【作者】 秦晓；

【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】 第一部分三维激光扫描技术在耳后扩张器移位中的应用研究研究目的:通过三维激光扫描技术对维持扩张(养皮)前、后耳后扩张器进行扫描并利用相关软件对数字模型进行重建、拟合,将扩张器的三维构形与时间过程相结合进行四维动态研究;对维持扩张前、后耳后扩张器不同标志点的下移距离进行测量,为临床医生埋置耳后皮肤扩张器时的准确定位提供参考依据;对维持扩张前、后耳后扩张器的移位距离及其影响因素进行初步的统计分析,为扩张器的移位程度的预测、制定合理的维持扩张时间提供理论依掘,以便在二期手术时获得耳后皮瓣最有效的扩张效应。研究对象和方法:在中国医学科学院整形外科医院外耳中心2007-2009年间入院行皮肤扩张法耳廓再造术的小耳畸形患者中,对满足以下条件的74例患者:1)、年龄6～9岁。2)、单侧Ⅰ度、Ⅱ度小耳畸形。3)、耳后扩张皮肤无赘生物、无瘢痕组织,既往未行手术、激光脱毛等治疗者。4)、耳后发际线正常者。5)、耳后扩张皮肤无血运障碍、无破溃者。6)、耳后扩张器及注射壶无渗漏,扩张过程顺利者。7)、患者及家属能够配合扫描工作者。对上述患者分别于维持扩张前、后进行三维激光扫描获取三维数据,利用Polyworks软件对两次获得的三维数字模型进行重建、拟合并选取扩张器上基点、下基点及下极点作为标志点进行下移距离的测量。用SAS 6.12统计软件分别对三个标志点的下移距离与引入的五个自变量(性别、残耳类型、皮瓣血肿、维持扩张天数和注水量)进行多元线性回归分析。结果:年龄:6岁～9岁,平均7.7岁。男性43例,女性3l例。Ⅰ度小耳畸形26例,Ⅱ度小耳畸形患者48例,无血肿者64例,有血肿者10例,注水53～87毫升,平均70.4毫升(70.4±7.5),维持扩张20～50天,平均29.6天(29.6±5.7),经过维持扩后,扩张器上基点下移5.0～13.8毫米,平均8.5毫米(8.5±2.2)。下基点下移4.0～10.0毫米,平均6.3毫米(6.3±1.6)。下极点下移4.3～12毫米,平均7.5(7.5±2.1)毫米。皮瓣血肿(H)、维持扩张天数(D)、注水量(V)三个自变量的偏回归系数对扩张器三个标志点的下移均有统计学意义,得出多元线性回归方程模型如下:上基点下移距离=-11.35+2.05×H+0.14×D+0.22×V,下基点下移距离=-8.24+0.66×H+0.1×D+0.17×V,下极点下移距离=-10.37+1.87×H+0.11×D+0.20×V。扩张器三个标志点的下移回归方程模型中,注水量的标准化回归系数最大,维持扩张时间次之,皮瓣血肿最小。结论:1、扩张器的扩张效应具有时间变量的特征,耳后皮肤扩张器在经过维持扩张后发生不同程度的下移,是造成二期手术耳廓上部无毛区皮瓣覆盖不足的原因之一。2、耳后皮肤扩张器三个标志点经过维持扩张后均有下移,尤其是上基点下移5.0～13.8毫米,平均8.5毫米,对选择合理的扩张器置入位置有一定的参考意义:在确定扩张器的置入位置时,除了参考残耳、发际线及对侧耳廓位置外,扩张器下移距离也应预计在内,这样才能在二期手术时获得最有效的扩张效应。3、6-9岁年龄段患者中,皮瓣血肿、维持扩张天数、注水量对扩张器各个标志点的下移程度的影响则都是正向的。其中注水量对三个标志点下移的影响最大,维持扩张时间次之,皮瓣血肿的影响最小。第二部分三维激光扫描技术在耳后扩张器表面积测量中的应用研究研究目的:利用三维激光扫描技术对维持扩张前、后的耳后扩张器总面积及扩张器上、中、下1/3三部分面积分别进行测量,通过量化指标分析耳后扩张器在经过维持扩张后面积变化特点,指导临床针对面积变化特点采取措施,以提高皮瓣的有效扩张;对耳后扩张器表面积与注水量的关系进行分析,为临床合理注水、实现定量扩张提供理论依据。研究对象和方法:在中国医学科学院整形外科医院外耳中心2007-2009年间入院行皮肤扩张法耳廓再造术的小耳畸形患者中,选择57例患者。患者选择标准:1)、年龄6～9岁。2)、单侧Ⅱ度小耳畸形患者,残耳呈花生状,外耳道闭锁。3)、耳后扩张区皮肤无耳赘、无瘢痕组织,既往未行任何手术及激光脱毛等治疗者。4)、面部对称,乳突区骨骼发育正常,耳后发际线正常者。5)、耳后扩张皮肤无血运障碍、无破溃者。6)、耳后扩张器及注射壶无渗漏,扩张过程顺利者。7)、能够配合扫描工作者。对上述患者分别于维持扩张前、后对耳后皮肤扩张器进行三维激光扫描获取三维数据,利用Polyworks软件对三维数字模型进行重建,精确测量耳后扩张器表面积,用SAS 6.12统计软件分别对维持扩张前、后耳后扩张器表面积的差异及扩张器上、中、下三部分比值的差异进行配对T检验,并对注水量与扩张器表面积的关系进行简单线性回归分析。结果:1、57例患者,年龄:6岁～9岁,平均7.9岁。扩张器注水量53～78ml,平均70.3ml(70.3.0±7.6ml)。静止扩张30±2天。通过对注水量(V)和耳后扩张器表面积(S)进行简单线性回归分析发现两者之间存在一定的线性关系,可用回归方程表示为:S_前=599.36+77.15×V,S_后=505.99+75.45×V。2、57例患者根据注水量分为≤65毫升组,66～70毫升组,71～75毫升组,≥76毫升组。各注水量组维持扩张前耳后扩张器平均表面积为5422.614±402.933mm~2,5699.741±294.814mm~2,6230.484±194.480mm~2,6772.997±395.589mm~2,维持扩张后分别为5211.173±351.011 mm~2,5463.147±311.991mm~2,6040.934±137.671mm~2,6552.796±316.624mm~2。各注水量组进行配对t检验,p＜0.01,维持前、后扩张器表面积的差异均有显著性意义。3、71～77毫升组中,维持扩张前耳后扩张器上、中、下1/3面积百分比分别为30.03±1.42%,34.46±1.85%,35.51±1.65%,维持扩张后分别为24.8±2.73%,36.12±1.36%,39.08±2.31%,对维持扩张前、后的扩张器上、中、下1/3面积百分比分别进行配对t检验,p＜0.01,有统计学意义。结论:1、耳后扩张器经过维持扩张后皮瓣面积变化有一定特点,扩张皮瓣总面积较扩张前略有减少,其中,扩张器上1/3所占总面积百分比较扩张前明显减少,但中、下1/3则较扩张前增加。经过维持扩张后扩张器上1/3面积的减少是导致二期耳再造手术时支架上部无毛区皮瓣覆盖不足的又一重要原因,因此有必要从注水等环节来弥补上1/3面积的减少。3、53～87毫升注水量范围内,耳后扩张器表面积与注水量之间存在良好的线性关系,说明注水量在达到87毫升时仍然能够获得扩张器表面积的增加,属于有效扩张范围。更多还原

【Abstract】 Objective:To study the change of the position of the post-auricular expander during the expansion maintenance period.Offer theoretical proof for the exact location of the expander implantation and determine a reasonable expansion maintenance time,enhance the effective expansion and increase the available expanded skin area.Methods:A total of 74 cases of patients of unilateral microtia who underwent post-auricular expander implantation between 2007 and 2009 in Auricular Reconstructive Center of plastic surgical hospital of Chinese Academy of Medical Sciences.The Selected criteria of the patients was:1.Aged 6～9 years old.2.The patient must be typeⅠ、typeⅡmicrotia.3.The patients had no previous laser depilation history and no previous surgery history, the post-auricular skin was intact,there is no scar and no tag was left. 4.In the post-auricular skin,the hairline was normal.5.No necrosis of expanding post-auricular flaps was occurred.6.No expander leakage and infiltration was occurred during expansion period.7.The patients could co-operate to the scanning work.Obtained the scanning digital model of post-auricular of expanders by the three-dimensional laser scanning technique before the expansion maintenance period and after the expansion maintenance period respectively,measured the movement distance of three mark point by overlay of the two three-dimensional digital modles with polyworks software,the available data and the affected factors such as sex, type of microtia,injected saline volume,expansion maintenance period and the flap hematoma were analyzed by multivariate linear regression.Result:All of the patients aged 6-9 years old,average 7.7 years old.43 of them was male,31 was female.26 was typeⅠmicrotia,48 was typeⅡmicrotia. Hematoma occurred in 10 cases.The injected saline volume was 53～87ml, average 70.4ml.The expansion maintenance period ranged was 20～50 days, average 29.6 days.The movement distance of the superior base point（SBP） ranged from 5.0 to 13.8mm,average 8.5mm,the movement distance of inferior basis point（IBP） ranged from 4 to 10mm,average 6.3mm,the movement distance of the inferior polar point（IPP） ranged from 4.3 to 12mm,average7.5mm.The available data were analyzed and three multiple linear regression equation models were drawn:SBP=-11.35+2.05×H+0.14×D+0.22×V,IBP＝-8.24+0.66×H+0.1×D+0.17×V,IPP＝-10.37+1.87×H+0.11×D+0.20×V.V=injected saline volume,D=expansion maintenance period,H＝flap hematoma.Conclusion:1.For the post-auricular expander,the expansion effect will change over time and the marking points position will moved downward after the expansion maintenance period,which due to the insufficient skin coverage of the auricular cartilage framework.2、Besides the position of the remnant ear,hairline and the normal auricle, the movement of expander after expansion maintenance period was another factors which should be considered when expander implantation.3、For the patients aged from 6-9 years old,the movement of the expander was unrelated to sex and the type（typeⅠand typeⅡ） of the remnant ear,however,the injected saline volume,the expansion maintenance period and the flap hematoma affected the movement of the expander positively.Among the factors,the injected saline volume effect the most,then followed the expansion maintenance period,the flap hematoma effect finally. Objective:To study the change of the expanded surface-area during the expansion maintenance period by measuring the whole expanded surface-area of post-auricular expander and the surface-area of three equal part of the post-auricular expander,to explore the relationship between the expanded surface-area tissue expander and the injected saline volume primarily.Offer theoretical proof for effective expansion and Quantitative expansion.Methods:A total of 57 cases of patients of unilateral microtia who underwent post-auricular expander implantation between 2007 and 2009 in Auricular Reconstructive Center of plastic surgical hospital of Chinese Academy of Medical Sciences were selected.The selected criteria of the patients was: 1.Aged 6～9 years old.2.The patients must be typeⅡmicrotia.3.The patients had no previous laser depilation history and no previous surgery history.The post-auricular skin was intact and no scar or tag was left.4. In the post-auricular skin,the hairline was normal,facial soft tissue presents symmetry.5.No necrosis of expanding post-auricular flaps was occured.6.No expander leakage and infiltration was occurred during expansion period.7.The patients could co-operate to the scanning work. Obtained the scanning digital model of post-auricular of expanders by the three-dimensional laser scanning technique and measured the expanded surface-area before the expansion maintenance period（S₁） and after the expansion maintenance period（S₂） by polyworks software,the difference of expanded surface-area were analyzed by T test,the relationship between the expanded surface area and the injected saline volume were analyzed by simple linear regression.Result:1.Among all of the 57 patients,aged 6-9 years old,average 7.9 years old. The injected saline volume was 53～87ml,average 70.3m1（70.3.0±7.6）.The expansion maintenance period was 30±2 days.We got equations expressed the relationship between the expanded surface area and the injected saline volume:S₁=599.36+77.15×V.S₂=505.99+75.45×V,A=the expanded surface area,V=the injected saline volume. 2、For≤65 ml group,66-70 ml group,71-75 ml group and≥76ml group,the average expanded area before the expansion maintenance period was 5422.614±402.933mm²,5699.741±294.814mm²,6230.484±194.480mm²,6772.997±395.589mm² respectively,the average expanded area after the expansion maintenance period was 5211.173±351.011mm²,5463.147±311.991mm²,6040.934±137.671mm²,6552.796±316.624mm² respectively,all groups showed statistically significant difference（P＜0.01）.3、For 71-77ml group,the percentage of area of the upper one-third of expander,middle one-third of the expander and lower one-third of the expander before the expansion maintenance period was 30.03±1.42%, 34.46±1.85%,35.51±1.65%,respectively,the percentage of area of the upper one-third of expander,middle one-third of the expander and lower one-third of the expander after the expansion maintenance period was 24.8±2.73%,36.12±1.36%,39.08±2.31%respectively,it also showed statistically significant difference（P＜0.01）.Conclusion:1.After expansion maintenance period,the expanded area of the whole expander was decreased.For the three equal part of expander,the expanded area percentage of the upper one-third part was decreased,that of the middle one-third and the lower one-third part was decreased,which was another cause which due to the insufficient skin coverage of the auricular cartilage framework.2、As the injected saline volume ranged from 53 to 87ml,the injected saline volume and the expanded surface-area maintained a linear relationship,an effective expansion could be acquired when the injected saline volume reaches to 87ml.更多还原