Aesthetic reconstruction of the scar contracture deformity in chin and neck with expanded flaps based on the "MRIS" principle
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摘要:
目的 以获得更好的美学效果为目标，探讨颏颈部瘢痕挛缩畸形的手术整复策略。 方法 采用回顾性观察性研究方法。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34例烧伤后颏颈部瘢痕挛缩畸形患者（男13例、女21例，年龄12~54岁），其中单纯颏部受累者4例、单纯颈部受累者7例、颏部和颈部均受累者23例。瘢痕面积48~252 cm2。对所有患者均采用扩张皮瓣进行手术治疗，治疗遵循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。Ⅰ期埋置额定容量为80~400 mL长方形或肾形皮肤软组织扩张器（以下简称扩张器），常规扩张至扩张器额定容量的3~5倍。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。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。 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、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、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例患者术后扩张皮瓣均成活，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，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。 结论 基于“MRIS”原则采用扩张皮瓣整复颏颈部瘢痕挛缩畸形有利于提升手术质量，获得较好的美学效果。 Abstract:Objective The surgical reconstruction strategy for scar contracture deformity in chin and neck was explored, aiming to obtain better aesthetic outcome. Methods A retrospective observational study was conducted. From December 2017 to April 2021, 34 patients with scar contracture deformity in chin and neck after burns were hospitalized in the Department of Plastic Surgery of the First Affiliated Hospital of Army Medical University (the Third Military Medical University), aged 12-54 years, including 13 males and 21 females, 4 cases with chin affected only, 7 cases with neck affected only, and 23 cases with both chin and neck affected. The scar areas were 48-252 cm2. All the patients were treated by operation with expanded flaps, following the "MRIS" principle of matching of the color and thickness of the repair flaps (match), reconstructing of the aesthetic features of subunits (reconstruction), design of incision according to the plastic principle (incision), and prevention of the surgical incision scar (scar). The rectangular or kidney shaped skin and soft tissue expander (hereinafter referred to as the expander) with rated capacity of 80-400 mL was embedded in the first stage, which was routinely expanded to 3-5 times of the rated capacity of the expander. In the second stage, scar resection and expanded flap excision were performed to repair the secondary wound, and the flap donor site was sutured directly. The expansion ratio of the expander (with average value being calculated), the type of flaps used, the reconstruction of local aesthetic morphology, the appearance of postoperative incision, the survival of flap, and the situation of donor and recipient sites observed during follow-up were recorded. Results Among the 34 patients, the average expansion ratio of the implanted expander was 3.82 times of the rated capacity of the expander. Three cases were repaired by the expanded local pedicled flap only, 19 cases by the expanded shoulder and/or chest perforator pedicled flap only, 10 cases by the expanded local pedicled flap combined with the expanded shoulder and/or chest perforator pedicled flap, and 2 cases by the expanded local pedicled flap combined with the expanded free flap of the second intercostal perforator of internal thoracic artery. After scar resection, the shapes of lower lip and chin-lip groove were reconstructed in 10 cases, chin process reconstruction and chin lengthening were performed in 16 cases, and the cervico-mental angle and mandibular margin contour were reconstructed in 28 cases. The surgical incision was concealed, most of which were located at the natural junction or turning point of the chin and neck subunits. The vertical incision of neck was Z-shaped or fishtail-shaped. All the expanded flaps in 34 patients survived after operation, of which 8 patients had minor necrosis at the edge or tip of the expanded flaps 1-3 days after operation and healed after dressing change. During the follow-up of 3-18 months, little difference in color and thickness between the expanded flap and the skin of chin and neck was observed, and the aesthetic shape of chin and neck was significantly improved, with mild scar hyperplasia of surgical incision. Conclusions Reconstruction of scar contracture deformity in chin and neck by using expanded flaps based on the "MRIS" principle is beneficial to improve the quality of surgery and achieve better aesthetic outcome. -
Key words:
- Cicatrix /
- Dilatation /
- Surgical flaps /
- Chin and neck /
- Aesthetic repair /
- "MRIS" principle
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张家平：研究设计、实施与论文撰写；袁希、江旭品、刘杰、陈卓：手术实施与资料收集；李娅萍：手术护理保障与术中资料收集；王红霞：术后康复与宣传教育所有作者均声明不存在利益冲突本刊编辑委员会
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参考文献
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1 采用右侧肩部扩张锁骨上动脉穿支皮瓣带蒂转移美学整复例1患者烧伤后下颏瘢痕挛缩畸形。1A、1B.分别为Ⅰ期术前正面和侧面观，显示下颏亚单位轮廓破坏、颏唇沟和下颏突起消失、下颏短小且退缩；1C.Ⅰ期术前小口畸形；1D.Ⅱ期术前，右侧肩部皮肤软组织扩张器置入术后3个月；1E.Ⅱ期颏部瘢痕切除、小口开大、颏唇沟再造、扩张锁骨上动脉穿支皮瓣带蒂修复术后即刻；1F.Ⅱ期术后3周断蒂术后即刻；1G、1H.分别为断蒂术后18个月正面和侧面观，下唇形态、下颏亚单位轮廓与局部美学特征良好；1I.断蒂术后18个月，小口畸形显著矫正
2 采用扩张肩胸部穿支皮瓣带蒂转移美学整复例2患者烧伤后颏颈部瘢痕挛缩畸形。2A、2B、2C、2D、2E.分别为Ⅰ期术前右侧后仰、右侧平视、正面、左侧平视和左侧后仰观，显示颏颈亚单位轮廓破坏、美学特征消失；2F.Ⅱ期术前，扩张5个月后；2G.Ⅱ期颏颈部瘢痕切除、颏唇沟再造、颈部轮廓成形、扩张锁骨上动脉穿支皮瓣与扩张颈横动脉颈段皮支皮瓣带蒂修复术后即刻；2H.Ⅲ期皮瓣断蒂和下颏成形术后即刻；2I、2J、2K、2L、2M.分别为Ⅲ期术后5个月患者右侧后仰、右侧平视、正面、左侧平视和左侧后仰观，显示颏颈亚单位轮廓和美学特征显著改善
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） 
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