Clinical application of expanded internal mammary artery perforator flap combined with vascular supercharge in reconstruction of faciocervical scar
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摘要:
目的 总结扩张的胸廓内动脉穿支(IMAP)皮瓣联合血管增压在面颈部瘢痕整复中的临床应用经验。 方法 采用回顾性观察性研究方法。2012年9月—2021年5月,上海交通大学医学院附属第九人民医院收治23例符合入选标准的烧创伤后面颈部瘢痕患者,其中男18例、女5例,年龄11~58岁,均采用扩张的IMAP皮瓣整复。Ⅰ期根据瘢痕部位和范围在前胸置入1个或2个合适额定容量的皮肤软组织扩张器,术中注意保护IMAP、锁骨上动脉胸支和胸外侧动脉,术后注入生理盐水进行扩张。Ⅱ期行皮瓣转移术,术前使用彩色多普勒超声血流探测仪明确优势IMAP。切除面颈部瘢痕,形成面积为9 cm×7 cm~28 cm×12 cm的创面,术中注意保留颞浅动静脉或面动静脉穿支。以优势IMAP为蒂,根据瘢痕切除后创面面积和位置设计皮瓣:对于中小面积的创面,采用IMAP单蒂皮瓣转移修复;对于缺损面积较大者,利用吲哚菁绿血管造影(ICGA)评价前胸各血管的供血范围,当IMAP不足以供养整块皮瓣时,利用锁骨上动脉胸支或胸外侧动脉进行血管增压,设计双蒂皮瓣。根据供受区间的距离,选择带蒂或游离转移皮瓣。转移皮瓣后再次行ICGA判断皮瓣血供。将供瓣区直接拉拢缝合。统计皮肤软组织扩张器置入个数、额定容量、注射生理盐水量和扩张周期,优势IMAP位置,采用皮瓣总个数和不同血管蒂类型皮瓣个数、皮瓣面积,Ⅱ期术后皮瓣存活情况、供受区常见并发症发生情况和随访情况。 结果 共置入25个皮肤软组织扩张器,皮肤软组织扩张器额定容量为200~500 mL,注射生理盐水量855~2 055 mL,扩张周期4~16个月。术前在第2肋间(20侧)或第3肋间(5侧)探及优势IMAP。共切取25个扩张皮瓣,其中2个IMAP带蒂皮瓣、11个IMAP游离皮瓣、4个锁骨上动脉胸支带蒂+IMAP游离皮瓣、8个IMAP+胸外侧动脉游离皮瓣,皮瓣面积10 cm×8 cm~30 cm×14 cm。Ⅱ期术后3例患者出现皮瓣尖端坏死,经常规换药后愈合;1例患者IMAP和面动脉吻合处出现血管蒂局部扭转、血栓栓塞,手术探查取出血栓、重新吻合血管后,血供恢复正常。14例患者在Ⅱ期术后1~6个月进行了皮瓣修薄手术。随访4个月~9年,所有患者皮瓣外观良好,面颈部功能改善,供区可见线性瘢痕形成;1例女性患者出现明显乳头移位,双侧乳房不对称。 结论 扩张IMAP皮瓣颜色、质地与面颈部皮肤组织匹配,且切取后对胸部供区的损伤小,联合血管增压可灵活设计双蒂皮瓣,进一步改善血供,扩大皮瓣切取面积,是大面积面颈部瘢痕整复的良好选择。 Abstract:Objective To summarize the clinical experience of expanded internal mammary artery perforator (IMAP) flap combined with vascular supercharge in reconstruction of faciocervical scar. Methods The retrospective observational study was conducted. From September 2012 to May 2021, 23 patients with postburn or posttraumatic faciocervical scars who met the inclusion criteria were admitted to Shanghai Ninth People's Hospital of Shanghai Jiao Tong University School of Medicine, including 18 males and 5 females, aged from 11 to 58 years, all of whom were reconstructed with expanded IMAP flaps. At the first stage, one or two skin and soft tissue expander (s) with appropriate rated capacity were implanted in the anterior chest area according to the location and size of the scars. The IMAP, thoracic branch of supraclavicular artery, and lateral thoracic artery were preserved during the operation. The skin and soft tissue expanders were inflated with normal saline after the operation. The flaps were transferred during the second stage. The dominant IMAP was determined preoperatively using color Doppler ultrasound (CDU) blood flow detector. The faciocervical scars were removed, forming wounds with areas of 9 cm×7 cm-28 cm×12 cm, and the perforators of superficial temporal artery and vein or facial artery and vein were preserved during the operation. The flaps were designed according to the area and size of the wounds after scar resection with the dominant IMAP as the pedicle. Single-pedicle IMAP flaps were used to repair small and medium-sized wounds. For larger defects, the blood perfusion areas of vessels in the anterior chest were evaluated by indocyanine green angiography (ICGA). In situations where the IMAP was insufficient to nourish the entire flap, double-pedicle flaps were designed by using the thoracic branch of supraclavicular artery or lateral thoracic artery for supercharging. Pedicled or free flap transfer was selected according to the distance between the donor areas and recipient areas. After transplantation of flaps, ICGA was conducted again to evaluate blood perfusion of the flaps. The donor sites of flaps were all closed by suturing directly. Statistics were recorded, including the number, rated capacity, normal saline injection volume, and expansion period of skin and soft tissue expanders, the location of the dominant IMAP, the total number of the flaps used, the number of flaps with different types of vascular pedicles, the flap area, the flap survival after the second stage surgery, the occurrence of common complications in the donor and recipient areas, and the condition of follow-up. Results Totally 25 skin and soft tissue expanders were used in this group of patients, with rated capacity of 200-500 mL, normal saline injection volume of 855-2 055 mL, and expansion period of 4-16 months. The dominant IMAP was detected in the second intercostal space (20 sides) or the third intercostal space (5 sides) before surgery. A total of 25 expanded flaps were excised, including 2 pedicled IMAP flaps, 11 free IMAP flaps, 4 pedicled thoracic branch of supraclavicular artery+free IMAP flaps, and 8 free IMAP+lateral thoracic artery flaps, with flap areas of 10 cm×8 cm-30 cm×14 cm. After the second stage surgery, tip necrosis of flaps in three patients occurred, which healed after routine dressing changes; one patient developed arterial embolism and local torsion on the vascular pedicle at the anastomosis of IMAP and facial artery, and the blood supply recovered after thrombectomy and vascular re-anastomosis. Fourteen patients underwent flap thinning surgery in 1 month to 6 months after the second stage surgery. The follow-up for 4 months to 9 years showed that all patients had improved appearances of flaps and functions of face and neck and linear scar in the donor sites of flaps, and one female patient had obvious nipple displacement and bilateral breast asymmetry. Conclusions The expanded IMAP flap is matched in color and texture with that of the face and neck, and its incision causes little damage to the chest donor sites. When combined with vascular supercharge, a double-pedicle flap can be designed flexibly to further enhance the blood supply and expand the flap incision area, which is a good choice for reconstruction of large faciocervical scar. -
Key words:
- Surgical flaps /
- Face /
- Neck /
- Cicatrix /
- Perforator flap /
- Internal mammary artery /
- Skin and soft tissue expansion /
- Vascular supercharge
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近年来,随着我国经济的快速发展,瘢痕患者对手术修复后的美观要求不断提高。颏部与颈部在解剖上紧密相连,既是人体功能部位,又是重要的美学单元。颏颈部深度烧伤后常常出现瘢痕挛缩,导致功能障碍和容貌毁损。自20世纪50年代以来,颏颈部瘢痕畸形的整复手术经历了从皮片移植术到(扩张)皮瓣移植术的发展过程,形成了修复遵循亚单位原则、移植物遵循供区相似替代(like to like)原则,以及以重建颈颏角为重点的畸形矫正策略,显著提升了修复质量[1, 2, 3, 4, 5, 6]。然而,作为人体重要的美学单元,颏颈部具有丰富的局部美学特征,除颈颏角外,还包括下唇缘、颏唇沟、下颏突起、最适下颏长度和下颌缘轮廓线等。这些美学特征常因瘢痕而破坏,若不能在手术中予以重构,则术后仍难达到良好的美学形态。本研究团队在前人基础上,提出以重构上述亚单位局部美学特征为核心的颏颈部瘢痕挛缩畸形美学整复策略,即修复皮瓣色泽与厚度匹配(match)、亚单位美学特征重构(reconstruction)、按整形原则设计切口(incision)和预防手术切口瘢痕(scar)的“MRIS”原则,以期进一步提升颏颈部瘢痕挛缩畸形术后美学效果。
1. 对象与方法
本回顾性观察性研究符合《赫尔辛基宣言》的基本原则,仅对病历资料进行回顾性分析,不泄露患者隐私。
1.1 入选标准
纳入标准:确诊为烧伤后颏颈部瘢痕挛缩畸形,接受基于“MRIS”原则的颏颈部瘢痕挛缩畸形治疗,术后随访3个月以上者。排除标准:病历资料不全的患者。
1.2 临床资料
2017年12月—2021年4月,陆军军医大学(第三军医大学)第一附属医院整形外科收治的34例烧伤后颏颈部瘢痕挛缩畸形患者符合入选标准,纳入本研究。患者中男13例、女21例,年龄12~54岁,瘢痕挛缩畸形病程5个月~27年。原发致伤原因均为热力烧伤。患者中,单纯颏部瘢痕挛缩畸形者4例、单纯颈部瘢痕挛缩畸形者7例、颏部和颈部均受累的瘢痕挛缩畸形者23例。瘢痕面积48~252 cm2。所有患者均存在颏部和/或颈部多个美学特征破坏或消失,如小口畸形,唇外翻,下颏短小和/或退缩,颏唇沟、下颏突起、下颌缘轮廓线或颈颏角消失等。15例患者既往行局部瘢痕松解+植皮术。
1.3 治疗方法
手术在静脉复合麻醉下分2期进行:Ⅰ期埋置皮肤软组织扩张器(以下简称扩张器),以形成扩张(穿支)皮瓣;Ⅱ期行瘢痕切除+切取扩张皮瓣修复继发创面,将供瓣区直接缝合。治疗遵循“MRIS”原则。
1.3.1 修复皮瓣色泽与厚度匹配
扩张器的埋置部位优选局部和邻位,使形成的扩张皮瓣与颏颈部皮肤色泽接近。对于颏部瘢痕患者,若颏下区有足量正常皮肤,则选择于颏下区埋置扩张器;否则,优选于肩部锁骨上动脉穿支皮瓣供瓣区埋置扩张器。对于颈部严重瘢痕患者,优选于邻位肩胸部穿支皮瓣供瓣区埋置扩张器,包括锁骨上动脉穿支皮瓣、颈横动脉颈段皮支皮瓣和胸廓内动脉第2肋间穿支皮瓣供瓣区。本组病例埋置的扩张器为额定容量80~400 mL的长方形或肾形扩张器,术后每周注射生理盐水1次扩张,最终将扩张器扩张至其额定容量的3~5倍。
1.3.2 亚单位美学特征重构
以舌骨为界,该研究团队将颏颈部分为2个美学亚单位:(1)颏部美学亚单位,包括下唇、下颏和颏下区;(2)颈部美学亚单位,包括颈前区(不含颏下区)和胸锁乳突肌区。亚单位美学特征重构的要点如下:(1)按亚单位切除瘢痕与修复。对于颏部瘢痕,若范围超过下颏的2/3,通常行颏部瘢痕全切除,切除范围两侧至颏面沟,上界至下唇缘,下界至下颌骨下缘。对于颈部广泛瘢痕,切除范围上界至下颌骨下缘,下界至胸锁关节与锁骨一线,两侧至胸锁乳突肌后缘。切除组织包括瘢痕和皮下脂肪。原则上,各亚单位尽可能以单一皮瓣修复。(2)重建局部美学特征。术中切除瘢痕后,基于美学标准,重建亚单位内局部美学特征。对于颏部瘢痕挛缩患者,若伴有唇外翻,术中设计新的下唇缘,松解和切除挛缩组织,重构出下唇形态并行颏唇沟再造;若伴有小口畸形,采用Y-V黏膜瓣行小口开大术;若伴有下颏畸形,则行下颏成形术。对于单纯下颏退缩者,利用扩张皮瓣的厚度增厚下颏突起;若同时伴有下颏短小和退缩,则利用扩张皮瓣延长下颌长度和重构下颏突起,具体方法是在断蒂时将皮瓣蒂部从皮下浅层剖开,形成新的皮下组织瓣,并将其反折固定于下颏部。对于颈部挛缩畸形患者,重点行颈部轮廓成形术,方法为术中切除瘢痕组织和皮下脂肪,沿下颌角、下颌下腺与舌骨连线水平将挛缩的颈阔肌及其深部组织横断;必要时也可设计并切取颈阔肌组织瓣,将组织瓣向上翻转并固定于下颌缘。对部分挛缩严重患者,视情况可将挛缩的舌骨下肌群及其周边组织在舌骨-甲状软骨沟处部分切断松解,以加深颈颏角。术后常规佩戴弹力套塑形,以获得稳定的颏颈部美学形态。
1.3.3 按整形要求设计切口
包括隐藏手术切口和避免垂直方向直线切口。(1)隐藏手术切口:对于颏颈部严重瘢痕挛缩畸形患者,通常采用2个独立的扩张皮瓣分别修复颏部和颈部亚单位,将2个皮瓣在舌骨上方对接缝合,使缝合切口隐藏于颏下区;对于颈前区残留部分正常皮肤组织的患者,通常采用单纯局部扩张推进皮瓣或局部扩张推进皮瓣联合邻位扩张带蒂皮瓣修复,以避免颈前中央区遗留垂直方向手术切痕。对于颈部瘢痕上界接近或超过下颌缘的患者,若面部条件允许,常规采用面部局部扩张皮瓣覆盖下颌缘,并与修复颈部的扩张皮瓣对接缝合于下颌缘一线,以隐藏手术切口和增强下颌缘轮廓线。(2)避免垂直方向直线切口:将颈部垂直方向的手术切口常规设计成Z字形或鱼尾状,以避免直线切口术后挛缩。
1.3.4 预防手术切口瘢痕
对所有手术切口均采用整形美容皮下减张技术缝合。术后常规应用弹力套和硅酮贴行抗瘢痕治疗3~6个月。对于严重瘢痕体质患者,术后2周开始对手术切口行强脉冲光治疗(波长为560或590 nm,能量为13~18 J/cm2,每月1次,共3次)。
1.4 观察指标
记录扩张器的扩张倍数(计算平均值)、采用皮瓣类型、局部美学形态重构情况、术后切口外观与皮瓣成活情况及随访观察的供受区情况。
2. 结果
34例患者埋置扩张器的平均扩张倍数为扩张器额定容量的3.82倍。3例患者采用单纯扩张局部带蒂皮瓣、19例患者采用单纯扩张肩胸部穿支带蒂皮瓣(涉及颈横动脉颈段皮支者7例、涉及锁骨上动脉穿支者3例、涉及胸廓内动脉第2肋间穿支者6例、涉及颈横动脉颈段皮支联合胸廓内动脉第2肋间穿支者3例)、10例患者采用扩张局部带蒂皮瓣联合扩张肩胸部穿支带蒂皮瓣(联合颈横动脉颈段皮支者6例、联合胸廓内动脉第2肋间穿支者3例、联合锁骨上动脉穿支者1例)、2例患者采用扩张局部带蒂皮瓣联合扩张胸廓内动脉第2肋间穿支游离皮瓣。瘢痕切除后,重构下唇形态和颏唇沟者10例、重构下颏突起和延长下颏长度者16例、重构颈颏角和下颌缘轮廓线者28例。手术切口较为隐蔽,多数位于颏部和颈部亚单位自然交界或转折处;颈部垂直方向切口呈Z字形或鱼尾状。34例患者术后皮瓣均成活,其中8例患者扩张皮瓣术后1~3 d出现远端边缘或尖端少许坏死,主要为扩张皮瓣远端回流障碍所致,换药后愈合。随访3~18个月,扩张皮瓣色泽、厚度与颏颈部皮肤差异小,颏颈部美学形态显著改善,手术切口瘢痕增生较轻。
例1
男,23岁,因煤气爆炸烧伤后面部瘢痕增生伴挛缩畸形8个月余入院。诊断:面部瘢痕增生伴挛缩畸形、小口畸形。体格检查:瘢痕分布于面部(面积约60 cm2),以下颏为主,瘢痕色红、质硬并且高出正常皮肤。下颏形态轮廓破坏、小口畸形、颏唇沟及下颏突起消失、下颏短小且退缩。入院后Ⅰ期于右侧肩部置入1个长方形扩张器(额定容量为300 mL),术后注射生理盐水3个月,将扩张器扩张至其额定容量的3.04倍,行Ⅱ期颏部亚单位瘢痕切除+右侧肩部扩张锁骨上动脉穿支皮瓣带蒂转移修复术、小口畸形矫正术。术中重构下唇缘、再造颏唇沟凹陷;以扩张皮瓣中央区(较薄部分)覆盖颏唇沟处创面,以扩张皮瓣近蒂部(较厚部分)增厚下颏突起。将供瓣区直接缝合。术后3周断蒂,断蒂时利用皮瓣蒂部组织适当延长下颏长度。手术切口位于颏部亚单位自然转折处。术后皮瓣成活。随访18个月,颏部亚单位轮廓和下唇形态好,小口畸形得以矫正,颏唇沟和下颏突起等美学特征显著改善。见图1。
例2
女,31岁,因火焰烧伤后面颈部瘢痕增生伴挛缩畸形影响外观和功能17年入院。既往行颈部瘢痕松解+中厚皮移植术。入院诊断:面颈部瘢痕挛缩畸形伴功能障碍。体格检查:下颏和颈部大片挛缩瘢痕(面积约198 cm2),其间见挛缩皮片;伴有小口畸形、嘴角牵拉畸形、下唇外翻,颏唇沟、下颏突起、颈颏角和下颌缘轮廓线消失,颈部活动受限。入院后Ⅰ期行双侧面部、肩胸部扩张器置入术,其中左侧面部置入1个肾形、额定容量80 mL扩张器,右侧面部置入1个肾形、额定容量100 mL扩张器,左侧肩胸部置入1个长方形、额定容量350 mL扩张器,右侧肩胸部置入1个长方形、额定容量为400 mL扩张器,术后注射生理盐水5个月,分别将左侧面部、右侧面部、左侧肩胸部、右侧肩胸部扩张器扩张至其额定容量的3.68、3.85、3.73和3.91倍,行Ⅱ期颏颈部瘢痕切除与畸形矫正+面部、肩胸部扩张器取出+扩张皮瓣转移修复术。左侧以颈横动脉颈段皮支为蒂,切取扩张皮瓣修复下颏单元;右侧以锁骨上动脉穿支为蒂,切取扩张皮瓣修复颈部单元。将供瓣区直接缝合。推进面部扩张皮瓣覆盖下颌缘。术中行小口开大术,下唇缘重构、颏唇沟再造术;沿下颌角、下颌下腺与舌骨连线水平将挛缩的颈阔肌及其深部组织横断,重建颈颏角和下颌缘弧度。术后3周,行Ⅲ期左侧扩张颈横动脉颈段皮支皮瓣断蒂术和下颏成形术(延长下颏和再造下颏突起)。手术切口位于颏部和颈部亚单位自然交界或转折处,颈部垂直方向切口呈鱼尾状。术后皮瓣成活。随访5个月,颏颈部亚单位轮廓好,局部美学特征显著改善,颈部活动自如,手术切口瘢痕轻度增生。见图2。
3. 讨论
如何在恢复功能的基础上获得更好的美学形态,一直是面颈部瘢痕挛缩畸形整复领域的重要问题。围绕这一问题,国内外学者进行了长期探索和实践。Gonzalez-Ulloa[2]最早提出面部亚单位概念与划分。Edgerton和Hansen[3]提出移植物供区选择的相似替代原则。Tsai等[7]总结了颈部瘢痕整复的系列方法,包括手术时机、挛缩松解程度、避免手术线性瘢痕、注意“动员”颈部正常皮肤以及重建颈颏角等。国内李青峰教授提出大面积面部软组织缺损修复的“MLT”原则[选择颜色质地匹配(match)、面积足够大(large)、厚度足够薄(thin)的组织进行修复],章一新教授、昝涛教授团队提出颈部瘢痕挛缩的重建新策略[4,8, 9]。然而,对于面颈部瘢痕挛缩畸形美学修复的定义和标准,目前未形成统一认识,手术效果仍多数依赖于医师的个人经验。本文作者认为,对于面颈部瘢痕挛缩畸形的美学修复,其定义和标准应以是否重构出符合或接近审美标准的亚单位局部美学特征为重要标志。
对于如何重构出符合审美标准的颏颈部局部亚单位美学特征,除遵循既往相关原则外,本文作者认为其关键要点如下:(1)邻近皮瓣超量扩张。肩胸部的皮肤色泽与颏颈部非常匹配,是修复颏颈部瘢痕的理想供瓣区。该区域可切取锁骨上动脉穿支皮瓣、颈横动脉颈段皮支皮瓣和胸廓内动脉第2 肋间穿支皮瓣[10, 11, 12]。其中,锁骨上动脉穿支皮瓣和颈横动脉颈段皮支皮瓣的蒂部更邻近颏颈部,有利于皮瓣转移和修复更大面积的颏颈部瘢痕,是局部条件允许时修复颏颈部瘢痕的优选皮瓣[13, 14, 15]。在这方面,国内马显杰教授团队做了大量富有临床指导价值的工作。在本组采用肩胸部穿支皮瓣修复的病例中,约2/3的患者选用锁骨上动脉穿支皮瓣和颈横动脉颈段皮支皮瓣,进一步证实这2种皮瓣临床应用的可靠性。然而,肩胸部皮肤软组织的厚度显著厚于颈部皮肤软组织。本文作者观察到,行肩胸部皮肤软组织扩张时,若仅常规扩张至扩张器额定容量的2倍,扩张后的皮瓣仍显臃肿,而经3倍以上扩张后的皮瓣厚度则与受区较为匹配,尤其是当患者为女性时,扩张倍数宜增加至4~5倍。在本组病例中,所有患者肩胸部皮瓣扩张时的扩张倍数均超过3倍,少数患者达到5倍,从而使修复后的皮肤软组织与颏颈部正常组织厚度接近,提升了术后美观效果。(2)熟知审美标准。例如,口裂的宽度以两侧口角位于瞳孔垂直线上为标准,正常颏唇沟的深度标准约为4 mm,下颏突起的高度以下颏的突出点在鼻尖与唇珠连线的延长线上为宜,下颏长度占全脸长度的1/6~1/5,颈颏角以90~110°为宜,颏下线与胸锁乳突肌的夹角以90°为标准等。(3)再造美学特征。基于上述美学标准,术中切除瘢痕后行小口开大术、颏唇沟再造术、下颏成形术、颈部轮廓成形术等,重构出符合或接近审美标准的局部美学特征。例如,术中充分切除和松解下唇下方挛缩组织,重构颏唇沟,并选用扩张皮瓣最薄的部分覆盖,如此可获得良好的颏唇沟再造效果。对于颏部瘢痕畸形,则根据患者的具体情况行下颏成形术。对于下颏突起破坏的患者,术中以扩张皮瓣较厚部分覆盖下颏部以增厚下颏突起;对下颏过短伴下颏突起特征消失的患者,术中将修复下颏的带蒂皮瓣的蒂部剖开,形成皮肤蒂和皮下组织蒂,将皮下组织蒂适当修剪后反折缝合固定于下颏部,从而获得接近美学标准的下颏长度和下颏突起。对于颈部严重瘢痕畸形患者,以往主要强调颈颏角成形的重要性。然而,由于该类患者的颈颏角和下颌缘弧度往往同时受损,若仅仅再造颈颏角,术后颈部的美观效果则仍不够理想。本研究团队采用沿下颌角、下颌下腺与舌骨连线,将颈阔肌及其深部的挛缩组织予以横断,或横断后形成组织瓣整体向上翻转,反折固定于下颌缘的手术策略,不仅可以再造出清晰的颈颏角,而且能重构出良好的下颌缘弧度,从而增强术后颈部轮廓特征,获得更好的颈部美学形态。
切口瘢痕是影响整形手术美学效果的共性问题。近年来,随着光电技术的发展,瘢痕的防治有了更多新的手段,但手术切口瘢痕仍难避免,隐藏手术切口对于提升整形术后美观效果仍具有十分重要的意义。对于颏颈部瘢痕整复手术而言,将手术切口设计在颏部和颈部亚单位的自然分界或转折处是隐藏手术切口的良好策略。对于颈部的广泛增生性瘢痕,尽量采用单一扩张皮瓣修复,避免皮瓣拼接产生新的手术切痕,尤其是垂直方向的手术切痕;同时,将皮瓣的上界设计于颏下区和下颌缘,下界于胸锁关节与锁骨,两侧至胸锁乳突肌后缘,如此,可获得较为理想的隐藏手术切口效果。对于颈前区部分受累的患者,优选单纯局部扩张推进皮瓣或局部扩张推进皮瓣联合邻位扩张带蒂皮瓣进行修复,使垂直方向手术切痕远离颈前中央区,避免患者着衬衣时手术切痕外露。为预防术后切口瘢痕挛缩,应常规将颈部垂直方向切口设计成Z字形或鱼尾状。此外,严重的颏颈部瘢痕挛缩畸形患者多为瘢痕体质,除采用良好的缝合技术以减轻切口瘢痕增生外,术后6个月内采取个性化的综合措施防治手术切口瘢痕对于提升术后美观效果同样十分重要,常用的方法包括光电治疗、涂抹抗瘢痕凝胶和压力治疗等[16, 17, 18, 19]。
综上,随着人们对瘢痕治疗美观要求的进一步提高,既往以功能重建为主要目的的颏颈部瘢痕畸形整复策略已难满足患者需求。本研究团队结合前人工作基础,提出基于“MRIS”原则的颏颈部瘢痕挛缩畸形美学整复新策略,其核心理念在于重构符合或接近审美标准的亚单位美学特征,以期为美学意义上的瘢痕整复治疗提供有益参考。
·读者·作者·编者·
本刊可直接使用英文缩写的常用词汇
已被公知公认的缩略语如ATP、CT、DNA、HBsAg、Ig、mRNA、PCR、RNA,可不加注释直接使用。对本刊常用的以下词汇,也允许在正文中图表以外处直接使用英文缩写(按首字母排序)。
脱细胞真皮基质(ADM) 重症监护病房(ICU) 动脉血氧分压(PaO2) 丙氨酸转氨酶(ALT) 白细胞介素(IL) 磷酸盐缓冲液(PBS) 急性呼吸窘迫综合征(ARDS) 角质形成细胞(KC) 反转录-聚合酶链反应(RT-PCR) 天冬氨酸转氨酶(AST) 半数致死烧伤面积(LA50) 全身炎症反应综合征(SIRS) 集落形成单位(CFU) 内毒素/脂多糖(LPS) 超氧化物歧化酶(SOD) 细胞外基质(ECM) 丝裂原活化蛋白激酶(MAPK) 动脉血氧饱和度(SaO2) 表皮生长因子(EGF) 最低抑菌浓度(MIC) 体表总面积(TBSA) 酶联免疫吸附测定(ELISA) 多器官功能障碍综合征(MODS) 转化生长因子(TGF) 成纤维细胞(Fb) 多器官功能衰竭(MOF) 辅助性T淋巴细胞(Th) 成纤维细胞生长因子(FGF) 一氧化氮合酶(NOS) 肿瘤坏死因子(TNF) 3-磷酸甘油醛脱氢酶(GAPDH) 负压伤口疗法(NPWT) 血管内皮生长因子(VEGF) 苏木精-伊红(HE) 动脉血二氧化碳分压(PaCO2) 负压封闭引流(VSD) 刘云菡:酝酿并且设计研究、实施研究、撰写论文;黄昕:指导研究、修改论文;李海洲、高雅姗、顾舒晨:实施研究;邝依敏(马来西亚籍)、骆申英、张泽伟:采集数据、分析/解释数据;顾斌、昝涛:设计研究、经费支持、指导所有作者均声明不存在利益冲突 -
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4 扩张的胸廓内动脉穿支(IMAP)+胸外侧动脉游离皮瓣整复例3患者面颈部烧伤后瘢痕。4A.Ⅱ期术前右侧颈部、胸部皮肤扩张及左面部瘢痕情况;4B.Ⅱ期术中游离皮瓣,解剖右侧胸廓内动脉第3穿支(黄色箭头)和胸外侧动脉(白色箭头);4C.Ⅱ期术中吲哚菁绿血管造影(ICGA)前皮瓣外观;4D.Ⅱ期术中夹闭胸外侧动脉,行ICGA显示IMAP最大灌注期供血不佳;4E.Ⅱ期术中夹闭IMAP,行ICGA显示胸外侧动脉最大灌注期供血不佳;4F.Ⅱ期术中同时开放IMAP和胸外侧动脉,再次行ICGA显示皮瓣血运良好;4G.Ⅱ期术中将右侧前胸皮瓣转移至左侧面颈部;4H.随访3年,中下面部皮瓣颜色、质地与周围正常皮肤相近,恢复了正常的下颌轮廓
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