【作者】 何亭；

【导师】 黄晓元；

【作者基本信息】 中南大学 ， 外科学， 2013， 博士

【摘要】 目的：总结与比较颈部瘢痕畸形的修复方法,探讨每种修复方法的主要优缺点。方法：收集我院2002年3月-2013年3月因热液烫伤、火烧伤、电击伤、化学烧伤、手术创伤等造成的颈部瘢痕畸形患者共计236例。包括Z字成形及其类似手术14例,断层皮片移植术144例,皮肤扩张邻位皮瓣修复术72例,单纯邻近皮瓣修复术3例,皮肤扩张断层皮片移植术3例。统计患者颈部瘢痕松解后面积、手术次数、术后并发症、随访等数据,对于断层皮片移植术和皮肤扩张邻位皮瓣修复两种手术方式,采取两独立样本的非参数检验,比较患者年龄对手术方法选择的影响,以及瘢痕松解后创面面积对手术方法选择的影响。结果：236例颈部瘢痕畸形病例,瘢痕松解后创面面积(S)≤0.5%TBSA者占17.80%,0.5%TBSA<S≤1%者占55.08%,1%TBSA<S≤2%者占23.73%,S>2%者占3.39%。Z字成形及类似手术14例,术后创面均一期愈合,手术效果满意。断层皮片术144例,部分皮片坏死23例、供皮区感染8例。皮肤扩张邻位皮瓣修复术的72例患者中,2例邻近皮瓣术后出现血运障碍,高压氧辅助治疗后好转；扩张囊破裂4例、注射壶或扩张囊外露5例、创腔感染2例、术后出血3例。单纯邻近皮瓣修复术3例,术后皮瓣全部成活,效果满意。皮肤扩张断层皮片移植术3例,术后皮片全部成活,效果满意。7例术后2-10年再次发生瘢痕挛缩畸形再次手术治疗。对比断层皮片移植术和皮肤扩张邻位皮瓣术,两种手术方式的患者年龄、患者的瘢痕松解后面积有显著差异(P<0.05)。采用皮肤扩张邻位皮瓣修复术的患者的年龄总体分布大于采用断层皮片修复术的患者,瘢痕松解后面积小于采用断层皮片修复术的患者,两者有显著性差异(P<0.05)。结论：颈部瘢痕畸形修复方法的选择,需综合患者全身皮肤情况、瘢痕挛缩程度、瘢痕松解后面积大小及患者的年龄综合决定。纵行的带状或蹼状挛缩瘢痕,可采取Z字成形及类似手术方式解决。年龄较小、瘢痕面积较大或需尽快矫正畸形的患者,采用游离皮片移植的方式。若患者有合适的供瓣区,以皮肤扩张的方法获取邻近的皮瓣最佳。在全身广泛瘢痕的患者,需结合患者自身的需求和条件,联合应用扩张器、断层皮片移植、邻近皮瓣的方式,以期达到满意的功能重建和外观重建效果。更多还原

【Abstract】 Objectives:To summarize and compare the different surgical techniques of neck scar plastic and reconstruction, and to disscuss the main advantages and disadvantages of these treatment strategies.Methods:236cases from march2002to march2013are collected. These cases were diagnosed as different extent of neck scar due to flame, hot fluid, electric injury and other reasons.14of the cases were treated by Z-plasty and the similar ways,144by split-thickness skin graft,72by expanded local flap,3by local flap,3by slipt-thickness expanded skin graf. Statistics are include the age of the patients, the area of the wound after tension-free, the times of operations, the postoperative complications, follow-ups and etc. Different surgical strategies are compared based on the age of patient and size of wound after tension-free treatment through two independent samples nonparametric tests.Results:The area of the wound after tension-free treatment(S) derives from0.1%TBSA to4.5%TBSA. Among which, the propotion of the cases that S≤0.5%TBSA is17.80%, while the propotion of the cases that0.5%TBSA<S≤1%is55.08%, and that of1%TBSA<S≤2%is 23.73%, that of S>2%is3.39%. The14cases treated by Z-plasty and the similar operations all acquired satisfied prognosis. During the144cases of split-thickness skin graft,31cases suffered from partial necrosis of the skin while8of them suffered from infection of the donor site. While during the cases treated by expanded local flap,2cases developed hemodynamic disorder while recovered after hyperbaric treatment,4cases suffered from burst of the expander,5cases suffered from expose of the injection pot or expander,2cases suffered from the infection of the cavity and3cases suffered from bleeding of the cavity.7of the cases underwent reoperations2-10years after the first operations. The3cases of local flap and3cases of slipt-thickness expanded skin graft are all survived. There is signifcant difference of patients age and size of wound after tension-free(S) treatment between the expanded local flap and slipt-thickness strategies (P<0.05). The patient age of the former is elder than the latter while the size of wound after tension-free is smaller (P<0.05)Conclusions:The stategies of plastic and reconstrction of neck scar should be made carefully balanced the skin station of the body, the age of patient, the contraction of the scar, the size of wound after tension-free treatment. Banded and verticle scars which settled inside the normal skin could be treated with Z-plasty and the similar method. Split-thickness skin graft is a choice for younger patients and larger size of wound after tension-free treatment,and this method is better for the patients who need to free the contraction as soon as possible. However, if the patients have proper doner site for local flap, the local flap assistant by expansion is better consider of the minor compliance in donor site and better color and texture that similar to neck. On the patients who suffered from extensive burns, the stategies should be made carefully and all the methods for reconstruction could be used together.更多还原