扩张皮瓣修复钛网颅骨成形术后钛网外露创面的临床效果

计鹏; 胡大海; 韩夫; 杨晨; 张智; 佟琳; 张月; 韩军涛; 陶克

doi:10.3760/cma.j.cn501120-20200613-00306

扩张皮瓣修复钛网颅骨成形术后钛网外露创面的临床效果

doi: 10.3760/cma.j.cn501120-20200613-00306

空军军医大学第一附属医院全军烧伤中心，烧伤与皮肤外科，西安　　710032

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通讯作者:
陶克，Email：taoke918@fmmu.edu.cn

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出版历程
- 收稿日期: 2020-06-13

Clinical effects of expanded flap in repairing the wounds with exposed titanium mesh after cranioplasty with titanium mesh

Department of Burns and Cutaneous Surgery, Burn Center of PLA, the First Affiliated Hospital of Air Force Medical University, Xi'an 710032, China

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Corresponding author: Tao Ke, Email: taoke918@fmmu.edu.cn

摘要

摘要: 目的探讨应用皮肤软组织扩张器（下称扩张器）制作的扩张皮瓣修复钛网颅骨成形术后钛网外露创面的临床效果。方法采用回顾性观察性研究方法。2015年4月—2019年10月，空军军医大学第一附属医院收治13例钛网颅骨成形术后钛网外露创面患者，其中男10例、女3例，年龄18~70岁，钛网外露出现时间为钛网颅骨成形术后3个月~4年，钛网外露创面面积：1.5 cm×0.6 cm~6.3 cm×6.0 cm。Ⅰ期于钛网外露创面周围边缘1 cm以远的正常头皮下置入1个或2个额定容积50~200 mL方形扩张器，注水时间2~3个月，总注水量为扩张器额定容积的1.6~2.0倍。Ⅱ期行扩张器取出及扩张皮瓣（面积为4.1 cm×1.8 cm~9.1 cm×7.9 cm）转移修复钛网外露创面。统计扩张器置入部位，扩张皮瓣转移形式，术后钛网外露部位创面愈合情况、扩张皮瓣成活情况；随访头部切口瘢痕及外形情况。结果本组患者中7例扩张器置入部位为颞部、6例为顶部。11例患者扩张皮瓣推进转移，2例患者扩张皮瓣易位转移。本组患者术后均成功保留钛网且头部创面均愈合。1例患者扩张皮瓣尖端坏死通过换药处理后治愈，12例患者扩张皮瓣转移后全部成活。术后12个月随访，本组患者外露钛网保留，切口愈合好，切口瘢痕隐蔽，头皮毛发生长良好，头部外观较佳。结论采用扩张皮瓣修复钛网颅骨成形术后钛网外露创面，能有效地覆盖创面并保留外露钛网，获得良好的功能和外形。
- 扩张术 /
- 外科皮瓣 /
- 伤口愈合 /
- 颅骨成形术 /
- 钛网外露
Abstract: Objective To explore the clinical effects of expanded flap made by skin and soft tissue expander (hereinafter referred to as expander) in repairing the wounds with exposed titanium mesh after cranioplasty with titanium mesh. Methods A retrospective observational study was conducted. From April 2015 to October 2019, 13 patients with wounds with exposed titanium mesh after cranioplasty with titanium mesh were admitted to the First Affiliated Hospital of Air Force Medical University, including 10 males and 3 females, aged 18 to 70 years. Exposure of titanium mesh occurred 3 months to 4 years after cranioplasty with titanium mesh. The wound area of exposed titanium mesh ranged from 1.5 cm×0.6 cm to 6.3 cm×6.0 cm. In the first stage, one or two square expanders with rated capacity of 50-200 mL were placed under the normal scalp 1 cm away from the edge of the wound surface of exposed titanium mesh. The water injection time was 2 to 3 months with the total water injection volume being 1.6 to 2.0 times of the rated capacity of expander. In the second stage, the expander was removed and the expanded flap (size ranging from 4.1 cm×1.8 cm to 9.1 cm×7.9 cm) was transferred to repair the wound of exposed titanium mesh. The placement site of the expander, the transfer form of the expanded flap, the postoperative wound healing of the titanium mesh exposed site, and the survival of expanded flap were recorded. The scar of the head incision and the appearance of head were followed up. Results Among the patients in this group, the expanders of 7 were placed in the temporal region, while the other 6 were placed at the top. The 11 patients were treated with advanced expanded flap, while the other 2 patients were treated with pedicled expanded flap. The head wounds of patients in this group successfully healed with retaining of the titanium mesh. The wound was healed after dressing change in 1 patient with necrosis at the tip of the expanded flap. The expanded flaps of 12 patients survived after transfer. Patients in this group were followed up for 12 months after surgery, the exposed titanium meshes were retained, the incisions healed well with the scars concealed, the hair on the scalp grew well, and the appearance of head was comparatively good. Conclusions Using expanded flap in the repair of the wounds with exposed titanium mesh after cranioplasty with titanium mesh can effectively cover the wound and retain the titanium mesh, achieving good function and appearance.
- Dilatation /
- Surgical flaps /
- Wound healing /
- Cranioplasty /
- Titanium mesh exposure
所有作者均声明不存在利益冲突

增生性瘢痕是创面愈合过程中常见的并发症。相关研究表明，A型肉毒毒素（BTX-A）对预防和治疗增生性瘢痕有效果，但其具体机制尚不明确。本研究旨在探索BTX-A对增生性瘢痕形成的潜在抑制机制。作者培养人增生性瘢痕来源的Fb，用TGF-β₁和不同浓度的BTX-A进行处理后检测细胞增殖率和存活率、总胶原蛋白量、Ⅰ型胶原和Ⅲ型胶原表达量以及转录和翻译水平等。结果显示，BTX-A抑制人Fb的增殖；Ⅰ型胶原和Ⅲ型胶原的mRNA表达水平在TGF-β₁的作用下明显增强，但用梯度浓度的BTX-A处理后，上调的α平滑肌肌动蛋白、Ⅰ型胶原和Ⅲ型胶原mRNA表达水平明显受到抑制（P<0.05）；BTX-A抑制Smad2/3与胞外信号调节激酶（ERK）的磷酸化水平。ERK抑制剂PD98059的效果与BTX-A的效果相似。这些结果显示BTX-A通过抑制TGF-β₁/Smad和ERK途径，从而抑制人Fb的增殖及胶原蛋白表达，减轻体外ECM的过度沉积。此研究结果为预防和治疗增生性瘢痕提供了新的科学参考，但BTX-A对瘢痕形成的影响还有待进一步研究。

樊拂晓，编译自《J Cosmet Dermatol》，2021，20(5):1374-1380；徐庆连，审校

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参考文献(30)

[1]	De LucaGP,VolpinL,FornezzaU,et al.The role of decompressive craniectomy in the treatment of uncontrollable post-traumatic intracranial hypertension[J].Acta Neurochir Suppl,2000,76:401-404.DOI: 10.1007/978-3-7091-6346-7_83.
[2]	BrownDA,WijdicksEFM.Decompressive craniectomy in acute brain injury[J].Handb Clin Neurol,2017,140:299-318.DOI: 10.1016/B978-0-444-63600-3.00016-7.
[3]	ZeidermanMR,PuLLQ.Contemporary reconstruction after complex facial trauma[J/OL].Burns Trauma,2020,8:tkaa003[2020-06-13].https://pubmed.ncbi.nlm.nih.gov/32341916/.DOI: 10.1093/burnst/tkaa003.
[4]	AshayeriK,Jackson EM,HuangJ,et al.Syndrome of the trephined: a systematic review[J].Neurosurgery,2016,79(4):525-534.DOI: 10.1227/NEU.0000000000001366.
[5]	LiangES, TipperG, HuntL, et al. Cranioplasty outcomes and associated complications: a single-centre observational study[J]. Br J Neurosurg, 2016,30(1):122-127.DOI: 10.3109/02688697.2015.1080216.
[6]	SahooNK,TomarK,ThakralA,et al.Complications of cranioplasty[J].J Craniofac Surg,2018,29(5):1344-1348.DOI: 10.1097/SCS.0000000000004478.
[7]	闫焦,王继华,何永静,等.颅骨成形术术后钛网外露原因及防治进展[J]. 中国医疗美容, 2019,9(1):102-107. DOI: 10.19593/j.issn.2095-0721.2019.01.026.
[8]	邵明辰,程鹏,崔彦魁.手术治疗颅骨修补术后钛网外露16例临床体会[J].中国医疗美容,2019,9(11):28-31.DOI: 10.19593/j.issn.2095-0721.2019.11.007.
[9]	MukherjeeS,ThakurB,HaqI,et al.Complications of titanium cranioplasty--a retrospective analysis of 174 patients[J].Acta Neurochir (Wien),2014,156(5):989-998.DOI: 10.1007/s00701-014-2024-x.
[10]	HaywardRD.Cranioplasty: don't forget the patient's own bone is cheaper than titanium[J].Br J Neurosurg,1999,13(5):490-491.
[11]	LiA, AzadTD, VeeravaguA, et al. Cranioplasty complications and costs: a national population-level analysis using the MarketScan longitudinal database[J]. World Neurosurg, 2017,102:209-220.DOI: 10.1016/j.wneu.2017.03.022.
[12]	JeyaraCP. Reconstruction of large calvarial defects using titanium mesh versus autologous split thickness calvarial bone grafts: a comprehensive comparative evaluation of the two major cranioplasty techniques[J].J Maxillofac Oral Surg,2018,17(3):308-323.DOI: 10.1007/s12663-017-1047-2.
[13]	侯宏义,王璐旭,谢松涛,等.颅骨修补术后钛网外露的整形外科修复[J].中华神经外科疾病研究杂志,2018,17(4):349-351.
[14]	ThienA,KingNKK,AngBT,et al.Comparison of polyetherether- ketone and titanium cranioplasty after decompressive craniectomy[J].World Neurosurg,2015,83(2):176-180.DOI: 10.1016/j.wneu.2014.06.003.
[15]	吴杉英,黄祖根,薛华栋,等.VSD联合组织瓣修复颅骨修补术后钛网外露[J].福建医科大学学报,2019,53(3):201-202.
[16]	ZhaoJY, SongGD, ZongXL, et al. Using the reversed temporal island flap to cover small forehead defects from titanium mesh exposure after cranial reconstruction[J]. World Neurosurg, 2018,112:e514-e519.DOI: 10.1016/j.wneu.2018.01.070.
[17]	KwiecienGJ, RuedaS, CoutoRA, et al. Long-term outcomes of cranioplasty: titanium mesh is not a longterm solution in high-risk patients[J].Ann Plast Surg, 2018,81(4):416-422. DOI: 10.1097/SAP.0000000000001559.
[18]	徐中,刘惠祥,沈鸟松,等.颅骨修补术后皮瓣坏死与钛网外露原因分析及防治[J].中国临床神经外科杂志,2015,20(1):28-30.DOI: 10.13798/j.issn.1009-153X.2015.01.009.
[19]	邵珠平,李文化,张波,等.皮肤减张缝合修复颅骨修补术后钛网外露的效果[J].中国临床神经外科杂志,2014,19(11):681-682.DOI: 10.13798/j.issn.1009-153X.2014.11.015.
[20]	柯家祥,李蓓,朱志军.应用局部皮瓣修复头部电烧伤颅骨外露[J].中国美容医学,2017,26(8):51-53.DOI: 10.15909/j.cnki.cn61-1347/r.001891.
[21]	梁日初,崔晟华,杨锋,等.颞浅筋膜转移联合游离植皮修补颅骨钛网外露16例疗效分析[J].中南医学科学杂志,2014,42(6):613-615.DOI: 10.3969/j.issn.2095-1116.2014.06.021.
[22]	李岩,郑鲁,张志华.游离腹直肌肌皮瓣修复头部慢性溃疡致癌变一例[J].中华烧伤杂志,2003,19增刊:60.DOI: 10.3760/cma.j.issn.1009-2587.2003.z1.033.
[23]	汤海萍,滕国栋,姜凯.游离皮瓣在颅骨外露的头皮缺损中的应用[J].中国美容医学,2013,22(4):431-433.DOI: 10.3969/j.issn.1008-6455.2013.04.005.
[24]	TakumiI,AkimotoM.One-stage reconstruction using a vascularized calvarial flap for intractable scalp ulcers in relation with cranial implants without removing the whole prosthesis[J].Neurosurg Rev,2009,32(3):363-368.DOI: 10.1007/s10143-009-0196-2.
[25]	赵阳,何铁英,韩玲.软组织扩张器一期修复电击伤颅骨外露并感染的临床研究[J].北方药学,2011,8(7):47-48,8.
[26]	温从吉,王书军,于海洲,等.组织扩张器在头皮缺损伴颅骨外露创面早期修复中的应用[J/CD].中华损伤与修复杂志:电子版,2019,14( 6):452-454.DOI: 10.3877/cma.j.issn.1673-9450.2019.06.011.
[27]	董琛,余州,马显杰.皮肤软组织扩张方法与机制的研究进展[J].中华实验外科杂志,2019,36(8):1513-1517.DOI: 10.3760/cma.j.issn.1001-9030.2019.08.057.
[28]	AustadED,PasykKA,McClatcheyKD,et al.Histomorphologic evaluation of guinea pig skin and soft tissue after controlled tissue expansion[J].Plast Reconstr Surg,1982,70(6):704-710.DOI: 10.1097/00006534-198212000-00008.
[29]	林建滨.颅骨缺损钛网修补的常见问题及处理[J].中外医疗,2016,35(30):76-78,81.DOI: 10.16662/j.cnki.1674-0742.2016.30.076.
[30]	陈淑强,马显杰.皮肤软组织扩张术后并发症的研究及防治现状[J].中国美容整形外科杂志,2019,30(2):124-125,后插2-2-后插2-3.DOI: 10.3969/j.issn.1673-7040.2019.02.017.

1 头顶部扩张皮瓣推进转移修复例1患者左侧颞部钛网颅骨成形术后钛网外露创面。1A.入院时钛网颅骨成形术后2年，颞部钛网外露2个月余；1B.皮肤软组织扩张器（以下简称扩张器）置入后2个月头部钛网及扩张器CT影像；1C.扩张后2个月，扩张皮瓣转移术前；1D.扩张皮瓣转移术后即刻重建头皮外观；1E.扩张皮瓣转移术后3个月，钛网表面扩张皮瓣无破溃，毛发稍稀疏；1F.扩张皮瓣转移术后12个月，皮瓣与正常头皮基本一致，术区切口瘢痕隐蔽，毛发生长良好

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2 右侧颞顶部扩张皮瓣推进转移修复例2患者右侧颞顶部钛网颅骨成形术后钛网外露创面。2A.皮肤软组织扩张器（以下简称扩张器）置入后3个月余；2B.扩张器置入后3个月余，头部钛网及扩张器CT影像；2C.扩张器取出，钛网下硬脑膜完整、表面可见部分肉芽组织，钛网部分去除；2D.扩张皮瓣重建头皮术后即刻；2E.扩张皮瓣转移术后8 d，切口愈合良好；2F.扩张皮瓣转移术后12个月，皮瓣存活良好，未见钛网外露，去除钛网区域头皮略凹陷，术区切口线状瘢痕形成

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