【作者】 于大山；

【导师】 庄洪兴； 蒋海越； 杨庆华；

【作者基本信息】 中国协和医科大学 ， 外科学， 2009， 博士

【摘要】 第一部分扩张器自体肋软骨耳廓再造术负压引流作用原理及对扩张皮瓣血液循环的影响目的:(1)明确扩张器自体肋软骨耳廓再造术负压引流装置的作用原理和负压变化规律;(2)研究负压引流对扩张皮瓣血液循环的影响及适宜的负压引流强度。指导临床耳廓再造负压引流的合理、有效使用。方法:(1)北京协和医学院整形外科医院外耳整形与再造中心耳廓再造病例40例,随机分为两组。分别采用两种负压引流装置,均给予-60kPa负压引流,术后即刻、2小时、4小时、8小时、24小时分别测量两组不同负压引流装置的负压值、引流液量,及两组引流装置的容积,绘制容积与负压变化曲线。(2)红外热像仪观测21例再造耳廓术后即刻分别给予0、-20、-40和-60kPa负压引流强度时皮瓣近端(再造耳耳甲腔)、远端(再造耳耳轮缘)温度变化,反映再造耳廓扩张皮瓣动脉血供。21例患者随机分为三组,分别给予-20、-40和-60kPa负压引流。术后即刻、5天、10天分别测量三组再造耳廓长、宽,计算差值,代表再造耳廓肿胀情况,反映再造耳廓皮瓣静脉回流。结果:(1)两组引流装置容积差异有统计学意义(P＜0.01);随引流液增多,引流容积减小,负压也逐渐下降。但引流容积大的引流装置负压下降缓慢,引流容积小的引流装置负压下降速度快(差异有统计学意义,P＜0.01);两组负压引流装置在术后4小时内,引流液量无明显差别,而8小时后引流容积大的引流装置引流液量多于引流容积小的引流装置(差异有统计学意义,P＜0.01)。(2)扩张器自体肋软骨耳廓再造术负压引流强度在0至-60kPa范围内,随负压强度增大,再造耳廓皮瓣温度增高(差异有统计学意义,P＜0.01);且近端温度增加大于远端,差异具有统计学意义(P＜0.01);再造耳廓皮瓣肿胀程度随负压值增大,先下降后增加(差异有统计学意义,P＜0.01)。结论:(1)引流装置容积影响负压的维持时间,从而影响负压实际作用效果。在满足临床负压强度及封闭前提下,选用容积相对较大的负压引流装置受引流液量影响较小,有利于负压引流的确切作用效果及有效作用时间。(2)扩张器自体肋软骨耳廓再造术中负压引流对再造耳廓皮瓣动脉供血及静脉回流均有影响,且负压作用不局限于引流管周围,在皮瓣近端及远端均有体现。-40kPa负压引流对再造耳廓动脉供血及静脉回流均有促进作用,可供临床设定负压引流强度提供参考。第二部分兔耳廓再造模型负压引流对扩张皮瓣循环影响的机理及组织学研究目的:研究兔耳廓再造模型中(1)负压引流与皮瓣下压力的关系、产生机理和对皮瓣血运的影响;(2)负压引流作用后再造耳廓皮瓣微循环的组织学及超微结构变化以及组织水肿影响,探讨负压引流影响血供的机理;(3)负压引流引起的扩张皮瓣与软骨支架间组织结构变化,寻找皮瓣与软骨生物性结合的证据及其发生时间,探讨负压引流的有效作用时间。方法:免背两侧对称部位分别植入50ml肾型扩张器,注水扩张15天(注水80ml),维持扩张15天后取出扩张器,形成C形皮瓣,植入硅胶耳支架作为耳廓再造动物模型。(1)皮瓣深面硅胶耳支架耳轮及耳甲腔部位安置微型正压感受器,皮瓣表面对应部位标记激光多普勒血流仪检测位点。分别给予0、-10、-20和-40kPa负压引流,测定皮瓣下压力值及皮瓣血流灌注量。(2)兔耳廓再造模型同上,实验组接-15kPa负压引流,对照组无负压作用。术后1、3、5天切取两组皮肤、皮下组织,光镜及透射电镜下观察;干湿法检测实验组和对照组皮瓣组织的含水量变化。(3)免背两侧对称部位植入30ml圆型扩张器,注水50ml,15天后取出扩张器,形成C形皮瓣,皮瓣下植入兔自体片状耳廓软骨。实验组接-15kPa负压引流,对照组无负压作用。于术后2、4、6天切取两组皮肤、皮下、软骨全层组织,大体、光镜及扫描电镜下观察。结果:(1)0至-40kPa负压强度范围内,随负压强度增大,皮瓣下的正压逐渐增大,耳轮与耳甲腔部位无差别(P＞0.05)。皮瓣血流灌注量先增加后下降(P＜0.01)。耳轮部位较耳甲腔部位血运差,差异有统计学意义(P＜0.01)。(2)实验组与对照组在1、3、5天的微循环血管口径及皮瓣组织含水量差异显著(P＜0.01);术后5天微血管密度差异无统计学意义(P＞0.05);实验组:术后1天毛细血管腔明显扩张,内皮细胞间隙较大;3天可见血管出芽增生,内皮细胞间隙缩小;5天血管出芽和内皮细胞增生仍显著,内皮细胞连接紧密,吞饮小泡少见。对照组:毛细血管形态无明显改变,术后5天见血管出芽增生,而内皮细胞间隙较大,吞饮小泡较多。(3)术后皮瓣成活良好,移植软骨均存活良好,未见排异反应。术后2天,实验组皮瓣与软骨支架贴附紧密;对照组皮瓣与软骨支架间有积液存在,影响贴附。术后4天实验组皮瓣与软骨间出现纤维组织连接;对照组皮瓣与支架间间隙明显,未见明显纤维连接组织。术后6天实验组软骨周围纤维组织与皮瓣深面纤维组织融合,难以分辨,皮瓣与软骨支架间隙基本消失;对照组软骨周围纤维组织增厚,皮瓣与支架间隙仍然存在。结论:兔耳廓再造模型中,(1)负压引流作用于再造耳廓,皮瓣下正压与负压同时存在,分布均匀,对皮瓣的血运同时产生抑制和促进两种相反作用。在-20kPa以下负压引流强度,促进作用占据优势地位,负压引流强度超过-20kPa后,皮瓣血运开始受到抑制。耳甲腔处于皮瓣蒂部,血运较为充足,血运受负压引流强度影响小;而耳轮是耳廓最突出的部位,且处于皮瓣远端,血运相对较差,对负压引流作用敏感。(2)负压引流能扩张皮瓣毛细血管,并可以加强内皮细胞间的连接,有效的减轻皮瓣术后水肿。促进血管出芽增生,从而改善创面微循环,有利于创面愈合,早期以微血管扩张为主。(3)负压引流能减少皮瓣与软骨支架之间的渗出,促进皮瓣与支架间贴附及纤维组织增生,较早形成生物性结合,保证移植后软骨支架的营养供给,促进软骨成活,伤口愈合。负压引流的有效作时间为4-6天,为临床拔管时机提供实验依据,防止因引流管放置时间过长引起的并发症发生。更多还原

【Abstract】 Part one The Principles and Effects of Vacuum Drainage on blood circulation of expanded skin flap in Ear reconstruction using skin expander combined with autogenous costal cartilage transplantationObjectives:To investigate(1) The principles and negative pressure change styles of two different Vacuum Drainage systems;(2) The effects on blood circulation of expanded skin flap and appropriate intensity of negative pressure caused by Vacuum Drainage in Ear reconstruction using skin expander combined with autogenous costal cartilage transplantation,for correct and efficient use of Vacuum Drainage in clinic.Methods:(1) 40 patients(Auricular Reconstructive Center of Plastic Surgery Hospital, PUMC,Beijing,PR.China) were divided into two groups randomly using different Vacuum Drainage system.Set the initial intensity of Vacuum Drainage -60kPa.Measure the volume of two Vacuum Drainage systems and record the numerical value of negative pressure,quantity of leakage,0,2,4,8,24 hours postoperatively.Draft the volume-pressure curve diagram.(2) Using infrared thermography post-operational instantly to detect the temperature of proximal(concha) and distal(helix) part of the expanded flaps—represent the arterial blood supply of flaps—of 21 reconstructed ears while 0,-20,-40 and -60kPa Vacuum Drainage were applied.3 groups were divided randomly of 21 patients,-20,-40 and -60kPa Vacuum Drainage were gave separately.The length and width of reconstructed ears—represent the swelling degree—were measured instantly and 5,10days postoperatively.The differences were calculated and stand for venous return of flaps.Results:(1) The volume difference of two Vacuum Drainage systems were significant(P＜0.01);The intensity of Vacuum Drainage was lower according to the decrease of Vacuum Drainage volume,accompanying with the increase of leakage quantity.The Vacuum intensity lower speed of small volume drainage system was significant fast than the big volume Drainage system(P＜0.01);The leakage quantity of big volume drainage system was significant high than small volume drainage system at the 8,24 hours postoperatively(P＜0.01).(2) 0 to -60kPa,following the strengthen of intensity of Vacuum Drainage,the flap temperature of reconstructed ears increased(P＜0.01),the increase in value of proximal(concha) part was significant high than distal(helix) part (P＜0.01);but the swelling degree of reconstructed ears firstly decreased,and then increased(P＜0.01).Conclusions:(1) The volume of drainage system affects the endurance period and actual using result of Vacuum Drainage.In clinical,the intensity of Vacuum Drainage of big volume drainage system was less influenced by the leakage quantity and contributed to the endurance period and actual using result of Vacuum Drainage.(2) Vacuum Drainage influenced both arterial blood supply and venous return of flaps in Ear reconstruction. The effects of Vacuum Drainage were presented both proximal and distal part of the flap. -40kPa Vacuum Drainage was benefited to both arterial blood supply and venous return. It can be consulted by clinical use. Part two The mechanism and histological studys of Vacuum Drainage on blood circulation of expanded skin flap in Rabbit Ear reconstruction ModelObjectives:Vacuum Drainage was used in Rabbit Ear reconstruction Model to investigate(1) The mechanism and relations and flap blood circulation change accompanying with the pressure change under the expanded skin flap;(2) The histological and ultramicro structure and tissue water content changes of the expanded skin flap;(3) The histological and structure changes between the expanded skin flap and the cartilage framework.Discuss the possible mechanism of blood supply improvement and the efficient period of the Vacuum Drainage.Methods:2 kidney-shaped skin expanders,with a 50ml potential volume,were implanted into the subcutaneous pocket dissected at symmetrical part of rabbit back separately.The total expansion volume was 80ml each and took about 15 days.After additional 15 days static expansion phase,the expanders were removed.A "C"-shaped skin flap,pedicled anteriorly,was elevated and a carved silicon gel ear framework was inserted under the flap.The rabbit ear reconstruction model was established.(1) While 0, -10,-20 and -40kPa Vacuum Drainage were applied separately,mini-pressure detectors were applied to measure the pressure of the helix(Group A) and the concha(Group B) part of reconstructed ear under the flap.Laser Doppler Flowmetry was used on same place of the flap surface to measure the perfuse unit(PU).(2) Same experimental model, -15kPa Vacuum Drainage was applied to treated group,no negative pressure was applied to control group.Histological specimen of both two groups were harvested 1,3,5 days postoperatively and observed under the optical microscope and the transmission electron microscope.Total tissue water content was measured by the method of wet-dry subtraction for both treated and control groups.(3) 2 circular shaped skin expanders,with a 30ml potential volume,were implanted into the subcutaneous pocket dissected at symmetrical part of rabbit back separately.Each expander was injected 50ml normal saline.After additional 15 days static expansion phase,the expanders were removed.A "C"-shaped skin flap,pedicled anteriorly,was elevated and an autogenous lamellar rabbit auricular cartilage was inserted under the flap.-15kPa Vacuum Drainage was applied to treated group,no negative pressure was applied to control group.Histological specimen of both two groups were harvested 2,4,6 days postoperatively and observed under naked eye and the optical microscope and the scanning electronic microscope.Results:(1) 0 to -40kPa Vacuum Drainage,The positive pressures unde flap was increased according to the increase of Vacuum Drainage,no significant difference was found in two groups(P＞0.05).The PU of flap firstly increased,and then decreased(P＜0.01).The PU of Group B was significant high than Group A(P＜0.01).(2) There is significant difference between all specimen of treated and control groups in the blood capillary antilinear and the tissue water content(P＜0.01).The microvessel density in 5 days postoperatively specimen of two group was approximately(P＞0.05).Treated group:expanded capillaries were observed and cell space was narrowed at 1 day after treatment;more significant expansion and the budding of capillaries was found at 3 days postoperatively;the expansion and budding of capillaries were still significant on the 5th day postoperatively,while cell junction was compacted.Control group:no significant morphological changes in capillaries;capillary budding was observed on the 5th day, while cell junction was still loose.(3) The skin flap and cartilage takes good,no rejection was observed.2 days after operation:skin flap and the cartilage were sticking tightly in treated group,while there were transudate accumulated under flap and blocked the attachment of flap and cartilage in control group.In treated group,plenty of fibrous tissues between skin flap and cartilage were observed on the 4th day postoperatively.6 days after operation,the fibrous tissues around the cartilage and the fibrous tissues under the skin flap were mixed together and hardly to discern.No visible interspace can be found between flap and cartilage.There is no apparent fibrous tissues were detected 4th day postoperatively in control group,the fibrous tissues were thick but the interspace between flap and cartilage still significant on the 6th day postoperatively.Conclusions:Vacuum Drainage was used in Rabbit Ear reconstruction Model(1) Negative and positive pressure was both existed under the skin flap.The pressures were well-distributed and bring two adverse effects to blood supply of expanded skin flap. Improving effect took the superiority while the intensity of Vacuum Drainage was lower than -20kPa,but the blood supply of expanded skin flap would be compromised when the intensity of Vacuum Drainage exceeded -20kPa.The concha part was located at pedicle of the flap and was less influenced by Vacuum Drainage than helix part which was located at distal of the flap.(2) The capillaries expansion,the compacted vascular endothelial cell junction,less tissue edema and more efficient microcirculation can be obtained by using proper Vacuum Drainage.The improving of microcirculation of skin flap was mainly come from capillaries expansion instead of the budding and proliferation of capillaries in the early stage.(3) Vacuum Drainage can efficient reduce the transudate, improve the attachment and the fibrous tissues proliferation,induce the formation of organismic-bind between flap and cartilage early and improve the survival of the cartilage grafts.The efficacious period of Vacuum Drainage would be 4-6 days.That was indicated the appropriate time for removing Vacuum Drainage to avoid the complications caused by excess drainage time.更多还原