【作者】 于海生；

【导师】 陈石海；

【作者基本信息】 广西医科大学 ， 外科学， 2007， 硕士

【摘要】 目的回顾性分析应用Nd:YAG激光治疗的皮肤血管瘤病例,并复习有关国内外文献资料,探讨激光对皮肤血管瘤的治疗效果,影响治疗效果的因素,适应症的选择及并发症的防治。方法收集1999年8月～2006年6月间在广西医科大学第一附属医院整形美容外科采用532nm Nd:YAG激光治疗的皮肤血管瘤共546例,其中资料完整、随访超过6个月以上的患者501例,共552处病变。根据病变条件先选择较小激光能量密度进行试打,确定参数后进行激光治疗。术后病变处常规冰敷15-30分钟。外敷紫花烧伤膏和金霉素眼膏至创面干燥、结痂。2-3个月后可进行第二次治疗。门诊定期随访观察,最短6个月,最长达6年。判断疗效的标准:痊愈:病变及其表面颜色完全消退或消退≥90%,皮肤颜色、质地恢复正常,经6个月以上的随访无复发;显效:病变消退达60%～89%,皮肤颜色、质地基本恢复正常,无并发症发生,经6个月以上的随访无复发;有效:病变及其表面颜色消退达30%～59%,可有色素沉着,无疤痕形成及色素缺失;无效:病变及其表面颜色无变化或消退＜30%,或有色素缺失,或有浅表疤痕形成。结果1.激光治疗后近期观察激光治疗后病变创面均有不同程度的水肿,一般24-48小时达高峰,72小时左右创面干燥、结痂,7-14天结痂自然脱落。3个月内病变处避免日晒,一般无色素沉着。2.临床疗效及影响因素血管瘤总治愈率为60.9%,总有效率为:86.2%;浅层皮肤血管瘤和深层皮肤血管瘤的治愈率分别为:67.4%、40.2%,有效率分别为:89.5%、75.8%。单纯激光治疗的血管瘤治愈率为56.0%,经平阳霉素和地塞米松局部注射或口服强的松与激光联合治疗(联合治疗)的血管瘤治愈率为70.4%。统计学分析结果表明:在Nd:YAG激光治疗的血管瘤病例中,浅层皮肤血管瘤和联合方法的治疗效果分别优于深层皮肤血管瘤和单纯激光的治疗效果(回归系数分别为1.209、-0.818,OR值分别为3.350、0.441,P值均＜0.01)。同时显示,在一定范围内,病变的面积越大,治疗效果越差;激光的能量密度越高、治疗的次数越多、治疗效果越好(方程系数分别为0.265、-0.071、-0.160,优势比分别为1.303、0.931、0.852,P值均＜0.05)。3.不良反应本组552处病变中,15处出现表浅性疤痕(2.7%),16处出现色素沉着(2.9%);12处出现色素缺失(2.2%);未见溃疡形成等其它不良反应及意外损伤。结论1.Nd:YAG激光治疗皮肤血管瘤是一种安全、有效的治疗方法。能在符合美容要求的前提下,较大程度地控制血管瘤的生长,促进其消退,特别适用于颜面四肢等暴露部位。2.Nd:YAG激光对皮肤血管瘤的治疗效果与激光参数选择及病变条件有关,在临床治疗过程中,通过对激光参数的调整和加强血管瘤激光治疗适应症的选择,可提高血管瘤的治愈率。3.激光的穿透能力有限,对于位置深、面积大的皮肤血管瘤根据具体情况与其它方法如平阳霉素加地塞米松局部注射、激素口服等联合治疗,可以提高皮肤血管瘤的治愈率,减少并发症的发生。4.Nd:YAG激光有导致色素沉着、色素缺失、疤痕形成的风险,可能与病人的肤色、体质及激光能量密度过高和治疗后创面的护理不当等因素有关,治疗过程中应加以注意。更多还原

【Abstract】 OBJECTIVEThe study aims at observing the therapeutic efficacy of the cutaneous hemangiomas, the influencing factors of the effects, the choice of the indication and the prevention of the adverse effects by the retrospective analysis of the cases treated with 532nm Nd:YAG laser and the review of the relevant data.METHODBetween August 1999 and June 2006, the 546 cases with hemangiomas were treated with 532nm Nd:YAG laser in department of plastic and aesthetic, the first affiliated hospital of Guangxi medical university. A total 501 cases(552 lesions) were followed up over 6 months and have integrity dada among the 546 cases.At first, we should tentatively treat with the lower parameters of laser on the basis of the conditions of tumors and then cure the lesions in the decided parameters. The lesions were usually covered with ice about 15-30 minutes after treament and were overlaid in burn cream and oculentum aureomycini every day to form an incrustation. The next treatment might be carried out after 2-3 months. All the patients were followed up for 0.5-6 years.The judgment of the therapeutic effects: cure: the tumors disappeared completely or≥90%, the color and texture of the skin recovered completely, there were not recurrence by being followed up; obvious effects: the tumors extinguished 60%-89%, the color and texture of the skin recovered visibly without recurrence by being followed up, there were not any complications; ordinary effects: the tumors and the color of the skin extinguished 30%-59%, the skin of the lesions might have slight chromatosis, but there were not scaring and absence of pigment; inefficacy: the tumors had no amelioration or extinguished < 30%, or the complications, such as absence of serious pigment or obvious scaring et al, had taken place.RESULTS1. Recent Observation The lesions had a different extent hydroncus that would go to a peak about 24-48 hours, and the crustas would be formed in 72 hours and would be off between 7-14 days after treatment. The skin of lesions had not usually chromatosis without being exposed to sun in 3 months.2. Clinical Effects and Influencing Factors The cure rate of the total cases, the hemangiomas in superficial and deep-seated skin were respectively 60.9%, 67.4% and 40. 2%, and the effective rate of them were 86. 2%, 89. 5%, 75. 7%; the cure rate of the hemangiomas , on laser and combined methods, were respectively 56.0% and 70. 4%. The analytic result of the statistics: the therapeutic effects of the superficial hemangiomas and the combined methods were more excellent than that of the deep-seated hemangiomas and the only laser treatment(B=1.209、-0.818, Exp(B)=3.350、0.441, Sig<0.01). The smaller size of hemandiomas, the higher energy of laser and the more therapeutic times, the therapeutic effects of hemangiomas were more excellent (B=0.265、-0.071、-0.160,Exp(B)=1.303、0.931、0.852, Sig<0.05).3.Adverse Effect Among 552 lesions, 15 lesions had atrophic scar(2.7%) , 16 lesions present pigmentation(2.9%), 12 lesions appeared absence of pigment(2.2%), other complications, such as elcosis et al, did not take place.CONCLUSION 1. It is a safe and active method to treat cutaneous hemangiomas with 532nm Nd:YAG laser. Since 532nm Nd:YAG laser can restrain effectually the growth of hemangiomas and facilitate its extinction on the premise that being in line with the aesthetics, it is particularly proper to treat the cutaneous hemangiomas in the exposed position.2. Since the therapeutic effects of the cutaneous hemangiomas on 532nmNd:YAG laser were closely concerned with the parameters of the laser and the conditions of the lesions, the cure rate of the cutaneous hemangiomas can be improved by adjusting the parameters of the laser and selecting the correct cases.3. Because the depth that laser can arrive is restrict, according to the conditions of the lesions, laser can be combined with other methods, such as local injection of pingyangmycin and Dexamethasone, taking prednisone et al, to raise the cure rate and decrease complications.4. 532nm Nd:YAG laser has the risk of chromatosis, absence of pigment and scarring, which may be relational with many factors , such as the complexion and constitution of patients, the exorbitant energy density of laser and the unsuitable nursing of lesions et al; therefore, we must be cautious in the therapeutic progress.更多还原