【作者】 张晋光；

【导师】 庄洪兴； 蒋海越； 杨庆华； 何乐人；

【作者基本信息】 中国协和医科大学 ， 整形外科， 2010， 博士

【摘要】 第一部分半侧颜面短小综合症患者头面部软组织对称性的三维测量及初步分析研究目的：通过对CT扫描数据三维重建,对伴小耳畸形的半侧颜面短小综合症患者的头面部软组织进行CT扫描及数字模型的重建；通过测量软件对头面部对称性差异进行测量和分析,为伴小耳畸形的半侧颜面短小综合症患者的颜面畸形的矫正和外耳再造提供理论依据。研究对象和方法：在2008年～2010年间入院的伴单侧小耳畸形的半侧颜面短小综合症的患者中,选择30例患者。对上述患者进行头颅CT扫描以及数字模型重建。在重建的三维数字模型上选择28个定点,通过测量软件进行测量,并进行初步的分析。测量内容包括：1、空间直线距离：2、弧度测量；3、角度测量；4、面积测量；4、体积测量；本研究的目的是对伴小耳畸形的半侧颜面短小综合症患者的头面部软组织的差异程度进行分析,数据分析以健侧头面部软组织为对照,测量并分析患侧头面部软组织与健侧的差异。测量结果通过SPSS13.0软件进行统计学分析。结果：1、具有显著性统计学差异的有：双侧鼻翼点到X轴、Y轴的空间距离；双侧颊点到X轴、Y轴、Z轴的空间距离；双侧下颌角点到X轴、Y轴、Z轴的空间距离；双侧耳屏点到X轴的空间距离。2、弧长测量方面：所测量弧长均有显著性统计学差异。3、在角度测量方面：角度②、⑤、⑥有显著性统计学差异。4、面积测量方面：下颌区的面积、颧区的面积、颏区的面积具有显著性统计学差异。5、体积测量方面：下颌区的体积、颧区的体积、颏区的体积、颞区的体积具有显著性统计学差异。结论：1、伴小耳畸形的半侧颜面短小综合症患者头面部不对称畸形是三维轴向的不对称畸形。2、除了小耳畸形外,下颌区畸形是伴小耳畸形的半侧颜面短小综合症面部不对称的主要表现和手术治疗的重点。3、外眦、鼻翼,畸形程度较轻,下颌角点和耳屏点不对称程度最明显。4、颞区的畸形直接影响外耳再造时耳支架的雕刻和放置。第二部分三维颅骨模型在外耳再造耳支架放置位置选择中的应用研究研究目的：探讨三维颅骨模型在外耳再造耳支架位置选择中的应用,比较使用三维颅骨模型和未使用三维颅骨模型对耳支架放置位置选择的影响,为外耳再造术提供新的思路。研究对象和方法：在2008年3月～2010年3月间入院的患者中,选取应用自体肋软骨支架移植外耳再造、单侧小耳畸形的半侧颜面短小的患者40例,其中20例术前头颅CT扫描,并利用快速成型技术制作出三维颅骨模型作为术前设计耳支架放置位置的模板,并在术后半年后进行随访调查。同时随机随访未应用三维颅骨模型进行术前设计的患者20例做对照组。随访调查内容包括：1、评价再造耳廓位置的对称性。应用SPSS 13.0软件,用卡方检验进行分析应用和未应用三维颅骨模型在再造耳位置对称性方面的差异有无显著性意义。2、评价颅耳角的差异。应用SPSS 13.0软件,用卡方检验进行分析应用和未应用三维颅骨模型在再造耳的耳颅角的差异有无显著性意义。结果：1、在再造耳廓位置及对称性方面,应用三维颅骨模型的患者组与未应用三维颅骨模型的患者组,两者之间的差异有显著的统计学意义(P=0.0424,P＜0.05)。2、在再造耳颅耳角方面,应用三维颅骨模型的患者与未应用三维颅骨模型的患者,两者之间无显著性差异(P=0.799,P＞0.05)结论：应用三维颅骨模型在外耳再造术前耳支架放置位置确定方面具有临床价值,是一种技术上的进步,有利于提高手术效果。第三部分小耳畸形患者的再造耳有限元模型研究目的：通过建立再造耳有限元模型,验证该系统的可行性和实用性。寻找解决耳再造手术术难以预测术后外耳形态变化障碍的最佳途径,并探索新的、更有效的手术方法。方法：选择1例伴单侧小耳畸形的半侧颜面短小患者一例,于外耳再造术后半年,进行头面部三维螺旋CT扫描,对外耳结构进行三维重建,对已构建的再造耳的三维几何模型采用手工划分的方式构建网格。然后应用有限元软件包ANSYS对划分的网格结构进行有限元分析,建立再造耳有限元模型。模型建立后,应用有限元软件包ANSYS对不同时间点的变化进行分析。结果：获取的再造耳有限元模型由52566个单元和84787个网格点组成。该模型在一定程度上反映了再造耳的生物力学性能,具有真实有效性。术后再造耳的形态变化均以数据和图像两种形式输出。经模拟后的软组织特征点的受力最显著的是外耳轮上缘、其次是舟状窝,其他标志点变化不大。再造耳形变的结果,提供了对外耳再造手术的手术方案进行修订,具有很高的临床应用价值。结论：本实验应用有限元技术,建立了一个能够反映外耳部分软组织生物力学性能,包含皮肤、软骨支架的有限元模型；并可以在患者再造耳有限元模型上进行手术后形变的模拟和预测。更多还原

【Abstract】 The First PartThe Three-Dimensional Measurement and Preliminary Analysis of the Symmetry of Cranial Soft Tissue of the Patients of The Hemifacial Microsomia Patients with MicrotiaObjective:To obtain the CT scanning data and reconstruct digital model of the cranial soft tissue of the patients of the hemifacial microsomia patients with microtia by three-dimensional CT scanning technique. To measure and analyze the symmetry of cranial soft tissue preliminarily. To provide theoretical proof of cranial soft tissue in the patients with hemifacial microsomia patients.Methods:A total of 30 cases of patients of the hemifacial microsomia patients with microtia who underwent auricular reconstruction between 2008 and 2010 were chosed. After obtainning the data and reconstructing digital skull model of the patients, we selected 28 mark points in the digital model to measure and analyzed the symmetry of cranial soft tissue preliminarily. The measurement data contained:1. the measurement of space distance.2.The measurement of radian.3. The measurement of angle.4. The measurement of area.5. The measurement of volume. The data were analyzed by SPSS 13.0Result:1. In all the mark points, the items with significant statistics difference were:the space distance from alae nas point to X axis and to Y axis, the cheek point to X axis、Y axis and to Z axis; gonial angle point to X axis,Y axis and to Z axis;tragion point to X axis.2. In the arc length:all the arc length which were measured had significant statistics difference.3. In the angle which was measured, the second, the fifth and the sixth had significant statistics difference.4. In all the area measured,, the items had significant statistics difference were: the area of mandibular area, zygomatic region, and mental region.5. In all the area measured, the items with significant statistics difference were:the area of mandibular area, zygomatic region and mental region. 5. In all the volume measured, the items with significant statistics difference were:the volume of mandibular area, zygomatic region, mental region and temperal region. Conclusion:1. The asymmetric deformity of cranial soft tissue in the hemifacial microsomia with microtia was multi-aspect deformity.2. Except for microtia, the deformity of mandibular area was the principal appearance and the key of the treatment.3. The degree of deformity of the angulus oculi lateral is and alae nas were fairly light, and the most severe deformity existed in the tragion point and mandible point.4.The deformity of temporal region has direct relationship with the f ibracation and location of ear framework.The Second PartThe Application of the Three-Dimensional skull Mould in the choice of the auricular framework location in the reconstruction of the external earObjective:To probe the application of the three-dimensional skull mould in the choice of the auricular framework location in the reconstruction of the external ear. To compare the two groups with or without using the three-dimensional skull mould in the choice of the auricular framework’s location in the ear reconstruction.Methods:We selected 20 cases of patients of hemifacial microsomia with unilateral microtia who underwent auricular reconstruction between 2008 and 2010. Three-dimensional CT scanning technique and rapid prototyping technology were used to manufacture three-dimensional skull mould of the patient before the operation.40 cases of patients were followed up. Two groups of the shape and symmetry of the reconstructed auricle were compared by 4 surgeons, and two groups of the cranioauricular angle were compared also. The data were analyzed by SPSS 13.0 and Pearson’X2 test.Result:1. The patients using the three-dimensional skull mould were compared with those without using skull mould in the shape and symmetry of the reconstructed auricle and it showed significant difference statistically (P= 0.0424, P<0.05).2. The patients using the three-dimensional skull mould were compared with those without using the skull mould in the cranioauricular angle of the reconstructed auricle and it showed no significant difference statistically (P=0.799, P>0.05).Conclusion:Three-dimensional skull mould has clinical value in the ear reconstruction. It was technical improvement in the ear econstruction.The third PartFinite element modeling study of the reconstructed ear in patients with microtiaobjective:The purpose of this research is to create 3D finite element model of reconstructed ear, To create a system for predicting the reconstructed ear deformation. To investigate a more effective method for ear sugery.Material and methods:Finite Element modeling study of one patient of the hemifacial microsomia patient with microtia was carried out after CT scanning and reconstruction of the ear. Development of 3D finite element model of the ear boundary conditions were set and the mesh was manually made by using tetrahedrons on the basis of 3 CAD models of skin, and cartilage framework. Finite element model of the reconstructed ear was then developed by means of ANSYS software package. Surgical simulation and prediction of reconstructed deformation resulting from different skin retraction rates in the future.The different time points were chosen to evaluate the ear deformation by means of ANSYS soft warepackage. The reconstructed ear was evaluated at different time points.Result:There were 52566 elements and 84787 nodes in the reconstructed ear. Finite element model of the ear reflected the biomechanical features in some respect. Results were outputed in form of medical images. The most apparent tissue displacement was superior helix of the renconstructed ear, followed with scaphoid fossa. And tragus is the least affected.Conclusion:This paper addressed to create a digital model of the reconstructed ear on the bas is of finite element method. The post-operation ear deformation could be predicted.The paper focused on the prediction of reconstructed ear deformation resulting from the skin tissue retraction.更多还原