【作者】 安波；

【导师】 孙广慈； 庄洪兴；

【作者基本信息】 中国协和医科大学 ， 整形外科， 2001， 博士

【摘要】 正常耳廓系由细薄的皮肤软组织包裹弹力软骨支架所组成的形态复杂的薄壳结构，耳廓再造术一直被认为是整形外科中最为困难、复杂的手术之一。每个人的耳廓大小与形状不尽相同，因各种原因需行耳廓再造时，在临床工作中均需分别对待。成功的耳廓再造术取决于两个因素：塑形良好的软骨支架和充裕覆盖支架的皮肤组织。在目前，耳廓再造的软骨支架仍以自体肋软骨为好；皮肤则以尽量利用残耳后乳突区皮肤为主，扩张后皮肤量的增加与变薄，更有利于显示雕塑软骨支架的四层面概念，使再造的耳廓形态达到满意的结果。 目前，对于自体肋软骨游离移植生物学转归系统的研究报道不多。对于自体肋软骨移植后能否成活，肋软骨膜在移植软骨中的作用，供区的修复以及软骨间的愈合方式等均存在不同的看法；特别是对先天性小耳畸形患儿的手术时机的选择，肋软骨膜在移植软骨生长中的作用以及学龄前儿童再造耳能否随年龄增长而与正常耳同步按比例生长等均存在不同的观点。随着皮肤扩张术在外耳再造中的应用，更需了解扩张皮瓣对自体肋软骨支架的影响。因此，进一步研究和明确自体肋软骨游离移植的生物学转归，将会更好地指导我们的临床工作。本课题主要通过动物实验、临床病理标本检查和病例随访三方面的研究工作来探讨相关问题，以期能指导临床。 在动物实验研究中，3个月幼龄猪自体肋软骨游离移植术后3、6个月经大体观察、测量、光镜、电镜检查及细胞外基质GAG和胶原含量检测表明：移植软骨块能成活、生长，若同时携带软骨膜移植，则成活、生长更为显著，二者对移植软骨的成活和生长起互补及加强作用，主要表现在移植软骨块的长度、重量、体积显著增大(P＜0.001)，移植后6个月软骨块的GAG及胶原分泌明显提高(P＜0.001)，在光镜和电镜中存在具有活力的软骨细胞。但移植软骨的成活不完全，主要表现在移植3个月后软骨组织中有局灶性坏死，GAG及胶原含量明显下降(P＜0.001)。术后6个月上述情况均有明显改善，说明移植软骨的生物学特性逐渐向正常状态恢复。另外，肋软骨间不能融合，其愈合主要为纤维结缔组织连接。 在临床上，先天性小耳畸形由于乳突区皮肤面积不足，给耳廓再造带来一定的困难，利用皮肤扩张术可以使耳后无毛皮肤得以充分扩张提供足够的无毛皮肤覆盖耳支架前面，基本解决了皮肤不足的问题；同时使扩张后皮肤变薄，达到理想厚度，为耳廓的塑形提供了有利条件：去除纤维包膜的扩张皮瓣与耳支架贴附紧密并增强支架血供，为耳支架的成活和生长提供了良好的外部条件。在肋软骨支架方面，我们强调了带软骨膜的软骨移植和支架四层面的合理塑型，提出肋软骨采取和雕塑时的注意事项。临床观察8例肋软骨移植后的组织学检更多还原

【Abstract】 Normal external ear is a shell structure of complicated shape which is made by flimsy skin tissue that warps elastic cartilage. Ear reconstruction is one of the most difficult and complicated plastic surgery. When ear reconstruction is needed by various reasons,we should treat it respectively as the size and shape of each is different. The success of ear reconstruction is made by two factors:good framework of sculpted cartilage and enough integument of skin tissue to cover the framework.Now, the framework is often made by costal cartilage autograft and the skin tissue is provided by the skin in mastoid region . When the skin has been expanded with expander, Its quantity increases and the quality becomes thinner, which is better for the display of the four layer concept of the sculpted cartilage framework.Thus,the shape of the reconstructed ear can get more satisfied outcome.Now, the systemic report is not enough about the biological result of costal cartilage free autograft. There are different viewpoints about the live of costal cartilage autograt, the repair of offer region and the recovery style of the cartilage ,especially about the selection of surgical time in congenital microtia, the use of chondrium in the growth of cartilage autograft and the growth ability of the reconstructed ear in preschool children .With the use of skin expansion in the ear reconstruction, it is better to know the effect of the expanded skin flap on the cartilage framework.So we studied biological change of costal cartilage free autograft in reconstructed ear to offer advice in our clinical practice. This study includes three respects of animal experiment, clinical examination of autograft cartilage and followed cases.The experiment of costal cartilage autograft in three-month old pig has proved that autograft cartilage can live and grow after three or six months by gross observation, examinations of histology and TEM(transmission electron microscopy) and measurement of the content of GAG (glycosaminoglycan) and collagen in extracelluar matrix. If cartilage autograft with chondrium, the live and growth of autograft becomes more evident. It is mainly expressed in that the length, weight and volume of the graft cartilage increased strikingly (P<0. 001). The secretion of GAG and collagen increased after six months (P<0. 001) and there is young and viable cartilage cell in the examination of histology and TEM. At the same更多还原