasopharyngeal skull base necrosis involving bilateral internal carotid artery necrosis, and selects a new, effective and safe method. This method has sufficient tissue quantity, adjustable length and rich blood supply, thereby improving the clinical treatment effect, improving the patient's quality of life, and saving the patient's time and economic costs.

[0026] 2. The method of the present invention is combined with ultrasound before surgery to clearly determine the vascular conditions of the donor tissue (free anterolateral femoral myocutaneous flap) and the recipient tissue (facial artery and vein, superior thyroid artery and vein). This method is a routine examination method, simple and easy to perform, and provides a good guarantee for the success of the operation.

[0027] 3. The method of the present invention selects the anterolateral thigh myocutaneous flap as a universal flap with its own advantages: the vascular pedicle of the descending branch of the lateral femoral circumflex artery is of sufficient length (8-15 cm), which can easily complete microanastomosis with the affected blood vessels in the neck (such as the facial artery and vein, and the superior thyroid artery and vein), and no vascular transplantation is required, which significantly reduces the complexity of the operation; the flap excision area is located on the anterolateral side of the thigh, and the postoperative wound surface can be closed by direct suture, avoiding additional skin grafting operations and minimizing scars and functional disorders in the donor area; the perforating blood vessels of the flap are distributed in a "hub-and-spoke" manner, allowing the design of a single-vascular pedicle multi-skin island structure, which can achieve complex reconstruction in three-dimensional space. BRIEF DESCRIPTION OF THE DRAWINGS

[0028] Figure 1 Detailed operation flow chart of the method of the present invention;

[0029] Figure 2 This is the preoperative nasopharyngeal skull base CTA examination image;

[0030] Figure 3 This is the preoperative enhanced MRI scan of the nasopharynx and skull base;

[0031] Figure 4 To prepare the repair flap diagram during the operation according to the blood supply of the anterolateral femoral myocutaneous flap located by preoperative ultrasound;

[0032] Figure 5 This is the examination picture shown under nasal endoscopy after surgery;

[0033] Figure 6 This is an examination image of the postoperative MRI enhanced scan. DETAILED DESCRIPTION

[0034] A method for repairing nasopharyngeal skull base necrosis using a free anterolateral thigh myocutaneous flap comprises the following steps:

[0035] S1: Obtain the lesion area to be repaired

[0036] CTA imaging equipment and MRI enhanced scanning equipment were used to obtain CTA images and MRI enhanced scanning images of the patient's nasopharyngeal skull base necrosis respectively; the CTA images and MRI enhanced scanning images were compared and analyzed to determine the patient's resected nasopharyngeal skull base necrosis area and the lesion area to be repaired.

[0037] In this step, for patients with nasopharyngeal skull base necrosis, after the initial evaluation and subsequent nasopharyngeal skull base CTA and MRI enhanced scan evaluation, the severity of the patient's nasopharyngeal skull base necrosis is judged by combining the lesion areas such as the nasopharynx, oropharynx, skull base, and bilateral internal carotid arteries. If the lesion areas such as the nasopharynx, oropharynx, and bilateral internal carotid arteries are all severely necrotic, the patient's nasopharyngeal skull base is judged to have severe necrosis. If there are 1-2 necrosis sites in the lesion areas such as the nasopharynx, oropharynx, and bilateral internal carotid arteries, the patient's nasopharyngeal skull base necrosis is judged to be moderate. Based on the above necrosis situation, the next step is carried out.

[0038] S2: Creation of repair flap

[0039] Using ultrasound imaging equipment, ultrasonic imaging is performed on the patient's neck and thigh blood vessels to obtain an image of the recipient blood supply in the neck and an image of the blood supply and perforator distribution of the anterolateral femoral myocutaneous flap in the thigh. A repair flap is produced based on the images of the blood supply and perforator distribution of the lesion area to be repaired and the anterolateral femoral myocutaneous flap in the thigh obtained in step S1;

[0040] In this step, the anterolateral thigh myocutaneous flap, as a universal flap, has its own advantages: the vascular pedicle of the descending branch of the lateral femoral circumflex artery is of sufficient length (8-15 cm), which can easily complete microanastomosis with the affected blood vessels in the neck (such as the facial artery and superior thyroid artery), and no vascular transplantation is required, which significantly reduces the complexity of the operation; the flap excision area is located on the anterolateral thigh, and the postoperative wound surface can be closed by direct suture, avoiding additional skin grafting operations and minimizing scars and functional disorders in the donor site; the perforating vessels of this flap are distributed in a "hub and spoke" manner, allowing the design of a single vascular pedicle and multiple skin island structures, which can achieve complex reconstruction in three-dimensional space. Therefore, the free anterolateral thigh myocutaneous flap can, to a certain extent, compensate for the role of the temporalis muscle flap in the repair and reconstruction of nasopharyngeal skull base necrosis for severe nasopharyngeal skull base necrosis, especially nasopharyngeal skull base necrosis involving nasopharynx, oropharynx, and bilateral internal carotid artery necrosis, thereby improving the success rate of surgical treatment and patient healing.

[0041] In one embodiment, the specific steps for making a repair flap are as follows:

[0042] The descending branch of the lateral femoral circumflex artery and its perforators are used as vascular pedicles in the thigh. The size of the skin flap is designed according to the lesion area to be repaired. The skin flap incision with a design area of the size of the lesion area to be repaired can be (10-15) cm × (8-10) cm. Preferably, the design area is 15 cm × 8 cm. The arc-shaped incision with a design length of the upper vascular pedicle and the length of the lesion area to be repaired can be (12-15) cm. Preferably, the design length of the vascular pedicle is 15 cm. The incision is made along the incision line, and the upper vascular pedicle of the lateral femoral circumflex artery and vein is dissected and protected. The perforators are dissected and protected, and the vascular pedicle of the lateral femoral circumflex artery and vein is ligated and cut off. In other embodiments, the size of the skin flap incision, arc-shaped incision, etc. can be made according to the specific repair flap required, which will not be repeated here.

[0043] S3: Repair of nasopharyngeal skull base necrosis

[0044] The necrosis of the nasopharyngeal skull base in the lesion area to be repaired is removed, and the resected part of the lesion area to be repaired is repaired using a repair flap through vascular anastomosis under a microscope.

[0045] In one embodiment, the specific operation of resecting the nasopharyngeal skull base necrosis in the lesion area to be repaired is:

[0046] First, a 2-cm arcuate incision is made along the inferior margin of the mandible. The skin, subcutaneous tissue, and platysma muscle are incised. A flap is made deep to the platysma muscle. The facial artery and vein, and the marginal mandibular branch of the facial nerve are identified and protected. The facial nerve and its branches are then ligated, cut, and marked for future use.

[0047] Next, continue the incision upward along the midline of the face to the midline of the lower lip, cut to the median surface of the mandible, and separate along the surface of the mandible to expose the median surface of the mandible. Use a small 6-hole titanium plate to shape and mark it;

[0048] Finally, the mandible is split along the mandible using an electric saw, and endoscopic debridement of the necrotic lesion at the nasopharyngeal skull base is performed. During this procedure, the internal carotid artery is dissected and protected or ligated as appropriate.

[0049] In one embodiment, the specific steps of using a repair flap to repair the excised portion of the lesion area to be repaired are:

[0050] The repair flap was transferred to the oropharynx, nasopharynx, and skull base of the lesion to be repaired. The flap was then placed through a tunnel in the submandibular parapharyngeal space to the oropharynx, parapharynx, and skull base. The flap was sutured and secured to the incisional margins of the oropharynx, nasopharynx, parapharynx, and floor of mouth. The repair flap was then packed and secured. Under a microscope, the lateral femoral circumflex artery was microanastomosed to the facial artery, and the lateral femoral circumflex vein was microanastomosed to the facial vein and posterior mandibular vein using a venous stapler. Examination revealed a good blood supply to the flap. The remaining oral wounds were sutured in layers, the mandible was anatomically reduced, and a titanium plate pre-drilled before osteotomy was used for rigid internal fixation. The submandibular, lower lip, and leg incisions were sutured in layers in alignment.

[0051] The present invention will be further described below in conjunction with specific implementation methods. It should be noted that, under the premise of no conflict, the various embodiments or technical features described below can be arbitrarily combined to form new embodiments.

[0052] Unless otherwise specified, the experimental methods in the following examples are conventional methods and were performed according to the techniques or conditions described in literature in the field or according to product specifications. The materials, reagents, and equipment used in the following examples are all commercially available unless otherwise specified.

[0053] Example 1

[0054] A method of repairing nasopharyngeal skull base necrosis using a free anterolateral thigh myocutaneous flap, such as Figure 1 The specific operation flow chart shown includes the following steps:

[0055] S1: Patient selection: For patients with nasopharyngeal skull base necrosis, nasopharyngeal skull base CTA and MRI enhanced scans are performed to evaluate the condition, and severe nasopharyngeal skull base necrosis is considered, especially nasopharyngeal skull base necrosis involving the nasopharynx, oropharynx, and bilateral internal carotid artery necrosis. Figure 2-Figure 3 shown.

[0056] in, Figure 2 A preoperative nasopharyngeal skull base CTA examination showed that the lesion involved the nasopharynx, oropharynx, and bilateral internal carotid arteries;

[0057] Figure 3 A preoperative enhanced MRI scan of the nasopharynx and skull base showed that the lesion involved the nasopharynx, oropharynx, and bilateral internal carotid arteries.

[0058] In summary, Figure 2 and Figure 3 The images all indicate that the lesions involve the nasopharynx, oropharynx, and bilateral internal carotid arteries, indicating severe necrosis of the nasopharyngeal skull base in the patient, requiring repair of the necrosis of the nasopharyngeal skull base.

[0059] S2: Obtain the lesion area to be repaired

[0060] Obtain CTA images and MRI enhanced scanning images of the patient's nasopharyngeal skull base respectively; compare and analyze the CTA images and MRI enhanced scanning images to determine the patient's resected nasopharyngeal skull base necrosis range and the lesion area to be repaired.

[0061] S3: Preoperative ultrasound positioning and creation of repair flap

[0062] Using ultrasound imaging equipment, ultrasonic imaging is performed on the patient's neck and thigh blood vessels to obtain an image of the recipient blood supply in the neck and an image of the blood supply and perforator distribution of the anterolateral femoral myocutaneous flap in the thigh. A repair flap is produced based on the images of the blood supply and perforator distribution of the lesion area to be repaired and the anterolateral femoral myocutaneous flap in the thigh obtained in step S1;

[0063] The specific steps for making a repair flap are as follows:

[0064] A flap the size of the lesion to be repaired is designed in the thigh using the descending branch of the lateral circumflex femoral artery and its perforators as its vascular pedicle. The skin is incised according to the designed incision. The vascular pedicles of the lateral circumflex femoral artery and vein are dissected and protected. An appropriate anterolateral thigh myocutaneous flap is prepared. The pedicles are ligated and severed, and the incision is sutured layer by layer. The designed area is 15 cm x 8 cm, and the designed length of the pedicle is 15 cm.

[0065] S4: Surgical approach to repair nasopharyngeal skull base necrosis

[0066] First, a 2-cm arcuate incision is made along the inferior margin of the mandible. The skin, subcutaneous tissue, and platysma muscle are dissected. A flap is created deep to the platysma muscle, and the facial artery and vein, as well as the marginal mandibular branch of the facial nerve, are dissected and identified. The facial nerve and its branches are protected, ligated, and marked for future use. Next, the incision is continued upward along the midline of the face to the midline of the lower lip. The mandibular surface is dissected and separated along the mandibular surface to expose the median mandibular surface. A small 6-hole titanium plate is used to shape and mark the surface. Finally, an electric saw is used to split the mandible along the mandible, and endoscopic debridement of the necrotic lesion at the nasopharyngeal skull base is performed. During this procedure, the internal carotid artery is dissected and protected or ligated as appropriate.

[0067] The repair flap was transferred to the oropharynx, nasopharynx, and skull base of the lesion to be repaired. The flap was then placed through a tunnel in the submandibular parapharyngeal space to the oropharynx, nasopharynx, parapharynx, and skull base. The flap was sutured and secured to the incisional margins of the oropharynx, nasopharynx, parapharynx, and floor of mouth. The repair flap was then packed and secured. Under a microscope, the lateral femoral circumflex artery was microanastomosed to the facial artery, and the lateral femoral circumflex vein was microanastomosed to the facial vein and posterior mandibular vein using a venous stapler. Examination revealed a good blood supply to the flap. The remaining oral wounds were sutured in layers, the mandible was anatomically reduced, and a titanium plate pre-drilled before osteotomy was used for rigid internal fixation. The submandibular, lower lip, and leg incisions were sutured in layers in alignment.

[0068] S5: Efficacy evaluation

[0069] MRI enhanced scan showed that the flap healed well and the patient's pain and malodor were relieved. Figure 5-Figure 6 As shown in the figure, Figure 5 The lesion was cleared and the flap healed well under nasal endoscopy. Figure 6 MRI enhanced scan showed that the lesion was cleared and the flap healed well.

[0070] The above embodiments are only preferred embodiments of the present invention and cannot be used to limit the scope of protection of the present invention. Any non-substantial changes and replacements made by technicians in this field on the basis of the present invention fall within the scope of protection required by the present invention.

Claims

1. A method for repairing nasopharyngeal skull base necrosis using a free anterolateral thigh myocutaneous flap, characterized in that: The steps include: S1: Resection of nasopharyngeal skull base necrosis to obtain the lesion area to be repaired S2: Creation of repair flap Using ultrasound imaging equipment, ultrasonic imaging is performed on the patient's neck and thigh blood vessels to obtain an image of the recipient blood supply in the neck and an image of the blood supply and perforator distribution of the anterolateral femoral myocutaneous flap in the thigh. A repair flap is produced based on the images of the blood supply and perforator distribution of the lesion area to be repaired and the anterolateral femoral myocutaneous flap in the thigh obtained in step S1; S3: Repair of nasopharyngeal skull base necrosis The lesion area to be repaired is repaired using a repair flap through vascular anastomosis under a microscope.

2. The method for repairing nasopharyngeal skull base necrosis using a free anterolateral thigh myocutaneous flap according to claim 1, characterized in that: In step S1, the specific operations for obtaining the lesion area to be repaired are: CTA imaging equipment and MRI enhanced scanning equipment were used to obtain CTA images and MRI enhanced scanning images of the patient's nasopharyngeal skull base necrosis respectively; the CTA images and MRI enhanced scanning images were compared and analyzed to determine the patient's resected nasopharyngeal skull base necrosis area and the lesion area to be repaired.

3. The method for repairing nasopharyngeal skull base necrosis using a free anterolateral thigh myocutaneous flap according to claim 1, characterized in that: In step S2, the specific steps of making the repair flap are as follows: In the thigh, the descending branch and perforating branches of the lateral circumflex femoral artery are used as the vascular pedicle. The size of the flap is designed according to the lesion area to be repaired. The skin is incised according to the designed incision. The vascular pedicle of the lateral circumflex femoral artery and vein is dissected and protected. A suitable anterolateral thigh muscle flap is prepared. The vascular pedicle of the lateral circumflex femoral artery and vein is ligated and cut off, and the incision is sutured layer by layer.

4. The method for repairing nasopharyngeal skull base necrosis using a free anterolateral thigh myocutaneous flap according to claim 3, characterized in that: In step S2, the flap size is designed according to the lesion area to be repaired, with the designed area being (10-15) cm×(8-10) cm and the designed length of the vascular pedicle being (12-15) cm.

5. The method for repairing nasopharyngeal skull base necrosis using a free anterolateral thigh myocutaneous flap according to claim 1, characterized in that: In step S1, the specific operations for removing the nasopharyngeal skull base necrosis and obtaining the lesion area to be repaired are as follows: First, a 2-cm arcuate incision is made along the inferior margin of the mandible. The skin, subcutaneous tissue, and platysma muscle are incised. A flap is made deep to the platysma muscle. The facial artery and vein, and the marginal mandibular branch of the facial nerve are identified and protected. The facial nerve and its branches are then ligated, cut, and marked for future use. Next, continue the incision upward along the midline of the face to the midline of the lower lip, cut to the median surface of the mandible, and separate along the surface of the mandible to expose the median surface of the mandible. Use a small 6-hole titanium plate to shape and mark it; Finally, an electric saw is used to split the mandible along the mandible, and under an endoscopic system, the nasopharyngeal skull base necrotic lesion is removed. During the operation, the internal carotid artery is dissected and protected or ligated according to the situation.

6. The method for repairing nasopharyngeal skull base necrosis using a free anterolateral thigh myocutaneous flap according to claim 1, characterized in that: In step S3, the specific steps of using the repair flap to repair the lesion area to be repaired are: The repair flap is transferred to the oropharynx, nasopharynx, parapharynx, and skull base areas of the lesion to be repaired, and enters the oropharynx, nasopharynx, parapharynx, and skull base areas through the submandibular parapharyngeal space tunnel. The flap is sutured and fixed to the incision edge of the oropharynx, parapharynx, and floor of mouth areas. The repair flap is packed and fixed. Under a microscope, the lateral femoral circumflex artery is micro-anastomosed to the facial artery, and the lateral femoral circumflex vein is micro-anastomosed to the facial vein and posterior mandibular vein using a venous anastomosis device. Examination showed that the flap had a good blood supply. The remaining wounds in the mouth were sutured in layers, the mandible was anatomically repositioned, and a titanium plate pre-punched before osteotomy was used for rigid internal fixation. The submandibular, lower lip, and leg incisions were sutured in layers.

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